Selected Topics from Coding Clinic NYHIMA's 79th Annual Conference June 2, 2014 Barry Libman, MS,...

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Selected Topics fromSelected Topics fromCoding ClinicCoding Clinic

NYHIMA's 79th Annual Conference NYHIMA's 79th Annual Conference June 2, 2014June 2, 2014

Barry Libman, MS, RHIA, CDIP, CCS, CCS-PPresident, Barry Libman Inc.President, Libman Education

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Coding ClinicCoding Clinic for ICD-9 / ICD-10for ICD-9 / ICD-10

• Published quarterly by the AHA

• Coding Clinic is the official publication for ICD-9 / ICD-10 coding guidelines and advice as designated by the four cooperating parties:- AHA- AHIMA- CMS- NCHS

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AHA Coding Clinic AdvisorAHA Coding Clinic Advisor

• Coding Clinic question submission

• 1) Visit www.CodingClinicAdvisor.com

• 2) Click on Log in/Register

• 3) Enter coding question

• 4) Include applicable back-up documentation

• 5) Submit

• 6) Submission confirmation will be sent with a tracking number

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Coding ClinicCoding Clinic transition timeline transition timeline

• Fall 2013: The last meeting of the AHA Coding Clinic Editorial Advisory Board (EAB) meeting where ICD-9-CM questions were addressed

• January 1, 2014: AHA Central Office no longer accepts nor respond to requests for ICD-9-CM coding advice

• First Quarter 2014: • - Last issue of Coding Clinic for ICD-9-CM was

published• - First issue of Coding Clinic for ICD-10-CM and ICD-

10-PCS was published; Second Quarter 2014 also available

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Coding ClinicCoding Clinic transition transition

• No plans to translate all previous issues of Coding Clinic for ICD-9-CM into ICD-10-CM/PCS since many of the questions published arose out of the need to provide clarification on the use of ICD-9-CM and would not be readily applicable to ICD-10-CM/PCS.

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CMS statementCMS statement

• “On April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. No. 113-93) was enacted, which said that the Secretary may not adopt ICD-10 prior to October 1, 2015.

• Accordingly, the U.S. Department of Health and Human Services expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning October 1, 2015.

• The rule will also require HIPAA covered entities to continue to use ICD-9-CM through September 30, 2015.”

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ICD-9-CMICD-9-CM

• Coding Clinic Second Quarter 2014

• The Cooperating Parties have reviewed the original plan not to address any ICD-9-CM questions and have decided to uphold the plan and go forward with only providing advice on ICD-10-CM and PCS

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Today’s Today’s Coding ClinicCoding Clinic topics topics

– ICD-10 Coding Clinics:

– Assigning Codes Using Prior Encounters Q3 2013

– Decompensated Systolic Heart Failure Q2 2013

– Diabetes and Osteomyelitis Q4 2013

– Diabetic Mellitus with Hyperglycemia Q3 2013

– Diabetes with Ketoacidosis Q3 2013

– Diabetes Mellitus Type 2 with Ketoacidosis Q1 2013

– Pneumonia and Hemoptysis Q4 2013

– Healthcare Acquired (Nosocomial) Condition Q4 2013

– Endoscopic Banding of Esophageal Varices Q4 2013

– Root Operation for Bone Marrow Biopsy Q4 2013

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Today’s Today’s Coding ClinicCoding Clinic topics topics

• ICD-9 Coding Clinics:

• History of Ductal Carcinoma Q1 2012

• Heart Failure with Preserved or Reduced Ejection Fraction Q1 2014

• Immune Thrombocytopenic Purpura and Pancytopenia Q1 2014

• Traumatic Urinary Catheterization Q1 2014

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Assigning Codes Using Prior Assigning Codes Using Prior Encounters Q3 2013Encounters Q3 2013

• Question:

• Is there a guideline or rule that indicates that you should only use the medical record documentation for that specific visit/admission for diagnosis coding purposes?

• Does each visit or admission stand alone?

• Would the coder go back to previous encounter records to assist in the coding of a current visit or admission?

