njpr current topics in icd-10 presented by: diane stoner, rhit, ccs senior health information...

NJPR

CURRENT TOPICS IN ICD-10

Presented by:

Diane Stoner, RHIT, CCS

Senior Health Information Consultant, NJPR

AHIMA-APPROVED ICD-10 TRAINER

1

NJPR Disclaimer

The ICD-10 codes presented by NJPR are based on the 2013 Complete Official Draft Code Set of ICD-10-CM and ICD-10-PCS. Updates, corrections and revisions will be issued for the ICD-10 code set prior to and after implementation, therefore some of the codes presented may become invalid. The most current ICD-10 books, updates and revisions regularly issued by The Centers for Medicare and Medicaid Services (CMS) are the official source for code look up and assignment and should be referenced prior for coding instruction.

NJPR and its instructors assume no responsibility for the use of these codes outside of its intended use and disclaim any liability that may result from the use of this information for coding and billing purposes.

2

ICD-10-PCS Code Changes

– Four codes added under new technology application, valid

October 1, 2013 – Three new codes added and three

codes deleted, to correct body part value for temporary occlusion of abdominal aorta

3

ICD-10-PCS Code Changes Four codes added under new technology application

Valid October 1, 2013

08H005Z Insertion of Epiretinal Visual Prosthesis into Right Eye, Open Approach

08H105Z Insertion of Epiretinal Visual Prosthesis into Left Eye, Open Approach

30280B1 Transfusion of Nonautologous 4-Factor Prothrombin Complex Concentrate into Vein, Open Approach

30283B1 Transfusion of Nonautologous 4-Factor Prothrombin Complex Concentrate into Vein, Percutaneous Approach

4


Three new codes added, to correct body part value for temporary occlusion of abdominal aorta

- New: 04V00DJ* Restriction of Abdominal Aorta with Intraluminal Device, Temporary, Open Approach

- New: 04V03DJ* Restriction of Abdominal Aorta with Intraluminal Device, Temporary, Percutaneous Approach

- New: 04V04DJ* Restriction of Abdominal Aorta with Intraluminal Device, Temporary, Percutaneous Endoscopic Approach

5


*Appendix G – Character meanings for the Heart and Great Vessels

Root Operation V - Restriction

Qualifier - character 7

J - temporary

6


Three codes deleted, to correct body part value for temporary occlusion of abdominal aorta

- Deleted: 02VW0DJ* Restriction of Thoracic Aorta with Intraluminal Device, Temporary, Open Approach

- Deleted: 02VW3DJ* Restriction of Thoracic Aorta with Intraluminal Device, Temporary, Percutaneous Approach

- Deleted: 02VW4DJ* Restriction of Thoracic Aorta with Intraluminal

Device, Temporary, Percutaneous Endoscopic Approach

7

New ICD-10-PCS codes for FY 2014

08H[0,1]05Z - Insertion of Epiretinal Visual Prosthesis into Right Eye, into Left Eye, Open Approach (2 codes)

8

New ICD-9-CM codes for FY 2014

14.81 Implantation of epiretinal visual prosthesis

14.82 Removal of epiretinal visual prosthesis

14.83 Revision of epiretinal visual prosthesis

9

RETINAL IMPLANTS AND WHO NEEDS THEM

Retinal implants restore vision in patients that are blind due to photoreceptor loss from retinitis pigmentosa.

Retinitis pigmentosa is a rare, inherited, blinding disease in which light sensitive photoreceptor cells of the eye slowly and progressively degenerate and die. However the retinal neurons, e.g. bipolar cells or ganglion cells, are retained and still work.

10

HEALTHY EYES

In a healthy eye, the photoreceptors (rods and cones) in the retina convert light into tiny electrochemical impulses that are sent through the optic nerve and into the brain, where they are decoded into images. If the photoreceptors no longer function correctly - due to conditions such as retinitis pigmentosa - the first step in this process is disrupted, and the visual system cannot transform light into images.

11

How does the Epiretinal Visual Prosthesis System work?

