1. DIAGNOSIS CODING FOR LONG TERM CARE SETTINGS DIAGNOSIS CODING FOR LONG TERM CARE SETTINGS Presented by: Lizeth Flores, RHIT & Khaleelah Wagner, RHIA Anderson Health Information Systems, Inc. 940 W. 17 th Street, Suite B Santa Ana, California, 92706 Tel. (714) 558-3887 Email: office@ahis.net

2. Objectives Participants will: Participants will: Correctly assign ICD-9-CM codes to diagnoses Correctly assign ICD-9-CM codes to diagnoses Correctly identify primary / Secondary diagnoses Correctly identify primary / Secondary diagnoses Learn 2009 coding updates Learn 2009 coding updates

3. Purpose of ICD- 9-CM Coding Gather statistical data Gather statistical data Reporting diagnoses and provides a method for sequencing diagnosis to support reimbursement Reporting diagnoses and provides a method for sequencing diagnosis to support reimbursement Ensure compliance with Federal Reporting Standards for diagnoses Ensure compliance with Federal Reporting Standards for diagnoses Provide insight into the types of residents and conditions Provide insight into the types of residents and conditions Health Research Health Research

4. Definition Principal Diagnosis “FIRST LISTED DIAGNOSES” is the diagnosis that is chiefly responsible for the admissions to, continued residence in the nursing facility and the diagnosis that support the reimbursement and should be sequenced first.” “FIRST LISTED DIAGNOSES” is the diagnosis that is chiefly responsible for the admissions to, continued residence in the nursing facility and the diagnosis that support the reimbursement and should be sequenced first.”

5. Types of Codes Used in LTC 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. 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. 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. 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.

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

7. Types of Codes -3 History of – (Hx) – history codes are acceptable on any Medical record regardless of reason for admission/encounter. 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. 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. There are two types of history V-codes, personal and family.

8. Medicare Medicare diagnosis needs to be consistent with covered services & MDS. Medicare diagnosis needs to be consistent with covered services & MDS.

9. Medicare -2 Resident must have a 3-day qualifying hospital stay. Resident must have a 3-day qualifying hospital stay. Physician must certify the need for skilled nursing services. Physician must certify the need for skilled nursing services. Skilled services must be related to the condition treated during the qualifying 3 day hospital stay. Skilled services must be related to the condition treated during the qualifying 3 day hospital stay.

10. Examples Resident was treated for UTI at the hospital and is still on IV antibiotic therapy. Resident was treated for UTI at the hospital and is still on IV antibiotic therapy. Resident had surgery for a bowel obstruction and needs care to the surgical site and physical / occupational therapy Resident had surgery for a bowel obstruction and needs care to the surgical site and physical / occupational therapy

11. What to Code? ALL CONDITIONS THAT EXIST AT THE TIME OF ADMISSION, THAT EFFECT TREATMENT RECEIVED

12. Do NOT Code DIAGNOSES THAT DO NOT AFFECT TREATMENT OR LENGTH OF STAY DIAGNOSES THAT DO NOT AFFECT TREATMENT OR LENGTH OF STAY WHEN CONDITION NO LONGER EXISTS WHEN CONDITION NO LONGER EXISTS DO NOT ASSIGN PROCEDURE CODES DO NOT ASSIGN PROCEDURE CODES Examples: Fractured forearm 6 years ago, pneumonia, UTI that were resolved (these will only be coded if the Resident is admitted with Antibiotics ) Examples: Fractured forearm 6 years ago, pneumonia, UTI that were resolved (these will only be coded if the Resident is admitted with Antibiotics )

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

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

15. Locating Principal Diagnosis

16. Principal Diagnosis When two or more inter-related conditions potentially meet the definition of principal diagnosis When two or more inter-related conditions potentially meet the definition of principal diagnosis Either may be sequenced first unless therapy is being provided, the Tabular list or Alphabetic Index indicate otherwise. Either may be sequenced first unless therapy is being provided, the Tabular list or Alphabetic Index indicate otherwise. Inter-related conditions – two or more diagnosis that equally meet the definition of principal diagnosis. Inter-related conditions – two or more diagnosis that equally meet the definition of principal diagnosis.

