pulmonology icd-10 cm training. icd-10-cm will be valid for dates of service on or after october 1,...
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• ICD-10-CM will be valid for dates of service on or after October 1, 2015– Outpatient dates of service of October 1, 2015 and
beyond. – Inpatient hospital service claims, is effective for dates of
discharge after September 30, 2015
ICD-10-CM Compliance Dates
• Covered Entities– Everyone covered by the Health Insurance Portability
Accountability Act (HIPPA)
• Non-Covered Entities– Worker’s Compensation– Auto Insurance– Non covered HIPAA entities are exempt but are
encouraged to adapt the new code set
Covered and Non-Covered Entities
• 21 Chapters• Alpha-numeric codes; not case-sensitive
– Codes begin with Alpha letter, A-Z, excluding U– Common errors
• I verses 1• O verses 0
• “X” Placeholder• 3 to 7 characters
– Decimal following 3rd character
ICD-10 Code Structure
• Placeholder “X”– Used for future expansion of a code– Fills in empty characters when a 6th and/or 7th character
apply– The placeholder may be used in different scenarios but
should never serve as the final character.
Example: W19.XXXA Unspecified fall, Initial Encounter
ICD-10 Code Structure
• 7th Character– Provides specified information regarding the clinical visit– Is required for certain categories and must be reported in
the seventh position– May be alpha or numeric– Has different meanings depending on the coding category
ICD-10 Code Structure
• Laterality– Some ICD-10-CM codes indicate laterality, specifying
whether the condition occurs on the left, right or is bilateral.
– If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.
– If the side is not identified in the medical record, assign the code for the unspecified side.
OGCR section 1.B.13
ICD-10 Code Structure
• “Other” Codes– Codes titled “other” or “other specified” are for use when
the information in the medical record provides detail for which a specific code does not exist.
• “Unspecified” Codes– Codes titled “unspecified” are for use when the
information in the medical record is insufficient to assign a more specific code.
OGCR section 1.A.9.a.b
ICD-10 Code Structure
• Excludes Notes– Excludes1
• A type 1 Excludes note is a pure excludes note• It means “NOT CODED HERE”• The code excluded should never be used at the same time• When two conditions cannot occur together
– Excludes2• Represents “Not included here”• The condition excluded is not part of the condition represented
by the code• It is acceptable to use both the code and the excluded code
together, when appropriateOGCR section 1.A.12.a.b
ICD-10 Structure
• “Code First” and “Use Additional Code”– ICD-10 has a coding convention that requires the
underlying condition be sequenced first followed by the manifestation.
– These instructional notes indicate the proper sequencing order of the codes.
OGCR section 1.A.13
• The “-” indicates there are additional reporting options
ICD-10 Code Structure
Chronic Obstructive Pulmonary Disease (COPD)ICD-9 Code ICD-10 Code Description Excludes1 Excludes2
496 J44.9 Chronic obstructive pulmonary disease, unspecified
Applicable to:• Chronic obstructive
airway disease NOS• Chronic obstructive
lung disease NOS
• Bronchiectasis (J47.-)• Chronic bronchitis NOS
(J43)• Chronic simple and
mucopurulent bronchitis (J14.-)
• Chronic tracheitis (J42)• Chronic tracheobronchitis
(J42)• Emphyysema without
chronic bronchitis (J43.-)• Lung diseases due to
external agents (J60-J70)
N/A
There are more specific code choice selections below:
491.22493.21
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
491.21493.22
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
• Code also type of asthma, if applicable (J45)• Use additional code to identify:
– Exposure to environmental tobacco smoke (Z77.22)– History of tobacco use (Z87.891)– Occupational exposure to environmental tobacco
smoke (Z57.31)– Tobacco dependence (F17.-)– Tobacco use (Z72.0)
COPD Documentation Tips
Shortness of breathICD-9 Code ICD-10 Code Description Excludes1 Excludes2
786.05 R06.02 Shortness of breath
• abnormalities originating in the perinatal period (P29.1-)
• specified arrhythmias (I47-I49)
• acute respiratory distress syndrome (J80)
• respiratory arrest (R09.2)• respiratory arrest of
newborn (P28.81)• respiratory distress
syndrome of newborn (P22.-)
• respiratory failure (J96.-)• respiratory failure of
newborn (P28.5)• tachypnea NOS (R06.82)• transient tachypnea of
newborn (P22.1)
• abnormal findings on antenatal screening of mother (O28.-)
• certain conditions originating in the perinatal period (P04-P96)
• signs and symptoms classified in the body system chapters
• Page 935• signs and symptoms of
breast (N63, N64.5)
There are more specific code choice selections below:
786.09 R06.00 Dyspnea, unspecified
786.02 R06.01 Orthopnea
786.09 R06.09 Other forms of dyspnea
• Use of symptom codes– Codes that describe symptoms and signs are acceptable for reporting purposes when a
related definitive diagnosis has not been established (confirmed) by the provider.
