One of the greatest features pertaining to ICD-10-CM/PCS that we as coders can look forward to is greater specificity. For the most part, the coding guidelines for ICD-10-CM regarding poisonings and injuries will remain the same as they are now in ICD-9-CM. A seventh character extension which identifies the encounter is one of the new features in ICD-10-CM. Refer to Section I.C.19.a of ICD-10-CM Official Guidelines for Coding and Reporting.

1. A - Initial encounter:     Used while patient is receiving active treatment for the condition. Examples of active treatment:
2. surgical treatment
3. emergency department encounter
4. evaluation and treatment by a new physician
5. D - Subsequent encounter:     Used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care:
6. cast change or removal
7. removal of external or internal fixation device
8. medication adjustment
9. S – Sequela:     Used for complications or conditions that arises as a direct result of a condition or injury. Example of sequel care:
10. painful scar formation secondary to 3rd degree burn right lower leg
11. complete quadriplegia secondary to traumatic C2 displaced vertebral fracture - G82.51 & S12.100S

FROM THE AUTHOR

Please note the last paragraph of Section I.C.19. a of ICD-10-CM Official Guidelines for Coding and Reporting regarding application of “S” as the seventh character.

When using 7th character “S”, it is necessary to use both the injury code that precipitated the sequel and the code for the sequel itself.     The “S” is added only to the injury code, not the sequel code. The 7th character “S” identifies the injury responsible for the sequel.   The specific type of sequel is sequenced first, followed by the injury code.

Injuries – Section I.C.19.b of the ICD-10-CM Official Guidelines for Coding and Reporting

• A separate code should be assigned for each individual injury unless a combination code is provided.
• Code T07 for Unspecified multiple injuries should not be assigned in the inpatient setting unless supporting documentation for a more specific code is not available. Always query the MD in an attempt to gain information to support a more specific diagnosis code.
• Do not assign traumatic injury codes (S00-T14.9) for normal healing surgical wounds or to identify complications of surgical wounds.
• Sequence first the more serious injury as determined by the MD/provider and receiving main focus of treatment.
• Do not assign a code for superficial injuries (abrasions or contusions) when a more severe injury is associated with the same site.
• When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury is sequenced first with additional code(s) for injuries to nerves and spinal cord and/or injury to blood vessels. When the primary injury is to the blood vessels or nerves, that injury should be sequenced first.

Traumatic Fractures – Section I.C.19.c of the ICD-10-CM Official Guidelines for Coding and Reporting

• Once again, specificity is the name of the game. ICD-10-CM fracture codes can now indicate the fracture type:
• Greenstick
• Transverse
• Oblique
• Spiral
• Comminuted
• Segmental
• Documentation should specify:
• Displaced
• Non-displaced
• Open
• Closed
• Laterality
• Specific anatomical site
• Routine vs delayed healing
• Non-union
• Mal-union
• Type of encounter
• A fracture not indicated as displaced or non-displaced should be coded as displaced.
• A fracture not indicated as open or closed should be coded to closed.
• Multiple fractures are sequenced in accordance with the severity of the fracture.
• Fracture extensions are expanded to include:
• 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 non-union
• P – Subsequent encounter for fracture with Mal-union
• S – Sequela
• Fractures in a patient with known Osteoporosis should be assigned a code from category M80 (non-traumatic fracture), even if the patient had a minor fall or trauma. Refer to Section I.C.13 of the ICD-10-CM Official Guidelines for Coding and Reporting.

Open Fracture Classification System

The Gustilo open fracture classification system is utilized in the 7th character extender lists for some fractures. This indicates the energy of the fracture, soft tissue damage and the degree of contamination. The Gustilo classification system is divided into 3 major categories.

Facilities will need to educate their providers on using the scale below to ensure supporting documentation for proper code assignment. This will also help lessen the number of queries sent to the provider.

Grade I

• Low energy, wound less than 1 cm with minimal soft tissue damage
• Wound bed is clean
• Bone injury is simple with minimal comminution
• With intramedullary nailing, average time to union is 21–28 weeks

Grade II

• Wound is > than 1cm with moderate soft tissue damage
• High energy wound > than 1cm with extensive soft tissue damage
• Wound bed is moderately contaminated
• fracture contains moderate comminution
• With intramedullary nailing, average time to union is 26-28 weeks

Grade III

The following fracture types automatically results in classification as type III.

• Segmental fracture with displacement
• Fracture with diaphyseal segmental loss
• Fracture with associated vascular injury requiring repair
• Farmyard injuries or highly contaminated wounds
• High velocity gunshot wound
• Fracture caused by crushing force from fast moving vehicle

Grade IIIA

• Wound less than 10cm with crushed tissue and contamination
• Adequate soft tissue coverage of bone is usually possible
• With intramedullary nailing, average time to union is 30-35 weeks

Grade IIIB

• Wound greater than 10cm with crushed tissue and contamination
• Inadequate soft tissue coverage and requires regional or free flap
• With intramedullary nailing, average time to union is 30-35 weeks

Grade IIIC

• Associated major arterial injury with fracture which requires repair for limb salvage
• In some cases it will be necessary to consider BKA following tibial fracture

Seventh character extensions to designate the specific type of open fracture – based on the Gustilo open fracture classification.

