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ICD-10-CM Coding for Home Health:

Intermediate/Advanced

Arlynn Hansell, PT, HCS-D, HCS-H, HCS-O, COS-C

Owner

Therapy and More, LLC

Cincinnati, OH1

Presented to the

April , 2019

Objectives1. Coding conventions and guidelines: Focus on the assumptions within the coding system.

2. Creating a compliant record and impact on Payment: Describe how documentation, OASIS,

coding all work together to affect payment.

3. Z codes versus Complications: Work on scenarios for assigning Z codes versus a complication code.

4. Sepsis: State the difference between Sepsis, SIRS, Septic Shock, and identify in documentation

correct infection verbiage for accurate coding.

5. Neoplasms & anemia: Identify when surgical aftercare is needed for neoplasms versus the diagnosis

itself

6. Diabetes: Demonstrate how to choose the right code when dealing with all the possible

manifestations.

7. Cardiopulmonary: Identify the complexities of combination coding of hypertension, heart failure,

CKD, and COPD versus emphysema.

8. CVA: Learn to choose the right code to identify the sequela of the disease

9. Poisoning and adverse effects: Identify the difference between poisoning and adverse effects, and

how to code these diagnoses in ICD-10.

2

Official Sources

• Official/Approved Coding Sources

• Official Coding Guidelines: published annually; effective every October 1st

• Coding Clinic: published quarterly by the American Hospital Association

• Subscription required

• Official Sources – NOT Official Coding Guidelines. These are allowed sources, but do not rise to the level of official coding guidelines.

• OASIS Guidance Manual

• CMS Q&As

• CMS Annual Final Rule

3

Official Coding Guidelines• ICD-10-CM Official Guidelines for Coding and Reporting were revised for 2019

(effective October 1, 2018) and can be found at:

• https://www.cdc.gov/nchs/icd/data/10cmguidelines-FY2019-final.pdf

• The conventions, general guidelines, and chapter-specific guidelines are applicable to all health care settings, unless otherwise indicated.

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Assigning DiagnosesGuidance, tips, and keys

5

Each encounter stands alone!

• Diagnoses must be based on documentation for the current encounter.

• The medical record must always reflect the patient’s current condition.

• The key to code selection is based on active treatment!

Example: An infected surgical wound being treated with antibiotics:• SOC: coded T81.4xxA.

• Recert: the wound still requires care, but the infection is no longer receiving active treatment (eg. Antibiotics, wound vac)

• Recert - coded T81.4xxD.

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The Provider

• In the context of the guidelines, the term provider is used throughout the guidelines to mean physician or other qualified heath care practitioner who is legally accountablefor establishing the patient’s diagnosis.

• Hospice clinicians and coders must work in collaboration with the Hospice medical director and/or attending physician to identify the patient’s related and non-related diagnoses.

• Document all communication with the physician related to diagnoses.

7

The Assessing Clinician

• The assessing clinician is responsible for selecting and sequencing the diagnoses, in conjunction with the physician to provide the best description of the patient’s condition.

• The coder is responsible for assigning the codes and ensuring that the coding is compliant with coding rules.

• The assessing clinician must agree with any changes to the coding made by the coder.

• Documentation of collaboration between the clinician, the physician, and the coder is imperative!

8

What would you do?

Mr. P was referred for care of a “wound” on his right ankle. The physician documentation notes “diabetic pressure ulcer.” The assessing clinician listed diabetes, pressure ulcer on ankle, then stage 2.

How would you code this? a) The same, since the assessing clinician is responsible for determining the diagnoses and

sequencing.

b) Sequence the pressure ulcer site first, the stage, and then the diabetes, since the focus is wound care to the ulcer.

c) Request physician clarification regarding the diagnosis before assigning the codes.

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What would you do? Answer

Mr. P was referred for care of a “wound” on his right ankle. The physician documentation notes “diabetic pressure ulcer.” The assessing clinician listed diabetes, pressure ulcer on ankle, then stage 2.

How would you code this?

a) The same, since the assessing clinician is responsible for determining the diagnoses and sequencing.

b) Sequence the pressure ulcer site first, the stage, and then the diabetes, since the focus is wound care to the ulcer.

c) Request physician clarification regarding the diagnosis before assigning the codes.

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Documentation, Compliance,Coding, and Billing

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Home care is a challenge!

• Increased emphasis on fraud and abuse and scrutiny of home health agencies’ compliance with regulations:

• Medicare coverage and eligibility

• Home Health PPS and HIPAA

• Coding and OASIS

• Coding, OASIS, and regulatory guidance updates never stop!

• Annual coding guidelines and code revisions – effective October 1st

• HH PPS Final Rule brings changes in case-mix points and assignment of codes to case-mix resource groups – effective January 1st

• Requirement for more specific documentation

• Pressure to “get it right” AND to increase revenue!

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5 Elements Critical to Compliance and the Final Claim

Documentation

Comprehensive Assessment and OASIS

Diagnosis Codes

Physician Orders

POC

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The OASIS and POC don’t justify care – documentation does!

• All 5 elements of home health care and services must support the claim submitted to Medicare.

• Elements are interrelated and co-dependent.

• Codes or OASIS responses do not automatically support medical necessity.

• Medical necessity is supported by the entirety of the medical record throughout the episode.

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It all must make sense together….

• All progress notes and case management coordination should match the focus of care from SOC through discharge.

• The documentation must support the codes.

• The conditions coded must be addressed in the POC.

• Without consistent and accurate documentation, accurate coding is impossible.

15

Conventions, Guidelines and

Instructions

16

Hierarchy of Importance

Conventions

and

Tabular instructions

Chapter-Specific Guidelines

General Coding Guidelines17

Conventions

Back it up: what does ICD-10-CM stand for: International Classification of Diseases, 10th Revision, Clinical Modification.

• Conventions are the general rules for use of the classification (again, the ICD-10-CM), independent of the guidelines (see slide 43).

• The conventions are incorporated within the Alphabetic Index and Tabular List as instructional notes.

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Conventions

and


Convention 6: Abbreviations: NEC and NOS

• NEC = Not elsewhere classifiable; other specified.

• NOS = Not otherwise specified; unspecified.

• For NEC codes, the specific condition must be linked to the main term and coded.

• Coding guidance states the “with” convention does not apply to “not elsewhere classified (NEC)” index entries that cover broad categories of conditions. Specific conditions must be linked by the terms “with,” “due to” or “associated with.”

• Coding professionals should not assume a causal relationship when the diabetic complication is “NEC.”

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Conventions

and


Convention 13: Etiology/Manifestation convention

• “Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying 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.”

• Per the Coding Clinic, this wording was an attempt to clarify that codes with the instruction to “code first” the underlying condition applies only if an underlying condition is actually present.

• Per the HH PPS Overview, v7218, Oct 2018, “If there is incorrect or invalid pairing of manifestation and etiology diagnosis codes, neither the etiology nor manifestation codes contribute to the score.” (Potential loss of reimbursement $$).

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Conventions

and


Convention 15: “With” or “In”• The term “with” or “in” should be interpreted to mean “associated with” or

“due to” when it appears in the code title, the Alphabetic Index, or an

instructional note in the Tabular List.

• The classification presumes a causal relationship between the two conditions

linked by these terms in the Alphabetic index or Tabular List.

• These conditions should be coded as related even in the absence of provider

documentation explicitly linking them, unless the provider documentation clearly

states the conditions are unrelated or when another guideline exists that

specifically requires a documented linkage between two conditions (e.g.,

sepsis guidelines for “acute organ dysfunction that is not clearly associated

with the sepsis”).

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Conventions

and


7th Character Clarification…

A, D, or S?

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Complications

• It is appropriate to assign the 7th character ‘A’ (initial encounter) to a complication code for home health or rehab, as long as the patient continues to receive activetreatment. Common to home health are:

– Antibiotic therapy for postoperative infection

• IV or oral

– Wound vac treatment of wound dehiscence

– Malunion or nonunion of fracture when the patient delayed seeking treatment

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“D” (Subsequent Encounter)

• 7th character “D,” subsequent encounter, is used for encounters after the patient has completed active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.

Examples of subsequent care in home health are:

– Follow-up visits following treatment of an injury or condition

– Care following a fracture without complications

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“S” (Sequela)

• Sequela versus Complication

• Sequela: occurs after the healing phase of the care or condition is complete. Think of this as the late effect.

• Complication: occurs while the patient is still healing from the care or condition

• There is no time limit for the development of a residual condition or when a sequela code can be used.

• A residual may be apparent early, such as with a cerebral infarction, or it may occur months or years later, such as that due to a previous injury.

• There may be more than one residual.

• The sequela may or may not have a 7th character of ‘S’.

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Look at this sequela scenario

Patient admitted for PT with an unsteady gait, caused by strabismus, a result of an intracranial abscess 6 months ago.

M1021a: R26.81, Unsteadiness on feet

M1023b: H50.9, Unspecified strabismus

M1023c: G09, Sequelae of inflammatory diseases of central nervous system

Index: Sequelae abscess, intracranial or intraspinal (conditions in G06) G09

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Sequela Manifestation Exception

• Some codes combine the presenting problem with the sequela in one code,

such as sequelae of cerebral infarction (stroke). • Facial droop and dysphagia due to a cerebral infarct

• I69.392 Facial weakness following cerebral infarction

• I69.391 Dysphagia following cerebral infarction

• R13.10 Dysphagia, unspecified

• Some sequelae are manifestation codes.• Cervical spondylopathy due to childhood rickets

E64.3 Sequelae of rickets

M49.82 Spondylopathy in diseases classified elsewhere, cervical region

The manifestation convention takes precedence over the sequela

guideline! Therefore, the sequela code must be sequenced first, since a

manifestation code may never be the first-listed or primary diagnosis.27

Sequelae Coding Practice

• Pseudobulbar affect resulting from a CVA

• Epilepsy following an intracranial injury

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Sequelae Coding Answers

• Pseudobulbar affect resulting from a CVA

• I69.398, Other sequelae of cerebral infarction

• F48.2, Pseudobulbar affect

• Convention to “Code first” underlying cause at F48.2 trumps the general coding

guideline which states to “Code first” the sequela.

• Epilepsy following an intracranial injury

• G40.909, Epilepsy, unspecified, not intractable without status epilepticus

• S06.9x0S, Unspecified intracranial injury without loss of consciousness, sequela

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OASIS Guidance

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M1021: Primary Diagnosis

• The chief reason for providing home care and the diagnosis most related to the current plan of care. Must be reflective of the F2F.

• The most “serious” condition that requires the most intensive skilled home health services.

• Best reflects the care being provided for the episode.

• May or may not be related to a recent hospital stay, but must relate to skilledservices (SN, PT, OT, SLP) provided by the home health agency.

• Consider services, medications, treatments, and procedures.

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M1023: Other Diagnosis

• Co-morbid conditions that:

• Exist at the time of the assessment;

• Are actively addressed in the POC; and

• Have the potential to affect the patient’s responsiveness to treatment and/or the rehabilitative process

• Determination of secondary diagnoses is based on:

– Clinician’s assessment of the patient;

– Information in medical record; and

– Input from the patient’s physician.

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Selection and Sequencing of Diagnoses

• The assessing clinician is accountable for identifying the diagnoses, symptom control ratings, and sequencing of the diagnoses and must agree to any changes.

• Onset and exacerbation dates are not mandated by CMS.

• Diagnoses selected must be:

• Relevant to the POC;

• Unresolved;

• Verified by the current treatment regimen and the physician; and

• Supported by the patient’s medical record documentation – the home health POC, clinical comprehensive assessment, medical condition, and clinical care needs.

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M1028: Active Diagnoses

• Identifies whether specific diagnoses are present and active at the SOC/ROC.

• Must be associated with the home health episode of care.

For the guidance and complete list of codes permitted, see the OASIS-D Guidance Manual, item M1028

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OASIS-D addition

M1028: Response 1

• Select Response 1, if the patient has an active diagnosis of:

• Peripheral Vascular Disease (PVD) where the problem is arterial. Venous diseases are not associated with a risk of pressure ulcers.

• Codes that start with the first 3 characters of I73

• For example: I73.9, Peripheral vascular disease, unspecified

• If physician documents stasis ulcers, chronic venous insufficiency, or stasis dermatitis – assign diagnosis code I87.2, not I73.9.

OR

• Peripheral Arterial Disease (PAD)

• Codes that start with the first 4 characters of: I70.2, 170.3, 170.4, 170.5, 170.6, 170.7, and 170.91 and I70.92

Excludes: I70.90, (Unspecified atherosclerosis)

For example: I70.201, Unspecified atherosclerosis of native arteries of extremities, right leg

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M1028: Response 2• Select Response 2, if the patient has an active diagnosis of Diabetes Mellitus (DM)

indicated by any one of the following diagnosis codes that start with:

• E08 Diabetes mellitus due to underlying condition

• E09 Drug or chemical induced diabetes mellitus

• E10 Type 1 diabetes mellitus

• E11 Type 2 diabetes mellitus

• E13 Other specified diabetes mellitus

• If a patient has diabetes and either PVD or PAD, a combination code is assigned –

e.g., E11.51,Type 2 diabetes mellitus with diabetic peripheral angiopathy with

gangrene.

• Both [1] - PVD/PAD and [2] - DM should be checked.

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Symptom CodesChapter 18

(R00 – R99)

37PDGM WARNING

Symptoms

Guidelines

Section I.C.18.a-c

• Codes that describe symptoms and signs are acceptable for reporting purposes when

a related definitive diagnosis has not been established (confirmed) by the provider.

• 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 that diagnosis,

such as the various signs and symptoms associated with complex syndromes.

• The definitive diagnosis code should be sequenced before the symptom code.

• Signs or symptoms that are associated routinely with a disease process should not be

assigned as additional codes, unless otherwise instructed by the classification.

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Symptoms

• Despite the guidance, many coders persist in listing symptom codes in the charts. This is largely due in part to the referral indicating these symptoms. Ultimately, we must follow coding guidance though.

• The Guidance Manual describes the difference between a symptom and a sign. It is stated in Chapter 18: “For example, a patient may report a symptom by stating that he/she is feeling dizzy. A physician may report a sign, such as fever or irregular heartbeat.” The H&P may indicate all these, with a diagnosis of A fib, for example. What should be coded is the A fib, as that is the definitive diagnosis that is the cause of these signs and symptoms.

• This aligns well with PDGM coding, in that all of the symptom codes will result in a claim denial if they are used in the primary coding position M1021.

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M62.81 Muscle Weakness (generalized)

Per dh Coding Tips: Use M62.81 for true muscle weakness as a result of musculoskeletal disorders, neuromuscular disease, or degenerative disease, that are otherwise unidentified. Unilateral weakness associated with stroke, brain disorders or injury is coded to hemiplegia/hemiparesis, not M62.81. Muscle group measurements are not required but measurable muscle weakness must be documented.

What is recommended by the Final Rule is to use the Muscle wasting and atrophy codes (M62.5-). Under PDGM, this code falls into the MS_Rehab Clinical Grouping, whereas M62.81 does not.

HOWEVER: when using this code, there must be clear documentation of this diagnosis and preferably measurements indicating the wasting condition.

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R53.0 Neoplastic (malignant) related fatigue

• Has a code first note for “associated neoplasm”

• Take-away message: if the chart speaks of fatigue, and the patient has a neoplasm, before doing a knee-jerk insertion of R53.83, Fatigue, query the physician if the fatigue is related to the cancer.

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R53.82 Chronic fatigue, unspecified

• Clarifying term: Chronic fatigue syndrome NOS

• Chronic fatigue syndrome is a disorder in which the patient has a combination of symptoms such as sore throat, swollen lymph nodes, joint pain, headache, muscle pain, impairment of short term memory, and fatigue and malaise not related to exertion.

• Typically, the patient must have the symptoms chronically for six months or longer for a diagnosis of chronic fatigue syndrome to be made.

• Must be stated by the physician

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Z CodesChapter 21

(Z00-Z99)

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General Guidelines• Z codes may be used as either a first-listed (principal/primary diagnosis) or

secondary code, depending on the circumstances of the encounter.

• Hospice can NEVER use a Z code as a principal/primary diagnosis.

• There are no Z codes for:

• Traumatic fractures

• Pathological fractures

• Aftercare of an injury

• Assign the acute injury code with the appropriate 7th character.

• Aftercare following surgery on musculoskeletal system

• Closet match: code Z47.89, Other orthopedic aftercare, NEC

• Encounter for rehab (therapy-only)

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Status Codes

• Explain a patient’s medical condition that:

• Currently exists and is not receiving any treatment; but

• Has the potential to affect the POC; and

• May require continued monitoring

• Indicate a patient is either:

• A carrier of disease; or

• Has a sequela or residual of a past disease or condition

• Are informative, because the status may affect the course of treatment and its outcome

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Transplant Status

• Z94.- is for Transplanted organ and tissue status• This does not include vascular grafts – those are in Z95.-

• These indicate a transplant has occurred in the past (no time limits –could be yesterday, could be 20 years ago)

• Provide information as to the type of transplant, if needed

• Do not use if the diagnosis code includes the information provided

• T86.2-, Complications of heart transplant

• Z94.1, Heart transplant status, would be unnecessary to add

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Noncompliance Status Codes

47

Social Determinants of Health

• Category Z55 – Z65

• Can assign codes based on medical record documentation from clinicians involved in the care of the patient

• Information does not have to be from the patient’s provider as this information represents social information

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History Codes

• History Z codes explain a patient’s past medical condition that no longer exists

• Is not receiving any treatment

• Has the potential for recurrence, may require continued monitoring

• Subcategories Z85.0 - Z85.7:• Assigned for the former site of a primary malignancy

• Subcategory Z85.8-:

• Assigned for the former site(s) of either a primary or secondary malignancy

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“Encounter for”

• Attention to Z codes explain a patient’s medical condition that currently exists, is receiving

treatment, and is affecting the POC. The agency must be actively doing something related to

or about the condition or sequela – cleansing, feeding, or teaching.

• Z43.-, Encounter for attention to artificial openings

THINK…Is the agency providing care (Z43) or just

reporting that the artificial opening exists (Z93)?

• Adjustment and management and Fitting and adjustment Z codes are used when the

agency performs the task.

– Z45.-, Encounter for adjustment & management of implanted device

Note: Z45.0-, Encounter for adjustment & management of cardiac device, is assigned only when

the agency is reprogramming the device either manually or via computer. See Z95.- for presence.

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DrainsAgencies care for many types of drains. To code these correctly, these questions need to be answered:

• Was the drain placed during a surgical procedure, the aftercare of which is the agency’s focus?

Code surgical aftercare; a unique drain code is not required

• Is the sole purpose of the agency’s presence in the home to change or remove the drain?

Z48.03, Encounter for change or removal of drains

Note this is unlikely, as the agency should be doing something more than just changing or removing a drain

• Or must the agency provide specific interventions for the drain?

Agency providing interventions: Z43.8, Encounter for attention to other artificial openings

• Is the patient or cg independent in the care of the drain:

• Patient or cg independent: no code required

• PleurX catheter:

Z48.03, Encounter for change or removal of drains

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Ostomies

Ostomies are heavy users of Attention to and Status codes

• 3 things must be known to use the correct code:

1. Type of opening (colostomy, ileostomy, etc.)

2. Who is providing care to the ostomy – this determines Status or Attention to

3. Is it routine or complicated care – this determines Z code or complication code

• Note: Z43.-, Attention to codes are used for active care to the artificial opening. Do not use with a complication.

