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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!

ICD-Trainer: Burnt marshmallows at summer’s end

Be careful at your end-of-summer camp out!

Be careful at your end-of-summer camp out!

First into the Fix ‘em Up Clinic today is Jeff. He took part in a s’more eating contest at camp last night. I’ve personally never understood the appeal of burned marshmallows, but Jeff, well he was so determined to claim the s’mores title that he ate a few marshmallows that were a little too hot. As in, they were on fire. And while fire eating is fine for professionals, for a kid at camp, it’s not such a great idea.

Dr. Sunni Daze examines Jeff and documents burns to the mouth, pharynx, tongue, and lips. The burns of the mouth, pharynx, and tongue are easy. One code covers all three and it does not specify degree of the burn. Since this is Jeff’s initial visit, we would report T28.5XXA.

The lip burns require a little more information. We need to know what degree of burns Jeff suffered on his lips. Fortunately for him, Dr. Daze notes the burns are first degree, so we would report T20.12XA (burn of first degree of lip[s]).

ICD-10-CM does not include separate codes for the upper and lower lip, so T20.12XA covers one lip or both.

We also find the following note under pretty much all of the burn codes:

  • Use additional external cause code to identify the source, place and intent of the burn (X00-X19, X75-X77,X96-X98, Y92)

We definitely need an X00-X19 code, which in Jeff’s case is X10.1XXA (contact with hot food, initial encounter).

The X75-X77 codes are for intentional self-harm. Overeating burning marshmallows doesn’t quite qualify as planning to hurt yourself. Jeff just got caught up in the moment.

The X96-X98 are codes for assault. Again, not applicable in Jeff’s case.

For our place of occurrence, we’ll use Y92.833 (campsite as the place of occurrence of the external cause). Notice we do not need a seventh character for this code.

Dr. Daze is done for the day and so are we. Remember to make sure your food isn’t on fire before you eat it.Editor’s Note: This article is an excerpt from the ICD-10 Trainer Blog

Dual coding/CDI highlights holes in ICD-10 education, documentation, and program efficiencies

Have you started dual coding for ICD-9 and ICD-10? Two facilities shared their experiences during a July AHA webinar. The first task is to determine what dual coding means for your facility, said Nelly Leon-Chisen, RHIA, director of coding and classification for the AHA. Are you coding records concurrently in ICD-9 and ICD-10, or are you coding in ICD-9 and then going back and coding in ICD-10? Figure out which approach will work best at your facility.

Also, are you coding natively in ICD-9 and ICD-10 or are you using some type of crosswalk? Again, that’s up to each facility to decide. One caution about crosswalks, though. You can’t code from a crosswalk alone. That’s not their purpose. A crosswalk can get you to the correct area of the codebook, but it won’t give you the precise code in most cases. Most ICD-9 codes map to multiple ICD-10 codes because the ICD-10 codes are more specific. If every code had a one-to-one match, we wouldn’t need to move to ICD-10.


Join us to learn more about CDI’s role in dual coding on 9/10/14.

A third point to consider: Is one person coding the same record in ICD-9 and ICD-10 or is one coding it in ICD-9 and someone else coding it in ICD-10? Cindy Hutchinson, CCS, CCS‐P, corporate director of coding services for Intermountain Healthcare in Utah, shared that her coders are coding the same record in both systems. Initially, different coders were coding the record in ICD-9 and ICD-10; once the same coders started coding the records in both systems, it made them more efficient, she said.

Nine months into dual coding, most coders are back to their baseline productivity, with the exceptions of complex surgical cases and Intermountain’s children’s hospital.

Linda M. DiGregorio, RHIA, CCS, associate director clinical documentation, coding, and reimbursement for Winthrop University Hospital in New York, said her coders began dual coding with obstetrics cases in January. In February, they added concurrent dual coding of all hip and knee replacement surgeries, in addition to open reduction internal fixation cases. This month, they also began concurrently dual coding cardiac cases.

DiGregorio said coding productivity has dropped 60%.

Editor’s Note: This article originally published on the ICD-10 Trainer Blog.  Join Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA; Rebecca “Ali” Williams, RN, MSN, CCDS; and Tara L. Bell, RN, MSN, CCM, on September 10, 1 p.m., Eastern, for the webinar “Dual Coding/CDI: Practical Steps to Advance your Facility’s ICD-10-CM/PCS Readiness.”

Guest Post: Have you had a CDI check-up lately?

