By Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer
A large part of ICD-9-CM and ICD-10-CM are very much alike, beyond the construction of the codes themselves going from a maximum of five numbers to a maximum of seven alphanumeric combinations. Let’s take a look at some of the significant changes between the two code sets and their official guidelines.
Neoplasms
The ICD-10-CM Official Guidelines for Coding and Reporting include dramatically more direction for accurately coding neoplasms. In addition to those specifically provided in ICD-9-CM, our new code set includes these additional subsections of guidance:
- Malignancy in two or more noncontiguous sites
- Disseminated malignant neoplasm, unspecified
- Malignant neoplasm without specification of site
- Sequencing of neoplasm codes
- Current malignancy versus personal history of malignancy
- Leukemia, multiple myeloma, and malignant plasma cell neoplasms in remission versus personal history of leukemia
- Aftercare following surgery for neoplasm
- Follow-up care for completed treatment of a malignancy
- Prophylactic organ removal for prevention of malignancy
One of the biggest changes in ICD-10-CM is the guideline for sequencing neoplasm and anemia:
When the admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by code D63.0, Anemia in neoplastic disease.
The ICD-9-CM guidelines instruct coders to code the anemia as the principal diagnosis because it is the reason the admission occurred.
Diabetes mellitus
Reporting diabetes mellitus has become the job of virtually all coders, regardless of the type of facility due to the number of Americans diagnosed with some version of this chronic illness.
The real difference between the two sets of guidelines comes down to the fact that coding this specific diagnosis has gotten simpler:
Each type of diabetes mellitus has its own code category and controlled vs. uncontrolled is not a detail reported in ICD-10-CM, so the Official Guideline related to reporting the 5th digit has been deleted.
Sequencing of the diabetes code and the code for a manifestation are no longer required in ICD-10-CM due to an increased number of combination codes.
Mental and behavioral disorders
For those of you familiar with this chapter, you know that ICD-9-CM provided no official guidelines at all. However, ICD-10-CM does provide some support. For example, guideline 5a (pain disorders related to psychological factors) states:
Assign code F45.41, for pain that is exclusively related to psychological disorders. As indicated by the Excludes 1 note under category G89, a code from category G89 should not be assigned with code F45.41.
Code F45.42, Pain disorders with related psychological factors, should be used with a code from category G89, Pain, not elsewhere classified, if there is documentation of a psychological component for a patient with acute or chronic pain.
ICD-10-CM also includes guidelines for reporting mental and behavioral disorders due to a psychoactive substance.
Nervous system
One significant addition to the ICD-10-CM guidelines is direction for the accurate reporting of the dominant and non-dominant side as they relate to conditions such as hemiplegia, hemiparesis, and monoplegia.
Guideline 6a states:
Codes from category G81, Hemiplegia and hemiparesis, and subcategories G83.1, Monoplegia of lower limb, G83.2, Monoplegia of upper limb, and G83.3, Monoplegia, unspecified, identify whether the dominant or nondominant side is affected. Should the affected side be documented, but not specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows:
• For ambidextrous patients, the default should be dominant.
• If the left side is affected, the default is non-dominant.
• If the right side is affected, the default is dominant.
Hypertension
One important change in this chapter is the elimination of malignancy or benign state of the patient’s hypertension. In ICD-10-CM, essential hypertension is its own code category with no additional details required. Therefore, the guideline in ICD-9-CM about reporting Hypertension, Essential or NOS has been eliminated in ICD-10-CM.
Respiratory conditions
The ICD-9-CM guidelines related to the overlapping nature of chronic obstructive pulmonary disease (COPD) and asthma, acute bronchitis with COPD, and acute exacerbation of asthma have not been carried over into ICD-10-CM. Only the guideline directing the reporting of acute exacerbation of chronic obstructive bronchitis and asthma remains.
ICD-10-CM does include a new guideline for reporting ventilator-associated pneumonia when the provider’s documentation has specifically identified a cause-and-effect relationship between the pneumonia and the time spent on the ventilator.
Pregnancy-related conditions
As you may know, ICD-10-CM will require the details of the number of weeks of gestation and trimester to determine the correct code(s). Therefore, ICD-10-CM includes new official guidelines for:
- Final character for trimester
- Selection of trimester for inpatient admissions that encompass more than one trimester
- Unspecified trimester
There is also a new guideline for ICD-10-CM regarding the determination of the character to report the seventh character for fetus identification. The ICD-10-CM guidelines provide direction for the reporting of additional factors when caring for a pregnant woman:
- Pre-existing conditions versus conditions due to the pregnancy
- Pre-existing hypertension in pregnancy
- Sepsis and septic shock complicating abortion, pregnancy, childbirth, and the puerperium
- Puerperal sepsis
- Alcohol and tobacco use during pregnancy, childbirth, and the puerperium
- Poisoning, toxic effects, adverse effects, and underdosing in a pregnant patient
- Abuse of a pregnant patient
Pressure ulcers
ICD-9-CM official guidelines directing the reporting of bilateral pressure ulcers of the same or different sites and stages have been eliminated. ICD-10-CM provides combination codes of sites and stages, thereby making those guidelines unnecessary.
Musculoskeletal conditions
Additional guidelines in ICD-10-CM provide direction for some complexities when reporting diagnoses for musculoskeletal conditions:
- Site and laterality, specifically bone versus joint
- Acute traumatic versus chronic or recurrent musculoskeletal conditions
- Osteoporosis with and without a current pathological fracture
ICD-10-CM also eliminates the official guideline related to reporting aftercare of fractures because the seventh character relays this detail.
Newborn (perinatal) conditions
Changes in these guidelines have also occurred to reflect the coding changes from ICD-9-CM to ICD-10-CM. The ICD-10-CM official guidelines expand on what was offered in ICD-9-CM:
- Observation and evaluation of newborns for suspected conditions not found
- Coding additional perinatal diagnoses
- Prematurity and fetal growth retardation
- Low birth weight and immaturity status
- Stillbirth
Signs and symptoms
ICD-9-CM offered no official guidance for reporting conditions using codes from this chapter. However, ICD-10-CM has added several official guidelines to support coder accuracy.
For example, ICD-10-CM guideline 18a states:
Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
The ICD-10-CM guidelines also instructs you to report signs and symptoms when they are not integral to a disease process, but not to report them when the sign or symptom is integral.
If a combination code identifies both the definitive diagnosis and common symptoms of that diagnosis, you should only report the combination code.
ICD-10-CM also includes guidelines for:
- Repeated falls
- Coma scale
- Functional quadriplegia
- SIRS due to a non-infectious process
- Death NOS
Poisonings
ICD-10-CM has expanded the official guidelines to instruct coders not to code directly from the Table of Drugs.
Use as many codes as necessary to describe completely all drugs and medicinal or biological substances.
If the same code would describe the causative agent for more than one adverse reaction, poisoning, toxic effect, or underdosing, assign the code only once. If two or more drugs, medicinal, or biological substances are reported, code each individually unless a combination code is listed in the Table of Drugs and Chemicals.
A provision for reporting underdosing, in addition to overdosing, has also been added.
This has been an overview of some of the more significant changes to the Official Guidelines for Coding and Reporting as we transition from ICD-9-CM to ICD-10-CM. For the most part, these adjustments provide a greater level of support for every coder to report diagnoses, signs, and symptoms with accuracy.
Editor’s note:Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, of Safian Communications Services in Orlando, Florida, is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee. Email her at ssafian@embarqmail.com.