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Medical Coding in History

The Black Death

Medical coding in its earliest form started as an attempt to avoid the Black Death. The bubonic plague, caused by the bacteria Yersinia pestis, arrived in Sicily via ship rats in 1347. It spread rapidly, reaching England in 1348. Almost half the city of London’s population of 70,000 died of the disease over the next 2 years. Given that life expectancy at the time was about 26 years and about 35% of children died before the age of 6, the Black Death contributed to the increased demise of the already death-ridden populace.

Italian author Giovanni Bocaccio lived through the plague in Florence in 1348. In his book The Decameron (1921), he describes how the Black Death got its name:

In men and women alike it first betrayed itself by the emergency of certain tumors in the groin or the armpits, some of which grew as large as a common apple…. The form of the malady began to change, black spots or livid making their appearance in many cases on the arm or the thigh or elsewhere, now few and large, then minute and numerous. These spots were an infallible token of approaching death.

The plague was highly contagious. As soon as people realized that contact with the sick could mean death, they isolated themselves. As Bocaccio describes:

Citizen avoided citizen, how among neighbors was scarce found any that showed fellow-feeling for another, how kinsfolk held aloof and never met. Fathers and mothers were found to abandon their own children, untended, unvisited, to their fate, as if they had been strangers.

Once the initial scourge was over, isolated outbreaks of plague continued in Europe throughout the next 3 centuries. It became an increasingly urban disease due to poor sanitation and crowded living conditions. The Great Plague of 1665 killed 25% of London’s population.  Figure 1-1  illustrates the garb worn by “plague doctors,” who filled the beak area with herbs that were thought to ward off the Black Death.

The London Bills of Mortality, shown in  Figure 1-2 , were published weekly, and as of 1629 included the cause of death. Information was collected by parish clerks in various geographic areas. In order to determine which areas had the most cases of plague, Londoners purchased copies of the Bills and tracked the spread of the disease from one parish to another in order to avoid it. During one week in 1665, when the total number of London deaths was 8,297, bubonic plague accounted for 7,165 of those deaths.

Causes of death found in the Bills include diseases recognized today, such as jaundice, smallpox, rickets, spotted fever, and plague. Other conditions have creative descriptions, such as “griping in the guts,” “rising of the lights” (croup), “teeth,” “king’s evil” (tubercular infection), “bit with a mad dog,” and “fall from the belfry.”

John Graunt, a London merchant, published Reflections on the Weekly Bills of Mortality in 1665. Its central theme was that deaths from plague needed to be examined in the context of all the other causes of mortality in order to understand the effects of all diseases. The 60 disease categories in the Bills constituted the first systematic attempt to analyze the incidence of disease.

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FIGURE 1-1 Plague doctor. The beak was filled with herbs thought to ward off the Black Death.

Courtesy of Wellcome Library, London.

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FIGURE 1-2 London Bills of Mortality, 1665.

Courtesy of Wellcome Library, London.

It was at this point that the science of epidemiology, the study of epidemics, was born.

During the 18th century, additional classifications were authored by Linnaeus in Sweden (Genera Morborum, 1763), Bossier de Lacroix in France (Nosologia Methodica, 1785), and Cullen in Scotland (Synopsis Nosologic Methodicae, 1785). Nosology is the branch of medicine that deals with classification of diseases.

William Farr and the Cholera Studies

As the first medical statistician for the General Register Office of England, Dr. William Farr revamped the Cullen disease classification to standardize the terminology and utilize primary diseases instead of complications. Farr incorporated additional data into his classification, enabling reporting and analysis of factors such as occupation and its effect on cause of death.

Farr’s dedication to what he called “hygology,” derived from hygiene, was evident in his analysis of the London cholera outbreak of 1849. More than 300 pages of tables, maps, and charts reviewed the possible influence of almost every conceivable death-related factor, including age, sex, rainfall, temperature, and geography. Even day of the week and property value were examined (Eyler, 2001).

The single association consistently present was the inverse relationship between cholera mortality and the elevation of the decedent’s residence above the Thames River. Unfortunately, this led Farr to the erroneous conclusion that the air was more polluted lower by the river, causing the transmission of cholera. He later converted to the correct waterborne germ theory of the disease after conducting a study during a second epidemic in 1866, which included data about the source of drinking water for those who died.

International List of Causes of Death

The need for a uniform classification of causes of death was recognized at the International Statistical Congress convened in Brussels in 1853. The Congress requested that Farr prepare a classification for consideration at its next meeting in Paris in 1855. His classification was based primarily on anatomical site and consisted of 138 rubrics (“History of Development,” n.d.).The list was adopted in 1864 and revised at four subsequent Congresses.

Farr died in 1883, and Jacques Bertillon, the chief statistician of the city of Paris, prepared a revised list that was adopted by the International Statistical Institute in 1893. Known as the Bertillon Classification, it was the first standard system implemented internationally. The American Public Health Association recommended its use in the United States, Canada, and Mexico by 1898. Delegates from 26 countries adopted the Bertillon Classification in 1900, and subsequent revisions occurred through 1920.

Beyond Death

After Bertillon’s death in 1922, interest grew in using the classification to categorize not only causes of mortality, but also causes of morbidity. Morbidity is a diseased state or the incidence of disease in a population. As early as 1928, the Health Organization of the League of Nations published a study defining how the death classification scheme would need to be expanded to accommodate disease tabulation.

Finally, in 1949, at the Sixth Decennial Revision Conference in Paris, the World Health Organization (WHO) approved a comprehensive list for both mortality and morbidity and agreed on international rules for selecting the underlying cause of death. Known as the “Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death,” it is generally referred to as ICD. From this point forward, the use of ICD was expanded for indexing and retrieval of records and for data concerning the planning and evaluation of health services.

Modern Times

The purpose of the ICD and of WHO sponsorship is to promote international comparability in the collection, classification, processing, and presentation of morbidity and mortality statistics. The United States implemented ICD-1 in 1900 and participated in every revision through ICD-7 until 1968. ICD was used for death classification until the sixth revision, when disease indexing began, and ICD was used for both purposes. With the eighth revision, the United States developed its own version, known as ICDA-8 or ICD-Adapted, due to disagreements over the circulatory section of the international version.

The International Conference for the Ninth Revision was attended by delegations from 46 countries. The classification was being pushed in the direction of more detail by those who wanted to use it for evaluation of medical care or for payment purposes. However, users in less sophisticated areas did not need a high level of detail in order to evaluate their healthcare activities. Steps were taken to ensure the usefulness of the new revision for all users, and the World Health Assembly adopted the ICD-9 revision in May 1976 for implementation effective January 1, 1979. As it did with ICD-8, the United States adopted a clinical modification of the international version, and ICD-9-CM (clinical modification) was used in the United States until October 1, 2015.

ICD-10 was endorsed by the WHO in 1990. Although ICD-10 has been used in the United States since 1999 to classify mortality data from death certificates, ICD-9 has been used for all other purposes, including billing and reimbursement.

ICD-10-CM is the diagnosis classification that will eventually be used in all healthcare settings by all types of providers. It was developed by the National Center for Health Statistics (NCHS) and the Centers for Disease Control and Prevention (CDC) as a clinical modification (CM) of the ICD-10 system used throughout the world. Other countries, such as Canada and Australia, have their own modifications of the international standard code set. The following table summarizes the differences between ICD-9-CM and ICD-10-CM and offers some of the benefits of specificity in the newer system.

ICD-9-CM Diagnosis Codes Versus ICD-10-CM Diagnosis Codes

ICD-9-CM Diagnosis Codes

ICD-10-CM Diagnosis Codes

Approximately 14,000 diagnosis codes

Approximately 69,000 diagnosis codes

Valid codes have three to five characters

Valid codes have three to seven characters

Decimal used after third character

Decimal used after third character

First character is alpha (E and V only) or numeric

First character is always alpha

Characters two through five are numeric

Second character is numeric

Characters three through seven are alpha or numeric

Laterality not addressed

Separate codes for laterality (left, right, bilateral) where appropriate

Initial versus subsequent encounters not addressed

Separate codes for initial and subsequent encounters in some chapters

Combination codes for commonly associated conditions are limited

Many combination codes available

Injuries grouped by type of injury

Injuries grouped by anatomic site

Some clinical concepts not represented, such as underdosing, blood alcohol level

Additional concepts available

Source:  Modified from ICD-10 Implementation Guide for Large Practices, 2013. Centers for Medicare and Medicaid Services. Available at  https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10_LargePractice_Handbook_060413[1].pdf .

ICD-10-PCS is the classification system that will eventually be used by hospitals to code inpatient procedures. These procedure codes will be used only in the United States. They were developed by 3M under contract with the Centers for Medicare and Medicaid Services (CMS) as a replacement for the outdated ICD-9-CM Procedure Codes. Because ICD-9 procedure codes have only four digits, the system has been severely limited in its ability to accommodate new technology and advances in surgical techniques. ICD-10-PCS is dramatically different in structure and methodology, utilizing the “root operation” concept, which describes the objective of the procedure. Other differences between ICD-9 Procedure Codes and ICD-10-PCS are as follows.

ICD-9-CM Procedure Codes Versus ICD-10-PCS Procedure Codes

ICD-9-CM Procedure Codes

ICD-10-PCS Procedure Codes

Approximately 4,000 procedure codes

Approximately 72,000 procedure codes

Valid codes have four digits, all numeric

Valid codes all have seven alphanumeric characters (the letters O and I are not used, to avoid confusion with 0 and 1)

Decimal used after second digit

No decimals used

Procedure codes often contained diagnostic concepts

Procedure codes are descriptive of the body system, body part, root operation, approach, device, and certain additional qualifying characters

No diagnostic information is included

Eponymic (named after a person) terms were common

No eponyms

Coding process involved finding procedure in the index and verifying it in the tabular lists

Coding process is directly from body system/root operation tables Each row in a table defines valid combinations of code values

Source:  Modified from ICD-10 Implementation Guide for Large Practices, 2013. Centers for Medicare and Medicaid Services. Available at  https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10_LargePractice_Handbook_060413[1].pdf .

Reflection of Society

Changes to ICD-9-CM over the years mirrored events in American society. The ICD-9-CM Coordination and Maintenance Committee, a joint effort of the National Center for Health Statistics (NCHS) and the CMS, considered code changes yearly. Although it was possible to code any disease using ICD-9-CM, newly identified or newly concerning conditions often fell into an “other” category, and the assignment of new specific codes was necessary to identify and count those disease entities.

1986

New codes assigned for HIV and AIDS. These were previously coded to the “deficiency of cell-mediated immunity” category. By 1986, over 15,000 deaths due to AIDS-related conditions had occurred in the United States, and the need for codes was evident.

1989

Lyme disease hit the news and was assigned an individual code. Although first observed in the United States in 1977 near Lyme, Connecticut, its identification as a tickborne illness caused growing concern throughout the rest of the country.

1991

Kaposi’s sarcoma was previously coded in the “other malignant neoplasm” category. Its incidence in AIDS patients made the need to separately identify it more important.

1992

As the popularity of contact lenses grew among Americans, so did the problems associated with them. A new code for corneal disease due to contact lenses was implemented.

1992

What do cooking oil in Spain and L-tryptophan in New Mexico have in common? More than 300 people died in Spain in 1981 due to “toxic oil syndrome,” reportedly due to use of contaminated cooking oil. A similar situation occurred in New Mexico in 1989, and on that occasion L-tryptophan was blamed. It was subsequently banned in the United States by the Food and Drug Administration (FDA). Both events involved eosinophilia myalgia syndrome, which got a new code in 1992. The Spanish epidemic is now thought to have been caused by organophosphate poisoning from insecticides (Woffinden, 2001).

1993

A newly understood connection between some types of HPV (human papillomavirus) and cervical cancer resulted in the assignment of a separate code for HPV. Investigators have found evidence of HPV in more than 90% of cervical cancers (CDC, n.d.).

1993

With the increasing use of potent antibiotics and other drugs to combat infection, the crafty bugs have developed resistance to those drugs. A series of codes to identify infection with drug-resistant microorganisms was created.

1995

As “couch potatoes” got fatter, the condition of “morbid obesity” got a separate code to distinguish it from other obesity. Morbid obesity is defined as greater than 125% over normal body weight.

1995

Sensational news reports about a “flesh-eating disease” described the effects of Group A streptococcus manifested as necrotizing fasciitis, a severe soft-tissue infection that can result in gangrene. A new code was assigned.

1996

As more premature infants survived due to better medical care, the incidence of RSV bronchiolitis increased. This was due to the respiratory syncytial virus. A new code was developed for identification purposes.

1996

A sign of the times was the addition of a new code for adult sexual abuse.

1997

Cryptosporidiosis and cyclosporosis got their own codes. These previously rare parasites began showing up more often. An outbreak in Wisconsin where 403,000 people were affected by their drinking water, and additional outbreaks a few years later thought to be caused by imported raspberries, pointed to the need for separate codes.

2002

Although toxic shock syndrome was identified in 1980, it did not receive its own code until 2002. Originally diagnosed in women using high-absorbancy tampons, toxic shock syndrome is now identified in other patients, both male and female, who are infected with Staphylococcus aureus.

2002

Newly arrived in the United States, the mosquito-borne West Nile Virus was assigned its own code.

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2002

Codes for the external causes of injury are also part of ICD. A new code was needed to identify injuries from paintball guns.

2002

Codes for coronary atherosclerosis had been around for years, but a new code was implemented to identify coronary atherosclerosis in a transplanted heart.

2002

An entire series of codes was added to classify the external causes of injury and death due to terrorism. Among them were codes for terrorism involving biological weapons and terrorism involving destruction of aircraft, including aircraft used as a weapon.

2003

The evening news showed international air travelers wearing surgical masks. The reason—fear of contracting SARS, severe acute respiratory syndrome. This viral illness appeared in southern China in November 2002. Within 8 months, more than 8,000 people had contracted SARS, with almost 800 dying of the disease. SARS was assigned a new diagnosis code in 2003.

2004

“Dermatitis due to other radiation” was added. It includes tanning beds as radiation sources.

2005

The ever-popular “postnasal drip” got a separate code.

2006

Societal interest in combatting obesity resulted in new codes for pediatric body mass index (BMI) and personal history of bariatric surgery.

2006

A more specific code for altered mental status allowed tracking of this condition that often requires medical care.

2007

Changes in code terminology were needed to reflect current usage. “Sexually transmitted disease” replaced “venereal disease.”

2008

Recognition of environmental causes of illness included exposure to mold, which got its own code.

2009

Quality improvement programs requested and received new codes to categorize operative errors, such as wrong procedure, wrong patient, or wrong body part.

2009

Ongoing U.S. military involvement overseas required implementation of a new code for “family disruption due to family member on military deployment.”

2010

A code added for crack cocaine poisoning.

2011

The last regular, annual updates were made to ICD-9-CM.

2012

The Coordination and Maintenance Committee implemented a partial freeze to both ICD-9-CM and ICD-10-CM/PCS, in effect until October 1, 2015. The purpose of the freeze was to facilitate the planned implementation of ICD-10 in 2014, without the need to deal with major last-minute changes.

2013

Limited updates were allowed to capture new technologies and diseases.

2014

On March 27, 2014, the U.S. House of Representatives passed by voice vote H.R. 4302, a bill “to amend the Social Security Act to extend Medicare payments to physicians and other provisions of the Medicare and Medicaid programs, and for other purposes.” The intent of this bill was to “patch” the sustainable growth rate (SGR) formula for physician payment that was set to expire on March 31, 2014. The U.S. Senate passed the bill on March 31 and it was signed into law by the president on April 1, 2014. The bill contained a clause prohibiting the Secretary of Health and Human Services from requiring implementation of ICD-10-CM and ICD-10-PCS until October 1, 2015. This additional delay will give unprepared providers more time to ready their practices for ICD-10.

Preparation for Coding Success

Because of the greatly increased level of detail in ICD-10-CM and ICD-10-PCS, it is even more important that individuals involved in coding and billing be prepared to use the new systems correctly. In addition to studying medical terminology, anatomy and physiology, and disease processes, exposure to real or sample provider documentation is very important. Being able to read a discharge summary or an operative report and visualize what was done is key to assigning correct codes.

References

Bocaccio, G. (1921). The decameron. (J. M. Rigg, Trans.). London: The Navarre Society. (Original work published in 1348–1353)

Centers for Disease Control and Prevention. (n.d.). HPV-associated cancers statistics. Retrieved December 10, 2013, from  http://www.cdc.gov/cancer/hpv/statistics/

Eyler, J. M. (2001). The changing assessments of John Snow’s and William Farr’s cholera studies. Soz.-PrŠventivmed, 46, 225–232. Retrieved December 11, 2013, from  http://www.epidemiology.ch/history/papers/eyler-paper-1.pdf

History of the development of the ICD. (n.d.). Retrieved December 10, 2013, from  http://www.who.int/classifications/icd/en/HistoryOfICD.pdf

Woffinden, B. (2001, August 25). Cover-up. The Guardian. Retrieved December 10, 2013, from  http://www.theguardian.com/education/2001/aug/25/research.highereducation

CHAPTER 2

Diagnosis Coding: A Number for Every Disease

What Is a Diagnosis?

A diagnosis is the identification of a disease from its symptoms. Obviously, the next question is, “What is a symptom?” You are the best judge of that, because a symptom is a perceptible change in your body or its functions that can indicate disease. Although it is possible to be sick or have a disease and have no symptoms, a symptom is a hint that there may be a problem and that you should seek professional help.

When you have a sore throat, that is a symptom. If the sore throat lasts more than a day or two, you will probably visit your doctor to get his or her opinion about the cause of the sore throat. Based on your symptom, the sore throat, and an exam of your physical condition, the doctor may arrive at a diagnosis. More than 100 diagnoses could possibly be the cause of your sore throat. How will the doctor arrive at the correct diagnosis?

Deducing the Diagnosis: History

The first step in the path toward a diagnosis is the history. The doctor may ask you questions such as the following:

img How long have you had the sore throat? (duration)

img What part of your throat hurts? (location)

img Is the pain continuous? Does it become better or worse? (timing)

img How does it compare to other sore throats you have had? (severity)

img Do you also have other symptoms? (associated signs and symptoms)

img What are you doing when it hurts? (context)

img How would you describe the pain? (quality)

img What have you done to obtain relief? Did it work? (modifying factors)

These eight categories of questions are known as the History of Present Illness (HPI). They constitute a chronological description of your present illness from the first sign or symptom to the present. Once you have responded to these questions, the direction to go next will usually be clearer to the doctor.

Review of Systems (ROS) is an inventory of body systems obtained through a series of questions that seek to identify signs and/or symptoms that you may be experiencing ( Figure 2-1 ). Your doctor may give you a check-off form to fill out in order to get your responses to these questions.

There are 14 systems that the doctor may review:

Constitutional  

Weight, temperature, fatigue, sleep habits, eating habits

Eyes

Vision, use of glasses, pain, blurry vision, halos, redness, tearing, itching

Ears, Nose, Mouth, Throat

Pain, hearing loss, infections, nose bleeds, ringing in ears, runny nose, colds, toothaches, sore throat, sores

Cardiovascular

Chest pain, shortness of breath on exertion, murmurs, palpitations, varicose veins, edema, hypertension

Respiratory

Cough, wheezing, bronchitis, color of sputum, spitting up blood

Gastrointestinal

Stomach pain, heartburn, nausea, vomiting, bloating, bowel movements, hemorrhoids, indigestion

Genitourinary

Blood in urine, incontinence, pain on urination, urgency, frequency, urinating at night, dribbling Female: menstrual history, sexual history, infections, Pap smears, menopause Male: hernias, sexual history, pain, discharge, infections

Musculoskeletal

Joint pain, swelling, redness, limited range of motion, stiffness, deformity

Skin/Breast

Lesions, lumps, sores, bruising, itching, dryness, moles

Neurological

Dizziness, fainting, seizures, falls, numbness, pain, abnormal sensation, vertigo, tremor

Psychiatric

Depression, anxiety, memory loss, sleep problems, nervousness

Endocrine

Hot or cold intolerance, goiter, protruding eyeballs, diabetes, hair distribution, increasing thirst, thyroid disorders

Hematologic/Lymphatic Allergy/Immune

Anemia, bruising, enlarged lymph nodes, transfusion history Hay fever, drug or food allergies, sinus problems, HIV status, occupational exposure

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FIGURE 2-1 “Review of symptoms” form your doctor may ask you to complete.

The doctor may perform all or part of the review of systems, depending on your presenting problem. The review of systems is intended to identify symptoms you may have forgotten to mention. It also explores and provides support for the doctor’s theory about the cause of your symptom. If he feels that the sore throat is due to a respiratory allergy, you can expect to see the respiratory and allergy portions emphasized in the review of systems.

Because hereditary or environmental factors contribute to many diseases, the final part of the history performed by the doctor is the past, family, and social history.

Past history includes illnesses, surgeries, medications, and allergic reactions. A thorough documentation of past history should include checking by the physician for objective evidence that the reported conditions actually existed. Lab results and diagnostic testing reports in your medical record should support the history.

Family history covers any factor within your immediate family that may affect you or the probability that you will have specific conditions, such as cancer, diabetes, heart disease, or other hereditary risk factors. The presence of communicable diseases that are not hereditary can also be important if you are exposed through contact with your family.

Social history encompasses a wide variety of habits, including the following:

img Smoking history: How much, how long

img Alcohol intake: Type, quantity, frequency

img Other drug use: Type, route, frequency, duration

img Sexual activity: Gender orientation, birth control, marital status, risk factors

img Work history: Occupation, risk factors

img Hobbies, activities, interests

The information in the social history not only provides additional information relevant to determining the cause of the presenting symptoms but also can facilitate the physician–patient relationship if your doctor knows more about you as a person and not just as a body.

Deducing the Diagnosis: Exam

According to the federal government’s Center for Medicare and Medicaid Services (CMS), your doctor can perform 12 different types of physical examinations. Unless you are seeing a specialist, your doctor will usually perform a “general multisystem examination,” including the systems he or she feels are relevant to your presenting problem or symptom.

The following are a few definitions of terms used in describing physical exam procedures:

img Palpation: Examination by pressing on the surface of the body to feel the organs or tissues underneath.

img Auscultation: Listening to sounds within the body, either by direct application of the ear or through a stethoscope.

img Percussion: A method of examination by tapping the fingers at various points on the body to determine the position and size of structures beneath the surface.

The officially defined “general multisystem examination” includes the following (Center for Medicare and Medicaid Services, n.d.) categories.

CONSTITUTIONAL

img Measurement of any three of the following seven vital signs:

img Sitting or standing blood pressure

img Supine blood pressure

img Pulse rate and regularity

img Respiration

img Temperature

img Height

img Weight

img General appearance of the patient (e.g., development, nutrition, body habits, deformities, attention to grooming)

EYES

img Inspection of conjunctivae and lids

img Examination of pupils and irises (e.g., reaction to light and accommodation, size and symmetry)

img Ophthalmoscopic examination of optic discs (e.g., size, C/D ratio, appearance) and posterior segments (e.g., vessel changes, exudates, hemorrhages)

EARS, NOSE, MOUTH, AND THROAT

img External inspection of ears and nose (e.g., overall appearance, scars, lesions, masses)

img Otoscopic examination of external auditory canals and tympanic membranes

img Assessment of hearing (e.g., whispered voice, finger rub, tuning fork)

img Inspection of nasal mucosa, septum, and turbinates

img Inspection of lips, teeth, and gums

img Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx

NECK

img Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)

img Examination of thyroid (e.g., enlargement, tenderness, mass)

RESPIRATORY

img Assessment of respiratory effort (e.g., intercostals retractions, use of accessory muscles, diaphragmatic movement)

img Percussion of chest (e.g., dullness, flatness, hyperresonance)

img Palpation of chest (e.g., tactile fremitus)

img Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs)

CARDIOVASCULAR

img Palpation of heart (e.g., location, size, thrills)

img Auscultation of heart with notation of abnormal sounds and murmurs

img Examination of

img Carotid arteries (e.g., pulse amplitude, bruits)

img Abdominal aorta (e.g., size, bruits)

img Femoral arteries (e.g., pulse amplitude, bruits)

img Pedal pulses (e.g., pulse amplitude)

img Extremities for edema and/or varicosities

CHEST (BREASTS)

img Inspection of breasts (e.g., symmetry, nipple discharge)

img Palpation of breasts and axillae (e.g., masses or lumps, tenderness)

GASTROINTESTINAL (ABDOMEN)

img Examination of abdomen with notation of presence of masses or tenderness

img Examination of liver and spleen

img Examination for presence or absence of hernia

img Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses

img Obtain stool sample for occult blood test when indicated

GENITOURINARY

Male

img Examination of the scrotal contents (e.g., hydrocele, spermatocele, tenderness of cord, testicular mass)

img Examination of the penis

img Digital rectal examination of prostate gland (e.g., size, symmetry, nodularity, tenderness)

Female

Pelvic examination (with or without specimen collection for smears and cultures) including:

img Examination of external genitalia (e.g., general appearance, hair distribution, lesions) and vagina (e.g., general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)

img Examination of urethra (e.g., masses, tenderness, scarring)

img Examination of bladder (e.g., fullness, masses, tenderness)

img Examination of the cervix (e.g., general appearance, lesions, discharge)

img Examination of the uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent, or support)

img Examination of the adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity)

LYMPHATIC

Palpation of lymph nodes in two or more areas:

img Neck

img Axillae

img Groin

img Other

MUSCULOSKELETAL

img Examination of gait and station

img Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)

img Examination of joints, bones, and muscles of one or more of the following six areas: (1) head and neck; (2) spine, ribs, and pelvis; (3) right upper extremity; (4) left upper extremity; (5) right lower extremity; and (6) left lower extremity. The examination of a given area includes:

img Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions

img Assessment of range of motion with notation of any pain, crepitation, or contracture

img Assessment of stability with notation of any dislocation (luxation), subluxation, or laxity

img Assessment of muscle strength and tone (e.g., flaccid, cogwheel, spastic, with notation of any atrophy or abnormal movements

SKIN

img Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)

img Palpation of skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening)

NEUROLOGIC

img Test cranial nerves with notation of any deficit

img Examination of deep tendon reflexes with notation of any pathological reflexes (e.g., Babinski)

img Examination of sensation (e.g., by touch, pin vibration, proprioception)

PSYCHIATRIC

img Description of patient’s judgment and insight

img Brief assessment of mental status, including:

img Orientation to time, place, and person

img Recent and remote memory

img Mood and affect (e.g., depression, anxiety, agitation)

Reality Check

You are thinking, “My doctor spent 15 minutes with me and didn’t do half of this stuff!” You are correct. The extent of the examination will depend on what your doctor needs to examine or measure in order to identify the cause of your sore throat. A likely scenario would be taking your vital signs (done by the nurse), examining your throat, looking at your ears to see if your tympanic membranes are involved, listening to your chest, and possibly palpating your lymph nodes. The doctor will also observe your general appearance for additional signs.

Some of the information obtained during the physical exam is noted solely by observation. The doctor can tell just by looking whether you have a rash that might indicate a disease related to a sore throat. Likewise, your ability to walk across the room and climb up on the exam table will provide clues to your gait. The discussion between you and your doctor will yield information about your judgment and insight into your mental status.

Deducing the Diagnosis: Medical Decision Making

Now that your doctor knows the history of your sore throat and has examined you, the next step in the process of arriving at a diagnosis is medical decision making. This involves assessment of the objective data and selection of the most likely cause of your sore throat. It may involve additional diagnostic testing, such as a throat culture to check for bacteria. If you are a smoker or if it is goldenrod season, the doctor may suspect other causes.

In complicated cases with many presenting symptoms, the doctor may use the process of differential diagnosis, which is weighing the probability of one disease versus another as the cause of the patient’s symptoms. Sore throat can be caused by bacterial or viral infection, throat irritation or inflammation, allergic reaction, fungal infection, or even just dry air.

Your doctor will make a decision about why your throat is sore and provide a treatment plan that may involve prescription or over-the-counter medications; symptomatic treatments, such as gargles; or environmental changes, such as a humidifier.

Documenting the Diagnosis

Once the decision-making process is complete, the doctor must document the diagnosis in your medical record. A complete diagnostic statement always includes the following:

img Site: The physical location; if the location has laterality (left or right), it must be documented as well.

img Etiology: The cause of the condition.

For your sore throat, a complete diagnostic statement might be the following:

img “Strep pharyngitis”

img Site = pharynx

img Etiology = streptococcal bacteria

What Number Is My Diagnosis?

Now that you have a diagnosis documented in words by your doctor, it can be converted into a diagnosis code number. The International Classification of Diseases, Revision 10, Clinical Modification (ICD-10-CM) will be used in the United States for diagnosis coding as of 2015. It contains over 71,000 unique codes. This does not mean that each of the more than 100,000 known disease entities has a separate code. When the phrase “diagnosis code” is used, its actual meaning is “diagnosis category code.”

An example of a diagnosis category is R79.0, “Abnormal level of blood mineral.” This code category includes abnormal blood levels of cobalt, copper, iron, magnesium, or zinc. Use of R79.0 does not tell you which mineral is abnormal. Nor does it tell you whether the blood level is abnormally low or abnormally high.

A diagnosis code category is analogous to a zip code. The zip code 04558 is for Maine, but it covers two towns, New Harbor and Pemaquid. With just the zip code number, it is not possible to positively identify which town is intended.

The translation process known as coding takes the words documented as a diagnosis and converts them into a diagnosis category code number. This is necessary not only for statistical purposes, but also because of the variation in the naming conventions for diseases. Regional differences in medical terminology in the United States may result in several different terms for the same disease entity.

Your sore throat diagnosis, “strep pharyngitis,” is assigned to a category code number by a two-step process.

1. The main term or noun, “pharyngitis,” is located in the alphabetical part of ICD-10-CM, the index to diseases; the subterm or adjective “strep” is searched for under “pharyngitis” ( Figure 2-2 ).

2. A category code number, J02.0, is listed next to the entry for “Pharyngitis, streptococcal.” In order to ensure that this number is correct, it is necessary to verify the number in the numerical part of ICD-10-CM, known as the tabular list ( Figure 2-3 ).

The diagnostic terms listed under J02.0 include not only streptococcal pharyngitis, but also septic pharyngitis and streptococcal sore throat. Previously, in ICD-9-CM, the code for strep pharyngitis also included strep laryngitis and strep tonsillitis. These have their own codes in ICD-10-CM, an example of its higher specificity.

img

FIGURE 2-2 Pharyngitis index entries.

Reproduced from ICD-10-CM Code Index to Diseases and Injuries, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html.

img

FIGURE 2-3 Pharyngitis tabular entries.

Reproduced from ICD-10-CM Tabular List of Diseases and Injuries, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html.

How Hard Can This Be?

The two-step coding process just described sounds straightforward: look in the alphabetical index and then verify the number in the tabular list. Why can’t this be done by a computer? In fact, most hospitals and other medical facilities do use computerized coding tools called encoders to facilitate the coding process. They range from simple programs that are only replications of the coding books in a computerized format to sophisticated interactive software that asks all of the questions necessary to arrive at the correct diagnosis category code.

For your sore throat diagnosis, the simple encoder would bring up the list of pharyngitis entries, and the coding analyst would have to select “streptococcal” from that list. The sophisticated encoder would find pharyngitis and then ask the user the questions “Due to bacteria?” and then “Due to which bacteria?” before selecting a code. Branching logic in the sophisticated products ensures correct code selection in complex disease entities.

Why can’t the computer do it all? The coding process is subject to any number of potential problems that make it essential that a coding analyst, a knowledgeable human being, be involved. Because diagnosis codes are often used to determine reimbursement, the coding process is governed by rules that must be followed by any entity submitting a claim for payment by a third party such as a government program or private insurance.

Failure to follow these rules can result in the submission of a false claim, which is subject to criminal and civil penalties, including imprisonment and fines.

What can go wrong in the diagnosis coding process?

img Illegible physician handwriting

img Look at  Figure 2-4 . What do you think it says?

img

FIGURE 2-4 Illegible handwriting.

img Illogical physician diagnosis documentation

img “#1) Chest pain secondary to #1”

img “Fractured ear lobe” (not anatomically possible)

img Lack of physician documentation

img Transcription errors by typist or voice-recognition systems

img “Baloney amputation” (should be below-knee amputation)

img “Liver birth” (should be live birth)

img Content of the rest of the patient’s medical record does not support the diagnosis documented

img Lack of specificity

img “Anemia” (there are several hundred different types of anemia)

Each of these issues must be resolved before an accurate diagnosis code can be assigned.

What Are the Rules?

The rules for diagnosis coding in the United States are developed and approved by the Cooperating Parties for ICD-10-CM, which include the CMS, the National Center for Health Statistics (NCHS), the American Hospital Association (AHA), and the American Health Information Management Association (AHIMA). Both ICD-10-CM and the Official Guidelines for Coding and Reporting are in the public domain and may be accessed at no charge on the Internet or via public document depository library services (National Center for Health Statistics, 2014).

The rules are 117 pages and consist of the following:

img Conventions and general coding guidelines

img Chapter-specific guidelines

img Selection of principal diagnosis for inpatients

img Reporting additional diagnoses for inpatients

img Diagnostic coding and reporting guidelines for outpatient services

img Present-on-admission reporting guidelines

In addition to the official rules, federal and state government programs such as Medicare and Medicaid promulgate regulations intended to define appropriate code usage or add the weight of law to the guidelines. An example was the Medicare transmittal that defined for its contractors the appropriate rules for ICD-9-CM coding for diagnostic tests (Department of Health and Human Services, 2001). This transmittal was initially issued because of concerns about contractors in different geographic locations inconsistently interpreting the official guidelines. The transmittal language was later incorporated into the official claims processing manual.

Conventions: Section I.A.

Punctuation:

img Brackets [ ] are used in the tabular list to enclose synonyms, alternative wording, or explanatory phrases.

img Parentheses ( ) are used to enclose supplementary words that may be either present or absent in the statement of a disease without affecting the code number to which it is assigned. For example, see the following index entry:

Hallucinosis (chronic) F28

It makes no difference whether the word chronic is present in the diagnosis.

img Colons (:) are used in the tabular list after an incomplete term that needs one or more of the words following the colon to make it assignable to a specific category.

Abbreviations:

img NEC means “not elsewhere classifiable.” This is equivalent to “other specified,” which means the documentation in the medical record provides detail for which a specific code does not exist.

img NOS means “not otherwise specified.” This is equivalent to “unspecified,” indicating that the documentation in the medical record is insufficient to assign a more specific code.

Standard meanings:

img “And” should be interpreted to mean either “and” or “or.”

img “With” should be interpreted to mean “associated with” or “due to.”

Instructional Notes: Section I.A.

img “See” following a main term in the alphabetic index means that another term should be referenced. The correct code will not be located unless this instruction is followed.

img “See also” means that there is another main term that may have useful additional index entries that are helpful, but it is not mandatory to follow the “see also” instruction if the necessary code is found under the original main term.

img “Code first” mandates that the underlying etiology or cause of the condition to be coded must be coded first, and then the manifestation.

img “Use additional code” will be found at the etiology listing to remind coders that the manifestation should also be coded.

img “Code also” means that two codes may be needed to fully describe a condition, but the sequence of those codes is not defined.

img “Excludes type 1” is used when two conditions cannot occur together and should not be coded together.

img “Excludes type 2” means the excluded condition is not part of the condition represented by the code, but the two codes may be used together, if appropriate.

General Coding Guidelines: Section I.A.

These guidelines tell coding analysts the basic information they need in order to code correctly, based on physician documentation.

img Locate each term in the alphabetic index and verify the code selected in the tabular list. The alphabetic index does not always provide the full code, so it is mandatory to reference the tabular list as well. Read and be guided by any instructional notations.

img Valid diagnosis codes may have three, four, five, six, or seven characters. Any code with more than three characters has a decimal point after the third character. A code with fewer than seven characters may only be used if it is not further subdivided.

Example: “J14 Hemophilus pneumonia” may be used because it is not further subdivided. “J15 Bacterial pneumonia, NEC” may not be used with only three characters, because it is further subdivided into several four-character codes.

ICD-10-CM uses a placeholder, character “X,” at certain codes to allow for future expansion. The “X” placeholder may also be needed if a code that requires a seventh character is not a six-character code; the X must be used to fill in the empty characters.

img Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable if a related definitive diagnosis has not been established by the physician.

Example: R55, syncope (fainting), is a symptom code. It may be used if the physician does not identify and document a diagnosis responsible for the fainting.

img Signs and symptoms that are an integral part of a disease process should not be assigned as additional codes.

Example: Shortness of breath is integral to congestive heart failure and would not be coded separately.

img Signs and symptoms that may not be associated routinely with a disease process should be coded when present.

img Some single conditions may require more than one code for a full description. Generally, one code is for the etiology and the other is for the manifestation of the disease. Additional situations requiring more than one code are related to sequelae, complications, and obstetrical cases.

img When a condition is described as both acute and chronic, code both and sequence the acute code first.

Example: Acute sinusitis is J01.90. Chronic sinusitis is J32.9. Both codes would be used for a diagnostic statement of “Acute and chronic sinusitis.”

img Combination codes are single codes used for a combination of two diagnoses, or a diagnosis with an associated manifestation or complication. Do not use multiple codes if a combination code describes all of the elements.

Example: Acute cholecystitis is K81.0. Chronic cholecystitis is K81.1. Acute cholecystitis with chronic cholecystitis is K81.2. Only K81.2 would be used to describe both.

img A sequela, or late effect, is the residual effect after the acute phase of an illness or injury has terminated. There is no time limit as to when a sequela code can be used. The condition or nature of the sequela is coded first, and the sequela code second.

What Is the Structure of the Diagnosis Codes?

How is the diagnosis system set up to handle the thousands of coding categories in a logical fashion? The 21 chapters in the Classification of Diseases and Injuries are divided along two major schemes:

1. Anatomic system chapters, such as “Diseases of the Digestive System”

2. Disease or condition categories, such as the “Neoplasms” chapter, where all neoplasms are found, regardless of anatomic location

Chapter Title

Code Range

  1. Certain Infectious and Parasitic Diseases

A00–B99

  2. Neoplasms

C00–D49

  3. Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism

D50–D89

  4. Endocrine, Nutritional, and Metabolic Diseases

E00–E89

  5. Mental, Behavioral, and Neurodevelopmental Disorders

F01–F99

  6. Diseases of the Nervous System

G00–G99

  7. Diseases of the Eye and Adnexa

H00–H59

  8. Diseases of the Ear and Mastoid Process

H60–H95

  9. Diseases of the Circulatory System

I00–I99

10. Diseases of the Respiratory System

J00–J99

11. Diseases of the Digestive System

K00–K95

12. Diseases of the Skin and Subcutaneous Tissue

L00–L99

13. Diseases of the Musculoskeletal System and Connective Tissue

M00–M99

14. Diseases of the Genitourinary System

N00–N99

15. Pregnancy, Childbirth, and the Puerperium

O00–O9A

16. Certain Conditions Originating in the Perinatal Period

P00–P96

17. Congenital Malformations, Deformations, and Chromosomal Abnormalities

Q00–Q99

18. Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified

R00–R99

19. Injury, Poisoning, and Certain Other Consequences of External Causes

S00–T88

20. External Causes of Morbidity

V00–Y99

21. Factors Influencing Health Status and Contact with Health Services

Z00–Z99

Within each ICD-10-CM chapter and section, there are categories that are arranged in a mostly logical fashion, either by body site or by the cause or etiology. Subcategories are arranged the same way, with a fourth character of “8” generally used to indicate some “other” specified condition, and the fourth character “9” usually reserved for unspecified conditions.

Which Diagnosis Is Listed First?

The sequencing of diagnosis codes is intimately linked to reimbursement, and thus is also defined by official rules.

INPATIENT

The Uniform Hospital Discharge Data Set, or UHDDS, applies to diagnosis sequencing for all non-outpatient settings (inpatient, short-term care, acute care, psychiatric, and long-term care hospitals; home health agencies; rehab facilities; and nursing homes). It has been in use since 1985 and defines the principal diagnosis as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care” (“1984 Revision,” 1985). According to this definition, if you are admitted to the hospital because of chest pain but fall out of bed and break your hip, the chest pain will still be your principal diagnosis, even if you end up staying an extra 2 weeks to have your hip repaired.

The sequencing rules for inpatients are found in Sections II and III.

img Do not use a symptom or sign as the principal diagnosis if a definitive diagnosis has been established.

img If there are two or more interrelated conditions that could each meet the definition of principal diagnosis, either may be sequenced first.

img Comparative/contrasting conditions documented as “either/or” are sequenced according to the circumstances of the admission.

img If a symptom is followed by comparative/contrasting conditions, all are coded, with the symptom first. However, if the symptom is integral to the conditions listed, no code for the symptom is reported.

img Even if the original treatment plan is not carried out, follow the definition for principal diagnosis.

img If admission is for treatment of a complication, the complication code is sequenced first.

img If a patient is admitted for inpatient care after outpatient surgery at the same hospital, and if the reason for admission is a complication, that code would be sequenced first. If the admission is for another condition unrelated to the surgery, the unrelated condition goes first. If no complication or other condition is documented as responsible for the admission, use the reason for the outpatient surgery as the principal diagnosis.

img When the admission is for rehab, use the condition for which the service is being performed as the principal diagnosis. If that condition is no longer present, such as in a patient who is being admitted after a hip replacement, use the appropriate aftercare code as the principal diagnosis.

img If the diagnosis is documented as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “rule out,” the condition is coded as if it existed. Note that this rule varies significantly from that for outpatients (see the following section).

OUTPATIENT AND PHYSICIAN OFFICE

Because the UHDDS does not apply to outpatients, the selection of the first diagnosis is governed by the ICD-10-CM official guidelines. The first-listed diagnosis is defined as “the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided” (National Center for Health Statistics, 2014). Additional rules for outpatient sequencing are as follows:

img Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis.” Rather, code the condition to the highest degree of certainty for that encounter/visit, such as signs, symptoms, abnormal test results, or other reason for the visit. Note that this rule for outpatient sequencing differs significantly from that noted previously for inpatients.

img For patients receiving diagnostic services only, sequence first the diagnosis, condition, problem, or other reason shown to be responsible for the service. For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnoses, assign code Z01.89. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the nonroutine test. For outpatient encounters for diagnostic tests that have been interpreted by a physician and the final report is available at the time of coding, code any confirmed or definitive diagnoses documented in the interpretation.

img For patients receiving therapeutic services only, code first the diagnosis responsible for the service. An exception to this rule occurs if the encounter is for chemotherapy or radiation therapy, in which case the Z code for the service is listed first and the diagnosis second.

img For pre-op exams, use the appropriate Z code, followed by the condition necessitating the surgery and any findings related to the pre-op evaluation.

img For ambulatory surgery, use the diagnosis for which the surgery was performed. If the post-op diagnosis differs from the pre-op, select the post-op for coding.

img For routine prenatal visits when no complications are present, use the Z34 code for supervision of pregnancy. If the pregnancy is high-risk, a code from category O09 should be used.

img Encounters for general medical examinations should be coded according to whether abnormal findings resulted; a code for the finding should be used as an additional diagnosis.

What’s in Each Diagnosis Chapter?

As each ICD-10-CM diagnosis chapter is discussed, any applicable coding rules from the official guidelines will be included.

CHAPTER 1: CERTAIN INFECTIOUS AND PARASITIC DISEASES (A00–B99)

The diseases in this chapter are those considered to be communicable, either from human to human or from another host, such as a mosquito, to humans. Parasites are organisms that live in or feed on humans, such as worms. This chapter is the realm of public health departments across the nation that monitor and try to prevent outbreaks of communicable diseases.

The structure of this chapter is based primarily on the organism causing the condition to be coded, but it can also be grouped according to the primary body system affected. An example is the intestinal infectious diseases section (A00–A09), which includes cholera, typhoid, salmonella, shigellosis, food poisoning, and other intestinal infections. As new organisms are identified and new outbreaks of infectious diseases occur, additional codes are added to this chapter. Some of the conditions in this chapter represent diseases thought to be eradicated, such as smallpox. The last known case was in 1977. However, small quantities of the virus exist in research laboratories, and the potential for accidental exposure is still present, so it is necessary to retain the code for possible future use. For some conditions, vaccines have been developed for prevention but the diseases continue to occur in other age groups where many individuals have not been vaccinated. An example is whooping cough in adults.

