ICD-9-CM ICD-10-CM

Sponsored by:
INOVA
Presented by:
Teri Romano, RN, MBA, CPC, CMDP
August 19, 2015
CONNECT WITH US AT
WWW.KARENZUPKO.COM
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FOCUS
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Documentation! 
Diagnosis codes that get paid.
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Diagnosis codes that accurately portray your patient population.
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
ICD‐9 is out of date and running out of space for new codes.
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ICD‐10 is the international standard to report and monitor disease and mortality – USA must adopt for reporting and surveillance.
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ICD codes are core elements of many health information technology systems making the conversion to ICD‐10‐CM necessary to fully realize benefits of HIT adoption.
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It is mandated by CMS for all HIPAA‐covered entities.
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Today‐payors use diagnosis codes to:
 Deny payment based on a lack of medical necessity/wrong ICD‐10 code.
 Build payment policies based on specific diagnosis codes.
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Today and future‐ payors will use diagnosis codes to  Establish reimbursement in risk based contracting models.
 Determine payment in ACO ( shared savings) and bundled payment models.
 Determine patient complexity to justify inpatient status and establish post‐
op visit benchmarks.
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Source: https://www.cms.gov/Medicare/Coding/ICD10/ Downloads/ICD‐10‐guidance.pdf
ICD‐9‐CM
ICD‐10‐CM
• 3‐5 characters in length
• Approximately 14,000 codes
• 3‐7 characters in length
vs.
• Approximately 69,000 codes
• Limited space for adding new codes
• Flexibility for adding new codes
• Lacks detail
• Very specific
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ICD‐9‐CM Code Structure ICD‐10‐CM Code Structure
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First Character C, D
N
Chapters Pertinent to Breast Surgery
Neoplasms
Genitourinary (Breast)
R
Symptoms/Signs
Z
Other Reasons for Health Care N
Category
Etiology,
Anatomic Site, Severity
Extension
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ICD‐10 says:
“Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.”
Examples:
You send the patient to their cardiologist for a pre‐op evaluation for co‐existing cardiac conditions.
 The patient has ESRD and you request clearance by his physician.

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Action:

Code the primary reason for the visit (breast cancer) and the underlying conditions if they affect your treatment/surgical plan.
Why?
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Accurately portray the complexity of your patient population.
Patient complexity will impact payment models, risk‐based contracting, ACOs, and bundled payments.
Patient complexity also impacts inpatient status, number of post‐
op visits and more.
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Asthma
 COPD

Kidney Disease  HTN/Angina/Heart Disease

Nicotine Dependence  Alcohol Abuse/ Dependence/Use

Diabetes
 Other?

Obesity/BMI
 Personal History of… 11
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“Other” or “Other Specified”
 Use when information in the medical record provides needed detail, but a specific code does not exist.