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• Answer:

• Documentation for the current encounter should clearly reflect those diagnoses that are current and relevant for that encounter.

• Conditions documented on previous encounters may not be clinically relevant on the current encounter.

• The physician is responsible for diagnosing and documenting all relevant conditions. A patient’s historical problem list is not necessarily the same for every encounter/visit.

• It is the physician’s responsibility to determine the diagnoses applicable to the current encounter and document in the patient’s record. When reporting recurring conditions and the recurring condition is still valid for the outpatient encounter or inpatient admission, the recurring condition should be documented in the medical record with each encounter/admission.

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• Answer (continued):

• However, if the condition is not documented in the current health record, it would be inappropriate to go back to previous encounters to retrieve a diagnosis without physician confirmation.

• This is an area where coders and/or department managers may need to educate physicians and/or practice managers on the need to include complete diagnoses when outpatient services are ordered and to continue to document chronic or longstanding conditions on each admission/encounter record.

• Please note this advice applies to both ICD-9-CM and ICD-10-CM.

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Decompensated Systolic Decompensated Systolic Heart Failure Q2 2013Heart Failure Q2 2013

• Question:

• Coding Clinic, Third Quarter 2008, p. 12, states “decompensated indicates that there has been a flare-up (acute phase) of a chronic condition.”

• Should this general definition of decompensated be applied when assigning ICD-10-CM codes as well?

• For example, what is the appropriate ICD-10-CM code assignment for a diagnosis of chronic systolic heart failure, currently decompensated?

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Decompensated Systolic Heart Decompensated Systolic Heart Failure Q2 2013Failure Q2 2013

• Answer:

• Assign code I50.23, Acute on chronic systolic heart failure, for decompensated systolic heart failure.

• As previously stated “decompensated” indicates there has been a flare-up (acute phase) of a condition.

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Diabetes and Osteomyelitis Q4 2013Diabetes and Osteomyelitis Q4 2013

• Question:

• Coding Clinic, First Quarter 2004, pages 14-15, indicated that “ICD-9-CM assumes a relationship between diabetes and osteomyelitis when both conditions are present, unless the physician has indicated in the medical record that the acute osteomyelitis is totally unrelated to the diabetes.”

• Is the same relationship between diabetes and osteomyelitis true for ICD-10-CM?

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Diabetes and Osteomyelitis Q4 2013Diabetes and Osteomyelitis Q4 2013

• Answer:

• No, ICD-10-CM does not presume a linkage between diabetes and osteomyelitis.

• The provider will need to document a linkage or relationship between the two conditions before it can be coded as such.

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Diabetes and OsteomyelitisDiabetes and Osteomyelitis

• 250.80 with 730.27 or E11.69 with M86.9

• DM with Osteomyelitis

• MS-DRG: 638 Diabetes w CC

• Cost weight: .8252

• M86.9 and E11.9

• Osteomyelitis and DM

• DRG: 541 Osteomyelitis w/o CC/MCC

• Cost weight: .9743

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Osteomyelitis in the IndexOsteomyelitis in the Index

• Osteomyelitis M86.9

• acute M86.10

• carpus M86.14-

• clavicle M86.11-

• femur M86.15-

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Diabetic Mellitus with Hyperglycemia Diabetic Mellitus with Hyperglycemia Q3 2013Q3 2013

• Question:

• Is it appropriate to assign a code for hyperglycemia together with another diabetes code?

• For example, if hyperglycemia is documented along with type 2 diabetic retinopathy, should multiple diabetes codes be assigned?

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Diabetic Mellitus with Hyperglycemia Diabetic Mellitus with Hyperglycemia Q3 2013Q3 2013

• Answer:

• Yes, assign codes E11.319, Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema, and E11.65, Type 2 diabetes mellitus with hyperglycemia.

• Any combination of the diabetes codes can be assigned together, unless one diabetic condition is inherent in another.