The Argus® II System • epiretinal implant that is fully implanted in and around the eye

• miniature video camera housed in the patient’s glasses captures a scene

• video is sent to a small patient-worn computer (i.e., the video processing unit – VPU

• processes and transformed into instructions that are sent back to the glasses

• real time video signals are wirelessly transmitted to the implant

12

How does the Epiretinal Visual Prosthesis System work?

• signals are then sent to the electrode array, which emits small pulses of electricity

• pulses are intended to bypass the damaged photoreceptors and stimulate the retina’s remaining cells which are secured at the level of ganglion cells

• overlying neurons signals are transmitted to a retinal stimulator that is secured at the level of ganglion cells

• transmits the visual information along the optic nerve to the brain

• process is intended to create the perception of patterns of light which patients can learn to interpret as visual patterns

13

GEM CROSSWALKNew 2014 entry

Example: 08H[0,1]05Z – Insertion of Epiretinal Visual

Prosthesis into Right Eye, Open Approach (2 codes)

To/from 14.81 – Implantation of Epiretinal Visual Prosthesis

14


30280B1 Transfusion of Nonautologous 4-Factor Prothrombin Complex Concentrate into Vein, Open Approach

30283B1 Transfusion of Nonautologous 4-Factor Prothrombin Complex Concentrate into Vein, Percutaneous Approach

15

New ICD-9-CM codes for FY 2014

00.96 - Infusion of 4-Factor Prothrombin Complex Concentrate

16

What is Infusion of 4-Factor Prothrombin Complex Concentrate?

Administration of prothrombin complex concentrate (PCC) is used for the immediate reversal of the anticoagulant effect of vitamin K antagonists, for example in case of intracranial hemorrhage or life-threatening bleeding.

There are two types of PCCs containing four (vitamin K-dependent) factors II, VII, IX

and X. containing mainly factors II, IX, and X.

17

What is Infusion of 4-Factor Prothrombin Complex Concentrate?

Voils and Baird performed a systematic review on the efficacy of these agents in clinical studies, specifically comparing the 3-factor and 4-factor concentrates.

The conclusion was that 4-factor PCCs result in a more reliable correction of the INR compared to 3-factor concentrates.

Kcentra™ 4F-PCC is FDA-approved for rapid Warfarin reversal in patients experiencing an acute major bleed.

18

GEM CROSSWALKNew 2014 entry

Example: 3028[0,3]B1 – Transfusion of Nonautologous

4-Factor Prothrombin Complex Concentrate in Vein, Percutaneous Approach (2 codes)

To/From 00.96 Infusion 4-Factor Prothrombin Complex Concentrate

19


• 04V00DJ*, restriction of abdominal aorta with intraluminal device, temporary, open approach

• 04V03DJ*, restriction of abdominal aorta with intraluminal device, temporary, percutaneous approach

• 04V04DJ*, restriction of abdominal aorta with intraluminal device, temporary, percutaneous endoscopic approach

To/from 39.77 Temporary (partial) therapeutic endovascular occlusion of vessel

20

Estimating the Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments

• Ninety-nine percent (99%) of the cases showed no change in MS-DRG when coded in ICD-10-CM/PCS.

• Of the 1% of the cases with MS-DRG shifts. • 45% of those shifted to higher weight MS-DRGs• 55% shifted to lower weight MS-DRGs. • Payment increases and decreases due to a change in DRG assignment are

estimated to essentially net out. • MS-DRG shifts due to re-coding in ICD-10 are caused by unavoidable

differences between the two classification systems.

21

Estimating the Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments

2014 GEM reimbursement update available Oct 2013

22

INDEX ISSUES

AND

CLINICAL DOCUMENTATION

OPPORTUNITIES

23

AKIAcute Kidney Injury

(Nontraumatic)

No ICD-10 CM index listing for

acute nontraumatic kidney injury

24

ICD-10-CM Index

Injury

Kidney S37.00-

Specified S37.09-

25

No ICD-10 CM Index listing for…

Injury

Renal

Kidney – see condition

Renal – see condition

Acute – see condition26

S37.0 Injury of Kidney

Excludes 2 note: acute kidney injury (nontraumatic) (N17.9)

N17.9 Acute kidney failure, unspecified

Acute kidney injury (nontraumatic)

Excludes 2 note: traumatic kidney injury (S37.0-)

27

FRACTURE GUIDELINES and CDI ORTHO OPPORTUNITIES

A fracture not indicated as open or closed should be coded to closed.

