Understand what ICD-10 is all about, what it looks like, and how it will affect you and your team. Learn how to create a focused and organized strategic ICD-10 plan Evaluate and enhance clinical documentation to capture greater detail. Set up and establish documentation agreement with code factors. Get an important timeline to follow so you’re prepped and ready.

1. Brought to you by:

2. What Do I Need to Know Now about ICD-10?

3. ICD-10 Delay
Delay could cost between
$1 and $6 billion
Prepared? Relax and
refresh in time for 2015
Not prepared?
 Be proactive now
 Review and adjustment
documentation quality
 Delay allows for attention to coding
and billing procedures

4. Haven’t We Been Here Before?

5. Per CMS Acting Administrator, Merilyn Tavenner
Feb. 6, 2013: “We will
not abandon ICD-10”
 Too much work has already
been done to turn back now
 The old system won’t work with
new technologies
 That would penalize innovators
 It is necessary for health care
reform

6. Why in the World Do We Have to Change?
 WHO says so!
 US is the only civilized country
NOT on ICD-10
 Too much complaining about
costs and time

7. What’s Wrong with ICD-9?
 ICD-9 is 30 years old
 ICD-9 lacks specificity
 ICD-9 does not reflect new
services
 ICD-9 doe not compare costs
and outcomes
 ICD-9 is limited (13,000
codes)

8. What Can I Expect with ICD-10?
 ICD-10 will encompass more
precise documentation
 ICD-10 will allow for more
accuracy when determining
medical necessity for the
services rendered
 ICD-10 will allow providers to
code more accurately which
will contribute to the health
care quality improvement
initiatives

9. ICD-9 vs. ICD-10
 ICD-9-CM diagnosis
codes, 3-5 digits –
14,000 total
 ICD-10-CM diagnosis
codes, 3-7 digits –
68,000 total

10. Similarities? Not!
 3-7 characters in length – each
added digit adds specificity to
the code
 7th character can represent
visit encounters (initial,
subsequent or sequelae for
injuries and external causes
 7th character is used only for
certain sections (e.g.
musculoskeletal, injuries and
external causes of injury)
 Some codes will use “x” as a
place holder for characters 4-6
weeks when needed

11. How are ICD-9 and ICD-10 Different?
ICD-10
ICD-9

12. Let’s Compare

14. Myths or Fact?
 ICD-10 will replace CPT
 The number of codes
make ICD-10 impossible
to use
 ICD-10 is already out of
date
 Workers comp and Auto
insurance will still use
ICD-9

15. Workers Comp

16. ICD-10 Coding and Documentation
Site
Laterality
 5th or 6th digit - Sciatica
 Left – M54.31
 Right – M54.32
Episodes of care
 7th digit
 A D S
Injuries

17. The 7th Character
 A – Initial encounter, while patient is receiving active treatment such
as surgery, ER, or evaluation and treatment by a new physician.
 D – Subsequent encounter, routine care during the healing or
recovery phase, such a cast change, medication adjustment, aftercare
and follow up.
 S – Sequela, complications or conditions that arise as a direct result
of a condition, such as a degenerative disc disease a year after a neck
sprain. Sequela code (i.e. DDD) is first, then the injury code.

18. Placeholder “x” character
 Placeholder character
“x” in positions 4, 5,
and/or 6 in certain codes
to allow for future
expansion.
7th Characters
The 7th character must always be the
7th character in the data field. If a
code that requires a 7th character is
not 6 characters, a placeholder “x”
must be used to fill in the empty
characters

19. For Example
ICD-10-CM code for chronic gout due to renal impairment, left
shoulder, without tophus.
NOTE: there are 11 gout codes in ICD-9 and 365 in ICD-10

20. Important Definitions Carry Over
“Includes”
This note appears immediately under a three-digit code title to further define
clarify, or give examples of the content of a code category.
“And”
The word “and” should be interpreted to mean either “and” or “or” when it
appears in a title… “either or”
NEC “Not elsewhere classified”
Used when the information in the medical record provides detail for which
specific code does not exist
NOS “Not otherwise “specified” or “unspecified”
Used when the information in the medical record is insufficient to assign a
more specific code.

