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Reveal the fact(s) behind the funny

Don't delay!

Don’t delay!

If I hear one more person poke fun at ICD-10-CM code V97.33XD (sucked into a jet engine, subsequent encounter), I am going to develop a very strong case of R45.850. (That’s homicidal ideation in case you don’t have your code book handy.)

First of all, most of the people making fun of this code don’t actually understand what the code is conveying. See the New York Times, an Alabama physicians group, Healthcare Dive, The Boston Globe, and on and on and on.

The subsequent encounter part is not saying the person was sucked into a jet engine twice (what are the odds of that?). It’s telling us that the person is being seen for a subsequent encounter for injuries suffered when he or she was sucked into the jet engine. (And you can indeed survive being sucked into a jet engine as long as you are not on that television show Lost.)

The seventh character is one of the main new concepts in ICD-10-CM. Maybe we need to do a better job of explaining what it means.

In most cases the seventh character indicates the episode of care. If the patient is receiving active treatment, you use seventh character A in most cases.

If the patient is being seen for routine follow up, the seventh character becomes D, again in most cases.

When the patient develops a complication or a condition that arises as a direct result of a condition, that’s a sequela reported with seventh character S (always).

Fracture codes have some additional seventh characters for nonunions, malunions, delayed healing, and open fractures. Most injury codes only give you three choices: A, D, and S.

Do the physicians at your organization know what the seventh character actually means? If not, here’s a perfect example you can use to explain it. V97.33XD doesn’t mean sucked into a jet engine twice. It means the patient is actually recovering from injuries sustained by his or her sole encounter with a jet engine.


New Guidelines include information on sequelae, sepsis, fracture coding

We’re still living under a code freeze as we (eagerly) await ICD-10 implementation. However, the four Cooperating Parties are still tweaking the ICD-10-CM Official Guidelines for Coding and Reporting. Both the Centers for Disease Control and Prevention and CMS posted the new guidelines on their websites last week. You can also download PDFs of the codes and indexes as well.


CDC released new ICD-10 Guidelines

The Guidelines don’t contain major changes, but CDI and coding professionals should download and read through them. New for 2015 are examples of sequelae, information about sepsis and severe sepsis, and additional information on fracture coding.

The specific examples of sequelae include:

  • Scar formation resulting from a burn
  • Deviated septum due to a nasal fracture
  • Infertility due to tubal occlusion from old tuberculosis

The updated the Guidelines for sepsis, focused on postprocedural infection and postprocedural septic shock. When the patient develops a postprocedural infection and severe sepsis, first report the code for the precipitating complication, such as code T81.4 (infection following a procedure). You should also report R65.20 (severe sepsis without septic shock) and a code for the systemic infection. If the postprocedural infection leads to septic shock, you still code the precipitating complication first, but now report code T81.12- (postprocedural septic shock) and a code for the systemic infection.

ICD-10-CM now includes additional information on the seventh character for pathologic fractures. The seventh character denotes the episode of care. Use seventh character A when the patient is undergoing active treatment, which now includes evaluation and continuing treatment by the same or a different physician.

The Guidelines further state:

While the patient may be seen by a new or different provider over the course of treatment for a pathological fracture, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time.

You’ll find the same information under the Guidelines for Chapter 19, Injury, Poisoning, and Certain Other Consequences of External Causes. You’ll also see some additional information on complications:

  • For complication codes, active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier precipitating problem.
  • The guidelines further clarify that seventh character D is used when the patient has an x-ray to check the healing status of a fracture.
  • When it comes to external cause codes, the guidelines now specify that the seventh character for external cause should be the same as the one for the code assigned for the associated injury or condition for the encounter.

You probably know that you only assign a place of occurrence code once. Well, most of the time. ICD-10-CM now specifics that when the patient suffers a new injury during hospitalization (which should be rare), you can assign an additional place of occurrence code.

