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 2017, 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 128

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 128

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 128

5 ICD-10-CM Coding Tips 1 Outline FY18 Updates ICD-10-CM Websites Coding Conventions Chapter Specific Guidelines Differences Between Initial and Subsequent Encounter for 7 th Character 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 128

6 FY 2018 Updates Updates for FY18 include: Clarification on coding hip replacement following hip fracture Clarification of pathologic fracture coding Diabetic coding when insulin and oral agents are used AMI Non-pressure chronic ulcers 3 FY 2018 Updates Clarification to With Definition Clarification to code also note Pulmonary Hypertension Neoplasm of Ectopic Tissue Blindness 4 FH54 - Developed by Polaris Group Page 5 of 128

7 FY 2018 Updates (Updated language in bold) 5 Clarification to With Definition The word with or in should be interpreted to mean associated with or due to when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. 6 FH54 - Developed by Polaris Group Page 6 of 128

8 Clarification to With Definition 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 or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for acute organ dysfunction that is not clearly associated with the sepsis ). 7 Clarification to With Definition For conditions not specifically linked by these relational terms in the classification or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related. 8 FH54 - Developed by Polaris Group Page 7 of 128

9 Code Also Note A code also note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing directions. The sequencing depends on the circumstances of the encounter. So if you are looking up a code and see a Code also note, you would also code any of these diagnoses listed in the note that the resident may have. 9 Diabetes Mellitus and the Use of Insulin and Oral Hypoglycemic Drugs If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11-, Type 2 diabetes mellitus, should be assigned. An additional code should be assigned from category Z79 to identify the long-term (current) use of insulin or oral hypoglycemic drugs. 10 FH54 - Developed by Polaris Group Page 8 of 128

10 Diabetes Mellitus and the Use of Insulin and Oral Hypoglycemic Drugs If the patient is treated with both oral medications and insulin, only the code for long-term (current) use of insulin should be assigned. Code 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. This is for Diabetes Mellitus and Secondary Diabetes. 11 Malignant Neoplasm of Ectopic Tissue Malignant neoplasms of ectopic tissue are to be coded to the site of origin mentioned, e.g., ectopic pancreatic malignant neoplasms involving the stomach are coded to malignant neoplasm of pancreas, unspecified (C25.9). 12 FH54 - Developed by Polaris Group Page 9 of 128

11 Blindness If blindness or low vision of both eyes is documented but the visual impairment category is not documented, assign code H54.3, Unqualified visual loss, both eyes. If blindness or low vision in one eye is documented but the visual impairment category is not documented, assign a code from H54.6-, Unqualified visual loss, one eye. 13 Blindness If blindness or visual loss is documented without any information about whether one or both eyes are affected, assign code H54.7, Unspecified visual loss. 14 FH54 - Developed by Polaris Group Page 10 of 128

12 Pulmonary Hypertension Pulmonary hypertension is classified to category I27, Other pulmonary heart diseases. For secondary pulmonary hypertension (I27.1, I27.2-), code also any associated conditions or adverse effects of drugs or toxins. The sequencing is based on the reason for the encounter. 15 Acute Myocardial Infarction, Unspecified Code I21.9, Acute myocardial infarction, unspecified, is the default for unspecified acute myocardial infarction or unspecified type. If only type 1 STEMI or transmural MI without the site is documented, assign code I21.3, ST elevation (STEMI) myocardial infarction of unspecified site. 16 FH54 - Developed by Polaris Group Page 11 of 128

13 Subsequent Acute Myocardial Infarction A code from category I22, Subsequent ST elevation (STEMI) and non-st elevation (NSTEMI) myocardial infarction, is to be used when a patient who has suffered a type 1 or unspecified AMI has a new AMI within the 4 week time frame of the initial AMI. A code from category I22 must be used in conjunction with a code from category I Subsequent Acute Myocardial Infarction The sequencing of the I22 and I21 codes depends on the circumstances of the encounter. Do not assign code I22 for subsequent myocardial infarctions other than type 1 or unspecified. For subsequent type 2 AMI assign only code I21.A1. For subsequent type 4 or type 5 AMI, assign only code I21.A9. 18 FH54 - Developed by Polaris Group Page 12 of 128

