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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] 52 53