• B – Initial encounter for open fracture type I or II (open fracture NOS )
• C – Initial encounter for open fracture type IIIA, IIIB, or IIIC
• 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
• 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
• M – Subsequent encounter for open fracture type I or II with non-union
• N – Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with non-union
• Q – Subsequent encounter for open fracture type I or II with mal-union
• R – Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with mal-union

The Gustilo classification is not used for all bones or all fracture types (such as Greenstick fracture or Torus fracture). Coders will need to be sure to look at each 7th character extender box for correct assignment.

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

Coders probably sometimes feel as if they are searching for the proverbial needle in the haystack. They must evaluate an entire medical record to pick out the key condition responsible for a patient’s admission and other conditions that affect the patient’s treatment. Not easy considering the issues with incomplete, illegible, and conflicting documentation that may be present. And then there are the numerous coding rules of which coders must be aware and stay current. Our hats off to coders everywhere.

Last week, we reviewed the CERT findings from the July 2014 Medicare Compliance Quarterly Newsletter which focused on documentation deficiencies. This week we will look at some coding errors identified by the Recovery Auditors (RACs) detailed in the July Compliance Newsletter. These are brief summaries of the examples given in the newsletter. I encourage everyone to carefully review the examples in the newsletter for complete understanding.

Heart Failure and Shock (MS-DRGs 291, 292 and 293)

The RACs identified errors for these DRGs in both the sequencing of the principal diagnosis and in improper coding of the secondary diagnosis.

• The patient presented with decompensated congestive heart failure (CHF) and a pleural effusion with pulmonary edema. The physician did not state the cause of the pleural effusion so this should be coded as pleural effusion not otherwise specified (NOS) (511.9), instead of pleural effusion not elsewhere classified (NEC) (511.8). Coding Clinic has noted that pulmonary effusions are often seen with CHF with and without pulmonary edema and may be reported as an additional diagnosis. In this case the change in the secondary diagnosis changes the DRG assignment from 291 to 292, resulting in an overpayment.
• In the second example provided, a patient is diagnosed with CHF and an acute myocardial infarction. The reason for admission as determined after study was the acute MI (410.71), not the heart failure (428.20) also changing the DRG assignment to a lower weighted DRG.

NOTE

Medical Management Plus Inpatient Coders offer the following comments concerning pleural effusions with CHF: Coders assume a relationship between pleural effusions and CHF unless stated otherwise. Pleural effusion is considered to be integral to the CHF disease process and will normally clear with treatment for the CHF. It would not typically be assigned its own diagnosis code. Pleural effusions may only be reported as an additional diagnosis if the condition is specifically evaluated or treated, but reporting is not required. Evaluation may involve special x-rays such as decubitus views or diagnostic thoracentesis and it may be necessary to address the effusion by therapeutic thoracentesis or chest tube drainage.

Effective 2009, ICD-9 code 511.8 required a 5th digit and was removed from the MCC list. Both 511.8x and 511.9 are now CCs.

Postoperative or Posttraumatic Infections with Operating Room (OR) Procedure with Complications and Comorbidities (CC) (MS-DRG 857)

Both examples given for this DRG involve improper diagnosis code assignment in cases where the infection and complications were associated with implanted devices and not with the surgical procedure itself. In these examples, code 998.59 (postoperative infections) should not have been assigned as the principal diagnosis code because it excludes infections due to implanted devices.

• The first involved a total knee prosthesis which should have been coded with a principal diagnosis code of 996.66, Infection and inflammatory reaction due to internal prosthetic device implant and graft. The secondary diagnosis code of 998.12, hemorrhage or hematoma complicating a procedure, was replaced with ICD-9 diagnosis code 997.77 other complication due to internal joint prosthesis. This resulted in a DRG change from 857 to 487.
• The second patient was treated surgically for a pocket infection of a pacemaker. A correct principal code assignment of 996.61, Infection and inflammatory reaction due to cardiac device, implant, and graft changed the MS-DRG from DRG 857 to DRG 261.

Amputations (MS-DRGs 239, 240, 241, 474, 475, and 476)

The final inpatient coding errors involved secondary diagnoses coded with amputation DRGs. The code assignments were not supported by the physician documentation for acute heart failure or acute renal failure. Removing or correcting these diagnosis codes removed the MCC resulting in lower weighted DRGs.

Coders have a difficult task of reviewing an entire medical record and selecting the appropriate principal and secondary diagnoses. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care” but careful consideration must be used in making this determination, such as what was the actual reason for the admission and the focus of treatment. Also, secondary diagnoses must be clearly supported by the physician’s documentation in the medical record and correctly selected based on coding guidelines. Errors in code sequencing and selection can easily lead to an overpayment.

The Signs and Symptoms category in I-9 has received a major overhaul in I-10. Not only have there been organizational changes; several new conditions have also been included in the chapter.  Let’s take a closer look at the differences...

