(and how to fix them!) Presented by Jennifer Warfield, BSN, HCS-D, COS-C Education Director, PPS Plus
Top 10 ICD-10 Coding Errors (and how to fix them!) Top 10 Primary Diagnoses In ICD-10 ICD-10 Codes ICD-10 Description ICD-10 Frequency ICD-9 Code ICD-9 Frequency In ICD-9 Top 10? Z47 Orthopedic Aftercare 6.6% V54 7.9% Yes I50 Heart Failure 6.1% 428 6.3% Yes Z48 Encounter for Other Post-op Aftercare 5.7% V58 7.2% Yes E11 Type 2 Diabetes Mellitus 5.6% 250 6.2% Yes J44 Chronic Obstructive Pulmonary Disease 4.9% 491 3.1% Yes I10 Essential (primary) Hypertension 3.6% 401 3.6% Yes L89 Pressure Ulcer 3.5% 707 4.3% Yes M62 Other Disorders of Muscles 3.4% 728 2.1% Yes I69 Sequelae of Cerebrovascular Disease 3.2% 438 2.9% Yes R26 Abnormalities of Gait & Mobility 2.4% 781 1.2% No Top 10 ICD-10-CM Issues since ICD-10 Implementation 1. Utilizing acute injury 7th character A codes 2. Diagnoses not supported by medical record documentation 3. The POC includes codes for resolved conditions 4. Non-specific codes used when the medical record supported a higher specificity 5. Etiology/manifestation conditions coded as separate and non-related conditions 6. Sequencing of diagnoses does not support the service intensity or Focus of Care 7. Supportive diagnosis or condition codes were not included for Therapies 8. Failure to include Tobacco Use or history when required for cardio-pulmonary diagnoses 9. Use of Z codes for complicated wounds 10. Failure to include conditions with potential to affect the patient s response to treatment 7th Character Use Since 2013, most were taught that home health would never use the 7th character A. We learned that A would only be used for the initial episode acute care settings (hospitals, ERs, doctor s offices) and D was reserved for subsequent episodes of care (home health) Initial grouper didn t even accept A in home health Focus on the word "active" rather than "initial" Clarifications The coding clinic has since clarified the use of the 7th character - 7th character A while used for the initial encounter should be used when a patient is actively receiving treatment for a condition - use when patient is actively getting care for conditions such as wounds or IV therapy Grouper has been updated to accept A in certain conditions Active treatment can begin in the inpatient or physician office setting and continue when the patient is discharged to home and still be considered the Initial Encounter, even if the patient has been seen by multiple providers. 1
Never use 7th character A for injuries, use characters denoting subsequent encounter or sequela. Once a patient has received treatment for an injury by a physician, emergency department or inpatient facility, home health provides routine care for the healing or recovery phase. In the routine or recovery phase, the 7th character D is used The most common home health examples requiring subsequent encounter 7th characters are healing traumatic or pathological fractures. There are 12 different 7th characters for subsequent encounter to choose from, depending on the healing status or type of complication. Most used in home health: - A active treatment - D routine aftercare - S sequela For complication codes, active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier precipitating problem Examples Patient with fractured R distal ulna. Has severe swelling. Casting delayed until edema subsides. - S52.601A Patient with fractured R distal ulna from a fall. Arm is in a cast. - S52.601D Patient with healed fracture of distal R ulna a year ago. Bone has not aligned correctly causing chronic pain. - S52.601S Patient with an infection of a cholecystectomy incision referred to home health for wound care and IV antibiotics - T81.4XXA Patient with disruption of abdominal incision. Not infected and has been left to heal by secondary intention. - T81.31XD Documentation to Support Diagnoses The fi rst 6 diagnoses on the POC must match the OASIS and the Final Bill. All diagnoses must be supported by the provider s documentation If there is documentation of a manifestation but the etiology has not been documented by the physician, coder must get verifi cation from provider. i.e., stasis ulcer with no etiology. Coding from medication list or patient statement. Keep in mind that many medications are used off formulary so diagnoses must be verifi ed Do not code possible, borderline, or suspected diagnoses. Code symptoms until defi nitive diagnosis is made Coding Resolved Conditions Resolved conditions should be coded as history of if still relevant to current POC - patient with current lung neoplasm had mastectomy for breast cancer two years ago. - patient with primary diagnosis of HTN had a TIA six months ago - patient with a foley catheter has a history of frequent UTIs Do not code resolved conditions that have no impact on current POC - resolved breast cancer two years ago for a patient with TKA - UTI a year ago in a patient admitted for fractured arm 2