17. Example Resident admitted with Pneumonia and UTI – either can be used as the principal diagnosis if the resident is still receiving antibiotic therapy Resident admitted with Pneumonia and UTI – either can be used as the principal diagnosis if the resident is still receiving antibiotic therapy

18. Principal Diagnosis -2 The first Dx identifies the main reason for the resident’s admission/encounter The first Dx identifies the main reason for the resident’s admission/encounter The terms Admission and encounter can be used interchangeably and are used all healthcare settings. (they have the same meaning) The terms Admission and encounter can be used interchangeably and are used all healthcare settings. (they have the same meaning)

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

20. Diagnosis Sequencing The order in which codes are listed is called sequencing. The coder should make every effort to record the codes in a logical sequence that is descriptive of the resident’s condition. The order in which codes are listed is called sequencing. The coder should make every effort to record the codes in a logical sequence that is descriptive of the resident’s condition.

21. Choose the Correct Sequence… Diabetes Diabetes Diabetic retinopathy Diabetic retinopathy UTI (on antibiotics) UTI (on antibiotics) Chronic Back Pain Chronic Back Pain Hyperlipidemia Hyperlipidemia Osteoporosis Osteoporosis

22. Secondary Diagnoses To further support Medicare covered skilled services – usually in order of complexity. To further support Medicare covered skilled services – usually in order of complexity. May have multiple secondary codes May have multiple secondary codes List and code conditions related to therapy and services provided List and code conditions related to therapy and services provided Review and update as condition changes – sequence may change over time Review and update as condition changes – sequence may change over time Billing staff should work with Nursing and Health Information Department to know which diagnoses are current, which is principal, etc. Billing staff should work with Nursing and Health Information Department to know which diagnoses are current, which is principal, etc.

23. Secondary Diagnoses -2 Order by complexity. Order by complexity. Assign the condition with the higher complexity first. (those that require the most resources i.e. wound care vs. hypertension) Assign the condition with the higher complexity first. (those that require the most resources i.e. wound care vs. hypertension) All conditions present at the time of admission, and that affect the treatment provided and length of stay should be coded. All conditions present at the time of admission, and that affect the treatment provided and length of stay should be coded.

24. Acute Diagnoses Acute dx treated in the hospital should be coded until the condition is resolved, after the resident is transferred to the SNF Acute dx treated in the hospital should be coded until the condition is resolved, after the resident is transferred to the SNFExamples:MRSAPneumoniaUTI

25. ICD-9-CM Official Guidelines for Coding & Reporting www.cdc.gov/nchs/data/icd9/cdguide.pdf www.cdc.gov/nchs/data/icd9/cdguide.pdf www.cdc.gov/nchs/data/icd9/cdguide.pdf Latest Revision October 1, 2008 Latest Revision October 1, 2008 Codes revised twice per year April and October Codes revised twice per year April and October April codes will come out only if significant or important and can not wait until October April codes will come out only if significant or important and can not wait until October

26. ICD-9-CM Coding Book Disease and Procedures (Books 1-3) Disease and Procedures (Books 1-3) Alphabetical/Tabular (numeric) Index Alphabetical/Tabular (numeric) Index

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

28. How to Select Codes Locate each main term and subterm in the alphabetical index, i.e., Chronic Kidney Disease Disease 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 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 Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List

29. Let’s Practice Scabies Scabies Colitis Colitis MRSA of blood MRSA of blood Hypertension Hypertension Benign prostatic hypertrophy (BPH) Benign prostatic hypertrophy (BPH)

30. Some Help Scabies - 133.0 Scabies - 133.0 Colitis – 558.9 Colitis – 558.9 MRSA of blood – 041.12 MRSA of blood – 041.12 Hypertension – 401.9 Hypertension – 401.9 Bening Prostate Hypertrophy 600.00 Bening Prostate Hypertrophy 600.00

31. Tabular List Instructions for conditions that require multiple coding can appear in the Tabular List. 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 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). 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. It is mandatory to follow the “code also” instructions to assign both codes.

