ICD-10-CM Coding Tips

Transcription

1 ICD-10-CM Coding Tips for clients of: Content developed and presented by: 3030 N. Rocky Point Drive, Suite 240 Tampa, FL

2 ICD-10-CM Coding Tips Limited Copyright: October 2018, Polaris Group All materials are protected under the copyright laws. The limited copyright allows the purchaser to copy for use but not for distribution. FH54 - Developed by Polaris Group Page 1 of 158

3 ICD-10-CM Coding Tips POST TEST 1. When coding a hip replacement following a fracture, should the hip replacement or hip fracture code be used as the primary first-listed diagnosis? 2. The care team needs to identify and sequence codes to ensure an accurate claim. a. True b. False 3. The previous V codes for Therapy in ICD-9-CM do not exist in ICD-10-CM. Which statement(s) below apply: a. Underlying diagnosis that warrants therapy would be listed first on claim b. Still use treatment diagnoses for therapy on claim c. All of the above 4. For aftercare of a fracture, assign the acute fracture code with the appropriate 7th character such as D for Subsequent (aftercare) or S for Sequela (complications or late effects). a. True b. False 5. The process for selecting a code includes: a. First locate term in the Alphabetic Index b. Then verify in the Tabular List c. Read and be guided by instructional notations that appear in both d. Essential to use both Alphabetic Index and Tabular List e. All of the above FH54 - Developed by Polaris Group Page 2 of 158

4 ICD-10-CM Coding Tips POST TEST ANSWERS 1. When coding a hip replacement following a fracture, should the hip replacement or hip fracture code be used as the primary first-listed diagnosis? Hip Fracture 2. The care team needs to identify and sequence codes to ensure an accurate claim. True 3. The previous V codes for Therapy in ICD-9-CM do not exist in ICD-10-CM. Which statement(s) below apply: a. Underlying diagnosis that warrants therapy would be listed first on claim b. Still use treatment diagnoses for therapy on claim c. All of the above 4. For aftercare of a fracture, assign the acute fracture code with the appropriate 7th character such as D for Subsequent (aftercare) or S for Sequela (complications or late effects). True 5. The process for selecting a code includes: a. First locate term in the Alphabetic Index b. Then verify in the Tabular List c. Read and be guided by instructional notations that appear in both d. Essential to use both Alphabetic Index and Tabular List e. All of the above FH54 - Developed by Polaris Group Page 3 of 158

5 ICD-10-CM Coding Tips 1 Outline ICD-10-CM Websites FY19 Updates Section I MDS Updates Coding Conventions Process for Coding Chapter Specific Guidelines 7 th Characters Documentation to Support Coding Accurate Diagnoses that Support Medical Record Questionable Principal Diagnoses Coding Issues Identified ICD-10 Examples/Case Studies 2 FH54 - Developed by Polaris Group Page 4 of 158

6 FY 2019 Updates (Updates appear in BOLD text throughout slides where they apply) 3 FY2019 Updates Clarification of the With Definition Documentation by Clinicians Other than the Patient's Provider Coding for Healthcare Encounters in Hurricane Aftermath Sequencing of External Causes of Morbidity Codes Other External Causes of Morbidity Code Issues 4 FH54 - Developed by Polaris Group Page 5 of 158

7 FY2019 Updates Use of Z codes Sepsis Due to a Postprocedural Infection Postprocedural Infection and Postprocedural Septic Shock Factitious Disorder Hypertension with Heart Disease Hypertensive Chronic Kidney Disease Adult and Child Abuse, Neglect and Other Maltreatment 5 ICD-10-CM Websites 6 FH54 - Developed by Polaris Group Page 6 of 158

8 ICD-10-CM Websites CDC CMS 0/2019-ICD-10-CM.html ICD-10-CM Codes 7 ICD-10-CM Websites AHIMA ICD-10 General Information CMS Look-Up Tool that allows users to search for codes by ICD-10 description keywords: 8 FH54 - Developed by Polaris Group Page 7 of 158

9 Coding Conventions/General Coding Guidelines 9 Clarification of the With Definition The word with or in means associated with or due to when it appears in a code title, the Alphabetic Index (either under a main term or subterm), or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms Update: Added under main term or subterm 10 FH54 - Developed by Polaris Group Page 8 of 158

10 Alphabetical Index Cough R05 With Example With hemorrhage See Hemoptysis R04.2 With Influenza See Influenza with respiratory manifestations. Tabular Index Cough R05 excludes cough with hemorrhage Hemoptysis R04.2 includes Blood stained sputum and cough with hemorrhage. The cough and hemorrhage are related. You would not code both cough and hemoptysis 11 Code Assignment and Clinical Criteria The assignment of a diagnosis code is based on the provider s diagnostic statement that the condition exists. The provider s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. 12 FH54 - Developed by Polaris Group Page 9 of 158

11 Documentation by Clinicians Other than the Patient's Provider FY19 Update: Code assignment is based on the documentation by patient's provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis). 13 Documentation by Clinicians Other than the Patient's Provider There are a few exceptions, such as codes for: Body Mass Index (BMI) - by dietician Depth of non-pressure chronic ulcers Pressure ulcer stage by Nurse Coma scale by Emergency Medical Tech NIH stroke scale (NIHSS) codes 14 FH54 - Developed by Polaris Group Page 10 of 158

12 Documentation by Clinicians Other than the Patient's Provider Code assignment may be based on medical record documentation from clinicians who are not the patient s provider since this information is typically documented by other clinicians involved in the care. However, the associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) must be documented by the patient s provider. 15 Default Codes The default code is listed next to a main term in the Alphabetic Index. Family of codes then listed under main term/default code It s the condition that is most commonly associated with the main term, or is the unspecified code for the condition. If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned. So if you just have a generic diagnosis with no detail use code listed next to main term. 16 FH54 - Developed by Polaris Group Page 11 of 158

13 Default Code Example So if you didn t have any more information than a generic dx of Hypertension, you would use the code next to main term hypertension which is I10 17 Default Code Example So if you didn t have any more information than a generic dx of Diabetes, you would use the code next to main term which is E FH54 - Developed by Polaris Group Page 12 of 158

14 Family of Codes Family of codes refers to codes that have the same letters/numbers for the first three characters before the decimal. We want to use codes from the same family For example, if you are coding E11 for type 2 diabetes, you pick combination codes from this family of codes. You would not want codes from E11 (type 2) on the same diagnosis list/claim with codes from E10 (type 1). 19 Family of Codes Example E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E Type 2 diabetes mellitus with foot ulcer **All of these codes could be on same claim since from the same family of codes.**** 20 FH54 - Developed by Polaris Group Page 13 of 158

15 Family of Codes Example Another example would be choosing same underlying cause of cerebrovascular disease in I69 codes. You would want to stay in same number after. indicating same underlying cause I Dysphasia following nontraumatic subarachnoid hemorrhage I Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage NOT: I Aphasia following other cerebrovascular disease 21 Placeholder Character The ICD-10-CM utilizes a placeholder character X. The X is used as a placeholder for future expansion. Where a placeholder exists, the X must be used in order for the code to be valid. When a 5 character code requires a 7 th character, then X is used to ensure the 7 th character is the 7 th character. 22 FH54 - Developed by Polaris Group Page 14 of 158

16 Placeholder Character 7 th Character T Disruption of external operation (surgical) wound, not elsewhere classified, - 7 th character required to indicate subsequent encounter The above family of codes requires a 7 th character. Code is only 5 characters Add X as placeholder to create a valid code T81.31xD 23 7 th Characters Episodes of Care definitions related to 7 th Character Sample Common Definitions: (There are many other options) Initial Encounter (A) - Each encounter where receiving active treatment surgical treatment emergency department encounter evaluation and treatment by the same or a different physician (but still during active treatment) 24 FH54 - Developed by Polaris Group Page 15 of 158

17 Initial Encounter Additional Examples Additional examples provided by AHA: Diagnosis and assessment of acute injury and definitive treatment (e.g., suture repair, fracture reduction) Malunions/Nonunions when patient delayed seeking treatment for fracture Referral to orthopedist for injury evaluation and treatment plan development Antibiotic therapy for postoperative infection Wound vac treatment of wound dehiscence 25 7 th Characters We would most likely NOT use the 7 th character A in LTC but need to recognize this code coming from the hospital and know that we would need to change 7 th character to appropriate subsequent character such as D. ****This applies to certain chapters like Chapter 13 (musculoskeletal) and Chapter 19 (Fractures). 26 FH54 - Developed by Polaris Group Page 16 of 158

18 7 th Characters Subsequent Encounter (D) After completion of active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase Frequently used in LTC 27 7 th Characters Subsequent Encounter (D) Examples: cast change or removal removal of external or internal fixation device medication adjustment X-ray to check healing status of a fracture other aftercare and follow-up visits following treatment of the injury or condition 28 FH54 - Developed by Polaris Group Page 17 of 158

19 Subsequent Encounter Additional Examples Additional examples provided by AHA: Rehabilitative therapy encounters (e.g., physical therapy, occupational therapy) Suture removal Follow up visits to assess healing status (regardless of whether the follow up is with the same or a different provider) Dressing changes and other aftercare 29 Subsequent Encounter Fracture malunions and nonunions are assigned the appropriate 7th character for subsequent encounter for malunion or nonunion (unless the patient delayed seeking fracture treatment). 30 FH54 - Developed by Polaris Group Page 18 of 158

20 7 th Character Example So S72.001D for example would be Fracture of Unspecified part of neck of right femur, and 7 th character D means subsequent encounter for closed fracture with routine healing. The 7 th character of D indicates this is an aftercare code th Character 32 FH54 - Developed by Polaris Group Page 19 of 158

21 Sequela 7th Character Sequela (Late Effect): Residual effect (condition produced) arising as a direct result of an acute condition. When using 7 th character S, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The S is added only to the injury code, not the sequela code. The 7 th character S identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code. 33 Sequela Examples Scar formation after a burn Traumatic arthritis following previous gunshot wound Quadriplegia due to spinal cord injury Skin contractures due to previous burns Auricular chondritis due to previous burns Chronic respiratory failure following drug overdose 34 FH54 - Developed by Polaris Group Page 20 of 158

