RSSAll Entries in the "ICD-10" Category

Q&A: Coding mixed cardiogenic and septic shock

Have CDI questions?

Have CDI questions?

Q: If the attending documented, “likely mixed cardiogenic and septic shock,” can I assign codes R57.0 and R65.21?

A: Refer to the documentation within the code book. If you open the book to the R57 code grouping (Shock not elsewhere classified) listed below there is an Excludes1 note. Remember, Excludes 1 notes instruct us that we cannot use codes from this grouping with those listed within the Excludes 1 note. Cardiogenic shock (R57.2) falls within this grouping. Also listed is R65.2 septic shock. Purely relying on the coding conventions, I would conclude that we cannot code septic shock with cardiogenic shock. See the image below. [more]

Guest Post: New ICD-10-CM/PCS codes up the ante in coding compliance, part 3: Right heart failure

James S. Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Editor’s note: With the fiscal year 2018 ICD-10-CM/PCS codes released, Kennedy unpacked some of the compliance pitfalls and opportunities awaiting CDI and coding professionals when these new codes are implemented on October 1. Some of these issues may be addressed in the 2018 ICD-10-CM Official Guidelines for Coding and Reporting or the American Hospital Association’s Coding Clinic, Fourth Quarter, 2017, so be sure to compare Kennedy’s opinions with these documents. This article is part three in a three-part series. Click here to read parts one and two!

Right Heart Failure

Notice that we now have new codes for acute, chronic, and acute-on-chronic right heart failure. Remember also that Coding Clinic, Third Quarter, 2013, p. 33, states that the documented term of “decompensated” indicates that there has been a flare-up (acute phase) of a chronic condition. [more]

Guest Post: New ICD-10-CM/PCS codes up the ante in coding compliance, part 2: Pediatric Glasgow coma scales

James S. Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Editor’s note: With the fiscal year 2018 ICD-10-CM/PCS codes released, Kennedy unpacked some of the compliance pitfalls and opportunities awaiting CDI and coding professionals when these new codes are implemented on October 1. Some of these issues may be addressed in the 2018 ICD-10-CM Official Guidelines for Coding and Reporting or the American Hospital Association’s Coding Clinic, Fourth Quarter, 2017, so be sure to compare Kennedy’s opinions with these documents. This article is part two in a three-part series. Click here to read part one. Return to the blog next week to read part three!

Pediatric Glasgow coma scales

In what should have been a welcome change, the National Center for Health Statistics amended the ICD-10-CM Alphabetic Index to allow for reporting of the clinical descriptors of the pediatric Glasgow coma scale. Notice that in the best motor response section, “flexion to pain” gets three points in the clinical scale whereas “withdrawal from pain” gets four points. Now notice how ICD-10-CM manages these conditions in 2018: [more]

Note from the Instructor: Your 2018 IPPS Final Rule questions, answered

Allen Frady

Allen Frady, RN-BSN, CCDS, CCS, CRC

By Allen Frady, RN-BSN, CCDS, CCS, CRC

Yesterday, 845+ codes took effect thanks to the fiscal year 2018 IPPS Final Rule, which was released at the beginning of August. As you review the updates, additions, and deletions in this year’s rule, I wanted to answer some of your burning questions to help guide you through this transition.

1.) Is it true that chronic obstructive pulmonary disease (COPD) does not have to be sequenced before pneumonia?

The Index for 2017 had the language “use additional code to identify infection.” This was misinterpreted as applying to conditions such as pneumonia by both coders using the index and the AHA’s Coding Clinic. “Use additional code” means that a subsequent diagnosis must be sequenced as a secondary code. However, “use additional code to identify infection,” usually means to assign an additional organism code from the organism code category of B95 to B97. [more]

Q&A: Reporting right-sided heart

SharmeBrodie_May2017

Sharme Brodie RN, CCDS, answered this week’s CDI question.

