ICD-10 Coding Basics - CMS
ICD-10-CM StructureICD-10-CMICD-9-CM 3-5 characters First character is numeric oralpha (E or V) Characters 2-5 are numeric Always at least 3 characters Use of decimal after 3characters 3-7 characters– 3 characters before the decimal and up to 4characters after the decimal 1st character is alpha (all letters except U are used)2nd character is numericCharacters 3-7 are alpha or numericAlpha characters are not case-sensitive(e.g., Right ankle sprain, initial encounter:S93.401A, S93.401a, s93.401A, s93.401a)www.cms.gov/NPC
Similarities to ICD-9-CM Tabular List– Chronological list of codes divided into chapters based onbody system or condition– Same hierarchical structure– Chapters in Tabular structured similarly to ICD-9-CM, withminor exceptions A few chapters have been restructured Sense organs (eye and ear) separated from NervousSystem chapter and moved to their own chapterswww.cms.gov/NPC
Similarities to ICD-9-CM Index– Alphabetical list of terms and their corresponding codes– Indented subterms appear under main terms– Same structure as ICD-9-CM Alphabetic Index of Diseases and Injuries Alphabetic Index of External Causes Table of Neoplasms Table of Drugs and Chemicalswww.cms.gov/NPC
Similarities to ICD-9-CM Many conventions have same meaning– Abbreviations, punctuation, symbols, notes such as “codefirst” and “use additional code” Nonspecific codes (“unspecified” or “not otherwise specified”)are available to use when detailed documentation to supportmore specific code is not availablewww.cms.gov/NPC
Similarities to ICD-9-CM Codes are looked up the same way– Look up diagnostic terms in Alphabetic Index, then– Verify code number in Tabular List Codes are invalid if they are missing an applicable characterwww.cms.gov/NPC
Similarities to ICD-9-CM ICD-10-CM Official Guidelines for Coding and Reportingaccompany and complement ICD-10-CM conventions andinstructions Adherence to the official coding guidelines in all healthcaresettings is required under the Health Insurance Portability andAccountability Act (HIPAA)www.cms.gov/NPC
Differences from ICD-9-CM Expanded detail and specificity Codes reflect modern medicine and updated medicalterminology Laterality (side of the body affected) has been added torelevant codes Expanded use of combination codes– Certain conditions and associated common symptomsor manifestations– Poisonings and associated external causewww.cms.gov/NPC
Combination Codes – Examples I25.110 Atherosclerotic heart disease of native coronary arterywith unstable angina pectoris E11.311 Type 2 diabetes mellitus with unspecified diabeticretinopathy with macular edema K71.51 Toxic liver disease with chronic active hepatitis withascites K50.012 Crohn’s disease of small intestine with intestinalobstructionwww.cms.gov/NPC
Differences from ICD-9-CM In Tabular, injuries grouped by anatomical site ratherthan type of injuryICD-9-CMFractures (800-829)Dislocations (830-839)Sprains and strains (840-848)ICD-10-CMInjuries to the head (S00-S09)Injuries to the neck (S10-S19)Injuries to the thorax (S20-S29)www.cms.gov/NPC
Addition of 7th Character 7th character used in certain chapters (e.g., Musculoskeletal,Obstetrics, Injuries, External Causes) Different meaning depending on section where it is being used Must always be used in the 7th character position When 7th character applies, codes missing 7th character areinvalidwww.cms.gov/NPC
7th Character Describing EncounterInitial encounter: As long as patient is receiving active treatment for the condition.Examples of active treatment are: surgical treatment, emergency department encounter,and evaluation and treatment by a new physician.Subsequent encounter: After patient has received active treatment of the condition andis receiving routine care for the condition during the healing or recovery phase.Examples of subsequent care are: cast change or removal, removal of external or internalfixation device, medication adjustment, other aftercare and follow up visits followingtreatment of the injury or condition.Sequela: Complications or conditions that arise as a direct result of a condition (e.g., scarformation after a burn).Note: For aftercare of injury, assign acute injury code with 7th character forsubsequent encounter.www.cms.gov/NPC
