Insights icd10 & Your Bottom Line
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The document outlines key changes in medical coding guidelines, emphasizing the importance of accurate documentation for diagnoses and the relationship between conditions. It covers specific coding requirements, including the use of the term 'with', complications of care, and guidelines for categorizing conditions such as hypertension crises and pressure ulcers. Additionally, it addresses codes related to high-risk pregnancies, newborn evaluations, and includes instructions for maintaining specificity in coding practices.
Insights icd10 & Your Bottom Line
- 2. Agenda • Key changes and revisions • Written guidance from CMS and OIG that may negate a new guideline • Chapter-specific changes • How to tell when you need documentation and when you don’t
- 3. “WITH” – Why It’s Important With Means “associated with” or “due to” Presumes a casual relationship between two conditions linked by these termsConditions should be coded as related, even if provider documentation does not explicitly link them The word “with” in the alphabetic index immediately follows the main term
- 4. 1. amyotrophy E11.44 2. arthropathy NEC E11.618 3. autonomic (poly) E11.43 4. cataract E11.36 5. Charcot's joints E11.60 6. chronic kidney disease E11.22 7. circulatory complication NEC E11.59 8. complication E11.8 9. specified NEC E11.69 10. dermatitis E11.620 11. foot ulcer E11.621 12. gangrene E11.52 13. gastroparalysis E11.43 14. gastroparesis E11.43 15. glomerulonephrosis, intracapillary E11.21 16. glomerulosclerosis, intercapillary E11.21 17. hyperglycemia E11.65 18. hyperosmolarity E11.00 Diabeties, diabetic (mellitius) (sugar) E11.9 -with
- 5. 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.
- 6. 2016 OIG Work Plan Review the medical record documentation to ensure it supports the diagnoses that MA organizations submitted to CMS for use in risk-score calculations. Medical record documentation does not always support the diagnosis submitted to CMS by MA organizations. MA organizations are required to submit risk adjustment data to CMS in accordance with HHS OIG Work Plan. Inaccurate diagnoses may cause CMS to pay MA organizations improper amounts.
- 7. Specific Coding is NOW Is Medicare going to phase in the requirement to code to the highest level of specificity?* No, providers should already be coding to the highest level of specificity. As of 10/1/2016, providers are required to code to accurately reflect the clinical documentation. *Submitted to CMS 8/8/2016
- 8. Sequela Late effects • There is no time limit for a sequela code. • The residual effect may be apparent early or may occur months or years later. • Coding is usually sequenced with two codes: 1. The condition or nature of the sequela 2. The sequela code • 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 effect. Sequela a residual effect after the acute phase of an illness or injury An exception to the above rule: If the code for the sequela is followed by a manifestation code identified in the Tabular list and title, OR the sequela code has been expanded (fourth, fifth, sixth character levels) to include the manifestation(s).
- 9. Effective for date of service October 1, 2016 S and T ICD10 CM codes from Chapter 19 requiring a seventh character of “S” will receive a designation of NPD in the commercial clinical editor.* Affects approximately 9,600 diagnosis codes from chapter 19, which currently do not have the NPD designation. NPD Designation *Based on recent clarification from the American Hospital Association.
- 10. For BMI Depth of Non-pressure Ulcers Pressure Ulcer Stage Coma Scale NIH Stroke Scale Code assignment may be based on the medical record documentation from clinicians who are not the patient’s provider.* *physician, or other qualified health care practitioner legally accountable for establishing the patient’s diagnosis Specific Documentation The associated diagnosis, i.e. Overweight Obesity Acute stroke Pressure ulcer must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be asked for clarification.
- 11. Nurse documents patient’s weight, height, and BMI data Physician does not document the patient’s obesity An obesity code should not be used Examples Physician documents the patient’s obesity The obesity code can be used
- 12. • The guideline extends to any complications of care, regardless of the chapter where the code is located. • Not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, plus an indication in the documentation that it is a complication. • Query the provider for clarification, if the complication is not clearly documented. Documentation of the Complications of Care Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification.
- 13. Excludes1 Exception When the two conditions are unrelated to each other For example: Code F45.8 (other somatoform disorders) 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. Psychogenic dysmenorrhea is also an inclusion term under F45.8, and a patient could have that as well as sleep related teeth grinding. The two conditions are clearly unrelated, so both G47.63 and F45.8 can be reported.
