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ICD-10 tidbits from Hotlanta

Greetings from Atlanta! I spent the weekend collecting all kinds of tips and information about ICD-10 during the AHIMA Conference pre-conference sessions. These are just a few of the best tidbits from the weekend.

TipsI found the absolute best reason to transition to ICD-10, courtesy of Gerri Walk, RHIA, CCS-P, from HRS in Baltimore: We’re staving off dementia! Use your brain or lose it and ICD-10 is going to let us exercise our brains. A lot.

Donna L. Rudolph, RHIT, CCS, and Joanne Schade-Boyce, BSHD, MS, COC, ACS, PCS, from Health Revenue Assurance Associates talked about the hidden impact of ICD-10. For example, the timeframe for an acute MI in ICD-10-CM goes from eight weeks to four weeks. Not only is that going to be a struggle for coders to remember, it can also affect your MS-DRG, Donna says.

Have you thought about how you current coding policies and procedures will have to change under ICD-10? We’re so focused on education right now, we may not be assessing policies and procedures, Joanne says.

You’ll hear lots more from Joanne and Donna’s presentation in an upcoming issue of JustCoding.

When are you planning to start dual coding and which method are you going to use? Are you going to code concurrently or retrospectively? How many records are you going to code in ICD-10 and how will you check the accuracy? Kimberly Carr, RHIT, CCS, CDIP, manager of clinical documentation for HRS, raised all of those questions during her session on justifying the cost of dual coding. One of the biggest advantages to dual coding: reducing your risk for inaccurate coding because coders will be more comfortable in ICD-10. And, oh, by the way, that will reduce your productivity loss as well.

How do you get to the Carnegie Hall of ICD-10? Practice, practice, practice. That’s Donna’s line, but it was a consistent theme across multiple presentations. The best way for coders to learn ICD-10 and get comfortable is to practice coding actual records in ICD-10. The challenge is to find the time.

More on these presentations and other ICD-10 sessions from AHIMA later.

With use, ICD-10-CM codes will stick in your memory

People are creatures of habit. Some of them are good, some not so good.

6_BrainWithArteries-no labelCoders, too, are creatures of habit. We know certain codes without having to look them up. (Anyone know the code for unspecified diabetes?) We know where to look in the record for certain information.

One reason coders are worried about the transition to ICD-10-CM is we’re losing all of those codes we know so well. Now we’ll have to look up diabetes unspecified instead of entering 250.00. In case you’re interested, the ICD-10-CM code is E11.9. Yes, we still have unspecified codes in ICD-10-CM.

I had an interesting conversation with AHIMA’s Ann Barta, MSA, RHIA, CDIP, earlier this week. We were talking about how sepsis coding will change in ICD-10-CM and she made an interesting observation.

Ann commented that all coders have a group of ICD-9-CM codes that they know by heart. We didn’t learn those codes overnight. I doubt anyone sat down with an ICD-9-CM manual and decided to memorize certain codes. You learn them by using them over and over again.

The same thing will happen with ICD-10-CM, Ann says. She has been working with ICD-10-CM for seven years now (she’s way ahead of the rest of us). And at this point, she already has some ICD-10-CM codes memorized.

So if you’re worried about ICD-10-CM because you’re losing your comfortable codes, don’t be. You didn’t have the ICD-9-CM codes memorized when you started coding. You learned them as you went. The same thing will happen in ICD-10-CM.

One caveat though. Don’t expect to memorize ICD-10-PCS codes. Ann by now knows the first three characters (section, body system, root operation), so she can go right to the tables. However, she still looks up the last four in part because the fourth character—body part—changes with each body section. The ICD-10-PCS codes are a little too complex to memorize completely, but if you know the first three, you can get to the correct table, and that’s the important thing for PCS.

Don’t stop at the Alphabetic Index

In ICD-9-CM, we know not to code solely from the Alphabetic Index. After all, the code could have additional digits or excludes notes or other coding directions (such as “code first” or “use an additional code”).

question marksGuess what—that won’t change in ICD-10-CM. We still have to look up the actual code in the Tabular List.

ICD-10-CM codes can be up to seven characters in length. The Alphabetic Index rarely lists all seven.