Unspecified Codes Codes titled other or other specified are for use when the information in the medical records provides detail for which there is no code listed. Codes titled unspecified are for use when the information in the medical record is insufficient to assign a more specified code. Some unspecified codes in a category are not case-mix codes and will affect HHRG score. - I69.3 codes is the default code for CVA or stroke but I69.3 codes with a 6th character of 9 are not case mix as they are codes that do not specify an affected side (should always be documented) Unspecified codes should be reported when they are the codes that most reflect what is known and documented by the provider. It is inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code. Unspecified Examples: - Anemia D64.9 - Abdominal Pain R10.9 - Angina I20.9 - COPD J44.9 - Alzheimer's G30.9 Other & Unspecified Codes Documentation states Diabetic Osteomyelitis - Diabetes with other specified complications E11.69 - Osteomyelitis M86.- Using E11.8 Diabetes with unspecified complications is incorrect. If a complication is the result of diabetes (or any other condition) there must be documentation of the complication. Etiology & Manifestation Codes Certain diagnosis codes are only to be used as the manifestation of a documented etiology. Manifestation codes can never be primary. In most cases there are: - Notes at etiology codes requiring a manifestation that state use additional code - Notes at manifestation codes that state code first Sequence with the manifestation immediately following the etiology code - Alzheimer's - G30.9 - Dementia in conditions classified elsewhere - F02.- There are some manifestation situations that that will not have the wording in diseases classified elsewhere with the etiology code. Instead, code will usually have the use additional code. Example: Atherosclerosis of native arteries of R leg with ulceration of thigh - I70.231 Non-pressure chronic ulcer of R thigh limited to skin breakdown - L97.111 Not a true etiology/manifestation coding but is a mandatory multiple coding situation 3
Sequencing of Codes Some coding rules indicate that one code must be coded before another code as in: 1. Conditions due to an underlying condition Diabetes due to underlying condition E08 code first the underlying disease 2. Etiology/Manifestation Pairing Dementia in conditions classified elsewhere - F02.- code first the etiology code 3. Use additional code scenarios Hypertensive CKD - I12 code also the stage of the CKD If mandatory sequencing not specified, code conditions according to POC. If the use of a Z code is required and not mandated as primary, they can be sequenced at the bottom of list. There is no requirement in HH that all diagnoses be coded. Only code those that have a direct impact or the potential to have an impact on the POC. Codes to Support Therapy There are no truly therapy diagnoses. There are many diagnoses that support the need for therapy. Ultimately, the therapist s evaluation and documentation will support the need for therapy. Conditions that are integral to a disease process or injury being addressed by therapy are not coded separately. If episode is therapy only, code the condition or problem that is causing the condition that therapy will be addressing. - Severe weakness due to exacerbation of COPD. Abnormalities of Gait - Ataxic Gait - R26.0 - Paralytic Gait - R26.1 - Difficulty in walking, NEC R26.2 (not case mix) - Unspecified abnormalities of gait & mobility - R26.81 - Other abnormalities of gait & mobility - R26.89 - Unspecified abnormalities - R26.9 (not case mix) Suggest discussing with therapist or reviewing evaluation for specifics Repeated falls - Falling or tendency to fall - R29.6 Use for encounters when a patient has recently fallen and the reason for the fall is being investigated Can be used as primary diagnosis History of falls - History of falls - Z91.81 - At risk for falls - Z91.81 Use when a patient has fallen in the past and/or is at risks for falls May be used in conjuction with each other 4
Tobacco Use Codes Some Cardiac and most Respiratory conditions in ICD-10 require the addition of Tobacco Use when applicable Exposure to environmental tobacco smoke (Z77.22) Exposure to tobacco smoke during the prenatal period (P68.81) History of tobacco use (Z87.89) Occupational exposure to environmental spoke (Z57.31) Tobacco dependence (must be specified by provider) (F17.- ) Tobacco use (Z72.0) Z Codes Used for circumstances other than disease, injury or external causes that are listed as problems. History, aftercare, status, encounters, etc. Some Z codes can only be primary, some can only be secondary and still others can be either (reference PX/SX next to code in tabular list of manual). Never use for complications (infected or dehisced wounds). Use the appropriate T81 code instead. Aftercare Z Codes Never use for aftercare of injuries or fractures. Use instead the original injury code with the appropriate 7th character from Chapter 19 Generally listed as primary to indicate the reason for the encounter But can be used as a secondary code to indicate that aftercare is being provided as well as the primary reason for the admission Example: Patient admitted to HH following an MI. Also had a pacemaker inserted. Acute MI - I21.- Aftercare following surgery to circulatory system - Z48.812 Comorbidities Comorbidities are the simultaneous presence of two chronic diseases or conditions in a patient May be long-standing, occurred at the time of or at any time after the primary condition Usually coded as a secondary diagnoses if it affects the POC even if it is not the focus of the current episode of care Must be documented by the provider 5