ICD-10 Orientation In Post Acute Care (Part II)Rhonda Anderson, RHIA

Anderson Health Information Systems, Inc.

Location, Date, Time

•Northern CaliforniaFairfield Post Acute Rehab

March 20, 2014

9:00am – 3:00pm

• Southern CaliforniaGarden View Post Acute Rehab

April 9, 2014

9:00am – 3:00pm2

Presenters

• Staci LePage, RHIT

Email: stacilepage@comcast.net

Mobile: 916-202-5797

•Khaleelah Wagner, RHIA

Email: khaleelahwagner@hotmail.com

Mobile: 909-717-71023

General Coding Guidelines

• Locating a code in the ICD-10-CM• Level of detail coding• Code/codes from A00.0 through Z99.8• Signs and symptoms are acceptable for

reporting purposes when a related diagnosis has not been established• Signs and symptoms that are associated

routinely with a disease process should not be assigned as additional codes

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General Coding Guidelines -2

•Acute and Chronic Conditions• If the same condition is described as both acute

and chronic, and separate subentries exist, code both and sequence the acute code 1st

• Combination Code• Is a single code used to classify two diagnoses,

or• A diagnosis with an associated complication or

manifestation 5

General Coding Guidelines -3

• Late Effects (Sequela)• Residual effect (condition produced) after the

acute phase of an illness/injury has terminated• There is no time limit on when a sequela code

can be used• Coding generally requires two codes• Condition/nature of the late effect is sequenced

1st; the sequela code is sequenced 2nd

• Exception is when the sequela code is part of the 4th, 5th or 6th character of a code

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General Coding Guidelines -4

• Late Effects (Sequela)• The code for the acute phase of an illness or

injury that led to the sequela is never used with a code for the late effect

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General Coding Guidelines -5

• BMI & Pressure Ulcer Stages Documentation• Assignment may be based on medical record

documentation from clinicians who are not the patient’s providers• Dietitian often documents the BMI and nurse

often documents the pressure ulcer stages• The associated diagnosis must be documented by

the patient’s provider• BMI codes should only be reported as secondary

diagnoses8

Complications Of Care

• Code assignment is based on the provider’s documentation •Not all conditions that occur during or

following surgery are classified as complications•When admission is for treatment of a

complication, the complication code is sequenced as the principal diagnosis

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Complications of Care -2

•Must be a cause-and-effect relationship between the care provided, the condition and an indication in the documentation that it is a complication

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OSHPD / Principal Diagnosis Definition•Uniform Hospital Discharge Data Set

(UHDDS)/Principal diagnosis is defined as that condition established, after study, to be the chief cause of the admission of the patient to the facility for care• Condition must be identified in the H&P or

documented in the current inpatient medical record

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Acute Hospital – Principal Dx

•What that means to a SNF• Acute hospital diagnosis• Late effects of the acute diagnosis• Reason for the admission to Acute and the SNF

(bundled payments) – one facility gets paid and the other is paid by that facility.

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Principal Diagnosis

• Two or more interrelated conditions with each potentially meeting the definition• Diseases in the same ICD-10-CM chapter or

manifestations characteristically associated with a certain disease, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, or the code book indicate otherwise

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Principal Diagnosis -2

• Two or more interrelated conditions that equally meet the definition• When two or more diagnoses equally meet the

criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the code book does NOT provide sequencing direction, any one of the diagnoses may be sequenced first

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Other Diagnoses

• Two or more comparative or contrasting conditions• When two or more diagnoses are documented as

“either/or”, they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. • Either diagnosis may be sequenced first.• When a symptom is followed by

contrasting/comparative diagnoses, the symptom code is sequenced first.

