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My experience at an AHIMA trainer session Part 2

In a recent post, I talked about my experience attending an American Health Information Management Association (AHIMA) Academy for ICD-10 trainer session. While I am excited about certain aspects of ICD-10-CM, I’m not as quick to warm up to ICD-10-PCS, which is very different from what we currently use in ICD-9-CM Volume 3.

The use of the many tables and definitions of certain procedures make this system much more applicable in a clinical sense. However, I did find myself having to continually reference definitions of the various root operations in the front of the PCS manual.

I would read a question and have to really think about whether the question was about a “change,” “replacement,” “extraction,” “extirpation,” etc.

Extirpation was my word of the day. I looked this word up in the Merriam-Webster Dictionary only to find the definition includes the following:

• To pull up by the roots
• To destroy completely
• To remove by surgery

Well, that didn’t help me much considering some of my choices for root operations include destruction, resection, transplantation, and excision, which all seem similar, don’t they?

Luckily, the introduction to the ICD-10-PCS manual provides a specific definition for extirpation, which is “taking or cutting out solid matter from a body part” (e.g., removal of a calculus). I’m glad this definition was in the manual otherwise I would have had a hard time using the official definition.

One of the comments people made at the AHIMA session was, “Will all my physicians have to document ‘extirpation’?”  Rest assured, physicians do not need to use this exact verbiage for coders to assign the appropriate ICD-10-PCS codes.

However, because of the way the ICD-10-PCS system is set up, you do need to understand what the root operations are so you can reference the correct part of the procedure tables, identify the procedures the physicians document, and assign the correct codes.

ICD-10 solves some old problems, but also creates new ones

As each day passes, we get closer to the implementation date of ICD-10-CM and ICD-10-PCS. I have been scouring the ICD-10 manual to identify things that will change (some things for the better, some not so much). For example, substance abuse/dependence codes (ICD-9-CM categories 303-305) in ICD-10 present solutions to ongoing challenges for coders but also create new issues.

In ICD-9-CM, we are given specific descriptors for the fifth digit (e.g., continuous, episodic) for substance abuse or dependence depending on the frequency of substance abuse. Do physicians usually document these specific terms? Not really. We seem to default to the fifth digit ‘0’ for ‘Unspecified’ more often than not. So what’s new and great when it comes to assigning codes for substance abuse and dependence in ICD-10-CM?

In ICD-10-CM, the only ICD-9-CM fifth digit descriptor that has a counterpart in ICD-10 is ‘in remission’. This solves one problem but leaves us with the age old issue of “once an alcoholic, always an alcoholic.” So when is it considered ‘in remission’ and when is it a history of alcoholism?

You will still need to assign codes based on physician documentation because there is a separate code for a personal history of alcohol dependence (F10.21). ICD-10-CM will get very specific in relation to alcohol abuse (F10.1xx) and alcohol dependence (F10.2xx). The 6th digits further identify the following:

• Uncomplicated
• Intoxicated
• Associated with an alcohol induced disorder
• Other specific information

Many times physicians do not document specifics such as “abuse” or “dependence.” So one note of interest is that in ICD-10-CM, coders have a new code category that indicates just alcohol use (F10.9). It excludes those conditions described as abuse or dependence.

At first, I started to think that this may cause patients to refrain (even more than they probably do now) when they provide information related to drinking habits, especially when a code can be assigned for it. But the good news is that this code is only meant to be reported for patients with current intoxication and/or alcohol induced disorders, not just simply alcohol use. The categories for drug abuse, dependence and use are set up exactly like the codes for alcohol disorders with categories for abuse, dependence and use.

ICD-10-CM will also provide additional specificity with supplementary codes for blood alcohol levels (Y90).

Y90: Evidence of alcohol involvement determined by blood alcohol level

Code first any associated alcohol related disorders (F10)

• Y90.0 Blood alcohol level of less than 20 mg/100 ml
• Y90.1 Blood alcohol level of 20-39 mg/100 ml
• Y90.2 Blood alcohol level of 40-59 mg/100 ml
• Y90.3 Blood alcohol level of 60-79 mg/100 ml
• Y90.4 Blood alcohol level of 80-99 mg/100 ml
• Y90.5 Blood alcohol level of 100-119 mg/100 ml
• Y90.6 Blood alcohol level of 120-199 mg/100 ml
• Y90.7 Blood alcohol level of 200-239 mg/100 ml
• Y90.8 Blood alcohol level of 240 mg/100 ml or more
• Y90.9 Presence of alcohol in blood, level not specified

I think this could be helpful with criminal investigations for drunk driving accidents, work accidents, and other alcohol-related disorders that can be further identified by the amount of alcohol content in the patient’s blood.

