ICD-10-CM Official Guidelines for Coding and Reporting for FY 2018

on Monday, 28 August 2017. All News Items | Documentation | Coding

Change, the one Constant in Health Care

It’s hard to believe that school is back in session and fall is just around the corner. Here in the Deep South, fans celebrate the return of high school football on Friday night and SEC football on Saturday. Whether you are on a team or a supportive spectator, to truly enjoy the game, you need to have an understanding of the game rules.

This is also the time of year when the IPPS Final Rule and ICD-10-CM Official Guidelines for Coding and Reporting are released for the coming Fiscal Year (FY). For Professional Coders and CDI Specialists, to accurately reflect the severity of illness and resource consumption for your patient population, you need to have an understanding of the changes. This week we focus on highlights from the FY 2018 ICD-10-CM Official Guidelines for Coding and Reporting. 

NARRATIVE Changes

Narrative changes within the Guidelines appear in bold text.

“With”

“The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List.

In the 2017 Guidelines update, guidance was changed to include that “The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular list. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. New in 2018 this guidance goes on to include the following: “or when another guidelines exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for “acute organ dysfunction that is not clearly associated with the sepsis”).  For conditions not specifically linked by these relational terms in the classification, or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related.”

“Code also” note

“A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. The sequencing depends on the circumstances of the encounter.”

Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer-Stages, Coma Scale, and NIH Stroke Scale

Prior to ICD-10 there was no way to capture the National Institutes of Health Stroke Scale (NIHSS). Coding the NIHSS was first included in this section of the Guidelines in 2017 and instructed that coders may code this “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 information is typically documented by other clinicians involved in the care of the patient… codes should only be reported as secondary diagnoses.”

In the FY 2018 IPPS Final Rule, CMS finalized the proposal to refine the Stroke 30-Day Mortality Rate Measure for the FY 2023 payment determination by including the National Institutes of Health (NIH) Stroke Scale.

Key Takeaway’s for Hospitals

CMS “proposed this measure now to inform hospitals that they should begin to include the NIH stroke severity scale codes in the claims they submit for patients with a discharge diagnosis of ischemic stroke.”

  • You will need to work with your Physicians to ensure that they are measuring and recording stroke severity.
  • Coders will need to include the appropriate ICD-10 code from the Physician’s documented NIH Stroke Scale score.
  • CMS clarified in the FY 2018 IPPS Final Rule that “The intent of the risk adjustment for stroke severity is to account for patients’ clinical status at the time they are admitted to the hospital. Therefore, the refined Stroke 30-Day Morality Rate measure would utilize only the initial NIH Stroke Scale score, which is administered upon admission.”
  • Advice on the subcategory to report the NIH Stroke Scale scores can be found in Coding Clinic 2016, 4th Quarter, page 61.

In addition to narrative changes, it is essential for the Professional Coder and/or CDI Specialist to pay close attention to when there is guidance to query the provider. The following table details when a query is advised.  

When to Query the Provider
Guidelines SectionQuery Opportunity
Excludes 1 “An exception to the Excludes 1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes 1 note are related or not, query the provider.”
Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale “Code assignment may be based on medical record documentation from clinicians who are not the patient’s provider…since this information is typically documented by other clinicians involved in the care of the patient…However, the associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) 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.”
Documentation of Complications of Care “There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.”
Borderline Diagnosis “Whenever the documentation is unclear regarding a borderline condition, coders are encouraged to query for clarification.”
Coding of Sepsis “Negative or Inconclusive blood cultures and sepsis” “Negative or inconclusive blood cultures do not preclude a diagnosis of sepsis in patients with clinical evidence of the condition; however, the provider should be queried.”
“Urosepsis” “The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis…should a provider use this term, he/she must be queried for clarification.”
Acute Organ Dysfunction that is not clearly associated with sepsis “If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider.”
Severe Sepsis “The coding of severe sepsis requires a minimum of 2 codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis…due to the complex nature of severe sepsis, some cases may require querying the provider prior to assignment of the codes.”
Sequencing of Severe Sepsis “Severe sepsis may be present on admission, but the diagnosis may not be confirmed until sometime after admission. If the documentation is not clear whether severe sepsis was present on admission, the provider should be queried.”
Malignancy in two or more noncontiguous sites “A patient may have more than one malignant tumor in the same organ…should the documentation be unclear, the provider should be queried as to the status of each tumor so that the correct codes can be assigned.”
Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplasms in remission versus personal history There are codes indicating whether or not these conditions have achieved remission. “If the documentation is unclear as to whether the leukemia has achieved remission, the provider should be queried.”
Sequencing of Acute Respiratory Failure and Another Acute Condition “If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.”
Ventilator Associated Pneumonia “If the documentation is unclear as to whether the patient has a pneumonia that is a complication attributable to the mechanical ventilator, query the provider.”
Patients Admitted with Pressure Ulcers Documented as Healed “Pressure ulcers described as healing should be assigned the appropriate pressure ulcer stage code based on the documentation in the medical record…If the current documentation is unclear as to whether the patient has a current (new) pressure ulcer or if the patient is being treated for a healing pressure ulcer, query the provider.”
Non-Pressure Chronic Ulcers “Non-pressure ulcers described as healing should be assigned the appropriate non-pressure ulcer code based on the documentation in the medical record…if the documentation is unclear as to whether the patient has a current (new) non-pressure ulcer or if the patient is being treated for a healing non-pressure ulcer, query the provider.”
Acute Traumatic versus Chronic or Recurrent Musculoskeletal Conditions “Many musculoskeletal conditions are a result of previous injury or trauma to a site, or are recurrent conditions…If it is difficult to determine from the documentation in the record which code is best to describe a condition, query the provider.”
Chronic Kidney Disease and Kidney Transplant Status “Patients who have undergone kidney transplant may still have some form of chronic kidney disease (CKD) because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication…If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.”
SIRS due to Non-Infectious Process “If acute organ dysfunction is documented, but it cannot be determined if the acute organ dysfunction is associated with SIRS or due to another condition (e.g., directly due to the trauma), the provider should be queried.”
Kidney Transplant Complications “If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.”
Present on Admission (POA)Reporting Guidelines “These guidelines are not a substitute for the provider’s clinical judgment as to the determination of whether a condition was/was not present on admission. The provider should be queried regarding issues related to the linking of signs/symptoms, timing of test results, and the timing of findings.”
Timeframe for POA Identification and Documentation “In some clinical situations, it may not be possible for a provider to make a definitive diagnosis (or a condition may not be recognized or reported by the patient) for a period of time after admission. In some cases it may be several days before the provider arrives at a definitive diagnosis. This does not mean that the condition was not present on admission…If at the time of code assignment the documentation is unclear as to whether a condition was present on admission or not, it is appropriate to query the provider for clarification.”
Assigning the POA Indication “U” for unknown is assigned “when the medical record documentation is unclear as to whether the condition was present on admission. “U” should not routinely be assigned and used only in very limited circumstances. Coders are encourages to query the providers when the documentation is unclear.”
Source: ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 (October 1, 2017 – September 30, 2018) at https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf

This article provides an overview, be aware that there are several additions to the Chapter-Specific Coding Guidelines (i.e., patient admission/encounter for the insertion of implantation of radioactive elements, diabetes mellitus, blindness, pulmonary hypertension, acute myocardial infarction (AMI) and non-pressure chronic ulcers). Reading the Guidelines is a must for Coding and CDI Professionals as you prepare for the rule changes to the “game” with the start of the 2018 IPPS Fiscal Year on October 1.    

 Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc.  Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system.  In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare.  You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful

 

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