• (Chapter 16) is now (Chapter 18)
• In addition to symptom guidelines, guidelines for several other conditions are listed in Chapter 18, i.e., Repeated falls, coma scale, functional quadriplegia, SIRS due to non-infectious process, and death nos
• Some of the symptoms previously found in a specific chapter, have been moved into the symptom chapter.
• Example 1: Hematuria, previously listed in the (Genitourinary System) is now listed in the (Symptoms) chapter
• Example 2: Sinus Bradycardia, previously listed in the (Diseases of the Circulatory System) is now listed in the (Symptoms) chapter
• Symptoms are sequenced by body system within the chapter (called blocks)

Chapter 18 is organized in the following blocks:

‍

The following is the beginning of the Symptom Chapter (block) for circulatory and respiratory systems in the tabular section:

R00 | Abnormalities of heart beat

R00.0 | Tachycardia, unspecified

NOTE

Reviewer’s Note: Sinus Bradycardia is now listed in the symptom chapter instead of in (Diseases of the Circulatory System) chapter as it was in I-9.

Rapid heart beat

Sinoauricular tachycardia NOS

Sinus (sinusal) tachycardia NOS

R00.1 | Bradycardia, unspecified

Sinoatrial bradycardia

Sinus bradycardia

Slow heart beat

Vagal bradycardia

R00.2 | Palpitations

Awareness of heart beat

R00.8 | Other abnormalities of heart beat

R00.9 | Unspecified abnormalities of heart beat

Official ICD-9-CM Guidelines for Coding and Reporting

Reviewer’s observation: I-9 previously provided only general guidelines for coding signs and symptoms under Section II. Selection of Principal Diagnosis. We now have chapter-specific guidelines for coding signs and symptoms in I-10.

I-9

Chapter 16: Signs, Symptoms and Ill-Defined Conditions (780-799)

Reserved for future guideline expansion

I-10

Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99)

Chapter 18 includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded. Signs and symptoms that point to a specific diagnosis have been assigned to a category in other chapters of the classification.

1. Use of symptom codes
2. Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
   
   
3. Use of a symptom code with a definitive diagnosis code
4. EXAMPLE
5. Respiratory arrest (R09.2) should not be coded in addition to Respiratory Failure (J96-).
6. Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code. Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
   
   
7. Combination codes that include symptoms
8. ICD-10-CM contains a number of combination codes that identify both the definitive diagnosis and common symptoms of that diagnosis. When using one of these combination codes, an additional code should not be assigned for the symptom.
   
   
9. Repeated falls
10. Code R29.6, Repeated falls, is for use for encounters when a patient has recently fallen and the reason for the fall is being investigated.
11. Code Z91.81, History of falling, is for use when a patient has fallen in the past and is at risk for future falls. When appropriate, both codes R29.6 and Z91.81 may be assigned together.
    
    
12. Coma scale
13. The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis code(s).
14. These codes, one from each subcategory, are needed to complete the scale. The 7th character indicates when the scale was recorded. The 7th character should match for all three codes.
15. At a minimum, report the initial score documented on presentation at your facility. This may be a score from the emergency medicine technician (EMT) or in the emergency department. If desired, a facility may choose to capture multiple coma scale scores. Assign code R40.24, Glasgow coma scale, total score, when only the total score is documented in the medical record and not the individual score(s).
    
    
16. Functional quadriplegia
17. Functional quadriplegia (code R53.2) is the lack of ability to use one’s limbs or to ambulate due to extreme debility. It is not associated with neurologic deficit or injury, and code R53.2 should not be used for cases of neurologic quadriplegia. It should only be assigned if functional quadriplegia is specifically documented in the medical record.
    
    
18. SIRS due to non-infectious process
19. NOTE
20. This guideline has been moved from Chapter 17: Injury and Poisoning (I-9).
21. The systemic inflammatory response syndrome (SIRS) can develop as a result of certain non-infectious disease processes, such as trauma, malignant neoplasm, or pancreatitis. When SIRS is documented with a noninfectious condition, and no subsequent infection is documented, the code for the underlying condition, such as an injury, should be assigned, followed by code R65.10, Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction, or code R65.11, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction. If an associated acute organ dysfunction is documented, the appropriate code(s) for the specific type of organ dysfunction(s) should be assigned in addition to code R65.11. 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.
    
    
22. Death NOS
23. Code R99, Ill-defined and unknown cause of mortality, is only for use in the very limited circumstance when a patient who has already died is brought into an emergency department or other healthcare facility and is pronounced dead upon arrival. It does not represent the discharge disposition of death.

Remember:

• Symptom codes are not coded and reported when a confirmed diagnosis has been established by the provider.
• Chapter 18 contains many, but not all codes for symptoms.

As you can see, there have been several changes to the symptom chapter for I-10. In my personal opinion, organizing the symptoms in “blocks” under each specific body system, makes the information much easier to locate specific symptoms at-a-glance.

Resources:

ICD-9-CM Coding book by Ingenix ICD-10-CM Coding Book by Ingenix AHIMA ICD-10-CM Training Manual

Our next topic for the I-10 corner is the mental health chapter, Mental, Behavioral, and Neurodevelopmental Disorders. Chapter 5 is another example of the massive expansion of codes in ICD-10. I have highlighted some changes and included tips that I think are important to know for coding these conditions.

See below how the codes in this chapter are no longer grouped by psychotic, non-psychotic disorders, or mental retardation.