• Use of a symptom code with a definitive diagnosis code– Codes for signs and symptoms may be reported in addition to a related definitive
diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code.
– Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
• Combination codes that include symptoms– ICD-10-CM contains a number of combination codes that identify both the definitive
diagnosis and common symptoms of that diagnosis. When using one of these combination codes, an additional code should not be assigned for the symptom.
Documentation Tips
Sleep apnea (adult) (pediatric)ICD-9 Code ICD-10 Code Description Excludes1 Excludes2
327.20780.51
G47.30 Sleep apnea, unspecified
Applicable to:• Sleep apnea NOS
• Apnea NOS (R06.81)
• Cheyne-Stokes breathing (R06.3)
• Pickwickian syndrome (E66.2)
• Sleep apnea of newborn (P28.3)
• nightmares (F51.5)• nonorganic sleep disorders
(F51.-)• sleep terrors (F51.4)• sleepwalking (F51.3)
There are more specific code choice selections below: SEE NEXT SLIDE
Sleep apneaICD-9 Code ICD-10 Code Description Excludes1 Excludes2
327.21 G47.31 Primary central sleep apnea • Apnea NOS (R06.81)
• Cheyne-Stokes breathing (R06.3)
• Pickwickian syndrome (E66.2)
• Sleep apnea of newborn (P28.3)
• nightmares (F51.5)
• nonorganic sleep disorders (F51.-)
• sleep terrors (F51.4)
• sleepwalking (F51.3)
327.22 G47.32 High altitude periodic breathing
327.23 G47.33 Obstructive sleep apnea (adult) (pediatric)
327.24 G47.34 Idiopathic sleep related nonobstructive alveolar hypoventilation
Applicable To:• Sleep related hypoxia
327.25 G47.35 Congenital central alveolar hypoventilation syndrome
327.26 G47.36 Sleep related hypoventilation in conditions classified elsewhere
327.27 G47.37 Central sleep apnea in conditions classified elsewhere
327.29 G47.39 Other sleep apnea
Code also any associated underlying condition
Other nonspecific abnormal finding of lung fieldICD-9 Code ICD-10 Code Description Excludes1 Excludes2
793.19 R91.8 Other nonspecific abnormal finding of lung field
Applicable To:• Lung mass NOS found
on diagnostic imaging of lung
• Pulmonary infiltrate NOS
• Shadow, lung
• abnormal findings on antenatal screening of mother (O28.-)
• diagnostic abnormal findings classified elsewhere - see Alphabetical Index
N/A
There are more specific code choice selections below:
793.11 R91.1 Solitary pulmonary nodule
Applicable to:• Coin lesion lung• Solitary pulmonary nodule, subsegmental branch of the
bronchial tree
Includes:• nonspecific abnormal findings on diagnostic imaging by computerized axial tomography [CAT
scan]• nonspecific abnormal findings on diagnostic imaging by magnetic resonance imaging [MRI]
[NMR]• nonspecific abnormal findings on diagnostic imaging by positron emission tomography [PET
scan]• nonspecific abnormal findings on diagnostic imaging by thermography• nonspecific abnormal findings on diagnostic imaging by ultrasound [echogram]• nonspecific abnormal findings on diagnostic imaging by X-ray examination
Documentation Tips
AsthmaICD-9 Code ICD-10 Code Description Excludes1 Excludes2
493.00, 493.10 J45.20 Mild intermittent asthma, uncomplicated or NOS
• bronchitis due to chemicals, gases, fumes and vapors (J68.0)
• cystic fibrosis (E84.-)
493.01, 493.11 J45.22 Mild intermittent asthma with status asthmaticus
N/A N/A
493.02, 493.12 J45.21 Mild intermittent asthma with (acute) exacerbation
N/A N/A
493.82 J45.991 Cough variant asthma N/A N/A
493.90 J45.909J45.998
Unspecified asthma, uncomplicatedOther asthma
N/A N/A
493.91 J45.902 Unspecified asthma with status asthmaticus
• bronchitis due to chemicals, gases, fumes and vapors (J68.0)
• cystic fibrosis (E84.-)
493.92 J45.901 Unspecified asthma with (acute) exacerbation
• bronchitis due to chemicals, gases, fumes and vapors (J68.0)
cystic fibrosis (E84.-)
Asthma Severity ChartINTERMITTENT MILD
PERSISTENTMODERATE PERSISTENT
SEVERE PERSISTENT
SYMPTOMS 2 or less daysper week
More than 2days perweek
Daily Throughoutthe day
NIGHTIME AWAKENINGS
2 x’s permonth or less
3 – 4 x’s permonth
More thanonce perweek but notnightly
Nightly
RESCUE INHALER USE
2 or less daysper week
More than 2days perweek, but notdaily
Daily Several timesper day
INTERFERENCE WITH NORMAL ACTIVITY
None Minorlimitation
Somelimitation
Extremelylimited
LUNG FUNCTION FEVI>80% predicted and normal between exacerbations
FEV1>80%predicted
FEV1 60 –80%predicted
FEV1 lessthan 60%predicted
• When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site (e.g. tracheobronchitis to bronchitis in J40).