Examples:
 N64.89 Other specified disorders of the breast
▪ Galactocele
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
Unspecified”
 Use when the information in the medical record is insufficient to assign a more specific code.
 Beware of unspecified codes! Denial risk!
Example:
 K64.9 Disorder of breast, Unspecified 13
Laterality of one of the biggest changes in coding for disorders of the breast
For example: C 50.311 Malignant neoplasm of lower‐inner quadrant of right female breast
C 50.312 Malignant neoplasm of lower‐inner quadrant of left female breast
Tip: For laterality often a 1 in a code will indicate right, a 2 will indicate left.
Tip: No bilateral code exists. If the diagnosis is bilateral, use both the right and left codes.
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Utilize technology to facilitate finding the right code!
EMR, www.ICD10data.com, and more!
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CHAPTER 18: S Y M P TO M S , S I G N S A N D A B N O R M A L C L I N I C A L
A N D L A B O R ATO R Y F I N D I N G S
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Chapter Organization
R00‐R99
R
Category
Etiology,
Extension
Anatomic Site, Severity
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Do code signs and symptoms if a definitive diagnosis is not known. You see a patient with abnormal mammogram prior to a biopsy.
Do not code signs and symptoms if a more definitive diagnosis is known. For example, don’t code abnormal mammogram if the biopsy shows cancer.
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Abnormal Mammogram ICD‐9
793.80 Abnormal mammogram, unspecified
793.81 Mammographic microcalcification
793.82 Inconclusive mammogram
793.89 Other (abnormal) findings on
radiological examination of breast
ICD‐10
R92.0 Mammographic microcalcification found on diagnostic imaging of breast
R92.1 Mammographic calcification found on diagnostic imaging of breast
R92.2 Inconclusive mammogram
R92.8 Other abnormal and inconclusive
findings on diagnostic imaging of breast
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Abnormal Mammogram
Do NOT Say: Abnormal mammogram
DO Say: Microcalcification found on mammogram
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CHAPTER 14: D I S EA S E S O F T H E G E N I TO U R I N A RY ( I N C LU D ES B R EA S T )
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Chapter Organization
N00‐N99
N
Category
Etiology,
Extension
Anatomic Site, Severity
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Breast Disorders
ICD‐9
611.72 Lump or mass in breast
ICD‐10
N63 Unspecified lump in breast
611.0 Inflammatory disorder of breast
N61 Inflammatory disorder of breast
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Breast Cyst (N60.‐)
ICD‐9 ICD‐10 610.0 Solitary cyst of breast
N60.01 Solitary cyst of right breast
N60.02 Solitary cyst of left breast
N60.09 Solitary cyst of unspecified breast
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Cyst in Breast
Do NOT Say: Breast cyst (N60.09, unspecified)
DO Say: Cyst right breast (N60.01)
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Diffuse Cystic Mastopathy (N60.‐)
ICD‐9 610.1 Diffuse cystic
mastopathy
ICD‐10 N60.11 Diffuse cystic mastopathy
right breast
N60.12 Diffuse cystic mastopathy of left breast
N60.19 Diffuse cystic mastopathy
cyst of unspecified breast
Cystic breast, fibrocystic disease of breast.
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Other Breast Disorders
611.1 611.2
611.3
611.4
611.5 611.79
ICD‐9 Hypertrophy of breast
Fissure of nipple
Fat necrosis of breast
Atrophy of breast
Galactocele
Other signs and symptoms in breast
N62 N60.02
N64.1
N64.2
N64.8
N64.51
N64.52
N64.53
N64.59
ICD‐10 Hypertrophy of breast
Fissure and fistula of breast
Fat necrosis of breast
Atrophy of breast
Other disorders of the breast
Induration
Nipple discharge
Retraction of nipple
Other
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Fibroadenosis of Breast
ICD‐9
610.2 Fibroadenosis of breast
ICD‐10
N60.21 Fibroadenosis of right breast
N60.22 Fibroadenosis of left breast
N60.29 Fibroadenosis of unspecified breast
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CHAPTER 2 :
NEOPLASMS
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Chapter Organization
C00‐D49
C or D
Category
Image source: http://upload.wikimedia.org/wikipedia/commons/8/8b/Cranial_bones_en.svg
Etiology,
Extension
Anatomic Site, Severity
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
Most significant changes in ICD‐10
 Laterality. Now codes for right or left breast
 Male breast cancer codes expanded. Mirror female anatomic sites and laterality
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Category of Neoplasm
Type of Neoplasm
Malignant, primary
Information
Cancer, first site
Malignant, secondary
Metastatic site
Carcinoma in situ
Benign
The risk of transforming to cancer is high
Non‐cancer
Uncertain behavior
Histologic diagnosis made by pathologist, morphology of tumor is uncertain
The pathology is unknown at the time of encounter
Unspecified
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Overlapping sites should be classified to a .8 code unless a combination code exists.
 Example: C50.8.‐ Malignant neoplasm of overlapping sites of breast
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Primary Malignancies With overlapping site boundaries
A primary malignancy that overlaps two or more contiguous sites should be classified to the subcategory .8 overlapping lesions, unless there is a combination code.
Example:
Malignant neoplasm of overlapping sites of left female breast C50.812
Without overlapping boundaries
For multiple neoplasms that are not contiguous code for each site
Example:
Breast areola C50.9‐
Breast lower‐outer quadrant C50.5‐
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
“History of” vs. “Active” neoplasms codes
 No further treatment – no further treatment then use a Z85.‐ code
