copyright © 2013 delmar, cengage learning. all rights reserved. icd-10-cm coding chapter 6b

Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

ICD-10-CM Coding

Chapter 6B


ICD-10-CM • International Classification of Diseases,

10th Revision, Clinical Modification– Developed in the United States

– Used to classify morbidity data from inpatient and outpatient records


ICD-10-PCS

• International Classification of Diseases, 10th

Revision, Procedure Classification System– Developed in the United States

– Used to classify procedures from inpatient records only


ICD-9-CM Legacy Coding System

• Effective October 1, 2013, when ICD-10-CM

and ICD-10-PCS are implemented, the

ICD-9-CM will become a legacy coding system.


Transition to ICD-10-CM/PCS

© C

eng

age

Lea

rnin

g 2

013


Transition to ICD-10-CM/PCS (cont.)

© C

eng

age

Lea

rnin

g 2

013


Mandatory Reporting of ICD-10-CM/PCS

Codes• Effective October 1, 2013, ICD-10-CM will

be used for all diagnosis coding and ICD-10-PCS will be used for inpatient

hospital procedure coding.


General Equivalency Mappings

• These are translation crosswalks used to

roughly identify ICD-10-CM codes and their

ICD-9-CM equivalent codes.


Purpose of Reporting ICD-10-CM Codes

• Medical necessity – Determination that a service or procedure rendered is

reasonable and necessary for the diagnosis or treatment of an illness or injury

• Reporting a ICD-10-CM justifies the procedure codes reported.


ICD-10-CM Index to Diseases and Injuries

• Alphabetic listing of terms that include– Specific illnesses

– Injuries

– Eponyms

– Abbreviations

– Other descriptive diagnostic terms


ICD-10-CM Index

• The index of ICD-10-CM contains– Index to Diseases and Injuries

• Table of Neoplasms

• Table of Drugs and Chemicals

– Index to External Causes

• Main terms, subterms, and qualifiers are

used to locate codes in the index.


Index to Diseases

• Main terms– Printed in boldface type and are followed by the code

number

• Subterms (essential modifiers) – Qualify the main term by listing alternate sites,

etiology, or clinical status

• Qualifiers– Supplementary terms that modify subterms


ICD-10-CM Coding Conventions

• Format and typeface• Eponyms and abbreviations• Punctuation• Tables• Notes, excludes, and inclusion• Etiology and manifestation rules• “And”, “Due to”, “With”• Cross references


Neoplasm Table

• Neoplasms– New growths or tumors, where cell reproduction is out

of control.

– Provider should specify whether the tumor is benign or malignant.

– Neoplasms should be coded from the pathology report.


Neoplasm Table

• Indexed by anatomic site and contains four

cellular classifications– Malignant

• Primary

• Secondary

• Carcinoma in situ

– Benign

– Uncertain behavior

– Unspecified


Neoplasm Table

• Primary malignancy – Original tumor site

– All malignant tumors are considered primary• Unless otherwise documented as metastatic or secondary


Neoplasm Table (cont.)

• Primary malignancy– Malignancy is coded as the primary site if the

diagnostic statement documents• Metastatic from a site

• Spread from a site

• Primary neoplasm of a site

• Malignancy for which no specific classification is documented

• Recurrent (repeating) tumor


Neoplasm Table (cont.)

• Secondary malignancy– Tumor has spread to a secondary site.

• Either adjacent to the primary site or to a distant area of the body


Secondary Malignancies

• Metastatic and show that a primary cancer has spread to another area.


Secondary Malignancies (cont.)

• Cancer described as metastatic from a site is primary of that site.– Assign code to the primary neoplasm.

– Assign second code to the secondary neoplasm of the specified site or unspecified site.



• Cancer described as metastatic to a site is considered secondary of that site.– Assign one code to the secondary site and a second

code to the specified primary site or unspecified site.



• When anatomic sites are recognized as metastatic– Assign secondary neoplasm code(s) to those sites.

– Assign unspecified site code to the main malignant neoplasm.



• If the diagnostic statement does not specify whether the neoplasm site is primary or secondary– Code the site as primary unless the documented site is

one of the following: bone, brain, diaphragm, heart, liver, lymph nodes, mediastinum, meninges, peritoneum, pleura, retroperitoneum, or spinal cord.


Anatomic Site Not Documented• If the cancer diagnosis does not contain

documentation of the anatomic site but the term metastatic is documented, then assign codes for “unspecified site” for both the primary and secondary sites.


