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Chapter 7. Cardiovascular System The increased specificity of ICD-10-CM makes it imperative that physicians document more detailed information and that coders are able to determine from documentation the code or codes appropriate for the patient’s condition. Valvular Disorders Acute rheumatic fever, a complication of strep pharyngitis in children, results in various cardiac conditions in more than a third of patients affected. Depending on the extent of heart inflammation involved, patients with the acute form of the disease may develop heart failure, pericarditis, myocarditis, and endocarditis, which is manifested as insufficiency of the mitral (65 to 70 percent of cases) and aortic valves (25 percent of cases). DEFINITIONS pericarditis. Inflammation affecting the pericardium. Figure 7.11: Valvular Function Chronic disease may result in arrhythmias, ventricular dysfunction, and dilation of the atria. In adults, acute rheumatic fever is the most common cause of mitral valve stenosis and the leading cause for valvular replacement surgery. Although the mitral valve is most commonly affected, the aortic and tricuspid valves may also be involved. Chronic manifestations due to protracted disease and continued valve deformity occur in an estimated 9 to 39 percent of adults with previous rheumatic heart disease. Two to 10 years after an acute episode of rheumatic fever, the valve apparatus may fuse, with resulting stenosis or stenosis with insufficiency. Each recurrent episode can extend the valvular damage. For acute rheumatic heart conditions, there is a one-to-one mapping of the appropriate ICD-9-CM code to the appropriate ICD-10-CM code. For instance, ICD-9-CM code 391.0 for acute rheumatic pericarditis directly correlates to code IØ1.1 in ICD-10-CM. This is also true for some valvular diseases resulting from rheumatic fever. Although ICD-9-CM does classify some conditions as rheumatic in nature, ICD-10-CM has distinguished, in large part, specific valvular diseases caused by rheumatic fever versus those not related to the disease, as well as the specific valve involved as shown in the following table. This differentiation does not always result in additional ICD-10-CM codes, as demonstrated by ICD-9-CM codes 396.0 through 396.8, which map to ICD-10-CM code IØ8.Ø. © 2012 OptumInsight, Inc. 195 Comprehensive Anatomy and Physiology for ICD-10-CM and ICD-10-PCS Coding Coding for Diseases of the Heart Valves ICD-9-CM ICD-10-CM Rheumatic 394.0 Mitral stenosis I05.0 Rheumatic mitral stenosis 394.2 Mitral stenosis with insufficiency I05.2 Rheumatic mitral stenosis with insufficiency 394.9 Other and unspecified mitral valve diseases I05.8 I05.9 Other rheumatic mitral valve diseases Rheumatic mitral valve disease, unspecified 396.0 Mitral valve stenosis and aortic I08.0 valve stenosis Rheumatic disorders of both mitral and aortic valves 396.1 Mitral valve stenosis and aortic I08.0 valve insufficiency Mitral valve insufficiency and aortic valve stenosis Mitral valve insufficiency and aortic valve insufficiency Rheumatic disorders of both mitral and aortic valves 397.0 Diseases of tricuspid valve I07.0 I07.1 I07.2 I07.8 I07.9 Rheumatic tricuspid stenosis Rheumatic tricuspid insufficiency Rheumatic tricuspid stenosis and insufficiency Other rheumatic tricuspid valve diseases Rheumatic tricuspid valve disease, unspecified 397.1 Rheumatic diseases of pulmonary valve I09.89 Other specified rheumatic heart diseases 397.9 Rheumatic diseases endocardium valve unspecified I08.1 Rheumatic disorders of both mitral and tricuspid valves Rheumatic disorders of both aortic and tricuspid valves Combined rheumatic disorders of mitral, aortic, and tricuspid valves Other rheumatic multiple valve diseases Rheumatic multiple valve disease, unspecified Rheumatic diseases of endocardium, valve unspecified 396.2 396.3 I08.2 I08.3 I08.8 I08.9 I09.1 There are many differences between the ICD-9-CM and ICD-10-CM terminology used for valvular disorders. Key differences can be as simple as a “disorder” code in ICD-9-CM becoming more specific in ICD-10-CM; however, there are some important terms to be aware of. DEFINITIONS insufficiency. Inadequate closure of the valve, allowing abnormal backward blood flow. regurgitation. Abnormal backward flow. stenosis. Narrowing or constriction of a passage. Insufficiency is, in general, the inability to perform a function adequately or to the level necessary for the human body. When using the term with regard to valve function, it typically means the valve isn’t functioning as well as it should be, allowing blood to flow back into the chamber inappropriately. Prolapse, specifically mitral valve prolapse, occurs when the cusps of the mitral valve protrude into the left atrium during ventricular systole. It is sometimes referred to as mitral valve prolapse syndrome. Stenosis means narrowing or contracted. Regarding the valves, it describes a condition in which there has been a narrowing or a stricture caused by a multitude of factors, such as calcification or a congenital malformation. Understanding these three terms helps when reporting valve disorders in ICD-10-CM. It is not known how payers will handle unspecified codes under the ICD-10-CM code set, so it is important to always code to the highest level of specificity. This may mean querying the provider for additional information. 