14 Other Types of Myocardial Infarction The ICD-10-CM provides codes for different types of myocardial infarction. Type 1 myocardial infarctions are assigned to codes I21.0-I21.4. Type 2 myocardial infarction, and myocardial infarction due to demand ischemia or secondary to ischemic balance, is assigned to code I21.A1, myocardial infarction type 2 with a code for the underlying cause. 19 Other Types of Myocardial Infarction Do not assign code I24.8, Other forms of acute ischemic heart disease for the demand ischemia. Sequencing of type 2 AMI or the underlying cause is dependent on the circumstances of admission. When a type 2 AMI code is described as NSTEMI or STEMI, only assign code I21.A1. 20 FH54 - Developed by Polaris Group Page 13 of 128

15 Other Types of Myocardial Infarction Codes I21.01-I21.4 should only be assigned for type 1 AMIs. Acute myocardial infarctions type 3, 4a, 4b, 4c and 5 are assigned to code I21.A9, Other myocardial infarction type. The "Code also" and "Code first" notes should be followed related to complications, and for coding of postprocedural myocardial infarctions during or following cardiac surgery. 21 Non-Pressure Chronic Ulcers Added the following for non-pressure ulcers which is same as pressure ulcer coding: Patients admitted with non-pressure ulcers documented as healed No code is assigned if the documentation states that the non-pressure ulcer is completely healed. 22 FH54 - Developed by Polaris Group Page 14 of 128

16 Non-Pressure Chronic Ulcers Patients admitted with non-pressure ulcers documented as healing Assign the appropriate non-pressure ulcer code based on the documentation in the medical record. If the documentation does not provide information about the severity of the healing non-pressure ulcer, assign the appropriate code for unspecified severity. 23 Non-Pressure Chronic Ulcers If the documentation is unclear as to whether the patient has a current (new) nonpressure ulcer or if the patient is being treated for a healing non-pressure ulcer, query the provider. For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and severity of the nonpressure ulcer at the time of admission. 24 FH54 - Developed by Polaris Group Page 15 of 128

17 Patient Admitted with Non-Pressure Ulcer that Progresses to Higher Stage If a patient is admitted to an inpatient hospital with a non-pressure ulcer at one severity level and it progresses to a higher severity level, two separate codes should be assigned: one code for the site and severity level of the ulcer on admission and a second code for the same ulcer site and the highest severity level reported during the stay. 25 Coding of Pathologic Fractures ** New wording in bold** 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. 26 FH54 - Developed by Polaris Group Page 16 of 128

18 Coding of Injuries When coding injuries, assign separate codes for each injury unless a combination code is provided, in which case the combination code is assigned. Codes from category T07, Unspecified multiple injuries should not be assigned in the inpatient setting unless information for a more specific code is not available. 27 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. 28 FH54 - Developed by Polaris Group Page 17 of 128

19 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. 29 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 firstlisted or principal diagnosis. Coding Clinic advises next code to be Z96.xx to specify which joint has been replaced. 30 FH54 - Developed by Polaris Group Page 18 of 128

20 ICD-10-CM Websites 31 ICD-10-CM Websites CDC CMS 0/2018-ICD-10-CM-and-GEMs.html ICD-9-CM to ICD-10-CM Crosswalk 32 FH54 - Developed by Polaris Group Page 19 of 128

21 ICD-10-CM Websites AHIMA ICD-10 General Information CMS lookup tool that allows users to search for codes by ICD-10 description keywords: 33 Coding Conventions and Terms in ICD-10-CM 34 FH54 - Developed by Polaris Group Page 20 of 128

22 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. 35 Default Codes The default code is listed next to a main term in the ICD-10-CM Alphabetic Index. Family of codes then listed under main term/default code Represents that 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. 36 FH54 - Developed by Polaris Group Page 21 of 128

23 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 37 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 22 of 128

24 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). 39 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.**** 40 FH54 - Developed by Polaris Group Page 23 of 128

25 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 41 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. 42 FH54 - Developed by Polaris Group Page 24 of 128

26 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 43 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) 44 FH54 - Developed by Polaris Group Page 25 of 128

27 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 45 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). 46 FH54 - Developed by Polaris Group Page 26 of 128

28 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 47 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 48 FH54 - Developed by Polaris Group Page 27 of 128

29 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 49 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). 50 FH54 - Developed by Polaris Group Page 28 of 128

30 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 52 FH54 - Developed by Polaris Group Page 29 of 128

31 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. 53 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 54 FH54 - Developed by Polaris Group Page 30 of 128

32 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. 55 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 56 FH54 - Developed by Polaris Group Page 31 of 128

33 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 57 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. 58 FH54 - Developed by Polaris Group Page 32 of 128

34 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 59 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 60 FH54 - Developed by Polaris Group Page 33 of 128

