Michelle A. Leppert, CPC, is a senior managing editor specializing in outpatient coding for JustCoding.com, which provides coders, coding supervisors, and health information management (HIM) directors with educational resources to test their coding knowledge, employ correct coding guidelines, and stay abreast of CMS transmittals.
In addition, she writes and edits the HCPro Inc. publications, Briefings on APCs and APCs Weekly Monitor. Email her at email@example.com.
One of the advantages to coding in ICD-10-CM is how much information is packed into a single code. You’ll find combination codes throughout the ICD-10-CM Manual. In many cases, you are coding the same information, but instead of adding a fifth character or in some cases an additional code, everything you need is in one code.
In ICD-9-CM, we have two main codes for spina bifida:
- 741.0, spina bifida with hydrocephalus
- 741.1, spina bifida without hydrocephalus
Those codes each require a fifth digit to specify the location:
- 0, Unspecified region
- 1, Cervical region
- 2, Dorsal (thoracic) region
- 3, Lumbar region
In ICD-10-CM, the location is an integral part of the code:
- Q05.0, cervical spina bifida with hydrocephalus
- Q05.1, thoracic spina bifida with hydrocephalus
- Q05.2, lumbar spina bifida with hydrocephalus
- Q05.3, sacral spina bifida with hydrocephalus
- Q05.4, unspecified spina bifida with hydrocephalus
- Q05.5, cervical spina bifida without hydrocephalus
- Q05.6, thoracic spina bifida without hydrocephalus
- Q05.7, lumbar spina bifida without hydrocephalus
- Q05.8, sacral spina bifida without hydrocephalus
- Q05.9, spina bifida, unspecified
You’re still coding the exact same information, it’s just set up differently.
One difference to note however is Arnold-Chiari syndrome, which is a malformation of the brain. In ICD-9-CM, it is including under spina bifida with hydrocephalus. In ICD-10-CM, it has its own code series: (Arnold-Chiari syndrome, type II, Q07.0-), which provides additional details about the condition.
You’ll find some differences in the information required to code cleft lip, cleft palate, or both. In ICD-9-CM, the codes for cleft lip, cleft palate, and cleft palate with cleft lip are divided into:
- Unilateral complete
- Unilateral incomplete
- Bilateral complete
- Bilateral incomplete
The ICD-10-CM codes are more specific about where the anomaly is located. For example, for a cleft palate, you will choose from these codes:
- Q35.1, cleft hard palate
- Q35.3, cleft soft palate
- Q35.5, cleft hard palate with cleft soft palate
- Q35.7, cleft uvula
- Q35.9, cleft palate, unspecified
For a cleft lip, you have these three choices:
- Q36.0, cleft lip, bilateral
- Q36.1, cleft lip, median
- Q36.9, cleft lip, unilateral
As you can probably guess, the codes for cleft palate with cleft lip provide a wealth of detail about the patient’s particular problem. Those codes include:
- Q37.0, cleft hard palate with bilateral cleft lip
- Q37.1, cleft hard palate with unilateral cleft lip
- Q37.2, cleft soft palate with bilateral cleft lip
- Q37.3, cleft soft palate with unilateral cleft lip
- Q37.4, cleft hard and soft palate with bilateral cleft lip
- Q37.5, cleft hard and soft palate with unilateral cleft lip
- Q37.8, unspecified cleft palate with bilateral cleft lip
- Q37.9, unspecified cleft palate with unilateral cleft lip
Our last congenital malformation for the day is syndactyly. In ICD-9-CM, the codes include webbing of digits and are divided into fingers and toes, and with or without fusion.
ICD-10-CM codes report the same information, but separate out webbing and fusion into different code series. The ICD-10-CM codes also include laterality.
For fused toes on the right foot, report Q70.21. For webbed toes on the right foot, you would use code Q70.31. And so on.
Actress Angelina Jolie made headlines with her New York Times editorial explaining her decision to undergo a prophylactic double mastectomy to reduce her chances of breast cancer. She also plans to have her ovaries removed.
