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The transition from I-9 to I-10 is a long journey, encompassing every department and setting. And one of the ICD-10monitor.enews contributing editors makes the best case when she writes, “Why We Love ICD-10-CM and So Will You.” Here is how Sarah A. Serling, CPC, CPC-H, CPC-I, CCS-P, CCS, ICD-10-CM/PCS Trainer for Precyse Solutions, shares her refreshing outlook:

Close your eyes and imagine a coding classification system created for coders instead of statisticians, developed with the help of people who actually use the codes!

Well, even if you can’t envision it, it will become a reality on Oct. 1, 2013 — the official launch date for ICD-10-CM. This coding system, including the ICD-10-CM Official Guidelines for Coding and Reporting, will replace the ICD-9-CM code set for diagnosis reporting.

Unlike ICD-9-CM, ICD-10-CM was created to classify morbidity data for medical records, medical care assessment, ambulatory care and other forms of medical services, as well as for basic health statistics. ICD-10-CM’s expanded scope improves the grouping of codes by disease process, which in turn gives healthcare professionals the ability to match code selection to actual care and treatment.  Thus, the codes need to be more specific than those used for statistical data in order to describe the clinical characteristics of a patient accurately.  

Although there are many differences between ICD-10-CM and ICD-9-CM, the new code set keeps the same basic format as well as many of the same conventions as the old one; therefore, it will not be completely foreign to coders already familiar with the current system. Chapters have been added, reorganized and rearranged due to advances in understanding of the science and pathophysiology of disease. For example, rather than grouping codes by injury or type of wound, ICD-10-CM groups injuries by the site and then the type. Even seemingly insignificant changes make ICD-10-CM easier to use, for example its utilization of complete subcategory code titles so coders don’t have to go back several pages to read previous descriptors just to understand what a code really means.

What coder hasn’t struggled to find the right code because there is not enough clinical specificity in available codes due to space and number constraints? The vagueness inherent in ICD-9-CM makes it difficult for coders to accurately determine appropriate assignments. ICD-10-CM not only offers coders greater specificity, but also clinical concepts and terminology that are more relevant to ambulatory care encounters, making the system more applicable in non-hospital encounters than ICD-9-CM. For example:

•    Laterality is not a code qualifier in ICD-9 even though documentation often is provided in the record. In ICD-10-CM, coders must identify conditions by “left side,” “right side” or “bilaterality” for applicable diagnoses, and if documentation in the medical record does not provide the location, a code for “unspecified” is still available.

The terminology in ICD-10-CM also is more up-to-date and consistent with current clinical practice. The new classification system includes diseases and clinical concepts that don’t exist in ICD-9-CM, such as:

•    T45.526D – Underdosing of antithrombotic drugs, subsequent encounter  
•    Y90.5 – Blood-alcohol level of 100-119 mg/100 ml

Coders frequently are forced to assign unspecified codes due to specific terminology in ICD-9-CM that is not commonly used in clinical practice. Take hypertension, for example:

•    ICD-9-CM:     401.x Essential hypertension (specify malignant, benign, unspecified )
•    ICD-10-CM:    I10 Essential (primary) hypertension (includes high blood pressure, arterial, benign, essential, malignant, primary and systemic)

Malignant and benign hypertension no longer are considered clinically significant, meaning they are not typically documented in the physician’s diagnostic statement, resulting in assignment of the unspecified code 401.9.

ICD-10-CM has modified several chapter-specific guidelines based on new knowledge about conditions and/or disorders. For example:

•    The time frame for use of acute myocardial infarction (AMI) in Chapter 9, Diseases of the Circulatory System, has been changed from eight weeks or less in ICD-9 to four weeks or less in ICD-10-CM.

•    There also has been a major change in the cutoff point for differentiating abortion from fetal death, a switch from 22 to 20 weeks in Chapter 15, Pregnancy, Childbirth and the Puerperium. Additionally in this chapter, the codes now are identified by the trimester in which the condition occurred rather than by the episode of care (delivered, antepartum, etc.) used in ICD-9.

Coding the cause of injury, the intent, and the place, activity and status at the time of occurrence in ICD-9-CM is a laborious process requiring several codes. For example, to log attempted suicide by ingestion of barbiturates in ICD-9-CM, coders need to assign multiple codes:

•    967.0 - Poisoning by barbiturates  
•    E950.1 - Suicide and self-inflicted poisoning by barbiturates  
•    Additional codes to specify the effects of the poisoning, the place of occurrence and the    activity and status of the patient at the time.

In contrast, here is an example of an ICD-10-CM combination code for poisonings and their associated external cause:

•    T42.3x2S - Poisoning by barbiturates, intentional self-harm, sequela (7th character “S”)

The multiple coding rules in ICD-9-CM are complex and confusing. While there are a few combination codes in ICD-9-CM through which a single code is used to classify two diagnoses or a diagnosis and a complication, ICD-10-CM has many more combination codes, including some for certain conditions and manifestations, and others for both diagnosis and commonly associated symptoms. This change will eliminate sequencing problems and result in fewer cases documented by more than one code. For example:

•    I25.110 - Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
•    K50.011 - Crohn’s disease of small intestine with rectal bleeding
•    K57.21 - Diverticulitis of large intestine with perforation and abscess with bleeding
•    E11.341 - Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema

Supplementary classifications of the external causes of morbidity, or E codes and V codes noting factors influencing health status, are incorporated into the ICD-10-CM classification system.  These codes and descriptions are located throughout all chapters of ICD-10-CM and no longer are designated as E codes and V codes as in ICD-9-CM.

Most of the coding conventions/rules are the same in ICD-10-CM as they were in ICD-9, but there are a few changes. One of the most significant changes is the addition of the Excludes 1 and Excludes 2 code use instructions. Excludes 1 signifies “not coded here.” The code being excluded is never used with the code in question, and the two conditions cannot occur together or be coded together. Exclude 2 signifies “not included here.” The condition being excluded is not a part of the condition represented by the code, and it is acceptable to use both codes together if the patient has both conditions.

In summary, complete, accurate and detailed documentation will be necessary for assigning appropriate ICD-10-CM codes, just as it is in ICD-9-CM. For coders, ICD-10-CM is a much-improved, more functional system of classification.

Despite the many differences between ICD-10-CM and ICD-9-CM, it will not be difficult for experienced coders to learn the new system and use it proficiently – thus the reason we love ICD-10-CM!

October 4, 2010

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