1. Country Villa Health Services MRD Workshop December 2010 Presented By Lizeth Flores, RHIT Anderson Health Information Systems Inc. lizeth@ahis.net

2. Objectives Participants will: –Correctly assign ICD-9-CM codes to diagnoses –Correctly identify primary / Secondary diagnoses –Identify correct sequence of diagnoses for coding assignment –Learn 2010-2011 coding updates

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4. Assigning Code Numbers Both the Alphabetic Index and the Tabular List must be used when locating and assigning a code. Do not rely on just one since this can lead to errors in code assignment and a less specific code selection

5. How to Select Codes Locate each main term and subterm in the alphabetical index, i.e., Chronic Kidney Disease Disease 1. Disease 2. Kidney 3. Chronic Verify the code selected in the Tabular list Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List

6. Code to the Highest Level of Specificity Assign 3 digit codes only if there are no four digit codes within the category. –There are only 100 codes with only 3 digits Assign 4 digit codes only if there is no fifth digit. Assign 5 digit codes when indicated. Samples – 486, 401.x, 250.xx

7. Types of Codes used in post acute care Settings Aftercare – used when the initial treatment of a disease or injury has been performed and the patients still requires continued care to heal or recover. Categories V51-V58 Late Effects – a late effect is a residual condition that remains and requires medical evaluation, rehab treatments and/or nursing care after the initial illness or injury.

8. Types of Codes -3 History of – (Hx) – history codes are acceptable on any Medical record regardless of reason for admission/encounter. A history code is distinct from a “status” code in that history codes indicate that the patient no longer has the condition and “status” codes indicated a present state. There are two types of history V-codes, personal and family.

9. Types of Codes -2 Chronic Conditions – Conditions that are stable but still require management or treatment. Acute Conditions –acute care codes should only be reported until the condition is resolved. Therapy – Physical, occupational, speech and respiratory therapy.

10. Examples Status post ORIF of hip fracture V54.11 History of frequent falls V15.88 Admission for physical therapy following hip fracture V57.1, V54.13

11. Let’s Practice Colitis Hypertension Benign prostatic hypertrophy (BPH)

12. Definition of Principal Diagnosis “FIRST LISTED DIAGNOSES” is the diagnosis that is chiefly responsible for the admission to the facility and the diagnosis that supports the reimbursement and should be sequenced first.”

13. Locating Diagnoses Transfer Records History & Physical Progress Notes Admission Orders

14. Additional Sources of Information Discharge summary Transfer documentation, Surgical reports Consultations Physician Progress notes Lab reports and radiological studies

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16. Choose the Principal Diagnosis Fall 3 months ago Chronic kidney disease Above the knee amputation Rt. Leg (10 days ago) Anemia MRSA of surgical wound (resolved)

17. Combination Codes Single codes used to classify two diagnosis or a diagnosis with a manifestation Example: Candidiasis with meningitis 112.83

18. Combination Codes Etiology codes – USE ADDITIONAL CODE Manifestation codes – CODE 1 st Underlying Dx. Codes in parentheses identify conditions that require multiple coding. Also, codes in parentheses CAN NOT be sequenced as PRINCIPAL Dx.

19. Combination Codes Anosmia following CVA 438.6, 781.1 “with”, “with mention of”, or “associated with” – this code can only be used if both conditions are present Kidney Infection …..590.9 with Calculus 592.0

20. Multiple Coding Instructions for conditions that require multiple coding can appear in the Tabular List. –“Code also underlying disease”, “Use additional code, if desired, to identify manifestation, as …” “Code also” instructs the coder to: Code the underlying disease, or etiology first as the primary diagnosis, followed by the code (s) for manifestation (s). It is mandatory to follow the “code also” instructions to assign both codes.

21. Slanted Brackets [ ] Indicate proper sequencing for the two codes listed. –The code number before the bracket is coded first. –The code number inside the brackets is coded second. Codes in brackets in the alphabetic index can NEVER be sequenced as the principal diagnosis.

22. EXAMPLES 1.Arthritis, arthritic --- due to or associated with hypothyroidism 244.9 [713.0]

23. Multiple Coding Examples: –Aftercare following kidney transplant –V58.44 (aftercare involving organ transplant), –V42.0 (Organ/tissue replacement by transplant, kidney) –Aftercare following arteriocoronary bypass –V58.73 (aftercare following surgery of the circulatory system), V45.81(aortocoronary bypass status) –  use aftercare codes to provide better detail

24. Let’s Practice 1. Chronic Peptic Ulcer with Hemorrhage 2. Diverticulitis of Duodenum “with” bleeding

25. YES IT’S TRUE V CODES CAN BE USED AS THE 1 ST LISTED DIAGNOSIS

26. V- Codes Per ICD-9-CM Official Guidelines for Coding and Reporting, aftercare codes are generally first to explain the specific reason for the encounter (admission) Certain aftercare code categories need a secondary dx code to describe the resolving condition or sequelae For others (V codes) the condition is inherent in code title

