PNEUMONIA

Pneumonia is a common illness seen in the healthcare industry that affects millions of people each year in the United States. Bacteria are the most common cause of pneumonia in adults.

• Community Acquired Pneumonia (CAP) is acquired by people that have not recently been hospitalized or live in some type of healthcare facility such as a nursing home.
• Healthcare Associated Pneumonia (HCAP) is acquired by people while they’ve been in a healthcare facility such as a nursing home.
• Hospital Acquired Pneumonia (HAC) is acquired while a patient is hospitalized.

NOTE FROM AUTHOR
When a patient is admitted to the hospital with either HCAP or HAC, code Y95 for Nosocomial Condition should also be added – Refer to Coding Clinic 4th Qtr. 2013 page 118.

External sources may also be the source of Pneumonia.

• Aspiration Pneumonia – Caused by the inhalation of foreign material such as food, liquids, vomit or gastric secretions.
• Pneumonitis due to Inhalation of Food and Vomit – J69.0
• Code also any associated foreign body in the respiratory tract from category T17
• Pneumonitis due to Inhalation of Oil and Essences – J69.1
• Code first (T51-T65) to identify substance
• Pneumonitis due to Inhalation of Other Solids and Liquids – J69.8
• Code first (T51-T65) to identify substance
• Radiation Pneumonitis (J70.0) – Due to exposure of therapeutic doses of radiation.
• Use additional code (W88-W90, X39.0) to identify the external cause
• Ventilator Assisted Pneumonitis – J95.851

NOTE FROM MANUAL

Official ICD-10-CM Guidelines for Coding and Reporting – Section I.C.10.d.1

As with all procedural or post-procedural complications, code assignment is based on the provider’s documentation of the relationship between the condition and the procedure. Code J95.851, should be assigned only when the provider has documented Ventilator Associated Pneumonia (VAP). An additional code to identify the organism (e.g., Pseudomonas aeruginosa, code B96.5) should also be assigned. Do not assign an additional code from categories J12.0-J18.9 to identify the type of pneumonia.

Code J95.851 should not be assigned for cases where the patient has pneumonia and is on a mechanical ventilator and the provider has not specifically stated that the pneumonia is ventilator-associated pneumonia. If the documentation is unclear as to whether the patient has a pneumonia that is a complication attributable to the mechanical ventilator, query the provider.

NOTE FROM MANUAL

Official ICD-10-CM Guidelines for Coding and Reporting – Section I.C.10.d.2

A patient may be admitted with one type of pneumonia (e.g., code J13, Pneumonia due to Streptococcus pneumonia) and subsequently develop ventilator associated pneumonia (VAP) J95.851. In this instance, the principal diagnosis would be the appropriate code from categories J12.0-J18.9 for the pneumonia diagnosed at the time of admission. Code J95.851, Ventilator associated pneumonia, would be assigned as an additional diagnosis when the provider has also documented the presence of ventilator associated pneumonia.

RESPIRATORY FAILURE

In ICD-10-CM there will be combination codes to include Hypoxia and Hypercapnia

Acute Respiratory Failure

• Unspecified Whether with Hypoxia or Hypercapnia – J96.00
• With Hypoxia – J96.01
• With Hypercapnia – J96.02

Chronic Respiratory Failure

• Unspecified Whether with Hypoxia or Hypercapnia – J96.10
• With Hypoxia – J96.11
• With Hypercapnia – J96.12

Acute on Chronic Respiratory Failure

• Unspecified Whether with Hypoxia or Hypercapnia – J96.20
• With Hypoxia – J96.21
• With Hypercapnia – J96.22

Respiratory Failure, Unspecified

• Unspecified Whether with Hypoxia or Hypercapnia – J96.90
• With Hypoxia – J96.91
• With Hypercapnia – J96.92

Post-procedure Respiratory Failure

            Excludes 1 – Respiratory Failure in other conditions (J96)

• Acute Post-procedure Respiratory Failure – J95.821
• Acute and Chronic Post-procedure Respiratory Failure – J95.822

Respiratory Failure is always due to an underlying condition. Sequencing will be dependent on the circumstances of the admission. If two conditions are equally responsible and there are no chapter specific guidelines, the guideline for two or more diagnosis that equally meets the definition of principal diagnosis may be applied.

If the documentation is not clear as to whether Acute Respiratory Failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.

Official Guidelines for Coding and Reporting – Section I.C.10.b.3

BRONCHITIS

Manifestations of Acute Bronchitis can now be reflected in ICD-10-CM under category J20.

Acute Bronchitis due to:

• Mycoplasma Pneumoniae – J20.0
• Hemophilus Influenza – J20.1
• Streptococcus – J20.2
• Coxsackievirus – J20.3
• Parainfluenza Virus – J20.4
• Respiratory Syncytial Virus – J20.5
• Rhinovirus – J20.6
• Echovirus – J20.7
• Other Specified Organism – J20.8
• Unspecified – J20.9

EMPHYSEMA

Emphysema is a type of Chronic Obstructive Pulmonary Disease (COPD) involving damage to the air sacs (alveoli) in the lungs.

ICD-10 will now have codes to cover two different forms of Emphysema.

• Panlobular Emphysema (J43.1) - alveolar destruction occurs in all alveoli within the lobule simultaneously.
• Centrilobular Emphysema (J43.2) - destruction that begins at the center of the lobule.

When reporting categories for COPD (J44), Asthma (J45), Chronic Bronchitis (J42) and Emphysema (J43), an additional code should be assigned to show any specific external factors such as:

• Exposure to environmental tobacco smoke (Z77.22)
• Exposure to tobacco smoke in the perinatal period (P96.81)
• History of tobacco use (Z87.891)
• Occupational exposure to environmental tobacco smoke (Z57.31)
• Tobacco dependence (F17-)
• Tobacco use (Z72.0)

SINUSITIS

In ICD-10, there will also be individual codes for Acute Sinusitis, Acute Recurrent Sinusitis and Chronic Sinusitis for each individual sinus cavity.

• Acute Sinusitis – defined as symptoms of less than 4 weeks’ duration.
• Maxillary – J01.00
• Frontal – J01.10
• Ethmoidal – J01.20
• Sphenoidal – J01.30
• Pansinusitis – J01.40
• Other Acute Sinusitis – J01.80
• Acute Sinusitis, Unspecified – J01.90
• Acute Recurrent Sinusitis – defined as three or more episodes per year, with each episode lasting less than 2 weeks.
• Maxillary – J01.01
• Frontal – J01.11
• Ethmoidal – J01.21
• Sphenoidal – J01.31
• Pansinusitis – J01.41
• Other Acute Recurrent Sinusitis – J01.81
• Acute Recurrent Sinusitis, Unspecified – J01.91
• Chronic Sinusitis – defined as symptoms lasting longer than 8 weeks.
• Maxillary – J32.0
• Frontal – J32.1
• Ethmoidal – J32.2
• Sphenoidal – J32.3
• Pansinusitis – J32.4
• Other Chronic Sinusitis – J32.8
• Other Chronic Sinusitis, Unspecified – J32.9

Pansinusitis is when each sinus cavity on one or both sides of the face is affected. When multiple sinus cavities are affected but not Pansinusitis, a code from Other Acute, Acute Recurrent or Chronic (J01.80, J01.81 or J32.8) should be assigned.

Note:   When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should then be classified to the lower anatomic site. One example would be Tracheobronchitis to Bronchitis – J40.

INFLUENZA

NOTE FROM MANUAL

Official ICD-10-CM Guidelines for Coding and Reporting – Section I.C.10.C

Code only confirmed cases of influenza due to certain identified influenza viruses (category J09), and due to other identified influenza virus (category J10). This is an exception to the hospital inpatient guideline Section II, H. (Uncertain Diagnosis).