35 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. 61 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 62 FH54 - Developed by Polaris Group Page 34 of 128

36 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) 63 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. 64 FH54 - Developed by Polaris Group Page 35 of 128

37 Laterality Example L Pressure ulcer of right hip, stage 2 Healing pressure ulcer of right hip, stage 2 65 More Laterality Examples 66 FH54 - Developed by Polaris Group Page 36 of 128

38 More Laterality Examples 67 Laterality for Base of Skull Laterality for base of skull fractures S02.101D Fracture of base of skull, right side, subsequent encounter 68 FH54 - Developed by Polaris Group Page 37 of 128

39 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** 69 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 70 FH54 - Developed by Polaris Group Page 38 of 128

40 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. 71 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). 72 FH54 - Developed by Polaris Group Page 39 of 128

41 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. 73 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. 74 FH54 - Developed by Polaris Group Page 40 of 128

42 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. Means that these codes are mutually exclusive so they are NEVER used together such as a congenital form verses an acquired form of the same condition. 75 Excludes1 Example Telling you that aftercare for healing fx is not included in Z47 Orthopedic Aftercare 76 FH54 - Developed by Polaris Group Page 41 of 128

43 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, query the provider. 77 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. 78 FH54 - Developed by Polaris Group Page 42 of 128

44 Excludes1 Exception Example However 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. 79 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. 80 FH54 - Developed by Polaris Group Page 43 of 128

45 Excludes2 Example Telling you that fitting and adjustment is excluded but may use both codes 81 Code Also Example 82 FH54 - Developed by Polaris Group Page 44 of 128

46 ICD-10-CM Coding Examples 83 ICD-10-CM Coding Example #1 84 FH54 - Developed by Polaris Group Page 45 of 128

47 ICD-10-CM Coding Example #1 85 ICD-10-CM Coding Example #2 86 FH54 - Developed by Polaris Group Page 46 of 128

48 ICD-10-CM Coding Example #2 87 ICD-10-CM Coding Example #3 88 FH54 - Developed by Polaris Group Page 47 of 128

49 ICD-10-CM Coding Example #3 89 ICD-10-CM Coding Example #3 90 FH54 - Developed by Polaris Group Page 48 of 128

50 ICD-10-CM Coding Example #4 91 ICD-10-CM Coding Example #4 92 FH54 - Developed by Polaris Group Page 49 of 128

51 ICD-10-CM Coding Example #4 93 ICD-10-CM Coding Example #4 94 FH54 - Developed by Polaris Group Page 50 of 128

52 ICD-10-CM Coding Example #5 Unspecified Code 95 ICD-10-CM Coding Example #5 Unspecified Code 96 FH54 - Developed by Polaris Group Page 51 of 128

53 ICD-10-CM Coding Example #6 Unspecified Code 97 ICD-10-CM Coding Example #6 Unspecified Code 98 FH54 - Developed by Polaris Group Page 52 of 128

54 Chapter-Specific Guidelines Will address additional coding guidelines not already covered in General Guidelines 99 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. 100 FH54 - Developed by Polaris Group Page 53 of 128

55 101 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. 102 FH54 - Developed by Polaris Group Page 54 of 128

56 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. 103 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. 104 FH54 - Developed by Polaris Group Page 55 of 128

57 Status Z Code vs. Diagnosis Code For example, code Z94.1, Heart transplant status, should not be used with a code from subcategory T86.2, Complications of heart transplant. The status code does not provide additional information. The complication code indicates that the patient is a heart transplant patient. 105 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. 106 FH54 - Developed by Polaris Group Page 56 of 128

58 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. It is not for use for patients who have addictions to drugs. Assign the appropriate code for the drug dependence instead. 107 Other Status Z Codes Z93 Artificial opening status Z95 Presence of cardiac and vascular implants and grafts Z97 Presence of other devices Z98 Other post procedural status 108 FH54 - Developed by Polaris Group Page 57 of 128

59 History (of) History Z Codes 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 109 Aftercare Aftercare Z Codes 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. 110 FH54 - Developed by Polaris Group Page 58 of 128

60 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. 111 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. 112 FH54 - Developed by Polaris Group Page 59 of 128

61 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 113 Z47 Orthopedic Aftercare Example 114 FH54 - Developed by Polaris Group Page 60 of 128

62 Orthopedic Aftercare Examples 115 Sequela (Late Effects) A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. Example: May be used for recent CVA resident who was just treated during recent hospital stay or could be CVA from several years ago. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. 116 FH54 - Developed by Polaris Group Page 61 of 128

