In the next eMDs Insights Blog Series, we will be exploring the specifics of ICD-10-CM. In this first post, we will start at the top - how the ICD-10 is organized and structured. In future posts, we will explore the specific differences between ICD-9-CM and ICD-10 CM for the most common codes by specialty. In order to maintain consistency with and adherence to CMS published policy, we will use material originally published by CMS in its "Road to 10" series for these initial educational posts. Some of the material may be reorganized for readability and brevity. About ICD-10 The ICD-9 code sets used to report medical diagnoses and inpatient procedures is slated to be replaced by ICD-10 code sets on October 1, 2015. ICD-10 consists of two parts:
- ICD-10-CM diagnosis coding which is for use in all U.S. health care settings.
- ICD-10-PCS inpatient procedure coding which is for use in U.S. hospital settings.
ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by the Health Insurance Portability Accountability Act (HIPAA), not just those who submit Medicare or Medicaid claims:
- Claims for services provided on or after the compliance date should be submitted with ICD-10 diagnosis codes.
- Claims for services provided prior to the compliance date should be submitted with ICD-9 diagnosis codes.
The change to ICD-10 does not affect CPT coding for outpatient procedures.
- Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of any or all of the 4th, 5th, and 6th characters. Digits 4-6 provide greater detail of etiology, anatomical site, and severity. A code using only the first three digits is to be used only if it is not further subdivided.
- A code is invalid if it has not been coded to the full number of characters required. This does not mean that all ICD-10 codes must have 7 characters. The 7th character is only used in certain chapters to provide data about the characteristic of the encounter. Examples of where the 7th character can be used include injuries and fractures, as illustrated in the following tables:
|Injuries and External Causes
||Initial Encounter for closed fracture
||Initial encounter for open fracture
||Subsequent encounter for fracture with routine healing
||Subsequent encounter for fracture with delayed healing
||Subsequent encounter for fracture with non-union
||Subsequent encounter for fracture with malunion
A dummy placeholder of “X” is used with certain codes to allow for future expansion and/or to fill out empty characters when a code contains fewer than 6 characters and a 7th character applies. When a placeholder character applies, it must be used in order for the code to be considered valid. Below are specific examples of ICD-10 diagnosis codes. The use of combination codes, increased specificity, and the “X” placeholder is illustrated:
||Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
||Non-displaced fracture of base of neck of right femur, subsequent encounter for closed fracture with delayed healing
||Malignant neoplasm of lower-outer quadrant of right female breast
||Malignant neoplasm of lower-outer quadrant of left female breast
||Primary open-angle glaucoma, moderate stage
ICD-10-CM Indexes A comprehensive listing of 2015 diagnosis codes can be found in the ICD-10-CM Index to Diseases and Injuries (alphabetical) and ICD-10-CM Tabular List of Diseases and Injuries which can be accessed from the following links:
A summary of the chapters found in the Tabular List has been provided below:
||Estimated # of Codes
||Certain infectious and parasitic diseases
||Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism
||Endocrine, nutritional and metabolic diseases
||Mental, behavioral and neurodevelopment disorders
||Diseases of the nervous system
||Diseases of the eye and adnexa
||Diseases of the ear and mastoid process
||Diseases of the circulatory system
||Diseases of the respiratory system
||Diseases of the digestive System
||Diseases of he skin and subcutaneous tissue
||Diseases of the musculoskeletal system and connective tissue
||Diseases of the genitourinary system
||Pregnancy, childbirth and puerperium
||Certain conditions originating in the perinatal period
||Congenital malformations, deformations and chromosomal abnormalities
||Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
||Injury, poisoning and certain other consequences of external causes
||External causes of morbidity
||Factors influencing health status and contact with health services
External Cause Code Reporting If you have not been reporting ICD-9-CM external cause codes, you will not be required to report ICD-10-CM codes found in Chapter 20 unless a new State or payer-based requirement about the reporting of these codes is instituted. If such a requirement is instituted, it would be independent of ICD-10-CM implementation. In the absence of a mandatory reporting requirement, you are encouraged to voluntarily report external cause codes, as they provide valuable data for injury research and evaluation of injury prevention strategies. Native Coding and Unspecified Codes Native coding means to assign an ICD-10 diagnosis code directly based on clinical documentation. Practices are encouraged by CMS to natively code using ICD-10 code reference sources instead of using crosswalks, which should be used for general knowledge. Specific codes reflecting the most appropriate level of certainty known for an encounter should be evaluated first:
- 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.
- 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 is not known or available about a particular health condition to assign a more specific code, coding should comply with the payer guidelines for the use of unspecified codes.