10/26/2014

Advanced Cardiac Coding with ICD-10-CM/PCS October 28, 2014 Karen Feltner, RHIA, CCS

Plan for Today What are we discussing today? • ICD-10-CM for cardiac diagnoses • ICD-10-PCS for circulatory system • Coding examples 2

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Latest on Implementation • Another delay was implemented with passage of H.R. 4302, Protecting Access to Medicare Act of 2014, mainly creates a temporary “fix” to the Medicare sustainable growth rate (SGR) on March 31, 2014. This act prohibits implementation before October 1, 2015 • This delay was not expected by CMS as evidenced by the announcement of no further delay in February 2014. 3

How Are They Similar? • ICD-9-CM and ICD-10-CM are alpha numeric. – ICD-9-CM uses alpha characters V and E as first character in some codes • Characters 2-5 are numeric – ICD-10-CM uses alpha and numeric characters. • The first character is an alpha character. • Character 2 is a numeric character. • Characters 3 through 7 may be alpha or numeric. • The letter U is not used in ICD-10-CM – A decimal is used after the third character for both coding systems. 4

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How They are Similar • ICD-9-CM and ICD-10-CM both have Tabular and Alphabetic index – Neoplasm table – Table of Drug and Chemicals – External cause code index

• Codes are found using same process – Main Term-condition, disease, injury – Subterm-more specific descriptors 5

How They are Similar • Conventions common to both systems – Boldface type – Italicized type – Includes Notes – Inclusion Notes – Abbreviations • NEC -Not Elsewhere Classifiable • NOS-Not Otherwise Specified 6

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More How They are Similar • Instructional notes – See notes-mandatory cross references • Must look elsewhere for correct code

– See also notes-recommended reference to alternate terms • More specific code may be found at alternate term

– Code First/Use Additional Code – Code Also 7

Structure of ICD-10-CM Codes • ICD-10-CM codes may consist of up to seven characters, with the seventh character extensions representing visit encounter or sequelae for injuries and external causes.

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What’s Different? • Two types of Excludes notes – Excludes1 notes – Excludes2 notes

• Codes may be incomplete in Index – How do we identify an incomplete code in the ICD-10-CM index? • Under main term Fracture, femur - - shaft (lower third) (middle third) (upper third) S72.30– – – –

- - - comminuted (displaced) S72.35- - - - nondisplaced S72.35- - - oblique (displaced) S72.33- - - - nondisplaced S72.33-

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Placeholder Character - X • The 7th character is required for some codes. • No 7th character = invalid code • What happens if the code does not have 6 characters and a 7th character is required • We now have a placeholder character- X used to fill the code as needed • The X is used to fill the code so the 7th character is in the 7th position. 10

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Hypertension No change in Official Coding Guidelines • ICD-9-CM • ICD-10-CM – Hypertension table • • • •

Malignant Benign Unspecified Hypertensive heart disease • Hypertensive chronic kidney disease • Hypertensive heart and chronic kidney disease

– No hypertension table • Hypertensive heart disease • Hypertensive chronic kidney disease • Hypertensive heart and chronic kidney disease 11

Hypertension • In ICD-10-CM, hypertension is coded I10 – None of these descriptors changes the code assignment: malignant, accelerated, benign, essential, idiopathic, uncontrolled, or systemic

• Hypertensive heart disease – Must be specified hypertensive or due to hypertension – Hypertension code assignment affected by presence of heart failure 12

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Hypertension • Hypertension and Chronic Kidney disease – Cause-and-effect relationship assumed if both hypertension and chronic kidney disease present – Additional code is used to identify stage of chronic kidney disease – Acute kidney failure is not included. 13

Hypertension • Hypertensive Heart and Chronic Kidney Disease – Coding guidelines are the same – If patient has chronic kidney disease and hypertensive heart disease, then a code from I13 hypertensive heart and chronic kidney disease – If heart failure is present, another code is required 14

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Hypertension • Hypertension and other conditions – Two codes required

• Secondary hypertension – Two codes required – Sequencing of the codes dependent on circumstances

• Postprocedural hypertension (I97.3) – Complication of surgery 15

Myocardial Infarction • Acute Myocardial Infarction – Time frame for acute = 4 weeks ICD-10-CM – Time frame for acute = 8 weeks ICD-9-CM

• Classification axis – ST elevation (STEMI) myocardial infarction • Codes specify wall involved or artery involved

– Non ST elevation (NSTEMI) myocardial infarction 16

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Myocardial Infarction • Acute Myocardial infarction – Nontransmural/subendocardial AMI coded as subendocardial – NSTEMI converts to STEMI is coded as STEMI – STEMI converts to NSTEMI due to intervention is coded STEMI – Code for the acute MI can be reported throughout the four weeks if patient requires care – If continued care required for the AMI after four weeks use aftercare code should be used 17