In some coding categories, lots of detailed codes are available but the usual medical record documentation is too scanty to allow their use. An example from this chapter is tuberculosis. In ICD-9-CM, fifth-digit code assignment was based on the method by which the mycobacterium infection was confirmed (i.e., microscopy, bacterial culture, histological examination). This information was almost never readily available; in ICD-10-CM the classification of tuberculosis is based solely on the organs involved.

Specific official coding guidelines for conditions in this chapter include the following:

HIV (Human Immunodeficiency Virus Infections)

Seven code categories are available to describe HIV situations:

B20

HIV disease (includes AIDS)

O98.7_

HIV disease complicating pregnancy, childbirth, and the puerperium

Z21

Asymptomatic HIV infection status

R75

Inconclusive laboratory evidence of HIV

Z20.6

Exposure to HIV

Z11.4

Encounter for HIV screening

Z71.7

HIV counseling

The physician’s diagnostic statement that the patient is HIV positive or has an HIV-related illness is sufficient to code. Current documentation of positive serology or culture is not required.

HIV (Human Immunodeficiency Virus Infections)

Reason for Encounter

Use Codes

Treatment of HIV-related condition, AIDS

B20 plus additional codes for HIV-related conditions

Treatment of unrelated condition, such as an injury

Code for unrelated condition plus B20, plus codes for HIV-related conditions

Patient is “HIV-positive” without symptoms

Z21

Inconclusive HIV serology, no definitive diagnosis and no manifestations

R75

Previously diagnosed HIV-related illness; once the patient has developed an HIV-related illness, he or she should always be assigned to B20, never R75 or Z21

B20

HIV infection in pregnancy Note: Codes from Chapter 15 always take sequencing priority

O98.7_ plus B20, plus codes for HIV-related conditions

Asymptomatic HIV during pregnancy

O98.7_ plus Z21

HIV testing

Z11.4

Receive results of HIV testing if results are negative Note: If results are positive, see previous guidelines above

Z71.7

Source:  Data from International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), 2014. Centers for Medicare and Medicaid Services and the National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

Sepsis, Severe Sepsis, and Septic Shock

Sepsis is an illness in which the body has a severe response to bacteria or other germs. This response may be called systemic inflammatory response syndrome (SIRS). Septic shock refers to circulatory failure associated with severe sepsis.

Sepsis, Severe Sepsis, and Septic Shock

Reason for Encounter

Use Code

Urosepsis

This is a nonspecific term with no default code. The provider must be queried for clarification if this term is used.

Bacteremia/septicemia (bacteria in blood) without documented sepsis diagnosis

Use R78.81.

Sepsis

Code for underlying systemic infection, or A41.9 if organism not specified.

Severe sepsis (sepsis with organ dysfunction)

Code for underlying systemic infection plus a code from R65.2_ denoting severe sepsis, plus codes for the associated acute organ dysfunctions.

Septic shock (severe sepsis with circulatory failure)

Code for systemic infection plus R65.21, plus codes for other acute organ dysfunctions.

Sepsis or septic shock due to a postprocedural infection

T81.4, infection following a procedure or O86.0, infection of obstetrical surgical wound, is coded first, plus the code for the specific infection and any acute organ dysfunctions.

Source:  Data from International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), 2014. Centers for Medicare and Medicaid Services and the National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

Infections Resistant to Antibiotics

Related to the infectious disease codes are the Z16 codes for infection with antimicrobial-resistant organisms, which would be used as additional codes secondary to the infection code. In some cases, the infection codes themselves include resistance, such as A41.02, infection due to methicillin-resistant Staphylococcus aureus (MRSA), in which case a Z16 code would not be used.

CHAPTER 2: NEOPLASMS (Coo–D49)

The word neoplasm means “new growth.” From a coding perspective, there are four types of neoplasms:

img Malignant: In common usage, the term cancer is used to describe a malignant neoplasm. These new growths are usually invasive, spreading to the lymph system and to distant sites in the body (metastases).

img Primary: Malignant neoplasm in the site where it originated

img Secondary: Malignant neoplasm in the site it has metastasized to, or spread to

img In situ: Carcinoma cells that are still confined to the original site and are undergoing malignant changes

img Benign: Although benign neoplasms do not spread to other sites, their growth may cause problems due to size, putting extra pressure on nearby structures. Some benign neoplasms, such as adenomatous polyps of the colon, are classified as benign but are considered “precancerous,” requiring ongoing monitoring.

img Uncertain behavior: For some tumors, a decision cannot be made about whether they are benign or malignant, even upon pathology examination.

img Unspecified nature: This category is for neoplasm documentation that is not specific enough to determine the behavior.

Specific official coding guidelines for conditions in this chapter include the following.

Neoplasms

Reason for Encounter

Use Code

Treatment of the primary malignancy (not chemo or radiation)

Code for malignant neoplasm of primary site

Treatment of a secondary (metastatic) site only

Code for malignant neoplasm of secondary site

Treatment of anemia associated with malignancy

Code for malignancy plus code for anemia

Treatment of anemia associated with chemotherapy, immunotherapy, or radiation therapy

Code for anemia plus code for neoplasm, plus code for the adverse effect

Treatment of dehydration due to malignancy or therapy

Code for dehydration plus code for malignancy

Treatment of complication of surgery

Code for complication

Treatment of pathological fracture due to neoplasm

Code for fracture plus code for neoplasm

Chemotherapy

Z51.11 plus code for malignancy

Radiation therapy

Z51.0 plus code for malignancy

Immunotherapy

Z51.12 plus code for malignancy

Cancer in a pregnant patient

Code from O9A.1_ malignant neoplasm complicating pregnancy, childbirth, or the puerperium, plus code for malignancy

Source:  Data from International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), 2014. Centers for Medicare and Medicaid Services and the National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

Care must be taken when the term metastatic is used. It can mean either a primary neoplasm that is spreading, such as a laryngeal tumor that has spread to a cervical lymph node, or it can be documented by the physician to refer to the metastatic site, such as “metastatic cancer, lymph node.”

In assigning neoplasm codes, it is essential that the search begin by looking for the morphologic type (name such as carcinoma, glioma, or leiomyoma). This is necessary in order to learn whether the neoplasm is malignant, benign, or other. Once this information is in hand, the search moves to the anatomic site. ICD-10-CM, like its predecessor, contains a Neoplasm Table arranged alphabetically by anatomic site.

Neoplasm Table Sample

img

Source:  Data from International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), 2014. Centers for Medicare and Medicaid Services and the National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

The guidelines include several rules about coding based on the extent of involvement of the neoplasm:

img A primary malignant neoplasm that overlaps two or more contiguous sites should be classified to the subcategory .8 (overlapping lesion) unless the combination is specifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous, such as tumors in different quadrants of the same breast, codes for each site should be assigned.

img Code C80.0, disseminated malignant neoplasm, unspecified, is for use only in those cases where the patient has advanced metastatic disease and no known primary or secondary sites are specified.

img When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and no evidence of any existing primary malignancy, a personal history of malignant neoplasm code from Z85 should be used.

CHAPTER 3: DISEASES OF THE BLOOD AND BLOOD-FORMING ORGANS (D50–D89)

Anemia accounts for the largest portion of this chapter. In order to classify it correctly, detailed documentation is needed. Deficiency anemias can be due to blood loss, malabsorption of nutrients, or nutritional deficiencies. Hemolytic anemias, in which red cells are destroyed at an abnormal rate, can be hereditary or acquired. Aplastic anemia occurs when the bone marrow fails to produce the normal amount of blood components. The other major part of this chapter is coagulation defects—when the blood does not clot properly. The most well-known condition of this type is hemophilia. Diseases of the white blood cells, with the exception of leukemia, also are in this chapter. Leukemia is in the neoplasms chapter.

Diseases of the spleen are included in this chapter, as are complications of spleen procedures.

There are no official coding guidelines related to this chapter.

CHAPTER 4: ENDOCRINE, NUTRITIONAL, AND METABOLIC DISEASES (E00–E89)

Endocrine glands secrete hormones directly into the bloodstream. The hormones travel to target organs and often are involved with metabolism, the chemical processes that take place in living tissues that are necessary for the maintenance of the organism. A disease state in an endocrine gland can affect not only the target organ but also related systems. This is demonstrated clearly in the complications of diabetes, which can affect the kidneys, eyes, nerves, and peripheral vascular system.

The endocrine diseases are organized according to the involved endocrine gland: thyroid, pancreas, parathyroid, pituitary, thymus, adrenal, ovarian, and testicular. The nutritional deficiencies are arranged with malnutrition first, followed by the various vitamin and mineral deficiencies. The metabolic disorders follow the substance being metabolized, such as carbohydrates, proteins, lipids. Additional codes for obesity round out the chapter.

Diabetes Mellitus

Diabetes coding changed radically with the introduction of ICD-10-CM. Previously, it was categorized as insulin-dependent or non-insulin-dependent and controlled or uncontrolled. ICD-10-CM has five categories of diabetes that are then further subdivided based on the body systems involved and the complications affecting them:

E08

Diabetes mellitus due to an underlying condition (secondary diabetes)

E09

Drug or chemical-induced diabetes mellitus (secondary diabetes)

E10

Type 1 diabetes

E11

Type 2 diabetes

E13

Other specified diabetes mellitus

Physician documentation of the type of diabetes is essential. It cannot be assumed that all patients on insulin are Type 1. If the type is not documented in the medical record, the default is E11, Type 2.

Diabetes Mellitus

Reason for Encounter

Use Code

Treatment of Type 1 diabetes (includes “brittle diabetes,” juvenile onset diabetes)

E10._: Use as many codes from this category as needed to describe all the complications of the disease. Use Z79.4 to denote long-term (current) use of insulin.

Treatment of Type 2 diabetes

E11._: Use as many codes from this category as needed to describe all the complications of the disease. If the patient uses insulin on an ongoing basis, use Z79.4.

Complications of diabetes, such as retinopathy, nephropathy, ketoacidosis, coma, ulcer

Code to the type of diabetes and organ system involvement.

Treatment of a secondary diabetes

Code first the underlying condition or the drug or chemical causing the diabetes, then the E08, E09, or E13 codes for the type of diabetes and organ involvement. If the patient uses insulin on an ongoing basis, use Z79.4.

Dietary counseling

Z71.3 plus code for diabetes.

Preexisting diabetes in pregnancy

O24.0_ or O24.1_: Code is based on the type of diabetes and trimester of pregnancy or childbirth or puerperium.

Gestational diabetes

O24.4_: Code based on trimester of pregnancy or childbirth or puerperium.

Source:  Data from International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), 2014. Centers for Medicare and Medicaid Services and the National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

A potentially problematic diagnosis category in this chapter is thyroid disorders (E00–E07). If the physician does not enunciate clearly or spell the words when dictating, you could end up with the wrong disease. “Hypothyroidism” and “hyperthyroidism” sound very similar to voice-recognition systems.

CHAPTER 5: MENTAL, BEHAVIORAL, AND NEURODEVELOPMENTAL DISORDERS (F01–F99)

The American Psychiatric Association (APA) has defined a mental disorder as “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotional regulation or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning” (Maisel, 2013). The APA’s Diagnostic and Statistical Manual of Mental Disorders, 5th edition (known as DSM-5) is a tool to assist clinicians in the diagnosis of mental disorders. It consists of an index of mental illnesses accompanied by listings of possible symptoms and diagnostic criteria. This classification is not used for healthcare billing purposes. In many cases, the clinician uses the DSM criteria to arrive at a DSM diagnosis that is then cross-walked to an ICD-10-CM diagnosis code.

More than other specialties, psychiatry is likely to have codeable services that are rendered by providers other than physicians. Clinical psychologists, counselors, social workers, and therapists participate in services for psychiatric patients. Psychiatry is also heavily involved with the legal system because of the need for involuntary treatment of some patients and the use of mental illness as a defense in legal cases.

ICD-10-CM includes some new terminology in this chapter. Mental retardation is now known as “intellectual disabilities.” Stuttering has the new title of “childhood onset fluency disorder.” Areas where DSM-5 and ICD-10-CM are no longer in sync include “autism spectrum disorder.” In DSM-5, this new diagnostic entity encompasses autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder, which are all still separate in ICD-10-CM.

Official coding guidelines for this chapter include the following:

img Pain that is exclusively related to psychological disorders should be coded using F45.41. Code F45.42, pain disorders with related psychological factors, should be used along with a code from category G89, pain, if there is documentation of a psychological component for a patient with acute or chronic pain.

img The section on mental and behavioral disorders due to psychoactive substance use includes coding categories of use, abuse, and dependence for various substances. If provider documentation refers to more than one pattern of use, the following hierarchy should be used to assign the code.

Use, Abuse, and Dependence

Documented

Assign Only the Code For

Use and abuse

Abuse

Abuse and dependence

Dependence

Use and dependence

Dependence

Use, abuse, and dependence

Dependence

Source:  Data from International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), 2014. Centers for Medicare and Medicaid Services and the National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

Some of the dependence category codes have subdivisions for “in remission.” These codes should only be used when provider documentation of remission is present.

CHAPTER 6: DISEASES OF THE NERVOUS SYSTEM (G00–G99)

The nervous system is responsible for sensory and motor activities, for behavior, and for regulation of the internal organs. Sensory functions are those of vision, smell, hearing, taste, touch, and proprioception (the body’s awareness of itself). Motor functions are those of movements, such as swallowing and heartbeat. In ICD-10-CM, diseases of the eye and ear have been moved from the nervous system chapter to their own chapters.

Coding nervous systems conditions requires knowledge of the location or site of the condition. The central nervous system is the brain and the spinal cord. The peripheral nervous system includes all other nervous system elements, such as the facial nerves, cranial nerves, and nerves in the extremities.

Central nervous system diseases include infections, such as encephalitis and meningitis, and degenerative disorders, such as Alzheimer’s disease, Parkinson’s disease, and other types of tremor. Some of these diseases are hereditary and some are acquired. Multiple sclerosis, cerebral palsy, migraine, and epilepsy are other central nervous system conditions.

The hemiplegia (paralysis of one side of the body) and monoplegia (paralysis of one upper or lower limb) codes in this chapter (G81 and G83.1–G83.3) are intended for use only when the condition is reported without further specification or is stated to be old or longstanding but of unspecified cause. A fifth digit is used with these codes to indicate whether the patient’s dominant or nondominant side is affected. If the affected side is documented but not specified as dominant or nondominant, the code selection is as follows.

Hemiplegia and Monoplegia

Side Affected

Default

Ambidextrous

Dominant

Left side

Nondominant

Right side

Dominant

Source:  Data from International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), 2014. Centers for Medicare and Medicaid Services and the National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

The peripheral nervous system is involved in many common conditions, such as carpal tunnel syndrome, peripheral neuropathy, Bell’s palsy, and hereditary conditions such as muscular dystrophy.

Most of the official guidelines for this chapter are related to pain coding. Category G89, pain, not elsewhere classified, has subcategories defining central pain syndromes, acute pain, chronic pain, neoplasm-related pain, and chronic pain syndrome. A code from this section should not be assigned if the underlying diagnosis is known, unless the reason for the encounter is for pain control/management, and not management of the underlying condition.

Pain

Reason for Encounter

Use Codes

Pain control or management

Code from G89 plus code for underlying cause and site of the pain

Post-op pain not associated with a specific complication

G89

Pain associated with a specific post-op complication

Code from Chapter 19 plus additional code for acute or chronic pain, G89.18 or G89.28

Insertion of neurostimulator for pain control

Code from G89

Treatment of underlying condition and neurostimulator is inserted for pain control during same encounter

Code for underlying condition plus pain code from G89

Treatment of underlying condition only

Code for underlying condition

Treatment of chronic pain

Code for chronic pain—no time limit to define when it becomes chronic. Do not use codes for chronic pain syndrome or central pain syndrome unless documented as such

Treatment of neoplasm-related pain

Code G89.3 plus code for underlying neoplasm

Treatment of neoplasm and pain is also documented

Code for neoplasm plus code G89.3

Source:  Data from International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), 2014. Centers for Medicare and Medicaid Services and the National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

CHAPTER 7: DISEASES OF THE EYE AND ADNEXA (H00–H59)

This brand-new chapter includes diseases of the eye, visual disturbances, glaucoma, disorders of the optic nerve and visual pathway, disorders of the ocular muscles, blindness, and complications of eye procedures. Many codes in this chapter have subdivisions for left eye, right eye, bilateral eyes, and unspecified laterality. If no bilateral code is available and the condition is bilateral, assign codes for both the right and left sides. If the laterality is not documented, use the “unspecified” code.

The official guidelines for Chapter 7 are all related to glaucoma coding. Most glaucoma categories define the type of glaucoma, the laterality, and the stage of the disease (i.e., mild, moderate, severe, indeterminate, and unspecified).

img Use as many codes from category H40 as needed to fully identify the glaucoma.

img If the patient has bilateral glaucoma and both eyes are the same type and stage, assign only one code, for bilateral. If the patient has bilateral glaucoma of the same type and stage and the code does not include a bilateral option, assign only one code for the type and stage.

img If the patient has bilateral glaucoma and each eye is different and the category includes laterality codes, assign an individual code for each eye based on its characteristics.

img If the patient is admitted with glaucoma and the stage progresses during the admission, assign the code for the highest stage.

img “Indeterminate stage” is used when there is documentation that the stage cannot be determined. “Unspecified” is used when there is no documentation regarding the stage.

CHAPTER 8: DISEASES OF THE EAR AND MASTOID PROCESS (H60–H95)

As in Chapter 7 on the eye, this chapter includes left, right, bilateral, and unspecified laterality codes. Although there are no official guidelines for this chapter, logic would dictate that the laterality guideline for the eye chapter be followed for ears. If the condition is bilateral and no bilateral code is available, use two codes for left and right. If the laterality is not documented, use unspecified.

The categories for otitis media (H65, nonsuppurative, and H66, suppurative and unspecified) include “use additional code” instructional notes to identify various types of exposure to tobacco smoke. In addition, allergic otitis media is separately identified and subdivided into acute and subacute and chronic. Codes for perforation of the tympanic membrane are located in this chapter (H72) but it is important to note that this does not include a traumatic rupture.

CHAPTER 9: DISEASES OF THE CIRCULATORY SYSTEM (I00–I99)

The circulatory system encompasses the heart, arteries, veins, and capillaries. Its purpose is to obtain oxygen from the lungs, distribute it to tissues via blood flow, and release carbon dioxide, the waste product of the body’s metabolism or energy consumption. The heart is the pump that makes the circulatory system work.

The lymph system, which produces and distributes immune cells, is also included in this chapter. Congenital heart conditions are found in Chapter 17, whereas circulatory conditions related to pregnancy are in Chapter 15.

Interestingly, this chapter starts with an infectious disease. Rheumatic fever is a febrile inflammatory condition that may occur after infection with group A strep. It can cause arthritis and other joint symptoms, but its primary complication is carditis and damage to the heart, particularly the valves. Hypertension, or high blood pressure, is defined as blood pressure consistently greater than 140 mm Hg systolic or 90 mm Hg diastolic. Systolic is the top number in your blood pressure and represents the pressure when the heart beats. Diastolic is the bottom number and represents the pressure when the heart rests. In ICD-9-CM, hypertension was categorized as benign, malignant, or unspecified; in ICD-10-CM, it is either essential (primary) or secondary, with additional code categories to define heart and/or kidney disease due to hypertension.

Heart attack, or myocardial infarction (MI), is another group of codes in this chapter. It is a form of ischemic heart disease, in which the supply of blood to the heart is blocked, usually due to arteriosclerosis. Distinctions are made between “STEMI” and “non-STEMI” myocardial infarctions, based on ECG patterns. An ECG (electrocardiogram) translates the electrical activity of the heart into line tracings. Points on the line are known by the initials P, Q, R, S, and T. The ST segment represents the period when the ventricle of the heart is contracting but no electricity is flowing through it ( Figure 2-5 ). STEMI stands for “ST elevation myocardial infarction,” in which a coronary artery is blocked, causing damage to the heart muscle supplied by the artery. This causes a characteristic elevation in the ST segment of the ECG, hence the name. In a non-STEMI, or NSTEMI, the artery is partially or temporarily blocked, resulting in less damage and no ST elevation.

img

FIGURE 2-5 EKG S-T segment.

Varicose veins, thrombophlebitis, hemorrhoids, and deep vein thrombosis are the most commonly seen conditions of the arteries and veins.

This chapter has a number of official coding rules.

Circulatory System

Reason for Encounter

Use Code

Hypertension with heart disease—causal relationship stated (due to hypertension) or implied (hypertensive)

I11: Hypertensive heart disease. Use additional code from I50 to identify the type of heart failure, if present.

Hypertension with heart disease—causal relationship not documented

Code heart disease and hypertension separately. Sequence according to the circumstances of the encounter.

Hypertensive renal disease with chronic renal failure

Assign a code from category I12. ICD-10-CM assumes a causal relationship is present. Use additional code from N18 to identify the stage of chronic kidney disease.

Hypertensive heart and renal disease—causal statement for heart disease present

Category I13. Use an additional code from I50 if the patient has heart failure and a code from N18 to identify the stage of chronic kidney disease.

Hypertensive cerebrovascular disease

Code from I60–I69 plus hypertension code.

Hypertensive retinopathy

H35.0 plus code from I10–I15.

Secondary hypertension

Code for underlying cause and code from I15 for hypertension. Sequence according to the circumstances of the admission.

Transient hypertension, or elevated blood pressure without hypertension diagnosis

R03.0: Elevated blood pressure reading without diagnosis of hypertension.

Hypertension stated as controlled or uncontrolled

Appropriate code from I10–I15.

Sequelae of cerebrovascular disease, such as neurological deficits

Code for deficit plus code from category I69.

Angina due to coronary artery disease

Causal relationship is assumed in patients with both angina and atherosclerosis, unless the documentation indicates otherwise. Use combination code from I25.11_ or I25.7_.

Acute NSTEMI evolving to STEMI during encounter

Use code for STEMI.

Acute STEMI converts to NSTEMI due to use of antithrombolytic

Use code for STEMI.

Subsequent acute STEMI or NSTEMI within 28 days of previous acute MI

Code from I22 to describe new MI and code from I21 to indicate existing MI. Sequence according to circumstances of admission.

Chest pain, no cause identified

Chest pain code is R07.9.

Chest pain, cause identified

Code for cause.

Cerebrovascular accident (CVA, stroke) with positive diagnostic tests and symptoms still occurring after 24 hours

CVA code is I63_.

Presentation as stroke/CVA but diagnostic tests are negative and symptoms are resolved within 24 hours

TIA (transient ischemic attack) G45.9.

Source:  Data from International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), 2014. Centers for Medicare and Medicaid Services and the National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

CHAPTER 10: DISEASES OF THE RESPIRATORY SYSTEM (J00–J99)

Starting at the top, the respiratory system consists of the nasal cavity and sinuses, the mouth, throat (pharynx and larynx), bronchi, and lungs. Its function is to bring in air, containing oxygen, and to release carbon dioxide. The oxygen passes into the blood in an exchange process that takes place in the alveoli of the lungs; carbon dioxide passes from the blood into the lungs and is exhaled.

The coding categories for lung diseases due to external agents read like a list of poor labor conditions from American history: coal workers’ pneumoconiosis (black lung disease), mushroom workers’ lung, farmers’ lung, cheese washers’ lung, bauxite fibrosis, and chemical bronchitis.

In ICD-10-CM, asthma is classified as mild intermittent, mild persistent, moderate persistent, or severe persistent. The definitions of these levels of severity were formulated by the National Institutes of Health (U.S. Department of Health and Human Services, 2012). If the provider does not document the level of severity, the asthma should be classified as J45.90_ unspecified.

Official coding guidelines for this chapter are as follows.

Respiratory System

Reason for Encounter

Use Code

Pneumonia, unspecified organism

J18.9.

Pneumonia, known cause. Physician must document bacterial or viral cause

Code from J12–J16.

Pneumonia in diseases classified elsewhere

Code for underlying disease (read “Excludes I” note), then J17.

Lobar pneumonia (the same term is sometimes used for two different diseases)

J18.1 for lobar pneumonia, unspecified organism, for site (lobe). J13 for pneumococcal (lobar is synonym).

Chronic obstructive pulmonary disease (COPD) with acute exacerbation (worsening or decompensation), cause not identified

J44.1.

COPD with acute lower respiratory infection

J44.0 plus additional code to identify infection.

COPD with asthma

COPD code plus code from category J45 to identify type of asthma.

Acute respiratory failure

Acute respiratory failure (J96.0) or acute and chronic respiratory failure (J96.2) may be listed as a principal diagnosis if appropriate, or as a secondary diagnosis if it occurs after admission or is present on admission but does not meet the criteria for principal diagnosis.

Asthma; the physician must document the level of severity and whether acute exacerbation or status asthmaticus is present

J45_.

Ventilator-associated pneumonia (VAP)

Assign J95.851 only when the provider has documented VAP. Should not be assigned when the patient has pneumonia and is on a ventilator and the provider has not stated it is VAP.

Source:  Data from International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), 2014. Centers for Medicare and Medicaid Services and the National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

CHAPTER 11: DISEASES OF THE DIGESTIVE SYSTEM (K00–K94)

The length of the average digestive system is an amazing 27 to 28 feet! The basic function of this system is to prepare food for absorption by mechanical and chemical methods. In mechanical digestion, food is ground, torn, chewed, shaken, and mixed with saliva and stomach juices. In the small intestine, the dissolved food particles are mixed with enzymes and are absorbed through the lining of the intestine into the intestinal–hepatic portal venous system where nutrients move into the bloodstream and then are delivered to the rest of the body.

Coding categories for the digestive system are arranged according to the physical site of the disease: teeth, gums, jaw, salivary glands, oral soft tissues, tongue, esophagus, stomach, duodenum, appendix, abdominal cavity, intestine, colon, rectum, anus, liver, gallbladder, and pancreas. The pancreas serves an endocrine function by producing insulin, but it is also considered a digestive organ because it secretes enzymes that aid in digestion of proteins, fats, and carbohydrates.

Gastrointestinal infections that are contagious are located in the infectious disease chapter; gastrointestinal neoplasms are located in Chapter 2. Conditions of the jaw have been moved to the musculoskeletal diseases in Chapter 13.

There are no official coding guidelines for the digestive system disease chapter.

Some digestive conditions will require more provider documentation to code accurately in ICD-10-CM. For example, hemorrhoids are now coded according to stage:

img First degree: Hemorrhoids (bleeding) without prolapse outside anal canal

img Second degree: Hemorrhoids (bleeding) that prolapse with straining but retract spontaneously

img Third degree: Hemorrhoids (bleeding) that prolapse with straining and require manual replacement inside anal canal

img Fourth degree: Hemorrhoids (bleeding) with prolapsed tissue that cannot be manually replaced

The term bleeding is in parentheses, indicating that it is a nonessential modifier, so the bleeding can be present or absent.

Ulcers are classified according to site (i.e., duodenal, gastric) by acute, chronic, or unspecified, and by the presence or absence of hemorrhage and/or perforation.

One of the common conditions in the gastrointestinal (GI) tract is bleeding. If the cause of the bleeding is identified, the code for that condition, with hemorrhage, is used. The code for gastrointestinal hemorrhage, K92.2, is used only when the bleeding is documented but no bleeding site or cause is identified. The most common causes of GI bleeding are ulcers and diverticular disease.

CHAPTER 12: DISEASES OF THE SKIN AND SUBCUTANEOUS TISSUE (L00–L99)

The skin is part of what is known as the integument. This protective covering keeps the deeper tissues from drying out and protects them from injury and infection. The epidermis is the outer layer. It contains nerve endings, hair shafts, sweat gland openings, and several layers of cells. As old cells are worn away, they are replaced. The dermis is the next layer, consisting of hair follicles, sebaceous glands, sweat glands, nerves, arteries, veins, and connective tissue. The superficial fascia is the deepest layer of integument. It is the layer between the skin and the muscle or bone. In addition to the hair follicles and sebaceous and sweat glands, the nails are an important appendage to the skin. They grow through proliferation of cells at their roots, pushing the new nail growth out. Coding for skin conditions is divided into categories for infections, inflammatory conditions, and other diseases.

This chapter has a few differences from the regular coding schemes. Sunburn is in this chapter, not in the injury chapter that contains other types of burns. A number of skin infections, despite the fact that they may be contagious, such as impetigo, are in this chapter instead of Chapter 1 of ICD-10-CM. Acute lymphadenitis is in this chapter, while chronic lymphadenitis is in the circulatory chapter.

A common skin condition among those with limited mobility, particularly the elderly, is the ulcer. Decubitus ulcers, also known as pressure ulcers or bedsores, result from pressure on skin points from the patient’s body weight and the resulting lack of blood circulation. Other types of skin ulcers can result from hypertension, diabetes, or phlebitis, an inflammation of the veins.

All of the official guidelines for this chapter are related to pressure ulcers:

img Pressure ulcers are classified in ICD-10-CM according to a sixth digit describing severity:

1—Stage 1: Skin changes limited to erythema only

2—Stage 2: Pressure ulcer with abrasion, blister, partial thickness skin loss involving epidermis and dermis

3—Stage 3: Pressure ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue extending to underlying fascia

4—Stage 4: Pressure ulcer with necrosis of muscle, bone, and supporting structures (tendon or joint capsule) 0—Unstageable: Pressure ulcer whose stage cannot be clinically determined (covered by eschar or treated with skin or muscle graft, or documented as deep tissue injury but not due to trauma)

The stages defined in ICD-10-CM are aligned with those defined by the National Pressure Ulcer Advisory Panel in 2007 (NPUAP, n.d.).

An additional sixth digit (9) is used for unspecified stage. When there is no documentation regarding the stage of the ulcer, assign the code for unspecified stage.

Note that according to section 1.B.14 of the official guidelines the documentation of ulcer stage may be done by a clinician who is not the patient’s attending provider.

img No ulcer code is assigned if the patient is admitted with an ulcer documented as completely healed.

img Ulcers documented as healing should be coded with the appropriate stage based on documentation.

img If a pressure ulcer progresses to a higher stage during an encounter, assign the code for the highest stage reported for that site.

Nonpressure chronic ulcers are classified to category L97. They include chronic ulcer of skin, nonhealing ulcer of skin, trophic ulcer of skin, tropical ulcer of skin, noninfected sinus of skin, and ulcer of skin, not otherwise specified. The severity classification of nonpressure chronic ulcers, represented by a sixth digit, is as follows:

1. Skin breakdown only

2. Exposed fat layer

3. Muscle necrosis

4. Bone necrosis

5. Unspecified severity

If the patient has an underlying condition contributing to the ulcers, it should be coded first. The additional code from L97 will provide better specificity about the site and depth of the ulcer.

CHAPTER 13: DISEASES OF THE MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE (MOO–M99)

This chapter covers the bones, joints, muscles, and fascia. The adult body contains more than 200 bones and approximately 600 muscles, so it is important to be specific in coding diseases and conditions of these systems. Because they are made primarily of mineral salts such as calcium and are more durable than other body tissues, bones are frequently the only thing left when remains must be examined in conjunction with scientific or legal investigations. The length of various individual bones can be used to estimate the height of a person, and the structure of the pelvis can be used to differentiate between male and female skeletons.

Three types of muscles produce movement within the body. Cardiac muscle in the heart wall and smooth muscle in the stomach, intestine, and blood vessels are known as involuntary muscles. They work without conscious direction from you, and you do not have conscious control over them. Your heart continues to beat without your telling it to do so; you are not able to prevent the smooth muscle in your stomach from contracting when you vomit. Skeletal muscles, those attached to the bones, are voluntary because they are under your control. Muscles make up more than 40% of your body weight.

Other parts of the musculoskeletal system are ligaments, which connect bone to bone, and tendons, which connect muscle to bone. Fascia is the covering of the muscles, and it also contains blood vessels and nerves.

Joints are points at which bones are connected to each other. The shape of the joint determines how it will be able to move:

img Ball and socket joints, such as the hip and shoulder joints, permit movement in basically three directions.

img Hinge joints, such as the elbow and ankle, permit movement that is mostly restricted to one plane.

img Pivot joints, such as the skull on the first vertebra in the neck, allow for rotation of the head from side to side.

img Sutures between the bones of the skull are joints but are immovable after age 5.

img Cartilaginous joints, such as the discs between the vertebra, allow for only partial movement.

img Gliding joints occur where two flat surfaces of bone glide across each other.

Damage to joints, tendons, and ligaments occurs with aging, trauma, and with inappropriate use.

There are more than seven times as many codes in this chapter as there were in the same chapter in ICD-9-CM. The addition of laterality to many codes and the greater specificity of joint codes accounts for this increase.

The official coding guidelines for the musculoskeletal system chapter are as follows:

img For some conditions where more than one bone, joint, or muscle is usually involved, a “multiple sites” code is available. If no such code is available, multiple codes should be used to indicate the different sites involved.

img For certain conditions, the bone may be affected at the joint at an upper or lower end. Though the portion of the bone affected is at the joint, the site designation will be the bone, not the joint.

It is important to note that current acute bone or joint injuries are coded to the appropriate selection from Chapter 19, on injuries. If the musculoskeletal condition is the result of a previous injury or trauma or is a recurrent condition, it may be found in Chapter 13.

img Chapter 13 has several categories for pathological fractures:

M48.4_  Stress or fatigue fractures of vertebrae

M48.5_  Collapsed vertebrae

M80.0_  Osteoporosis with current pathological fracture

M84.3_  Stress or fatigue fracture

M84.4_  Pathological fracture, NEC

M84.5_  Pathological fracture in neoplastic disease

M84.6_  Pathological fracture in other diseases

These categories require the use of a seventh character to identify the type of encounter and/or problems associated with healing:

A Initial encounter for fracture. Use this character as long as the patient is receiving active treatment for the fracture (surgical treatment, ER encounter, evaluation and treatment by new physician).

D Subsequent encounter for fracture with routine healing. To be used for encounters after the patient has completed active treatment.

G Subsequent encounter for fracture with delayed healing

K Subsequent encounter for fracture with nonunion

P Subsequent encounter for fracture with malunion

S Sequela

img A code from M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.

CHAPTER 14: DISEASES OF THE GENITOURINARY SYSTEM (NOO–N99)

The urinary portion of this system comprises the kidneys, ureters (tubes connecting the kidneys to the bladder), bladder, and urethra (tube from bladder to the outside). Its function is to eliminate waste products and also to maintain chemical and body water balances. If it is a hot day and you do not drink enough water, the volume of your urine will decrease as the kidneys work to maintain the appropriate internal balance.

The genital portion of this system includes not only what is normally thought of as genitalia, but also the breasts. The male genital portion covers the prostate, penis, testes, spermatic cord, and seminal vesicles. The female portion includes the ovaries, fallopian tubes, uterus, vagina, cervix, clitoris, labia, and vulva. Reproduction and preservation of the human species are the tasks of these systems.

Kidney failure may lead to the need for the patient to undergo dialysis. In this procedure, a dialysis machine serves as a substitute for the kidney, filtering out salts and urea wastes into a solution that can be discarded.

The presence of stones, or calculi, can occur in the kidney, ureters, bladder, or urethra. Often painful, these stones are usually formed of calcium or uric acid. They can prevent the passage of urine if located in the wrong spot. The flow of urine can also be affected by conditions in the prostate because the urethra passes through the prostate on its way to the penis. Enlargement of the prostate is found in more than 40% of men over the age of 70. For coding purposes, the cause of the hypertrophy must be specified.

Breast disorders, with the exception of neoplasms, are also located in this chapter. They are not restricted to use in female patients. Breast neoplasms are found in Chapter 2, “Neoplasms.”

Coding for female genital tract conditions is organized along inflammatory versus noninflammatory conditions. Recurrent pregnancy loss (N96) and female infertility (N97) are also part of this chapter.

The official coding guidelines for this chapter are related to chronic kidney disease (CKD). There are individual codes for the five stages of CKD, plus an additional code for end-stage renal disease (ESRD).

img If both a stage of CKD and ESRD are documented, assign the code for ESRD only (N18.6).

img 14.a.2. The presence of CKD in a patient who has undergone a kidney transplant does not automatically constitute a transplant complication. Assign the appropriate N18 code for the patient’s stage of CKD and code Z94.0 for kidney transplant status.

img CKD patients with other serious conditions, such as diabetes or hypertension, may have combination codes from those chapters as their principal or first-listed diagnosis. An N18 code should be used to indicate the stage of CKD.

CHAPTER 15: PREGNANCY, CHILDBIRTH, AND THE PUERPERIUM (OOO–O9A)

This chapter is the most complex within ICD-10-CM in terms of the official guidelines. It contains codes for many conditions that are classified elsewhere, but which are coded within this chapter if the patient is pregnant or has delivered and is within the puerperium, or postpartum period, defined as 6 weeks (42 days) after delivery. An additional term used in ICD-10-CM is the peripartum period, which is the last month of pregnancy and 5 months postpartum. General rules for obstetric cases are the following:

img Codes from Chapter 15 have sequencing priority over codes from other chapters. Additional codes from other chapters may be used with Chapter 15 codes to further specify conditions. If the patient is being seen for an unrelated condition and the provider documents incidental pregnancy, code Z33.1, pregnant state, incidental, should be used instead of a Chapter 15 code.

img Codes from Chapter 15 are to be used only for coding maternal records, never newborn records.

img Many of the codes in Chapter 15 have a final character specifying the trimester of the pregnancy:

First trimester: less than 14 weeks

Second trimester: 14 weeks, 0 days, to less than 28 weeks, 0 days

Third trimester: 28 weeks, 0 days, until delivery

Some codes do not have this component because the condition always appears in a specific trimester; other codes may only have trimester characters for two trimesters because that is when the condition occurs. Provider documentation of the number of weeks may be used to assign the appropriate trimester.

img If the patient is admitted for complications of pregnancy in one trimester and the encounter lasts into the next trimester, the code for the trimester in which the complication developed or when the admission occurred should be used, not the trimester of discharge.

img Although codes for “unspecified trimester” exist, they should only be used when it is not possible to obtain clarification of insufficient documentation in the record.

img Certain codes for complications require the use of a seventh character on the maternal record to identify the fetus with the condition. Assign a seventh character of “0” for single gestations or when the documentation is insufficient to determine which fetus, from multiple gestations, is affected and it is not possible to obtain clarification or when it is not clinically possible to determine which fetus is affected. If it is a multiple gestation, a seventh character 1–9 is used. A code from category O30, multiple gestation, must also be used to identify the type of multiple gestation.

Pregnancy, Childbirth, and the Puerperium

Reason for Encounter

Use Code

Other condition, pregnancy is incidental

Code for other condition plus Z33.1, pregnant state, incidental.

Prenatal outpatient visits for patients with high-risk pregnancies

Code from category O09, supervision of high-risk pregnancy. Other codes from Chapter 15 may be used as secondary diagnoses if appropriate.

Prenatal visit, routine, no complications present

Code from category Z34, encounter for supervision of normal pregnancy. Do not use Chapter 15 code with these.

Normal vaginal delivery (full term, single healthy infant, no complications during antepartum, delivery, or postpartum during the delivery episode); if the mother had a complication at some point during the pregnancy but it is not present at the time of admission for delivery, O80 may be used

O80 plus Z37.0 for outcome of delivery. Do not use any other Chapter 15 code with O80.

Other delivery (inpatient)

Main circumstances or complication of delivery, plus code from category Z37, outcome of delivery.

C-section delivery (inpatient)

Condition established after study that was responsible for the patient’s admission. Condition that resulted in the performance of the C-section, or reason for admission unrelated to condition resulting in delivery. Code from category Z37 for outcome of delivery is required.

Complication of pregnancy but no delivery occurs (inpatient)

Code corresponding to the principal complication of the pregnancy. If more than one exists, and all are treated or monitored, any may be sequenced first.

Sepsis, septic shock, or severe sepsis

Assign additional code for specific infection. If severe sepsis is present, assign R65.2 and additional codes for associated organ dysfunctions.

Puerperal sepsis

Code O85 plus secondary code to identify causal organism. A40, streptococcal sepsis, and A41, other sepsis, should not be used for puerperal sepsis.

HIV-related illness during pregnancy, childbirth, or the puerperium

Code from category O98.7_. HIV disease complicating pregnancy, childbirth, and the puerperium plus codes for the HIV-related illnesses.

Asymptomatic HIV infection status during pregnancy, childbirth, or the puerperium

Code from O98.7_ plus Z21, asymptomatic HIV infection status.

Diabetes mellitus in pregnancy

Code from category O24 plus diabetes code from E08–E13 and Z79.4 for longterm use of insulin, if appropriate.

Gestational (pregnancy-induced) diabetes

Code from O24.4. These codes include diet controlled and/or insulin controlled. If both are used, assign only the insulin-controlled code. Do not use Z79.4.

Preexisting hypertension in pregnancy

Category O10 includes codes for hypertensive heart and CKD. Add a secondary code from the appropriate hypertension category to identify the type of heart failure or CKD.

Pregnancy-associated cardiomyopathy

CO90.3 is usually diagnosed in the third trimester of pregnancy but continues to progress months after delivery. Use only in patients who did not have preexisting heart disease.

Fetal condition affecting the management of the mother; assign only when the fetal condition is actually responsible for modifying the management of the mother, requiring diagnostic studies, additional observation, special care, or termination of pregnancy

Code from O35 or O36 categories.

Tobacco or alcohol use during pregnancy, childbirth, and the puerperium

O99.33 is the code for smoking complicating pregnancy. O99.31 is the code for alcohol use complicating pregnancy.

Poisoning, toxic effects, adverse effects, and underdosing in a pregnant patient

Category O9A.2 sequenced first, plus the appropriate injury, poisoning, toxic effect, adverse effect, or underdosing code plus additional codes for condition caused.

In utero surgery

Code from category O35 to identify the fetal condition.

Delivery outside hospital, admitted for routine postpartum care, no complications

Z39.0. Encounter for care and examination of mother immediately after delivery.

Pregnancy-related complication after the 6-week puerperium

Chapter 15 codes may be used after the puerperium if the provider documents the condition is pregnancy related.

Sequelae of complication of pregnancy, childbirth, or the puerperium

Sequela code plus O94.

Abuse in a pregnant patient

O9A.3 for physical abuse, O9A.4 for sexual abuse, or O9A.5 for psychological abuse, plus codes for any associated current injury.

Source:  Data from International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), 2014. Centers for Medicare and Medicaid Services and the National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

The categories of abortion are spontaneous, termination of pregnancy, and failed attempted termination of pregnancy. Spontaneous abortions are classified as one of the following:

1 = incomplete (retained products of conception)

2 = complete (all products of conception have been expelled from the uterus)

The following official coding guidelines relate to abortion.

Abortion

Reason for Encounter

Use Code

Treatment of spontaneous abortion

Category O03._.

Elective termination of pregnancy, uncomplicated

Z33.2.

Treatment of complications following (induced) termination of pregnancy

Category O04.

Treatment after failed attempted termination of pregnancy

Category O07.

Complication of pregnancy leading to an abortion

Abortion code plus additional Chapter 15 codes for complications of pregnancy.

Attempted abortion with liveborn fetus

Z33.2 plus Z37 outcome of delivery.

Retained products of conception following an abortion

Code from category O03, O07.4, or Z33.2. Appropriate even if the patient was discharged previously with a diagnosis of complete abortion.

Missed abortion (fetal death prior to 20 completed weeks, gestation, with retained fetus)

Use code O02.1. Note the change from 22 weeks in ICD-9-CM to 20 weeks in ICD-10-CM.

Ectopic pregnancy (outside the uterus)

Category O00.

Source:  Data from International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), 2014. Centers for Medicare and Medicaid Services and the National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

CHAPTER 16: CERTAIN CONDITIONS ORIGINATING IN THE PERINATAL PERIOD (POO–P96)

It is easy to confuse this chapter with the next chapter on congenital malformations because both are concerned with conditions present during early childhood. The congenital chapter is descriptive of structural defects and certain chromosomal abnormalities present at birth. The perinatal chapter includes not only some conditions that start in utero but also others that occur as a result of the birth process or shortly thereafter. The perinatal period is defined as beginning before birth and lasting through the 28th day of life.