22 Sequela Coding Example 1 Diagnosis: Right claw hand deformity due to old (healed) upper arm median nerve injury would be coded in following order: M S44.11XS Acquired clawhand, right hand Injury of median nerve at upper arm level, right arm, sequela Sequela is listed first followed by the injury that lead to the sequela with 7 th character S. 35 Sequela Example 2 Patient presents for release of skin contracture due to third degree burns of the right hand that occurred due to a house fire five years ago. Principal Dx: L90.5, Scar conditions and fibrosis of skin Secondary codes: T23.301S, Burn of third degree of right hand, unspecified site, sequela X00.0XXS, Exposure to flames in uncontrolled fire in building or structure, sequela 36 FH54 - Developed by Polaris Group Page 21 of 158

23 Expanded Combination Codes A combination code is a single code used to classify: Two diagnoses, or A diagnosis with a secondary process (manifestation) A diagnosis with a complication 37 Combination Codes ONLY assign a combination code when it fully identifies the diagnostic conditions involved or when the Alphabetic Index directs. Multiple coding would be incorrect if a combination code would fully describe a condition. When the combination code lacks necessary specificity in describing the manifestation or complication, an additional secondary code should be used. 38 FH54 - Developed by Polaris Group Page 22 of 158

24 Combination Code Examples I Atherosclerotic heart disease of native coronary artery with unstable angina pectoris K71.51 Toxic liver disease with chronic active hepatitis with ascites K Crohn s disease of small intestine with intestinal obstruction 39 Diabetes Combination Code Examples E11.3 Type 2 diabetes mellitus with ophthalmic complications E11.31 Type 2 diabetes mellitus with unspecified diabetic retinopathy E Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema 40 FH54 - Developed by Polaris Group Page 23 of 158

25 Combination Code Mistakes Common coding mistake being identified is the lack of using proper combination codes. Many providers continue to report two codes when ICD-10-CM provides a single combination code. 41 Combination Code Mistakes For example, when a patient with diabetes mellitus and polyneuropathy is seen, two codes are being reported to explain the diagnosis fully as: E11.9 Type 2 diabetes mellitus without complications G62.9 Polyneuropathy, unspecified INCORRECT 42 FH54 - Developed by Polaris Group Page 24 of 158

26 Correct Combination Example Diabetes mellitus and polyneuropathy should be coded as: E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy (Type 2 diabetes mellitus with diabetic neuralgia) 43 Laterality ICD-10-CM allows us to specify left, right, or bilateral for certain codes. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, code unspecified side. 44 FH54 - Developed by Polaris Group Page 25 of 158

27 Laterality Example L Pressure ulcer of right hip, stage 2 Healing pressure ulcer of right hip, stage 2 45 More Laterality Examples 46 FH54 - Developed by Polaris Group Page 26 of 158

28 More Laterality Examples 47 Laterality Examples Diabetes with diabetic retinopathy E DM d/t underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye **1 as the 7 th character indicates right eye** 48 FH54 - Developed by Polaris Group Page 27 of 158

29 Laterality & Dominant/Non-Dominant Side If the affected side is documented but not specified as dominant or nondominant, and classification system does not indicate a default, code as follows: For ambidextrous residents, the default should be dominant. If the left side is affected, the default is nondominant. If the right side is affected, the default is dominant. I Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side 49 Bilateral Clarification When a patient has a bilateral condition and each side is treated during separate encounters, assign the bilateral code (as the condition still exists on both sides), including for the encounter to treat the first side. 50 FH54 - Developed by Polaris Group Page 28 of 158

30 Bilateral Clarification For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). 51 Bilateral Clarification The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously treated side. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate. 52 FH54 - Developed by Polaris Group Page 29 of 158

31 Expanded Excludes Notes Excludes notes tell you that the code you are looking up excludes a certain diagnosis. Type 1 and Type 2 Each type has different definition for use but similar in that codes excluded from each other are independent of each other. 53 Excludes1 Definition A type 1 Excludes note is a pure excludes note. It means NOT CODED HERE! Exclude note tells you that the excluded diagnosis should never be used with the code you are looking up. These codes are mutually exclusive so they are NEVER used together such as a congenital form verses an acquired form of the same condition. 54 FH54 - Developed by Polaris Group Page 30 of 158

32 Excludes1 Example Telling you that aftercare for healing fx is not included in Z47 Orthopedic Aftercare 55 Excludes1 Exceptions An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, ask the provider. 56 FH54 - Developed by Polaris Group Page 31 of 158

33 Excludes1 Exception Example Code F45.8, Other somatoform disorders, has an Excludes1 note for sleep related teeth grinding (G47.63), because teeth grinding is an inclusion term under F45.8. Only one of these two codes should be assigned for teeth grinding. 57 Excludes1 Exception Example Psychogenic dysmenorrhea is also an inclusion term under F45.8, and a patient could have both this condition and sleep related teeth grinding. In this case, the two conditions are clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 together. 58 FH54 - Developed by Polaris Group Page 32 of 158

34 Excludes2 Definition An excludes2 note means NOT INCLUDED HERE! Indicates although the excluded condition is not part of the condition it is excluded from, a patient may have both conditions at the same time. May be acceptable to use both the code and the excluded code together if supported by medical record documentation. 59 Excludes2 Example Telling you that fitting and adjustment is excluded but may use both codes 60 FH54 - Developed by Polaris Group Page 33 of 158

35 Code Also Example 61 Coding for Healthcare Encounters in Hurricane Aftermath FY19 Updates: Use of External Cause of Morbidity Codes An external cause of morbidity code should be assigned to identify the cause of the injury(ies) incurred as a result of the hurricane. The use of external cause of morbidity codes is supplemental to ICD-10-CM codes. 62 FH54 - Developed by Polaris Group Page 34 of 158

36 Coding for Healthcare Encounters in Hurricane Aftermath External cause of morbidity codes are never to be recorded as a principal diagnosis. The appropriate injury code should be sequenced before any external cause codes. The external cause of morbidity codes capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, 63 Coding for Healthcare Encounters in Hurricane Aftermath such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person s status (e.g., civilian, military). Should not be assigned for encounters to treat hurricane victims medical conditions when no injury, adverse effect or poisoning is involved. 64 FH54 - Developed by Polaris Group Page 35 of 158

37 Coding for Healthcare Encounters in Hurricane Aftermath Should be assigned for each encounter for care and treatment of the injury. May be assigned in all health care settings which is any location where medical care is provided by licensed healthcare professionals. Purpose is to capture complete and accurate ICD-10-CM data in the aftermath of the hurricane. 65 Sequencing of External Causes of Morbidity Codes Codes for cataclysmic events, such as a hurricane, take priority over all other external cause codes except child and adult abuse and terrorism and should be sequenced before other external cause of injury codes. Assign as many external cause of morbidity codes as necessary to fully explain each cause. 66 FH54 - Developed by Polaris Group Page 36 of 158

38 Sequencing of External Causes of Morbidity Codes For example, if an injury occurs as a result of a building collapse during the hurricane, external cause codes for both the hurricane and the building collapse should be assigned, with the external causes code for hurricane being sequenced first. 67 Sequencing of External Causes of Morbidity Codes For injuries caused directly from the hurricane, assign the appropriate code(s) for the injuries, followed by: X37.0-, Hurricane (with the appropriate 7th character), and any other applicable external cause of injury codes. Also Code X37.0- for injuries caused from flooding by a levee breaking related to the hurricane. 68 FH54 - Developed by Polaris Group Page 37 of 158

39 Sequencing of External Causes of Morbidity Codes Code X38.-, Flood (with the appropriate 7th character) when an injury is from flooding resulting directly from the storm. Code X36.0.-, Collapse of dam or man-made structure, should not be assigned when the cause of the collapse is due to the hurricane. Code X36.0- is limited to collapses of manmade structures due to earth surface movements, not due to storm surges directly from a hurricane. 69 Other External Causes of Morbidity Code Issues For injuries that are not a direct result of the hurricane, such as an evacuee that has incurred an injury as a result of a motor vehicle accident, assign the appropriate external cause of morbidity code(s) to describe the cause of the injury, but do not assign code X37.0-, Hurricane. 70 FH54 - Developed by Polaris Group Page 38 of 158

40 Other External Causes of Morbidity Code Issues If it is not clear whether the injury was a direct result of the hurricane, assume the injury is due to the hurricane and assign code X37.0-, Hurricane, as well as any other applicable external cause of morbidity codes. 71 Other External Causes of Morbidity Code Issues In addition to code X37.0-, Hurricane, other possible applicable external cause of morbidity codes include: W54.0-, Bitten by dog X30-, Exposure to excessive natural heat X31-, Exposure to excessive natural cold X38-, Flood 72 FH54 - Developed by Polaris Group Page 39 of 158

41 Use of Z codes Z codes (other reasons for healthcare encounters) may be assigned as appropriate to further explain the reasons for presenting for healthcare services, including transfers between healthcare facilities. The ICD-10-CM Official Guidelines for Coding and Reporting identify which codes may be assigned as principal or first-listed diagnosis only, secondary diagnosis only, or either depending on the circumstances. 73 Z Codes and External Cause of Injury Codes Assign as many codes as necessary to fully explain each healthcare encounter. Since patient history information may be very limited, use any available. documentation to assign the appropriate external cause of morbidity and Z codes. 74 FH54 - Developed by Polaris Group Page 40 of 158

42 DO NOT Report Same Diagnosis Code More Than Once Each unique ICD-10-CM diagnosis code may be reported only once for an encounter. This applies to bilateral conditions when there are no distinct codes identifying laterality or two different conditions classified to the same ICD- 10-CM diagnosis code. 75 When To Use Multiple Coding For A Single Condition With the etiology/manifestation codes where a combination code doesn t exist. Other conditions where you see use additional code note. Follow sequencing for etiology/manifestation so underlying condition first followed by manifestation or additional code. 76 FH54 - Developed by Polaris Group Page 41 of 158

