WHAT changes will Medical Coders and Heavy Data Users see?
ICD-10-CM will be similar to ICD-9-CM because they have the:
- Same basic guidelines
- Same basic layout/organization
- Same basic index
- Same basic tabular
- Same basic format (category, etiology, and manifestation)
The ICD-10 code set has updated “features”—language and classification based on current medical practice. Some areas will be affected by ICD-10 in terms of clinical documentation, more than others. The greatest affect in clinical documentation will occur with:
- Injuries (fractures, sprains, poisoning, burns, complications of, etc.) require specific detail. Injuries account for approximately half (50%) of the increase in codes
- Fractures account for approximately twenty-five percent (25%) of all ICD-10 diagnosis codes and will include additional classification of the stage of healing: “initial”, “subsequent”, “sequlea,” and healing type of “routine” or “delayed.” Laterality also will be classified.
- Laterality (right vs. left) specification, where applicable. Laterality accounts for approximately one third (1/3) of the increase in diagnosis codes
- Changes in disease classifications and definitions. Some examples include:
- Diabetes Mellitus codes are expanded to include the classification of the diabetes and the manifestation. No longer classified as controlled/uncontrolled.
- Trimester and week gestation are incorporated in the codes and descriptions
- Acute Myocardial infarction time period changed from 8 weeks to 4 weeks
- Substance Abuse includes abuse vs. dependence and blood alcohol levels
ICD-10-PCS will be dramatically different. ICD-10-PCS is primarily used by Inpatient Medical Coders and Trauma &/or Cancer Registrars.