Editor’s Note: This article was originally published on the ICD-10 Trainer Blog.

One year from implementation…again

October 2015 calendar

Another year to go…

I don’t know about you, but I’m starting to feel a little like Chicken Little, yelling, “ICD-10 is coming!” instead of “The sky is falling!” And we’re all probably being met with the same polite (or not so polite) skepticism from our colleagues each time the ICD-10 implementation date changes.

Never fear, ICD-10 will be here no matter how much fuss the AMA and Congress put up. Why? Because ICD-9-CM isn’t getting it done anymore. ICD-9-CM is vague, out of room, and out of date.

Think about this: The National Committee on Vital and Health Statistics actually sent a letter to the Secretary of Health and Human Services recommending the U.S. move to ICD-10 more than 10 years ago.

How do we make sure we actually implement ICD-10 next year? Talk about the specific benefits of ICD-10 as they relate to your audience. Talk to brain surgeons about the detailed ICD-10-CM codes for cerebral infarctions such as due to:

  • Thrombosis of precerebral arteries
  • Embolism of precerebral arteries
  • Unspecified occlusion or stenosis of precerebral arteries
  • Thrombosis of cerebral arteries
  • Embolism of cerebral arteries
  • Unspecified occlusion or stenosis of cerebral arteries

Think how much easier it will be, Doctor, to follow your patient’s progress and track how well different treatment methods work with all of these additional details (ICD-10-CM also includes more detailed codes for sequela from a cerebral infarction). Image the research possibilities. Consider the medical and treatment advances you can make. [more]

Searching for agreement with ICD-10 code assignment

Don't let physician education become a tug of war at your facility.

ICD-10 reconciliation should be a learning process. Start now.

The ICD-10 transition has been nothing if not contentious. We’ve had delays mandated by both CMS and Congress, as well as ongoing attempts by the AMA to kill ICD-10 altogether.

Another discordant note is a lack of coder agreement. Not on the merits of ICD-10, but on which codes to assign.

Both 3M’s Donna Smith, RHIA, and AHIMA’s Angie Comfort, RHIA, CDIP, CCS, say determining the correct code isn’t a sure thing. Coders aren’t always ending up at the same code. Why?

Well, first of all, the system isn’t live so no one is really coding in it, so there is still some guess work involved.

Second, physician documentation is not where we need it to be even for ICD-9.

Third, not everyone is finding the same information in the record. In many cases physicians already document laterality, Smith says; it’s just that coders might not know where to look for it.

Fourth, we still don’t have a ton of guidance for the grey areas. We have 30 years’ worth of Coding Clinic advice for ICD-9. We have a few issues for ICD-10.

Many organizations are doing some type of dual or double coding but how many actually check to make sure coders come up with the correct answer? That’s  another problem: How do you decide who got the correct answer?

You need a plan, Smith says. Part of which should include identifying the top diagnoses and procedures at your organization. Pull actual cases that include those conditions or procedures and have all of your coders code the record.

Once you’ve done that, compare the results, Comfort says. Did you all come up with the same answer? Probably not.

Agreement rates are pretty low right now, according to Smith. So you came up with one code and your coworker came up with a different one. Maybe a third coworker came up with something completely different. Now what?

Sit down and talk about it, both Comfort and Smith say. No one knows everything about ICD-10 yet (no one knows everything about ICD-9 either and it’s been around way longer). Try to figure out why you came up with different codes. Did someone miss a piece of information in the documentation? Did someone make an assumption based on his or her knowledge of the physician’s habits? Is the physician’s documentation so vague that everyone was just guessing?

If you can’t come to an agreement among yourselves, ask Coding Clinic. Send the de-identified record to AHA and ask them how to code it. Coding Clinic loves real-life examples, Smith says. So send them in. The more actual documentation they can look at, the better they can answer questions for everyone.