63 Sequela (Late Effects) 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. We use the Sequela or Late Effects code in LTC which are the I69 codes in ICD-10-CM just like we used the 438 (Late Effects) codes rather than 436 (Acute) codes in ICD-9-CM. 117 Sequelae of Cerebrovascular Disease Category I69 is used to indicate conditions classifiable to categories I60-I67 as the causes of sequela (neurologic deficits), themselves classified elsewhere. Categories I60-I67 are the acute codes used by hospital not LTC These late effects include neurologic deficits that persist after initial onset of conditions in categories I60-I FH54 - Developed by Polaris Group Page 62 of 128

64 Sequelae of Cerebrovascular Disease Examples I Dysphagia 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. 119 NIHSS Stroke Scale The NIH stroke scale (NIHSS) codes (R ) can be used in conjunction with acute stroke codes (I63) to identify the patient's neurological status and the severity of the stroke. The stroke scale codes should be sequenced after the acute stroke diagnosis code(s). Remember that we do not use Acute Stroke Codes I60-I67 in LTC, but look out for these stroke scale codes from hospital. 120 FH54 - Developed by Polaris Group Page 63 of 128

65 Pressure Ulcer Coding For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission. If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: 121 Pressure Ulcer Coding One code for the site and stage of the ulcer on admission AND Second code for the same ulcer site and the highest stage reported during the stay. 122 FH54 - Developed by Polaris Group Page 64 of 128

66 Zika Virus A92.5 Zika Virus Code only confirmed cases If the provider documents suspected, possible or probable Zika, do not assign code A92.5. Assign a code(s) explaining the reason for encounter (such as fever, rash, or joint pain) or Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. 123 Documentation To Support Coding & Claim 124 FH54 - Developed by Polaris Group Page 65 of 128

67 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 125 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. 126 FH54 - Developed by Polaris Group Page 66 of 128

68 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. 127 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 128 FH54 - Developed by Polaris Group Page 67 of 128

69 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 129 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 130 FH54 - Developed by Polaris Group Page 68 of 128

70 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 131 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 132 FH54 - Developed by Polaris Group Page 69 of 128

71 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 Dysphagia, (excludes following a CVA) I69.xxx Sequelae of cerebrovascular disease codes 133 Selection of Principal and Admitting Diagnosis No change in process 134 FH54 - Developed by Polaris Group Page 70 of 128

72 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 135 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. 136 FH54 - Developed by Polaris Group Page 71 of 128

73 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. 137 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. 138 FH54 - Developed by Polaris Group Page 72 of 128

74 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 139 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) 140 FH54 - Developed by Polaris Group Page 73 of 128

75 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. 141 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). 142 FH54 - Developed by Polaris Group Page 74 of 128

76 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. 143 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. 144 FH54 - Developed by Polaris Group Page 75 of 128

77 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). 145 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. 146 FH54 - Developed by Polaris Group Page 76 of 128

78 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. 147 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. 148 FH54 - Developed by Polaris Group Page 77 of 128

79 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). 149 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. 150 FH54 - Developed by Polaris Group Page 78 of 128

80 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. 151 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. 152 FH54 - Developed by Polaris Group Page 79 of 128

81 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. 153 Questionable Principal Diagnosis Codes 154 FH54 - Developed by Polaris Group Page 80 of 128

82 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. 155 Z Encounter for Other Specified Aftercare The underlying diagnosis that resulted in the need for therapy would be listed as the principal diagnosis instead. 156 FH54 - Developed by Polaris Group Page 81 of 128

83 Z96.xxx Joint Replacement Codes (Z96.64x, Z96.65x) Z96.xxx codes should not be principal firstlisted 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. 157 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. 158 FH54 - Developed by Polaris Group Page 82 of 128

84 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. 159 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. 160 FH54 - Developed by Polaris Group Page 83 of 128

85 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 161 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. 162 FH54 - Developed by Polaris Group Page 84 of 128

86 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. 163 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. 164 FH54 - Developed by Polaris Group Page 85 of 128

87 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. 166 FH54 - Developed by Polaris Group Page 86 of 128

88 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. 167 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. 168 FH54 - Developed by Polaris Group Page 87 of 128

89 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). 169 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. 170 FH54 - Developed by Polaris Group Page 88 of 128

90 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. 171 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. 172 FH54 - Developed by Polaris Group Page 89 of 128

91 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 173 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. 174 FH54 - Developed by Polaris Group Page 90 of 128

