Don’t blame the AMA for the most recent ICD-10 delay, says Steven Stack, MD, immediate past chair of the AMA Board of Trustees. Stack gave the keynote address at the AHIMA ICD-10 and CAC Summit in Washington today.
The AMA wants to kill ICD-10, Stack says, but also did not want Congress to pass another patch to the Sustainable Growth Rate. So the AMA actually pushed for Congress to kill the bill.
In some ways, ICD-10 was in the wrong place at the wrong time. Physicians—and the rest of the healthcare industry—have been dealing with so many other mandates that either don’t work as intended or don’t work at all. Stack called EHRs “not ready for prime time” and says Meaningful Use has been overbuilt and is irrational in many ways.
“We’re all using tools that aren’t quite as good as they should be,” Stack says. Physicians are frustrated by all of the mandates that they’ve been faced with in recent years.
Stack, a practicing ED physician, acknowledges the increased specificity in ICD-10 could provide value, but doesn’t really matter much to the physician at the time he or she is seeing the patient. He used the example of an elderly patient seen in the ED for a hip fracture. ICD-10-CM includes multiple codes that include specific details about the fracture.
“I know there’s value to that information, but at that point, I don’t really care,” Stack says. “I know the bone is broken, I know it needs surgical treatment, and the patient can’t go home. That’s all I need to know.”
Based on Stack’s comments, it seems many of the physician frustrations with ICD-10 center on EHRs. “We’re clicking and checking through stuff and not really telling the story we want to tell,” Stack says.
During the question and answer portion of Stack’s presentation, an audience member pointed out that documentation drives coding. She asked how the AMA plans to do great things with diabetes treatment and diagnosis if physicians don’t document the patient’s condition well.
Stack never quite answered the question. “Physicians have an obligation to completely and accurately document,” Stack says. “That doesn’t mean we don’t fail to achieve that obligation.”
He added that physicians don’t always document details because they don’t affect clinical judgment.
The AHIMA ICD-10 and CAC Summit continues through April 23.
Coding for pressure ulcers in ICD-10-CM requires precise documentation of the ulcer’s location, which really shouldn’t surprise anyone. ICD-10-CM includes increased specificity for almost every condition.
For pressure ulcers, coders need to know laterality for the limbs (e.g., right lower leg, left elbow). For ulcers on the back, the physician should document where on the back the ulcer is (i.e., upper, middle, lower, or presacral).
The physician should also document the stage of the ulcer:
- Stage I: Intact skin with non-blanchable redness of a localized area, usually over a bony prominence.
- Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.
- Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.
- Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.
- Unstageable: Full thickness tissue loss, in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
If the ulcer can be staged after treatment, the physician should revise the staging.
When you look up ulcer, pressure, in the ICD-10-CM Alphabetic Index, you’ll find the codes listed two different ways:
- By site
- By stage
If you look under ulcer, pressure, stage 1, you see a list of all of the possible anatomic sites for a stage 1 pressure ulcer. ICD-10-CM also helpfully includes the description of the stage.
Another helpful thing in ICD-10-CM: the guidelines tell us we can use documentation from other clinicians to stage the ulcer. So the nurse can document the ulcer is stage 2 and we can code from that documentation. We can also code the ulcer as stage 2 if the nurse documents “ulcer with partial thickness skin loss involving the dermis.” We can use either a stage number or the description of the ulcer.
If a clinician cannot stage an ulcer at a given time because the bottom cannot be visualized, we can report it as unstageable. For example, if the patient has a pressure ulcer of the left elbow and our provider documents he or she can’t determine the stage, we would report L89.020 (pressure ulcer of left elbow, unstageable).
However, our awesome wound care nurse debrides the ulcer and determines it is a stage 3 pressure ulcer. Going forward we would report L89.023 (pressure ulcer of left elbow, stage 3).
Unstageable and unspecified are not the same, however. If the clinician simply fails to document a stage, we would report L89.029 (pressure ulcer of left elbow, unspecified stage).
Here comes Peter Cottontail, hopping down the bunny trail—and right into a gopher hole. Stupid rodents.
After a thorough exam and some x-rays, Dr. Long diagnoses Peter with a broken right foot. That’s a big foot on that bunny, Dr. Long. Can you be a little more specific?
