Brenda Edwards, CPC

The implementation date for ICD-10 is quickly approaching.  The new code set could be thought of as an enhancement of our current ICD-9 codes.  ICD-10 will allow for a more accurate story to be told about the condition(s) for which the patient is being treated. 

Looking for more information on preparing your practice for the ICD-10 transition? Learn what to expect and how to be ready for Oct. 1 from our experts at 

, a new conference for physicians and office administrators. Join us May 2 & 3 in Newport Beach, Calif.

With nearly 70,000 codes, it will be virtually impossible to memorize codes as in the days of ICD-9.  The use of unspecified codes could be restricted by payers and the importance of proper look-up cannot be over emphasized. 

Here are three steps to ensure you select the proper ICD-10 codes:

Step 1: Find the condition in the alphabetic index.


Begin the process by looking for the main term in the alphabetic index.  After locating the term, review the sub terms to find the most specific code available.  Instructional notes in this section will help guide the reader with information such as “see,” “see also,” “with,”"without,” “due to,” and “code by site.” 

Step 2: Verify the code and identify the highest specificity.


The second step in the process is verifying the code in the tabular index.  This is the alphanumeric listing which organizes codes by disease and injury.   Additional detail is found here to create the most complete code.  For example, the default code for asthma in the alphabetic index is J45.909.  If is the reader selects this code without consulting the tabular index, an unspecified code would be reported. 

The tabular index identifies severity (intermittent, mild persistent, moderate persistent, or severe persistent) as well as complications such as an acute exacerbation or status asthmaticus.  Notes provide guidance for additional conditions which would need to be reported to identify exposure to tobacco smoke or use of tobacco. 

The tabular index also contains information identifying the length of a code; this is important since a code is anywhere from three to seven characters long.  This index includes additional information such as “Excludes 1” and “Excludes 2” status.  The exclude notes identify codes that you can never reported together (Excludes 1) and codes that you can never report at the same time (Excludes 2). 

An example of this is code J04.0 (acute laryngitis).  The information below the code has an entry for “Excludes 1” indicating it would be inappropriate to report J05.0 (acute obstructive laryngitis) since laryngitis is already included in J04.0.  An additional note is found for “Excludes 2” which instructs it could be appropriate to report J37.0 (chronic laryngitis) with J04.0 since a chronic condition and an acute exacerbation could occur at the same time.

Step 3: Review the chapter-specific coding guidelines. 


The final step in locating a code is a review of the chapter-specific coding guidelines found before the alphabetic index of the ICD-10 manual.  This index includes guidelines for specific diagnoses or conditions.  Some of the more complex diagnosis codes can be found here including HIV and sepsis. Without consulting this section, important sequencing guidelines would be missed. 

For instance, anemia sequencing varies when it is reported with neoplasm.  If you are treating a patient for anemia that is associated with a malignancy, the sequencing order is different than if you are treating a patient for anemia associated with chemotherapy, immunotherapy, and radiation therapy.   

Disruption in reimbursement could occur during the transition from ICD-9 to ICD-10.  One way to mitigate this is by ensuring the most accurate code is initially submitted.  Accomplish this by doing the three-step approach in finding the condition in the alphabetic index, verifying the code and looking for the highest specificity in the tabular index, and reviewing the chapter-specific coding guidelines for any additional guidance.

Articles

Avoid disruptions in your practice’s reimbursement by following these three steps to submit the most accurate code the first time, every time.

Three Steps to Selecting ICD-10 Codes Accurately 

As you prepare for next year’s ICD-10 implementation by studying the new codes, don’t forget to study how to use these codes.

The official guidelines for coding and reporting in the ICD-10-CM book are an invaluable resource for both physicians and coders.

The beginning of the book offers general conventions and guidelines to give overall instruction for using the book as a whole. Some of these guidelines mirror what’s written in ICD-9-CM (e.g., level of detail in coding, how to locate a code); while other guidelines are specific to the new codes (e.g., borderline diagnosis, laterality).

Chapter specific coding guidelines explain the finer points of some of the more complicated diagnoses, including anemia associated with other conditions, diabetes, hypertension with other diseases, injuries, HIV infections, sepsis, pressure ulcers, and pregnancy. These guidelines assist in determining sequencing, stages for some disease processes, and the hierarchy of certain codes.

Anemia is sequenced as the principal diagnosis when associated with chemotherapy, immunotherapy, and radiation therapy. Anemia is sequenced as a second diagnosis when associated with a malignancy. This is also a case where the guidelines differ between ICD-10-CM and ICD-9-CM.

Correctly applying the guidelines will also enable coding diabetes to the highest level of specificity. This should include the type of diabetes, insulin use, and diabetes with other conditions.

Circulatory system diseases can be very intricate, but the guidelines explain the coding. Such is the case with hypertension with co-existing conditions. Information includes sequencing and use of additional codes when needed. Information and definitions are also included in the guidelines to explain acute myocardial infarctions (AMI). Again, there are significant changes from ICD-9-CM to ICD-10-CM; in this case the difference is in terms of the timeframe for current and old AMI.

