ICD-10: Change With Our Coding Times

Published in Coding Edge – October 2010

ICD-10-CM is happening, so be sure documentation is specific for this extensive code set.

By Susan Ward, CPC, CPC-H, CPC-I, CEMC, CPCD, CPRC

Change is inevitable, especially in the medical coding profession. There is a lot of talk going around about whether ICD-10-CM really will come to fruition. I talk to people in the medical coding and billing world every day and I am surprised at how many have no idea about ICD-10-CM. The ones who do know about it say, “Well, I’ll believe it when I see it really happen.”

ICD-10-CM is happening and Oct. 1, 2013 is the day when it will be realized in the United States. Providers, payers and coders alike must prepare for this enormous transition. We all face learning totally new code sets with changing guidelines—going from 19 chapters to 21 chapters of guidelines.

Review the New Guidelines

Chapter 2 still brings us Neoplasms, without too many changes.

The ICD-10-CM Official Guidelines for Coding and Reporting 2010 (www.cms.gov/ICD10/Downloads/7_Guidelines10cm2010.pdf) provides additional guidelines to assist with further specificity. Here are the new (excerpted) guidelines that coders must follow:

j. Disseminated malignant neoplasm, unspecified

Only use code C80.0 Disseminated malignant neoplasm, unspecified for those cases where the patient has advanced metastatic disease and no known primary or secondary sites are specified. Don’t use it in place of assigning codes for the primary site and all known secondary sites.

k. Malignant neoplasm without specification of site

Code C80.1 Malignant neoplasm, unspecified equates to cancer, unspecified. Only use this code when no determination can be made as to the primary site of a malignancy. This code rarely should be used in the inpatient setting.

l. Sequencing of neoplasm codes

1) Encounter for treatment of primary malignancy

If the reason for the encounter is for treatment of a primary malignancy, assign the malignancy as the principal/first listed diagnosis. Sequence the primary site first, followed by any metastatic sites.

2) Encounter for treatment of secondary malignancy

When an encounter is for a primary malignancy with metastasis, and treatment is directed toward the metastatic (secondary) site(s) only, the metastatic site(s) is designated as the principal/first listed diagnosis. Code the primary malignancy as an additional code.

3) Malignant neoplasm in a pregnant patient

Codes from chapter 15, Pregnancy, Childbirth, and the Puerperium, are always sequenced first on a medical record. First, use a code from subcategory O94.1 Malignant neoplasm complicating pregnancy, childbirth, and the puerperium, followed by the appropriate code from chapter 2 to indicate the type of neoplasm.

4) Encounter for complication associated with a neoplasm

When an encounter is for management of a complication associated with a neoplasm, such as dehydration, and the treatment is only for the complication, code the complication first followed by the appropriate code(s) for the neoplasm.

The exception to this guideline is anemia. When the admission/encounter is for management of anemia associated with the malignancy, and the treatment is for anemia only, sequence the appropriate code for the malignancy as the principal or first-listed diagnosis followed by code D63.0 Anemia in neoplastic disease.

5) Complication from surgical procedure for treatment of a neoplasm

When an encounter is to treat a complication resulting from a surgical procedure performed to treat the neoplasm, designate the complication as the principal/first listed diagnosis. See guidelines for coding a current malignancy versus personal history to determine if the code for the neoplasm should also be assigned.

6) Pathologic fracture due to a neoplasm

When an encounter is for a pathological fracture due to a neoplasm, and if the focus of treatment is the fracture, sequence a code from subcategory M84.5 Pathological fracture in neoplastic disease first, followed by the code for the neoplasm.

If the focus of treatment is the neoplasm with an associated pathological fracture, first sequence the neoplasm code, followed by a code from M84.5 for the pathological fracture. The “code also” note at M84.5 provides this sequencing instruction.

m. Current malignancy versus personal history of malignancy

When a primary malignancy is excised, but further treatment—such as additional surgery for the malignancy, radiation therapy, or chemotherapy—is directed to that site, use the primary malignancy code until treatment is complete.

