ICD-10 FAQ

FAQ 1.  What is ICD-10-CM?

ICD-10-CM is the current diagnosis code set used in the United States, effective October 1, 2015.  There is another code set known as ICD-10-PCS (Procedure Coding System).  ICD-10-PCS will be discussed in FAQ 7 below.  

The International Classification of Diseases (ICD) is the copyrighted official publication of the World Health Organization (WHO). The primary purpose of ICD is for epidemiological tracking of illness and injury. ICD has been used in the US since 1949 (ICD­6). The first formal US adaption was by the US Public Health Service with ICD­7. The current US adaptions are controlled by the "cooperating parties": National Center for Health Statistics/CDC (NCHS), Centers for Medicare and Medicaid Services (CMS), American Hospital Association (AHA), and American Health Information Management Association (AHIMA).

FAQ 2.  How is ICD-10 organized?  

The ICD-10-CM code set contains an alphabetic Index to Diseases and Injuries, a Neoplasm Table, a Table of Drugs and Chemicals, Index to External Causes, and 21 chapters in the Tabular List of Diseases and Injuries.  The table below provides ICD-10-CM tabular chapter subjects and corresponding alphanumeric code ranges.

                           Chapter

 Alpha Numeric

1. Certain Infectious and Parasitic Diseases

 A00-B99

2. Neoplasms  

 C00-D49

3. Blood and Blood-forming Organs

 D50-D89

4. Endocrine, Nutritional and Metabolic Diseases  

 E00-E89

5. Mental, Behavioral, and Neurodevelopmental Disorders  

 F01-F99

6. Nervous System  

 G00-G99

7. Eye and Adnexa  

 H00-H59

8. Ear and Mastoid Process  

 H60-H95

9. Circulatory System  

 I00-I99

10. Respiratory System  

 J00-J99

11. Digestive System  

 K00-K95

12. Skin and Subcutaneous Tissue  

 L00-L99

13. Musculoskeletal System and Connective Tissue  

 M00-M99

14. Genitourinary System  

 N00-N99

15. Pregnancy, Childbirth and the Puerperium  

 O00-O9A

16. Certain Conditions Originating in the Perinatal Period  

 P00-P96

17. Congenital Malformations, Deformations and Chromosomal Abnormalities  

 Q00-Q99

18. Symptoms, Signs and Abnormal Clinical and Laboratory Findings  

 R00-R99

19. Injury, Poisoning and Certain Other Consequences of External Causes  

 S00-T88

20. External Causes of Morbidity  

 V00-Y99

21. Factors Influencing Health Status and Contact with Health Services  

 Z00-Z99

Injury codes S00-S99 are listed by anatomical location and type of injury.  The following table illustrates truncated codes by anatomical position and injury type:

 

Superficial

Open

Wound

Fracture

Dislocation/

Sprain

Nerve

Blood Vessel

Organ

Crush

Amputation

Other

Head

S00

S01

S02

S03

S04

S05

S06

S07

S08

S09

Neck

S10

S11

S12

S13

S14

S15

S16

S17

S18

S19

Thorax (front/back)

S20

S21

S22

S23

S24

S25

S26

S27

S28

S29

Lower Torso (front/back)

S30

S31

S32

S33

S34

S35

S36

S37

S38

S39

Shoulder & Upper Arm

S40

S41

S42

S43

S44

S45

S46

S47

S48

S49

Elbow & Forearm

S50

S51

S52

S53

S54

S55

S56

S57

S58

S59

Wrist & Hand

S60

S61

S62

S63

S64

S65

S66

S67

S68

S69

Hip & Thigh

S70

S71

S72

S73

S74

S75

S76

S77

S78

S79

Knee & Lower Leg

S80

S81

S82

S83

S84

S85

S86

S87

S88

S89

Ankle & Foot

S90

S91

S92

S93

S94

S95

S96

S97

S98

S99

FAQ 3.  How are poisoning, adverse effect and underdosing codes sequenced?

Codes T36-T50 describe poisoning by, adverse effect of, and underdosing of drugs, medicaments and biological substances.   These are combination codes which include both the substance that was take as well as the intent (e.g. accidental, intentional self-harm, undetermined).  No additional external cause code is required for this code set.  A poisoning codes (accidental, intentional self-harm, assault and undetermined intent) may be a primary code, with manifestations sequenced following the poisoning code.  For example, intentional overdose of benzodiazepine with intent to self-harm, resulting in respiratory failure with hypoxia would be sequenced as follows:

1. T42.4X2A

2. J96.01

For adverse effect of a drug that has been correctly prescribed and properly administered, assign code(s) which describe the nature of the adverse effect, followed by the appropriate code from the T36-T50 code set.  For example, new onset urticaria due to Lisinopril would be sequenced as follows:

1. L50.8

2. T46.4X5A

ICD-10-CM introduced a code set for underdosing of medications, which is defined as taking less of a medication than is prescribed by a provider or a manufacturer's instruction.  Underdosing codes should never be assigned as principal or first-listed codes.  For example, intractable generalized epileptic seizure, prescribed Dilantin with lab phenytoin level 4 ug/ml would be coded:

1. G40.319

2. T42.06XA

Additional ICD-10-CM codes are available to describe underdosing intent as documented:

Z91.120  Patient's intentional underdosing of medication regimen due to financial hardship

Z91.128  Patient's intentional underdosing of medication regimen for other reason

Z91.130  Patient's unintentional underdosing of medication regimen due to age-related disability

Z91.138  Patient's unintentional underdosing of medication regimen for other reason

FAQ 4.  Will there be updates and revisions to ICD-10-CM?