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Index and DiabetesIndex and Diabetes

ICD-10-CM Index:• out of control – code to Diabetes by type with

hyperglycemia• poorly controlled – code to Diabetes by type with

hyperglycemia

ICD-9-CM Index:• poorly controlled – code to Diabetes by type with

5th digit for not stated as uncontrolled

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Diabetes with Ketoacidosis Q3 2013Diabetes with Ketoacidosis Q3 2013

• Question:

• Coding Clinic for ICD-9-CM states that ketoacidosis is inherently uncontrolled diabetes. Therefore, how would you report uncontrolled type I diabetes with ketoacidosis in ICD-10-CM?

• Should the code for diabetes with hyperglycemia (E10.65) be reported in addition to the code for diabetes ketoacidosis (E10.10)?

• Or should only the code for diabetic ketoacidosis be reported since ketoacidosis is considered uncontrolled diabetes?

• We believe that the two codes are redundant; however, there are no instructional and/or excludes notes to guide coders as to the appropriate reporting of uncontrolled type I diabetes with ketoacidosis.

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Diabetes with Ketoacidosis Q3 2013Diabetes with Ketoacidosis Q3 2013

• Answer:

• No, in this case, it is not appropriate to assign code E10.65, Type 1 diabetes mellitus with hyperglycemia, together with code E10.10.

• Assign only code E10.10, Type 1 diabetes mellitus with ketoacidosis without coma.

• Ketoacidosis signifies uncontrolled diabetes.

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Diabetes Mellitus Type 2 with Diabetes Mellitus Type 2 with Ketoacidosis Q1 2013Ketoacidosis Q1 2013

• Question:

• What is the correct code assignment for type 2 diabetes mellitus with diabetic ketoacidosis?

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Diabetes Mellitus Type 2 with Diabetes Mellitus Type 2 with Ketoacidosis Q1 2013Ketoacidosis Q1 2013

• Answer:

• Assign code E13.10, Other specified diabetes mellitus with ketoacidosis without coma, for a patient with type 2 diabetes with ketoacidosis.

• Given the less than perfect limited choices, it was felt that it would be clinically important to identify the fact that the patient has ketoacidosis.

• The National Center for Health Statistics (NCHS), who has oversight for volumes I and II of ICD-10-CM, has agreed to consider a future ICD-10-CM Coordination and Maintenance Committee meeting proposal.

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Pneumonia and Hemoptysis Q4 2013Pneumonia and Hemoptysis Q4 2013

• Question:

• “Hemorrhagic” is no longer a non-essential modifier for pneumonia in the ICD-10-CM Index to Diseases.

• Is a code reported for hemoptysis when it occurs with pneumonia?

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Pneumonia and Hemoptysis Q4 2013Pneumonia and Hemoptysis Q4 2013

• Answer:

• Sequence the appropriate code for the pneumonia first.

• Assign code R04.2, Hemoptysis, as an additional code when the condition occurs with pneumonia.

• Although code R04.2 is a Chapter 18 code, codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with the diagnosis.

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Healthcare Acquired (Nosocomial) Healthcare Acquired (Nosocomial) Condition Q4 2013Condition Q4 2013

• Question:

• A patient is admitted to the hospital and diagnosed with severe sepsis due to healthcare associated pneumonia. The physician documented that her healthcare associated pneumonia was due to her recent hospitalization.

• During a recent ICD-10-CM training it was suggested that code Y95 Nosocomial condition could be assigned in addition to R65.20, Severe sepsis without septic shock, and J18.9 Pneumonia, unspecified organism.

• There is currently no indexing in the ICD-10-CM index that supports this assignment. Is it appropriate to assign code Y95, Nosocomial condition based on the documentation of healthcare associated pneumonia or hospital acquired pneumonia?

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Healthcare Acquired (Nosocomial) Healthcare Acquired (Nosocomial) Condition Q4 2013Condition Q4 2013

• Answer:

• Yes, it is appropriate to assign code Y95, Nosocomial condition, for a documented healthcare acquired condition.

• Code Y95 can be found on the Index to External Causes under the main term “Nosocomial condition.”