Editor’s note: This article is an excerpt from the ICD-10 Trainer Blog. Join ACDIS/HCPro tomorrow, Wednesday Sept. 10 for Dual Coding/CDI: Practical Steps to Advance your Facility’s ICD-10-CM/PCS Readiness.

Get focused about ICD-10 CDI targets

Keep on going!

Keep on going!

You’ve heard it before but it bears repeating. ICD-10-CM will not eliminate problem areas for documentation, says James Fee, MD, CCS, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, associate director of Huff DRG Review Services in Eads, Tennessee. If a condition is a documentation problem area in ICD-9-CM, it will likely continue to be a problem in ICD-10-CM.

ICD-10-CM requires more specificity than ICD-9-CM for many diagnoses, so queries will likely increase. Coders and CDI specialists can query for numerous things in ICD-10-CM, but they should focus only on the information that will impact payment, performance reporting, or profiling first.
Before sending a query, however, make sure the information isn’t somewhere else in the medical record. For example, a physician documents a left arm fracture. Instead of querying the physician for more detailed information–type of fracture, displaced or non-displaced, open or closed, exact location–check the radiology report. If the radiologist documented a torus fracture of the upper end of the right radius, coders can use that information to assign the correct ICD-9-CM or ICD-10-CM code, says Kristi Stanton, RHIT, CCS, CPC, CIRCC, AHIMA-approved ICD-10-CM/PCS trainer and AHIMA ICD-10 ambassador; a senior consultant with the Haugen Group in Denver.
The AHA’s Coding Clinic for ICD-10-CM/PCS addressed this in the First Quarter 2013 issue. As long as the physician documents that the patient has a fracture, coders can pull details such as laterality and specific parts of the bone from the radiologist’s report, Stanton says.
ICD-10-PCS will present some significant problems that could result in queries, Fee says. Each ICD-10-PCS code must have seven characters and each character represents a specific piece of information. Coders need each piece of information in order to build the correct ICD-10-PCS code.
However, physicians currently don’t report body parts and devices in a way that can be linked to ICD-10 PCS, Fee says.
“Look at your top procedures and educate the physicians about what they need to know and document,” Fee says. Make the education concrete and concise. If they are already documenting an element, don’t spend time discussing it. Mention it, tell them they are already documenting it, and move on.
Spinal surgeries could be particularly problematic, because the devices in ICD-10-PCS don’t match up with the physician definitions of devices, Fee says.
Some queries will actually go away in ICD-10, Fee says. Coders will no longer need to query for excisional debridement. The root operation in ICD-10-PCS will be excision. In addition, coders won’t need to query for benign or malignant hypertension. ICD-10-CM includes only one code for hypertension-I10.
Editor’s Note: This article is an excerpt from the July issue of Briefings on Coding Compliance Strategies.

ICD-10 for CDI Boot Camp offered in Arizona Sept. 22

Cheryl Ericson CDI Boot Camp instructor heads to Arizona.

Cheryl Ericson CDI Boot Camp instructor heads to Arizona.

The ICD-10 for CDI Boot Camp provides experienced CDI specialists with in-depth education on new and changing ICD-10-CM documentation requirements. Our next two-and-a-half day class takes place in Avondale (Phoenix), Arizona, September 22. The course includes in-depth discussion of the documentation changes required by the new code set, highlighting areas of query concern and delving into the strategies that can improve documentation today without negatively affecting providers.

Changes in the ICD-10 Official Guidelines for Coding and Reporting affect diagnosis sequencing via combination codes and includes and excludes notes. CDI professionals need to understand how effective documentation can help ameliorate such difficulties for the coders and be able to protect their facility’s coding and reimbursement from adverse effects. To that end, this class provides insight into some of the potential obstacles facing your CDI program to help organizations improve documentation habits now.

Learn more about the ICD-10 for CDI Boot Camp and ACDIS’ suite of additional Boot Camp offerings by contacting Brooke Drozdowicz at

Hope to see you there!