ICD-10-CM: The Sage Continues UHIMA Kathy DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA UASI Kathy.devault@uasisolutions.com
Objectives Review quality documentation Discuss use of unspecified codes Discuss opportunities in ICD-10-CM Review relevant Coding Clinic advice for ICD-10-CM
Quality... If you pursue reimbursement, you will miss The High Quality Medical Record but If you pursue a High Quality Medical Record, The proper reimbursement will follow
Quality... Complete, accurate coded data essential for: Improved quality of patient care Decision-making on healthcare policies Optimizing resource utilization Identifying and reducing medical errors Clinical research, epidemiological studies Physician documentation... Cornerstone of accurate coding
Implementation Concerns Realized? Documentation Productivity Quality Data Claims Processing Denials
Current State of ICD-10 Too soon to follow the money Workflow has been primary focus Next steps: Improve quality Increase specificity Some Medicare contractors are still working on issues with local coverage policies and coding
Documentation Deficiencies Identify documentation deficiencies Accurate reflection of: Severity of illness Risk of mortality Quality Core measures PQRS
Unspecified Codes Use of some unspecified codes is expected Unspecified diagnosis codes are indicative of incomplete clinical documentation Should only be used when no specific code is available or exact diagnosis not known yet Unspecified code rate: Recommended rate around 20% Reflects organizations opportunity to improve documentation and better leverage ICD-10 specificity
ICD-10-CM Coding Opportunities
Respiratory Failure Acuity Acute Chronic Acute on Chronic Specificity Hypercapnic Hypoxemic UNSPECIFIED is an option
Anemia Type of Anemia Nutritional Hemolytic Aplastic Due to blood loss Acute Chronic Other... Specify Link to laboratory findings
Anemia Coding Clinic 1 st Quarter, 2014, pages 15-16 Q: We are considering developing internal guidelines and obtaining medical staff approval to code acute blood loss anemia. The guidelines would specify lab values pre and post-surgery, as well as some clinical signs to allow coders to code acute blood loss anemia without the need to have physician documentation. Would this be acceptable?
Anemia Coding Clinic A: No, it is not acceptable. The Official Coding Guidelines, section III.B, states: Abnormal findings are not coded and reported unless the physician indicates their clinical significance.... Internal guidelines should not replace physician documentation Facility guidelines must not conflict with the Official ICD- 10-CM Guidelines for Coding and Reporting developed by the Cooperating Parties and, additionally they should not be developed to replace the physician documentation needed to support code assignment
Diabetes Mellitus By type... with Amytrophy Arthropathy Autonomic (poly)neuropathy Cataract Charcot s joints Chronic kidney disease Circulatory complication Complication Dermatitis Foot ulcer Gangrene Gastroparesis.... Hyperglycemia Hypoglycemia Kidney complications NEC Nephropathy Neuralgia Neuropathy Ophthalmic complication Neuropathy Polyneuropathy Retinopathy Skin ulcer
Diabetes Coding Clinic 1 st Q, 2016, pages 11-12 Q: The ICD-10-CM Alphabetic Index entry for Diabetes with includes listing for conditions associated with diabetes, which was not the case in ICD-9-CM. Does the provider need to document a relationship between the two conditions or should the coder assume a causal relationship?
Diabetes Coding Clinic A:... The term with means associated with or due to, when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List and that is how it s meant to be interpreted when assigning codes for diabetes with associated manifestations and/or conditions. The classification assumes a cause-and-effect relationship between diabetes and certain diseases of the kidneys, nerves, and circulatory system.
Diabetes Coding Clinic A (continued): However, if the physician documentation specifies diabetes mellitus is not the underlying cause of the other condition, the condition should not be coded as a diabetic complication.
Diabetes Coding Clinic 3 rd Q 2012, page 3 also applies to ICD-10-CM: It is note required that two conditions be listed together in the health record. However, the provider needs to document the linkage, except for situations where the classification assumes an association (e.g. hypertension with chronic kidney involvement). When the provider establishes a linkage or relationship between the two conditions, they should be coded as such.
Acute Renal Failure Underlying contributing condition Due to: Trauma Acute tubular necrosis (ATN) Acute cortical necrosis Acute medullary necrosis Acute renal insufficiency and Acute kidney disease not reported as acute renal failure
Chronic Kidney Disease (CKD) Stage: Stages 1-5 ESRD Underlying cause diabetes, htn, etc. Associated diagnoses/conditions Dependence on dialysis UNSPECIFIED is an option
ESRD Coding Clinic 4 th Quarter, 2013, page 124 Q: There does not appear to be a counterpart ICD-10-CM code to the ICD-9- CM code V56.0, Encounter for extracorporeal dialysis. How should a patient encounter for hemodialysis be coded? Should it be coded to End Stage Renal Disease (ESRD)?
ESRD Coding Clinc A: Yes, your are correct. There is no ICD-10- CM counterpart to the ICD-9-CM code V56.0. For an encounter for dialysis, assign the appropriate code for the underlying disease/reason for dialysis. Do not assume that the patient has ESRD. Hemodialysis may be used to treat acute renal failure as well as chronic kidney disease.
Heart Failure Category I50 I50.1 I50.2 I50.3 I50.4 I50.9 Left ventricular failure Systolic (congestive) heart failure Diastolic (congestive) heart failure Combines systolic and diastolic heart failure Heart failure, unspecified Includes: Acute, chronic and acute on chronic
Heart Failure Coding Clinic 1 st Q 2016, pages 10-11 Q: Please reconsider the advice previously published in Coding Clinic, stating that the coder cannot assume either diastolic or systolic failure or a combination of both, based on documentation of heart failure with preserved ejection fraction (HFpEF) or heart failure with reduced ejection fraction (HFrEF). Would it be appropriate to code diastolic or systolic heart failure when the provider documents HFpEF or HFrEF?
