UHS, Inc.

ICD-10-CM/PCS
Physician Education
General Surgery

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 ICD-10 Implementation

• October 1, 2015 – Compliance date for

implementation of ICD-10-CM (diagnoses) and
ICD-10-PCS (procedures)
– Ambulatory and physician services provided on or after
10/1/15
– Inpatient discharges occurring on or after 10/1/15

• ICD-10-CM (diagnoses) will be used by all

providers in every health care setting

• ICD-10-PCS (procedures) will be used only for

hospital claims for inpatient hospital procedures
– ICD-10-PCS will not be used on physician claims, even
those for inpatient visits
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 Why ICD-10

Current ICD-9 Code Set is:

– Outdated: 30 years old
– Current code structure limits amount of
new codes that can be created
– Has obsolete groupings of disease families
– Lacks specificity and detail to support:
• Accurate anatomical positions
• Differentiation of risk & severity
• Key parameters to differentiate disease manifestations

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Diagnosis Code Structure

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ICD-10-CM Diagnosis Code Format

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Comparison: ICD-9 to ICD-10-CM

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Procedure Code Structure
ICD-10-PCS Code Format

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 ICD-10 Changes Everything!

• ICD-10 is a Business Function Change, not just

another code set change.

• ICD-10 Implementation will impact everyone:

– Registration, Nurses, Managers, Lab, Clinical Areas,
Billing, Physicians, and Coding

• How is ICD-10 going to change what you do?

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 ICD-10-CM/PCS
Documentation Tips

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 ICD-10 Provider Impact
• Clinical documentation is the foundation of successful ICD-
10 Implementation

• Golden Rule of Documentation

– If it isn’t documented by the physician, it didn’t happen
– If it didn’t happen, it can’t be billed

• The purpose in documentation is to tell the story of what

was performed and what is diagnosed accurately and
thoroughly reflecting the condition of the patient
– what services were rendered and what is the severity of illness

• The key word is SPECIFICITY

– Granularity
– Laterality

• Complete and concise documentation allows for accurate

coding and reimbursement
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 Gold Standard Documentation Practices
1. Always document diagnoses that contributed to the reason for
admission, not just the presenting symptoms

2. Document diagnoses, rather that descriptors

3. Indicate acuity/severity of all diagnoses

4. Link all diseases/diagnoses to their underlying cause

5. Indicate “suspected”, “possible”, or “likely” when treating a

condition empirically

6. Use supporting documentation from the dietician / wound care to

accurately document nutritional disorders and pressure ulcers

7. Clarify diagnoses that are present on admission

8. Clearly indicate what has been ruled out

9. Avoid the use of arrows and symbols

10. Clarify the significance of diagnostic tests

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 ICD-10 Provider Impact

The 7 Key Documentation Elements:

1.Acuity – acute versus chronic
2.Site – be as specific as possible
3.Laterality – right, left, bilateral for paired organs and
anatomic sites
4.Etiology – causative disease or contributory drug, chemical,
or non-medicinal substance
5.Manifestations – any other associated conditions
6.External Cause of Injury – circumstances of the injury or
accident and the place of occurrence
7.Signs & Symptoms – clarify if related to a specific condition
or disease process

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 ICD-10 Documentation Tips

Document all acute or chronic conditions

that are being:

– Clinically evaluated or

– Diagnostically tested or

– Therapeutically treated or

– Cause an increased Length of Stay (LOS) or nursing

care

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 ICD-10 Documentation Tips

Do not use symbols to indicate a disease.

For example “↑lipids” means that a laboratory result

indicates the lipids are elevated
– or “↑BP” means that a blood pressure reading is high

These are not the same as hyperlipidemia or hypertension

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 ICD-10 Documentation Tips
Site and Laterality – right versus left
–bilateral body parts or paired organs
Example – cellulitis of right upper arm

Stage of disease – acute vs. chronic vs. acute on chronic

Example – stage of pressure ulcer:
– L89.011 Pressure ulcer of right elbow, stage 1
– L89.021 Pressure ulcer of left elbow, stage 1

Episode of care – initial, subsequent, and sequelae

Example - lower leg fracture:
– A initial encounter for closed fracture
– B initial encounter for open fracture type I or II
– C initial encounter for open fracture type IIIA, IIIB, or IIIC
– D subsequent encounter for closed fracture with routine healing
– H subsequent encounter for open fracture type I or II with delayed
healing
– K subsequent encounter for closed fracture with nonunion
– S sequelae
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 ICD-10 Documentation Tips