Kelli Estes

Kelli Estes

By Kelli Estes, RN, CCDS

A large number of hospitals across the country have some version of a CDI program in place. With ICD-10 implementation on our heels, it is recommended by AHIMA that all hospitals have a “mature” CDI program in place by October 1, 2014.

In October 2013, I attended the AHIMA pre-conference coding meeting in Atlanta. An informal polling of the audience led to some interesting revelations regarding CDI program maintenance and growth through audits. Most everyone in the room professed to having an internal and external audit process in place for coding, but only a few hands went up when asked about having a CDI-specific audit process. Additionally, recommendations were made to have outside auditors assess CDI programs currently operating under ICD-9 to leverage their stability during the transition to ICD-10.

A thorough, CDI-specific audit can illustrate how viable any CDI program will be come ICD-10, particularly considering projections of a 25% decrease in productivity as a result of ICD-10. Let’s face it!  If you have CDI problems with ICD-9, you will have those same problems with ICD-10. So don’t delay  developing policies and procedures for CDI audit processes including conducting your own internal audits and hiring an external audit team.

What should should you audit for? Good question. Here are some of the items we recommend:

  • CDI specialists’ query writing skill/compliance
  • Missed opportunities to capture MCCs/CCs as well as further severity of illness and risk of mortality
  • Query trends to identify educational opportunities for physicians
  • Productivity when reviewing patient records

Most models of CDI look similar on the surface, but when assessing the detail in the various moving parts you will find differences that could cost your organization big in the long run. You want to make sure you are working smarter, not harder. You also need to identify process improvement needs such as collaboration with other healthcare team members involved in the care of the patient  (i.e., nutrition, wound care, care management, core measures). The only way to capture this type of information best is by reviewing a random selection of CDI cases and overall processes.

Editor’s Note: Estes has spent more than a decade as a clinical documentation specialist and consultant, presently with DCBA Inc., in Atlanta. She holds the CCDS certification through ACDIS and was in the first group of participants to sit for the exam. Since joining DCBA in 2005, Kelli has assisted with project management in dozens of CDI program implementations. She is highly skilled in the overall process of CDI program start-up and enjoys guiding the decision-making required to implement and sustain longevity in any viable program. Estes has also been involved in CDI program follow-up assessments and has written several articles for DCBA’s monthly newsletter, CDI Monthly, where this article was originally published. To subscribe to CDI Monthly, click here.

For additional information on performing program audits read these related articles from ACDIS:

Eight ICD-10 diagnoses to examine for CDI opportunities at your facility

Adelaide LaRosa

Adelaide LaRosa

There are many conditions you need to have on your radar as you think about ICD-10 documentation. We already know physicians will need to do a better job at documenting laterality in ICD-10, says Adelaide La Rosa, RN, BSN, CCDS, director of HIM, CDI, and clinical data management at Catholic Health Services of Long Island in New York. La Rosa advises CDI and HIM professionals to be on the lookout for documentation of laterality in cancers, cerebral infarction, pressure ulcers, extremity atherosclerosis, arthritis, fractures, sprains, joint pain and effusion, dislocations, and tears.

In addition to laterality, La Rosa recommends working with physicians to document information specific to the following conditions:
  1. Urinary tract infections (UTI). Discuss how documentation of a UTI corresponds with how it’s coded, La Rosa said. “In coding, it’s one word that’s missed and the whole coding changes,” she said. Documentation of a UTI will result in coding for a UTI. However, documentation of a UTI with evidence of systemic infection results in coding for sepsis, and documentation of a UTI with evidence of systemic infection and organ dysfunction results in coding for severe sepsis, according to La Rosa.
  2. Arteriosclerotic heart disease (ASHD). Make sure physicians document the location of ASHD and its associated symptoms, La Rosa said. The new code set will break things down based on whether ASHD exists without angina pectoris, with unstable angina pectoris, with angina pectoris with documented spasm, with other form of angina pectoris, or with unspecified angina pectoris, La Rosa says.
  3. Myocardial infarction (MI). Documentation for MI must include whether it was an ST-elevation MI or a non-ST-elevation MI, according to La Rosa. ICD-10 codes require documentation of the coronary artery involved and the site of the MI, so physicians should start including this information in patient records now, she says.
  4. Asthma. Medication requirements and documentation of symptoms help determine the severity of asthma, according to La Rosa. In ICD-10  we will see codes for mild intermittent, mild persistent, moderate persistent, and ­severe persistent asthma, according to La Rosa. HIM and CDI professionals should meet with their organization’s chief pulmonologist to clarify these categories and determine what information needs to be in the record to capture disease severity, La Rosa says.
  5. Diabetes mellitus. Work with your physicians to ensure they are documenting the underlying conditions associated with diabetes mellitus, La Rosa says. Documentation should include complication and manifestation information so you’re not missing patient data when coding in ICD-10, she adds.
  6. Gout. Specific documentation is required when coding for gout in ICD-10. Make sure physicians document the cause, the specific site, and whether it is acute or chronic, La Rosa said. “If this is obviously documented in the charts, the coder, [or the] CDI specialist, will get to the highest level of coding based on that documentation,” she says.
  7. Dementia. Physicians should document the cause of a patient’s dementia, but also any behavioral disturbances that may reflect the severity of the illness, according to La Rosa. This added documentation is especially important for patients transferred to another facility for additional care, she says.
  8. Cerebral infarction. Ensure physician documentation captures the severity, acuity, location, and laterality of this condition as well as the affected side (dominant or nondominant) and residual effect, La Rosa said. If the precerebral artery caused the cerebral infarction, physicians must document the location or origin of the thrombosis, embolism, and occlusion or stenosis, because this information will “drive the code,” according to La Rosa.

