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ICD-10-CM: Expanding Your Clinical Horizons
There are many new sections in ICD-10 that will require coders to "code outside the box." Expanding knowledge of some basic clinical parameters will help coders capture the increased specificity of ICD-10-CM.
ICD-9 contains 10 codes for migraine headache, including 5th digit subclassifications to indicate status and intractability. ICD-10 has 39 codes which covers the category of migraine and variations, with increased specificity to a very detailed level, such as, "Short lasting unilateral neualgiform headache with conjunctival injection and tearing, intractable (SUNCT)." Coders will need to fine tune their clinical language skills as they probe deeper into the patient's medical record and query the physician appropriately to obtain the required level of specificity.
Another example of a coding situation which may require coders to request more clinical information from providers is the correct code assignment for coma. ICD‐10‐CM has expanded the codes for coma and requires further information based on the Glascow Coma Scale (GCS). Documentation currently does not always give us this level of detail in the medical record and physicians will need to be educated on the new requirements.
Coders who work with neuro-intensivists, for example, may have information available to determine the comatose patient has a skull fracture. However, the documentation may not indicate how and when the GCS determination was made, which is necessary to complete the 7th character requirement. Currently, in ICD-9-CM, we do not code based on the coma scale, so additional documentation requirements will be challenging with ICD‐10‐CM.
The GCS codes are intended primarily for trauma registry and research, but may be utilized by all users of the classification who have a need for the information.
IN THE NEWS
On April 26, 2011, AAPC and CMS will team up to present a two-hour ICD-10 Code-A-Thon, complete with information and a Q&A session. Rhonda Buckholtz, AAPC's Vice President of ICD-10 Education and Training, will speak for 20 minutes and then a CMS representative will speak for ten. The Q&A portion will fill the balance of the time. This event will be worth 2 CEUs. Watch AAPC's website for more details.
Chief complaint: Patient presents for a scheduled school age well child visit. The patient is an 11 year old male. Patient is accompanied by father. Parents have no specific concerns. Diet: Adequate amount of calcium intake. The child drinks 46 ounces of water per day. The source is city water. Currently eating age appropriate foods daily. Diet is appropriate for age. No eating disorders. Sleep: Sleep patterns are normal. No sleep disturbances experienced. Hearing screen is normal. Child does get along with parents and siblings and does chores. Patient is in the sixth grade. School performance is average. The patient is active. Anticipatory Guidance: No drugs or alcohol in the home. Standard anticipatory guidance and safety sheet given.
HPI: Presents for physical exam. Patient feeling well. Immunizations will have to wait until shot records comes in.
ROS: The patient denies constitutional symptoms, respiratory symptoms, gastrointestinal symptoms, male genital problems, and skin, hair, and nail symptoms.
Current Meds: None
Past Medical History: Physical and dental exam in 2008. Eye exam in 2007.
Family History: Unremarkable
Social History: The home is smoke free.
Objective: BP: 98/78, Pulse: 72, Temp: 97.8, Ht: 59", Wt: 117lbs, BMI: 23.6.
Exam: Const: Healthy appearing child, well nourished and alert. Weight within the normal range for stated age. Communicates normally. Eyes: 20/20 in both eyes without correction. No discharge from the eyes. PERRL. Normal eye movement. ENMT: Auditory canals are patent. Tympanic membranes normal landmarks, no fluid or erythema bilaterally. Nasal mucosa shows moistness and normal color, but no discharge. Oral mucosa: pink, smooth, and moist. Neck: supple, with no adenopathy. Resp: Respiration rate is normal. Lungs are clear bilaterally. CV: Rate is regular. Rhythm is regular. Pedal pulses: 2+ and equal bilaterally. GI: Abdomen is nondistended, nontender and soft. Bowel sounds normoactive. No palpable hepatosplenomegaly. GU: Normal genitalia. No hernias. Musculo: Spine: No scoliosis. Upper extremities: Strength: Normal and symmetric. ROM is physiologic. Lower extremities: normal and symmetric. ROM is physiologic. Skin: No rash or lesions. Neuro: Mood is normal. Affect is normal.
Assessment and plan: Normal physical exam. Follow up prn.
ICD-9-CM Diagnosis: V20.2
ICD-10-CM Code: Z00.129 Encounter for routine child health examination without abnormal findings.
Rationale: In ICD-10-CM codes for routine examinations require a component for normal exams vs. abnormal exams. If providers document any abnormal findings you would select a code that indicates "with abnormal findings" and then follow that with the code for the abnormal finding.
Index lookup: Examination, child (over 28 days old)
We will be sharing a number of steps to help your practice successfully implement ICD-10-CM. They are also found in your ICD-10 Implementation Tracker on AAPC's website.
Step 10: Phase I training
Phase I training is a general training process that includes ICD-10-CM guidelines, understanding of the general code set, and regulatory and guidance issues. Reinforce the need for code specificity and proper documentation that supports the coding. All staff members should be involved in phase I training, which should take 8–10 hours per staff member, and should occur approximately 6–12 months prior to the compliance date.
This ICD-9 to ICD-10 Reference Sheet shows how the code sets are organized, with easy color coding to help you find what you're looking for. It also has pneumonic tips to help you remember where the new codes are located.