Cause of Injury

– Mechanism
• How it happened

– Place of occurrence
• Where it happened

– Activity
• What was the patient doing

– External Cause
• Work-related, leisure

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 ICD-10 Documentation Tips

Glasgow Coma
- ICD-10-CM coding will need the score from each of the
assessment areas
– Eye opening
– Verbal response
– Motor response

» R40.211 Coma scale, eyes open never

» R40.212 Coma scale, eyes open to pain
» R40.213 Coma scale, eyes open to sound
» R40.214 Coma scale, eyes open spontaneously

–Report the Glasgow coma scale total score

» R40.241 Glasgow coma scale score 13 – 15
» R40.242 Glasgow coma scale score 9 - 12
» R40.243 Glasgow coma scale score 3 – 8

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 ICD-10 Documentation Tips

Crohn's disease
- Specify the site
• Colon
• Duodenum
• Ilium
• Jejunum
• Small intestine

Include any manifestations:

– K50.00 Crohn's disease of small intestine without complications

– K50.011 Crohn's disease of small intestine with rectal bleeding
– K50.012 Crohn's disease of small intestine with intestinal obstruction
– K50.013 Crohn's disease of small intestine with fistula
– K50.014 Crohn's disease of small intestine with abscess
– K50.018 Crohn's disease of small intestine with other complication
– K50.019 Crohn's disease of small intestine with unspecified complications

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 ICD-10 Documentation Tips

Diabetes - include the type or cause of diabetes

– Type I
– Type II
– Due to drugs and chemicals
– Due to underlying condition
– Other specified diabetes
– Link any manifestations to the diabetes
• Circulatory, renal, neurological, ophthalmic, skin, other

•E08 - Diabetes mellitus due to underlying condition

– E08.10 Diabetes mellitus due to underlying condition with ketoacidosis
without coma
– E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with
coma
•E11 - Type 2 diabetes mellitus
– E11.311 Type 2 diabetes mellitus w/ unspecified diabetic retinopathy with
macular edema
– E11.319 Type 2 diabetes mellitus w/ unspecified diabetic retinopathy without
macular edema

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 ICD-10 Documentation Tips

Fractures – clearly document all aspects

– Cause – traumatic, stress, pathological

– Location – which bone, which part of the bone, laterality

– Type – displaced, non-displaced, open, closed

– Encounter – initial, subsequent, sequelae

– External cause – how the fractured occurred and the activity

• Example - Fall while skiing

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 ICD-10 Documentation Tips

Open fractures - Please specify the severity using the

Gustilo-Anderson Open Fracture Classification system for
forearm, femur, and lower leg

–Type I: The wound is smaller than 1 cm, clean, and generally caused by a fracture
fragment that pierces the skin (i.e., inside-out injury).
–Type II: The wound is longer than 1 cm, not contaminated, and without major
soft tissue damage or defect. This is also a low-energy injury.
–Type III: The wound is longer than 1 cm, with significant soft tissue disruption.
The mechanism often involves high-energy trauma, resulting in a severely unstable
fracture with varying degrees of fragmentation.

–Type III fractures are further divided into

• III A: Soft tissue coverage of the fractured bone is adequate.
• III B: Disruption of the soft tissue is extensive, that local or distant flap
coverage is necessary.
• III C: Any open fracture that is associated with an arterial injury that a
physician must repair, regardless of the degree of soft tissue injury.

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 ICD-10 Documentation Tips

Pathologic (non-traumatic) fractures:

– Exact location of fracture –

• Bone, part of the bone, and laterality

– Etiology of the fracture –

• osteoporosis, neoplastic disease, other specified

– Encounter type –
• initial encounter, subsequent encounter with routine
healing, subsequent encounter with delayed healing,
malunion, nonunion, or sequelae

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 ICD-10 Documentation Tips
Neoplasm

– Location
• Detailed location
• Left, Right, Bilateral

– Morphology
• Malignant, Benign
• Primary , Secondary
• In situ
• Uncertain behavior, Unspecified behavior

– Histology
• Identified by cytology, histology or pathology findings

– Stage / Metastatic
• Different, distinct locations
– Different primaries
– Metastatic sites

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 ICD-10 Documentation Tips
Neoplasm continued

– Is patient being admitted for treatment of the neoplasm or an

adverse reaction / complication?
• Treatment - surgery, chemotherapy, immunotherapy, radiation
• Adverse reaction of treatment – neutropenic fever secondary to chemo
• Complication of the disease – anemia due to malignancy

– Document if a complication is part of the disease process or

an adverse effect of treatment
• Anemia due to malignancy or due to chemotherapy

– History of
• Malignancies previously removed and no longer receiving active
treatment
• Clearly document for follow-up and medical surveillance

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 ICD-10 Documentation Tips

Drug Under-dosing is a new code in ICD-10-CM.