• Use additional code, where applicable, to identify:– exposure to environmental tobacco smoke (Z77.22)– exposure to tobacco smoke in the perinatal period (P96.81)– history of tobacco use (Z87.891)– occupational exposure to environmental tobacco smoke (Z57.31)– tobacco dependence (F17.-)– tobacco use (Z72.0)
Documentation Tips
CoughICD-9 Code ICD-10 Code Description Excludes1 Excludes2
786.2 R05 Cough • Cough with hemorrhage (R04.2)
• Smoker’s Cough (J41.0)
N/A
• Symptom Codes – Codes that describe symptoms and signs are acceptable for reporting
purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
• Use of a symptom code with a definitive diagnosis code– Codes for signs and symptoms may be reported in addition to a
related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis code.
• Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
Cough Documentation Tips
Cystic fibrosisICD-9 Code ICD-10 Code Description Excludes1 Excludes2
277.00 E84.9 Cystic fibrosis, unspecified
Includes:mucoviscidosis
• androgen insensitivity syndrome (E34.5-)
• congenital adrenal hyperplasia (E25.0)
• Ehlers-Danlos syndrome (Q79.6)
• hemolytic anemias attributable to enzyme disorders (D55.-)
• Marfan's syndrome (Q87.4)• 5-alpha-reductase
deficiency (E29.1)
N/A
There are more specific code choice selections below:
277.02 E84.0 Cystic fibrosis with pulmonary manifestationsUse additional code to identify any infectious organism present, such as: Pseudomonas (B96.5)
277.01 E84.11 Meconium ileus in cystic fibrosisExcludes1: meconium ileus not due to cystic fibrosis (P76.0)
277.03 E84.19 Cystic fibrosis with other intestinal manifestationsDistal intestinal obstruction syndrome
277.09 E84.8 Cystic fibrosis with other manifestations
Pulmonary fibrosisICD-9 Code ICD-10 Code Description Excludes1 Excludes2
515 J84.10 Pulmonary fibrosis, unspecified
Applicable to:• Capillary fibrosis of lung• Cirrhosis of lung
(chronic) NOS• Fibrosis of lung
(atrophic) (chronic) (confluent) (massive) (perialveolar) (peribronchial) NOS
• Induration of lung (chronic) NOS
• Postinflammatory pulmonary fibrosis
• drug-induced interstitial lung disorders (J70.2-J70.4)
• interstitial emphysema (J98.2)• lung diseases due to external
agents (J60-J70)• pulmonary fibrosis (chronic)
due to inhalation of chemicals, gases, fumes or vapors (J68.4)
• pulmonary fibrosis (chronic) following radiation (J70.1)
N/A
There are more specific code choice selections below:
J84.89 Other specified interstitial pulmonary diseases
• When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site (e.g. tracheobronchitis to bronchitis in J40).