• For reversal/closure of an ostomy: assign Z48.-. Use the aftercare code for the reason for the original ostomy.

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Ostomies

• Attention to: agency is providing active, skilled care

• Z43.-, Encounter for attention to artificial openings

• Only Z43.0 (Trach), Z43.5 (Cystostomy) and Z43.6 (Other artificial openings urinary tract) earn case-mix points. Don’t bury these at the bottom of the coding list if the agency is providing care!

• Z43.5 (Cystostomy) and Z46.6 (common Foley code) can sometimes be confusing for coders. Z43.5 is used when the agency will be removing or replacing a catheter from an artificial opening; Z46.6 is used when the agency is removing and replacing an indwelling catheter in a natural opening. Sometimes, the patient may have both codes assigned, as one code is for the “site”, the other is for the catheter.

• Z43.5 is case-mix; Z46.6 is not, so it is important to be sure the correct code is utilized to either avoid upcoding, or avoid losing out on potential case-mix points.

• Status codes: device is present but the agency is not providing care.

• Z93.-, Artificial opening status

• Earn no case-mix points

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Z Code Quick Codes

• Teaching patient and caregiver on care of new gastrostomy

• Previous diabetic foot ulcer

• New artificial left arm

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Z Code Quick Codes Answers

• Teaching patient and caregiver on care of new gastrostomy

• Z43.1, Encounter for attention to gastrostomy

• Previous diabetic foot ulcer

• Z86.31, Personal history of diabetic foot ulcer

• Do not use for current diabetic ulcer.

• New artificial left arm

• Z97.12, Presence of artificial left arm (complete) (partial)

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Coding Joint Replacements

• When the cause is not an injury, but a condition, such as osteoarthritis:

• Assign Z47.1, Aftercare following joint replacement surgery

• Routine care will be provided

• The status code for the joint replaced (Z96.6-) is also coded.

• An aftercare code is not appropriate, per Q3 2016 Coding Clinic guidance:

• When the cause is to treat a fracture

• When a patient is receiving another joint prosthesis after having one removed due to a still-resolving complication, such as a mechanical loosening,

• Rather, in these cases, assign the fracture code (see Excludes 1 note at Z47 ) or the code for the specific complication with the appropriate 7th character to

indicate whether the patient is still receiving active treatment or not.

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Joint Explantation Clarification

• Use Z47.3, Aftercare following explantation of joint prosthesis:

• The complication has completely resolved

• The entire joint has been removed

• A new one has been inserted via a staged, planned procedure.

For example, patient had an infected joint which was totally removed, the infection is completely resolved, and a new joint has been inserted during a planned procedure at a later date.

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Joint Explantation Clarification

• Do NOT use Z47.3- when:

• There is a mechanical complication, such as loosening of a joint. The complication remains until another joint is inserted.

• Code the complication with the appropriate 7th character.

• Do NOT use Z47.3- when:

• There is a joint revision.

• Code the complication with the appropriate 7th character.

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Assign Z89.-, Acquired absence of joint following explantation of joint

prosthesis, with or without presence of antibiotic-impregnated cement

spacer, until new joint is inserted. Then, Z96.6-, Presence of orthopedic

joint implant, will be coded.

Joint Explantation ScenarioTherapy-only admission for aftercare following insertion of a new left knee joint

prosthesis. The first prosthesis became infected and was removed 8 weeks ago. The infection was treated with antibiotics and is completely resolved. He also has osteoarthritis in his right knee, which he will have replaced in the near future.

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Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

Joint Explantation Scenario

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So, what do we need to know?• Focus of care:

• Is the focus related to, or due to, anything?

• Do we need further clarification from the physician or clinician for any diagnosis?

• What are the appropriate comorbidities?

Joint Explantation Coding Therapy-only admission for aftercare following insertion of a new left knee joint

prosthesis. The first prosthesis became infected and was removed 8 weeks ago. The infection was treated with antibiotics and is completely resolved. He also has osteoarthritis in his right knee, which he will have replaced in the near future.

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Diagnosis ICD-10-CM

M1021a Aftercare following explantation of knee joint prosthesis Z47.33

M1023b Unilateral primary osteoarthritis, right knee M17.11

M1023c Presence of left artificial knee joint Z96.652

A new joint prosthesis was inserted via a staged procedure following removal of the previous one, and the complication is completely resolved. Therefore, coding Z47.33 is appropriate.

Unilateral osteoarthritis defaults to primary. A new prosthesis was inserted, so presence of artificial joint is coded.

Joint Replacement Complications

• Reminder, joint replacement surgery involves removing part of an arthritic or damaged

joint and replacing it with a prosthetic device.

• Common complications from this surgery include:

• Dislocation of the prosthesis

• Loosening of the prosthesis

• Breakage or fracture of the prosthesis

• Infection due to the prosthesis

• These situations would begin their coding in the T84.- category (Complications of

internal orthopedic prosthetic devices, implants and grafts)

• Do not assign the Z96.6- code subcategory (Presence of orthopedic joint implants) if

the joint is indicated by the complication code.

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Aftercare Codes

• Are generally first-listed to explain the specific reason for the encounter, but may be used as an additional code when aftercare is provided in addition to the reason for admission.

• Example: Care of a stage 3 pressure ulcer may be more of a focus than aftercare following surgery.

• Should be used in conjunction with other aftercare or diagnosis codes to provide more detail on the encounter, such as:

• Fitting and adjustment

• Attention to artificial openings

• Encounter for change of surgical dressing

• Sequencing of multiple aftercare codes depends on the circumstances of the encounter.

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Aftercare Scenario

Patient admitted for aftercare following a thyroidectomy to remove a thyroid goiter. She is now being treated with Synthroid for hypothyroidism.

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Diagnosis ICD-10-CM

M1021a

M1023

M1023

Aftercare Scenario Coding

Patient admitted for aftercare following a thyroidectomy to remove a thyroid goiter. She is now being treated with Synthroid for hypothyroidism.

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Diagnosis ICD-10-CM

M1021a Encounter for other specified surgical aftercare Z48.89

M1023 Postprocedural hypothyroidism E89.0

M1023 Hormone replacement therapy Z79.890

The thyroid is an endocrine gland. There is no aftercare code for the endocrine system in the Index. Therefore, “other specified surgical aftercare” is coded.

The hypothyroidism is due to surgery (postprocedural). Synthroid is a replacement for the thyroid hormone. E89.0 is the code that the Alphabetic Index leads to “acquired absence of thyroid” and also acts

as a status code in this scenario.

Long-Term Drug Use

• Z79.- category (Long term (current) drug therapy)

• Indicates patient’s continuous use of a prescribed drug for long-term treatment or prophylactic use

• Not for use for drug addictions or for medications used to prevent withdrawal symptoms or detoxify (e.g. methadone maintenance).

• Assign the appropriate code for drug dependence instead.

• Do not assign for meds used for a short period of time to treat an acute illness or injury

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Presence of Implants and Grafts

• Codes capture a patient’s implant or graft (joint prosthesis, heart valve, bypass graft, etc.)

• Used for routine care only – if there is a complication, the complication code typically covers it

• Z96.6- used for orthopedic joint implants• Can be used with Z47.1, Aftercare, or simply to capture the replaced joint when no

other care is needed

• Use the bilateral code when both joints have been replaced, even if the joints were replaced in different encounters.

• * Many seasoned coders prefer to code the joints separately when one is a “new” joint and one is older, as the date differences help to paint the picture. It is a style decision.

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Understanding the Terms

• Localized infection is an infection that is limited to a specific part of the body and has localized symptoms, such as cellulitis, pneumonia, or a UTI.

• Bacteremia (R78.81) is the presence of bacteria in the blood, and Bacteriuria(R82.71) is the presence of bacteria in the urine, both identified through laboratory testing.

• They are most often asymptomatic; and

• They can progress to a systemic inflammatory response (SIRS) or to a systemic infection (Sepsis).

• Documentation of bacteremia or bacteriuria with clinical signs and symptoms of a systemic infection such as fever, chills, or tachycardia should be clarified with the physician to ensure proper code assignment.

• Systemic inflammatory response syndrome (SIRS) is an inflammatory state affecting the whole body, frequently a response of the immune system to infection.

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Understanding the Terms (cont.)

• Sepsis is SIRS due to infection, which does not have to be proven by a positive culture. This can trigger inflammation throughout the body that may progress in severity causing severe sepsis.

• Severe sepsis is SIRS due to an infection that progresses to organ dysfunction, such as respiratory, kidney, liver, or heart failure, which can result in septic shock.

• Septic shock is a potentially lethal drop in blood pressure due to the presence of bacteria in the blood that causes circulatory failure.

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Required Documentation

• Frequently, sepsis and the acute infectious process are resolved in the inpatient setting.

• Consider whether sepsis remains unresolved at SOC.

• Do not assume this based on the continuation of oral antibiotics. The physician should be queried.

• The importance of documenting relevant information must be stressed to physicians, which includes:

• The inflammatory condition and if it is infectious or noninfectious;

• If infectious, the causal organism; and

• If noninfectious, what the specific process is.

71

Coding Sepsis

• Septicemia and sepsis are often used synonymously.

• Index: Septicemia A41.9 meaning sepsis – see Sepsis

• The codes assigned depend on:

• The underlying cause of the sepsis;

• The causative organism, if applicable; and

• Other relevant co-existing conditions.

• Sepsis codes are primarily found in Chapter 1 and Chapter 18 (Symptoms, signs and abnormal clinical laboratory findings, not elsewhere classified).

• Sepsis is a potentially life-threatening complication of systemic infection in which the body’s inflammatory response can progress to organ failure and ultimately death.

• Occurs in 3 stages:

Sepsis Severe Sepsis Septic Shock

72

https://en.wikipedia.org/wiki/Sepsis73

Coding Sepsis (cont.)

• For a diagnosis of sepsis, assign the appropriate code for the underlying systemicinfection first:

• A40.-, Streptococcal sepsis; or

• A41.-, Other sepsis

• A40 and A41 categories are combination codes that describe both the systemic inflammatory response and the organism causing it – e.g., A41.52, Sepsis due to Pseudomonas.

• If the type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified organism.

74

Coding: Severe Sepsis and Septic Shock

Coding guidelines instruct to assign:

1. Code for the underlying systemic infection;

2. Code from subcategory R65.2-, Severe sepsis;

– R65.20, Severe sepsis without septic shock; or

– R65.21, Severe sepsis with septic shock

3. Additional code(s) for any associated acute organ dysfunction

Exception: If circulatory failure is the only dysfunction, do not code, as septic shock

indicates the presence of circulatory failure.

Note: The codes for severe sepsis and septic shock (R65.2-) can never be listed as primary.

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Coding Septic Shock

• Septic shock generally refers to circulatory failure associated with severe sepsis, and it represents a type of acute organ dysfunction.

• Sequence as follows:

1. First: the systemic infection code (A40.- or A41.-).

2. Next: code R65.21, Severe sepsis with septic shock or

T81.12-, Postprocedural septic shock, initial encounter

3. Then, assign additional code(s) for any other acute organ dysfunction(s), if applicable.

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Urosepsis

• Urosepsis is a systemic reaction of the body (SIRS) to a bacterial infection of the urogenital organs.

• Bacteremia: presence of bacteria in the blood (R78.81).

• Per chapter-specific coding guidelines for sepsis:

• The term urosepsis is a nonspecific term.

• Urosepsis ≠ Sepsis

• It has no default code in the Alphabetic Index.

• Urosepsis - code to condition

• If a provider uses this term, he/she must be queried for clarification.

• Is this a UTI, bladder infection, or bloodstream-specific infection?

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Good Old UTI

• So we understand that when urosepsis is documented, this does NOT necessarily mean UTI. But when it does….

• Certain codes for localized infections are found outside of Chapter 1.

• Eg: Urinary tract: N39.0 is in Chapter 14

• These infection codes do not include the infectious organism

• Tabular instruction at N39.0:

Use Additional Code

code (B95-B97), to identify infectious agent.

78

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=7&sk=B95-B97

Code these sepsis scenarios…

• Sepsis due to an acute respiratory infection

• Sepsis due to acute cystitis with hematuria caused by Escherichia coli [E. coli]

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Sepsis or Severe Sepsis with Localized Infection

• If the reason for admission is both sepsis or severe sepsis and a localized infection, such as pneumonia or cellulitis:

• Code for the underlying systemic infection should be assigned first

• Code for the localized infection should be assigned next

Patient admitted with sepsis due to MSSA pneumonia

M1021a: A41.01, MSSA sepsis

M1023b: J15.211, MSSA pneumonia

Note: Chapter-Specific guidelines for when sepsis/severe sepsis develops afteradmission do not apply to home health.

80

Code this scenario:

• Streptococcal sepsis resulting in acute respiratory failure with hypoxia

81

Coding for scenario:

• Streptococcal sepsis resulting in acute respiratory failure with

hypoxia

Why is Severe Sepsis, R65.20 coded?

Because respiratory failure is organ dysfunction. With severe sepsis, organ dysfunction is present.

82

Streptococcal sepsis A40.9

Severe sepsis without septic shock R65.20

Acute respiratory failure with hypoxia J96.01

Postprocedural Sepsis

• Sepsis resulting from a postprocedural infection is a complication of care.

• The physician MUST clearly document the cause-and-effect relationship.

Coding:

1. Code first the postprocedural infection code (complication code) from T81.40 to T81.43, Infection following a procedure

2. Assign an additional code for sepsis following a procedure: T81.44 (NEW for 2019)

3. Next, code the systemic infection (A40.- or A41.-).

4. Then, in cases of severe sepsis, assign R65.2- (Severe sepsis w/wo shock) and additional code(s) for any acute organ dysfunction.

83

Let’s take a look…

• Confirmed sepsis due to deep incision infected with Pseudomonas, post bowel

resection, being treated with oral antibiotics following course of IV antibiotics

Rationale:

– The postprocedural complication is sequenced first.

– Treatment with antibiotics – oral or IV – is considered active care. Therefore, the appropriate 7th

character is “A.”

– The code for sepsis following a procedure is coded next.

– The systemic infection is coded after that.

– Note: Taking oral antibiotics does not confirm sepsis is still present – must query the physician. 84

Infection following a procedure, deep incisional surgical site T81.42xA

Sepsis following a procedure T81.44

Sepsis due to Pseudomonas A41.52

Postprocedural Septic Shock

• If a postprocedural infection has resulted in postprocedural septic shock:

1. Code first the precipitating complication, such as T81.4, Infection following a procedure, or O86.0,

Infection of obstetrical surgical wound;

2. Assign an additional code for sepsis following a procedure: T81.44 (NEW for 2019)

3. Next, assign a code from category A40 or A41 for the systemic infection;

4. Followed by code T81.12-, Postprocedural septic shock;

5. Then, code any associated acute organ dysfunction, if applicable.

85


• Gram-negative sepsis resulting in septic shock due to an infected new

colostomy being treated with IV antibiotics.

• What is the focus of care?

• Sepsis-wise, what do we code? How do we account for the septic shock?

• Do we code the antibiotics?

86


• Gram-negative sepsis resulting in septic shock due to an infected new

colostomy being treated with IV antibiotics.

Rationale:

– The postprocedural infection is sequenced first, followed by sepsis following a

procedure, and then postprocedural septic shock.

– It there is another type of organ failure, the code(s) should be sequenced following the

systemic infection.87

Colostomy infection K94.02

Sepsis following a procedure T81.44

Postprocedural septic shock T81.12xA

Gram-negative sepsis, unspecified A41.50

Adjustment and management of vascular access device Z45.2

Long-term (current) use of antibiotics Z79.2

SIRS due to Non-infectious Process

• When SIRS is documented as due to a noninfectious disease process, such as

trauma, malignant neoplasm, or pancreatitis, and no subsequent infection is

documented:

1. Code first the underlying condition, such as an injury.

2. Next, code:

• R65.10, Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute

organ dysfunction,

OR

• R65.11, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ

dysfunction.

3. If acute organ dysfunction is documented, use additional code(s) to specify the dysfunction –

e.g., hepatic failure.

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Sepsis/Severe Sepsis due to Non-infectious Process

• If sepsis or severe sepsis is documented as associated with a non-infectious condition, such as a serious injury, and this condition meets the definition for principal/primary diagnosis:

• Code the noninfectious condition first

• Code the resulting infection.

• If severe sepsis is present:

• Code from subcategory R65.2, Severe sepsis, should also be assigned

• Code the associated organ dysfunction code(s).

• If the infection meets the definition of principal/primary diagnosis, it should be sequenced before the non-infectious condition.

89

Sepsis/Severe Sepsis due to Non-infectious Process (cont.)

• When both the associated non-infectious condition and the infection meet the definition of principal/primary diagnosis, either may be assigned as the principal/primary diagnosis.

• When a non-infectious condition leads to an infection resulting in severe sepsis:

• Code from R65.2

• Code the associated acute organ dysfunction.

• Only one code from category R65 should be assigned. Therefore, a code from subcategory R65.1, SIRS of non-infectious origin, should not also be assigned.

90

Carrier

• A person who has a positive MSSA or MRSA colonization test, which may be stated as “screen positive” or “swab positive,” is known as a “carrier.”

• A “carrier” does not necessarily have an active infection, but may have a positive swab in the nose, axilla, etc., and is coded as:

• Z22.321, Carrier or suspected carrier of MSSA

• Z22.322, Carrier or suspected carrier of MRSA

• If it is documented that a patient has MSSA or MRSA colonization andinfection, you may assign both codes.

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MRSA… A Combination Code

• Code B95.62, MRSA infection as the cause of diseases classified elsewhere, is a combination code, which includes the organism and resistance to penicillins.

• Do not assign a code from subcategory Z16.11, Resistance to penicillins, as an additional diagnosis.

• If MRSA is documented as resistant to another antibiotic, such as Vancomycin, add a Z16, Resistance to antimicrobial drugs code for the other antibiotic.

• For other organisms which identify drug resistance, assign a code from category Z16 after the organism code.

92

MRSA Examples:

• There are two disease processes that include all 3 elements in the combination code for MRSA – infection, causative organism, and resistance to penicillins –and only one code is required:

1. Sepsis due to MRSA – A41.02

2. Pneumonia due to MRSA – J15.212

• If the documentation indicates MRSA as the cause of any other infection, two codes are required.

Eg. Cellulitis of face due to MRSA

– L03.211, Cellulitis of face

– B95.62, MRSA as the cause of diseases classified elsewhere

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HIV B20: Use with !• Some states and U.S. territories will deny B20 as the primary diagnosis under

privacy protection laws, and some prohibit coding it at all.

• In these cases, look for an HIV-related condition, such as B59 Pneumocystis pneumonia, and sequence this as the first-listed diagnosis.

