ICD-10-CM is full speed ahead. The Senate approved the Medicare Sustainable Growth Rate (SGR) bill that did not include a reference to an ICD-10 delay. The October 1 implementation date is only a few short months away, increasing the urgency for those still preparing.
 
It is imperative that providers’ documentation be clear, detailed and concise. This will require education and working with referring physicians to obtain as much information as possible for the anesthesiologist to document to the highest specificity. Documentation requirements that may have not been presented in the past are now requirements for ICD-10 coding. The following are types of documentation requirements covered in I-10:

  • Laterality (right, left or bilateral)
  • Site specificity
  • Identification of the fetus affected by certain complications of pregnancy, childbirth and puerperium in multiple gestation pregnancies
  • Identification of the trimester for complications occurring during pregnancy
  • Episode of care (initial, subsequent, sequela) for injuries, poisoning, external causes and other conditions
  • Combination codes (etiology and manifestations) (related conditions) (disease, injury or other medical condition and complications) (diseases or other medical conditions and common signs or symptoms)
  • Current codes have been moved to new categories or chapters – Example is fractures (see below)

Diagnoses from Chapter 19, Injury, Poisoning and Certain Other Consequences of External Causes, require the documentation to have much greater specificity, most notably for fractures and burns. For example, note below the following documentation required to arrive at an accurate code for fractures:       

Required Documentation for Coding Fractures:

  • Traumatic vs. Non Traumatic* (pathological)
  • Laterality (left or right)
  • Specific site of the facture (proximal, distal, and shaft)
  • Malunion or Nonunion
  • Routine vs. delayed healing
  • Displaced vs. non displaced
  • Type of encounter:
    A-Initial encounter: used while the patient is receiving active treatment for the conditions.1
    • Open vs. closed
    • Some open fracture codes allow for further classification based on the Gustilo open fracture classification (i.e., type I, II, IIIA, IIIB, IIIC)
    D- Subsequentencounter: used after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase
    S- Sequela: used for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn.
    *Per the guidelines for Chapter 19, “A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone."2
  • In ICD-9, if the fracture was documented traumatic or pathological, per the guidelines, the coder was to assign the first listed. ICD-10 does not have this guideline. The provider will need to clearly document the fracture as traumatic or pathologic in order for an accurate ICD-10 code to be assigned. ICD-10 guidelines state I.C13.b “If it is difficult to determine from the documentation in the record which code is best to describe a condition, query the provider”.3

Required Documentation for Coding Injuries

  • Superficial injuries (Abrasions or Contusions) vs. Lacerations.
    • Laterality
    • Type
    • Anatomic site
    • Type of encounter:
      A-Initial encounter
      D- Subsequent
      S- Sequela
  • Anatomic site (joint specific)
    • Left, right, anterior, posterior, inferior, percentage displaced, medical and lateral
    • Type of encounter:
      A-Initial encounter
      D- Subsequent
      S- Sequela
  • Dislocations, Sprain of joints and ligaments, Tears – specifically, with meniscus injuries location and type are also required. 
    • Traumatic vs. nontraumatic (old)
    • Location
    • Type   
    • Laterality
      • Anatomic site (joint specific) - Left, right, anterior, posterior, inferior, percentage displaced, medial and lateral
    • Type of encounter:
      A-Initial encounter
      D- Subsequent
      S- Sequela 

Required Documentation for Coding Burns

“There is a distinction between burns and corrosions. The burn codes are for thermal burns, (except sunburns), that come from a heat source, such as a “fire or hot appliance”.  The burn codes are also for burns resulting from electricity and radiation. Corrosions are burns “due to chemicals”.4

Burns are classified by depth, extent and by agent. 

  • Depth: 
    First degree: erythema
    Second degree: blistering
    Third degree: full – thickness involvement

Codes are assigned for each burn site (body region). Burns can be of different depths on different body surfaces.

Additionally, burns are classified according to extent of body surface involved using the “rule of nines” for estimating body surface involvement:

  • Head and neck are assigned 9%
  • Each arm is 9%
  • Each leg is 18%
  • Both anterior and posterior are 18% each
  • Genitalia is 1%

Providers may change these percentage assignments where necessary to accommodate infants and children who have proportionately larger heads than adults, and patients who have large buttocks, thighs or abdomen that involve burns.

Of note, encounters for the treatment of the late effects of burns or corrosions (i.e. contractures of joints or scars) are coded with a 7th character “S” to identify sequelae.

1ICD-10 – CM, 2015 Complete Draft Code Set, Chapter 19 - Injury, Poisoning, and Certain Other Consequences of External Causes, Page 19.
2ICD-10 – CM, 2015 Complete Draft Code Set, Chapter 13 - Diseases of the Musculoskeletal System and Connective Tissue, Page 1 9.
3ICD-10 – CM, 2015 Complete Draft Code Set, Chapter 13, Diseases of the Musculoskeletal System and Connective Tissue,  Page 14
4ICD-10 – CM, 2015 Complete Draft Code Set, Chapter 19, Injury, Poisoning, and Certain Other Consequences of External Causes, Page 19.

References
ICD-9-CM for Physicians Volumes 1 & 2 Ingenix/OptumInsight
The Complete Official Draft Codebook 2015 ICD-10-CM American Medical Association

Author - Female

About the author

Mary Jo Gross, CPC, CANPC of Compliance – Anesthesia and Pain Management, McKesson Business Performance Services