– It identifies situations in which a patient has taken less of a

medication than prescribed by the physician.
• Intentional versus unintentional

– Documentation requirements include:

• The medical condition
• The patient’s reason for not taking the medication
– example – financial reason
– Z91.120 – Patient’s intentional underdosing of
medication due to financial hardship

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 ICD-10 Documentation Tips

Codes for postoperative complications have been expanded and a

distinction made between intraoperative complications and post-
procedural disorders

•The provider must clearly document the relationship between the

condition and the procedure
– Example:
• D78.01 –Intraoperative hemorrhage and hematoma of spleen
complicating a procedure on the spleen
• D78.21 –Post-procedural hemorrhage and hematoma of spleen following
a procedure on the spleen

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 ICD-10 Documentation Tips
Intra-operative Post-procedural
Accidental puncture / laceration Timing:
•Post-procedure
•Late effect
Same or different body system Classify as:
•An expected post-procedural
Blood product
condition
Central venous catheter •An unexpected post-procedural
Drug: condition, related to the
•What adverse effect patient’s underlying medical
•Drug name comorbidities
•Correctly prescribed •An unexpected post-procedural
•Properly administered condition, unrelated to the
procedure
Encounter: •An unexpected post-procedural
•Initial condition related to surgical care
•Subsequent (a complication of care)
•Sequelae

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 ICD-10 Documentation Tips

ICD-10-PCS does not allow for unspecified procedures,

clearly document:

•Body System
– general physiological system / anatomic region

•Root Operation
– objective of the procedure

•Body Part
– specific anatomical site

•Approach
– technique used to reach the site of the procedure

•Device
– Devices left at the operative site
 ICD-10 Documentation Tips

Example – spinal fusion

•Root Operation
–Fusion

•Body Part
–Thoracic vertebral joints 2 - 7

•Approach
– Open (anterior/posterior) and Column (anterior/posterior)

•Device
–Autologous tissue substitute
 ICD-10 Documentation Tips
Most Common Root Operations for General Surgery:
Bypass – altering the Drainage – taking or Release – freeing a Resection – cutting out
route of passage letting out fluids &/or body part from an or off without
gases abnormal physical replacement all of a
constraint body part

Detachment – cutting Excision – cutting out Repair – restoring, to Restriction – partially

off all of part of the or off without the extent possible, a closing an orifice or
upper or lower replacement a portion body part lumen of a tubular
extremity of a body part body part
Dilation – expanding Fusion – joining Replacement – putting Supplement – putting
an orifice or the lumen together portions of in a biological or in a biological/
of a tubular body part an articular body, synthetic material that synthetic material to
rendering it immobile takes the place &/or reinforce / augment
function
Division – cutting into Reattachment – Reposition – moving Transfer – moving,
a body part to putting back in or on to its normal location without taking out, all
transect the body part all or a portion of a or a portion of a body
separate body part part to another
location 31
 ICD-10 Documentation Tips
Most Common Device Types for General Surgery:
Artificial sphincter External fixation Intraluminal device, Spinal stabilization
device plain drug-eluting or device, facet
radioactive replacement
Cardiac lead Extraluminal device Intramedullary Spinal stabilization
internal fixation device, interspinous
device process device
Cardiac rhythm Feeding device Liner Spinal stabilization
related device device, pedicle-based
device
Contraceptive device Hearing device, bone Monitoring device Stimulator generator
conduction
Contractility Hearing device, Pacemaker, single or Stimulator lead
modulation device cochlear prosthesis dual
Defibrillator Interbody fusion Radioactive element Tracheostomy device
device
Drainage device Internal fixation Spacer Vascular access
device device, reservoir or
pump 32
 ICD-10 Documentation Tips
Most Common Root Operations for Gastroenterology:
Bypass – altering the Drainage – taking or Repair – restoring, to Restriction – partially
route of passage letting out fluids &/or the extent possible, a closing an orifice or
gases body part lumen of a tubular body
part