Editor’s Note: This article was originally published in our sister website

Guest Post: ICD-10 delay provides CDI teams time to find hidden documentation solutions

kelli(new photo)

Kelli Estes

Taming the ICD-10 Extraneous Query Beast!

By Kelli Estes, RN, CCDS

Whether ICD-10-CM/PCS implementation is six or 18 months away, the code set expanding from 14,000 to 73,000 codes will create a query volume of epic proportion if we don’t bring things down to a 10,000-foot view and get some much needed perspective. It is simply not the intent of a CDI program to query providers for everything from soup to nuts considering such code volumes.

CDI specialists cannot possibly be productive if they are expected to be the gatekeeper for capturing all clinical documentation drilling down to the deepest level of ICD-10 specificity with an exponential growth in code volume. It just won’t happen in the real world.

I think we have to remember ICD-9-CM already provides “some” specificity in certain conditions that many physicians never tap into resulting in the use of unspecified codes, as things currently stand today. There will still be unspecified codes available in ICD-10. While I am certainly not suggesting we brush off the urgent need for being more specific, I do caution against getting stuck in some apocalyptic thought process that workflow will gridlock once ICD-10-CM/PCS goes live in all hospitals across the country. There will still be a learning curve that lingers after the “go live” date for ICD-10.  We prep and plan, but we have to actually “go there” before we can get a realistic grasp on all of this.

CDI Tip: Besides educating providers with issues common to their practice, we need to also take a collaborative approach and start developing smart assessment tools to be used within or as an adjunct to the EHR (electronic health records). This will help providers improve documentation specificity pro-actively by providing choices that lead to the necessary words for depicting a really accurate clinical picture useful for ICD-10 code selection.

For example, the following choices are necessary for drilling down to the most specific fracture code:

  • Traumatic, Pathologic, Stress
  • Anatomical specificity
  • Laterality:  Right, Left
  • Open, Closed
  • Displaced, Nondisplaced
  • Initial encounter, subsequent encounter, sequelae
  • Gustilo-Anderson Fracture Scale

Changes to note from ICD-9-CM to ICD-10-CM include:

  1. Fractures not indicated as displaced or non-displaced in documentation will be coded as displaced
  2. Fractures not indicated as closed or open in documentation will be coded as closed

With the delay of ICD-10-CM/PCS implementation it only makes sense for CDI teams to embrace the additional time to fine tune strategies for educating providers and develop useful tools to enhance documentation improvement. Learn ICD-10-CM/PCS now. Practice ICD-10 CDI now. That way, when everybody else is scrambling at the last minute, you’ll be ready.

Editor’s Note: Estes has spent more than a decade as a clinical documentation specialist and consultant, presently with DCBA Inc., in Atlanta. She holds the CCDS certification through ACDIS and was in the first group of participants to sit for the exam. Since joining DCBA in 2005, Kelli has assisted with project management in dozens of CDI program implementations. She is highly skilled in the overall process of CDI program start-up and enjoys guiding the decision-making required to implement and sustain longevity in any viable program. Estes has also been involved in CDI program follow-up assessments and has written several articles for DCBA’s monthly newsletter, CDI Monthly, where this article was originally published. To subscribe to CDI Monthly, click here.