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ICD10 Gotcha Moments: Lessons learned
during the I10 Transition
1
Excludes 1 Notes
Excludes1
• A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An
Excludes1 note indicates that the code excluded should never be used at the same
time as the code above the Excludes1 note. An Excludes1 is used when two
conditions cannot occur together, such as a congenital form versus an acquired
form of the same condition.
Excludes2
• A type 2 Excludes note represents “Not included here”. An excludes2 note
indicates that the condition excluded is not part of the condition represented by
the code, but a patient may have both conditions at the same time. When an
Excludes2 note appears under a code, it is acceptable to use both the code and the
excluded code together, when appropriate.
2
Excludes 1 Notes
Patient admitted with recurrent major moderate
depression (F331), suicidal ideation (R45851),
and borderline personality disorder (F603).
3
Excludes 1 Notes
Tricare denied the claim due to Excludes 1 note.
4
Excludes 1 Notes
There are circumstances that have been identified where some
conditions included in Excludes1 notes should be allowed to both be
coded, and thus might be more appropriate for an Excludes2 note.
However, due to the partial code freeze, no changes to Excludes notes
or revisions to the official coding guidelines can be made until October
1, 2016. This new guidance concerning Excludes1 notes is intended to
allow conditions to be reported together when appropriate even
though they may currently be subject to an Excludes1 note. This
coding advice has been approved by the four Cooperating Parties—
the American Health Information Management Association (AHIMA),
the American Hospital Association (AHA), the Centers for Medicare
and Medicaid Services (CMS), and the National Center for Health
Statistics (NCHS). This advice will also be published in the 4th Quarter
2015 issue of Coding Clinic for ICD-10-CM and ICD-10-PCS.
http://www.cdc.gov/nchs/data/icd/Interim_advice_updated_final.pdf
5
Complication Associated with a Neoplasm
Case example:
• Has large B cell Lymphoma, has received 2 rounds of CHOP
• The patient now presents with a possible Tracheal Erosion, tear or invasion from malignancy.
May have an esophageal perforation or tear
• Possible Tracheal-Esophageal Fistula
•
•
•
Patient is positive for a diagnosis of large B-cell lymphoma. CT of the chest shows mediastinal
adenopathy. Patient has received 2 cycles of R-CHOP chemotherapy. He is complaining of GI
upset and the feeling of dysphagia. His oral intake is poor. He feels weak, has lost weight.
Yesterday he was admitted after a CT of the chest revealed a possible erosion of the trachea.
We have consulted pulmonary and thoracic surgery and a plan of care will be discussed
today. At this point, he is NPO receiving antibiotics.
The patient is transferred to another acute care hospital for the insertion of a tracheal stent.
Question: In this case the patient record shows the patient to possibly have a tear or
a perforation of the trachea due to invasion from the malignancy. In this case, would
the tracheal tear/perforation, or the malignancy be sequenced first?
6
Complication Associated with a Neoplasm
In the ICD9CM Official Coding Guidelines, the
verbiage associated with the reporting of
complications appears as below, followed by
examples for anemia, dehydration and
complications of surgical care:
Coding and sequencing of complications
Coding and sequencing of complications associated with the
malignancies or with the therapy thereof are subject to the
following guidelines:
7
Complication Associated with a Neoplasm
In the ICD10 manual, that verbiage has changed to:
4) Encounter for complication associated with a neoplasm
(ICD-10-CM Official Guidelines for Coding and Reporting FY 2015 Page
29 of 116)
When an encounter is for management of a complication associated
with a neoplasm, such as dehydration, and the treatment is only for
the complication, the complication is coded first, followed by the
appropriate code(s) for the neoplasm.
The exception to this guideline is anemia. When the
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 code D63.0, Anemia in neoplastic disease
8
Complication Associated with a Neoplasm
• AHA Coding Clinic 4th Q 2015 pages 20 – 21 the AHA advised that,
“Previously published ICD-9-CM advice that is still relevant and
applicable to ICD-10 will continue to be re-published in Coding
Clinic for ICD-10- CM/PCS.”