43 When To Use Multiple Coding For A Single Condition Example A secondary code from category: B95, Streptococcus, Staphylococcus, and Enterococcus, as the cause of diseases classified elsewhere, or B96, Other bacterial agents as the cause of diseases classified elsewhere, may be required to identify the bacterial organism causing the infection. A use additional code note will normally be found at the infectious disease code, indicating a need for the organism code to be added as a secondary code. 77 When To Use Multiple Coding For A Single Condition Example N30.00 Acute cystitis without hematuria B96.20 Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere The use additional code note at category N30 prompts the coder that an additional code is required to identify the infectious agent (organism). The instructional note at code sections B95-B97 explain that these codes are supplementary or additional codes. 78 FH54 - Developed by Polaris Group Page 42 of 158

44 Code First When there is a code first note and an underlying condition is present, the underlying condition should be sequenced first. If same condition is described as both acute (subacute) and chronic, code both and sequence the acute (subacute) code first. 79 Code First Example N13.8 Other obstructive and reflux uropathy Code First: if applicable any causal condition such as BPH Sequence: N40.1 BPH N13.8 Other obstructive and reflux uropathy 80 FH54 - Developed by Polaris Group Page 43 of 158

45 Both Acute and Chronic Example When looking up Failure, Heart you will see: So acute congestive and chronic congestive are at the same indentation level but you would code acute before chronic if patient had both conditions. 81 Chapter Specific Guidelines Will address additional coding guidelines not already covered in General Guidelines 82 FH54 - Developed by Polaris Group Page 44 of 158

46 Chapter-Specific Coding Guidelines In addition to general coding guidelines, there are guidelines for specific diagnoses and/or conditions in the classification. Unless otherwise indicated, these guidelines apply to all health care settings. There are 21 chapters in the Official Coding Guidelines for ICD-10-CM. 84 FH54 - Developed by Polaris Group Page 45 of 158

47 Chapters Reserved for Future Guideline Expansion Chapter 3: Disease of the blood and bloodforming organs and certain disorders involving the immune mechanism (D50-D89) Chapter 8: Diseases of the Ear and Mastoid Process (H60-H95) Chapter 11: Diseases of the Digestive System (K00-K95) ** These chapters don t have instructions in Official Coding Guidelines as of yet** 85 Ch. 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z99) Z codes are for use in any healthcare setting. Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. 86 FH54 - Developed by Polaris Group Page 46 of 158

48 Status Z Codes Status Status codes indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition. A status code is informative, because the status may affect the course of treatment and its outcome. 87 Status Z Codes A Status Z code is distinct from a history code. The history code indicates that the patient no longer has the condition. A Status Z code should not be used with a diagnosis code from one of the body system chapters, if the diagnosis code includes the information provided by the status code. 88 FH54 - Developed by Polaris Group Page 47 of 158

49 Status Z Code vs. Diagnosis Code For example, code Z94.1, Heart transplant status, should not be used with a code from subcategory T86.20, Unspecified complications of heart transplant. The status code does not provide additional information. The complication code indicates that the patient is a heart transplant patient. 89 Status Z Code Examples Z16, Resistance to antimicrobial drugs This code indicates that a patient has a condition that is resistant to antimicrobial drug treatment. Sequence the infection code first. Z22, Carrier of infectious disease Carrier status indicates that a person harbors the specific organisms of a disease without manifest symptoms and is capable of transmitting the infection. 90 FH54 - Developed by Polaris Group Page 48 of 158

50 Status Z Code Z79 Z79 Long-term (current) drug therapy Codes from this category indicate a patient s continuous use of a prescribed drug (including such things as aspirin therapy) for the long-term treatment of a condition or for prophylactic use. 91 History Z Codes History (of) There are two types of history Z codes, personal and family. History codes should only be used if it affects the current encounter or treatment. Z80 Family history of primary malignant neoplasm Z85 Personal history of malignant neoplasm Z Personal History of Nicotine Dependence 92 FH54 - Developed by Polaris Group Page 49 of 158

51 Aftercare Z Codes Aftercare Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. 93 Aftercare Z Codes The aftercare Z code should not be used if treatment is directed at a current, acute disease. Use dx code instead. The aftercare Z codes should not be used for traumatic injuries. The aftercare codes are generally first-listed (principal) diagnosis to explain the specific reason for the encounter. 94 FH54 - Developed by Polaris Group Page 50 of 158

52 Aftercare Z Codes Certain aftercare Z code categories need a secondary diagnosis code to describe the resolving condition or sequela. For others, the condition is included in the code title. Additional Z code aftercare category terms include fitting and adjustment, and attention to artificial openings. Status Z codes may be used with aftercare Z codes to indicate the nature of the aftercare. 95 Aftercare vs. Status Z Codes A status Z code should NOT be used when the aftercare Z code indicates the type of status, such as using: Z43.0, Encounter for attention to tracheostomy USE THIS CODE Z93.0, Tracheostomy status NOT THIS CODE AND NOT BOTH CODES 96 FH54 - Developed by Polaris Group Page 51 of 158

53 Z47 Orthopedic Aftercare Example 97 Orthopedic Aftercare Examples 98 FH54 - Developed by Polaris Group Page 52 of 158

54 Chapter 1 Certain Infectious and Parasitic Diseases (A00-B99) Includes greater specificity and more combination codes that include organism Disease will say code also organism from this chapter 99 Infections Resistant to Antibiotics Many bacterial infections are resistant to current antibiotics. It is necessary to identify all infections documented as antibiotic resistant. Assign a code from category Z16, Resistance to antimicrobial drugs, following the infection code only if the infection code does not identify drug resistance. 100 FH54 - Developed by Polaris Group Page 53 of 158

55 Infections Resistant to Antibiotics Example 101 Sepsis Due to a Postprocedural Infection - NEW FY19 Updates: For infections following a procedure, a code from T T81.43 Infection following a procedure that identifies the site of the infection should be coded first, if known. Assign an additional code for sepsis following a procedure (T81.44) Use an additional code to identify the infectious agent 102 FH54 - Developed by Polaris Group Page 54 of 158

56 Sepsis Due to a Postprocedural Infection - NEW Use T80.2, For infections following: infusion transfusion therapeutic injection Immunization Or code T88.0-, Infection following immunization, first, followed by the code for the specific infection. 103 Sepsis Due to a Postprocedural Infection - NEW An appropriate code from subcategory R65.2 should also be assigned if the patient has severe sepsis. With additional codes(s) for any acute organ dysfunction. 104 FH54 - Developed by Polaris Group Page 55 of 158

57 Postprocedural Infection and Postprocedural Septic Shock - NEW If a postprocedural infection has resulted in postprocedural septic shock, assign R65.2, Sepsis due to postprocedural infection followed by code: T81.12-, Postprocedural septic shock Do not assign code R65.21, Severe sepsis with septic shock. Additional code(s) should be assigned for any acute organ dysfunction. 105 Chapter 4 Endocrine, Nutritional, and Metabolic Diseases (E00-E89) Diabetes is no longer distinguished between controlled or uncontrolled Combination codes for Diabetes 106 FH54 - Developed by Polaris Group Page 56 of 158

58 Diabetes Mellitus The diabetes mellitus codes are combination codes that include: type of diabetes mellitus body system affected complications affecting that body system Use as many codes from this category as necessary to fully describe all the complications of the disease. 107 Diabetes Categories E08: Diabetes due to underlying condition E09: Drug or Chemical induced diabetes E10: Type I E11: Type II If the type of diabetes is not designated in the medical record but the medical record does indicate insulin is used, the default is E11: Type 2 should be assigned. 108 FH54 - Developed by Polaris Group Page 57 of 158

59 Diabetes Categories E08.64: Diabetes due to an underlying condition with hypoglycemia E09.64: Drug or chemical induced diabetes with hypoglycemia E10.64: Type I diabetes with hypoglycemia E11.64: Type II diabetes with hypoglycemia 6 th character 1 (with coma) or 9 (without coma) 109 Diabetes Mellitus and the Use of Insulin and Oral Hypoglycemic Drugs Z79.4, Long-term (current) use of insulin, should be coded if the patient is treated with insulin or both oral medications and insulin. Z79.4 should not be assigned if insulin is given temporarily to bring a type 2 patient s blood sugar under control during an encounter. 110 FH54 - Developed by Polaris Group Page 58 of 158

60 Chapter 5 - NEW Mental, Behavioral and Neurodevelopmental Disorders (F01 F99) FY19 Updates Factitious Disorders 111 Factitious Disorder Factitious disorder (Munchausen s syndrome) imposed on self is when a person falsely reports or causes their own physical or psychological signs or symptoms. Use appropriate code from subcategory F68.1-, Factitious disorder imposed on self. 112 FH54 - Developed by Polaris Group Page 59 of 158

61 Factitious Disorder Munchausen s syndrome by proxy (MSBP) is a disorder in which a caregiver (perpetrator) falsely reports or causes an illness or injury in another person (victim) under his or her care, a child, an elderly adult person who has a disability 113 Factitious Disorder Also referred to as factitious disorder imposed on another or factitious disorder by proxy. The perpetrator, not the victim, receives code: F68.A, Factitious disorder imposed on another 114 FH54 - Developed by Polaris Group Page 60 of 158

62 Factitious Disorder For the victim of a patient suffering from MSBP, assign the appropriate code from categories: T74, Adult and child abuse, neglect and other maltreatment, confirmed, or T76, Adult and child abuse, neglect and other maltreatment, suspected. 115 Chapter 6 Diseases of the Nervous System (G00-G99) Alzheimer s has been assigned it s own category and classified according to onset Laterality provides more specific codes 116 FH54 - Developed by Polaris Group Page 61 of 158