Control – stopping, or Excision – cutting out or Replacement – putting Supplement – putting in

attempting to stop, off without replacement in a biological or a biological/ synthetic
post-procedural a portion of a body part synthetic material that material to reinforce /
bleeding takes the place &/or augment
function
Dilation – expanding an Reattachment – putting Reposition – moving to Transfer – moving,
orifice or the lumen of a back in or on all or a its normal location without taking out, all
tubular body part portion of a separate or a portion of a body
body part part to another location

Division – cutting into a Release – freeing a body Resection – cutting out Transplantation –
body part to transect part from an abnormal or off without putting in or on all or a
the body part physical constraint replacement all of a portion of a living body
body part taken from another
individual or animal33
 ICD-10 Documentation Tips
Most Common Device Types for Gastroenterology:

Artificial sphincter Extraluminal Intraluminal Radioactive

device device, plain or element
radioactive

Drainage device Feeding device Monitoring device

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 ICD-10 Documentation Tips
Most Common Root Operations for Nephrology / Urology:
Bypass – altering the route Release – freeing a body Resection – cutting out or
of passage part from an abnormal off without replacement
physical constraint all of a body part

Dilation – expanding an Repair – restoring, to the Restriction – partially

orifice or the lumen of a extent possible, a body closing an orifice or lumen
tubular body part part of a tubular body part

Drainage – taking or letting Replacement – putting in a Supplement – putting in a

out fluids &/or gases biological or synthetic biological/ synthetic
material that takes the material to reinforce /
place &/or function augment

Excision – cutting out or off Reposition – moving to its Transplantation - putting

without replacement a normal location in or on all or a portion of
portion of a body part a living body taken from
another individual or
animal 35
 ICD-10 Documentation Tips

Most Common Device Types for Nephrology / Urology:

Artificial sphincter Extraluminal Intraluminal Stimulator lead

device device, plain,
drug-eluting or
radioactive
Drainage device Infusion device Monitoring device

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 ICD-10 Documentation Tips
Most Common Root Operations for Otorhinolaryngology:
Control – stopping, Drainage – taking or Repair – restoring, to Restriction – partially
or attempting to letting out fluids &/or the extent possible, a closing an orifice or
stop, post-procedural gases body part lumen of a tubular
bleeding body part
Dilation – expanding Excision – cutting out Replacement – Supplement – putting
an orifice or the or off without putting in a biological in a biological/
lumen of a tubular replacement a or synthetic material synthetic material to
body part portion of a body that takes the place reinforce / augment
part &/or function
Division – cutting into Release – freeing a Reposition – moving Transfer – moving,
a body part without body part from an to its normal location without taking out,
draining fluids &/or abnormal physical all or a portion of a
gases from the body constraint body part to another
part in order to location to take over
transect the body Resection – cutting the function of all or
part out or off without a portion of the body
replacement all of a part
body part 37
 ICD-10 Documentation Tips

Most Common Device Types for Otorhinolaryngology :

Drainage device Hearing device, Intraluminal Radioactive

bone conduction device element

Extraluminal Hearing device, Monitoring device

device cochlear
prosthesis

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 ICD-10 Documentation Tips
Most Common Root Operations for Ophthalmology:
Control – stopping, or Extirpation – taking or Removal – taking out or Resection – cutting out
attempting to stop, cutting out solid matter off a device from a body or off without
post-procedural from a body part part replacement all of a
bleeding body part

Division – cutting into a Extraction – pulling or Repair – restoring, to Supplement – putting in

body part to transect stripping out or off all of the extent possible, a a biological/ synthetic
the body part a portion of a body part body part material to reinforce /
augment

Drainage – taking or Insertion – putting in a Replacement – putting Transfer – moving,

letting out fluids &/or non-biological appliance in a biological or without taking out, all
gases that does not take the synthetic material that or a portion of a body
place of the body part takes the place &/or part to another location
function
Excision – cutting out or Release – freeing a body Reposition – moving to
off without replacement part from an abnormal its normal location
a portion of a body part physical constraint

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 Summary
The 7 Key Documentation Elements:
1.Acuity – acute versus chronic
2.Site – be as specific as possible
3.Laterality – right, left, bilateral for paired organs and
anatomic sites
4.Etiology – causative disease or contributory drug, chemical,
or non-medicinal substance
5.Manifestations – any other associated conditions
6.External Cause of Injury – circumstances of the injury or
accident and the place of occurrence
7.Signs & Symptoms – clarify if related to a specific condition
or disease process

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