3/20/2017. CONNECTING THE LATEST GUIDANCE FY2017 FOR ICD-10 MATTERS Kyla D. Harrison, RN, BSN, HCS-D, COS-C Visiting Nurse Association of Kansas City

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1 CONNECTING THE LATEST GUIDANCE FY2017 FOR ICD-10 MATTERS Kyla D. Harrison, RN, BSN, HCS-D, COS-C Visiting Nurse Association of Kansas City Coding needs met in many different ways: 1. Fulltime Coders HCS-D 2. Contract Coding Agencies very expensive but flexible and useful for vacations, growth, etc. 3. Managers fill dual roles 4. Clinicians fill dual roles October 1, 2016 September 30, 2017 Approved by four organizations AHA, AHIMA, CMS, and NCHS Focus for this presentation is the changes and updates for the new guidance that is the most confusing to provide clarification 114 pages see website for full listing of guidance _final.pdf 1

2 ANY condition listed under a sub term with in the Index should be interpreted as linked to the main term when both conditions are present, according to the Q Coding Clinic. This guidance is a complete about-face from previous instruction Not all coders are using this guidance still seeing this now from SNFs, hospitals and physician offices 2

3 Cautions: Read carefully the entire referral to ensure that the connecting diagnosis is NOT attributed to something else Example Referral lists Diabetes and ESRD, but patient has Polycystic Kidney Disease also listed. Do not assume the relationship between DM and ESRD on this scenario. Implications for reimbursement - unknown at this point You can gain spaces (top 6) that appear in the oasis by combining more codes- possibly increase case-mix Could bring more revenue - MOST COMMON Hypertension and Heart Disease Diabetes and Manifestations Parkinson s and Dementia HTN and CKD long-standing and still continues 3

4 WITH Hypertension and Heart Disease WITH Hypertension Etiology I11.0 Hypertensive heart disease with heart failure Heart Disease Manifestation I51.4 Myocarditis, unspecified through I51.9 Heart disease, unspecified And all of HF I50.- Heart failure includes many diagnoses The classification presumes a causal relationship between hypertension and heart involvement. As the two conditions are linked by the term with in the Alphabetic Index. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated, according to the FY2017 official coding guidelines, released Aug.5, and effective Oct. 1,

5 ADR (Additional Documentation Request) can result possibly if coders do not use new guidance I10 HTN is not appropriate in a coding sequencing on a patient with a diagnosis of I50.- also. Potential alert to CMS when these 2 codes appear together that they should be coded as I11.0 plus I50.- instead. CMS has opened the door to allow auditors to begin denying claims for code specificity also so experts are suggesting querying the physician for more specificity with CHF. There can be more than one type of CHF coded on the same claim- example- I50.21 Acute Systolic (congestive) heart failure I50.32 Chronic Diastolic (congestive) heart failure Coding Clinic guidance Q Physician Diagnosis Documentation of Heart Failure with reduced ejection fraction HFrEF (I just saw this one on a referral) is the same as I50.2- Systolic Heart Failure OR Heart Failure with preserved ejection fraction is the same as I50.3- Diastolic Heart Failure 5

6 CODING SCENARIO #1 Mr. Breathless was admitted to home health after a hospitalization to treat and exacerbation of Acute Diastolic CHF with increased SOB and LE edema. His past medical history included HTN CODING SCENARIO #1 ANSWERS 1. I11.0 Hypertensive Heart Disease with Heart Failure 2. I50.31 Acute Diastolic Heart Failure WITH Diabetes (E08.- E11.-) Manifestations are captured by the fourth character 6

7 Diabetes Etiology E08 due to underlying condition E09 Drug or chemical induced DM E10 Type 1 E11 Type 2 E13 Other Specified DM Manifestations Renal Ophthalmic Neuro Circulatory Ulcers Renal 4 th character 2 Nephropathy -.21 Other diabetic kidney complications -.29 Chronic kidney disease nd code required for stage of CKD CODING SCENARIO #2 Mr. Polly is admitted to home health from the dialysis center for changes in his diabetic oral hypoglycemic meds. He has dialysis M-W-F for his ESRD