• Previous ICD-9-CM Coding Clinics that instruct to report the
malignancy first appear in the following references:
•
•
•
•
•
•
•
GI Bleed due to malignancy – 3rd Q 2013 page 8
Ascites due to malignancy – 4th Q 2007 pages 95 – 96
Dysphagia due to malignancy – 5th Issue 1993 page 16
Seizures due to mets – May/June 1984 page 14
Esophageal Obstruction due to mets – 2nd Q 1997 page. 3
Small Bowel Obstruction due to CA – 2nd Q 1997 page 3
Ureteral Obstruction due to mets – 2nd Q 1997 page 4.
9
Complication Associated with a Neoplasm
Question: The guideline verbiage change has
brought up the question of does this imply that
complications of a malignancy or metastasis such as
an obstruction, a hemorrhage, seizures, a
perforation now require that complication (the
obstruction, hemorrhage, seizure, perforation) to
now be the principal diagnosis instead of the
malignancy? Does the verbiage in the ICD-10-CM
Official Coding Guidelines negate the instruction in
CC 4th Qtr. 2015 to follow previous ICD-9-CM advice
regarding the coding and sequencing of
“complications” of malignancies?
10
Complication Associated with a Neoplasm
Answer from AHIMA Code-Check™
As you have noted, the ICD-10-CM Official Guidelines for
Coding and Reporting provide additional chapter specific
sequencing guidelines for neoplasms compared to the ICD-9CM guidelines. Now, in ICD-10-CM, when an encounter for a
complication is associated with a neoplasm and the treatment
is only for the complication, the complication is coded first,
followed by the appropriate code(s) for the neoplasm.
• Due to the expanded ICD-10-CM guidelines for sequencing
complications associated with neoplasms the past ICD-9CM Coding Clinic examples you provided illustrating the
advice to report the malignancy first followed by the
associated complication code is not relevant in ICD-10CM.
11
Complication Associated with a Neoplasm
• The AHA 2015 Q4 Coding Clinic for applying past issues of AHA
Coding Clinic for ICD-9-CM to ICD-10 states:
– “Previously published ICD-9-CM advice that is still relevant and
applicable to ICD-10 will continue to be re-published in Coding
Clinic for ICD-10-CM/PCS.”
– “If a particular guideline has remained exactly the same in both
coding systems, and Coding Clinic for ICD-9-CM has published an
example of the application of that guideline, it’s more than likely
that the interpretation would be similar.”
• In this case example, the ICD-9-CM and ICD-10-CM guidelines are
not exactly the same.
• We submitted this question also to AHA and currently it is under
review by the Editorial Advisory Board (EAB).
12
Nervous System Gotcha’s
Question: In ICD9, functional quadriplegia
served as a MCC when it was with/due to
cerebral palsy.
Answer from AHA Central Office: Assign G80.8,
Other cerebral palsy, when the physician
documents cerebral palsy with functional
quadriplegia
13
Cardiovascular Gotcha’s
The Official Coding Guidelines for the reporting of acute myocardial
infarctions say that:
• For encounters occurring while the myocardial infarction is equal to,
or less than, four weeks old, including transfers to another acute
setting or a post acute setting, and the patient requires continued
care for the myocardial infarction, codes from category I21 may
continue to be reported.
• Between the Official Coding Guidelines, and the AHA Coding Clinics,
there is for:
– When the patient has a MI and is transferred to another hospital for
continued care.
– When the patient returns within 4 weeks with another new MI
– When the MI is healed/old past 4 weeks.
14
Cardiovascular Gotcha’s
However, there doesn’t seem to be any guidance when you want to
show the patient has had a MI within the last 4 weeks but currently is
not seeking care/treatment.
Direct treatment/medication is always continued for an AMI, for a
certain time frame after an acute MI. In ICD9 an acute MI that
occurred in the same time frame would be reported as a subsequent
MI or history of MI, but did not impact the DRG.
• Reporting the MI as an acute secondary diagnosis moves the DRG
from a CHF DRG to an MI DRG.
• If an acute MI is reported, it also has impact on Quality Metrics and
MI reporting, and may result in failed measures when the MI is not
actually acute the current episode of care.
