INTRODUCTION TO ICD10 CM Created by Alejandra Munoz

INTRODUCTION TO ICD-10 -CM Created by Alejandra Munoz, CPC, NCICS

ICD-10 -CM Manual Format Contains two Volumes: • Index – An alphabetical list of term and their corresponding codes. • Tabular List – A sequential, alphanumeric list of codes divided into chapters

ICD-10 -CM Index There are two sections within the Index: • Index to Diseases and Injuries – This is considered the main index. Within the Index to Diseases and Injuries are the: -Neoplasm Table -Drugs and Chemical Table • Index to External Causes of Injury

Neoplasm Table • The Neoplasm Table is found in the Index by referencing the term “Neoplasm”. • The Neoplasm Table contains a listing of neoplasms according to site and type.

Drugs and Chemical Table • It is divided according to the: -Types of poisoning -Adverse effect, or -Underdosing

ICD-10 -CM Tabular List • The Tabular List is divided into chapters based on: -Body System, or -Condition -There are 21 chapters Example: -Chapter 1 – Certain Infectious and Parasitic Diseases -Chapter 6 – Diseases of the Nervous System

ICD-10 -CM Chapters • Chapter 1 – Certain Infectious and Parasitic Diseases • Chapter 2 – Neoplasms • Chapter 3 – Diseases of the Blood and Blood. Forming Organs and Certain Disorders involving the immune Mechanism • Chapter 4 – Endocrine, Nutritional, and Metabolic Diseases

ICD-10 -CM Chapters • Chapter 5 – Mental, Behavioral and Neurodevelopmental Disorders • Chapter 6 – Diseases of the Nervous System • Chapter 7 - Diseases of the Eye and Adnexa • Chapter 8 – Diseases of the Ear and Mastoid Process • Chapter 9 – Diseases of the Circulatory System • Chapter 10 – Diseases of the Respiratory System

ICD-10 -CM Chapters • Chapter 11 – Diseases of the Digestive System • Chapter 12 – Diseases of the Skin and Subcutaneous Tissue • Chapter 13 – Diseases of the Musculoskeletal System • Chapter 14 – Diseases of the Genitourinary System • Chapter 15 – Pregnancy, Childbirth, and the Puerperium

ICD-10 -CM Chapters • Chapter 16 – Certain Conditions Originating in the Perinatal Period • Chapter 17 – Congenital Malformations, Deformations, and Chromosomal Abnormalities • Chapter 18 – Symptoms, Signs, and Abnormal Clinical and Laboratory Findings

ICD-10 -CM Chapters • Chapter 19 – Injury, Poisoning, and Certain Other Consequences of External Causes • Chapter 20 – External Causes of Morbidity • Chapter 21 – Factors Influencing Health Status and Contact with Health Services

ICD-10 -CM Chapters • It is important for coders to have an understanding of the information contained within the various chapters to ensure accurate coding. • Review the types of codes found in each chapter.

Coding Conventions • Coding conventions are instructional notes, punctuation marks, abbreviations, and symbols that are used throughout ICD-10 -CM to provide direction when selecting a code.

Instructional Notes Instructional notes appear in the Alphabetical Index and Tabular List • INCLUDES: This notation is used to define and/or give examples of the content of a particular category or block of categories within ICD-10 -CM

Instructional Notes • EXCLUDES 1: This note means that the terms listed are not coded to the category or subcategory. It means NOT CODED HERE. • EXCLUDED 2: This note is used to signal that the terms listed after the note are not part of the conditions represented by the code or code block. It means NOT INCLUDED HERE.

Instructional Notes • SEE: This is used in the Alphabetical Index and instructs the coder to cross-reference the term or diagnosis that follows the notation. • SEE ALSO: This is also a cross-reference note that refers the coder to another location in the Index.

Instructional Notes • USE ADDITIONAL CODE: This notation appears in the Tabular List and instructs the coder to use an additional code to identify the manifestation that is present. • CODE ALSO: This notation is used to indicate to the coder that two codes are needed to fully code the diagnostic phrase being coded.

