ICD-10-CM: The Sage Continues UHIMA Kathy DeVault, MSL, RHIA, CCS, - - PowerPoint PPT Presentation

ICD-10-CM: The Sage Continues

UHIMA

Kathy DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA UASI Kathy.devault@uasisolutions.com

• Review quality documentation
• Discuss use of unspecified codes
• Discuss opportunities in ICD-10-CM
• Review relevant Coding Clinic advice for

ICD-10-CM

Objectives

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

Quality . . .

• Documentation
• Productivity
• Quality
• Data
• Claims Processing
• Denials

Implementation Concerns Realized?

• 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

Current State of ICD-10

• Identify documentation deficiencies
• Accurate reflection of:
• Severity of illness
• Risk of mortality
• Quality
• Core measures
• PQRS

Documentation Deficiencies

• 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

Unspecified Codes

ICD-10-CM Coding Opportunities

• Acuity
• Acute
• Chronic
• Acute on Chronic
• Specificity
• Hypercapnic
• Hypoxemic
• UNSPECIFIED is an option

Respiratory Failure

• Type of Anemia
• Nutritional
• Hemolytic
• Aplastic
• Due to blood loss
• Acute
• Chronic
• Other . . . Specify
• Link to laboratory findings

Anemia

1st 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

Anemia – Coding Clinic

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

1st 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

3rd 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.

Diabetes – Coding Clinic

• 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

Acute Renal Failure

• Stage:
• Stages 1-5
• ESRD
• Underlying cause – diabetes, htn, etc.
• Associated diagnoses/conditions
• Dependence on dialysis
• UNSPECIFIED is an option

Chronic Kidney Disease (CKD)

4th 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 Clinic

• 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.

ESRD – Coding Clinc

• I50.1

Left ventricular failure

• I50.2

Systolic (congestive) heart failure

• I50.3

Diastolic (congestive) heart failure

• I50.4

Combines systolic and diastolic heart failure

• I50.9

Heart failure, unspecified

• Includes: Acute, chronic and acute on chronic

Heart Failure – Category I50

1st 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.

Heart Failure – Coding Clinic

 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

Cardiac Arrest

• Due to alcohol
• Due to drugs
• Post-procedural
• Acuity . . . Acute, Subacute, Chronic
• Severity . . . With or without coma
• Associated diagnoses/conditions

Hepatic Encephalopathy

1st 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.

OB – Selection of Principal Diagnosis

• Site
• Specificity of bone (distal, proximal, shaft, etc.)
• Laterality
• Traumatic
• Pathologic
• Osteoporosis
• Neoplastic disease
• Other
• Type
• Encounter – Active, Subsequent, etc.

Fractures

• 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.

Underdosing

• Affected body system
• Specific condition
• Document whether a:
• Complication of care; OR
• Expected procedural outcome
• Document when:
• Intraoperative
• Postoperative

Surgical 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.

Complications

1st 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
• nly applied when the underlying conditions listed

in the note are present. If these conditions are not present, the code first note is not applicable.

ICD-10-CM Convention – Coding Clinic

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

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 Sneak Peek. . .

• 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
• sticCodes/ICD-9-CM-C-and-M-Meeting-Materials-

Items/2016-03-09- MeetingMaterials.html?DLPage=1&DLEntries=10&DLSort=0 &DLSortDir=descending

FY2017 Code Changes

Thank you!

Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA Kathy.devault@uasisolutions.com

Questions?