Diagnosis Coding Problematic Areas: Coding & Sequencing

Diagnosis Coding Problematic Areas: Coding & Sequencing OBJECTIVES Guideline information Sepsis, Severe Sepsis, Septic Shock HIV Diabetes Under/Over-dosing Hypertension Ulcers Burns INCLUDES, USE ADDITIONAL CODE, CODE FIRST AND CODE ALSO Majority of the codes we look at today will have these: Includes appears immediately under certain categories to further define, clarify, or give examples of the content of a code category Use additional code are instructional notes and provide sequencing instruction. They may appear independently of each other or to designate certain etiology/manifestation paired codes Code first requires the underlying condition to be sequenced first, followed by the manifestation. Code also note alerts the coder that more than one code may be required to fully describe the condition DEF and TIP: It is another thing that you will find is some books that you would want to review to help in your coding PAY CLOSE ATTENTION TO THESE 1

EXCLUDES 1 EXCLUDES 1 note is a pure excludes note. It means: NOT CODED HERE! An EXCLUDES 1 note indicates that the code excluded should never be used at the same time as the code above the EXCLUDE 1 note. An EXCLUDES 1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. Example: R78.8 Finding of other specified substances, not normally found in blood R78.81 Bacteremia EXCLUDES 1: sepsis-code to specified infection (A00-B99) EXCLUDES 2 EXCLUDES 2 note represents: NOT INCLUDED HERE An EXCLUDES 2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an EXCLUDES 2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate. Example: I10 Essential (primary) hypertension EXCLUDES 2 essential (primary) hypertension involving vessels of brain(i60-i69) essential (primary) hypertension involving vessels of eye (H35.0-) DOCUMENTATION OF COMPLICATIONS OF CARE Code assignment is based on the provider s documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-andeffect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented. 2

SEPSIS INFECTION Sepsis refers to an infection due to any organism that triggers the systemic inflammatory response syndrome (SIRS) Sepsis in the title include the concept of SIRS Assign sepsis ONLY when the provider makes such a diagnosis. Subcategory R65.2, Severe sepsis, should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented. Sepsis and acute organ dysfunction, but medical record indicates it is not related, do not assign R65.2 Severe sepsis SEQUENCING SEPSIS Coding of these conditions is dependent on the documentation. If severe sepsis is present on admission, and meets the definition of principal diagnosis: Code, the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2 as required by the sequencing rules in the Tabular List. A code from subcategory R65.2 can never be assigned as a principal diagnosis. Severe sepsis develops during an encounter (it was not present on admission): Code the underlying systemic infection and the appropriate code from subcategory R65.2 should be assigned as secondary diagnoses. Severe sepsis may be present on admission but the diagnosis may not be confirmed until sometime after admission. If the documentation is not clear whether severe sepsis was present on admission, the provider should be queried. SEPSIS Code for the underlying systemic infection Cases that do not result in any associated organ dysfunction, a single code for the type of sepsis should be used Category A40.- or A41.81, has the 3 rd character specifying the strain Other types of sepsis can be classified to other organisms Candidal sepsis (B37.7) Disseminated herpesviral disease (B00.7) If the type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified organism Urosepis is not an ICD-10-CM code, query provider 3

SEVERE SEPSIS Coding requires a minimum of two codes: Code for the systemic infection (A40.-, A41.-, B37.7) Followed by appropriate code from subcategory R65.2-, Severe Sepsis If the causal organism is not documented, assign A41.9, Sepsis, unspecified for the infection Additional code for the associated organ dysfunction are required if documented SEPTIC SHOCK Coding requires a minimum of 2 codes: Code for the systemic infection should be sequenced first (A40.-, A41.-, B37.7) Followed by code R65.21, Severe sepsis with septic shock, OR Code T81.12, Postprocedural septic shock. Any additional codes for the other acute organ dysfunctions should also be assigned. SEPSIS AND SEVERE SEPSIS WITH LOCALIZED INFECTION Reason for admission is both sepsis or severe sepsis and a localized infection (such as pneumonia or cellulitis) Code(s) for the localized systemic infection should be assigned first Followed by code for the localized infection If severe sepsis, the appropriate code from subcategory R65.2 should also be assigned for any acute organ dysfunction. If admitted with a localized infection, and sepsis/severe sepsis doesn t develop until after admission, Code the localized infection should be assigned first, Followed by the appropriate sepsis/severe sepsis codes If severe sepsis, the appropriate code from subcategory R65.2 should also be assigned for any acute organ dysfunction. 4

