This document provides an overview of the transition from ICD-9-CM to ICD-10-CM for medical documentation and coding. It discusses the history and advantages of ICD-9 and ICD-10. Major changes include greater specificity in ICD-10 such as laterality, complications, and 7th characters to indicate encounter type. Documentation must reflect this level of detail for accurate coding. Examples illustrate how clinical notes should document diagnoses and injuries to support appropriate ICD-10 codes.

1. Documentation and Coding for ICD-
10 CM
Diane Bartlett, CPC
Presented March 13,2015

2. History of ICD-9
• History of ICD-9-CM
• •
• World Health Organization (WHO) developed ICD-
9 for use worldwide
• •
• U.S. developed clinical modification (ICD-9-CM)
• It was Implemented in 1979 in U.S. and annual
updates are done on October 1st.

3. Advantages of ICD-10
• ICD-9-CM is Outdated
• •
• 30 years old–technology has changed
• •
• Many categories full
• •
• Not descriptive enough

4. Advantages of ICD-10
• What Characteristics Are
• Needed in a Coding System?
• •
• Flexible enough to quickly incorporate emerging
diagnoses and procedures
• •
• Exact enough to identify diagnoses and
procedures precisely
• ICD-9-CM is neither of these

5. Advantages of ICD-10
• Reimbursement and Quality Problems With ICD-9
• Example–fracture of wrist–Patient fractures left wrist
• A month later, fractures right wrist
• ICD-9-CM does not identify left versus right–requires
additional documentation–ICD-10-CM describes Left
versus right,
• Initial encounter, subsequent encounter
• Routine healing, delayed healing, nonunion, or mal-
union

6. Some ICD-10 Major Modifications
• Added trimesters to obstetrical codes (5th digits from
ICD-9-CM will not be used)
• •
• Revised diabetes mellitus codes (5th digits from ICD-
9-CM will not be used for controlled or uncontrolled)
• •
• Expanded codes (e.g., injury, diabetes)
• •
• Added code extensions for injuries and
• external causes of injuries

7. Laterality is added
• Laterality –Left Versus Right
• C50.1Malignant neoplasm, of central portion
• of breast
• C50.111Malignant neoplasm of central
portion of right female breast
• C50.112 Malignant neoplasm of central
portion of left female breast

8. Structural Differences
• Structural Differences–ICD-9-CM
• Diagnoses•ICD-9-CM has 3–5 digits
• Chapters 1–17: all characters are numeric
• Supplemental chapters: first digit is alpha (E or V),
remainder are numeric
• •
• Examples:
• 496 Chronic airway obstruction (NEC)
• 511.9 Unspecified pleural effusion
• V02.61 Hepatitis B carrier

9. Structural Differences
• Structural Differences ICD-10-CM Diagnoses
• ICD-10-CM has 3–7 digits
• Digit 1 is alpha (A–Z, not case sensitive)
• Digit 2 is numeric
• Digit 3 is alpha (not case sensitive) or numeric
• Digits 4–7 are alpha (not case sensitive) or numeric
• –A66 Yaws
• –A69.20 Lyme disease, unspecified
• –O9A.311 Physical abuse complicating pregnancy, first
• trimester
• –S42.001A Fracture of unspecified part of right clavicle,
• initial encounter for closed fracture

10. The Placeholder Character
• In ICD-10 the placeholder is character X
• It is used in certain codes to allow for future
expansion
• Certain codes have a 7th character. If a code
that requires a 7th character is not 6
characters, a placeholder X must be used to fill
in the empty characters

11. Placeholder Examples
• Examples
• S17.0XXA Crushing injury of larynx and
trachea, initial encounter
• S01.02XA Laceration with foreign body of
scalp, initial encounter

12. Chapter Specific Changes
• Chapter 4: Endocrine, nutritional and
metabolic diseases
• ICD-10-CMs five categories for diabetes
mellitus
• E08 Diabetes mellitus due to underlying
conditions (examples, cystic fibrosis,
malignant neoplasm, cushings)
• E09 Drug, or chemical induced diabetes
• E10 Type 1 diabetes mellitus

13. Chapter 4
• E11 Type 2 diabetes mellitus
• E13 Other specified diabetes mellitus
(examples post-pancreatectomy diabetes
mellitus)
• ICD-10-CM classifies inadequately controlled,
out of control, and poorly controlled DM to
DM, by type, with hyperglycemia
• The terms controlled and uncontrolled are
eliminated.