• Use additional code, where applicable, to identify:– exposure to environmental tobacco smoke (Z77.22)– exposure to tobacco smoke in the perinatal period (P96.81)– history of tobacco use (Z87.891)– occupational exposure to environmental tobacco smoke (Z57.31)– tobacco dependence (F17.-)– tobacco use (Z72.0)
Documentation Tips
SarcoidosisICD-9 Code ICD-10 Code Description Excludes1 Excludes2
135 D86.9 Sarcoidosis, unspecified • autoimmune disease (systemic) NOS (M35.9)
• functional disorders of polymorphonuclear neutrophils (D71)
• human immunodeficiency virus [HIV] disease (B20)
N/A
There are more specific code choice selections below:
135 D86.0 Sarcoidosis of lung
Idiopathic interstitial pneumoniaICD-9 Code ICD-10 Code Description Excludes1 Excludes2
516.30 J84.111 Idiopathic interstitial pneumonia, not otherwise specified
• lymphoid interstitial pneumonia (J84.2)
• pneumocystis pneumonia (B59)
N/A
There are more specific code choice selections below:
516.31 J84.112 Idiopathic pulmonary fibrosis
516.32 J84.113 Idiopathic non-specific interstitial pneumonitis
516.33 J84.114 Acute interstitial pneumonitis
516.34 J84.115 Respiratory bronchiolitis interstitial lung disease
516.36 J84.116 Cryptogenic organizing pneumonia
516.37 J84.117 Desquamative interstitial pneumonia
• When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it shouldbe classified to the lower anatomic site (e.g. tracheobronchitis to bronchitis in J40).
• Use additional code, where applicable, to identify:– exposure to environmental tobacco smoke (Z77.22)– exposure to tobacco smoke in the perinatal period (P96.81)– history of tobacco use (Z87.891)– occupational exposure to environmental tobacco smoke (Z57.31)– tobacco dependence (F17.-)– Tobacco use (Z72.0)
Documentation Tips
BronchiectasisICD-9 Code ICD-10 Code Description Excludes1 Excludes2
494.0 J47.9 Bronchiectasis, uncomplicated
Applicable to:• Bronchiectasis NOS
• congenital bronchiectasis (Q33.4)
• tuberculous bronchiectasis (current disease) (A15.0))
N/A
There are more specific code choice selections below:
494.1 J47.0 Bronchiectasis with acute lower respiratory infectionApplicable to: Bronchiectasis with acute bronchitis
494.1 J47.1 Bronchiectasis with (acute) exacerbation
• When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it shouldbe classified to the lower anatomic site (e.g. tracheobronchitis to bronchitis in J40).
• Use additional code, where applicable, to identify:– exposure to environmental tobacco smoke (Z77.22)– exposure to tobacco smoke in the perinatal period (P96.81)– history of tobacco use (Z87.891)– occupational exposure to environmental tobacco smoke (Z57.31)– tobacco dependence (F17.-)– Tobacco use (Z72.0)
Documentation Tips
Multiple sclerosisICD-9 Code ICD-10 Code Description Excludes1 Excludes2
340 G35 Multiple sclerosis
Applicable To:• Disseminated multiple
sclerosis• Generalized multiple
sclerosis• Multiple sclerosis NOS• Multiple sclerosis of
brain stem• Multiple sclerosis of
cord
N/A
Chronic Obstructive Pulmonary Disease (COPD)ICD-9 Code ICD-10 Code Description Excludes1 Excludes2
496491.20
J44.9 Chronic obstructive pulmonary disease, unspecified
Applicable to:• Chronic obstructive
airway disease NOS• Chronic obstructive
lung disease NOS
• Bronchiectasis (J47.-)• Chronic bronchitis NOS
(J43)• Chronic simple and
mucopurulent bronchitis (J14.-)
• Chronic tracheitis (J42)• Chronic tracheobronchitis
(J42)• Emphyysema without
chronic bronchitis (J43.-)• Lung diseases due to
external agents (J60-J70)
N/A
There are more specific code choice selections below:
491.22493.21
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
491.21493.22
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
• Code also type of asthma, if applicable (J45)• Use additional code to identify:
– Exposure to environmental tobacco smoke (Z77.22)– History of tobacco use (Z87.891)– Occupational exposure to environmental tobacco
smoke (Z57.31)– Tobacco dependence (F17.-)– Tobacco use (Z72.0)
COPD Documentation Tips
Other respiratory disordersICD-9 Code ICD-10 Code Description Excludes1 Excludes2
519.8 J98.8 Other specified respiratory disorders
• newborn apnea (P28.4)
• newborn sleep apnea (P28.3)
• apnea NOS (R06.81)• sleep apnea (G47.3-)
There are more specific code choice selections below:
J98.01 Acute bronchospasm
J98.09 Other diseases of bronchus, not elsewhere classified
J98.11 Atelectasis
J98.19 Other pulmonary collapse
J98.2 Interstitial emphysema
J98.3 Compensatory emphysema
J98.4 Other disorders of lung
J98.5 Diseases of mediastinum, not elsewhere classified
J98.6 Disorders of diaphragm
J98.9 Respiratory disorder, unspecified
• When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it shouldbe classified to the lower anatomic site (e.g. tracheobronchitis to bronchitis in J40).
