ICD-10 Roundtable 139

October 12, 2021

In the news…. Announcement Addition of April 1st Maintenance of the ICD-10-CM and ICD-10-PCS Coding Systems In the fiscal year 2022 Hospital Inpatient Prospective Payment System final rule published on August 2, 2021, the Centers for Medicare & Medicaid Services (CMS) announced it is adopting an April 1 implementation date for ICD-10-CM and ICD-10-PCS code updates, in addition to the annual October 1 update, beginning with April 1, 2022. This April 1 code update would be in addition to the existing April 1 update under section 1886(d)(5)(k)(vii) of the Act for diagnosis or procedure code revisions needed to describe new technologies and medical services for purposes of the new technology add-on payment process. The April 1 implementation will use a phased-in approach, such that initially, the number and nature of the code updates would be fewer and less comprehensive as compared to the existing October 1 update. Earlier recognition of diagnoses, conditions, and illnesses as well as procedures, services, and treatments in the claims data would be beneficial for purposes of reporting, data collection, tracking clinical outcomes, claims processing, surveillance, research, policy decisions and data interoperability. The existing established process for code maintenance will be used, meaning that the codes will be presented at the ICD-10 Coordination and Maintenance Committee meeting with opportunity for public comment. Coding guidelines and coding advice will be updated as needed. Any new ICD-10 code updates finalized for implementation on the following April 1 would be announced in November of the prior year.

CM Guidelines Changes Please note anything in bold in new for FY 2022

Section 1: Conventions Laterality When laterality is not documented by the patient’s provider, code assignment for the affected side may be based on medical record documentation from other clinicians. If there is conflicting medical record documentation regarding the affected side, the patient’s attending provider should be queried for clarification. Codes for “unspecified” side should rarely be used, such as when the documentation in the record is insufficient to determine the affected side and it is not possible to obtain clarification Documentation by Clinicians Other than the Patient's Provider

Code assignment is based on the documentation by the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis). There are a few exceptions when, such as codes for the Body Mass Index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis). since this In this context, “clinicians” other than the patient’s provider refer to healthcare professionals permitted, based on regulatory or accreditation requirements or internal hospital policies, to document in a patient’s official medical record. These exceptions include codes for:

• Body Mass Index (BMI) • Depth of non-pressure chronic ulcers • Pressure ulcer stage • Coma scale • NIH stroke scale (NIHSS) • Social determinants of health (SDOH) • Laterality • Blood alcohol level

This information is typically, or may be, documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale). However, the associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer, or a condition classifiable to category F10, Alcohol related disorders) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification. For social determinants of health, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses. The BMI, coma scale, NIHSS codes, blood alcohol level and codes for social determinants of health categories Z55-Z65 should only be reported as secondary diagnoses.

See Section I.C.21.c.17 for additional information regarding coding social determinants of health. . . .

For social determinants of health, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses. Patient self-reported documentation may also be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the health record by either a clinician or provider.

Section 1.C: Chapter-Specific Coding Guidelines

Chapter Description

Chapter 1: Certain Infectious and Parasitic Diseases

(d) Asymptomatic human immunodeficiency virus (i) History of HIV managed by medication (g) Signs and symptoms without definitive diagnosis of COVID-19 (l) Multisystem Inflammatory Syndrome (m)Post COVID-19 Condition

Chapter 2: Neoplasms (C00-D49)

s. Breast Implant Associated Anaplastic Large Cell Lymphoma

Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89)

Diabetes mellitus and the use of insulin, oral hypoglycemics, and injectable non-insulin drugs (also applies to secondary diabetes)

Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01 – F99)

Psychoactive Substance Use, Unspecified Medical Conditions Due to Psychoactive Substance Use, Abuse and Dependence Blood Alcohol Level

Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99)

Unstageable pressure ulcers

Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A)

Final character for trimester

Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

e. Coma 1) Coma Scale

Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88)

Burns and corrosions classified according to extent of body surface involved

Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)

History (of) Counseling Social Determinants of Health

Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99), U07.1, U09.9

a. Human Immunodeficiency Virus (HIV) Infections

2)Selection and sequencing of HIV codes

(d)Asymptomatic human immunodeficiency virus

Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, is to be applied when the patient without any documentation of symptoms is listed as being “HIV positive,” “known HIV,” “HIV test positive,” or similar terminology. Do not use this code if the term “AIDS” or “HIV disease” is used or if the patient is treated for any HIV-related illness or is described as having any condition(s) resulting from his/her HIV positive status; use B20 in these cases

(h)Encounters for testing for HIV

Use additional codes for any associated high-risk behavior, if applicable.