In this context, “confirmation” does not require documentation of positive laboratory testing specific for avian or other novel influenza A or other identified influenza virus. However, coding should be based on the provider’s diagnostic statement that the patient has avian influenza, or other novel influenza A, for category J09, or has another particular identified strain of influenza, such as H1N1 or H3N2, but not identified as novel or variant, for category J10.

If the provider records “suspected” or “possible” or “probable” avian influenza, or novel influenza, or other identified influenza, then the appropriate influenza code from category

J11, Influenza due to unidentified influenza virus, should be assigned. A code from category J09, Influenza due to certain identified influenza viruses, should not be assigned nor should a code from category J10, Influenza due to other identified influenza virus.

Subcategory J10.8 - Influenza due to Other Identified Influenza Virus with Other Manifestation has been expanded to reflect the manifestations of the Influenza.

Influenza Due to Other Identified Influenza Virus with -

• Encephalopathy – J10.81
• Myocarditis – J10.82
• Otitis Media – J10.83
• Other Manifestation – J10.89

To derive at the most appropriate code for any condition, be sure to always read the additional instructions and Excludes Notes in your coding book and/or encoder.

Over the next several months a lot of information will be posted concerning the do’s and don’ts of ICD-10-CM. At times it may be overwhelming. You will find the transition to be easier and less stressful the earlier you start training.

This week the focus will be on the Respiratory System. Many familiar conditions are identified in this chapter such as Asthma, COPD and Pneumonia.

The Respiratory System is made up of organs and tissues that enable us to breathe.

Airways

• Mouth
• Nose and Nasal Cavities
• Pharynx
• Larynx
• Trachea
• Bronchial Tubes or Bronchi, and their tubes

Lungs

• Right Lung – 3 lobes
• Upper
• Middle
• Lower
• Left Lung – 2 lobes
• Upper
• Lower

Lower Linked Vessels – Provide pulmonary circulation

Muscles

• Diaphragm
• Intercostal
• Abdominal
• Muscles in the Neck and Collarbone area – (accessory muscles)

Here is a list of common signs and symptoms seen in the Respiratory System that may be indicative of a more severe condition. Keep in mind, you always want to be as specific as possible when coding for appropriate reimbursement and data quality.

• Cough
• Dyspnea
• Asphyxia
• Shortness of breath
• Epistaxis
• Hemoptysis
• Rales
• Hypoxemia
• Intercostal pain
• Tachypnea
• Hyperventilation
• Respiratory arrest

Categories J00 – J99

• J00 – J06 Acute Upper Respiratory Infections
• J09 – J18 Influenza and Pneumonia
• J20 – J22 Other Acute Lower Respiratory Infections
• J30 – J39 Other Diseases of Upper Respiratory Tract
• J40 – J47 Chronic Lower Respiratory Diseases
• J60 – J70 Lung Diseases due to External Agents
• J80 – J84 Other Respiratory Diseases Principally Affecting the Interstitium
• J85 – J86 Supportive and Necrotic Conditions of the Lower Respiratory Tract
• J90 – J94 Other Diseases of the Pleura
• J95 Intraoperative and Postprocedural Complications and Disorders of Respiratory System, Not Elsewhere Classified
• J96 – J99 Other Diseases of the Respiratory System

Classification changes in ICD-10 will provide greater specificity.

While the overall organization of ICD-10 is similar to ICD-9, diseases have been rearranged. Certain diseases/disorders have been removed from other chapters and placed in Chapter 10.

• Streptococcal Pharyngitis (J02.0) now classified in Chapter 10, no longer will be classified with the Infectious and Parasitic Disease Chapter.
• Ventilator Associated Pneumonia (J95.851) was previously found in the “Injury and Poisoning” Chapter in ICD-9-CM.
• Intraoperative and post-procedure complications pertaining to the Respiratory System have been grouped together in Chapter 10 – J95.

Some codes in Chapter 10 have been expanded to include notes indicating that an additional code should be assigned or an associated condition should be sequenced first. Example:

• Use additional code to identify the infectious agent
• Use additional code to identify the virus
• Code first any associated lung abscess
• Code first the underlying disease
• Use additional code to identify other conditions such as tobacco use or exposure

As with any chapter in ICD-10, coders must be familiar with the Official Coding Rules and Guidelines. Refer to http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

COPD and ASTHMA

Many of the instructions in ICD-9-CM pertaining to COPD have been eliminated in ICD-10-CM. Here are the two hair splitting requirements in ICD-9 that have been eliminated in ICD-10:

• Physicians will no longer have to distinguish Asthma as Intrinsic or Extrinsic.
• Will no longer need separate codes for “Chronic Obstructive Asthma”, as opposed to “Chronic Obstructive Bronchitis” or plain ole “COPD”.
• In ICD-10-CM, Asthma is just Asthma and COPD is just COPD.

If a patient is documented with both COPD and Asthma, two codes will be required to show each condition.

EXAMPLE
Patient presented to ER with gradual increase in shortness of breath which was unresponsive to home nebulizer treatments. In the ER, patient received more respiratory treatments; however, the patient was admitted after he failed to improve. Theophylline level was 5.9 upon admission. Chest x-ray showed no evidence of active infiltrates. The patient was bolused with IV Steroids and started on frequent respiratory therapy treatments. IV Aminophylline boluses and drip were used to increase his theophylline level to therapeutic range. The patient gradually cleared and by the next day was much better. IV Aminophylline was changed to PO. The Ventolin treatments were decreased to q 4 hr. and his Steroids were rapidly tapered back to 10 mg of Prednisone.

Discharge Diagnosis: Moderate persistent Asthma with Status Asthmaticus – J45.42
Acute Exacerbation of COPD – J44.1

NOTE FROM MANUAL

Official ICD-10-CM Guidelines for Coding and Reporting – Section I.C.10.a

The Codes in categories J44 and J45 distinguish between uncomplicated cases and those in acute exacerbation.

An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection.

Terminology terms have been updated and added to reflect current the clinical classification of Asthma – J45. Asthma must be documented as mild, moderate or severe. Mild Asthma must be documented as intermittent or persistent.

DEFINITON

‍

• Mild intermittent Asthma
• Uncomplicated – J45.20
• With (Acute) Exacerbation – J45.21
• With Status Asthmaticus – J45.22
• Mild persistent Asthma
• Uncomplicated – J45.30
• With (Acute) Exacerbation – J45.31
• With Status Asthmaticus – J45.32
• Moderate persistent Asthma
• Uncomplicated – J45.40
• With (Acute) Exacerbation – J45.41
• With Status Asthmaticus – J45.42
• Severe persistent Asthma
• Uncomplicated – J45.50
• With (Acute) Exacerbation – J45.51
• With Status Asthmaticus – J45.52

Intrinsic (non-allergic) and Extrinsic (allergic) Asthma will both be classified to J45.909 – Unspecified Asthma, Uncomplicated.

MMP highly recommends an early start with ICD-10-CM/PCS training. There is no doubt the transition will be challenging. Any type of procrastination is sure to bring on stress with increased complexity and costs. Early planning and preparation will be the key to a smooth and successful transition. For timely updates and informative articles, Continue to follow MMP through their weekly newsletter Wednesday@One Part 2 of Chapter 10 – Diseases of the Respiratory System will post March 12, 2014.

Illustration: Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000. www.bartleby.com/107/. [Date of Printout].

For the I-10 Corner this week, we are discussing a few of the specific coding differences for cardiac diagnoses and conditions in ICD-9-CM and ICD-10-CM.

Angina Pectoris with Atherosclerotic Heart Disease (ASHD):

I-9

Angina, Unspecified (413.9)

ASHD, Unspecified (414.00)

I-10

Angina with ASHD, Unspecified—see Arteriosclerosis, Coronary (artery), Unspecified (I20.9)

NOTE FROM AUTHOR
Attention: Two codes in I-9 vs. one code in I-10

Atrial Fibrillation:

I-9

Atrial Fibrillation (established) (paroxysmal) (427.31)

I-10

Atrial Fibrillation or Auricular (established) (I48.91)

Chronic (I48.2)

Paroxysmal (I48.0)

Permanent (I48.2)

Persistent (I48.1)

Atrial Flutter:

I-9

Atrial Flutter or Auricular (427.32)

I-10

Atrial Flutter or Auricular (I48.92)

Atypical (I48.4)

Type I (I48.3)

Type II(48.4)

Typical (I48.3)

NOTE FROM AUTHOR
Attention: There are specific descriptions for Atrial Fibrillation and Atrial Flutter in I-10. In addition, there are no specific codes for Postoperative Fibrillation or Postoperative Flutter in the alpha index.

Heart Failure:

I-9

Congestive Heart Failure (compensated) (decompensated) (428.0)

Diastolic (428.30)

Acute (428.31)

Acute on Chronic (428.33)

Chronic (428.32)

Systolic (428.20)

Acute (428.21)

Acute on Chronic (428.23)

Chronic (428.22)

I-10

Congestive Heart Failure (compensated) (decompensated) (I50.9)

Diastolic (congestive) (I50.30)

Acute (congestive) (I50.31)

            and (on) chronic (congestive) (I50.33)

Chronic (congestive) (I50.32)

            and (on) acute (congestive) (I50.33)

Combined with Systolic (congestive) (I50.40)

            Acute (congestive) (I50.41)

                        And (on) chronic (congestive) (I50.43)

            Chronic (congestive) (I50.42)

                        And (on) acute (congestive) (I50.43)

Systolic (congestive) (I50.20)

Acute (congestive) (I50.21)

            and (on) chronic (congestive) (I50.23)

Chronic (congestive) (I50.22)

            and (on) acute (congestive) (I50.23)

Combined with Diastolic (congestive) (I50.40)

            Acute (congestive) (I50.41)

                        And (on) chronic (congestive) (I50.43)

            Chronic (congestive) (I50.42)

                        And (on) acute (congestive) (I50.43)

Myocardial Infarction (MI):

I-9

Infarct, Myocardial (acute or with a stated duration of 8 weeks or less) (with Hypertension) (410.9x)

NOTE FROM MANUAL
Note—Use the following fifth-digit subclassification with category 410:

0 - episode unspecified

1 - initial episode

2 - subsequent episode without recurrence

I-10

Infarct, Myocardial (acute) (with stated duration of 4 weeks or less) (I21.3)

NOTE FROM AUTHOR
Attention:

• For the episode of care in I-10, MIs are identified as either Acute (I21.xx) or Subsequent (I22.xx).
• The timeframe (stated duration of the MI) has decreased in I-10 to 4 weeks from 8 weeks in I-9.

Most MIs are considered to be ST-Elevation (STEMI) unless stated as Non-ST Elevation (NSTEMI) or Subendocardial.

STEMI

Anterior (anteroapical) (anterolateral) (anteroseptal) (Q wave) (wall) (I21.09)

Inferior (I21.09) (diaphragmatic) (inferolateral) (inferoposterior) (wall) NEC (I21.19)

Inferoposterior Transmural (Q wave) (I21.11)

Lateral (I21.29) (apical-lateral) (basal-lateral) (high) (I21.29)

Posterior (I21.29) (posterobasal) (posterolateral) (posteroseptal) (true) I21.29)

Septal (I21.29)

Specified NEC (I21.29)

NSTEMI

Subendocardial (I21.4)

Non-Q wave NOS (I21.4)

Nontransmural NOS (I21.4)

If NSTEMI evolves to STEMI, assign the STEMI code. If STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as STEMI.

NOTE FROM AUTHOR
For Acute MIs, we can now identify the specific coronary artery impacted. For example, per the alpha index:

Infarct, Myocardial, Involving

Coronary artery of anterior wall NEC (I21.09)

Coronary artery of inferior wall NEC (I21.19)

Diagonal coronary artery (I21.02)

Left anterior descending coronary artery (I21.02)

Left circumflex coronary artery (I21.21)

Left main coronary artery (I21.01)

Oblique marginal coronary artery (I21.21)

Right coronary artery (I21.11)

Please refer to the our article, ICD-10-CM Diseases of the Circulatory System, describing specific coding guidelines for cardiac diagnoses and conditions.

I hope this article has been beneficial in helping you become more familiar with cardiac diagnoses and conditions in ICD-10-CM.           

For the I-10 Corner this week, we’re discussing a few of the procedural coding guidelines for Cardiac Bypass Procedures, including a few examples.

Remember: The letters I and O and not used in PCS since they are easily confused with numbers one (1) and zero (0).

ICD-10-PCS Coding Guidelines

Coronary Bypass Procedures

B3.6b. Coronary arteries are classified by number of distinct sites treated, rather than number of coronary arteries or anatomic name of a coronary artery (e.g., left anterior descending). Coronary artery bypass procedures are coded differently than other bypass procedures as described in guideline B3.6a. Rather than identifying the body part bypassed from, the body part identifies the number of coronary artery sites bypassed to, and the qualifier specifies the vessel bypassed from.

Example: Aortocoronary artery bypass of one site on the left anterior descending coronary artery and one site on the obtuse marginal coronary artery is classified in the body part axis of classification as two coronary artery sites and the qualifier specifies the ‘aorta’ as the body part bypassed from.

B3.6c. If multiple coronary artery sites are bypassed, a separate procedure is coded for each coronary artery site that uses a different device and/or qualifier.

Example: Aortocoronary artery bypass and internal mammary coronary artery bypass are coded separately.

Coronary Excision for Graft

B3.9. If an autograft is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded.

Example: Coronary bypass with excision of saphenous vein graft; excision of saphenous vein is coded separately.

Coding Example: CABG of LAD using left internal mammary artery, open; off pump (02100Z9). Root Operation: Bypass, Coronary Artery, One Site, (0210), Open (0), No Device (z), Internal Mammary, Left (9).

                Note: The Internal Mammary Artery = No Device. It is not considered graft material.

Coding Example: Open coronary artery bypass graft of three coronary arteries using left autologous greater saphenous vein (021209w). Root Operation: Bypass, Coronary Artery, Three Sites (0212), Open, (0), Autologous Venous Tissue (9), Aorta (w).

Note: For Coronary Bypass, the Body Part identifies the number of coronary artery sites bypassed to-- which is the Aorta.

Coronary Body Parts

B4.4 The coronary arteries are classified as a single body part that is further specified by number of sites treated and not by name or number or arteries. Separate body part values are used to specify the number of sites treated when the same procedure is performed on multiple sites in the coronary arteries.

Example: Angioplasty of two distinct sites in the left anterior descending coronary artery with placement of two stents is coded as Dilation of Coronary Arteries, Two Sites, with Intraluminal Device.

Example: Angioplasty of two distinct sites in the left anterior descending coronary artery, one with stent placed and one without, is coded separately as Dilation of Coronary Artery, One Site, with Intraluminal Device, and Dilation of Coronary Artery, One Site, with no device.

Coding Example: PTCA of two coronary arteries: RCA with stent (intraluminal device) (02703DZ) and LAD without stent (02703ZZ). Root Operation: Dilation, Artery, Coronary, One Site (0270)—one with an intraluminal device and one without.

Note: Coronary arteries are counted as single body parts. It doesn’t matter how many arteries were treated. The main distinguishing factor is the number of sites treated.

MMP hopes this article was beneficial in helping you become more familiar with cardiac bypass procedures in ICD-10-PCS.         

For the I-10 Corner this week, we’re focusing on diagnostic coding guidelines, plus a few examples,for Chapter 9: Diseases of the Circulatory System (I00-I99)

Quick Tips:

• The types of hypertension (benign, malignant, accelerated, etc.) are all listed as modifiers in I-10. The Hypertension table has been deleted.
• Combination codes include Coronary Artery Disease (CAD) plus all types of Angina. These combination codes include native arteries as well as CAD of bypass graft(s).
• The time frame for Acute Myocardial Infarction (AMI) codes have changed from eight (8) weeks or less to four (4) weeks or less (within 28 days).
• Myocardial Infarction (MI) codes specify ST Elevation (STEMI) Myocardial Infarction, along with the site of the MI, or Non-ST (NSTEMI) Myocardial Infarction, in each descriptive heading.
• Atrial Fibrillation and Atrial Flutter can now be identified as paroxysmal, persistent, typical, atypical, and unspecified.
• 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.

ICD-10-CM Coding Guidelines

9 .a. 1) Hypertension with heart disease

Heart conditions classified to I50.-I51.9, are assigned to a code from category I11, Hypertensive heart disease, when a causal relationship is stated (due to hypertension) or implied (hypertensive). Use an additional code from category I50, Heart failure, to identify the type of heart failure in those patients with heart failure.

The same heart conditions (I50.-, I51.9) with hypertension, but without a stated causal relationship, are coded separately. Sequence according to the circumstances of the admission/encounter.

9. a. 2) Hypertensive chronic kidney disease

Assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension and a condition, classifiable to category N18, Chronic kidney disease (CKD), are present. Unlike hypertension with heart disease, ICD-10-CM presumes a cause-and-effect relationship and classifies chronic kidney disease with hypertension as hypertensive chronic kidney disease.

The appropriate code from category N18 should be used as a secondary code with a code from category I12 to identify the stage of chronic kidney disease.

See Section I.C.14 Chronic kidney disease.

If a patient has hypertensive chronic kidney disease and acute renal failure, an additional code for the acute renal failure is required.

9. a. 3) Hypertensive heart and chronic kidney disease

Assign codes from combination category I13, Hypertensive heart and chronic kidney disease, when both hypertensive kidney disease and hypertensive heart disease are stated in the diagnosis. Assume a relationship between the hypertension and the chronic kidney disease, whether or not the condition is so designated. If heart failure is present, assign an additional code from category I50 to identify the type of heart failure.

The appropriate code from category N18, Chronic kidney disease, should be used as a secondary code with a code from category I13 to identify the stage of chronic kidney disease.

See Section I.C.14 Chronic kidney disease

The codes in category I13, Hypertensive heart and chronic kidney disease, are combination codes that include hypertension, heart disease and chronic kidney disease. The Includes note at I13 specifies that the conditions included at I11 and I12 are included together in I13. If a patient has hypertension, heart disease and chronic kidney disease, then a code from I13 should be used, not individual codes for hypertension, heart disease and chronic kidney disease, or codes from I11 or I12.

Example: CKD, stage 3, with CHF due to Hypertension is coded to I113.0 (Hypertensive heart and chronic kidney disease with CHF, Stage 3 CKD), I50.9 (Heart failure, unspecified), and N18.3 (CKD, Stage 3).

9. a. 4) Hypertensive cerebrovascular disease

For hypertensive cerebrovascular disease, first assign the appropriate code from categories I60-I69, followed by the appropriate hypertension code.

9. a. 5) Hypertensive retinopathy

Subcategory H35.0, Background retinopathy and retinal vascular changes, should be used with a code from category I10-I15, Hypertensive disease to include the systemic hypertension. The sequencing is based on the reason for the encounter.

9. a. 6) Hypertension, secondary

Secondary hypertension is due to an underlying condition. Two codes are required: one to identify the underlying etiology and one from category I14 to identify the hypertension. Sequencing of codes is determined by the reason for admission/encounter.

9. a. 7) Hypertension, transient

Assign code R03.0, Elevated blood pressure reading without diagnosis of hypertension, unless patient has an established diagnosis of hypertension. Assign code O13.-, Gestational [pregnancy-induced] hypertension without significant proteinuria, or O14.-, Pre-eclampsia, for transient hypertension of pregnancy.

9. a. 8) Hypertension, controlled

This diagnostic statement usually refers to an existing state of hypertension under control by therapy. Assign the appropriate code from categories I10-I15, Hypertensive diseases.

9. a. 9) Hypertension, uncontrolled

Uncontrolled hypertension may refer to untreated hypertension or hypertension not responding to current therapeutic regimen. In either case, assign the appropriate code from categories I10-I15, Hypertensive diseases.

9. b. Atherosclerotic coronary artery disease and angina

I-10 has combination codes for atherosclerotic heart disease with angina pectoris. The subcategories for these codes are I25.11, Atherosclerotic heart disease of native coronary artery with angina pectoris and I25.7, Atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris.

When using one of these combination codes it is not necessary to use an additional code for angina pectoris. A causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris, unless the documentation indicates the angina is due to something other than the atherosclerosis.

Example: A patient is diagnosed with CAD and Angina with no previous history of a CABG. The correct code is I25.19 (ASHD of Native Coronary Artery with other forms of Angina Pectoris).

If a patient with coronary artery disease is admitted due to an AMI, the AMI should be sequenced before the coronary artery disease.

See Section I.C.9. Acute myocardial infarction (AMI)

9. c. Intraoperative and post-procedural cerebrovascular accident

Medical record documentation should clearly specify the cause-and-effect relationship between the medical intervention and the cerebrovascular accident in order to assign a code for intraoperative or post-procedural cerebrovascular accident.

Proper code assignment depends on whether it was an infarction or hemorrhage and whether it occurred intraoperatively or postoperatively. If it was a cerebral hemorrhage, code assignment depends on the type of procedure performed.

9. d. 1(Category I69, sequelae of cerebrovascular disease

Category I69 is used to indicate conditions classifiable to categories I60-I67 as the causes of sequel (neurologic deficits), they themselves classified elsewhere. These “late effects” include neurologic deficits that persist after initial onset of conditions classifiable to categories I60-I67. The neurologic deficits caused by cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition classifiable to categories I60-I67.

Codes from category I69, Sequelae of cerebrovascular disease, that specify hemiplegia, hemiparesis and monoplegia identify whether the dominant or nondominant side is affected. Should the affected side be documented, but not specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows:

9. d. 2) Codes from category I69 with codes from I60-I67

Codes from category I69 may be assigned on a health care record with codes from I60-I67, if the patient has a current cerebrovascular disease and deficits from an old cerebrovascular disease.

9. d. 3) Codes from category I69 and Personal history of transient ischemic attack (TIA) and cerebral infarction (Z86.73)

Codes from category I69 should not be assigned if the patient does not have neurologic deficits.

See Section I.C.21.4 History (of) for use of personal history codes

9. e. 1) Acute myocardial infarction (AMI) --ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI)

The ICD-10-CM codes for AMI identify the site, such as anterolateral wall or true posterior wall. Subcategories I21.0-I21.2 and code I21.3 are used for STEMI. Code I21.4, NSTEMI myocardial infarction, is used for NSTEMI and nontransmural MIs.

If NSTEMI evolves to STEMI, assign the STEMI code. If STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as STEMI.

For encounters occurring while the myocardial infarction is equal to, or less than, four weeks old, including transfers to another acute setting or a post-acute setting, and the patient requires continued care for the myocardial infarction, codes from category I21 may continue to be reported. For encounters after the 4 week time frame and the patient is still receiving care related to the MI, the appropriate aftercare code should be assigned, rather than a code from category I21. For old or healed MIs not requiring further care, code I25.2, Old myocardial infarction, may be assigned.

9. e. 2) Acute myocardial Infarction, unspecified

Code I21.3, STEMI of unspecified site, is the default for the unspecified term acute myocardial infarction. If only STEMI or transmural MI without the site is documented, query the provider as to the site, or assign code I21.3.

9. e. 3) AMI documented as nontransmural or subendocardial but site provided

If an AMI is documented as nontransmural or subendocardial, but the site is provided, it is still coded as a subendocardial AMI.

See Section I.C.21.3 for information on coding status post administration of tPA in a different facility within the last 24 hours.

9. e. 4) Subsequent acute myocardial infarction

A code from category I22, Subsequent STEMI and NSTEMI, is to be used when a patient who has suffered an AMI has a new AMI within the 4 week time frame of the initial AMI. A code from category I22 must be used in conjunction with a code from category I21. The sequencing of the I22 and I21 codes depends on the circumstances of the encounter.

Example: A patient is being treated for an Acute Non-ST Anterior Wall MI which she suffered 5 days ago. The patient also has Atrial Fibrillation. The correct diagnoses are: I21.4 (Non-ST Elevation (NSTEMI) Myocardial Infarction) and I48.91 (Unspecified Atrial Fib).

The next I-10 corner will be featured around a PCS discussion for Chapter 9: Diseases of the Circulatory System (I00-I99)

In the last I-10 Corner article we covered Part One of Musculoskeletal System in ICD-10-CM. For this week, Part Two will address the procedures for the Musculoskeletal System. For the PCS portion, we will cover some key points and guidelines that are necessary for you to assign the correct ICD-10-PCS codes.

For those of you who attended AHIMA’s ICD-10-CM/PCS training classes you already know the underlying meaning of the title. In ICD-10-PCS, this sentence helps us to identify the names of the seven characters and what they represent for a code in PCS. Notice below the sharp contrast between ICD-9 and ICD-10-PCS for a left total knee replacement:

ICD-9-CM: Total Knee Replacement, 81.54

ICD-10-PCS: Left Total Knee Replacement, with insertion of total knee prosthesis 0SRD0JZ

‍ICD-10-PCS for the Musculoskeletal System – Part 2

11 of the 31 Body Systems pertain to the MS System                  

• Muscles
• Tendons
• Bursae and Ligaments
• Head and facial bones
• Upper bones
• Lower bones
• Upper joints
• Lower joints
• Anatomical regions general
• Anatomical regions upper extremities
• Anatomical regions lower extremities Example of Root Operation Groups typically seen with Chapter 13
• Excision – Biopsy of muscle
• Detachment – Below knee amputation
• Division - Osteotomy
• Release – Carpal tunnel release
• Reattachment – Reattachment of hand
• Reposition – Fracture reduction
• Transfer – Tendon transfer
• Replacement – Total hip replacement
• Supplement – Placing a new acetabular liner in a previous hip replacement
• Revision – Re-cementing hip prosthesis
• Fusion – Spinal fusion
• Inspection – Diagnostic Arthroscopy
• laterality
• type and material the device is made of, i.e., synthetic substitute or autologous tissue substitute
• specific surface replaced in partial hip and knee replacements
• cemented vs. un-cemented

Arthroplasty of Hip and Knee

Often, the hip bearing surface was not known and was not reported. In ICD-10-PCS, you must know the type of surface for arthroplasty of the hips and knees in order to assign the correct procedure code.

You need to know:

• laterality
• type and material the device is made of, i.e., synthetic substitute or autologous tissue substitute
• specific surface replaced in partial hip and knee replacements
• cemented vs. un-cemented

ICD-10-PCS Coding Guideline

Conventions

A11

Many of the terms used to construct PCS codes are defined within the system. It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear.

Example: When the physician documents “partial resection” the coder can independently correlate “partial resection” to the root operation Excision without querying the physician for clarification.

B3. Root Operation

Overlapping Body Layers

B3.5

If the root operations Excision, Repair or Inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded.

Example: Excisional debridement that includes skin and subcutaneous tissue and       muscle is coded to the muscle body part.

Fusion Procedures of the Spine

B3.10a

The body part coded for a spinal vertebral joint(s) rendered immobile by a spinal fusion procedure is classified by the level of the spine (e.g. thoracic). There are distinct body part values for a single vertebral joint and for multiple vertebral joints at each spinal level.

Example: Body part values specify Lumbar Vertebral Joint, Lumbar Vertebral Joints, 2 or More and Lumbosacral Vertebral Joint.

B3.10b

If multiple vertebral joints are fused, a separate procedure is coded for each vertebral joint that uses a different device and/or qualifier.

Example: Fusion of lumbar vertebral joint, posterior approach, anterior column and fusion of lumbar vertebral joint, posterior approach, posterior column are coded separately.

B3.10c

Combinations of devices and materials are often used on a vertebral joint to render the joint immobile. When combinations of devices are used on the same vertebral joint, the device value coded for the procedure is as follows:

• If an interbody fusion device is used to render the joint immobile (alone or containing other material like bone graft), the procedure is coded with the device value Interbody Fusion Device
• If bone graft is the only device used to render the joint immobile, the procedure is coded with the device value Nonautologous Tissue Substitute or Autologous Tissue Substitute
• If a mixture of autologous and nonautologous bone graft (with or without biological or synthetic extenders or binders) is used to render the joint immobile, code the procedure with the device value Autologous Tissue Substitute

Examples: Fusion of a vertebral joint using a cage style interbody fusion device containing morsellized bone graft is coded to the device Interbody Fusion Device.

Fusion of a vertebral joint using a bone dowel interbody fusion device made of cadaver bone and packed with a mixture of local morsellized bone and demineralized bone matrix is coded to the device Interbody Fusion Device.

Fusion of a vertebral joint using both autologous bone graft and bone bank bone graft is coded to the device Autologous Tissue Substitute.

Release procedures

B3.13

In the root operation Release, the body part value coded is the body part being freed and not the tissue being manipulated or cut to free the body part.

Example:         Lysis of intestinal adhesions is coded to the specific intestine body part value.

Release vs. Division

B3.14

If the sole objective of the procedure is freeing a body part without cutting the body part, the root operation is Release. If the sole objective of the procedure is separating or transecting a body part, the root operation is Division.

Examples: Freeing a nerve root from surrounding scar tissue to relieve pain is coded to the root operation Release. Severing a nerve root to relieve pain is coded to the root operation Division.

B4. Body Part

Branches of body parts

B4.2

Where a specific branch of a body part does not have its own body part value in PCS, the body part is coded to the closest proximal branch that has a specific body part value.

Example: A procedure performed on the popliteus tendon is coded to the lower leg tendon body part.

Tendons, ligaments, bursae and fascia near a joint

B4.5

Procedures performed on tendons, ligaments, bursae and fascia supporting a joint are coded to the body part in the respective body system that is the focus of the procedure. Procedures performed on joint structures themselves are coded to the body part in the joint body systems.

Example: Repair of the anterior cruciate ligament of the knee is coded to the knee bursae and ligament body part in the bursae and ligaments body system.

Knee arthroscopy with shaving of articular cartilage is coded to the knee joint body part in the Lower Joints body system.

Skin, subcutaneous tissue and fascia overlying a joint

B4.6

If a procedure is performed on the skin, subcutaneous tissue or fascia overlying a joint, the procedure is coded to the following body part:

• Shoulder is coded to Upper Arm
• Elbow is coded to Lower Arm
• Wrist is coded to Lower Arm
• Hip is coded to Upper Leg
• Knee is coded to Lower Leg
• Ankle is coded to Foot

Fingers and toes

B4.7

If a body system does not contain a separate body part value for fingers, procedures performed on the fingers are coded to the body part value for the hand. If a body system does not contain a separate body part value for toes, procedures performed on the toes are coded to the body part value for the foot.

Example: Excision of finger muscle is coded to one of the hand muscle body part values in the Muscles body system.

ICD-10-CM Chapter 13 Musculoskeletal System – Part 1
In the last I-10 Corner article we covered Infectious and Parasitic Diseases. Our next chapter to review is the Musculoskeletal System which we will cover in two parts. Part one will cover ICD-10-CM and Part two will address ICD-10-PCS. In ICD-10-CM, we will highlight some changes we thought were important for you to be aware of. For instance, The Musculoskeletal System chapter received numerous code expansions partly due to ‘laterality’ being required for code assignment.

Example: Right Medial Epicondylitis

First, take a look below and see how the subchapters or blocks have expanded.

This chapter contains the following blocks:

M00-M02        Infectious Arthropathies

M05-M14        Inflammatory Polyarthropathies

M15-M19        Osteoarthritis

M20-M25        Other Joint Disorders

M26-M27        Dentofacial Anomalies [including malocclusion] and Other Disorders of Jaw

M30-M36        Systemic Connective Tissue Disorders

M40-M43        Deforming Dorsopathies

M45-M49        Spondylopathies

M50-M54        Other Dorsopathies

M60-M63        Disorders of Muscles

M65-M67        Disorders of Synovium and Tendon

M70-M79        Other Soft Tissue Disorders   

M80-M85        Disorders of Bone Density and Structure

M86-M90        Other Osteopathies

M91-M94        Chondropathies

New in Chapter 13

• Big code expansion in this chapter to identify type, site and laterality
• Clarifications for coding joint vs. specific affected bone (see coding guideline)
• Acute traumatic vs. chronic/recurrent conditions are defined with coding instructions
• Osteoporosis and Pathological Fracture information now included in ICD-10-CM Coding Guidelines
• Many codes relocated from other chapters in ICD-9-CM, i.e., Gout, Osteomalacia and Malocclusion
• Lots of other instructions such as:
• Use an external cause code
• Code first underlying disease
• Code also any associated underlying condition
• Use additional code to identify
• Code first poisoning due to drug or toxin
• Code first underlying neoplasm
• Use additional code to identify infectious agent
• Instructions for coding pathological fractures, needs 7th digit extension to identify episode of care (see below)
  Example:
  A Initial encounter for fracture
  D Subsequent encounter for fracture with routine healing
  G Subsequent encounter for fracture with delayed healing
  K Subsequent encounter for fracture with nonunion
  P Subsequent encounter for fracture with Malunion
  S Sequela
• Intraoperative and Postprocedural Complications of the Musculoskeletal System located within this chapter
• Acute traumatic fractures reassigned to Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes

ICD-10-CM Coding Guidelines

1. Site and laterality
   Most of the codes within Chapter 13 have site and laterality designations. The site represents the bone, joint or the muscle involved. For some conditions where more than one bone, joint or muscle is usually involved, such as osteoarthritis, there is a “multiple sites” code available. For categories where no multiple site code is provided and more than one bone, joint or muscle is involved, multiple codes should be used to indicate the different sites involved.
2. Bone versus joint
   For certain conditions, the bone may be affected at the upper or lower end, (e.g., avascular necrosis of bone, M87, Osteoporosis, M80, M81). Though the portion of the bone affected may be at the joint, the site designation will be the bone, not the joint.
3. Acute traumatic versus chronic or recurrent musculoskeletal conditions
   Many musculoskeletal conditions are a result of previous injury or trauma to a site, or are recurrent conditions. Bone, joint or muscle conditions that are the result of a healed injury are usually found in chapter 13. Recurrent bone, joint or muscle conditions are also usually found in chapter 13. Any current, acute injury should be coded to the appropriate injury code from chapter 19. Chronic or recurrent conditions should generally be coded with a code from chapter 13. If it is difficult to determine from the documentation in the record which code is best to describe a condition, query the provider.
4. Coding of Pathologic Fractures
   Seventh (7th) character A is for use as long as the patient is receiving active treatment for the fracture. Examples of active treatment are: surgical treatment, emergency department encounter, evaluation and treatment by a new physician. Seventh (7th) character D is to be used for encounters after the patient has completed active treatment. The other 7th characters, listed under each subcategory in the Tabular List, are to be used for subsequent encounters for treatment of problems associated with the healing, such as malunions, nonunions, and sequelae.
   Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes.
   See Section I.C.19. Coding of traumatic fractures.
5. Osteoporosis
   Osteoporosis is a systemic condition, meaning that all bones of the musculoskeletal system are affected. Therefore, site is not a component of the codes under category M81, Osteoporosis without current pathological fracture. The site codes under category M80, Osteoporosis with current pathological fracture, identify the site of the fracture, not the osteoporosis.
6. Osteoporosis without current pathological fracture
   Category M81, Osteoporosis without current pathological fracture, is for use for patients with osteoporosis who do not currently have a pathologic fracture due to the osteoporosis, even if they have had a fracture in the past. For patients with a history of osteoporosis fractures, status code Z87.310, Personal history of (healed) osteoporosis fracture, should follow the code from M81.
7. Osteoporosis with current pathological fracture
   Category M80, Osteoporosis with current pathological fracture, is for patients who have a current pathologic fracture at the time of an encounter. The codes under M80 identify the site of the fracture. A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.

Musculoskeletal System examples of why you need to brush up on your Anatomy and Physiology

Infectious Arthropathy - may also be referred to as Pyogenic or Septic Arthritis. Organisms invade the joint by:

• direct infection of joint; example: infected surgical hip wound
• indirect contamination; infection in bloodstream

Enteropathic Arthropathy - diseases of joints linked to gastrointestinal tract inflammation such as Inflammatory Bowel Disease or Crohn’s Disease.

Palindromic Rheumatism - is a sudden onset of inflammation in one or several joints. Lasts a few hours to a few days and is suddenly gone.

Dorsopathies - is a general term referring to conditions affecting the back or spine. Conditions such as Scoliosis, Spondylosis and Intervertebral disc disorders are included here.

Fragility Fracture -sustained with trauma no more than a fall from a standing height or less that occurs under circumstances that would not cause a fracture in a normal healthy bone.

Skeletal Fluorosis - this is excessive intake of fluoride causing the bones to become hardened and vulnerable to fractures.

In closing, the more you study this chapter the less you will feel overwhelmed. Once you do this, you will become familiar with the clinical information so that you can educate your physicians of what is required for more specific documentation.

Don’t forget to consult Coding Clinic for ICD-10-CM/PCS information!

Methicillin-resistent Staphylococcus Aureus (MRSA) Infection

MRSA is a very tough to treat infection caused by a strain of staph bacteria that has become resistant to commonly used antibiotics generally used to treat ordinary staph infections.

• Can be life threatening.
• MRSA infection can be contagious by:
• Person-to-person / skin-to-skin contact.
• Coming in contact with materials or surfaces touched by a MRSA infected person or carrier

• A “carrier” is a person that that harbors the organism (MRSA) without manifesting symptoms of the infection.
• A carrier (Z22.322) can transmit the MRSA infection.
• Requires “isolation” while being treated.
• Typically causes skin sores and infections such as:
• Abscess
• Boils
• Stys
• Ulcers
• Cellulitis
• Impetigo
• Carbuncles
• MRSA can quickly spread once the germ has entered into the body.
• Bones
• Joints
• Bloodstream (Sepsis - )
• Muscle, Fascia (Necrotizing Fasciitis)
• Organs
• Brain (Meningitis)
• Heart (Endocarditis)
• Lungs (Pneumonia)
• Kidneys (UTI associated with Foley Catheter)

Health Care-Associated MRSA (HA-MRSA)

• Affects people who have been treated in a health-care facility such as:
• Hospitals
• Nursing Homes
• Rehab facilities
• Dialysis center
• Physician’s office
• Commonly seen in patients with:
• Weakened immune system from:
• Illness
• Long term medication therapy
• Cancer treatment
• Surgical history within a year
• Lengthy admissions to hospitals and/or long-term care facilities
• Chronic Kidney Disease on hemodialysis
• History of IV drug use

Community-Associated MRSA (CA_MRSA)

• MRSA showing up in healthy people outside of a health care setting
• Healthy people who may also be at risk:
• Military
• Children at day-care
• Athletes
• Prison inmates
• People who share items such as towels and razors
• People who have gotten tattoos and/or piercings

Signs and Symptoms

• Non-healing wound
• Headache
• Fatigue
• Rash
• Fever and chills
• Low blood pressure
• Shortness of breath
• Chest pain
• Weakness

Treatment

MRSA is resistant to some antibiotics but is still a treatable condition. There are some kinds of antibiotics that still work.

• Treatment often starts with Bactrim and Vancomycin.
• Other antibiotics used are:
• Clindamycin
• Minocycline
• Tygacil
• Cubicin
• Zyvox
• Synercid
• Unfortunately, even with these medications, there is emerging antibiotic resistance developing.
• Antibiotics are not always necessary.
• With early detection, in cases of a skin abscess or boil caused by MRSA, an incision and drainage may be all that is necessary.

Selection and Sequencing of MRSA Codes

Coding Guidelines:

• Section I.C.1.e.1.a. – Combination Codes for MRSA Infection:   When a patient is diagnosed with an infection that is due to Methicillin Resistant Staphylococcus Aureus (MRSA), and that infection has a combination code that includes the causal organism (e.g., Sepsis, Pneumonia) assign the appropriate combination code for the condition (e.g., code A41.02, Sepsis due to Methicillin Resistant Staphylococcus Aureus or code J15.212, Pneumonia due to Methicillin Resistant Staphylococcus Aureus). Do not assign code B95.62, Methicillin Resistant Staphylococcus Aureus Infection as the cause of diseases classified elsewhere, as an additional code because the combination code includes the type of infection and the MRSA organism. Do not assign a code from subcategory Z16.11, Resistance to Penicillins, as an additional diagnosis.
• Section I.C.1.e.1.b. – Other Codes for MRSA Infection:   When there is documentation of a current infection (e.g., wound infection, stitch abscess, urinary tract infection) due to MRSA, and that infection does not have a combination code that includes the causal organism, assign the appropriate code to identify the condition along with code B95.62, Methicillin Resistant Staphylococcus Aureus Infection as the cause of diseases classified elsewhere for the MRSA infection. Do not assign a code from subcategory Z16.11, Resistance to Penicillins.
• Section I.C.e.1.c. – Methicillin Susceptible Staphylococcus Aureus (MSSA) and MRSA Colonization:   The condition or state of being colonized or carrying MSSA or MRSA is called colonization or carriage, while an individual person is described as being colonized or being a carrier. Colonization means that MSSA or MRSA is present on or in the body without necessarily causing illness. A positive “MRSA screen positive” or “MRSA nasal swab positive”.
• Assign code Z22.322, Carrier or suspected carrier of Methicillin Resistant Staphylococcus Aureus, for patients documented as having MRSA colonization. Assign code Z22.321, Carrier or suspected carrier of Methicillin Susceptible Staphylococcus Aureus, for patient documented as having MSSA colonization. Colonization is not necessarily indicative of a disease process or as the cause of a specific condition the patient may have unless documented as such by the provider.

• Section I.C.1.e.1.d. – MRSA Colonization and Infection:   If a patient is documented as having both MRSA colonization and infection during a hospital admission, code Z22.322, Carrier or suspected carrier of Methicillin Resistant Staphylococcus Aureus, and a code for the MRSA infection may both be assigned.

Methicillin-susceptible Staphylococcus Aureus (MSSA) Infection

Another commonly known infection caused by the staph bacteria is Methicillin-susceptible Staphylococcus Aureus (MSSA). MSSA is able to be treated with most penicillin based antibiotics and has yet become resistant to the more common antibiotics enabling the treatment to be cleared up easier than it would be if it was resistant in the case of MRSA.

MSSA can be as serious as MRSA. Signs and symptoms are the same.

The implementation date of ICD-10-CM/PCS is fast approaching. ICD-10-CM/PCS will require coders to possess an in-depth knowledge and understanding of anatomy & physiology and pathophysiology.   Coders’, who are well-versed on how a body in both the healthy state as well as during the disease process should function, will be better prepared to query providers for clarification when additional documentation is required.  In turn, a coder will be able to make appropriate correlations when reviewing documentation and be able to avoid needless queries.

Sepsis, Severe Sepsis and Septic Shock

In ICD-10-CM, there are some terminology changes and revisions. An example in Chapter 1 is that the term Sepsis has replaced Septicemia.

Sepsis is a potential life threatening disease in which the body has a reaction to the presence of pathogenic organisms or toxins that have been released in the bloodstream and tissues.

• Also call “blood poisoning”.
• Patients with Sepsis will appear very sick.
• Diagnosis based on clinical signs and symptoms of infection or systemic inflammation and not on location of infection.
• Sepsis can be diagnosed without positive blood cultures especially when the patient has recently been treated with antibiotics.
• Signs and symptoms can be different from person to person.
• Elderly 80 year old female with UTI may have fever, tachycardia with an increase in white blood count
• A 3 year old child with appendicitis may have low body temp and low white count.
• The same signs and symptoms for Sepsis can also be caused by other disorders.

Coders should never code Sepsis based solely on clinical signs and symptoms alone. Provider clarification and documentation is imperative for the correct code assignment.

Note: When coding Sepsis, it is very important to read the Coding Guidelines and to stay abreast with the ever-changing quarterly updates.

Sepsis has 3 stages. Each stage is indicative of a higher level of severity.

1. Sepsis:     Coding Guideline – Section I.C.1.d.1.a.
2. Assign the appropriate code for the underlying systemic infection showing the type of causal organism. Example:   E coli Sepsis - A41.51.
3. Assign code A41.9 for Sepsis without a specified organism documented.
4. Signs and Symptoms – Patient must exhibit at least 2 of the following:
5. Fever above 100.4 or below 95.
6. Heart rate (tachycardia) higher than 90 beats per minute.
7. Respiratory rate higher than 20 breaths per minute or PaCO2<32 mmHg (4.3 kPa)
8. Confirmed or probable infection.
9. Shaking chills.
10. Leukocytosis
11. Greater than 10% immature bands
12. Hemorrhagic skin rash
13. Hypotension
14. The term “Urosepsis” is not to be considered synonymous with “Sepsis”.
15. There will no longer be a default code for Urosepsis.
16. Provider must be queried for clarification on whether the patient has Sepsis and/or UTI.
17. Severe Sepsis:     Coding Guideline – Section I.C.1.d.1.b.
18. Sepsis with an associated acute organ dysfunction/failure.
19. Coding Guideline – Section I.C.1.d.1.a.iv
20. Documentation must indicate that the acute organ dysfunction is associated with the Sepsis.
21. Query provider if documentation does not clearly show whether the acute organ dysfunction is associated to Sepsis or another condition.
22. Requires a minimum of two codes:
23. Code for underlying systemic infection.
24. Following code from subcategory R65.2.
25. Additional code should also be assigned to identify specific acute organ dysfunction/failure.
26. Patient’s usually treated in ICU.
27. Signs and Symptoms – Patient must exhibit at least 2 of the signs/symptoms listed above and at least one of the following:
28. Significant decrease in urine output.
29. Altered mental status (AMS).
30. Decrease in platelet count.
31. Difficulty breathing.
32. Abdominal pain.
33. Acidosis
34. Nausea and vomiting
35. Diarrhea
36. Cold, clammy and pale skin
37. Septic Shock:     Coding Guideline – Section I.C.1.d.2.
38. Severe Sepsis with extreme hypotension lasting for more than one hour without the return to normal pressure following adequate IV fluid infusion or the need for vasopressors/inotropes to maintain blood pressure.
39. Code for the underlying systemic infection should be sequenced first.
40. Assign following code R65.21 – Severe Sepsis with Septic Shock.
41. Severe Sepsis with Septic Shock must be assigned if Septic Shock is documented in the medical record, even if the term Severe Sepsis is not documented.

Sepsis due to a Post-procedural Infection:     Coding Guideline – Section I.C.1.d.5.

• Code assignment is based on provider documentation clarifying a relationship between the infection and the procedure.
• A code for the post-procedure infection should be assigned first – Example:
• T83.51 - Infection and Inflammatory Reaction due to Indwelling Urinary Catheter
• T80.21 – Infection due to Central Venous Catheter
• Appropriate code from subcategory R65.2 should be assigned if patient is diagnosed with Severe Sepsis along with a code to identify the associated acute organ dysfunction.

Patients at Risk

• Elderly
• Very young babies
• Diabetics
• Recently hospitalized and/or recent invasive surgical procedures
• With wounds or injuries, such as burns
• Weakened immune systems secondary to illnesses and/or drug therapy

Common Sources of Infection

• Urinary Catheters
• Surgical incisions
• Open wounds such as pressure ulcers, burns etc.
• Invasive devices such as IV catheters, breathing tubes etc.
• Surgical drains
• Prosthetic devices

Common Body Sites Where Infections May Start – (Examples)

• Bones – (Diabetics with Osteomyelitis)
• Bloodstream
• Intestines – (Diverticulitis, Peritonitis)
• Kidneys – (Urinary Tract Infection, Pyelonephritis)
• Lungs – (Pneumonia)
• Pancreas – (Pancreatitis)
• Skin – (Cellulitis, Pressure Ulcers)

The implementation date of ICD-10-CM/PCS is fast approaching. ICD-10-CM/PCS will require coders to possess an in-depth knowledge and understanding of anatomy & physiology and pathophysiology.   Coders’, who are well-versed on how a body in both the healthy state as well as during the disease process should function, will be better prepared to query providers for clarification when additional documentation is required.  In turn, a coder will be able to make appropriate correlations when reviewing documentation and be able to avoid needless queries.

This month MMP will focus on some of the important changes and guidelines covering Chapter One “Certain Infectious and Parasitic Diseases”.

Chapter 1 is divided into 22 separate blocks covering two alpha characters A00-B99 and includes:

• Diseases generally recognized as communicable or transmissible as well as a few diseases of unknown but possibly infectious origin.

Type I Excludes:

• Certain localized infections – refer to body system related chapters.
• Influenza and other acute respiratory infections (J00-J22)

Type 2 Excludes:

• Carrier or suspected carrier of infectious disease (Z22.-)

A separate subchapter was created for “Infections with a Predominantly Sexual Mode of Transmission” (A50-A64) to appropriately group these type diseases together:

• Human Immunodeficiency Virus (HIV) is excluded in this range of codes.

For cases with infections shown to have an associated drug resistance, code Z16 should be assigned in addition to the infection code to show the associated drug resistance.                      

• Coding Guideline I.C 1.c. – Infections Resistant to Antibiotics:  Many bacterial infections are resistant to current antibiotics. It is necessary to identify all infections documented as antibiotic resistant.

Streptococcal Sore Throat has been relocated from Chapter 1 to Chapter 10 – Diseases of the Respiratory System.

Tuberculosis (TB):  

• ICD-10-CM will not ask for information denoting how the disease was identified.
• The codes for Tuberculosis have been restructured and consolidated. Assignment is now based on anatomical site or type.

Intestinal Infections:

• Codes will now identify type of infection.
• Viral
• Bacterial
• Fungal or parasitic/amebic
• Options available for “Other “ and “Unspecified”

Categories B95.0-B99.9 are supplementary codes to identify the infectious agent(s) in diseases classified elsewhere in which there is no organism identified as part of the infection code.

• Refer to Coding Guideline I.C.1.b.

Human Immunodeficiency Virus (HIV) Infections

HIV is the virus that can lead to AIDS (Acquired Immunodeficiency Syndrome).   People with this illness are much more vulnerable to infections due to the attack and alteration to their immune system. This is prone to get worse as the disease progresses. The human body is not capable of fighting off this virus. Once a person is infected with HIV, it is an affliction for the rest of their life.

HIV is found in the body fluids of an infected person and can be transmitted:

• From one person to another through blood-to-blood and/or sexual contact.
• Newborn infants can acquire HIV:
• During pregnancy
• Through delivery
• Through breast feeding
• Blood transfusion
• Sharing hypodermic needles

There is a subcategory and four codes to classify the HIV virus in ICD-10-CM.

B20 - Human Immunodeficiency Virus (HIV) disease

Assign code B20 as the principal diagnosis when a patient is admitted with an HIV-related condition. An additional diagnosis code should be used to identify all reported manifestations of HIV infection.

• Refer to Coding Guideline I.C.1.a.2.a.
• Code only confirmed cases of HIV infection.
• Confirmation does not require a positive serology or culture for HIV. The physician’s diagnostic statement is sufficient.
• Refer to Coding Guideline I.C. 1.a.1.
• People with HIV can acquire many infections that are called “Opportunistic Infections” or OIs.

Includes:

• Acquired Immune Deficiency Syndrome (AIDS)
• AIDS-related Complex (ARC)
• HIV Infection, Symptomatic

Excludes Type 1:

• Asymptomatic Human Immunodeficiency Virus (HIV) Infection Status (Z21)
• Exposure to HIV virus (Z20.6)
• Inconclusive Serologic Evidence of HIV (R75)

Z21 - Asymptomatic Human Immunodeficiency Virus (HIV) Infection Status

Code Z21 is used for reporting a patient diagnosed with a positive HIV status but has never been diagnosed with any type of manifestation or OI.

• Includes HIV positive NOS
• Once a patient has developed an HIV-related OI, the patient should always be assigned code B20 for any future admission/encounter.
• Code Z21 should never be assigned again for a patient diagnosed with HIV/AIDS even if there is no infection or HIV related condition during that present admission.
• Codes B20 and Z21 should never be assigned together during the same admission.

R75 - Inconclusive laboratory evidence of Human Immunodeficiency Virus (HIV)

• An inconclusive serology test, but no definitive diagnosis or manifestation of the HIV infection.

Z20.6 - Exposure to HIV Virus

This code is assigned only when a patient has been exposed or may have come in contact with the HIV virus.

Some Common HIV Infections:   (this list is not all or inclusive)

• Pneumocystis pneumonia (PCP) - Serious infection which causes inflammation and fluid buildup in the lungs.
• Cytomegalovirus - An opportunistic infection which takes advantage of a patient’s weakened immune system.
• Tuberculosis (TB) - Leading cause of death for people infected with HIV.
• Mycobacterium Avium Complex (MAC) - Usually happens only after a patient has been diagnosed with AIDS and when their CD4 cell counts drop below 50.
• Dementia - AIDS dementia is caused by the HIV virus itself, not by the opportunistic infections.
• AIDS Wasting Syndrome - Occurs when a patient with AIDS has lost at least 10% of their body weight -- especially muscle. The patient could experience at least 30 days of diarrhea, extreme weakness and fever that's not related to an infection.
• Non-Hodgkin’s Lymphoma - As a result of a weakened immune system, a patient is prone to develop certain cancers.
• Lipodystrophy - Also known as “fat redistribution”.   This is when the body has problems in the way it produces, uses, and stores fat.
• Kaposi’s Sarcoma (KS) - Type of cancer affecting mainly the skin, mouth, and lymph nodes (infection-fighting glands). Other organs such as the lungs and gastrointestinal tract can be affected as well.

A list of Meds currently available in the US

‍Note: When coding the HIV Disease and Sepsis, it is very important to read and familiarize yourself with the Coding Guidelines.