It could be possible to use one of these codes in an adult patient if there is no other code defining the condition for which the patient is being treated. Most conditions in this chapter do not last beyond infancy. However, some, such as bronchopulmonary dysplasia, can last for the lifetime of the patient and be the cause of later problems.

All clinically significant conditions noted on routine newborn examination should be coded. A condition is clinically significant if it requires clinical evaluation, therapeutic treatment, diagnostic procedures, extended hospital stay, increased nursing care or monitoring, or has implications for future healthcare needs.

Official coding guidelines for the perinatal chapter are as follows.

Perinatal Conditions

Reason for Encounter

Use Code

Birth episode of newborn infant

Category Z38. This code can only be used once.

Care of infant transferred in after birth

Code(s) for condition(s) being treated (do not use Z38).

Observation and evaluation of newborn or infant for suspected condition not found

The official guidelines for 2014 stated that this section is “reserved for future expansion.”

Infant being treated for health problem caused by birth process or community-acquired conditions

If not specified, the default is due to the birth process, and the Chapter 16 code should be used. If the condition is community acquired, do not use Chapter 16.

Prematurity or fetal growth retardation

Do not assign a prematurity code unless it is documented. Codes in categories P05 and P07 should be based on recorded birth weight and gestational age. Sequence birth weight before gestational age if both are available. Use when the listed conditions are affecting the patient’s current health status.

Bacterial sepsis of newborn

P36 includes congenital sepsis. If not documented as community acquired, the default is congenital. If the P36 code does not include the bacterial agents, add an additional code from B96.

Source:  Data from International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), 2014. Centers for Medicare and Medicaid Services and the National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

If the institution maintains separate medical records for stillbirths, code P95 may be used. It should not be used on maternal records.

CHAPTER 17: CONGENITAL MALFORMATIONS, DEFORMATIONS, AND CHROMOSOMAL ABNORMALITIES(QOO–Q99)

Congenital anomalies are structural or metabolic defects that are present at birth. The common term for these conditions is birth defects. A major anomaly is apparent at birth in 3%–4% of newborns; up to 7.5% of children manifest a congenital defect by the time they are 5 years old. Such defects may be due to genetics or teratogens, which are chemical or radiologic in nature and affect normal fetal development. Approximately 4,000 congenital anomalies have been identified (CDC, n.d.).

For coding purposes, it is important that the physician define a condition as congenital if it is a condition that could be either congenital or acquired. For example spina bifida, which is a lack of closure of the spinal cord’s bony encasement, can only be congenital. However, obstruction of the intestine can be either congenital or acquired. For conditions where either possibility exists, the coder cannot make the assumption that the condition is congenital just because the patient is very young.

Likewise, it may be appropriate to use a code for a congenital condition for an older patient. It is legitimate to do this as long as the condition still exists and the patient is receiving treatment for it.

New medical terminology may result in the use of a term before a code exists. Syndromes are often eponymic, which means they are named after a person. An example of both is Partington syndrome. It is named after an Australian geneticist and describes X-linked intellectual disability and focal dystonia of the hands (National Library of Medicine, 2013). Because this syndrome does not have a code, it would be necessary to code the chromosome deficiency and the mental retardation separately.

For the birth admission, the appropriate code from category Z38, liveborn infants, according to place of birth and type of delivery, should be sequenced as the principal diagnosis, followed by any congenital anomaly codes.

CHAPTER 18: SYMPTOMS, SIGNS, AND ABNORMAL CLINICAL AND LABORATORY FINDINGS, NOTELSEWHERE CLASSIFIED (ROO–R99)

Earlier, we defined a symptom as an observation you make about your body, a subjective opinion on your part. A sign is observable by the physician; it is an objective finding.

Because diagnosis sequencing is linked to payer reimbursement of healthcare providers, rules about sequencing signs and symptoms have been developed.

Signs and Symptoms

Reason for Encounter

Use Code

Treatment of a sign or symptom for which a definitive diagnosis is made

Code for definitive diagnosis. Symptom codes may be reported as secondary if the sign or symptom is not routinely associated with that definitive diagnosis. Do not use an additional code for the symptom if the principal diagnosis is a combination code that includes the symptoms already.

Treatment of a sign or symptom for which a definitive diagnosis has not yet been reached

Code for the sign or symptom.

Treatment of a sign or symptom in an outpatient setting where no additional workup is performed

Code for the sign or symptom.

The patient has recently fallen and the reason for the fall is being investigated

Use R29.6, repeated falls. Use code Z91.81, history of falling, when the patient has fallen in the past. If appropriate, these two codes may be used together.

Traumatic brain injury, acute cerebrovascular disease, or sequelae of cerebrovascular disease with documented coma scale score

Use R40._ as a secondary code if documented. A seventh character must be used to denote when the score was documented.

Lack of ability to use one’s limbs or to ambulate, due to extreme debility, is functional quadriplegia (R53.2)

Do not use this code for cases of neurologic quadriplegia.

SIRS (systemic inflammatory response syndrome) due to noninfectious disease process such as trauma, malignant neoplasm, or pancreatitis

Use R65.10 without acute organ dysfunction or R65.11 with acute organ dysfunction.

Death, not otherwise specified

Use R99. Only use for patients who are pronounced dead on arrival at a healthcare facility. Not the same as the discharge disposition of death.

Source:  Data from International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), 2014. Centers for Medicare and Medicaid Services and the National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

The positioning of some conditions in Chapter 18 and other similar wordings in the individual disease chapters is sometimes puzzling. Abdominal pain is in this chapter as a symptom, whereas joint pain would be considered a diagnosis because it is in the musculoskeletal chapter. Specific wording used by providers can cause unintended codes. “Seizures” is in the symptom chapter, whereas “epilepsy” is a diagnosis in the nervous system chapter. If health record documentation appears to indicate the patient has epilepsy, but the provider uses only the term seizures, an explanation of the coding differences should be provided and clarification sought.

This chapter also includes codes for nonspecific and nonspecific abnormal results of diagnostic tests. These codes would ordinarily not be used unless no additional information is available. They could, for example, be used as the reason for conducting additional testing to reach a clear diagnosis.

CHAPTER 19: INJURY, POISONING, AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES (SOO–T88)

This chapter in the ICD-10-CM tabular list is huge. It covers not only what we ordinarily think of as injury and poisoning, but also burns and toxic effects of nonmedicinal substances. Significant levels of detail are required in physician documentation to ensure correct coding of conditions from this chapter. In ICD-9-CM, injuries were grouped by type, but in ICD-10-CM they are grouped by body part, with all injuries of a specific site grouped together. Laterality is part of every coding scheme in this chapter where it is appropriate. Definitions of terms commonly used with injuries are helpful.

Fractures

A fracture is a break of any size in a bone:

img Closed: Skin is intact

img Open: A break in the skin occurs (compound fracture)

If the type of fracture is not documented or available, the default is closed.

In some coding categories, it is also necessary to know if the fracture is displaced or nondisplaced:

img Displaced: The bone is broken into two or more pieces and moved, so the proper anatomical alignment is no longer maintained.

img Nondisplaced: The bone is cracked or broken all the way through but has not moved out of correct anatomical alignment.

If a fracture is not documented as displaced or nondisplaced, it is coded to displaced.

Fracture Character Extensions As in the musculoskeletal chapter, fracture codes require the use of a seventh character defining the episode of care:

A

Initial encounter for closed fracture

B

Initial encounter for open fracture

D

Subsequent encounter for fracture with routine healing

G

Subsequent encounter for fracture with delayed healing

K

Subsequent encounter for fracture with nonunion

P

Subsequent encounter for fracture with malunion

S

Sequela of fracture

Categories S52, fracture of forearm; S72, fracture of femur; and S82, fracture of lower leg use a different seventh character fracture extension based on a system known as the Gustilo open fracture classification. This system uses the mechanism of injury, extent of soft-tissue damage, and degree of bone injury or involvement to classify open fractures as type I, II, or III:

Type I: Wound less than 1 cm, clean

Type II: Wound greater than 1 cm with moderate soft-tissue damage

Type III: High-energy wound greater than 1 cm with extensive soft-tissue damage

Type IIIA: Adequate soft-tissue cover

Type IIIB: Extensive soft-tissue loss and bone exposure

Type IIIC: Arterial injury requiring repair (Kim & Leopold, 2012)

The additional seventh character fracture extensions for the forearm, femur, and lower leg open fractures are as follows:

B

Initial encounter for open fracture type I or II

C

Initial encounter for open fracture type IIIA, IIIB, or IIIC

E

Subsequent encounter for open fracture type I or II with routine healing

F

Subsequent encounter for open fracture type IIIA or IIIB or IIIC with routine healing

H

Subsequent encounter for open fracture type I or II with delayed healing

J

Subsequent encounter for open fracture type IIIA or IIIB or IIIC with delayed healing

M

Subsequent encounter for open fracture type I or II with nonunion

N

Subsequent encounter for open fracture type IIIA or IIIB or IIIC with nonunion

Q

Subsequent encounter for open fracture type I or II with malunion

R

Subsequent encounter for open fracture type IIIA or IIIB or IIIC with malunion

Stress fractures are hairline cracks in bone that are due to repeated or prolonged force against the bone, not a blow to the bone. Sports or exercise can cause stress fractures. Because they are not considered an injury, they are found in the musculoskeletal chapter in ICD-10-CM, not the injury chapter.

Pathological fractures are caused by disease, not injury. The most common causes are osteoporosis and cancer. In these fractures, the bone structure itself is abnormal, contributing to the break. This type of fracture is also found in the musculoskeletal chapter.

When a bone that forms part of a joint is displaced from that location, it is known as a dislocation. Dislocations can also be categorized as open if the skin is broken. A partial or incomplete dislocation is called a subluxation. These usually occur as a result of injury. In parallel with the classification of fractures, a dislocation due to disease rather than injury is found in the musculoskeletal chapter.

Open Wounds

In addition to cuts, lacerations, and punctures, open wounds also include injuries such as animal bites (including human), traumatic amputation, and avulsion. The latter is defined as forcible pulling away of tissue. Open wounds are further classified as to whether a foreign body is present.

Superficial Injuries

Superficial injuries include the following:

img Contusions

img Abrasion or friction burns

img Blisters (nonthermal)

img External constriction

img Superficial foreign body (such as splinters)

img Insect bite (nonvenomous)

img Other superficial bites

img Unspecified superficial injuries

Foreign Bodies

Foreign bodies (nonsuperficial) in open wounds are classified in that coding category. Superficial foreign bodies are classified with superficial injuries, as described previously. A separate category is used for the effects of foreign bodies entering through an orifice, or natural opening in the body (T15–T19). This would include, for example, a pencil eraser in the ear or a piece of steak stuck in the throat.

Injury, Burn, and Corrosions Character Extensions

Injury and burn codes in Chapter 19, except for fractures, have a seventh character extension that describes, in general terms, the circumstances of the encounter:

A

Initial encounter: Used while the patent is receiving active treatment for the injury. Examples include surgical treatment, an ER encounter, or treatment by a new provider.

D

Subsequent encounter: Used for encounters after the patient has received active treatment and is now receiving routine care during the healing or recovery phase. Examples include medication adjustment or removal of a cast or fixation device.

S

Sequela: Used for complications or conditions that arise as a direct result of an injury, such as a scar.

The official diagnosis coding guidelines related to injuries are as follows.

Injuries and Fractures

Reason for Encounter

Use Code

Multiple injuries

Use separate code for each injury unless a combination code is available. Do not use the unspecified multiple injury code T07 unless information for specific codes is not available. Sequence the code for the most serious injury first.

Abrasions or contusions

Do not code if associated with more severe injuries of same site.

Primary injury with minor damage to nerves or blood vessels

Sequence primary injury first.

Multiple fractures of same bones but different bone parts

Code individually by site.

Multiple fractures

Sequence in order of severity.

Dislocation associated with fracture of same site

Code fracture only.

Source:  Data from International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), 2014. Centers for Medicare and Medicaid Services and the National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

Burns

In addition to thermal burns due to flames, the ICD-10-CM burn classification includes burns caused by electricity, lightning, hot liquids (scalding), radiation, and hot objects. ICD-10-CM uses a new term, corrosions, to describe burns due to chemicals.

In addition to coding the location or site of the burn, it is necessary to assign a second code to indicate the percentage of body area involved in the burn. This is calculated using what is known as the “rule of nines.”  Figure 2-6  illustrates the percentage of body surface associated with body areas.

img

FIGURE 2-6 Rule of nines.

The “rule of palms” is useful for smaller areas. The size of the victim’s palm is approximately 1% of body area, so the number of palms will equal the percentage. The definition for the smallest area code in ICD-10-CM is 10% or less, so it is not necessary to measure precisely unless more than 10% is involved.

img First-degree burn: Only the outer layer of the skin, the epidermis, is involved. Symptoms include redness, tenderness, pain, and swelling.

img Second-degree burn: Penetrates into the dermis. Such burns are characterized by blisters, redness, swelling, and fluid seepage.

img Third-degree burns: Involves all three layers of the skin. The appearance of the skin is white, charred, and dry.

Burns of the eye and internal organs (T26–T28) are classified by site, but not degree.

Official ICD-10-CM coding guidelines for burns are as follows.

Burns

Reason for Encounter

Use Code

Multiple external burns

Sequence the code for the highest degree of burn first. Code separately. Only use the multiple burn code (T30) if location not documented.

Multiple burns, both internal and external sites

Circumstances of admission govern the principal or first-listed diagnosis.

Nonhealing burns, including necrosis of burned skin

Code as acute burns.

Multiple burns of same local site but different degrees

Classify to subcategory of the highest degree recorded.

Infected burn site

Use additional code to identify infection.

Mortality of burn victim during episode of care, or third-degree burn of >20% body area

Use category T31 or T32.

Treatment of sequelae of burns (scars, joint contractures)

Burn or corrosion code with a seventh character of S.

Source:  Data from International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), 2014. Centers for Medicare and Medicaid Services and the National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

Poisoning, Adverse Effects, and Toxicity

The definitions of these terms are a little different than those used in the average murder mystery:

img Poisoning occurs when a drug, medicinal substance, or other biological substance is not used correctly. This can occur through:

img Wrong dosage taken by patient

img Wrong dosage administered to patient

img Medication taken by wrong person

img Overdose (intentional or accidental)

img Nonprescribed drug taken with correctly prescribed and properly administered drug

img Medications taken in combination with alcohol or over-the-counter medications

img Adverse effects occur when a drug is correctly prescribed and properly administered but there are side effects:

img Drug allergy or hypersensitivity

img Drug intoxication

img Drug toxicity (including cumulative effects)

Toxic effects, from a coding perspective, refer to exposure to or contact with nonmedicinal substances such as chemicals, gases, metals, foods, and substances such as latex and silicone.

Underdosing is a new category in ICD-10-CM, defined as taking less of a medication than is prescribed or as instructed by the manufacturer, either inadvertently or deliberately.

The ICD-10-CM includes a large table of drugs and chemicals that is used to locate the correct code for poisoning. Additional codes for external causes are not required because these are combination codes that include the cause. The table has columns for adverse effect and underdosing, as well as four columns for poisoning intent:

img Accidental or unintentional (default if no intent documented)

img Intentional self-harm

img Assault

img Undetermined (documentation that intent cannot be determined)

The official diagnosis coding rules for these categories are as follows.

Poisoning and Adverse Effects

Reason for Encounter

Use Code

Adverse effect of a drug correctly prescribed and properly administered

Code for nature of the adverse effect plus T code for adverse effect of the drug

Condition caused by error in prescription or administration of drug

T code for accidental poisoning plus code for manifestation

Intentional overdose

T code for intentional self-harm poisoning plus code for manifestation

Nonprescribed drug in combination with correctly prescribed and administered drug

T code for accidental poisoning plus code for manifestation

Toxic effect of nonmedicinal substances

Code for toxic effect (T51–T65) plus code to specify nature of toxic effect

Source:  Data from International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), 2014. Centers for Medicare and Medicaid Services and the National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

Codes are also available for effects of other external causes:

img Environmental factors, such as radiation, cold, heat and light, air pressure

img Anaphylactic shock due to food reactions

img Early complications of trauma, such as compartment syndrome, shock, fat embolism, subcutaneous emphysema

img Adult and child abuse, neglect, and other maltreatment

Codes for these conditions are classified as to whether they are suspected or confirmed, based on provider documentation. For confirmed cases, additional codes should be used to identify the cause of any physical injuries. A perpetrator code (Y07) can be added, if known.

Complications of Surgical and Medical Care

Assignment of a code from this section does not imply that the surgical or medical care was inadequate. It does denote that a relationship between the care and the current condition has been documented, and that the current condition is more than routinely expected. There is no officially defined time limit on when the complication must occur.

Some complications are due to the presence of internal prosthetic devices, implants, or grafts. They may involve mechanical complications, such as breakage, leaking, or obstructions, or they may involve infection or inflammatory reaction. Other complications, such as pain, hemorrhage, stenosis, and fibrosis, also have codes defined by the type of internal device.

Complications of organ transplants are also in this section, as are systemic conditions such as post-op shock, accidental laceration during the procedure, postop infections, blood transfusion reactions, foreign bodies accidentally left in the patient, and many of the other unfortunate circumstances that may occur. Some intraoperative and postprocedural complication codes are found within the body system chapters with codes specific to the organs and structures of that body system.

CHAPTER 20: EXTERNAL CAUSES OF MORBIDITY (VOO–Y99)

External cause codes identify the following:

img How an injury or health condition happened (cause)

img The intent (unintentional/intentional)

img The place where the event occurred

img The activity of the patient at the time of the event

img The patient’s status, such as civilian or military

These are never used as the principal or first-listed code; they are always used in a supplementary fashion. They are used primarily for statistical purposes in gathering data on injury cause, extent, and location. This data can be used for injury prevention and education programs.

The major categories of external cause codes include transport accidents, falls, fire and flames, natural and environmental causes, assaults, self-inflicted injuries, and misadventures to patients during surgical and medical care.

A new feature of ICD-10-CM is the ability to code the patient’s documented blood alcohol level (Y90._).

Reporting of external causes is not mandatory on a national level, and such codes are not generally used in healthcare billing and reimbursement.

CHAPTER 21: FACTORS INFLUENCING HEALTH STATUS AND CONTACT WITH HEALTH SERVICES (ZOO–Z99)

This chapter in ICD-10-CM is used to identify situations in which patients who are not currently sick require health services.

Z codes are controversial in the healthcare reimbursement arena because they may represent services for which some payers will not pay. The official diagnosis coding guidelines and the enforcement of the HIPAA standard code set rules have helped in recent years to enforce appropriate coding and insurance coverage.

Z codes are used in the following circumstances:

img When a person who is not currently sick encounters health services for a specific reason, such as to act as an organ donor, to receive prophylactic care such as inoculations or screenings, or to receive counseling on a health-related issue.

img When a person with a resolving disease or injury or a chronic long-term condition requiring continuous care encounters the health care system for specific aftercare of that disease or injury. Examples are dialysis for renal disease, chemotherapy for malignancy, and cast change. A diagnosis or symptom code should be used instead of a Z code whenever a current, acute diagnosis is being treated or a sign or symptom is being studied.

img When circumstances or problems influence a person’s health status but are not in themselves a current illness or injury.

img For newborns, to indicate birth status.

Z Code Category Definitions

The official guidelines are specific about which Z code category each code belongs in and also define which Z codes must be only primary or only secondary.

Contact/Exposure

Z20

Patients do not show any sign or symptom of a communicable disease but have been exposed to it

Z77

Contact or exposure hazardous to health (chemicals, pollution)

Contact/exposure codes are used as a first-listed code to indicate a reason for testing or as a secondary code to identify a potential risk.

Inoculations and Vaccinations Patient is being seen for a prophylactic inoculation against a disease.

Z23

Because this is a single code for all vaccinations, the type given can only be identified via the procedure code.

Status Codes The patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition, which can include the presence of a prosthetic or mechanical device or transplanted organ from previous treatment. The status code differs from a history code because the latter indicates the patient no longer has the condition.

Z14

Genetic carrier

Z15

Genetic susceptibility to disease (not principal or first listed)

Z16

Resistance to antimicrobial drugs (sequence infection code first)

Z17

Estrogen receptor status

Z18

Retained foreign body fragments

Z21

Asymptomatic HIV infection status (tested positive but no signs or symptoms)

Z22

Carrier of infectious disease

Z28.3

Underimmunization status

Z33.1

Pregnant state, incidental (secondary only)

Z66

Do not resuscitate (order must be documented)

Z67

Blood type

Z68

Body mass index (adult codes for ages 21 and older; pediatric codes for ages 2–20)

Z74.01

Bed confinement status (bedridden)

Z76.82

Awaiting organ transplant status

Z78

Other specified health status

Z79

Long-term (current) drug therapy (long-term therapeutic or prophylactic use, not for drug addiction or detox)

Z88

Allergy status to drugs, medicaments, and biological substances

Z89

Acquired absence of limb (post-traumatic, postprocedural)

Z90

Acquired absence of organs NEC (a few are in other chapters)

Z91.0

Allergy status, other than to drugs and biological substances (food, insects, latex, contrast media)

Z92.82

Status post administration of tPa in different facility in last 24 hours (assign code for condition being treated with tPa first)

Z93

Artificial opening status (not used if opening requires attention)

Z94

Transplanted organ and tissue status

Z95

Presence of cardiac and vascular implants and grafts

Z96

Presence of other functional implants

Z97

Presence of other devices

Z98

Other postprocedural states (includes Z98.85 to indicate a transplanted organ has been previously removed)

Z99

Dependence on enabling machines and devices NEC

History Codes History codes indicate personal or family history. Personal history codes explain a patient’s past medical condition that no longer exists and for which he or she is not receiving any treatment but that may have the potential for recurrence, and thus may require monitoring.

Family history codes are used when a patient has a family member who has had a particular disease that causes the patient to be at higher risk of also contracting that disease.

Z80

Family history of primary malignant neoplasm

Z81

Family history of mental and behavioral disorders

Z82

Family history of certain disabilities and chronic diseases

Z83

Family history of other specific disorders

Z84

Family history of other conditions

Z85

Personal history of malignant neoplasm

Z86

Personal history of certain other diseases

Z87

Personal history of other diseases and conditions

Z91.4_

Personal history of psychological trauma NEC

Z91.5_

Personal history of self-harm

Z91.8_

Other specified personal risk factors NEC (except Z91.83)

Z92

Personal history of medical treatment (except contraception and tPa)

Screening Screening is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease. The Z code indicates that a screening exam is planned. A Z code is not used if the patient already has a sign or symptom; this is a diagnostic exam, not a screening. In those cases, the sign or symptom is used to explain the reason for the test. Screening codes may be first listed if the reason for the visit is specifically the screening exam. It may be a secondary code if the screening is done during an office visit for other health problems.

Z11

Encounter for screening for infectious and parasitic diseases

Z12

Encounter for screening for malignant neoplasm

Z13

Encounter for screening for other diseases and disorders (except Z13.9)

Z36

Encounter for antenatal screening for mother

Observation Observation codes are only used in limited circumstances when the patient is being observed for a suspected condition that is ruled out. They should not be used if an injury or illness or any signs or symptoms related to the suspected condition are present. In those cases, the diagnosis or symptom code would be used. It is used as a principal diagnosis only (except for Z03.7, maternal and fetal conditions, which may be used as secondary if appropriate).

Z03

Encounter for medical observation for suspected diseases and conditions, ruled out

Z04

Encounter for examination and observation for other reasons (except Z04.9)

Aftercare Aftercare is when the initial treatment of a disease has been performed but the patient requires continued care during the healing or recovery phase or for the long-term consequences of the disease. The aftercare Z code is not used if the treatment is directed at a current, acute disease, in which case the diagnosis code would be used. Exceptions to this rule are chemotherapy, immunotherapy, and radiation therapy. If the purpose of the encounter is to receive one of these therapies, the appropriate Z51 code would be first, accompanied by the diagnosis code for the neoplasm being treated. The aftercare Z codes would not be used for aftercare for injuries. Instead, the acute injury code should be used with a seventh character for the subsequent encounter.

Z42

Encounter for plastic and reconstructive surgery following medical procedure or head injury

Z43

Encounter for attention to artificial openings

Z44

Encounter for fitting and adjustment of external prosthetic device

Z45

Encounter for adjustment and management of implanted device

Z46

Encounter for fitting and adjustment of other devices

Z47

Orthopedic aftercare

Z48

Encounter for other postprocedural aftercare

Z49

Encounter for care involving renal dialysis

Z51

Encounter for other aftercare

Follow-up The follow-up codes are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. They imply that the condition has been fully treated and no longer exists. Follow-up codes may be used with history codes to provide the full picture of the healed condition and its treatment. The follow-up code would be sequenced first. If the condition is found to have recurred, the diagnosis code should be used instead of the follow-up code. Do not confuse the follow-up codes with aftercare codes or injury codes with a subsequent seventh character; those codes are for a healing condition or its sequelae, not for a condition that no longer exists.

Z08

Encounter for follow-up exam after completed treatment for malignant neoplasm

Z09

Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm

Z39

Encounter for maternal postpartum care and examination

Donor The donor code is used for living individuals who are donating blood or other body tissue to another person. Not for self-donation or cadaveric donations.

Z52

Donors of organs and tissues

Counseling Counseling codes are used when the patient or family member receives assistance in the aftermath of an illness or injury or when support is required in coping with family or social problems.

Z30.0_

Encounter for general counseling and advice on contraception

Z31.5

Encounter for genetic counseling

Z31.6_

Encounter for general counseling and advice on procreation

Z32.2

Encounter for childbirth instruction

Z32.3

Encounter for childcare instruction

Z69

Encounter for mental health services for victim or perpetrator of abuse

Z70

Counseling related to sexual attitude, behavior, and orientation

Z71

Persons encountering health services for other counseling and medical advice NEC

Z76.81

Expectant mother prebirth pediatrician visit

Encounters for Obstetrical and Reproductive Services A Z code may be used for routine visits if none of the problems or complications included in the codes from the obstetrics chapter exist.

Z30

Encounter for contraceptive management

Z31

Encounter for procreative management

Z32.2

Encounter for childbirth instruction

Z32.3

Encounter for childcare instruction

Z33

Pregnant state (includes code for elective termination of pregnancy)

Z34

Encounter for supervision of normal pregnancy

Z36

Encounter for antenatal screening of mother

Z3A

Weeks of gestation (use the date of admission to determine weeks of gestation for inpatient admissions that encompass more than one gestational week)

Z37

Outcome of delivery (use on all maternal records; always secondary)

Z39

Encounter for maternal postpartum care and examination

Z76.81

Expectant mother prebirth pediatrician visit

Newborns and Infants The following Z codes apply to newborns and infants:

Z00.1_

Encounter for routine child health examination

Z38

Liveborn infants according to place of birth and type of delivery (principal only)

Z76.1

Encounter for health supervision and care of foundling

Routine and Administrative Examinations These include general check-ups or exams such as pre-employment physicals. These codes are not used if the exam is for diagnosis of a suspected condition or for treatment purposes. During a routine exam, if a diagnosis or condition should be discovered, it should be coded as an additional code. Pre-op exam codes are for clearance only, not the treatment given.

Z00

Encounter for general examination without complaint, suspected or reported diagnosis

Z01

Encounter for other special examination without complaint, suspected or reported diagnosis

Z02

Encounter for administrative examination (except Z02.9)

Z32.0_

Encounter for pregnancy test

Miscellaneous Z Codes These capture a number of other healthcare encounters that do not fall into another category.

Z23

Immunization not carried out (except Z28.3)

Z40

Encounter for prophylactic surgery (use additional code to identify the associated risk factor)

Z41

Encounters for procedures for purposes other than remedying health state (cosmetic, piercing)

Z53

Persons encountering health services for specific procedures and treatment, not carried out (contraindicated, patient’s decision)

Z55

Problems related to education and literacy

Z56

Problems related to employment and unemployment

Z57

Occupational exposure to risk factors

Z58

Problems related to physical environment

Z59

Problems related to housing and economic circumstances

Z60

Problems related to social environment

Z62

Problems related to upbringing

Z63

Other problems related to primary support group, including family circumstances

Z64

Problems related to certain psychosocial circumstances

Z65

Problems related to other psychosocial circumstances

Z72

Problems related to lifestyle

Z73

Problems related to life management difficulty

Z74

Problems related to care provider dependency (except Z74.01)

Z75

Problems related to medical facilities and other health care

Z76.0

Encounter for issue of repeat prescription

Z76.3

Health person accompanying sick person

Z76.4

Other boarder to healthcare facility

Z76.5

Malingerer (conscious simulation)

Z91.1_

Patient’s noncompliance with medical treatment and regimen

Z91.83

Wandering in diseases classified elsewhere

Z91.89

Other specified personal risk factors, NEC

Nonspecific Z Codes These codes are so nonspecific that there can be little justification for their use in the inpatient setting and they should only be used in the outpatient setting when there is no further documentation to permit more precise coding.

Z02.9

Encounter for administrative examinations, unspecified

Z04.9

Encounter for examination and observation for unspecified reason

Z13.9

Encounter for screening, unspecified

Z41.9

Encounter for procedure for purposes other than remedying health state, unspecified

Z52.9

Donor of unspecified organ or tissue

Z86.59

Personal history of other mental and behavioral disorders

Z88.9

Allergy status to unspecified drugs, medicaments, and biological substances status

Z92.0

Personal history of contraception

Z Codes That May Only Be Principal/First-Listed Diagnosis The following Z codes/categories may only be reported as the principal or first-listed diagnosis, unless there are multiple encounters on the same day and the records are combined.

Z00

Encounter for general examination without complaint, suspected or reported diagnosis

Z01

Encounter for other special examination without complaint, suspected or reported diagnosis

Z02

Encounter for administrative examination

Z03

Encounter for medical observation for suspected diseases and conditions ruled out

Z04

Encounter for examination and observation for other reasons

Z31.81

Encounter for male factor infertility in female patient

Z31.82

Encounter for Rh incompatibility status

Z31.83

Encounter for assisted reproductive fertility procedure cycle

Z31.84

Encounter for fertility preservation procedure

Z33.2

Encounter for elective termination of pregnancy

Z34

Encounter for supervision of normal pregnancy

Z38

Liveborn infants according to place of birth and type of delivery

Z39

Encounter for maternal postpartum care and examination

Z42

Encounter for plastic and reconstructive surgery following medical procedure or healed injury

Z51.0

Encounter for antineoplastic radiation therapy

Z51.1_

Encounter for antineoplastic chemotherapy and immunotherapy

Z52

Donors of organs and tissues

Z76.1

Encounter for health supervision and care of foundling

Z76.2

Encounter for health supervision and care of other healthy infant and child

Z99.12

Encounter for respirator (ventilator) dependence during power failure

How Can You Code Your Conditions?

If you have a sign, symptom, or diagnosis that you want to code, follow these steps:

1. Look for the condition in the alphabetical index. You may have to look in more than one place. If you don’t find it listed under one of the terms, look under the others.

2. Once you have found the term, look at everything indented beneath it to see if there are other words from your diagnosis statement that apply.

3. After you have located what seems to be the correct term in the alphabetical index, look up the number in the tabular list.

4. Make sure you read all of the notes associated with your numeric code. Some of the notes may be at the top of the heading under which your number is listed. Some of the notes are “includes” that tell you what is included under this number, whereas others are “excludes” that may point you to another chapter and diagnosis code.

Keeping Up-to-Date

ICD-10-CM is updated once a year, effective October 1 of that year. Diagnosis codes are added to cover newly identified disease states. CMS and the NCHS publish these agenda in the United States with the approval of the World Health Organization. The diagnosis section of ICD-10-CM is the responsibility of NCHS, and the CMS handles the PCS (Procedure Coding System) procedure section. The other two cooperating parties on ICD-10-CM are AHIMA and the AHA. The central office on ICD-10-CM, housed at the AHA headquarters in Chicago, publishes Coding Clinic, a quarterly publication covering updates, coding guidelines, and readers’ questions.

It is imperative that you use the currently implemented version of ICD-9-CM or ICD-10-CM to research or solve personal coding-related concerns. When codes are revised, the code used is based on the date of service of your procedure. There is no longer any grace period during which it is okay to use either old or new codes.

Misdiagnosis: The Wrong Path

The patient was a 39-year-old male previously in good health. He was on summer vacation near the ocean, and over a 2-day period he participated in several strenuous activities, such as swimming, sailing, jogging, even putting out a small forest fire. He later experienced chills and was so tired that he went to bed early. By the next morning, one leg was weak. It became paralyzed by the afternoon, and by evening the other leg was weakened. He had a temperature of 102 degrees Fahrenheit. The family physician who examined the patient decided he had a cold.

By the second day, the paralysis had spread to all body areas below the chest. A specialist examined the patient and decided the problem was a blood clot in the lower spinal cord. Not until the 15th day of the illness was another diagnosis made. The patient was Franklin Delano Roosevelt, and the diagnosis was poliomyelitis.

Even long after Roosevelt’s death, the debate about the cause of his paralytic illness continues. At the time, the diagnosis of polio seemed appropriate because it was the most common cause of paralysis in the United States, it was contracted during the summer, and it was accompanied by fever. Researchers looking at the diagnosis retrospectively point to the patient’s age of 39 and the lack of physician knowledge about other potential causes as indicative of the fact that the actual culprit was Guillain-Barre syndrome, an autoimmune condition (Goldman et al., 2003).

Misdiagnosis can occur when:

img Doctors lack sufficient time to analyze a problem thoroughly

img Testing is not performed in order to save money

img Knowledge about less common diseases is lacking

img Patients do not communicate complete information

img Tests are not completed due to patient noncompliance

img Testing errors occur (equipment failure, human error)

img Objective testing is not possible

img Diagnosis is difficult to confirm

Diagnosis is required for desired treatment implementation. If you obtain information that indicates to you that the wrong diagnosis has been made, it is important that you discuss the matter with your physician. He can review the facts with you and, if necessary, change his opinion. It is important that the incorrect diagnosis does not remain on your medical record, because it could affect your future treatment and well-being.

References

1984 Revision of the Uniform Hospital Discharge Data Set. (1985, July 31). Federal Register50(147), 31038–31040.

Center for Medicare and Medicaid Services. (n.d.). Documentation guidelines—evaluation and management services. Retrieved January 20, 2014, from http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf

Centers for Disease Control and Prevention. (n.d.). Facts about birth defects. Retrieved January 21, 2014, from http://www.cdc.gov/ncbddd/birthdefects/facts.html

Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2001, September 26). Transmittal AB-01-144. Retrieved January 20, 2014, from http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/AB01144.pdf

Goldman, A. S., Schmalstieg, E. J., Freeman, D. H. Jr., Goldman, D. A., & Schmalstieg, F. C. Jr. (2003). What was the cause of Franklin Delano Roosevelt’s paralytic illness? Journal of Medical Biography11(4), 232–240.

Kim, P., & Leopold, S. (2012). Gustilo-Anderson classification. Clinical Orthopaedic Related Research470(11), 3270–3274.

National Center for Health Statistics. (2014). ICD-10-CM official guidelines for coding and reporting. Retrieved January 20, 2014, from http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf

National Library of Medicine. (2013, May). Genetics home reference. Retrieved January 21, 2014, from http://ghr.nlm.nih.gov/condition/partington-syndrome

National Pressure Ulcer Advisory Panel. (n.d.). Pressure ulcer stages/categories. Retrieved January 7, 2014, from http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/

Maisel, E. (2013, July 23). The new definition of a mental disorder. Psychology Today. Retrieved January 5, 2014, from http://psychologytoday.com/blog/rethinking-psychology/201307/the-new-definition-mental-disorder

U.S. Department of Health and Human Services, National Institutes of Health, National Heart Lung and Blood Institute. (2012, September). Asthma care quick reference. Publication 12-5075. Retrieved January 6, 2014, from http://www.nhlbi.nih.gov/guidelines/asthma/asthma_qrg.pdf

CHAPTER 3

Procedure Coding: Location, Location, Location

Coding Paths Diverge

In addition to the patient’s diagnosis, the other pieces of information associated with every healthcare encounter are the procedure codes, the dates the procedures were performed, the location in which they were performed, and the physician or other provider who performed them.

The term procedure coding encompasses a wide variety of services to patients:

img Surgery: Operative treatment of disease or injury

img Anesthesia: The process of blocking pain or other perceptions

img Radiology: The use of imaging modalities for diagnosis, interventional techniques, or radiation therapy for treatment

img Laboratory: Testing performed on biological specimens to get information about the health of a patient

img Pathology: Diagnosis of disease based on the gross and microscopic examination of cells and tissues

img Diagnostic testing: Nonlab, nonradiologic testing to arrive at a diagnosis

img Evaluation and management: “Visits” to evaluate patients and manage their care

img Psychiatric: Treatment of mental or emotional disorders

img Osteopathic: Branch of medicine that uses manipulative techniques to supplement treatment of disease

img Chiropractic: Focuses on spinal function to improve health

img Rehabilitation: Physical, occupational, speech, and other therapies to improve functioning

img Alternative: Diagnostic or treatment methods with theoretical bases that differ from conventional medicine, such as acupuncture

img Preventive: Actions, such as vaccinations, to prevent disease or injury

All types of providers, whether facilities or individual practitioners, use ICD-10-CM diagnosis codes. This is not true for procedure or supply codes. The type of billing code used depends on several factors:

img Location, or site of service where the procedure was performed

img Type of charge being coded:

img Professional

img Facility

img Dental

img Durable medical equipment, prosthetics, or supplies

img Drugs and biologics

In this chapter, we will focus on procedure coding for professional services and facility services.

Hospital Procedures Versus Doctor’s Procedures

As a case study, let’s assume that you have always been in good health, but that over the weekend you started having pain in your stomach region. It started near your navel and then became more and more severe as it moved toward the lower right side of your abdomen. You decided to go to the emergency room. After the exam and some lab work, the doctor decided that you had appendicitis. A surgeon was contacted, and you were taken to the operating room for an appendectomy, or removal of your appendix.

From the time you entered the emergency room to the time you were discharged home after recuperation from your surgery, the hospital maintained a medical record documenting every occurrence during your stay. In addition to documentation by the emergency room physician and the surgeon, your medical record also includes notes by the nursing staff; orders from physicians; reports of diagnostic testing results, such as lab work; administrative paperwork, such as consent forms; visits by allied health personnel, such as the dietitian; your vital signs; and details such as whether you went to the bathroom.

The surgeon who removed your appendix will also start a medical record for you at his office, even though you have not yet been there. At this point, it will probably contain a copy of the operative report dictated by the surgeon for the hospital record and a copy of the hospital “face sheet” of demographics with your name, address, and insurance information. When you visit the surgeon for a follow-up visit after your surgery, he will add a progress note to his office chart.

After you are discharged from the hospital, your medical record will be processed by the facility’s health information department. If the facility is still using paper records, the chart will be assembled into a standard order, checked for missing documentation and signatures, placed in a folder, and the diagnoses and procedures coded. In an increasing number of hospitals, all of the documentation is maintained electronically, in which case many signature and report deficiencies are automatically identified and the provider notified.

As a patient, you are issued a unique number under which all of your health information is maintained. These numbers are specific to a facility or chain of facilities; they are not used across organizational boundaries, with a few exceptions. Known as a patient number, medical record number, or patient identifier, this unique number follows you throughout your care. Patients who are admitted to the hospital as inpatients generally receive a wristband with their name and medical record number. This is used to prevent identity errors and resulting incorrect medication administration, wrong surgery, or lab specimen errors.

Medical coding analysts will look at your record in order to assign ICD-10-CM diagnosis codes to your diagnosis “acute appendicitis,” and they will also assign ICD-10-PCS procedure codes to your procedure “appendectomy.” They may also check the results of the surgical pathology examination of your appendix to determine whether you actually had appendicitis. The diagnosis and procedure codes will be routed to the hospital business office, where a bill will be generated for the facility charges incurred during your stay. If you have insurance, a claim with the diagnosis and procedure codes will be sent to that payer for reimbursement.

Meanwhile, the surgeon is also interested in getting paid. The surgeon’s claim form to your insurance company will usually contain the same ICD-10-CM diagnosis codes used by the hospital, but the procedure code will be different. The surgeon will use Current Procedural Terminology, also known as CPT.

Why the Difference? How Did It Come About?

HOSPITAL PROCEDURE CODING

Coding started as a way to categorize deaths. It evolved into a method of indexing hospital diagnoses and procedures in order to assess the healthcare status and needs of the living. The first advocate of hospital statistics was Florence Nightingale, the famous nurse ( Figure 3-1 ).

img

FIGURE 3-1 Florence Nightingale.

© National Library of Medicine

While serving in a battlefront hospital during the Crimean War of the 1850s, Nightingale observed that far more soldiers died of disease than of war injuries. Her relentless efforts to improve sanitation helped reduce the mortality rate in her hospital from 33% to 2% in 1 year, 1855 (Gill & Gill, 2005). When she returned to England after the war, she submitted a statistical report to the British government, hoping to convince them that improvement of sanitary conditions in local hospitals would also reduce deaths. The government refused to allow her to publish her data. She persisted, using army data already available, informing the public of her cause. When she began her campaign, life expectancy in England was 39 years. When she died 50 years later in 1910, it had risen to 55, at least, in part, due to her efforts (Small, 1998).

Before 1960, hospitals used various systems to index procedures. With the manual methods in use at that time, “indexing” literally meant using index cards. A card was set up for each procedure code or category, and the medical record numbers of patients who underwent that procedure were written on the card, along with the date of the procedure. At the same time, statistical reports were prepared showing how many of various procedures were performed monthly or annually. If researchers needed information on cases from a particular procedure category, the medical records could be pulled based on the information in the indexes.

The first revision of the International Classification of Diseases (ICD) that contained procedure codes was a version of ICDA-7 issued by the U.S. Public Health Service in 1959. It contained procedure codes with up to three digits. ICDA-8, also with three-digit codes, was used from 1970 to 1978, and ICD-9-CM has been in effect since 1979 and will be until 2015. The latter classification was expanded to four-digit codes for procedures. Starting on October 1, 2015, ICD-10-PCS (Procedure Coding System) goes into effect, with more than 71,000 procedure codes, each containing seven characters.

Concurrent with the development of consistent procedure coding systems was the initiation of the Uniform Hospital Discharge Data Set (UHDDS). Although vital statistics data, such as births, deaths, and marriages, had uniform definitions in the United States, there was no agreement before 1973 on what data should be collected and reported by hospitals. The NCHS collected hospital data, but the emphasis was on the institutions’ overall activities, not the problems of their patients. The statistics described how busy they were, but not what they were accomplishing in the way of patient care (White, n.d.).

An amendment to the Public Health Act in 1974 made the National Committee on Vital and Health Statistics a statutory body and required that there be an annual report to Congress on the health of the American people. Health United States 1975 ( Figure 3-2 ) was a hit with the press (U.S. Department of Health, Education, and Welfare, 1975).

It reported in one place, for the first time, 603 pages of health-related data, such as the average physician fee for an initial office visit ($12.17 for a pediatrician and $17.62 for a surgeon) and the average net income of physicians ($43,570 for a pediatrician and $62,320 for a surgeon).

Hospital discharge data by diagnostic category was skimpy, and there was no information about hospital procedures except for the number of hospitals reporting various types of services, such as burn units, home care, renal dialysis, and blood banks.

img

FIGURE 3-2 Health United States 1975.

Reproduced from National Center for Health Statistics. Health, United States, 1975. DHEW Publication No. (HRA) 76-1232. Rockville, Maryland. Courtesy of CDC.

Currently, the UHDDS Procedure Code Guidelines, developed in 1973 and revised in 1985, govern the types of procedure code data collected on hospital inpatients. Additional rules developed by Medicare with the advent of its Prospective Payment System (PPS) have come into play because of the link between procedure coding and reimbursement.