7th Character – FracturesA Initial encounter for closed fractureB Initial encounter for open fractureD Subsequent encounter for fracture with routine healingG Subsequent encounter for fracture with delayed healingK Subsequent encounter for fracture with nonunionP Subsequent encounter for fracture with malunionS Sequelawww.cms.gov/NPC
Placeholder “X” Addition of dummy placeholder “X” (or “x”) is used in certaincodes to:– Allow for future expansion– Fill in empty characters when a code contains fewer than 6 characters and a 7thcharacter applies “X” is not case-sensitive– T46.1x5A or T46.1X5A– Adverse effect of calcium-channel blockers, initial encounter– T15.02xD or T15.02XD– Foreign body in cornea, left eye, subsequent encounter When the placeholder character applies, it must be usedin order for the code to be validwww.cms.gov/NPC
Excludes Notes Excludes1 note– Indicates that code identified in the note and code where the note appearscannot be reported together because the 2 conditions cannot occur togetherExample:E10 Type 1 Diabetes mellitusExcludes1: diabetes mellitus due to underlying condition (E08.-)drug or chemical induced diabetes mellitus (E09.-)gestational diabetes (O24.4-)hyperglycemia NOS (R73.9)neonatal diabetes mellitus (P70.2)postpancreatectomy diabetes mellitus (E13.-)postprocedural diabetes mellitus (E13.-)secondary diabetes mellitus NEC (E13.-)type 2 diabetes mellitus (E11.-)www.cms.gov/NPC
Excludes Notes Excludes2 note– Indicates that condition identified in the note is not part of the conditionrepresented by the code where the note appears, so both codes may bereported together if the patient has both conditionsExample:L89 Pressure ulcerExcludes2: decubitus (trophic) ulcer of cervix (uteri) (N86)diabetic ulcers (E08.621, E08.622, E09.621,E09.622, E10.621, E10.622, E11.621, E11.622,E13.621, E13.622)non-pressure chronic ulcer of skin (L97.-)skin infections (L00-L08)varicose ulcer (I83.0, I83.2)www.cms.gov/NPC
ICD-10-CM Specificity Examples Increased specificity– S72.044G Nondisplaced fracture of base of neck of rightfemur, subsequent encounter for closed fracture withdelayed healing– I69.351 Sequelae of cerebral infarction, Hemiplegia andhemiparesis following cerebral infarction affecting rightdominant side– Z47.81 Encounter for orthopedic aftercare following surgicalamputation– Z48.21 Encounter for aftercare following hearttransplantwww.cms.gov/NPC
ICD-10-CM Laterality Examples Laterality– C50.511 Malignant neoplasm of lower-outer quadrant ofright female breast– H01.111 Allergic dermatitis of right upper eyelid– L89.223 Pressure ulcer of left hip, stage 3www.cms.gov/NPC
ICD-10-CM Coding ExamplesType 1 diabetes mellitus with diabetic nephropathyStep 1Look up term in Alphabetic Index:Diabetes, diabetic (mellitus) (sugar) E11.9type 1 E10.9withnephropathy E10.21www.cms.gov/NPC
ICD-10-CM Coding ExamplesType I diabetes mellitus with diabetic nephropathyStep 2Verify code in Tabular:E10 Type 1 diabetes mellitusE10.2 Type 1 diabetes mellitus with kidney complicationsE10.21 Type 1 diabetes mellitus with diabetic nephropathyType 1 diabetes mellitus with intercapillary glomerulosclerosisType 1 diabetes mellitus with intracapillary glomerulonephrosisType 1 diabetes mellitus with Kimmelstiel-Wilson diseaseCode Assignment: E10.21www.cms.gov/NPC
ICD-10-CM Coding ExamplesAcute cystitis with hematuriaStep 1Look up term in Alphabetic Index:Cystitis (exudative) (hemorrhagic) (septic) (suppurative) N30.90acute N30.00with hematuria N30.01www.cms.gov/NPC
ICD-10-CM Coding ExamplesAcute cystitis with hematuriaStep 2Verify code in Tabular:N30 CystitisUse additional code to identify infectious agent (B95-B97)N30.0 Acute cystitisExcludes1: irradiation cystitis (N30.4-)trigonitis (N30.3-)N30.00 Acute cystitis without hematuriaN30.01 Acute cystitis with hematuriaCode Assignment: N30.01www.cms.gov/NPC
ICD-10-CM Coding ExamplesFracture (traumatic) of proximal third of scaphoid bone, leftwrist, initial encounterStep 1Look up term in Alphabetic Index:Fracture, traumaticscaphoid (hand) – see also Fracture, carpal, navicularcarpal bone(s) S62.10navicular S62.00 –proximal third (displaced) S62.03nondisplaced S62.03-www.cms.gov/NPC
ICD-10-CM Coding ExamplesFracture (traumatic) of proximal third of scaphoid bone, left wrist, initial encounterStep 2Verify code in Tabular:S62 Fracture at wrist and hand levelNote: A fracture not indicated as displaced or nondisplaced should be coded to displacedNote: A fracture not indicated as open or closed should be coded to closedThe appropriate 7th character is to be added to each code from category S62:A Initial encounter for closed fractureB Initial encounter for open fractureD Subsequent encounter for fracture with routine healingG Subsequent encounter for fracture with delayed healingK Subsequent encounter for fracture with nonunionP Subsequent encounter for fracture with malunionS Sequelawww.cms.gov/NPC