94

States with Restrictions• Alaska

• Arizona

• California

• Colorado

• Connecticut

• DC

• Delaware

• Hawaii

• Idaho

• Illinois

• Nevada

• New Jersey

• New Mexico

• North Dakota

• Oregon

• Puerto Rico

• South Carolina

• Texas

• Utah

• Washington

• West Virginia

• Wisconsin

• Wyoming

95

These states restrict the coding of B20 as primary, some prohibit the use of the code altogether. Contact the state OEC for specific restrictions.

Coding HIV Disease

• Code only confirmed cases of HIV infection/illness.

• This is an exception to the hospital inpatient guideline Section II, H, which states if the documentation indicates uncertainty – e.g., “possible,” “probable,” or “likely” – code the condition as if it existed or was established.

• Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, is to be assigned when the patient without any documentation of symptoms is listed as being “HIV positive,” “known HIV,” “HIV test positive,” or similar terminology.

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Asymptomatic HIV

• Do not use this code:

• If the term “AIDS” is used; or

• If the patient is treated for any HIV-related illness; or

• If the patient is described as having any condition(s) resulting from his/her HIV status.

Code B20 (HIV disease), instead.

97

What is a neoplasm?

• “Neoplasm” is an abnormal mass of tissue that results when cells divide more than they should or do not die when they should, which can be either malignant (cancerous), or benign, (not cancerous).

• The terms tumor, fibroid, adenoma, myoma, and sarcoma indicate a neoplasm.

• A tumor is an abnormal mass of tissue, which may be solid or fluid-filled. A tumor does notautomatically mean cancer.

• Tumors can be:

• benign (not cancerous)

• pre-malignant (pre-cancerous)

• malignant (cancerous).

• For unspecified terms, such as mass, lesion, lump, or disease, reference the Alphabetic index.

99

Types of Neoplasms (cont.)

• Primary versus Secondary site

• If “metastatic from,” is stated, this refers to where the primary site is.

• A secondary site is metastatic from a primary site. If the medical record states “metastatic to,” this refers to where the secondary site is.

• Primary coding versus Secondary coding• For coding purposes, primary refers to M1021a (principal/primary diagnosis)

• Secondary coding refers to M1023 items. This is NOT the same as primary or secondary site!

100

Sequencing Guidelines

• If the focus of care is the primary malignancy, assign that as the principal/primary

diagnosis, unless the encounter is solely for the administration of chemotherapy or

immunotherapy. Then, assign the appropriate Z51- code first.

• Any mention of extension, invasion, or metastasis to another site is coded as a

secondary malignant neoplasm to that site, which may be listed as primary or

secondary, depending on the focus of care.

• If there is a primary neoplasm and treatment is directed toward the secondary site, code

the secondary site first, even if primary site is still present.

Example: Colon cancer with focus on metastasis to the liver

‒ M1021a: C78.7, Secondary malignant neoplasm of liver

‒ M1023 (b-…): C18.9, Malignant neoplasm of colon, unspecifiedcolon, unspecified

101

Overlapping Sites and Multiple Neoplasms of Same Site

• If the medical record states “contiguous sites,” this refers to multiple neoplasms with overlapping boundaries, in which the point of origin (primary site) cannot be determined.

– For example, a cancer may involve the cheek and nose.

• A primary malignant neoplasm that overlaps two or more contiguous (overlapping) sites should be classified to the subcategory/code .8 (‘overlapping lesion’), unless the combination is specifically indexed elsewhere.

• For multiple neoplasms of the same site that are not contiguous, such as tumors in different quadrants of the breast, codes for each site should be assigned.

102

Primary Malignancy Excised• When a primary malignancy has been excised:

• And further treatment, such as an additional surgery for the malignancy, radiation therapy, or chemotherapy is directed to that site

• the primary malignancy code should be used until treatment is completed.

Code Z48.3, Aftercare following surgery for neoplasm

Code neoplasm code

• These can go in either order dependent upon focus of care.

• When a primary malignancy has been previously excised or eradicated from its site:

• There is no further treatment directed to that site, and

• There is no evidence of any existing primary malignancy, and

• The physician has documented that it is eradicated

• a code should be used to indicate the former site of the malignancy (history).

Code Z48.3, Aftercare following surgery for neoplasm

Code Z85.-, Personal history of malignant neoplasm

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Symptoms, Signs, and Ill-Defined Conditions Guidelines

• The patient may have symptoms, such as weakness, fatigue, and shortness of breath, due to the neoplastic disease. Do NOT assign these in place of, or sequence in priority, over the malignancy.

• However, the patient may experience symptoms associated with, but not integral to, the neoplastic disease:

• Symptoms such as nausea and vomiting:

• Assign these after the code for the malignancy in sequencing of other codes as appropriate.

• Example:

• Patient admitted to home care for treatment of persistent N&V due to gastric malignancy

• C16.9, Malignant neoplasm of stomach, unspecified

• R11.2, Nausea with vomiting, unspecified (persistent)

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What NOT to code….

Per Coding Clinic:

Categories Z40-Z53, Encounters for other specific health care, include a range of specific

encounters to indicate that a person not currently ill is encountering the health service for a

specific reason (i.e., organ donor, prophylactic care, etc.). Assignment of the appropriate code

from these categories, depends on the reason for the encounter or visit.

An encounter for a patient who has already had surgery and is being seen during the healing

or recovery phase would be assigned an after care code.

It is not appropriate to assign a code describing an encounter for the initial surgery and an

encounter for aftercare for the same visit.

Therefore:

Code Z40.01, Encounter for prophylactic removal of breast, is describing the episode of care for

the surgery to remove the breast. Since the home health visit is not the encounter where the breast

is actually removed, code Z40.01 would not be assigned for this encounter.

Code Z42.1, Encounter for breast reconstruction following mastectomy, would not be assigned

for the home health visit since the breast is not reconstructed during the visit.105

X

X

Guidelines: Anemia• When the admission/encounter is for management of an anemia associated with the

malignancy and the treatment is only for anemia, sequence the appropriate code for the

malignancy as the principal/primary or first-listed diagnosis, followed by the

appropriate anemia code (such as D63.0).

• Neoplasm

• D63.0, Anemia in neoplastic disease

• When the admission/encounter is for management of an anemia associated with an

adverse effect of the administration of chemotherapy or immunotherapy and the

treatment is only for anemia, the anemia code is sequenced first, followed by the

appropriate codes for the neoplasm and the adverse effect.

– D64.81, Anemia due to antineoplastic chemotherapy

– Neoplasm

– T45.1X5D, Adverse effect of antineoplastic and immunosuppressive drugs, subsequent

encounter

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Guidelines: Anemia (cont.)

• When the admission/encounter is for management of an anemia associated with an adverse effect of radiotherapy, sequence the anemia first, followed by the appropriate neoplasm code and code Y84.2.

– D61.2, Aplastic anemia due to radiation

– Neoplasm

– Y84.2, Radiological procedure and radiotherapy as cause of abnormal reaction of patient or of later complication, without mention of misadventure at time of procedure

107

Guidelines: Other Complications

• When the admission/encounter is for management of a complication associated with a neoplasm, such as dehydration, and the treatment is only for the complication, (e.g., intravenous rehydration), the complication is coded first, followed by the appropriate code(s) for the malignancy.

1. Complication: E86.0, Dehydration

2. Malignancy: Neoplasm

• When the admission/encounter is for management of a complication associated with a neoplasm or treatment of a complication resulting from a surgical procedure, code the complication first, if treatment is directed at resolving the complication.

108

Transplant ComplicationPatient had a left kidney transplant 5 years ago and was diagnosed with cancer

in that kidney 2 months ago. Physician documentation notes kidney transplant failure due to the cancer in the renal pelvis of the left kidney.

109

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c





Transplant ComplicationPatient had a left kidney transplant 5 years ago and was diagnosed with cancer

in that kidney 2 months ago. Physician documentation notes kidney transplant failure due to the cancer in the renal pelvis of the left kidney.

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Diagnosis ICD-10-CM

M1021a Kidney transplant failure T86.12

M1023b Malignant neoplasm associated with transplanted organ C80.2

M1023c Malignant neoplasm of left renal pelvis C65.2

A malignant neoplasm of a transplanted organ is coded as an “other complication of transplant, unless specified by the physician as failure or rejection.

Index: Complication transplant Follow instructional note at T86 to use an additional code for malignancy associated with

organ transplant (C80.2). C80.2 instructs to code first complication of transplanted organ (T86.-) and to use

additional code to identify the specific malignancy.

Prophylactic Organ Removal

A response from the Coding Clinic on 8/17/16 regarding the coding for patients who have opted for prophylactic breast removal for a genetic susceptibility or strong family history states:

Assign an aftercare code for a home health visit during the healing and recovery phase, following the initial treatment (surgery) for removal of the breast.

• The assignment of an additional code under subcategory Z90.1-, Acquired absence of breast and nipple, provides additional information to more fully capture the patient’s condition and reason for aftercare.

• The term “Encounter for” describes the reason for the current episode of care.

• Code Z40.01, Encounter for prophylactic removal of breast, is describing the

episode of care for the surgery to remove the breast. Reminder, since the home

health visit is not the encounter where the breast is actually removed, code Z40.01

would not be assigned for this encounter. 111

What to do?

• Example: Patient with a strong family history of breast cancer and positive genetic testing for susceptibility for breast cancer who had a prophylactic bilateral mastectomy is coded:

• M1021a: Z48.89, Aftercare for other specified surgical aftercare

• M1023: Z15.01, Genetic susceptibility to malignant breast neoplasm

• M1023: Z80.3, Family history of malignant neoplasm of breast

• M1023: Z90.13, Acquired absence of bilateral breasts and nipples

112

Question from coder…

How would I code a patient who has primary cancer of the right upper outer quadrant of her breast that has eroded through the skin?

– C50.411, Malignant neoplasm of upper-outer quadrant of right female breast

Index: Ulcer malignant – see Neoplasm, malignant, by site

113

Pathological Fracture due to Neoplasm

• When an encounter is for a pathological fracture due to a neoplasm, and the focus of treatment is the fracture:

1. Sequence first: a code from subcategory M84.5-, Pathological fracture in neoplastic disease

2. Next: the neoplasm

• If the focus of treatment is the neoplasm with an associated pathological fracture:

1. Sequence first: the neoplasm

2. Next: a code from M84.5- for the pathological fracture

114

Neoplasm-related Pain

• G89.3 Neoplasm related pain (acute) (chronic) is used for:

• Cancer associated pain

• Pain due to malignancy (primary)(secondary)

• Tumor associated pain

• Encounter for PAIN MANAGEMENT

• It is not necessary to also code the site of the pain, for example, M79.621, Pain in right upper arm.

115

Code this SOC…

Patient has metastatic bone cancer from the lung, which had been removed. Her oncologist documented that the lung cancer was eradicated with the surgery. She has chronic pain and is taking Morphine.

While standing at home, she felt a sudden sharp pain in her hip. She went to the ER, where it was determined that she had a fracture at the neck of the femur and worsening of her anemia due to the cancer.

116





117

Clarifications:

The primary focus of care is physical therapy due to the fracture.

Nursing will address her anemia and pain management.

The chronic pain is due to the cancer (bone).

The right femur has the fracture. Is this pathological or traumatic?

So, what do we code?

• Focus of care:



Code this SOC…

118

Diagnosis ICD-10-CM

M1021a

M1023

M1023

M1023

M1023

M1023

Other

Coding for SOC

119

Diagnosis ICD-10-CM

M1021a Pathological fracture in neoplastic disease, (R) femur M84.551D

M1023 Secondary malignant neoplasm of bone C79.51

M1023 Neoplasm related pain G89.3

M1023 Anemia in neoplastic disease D63.0

M1023 Personal history of other malignant neoplasm of bronchus and lung Z85.118

M1023 Acquired absence of lung Z90.2

Other Long-term (current) use of opiate analgesic Z79.891

The pathological fracture is the focus of care, so it is coded first (primary). The bone cancer, the cause of the fracture, pain, and anemia are listed next. The lung cancer was eradicated with the removal of the lung. Therefore, personal history of

the cancer and acquired absence of the lung are coded.What if pain management was the focus of care?

Endocrine, Nutritional and Metabolic Diseases

Chapter 4

(E00-E89)

120

Diabetes

• Diabetes is a disease in which the body cannot process food for use as energy.

• The pancreas beta cells make insulin to process glucose. If insulin doesn’t break

down the glucose so it can reach the cells, glucose builds up in the blood,

resulting in high blood sugar (hyperglycemia).

• There are 5 categories for diabetes:

– Primary (because of the pancreas failure)

• E10 Type 1 diabetes: beta cells are destroyed, so the body does not make insulin

• E11 Type 2 diabetes: body does not make or use insulin well (insulin resistance)

– Secondary (something else caused it to happen)

• E08 Diabetes due to underlying condition

• E09 Drug or chemical induced diabetes

• E13 Other specified diabetes

122

Type 1.5 Diabetes

• Type 1.5 is:

– A form of diabetes sometimes called “double diabetes,” in which an adult has aspects of both Type 1 and Type 2 diabetes.

– Have autoimmune destruction of beta cells of Type 1 diabetes

– Have insulin resistance characteristic of Type 2 diabetes

– Also known as Latent Autoimmune Diabetes of Adults (LADA).

• Assign a code from E13.-, Other specified diabetes mellitus

123

Primary versus Secondary Diabetes

Primary Diabetes Mellitus

(E10 and E11)

• Caused by the inability of the body to produce or properly use insulin –not by another condition.

• Type 1 (E10) always requires insulin – do not code insulin.

• Type 2 (E11) may require insulin –code insulin use if present.

• If the type of diabetes is not stated, the default is Type 2.

Secondary Diabetes Mellitus

(E08, E09, and E13)

• Always caused by another condition or event such as:

• Cystic fibrosis

• Malignant neoplasm of pancreas

• Pancreatectomy

• Adverse effect of drug

• Poisoning

• May require insulin – code insulin use if present.

• Sequencing based on the Tabular List instructions for each of the categories.

124

Secondary Diabetes• E08.-, Diabetes due to underlying condition

• Code 1st underlying condition• Eg, Cushing's Syndrome, cystic fibrosis, pancreatic cancer

• Use an additional code for insulin (Z79.4) or oral antidiabetic drugs (Z79.84)

• E09.-, Drug or chemical induced diabetes• Code 1st poisoning T36-T65 due to drug or toxin, if applicable

• Use additional code for adverse effect, if applicable, to identify the drug (T36-T65)

• Use an additional code for insulin (Z79.4) or oral antidiabetic drugs (Z79.84)

• E13.-, Other specified diabetes• Use an additional code for insulin (Z79.4) or oral antidiabetic drugs (Z79.84)

• Includes:• Postpancreatectomy DM

• Postprocedural DM

• Secondary DM NEC

125

Hypo or Hyperglycemia? Controlled or Out of Control?

• Per Coding Clinic Q1 2017 guidance, diabetes stated as uncontrolled could be either diabetes with hyperglycemia or with hypoglycemia.

• If the record does not indicate which it is, query the physician.

• Hyperglycemia: high blood glucose (5th character of 5).• Exx.65

• Hypoglycemia: too much insulin and too little glucose in the blood (5th character of 4).

• Exx.64-

• The Alphabetic Index instructs when physician states:

• out of control

• poorly controlled

• E11.65, Type 2 diabetes mellitus with hyperglycemia

126

diabetes, by type, with hyperglycemia

Uncontrolled Flow Sheet

127

Uncontrolled

Out of control

Poorly controlled

Hyperglycemia

Hypoglycemia

Verify

Ver

ify

Diabetic Manifestations

• Diabetes is the largest and most common group of etiology/manifestation combinations.

• The conditions indented below “with” in the Index are assumed manifestations, even in the absence of physician documentation explicitly linking them, unless it is clearly documented that the conditions are not related.

• Most of these pairings do not require a second code.

• One combination code is required EXCEPT for identifying:– Ulcer site;

– Stage of kidney disease;

– Other specified complication (e.g., osteomyelitis); and

– Insulin use.

128

Diabetes (Alphabetic Index)

129

The conditions indented below “with” are assumed manifestations, unless documented as due to another cause. Read documentation thoroughly!

Reminder, for NEC codes, the specific condition must be linked to the main term andcoded – e.g., CAD and MI are not assumed manifestations of diabetes!

Diabetic Manifestations- CKD, Neuropathy: E11.2-, E11.4-

• If the physician documents both diabetic chronic kidney disease and nephropathy, code diabetic CKD only, which is more specific.

• Diabetic polyneuropathy and peripheral autonomic neuropathy are neurological

manifestations.

• Polyneuropathy is damage to multiple nerves on both sides of the body, causing weakness,

numbness, pins-and-needles and burning pain, which usually begins in the hands and feet.

• Autonomic neuropathy is a nerve disorder that affects involuntary body functions, including heart

rate, blood pressure (orthostatic hypotension), perspiration, and digestion (the gut…gastroparesis).

• Gastroparesis is an inclusion term for all types of diabetes. Coding K31.84

(Gastroparesis) following Exx.43 is optional (but it does help to paint the patient

picture).

130

Diabetic Manifestations- circulatory: E11.5-

• Common circulatory manifestations of diabetes are peripheral angiopathy and gangrene.

• What is peripheral angiopathy? Angiopathy = arterial disease. May be documented as diabetic PVD, PAD, peripheral atherosclerosis. Peripheral angiopathy is arterial, not venous, often affecting blood vessels in the legs and feet.

• Blood vessel disease caused by high blood sugar levels.

• Increases risk of atherosclerosis, the build-up of plaque in the arteries. This can limit the blood supply to a body part, which can create the need for amputation.

• E11.51, add atherosclerosis code (eg, I70.2-)

• Cannot code diabetes with gangrene without “automatically” including peripheral angiopathy. When you follow the “with” gangrene, you are directed to:

• E11.52, Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene.

131

Diabetic Manifestations- ulcers

• Common skin manifestations of diabetes are foot ulcers and lower limb ulcers due to the circulatory problems experienced.

132

Diabetic Foot Ulcers E11.621

• Ulceration of the foot is assumed related to diabetes unless another cause is indicated.

• E11.621 has a Use Additional Code convention to identify the site of the ulcer

(L97.4-, L97.5-).

• If the patient had a diabetic foot ulcer in the past, either healed or on an amputated

limb, also code Z86.31, Personal history of diabetic foot ulcer.

133

Diabetic Foot Ulcers and L97.4-, L97.5-

• L97.4 Non-pressure chronic ulcer of heel and midfoot

• L97.5 Non-pressure chronic ulcer of other part of foot

Code First (L97)

any associated underlying condition, such as:

• any associated gangrene (I96)

• atherosclerosis of the lower extremities (I70.23-, I70.24-, I70.33-, I70.34-, I70.43-

, I70.44-, I70.53-, I70.54-, I70.63-, I70.64-, I70.73-, I70.74-)

• diabetic ulcers

(E08.621, E08.622, E09.621, E09.622, E10.621, E10.622, E11.621, E11.622, E13.621

, E13.622)

Remember, diabetic atherosclerosis of the peripheral arteries is coded to Exx.5-, so this must be listed first, before the I70.- code.

134

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=7&sk=I96

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=7&sk=I70.23












https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=7&sk=E08.621










Diabetic Osteomyelitis

• Osteomyelitis is a bone infection

• Can be a complication of diabetes

• E11.69, Type 2 diabetes mellitus with other specified complication

• Has a Use Additional Code convention to identify the complication.