196 © 2012 OptumInsight, Inc. Comprehensive Anatomy and Physiology for ICD-10-CM and ICD-10-PCS Coding DEFINITIONS aphasia. Partial or total loss of the ability to comprehend language or communicate through speaking, the written word, or sign language. Aphasia may result from stroke, injury, Alzheimer's disease, or other disorder. Common types of aphasia include expressive, receptive, anomic, global, and conduction. apraxia. Impaired sequencing of motor skills. Apraxia can be used to describe a variety of symptoms, from an awkward gait to anomalous speech. ataxia. Defect in muscular coordination, seen especially when voluntary muscular movements are attempted. cognitive. Having to do with being aware by drawing from knowledge, such as judgment, reason, perception, and memory. cortical. Pertaining to the cortex, which is the outer portion of an organ. In the brain it refers to the outer part of the cerebrum. dysarthria. Difficulty pronouncing words. dysphagia. Difficulty and pain upon swallowing. Common causes of dysphagia are esophagitis, Barrett's esophagus, or late effect of a stroke. hemianopsia. Loss of partial vision or complete blindness in half of the visual field of one (unilateral hemianopsia) or both (bilateral hemianopsia) eyes. hemiplegia. Paralysis of one side of the body. monoplegia. Loss or impairment of motor function in one arm or one leg. subcortical. Pertaining to the part of the brain below the cebral cortex. 218 Intracerebral hemorrhage accounts for 10 to 15 percent of all strokes. This type of stroke is associated with a much higher rate of mortality than that of the more common acute ischemic stroke, caused by thrombosis or embolism. Intracerebral hemorrhages (nontraumatic) are classified to category 430 in ICD-9-CM, and traumatic hemorrhages are classified to category 851, regardless of where the bleeding occurs in the brain. ICD-10-CM classifies intracerebral hemorrhages according to whether the bleed was traumatic or nontraumatic, but also designates the specific part of the brain in which the bleed occurred for nontraumatic bleeds. Coding for Intracerebral Hemorrhage ICD-9-CM ICD-10-CM 431 I61.0 Intracerebral hemorrhage I61.1 I61.2 I61.3 I61.4 I61.5 I61.6 I61.8 I61.9 Nontraumatic intracerebral hemorrhage in hemisphere, subcortical Nontraumatic intracerebral hemorrhage in hemisphere, cortical Nontraumatic intracerebral hemorrhage in hemisphere, unspecified Nontraumatic intracerebral hemorrhage in brain stem Nontraumatic intracerebral hemorrhage in cerebellum Nontraumatic intracerebral hemorrhage, intraventricular Nontraumatic intracerebral hemorrhage, multiple localized Other nontraumatic intracerebral hemorrhage Nontraumatic intracerebral hemorrhage, unspecified Residual Effects of Cerebrovascular Disease When a brain injury occurs due to a stroke or other type of cerebrovascular disease or due to a traumatic injury to the brain, residual effects can occur according to the severity and the site of the brain injury. This includes paralysis; speech and language problems, such as aphasia, dysarthria, and dysphasia; and cognitive defects. For both coding classification systems, these residual neurological deficits are reported in addition to the underlying brain injury code regardless of when the deficit occurs. Once again, ICD-10-CM classifies these conditions with greater specificity, including hemiplegia and monoplegia for which ICD-10-CM indicates if the left or right side or limb is dominant. ICD-9-CM simply refers to the dominant side, with no distinction between right and left. Speech deficits are also classified in much more detail in ICD-10-CM, specifying the underlying cause of the condition, as indicated in the following table. © 2012 OptumInsight, Inc. Comprehensive Anatomy and Physiology for ICD-10-CM and ICD-10-PCS Coding Central Nervous System (0) Procedures involving the central nervous system can cover a variety of areas and a number of different types of procedures, such as nerve transfers and mapping procedures. A compiled table for body system character 0 Central Nervous System shows all of the valid characters for that system under ICD-10-PCS. Operation–Character 3 1 Bypass Body Part–Character 4 0 Brain Approach–Character 5 Device–Character 6 Qualifier–Character 7 0 Open 0 Drainage Device 0 Nasopharynx 2 Monitoring Device 1 Mastoid Sinus 2 Change 1 Cerebral Meninges 3 Percutaneous 5 Destruction 2 Dura Mater 4 Percutaneous Endoscopic 3 Infusion Device 2 Atrium 8 Division 3 Epidural Space X External 7 Autologous Tissue Substitute 3 Blood Vessel 9 Drainage 4 Subdural Space J Synthetic Substitute 4 Pleural Cavity B Excision 5 Subarachnoid Space K Nonautologous Tissue Substitute 5 Intestine C Extirpation 6 Cerebral Ventricle M Electrode 6 Peritoneal Cavity D Extraction 7 Cerebral Hemisphere Y Other Device 7 Urinary Tract F Fragmentation 8 Basal Ganglia Z No Device 8 Bone Marrow H Insertion 9 Thalamus 9 Fallopian Tube J Inspection A Hypothalamus B