Preparing for ICD-10-CM/PCS: What does a coder need to do now?

1. Preparing for ICD-10-CM/PCS: What does a coder need to do now? Presented by: Jennifer McManis, RHIT

2. ICD-10-CM/PCS • Compliance Timeline • Training Timeline • Continuing Education Requirements • Myth Busters • Code Structure • Coding Fundamentals • Case Studies • Resources

3. Implementation Date • ICD-10-CM/PCS Compliance Deadline • October 1, 2013 • Claims for services provided on or after this date must use ICD-10 codes • CPT codes will continue to be used for outpatient services

4. Compliance Timeline • January 1, 2010 • Internal testing of Version 5010 for electronic claims • December 31, 2010 • Internal testing must be complete • January 1, 2011 • External Testing of Version 5010 claims • CMS begins accepting Version 5010 • Version 4010 continue to be accepted • January 1, 2012 • All claims must use Version 5010 • Version 4010 no longer accepted

5. Outpatient Coder Training • Outpatient Coder Training • Approximately 16 hours • 2011-2012 • Review code Structure & Coding Conventions. • Learn the fundamentals • Analyze & practice applying the ICD-10-CM guidelines • Review and refresh knowledge of A & P concepts

6. Outpatient Coding Training • 2012-2013 • Become an expert in applying ICD-10-CM codes to outpatient cases in the six to nine months preceding October 1, 2013. • Practice using ICD-10-CM codes each week leading into “go live” on October 1, 2013. • Network with peers to seek answers to cases and confirm application of ICD-10-CM codes. • Take advantage of component MHIMA training opportunities

7. Inpatient Coder Training • Approximately 50 hours • 2011-12 • Review code structure and coding conventions for ICD-10-CM and ICD-10-PCS. • Learn the fundamentals of the ICD-10-CM and ICD-10-PCS systems. • Analyze and practice applying the ICD-10-CM and ICD-10-PCS Coding Guidelines. • Continue to study ICD-10-PCS definitions (memorize the definitions of approaches and root operations). • Continue to review and refresh knowledge of anatomy and physiology concepts

8. Inpatient Coder Training • 2012-13 • Become an expert in applying ICD-10-CM and ICD-10-PCS codes to inpatient cases in the 6 to 9 months preceding October 1, 2013 • Practice using ICD-10-CM and ICD-10-PCS codes each week leading into “go live” on October 1, 2013 • Network with peers to seek answers to cases and confirm application of ICD-10-CM/PCS codes • Take advantage of MHIMA training opportunities

9. Continuing Education Unit (CEU) Requirements • Required to participate in a predetermined number of mandatory baseline educational experiences specific to ICD-10-CM/PCS. • *Can Begin Earning CEU’s January 1, 2011 thru December 31, 2013 • 2009 or 2010 ICD-10 –CM Academy

10. CEU Requirements • Total number of ICD-10-cm/PCS CEU required, by AHIMA Credential • CHPS- 1 CEU • CHDA; RHIT;RHIA- 6 CEUs • CCS-P- 12 CEUs • CCS; CCA- 18 CEUs • If you hold more than one credential, only report the highest number of CEUs

11. CEU Requirements • CEU requirements will be included within the total number of CEUs required for a given CEU Cycle. For example, if you hold an RHIA credential, you will obtain 6 CEUs that are in relation to ICD-10-CM/PCS along with the additional 24 CEUs to complete your recertification cycle. • Reporting of the CEUs will be made available by Fall of 2011

12. Myths • October 1, 2013 is considered a flexible date • Implementation planning should be undertaken with an assumption that DPHHS will grant an extension • Worker’s comp & auto insurance companies may choose not to implement ICD-10-CM/PCS • State Medicaid Programs will not be required to update their systems in order to utilize ICD-10-CM/PCS • The increased number of codes will make the new coding system impossible to use • Developed without any clinical input • There will no hard copy of ICD-10-CM/PCS • All coding will be done electronically

13. Myths • Developed a number of years ago, so it is out of date • Unnecessarily detailed medical record documentation will be required • Implementation can wait until after electronic health records and other health care initiatives have been established • ICD-10-CM based super bills will be too long or too complex • The GEMs are intended to facilitate the process of coding medical records • Each payer will be required to develop their own mappings, GEM have been developed for CMS use only • Medically unnecessary diagnostic tests will need to be performed in order to assign an ICD-10-CM code • CPT will be replaced by ICD-10-CM/PCS