When a primary malignancy previously is excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, use a code from category Z85 Personal history of primary and secondary malignant neoplasm to indicate the former site of the malignancy.

See Section I.C.21.4 Factors influencing health status and contact with health services, History (of).

n. Leukemia in remission versus personal history of leukemia

The categories for leukemia, and category C90 Multiple myeloma have codes for in remission. There are also codes Z85.6 Personal history of leukemia and Z85.79 Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues. Query the provider if the documentation is unclear as to whether the patient is in remission.

See Section I.C.21.4, Factors influencing health status and contact with health services, History (of).

o. Aftercare following surgery for neoplasm

See Section I.C.21.7, Factors influencing health status and contact with health services, Aftercare.

p. Follow-up care for completed treatment of a malignancy

See Section I.C.21.8, Factors influencing health status and contact with health services, Follow-up.

q. Prophylactic organ removal for prevention of malignancy

See Section I.C.21.14, Factors influencing health status and contact with health services, Prophylactic organ removal.

r. Malignant neoplasm associated with transplanted organ

Code a malignant neoplasm of a transplanted organ as a transplant complication. Assign first the appropriate code from category T86 Complications of transplanted organ, followed by code C80.2 Malignant neoplasm associated with transplanted organ. Use an additional code for the specific malignancy.

Precisely Describe the Dx

With the additional guidelines we can select more specific codes. Compare the description of the ICD-9-CM code with the following description of the ICD-10-CM code:

  ICD-9-CM   ICD-10-CM
Carcinoma skin of breast 173.5   C44.52  
Carcinoma skin of chest 173.5   C44.59  
Melanoma InSitu skin of cheek 172.3   D03.39  
Carcinoma InSitu skin of cheek 232.3   D04.39  
Carcinoma skin of nose 173.3   C44.31  

 

By comparing the differences with the specificity, you can realize what ICD-10-CM means to the future of coding. ICD-10-CM also will bring laterality to coding skin cancers, so physicians will need to document which side of a patient’s body has skin cancer (e.g., documenting skin cancer on the right or left leg, or the right or left arm).

If you don’t have access to a draft of the new code set, AAPC has an online ICD-10-CM code translator on its website (www.aapc.com/ICD-10/codes/). This tool can help you and your practice assess where your provider’s documentation may be lacking specificity to choose ICD-10-CM codes properly so you can accurately code their claims beginning Oct. 1, 2013.

Contact dermatitis currently is reported as 692.9 regardless of if it is contact or allergic dermatitis, but with ICD-10-CM we need to have documentation to support more specific code descriptions:

                L23.9       Allergic contact dermatitis, unspecified cause

                L24.9       Irritant contact dermatitis, unspecified cause

                L25.9       Unspecified contact dermatitis, unspecified cause

                L30.8       Other specified dermatitis

                L30.9       Dermatitis, unspecified

To support the ICD-10-CM equivalency codes for ICD-9-CM code 782.0 Disturbance of skin sensation you’ll need documentation to support:

                R20.0      Anesthesia of skin

                R20.1      Hypoesthesia of skin

                R20.2      Paresthesia of skin

                R20.3      Hyperesthesia

                R20.8      Other disturbances of skin sensation

                R20.9      Unspecified disturbances of skin sensation

Revisit Medical Terminology and Anatomy

Specific supporting documentation helps better describe what is happening with the patient, but a clear understanding of medical terminology and anatomy is necessary to properly assign codes. Just as we continue to educate ourselves on yearly code changes, fee schedule changes, health care changes, and payer changes, even expert coders should consider taking a refresher course in terminology.

Dead-on Documentation Is a Must

Documentation, or lack of it, has always been a coder’s nemesis. One of the goals of moving to ICD-10-CM is to avoid an “unspecified” diagnosis, when possible. Start now by showing your physician what documentation is necessary in the coming years. Take time to review ICD-10-CM codes and coding current superbills, charge tickets, and/or documentation. Challenge yourself to see what your practice can do to be ahead of the game that will commence Oct. 1, 2013. Don’t be surprised if some of your payers require more information to support “unspecified” code selection. Continue to educate yourself and know AAPC will guide you all the way.

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