• Use the appropriate code for the osteomyelitis (M86.-) after coding diabetes with other specified manifestation.

• Follow guidance for the addition of other codes as required to specify the complete condition.

135

Secondary diabetes: Post Pancreatectomy

• Since the pancreas is the organ that produces insulin, the removal of even part of it can result in secondary diabetes. In this situation, assign the following codes:

• Postsurgical hypoinsulinemia (E89.1)

• Diabetes code from category E13.-

• Acquired absence of pancreas, total or partial (Z90.41-)

• Insulin use (Z79.4), if applicable

Note: The Z codes may be sequenced after more relevant diagnoses, as applicable.

136

Let’s take a look…Nursing is ordered for management of uncontrolled diabetes which developed

following a pancreatectomy for pancreatic cancer, teaching of insulin administration, and postop assessment.

137

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

M1023d

M1023e

M1023f

Pancreatectomy

138





What diabetes category (type) will be used? (E08., E09., etc.)

Pancreatectomy

139





The physician has stated the uncontrolled diabetes is hypoglycemia.

It is uncertain if the cancer is resolved, so chemotherapy and

radiation will begin in 2 weeks.

Let’s take a look…Nursing is ordered for management of uncontrolled diabetes with hypoglycemia,

which developed following a pancreatectomy for pancreatic cancer, teaching of insulin administration, and postop assessment. Chemotherapy and radiation will be started in 2 weeks.

140

Diagnosis ICD-10-CM

M1021a Postprocedural hypoinsulinemia E89.1

M1023b Other specified diabetes mellitus with hypoglycemia without coma

E13.649

M1023c Aftercare following surgery for neoplasm Z48.3

M1023d Malignant neoplasm of pancreas, unspecified C25.9

M1023e Long-term (current) use of insulin Z79.4

M1023f Acquired total absence of pancreas Z90.410

Key Points for the Scenario

• Reference “Hypoinsulinemia, postprocedural” in the Index.

• Follow the instructional notes at E89.1 to use additional codes, as applicable, to identify the acquired absence of pancreas, diabetes (postpancreatectomy) (postprocedural), and insulin use.

• This does not give sequencing direction. The focus of care, diabetes, which is a result of the pancreatectomy, should be listed immediately after E89.1. Absence of the pancreas and insulin use may be sequenced after the other more relevant diagnoses.

• “Uncontrolled” diabetes is coded with “hypoglycemia” or “hyperglycemia.”

• Z48.3 instructs to use an additional code for the neoplasm.

• The inclusion term for Z90.410 is Acquired absence of pancreas NOS. Therefore, assign this code if total or partial is not stated. (If partial is stated, then use code Z90.411).

141

Diabetes Scenario #1Patient referred with diagnoses of r/o sepsis, gangrene with muscle necrosis of (L) great

toe ulcer, Type I diabetes, and PVD. SN is ordered for administration of IV Vancomycin, lab draws for peak and trough levels, and wound care to the PICC line site and toe.

142

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

M1023d

M1023e

M1023f

Other

Diabetes Scenario #1 CodingPatient referred with diagnoses of r/o sepsis, gangrene with muscle necrosis of (L) great toe

ulcer, Type 1 diabetes, and PVD. SN is ordered for administration of IV Vancomycin, lab draws for peak and trough levels, and wound care to the PICC line site and toe.

143

Diagnosis ICD-10-CM

M1021a Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.52

M1023b Atherosclerosis of native arteries of extremities with gangrene, left leg I70.262

M1023c Type 1 diabetes mellitus with foot ulcer E10.621

M1023d Non-pressure chronic ulcer of other part of left foot with necrosis of muscle L97.523

M1023e Type 1 diabetes mellitus with other manifestation E10.69

M1023f Adjustment and management of vascular access device Z45.2

Other Long-term (current) use of antibioticsEncounter for therapeutic drug level monitoringAttention to nonsurgical dressing

Z79.2Z51.81Z48.00

Key Points for the Scenario• R/O (suspected, uncertain, probable, etc.) diagnoses may only be coded by the

hospital, not home health.

• The toe ulcer, PVD and gangrene are all linked to the diabetes by the “with” convention.

• The instructional note at Z51.81 and Z79 to “Code also” the other condition provides no sequencing guidance.

• Insulin use is not coded with Type 1 diabetes, since all Type 1 diabetics require insulin.

144

Diabetes Scenario #2

Patient developed diabetes with polyneuropathy due to long-term use of steroids, which she continues to take for rheumatoid arthritis. She was started on Glucophage.

145

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

M1023d

M1023e

Diabetes Scenario #2 CodingPatient developed diabetes with polyneuropathy due to long-term use of steroids, which

she continues to take for rheumatoid arthritis. She was started on Glucophage.

146

Diagnosis ICD-10-CM

M1021a Drug or chemical induced diabetes mellitus with neurological complications with polyneuropathy

E09.42

M1023b Adverse effect of glucocorticoids T38.0X5D

M1023c Rheumatoid arthritis, unspecified M06.9

M1023d Long-term (current) use of systemic steroids Z79.52

M1023e Long-term (current) use of oral hypoglycemic drugs Z79.84

Since diabetes is drug-induced, it is coded to E09.

There is no indication that the steroids were not ordered or were taken improperly, so this

is an adverse effect. Sequence the effect(s), T code, then the reason for the drug.

The 7th character for the adverse effect is a “D”

What if the patient was on both an oral antidiabetic medication and insulin?

Overweight/Obesity

E66 Overweight and obesity

Use additional code to identify body mass index (BMI), if known (Z68.-)

E66.0 Obesity due to excess calories

E66.01 Morbid (severe) obesity due to excess calories

E66.09 Other obesity due to excess calories

E66.1 Drug-induced obesity

E66.2 Morbid (severe) obesity with alveolar hypoventilation

Pickwickian syndrome

E66.3 Overweight

E66.8 Other obesity

E66.9 Obesity, unspecified

Reminder, cannot code these conditions (or BMI value) without physician verification!

148

Mental, Behavioral and Neurodevelopmental

Disorders Chapter 5(F01-F99)

149

Documenting Mental and Behavioral Disorders

• Psychiatric/mental disorders should NOT be coded unless documented by the physician.

• A psychiatric/mental disorder, which always impacts the care, should be coded as a comorbidity and addressed in the plan of care.

• A primary diagnosis of a psychiatric/mental disorder may require a psychiatric nurse to provide services. However, certain services, such as administration of IM medications for treatment of a psychiatric diagnosis, do not require a psych nurse.

150

Dementia

Dementia is not a disease; it is a group of symptoms affecting memory, thinking and social abilities that interferes with daily functioning.

• Vascular Dementia: related to different vascular mechanisms.

• Result of infarction of the brain due to vascular disease.

• Typically: CVA

• Dementia in other diseases: due to direct physiological effects of a general medical condition

• Example: Alzheimer’s disease, Parkinsons, Huntingtons

• Unspecified dementia: not a manifestation of another condition. Use when there is no etiology stated by physician.

151

Vascular Dementia (F01)

• A result of infarction of the brain due to vascular disease, including hypertensive

cerebrovascular disease.

• Includes: arteriosclerotic dementia

• Code first the underlying physiological condition or sequelae of cerebrovascular disease.

• Note: Per Coding Clinic, “Code first” applies only when the information is known, except for

etiology/manifestation pairings. However, home health and hospice claims have been rejected

when F01.5- was listed as the primary diagnosis.

• Possible etiologies:

• CVA / Stroke

• Multiple small strokes (“multi-infarct” dementia)

• Hypertensive vascular disease

• Cerebral atherosclerosis 152

Vascular Dementia (cont.)

• F01.5 Vascular dementia

• F01.50 Vascular dementia without behavioral disturbance

• F01.51 Vascular dementia with behavioral disturbance

• Use additional code, if applicable, to identify wandering in vascular dementia (Z91.83).

• When wandering is coded, the corresponding condition should indicate “with behavior problems,” even if the patient does not have other behavioral disturbances.

• Behavioral disturbances include:

• Aggressive behavior

• Combative behavior

• Violent behavior

153

Dementia as a Manifestation

• F02 Dementia in other diseases classified elsewhere

• Code first the underlying physiological condition, such as: Alzheimer’s, dementia with Lewy bodies, frontotemporal dementia, Huntington’s disease, multiple sclerosis, Parkinson’s disease, Pick’s disease, polyarteritis nodosa, etc.

• F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance

• F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance

Use additional code, if applicable, to identify wandering in conditions classified elsewhere (Z91.83)

154

Unspecified Dementia

• F03, Unspecified dementia, has the following code options:

• F03.90 Unspecified dementia without behavioral disturbance

Dementia NOS

• F03.91 Unspecified dementia with behavioral disturbance

• “Use additional code, if applicable, to identify wandering in unspecified dementia (Z91.83)”

• Includes: Presenile dementia NOS, Presenile psychosis NOS, Primary degenerative dementia NOS,

Senile dementia NOS, Senile dementia depressed or paranoid type, Senile psychosis NOS

• Excludes 1: senility (R41.81)

Note:

– There is no “Code first” instruction.

– May be assigned as the primary diagnosis, except in hospice.

155

Mental and Behavioral Disordersdue to Psychoactive Substance Use (F10-F19)

• Assign mental and behavior disorders due to psychoactive substance use only when the provider documents that the psychoactive substance use is associated with a mental or behavioral disorder.

– Alcohol

– Opioid

– Cannabis

– Sedatives, hypnotics

– Other stimulant

– Hallucinogenic

– Nicotine

– Other psychoactive substance

– HOWEVER: if a patient is taking opiates for pain control, and you enter the Z79.891, Long term (current) use of opiate analgesic code, you MAY NOT then enter a code for opiate abuse or dependence without the physician stating this is a disorder.156

Mental and Behavioral Disordersdue to Psychoactive Substance Use (cont.)

• When the provider documentation refers to use, abuse, and/or dependence of

the same substance, only one code should be assigned to identify the pattern of

use, based on the following hierarchy:

• Use + abuse = abuse

• Abuse + dependence = dependence

• Use + dependence = dependence

• Use + abuse + dependence = dependence

Code the longest word!

157

Nicotine Dependence (F17)

• F17.2 Nicotine dependence

• Use the appropriate code to specify nicotine product, when known – cigarettes, chewing tobacco, other, or unspecified.

• F17.21 Nicotine dependence, cigarettes

• If the physician documents “smoker,” assign a code from F17.21- for cigarette use or F17.29- for electronic cigarettes (CC 2nd Q 2017).

• For tobacco use with stated dependency, assign F17.210.

• For tobacco use not otherwise specified, assign Z72.0.

• Assign codes F17.210 and F17.290 for cigarette and e-cigarette use.

• Assign F17.290 if only using e-cigarette or “vaping” with nicotine.

• There is no code for “vaping” without nicotine.

• Do not use code F17.211, Nicotine dependence, cigarettes, in remission, to report a history of tobacco use in a patient who has quit smoking.

• History of smoking should be coded (Z87.891).

158

Mood [Affective] Disorders (F30-F39)

• F31 Bipolar disorder• Manic-depressive illness; Manic-depressive psychosis; Manic-

depressive reaction

• Note: No additional code for depression or depressive disorder should be assigned with bipolar disorder.

• F32 Major depressive disorder, single episode

• F32.9 Major depressive disorder, single episode, unspecified

• Depression NOS; Depressive disorder NOS; Major depression NOS

• F33 Major depressive disorder, recurrent

159

Anxiety Depression (F41.8)

• F41.8, Anxiety depression• Documentation must link depression and anxiety, establishing a cause-and-effect

relationship, such as anxiety with depression – not anxiety and depression. Use of “with” is

interpreted to mean “associated with” or “due to.”

• Anxiety and depression is coded to: F41.9, F32.9

160

Coding Practice for Mental Disorders

• Caffeine use and abuse with anxiety disorder

• Depression and dementia with wandering

• CVA resulting in vascular dementia

161

Coding Practice Answers• Caffeine use and abuse with anxiety disorder

‒ F15.180, Other stimulant abuse with stimulant-induced anxiety disorder

• Depression and dementia with wandering

– F32.9, Major depressive disorder, single episode, unspecified

– F03.91, Unspecified dementia with behavioral disturbance

– Z91.83, Wandering in diseases classified elsewhere

• CVA resulting in vascular dementia

– I69.318, Other symptoms and signs involving cognitive functions following cerebral infarction

– F01.50, Vascular dementia without behavioral disturbance

162

Diseases of the Nervous System

Chapter 6(G00-G99)

163

Systemic Atrophies Primarily Affecting the CNS (G10-G14)

• G14 Postpolio syndrome

• Documentation must specifically state “post polio syndrome.”

• This is different than sequelae of poliomyelitis or residual deficits related

to resolved poliomyelitis.

• When the medical record only specifies residual deficits due to resolved

poliomyelitis, assign B91, Sequelae of poliomyelitis.

164

Parkinson’s vs Parkinsonism

Parkinson’s disease and Parkinsonism are different conditions

• Parkinson’s is “a progressive disorder of the nervous system”

• Essentially normal MRI that excludes other causes for the symptoms

• Parkinsonism is a reference “to symptoms of Parkinson’s disease (e.g., slow

movements and tremors), regardless of the cause”

• Can be caused by several conditions (eg, Muhammad Ali)

• Coding Dementia in Parkinson’s versus Parkinsonism

Per the Coding Tips from DecisionHealth in G20, Parkinson’s Disease:

165

Do not confuse a patient who has Parkinson’s disease with dementia and a patient who has dementia with Parkinsonism. When a patient is reported to have Parkinson’s disease and dementia, assign G20 followed by a code from category F02.8-, Dementia in diseases classified elsewhere. By contrast, dementia with Parkinsonism, which is also known as Lewy body dementia or dementia with Lewy bodies, is coded to G31.83, followed by a code from the F02.8- category. G20 cannot be coded with G31.83.

So….Coding Dementia in Parkinson’s versus Parkinsonism

• Dementia in Parkinson’s

‒ G20, Parkinson’s disease

‒ F02.80, Dementia in other diseases classified elsewhere without behavioral disturbance

Note: There is no instructional note in the Tabular list at G20 to use an additional code for the dementia. But if you look up Dementia in Parkinson’s disease it is indicated as G20 [F02.80].

• Dementia in Parkinsonism

‒ G31.83, Dementia with Lewy bodies (Parkinsonism)

‒ F02.80, Dementia in other diseases classified elsewhere without behavioral disturbance

Look up the manifestation (dementia) in the Index.166

Degenerative Diseases of the Nervous System

• G30 Alzheimer’s Disease

Includes: Alzheimer’s dementia senile and presenile forms

Excludes 1: senile degeneration of brain NEC (G31.1)

senile dementia NOS (F03)

senility NOS (R41.81)

Use additional code to identify:

delirium, if applicable (F05);

dementia with behavioral disturbance (F02.81) (wandering is the most common behavioral disturbance);

dementia without behavioral disturbance (F02.80)

167

Alzheimer’s Disease

G30.0, Alzheimer’s disease with early onset

G30.1, Alzheimer’s disease with late onset

G30.8, Other Alzheimer’s disease

G30.9, Alzheimer’s disease, unspecified

• Early = diagnosed prior to age 65

• Late = diagnosed after age 65

168

Lewy Body DementiaPatient with new diagnosis of Lewy body dementia is admitted for teaching of disease process

and new medication regimen to his wife. He has a history of Parkinsons. He is agitated and has

outbursts that are occurring more frequently.

169

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

M1023d


• Do we code the Parkinsons? How is this captured?

Lewy Body DementiaPatient with new diagnosis of Lewy body dementia is admitted for teaching of disease process

and new medication regimen to his wife. He has a history of Parkinsons. He is agitated and has

outbursts that are occurring more frequently.

170

Diagnosis ICD-10-CM

M1021a Dementia with Lewy bodies G31.83

M1023b Dementia in other diseases classified elsewhere with behavioral disturbance

F02.81

Multiple Sclerosis (MS) (G35)

• If the POC addresses only one MS-related problem:

– List that problem first. For example:

1. Fitting and adjustment of urinary catheter (Z46.6)

2. Urinary incontinence (R32)

3. Multiple sclerosis (G35)

• When focus of the POC – new onset or exacerbation or more than one aspect is being addressed:

– List MS first. For example:

1. Multiple sclerosis (G35)

2. Urinary incontinence (R32)

3. Fitting and adjustment of urinary catheter (Z46.6)

171

Hemiplegia and Monoplegia

• Codes from category G81, Hemiplegia and hemiparesis, and subcategories G83.-,

Monoplegia, identify whether the dominant or non-dominant side is affected.

• Hemiplegia = paralysis of the same side of the body

• Monoplegia = paralysis of one limb or region of the body

• Hemiparesis = weakness of one side of the body

• If the affected side is documented, but not specified as dominant or non-dominant,

and the classification system does not indicate a default, code as follows:

• If the right side is affected, the code default is dominant.

• If the left side is affected, the code default is non-dominant.

• For ambidextrous patients, the code default is dominant.

172

Hemiplegia and Monoplegia

G81, Hemiplegia and hemiparesis, and subcategories G83.-, Monoplegia, are used for patients with causative injuries OTHER THAN cerebrovascular disease (eg, CVA).

• Resultant of brain or spinal cord injuries

1. Code the paralysis/paresis

2. Code the injury with the 7th character “S” to report a sequela of the injury

They have an Excludes 1 note: hemiplegia and hemiparesis due to sequela of cerebrovascular disease (I69.-)

173

CVA

Spinal Cord Injuries (SCI)

• What it is:• The spinal cord is a bundle of nerves that runs down the middle of the back. It carries signals back

and forth between the body and the brain. A spinal cord injury disrupts the signals.

• Injury Types• Predominantly caused by trauma: gun shot wounds, MVA, falls, sporting events.

• Non-trauma: infection, tumors, poor blood flow (ischemia).

• SCI can be classified as:• Complete: total loss of signals

• Incomplete: some movement or sensation below the level of the injury

• Paralysis from a SCI is also known as:• Paraplegia: This paralysis affects all or part of the trunk, legs and pelvic organs. ARMS are NOT

involved.

• Tetraplegia/Quadriplegia: arms, hands, trunk, legs and pelvic organs are all affected by the spinal cord injury.

174

SCI coding guidance• If there are multiple levels of injury, code the highest anatomical injury level only

for each section of the spine.

• E.g.: Injured at C7, T1, T2, T12, L3: code only the C7, T1, L3 injuries.

• Code also any vertebral fractures that occurred (S##.-)

• Code also any open wounds that occurred (S##.-)

175

SCI Sequela

• These are sequela OF the SCI, meaning “…complications or conditions that arise”:

• Contractures

• Quadriplegia

• Paraplegia

• Sequencing Rule:

1. Code FIRST the sequela (for example paraplegia)

2. Then code the injury that precipitated the sequela (eg. SCI that caused the paraplegia). The 7th character “S” is added here to the injury code.

176

Basic Rules for Coding Pain

• Determine if the pain code provides additional information, or, is the pain integral to the condition.

• If it does provide additional information, decide whether it should be primary or secondary.