(i) History of HIV managed by medication

If a patient with documented history of HIV disease is currently managed on antiretroviral medications, assign code B20, Human immunodeficiency virus [HIV] disease. Code Z79.899, Other long term (current) drug therapy, may be assigned as an additional code to identify the long-term (current) use of antiretroviral medications

Related Coding clinics

Anemia admission with history of HIV, correct reporting

ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2020 Page: 97 Effective with discharges: October 2, 2020

Question: A 68-year-old male was admitted due to anemia. The patient also has a past medical history of HIV disease, currently on antiretrovirals (ARVs). The patient had a history of CD4 count less than 200 with a current CD4 of 335. The provider's diagnostic statement listed, "HIV disease on ARVs (CD4 335, VL undetectable)" as a secondary diagnosis. What is the appropriate HIV code for this patient? Answer: Assign code B20, Human immunodeficiency virus [HIV] disease, for this patient. The provider documented HIV disease, which is specifically classified to code B20. As with any other condition, query the provider for clarification when there is conflicting documentation.

Influenza admission with history of HIV, correct reporting

ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2020 Page: 97,98 Effective with discharges: October 1, 2020 Question: A 55-year-old with a personal history of end-stage renal disease (ESRD) and long-standing history of HIV disease presented due to influenza. The provider documented HIV disease on current treatment with a CD4 level over 1,000 and an undetectable viral load. What is the appropriate HIV code for this patient? Answer: Assign code B20, Human immunodeficiency virus [HIV] disease, for this patient. Provider documentation indicated HIV disease, which is specifically classified to code B20. As with any other condition, query the provider for clarification when there is conflicting documentation.

Cryptococcal meningitis in HIV positive patient

ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2019 Pages: 9-10 Effective with discharges: March 20, 2019 Related Information Question: Current literature states that cryptococcal meningitis is a major HIV-related infection. When a patient who is HIV positive presents due to this condition, is it appropriate to assume a linkage between the HIV and the meningitis and assign code B20, Human immunodeficiency virus [HIV] disease? How should HIV be coded in a patient with cryptococcal meningitis? Answer: The ICD-10-CM classification does not assume a relationship between cryptococcal meningitis and HIV. Therefore, do not assume that cryptococcal meningitis is an HIV-related infection without provider documentation linking the two conditions. If the medical record documentation does not indicate AIDS, HIV-related infection or other similar terminology indicating the patient has AIDS, it is not appropriate to assign code B20, Human immunodeficiency virus [HIV] disease.

Follow-up care for asymptomatic HIV positive patient on antiretroviral therapy

ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2019 Page: 11 Effective with discharges: March 20, 2019 Related Information Question: A 25-year-old asymptomatic HIV positive patient, who is on antiretroviral therapy, presents to the physician's office for follow-up care. The patient is asymptomatic, has not been diagnosed with any HIV illnesses or related diseases, and is taking antiretroviral medication prophylactically. How should this case be coded since the patient is being treated (code B20 or code Z21)? Answer: Assign code Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, as the first-listed diagnosis. The protocol is to treat asymptomatic patients prophylactically with antiretroviral drugs to suppress the virus and prevent progression of the illness. The fact that the patient is receiving medication does not indicate AIDS or HIV disease See First Quarter 2019 Coding Clinic for more HIV positive/HIV disease/AIDS examples

g. Coronavirus infections

1) COVID-19 infection (infection due to SARS-CoV-2)

(g) Signs and symptoms without definitive diagnosis of COVID-1 • R05.1 Acute cough, or R05.9, Cough, unspecified

(j) Follow-up visits after COVID-19 infection has resolved For individuals who previously had COVID-19 without residual symptom(s) or condition(s), and are being seen for follow-up evaluation, and COVID-19 test results are negative, assign codes Z09, Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm, and Z86.16, Personal history of COVID-19. For follow-up visits for individuals with symptom(s) or condition(s) related to a previous COVID-19 infection, see guideline I.C.1.g.1.m. See Section I.C.21.c.8, Factors influencing health states and contact with health services, Follow-up

(l) Multisystem Inflammatory Syndrome If MIS develops as a result of a previous COVID-19 infection, assign codes M35.81, Multisystem inflammatory syndrome, and B94.8, Sequelae of other specified infectious and parasitic diseases.

If an individual with a history of COVID-19 develops MIS and the provider does not indicate the MIS is due to the previous COVID-19 infection, assign codes M35.81, Multisystem inflammatory syndrome, and Z86.16, Personal history of COVID-19 U09.9, Post COVID-19 condition, unspecified.

Related Coding clinics New/Revised Frequently Asked Questions Regarding ICD-10-CM/PCS Coding for COVID-19 Revised August 27, 2021, Coding Clinic 4th Quarter 2021 Question: A child diagnosed with COVID-19 several weeks ago is now admitted with multisystem inflammatory syndrome in children (MIS-C) due to COVID-19. The patient no longer has COVID-19. How should this be coded? (7/23/2020; revised 12/11/2020, 8/25/21) Answer: Assign code M35.8, Other specified systemic involvement of connective tissue, for discharges prior to January 1, 2021, or code M35.81, Multisystem inflammatory syndrome, for discharges after January 1, 2021, as the principal diagnosis, for the MIS-C, and code B94.8, Sequelae of other specified infectious and parasitic diseases, for discharges/encounters prior to October 1, 2021, or code U09.9, Post COVID-19 condition, unspecified, for discharges/encounters on or after October 1, 2021, as a secondary diagnosis for the sequelae of a COVID-19 infection. If the documentation is not clear regarding whether the physician considers a condition to be an acute manifestation of a current COVID-19 infection vs. a residual effect from a previous COVID-19 infection, query the provider. As stated in the ICD-10-CM Official Guidelines for Coding and Reporting, the provider’s documentation that the individual has COVID-19 is sufficient for coding purposes.