ICD-10-CM adds specificity, but it still does not solve all of the problems we encounter with ICD-9-CM, such as knowing when to assign a history of alcoholism and when to code as alcoholism “in remission.” Makes our jobs all the more interesting, right? I’ll post some other topics like this in future blog posts. Happy coding!

Excludes notes get a makeover in ICD-10

Excludes notes in ICD-10 will have a slightly different look.

Currently in ICD-9, there are simply excludes notes listed below codes in italic font. In ICD-10, there are two types of exclude notes:

• Excludes1: A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes1 note indicates that the code excluded should never be reported with the code above the Excludes1 note. An Excludes1 is used to indicate when two conditions cannot occur together, such as a congenital form and an acquired form of the same condition.
• Excludes2: A type 2 Excludes note is used to indicate ”not included here.” An Excludes2 note means that the condition excluded is not part of the condition under which it is listed, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to report both the code and the excluded code together.

Consider the following ICD-10 code:

F11.2 Opioid dependence

Excludes1: opioid abuse (F11.1x) opioid use, unspecified (F11.9x)

Excludes2: opioid poisoning (T40.0x-T40.2x)

Part 2: One coder’s cost-effective strategy for education

In my last blog post, I explained how I tackled the challenge of educating myself about ICD-10, realizing the significant cost that would be associated with registering for every ICD-10 Webinar, seminar, and educational session under the sun.

In addition to creating quizzes and memory aids to help myself learn ICD-10 codes, I also worked to refine my own coding reference Excel spreadsheet, which became a valuable tool and part of my daily routine.

I read through most of the 2003 Draft ICD-10-CM Official Guidelines for Coding and Reporting for Acute Short-term and Long-term Hospital Inpatient and Physician Office and other Outpatient Encounters and then I began to crosswalk a homegrown coding reference Excel spreadsheet that I currently use on a daily basis to ICD-10. My plan was to complete crosswalking my spreadsheet and then after purchasing an ICD-10 Manual, proceed to practice assigning ICD-10 codes for charts that I code on a regular basis.

I also started to incorporate ICD-10 into my daily discussions with other coders. When I answered an ICD-9 coding question, I would also provide the ICD-10 codes, especially when the discussion was about controversial, problematic issues related to ICD-9 (e.g., there is not a specific enough code). I felt that this daily application and routine of looking up of ICD-10 codes for various questions that I answer on listservs and through other informal coding discussions would get me into an ICD-10 coding frame of mind.

After that, I started to read through the ICD-10-PCS reference manual, and I started memorizing the characters for each section and body system for the procedural coding system. I also planned to create a quiz on the structural differences between ICD-9-CM Volume 3 and ICD-10-PCS. I had recently written a comprehensive training module on ICD-9-CM Volume 3 procedures, and my plan was to update that training module as well as any other ICD-9 Volume 3 reference sheets that I had.

At the beginning of 2009, I noted the updated 2009 official coding guidelines, namely  ICD-10-CM Official Guidelines for Coding and Reporting, and prepared notes detailing the differences between the 2003 and the 2009 guidelines. I also updated my coding files that I had downloaded to my desktop for daily use to reflect the new 2009 coding system.

At that point, I had heard about the possible freeze of ICD-10, so I decided to hold off on completing the conversion of my diagnosis and procedure reference sheets and training materials until at least 2010 in hopes of being able to plan around any possible freezes. Access a recent ICD-10 Watch post to learn more about this possible freeze.

I continue to code with ICD-10-CM and ICD-10-PCS when answering coding questions, and I continue to study the ICD-10-PCS reference manual. If you’re looking for a low-cost strategy for acquiring ICD-10 education, keep in mind that all of this practice using ICD-10 costs only my time.

Tune in for my next blog post, when I share some ideas for building on this foundation of knowledge.

Has your coding team come up with some cost-effective strategies for learning about ICD-10? Post a comment, and share your tips with other ICD-10 Watch subscribers.

Check out AHIMA ICD-10 resources

To prepare for the transition to ICD-10-CM and ICD-10-PCS, it may be helpful to have a list of resources that are currently available either online or in print through the American Health Information Management Association (AHIMA):

• The association’s official ICD-10-CM and PCS Web site
• Educational sessions on anatomy and physiology
• Checklist for preparation
• Articles such as the ICD-10-CM/PCS gap analysis of workflow tool (Journal of AHIMA)
• Body of Knowledge on the AHIMA website contains many relevant articles, position statements and position statements
• Codewrite contains the “ICD-10 Checkpoint,” which shows comparative case scenarios using ICD-9-CM to ICD-10-CM codes
• AHIMA Academy for ICD-10-CM/PCS Trainers workshops

As one of the four cooperating parties for ICD-10-CM/PCS, the AHIMA is a valid resource for education and information regarding ICD-10-CM. Although many of us consider it quite early to get formal training, I think reading about any related issues pertaining to the ongoing preparation will only enable us to transition easily and seamlessly to this exciting new system on October 1, 2013.