PHYSICIAN PROCEDURE CODING

Prior to 1981, a number of different systems were used to code physician procedures. There was no requirement that a code number be submitted with a claim for payment, so many physicians merely submitted a verbal description of what they had done. This required the insurance companies to figure out what some of the arcane descriptions meant before they could decide how much to pay.

When Medicare was enacted in 1965, physicians looked for a better system to report their services. What better group to design a physician coding system than their own professional organization, the American Medical Association (AMA). The first edition of Current Procedural Terminology (CPT) was published by the AMA in 1966. Primarily containing surgical procedure codes, with smaller sections on medicine, laboratory, and radiology, it consisted of four-digit code numbers.

Expansion of CPT led to the following:

img Adoption of five-digit codes in CPT-2 (1970)

img Addition of modifiers for further specificity in reporting in CPT-3 (1973)

img Inclusion of additional codes for new technology in CPT-4 (1977)

In 1992, the Evaluation and Management (E&M) codes were added to describe cognitive efforts involved with nonsurgical services. CPT is updated annually to reflect changes in medical and surgical services.

In 1983, the federal government entered into an agreement with the AMA that CPT would be the mechanism for reporting physician services under Medicare. As is usually the case, other payers followed Medicare procedures and by 1990 CPT had become the single uniform system for reporting of physician services. Today, it is estimated that over 95% of services provided by physicians are reported using the CPT coding system (Harris, 1997).

Whereas ICD-10-PCS is a system in the public domain, CPT remains a proprietary system owned and operated by the AMA. It is not possible to obtain a copy of CPT without purchase.

What About HCPCS?

This system (pronounced “hic-pics”) is the Healthcare Common Procedure Coding System. CPT is considered a part of HCPCS, known as Level I. There are also more than 6,000 alphanumeric Level II codes, which are used to identify healthcare equipment and supplies and drugs (CMS, 2014b). Level II code descriptors identify similar items or services, rather than specific brand names. For example, HCPCS code J3410 has the description of “Injection, hydroxyzine HCL up to 25 mg.” This code does not vary, even if the drug administered is a brand name formulation rather than a generic. The same code is used regardless of manufacturer or supplier. If you visit your doctor and he administers a medication to you during the visit, his claim form to the payer will include a CPT code for his service plus a HCPCS Level II J code for the medication. Retail pharmacies use yet another coding system, the National Drug Codes (NDC). Under consideration is the elimination of the HCPCS J codes and the requirement that all providers and suppliers use the NDC codes. The NDC codes are 11 digits long, which is problematic for the billing systems in many doctors’ offices.

Dental codes, Current Dental Terminology (CDT), are also part of HCPCS Level II. CDT is maintained by the American Dental Association and is used only for dental billing.

“Miscellaneous” and “temporary” HCPCS Level II codes change frequently and are used for new items or services that haven’t yet made it to the permanent section of codes. Miscellaneous codes can be used to bill for items for which no other codes exist.

The fact that CPT is part of HCPCS, and the existence of the 1983 agreement that the AMA would have the “sole responsibility and authority to revise, update, or modify” CPT and to “continue to print, publish, sell, and otherwise disseminate” (U.S. Department of Health and Human Services, 1998) CPT even though it is being used as part of a required code set for federal health program billing purposes has caused accusations that the government “granted the AMA what has been characterized as a ‘statutory monopoly’… a financial windfall for the AMA in the form of CPT-related book and CD sales with revenue of more than $71 million a year” (Lott, 2001).

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires, under its Administrative Simplification section, that the Department of Health and Human Services define national standards for the electronic transaction of healthcare information, including provider and facility claims. As of October 16, 2003, standard code sets had to be implemented by all parties who transmit information electronically. ICD-9-CM was the standard code set for diagnoses, whereas ICD-9-CM procedure codes were the rule for inpatient hospital procedures, CDT for dental services, and HCPCS (including the AMA-controlled CPT) was for the following services:

img Physician services

img Physical and occupational therapy services

img Radiological procedures

img Clinical laboratory tests

img Other medical diagnostic procedures

img Hearing and vision services

img Transportation services, including ambulance

The designation of CPT as a standard code set under HIPAA further reinforced its position as a major procedure coding authority. In 2009, the Final Rule was published, changing the diagnosis coding system to ICD-10-CM and the hospital inpatient procedure coding system to ICD-10-PCS (“HIPAA Administrative Simplification,” 2009). No change was made to CPT as the standard code set for physician and ancillary services billing. The original effective date of this change was October 1, 2013, but the secretary of Health and Human Services authorized a 1-year delay to 2014. On April 1, 2014, another delay was enacted as part of a patch to the sustainable growth rate (SGR) Medicare payment formula, postponing the implementation of ICD-10-CM and ICD-10-PCS until October 1, 2015.

Where It’s At

The location where the service or product is provided determines which procedure code set is used. As is the case with many other facets of healthcare billing, the methods of identifying the location differ between professional claims and facility claims. Professional billing uses place of service codes defined by the CMS (CMS, 2012). Facility billing uses the concept of “bill type,” a four-digit alphanumeric code where the second digit represents the type of facility, the third digit represents the classification (clinics only), and the fourth digit equals the frequency of the bill. The first digit is always a leading zero (CMS, 2014a). The following table shows the correlation between bill type and place of service. The character X is used as a placeholder for the fourth digit, indicating bill frequency.

Bill Type

Place of Service (Location)

011X

Hospital inpatient Part A or Hospital inpatient Part B

21 (inpatient hospital) or 51 (psychiatric)

012X

013X

Hospital outpatient

22 (outpatient hospital) or 23 (hospital emergency room)

021X

Skilled nursing

31 (skilled nursing facility)

033X

Home health

12 (patient home)

071X

Rural health clinic

72 (rural health clinic)

072X

Freestanding dialysis center

65 (end-stage renal disease facility)

075X

Comprehensive outpatient rehab

62 (comprehensive outpatient rehab facility)

076X

Community mental health center

53 (community mental health center)

083X

Hospital outpatient ASC (ambulatory surgical center)

24 (ambulatory surgical center)

Source:  Data from CMS Publication 100-4 Medicare Claims Processing Manual, Chapter 25, 2013. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c25.pdf.

A number of additional professional services place of service or location codes are available, including the following:

03

School

04

Homeless shelter

09

Prison or correctional facility

11

Doctor’s office

13

Assisted living facility

14

Group home

17

Walk-in retail health clinic

25

Birthing center

26

Military treatment facility

32

Nursing facility

33

Custodial care facility

34

Hospice

55

Residential substance abuse treatment facility

56

Psychiatric residential treatment center

71

Public health clinic

The location or place of service is important in coding because many payers have different reimbursement schedules, copay amounts, or coverage limitations depending on where the service is provided.

The Evaluation and Management (E&M) codes in CPT are defined based on location:

img Hospital inpatient

img Office or other outpatient

img Hospital observation

img Emergency department

img Nursing facility (skilled, intermediate, long-term care, psychiatric residential treatment center)

img Boarding home, custodial care, assisted living

img Home (private residence)

ICD-10-PCS Procedure Coding Guidelines

HOSPITAL INPATIENTS ONLY

Item 12 of the UHDDS guidelines states that procedure codes and dates of all significant procedures are to be reported (Federal Register, 1985). The identity (number) of the person performing the procedure must also be reported.

What is a “significant procedure”? A significant procedure can be one or more of the following:

img Surgical in nature:

img Incision

img Excision

img Amputation

img Introduction

img Endoscopy

img Repair

img Destruction

img Suture

img Manipulation

img Carries a procedural risk:

img Professionally recognized risk that a procedure may potentially cause body impairment, injury, disease, or death

img Trauma risk: Procedures that are invasive, able to produce tissue damage, or introduce toxic or noxious substances

img Physiologic risk: Procedures that use any drug or physical substance that can affect the body

img Any procedure using pre- or postoperative medications

img Procedures that use long-life radioisotopes

img Carries an anesthetic risk:

img Any procedure using general anesthesia

img Any local, regional, or other type of anesthesia causing functional impairment that requires care in usage to protect the patient from harm

img Requires specialized training:

img Specialized professionals, qualified technicians, or clinical teams specifically trained for the performance of the procedure

SELECTION OF PRINCIPAL PROCEDURE

The principal procedure is defined in the UHDDS as “one that was performed for definitive treatment rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication. If there appear to be two procedures that are principal, then the one most related to the principal diagnosis should be selected as the principal procedure.”

Selection of the principal procedure is related to inpatient reimbursement. Because there is the potential of manipulating coding in order to receive a higher reimbursement rate, additional coding guidelines for the selection of principal procedure and sequencing of other procedures were developed as part of ICD-10-PCS.

Circumstances

Principal Procedure

Procedure performed for definitive treatment of both principal diagnosis and secondary diagnosis

Procedure performed for definitive treatment most related to principal diagnosis

Procedure performed for definitive treatment and diagnostic procedures performed for both principal diagnosis and secondary diagnosis

Procedure performed for definitive treatment most related to principal diagnosis

Diagnostic procedure performed for the principal diagnosis and a procedure performed for definitive treatment of a secondary diagnosis

Diagnostic procedure performed for the principal diagnosis

No procedures performed that are related to principal diagnosis; procedures performed for definitive treatment and diagnostic procedures performed for secondary diagnoses

Procedure performed for definitive treatment of secondary diagnosis since there are no procedures (definitive or nondefinitive treatment) related to principal diagnosis

Source:  Data from ICD-10-PCS Official Guidelines for Coding and Reporting, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/PCS-2014-guidelines.pdf.

The selection of the principal procedure is not always clear-cut. Let’s go back to our case sample in which you were admitted as an inpatient and had an appendectomy to resolve your appendicitis. If, during your hospital stay, you fell out of bed and broke your hip, you might have undergone an additional surgery to repair your hip fracture. Both the appendectomy and the hip surgery meet the criteria of being performed for definitive treatment. Even though the hip repair is a more expensive procedure taking more time, the appendectomy is the principal procedure because it is most related to your principal diagnosis of appendicitis.

If more than one definitive procedure is equally related to the principal diagnosis, the most resource-intensive or complex procedure is generally designated as the principal procedure.

PCS OVERVIEW AND CONVENTIONS

This section should be used in conjunction with the ICD-10-PCS Reference Manual, which has numerous examples of PCS codes, as well as coding exercises. It is free of charge and is located at http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html.

ICD-10-PCS represents a radical change from the ICD-9-CM procedure coding system being used for inpatient hospitalizations until October 1, 2015. The old system paralleled the old ICD-9-CM diagnosis coding structure; an alphabetical index was used to look up a procedure in the tabular list. With only four digits available for ICD-9-CM procedure codes, the system is severely limited in its ability to accommodate new procedures and new technology. PCS takes a new approach, in that codes are “built” using flexible components within a seven-character alphanumeric format. Each character in the code represents an aspect of the procedure, as seen in this example from the Medical and Surgical section.

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

One of 34 possible values can be assigned to each of the 7 characters in a procedure code. All letters may be used, with the exception of I and O, because of their potential confusion with the numbers 1 and 0. Numbers 0 through 9 are also used. Ten numbers plus 24 letters totals the 34 possible values for each character. This means that the system is almost infinitely expandable, a big improvement over ICD-9-CM.

It is important to understand that the meaning of any single value is dependent on the preceding values in the code. An example is the fourth character for body part. In the code for gastrointestinal resection, which starts with 0DT, the fourth character value of “6” is for stomach. However, in the code for resection in the respiratory system, which starts with 0BT, the fourth character of “6” is for the right lower lobe of the bronchus.

Although there is an alphabetic index in PCS, it is not mandatory to use the index first.

This represents a departure from the coding process in both the old ICD-9-CM procedure coding and the new ICD-10-CM diagnosis coding systems. The purpose of the alphabetic index in PCS is to point the coder in the direction of the correct table where all the necessary information is located to construct a valid procedure code.

Each PCS table starts with the first three defined characters. Examples include the following:

0LN

Section:

0

Medical and surgical

 

Body system:

L

Tendons

 

Root operation:

N

Release

BT2

Section:

B

Imaging

 

Body system:

T

Urinary system

 

Procedure:

2

CT scan

Once the appropriate table is located, valid procedure codes must contain characters four through seven on the same line within the table. In the following table, 08D8XZZ is a valid code. However, code 08DKXZZ is not a valid code, because the value X for an external approach, which is the fifth character, is not on the same line with the fourth character (K) for left lens. Logically, this makes sense, because you cannot have an external approach to the lens because it is not on the outside of the eye.

Section:

0

Medical and surgical

Body system:

8

Eye

Root operation:

D

Extraction

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

SECTIONS

PCS is divided into 16 sections, or broad procedural categories, with the number of valid codes in each section for 2014 as follows. Sections 0–9 are generally referred to as the medical- and surgical-related sections, whereas sections B–H are the ancillary sections. Official coding guidelines are only available for the Medical and Surgical and Obstetrics sections, with more than 86% of the total valid codes occurring in these two sections.

Character 1: Section Value

Section Title

Number of Valid Codes (2014)

0

Medical and surgical

61,898

1

Obstetrics

300

2

Placement

861

3

Administration

1,388

4

Measurement and monitoring

339

5

Extracorporeal assistance and performance

41

6

Extracorporeal therapies

42

7

Osteopathic

100

8

Other procedures

60

9

Chiropractic

90

B

Imaging

2,934

C

Nuclear medicine

463

D

Radiation therapy

1,939

F

Physical rehabilitation and diagnostic audiology

1,380

G

Mental health

30

H

Substance abuse treatment

59

 

Total

71,924

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Medical- and Surgical-Related Sections (0–9)

MEDICAL AND SURGICAL SECTION (0)

M&S Body System Guidelines

In addition to specific body systems, such as the urinary, muscle, and respiratory systems, there are also tables with body system characters representing more general anatomical regions, such as the pelvic cavity. These should only be used when the procedure is performed on an anatomical region rather than a specific body part, such as drainage of a body cavity.

The line of reference for general body system values of “upper” and “lower” in some systems is above or below the diaphragm.

M&S Root Operations Definitions

The third character in PCS medical- and surgical-related codes is the root operation. It is the answer to the question, “What is the objective of the procedure?” The root operations can be grouped by similar objectives, as follows.

Root operations that take out some or all of a body part:

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Root operations that take out solids/fluids/gases from a body part:

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Root operations that involve cutting or separation only:

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Root operations that put or put back or move some or all of a body part:

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Root operations that alter the diameter or route of a tubular body part:

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Root operations that always involve a device:

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Root operations involving examination only:

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Root operations that include other repairs:

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Root operations that include other objectives:

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

M&S Root Operation Guidelines

General guidelines:

img Components of a procedure specified in the root operation definition are not coded separately.

img Procedural steps necessary to reach and/or close the operative site are not coded separately.

Multiple procedures during the same operative episode are coded under the following circumstances:

img The same root operation is performed on different body parts.

img The same root operation is repeated at different body sites that are included in the same body part value.

img Multiple root operations with distinct objectives are performed on the same body part.

img The intended root operation is attempted using one approach but is converted to a different approach.

Discontinued procedures:

img If the intended procedure is discontinued, code the procedure to whatever root operation was completed. If no other root operation was completed, code the procedure to the inspection root operation.

Biopsies:

img Biopsy procedures are coded by technique to the root operations excision, extraction, or drainage with a qualifier of diagnostic.

img If the biopsy procedure is followed by a more definitive procedure at the same site, both are coded.

Overlapping body layers:

img If the root operations excision, repair, or inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is used.

Bypass procedures:

img Bypass procedures are coded with a fourth character body part of where the bypass is from and a qualifier of the body part the bypass is to.

img An exception to the above is coronary arteries. They are coded according to the number of distinct sites treated, not the number of arteries. The body part is the number of artery sites bypassed to and the qualifier is the vessel bypassed from.

img If multiple coronary artery sites are bypassed, each site that uses a different device and/or qualifier is coded separately.

Control versus more definitive root operations:

img If the attempt to stop postprocedural bleeding is unsuccessful, and any of the definitive root operations is then performed, then that root operation is coded instead of control.

Excision versus resection:

img Resection of a specific body part is coded whenever all of the body part is cut out or off, rather than coding a less specific body part.

Excision for graft:

img If an autograft is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded.

Spinal fusion procedures:

img At each spinal level, there are distinct body part values for single and multiple vertebral joints at each spinal level.

img If multiple vertebral joints are fused, a separate procedure is coded for each vertebral joint that uses a different device and/or qualifier.

img When combinations of devices and materials are used on the same vertebral joint, the device value (character 6) is:

img Interbody fusion device (alone or containing bone graft); code to device interbody fusion device.

img Bone graft alone; code to device autologous or nonautologous tissue substitute.

img Mixture of autologous and nonautologous bone graft, with or without extenders or binders; code to autologous tissue substitute.

Inspection procedures:

img Inspection of a body part performed in order to achieve the objective of the procedure is not coded separately.

img If multiple tubular body parts are inspected, the most distal part is coded.

img If multiple nontubular body parts in a region are inspected, the body part that specifies the entire area is coded.

img When both an inspection procedure and another procedure are performed on the same body part during the same episode, and the inspection procedure is performed using a different approach than the other procedure, the inspection procedure is coded separately.

Occlusion versus restriction for vessel embolization procedures:

img If the objective of embolization is to completely close a vessel, code to occlusion.

img If the objective is to narrow the lumen of the vessel, code to restriction.

Release procedures:

img The body part value coded is the part being freed, not the tissue being manipulated or cut to free the body part.

img If the sole objective is freeing a body part without cutting it, code to release.

img If the sole objective is separating or transecting the body part, code to transection.

Reposition for fracture treatment:

img Reduction of a displaced fracture is coded to reposition and any associated cast or splint application is not coded separately.

img Treatment of a nondisplaced fracture is coded to the procedure performed.

img Casting of a nondisplaced fracture is coded to immobilization in the placement section.

Transplantation versus administration:

img Putting in a mature and functioning living body part taken from another individual or animal is coded to transplantation.

img Putting in autologous or nonautologous cells is coded to the Administration section.

M&S Body Part Guidelines

General:

img If a procedure is performed on a portion of a body part that does not have a specific value, code to the value for the whole body part.

img If the prefix peri- is combined with a body part to identify the site, the procedure is coded to the body part named.

Branches of body parts:

img If a specific branch of a body part does not have its own value, code to the closest proximal branch that does have a specific value.

Bilateral body part values:

img If the identical procedure is performed bilaterally and a bilateral body part value is available, code once using the bilateral body part value.

img If a bilateral body part value is not available, code twice using the left and right values.

Tendons, ligaments, bursae, and fascia near a joint:

img Procedures performed on tendons, ligaments, bursae, and fascia supporting a joint are coded to the body part in the body system that is the focus of the procedures.

img Procedures performed on joint structures themselves are coded to the body part in the joint body system.

Skin, subcutaneous tissue, and fascia overlying a joint:

img Procedures performed on the skin, subcutaneous tissue or fascia overlying a joint are coded to the following body parts:

img Shoulder is coded to upper arm.

img Elbow is coded to lower arm.

img Wrist is coded to lower arm.

img Hip is coded to upper leg.

img Knee is coded to lower leg.

img Ankle is coded to foot.

Fingers and toes:

img If a body system does not contain a separate body part value for:

img Fingers, code to body part value for hand.

img Toes, code to body part value for foot.

Upper and lower intestinal tract:

img The root operations change, inspection, removal, and revision within the gastrointestinal body system contain general body part values of the following:

img Upper intestinal tract: Includes the portion from the esophagus down to and including the duodenum

img Lower intestinal tract: Includes the portion from the jejunum down to and including the rectum and anus

M&S Approach Guidelines

For the seven medical- and surgical-related sections, the fifth character is used to define the approach or technique used to reach the site of the procedure:

0

Open: Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure

3

Percutaneous: Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure

4

Percutaneous endoscopic: Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure

7

Via natural or artificial opening: Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure

8

Via natural or artificial opening endoscopic: Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure

F

Via natural or artificial opening with percutaneous endoscopic assistance

X

External: Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane

Open approach with percutaneous endoscopic assistance:

img Procedures performed using the open approach with percutaneous endoscopic assistance are coded to the open approach.

External approach:

img Procedures performed within an orifice on structures that are visible without the aid of any instrumentation are coded to external approach.

img Procedures performed indirectly by the application of external force through intervening body layers are coded to external approach.

Percutaneous procedure via device:

img Procedures performed percutaneously via a device placed for the procedure are coded to percutaneous approach.

M&S Device Guidelines

img A device is coded only if a device remains after the procedure is completed.

img If no device remains, the device value of “no device” Z is used.

img Materials such as sutures, ligatures, radiological markers, and temporary postoperative wound drains are not coded as devices.

img Procedures performed on a device only and not on a body part are coded to change, irrigation, removal, or revision.

img A separate procedure to put in a drainage device is coded to root operation drainage with a device value of “drainage device.”

OBSTETRICS SECTION (1)

The seven code characters retain the same meanings in the Obstetrics section.

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Obstetrics Body Systems

The body system for this section is Pregnancy (0).

Obstetrics Root Operations

Two of the 12 root operations in the Obstetrics section are unique:

img Abortion (A): Artificially terminating a pregnancy

img Delivery (E): Assisting the passage of the products of conception from the genital canal

The other root operations available in valid obstetrics codes have the same meanings as in the Medical and Surgical section. They are the following:

img Change (2)

img Drainage (9)

img Insertion (H)

img Inspection (J)

img Removal (P)

img Repair (Q)

img Reposition (S)

img Resection (T)

img Transplantation (Y)

Obstetrics Body Parts

The Obstetrics section of ICD-10-PCS includes procedures performed on the products of conception. Procedures performed on a pregnant female, other than on the products of conception, are coded to the appropriate root operation in the Medical and Surgical section (0). Thus, only three possible body part values are available in this section:

img Products of conception (0)

img Products of conception, retained (1)

img Products of conception, ectopic (2)

Obstetrics Qualifiers

Obstetrics qualifiers include the types of C-sections, types of deliveries, types of abortifacients, fluids removed in drainage procedures on products of conception, and body systems repaired or transplanted within products of conception.

PLACEMENT SECTION (2)

The seven characters retain the same meaning in the Placement section.

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Placement Body Systems

The Placement body systems are the following:

W

Anatomical regions

Y

Anatomical orifices

Placement Root Operations

Only those procedures performed without making an incision or puncture are coded:

0

Change: Taking out or off a device from a body region and putting back an identical or similar device in or on the same body region without cutting or puncturing the skin or a mucous membrane

1

Compression: Putting pressure on a body region

2

Dressing: Putting material on a body region for protection

3

Immobilization: Limiting or preventing motion of a body region

4

Packing: Putting material in a body region or orifice

5

Removal: Taking out or off a device from a body region

6

Traction: Exerting a pulling force on a body region in a distal direction

Placement Approach

The placement approach is always external (X).

Placement Devices

0

Traction apparatus

1

Splint

2

Cast

3

Brace

4

Bandage

5

Packing material

6

Pressure dressing

7

Intermittent pressure device

8

Stereotactic device

9

Wire

Y

Other device

Z

No device

Placement Qualifier

The Placement qualifier is always Z, no qualifier.

ADMINISTRATION SECTION (3)

The seven characters retain the same meaning in the Administration section, except that the sixth character refers to a substance instead of a device.

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

The codes in this section describe procedures in which a diagnostic or therapeutic substance is given to a patient.

Administration Body Systems

The codes for body systems are the following:

0

Circulatory

C

Indwelling device

E

Physiological systems and anatomical regions

Administration Root Operations

0

Introduction: Putting in or on a therapeutic, diagnostic, nutritional, physiological, or prophylactic substance except blood or blood products

1

Irrigation: Putting in or on a cleansing substance

2

Transfusion: Putting in blood or blood products

Administration Approach

All approaches are used in this section, except percutaneous endoscopic.

Administration Substances

Substances include a wide variety of blood components, as well as substance categories such as contrast agents or local anesthetics, stem cells, and fertilized ovum.

Administration Qualifiers

Qualifiers are used to identify autologous versus nonautologous, specific drug types, and diagnostic procedures.

MEASUREMENT AND MONITORING SECTION (4)

The seven code characters in this system are slightly different.

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Measurement and Monitoring Body Systems

A

Physiological systems

B

Physiological devices

Measurement and Monitoring Root Operations

0

Measurement: Determining the level of a physiological or physical function at a single point in time

1

Monitoring: Determining the level of a physiological or physical function repetitively over a period of time

Measurement and Monitoring Body Systems

Character 4 defines the specific system being measured or monitored.

Measurement and Monitoring Function/Device

Character 6 specifies the physiological or physical function being measured or monitored, or the device used.

Functions

0

Acuity

1

Capacity

2

Conductivity

3

Contractility

4

Electrical activity

5

Flow

6

Metabolism

7

Mobility

8

Motility

9

Output

B

Pressure

C

Rate

D

Resistance

F

Rhythm

G

Secretion

H

Sound

J

Pulse

K

Temperature

L

Volume

M

Total activity

N

Sampling and pressure

P

Action currents

Q

Sleep

R

Saturation

Devices

S

Pacemaker

T

Defibrillator

V

Stimulator

Monitoring and Measurement Qualifiers

Qualifiers are used to further define parts of various body systems.

EXTRACORPOREAL ASSISTANCE AND PERFORMANCE SECTION (5)

In this section, character 5 describes the duration of the procedure, rather than the approach.

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Extracorporeal Assistance Body System

Only one body system, physiological systems (A), is available.

Extracorporeal Assistance Root Operations

0

Assistance: Taking over partial control of the physiological function.

1

Performance: Taking complete control of the physiological function.

2

Restoration: Returning, or attempting to return, a physiological function to its original state. Note that this applies only to external cardioversion and defibrillation. Failed cardioversion is coded the same as successful.

Extracorporeal Body Systems

2

Cardiac

5

Circulatory

9

Respiratory

C

Biliary

D

Urinary

Extracorporeal Duration (Character 5)

0

Single occurrence

1

Intermittent

2

Continuous

3

Less than 24 consecutive hours

4

24–96 consecutive hours

5

Greater than 96 consecutive hours

6

Multiple occurrences

Extracorporeal Assistance Qualifiers

The qualifiers define the type of assistance used, such as balloon pump or hyperbaric oxygenation.

EXTRACORPOREAL THERAPIES SECTION (6)

Similar to the previous section in the assignment of code characters, this section includes other extracorporeal procedures that are not defined as assistance or performance.

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Extracorporeal Therapies Body System

The body system is physiological systems (A).

Extracorporeal Therapies Root Operations

0

Atmospheric control: Pressure and composition

1

Decompression: Elimination of undissolved gas from body fluids

2

Electromagnetic therapy: Treatment by electromagnetic rays

3

Hyperthermia: Raising of body temperature

4

Hypothermia: Lowering of body temperature

5

Pheresis: Separation of blood products

6

Phototherapy: Treatment by light rays

7

Ultrasound therapy: Treatment by ultrasound

8

Ultraviolet light therapy: Treatment by ultraviolet lights

9

Shock wave therapy: Treatment by shock waves

Extracorporeal Therapies Body Systems

0

Skin

1

Urinary

2

Central nervous

3

Musculoskeletal

5

Circulatory

Z

None

Extracorporeal Therapies Duration (Character 5)

0

Single occurrence

1

Multiple occurrences

Extracorporeal Therapies Qualifiers

Character 6 is always value Z, none. The qualifiers in character 7 are used to indicate which blood products are separated in pheresis and which part of the circulatory system is affected in ultrasound therapy.

OSTEOPATHIC SECTION (7)

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Osteopathic Body System

The system is anatomical regions (W).

Osteopathic Root Operation

The root operation is treatment (0).

Osteopathic Body Regions

0

Head

1

Cervical

2

Thoracic

3

Lumbar

4

Sacrum

5

Pelvis

6

Lower extremities

7

Upper extremities

8

Rib cage

9

Abdomen

Osteopathic Approach

The approach is always external (X).

Osteopathic Methods

Methods are not defined specifically in PCS other than as follows:

0

Articulatory, raising

1

Fascial release

2

General mobilization

3

High velocity, low amplitude

4

Indirect

5

Low velocity, high amplitude

6

Lymphatic pump

7

Muscle energy, isometric

8

Muscle energy, isotonic

9

Other method

Osteopathic Qualifier

The qualifier is always Z, none.

OTHER PROCEDURES SECTION (8)

This section includes procedures that are not found in the other medical- and surgical-related sections.

img

Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Other Procedures Body Systems

C

Indwelling device

E

Physiological systems and anatomical regions

Other Procedures Root Operations

0

Other procedures: Methods that attempt to remediate or cure a disorder or disease

Other Procedures Body Regions

1

Nervous system

2

Circulatory system

9

Head and neck region

H

Integumentary system and breast

K

Musculoskeletal system

U

Female reproductive system

V

Male reproductive system

W

Trunk region

X

Upper extremity

Y

Lower extremity

Z

None

Other Procedures Methods

0

Acupuncture

1

Therapeutic massage

6

Collection

B

Computer-assisted procedure

C

Robotic-assisted procedure

D

Near-infrared spectroscopy

Y

Other method

Other Procedures Approach

Standard approach definitions are used.

Other Procedures Qualifiers

Qualifiers include procedures such as suture removal, examination, piercing, plus specifics of either breastmilk or sperm for method collection, in vitro fertilization, meditation, and yoga therapy.

CHIROPRACTIC SECTION (9)

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Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Chiropractic Body System

The body system is anatomical regions (W).

Chiropractic Root Operation

B

Manipulation: Manual procedure that involves a directed thrust to move a joint past the physiological range of motion, without exceeding the anatomical limit

Chiropractic Body Regions

0

Head

1

Cervical

2

Thoracic

3

Lumbar

4

Sacrum

5

Pelvis

6

Lower extremities

7

Upper extremities

8

Rib cage

9

Abdomen

Chiropractic Approach

The approach is always external (X).

Chiropractic Methods

Methods are not defined within PCS, except as follows:

B

Nonmanual

C

Indirect visceral

D

Extra-articular

F

Direct visceral

G

Long lever specific contact

H

Short lever specific contact

J

Long and short level specific contact

K

Mechanically assisted

L

Other method

Chiropractic Qualifier

The qualifier is always Z, none.

Ancillary Sections (B–D and F–H)

The six ancillary sections all use a third coding character called “root type,” instead of root operation. It defines the type of procedure performed. Characters 4, 5, and 6 also have different definitions, as described in the following sections.

IMAGING SECTION (B)

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Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Imaging Body Systems

Many values are possible, similar to the Medical and Surgical section.

Imaging Root Types

Root type describes the category of procedure performed:

0

Plane radiography: Planar display of an image developed from the capture of external ionizing radiation on photographic or photoconductive plate

1

Fluoroscopy: Single plane or bi-plane real-time display of an image developed from the capture of external ionizing radiation on a fluorescent screen

2

CT scan: Computer reformatted digital display of multiplanar images developed from the capture of multiple exposures of external ionizing radiation

3

MRI: Computer reformatted digital display of multiplanar images developed from the capture of radio frequency signals emitted by nuclei in a body site excited within a magnetic field

4

Ultrasonography: Real-time display of images of anatomy or flow information developed from the capture of reflected and attenuated high-frequency sound waves

Imaging Body Parts

Defines more specifically the part of the body system from character 2.

Imaging Contrast

0

High osmolar

1

Low osmolar

Y

Other contrast

Z

None

Imaging Qualifier (Character 6)

Many tables contain a value of Z, none, for character 6, but in a few cases it is used to provide more detail about technique, such as with and without contrast, identified as unenhanced and enhanced.

Imaging Qualifier (Character 7)

Character 7 usually has a value of Z, none, but a few tables have entries such as intraoperative, guidance, or other descriptive enhancements.

NUCLEAR MEDICINE SECTION (C)

This section is very similar to the Imaging section, except that character 5 is used to describe the radionuclide, or radiation source, used in the procedure.

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Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Nuclear Medicine Body Systems

Many options are available, similar to the Medical and Surgical section.

Nuclear Medicine Root Types

1

Planar nuclear imaging: Introduction of radioactive materials into the body for single-plane display of images developed from the capture of radioactive emissions

2

Tomographic (tomo) nuclear medicine imaging: Introduction of radioactive materials into the body for three-dimensional display of images developed from the capture of radioactive emissions

3

Positron emission tomographic (PET) imaging: Introduction of radioactive materials into the body for three-dimensional display of images developed from the simultaneous capture, 180 degrees apart, of radioactive emissions

4

Nonimaging nuclear medicine uptake: Introduction of radioactive materials into the body for measurements of organ function, from the detection of radioactive emissions

5

Nonimaging nuclear medicine probe: Introduction of radioactive materials into the body for the study of distribution and fate of certain substances by the detection of radioactive emissions from an external source

6

Nonimaging nuclear medicine assay: Introduction of radioactive materials into the body for the study of body fluids and blood elements, by the detection of radioactive emissions

7

Systemic nuclear medicine therapy: Introduction of unsealed radioactive materials into the body for treatment

Nuclear Medicine Body Parts

Many options are available to further define the body system in character 2.

Nuclear Medicine Radionuclide

Many options are available to define the actual element used, such as cobalt-58 or gallium-67.

Nuclear Medicine Qualifiers (Characters 6 and 7)

The qualifiers are always Z, none.

RADIATION THERAPY SECTION (D)

Defines the procedures used for radiation treatment of cancer.

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Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Radiation Therapy Body Systems

Many options are available, similar to the Medical and Surgical section.

Radiation Therapy Root Type

The root type defines the modality used in radiation therapy:

0

Beam radiation

1

Brachytherapy

2

Stereotactic radiosurgery

Y

Other radiation

Radiation Therapy Body Part

Defines the specific area that the radiation therapy is focused on.

Radiation Therapy Modality Qualifier

The qualifier further defines the therapy given, using terms such as hyperthermia, photons, electrons, and neutrons.

Radiation Therapy Isotope

Defines the specific radioactive material used in therapy, such as cesium-137 or strontium-90.

Radiation Therapy Qualifier

The therapy qualifier is either intraoperative (0) or none (Z).

PHYSICAL REHABILITATION AND DIAGNOSTIC AUDIOLOGY SECTION (F)

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Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Rehab and Audiology Section Qualifier (Character 2)

In this section, character 2 is known as a section qualifier. It merely defines which type of treatment is being provided:

0

Rehabilitation

1

Diagnostic audiology

Rehab and Audiology Root Types

Assessment Determination of the patient’s diagnosis when appropriate, need for treatment, planning for treatment, periodic assessment and documentation related to the following activities:

0

Speech assessment

1

Motor and/or nerve function assessment

2

Activities of daily living assessment

3

Hearing assessment

4

Hearing aid assessment: Appropriateness and/or effectiveness

5

Vestibular assessment

Treatment Use of specific activities or methods to develop, improve, and/or restore the performance of necessary functions, compensate for dysfunction, and/or minimize debilitation:

6

Speech treatment: Improve, augment, or compensate for impairment

7

Motor treatment

8

Activities of daily living treatment

9

Hearing treatment

B

Cochlear implant treatment

C

Vestibular treatment

Fitting Design, fabrication, modification, selection, and/or application of splint, orthosis, prosthesis, hearing aids, and/or other rehabilitation device:

D

Device fitting

Caregiver Training Educating caregiver with the skills and knowledge used to support the patient’s optimal level of function:

F

Caregiver training

Rehab and Audiology Body System and Region

Many options are possible.

Rehab and Audiology Type Qualifier (Character 5)

More than 100 different tests or methods for assessments and types of training are available.

Rehab and Audiology Equipment (Character 6)

Many types of equipment can be coded, such as audiometer, sound booth, prosthesis, and cochlear implant.

Rehab and Audiology Qualifier (Character 7)

Character 7 is always Z, none.

MENTAL HEALTH SECTION (G)

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Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

This section is not as specific as many others, because it uses only three of the seven available characters. The Body System and Qualifier fields are not used and are always value Z, none.

Mental Health Root Types

Codes for the procedure performed:

1

Psychological tests: The administration and interpretation of psychological tests and measurement instruments for the assessment of psychological function

2

Crisis intervention: Treatment of a traumatized, acutely disturbed, or distressed individual for the purpose of short-term stabilization

3

Medication management: Monitoring and adjusting the use of medications for treatment of a mental health disorder

5

Individual psychotherapy: Treatment of an individual with a mental health disorder by behavioral, cognitive, psychoanalytic, psychodynamic, or psychophysiological means to improve functioning or well-being

6

Counseling: The application of psychological methods to treat an individual with normal developmental issues and psychological problems in order to increase function, improve well-being, alleviate distress, address maladjustment, or to resolve crises

7

Family psychotherapy: Treatment that includes one or more family members of an individual with a mental health disorder by behavioral, cognitive, psychoanalytic, psychodynamic, or psychophysiological means to improve functioning or well-being

B

Electroconvulsive therapy: The application of controlled electrical voltages to treat a mental health disorder

C

Biofeedback: Provision of information from the monitoring and regulating of physiological processes in conjunction with cognitive-behavioral techniques to improve patient functioning or well-being

F

Hypnosis: Induction of a state of heightened suggestibility by auditory, visual, or tactile techniques to elicit an emotional or behavioral response

G

Narcosynthesis: Administration of intravenous barbiturates in order to release suppressed or repressed thoughts

H

Group psychotherapy: Treatment of two or more individuals with a mental health disorder by behavioral, cognitive, psychoanalytic, psychodynamic, or psychophysiological means to improve functioning or well-being

J

Light therapy: Application of specialized light treatments to improve functioning or well-being

Mental Health Type Qualifier (Character 4)

The qualifier further defines the type of therapy, test, or treatment, as appropriate to the root type procedure.

SUBSTANCE ABUSE TREATMENT SECTION (H)

This is another section that only uses three characters in building codes.

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Source:  Data from ICD-10-PCS Reference Manual, 2014. Centers for Medicare and Medicaid Services. Available at http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2014-Reference-Manual.zip.

Substance Abuse Root Types

2

Detoxification services: Detoxification from alcohol and/or drugs

3

Individual counseling: The application of psychological methods to treat an individual with addictive behavior

4

Group counseling: The application of psychological methods to treat two or more individuals with addictive behavior

5

Individual psychotherapy: Treatment of an individual with addictive behavior by behavioral, cognitive, psychoanalytic, psychodynamic, or psychophysiological means

6

Family counseling: The application of psychological methods that includes one or more family members of an individual with addictive behavior

8

Medication management: Monitoring and adjusting the use of replacement medications for the treatment of addiction

9

Pharmacotherapy: The use of replacement medications for treatment of addiction

Substance Abuse Type Qualifier (Character 4)

This qualifier further defines the type of therapy, pharmacotherapy, or counseling.

PCS Body Part and Device Keys

The ICD-10-PCS Reference Manual includes a body part key that can be helpful in determining which body part should be used for a specific anatomic structure. For example, the term “lesser trochanter” will not be found in the section table. If that term is located in the body part key, it indicates that the body part of upper femur, left or right, should be used in building the code. Likewise, the device key provides a crosswalk from brand-name devices to the appropriate device category, such as specifying that “Wallstent© endoprosthesis” is in the intraluminal device category.

PCS Coding Challenges

The ability to assign the correct ICD-10-PCS code to a documented procedure relies heavily on three types of coder knowledge (Rousse, 2013):

1. Foundational knowledge: Knowledge of medical terminology, anatomy and physiology, and pathophysiology

2. Conceptual knowledge: Familiarity with official coding guidelines, root operation definitions, the body part key, and the device key

3. Interpretive knowledge: The ability to use critical thinking to translate clinical documentation into appropriate root operations

The Official Guidelines for Coding and Reporting (CMS, 2014c) state:

Many of the terms used to construct PCS codes are defined within the system. It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear. (Convention A.11)

The real issue, then, is how often the correlation is not clear. The process of learning medical terminology involves prefix and suffix meanings. In the old coding system, -ectomy generally meant “excision.” Now -ectomy can mean either “root operation excision” or “root operation resection,” depending on what and how much was removed.

Some of the root operation terms are unusual, such as extirpation and detachment. Some commonly used terms, such as amputation, are not root operations in PCS. There is little correlation between the terminology in PCS and that found in CPT, which physicians continue to use for their own billing. Because physicians are not expected to use PCS terms, they continue to use their own familiar terminology, including eponyms such as Whipple procedure or McBride bunionectomy. The coder, who might previously have assigned codes based solely on the documented name of the procedure, now has to read the description of the surgical technique and code what was actually done. Additional code characters use details usually not considered under the old system, such as laterality and approach. Devices and substances were also not coded as specifically.

Computer-assisted coding (CAC) uses natural-language processing to “read” reports, identify relevant codeable terms, and suggest codes to the coder, who then makes the final determination of the correct code assignment. A study conducted by the AHIMA Foundation found that the use of CAC resulted in a 22% reduction in the amount of coding time per record and did not result in reduced accuracy when used by a credentialed coder (Dougherty, Seabold, & White, 2013). PCS is an elegant system in its structure and expandability, but it is a labor-intensive system. CAC technology can be used to make up for some of the coder productivity declines inherent in PCS use.

CPT Procedure Coding

For all medical and surgical services other than hospital inpatient, the CPT (Current Procedural Terminology) code consists of five numbers representing a unique service. The classification structure is divided into six main sections:

img Anesthesia (00100 to 01999)

img Surgery (10021 to 69990)

img Radiology (70010 to 79999)

img Pathology and Laboratory (80047 to 89399)

img Medicine (90281 to 99607)

img Evaluation and Management (99201 to 99499)

Despite the fact that the system is divided into categories, a CPT code from any category may be used by any physician or surgeon, regardless of specialty. The Evaluation and Management section is used by all specialties and represents some of the most frequently billed services. Code 99213, which is an expanded office visit for an established patient, was the number one CPT procedure code submitted to Medicare in 2011, with more than 100 million visits totaling more than $6.7 billion in allowed charges (CMS, n.d.).

The index to CPT is organized alphabetically and includes main terms that may denote a procedure or service, an organ or anatomic site, a condition, or synonyms, eponyms, or abbreviations. When searching the index, if a listing is not found under what appears to be the main term, search under one of the other words in the procedure description. Once a main term has been located, review the subterms below it to determine which is the most appropriate, given the description of the procedure that was performed.

Unlike ICD-10-PCS procedure coding, no official national rules govern the use of CPT. However, CPT codes can also be a determinant in reimbursement, thus various governmental agencies have developed their own guidelines to ensure consistency and conformity to coding definitions. Each section of CPT itself also has instructions applicable to that section.

If the CPT definition of a code includes a defined time period, there must be documentation from the physician indicating how much time he or she spent performing the service. An example of this would be 90804, which is “Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient.” Codes with the time specified in the definition are known as “time-based” codes.

Sometimes there is no existing CPT code that adequately describes the procedure performed. This may be due to new techniques, additional technological developments, or procedures performed on anomalous anatomy caused by congenital malformations. Each section of CPT has an “unlisted” code, usually ending in “99,” that is to be used in this situation. It is important to note that the presence of a code in CPT describing a service does not mean that a specific third-party payer will reimburse for that service.

CPT Modifiers

An additional feature of CPT is the use of “modifiers” to indicate that specific circumstances have changed the performed service. An example would be the use of modifier -50 to indicate that a procedure not already defined as bilateral was performed on both sides of the body at the same episode of care. Modifiers play a key role in explaining to payers why procedures that look like they should not be paid separately are in fact justified. Modifiers that affect pricing or payment should be placed in the first position after the procedure code on the claim to ensure correct processing.

Some of the most commonly used HCPCS modifiers are (“Fact Sheets on CPT Modifiers,” n.d.) the following:

22

Increased procedural service, which is service greater than that usually required. This could occur if, for example, a surgeon is operating on a patient who is grossly obese. It takes more work to cut through additional tissue.

24

Unrelated evaluation and management (E&M) service by the same physician or other qualified healthcare professional during a postoperative period. If you fall and break your ankle and have a surgical repair, there is a 90-day global period after the surgery where follow-ups are included in the charge for the surgery. If you fall and break your wrist during that time and go to the same doctor, he would use a -24 modifier on your wrist-related office visit to tell the payer it is unrelated to the previous surgery.

