ICD-10 Updates

1
ICD-10 Updates Roundtable

• Presented by
• AHIMA Approved ICD-10-CM/PCS Trainers
• Sue Roehl, RHIT, CCS
• Deb Selland, RHIT, CCS

2
Disclaimer

• The presenters have made every reasonable effort
  to ensure accuracy of the information provided in
  this material.
• The presenters make no guarantee the information
  compiled or presented is error-free.

3
Agenda
830 1010 What Happened? Whats Next
1000-1015 Break
1015-1200 Coding and Documentation Tips
1200-1230 Roundtable
4
What Happened?

• SGR (Sustainable Growth Rate)
• 1997
• Law passed to control physician spending
• Congress has been passing short-term patches to
  avoid those spending cuts ever since (up to 24
  of physician reimbursement)
• Latest patch was set to expire on 3/31/2014

5
What Happened?

• H.R. 4302 introduced to House at 1157 p.m. on
  3/25/14
• 1-year patch
• Section 212-included new delay in ICD-10
  implementation wording
• Placed on the Suspension Calendar

6
What Happened?

• What is a Suspension Calendar?
• Suspension of rules
• Normally used for benign, noncontroversial bills
  such as the naming of post offices
• Voice vote (no roll call)
• No amendments to bills allowed (so Section 212
  could not be removed)
• Allows up to 40 minutes for discussion before vote

7
What Happened?

• 1132 a.m. House was announced in recess
• 1208 p.m. House called to order and bill was
  read
• 1209 p.m. Bill passed with no discussion

8
What Happened?

• Members not given usual 15 minute notice that
  House was calling to order
• Members were not notified that vote would take
  place
• Vote was done when most members were out of the
  room
• Estimated only 5 or 6 representatives actually
  voted

9
What Happened?

• No public records are kept for voice votes so it
  is not known how many voted or which
  representatives got to vote
• AHIMA had enough votes to kill the bill if all
  435 representatives had been aware the vote was
  taking place
• Many members of Congress were outraged by the
  process used to get the bill passed in the House

10
What Happened?

• 3/27 Placed on the Senate schedule
• 3/31 Passed Senate
• Set to expire on 3/31
• Senate did debate the bill although ICD-10 part
  of legislation was NOT MENTIONED

11
What Happened?

• Passed 64-35
• Senator Hoeven-yeah
• Senator Heitkamp-did not vote
• 4/1/2014 Signed into law by President Obama at
  530 p.m.

12
Whats Next?

• AHIMA recommends that organizations continue with
  preparations under the assumption that next year
  is the go live year.
• CCHIIM has determined that all certification
  exams will continue testing on ICD-9-CM until a
  new coding classification system is officially
  implemented.

13
Whats Next?

• The Coalition for ICD10 (includes AHIMA) is
  working on a letter to the Department of Health
  and Human Services seeking clarification
• Exact length of delay
• How new compliance date will be issued
• Voluntary use of ICD-10

14
Whats Next?

• Advocacy Assistant
• http//capwiz/com/ahima/home
• Let our Legislators know how ICD-10 delay affects
  your organization

15
Whats Next?

• Continue dual coding
• Learn to code. Turn off translation tools.
• Do not lose momentum
• Strengthen clinical documentation improvement
  programs
• Work with vendors on transition readiness
• Train coders and other stakeholders

16
FAQs

• Q Can the law be rescinded?
• A Not likely. Not enough time between now and
  10/1/14 to get it done.
• Q Was this legal?
• A Yes. Some Members of Congress have vowed to
  keep a closer eye on this type of maneuver in the
  future.

17
FAQs

• Q What about the code freeze?
• A There were already a few ICD-10 procedure
  codes being introduced on 10/1/2014. These will
  still be implemented. Any ICD-9 updates are
  unknown at this time since it was to be retired
  this year.