14. ICD 10-CM Code Structure • ICD 10-CM • Contains more than 68,000 codes • Compare this to ICD-9-CM which contains 13,000 codes • Consists of 3-7 characters • First digit is alpha • All Letters are used except U • 4th,5th,6th & 7th Digits can be numeric • Decimal placed after the 1st three characters

15. ICD-10-CM Code Structure • ICD-10-CM Code Structure • XXX.XXX X • 1st 3 Characters- Category • 4th 5th 6th Characters-Etiology, Anatomic Site, Severity • 7th Character-Extension (Visit Encounter, Sequelae, External Causes) • ICD-9-CM Code Structure • XXX.XX • 1st 3 Characters-Category • 4th 5th Characters- Etiology, Anatomic Site, Manifestation

16. ICD-10-CM • Structure • Index & Tabular List • Two Parts of the Index • Disease & Injury • Table of Drugs & Chemicals • Neoplasm Table • External Causes • Coding Guidelines • Some changes from ICD-9 • Fractures- Default Displaced • 2 Categories for Acute MI • Acute MI is 4 weeks instead of 8 weeks • Osteoporosis with current pathological fracture • V codes are now Z Codes

17. ICD-10-CM • New Features • Combination codes for conditions & common symptoms • Combination codes for poisonings & external causes • Added laterality • Added extensions for episode of care • Expanded codes • Inclusion of trimester in obstetric codes and elimination of fifth digits for episode of care • External cause codes no longer a supplementary classification

18. ICD-10-CM • Diabetes Mellitus Codes • No Longer Classified as uncontrolled/controlled • Includes diabetes & the complication • Injuries • Grouped by Anatomical site rather than type of injury • Code Extension to identify (7th Character) • A- Initial encounter • D-Subsequent encounter • S-Sequelae

19. ICD-10-CM • Code Examples • I10- Hypertension • Hypertension Table Removed • Combination codes Certain Conditions and Associated Symptoms • K57.21-Diverticulitis of large intestine with perforation and abscess with bleeding • I25.110- Arteriosclerotic Heart Disease of native coronary artery with unstable angina pectoris • K571.51- Toxic Liver disease with chronic active hepatitis with ascites • E10.610- Type 1 diabetes mellitus with diabetic neuropathic arthropathy

20. ICD-10-CM • Combination codes for poisonings and their external cause • T42.3x2S- Poisoning by barbituates, intentional self-harm, sequela • Laterality • C50.212- Malignant neoplasm of upper-inner quadrant of left female breast • L89.213- Pressure ulcer of right hip, stage III

21. ICD-10-CM • Codes for clinical concepts that do not exist in ICD-9-CM • T45.526D-Underdosing of antithrombotic drugs, subsequent encounter • Z67.40- Type O Blood, RH positive • Codes for postoperative complications, intraoperative, and post-procedural disorders • D78.01- Intraoperative hemorrhage and hematoma of spleen complicating a procedure on the spleen • D78.21- Post-procedural hemorrhage and hematoma of spleen following a procedure on the spleen • Obstetric codes identify trimester instead of episode of care • 026.02- Excessive weight gain in pregnancy, second trimester

22. ICD-10-CM Coding Guidelines • Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99) • d. Sepsis, Severe Sepsis, and Septic Shock • Case Study: • Patient was taken to the emergency department and admitted to the hospital after being found semi-conscious with markedly abnormal vital signs, a fever of over 39 degrees C, a heart rate of 110, and a respiratory rate of 22/min. Final diagnoses included sepsis and septic shock with acute respiratory failure • Answer: • A41.9 Sepsis (generalized) • R65.21 Shock, septic (due to severe sepsis) • J96.0 Failure, respiration, respiratory, acute

23. ICD-10-CM Coding Guidelines • Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89) a. Diabetes mellitus • 6) Secondary Diabetes Mellitus • Case Study • This 34-year-old patient is being seen for ongoing management of steroid-induced diabetes mellitus which was due to the prolonged use of corticosteroids, which have been discontinued. The patient’s diabetes is managed with insulin which he has been taking for the last two years • Answer: • T38.0x5S Refer to Drug and Chemical Table, Corticosteroid, adverse effect • E09.9 Diabetes, diabetic, (mellitus) (sugar), due to drug or chemical • Z79.4 Long-term (current) drug therapy (use of), insulin

24. ICD-10-CM Coding Guidelines • Chapter 9 Diseases of Circulatory System (I00-I99) • Case Study • Patient is seen for treatment of unstable angina. The patient has a history of atherosclerotic heart disease and underwent a 3-vessel coronary bypass approximately 2 years ago. The patient recently underwent a cardiac catheterization of all three coronary bypass grafts which showed them patent • Answer: • I25.110 Angina (attack) (cardiac) (chest) (heart) (pectoris) (syndrome) (vasomotor), with atherosclerotic heart disease – see Arteriosclerosis, coronary (artery), native vessel with angina pectoris, unstable • Z95.1 Status (post), aortocoronary bypass

