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Selected Topics from Coding Clinic NYHIMA's 79th Annual Conference June 2, 2014 Barry Libman, MS, RHIA, CDIP, CCS, CCS-P President, Barry Libman Inc. President,

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Presentation on theme: "Selected Topics from Coding Clinic NYHIMA's 79th Annual Conference June 2, 2014 Barry Libman, MS, RHIA, CDIP, CCS, CCS-P President, Barry Libman Inc. President,"— Presentation transcript:

1 Selected Topics from Coding Clinic NYHIMA's 79th Annual Conference June 2, 2014 Barry Libman, MS, RHIA, CDIP, CCS, CCS-P President, Barry Libman Inc. President, Libman Education

2 2 Coding Clinic for ICD-9 / ICD-10 Published quarterly by the AHA Coding Clinic is the official publication for ICD-9 / ICD-10 coding guidelines and advice as designated by the four cooperating parties: -AHA -AHIMA -CMS -NCHS

3 3 AHA Coding Clinic Advisor Coding Clinic question submission 1) Visit 2) Click on Log in/Register 3) Enter coding question 4) Include applicable back-up documentation 5) Submit 6) Submission confirmation will be sent with a tracking number

4 4 Coding Clinic transition timeline Fall 2013: The last meeting of the AHA Coding Clinic Editorial Advisory Board (EAB) meeting where ICD-9-CM questions were addressed January 1, 2014: AHA Central Office no longer accepts nor respond to requests for ICD-9-CM coding advice First Quarter 2014: - Last issue of Coding Clinic for ICD-9-CM was published - First issue of Coding Clinic for ICD-10-CM and ICD-10- PCS was published; Second Quarter 2014 also available

5 5 Coding Clinic transition No plans to translate all previous issues of Coding Clinic for ICD-9-CM into ICD-10-CM/PCS since many of the questions published arose out of the need to provide clarification on the use of ICD-9-CM and would not be readily applicable to ICD-10-CM/PCS.

6 6 CMS statement “On April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. No ) was enacted, which said that the Secretary may not adopt ICD-10 prior to October 1, Accordingly, the U.S. Department of Health and Human Services expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning October 1, The rule will also require HIPAA covered entities to continue to use ICD-9-CM through September 30, 2015.”

7 7 ICD-9-CM Coding Clinic Second Quarter 2014 The Cooperating Parties have reviewed the original plan not to address any ICD-9-CM questions and have decided to uphold the plan and go forward with only providing advice on ICD- 10-CM and PCS

8 8 Today’s Coding Clinic topics –ICD-10 Coding Clinics: –Assigning Codes Using Prior Encounters Q –Decompensated Systolic Heart Failure Q –Diabetes and Osteomyelitis Q –Diabetic Mellitus with Hyperglycemia Q –Diabetes with Ketoacidosis Q –Diabetes Mellitus Type 2 with Ketoacidosis Q –Pneumonia and Hemoptysis Q –Healthcare Acquired (Nosocomial) Condition Q –Endoscopic Banding of Esophageal Varices Q –Root Operation for Bone Marrow Biopsy Q4 2013

9 9 Today’s Coding Clinic topics ICD-9 Coding Clinics: History of Ductal Carcinoma Q Heart Failure with Preserved or Reduced Ejection Fraction Q Immune Thrombocytopenic Purpura and Pancytopenia Q Traumatic Urinary Catheterization Q1 2014

10 10 Assigning Codes Using Prior Encounters Q Question: Is there a guideline or rule that indicates that you should only use the medical record documentation for that specific visit/admission for diagnosis coding purposes? Does each visit or admission stand alone? Would the coder go back to previous encounter records to assist in the coding of a current visit or admission?

11 11 Assigning Codes Using Prior Encounters Q Answer: Documentation for the current encounter should clearly reflect those diagnoses that are current and relevant for that encounter. Conditions documented on previous encounters may not be clinically relevant on the current encounter. The physician is responsible for diagnosing and documenting all relevant conditions. A patient’s historical problem list is not necessarily the same for every encounter/visit. It is the physician’s responsibility to determine the diagnoses applicable to the current encounter and document in the patient’s record. When reporting recurring conditions and the recurring condition is still valid for the outpatient encounter or inpatient admission, the recurring condition should be documented in the medical record with each encounter/admission.