Actually, we need Dr. Long to be a lot more specific. If we look up Fracture, foot in the ICD-10-CM Alphabetic Index, we find the following choices:
- astragalus—see Fracture, tarsal, talus
- calcaneus—see Fracture, tarsal, calcaneus
- cuboid—see Fracture, tarsal, cuboid
- cuneiform—see Fracture, tarsal, cuneiform
- metatarsal—see Fracture, metatarsal
- navicular—see Fracture, tarsal, navicular
- talus—see Fracture, tarsal, talus
- tarsal—see Fracture, tarsal
- toe—see Fracture, toe
So before we can even get to any code, we need to know which bone Peter broke. After consulting the x-rays, Dr. Long documents fractures of the cuboid, lateral cuneiform, and medial cuneiform.
For these injuries, we need three different ICD-10-CM codes—one for each bone. We also need to know whether the fractures are displaced or non-displaced and open or closed.
We do have some defaults, though, for coding fractures. If the physician does not document displaced or nondisplaced, code it as displaced. If the physician does not document whether the fracture is open or closed, code it as closed.
We can use those defaults to code Peter’s fractures as:
- S92.211A, displaced fracture of cuboid bone of right foot, initial encounter
- S92.221A, displaced fracture of lateral cuneiform of right foot, initial encounter
- S92.231A, displaced fracture of intermediate cuneiform of right foot, initial encounter
Dr. Long also notices that Peter suffered a dislocated right ankle. That was some hole he hopped into. For an ankle dislocation, we need to know whether the injury is a dislocation or subluxation, laterality, and encounter.
We know all of that information—dislocation, right ankle, initial encounter. That gives us ICD-10-CM code S93.04XA, dislocation of right ankle joint.
Notice that we do need a placeholder X so our seventh character ends up in the seventh spot.
Dr. Long also documented a sprained right ankle. In order to code the sprain, we need to know which specific ligament is involved.
In case you are not up on your ankle anatomy, we could be coding for the:
- Calcaneofibular ligament
- Deltoid ligament
- Tibiofibular ligament
- Internal collateral ligament
- Talofibular ligament
The internal collateral and talofibular ligaments are grouped into one code for other ligaments.
Dr. Long thankfully documented that Peter sprained the anterior tibiofibular and calcaneofibular ligaments. That leads us to codes:
- S93.431A, sprain of tibiofibular ligament of right ankle, initial encounter
- S93.411A, sprain of calcaneofibular ligament of right ankle, initial encounter
Dr. Long puts a cast on Peter’s foot, gives him some crutches, and tells him to avoid hopping on that foot for 6-8 weeks.
Now it’s time for us to hop on out of the clinic to enjoy a long weekend!
A patient undergoes a hysterectomy and experiences post-procedural bleeding. The surgeon cauterizes the bleed and evacuates a blood clot.
Control (stopping, or attempting to stop, postprocedural bleeding) in ICD-10-PCS represents a very limited set of procedures. You will use root operation Control when the only objective of the procedure is to stop hemorrhaging after a procedure.
Procedures that fall under Control include:
- Irrigating or evacuating a hematoma at the operative site
- Ligation of arterial bleeders
- Cautery with blood clot evacuation
- Drainage at previous operative site to stop bleeding
The site of the bleeding is coded as an anatomical region and not to a specific body part. For our patient with the post-hysterectomy bleed, we would report 0W3R8ZZ (hysteroscopy with cautery of post-hysterectomy oozing and evacuation of clot).
Other Control procedures include:
- 0X3F0ZZ, open exploration and ligation of post-op arterial bleeder, left forearm
- 0W3H0ZZ, control of post-operative retroperitoneal bleeding via laparotomy
- 0W3C0ZZ, reopening of thoracotomy site with drainage and control of post-op hemopericardium
- 0Y3F4ZZ, arthroscopy with drainage of hemarthrosis at previous operative site, right knee
What happens when the physician needs to perform a more involved procedure to stop the bleeding? For example, a physician needs to resect the spleen in order to control post-procedural bleeding. Do you report a Control procedure, a Resection procedure, or both?