CODE COMPARISON

‍NOTE FROM ICD-10-CM CODER TRAINING MANUAL 2014

Many title changes for categories and subcategories were made in Chapter 5. Such as:Bipolar 1 Disorder, Single Manic Episode (296.0x) = Manic Episode (F30.xx)

Many changes were made due to outdated terminology. Examples can be seen in the accompanying table.

DID YOU KNOW?

DRG Shift

The CMS ICD-10 website contains information on the ICD-10 MS-DRG Conversion Project. An article from CMS, “Estimating the Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments”, lists the top 10 MS-DRGs that shift to another DRG when re-coded with ICD-10. DRG 885, Psychoses is on that list. Currently, ICD-9 cases that have 296.20, Major Depression, Single Episode, Unspecified sequenced as the principal diagnosis will group to DRG 885, Psychoses. Under ICD-10, this same diagnosis is assigned to F32.9 (also includes Depression NOS) which groups the case to DRG 881, Depressive Neuroses, a lower-weighted DRG. Interestingly, many hospitals in Alabama have DRG 885 listed in their top 10 diagnoses each year. It would be a good idea to see how this change will impact your facility.

A large classification change was made to the drug and alcohol abuse/dependence codes.

• There are codes to denote alcohol and drug “use”.
• No longer identify “Continuous” and “Episodic” in I-10
• Can code Blood Alcohol Levels as an additional code, if applicable:
  Y90.0, Evidence of alcohol involvement determined by blood alcohol level

Chapter 5 Guidelines

• Physician documentation of a history of drug or alcohol dependence is coded as “in remission”.
• For psychoactive substance use, abuse and dependence:

TIP

The codes in Chapter 5 parallel the codes in DSM-IV TR (Diagnostic and Statistical Manual of Mental Disorders-4 Text Revision) in most cases….from the ICD-10-CM Coder Training Manual, 2014 Instructor’s Edition. Psychiatrists tend to document these conditions as they are listed in the codebooks, which can make mental health coding a little easier. In addition, I hope all of the information provided to you in the I-10 Corner has helped make your job a little easier.

Have you ever seen the guy spinning numerous plates at once at the top of poles? This used to be a regular segment on the Ed Sullivan Show many years ago. Sometimes keeping up with all the different payer regulations is like spinning plates. For example, there are numerous ways to report bilateral procedures, but Medicare only wants it one way. Reporting it wrong will end up in a denial for certain procedures. Coders’ heads are spinning like those plates.

Medicare has published MLN Matters Article SE1422 to address improper Medicare billing of bilateral surgical procedures and date of service Medically Unlikely Edits (MUEs). As a reminder, per Medicare’s MUE webpage an MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single patient on a single day of service.  Medicare FAQ 2277 explains that line-item MUEs are adjudicated separately against the MUE value for the procedure code on thatline. The appropriate use of CPT modifiers (such as -76, -77, -59, or anatomic modifiers) to report the same code on separate lines of a claim will enable a provider to report medically reasonable and necessary units of service in excess of an MUE value. 

Medicare, with back-up from the Office of Inspector General, is convinced that providers are inappropriately by-passing line item MUEs by reporting multiple line items. To address this concern, CMS is converting most MUEs into per day edits. That means that all lines of a CPT code will be denied if the units for that CPT code exceed the MUE limit for the day of service. In this case, reporting CPT codes on separate lines, with or without modifiers, will not by-pass the edits.

CMS is also adding MUE Adjudicator Indicators (MAIs) to indicate the type of MUE and its basis.

• An MAI of 3 indicates an MUE based on clinical information such as billing patterns or prescribing information. Exceptions to the MUE limits can occur but would be rare, so Medicare considers items exceeding MUE limits when the MAI is 3 to be a billing error. Providers can appeal denials for MUEs with an MAI of 3 if they have verified that the units are correct, the service is medically necessary, and they have correctly interpreted all coding instructions.
• An MAI of 2 indicates an MUE based on regulation or subregulatory instruction (“policy”), including the instruction that is inherent in the code descriptor or its applicable anatomy. MUE denials where the MAI is 2 will not be overturned on appeal.
• If a provider receives an MUE denial and determines that the units originally billed were incorrect due to a clerical error, they can request a reopening instead of having to go through the appeals process. They can then submit a corrected claim with the correct number of units.

There is now a revised July 1, 2014 update on the MUE webpage that identifies the published MUE edits with an MAI value of 1 (line edit), 2 (date of service edit: policy) or 3 (date of service edit: clinical).

These per day MUEs will create a problem with bilateral codes for surgical procedures if they are not billed according to Medicare instructions. Medicare instructs in the Medicare Claims Processing Manual and the National Correct Coding Initiative Manual that bilateral surgical procedures (if bilateral is not included in the code description) should be reported using a single unit of service and the -50 modifier. If these procedures are incorrectly reported on two lines with RT and LT modifiers or on one line with units of 2, they may exceed the MUE if the per day MUE limit is one. A date of service MUE of one is fairly common for bilateral surgical procedures. The article only discusses bilateral surgical procedures; it does not address the correct reporting of bilateral radiology procedures.