8 CODING SCENARIO #2 ANSWERS E11.22 Diabetic Chronic Kidney Disease N18.6 ESRD Z99.2 Dependence on Renal Dialysis Ophthalmic 4 th character 3 Requires a 7 th character as of October 1, 2016 Right, left, both, unspecified to specify laterality Assumed relationship based on with Retinopathy Macular Edema Cataracts-.36 Coding Clinic Q CODING SCENARIO #3 Mr. Blind admitted to home health due to change in diabetic medication increased Glucophage dosage at the doctor office. The doctor wants to make sure patient is taking medications correctly due to his eyesight is blurred with cataracts in both eyes

9 CODING SCENARIO #3 ANSWERS 1. E11.36 Type 2 DM with Diabetic Cataract 2. Z79.84 Long term (current) use of Oral Hypoglycemic drugs Neurological 4 th character 4 Unspecified neuropathy-.40 Mononeuropathy -.41 Polyneuropathy- specific type- code to.42 Peripheral neuropathy is the same thing as polyneuropathy = code as diabetic polyneuropathy Neuralgia -.42 Myasthenia -.44 Amyotrophy -.44 Antonomic neuropathy -.43 Gastroparesis NEC-.49 CODING SCENARIO #4 Mrs. Gloves is admitted to home health for physical therapy due to gait instability due to peripheral neuropathy. Mrs. Gloves also has had diabetes for 20 years. 1. 9

10 CODING SCENARIO #4 ANSWERS 1. E11.42 Type 2 DM with Diabetic Polyneuropathy Circulatory 4 th character 5 Peripheral angiopathy without gangrene-.51 Peripheral angiopathy with gangrene-.52 Other circulatory manifestations would need physician confirmation (CAD, MI, HTN, etc.) Example: Hypertension due to Diabetes would need to be stated in the referral H&P E11.59 (Type 2 DM with other circulatory complications) I15.2 (Hypertension secondary to endocrine disorders) CODING SCENARIO #5 Mr. Smoker has new diagnosis of Peripheral Angiopathy. He has a past medical history of diabetes for many years

11 CODING SCENARIO #5 ANSWERS 1. E11.51 Type 2 DM with Diabetic peripheral angiopathy without gangrene Ulcers 4 th character 6 Foot ulcer requires a second code from L97.- Dermatitis Skin ulcer NEC Skin complication NEC-.628 Osteomyelitis DM with other specified complication code nd code for the location and type of osteomyelitis CODING SCENARIO #6 Ms. Sugar admitted to home health for dressing changes after a referral from the wound care center for a diabetic ulcer on the right foot plantar surface with exposed fat layer

12 CODING SCENARIO #6 ANSWERS 1. E Type 2 DM with Foot Ulcer 2. L Non-pressure chronic ulcer of right heel and midfoot with fat layer exposed 3. Z48.00 Encounter for change or removal of nonsurgical wound dressing WHAT IF ALL THESE DIAGNOSES ARE ON THE SAME PATIENT???? Diabetes, HTN, CKD, CHF Condition that is the primary reason for the home health admission decides the sequencing of these four diagnoses Biggest source of confusion for home health coders since new guidance release An etiology code (HTN or DM) must be sequenced prior to a manifestation code (CHF or CKD) Clinicians may need education to understand why the CHF is not primary when that is the focus of their care (HTN is first if both present) OR an ESRD patient has DM listed first. 12

13 Etiology Diabetes HTN Manifestation CKD CHF CODING SCENARIO #7 Ms. Norman was admitted to home health for teaching of insulin administration for her type 2 diabetes. She also has a past medical history of stage 3 CKD, HTN, and chronic diastolic CHF. How would you code this? CODING SCENARIO #7 ANSWERS 1. E11.22 DM type 2 with CKD 2. I13.0 HTN with CHF 3. N18.3 CKD stage 3 4. I50.32 Chronic diastolic CHF 5. Z79.4 Insulin 13