92 F10.10 (Alcohol Abuse, Uncomplicated) As with all other diagnoses, the codes for psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis The codes are to be used only when the psychoactive substance use is associated with a mental or behavioral disorder, and such a relationship is documented by the provider. 175 F10.10 (Alcohol Abuse, Uncomplicated) Reportable Diagnosis For reporting purposes the definition for other diagnoses is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring 176 FH54 - Developed by Polaris Group Page 91 of 128

93 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 principle; but rather the underlying disease should be listed first. 177 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. 178 FH54 - Developed by Polaris Group Page 92 of 128

94 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. 179 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 180 FH54 - Developed by Polaris Group Page 93 of 128

95 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 181 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) 182 FH54 - Developed by Polaris Group Page 94 of 128

96 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. 183 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. 184 FH54 - Developed by Polaris Group Page 95 of 128

97 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). 185 Coding Issues Identified Using External Cause of Injury codes as primary. Not required unless required by particular state. 186 FH54 - Developed by Polaris Group Page 96 of 128

98 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. 187 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. 188 FH54 - Developed by Polaris Group Page 97 of 128

99 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. 189 Sequencing 190 FH54 - Developed by Polaris Group Page 98 of 128

100 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 191 Diagnosis Coding S72.112D I25.10 I48.91 Z51.81 Z79.01 S72.112D 192 FH54 - Developed by Polaris Group Page 99 of 128

101 Communication is Key 193 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 100 of 128

102 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. 195 ICD-10-CM Case Studies 196 FH54 - Developed by Polaris Group Page 101 of 128

103 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. 197 ICD-10-CM Answers for Coding Example #1: I Dysphagia 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 198 FH54 - Developed by Polaris Group Page 102 of 128

104 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. 199 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 200 FH54 - Developed by Polaris Group Page 103 of 128

105 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. 201 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 202 FH54 - Developed by Polaris Group Page 104 of 128

106 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. 203 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 204 FH54 - Developed by Polaris Group Page 105 of 128

107 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) 205 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. 206 FH54 - Developed by Polaris Group Page 106 of 128

108 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 207 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. 208 FH54 - Developed by Polaris Group Page 107 of 128

109 Hip Fracture Case Study Hospital Discharge Diagnoses: Fracture of Left Greater Trochanter Left Hip Replacement Osteoporosis Senile Dementia CHF 209 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 210 FH54 - Developed by Polaris Group Page 108 of 128

110 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? 211 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. 212 FH54 - Developed by Polaris Group Page 109 of 128

111 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** 213 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. 214 FH54 - Developed by Polaris Group Page 110 of 128

112 CVA Case Study Discharge Diagnoses from hospital: Acute CVA (I63.9) Aphasia Left Hemiparesis Stage 2 pressure ulcer to right buttocks 215 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? 216 FH54 - Developed by Polaris Group Page 111 of 128

113 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 217 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 112 of 128

114 Summary of ICD-10-CM Coding Use combination code where available Use multiple codes if necessary to fully describe a condition Laterality specify side(s) if code available Use Placeholder X as appropriate Use 7 th character if indicated to indicate subsequent care (aftercare) or sequela (late effects). 219 Summary of ICD-10-CM Coding No more Z code (formerly V code) as primary for therapy. Instead use diagnosis that warrants the therapy as principal diagnosis. Continue to use Therapy Treatment codes No more aftercare for fractures. Use acute fracture code with appropriate subsequent 7 th character such as D for aftercare or S for sequela. 220 FH54 - Developed by Polaris Group Page 113 of 128

115 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 114 of 128

116 If you have any questions, please contact your MAC at their toll-free number. That number is available at Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory- Interactive-Map/. Page 2 of 2 FH54 - Developed by Polaris Group Page 115 of 128

117 ICD 10 CM SNF Quick Reference General Info Resources for Coding: In order of priority or precedence: 1. ICD 10 CM code set 2. Official Coding Guidelines 3. Coding Clinic (requires subscription) Websites: CDC CMS ICD 10 CM and GEMs.html ICD 10 CM Crosswalk AHIMA ICD 10 General Information CMS lookup tool that allows users to search for codes by ICD 10 description keywords: coverage database/staticpages/icd 10 codelookup.aspx Format/Steps to Coding ICD 10 CM Format Steps to Coding: (Process is not new) Two main parts: The Index alphabetical list of terms and their corresponding code. Tabular List sequential, alphanumeric list of codes divided into chapters based on body system or condition. 1. First locate term in the Alphabetic Index 2. Then verify in the Tabular List 3. Read and be guided by instructional notations that appear in both 4. Essential to use both Alphabetic Index and Tabular List 5. Alphabetic Index does not always provide the full code 6. Selection of the full code, including laterality and any applicable 7th character can only be done in the Tabular List. FH54 - Developed by Polaris Group Page 116 of 128

