Basic ICD 10-CM/PCS and ICD-9-CM Coding, 2015 Edition

1. Basic ICD 10-CM/PCS and ICD-9-CM Coding, 2015 Edition Chapter 3: Introduction to the Uniform Hospital Discharge Data Set and Official Coding Guidelines

2. Learning Objectives • Review the chapter’s learning objectives • Concepts in this chapter may require extra time to study • Recognize the importance of learning about: • UHDDS elements including principal diagnosis, other diagnoses, complication, comorbidity, significant procedure, and principal procedure definitions • Uniform Bill 04 • Official coding guidelines

3. UHDDS • Uniform Hospital Discharge Data Set • Minimum, common core set of data • Originally intended for acute care, short-term hospitals • Application of UHDDS definitions has been expanded to include all non-outpatient settings, including acute care, short term, long-term care, and psychiatric hospitals; home health agencies, rehab facilities, nursing homes, and such

4. UHDDS Data Elements • Specific items regarding patients and their care: • Personal identification number: health record number • Date of birth • Sex • Race • Ethnicity (Hispanic/Non Hispanic) • Residence: zip code or code for foreign residence

5. UHDDS Data Elements (continued) • Specific items (continued) • Hospital identification: provider number • Admission and discharge dates • Physician identification: physician number • Disposition of patient • Expected payer for most of the bill

6. UHDDS Data Elements (continued) • Clinical information is part of UHDDS • All diagnoses affecting the current hospital stay must be reported • All significant procedures, dates, and person performing the procedure must be reported • Definition of principal and secondary diagnosis and procedure included in UHDDS

7. Principal and Other Diagnoses • Principal diagnosis • The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care • Other diagnoses • All conditions that coexist at the time of admission, that develop subsequently, or that affect treatment received and/or length of stay

8. Complications and Comorbidities • A complication or comorbidity is defined as additional diagnosis that may have an impact on the payment received through the Medicare-severity diagnosis-related group (MS-DRG) inpatient acute care prospective payment system from Medicare

9. Significant Procedure • Significant procedure • All significant procedures are to be reported • A procedure is identified as significant when it: • Is surgical in nature • Carries a procedural risk • Carries an anesthetic risk • Requires specialized training

10. Principal Procedure • Principal procedure • Procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes or is necessary to take care of a complication • If two procedures appear to be principal, the one most related to the principal diagnosis should be selected

11. UHDDS Data Elements • Complication • An additional diagnosis that describes a condition arising after the beginning of the hospital observation and treatment and then modifying the course of the patient’s illness or the medical care required • Comorbidity • A pre-existing condition that, because of its presence with a specific principal diagnosis, will cause an increase in the patient’s length of stay

12. Uniform Bill-04 • See Appendix F for sample UB-04 institutional paper claim form, with an electronic claims version 4010 • Used for Medicare Part A and other payer claims from hospitals and other healthcare institutions (home care, skilled nursing facility care) • Eighteen diagnosis codes • In addition, there are spaces for: • One admitting diagnosis, • Three reason for visit diagnoses, • Three E-codes • Six procedure codes and dates

13. Expanded Number of Codes • Effective 1/1/2011, CMS expanded the number of ICD-9-CM diagnosis and procedure codes allowed to be processed on institutional claims through the implementation of version 5010/837I of the electronic claims transaction standards. • Commonly referred to as the 837I, most likely used for claim submissions by institutions

14. Expanded Number of Codes • 25 diagnosis codes with associated present on admission indicator • 1 Principal diagnosis • 24 Additional diagnosis • 25 procedure codes

15. Present on Admission (POA) • Diagnosis “indicator” to be reported with each diagnosis code—was condition present on admission? • Four choices: Yes, No, Documentation insufficient, or Clinically undetermined • Reported for discharges from acute care hospitals or other facilities as required

16. Present on Admission (POA) • Comprehensive POA guidelines are included in the ICD-9-CM Official Guidelines for Coding and Reporting • Guidelines were created by The Cooperating Parties for ICD-9-CM that include a representative from • AHIMA, AHA, CMS, and National Center for Health Statistics (NCHS)

17. Principal Diagnosis Definition • Principal diagnosis is “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care” • Principal diagnosis relates only to inpatient care • Specific guidelines must be followed

18. Selection of Principal Diagnosis • Relates only to all inpatient settings to report patient data • Not applied to coding of outpatient visits • Depends on circumstances of admission • Related to but not the same as admitting diagnosis • Key words “after study” are integral part of the principal diagnosis definition

19. Official ICD-9-CM Guidelines • Official ICD-9-CM guidelines for coding and reporting are used to select principal and other diagnoses • Guidelines printed in most publishers’ versions of ICD-9-CM code books

