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.  You may also hear about ICD-10-PCS (Procedure Coding System), another code set used for inpatient hospital procedures.  ICD-10-PCS will be discussed in FAQ 9 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 (ICD­-6). The US version of ICD is managed by the National Center for Healthcare Statistics (NCHS) of the CDC with additional oversight by the cooperating parties: Centers for Medicare and Medicaid Services (CMS), American Hospital Association (AHA), and American Health Information Management Association (AHIMA). ICD-10-CM is the HIPPA transaction code set for diagnosis coding. The ICD-10-CM Official Guidelines for Coding and Reporting provides the rules for using the code set.

FAQ 2.  How is ICD-10 organized?                                                                                   

The ICD-10-CM tabular divides Diseases and Injuries into 21 sections or chapters.  It also contains three index tables for conditions related to 1) Chemicals and Drugs, 2) External Causes of Injury, and 3) Neoplasms which can expedite finding codes for those issues.  Unlike ICD-9-CM, no chapter in ICD-10-CM is considered as supplementary. The table below lists the 21 sections for Diseases and Injuries:

                            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

Most codes related to orthopedic conditions, injuries, poisonings and certain other external causes require a 7th character to indicate the phase of care (see FAQ 4).

FAQ 3: In ICD 10-CM, how would a common diagnosis such as “ACS” be coded.

An important principle of coding is to use the diagnosis which best describes your clinical impression and to be as specific as possible. For example, using a non-specific diagnosis of “chest pain” (which codes to R07.9 “chest pain, unspecified”) is much less specific then using “precordial pain” (R07.2) when using a symptom code. On the other hand, ICD-10 includes several specific diagnoses such as unstable angina, STEMI, and NSTEMI (I20-21 for initial cardiac insult) which should be used when applicable.  Acute coronary syndrome (ACS) codes at I24.9 (Acute ischemic heart disease, unspecified). Additional codes are available to indicate presence or absence of additional risk factors, e.g. patient smokes, is an ex-smoker, or never smoked.

FAQ 4: In ICD 10-CM, how would a traumatic fracture from a trampoline fall be coded?

Orthopedic codes represent about 25% of codes found in ICD-10. It is important to clearly specify where the fracture is located (e.g. ramus of right mandible), and laterality (e.g. right ilium). In the example of an ankle fracture, it is important to describe whether it was displaced or nondisplaced, and whether it was a fracture of the medial malleolus, lateral malleolus, bi-malleolar or tri-malleolar fracture of the right or left lower leg.  For example, a non-displaced right lateral malleolar fracture would be coded to S82.64XA. Additional codes that could be extracted from your documentation would specify if the fracture resulted from a fall (e.g. W17.89XA Other fall from one level to another, initial encounter), and even the location of the fall or activity (e.g. Y93.44 Activity, trampolining) when you provide these details in your ED note.

ICD-10 Guidelines provide that fractures not specified as displaced or non-displaced should be coded to displaced.  Fractures not specified as open or closed are coded to closed.  The ICD-10 codes for fractures use a 7th character to indicate, among other things, initial versus subsequent encounters for fractures.  Initial encounter is used while the patient is receiving active treatment for the fracture.   Initial encounter may also be assigned when a patient is transferred to another facility (e.g. trauma center) for higher level of care during the period of active treatment. A subsequent visit code would be used if an x-ray was being obtained to check healing status of fracture or if there was only a cast change or removal.  Documentation for subsequent encounters should describe routine healing, delayed healing, malunion or nonunion of fractures.  The suffix “S” for sequela is appropriate for other late effect manifestations or complications of an injury, exclusive of delayed healing, malunion or nonunion of fractures.  

FAQ 5.  How are poisoning, adverse effect and under dosing codes sequenced?

Codes T36-T50 describe poisoning by, adverse effect of, and under dosing of drugs, medications, and biological substances.   These are combination codes which include both the substance that was taken 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 code (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 (Poisoning by benzodiazepines, intentional self-harm, initial encounter)   
  2.         J96.01 (Acute respiratory failure with hypoxia)   

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 (manifestation), 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 (Other urticaria)   
  2.        T46.4X5A (Adverse effect of angiotensin-converting-enzyme inhibitors, initial encounter)   

 

ICD-10-CM introduced a code set for under dosing of medications, which is defined as taking less of a medication than is prescribed by a provider or a manufacturer’s instruction.  Under dosing 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 (Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus)   
  2.        T42.0X6A (Underdosing of hydantoin derivatives)   

 

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

 

Z91.120

Patient’s intentional under dosing of medication regimen due to financial hardship

Z91.128

Patient’s intentional under dosing of medication regimen for other reason

Z91.130

Patient’s unintentional under dosing of medication regimen due to age-related disability

Z91.138

Patient’s unintentional under dosing of medication regimen for other reason

 

FAQ 6.  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) (who are responsible for PCS codes) and the Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics (NCHS) (who are responsible for CM codes).  Each agency is responsible for approving coding changes, developing errata, addenda and other modifications within their area of responsibility.  Requests for coding changes are submitted to the committee for discussion at either the Spring or Fall C&M meeting. Almost all ICD-10-CM code additions and changes come from medical specialty societies or health care related groups. A public comment period follows which helps guide the agencies whether to accept, deny or modify the code proposals. 

