April 2, 2014

Coding Clinic for ICDICD-1010-CM

Selected Topics from ICDICD-10 Coding Clinic

• Published quarterly by the AHA • Coding Clinic is the official publication for ICD-10-CM coding guidelines and advice as designated by the four cooperating parties:

LHIMA, April 2, 2014

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

AHA AHIMA CMS NCHS

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AHA Coding Clinic Advisor

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Coding Clinic transition timeline

Coding Clinic question submission

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

1) Visit www.CodingClinicAdvisor.com 2) Click on Log in/Register

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

3) Enter coding question 4) Include applicable back-up documentation

First Quarter 2014: - Last issue of Coding Clinic for ICD-9-CM will be published - First issue of Coding Clinic for ICD-10-CM and ICD-10PCS will be published

5) Submit 6) Submission confirmation will be sent with a tracking number 3

Coding Clinic transition

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Today’ Today’s topics Assigning Codes Using Prior Encounters Q3 2013

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-9CM and would not be readily applicable to ICD10-CM/PCS.

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 Injection of Sclerosing Agent into an Esophageal Varix Q1 2013 Root Operation for Bone Marrow Biopsy Q4 2013 Encounter for Dialysis Q4 2013 5

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April 2, 2014

Assigning Codes Using Prior Encounters Q3 2013

Assigning Codes Using Prior Encounters Q3 2013 Answer:

Question:

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

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?

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.

Does each visit or admission stand alone?

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.

Would the coder go back to previous encounter records to assist in the coding of a current visit or admission? 7

Assigning Codes Using Prior Encounters Q3 2013

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Decompensated Systolic Heart Failure Q2 2013

Answer (continued):

Question:

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.

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

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.

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?

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

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Decompensated Systolic Heart Failure CC Q2 2013

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Diabetes and Osteomyelitis Q4 2013

Answer:

Question:

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

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.”

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

Is the same relationship between diabetes and osteomyelitis true for ICD-10-CM? 11

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April 2, 2014

Diabetic Mellitus with Hyperglycemia Q3 2013

Diabetes and Osteomyelitis Q4 2013 Answer:

Question:

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

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

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

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 Q3 2013

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Diabetes with Ketoacidosis Q3 2013 Question:

Answer:

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?

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.

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?

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

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 Mellitus Type 2 with Ketoacidosis Q1 2013

Diabetes with Ketoacidosis Q3 2013 Answer:

Question:

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

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

Assign only code E10.10, Type 1 diabetes mellitus with ketoacidosis without coma. Ketoacidosis signifies uncontrolled diabetes.

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April 2, 2014

Diabetes Mellitus Type 2 with Ketoacidosis Q1 2013

Pneumonia and Hemoptysis Q4 2013

Answer:

Question:

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

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

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.

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

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. 19

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Healthcare Acquired (Nosocomial (Nosocomial)) Condition Q4 2013

Pneumonia and Hemoptysis Q4 2013

Question:

Answer:

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.

Sequence the appropriate code for the pneumonia first. Assign code R04.2, Hemoptysis, as an additional code when the condition occurs with pneumonia.

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.

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.

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? 21

Healthcare Acquired (Nosocomial (Nosocomial)) Condition Q4 2013

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Endoscopic Banding of Esophageal Varices Q4 2013

Answer:

Question:

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

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.

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

What is the appropriate ICD-10-PCS body system for esophageal varices: gastrointestinal system or lower veins? 23

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April 2, 2014

Endoscopic Banding of Esophageal Varices Q4 2013

Endoscopic Banding of Esophageal Varices Q4 2013

Question (continued):

Answer:

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);

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.”

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.

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

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

The index under ligation states “See occlusion.”

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Endoscopic Banding of Esophageal Varices Q4 2013

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Injection of Sclerosing Agent into an Esophageal Varix Q1 2013

Answer (continued):

Question:

Assign the following ICD-10-PCS code:

What is the ICD-10-PCS code assignment for injection of a sclerosing agent into an esophageal varix of the lower esophagus?

• 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 27

Injection of Sclerosing Agent into an Esophageal Varix Q1 2013

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Root Operation for Bone Marrow Biopsy Q4 2013

Answer:

Question:

Assign code 3E0G8TZ, Introduction of destructive agent into upper GI, via natural or artificial opening endoscopic, for the injection of a sclerosing agent into the esophageal varix.

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

This is the correct code assignment, since the application of a sclerosing agent via injection into a varix prevents bleeding rather than destroying tissue. In ICD-10-PCS, the root operation “destruction” is defined as physical eradication of all or a portion of a body part by the direct use of energy, force or a destructive agent. Conversely, the root operation “introduction” is defined as putting in or on a therapeutic, diagnostic, nutritional, physiological, or prophylactic substance except blood or blood products.

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April 2, 2014

Root Operation for Bone Marrow Biopsy Q4 2013

Encounter for Dialysis Q4 2013

Answer:

Question:

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

There does not appear to be a counterpart ICD-10CM code to the ICD-9-CM code V56.0, Encounter for Extracorporeal dialysis.

• Biopsy procedures are coded using the root operations: “Excision,” “Extraction,” or “Drainage,” and the qualifier “Diagnostic.” • The qualifier “Diagnostic” is used only for biopsies.

How should a patient encounter for hemodialysis be coded?

• Please note that 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.

Should it be coded to End Stage Renal Disease (ESRD)? 31

Encounter for Dialysis Q4 2013

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Questions?

Answer: Barry Libman, MS, RHIA, CDIP, CCS, CCS-P President, Barry Libman Inc. President, Libman Education 978-369-7180 [email protected]

Yes, you are correct. There is no ICD-10-CM counterpart to the ICD-9-CM code V56.0. For an encounter for dialysis, assign the appropriate code for the underlying disease/reason for the dialysis.

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Do not assume that the patient has ESRD. Hemodialysis may be used to treat acute renal failure as well as chronic kidney disease. 33

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