In ICD-9-CM, we would report V50.4 (prophylactic organ removal) followed by the appropriate genetic susceptibility code (V84.01, genetic susceptibility to malignant breast cancer) and the appropriate family history codes (V16.3, family history of malignant breast neoplasm and 16.41, family history of malignant neoplasm of ovary).
In ICD-10-CM, we again list the encounter for the prophylactic removal of breast as our principal diagnosis code, followed by the appropriate codes to identify the associated risk factor (such as genetic susceptibility or family history).
For Angelina’s case, we would report:
- Z40.01, encounter for prophylactic removal of breast
- Z15.01, genetic susceptibility to malignant neoplasm of breast
- Z80.3, family history of malignant neoplasm of breast
- Z80.41, family history of malignant neoplasm of ovary
We still end up with four codes telling the same story. The codes just look different.
Now that we have our diagnoses in order, let’s consider the actual double mastectomy.
Angelina is undergoing a surgical procedure, which gives us our first character: 0. Our second character is H, for body system skin and breast.
That brings us to our third character, the root operation. According to the ICD-10-PCS guidelines, coders must select the root operation that describes the intent of the procedure, regardless of what the physician calls it in the documentation. So we need to know what the surgeon is doing.
Is the surgeon removing part of a body part (excision) or all of the body part (resection)? For a partial mastectomy, we would use excision. For a radical mastectomy, which involves removing not only the breast but also the underlying chest muscle (including pectoralis major and pectoralis minor) and lymph nodes, we would use resection.
Fortunately, surgeons rarely perform a total mastectomy now. They more commonly perform a partial mastectomy or a modified radical mastectomy. In a modified radical mastectomy, the surgeon removes the breast (including the skin, breast tissue, areola, and nipple) and most of the lymph nodes under the arm.
We don’t have Angelina’s chart to see exactly what her surgeon documented, but because she underwent a nipple delay, which is designed to save the nipple and does not talk about lymph nodes being removed, we’ll call the procedure a partial mastectomy.
That gives us our third character: B (excision).
Go to your ICD-10-PCS manual (or your online PDF) and find the table for OHB (medical and surgical, skin and breast, excision).
We have three choices for our fourth character:
- T, breast, right
- U, breast, left
- V, breast, bilateral
In Angelina’s case, it’s bilateral, so our fourth character is V.
A mastectomy is an open procedure, which means our fifth character is 0. We only have one choice for a sixth character (Z), which makes things pretty easy. Choosing a seventh character for this surgery is also easy. Our two choices are diagnostic (X) and no qualifier (Z).
We know it’s not a diagnostic procedure, so our seventh character is Z.
Put all of them together and we get: 0HBV0ZZ (excision of bilateral breast, open approach).
The ICD-10-PCS codes for 2014 are now available on the CMS website. CMS also posted the 2014 ICD-10-PCS guidelines and an ICD-10-PCS reference manual.
- 08H005Z, insertion of epiretinal visual prosthesis into right eye, open approach
- 08H105Z, insertion of epiretinal visual prosthesis into left eye, open approach
- 30280B1, transfusion of nonautologous 4-factor prothrombin complex concentrate into vein, open approach
- 30283B1, transfusion of nonautologous 4-factor prothrombin complex concentrate into vein, percutaneous approach
The update also includes three new codes added and three codes deleted, to correct body part value for temporary occlusion of abdominal aorta.
The new codes are:
- 04V00DJ , restriction of abdominal aorta with intraluminal device, temporary, open approach
- 04V03DJ, restriction of abdominal aorta with intraluminal device, temporary, percutaneous approach
- restriction of abdominal aorta with intraluminal device, temporary, percutaneous endoscopic approach
These three codes were deleted:
- 02VW0DJ, restriction of thoracic aorta with intraluminal device, temporary, open approach
- 02VW3DJ, restriction of thoracic aorta with intraluminal device, temporary, percutaneous approach
- 02VW4DJ, restriction of thoracic aorta with intraluminal device, temporary, percutaneous endoscopic approach
In addition, the section title for the Radiation Oncology section was revised to Radiation Therapy. No code titles were changed.