(m) Post COVID-19 Condition For sequela of COVID-19, or associated symptoms or conditions that develop following a previous COVID-19 infection, assign a code(s) for the specific symptom(s) or condition(s) related to the previous COVID-19 infection, if known, and code U09.9, Post COVID-19 condition, unspecified. Code U09.9 should not be assigned for manifestations of an active (current) COVID-19 infection. If a patient has a condition(s) associated with a previous COVID-19 infection and develops a new active (current) COVID-19 infection, code U09.9 may be assigned in conjunction with code U07.1, COVID-19, to identify that the patient also has a condition(s) associated with a previous COVID-19 infection. Code(s) for the specific condition(s) associated with the previous COVID-19 infection and code(s) for manifestation(s) of the new active (current) COVID-19 infection should also be assigned.

Related Coding Clinic Also see https://journal.ahima.org/ahima-and-aha-faq-on-icd-10-cm-coding-for-covid-19/ for guidance. They are usually published here before being published in coding clinic.

New/Revised Frequently Asked Questions Regarding ICD-10-CM/PCS Coding for COVID-19 Revised August 27, 2021, Coding Clinic 4th Quarter 2021 Question: The patient presents to the facility with symptoms such as generalized weakness and lack of appetite, and the provider documents a diagnosis of “post COVID-19 syndrome.” How should this be coded? (12/11/2020; revised 8/25/21) Answer: [Effective 10/1/21:] For discharges/encounters on or after October 1, 2021, assign codes R53.1, Weakness, R63.0, Anorexia, and U09.9, Post COVID-19 condition, unspecified, for a diagnosis of post COVID-19 syndrome with generalized weakness and lack of appetite This is supported by the instructional note at code U09.9 to “code first the specific condition related to COVID-19 if known.” [Prior to 10/1/21:] For discharges/encounters prior to October 1, 2021, unless the provider specifically documents that the symptoms are the result of COVID-19, assign code(s) for the specific symptom(s) and a code for personal history of COVID-19. “Post COVID-19 syndrome” indicates temporality, but not that the current symptom(s) or clinical condition(s) are a residual effect (sequelae) of COVID-19. As stated in the ICD-10-CM Official Guidelines for Coding and Reporting, in the absence of Alphabetic Index guidance for coding syndromes, assign codes for the documented manifestations of the syndrome. The appropriate personal history code is Z86.19, Personal history of other infectious and parasitic diseases, for discharges/encounters prior to January 1, 2021 or code Z86.16, Personal history of COVID-19, for discharges/ encounters after January 1, 2021. If the provider documents that the symptoms are the result (residual effect) of COVID-19, assign code(s) for the specific symptom(s) and code B94.8, Sequelae of other specified infectious and parasitic diseases. According to the ICD-10-CM Official Guidelines for Coding and Reporting, a sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. Question: A patient was COVID-19 positive at a short term acute care hospital where he was being cared for COVID-19 related respiratory problems and completed treatment with Remdesivir and Dexamethasone. After more than a two-month stay, the patient is now transferred to a long-term care hospital (LTCH) with acute respiratory failure for tracheostomy weaning. At the time of transfer, the patient had been weaned from ventilator to tracheostomy collar at 28%. Diagnosis on admission was history of COVID-19, acute respiratory failure, and tracheostomy dependence. When queried regarding the patient’s COVID-19 status on admission to the LTCH, the provider indicated that the patient was no longer infectious and is being admitted only to treat the residual respiratory failure requiring oxygenation via tracheostomy. May we assign code J96.90 as a principal diagnosis, followed by code Z86.16, Personal history of COVID-19, since the patient no longer has a COVID-19 infection? (3/1/21; revised 8/25/21) Answer: Query the provider whether “residual respiratory failure” refers to acute on chronic, or chronic