63 Dominant/Non-Dominant Side Codes from the following category or subcategories identify whether the dominant or non-dominant side is affected: G81, Hemiplegia and hemiparesis G83.1, Monoplegia of lower limb G83.2, Monoplegia of upper limb G83.3, Monoplegia, unspecified 117 Laterality & Dominant/Non-Dominant Side If the affected side is documented but not specified as dominant or nondominant, and classification system does not indicate a default, code as follows: For ambidextrous residents, the default should be dominant. If the left side is affected, the default is nondominant. If the right side is affected, the default is dominant. I Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side 118 FH54 - Developed by Polaris Group Page 62 of 158

64 Pain: G89 This code includes Acute and Chronic Pain that is not coded elsewhere and when the admission is for pain control or pain management. G89 Pain Codes may be first listed when the reason for the stay is pain control and NOT management of the underlying condition. Expected post-operative pain should NOT be coded. 119 Pain: G89 When an admission is aimed at treating an underlying condition, code the underlying condition instead. Pain is included with some specific codes: Pain related to psychological factors: F45.41 Pain as a complication: T84.84xx Pain related to prosthetic device Symptoms and Signs: R10.2 Pelvic Pain 120 FH54 - Developed by Polaris Group Page 63 of 158

65 Chapter 7 Diseases of the Eye and Adnexa (Appendages of the Eye) (H00-H59) Now designated chapter New codes based on laterality Combination codes for type and stage of glaucoma 121 Glaucoma Assign as many codes from category H40, Glaucoma, as needed to identify: type of glaucoma for each eye the affected eye(s) the glaucoma stage for each eye Assignment of the seventh character 4 for indeterminate stage should be used when the stage cannot be clinically determined. 122 FH54 - Developed by Polaris Group Page 64 of 158

66 Glaucoma Specificity 123 Chapter 9 Diseases of the Circulatory System (I00-I99) Laterality codes Dominant/non-dominant default codes Sequela 124 FH54 - Developed by Polaris Group Page 65 of 158

67 Sequela (Late Effects) A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has ended. There is no time limit on when a sequela code can be used. The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effects. 125 Sequela (Late Effects) Categories I60-I67 are the acute codes used by hospital not LTC. We use the Sequela or Late Effects code in LTC which are the I69 codes. These late effects include neurologic deficits that persist after initial onset of conditions in categories I60-I FH54 - Developed by Polaris Group Page 66 of 158

68 Sequelae of Cerebrovascular Disease Examples I Dysphasia following nontraumatic subarachnoid hemorrhage I Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side I69.30 Unspecified sequelae of cerebral infarction **The I69 sequelae codes will be very common for LTC. 127 Hypertension with Heart Disease FY19 Updates in Bold: Hypertension with heart conditions classified to I50.- (Heart Failure) or I51.4-I51.7, I51.89, I51.9, (Myocarditis, Myocardial degeneration, Cardiomegaly, Other ill-defined heart diseases, Heart Disease Unspecified) are assigned to a code from category I11, Hypertensive heart disease. Use additional code(s) from category I50, Heart failure, to identify the type(s) of heart failure in those patients with heart failure. 128 FH54 - Developed by Polaris Group Page 67 of 158

69 Hypertension with Heart Disease The same heart conditions (I50.-, I51.4-I51.7, I51.89, I51.9) with hypertension are coded separately if the provider has documented they are unrelated to the hypertension. 129 Hypertensive Chronic Kidney Disease Assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD), are present. CKD should not be coded as hypertensive if the provider indicates the CKD is not related to the hypertension. 130 FH54 - Developed by Polaris Group Page 68 of 158

70 Chapter 12 Diseases of the Skin and Subcutaneous Tissue (L00-L99) Skin Infections Dermatitis Pressure Ulcers Non-Pressure Ulcers A 131 Pressure Ulcer Codes: L89 The Pressure Ulcer codes are combination codes that identify the site and stage and sometimes laterality. Site is designated by the 4 th character Laterality is designated by the 5 th character L89.3: Pressure Ulcer of Buttock L89.30 Pressure Ulcer of Unspecified Buttock L89.31 Pressure Ulcer of Right Buttock L89.32 Pressure Ulcer of Left Buttock 132 FH54 - Developed by Polaris Group Page 69 of 158

71 Pressure Ulcer Codes: L89 Stage is designated by the sixth character L89.31 Pressure Ulcer of the Right Buttock L Pressure ulcer of right buttock, unstageable L Pressure ulcer of right buttock, Stage I L Pressure ulcer of right buttock, Stage 2 L Pressure ulcer of right buttock, Stage 3 L Pressure ulcer of right buttock, Stage 4 L Pressure ulcer of right buttock, unspecified 133 Non-Pressure Ulcers: L97 Non-Pressure Ulcers are not coded by stage, as we do not stage these ulcers. A severity code is still used at the 6 th character and is based on wound appearance. 134 FH54 - Developed by Polaris Group Page 70 of 158

72 Non-Pressure Chronic Ulcer Severity Scale L97.xx1 Limited to breakdown of skin L97.xx2 With fat layer exposed L97.xx3 With necrosis of muscle L97.xx4 With necrosis of bone L97.xx5 with muscle involvement without evidence of necrosis L97.xx6 with bone involvement without evidence of necrosis L97.xx8 Other specified severity L97.xx9 Unspecified severity 135 Coding Instruction for Healing Status: Pressure and Non-Pressure No code is assigned if the ulcer is coded as healed at admission. If healing at admission, assign the code based on the assessment/documentation of the site and severity at admission. Code unspecified if not documented If present on admission and healed at discharge, code for the site and severity at admission. 136 FH54 - Developed by Polaris Group Page 71 of 158

73 Coding Instruction for Healing Status: Pressure and Non-Pressure If resident is admitted with an ulcer at one severity level and it progresses to a higher severity level, two separate codes should be assigned. One for the site and severity level of the ulcer on admission A second for the site and highest severity level reported during the stay. 137 Chapter 13 Diseases of the Musculoskeletal System and Connective Tissue (M00-M99) Arthropathy / Arthritis Osteoporosis Pathological Fractures Does not include acute injuries (fractures) 138 FH54 - Developed by Polaris Group Page 72 of 158

74 Musculoskeletal System - Site and Laterality Most of the codes within Chapter 13 have site and laterality designations. The site represents the bone, joint or the muscle involved. Use multiple sites code for some conditions where more than one bone, joint or muscle is usually involved, such as osteoarthritis. For categories where no multiple site code is provided, multiple codes should be used to indicate the different sites involved. 139 Osteoporosis Osteoporosis is a systemic condition, meaning that all bones of the musculoskeletal system are affected. Therefore, site is not a component of the codes under category M81, Osteoporosis without current pathological fracture. The site codes under category M80, Osteoporosis with current pathological fracture, identify the site of the fracture, not the osteoporosis. 140 FH54 - Developed by Polaris Group Page 73 of 158

75 Coding of Pathologic Fractures 7th character D is to be used for encounters after the patient has completed active treatment for the fracture and is receiving routine care for the fracture during the healing or recovery phase. 141 Pathologic Fracture Coding Example Fracture of left femur, pathologic, subsequent encounter. Resident has Osteoporosis causing fracture. Postmenopausal age. M80.052D Age-related osteoporosis with current pathological fracture, left femur, 7 th character D, for subsequent encounter for fracture with routine healing 142 FH54 - Developed by Polaris Group Page 74 of 158

76 Chapter 14 Diseases of the Genitourinary System (N00-N99) Kidney Disease Neurogenic Bladder/ Obstructive Uropathy 143 Kidney Disease Chronic Kidney Disease is classified according to severity: N18.1: Stage 1 N18.2: Stage 2 (Mild) N18.3: Stage 3 (Moderate) N18.4: Stage 4 (Severe) N18.5: Stage 5 (Excludes ESRD requiring dialysis) N18.6: ESRD requiring dialysis 144 FH54 - Developed by Polaris Group Page 75 of 158

77 Neuromuscular Dysfunction of the Bladder Neuropathic Bladder: N31 Uninhibited: N31.0 Reflux: N31.1 Flaccid: N31.2 Obstructive and Reflux Uropathy: N13 Specified: N13.8 Unspecified: N13.9 Retention of Urine (In Section R: Symptoms) Retention of Urine, unspecified: R Chapter 18 Not Classified Elsewhere Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, not Elsewhere Classified (R00-R99) Signs and symptoms that are routinely associated with a disease should not be assigned as an additional diagnosis. Not Classified Elsewhere are common for therapy codes. For example: R26.2 Difficulty in walking, not elsewhere classified R26.9 Unspecified abnormalities of gait and mobility 146 FH54 - Developed by Polaris Group Page 76 of 158

78 Chapter 19 Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88) Expanded injury codes including anatomic site, laterality, type of injury, severity, and complications Most codes require 7 th character Use acute fx code with appropriate 7 th character for subsequent care such as D. 147 Application of 7 th Characters in Chapter 19 including Fractures Most categories in this chapter have three 7th character values (with the exception of fractures): A, initial encounter D, subsequent encounter S, Sequela Late effects but not under active treatment for an acute condition (rarely use) More categories are listed for fractures 148 FH54 - Developed by Polaris Group Page 77 of 158

79 7 th Character th Character Sequela May be appropriate to use 7 th character S for sequela for a fracture May be long-term resident with long term effect of non-healing fracture, but rarely if ever for Medicare resident receiving rehab since that would be subsequent encounter such as D. 150 FH54 - Developed by Polaris Group Page 78 of 158

80 Coding of Traumatic Fractures/Injuries The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first. A fracture not indicated as open or closed should be coded as Closed. A fracture not indicated whether displaced or not displaced should be coded to Displaced. 151 Admissions/Encounters for Rehabilitation When the purpose for the admission/encounter is rehabilitation, sequence first the code for the condition for which the service is being performed. If the condition for which the rehabilitation service is being provided is no longer present, report the appropriate aftercare code as the first-listed or principal diagnosis, unless the rehabilitation service is being provided following an injury. 152 FH54 - Developed by Polaris Group Page 79 of 158