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Endoscopic Banding of Esophageal Endoscopic Banding of Esophageal Varices Q4 2013Varices Q4 2013

• Question:

• A patient with hematemesis presents for esophagogastroduodenoscopy. The patient is found to have esophageal varices, and therefore, ligation of esophageal varices was performed using bands placed via a band ligation device.

• What is the appropriate ICD-10-PCS body system for esophageal varices: gastrointestinal system or lower veins?

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• Question (continued):• In ICD-10-PCS, ligation is coded to the root operation

occlusion. Therefore, if we use table “06L” for occlusion of lower veins, there is the appropriate body part and a device value for the bands (extraluminal device);

• However, there is no approach value for via natural or artificial opening endoscopic.

• However, if we use the “0DL” table for occlusion of gastrointestinal system and use “esophagus” for the body part, there is the appropriate approach value but there is no device option for the bands.

• What is the appropriate ICD-10-PCS code assignment for endoscopic banding of esophageal varices?

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• Answer:

• Esophageal varices are enlarged veins in the esophagus, which can spontaneously rupture and cause severe bleeding. Endoscopic banding of esophageal varices involves completely occluding blood flow and meets the definition of root operation “occlusion.”

• The lumen of the esophageal vein is being banded, not the esophagus.

• The index under ligation states “See occlusion.”

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• Assign the following ICD-10-PCS code:

• 06L34CZ Occlusion of esophageal vein with extraluminal device, percutaneous endoscopic approach.

• The ICD-10-PCS tables currently do not use approaches containing the phrase “via natural or artificial opening” for body part values in the cardiovascular body systems.

• The use of this approach for blood vessel body parts could change over time if requests for additional codes are made through the ICD-10-PCS Coordination and Maintenance process.

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Endoscopic Banding of Esophageal Endoscopic Banding of Esophageal VaricesVarices

• MS-DRG 432 Cirrhosis & alcoholic hepatitis w/ MCC

• Cost weight: 01.7150

• 571.2 Alcoholic cirrhosis

• 456.20 bleeding esophageal varices

• 42.33 endoscopic ligation esophageal varices

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Endoscopic Banding of Esophageal Endoscopic Banding of Esophageal VaricesVarices

• MS-DRG 981 Extensive O.R. procedure unrelated to principal diagnosis w/ MCC

• Cost weight: 4.9319

• K70.30 Alcoholic cirrhosis of liver without ascites

• I85.11 Secondary esophageal varices with bleeding

• 06L34CZ Occlusion of esophageal vein with extraluminal device, percutaneous endoscopic approach.

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Root Operation for Bone Marrow Root Operation for Bone Marrow Biopsy Q4 2013Biopsy Q4 2013

• Question:

• What is the ICD-10-PCS root operation for bone marrow biopsy?

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Root Operation for Bone Marrow Root Operation for Bone Marrow Biopsy Q4 2013Biopsy Q4 2013

• Answer:

• Biopsy of bone marrow is coded to the root operation “Extraction” with the qualifier “Diagnostic.”

• Biopsy procedures are coded using the root operations: “Excision,” “Extraction,” or “Drainage,” and the qualifier “Diagnostic.”

• The qualifier “Diagnostic” is used only for biopsies.

• Please note: a specific index entry for “bone marrow biopsy” has been added to the ICD-10-PCS, and a new guideline for biopsy has been included in the ICD-10-PCS Official Guidelines for Coding and Reporting.

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Bone Marrow BiopsyBone Marrow Biopsy

• Biopsy

• see Drainage with qualifier Diagnostic

• see Excision with qualifier Diagnostic

• Bone Marrow see Extraction with qualifier diagnostic

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History of Ductal Carcinoma in Situ History of Ductal Carcinoma in Situ Q1 2012Q1 2012

• Question:

• Should code V10.3, Personal history of malignant neoplasm, Breast, be reported for history of ductal carcinoma in situ (DCIS) of the breast?