Sometimes ICD-10-CM is nice enough to let us know we need additional characters by putting a dash at the end of the code in the Alphabetic Index. For example, if you look up unilateral conductive deafness, the Alphabetic Index gives you code H90.1-.

When you look up H90.1- in the Tabular List, you find two choices:

  • H90.11, conductive hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side
  • H90.12, conductive hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side

Coding life would be easy (well, easier) if ICD-10-CM did that for all of the codes that require additional characters. Alas, it does not.

Look up gout, chronic, idiopathic, multiple sites in the Alphabetic Index. You see code M1A.09. That’s all. However, when you flip back to the Tabular List, you find out that you need a seventh character. Actually you need a sixth character placeholder and a seventh character to denote:

  • 0, without tophus (tophi)
  • 1, with tophus (tophi)

For chronic idiopathic gout of multiple sites without tophus, you would report code M1A09X0.

Most of the codes without the dash actually require placeholders. You can have up to three X placeholders in a single code. You’ll usually find those in the External Causes section, such as:

  • W64.XXXA, exposure to other animate mechanical forces, initial encounter
  • W73.XXXD, other specified cause of accidental non-transport drowning and submersion, subsequent encounter
  • W85.XXXS, exposure to electric transmission lines, sequela

Don’t be fooled by the lack of a dash. Make sure you check the Tabular List to get the complete code.

CMS posts updated GEMs files

First we saw the new ICD-10-PCS codes and guidelines in May, followed by the new ICD-10-CM codes in June and the ICD-10-CM guidelines in July. Now we have updated general equivalence mappings (GEMs) from CMS for both ICD-10-CM and ICD-10-PCS.

GEMs are a way to translate ICD-9 codes into ICD-10 codes and vice versa. The maps are a great tool and will get you to the correct code neighborhood, but they won’t always take you to the correct house. If you always had a one-to-one translation, moving to ICD-10 would be pointless.

news01In some cases, one ICD-9-CM code maps directly to one ICD-10-CM code. For example, paratyphoid fever A maps from ICD-9-CM code 002.1 directly to ICD-10-CM code A01.1.

More commonly, you’ll get a one-to-many match when you go from ICD-9-CM to ICD-10-CM. For example, in ICD-9-CM, simple chronic conjunctivitis goes from one code (372.11) to four codes:

  • H10.421, simple chronic conjunctivitis, right eye
  • H10.422, simple chronic conjunctivitis, left eye
  • H10.423, simple chronic conjunctivitis, bilateral
  • H10.429, simple chronic conjunctivitis, unspecified eye

You cannot code directly from the GEMs, but they will point you in the right direction. Look at your common diagnoses by ICD-9-CM code, then plug those codes into the GEMs and see where the GEMs take you. You can use the GEMs to familiarize yourself with the ICD-10-CM codes (and the ICD-10-PCS codes for inpatient procedures). You can also see what the ICD-10-CM options are for diagnoses you commonly report. That can help you educate your physicians about any additional documentation they will need to provide for ICD-10.

 

ICD-10 on Opening Day

Anytown’s baseball team just completed its home opener and while the team came away with a win, not all of the players made it through the game.

Eddie the outfielder suffered a painful run-in with the left-field fence in the second inning. Eddie raced back to catch a fly ball and jumped up. Unfortunately, he was too close to the fence and ripped his right ear open on the top of the fence.  He cut through the cartilage in his ear and now sports a spiffy row of stitches. Fence 1, Eddie 0.

Dr. Selig documented no foreign body in the laceration and also noted this was Eddie’s first visit. That gives us ICD-10-CM code S01.311A, laceration without foreign body of right ear, initial visit.

We can also add some codes for external causes:

  • W18.01xA, striking against sports equipment with subsequent fall, initial encounter (if you consider the fence a piece of baseball equipment)
  • Y92.320, baseball field as the place of occurrence of the external cause
  • Y93.64, activity, baseball

Eddie’s teammate Ken also suffered a setback in the first game of the season. Ken failed to move out of the path of an oncoming fastball and earned a free base—and a massive bruise to his hip. Fortunately, the pitch wasn’t that fast, so Ken didn’t suffer any breaks, but he’s going to be sore for a while.