SEPSIS DUE TO A POSTPROCEDURAL INFECTION Code requires a minimum of 3 codes: Assign code T81.40 to T81.43- Infection following procedure or Assign code O86.00-O86.03 Infection of obstetric surgical wound, that identifies the site of the infection, if known Use additional code for sepsis following a procedure (T81.44) or sepsis following an obstetric procedure (O86.04) Use an additional code to identify the infectious agent If severe sepsis, the appropriate code from subcategory R65.2 should also be assigned for any acute organ dysfunction. SEPSIS DUE TO A POSTPROCEDURAL INFECTION Code requires a minimum of 2 codes: Assign a code from subcategory T80.2, Infections following infusion, transfusion, therapeutic injection, or immunization or code T88.0 -, infection following immunization should be code first. Followed by the code for the specific infection If severe sepsis, the appropriate code from subcategory R65.2 should also be assigned for any acute organ dysfunction. SEPSIS DUE TO A POSTPROCEDURAL INFECTION Code requires a minimum of 2 codes: If a postprocedural infection resulted in postprocedural septic shock, assign the codes indicated above for sepsis due to postprocedural infection first Followed by code t81.12-, postprocedural shock Do not assign R65.21, severe sepsis with septic shock Additional code(s) should be assigned for any acute organ dysfunction 5

SEPSIS AND SEVERE SEPSIS ASSOCIATED WITH A NONINFECTIOUS PROCESS (CONDITION) Code requires a minimum of 2 codes: Code for the noninfectious condition should be sequenced first (if condition meets definition for principal diagnosis) Followed by the code for the resulting infection If severe sepsis, the appropriate code from subcategory R65.2 should also be assigned for any acute organ dysfunction. It is not necessary to assign a code from subcategory R65.1 of non-infectious origin, in these cases SEPSIS AND SEVERE SEPSIS ASSOCIATED WITH A NONINFECTIOUS PROCESS (CONDITION) Code requires a minimum of 2 codes: If the infection meets the definition of principal diagnosis, it should be sequenced before the noninfectious condition When both meet the definition of principal diagnosis, either may be assigned as principal diagnosis Only one code from category R65 should be assigned CODE THESE 1. Patient has Sepsis due to E. Coli 2. Patient with severe sepsis due to E. Coli and acute renal failure 3. Patient with septic shock, acute respiratory failure and hemophilus influenza pneumonia 6

HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTIONS Code only confirmed cases Exception to the hospital inpatient Confirmation does not require documentation of positive serology or culture Provider s diagnostic statement is sufficient HIV positive HV-related illness HUMANIMMUNODEFICIENCY VIRUS (HIV) INFECTIONS Admitted for an HIV-related condition Principal diagnosis should be B20 Followed by additional diagnosis codes for all reported HIV-related conditions. Sample: Acute lymphadenitis (in neck) secondary to HIV infection with opioid dependence. B20 Human immunodeficiency virus (HIV) disease * F11.20 Opioid dependence, uncomplicated * Note L04.0 lymphadenitis has a EXCLUDE 1 HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTIONS Admitted for an unrelated condition Unrelated should be the principal diagnosis Other diagnoses would be B20 followed by additional diagnosis codes for all reported HIV-related conditions. Sample: John is coming into today for surgery for calculus of gallbladder with acute cholecystitis and he has HIV. K80.00 Calculus of gallbladder with acute cholecystitis B20 Human Immunodeficiency virus (HIV) disease 7

HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTIONS Pregnancy Chapter 15 always takes sequencing priority HIV Infection in pregnancy.. HIV disease complicating pregnancy.. O98.7- should be coded as the principal diagnosis Followed by B20 Followed by HIV-related illness Asymptomatic HIV admission/encounter HIV disease complicating pregnancy.. O98.7- should be coded as the principal diagnosis Followed by Z21 HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTIONS Z21, Asymptomatic human immunodeficiency virus [HIV] infection HIV positive, known HIV, HIV test positive, or similar terminology. Do not use this code if the term AIDS is used or treated for any HIV-related illness or is described as having any condition(s) resulting from his/her HIV positive status R75, Inconclusive HIV serology No definitive diagnosis or manifestations of the illness Z11.4, Encounter for screening Z71.7, HIV counseling CODE THESE 1. Mary is HIV positive and has a fever and shortness of breath. The diagnostic workup, including chest x-ray and sputum culture, resulted in a diagnosis of Pneumocystis pneumonia due to AIDS. 2. Agranulocytosis due to HIV infection 8