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

33. EXAMPLES 1.Arthritis, arthritic --- due to or associated with hypothyroidism 244.9 [713.0] 244.9 [713.0] 2. UTI due to E.coli 599.0, [041.4] 599.0, [041.4]

34. Let’s have a look See 429 section See 429 section Under Cardiovascular Disease, Unspecified Under Cardiovascular Disease, Unspecified Excludes: That due to hypertension Excludes: That due to hypertension

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

36. Non-Specific Codes NEC – Not Elsewhere Classified NEC – Not Elsewhere Classified NOS – Not Otherwise Specified NOS – Not Otherwise Specified Codes are used only when neither the diagnostic statement nor a thorough review of the clinical record provides adequate information to permit assignment of a more specific code Codes are used only when neither the diagnostic statement nor a thorough review of the clinical record provides adequate information to permit assignment of a more specific code

37. 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) 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 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 For others (V codes) the condition is inherent in code title

38. 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 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. V-codes can be used to represent status or history. Examples: Examples: Status Cardiac Pacemaker V45.01 Status Cardiac Pacemaker V45.01 Status heart valve prosthesis V43.3 Status heart valve prosthesis V43.3 History of falls V15.88 History of falls V15.88 History of alcoholism V11.3 History of alcoholism V11.3 Remember not to use acute care codes when coding aftercare Remember not to use acute care codes when coding aftercare

39. Combination Codes A single code used to classify TWO (2) diagnoses or a diagnosis with an associated manifestation or complication. A single code used to classify TWO (2) diagnoses or a diagnosis with an associated manifestation or complication. Key words: Key words: “AND”, “AND/OR” “AND”, “AND/OR” “WITH”, “WITH MENTION OF” OR “ASSOCIATED WITH” “WITH”, “WITH MENTION OF” OR “ASSOCIATED WITH” “EXCLUDES” “EXCLUDES”

40. Let’s Practice 1. Chronic Peptic Ulcer with Hemorrhage 1. Chronic Peptic Ulcer with Hemorrhage 2. Cerebral thrombosis with cerebral infarction 2. Cerebral thrombosis with cerebral infarction 3. Diverticulitis of Duodenum “with” bleeding 3. Diverticulitis of Duodenum “with” bleeding

41. Combination Codes -2 Certain conditions have both underlying etiology and multiple body system manifestations, due to the underlying etiology. Code the underlying etiology first, followed by the manifestation. Certain conditions have both underlying etiology and multiple body system manifestations, due to the underlying etiology. Code the underlying etiology first, followed by the manifestation.

42. Combination Codes -3 Etiology codes – USE ADDITIONAL CODE Etiology codes – USE ADDITIONAL CODE Manifestation codes – CODE 1 st Underlying Dx. 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. Codes in parentheses identify conditions that require multiple coding. Also, codes in parentheses CAN NOT be sequenced as PRINCIPAL Dx.

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

44. Manifestation Codes -2 Diabetic Neuropathy Diabetic Neuropathy Diabetes with neurological manifestations must be coded first (250.60) Diabetes with neurological manifestations must be coded first (250.60) The tabular list will guide you to “Use additional code to identify manifestation, as:” The tabular list will guide you to “Use additional code to identify manifestation, as:” Polyneuropathy in diabetes (357.2) 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…) 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…)

45. Let’s Code 1. ALZHEIMER’S DEMENTIA 1. ALZHEIMER’S DEMENTIA 2. DIABETIC GLAUCOMA 2. DIABETIC GLAUCOMA

46. Multiple Coding Multiple Coding of Diagnoses Multiple Coding of Diagnoses Find the main term in the Alphabetical Index to locate the code number reference. Check the reference in the Tabular List for notes and instructions “associated with”, “due to”, “secondary to”, etc. are clues that multiple coding may be necessary. Find the main term in the Alphabetical Index to locate the code number reference. Check the reference in the Tabular List for notes and instructions “associated with”, “due to”, “secondary to”, etc. are clues that multiple coding may be necessary.

47. Multiple Coding -3 “Associate with”, “Due to”, or “Secondary to”… “Associate with”, “Due to”, or “Secondary to”… Frequently needed to completely identify diagnosis of resident’s in long term care facilities. Frequently needed to completely identify diagnosis of resident’s in long term care facilities. Residents are often treated for the functional manifestations of a disease. Multiple coding is needed to identify both the underlying disease and the manifestations. Residents are often treated for the functional manifestations of a disease. Multiple coding is needed to identify both the underlying disease and the manifestations.

