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Take Control of post-operative bleeding in ICD-10-PCS

A patient undergoes a hysterectomy and experiences post-procedural bleeding. The surgeon cauterizes the bleed and evacuates a blood clot.

guidelines01_53597356In ICD-10-PCS, how do you code the cauterization? With the root operation Control (third character 3).

Control (stopping, or attempting to stop, postprocedural bleeding) in ICD-10-PCS represents a very limited set of procedures. You will use root operation Control when the only objective of the procedure is to stop hemorrhaging after a procedure.

Procedures that fall under Control include:

  • Irrigating or evacuating a hematoma at the operative site
  • Ligation of arterial bleeders
  • Cautery with blood clot evacuation
  • Drainage at previous operative site to stop bleeding

The site of the bleeding is coded as an anatomical region and not to a specific body part. For our patient with the post-hysterectomy bleed, we would report 0W3R8ZZ (hysteroscopy with cautery of post-hysterectomy oozing and evacuation of clot).

Other Control procedures include:

  • 0X3F0ZZ, open exploration and ligation of post-op arterial bleeder, left forearm
  • 0W3H0ZZ, control of post-operative retroperitoneal bleeding via laparotomy
  • 0W3C0ZZ, reopening of thoracotomy site with drainage and control of post-op hemopericardium
  • 0Y3F4ZZ, arthroscopy with drainage of hemarthrosis at previous operative site, right knee

What happens when the physician needs to perform a more involved procedure to stop the bleeding? For example, a physician needs to resect the spleen in order to control post-procedural bleeding. Do you report a Control procedure, a Resection procedure, or both?

According to ICD-10-PCS guideline B3.7:

If an attempt to stop post-procedural bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.

So for our patient who lost her spleen, we would report 07TP0ZZ (resection of spleen, open approach) or 07TP4ZZ (resection of spleen, percutaneous endoscopic approach).

Back to infect: mumps and whooping cough

Don’t look now, but mumps are making a comeback. How do we code mumps in ICD-10-CM?

plague germsPretty much the same way we code them in ICD-9-CM. The codes just look a little different.

In ICD-10-CM, we can assign one of the following codes for a patient with mumps:

  • B26.1, mumps orchitis
  • B26.1, mumps meningitis
  • B26.2, mumps encephalitis
  • B26.3, mumps pancreatitis
  • B26.8, mumps with other complications
  • B26.9, mumps without complication

One difference you’ll find is an increase in the named complications of mumps. In ICD-9-CM, we have codes for mumps hepatitis, mumps polyneuropathy, and other.

ICD-10-CM specifies these complications:

  • B26.81, mumps hepatitis
  • B26.82, mumps myocarditis
  • B26.83, mumps nephritis
  • B26.84, mumps polyneuropathy
  • B26.85, mumps arthritis
  • B26.89, other mumps complications

Well, that’s not so bad.

What about whooping cough (also known as pertussis), another reappearing disease?

In ICD-9-CM and ICD-10-CM, we see separate codes for whooping cough due to Bordetella, but ICD-10-CM specifies the type of Bordetella:

  • A37.0, whooping cough due to Bordetella pertussis
  • A37.1, whooping cough due to Bordetella parapertussis
  • A37.8, whooping cough due to other Bordetella species
  • A37.9, whooping cough, unspecified species

Each of those categories includes two subcategory codes to identify whether the patient has pneumonia as well. In ICD-9-CM, we needed a second code to identify the pneumonia.

Don’t worry about getting confused on this change. An Excludes1 note (not coded here) under ICD-10-CM category J17 (pneumonia in diseases classified elsewhere) tells us not to use a code from A37 and one from J17 together.


Take a look around with ICD-10-PCS root operation Inspection

Sometimes a physician just needs to take a look around a body part and see what’s what. If the physician’s sole objective is to examine a body part, either visually or manually, report the procedure using root operation Inspection (third character J).

guidelines01_53597356Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers.

If the physician discontinues a procedure before performing any other root operation, you would also report the procedure using root operation Inspection.