DIABETES Diabetes mellitus codes are combination codes that include: the type of diabetes mellitus, the body system affected, and the complications affecting that body system. Assign as many codes from categories E08 E13 as needed to identify all of the associated conditions that the patient has They should be sequenced based on the reason for a particular encounter. DIABETES Significant Changes- 5 Categories E08 DM due to underlying condition E09 Drug or chemical-induced DM E10 Type I DM E11 Type II DM (includes Diabetes NOS) E13 Other specified DM Complication category is Identified by the 4th character E--.2 Type_ DM with kidney complications E--.3 Type_ DM with ophthalmic complications E--.4 Type_ DM with neurological complications E--.5 Type_ DM with circulatory complications E--.6 Type_ DM with other specified complications E--.8 Type_ DM with unspecified complications E--.9 Type_ DM without complications Note: no 7 DIABETES ANDTHE USE OF INSULIN Coding requires minimum of 2 codes: 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. Code Z79.4, Long-term (current) use of insulin, should also be assigned to indicate that the patient uses insulin. 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. 9

UNDERDOSE OF INSULIN DUE TO INSULIN PUMP FAILURE Coding requires minimum of 2 codes: Code from subcategory T85.6, Mechanical complication of other specified internal and external prosthetic devices, implants and grafts, that specifies the type of pump malfunction, as the principal or first-listed code, Followed by code T38.3x6-, Underdosing of insulin and oral hypoglycemic associated complications due to the under-dosing should also be assigned. And any associated complication (type of diabetes with complication) OVERDOSE OF INSULIN DUE TO INSULIN PUMP FAILURE Coding requires a minimum of 2 codes: Code from category T85.6-, Mechanical complication of other specified internal and external prosthetic devices, implants and grafts, as the principal or first-listed code, Followed by code T38.3x1-, Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentional). And any associated complication (type of diabetes with complication) SECONDARY DIABETES (E08, EO9 AND E13) Coding requires a minimum of 2 codes: Use of insulin or oral hypoglycemic drugs Code the secondary diabetes code Followed by the code for insulin (Z79.4) or oral hypoglycemic (Z79.84) Do not code both, only Z79.4 Due to pancreatectomy Code E89.1 Postprocedural hypoinsulineumia first Followed by E13 category Followed by additional code from Z90.41- acquired partial absence of pancreas Due to drugs Code first the E09.9 code for drug or chemical induced diabetes mellitus without complications Followed by T38.0X5- Adverse effect of glucocorticoids and synthetic analogues 10

HYPERTENSION Classification presumes a causal relationship between: Hypertension and heart involvement Hypertension and kidney involvement Linked by the term with, or associated with, or due to Coded as related even in the absence of provider documentation explicitly linking them, unless Documentation clearly states the conditions are unrelated to the hypertension, then code them separately HYPERTENSION WITH HEART DISEASE Coding requires a minimum of 2 codes: Hypertension with heart conditions classified to I50.- or I51.4-I51.7, I51.89, I51.9 are assigned to a code from category I11, Hypertension heart disease (if causal relationship) Code I11.- Hypertension heart disease as primary code Use additional code from category I50.- Heart failure, to identify the type of heart failure HYPERTENSION WITH HEART CONDITIONS UNRELATED The same heart conditions (I50.- or I51.4-I51.7, I51.89, I51.9) with hypertension are coded separately if the provider has documented they are unrelated to the hypertension. Sequence according to the circumstances of the admission/encounter. 11

HYPERTENSION CHRONIC KIDNEY DISEASE Coding requires a minimum of 2 codes: Assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD), are present. Use code I12, Hypertension chronic kidney disease An additional code from category N18.- to identify the stage of chronic kidney disease If a patient has hypertensive chronic kidney disease and acute renal failure, an additional code for the acute renal failure is required. CKD should not be coded as hypertension if the provider indicates the CKD is not related to the hypertension HYPERTENSION HEART AND CHRONIC KIDNEY DISEASE Coding requires a minimum of 2 codes: Assign codes from combination category I13, Hypertensive heart and chronic kidney disease, when both hypertensive kidney disease and hypertensive heart disease are stated in the diagnosis. Assume a relationship between the hypertension and the chronic kidney disease, whether or not the condition is so designated. Use code I13, Hypertension heart and chronic kidney disease An additional code from category I50 to identify heart failure An additional code from category N18 to identify CKD If a patient has both CKD and acute renal failure, an additional code for the acute renal failure is required. OTHER HYPERTENSION CODING Coding requires a minimum of 2 codes: Hypertensive Cerebrovascular Disease First assign the appropriate code from categories I60-I69, Followed by the appropriate hypertension code. Hypertension, retinopathy Subcategory H35.0, should be used with Code from category I10-I15 Sequencing of codes is determined by the reason for admission/encounter Hypertension, Secondary First assign code to identify the underlying etiology and Follow from category I15 to identify the hypertension. Sequencing of codes is determined by the reason for admission/encounter 12