81 Admissions/Encounters for Rehabilitation For rehabilitation services following active treatment of an injury, assign the injury code with the appropriate seventh character for subsequent encounter as the first-listed or principal diagnosis. 153 Admissions/Encounters for Rehabilitation If the patient requires rehabilitation post hip replacement for right intertrochanteric femur fracture, report code S72.141D, Displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, as the first-listed or principal diagnosis. Coding Clinic advises next code to be Z96.xx to specify which joint has been replaced. 154 FH54 - Developed by Polaris Group Page 80 of 158

82 Adult and Child Abuse, Neglect and Other Maltreatment - NEW FY19 Update: For confirmed cases of forced sexual exploitation/forced labor exploitation code: Z04.81, Encounter for examination and observation of victim following forced sexual exploitation, or Z04.82, Encounter for examination and observation of victim following forced labor exploitation T76 is for Suspected Abuse 155 Documentation To Support Coding & Claim 156 FH54 - Developed by Polaris Group Page 81 of 158

83 Medicare Claims Processing Manual Chapter 25, SNF Part A Billing SNFs enter the ICD-CM code for the principal diagnosis in form locator (FL 67) on UB-04. The code must be reported according to Official Guidelines for Coding and Reporting, as required by the Health Insurance Portability and Accountability Act (HIPAA), including any applicable guidelines regarding the use of V Codes. The code must be the full ICD-CM diagnosis code, including all five digits (for ICD-9) or all seven digits (for ICD-10). 157 Medicare Claims Processing Manual Chapter 25, SNF Part A Billing Other Diagnosis Codes Required The SNF enters the full ICD-CM codes for up to 8 additional conditions in the appropriate form locator (FL 67A-Q). Required when other condition(s) coexist or develop(s) subsequently during the patient s treatment. 158 FH54 - Developed by Polaris Group Page 82 of 158

84 Medicare Claims Processing Manual Medicare does not have any additional requirements regarding the reporting or sequence of the codes beyond those contained in the ICD-CM guidelines. 159 Importance of Accurate Coding Principal/Primary Diagnosis (Field 67 of the UB- 04) is being scrutinized very closely by the MACs. National Coverage Determinations (NCD) or Local Coverage Determinations (LCD) that require specific diagnoses trigger claims if correct diagnosis is not included. Claims are data mined using the diagnosis. 160 FH54 - Developed by Polaris Group Page 83 of 158

85 Benefits of Accurate Coding Provides accurate clinical picture of the resident Assists in minimizing Medical Review by Fiscal Intermediary (FI), Medicare Administrative Contractor (MAC), or Recovery Audit Contractor (RAC) Supports Skilled Services provided Supports Medical Necessity of services Helps to ensure appropriate payment Used for future policy making 161 Clinical Documentation to Support ICD-10-CM Review current clinical documentation practices Documentation tips for certain diagnoses are available at: AHIMA.org/icd10 Guidelines will be updated periodically so get from website so they are current Click on documentation View Documentation Tips FH54 - Developed by Polaris Group Page 84 of 158

86 Medical Record Must Support Codes Review all available records to determine appropriate assignment of ICD-10-CM Codes Hospital H & P Discharge Summary Physician / NP Progress Notes Consultation Notes Physician / NP Orders 163 Medical Record Must Support Codes Justifying medically necessary services depends on specificity of diagnosis coding Coding must be supported in medical record If specificity is documented in record; the more specific code must be used When more specificity is not known, an Unspecified or Default code is acceptable to use. 164 FH54 - Developed by Polaris Group Page 85 of 158

87 Medical Record Must Support Codes Under Audit, use of a Default or unspecified code is acceptable only if there is no additional documentation in record that supports a more specific code which should have been used. With that said, physicians will need to provide more specificity when known. 165 FISS Editing FISS editing is now being updated to ensure that all of the National Coverage Determination (NCD) edits within Reason Code ranges 3xxxx and 59xxx that are tied to the diagnosis code fields (other than the primary diagnosis field) include the admitting diagnosis field for Inpatient claims on Types of Bill (TOB) 011x, 012x, 018x, 021x, and 022x. So more importance on correct admitting dx 166 FH54 - Developed by Polaris Group Page 86 of 158

88 Diagnosis Updates for New Admissions Part A 1) Discharge Summary will likely be the best document to provide and support more specific codes Try to obtain as quickly as possible When received; review and update diagnoses as appropriate 2) Transfer Form (Review first) 3) Physician/NP visit documentation 167 Diagnosis Updates for LTC Residents Long-Term Resident Going to Physician Appointment Ask for diagnosis updates after visit in order to update diagnoses if indicated Long-Term Resident with ER Visit Review form upon return to see if any changes and updated accordingly Long-Term Resident Seen by MD/NP in Facility Update diagnoses based on physician progress notes 168 FH54 - Developed by Polaris Group Page 87 of 158

89 Common Treatment Codes Used by Physical Therapy M62.81 Muscle weakness, generalized R26.2 Difficulty walking, not elsewhere classified R26.9 Unspecified abnormalities of gait and mobility R29.3 Abnormal posture R29.6 Repeated falls 169 Common Treatment Codes Used by Occupational Therapy M62.81 Muscle weakness, generalized R27.8 Other lack of coordination R29.3 Abnormal posture R53.1 Weakness R29.6 Repeated falls R Cognitive Communication deficit R63.3 Feeding difficulties 170 FH54 - Developed by Polaris Group Page 88 of 158

90 Common Treatment Codes Used by Speech Therapy R47.9 R13.10 Unspecified speech disturbances Dysphagia, unspecified, difficulty swallowing NOS R47.01 Aphasia (excludes aphasia following CVA) R47.02 Dysphasia, (excludes following a CVA) I69.xxx Sequelae of cerebrovascular disease codes 171 Diagnosis Codes and the MDS 172 FH54 - Developed by Polaris Group Page 89 of 158

91 MDS 3.0 Section I The items in this section are intended to code diseases that have a direct relationship to the resident s current functional, cognitive, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident s current health status. 173 NEW 2018 MDS Primary Medical Condition Category for Quality Measures 174 FH54 - Developed by Polaris Group Page 90 of 158

92 NEW 2018 MDS Primary Medical Condition Category for Quality Measures Identifies the primary medical condition category that resulted in admission and that influences the resident s functional outcomes. THIS SECTION IS FOR QUALITY MEASURE PURPOSES ONLY. FINAL RULE STATES THAT FIRST LISTED I8000 CODE WILL AFFECT PATIENT DRIVEN PAYMENT MODEL (PDPM) COMING IN OCTOBER NEW 2018 MDS Primary Medical Condition Category for Quality Measures Review the documentation in the medical record to identify the resident s primary medical condition associated with admission. Sources include: H&P, transfer documents, discharge summary, progress notes, etc. 176 FH54 - Developed by Polaris Group Page 91 of 158

93 NEW 2018 MDS Primary Medical Condition Category for Quality Measures Complete only if A0310B = 01 If codes 1 13 do not apply, use code 14, Other Medical Condition, and proceed to I0020A. Code 01, Stroke ischemic stroke, subarachnoid hemorrhage, cerebral vascular accident (CVA), and other cerebrovascular disease. Code 02, Non-Traumatic Brain Dysfunction Alzheimer s disease, dementia with or without behavioral disturbance, malignant neoplasm of brain, and anoxic brain damage. 177 NEW 2018 MDS Primary Medical Condition Category for Quality Measures Code 03, Traumatic Brain Dysfunction - traumatic brain injury, severe concussion, and cerebral laceration and contusion Code 04, Non-Traumatic Spinal Cord Dysfunction - spondylosis with myelopathy, transverse myelitis, spinal cord lesion due to spinal stenosis, and spinal cord lesion due to dissection of aorta 178 FH54 - Developed by Polaris Group Page 92 of 158

94 NEW 2018 MDS Primary Medical Condition Category for Quality Measures Code 05, Traumatic Spinal Cord Dysfunction paraplegia and quadriplegia following trauma Code 06, Progressive Neurological Conditions - multiple sclerosis and Parkinson s disease Code 07, Other Neurological Conditions - cerebral palsy, polyneuropathy, and myasthenia gravis Code 08, Amputation - acquired absence of limb 179 NEW 2018 MDS Primary Medical Condition Category for Quality Measures Code 09, Hip and Knee Replacement - total knee/hip replacement. If hip replacement is secondary to hip fracture, code as fracture Code 10, Fractures and Other Multiple Trauma - hip fracture, pelvic fracture, and fracture of tibia and fibula Code 11, Other Orthopedic Conditions - unspecified disorders of joint 180 FH54 - Developed by Polaris Group Page 93 of 158

95 NEW 2018 MDS Primary Medical Condition Category for Quality Measures Code 12, Debility, Cardiorespiratory Conditions - chronic obstructive pulmonary disease (COPD), asthma, and other malaise and fatigue Code 13, Medically Complex Conditions - diabetes, pneumonia, chronic kidney disease, open wounds, pressure ulcer/injury, infection, and disorders of fluid, electrolyte, and acid-base balance 181 NEW 2018 MDS Primary Medical Condition Category for Quality Measures Code 14, Other Medical Condition - If the resident s primary medical condition category is not one of the listed categories. Enter the International Classification of Diseases (ICD) code, including the decimal, in I0200A. If item I0020 is coded 1 13, do not complete I0020A. 182 FH54 - Developed by Polaris Group Page 94 of 158

96 MDS Section I0100 Active Diagnoses 183 Diagnosis Codes and the MDS The disease conditions in this section require a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days. Review clinical record for current diagnoses including hospital progress notes, transfer documentation, discharge summary, physician orders, etc. Ensure that diagnoses in Section I support medications, MDS coding including interviews, and include therapy treatment diagnoses. 184 FH54 - Developed by Polaris Group Page 95 of 158

97 MDS 3.0 Section I Determine whether diagnoses are active: Once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident s current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. 185 MDS 3.0 Section I Do not include conditions that have been resolved, do not affect the resident s current status, or do not drive the resident s plan of care during the 7-day look-back period, as these would be considered inactive diagnoses. 186 FH54 - Developed by Polaris Group Page 96 of 158