21. ICD-9 and ICD-10 Similarities
[ ] Brackets are use in the tabular list
to enclose synonyms, alternative
wording or explanatory phrases.
Brackets are used in the Index to
identify manifestation codes
( ) Parentheses are used in both the
Index and Tabular to enclose
supplementary words that may be
present or absent in the statement
of a disease or procedure without
affecting the code number to which
it is assigned. The terms within the
parentheses are referred to as
nonessential modifiers

22. Sequencing
“Code First/Use additional code”
Provides instructions on how to “sequence”
the codes. Signals that that an additional code
should be reported to provide a more
complete picture of the diagnosis
“Code Also”
Alerts the coder that more than one code may
be required to fully describe the condition. The
sequencing of the codes depends on the
severity and/or the reason for the encounter

23. So What is “Excludes 1” or “Excludes 2”?
 Similar to Correct Coding
Initiative Edits for CPT Codes
 Dictates when certain codes
can be used together and when
not
 The explanation will be helpful
in the long run

24. Remember the CCI Edits?
Excludes 1 - is used when two
conditions cannot occur
together or “NOT CODED
HERE!” Mutually exclusive
codes; two conditions that
cannot be reported together
(A condition may be acquired
OR congenital but not both!)

25. Remember the CCI Edits?
Excludes 2 – Indicates “NOT
INCLUDED HERE.” Although the
excluded condition is not part of
condition, it is excluded from, a
patient may have both conditions
at the same time. The excluded
code and the code above the
excludes can be used together if
the documentation supports
them.

26. HIPAA Electronic Transaction Standards
The new version of the standard
for electronic health care
transactions (Version5010) is
essential to the use of ICD-10
codes because the current
standard (Version 4010/4010A1),
cannot accommodate the use of
the greatly expanded ICD-10
code set.

27. CMS-1500 Claim Form
 Revision 02/12
 Changed to match the
electronic format (5010)
and ICD-10 codes
 Adds space for eight more
diagnosis codes in box 21
 Jan 6th, 2014 – Health plans
and clearing houses must
accept the form.
 April 1st, 2014 – Providers
must use the new form

29. Chapter 6: Guidelines for diseases of the nervous
system (G00-G99)
 Dominant or non-dominant side in hemiplegia
(G81):
 For ambidextrous patients, default is dominant
 If the left side is affected, default is non-
dominant
 If the right side is affected, default is dominant
 Pain (G89 pain, not elsewhere classified)
 For generalized acute, chronic, post-
thoracotomy, post-procedural, or neoplasm
related.
 Localized pain codes are found in other
chapters (i.e. M54.9, back pain)
 G89 can be the principal diagnosis when it is
reason for visit

30. Migraines: 44 Choices
Documentation must include:
 With or without aura
 Intractable or not intractable
 With or without status migrainosus
 Persistent or chronic
 With or without vomiting
 With or without opthalmoplegic,
menstrual, etc.
 Induced by ICD-10 training 

31. Chapter 13-Diseases of the Musculoskeletal
System and Soft Tissue
 Our Wheelhouse
 M-00 through M-99 series

32. General Coding Guidelines
 If the condition is bilateral and
there is no bilateral code, then
you have to list the left and
right code separately
 List unspecified if laterality is
not described

33. Examples of Common Codes
Cervicobrachial
Syndrome
 M53.1
 (excludes 2: cervical disc
disorder)
Cervicocranial
Syndrome
 M53.0
 Posterior cervical
sympathetic syndrome
Coccygodynia
 M53.3
 Defined as
Sacrococcygeal disorders,
not elsewhere classified
 In the neighborhood with
Spinal Instabilities
 M53.2X2-Spinal instabilities, cervical
region

34. Talk About Detail!
 Take 847.0 Cervical Sprain
 Could be S13.4xxA
 Could be S13.8xxA
 Much more detail is possible in
ICD-10
 Item one: sprain of ligaments of
the cervical spine
 Item two: sprain of joints and
ligaments of other parts of the
neck

35. Remember 728.85?

36. Pes Planus—Now a Code!!

39. Kissing Spine-Comparison
ICD-9
Kissing
Osteophyte 721.5
Spine 721.5
Vertebra 721.5
ICD-10
Kissing Spine, unspecified M48.20
Occipito-atlanto region M48.21
Cervical region M48.22
Cervicothoracic region M48.23
Thoracic region M48.24
Thoracolumbar region M48.25
Lumbar region M48.26
Lumbosacral region M48.27