18
FAQs

• Q Why not just skip to ICD-11?
• A The date to present ICD-11 to the World Health
  Organization Assembly has been pushed back to
  2017 at the earliest. It would then need to be
  modified to ICD-11-CM for use in the United
  States which would take many more years.
• Sues tombstone Still Waiting For I-10

19
Coding and Documentation Tips
20
Anemia

• When the admission/encounter is for management of
  anemia
• Associated with a malignancy
• Code the malignancy first followed by the anemia
  code
• Associated with adverse effect of chemo,
  immunotherapy, or radiation therapy
• Code the anemia first followed by the neoplasm
  and adverse effect code
• Change from ICD-9 Coding Guideline

21
Anemia

• Coding Tips
• Anemia in chronic kidney disease
• Code first the underlying CKD followed by the
  anemia in CKD code D63.1
• Anemia in other chronic diseases
• Code first the underlying chronic disease
  followed by code D63.8, anemia in other chronic
  diseases classified elsewhere

22
Anemia

• Documentation Tips
• Type of anemia needs to be documented
• Postoperative blood loss
• Postoperative acute blood loss
• Acute blood loss
• Chronic blood loss
• Aplastic
• Pernicious
• Iron deficiency
• Vitamin deficiency
• Due to neoplastic disease

23
Anemia

• Documentation Tips
• Cannot code anemia from abnormal laboratory
  findings, blood loss during a procedure, and/or
  blood transfusions. It is appropriate to query
  the provider if findings suggest an anemia
  diagnosis.
• Acute blood loss anemia results from a sudden,
  significant loss of blood over a brief period of
  time
• Acute blood loss anemia may follow surgery but is
  not necessarily a complication of the procedure
  and should not be coded as a postoperative
  complication unless the physician identifies it
  as such.

24
Circulatory System

• Hypertension
• No longer classified by benign, malignant or
  unspecified
• With heart disease codes to hypertensive heart
  disease when a causal relationship is stated -
  such as due to . or hypertensive. If no causal
  relationship, code each condition separately.
• With chronic kidney disease, I-10 assumes a
  causal relationship even if not stated as such.
  Assign an additional code to identify the stage
  of the CKD.
• With hypertensive heart and chronic kidney
  disease assigned combination codes. Assign
  additional code for type of heart failure if
  present and stage of CKD.

25
Circulatory System

• Hypertension
• Secondary hypertension requires two codes. One to
  identify the underlying etiology and one to
  identify the hypertension. Sequencing is
  determined by the reason for the
  admission/encounter.
• Transient codes to R03.0, Elevated blood pressure
  reading without diagnosis of hypertension

26
Circulatory System

• Myocardial Infarctions
• Classified by ST elevation or non-ST elevation
• Intermediate coronary syndrome (411.1) is now
  unstable angina (I20.0)
• Acute coronary occlusion without MI (411.81) is
  now acute coronary thrombosis not resulting in MI
  (I24.0)

27
Circulatory System

• Myocardial Infarctions
• Time frame for subsequent MI is 4 weeks
• Different from ICD-9 where time frame was 8
  weeks or less

28
Circulatory System

• Congestive Heart Failure
• Unspecified heart failure
• The congestive component of CHF cannot be
  reported without documentation of diastolic or
  systolic

29
Circulatory System

• Gangrene has moved from the Symptoms and Signs
  chapter to the Circulatory System chapter.

30
Diabetes

• Combination codes include the type of diabetes
  and the affected body system.
• The provider must link the complication with the
  diabetes. If the conditions are not linked, the
  combination codes can not be assigned.
• Assign as many codes as necessary to describe all
  diabetic complications/body systems involved.
• Sequencing is based on the reason for the
  encounter

31
Diabetes

• Combination codes include the type of diabetes
  and the affected body system.
• Coding Guideline A. 15 the word with should be
  interpreted to mean associated with or due to
  when it appears in a code title, the Alphabetic
  Index, or an instructional note in the Tabular
  List.

32
Diabetes

• Type 2 diabetes is the default when patient is on
  insulin but the provider does not indicate the
  type of diabetes. Assign an additional code
  (Z79.4) for long-term (current) use of insulin.
• Do not assign code Z79.4 if insulin is given
  temporarily to control Type 2 diabetes during an
  encounter.
• Underdose of insulin due to insulin pump failure
• Assign a code from subcategory T85.6-, mechanical
  complication followed by T38.3x6-, underdosing of
  antidiabetic drugs.
• Assign additional codes for the type of diabetes
  and any associated diabetic complications

33
Diabetes

• Overdose of insulin due to insulin pump failure
• Assign a code from subcategory T85.6-, mechanical
  complication followed by code T38.3x1-, poisoning
  by antidiabetic drugs, accidental
  (unintentional).
• Secondary diabetes
• Always caused by another condition or event
• Sequencing based on Tabular List instructions
• E08, code first the underlying condition
• E09, code first poisoning due to drug or toxin,
  if applicable use additional code for adverse
  effect