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Other Diagnoses -2

• Two or more comparative or contrasting conditions (cont.)• All the contrasting/comparative diagnoses

should be coded as additional diagnoses.• These should never be principal diagnoses

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Signs, Symptoms, Ill-defined Conditions• Codes for symptoms, signs, and ill-defined

conditions – are NOT to be used as a principal diagnosis when a definitive diagnosis has been established.• THIS APPLIES TO SNF, ACUTE and other

health-care locations

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Uncertain Diagnoses

• If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed/established•Applicable only to inpatient admissions to

short-term, acute, long-term care & psychiatric hospitals 18

Sequencing Of Codes

•Determined by the reason for admission/encounter, with the highest acuity diagnoses sequenced 1st

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Specificity Of Coding

•With added laterality, need greater documentation from your MD’s•Hypertensive Retinopathy H35.03_• H35.031 right eye• H35.032 left eye• H35.033 bilateral• H35.039 unspecified (this would be a ?? for

billing most likely!!)• *code also any associated hypertension (I10) 20

Chapter 1 – Infectious & Parasitic Diseases A00-B99• B95 Streptococcus, Staphylococcus, and

Enterococcus as the cause of diseases classified elsewhere• B96 Other bacterial agents as the cause of

diseases classified elsewhere• B97 Viral agents as the cause of diseases

classified elsewhere

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Sepsis

•UROsepsis – The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alpha index.•QUERY THE DOCTOR!!!• Sepsis with organ dysfunction• follow guidelines for severe sepsis

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Chapter 1 – Infectious & Parasitic Diseases A00-B99 -2

• Sepsis (ICD-9 = 995.91)• Unspecified organism, A41.9, if type of infection

is not specified• Severe sepsis R65.2 should not be assigned

unless severe sepsis or acute organ dysfunction is documented

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Sepsis – Severe

• Requires two codes• First code for underlying systemic infection

followed by a code from subcategory R65.2, Severe Sepsis• Casual organism should be documented; if

not – assign A41.9 Sepsis, unspecified organism• Where do we look for this information?

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Sepsis Example

• This long-term multiple sclerosis patient was admitted for continuing long-term antibiotic therapy for a urinary tract infection due to E. coli. •What do we code?

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Sepsis Answers

•N39.0 Infection, urinary tract• B96.20 Infection, E. coli• Z79.2 Long-term use of antibiotics•G35 Sclerosis, multiple• The long-term use code is assigned for use of the

antibiotics. Instructional notes under N39.0 indicate to use an additional code (B95-B97), to identify infectious agent

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Chapter 1 – Infectious & Parasitic Diseases A00-B99 -3

•When a patient is diagnosed with an infection that is d/t MRSA, and that infection has a combination code that includes the causal organism, assign the appropriate combo code:• A41.02 Sepsis d/t MRSA, or• J15.212 Pneumonia d/t MRSA

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Chapter 1 -4

•When a patient is diagnosed with an infection that is d/t MRSA, and that infection has a combination code that includes the causal organism, assign the appropriate combo code:• B95.62 MRSA as the cause of conditions

classified elsewhere • Only used when the infection does not have a combo

code that includes the causal organism28

Chapter 1 -5

•MRSA/MSSA Colonization:• A positive MRSA colonization test may be

documented by the MD as “MRSA screen positive” or “MRSA nasal swab positive”• Assign Z22.322, carrier or suspected carrier of

MRSA• Colonization is not indicative of a disease

process• If patient is documented as having both MRSA

colonization and infection, code both29

Chapter 1 -6

•HIV infections• Code only confirmed cases of HIV infection,

•MD’s diagnostic statement is sufficient• Admit for HIV-related condition, principal

diagnosis should be B20, followed by code for HIV-related condition• Z21 is assigned when the patient w/o any

documentation of symptoms is listed as “HIV positive” or “known HIV” 30

Chapter 2 – Neoplasms C00-D49

• Increase in subcategories from 9, to 21 in ICD-10-CM•Greater specificity by site and laterality• Need to know: upper, lower, overlapping

sites, left, right, etc.• If cancer treatment is done, then a history

code is assigned - Z85.

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Primary Malignancy Previously Excised•When there is no further treatment directed

to a primary site and no evidence of any primary malignancy, the following is coded:• Z85. Personal history of malignant neoplasm

(meant for coding of primary sites only)• Any mention of metastasis to another site is

coded as a malignant secondary neoplasm to that site.