ICD-10-CM Coding ExamplesFracture (traumatic) of proximal third of scaphoid bone, left wrist, initial encounterStep 2 ContinuedVerify code in Tabular:S62.03 Fracture of proximal third of navicular [scaphoid] bone of wristS62.031 Displaced fracture of proximal third of navicular [scaphoid] bone of right wristS62.032 Displaced fracture of proximal third of navicular [scaphoid] bone of left wristS62.033 Displaced fracture of proximal third of navicular [scaphoid] bone of unspecified wristS62.034 Nondisplaced fracture of proximal third of navicular [scaphoid] bone of right wristS62.035 Nondisplaced fracture of proximal third of navicular [scaphoid’ bone of left wristS62.036 Nondisplaced fracture of proximal third of navicular [scaphoid] bone ofunspecified wristCode Assignment: S62.032Awww.cms.gov/NPC
ICD-10-CM Coding ExamplesAdmission to rehabilitation facility for physical and occupational therapyfollowing hospitalization for a left hip (femoral neck) fractureStep 1Look up term in Alphabetic Index:Fracture, femur, femoral, neck – see Fracture, femur, upper end, neckFracture, femur, upper end, neck S72.00-www.cms.gov/NPC
ICD-10-CM Coding ExamplesAdmission to rehabilitation facility for physical and occupational therapy followinghospitalization for a left hip (femoral neck) fractureStep 2Verify code in Tabular:S72- Fracture of femurNote: A fracture not indicated as open or closed should be coded to closedA fracture not indicated as open or closed should be coded to closedThe open fracture designations are based on the Gustilo open fracture classificationwww.cms.gov/NPC
ICD-10-CM Coding ExamplesStep 2 continuedVerify code in Tabular continued: The appropriate 7th character is to be added to all codes from category S72A - initial encounter for closed fractureB - initial encounter for open fracture type I or IIinitial encounter for open fracture NOSC - initial encounter for open fracture type IIIA, IIIB, or IIICD - subsequent encounter for closed fracture with routine healingE - subsequent encounter for open fracture type I or II with routine healingF - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healingG - subsequent encounter for closed fracture with delayed healingH - subsequent encounter for open fracture type I or II with delayed healingJ - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healingK - subsequent encounter for closed fracture with nonunionM - subsequent encounter for open fracture type I or II with nonunionN - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunionP - subsequent encounter for closed fracture with malunionQ - subsequent encounter for open fracture type I or II with malunionR - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunionS - sequelawww.cms.gov/NPC
ICD-10-CM Coding ExamplesAdmission to rehabilitation facility for physical and occupational therapyfollowing hospitalization for a left hip (femoral neck) fractureStep 2 continuedVerify code in Tabular:S72.00- Fracture of unspecified part of neck of femurFracture of hip NOSFracture of neck of femur NOSS72.001- Fracture of unspecified part of neck of right femurS72.002- Fracture of unspecified part of neck of left femurS72.009- Fracture of unspecified part of neck of unspecified femurCode Assignment: S72.002Dwww.cms.gov/NPC
ICD-10-CM Coding ExamplesPlacenta previa with hemorrhage, second trimesterStep 1Look up term in Alphabetic Index:Placenta, placental – see Pregnancy, complicated by (care of) (management affectedby), specified conditionPregnancy, complicated by (care of) (management affected by)placenta previa O44.1without hemorrhage O44.0-www.cms.gov/NPC
ICD-10-CM Coding ExamplesStep 2Verify code in Tabular:O44- Placenta previaO44.1- Placenta previa with hemorrhageLow implantation of placenta, NOS or with hemorrhageMarginal placenta previa, NOS or with hemorrhagePartial placenta previa, NOS or with hemorrhageTotal placenta previa, NOS or with hemorrhageO44.10 Placenta previa with hemorrhage, unspecified trimesterO44.11 Placenta previa with hemorrhage, first trimesterO44.12 Placenta previa with hemorrhage, second trimesterO44.13 Placenta previa with hemorrhage, third trimesterCode Assignment: O44.12www.cms.gov/NPC