34
Diabetes

• Documentation Tips
• Type
• Type 1
• Type 2
• Due to drug or chemical
• Due to underlying condition
• Other specified

35
Diabetes

• Documentation Tips
• Uncontrolled
• No longer coded in ICD-10
• Inadequate control, out of control, or poorly
  controlled codes to diabetes by type with
  hyperglycemia
• Do not assign based on lab test results

36
Diabetes

• Documentation Tips
• Diabetic nonproliferative retinopathy
• Mild
• Moderate
• Severe
• Diabetic ulcers
• Site
• Laterality if applicable

37
Fractures

• Pathological
• 3 causal categories
• Due to neoplastic disease
• Due to osteoporosis
• Due to other specified disease

38
Fractures

• Pathological
• M80
• Osteoporosis with current pathological fracture
• Identify the site of the fracture
• Used for any patient with known osteoporosis who
  suffers a fracture, even from a minor fall or
  trauma, if that fall or trauma would not usually
  break a normal, healthy bone.

39
Fractures

• Pathological due to a neoplasm
• When the focus of treatment is the fracture
• Subcategory M84.5 - Pathological fracture in
  neoplastic disease is sequenced first, followed
  by a code for the neoplasm
• When the focus of treatment is the neoplasm
• The neoplasm code is sequenced first, followed by
  a code for the pathological fracture

40
Fractures

• Pathological fracture codes require a 7th
  character extension
• Initial encounter (A) active treatment
• Surgical treatment
• Emergency department encounter
• Evaluation and treatment by a new physician
• Subsequent encounter (D)
• Cast changes, removal
• Complications of fractures, malunion

41
Fractures

• Pathological Fractures
• Documentation
• Site
• Laterality
• Etiology (osteoporosis, neoplasm, other)
• Encounter (initial, subsequent with routine
  healing, subsequent with delayed healing,
  malunion or nonunion, sequela)

42
Fractures

• Traumatic Fractures
• Documentation
• Site
• Laterality
• Encounter
• Initial for closed fracture
• Initial for open fracture
• Subsequent with routine healing
• Subsequent with delayed healing, malunion, or
  nonunion
• Sequela

43
Fractures

• Traumatic fractures
• Not indicated as open or closed. Code to closed.
• Not indicated as displaced or not displaced. Code
  to displaced.
• Require 7th character extension
• Initial encounter
• Active treatment for the fracture
• Surgical treatment
• Emergency department encounter
• Evaluation and treatment by a new physician
• Delayed seeking treatment for the fracture

44
Fractures

• Traumatic fractures
• Require 7th character extension
• Subsequent encounter
• Patient has completed active treatment and is
  receiving routine care during the healing or
  recovery phase
• Cast change or removal
• Removal of external or internal fixation device
• Medication adjustment
• Follow-up visits

45
Fractures

• Aftercare
• Aftercare Z codes should NOT be used for
  aftercare of traumatic fractures. Instead assign
  the acute fracture code with appropriate 7th
  character extension.

46
Fractures

• Open fractures
• Gustilo classification
• I
• Low energy, wound less than 1 cm
• II
• Wound greater than 1 cm with moderate soft tissue
  damage

47
Fractures

• Open fractures
• Gustilo classification
• III
• High energy, wound greater than 1 cm. with
  extensive soft tissue damage
• IIIA adequate soft tissue cover
• IIIB inadequate soft tissue cover
• IIIC associated with arterial injury

48
Fractures

• Coding Tip
• There is no combination code for fractures of the
  tibia/fibula. Each bone, each bone site,
  displaced/non-displaced, open or closed, are
  assigned separately.

49
Glasgow Coma Scale

• 15 point scale for estimating and categorizing
  the outcomes of brain injury on the basis of
  overall social capability or dependence on others

50
Glasgow Coma Scale

• Coding tips
• Codes are used with traumatic brain injury, acute
  cerebrovascular disease or sequelae of
  cerebrovascular disease codes
• Sequenced after the diagnosis code
• At a minimum, the initial score documented on
  presentation to facility should be coded

51
Glasgow Coma Scale

• Coding tips
• 7th character indicates where the scale was
  recorded
• 0 - unspecified time
• 1 - in the field (EMT or ambulance)
• 2 - at arrival to emergency department
• 3 - at hospital admission
• 4 - 24 hours or more after hospital admission

52
Glasgow Coma Scale

• Coding tips
• 7th character indicates where the scale was
  recorded
• 0 - unspecified time
• 1 - in the field (EMT or ambulance)
• 2 - at arrival to emergency department
• 3 - at hospital admission
• 4 - 24 hours or more after hospital admission

53
Neoplasm

• Neoplasm table in the Alphabetic Index is
  referenced first unless the histological term is
  documented, then that term is referenced first.