• Should the MI be assigned as a secondary diagnosis?
15
Cardiovascular Gotcha’s
Answer from AHIMA Code-Check™
According to the ICD-10-CM Coding and Reporting Guidelines, history of MI is coded
after 28 days from event or initial diagnosis, therefore this recent MI must be coded as
an initial NSTEMI. While the principal diagnosis remains I50.43, any coexisting
conditions that meet the criteria of “Additional Diagnoses” must be reported. As a
result, the DRG will be affected by the assignment of I21.4 as well as other conditions
that were present on admission and clinically significant:
– I50.43
– I42.9
– I25.10
– Z98.61
– I21.4
Acute on chronic combined systolic (congestive) and diastolic
(congestive) heart failure
Cardiomyopathy, unspecified
Atherosclerotic heart disease of native coronary artery without
angina pectoris
Coronary angioplasty status
Non-ST elevation (NSTEMI) myocardial infarction
16
Cardiovascular Gotcha’s
Rationale for recommended coding assignment:
• Based on the documentation provided, the patient’s initial
myocardial infarction took place only ten days prior to this
inpatient encounter. While the recent NSTEMI was not
directly treated, this event poses an additional health risk
given the patient’s CAD, CHF, and other comorbidities.
• Particular coding advice relevant to the diagnosed NSTEMI
was provided by AHA Coding Clinic®, First issue 2013. The
above coding recommendations are supported by the 2016
ICD-10-CM Official Coding and Reporting Guidelines,
sections I.C.9.e(1)-e(4) and Section III:
• We submitted to AHA and this question is currently under
review with the Editorial Advisory Board.
17
Cardiovascular Gotcha’s
Transcatheter Valve Replacements with Right Heart Cath
• Please note, that even in instances that the physicians
document that a right heart cath is performed and
hemodynamic evaluations are taken; that per Coding Clinic
Third Quarter 2013 , that service is required to put in the
valve, and would not be reported separately!
• The CC goes on to say that in instances that a full heart cath is
performed, those can be reported separately.
18
Cardiovascular Gotcha’s
19
Cardiovascular Gotcha’s
Pacemakers and AICD Insertions
• When coding the insertions of Pacemakers,
ICD’s, etc…..the rules have not changed: it
still is crucial to code both the insertion of the
device, and the insertion of the leads.
• If you miss reporting the lead insertions – you
will end up in an incorrect DRG!!!!
20
Cardiovascular Gotcha’s
• Review your ICD10 PCS Codebook. See Appendix L:
Procedure Combination Tables
• As written in the book, “CMS has identified in the MS-DRG
v 32 Definitions manual, certain procedure combinations
that MUST occur in order to assign a specific MS-DRG”.
• There are several DRG’s in this resource, that tell you that
when you are reporting these services, that a combination
of codes has to be reported, or you will end up in the
wrong DRG. Pacemakers, Neurostimulators,
Pancreatic/Kidney Transplants are some examples.
21
Gastrointestinal Gotcha’s
• For endoscopic banding of esophageal varices,
the procedure is being performed on the veins
of the esophagus, not the body part
esophagus.
• In addition, AHA Coding Clinic Fourth Quarter
2013 Pages: 112-113, provides guidance that
the correct root operation for this type of
procedure is “occlusion”.
22
Non-Excisional Debridements
• In ICD-9-CM, when reporting debridement
procedures, generally only excisional
debridements impacted the DRG.
• In ICD-10-CM/PCS non-excisional
debridements have as much potential to
impact the DRG as excisional debridements
do.