25. ICD-10-CM Coding Guidelines • Chapter 12: Diseases of Skin and Subcutaneous Tissue (L00-L99) • a. Pressure ulcer stage codes • Case Study • This patient has a gangrenous pressure ulcer of the right hip and a pressure ulcer of the sacrum documented by the physician. The nursing assessment indicates a stage II pressure ulcer of the sacrum with a stage III decubitus ulcer of the right hip. • Answer: • I96 Ulcer, gangrenous – see Gangrene. Gangrene, gangrenous (connective tissue) (dropsical) (dry) (moist) (skin) (ulcer) (see also necrosis), Necrosis, skin or subcutaneous tissue NEC • L89.213 Ulcer, ulcerated, ulcerating, ulceration, ulcerative, pressure (pressure area) stage III, (healing) (full thickness skin loss involving damage or necrosis of subcutaneous tissue) • L89.152 Ulcer, ulcerated, ulcerating, ulceration, ulcerative, pressure (pressure area) stage II, (healing) (abrasion, blister, partial thickness skin loss involving epidermis and/or dermis) sacral region (tailbone

26. ICD-10-CM Coding Guidelines • Chapter 9: Diseases of Circulatory System (I00-I99) • a. Hypertension • 1) Hypertension with Heart Disease • 3) Hypertensive Heart and Chronic Kidney Disease • Case Study • This patient is hospitalized with a diagnosis of congestive heart failure due to hypertensive heart disease. Patient also has Stage 5 chronic kidney failure. The patient has been prescribed Lasix previously but admits he forgets to take his medication every day. This is due to his advanced age.

27. ICD-10-CM Coding Guidelines • Answer: • I13.2 Disease, diseased, heart (organic), hypertensive – see Hypertension, heart. Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic), heart (disease) with kidney disease (chronic) – see Hypertension, cardiorenal (disease), with heart failure, with stage 5 or end stage renal disease • I50.9 Failure, heart (acute) (sudden), congestive (compensated) (decompensated). The “use additional code” statement under code I13.2 indicates the use of this code to identify the type of heart failure • N18.5 Disease, diseased, kidney (functional) (pelvis), chronic, stage 5. The “use additional code” statement under code I13.2 indicates the use of this code to identify the stage of the chronic kidney disease • T50.1x6A Refer to Table of Drugs and Chemicals, Lasix, underdosing • Z91.130 Noncompliance, medication regimen, underdosing, unintentional, due to patient’s age-related debility

28. ICD-10-CM Coding Guidelines • Chapter 20: Chapter 20: External Causes of Morbidity (V01-Y99) • Case Study • An 18 year-old driver of a car that collided with a pickup truck on the interstate highway. The driver confessed to using his cell phone to send a text message to his girlfriend. • Assign the external cause codes only • Answer: • V43.53xA Index to External Causes. Accident, car – see Accident, transport, car occupant, Accident, transport, car occupant, driver, collision (with) pickup truck (traffic) • Y92.411 Index to External Causes, Place of occurrence, highway (interstate) • Y93.c2 Index to External Causes, Activity (involving) (of victim at time of event), cellular, telephone

29. ICD-9-CM Coding Guidelines • Chapter 21: Factors influencing health status and contact with health services (Z00-Z99) • Case Study • This patient had a lateral wall STEMI and was brought by ambulance to the emergency room. He received tPA and was transferred to a tertiary care center for continued care. The patient was received with tPA infusion continuing, and immediately taken to the cardiac cath lab.  Answer: • I21.29 Infarct, infarction, myocardium, myocardial (acute) (with stated duration of 4 weeks or less), ST elevation (STEMI), lateral (apical-lateral) (basal-lateral) (high) • Z92.82 Status(post) – see also Presence (of), administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility

30. ICD-10-PCS • ICD-10-PCS • Inpatient Procedures • Contains • Over 72,000 codes • 7 Character-alphanumeric code structure • Each character contains up to 34 possible values • The letter O is not used • No Decimals

31. ICD-10-PCS • Structure • Index • Codes found based on type of procedure- No diagnostic information in the description • One you know the tables; you can go directly to the tables the index does not need to be used first • First Three values in the index direct you to the table Tables • Each page in the section is composed of rows that specify valid combinations of code values • Root Operations • Approach