12 12 Assigning Codes Using Prior Encounters Q Answer (continued): However, if the condition is not documented in the current health record, it would be inappropriate to go back to previous encounters to retrieve a diagnosis without physician confirmation. This is an area where coders and/or department managers may need to educate physicians and/or practice managers on the need to include complete diagnoses when outpatient services are ordered and to continue to document chronic or longstanding conditions on each admission/encounter record. Please note this advice applies to both ICD-9-CM and ICD-10- CM.

13 13 Decompensated Systolic Heart Failure Q Question: Coding Clinic, Third Quarter 2008, p. 12, states “decompensated indicates that there has been a flare- up (acute phase) of a chronic condition.” Should this general definition of decompensated be applied when assigning ICD-10-CM codes as well? For example, what is the appropriate ICD-10-CM code assignment for a diagnosis of chronic systolic heart failure, currently decompensated?

14 14 Decompensated Systolic Heart Failure Q Answer: Assign code I50.23, Acute on chronic systolic hea rt failure, for decompensated systolic heart failure. As previously stated “decompensated” indicates there has been a flare-up (acute phase) of a condition.

15 15 Diabetes and Osteomyelitis Q Question: Coding Clinic, First Quarter 2004, pages 14-15, indicated that “ICD-9-CM assumes a relationship between diabetes and osteomyelitis when both conditions are present, unless the physician has indicated in the medical record that the acute osteomyelitis is totally unrelated to the diabetes.” Is the same relationship between diabetes and osteomyelitis true for ICD-10-CM?

16 16 Diabetes and Osteomyelitis Q Answer: No, ICD-10-CM does not presume a linkage between diabetes and osteomyelitis. The provider will need to document a linkage or relationship between the two conditions before it can be coded as such.

17 17 Diabetes and Osteomyelitis with or E11.69 with M86.9 DM with Osteomyelitis MS-DRG: 638 Diabetes w CC Cost weight:.8252 M86.9 and E11.9 Osteomyelitis and DM DRG: 541 Osteomyelitis w/o CC/MCC Cost weight:.9743

18 18 Osteomyelitis in the Index Osteomyelitis M86.9 acute M86.10 carpus M clavicle M femur M86.15-

19 19 Diabetic Mellitus with Hyperglycemia Q Question: Is it appropriate to assign a code for hyperglycemia together with another diabetes code? For example, if hyperglycemia is documented along with type 2 diabetic retinopathy, should multiple diabetes codes be assigned?

20 20 Diabetic Mellitus with Hyperglycemia Q Answer: Yes, assign codes E11.319, Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema, and E11.65, Type 2 diabetes mellitus with hyperglycemia. Any combination of the diabetes codes can be assigned together, unless one diabetic condition is inherent in another.

21 21 Index and Diabetes ICD-10-CM Index: out of control – code to Diabetes by type with hyperglycemia poorly controlled – code to Diabetes by type with hyperglycemia ICD-9-CM Index: poorly controlled – code to Diabetes by type with 5 th digit for not stated as uncontrolled

22 22 Diabetes with Ketoacidosis Q Question: Coding Clinic for ICD-9-CM states that ketoacidosis is inherently uncontrolled diabetes. Therefore, how would you report uncontrolled type I diabetes with ketoacidosis in ICD-10- CM? Should the code for diabetes with hyperglycemia (E10.65) be reported in addition to the code for diabetes ketoacidosis (E10.10)? Or should only the code for diabetic ketoacidosis be reported since ketoacidosis is considered uncontrolled diabetes? We believe that the two codes are redundant; however, there are no instructional and/or excludes notes to guide coders as to the appropriate reporting of uncontrolled type I diabetes with ketoacidosis.

23 23 Diabetes with Ketoacidosis Q Answer: No, in this case, it is not appropriate to assign code E10.65, Type 1 diabetes mellitus with hyperglycemia, together with code E Assign only code E10.10, Type 1 diabetes mellitus with ketoacidosis without coma. Ketoacidosis signifies uncontrolled diabetes.

24 24 Diabetes Mellitus Type 2 with Ketoacidosis Q Question: What is the correct code assignment for type 2 diabetes mellitus with diabetic ketoacidosis?

25 25 Diabetes Mellitus Type 2 with Ketoacidosis Q Answer: Assign code E13.10, Other specified diabetes mellitus with ketoacidosis without coma, for a patient with type 2 diabetes with ketoacidosis. Given the less than perfect limited choices, it was felt that it would be clinically important to identify the fact that the patient has ketoacidosis. The National Center for Health Statistics (NCHS), who has oversight for volumes I and II of ICD-10-CM, has agreed to consider a future ICD-10-CM Coordination and Maintenance Committee meeting proposal.