Through our 835 claims analysis (HIQUP reports), MMP has identified denials of services that appear to be the result of inappropriate reporting of bilateral surgical procedures with RT and LT instead of the -50 modifier. For example, such CPT codes as 30140, 49505, 64483, and 67904 submitted with RT/LT modifiers are being denied with Claim Adjustment Reason Code (CARC) 151 (information submitted does not support this many services).

Hospitals need to watch for these types of denials and educate coders and billers or adjust chargemasters to assure bilateral surgical procedures are being reported correctly. Hospitals will also need to be aware of the per day MUEs and their respective MAIs for other services that may be affected. Something else to watch for and another acronym to remember.

In this week’s article, we’re discussing a few of the changes for ICD-10-CM in the Nervous System (Chapter 6): Alzheimer’s Dementia, Epilepsy, Hemiparesis/Hemiplegia (Dominant vs. Non-Dominant), Migraine, Phantom Limb Pain and Sleep Apnea

Alzheimer’s Dementia

I-9: Alzheimer’s Dementia

• with behavioral disturbance (aggressive) (combative) (violent) (331.0 / 294.11)
• without behavioral disturbance (331.0 / 294.10)

NOTICE:

The category for Alzheimer’s disease (G30) has been expanded to reflect onset (early vs. late)

I-10: Alzheimer’s Dementia

• behavioral disturbance (G30.9 / F02.81)
• early onset (G30.0 / F02.81)
• late onset (G30.1 / F02.80)
• specified NEC (G30.8 / F02.80)

Epilepsy

Terms for Epilepsy have been updated to classify the disorder, e.g,

• Localization-related Idiopathic Epilepsy
• Generalized Idiopathic Epilepsy
• Special Epileptic Syndromes

Example:

I-9: Epilepsy, epileptic (idiopathic) (345.9)

Epilepsy, localization related (focal) (partial) and (epileptic syndromes)

• With
• Complex partial seizures (345.4)
• Simple partial seizures (345.5)

NOTICE:

Within each category, more specificity can be described to identify: Seizures of Localized Onset, Complex Partial Seizures, Intractable and Status Epilepticus.

I-10: Epilepsy, epileptic, epilepsia (attack) (cerebral) (convulsion) (fit) (seizure) (G40.909)

Epilepsy, localization-related (focal) (partial)

• Idiopathic (G40.009)
• With seizures of localized onset (G40.009)
• Intractable (G40.019)
• With status epilepticus (G40.011)
• Without status epilepticus (G40.019)
• Not intractable (G40.009)
• With status epilepticus (G40.001)
• Without status epilepticus (G40.009)

NOTE

Category G40, Epilepsy and Recurrent Seizures

The following terms are to be considered equivalent to intractable:

• Pharmacoresistent (pharmacologically resistant)
• Treatment resistant
• Refractory (medically)
• Poorly controlled

Hemiplegia and Hemiparesis  (Dominant vs. Non-Dominant Side)

This category is to be used only when the listed conditions are reported without further specification, or are stated to be old or longstanding but of unspecified cause. The category is also for use in multiple coding to identify these conditions resulting from any cause.                                      

I-9:

The following fifth-digits are for use with codes 342.0-342.9:

• 0 affecting unspecified side
• 1 affecting dominant side
• 2 affecting non-dominant side

I-10:

Per ICD-10-CM Official Coding Guidelines: Codes from category G81, Hemiplegia and hemiparesis, and subcategories, G83.1, Monoplegia of lower limb, G83.2, Monoplegia of upper limb, and G83.3, Monoplegia, unspecified, identify whether the dominant or non-dominant side is affected.

Should the affected side be documented, but not specified as dominant or non-dominant, and the classification system does not indicate a default, code selection is as follows:

• For ambidextrous patients, the default should be dominant
• If the left side is affected, the default is non-dominant
• If the right side is affected, the default is dominant

Example: G81.9 Hemiplegia, unspecified

• G81.90:  Hemiplegia, unspecified affecting unspecified side
• G81.91:  Hemiplegia, unspecified affecting right dominant side
• G81.92:  Hemiplegia, unspecified affecting left dominant side
• G81.93:  Hemiplegia, unspecified affecting right non-dominant side
• G81.94:  Hemiplegia, unspecified affecting left non-dominant side

            Excludes1: Hemiplegia and hemiparesis due to sequela of cerebrovascular disease

Migraine

I-9: Migraine, Unspecified (Idiopathic) (346.9x)

I-10: Migraine, Unspecified (Idiopathic) (G43.909)

NOTE

Category G43, Migraine

The following terms are to be considered equivalent to intractable:

• Pharmacoresistent (pharmacologically resistant)
• Treatment resistant
• Refractory (medically)
• Poorly controlled

Phantom Limb

The sensation that an amputated or missing limb is still attached to the body and is moving along with other body parts. An estimated 60% to 80% of people that have had an amputation, experience phantom sensations in the amputated limb with the majority being painful.  

I-9: Phantom limb (syndrome) (353.6)

NOTICE:

I-10 has given us the ability to identify whether pain is present or not after an amputation.