48. Multiple Coding -4 Examples: Examples: Aftercare following kidney transplant Aftercare following kidney transplant V58.44 (aftercare involving organ transplant), V58.44 (aftercare involving organ transplant), V42.0 (Organ/tissue replacement by transplant, kidney) V42.0 (Organ/tissue replacement by transplant, kidney) Aftercare following arteriocoronary bypass Aftercare following arteriocoronary bypass V58.73 (aftercare following surgery of the circulatory system), V45.81(aortocoronary bypass status) V58.73 (aftercare following surgery of the circulatory system), V45.81(aortocoronary bypass status)  use aftercare codes to provide better detail  use aftercare codes to provide better detail

49. Multiple Coding -5 “Code, if applicable any causal condition first” notes indicate that the code may be assigned as a principal diagnosis when the underlying cause is not known. “Code, if applicable any causal condition first” notes indicate that the code may be assigned as a principal diagnosis when the underlying cause is not known. Example: Example: Lt. heel ulcer 707.14 Lt. heel ulcer 707.14

50. Multiple Coding -6 When the causal condition is known, that code should be sequenced as the principal diagnosis and the manifestation as second. When the causal condition is known, that code should be sequenced as the principal diagnosis and the manifestation as second. Example: Example: Atherosclerotic ulcer of Lt. heel 440.23, 707.14 Atherosclerotic ulcer of Lt. heel 440.23, 707.14

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

52. Acute and Chronic Complications Acute complications Acute complications Need Immediate treatment/life threatening Need Immediate treatment/life threatening Diabetic Ketoacidosis Diabetic Ketoacidosis Hyperglycemia / Hypoglycemia Hyperglycemia / Hypoglycemia Hypokalemia Hypokalemia

53. Chronic Conditions Chronic conditions under treatment are coded even though the condition is under control with medication Chronic conditions under treatment are coded even though the condition is under control with medication 250.xx Diabetes is a common chronic condition that is treated and controlled with medication or diet 250.xx Diabetes is a common chronic condition that is treated and controlled with medication or diet Code diabetes even though it is under control and the resident has no complications Code diabetes even though it is under control and the resident has no complications

54. Reviewing Documentation Reviewing documentation for DX of DM and type Reviewing documentation for DX of DM and type Look for documentation on: Look for documentation on: H&P H&P Discharge summary Discharge summary Surgical reports Surgical reports Physicians’ progress notes Physicians’ progress notes Clarify with attending physician

55. Coding Diabetes Metabolic manifestations of the disease – require only one code Metabolic manifestations of the disease – require only one code Examples: Examples: Diabetes with ketoacidosis 250.1x Diabetes with ketoacidosis 250.1x Diabetes with osmolarity 250.2x Diabetes with osmolarity 250.2x Diabetes with other coma 250.3x Diabetes with other coma 250.3x

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

57. Combination Codes -2 Example: Example: Diabetic foot ulcer Diabetic foot ulcer Diabetes with other manifestation Diabetes with other manifestation 250.8x 250.8x Ulcer of lower limb, except decubitus Ulcer of lower limb, except decubitus 707.1x 707.1x

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

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

60. Stasis Ulcers The most common type of vascular 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. 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 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 Category 870-897 Codes for wounds are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds

62. Skin Tears and Abrasions Abrasions and skin tears are found in the Alphabetical Index under “injury, superficial” Abrasions and skin tears are found in the Alphabetical Index under “injury, superficial” The fourth digit assignment identifies: The fourth digit assignment identifies: Abrasions Abrasions Insect bites Insect bites Infections Infections Superficial foreign body Superficial foreign body Blisters Blisters

63. Cellulitis Skin tears or ulcers may become reddened, infected or swollen. Do not assume the diagnosis of cellulitis unless it is documented by a physician. Skin tears or ulcers may become reddened, infected or swollen. Do not assume the diagnosis of cellulitis unless it is documented by a physician. If cellulitis is present code both the cellulitis and skin ulcer or skin tear to describe the cellulitis as a complication of a skin ulcer or skin tear If cellulitis is present code both the cellulitis and skin ulcer or skin tear to describe the cellulitis as a complication of a skin ulcer or skin tear

64. 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. 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. 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.