Primary Malignancy Site No Longer Present

• Do not assign the code for primary unspecified site. Instead, classify the previous primary site by assigning the appropriate code from category Z85, “Personal history of malignant neoplasm.”


Contiguous or Overlapping Sites

• Contiguous sites (or overlapping sites) occur when the origin of the tumor (primary site) involves two adjacent sites.

• Neoplasms with overlapping site boundaries are classified to the fourth-digit subcategory .8, “Other.”


Re-excision of Tumor• A surgeon, when performing a second

excision to widen the margins of the original tumor site – Ensures that all tumor cells have been removed.

– Uses the diagnostic statement found in the report of the original excision to code the reason for the re-excision.


Coding Tip• Read notes that apply to the condition you

are coding.

• Never assign a code directly from the table or Index to Diseases.

• Be certain codes represent the current status of the neoplasm.


Coding Tip• Assign a neoplasm code

– If a tumor has been excised and the patient is still undergoing radiation or chemotherapy

• Assign a Z code – If a tumor is not present

– If a patient is not receiving treatment but is returning for follow-ups


Coding Tip• In a pathology report

– Classification stated on a pathology report overrides morphology classification in the Index to Diseases.


Table of Drugs and Chemicals• Alphabetic index of medicinal, chemical,

and biological substances that result in poisonings, adverse effects, and underdosing.


Table of Drugs and Chemicals• Six columns in the table

– Poisoning: Accidental

– Poisoning: Intentional Self-harm

– Poisoning: Assault

– Poisoning: Undetermined

– Adverse effects

– Underdosing


Table of Drugs and Chemicals

Codes in categories T36 to T65 are combination codes that include the substance related to the adverse effect, poisoning, toxic effects, and underdosing, as well as the external cause.


Official Guidelines for Coding

The occurrence of drug toxicity is classified as

• Adverse effects

• Poisoning

• Underdosing

• Toxic effects


Index to External Causes

• These are arranged in alphabetical order,

indicating the main event that caused

the injury.

• These codes are secondary codes.


ICD-10-CM Tabular List

• Chronological list of codes contained in the 21 chapters

• Based on body system or condition


Tabular List

• Major topic headings, also called code block– Printed in bold uppercase letters and followed by codes

in parentheses


Tabular List

• Categories– Major topics are divided into three-character

categories.

• Subcategories– These contain either four or five characters.

• Codes may contain three, four, five, six, or seven characters.


Placeholder character

• ICD-10-CM uses the character “x” as a

placeholder.

• When a placeholder exists, the x must be

entered in order for the code to be considered

valid.


ICD-10-CM External Cause Codes

• Injury, poisoning, and certain other

consequences of external causes of

morbidity are incorporated in

ICD-10-CM in

– Chapter 19 – S and T codes

– Chapter 20 – V-Y codes


ICD-10-CM Health Status and Contact with Health Services Codes

• Factors influencing health status and contact

with health services are found in Chapter 21

of the ICD-10-CM (Z codes).

• These codes are always reported as diagnosis

codes.


Morphology of Neoplasm Codes

• Effective October 1, 2013, provider offices

will report morphology codes.

• Morphology indicates the tissue type of a

neoplasm.


Official Guidelines for Coding and Reporting

• CMS and NCHS prepare the

ICD-10-CM Official Guidelines for Coding

and Reporting.


ICD-10-CM Guidelines Sections

• Section I: Conventions, general coding guidelines, and chapter-specific guidelines• Section II: Selection of principal diagnosis• Section III: Reporting additional diagnosis• Section IV: Diagnostic coding and reporting guidelines for outpatient services• Appendix I: Present on admission reporting guidelines


Guidelines for Outpatient Services

• Selection of first-listed diagnosis

• ICD-10-CM Tabular List of Diseases

• Accurate reporting of ICD-10-CM diagnosis

codes

• Codes that describe signs and symptoms

• Encounters for circumstances other than a

disease or injury (Z codes)


Guidelines for Outpatient Services (cont.)

• Level of detail in coding

• ICD-10-CM code for the diagnosis, condition,

problem, or other reason for encounter/visit

• Uncertain diagnosis

• Chronic diseases

• Code all documented conditions that coexist

• Patients receiving diagnostic services only



• Patients receiving therapeutic services only

• Patients receiving preoperative evaluations

only

• Ambulatory surgery or outpatient surgery

• Routine outpatient prenatal visits



• Encounters for general medical examinations

with abnormal findings

• Encounters for routine health screenings

copyright © 2013 delmar, cengage learning. all rights reserved. icd-10-cm coding chapter 6b

Documents