I-10: Phantom limb syndrome (G54.7)

• with pain (G54.6)
• without pain (G54.7)

Sleep Apnea

Sleep Apnea has its own subcategory with fifth character specificity identifying the type

Example:      

I-9: Sleep Apnea, Unspecified (780.57)

• with
• Hypersomnia, unspecified (780.53)
• Hyposomnia, unspecified (780.51)
• Insomnia, unspecified (780.51)
• Sleep disturbance (780.57)
• Central, in conditions classified elsewhere (327.27)
• Obstructive (adult) (pediatric) (327.23)
• Organic (327.20)
• other (327.29)
• Primary central (327.21)

I-10: Sleep Apnea, Unspecified (G47.30)

• Central (primary) (G47.31)
• in conditions classified elsewhere (G47.37)
• Obstructive (adult) (pediatric) (G47.33)
• Primary central (G47.31)
• Specified NEC (G47.39)

As you can see, there are several new terms and descriptions in the Nervous System Chapter for I-10-CM, providing more specificity and better clarity of certain conditions. If we can take just a little extra time assigning diagnosis codes for I-10, we will reflect the true severity of illness (SOI) for each and every patient.

Resources:

ICD-10-CM Coding Book by Ingenix

AHIMA ICD-10-CM Training Manual

Wikipedia

All Medicare discharges from acute Inpatient Prospective Payment System (IPPS) hospitals are not created equal. Specifically, hospitals must determine whether the patient was “discharged” or “transferred” from the hospital.

In May, the Office of Inspector General (OIG) released the report, Medicare Inappropriately Paid Hospitals’ Inpatient Claims Subject to the Postacute Care Transfer Policy.

This was not a new type of review for the OIG. In prior similar reviews, the OIG found issues and made the following recommendations to the Centers for Medicare and Medicaid Services (CMS):

• Recommend that CMS provide hospitals education regarding the transfer policy
• Require Medicare Administrative Contractors (MACs) to put edits in place to “prevent and detect postacute care transfers that are miscoded as discharges.”

In spite of prior OIG reviews and recommendations, the OIG once again found in more recent reviews that hospitals not complying with the policy received approximately $12.2 million in overpayments from Medicare contractors. In the May report, the OIG once again conducted a review with the objective of determining if appropriate payments were being made to hospitals by Medicare for claims subject to the postacute care transfer policy. Before examining the report findings, I believe it is important to first have a basic understanding of Medicare’s Postacute Transfer Policy.

Postacute Care Transfer (PACT) Policy Background

• This policy was established by CMS effective October 1, 1998.
• The purpose of this policy is to prevent Medicare from having to pay twice for the same care: once to the hospital as a MS-DRG payment and second to a postacute facility or level of care.
• This policy distinguishes between beneficiary “discharges” and “transfers” from IPPS hospitals.
• A discharge status code is required by CMS for all inpatient claims. This two-digit code determines whether Medicare pays for a “discharge” or a “transfer.”
• Full Medicare Severity Diagnosis-Related Group (MS-DRG) payments are made for inpatient “discharges” to home or certain types of health care institutions.
• A per diem rate is paid for each day of the stay for “transfers.” This amount is not to exceed the full MS-DRG payment made for discharges to home.
• A “transfer” MS-DRG rate is paid for Medicare inpatients who have a qualifying DRG and one of the following discharge status codes assigned:

(Source: MLN Matters Number: SE0801at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf)

How CMS determines what DRGs will be Transfer DRG:

• The DRG has a least 2,050 total postacute care transfer cases;
• At least 5.5 percent of the cases in the DRG are discharged to postacute care prior to the geometric mean length of stay (LOS)for the DRG;
• The DRG must have a geometric mean LOS greater than 3 days; and
• If the DRG is a paired set based on the presence/absence of a comorbidity or complication, both paired DRGs are included if either one meets the first three criteria.

Again, the May OIG Report was conducted to determine if inpatient claims subject to the postacute care transfer policy were being appropriately paid by Medicare. The OIG reviewed Medicare beneficiary transfers to postacute care with dates of service from January 2009 through September 2012. Specific claims were identified through data analysis. Specific OIG findings and recommendations are as follows:

OIG Findings by the Numbers:

• 6,635: The number of inappropriately paid claims by Medicare for claims subject to the postacute care transfer policy.
• 91%: The percentage of inappropriately paid claims where the inpatient hospitalization was followed by claims for home health services.
• $19,471,432: The amount Medicare overpaid to hospitals due to Common Working File (CWF) edits related to home health care, SNFs, and non-IPPS hospital not working properly.
• $31.7 million: The approximate amount of money that Medicare could have saved over 4 years if it had had controls to ensure that the Common Working File (CWF) edits were working properly.

OIG Recommendations to CMS:

• “Direct the Medicare contractors to recover the $19,471,432 in identified overpayments in accordance with CMS’s policies and procedures;
• direct the Medicare contractors to identify any transfer claims on which the patient discharge status was coded incorrectly and recover any overpayments after our audit period;
• correct the CWF edits and ensure that they are working properly; and
• educate hospitals on the importance of reporting the correct patient discharge status codes on transfer claims, especially when home health services have been ordered.”