40. Case Study
Sixty one year old female present to your office with ongoing right hip pain and stiffness.
Patient stated she had a soft tissue injury to her right hip six years ago following a bicycle
accident. X-rays at the time negative for fracture.
Tenderness to the palpation in the right hip, with a positive Patrick’s test on the right
reproducing the hip symptoms. X-rays of the left hip were unremarkable, however, the right
hip showed sclerosis of the superior aspect of the acetabulum.
DX: Post-traumatic osteoarthritis of the right hip
ICD-10:
M99.06 Segmental and somatic dysfunction of the lower extremity
M16.51 Unilateral post-traumatic osteoarthritis, right hip

42. Coding Symptoms
 Chapter 18: Guidelines for symptom signs,
and abnormal clinical findings, not
elsewhere classified
 Use of symptom codes
 Acceptable when a definitive diagnosis has not
been established by the provider
 With a definitive diagnosis
 Only when the symptom is not routinely associated
with the diagnosis
 In a combination code
 Don’t code the symptom separately if it is part of a
combination code.

43. General coding guidelines
 Use codes that describe symptoms
and signs ONLY if that is the highest
level of diagnostic certainty
documented by the doctor.
 Use if other diagnosis has been
established (confirmed) by the
provider. (see R00 to R99)
 Signs and symptoms that are
associated routinely with a disease
process should not be assigned as
additional codes, unless otherwise
instructed by the classification.
 Additional signs and symptoms that
are not routinely associated with a
disease may be reported.

44. How do I Find the ICD-10 Code?

45. Can We Just Crosswalk from ICD-9?
 General Equivalence Mappings
(GEMs)
 Some pointing based on the
initial set up
 Three possible ways to define
subluxation: M99.01, M99.11,
or S13.11
 Time will tell

46. ChiroCode ICD-10
Three Methods using the
ChiroCode ICD-10 book:
1. Commonly used code
list
2. GEMs code map
3. Alphabetic index
4. Always confirm the code
using the Tabular list

47. One-to-one Mapping
723.1 Cervicalgia
M54.2 Cervicalgia

48. One-to-Five Mapping
 724.4 Thoracic or lumbosacral
neuritis (radicular syndrome of
the lower limbs)
•ICD-10 – M54.14,
M54.15, M54.16,
M54.17, M54.18
Radiculopathy

49. What We Have Now: 729.2

50. Combination Mapping
 724.3 Sciatica
 M54.30 Sciatica,
unspecified side
 M54.31 Sciatica, right side
 M54.32 Sciatica, left side
OR
 M54.40 Sciatica with
lumbago, unspecified
 M54.41 Sciatica with
lumbago, right side
 M54.42 Sciatica with

51. Coding Whiplash
 Sprain VS. Strain
 847.0: Sprain of Neck (Includes
strain of joint capsule, ligament,
muscle, tendon)
 S13.4 _ _ _ Sprain of ligaments of
the cervical spine
 S16.1xxA STRAIN of muscle,
fascia and tendon at neck level,
initial encounter

52. Sprain Vs. Strain
“Exam findings are consistent with the strain and sprain of the
ligaments and muscles of the cervical spine and acute traumatic
headache, which does not respond to over the counter
medications. Patient was the driver of a vehicle that collided with
another motor vehicle on the interstate. He was not treated at the
scene.”
 S13.4xxA Sprain of ligaments of the cervical spine, initial encounter
 S16.1xxA Strain of muscles, fascia and tendon at neck level, initial
encounter
 G44.311 Acute post-traumatic headache, intractable
 V49.40xA Driver injured in collision with unspecified motor vehicle,
traffic accident, initial encounter
 Y92.411 Interstate as place of occurrence external cause

53. Headaches
 In ICD-9, the codes might be:
 339.21 Acute post-traumatic headache
 GEMs suggest:
 G44.319 Acute post-traumatic headache, not intractable
NOTE: in the index, G44.319 is next to G44.311 which is the intractable
version of this condition.
Intractable means “hard to control or deal with”
This must be documented in order to select the correct code

55. For Example
S30.0xxD-Contusion of
lower back and pelvis,
subsequent encounter
We will have to wait to
see whether this will be
required throughout
the episode of care, or
only on first visit using
“A”