Cerebral Cisterns K Map B Pons F Olfactory Nerve N Release C Cerebellum G Optic Nerve P Removal D Medulla Oblongata H Oculomotor Nerve Q Repair E Cranial Nerve J Trochlear Nerve S Reposition F Olfactory Nerve K Trigeminal Nerve T Resection G Optic Nerve L Abducens Nerve U Supplement H Oculomotor Nerve M Facial Nerve W Revision J Trochlear Nerve N Acoustic Nerve X Transfer K Trigeminal Nerve P Glossopharyngeal Nerve L Abducens Nerve Q Vagus Nerve M Facial Nerve R Accessory Nerve N Acoustic Nerve S Hypoglossal Nerve P Glossopharyngeal Nerve X Diagnostic Q Vagus Nerve Z No Qualifier R Accessory Nerve S Hypoglossal Nerve T Spinal Meninges U Spinal Canal V Spinal Cord W Cervical Spinal Cord X Thoracic Spinal Cord Y Lumbar Spinal Cord This table provides a great basis from which to study important terminology concerning the central nervous system, as well as terms used throughout ICD-10-PCS in general. 390 © 2012 OptumInsight, Inc. Chapter 14. Anatomy and Physiology and the ICD-10-PCS Code Set: Nervous and Circulatory Systems Root Operation — Character 3 The root operation character is one of the first key decisions required in the ICD-10-PCS coding process. Understanding the meanings of the various root operations is vital to code selection. Each body system has its own list of appropriate root operations. The characters are consistent across all body systems in the medical and surgical section of ICD-10-PCS, but not all root operation characters are used in all tables. Refer to Appendix C for the full definition of all root operations in ICD-10-PCS. The root operations used in the central nervous system table are as follows: Root Operation Character Value Root Operation Character Value Bypass 1 Inspection J Change 2 Map K Destruction 5 Release N Division 8 Removal P Drainage 9 Repair Q Excision B Reposition S Extirpation C Resection T Extraction D Supplement U Fragmentation F Revision W Insertion H Transfer X The terms used in ICD-10-PCS may not be the terms used in documentation by the providers. A good example of this is the root operation extirpation, a term not familiar to many coders. Extirpation is the removal of solid matter from a body part, oftentimes a tubular body part, although that is not required. This term may not be found in the operative report. However, knowledge and understanding of the PCS definition of this term is required for accuracy in assignment of the most appropriate ICD-10-PCS code. Body Part — Character 4 The body part characters in ICD-10-PCS detail the specific site where the procedure was performed. Again, the physician may use different terminology than is used in the table, so it is vital to understand not only the term as given in the table but also associated terms. © 2012 OptumInsight, Inc. 391 Comprehensive Anatomy and Physiology for ICD-10-CM and ICD-10-PCS Coding Figure 14.1: Brain Sections Thalamus 9 Choroid plexus 6 Cerebrum 0 Hypothalamus A Basal ganglia 8 Third ventricle 6 Cerebral aqueduct 6 Pons B Subarachnoid space 5 Dura mater 2 Medulla oblongata D Cerebellum C Choroid plexus 6 Fourth ventricle 6 Spinal cord V Character Value – 0, Brain Associated Terms: Cerebrum, Corpus callosum, Encephalon The cerebrum is the large uppermost section of the brain, which is divided into two hemispheres. The corpus callosum is the band of nerve fibers that joins the two cerebral hemispheres together. Encephalon is a term that is used to refer to all of the contents of the cranium, such as the cerebrum, the cerebellum, and the other structures of the brain. Character Value – 1, Cerebral Meninges Associated Terms: Arachnoid mater, Leptomeninges, Pia mater The meninges are the membranes that enclose the brain and the spinal cord, and the cerebral meninges are those that specifically enclose the cerebrum. The arachnoid membrane or mater/sheath lies between the dura mater and the pia mater to help protect the brain. The pia mater is the inner most layer of membrane helping to protect the brain. This membrane layer is rich in blood vessels to help supply the nervous tissue. The leptomeninges is a term used to describe both the pia mater and the arachnoid membrane in combination with one another. Character Value — 2, Dura Mater Associated Terms: Cranial dura mater, denticulate ligament, diaphragma sellae, falx cerebri, spinal dura mater, tentorium cerebelli The dura mater is the outermost membrane of those that enclose the brain and spinal cord. The denticulate ligaments are “tooth-like” portions of ligament that attach the pia mater to the dura mater and arachnoid membranes, and are known to give some stability to the spinal cord with the vertebral column. Several of these terms are different types of dura mater. The diaphragma sellae is the portion of the dura mater that creates a partition between the pituitary gland and the brain above. The falx cerebri is a sickle-shaped fold of the dura mater that extends into the fissure between the two hemispheres of the cerebrum. The tentorium cerebelli is a horizontal projection of the meningeal dura mater that separates the cerebellum in the posterior cranial fossa from the posterior portion of the cerebral hemispheres. 392 © 2012 OptumInsight, Inc.