27. Coding Clinic Fourth Quarter 1999 Published rules for the use of V codes Addressed the use of V codes in LTC settings Coding clinic Fourth Quarter 2003 Clarified the use of aftercare V codes for all subsequent encounters after the initial treatment for a fracture “for statistical purposes, a facture should only be reported once”

28. V- Codes -2 V-codes are assigned to problems that affect the patient’s health but are not in themselves a current illness or injury V-codes can be used to represent status or history. Examples: –Status Cardiac Pacemaker V45.01 –Status heart valve prosthesis V43.3 –History of falls V15.88 –History of alcoholism V11.3 Remember not to use acute care codes when coding aftercare

29. Let’s Practice Admitted for physical therapy, status post total knee replacement due to arthritis 1) Admission – rehabilitation – physical 2 ) Aftercare – following surgery for – joint replacement 3) Replacement – joint – Knee V57.1, V54.81, V43.65

30. Let’s Practice Which of the following is a late effect? a. End stage renal disease b. Anosmia following recent CVA c. Diabetic retinopathy d. Paraplegia due to polio

31. Let’s Code Left hemiplegia secondary to CVA (patient is right handed) Late Effects Cerebrovascular disease With hemiplegia – nondominant side

32. Infections Codes from categories 041 or 079 can be used as principal diagnosis as long as the nature or site of the infection is not specified or when the Alphabetical index instructs you to do so.

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34. Code it Gastroenteritis due to E.coli MRSA infection of Lt. toe Herpetic septicimia

35. Neoplasms with Metastasis Two codes –One for primary (original site) –One for each secondary site Code primary before secondary –Except when using “V” code for primary site that has been surgically removed

36. Neoplasms with Metastasis Determine the primary site Turn to Neoplasms Table Ex: Carcinoma of Rectum (154.1) Find Neoplasm, rectum, malignant, primary

37. Neoplasms with Metastasis Ex: Secondary malignant neoplasm of prostate (198.82) Find Neoplasm, prostate, malignant, secondary Determine the site(s) of metastasis Turn to Neoplasm table Find correct subterm(s) for site Cross over to Malignant and column secondary

38. Unknown secondary sites Ex: Cancer of Lower lobe of lung with metastases (162.5, 199.0) Code primary site first To code the unknown secondary site –Refer to Neoplasm table –Multiple sites NEC –Cross over to column for code (199.0)

39. Unknown Primary Site Refer to neoplasm table Unknown or Unspecified site Cross over to primary column 199.1 Sequence after secondary site(s) Ex: abdominal metastasis from unknown origin (198.89, 199.1) Unknown primary would not be used as principle diagnosis in SNF The metastatic site is coded first

40. “V” Codes for Cancer Primary site must still be identified if removed, eradicated no longer under treatment Use a personal history V-code, History,site, malignant neoplasm Identify primary site responsible for metastasis but no longer present Secondary site code is sequenced first and then the V-code

41. “V” Codes for Cancer Do not use codes from category V10 for secondary metastatic sites removed or not ICD-9-CM does not provide code numbers for “history of secondary neoplasm site

42. V58.42 Neoplasm Official coding guidelines for neoplasm apply when using the aftercare following surgery for neoplasm V58.42 Aftercare code V58.42 may be used with either the current neoplasm code or a code from category V10, whichever is applicable

43. V-Codes (2010) V12.41 Personal history of benign neoplasm of the brain. –Previously, no code to indicate that the patient had benign growth. These can cause serious symptoms in the patient.

44. Endocrine, Nutritional and Metabolic Diseases and immunity disorders Examples: Hypothyroidism Diabetes Metabolic disorders Obesity

45. Code It Hypothyroidism due to history of thyroid cancer (thyroid removed) Uncontrolled, Type II Diabetes

46. Manifestations Codes There are written instructions in ICD-9-CM coding books for sequencing codes. The underlying Dx (cause/s) coded first, followed by codes for manifestations.

47. Combination Codes Some Diabetic Conditions Require 2 Codes – “Diabetic” or “Due to” One Code for Cause One Code for Complication – Always sequence cause before complication

48. Combination Codes Example: –Diabetic foot ulcer Diabetes with other manifestation –250.8x Ulcer of lower limb, except decubitus –707.1x

49. Manifestation Codes Diabetic Neuropathy Diabetes with neurological manifestations must be coded first (250.60) The tabular list will guide you to “Use additional code to identify manifestation, as:” Polyneuropathy in diabetes (357.2) The tabular section will tell you that this code is not allowed as a principal Dx and will guide you to code underlying disease, as (Diabetes with complication…)

50. Let’s Code 1. DIABETIC GLAUCOMA

51. Chronic Illnesses Chronic illnesses that are managed with medication or treatments, such as hypertension, hypothyroidism, diabetes mellitus, atrial fibrillation, assign the appropriate ICD 9 code The chronic condition exists, but is under control by medication

52. Myocardial Infarction A code from category 410.XX must be assigned if the admission is strictly for rehabilitation within eight weeks of the acute MI. The fifth digit 2 would be used in LTC to designate observation, treatment or evaluation of MI within eight weeks of onset, following the acute phase or in the healing state.