36 1. A 53-year-old tobacco user was diagnosed with CHF due to hypertension. 2. New patient with congestive heart failure due to hypertension heart disease comes to the office today. Patient also has CKD stage 5. He has been prescribed Lasix but admits he does not take it regularly, due to his age he forgets. PRESSURE ULCER STAGES (L89) Codes from category L89, Pressure ulcer, are combination codes that identify the site of the pressure ulcer as well as the stage of the ulcer. The ICD-10-CM classifies pressure ulcer stages based on severity, which is designated by stages 1-4, unspecified stage and unstageable. Assign as many codes from category L89 as needed to identify all the pressure ulcers the patient has, if applicable. If healed, assign codes for the for the encounter (Z09) and the personal history of the pressure ulcer (Z72.2) No code is assigned for a pressure ulcer documented as completely healed UNSTAGEABLE PRESSURE ULCERS Assignment of the code for unstageable pressure ulcer (L89.--0) should be based on the clinical documentation. These codes are used for pressure ulcers whose stage cannot be clinically determined (e.g., the ulcer is covered by eschar or has been treated with a skin or muscle graft) and pressure ulcers that are documented as deep tissue injury but not documented as due to trauma. This code should not be confused with the codes for unspecified stage (L89. 9). When there is no documentation regarding the stage of the pressure ulcer, assign the appropriate code for unspecified stage (L89.-9). Ulcer progresses to another severity during admission. Two codes should be assigned: one code for the site and severity on admission and a second for the highest severity reported during the stay 13

SAMPLE An elderly patient was evaluated and treated for three pressure ulcers: stage 4 on the left buttock, stage 2 on the right buttock and stage 3 on the sacral area. L89.324 Ulcer, pressure, buttock, stage 4 L89.153 Ulcer, pressure, sacral region (tailbone) stage 3 L89.312 Ulcer, pressure, buttock, stage 2 CODING OF BURNS AND CORROSIONS The ICD-10-CM makes a distinction between burns and corrosions. The burn codes are for thermal burns, except sunburns, that come from a heat source, such as a fire or hot appliance. The burn codes are also for burns resulting from electricity and radiation. Corrosions are burns due to chemicals. The guidelines are the same for burns and corrosions. Current burns (T20-T25) are classified by depth, extent and by agent (X code). Burns are classified by depth as first degree (erythema), second degree (blistering), and third degree (full-thickness involvement). Burns of the eye and internal organs (T26-T28) are classified by site, but not by degree. SEQUENCING OF BURN AND RELATED CONDITION CODES Sequence first the code that reflects the highest degree of burn when more than one burn is present. Burns of the same anatomic site (side) but of different degrees identifying the highest degree recorded in the diagnosis only. When the reason for the admission or encounter is for treatment of external multiple burns, sequence first the code that reflects the burn of the highest degree. When a patient has both internal and external burns, the circumstances of admission govern the selection of the principal diagnosis or first-listed diagnosis. When a patient is admitted for burn injuries and other related conditions such as smoke inhalation and/or respiratory failure, the circumstances of admission govern the selection of the principal or first-listed diagnosis. 14

BURNS AND CORROSIONS CLASSIFIED ACCORDING TO EXTENT OF BODY SURFACE Assign codes from category T31, Burns classified according to extent of body surface involved, or T32, Corrosions classified according to extent of body surface involved. It is advisable to use category T31 as additional coding when needed to provide data for evaluation burn mortality, such as needed by burn units. It is also advisable to use as an additional code for reporting when there is mention of third-degree burn involving 20 percent or more of the body surface. T31 and T32 are based on the classic rule of nines in estimating body surface involved. SAMPLE Patient admitted for total of 30% TBSA of second degree burn on right forearm, second degree of right axilla and 20% third degree on chest wall, as well as severe smoke inhalation. While cooking in her home kitchen. T59.811A J70.5 T21.31XA T22.211A T22.241A T31.32 X08.8XXA Y92.010 Y93.G3 Toxic effect of smoke, accidental, initial encounter Respiratory condition due to smoke inhalation Burn of third degree of chest wall, initial encounter Burn of second degree of right forearm, initial encounter Burn of second degree of right axilla, initial encounter Burns involving 30% of body surface, with 20-29% third degree Exposure to other specified smoke, fire and flames, initial encounter Place of occurrence, house, kitchen Activity, cooking and baking QUESTIONS? 15