Q: If you have an acute exacerbation of a chronic right heart failure (CHF) with a preserved ejection fraction (EF)— above 55%—can you code it as heart failure with preserved EF? All the clinical symptoms are exemplifying right failure. For example, ascites, pronounced neck vein distension, swelling of ankles and feet, etc.

A: ICD-10-CM has codes associated with the documentation of right-sided failure and for left-sided failure. Each ventricle supplies different portions of the circulation, so heart failure can be described as either right or left depending on the symptoms. When the right ventricle fails, we call it right-heart failure. In this case, fluid backs up into the peripheral circulation, into the legs, head, and the liver. Right-sided or right ventricular (RV) heart failure usually occurs as a result of left-sided failure. [more]

Guest Post: New ICD-10-CM/PCS codes up the ante in coding compliance, part 1: Myocardial infarction

James S. Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Editor’s note: With the fiscal year 2018 ICD-10-CM/PCS codes released, Kennedy unpacked some of the compliance pitfalls and opportunities awaiting CDI and coding professionals when these new codes are implemented on October 1. Some of these issues may be addressed in the 2018 ICD-10-CM Official Guidelines for Coding and Reporting or the American Hospital Association’s Coding Clinic, Fourth Quarter, 2017, so be sure to compare Kennedy’s opinions with these documents. This article is part one in a three-part series. Return to the blog next week for the next installment! [more]

Guest Post: Altered mental status remains a challenge in ICD-10-CM – part 1

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

By James Kennedy, MD, CCS, CDIP

In ICD-10-CM, defining, diagnosing, and documenting the various forms of altered mental status and their underlying causes remains an ongoing challenge for physicians and their facilities.

Even the esteemed New England Journal of Medicine states that, “‘Altered mental status,’ a nonspecific term that is frequently used to describe alterations in alertness, cognition, or behavior, is commonly encountered in the emergency setting.” If you have a subscription or access through your medical library, review the discussion at www.nejm.org/doi/full/10.1056/NEJMcps1603154. [more]

TBT: Primary, principal, and secondary diagnoses

ask ACDISQ: Sometimes I confuse the secondary diagnosis for the primary diagnosis. Do you have any tips for me to help me discern better?

A: This question touches on several concepts essentially at the core of CDI practices. I think you are confusing three definitions:

  1. Primary diagnosis
  2. Principal diagnosis
  3. Secondary diagnosis

Let’s take each of these individually.

[more]

Guest Post: Improving the selection of a principal diagnosis

Commeree_Adrienne_web_106x121

Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP

by Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP

The selection of the principal diagnosis is one of the most important steps when coding an inpatient record. The diagnosis reflects the reason the patient sought medical care, and the principal diagnosis can drive reimbursement.

But while code selection may seem fairly straightforward in some cases, it can seem like throwing a dart at a board in others. Multiple factors must be considered and reviewed before a coder can assign a diagnosis as principal. There may be many reasons a patient went to the hospital, and multiple conditions may have been treated during that patient’s stay. Because of these complicating factors, relying solely on a software program to discern the principal diagnosis might lead to errors. A thorough review of the documentation, along with a solid understanding of the Official Guidelines for Coding and Reporting, instructional notes, and Coding Clinic issues, is imperative.

The ICD-10-CM Official Guidelines for Coding and Reporting state:

The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

The UHDDS collects data on patients related to race and ethnicity and is issued by the Centers for Disease Control and Prevention. Its definitions are used by acute care hospitals to report inpatient data elements that factor in the DRG classification system, which is how the hospital receives reimbursement for the inpatient admission.

Coders and CDI professionals must review all the documentation by the physician or any qualified healthcare practitioner who, per the coding guidelines, is legally accountable for establishing the patient’s diagnosis.

Parts of the medical record include the history and physical, progress notes, orders, consultation notes, operative reports, and discharge summary. While reading through a provider’s documentation, coders must ask themselves: “Is this condition requiring any diagnostic evaluation, therapeutic work, treatment, etc.?”

Once a medical record has been completely reviewed, coders must decide which code identifies the reason the patient was admitted and treated: What condition “bought the bed”?