14. Chapter 4
• Diabetes Mellitus codes have been expanded
to reflect manifestations and complications of
the disease by using 4th or 5th characters
rather than by using an additional code.
Examples:
In ICD-9-CM
Diabetes type II with diabetic peripheral
neuropathy (not uncontrolled)
250.60 DM with neurological complications

15. Chapter 4
• 357.2 polyneuropathy in diabetes
• In ICD-10-CM
• E11.42 Type 2 diabetes with diabetic
polyneuropathy ( and diabetic neuralgia)

16. Chapter 6
Diseases of the Nervous System
• Dominant/Nondominant Side
• Codes from category G81, Hemiplegia and
hemiparesis, and Monplegia of upper and
lower limb indentify whether the dominant or
nondominant side is affected, as do codes
from category I69, Sequelae of
Cerebrovascular Disease, that specify
hemiplegia or hemiparesis.

17. Chapter 9
Diseases of the Circulatory System
• Hypertension
• In ICD-9 hypertension codes classify the type of
hypertension (benign, malignant, unspecified).
• In ICD-10 hypertension codes no longer specify
the type.
• Cerebral infarctions are now coded by artery
affected by the thrombosis or embolism and by
laterality. Cerebral occlusion without infarction
are classified by artery and laterality as well.

18. Chapter 9
Diseases of the Circulatory System
• Acute myocardial infarction in ICD-10
• These codes specify ST elevation MI and non
ST elevation MI and identify the site, such as
anterolateral wall or true posterior wall as well
as the artery involved.
• A new category, I22, has been added for
subsequent STEMI and non STEMI occurring
within four weeks of a previous acute MI.

19. MI Continued
• Examples:
• I21.01 ST elevation (STEMI) myocardial
infarction of anterior wall involving left main
coronary artery.
• I21.02 ST elevation myocardial infarction of
anterior wall involving left anterior descending
coronary artery.
• Non-STEMI infarctions do not specify the site.

20. Chapter 13
Diseases of the Musculoskeletal
System
• Recurrent bone, joint or muscle conditions
that are the result of a healed injury are found
in this chapter.
• Any current, acute injury should be coded
with an injury code from chapter 19.

21. Chapter 13
• Osteoporosis
• Osteoporosis is classified as either
• Age related (M80.0-) or
• Other osteoporosis (each having its own code)
• Drug-induced
• Idiopathic
• Osteoporosis of disuse
• Post-oophorectomy osteoporosis
• Post –surgical osteoporosis
• Post –traumatic osteoporosis

22. Osteoporosis
• In addition, osteoporosis is coded either:
• With current pathological fracture
• Or
• Without current pathological fracture
• In ICD-10 the default code for a fracture
following a minor injury in a patient with
known osteoporosis is M80.- (Osteoporosis
with current pathological fracture)

23. Chapter 19
Injury and Poisoning
• In ICD-10 injuries are first classified by site of
injury, then by type of injury.
• In ICD-9 injuries are first classified by type of
injury

24. Chapter 19
• Use of 7th characters in Chapter 19
• Most codes in this chapter have a 7th character
requirement
• A: Initial encounter
• D: Subsequent encounter
• S: Sequela

25. 7th Characters in Chapter 19
• A: Initial encounter
• This is used while the patient is receiving
active treatment for the condition.
• Examples of active treatment are:
• Surgical treatment
• ED encounter
• Evaluation and Management by a new
physician

26. 7th Characters in Chapter 19
• D: Subsequent encounter
• This is used for encounters after the patient
has received active treatment and is receiving
routine care during the healing or recovery
phase.
• Examples
• Follow-up visits including med adjustments
• Cast change or removal

27. 7th Characters in Chapter 19
• S: Sequela
• This is used for complications or conditions
that arise as a direct result of a condition, such
as scar formation after a burn.
• We use two codes to describe a sequela
• The code for the sequela itself
• The code that precipitated the sequela (with
7th character S)

28. 7th Characters for Fractures
Episode of care
• A: Initial encounter for closed fracture
• B: Initial encounter for open fracture
• D: Subsequent encounter for fx with routine
healing
• G: Subsequent encounter for fx with delayed
healing
• K: Subsequent enc for fx with nonunion
• S: Sequela

29. Burns and Corrosions
Chapter 19
• The ICD-10 CM makes a distinction between
burns and corrosions.
• The burn codes are for thermal burns, (except
sunburn) as well as burns from electricity or
radiation.
• Burns are classified by depth, extent, and by
agent.