A fracture not indicated whether displaced or not displaced should be coded to displaced.

28

ICD-10-CM Traumatic Fracture 7th character

A - initial encounter for closed fracture

B - initial encounter for open fracture

D - subsequent encounter for fracture with routine healing

G - subsequent encounter for fracture with delayed healing

K - subsequent encounter for fracture with nonunion

P - subsequent encounter for fracture with malunion

S - sequela

29


INITIAL ENCOUNTER

The patient is receiving active treatment for the fracture

Examples of active treatment • surgical treatment• emergency department encounter• evaluation and treatment by a new physician• patient who delayed seeking treatment for the

fracture or nonunion.

30


SUBSEQUENT CARE

• Encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase

Examples of fracture aftercare

• cast change or removal• removal of external or internal fixation device• medication adjustment• follow-up visits following fracture treatment.

31


SEQUELAE

• Complication or the condition as a result of the injury

Example – Scar

– Sequelae is sequenced first.– Injury code is sequenced as a secondary

diagnosis with the 7th character “S”.32

GUSTILO OPEN FRACTURE CLASSIFICATION

Classifies open fractures into three major categories (Type 1, Type II, Type III) depending on the mechanism of the injury, soft tissue damage and degree of skeletal involvement

33


• Type I – usually a simple fracture with wound less than 1 cm and minimal soft tissue injury

• Type II – usually a simple fracture with wound

greater than 1 cm and moderate soft tissue injury

• Type III – fractures that involve extensive damage

to the soft tissues including muscle, skin and neurovascular structures

34


• Subtype IIIA – open fracture with adequate soft tissue coverage despite fracture severity

• Subtype IIIB – open fracture with extensive soft

tissue loss

• Subtype IIIC – open fracture which involves major

arterial injury requiring repair for limb salvage

35


S52 Fracture of forearm

List of appropriate 7th character is to be added to all codes from category S52 [unless otherwise indicated].

• A initial encounter for closed fracture• B initial encounter for open fracture type I or II initial

encounter for open fracture NOS• C initial encounter for open fracture type IIIA, IIIB, or

IIIC

36




• D subsequent encounter for closed fracture with routine healing

• E subsequent encounter for open fracture type I or II with

routine healing• F subsequent encounter for open fracture type IIIA,

IIIB, or IIIC with routine healing

37




• G subsequent encounter for closed fracture with delayed healing

• H subsequent encounter for open fracture type I or II with delayed healing

• J subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing

• S sequela

38


NONUNION

Care of complications of fractures with nonunion are coded with the 7th character

• K- subsequent encounter for closed fracture with nonunion

• M - subsequent encounter for open fracture Type 1 or II with nonunion

• N - subsequent encounter for open fracture type IIIA, IIIB, IIIC with nonunion

39


MALUNION

Care of complications of fractures with malunion are coded with the 7th character

• P - subsequent encounter for closed fracture with malunion

• Q - subsequent encounter for open fracture Type 1 or Type 2 with malunion

• R - subsequent encounter for open fracture Type IIIA, IIIB, IIIC with malunion

40

ICD-10-CM Fractures

A code from category M80, not a traumatic fracture code, should be used for any 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.

41

ICD-10-CM Traumatic Fractures

The aftercare Z codes should not be used for aftercare for traumatic fractures. For aftercare of a traumatic fracture, assign the acute fracture code with the appropriate 7th character.