25

Two procedures performed during the same episode of care: one was an E&M service, such as an office visit, and the other was a procedure. Normally, the visit would be included in the charge for the procedure, but if there is significant separate documentation of the E&M the use of both procedure codes could be justified. This situation often occurs when a patient comes in for an office visit for ongoing medical conditions, such as hypertension, and then has another problem that requires a procedure, such as removing a wart.

26

Professional component of a service. Many procedures have a professional component and a technical component. An example is a chest X-ray. The technical component consists of the equipment used to do the X-ray, the salary of technician who performs the exam, and the costs of supplies, such as films. The professional component is for the physician who interprets the films and documents his findings. (This is a pricing modifier and thus should be listed first.)

50

A procedure that was performed bilaterally. It can only be used for procedures that can anatomically be bilateral. For example, a bladder procedure could not be bilateral because you only have one bladder. Some CPT codes already indicate that the procedure is bilateral, such as 58605, ligation or transection, fallopian tube(s), unilateral or bilateral. This code would be used for all operations of this type, whether unilateral or bilateral. It would not be appropriate to add a -50 modifier to this code for a bilateral procedure.

52

A service partially reduced or eliminated at the discretion of the physician. This could include a time-based procedure that is not performed for the entire time specified in the code description.

53

Surgical procedure terminated after the start of anesthesia, due to extenuating circumstances, for the well-being of the patient. This modifier is used only for physician professional services; it is not used for hospital facility outpatient billing. (This is a pricing modifier and thus should be listed first.)

54

Surgeon is billing for surgical care only and others are providing the preoperative and postoperative care in the global surgical period.

57

Decision for surgery. For example, this modifier can be used by the surgeon who performed your appendectomy in order to bill for the visit during which he decided that you needed surgery. If the visit and the surgery occur on the same calendar date, the payer would normally consider the visit to be part of the surgical package. Using the modifier -57 on the visit code tells the payer that the surgeon did not make the decision to do surgery until that day. Obviously, this modifier cannot be used with elective, scheduled procedures.

58

A staged or related procedure during the postoperative period. This would denote a procedure that was planned at the time of the original procedure, more extensive than the original procedure, or a therapeutic procedure following a diagnostic surgical procedure. If the second procedure is for a complication of the first and a return trip to the operating room is required, then modifier -78 is used instead.

59

A procedure was distinct or separate from other procedures performed on the same date. Let’s assume that you had two skin lesions, one on each arm, that are excised by a dermatologist. Because the skin is considered to be a single organ covering the entire body, these cannot be coded as bilateral procedures. It would be appropriate to code the first excision and then code the second with a -59 modifier to indicate the separate site. This tells the insurance company that the doctor is not inadvertently submitting a duplicate procedure. The -59 can be used for a different site, a separate lesion or injury, a different operative session, or a different patient encounter.

62

Co-surgeons jointly performing a single procedure. Each surgeon bills the same code with a -62 modifier. Payment to each is usually 62.5% of the normal amount. (Note that this is a pricing modifier and thus should be listed first.)

73

An ambulatory surgery center (ASC) discontinued a procedure prior to the administration of anesthesia. This modifier is used by ASCs to demonstrate use of their resources when the patient is prepared for surgery and taken to the room where the procedure is to be performed but the procedure is canceled before anesthesia has been administered. This could happen if the patient’s blood pressure is too high, if new lab results reveal contraindications to surgery, or other reasons. If a procedure is cancelled before the patient goes to the procedure room, the procedure is not reported at all.

74

This is the ASC equivalent of modifier -53 used by physicians. It identifies procedures that are discontinued after the administration of anesthesia. If more than one procedure was planned, and one or more completed, the completed procedure(s) would be reported without the modifier. It should only be used if none of the procedures were fully completed.

76

A repeat procedure by the same physician or other qualified healthcare professional. It is used to note the same exact procedure, same site, same provider, and same date. This modifier is often used with radiological procedures performed more than once on a date, as required by the patient’s condition. Another example would be multiple EKGs to monitor a patient’s heart condition.

77

A repeat procedure by another physician. It is used to note the same exact procedure, same site, same date, but different doctor. It is just like modifier -76, but a different physician performed the second or subsequent procedure. Not used with E&M services.

78

Return to the operating room for a related procedure during the postoperative period. This modifier is often used when complications of the original procedure require an additional procedure.

79

Unrelated procedure or service by the same physician during the postoperative period. This is the surgical equivalent of modifier -24.

80

Assistant surgeon. This doctor bills the same code as the surgeon but adds an -80 modifier.

91

Repeat clinical lab. Used when multiple results are necessary in the course of treatment on the same date. Should not be used for repeats due to equipment failure or inadequate specimens. If the second test is performed on a specimen from a different site, modifier -59 should be used instead of modifier -91.

Many other modifiers also are available. For example, anesthesia modifiers identify the type of provider and supervision. Anatomical modifiers are available to identity fingers, toes, eyelids, and coronary arteries. Situational modifiers are also available for ambulance services, mammography, durable medical equipment (DME), and orthotics and prosthetics. Different payers may have different rules about which modifiers are valid in various service locations.

Additional CPT Coding Guidelines

Each section of CPT has coding guidelines to direct the use of the codes in that section.

ANESTHESIA

The services in this section include pre- and postoperative visits, anesthesia care during the procedure, fluid or blood administration, and standard monitoring of vital signs, heart rate, and rhythm. In addition, there is an official definition of anesthesia time, which “begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating room or an equivalent area and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under post-operative supervision” (AMA, 2014).

Each anesthesia case also has an indicator of how sick the patient was. Some payers will increase the amount of reimbursement for sicker patients (“Anesthesia Physical Status Modifiers,” 2013):

P1

Normal healthy patient

P2

Patient with mild systemic disease

P3

Patient with severe systemic disease

P4

Patient with severe systemic disease that is a constant threat to life

P5

Moribund patient who is not expected to survive without the operation

P6

Brain-dead patient whose organs are being removed for donor purposes

Separate codes also are available to denote patients younger than age 1 or older than age 70, emergency anesthesia, and the use of total body hypothermia or controlled hypotension.

SURGERY

Codes in this section always include the following services in what is known as a “surgical package.” This means that these services should not be billed in addition to the code for the surgical procedure (AMA, 2014):

img Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia

img One related evaluation and management encounter on the day before or the day of surgery (apart from the decision for surgery)

img Immediate postoperative care, such as talking with the patient’s family, dictating the operative report, and so on

img Writing orders

img Evaluating the patient in the postanesthesia recovery unit

img Typical post-op follow-up care

The time frame for the surgical package, or “global period,” is related to the seriousness of the surgery and the length of time needed for follow-up. The standard periods are the following:

img 0 days: day of surgery only

img 10 days: day of surgery and 10 days after (11 days total)

img 90 days: day before surgery, day of surgery, and 90 days after (92 days total)

Care for complications or unrelated problems is not included and could be billed separately during the global period using the modifiers described earlier to indicate the situation.

Surgical coding is based on the documentation in the patient’s medical record. For procedures that are performed in an operating room, the surgeon prepares an operative report in which he describes the procedures performed, the type of anesthesia used, the techniques employed, specimens removed, estimated blood loss, pre- and postoperative diagnoses, the names of the surgeon and any assistants, and whether any complications occurred.

Some of the procedure categories in the surgery section are coded using methods requiring precise measurements. For example, skin lesion removal is categorized according to the method of removal, without regard to whether the lesion is benign or malignant (cancerous), and the size of the lesion. In the case of cancerous lesions, the margin of surrounding skin that is removed is also counted. If the physician does not document all of this, the coder has to rely on the measurements in the pathology report, which may be smaller due to shrinkage of the specimen. Suturing of wound repairs also relies on size. In this type of coding, the lengths of wounds repaired in the same manner in the same anatomic group are added together to get the final measurement and code.

In the musculoskeletal category, one must be mindful of the fact that fracture treatment (open or closed) can be confused with the type of fracture (open or closed). It is possible to perform an open treatment of a closed fracture. Open treatment refers to surgical opening of the fracture site; internal fixation devices may be used to treat the fracture.

Many procedures are now performed endoscopically. A surgical endoscopy always includes a diagnostic endoscopy. It may be appropriate to use more than one code for an endoscopy if more than one procedure is performed during the same session, such as removal of foreign body, biopsy, snare, dilation, or control of bleeding.

An oft-used category in the Surgery section is Maternity Care and Delivery. Obstetrics, like surgery, has a global package of services:

img Antepartum care: monthly visits up to 28 weeks, biweekly visits to 36 weeks, and weekly visits until delivery.

img Delivery: admission to the hospital, management of uncomplicated labor, vaginal or cesarean delivery.

img Postpartum care: hospital and office visits following delivery.

RADIOLOGY

Some radiologic procedures are coded using what is known as “component coding.” This occurs when part of the procedure is actually a surgical procedure, whereas the other part is the supervision and interpretation by the radiologist. An example is a knee arthrogram, which is an X-ray study of the knee joint after the injection of contrast media, which makes the details of the joint more visible. In this case, there is one code for the injection and a second code for the radiological supervision and interpretation of the films. If the radiologist does both procedures, he gets to bill both. If an orthopedist does the injection, then the radiologist only bills for the supervision and interpretation. The separate code for injection of contrast is not used if the code description for a CT, an MRA, or an MRI defines a procedure as being “with contrast.” An example is 73701, which is defined as “computed tomography, lower extremity, with contrast material.”

Component coding is also used in interventional radiology, in which catheters may be threaded through blood vessels to treat conditions located far from the point of entry. An example would be inserting a catheter into an artery in the leg and maneuvering it through the body to the location of an aneurysm (i.e., a weak spot in the wall of a blood vessel), possibly in the brain. A detachable coil is passed through the catheter and left at the aneurysm site. The body reacts to the coil by forming a blood clot around it, thus strengthening the wall of the blood vessel. Interventional radiology coding requires extensive knowledge of anatomy as well as thorough documentation by the radiologist of the entry site, all vessels imaged, and any contrast injections performed.

Radiation oncology and radiopharmaceutical therapy are also part of this section. They include codes for various types of radiation or radiopharmacy therapy for cancer. In addition to the actual treatments themselves, codes are available for clinical treatment planning, which involves localization of the tumor, measurement of the patient’s body contour, and calculation of the optimum treatment sequences to treat the diseased area while protecting other organs from adverse effects of radiation.

Mammography is a frequently performed radiologic procedure. Screening mammograms are performed on a regular basis as a preventive measure in the identification of breast cancer. If a patient has abnormal findings, a diagnostic mammogram may be done.

PATHOLOGY AND LABORATORY

This section is challenging to coding analysts because of the variety of personnel involved in laboratory testing and because of the use of “panels” to lump certain groups of tests together. Some laboratory procedures are performed by physicians, whereas others are performed by technicians under the supervision of a physician.

Surgical pathology involves the gross and microscopic exam of different types of tissue that were removed at surgery. The gross exam is the appearance of the specimen to the eyes of the pathologist; the microscopic exam is the examination of portions of the tissue specimen under a microscope. An autopsy is similar to surgical pathology except that it is the examination of the body after death. It is performed to determine the cause of death or to verify the diagnosis.

MEDICINE

Services in this section are primarily diagnostic procedures from a variety of specialties, including some that would normally be thought of as surgical, not medical, such as ophthalmology (eye) and otorhinolaryngology (ear, nose, and throat). Psychiatry is one of the specialties covered in this section. Many of the codes in the psychiatry section are time-based codes.

CPT also contains a few codes for services thought of as alternative therapies, such as acupuncture. Practitioners who use alternative treatments have initiated their own code set, known as Alternative Billing Codes (ABC) codes, which are authorized under HIPAA as acceptable for internal, statistical, and cash transactions, but are not yet part of the official code set recognized under HIPAA for third-party billing (“ABC Codes Explained,” n.d.).

EVALUATION AND MANAGEMENT (E&M)

Last in numerical order, but certainly not last in terms of utilization for billing purposes, the Evaluation and Management (E&M) section is probably the least understood and most controversial. Prior to 1992, this section occupied only four pages in CPT. The coding system for office visits was simple, based on four levels of visits.

The year 1991 was busy in the healthcare coding world. The predecessor of the CMS, the Health Care Financing Administration (HCFA), implemented a new fee schedule for Medicare services. It was based on a system known as RBRVS, or the Resource-Based Relative Value Scale. The system assigned relative-value units to each CPT code, based on physician work effort, practice expense, and malpractice insurance expense. The system was an effort to move away from the previous “usual and customary” method of calculating fees based on prevailing charges that was faulted for driving up the cost of health care.

The RBRVS also recognized that the cognitive efforts expended by primary care providers such as internists, family practitioners, and pediatricians needed to be more highly valued in comparison to surgical services. A new scheme for coding office visits and other E&M services was implemented in 1992. The instructions and guidelines for these services now occupy 44 pages in CPT, compared with 4 pages prior to 1991 (Nirschl, 2001). The medical profession was not happy with these new codes because they required substantial amounts of additional documentation. Many practitioners felt they had to document items that were not essential to patient care in order to justify their billing.

Currently, two sets of E&M documentation guidelines issued by Medicare are in use: 1995 and 1997. Physicians may use either set. A draft revision of the guidelines was released in 2000, and CMS contracted with a private firm to develop clinical vignettes to provide guidance on coding for various medical specialties. The 2000 guidelines were never implemented. In fact, the Health and Human Services Advisory Committee on Regulatory Reform voted in 2002 to abolish the E&M guidelines.

Put bluntly, physicians do not like these codes. They are extremely complex and difficult to interpret. In studies where physicians and coding analysts assigned E&M codes to hypothetical cases, the coding analysts agreed with expert opinion only 57% of the time (King, Lipsky, & Sharp, 2002), whereas agreement by physicians was only 52% (King, Sharp, & Lipsky, 2001). This indicates a lot of gray areas in coding these services.

The three key components of an E&M service are history, exam, and medical decision making. These are the components that the physician must tally when arriving at an overall level for the E&M service. For example, a Level 4 established patient office visit (99214), for which Medicare will reimburse about $115 in Oklahoma ($145 in New York City), requires a detailed history, a detailed exam, and moderately complex decision making. To document this level of care and justify the claim to the payer, the doctor will have to document the following:

img At least four elements of the history of present illness

img Review of two to nine systems

img At least one part of the past, family, or social history

img Examination of five to seven body areas or systems

img Review of three types of data

img Presence of existing problems that are worsening or new problems that may or may not require additional workup

img Risks of treatment options or procedures proposed

The AMA has defined the average amount of time for this level of visit as 25 minutes. If your doctor spends 25 minutes with you and more than half of that time is spent on counseling and coordination of care, such as talking with you about test results, treatment options, prognosis and risk factors, the doctor can bill for a Level 4 visit without documenting all of the key component items just listed. He merely has to state, “I spent more than 50% of this 25-minute visit discussing [topic of discussion] with the patient.”

If we assume that the physician works a 10-hour day, with an hour for lunch, he has a total of 540 minutes to see patients. He can accommodate 21 patients at 25 minutes apiece if he bills based on the amount of time he spends talking with you. Or, he can adopt methods that allow him to document all of the required pieces more quickly in order to get the same level of payment in fewer minutes. Using the latter approach, he could conceivably double the number of patients seen, thus doubling his reimbursement. This is legitimate, assuming that all the necessary documentation is present in your medical record and all the visits were medically necessary. An argument could be made that the E&M system rewards documentation and not face-to-face patient care.

The following is the process for assigning an E&M code:

img Determine the location (place of service) where the E&M service was performed

img Select the appropriate category of E&M code based on the location

img Score the documentation counting the elements of the key components (history, exam, medical decision making) or using the counseling and coordination of care option

Under normal circumstances, a physician may only bill one E&M service per patient per day. If your doctor sees you in his office and decides that you are so sick you need to be admitted to the hospital and then stops by the hospital later that day to see you, he must “roll up” the office services into the code for the initial inpatient hospital care. Likewise, if you go to the emergency room and the ER physician decides you need to be observed for a period of time to monitor your condition, he may place you in observation status. The emergency room service must be “rolled up” into the observation service code for that date. Exceptions to the rule of one E&M per day would need to be justified through the use of modifiers indicating the circumstance.

Critical care in CPT terms does not occur just because you are in a critical care unit. Sometimes patients in those units may be there because they are awaiting a bed elsewhere in the hospital, awaiting the completion of discharge or transfer arrangements, or other administrative reasons. In order to meet the CPT definition of critical care, the patient must be critically ill or injured to the extent that one or more vital organ system is impaired and there is a high probability of imminent or life-threatening deterioration in his or her condition. In addition, the service provided must involve highly complex medical decision making to assess, manipulate, and support single or multiple vital organ system failure or prevent further life-threatening deterioration of the patient’s condition (AMA, 2014).

CPT codes for adult critical care are time based: for the first 30 minutes (or less), and then for each additional 30 minutes. Physicians must clearly document their time on adult critical care. For children 71 months of age or younger, the neonatal and pediatric critical care codes are “per day” codes, which means that all critical care services that date are included.

Procedure Coding Summarized

In this chapter, you have learned that procedure coding depends on the location where the service is provided and the type of charge being coded.

 

Hospital Inpatients

All Others

Facility Bill

ICD-10-PCS procedure codes (as of October 1, 2015)

CPT / HCPCS procedure codes

Physician Bill

CPT / HCPCS procedure codes

CPT / HCPCS procedure codes

Procedure coding also depends, ultimately, on the physician’s documentation in the medical record. The physician may know that he or she performed a procedure, but if it isn’t documented, it wasn’t done, as far as the coder is concerned.

Up to the Minute

The CPT Editorial Panel, in conjunction with medical and surgical specialty societies, receives and reviews suggestions for changes to CPT. CPT codes are updated annually, effective on January 1st. When codes change, the date of service of the procedure determines whether an old or new code is appropriate. It is imperative that the current version of CPT be used for coding and payment purposes.

References

ABC codes explained. (n.d.). Retrieved March 23, 2014, from http://www.abccodes.com/ali/abc_codes/

American Medical Association. (2014). Current procedural terminology 2014. Chicago, IL: AMA Press.

Anesthesia physical status modifiers fact sheet. (2013, April). WPS Health Insurance website. Retrieved January 22, 2014, from http://wpsmedicare.com/j5macpartb/resources/modifiers/modifier-anes-physstatus.shtml

Centers for Medicare and Medicaid Services. (n.d.). Top 200 Level I HCPCS/CPT codes CY 2011. Retrieved January 22, 2014, from http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareFeeforSvcPartsAB/downloads/LEVEL1SERV11.pdf?agree=yes&next=Accept

Centers for Medicare and Medicaid Services. (2012). Place of service code set. Retrieved January 22, 2014, from http://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html

Centers for Medicare and Medicaid Services. (2014b, February 7). Claims processing manual.Publication 100-4. Chapter 25, section 75.1.

Centers for Medicare and Medicaid Services. (2014a). Healthcare Common Procedure Coding System. Retrieved January 21, 2014, from http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html

Centers for Medicare and Medicaid Services. (2014c). ICD-10-PCS official guidelines for coding and reporting. Retrieved January 22, 2014, from http://www.cms.gov/Medicare/Coding/ICD10/Downloads/PCS-2014-guidelines.pdf

Dougherty, M., Seabold, S., & White, S. E. (2013, July). Study reveals hard facts on CAC. Journal of AHIMA, 84(7), 54–56.

Fact sheets on CPT modifiers. (n.d.). Wisconsin Physician Services website. Retrieved January 22, 2014, from http://wpsmedicare.com/j5macpartb/resources/modifiers/

Federal Register. (1985, July 31). 50(147), 31038–31040.

Gill, C. J., & Gill, G. C. (2005). Nightingale in Scutari: Her legacy reexamined. Clinical Infectious Diseases40(12), 1799–1805.

Harris T. (1997, April 16). Physician’s Current Procedural Terminology (CPT). Statement of the American Medical Association to the Subcommittee on Health Data Needs, Standards and Security, National Committee on Vital Health Statistics Department of Health and Human Services. Retrieved January 21, 2014, from http://www.aapsonline.org/medicare/amacpt.htm

HIPAA Administrative Simplification: Modifications to medical data code set standards to adopt ICD-10-CM and ICD-10-PCS. (2009, January 1). Federal Register, 74(11), 3328.

King, M. S., Lipsky, M. S., & Sharp, L. (2002). Expert agreement in Current Procedural Terminology evaluation and management coding. Archives of Internal Medicine162(3), 316–320.

King, M. S., Sharp, L., & Lipsky, M. S. (2001). Accuracy of CPT evaluation and management coding by family physicians. Journal American Board of Family Practice, 14(3), 184–192.

Lott, T. (2001, July 27). Letter from Senator Trent Lott (R-Miss.) to Health and Human Services Secretary Tommy G. Thompson. Retrieved January 13, 2014, from http://www.aapsonline.org/medicare/lottcptletter.htm

Nirschl, R. (2001). Return to CPT 1991 E&M billing system. Bulletin of the American Academy of Orthopaedic Surgeons. Retrieved January 22, 2014, from http://www2.aaos.org/bulletin/feb01/ptvw.htm

Rousse, J. T. (2013, Summer). From novice to expert: Problem solving in ICD-10-PCS procedural coding. Perspectives in Health Information Management. Retrieved January 22, 2014, from http://perspectives.ahima.org/from-novice-to-expert-problem-solving-in-icd-10-pcs-procedural-coding/#.Ut_zSc7na70

Small, H. (1998). Florence Nightingale, avenging angel. New York, NY: St. Martin’s Press.

United States Public Health Service. (1959). International Classification of Diseases, adapted for indexing hospital records by diseases and operations. Publication No. 719. Washington, DC, U.S. Dept. of Health, Education, and Welfare, Public Health Service, National Center for Health Statistics.

U.S. Department of Health, Education, and Welfare, Public Health Service, Health Resources Administration, National Center for Health Statistics. (1975). Health United States 1975. DHEW Publication No. (HRA) 76–1232. Retrieved January 21, 2014, from http://www.cdc.gov/nchs/hus/previous.htm#editions

U.S. Department of Health and Human Services, Health Care Financing Administration, American Medical Association. (1998, July 28). Agreement. Retrieved January 21, 2014, from http://www.aapsonline.org/ama-hcfa-cpt-signed-agreement-1983.pdf

White, K. (n.d.). Reflections on the past and challenges for the future. The U.S. National Committee on Vital and Health Statistics. Retrieved January 21, 2014, from http://www.ncvhs.hhs.gov/ncvhs50white.htm

CHAPTER 4

How Codes Are Used for Reimbursement

The Price Is Right

When you go to the grocery store and purchase a can of beans, you are pretty certain that you are being charged the same price as everyone else, the price that is posted on the shelf. If you pick a different brand the price may be higher or lower, but once again the price will be the same for everyone. But—wait a minute—if you have a supermarket discount card for the clerk to scan, your price after the discount could be less.

Healthcare prices work the same way. If you are a self-pay patient with no insurance, you will be billed the full price and will be expected to pay it. If you have medical insurance, your insurance company will be billed the same price but will pay less, due to contractual agreements with the providers. If you are able to qualify for a public assistance health insurance program due to your income level, the bill will still be the same, but that program will also pay less than the full amount.

Here’s what the reimbursement for your surgeon’s bill for your appendectomy might look like:

Procedure:

Appendectomy

CPT code billed:

44950 Appendectomy

Surgeon’s charge:

$1,250

If you are a self-pay patient with no insurance, you will be expected to pay the $1,250.

If you have Medicare, the payment amounts will look like this:

Insurance:

Medicare

Surgeon’s charge:

$1,250

Medicare fee schedule amount:

$638

Medicare payment:

80% × $638 = $510

Patient coinsurance:

20% × $638 = $128

What happens to the other $612 ($1,250 – $638) that nobody is paying for? This amount is known as the “contractual allowance.” In exchange for being a Medicare provider and receiving payments from Medicare, the physician has in essence entered into a “contract” to accept what Medicare pays. The contractual allowance is the difference between the physician’s charge and the amount he or she has agreed to accept. Even if you have secondary insurance that covers what Medicare does not pay, it will only pay your 20% co-insurance; it will not pay the contractual allowance.

If you have a commercial insurance carrier, the payment might look like this:

Surgeon’s charge:

$1,250

Insurance:

Commercial Express

Fee schedule amount:

$700

Insurance payment:

80% × $700 = $560

Patient coinsurance:

20% × $700 = $140

Contractual allowance:

$550

If your insurance is a health maintenance organization (HMO) or preferred provider organization (PPO), you may have a limit on the amount you have to pay out of pocket—usually a flat rate. In that case, the payment could be:

Surgeon’s charge:

$1,250

Insurance:

HMO Hometown

Fee schedule amount:

$600

Patient copay for surgery:

$100

Insurance payment:

$500

Contractual allowance:

$650

Hospitals also have charges, which are often two to four times what they expect to collect from insurers and managed care plans. One of the reasons for this is that hospitals routinely quantify the amount of bad debt and charity care they provide. This helps with fund-raising and is used to meet charitable obligations. However, valuing these at full charge greatly overestimates the amount of bad debt and charity care actually provided. Those who pay full charge are usually patients with HSAs, foreign patients, and the uninsured. This is known as cost shifting. In most hospitals, only 3% of total revenue comes from patients who are uninsured, primarily because they are unable to pay. Almost half of all personal bankruptcies are related to medical bills (Anderson, 2004). Hospitals and other providers can, and do, turn accounts over to collection agencies, garnish wages, and file property liens in order to collect.

Hospitals have come under increasing criticism of their practices with regard to uninsured patients. In February 2004, the U.S. Department of Health and Human Services (HHS) clarified its position on charges. Previously, the industry interpretation of government regulations about charges was that all patients had to be billed using the same schedule of charges. The new interpretation offers more flexibility to hospitals that want to offer discounts to certain patients. HHS clarified that hospitals may develop their own indigency programs with their own definitions, but maintained the stipulation that the criteria must be applied uniformly to Medicare and non-Medicare patients. The result of these changes is that uninsured patients may get the same types of discounts that large payers receive via the contractual allowance.

Geographic location also makes a difference in the amount of reimbursement to both physicians and facility providers. Although Medicare is thought of as a national program, the methods used to calculate reimbursement take into account what is known as a Geographic Practice Cost Index (GPCI, pronounced “gypsy”). Office space is cheaper in Mississippi than in Boston, and the cost of malpractice insurance also varies from state to state. Each CPT code has a relative value (RVU) associated with it, composed of values for physician work, practice expense, and malpractice insurance cost. The total RVU is multiplied by a dollar amount conversion factor and the GPCI to get the fee schedule amount for a specific area. The Medicare fee schedule has to be budget neutral, meaning that the total expenditure on health care cannot change. This means that if the value of one procedure code goes up, one or more of the others must go down.

Staking a Claim

Regardless of the type of insurance, almost all reimbursement to healthcare providers and facilities is based on procedure and diagnosis codes. Payers receive this information on a claim form, usually submitted electronically. More than 99% of Medicare Part A claims and 95% of Medicare Part B claims transactions are submitted electronically.

There are two types of claim formats used by different types of providers. The CMS-1500 claim format is used by physicians and mid-level providers who are billing independently, whereas the CMS-1450 or UB-04 claim format is used by hospitals, home health agencies, ambulance services, rehab facilities, dialysis clinics, and other facilities. It is important to understand that although CMS continues to refer to the CMS-1500 and the CMS-1450 in its regulatory documentation, the industry now refers to the claim submission formats as “5010” or “837.” The 5010 format was agreed upon by the Accredited Standards Committee (ASC) of the American National Standards Institute in an effort to standardize claims submission across all payers. Implementation of the 5010 format, as of January 1, 2012, was also important because it accommodated the increased number of characters required by ICD-10-CM and ICD-10-PCS codes (CMS, 2013a).

CMS-1500 Form or 837P (Professional) Format

The electronic format has space for 12 diagnosis codes and 6 procedure codes ( Figure 4-1 ). A unique feature of the CMS-1500 is the ability to link a procedure code to one or more of the diagnosis codes. This is important in providing medically necessary justification for procedures performed. An example of this situation would be a patient brought to the emergency department after a traffic accident. The patient has a closed fracture of the radius, a bone in the arm. The physician treats the fracture with closed reduction and casting. However, the patient is also experiencing chest pain, and an electrocardiogram is performed to assess the condition of the patient’s heart. The diagnosis codes listed on the claim form are for closed fracture, radius, and a second code for chest pain. Under normal circumstances, a third-party payer would not think that an EKG was medically necessary for an arm fracture. However, if the diagnosis of chest pain has been linked to the EKG procedure code, that will tell the payer the real reason for the EKG, and the payer would then most likely pay the claim.

img

FIGURE 4-1 CMS-1500 Form or 837P (Professional) Format.

Courtesy of NUCC.

The line on which each procedure (CPT or HCPCS code) is reported also has columns for the date(s) of service, place of service, type of service, up to four modifiers, the diagnosis code link, the charge for the service, and the number of days or times (units) the procedure was performed.

The 1500 form also has spaces for the provider’s identification and tax ID number, patient demographic and insurance information, referring physician information required for consultations and diagnostic testing, and other information related to processing the claim and determining whether it will be paid.

CMS-1450 or UB-04 Form or 837I (Institutional) Format

The UB-04 form ( Figure 4-2 ) has space for more diagnosis codes than the CMS-1500 form (principal diagnosis, plus 24 others, as compared to 12 on the CMS-1500). However, it is not possible to link the procedures to a specific diagnosis. There is also room for the principal procedure and 24 others, with a date space adjacent to each procedure code.

In addition to the reported diagnosis and procedure codes, the UB-04 uses revenue codes to lump together the charges for different categories of services, such as radiology, IV solutions, and drugs. The claim form contains the revenue codes with the number of service units for each and the total charge. The only time that individual procedure charges are itemized on a UB-04 is for hospital outpatient procedures paid under prospective payment (see “Payment Methodologies” later in this chapter).

img

FIGURE 4-2 CMS-1450 or UB-04 Form or 837I (Institutional) Format.

Courtesy of Centers for Medicare and Medicaid Services.

Claims Submission

Claims are sent from the provider or facility to the payer via one of three methods:

img Paper. Although the days of a clerk printing out a paper claim form are almost gone, there are still providers who submit claims manually, on paper forms. CMS requires all payers except facilities with fewer than 25 full-time equivalent employees (FTEs) and other providers with fewer than 10 FTEs to file initial claims electronically (CMS, 2013b).

img Electronic via billing entity or clearinghouse. These businesses submit claims on behalf of providers. They may format billing data to meet the needs of individual payers and perform edits on the billing data to verify completion of all required fields.

img Electronic direct. Electronic submission of claims has the advantage of speeding up the payment process. It requires less processing by the payer than manual paper claims and usually employs front-end edits to ensure correct, or “clean,” claims.

Claims Processing and Adjudication

Once the insurance company or other payer has received the claim information, either electronically or on paper, it processes the claim. This can involve extracting data from the claim, scanning claims for retention, and validating specific data elements. Checking the claim at this point may result in rejection of the claim for reasons having nothing to do with the diagnosis and procedure codes, such as the following:

img The payer cannot identify the patient as being insured with his or her company.

img The patient’s coverage with the payer terminated before the date of service on the claim.

img The time limit for filing the claim has expired.

img It is a duplicate claim.

The claims adjudication process involves review of the claim to make sure that the service provided is covered under the specific insurance plan and that all required information is available. Adjudication of physician or other professional services claims occurs at the line-item level, charge by charge by charge. One line of a claim may be paid, but others rejected. In addition to deciding whether a specific charge will be paid, the adjudication process also determines how much will be paid. The payment amount is based on the fee schedule amount for that procedure, the place of service, and any applicable contract stipulations. Another factor will be whether you, the patient, have met your deductible for the current year. If not, you will be liable for the portion of the reimbursed amount that is less than or equal to your deductible. You will be paying the doctor instead of the insurance company paying the doctor.

Many, many errors on the part of the payer are possible during the claims adjudication process:

img Newly enrolled individuals have not yet been loaded into the company’s system.

img Errors are present in names, dates of birth, addresses, and other demographic information.

img The payer has incorrectly rekeyed claims information into its own system.

img The system has programming errors.

img The system does not recognize modifiers justifying additional payment.

img The system has not been updated to reflect new diagnosis and procedure codes.

img Prior authorizations for services have not been loaded into the system.

img Payment amounts specified in current contracts have not been updated.

Claims that require additional information or that need correction of errors are “pended.” The provider is notified of the reason why the claim is pended and what needs to be done. Claims that complete the adjudication process are referred to as “finalized claims.” Finalized claims can be one of three things: paid, rejected, or denied. A payment advice or remittance advice notice is sent to the provider notifying them of the outcome. A check or electronic deposit payment is also sent for paid claims.

The Rejection Puzzle

Figuring out why a claim has been rejected is often difficult and frustrating. Prior to 2003, approximately 4,000 different remittance advice codes were in use. Many had the same meanings, with minor differences in wording. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 contained an Administrative Simplification provision that addressed the need not only for standardized code sets for diagnoses and procedures but also for standard transactions such as remittance advice codes. As a result, the thousands of remittance advice codes were condensed into a little more than 200.

If you receive an explanation of benefits indicating that a service was denied, it is important to work with your doctor to determine why. In some cases, the insurer may be requesting additional information from you. This could happen in the case of an auto accident, where the auto insurance is supposed to pay first. Another situation like this would be if you were to fall on private property and injure yourself. The property owner’s liability insurance might be the primary payer. You and your doctor are both interested in making sure he is paid, so it is essential that you cooperate in efforts to resolve denials and rejections.

Medical Necessity

Determination of medical necessity involves comparing the procedure being billed to the diagnosis submitted. If you receive a denial notice from the payer that the procedure was “not medically necessary,” it means that your payer does not think the procedure or test was justified for the diagnosis given. Medicare carriers publish what are known as “Local Coverage Determinations” (LCDs) that contain lists of diagnosis codes that validate procedures such as EKGs, chest X-rays, and others. If your diagnosis is not on the list, your claim will be rejected. Screening exams, such as Pap smears, mammograms, and colonoscopies, also are subject to frequency limitations dictating how often they will be paid.

If the provider of the service knows in advance that a service is likely to be deemed not medically necessary, he or she can ask the patient to sign an Advance Beneficiary Notice (ABN) in which the patient acknowledges the possibility the claim will not be paid and agrees to be financially liable for the charge. ABNs must be specific to the service provided; they cannot be blanket forms covering any and all services. Without an ABN signed before the service occurs, the provider cannot bill the beneficiary if the claim is rejected.

Some services are never covered, such as cosmetic surgery. Patients can be billed for noncovered procedures without an ABN.

Instead of rejecting the claim, some payers will “downcode” it based on the diagnosis. For example, if your doctor bills a Level 4 established office visit code (99214) when he sees you for your sore throat, your insurance company may decide that a sore throat should never be more complicated than a Level 3 service. In fact, the insurer may implement a process of rejecting all Level 4 and 5 claims and require physicians to submit additional documentation in order to be paid. This practice penalizes not only physicians who might use the higher level codes without clinical justification, but all other physicians who actually document according to the requirements of the higher levels. The AMA (2005) has developed policies strongly opposing downcoding.

Payment Methodologies

Just as the coding systems are different, the payment methodologies for inpatient hospital, outpatient hospital, and professional claims also differ. Many commercial payers follow the lead of Medicare once it has implemented a specific payment system.

FEE FOR SERVICE

The most traditional payment mechanism is known as fee for service. It is simple. A service is billed using a CPT or ICD procedure code. The payer has a fee schedule with a set reimbursement amount for each service it covers. The provider gets the fee schedule amount less any deductible or coinsurance owed by the patient.

Most physician services are paid according to a fee schedule. Clinical laboratory services are paid based on a laboratory fee schedule, and ambulance services on an ambulance fee schedule.

REASONABLE COST OR COST BASED

Under this method, providers or facilities submit an annual cost report that details the expenses of running their businesses. The rules for completing the cost report are extensive. They include data on bed utilization, salaries by cost center, expenses by cost center, indirect costs related to items such as medical education, cost-to-charge ratios (how much it costs to provide a service per dollar charged), capital expenditures, and other items. In many cases the facility has been receiving periodic interim payments from the payer throughout the year, and the cost report is then used to “settle” or reconcile the costs to the payments already received. For Medicare, the cost reports are submitted to the Fiscal Intermediary (FI), which reviews and/or audits the cost report and then submits it to the CMS for reporting.

Periodic interim payments (PIP) are available to inpatient hospitals, skilled nursing facility services, hospice services, and critical access hospitals (small hospitals in rural areas that are needed to ensure access to health care for local populations). Facilities are supposed to self-monitor their PIP payments to ensure they are not receiving overpayments, and penalties are in place if overpayment exceeds 2% of the total in two consecutive fiscal reporting periods.

PROSPECTIVE PAYMENT: INPATIENT HOSPITAL

Government health planners who were interested in restraining the costs of Medicare, Medicaid, and other insurance programs realized that cost-based reimbursement was a sure way to eat up dollars faster and faster. In order to change hospital behavior to encourage more efficient management of medical care, Medicare introduced hospital inpatient prospective payment in 1983. Using a system developed by Yale University in the 1970s, reimbursement to hospitals was based on diagnosis-related groups (DRGs). Data already appearing on the claim form are used to assign each patient discharge into a DRG:

img Principal diagnosis

img Complications and comorbidities (CCs)

img Surgical procedures

img Age

img Gender

img Discharge disposition (died, transferred, went home)

The principal diagnosis, the reason the patient was admitted to the hospital, determines to which Major Diagnostic Category (MDC) the case will be assigned. There are 25 MDCs, based on body organ system or disease (CMS, 2014):

MDC 1

Diseases and disorders of the nervous system

MDC 2

Diseases and disorders of the eye

MDC 3

Diseases and disorders of the ear, nose, mouth, and throat

MDC 4

Diseases and disorders of the respiratory system

MDC 5

Diseases and disorders of the circulatory system

MDC 6

Diseases and disorders of the digestive system

MDC 7

Diseases and disorders of the hepatobiliary system and pancreas

MDC 8

Diseases and disorders of the musculoskeletal system and connective tissue

MDC 9

Diseases and disorders of the skin, subcutaneous tissue, and breast

MDC 10

Endocrine, nutritional, and metabolic diseases and disorders

MDC 11

Diseases and disorders of the kidney and urinary tract

MDC 12

Diseases and disorders of the male reproductive system

MDC 13

Diseases and disorders of the female reproductive system

MDC 14

Pregnancy, childbirth, and the puerperium

MDC 15

Newborns and other neonates with conditions originating in the perinatal period

MDC 16

Diseases and disorders of blood, blood forming organs, immunologic disorders

MDC 17

Myeloproliferative diseases and disorders, poorly differentiated neoplasms

MDC 18

Infectious and parasitic diseases, systemic or unspecified sites

MDC 19

Mental diseases and disorders

MDC 20

Alcohol/drug use and alcohol-/drug-induced organic mental disorders

MDC 21

Injuries, poisonings, and toxic effects of drugs

MDC 22

Burns

MDC 23

Factors influencing health status and other contacts with health services

MDC 24

Multiple significant trauma

MDC 25

Human immunodeficiency virus infections

Within each MDC, the next partition is based on whether a significant procedure was performed and whether the patient had complications or comorbidities. Patient age and length of stay in the hospital may also affect DRG assignment. There are over 500 DRGs. Those without significant procedures are known as “medical” DRGs, whereas those with significant procedures are “surgical” DRGs.

Once a DRG has been assigned, the determination of the reimbursement amount can start. Each DRG has a relative weight assigned to it. Patients in a given DRG are assumed to have similar conditions, receive similar services, and use similar amounts of hospital resources. The prospective payment system is based on paying the average cost to treat patients in that DRG. The DRG weights are adjusted annually. As might be expected, the more complex the DRG, the higher the weight.

The DRG for a heart transplant has a weight of more than 25.0, whereas the DRG for an uncomplicated appendectomy is less than 1.0. In order to calculate the reimbursement rate, the weight for the DRG is multiplied by a base payment amount, which has geographical wage and cost of living factors built in. In addition, if the hospital is a teaching facility it will receive additional Indirect Medical Education funds. If it treats a disproportionately high percentage of low-income patients, it will receive extra funding as a result.

Some patients are known as “outliers.” This means that the charges for their care greatly exceed the average amount considered normal for a particular DRG. Complications, additional unplanned surgery, or other reasons can cause an outlier. For fiscal year 2014, the charges for the outlier must exceed the DRG payment amount by $21,748. Assume that a patient was admitted for a cholecystectomy (removal of the gallbladder) with exploration of the common bile duct. This case would fall under DRG 413, and the reimbursement amount would be around $9,803, depending on the geographic location of the hospital. In order to get extra payment over and above the $9,803, the patient’s charges would have to total at least $31,551. Until the charges reached that point, the hospital would not get one extra dime. If a patient is admitted because of a heart attack and falls out of bed, breaking his leg, the hospital will not get any additional money for the extra days that patient will spend in the hospital, unless he eventually becomes an outlier.

Like many other aspects of healthcare reimbursement, the ability to code completely to reach the correct DRG depends largely on physician documentation. Coders are not allowed to make assumptions about what might have been. The presence of laboratory results in a chart indicating the culture of bacteria or a chest X-ray consistent with pneumonia cannot be used for coding purposes unless the physician documents their existence. Because better documentation under prospective payment systems equals better coding, which results in higher reimbursement, physicians have been “urged” to improve documentation by including additional complications and comorbidities. The following list represents diagnoses that can make a payment difference in surgical cases:

img Acute blood loss anemia

img Ileus (intestinal slowdown)

img Phlebitis (IV site)

img Postoperative infection

img Respiratory failure

Surgeons have been told that documenting these complications demonstrates how sick their patients are. Documenting these conditions in addition to the principal diagnosis also means more money for the hospital.

PROSPECTIVE PAYMENT: AMBULATORY SURGICAL CENTERS

Ambulatory surgical centers (ASCs) have been covered under Medicare since 1982. Their primary function is to perform surgical procedures that can be done safely in an outpatient setting, but require a higher level of service than is normally found in a doctor’s office. ASC procedures are generally called “day surgery.” The patient undergoes surgery, receives recovery nursing services, and then goes home the same day.

Unlike the DRG system, the ASC prospective payments are based only on the procedures, with a specific payment rate based on weights from the hospital Outpatient Prospective Payment System (OPPS). If more than one procedure is performed, the ASC receives full payment for the procedure with the highest rate, while most additional procedures are paid at 50%.

Like the DRG system, the ASC rates are updated annually, and newly approved procedure codes eligible for ASC payment are added to the payment scheme. Items covered under prospective payment to the facility include nursing services, recovery room services, anesthetic agents, and supplies such as dressings, casts, and splints. Drugs and implantable devices may or may not be bundled into the facility payment. Payment to the physician performing the ASC procedure is made separately.

PROSPECTIVE PAYMENT: SKILLED NURSING FACILITIES

Skilled nursing facilities (SNFs) care for patients who require the skilled services of licensed nursing staff or skilled rehabilitation, including physical therapy, occupational therapy, and speech/language pathology services. In order to qualify for Medicare coverage of skilled nursing, the patient must have been hospitalized for at least 3 days prior to being admitted to the skilled facility and must be admitted within 30 days after being discharged from the hospital. SNFs were paid under a retrospective cost-based system until July 1998. Since then, a payment scheme based on the acuity or illness of the patient has been used. It measures the intensity of care required and the amount of resources used.

Resource utilization groups (RUGs) are similar to DRGs in concept. Each facility is paid a daily rate based on the needs of individual Medicare patients, with an adjustment for local labor costs. Sixty-six individual levels are found within the eight major RUG-IV categories:

img Rehabilitation/Extensive Services (9 levels). Patients in this category need extensive medical services, such as tracheostomy care, ventilator/respirator support, or isolation for active infectious disease plus therapy services.

img Special Rehabilitation (14 levels). Based on the number of minutes per week and types of therapy provided.

img Extensive Services (3 levels). Extensive medical services but not therapy.

img Special Care (divided into 2 categories: high and low) (16 levels). Patients receiving parenteral/IV feedings, feeding tube, dialysis, radiation therapy, or respiratory therapy in specific medical conditions such as pneumonia, multiple sclerosis, Parkinson’s disease, COPD, or skin ulcers.

img Clinically Complex (10 levels). Conditions such as pneumonia, hemiplegia, burns, surgical wounds, or treatment such as IV medications, chemotherapy, or transfusions.

img Behavioral Symptoms and Cognitive Impairment (4 levels). Patients with hallucinations or delusions, rejection of care, wandering, or physical or verbal behavioral symptoms toward others.

img Reduced Physical Functioning (10 levels). Patients in this category have needs that are primarily for activities of daily living or general supervision, such as bowel training, prosthesis care training, eating or swallowing training, bed transfer training, or splint/brace assistance.