When we review Dr. Selig’s note, we find that he did not document laterality or encounter. That means we need to query.

ICD-10-CM does contain a code for contusion to unspecified hip, but in order for any contusion code to be valid, we need a seventh character to denote the encounter. Since we’re asking for one piece of information, we may as well ask for both. That way the record will be more complete and we don’t need to worry about a possible denial for an unspecified code.

Dr. Selig responds (three days later) with a notation of left hip, initial encounter, so we would report:

  • S70.02xA, contusion of left hip
  • W21.03xA, struck by baseball
  • Y92.320, baseball field as the place of occurrence of the external cause
  • Y93.64, activity, baseball

Note that we need placeholders for codes for the contusion and the struck by baseball. Without the X placeholder, the seventh character ends up in the sixth position, making the code invalid.

Eddie and Ken will both be back on the field tomorrow, but their teammate Keith is headed for the injured reserve. Keith slid into second and dislocated his right ankle when he hit the bag awkwardly. To add insult to injury, he was out. He had larceny in his heart, but lead in his feet. And now a cast to go with it.

What do we need in Dr. Selig’s documentation to code Keith’s dislocated ankle?

  • Laterality (right)
  • Encounter (initial)
  • Dislocation or subluxation (dislocation)

That gives us:

  • S93.04xA, dislocation of right ankle joint, initial encounter
  • Y92.320, baseball field as the place of occurrence of the external cause
  • Y93.64, activity, baseball

We would not report W18.01xA because Keith didn’t fall. ICD-10-CM does not contain a code for sliding into a base. At least not yet.

A chilling selection of ICD-10-CM external causes codes

So how would you like to explain this accident to your physician? Doctor, I was crossing the street wearing ice skates and was hit by a bicycle.

Believe it or not, there’s an ICD-10-CM code for just such an occasion:

  • V06.19, pedestrian with other conveyance injured in collision with other nonmotor vehicle in traffic accident

That code includes a long list of specific circumstances, such as:

  • Pedestrian on ice-skates injured in collision with other nonmotor vehicle in traffic accident
  • Pedestrian on sled injured in collision with other nonmotor vehicle in traffic accident
  • Pedestrian on snowboard injured in collision with other nonmotor vehicle in traffic accident
  • Pedestrian on snow-skis injured in collision with other nonmotor vehicle in traffic accident

Odds are, you won’t use code V06.19 often, but it’s there if you need it.

ICD-10-CM contains a wide range of codes for external causes, so let’s look at some of the others you may need during the winter.

New England is bracing for a major snow storm this weekend, so we may see people come in with various injuries caused by activities involving ice and snow (Y93.2). Note that the Y93.2 series excludes injuries related to shoveling ice and snow. They have their own external causes code—Y93.H1.

We’ll also report X37.2 (blizzard [snow][ice]).  Don’t forget the seventh character to denote the encounter.

Perhaps your patient is Lindsey Vonn, the Olympic skier who recently suffered torn knee ligaments in a horrible crash during a race. If we code the activity of skiing, we need to know what type of skiing:

  • Y93.23, activity, snow (alpine) (downhill) skiing, snow boarding, sledding, tobogganing, and snowtubing
  • Y93.24, activity, cross country skiing

In Lindsey’s case, it’s downhill skiing, so we would code Y93.23 in addition to her injury codes.

What other trouble can we get into in the snow? We could fall because of the snow and ice (it’s not fun, I don’t recommend it). In that case, we would report a code from the W00.- series (fall due to ice and snow):

  • W00.0, fall on same level due to ice and snow
  • W00.1, fall from stairs and steps due to ice and snow
  • W00.2, other fall from one level to another due to ice and snow
  • W00.9, unspecified fall due to ice and snow

These codes require a seventh character to denote the encounter, so we’ll need to add two X placeholders so our seventh character ends up in the seventh place.

W00.0 also includes collusions with another person, so when you go sliding across the icy sidewalk straight into an innocent bystander, you get W00.0XXA (for the initial encounter).