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Chapter 3 – Blood and Blood forming Organs, Certain Immune Disorders D50-D89•D50-D53 Nutritional anemias•D55-D59 Hemolytic anemias•D60-D64 Aplastic and other anemias•D65-D69 Coagulation defects•D70-D77 Other disorders of the blood•D78 Postprocedural complications spleen•D80-D89 Disorders involving immunity

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Chapter 4 – Endocrine, Nutritional, Metabolic E00-E89•Diabetes Mellitus• Combination codes• Includes the type of diabetes, the body system

affected, and the complications affecting that body system• Many codes within a particular category as are

necessary to describe all of the complications of the disease may be used• Sequenced based on the reason for a particular

encounter34

Chapter 4 – Endocrine, Nutritional, Metabolic E00-E89 -2

• E08 Diabetes d/t underlying condition• E09 Drug or chemical induced diabetes• Secondary diabetes is always caused by another

condition or event

• E10 Type I Diabetes Mellitus• E11 Type II Diabetes Mellitus• E13 Other specified Diabetes Mellitus• Z79.4 Long-term use of insulin 35

Type Of Diabetes

• If the type of diabetes is not documented in the record, the default is E11., Type 2 diabetes• If the type is not indicated, but the patient

uses insulin, code E11. Type 2 diabetes + Z79.4 long-term use of insulin• Need to know:• type of DM• body system affected + complications

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Diabetes Example

• Resident admitted to SNF following foot amputation d/t diabetic PVD. PT and OT ordered with plan for the resident to return home. Staff to change dressings and report any suture site breakdown to MD. Other diagnoses include gastroparesis d/t Type 2 diabetes (receiving insulin), mitral valve regurgitation with aortic stenosis, inguinal hernia, generalized DJD and COPD. 37

Diabetic Answer

• Z47.81 Aftercare, following surg, amp• E11.51 Diabetes, type 2, w/peri angiopath• E11.43 Diabetes, type 2, w/gastroparesis• I08.0 Regurgitation, mitral, w/aortic valve •K40.90 Hernia, inguinal •M15.9 Disease, joint, degenerative• J44.9 Disease, pulmonary, chronic obstruc• Z79.4 Long-term use insulin• Z89.439 Acquired absence of unspec foot

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Rationale

• Both PVD and gastroparesis are d/t type 2 diabetes. Codes assigned for both conditions. • Z47.81 has a “use add’l code” note to

identify the limb and level of amp Z89.439 Documentation doesn’t specify which foot was amp, so 6th digit of 9 is assigned. • Pt uses insulin, so Z79.4 is assigned.

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Dehydration

• E86.0 Dehydration• Need to know if this is a current condition,

otherwise do NOT code

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Chapters 5 – Mental & Behavior Disorders F01-F99• F01. Vascular Dementia • F02. Dementia in other diseases classified

elsewhere• F03. Unspecified Dementia• *All of above are coded:• with behavioral disturbance, or• without behavioral disturbance

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Key to Psychoactive Drug UseDocumentation•Make sure each psychoactive drug includes

diagnosis for use• Behavioral disturbance??? Justification for

psychotropic meds??? Documentation of aggressive, combative or violent?•Use of antipsychotic meds need specific

medical diagnosis to justify use:• Schizophrenia - F20., Bipolar – F31., Psychosis

(delusions or hallucinations) – F29. 42

Bipolar Disorder – F31

• Expanded subcategories:• F31.1 Bipolar, current episode manic• F31.3 Bipolar, current episode depressed• F31.6 Bipolar, current episode mixed• F31.7 Bipolar, currently in remission

• Need to know for above:• with or without psychotic features• mild, moderate, severe

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Substance Abuse Codes

• Expanded to include intoxication and specific mood states that are a result of a variety of substances:• Anxiety, sleep disorder, psychosis• By drug type:• Alcohol, Opioid, Cannabis, Sedative/hypnotic,

Cocaine, other stimulant, hallucinogen, nicotine, inhalant)

• Example: F10.180 Alcohol abuse with alcohol- induced anxiety disorder 44