The Resident Assessment Instrument (RAI) is used to gather and document information about the patient. In addition to information about the patient’s medical condition, the RAI includes a number of items covering functional and social activities, customary habits or practices at home, and psychosocial well-being. The data from the RAI are used to classify the patient into a RUG group, and payment to the facility is based on the group.

PROSPECTIVE PAYMENT: HOME HEALTH AGENCY

To receive home health services covered by Medicare, a patient must be homebound, have a need for skilled nursing care or services such as physical therapy or speech therapy, be under a plan of care periodically recertified by a physician, and receive care from a Medicare-certified home health agency. Agencies receive a lump sum payment to cover each 60-day episode of home health care, based on the patient’s needs. In 2010, this sum was about $2,200 plus market basket and local wage adjustments. A dataset known as OASIS (Outcome and Assessment Information Set) is completed on each client. A home health resource group (HHRG) is assigned based on OASIS data related to the clinical condition and functional status of the patient and the types of services needed.

If the home health agency is well managed and works efficiently, it can keep any profit it makes from the prospective payments by lowering costs per visit or by reducing the number of services while still maintaining a quality outcome for the patient.

PROSPECTIVE PAYMENT: HOSPITAL OUTPATIENT

In August 2000, Medicare implemented a prospective payment system for hospital outpatient services. Similar to DRGs for inpatients, this system is known as Ambulatory Payment Classification, or APC. Like DRGs, each APC contains clinically similar conditions using the same level of facility resources. There are approximately 800 APCs, including procedure-based, medical, and ancillary groups, such as laboratory or radiology testing. The unit of service for an APC is one calendar day. Unlike DRGs, hospitals may be paid a prospective rate for more than one APC per day, depending on the circumstances of the encounter. Multiple surgical services furnished on the same day are subject to discounting. The full APC amount is paid for the surgical procedure with the highest APC weight, and 50% is paid for any other surgical procedure performed at the same time.

APC payment for a given procedure includes facility charges, drugs, supplies, and time. Some items are paid separately on a “pass-through” basis primarily because they may have been developed too recently to have been taken into consideration during the establishment of the APC rates. There is a provision for APC outliers, which may result in increased reimbursement if the total cost for a service exceeds 1.75 times the APC payment and also exceeds a fixed-dollar threshold calculated each year.

RISK-ADJUSTED PAYMENT: MEDICARE ADVANTAGE PLANS

Medicare Advantage Plans, known as Medicare Part C, must provide all Part A and Part B benefits. Some Medicare Advantage Plans also offer prescription drug coverage. These plans are private plans paid on a capitated basis. Medicare uses beneficiary characteristics, such as age, prior health conditions, and the severity of diagnoses reported on claim forms to determine payment rates. Similar to DRGs, the Hierarchical Condition Category (HCC) system looks at reported diagnosis codes to determine how sick a patient is. A list is published annually by CMS defining which diagnoses qualify for additional risk-adjusted payment. Provider documentation must support the evaluation and treatment of reported diagnoses.

How Payment Methods Affect Coding

Long ago and far away, coding began as a systematic method of tracking disease incidence. Its entanglement with reimbursement systems has greatly increased its importance within healthcare organizations. For years, the hospital medical record departments where coding occurred were dusty file rooms that existed primarily because of documentation-related regulatory requirements. With the implementation of inpatient prospective payment via DRGs in 1983, coding made a difference in reimbursement for the first time. Coders were elevated out of the dark basements into the financial limelight. Medical record departments were transformed into “health information management departments.”

With the newly focused attention on coding, and the potential dollars to be made from using the “right” codes, came the perils of ethical dilemmas and pressure for coders to contribute to the financial success of their employers.

References

American Medical Association. (2005). Model managed care contract. (4th ed.). Chicago, IL: American Medical Association.

Anderson, G. (2004, June 24). A review of hospital billing and collection practices. Testimony before the Committee on Energy and Commerce, United States House of Representatives. Retrieved December 11, 2013, from  http://www.gpo.gov/fdsys/pkg/CHRG-108hhrg95446/html/CHRG-108hhrg95446.htm

Centers for Medicare and Medicaid Services. (2013a). An introductory overview of the HIPAA 5010. Retrieved January 20, 2014, from  http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0904.pdf

Centers for Medicare and Medicaid Services. (2013b). Medicare claims processing. Publication 100-04. Chapter 24, Section 90. Retrieved January 20, 2014, from  http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c24.pdf

Centers for Medicare and Medicaid Services. (2014). Acute inpatient prospective payment system. Retrieved January 20, 2014, from  http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2014-IPPS-Final-Rule-Home-Page-Items/FY-2014-IPPS-Final-Rule-CMS-1599-F-Tables.html?DLPage=1&DLSort=0&DLSortDir=ascending

CHAPTER 5

Coding for Dollars

Healthcare Fraud and Abuse

As funding and reimbursement for health care cover less and less of the cost of providing care, the temptation to find “loopholes” in the reimbursement systems grows.

The U.S. Department of Health and Human Services (HHS) established a Fraud and Abuse Control Program, effective January 1, 1997. The Office of Inspector General (OIG) carries out nationwide audits, investigations, and inspections in order to protect the integrity of HHS programs. Included as subjects of the investigatory efforts would be any healthcare program that receives and distributes federal funds. The OIG also has the authority to investigate hospitals, pharmaceutical manufacturers, third-party medical billing companies, ambulance companies, physician practices, nursing facilities, home health agencies, clinical laboratories, hospices, and companies that supply durable medical equipment, prosthetics, and orthotics. In other words, almost anybody and everybody associated with health care. The OIG can also involve the Federal Bureau of Investigation (FBI) or other federal agencies, as needed, to assist with investigations.

The HHS OIG is primarily concerned with compliance, which means establishing a business environment that complies with principles of business practice, as identified by the OIG, that are intended to increase the stability of the Medicare Trust Fund by reducing fraud and abuse in the claims process. Fraud can occur due to deliberately unethical behavior or because of mistakes and ignorance of the law.

The OIG has the force of law behind its investigations and prosecutions. Some of the laws it enforces cover business processes and relationships:

img The “Stark” laws (named after Congressman Pete Stark of California) address financial interests of physicians in companies or services to which they refer patients or submit claims. An extensive list of designated services is covered.

img The Anti-Kickback statute prohibits the knowing payment of anything of value to influence referral of federal healthcare program business.

img Patient antidumping statutes were passed as a result of the days in which hospitals would do “financial triage,” placing the poor and uninsured back into the ambulance and sending them to the public hospital. These laws require that any patient presenting for emergency care be given an appropriate medical screening exam to determine whether he or she has an emergency condition. If such a condition exists, the patient must be stabilized before being discharged or transferred.

Civil monetary penalties may be imposed on corporations or individuals found to have violated federal regulations related to healthcare financial transactions. The maximum civil monetary penalty is currently $10,000 per item or service, with the possibility of triple penalties in some instances. Some of the actions for which civil monetary penalties may be imposed include the following (Centers for Medicare and Medicaid Services [CMS], n.d.):

img Submitting a claim or claims that the person knows or should know is for an item or service that is not medically necessary

img Failing to provide an itemized statement when requested by a Medicare beneficiary

img Making unsolicited telephone contacts with Medicare beneficiaries regarding furnishing covered durable medical equipment

img Billing for an assistant at a cataract surgery

img Charging a beneficiary for completing and submitting claim forms

img Charging a Medicare beneficiary more than the limiting charge (nonparticipating physicians or suppliers)

img Hiring an individual who has been excluded from participation in federal healthcare programs

Exclusion from federal healthcare programs can occur as a result of convictions for program-related fraud and patient abuse, licensing board actions, and default on health educational assistance loans. The exclusion extends beyond direct patient care or billing and claims to any type of receipt of federal funds, even a salary for serving as an administrative functionary. Employers who knowingly hire excluded individuals may themselves be fined or prosecuted. A list of excluded individuals and entities is available on the HHS OIG website. During fiscal year 2012, the OIG excluded 3,131 individuals and entities from participating in federal healthcare programs. The following were some of the reasons for exclusions:

img Licensure revocation (1,463)

img Patient abuse or neglect (212)

img Criminal convictions for crimes related to Medicare and Medicaid (912)

img Criminal convictions for crimes related to other healthcare programs (287)

Consider the following example exclusion cases from 2012, as reported by HHS (2013):

img In Texas, a nurse was convicted for capital murder for injecting bleach into dialysis lines, killing five patients. Exclusion for 60 years.

img In Ohio, a pediatrician was convicted for unlawful sexual contact with a minor. Exclusion for 50 years.

img In California, a physician was convicted for involuntary manslaughter related to inappropriate administration of Propofol and patient abandonment. Exclusion for 50 years.

One of the ways the OIG gets information on questionable practices is through qui tam, or “whistle-blower,” suits. Qui tam litigation allows private citizens to act on the government’s behalf in filing lawsuits alleging that an individual or corporation has violated the federal False Claims Act. Anyone who has information about the practices of a provider can be a whistle-blower. In some cases, that individual turns out to be a current or former employee of the organization being investigated. The whistle-blower may receive up to 25% of the money the government recovers.

Recent settlements of qui tam fraud cases during the past few years have been quite dramatic. For example, U.S. Renal Care agreed to pay $7.3 million to resolve allegations it billed for more Epogen than it actually administered to patients. Epogen is used to treat anemia often found in end-stage renal disease patients. Manufacturers of Epogen supply about 11% more drug in each vial than is listed on the label, because it is impossible to extract all of the drug from the vial with a syringe. The extra amount is called “overfill.” Between 2004 and 2011, the company billed Medicare for the extra percentage of Epogen, even though it was not administered. This qui tam case was brought by a registered nurse who formerly worked at the company and who had tried to remedy the situation internally, to no avail. She will receive $1.3 million.

Similarly, Imagimed LLC, a New York–based company, will pay $3.57 million to resolve allegations that from 2001 to 2008 it conducted MRI scans with contrast media and without direct supervision by a physician, despite federal regulations requiring such oversight because of the potential for a serious adverse reaction, such as anaphylactic shock. This case was brought by another radiologist, who will receive $565,500.

During fiscal year 2012, the OIG won or negotiated over $3.0 billion in healthcare fraud judgments and settlements. Enforcement actions by the department included the following:

img 1,131 new criminal healthcare fraud investigations were opened.

img 2,032 healthcare fraud criminal investigations were pending.

img 452 cases with criminal charges were filed, involving 892 defendants.

img 826 criminal convictions were made.

img 885 new civil investigations were opened.

img 1,023 civil healthcare fraud cases were pending.

Each year, the OIG publishes a work plan to define its areas of focus for the coming year. For 2013, some of the “hot” topics were the following:

img Hospitals

img Same-day readmissions: Two DRGs paid instead of one

img Discharges versus transfers: Full DRG paid for discharge, only partial DRG for transfers

img Mechanical ventilation time documentation: Must have 96 hours for certain higher-weighted DRGs

img Inpatient outlier payments: Inflation of costs to qualify as outlier

img Nursing homes:

img Oversight of minimum data set: Accuracy of information

img Hospitalizations of nursing home residents

img Home health agencies

img Prospective payment system documentation

img Missing or incorrect OASIS data

img Home health face-to-face requirement: Physician must see the patient within 90 days before or 30 days into home health episode of care

img Physicians:

img High utilization of sleep testing procedures

img Use of procedure modifiers during the global surgery period

img Place of service coding errors

img Inappropriate payments for evaluation and management services

Other areas reviewed include hospice, medical equipment and supplies, ambulance services, psychiatric facilities, and prescription drug issues. The OIG also reviews Part A and Part B contractors that process and pay claims (Wynia, 2000).

OIG Compliance Guidance

In response to the large number of identified compliance issues, the OIG has issued compliance program guidance papers for hospitals, nursing facilities, ambulance services, hospices, individual and small medical practices, third-party billing organizations, clinical laboratories, home health agencies, durable medical equipment and prosthetics and orthotics suppliers, and pharmaceutical manufacturers. Each addresses the seven critical components of an effective compliance program:

img Implementing written policies, procedures, and standards of conduct

img Designating a compliance officer and compliance committee

img Conducting effective training and education

img Developing effective lines of communication

img Enforcing standards through well-publicized disciplinary guidelines

img Conducting internal monitoring and auditing

img Responding promptly to detected offenses and developing corrective action

img If the healthcare entity implements a compliance program that meets these criteria, it may be looked upon favorably should a future problem be identified by the OIG, as at demonstrates that it has made an effort to comply.

What Does This Have to Do with Coding?

Think about the implications of a diagnosis or procedure code equal to a certain number of dollars. Do the light bulbs go on? Is there a huge potential for increasing reimbursement through fraudulent coding? The answer is a most definite “yes.”

A survey of American doctors conducted in 2000 indicated that 39% admitted to having used tactics such as exaggerating symptoms, changing billing diagnoses, or reporting signs or symptoms the patients did not have in order to secure additional services felt to be clinically necessary (Hyman, 2001). A 2004 study found that “physicians whose practices include larger numbers of Medicaid or managed care patients seem more willing to deceive third-party payers than are other physicians. Deception may be a symptom of a flawed system, in which physicians are asked to implement financing policies that conflict with their primary obligation to the patient” (Bogardus, Geist, & Bradley, 2004).

One of the first signs of inappropriate or fraudulent inpatient coding is known as “DRG creep.” It can be identified when a hospital’s case mix index, or average of the total of the values assigned to all DRGs for that hospital’s patients, increases from year to year, or when the incidence of high-severity codes is found at a higher level than the incidence of that severity of disease is found in the population.

Although it would be nice to think that an increase in higher-weighted DRGs is due to improved physician documentation in the medical record, it could also be due to increased use of specialized expert software systems that identify potential diagnoses that could be used to maximize reimbursement. Once the needed diagnosis is identified, a “query form” can be sent to the physician to see if perhaps he or she “forgot” to document that condition in the chart. Rules for the use of query forms indicate they cannot lead the physician to document specifically to increase reimbursement. The sticky note illustrated in  Figure 5-1  is an example of an inappropriate query.

Queries should be used in the following circumstances (American Health Information Management Association [AHIMA], 2008a):

img Clinical indicators of a diagnosis but no documentation of the condition

img Clinical evidence for a higher degree of specificity or severity

img A cause-and-effect relationship between two conditions or organism

img An underlying cause when admitted with symptoms

img Only the treatment is documented (without a diagnosis documented)

img Present on admission (POA) indicator status

img

FIGURE 5-1 Inappropriate query.

DRGs often occur in pairs or threes, one without a complication or comorbidity (CC) and one or two with. The latter always pay more.

Consider the following example:

DRG 460: Spinal fusion except cervical without major CC (weight = 3.8783)

DRG 459: Spinal fusion except cervical with major CC (weight = 6.5390)

DRG 460 without the complication or comorbidity is worth around $22,400, varying by geographic location and case mix index. Adding a major complication or comorbidity brings in an additional $15,000.

An analysis of 2006–2008 Medicare inpatient discharge data showed that documentation and coding improvements resulted in increased reporting of complications and comorbidities. The percentage of cases without a CC or major complication or comorbidity (MCC) dropped more than six points. Among DRGs that are split in some fashion based on secondary diagnoses, all but three demonstrated a pattern of large shift toward the higher-weighted, higher-severity DRGs (MedPac, 2010).

Other hospital abuses are specificity related. Coders are not supposed to make assumptions about diagnoses based on lab work or other diagnostic results in the chart. Coding is supposed to be based on physician documentation. However, in some facilities a positive culture report was a signal to coders that a bacterial diagnosis could be assigned, even without physician documentation. In January 2003, a whistle-blower suit brought by a coder at a Tennessee hospital alleged a number of DRG coding violations, including specific instructions to coders to upcode or use complications, even in the absence of complete chart documentation. The hospital settled for $2 million and the whistle-blower received $350,000.

CMS has identified additional healthcare settings with documentation and coding problems. A 2010 OIG report, “Questionable Billing Practices by Skilled Nursing Facilities,” found that 26% of claims submitted by skilled nursing facilities were not supported by medical record documentation (HHS, 2010). Time documentation to support the number of minutes for ultra high therapy billing was missing. Likewise, the OIG determined that home health agencies submitted 22% of claims in error because services were unnecessary or claims were coded inaccurately, resulting in $432 million in improper payments.

Coding is extremely complex. The rules differ depending on the site of service and who is submitting a bill. Because there are areas of coding that are open to interpretation, it is often the case that coding errors are mistakes, not intentional. This can be taken into account by investigators if they see mistakes but not a pattern of “mistakes.” An example would be investigation by the OIG into the correct assignment of principal diagnosis codes. According to official diagnosis coding guidelines, when a patient has a urinary tract infection, that code is sequenced first, before the code for the organism. If the order of the codes is switched, then a DRG with a higher weight is assigned. If all the cases of this type in a hospital were sequenced improperly, that facility might be charged with intentional fraud. In another facility, if only a few cases were improperly sequenced, no pattern would be identified, and the facility would have to refund money, but it is unlikely that the facility would be accused of fraud (Prophet, 1997).

Coders, even in settings such as physician offices, confront ethical dilemmas on a daily basis. As employees, they want to see their organizations succeed financially. As professionals, they want to adhere to the standards of conduct and ethical principles defined by their professional organizations. The Standards of Ethical Coding of the American Health Information Management Association (2008b) defines expected behavior among coders:

Standards of Ethical Coding

Coding professionals should:

1. Apply accurate, complete, and consistent coding practices for the production of high-quality healthcare data.

2. Report all healthcare data elements (e.g., diagnosis and procedure codes, present on admission indicator, discharge status) required for external reporting purposes (e.g., reimbursement and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules, and guidelines.

3. Assign and report only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, rules, and guidelines.

4. Query provider (physician or other qualified healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g., present on admission indicator).

5. Refuse to change reported codes or the narratives of codes so that meanings are misrepresented.

6. Refuse to participate in or support coding or documentation practices intended to inappropriately increase payment, qualify for insurance policy coverage, or skew data by means that do not comply with federal and state statutes, regulations, and official rules and guidelines.

7. Facilitate interdisciplinary collaboration in situations supporting proper coding practices.

8. Advance coding knowledge and practice through continuing education.

9. Refuse to participate in or conceal unethical coding or abstraction practices or procedures.

10. Protect the confidentiality of the health record at all times and refuse to access protected health information not required for coding-related activities (examples of coding-related activities include completion of code assignment, other health record data abstraction, coding audits, and educational purposes).

11. Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.

Preventive Measures

Coding managers and others involved in the process of coding for reimbursement purposes should be proactive in identifying potential risk areas. Comparative data are available for all types of facilities to compare their DRG, APC, or other payment category results to national or regional norms. Using outside auditors to review coding practices and patterns is advisable to increase objectivity. Billing system edits and payer rejection data are good sources of information to prompt educational efforts for coders.

In June 2004, the OIG published “Draft Supplemental Compliance Program Guidance for Hospitals.” It focuses on activities that are most likely to represent a potential source of liability. It includes the following onerous statements (U.S. Department of Health and Human Services, 2005):

Perhaps the single biggest risk area for hospitals is the preparation and submission of claims or other requests for payment…. Common and longstanding risks associated with claims preparation and submission include inaccurate or incorrect coding, upcoding, unbundling of services, billing for medically unnecessary services or other services not covered by the relevant health care program, billing for services not provided, duplicate billing, insufficient documentation, and false or fraudulent cost reports.

The need to monitor and improve coding and documentation practices is ongoing and necessary to ensure payment accuracy.

References

American Health Information Management Association. (2008a). Managing an effective query process. Journal of AHIMA, 79(10), 83–88.

American Health Information Management Association. (2008b). AHIMA Standards of Ethical Coding. Retrieved December 16, 2013, from http://library.ahima.org/xpedio/groups/public/documents/ahima/bok2_001166.hcsp?dDocName=bok2_001166

Bogardus, S., Geist, D. E., & Bradley, E. H. (2004). Physicians’ interactions with third-party payers: Is deception necessary? Archives of Internal Medicine, 164(17), 1941.

Centers for Medicare and Medicaid Services. (n.d.). Description of civil monetary penalties (CMPs). Retrieved December 13, 2013, from http://oig.hhs.gov/fraud/enforcement/cmp/index.asp

Hyman, D. A. (2001). Health care fraud and abuse: Market change, social norms, and the trust reposed in the workmen. Journal of Legal Studies, 30, 531–567.

MedPac. (2010, March). Report to the Congress: Medicare payment policy 2010. Retrieved December 16, 2013 from http://medpac.gov/chapters/Mar10_Ch02A_APPENDIX.pdf

Prophet, S. (1997). Fraud and abuse implications for the HIM professional. Journal of AHIMA, 68(4), 52–56.

U.S. Department of Health and Human Services, Office of Inspector General. (2005, January 31). Draft supplemental compliance guidance for hospitals. Federal Register, 70(19), 4859–4860.

U.S. Department of Health and Human Services, Office of Inspector General. (2010, December). Questionable billing by skilled nursing facilities. Report OEI-02-09-00202. Washington, DC: Office of Evaluation and Inspection Services.

U.S. Department of Health and Human Services, Office of Inspector General. (2013). Healthcare Fraud and Abuse Control Program report, fiscal year 2013. Retrieved December 13, 2013, from http://oig.hhs.gov/publications/docs/hcfac/hcfacreport2012.pdf

Wynia, M. (2000). Physician manipulation of reimbursement rules for patients: Between a rock and a hard place. Journal of the American Medical Association, 283(14), 1861.

CHAPTER 6

Solving Your Healthcare Coding Problems

Most healthcare coding problems affecting patients become evident under one of two circumstances:

img You are denied for insurance

img You are denied by insurance

Get a Life

When you apply for life insurance, the standard application form includes a space for your signature authorizing the company to check your medical information from various sources. One of those sources may be the Medical Information Bureau (MIB Group, Inc.). Founded in 1902, MIB is a nonprofit association of more than 500 U.S. and Canadian life and health insurance companies. MIB describes its core fraud protection services as “alerting underwriters to errors, omissions or misrepresentations made on insurance applications” (MIB, n.d.).

MIB maintains a database of individuals who have applied for insurance in the past 7 years. The database includes information on about 230 medical conditions that indicate an applicant’s risk. Additional information, such as hazardous occupations or adverse driving records, also is included. When you apply for insurance, the company, with your authorization, can check to see if you have an MIB record, and if so, what your risk factors are. Likewise, if you have a physical exam in conjunction with your application, information from that exam, such as high blood pressure or an abnormal EKG, can be added to your MIB record.

You can obtain a copy of your MIB record once per year at no charge. Additional copies are available for a small fee, unless you have been turned down for insurance based on MIB as an information source, in which case you may obtain an additional copy at no charge. For more information about your MIB record, contact MIB at 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts, 02184-8734.

For the Record

If you think that medical information about you may be incorrect, you probably need to obtain a copy of your medical record. The federal Health Insurance Portability and Accountability Act (HIPAA) requires healthcare providers, health plans, and healthcare clearinghouses to allow you access to your medical records. A fee is often charged to cover the cost of copying the medical records. It may be more economical to review the record in person at the doctor’s office, hospital, or other facility and then request copies of only the relevant information you need.

The following parts of your record can be helpful in addressing errors or incorrect bills:

img Face sheet. This form is usually found with inpatient hospital records. It contains your demographic information, such as your date of birth, address and phone number, insurance policy numbers, and the dates of your admission and discharge. More important, it also contains the principal and other diagnoses, the principal and other procedures, and the diagnosis and procedure codes that were assigned by the hospital. These codes should match up with the codes submitted on claims forms to your insurance company.

img Doctors’ orders. Nothing can be done to you or for you without a doctor’s order. Physicians order tests, treatments, medications, diets, and nursing interventions, such as vital signs or dressing changes. If you are disputing charges on a bill, checking what was billed against the orders in the record may disclose errors.

img Operative report. If you had surgery, the surgeon is required to document the type of operation, the technique used, operative findings, complications, and estimated blood loss. The description of the procedure in the operative report should match the description of the procedure code for which you were billed. If more than one procedure was performed, payers may invoke bundling rules that define which procedures will be paid and which will not.

img History and physical. This report, known as the “H&P,” is the initial assessment of your medical history and your physical and emotional status when you entered the hospital. It could be important with regard to issues of medical necessity. Were you sick enough to require hospitalization and the treatments that were ordered?

img Discharge summary. An account of your hospital course, this report is where the doctor makes his or her final statement about your diagnoses and procedures and also where plans for your ongoing treatment or follow-up are documented. The diagnoses and procedures here should match up with the face sheet and with any claims submitted to your payer.

How Do Coding Errors Occur?

Medical coding analysts are involved in constant decision making. Is it this diagnosis or that? Which diagnosis should be principal? Was the procedure bilateral? Did the physician document enough time to code critical care? Even the task of deciphering physician handwriting involves deciding what was actually documented. According to Morris and colleagues (2000), coders generally make two types of errors when making coding decisions:

img Performance errors: Misreading words, missing details important to the code assignment, failing to pull together details from various parts of the record, transposing digits in code numbers

img Systematic errors: Lack of sufficient medical knowledge to understand the documentation, lack of knowledge of or misapplication of coding rules

Although coding without physician documentation flies in the face of compliance guidance, offices and facilities in a hurry to keep their cash flow moving will code with only parts of the record complete. For example, a pathology report with the ultimate diagnosis for a surgical specimen may not be available for a week after the surgery. If the patient has been discharged, the hospital will be interested in getting its bill out right away. Coding may be based on the surgeon’s postoperative diagnosis, and if the surgeon is wrong, the diagnosis could be something different once the pathology report is available. In the CPT realm, the coding of excision of skin lesions depends on whether the lesion is cancerous, thus coding before the pathology report is available could lead to inaccurate procedure codes and inappropriate reimbursement.

Coders may rely heavily on reports that are transcribed from the physician’s dictation. If errors are made in transcription, they can also result in incorrect coding. Implementation of the electronic health record (EHR) has caused new challenges. If a copy-and-paste function is available, documentation for a specific date of service may include other information from previous encounters that clouds the picture of what was actually done on the date being billed. A study by the HHS OIG released in December 2013 found that only 24% of hospitals had policies in place regarding the use of copy-and-paste (HHS, 2013). In addition, only 44% of hospital audit logs of EHR data entry record the method of entry: copy-and-paste, direct entry, or speech recognition. As a result of this study, the OIG recommended that CMS develop guidelines for copy-and-paste and mandate that audit logs be operational whenever EHRs are used.

When EOB = No

Your first inkling that your insurance is denying or rejecting a claim for your treatment is usually when you receive an Explanation of Benefits (EOB) from your payer. Medicare refers to this as a Medicare Summary Notice, or MSN ( Figure 6-1 ). It tells you what was billed, what has been approved, what has been paid, and what you have to pay. If a claim or part of a claim was rejected, the EOB will use a reason code to tell you why. The problem with the reason codes is that they are not always specific enough to identify the actual problem. Consider the following example: “Claim lacks information needed for adjudication.” You are shaking your head and asking, “What information?”

As you investigate the cause of the rejection and work to obtain payment for the claim, it is essential that you maintain a record of your contacts and correspondence:

img Set up a file folder or electronic folder for each provider. If you don’t have file folders, even just a folded piece of paper with the provider’s name on the outside can help keep your documents in order.

img Make sure you keep all of the EOBs, even those that do not indicate a rejection. They can be useful if you are later involved in a dispute about the bill for service.

img When you receive bills from providers, put them in the appropriate folder, by date. If you pay the bill in person or send a check, keep any receipts or cancelled checks or credit card statements attached to the corresponding bill. If you pay electronically, make sure the electronic copy will be available in the future in case you need it.

img

FIGURE 6-1 Medicare Summary Notice.

Courtesy of Centers for Medicare and Medicaid Services.

img When you are involved in discussions with provider business offices or insurance company customer service centers, make a note of the date and time of your call and the specific name of the individual with whom you speak.

img Keep copies of letters or other correspondence you send to providers or insurers.

All of these materials may be needed in backing up future appeals if your initial efforts are not successful.

1. CONTACT THE PROVIDER

As a first step after receiving a rejection or denial, it is advisable to contact the healthcare provider that submitted the claim. Sometimes you will receive your EOB before the provider gets its remittance advice, so it is possible it may not be aware of your problem. The provider’s business office should be able to help you analyze the rejection and let you know whether the provider plans to appeal. The office staff may be better at figuring out why the claim was rejected than you, so it is worth a phone call.

Inconsistencies and omissions are obvious provider errors in claims submissions. Some of the coding-related rejection reasons the provider should be able to fix and resubmit are the following:

img Missing data elements, such as a diagnosis code, procedure code, or date of service.

img Incorrect data elements, such as diagnosis or procedure codes that are not valid on the date of service (remember that all coding systems change at least annually).

img Inconsistent data elements, such as diagnosis or procedure codes that do not match with your gender or age. It is also possible for a procedure code to be inconsistent with the place of service, such as an inpatient code used in a doctor’s office.

img Incorrectly used data elements, such as modifiers that do not go with the type of procedure code used.

img Requested documentation not sent; the provider must send copies of your medical record when requested for review and approval.

Ask for an itemized bill for the episode of care containing denied services.

2. CONTACT THE INSURER OR OTHER THIRD-PARTY PAYER

If the rejection is for a reason other than a provider error, contact the insurer to discuss the reason for the rejection.

Rejections of this type include:

img Coverage issues. The insurer may not cover the procedure for a variety of reasons. It may be due to the specific plan you have, due to the place where the service was provided, or due to the type of provider that performed the service. Routine or screening examinations and preventive services often are not covered. The procedure code for the denied service and the diagnosis should be verified.

img Medical necessity. Insurance companies pay for procedures and tests that are intended to improve your condition. They do not cover cosmetic procedures or experimental procedures, and they might have defined lists of diagnoses for which various procedures are indicated. If your doctor uses a diagnosis not on the list, the claim will not be paid. This can be a coding problem, because the documented diagnosis may not have been coded to the appropriate level of specificity, thus causing the denial.

img Frequency limits. Some services are only covered up to a limited number of times within a specified time period. Rejections of this type can be coding problems if an error has been made, for example, in coding the number of chest X-rays you had on a given date.

In interactions with insurance companies, it is important to use the term appeal. If you use the term complaint there may not be an associated time limit within which the company is required to respond. However, with an appeal, a legally mandated time frame usually exists.

3. REQUEST AN INTERNAL REVIEW

If you are not satisfied with the results communicated to you by your payer, you may request an internal review. This process varies from payer to payer. You will usually have to complete a formal appeal form and submit it. There may be a time limit for appeals, so make sure you find out how soon you are required to appeal. Employer-sponsored health plans are required to allow you at least 180 days to appeal. In many cases, the back of the EOB form has information about how to make an appeal.

At this point, it may also be helpful to involve others in your efforts. Your employer’s human resources department may be able to assist you in negotiating with the payer. Your employer contracts with the payer to provide coverage, so your employer has a vested interest in making sure its employees are receiving appropriate coverage and service. If you are a senior citizen, every state has a Senior Health Insurance Assistance Program (SHIP) to help older adults with insurance problems (Seniors Resource Guide, n.d.).

4. REQUEST AN EXTERNAL REVIEW

Once you have exhausted your payer’s internal review process, in most states you can request an external review. Rules often govern what types of issues can be appealed. Medical necessity cases are the norm. It may also be a requirement that the amount of money in question meet a certain threshold, such as $100 or $500. A helpful website containing information about insurance appeals and various state regulations is the Kaiser Family Foundation at www.kff.org/health-costs/report/a-consumer-guide-to-handling-disputes-with-your-employer-or-private-health-plan.

5. CONTACT THE PROVIDER AGAIN

If all else fails, contact the provider once again and explain your situation. Ask the provider if he or she would consider lowering the price of the denied procedure, service, supply, or drug so that you will have to pay less out of pocket.

References

MIB Group, Inc. (n.d.). Retrieved December 17, 2013, from http://www.mib.com/facts_about_mib.html

Morris, W. C., Heinze, D. T., Warner H. R., Primack, A., Morsch, A. E., Sheffer, R. E., … Jimmink, M. A. (2000). Assessing the accuracy of an automated coding system in emergency medicine. Proceedings of the American Medical Informatics Association Symposium, 595–599.

Seniors Resource Guide. (n.d.). Find your state’s State Health Insurance Assistance Program (SHIP). Retrieved December 13, 2013, from http://www.seniorsresourceguide.com/directories/National/SHIP/

U.S. Department of Health and Human Services, Office of Inspector General. (2013, December). Not all recommended fraud safeguards have been implemented in hospital EHR technology. OEI-01-11-00570. Retrieved December 18, 2013, from http://oig.hhs.gov/oei/reports/oei-01-11-00570.pdf

CHAPTER 7

Coding as a Career

Is It Right for You?

Now that you have all the details about medical coding, what it is, and how it works, you may be wondering about a career in this field.

According to the U.S. Department of Labor, Bureau of Labor Statistics (BLS, 2012), job prospects for medical records and health information technicians will grow much faster than average through 2020. About 179,500 individuals are already employed in this field, with about 39% working for hospitals.

This is one of the few health occupations in which there is little or no patient contact.

Average salaries for coders vary by geographic region, size of facility, and type of employer. Entry-level positions are in the $30,000 to $35,000 range. Individuals who are experienced, specialized, or supervisors can make as much as $50,000 to $60,000 or more. Working conditions are generally good and are in standard office settings.

Do the following attributes describe you?

img Excellent problem-solving skills

img Detail oriented

img Excellent reading comprehension

img Ability to work independently

img Good written/verbal communication skills

img Enthusiasm for learning

img Computer literate

img Ability to multitask

img Team player

If you enjoy solving puzzles or reading mysteries, coding might just be the right career for you. Every record you review will be different. Every doctor has different methods of documenting care. New vocabulary appears in response to changing technology. Codes change annually, and the rules change periodically as well. Coding is never the “same old, same old.”

Where to Start?

Employers who are hiring coders will be looking for either experience or certification. Although it is possible to start out in a clerical position and work your way up to being a coder, those opportunities are not plentiful. It is not necessary to have a college degree to get a job as a coder, but certification helps.

Two national organizations grant credentials to coders:

img The American Health Information Management Association (AHIMA) grants the Certified Coding Associate (CCA), Certified Coding Specialist (CCS), and Certified Coding Specialist–Physician (CCS-P) credentials. All are based on successful completion of a national exam. All exams require a high school diploma or equivalent and, although not required, substantial coding experience is recommended. Additional information from AHIMA is available at http://www.ahima.org.

img The American Academy of Professional Coders (AAPC) grants the Certified Professional Coder (CPC) and Certified Professional Coder-Hospital (CPC-H) credentials. These are also based on a national exam. Candidates must have 2 years of full-time coding experience. Those without experience may complete the exam but will be designated as apprentices until the required time period is fulfilled. Additional information from the AAPC is available at http://www.aapc.com.

A prerequisite for any type of coding certification or study is a thorough knowledge of medical terminology, disease processes, and anatomy and physiology. Courses in these subjects are available at community colleges and trade schools in every state. Many colleges also offer distance learning programs in which classes can be completed at home.

Reference

Bureau of Labor Statistics, U.S. Department of Labor. (2012). Occupational outlook handbook, 201213 edition: Medical records and health information technicians. Retrieved December 21, 2013, from http://www.bls.gov/ooh/healthcare/medical-records-and-health-information-technicians.htm

APPENDIX A

List of ICD-10-CM Three-Character Diagnosis Categories

Note: All valid ICD-10-CM diagnosis codes have three, four, five, or six characters. Each diagnosis falls under one of the three-character categories listed below. If a three-character category is subdivided into more specific codes with four, five, or six digits, the subdivisions must be used, not the three-character category. An example is Cholera, category A00. It is further subdivided into A00.0, A00.1, and A00.9 for different causes of cholera as well as cholera, unspecified; thus, the four-character codes must be used. NEC means “not elsewhere classified,” which means that the documented disease or condition does not have a specific code.

1. CERTAIN INFECTIOUS AND PARASITIC DISEASES

A00   

Cholera

A01

Typhoid and paratyphoid fevers

A02

Other salmonella infections

A03

Shigellosis

A04

Other bacterial intestinal infections

A05

Other bacterial foodborne intoxications, NEC

A06

Amebiasis

A07

Other protozoal intestinal diseases

A08

Viral and other unspecified intestinal infections

A09

Infectious gastroenteritis and colitis, unspecified

A15

Respiratory tuberculosis

A17

Tuberculosis of nervous system

A18

Tuberculosis of other organs

A19

Miliary tuberculosis

A20

Plague

A21

Tularemia

A22

Anthrax

A23

Brucellosis

A24

Glanders and meliodosis

A25

Rat-bite fever

A26

Erysipeloid

A27

Leptospirosis

A28

Other zoonotic bacterial diseases, NEC

A30

Leprosy (Hansen’s disease)

A31

Infection due to other mycobacteria

A32

Listeriosis

A33

Tetanus neonatorum

A34

Obstetrical tetanus

A35

Other tetanus

A36

Diphtheria

A37

Whooping cough

A38

Scarlet fever

A39

Meningococcal infection

A40

Streptococcal sepsis

A41

Other sepsis

A42

Actinomycosis

A43

Nocardiosis

A44

Bartonellosis

A46

Erysipelas

A48

Other bacterial diseases, NEC

A49

Bacterial infections of unspecified site

A50

Congenital syphilis

A51

Early syphilis

A52

Late syphilis

A53

Other and unspecified syphilis

A54

Gonococcal infection

A55

Chlamydial lymphogranuloma (venereum)

A56

Other sexually transmitted chlamydial diseases

A57

Chancroid

A58

Granuloma inguinale

A59

Trichomoniasis

A60

Anogenital herpesviral (herpes simplex) infections

A63

Other predominantly sexually transmitted diseases, NEC

A64

Unspecified sexually transmitted disease

A65

Nonvenereal syphilis

A66

Yaws

A67

Pinta (carate)

A68

Relapsing fevers

A69

Other spirochetal infections

A70

Chlamydia psittaci infections

A71

Trachoma

A74

Other diseases caused by chlamydiae

A75

Typhus fever

A77

Spotted fever (tick-borne rickettsioses)

A78

Q fever

A79

Other rickettsioses

A80

Acute poliomyelitis

A81

Atypical viral infections of central nervous system

A82

Rabies

A83

Mosquito-borne viral encephalitis

A84

Tick-borne viral encephalitis

A85

Other viral encephalitis, NEC

A86

Unspecified viral encephalitis

A87

Viral meningitis

A88

Other viral infections of central nervous system, NEC

A89

Unspecified viral infection of central nervous system

A90

Dengue fever

A91

Dengue hemorrhagic fever

A92

Other mosquito-borne viral fevers

A93

Other arthropod-borne viral fevers, NEC

A94

Unspecified arthropod-born viral fever

A95

Yellow fever

A96

Arenaviral hemorrhagic fever

A98

Other viral hemorrhagic fevers, NEC

A99

Unspecified viral hemorrhagic fever

B00

Herpesviral (herpes simplex) infections

B01

Varicella (chickenpox)

B02

Zoster (herpes zoster)

B03

Smallpox

B04

Monkeypox

B05

Measles

B06

Rubella (German measles)

B07

Viral warts

B08

Other viral infections characterized by skin and mucous membrane lesions, NEC

B09

Unspecified viral infection characterized by skin and mucous membrane lesions

B10

Other human herpes viruses

B15

Acute hepatitis A

B16

Acute hepatitis B

B17

Other acute viral hepatitis

B18

Chronic viral hepatitis

B19

Unspecified viral hepatitis

B20

Human immunodeficiency virus (HIV) disease

B25

Cytomegaloviral disease

B26

Mumps

B27

Infectious mononucleosis

B30

Viral conjunctivitis

B33

Other viral diseases, NEC

B35

Dermatophytosis

B36

Other superficial mycoses

B37

Candidiasis

B38

Coccidiomycosis

B39

Histoplasmosis

B40

Blastomycosis

B41

Paracoccidiomycosis

B42

Sporotrichosis

B43

Chromomycosis and pheomycotic abscess

B44

Aspergillosis

B45

Cryptococcosis

B46

Zygomycosis

B47

Mycetoma

B48

Other mycoses, NEC

B49

Unspecified mycosis

B50

Plasmodium falciparum malaria

B51

Plasmodium vivax malaria

B52

Plasmodium malariae malaria

B53

Other specified malaria

B54

Unspecified malaria

B55

Leishmaniasis

B56

African trypanosomiasis

B57

Chagas’ disease

B58

Toxoplasmosis

B59

Pneumocystosis

B60

Other protozoal diseases, NEC

B65

Schistosomiasis (bilharziasis)

B66

Other fluke infections

B67

Echinococcosis

B68

Taeniasis

B69

Cysticercosis

B70

Diphyllobothriasis and sparganosis

B71

Other cestode infections

B72

Dracunculiasis

B73

Onchocerciasis

B74

Filariasis

B75

Trichinellosis

B76

Hookworm diseases

B77

Ascariasis

B78

Strongyloidiasis

B79

Trichuriasis

B80

Enterobiasis

B81

Other intestinal helminthiases, NEC

B82

Unspecified intestinal parasitism

B83

Other helminthiases

B85

Pediculosis and phthiriasis

B86

Scabies

B87

Myiasis

B88

Other infestations

B89

Unspecified parasitic disease

B90

Sequelae of tuberculosis

B91

Sequelae of poliomyelitis

B92

Sequelae of leprosy

B94

Sequelae of other and unspecified infectious and parasitic diseases

B95

StreptococcusStaphylococcus, and Enterococcus as the cause of diseases classified elsewhere

B96

Other bacterial agents as the cause of diseases classified elsewhere

B97

Viral agents as the cause of diseases classified elsewhere

B99

Other and unspecified infectious diseases

2. NEOPLASMS

C00   

Malignant neoplasm of lip

C01

Malignant neoplasm of base of tongue

C02

Malignant neoplasm of other and unspecified parts of tongue

C03

Malignant neoplasm of gum

C04

Malignant neoplasm of floor of mouth

C05

Malignant neoplasm of palate

C06

Malignant neoplasm of other and unspecified parts of mouth

C07

Malignant neoplasm of parotid gland

C08

Malignant neoplasm of other and unspecified major salivary gland

C09

Malignant neoplasm of tonsil

C10

Malignant neoplasm of oropharynx

C11

Malignant neoplasm of nasopharynx

C12

Malignant neoplasm of pyriform sinus

C13

Malignant neoplasm of hypopharynx

C14

Malignant neoplasm of other and ill-defined sites in the lip, oral cavity, and pharynx

C15

Malignant neoplasm of esophagus

C16

Malignant neoplasm of stomach

C17

Malignant neoplasm of small intestine

C18

Malignant neoplasm of colon

C19

Malignant neoplasm of rectosigmoid junction

C20

Malignant neoplasm of rectum

C21

Malignant neoplasm of anus and anal canal

C22

Malignant neoplasm of liver and intrahepatic bile ducts

C23

Malignant neoplasm of gallbladder

C24

Malignant neoplasm of other and unspecified parts of biliary tract

C25

Malignant neoplasm of pancreas

C26

Malignant neoplasm of other and ill-defined digestive organs

C30

Malignant neoplasm of nasal cavity and middle ear

C31

Malignant neoplasm of accessory sinuses

C32

Malignant neoplasm of larynx

C33

Malignant neoplasm of trachea

C34

Malignant neoplasm of bronchus and lung

C37

Malignant neoplasm of thymus

C38

Malignant neoplasm of heart, mediastinum, and pleura

C39

Malignant neoplasm of other and ill-defined sites in the respiratory system and intrathoracic organs