Subsequent MI I22 category • An AMI that occurs after the initial diagnosis but during the acute phase (4 weeks) of an AMI is coded from I22 category • Can be coded as NSTEMI or STEMI • Subsequent MI code requires reporting of the AMI code for initial MI also per coding guidelines (Chapter 9 Official Coding Guidelines I.C.9.e.4) • Sequencing would depend on circumstances of admission • Healed or old MI (asymptomatic) I25.2 18

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Myocardial Infarction • Risk Factors in ICD-10-CM – Z77.22 Exposure to environmental tobacco smoke – Z87.891 History of tobacco use – Z57.31 Occupational exposure to environmental tobacco smoke – F17.- Tobacco dependence • Further specified as to type of tobacco

– Z72.0 Tobacco use 19

Myocardial Infarction • AMI complications within 28 day period – I23.0 Hemopericardium – I23.1 Atrial septal defect – I23.2 Ventricular septal defect – I23.4 Rupture of chordae tendineae – I23.5 Rupture of papillary muscle – I23.6 Thrombosis of atrium, auricular appendage and ventricle – I23.7 Postinfarction angina – I23.8 Other complications

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Angina • ICD-10-CM has combination codes for ASHD with angina pectoris. – A second code for angina is not used with this code. – A causal relationship is assumed UNLESS the angina is documented as due to another cause

• Unstable angina-Code I20.0 is used as principal diagnosis if no underlying condition identified 21

Atherosclerosis • Atherosclerosis of coronary artery or bypass grafts – Codes specify presence or absence of angina • Use native coronary artery if no previous coronary bypass

– Codes for atherosclerosis of grafts or transplanted heart • Type of graft specified • Presence or absence of angina 22

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Cardiac Arrest • Can be listed as principal or first listed diagnosis if cause is not known • Can be coded if it occurs during the hospital stay • Note code descriptions vary– Cardiac arrest due to underlying cardiac condition – Cardiac arrest due to other underlying condition – Cardiac arrest cause unspecified. – Also codes for cardiac arrest during or after surgery • Detail includes type of surgery 23

Cerebrovascular Disease • Cerebral Infarction (I63) – Thrombosis, embolism , occlusion or stenosis – Also, which precerebral or cerebral artery – Infarction only coded if specified – Queries may be required to clarify the type and site of cerebral infarction – If specifics not available, use I63.9 Cerebral infarction, unspecified 24

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Dominant Side • From Official Coding Guidelines I.9.d.1 Codes from category I69, Sequelae of cerebrovascular disease, that specify hemiplegia, hemiparesis and monoplegia identify whether the dominant or nondominant side is affected. Should the affected side be documented, but not specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows: – For ambidextrous patients, the default should be dominant. – If the left side is affected, the default is nondominant. – If the right side is affected, the default is dominant 25

Stroke as Complication • ICD-10-CM provides codes for intraoperative and postoperative stroke – Must have cause-and-effect relationship documented – Codes vary depending on type of surgery • Nervous system procedure • Cardiac surgery • Other surgery

– Codes vary also based on whether intraoperative versus postoperative – Additional code used to specify type of stroke 26

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Sequelae or Current Deficit • Neurological deficits may occur at onset of the condition. • All neurological deficits are reported even if they clear before the patient is discharged. • I69 Sequelae codes are not used for current acute deficits with stroke • I69 are not used for sequelae of traumatic brain injuries 27

Sequelae • Late effect (ICD-9-CM) or Sequelae of cerebrovascular disease – Conditions that persist after initial stroke – Codes based on cause of sequelae and type of deficit • Maybe used as principal diagnosis when treatment of the sequalae is purpose of encounter • Maybe used as additional diagnoses 28

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What About Procedure Codes? • ICD-10-PCS has been created for coding of procedures-inpatient in most areas • Procedure codes are built based on type of service, body system and root operation. • Coders build the ICD-10-PCS code based on the appropriate table • Coders do not have to start at the index but can rather go directly to the table 29

ICD-10-PCS Features • Completeness—There is a unique code for all substantially different procedures. • Expandability—As new procedures are developed, the structure of ICD-10-PCS allows them to be easily incorporated as unique codes. • Multi-axial—ICD-10-PCS consists of independent characters, with each individual component retaining its meaning across broad ranges of codes to the extent possible. • Standardized terminology—ICD-10-PCS includes definitions of the terminology used. Each term is assigned a specific meaning. 30