Coding injuries in ICD-10 brings many more code possibilities. The guidelines explain the seventh character requirements for both the treatment of a condition and the healing status of fractures.

Take a look at the conventions (1.A) for ICD-10-CM for starters. Note this important rule of thumb, right at the start of the section: "The conventions and instructions of the classification take precedence over guidelines." In other words, if the tabular index gives an instruction that differs from the guidelines in the front of the manual, follow the tabular index guidelines.

Highlights of the general conventions include:

1.A.4 and 1.A.5: Seventh character extenders and placeholders. 

ICD-10-CM uses a placeholder “X” for two purposes

Fill in the empty characters for codes that require a seventh character extender, but are not six characters in length.

Example: S09.21, traumatic rupture of right ear drum:

The partial code is five characters in length

A placeholder “X” must be used to append the seventh character

Excludes1: The code(s) listed under Excludes1 should never be coded with the code above the Excludes1 note.

Excludes 2. The conditions excluded are not a part of the condition listed above it (if the documentation states both conditions exist together, both should be reported).

Highlights of the general guidelines (Section 1.B) include:

If no bilateral code exists and the condition is bilateral, two codes must be assigned (one for right and one for left) to report the complete condition.

Unspecified codes have acceptable uses and are necessary at times, but each encounter should be coded to the level of certainty known. Example of appropriate use: When a definitive diagnosis has not been established by the end of the encounter.

You can never become too familiar with the guidelines. Study them and highlight the trickier areas for quick reference. This knowledge will prove to be incredibly helpful to you and your physician.

Brenda Edwards, CPC, CPMA, CPC-I, CEMC, entered the coding and billing profession 25 years ago, and has been involved in many aspects of the field. Her current responsibilities include chart auditing, coding and compliance education, and contributing articles to AAPC and industry publications. Brenda is an 

 trainer and has presented for AAPC workshops, regional conferences, and local chapter meetings. She has also served on the AAPCCA Local Chapter Board of Directors.

Learning how to use the new ICD-10 codes prior to implementation will be just as important as learning the new codes.

Key Changes to Note When Preparing for the ICD-10 Transition 

Some industry professionals believe we won’t need ICD-9-CM books after the October 1, 2014, implementation of ICD-10. That is simply not true.

Here are a few reasons you should keep your ICD-9-CM on the shelf:

 Think about all the claims that will need to be filed that weren’t entered into the billing system before the code set change. If you use ICD-10-CM codes on claims prior to October 1, 2014, the service will be denied.

Think about the hospital stays that overlap from September 2014 to October 2014. Since ICD-10-CM is date-of-service driven, you will still need to access ICD-9-CM for a long time. Did you know you can either submit the services prior to October 1 with ICD-9-CM codes or wait until the patient is discharged to submit a hospital stay that began prior to October 1, 2014, and submit all dates with ICD-10-CM codes?

Think about the claims that are denied or require further review. You will need to use your trusty ICD-9-CM book to determine if the most specific code was submitted the first time.

Think about processing workers' compensation and third-party liability claims. Neither is required to convert to ICD-10-CM codes as the rest of the industry and will continue for an indefinite amount of time to use ICD-9-CM codes.

Think about the continually updated tips and notes you’ve written in the margins, particularly as they relate to protocols you’ve learned in dealing with various payers.

Think about reworking a service that was submitted to an incorrect payer. You may not know for months, or even a year, that a claim should have been submitted to a different payer.

Think about simply getting one last ICD-9-CM book to handle all the aforementioned needs in the future because your current copy has several torn pages, is missing the cover, sports a handful of coffee mug stains, and/or was once accidentally dropped in a full bathtub (don’t ask).

If you have one of the AAPC’s ICD-9-CM books, you will find enhanced resources in addition to the official government versions of volume one and volume two. You may rely on these helpful resources more than you realize:

Illustrations and clinically oriented definitions to aid in correct
        code assignment

Color coding, symbols, and footnotes which alert coders to coding and reimbursement issues

Additional digit-required symbols to ensure the most specific code is used

Indicators for the appropriate use of V-codes including sequencing order

Edits to codes which are age- or sex-specific

Definitions for many conditions which help determine the most specific diagnosis code

ICD-10-CM quick references for the most commonly reported ICD-9-CM codes

Alerts to properly use for manifestation codes, including when two codes are required and
         sequencing rules

Code alerts for "other specified" and "unspecified" codes

Don’t start ripping out pages from your ICD-9-CM book to use as fire kindling or to line the bottom of a birdcage. It makes sense to have a 2014 ICD-9-CM on hand, even after the transition to ICD-10.

, CPMA, CPC-I, CEMC, has been involved in many aspects of coding and billing since entering the profession more than 25 years ago. Her responsibilities at Kansas Medical Mutual Insurance Company include chart auditing, coding and compliance education, and contributing articles to the company’s website and publication. An 

-approved PMCC instructor, workshop presenter, and ICD-10 trainer, Edwards is a frequent speaker for local AAPC chapters in Kansas and Missouri and has presented at AAPC regional conferences. She currently serves as vice chair of the AAPC Chapter Association Board. E-mail her 

What should your medical practice do with your ICD-9-CM book after October 1, 2014? Keep it.