If a patient comes in suffering from hypothermia (T68-), we need use additional code to identify source of exposure:

  • Exposure to excessive cold of man-made origin (W93)
  • Exposure to excessive cold of natural origin (X31)

W93 requires a seventh character to denote the encounter type and includes:

  • Excessive cold as the cause of chilblains NOS
  • Excessive cold as the cause of immersion foot or hand
  • Exposure to cold NOS
  • Exposure to weather conditions

W93 specifically excludes:

  • cold of man-made origin (W93.-)
  • contact with or inhalation of:
  • dry ice (W93.-)
  • liquefied gas (W93.-)

All of these winter codes are making me cold. Pass the hot chocolate.

Black (and blue) Friday at Fix ‘Em Up Clinic

Black Friday marks the beginning of the holiday shopping season—and the holiday injury season at Fix ‘Em Up Clinic.

Patients started showing up shortly after the stores opened this morning with shopping related injuries.

Heather came in complaining of a sore right wrist after being shoved to the during a midnight madness free-for-all at the local mall.

Dr. Carroll documents a traumatic rupture of tendons in Heather’s wrist, contusions and abrasions to her hand, and contusions to her knees.

Apparently Dr. Carroll enjoyed too much turkey on Thanksgiving because he forgot to document some important information.

We need to know:

  • Encounter (initial, subsequent, sequela)
  • Laterality for the wrist and hand injuries—we can’t use Heather’s complaint to decide which side she injured. Dr. Carroll must include that information in his documentation
  • Specific ligament ruptured –collateral ligament, radiocarpal, ulnocarpal, or other. Other doesn’t not mean unspecified. ICD-10-CM does include a code for unspecified ligament, but we want to avoid unsing unspecified unless absolutely necessary.

 

We do know the knee contusions are bilateral because Dr. Carroll documented knees.

Let’s see what additional information Dr. Carroll can provide about Heather’s injuries.

In response to our query, Dr. Carroll provides the following:

Initial encounter for traumatic rupture of radiocarpal and collateral ligaments of right wrist; contusions to right hand, abrasions on left palm; contusions on both knees.

Great, now we can report the following codes:

  • S63.311A, traumatic rupture of collateral ligament of right wrist, initial encounter
  • S63.321A, traumatic rupture of right radiocarpal ligament, initial encounter
  • S60.221A, contusion of right hand, initial encounter
  • S60.512A, abrasion of left hand, initial encounter
  • S80.01XA, contusion of right knee, initial encounter
  • S80.02XA, contusion of left knee, initial encounter

If Heather had suffered injuries to her fingers in addition to the abrasions and contusions to her hands, we would need to code those injuries separately by the specific finger injured.

We can also report the following external causes codes if the payer wants them:

  • W03.XXXA, other fall on same level due to collision with another person
  • Y92.59, other trade areas as the place of occurrence of the external cause (the mall)
  • Y93.01, activity, walking, marching and hiking

Sadly, ICD-10-CM does not yet include a code for door-buster shopping, or any shopping for that matter.

Our next patient Rex really wanted that jersey at the sporting goods store in the mall, but unfortunately for him, someone else wanted it more. Rex arrived at Fix ‘Em Up with some pretty nasty bruises as well as a broken leg. The other guy really didn’t fight fair it seems.

Dr. Morang documents an initial visit for:

  • Contusions to the right periocular area
  • Closed, nondisplaced fracture of zygomatic arch (that explains the really nasty bruise on Rex’s face)
  • Laceration of the lower lip (no foreign body in wound)
  • Open displaced oblique fracture of shaft of right tibia (Gustilo class I)

Apparently Dr. Morang slept off the Thanksgiving turkey better than Dr. Carroll. With this documentation, we can code the following:

  • S82.231B, displaced oblique fracture of shaft of right tibia, initial encounter
  • S00.11XA, contusion of right eyelid and periocular area, initial encounter
  • S02.402, zygomatic fracture, unspecified, initial encounter
  • S01.511A, laceration without foreign body of lip, initial encounter

I think I’ll wait for Cyber Monday. It’s way too dangerous out there.

