Welcome to the AASM Coding Education Program. Our third module will address Diagnostic Coding in the Sleep Center. Our learning objectives for this module are identify key terminology used in diagnostic coding, identify diagnostic coding manuals used in the sleep center, explain diagnosis coding guidelines and how to read diagnosis coding manuals, and review diagnosis codes for sleep medicine. Because payment isn't tied directly to diagnosis codes, many people think that diagnostic coding isn't as important as procedure coding. The patient's diagnosis is important for accurate billing, and without accurate assignment of diagnoses, reimbursement won't be obtained. The diagnosis helps to determine and justify the level of service provided. Diagnoses justify medical necessity for the procedure, which is required for payment. Diagnoses are also important for statistical purposes. Checking diagnoses helps determine trends in disease, which can help hospitals, states, and nations plan for outbreaks and health crises. Diagnostic coding is complex and may be intimidating to new staff. Proper diagnostic coding requires a working knowledge of medical terminology. Even though it is the physician who assigns the patient's diagnosis, using diagnostic coding manuals and reviewing physician documentation requires a basic understanding of anatomy and physiology. Medical terminology, which is often derived from Latin, can seem like a foreign language to anyone unfamiliar with it. For coders who will be reviewing a lot of clinical documentation, it may be beneficial to purchase a medical terminology textbook or take a biomedical terminology course online or at a local community college. There are several terms and concepts used in diagnostic coding that may be new to you. Diagnosis codes are codes for the patient's condition, sign, or symptom. The condition, sign, or symptom is determined by the physician during the procedure or office visit. For example, obstructive sleep apnea is a common diagnosis encountered in the sleep center. A primary diagnosis is the main reason for a patient's visit. While the patient may have multiple conditions, the primary diagnosis should justify the visit and or procedure performed. Again, obstructive sleep apnea is a good example of a primary diagnosis that justifies polysomnography. There are three primary diagnosis manuals that sleep coders should be familiar with. The International Classification of Diseases 10th Revision Clinical Modification or ICD-10-CM, the International Classification of Diseases 10th Revision Procedure Coding System or ICD-10-PCS, and the International Classification of Sleep Disorders 3rd Edition or ICSD-3. The ICD-10-CM contains codes and code descriptions for medical diagnoses. The ICD-10-PCS contains procedure codes for inpatient hospital services. The ICSD-3 includes diagnostic criteria and descriptive information about all sleep disorders. This manual is most useful for sleep physicians. The ICD-10 coding system is divided into two main parts. The first part is known as the alphabetical index. It contains the index to diseases and injuries, which groups all the conditions, diseases, and circumstances that a health care provider may encounter by letter. The second part is called the tabular list. It is divided into chapters based on condition and or body system and is similar to the index of any book. Coders should never code diseases from the index. Code descriptions and other coding instructions are only found in the tabular list. This vital information is needed for correct coding. The tabular list includes chapters on both external cause codes and codes for factors influencing health status and contact with health services. The alphabetic index and the tabular list are usually published together and often the index is much longer than the tabular and can be found at the front of the book. ICD-10-PCS is a procedural coding system. The codes contained in this codebook are used for inpatient hospital procedures and are not applicable for the discussion in this coding module. To better understand the current system for diagnostic coding, it is important to understand the history and origins of the ICD. Scientists began to classify causes of death in the 17th century. This was done by an English statistician who looked at the causes of death of children before age 6. In the 18th century, additional work was done to classify diseases. The first international list of causes of death was developed in the late 19th century and is considered to be the first version of the International Classification of Diseases. The first published manual linking illnesses to numeric codes wasn't developed until 1944. Considering this history, it is clear that the statistical value of the ICD was one of the main reasons to begin classifying disorders. Causes were not linked to procedures in any formalized way until much more recently. In more recent history, the ICD-10 was first released by the World Health Organization in 1992 and implemented in the United States