54
Neoplasm

• Histology The study of the form of structures
  seen under the microscope.
• Morphology The science of structure and form of
  organisms without regard to function
• Examples of Histological/Morphology Types
• Carcinoma
• Leukemia
• Lymphoma
• Myeloma
• Sarcoma
• Mesothelioma
• CNS (glioma, blastoma)

55
Neoplasm

• First listed diagnosis is determined by where the
  treatment is directed
• If treatment is directed to primary neoplasm,
  that site is sequenced first
• If treatment is directed to secondary site, that
  site is sequenced first
• If admission/encounter is for administration of
  chemo, immunotherapy or radiation therapy, the
  appropriate Z51.- code is listed first

56
Neoplasm

• Primary malignant neoplasms overlapping site
  boundaries
• If overlaps two or more contiguous (next to each
  other) sites classify 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

57
Neoplasm

• Primary malignancy previously excised
• If the primary site has been previously excised
  or eradicated and there is no further treatment
  directed to that site, a code from Z85 should be
  assigned.

58
Neoplasm

• Documentation tips
• General Site
• Example colon
• Specific Site
• Ascending, cecum, descending, with rectum,
  distal, sigmoid, transverse, etc.
• Histology/Morphology type

59
Newborn

• Category Z38
• Liveborn infants according to place of birth and
  type of delivery
• Always sequenced first
• Used on the initial record of a newborn ONLY, not
  by the receiving hospital in the event of a
  transfer

60
Newborn

• Newborn Disorders Related to Length of Gestation
  and Fetal Growth
• Codes from P07, Disorders of newborn related to
  short gestation and low birth weight, NEC, are
  for use on a child or adult who was premature or
  had a low birth weight as a newborn and is
  affecting the patients current health status.

61
Newborn

• Documentation
• Related to slow fetal growth and fetal
  malnutrition
• Related to short gestation and low birth weight
• Related to long gestation and high birth weight

62
Newborn

• Documentation
• Gestational age
• Light for gestational age (light for dates)
• Small for gestational age (small for dates)
• When birth weight and gestational age are both
  documented
• Sequence the code for birth weight first followed
  by the code for gestational age

63
Nervous System

• Dominant/nondominant side
• If the affected side is documented but not
  specified as dominant or nondominant and the
  classification system does not indicate a
  default, code selection is as follows
• For ambidextrous patients, the default should be
  dominant
• If the left side is affected, the default is
  non-dominant
• If the right side is affected, the default is
  dominant

64
Nervous System

• Documentation
• Hemiplegia
• Flaccid
• Spastic
• Unspecified
• Dominant/nondominant
• Unspecified side
• Right dominant side
• Left dominant side
• Right nondominant side
• Left nondominant side

65
Repeated Falls

• 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
• Code Z91.81 History of falling
• Is for use when a patient has fallen in the past
  and is at risk for future falls

66
Respiratory System

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

67
Respiratory System

• Acute and chronic respiratory failure may be
  assigned as principal diagnosis when it is the
  condition established after study to be chiefly
  responsible for occasioning the admission.

68
Respiratory System

• Respiratory failure may be listed as a secondary
  diagnosis if it occurs after admission or does
  not meet the definition of principal diagnosis.

69
Respiratory System

• If respiratory failure and another acute
  condition are equally responsible for occasioning
  the admission, and there are no chapter- specific
  sequencing rules, the guideline for two or more
  diagnoses equally meeting the definition of
  principal diagnosis may be applied.

70
Respiratory System

• 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.