30. Adverse effect, Poisoning and
Underdosing
• An adverse effect code is used when a drug
has been correctly prescribed and properly
administered.
• A code to describe the nature of the adverse
effect is coded, followed by a code for the
adverse effect of the drug.
• Example: Tachycardia R00.0, T48.6X5A

31. Adverse Effect, Poisoning and
Underdosing
• Poisoning is coded when a medication is
improperly used
• Examples are overdose, wrong substance
given or taken in error, wrong route of
administration.
• When a reaction results from the interaction
of drugs or alcohol, this would be classified as
a poisoning.

32. Adverse Effect, Poisoning and
Underdosing
• Underdosing is a new category and refers to
taking less of a medication prescribed by a
provider or manufacturer’s instructions.
• There are additional codes for noncompliance
to indicate intent, if known. (Z91-)
• Examples:
• Patient’s intentional underdosing due to cost
of medicine. Z91.128

33. Inoculations and Vaccinations
Chapter 21
• Code Z23 is for encounters for inoculations
and vaccinations, or as a secondary code if the
vaccination is given as a routine part of
preventive health care.
• The procedure code (the vaccine product)
indentifies the type(s) of immunizations given.

34. Chapter 10
Diseases of the Respiratory System
• Sinusitis
• ICD-10 classifies sinusitis as acute or chronic
similar to ICD-9, but ICD-10 also classifies
acute, recurrent sinusitis.
• Recurrent sinusitis in ICD-10 is 3 or more
episodes in a year, each lasting less than 2
weeks.

35. Chapter 10
Diseases of the Respiratory System
• Asthma J45.-
• In ICD-10, there are 6 categories of asthma
• Mild intermittent asthma
• Mild persistent asthma
• Moderate persistent asthma
• Severe persistent asthma
• Unspecified asthma
• Other asthma (including exercise induced and
cough variant asthma)

36. Preventive Care Codes
• The categories for routine preventive (well)
exams now include codes for exams with and
without abnormal findings.
• Z00.00 Encounter for general adult medical
exam without abnormal findings
• Z00.01 Encounter for general adult medical
exam with abnormal findings

37. Preventive Care Codes
• In this context, abnormal findings mean
abnormal results are known at the time the visit
is being coded.
• If the encounter is being coded before test results
are back, it is acceptable to assign the code for
with normal findings.
Routine exams for children (Z00.021 and Z00.029
are also classified with and without abnormal
findings, as are Encounters for routine
gynecological exam (Z01.411 and Z01.419)

38. So How Does This Affect
Documentation
• The Diabetes complication must be stated in
the encounter note or the correct code cannot
be assigned.
• For patients who have hemi-paresis from a
stroke, dominant or dominant side affected
should be stated in the encounter note.
• An acute MI should be stated as STEMI or Non
STEMI and by the wall affected.

39. Documentation Challenges
• Osteoporosis should be stated as age-related
or due to other causes to be correctly coded.
• It should also be stated if there is a current
pathological fracture
• Asthma should be stated as mild, moderate or
severe and also intermittent or persistent.

40. Documentation Challenges
• Injuries
• It should be stated in the encounter note or
easily inferred, if this is the initial encounter or
a subsequent encounter for an injury.
• Fractures
• It should be stated in the note if the patient is
being seen for initial or subsequent encounter,
and if routine healing is taking place or a
complication.

41. Sample Notes
• X is a 9 Years & 7 Months Old male accompanied by a his
mother. His medical records were obtained from the
patient and his mother. This 9 years & 7 months old male
was seen today for injury to his right little toe. The injury to
his right little toe occurred on 02/26/2015 when he was
walking and stubbed his right little toe on a wooden bench.
• There was immediate pain right little toe. He did try to
walk on it. There was swelling when the injury occurred:
right little toe. There was bruising when the injury
occurred: . His skin is intact.
• He had X-rays on 02/27/2015 at X hospital.
• The patient is full weight bearing on right.