The ICD-10 Coordination and Maintenance Committee (C&M) is a Federal interdepartmental committee comprised of representatives from the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics (NCHS).  The committee is responsible for approving coding changes, developing errata, addenda and other modifications.  Requests for coding changes are submitted to the committee for discussion at either the Spring or Fall C&M meeting.

The C&M Committee meeting held in September 2015 discussed ICD-10-CM revisions and updates including discussion topics for laterality of rectal and peri-rectal abscess, asthma control status, atrial fibrillation, clostridium difficile recurrence, contact with knives and other sharp objects, heart failure, and the addition of a new ICD-10-CM category X50 for Overexertion and strenuous or repetitive movements. The agenda for the March 2016 meeting contains topics including discussion of Zika virus, TMJ, and post-operative seroma.   No decisions for ICD-10-CM updates are decided during the meetings. 

Sources:  http://www.cdc.gov/nchs/data/icd/Topic_Packet_09_22_23_15.pdf

http://www.cdc.gov/nchs/data/icd/tentative_agendamarch2016.pdf

For requests to update the ICD-10-CM codes, please note The Centers for Disease Control and Prevention (CDC) is responsible for the development and maintenance of ICD-10-CM. Please send your ICD-10-CM comments to: Donna Pickett, CDC nchs@cdc.gov

FAQ 5. Are "unspecified" diagnosis codes permitted with ICD-10-CM?

Yes, these types of codes are permitted when a more specific diagnosis is not available at the time of the encounter. For example, if the patient is diagnosed with a pneumonia but the physician is not able to determine additional detail than "Pneumonia, organism unspecified" (J18.9) is a permissible diagnosis. However, if the pneumonia was associated with aspiration of vomit (J69.0) or Avian influenza (J09.X1), then those specific codes would be used.

Specificity is of particular importance, for example, as to the location of an injury, abdominal, back or limb pain. A specific diagnosis should indicate if an injury was of the left/ right forearm or upper arm or 3rd digit finger as opposed to non-specific term "arm" or "finger."

The [ICD] Official Guidelines for Coding and Reporting says:

Signs/symptoms and "unspecified" codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient's health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.

If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn't known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate "unspecified" code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient's condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code. (underline added)

This information was also published in Coding Clinic, Second Quarter 2013, pages 29-30.

Payers may need to be reminded, "Adherence to these guidelines when assigning ICD-10-CM diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPAA)."  (ICD-10-CM Official Guidelines for Coding and Reporting)

FAQ 6.  Are External Cause Codes required for ICD-10-CM?

There is no national requirement for mandatory ICD-10-CM external cause code reporting. Unless you are subject to a State-based external cause code reporting mandate or these codes are required by a particular payer, you are not required to report ICD-10-CM codes found in Chapter 20 of the ICD-10-CM, External Causes of Morbidity.  Check with your local payers to determine whether they require external cause codes.

FAQ 7.  What is ICD-10-PCS?

ICD-10-PCS (Procedure Coding System) is currently designated to replace Volume 3 of ICD-9-CM for hospital inpatient use. PCS is ONLY for hospital use at this time. CMS has stated ICD-10-PCS is not intended to replace CPT.

CPT remains the procedure-coding standard for physicians, regardless of whether the physician services were provided in the inpatient or outpatient setting. Any third party payer asking for Volume 3 procedure codes to be submitted along with CPT codes for outpatient services is in violation of HIPAA regulations and subject to fines by CMS.

Some preliminary inpatient hospital testing of ICD-10-PCS has indicated that the new procedure coding system is problematic to learn for both experienced and inexperienced coders.

FAQ 8.  Where can I learn more about ICD-10-CM and ICD-10-PCS?

For the first few months of ICD-10 implementation, the ICD-10 Coordination Center (ICC) appointed an ombudsman (William Rogers MD) and served to respond to provider questions and concerns about ICD-10. The ICC is now closed and will no longer accept inquiries.

ICD-10-CM official Guidelines:  http://www.cdc.gov/nchs/data/icd/10cmguidelines_2016_Final.pdf

ICD-10 Fee-For-Service educational resources, including MLN Matters® articles, MLN products, MLN Connects® videos, and CMS resources: http://www.cms.gov/Medicare/Coding/ICD10/Medicare-Fee-for-Service-Provider-Resources.html on the CMS website

For requests to update the ICD-10-CM codes, please note The Centers for Disease Control and Prevention (CDC) is responsible for the development and maintenance of ICD-10-CM. Please send your ICD-10-CM comments to: Donna Pickett, CDC nchs@cdc.gov

For requests to update ICD-10-PCS codes, send such recommendations to Pat Brooks, CMS at patricia.brooks2@cms.hhs.gov

For questions about Claims Processing and Payment or Local Coverage Determinations:

Contact  your Medicare Administrative Contractor (MAC) for guidance. You can find the list of MACs at this link: https://www.cms.gov/Medicare/Coding/ICD10/ICD-10-Provider-Contact-Table.pdf 

Additional resources are located on the ACEP website: 

ICD-10-CM and the Emergency Physician

ICD-10-CM For the Busy Emergency Physician

ICD-10-CM ED Clinical Examples

  

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date. The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer. For information about this FAQ/ Pearl, or to provide feedback, please contact David A. McKenzie, CAE, Reimbursement Director, ACEP at (972) 550-0911, Ext. 3233 or dmckenzie@acep.org

Updated 03/08/2016

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