56. V – Y Codes
Chapter 20: Guidelines for external causes of morbidity (V00-Y99)
 Never sequenced first
 Provide data about the cause, intent, place, activity, or status of the accident or
patient
 No national requirement to use these codes, but voluntary reporting is
encouraged
Y92 Place of occurrence should be listed after other codes, used only once an initial
encounter, in conjunction with Y93
Y93 Activity code should be used only once, at initial encounter

57. V, W, X, Y Codes
For Fun
 Bus Occupant V79.9
(collision with) Animal in traffic
being ridden
 Bus Occupant V70.3
(collision with) animal, non-
traffic
 Bus Occupant V70.4
(collision with) animal, while
boarding or alighting

58. E Codes in ICD-9 Expanded
 External Cause Codes
 Do you use them?
E844.8
Sucked up into a jet
without damage to
the airplane; ground
crew

59. ICD-10-CM Increased Specificity
Updated Code V97.33
Sucked into a jet without damage to the airplane

60. V91.07XA

61. V95.43XA
Spacecraft collision injuring occupant

62. Z63.1--Problems in relationship with in-laws

63. Say What??
 G44.82
Headache associated with sexual
activity
 W22.01xD
Walked into wall, subsequent encounter
 Y34
Unspecified event, undetermined intent
 R45.2
Unhappiness

64. Case Example
While playing tennis in a tournament at the
Clay Court Country Club, a male player
sprained his right wrist and was treated by his
Chiropractor close to the courts.
 S63.5001A Unspecified sprain of right wrist, initial
encounter
 Y93.73 Activity, racquet and hand sports
 Y92.312 Tennis Court (place of occurrence for
external cause)

65. What Should I Do Now?
 Concentrate on perfecting
documentation
 Learn the subtle nuances in
your current diagnosis
protocols
 Begin to discern what each
means to you

66. What Does the Documentation Look Like?
Codes must be supported by
the documentation in
patient record
The AAPC estimates an
increase in docuemtation
time of 15%
The AAPC also found that
65% of physician notes were
not specific

67. What the Does Documentation Look Like?
Examples of details
not necessary in ICD-
9:
Side of dominance
Trimesters
Stages of healing
Laterality
Ordinality
External causes

68. What Does the Documentation Look Like?
S: Mrs. Finley presents today after having a new cabinet fall on her last week suffering a concussion, as well as
some cervicalgia. She was cooking at diner at the home she shares with her husband. She did not seek
treatment at all that time. She states that the people put in the cabinet in her kitchen missed the stud by
about two inches. Her husband, who was home with her at the time told her she was “out cold” for about two
minutes. The patient continues to have cephalgias since it happened, primarily occipital, extending up into the
bilateral occipital and parietal regions. The headaches come on suddenly, last for long periods of time, and
occur every day. They are not relieved by Advil. She denies any vision changes, any taste changes, any smell
changes. The patient has a marked amount of tenderness across the superior trapezius.
O: Her weight is 188 which is up 5 pounds from the last time, blood pressure 144/82, pulse rate 70,
respirations are 18. She has full strength in her upper extremities. DTRs in the biceps and triceps are adequate.
Grip strength is adequate. Heart rate is regular and lungs are clear.
A: Status post concussion with acute persistent headaches
Cervicalgia
Cervical somatic dysfunction
P: The pain at this time is to send her for physical therapy, three times a week for four weeks for cervical soft
tissue muscle massage, as well as upper dorsal. We’ll recheck her in one month. Sooner if needed

70. Know the IT Impact You’ll Face
 What changes will need to be
made?
 Do they have available
upgrades?
 When will the upgrades be
available?
 Upgrade and your maintenance
agreement
 Will they continue to provide
support?
 Parallel coding?
 How long will my system be
down?

71. Cross Walk Exercise
 Make a list of the 10 most
common DX codes you tend
to use
 Can you list 10 more?
 Run the list from your
computer
 Practicum Exercise!

72. It’s a Peek!!

73. ICD-10 in My Practice
 Medicare: Free training
 Chirocode.com: free email alerts
and webinars, more training,
memberships, chart audits, and
coding tools
 FindACode.com: Crosswalks and
other advanced tools
 ICD10Moinitor.com: Free
Articles
 AAPC.com and AHIMA.org

74. Recommended Tools

76. FindACode.com