According to ICD-10-PCS guideline B3.7:
If an attempt to stop post-procedural bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.
So for our patient who lost her spleen, we would report 07TP0ZZ (resection of spleen, open approach) or 07TP4ZZ (resection of spleen, percutaneous endoscopic approach).
Don’t look now, but mumps are making a comeback. How do we code mumps in ICD-10-CM?
In ICD-10-CM, we can assign one of the following codes for a patient with mumps:
- B26.1, mumps orchitis
- B26.1, mumps meningitis
- B26.2, mumps encephalitis
- B26.3, mumps pancreatitis
- B26.8, mumps with other complications
- B26.9, mumps without complication
One difference you’ll find is an increase in the named complications of mumps. In ICD-9-CM, we have codes for mumps hepatitis, mumps polyneuropathy, and other.
ICD-10-CM specifies these complications:
- B26.81, mumps hepatitis
- B26.82, mumps myocarditis
- B26.83, mumps nephritis
- B26.84, mumps polyneuropathy
- B26.85, mumps arthritis
- B26.89, other mumps complications
Well, that’s not so bad.
What about whooping cough (also known as pertussis), another reappearing disease?
In ICD-9-CM and ICD-10-CM, we see separate codes for whooping cough due to Bordetella, but ICD-10-CM specifies the type of Bordetella:
- A37.0, whooping cough due to Bordetella pertussis
- A37.1, whooping cough due to Bordetella parapertussis
- A37.8, whooping cough due to other Bordetella species
- A37.9, whooping cough, unspecified species
Each of those categories includes two subcategory codes to identify whether the patient has pneumonia as well. In ICD-9-CM, we needed a second code to identify the pneumonia.
Don’t worry about getting confused on this change. An Excludes1 note (not coded here) under ICD-10-CM category J17 (pneumonia in diseases classified elsewhere) tells us not to use a code from A37 and one from J17 together.
Sometimes a physician just needs to take a look around a body part and see what’s what. If the physician’s sole objective is to examine a body part, either visually or manually, report the procedure using root operation Inspection (third character J).
If the physician discontinues a procedure before performing any other root operation, you would also report the procedure using root operation Inspection.
Examples of Inspection include:
- 0WJ90ZZ, thoracotomy with exploration of right pleural cavity
- 0CJS8ZZ, diagnostic laryngoscopy:
- 0SJD0ZZ, exploratory arthrotomy of left knee:
- 0UJD8ZZ, colposcopy with diagnostic hysteroscopy:
- 0DJD7ZZ, digital rectal exam
One other thing to keep in mind: if the physician begins a procedure laparoscopically and must convert it to an open procedure, report the laparoscopic procedure is reported as an inspection.
For example, the surgeon begins a cholecystectomy using a laparoscopic approach, but must complete it using an open approach. Report an open cholecystectomy (0FT40ZZ) and a percutaneous endoscopic inspection of the gall bladder (0FJ44ZZ).
If the physician inspects the body part(s) to achieve the objective of a procedure, do not code the inspection separately.
If the physician inspects multiple non-tubular body parts in a region, report the body part that specifies the entire area inspected.
If you code for pregnant patients and newborns, you may occasionally wonder which record to code a condition on. Is it something you code for the mother or for her offspring?
- Chapter 15, Pregnancy, Childbirth and the Puerperium (O00-O9A). These codes are only used on the mother’s record.
- Chapter 16, Certain Conditions Originating in the Perinatal Period (P00-P96). These codes are only reported for the newborn. These codes include conditions that have their origin in the fetal or perinatal period (before birth through the first 28 days after birth) even if morbidity occurs later.
Make sure you code all clinically significant conditions noted on a routine newborn examination. A condition is clinically significant if it requires any of the following:
- Clinical evaluation
- Therapeutic treatment
- Diagnostic procedures
- Extended length of hospital stay
- Increased nursing care and/or monitoring
- Has implications for future health care needs
What types of problems can newborns have? Well, the baby may arrive too early. We would use codes from category P07.3- to report 28 completed weeks or more but less than 37 completed weeks (196 completed days but less than 259 completed days) of gestation.