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History of Ductal Carcinoma in Situ History of Ductal Carcinoma in Situ Q1 2012 Q1 2012

• Answer:

• No, code V10.3 is not correct. Assign code V13.8, Personal history of other diseases, other specified diseases, for history of DCIS. It is not appropriate to assign code V10.3, Personal history of malignant neoplasm of breast, since DCIS (code 233.0) is not classified as a primary malignancy. Code V10.3 is reserved for personal history of “primary” breast malignancy for conditions classifiable to 174 and 175, as the inclusion note under code V10.3 indicates.

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Heart Failure with Preserved or Reduced Heart Failure with Preserved or Reduced Ejection Fraction Q1 2014Ejection Fraction Q1 2014

• Question:• If a physician documents heart failure with - preserved ejection fraction (HFpEF), or - preserved systolic function, or alternatively - reduced ejection fraction (HFrEF), - low ejection fraction, - reduced systolic function, or - other similar terms-

• Can the coder assume the physician means “diastolic heart failure” or “systolic heart failure,” respectively, and apply the proper ICD-9-CM code based on the documented clinical circumstances?

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Heart Failure with Preserved or Reduced Heart Failure with Preserved or Reduced Ejection Fraction Q1 2014Ejection Fraction Q1 2014

• Answer:

• No, the coder cannot assume either diastolic or systolic failure or a combination of both, based on these newer terms.

• Therefore, query the provider to clarify whether the patient has diastolic or systolic heart failure.

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Immune Thrombocytopenic Purpura and Immune Thrombocytopenic Purpura and Pancytopenia Q1 2014Pancytopenia Q1 2014

• Question:

• When a patient has both immune thrombocytopenic purpura and pancytopenia, are both conditions coded?

• Or, does the rule for not coding thrombocytopenia with pancytopenia apply?

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Immune Thrombocytopenic Purpura and Pancytopenia Q1 2014

• Answer:

• Assign both codes 287.31, Immune thrombocytopenic purpura, and 284.19, Other pancytopenia, for immune thrombocytopenic purpura and pancytopenia. Although code 284.19 includes a deficiency in the number of platelets in the body, it does not identify that the patient has immune thrombocytopenic purpura.

• Therefore, code 287.31 is needed to identify this condition.

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Traumatic Urinary Catheterization Q1 2014Traumatic Urinary Catheterization Q1 2014

• Question:

• The patient was admitted to the hospital for treatment of multiple injuries. In the ER, the patient experienced a urethral injury as a result of an unsuccessful traumatic Foley catheter insertion. This resulted in bloody output from the urethra and urology was consulted for this issue.

• In the final diagnostic statement the provider listed, “Traumatic Foley catheterization.” How should this diagnosis be coded?

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• Answer:

• In this case, injury to the urethra was a result of the procedure.

• Assign codes 997.5, Urinary complications, and 867.0, Injury of pelvic organs, bladder and urethra, without mention of open wound into cavity, and E870.8, Misadventures to patient during surgical and medical care, Other specified medical care.

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• A traumatic catheterization would not be coded unless there is documentation of a specific complication or injury. If the extent of the traumatic catheterization is questionable, query the physician as to the extent of the injury to the urethra.

• Additionally, the bleeding would not be coded separately since it is considered inherent to the injury.

• This is a different situation than that published in Coding Clinic, November-December 1985, page 15, where the patient pulled out his own catheter, and an injury code was assigned instead of a complication code.

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• Question:

• The patient was admitted for surgical treatment of rectosigmoid cancer. A Foley catheter was inserted prior to surgery. After surgery, the provider noted red blood cells in the urinalysis. However, there was no documentation of a complication or injury related to the catheter insertion.

• How would this be coded?

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• Answer:

• Do not assign a complication or injury code. Although red blood cells may be present in the urinalysis following urinary catheter insertion, this does not necessarily indicate a complication and/or injury. Unless the physician documents traumatic catheterization with a specific injury or complication it is not coded as such.

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Questions?Questions?

Barry Libman, MS, RHIA, CDIP, CCS, CCS-PPresident, Barry Libman Inc.President, Libman Education

[email protected]

www.BarryLibmanInc.comwww.LibmanEducation.com

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Selected Topics from Coding Clinic NYHIMA's 79th Annual Conference June 2, 2014 Barry Libman, MS,...

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