EDITOR’S NOTE: This article is the first installment in this two-part series.

ICD-10 has finally been implemented!


Thirty-six years after the implementation of ICD-9-CM, ICD-10-CM/PCS is here! From most perspectives, the ICD-10 implementation has started smoothly. There have been some reports of a few software glitches, but most of the identified issues were corrected quickly. Are there areas of concern? In some organization types, there were always ICD-9-CM questions, and those organizations continue to question under ICD-10.

The first area of concern would be the non-acute organizations including Home Health, Inpatient Rehabilitation Facilities, and Skilled Nursing Facilities. These organizations have struggled in the past with coding guidance that is applicable to their settings. Various issues of Coding Clinic (e.g., Fourth Quarter 2012, pp. 90–98; Fourth Quarter 2013, pp. 127–129) have provided some guidance for skilled nursing facilities and inpatient rehabilitation facilities. In some instances, these organizations do not have access to Coding Clinic, which creates a knowledge gap. The ICD-10-CM Official Coding and Reporting Guidelines for FY 2016 specifically say these guidelines apply to “all healthcare settings.” Sections II and III apply to non-outpatient healthcare settings.  

The principal diagnosis or first listed code has undergone quite the change with the advent of the 7th character for these providers. The concept of “initial” and “subsequent” are easily confused with the concepts of “new” and “established” that are associated with Evaluation and Management code assignment. For ICD-10-CM coding, the coder should focus on the type of treatment provided by the physician and not if the visit is the first or the fourth visit. According to the ICD-10-CM guidelines, examples of active treatment are surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician.

Active treatment occurs during the initial phase of an injury. For example, if a resident fell and sustained a cut to the right hand, which was treated at the facility, the 7th character would be reported as an initial encounter because the diagnosis and dressing of the wound occurred at the facility.

The ICD-10-CM guidelines further provide examples of subsequent treatment, such as a cast change or removal, an x-ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare, and follow-up visits following treatment of the injury or condition.

The subsequent encounter occurs after the active phase has occurred and the patient is in recovery or healing phase. For example, the patient who sustained a fall and was sent to the hospital emergency room and was diagnosed with a fracture of the left tibia, which was surgically repaired at the hospital, and transferred to inpatient rehabilitation facility for continued rehabilitation would report the injury as subsequent, as the active phase has been completed.

The recovery from strokes is very similar in ICD-9-CM and ICD-10-CM. The terminology has changed from “late effects” to “sequel.” There are combination codes that combine the stroke and continued residuals after the stroke, such as hemiparesis or aphasia. It is important to note the further specificity in ICD-10-CM, which includes the type and laterality of the stroke.

Another new concept is the guideline for dominance. If the right side is affected and dominance is not documented, the coder can assume that it is dominant. If the left side is affected and dominance is not documented, the coder can assume that it is non-dominant. This guideline change will increase the specificity of reported codes in this area.

The additional areas of angst are the tools that provide information for reimbursement for these settings. They all include diagnosis codes. Should these codes be initial or subsequent? According to the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) Training Guide, this document should include the acute or initial codes. The UB-04 (the claim form) will report the subsequent codes. The MDS 3.0, which is the reimbursement tool for skilled nursing facilities, will accept ICD-10-CM codes according to the Resident Assessment Instrument (RAI) instructions. The UB-04 requires ICD-10 codes as well.

Are there other organizations that may have some gaps as we continue the ICD-10 transition? The next article will discuss Retail Pharmacies, Medical Device companies, and Durable Medical Equipment organizations.


Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer

Laurie M. Johnson, MS, RHIA, FAHIMA is currently a senior healthcare consultant for Revenue Cycle Solutions based in Pittsburgh, Pa. Laurie is an AHIMA approved ICD-10-CM/PCS Trainer. She has more than 35 years of experience in health information management and specializes in coding and related functions. She has been a featured speaker in over 40 conferences and will be speaking at 2017 AHIMA Coding Community Meeting in Los Angeles, Ca. Laurie has been a frequent guest on Talk Ten Tuesdays.

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