We have nine different choices to specify exactly how early our bundle of joy arrived, plus an unspecified code. If the newborn arrives at 31 weeks, four days, we would report P07.34.
Maybe our baby is underweight for gestational age. ICD-10-CM includes codes for:
- P07.0-, extremely low birth weight newborn
- P07.1-, other low birth weight newborn
The codes in these categories specify weight ranges. So if the newborn weighs 850 grams at birth, we would report P07.03 (extremely low birth weight newborn, 750-999 grams).
So we have a preemie with a low birth weight. Which condition do we sequence as the principal diagnosis for the birth encounter? It’s a trick question because the answer is neither. When coding the birth episode in a newborn record, we will always assign a code from category Z38.- (liveborn infant) as the principal diagnosis. Birth takes precedence.
Z38.- still gives us plenty of options and we need some specific details to choose the correct code. First, how many babies? Where did the baby arrive? How was the baby delivered? You could conceivably have a different place and method if mom is delivering more than one baby.
For example, if mom gives birth to twins in the hospital, she could deliver one vaginally (Z38.30) and one by cesarean (Z38.31).
Alternately, she could have one on the way to the hospital (Z38.4, twin liveborn infant, born outside hospital) and one vaginally in the hospital. Don’t assume it will be the same for each infant in a multiple birth.
Chapter 16 codes may be used throughout the life of the patient if the condition is still present.
Sometimes a surgeon must take drastic action and amputate a patient’s upper or lower extremity. For these cases, we would use ICD-10-PCS root operation Detachment (third character 6).
ICD-10-PCS defines Detachment as cutting off all or part of the upper or lower extremities. You will need to pay close attention to the details of the operative note to determine which specific body part the physician is detaching.
The body part value is the site of the detachment. You may need a qualifier to further specify the level where the extremity was detached.
For example, the physician amputates the patient’s right upper arm. When we look at the table (0X6), we first see body part choices for:
- Right upper arm
- Left upper arm
- Right lower arm
- Left lower arm
The approach is always open and your only device choice is no device. When we get to the qualifier, we have three options:
- 1, high
- 2, mid
- 3, low
The physician needs to document where he or she performed the detachment. If that information is not in the operative report, query. We do not have unspecified or default codes in ICD-10-PCS. The codes for detachment of the leg include the same choices.
CMS’ ICD-10-PCS Reference Manual defines the qualifiers as:
- High: amputation at the proximal portion of the shaft of the humerus or femur
- Mid: amputation at the middle portion of the shaft of the humerus or femur
- Low: amputation at the distal portion of the shaft of the humerus or femur
We can choose from even more possibilities when it comes to a detachment of the hand. In addition to laterality for the body part (right hand or left hand), we also need to know whether the physician removed the complete hand (qualifier 0) or only part. If only part, which part? Our choices include:
- 4, complete 1st ray
- 5, complete 2nd ray
- 6, complete 3rd ray
- 7, complete 4th ray
- 8, complete 5th ray
- 9, partial 1st ray
- B, partial 2nd ray
- C, partial 3rd ray
- D, partial 4th ray
- F, partial 5th ray
You’ll see the same options for detachment of the foot (OY6).
Perhaps the surgeon only removes a digit (finger or toe). We need to know the specific digit, such as right thumb or left little toe. We also see these four qualifier choices:
- 0, complete
- 1, high
- 2, mid
- 3, low
Be sure the physicians are documenting the detail you need to code for a detachment. You should also brush up on your anatomy of the hand and foot (and make sure you know what a ray is) if you see these procedures in your facility.
Map (third character K) is a very narrowly defined ICD-10-PCS root operation. By definition, Map procedures are used to locate the route of passage of electrical impulses and/or locate functional areas in a body part.
- Central nervous system (00K)
- Heart and great vessels (02K)
If you look at those tables, you’ll see very few options. The table for the central nervous system offers these body parts:
- 0, brain
- 7, cerebral hemisphere
- 8, basal ganglia
- 9, thalamus
- A, hypothalamus
- B, pons
- C, cerebellum
- D, medulla oblongata
For the heart and great vessels, we get only one body part choice: conduction mechanism.