What the Hospital Needs to know:

“The Federal Register emphasizes that the hospital is responsible for coding the bill on the basis of its discharge plan for the patient. If the hospital subsequently determines that postacute care was provided, it is responsible for either coding the original bill as a transfer or submitting an adjusted claim.”

63 Fed. Reg. 40954, 40980 (July 31, 1998). See also MLN Matters Number: SE0408.

There were no changes made to the Post-Acute payment policy for the current 2014 CMS Fiscal Year that goes from October 1, 2013 through September 30, 2014. A complete list of applicable DRGs can be found in Table 5 of the IPPS Final Rule.

Specific detail regarding the PACT policy can be found in the Code of Federal Regulations (CFR) Title 42: Public Health §412.4 Discharges and transfers.

Have you ever questioned whether a patient actually has a UTI or not, based on the clinical signs and symptoms documented in the medical record, even if “UTI” is documented by the physician? In this week’s article, we'll be discussing UTIs in more specified detail to help with this very issue, as well as CKD.

UTI

Lab Results

We all should be aware that urine cultures growing greater than 100,000 colony forming units (CRU/mL) usually indicates that an infection is present.

Sometimes an infection, if symptoms are present, may be indicated with lower numbers (1,000 to 100,000 CFU/mL).

If a patient has a urine sample collected with a catheter, which minimizes contamination, results of 1,000 to 100,000 CFU/mL may be considered significant.

Symptoms of a UTI

• Painful urination
• Frequent urination
• Urine that is cloudy, bloody, or has an odor
• Pain and pressure in the pubic bone area (women) and rectal pressure (men)
• Feeling of a full bladder but only have drops of urine on urination
• Tiredness
• Weakness
• Fever if the UTI has spread to the kidneys or blood
• Fever is not common with a UTI of the lower urinary tract (urethra or bladder)

NOTE FROM 2Q Coding Clinic, page 20

The provider must clearly document the causal relationship between the UTI and catheter. A coder cannot automatically assign a Catheter-Associated Urinary Tract Infection (CAUTI) when the patient has an indwelling catheter and then develops a UTI.

However, preventing and tracking CAUTIs is very important so if a patient has an indwelling catheter and a UTI, the coder should query the provider as to the cause of the UTI. This information should be documented in the record, as well.

UTI’s in the Elderly

TIP

Look for catheter use in the elderly.

Symptoms can appear non-specific and a diagnosis may be more difficult to determine in the elderly population and/or for those patients in healthcare settings requiring long-term catheter use.

UTI Due to a Catheter--See Complication, catheter, urethral, indwelling, infection and inflammation in the alphabetic index.

• ICD-9--(996.64)
• ICD-10—(T83.51X_) (seven characters)
• initial encounter
• subsequent encounter
• sequela

Contaminant

Remember, if a UTI is documented and the urine sample grows >100,000 colonies, but is labeled as contaminated, no UTI code is reported.

Something You May Not Know

• Females get UTIs more frequently than males.
• For patients that have frequent UTIs, their bacteria may become resistant to antibiotics over time.
• Patients may be more prone to recurring UTIs if the following are present:
• Kidney disease
• Diseases that affect the kidneys, i.e. Diabetes, Hypertension, etc.
• Compromised immune systems

Chronic Kidney Disease

Chapter 14: Disease of Genitourinary System (I-10)-Coding Guidelines

(Unless otherwise indicated, these guidelines apply to all health care settings)

1. 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. Stage 2, code N18.2, equates to mild CKD; stage 3, code N18.3, equates to moderate CKD; and stage 4, code N18.4, equates to severe CKD. Code N18.6, End stage renal disease (ESRD), is assigned when the provider has documented end-stage-renal disease (ESRD).
   
   If both a stage of CKD and ESRD are documented, assign code N18.6 only.
   
   
2. 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. Assign the appropriate N18 code for the patient’s stage of CKD and code Z94.0, Kidney transplant status. If a transplant complication such as failure or rejection or other transplant complication is documented, see section I.C.19.g for information on coding complications of a kidney transplant. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.
   
   
3. Chronic kidney disease with other conditions
   
   Patients with CKD may also suffer from other serious conditions, most commonly diabetes mellitus and hypertension. The sequencing of the CKD code in relationship to codes for other contributing conditions is based on the conventions in the Tabular List.

See I.C.9. Hypertensive chronic kidney disease

See I.C.19. Chronic kidney disease and kidney transplant complications

NOTE FROM 3Q Coding Clinic, page 3

Complications of a transplanted organ are assigned when the transplanted organ is being rejected by the recipient or there are other complications or diseases of the transplanted organ. Ex: A patient develops Acute Renal Failure after a transplant. If the post-transplant condition affects the function of the transplanted organ, two codes are required. One for the Complication of the Transplanted Organ (996.81) (T86.12), which is sequenced as the principal diagnosis, and a second code describing the Acute Renal Failure (584.9) (N17.9).

Pre-existing conditions or medical conditions that develop after a transplant are coded as Complications of the Transplanted Organ only when they affect the function of that organ.

Status code V42.0 should only be used if there is no complication of the organ replaced. A V42.x status code is never used in conjunction with a (996.8x) code if there is no complication of the same transplanted organ.