C40

Malignant neoplasm of bone and articular cartilage of limbs

C41

Malignant neoplasm of bone and articular cartilage of other and unspecified sites

C43

Malignant melanoma of skin

C44

Other and unspecified malignant neoplasm of skin

C45

Mesothelioma

C46

Kaposi’s sarcoma

C47

Malignant neoplasm of peripheral nerves and autonomic nervous system

C48

Malignant neoplasm of retroperitoneum and peritoneum

C49

Malignant neoplasm of other connective and soft tissue

C4A

Merkel cell carcinoma

C50

Malignant neoplasm of breast

C51

Malignant neoplasm of vulva

C52

Malignant neoplasm of vagina

C53

Malignant neoplasm of cervix uteri

C54

Malignant neoplasm of corpus uteri

C55

Malignant neoplasm of uterus, part unspecified

C56

Malignant neoplasm of ovary

C57

Malignant neoplasm of other and unspecified female genital organs

C60

Malignant neoplasm of penis

C61

Malignant neoplasm of prostate

C62

Malignant neoplasm of testis

C63

Malignant neoplasm of other and unspecified male genital organs

C64

Malignant neoplasm of kidney, except renal pelvis

C65

Malignant neoplasm of renal pelvis

C66

Malignant neoplasm of ureter

C67

Malignant neoplasm of bladder

C68

Malignant neoplasm of other and unspecified urinary organs

C69

Malignant neoplasm of eye and adnexa

C70

Malignant neoplasm of meninges

C71

Malignant neoplasm of brain

C72

Malignant neoplasm of spinal cord, cranial nerves, and other parts of central nervous system

C73

Malignant neoplasm of thyroid gland

C74

Malignant neoplasm of other endocrine glands and related structures

C76

Malignant neoplasm of other and ill-defined sites

C77

Secondary and unspecified malignant neoplasm of lymph nodes

C78

Secondary malignant neoplasm of respiratory and digestive organs

C79

Secondary malignant neoplasm of other sites

C7A

Malignant neuroendocrine tumors

C7B

Secondary neuroendocrine tumors

C80

Malignant neoplasm without specification of site

C81

Hodgkin lymphoma

C82

Follicular lymphoma

C83

Non-follicular lymphoma

C84

Mature T/NK cell lymphomas

C85

Other specified and unspecified types of non-Hodgkin’s lymphoma

C86

Other specified types of T/NK cell lymphoma

C88

Malignant immunoproliferative diseases

C90

Multiple myeloma and malignant plasma cell neoplasms

C91

Lymphoid leukemia

C92

Myeloid leukemia

C93

Monocytic leukemia

C94

Other leukemias of specified cell type

C95

Leukemia of unspecified cell type

C96

Other and unspecified malignant neoplasms of lymphoid, hematopoietic, and related tissue

D00

Carcinoma in situ of oral cavity, esophagus, and stomach

D01

Carcinoma in situ of other and unspecified digestive organs

D02

Carcinoma in situ of middle ear and respiratory system

D03

Melanoma in situ

D04

Carcinoma in situ of skin

D05

Carcinoma in situ of breast

D06

Carcinoma in situ of cervix uteri

D07

Carcinoma in situ of other and unspecified genital organs

D09

Carcinoma in situ of other and unspecified sites

D10

Benign neoplasm of mouth and pharynx

D11

Benign neoplasm of major salivary glands

D12

Benign neoplasm of colon, rectum, anus, and anal canal

D13

Benign neoplasm of other and ill-defined parts of digestive system

D14

Benign neoplasm of middle ear and respiratory system

D15

Benign neoplasm of other and unspecified intrathoracic organs

D16

Benign neoplasm of bone and articular cartilage

D17

Benign lipomatous neoplasm

D18

Hemangioma and lymphangioma, any site

D19

Benign neoplasm of mesothelial tissue

D20

Benign neoplasm of soft tissue of retroperitoneum and peritoneum

D21

Other benign neoplasm of connective and other soft tissue of head, face, and neck

D22

Melanocytic nevi

D23

Other benign neoplasms of skin

D24

Benign neoplasm of breast

D25

Leiomyoma of uterus

D26

Other benign neoplasm of uterus

D27

Benign neoplasm of ovary

D28

Benign neoplasm of other and unspecified female genital organs

D29

Benign neoplasm of male genital organs

D30

Benign neoplasm urinary organs

D31

Benign neoplasm of eye and adnexa

D32

Benign neoplasm of meninges

D33

Benign neoplasm of brain and other parts of central nervous system

D34

Benign neoplasm of thyroid gland

D35

Benign neoplasm of other and unspecified endocrine glands

D36

Benign neoplasm of other and unspecified sites

D37

Neoplasm of uncertain behavior of oral cavity and digestive organs

D38

Neoplasm of uncertain behavior of middle ear and respiratory and intrathoracic organs

D39

Neoplasm of uncertain behavior of female genital organs

D3A

Benign neuroendocrine tumors

D40

Neoplasm of uncertain behavior of male genital organs

D41

Neoplasm of uncertain behavior of urinary organs

D42

Neoplasm of uncertain behavior of meninges

D43

Neoplasm of uncertain behavior of brain and central nervous system

D44

Neoplasm of uncertain behavior of endocrine glands

D45

Polycythemia vera

D46

Myelodysplastic syndromes

D47

Other neoplasms of uncertain behavior of lymphoid, hematopoietic, and related tissue

D48

Neoplasm of uncertain behavior of other and unspecified sites

D49

Neoplasm of unspecified behavior

3. DISEASES OF THE BLOOD AND BLOOD-FORMING ORGANS AND CERTAIN DISORDERS INVOLVING THE IMMUNE MECHANISM

D50   

Iron deficiency anemia

D51

Vitamin B12 deficiency anemia

D52

Folate deficiency anemia

D53

Other nutritional anemias

D55

Anemia due to enzyme disorders

D56

Thalassemia

D57

Sickle-cell disorders

D58

Other hereditary hemolytic anemias

D59

Acquired hemolytic anemia

D60

Acquired pure red cell aplasia (erythroblastopenia)

D61

Other aplastic anemias and other bone marrow failure syndromes

D62

Acute posthemorrhagic anemia

D63

Anemia in chronic diseases classified elsewhere

D64

Other anemias

D65

Disseminated intravascular coagulation (defibrination syndrome)

D66

Hereditary factor VIII deficiency

D67

Hereditary factor IX deficiency

D68

Other coagulation defects

D69

Purpura and other hemorrhagic conditions

D70

Neutropenia

D71

Functional disorders of polymorphonuclear neutrophils

D72

Other disorders of white blood cells

D73

Diseases of spleen

D74

Methemoglobinemia

D75

Other and unspecified diseases of blood and blood-forming organs

D76

Other specified diseases with participation of lymphoreticular tissue and reticulohistiocytic tissue

D77

Other disorders of blood and blood-forming organs in diseases classified elsewhere

D78

Intraoperative and postprocedural complications of the spleen

D80

Immunodeficiency with predominantly antibody defects

D81

Combined immunodeficiencies

D82

Immunodeficiency associated with other major defects

D83

Common variable immunodeficiency

D84

Other immunodeficiencies

D86

Sarcoidosis

D89

Other disorders involving the immune mechanism, NEC

4. ENDOCRINE, NUTRITIONAL, AND METABOLIC DISEASES

E00   

Congenital iodine-deficiency syndrome

E01

Iodine-deficiency related thyroid disorders and allied conditions

E02

Subclinical iodine-deficiency hypothyroidism

E03

Other hypothyroidism

E04

Other nontoxic goiter

E05

Thyrotoxicosis (hyperthyroidism)

E06

Thyroiditis

E07

Other disorders of thyroid

E08

Diabetes mellitus due to underlying condition

E09

Drug or chemical induced diabetes mellitus

E10

Type 1 diabetes mellitus

E11

Type 2 diabetes mellitus

E13

Other specified diabetes mellitus

E15

Nondiabetic hypoglycemic coma

E16

Other disorders of pancreatic internal secretion

E20

Hypoparathyroidism

E21

Hyperparathyroidism and other disorders of parathyroid gland

E22

Hyperfunction of pituitary gland

E23

Hypofunction and other disorders of the pituitary gland

E24

Cushing’s syndrome

E25

Adrenogenital disorders

E26

Hyperaldosteronism

E27

Other disorders of adrenal gland

E28

Ovarian dysfunction

E29

Testicular dysfunction

E30

Disorders of puberty, NEC

E31

Polyglandular dysfunction

E32

Diseases of thymus

E34

Other endocrine disorders

E35

Disorders of endocrine glands in diseases classified elsewhere

E36

Intraoperative complications of endocrine system

E40

Kwashiorkor

E41

Nutritional marasmus

E42

Marasmic kwashiorkor

E43

Unspecified severe protein-calorie malnutrition

E44

Protein-calorie malnutrition of moderate and mild degree

E45

Retarded development following protein-calorie malnutrition

E46

Unspecified protein-calorie malnutrition

E50

Vitamin A deficiency

E51

Thiamine deficiency

E52

Niacin deficiency (pellagra)

E53

Deficiency of other B group vitamins

E54

Ascorbic acid deficiency

E55

Vitamin D deficiency

E56

Other vitamin deficiencies

E58

Dietary calcium deficiency

E59

Dietary selenium deficiency

E60

Dietary zinc deficiency

E61

Deficiency of other nutrient elements

E63

Other nutritional deficiencies

E64

Sequelae of malnutrition and other nutritional deficiencies

E65

Localized adiposity

E66

Overweight and obesity

E67

Other hyperalimentation

E68

Sequelae of hyperalimentation

E70

Disorders of aromatic amino-acid metabolism

E71

Disorders of branched-chain amino-acid metabolism and fatty-acid metabolism

E72

Disorders of amino-acid transport

E73

Lactose intolerance

E74

Other disorders of carbohydrate metabolism

E75

Disorders of sphingolipid metabolism and other lipid storage disorders

E76

Disorders of glycosaminoglycan metabolism

E77

Disorders of glycoprotein metabolism

E78

Disorders of lipoprotein metabolism and other lipidemia

E79

Disorders of purine and pyrimidine metabolism

E80

Disorders of porphyrin and bilirubin metabolism

E83

Disorders of mineral metabolism

E84

Cystic fibrosis

E85

Amyloidosis

E86

Volume depletion

E87

Other disorders of fluid, electrolyte, and acid-base balance

E88

Other and unspecified metabolic disorders

E89

Postprocedural endocrine and metabolic complications and disorders, NEC

288

Diseases of white blood cells

289

Other diseases of blood and blood-forming organs

5. MENTAL AND BEHAVIORAL DISORDERS

F01   

Vascular dementia

F02

Dementia in other diseases classified elsewhere

F03

Unspecified dementia

F04

Amnestic disorder due to known physiological condition

F05

Delirium due to known physiological condition

F06

Other mental disorders due to known physiological condition

F07

Personality and behavioral disorders due to known physiological condition

F09

Unspecified mental disorder due to known physiological condition

F10

Alcohol-related disorders

F11

Opioid-related disorders

F12

Cannabis-related disorders

F13

Sedative-, hypnotic-, or anxiolytic-related disorders

F14

Cocaine-related disorders

F15

Other stimulant-related disorders

F16

Hallucinogen-related disorders

F17

Nicotine dependence

F18

Inhalant-related disorders

F19

Other psychoactive substance–related disorders

F20

Schizophrenia

F21

Schizotypal disorder

F22

Delusional disorders

F23

Brief psychotic disorder

F24

Shared psychotic disorder

F25

Schizoaffective disorder

F28

Other psychotic disorder not due to a substance or known physiological condition

F29

Unspecified psychosis not due to a substance or known physiological condition

F30

Manic episode

F31

Bipolar disorder

F32

Major depressive disorder, single episode

F33

Major depressive disorder, recurrent

F34

Persistent mood (affective) disorders

F39

Unspecified mood (affective) disorder

F40

Phobic anxiety disorders

F41

Other anxiety disorders

F42

Obsessive-compulsive disorder

F43

Reaction to severe stress, and adjustment disorders

F44

Dissociative and conversion disorders

F45

Somatiform disorders

F48

Other nonpsychotic mental disorders

F50

Eating disorders

F51

Sleep disorders not due to a substance or known physiological condition

F52

Sexual dysfunction not due to a substance or known physiological condition

F53

Puerperal psychosis

F54

Psychological and behavioral factors associated with disorders or diseases classified elsewhere

F55

Abuse of nonpsychoactive substances

F56

Unspecified behavioral syndromes associated with physiological disturbances and physical factors

F60

Specific personality disorders

F63

Impulse disorders

F64

Gender identity disorders

F65

Paraphilias

F66

Other sexual disorders

F68

Other disorders of adult personality and behavior

F69

Unspecified disorder of adult personality and behavior

F70

Mild intellectual difficulties

F71

Moderate intellectual difficulties

F72

Severe intellectual difficulties

F73

Profound intellectual difficulties

F78

Other intellectual difficulties

F79

Unspecified intellectual difficulties

F80

Specific developmental disorders of speech and language

F81

Specific developmental disorders of scholastic skills

F82

Specific developmental disorders of motor function

F84

Pervasive developmental disorders

F88

Other disorders of psychological development

F89

Unspecified disorder of psychological development

F90

Attention-deficit hyperactivity disorders

F91

Conduct disorders

F93

Emotional disorders with onset specific to childhood

F94

Disorders of social functioning with onset specific to childhood and adolescence

F95

Tic disorder

F98

Other behavioral and emotional disorders with onset usually occurring in childhood and adolescence

F99

Mental disorder, not otherwise specified

6. DISEASES OF THE NERVOUS SYSTEM

G00   

Bacterial meningitis, NEC

G01

Meningitis in bacterial diseases classified elsewhere

G02

Meningitis in other infectious and parasitic diseases classified elsewhere

G03

Meningitis due to other and unspecified causes

G04

Encephalitis, myelitis, and encephalomyelitis

G05

Encephalitis, myelitis, and encephalomyelitis in diseases classified elsewhere

G06

Intracranial and intraspinal abscess and granuloma

G07

Intracranial and intraspinal abscess and granuloma in diseases classified elsewhere

G08

Intracranial and intraspinal phlebitis and thrombophlebitis

G09

Sequelae of inflammatory diseases of central nervous system

G10

Huntington’s disease

G11

Hereditary ataxia

G12

Spinal muscular atrophy and related syndromes

G13

Systemic atrophies primarily affecting central nervous system in diseases classified elsewhere

G14

Postpolio syndrome

G20

Parkinson’s disease

G23

Other degenerative diseases of basal ganglia

G24

Dystonia

G25

Other extrapyramidal and movement disorders

G26

Extrapyramidal and movement disorders in diseases classified elsewhere

G30

Alzheimer’s disease

G31

Other degenerative diseases of nervous system, NEC

G32

Other degenerative disorders of nervous system in diseases classified elsewhere

G35

Multiple sclerosis

G36

Other acute disseminated demyelination

G37

Other demyelinating diseases of central nervous system

G40

Epilepsy and recurrent seizures

G43

Migraine

G44

Other headache syndromes

G45

Transient cerebral ischemic attacks and related syndromes

G46

Vascular syndromes of brain in cerebrovascular diseases

G47

Sleep disorders

G50

Disorders of trigeminal nerve

G51

Disorders of facial nerve

G52

Disorders of other cranial nerves

G53

Cranial nerve disorders in diseases classified elsewhere

G54

Nerve root and plexus disorders

G55

Nerve root and plexus disorders in diseases classified elsewhere

G56

Mononeuropathies of upper limb

G57

Mononeuropathies of lower limb

G58

Other mononeuropathies

G59

Mononeuropathy in diseases classified elsewhere

G60

Hereditary and idiopathic neuropathy

G61

Inflammatory polyneuropathy

G62

Other and unspecified polyneuropathies

G63

Polyneuropathy in diseases classified elsewhere

G64

Other disorders of peripheral nervous system

G65

Sequelae of inflammatory and toxic polyneuropathies

G70

Myasthenia gravis

G71

Primary disorders of muscles

G72

Other and unspecified myopathies

G73

Disorders of myoneural junction and muscle in diseases classified elsewhere

G80

Cerebral palsy

G81

Hemiplegia and hemiparesis

G82

Paraplegia (paraparesis) and quadriplegia (quadriparesis)

G83

Other paralytic syndromes

G89

Pain, NEC

G90

Disorders of autonomic nervous system

G91

Hydrocephalus

G92

Toxic encephalopathy

G93

Other disorders of brain

G94

Other disorders of brain in diseases classified elsewhere

G95

Other and unspecified diseases of spinal cord

G96

Other disorders of central nervous system

G97

Intraoperative and postprocedural complications and disorders of nervous system, NEC

G98

Other disorders of nervous system, NEC

G99

Other disorders of nervous system in diseases classified elsewhere

7. DISEASES OF THE EYE AND ADNEXA

H00   

Hordeolum and chalazion

H01

Other inflammation of eyelid

H02

Other disorders of eyelid

H04

Disorders of lacrimal system

H05

Disorders of orbit

H10

Conjunctivitis

H11

Other disorders of conjunctiva

H15

Disorders of sclera

H16

Keratitis

H17

Corneal scars and opacities

H18

Other disorders of cornea

H20

Iridocyclitis

H21

Other disorders of iris and ciliary body

H22

Disorders of iris and ciliary body in diseases classified elsewhere

H25

Age-related cataract

H26

Other cataract

H27

Other disorders of lens

H28

Cataract in diseases classified elsewhere

H30

Chorioretinal inflammations

H31

Other disorders of choroid

H32

Chorioretinal disorders in diseases classified elsewhere

H33

Retinal detachments and breaks

H34

Retinal vascular occlusions

H35

Other retinal disorders

H36

Retinal disorders in diseases classified elsewhere

H40

Glaucoma

H42

Glaucoma in diseases classified elsewhere

H43

Disorders of vitreous body

H44

Disorders of globe

H46

Optic neuritis

H47

Other disorders of optic (2nd) nerve and visual pathways

H49

Paralytic strabismus

H50

Other strabismus

H51

Other disorders of binocular movement

H52

Disorders of refraction and accommodation

H53

Visual disturbances

H54

Blindness and low vision

H55

Nystagmus

H57

Other disorders of eye and adnexa

H59

Intraoperative and postprocedural complications and disorders of eye and adnexa, NEC

8. DISEASES OF THE EAR AND MASTOID PROCESS

H60   

Otitis externa

H61

Other disorders of external ear

H62

Disorders of external ear in diseases classified elsewhere

H65

Nonsuppurative otitis media

H66

Suppurative and unspecified otitis media

H67

Otitis media in diseases classified elsewhere

H68

Eustachian salpingitis and obstruction

H69

Other and unspecified disorders of Eustachian tube

H70

Mastoiditis and related conditions

H71

Cholesteatoma of middle ear

H72

Perforation of tympanic membrane

H73

Other disorders of tympanic membrane

H74

Other disorders of middle ear and mastoid

H75

Other disorders of middle ear and mastoid in diseases classified elsewhere

H80

Otosclerosis

H81

Disorders of vestibular function

H82

Vertiginous syndromes in diseases classified elsewhere

H83

Other diseases of inner ear

H90

Conductive and sensorineural hearing loss

H91

Other and unspecified hearing loss

H92

Otalgia and effusion of ear

H93

Other disorders of ear, NEC

H94

Other disorders of ear in diseases classified elsewhere

H95

Intraoperative and postprocedural complications and disorders of ear and mastoid process, NEC

9. DISEASES OF THE CIRCULATORY SYSTEM

I00   

Rheumatic fever without heart involvement

I01

Rheumatic fever with heart involvement

I02

Rheumatic chorea

I05

Rheumatic mitral valve diseases

I06

Rheumatic aortic valve diseases

I07

Rheumatic tricuspid valve diseases

I08

Multiple valve diseases

I09

Other rheumatic heart diseases

I10

Essential (primary) hypertension

I11

Hypertensive heart disease

I12

Hypertensive chronic kidney disease

I13

Hypertensive heart and chronic kidney disease

I15

Secondary hypertension

I20

Angina pectoris

I21

ST elevation (STEMI) and non-ST (NSTEMI) myocardial infarction

I22

Subsequent ST elevation (STEMI) and non-ST (NSTEMI) myocardial infarction

I23

Certain current complications following ST elevation (STEMI) and non-ST (NSTEMI) myocardial infarction (within the 28 day period)

I24

Other acute ischemic heart diseases

I25

Chronic ischemic heart disease

I26

Pulmonary embolism

I27

Other pulmonary heart diseases

I28

Other diseases of pulmonary vessels

I30

Acute pericarditis

I31

Other diseases of pericardium

I32

Pericarditis in diseases classified elsewhere

I33

Acute and subacute endocarditis

I34

Nonrheumatic mitral valve disorders

I35

Nonrheumatic aortic valve disorders

I36

Nonrheumatic tricuspid valve disorders

I37

Nonrheumatic pulmonary valve disorders

I38

Endocarditis, valve unspecified

I39

Endocarditis and heart valve disorders in diseases classified elsewhere

I40

Acute myocarditis

I41

Myocarditis in diseases classified elsewhere

I42

Cardiomyopathy

I43

Cardiomyopathy in diseases classified elsewhere

I44

Atrioventricular and left bundle-branch block

I45

Other conduction disorders

I46

Cardiac arrest

I47

Paroxysmal tachycardia

I48

Atrial fibrillation and flutter

I49

Other cardiac arrhythmias

I50

Heart failure

I51

Ill-defined descriptions and complications of heart disease

I52

Other heart disorders in diseases classified elsewhere

I60

Nontraumatic subarachnoid hemorrhage

I61

Nontraumatic intracerebral hemorrhage

I62

Other and unspecified nontraumatic intracranial hemorrhage

I63

Cerebral infarction

I65

Occlusion and stenosis of precerebral arteries, not resulting in cerebral infarction

I66

Occlusion and stenosis of cerebral arteries, not resulting in infarction

I67

Other cerebrovascular diseases

I68

Cerebrovascular disorders in diseases classified elsewhere

I69

Sequelae of cerebrovascular disease

I70

Atherosclerosis

I71

Aortic aneurysm and dissection

I72

Other aneurysm

I73

Other peripheral vascular disease

I74

Arterial embolism and thrombosis

I75

Atheroembolism

I76

Septic arterial embolism

I77

Other disorders of arteries and arterioles

I78

Diseases of capillaries

I79

Diseases of arteries, arterioles, and capillaries in diseases classified elsewhere

I80

Phlebitis and thrombophlebitis

I81

Portal vein thrombosis

I82

Other venous embolism and thrombosis

I83

Varicose veins of lower extremities

I85

Esophageal varices

I86

Varicose veins of other sites

I87

Other disorders of veins

I88

Nonspecific lymphadenitis

I89

Other noninfective disorders of lymphatic vessels and lymph nodes

I95

Hypotension

I96

Gangrene, NEC

I97

Intraoperative and postprocedural complications and disorders of circulatory system, NEC

I99

Other and unspecified disorders of circulatory system

10. DISEASES OF THE RESPIRATORY SYSTEM

J00   

Acute nasopharyngitis (common cold)

J01

Acute sinusitis

J02

Acute pharyngitis

J03

Acute tonsillitis

J04

Acute laryngitis and tracheitis

J05

Acute obstructive laryngitis (croup) and epiglottitis

J06

Acute upper respiratory infections of multiple or unspecified sites

J09

Influenza due to certain identified influenza viruses

J10

Influenza due to other identified influenza virus

J11

Influenza due to unidentified influenza virus

J12

Viral pneumonia, NEC

J13

Pneumonia due to Streptococcus pneumonia

J14

Pneumonia due to Hemophilus influenza

J15

Bacterial pneumonia, NEC

J16

Pneumonia due to other infectious organisms, NEC

J17

Pneumonia in diseases classified elsewhere

J18

Pneumonia, unspecified organism

J20

Acute bronchitis

J21

Acute bronchiolitis

J22

Unspecified acute lower respiratory infection

J30

Vasomotor and allergic rhinitis

J31

Chronic rhinitis, nasopharyngitis and pharyngitis

J32

Chronic sinusitis

J33

Nasal polyp

J34

Other and unspecified disorders of nose and nasal sinuses

J35

Chronic diseases of tonsils and adenoids

J36

Peritonsillar abscess

J37

Chronic laryngitis and laryngotracheitis

J38

Diseases of vocal cords and larynx, NEC

J39

Other diseases of upper respiratory tract

J40

Bronchitis, not specified as acute or chronic

J41

Simple and mucopurulent chronic bronchitis

J42

Unspecified chronic bronchitis

J43

Emphysema

J44

Other chronic obstructive pulmonary disease

J45

Asthma

J47

Bronchiectasis

J60

Coalworkers’ pneumoconiosis

J61

Pneumoconiosis due to asbestos and other mineral fibers

J62

Pneumoconiosis due to dust containing silica

J63

Pneumoconiosis due to other inorganic dusts

J64

Unspecified pneumoconiosis

J65

Pneumoconiosis associated with tuberculosis

J66

Airway disease due to specific organic dust

J67

Hypersensitivity pneumonitis due to organic dust

J68

Respiratory conditions due to inhalation of chemicals, gases, fumes, and vapors

J69

Pneumonitis due to solids and liquids

J70

Respiratory conditions due to other external agents

J80

Acute respiratory distress syndrome

J81

Pulmonary edema

J82

Pulmonary eosinophilia

J84

Other interstitial pulmonary diseases

J85

Abscess of lung and mediastinum

J86

Pyothorax

J90

Pleural effusion, NEC

J91

Pleural effusion in conditions classified elsewhere

J92

Pleural plaque

J93

Pneumothorax and air leak

J94

Other pleural conditions

J95

Intraoperative and postprocedural complications and disorders of respiratory system, NEC

J96

Respiratory failure, NEC

J98

Other respiratory disorders

J99

Respiratory disorders in diseases classified elsewhere

11. DISEASES OF THE DIGESTIVE SYSTEM

K00   

Disorders of tooth development and eruption

K01

Embedded and impacted teeth

K02

Dental caries

K03

Diseases of hard tissues of teeth

K04

Diseases of pulp and periapical tissues

K05

Gingivitis and periodontal diseases

K06

Other disorders of gingiva and edentulous alveolar ridge

K08

Other disorders of teeth and supporting structures

K09

Cysts of oral region, NEC

K11

Diseases of salivary glands

K12

Stomatitis and related lesions

K13

Other diseases of lip and oral mucosa

K14

Diseases of tongue

K20

Esophagitis

K21

Gastro-esophageal reflux disease

K22

Other diseases of esophagus

K23

Disorders of esophagus in diseases classified elsewhere

K25

Gastric ulcer

K26

Duodenal ulcer

K27

Peptic ulcer, site unspecified

K28

Gastrojejunal ulcer

K29

Gastritis and duodenitis

K30

Functional dyspepsia

K31

Other diseases of stomach and duodenum

K35

Acute appendicitis

K36

Other appendicitis

K37

Unspecified appendicitis

K38

Other diseases of appendix

K40

Inguinal hernia

K41

Femoral hernia

K42

Umbilical hernia

K43

Ventral hernia

K44

Diaphragmatic hernia

K45

Other abdominal hernia

K46

Unspecified abdominal hernia

K50

Crohn’s disease (regional enteritis)

K51

Ulcerative colitis

K52

Other and unspecified noninfective gastroenteritis and colitis

K55

Vascular disorders of intestine

K56

Paralytic ileus and intestinal obstruction without hernia

K57

Diverticular disease of intestine

K58

Irritable bowel syndrome

K59

Other functional intestinal disorders

K60

Fissure and fistula of anal and rectal regions

K61

Abscess of anal and rectal regions

K62

Other diseases of anus and rectum

K63

Other diseases of intestine

K64

Hemorrhoids and perianal venous thrombosis

K65

Peritonitis

K66

Other disorders of peritoneum

K67

Disorders of peritoneum in infectious diseases classified elsewhere

K68

Disorders of retroperitoneum

K70

Alcoholic liver disease

K71

Toxic liver disease

K72

Hepatic failure, NEC

K73

Chronic hepatitis, NEC

K74

Fibrosis and cirrhosis of liver

K75

Other inflammatory liver diseases

K76

Other diseases of liver

K77

Liver disorders in diseases classified elsewhere

K80

Cholelithiasis

K81

Cholecystitis

K82

Other diseases of gallbladder

K83

Other diseases of biliary tract

K85

Acute pancreatitis

K86

Other diseases of pancreas

K87

Disorders of gallbladder, biliary tract and pancreas in diseases classified elsewhere

K90

Intestinal malabsorption

K91

Intraoperative and postprocedural complications and disorders of digestive system, NEC

K92

Other diseases of digestive system

K94

Complications of artificial openings of the digestive system

K95

Complications of bariatric procedures

12. DISEASES OF THE SKIN AND SUBCUTANEOUS TISSUE

L00   

Staphylococcal scalded skin syndrome

L01

Impetigo

L02

Cutaneous abscess, furuncle, and carbuncle

L03

Cellulitis and acute lymphangitis

L04

Acute lymphadenitis

L05

Pilonidal cyst and sinus

L08

Other local infections of skin and subcutaneous tissue

L10

Pemphigus

L11

Other acantholytic disorders

L12

Pemphigoid

L13

Other bullous disorders

L14

Bullous disorders in diseases classified elsewhere

L20

Atopic dermatitis

L21

Seborrheic dermatitis

L22

Diaper dermatitis

L23

Allergic contact dermatitis

L24

Irritant contact dermatitis

L25

Unspecified contact dermatitis

L26

Exfoliative dermatitis

L27

Dermatitis due to substances taken internally

L28

Lichen simplex chronicus and prurigo

L29

Pruritus

L30

Other and unspecified dermatitis

L40

Psoriasis

L41

Parapsoriasis

L42

Pityriasis rosea

L43

Lichen planus

L44

Other papulosquamous disorders

L45

Papulosquamous disorders in diseases classified elsewhere

L49

Exfoliation due to erythematous conditions classified according to extent of body surface involved

L50

Urticaria

L51

Erythema multiforme

L52

Erythema nodosum

L53

Other erythematous conditions

L54

Erythema in diseases classified elsewhere

L55

Sunburn

L56

Other acute skin changes due to ultraviolet radiation

L57

Skin changes due to chronic exposure to nonionizing radiation

L58

Radiodermatitis

L59

Other disorders of skin and subcutaneous tissue related to radiation

L60

Nail disorders

L62

Nail disorders in diseases classified elsewhere

L63

Alopecia areata

L64

Androgenic alopecia

L65

Other nonscarring hair loss

L66

Cicatrical alopecia (scarring hair loss)

L67

Hair color and hair shaft abnormalities

L68

Hypertrichosis

L70

Acne

L71

Rosacea

L72

Follicular cysts of skin and subcutaneous tissue

L73

Other follicular disorders

L74

Eccrine sweat disorders

L75

Apocrine sweat disorders

L76

Intraoperative and postprocedural complications of skin and subcutaneous tissue

L80

Vitiligo

L81

Other disorders of pigmentation

L82

Seborrheic keratosis

L83

Acanthosis nigricans

L84

Corns and callosities

L85

Other epidermal thickening

L86

Keratoderma in diseases classified elsewhere

L87

Transepidermal elimination disorders

L88

Pyoderma gangrenosum

L89

Pressure ulcer

L90

Atrophic disorders of skin

L91

Hypertrophic disorders of skin

L92

Granulomatous disorders of skin and subcutaneous tissue

L93

Lupus erythematosus

L94

Other localized connective tissue disorders

L95

Vasculitis limited to skin, NEC

L97

Non-pressure chronic ulcer of lower limb, NEC

L98

Other disorders of skin and subcutaneous tissue, NEC

L99

Other disorders of skin and subcutaneous tissue in diseases classified elsewhere

13. DISEASES OF THE MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE

M00   

Pyogenic arthritis

M01

Direct infections of joint in infectious and parasitic diseases classified elsewhere

M02

Postinfective and reactive arthropathies

M05

Rheumatoid arthritis with rheumatoid factor

M06

Other rheumatoid arthritis

M07

Enteropathic arthropathies

M08

Juvenile arthritis

M10

Gout

M11

Other crystal arthropathies

M12

Other and unspecified arthropathy

M13

Other arthritis

M14

Arthropathies in other diseases classified elsewhere

M1A

Chronic gout

M15

Polyosteoarthritis

M16

Osteoarthritis of hip

M17

Osteoarthritis of knee

M18

Osteoarthritis of first carpalmetacarpal joint

M19

Other and unspecified osteoarthritis

M20

Acquired deformities of fingers and toes

M21

Other acquired deformities of limbs

M22

Disorder of patella

M23

Internal derangement of knee

M24

Other specific joint derangements

M25

Other joint disorder, NEC

M26

Dentofacial anomalies (including malocclusion)

M27

Other diseases of jaws

M30

Polyarteritis nodosa and related conditions

M31

Other necrotizing vasculopathies

M32

Systemic lupus erythematosus (SLE)

M33

Dermatopolymyositis

M34

Systemic sclerosis (scleroderma)

M35

Other systemic involvement of connective tissue

M36

Systemic disorders of connective tissue in diseases classified elsewhere

M40

Kyphosis and lordosis

M41

Scoliosis

M42

Spinal osteochondrosis

M43

Other deforming dorsopathies

M45

Ankylosing spondylitis

M46

Other inflammatory spondylopathies

M47

Spondylosis

M48

Other spondylopathies

M49

Spondylopathies in diseases classified elsewhere

M50

Cervical disc disorders

M51

Thoracic, thoracolumbar, and lumbosacral intervertebral disc disorders

M53

Other and unspecified dorsopathies, NEC

M54

Dorsalgia

M60

Myositis

M61

Calcification and ossification of muscle

M62

Other disorders of muscle

M63

Disorders of muscle in diseases classified elsewhere

M65

Synovitis and tenosynovitis

M66

Spontaneous rupture of synovium and tendon

M67

Other disorders of synovium and tendon

M70

Soft tissue disorders related to use, overuse, and pressure

M71

Other bursopathies

M72

Fibroblastic disorders

M75

Shoulder lesions

M76

Enthesopathies, lower limb, excluding foot

M77

Other enthesopathies

M79

Other soft tissue disorders, NEC

M80

Osteoporosis with current pathological fracture

M81

Osteoporosis without current pathological fracture

M83

Adult osteomalacia

M84

Disorder of continuity of bone

M85

Other disorders of bone density and structure

M86

Osteomyelitis

M87

Osteonecrosis

M88

Osteitis deformans (Paget’s disease of bone)

M89

Other disorders of bone

M90

Osteopathies in diseases classified elsewhere

M91

Juvenile osteochondrosis of hip and pelvis

M92

Other juvenile osteochondrosis

M93

Other osteochondropathies

M94

Other disorders of cartilage

M95

Other acquired deformities of musculoskeletal system and connective tissue

M96

Intraoperative and postprocedural complications and disorders of musculoskeletal system, NEC

M99

Biomechanical lesions, NEC

14. DISEASES OF THE GENITOURINARY SYSTEM

N00   

Acute nephritic syndrome

N01

Rapidly progressive nephritic syndrome

N02

Recurrent and persistent hematuria

N03

Chronic nephritic syndrome

N04

Nephrotic syndrome

N05

Unspecified nephritic syndrome

N06

Isolated proteinuria with specified morphological lesion

N07

Hereditary nephropathy, NEC

N08

Glomerular disorders in diseases classified elsewhere

N10

Acute tubulo-interstitial nephritis

N11

Chronic tubulo-interstitial nephritis

N12

Tubulo-interstitial nephritis, not specified as acute or chronic

N13

Obstructive and reflux uropathy

N14

Drug- and heavy-metal-induced tubulo-interstitial and tubular conditions

N15

Other renal tubulo-interstitial diseases

N16

Renal tubulo-interstitial disorders in diseases classified elsewhere

N17

Acute renal failure

N18

Chronic kidney disease (CKD)

N19

Unspecified renal failure

N20

Calculus of kidney and ureter

N21

Calculus of lower urinary tract

N22

Calculus of urinary tract in diseases classified elsewhere

N23

Unspecified renal colic

N25

Disorders resulting from impaired renal tubular function

N26

Unspecified contracted kidney

N27

Small kidney of unknown cause

N28

Other disorders of kidney and ureter, NEC

N29

Other disorders of kidney and ureter in diseases classified elsewhere

N30

Cystitis

N31

Neuromuscular dysfunction of bladder, NEC

N32

Other disorders of bladder

N33

Bladder disorders in diseases classified elsewhere

N34

Urethritis and urethral syndrome

N35

Urethral stricture

N36

Other disorders of urethra

N37

Urethral disorders in diseases classified elsewhere

N39

Other disorders of urinary system

N40

Enlarged prostate

N41

Inflammatory diseases of prostate

N42

Other and unspecified disorders of prostate

N43

Hydrocele and spermatocele

N44

Noninflammatory disorders of testis

N45

Orchitis and epididymitis

N46

Male infertility

N47

Disorders of prepuce

N48

Other disorders of penis

N49

Inflammatory disorders of male genital organs, NEC

N50

Other and unspecified disorders of male genital organs

N51

Disorders of male genital organs in diseases classified elsewhere

N52

Male erectile dysfunction

N53

Other male sexual dysfunction

N60

Benign mammary dysplasias

N61

Inflammatory disorders of breast

N62

Hypertrophy of breast

N63

Unspecified lump in breast

N64

Other disorders of breast

N65

Deformity and disproportion of reconstructed breast

N70

Salpingitis and oophoritis

N71

Inflammatory diseases of uterus, except cervix

N72

Inflammatory disease of cervix uteri

N73

Other female pelvic inflammatory disease

N74

Female pelvic inflammatory disorders in diseases classified elsewhere

N75

Diseases of Bartholin’s gland

N76

Other inflammation of vagina and vulva

N77

Vulvo vaginal ulceration and inflammation in diseases classified elsewhere

N80

Endometriosis

N81

Female genital prolapse

N82

Fistulae involving female genital tract

N83

Noninflammatory disorders of ovary, fallopian tube, and broad ligament

N84

Polyp of female genital tract

N85

Other noninflammatory disorders of uterus, except cervix

N86

Erosion and ectropion of cervix uteri

N87

Dysplasia of cervix uteri

N88

Other noninflammatory disorders of cervix uteri

N89

Other noninflammatory disorders of vagina

N90

Other noninflammatory disorders of vulva and perineum

N91

Absent, scanty, and rare menstruation

N92

Excessive, frequent, and irregular menstruation

N93

Other abnormal uterine and vaginal bleeding

N94

Pain and other conditions associated with female genital organs and menstrual cycle

N95

Menopausal and perimenopausal disorders

N96

Recurrent pregnancy loss

N97

Female infertility

N98

Complications associated with artificial fertilization

N99

Intraoperative and postprocedural complications and disorders of genitourinary system, NEC

15. PREGNANCY, CHILDBIRTH, AND THE PUERPERIUM

O00   

Ectopic pregnancy

O01

Hydatidiform mole

O02

Other abnormal product of conception

O03

Spontaneous abortion

O04

Complications following (induced) termination of pregnancy

O07

Failed attempted termination of pregnancy

O08

Complications following ectopic and molar pregnancy

O09

Supervision of high-risk pregnancy

O10

Pre-existing hypertension complicating pregnancy, childbirth, and the puerperium

O11

Pre-existing hypertensive disorder with superimposed proteinuria

O12

Gestational (pregnancy-induced) edema and proteinuria without hypertension

O13

Gestational (pregnancy-induced) hypertension without significant proteinuria

O14

Pre-eclampsia

O15

Eclampsia

O16

Unspecified maternal hypertension

O20

Hemorrhage in early pregnancy

O21

Excessive vomiting in pregnancy

O22

Venous complications in pregnancy

O23

Infections of genitourinary tract in pregnancy

O24

Diabetes mellitus in pregnancy, childbirth, and the puerperium

O25

Malnutrition in pregnancy, childbirth, and the puerperium

O26

Maternal care for other conditions predominantly related to pregnancy

O28

Abnormal findings on antenatal screening of mother

O29

Complications of anesthesia during pregnancy

O30

Multiple gestation

O31

Complications specific to multiple gestation

O32

Maternal care for malpresentation of fetus

O33

Maternal care for disproportion

O34

Maternal care for abnormality of pelvic organs

O35

Maternal care for known or suspected fetal abnormality and damage

O36

Maternal care for other fetal problems

O40

Polyhydramnios

O41

Other disorders of amniotic fluid and membranes

O42

Premature rupture of membranes

O43

Placental disorders

O44

Placenta previa

O45

Premature separation of placenta (abruptio placentae)

O46

Antepartum hemorrhage, NEC

O47

False labor

O48

Late pregnancy

O60

Preterm labor

O61

Failed induction of labor

O62

Abnormalities of forces of labor

O63

Long labor

O64

Obstructed labor due to malposition and malpresentation of fetus

O65

Obstructed labor due to maternal pelvic abnormality

O66

Other obstructed labor

O67

Labor and delivery complicated by intrapartum hemorrhage, NEC

O68

Labor and delivery complicated by abnormality of fetal acid-base balance

O69

Labor and delivery complicated by umbilical cord complications

O70

Perineal laceration during delivery

O71

Other obstetric trauma

O72

Postpartum hemorrhage

O73

Retained placenta and membranes, without hemorrhage

O74

Complications of anesthesia during labor and delivery

O75

Other complications of labor and delivery, NEC

O76

Abnormality in fetal heart rate and rhythm complicating labor and delivery

O77

Other fetal stress complicating labor and delivery

O80

Encounter for full-term uncomplicated delivery

O82

Encounter for cesarean delivery without indication

O85

Puerperal sepsis

O86

Other puerperal infections

O87

Venous complications in the puerperium

O88

Obstetric embolism

O89

Complications of anesthesia during the puerperium

O90

Complications of the puerperium, NEC

O91

Infections of the breast associated with pregnancy, the puerperium, and lactation

O92

Other disorders of the breast and disorders of lactation associated with pregnancy and the puerperium

O94

Sequelae of complication of pregnancy, childbirth, and the puerperium

O98

Maternal infectious and parasitic diseases classifiable elsewhere but complicating pregnancy, childbirth, and the puerperium

O99

Other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth, and the puerperium

O9A

Maternal malignant neoplasms, traumatic injuries, and abuse classifiable elsewhere but complicating pregnancy, childbirth, and the puerperium

16. CERTAIN CONDITIONS ORIGINATING IN THE PERINATAL PERIOD

P00   

Newborn (suspected to be) affected by maternal conditions which may be unrelated to present pregnancy

P01

Newborn (suspected to be) affected by maternal complications of pregnancy

P02

Newborn (suspected to be) affected by complications of placenta, cord, and membranes

P03

Newborn (suspected to be) affected by other complications of labor and delivery

P04

Newborn (suspected to be) affected by noxious substances transmitted via placenta or breastmilk

P05

Disorder of newborn related to slow fetal growth and fetal malnutrition

P07

Disorders of newborn related to short gestation and low birthweight, NEC

P08

Disorders of newborn related to long gestation and high birthweight

P09

Abnormal findings on neonatal screening

P10

Intracranial laceration and hemorrhage due to birth injury

P11

Other birth injuries to central nervous system

P12

Birth injury to scalp

P13

Birth injury to skeleton

P14

Birth injury to peripheral nervous system

P15

Other birth injuries

P19

Metabolic academia in newborn

P22

Respiratory distress of newborn

P23

Congenital pneumonia

P24

Neonatal aspiration

P25

Interstitial emphysema and related conditions originating in the perinatal period