respiratory failure. Assign the appropriate respiratory failure code based on the response, followed by code B94.8, Sequelae of other specified infectious and parasitic diseases, for discharges/encounters prior to October 1, 2021, or code U09.9, Post COVID-19 condition, unspecified, for discharges/encounters on or after October 1, 2021, as a secondary diagnosis, for the sequelae of COVID-19 infection, since the patient has been documented as no longer infectious for COVID-19. Although the provider referred to “history of COVID-19,” a personal history code is inappropriate in this case. As defined in the ICD-10-CM Official Guidelines for Coding and Reporting, Section IB. “A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated.” In addition, Section I. C.21,c,( 4) states “Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring.” Question: A patient with a history of COVID-19 infection was admitted for treatment of acute hyperkalemia and acute kidney injury with chronic kidney disease. Follow-up COVID-19 testing was positive. The provider documented, “COVID likely reflective of old noninfectious virus.” How is the COVID-19 status captured for this patient? Does the Official Coding and Reporting Guideline I.C.1.g.1.a., “code only confirmed cases” apply when the provider documents the patient as “noninfectious” but has a positive COVID-19 test during the admission? (8/25/21) Answer: Assign code Z86.16, Personal history of COVID-19. While the patient had a positive COVID-19 test, the provider documented that the patient was not actively infectious during this admission. When the provider documents “noninfectious” or “not infectious” COVID-19 status, this indicates that the patient no longer has an active COVID-19 infection, therefore assign code Z86.16 instead of code U07.1, COVID-19. Although guideline I.C.1.g.1.a., states: “Code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as documented by the provider or documentation of a positive COVID-19 test result,” in this scenario the provider has clarified the patient no longer has an active COVID-19 infection. Therefore, code U07.1, COVID-19, is not appropriate and the Official Coding Guideline I.C.1.g.1.a., regarding a positive COVID-19 test result would not apply. If the documentation is unclear, as to whether the patient has an active COVID-19 infection or a personal history, query the provider for clarification Question: A patient presented to the hospital with acute respiratory failure and COPD exacerbation. It was noted that the patient tested positive for COVID-19 approximately 80 days prior to this admission. A repeat COVID-19 test was performed and came back positive but the provider documented she did not consider the patient’s status to be a COVID-19 “reinfection.” The discharge summary states: “history of COVID infection currently still testing positive for COVID.” Is it appropriate to assign code Z86.16, Personal history of COVID-19, or code U07.1, COVID-19 since there is a positive test? (8/25/21) Answer: Although the patient is still testing positive for COVID-19, the provider has documented the patient’s condition was a previous history of a COVID-19 infection and not a reinfection, therefore it would be

appropriate to assign code Z86.16, Personal history of COVID-19.

Question: A patient presented for treatment of bulbous pemphigoid bulla with surrounding cellulitis. During the admission, the patient was tested for COVID-19. Although the patient was completely vaccinated, the physician documented the COVID-19 test was positive. The patient was subsequently placed in isolation and instructed discharge. How is COVID-19 coded in this scenario? (8/25/21) Answer: Assign code U07.1, COVID-19. The provider’s assessment stated “COVID-19 virus detected,” and it is possible for a COVID-19 infection to occur despite vaccination. This is consistent with Official Guidelines for Coding and Reporting, Section I.C.1.g.1.a., which states: Code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as documented by the provider or documentation of a positive COVID-19 test result.

Chapter 2: Neoplasms (C00-D49) s. Breast Implant Associated Anaplastic Large Cell Lymphoma Breast implant associated anaplastic large cell lymphoma (BIA-ALCL) is a type of lymphoma that can develop around breast implants. Assign code C84.7A, Anaplastic large cell lymphoma, ALK-negative, breast, for BIA-ALCL. Do not assign a complication code from chapter 19

Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89) Note the same changes were applied to secondary diabetes mellitus. Please note this also differs from previous advice.

a. Diabetes mellitus

3) Diabetes mellitus and the use of insulin and, oral hypoglycemics, and injectable non-insulin drugs . . . If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11-, Type 2 diabetes mellitus, should be assigned. An a Additional code(s) should be assigned from category Z79 to identify the long-term (current) use of insulin, or oral hypoglycemic drugs, or injectable non-insulin antidiabetic, as follows: If the patient is treated with both oral medications and insulin, only the code for long-term (current) use of insulin both code Z79.4, Long term (current) use of insulin, and code Z79.84, Long term (current) use of oral hypoglycemic drugs, should be assigned

Chapter 5: Mental, Behavioral and Neurodevelopmental disorders

b. Mental and behavioral disorders due to psychoactive substance use

3) Psychoactive Substance Use, Unspecified As with all other unspecified diagnoses, the codes for unspecified psychoactive substance use (F10.9- , F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-, F18.9-, F19.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). These codes are to be used only when the psychoactive substance use is associated with a substance related physical disorder included in (chapter 5 disorders (such as sexual dysfunction, and sleep disorder), or a mental or behavioral disorder) or medical condition, and such a relationship is documented by the provide

4) Medical Conditions Due to Psychoactive Substance Use, Abuse and Dependence

Medical conditions due to substance use, abuse, and dependence are not classified as substance-induced disorders. Assign the diagnosis code for the medical condition as directed by the Alphabetical Index along with the appropriate psychoactive substance use, abuse or dependence code. For example, for alcoholic pancreatitis due to alcohol dependence, assign the appropriate code from subcategory K85.2, Alcohol induced acute pancreatitis, and the appropriate code from subcategory F10.2, such as code F10.20, Alcohol dependence, uncomplicated. It would not be appropriate to assign code F10.288, Alcohol dependence with other alcohol-induced disorder.