AAPC shares perspective on coder training

Since the Department of Health and Human Services’ January announcement on the final rule for the implementation of ICD-10, many questions have popped up. Some in the industry feel that if they do not contract a trainer or a consultant to provide training right now, they will fall behind and not meet the October 2013 compliance date.

However, the American Academy of Professional Coders’ (AAPC) emphasizes that now is not the time to begin training. Will you really remember everything you’re learning in 2009 four years later in 2013? Chances are that you will not, and to make the implementation as seamless and efficient as possible, the AAPC recommends holding off on training for the time being.

Our plan is unique in that our trainers will undergo an intensive “Train the Trainer” program, which we are not opening to the general healthcare population to ensure consistency with correct information conveyed to the healthcare community.

I must reiterate that now is not the time to begin learning the ICD-10 code set. The best time to begin is late in 2012 or early 2013. The AAPC has streamlined its training curriculum into different phases, starting this summer, when the association will give a three-part, free introduction to ICD-10 implementation Webinar. For more information, visit the AAPC’s ICD-10 Web page.

ICD-10 guideline for urosepsis illustrates need for specific documentation

One of the most poorly documented and miscoded diagnosis is when a physician documents the term “urosepsis.” Does the physician mean that the patient has a systemic infection originating from a urinary origin, or does the patient simply have a urinary tract infection (UTI)? Currently, the default ICD-9-CM code for a UTI  is 599.0.

I had mixed feelings when I saw the following guideline in the ICD-10 Official Guidelines for Coding and Reporting (2009 version) for urosepsis:

(ii) Urosepsis
The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification.

The ICD-10-CM alphabetic index states:

Urosepsis – code to condition

On one hand, it will prevent (or hopefully prevent) coders from assigning a diagnosis for sepsis when the patient has only a UTI. But on the other hand, I think this will only lead to more physician queries because it is fairly common for physicians to use this term.

The implementation of ICD-10 will inherently bring with it the need for more specific documentation. With that increased need for specificity, physicians must revise their documentation for conditions such as urosepsis.

Monitor CMS’ ICD-10 Q&As

With all the complexities related to the implementation of ICD-10, it’s no wonder that so many in the healthcare industry have a number of questions related to the various aspects of this new coding system. While the list of questions and answers posted on this CMS Web page is not as extensive as you might hope, CMS has addressed a number of common queries and provided helpful links within the posts. Consider the following Q&A:

QUESTION: Are there any instances when there is no translation between an International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) code and an International Classification of Diseases, 10th Edition (ICD-10) code? How do the General Equivalency Mappings handle this situation?

ANSWER: Yes, there are instances where there is not a translation between an ICD-9-CM code and an ICD-10 code. When there is no plausible translation from a code in one system to any code in the other system, the “No Map” flag indicates this. For example, the following codes are marked with the “No Map” flag:

• ICD-10-CM code Y71.3 – Surgical instruments, materials and cardiovascular devices (including sutures) associated with adverse incidents, which 
• ICD-9-CM procedure code 89.8 – Autopsy, which has no reasonable translation in ICD-10-Procedure Coding System.

For more information on this subject, see page 16 of the publication titled Procedure Code Set General Equivalence Mappings ICD-10-PCS to ICD-9-CM and ICD-9-CM to ICD-10-PCS 2009 Version Documentation and User’s Guide. The User’s Guide is posted in the Downloads Section within the file labeled “2009 Mapping – ICD-10-PCS to ICD-9-CM and ICD-9-CM to ICD-10-PCS; and User Guide, Reimbursement Guide, Diagnosis, and Procedures.”

On May 19, CMS hosted a conference call during which it addressed in further detail the use of General Equivalence Mappings (GEMs). The CMS representative said they had about 6,000 registrants for the call, so it looks like many of you are in planning mode, which is great news! A transcript of the call will be available on the CMS Web site soon.

Alleviate fears with ICD-10 fact sheet

Discussions are starting regarding ICD-10, and there are many rumblings in the coding community. Just like anything else, something new and different can bring on feelings of being overwhelmed. Yes, ICD-10 does have a different look and feel, but it is not as challenging as many may believe. Many people have expressed to me their fears about this new coding system, conveying that they have heard how difficult it will be to use ICD-10. I am posting an ICD-10 fact sheet CMS published that will hopefully alleviate some fears and end some of the myths generated in the coding community.