71
Respiratory System

• Coding Tips
• Pay close attention to all Includes, Excludes1,
  and Excludes2 instructional notes within the
  Respiratory System chapter
• When a respiratory condition is described in more
  than one site not specifically indexed, it is
  classified to the lowest anatomic site (i.e.
  tracheobronchitis to bronchitis)

72
Respiratory System

• Documentation Tips
• Asthma
• Mild intermittent
• Mild persistent
• Moderate persistent
• Severe persistent
• Asthma
• Uncomplicated
• Acute exacerbation
• Status asthmaticus

73
Respiratory System

• Worldallergy.com

Asthma Severity Frequency of Daytime Symptoms
Intermittent 2 times per week
Mild Persistent gt 2 times per week
Moderate Persistent Daily. May restrict physical activity
Severe Persistent Throughout the day. Frequent severe attacks limiting ability to breathe.
74
Respiratory System

• Documentation Tips
• COPD
• Acute lower respiratory infection
• Acute exacerbation
• COPD with asthma assigned to two separate codes
• Bronchitis
• Not specified as acute or chronic
• Simple chronic
• Mucopurulent chronic
• Mixed simple and mucopurulent chronic
• Unspecified chronic
• Acute
• Different than ICD-9 where one code (493.22) was
  assigned

75
Respiratory System

• Documentation Tips
• Acute bronchitis
• Due to mycoplasma pneumonia
• Due to hemophilus influenza
• Due to streptococcus
• Due to coxsackie virus
• Due to parainfluenza virus
• Due to rhinovirus
• Due to echovirus
• Due to other specified organism
• Unspecified

76
Respiratory System

• Documentation Tips
• Emphysema
• Unilateral pulmonary
• Panlobular
• Centrilobular
• Other

77
Respiratory System

• Documentation Tips
• Respiratory Failure
• Acute
• Chronic
• Acute and chronic
• Unspecified
• Respiratory Failure
• Unspecified whether with hypoxia or hypercapnia
• With hypoxia
• With hypercapnia

78
Respiratory System

• Documentation Tips
• Mechanical ventilation
• Duration (lt 24 hours, 24-96 hours, gt96
  consecutive hours)
• Type (CPAP, IPAP, Continuous negative airway
  pressure, Intermittent negative airway pressure)

79
Respiratory System

• Documentation Tips
• Mechanical ventilation
• Calculation of duration
• Start time begins when
• Endotracheal intubation is performed in the ER or
  hospital followed by initiation of mechanical
  ventilation or
• Initiation of mechanical ventilation through
  tracheostomy was performed in the ER or hospital
  or
• Patient is admitted already on mechanical
  ventilation after previous intubation or
  tracheostomy

80
Respiratory System

• Documentation Tips
• Mechanical ventilation
• Calculation of duration
• Ends when
• Patient is extubated or
• Ventilation is discontinued for patient with
  tracheostomy after any weaning period is
  completed or
• Patient is discharged or transferred while still
  on ventilator

81
Sepsis, severe sepsis, septic shock

• Sepsis, Severe sepsis, septic shock
• Acute organ dysfunction and sepsis in a patient
  must be associated in order to assign a severe
  sepsis code. If documentation is unclear, query
  the provider.
• Septic shock represents a type of acute organ
  dysfunction
• The code for the systemic infection is sequenced
  first followed by R65.21, Severe sepsis with
  septic shock or T81.12, Postprocedural septic
  shock

82
Sepsis, Severe Sepsis, Septic shock

• A code from subcategory R65.2xx can never be
  assigned as principal/first-listed diagnosis.
• (b) Severe sepsis
• The coding of severe sepsis requires a minimum of
  2 codes first a code for the underlying systemic
  infection, followed by a code from subcategory
  R65.2, Severe sepsis. If the causal organism is
  not documented, assign code A41.9, Sepsis,
  unspecified organism, for the infection.
  Additional code(s) for the associated acute organ
  dysfunction are also required.

83
Sepsis, Severe Sepsis, Septic shock

• Sequencing of sepsis, severe sepsis and localized
  infection
• If both sepsis/severe sepsis and a localized
  infection (such as pneumonia) are present on
  admission, code the underlying systemic infection
  first followed by the localized infection
• If a localized infection is POA and sepsis/severe
  sepsis develops after admission, the localized
  infection should be first-listed followed by the
  appropriate sepsis codes.

84
Sepsis, Severe Sepsis, Septic shock

• Sepsis due to a postprocedural infection should
  be sequenced first, followed by the code for the
  specific infection. Codes for severe sepsis and
  any acute organ dysfunction may also be assigned
  as appropriate.

85
Sepsis, Severe Sepsis, Septic shock

• Severe sepsis and postprocedural septic shock
• The code for the precipitating complication
  should be sequenced first (such as infection
  following a procedure or infection of obstetrical
  wound) followed by the code for severe sepsis
  with septic shock and a code for the systemic
  infection.