Examples of Map procedures include:
- 00K83ZZ, percutaneous mapping of basal ganglia
- 00K00ZZ, intraoperative whole brain mapping via craniotomy
- 00K74ZZ, mapping of left cerebral hemisphere, percutaneous endoscopic
- 02K80ZZ, intraoperative cardiac mapping during open heart surgery
The codes for complications of pregnancy, childbirth, and the puerperium appear in Chapter 11 in ICD-9-CM. They move to Chapter 15 in ICD-10-CM. But you will find some more significant changes than just where the codes are located.
In ICD-9-CM, you often need a fifth character to denote whether the mother gave birth during the encounter. For example, if a patient is diagnosed with transient hypertension in pregnancy, you would report 642.3x. The fifth digit denotes:
- 0, unspecified as to episode of care or not applicable
- 1, delivered, with or without mention of antepartum condition
- 2, delivered, with mention of postpartum complication
- 3, antepartum condition or complication
- 4, postpartum condition or complication
In ICD-10-CM, the codes specify the trimester of the pregnancy in which the condition occurred. For example, if a patient is diagnosed with antepartum transient hypertension (ICD-9-CM code 642.33), you have four choices in ICD-10-CM:
- O13.1, gestational [pregnancy-induced] hypertension without significant proteinuria, first trimester
- O13.2, gestational [pregnancy-induced] hypertension without significant proteinuria, second trimester
- O13.3, gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester
- O13.9, gestational [pregnancy-induced] hypertension without significant proteinuria, unspecified trimester
Note that the first character is a capital O not a zero. All ICD-10-CM codes start with a letter. However, you may see a zero or two later in some codes.
Coding for multiple fetuses will also present some challenges. ICD-10-CM codes specify the number of fetuses as well as whether the fetuses are monochorionic (share the same placenta) and/or monoamniotic (share the same amniotic sac). The codes are further divided by trimester.
A patient comes in for care related to the fetus and possible delivery problems. She is pregnant with twins and is in her second trimester. Our possible codes include:
- O30.002, twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, second trimester
- O30.012, twin pregnancy, monochorionic/monoamniotic, second trimester
- O30.022, conjoined twin pregnancy, second trimester
- O30.032, twin pregnancy, monochorionic/diamniotic, second trimester
- O30.042, twin pregnancy, dichorionic/diamniotic, second trimester
- O30.092, twin pregnancy, unable to determine number of placenta and number of amniotic sacs, second trimester
Note the difference between O30.002 and O30.092. Use O30.002 if the physician does not specify the number of placentas or amniotic sacs. If the physician documents that he or she cannot tell how many there are, use O30.092.
Another aspect worth noting is the seventh character for complications of labor and delivery (O60-O77). The seventh character identifies the fetus involved. If the mom is only carrying one, the seventh character is always 1. That’s pretty easy.
However, if the mother is carrying multiple fetuses, you need to look for documentation that specifies which fetus is affected. For example, if the physician documents obstructed labor due to breech presentation for one twin, he or she needs to specify fetus 1 or fetus 2. If fetus 2 is involved, report O64.1XX2. The base code is only four characters long, so we need two X placeholders to move the seventh character to the seventh position.
We also need to assign a code from category O30 when multiple fetuses are involved.
ICD-10-CM includes codes that specify when a condition, such as hypertension or diabetes, is pre-existing (meaning before the patient became pregnant) and when it is due to the pregnancy.
Codes from Chapter 15 take precedence over codes from other chapters unless the provider documents that the pregnancy is incidental to the encounter. For example, a pregnant woman cuts her hand on broken glass and needs stitches. The injury has nothing to do with pregnancy. The fact that she is pregnant doesn’t impact care unless, for some reason, she would need anesthesia. In this case, you would report the laceration and also report Z33.1 (pregnant state, incidental).
ICD-10-CM also includes Z codes to denote the weeks of gestation. Codes from category Z3A.- are for use, only on the maternal record, to indicate the weeks of gestation of the pregnancy. Code first complications of pregnancy, childbirth, and the puerperium (O00-O9A).
The specified weeks of gestation go from less than eight (Z3A.01) all the way through more than 42 weeks gestation of pregnancy (Z3A.49).