• Use additional code, where applicable, to identify:– exposure to environmental tobacco smoke (Z77.22)– exposure to tobacco smoke in the perinatal period (P96.81)– history of tobacco use (Z87.891)– occupational exposure to environmental tobacco smoke (Z57.31)– tobacco dependence (F17.-)– Tobacco use (Z72.0)
Documentation Tips
Localized swelling, mass and lump, trunkICD-9 Code ICD-10 Code Description Excludes1 Excludes2
786.6 R22.2 Localized swelling, mass and lump, trunk
• abnormal findings on diagnostic imaging (R90-R93)
• edema (R60.-)• enlarged lymph
nodes (R59.-)• localized adiposity
(E65)• swelling of joint
(M25.4-)• intra-abdominal or
pelvic mass and lump (R19.0-)
• intra-abdominal or pelvic swelling (R19.0-)
• abnormal findings on antenatal screening of mother (O28.-)
• certain conditions originating in the perinatal period (P04-P96)
• signs and symptoms classified in the body system chapters
• signs and symptoms of breast (N63, N64.5)
• breast mass and lump (N63)
• Symptom Codes – Codes that describe symptoms and signs are acceptable for reporting
purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
• Use of a symptom code with a definitive diagnosis code– Codes for signs and symptoms may be reported in addition to a
related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis code.
• Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
Documentation Tips
On October 01, 2015 we will monitor claims for date of service rules
• Outpatient claims cannot have crossover dates • Outpatient claims will be coded according to date of
service• Inpatient facility claims will be coded per date of discharge
We will monitor claims to resolve any unanticipated problems with the submission process
Monitor Claims
• We will monitor for claim denials• We will monitor editing trends for ICD-10 Coding
guidelines• We will provide feedback to the physicians regarding
supporting documentation requirements • We will monitor WC or Liability carriers for published
rules on use of ICD-9 or ICD-10 code sets
Claim Denial and Management
• Client will need to update – Templates– Order Sets– Superbills– Favorites
• Future Orders– Remove ICD-9 code add ICD-10 code
Client Responsibilities
All Conditions treated or assessed must be documented in the medical record. In addition to the documentation tips reviewed, below are more areas to document that will ensure proper ICD-10-CM code selection.
• Site specificity• Document notation of qualifiers
– Exacerbation– Manifestations– Relapse– Status– Stages
• Indicate acute or chronic• Indicate underlying or external cause factors
– Medication– Smoke– Accidents– Mechanical failure
• Laterality– Bilateral– Right – Left
Documentation – Start Now
• Episode of Care for injuries, poisoning, external causes and other conditions– Initial Encounter
• Use while the patient is receiving active treatment of the condition– Active treatment includes surgical treatment, an emergency encounter, and
evaluation and treatment by a new physician
– Subsequent Encounter• Used on encounter after the patient has received active treatment of
the condition and is receiving routine care for the condition during the healing or recovery phase.
– Medication adjustments, aftercare, device adjustments, cast change
– Sequela• Used for complications or conditions that arise as a direct result of a
condition, late effect
Documentation – Start Now
• Combination codes that capture– Etiology and manifestation– Related conditions– Disease, injury or other medical condition and
complications– Disease or other medical conditions and common signs or
symptoms
• Add ICD-10 Codes to patient Problem List
Documentation – Start Now
UnderdosingUnderdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer’s instruction. For underdosing, assign the code from categories T36-T50 (fifth or sixth character “6”).
Codes for underdosing should never be assigned as principal or first-listed codes. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded.
Noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.6-Y63.9) codes are to be used with an underdosing code to indicate intent, if known.
OGCR Section 1.C.19.e.5.c
Official Guidelines for Coding and Reporting
Centers for Disease Control and Prevention (ICD-10-CM)http://www.cdc.gov/nchs/icd/icd10cm.htm
Questions