86
Sepsis, Severe Sepsis, Septic shock

• Documentation Tips
• Urosepsis directs the coder to code to
  condition. Urosepsis does not default to UTI.
• Different than ICD-9 guidance

87
Sequelae of Cerebrovascular Disease

• No time limit on when a sequela code can be
  assigned
• Sequelae includes conditions specified as such or
  as residuals which may occur at any time after
  the onset of the causal condition
• Coding of sequela generally requires two codes
• Nature of the sequela sequenced first
• Sequela code second

88
Sequelae of Cerebrovascular Disease

• Exception
• When the code for the sequela is followed by a
  manifestation code identified in the Tabular List
• Exception
• When the sequela code has been expanded to
  include the manifestation

89
Sequelae of Cerebrovascular Disease

• A code for the acute phase of illness or injury
  is never assigned with a sequela code.
• Codes from I69, Sequelae of cerebrovascular
  disease, should NOT be assigned if the patient
  does not have neurologic deficits.

90
Sequelae of Cerebrovascular Disease

• Documentation Tips
• Specification of cause
• Nontraumatic subarachnoid hemorrhage
• Nontraumatic intracerebral hemorrhage
• Nontraumatic intracranial hemorrhage
• Cerebral infarction
• Other cerebrovascular diseases
• Unspecified cerebrovascular diseases

91
Sequelae of Cerebrovascular Disease

• Documentation Tips
• Speech and language deficits
• Aphasia
• Dysphasia
• Dysarthria
• Fluency disorder
• Other speech and language deficits

92
Sequelae of Cerebrovascular Disease

• Documentation Tips
• Monoplegia, hemiplegia, hemiparesis and other
  paralytic conditions
• Unspecified side
• Right dominant side
• Left dominant side
• Right nondominant side
• Left nondominant side

93
Substance Abuse

• Documentation of Use, Abuse and Dependence of the
  same substance
• Only one code is assigned to identify the pattern
  of abuse
• If both use and abuse are documented, assign only
  the code for abuse
• If both abuse and dependence are documented,
  assign only the code for dependence
• If both use and dependence are documented, assign
  only a code for dependence

94
Substance Abuse

• Codes for psychoactive substance abuse should
  only be assigned based on provider documentation,
  including a patient in remission.

95
Substance Abuse

• Documentation Tips
• Blood alcohol level is coded to Y90.-
• Nicotine dependence
• Cigarettes
• Chewing tobacco product
• Unspecified
• Nicotine dependence
• Uncomplicated
• In remission
• With withdrawal
• With other nicotine-induced disorders
• With unspecified nicotine-induced disorders

96
Substance Abuse

• Documentation Tips
• Tobacco abuse NOS codes to Z72.0
• History of tobacco dependence codes to Z87.891

97
Symptoms and Signs

• Sign/symptom codes
• Can be assigned when a definitive diagnosis has
  not been established.
• Should NOT be assigned if routinely associated
  with the disease process
• If not routinely associated with the disease
  process they may be coded with the definitive
  diagnosis code sequenced first

98
Symptoms and Signs

• Contrasting/comparative diagnoses
• When a symptom code is followed by
  contrasting/comparative diagnoses, the symptom
  code is sequenced first followed by the
  contrasting/comparative diagnoses codes

99
Symptoms and Signs

• Outpatient coding
• Do NOT code probable, suspected,
  questionable, rule out, or working
  diagnosis or other similar terms indicating
  uncertainty. Code the condition to the highest
  degree of certainty for that encounter/visit,
  such as symptoms, signs, abnormal results, or
  other reason for the visit.

100
Symptoms and Signs

• If a combination code exists that identifies both
  the diagnosis and common symptoms of that
  diagnosis, NO additional code is assigned for the
  sign/symptom.

101
Symptoms and Signs

• Circumstances when to use a sign/symptom code
• A more specific diagnosis can not be determined
  even after all investigation
• Sign or symptom was transient with no cause
  determined
• Provisional diagnosis in a patient who fails to
  return
• Referred elsewhere before diagnosis determined
• More precise diagnosis not available
• Certain symptoms that in their own right
  represent important problems in medical care

102
Z codes

• Factors influencing health status and contact
  with health services
• Used in all health care settings
• May be used as principal/first-listed diagnosis
  or as secondary codes, depending on the
  circumstances of the visit/encounter.