53. Myocardial Infarction The fifth digit “1” should be used if the acute myocardial infarction occurred at the nursing facility and was the reason for transfer to the hospital or the cause of death. If the admission takes place after eight weeks assign code (412) Old Myocardial Infarction

54. Hypertension Unless the diagnosis statement specifies as “benign” or “Malignant” “unspecified” code (401.9) must be assigned

55. Heart Conditions Due to Hypertension When there is a casual relationship is states as “hypertensive” or “due to hypertension” heart conditions are assigned by Category 402 Hypertensive Heart Disease Arteriosclerotic disease due to hypertension 402.90

56. Circulatory System Let’s Code 1.Chronic hypertensive kidney disease

57. Respiratory System Let’s Code Aspiration Pneumonia Chronic bronchitis with emphysema

58. Skin Ulcers Clarification of clinical terms related to skin ulcers www.cms.hhs.gov/manuals/pm trans/r4som.pdfwww.cms.hhs.gov/manuals/pm trans/r4som.pdf Pressure Ulcer is a synonym for decubitus ulcer – due to prolonged pressure Subcategory 707.0x has fifth digits to identify site 2009- New- additional code must be used to identify stage

59. Skin Ulcers of Lower Limbs Non pressure ulcers of lower leg Fifth digits to identify site Multiple coding, code first the underlying dx, such as arteriosclerosis, diabetes, venous hypertension –i.e. diabetic ulcer of left fifth toe 250.80, 707.15

60. Stasis Ulcers The most common type of vascular ulcers –In Alphabetical index under “ulcer”, the index lists “venous” as a non-essential modifier under the subterm “stasis” that refers to code 459.81. –Under section 459.81 in the Tabular List you will be instructed to code any associated ulceration from category 707.0-707.9

61. Wounds Category 870-897 Codes for wounds are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds

62. V54.1 Aftercare for healing traumatic fracture For residents admitted to a SNF for care following treatment in the acute hospital for a traumatic fx use the aftercare codes from Subcategory V54.1 Do not code the (acute) fracture Coding Guidelines require an aftercare code be used after the initial encounter for care of a fx.

63. V54.1 Aftercare for healing traumatic fracture For statistical purposes, a fracture should only be coded once. If the same fx is coded for all encounters, it makes collection of fracture statistics difficult The V54.1 identifies the site of the fracture and that it is in the healing phases Aftercare for Fractures; Pathologic and Traumatic

64. V54.1 Aftercare for healing traumatic fracture The fifth digits identify the specific site of the healing fracture The fifth digit 9 is used for other specified sites If there are several bones that would be classified to the other specified site, only one code is used

65. V54.1 Aftercare for healing traumatic fracture DO NOT code V58.43 Aftercare following surgery for injury and trauma (conditions classifiable to 800-999) Exclusion note states “Excludes: aftercare for healing traumatic fracture” Remember to always refer to the tabular list and carefully read the instructions and exclusions.

66. Aftercare for healing Pathological fracture Pathological fracture is a fracture in a bone due to weakening of the bone structure by disease process such as osteoporosis. For admissions in LTC following a hospital stay for treatment of a pathological fracture assign a code from Subcategory V54.2 Aftercare for healing pathologic fracture A compression fracture of the vertebrae is considered pathologic if it is not caused by trauma

67. Hx of Fracture V13.51 personal hx of healed pathologic fx V13.52 personal hx of healed stress fx V15.51 personal hx of healed traumatic fx Note added to subcatagory 733.0 -use add’l code to identify personal hx of pathologic (healed) fx (V13.51)

68. V54.81 Joint replacement Joint replacement of knee for osteoarthritis (V58.78), V54.81, V43.65 Do not code the disease condition that was treated with the surgery 2008 will have a change in the tabular list for V58.78 that will exclude it when there is orthopedic aftercare; codes from section V54.01-V54.9 will be used.

69. Joint Replacement for Fx Use multiple coding to fully describe the resident’s condition FX hip (traumatic) with joint replacement V54.13, V54.81, V43.64 Do not use V58.43 Aftercare following surgery for injury and trauma-(not for fx) (conditions classifiable to 800-999) see excludes note: (V54.10-V54.19)

70. V57 Care Involving Rehab Category V57 does not indicate that rehab services were provided, only that the resident was admitted for this purpose Use only one code from Category V57 for an admission If the resident is admitted for multiple therapies, use V57.89

71. V57 Care Involving Rehab Code also the condition requiring the rehab, such as: –Residuals –Late effects –Aftercare –symptoms

72. V58 Aftercare Following Surgery The acute dx for which the surgery was preformed is not reported for aftercare encounters or admissions Use other aftercare or symptom codes to provide better detail Note the instructions with each code that identifies the range of conditions that are included in the aftercare code number –i.e. aftercare post cataract extraction with lens implant: V58.71, V45.61, V43.1

73. 2010 ICD-9-CM addenda Implementation date of new, revised and invalid codes October 1, 2010 See handout for code details

74. Happy Holidays