• If the pain code does not provide additional information, or the pain is integral to the condition, do not use it.

• Code as primary when the reason for the encounter is pain management and not management of the underlying condition.

177

Coding Pain

• Pain codes may be used to provide more detail about: – Acute (G89.1-) pain

– Chronic (G89.2-) pain

– Neoplasm related (G89.3) pain (acute) (chronic)

• There is no time frame for chronic pain, but MD must document or confirm the

diagnosis.

• When the definitive diagnosis is known and the focus of care is not pain

management, do not assign G89 – e.g., knee pain due to osteoarthritis.

178

Postoperative Pain• The provider’s documentation should guide the coding of postoperative pain.

• The default for post-thoracotomy and other postoperative pain not specified as

acute or chronic is the code for the acute form.

• Routine or expected postoperative pain immediately after surgery should not be

coded.

• Specific postoperative complication:

• Postoperative pain not associated with the complication is assigned to a postoperative pain

code in G89.

• Postoperative pain associated with a complication (such as painful wire sutures) is assigned to

the appropriate code(s) found in Chapter 19, Injury, poisoning, and certain other consequences

of external causes. If appropriate, use additional code(s) from category G89 to identify acute

or chronic pain (G89.18 or G89.28).179

Other Pain Codes

• G89.0, Central pain syndrome

• May be due to traumatic or brain-related damage to the central nervous system – e.g., from stroke, MS, tumors, epilepsy, Parkinson’s disease, etc.

• Must be specified by the physician

• G89.4, Chronic pain syndrome

• Not the same as chronic pain

• May be associated with significant psychosocial dysfunction

• Must be specified by the physician

180

Diseases of the Circulatory System

Chapter 9

(I00-I99)

181

Hypertensive Diseases at a glance

• Essential Hypertension (I10): high blood pressure. Force of blood flowing through the veins is consistently too high.

• Hypertensive Heart Disease (I11)

• Hypertensive Chronic Kidney Disease (CKD) (I12)

• Hypertensive Heart and Chronic Kidney Disease (I13)

• Secondary Hypertension (I15): high blood pressure due to another condition.

• Hypertensive Crisis (I16)

182

Causal Relationships• The classification presumes a causal relationship between hypertension and heart

involvement and between hypertension and kidney involvement, as the two conditions are linked by the term “with” in the Alphabetic Index.

183

From the Coding Clinic August 2018:

The word “with” or “in” should be interpreted to mean “associated with” or “due to”…these

conditions should be coded as related even in the absence of provider documentation

explicitly linking them, unless the documentation clearly states the conditions are

unrelated or when another guideline exists that specifically requires a documented linkage

between two conditions…” Official Guidelines for Coding and Reporting, Section 1.A.15

Hypertensive Heart Disease (I11)

• Hypertension with heart conditions classified to I50.- (Heart failure) or I51.4 - I51.9 (Myocarditis; Cardiomegaly) are assigned to a code from category I11.

• Use additional code(s) from category I50, Heart failure, to identify the type(s) of heart failure in those patients with heart failure.

• An additional code for I51.4 - I51.9 is not used if present with hypertension.

• If the provider has specifically documented another cause:

• Code hypertension and heart failure or condition from I51.4-I51.9 separately.

• Sequence based on circumstances of the encounter.

184

Hypertensive Chronic Kidney Disease (I12)

• Assign code from I12, Hypertensive chronic kidney disease, when both hypertension

and a condition classifiable to category N18, Chronic kidney disease, are present.

• CKD will still be coded as hypertensive even if the physician has specifically

documented a different cause, unless it is stated as Unrelated.

• The appropriate code from category N18 should be used as a secondary code to

identify the stage of the CKD.

• For patients with both acute renal failure and chronic kidney disease, an additional code for acute kidney failure (N17.-) is required.

185

What if the patient also has diabetes?

• Diabetes or hypertension may be coded first, depending on which is the focus of care.

• The Chapter-Specific guidance for CKD with other conditions states the sequencing of CKD is based on the conventions in the Tabular List.

• Code N18, Chronic kidney disease, instructs to code first any associated diabetic CKD or hypertensive CKD.

• The codes for diabetic CKD and hypertensive CKD instruct to use a additional code for the stage of CKD.

186

Let’s take a look…Patient was hospitalized with an exacerbation of his HTN and is referred to home care

for blood pressure monitoring and teaching of disease process and new medication regimen. He has co-morbid conditions of diabetes, managed with an oral med, and stage 3 CKD.

187

Diagnosis ICD-10-CM

M1021a Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I12.9

M1023b Type 2 diabetes mellitus with diabetic CKD E11.22

M1023c Chronic kidney disease, stage 3 N18.3

M1023d Long-term use of oral hypoglycemic drugs Z79.84

A different look…Patient was hospitalized with an exacerbation of his diabetes and is referred to home

care for teaching of disease process. He has co-morbid conditions of HTN and stage 3 CKD, and his diabetes is managed with an oral med.

188

Diagnosis ICD-10-CM

M1021a Type 2 diabetes mellitus with diabetic CKD E11.22

M1023b Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I12.9

M1023c Chronic kidney disease, stage 3 N18.3

M1023d Long-term use of oral hypoglycemic drugs Z79.84

Hypertensive Heart and CKD (I13)

• When both hypertensive heart disease (I11) and hypertensive chronic kidney disease (I12) are stated in the diagnosis, assign a combination code from I13.

• Assign additional codes to identify:

• Type(s) of heart failure (I50.-), if present

• Stage of chronic kidney disease (N18.1-N18.4, N18.9)

189

Ischemic Heart Diseases (I20-I25)

• For all categories of ischemic heart disease, use an additional code to identify the presence of hypertension (I10-I16).

• Do not assign a code from I20.- for a patient who also has coronary artery disease (CAD)/atherosclerotic heart disease (ASHD). Angina in a patient with CAD/ASHD should be coded to the appropriate I25.11- code.

190

Acute Myocardial Infarction

• Identify site: anterior, inferior, lateral, or true posterior wall.

• ST elevation myocardial infarction Type I (STEMI)

• Subcategories I21.0 - I21.3

• STEMI – transmural (Q wave)

• I21.9 = default code for acute MI unspecified or unspecified type

• If only Type I STEMI or transmural MI, without the site, is documented, assign code I21.3, ST elevation

MI of unspecified site.

• Type I Non ST elevation myocardial infarction (NSTEMI)

• Code I21.4 = NSTEMI

• Subendocardial, non-Q wave, and nontransmural

• Type I Acute MI documented as nontransmural or subendocardial, with the site identified,

should be coded as subendocardial AMI – I21.4.

191

More About Coding AMIs

• If a Type I NSTEMI evolves to a STEMI, assign the STEMI code.

• If a Type I STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as a STEMI.

• If a patient with CAD is admitted due to an acute MI, the MI should be sequenced before the CAD – NOT assumed with MI.

192

More About Coding AMIs

• An MI is considered “acute” 4 weeks (28 days) or less from the onset and still requires

care. Codes from category I21 are assigned.

• For MIs older than 4 weeks that still require care related to the MI, the appropriate

aftercare code (Z51.89, Encounter for other specified aftercare) should be assigned,

rather than an I21 code.

• For healed or old MIs, which are older than 4 weeks and do not require further care,

assign code I25.2, Old myocardial infarction.

– Index Infarction Myocardium healed or old I25.2

193

Subsequent AMI Codes

• Category I22 ‐ Subsequent MI:

• When a patient who has suffered a Type I MI or unspecified type of MI has a new

Type I AMI within the 4 week time frame of the initial AMI:

• A code from category I22 (Subsequent STEMI or NSTEMI) must be used

• In conjunction with a code from category I21 (STEMI or NSTEMI).

• Sequencing of I21 and I22 codes depends on the circumstances of the encounter.

• I22.- codes are only for Type 1 MI’s

• For subsequent Type 2 AMI, assign only code I21.AI.

• For subsequent Type 3, 4 or 5 AMI, assign only code I21.A9.

194

MI Quick Code Answers

• Patient post MI, unspecified site 2 weeks ago has CAD with angina. No history of prior

CABG. He had been a heavy smoker, but stopped a year ago. Focus of care is the MI.‒ I21.9, STEMI of unspecified site

‒ I25.119, Atherosclerotic heart disease with unspecified angina

‒ Z87.891, Personal history of nicotine dependence

• Patient had an inferior wall Q wave MI 3 weeks ago and was re-admitted to the hospital

for an anterior wall MI 4 days ago. Home care is being resumed. ‒ I21.19, STEMI involving inferior wall

‒ I22.0, Subsequent STEMI of anterior wall

• YOUR TURN: Patient with long standing atherosclerotic coronary artery disease

admitted with a non-ST elevation MI that occurred 45 days ago, and is now diagnosed

with post-infarction angina. – I23.7, Post-infarction angina

– I25.118, Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris 195

Coronary Artery Disease (CAD)

• CAD is atherosclerosis, a build-up of fatty deposits in the coronary arteries, resulting in ischemia (the heart muscle can’t get adequate oxygen).

• Again, if a patient with CAD is admitted for an MI, code the MI first.

• CAD is in the I25.- category

196

CAD and Angina

• Use combination codes for atherosclerotic heart disease with angina pectoris.

• A causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris, unless the documentation indicates the angina is due to another cause.

Note: A separate code for angina is not required when using one of the combination codes.

197

Diastolic and Systolic Dysfunction

• Diastolic dysfunction or systolic dysfunction is coded to I51.89 if not

related to heart failure.

• If related to heart failure, then diastolic heart failure or systolic heart failure

should be coded.

• If these conditions are present with hypertension, then do not code

them. These conditions are included in codes I11 and I13.

• Hypertensive Heart Disease (I11)

• Why not Hypertensive Chronic Kidney Disease (CKD) (I12)?

• Hypertensive Heart and Chronic Kidney Disease (I13)

198

Coding Heart Failure

• If the physician links diastolic or systolic dysfunction to heart failure, then diastolic or

systolic heart failure should be coded.

• Diagnoses of acute heart failure and diastolic dysfunction ≠ acute diastolic heart failure

• Code the heart failure separately

• Include I51.89, Other ill-defined heart diseases

• Do not code integral symptoms if due to heart failure:

• pulmonary congestion

• dependent and pulmonary edema

• Note: fluid overload ≠ edema. Fluid overload might still be coded.

• fluid retention

• SOB

• cough

• fatigue

• pleural effusion199

Coding Heart Failure

If unknown, query the physician as to the type.

• If more than one type of heart failure, code them all.

• Do NOT code CHF in addition to other types of heart failure.

• Is a nonessential modifier – e.g., acute systolic (congestive) HF

• Code acute before chronic.

• If one type of heart failure is acute and another type is chronic, such as acute

systolic heart failure and chronic diastolic heart failure, code the conditions

separately – not acute on chronic.

200

Classification of Stages

• Per the ABCD Classification of the American College of Cardiology

(ACC)/American Heart Association (AHA):

• Stage A is the presence of heart failure risk factors but no heart disease and no symptoms.

Do not code as heart failure.

• Code to Z91.89, Other specified personal risk factors, not elsewhere classified.

• Stage B is where heart disease is present but there are no symptoms. Thus, there are

structural changes in the heart before symptoms occur.

• Stage C involves structural heart disease, with symptoms.

• Stage D is end stage heart failure (I50.84).

201

I50 Heart Failure - More inclusion Terms

• Diagnostic terms added to heart failure terms under I50:

• I50.2 Systolic (congestive) heart failure• Heart failure with reduced ejection fraction [HFrEF]

• Systolic left ventricular heart failure

• Code also end stage heart failure, if applicable (I50.84)

• I50.3 Diastolic (congestive) heart failure• Diastolic left ventricular heart failure

• Heart failure with normal ejection fraction

• Heart failure with preserved ejection fraction [HFpEF] p d(iastolic)


• I50.4 Combined systolic (congestive) and diastolic (congestive) heart failure • Combined systolic and diastolic left ventricular heart failure

• Heart failure with reduced ejection fraction and diastolic dysfunction


202

Hint to remember

Heart Failure Quick Code Answers• HTN, CHF, acute systolic heart failure, and chronic diastolic heart failure with

pulmonary and dependent edema

– I11.0, Hypertensive heart disease with heart failure

– I50.21, Acute systolic (congestive) heart failure

– I50.32, Chronic diastolic (congestive) heart failure,

• YOUR TURN: End stage heart failure with preserved ejection fraction

– I50.30, Unspecified diastolic (congestive) heart failure

– I50.84, End stage heart failure

• YOUR TURN: Hypertension, systolic dysfunction, and stage 5 CKD

– I12.0, Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease

– N18.5, Chronic kidney disease, stage 5

– I51.89, Other ill-defined heart diseases203

NSTEMI

Patient admitted for aftercare following a Type 1 STEMI involving the left anterior descending (LAD) coronary artery due to CAD, and a subsequent CABG 10 days ago. The H&P notes an MI 6 months ago, chronic diastolic heart failure, and chronic systolic heart failure.

204

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

M1023d

M1023e

M1023f

Type 1 STEMI

205


• Do we code the diastolic and systolic heart failure separately or combined?

• What are the appropriate comorbidities?• The STEMI? Why or why not?

• CAD?

• Old MI?

• How do we acknowledge the CABG?

NSTEMIPatient admitted for aftercare following a Type 1 STEMI involving the left anterior

descending (LAD) coronary artery due to CAD, and a subsequent CABG 10 days ago. The H&P notes an MI 6 months ago, chronic diastolic heart failure, and chronic systolic heart failure.

206

Diagnosis ICD-10-CM

M1021a Aftercare following surgery circulatory system Z48.812

M1023b STEMI involving left anterior descending coronary artery I21.02

M1023c Atherosclerotic heart disease of native coronary artery without angina pectoris

I25.10

M1023d Old myocardial infarction I25.2

M1023e Chronic combined systolic (congestive) and diastolic (congestive) heart failure

I50.42

M1023f Aortocoronary bypass status Z95.1

Key Points for that Scenario

• The MI is sequenced first after the surgery aftercare per the guidance manual.

It is coded as acute, since it occurred less than 28 days prior to SOC.

• CAD, the reason for the surgery, is not resolved and is therefore coded still.

• Assign I25.2 (old MI), if an MI occurred greater than 4 weeks after the acute

attack and is not currently presenting with symptoms.

• Since both the diastolic and systolic heart failure are stated as chronic, the

combined code is assigned.

• Coding the bypass status codes identifies the type of surgery performed.

207

CADASIL

• CADASIL = Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy

• Added in the Alpha and Tabular Index

• Found under CADASIL or Arteriopathy.

• I67.850

• Code also any associated diagnosis, such as:

• Epilepsy (G40.-)

• Stroke (I69.8-)

• Vascular dementia (F01.-)

208

Sequelae of Cerebrovascular Disease• The codes at I69 are combination codes that include both the residual condition and

the specific cause of the sequela within six (6) subcategories, defined as:

• I69.0- Sequelae of nontraumatic subarachnoid hemorrhage

• I69.1- Sequelae of nontraumatic intracerebral hemorrhage

• I69.2- Sequelae of other nontraumatic intracranial hemorrhage

• I69.3- Sequelae of cerebral infarction

• Sequelae of stroke NOS

• I69.8- Sequelae of other cerebrovascular diseases

• I69.9- Sequelae of unspecified cerebrovascular diseases (Do not use!)

What if it is a traumatic brain hemorrhage? NOT a CVA – that is an injury. See Chapter 19.

209

I69.3-, Sequelae of cerebral infarction

• Reminder, this is for Sequela of stroke NOS. Used when diagnostic statements do

not specify the site or type of the cerebrovascular condition.

• Includes conditions specified as such or as residuals which may occur at any time

after the onset of the causal condition – in lay terms, this means there is no time

frame for deficits that persist after the initial onset.

• If the residual deficit, the sequelae, is hemiplegia, hemiparesis or monoplegia, the

affected side should be identified as dominant or nondominant.

210

Categories of CVA

I69.3 Sequelae of cerebral infarction

• I69.30 Unspecified sequelae of cerebral infarction

• I69.31 Cognitive deficits following cerebral infarction

• I69.32 Speech and language deficits following cerebral infarction

• I69.33 Monoplegia of upper limb following cerebral infarction

• I69.34 Monoplegia of lower limb following cerebral infarction

• I69.35 Hemiplegia and hemiparesis following cerebral infarction

• I69.36 Other paralytic syndrome following cerebral infarction

• I69.39 Other sequelae of cerebral infarction

211

https://codingcenter.decisionhealth.com/MVC/icd10/Details/I69.3









What if there are no deficits?

Codes from category I69 should not be assigned, if the patient does not have neurologic deficits.

Instead, code Z86.73, Personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits.

212

CVA Practice Patient is admitted to home care with left-sided weakness due to a right CVA. He is

left handed. He also has dysphagia due to the CVA. Therapy has stated the weakness is the greater issue.

Should we also code weakness M62.81?

Should we get the dysphagia stage clarified?

213

diagnosis ICD-10-CM

M1021a

M1023c

M1023d

CVA Practice

Patient is admitted to home care with left-sided weakness due to a right CVA. He is left handed. He also has oropharyngeal dysphagia due to the CVA. Therapy has stated the weakness is the greater issue.

214

Diagnosis ICD-10-CM

M1021a Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side

I69.352

M1023c Dysphagia following cerebral infarction I69.391

M1023d Dysphagia, oropharyngeal phase R13.12

PVD, PAD, Atherosclerosis• I73.9, PVD = Peripheral Vascular Disease. Disease or disorders of the circulatory

system outside of the brain and heart.

• Inclusion terms:

• Intermittent claudication

• Peripheral angiopathy NOS

• Spasm of artery

• Often used as a synonym for peripheral artery disease PAD (I73.9). This is a form of arterial insufficiency – blood circulation is decreased in the vessels that carry blood away from the heart.

• Atherosclerosis: build-up of fatty material inside the blood vessels. Cause of PVD/PAD.

• Atherosclerosis of the extremities is a specific diagnosis: I70.-

215

Venous Diseases

• Venous circulation: blood vessels (veins) carry blood back to the heart.

• Venous diseases:• Venous insufficiency – commonly caused by blood clots (DVT) or varicose veins.

• Venous hypertension – high blood pressure in the veins, can lead to skin problems like leg ulcers.

• Varicose veins – enlarged, dilated veins, overfilled with blood. Due to vein valve failure.

• Phlebitis – inflammation of a vein

• Venous stasis – slow blood flow in the veins.

• Due to different pathologies, each condition must be looked up in the Alpha Index to locate the correct disease process.

216

Coding Vascular Ulcers

• Coding of the ulcer itself will be covered in Chapter 11 (L00-L99)

• Coding arterial and venous ulcers is the same process

• First code the underlying disease process, e.g., atherosclerosis or venous insufficiency

• Next assign a code from L97.- to specify the location and severity of the ulcer

• Read all notes – it may be the Coding Tips that point you in the direction of including the code for the ulcer.

• For example, I87.2, Venous insufficiency, does not have a or Code Also convention. But it

does have a coding tip to add the ulcer code if the physician documents “stasis ulcer”.