98 Section I0100 Item I5100 Quadriplegia NEW Clarification Item I5100 Quadriplegia Quadriplegia primarily refers to the paralysis of all four limb caused by spinal cord injury. Coding I5100 Quadriplegia is limited to spinal cord injuries and must be a primary diagnosis and not the result of another condition. 187 Section I0100 Item I5100 Quadriplegia NEW Clarification Functional quadriplegia refers to complete immobility due to severe physical disability or frailty. Conditions such as cerebral palsy, stroke, contractures, brain disease, advanced dementia, etc. can also cause functional paralysis that may extend to all limbs hence, the diagnosis functional quadriplegia. 188 FH54 - Developed by Polaris Group Page 97 of 158

99 Section I0100 Item I5100 Quadriplegia NEW Clarification For individuals with these types of severe physical disabilities, where there is minimal ability for purposeful movement, their primary physician-documented diagnosis should be coded on the MDS and not the resulting paralysis or paresis from that condition. example, an individual with cerebral palsy with spastic quadriplegia should be coded in I4400 Cerebral Palsy, and not in I5100, Quadriplegia. 189 Diagnosis Codes and the MDS Diagnosis information captured on the MDS in Section I Disease Diagnoses I0100-I7900 (Diseases) includes check-off of 57 common diagnoses I8000 (Other Current or More Detailed Diagnoses and ICD-10-CM Codes) available for listing diagnoses with ICD-10-CM codes 190 FH54 - Developed by Polaris Group Page 98 of 158

100 MDS Section I Diagnosis Codes and the MDS When physician diagnosis is more specific than item description in I0100-I7900: Check the more general diagnosis in I0100-I7900 Enter the more detailed diagnosis using the appropriate ICD-10-CM code in I8000 (MDS 3.0 allows for 5 additional diagnoses) Example: Unilateral primary osteoarthritis, right hip I3700 Check item I3700 Arthritis I8000 Enter Unilateral primary osteoarthritis, right hip Code M FH54 - Developed by Polaris Group Page 99 of 158

101 Section I8000 and Aftercare Z Codes When Z codes are used, another diagnosis for the related primary medical condition should be checked in items I0100 I7900 or entered in I8000. Z codes CAN be primary diagnosis: Example: Z47.1 Aftercare for Joint Replacement combined with Z Code for Joint replaced such as Z However, some Z codes are too generic and don t need to be used: Z51.89 Encounter of other specified Aftercare 193 Diagnosis Codes and the MDS Z Codes can be reported in I8000 DO NOT report procedure codes in I8000 Procedure codes are not used in LTC Results in fatal error when submitted to national repository 194 FH54 - Developed by Polaris Group Page 100 of 158

102 Diagnosis Codes and the UB-04 For Part A residents: Create a list of ICD-10-CM diagnoses and codes upon admission, readmission and as needed (condition changes, MDS schedule, billing cycle) Medical Records, Accounting, Nursing and Therapy Services review diagnosis codes as applicable Discuss diagnoses in Medicare or other appropriate meetings to assist in determining final diagnosis sequencing TRIPLE CHECK Prior to billing each month 195 Selection of Principal and Admitting Diagnosis No change in process 196 FH54 - Developed by Polaris Group Page 101 of 158

103 Primary and Secondary Diagnosis Team determines primary and secondary diagnosis: When, who, & how communicated? Definition of Principal/Primary Diagnosis in SNF: Condition chiefly responsible for the resident s admission to SNF or continued SNF care. Field 67 on the UB-04 Diagnosis Codes on the UB-04 should: Support services provided during the claim dates of service. Describe the conditions that qualify for payment Support medical necessity 197 Continued Treatment of Acute Conditions in the LTC Facility Any acute condition treated at the hospital that continues to require follow-up or ongoing monitoring should be coded with an acute diagnosis code as long as the condition persists and require follow-up. In general, the status of the acute condition would be assessed whenever the MDS is updated - resident status change or at monthly review for billing. 198 FH54 - Developed by Polaris Group Page 102 of 158

104 Continued Treatment of Acute Conditions in the LTC Facility Codes for the acute medical condition treated and resolved in the hospital are assigned and reported by the hospital (i.e., cholecystitis, abdominal aortic aneurysm) but not coded or reported in the LTC facility. The LTC facility reports Z codes to identify the provision of aftercare. 199 Continued Treatment of Acute Conditions in the LTC Facility It is inaccurate to report an acute code for a resolved condition because it directly contradicts the Official Coding Guidelines for Coding and Reporting and is non-compliant with HIPAA regulations. 200 FH54 - Developed by Polaris Group Page 103 of 158

105 Initial Admission A resident was initially admitted to a LTC facility to receive physical and occupational therapy services due to aftercare for a healing right hip fracture. The resident remains in the facility because of his Parkinson's disease. Upon initial admission, the following codes would be reported in ICD-10-CM: Primary - S72.001D Fracture of unspecified part of neck of right femur, 7 th character D (subsequent encounter for closed fracture with routine healing) G20, Parkinson's disease 201 Initial Admission Followed by Continued Stay Code S72.001D is resolved and documented (usually at discontinuation of Medicare Part A stay). For the continued stay, (regardless of payer), code G20, Parkinson's disease, becomes the principal/primary diagnosis (reason for continued stay) (FL 67) 202 FH54 - Developed by Polaris Group Page 104 of 158

106 Continued Stay Followed by Hospital Stay A year later the resident is transferred to the hospital for treatment of pneumonia and returns to the nursing facility with an order for physical/occupational therapies and antibiotics. Upon returning to the facility, the following codes would be reported: Principal/Primary diagnosis: G20, Parkinson's disease (reason for return to the facility) (FL 67) followed by: J18.9, Pneumonia, unspecified organism Therapies would be documented but remember there is no longer a code for therapies. 203 Continued Stay Example Current LTC residents who transfer to the hospital to receive treatment for acute conditions (e.g., pneumonia) and return to the facility for further care of their chronic condition (e.g., COPD) may continue to receive care for the acute condition if unresolved. The principal diagnosis (first-listed) is the reason for the continued stay (e.g., COPD) in the nursing facility (FL 67). 204 FH54 - Developed by Polaris Group Page 105 of 158

107 Coding For Continued Stay A newly diagnosed condition (FL 67A) will be listed after the principal diagnosis (FL 67) to reflect new conditions that affect the resident. (The principal diagnosis may or may not be the reason for Medicare skilled services.) This works the same way for Part B as well. 205 Selection of Principal Diagnosis Admissions/Encounters for Rehabilitation When the purpose for the admission/encounter is rehabilitation, sequence first the code for the condition for which the service is being performed. 206 FH54 - Developed by Polaris Group Page 106 of 158

108 Part B Therapy For a current LTC resident receiving Part B therapy services, the principal diagnosis (FL 67) reported on the UB-04 is the reason for the continued stay in the LTC facility. Followed by the diagnosis or condition that warrants the need for the Part B therapy (FL 67A). For example, Parkinson s may be the principal diagnosis (reason they are in nursing home), followed by difficulty walking and history of falls (the reasons for the therapy). 207 Part B Therapy The medical diagnosis (UB-04 FL 67A) that identifies the reason for the Part B therapy services should be listed AFTER the reason for the continued stay (UB- 04 FL 67 principal dx). The principal dx (FL 67) is usually the same as admitting diagnosis (FL 69) for Part B like it is for Part A. Other ICD-10-CM codes for chronic conditions that affect the resident's progress may also be reported to support therapy services (UB-04 FL 67 B-Q). 208 FH54 - Developed by Polaris Group Page 107 of 158

109 Admission/Encounter for Rehab Example An admission/encounter for rehabilitation for right-sided dominant hemiplegia following a cerebrovascular infarction, report code I69.351, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, as the first-listed or principal diagnosis (FL 67). 209 Admission/Encounter for Rehab Example When a patient is being treated at the hospital for an acute medical condition (aspiration pneumonia) and is admitted to SNF for rehab, code the acute condition (aspiration pneumonia) as the first listed/principal diagnosis followed by any chronic conditions. 210 FH54 - Developed by Polaris Group Page 108 of 158

110 Selection of Principal Diagnosis If the condition for which the rehabilitation service is being provided is no longer present, report the appropriate aftercare code as the first-listed or principal diagnosis (FL 67), unless the rehabilitation service is being provided following an injury. 211 Admissions/Encounters for Rehabilitation For rehabilitation services following active treatment of an injury, assign the injury code with the appropriate seventh character for subsequent encounter as the first-listed or principal diagnosis. 212 FH54 - Developed by Polaris Group Page 109 of 158

111 Aftercare as Principal/First-Listed For example, If a patient with severe degenerative osteoarthritis of the hip, underwent hip replacement and the current encounter/admission is for rehabilitation, report code Z47.1, Aftercare following joint replacement surgery, as the firstlisted or principal diagnosis (FL 67). 213 Admission/Encounter for Rehab Example If the patient requires rehabilitation post hip replacement for right intertrochanteric femur fracture, report code S72.141D, Displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, as the firstlisted or principal diagnosis. 214 FH54 - Developed by Polaris Group Page 110 of 158

112 Therapy Primary/Medical Diagnosis According to Medicare Program Integrity Manual, the primary or medical diagnosis is the reason for therapy services. Therapy POT for new Medicare Part A stays require the medical reason to support the therapy services as documented by the physician or qualified practitioner. This medical diagnosis may NOT be the same diagnosis as the reason for continued stay (principal/primary/first-listed) diagnosis. 215 Therapy Primary/Medical Diagnosis Continued Stay Example A patient with Parkinson s disease returns after a hospitalization for pneumonia to start a new Medicare Part A stay. Pneumonia is identified as the medical diagnosis on the therapy POT to support skilled therapy services along with therapy treatment diagnosis. 216 FH54 - Developed by Polaris Group Page 111 of 158

113 Therapy Primary/Medical Diagnosis Example However, Parkinson s disease is the reason for the continued stay and continues to be sequenced first on record and UB-04. The reason for the new focus of care and Medicare Part A stay (pneumonia) is sequenced second. 217 Questionable Principal Diagnosis Codes 218 FH54 - Developed by Polaris Group Page 112 of 158