Real goals and benefits of ICD-10-PCS

You need enthusiasm and a desire to keeping learning to tackle the monumental task of learning ICD-10-PCS. In authoring an ICD-10 CM/PCS education program 10 hours per work I learn something new every day. The purpose of this blog is to share along the way with other coders.

This week while preparing a presentation titled “ICD-10-PCS-An Introduction” my research took me to assembling a list of the goals and benefits of ICD-10 PCS. There are so many myths regarding this new coding system that I want to share these REAL GOALS AND BENEFITS.

GOALS

  • Improve the accuracy and efficiency of procedure coding
  • Replace ICD-9-CM procedure codes with a more logical system
  • Improve communication with physicians by developing a code system that aligns more with the clinical aspects of various procedures
  • Allow coders to construct accurate codes with minimal effort

 

BENEFITS:

  • Completeness
  • Expandability
  • Standardized terminology
  • Multiaxial
  • May reduce coder’s anxiety because it better captures procedural descriptions and details
  • Anatomically detailed clinical data

ICD-10-PCS guidelines go right down to our fingers and toes!

ICD-10-PCS includes 31 root operations, but before you go there don’t forget to look at the Official Coding Guidelines for ICD-10-PCS. They are an extensive set of guidelines with instruction on how to use the root operations and cannot be overlooked.  

For example, ICD-10-PCS coding guideline, Body Part Guideline: Fingers and Toes (B4.7), tell us:

If a body system does not contain a separate body part value for fingers, procedures performed on the fingers are coded to the body part value for the hand. If a body system does not contain a separate body part value for toes, procedure performed on the toes are coded to the body part value for the foot.

Example: Excision of finger muscle is coded to one of the hand muscle body part value in the Muscles body system.

Think positively about ICD-10 and consider all the goals and benefits to breathe new life into our profession. For me, choosing to embrace ICD-10 fully and teach it to others has been exciting and fun.

ICD-10 coding for flaming tomato napalm

Over the weekend, Matt decided to grill up dinner, which sounds at first like a good idea.  He started with chicken, then added some vegetables, unfortunately including some cherry tomatoes. While he was grilling dinner, one of the tomatoes made a break for it, rolling off the grill and onto the patio of Matt’s single-family home.

Matt saw it go, considered it a goner, and went back to grilling. The tomato was not prepared to be ignored. It strategically placed itself under Matt’s left sandal. He stepped down and felt “flaming tomato napalm” squirt between his foot and his sandal. When he looked down to verify that the tomato had taken its revenge, he smacked his head into the grill, giving himself a mild concussion and opening a 3-inch gash on his forehead.

When he put his hand up to stem the flow of blood from his forehead, he dropped his grilling fork—straight into the top of his right foot.

After uttering a few choice phrases on the nature of cherry tomato terrorism, Matt arrived at Fix ‘Em Up Clinic for repairs.

So how would we report his multiple injuries? We don’t really have sequencing guidelines for ICD-10-CM that tell us which injury to code first, so let’s look at the injuries in the order Matt sustained them.

We know Matt’s burn is to the left foot, which takes us to ICD-10-CM code series T25 (burn and corrosion of ankle and foot). The first thing we notice is the entire series of codes needs a seventh character to specify the encounter—initial, subsequent, or sequela. We look to Dr. Tom A. Toe’s documentation and see that this is Matt’s first visit.

The next thing we need to know is the degree of the burn—first, second, third, or unspecified. Try to avoid unspecified even if you need to query. We also need to know where specifically the burn is—ankle, foot, toes, or multiple sites. Back to the documentation, when Dr. Toe has documented a second degree burn to the bottom of the foot. That leads us to T25.222A, burn of second degree of left foot.

But we aren’t done with this injury yet. Under T25.2 (burn of second degree of ankle and foot) we find this note: Use additional external cause code to identify the source, place, and intent of the burn (X00-X19, X75-X77,X96-X98, Y92). Fortunately, we have that information in our narrative of the accident:

  • X12.XXXA, contact with other hot fluids (the liquid inside the tomato)
  • Y92.018, other place in single-family (private) house as the place of occurrence of the external cause
  • Y93.G2, activity, grilling and smoking food

ICD-10-CM does not specify a patio as a place of occurrence (hence Y92.018), but does include a code for garden or yard. Since we don’t know where the patio is located (and it’s a patio, not the garden or yard), we’ll go with other place. “Other place” is not the same as “unspecified place.” We know where specifically Matt suffered his injuries, we just don’t have a code for it.