103
Z codes

• Factors influencing health status and contact
  with health services
• Certain Z codes may only be used as first-listed
  diagnosis
• Z38 Liveborn infants according to place of birth
  and type of delivery
• Z51.0 Encounter for antineoplastic radiation
  therapy
• Z51.1- Encounter for antineopolastic chemo and
  immunotherapy
• Z76.2 Encounter for health supervision and care
  of other healthy infant or child

104
Z codes

• Factors influencing health status and contact
  with health services
• Status codes are different than History of codes
• History of codes indicate the patient no longer
  has the condition

105
Z codes

• Factors influencing health status and contact
  with health services
• Two types of History of Z codes
• Personal- patient has a past medical condition
  that no longer exists and is not receiving
  treatment for
• Family- a patients family member(s) has had a
  particular disease that causes the patient to be
  at a higher risk

106
Z codes

• Factors influencing health status and contact
  with health services
• Common status codes
• Z33.1 Pregnant state, incidental
• Z68.- Body mass index
• Z79.-Long-term (current) drug therapy
• Z89.-Acquired absence of limb
• Z90.- Acquired absence of organs, NEC
• Z95.- Presence of cardiac and vascular implants
  and grafts

107
Z codes

• Factors influencing health status and contact
  with health services
• Aftercare Z codes
• Used in situations when the initial treatment of
  a disease has been performed and the patient
  requires continued care during the healing or
  recovery phase.
• Are NOT used for aftercare of injuries. The acute
  injury code is assigned with the appropriate 7th
  character extension for subsequent encounter.

108
Z codes

• Factors influencing health status and contact
  with health services
• Body Mass Index (BMI)
• Separated into adult, persons 21 years of age or
  older or pediatric, persons 2-20 years of age.

109
Z codes

• Factors influencing health status and contact
  with health services
• Body Mass Index (BMI)
• Adult Range
• 19 to 70
• Pediatric Range
• lt 5th percentile for age
• 5th percentile to lt85th percentile for age
• 85th percentile to lt95th percentile for age
• 95th percentile for age

110
Z codes

• Factors influencing health status and contact
  with health services
• Persons Encountering Health Services for
  Examinations (Z00-Z13)
• Codes have been expanded to allow for capturing
  an exam with abnormal findings
• These codes have instructional notes to assign an
  additional code to identify the abnormal findings.

111
Z codes

• Factors influencing health status and contact
  with health services
• Persons Encountering Health Services for
  Examinations (Z00-Z13)
• Z00.00 Encounter for general adult medical
  examination without abnormal findings
• Z00.01 Encounter for general adult medical
  examination with abnormal findings

112
Round Table Questions

• Question
• With the new respiratory failure codes, hypoxia
  vs hypercapnia-some of our physicians are using
  Type I and Type II-we think we can take it to the
  appropriate code based on its description. We
  would like confirmation of that as we cannot
  index type I or type II in the codebook.

113
Round Table Questions

• Answer (from AHIMA audit seminar Coding for
  Respiratory Services August 2009)
• Type 1 Respiratory failure
• Hypoxemic respiratory failure
• Decreased arterial oxygen level with normal or
  low arterial carbon dioxide level and normal or
  elevated pH level
• Type 2 Respiratory failure
• Hypercapneic respiratory failure
• Increased arterial carbon dioxide level and
  decreased pH level with or without decreased
  arterial oxygen level
• Also known as ventilatory failure or pump failure

114
Round Table Questions

• Answer
• Acute or chronic
• Type 1 (hypoxemic)
• Virtually always acute
• Rarely chronic
• Type 2 (hypercapneic)
• May be acute or chronic
• Acute Elevated PaCO2 and low pH levels
• Chronic pH levels higher than expected

115
Round Table Questions

• Answer
• ICD-10 does not provide codes for Type 1 or Type
  2 respiratory failure.
• Options are
• J96.00 acute respiratory failure unspecified with
  hypoxia or hypercapnia
• J96.01 acute respiratory failure with hypoxia
• J96.02 acute respiratory failure with hypercapnia
• J96.90 respiratory failure, unspecified,
  unspecified whether with hypoxia or hypercapnia
• J96.91 respiratory failure, unspecified, with
  hypoxia
• J96.92 respiratory failure, unspecified with
  hypercapnia

116
Round Table Questions

• Answer
• Coding Clinic 1st Quarter 2014
• Associated conditions documentation linkage
• Do two conditions have to be listed together in
  the diagnostic statement in order to assume an
  association?
• It is not required that two conditions be listed
  together in the health record. However, the
  provider needs to document the linkage, except in
  situations where the classification assumes an
  association (e.g. hypertension with chronic
  kidney involvement). When the provider
  establishes a linkage or relationship between two
  conditions, they should be coded as such.