20. Official ICD-9-CM Guidelines—Principal Diagnosis • Review principal diagnosis guidelines for: • Codes for symptoms, signs, and ill-defined conditions • Two or more interrelated conditions • Two or more diagnoses that equally meet the definition for principal diagnosis

21. Official ICD-9-CM Guidelines—Principal Diagnosis (continued) • Review principal diagnosis guidelines for: • Two or more comparative or contrasting conditions • A symptom(s) followed by contrasting/comparative diagnoses • Original treatment plan not carried out

22. Official ICD-9-CM Guidelines—Principal Diagnosis (continued) • Review principal diagnosis guidelines for: • Complications of surgery or other medical care • Uncertain diagnosis • Admission from observation unit • Admission from outpatient surgery

23. Official ICD-9-CM Guidelines—Additional Diagnosis • Reporting of additional diagnoses • All conditions that coexist at the time of the admission, that develop subsequently, or that affect the treatment received and/or the length of stay • Review additional diagnosis guidelines for: • Previous conditions • Abnormal findings • Uncertain diagnosis

24. ICD-10-CM Official Guidelines for Coding and Reporting • Developed by the Cooperating Parties (AHA, AHIMA, CMS, NCHS) • Section I • Structure and conventions of ICD-10-CM and the general guidelines that apply to the entire classification system • These are the fundamental coding rules for assigning ICD-9-CM codes

25. ICD-10-CM Official Guidelines for Coding and Reporting • Section II • Principal diagnosis selection • In determining the principal diagnosis, the coding conventions in ICD-10-CM, the Tabular List and the Alphabetic Index take precedence over all other guidelines • The importance of consistent, complete documentation in the medical record cannot be overemphasized

26. ICD-10-CM Official Guidelines for Coding and Reporting • Section II, Principal diagnosis selection • Review the ICD-10-CM guidelines • Guideline II.A • Codes for symptoms, signs and ill-defined conditions • Guideline II.A • Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis

27. ICD-10-CM Official Guidelines for Coding and Reporting • Section II, Principal diagnosis selection • Review the ICD-10-CM guidelines • Guideline II.C • Two or more diagnosis that equally meet the definition for principal diagnosis • Guideline II.D • Two or more comparative or contrasting conditions

28. ICD-10-CM Official Guidelines for Coding and Reporting • Section II, Principal diagnosis selection • Review the ICD-10-CM guidelines • Guideline II.E • A symptom(s) followed by contrasting or comparative diagnoses • NOTE: Guideline II.E has been deleted effective October 1, 2014 • This change does not apply to ICD-9-CM guidelines

29. ICD-10-CM Official Guidelines for Coding and Reporting • Section II, Principal diagnosis selection • Review the ICD-10-CM guidelines • Guideline II.F • Original treatment plan not carried out • Guideline II.G. • Complications of surgery and other medical care

30. ICD-10-CM Official Guidelines for Coding and Reporting • Section II, Principal diagnosis selection • Review the ICD-10-CM guidelines • Guideline II.H • Uncertain diagnosis • Guideline II.I • Admission from observation unit • Admission following medical observation • Admission following postoperative observation

31. ICD-10-CM Official Guidelines for Coding and Reporting • Section II, Review the ICD-10-CM guidelines • Principal diagnosis selection • Guideline II.J • Admission from outpatient surgery • When the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis • When no complication, or other condition, is documented as the reason for admission, assign the reason for the outpatient surgery as the principal diagnosis • When the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis

32. ICD-10-CM Official Guidelines for Coding and Reporting • Section II, Principal diagnosis selection • Review the ICD-10-CM guidelines • Guideline II.K • Admissions/Encounters for Rehabilitation • Sequence first the code for the condition for which the service is being performed • If the condition for which rehabilitation is no longer present, report the appropriate aftercare code as the first-listed or principal diagnosis

33. ICD-10-CM Official Guidelines for Coding and Reporting • Section II, Principal diagnosis selection • Review the ICD-10-CM guidelines • Guideline II.K • Admissions/Encounters for Rehabilitation • This guideline is addressing both inpatient principal diagnosis selection and outpatient first-listed diagnosis selection • This guideline is new to ICD-10-CM and not included in the ICD-9-CM guidelines • In ICD-9-CM, the V57 category code was assigned as the principal or first-listed diagnosis code for all rehabilitation visits. • No such category exists in ICD-10-CM

34. ICD-10-CM Official Guidelines for Coding and Reporting • Section III • Reporting of additional diagnoses • Conditions that affect patient care in terms of requiring • Clinical evaluation • Therapeutic treatment • Diagnostic procedures • Extend the length of hospital stay • Increased nursing care and/or monitoring

35. ICD-10-CM Official Guidelines for Coding and Reporting • Section III • Reporting of additional diagnoses • Diagnoses that relate to an earlier episode that have no bearing on the current hospital stay are to be excluded • These UHDDS definitions of principal and additional diagnosis apply to inpatient settings: hospitals including long term care and psych, home health, rehab facilities, nursing homes, and such