That takes us to Matt’s concussion and forehead laceration. Dr. Toe documented no loss of consciousness, so we would report S06.0X0A (concussion without loss of consciousness, initial encounter).

For the laceration, we need to know whether Matt had any foreign body in the wound (a check of the documentation says, no). When we look up laceration, forehead in the ICD-10-CM Alphabetic Index, we are directed to S01.81, laceration without foreign body of other part of head. When we go to the Tabular Index, we see that we need a seventh character to denote the encounter type, so our final code would be S01.81XA.

That brings us to Matt’s final injury, the fork to the foot. Matt removed the fork before coming to Fix ‘Em Up, and fortunately, nothing stayed behind in the punctures. Again, we need to know which foot (right), with or without foreign body (without), foot itself or toes (foot itself), and encounter type (initial). All of that brings us to: S91.331A (puncture wound without foreign body, right foot, initial encounter).

And with that, Dr. Toe is done with Matt and we are done with his diagnostic record. So it’s time to head home and fire up the grill. I will not be adding any cherry tomatoes though.

Too many codes? There’s no such thing

A writer paints a picture with words. The English language alone offers somewhere in the neighborhood of a quarter of a million words. But really how many does the average person use? According to Stephen Pinker’s book “The Language Instinct” the average American high-school graduate knows approximately 45,000 words. That’s  a pretty big disparity, but it makes sense.

How many people do you know who use antidisestablishmentarianism in regular conversation? By the way, antidisestablishmentarianism is the longest non-technical and non-coined word in the English language (watching Jeopardy! pays).

Some other odd words that you’ve probably never heard of include:

  • Erinaceous (like a hedgehog)
  • Lamprophony (loudness and clarity of voice)
  • Depone (to testify under oath)
  • Finnimbrun (a trinket or knick-knack)
  • Floccinaucinihilipilification (estimation that something is valueless)
  • Inaniloquent (pertaining to idle talk)

So what does this have to do with coding in general and ICD-10-CM coding in particular? A coder tells a story with codes. Like any good storyteller, you want that story to be as complete and accurate as possible. ICD-10-CM’s increased specificity will help you do that.

A lot of people get hung up on the huge increase in the number of codes. ICD-9-CM includes 14,567 diagnosis codes, while ICD-10-CM offers 69,833. Big, scary difference, right? Yes and no. You’ll have a lot more choices, but that doesn’t mean you’ll use them.

How often does a patient come in for a spacecraft fire injuring occupant (V95.44) or for being bitten by an orca (W56.21)? For that matter, how many cases of light chain deposition disease or variant Creutzfeldt-Jakob disease or Pallister-Killian mosaic syndrome do you see?

If you code for a specialty, you’ll generally use a small fraction of the available codes. Even if you code for several specialties, you still won’t use every code.

And a lot of the codes are just more detailed. They aren’t new conditions or new diseases. For example, look at the codes for serous detachment of retinal pigment epithelium. ICD-9-CM offers one code choice—362.42. So you’re coding this condition now. The difference is when you get to ICD-10-CM, you’ll have four choices:

H35.721, serous detachment of retinal pigment epithelium, right eye

H35.722, serous detachment of retinal pigment epithelium, left eye

H35.723, serous detachment of retinal pigment epithelium, bilateral

H35.729, serous detachment of retinal pigment epithelium, unspecified eye

The additional specificity could be an unexpected aid as well. Because many ICD-10-CM codes include laterality, you shouldn’t have to worry that a payer will reject a claim because of double billing if you can code two separate sites (index finger and middle finger) or different sides of the body (right arm and left arm).

Don’t get stuck on the number of new codes. You don’t need to memorize them and you won’t have to relearn how to code diagnoses from scratch. Probably 90-95% of the coding guidelines remain the same. It’s a big change and will certainly be a challenge, but don’t be afraid of the choices.