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ICD-10 FAQ

  • What is ICD-10-CM?
    Recommendations
    Answer

    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. Answers to questions about ICD-10 code interpretations or applications are published quarterly by the AHA in Coding Clinic for ICD-10 CM/PCS. This information is used by payers and auditors in their reviews of code use.

    Answer

    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. Answers to questions about ICD-10 code interpretations or applications are published quarterly by the AHA in Coding Clinic for ICD-10 CM/PCS. This information is used by payers and auditors in their reviews of code use.

  • How is ICD-10 organized?
    Recommendations
    Answer

    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).

    Answer

    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).

  • In ICD-10-CM, how would I report COVID-19 presentations?

    Recommendations
    Answer

    General Guidance for coding COVID-19 effective April 1, 2020

    When the COVID-19 virus is confirmed, code first ICD-10-CM U07.1 COVID-19, followed by the disease, condition or manifestation associated with the COVID-19 virus. 

    Clinical Impression

    Code First

    Also Code

    Other viral pneumonia

    U07.1

    J12.89

    Acute bronchitis due to other specified organisms

    U07.1

    J20.8

    Bronchitis , not specified as acute or chronic

    U07.1

    J40

    Unspecified  acute lower respiratory infection

    U07.1

    J22

    Respiratory Infection NOS, Other specified resp. disorders

    U07.1

    J98.8

    Acute Respiratory Distress Syndrome (ARDS)

    U07.1

    J80

    Suspected possible COVID-19 exposure ruled out

    Z03.818

     

    Exposure to someone confirmed to have COVID-19

    Z20.828

     

    ICD-10-CM Official Coding Guidelines - Supplement Coding encounters related to COVID-19 Coronavirus Outbreak  March 18, 2020 (CDC) 

    Answer

    General Guidance for coding COVID-19 effective April 1, 2020

    When the COVID-19 virus is confirmed, code first ICD-10-CM U07.1 COVID-19, followed by the disease, condition or manifestation associated with the COVID-19 virus. 

    Clinical Impression

    Code First

    Also Code

    Other viral pneumonia

    U07.1

    J12.89

    Acute bronchitis due to other specified organisms

    U07.1

    J20.8

    Bronchitis , not specified as acute or chronic

    U07.1

    J40

    Unspecified  acute lower respiratory infection

    U07.1

    J22

    Respiratory Infection NOS, Other specified resp. disorders

    U07.1

    J98.8

    Acute Respiratory Distress Syndrome (ARDS)

    U07.1

    J80

    Suspected possible COVID-19 exposure ruled out

    Z03.818

     

    Exposure to someone confirmed to have COVID-19

    Z20.828

     

    ICD-10-CM Official Coding Guidelines - Supplement Coding encounters related to COVID-19 Coronavirus Outbreak  March 18, 2020 (CDC) 

  • In ICD 10-CM, how would a common diagnosis such as “ACS” be coded.
    Recommendations
    Answer

    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.

    Answer

    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.

  • In ICD 10-CM, how would a traumatic fracture from a trampoline fall be coded?
    Recommendations
    Answer

    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.

    Answer

    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.

  • How are poisoning, adverse effect and under dosing codes sequenced?
    Recommendations
    Answer

    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

     

    Answer

    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

     

  • Will there be updates and revisions to ICD-10-CM?
    Recommendations
    Answer

    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. 

     

    Source: 

    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,

    Answer

    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. 

     

    Source: 

    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,

  • Are "unspecified" diagnosis codes permitted with ICD-10-CM?
    Recommendations
    Answer

    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.

    Answer

    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.

  • Are External Cause Codes required for ICD-10-CM?
    Recommendations
    Answer

    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.

    Answer

    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.

  • What is ICD-10-PCS?
    Recommendations
    Answer

    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.

    Answer

    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.

  • Where can I learn more about ICD-10-CM and ICD-10-PCS?
    Recommendations
    Answer

    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-FY2020_final.pdf

    https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2020-Coding-Guidelines.pdf

    ICD-10-CM Search Tool:  https://icd10cmtool.cdc.gov/?fy=FY2020

    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

    Answer

    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-FY2020_final.pdf

    https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2020-Coding-Guidelines.pdf

    ICD-10-CM Search Tool:  https://icd10cmtool.cdc.gov/?fy=FY2020

    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

Updated March 2020

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, ACEP Reimbursement Director at (972) 550-0911, ext. 3233 or dmckenzie@acep.org.

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