ICD-10-CM Coding ExamplesMorbid obesity, Body Mass Index (BMI) of 46Step 1Look up term in Alphabetic Index:Obesity E66.9morbid E66.01with alveolar hypoventilation E66.2due to excess calories E66.01www.cms.gov/NPC
ICD-10-CM Coding ExamplesMorbid obesity, Body Mass Index (BMI) of 46Step 2Verify code in Tabular:E66- Overweight and obesityUse additional code to identify body mass index (BMI), if known (Z68.-)E66.0- Obesity to excess caloriesE66.01 Morbid (severe) obesity due to excess caloriesE66.09 Other obesity due to excess caloriesZ68- Body Mass Index (BMI)Z68.4- Body mass index 40 or greater, adultZ68.42 Body mass index (BMI) 45.0-49.9, adultCode Assignment: E66.01, Z68.42www.cms.gov/NPC
ICD-10-CM Coding ExamplesExamination for admission to preschoolStep 1Look up term in Alphabetic Index:Examination, medical Z00.00preschool childrenfor admission to school Z02.0www.cms.gov/NPC
ICD-10-CM Coding ExamplesExamination for admission to preschoolStep 2Verify code in Tabular:Z02- Encounter for administrative examinationZ02.0 Encounter for examination for admission to educational institutionEncounter for examination for admission to preschool (education)Encounter for examination for re-admission to school following illness ormedical treatmentCode Assignment: Z02.0www.cms.gov/NPC
Unspecified Codes Unspecified codes have acceptable, even necessary, uses Unspecified codes should be reported when they mostaccurately reflect what is known about the patient’s conditionat the time of that particular encounter It would be inappropriate to select a specific code that is notsupported by the medical record documentation or conductmedically unnecessary diagnostic testing in order to determinea more specific code Avoid excessive use of non-specific codeswww.cms.gov/NPC
Unspecified Code ExamplesFracture of left wrist, follow-up visit, fracture healing wellStep 1Look up term in Alphabetic Index:Fracture, traumaticwrist S62.10carpal – see Fracture, carpal bonewww.cms.gov/NPC
Unspecified Code ExamplesStep 2Verify code in Tabular:S62 Fracture at wrist and hand levelNote: A fracture not indicated as displaced or nondisplaced should be coded todisplacedNote: A fracture not indicated as open or closed should be coded to closedThe appropriate 7th character is to be added to each code from category S62:A Initial encounter for closed fractureB Initial encounter for open fractureD Subsequent encounter for fracture with routine healingG Subsequent encounter for fracture with delayed healingK Subsequent encounter for fracture with nonunionP Subsequent encounter for fracture with malunionS Sequelawww.cms.gov/NPC
Unspecified Code ExamplesFracture of left wrist, follow-up visit, fracture healing wellStep 2 ContinuedVerify code in Tabular:S62.10 Fracture of unspecified carpal boneFracture of wrist NOSS62.101 Fracture of unspecified carpal bone, right wristS62.102 Fracture of unspecified carpal bone, left wristS62.109 Fracture of unspecified carpal bone, unspecified wristCode Assignment: S62.102Dwww.cms.gov/NPC
Unspecified Code ExamplesPneumoniaStep 1Look up term in Alphabetic Index:Pneumonia (acute) (double) (migratory) (purulent) (septic)(unresolved) J18.9www.cms.gov/NPC
Unspecified Code ExamplesPneumoniaStep 2Verify code in Tabular:J18 Pneumonia, unspecified organismCode first associated influenza, if applicable (J09.X1, J10.0-, J11.0-)J18.9 Pneumonia, unspecified organismCode Assignment: J18.9www.cms.gov/NPC
External Causes of Morbidity No national requirement for mandatory ICD-10-CM externalcause code reporting Reporting of ICD-10-CM codes in Chapter 20, External Causes ofMorbidity, is only required for providers subject to a state-basedexternal cause code reporting mandate or payer requirement In the absence of a mandatory reporting requirement, providersare encouraged to voluntarily report external cause codeswww.cms.gov/NPC
What is The Value of Reporting External Cause of InjuryCodes? Provide valuable data for injury research and evaluation ofinjury prevention strategies External cause of injury data are used at the national, state, andlocal levels to identify high-risk populations, set priorities, andplan and evaluate injury prevention programs and policies, andare potentially useful for evaluating emergency medical services(EMS) and trauma care systemswww.cms.gov/NPC