Related Coding Clinic

Cannabinoid hyperemesis syndrome associated with excessive cannabis use

ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2020 Page:8 Effective with discharges: March 5, 2020 Question: A patient presents with recurring nausea and vomiting for 4-5 days. The provider documented cannabinoid hyperemesis syndrome. What is the appropriate code assignment for cannabinoid hyperemesis syndrome? Answer: Assign code R11.2, Nausea with vomiting, unspecified, along with the appropriate uncomplicated code from category F12, Cannabis related disorders, for a diagnosis of cannabinoid hyperemesis syndrome. Cannabinoid hyperemesis syndrome is the definitive diagnosis; however, since there is no specific code for this condition, the symptom code for nausea and vomiting should be assigned. The Official Guidelines for Coding and Reporting for Syndromes state, "In the absence of Alphabetic Index guidance, assign codes for the documented manifestations of the syndrome."

When the pattern of substance use (i.e., dependence, abuse or use) is not documented, query the physician for clarification. Code T40.7X1A, Poisoning by cannabis (derivatives), accidental (unintentional), initial encounter, is not appropriate. The condition is not classified as an acute poisoning, since it is caused by heavy chronic marijuana use, not by a single use.

Psychoactive substance use and physical disorder

ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2020 Page: 9 Effective with discharges: March 5, 2020 Related Information Question: The Official Guidelines for Coding and Reporting for Psychoactive Substance Use, Unspecified (I.C.5.b.3.) state, "These codes are to be used only when the psychoactive substance use is associated with a physical, mental or behavioral disorder, and such a relationship is documented by the provider." Coding professionals are unclear as to what constitutes a "physical disorder." What does the term "physical" in guideline I.C.5.b.3 mean? Answer: Effective October 1, 2018, the guideline for psychoactive substance use, unspecified, (categories F10-F19 with fourth character 9) was revised and the term "physical" was added, to capture specific problems, such as sexual dysfunction and sleep disorder, included in the chapter 5 codes that are not mental disorders. This guideline revision was not intended to suggest other conditions would be classified as physical disorders when associated with substance use, abuse and/or dependence.

Alcoholic pancreatitis and alcohol dependence

ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2020 Page: 9 Effective with discharges: March 5, 2020 Question: A patient is diagnosed with acute alcoholic pancreatitis due to alcohol dependence. Would it be appropriate to assign code F10.288, Alcohol dependence with other alcohol-induced disorder, as an additional code assignment? Answer: Assign codes K85.20, Alcohol induced acute pancreatitis without necrosis or infection, and F10.20, Alcohol dependence, uncomplicated, for the alcoholic pancreatitis and alcohol dependence. In this context, alcoholic pancreatitis is not classified as an alcoholinduced disorder. Therefore, code F10.20 is

assigned rather than code F10.288, Alcohol dependence with other alcohol-induced disorder.

5) Blood Alcohol Level

A code from category Y90, Evidence of alcohol involvement determined by blood alcohol level, may be assigned when this information is documented and the patient’s provider has documented a condition classifiable to category F10, Alcohol related disorders. The blood alcohol level does not need to be documented by the patient’s provider in order for it to be coded.

12. Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99)

a. Pressure ulcer stage codes

2) Unstageable pressure ulcers . . . Assignment of the code for unstageable pressure ulcer (L89.--0) should be based on the clinical documentation. These codes are used for pressure ulcers whose stage cannot be clinically determined (e.g., the ulcer is covered by eschar or has been treated with a skin or muscle graft). This code should not be confused with the codes for unspecified stage (L89.--9). When there is no documentation regarding the stage of the pressure ulcer, assign the appropriate code for unspecified stage (L89.-- 9).

If during an encounter, the stage of an unstageable pressure ulcer is revealed after debridement, assign only the code for the stage revealed following debridement.

15. Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A)

a. General Rules for Obstetric Cases

3) Final character for trimester . . . When the classification does not provide an obstetric code with an “in childbirth” option, it is appropriate to assign a code describing the current trimester Also please note they changed all terms denoting “woman” or “mother” to patient

Related Coding Clinics

Urinary tract infection during delivery episode

ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2018 Page: 20 Effective with discharges: June 6, 2018 Question:

A patient presented to the hospital at 39 weeks gestation in active labor, with increasing back pain. She had a history of recurrent urinary tract infection (UTI) during the pregnancy. Urinalysis was positive for urinary tract infection and the provider confirmed this diagnosis. The patient received treatment for the infection and delivered a healthy infant. What is the appropriate code assignment for UTI that occurs during the delivery episode? Answer: Assign code O23.43, Unspecified infection of urinary tract in pregnancy, third trimester. Also, assign codes for the delivery, outcome of the delivery, weeks of gestation, and any other applicable codes.

18. Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

e. Coma scale Code R40.20, Unspecified coma, may be assigned in conjunction with codes for any medical condition.

Do not report codes for unspecified coma, individual or total Glasgow coma scale scores for a patient with a medically induced coma or a sedated patient.

1) Coma Scale The coma scale codes (R40.21- to R40.24-) can be used in conjunction with traumatic brain injury codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis code(s) If multiple coma scores are captured within the first 24 hours after hospital admission, assign only the code for the score at the time of admission. ICD-10-CM does not classify coma scores that are reported after admission but less than 24 hours later

Related Coding Clinics

Unspecified Coma

ICD-10-CM/PCS Coding Clinic, fFourth Quarter ICD-10 2021 Page: 112 Effective with discharges: October 1, 2021 Question: The Official Guidelines for Coding and Reporting section I.C.18.e. was revised effective October 1, 2020 to indicate that coma scale codes are to be used only in conjunction with traumatic brain injuries (TBI). Subcategory R40.2, Coma, was provided as the code range in this guideline, which includes code R40.20, Coma, unspecified. However, the coma scale codes start at subcategory R40.21, Coma scale, eyes open, and code R40.20 does not appear to capture any coma scale score information. Would code R40.20 be reported with non-traumatic brain injury conditions, such as intracerebral hemorrhage or stroke, when

the patient is also in a coma? Answer: Yes, it would be appropriate to report code R40.20, Coma, unspecified, with non-TBI conditions when the patient is also comatose. The intent of the coma guideline revision was to indicate that coma scale score codes should only be reported with traumatic brain injuries. Code R40.20 does not fall into the coma scale score code range. Therefore, assign code R40.20, when coma is documented and reporting requirements have been met. The Official Guidelines for Coding and Reporting section I.C.18.e. has been revised to clear up any confusion as follows: “Code R40.20, Unspecified coma, may be assigned in conjunction with codes for any medical condition.”

Medically Induced Coma

ICD-10-CM/PCS Coding Clinic, fFourth Quarter ICD-10 2021 Page: 112 Effective with discharges: October 1, 2021 Question: A patient suffered a traumatic brain injury with severe swelling of the brain due to a motor vehicle accident. The patient was placed in a medically induced coma to protect the brain and minimize the swelling and inflammation. Would it be appropriate to report code R40.20, Coma, unspecified, for a medically induced coma? Answer: No, it is not appropriate to report code R40.20 for a medically induced coma. The Official Guidelines for Coding and Reporting section I.C.18.e. states, “Do not report codes for unspecified coma, individual or total Glasgow coma scale scores for a patient with a medically induced coma or a sedated patient.”

Multiple glasgow coma scale scores pre and post admission

ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2021 Page: 4 Effective with discharges: June 7, 2021 Question: The Glasgow coma scale (GCS) is used to help evaluate the acuity of traumatic brain injuries. Therefore, would it be appropriate to report the most severe GCS score if the patient's score worsens after admission, but within the first 24 hours? Answer: ICD-10-CM does not classify scores that are reported after admission but less than 24 hours later. Therefore, only assign one code that represents the GCS score at the time of admission with a POA of "Y."

Traumatic subdural and subarachnoid hemorrhage with loss of consciousness

ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2021 Page: 5 Effective with discharges: June 7,

2021 Question: A patient with traumatic subarachnoid hemorrhage and traumatic subdural hemorrhage due to a fall was initially noted to have loss of consciousness (LOC), for approximately 30 minutes at the time of injury at home. Upon admission, the patient was awake, alert and oriented, but his neurological status declined and he became unresponsive and comatose for over 24 hours without regaining consciousness. He was discharged to a long-term care hospital for continued care. What seventh character is assigned for the LOC (e.g., the initial LOC at the time of the injury or the longest duration)? Additionally, what is the appropriate present on admission indicator (POA) for the traumatic brain hemorrhages with LOC? Answer: Assign codes S06.6X6A, Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter, S06.5X6A, Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter, and R40.20, Unspecified coma. Additionally, assign codes W19.XXXA, Unspecified fall, initial encounter, and Y92.009, Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause. Loss of consciousness of the longest duration should be reported. Assign POA indicator "Y," for the traumatic subarachnoid and subdural hemorrhage, as the injury was present on admission, and loss of consciousness is part of the disease process.

Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88)

d. Coding of Burns and Corrosions 6) Burns and corrosions classified according to extent of body surface involved

Assign codes from category T31, Burns classified according to extent of body surface involved, or T32, Corrosions classified according to extent of body surface involved, for acute burns or corrosions when the site of the burn or corrosion is not specified or when there is a need for additional data. . . Codes from categories T31 and T32 should not be used for sequelae of burns or corrosions

Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)

b. Z Codes Indicate a Reason for an Encounter or Provide Additional Information about a Patient Encounter Z codes are not procedure codes. A corresponding procedure code must accompany a Z code to describe any procedure performed

c. Categories of Z Codes

4) History (of A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered. The reason for the encounter (for example, screening or counseling) should be sequenced first and the appropriate personal and/or family history code(s) should be assigned as additional diagnos(es)

9) Donor These codes are only for individuals donating for others, as well as not for self-donations

10) Counseling The counseling Z codes/categories are . . . Z71 Persons encountering health services for other counseling and medical advice, not elsewhere classified . . . Code Z71.85, Encounter for immunization safety counseling, is to be used for counseling of the patient or caregiver regarding the safety of a vaccine. This code should not be used for the provision of general information regarding risks and potential side effects during routine encounters for the ad-ministration of vaccines.

17) Social Determinants of Health 1 Codes describing social determinants of health (SDOH) should be assigned when this information is documented. For social determinants of health, such as information found in categories Z55- Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses. For example, coding professionals may utilize documentation of social information from social workers, community health workers, case managers, or nurses, if their documentation is included in the official medical record. Patient self-reported documentation may be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the medical record by either a clinician or provider. Social determinants of health codes are located primarily in these Z code categories:

Z55 Problems related to education and literacy

1

Coding of social determinants using non-physician documentation

ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2018 Page: 18 Effective with discharges: February 18, 2018

Z56 Problems related to employment and unemployment Z57 Occupational exposure to risk factors Z58 Problems related to physical environment Z59 Problems related to housing and economic circumstances Z60 Problems related to social environment Z62 Problems related to upbringing Z63 Other problems related to primary support group, including family circumstances Z64 Problems related to certain psychosocial circumstances Z65 Problems related to other psychosocial circumstances

See Section I.B.14. Documentation by Clinicians Other than the Patient’s Provider. Chapter 22: Codes for Special Purposes (U00-U85) U07.0 Vaping-related disorder (see Section I.C.10.e., Vaping-related disorders) U07.1 COVID-19 (see Section I.C.1.g.1., COVID-19 infection) U09.9 Post COVID-19 condition, unspecified (see Section I.C.1.g.1.m)

PCS Guideline Changes

B3. Root Operation

Control vs. more definitive specific root operations

B3.7 The root operation Control is defined as, “Stopping, or attempting to stop, postprocedural or other acute bleeding.” If an attempt to stop postprocedural or other acute bleeding is unsuccessful, and to stop the bleeding requires performing a more definitive root operation, such as Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then the more definitive root operation is coded instead of Control. Control is the root operation coded when the procedure performed to achieve hemostasis, beyond what would be considered integral to a procedure, utilizes techniques (e.g., cautery, application of substances or pressure, suturing or ligation or clipping of bleeding points at the site) that are not described by a more specific root operation definition, such as Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection. If a more specific root operation definition applies to the procedure performed, then the more specific root operation is coded instead of Control. Example: Resection of spleen to stop bleeding is coded to Resection instead of Control Silver nitrate cautery to treat acute nasal bleeding is coded to the root operation Control.

Example: Liquid embolization of the right internal iliac artery to treat acute hematoma by stopping blood flow is coded to the root operation Occlusion. Example: Suctioning of residual blood to achieve hemostasis during a transbronchial cryobiopsy is considered integral to the cryobiopsy procedure and is not coded separately.

Related Coding Clinic 4th Quarter Coding Clinic

Explanation of the Revised Guideline for Control The revised guideline for Control is intended to clarify the appropriate use of this root operation. All three general types of scenarios involving procedures to control bleeding are provided in the revised guideline: 1. Those that should assign the root operation Control. 2. Those that should assign a more specific root operation. 3. Those that do not assign a separate code. Scenario 1: Procedures that meet the definition of the root operation Control use the same techniques—suturing or other ligation or clipping or cautery of bleeding points, application of substances or pressure to the site—as are typically meant by the term “achieving hemostasis” during surgery. When any or all of these techniques are used during a separate procedure performed to control acute bleeding, the root operation Control is assigned. In such cases, the diagnosis on the procedure report may include current or recent acute bleeding. Silver nitrate cautery to treat acute nasal bleeding is used in the revised guideline as an example of this type of scenario. The root operation Control can also be assigned as an additional code in those rare surgical cases where the documentation in the procedure report indicates that something unexpected occurred, requiring additional measures beyond routine hemostasis. An example is a surgical procedure where the procedure site had to be reopened before leaving the surgical suite, due to continued bleeding at the site. Scenario 2: Because the root operation Control is only assigned when the techniques used are the same as those typically used to “achieve hemostasis,” any procedure performed to control bleeding that uses a technique consistent with the definition of one of the other, more specific root operations, then the procedure code is assigned accordingly. A fundamental principle of ICD-10-PCS coding is that the root operation definitions determine the most accurate code that specifies physically what was done to the anatomic site. Assigning root operation Occlusion for liquid embolization of the right internal iliac artery to treat acute hematoma is used in the revised guideline as an example of this type of scenario. Scenario 3: Types of scenarios in which a separate code is not assigned are also covered in the revised guideline, to emphasize the fact that Control is not intended to be assigned for routine, expected techniques used

during a procedure to achieve hemostasis. The revised guideline uses transbronchial cryobiopsy with suctioning of residual blood to achieve hemostasis as an example, to remind coders that typical measures taken to achieve hemostasis are still considered integral to the procedure and are not coded separately.