23
DRG Shift Example #1 for Non-Excisional
Debridement
24
DRG Tables for Non-Excisional Case #1
592
SKIN ULCERS W MCC
1.4255
593
SKIN ULCERS W CC
1.0198
594
SKIN ULCERS W/O CC/MCC
0.7049
579
OTHER SKIN, SUBCUT TISS & BREAST PROC W MCC
2.6848
580
OTHER SKIN, SUBCUT TISS & BREAST PROC W CC
1.6155
581
OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC
1.1834
25
DRG Shift Example #2 for NonExcisional Debridement
26
DRG Tables for Non-Excisional Case #2
299
PERIPHERAL VASCULAR DISORDERS W MCC
1.4216
300
PERIPHERAL VASCULAR DISORDERS W CC
0.9994
301
PERIPHERAL VASCULAR DISORDERS W/O CC/MCC
0.7023
987
NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W MCC
3.2123
988
NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W CC
1.7533
989
NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC
1.0425
27
Musculoskeletal Gotcha’s
•
•
•
•
Autologous chondrocyte implantation (ACI)
Cartilage Transplantation
Carticel Procedure
Does this procedure go to DRG 470, Major Joint
Replacement or Reattachment of Lower
Extremity w/o MCC?
• Pictures on next few slides from Carticel
website:
http://www.carticel.com/patients/aboutcarticel/treatment-with-carticel
28
Musculoskeletal Gotcha’s
• The physician will determine if there is a cartilage defect and
arthroscopically harvest a healthy portion of cartilage.
• The physician sends the cartilage sample to an approved
facility (Genzyme) for cell processing which multiplies the
cartilage biopsy into millions of chondrocytes in about 5
weeks
29
Musculoskeletal Gotcha’s
• The second part of the procedure involves
removing the damaged cartilage through an
open incision
30
Musculoskeletal Gotcha’s
• The physician applies a patch (periosteum or
synthetic material) over the defect and injects
the cultured chondrocytes under the patch
31
Musculoskeletal Gotcha’s
• Supplement is defined as putting in or on biologic or synthetic
material that physically reinforces and/or augments the function of
a portion of a body part. The biological material can be nonliving or
living from the same individual.
• OCG B4.5… Procedures performed on tendons, ligaments, bursae
and fascia supporting a joint are coded to the body part in the
respective body system that is the focus of the procedure.
Procedures performed on joint structures themselves are coded to
the body part in the joint body systems. Example: Repair of the
anterior cruciate ligament of the knee is coded to the knee bursa
and ligament body part in the bursae and ligaments body system.
Knee arthroscopy with shaving of articular cartilage is coded to the
knee joint body part in the Lower Joints body system.
32
Musculoskeletal Gotcha’s
• Can start with supplement, lower joints, knee joint, left/right,
open, autologous tissue substitute:
33
Musculoskeletal Gotcha’s
Character
Value
Character
Value
Description
0
Section
Medical and Surgical
S
Body
System
Lower Joints
U
Root
Operation
Supplement
D
Body Part
Knee Joint, Left
0
Approach
Open
7
Device
Autologous Tissue Subsitute
Z
Qualifier
No Qualifier
Character Value Definition
34
Musculoskeletal Gotcha’s
• Inpatient DRGs 515- 517
• Use caution with encoders. Some pathways
lead to replacement and takes one to DRG 470
for joint replacement
– ACI
– Cartilage transposition
35
Reporting of ESRD
• In ICD-9-CM, the alphabetic index read as below.
• This supported the reporting of ESRD if the patient
record contained documentation of CKD and
documentation that the patient was on hemodialysis;
and served as an MCC in DRG calculations.
• Disease, diseased - see also Syndrome
– kidney (functional) (pelvis) (see also Disease, renal) 593.9
• chronic 585.9
– Requiring chronic dialysis 585.6
36
Reporting of ESRD
• The reporting of ESRD when CKD required dialysis
was validated in AHA Coding Clinic 2nd Qtr. 2013
page 5.
• With the transition to ICD-10-CM/PCS, the AHA
and Cooperating Parties have advised that “every
attempt was made to remain as consistent with
the ICD-9-CM guidelines as possible, unless there
was a change inherent to the ICD-10-CM
classification. “ Fourth Quarter ICD-10 2015 Pages: 20-21
37
ESRD – The ICD10 Gotcha!
• The alphabetic index for CKD has changed in ICD-10CM.
• The entry for chronic, requiring chronic dialysis no
longer appears in the alphabetic index:
Disease, diseased - see also Syndrome
kidney(functional) (pelvis) N28.9
chronic N18.9
hypertensive- see Hypertension, kidney
38
ESRD – The ICD-10 Gotcha!