65. Myocardial Infarction -2 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. 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 If the admission takes place after eight weeks assign code (412) Old Myocardial Infarction

66. Neoplasms Go to alphabetic index Go to alphabetic index Look up Ex: fibroma, upper jaw Look up Ex: fibroma, upper jaw Find “fibroma” Find “fibroma” Cross reference “see neoplasm, by site,benign” Cross reference “see neoplasm, by site,benign” Turn to neoplasm locate subterm Turn to neoplasm locate subterm “Jaw / upper” “Jaw / upper” Follow across to Benign Follow across to Benign Locate code 213.0 Locate code 213.0 Go to Tabular list for any coding instructions or notes* Go to Tabular list for any coding instructions or notes*

67. Neoplasms of Uncertain Behavior Only used when stated as such in Alpha Index Only used when stated as such in Alpha Index Ex: Gastrinoma of Duodenum (235.2) Ex: Gastrinoma of Duodenum (235.2) Look up: Gastrinoma, specified site Look up: Gastrinoma, specified site States to see Neoplasm,by site, uncertain behavior States to see Neoplasm,by site, uncertain behavior Uncertain behavior = difficult to distinguish from malignant behavior Uncertain behavior = difficult to distinguish from malignant behavior

68. Unspecified Behavior Unspecified behavior – only used when Neoplasm is not fully described Unspecified behavior – only used when Neoplasm is not fully described Or not specified as to behavior Or not specified as to behavior Or listed in Alphabetic index Or listed in Alphabetic index Ex: Neoplastic Cyst of Tongue Ex: Neoplastic Cyst of Tongue Cross reference Alpha Index Under Cyst, neoplastic see neoplasm,by site, unspecified nature Cross reference Alpha Index Under Cyst, neoplastic see neoplasm,by site, unspecified nature

69. Neoplasms with Metastasis Malignant Neoplasm from primary site Malignant Neoplasm from primary site Invade or spread via the Invade or spread via the Blood Blood Lymphatic system Lymphatic system Tissue to secondary metastatic site Tissue to secondary metastatic site Example: Lymphoma with malignant pleural effusion 202.80 (old code 197.2 after Oct. 1 st, 511.81 will be used) Example: Lymphoma with malignant pleural effusion 202.80 (old code 197.2 after Oct. 1 st, 511.81 will be used)

70. Neoplasms with Metastasis -2 Two codes Two codes One for primary (original site) One for primary (original site) One for each secondary site One for each secondary site Code primary before secondary Code primary before secondary Except when using “V” code for primary site that has been surgically removed Except when using “V” code for primary site that has been surgically removed

71. Neoplasms with Metastasis -3 Determine the primary site Determine the primary site Turn to Neoplasms Table Turn to Neoplasms Table Ex: Carcinoma of Rectum (154.1) Ex: Carcinoma of Rectum (154.1) Find Neoplasm, rectum, malignant, primary Find Neoplasm, rectum, malignant, primary

72. Neoplasms with Metastasis -4 Ex: Secondary malignant neoplasm of prostate (198.82 Ex: Secondary malignant neoplasm of prostate (198.82 Find Neoplasm, prostate, malignant, secondary Determine the site(s) of metastasis Find Neoplasm, prostate, malignant, secondary Determine the site(s) of metastasis Turn to Neoplasm table Turn to Neoplasm table Find correct subterm(s) for site Find correct subterm(s) for site Cross over to Malignant and column secondary Cross over to Malignant and column secondary

73. Unknown Secondary Sites Ex: Cancer of Lower lobe of lung with metastases (162.5, 199.0) Ex: Cancer of Lower lobe of lung with metastases (162.5, 199.0) Code primary site first Code primary site first To code the unknown secondary site To code the unknown secondary site Refer to Neoplasm table Refer to Neoplasm table Multiple sites NEC Multiple sites NEC Cross over to column for code (199.1) Cross over to column for code (199.1)