Instructional Notes • CODE FIRST: This notation appears in the Tabular List and instructs the coder to select a code to represent the etiology that caused the manifestation. This code is sequenced first. • DISEASES CLASSIFIED ELSEWHERE: Codes with this title are a component of the etiology/manifestation convention. This code title indicates that it is a manifestation code and is not permitted to be used as a first listed or principal diagnosis code.

Punctuation Marks Used in both the Index and Tabular List to provide guidance to coders when selecting codes. • Parentheses- Used in both the Index and Tabular List to enclose supplementary words that may be present or absent in the statement being coded. The code assignment is not affected.

Punctuation Marks • Nonessential modifiers- Terms found within the parentheses. • Brackets- Used in the Index to identify manifestation codes. • Colons- Used in the Tabular List after an incomplete term that needs one or more of the modifiers listed to make it assignable to a given category.

Abbreviations There are two (2) abbreviations used: • NEC: Not Elsewhere Classified. This represents “other specified. ” • NOS: Not Otherwise Specified. This is interpreted as “unspecified. ”

Symbols • The point dash symbol (. -) is used to signal to the coder that the code contains a list of options at a level of specificity past the three-character category.

Points to Remember • When selecting codes, the coder must follow all instructional notes present. • Instructional notes, abbreviations, and punctuations provide directions to coders. • When cross-references are present in the Index, the additional terms need to be referenced by the coder.

Necessary Documentation Coders need to review the medical documentation prior to selecting codes! This includes: • For inpatients, the Face Sheet • For outpatients, Encounter form • Problem List • Testing Results • Operative Reports • Discharge Summary/Final Notes

Laterality For bilateral sites, ICD-10 -CM indicates the specific site. EXAMPLE: At the 5 th character level the codes for a femoral fracture indicate the following: Unspecified fracture of unspecified femur—S 72. 90 Unspecified fracture of right femur—S 72. 91 Unspecified fracture of left femur—S 72. 92 An additional 6 th character of x is added an additional 7 th character is added to indicate the type of encounter: initial, subsequent, or sequelae

Main Terms For the following diagnostic statements, identify the main terms: • Compound fracture of the left tibia • Acute reticulosis of infancy • Ulcerative esophagitis with bleeding

Key Points to Remember • ICD-10 -CM provides greater granularity than ICD-9 -CM. • Medical Documentation needs to be more detailed. • Providers should be queried if information conflicts. • All instructional notes must be read. • The instructional notations should be used as a guide when selecting codes.

Diagnostic Coding Guidelines The ICD-10 -CM Official Guidelines for Coding and Reporting were developed by: • Centers for Medicare and Medicaid Services (CMS). • National Center for Health Statistics

Cooperating Parties for ICD-10 -CM The following organizations, known as the Cooperating Parties, have approved the guidelines: • American Hospital Association • American Health Information Management Association • Centers for Medicare and Medicaid Services • National Center for Health Statistics

General Coding Guidelines • Diagnosis codes are to be used and reported at their highest number of characters. • Codes that describe symptoms and signs are acceptable for coding when a definitive diagnosis has not been established. • Signs and Symptoms that are associated with a disease should not be reported.

General Coding Guidelines • Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present. • Multiple codes may be needed. • If the same condition is described as both acute (subacute) and chronic and separate subentries exist, code both and sequence acute condition first.

General Coding Guidelines • A sequela (late effect) effect is the residual effect after the acute phase of an illness or injury. • Each unique ICD-10 -CM diagnosis code may be reported only once for an encounter. • For bilateral sites, the final character of codes in the ICD-10 -CM indicates laterality.

General Coding Guidelines Principal Diagnosis: • A condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

General Coding Guidelines • When two or more interrelated conditions potentially meet the definition of principal diagnosis, either condition may be sequenced first. • When two or more contrasting/comparative diagnoses are documented as either/or they are coded as if confirmed and the diagnoses are sequenced according to the circumstances of the admission.

General Coding Guidelines • When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. • Sequence as the principal diagnosis the condition, which after study occasioned the admission to the hospital, even though treatment may not have been carried out due to unforseen circumstances.

General Coding Guidelines • When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. • If the diagnosis is qualified indicating uncertainty, code the condition as if it existed or was established. This is for inpatient cases only.

Reference: Bowie, M. (2014). Understanding ICD-10 -CM. Cengage.