118 ICD 10 CM SNF Quick Reference Level of Detail Diagnosis codes are to be used and reported at their highest number of characters available. (3 7 characters) Admit/Principal/Additional Diagnoses Admitting Diagnosis (UB 04 Field locator 69) Principal/Primary Diagnosis (UB 04 Field locator 67) Condition established after study to be chiefly responsible for the admission. Condition chiefly responsible for the resident s admission to SNF or reason for continued SNF care. Frequently matches Admitting Diagnosis Field 69 Additional Diagnoses (UB 04 Field locator 67 A Q) Additional conditions coexisting at the time of admission which developed subsequently, and which had an effect upon the treatment given for the length of stay. Abbreviations and Terms NEC Not Elsewhere Classifiable NOS Not Otherwise Specified [ ] Brackets Tabular List encloses synonyms, alternative wording or explanatory phrases. Alphabetic Index identifies manifestation codes. ( ) Parentheses Alphabetic Index nonessential modifiers that apply to subterms following a main term except when a nonessential modifier is mutually exclusive, the subentry takes precedence. : Colon Tabular List after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category. Other Used when the information in the medical record provides detail for which a specific code does not exist. Alphabetic Index entries with NEC in the line designate other codes in the Tabular List. Alphabetic Index entries represent specific diseases where no specific code exists so it is included within an other code. Provided by Polaris Group group.com 2 FH54 - Developed by Polaris Group Page 117 of 128

119 ICD 10 CM SNF Quick Reference Unspecified Use when the information in the medical record is insufficient to assign a more specific code. For those categories for which an unspecified code is not provided, the other specified code may represent both other and unspecified. Includes Notes Appears immediately under a three character code title to further define, or give examples of, the content of the category. Inclusion Terms List of terms that give conditions for when that code is to be used. May be synonyms of the code title, or, in the case of other specified codes, the terms are a list of the various conditions assigned to that code. Not necessarily exhaustive. Excludes1 NOT CODED HERE! A type 1 Excludes note is a pure excludes note. Indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. The two terms are mutually exclusive, so they would never be used together. Excludes2 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. Code First and Use Original Code Also used as sequencing rules in the classification for certain codes that are not part of an etiology/manifestation combination. And Means either and or or when it appears in a title. Provided by Polaris Group group.com 3 FH54 - Developed by Polaris Group Page 118 of 128

120 ICD 10 CM SNF Quick Reference With 2018 Update: The word with or in should be interpreted to mean associated with or due to when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. The word with should be interpreted to mean associated with or due to when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. 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 or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for acute organ dysfunction that is not clearly associated with the sepsis ). For conditions not specifically linked by these relational terms in the classification or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related. Provided by Polaris Group group.com 4 FH54 - Developed by Polaris Group Page 119 of 128

121 ICD 10 CM SNF Quick Reference See Alphabetic Index follows a main term indicating that another term should be referenced. It is necessary to go to the main term referenced with the see note to locate the correct code. See Also Alphabetic Index follows a main term instructing that there is another main term that may also be referenced that may provide additional Alphabetic Index entries that may be useful. Not necessary to follow the see also note when the original main term provides the necessary code. Code Also Note Two codes may be required to fully describe a condition, but this note does not provide sequencing direction. The sequencing depends on the circumstances of the encounter. Placeholder X Placeholder for future expansion. Where a placeholder exists, the X must be used in order for the code to be valid. Example: T36.0X1 Poisoning by penicillin, accidental 7 th Characters Use 7 th characters as applicable. Common with fracture codes to specify initial, subsequent, or sequela care. The 7 th character must always remain the 7 th character If a code that requires a 7 th character is not six characters, a placeholder X must be used to fill in the empty characters. Combination Codes Used to classify two diagnoses or diagnosis with manifestation or complication Must use combination code when it fully describes a condition. Otherwise use multiple codes to fully describe. Laterality Allows you to specify left, right, or bilateral If no bilateral code provided, code both left and right as separate codes. If the side is not identified, code unspecified. Common bilateral codes include pressure ulcers, fractures, and eye conditions such as glaucoma. Default Codes Listed next to a main term in the Alphabetic Index. Condition that is most commonly associated with the main term, so if more detail is not provided or can t be determined from physician, use default code. Default Code Example Appendicitis (pneumococcal) (retrocecal) K37 (K37 is the default code for Appendicitis) Provided by Polaris Group group.com 5 FH54 - Developed by Polaris Group Page 120 of 128