Examples of Inspection include:

  • 0WJ90ZZ, thoracotomy with exploration of right pleural cavity
  • 0CJS8ZZ, diagnostic laryngoscopy:
  • 0SJD0ZZ, exploratory arthrotomy of left knee:
  • 0UJD8ZZ, colposcopy with diagnostic hysteroscopy:
  • 0DJD7ZZ, digital rectal exam

One other thing to keep in mind: if the physician begins a procedure laparoscopically and must convert it to an open procedure, report the laparoscopic procedure is reported as an inspection.

For example, the surgeon begins a cholecystectomy using a laparoscopic approach, but must complete it using an open approach. Report an open cholecystectomy (0FT40ZZ) and a percutaneous endoscopic inspection of the gall bladder (0FJ44ZZ).

If the physician inspects the body part(s) to achieve the objective of a procedure, do not code the inspection separately.

If the physician inspects multiple non-tubular body parts in a region, report the body part that specifies the entire area inspected.

Things to consider as you move forward with ICD-10 plans

We know we’re facing at least a one-year delay in ICD-10 implementation. What you with that time? will directly affect how prepared you are for the eventual ICD-10 implementation.

guy with question marks (2)Here are some things to consider:

Coder training: How far along are you? Are all of your coders trained? Are they in the process of being trained? How are you going to keep their skills sharp until they actually start coding in ICD-10? If you are currently dual coding, will you continue to do so? You can use this extra time to add to coders’ clinical knowledge and comfort level with ICD-10.

Documentation: Here’s where you can really use the delay to your advantage. Start updating your EHR and query forms now. You have more time to make changes and get physicians used to the changes. Not sure where your physician documentation is falling short? You have more time to pinpoint the biggest problem areas, but you need to take advantage of the extra time.

Leadership buy-in (and, of course, money): Did you have trouble getting your CFO on board with spending lots of money to revamp everything for ICD-10? He or she is probably not very happy right now. Don’t let the leadership slack off on ICD-10 implementation plans.

Physician engagement: This is probably one of the biggest hurdles to ICD-10 implementation. A lot of organizations struggled to get physicians engaged in learning documentation requirements for ICD-10 before this latest delay. I think the problem is only going to get worse. Physicians will drag their heels and say, “why should I learn this? It’s never going to be implemented.” Before you talk with your physicians, make sure you have answers ready. Explain why ICD-10 is better (more specificity, better clinical picture of the patient, use of physician terminology—think asthma descriptions). Tell them how it will help their ratings and improve patient care. Stress that we don’t want them to code, we just want them to completely and accurately document their patients’ conditions and the procedures they performed.

We have two choices when it comes to this delay: put our ICD-10 preparations on hold (not really a good plan) or find ways to use the extra time to our advantage.

Make this extra time a gift

What a wild 12 days. On March 25, we were all preparing for the six-month-to-implementation milestone April 1. Some people were looking forward to that milestone more than others, but we had a plan.

guy with question marks (2)Then Congress got involved. Late March 25, the House introduced a bill designed to patch the Sustainable Growth Rate (SGR) for physician payments for another year. Okay, big deal, Congress has been punting on fixing the SRG for more than a decade. Only this year, someone slipped in a killer line:

The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets  as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal Regulations. 

Through some shady maneuverings, the House passed the bill on a voice vote March 27 when most of the representatives appeared to be out of the chamber. We have no idea who voted for or against the bill. In fact, we’re not even sure who voted.

After a weekend to mull the possibilities, the Senate passed the bill March 31 by a 64-35 margin. President Obama signed it into law April 1. How I wish that were a joke.

So where does that leave us?

Well, we are still without a new ICD-10 implementation date. Make no mistake, ICD-10 is coming. We’re just back to not knowing exactly when.

The transition to ICD-10 “remains inevitable and time-sensitive because of the potential risk to public health and the need to track, identify, and analyze new clinical services and treatments available for patients,” according to an AHIMA statement.

CMS is still considering a new date. The congressional bill doesn’t stipulate a new date. It just says HHS can’t mandate ICD-10 before October 1, 2015.

We also don’t know what will happen with the American Hospital Association’s (AHA) Coding Clinic. The AHA stopped accepting ICD-9 questions in January and was shifting to answering solely ICD-10 questions. Will Coding Clinic start accepting ICD-9 questions again? According to the AHA, staff members are currently evaluating how they will move forward. Stay tuned.