42

CDI for ORTHO CASES

Fx - open

- closed

- displaced

- nondisplaced

episode of care - initial

- subsequent

- sequela

Gustilo open fracture classification choices

Is fracture related to or due to osteoporosis - yes

- no43

SMOKING

ICD-9 305.1 or V15.82

ICD-10-CM smoker – see dependence drug, nicotine

Dependence drug, nicotine F17.200

with disorder F17.209

remission F17.201

specified disorder NEC F17.208

withdrawal F17.203

44

SMOKING

ICD-10-CM

Same code choices for chewing tobacco, cigarettes, and other nicotine specified products

Dependence, drug, nicotine, withdrawal is a CC.

F17.2- codes

Excludes 1

History of tobacco dependence Z87.891

45

Alcohol use, abuse and dependence in ICD-10-CM

USE

Use (of )

alcohol F10.99

with sleep disorder F10.982

harmful — see Abuse, alcohol

F10.99 is a CC because the code description reads“Alcohol use, unspecified with unspecified alcohol induced

disorder”

46


ABUSE alcohol (non-dependent) F10.10

with

anxiety disorder F10.180intoxication F10.129

with delirium F10.121uncomplicated F10.120

mood disorder F10.14other specified disorder F10.188

psychosis F10.159delusions F10.150

hallucinations F10.151sexual dysfunction F10.181sleep disorder F10.182

unspecified disorder F10.19

47


DEPENDENCEalcohol (ethyl) (methyl) (without remission) F10.20

with

amnestic disorder, persisting F10.26

anxiety disorder F10.280dementia, persisting F10.27intoxication F10.229

with delirium F10.221uncomplicated F10.220

mood disorder F10.24psychotic disorder F10.259

with

delusions F10.250

hallucinations F10.25148


DEPENDENCEalcohol (ethyl) (methyl) (without remission) F10.20

with

remission F10.21

sexual dysfunction F10.281sleep disorder F10.282

specified disorder NEC F10.288withdrawal F10.239

withdelirium F10.231perceptual disturbance F10.232uncomplicated F10.230

49

ICD-10-CM Coding Guidelines

Similarities

Changes

And

Major Changes

50


Fracture 7th characters

Mental Health diagnosis with manifestations

51


HIV GUIDELINES• Code ONLY confirmed cases as in ICD-9, this is an

exception to the basic coding guidelines• Code B20 – old 042• If a patient admitted for an HIV-related condition, use

the HIV code followed by additional diagnosis codes for all reported HIV-related conditions

• If a patient with HIV disease admitted for an unrelated illness, code condition first followed by the HIV code

• Code Z21 for asymptomatic HIV status

52


• Code only confirmed cases of influenza due to certain identified influenza viruses, and due to other identifiable influenza virus. This is an exception to the hospital inpatient guidelines.

• If documentation states “suspected”, “possible”, “probable” avian influenza or novel influenza or other identifiable influenza, a code from Category J11 (Influenza due to unidentified influenza virus) should be assigned.

53


Chronic kidney disease and hypertension

• ICD-10-CM presumes a causal relationship between HTN and CKD.

• Secondary code to identify the stage of kidney disease.

• If a patient has acute renal failure, an additional code for the acute renal failure is required.

54


Hypertensive heart diseases is coded when a causal relationship is stated (due to hypertension) or implied (hypertensive).

An additional code is needed to identify the type of heart failure for patients with heart failure.

55

ICD-10-CM Sepsis Coding Guidelines

• Sequencing of sepsis codes is dependent on circumstances of admission

• Assign A41.9 if type of infection or causal organism is not further specified (ICD-9 = 038.9)

• Urosepsis is not recognized as a disease in ICD-10

56

ICD-10-CM Sepsis Coding Guidelines

• A minimum of 2 codes is required for the coding of Sepsis with Associated Organ Dysfunction– One code for underlying infection– One code from subcategory (severe sepsis)

• Severe Sepsis is implied when septic shock is documented.

• Additional codes for the associated acute organ dysfunctions are also required

57

ICD-10-CM Neoplasm Coding Guidelines

The neoplasm table in the alphabetic index should be referenced first. However, if the histological term is documented, that term should be referenced first rather than going immediately to the neoplasm table, in order to determine which column in the neoplasm is appropriate.