122 ICD 10 CM SNF Quick Reference Etiology/Manifestation Underlying condition (etiology) should be coded first followed by the manifestation. Manifestation codes cannot be first listed or principal diagnosis codes. Use combination code if it includes both etiology and manifestation. Acute and Chronic If resident has both acute and chronic for same diagnosis or condition, Conditions code both, and code acute before chronic. Sequela (Late Effects) A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. Generally requires two codes sequenced in the following order: The condition or nature of the sequela is sequenced first. The sequela code is sequenced second. An exception would be those instances where the code for the sequela is followed by a manifestation code or the sequela code has been expanded to include the manifestation(s). Never use the code for the acute phase of an illness or injury that led to the sequela with a code for the late effects. Chapter Specific Guidelines Diabetes Mellitus 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. If the type of diabetes mellitus is not documented, the default is E11., Type 2 diabetes mellitus. If the patient is treated with both oral medications and insulin, only the code for long term (current) use of insulin should be assigned, Z79.4, Long term (current) use of insulin. Dominant/Non Dominant Side If the affected side is documented but not specified as dominant or non dominant, 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 non dominant. If the right side is affected, the default is dominant. Provided by Polaris Group group.com 6 FH54 - Developed by Polaris Group Page 121 of 128

123 ICD 10 CM SNF Quick Reference Glaucoma Assign as many codes from category H40, Glaucoma, as needed to identify: type of glaucoma the affected eye the glaucoma stage Many bilateral codes for glaucoma. Pressure Ulcers (Category L89) Combination codes that identify the site of the pressure ulcer (including laterality) as well as the stage of the ulcer. Z codes Z Codes are not used like the prior V codes were for Rehab. No ability to use a Z code for multiple therapies as Principal/First listed diagnosis. Underlying diagnosis would be listed first Continue to use therapy treatment diagnosis Aftercare Z Codes Related To Fractures Assign the acute fracture code with the appropriate 7th character such as: D for Subsequent (aftercare) or S for Sequela (complications or late effects) Hip Replacement following fracture 2018 Update: Code the injury (fracture) as the first listed primary diagnosis NOT the hip replacement followed by the Z96.6xx code to indicate what joint was replaced. Provided by Polaris Group group.com 7 FH54 - Developed by Polaris Group Page 122 of 128

124 ICD-10-CM MDS I8000 Crosswalk Please note that this crosswalk in no way replaces following steps for coding including looking up code first in Alphabetic Index and then verifying code in Tabular List following all instructions, notes, etc. and using all characters required for that code. Crosswalk just provides possible code categories as a point of reference. Dash = Additional characters may be required ****Remember that I8000 also requires additional active diagnoses that are not listed in check off section (I0100-I7900) MDS Section Diagnosis Description ICD 10 CM Code(s) I0100 Cancer See Neoplasm Table I0200 Anemia D50s D60s I0300 A Fib/Other Dysrhythmias I48., I49., R00., I47., I45., I0400 Coronary Artery Disease (CAD) I25.10 Angina I20.9 Angina with arteriosclerosis, coronary artery I MI I21., I25., I97. I22. ASHD I25.10 I0500 Deep Venous Thrombosis (DVT) I82. Pulmonary Embolism (PE) I26., I27. I0600 Heart Failure I50. Pulmonary Edema J81. I0700 Hypertension I10 (Default Code) and many chapters involved depending what its combined with I0800 Orthostatic Hypotension I95. I0900 Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD) I73.9 (more detail probably not needed) I1100 Cirrhosis K74., K70., or another chapter I1200 GERD or Ulcer K21.9 GERD w/ Esophagitis K21.0 Esophageal Ulcer K21., K22. Gastric Ulcer K25. Peptic Ulcer K27. I1300 Ulcerative Colitis K51. Crohn s Disease K50. I1400 Benign Prostatic Hyperplasia (BPH) N40.0 N40.1 I1500 Renal Insufficiency Acute N28.9 Chronic N18.9 Renal Failure N19., N17., N18. FH54 - Developed by Polaris Group Page 123 of 128