in 2015. It replaced the ICD-9, which had been used in the United States since 1979. The purpose of updating the ICD was to facilitate greater expansion of the coding system. The more expansive ICD-10 allows for improved specificity in coding, which in turn improves the quality of available healthcare data. The ICD-10 codebook is made up of 21 chapters. The following chapters are included. Certain Infectious and Parasitic Diseases Neoplasms Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism Endocrine Nutritional and Metabolic Diseases Mental Behavioral and Neurodevelopmental Disorders Diseases of the Nervous System Diseases of the Eye and Adnexa Diseases of the Ear and Mastoid Process Diseases of the Circulatory System and Diseases of the Respiratory System Diseases of the Digestive System Diseases of the Skin and Subcutaneous Tissue Diseases of the Musculoskeletal System and Connective Tissue Diseases of the Genitourinary System Pregnancy, Childbirth, and the Perperium Certain Conditions Originating in the Perinatal Period Congenital Malformations Deformations and Chromosomal Abnormalities Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified and Injury, Poisoning, and Certain Other Consequences of External Causes The remaining two chapters cover external causes of morbidity and factors influencing health status and contact with health services. External Causes of Morbidity are ICD-10 codes that range from V00 through Y99. These codes allow for the reporting of environmental events, circumstances, and conditions that cause injury, poisoning, and other adverse events. For example, there are external cause codes for all nature of causes of accidents such as powered appliance, electrical current, and so on. These codes are not required for reporting to all insurers and are generally used for data collection and statistical purposes. Z codes are found in the ICD-10 section called Factors Influencing Health Status and Contact with Health Services. These codes are used when circumstances other than a disease or injury result in an encounter or are recorded by providers as problems that affect care. For example, Z68, BMI, may be coded to indicate a factor that influences care. Similar to the CPT codebook, the ICD-10 codebook uses a specific code structure. ICD-10 codes are 3 to 7 characters in length. Codes with 4 or more characters include a decimal point following the third digit. For example, when submitting claims, code A12, A12.3, or A12.345, it is not appropriate to add zeros to the beginning or end of the code simply to make the code longer in length. This could result in a claim denial. The ICD-10 code system requires coders to assign diagnosis codes to the highest degree of specificity available. Within the code system, codes with more characters are more specific. Three-digit codes are generally used as the heading of a category. Categories may be further defined by 4-, 5-, and 6-character subcategories. In addition, certain codes require a 7th character extension. Most SLEE codes are 5 digits and must be coded as such. An example of this is described in detail on the next slide. Code G47 is the ICD-10 code for sleep disorders. It is subdivided into multiple 4-digit code categories including the category G47.1, hypersomnia. G47.10 is the ICD-10 code for hypersomnia unspecified. The ICD-10 is a complex coding system with many conventions and notes throughout the text. Notes throughout ICD-10 instruct the coder on how to assign diagnosis codes properly. A key at the bottom of each page explains the symbols used throughout the text. Beneath many bolded codes are lists of disorders that are part of that particular diagnosis code. This is a common occurrence in SLEE codes. In addition to these lists of disorders, some codes also include special notes which are described in the next few slides of this presentation. Code First Underlying Condition or Disease is a standard note used in the ICD-10 codebook. It means that the diagnosis in question is a secondary diagnosis and the primary diagnosis should be coded first. This occasionally occurs in SLEE codes. For example, with a sleep disorder due to a medical condition, the text below the sleep disorder code would instruct the coder to code the medical condition first as it is the primary diagnosis. Two types of excludes notes are used in the ICD-10 codebook. These notes provide the coder with information about what is included and excluded in the code. A Type 1 excludes note indicates that the coder should never use the excluded code with the code listed above the excludes note. A Type 2 excludes note means that a condition is not included in the code. For example, G47 Sleep Disorders includes the following Type 2 excludes notes, nightmares, non-organic sleep disorders, sleep terrors, and sleepwalking. Finally, the ICD-10 codebook also uses a Use Additional Code note. This note indicates that an additional code is required to specify something or identify something. For example, infection diagnoses often require an additional code