 Example: Z85.3 – Personal history of malignant neoplasm of breast
[Follow‐up visit 3 years post‐surgical resection with no evidence of disease]
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Breast Neoplasms
Location
Connective tissue, glandular soft parts Areola
Axillary tail Central portion
Inner
Lower
Lower‐inner
Lower‐outer
(More by site)
Malignant Malignant Primary
Secondary
C50.9‐
C79.81
Ca in
situ
D05.‐
Benign
D24.‐
Uncertain Behavior Unspecified
D48.6‐
D49.3
C50.0‐
C50.6‐
C50.1‐
C50.8‐
C50.8‐
C50.3‐
C50.5
D05.‐
D05.‐
D05.‐
D05.‐
D05.‐
D05.‐
D05.‐
D24.‐
D24.‐
D24.‐
D24.‐
D24.‐
D24.‐
D24.‐
D48.6‐
D48.6‐
D48.6‐
D48.6‐
D48.6‐
D48.6‐
D48.6‐
C79.81
C79.81
C79.81
C79.81
C79.81
C79.81
C79.81
D49.3
D49.3
D49.3
D49.3
D49.3
D49.3
D49.3
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C50.2‐
Malignant neoplasm of upper‐inner quadrant of breast
C50.21‐ Malignant neoplasm of upper‐inner quadrant of female breast
C50.211 Malignant neoplasm of upper‐inner quadrant of right female breast
C50.212 Malignant neoplasm of upper‐inner quadrant of left female breast
C50.219 Malignant neoplasm of upper‐inner quadrant of unspecified female breast
C50.22‐ Malignant neoplasm of upper‐inner quadrant of male breast
C50.221 Malignant neoplasm of upper‐inner quadrant of right male breast
C50.222 Malignant neoplasm of upper‐inner quadrant of left male breast
C50.229 Malignant neoplasm of upper‐inner quadrant of unspecified male breast
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Breast Cancer
Do NOT Say: Breast cancer (C50.919, unspecified)
DO Say: Breast cancer in the lower‐inner quadrant, right breast (C50.311)
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This code category has been expanded to include more specific types of carcinoma in situ.
ICD‐9‐CM (1code)
ICD‐10‐CM (12 codes)
233.0 Carcinoma in situ of breast
D05.00 D05.01 D05.02 D05.10 D05.11 D05.12 D05.80 D05.81 D05.82 D05.90 D05.91 D05.92 Lobular carcinoma in situ of unspecified breast
Lobular carcinoma in situ of right breast
Lobular carcinoma in situ of left breast
Intraductal carcinoma in situ of unspecified breast
Intraductal carcinoma in situ of right breast
Intraductal carcinoma in situ of left breast
Other type of carcinoma in situ of unspecified breast
Other specified type of carcinoma in situ of right breast
Other specified type of carcinoma in situ of left breast
Unspecified type of carcinoma in situ of unspecified breast
Unspecified type of carcinoma in situ of right breast
Unspecified type of carcinoma in situ of left breast
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Breast Cancer
Do NOT Say: Cancer in situ, breast ( D50.90, unspecified)
DO Say: Lobular carcinoma in situ, left breast (C50.02)
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These codes have equivalent mapping with ICD‐9‐CM.
Personal hx of malignant neoplasm of breast V10.3 = Z85.3
Family hx of malignant neoplasm of breast V16.3 = Z80.3
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ICD‐9‐CM
V82.71 Screening for genetic disease carrier status
ICD‐10‐CM
Z13.71 Encounter for non‐procreative screening for genetic disease carrier status
Z13.79 Encounter for other screening for genetic and chromosomal anomalies
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ICD‐10‐CM
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N99.61
N99.62
N99.71
N99.72
N99.81
Descriptor
Intraoperative hemorrhage and hematoma of a genitourinary system structure complicating a genitourinary system procedure
Intraoperative hemorrhage and hematoma of a genitourinary system structure complicating other procedure
Accidental puncture and laceration of a genitourinary system system structure during a genitourinary system procedure
Accidental puncture and laceration of a genitourinary system structure during other procedure
Other intraoperative complications and disorders of genitourinary system
ICD‐9‐CM Descriptor
998.11 Hemorrhage complicating a procedure
998.12 Hematoma complicating a procedure
998.11 Hemorrhage complicating a procedure
998.12 Hematoma complicating a procedure
Accidental puncture or laceration 998.2 during a procedure, not elsewhere classified
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ICD‐10‐CM Descriptor
ICD‐9‐CM Descriptor
998.11 Hemorrhage complicating a Postprocedural hemorrhage and procedure
hematoma of a genitourinary N99.820
system structure following a 998.12 Hematoma complicating a genitourinary system procedure
procedure
998.11 Hemorrhage complicating a Postprocedural hemorrhage and procedure
hematoma of a genitourinary N99.812
system structure following
998.12 Hematoma complicating a other procedure
procedure
N99.89 Other postprocedural 997.99 Complications affecting other complications and disorders of specified body systems, not the genitourinary system
elsewhere classified
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WHAT NOW?? NEXT STEPS.
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IDENTIFY YOUR TOP 20‐25 PRIMARY ICD‐9 CODES
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 The Books
 CMS  Your EHR/practice management information system. https://www.cms.gov/Medicare/Coding/ICD10/Other‐Content‐Types/ICD‐10‐Logo.jpg
https://commerce.ama‐assn.org/store/catalog/productDetail.jsp?product_id=prod1250081&navAction=push
http://www.cpticdpros.com/icd10‐coding.html
ICD‐9 Code
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ICD‐10 Code and Description
Potential Documentation Gaps
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 EHR‐ develop favorite “pick list”
 Cheat sheets: create reference guides by physician 49
AKA: Prospective
“Gap Analysis”
DUAL CODE: ICD‐9‐CM AND ICD‐10‐CM
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USING YOUR EMR AND OTHER TECHNOLOGY
UNDERSTAND THE LIMITATIONS!! 51
THANK YOU
Teri Romano
RN, MBA, CPC, CMDP
www.karenzupko.com
312.642.5616
[email protected]
@KarenZupkoAssoc
karenzupkoandassociates
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