AHIMA, AAPC, AHA, the Association for Clinical Documentation Improvement Specialists (ACDIS), and CMS are all stressing the same message: Don’t stop your implementation plans.

In 2012, when CMS delayed ICD-10 implementation from October 1, 2013, to October 1, 2014, many organizations put the brakes on their implementation plans. That turned out to be a big mistake, because many organizations reported having trouble regaining the momentum they lost. Now we get to find out how well we learned that lesson.

Organizations still need to figure out some other things, and while I would love to be able to give you a clear-cut, here-is-what-you-do plan, I can’t. Every organization is different. What works for a big health system won’t fly at a small physician practice. So you need to think about where you are right now, what you still need to accomplish before implementation, and how long it will take to complete that work. Then create a reasonable plan with milestones and measureable goals and use this delay to your advantage.

What goes on the baby’s chart?

If you code for pregnant patients and newborns, you may occasionally wonder which record to code a condition on. Is it something you code for the mother or for her offspring?

crying babyICD-10-CM divides the codes into two different chapters:

  • Chapter 15, Pregnancy, Childbirth and the Puerperium (O00-O9A). These codes are only used on the mother’s record.
  • Chapter 16, Certain Conditions Originating in the Perinatal Period (P00-P96). These codes are only reported for the newborn. These codes include conditions that have their origin in the fetal or perinatal period (before birth through the first 28 days after birth) even if morbidity occurs later.

Make sure you code all clinically significant conditions noted on a routine newborn examination. A condition is clinically significant if it requires any of the following:

  • Clinical evaluation
  • Therapeutic treatment
  • Diagnostic procedures
  • Extended length of hospital stay
  • Increased nursing care and/or monitoring
  • Has implications for future health care needs

What types of problems can newborns have? Well, the baby may arrive too early. We would use codes from category P07.3- to report 28 completed weeks or more but less than 37 completed weeks (196 completed days but less than 259 completed days) of gestation.

We have nine different choices to specify exactly how early our bundle of joy arrived, plus an unspecified code. If the newborn arrives at 31 weeks, four days, we would report P07.34.

Maybe our baby is underweight for gestational age. ICD-10-CM includes codes for:

  • P07.0-, extremely low birth weight newborn
  • P07.1-, other low birth weight newborn

The codes in these categories specify weight ranges. So if the newborn weighs 850 grams at birth, we would report P07.03 (extremely low birth weight newborn, 750-999 grams).

So we have a preemie with a low birth weight. Which condition do we sequence as the principal diagnosis for the birth encounter? It’s a trick question because the answer is neither. When coding the birth episode in a newborn record, we will always assign a code from category Z38.- (liveborn infant) as the principal diagnosis. Birth takes precedence.

Z38.- still gives us plenty of options and we need some specific details to choose the correct code. First, how many babies? Where did the baby arrive? How was the baby delivered? You could conceivably have a different place and method if mom is delivering more than one baby.

For example, if mom gives birth to twins in the hospital, she could deliver one vaginally (Z38.30) and one by cesarean (Z38.31).

Alternately, she could have one on the way to the hospital (Z38.4, twin liveborn infant, born outside hospital) and one vaginally in the hospital. Don’t assume it will be the same for each infant in a multiple birth.

Chapter 16 codes may be used throughout the life of the patient if the condition is still present.

Senate approves bill that includes ICD-10 delay

news blocksThe Senate passed HR 4302 designed to patch the Sustainable Growth Rate that included a provision to delay ICD-10 implementation until at least October 1, 2015. The bill, approved by the House in a controversial voice vote March 27, passed by a 64-35 margin. The Senate needed at least 60 yes votes to pass the bill.

President Obama must still sign the bill into law, but he is expected to do so.

The wait is on

The fate of the October 1, 2014 ICD-10 implementation date will remain in limbo until Monday.

The House of Representatives passed HR 4302 Thursday as a one-year fix to the Sustainable Growth Rate (SGR). Tucked into the bill was one sentence that could significantly impact the healthcare industry:

The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets  as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal Regulations.

The Senate is now expected to vote on the same bill Monday around 2 p.m. (Eastern).

question marksNo one seems quite sure who introduced the delay language into the bill, which is a compromise bill worked out by House and Senate leadership. The idea for the delay could have come from the AMA, which has been quite vocal in its opposition to ICD-10.