P26

Pulmonary hemorrhage originating in the perinatal period

P27

Chronic respiratory disease originating in the perinatal period

P28

Other respiratory conditions originating in the perinatal period

P29

Cardiovascular disorders originating in the perinatal period

P35

Congenital viral diseases

P36

Bacterial sepsis of newborn

P37

Other congenital infectious and parasitic diseases

P38

Omphalitis of newborn

P39

Other infections specific to the perinatal period

P50

Newborn affected by intrauterine (fetal) blood loss

P51

Umbilical hemorrhage of newborn

P52

Intracranial nontraumatic hemorrhage of newborn

P53

Hemorrhagic disease of newborn

P54

Other neonatal hemorrhage

P55

Hemolytic disease of newborn

P56

Hydrops fetalis due to hemolytic disease

P57

Kernicterus

P58

Neonatal jaundice due to other excessive hemolysis

P59

Neonatal jaundice from other and unspecified causes

P60

Disseminated intravascular coagulation of newborn

P61

Other perinatal hematological disorders

P70

Transitory disorders of carbohydrate metabolism specific to newborn

P71

Transitory neonatal disorders of calcium and magnesium metabolism

P72

Other transitory neonatal endocrine disorders

P74

Other transitory neonatal electrolyte and metabolic disturbances

P76

Other intestinal obstruction of newborn

P77

Necrotizing enterocolitis of newborn

P78

Other perinatal digestive system disorders

P80

Hypothermia of newborn

P81

Other disturbances of temperature regulation of newborn

P83

Other conditions of integument specific to newborns

P84

Other problems with newborn

P90

Convulsions of newborn

P91

Other disturbances of cerebral status of newborn

P92

Feeding problems of newborn

P93

Reactions and intoxications due to drugs administered to newborn

P94

Disorders of muscle tone of newborn

P95

Stillbirth

P96

Other conditions originating in the perinatal period

17. CONGENITAL MALFORMATIONS, DEFORMATIONS, AND CHROMOSOMAL ANOMALIES

Q00   

Anencephalus and similar anomalies

Q01

Encephalocele

Q02

Microcephaly

Q03

Congenital hydrocephalus

Q04

Other congenital malformations of brain

Q05

Spina bifida

Q06

Other congenital malformations of spinal cord

Q07

Other congenital anomalies of nervous system

Q10

Congenital anomalies of eyelid, lacrimal apparatus, and orbit

Q11

Anophthalmos, microphthalmos, and macrophthalmos

Q12

Congenital lens malformations

Q13

Congenital malformations of anterior segment of eye

Q14

Congenital malformations of posterior segment of eye

Q15

Other congenital malformations of eye

Q16

Congenital malformations of ear causing impairment of hearing

Q17

Other congenital malformations of ear

Q18

Other congenital malformations of face and neck

Q20

Congenital malformations of cardiac chambers and connections

Q21

Congenital malformations of cardiac septa

Q22

Congenital malformations of pulmonary and tricuspid valves

Q23

Congenital malformations of aortic and mitral valves

Q24

Other congenital anomalies of heart

Q25

Congenital malformations of great arteries

Q26

Congenital malformations of great veins

Q27

Other congenital malformations of peripheral vascular system

Q28

Other congenital anomalies of circulatory system

Q30

Congenital malformation of nose

Q31

Congenital malformation of larynx

Q32

Congenital malformation of trachea and bronchus

Q33

Congenital malformations of lung

Q34

Other congenital malformations of respiratory system

Q35

Cleft palate

Q36

Cleft lip

Q37

Cleft palate with cleft lip

Q38

Other congenital malformations of tongue, mouth and pharynx

Q39

Congenital malformation of esophagus

Q40

Other congenital malformations of upper alimentary tract

Q41

Congenital absence, atresia, and stenosis of small intestine

Q42

Congenital absence, atresia, and stenosis of large intestine

Q43

Other congenital malformations of intestine

Q44

Congenital malformations of gallbladder, bile ducts, and liver

Q45

Other congenital malformations of digestive system

Q50

Congenital malformations of ovaries, fallopian tubes, and broad ligaments

Q51

Congenital malformations of uterus and cervix

Q52

Other congenital malformations of female genitalia

Q53

Undescended and ectopic testicle

Q54

Hypospadias

Q55

Other congenital malformations of male genital organs

Q56

Indeterminate sex and pseudohermaphroditism

Q60

Renal agenesis and other reduction defects of kidney

Q61

Cystic kidney disease

Q62

Congenital obstructive defects of renal pelvis and congenital malformations of ureter

Q63

Other congenital malformations of kidney

Q64

Other congenital malformations of urinary system

Q65

Congenital deformities of hip

Q66

Congenital deformities of feet

Q67

Congenital musculoskeletal deformities of head, face, spine, and chest

Q68

Other congenital musculoskeletal deformities

Q69

Polydactyly

Q70

Syndactyly

Q71

Reduction defects of upper limb

Q72

Reduction defects of lower limb

Q73

Reduction defects of unspecified limb

Q74

Other congenital malformations of limbs

Q75

Other congenital malformations of skull and face bones

Q76

Congenital malformations of spine and bony thorax

Q77

Osteochondrodysplasia with defects of growth of tubular bones and spine

Q78

Other osteochondrodysplasias

Q79

Congenital malformations of musculoskeletal system, NEC

Q80

Congenital ichthyosis

Q81

Epidermolysis bullosa

Q82

Other congenital malformations of skin

Q83

Congenital malformations of breast

Q84

Other congenital malformations of integument

Q85

Phakomatoses, NEC

Q86

Congenital malformation syndromes due to known exogenous causes, NEC

Q87

Other specified congenital malformation syndromes affecting multiple systems

Q89

Other congenital malformations, NEC

Q90

Down syndrome

Q91

Trisomy 18 and trisomy 13

Q92

Other trisomies and partial trisomies of the autosomes, NEC

Q93

Monosomies and deletions from the autosomes, NEC

Q95

Balanced rearrangements and structural markers, NEC

Q96

Turner’s syndrome

Q97

Other sex chromosome abnormalities, female phenotype, NEC

Q98

Other sex chromosome abnormalities, male phenotype, NEC

Q99

Other chromosome abnormalities, NEC

18. SYMPTOMS, SIGNS, AND ABNORMAL CLINICAL AND LABORATORY FINDINGS, NEC

R00   

Abnormalities of heart beat

R01

Cardiac murmurs and other cardiac sounds

R02

Abnormal blood pressure reading, without diagnosis

R04

Hemorrhage from respiratory passages

R05

Cough

R06

Abnormalities of breathing

R07

Pain in throat and chest

R09

Other symptoms and signs involving the circulatory and respiratory systems

R10

Abdominal and pelvic pain

R11

Nausea and vomiting

R12

Heartburn

R13

Aphagia and dysphagia

R14

Flatulence and related conditions

R15

Fecal incontinence

R16

Hepatomegaly and splenomegaly, NEC

R17

Unspecified jaundice

R18

Ascites

R19

Other symptoms and signs involving the digestive system and abdomen

R20

Disturbance of skin sensation

R21

Rash and other nonspecific skin eruption

R22

Localized swelling, mass, and lump of skin and subcutaneous tissue

R23

Other skin changes

R25

Abnormal involuntary movements

R26

Abnormalities of gait and mobility

R27

Other lack of coordination

R29

Other symptoms and signs involving the nervous and musculoskeletal systems

R30

Pain associated with micturition

R31

Hematuria

R32

Unspecified urinary incontinence

R33

Retention of urine

R34

Anuria and oliguria

R35

Polyuria

R36

Urethral discharge

R37

Sexual dysfunction, unspecified

R39

Other and unspecified symptoms and signs involving the genitourinary system

R40

Somnolence, stupor and coma

R41

Other symptoms and signs involving cognitive functions and awareness

R42

Dizziness and giddiness

R43

Disturbance of smell and taste

R44

Other symptoms and signs involving general sensations and perceptions

R45

Symptoms and signs involving emotional state

R46

Symptoms and signs involving appearance and behavior

R47

Speech disturbances, NEC

R48

Dyslexia and other symbolic dysfunctions, NEC

R49

Voice disturbances

R50

Fever of other and unknown origin

R51

Headache

R52

Pain, unspecified

R53

Malaise and fatigue

R54

Age-related physical debility

R55

Syncope and collapse

R56

Convulsions, NEC

R57

Shock, NEC

R58

Hemorrhage, NEC

R59

Enlarged lymph nodes

R60

Edema, NEC

R61

Generalized hyperhidrosis

R62

Lack of expected normal physiological development in childhood and adults

R63

Symptoms and signs concerning food and fluid intake

R64

Cachexia

R65

Symptoms and signs specifically associated with systemic inflammation and infection

R66

Other general symptoms and signs

R69

Illness, not otherwise specified

R70

Elevated erythrocyte sedimentation rate and abnormality of plasma viscosity

R71

Abnormality of red blood cells

R73

Elevated blood glucose level

R74

Abnormal serum enzyme levels

R75

Inconclusive laboratory evidence of human immunodeficiency virus (HIV)

R76

Other abnormal immunological findings in serum

R77

Other abnormalities of plasma proteins

R78

Findings of drugs and other substances, not normally found in blood

R79

Other abnormal findings of blood chemistry

R80

Proteinuria

R81

Glycosuria

R82

Other and unspecified abnormal findings in urine

R83

Abnormal findings in cerebrospinal fluid

R84

Abnormal findings in specimens from respiratory organs and thorax

R85

Abnormal findings in specimens from digestive organs and abdominal cavity

R86

Abnormal findings in specimens from male genital organs

R87

Abnormal findings in specimens from female genital organs

R88

Abnormal findings in other body fluids and substances

R89

Abnormal findings in specimens from other organs, systems, and tissues

R90

Abnormal findings on diagnostic imaging of central nervous system

R91

Abnormal findings on diagnostic imaging of lung

R92

Abnormal findings on diagnostic imaging of breast

R93

Abnormal findings on diagnostic imaging of other body structures

R94

Abnormal results of function studies

R97

Abnormal tumor markers

R99

Ill-defined and unknown cause of mortality

19. INJURY, POISONING, AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES

S00   

Superficial injury of head

S01

Open wound of head

S02

Fracture of skull and facial bones

S03

Dislocation and sprain of joints and ligaments of head

S04

Injury of cranial nerve

S05

Injury of eye and orbit

S06

Intracranial injury

S07

Crushing injury of head

S08

Avulsion and traumatic amputation of part of head

S09

Other and unspecified injuries of head

S10

Superficial injury of neck

S11

Open wound of neck

S12

Fracture of cervical vertebrae and other parts of neck

S13

Dislocation and sprain of joints and ligaments at neck level

S14

Injury of nerves and spinal cord at neck level

S15

Injury of blood vessels at neck level

S16

Injury of muscle, fascia, and tendon at neck level

S17

Crushing injury of neck

S19

Other and unspecified injuries of neck

S20

Superficial injury of thorax

S21

Open wound of thorax

S22

Fracture of ribs, sternum, and thoracic spine

S23

Dislocation and sprain of joints and ligaments of thorax

S24

Injury of nerves and spinal cord at thorax level

S25

Injury of blood vessels of thorax

S26

Injury of heart

S27

Injury of other and unspecified intrathoracic organs

S28

Crushing injury of thorax, and traumatic amputation of part of thorax

S29

Other and unspecified injuries of thorax

S30

Superficial injury of abdomen, lower back, pelvis, and external genitals

S31

Open wound of abdomen, lower back, pelvis, and external genitals

S32

Fracture of lumbar spine and pelvis

S33

Dislocation and sprain of joints and ligaments of lumbar spine and pelvis

S34

Injury of lumbar and sacral spinal cord and nerves at abdomen, lower back, and pelvis level

S35

Injury of blood vessel at abdomen, lower back, and pelvis level

S36

Injury of intra-abdominal organs

S37

Injury of urinary and pelvic organs

S38

Crushing injury and traumatic amputation of abdomen, lower back, pelvis, and external genitalia

S39

Other and unspecified injuries of abdomen, lower back, pelvis, and external genitalia

S40

Superficial injury of shoulder and upper arm

S41

Open wound of shoulder and upper arm

S42

Fracture of shoulder and upper arm

S43

Dislocation and sprain of joints and ligaments of shoulder girdle

S44

Injury of nerves at shoulder and upper arm level

S45

Injury of blood vessels at shoulder and upper arm level

S46

Injury of muscle, fascia and tendon at shoulder and upper arm level

S47

Crushing injury of shoulder and upper arm

S48

Traumatic amputation of shoulder and upper arm

S49

Other and unspecified injuries of shoulder and upper arm

S50

Superficial injury of elbow and forearm

S51

Open wound of elbow and forearm

S52

Fracture of forearm

S53

Dislocation and sprain of joints and ligaments of elbow

S54

Injury of nerves at forearm level

S55

Injury of blood vessels at forearm level

S56

Injury of muscle, fascia, and tendon at forearm level

S57

Crushing injury of elbow and forearm

S58

Traumatic amputation of elbow and forearm

S59

Other and unspecified injuries of elbow and forearm

S60

Superficial injury of wrist, hand, and fingers

S61

Open wound of wrist, hand, and fingers

S62

Fracture at wrist and hand level

S63

Dislocation and sprain of joints and ligaments at wrist and hand level

S64

Injury of nerves at wrist and hand level

S65

Injury of blood vessels at wrist and hand level

S66

Injury of muscle, fascia, and tendon at wrist and hand level

S67

Crushing injury of wrist, hand, and fingers

S68

Traumatic amputation of wrist, hand, and fingers

S69

Other and unspecified injuries of wrist, hand, and fingers

S70

Superficial injury of hip and thigh

S71

Open wound of hip

S72

Fracture of femur

S73

Dislocation and sprain of joints and ligaments of hip

S74

Injury of nerves at hip and thigh level

S75

Injury of blood vessels at hip and thigh level

S76

Injury of muscle, fascia, and tendon at hip and thigh level

S77

Crushing injury of hip and thigh

S78

Traumatic amputation of hip and thigh

S79

Other and unspecified injuries of hip and thigh

S80

Superficial injury of knee and lower leg

S81

Open wound of knee and lower leg

S82

Fracture of lower leg, including ankle

S83

Dislocation and sprain of joints and ligaments of knee

S84

Injury of nerves at lower leg level

S85

Injury of blood vessels at lower leg level

S86

Injury of muscle, fascia, and tendon at lower leg level

S87

Crushing injury of lower leg

S88

Traumatic amputation of lower leg

S89

Other and unspecified injuries of lower leg

S90

Superficial injury of ankle, foot, and toes

S91

Open wound of ankle, foot, and toes

S92

Fracture of foot and toe, except ankle

S93

Dislocation and sprain of joints and ligaments at ankle, foot, and toe level

S94

Injury of nerves at ankle and foot level

S95

Injury of blood vessels at ankle and foot level

S96

Injury of muscle and tendon at ankle and foot level

S97

Crushing injury of ankle and foot

S98

Traumatic amputation of ankle and foot

S99

Other and unspecified injuries of ankle and foot

T07

Unspecified multiple injuries

T14

Injury of unspecified body region

T15

Foreign body on external eye

T16

Foreign body in ear

T17

Foreign body in respiratory tract

T18

Foreign body in alimentary tract

T19

Foreign body in genitourinary tract

T20

Burn and corrosion of head, face, and neck

T21

Burn and corrosion of trunk

T22

Burn and corrosion of shoulder and upper limb, except wrist and hand

T23

Burn and corrosion of wrist and hand

T24

Burn and corrosion of lower limb, except ankle and foot

T25

Burn and corrosion of ankle and foot

T26

Burn and corrosion confined to eye and adnexa

T27

Burn and corrosion of respiratory tract

T28

Burn and corrosion of other internal organs

T30

Burn and corrosion, body region unspecified

T31

Burns classified according to extent of body surface involved

T32

Corrosions classified according to extent of body surface involved

T33

Superficial frostbite

T34

Frostbite with tissue necrosis

T36

Poisoning by, adverse effect of, and underdosing of systemic antibiotics

T37

Poisoning by, adverse effect of, and underdosing of other systemic anti-infectives and antiparasitics

T38

Poisoning by, adverse effect of, and underdosing of hormones and their synthetic substitutes and antagonists, NEC

T39

Poisoning by, adverse effect of, and underdosing of nonopioid analgesics, antipyretics, and antirheumatics

T40

Poisoning by, adverse effect of, and underdosing of narcotics and psychodysleptics (hallucinogens)

T41

Poisoning by, adverse effect of, and underdosing of anesthetics and therapeutic gases

T42

Poisoning by, adverse effect of, and underdosing of antiepileptic, sedative-hypnotic, and antiparkinsonism drugs

T43

Poisoning by, adverse effect of, and underdosing of psychotropic drugs, NEC

T44

Poisoning by, adverse effect of, and underdosing of drugs primarily affecting the autonomic nervous system

T45

Poisoning by, adverse effect of, and underdosing of primarily system and hematologic agents, NEC

T46

Poisoning by, adverse effect of, and underdosing of agents primarily affecting the cardiovascular system

T47

Poisoning by, adverse effect of, and underdosing of agents primarily affecting the gastrointestinal system

T48

Poisoning by, adverse effect of, and underdosing of agents primarily acting on smooth and skeletal muscles and the respiratory system

T49

Poisoning by, adverse effect of, and underdosing of agents primarily affecting skin and mucous membrane and by ophthalmological, otorhinolaryngological, and dental drugs

T50

Poisoning by, adverse effect of, and underdosing of diuretics and other and unspecified drugs, medicaments, and biological substances

T51

Toxic effect of alcohol

T52

Toxic effect of organic solvents

T53

Toxic effect of halogen derivatives of aliphatic and aromatic hydrocarbons

T54

Toxic effect of corrosive substances

T55

Toxic effect of soaps and detergents

T56

Toxic effect of metals

T57

Toxic effect of other inorganic substances

T58

Toxic effect of carbon monoxide

T59

Toxic effect of other gases, fumes, and vapors

T60

Toxic effect of pesticides

T61

Toxic effect of noxious substances eaten as seafood

T62

Toxic effect of other noxious substances eaten as food

T63

Toxic effect of contact with venomous animals and plants

T64

Toxic effect of aflatoxin and other mycotoxin food

T65

Toxic effect of other and unspecified substances

T66

Radiation sickness, unspecified

T67

Effects of heat and light

T68

Hypothermia

T69

Other effects of reduced temperature

T70

Effects of air pressure and water pressure

T71

Asphyxiation

T73

Effects of other deprivation

T74

Adult and child abuse, neglect, and other maltreatment, confirmed

T75

Other and unspecified effects of other external causes

T76

Adult and child abuse, neglect, and other maltreatment, suspected

T78

Adverse effects, NEC

T79

Certain early complications of trauma, NEC

T80

Complications following infusion, transfusion, and therapeutic injection

T81

Complications of procedures, NEC

T82

Complications of cardiac and vascular prosthetic devices, implants, and grafts

T83

Complications of genitourinary prosthetic devices, implants, and grafts

 

 

T84

Complications of internal orthopedic prosthetic devices, implants, and grafts

T85

Complications of other internal prosthetic devices, implants, and grafts

T86

Complications of transplanted organs and tissue

T87

Complications peculiar to reattachment and amputation

T88

Other complications of surgical and medical care, NEC

20. EXTERNAL CAUSES OF MORBIDITY

External cause codes are intended to provide data for injury research and evaluation of injury prevention strategies. These codes capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred the activity of the patient at the time of the event, and the person’s status (e.g., civilian, military). There is no national mandatory requirement regarding use of these codes. State regulations or internal facility policies may require them. The groups of threecharacter codes are as follows:

V00–V09   

Pedestrian injured in transport accident

V10–V19

Pedal cycle rider injured in transport accident

V20–V29

Motorcycle rider injured in transport accident

V30–V39

Occupant of three-wheeled motor vehicle injured in transport accident

V40–V49

Car occupant injured in transport accident

V50–V59

Occupant of pick-up truck or van injured in transport accident

V60–V69

Occupant of heavy transport vehicle injured in transport accident

V70–V79

Bus occupant injured in transport accident

V80–V89

Other land transport accidents

V90–V94

Water transport accidents

V95–V97

Air and space transport accidents

V98–V99

Other and unspecified transport accidents

W00–W19

Slipping, tripping, stumbling, and falls

W20–W49

Exposure to inanimate mechanical forces

W50–W64

Exposure to animate mechanical forces

W65–W74

Accidental nontransport drowning and submersion

W85–W99

Exposure to electric current, radiation, and extreme ambient air temperature and pressure

X00–X19

Contact with heat and hot substances

X30–X39

Exposure to forces of nature

X52–X58

Accidental exposure to other specified factors

21. SUPPLEMENTARY CLASSIFICATION OF FACTORS INFLUENCING HEALTH STATUS AND CONTACT WITH HEALTH SERVICES

Z01   

Encounter for general examination without complaint, suspected or reported diagnosis

Z02

Encounter for administrative examinations

Z03

Encounter for medical observation for suspected diseases and conditions ruled out

Z04

Encounter for examination and observation for other reasons

Z08

Encounter for follow-up examination after completed treatment for malignant neoplasm

Z09

Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm

Z11

Encounter for screening for infectious and parasitic diseases

Z12

Encounter for screening for malignant neoplasms

Z13

Encounter for screening for other diseases and disorders

Z14

Genetic carrier

Z15

Genetic susceptibility to disease

Z16

Resistance to antimicrobial drugs

Z17

Estrogen receptor status

Z18

Retained foreign body fragments

Z20

Contact with or exposure to communicable diseases

Z22

Carrier of infectious diseases

Z23

Encounter for immunization

Z28

Immunization not carried out and underimmunized status

Z30

Encounter for contraceptive management

Z31

Encounter for procreative management

Z32

Encounter for pregnancy test and childbirth and childcare instruction

Z33

Pregnant state

Z34

Encounter for supervision of normal pregnancy

Z36

Encounter for antenatal screening of mother

Z37

Outcome of delivery

Z38

Liveborn infants according to place of birth and type of delivery

Z39

Encounter for maternal postpartum care and examination

Z40

Encounter for prophylactic surgery

Z41

Encounter for procedures for purposes other than remedying health state

Z42

Encounter for attention to artificial openings

Z44

Encounter for fitting and adjustment of external prosthetic device

Z45

Encounter for adjustment and management of implanted device

Z46

Encounter for fitting and adjustment of other devices

Z47

Orthopedic aftercare

Z48

Encounter for postprocedural aftercare

Z49

Encounter for care involving renal dialysis

Z51

Encounter for other aftercare

Z52

Donors of organs and tissues

Z53

Persons encountering health services for specific procedures and treatment, not carried out

Z55

Problems related to education and literacy

Z56

Problems related to employment and unemployment

Z57

Occupational exposure to risk factors

Z59

Problems related to housing and economic circumstances

Z60

Problems related to social environment

Z62

Problems related to upbringing

Z63

Other problems related to primary support group, including family circumstances

Z64

Problems related to certain psychosocial circumstances

Z65

Problems related to other psychosocial circumstances

Z66

Do not resuscitate

Z67

Blood type

Z68

Body mass index

Z69

Encounter for mental health services for victims and perpetrator of abuse

Z70

Counseling related to sexual attitude, behavior, and orientation

Z71

Person encountering health services for other counseling and medical advice, NEC

Z72

Problems related to lifestyle

Z73

Problems related to life management difficulty

Z74

Problems related to care provider dependency

Z75

Problems related to medical facilities and other health care

Z76

Persons encountering health services in other circumstances

Z77

Other contact with and (suspected) exposures hazardous to health

Z78

Other specified health status

Z79

Long-term (current) drug therapy

Z80

Family history of primary malignant neoplasm

Z81

Family history of mental and behavioral disorders

Z82

Family history of certain disabilities and chronic diseases (leading to disablement)

Z83

Family history of other specific disorders

Z84

Family history of other conditions

Z85

Personal history of malignant neoplasms

Z86

Personal history of certain other diseases

Z87

Personal history of other diseases and conditions

Z88

Allergy status to drugs, medicaments, and biological substances

Z89

Acquired absence of limb

Z90

Acquired absence of organs, NEC

Z91

Personal risk factors, NEC

Z92

Personal history of medical treatment

Z93

Artificial opening status

Z94

Transplanted organ and tissue status

Z95

Presence of cardiac and vascular implants and grafts

Z96

Presence of other functional implants

Z97

Presence of other devices

Z98

Other postprocedural states

Z99

Dependence on enabling machines and devices, NEC

APPENDIX B

General Equivalence Mapping (GEM) Files

The vast differences between ICD-9-CM and ICD-10-CM/PCS pose major challenges for many players in the healthcare arena. Providers and payers have to change their billing and claims processing systems. Researchers, public health administrators, actuaries, and others who rely on historical coded data have to be able to convert data from one system to the other. A need was also identified for a temporary “fix” that could be used in the transition period leading up to October 1, 2015, to run parallel databases and identify potential adverse effects of the change to ICD-10-CM/PCS. To address these issues, over a period of 3 years the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) developed the General Equivalence Mapping (GEM) files.

The GEMs include “forward mapping” from ICD-9-CM to ICD-10-CM diagnosis codes and from ICD-9-CM procedure codes to ICD-10-PCS procedure codes. They also include “backward mappings” in the other direction. The mappings attempt to find corresponding diagnosis codes between the two code sets, insofar as this is possible. Due to the greatly increased level of detail in ICD-10-CM and ICD-10-PCS, in many cases an exact match is not possible. The mappings include all reasonably equivalent codes and use indicators to note how close the match is.

The degree of matching is also affected by structural changes in ICD-10-CM. An example is the classification method in the chapter on pregnancy, childbirth, and the puerperium. In ICD-9-CM, the classification for most codes is broken down into the current episode of care: delivered, antepartum, postpartum, or unspecified. In ICD-10-CM, the last character in the code represents the trimester of pregnancy: first, second, third, or unspecified. Because the information needed for mapping is not even available, the degree of matching is much lower. A few coding concepts in ICD-10-CM, such as blood alcohol level and underdosing, do not exist in ICD-9-CM, so there is no match for those in the GEMs. Some CM chapters, such as those on neoplasms, infectious diseases, and the eye, contain a higher level of matches because the classification system is more similar between the two code sets.

A single entry in a GEM file is one in which a code in the original system is linked to one or more single codes in the target system. An example from the ICD-9-CM to ICD-10-CM GEM is the following:

ICD-9-CM

599.72

Microscopic hematuria has a valid link to

ICD-10-CM

R31.1

Benign essential microscopic hematuria, or also a valid link to

ICD-10-CM

R31.2

Other microscopic hematuria

Another scenario where matching may be complicated is with combination codes, where a single code represents more than one condition or a condition and an external cause. If there is no combination code in the other code set, or if a combination code in the other code set contains different elements, the mapping will be inexact.

A combination entry in a GEM file is one in which a code in the original system must be linked to more than one code in the target system in order to be a valid mapping. An example from the ICD-10-CM to ICD-9-CM GEM is the following:

ICD-10-CM

R65.21

Severe sepsis with septic shock must link to

ICD-9-CM

995.92

Severe sepsis and

ICD-9-CM

785.52

Septic shock

The following tables show the occurrence of translation alternatives in each GEM file (American Health Information Management Association, 2013).

Forward Mapping

img

Source:  Data from Practice Brief: Putting the ICD-10-CM/PCS GEMs into Practice. May 2013. American Health Information Management Association. Available at  http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050190.hcsp?dDocName=bok1_050190 .

Backward Mapping

img

Source:  Data from Practice Brief: Putting the ICD-10-CM/PCS GEMs into Practice. May 2013. American Health Information Management Association. Available at  http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050190.hcsp?dDocName=bok1_050190 .

The GEMs were developed to serve as an authoritative source for cross-walking between the ICD-9 and ICD-10 code sets. They are intended to serve as tools for large-scale data analysis, transition processes, and research. The GEMs are not intended to be a substitute for learning ICD-10 and are not intended for use in coding individual health records. As demonstrated in the forward and backward mapping tables, many codes have more than one possible translation; using the GEMs to code without agreement on which of the choices is the best within a healthcare entity could lead to chaos and inconsistent data.

In addition to the General Equivalence Mappings, CMS has also developed Reimbursement Mappings. These were derived from the GEMs and were used in converting the DRG algorithms into ICD-10. They differ from the GEMs in that for each ICD-10 code there is only one valid translation. This valid translation may be to a single ICD-9 code or to an ICD-9 “cluster” of two to six codes. The choice of a valid single ICD-9 code was made based on the prevalence of that code in a reference data source of approximately 47 million claims from Medicare and from the state of California. If the only valid mapping for an ICD-10 code is to an ICD-9 “cluster,” then all of the codes in the cluster must be used to ensure the reimbursable components of the ICD-10 code are reproduced in the ICD-9 translation.

Note that CMS does not use the GEMs or the Reimbursement Mappings to process claims. They work directly with the ICD-10 code sets and are converting all of their payment system rules to ICD-10.

The GEMs and the Reimbursement Mappings, with accompanying user’s guides, are in the public domain and are available at:

http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html

and

http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html .

Reference

American Health Information Management Association. (2013, May). Practice brief: Putting the ICD-10-CM/PCS GEMs into practice. Retrieved January 27, 2014, from  http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050190.hcsp?dDocName=bok1_050190

APPENDIX C

Uniform Billing Revenue Codes

How Hospitals Group Their Charges

The UB-04 CMS-1450 claim form used by hospitals to bill third-party payers necessitates the use of revenue codes to group like categories of charges. These are four-digit codes that describe all possible categories of hospital, home health, ambulance, or other facility charges. Most claims are submitted using revenue codes at the “zero” or “sum” level, which means using codes ending in zero, which are broader categories than using the full four digits for more detail. Individual payers may require fourth-digit detail for specific categories. An example of the level of detail is category 0110, room and board, private, where the fourth digit of the code is available to indicate different room types, such as 0112-OB private, 0113-peds private, 0114-psychiatric private, and others.

Accommodation Revenue Codes

0100

All inclusive rate

0110

Room and board, private

0120

Room and board, semi-private two bed

0130

Room and board, semi-private three or four beds

0140

Private, deluxe

0150

Room and board, ward, five or more beds

0160

Other room and board (sterile environment, self-care)

0170

Nursery

0180

Leave of absence

0190

Subacute care

0200

Intensive care

0210

Coronary care

Ancillary Revenue Codes

0220

Special charges

0230

Incremental nursing charge rate

0240

All inclusive ancillary (flat rate)

0250

Pharmacy

0260

IV therapy

0270

Medical/surgical supplies

0280

Oncology

0290

Durable medical equipment

0300

Laboratory

0310

Laboratory pathological

0320

Radiology diagnostic

0330

Radiology therapeutic and/or chemotherapy administration

0340

Nuclear medicine

0350

CT scans

0360

Operating room services

0370

Anesthesia

0380

Blood and blood components

0390

Administration, processing, and storage of blood and blood components

0400

Other imaging services (mammography, ultrasound)

0410

Respiratory services

0420

Physical therapy

0430

Occupational therapy

0440

Speech therapy

0450

Emergency room

0460

Pulmonary function

0470

Audiology

0480

Cardiology

0490

Ambulatory surgical care

0500

Outpatient services

0510

Clinic

0520

Free-standing clinic

0530

Osteopathic services

0540

Ambulance

0550

Skilled nursing

0560

Home health medical social services

0570

Home health aide

0580

Home health other visits

0590

Home health units of service

0600

Home health oxygen

0610

MRI or MRA (magnetic resonance imaging/angiography)

0620

Medical/surgical supplies (extension of 270)

0630

Pharmacy (extension of 250)

0640

Home IV therapy services

0650

Hospice services

0660

Respite care

0670

Outpatient special residence charges

0680

Trauma response

0700

Cast room

0710

Recovery room

0720

Labor and delivery room

0730

Electrocardiogram (EKG/ECG)

0740

Electroencephalogram (EEG)

0750

Gastro-intestinal services

0760

Specialty services (treatment or observation room)

0770

Preventive care services (administration of vaccines)

0780

Telemedicine

0790

Extracorporeal shock wave lithotripsy

0800

Inpatient renal dialysis

0810

Acquisition of body components

0820

Hemodialysis, outpatient or home

0830

Peritoneal dialysis, ourpatient or home

0840

Continuous ambulatory peritoneal dialysis, outpatient or home

0850

Continuous cycling peritoneal dialysis, outpatient

0880

Miscellaneous dialysis

0900

Behavioral health services

0910

Behavioral health services (extension of 900)

0920

Other diagnostic services

0930

Medical rehabilitation day program

0940

Other therapeutic services

0960

Professional fees

0970

Professional fees

0980

Professional fees

0990

Patient convenience items

1000

Behavioral health accommodations

2100

Alternative therapies

3100

Adult day care

Reference

Centers for Medicare & Medicaid Services. (n.d.). Medicare claims processing manual. Pub. 100-04. Chapter 25, Section 75.4. Retrieved December 31, 2013, from  http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c25.pdf

APPENDIX D

Remittance Advice Claim Adjustment Reason Codes

Tell Me Why

Claim Adjustment Reason Codes (CARCs) appear on the remittance advice received by your doctor to tell him why his claim for services he provided to you has been rejected and not paid. The rejection reason can determine whether it is appropriate for him to appeal or bill you instead. The reason codes may also appear on the “explanation of benefits” (EOB) you receive. These codes are maintained by the Washington Publishing Company and are updated three times a year. 1  The following table explains some of the most commonly used reason codes and the rejection categories they represent.

Code

Description

Category

4

Procedure code inconsistent with modifier or modifier missing

Modifiers

5

Procedure code or bill type inconsistent with place of service

Place of service

6

Procedure/revenue code inconsistent with patient’s age

Patient age

7

Procedure/revenue code inconsistent with patient’s gender

Patient gender

8

Procedure code inconsistent with provider specialty

Provider

9

Diagnosis inconsistent with patient age

Patient age

10

Diagnosis inconsistent with patient gender

Patient gender

11

Diagnosis inconsistent with procedure

Medical necessity

12

Diagnosis inconsistent with provider type

Provider

13

Date of death precedes date of service

Date of service

14

Date of birth follows date of service

Date of service

15

Payment adjusted because authorization is missing, invalid, or does not apply to service or provider

Prior authorization

16

Claim lacks information needed for adjudication *

Requested information

18

Duplicate claim

Duplicate

19

Claim denied because this is work-related injury/illness

Coverage

20

Claim denied because this injury/illness is covered by the liability carrier

Coverage

24

Charges covered under a capitation agreement

Managed care

26

Expenses incurred prior to coverage

Eligibility

27

Expenses incurred after coverage terminated

Eligibility

29

Time limit for filing has expired

Filing limit

31

Patient cannot be identified as our insured

Eligibility

35

Lifetime benefit maximum reached

Coverage

39

Service denied when preauthorization was requested

Prior authorization

40

Charges do not meet qualifications for emergent or urgent care

Medical necessity

49

Noncovered service because routine exam or screening procedure

Coverage

50

Noncovered because not deemed a medical necessity

Medical necessity

51

Noncovered because preexisting condition

Coverage

55

Procedure deemed experimental or investigational

Coverage

58

Procedure performed in an inappropriate or invalid place of service

Place of service

59

Charges adjusted based on multiple surgery or concurrent anesthesia rules

Information only

60

Outpatient services with this proximity to inpatient services are not covered

Coverage

96

Noncovered charges *

Coverage

97

Payment included in allowance for another service/procedure

Bundling

100

Payment made to patient/insured

Information only

107

Related or qualifying service not previously paid or identified on this claim

Procedure

109

Not covered by this payer; send claim to correct payer

Eligibility

110

Billing date predates service date

Date of service

114

Procedure/product not approved by the Food & Drug Administration

Coverage

115

Procedure postponed, canceled, or delayed

Information only

116

Advance notice signed by patient did not meet requirements

Medical necessity

117

Transportation only covered to the closest facility

Coverage

119

Benefit maximum reached

Coverage

122

Psychiatric reduction

Information only

133

Claim pended for further review

Information only

140

Health insurance number and name do not match

Eligibility

146

Diagnosis invalid for date of service

Diagnosis

149

Lifetime benefit reached

Coverage

150

Information submitted does not support this level of service

Medical necessity

151

Information submitted does not support this many services

Medical necessity

152

Information submitted does not support this length of service

Medical necessity

153

Information submitted does not support this dosage

Medical necessity

154

Information submitted does not support this day’s supply

Medical necessity

155

Patient refused the service

Information only

157

Service provided as a result of an act of war

Coverage

158

Service provided outside the United States

Coverage

159

Service provided as a result of terrorism

Coverage

160

Injury/illness was the result of an activity that is a benefit exclusion

Coverage

163

Attachment referenced on the claim was not received

Information only

164

Attachment referenced on the claim not received in a timely manner

Information only

167

This diagnosis not covered

Diagnosis

181

Procedure code invalid on date of service

Coding

182

Modifier invalid on date of service

Coding

184

Ordering provider not eligible to order services billed

Provider

189

Not otherwise classified or unlisted code when there is a specific code for service billed

Coding

A1

Claim denied *

 

A6

Prior hospitalization or 30-day transfer requirement not met

Coverage

A8

Ungroupable DRG

Information only

B1

Noncovered visits

Coverage

B6

Payment adjusted when performed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty

Provider

B7

Provider not certified/eligible to be paid for this service on this date of service

Provider

B8

Alternative services were available and should have been used

Medical necessity

B9

Not covered because patient is enrolled in a hospice

Coverage

B12

Services not documented in patient’s medical record

Information only

B13

Previously paid

Duplicate claim

B14

Only one visit or consultation per physician per day is covered

Coverage

B16

New patient qualification not met

Coding

B22

Payment adjusted based on the diagnosis

Diagnosis

*  For reason codes 16, 96, and A1, an additional remarks code is required to fully explain the reason for the rejection.

-------------------- 1  Available at:  http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/ . Accessed January 2, 2014.

APPENDIX E

Payment System Reference

The payment methodology for Medicare claims is often followed by other payers soon after Medicare implementation. This appendix is intended to describe the payment methodologies used by different types of facilities or providers.

Type of Provider or Facility or Service

Payment Method and Rate

Ambulance

Ambulance fee schedule

Ambulatory Surgery Center (ASC)

Prospective payment—Ambulatory Payment Classification (APCs)

Cancer Hospital

Reasonable cost

Certified Nurse Midwife (CNM)

100% of physician fee schedule if billing independently

Clinical Nurse Specialist (CNS)

85% of physician fee schedule if billing independently

Clinical Psychologist (CP) or Independently Practicing Psychologist (IPP)

100% of physician fee schedule. Limited range of services.

Certified Registered Nurse Anesthetist (CRNA) or Anesthesia Assistant (AA)

Anesthetist fee based on anesthesia base and time units

Clinical social worker (CSW)

75% of physician fee schedule

Comprehensive Outpatient Rehab Facility (CORF)

Fee schedule

Community Mental Health Center (CMHC)

Outpatient prospective payment (APC) for partial hospitalization

Critical Access Hospital (CAH)

Reasonable cost rule

Durable Medical Equipment (DME)

Fee schedule

End-Stage Renal Disease Facility (ESRD)

Composite fee schedule

Federally Qualified Health Center (FQHC)

Prospective payment

Home Health Agency (HHA)

Prospective payment—home health resource groups

Hospice

Daily rate based on level of care

Hospital Inpatient

Prospective Payment—Diagnosis Related Groups (DRG)

Hospital Outpatient

Prospective payment—Ambulatory Payment Classification (APC)

Hospital Outpatient Lab

Laboratory fee schedule

Hospital Outpatient Occupational Therapy

Fee schedule

Hospital Outpatient Physical Therapy

Fee schedule

Hospital Outpatient Speech Therapy

Fee schedule

Independent Diagnostic Testing Facility

Fee schedule

Inpatient Psychiatric

Prospective payment—IPF DRG per diem

Inpatient Rehab

Prospective payment IRF based on PAI (Patient Assessment Instrument)

Nurse Practitioners

85% of physician fee schedule if billing independently

Nursing home intermediate care

Covered by Medicaid—system varies from state to state

Nursing home skilled care (SNF)

Prospective payment—Resource Utilization Groups (RUGS)

Occupational therapy (private practice)

Fee schedule

Physical therapy (private practice)

Fee schedule

Physician assistant (PA)

85% if billing under own number with physician supervision

Physician services

Physician fee schedule or capitation for managed care

Rural health clinic (RHC)

Cost per visit rate

APPENDIX F

Useful Websites

The following websites may be useful in your search for additional information about coding, healthcare billing and reimbursement, fraud, and abuse.

Centers for Medicare and Medicaid Services (CMS)

http://www.cms.gov

This federal agency, part of the U.S. Department of Health and Human Services, is responsible for administering the Medicare and Medicaid programs. The website contains information about each program, information for professionals and consumers, and links to hundreds of other websites related to CMS programs. Because CMS is responsible for updating and maintaining ICD-10-PCS, this website is also the authoritative source for PCS guidelines and manuals.

State Health Facts

http://kff.org/statedata/

This website is operated by the Kaiser Family Foundation. It contains information about health programs in each state, along with data ranking state programs.

American Health Information Management Association (AHIMA)

http://www.ahima.org

AHIMA is the national professional organization for individuals in the health information management field. Its 71,000 members work in a variety of healthcare settings and perform a variety of functions, from coding to information department management. The website also contains information about health information management educational programs and credentials.

American Academy of Professional Coders (AAPC)

http://www.aapc.com

AAPC represents almost 129,000 individuals nationwide who are involved in the medical coding profession. The website includes information about AAPC educational programs and credentials.

National Center for Health Statistics

http://www.cdc.gov/nchs/

A wealth of information is available on this website about ICD-9-CM and ICD-10-CM, including the official coding and sequencing guidelines.

American Medical Association

http://www.ama-assn.org

As the owner of Current Procedural Terminology (CPT), the American Medical Association controls access to CPT files and data. The website includes information about how CPT is formulated, and CPT resources are available for purchase.

Medical Information Bureau

http://www.mib.com

The consumer section of the Medical Information Bureau (MIB) informs you what type of files are maintained on individuals and also provides information on how to order your file.

APPENDIX G

Uniform Hospital Discharge Data Set

The Uniform Hospital Discharge Data Set (UHDDS) originally developed and adopted in 1974 by the U.S. Department of Health, Education and Welfare, was revised in 1984 and implemented for federal health programs on January 1, 1986. Its purpose is to standardize definitions used in abstracting hospital inpatient data.

The current UHDDS consists of:

1.

Personal Identification: The unique number assigned to each patient within a hospital that distinguishes the patient and his or her hospital record from all others in that institution.

2.

Date of Birth: Month, day, and year of birth.

3.

Sex: Male or female.

4.

a. Race:

White

Black

Asian or Pacific Islander

American Indian / Eskimo / Aleut

Other

4.

b. Ethnicity:

Spanish origin / Hispanic

Non-Spanish origin / Non-Hispanic

5.

Residence:

Zip code

Code for foreign residence

6.

Hospital Identification: A unique institutional number within a data collection system.

7–8.

Admission and Discharge Dates: Month, day, and year of both admission and discharge. An inpatient admission begins with the formal acceptance by a hospital of a patient who is to receive physician, dentist, or allied services while receiving room, board, and continuous nursing services. An inpatient discharge occurs with the termination of the room, board, and continuous nursing services, and the formal release of an inpatient by the hospital.

9–10.

Physician Identification: Each physician must have a unique identification number within the hospital. The attending physician and the operating physician (if applicable) are to be identified.

Attending Physician: The clinician who is primarily and largely responsible for the care of the patient from the beginning of the hospital episode.

Operating Physician: The clinician who performed the principal procedure (see item 12).

11.

Diagnoses: All diagnoses that affect the current hospital stay.

Principal Diagnosis: The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

Other Diagnoses: All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.

12.

Procedure and Date: All significant procedures are to be reported.

A significant procedure is one that is surgical in nature, or carries a procedural risk, or carries an anesthetic risk, or requires specialized training. For significant procedures, the identity (by unique number within the hospital) of the person performing the procedure and the date must be reported.

When more than one procedure is reported, the principal procedure is to be designated. In determining which of several procedures is principal, the following criteria apply: The principal procedure is one that was performed for definitive treatment, rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication. If there appears to be two procedures that are principal, then the one most related to the principal diagnosis should be selected as the principal procedure.

Surgery includes incision, excision, amputation, introduction, endoscopy, repair, destruction, suture, and manipulation.

13.

Disposition of Patient: Discharged to home

Left against medical advice

Discharged to another short-term hospital

Discharged to a long-term care institution

Died

Other

14.

Expected Payer for Most of This Bill: The single major source that the patient expects will pay for his or her bill.

Reference

1984 Revision of the Uniform Hospital Discharge Data Set (UHDDS). (1985, July 31). Federal Register, 50(147), 31038–31040.