The American Medical Association (AMA) may not push for CMS to move directly to ICD-11 without implementing ICD-10 after all, according to a report of the AMA’s Board of Trustees. The report will be submitted to the House of Delegates during its June meeting and until approved by the delegates, it does not represent the AMA’s official position.
AMA members discussed potentially advocating for ICD-11 over ICD-10 during the AMA’s 2012 annual meeting. During that meeting, the AMA House of Delegates adopted Policy D-70.952 “Stop the Implementation of ICD-10.” The policy called for investigating the benefits of moving from ICD-9 to ICD-11.
It turns out that skipping ICD-10 may not be a good thing. The report to the board lists only three reasons to move directly to ICD-11:
- ICD-11 implementation would be costly and time-consuming regardless of whether the US implements ICD-10
- Physicians would only have to go through one transition, not two
- By waiting for ICD-11, healthcare organizations will have more time to adopt electronic medical records develop the electronic systems infrastructure for health information exchange
The AMA report lists six reasons not to wait for ICD-11 including:
- ICD-9 is outdated and limited (thanks for finally noticing)
- Healthcare will miss out on the improvements associated with ICD-10 coding, such as laterality, greater specificity, and more room to add codes
- Healthcare providers and coders will have a more difficult time learning ICD-11 without learning ICD-10 first
- Focusing solely on moving from ICD-9 to ICD-11 risks missing the opportunity to educate physicians and leaving them unprepared for the anticipated transition to ICD-10, which could result in significant cash flow disruptions
- ICD-10 should reduce payers’ requests for additional information, which eases the burden on physicians
- ICD-11 is still 20 years away from implementation (the World Health Organization is still working on the codes and ICD-11 won’t even be beta tested for another two or three years)
That does not mean that the AMA now endorses ICD-10 implementation. It doesn’t. The AMA touts its success in holding off ICD-10 implementation for more than a decade and for convincing HHS to push the date back from October 1, 2013, to October 1, 2014.
The AMA “harbors serious concerns and reservations” about the burden of ICD-10 implementation and based on current information, doesn’t not recommend moving from ICD-9 straight to ICD-11.
I think it’s great that the AMA is finally acknowledging some of the benefits of ICD-10, but I wish the AMA would actually endorse the switch. Change is never easy, but we’ve put this off long enough.
ICD-10 itself is getting a little long in the tooth. The World Health Organization released the first version of ICD-10 in 1998. Twenty-five countries already use ICD-10, although most don’t use it for reimbursement purposes like the US will.
The benefits to implementing ICD-10 outweigh the disadvantages and frankly, we can’t keep using ICD-9.
Healthcare organizations on both the provider and payer sides have already spent considerable time and money preparing for the transition. Better technology and better patient information are good things. I just wish the AMA would see it that way.
In a perfect world, inpatient facilities would receive the same payments for diseases and procedures after the switch to ICD-10-PCS. We know that won’t happen, that facilities will see some shift in MS-DRG assignment and as a result, different reimbursement.
Why will certain conditions track to different MS-DRGs? In part, code assignment to MS-DRGs will change because the coding guidelines are changing. Specificity is increasing in many cases and decreasing in a few.
ICD-10-CM also changes the meaning of some of the diagnosis descriptions by including more combination codes and is also changing the CC/MCC designations for some codes.
Don’t forget about coding errors. Coders may be incorrectly assigning an ICD-9-CM code now, which could lead to incorrect MS-DRG assignment. In ICD-10-PCS, coders may also assign an incorrect code by choosing the wrong root operation. That could also lead to a change in the MS-DRG.
Hospitals should begin looking at their top MS-DRGs and determining whether the documentation is sufficient to code in ICD-10. Then code the case in ICD-10 and see which MS-DRG it ends up in. Is it the same MS-DRG, a higher paying MS-DRG, or a lower paying one?
Then try and determine why the MS-DRG changed. Maybe you have more specific information. You could be picking up a CC or MCC you aren’t currently reporting. Are you correctly sequencing the codes?
Once you figure out what will happen with your top MS-DRGs, you’ll have a better understanding of the financial impact of ICD-10 and also have a starting point for physician education.