36. ICD-10-CM Official Guidelines for Coding and Reporting • Section III • Reporting of additional diagnoses • Guideline III.A Previous conditions • Guideline III.B Abnormal findings • Guideline III.C Uncertain diagnosis • If the diagnosis documented at the time of discharge is qualified as probable, suspected, likely, questionable, possible or still to be ruled out or other similar terms indicating uncertainty, code the condition as if it existed or was established • This guideline is applicable only to inpatient admissions

37. ICD-10-CM Official Guidelines for Coding and Reporting • Section IV • Guidelines for outpatient coding and reporting • Coding for patient visits in hospital outpatient, physician office or other ambulatory care center • Also clarified by Coding Clinic for ICD-10-CM these guidelines apply to the coding of physician services for professional fee billing regardless of the setting where the physician provided the service

38. ICD-10-CM Official Guidelines for Coding and Reporting • Section IV • Guideline IV.A • The term “first-listed” diagnosis is used instead of principal diagnosis in the outpatient settings • Selection of first-listed diagnosis • Outpatient surgery • Code the reason for surgery • Observation stay • For medical observation, code the medical condition

39. ICD-10-CM Official Guidelines for Coding and Reporting • Section IV • Guideline IV.B • Codes from A00.0–T88.9, Z00–Z99 • Any of these codes can be used • Guideline IV.C • Accurate reporting of ICD-10-CM diagnosis codes • Documentation should describe the patient’s condition

40. ICD-10-CM Official Guidelines for Coding and Reporting • Section IV • Guideline IV.D • Codes that describe symptoms and signs • Acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider • Guideline IV.E • Encounters for circumstances other than a disease or injury • Use of codes in chapter for Factors Influencing Health Status and Contact with Health Services (Z00–Z99)

41. ICD-10-CM Official Guidelines for Coding and Reporting • Section IV • Guideline IV.F • Level of Detail in Coding • Use of full number of characters required for a code • Guideline IV.G • ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit • First code represents condition chiefly responsible for visit • Additional codes describe coexisting conditions

42. ICD-10-CM Official Guidelines for Coding and Reporting • Section IV • Guideline IV.H • Uncertain Diagnosis • Do not code diagnoses documented as probably, suspected, questionable, rule out, or working diagnosis or other similar terms indicating uncertainty. • Rather, code the condition(s) to the highest degree of certainty for that condition/visit, such as symptoms, signs, abnormal test results, or other reasons for the visit • This differs from the coding practices used by short term, acute care, long-term care and psychiatric hospitals

43. ICD-10-CM Official Guidelines for Coding and Reporting • Section IV • Guideline IV.I • Chronic diseases • Coded and reported as many times as the patient receives care • Guideline IV.J • Code all documented conditions that coexist • Code all documented conditions that require or affect patient care treatment or management • Do not code conditions previously treated and no longer exist

44. ICD-10-CM Official Guidelines for Coding and Reporting • Section IV • Guideline IV.K • Patients receiving diagnostic services only • Sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter. • Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses

45. ICD-10-CM Official Guidelines for Coding and Reporting • Section IV • Guideline IV.K (continued, part 2) • Patients receiving diagnostic services only • For encounters for routine lab/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations • If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non-routine test

46. ICD-10-CM Official Guidelines for Coding and Reporting • Section IV • Guideline IV.K (continued, part 3) • Patients receiving diagnostic services only • For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation • Do no code related signs and symptoms as additional diagnosis • This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results (that are not coded in the inpatient setting)

47. ICD-10-CM Official Guidelines for Coding and Reporting • Section IV • Guideline IV.L • Patients receiving therapeutic services only • Sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided • Codes for other diagnoses (e.g. chronic conditions) may be sequenced as additional diagnoses

48. ICD-10-CM Official Guidelines for Coding and Reporting • Section IV • Guideline IV.L (continued, part 2) • Patients receiving therapeutic services only • The only exception to this rule is when the primary reason for the admission/encounter is chemotherapy or radiation therapy • For these, the appropriate Z code for the service is listed first, and the diagnosis or problem for which the service is being performed is listed second

49. ICD-10-CM Official Guidelines for Coding and Reporting • Section IV • Guideline IV.M • Patients receiving preoperative evaluations only • Sequence first a code from subcategory Z01.81, Encounter for pre-procedural examinations, to describe the pre-op consultations. • Assign a code for the condition to describe the reason for the surgery as an additional diagnosis • Code also any findings related to the pre-op evaluation

50. ICD-10-CM Official Guidelines for Coding and Reporting • Section IV • Guideline IV.N • Ambulatory Surgery • Code the diagnosis for which the surgery was performed • If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive