I enjoy what I do. For some weird reason, I like to read and do my best to interpret the Medicare regulations. I hope my efforts make it easier for hospitals to receive the appropriate reimbursement for the healthcare services they provide by helping them to follow Medicare’s documentation, coding and billing requirements. But unfortunately, the news I share is not always the best news or even fun. So before I get into the “not so fun” part of this article, I want to acknowledge National Radiologic Technology Week.

As in many areas of healthcare, radiology includes many different types of services, such as plain x-rays, computed tomography (CT), magnetic imaging resonance (MRI), ultrasound, nuclear medicine, interventional radiology, radiation oncology, and others. Radiologic technologists provide a valuable contribution to healthcare. How many times over the past year have you, your family or friends received radiologic services? How would your care have been affected without this technology? Within my own circle of family and friends – an x-ray for a broken wrist, annual mammogram, Dexa scan, MRI for spinal stenosis, and CT to rule out a pulmonary embolism. So thanks to all our radiology friends!

A few weeks ago an article reviewed some of the National Correct Coding Initiative (NCCI) guidance for respiratory services for their recognition week. Continuing that theme for National Radiology Week, let’s look at some of the NCCI instructions that apply to Medicare coding and billing for radiology services.

A recent NCCI edit (July 2014) bundled spinal myelography procedures (72240-72270) into procedures for CT neck, chest and lumbar studies (72125-72133). The code pairs may be reported together with the appropriate modifier when warranted. If both tests are medically necessary, distinctly ordered, and there is a separate interpretation for each procedure, then it is appropriate to append modifier 59 to the CT of the spine with contrast code to identify that it is a separate and distinct procedure. (CPT Assistant September 2014)

The following are selected excerpts from the Radiology chapter of the NCCI manual. For complete information regarding these topics and other radiologic issues, please see Chapter IX of the NCCI Policy Manual found in the downloads section of the Medicare NCCI Website.

• CPT code descriptors that specify a minimum number of views include additional views if there is no more comprehensive code specifically including the additional views.
• CPT Manual instructions state that in the presence of a clinical history suggesting urinary tract pathology complete ultrasound evaluation of the kidneys and urinary bladder constitutes a complete retroperitoneal ultrasound study (CPT code 76770). A limited retroperitoneal ultrasound (CPT code 76775) plus limited pelvic ultrasound (CPT code 76857) should not be reported in lieu of the complete retroperitoneal ultrasound (CPT code 76770).
• When a central venous catheter is inserted, a chest radiologic examination is usually performed to confirm the position of the catheter and absence of pneumothorax. Similarly when an emergency endotracheal intubation procedure (CPT code 31500), chest tube insertion procedure (e.g., CPT codes 32550, 32551, 32554, 32555), or insertion of a central flow directed catheter procedure (e.g., Swan Ganz)(CPT code 93503) is performed, a chest radiologic examination is usually performed to confirm the location and proper positioning of the tube or catheter. The chest radiologic examination is integral to the procedures, and a chest radiologic examination (e.g., CPT codes 71010, 71020) should not be reported separately.
• CPT code 75635 describes computed tomographic angiography of the abdominal aorta and bilateral iliofemoral lower extremity runoff. This code includes the services described by CPT codes 73706 (computed tomographic angiography, lower extremity...) and 74175 (computed tomographic angiography, abdomen...). CPT codes 73706 and 74175 should not be reported with CPT code 75635 for the same patient encounter. CPT code 73706 plus CPT code 74175 should not be reported in lieu of CPT code 75635.
• Diagnostic angiography (arteriogram/venogram) performed on the same date of service by the same provider as a percutaneous intravascular interventional procedure should be reported with modifier 59. If a diagnostic angiogram (fluoroscopic or computed tomographic) was performed prior to the date of the percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology. Report the repeat angiogram with modifier 59.
• Fluoroscopy reported as CPT codes 76000 or 76001 is integral to many procedures including, but not limited, to most spinal, endoscopic, and injection procedures and should not be reported separately. For some of these procedures, there are separate fluoroscopic guidance codes which may be reported separately.
• Computed tomography (CT) and computed tomographic angiography (CTA) procedures for the same anatomic location may be reported together in limited circumstances. If a single technical study is performed which is utilized to generate images for separate CT and CTA reports, only one procedure, either the CT or CTA, for the anatomic region may be reported. Both a CT and CTA may be reported for the same anatomic region if they are performed at separate patient encounters or if two separate and distinct technical studies, one for the CT and one for the CTA, are performed at the same patient encounter. The medical necessity for the latter situation is uncommon.
• If a breast biopsy, needle localization wire, metallic localization clip, or other breast procedure is performed with mammographic guidance (e.g., 19281,19282), the physician should not separately report a post procedure mammography code (e.g., 77051, 77052, 77055-77057, G0202-G0206) for the same patient encounter. The radiologic guidance codes include all imaging by the defined modality required to perform the procedure.
• CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.
• The code descriptor for CPT code 77417 states “Therapeutic radiology port film(s)”. The MUE value for this code is one (1) since it includes all port films.
• An MRI study of the brain (CPT codes 70551-70553) and MRI study of the orbit (CPT codes 70540-70543) are separately reportable only if they are both medically reasonable and necessary and are performed as distinct studies. An MRI of the orbit is not separately reportable with an MRI of the brain if an incidental abnormality of the orbit is identified during an MRI of the brain since only one MRI study is performed.

There are more rules on coding and reporting radiology services on a claim than there are slices of a CT scan. And that is not so fun!

Coding Kwashiorkor has been and continues to be a hot topic for contractors (e.g., Recovery Auditors and the Office of Inspector General (OIG)). In fact, auditing claims including a diagnosis of Kwashiorkor to determine if the record adequately supports the diagnosis was a new scope of work in the FY 2014 OIG Work Plan and is a continued scope of work in the FY 2015 OIG Work Plan. In the Work Plan the OIG indicates that “a diagnosis of Kwashiorkor on a claim substantially increases the hospitals’ reimbursement from Medicare.”

What is Kwashiorkor?

According to the National Institutes of Health, “Kwashiorkor is a form of malnutrition that occurs when there is not enough protein in the diet. Kwashiorkor is most common in areas where there is:

• Famine
• Limited food supply
• Low levels of education (when people do not understand how to eat a proper diet)
• Dates of service of records reviewed ranged from 2010 – 2013 with most records being prior to 2013.

This disease is more common in very poor countries. It often occurs during a drought or other natural disaster, or during political unrest.”

“Kwashiorkor is very rare in children in the United States. There are only isolated cases. However, one government estimate suggests that as many as 50% of elderly people in nursing homes in the United States do not get enough protein in their diet.

When Kwashiorkor does occur in the United States, it is usually a sign of child abuse and severe neglect.”

Kwashiorkor and the OIG Work Plan

In fulfillment of the Work Plan, the OIG has completed several hospital audits that found that hospitals had incorrectly billed Medicare inpatient claims with Kwashiorkor.

In the audit reports, the OIG indicates that Kwashiorkor generally affects children and the Medicare program is primarily provided to people age 65 or older. Yet, “for calendar years (CYs) 2010 and 2011, Medicare paid hospitals $711 million for claims that included a diagnosis for Kwashiorkor. Therefore, we are conducting a series of reviews of hospitals with claims that include this diagnosis code.”

Key Takeaways from 2014 OIG Reports:

• Consistent in the findings for all of the hospitals was that almost all claims reviewed did not comply with Medicare requirements for billing Kwashiorkor in that they used code 260 but should have used codes for other forms of malnutrition. In several instances removing code 260 did not result in a DRG change. When it did result in a DRG change it resulted in overpayments being made to the hospital.
• The combined overpayment by Medicare was $2,074,341. This is staggering when you consider that this amount is overpayment for one single secondary diagnosis code at only twelve hospitals.
• The reasons for coding errors sited by the hospitals included:
• Lack of clarity in the coding guidelines,
• Issues with the medical coding software program used to code the diagnosis; and
• Incorrect guidance from a third party consultant.

What Guidance is Available to Hospitals?

To answer the “lack of clarity in coding guidelines” for coding Kwashiorkor here are two resources that hospitals can look to for malnutrition coding guidance.

Coding Clinic

Volume 3, Issue 1 , page 3 of the October 2012 Medicare Quarterly Compliance Newsletter, provides an example of a Recovery Auditor findings where Kwashiorkor had been coded as a secondary major comorbidity incorrectly and refers the reader to Coding Clinic, Third Quarter 2009.

Specifically, Coding Clinic, Third Quarter 2009, p. 6 advises hospitals to only code 263.0 for moderate protein malnutrition as this category also includes protein-calorie malnutrition. Coding Clinic further advises that unless the physician specifically documents Kwashiorkor Code 260 should not be used.

Consensus Statement

The American Academy of Nutrition and Dietetics (the Academy) and the American Society for Parental and Enteral Nutrition (ASPEN) published a Consensus Statement in the May 2012 Journal of the Academy of Nutrition and Dietetics.

This article acknowledges that “the diagnosis of malnutrition in a patient is an undeniably complicating condition that in many cases significantly increased resource utilization in the acute care setting beyond that experienced by the patient in nutritional health.”

While hospitals have historically looked to serum albumin and prealbumin levels as an indicator of malnutrition, the Academy’s Evidence Analysis Library (EAL) analysis found that “acute-phase proteins do not consistently or predictably change with weight loss, calorie restriction, or nitrogen balance. They appear to better reflect severity of the inflammatory response rather than poor nutritional status.”

This article also notes that “CMS has also questioned the use of acute-phase serum proteins as primary diagnostic criteria for malnutrition since studies increasingly suggest limited correlation of these proteins with nutritional status.”

The Academy and Aspen state that two of the following six characteristics should be identified in a patient when diagnosing malnutrition:

• Weight loss;
• Loss of muscle mass;
• Loss of subcutaneous fat;
• Localized or generalized fluid accumulation that sometimes mask weight loss; and
• Diminished functional status as measure by hand grip strength
• Insufficient energy intake;

It is advised that these characteristics be assessed at the time of the hospital admission and “at frequent intervals throughout the patient’s stay in an acute, chronic, or transitional care setting.”

The article goes on to site a study by Fry and colleagues that “showed that preexisting “malnutrition and/or weight loss” was a positive predictive variable for all eight major surgery-associated “never events” (inexcusable outcomes in a health care setting.”

Assessment, diagnosis and treatment of malnutrition are critical for the wellbeing of our patients. Equally important is identifying the characteristics that need to be assessed in formulating the correct type of malnutrition (e.g. moderate or severe) diagnosis. This article contains a table with detailed clinical criteria to assist in determining the severity levels of malnutrition and I strongly encourage you to read this article.

This is Respiratory Care Week and we at MMP would like to thank all of you who provide respiratory care for your hard work and dedication to improving the respiratory health of your patients. When my oldest son was eleven, he had severe pneumonia that required an extended hospitalization. I remember anxiously watching as the respiratory care team provided wonderful services that helped him to recover. Healthcare is most appreciated when truly needed and I am most appreciative of the care given by those respiratory therapists to my young son.

That son now has two beautiful children, the youngest a one-year old daughter. She now understands the word “no” but very much does not like to hear it. Like her, for all of us, it is sometimes hard to be told “no” constantly. Unfortunately, Medicare’s National Correct Coding Initiative (NCCI) often tells providers “no” about the reporting of certain code combinations. Respiratory services are no exception and in honor of Respiratory Care Week, I thought I would review some of the CCI edits for respiratory services. The complete CCI edits can be found at the Medicare NCCI webpage. The information below comes from the NCCI Policy Manual, Chapter 11. Please refer to this manual for more information.

• Alternate methods of reporting data obtained during a spirometry or other pulmonary function session should not be reported separately. For example, the flow volume loop is an alternative method of calculating a standard spirometric parameter. CPT code 94375 is included in standard spirometry (rest and exercise) studies.
• If multiple spirometric determinations are necessary to complete the service described by a CPT code, only one unit of service should be reported. For example, CPT code 94070 describes bronchospasm provocation with an administered agent and utilizes multiple spirometric determinations as in CPT code 94010. A single unit of service includes all the necessary spirometric determinations.
• Complex pulmonary stress testing (CPT code 94621) is a comprehensive stress test with a number of component tests separately defined in the CPT Manual. It is inappropriate to separately code venous access, ECG monitoring, spirometric parameters performed before, during and after exercise, oximetry, O2consumption, CO2production, rebreathing cardiac output calculations, etc., when performed as part of a complex pulmonary stress test.
• CPT code 94060 (bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) describes a diagnostic test that is utilized to assess patient symptoms that might be related to reversible airway obstruction. It does not describe treatment of acute airway obstruction. CPT code 94060 includes the administration of a bronchodilator. It is a misuse of CPT code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction...) to report 94640 for the administration of the bronchodilator included in CPT code 94060. The bronchodilator medication may be reported separately.
• CPT code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction...) and CPT code 94664 (demonstration and/or evaluation of patient utilization of an aerosol generator...) generally should not be reported for the same patient encounter. The demonstration and/or evaluation described by CPT code 94664 is included in CPT code 94640 if it utilizes the same device (e.g., aerosol generator) that is used in the performance of CPT code 94640. If performed at separate patient encounters on the same date of service, the two services may be reported separately.
• CPT code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction...) describes either treatment of acute airway obstruction with inhaled medication or the use of an inhalation treatment to induce sputum for diagnostic purposes. CPT code 94640 should only be reported once during a single patient encounter regardless of the number of separate inhalation treatments that are administered. If CPT code 94640 is used for treatment of acute airway obstruction, spirometry measurements before and/or after the treatment(s) should not be reported separately. It is a misuse of CPT code 94060 to report it in addition to CPT code 94640. The inhaled medication may be reported separately.

There has been a lot of discussion about the last bullet point, which was new for 2014, that states that inhalation treatment “should only be reported once during a single patient encounter”. The issue is the definition of the term “encounter”. According to a statement issued by a coding specialist for NCCI, “encounter” in this instance means “direct personal contact in the hospital between a patient and a physician (or other clinician)… If the professional completes the inhalation service(s) and terminates the patient encounter but returns later that day to initiate additional inhalation treatment(s) reportable as CPT code 94640, an additional UOS (unit of service) of CPT code 94640 may be reported for this subsequent patient encounter.” We encourage all providers to clarify the interpretation of the term “encounter” with your Medicare Administrative Contractor (MAC) and other payers.

These NCCI rules again demonstrate that healthcare involves more than just providing patient care. Coding and billing play a major part in all aspects of healthcare. So someone in your Respiratory Care department needs to be aware of and understand the coding and billing requirements for Medicare and other payers. Because when Medicare says “no”, they mean “no”.

In this week’s article, we are featuring Neoplasms focusing mainly on the differences between ICD-9-CM and ICD-10-CM Coding Guidelines. There are only a few changes in the wording of the guidelines but there are several additional guidelines in ICD-10-CM. Only the differences in the two classification systems are listed below.

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

GUIDELINES COMPARISON

‍Primary malignant neoplasms overlapping site boundaries

A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified to the subcategory/code .8 ('overlapping lesion'), unless the combination is specifically indexed elsewhere.

For multiple neoplasms of the same site that are not contiguous such as tumors in different quadrants of the same breast, codes for each site should be assigned.

Malignant neoplasm of ectopic tissue

Malignant neoplasms of ectopic tissue are to be coded to the site of origin mentioned, e.g., ectopic pancreatic malignant neoplasms involving the stomach are coded to pancreas, unspecified (C25.9).

The neoplasm table in the Alphabetic Index should be referenced first. However, if the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate.

EXAMPLE

If the documentation indicates “adenoma,” refer to the term in the Alphabetic Index to review the entries under this term and the instructional note to “see also neoplasm, by site, benign.” The table provides the proper code based on the type of neoplasm and the site. It is important to select the proper column in the table that corresponds to the type of neoplasm. The Tabular List should then be referenced to verify that the correct code has been selected from the table and that a more specific site code does not exist.

See Section I.C.21. Factors influencing health status and contact with health services, Status, for information regarding Z15.0, codes for genetic susceptibility to cancer.

 ‍

GUIDELINES COMPARISON

‍Additional guidelines in ICD-10-CM

2.i) Malignancy in two or more noncontiguous sites

A patient may have more than one malignant tumor in the same organ. These tumors may represent different primaries or metastatic disease, depending the site. 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.

2.j) Disseminated malignant neoplasm, unspecified

Code C80.0, Disseminated malignant neoplasm, unspecified, is for use only in those cases where the patient has advanced metastatic disease and no known primary or secondary sites are specified. It should not be used in place of assigning codes for the primary site and all known secondary sites.

2.k) Malignant neoplasm without specification of site

Code C80.1, Malignant (primary) neoplasm, unspecified, equates to Cancer, unspecified. This code should only be used when no determination can be made as to the primary site of a malignancy. This code should rarely be used in the inpatient setting.

2.l) Sequencing of neoplasm codes

2.l.1) Encounter for treatment of primary malignancy

If the reason for the encounter is for treatment of a primary malignancy, assign the malignancy as the principal/first-listed diagnosis. The metastatic sites.

2.l.2) Encounter for treatment of secondary malignancy

When an encounter is for a primary malignancy with metastasis and treatment is directed toward the metastatic (secondary) site(s) only, the metastatic site(s) is designated as the principal/first-listed diagnosis. The primary malignancy is coded as an additional code.

2.l.3) Malignant neoplasm in a pregnant patient

When a pregnant woman has a malignant neoplasm, a code from subcategory O9A.1-, Malignant neoplasm complicating pregnancy, childbirth, and the puerperium, should be sequenced first, followed by the appropriate code from Chapter 2 to indicate the type of neoplasm.

2.l.4) Encounter for complication associated with a neoplasm

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.

2.l.5) Complication from surgical procedure for treatment of a neoplasm

When an encounter is for treatment of a complication resulting from a surgical procedure performed for the treatment of the neoplasm, designate the complication as the principal/first-listed diagnosis. See guideline regarding the coding of a current malignancy versus personal history to determine if the code for the neoplasm should also be assigned.

2.l.6) Pathologic fracture due to a neoplasm

When an encounter is for a pathological fracture due to a neoplasm, and the focus of treatment is the fracture, a code from subcategory M84.5, Pathological fracture in neoplastic disease, should be sequenced first, and followed by the code for the neoplasm.

If the focus of treatment is the neoplasm with an associated pathological fracture, the neoplasm code should be sequenced first, followed by a code from M84.5 for the pathological fracture.

2.m. Current malignancy versus personal history of malignancy

When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.

When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.

See Section I.C.21. Factors influencing health status and contact with health services, History (of)

2.n. Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplasms inremission versus personal history

The categories for leukemia, and category C90, Multiple myeloma and malignant plasma cell neoplasms, have codes indicating whether or not the leukemia has achieved remission.

There are also codes Z85.6, Personal history of leukemia, and Z85.79, Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues.

If the documentation is unclear, as to whether the leukemia has achieved remission, the provider should be queried.

See Section I.C.21. Factors influencing health status and contact with health services, History (of)

2.o. Aftercare following surgery for neoplasm

See Section I.C.21. Factors influencing health status and contact with health services, Aftercare

2.p. Follow-up care for completed treatment of a malignancy

See Section I.C.21. Factors influencing health status and contact with health services, Follow-up

2.q. Prophylactic organ removal for prevention of malignancy

See Section I.C. 21, Factors influencing health status and contact with health services, Prophylactic organ removal

NOTE FROM AUTHOR

Notice the dashes (-) in the neoplasm table below:

Note: Codes listed with a dash (-), following the code, have a required additional character for laterality. The tabular must be reviewed for the complete code.

Example: Adrenal cortex (C74.0-) requires a fifth digit to determine right, left, or unspecified adrenal cortex for code completion.

If you haven’t done so already, MMP strongly encourages you to review all of the ICD-10-CM Coding Guidelines for each chapter. Often, we tend to use our memory when utilizing the guidelines and a refresher just might be helpful. You may be amazed at the guidelines that you remember and those you may have forgotten.

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.

Resources:

AHIMA ICD-10-CM Training Manual

ICD-10-CM Coding Book by Ingenix

Part I can be found by clicking here.

Coding of Burns and Corrosions

There is now a distinction made in ICD-10-CM between burns and corrosions. Coding guidelines are the same for both burns and corrosions. The difference between the two would be:

• Burns – Thermal burns from a heat source.

1. Fire
2. Hot appliance
3. Electricity
4. Radiation
5. Sunburns are not included

• Corrosion – A burn secondary to chemicals (as it makes contact with external or internal tissue) such as:

1. Acids
2. Bases
3. Oxidizers
4. Solvents
5. Alkylants
6. Mustard gas

Current burns are classified in ICD-10-CM by:

• Body site
• Depth – Burns located at the same site but of different degrees is coded to the highest degree documented by provider
• First degree – erythema
• Second degree – blistering
• Third degree – full thickness injury
• Extent – Total Body Surface (TBS) for Third Degree Burns

1. Burns – Category T31
2. Corrosions – Category T32

• T31 and T32 are based on the classic “rule of nines” in estimating TBS

1. Head and neck – 9%
2. Each arm – 9%
3. Each leg – 18%
4. Anterior trunk – 18%
5. Posterior trunk – 18%
6. Genitalia – 1%

• Percentage assignment may be changed by providers to accommodate patients with larger heads, buttocks, thighs or abdomen
• Categories T30.0 and T30.4 for Burn or Corrosion of unspecified body region, unspecified degree are not to be assigned on inpatient accounts
• External cause / Agent
• Laterality
• Left
• Right
• Unspecified
• Encounter – Seventh character designates episode of care
• Initial encounter – A
• Subsequent encounter – D
• Sequela – S (encounters for late effects of burns or corrosions such as scars or joint contractures)

NOTE FROM ICD-10-CM OFFICIAL GUIDELINES FOR CODING AND REPORTING

Section I.C.19.d.3

Non-healing burns are coded as acute burns.

Necrosis of burned skin should be coded as a non-healed burn.

Sequencing Burns / Corrosions

• Sequence code reflecting the highest degree first when more than one burn/corrosion is documented
• When both internal and external burns/corrosions have been documented, the circumstances of admission govern the selection of the principal diagnosis
• When the admission is for burn injuries and other related conditions such as respiratory failure and/or smoke inhalation, the circumstances of admission govern the selection of principal diagnosis

Adverse Effects, Poisoning, Under-dosing and Toxic Effects

Codes within the category T36 – T65 range are combination codes. This would include the substance related to the poisoning, adverse or toxic effect, under-dosing and the external source. There will be no need to assign an additional external cause code in ICD-10-CM.

Adverse Effect

An appropriate code should be assigned for Adverse Effect when the drug was correctly prescribed and administered. An additional code should be assigned to show the manifestation of the Adverse Effect. Examples would be:

• Tachycardia
• Delirium
• GI Bleeding
• Renal Failure
• Respiratory Failure
• Nausea and vomiting

Poisoning

A Poisoning would constitute a reaction to the improper use of a medication via:

• Intentional overdose
• Error made in drug prescription
• Interaction of drugs and alcohol
• Nonprescription drug taken with correctly prescribed and administered drug

Poisoning codes have an associated intent shown in the 5th or 6th character.

• Accidental
• Intentional self-harm
• Assault
• Undetermined

An additional code should be assigned for all manifestations associated with poisonings.

A code for abuse or dependence should also be assigned if the provider documents a diagnosis of abuse or dependence of a drug/substance.

Coders should assign as many codes necessary to fully describe all drugs/substances and manifestations described for a particular admission.

Under-dosing

Under-dosing is a new concept under ICD-10-CM and is defined as taking less of a drug than is recommended or prescribed by a provider or the manufacturer.

• A code for under-dosing should never be assigned as a principal diagnosis.
• Noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.6-Y63.9) code is to be used with an under-dosing code to indicate intent, if known.

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.