• This change in indexing removes the reporting
structure that promotes the reporting of ESRD for
patient’s with CKD and chronic hemodialysis.
• This may impact the DRG assignment for some cases
that ESRD might have been the only MCC on the case.
• Previous Coding Clinics supporting the reporting of
ESRD for CKD with hemodialysis would no longer be
applicable, since ICD-10 guidance tells us we can follow
previous advise only if there were no changes to the
classification involving that advice.
39
ESRD – The Tabular Instructions
• Review of the ICD-10-CM Tabular Indexing of CKD, an Excludes
1 instructional note appears under the code for CKD stage 5:
• This supports that if a patient has stage 5 CKD and is on
hemodialysis, in those instances it would be appropriate to
report ESRD.
• This instruction however, does not apply to other levels of
CKD or CKD unspecified.
40
Pregnancy Gotcha’s
• Medicare Code Edits (MCE)
• Twin Pregnancy ICD9 code: 651.0X
41
Pregnancy Gotcha’s
• Twin Pregnancy ICD10 code: O30.0xxx
42
Pregnancy Gotcha’s
Other pregnancy conditions are on the Unacceptable Principal Diagnosis List
43
Definitions of Medicare Code Edits v33
https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/AcuteInpatientPPS/FY2016-IPPS-Final-Rule-HomePage-Items/FY2016-IPPS-Final-Rule-Data-Files.html
•
•
•
•
•
•
Invalid Diagnosis or Procedure Code
Age and Sex conflict
Pediatric Diagnoses (age 0- 17)
Procedures for females only
Procedures for males only
Manifestation codes not allowed as principal diagnosis
44
Pregnancy Gotcha’s
• Why is the DRG assignment for Delivery
but the patient did not deliver during this
visit?
45
Pregnancy Gotcha’s
• No procedure codes assigned
• Claim showed no procedure codes
• Diagnosis codes reviewed
46
Pregnancy Gotcha’s
47
Pregnancy Gotcha’s
48
Pregnancy Gotcha’s
• In researching, there was a diagnosis code assigned that in the
code descriptor had “in childbirth” which means in
labor/delivery.
• The specificity on this diagnosis codes is what drove the DRG.
• Code O98.82 revised to O98.813
• Once I changed the specificity from “in childbirth” to “in
pregnancy”, the DRG calculated correctly to 781- Other
Antepartum Diagnoses (a higher paying DRG than when the
patient delivers).
49
Pregnancy Gotcha’s
50
Pregnancy Gotcha’s
DRG’s 781/782 for Other Antepartum Diagnosis
• Diagnosis code O26.893Represents “Other Specified Pregnancy Related
Conditions, Third Trimester”.
• Is not on the CC list, but in discussion with 3M the note that “instead - it
simply considers this code as a medical complication that appropriately
groups to MSDRG 781 per Appendix B of V32. Please note if code O26.893
was reported by itself, the MSDRG returned would still be 781.”
• TAKE AWAY: Be sure to report all conditions identified in the antepartum
period as complications of the pregnancy as directed by the Official Coding
Guidelines. When no specific code exists for that complication, O26.893
serves as an OB Complicated diagnosis.
781
OTHER ANTEPARTUM DIAGNOSES W MEDICAL
COMPLICATIONS 0.7546 2.7
4.0
782
OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL
COMPLICATIONS 0.4057 1.7
2.3
51
Contact Information
Suzanne P. Drake RHIT, CCS, ICD-10-CM/PCS Trainer | Coding Quality and RAC Coordinator
Bon Secours Richmond Health System | Shared Services-Coding
5855 Bremo Road MOBN Suite 501 | Richmond, VA | 23226
W: 540-337-2625 F: 804-287-7835 | [email protected]
Christina Brown, RHIA, CCS, CCSP, CCDS | Coding Compliance & DRG Coordinator
Bon Secours Richmond Health System | Shared Services-Coding
5855 Bremo Road MOBN Suite 501 | Richmond, VA | 23226
W: 804-287-7414 | F: 804-287-7835 | [email protected]
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