Carcinoid (tumor) – see Tumor, carcinoid

Tumor, carcinoid has both benign and malignant codes

58


STAGES OF CHRONIC KIDNEY DISEASE (CKD)• The ICD-10-CM classifies CKD based on severity. The severity of CKD

is designated by stages 1-5. • Stages of CKD

– Stage 1 – N18.1– Stage 2 – N18.2 (mild)– Stage 3 – N18.3 (moderate)– Stage 4 – N18.4 (severe)– Stage 5 – N18.5

Note: Code CKD, Stage 5 requiring chronic dialysis to N18.6 (ESRD)

59


ANEMIA ASSOCIATED WITH MALIGNANCY

When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by the code for Anemia in neoplastic disease.

60


CODE ASSIGNMENTS FOR ENCOUNTERS SOLELY FOR THE ADMINISTRATION OF CHEMOTHERAPY, IMMUNOTHERAPY AND RADIATION THERAPY

• Z51.0 – Encounter for antineoplastic radiation therapy• Z51.11 – Encounter for antineoplastic chemotherapy• Z51.12 – Encounter for antineoplastic immunotherapy

61


DIABETES GUIDELINES

No more controlled vs. uncontrolled

• combination codes that include the type of DM, the body system affected and the complications affecting that body system

• should be sequenced based on the reason for a particular encounter. Assign as many codes as needed to identify all of the associated conditions that the patient has

.62


NERVOUS SYSTEM GUIDELINESDOMINANT/NONDOMINANT SIDE of HEMIPLEGIA

Default codes should be dominant if the right side is affected. If the left side is affected, the default is non-dominant.

63


LATERALITY

right

left

BILATERALITY

When the condition is bilateral, it is correct to assign a code for the left and right sides when there is no bilateral code available.

64


Some of the Ear diagnosis codes ask us to -

Use additional code to identify:• Exposure to environmental tobacco smoke (Z77.22)• Exposure to tobacco smoke in the perinatal period (P96.81)• History of tobacco use (Z87.891)• Occupational exposure to environmental tobacco smoke

(Z57.31)• Tobacco dependence (F17.-)• Tobacco use (Z72.0)

65


ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris.

The subcategories for these codes include coronary artery disease of the native coronary arteries, coronary artery bypass graft(s) and arteries of transplanted heart with angina.

66


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

67


Acute and subsequent myocardial infarctions -

ICD-9 Acute MI timeframe is 8 weeks ICD 10 Acute MI timeframe is 4 weeks

ICD-10 Initial MI code I21ICD-10 Subsequent MI code I22

Use a code from category I21 for the initial MI for that admission and any other subsequent admissions

that occur in the next 4 weeks

Any additional MIs that occurs during that 4 weeks timeframe from the initial MI is considered a subsequent MI and uses a code from the I22 category

68


The sequencing of the I22 and I21 codes depends on the circumstances of the encounter. Should a patient who is in the hospital due to an AMI have a subsequent AMI while still in the hospital, code I21 would be sequenced first as the reason for admission, with code I22 sequenced as a secondary code. Should a patient have a subsequent AMI after discharge for care of an initial AMI, and the reason for admission is the subsequent AMI, the I22 code should be sequenced first followed by the I21. An I21 code must accompany the I22 code to identify the site of the initial AMI, and to indicate that the patient is still within the 4 week time frame of healing from the initial AMI

69


Code I25.2 is used for an “old” or healed MI not requiring further care.

70


ICD-10-CM provides combination codes for complications commonly associated with Crohn’s disease. These combination codes can be found under category K50 (Crohn’s Disease).

71

ICD-10 PREGNANCY, CHILDBIRTH AND THE PUERPERIUM GUIDELINES

FINAL CHARACTER FOR TRIMESTER

The majority of codes in Chapter 15 have a final character indicating the trimester of pregnancy. The time frames for the trimesters are as follows:

• 1st trimester – less than 14 weeks, 0 days• 2nd trimester – 14 weeks, 0 days to less than 28 weeks, 0

days• 3rd trimester – 28 weeks, 0 days until delivery

72


If trimester is not a component of a code, it is because the condition always occurs in a specific trimester, or the concept of trimester of pregnancy is not applicable. Certain codes have characters for only certain trimesters because the condition does not occur in all trimesters, but it may occur in more than just one.