14 CODING SCENARIO #8 What would be the difference if CHF is the focus of care in this same scenario? CODING SCENARIO - #8 ANSWERS 1. I13.0 HTN heart disease with CHF 2. I50.32 Chronic diastolic CHF 3. E11.22 DM with CKD 4. N18.3 CKD stage 3 5. Z79.4 Insulin The HTN is the etiology so it would have to be listed before the manifestation which is the CHF DEMENTIA WITH PARKINSON S Parkinson s, Parkinsonism, and Lewy Body Dementia 14

15 If your referral has both Parkinson s and Dementia listed you may assume the connection due to the with wording in the Alphabetical Parkinsonism assign G20 for a diagnosis stated simply as Parkinsonism with no more details Parkinsonism with dementia - both in documentation then G31.83 plus F02.80 or.82 Parkinson s should be looked up under disease rather than Parkinson s to arrive at correct code 15

16 Confusion regarding Lewy Body Dementia has been clarified: Assign an additional code for dementia from the F category Patient with a diagnosis of Lewy body dementia needs 2 codes assigned G31.83 Lewy Body Dementia (does not carry case mix) F Dementia in other diseases classified elsewhere Clarification came in the Q Coding Clinic update CODING SCENARIO #10 Mr. Mask admitted to home health after hospitalization for exacerbation of Parkinson s disease. He needs nursing for medication adjustments and physical therapy for his shuffling gait due to the Parkinson s disease. Mr. Mask also had dementia and has been combative with his caregivers lately but no wandering CODING SCENARIO #10 ANSWERS 1. G20 Parkinson s Disease 2. F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance 16

17 CASE MIX UPDATES October 2016 through January 2017 Adding case mix points: CVA 8 new codes regarding cognitive sequelae DM Ophthalmic manifestations 62 IBS with diarrhea/constipation Heart disease and HTN awarded more points- up to 2 points in later episodes Pulmonary disorders lost points 2 years ago now back with 1 potential point depending on episode and therapy 11 codes effected for January 1, 2017 (including J43.9, J44.1, J44.9) September and December 2016 Issues- Coding Pro NRS supplies points increased and case mix increased Postprocedural hematomas of endocrine system Periorbital cellulitis 17

18 Loss of Case Mix Points Fracture of skull and facial bones 27 codes Injury of cranial nerve Gastrointestinal conditions that occur with neuro conditions Stroke conditions that interact with oasis dressing items Grouper CMS: To view the October 2016 Grouper, go to September 2016 Issue Diagnosis Coding Pro Periprosthetic fracture around internal prosthetic joint has been moved from T84.04 (chapter19) to M97 (Chapter 13) Hypoglycemic drugs code Z79.84 Hypertension adds more serious forms now available: I16.0 Hypertensive Urgency I16.1 Hypertensive Emergency I16.9 Hypertensive Crisis, unspecified Clarification from coding clinic the default for Osteoarthritis of a joint for a joint replacement is Primary Used to have to code unspecified knee if you didn t have primary or secondary in the documentation Now use specific knee joint M17.0 Bilateral Primary Osteoarthritis of knee M17.11 Unilateral Primary Osteoarthritis, right knee M17.12 Unilateral Primary Osteoarthritis, left knee 18

19 CHF- more specific codes Nonhealing surgical and trauma wounds Pathological fracture of the ribs and pelvis due to osteoporosis Rehab care code Z51.82 Use additional code to identify infection at J44.0 Aftercare for spinal surgery change from Z48.89 to Z47.89 Osteomyelitis could be added as a subterm under diabetes with Diagnosis Coding Pro Newsletter April 2017 MAHC CODERS CONNECTING THE DOTS WITH ICD-10! 19

20 Decision Health Coding Center Professional Decision Health Diagnosis Coding Pro Newsletters American Hospital Association Coding Clinic Centers for Medicare and Medicaid Official Guidelines for Coding and Reporting FY _final.pdf American Health Information Management Association (AHIMA) 20