217

I96 (Gangrene)

• I96, Gangrene, not elsewhere classified

• There is an Excludes I note at I96 for gangrene in other peripheral vascular diseases

(I73.-).

• Can assume that if a patient has gangrene, they also have PVD, but it does not

mean that if a patient has PVD, they also have gangrene. All beagles are dogs, but

not all dogs are beagles!

• The physician should specify the type of PVD.

Recommendation: If a patient has both PVD and gangrene, sequence

according to circumstances, until further guidance is received from the

Coding Clinic.

218

I96 (Gangrene)

• When diabetes and gangrene are both indicated in the documentation, the classification

makes the related link.

• Can get to E11.52 by looking up:

Gangrene with diabetes: See Diabetes, gangrene

Diabetes with gangrene

• Atherosclerosis + gangrene?: I70.26, Atherosclerosis of native arteries of extremities

with gangrene

• Diabetes and a gangrenous pressure ulcer? NO LINK.

• I96 and L89.- and E11.9

219

Diseases of the Respiratory System

Chapter 10

(J00-J99)

220

General Respiratory Chapter Notes

• Refer to the beginning of Chapter 10, Diseases of the Respiratory System, for notes that apply to all codes within this chapter.

• When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site (e.g., tracheobronchitis bronchitis in J40).

Pay close attention to the many inclusions and exclusions!

221

Respiratory Infections

• Influenza: since it involves both an upper and lower respiratory

infection, it does NOT meet the criteria to be assigned as a lower

respiratory infection in COPD.

• Acute bronchitis, pneumonia: may be included as a lower respiratory

infection in COPD.

222

Coding Pneumonia (J12-18)

• Code pneumonia using a combination code specifying the causative organism, when available.

• When no combination code exists, use an additional code from Chapter 1 (B95-B97) to identify the organism, if known.

• J18.-, Pneumonia, unspecified organism

• Code Lobar pneumonia to J18.1.

• Code Community-acquired pneumonia (CAP) to J18.9.

• Do not assign J18, if the causative agent is known.

Note: Instructional note at all categories to “Code first associated influenza, if applicable.”

223

Lobar Pneumonia, J18.1

• J18.1 assigned when:

• Causal organism is not specified

• Documentation indicates the pneumonia is specific to a lobe or part of a lobe

Per Coding Clinic 3rd quarter 2018:

If the specific organism causing the pneumonia is documented, assign a combination code indicating the specific pneumonia with the responsible organism.

224

Respiratory Coding

• The Alpha Index leads to J43.9, instead of J44.9, when searching Disease, lung, obstructive (chronic), with emphysema.

• Therefore, emphysema with unspecified COPD, whether chronic or an acute exacerbation, is coded to J43.

• If the COPD is further specified, such as chronic obstructive bronchitis or chronic obstructive asthma, assign a code from category J44.

• The instruction at J44.0, Chronic obstructive pulmonary disease with acute lower respiratory infection, states, “Code also to identify infection,” which allows either the code or the acute infection to be sequenced first.

Note: Aspiration pneumonia (J69.0) and ventilator-associated pneumonia (J95.851) are not

considered to be lower respiratory infections for J44.0.

225

Chronic Lower Respiratory Diseases

•J44 Other chronic obstructive pulmonary disease

–asthma with COPD–chronic asthmatic (obstructive) bronchitis–chronic bronchitis with airways obstruction–chronic bronchitis with emphysema–chronic emphysematous bronchitis–chronic obstructive asthma–chronic obstructive bronchitis–chronic obstructive tracheobronchitis

226

INCLUDES

COPD

• COPD is a generic term that represents any form of unspecified chronic obstructive lung disease with irreversible airway obstruction

• Comprised primarily of 3 related conditions:

• Chronic obstructive bronchitis

• Chronic obstructive asthma

• Chronic obstructive emphysema

• The default code for COPD is J44 with 3 subcategories:

• J44.0, Chronic obstructive pulmonary disease with acute lower respiratory infection

• Use additional code to identify the infection

• J44.1, Chronic obstructive pulmonary disease with (acute) exacerbation

• J44.9, Chronic obstructive pulmonary disease, unspecified

227

Exacerbation of COPD

• An acute exacerbation is a worsening or decompensation of a chronic condition and is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection.

Per the Coding Clinic…

– When assigning a code for end-stage chronic obstructive pulmonary disease (COPD), coders should not assume that “exacerbation” is synonymous with end stage.

– Therefore, in the absence of a specifically assigned code, when the physician documents end-stage lung disease, it would not be appropriate to assign a code for COPD exacerbation.

Code assignment for exacerbation is solely based upon the physician’s documentation of the condition!

228

COPD & Emphysema examples

• Emphysema with other specific components of COPD (eg, chronic obstructive bronchitis or chronic obstructive asthma): J44.-

• Emphysema and COPD: J43.9

• Emphysema and COPD exacerbation: J43.9

• “COPD exacerbation with emphysema” is coded to J43.9, and not J44.1, because the emphysema is a type of COPD and the term “COPD” doesn’t automatically mean chronic bronchitis.

• Emphysema, chronic obstructive bronchitis and COPD exacerbation: J44.1

• COPD with (acute) exacerbation: J44.1

229

COPD Wrap-up

Emphysema Emphysema and COPD

Emphysema / Chronic Bronchitis

COPD / Chronic Bronchitis

J43.- J43.- J44.- J44.-

230

Asthma J45.-

• Asthma is a condition in which your airways narrow and swell and produce extra

mucus. This can make breathing difficult and trigger coughing, wheezing and

shortness of breath.

• Reversible airway obstruction (vs. COPD, which is irreversible)

• Can have both asthma and other types of COPD

• When documentation indicates COPD of any type + any specified type of asthma, or

exacerbation of asthma, the asthma should also be coded (J45.-).

• If the physician has not specified the type of asthma, do not add the J45 code for asthma.

Example, do not add J45.909, Unspecified asthma, as unspecified is not a type of asthma.

231

Bronchitis and COPD

Patient is admitted to home care with acute bronchitis and decompensating COPD. He complains of SOB and weakness. He continues on a 10-day course of antibiotics for the bronchitis, which is the focus of care. He also has asthma and is on oxygen.

232

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

M1023d

Bronchitis and COPDPatient is admitted to home care with acute bronchitis and decompensating COPD. He

complains of SOB and weakness. He continues on a 10-day course of antibiotics for the bronchitis, which is the focus of care. He also has asthma and is on oxygen.

233

Diagnosis ICD-10-CM

M1021a Acute bronchitis, unspecified J20.9

M1023b COPD with acute lower respiratory infection J44.0

M1023c COPD with (acute) exacerbation J44.1

M1023d Dependence on supplemental oxygen Z99.81

J44.0 instructs “Code also: to identify the infection.” Sequence according to the POC. Decompensated/decompensating COPD is equivalent to an exacerbation of COPD. If the physician confirms both a diagnosis of a lower respiratory infection and an exacerbation of COPD,

both J44.0 and J44.1 should be assigned. Asthma with COPD is coded to J44, unless the type of asthma is specified. Short-term use of antibiotics to treat an acute infection is not coded.

COPD and EmphysemaPatient admitted following hospitalization for an exacerbation of COPD. She also

has emphysema. While in the hospital, she was treated for recurrent Clostridium difficile, and will continue on oral antibiotics for 5 more days. COPD is the focus of care.

234

Diagnosis ICD-10-CM

M1021a

M1023b

COPD and EmphysemaPatient admitted following hospitalization for an exacerbation of COPD. She also has

emphysema. While in the hospital, she was treated for recurrent Clostridium difficile, and will continue on oral antibiotics for 5 more days. COPD is the focus of care.

235

Diagnosis ICD-10-CM

M1021a Emphysema, unspecified J43.9

M1023b Enterocolitis due to Clostridium difficile, recurrent A04.71

Emphysema and unspecified COPD, whether chronic or an acute exacerbation, is coded to J43. See Index – Disease – lung – obstructive (chronic) – emphysema. This was also confirmed by the Coding Clinic.

Short-term use of antibiotics to treat an infection is not coded.

Pleural Effusion

• Pleural effusion (water on the lungs) is caused by the build-up of fluid between the pleura layers outside the lungs.

• Coded to J90, Pleural effusion, NOS

• Causes heart failure, cirrhosis, pneumonia, cancer

• Malignant pleural effusion has been caused by cancer

• Pleural effusion that occurs in other conditions:

• J91.0: malignant pleural effusion (code 1st underlying neoplasm)

• J91.8, manifestation code for pleural effusion in conditions classified elsewhere (code

1st underlying disease)

• Pleural effusion and CHF: code J91.8 in addition to the CHF code from I50.- only if

the condition is being specifically evaluated or treated.

236

Diseases of the Digestive System

Chapter 11(K00-K95)

237

Gastroparesis

• K31.84, Gastroparesis

• Inclusion term: gastroparalysis

• Code first underlying disease, if known, such as:

• anorexia nervosa (F50.0-)

• diabetes mellitus (E08.43, E09.43, E10.43, E11.43, E13.43)

• scleroderma (M34.-)

Note: There is no instructional note in the Index or Tabular List at diabetes to use an additional code for gastroparesis. Coding Clinic has stated a separate code for DM is optional, but not required since the combination code under diabetes includes both conditions. However, if you look at these codes, the description does not specifically state gastroparesis – it is a clarifying term. It is recommended to add the K code to “paint the picture”.

238

Ostomy Complications

• All colostomy, gastrostomy, enterostomy, and esophagostomy complications are

coded to category K94.

• This includes:• Mechanical complications

• e.g. excoriation and denuding of the skin surrounding the ostomy

• Infection of the ostomy site

• Hemorrhage of the ostomy site

• other complications

• No additional code should be used when coding skin complications unless an

infection is present – e.g., cellulitis.

• An additional code should be used to specify the infection and also the organism, if known.

• When there is an ostomy complication, do not assign a code for the ostomy status,

since it is included in the complication code.

239

Diseases of the Skin and Subcutaneous Tissue

Chapter 12(L00-L99)

240

Abscesses and Cellulitis

• Cellulitis = bacterial skin infection

• Abscess = tender mass full of pus and debris. So by definition, they are infected,

so follow the “use additional code” convention to identify the organism.

• Abscess does not automatically code to L02.-

• The code will follow by location:

• Eg, skin = L02.-; breast = N61.-; bone = osteomyelitis; post-surgical = complication T81.4-

• There is an instructional note for categories L00-L08 to: Use additional code (B95-B97) to identify infectious agent

• Sequence the organism after the infection.

• If you don’t know the organism, don’t code it.

241

Cellulitis and Acute Lymphangitis (L03)

• L03 Cellulitis and acute lymphangitis

• Cellulitis: A spreading bacterial infection of connective soft tissue extending into deep dermal and subcutaneous layers; produces circumscribed swelling, fever, and swollen lymph glands.

• Acute lymphangitis: A quickly spreading bacterial infection of the lymph vessels appearing as painful, red streaks visible throughout the skin surface.

• To find the codes, look under each main term in the Index.

• Use additional code (B95-B97) to identify organism (for L00-L08)

• The 4th, 5th, and 6th character identifies cellulitis or acute lymphangitis and the location.

• If cellulitis is associated with a wound or ostomy, sequence the wound or ostomy complication first.

242

Question from coder…

How should I code a patient with CHF who has edema, redness, and draining blisters on her lower legs? Would this be cellulitis?

• This is known as weeping edema, and the blisters are vesicular eruptions.

• Look in the Index under Blister, multiple, skin, nontraumatic R23.8 or Eruption, vesicular R23.8.

• Sequence the CHF, I50.9, first.

I50.9, CHF

R23.8, Other skin changes

243

What if the patient also has cellulitis?Patient has exacerbated CHF and cellulitis of her lower legs with worsening edema and

weeping blisters due to her CHF, which is the focus of care. Wound care and 7 days of

oral antibiotics ordered.

244

Diagnosis ICD-10-CM

M1021a Heart failure, unspecified I50.9

M1023b Cellulitis of right lower limb L03.115

M1023c Cellulitis of left lower limb L03.116

M1023d Other skin changes R23.8

Edema is integral to heart failure, so it is not coded. If the causative organism of the cellulitis is known, it would be sequenced immediately after the

cellulitis codes. Encounter for change or removal of non-surgical dressings (Z48.00) is not coded, due to the

complication (infection). Short-term use of antibiotics is also not coded.

PDGM Impact

245HHRG = 1.4818 (Cardiac_High)

What if the cellulitis is the focus of care?

Patient has exacerbated CHF and cellulitis of her lower legs with worsening edema and

weeping blisters due to her CHF. The cellulitis is the focus of care. Wound care and 7

days of oral antibiotics ordered.

246

Diagnosis ICD-10-CM

M1021a Cellulitis of left lower limb L03.116

M1023b Cellulitis of right lower limb L03.115

M1023c Heart failure, unspecified I50.9

M1023d Other skin changes R23.8

Edema is integral to heart failure, so it is not coded. If the causative organism of the cellulitis is known, it would be sequenced immediately after the

cellulitis codes. Encounter for change or removal of non-surgical dressings (Z48.00) is not coded, due to the

complication (infection). Short-term use of antibiotics is also not coded.

PDGM Impact

247

HHRG = 1.614 (Wound_Medium)

Unstageable vs. Unspecified

• Unstageable pressure ulcers (L89._ _0)• Should be based on clinical documentation and coded when the stage

cannot be clinically determined due to:

• Eschar/slough

• Skin or muscle graft

• Deep tissue injury not due to trauma

• Unspecified stage (L89._ _9)

• Intended for when there is no clinical documentation regarding the stage

Should not be used, since the stage can be coded based on the assessing clinician’s documentation

248

More guidance…

Skin Graft

• Aftercare following a skin graft is coded as an organ transplant (Z48.298).

• If a skin graft is not healing and is breaking down, this would be a complication of the skin

graft and would be coded T86.821, Skin graft (allograft) (autograft) failure. A complication

of a skin graft is a complication of an organ transplant.

• If a skin graft healed completely and reopens at the same site, it is coded as the worst stage it

was prior to the skin graft.

Muscle Flap

• Aftercare following a skin graft is coded as aftercare for skin and subcutaneous

tissue (Z48.817).

• If a muscle flap is not healing and is breaking down, this would be a complication of the

muscle graft and would be coded T84.410-, Breakdown (mechanical) of muscle and tendon

graft. 249

More guidance…

• Per WOCN guidance, stage 2 pressure ulcers do NOT include:

• Moisture associated skin damage

• Incontinence associated dermatitis

• Intertriginous dermatitis

• Medical adhesive related skin injury

• Traumatic wounds

• Medical Device related Pressure Ulcer

• Code as a pressure ulcer

• Code also Y79.2, Prosthetic and other implants, materials and accessory orthopedic devices associated with adverse incidents

250

Pressure Ulcer coding at-a-glance

• Treated with skin graft:

• Code as Unstageable pressure ulcer

• Z48.298, Encounter for aftercare following other organ transplant

• Treated with muscle flap


• Z48.817, Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue

• Debrided

• Code as a pressure ulcer; debridement is not surgery

• Sutured closed


• Surgically excised

• Code Z48.817, Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue

• No longer a pressure ulcer, it is now a surgical wound251

Pressure Ulcers surgically treated gone bad….

• Pressure ulcer treated with skin graft that is not healing

• Code: T86.821, Skin graft (allograft) (autograft) failure

• Follow use additional code instructions

• Code: unstageable pressure ulcer

• If, due to graft failure, the pressure ulcer becomes observable, code at its worst stage

• Code Z48.298, Encounter for aftercare following other organ transplant

• Pressure ulcer treated with muscle flap that is not healing

• Code: T86.891, Other transplanted tissue failure

• Code: unstageable pressure ulcer

• If, due to flap failure, the pressure ulcer becomes observable, code at its worst stage

• Code Z48.817, Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue

252

Pressure ulcer scenario…

Patient admitted for wound care to a gangrenous stage 3 pressure ulcer on the left hip and a healing stage 4 pressure ulcer on his right ankle. He also has diabetes, which is well-controlled with Metformin.

253

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

M1023d

M1023e

Coding for scenario…Patient admitted for wound care to a gangrenous stage 3 pressure ulcer on the left hip and

a healing stage 4 pressure ulcer on his right ankle. He also has diabetes, which is well-controlled with Metformin.

254

Diagnosis ICD-10-CM

M1021a Gangrene, not elsewhere classified I96

M1023b Pressure ulcer of left hip, stage 3 L89.223

M1023c Pressure ulcer of right ankle, stage 4 L89.514

M1023d Type 2 diabetes mellitus without complications E11.9

M1023e Long-term (current) use of oral hypoglycemic drug Z79.84

There is an instructional note at L89 to “Code first any associated gangrene (I96).” Sequence multiple ulcers according to severity, not necessarily the worst stage. The gangrenous

stage 3 would be more serious than the healing stage 4. This is not diabetic gangrene. The gangrene is linked to the pressure ulcer. Z48.00, Encounter for nonsurgical dressing, would NOT be coded for the complicated ulcer, but can

add one for the healing ulcer (ankle).

Chronic Ulcers Lower Extremity (L97)

• The Coding Clinic believes that all lower extremity ulcers require a minimum of two codes.

• If the medical record does not describe the underlying etiology, the physician should be queried.

• Clinicians are permitted to determine the severity of non-pressure ulcers based on clinical documentation.

• For all non-pressure chronic ulcers of the lower extremity, not elsewhere classified:

• Code first the underlying etiology;

• Followed by the code for the location and severity of ulcer.

• If there is gangrene, it should be coded first (I96) – see the code first note

• If the etiology code includes gangrene, do not add I96 as well.

255

What is NOT a non-pressure chronic ulcer:

• Traumatic wounds

• Pemphigoid lesions

• Cancerous lesions

• Blisters, scabs, keloids, keratosis

• Maceration due to incontinence, friction or irritants

• Breakdown of a surgical wound

• Drained/incised hematoma

• Cellulitis

• Abscess

• Dermatitis

• Eczema

256

Venous Stasis Ulcers

• Venous stasis ulcers are thought to occur due to improper functioning of venous valves, usually of the legs.

Index: Ulcer Stasis (venous) – See Varix, leg, with ulcer without varicose veins I87.2

I87.2 = Venous insufficiency (chronic) (peripheral)

• There is no instructional note to use an additional code for the ulcer at I87.2, but there is at I83.2 (varicose veins), I70.- (arterial ulcers) and other codes.

• However, L97.-, with the location and severity, should be coded for all non-pressure ulcers and has the instruction to “Code first any associated underlying condition.”

257

Arterial Ulcers

• Arterial ulcers, also known as ischemic ulcers, are caused by a lack of blood flow due

to blocked arteries in the lower extremities (atherosclerosis/arteriosclerosis), which are

mostly located on the lateral surface of the ankle or the distal digits.

• Index: Atherosclerosis (see also arteriosclerosis) Arteriosclerosis extremities (native

arteries) leg with: (gangrene, and intermittent claudication, rest pain and ulcer)

• Use additional code to identify severity of ulcer (L97.-).