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More about ICD-10-PCS • Conventions of the classification system require seven CHARACTERS in each code. • All numbers 0-9 are used as are all alphabetic characters EXCEPT the letter I and the letter O

1

2

3

4

5

6

7

Section Body System

Device

Root Operation Body Part

Qualifier

Approach

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Circulatory Body Systems Body System

Character

Heart and Great Vessels

2

Upper Arteries

3

Lower Arteries

4

Upper Veins

5

Lower Veins

6

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Third character = Root Operations Root operations that are bold are found in the Heart and Great Vessels body system Medical and Surgical Section Root Operations Alteration

Division

Inspection

Reposition

Bypass

Drainage

Map

Resection

Change

Excision

Occlusion

Restriction

Control

Extirpation

Reattachment

Revision

Creation

Extraction

Release

Supplement

Destruction

Fragmentation

Removal

Transfer

Detachment

Fusion

Repair

Transplantation

Dilation

Insertion

Replacement 33

Root Operation Examples • Bypass = Altering the route of passage of the contents of a tubular body part • Dilation= Expanding an orifice or the lumen of a tubular body part • Extirpation = Taking or cutting out solid matter from a body part • Restriction = Partially closing an orifice or lumen of a tubular body part 34

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Official Coding Guidelines • B3.6b Coronary arteries are classified by number of distinct sites treated, rather than number of coronary arteries or anatomic name of coronary artery. Coronary artery bypass procedures are coded differently than other bypass procedures. The body part identifies the number of coronary artery sites bypassed to, and qualifier specifies body part bypassed from. 35

Official Coding Guidelines • B3.6c If multiple coronary artery sites are bypassed, a separate procedure is coded for each coronary artery site that uses a different device and/or qualifier • Different types of grafts or qualifiers – Saphenous vein graft – Internal mammary artery – Radial artery graft 36

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Official Coding Guidelines • B3.9 If an autograft is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded. • Examples – Saphenous vein graft harvesting – Arterial graft harvesting

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Official Coding Guidelines • B3.12 If the objective of an embolization procedure is to completely close a vessel, Occlusion is coded. If the objective of an embolization procedure is to narrow the lumen of a vessel, the root operation Restriction is coded.

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Official Coding Guidelines • B4.2 Where a specific branch of a body part does not have its own body part value in PCS, the body part is coded to the close proximal branch that has a specific body part value • B4.4 The coronary arteries are classified as a single body part that is further specified by number of sites treated and not by name of the arteries. 39

What Does This All Mean? • Number of coronary artery sites bypassed, type of bypass graft used, origin of bypass and approach are used to determine the code for the bypass. • In order to code harvesting of the graft, one must know whether the greater or lesser saphenous veins on right or left side were used. If other veins or arteries are use, similar details are needed. • Cardiopulmonary bypass would also be coded if done 40

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PTCA and Stent Insertion •In ICD-9-CM, PTCA with insertion of one stent in one coronary artery, multiple codes are required. •00.66 •36.06 •00.40 •00.45 •In ICD-10-CM, fewer codes are required for the same procedure. Section

Body System

Root Operation

Body Part

Approach

Device

Qualifier

Med/Surg

Heart & Great Vessels

Dilation

One Coronary Site

Percutaneous

Intraluminal Device

None

0

2

7

0

3

D

Z

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Heart Catheterization • Heart Cath-In Index catheterization, heart, measurement cardiac 4A02 • Coronary angiogram-Index, angiography, heart – Two choices, plain radiograophy or fluoroscopy – Fluoroscopy=Single plane or bi-plane real time display of an image developed B21

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Heart Cath, continued • Note have multiple options for body part in B21 table for coronary vessels – Coronary artery, single – Coronary artery, multiple – Coronary artery bypass graft, single – Coronary artery bypass grafts, multiple – Internal mammary bypass graft, right – Internal mammary bypass graft, left – Bypass graft, other 43

Heart Cath, continued • Ventriculogram-Index Ventriculogram, cardiac-B21 table – Body Part Character 4 • Heart, right • Heart, left • Heart, right and left

• Need type of contrast used to build code (fifth character) – High osmolar – Low osmolar – Other contrast 44

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More Cardiac Diagnostics • Intraoperative fluorescence vascular angiography-see options for code in B21 table • EPS studies-see Measurement cardiac rhythm • Mapping of cardiac conduction is code beginning in table 02K in MedicalSurgical section

Defibrillators and Permanent Pacemakers

• Two codes for both procedures

– One for insertion of generator into subcutaneous tissue 0JH table – One for insertion of leads into heart 02H table – Codes for leads are based on where leads are placed-atrium, ventricle or both atrium and ventricle