But our work isn’t done after that. Are there any instructional notes or chapter-specific guidelines that give sequencing direction for coding? For example, if a patient is treated for decompensated diastolic congestive heart failure and also has hypertension, instructional notes within Chapter 9 of the ICD-10-CM manual, Diseases of the Circulatory System, give sequencing directives for the coding of these conditions.

“Decompensated,” according to Coding Clinic, Second Quarter 2013, indicates that there has been a flare-up (acute phase) of a chronic condition. I50.33 is the ICD-10-CM code for acute-on-chronic congestive heart failure. However, before assigning that code as the principal diagnosis, you must check the instructional notes directly under category I50 for heart failure. These notes, usually printed in red, give sequencing guidance for codes in this category.

Per the Official Guidelines for Coding and Reporting, “code first” informs coders that these conditions have both an underlying etiology and multiple body system manifestations due to that etiology:

“For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a ’use additional code’ note at the etiology code, and a ‘code first’ note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.

To code for the hypertension, the instructional notes guide the coder to reference code I11.0 (hypertensive heart disease with heart failure). More instructional guidance following the code helps the coder correctly assign the principal diagnosis for this patient.

But we’re still not done. Are there any issues of Coding Clinic that give more information regarding the assignment of a principal diagnosis? In reference to the example above, congestive heart failure with hypertension, documentation guidelines for reporting these two conditions have changed for 2017.

The Third Quarter 2016 Coding Clinic reiterates the documentation requirements and sequencing by stating that “the classification presumes a causal relationship between hypertension and heart involvement.”

The preceding example is one of many. A coder can have more than one diagnosis that fits the definition of a principal diagnosis, or possibly two diagnoses that are contrasting (either/or). If there are no chapter-specific guidelines for sequencing (is the patient pregnant? Does the patient have an HIV-related illness?), then refer to Section II, subsections B, C, D, and E, in the ICD-10-CM coding guidelines.

Editor’s note: This article originally appeared in JustCoding. Commeree is a coding regulatory specialist at HCPro in Middleton, Massachusetts. Contact her at acommeree@hcpro.com. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.

 

Guest Post: Relevant ICD-10 code proposals for CDI and coders

Allen Frady

Allen Frady, RN, BSN, CCDS, CCS

By Allen Frady, RN, BSN, CCDS, CCS

Editor’s note: The CMS ICD-10 Coordination and Maintenance Committee (CMC) met on March 7 and March 8 to discuss proposed code changes to ICD-10-CM and ICD-10-PCS. The committee is a federal committee comprised of representatives from CMS and the CDC’s National Center for Health Statistics (NCHS). The committee approves code changes, develops errata, addenda, and any other modification to the code sets. These code changes were discussed in hope of being amended in the 2018 code update, active October 1.

Among the many proposed changes to the code set, I noted 16 of particular interest to CDI specialists and coders. Remember, nothing is final until the September meeting of the CDC Coordination and Maintenance Committee(CMC), and of course, the CMS finalization.

AMI

Some of the most relevant talking points include possible changes related to heart disease. First, the CMC proposes reclassification of an unspecified acute myocardial infarction (AMI) to I21.9 AMI, including “unspecified myocardial infarction (acute) no otherwise specified (NOS).” Currently, “unspecified AMI” defaults to an STEMI. CDI specialists frequently prod physicians for additional specificity to ensure NSTEMI’s are not inadvertently reported as STEMI’s as it also affect quality standards.

Additionally, an unexpected proposal given the recent AHA Coding Clinic, First Quarter 2017, CMC proposes a new code I21.A1, Myocardial infarction type II (also called a Type II MI). Coding Clinic previously directed Type II MI to be coded as an NSTEMI. CMC’s proposal includes myocardial infarction due to demand ischemia and myocardial infarction secondary to ischemic imbalance as inclusion terms. The new proposed code would have a “code also underlying cause, if known” instructional note in the Tabular Index. Examples of precipitating events included in the proposal are:

  • anemia
  • chronic obstructive pulmonary disease (COPD)
  • heart failure
  • tachycardia
  • renal failure

There are, of course, other possible causes and the list provided is not intended to be comprehensive. This hopefully will circumvent the frustration CDI and coding professionals have had with the lack of an index entry for “Type II MI” for the last several years.