32. ICD-10-PCS • ICD-10 Structure • XXXXXXX • 1st- Section (Medical & Surgical; OB; Imaging) • 2nd- Body System • 3rd- Root Operation ( Resection, Transfusion) • 4th- Body Part • 5th- Approach • 6th- Device • 7th- Qualifier

33. ICD-10-PCS • Code Examples • 0HTT0ZZ- Right Total Mastectomy • 0X6C0ZZ- Amputation at left elbow level • 0FT44ZZ- Lap Chole • 0HBT0ZX- Right Breast Biopsy • 0- Medical Surgical • H- Skin & Breast • B-Excision • T- body Part • 0- Approach • Z-Device • X-Qualifier

34. ICD-10-PCS • Root Operations • 30 Root Operations • Identifies the objective of the procedure • In order to determine the appropriate root operation, the full definition of the root operation as contained in the PCS Tables must be applied. • Components of a procedure specified in the root operation definition and explanation are not coded separately. Procedural steps necessary to reach the operative site and close the operative site are also not coded separately. • Example: Resection of a joint as part of a joint replacement procedure is included in the root operation definition of Replacement and is not coded separately. Laparotomy performed to reach the site of an open liver biopsy is not coded separately.

35. ICD-10-PCS: Root Operations • Excision vs. Resection • PCS contains specific body parts for anatomical subdivisions of a body part, such as lobes of the lungs or liver and regions of the intestine. Resection of the specific body part is coded whenever all of the body part is cut out or off, rather than coding Excision of a less specific body part. • Example: Left upper lung lobectomy is coded to Resection of Upper Lung Lobe, Left rather than Excision of Lung, Left.

36. ICD-10-PCS: Root Operations • Biopsy followed by more definitive treatment • If a diagnostic Excision, Extraction, or Drainage procedure (biopsy) is followed by a more definitive procedure, such as Destruction, Excision or Resection at the same procedure site, both the biopsy and the more definitive treatment are coded. • Example: Biopsy of breast followed by partial mastectomy at the same procedure site, both the biopsy and the partial mastectomy procedure are coded. • Control vs. more definitive root operations • The root operation Control is defined as, “Stopping, or attempting to stop, postprocedural bleeding.” If an attempt to stop postprocedural bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control. • Example: Resection of spleen to stop postprocedural bleeding is coded to Resection instead of Control

37. ICD-10-PCS: Root Operations • Release procedures • In the root operation Release, the body part value coded is the body part being freed and not the tissue being manipulated or cut to free the body part. • Example: Lysis of intestinal adhesions is coded to the specific intestine body part value. • Release vs. Division • If the sole objective of the procedure is freeing a body part without cutting the body part, the root operation is Release. If the sole objective of the procedure is separating or transecting a body part, the root operation is Division. • Examples: Freeing a nerve root from surrounding scar tissue to relieve pain is coded to the root operation Release. Severing a nerve root to relieve pain is coded to the root operation Division.

38. ICD-10-PCS • Approach • Technique used to reach the site of the procedure • 7 Different Approaches • Open • Percutaneous • Percutaneous Endoscopic • Via Natural or Artificial Opening • Open with Percutaneous endoscopic assistance • External

39. ICD-10-PCS • Device • A device is coded only if a device remains after the procedure is completed. If no device remains, the device value No Device is coded.

40. ICD-10-PCS • Obstetrics • Products of conception • Procedures performed on the products of conception are coded to the Obstetrics section. Procedures performed on the pregnant female other than the products of conception are coded to the appropriate root operation in the Medical and Surgical section. • Example: Amniocentesis is coded to the products of conception body part in the Obstetrics section. Repair of obstetric urethral laceration is coded to the urethra body part in the Medical and Surgical section. • Procedures following delivery or abortion • Procedures performed following a delivery or abortion for curettage of the endometrium or evacuation of retained products of conception are all coded in the Obstetrics section, to the root operation Extraction and the body part Products of Conception, Retained. Diagnostic or therapeutic dilation and curettage performed during times other than the postpartum or post-abortion period are all coded in the Medical and Surgical section, to the root operation Extraction and the body part Endometrium

41. ICD-10-CM/PCS Resources • http://www.cms.gov/ICD10/ • Download the Index & Tabular • Compliance Dates • Quick Reference Guide • www.ahima.org • ICD-10-CM/PCS Resource Page

42. ICD-10-CM/PCS Resources • Subscribe and read the monthly ICD-TEN free newsletter from AHIMA • Complete exercises in the CodeWrite free e-newsletter from AHIMA • Network with peers in the ICD-10 Implementation CoP (available only to AHIMA members)