26 26 Pneumonia and Hemoptysis Q Question: “Hemorrhagic” is no longer a non-essential modifier for pneumonia in the ICD-10-CM Index to Diseases. Is a code reported for hemoptysis when it occurs with pneumonia?

27 27 Pneumonia and Hemoptysis Q Answer: Sequence the appropriate code for the pneumonia first. Assign code R04.2, Hemoptysis, as an additional code when the condition occurs with pneumonia. Although code R04.2 is a Chapter 18 code, codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with the diagnosis.

28 28 Healthcare Acquired (Nosocomial) Condition Q Question: A patient is admitted to the hospital and diagnosed with severe sepsis due to healthcare associated pneumonia. The physician documented that her healthcare associated pneumonia was due to her recent hospitalization. During a recent ICD-10-CM training it was suggested that code Y95 Nosocomial condition could be assigned in addition to R65.20, Severe sepsis without septic shock, and J18.9 Pneumonia, unspecified organism. There is currently no indexing in the ICD-10-CM index that supports this assignment. Is it appropriate to assign code Y95, Nosocomial condition based on the documentation of healthcare associated pneumonia or hospital acquired pneumonia?

29 29 Healthcare Acquired (Nosocomial) Condition Q Answer: Yes, it is appropriate to assign code Y95, Nosocomial condition, for a documented healthcare acquired condition. Code Y95 can be found on the Index to External Causes under the main term “Nosocomial condition.”

30 30 Endoscopic Banding of Esophageal Varices Q Question: A patient with hematemesis presents for esophagogastroduodenoscopy. The patient is found to have esophageal varices, and therefore, ligation of esophageal varices was performed using bands placed via a band ligation device. What is the appropriate ICD-10-PCS body system for esophageal varices: gastrointestinal system or lower veins?

31 31 Endoscopic Banding of Esophageal Varices Q Question (continued): In ICD-10-PCS, ligation is coded to the root operation occlusion. Therefore, if we use table “06L” for occlusion of lower veins, there is the appropriate body part and a device value for the bands (extraluminal device); However, there is no approach value for via natural or artificial opening endoscopic. However, if we use the “0DL” table for occlusion of gastrointestinal system and use “esophagus” for the body part, there is the appropriate approach value but there is no device option for the bands. What is the appropriate ICD-10-PCS code assignment for endoscopic banding of esophageal varices?

32 32 Endoscopic Banding of Esophageal Varices Q Answer: Esophageal varices are enlarged veins in the esophagus, which can spontaneously rupture and cause severe bleeding. Endoscopic banding of esophageal varices involves completely occluding blood flow and meets the definition of root operation “occlusion.” The lumen of the esophageal vein is being banded, not the esophagus. The index under ligation states “See occlusion.”

33 33 Endoscopic Banding of Esophageal Varices Q Answer (continued): Assign the following ICD-10-PCS code: 06L34CZ Occlusion of esophageal vein with extraluminal device, percutaneous endoscopic approach. The ICD-10-PCS tables currently do not use approaches containing the phrase “via natural or artificial opening” for body part values in the cardiovascular body systems. The use of this approach for blood vessel body parts could change over time if requests for additional codes are made through the ICD-10-PCS Coordination and Maintenance process.

34 34 Endoscopic Banding of Esophageal Varices MS-DRG 432 Cirrhosis & alcoholic hepatitis w/ MCC Cost weight: Alcoholic cirrhosis bleeding esophageal varices endoscopic ligation esophageal varices

35 35 Endoscopic Banding of Esophageal Varices MS-DRG 981 Extensive O.R. procedure unrelated to principal diagnosis w/ MCC Cost weight: K70.30 Alcoholic cirrhosis of liver without ascites I85.11 Secondary esophageal varices with bleeding 06L34CZ Occlusion of esophageal vein with extraluminal device, percutaneous endoscopic approach.

36 36 Root Operation for Bone Marrow Biopsy Q Question: What is the ICD-10-PCS root operation for bone marrow biopsy?

37 37 Root Operation for Bone Marrow Biopsy Q Answer: Biopsy of bone marrow is coded to the root operation “Extraction” with the qualifier “Diagnostic.” Biopsy procedures are coded using the root operations: “Excision,” “Extraction,” or “Drainage,” and the qualifier “Diagnostic.” The qualifier “Diagnostic” is used only for biopsies. Please note: a specific index entry for “bone marrow biopsy” has been added to the ICD-10-PCS, and a new guideline for biopsy has been included in the ICD-10-PCS Official Guidelines for Coding and Reporting.

