Unit 3 Lesson 5: ICD-10-CM

ICD-10-CM (clinical modification)

• code diagnoses (why received care)

• used in all healthcare settings

7th character of ICD-10-CM 4 options:

• A: initial encounter (active treatment

• D: subsequent encounter (follow-up/ healing process)

• S: sequela (complication or late effect)

• X: placeholder

ICD-10-PCS (procedure coding system)

• code inpatient hospital stays (what was done)

• hospital use ONLY

• hospital coders ONLY not Drs

ICD-10-CM stands for:

International Classification of Diseases, 10th Revision, Clinical Modification

Who maintains ICD-10-CM?

National Center for Health Statistics (NCHS)

ICD-10-CM key features

• 3-7 characters long

• combo of letter/numbers

• decimal point after 3rd digit 000.00

ICD-10-CM Structure Code

• 1st character: letter

  • CATEGORY

• 2nd-3rd: numbers

  • ETIOLOGY/LOCATION

• 4-6th: more details

  • SEVERITY, LATERALITY, ETC

• 7th: extension

  • EPISODE OF CARE

ICD-10-CM support what/why?

• medical necessity

• WHY service provided: signs, symptoms, conditions

CPT / HCPCS support what & why?

• what was done

• procedure or service performed

ICD-10-CM 1st character

• letter except U

• chapter or body system

ICD-10-CM 2nd character

• number

• condition or body region

ICD-10-CM 3rd character

• letter or number

• defines more specific diagnosis category

ICD-10-CM 4th-6th characters

• letter or number

• adds specificity

  • EX: right radius, closed fracture

ICD-10-CM 7th character

• letter or number

• describes the encounter

  • initial: active treatment

  • subsequent: healing stage

  • sequela: later effects or complications

ICD-10-CM manual coding steps

1. identify reason for visit

2. find main term in alphabetic index

3. review subterms

4. verify code in tabular list

5. apply instructional notes, as needed

alphabetic Index

• helps coders find main term

• codes: condition, disease, injury, or reason for visit

4 main sections of Alphabetic Index

1. Index to Diseases and Injuries (what happened)

2. Index to external causes (how it happened)

3. Table of neoplasms (codes for cancers/tumors)

4. Table of drugs and chemicals

Tabular List

• numerical list of all ICD-10-CM diagnosis codes

• grouped by chapter (21 total chapters)

• based on body system or type of condition

Tabular List used for:

• verify codes

• assign full, valid, & complete codes

• apply coding conventions and notes

Etiology

• underlying cause of disease or condition

manifestation

• symptoms that appear during sickness

• immediate effects of ongoing condition

sequela

• late effect, complication or long-term consequence

• happens after the initial condition has resolved

  • scarring, pain, stiff skin

ICD-10-CM sequence guidelines

1. etiology

2. manifestation

3. sequela

Coding Manifestations Rules

• etiology (condition) coded 1st

• 2nd manifestation condition

Rules for coding Sequela

• sequela coded 1st b4 etiology

• ALWAYS uses S for residual effects

ICD-10-CM Default Rules

1. If doesn’t say if fracture is open or closed

   1. CODE: CLOSED

2. Doesn’t say if fracture is displaced or not

   1. CODE: DISPLACED

3. Documents diabetes w/o specific type

   1. CODE: TYPE 2 DIABETES MELLITUS

4. Patient w/ gestational diabetes treated w/ insulin & diet

   1. CODE: GESTATIONAL DIABETES, INSULIN CONTROLLED ONLY

5. unconfirmed diagnosis; ONLY CODE SYMPTOMS

   1. EX: AB PAIN & NAUSEA; NOT APPENDICITIS

6. same condition is both acute & chronic

   1. CODE BOTH

   2. CODE ACUTE 1ST, CHRONIC 2ND

ICD-10-CM Coding conventions

• rules, symbols, and notes to guide you to right code

• in both alphabetic index and tabular list

brackets for conventions and guidelines

• in alphabetic index show manifestation codes

• in tabular list: to enclose synonyms, alternative words, or explanatory phrases

Parentheses (coding conventions and guidelines)

• encloses nonessential modifiers (appear in diagnosis but don’t affect the code selection)

colon (coding conventions and guidelines)

• incomplete term

  • has to be followed by subterm

NEC (coding conventions and guidelines)

• Not classified elsewhere

• code is known but no specific code exists

NOS (coding conventions and guidelines)

• Not otherwise specified

• Lacks enough detail to assign more specific code

• provider didn’t specify type, site, or cause of condition

Includes (coding conventions and guidelines)

• instructional notes

• clarifies examples of conditions that are part of the category

Excludes 1 (coding conventions and guidelines)

• instructional note

• NOT CODED HERE

• 2 mutually exclusive conditions make 2 codes can’t be coded together

Excludes 2 (coding conventions and guidelines)

• instructional note

• not included here, but CAN be coded together if both exist

• condition listed separate but can coexist

Code 1st (coding conventions and guidelines)

• instructional note

• must code underlying condition b4 coding the current condition

• when condition is secondary to another disease or disorder

Use additional code (coding conventions and guidelines)

• add more detail

• add another code to give extra info

• NOT ABOUT UNDERLYING CONDITION

• describing complication, manifestation, or associated condition

6 main steps to manual coding

1. identify main term

2. locate main term in alphabetic index

3. review subterms and nonessential modifiers

4. note the code from the alphabetic index

5. verify the code in the tabular list

6. add necessary characters (up to 7)

   1. Use X as placeholder for any missing character

7. check for additional codes

8. follow all coding guidelines

9. sequence codes correctly

10. review & submit

ICD-10-PCS

• International Classification of Diseases, 10th Revision, Procedure Coding System

• developed by CMS (Centers for Medicare & Medicaid Services)

• ALWAYS 7 characters long w/ NO decimals

ICD-10-PCS is used for

• coding inpatient hospital procedures (what was done)

• admitted patients

• hospital reimbursement for facility services