Do you want to work harder or work smarter? We all know electronic medical records (EMR) are great in some ways, not so great in others. Drop down menus make life easier for physicians, but can also result in physicians choosing the first version of a disease on the list. And that’s usually the most non-specific version of the disease.
Consider fracture codes. In ICD-10-CM, coders will need more detailed information in order to assign a fracture code, including:
- Specific site (which bone and where on the bone)
- Side (left or right)
- Type of fracture (open or closed, displaced or non-displaced)
- Encounter (initial, subsequent, sequela)
Why not prompt the physician to include that information? Consider adding a drop down for site of the fracture, the encounter, and the type of fracture. Make it easy for the physicians to give coders the information they need.
To assign a code for percutaneous transluminal coronary angioplasty (PTCA), coders need to know the device so add a drop down with these choices:
- Intraluminal Device, Drug-eluting
- Intraluminal Device
- Intraluminal Device, Radioactive
- No Device
Coders need additional information for pregnancy, both trimester and weeks of gestation. Add a drop down so the physician must include that information.
Avoid giving the physicians an easy out in the drop down menus. You want them to be as specific as possible, so force them to be specific.The more information coders have, the fewer queries they’ll need to make. And that saves everyone time.
Remember too that physicians may already be documenting some of this information. Coders just aren’t looking for it. So before you reinvent your EMR, make sure you know which changes will be beneficial.
Planning a big bonfire for October 1, 2014, using your ICD-9-CM Manuals? You might want to think again.
Not everyone is required to transition to ICD-10. Only HIPAA covered entities must begin using the ICD-10 code sets. Non-covered entities, such as can workers’ compensation and auto insurance carriers, still use ICD-9 if they choose.
As a result, we may be using ICD-9-CM forever. Or maybe just for a little while. Each non-covered entity will make its own decision on when or if to switch to ICD-10-CM. I wouldn’t be surprised if many of them wait a year (I know, not what you wanted to hear). I think eventually they will start using ICD-10-CM, hopefully before the transition to ICD-11, whenever that comes around.
In the meantime, talk with any workers’ compensation or auto insurance carriers you do business with and find out whether those plans will be moving to ICD-10. If not, you need to determine whether to keep a dual-coding system in place or not accept patients from those carriers.
I love the ICD-10-CM external causes codes. I’m weird, I know, but I’m also a writer and I love telling good stories. When I first started coding, my boot camp instructor Peggy Blue, MPH, CPC, CCS-P, said coders tell the patient’s story using codes. ICD-10-CM allows coders to tell better stories about patients and detail what happened to them and how.
Some of the external causes codes are pretty funny and you’ll probably never report them. If you work in an urban setting, you’ll probably never report W61.4- (contact with turkey) unless someone is trying to kill his or her own Thanksgiving dinner.
If you don’t live near water, you likely won’t need V94.1 (bather struck by watercraft) or W56.2- (contact with orca). Well, you might need the orca, dolphin (W56.0-), and sea lion codes (W56.1-) if you work near Sea World. But let’s hope you don’t have cause to use them.
The ICD-10-CM external causes codes include codes for encounters with a variety of animals including, but not limited to:
- Nonvenomous reptiles
The only thing missing seems to be an attacking partridge in a pear tree. Oh wait, that’s contact with other birds (W61.9-).
Those codes seem to get the most attention. In fact, Rep. Ted Poe, R-Texas, called out the turkey codes as a way to bolster his argument that the government should stop ICD-10 implementation. He’s even introduced a bill—H.R. 1701: Cutting Costly Codes Act of 2013—to that effect. Take two minutes and read the bill. Trust me, you’ll only need two minutes. It’s not very long.
Poe also mocked the codes for walking into a lamp post (W22.02-). I’ve made fun of that code too, mainly because I can’t image anyone actually admitting he or she walked into a lamp post. At least not sober.
Here’s something he didn’t consider though. How often does an abuse victim claim to have walked into a door or fallen down the stairs? So if a physician or nurse sees a patient who is always walking into things, the clinician might suspect abuse. Or that the patient has a problem with vision. That can be valuable information when forming a diagnosis and also to potentially support a criminal charge against an abuser. Or a bully.