114 Z Encounter for Other Specified Aftercare Z51.89 should not be listed as the principal firstlisted diagnosis for ICD-10-CM as a replacement for V57.xx codes from ICD-9-CM when the resident is admitted for rehabilitation services. Even though V57.xx crosswalks to Z51.89, Z51.89 should not be used for the principal diagnosis. 219 Z Encounter for Other Specified Aftercare The underlying diagnosis that resulted in the need for therapy would be listed as the principal diagnosis instead. 220 FH54 - Developed by Polaris Group Page 113 of 158

115 Z96.xxx Joint Replacement Codes (Z96.64x, Z96.65x) Z96.xxx codes should not be principal first-listed codes. Z47 for orthopedic aftercare should be the principal diagnosis in this case, followed by the Z96.xxx code, which indicates which joint was replaced. When looking up Z96.xxx you will see a note that says to code Z47, orthopedic aftercare first. 221 Z16.xx Z16.xx should not be the principal diagnosis. Z16.xx indicates that a patient has a condition that is resistant to antimicrobial drug treatment. Sequence the infection code first. 222 FH54 - Developed by Polaris Group Page 114 of 158

116 M62.81 and R26.81 Therapy treatment diagnosis codes (such as M62.81 or R26.81, muscle weakness, generalized, unsteadiness on feet, respectively) typically should not be used as the principal diagnosis. Instead the condition that is causing these symptoms and the need for therapy should be the principal diagnosis. 223 I60-I68 Acute Cerebrovascular Codes I60-I68 codes for Cerebrovascular Disease should not be used in the long-term care setting. Rather, the I69 codes for Sequela of Cerebrovascular Disease should be used since we are not treating the Acute CVA in the longterm care setting. 224 FH54 - Developed by Polaris Group Page 115 of 158

117 I69.xxx Codes Codes like I69.81 or I69.11 are non-specific codes and are therefore not billable. They now require a 6 th character in order to be valid. Example: I Attention and concentration deficit following other cerebrovascular disease I Memory deficit following nontraumatic intracerebral hemorrhage 225 Acute Conditions For example: K92.2, J96.01, J96.00, K62.5, J96.10, E86.0, E87.1, E87.0, I44.2, E87.2, E87.5, K40.30, K80.19, K85.90, E86.1, K80.43 and K57.80 Any acute condition treated at the hospital that continues to require follow up or ongoing monitoring should be coded with an acute diagnosis code as long as the condition persists and requires follow-up. 226 FH54 - Developed by Polaris Group Page 116 of 158

118 Acute Conditions In general, the status of the acute condition would be assessed whenever the MDS is updated (i.e., patient status change or at monthly review for billing). Codes for the acute medical condition treated and resolved in the hospital are assigned and reported by the hospital (i.e., Cholecystitis, abdominal aortic aneurysm) but not coded or reported in the LTC facility. 227 Acute Conditions The LTC facility reports Z codes to identify the provision of aftercare. It is inaccurate to report an acute code for a resolved condition on the health record or claim because it directly contradicts the Official Guidelines for Coding and Reporting. It is also non-compliant with HIPAA regulations. 228 FH54 - Developed by Polaris Group Page 117 of 158

119 R.xx Symptom Codes For example: R41.82, R55, R26.2, R27.0, R26.89, R13.12, R62.7, R26.0, R00.1, R29.6, R53.1, R78.81, R04.2, R65.10, R27.9, R06.02 and R52 Codes for symptoms, signs, and ill-defined conditions from ICD-10 CM Chapter 18 are not to be used as principal diagnosis when a related definitive diagnosis has been established. This section includes codes R00-R Personal History Codes (Z91.81, Z92.3, and Z92.21) There are two types of history Z codes, personal and family. Personal history codes explain a patient s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring. 230 FH54 - Developed by Polaris Group Page 118 of 158

120 Personal History Codes (Z91.81, Z92.3, and Z92.21) However, history codes may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. 231 Unspecified Laterality Codes For example, M17.10, C34.90, C56.9, C78.00, I and H81.10 Unspecified laterality codes should not be utilized. Even if the hospital documentation does not specify laterality, the SNF should determine laterality upon assessment of resident and code laterality accordingly. 232 FH54 - Developed by Polaris Group Page 119 of 158

121 Injury Codes with 7 th Character S For example, S32.000S, S72.141S, S06.5X0S, S02.8XXS and S32.89XS Injury codes with 7 th character S should not be principal first-listed diagnosis since according to the Official Coding Guidelines; the sequela code should be listed first followed by the injury that lead to the sequela, which includes the 7 th character S. S, Sequela - Late effects but not under active treatment for an acute condition (rarely use). 233 Unspecified and/or Generalized Codes Unspecified codes are not appropriate to use if there is a more specific diagnosis documented in the medical record. Please be sure they are using the greatest specificity as supported by medical record documentation. 234 FH54 - Developed by Polaris Group Page 120 of 158

122 Family of Codes Family of codes is the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved. 235 Family of Codes Examples include: H (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters. 236 FH54 - Developed by Polaris Group Page 121 of 158

123 Status Z Codes For example, Z98.1, Z95.5, Z93.1 and Z95.828, Z79.01 and Z90.5 Status Z codes indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition A status code is informative, because the status may affect the course of treatment and its outcome 237 Status Z Codes Status Z codes would not be listed as the principal, first-listed diagnosis. Status Z codes may be used with aftercare Z codes to indicate the nature of the aftercare. 238 FH54 - Developed by Polaris Group Page 122 of 158

124 Unacceptable Principal Diagnosis Z51.5, Z95.5, Z11.1 There are selected codes that describe a circumstance which influences an individual s health status but not a current illness or injury, or codes that are not specific manifestations but may be due to an underlying cause. These codes are considered unacceptable as a principal diagnosis. Manifestation codes cannot be principal; but rather the underlying disease should be listed first. 239 J17-Pneumonia in Diseases Classified Elsewhere J17 describes the manifestation of an underlying disease, not the disease itself. The underlying disease should be coded first. 240 FH54 - Developed by Polaris Group Page 123 of 158

125 External Causes of Morbidity Codes (W19.XXXD, W01.0XXD) External cause codes (V, W, X or Y codes) describe the circumstance causing an injury, not the nature of the injury, and therefore should not be used as a principal diagnosis. Instead, the injury itself should be first-listed primary diagnosis. 241 Other Generalized and/or Questionable Diagnoses Used G89.28 Other Chronic Pain Z74.1 Need for Assistance with Personal Care C80.1 Malignant (primary) Neoplasm Unspecified L Pressure ulcer of left heel, Stage I Q43.3 Congenital Malformations of intestinal fixation A53.9 Syphilis, unspecified 242 FH54 - Developed by Polaris Group Page 124 of 158

126 Other Generalized and/or Questionable Diagnoses Used K94.03 Colostomy malfunction D Elevated white blood cell count, unspecified Z47.2 Encounter for removal of Internal Fixation Device G47.00 Insomnia, unspecified 243 UB-04 Claim Issues Identified Since October 2016 So far, since flexibility rule has ended, mostly same issues that were seen in ICD-9-CM: Wrong Gender Wrong Age Group Wrong Diagnosis for Current Local Coverage Determinations (LCDs) But are seeing claim denials for not including manifestation codes on the claim (Novitas) 244 FH54 - Developed by Polaris Group Page 125 of 158

127 Coding Issues Identified Using unspecified codes for example, using code for Chronic CHF when medical record specified Acute on Chronic Diastolic or Systolic CHF. Using greater specificity than was supported by EHR. 245 Coding Issues Identified Coding pertinent ICD-10 codes on the 2 nd line of the claim instead of in the first 8 diagnoses. Remember that CMS only sees the first 8 diagnoses on an electronic claim. Not coding the primary diagnosis as the first-listed diagnosis placing it somewhere down the line. Not including therapy codes listed in the first eight codes in the sequence in order for them to be included on electronic claim. 246 FH54 - Developed by Polaris Group Page 126 of 158

128 Coding Issues Identified Incorrect laterality as compared to EHR. Improper sequence according to priority of codes. Incorrect codes used. Did not list diagnosis(es) that should have been coded. Not including the organism when there is an infection or; Coding the organism but not the infection. Remember, that the infection should be listed first, followed by the organism (when known). 247 Coding Issues Identified Using External Cause of Injury codes as primary. Not required unless required by particular state. 248 FH54 - Developed by Polaris Group Page 127 of 158

129 Coding Issues Identified Using pain as primary or as secondary code when resident was having expected routine postoperative pain. According to Official Coding Guidelines, expected routine post-operative pain should not be coded. 249 MDS Issues Not including all diagnoses that should have been coded. Not including more specific diagnosis with ICD- 10-CM code in Section I8000. Using incorrect codes not supported by EHR. 250 FH54 - Developed by Polaris Group Page 128 of 158

130 Therapy Issues Identified Therapy using whatever the facility used for the medical diagnosis regardless if that was the diagnosis that most supported their treatment plan or not. You want to ensure that billing is getting diagnosis codes from facility and not just from therapy since therapy medical diagnosis is not the same as the principal diagnosis for continued stay or for Medicare Part B. 251 Sequencing 252 FH54 - Developed by Polaris Group Page 129 of 158

131 Principal/Primary and Secondary Diagnosis Sequence Example Principal/Primary: S72.112D, Displaced fracture of greater trochanter of left femur, 7 th character D for subsequent encounter for closed fracture with routine healing. - Field 67 Additional diagnoses (FL 67A-Q) Rehab diagnosis if applicable I25.10 Artherosclerotic heart disease of native coronary artery without angina pectoris I48.91 Unspecified Atrial Fibrillation Z51.81 Encounter for therapeutic drug monitoring Z79.01 Long-term (current use) of anticoagulants 253 Diagnosis Coding S72.112D I25.10 I48.91 Z51.81 Z79.01 S72.112D 254 FH54 - Developed by Polaris Group Page 130 of 158

