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ICD-10-CM General Guidelines
The general guidelines in ICD-10-CM are intended to provide overall guidance on usage of the code set. The guidelines are similar to those in ICD-9-CM with a few exceptions. Let's take a look at some of them.
The guidelines are located in Section I.B of the code book. There is a general statement made at the beginning of the section regarding hierarchy of application of the guidelines. It states, "The conventions and instructions of the classification take precedence over guidelines." This means that if the guidelines give a certain instruction (eg, sequencing rules) but the Tabular Index gives a different instruction for a specific category or code block, then the instruction in the Tabular Index should be followed.
Other guidelines to pay attention to in the general ICD-10-CM guidelines:
I.B.13. Laterality: This is a new guideline as bilateral codes do not exist in ICD-9-CM, but in ICD-10-CM, some codes contain laterality in the code. The guideline state that 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. For example, a patient has bilateral carpal tunnel syndrome. The codes for carpal tunnel syndrome do not include a bilateral code. To report the bilateral condition, codes G56.01 Carpal tunnel, right upper limb code G56.02 Carpal tunnel, left upper limb, would need to be assigned.
I.B.16. Documentation of Complications of Care: this guideline gives direction regarding the requirements for a condition to be reported as a complication of care. It states that code assignment is based on the provider's documentation of a cause-and-effect relationship between the care provided, the condition, and that it is a complication. Discussions with physicians and other providers regarding specifics of their documentation is important to show the complexity of a patient's case. The guideline also states that if the documentation is not clear as to the relationship, the physician or other provider should be queried for clarification.
I.B.17. Borderline Diagnosis: If a physician or other provider documents a condition as being borderline at the time of discharge, there are two choices. If the term Borderline is referenced in the Alphabetic Index, and there is an entry for the specified borderline condition, then condition is coded. For example, borderline diabetes has a listed code in the Alphabetic Index of R73.09 Other abnormal glucose. If there is no entry, the condition is coded as if it exists. This guideline applies to inpatient or outpatient discharges. If the documentation is unclear, the guidelines again state to query the provider of service for clarification.
I.B.18. Use of Signs/Symptoms/Unspecified Codes: This is a new guideline for 2014. This guideline addresses the use of signs, symptoms, and unspecified codes. It states that unspecified codes have acceptable uses and are necessary at times, and each encounter should be coded to the level of certainty known for that encounter. Signs and symptoms are appropriate to report when a definitive diagnosis has not been established at the end of the encounter. If sufficient clinical information is unknown or unavailable (waiting on labs, etc) it is acceptable to report an unspecified code. The guideline further states, "Unspecified codes should be reported when they are the codes that most accurately reflects what is known about the patient's condition at the time of that particular encounter."
The final instruction regarding correct code assignment states it would be inappropriate to assign a more specific diagnosis code not supported by documentation. It is also inappropriate to order additional diagnostic testing to determine a more specific diagnosis code.
It is a good idea to familiarize yourself with all guidelines before the live date for ICD-10-CM, October 1, 2014. We are less than one year away from implementation.
In the coming issues, watch for articles that delve into the chapter specific guidelines to help ensure proper code assignment in ICD-10-CM.
IN THE NEWS
Back to School with CMS for ICD-10
CMS is launching a series of email update messages to help practices with ICD-10 preparations. The updates will have useful tips and resources to help a practice get up-to-date, or continue with, their ICD-10 preparations.
The series will cover:
- Resources available at no cost from CMS and medical/trade associations to help you identify specific steps your practice should take to get ready for ICD-10
- Simple tips for small practices that can have a big effect on ICD-10 preparedness
- Guidance on creating a plan to help see your practice through to the ICD-10 deadline
- Recommendations for how to discuss ICD-10 with trading partners, including vendors and payers
- Approaches to ICD-10 coding and documentation for specific conditions
- Options for training
- How to start ICD-10 testing, even if you do not have all your systems and software in place
As you move forward with ICD-10, be sure to watch for the Back to School messages with information and guidance from CMS to help you get ready for the October 1, 2014, deadline. Visit the CMS ICD-10 website for their latest news.
PREOPERATIVE DIAGNOSIS: Missed abortion. POSTOPERATIVE DIAGNOSIS: Missed abortion.
PROCEDURE: Suction dilatation and curettage. ANESTHESIA: General. COMPLICATIONS: None.
HISTORY: This is a 22-year-old white female, gravida 1, para 0, at 14 weeks by dates, confirmed on ultrasound, with spotting only and nonviable intrauterine pregnancy. Maternal blood type is A positive.
DETAILS OF PROCEDURE: After consent was obtained, the patient was taken to the operative suite. She was given general anesthetic and placed in the dorsal lithotomy position and prepped and draped in the usual sterile fashion. Her bladder was drained with a red Robinson catheter. The bimanual exam revealed a slightly enlarged retroverted uterus. A weighted speculum was placed in the posterior vaginal vault, and the anterior lip of the cervix was identified and grasped with single-tooth tenaculum. The uterus sounded to 10 cm and serially dilated to a 7 Hegar dilator, and a 7 curved suction curette was then placed into the uterine cavity. Suction curettage was performed with a moderate to large amount of tissue obtained, approximately 300 of blood loss. Sharp curettage was, likewise, performed; no further tissue obtained and very scant bleeding. IV Pitocin was then infused. Tenaculum was removed from the cervix. The speculum was removed from the vagina. The patient was awakened, taken to the recovery room in satisfactory condition.
O02.1 Missed abortion
Z3A.14 14 weeks gestation of pregnancy
Rationale: In this example, the patient is brought to the OR after suffering a missed abortion. The documentation indicates ultrasound places the patient at 14 weeks gestation and confirmed nonviable intrauterine pregnancy. There is an instructional note at the beginning of chapter 15, Pregnancy, Childbirth, and the Puerperium, that states a code from category Z3A, Weeks of gestation, should be assigned in addition to any chapter 15 codes to indicate the specific week of gestation.
While most codes in chapter 15 have a final character indicating the trimester of pregnancy, if the trimester is not a component of a code it is because the conditions always occurs in a specific trimester or the concept of trimester of pregnancy is not applicable. Under code O02.1, it defines missed abortion as early fetal death, before completion of 20 weeks of gestation with retention of dead fetus, a trimester designation is not applicable to the code.
ICD-10 IMPLEMENTATION STRATEGIES
We will be sharing a number of strategies to help your practice successfully implement ICD-10-CM. Please remember to track your progress in your ICD-10 Implementation Tracker on AAPC's website.
Choosing Delivery Methods
Different organizations have different methods of delivering notifications and messages. The best delivery method for each organization should be assessed. If the best method for your organization is by e-blast, distribution groups should be set up to deliver the right message to the right group. A good rule of thumb is to set them up by groupings that correlate to educational groups: Physicians and practitioners, coders and billers, management, ancillary staff, etc. If all messages are sent to all employees on a continuous basis, an organization runs the risk of staff ignoring or deleting messages without being read. If employees are being inundated with messages that mostly do not apply to them, they will tend to ignore them.
If the best method for delivery for your organization is by paper, the same distribution groups should apply so as not to waste paper, or again, have messages ignored. Remember, in order for good communication to occur, it must be to the right people at the right time.
ICD-9 to ICD-10 Mapping
AAPC has produced a handy, one-page reference sheet that will help you transition between the ICD-9 code set and ICD-10. It show how the code sets are organized, with easy color coding to help you find what you're looking for. It also has mnemonic tips (such as "C is for cancer" and "T is for toxicity") to help you remember where the new codes are located.