73


Assignment of the final character for trimester should be based on the trimester for the current admission/encounter.

This applies to the assignment of trimester for pre-existing conditions as well as those that develop during or are due to the pregnancy.

74


Whenever delivery occurs during the current admission, and there is “in childbirth” option for the obstetric complication being coded, the “in childbirth” code should be assigned.

75


UNSPECIFIED TRIMESTER

Each category that includes codes for trimester has a code for “unspecified trimester”. The “unspecified trimester” code should rarely be used, such as when the documentation in the record is insufficient to determine the trimester and it is not possible to obtain clarification.

76


• NEW• Assign a code from category Z3A (weeks of

gestation) on the maternal record to provide additional information about the pregnancy.

• SAME• Assign a code from category Z37 (Outcome of

Delivery) on all maternal records where a delivery has occurred.

77


Chapter 19 includes codes for traumatic fractures, burns, complications of care (pain from devices, transplant complications other than kidney) as well as adverse effects, poisonings, underdosing and toxic effects.

78


Codes from category T36-T65 (Adverse Effects, Poisonings, Underdosing and Toxic Effects) are combination codes that include the substances related to the adverse effect, the poisoning, underdosing and toxic effect as well as the external cause of the poisoning, underdosing and toxic effect.

79


Most categories in chapter 19 have seventh character classifications that are required for each applicable code. Most categories in this chapter have three extensions (with the exception of fractures): A, initial encounter, D, subsequent encounter and S, sequela.

80


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, assign the acute care injury code with the seventh character “D” (subsequent encounter).

81


ADVERSE EFFECT

The drug has been correctly prescribed and properly administered.

Assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug

The code for the drug should have a 5th or 6th character “5” (for example T36.0X5 Adverse effect of penicillins) .

82


POISONING

Poisoning is the improper use of a medication including overdose, wrong substance given or taken in error, wrong route of administration.

Poisoning codes have an associated intent: accidental, intentional self-harm, assault and undetermined. Use additional code(s) for all manifestations of poisonings.

83


UNDERDOSING

Underdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer’s instruction.

84


Codes for underdosing should never be assigned as principal 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.

85


PRESSURE ULCERS

Codes for pressure ulcers are combination codes that identify the site of the pressure ulcer as well as the stage of the ulcer.

86


• Code based on severity using stages 1-4, unspecified and unstageable

• Unstageable = Cannot be clinically determined – not the same as unspecified

• Healed: Do not code pressure ulcers documented as healed on admission

• Healing: Code to stage documented in record• Evolution of stage throughout admission: code the highest stage

reported for that site

87


PRESSURE ULCERS

The pressure ulcer category has specific coding instructions for gangrene -

. “Code first any associated gangrene”

88

REFERENCES• www.cms.hhs.gov/ICD9ProviderDiagnosticCodes• www.cms.gov/mmrr/Downloads/MMRR2011_001_02_A02.pdf • Ingenix OPTUM 2013 ICD-10-CM, The complete official draft code set• TruCode 2013, 2Q• http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/Downloads/March5-ICD9-

CM.pdf. • Prevention magazine, September 2013 issue, Answers Dr,Sanjay Gupta/The Neurosurgeon • Published: Dec 2012 - Marcel Levi• Systematic review: 3-factor versus 4-factor prothrombin complex concentrate for warfarin reversal:

does it matter? • Voils SA, Baird B, Thromb Res 2012;130:833-840• Wikipedia.com • A Fully Implantable Epiretinal Vision Prosthesis for Retinitis Pigmentosa Patients

Thomas Schanze, Uwe Thomas, EpiRet GmbH, Winchester Straße 8 D-35394 Gießen• Blind patients implanted with this prosthesis can perform spatial and motion tasks.

BY CONNI BERGMANN KOURY, EDITOR-IN-CHIEF • 2-sight.eu/en/product-en

89

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njpr current topics in icd-10 presented by: diane stoner, rhit, ccs senior health information...

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