125 ICD-10-CM MDS I8000 Crosswalk MDS Section Diagnosis Description ICD 10 CM Code(s) End Stage Renal Disease (ESRD) N18.6 I1550 Neurogenic Bladder N31.9 (more detail probably not needed) I1650 Obstructive Uropathy N13.9, N13.8 I1700 Multidrug Resistant Organism (MDRO) Z16. I2000 Pneumonia J18.9 (Default Code) or other J, A, or B code I2100 Septicemia (Sepsis) A41.9 or many other codes I2200 Tuberculosis A15.9 or other A or J codes I2300 UTI N39.0 or other codes I2400 Viral Hepatitis B19.9 or other B code I2500 Wound Infection Many codes I2900 Diabetes Mellitus E11.9 or other E code I3100 Hyponatremia E87.1 (more detail probably not needed) I3200 Hyperkalemia E87.5 (more detail probably not needed) I3300 Hyperlipidemia E78.5, E78. I3400 Thyroid Disorder Hypothyroidism E03., E02., E89. Hyperthyroidism E05. Hashimoto s Thyroiditis E06.3 I3700 Arthritis/DJD/Osteoarthritis M19., M15., M16., M17., M18. Rheumatoid Arthritis M06.9, M08., M06., M05. I3800 Osteoporosis M80., M81. I3900 Hip Fracture S72., S79. I4000 Other Fracture S or M code, etc. I4200 Alzheimer s Disease G30. I4300 Aphasia R47.01, F80.2, F80., I69., G31.01 I4400 Cerebral Palsy G80. I4500 CVA I69. I4800 Non Alzheimer s Dementia Lewy Body Dementia G31. FH54 - Developed by Polaris Group Page 124 of 128

126 ICD-10-CM MDS I8000 Crosswalk MDS Section Diagnosis Description ICD 10 CM Code(s) Vascular Dementia F01. Pick s G31. Pick s with Parkinson s G31. Pick s with Creutzfeldt Jakob Disease A81.00 I4900 Hemiplegia or Hemiparesis G81., G83., I69. I5000 Paraplegia G82., G80., G11., F44., A18., A52., G04. I5100 Quadriplegia G82., G80., I63., R53., S14. I5200 Multiple Sclerosis (MS) G35 (more detail not needed) I5250 Huntington s Disease G10 (more detail not needed) I5300 Parkinson s Disease G20 (more detail not needed) I5350 Tourette s Syndrome F95.2 (more detail not needed) I5400 Seizure Disorder or Epilepsy G40., or other codes I5500 Traumatic Brain Injury (TBI) S06. I5600 Malnutrition E46., E44., E43., E42., K91., E40., E41. I5700 Anxiety Disorder F41., F10., F15., F13., F12., F14., F06., F16., F18., F19., F40. I5800 Depression F32., F41., F44., F34., F33. I5900 Manic Depression F31. I5950 Psychotic Disorder F29. or many other codes I6000 Schizophrenia F20., F23., F21., F25., F32. I6100 Post Traumatic Stress Disorder (PTSD) F43. I6200 Asthma, COPD, Chronic Lung Disease J45., J44., or many other codes, J42., Asbestosis J61 I6300 Respiratory Failure J96., J95. I6500 Cataracts H26.9, Q12. or many other codes Glaucoma H40., H44., Q15., or other code Macular Degeneration H35. FH54 - Developed by Polaris Group Page 125 of 128

127 ICD-10-CM Coding Advice for Healthcare Encounters in Hurricane Aftermath August 2017 This document is intended to be used as a guide to help coding professionals when coding healthcare encounters of those individuals affected by a hurricane. This coding advice has been approved by the Four Cooperating Parties (American Hospital Association (AHA); American Health Information Management Association (AHIMA); Centers for Medicare and Medicaid Services (CMS); and National Center for Health Statistics (NCHS)). The advice, originally published in 2005, has been updated and includes ICD-10-CM codes. Further guidance will be provided, as necessary, as events unfold in the aftermath of the hurricane. 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 the application of ICD- 10-CM codes. External cause of morbidity codes are never to be recorded as a principal diagnosis (first-listed in non-inpatient settings). 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, 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). They should not be assigned for encounters to treat hurricane victims medical conditions when no injury, adverse effect or poisoning is involved. External cause of morbidity codes should be assigned for each encounter for care and treatment of the injury. External cause of morbidity codes may be assigned in all health care settings. For the purpose of capturing complete and accurate ICD-10-CM data in the aftermath of the hurricane, a healthcare setting should be considered as any location where medical care is provided by licensed healthcare professionals. 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. 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 as the first external cause code. FH54 - Developed by Polaris Group Page 126 of 128