Heart Failure Coding Clinic A: Based on additional information received, the EAB for Coding Clinic has reconsidered previously published advice about coding heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF)....These terms HFpEF and HFrEF are more contemporary terms that are being more frequently used, and can be further described as acute or chronic. Therefore, when the provider has documented HFpEF, HFrEF, or other similar terms noted above, the coder may interpret these as diastolic heart failure or systolic heart failure, respectively.
Cardiac Arrest Due to underlying cardiac condition Due to other underlying condition Post-procedural: During or following cardiac surgery During or following other surgery Any associated diagnoses/conditions UNSPECIFIED is an option
Hepatic Encephalopathy Due to alcohol Due to drugs Post-procedural Acuity... Acute, Subacute, Chronic Severity... With or without coma Associated diagnoses/conditions
OB Selection of principal diagnosis 1 st Q 2016, page 3 When an obstetric patient is admitted, the condition that prompted the admission should be sequenced as the principal diagnosis. A code for any complication of the delivery should be assigned as an addition diagnosis. For example, if a patient is admitted for treatment of preeclampsia, and fetal decelerations complicate spontaneous vaginal delivery, the preeclampsia should be sequenced as the principal diagnosis, rather than fetal decelerations. If there is not pregnancy complication prompting the admission, then a delivery complication code should be assigned as the principal diagnosis.
OB Selection of principal diagnosis Q: A patient is admitted for delivery following premature rupture of membranes. During the delivery the patient suffers a perineal laceration. What is the principal diagnosis? A: Assign a code for pregnancy complicated by premature rupture of membranes as the principal diagnosis. A code for the laceration should be assigned as an additional diagnosis.
OB Selection of Principal Diagnosis Q: The patient had no complications during pregnancy and is admitted in labor. The patient experiences a periurethral laceration during delivery that is repaired. What is the principal diagnosis? A: Assign a code for delivery complicated by periurethral tear as the principal diagnosis. In this case, the patient was admitted without any complications of the pregnancy; however, the patient suffers a tear during the delivery.
Fractures Site Specificity of bone (distal, proximal, shaft, etc.) Laterality Traumatic Pathologic Osteoporosis Neoplastic disease Other Type Encounter Active, Subsequent, etc.
Underdosing Specific drug underdosed Intention of underdosing Intentional Due to financial reasons Decreased cognitive ability Always a secondary diagnosis Important data related to 30-day readmission rates
Underdosing Underdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer s instructions. For underdosing, assign the code from categories T36-T50 (fifth or sixth character 6 ). Noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.6-Y63.9) codes are to be used with an underdosing code to indicate intent, if known.
Surgical Complications Affected body system Specific condition Document whether a: Complication of care; OR Expected procedural outcome Document when: Intraoperative Postoperative
Complications There must be a cause-and-effect relationship between the care provided and the condition and/or procedure, and an indication in the documentation that it is a complication. Code assignment is based on the provider s documentation of the relationship between the condition and the procedure Not all conditions that occur during or following medical care or surgery are classified as complications.
ICD-10-CM Convention Coding Clinic 1 st Q 2016, pages 39-40 Q: Some payers are denying claims when heart failure or sepsis codes are sequenced as the principal diagnosis because they are misinterpreting the code first note at categories I50, and A41. They are denying the claim based on the belief that the conditions listed in the note are always sequenced first, even though they patient may not have any of the conditions listed. Could you please clarify the intent of the instructional note?
ICD-10-CM Convention Coding Clinic A: The code first note means code first, if present. This instructional note is intended for conditions that have both an underlying etiology and manifestation, and indicates the proper sequencing order: etiology first, followed by the manifestation. However, this instructional note is only applied when the underlying conditions listed in the note are present. If these conditions are not present, the code first note is not applicable.
FY2017 Code Changes Coming soon: Over 5,000 new ICD-10 codes CMS plans to add about 5,500 new codes to ICD-10 ICD-10 currently includes about 70,000 diagnosis codes and 87,000 procedure codes. CMS intends to add about 3,650 procedure codes and 1,900 diagnosis codes in the proposed rule for fiscal year 2017, which begins on Oct. 1, 2016. The new codes would clear a backlog of changes proposed by the ICD-10 Coordination and Maintenance Committee. The agency says the backlog stems from a code-change freeze that was in place during the transition to ICD-10. About 97 percent of the new procedure codes relate to cardiovascular and lower joint care. Other new procedure codes would cover face transplants and donor organ perfusion. CMS will accept comments on the new codes until April 8.
FY2017 Code Changes Sneak Peek... The transition from ICD-9 to ICD-10 resulted in a reduction in the number of hypertension codes. In ICD-10- the type of hypertension malignant, benign, unspecified is no longer used as an axis of classification. Currently in ICD-10 there are no specific codes to reflect hypertension emergency or urgency. The proposed rule for FY 2017 includes 3 new hypertension codes: I16.0 Hypertensive urgency I16.1 Hypertensive emergency I16.9 Hypertensive crisis, unspecified None of the above new codes are included on the proposed CC or MCC lists for FY 2017.
FY2017 Code Changes 2017 ICD-10-CM proposed changes: ftp://ftp.cdc.gov/pub/health_statistics/nchs/publications/i CD10CM/2017/NewICD10CMCodes_FY2017.txt 2017 ICD-10-PCS proposed changes: https://www.cms.gov/medicare/coding/icd9providerdiagn osticcodes/icd-9-cm-c-and-m-meeting-materials- Items/2016-03-09- MeetingMaterials.html?DLPage=1&DLEntries=10&DLSort=0 &DLSortDir=descending
Questions? Thank you! Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA Kathy.devault@uasisolutions.com