B4. Body Part . . .

B4.1c If a procedure is performed on a continuous section of a tubular body part, code the body part value corresponding to the furthest anatomical site from the point of entry anatomically most proximal (closest to the heart) portion of the tubular body part. Example: A procedure performed on a continuous section of artery from the femoral artery to the external iliac artery with the point of entry at the femoral artery is coded to the external iliac body part. A procedure performed on a continuous section of artery from the femoral artery to the external iliac artery with the point of entry at the external iliac artery is also coded to the external iliac artery body part.

Iliofemoral endarterectomy and furthest point of entry

ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2021 Pages: 16-17 Effective with discharges: March 10, 2021 Question: The patient had calcified plaque involving the entire common femoral artery, extending into bilateral distal external iliac arteries, with stenotic lesions in the profunda femoris and superficial femoral arteries. The surgeon performed bilateral iliofemoral profunda femoris endarterectomy with a patch graft. During surgery, distal dissection of the external iliac artery was carried out bilaterally. Arteriotomy was made in the common femoral artery and plaque was removed. The external iliac, proximal common femoral and profunda femoris arteries were endarterectomized, with an eversion technique to the external iliac and common femoral arteries. The arteriotomy was then extended into the superficial femoral artery, atheromatous plaque was removed and Bovine pericardial patch was fashioned. When assigning ICD-10-PCS codes, what is considered the most proximal site (i.e., the most proximal site of surgical dissection or the most proximal anatomic site of the vessel)? Answer: Assign the following ICD-10-PCS code:

04CJ0ZZ Extirpation of matter from left external iliac artery, open approach, and

04CH0ZZ Extirpation of matter from right external iliac artery, open approach for the bilateral endarterectomies.

In procedures on the vascular system where a single procedure spans more than one body part as defined by the ICD-10-PCS body part value, the body part value assigned is the anatomically most proximal (closest to the heart) vessel operated on regardless of the access site/point of entry used to get to that vessel. The documentation states that calcified atheromatous plaque involved multiple body parts, and the dissection commenced at the external iliac artery and completed at the superficial femoral artery. Therefore, the external iliac artery is the most proximal anatomical vessel treated and the appropriate body part. No longer applicable…

Iliofemoral endarterectomy with patch repair

ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2016 Page: 31 Effective with discharges: March 18, 2016 Question: The patient presents for a left open iliofemoral endarterectomy with bovine patch repair. The plaque extended from the femoral bifurcation up to the mid external iliac artery. Since the plaque extended through two distinct body parts, should there be two extirpation codes assigned for the endarterectomy and two supplement codes assigned for the bovine patch repairs to capture both the femoral and external iliac arteries? Answer: The lesion (plaque) extended from the femoral bifurcation to the mid external iliac artery, and it is considered a continuation of a single lesion. For coding purposes, choose the furthest anatomical site from the point of entry. In this case, the dissection commenced at the bifurcation of the common femoral artery (where the common femoral splits to become the deep femoral and the superficial femoral) and was completed at the external iliac artery, so the body part value assigned is the external iliac artery. When surgery is performed on an overlapping lesion in a tubular body part, assign the body part value describing the furthest site from the point of entry. Assign the following ICD-10-PCS codes:

04CJ0ZZ Extirpation of matter from left external iliac artery, open approach

04UJ0KZ Supplement left external iliac artery with nonautologous tissue substitute, open approach

Upper and lower intestinal tract

B4.8 In the Gastrointestinal body system, the general body part values Upper Intestinal Tract and Lower Intestinal Tract are provided as an option for the root operations such as Change, Insertion, Inspection, Removal and Revision. Note: Updated guideline as we also have an insertion table for GI body system

E. New Technology Section

General guidelines

E1.a Example: XW04321 Introduction of Ceftazidime-Avibactam Anti-infective into Central Vein, Percutaneous Approach, New Technology Group 1, can be coded to indicate that Ceftazidime-Avibactam Anti-infective was administered via a central vein. XW043A6 Introduction of Cefiderocol Anti-infective into Central Vein, Percutaneous Approach, New Technology Group 6, can be coded to indicate that Cefiderocol Anti-infective was administered via a central vein. Note: Code was deleted so they updated the guideline Disclaimer All materials have been prepared for general information purposes only to permit you to learn more about coding and coding-related subject matter. Except where referenced, the information presented is not official coding advice, is not to be acted on as such, may not be current and is subject to change without notice. The directives in the ICD-10-CM/PCS manuals take precedence over advice published in Coding Clinic.