117
Round Table Questions

• Answer
• US National Library of Medicine National
  Institutes of Health
• Several articles on this site define Type I and
  II respiratory failure. With documentation of
  hypercapnia or hypoxia and respiratory failure,
  acute respiratory failure, chronic respiratory
  failure in the medical record- it appears
  appropriate to use the definitions of type I and
  II respiratory failure in the code assignment.

118
Round Table Questions

• Question
• When orthopedic coding initial vs subsequent
  encounters, our orthopedic surgeon says he
  considers recasting a fracture as part of the
  acute phase of treatment, yet the descriptions we
  have seen say the casting would be subsequent.
  What is correct, initial or subsequent?

119
Round Table Questions

• Answer
• If the documentation supports that frequent
  casting is part of the active treatment of the
  fracture, initial encounter may be the
  appropriate 7th character.
• However, per the coding guidelines cast change or
  removal would typically be assigned the 7th
  character for subsequent encounter.

120
Round Table Questions

• Coding guideline
• Initial encounter
• Active treatment for the fracture
• Surgical treatment
• Emergency department encounter
• Evaluation and treatment by a new physician
• Delayed seeking treatment for the fracture
• Subsequent encounter
• Patient has completed active treatment and is
  receiving routine care during the healing or
  recovery phase
• Cast change or removal
• Removal of external or internal fixation device
• Medication adjustment
• Follow-up visits

121
Round Table Questions

• Question
• How do the professional coders code trimester for
  the global billing of OB patients since it could
  cross several trimesters?

122
Round Table Questions

• Answer
• 3) Final character for trimester
• The majority of codes in Chapter 15 have a final
  character indicating the trimester of pregnancy.
  The timeframes for the trimesters are indicated
  at the beginning of the chapter.
• Assignment of the final character for trimester
  should be based on the providers documentation
  of the trimester (or number of weeks) for the
  current admission/encounter.

123
Round Table Questions

• Answer
• 4) Selection of trimester for inpatient
  admissions that encompass more than one trimester
• In instances when a patient is admitted to a
  hospital for complications of pregnancy during
  one trimester and remains in the hospital into a
  subsequent trimester, the trimester character for
  the antepartum complication code should be
  assigned on the basis of the trimester when the
  complication developed, not the trimester of the
  discharge. If the condition developed prior to
  the current admission/encounter or represents a
  pre-existing condition, the trimester character
  for the trimester at the time of the
  admission/encounter should be assigned.

124
Round Table Questions

• Answer
• If there is one claim submitted and the patient
  has delivered, submit the codes as appropriate
  for the time of delivery (i.e. 3rd trimester if
  the code requires a trimester).

125
Round Table Questions

• Question
• Can we code from the nurses notes for dominant
  vs. nondominant or does it have to be documented
  by a physician? Coding guidelines dont seem to
  address it.
• Answer
• There is no information available to indicate the
  dominant vs nondominant specification may be
  assigned from documentation other than provided
  by a physician. See previous slides for default
  code assignment of dominant vs. nondominant.

126
2014 ICD-10-CM is available at

• http//www.cdc.gov/nchs/icd/icd10cm.htm or
  http//www.cms.hhs.gov/ICD10
• 2014 ICD-10-CM Index to Diseases and Injuries
• 2014 ICD-10-CM Tabular List of Diseases and
  Injuries
• Instructional Notations
• 2014 Official Guidelines for Coding and Reporting
  
• 2014 Table of Drugs and Chemicals
• 2014 Neoplasm Table
• 2014 Index to External Causes
• 2014 Mapping ICD-9-CM to ICD-10-CM and ICD-10-CM
  to ICD-9-CM

127
Questions?Keep track of your questions for the
next Roundtable in the Fall!
128
References

• AHIMA.org
• Advance for Health Information Professionals
• AHIMA audio seminar Coding for Respiratory
  Services August 2009
• Coding Clinic 1st Quarter 2014 Page 15
• US National Library of Medicine National
  Institutes of Health