to identify the bacteria that caused the infection. The bacteria are coded with a separate ICD-10 code. Also, additional codes can be required if a diagnosis often results in another condition. For example, disorders that cause dementia will include a note instructing the coder to use an additional code for the dementia. Just as with the CPT codebook, it is important for a coder to know how to use the ICD-10 index. Volume 2 of the ICD-10, the index, is far larger than Volume 1 or the tabular. The index is helpful for locating codes. However, a coder should never code directly from the index. Coders should always review the descriptor and notes in the tabular to be sure that the appropriate code or codes are being reported. The tabular is also necessary to ensure that the coder is coding to the highest degree of specificity. To search the index, you can use a variety of different types of main terms. For example, the disease can be the main term, such as meningitis, or a condition can be the main term, such as injury. Below each main term in the index, you will find subterms, which list specific codes. For example, under the main term meningitis, you will find the code for chronic meningitis among many other subtypes that each have their own code number. The ICD-10 index is relatively easy to use to find sleep disorders. When using the ICD-10 index, there is usually more than one correct way to find a particular disorder. Sleep can be used as the coder's main term when searching the ICD-10 index. When searching sleep, a coder will find a number of sleep disorders, but not all sleep disorders. Most sleep disorders can be found using the main term disorder, which is a condition. Under disorder, searching the subterm sleep will help the coder find more sleep disorders. Insomnia and hypersomnia are appropriate main terms to find codes that can also be found using disorder as a main term. Sleep disorders don't have their own section in the ICD-10. Sleep disorder codes can be found in four chapters of the ICD-10 codebook, including the Mental, Behavioral, and Neurodevelopmental Disorders chapter, the Diseases of the Nervous System, and the Symptoms, Signs, and the Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified chapter. There is also one sleep code in the Factors Influencing Health Status and Contact with Health Services chapter. Sleep disorders that are induced by alcohol and drugs can be found in the Mental, Behavioral, and Neurodevelopmental Disorders chapter. Sleep disorders codes in this chapter include alcohol-induced sleep disorders, which use codes beginning with F10, as well as drug-induced sleep disorders, which use codes beginning with F11, F12, F13, and F14. Other sleep disorders that are found in the Mental, Behavioral, and Neurodevelopmental chapter of the ICD-10 can be coded with F51, sleep disorders not due to a substance or known physiological condition. Sleep disorders are also described in the Diseases of the Nervous System chapter of the ICD-10. The sleep codes are found under the main term heading G47 Sleep Disorders. A number of subcategories exist under the main term heading including insomnia, hypersomnia, circadian rhythm sleep disorders, sleep apnea, narcolepsy, and cataplexy, parasomnia, and sleep-related movement disorders. Included in the Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere classified chapter is R40.0 Somnolence. There is one sleep diagnosis found in the Z-Code section of the ICD-10. Behavioral insomnia of childhood is coded using the Z-Code Z73.81. The code is found under the category Z73.8. Other problems related to life management difficulty, which is found in section Z73, problems related to life management difficulty. The International Classification of Sleep Disorders Third Edition, or ICSD-3, is a publication of the American Academy of Sleep Medicine. ICSD-3 is primarily a resource for physicians. It provides the physician with information on how to diagnose patients with sleep disorders. The manual includes diagnostic criteria in addition to descriptions of the disorders, essential features, and other pertinent information. It is important to note that not every disorder listed in the ICSD-3 has a corresponding ICD-10 code. Some ICSD-3 diagnoses are listed in the text below an ICD-10 code. All sleep disorder centers are encouraged to obtain a current copy of the ICD-10-CM codebook and the ICSD-3 as references. Here are a few key takeaways from this module. Diagnostic coding is complex and may be intimidating to new staff. It will be helpful to obtain a working knowledge of medical terminology. Sleep coders should familiarize themselves with characters of the ICD-10-CM codebook which relate to the sleep field. Always remember, never code from the index, follow all coding instructions under the code header, and code to the highest level of specificity. You are now ready to move on to Module 4 where you will learn Evaluation and Management Coding for Sleep Medicine.

Diagnostic Coding

Sleep Center

ICD-10-CM

ICD-10-PCS

ICSD-3