Health Information Management

Take the fear out of switch to ICD-10-CM

JustCoding News: Outpatient, November 16, 2011

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Outpatient!

Coders shouldn’t fear the upcoming transition to ICD-10-CM. It’s not as scary or as completely revolutionary as they might think. They will have more code choices and new guidelines to learn, but they are still looking to the documentation to find the information they need.

Outpatient coders will still use CPT codes the same way they do now, says Robert S. Gold, MD, CEO of DCBA, Inc., a consulting firm in Atlanta. The only thing that will change is the how the diagnosis is named.

Don’t get stuck on memorization
Many coders know the ICD-9-CM codes they use the most without even having to look them up. That comfort level may inspire fear about using the new codes. After all, if the physician documents diabetes mellitus, coders can generally recall by memory the code 250.00.

Coders need to remember that the diagnostic conditions won’t necessarily be new to them, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of coding and HIM at HCPro, Inc., in Danvers, MA. Instead of relying on memory for the appropriate codes, coders will need to go back to the thought process of looking up codes (or going through all the decisions using an encoder rather than bypassing and overriding to directly enter the appropriate code). This step will be necessary until they get used to the new system.

But that thought alone shouldn’t keep coders up at night. “How to look up a code is still the same,” says McCall. Coders just need to look up the main term in the Alphabetic index or Table of Drugs and Chemicals, then verify the code assignment in the Tabular list, being careful to look for any instructional notes pertinent to the category of codes they are assigning.

Most of the coding guidelines will stay the same, but some of them will change. The challenge for coders will be to apply those new guidelines when they go against the way they’ve coded for years, cautions Jennifer Avery, CCS, CPC-H, CPC, CPC-I, senior regulatory specialist with HCPro, Inc., in Danvers, MA.

“Coders are very structured people and they don’t like it when guidelines change,” Avery says. “That’s going to be a struggle [for some coders].”

Coders who code both inpatient and outpatient records will still need to remember which hat they’re wearing, Avery says. As with ICD-9-CM, some of the ICD-10-CM guidelines vary depending on setting.

Dig in to documentation
With all of the attention around the increased specificity of ICD-10-CM codes, coders may be concerned that documentation will lack sufficient detail. And let’s face it, physicians don’t always provide enough information for coders to choose the most specific ICD-9-CM code.

Instead of panicking, coding managers should determine which conditions the providers at their facility or practice most often treat, says McCall. Then evaluate the documentation to see what additional information providers will need to document with the added specificity for ICD-10-CM.

“Identify the information that providers can document now,” McCall says. The additional information may not help with ICD-9-CM coding, but providers will already be documenting those details when ICD-10-CM rolls around.

“You can’t use the new codes now, but you can look to see what additional documentation you will need,” McCall adds.

Some things that weren’t important in ICD-9-CM will be needed in ICD-10-CM. For example, if a patient comes in with acute pancreatitis and is also identified as being alcohol dependent, coders can assign separate codes in ICD-9-CM for acute pancreatitis (577.0) and a code for alcohol dependence (303.xx or 305.xx) with no need to identify if the conditions are interrelated.

However, in ICD-10-CM, if coders get this same documentation it could prompt a query to the provider because there is a more specific combination code that can be assigned to identify the conditions being related—code K85.2 (Alcohol induced acute pancreatitis).

Physicians may not be accustomed to being asked for correlation of some conditions because in the past it wasn’t relevant to appropriate code assignment. But coders can report certain conditions in ICD-9-CM that will no longer have a default code in ICD-10, which will prompt coders to go back to the physicians’ for clarification, Avery says. “Physicians are used to be questioned about urosepsis as to whether they mean a urinary tract infection (UTI) or sepsis of a urinary source, but they also know that if they don’t clarify that coders can assign 599.0 for a UTI because in ICD-9-CM the term urosepsis defaults to a UTI.”

However, in ICD-10-CM, coders cannot assign a code for urosepsis without going back to the physician. When coders look the term up in the alphabetic index the term urosepsis directs the coder to code to condition, forcing a query, Avery says. “If we begin to educate the physicians’ now that urosepsis will no longer be a codeable diagnosis it may actually assist us with one of our longest running coding conundrums.”

Be sure to share this information with your physicians. “When physicians know what to put in the record, everything else works,” Gold says.

The way coders present information to a physician will also be important, Avery adds. If physicians know why coders are require the documentation, they are more likely to make the changes. If coders just send them a query asking them for additional information, they may not change how they document and coders will always be querying on the condition. “If they know that the specificity is necessary in order to code the condition in ICD-10 then it will make a difference,” Avery says.

Recognize the similarities
There are similarities between the code sets and the guidelines for using them. For example, ICD-10-CM still uses ‘code first’ notes to alert providers that two codes are necessary to fully classify the condition.

Just as with ICD-9-CM, in ICD-10-CM when physicians document both hypertension and chronic kidney disease, coders can assume a relationship between the two. And the guidelines still require coders to report the appropriate code for the stage of the chronic kidney disease along with the combination code for the hypertension and chronic kidney disease.

When coding injuries, coders will still assign separate codes for each injury unless they are coding burns or a combination code is available. When reporting burns, coders will still sequence first the code that reflects the highest degree of burn when more than one is present.

Embrace the differences
Some of the changes included in ICD-10-CM will actually simplify coding. Excludes notes are a great example. In ICD-9-CM, an Excludes note can mean two different things:

  • A particular code is not for use with a particular condition
  • A particular condition is not included in a particular code

ICD-10-CM will resolve that confusion by using two different excludes notes—Excludes1 and Excludes2—to differentiate the meanings.

An Excludes1 note is a pure excludes note, meaning it indicates that a coder should never use the code excluded at the same time as the code above the Excludes1 note. The two conditions cannot occur together.

An Excludes2 note means the condition is not included in the code. An Excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, coders may report both the code and the excluded code together when appropriate.

Get to know the placeholder
ICD-9-CM codes are three to five characters long. ICD-10-CM codes can be up to seven characters long and not every code with a seventh character has a sixth character—or even a fifth or fourth character for that matter. And if the character isn’t in the correct position, the code isn’t valid.

In those cases, such as poisonings or injuries, coders will need to add a placeholder so the seventh character ends up in the correct position. The placeholder is an ‘x’.

For example, a patient presents with an accidental poisoning by an antiallergic drug. For the initial encounter, coders would report T45.0x1A. In this case the x is merely a placeholder so the sixth and seventh characters are in the correct position. If a coder inadvertently omits the placeholder, the resulting code would be T45.01A, which is invalid.

Coders should also note that an ICD-10-CM code can start with an X (i.e., codes X00–X99). For example, in code category X78.0, the X is the category of codes and identifies intention of an injury, exposure, etc. The X series of codes is part of Chapter 20: External causes of morbidity. For example, X78.0xxA identifies an intention of self-harm from sharp glass.

The location of the X within the code matters. When x is in the fourth, fifth and/or sixth character, x is a placeholder. When X is at the beginning of the code, it indicates the chapter.

Coders and coding managers can begin preparing for ICD-10 now by learning the structure of the codes and guidelines. By drilling down to determine what the specific challenges that they’ll see at their facility, they can help conquer their fear of ICD-10-CM.

E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Outpatient!

Most Popular