258

Non-Pressure Ulcer Examples

• Atherosclerosis of native arteries of the left leg with an arterial ulcer of left ankle involving bone breakdown without necrosis

– I70.243, Atherosclerosis of native arteries of left leg with ulceration of ankle

– L97.326, Non-pressure chronic ulcer of left ankle with bone involvement without evidence of necrosis

• Stasis ulcer involving varicose veins of right lower extremity with ulcer of plantar surface of midfoot involving skin only

– I83.014, Varicose veins of right lower extremity with ulcer of heel and midfoot

– L97.411, Non-pressure ulcer of right heel and midfoot limited to breakdown of skin

259

Quick Codes

• Diabetic ulcer right great toe with fat exposure

• Stage 3 pressure ulcer of contiguous area involving the buttock and hip

• Stasis ulcer of right calf with muscle involvement

260

Quick Code Answers

• Diabetic ulcer right great toe with fat exposure

• E11.621, Type 2 diabetes mellitus with foot ulcer

• L97.522, Non-pressure chronic ulcer of other part of left foot with fat layer exposed

• Stage 3 pressure ulcer of contiguous area involving the buttock and hip

• L89.43, Pressure ulcer of contiguous site of back, buttock, and hip, stage 3

• Stasis ulcer of right calf with muscle involvement

• I87.2, Venous insufficiency

• L97.215, Non-pressure chronic ulcer of right calf with muscle involvement without evidence

of necrosis

261

Diseases of the Musculoskeletal System and Connective Tissue

Chapter 13(M00-M99)

262

What’s included?

• Chapter 13 includes codes for:

• Musculoskeletal disorders and conditions that have resulted from pathology,

not trauma;

• Bone, muscle, or joint conditions that are the result of a healed injury;

• Chronic or recurrent bone, muscle, or joint conditions.

Note: Any current, acute injury should be coded to the appropriate

injury code in Chapter 19 with the appropriate 7th character to indicate

the encounter.

263

Musculoskeletal Disorders vs Injuries –are you looking in the correct chapter?

Chapter 13 Musculoskeletal

• Healed injuries that cause bone, joint or muscle conditions

• Chronic or recurrent bone, joint or muscle conditions

• Chronic conditions induced by a traumatic event (traumatic arthritis)

Chapter 19 Injuries

• Current, acute injuries

• Current condition caused by trauma

• Sequela of traumatic injury

264

Arthritis

• Arthritis is a form of arthropathy

• Arthritis is a broad name given to any inflammatory joint disease, e.g.:

• Osteoarthritis

• Rheumatoid Arthritis

• Gout / Pseudogout

• Psoriatic arthritis

• SLE (Lupus)

• arthritis, arthritic (acute) (chronic) (nonpyogenic) (subacute) M19.90

• degenerative See Osteoarthritis

265

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=Arthritis, arthritic

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=(acute) (chronic) (nonpyogenic) (subacute)

https://codingcenter.decisionhealth.com/MVC/ICD10/Details/M19.90?includeResults=true

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=degenerative

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=Osteoarthritis

Osteoarthritis• What it is:

• Sometimes called degenerative joint disease or “wear and tear” arthritis, osteoarthritis (OA) is the most common chronic condition of the joints.

• It occurs when the cartilage or cushion between joints breaks down leading to pain, stiffness and swelling.

• Also known as:

• degenerative joint disease or degenerative arthritis

266

Osteoarthritis

• Code osteoarthritis (OA) in a patient’s joint as primary osteoarthritisif the type of OA, such as primary, secondary or generalized, is not specified, according to the Q4 2016 Coding Clinic update.

“When the type of osteoarthritis is not specified, “primary” is the default.” For example, you should assign M16.0 (Bilateral primary osteoarthritis of hip) for a patient documented as having bilateral osteoarthritis of the hips.

267

Osteoarthritis

Osteoarthritis M19.90

ankle M19.07

elbow M19.02

foot joint M19.07

+ generalized M15.9

+ hand joint M19.04

+ hip M16.1

+ interphalangeal

+ knee M17.9

+ post-traumatic NEC M19.92

+ primary M19.91

+ secondary M19.93

268

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=Osteoarthritis


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=ankle


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=elbow


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=foot joint


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=generalized


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=hand joint


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=hip


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=interphalangeal

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=knee


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=post-traumatic NEC


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=primary


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=secondary


+ primary M19.91

• Well, the Coding Clinic said if the osteoarthritis is unspecified, we can code primary as the default. So can I just use M19.91? When we expand this code:

• primary M19.91

ankle M19.07

elbow M19.02

foot joint M19.07

+ hand joint M19.04

+ hip M16.1

+ knee M17.1

shoulder M19.01

spine See Spondylosiswrist M19.03

269

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=primary


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=ankle


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=elbow


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=foot joint


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=hand joint


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=hip


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=knee


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=shoulder


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=spine

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=Spondylosis

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=wrist


M15 vs M19M15.0 Primary generalized (osteo)arthritis

• Includes (M15)

• arthritis of multiple sites

M19.90 Unspecified osteoarthritis, unspecified site

• Clarifying Terms

• Arthrosis NOS

• Arthritis NOS

• Osteoarthritis NOS

270

Rheumatoid Arthritis M05.-, M06.-

Coding Tips (M05)

• Rheumatoid arthritis classified here includes rheumatoid arthritis and associated conditions (see combination codes) that have an identified rheumatoid factor present. Do not assume the presence of rheumatoid factor when a diagnosis of rheumatoid arthritis is noted in the clinical record.

• Rheumatoid arthritis that is not specified with rheumatoid factor is coded to M06.-. There are many associated conditions that the classification assumes are related to rheumatoid arthritis. Consult the alphabetic index "arthritis, rheumatoid, with."

271

Coding Osteomyelitis

• Osteomyelitis can be assumed to be related to diabetes mellitus, unless another cause is stated (e.g., injury).

• Get as much information as possible:

• The causative organism

• Specific site

• Acute versus chronic (chronic must be confirmed by the physician)

• Has a Use Additional Code convention:

• Infectious agent (B95-B97) (causative organism)

• Identify any major osseous defect prn (M89.7-)

• Major osseous defect: absence or imperfection of bony structure as a result of extensive bone loss

272

Osteoporosis, NO Pathological Fracture• Osteoporosis is a systemic condition, meaning all the bones of the musculoskeletal

system are affected.

• M81, Osteoporosis without current pathological fracture, does not require a specific code for location.

• Default code is M81.0, Age-related osteoporosis without current pathological fracture, if the type of osteoporosis is not identified.

• M81.8-, Other osteoporosis without current pathological fracture

• Drug-induced, post-traumatic, idiopathic, etc.

• Add a code for personal history of healed osteoporosis fracture (Z87.310), if applicable.

273

Osteoporosis WITH Pathological Fracture• Site codes under M80, Osteoporosis with current pathological fracture, are

combination codes that identify the site of the fracture due to osteoporosis.

• A code from category M80 should be used when:

• Patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.

• Do not use a traumatic fracture code.

• Add a code for personal history of healed osteoporosis fracture (Z87.310), if

applicable.

274

Other Pathological Fractures

• Due to cancer:• M84.5-, Pathological fracture in neoplastic disease

• Code also underlying neoplasm

• Due to other disease• M84.6-, Pathological fracture in other disease

• Code also underlying condition

• Pathological fractures NEC• M84.4-, Pathological fracture, NEC

• Code also underlying cause if able to determine

• Stress fractures • M84.3-, Stress fracture

• Code also external cause

275

Periprosthetic Fracture

• A periprosthetic fracture is a broken bone that occurs around the implants of a total joint replacement or internal fixation device.

• Periprosthetic fracture coding:

• Captured with 2 codes:

1. Code for the specific traumatic or pathologic fracture

2. Code from the M97.- category (Periprosthetic fracture around internal prosthetic joint) in Chapter 13.

• If the prosthesis itself is broken:• Per Q4 2016 Coding Clinic guidance, if the prosthetic joint itself is fractured, then it is not a

periprosthetic fracture

• Is a complication of the implanted joint and should be captured with a code from T84.01- (Broken internal joint prosthesis) in Chapter 19.

276

Periprosthetic Fractures (cont.)

• Determine if the patient’s periprosthetic fracture is traumatic or pathologic.

• Two codes are required to fully capture this condition when it is the focus of home health care:

• The code for the specific fracture, whether traumatic or pathologic, and

• The code for the periprosthetic fracture.

• Sequence the traumatic or pathologic fracture first

• Such as with a code from S72.- category (Fracture of femur) or the M84.45- subcategory (Pathological fracture, femur and pelvis)

• Then follow it with the periprosthetic fracture code from the M97.- category.

277

Periprosthetic Fracture (cont.)

• For example, a patient who fell down the stairs, which resulted in a displaced periprosthetic fracture of her right intertrochanteric femur near her right hip prosthesis, would be coded:First with S72.141D, Displaced intertrochanteric fracture of right femur, subsequent

encounter for closed fracture with routine healing; and

Then with M97.01xD, Periprosthetic fracture around internal prosthetic right hip joint, subsequent encounter.

• Code a periprosthetic fracture with the appropriate fracture codes, even after it has been surgically repaired.

278

Diseases of the Genitourinary System

Chapter 14(N00-N99)

279

Chronic Kidney Disease

• Chronic Kidney Disease (CKD) is coded by the stage of the disease as stated by the physician.

• Codes are in the N18.- category:

• N18.1 = stage 1

• N18.2 = stage 2, mild CKD

• N18.3 = stage 3, moderate CKD

• N18.4 = stage 4, severe CKD

• N18.5 = stage 5, not requiring dialysis. If dialysis is required, code N18.6.

• N18.6 = End stage CKD (ESRD)

• N18.9 = CKD, unspecified stage

280

CKD

• If the patient is receiving dialysis (HDU or peritoneal), code as ESRD N18.6.

• Capture the dialysis (peritoneal or hemodialysis): Z99.2

• If both a stage of CKD and ESRD are documented, assign code N18.6 only.

• ESRD N18.6 can NOT be coded as primary in home health, as this would be a duplication of services (of the HDU facility).

• The stage may not be coded based on lab data such as the glomerular filtration rates (GFR).

281

Kidney Transplants

• Patients who have had kidney transplants may still have some degree of CKD, as the transplant may not fully restore kidney function.

• This is NOT considered a complication

• Code from N18.- for the stage of CKD

• Code also Z94.0, Kidney transplant status

282

Neurogenic Bladder

• Bladder dysfunction caused by neurologic damage such as a brain, spinal cord or nerve problem.

• Nerve damage can be the result of diseases such as MS, Parkinsons, diabetes.

• Symptoms: overflow incontinence, frequency, urgency, urge incontinence, retention.

• So, do we code these as well?

• Complications risks: recurrent infection, autonomic dysreflexia (dangerous spike in

BP), kidney failure, etc.

• Code as N31.9, Neuromuscular dysfunction of bladder, unsp.

• Assign additional code for any associated urinary incontinence from N39.3, N39.4

283

Injuries and Other Consequences of

External CausesChapter 19

(S00-T88)

284

Chapter-Specific Guidance

• The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent care.

– For example, for aftercare of an injury, assign the acute injury code with the appropriate 7th character “D”.

285

Coding Injuries

• Assign separate codes for each injury, unless there is a combination code.

• Do not code surgical wounds, whether healing or complicated, as traumatic injuries (S00. - T14.9).

• Even if the traumatic injury received sutures, it is still coded as a traumatic injury.

• Do not code superficial injuries, such as abrasions or contusions, when associated with more severe injuries of the same site.

• Sequence the code for the most serious injury first.

286

Traumatic Fractures• Fracture coding requires documentation of:

• Site;

• Laterality;

• Type of fracture;

• Whether it is displaced or not displaced;

• The encounter – initial, subsequent, or sequela; and

• The stage of healing.

• The fracture is coded with the appropriate 7th character.

287

Open Wounds

• Trauma wound = Open wound

• Open wound codes are meant only for traumatic injuries.

• NEVER code medically caused wounds as open wounds.

• Includes:

• Animal bites (venomous and nonvenomous)

• Abrasions, avulsions, contusions, skin tears

• Lacerations and cuts, puncture wounds

• Traumatic amputations

• 7th character is required.

• No aftercare Z code for surgery for injury / trauma.

Always ask: What kind of trauma is this?

288

Bites

• Coding bites depends on the kind of bite:

• Venomous bites: look up under the Table of Drugs & Chemicals

• Nonvenomous bites (insect, snake): code as Injury

• Animal bites: code as Injury:

• Contusion (superficial injury) if skin is intact

• Trauma wound (open wound) if skin is not intact

289

Superficial Injuries• Superficial: the injury involves the superficial structures, such as the first layer of

epidermis.

• Includes:

• Abrasions

• Blisters

• Contusions

• Uncomplicated skin tears

• Classified by body site, search in Alpha under “Injury, superficial”, then to body site

• Be sure you are getting the distinction between superficial injuries and trauma wounds correct.

• For correct coding, know:

• Correct wound assessment, thorough documentation that further describes the home health interventions

• Knowledge of the Payne-Martin skin tear classification tool

• Adherence to your MAC guidelines for what constitutes a need for skilled nursing care

290

Skin Tears

• Most skin tears are partial thickness wounds, superficial injuries.

• Require only simple wound care

• Not covered under the MCR benefit – NOT SKILLED CARE

• Even though it may have been caused by trauma, if the wound itself does not meet open wound criteria, it CANNOT be coded as a trauma wound.

• You MAY code it as a trauma wound if:

• The skin tear is extensive – i.e., extends into the dermis, or it no longer has a flap

• The wound is complicated – i.e., delayed healing, foreign body present, is infected

291

7th Characters for Traumatic Fractures

• The 7th character identifies: – Fracture type;

– Whether healing is routine, delayed, malunion; and

– Encounter type

• initial encounter (A, B, C) is used for each encounter where the patient is receiving active treatment for the fracture.

• The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.

292

Open Fracture Guidance• Open fracture designations are based on the

Gustilo open fracture classification:

• Grade I, Grade II, Grade IIIA, IIIB, IIIC

• Per Coding Guidelines, the open fracture designations in the assignment of the 7th character for fractures of the forearm, femur and lower leg, including ankle, are based on the Gustilo open fracture classification.

• When the Gustilo classification type is notspecified for an open fracture, the 7th character for open fracture type I or II should be assigned:

• B, E, H, M, or Q

293

Traumatic Fractures (cont.)

• Multiple fractures are coded individually and sequenced according to the severity of the fracture.

• A fracture not indicated as “displaced” or “not displaced” should be coded to displaced, when an option.

• A fracture not indicated as open or closed should be coded to closed.

• Do not code the wound additionally when the bone breaks through the skin in an open fracture.

• Complications of fractures should be reported with the appropriate 7th character for:Delayed healing;

Malunion; or

Nonunion.

294

Code complication first!

Complications after Surgical Repair• Care for complications of surgical treatment for fracture repairs during the healing

or recovery phase should be coded with the appropriate complication code until it is healed.

• For a patient with an infected surgical incision being treated with an antibiotic following repair of a fracture, assign 2 codes – may have different 7th characters.

• T81.4xxA, Infection following a procedure, initial encounter

• S72.002D, Fracture of unspecified part of neck of left femur, routine healing

295

Sequela of Fracture

• Assign 7th character “S,” sequela, for complications or conditions that arise as a direct result of a fracture.

• For example, patient with a right greater trochanter fracture due to falling out of bed refused a hip replacement. His fracture has healed, but his right leg is now significantly shorter than his left.

• M21.751, Unequal limb length (acquired), right femur

• S72.111S, Displaced fracture of greater trochanter of right femur, sequela

• W06.xxxS, Fall from bed, sequela

296

The residual condition is coded first. Search the Index under the main term “Deformity” to find “unequal limb length.”

The injury with 7th character “S” is coded next. A fracture not indicated as “displaced” or “not displaced” should be coded as “displaced,” when

this is an option. The 7th character for the external cause, which is found in the Index to External Causes, should

be the same as the injury code.

Code this scenario…Patient was admitted for SN, PT, and OT following a total right hip replacement due to a

traumatic fracture he sustained when he fell from his chair at home. He had a pulmonary embolism two years ago and is on Coumadin.

297

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

M1023d

M1023e

M1023f

Coding for scenario…Patient was admitted for SN, PT, and OT following a total right hip replacement due to a

traumatic fracture he sustained when he fell from his chair at home. He had a pulmonary embolism two years ago and is on Coumadin.

298

Diagnosis ICD-10-CM

M1021a Fracture of unspecified part of neck of (R) femur S72.001D

M1023b Long-term (current) use of anticoagulants Z79.01

M1023c Personal history of pulmonary embolism Z86.711

M1023d Fall from chair W07.xxxD

Key Points for the Scenario

• The fracture is coded, NOT aftercare following the joint replacement (Z47.1).

• The 7th character for rehab is “D” (subsequent encounter).

• The long-term use of an anticoagulant and the reason for it should be coded.

• The cause of the injury (fall) should be coded, but not the place of occurrence, which is used only once at the initial encounter for treatment – not home health – except for burns.

299

Amputations

• What it is:

• the removal of a limb by trauma, medical illness, or surgery.

• Causes:

• Trauma

• Surgical due to:

• circulatory disorders

• Diabetic foot infection or gangrene

• Sepsis with peripheral necrosis

• Types of common amputations:

• AKA (above-knee amputation), known as transfemoral amputation.

• BKA (below-knee amputation), known as transtibial amputation.

• TMA (transmetatarsal amputation): through the forefoot

300

Planned vs. Traumatic Amputation

Planned

Patient’s right great toe was amputated due to severe diabetic PVD.

• Z47.81, Aftercare following surgical amputation

• E11.51, Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene

• Z89.411, Acquired absence of right great toe

Traumatic

Patient’s right great toe was cut off when mowing the lawn with a power mower.

• S98.111D, Complete traumatic amputation of right great toe, subsequent encounter

• W28.xxxD, Contact with powered lawn mower, subsequent encounter

The status code for absence is not used, because the traumatic amputation code provides the information.

The 7th character “D” is assigned, since active care is not being provided.

The 7th character for the external cause code is the same as the injury.

301

Amputation Coding Guidance

• Coding amputations:

• Surgical Aftercare (AC): something went wrong, MD advised on surgical removal

of limb. Patient agreed to it!

• Traumatic Amputation: unexpected amputation at the scene of an accident, where

the limb is partially or entirely severed as a direct result of the accident. Even if

the physician converts a traumatic amputation, it is still coded as traumatic.

Patient was surprised!

302

Amputation example

A patient was trimming hedges and dropped the electric trimmer on his right foot, almost severing his foot at the ankle. The surgeon completed the amputation as a mid-calf (BKA) amputation and home health was ordered for amputation aftercare, including dressing changes.

303

M1021a: Traumatic amputation partial of right foot at ankle level, subsequent encounter S98.021D

M1023: Encounter for change or removal of surgical wound dressing Z48.01M1023: Lower limb amputation status, below the knee Z89.511M1023: Contact with powered garden and outdoor hand tools and machinery, subsequent encounter W29.3xxD

DecisionHealth Coding Center Scenarios 2017

Amputation Complications

• Complications: T87.- (Complications peculiar to reattachment and amputation)• Includes traumatic or surgical amputation

• Dehiscence of amputation stump wound: T87.81

• Infection also present? Code:

• FIRST: Dehiscence: T87.81

• NEXT: Infection: T87.4-

• THEN: Infection type (organism)

+ Complication (s) (from) (of)amputation stump NEC (surgical) (late) T87.9

dehiscence T87.81

+ infection or inflammation T87.40

+ necrosis T87.50

+ neuroma T87.30

specified type NEC T87.89

304

Burns and Corrosions• There is a distinction between burns and corrosions.