We know ICD-10 will change the way we code. We know it’s going to cost a lot of money and decrease productivity. But we also know (at least I hope we do) that ICD-10 will give us better data and a better clinical picture of the patient’s condition. That alone is a good reason to move forward with implementation.
Here are four other good reasons:
- ICD-9 is out of space
- We’ve already spent literally millions preparing for the change
- We can’t talk to the rest of the world about healthcare, diseases, and mortality rates
- We’re 15 years behind Canada
On a more serious note, we all hope we never have to use any of the codes under Y36.5 (war operations involving nuclear weapons).
- 354.0, carpal tunnel
- 715.04, osteoarthrosis, generalized, hand
- 719.43, pain in forearm
- 728.6, contracture of palmer fascia
How would we code Penny’s diagnoses in ICD-10-CM? Let’s start with her carpal tunnel. If we look up syndrome, carpal tunnel in the ICD-10-CM Alphabetic Index, it directs us to G56.0-. The dash tells us the code needs additional characters, so we absolutely must look in the Tabular Index.
You should never code from the Alphabetic Index alone, anyway. That’s one of the many things that won’t change after the transition to ICD-10-CM.
G56.0 gives us three choices:
- G56.00, carpal tunnel syndrome, unspecified upper limb
- G56.01, carpal tunnel syndrome, right upper limb
- G56.02, carpal tunnel syndrome, left upper limb
We need to review Dr. Morang’s documentation to determine the laterality so we can assign the most detailed code. ICD-10-CM does include an unspecified option, but we want to avoid reporting unspecified if at all possible. That means if the physician didn’t document laterality, query!
Moving on to the osteoarthrosis, we find a note in the Alphabetic Index that tells us to see also Osteoarthritis.
Generalized osteoarthrosis of the hand doesn’t really give us much to go on to find the correct ICD-10-CM code. We need more information.
Does Penny suffer from bony bumps on the finger joint closest to the fingernail (Heberden’s nodes), which would lead us to ICD-10-CM code M15.1 (Heberden’s nodes [with arthropathy]).
Or does she have bony bumps on the middle joint of the finger (Bouchard’s nodes)? In that case, we would report M15.2 (Bouchard’s nodes [with arthropathy]).
Does Dr. Morang mean Penny suffers from osteoarthritis of the hand joint or the bones in her hand in general?
We also need to know if the osteoarthrosis is primary, secondary, or post-traumatic.
For the pain in Penny’s forearm, we again need laterality. Our choices are:
- M79.631, pain in right forearm
- M79.632, pain in left forearm
- M79.639, pain in unspecified forearm
We also need to know if the pain is a separate problem or if it is a symptom of one of Penny’s other diagnoses. If it’s a symptom, we don’t code it separately (regardless of what Dr. Morang says).
Finally, we need to code the contracture of palmer fascia. You may be more familiar with the term Dupuytren’s contracture. Both lead us to the same ICD-10-CM code—M72.0 (palmar fascial fibromatosis [Dupuytren]).
Interestingly, M72.0 does not require laterality. We only have one code, which could be a problem if Penny develops the same condition in both hands.
So we’ll wish Penny well, but avoid shaking her hand.
You know what keeps you up at night thinking about the ICD-10 transition. Have you ever wondered what causes CMS officials to lose sleep?
For Denise Buenning, MsM, director of CMS’s administrative simplification group in the office of E-health standards and service, it’s the concern that small practices will not be ready to move to ICD-10. Buenning shared her concern with the audience at the AHIMA ICD-10-CM/PCS and CAC Summit in Baltimore April 24.
Large hospitals and systems have the resources and the awareness to be ready to go live October 1, 2014. However, small practices, those with one or two physicians, may not even be aware of ICD-10 because it’s not a priority for them. They are worried about seeing patients and keeping the doors open.
If they don’t transition to ICD-10, they won’t get paid. CMS is taking a number of steps, including “putting boots on the ground” in rural areas, to help small providers navigate the change, Buenning said.
CMS is considering a number of risk mitigation plans if small providers are not ready October 1, 2014, Buenning said.
“We are looking at everything except moving the implementation date,” as part of the risk mitigation, she added.