Sometimes there are no easy solutions when it comes to coding. After all record documentation has been thoroughly reviewed and analyzed there may be only one solution left. When in doubt, query the physician. The worst that can happen is the physician says ‘no’, right?

Resources:

American Association for Clinical Chemistry

ICD-10-CM Coding Book by Ingenix

AHIMA ICD-10-CM Training Manual

Medicine.Net

Appending modifier 59 to a procedure code on an outpatient claim may result in Medicare payment when the code would not have received payment without the modifier. This is a good thing if the modifier is used appropriately for the correct circumstances. But modifier 59 is often misused and this could be a compliance concern for your hospital. Understanding CCI edits and correct modifier usage is critical for compliant billing.

The healthcare industry has been dealing with the National Correct Coding Initiative policy (NCCI or CCI) and edits for over 15 years now, but correct billing and modifier usage continues to be difficult and confusing for a lot of providers. One of the most commonly used and misused modifiers is modifier 59 which identifies a distinct procedural service. In fact misuse of this modifier is such a problem, that CMS has repeatedly provided education, clarification, and examples on the proper use of modifier 59. Last week, they released a new MLN Matters Article, SE1418 that again clarifies the appropriate use of modifier 59.

First, let’s look at some general information about the CCI edits:

• They were developed to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims
• They are based on coding conventions defined in the American Medical Association's CPT Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices.
• The NCCI edits are updated quarterly and the NCCI Policy Manual is updated annually. The policy manual explains the rationale for the edits, the correct usage of modifiers, and specific policies for certain code pairs.
• The edits began in 1996 for Part B claims, and in 2000 for hospital claims. The Part B and hospital edits are not exactly the same.
• Procedure-to-Procedure (PTP) edits define when two HCPCS/CPT codes should not be reported together either in all situations or in most situations.
• A Correct Coding Modifier Indicator (CCMI) of “0” indicates the two codes should never be reported together by the same provider for the same patient on the same day of service. A CCMI of “1” indicates the codes may be reported together only in defined circumstances which are identified on the claim by the use of specific NCCI-associated modifiers.

“Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.” Modifier 59 should only be used if there is not another modifier that could be used to explain the circumstances. Modifier 25, not 59, is used to indicate separate and distinct Evaluation and Management (E/M) services.

The article contains a lot of information about the correct use and inappropriate uses of modifier 59. Providers should carefully review the complete article to fully understand how to use this important modifier. Some of the common uses of modifier 59 described in the article include:

• Different anatomic sites, which includes different organs and in some cases, different lesions in the same organ. However, since CCI edits are to prevent the inappropriate billing of lesions and sites that should not be considered to be separate and distinct, modifier 59 should only be used to identify clearly independent services that represent significant departures from the usual situations. The treatment of contiguous structures in the same organ or anatomic region does not constitute treatment of different anatomic sites, for examples nails, nails beds and adjacent soft tissue; posterior segment structures of the eye; and adjoining areas in the same shoulder.
• Different patient encounters on the same day. One huge issue here is how a patient encounter is defined. Recently an NCCI coding specialist clarified that “encounter” as used in the new NCCI paragraph concerning the use of CPT code 94640 for respiratory treatment represents direct personal contact in the hospital between a patient and a physician or other healthcare professional. In other words, there may be several different encounters with a patient during a day of an extended care episode. For CPT 94640 multiple encounters on the same date of service are reported with modifier 76, but there are codes where modifier 59 would be the appropriate modifier for different encounters on the same day. Beware that this definition of “encounter” may not apply to all CCI edits or be accepted by all Medicare contractors.
• Sequential “timed code” services – this generally refers to rehabilitative therapy services which are defined in 15 minutes intervals. If the therapy services are provided sequentially for a different 15 minute interval, then modifier 59 is appropriate.
• A diagnostic service that proceeds a therapeutic service if “(a) it occurs before the therapeutic procedure and is not interspersed with services that are required for the therapeutic intervention; (b) it clearly provides the information needed to decide whether to proceed with the therapeutic procedure; and (c) it does not constitute a service that would have otherwise been required during the therapeutic intervention.” The example given is angiography preceding a revascularization if the circumstances noted above are met.
• A diagnostic procedure subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure. For example, a chest x-ray after a chest tube insertion to verify placement is not appropriate for modifier 59, but a chest x-ray after a chest tube insertion when the patient experiences unexpected complications is appropriate for modifier 59.

One interesting paragraph in the article describes a common misuse of modifier 59 relating to the portion of the definition describing “a different procedure or surgery.” According to the article, providers should not use modifier 59 to by-pass a CCI edit based on the two codes being “different procedures” unless the two procedures are performed at separate anatomic sites or at separate patient encounters on the same date of service. Please refer to the exact wording in the article for a clear understanding of this instruction.

Getting the correct modifiers on the correct code is not as easy as it sounds. In the hospital setting, this often involves billers, coders, and the relevant hospital departments. It also includes a financial and compliance aspect. Hospitals need a well-planned approach in dealing with CCI edits and their impact on billing and reimbursement.

Our next chapter to address in the I-10 Corner is the Digestive System. Please review the table below so that you can see what areas of the chapter have either been expanded or restructured.

EXAMPLE