• Burns:

• Thermal from heat source:

• Fire

• Hot appliance

• Electricity

• Radiation

• Not sunburn

• Corrosions:

• Burns due to chemicals

• Use an external cause code to identify the source and intent of the burn, and the place (not body location) where it occurred.

305

Classification of Burns

• Current burns are classified by depth as first, second, and third degree.

• First degree burns include only the dermis and usually result in red and painful skin.

• Second degree burns can cause partial thickness (may present with blisters) or full thickness tissue loss (extend into the dermis).

• Third degree burns involve destruction of all levels of the skin, and are not painful, as the nerves have been destroyed.

• Burns of the eye and internal organs (T26-T28) are classified by site, but not by degree.

306

Guidelines for Coding Burns• Assign separate burn codes for a patient who suffers multiple burns to multiple body

sites.

• Codes for burns of “multiple sites” should only be assigned when the medical record documentation does not specify the individual sites.

• However, if a patient has multiple burns to the same body site, but the burns are of different degrees (for example, second and third degree burns to the left thigh), code only the most severe burns (for example, the third degree burns.)

• Sequence first the code that reflects the highest degree of burn when more than one burn is present.

• Non-healing burns are coded as acute burns.

• Necrosis of burned skin should be coded as an acute burn.

• Pay close attention to the many instructional notes!307

Categories T31 and T32

• Categories T20-T25 will receive a supplementary code of:

• Category T31, Burns classified according to extent of body surface involved, or

• Category T32, Corrosions classified according to body surface involved

• T31 and T32 are assigned for patients who have third degree burns over 20% or more of their bodies.

• Codes are based on the classic “rule of nines” in estimating body surface involved.

308

Sequelae of Burns

• Encounters for the treatment of the sequelae (late effects) of burns orcorrosions (e.g., scars or joint contractures) should be coded with a burn or corrosion code with the 7th character “S” for sequela.

• Code the sequela first, followed by the burn.

• Current acute burns or corrosions may be assigned to the same record as a sequela of a burn with the appropriate character of “A,” “D,” or “S”.

• Burns and corrosions do not heal at the same rate. Therefore, a healing wound may still exist with a sequela of a healed burn or corrosion.

309

Code this burn scenario…Patient admitted with a non-healing 3rd degree burn on the back of her right hand and severe scarring of

her right wrist from a healed 3rd degree burn, which both resulted from spattered hot oil while she was

cooking. SN for wound care and OT for wrist mobility.

310

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

M1023d

M1023e

What do we call the right wrist scarring?

Coding for burn scenarioPatient admitted with a non-healing 3rd degree burn on the back of her right hand and severe

scarring of her right wrist from a healed 3rd degree burn, which both resulted from spattered hot

oil while she was cooking. SN for wound care and OT for wrist mobility.

311

Diagnosis ICD-10-CM

M1021a Burn of 3rd degree of back of right hand T23.361D

M1023b Scar conditions and fibrosis of skin L90.5

M1023c Burn of 3rd degree of right wrist, sequela T23.371S

M1023d Contact with fats and cooking oils X10.2xxD

M1023e Kitchen in private house, place of occurrence of the external cause

Y92.010D

What is a complication?

• A complication is a problem that arises complicating the healing process of the initial illness, injury, or medical/surgical procedure.

• Delayed treatment

• Delayed healing

• Infection

• Foreign body

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Coding Complications

• There is no time limit.

• Reference the main term in the Index for the condition, and look for a subentry indicating the complication, such as:

• Adhesions postoperative (gastrointestinal tract) K66.0

• Colostomy malfunctioning K94.03

• Infection bacterial NOS

• If no entry is found, go to Complications in the Index and look for the appropriate subentry:

• Nature of complication (catheter, hemorrhage, vascular)

• Type of procedure (surgical, postprocedural, transplant)

• Anatomical site or body system (cardiac, endocrine, respiratory)

• Verify the code in the Tabular List and follow instructions for any additional codes.

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Complications of Care Documentation• Code assignment is based on the provider’s documentation of the relationship

between the conditions and the care or procedure, unless otherwise instructed by the classification.

• This guideline extends to any complication of care, regardless of the chapter the code is located in.

• Not all conditions that occur during or following medical care or surgery are classified as complications.

• There MUST be a cause-and-effect relationship between the care provided

• and the condition

• and an indication in the provider’s documentation that it is a complication.

• Query the provider for clarification, if the complication is not clearly documented.

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Types of Complications

Medical complications

• Infection and inflammation• Hemorrhage• Problems related to an injection, infusion, or transfusion – e.g.,

phlebitis, infection, or sloughing

Complications of surgical procedure

• Post-surgical infection of wounds, amputation stumps• Infection of grafts, devices, and prosthetics• Complication of transplanted organs• Disruption of surgical or trauma wounds

Mechanical complications

• Ostomies – e.g., malfunctioning• Grafts, devices, and prosthetics – e.g., insulin pump, dialysis

catheter, urinary catheter, prosthetic joint

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Complicated Post-Surgical Wounds• Dehisced surgical wounds:

– T81.31- External dehiscence. This is the default code when only dehiscence is stated.

– T81.32- Internal dehiscence of surgical wound

– T81.33- Dehiscence of traumatic injury wound repair

– T81.30- Unspecified dehiscence – should not be used – means unspecified type of wound, not unspecified surgical wound

• Postoperative Infection Definitions (per the CDC)

• Superficial incisional infection: involves only skin and subQ tissue.

• May be indicated by localized signs such as redness, pain, heat or swelling at the site of the incision, or by the drainage of pus.

• Deep incisional: involves deep tissues, such as fascial and muscle layers.

• May be indicated by the presence of pus or an abscess, fever with tenderness of the wound, or separation of incision edges exposing deeper tissues.

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Complicated Post-Surgical Wounds

• T81.4-, Infection following a procedure; post-procedural infection, NEC; stitch or wound abscess following a procedure

Use additional code to identify infection or severe sepsis (R65.2-), if applicable.

Remember, if active treatment is being provided, such as treatment with wound vac, assign the 7th character “A” for initial encounter. For infected wounds, the 7th character will be “A”.

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Code this wound complication…Patient admitted for wound care to a dehisced and infected surgical wound

following a laminectomy. Her IV antibiotics were discontinued after 3 days, and an oral antibiotic was prescribed for 10 days.

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Diagnosis ICD-10-CM

M1021a

M1023b

Coding for wound complication…Patient admitted for wound care to a superficial dehisced and infected surgical

wound following a laminectomy. Her IV antibiotics were discontinued after 3 days, and an oral antibiotic was prescribed for 10 days.

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Diagnosis ICD-10-CM

M1021a Disruption of external surgical wound, subsequent encounter

T81.31xD

M1023b Infection following a procedure, superficial incisional site, subsequent encounter

T81.41xA

There is no sequencing instruction for the surgical wound complications.

7th character “A” is assigned for the infection, since the patient is taking an antibiotic,

which is considered to be “active” treatment.

Short-term use of antibiotics is not coded.

Z48.01, Attention to surgical dressing, is also not coded, due to the complication.

Coding a Broken Joint Prosthesis

• Per Q4 2016 Coding Clinic guidance, a broken internal joint prosthesis is

considered a complication of that prosthesis.

• Assign a code from subcategory T84.01-, Broken internal joint prosthesis, when

a patient has a fracture that is specified as involving the internal joint

prosthesis itself.

• Find this code in the Alphabetic Index under “Complication, joint prosthesis

internal.” “Breakage (fracture) T84.01-” is a subentry modifier.

• In the Tabular List, the T84.01- subcategory further breaks down by the type

(hip, knee, and other) and side (right or left) of the internal joint prosthesis.

• Assign 7th character “A,” “D,” or “S,” found under the category.

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More wound complications…

• There is no code for a non-healing surgical wound, NEC.– Assign T81.89x-, Other complications of procedures, not elsewhere classified

• Amputation stump complications are coded to T87.3 - T87.8.

• T87.3-, Neuroma

• T87.4-, Infection

• T87.5-, Necrosis

• T87.81 - Dehiscence

• T87.89 - Other complications, such as stump: contracture, flexion, edema, and hematoma

‒ Excludes 2: phantom limb syndrome (G54.6-G54.7)

Note: These codes do not require a 7th character.

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Pain due to Medical Devices

• Pain associated with devices, implants, or grafts left in a surgical site (for example, a painful hip prosthesis) is assigned to the appropriate code(s) found in Chapter 19.

• Specific codes for pain due to medical devices are found in the T code section.

• Use additional code(s) from category G89 to identify acute or chronic pain due to presence of the device, implant, or graft (G89.18 or G89.28).

For example: Acute pain in left hip due to joint prosthesis implanted 4 months ago:

• T84.84xD, Pain due to internal orthopedic prosthetic devices, implants and grafts

• G89.18, Other acute postprocedural pain (Postoperative pain NOS)323

Complications Due to Insulin Pump Malfunction

Underdose of insulin due to pump failure:– A code from subcategory T85.6, Mechanical complication of other specified internal and external

prosthetic devices, implants and grafts, that specifies the type of pump malfunction, should be

assigned as the principal/primary or first-listed code, when it is the reason for the encounter;

– Followed by code T38.3X6-, Underdosing of insulin and oral hypoglycemic [antidiabetic] drugs.

– Additional codes for the type of diabetes mellitus and any associated complications due to the

underdosing should also be assigned.

Overdose of insulin due to pump failure:– T85.6-, Mechanical complication of other specified internal and external prosthetic, devices,

implants and grafts, should be assigned as the first-listed code, when it is the reason for the

encounter;

– Followed by code T38.3X1-, Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs,

accidental (unintentional).

– Additional codes should be assigned for other conditions resulting from the overdosing.

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Kidney Transplant Complications• Patients who have undergone a kidney transplant may still have some form of chronic kidney

disease (CKD) because the kidney transplant may not fully restore kidney function.

• Code T86.1- should not be assigned for post kidney transplant patients just because they still have CKD

• Code T86.1-, Complication of kidney transplant, should be assigned for documented complications of a kidney transplant:

• transplant failure

• rejection

• other transplant complication.

• If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.

• Conditions that affect the function of the transplanted kidney, other than CKD, should be assigned a code from T86.1- with a secondary code that identifies the complication.

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Other Transplant Complications • Codes under category T86, Complications of transplanted organs and tissues,

are for use for both complications and rejection of transplanted organs.

• A transplant complication code is only assigned if the complication affects the function of the transplanted organ.

• Two codes are required to fully describe a transplant complication:1. The appropriate code from category T86; and

2. A secondary code that identifies the complication.

• Pre-existing conditions or conditions that develop after the transplant are notcoded as complications, unless they affect the function of the transplanted organs.

• If the organ was removed due to failure or rejection, assign Z98.85, Transplanted organ removal status.

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Code this complication…

Patient fractured his right humerus at mid shaft (comminuted) when he fell after tripping over his dog at home. He has an ORIF, and the fixation device came loose resulting in a nonunion of the fracture.

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Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

Coding for complication…Patient fractured his right humerus at mid shaft (comminuted) when he fell after

tripping over his dog at home. He has an ORIF, and the fixation device came loose resulting in a nonunion of the fracture.

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Diagnosis ICD-10-CM

M1021a Displacement of internal fixation device of right humerus

T84.120D

M1023b Displaced comminuted fracture of shaft of humerus, right arm, subsequent encounter for fracture with nonunion

S42.351K

M1023c Falling over animal W01.0xxD

Key Points

• The complication is sequenced first.

• A code to identify the specified condition resulting from the complication is coded next.

• A fracture not stated as displaced or nondisplaced is coded as displaced.

• Coding the cause of the injury, found in the Index to External Causes of Injuries, is optional, in this case. The fall requires a 7th character – A, D, or S. Assign D, the same as the complication code.

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Medications

• Let’s review, from a clinician and OASIS standpoint, what we know about the proper assessment of medication usage:

• RIGHT person

• RIGHT medication

• RIGHT dose

• RIGHT time

• RIGHT route

• So if any of these points goes wrong, the result may either be a poisoning or an adverse effect.

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Table of Drugs and Chemicals

• Poisoning:• Overdose of substance• Wrong substance given or taken in error

• Adverse effect:

• Hypersensitivity, reaction, drug toxicity, etc., of correct substance properly

prescribed and administered

• Underdosing:

• Taking less of a medication than is prescribed or instructed by a

manufacturer, whether inadvertently or deliberately, including

discontinuing the use of a prescribed medication willingly

• Codes require a 7th character extension:• A - Initial encounter• D - Subsequent encounter• S - Sequela

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Adverse Effect versus PoisoningAdverse Effect

Drug correctly prescribed and properly administered

• First…assign the code for the adverse effect(s) – e.g., rash, slow pulse, confusion, dehydration, etc.

• Next…assign the med code(s) indicating adverse effect of the drug (T36-T50).

Sequencing:

1. E = Effect

2. T = T code

Poisoning

Something wrong happened, such as wrong drug, wrong dose, or wrong person

• First…assign a code from categories T36-T50. If the intent is unknown or unspecified, code as accidental.

• Next…code effect(s) of the poisoning.

Sequencing

1. T = T code

2. E = Effect

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Adverse Effect Scenario

Patient has been taking the prescribed amount of Lanoxin (Digoxin) for atrial flutter. However, he now has bradycardia and is toxic according to lab values. SN ordered for monitoring and lab draws.

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Diagnosis ICD-10-CM

M1021a Bradycardia R00.1

M1023b Adverse effect of cardiac-stimulant glycosides T46.0X5D

M1023c Unspecified atrial flutter I48.92

M1023d Encounter for therapeutic drug monitoring Z51.81

M1023e Long-term (current) use of other high risk med Z79.899

Poisoning ScenarioPatient has been taking Lasix 40mg. every morning and night for CHF. The

prescription bottle reads 40mg. daily. Now he is dehydrated and hypokalemic.

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Diagnosis ICD-10-CM

M1021a Poisoning by diuretics, subsequent encounter T50.1X1D

M1023b Dehydration E86.0

M1023c Hypokalemia E87.6

M1023d Heart failure, unspecified I50.9

Underdosing

Guideline: Codes for underdosing should never be assigned as principal/primary or first-listed codes. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded.

• For underdosing, assign:• C = Condition caused by the underdosing

• T = T code from categories T36-T50, with 5th or 6th character of 6 for underdosing of

the drug

• Z = Z code for the reason for underdosing (Z91.1-)

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Underdosing ScenarioPatient with a diagnosis of hypertension continued to experience elevated

blood pressure while taking her blood pressure medication. Upon patient interview, it was found she was taking it only once a day, instead of twice, as prescribed, because she couldn’t afford the cost of the drug.

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Diagnosis ICD-10-CM

M1021a Essential hypertension I10

M1023b Underdosing of other antihypertensive drugs, subsequent encounter

T46.5x6D

M1023c Patient's intentional underdosing of medication regimen due to financial hardship

Z91.120

Adverse Effect or Poisoning?Patient admitted to home health after being hospitalized for severe nausea and vomiting.

She took several 800 mg. tablets of ibuprofen which belonged to her daughter to manage worsening joint pain caused by generalized osteoarthritis. She usually takes Aleve, which was recommended by her doctor.

Is this an adverse effect or poisoning?

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Diagnosis ICD-10-CM

M1021a

M1023b

M1023

Adverse Effect CodingPatient admitted to home health after being hospitalized for severe nausea and

vomiting. She took several 800 mg. tablets of ibuprofen which belonged to her daughter to manage worsening joint pain caused by osteoarthritis. She usually takes Aleve, which was recommended by her doctor.

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Diagnosis ICD-10-CM

M1021a Poisoning by ibuprofen, accidental (unintentional), subsequent encounter

T39.311D

M1023b Nausea with vomiting, unspecified R11.2

M1023c Primary generalized (osteo)arthritis M15.0

The patient took the wrong dose of a medication prescribed for someone else. Therefore, this scenario is a poisoning and the T code for the drug is sequenced first.

The effects are coded next. Then, the reason for the drug is coded.

External Causesof Morbidity

Chapter 20(V00-Y99)

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Requirement for Reporting

• Reporting ICD-10 external cause codes is not required:

‒ Unless a provider is subject to a state-based external cause code reporting mandate or these codes are required by a particular payer.

Exception: Burns

• In the absence of a mandatory reporting requirement, providers are encouraged to report them, as they provide valuable data for injury research and evaluation of injury prevention strategies.

• They are located in the Index to External Causes of Injury.

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Purpose of External Cause Codes

These codes capture:

• How the injury or health condition happened (cause)

• The intent:

• unintentional or accidental

• intentional, such as suicide or assault

• The place where the event occurred (Y92)

• Typically used only once, at initial encounter for treatment

• The activity of the patient at the time of the event (Y93)

• Used only once, at initial encounter for treatment

• The person’s status (e.g., civilian, military) (Y99)

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Use of External Cause Codes

• If a home agency chooses to report external cause codes, only the codes for the intent and cause should be reported, except for burns.

• External cause codes for the place of encounter, activity, and status are used only once at the initial encounter for treatment (e.g., the patient was seen by a physician in the ER or urgent-care center to diagnose and order treatment first).

• Most often used for injuries

• Valid for use with:

• Infections

• Diseases due to an external source

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Use of External Cause Codes (cont.)

• Assign the external cause code with the applicable 7th character – “A,” “D,” or “S” for most categories.

• The 7th character for the external cause should match the 7th character of the code assigned for the associated injury or condition for the encounter.

• An external cause code may never be the primary diagnosis.

• No external cause code from Chapter 20 is needed, if the external cause and intent are included in a code from another chapter – e.g., T36.0X1-, Poisoning by penicillins, accidental (unintentional).

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Questions?

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Thank you for attending!

Arlynn Hansell, PT, HCS-D, HCS-O, HCS-H, COS-COwner, Therapy and More, LLCVP, Board of Medical Specialty Coding & Compliance (BMSC)Cincinnati, [email protected]

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mailto:[email protected]

Presented By

Arlynn Hansell, PT, HCS-D, HCS-H, HCS-O, COS-C, has been a Physical

Therapist in both the home health and SNF settings since October 1998,

holding positions of therapist, rehab manager, and quality/compliance

assurance. She is the owner of Therapy and More, LLC, where services

consist of OASIS auditing, ICD-10 coding for home health and hospice,

therapy visit note audits and end of episode quality reviews. In addition, she

assists agencies in achieving therapy documentation and practice excellence

in order to better position themselves against auditors.

Arlynn is appointed to the BMSC Home Health Advisory Panel, where she

serves as Vice Chair. She is a past member of the American Physical Therapy

Association, where she served as the past Vice President of the Home Health

Section. She is involved in the creation and editing of the HCS-D, HCS-O,

HCS-H certification exams, and is the editor of the Home Care Clinical

Specialist – OASIS D online guidance.

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