• Cardiac Resynchronization Therapy-slightly different procedure – CRT-P (pacemaker) – CRT-D (defibrillator) – Leads coded separately

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Coding Example #1 • Patient readmitted following acute (STEMI) inferior myocardial infarction two weeks prior to this encounter. Heart catheterization revealed arteriosclerotic heart disease. Patient desired to have time at home before having coronary artery bypass surgery. He is admitted at this time for his first coronary artery bypass. He undergoes aortocoronary bypass using the greater saphenous vein graft to two left coronary artery sites. The left internal mammary artery was bypassed to one coronary artery site. Greater saphenous vein was excised for vein graft from the left leg endoscopy through small incision. Surgery was performed on cardiopulmonary bypass. The patient did well and was discharged home in good condition. He is noted to have hyperlipidemia and medications were continued for this diagnosis. 47

0 Medical and Surgical 2 Heart and Great Vessels 1 Bypass: Altering the route of the contents of a tubular body part

1

Body Part

Approach

Coronary artery, two sites

0 Open

Device 9

Autologous Venous Tissue

Qualifier W Aorta

Code: 021109W Bypass two sites with saphenous vein graft

Body Part 0

Coronary artery one site

Approach 0 Open

Device Z No Device

Qualifier 9 IMA, Left

Code: 02100Z9 Bypass one site with left internal mammary artery Cardiopulmonary bypass-see Index, Bypass, cardiopulmonary 5A1221Z Harvesting saphenous vein graft- see Index, Excision, saphenous vein 06B table 06BQ4ZZ

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Coding example #1 Answers • Diagnoses – ASHD (native vessels) I25.10 – Acute inferior MI (STEMI) I21.19 – Hyperlipidemia E78.5

• Procedure Codes – Vein graft bypass two coronary sites 021109W – Bypass LIMA to one site 02110Z9 – Excision greater saphenous vein, left 06BQ4ZZ – Cardiopulmonary bypass 5A1221Z 49

Coding Example #2 • Patient is 64 year old male with AAA. He is brought to the hospital for open AA repair with Dacron graft replacement. He is also known to have diabetes type 2 controlled with insulin. His diabetes was monitored and treated with sliding scale insulin. He also has degenerative joint disease in his lumbar spine which required treatment with medication. He had resection of his 5.3 cm AAA with graft replacement. 50

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Coding Example #2 • Diagnoses – – – –

AAA I71.4 Diabetes Type 2 E11.9 Long term Insulin use Z79.4 Degenerative joint disease, lumbar spine M47.816

• Procedure –Medical-Surgical-Lower arteries-Replacement-Abdominal Aortaopen-Synthetic Substitute-No qualifier – 04R00JZ 51

Coding example #3 Patient came to hospital with unstable angina. He was taken emergently to the cardiac cath lab and underwent left heart cath (percutaneous), coronary angiography, left ventriculogram via femoral artery puncture. (Low osmolar contrast used) Findings were near total occlusion of the RCA and 80% stenosis of the left circumflex. Decision was made to do PTCA and stent insertion. The RCA had angioplasty reducing the stenosis to 10%; a drug eluting stent was placed in the RCA. The left circumflex had angioplasty with placement of a stent. He tolerated the procedure well. He was monitored post operatively. He was instructed on smoking cessation related to his nicotine addiction, smoking 2 packs of cigarettes per day. Final diagnosis is unstable angina due to coronary arteriosclerosis and nicotine addiction. He will follow up in the office in two weeks. 52

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Coding Example #3 Answers • Diagnoses – Arteriosclerosis with unstable angina I25.110 – Tobacco addiction (cigarettes)F17.210

• Procedures – – – – –

Left heart catheterization 4A023N7 Coronary angiography B2111ZZ Left ventriculogram B2151ZZ PTCA RCA with drug eluting stent 027034Z PTCA Left circumflex with plain stent 02703DZ 53

Procedure Examples 1. Open right femoral popliteal bypass graft for severe peripheral vascular disease using goretex graft. – Root Operation: Bypass – 041K0JL

2. Right renal artery atherectomy, percutaneous, for renal artery stenosis – Root Operation: Extirpation – 04C93ZZ 54

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Questions-Comments

ICD-10-CM ICD-10-PCS 55

Resources • Basic ICD-10-CM/PCS and ICD-9-CM Coding, 2012 edition Lou Ann Schraffenberger, MBA, RHIA, CCS, CCS-P, FAHIMA , AHIMA • ICD-10-CM and ICD-10-PCS Coding Handbook 2014, Nelly Leon-Chisen, RHIA, AHA • ICD-10-PCS Official Coding Guidelines 56

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