 The ICD-10-CM Coordination and Maintenance Committee (CMC) met March 7-8, 2017.  There were no requests for ICD-10 codes to capture new diagnoses or new technology for mid-year implementation on April 1, 2017. Therefore, there are no new ICD-10 diagnosis or procedure codes implemented on April 1, 2017.  

The CMC agenda addressed several dozen proposed code additions, deletions and revisions.  Some of the proposed changes have been expedited for inclusion in 2018 ICD-10-CM, effective October 1, 2017.   As such, comments for the code sets with expedited changes require comments no later than April 7, 2017. Comments for all other topics in the March 7-8, 2017 agenda are open until June 9, 2017. 

Proposed ICD-10-CM code changes presented and discussed during the March 7-8 meeting include:

Acute Appendicitis

Blepharitis

Breakthrough Pain

Electronic Nicotine Delivery System (ENDS)*

Gallbladder Diseases

Myocardial Infarction Classification Types*

Heart Failure Classification*

Infection Following a Procedure

Infection of Obstetric Surgical Wound

Non-Healing Traumatic Wounds and Surgical Wounds

Non-Ruptured Cerebral Aneurysm

Orbital Roof and Orbital Wall Fractures*

Pediatric Glasgow Coma Scale*

* Expedited review for inclusion in 2018 ICD-10-CM, effective October 1, 2017

Source: 

ICD-10 Coordination and Maintenance Committee Meeting Agenda March 7-8, 2017:

https://www.cdc.gov/nchs/data/icd/topic-packet_03_07_17.pdf

           

 

Requests for code changes to ICD-10-CM can be made by individuals or directed to the Coding and Nomenclature Advisory Committee.   Comments on proposals from a Coordination and Maintenance Committee meeting or requests for new/modified codes should be directed to: National Center for Health Statistics, ICD-10-CM Coordination and Maintenance Committee, nchsicd10CM@cdc.gov,

 

FAQ 7. 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 then "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." Diagnoses that do not list laterality when applicable, e.g. left vs. right, are more likely to be denied. For example, listing the diagnosis as “ankle sprain” (S93.409 Sprain of unspecified ligament of unspecified ankle) is more likely to elicit prepayment review than “right ankle sprain” (S93.401 Sprain of unspecified ligament of right ankle). The EP may not be able to tell which specific ligament is involved (e.g. calcaneofibular vs. tibiofibular) but should be able to note which side is affected.

The ICD-10-CM 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. (Section I.B.18,underline added)

This information was also published in AHA Coding Clinic® for ICD-10-CM/PCS, 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) Additional coding guidance is published quarterly in AHA Coding Clinic® for ICD-10-CM/PCS.

FAQ 8.  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. However, it is not unreasonable that this information would be part of the ED documentation and could be extracted by the hospital or other party as required.

FAQ 9.  What is ICD-10-PCS?

ICD-10-PCS (Procedure Coding System) is designed to replace Volume 3 of ICD-9-CM. As with ICD-9, ICD-10-PCS is ONLY used by hospitals to show inpatient resource utilization. It does not affect services provided in the outpatient setting, including the ED. It is not intended to show physician work, and CMS has stated ICD-10-PCS is not intended to replace CPT for physicians procedure coding.

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 ICD-10-PCS procedure codes to be submitted along with CPT codes for outpatient services is in violation of HIPAA regulations and subject to fines by CMS.

FAQ 10.  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) to respond to provider questions and concerns about ICD-10. The ICC is now closed and will no longer accept inquiries.

For requests to update the ICD-10-CM codes, please note The National Center for Healthcare Statistics of the CDC is responsible for the development and maintenance of ICD-10-CM. Please send your ICD-10-CM comments to:  National Center for Health Statistics, ICD-10-CM Coordination and Maintenance Committee, nchsicd10CM@cdc.gov

ICD-10-CM Official Guidelines:  https://www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf

 

 

2017 ICD-10-CM codes (indexes and tabular): http://www.cdc.gov/nchs/data/icd/icd10cm/2016/ICD10CM_FY20172016_Full_PDF.ZIP

http://www.cdc.gov/nchs/data/icd/icd10cm/2016/ICD10CM_FY20172016_Full_XML.ZIP

 

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 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 05/02/2017 

 

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