Other classifications of MIs exist. There are five in total and among the new code proposals for “other myocardial infarction type” specifies types 3, 4 and 5 as inclusion terms.

End-stage heart failure

Another interesting suggestion for the CDC comes from its recommendation for a new code for end-stage heart failure I50.84, to be used in conjunction with other heart failure codes. This represents potential for assignment to a higher level of severity within both the APR- and MS-DRG systems. There are also new inclusion notes for end-stage heart failure to be reported for the American College of Cardiology (ACC) stage “D” if the physician only writes “stage D heart failure,” it can be coded as end-stage heart failure. Furthermore, new inclusion terms direct the coder that diastolic heart failure and diastolic left ventricular heart failure include heart failure with preserved ejection fraction or with normal effusion. The same goes for systolic heart failure and the term reduced ejection fraction. Additional new codes related to heart failure include:

  • Acute right heart failure (I50.811) with an inclusion term of “acute ISOLATED RIGHT HEART FAILURE”
  • Biventricular heart failure (I50.82)
  • High output heart failure (I50.83)

I was somewhat unfamiliar with high output heart failure so for now, this reference from the National Institutes of Health will have to do:

“The syndrome of systemic congestion in a high output state is traditionally referred to as high output heart failure. However, the term is a misnomer because the heart in these conditions is normal, capable of generating very high cardiac output. The underlying problem in high output failure is a decrease in the systemic vascular resistance that threatens the arterial blood pressure and causes activation of neurohormones, resulting in an increase in salt and water retention by the kidney. Many of the high output states are curable conditions, and because they are associated with decreased peripheral vascular resistance, the use of vasodilator therapy for treatment of congestion may aggravate the problem.” 

Surgical codes

The CMC proposed a number of updates related to surgical wound infections. There are several new proposals for obstetrics infection codes and there were also proposals for other wound infection codes, such as:

  • 41, infection following a procedure, superficial surgical site which accounts for a stitch abscess.
  • Deep incisional site under T81.42
  • Intra-abdominal abscess under T81.43
  • Slow healing surgical wounds, covered in the includes notes for T81.84, NON-healing surgical wounds per changes to the inclusion notes.

Additional recommendations

CMC has a few other suggestions CDI and coding professional need to note, such as:

  1. Moving late effects of cerebral vascular accident (CVA) from an Excludes I to an Excludes 2 category, which seems appropriate in light of Coding Clinic, Fourth Quarter 2016, p. 40, as well as the 2017 Official Guidelines for Coding and Reporting, advice to override the Excludes 1 note and code late effects when present in tandem with a new current stroke, anyway.
  2. A new code for immunocompromised status which includes terms for immunodeficiency status and immunosuppressed status, Z78.2. ICD-10 code Z78.21 covers immunocompromised status due to conditions classified elsewhere such as HIV or cancer, and Z78.22 immunocompromised due to drugs. In the past, immunocompromised status did provide for additional severity and it’s role in risk adjustment methodologies could expand.
  3. Proposed codes for the pediatric coma scale which could eventually provide some additional severity for cases with catastrophic neurological compromise. In this author’s opinion, these codes would be a welcome additional to pediatric hospitals seeking to properly adjust for their quality, outcomes and mortality metrics.
  4. Codes for nicotine dependence via electronic nicotine delivery systems (e-sigs, anyone?).
  5. Proposals for alcohol abuse, in remission. Also noteworthy, the term “Alcohol use disorder” seems to fall under the codes for alcohol dependence per newly proposed inclusion terms. The same proposals are provided for opioid abuse, in remission as well as cannabis, cocaine, sedatives, etc.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps, click here. The views expressed do not necessarily represent those of ACDIS or its advisory board.