However, the AMA and numerous specialty societies sent a letter asking Congress NOT to pass this bill. They want a permanent fix to the SGR. They almost got one, too. The House passed a bill March 14 that would have fixed the SGR, but the Senate failed to pass it. Hence, the compromise with the additional language to delay ICD-10.

I actually feel kind of bad for CMS (never thought I would say that). The agency’s representatives have repeatedly and forcefully stated CMS was not changing the implementation date. Now, it might not have a choice. Congress could force CMS to change the date and at that point, who will take a new implementation date seriously?

And speaking of a new implementation date, notice that the language in the bill says CMS may not require ICD-10 “prior to October 1, 2015.” That doesn’t mean October 1, 2015, would be the new implementation date. So the date could get pushed back to 2016 or 2017. It will also reignite the debate about whether we should just wait for ICD-11. (Um, NO, we absolutely should not.)

AHIMA quoted a CMS estimate that a one-year delay could cost the industry between $1 billion and $6.6 billion. Healthcare providers are already feeling the pinch of budget constraints now and have spent literally billions on preparations so far. Who has the extra money to retrain coders and CDI and physicians when they have already provided training this year?

We would also be looking at a longer code freeze. The last regular update for ICD-9-CM happened back in 2011. If ICD-10 is delayed again, we’re looking at no new codes until at least October 2016.

During the House debate, no one talked about ICD-10, they all talked about the SGR. I fear the same will happen in the Senate. Because Congress doesn’t want to face the specter of a 24% cut in physician payments scheduled to hit April 1, the Senate will probably pass the SGR one-year fix. Which means they will probably also mandate the ICD-10 delay.

Hopefully, CMS, AHIMA, and like-minded organizations can do some wining and dining (and maybe some arm twisting) over the weekend to get the ICD-10 delay language removed. Sadly, I’m not optimistic.


House passes bill that includes ICD-10 delay

The House of Representatives passed HR 4302 today using a controversial surprise voice vote, bringing another ICD-10 delay closer to reality.

news blocksHR 4302 focuses on patching the Sustainable Growth Rate (SGR) for physician Medicare payments. Someone inserted a line in the bill that would prohibit CMS from implementing ICD-10 prior to October 1, 2015.

The House passed a bill to permanently fix the SGR March 14 by delaying portions of the Affordable Care Act, but the bill did not get passed in the Democrat-controlled Senate.

Thursday morning, members of the House debated the bill without mentioning the ICD-10 delay. All of the discussion focused on fixing the SGR.

The bill appeared to be on hold Thursday morning because the House did not have a quorum. However, the House took an unexpected recess that allowed Republican leaders to round up the votes needed to pass the bill.

The Senate is expected to vote on the bill tomorrow.

Will Congress force another ICD-10 delay?

CMS may be committed to an ICD-10 implementation date of October 1, 2014, but Congress may think otherwise.

news blocksHouse of Representatives bill H.R. 4015 is designed to patch the Sustainable Growth Rate formula that dictates Medicare reimbursement rates for physicians. However, it also includes the following language in Section 212:

The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets  as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal Regulations.

The language does not appear in a March 14 version that House members debated. It was added later.  This bill was negotiated at the leadership level in the House and Senate, and it is expected that there will be no debate before calling the bill to vote, according to AHIMA.

This is not the first time Congress has attempted to delay ICD-10 implementation, but it may be the one that works. Unlike previous attempts, such as the Cutting Costly Codes Act introduced in 2013, H.R. 4015 is not focused on ICD-10 implementation. The delay language appears to be just added in as a way to get it passed.

The House is expected to vote on the bill tomorrow (March 27). Even if the bill passes the House, it would still need to pass the Senate. Keep in mind, though, that if Congress doesn’t act before March 31, physicians face a 24% reduction in Medicare payments.

CMS estimates that a one-year delay to ICD-10 implementation could cost $1 billion to $6.6 billion, according to a statement from AHIMA officials.

”This is approximately 10-30% of what has already been invested by providers, payers, vendors and academic programs in your district,” AHIMA wrote in a statement. ”Without ICD-10, the return on investment in EHRs and health data exchange will be greatly diminished.”

A CMS representative declined to comment, saying the agency cannot comment on pending legislation.