External Cause Code ExampleInjury sustained from falling down ice-covered steps, initialencounterStep 1Look up term in the Index to External Causes:Fall, falling (accidental) W19from, off, out ofstairs, steps W10.9due to ice or snow W00.1www.cms.gov/NPC
External Cause Code ExampleInjury sustained from falling down ice-covered steps, initial encounterStep 2Verify code in Tabular:W00 Fall due to ice and snowIncludes: pedestrian on foot falling (slipping) on ice and snowThe appropriate 7th character is to be added to each code from category W00A - initial encounterD - subsequent encounterS – sequelaW00.1 Fall from stairs and steps due to ice and snowCode Assignment: W00.1xxAwww.cms.gov/NPC
External Cause Code ExampleSolo bicyclist (pedal cyclist) sustained injuries from a collisionwith a car in an intersection (initial encounter)Step 1Look up term in External Cause of Injury Index:Accident, pedal cycle – see Accident, transport, pedal cyclistAccident, transport (involving injury to) V99pedal cyclist V19.9drivercollision (with)car (traffic) V13.4nontraffic V13.0www.cms.gov/NPC
External Cause Code ExampleSolo bicyclist (pedal cyclist) sustained injuries from a collision with a car in anintersection (initial encounter)Step 2Verify code in Tabular:V13 Pedal cycle rider injured in collision with car, pick-up truck or vanThe appropriate 7th character is to be added to each code from category V13:A - initial encounterD - subsequent encounterS – sequelaV13.4xx- Pedal cycle driver injured in collision with car, pick-up truck or van in trafficaccidentCode Assignment: V13.4xxAwww.cms.gov/NPC
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ICD-10-CM Coding Examples . Fracture (traumatic) of proximal third of scaphoid bone, left wrist, initial encounter . Step 2 Verify code in Tabular: S62 Fracture at wrist and hand level . Note: A fracture not indicated as displaced or nondisplaced should be coded to displaced .
ICD-9 724.02 ICD-10 M48.06 Spinal stenosis, lumbar region ICD-9 720.2 ICD-10 M46.1 Sacroiliitis, not elsewhere classified ICD-9 724.8 ICD-10 R29.898 Other symptoms and signs involving the ** musculoskeletal system ICD-9 721.42 ICD-10 M47.16 Other spondylosis with myelopathy, lumbar region ICD-9 723.1 ICD-10 M54.2 Cervicalgia ICD
More on ICD-10. ICD-10-PCS replaces ICD-9-CM inpatient procedure coding: ICD-9-CM procedure codes 3 to 4 numeric digits ICD-10-CM codes 7 alphanumeric digits ICD-10-PCS code format substantially different from ICD -9 Unlike ICD-9, ICD-10
ICD-10 Tips from PHCS The Road to ICD-10 Flyer AMA ICD-10 Project Plan Template Educational Tools Folder Precyse University ICD-10 Physician Office Solution Brochure Precyse Catalog of ICD-10 Courses ICD-10 Precyse Apps for Physicians Resources Folder Free Resources ICD-9 to ICD-10 Crosswalk of Most Common ICD-9 .
According to CMS, GEMs are “a tool to assist with the conversion of ICD-9-CM codes to ICD-10 and the conversion of ICD-10 codes back to ICD-9-CM. The GEMs are forward and backward mappings between the ICD-9-CM and ICD-10 coding systems.” Watch out: Although you’ll see the term “cr
Chapter 2 – Introduction to ICD-10-CM and ICD-10-PCS Coding 135 Chapter 3 – ICD-10-CM and ICD-10-PCS Coding Conventions 138 Chapter 4 – Chapter-Specific Coding Guidelines: ICD-10-CM Chapters 1–10 141 Chapter 5 – Chapter-Specific Coding Guidelines: ICD-10-CM Chapters 11–21 143
Dec 14, 2010 · ICD-9. ICD-10. ICD-9. ICD-10. Inactive. Active. Combined Code Set. Core Technologies. ICD-9 and ICD-10 code values are unique. Generally, the industry is taking one of two approaches as it relates to the ICD-10 transition: Remediation: Modify/expand all systems and processes to accommodate ICD-
ICD-10 to ICD-10-CM Based on FY2017 ICD-10-CM codes Category and subcategory codes are shaded in grey and marked with an Cells shaded in pink and marked with an *indicate the preferred code when a single code maps to multiple codes (see Introduction) Reportable Neoplasms . Type of Code ICD-10 Category Chapter II (Neoplasms) ICD-10 Term . ICD .
of the previous ICD-9 coding system. The volume of ICD-10 codes as compared to ICD-9 codes is significant because in ICD-10, the code size has been expanded, code values and interpretations have been redefined and specificity has been further improved. Global ICD-10 adoption The current version of ICD is ICD-10, which was adopted by the World .