42. Continued Note
• Assessment of Studies
• X-RAY: X Hospital 2/27/15 left toes: this study
was reviewed. There is a Salter II fracture of
the proximal phalanx left little toe, in good
position.
• Assessment
• fracture proximal phalanx left little toe

43. Coding this condition
• ICD-9 code 826.0 Fracture of one or more
phalanges of the foot
• ICD-10 S92.515A
• S92.51 is Fracture of proximal phalanx of
lesser toe(s)
• 6th character 5 indicates non-displaced and
left toe
• 7th character indicates initial visit for closed
fracture

44. Rationale
• The ED physician would code initial encounter
for non-displaced fracture and this orthopedic
physician would also code initial encounter.
• The character A indicates this is the initial
encounter while the patient is receiving active
care for the fracture (new doctor).
• ICD-10 specifies the laterality, displaced vs
non-displaced and the specific part of the
bone fractured.

45. Salter-Harris Classification
• In ICD-10 physeal fractures of the long bones
(Humerus, femur, tibia, radius and ulna) can
also be specifically coded as Salter-Harris
fractures types I-IV.

46. Sample Note
• Reason For Visit: Follow up right navicular foot
fracture
• HPI: Patient presents today for follow up of his
right navicular foot fracture which occurred on
12/16/14. He was casted on 1/5/15. He denies
any discomfort at this time. He feels that his cast
is loose and it is bothering him. His short leg
cast has been removed and his skin is clean, dry
and intact. His exogen unit remains intact. He
has been using it daily as instructed.

47. Note Continued
• Assessment
• fracture right navicular
• Assessed FRACTURE, FOOT as unchanged Dr X MD
• Plan:
• Patient instructed to call with any questions or
concerns.He had a CT scan 2/18/15 which showed the
osteopenia and further healing of the navicular. His
original xrays did not show the fracture, so no follow
up xray was done today. He will weight bear to
tolerance out of the cast. He will work on motion and
strength. He will use the exogen unit for a total of 3
months. The trainer was contacted as well.

48. Coding this note
• ICD-9 825.22 Fracture of navicular, foot, closed
• ICD-10 S92.254D
• The 6th character indicates non-displaced and
right foot.
• The 7th character indicates a subsequent
encounter for fracture with routine healing.
• M85.871 Other specified disorders
(osteopenia) of bone density and structure,
right ankle and foot

49. Sample Note
• CC: f/u htn and dm.
• History of Present Illness:
• Patient is here for f/u htn and dm. Diabetes is
not well controlled and complicated by
diabetic neuropathy. Followed by dr. X. Patient
is on Insulin pump. Asthma is well controlled.
• Problem # 1: DIABETES MELLITUS, TYPE II,
ON INSULIN
• Assessment: Unchanged

50. Note Continued
• Problem # 2: ASTHMA, PERSISTENT, MILD (ICD-
493.90) (ICD10-J45.30)
• Assessment: Improved
• ICD-9 Coding
• 250.62 DM Type II uncontrolled, with
neurological complications
• 357.2 Diabetic peripheral neuropathy
• 493.90 Asthma, unspecified
• V58.67 Long term use (current) of insulin

51. Note Continued
• ICD-10 Coding
• E11.42 Type 2 DM with diabetic neuralgia
• E11.65 Type 2 DM with hyperglycemia
• Z79.4 Long term (current) use of insulin
• J45.30 Mild persistent asthma, uncomplicated

52. Rationale
• In ICD-9 Diabetes is classified as controlled or
uncontrolled. In ICD-10 diabetes stated as
poorly controlled, out of control or inadequate
control is coded as Diabetes (by type) with
hyperglycemia.
• Two codes are required to code DM type 2
with diabetic neuralgia in ICD-9. In ICD-10 one
code encompasses both conditions.

53. Rationale
• In both ICD-9 and ICD-10, routine use of
insulin is coded, except that in ICD-10 long
term (current) use of insulin is not coded for
Type 1 diabetes.
• In ICD-9, there is no code to specify the
severity or frequency of asthma symptoms. In
ICD-10 there is a specific code to identify mild,
persistent asthma.

54. Final Thoughts
• Many physicians are worried about the
increased specificity requirements they hear
about ICD-10.
• While there are many more codes to select
from, many of the increases in codes are due
to laterality.
• Most of ICD-10 follows the same coding
guidelines as ICD-9.

55. Questions ?