132 Communication is Key 255 Care Team Communication with Billing Nursing Department should utilize a form that is completed upon every admission listing Principal, Admitting and supporting diagnoses. The form should be completed by the appropriate clinical personnel and provided to the Business Office Manager for inclusion on the UB FH54 - Developed by Polaris Group Page 131 of 158

133 Diagnosis Sheet Business Office Manager IS NOT responsible for selection of diagnoses. Business Office Manager IS responsible for ensuring that the codes included on the claim are compliant and consistent with medical record documentation. 257 ICD-10-CM Case Studies 258 FH54 - Developed by Polaris Group Page 132 of 158

134 Coding Example #1 Resident is admitted to Shiny Skies Nursing and Rehabilitation Center following a CVA resulting in Left-Sided Hemiparesis and Dysphagia that required placement of a G- tube. Resident is left handed. Resident also has Type II Diabetes. Resident will be receiving PT for gait training, OT for muscle weakness, and ST for dysphagia. 259 ICD-10-CM Answers for Coding Example #1: I Dysphasia following cerebral infarction I Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side Z43.1 Attention to gastrostomy E11.59 Type II Diabetes with other circulatory complications R26.9 Unspecified abnormalities of gait/mobility M62.81 Muscle weakness, generalized R13.10 Dysphagia, unspecified 260 FH54 - Developed by Polaris Group Page 133 of 158

135 Coding Example #2 Resident is admitted to your facility status post traumatic greater trochanter displaced right femur fracture from a fall that occurred at home. Resident presented with a Stage II pressure ulcer on both heels and coccyx. Resident will be receiving both PT and OT services. Resident also has a diagnosis of Essential Hypertension. PT will be treating resident for Difficulty Walking and OT for muscle weakness. 261 ICD-10-CM Answers for Coding Example #2: S72.111D Displaced fracture of greater trochanter of right femur, subsequent encounter for closed fracture with routine healing (7 th character D ) R26.2 Difficulty in walking, not elsewhere classified M62.81 Muscle weakness, generalized L Pressure ulcer of right heel, stage 2 L Pressure ulcer of left heel, stage 2 L Pressure ulcer of sacral region, stage 2 I10 Essential (primary) Hypertension 262 FH54 - Developed by Polaris Group Page 134 of 158

136 Coding Example #3 Resident is admitted to Home Sweet Home following abdominal surgery for bowel obstruction. Resident has post operative superficial wound that requires BID dressing changes due to abdominal dehiscence. Resident also has newly diagnosed UTI with E. Coli isolated in the culture. Resident is symptomatic with frequency, urgency and burning upon urination. Oral antibiotics are ordered x10 days. Resident will not receive therapy upon admission. 263 ICD-10-CM Answers for Coding Example #3: T81.31xD Disruption of external operation (surgical) wound, not elsewhere classified, subsequent encounter Z Encounter for surgical aftercare following surgery on the digestive system Z48.01 Encounter for change or removal of surgical wound dressing N39.0 Urinary tract infection, site not specified B96.20 Unspecified E. coli, as the cause of diseases classified elsewhere 264 FH54 - Developed by Polaris Group Page 135 of 158

137 Coding Example #4 Resident is admitted to Shady Grove after repair of a Fractured Left Hip sustained due to a fall. Resident has Left Hip Osteoarthritis from dysplasia with chronic NSAID use. Additional diagnoses include Essential Hypertension, Sinus Bradycardia and Hyperlipidemia NOS. Admission orders include lab work to monitor effect of Simvastatin and Omacor. Resident will be receiving PT for treatment of difficulty walking and OT therapy services for muscle weakness. 265 ICD-10-CM Answers for Coding Example #4: S72.002D Fracture of unspecified part of neck of left femur (Fracture of hip NOS) (7 th character D- subsequent encounter for closed fracture with routine healing) M16.32 Unilateral osteoarthritis resulting from hip dysplasia, left hip Z79.1 Long-term (current) use of NSAIDS Z Other long term (current) drug therapy Z51.81 Therapeutic drug level monitoring 266 FH54 - Developed by Polaris Group Page 136 of 158

138 ICD-10-CM Answers for Coding Example #4: Continued R26.2 Difficulty in walking, not elsewhere classified M62.81 Muscle weakness, generalized R00.1 Bradycardia, unspecified I10 Hypertension (essential) E78.5 Hyperlipidemia (unspecified) 267 Coding Example #5 Resident was admitted to Daisy May SNF following a right total hip replacement at the hospital due to primary unilateral Osteoarthritis of right hip. Resident will be receiving PT for gait training due to difficulty walking. Resident will be receiving OT for muscle weakness. 268 FH54 - Developed by Polaris Group Page 137 of 158

139 ICD-10-CM Answers for Coding Example #5: Z47.1 Aftercare following joint replacement surgery (Note to use additional code to identify the joint (Z96.6-) Z Presence of right artificial hip joint M16.11 Unilateral primary osteoarthritis, right hip R26.2 Difficulty in walking, not elsewhere classified M62.81 Muscle weakness, generalized 269 Hip Fracture/Hip Replacement Case Study 89 Y/O female admitted to Daisy May Hospital for a greater trochanter fracture of left hip following a fall. It was determined that she needed a left hip replacement. Patient is receiving prophylactic anticoagulant Lovenox and also has a diagnosis of Congestive Heart Failure (CHF) and Senile Dementia. 270 FH54 - Developed by Polaris Group Page 138 of 158

140 Hip Fracture Case Study Hospital Discharge Diagnoses: Fracture of Left Greater Trochanter Left Hip Replacement Osteoporosis Senile Dementia CHF 271 Hip Fracture Case Study SNF Orders: PT and OT to eval and treat as indicated PT will be providing gait training for Difficulty Walking OT will be providing therapeutic activities and ADL retraining for muscle weakness Continue Lovenox therapy 272 FH54 - Developed by Polaris Group Page 139 of 158

141 Hip Fracture Case Study What is the admitting diagnosis (FL 69) for the claim/mds? What is the principal diagnosis (FL 67) for the claim/mds? List in order the other diagnoses (FL 67a-q) for the claim/mds? 273 Hip Fracture Case Study Answers Admitting diagnosis for claim (FL 69)/MDS: S72.112D, Displaced fracture of greater trochanter of left femur, 7 th character D for subsequent encounter for closed fracture with routine healing. Principal diagnosis for claim (FL 67)/MDS: S72.112D, Displaced fracture of greater trochanter of left femur, 7 th character D for subsequent encounter for closed fracture with routine healing. 274 FH54 - Developed by Polaris Group Page 140 of 158

142 Hip Fracture Case Study Answers Subsequent Diagnoses in order of priority: (FL 67aq)/MDS? Z Presence of left artificial hip joint I50.20 Unspecified systolic (congestive) heart failure R26.2 Difficulty in walking, not elsewhere classified M62.81 Muscle weakness, generalized Z79.01 Long-term (current use) of anticoagulants F03.90 Unspecified Dementia, Senile Dementia NOS **Remember to use injury code as primary for joint replacements resulting from injury** 275 CVA Case Study 79 y/o male admitted to Memorial Hospital after daughter found him slurring his words and unable to move left arm. Gentleman is Left Handed. Hospital determined that patient had suffered a Cerebrovascular Accident (CVA) from a blood clot. Patient will be on long-term Lovenox therapy and is receiving PT, OT, and ST therapies for gait training, muscle weakness, and aphasia. Patient also developed a Stage 2 pressure ulcer on right buttocks during hospital stay. 276 FH54 - Developed by Polaris Group Page 141 of 158

143 CVA Case Study Discharge Diagnoses from hospital: Acute CVA (I63.9) Aphasia Left Hemiparesis Stage 2 pressure ulcer to right buttocks 277 CVA Case Study What is the admitting diagnosis (FL 69) for the claim/mds? What is the principal diagnosis (FL 67) for the claim/mds? List in order the other diagnoses (FL 67a-q) for the claim/mds? 278 FH54 - Developed by Polaris Group Page 142 of 158

144 CVA Case Study Answers Admitting diagnosis for claim (FL 69)/MDS? I Aphasia following unspecified cerebrovascular disease or I Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side Principal diagnosis for claim (FL 67)/MDS? I Aphasia following unspecified cerebrovascular disease or I Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side 279 CVA Case Study Answers Subsequent Diagnoses in order of priority: (FL 67a-q)/MDS? I Aphasia following unspecified cerebrovascular disease or I Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side (which ever wasn t used as principal dx) M62.81 Muscle weakness, generalized R26.9 Unspecified abnormalities of gait and mobility Z79.01 Long-term (current use) of anticoagulants L Pressure Ulcer of Right Buttocks, Stage FH54 - Developed by Polaris Group Page 143 of 158

145 Post Test 281 FH54 - Developed by Polaris Group Page 144 of 158

146 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services MLN Matters Number: MM9753 Related Change Request (CR) #: CR 9753 Related CR Release Date: April 28, 2017 Effective Date: October 1, 2017 Related CR Transmittal #: R1832OTN Implementation Date: October 2, 2017 Update FISS Editing to Include the Admitting Diagnosis Code Field Provider Types Affected This MLN Matters Article is intended for providers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries. Provider Action Needed Change Request (CR) 9753 informs MACs about changes to system edits by the maintainer of Medicare's Fiscal Intermediary Shared System (FISS). Make sure that your billing staffs are aware of these changes. Background In prior system updates, Medicare required FISS to review diagnosis fields. CR9753 updates various system edits to look at the admitting diagnosis field. FISS editing is now being updated to ensure that all of the National Coverage Determination (NCD) edits within Reason Code ranges 3xxxx and 59xxx that are tied to the diagnosis code fields (other than the primary diagnosis field) include the admitting diagnosis field for Inpatient claims on Types of Bill (TOB) 011x, 012x, 018x, 021x, and 022x. Additional Information The official instruction, CR9753, issued to your MAC regarding this change is available at Guidance/Guidance/Transmittals/2017Downloads/R1832OTN.pdf. FH54 - Developed by Polaris Group Page 145 of 158