38 38 Bone Marrow Biopsy Biopsy see Drainage with qualifier Diagnostic see Excision with qualifier Diagnostic Bone Marrow see Extraction with qualifier diagnostic

39 39 History of Ductal Carcinoma in Situ Q Question: Should code V10.3, Personal history of malignant neoplasm, Breast, be reported for history of ductal carcinoma in situ (DCIS) of the breast?

40 40 History of Ductal Carcinoma in Situ Q Answer: No, code V10.3 is not correct. Assign code V13.8, Personal history of other diseases, other specified diseases, for history of DCIS. It is not appropriate to assign code V10.3, Personal history of malignant neoplasm of breast, since DCIS (code 233.0) is not classified as a primary malignancy. Code V10.3 is reserved for personal history of “primary” breast malignancy for conditions classifiable to 174 and 175, as the inclusion note under code V10.3 indicates.

41 41 Heart Failure with Preserved or Reduced Ejection Fraction Q Question: If a physician documents heart failure with -preserved ejection fraction (HFpEF), or -preserved systolic function, or alternatively -reduced ejection fraction (HFrEF), -low ejection fraction, -reduced systolic function, or -other similar terms - Can the coder assume the physician means “diastolic heart failure” or “systolic heart failure,” respectively, and apply the proper ICD-9-CM code based on the documented clinical circumstances?

42 42 Heart Failure with Preserved or Reduced Ejection Fraction Q Answer: No, the coder cannot assume either diastolic or systolic failure or a combination of both, based on these newer terms. Therefore, query the provider to clarify whether the patient has diastolic or systolic heart failure.

43 43 Immune Thrombocytopenic Purpura and Pancytopenia Q Question: When a patient has both immune thrombocytopenic purpura and pancytopenia, are both conditions coded? Or, does the rule for not coding thrombocytopenia with pancytopenia apply?

44 44 Immune Thrombocytopenic Purpura and Pancytopenia Q Answer: Assign both codes , Immune thrombocytopenic purpura, and , Other pancytopenia, for immune thrombocytopenic purpura and pancytopenia. Although code includes a deficiency in the number of platelets in the body, it does not identify that the patient has immune thrombocytopenic purpura. Therefore, code is needed to identify this condition.

45 45 Traumatic Urinary Catheterization Q Question: The patient was admitted to the hospital for treatment of multiple injuries. In the ER, the patient experienced a urethral injury as a result of an unsuccessful traumatic Foley catheter insertion. This resulted in bloody output from the urethra and urology was consulted for this issue. In the final diagnostic statement the provider listed, “Traumatic Foley catheterization.” How should this diagnosis be coded?

46 46 Traumatic Urinary Catheterization Q Answer: In this case, injury to the urethra was a result of the procedure. Assign codes 997.5, Urinary complications, and 867.0, Injury of pelvic organs, bladder and urethra, without mention of open wound into cavity, and E870.8, Misadventures to patient during surgical and medical care, Other specified medical care.

47 47 Traumatic Urinary Catheterization Q Answer (continued): A traumatic catheterization would not be coded unless there is documentation of a specific complication or injury. If the extent of the traumatic catheterization is questionable, query the physician as to the extent of the injury to the urethra. Additionally, the bleeding would not be coded separately since it is considered inherent to the injury. This is a different situation than that published in Coding Clinic, November-December 1985, page 15, where the patient pulled out his own catheter, and an injury code was assigned instead of a complication code.

48 48 Traumatic Urinary Catheterization Q Question: The patient was admitted for surgical treatment of rectosigmoid cancer. A Foley catheter was inserted prior to surgery. After surgery, the provider noted red blood cells in the urinalysis. However, there was no documentation of a complication or injury related to the catheter insertion. How would this be coded?

49 49 Traumatic Urinary Catheterization Q Answer: Do not assign a complication or injury code. Although red blood cells may be present in the urinalysis following urinary catheter insertion, this does not necessarily indicate a complication and/or injury. Unless the physician documents traumatic catheterization with a specific injury or complication it is not coded as such.

50 50 Questions? Barry Libman, MS, RHIA, CDIP, CCS, CCS-P President, Barry Libman Inc. President, Libman Education


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