- 14. Laterality • If no bilateral code is provided, and the condition is bilateral, assign separate codes for the right and left side. • If the side is not identified in the medical record, assign code for Unspecified. • If a patient has a bilateral condition, and each side is treated during separate encounters, assign the bilateral code. • For the 2nd encounter after one side has already been treated, and the condition NO longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists. NOTE: If treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate Some codes specify whether the condition is on the left, right, or bilateral RL
- 15. Laterality Example Patient has been evaluated for cataracts in both eyes. The right eye was previously fixed via surgical intervention Patient now presents to have the left eye re- evaluated for surgery. Initial visit: - Cataracts are diagnosed as bilateral - Bilateral code is chosen In the re-evaluation visit: - Condition only exists in the left eye
- 17. Zika Virus • Code only confirmed case of Zika virus as documented by the provider. • In this context, “confirmation” does not require documentation of the type of test performed • The physician’s diagnostic statement that the condition is confirmed is sufficient • This code should be assigned, regardless of the stated mode of transmission • If the provider documents “suspected,” “probable,” or “possible” Zika, do not use the code A92.5. Only code associated signs and symptoms
- 18. Hypertension Crisis Assign a code from category I16, Hypertensive crisis, for: • Documented hypertensive urgency • Hypertensive emergency • Unspecified hypertensive crisis Code any identified hypertensive disease (I10-I15). Sequencing is based on the reason for the encounter.
- 19. Acute Myocardial Infarction Encounters occurring while the myocardial infarction is < 4 weeks old, including transfers to another acute setting or a postacute setting, and the myocardial infarction meets the definition for “other diagnoses” (see Section III, Reporting Additional Diagnoses), codes from category I21 may continue to be reported.
- 20. Pressure Ulcers 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.
- 21. Supervision of High-Risk Pregnancy High-risk pregnancy complications during labor and delivery Assign the applicable complication codes from Chapter 15. No complications during the labor and delivery Assign code O80, Encounter for full-term uncomplicated delivery. Codes from category O09, Supervision of high-risk pregnancy, are intended for use only during the prenatal period.
- 22. When a Delivery Occurs An obstetric patient is admitted & delivery occurs during that admission The condition prompting the admission Is sequenced as the principal diagnosis. Multiple conditions prompted the admission Sequence the one most related to the delivery as the principal diagnosis. Any complication of the delivery Should be assigned as an additional diagnosis.
- 23. Gestational (pregnancy-induced) Diabetes Should not be assigned with codes from subcategory O24.2: Code Z79.4, Long-term (current) use of insulin Code Z79.84, Long term (current) use of oral hypoglycemic drugs The codes under subcategory O24.4 include: - Diet controlled - Insulin controlled - Controlled by oral hypoglycemic drugs If a patient with gestational diabetes is treated with both diet and insulin, only the code for insulin controlled is required. If a patient with gestational diabetes is treated with both diet and oral hypoglycemic medications, only code for “controlled by oral hypoglycemic drugs” is required.
- 24. Observation and Evaluation of Newborns for Suspected Conditions not Found Assign a code from category Z05, Observation and evaluation of newborns and infants for suspected conditions ruled out, to identify instances when a healthy newborn is evaluated for a suspected condition that is not found. If the patient has signs and symptoms of suspected problem do not use Z05. Only code the sign or symptom
- 25. Coma Scale Should be sequenced after the diagnosis code(s). The coma scale codes (R40.2-) can be used in conjunction with: - Traumatic brain injury codes - Acute cerebrovascular disease codes - Sequela of cerebrovascular disease codes May also be used to assess the status of the central nervous system for other non-trauma conditions (i.e., monitoring patients in the ICU regardless of the medical condition).
- 26. NIHSS Stroke Scale The NIH stroke scale NIHSS codes (R29.7-) can be used in conjunction with acute stroke code (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. At a minimum, report the initial score documented. You may choose to capture multiple stroke scale codes.
- 27. NIHSS Stroke Scale R29.700 R29.701 R29.702 R29.703 NIHSS score 0 NIHSS score 1 NIHSS score 2 NIHSS score 3
- 28. 7th Character A Used for each encounter where the patient is receiving active treatment for the condition 7th character “A,” initial encounter
- 29. Initial vs. Subsequent Encounter for Fractures The open fracture designations in the assignment of the 7th character for fractures of the forearm, femur, and lower leg (including ankle) are based on the Gustilo open fracture classification. When the Gustilo classification type is not specified for an open fracture, the 7th character for open fracture should be assigned (B,E,H,M,O).
- 30. Questions Please email your questions to: ashley.giaquinta@careoptimize.com To learn even more about CareOptimize and how we can help your bottom line, please visit our newly updated website: www.careoptimize.com