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

75. “V” Codes for Cancer Primary site must still be identified Primary site must still be identified If removed, eradicated no longer under treatment If removed, eradicated no longer under treatment Use a personal history V-code, History,site, malignant neoplasm Use a personal history V-code, History,site, malignant neoplasm Identify primary site responsible for metastasis but no longer present Identify primary site responsible for metastasis but no longer present

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

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

78. V58.42 Neoplasm -2 A primary malignancy A primary malignancy Previously excised or eradicated from its site Previously excised or eradicated from its site And there is no further tx directed to that site And there is no further tx directed to that site And there is no evidence of any existing primary malignancy, And there is no evidence of any existing primary malignancy, A code from Category V10 is used to identify the former site of malignancy A code from Category V10 is used to identify the former site of malignancy

79. V-Codes -2 V12.41 Personal history of benign neoplasm of the brain. 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. Previously, no code to indicate that the patient had benign growth. These can cause serious symptoms in the patient.

80. Late Effects of CVA’s (438.0-438.9) Rather than code the residual condition AND the late effect, combination codes that include the late effect should be used. Additionally, these can be used with a new CVA. Rather than code the residual condition AND the late effect, combination codes that include the late effect should be used. Additionally, these can be used with a new CVA. DO NOT code 436 for CVA codes from categories 430-436 are used for the initial episode of care for an acute CVA at the hospital DO NOT code 436 for CVA codes from categories 430-436 are used for the initial episode of care for an acute CVA at the hospital

81. Late Effect -2 A late effect is a residual condition that remains and requires nursing care after the initial phase of an illness or injury has passed A late effect is a residual condition that remains and requires nursing care after the initial phase of an illness or injury has passed Locate the codes in the Alphabetical Index under the main term “Late, effect (s)(of) Locate the codes in the Alphabetical Index under the main term “Late, effect (s)(of)

82. Late Effect -3 The residual condition is coded first and the late effect is sequenced second The residual condition is coded first and the late effect is sequenced second Multiple coding is required for most late effects Multiple coding is required for most late effects A late effect is not used as a principal dx, except for Category 438 Late Effect of CVA A late effect is not used as a principal dx, except for Category 438 Late Effect of CVA i.e. Left Hemiplegia due to CVA 438.20 i.e. Left Hemiplegia due to CVA 438.20

83. 438 Late Effect of CVA Official coding guidelines state that Category 438 is used for admission and encounter for post acute care following treatment of the CVA in the acute hospital Official coding guidelines state that Category 438 is used for admission and encounter for post acute care following treatment of the CVA in the acute hospital Codes from categories 430 to 436 are reserved for the “initial” (first) episode of care for an acute CVA that was provided in the qualifying hospital stay and should not be used in SNF Codes from categories 430 to 436 are reserved for the “initial” (first) episode of care for an acute CVA that was provided in the qualifying hospital stay and should not be used in SNF

84. 438 Combination/Multiple Coding Category 438 includes combination codes that describe both the cause and the residual deficit Category 438 includes combination codes that describe both the cause and the residual deficit Right hemiplegia due to old CVA 438.20 Right hemiplegia due to old CVA 438.20 More than one code my be used from category 438 to identify multiple residuals from a CVA More than one code my be used from category 438 to identify multiple residuals from a CVA Dysphagia and left hemiplegia post CVA 438.82, 438.20 Dysphagia and left hemiplegia post CVA 438.82, 438.20

85. 438 Use additional codes with category 438 if the combination code does not address all elements of diagnostic statement Use additional codes with category 438 if the combination code does not address all elements of diagnostic statement Multiple coding is used to identify residuals of CVA that do not have a specific code Multiple coding is used to identify residuals of CVA that do not have a specific code Seizure disorder following CVA 438.89, 780.39 Seizure disorder following CVA 438.89, 780.39

86. 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 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 Do not code the (acute) fracture Coding Guidelines require an aftercare code be used after the initial encounter for care of a fx. Coding Guidelines require an aftercare code be used after the initial encounter for care of a fx.

87. V54.1 Aftercare for Healing Traumatic Fracture -2 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 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 The V54.1 identifies the site of the fracture and that it is in the healing phases Aftercare for Fractures; Pathologic and Traumatic Aftercare for Fractures; Pathologic and Traumatic

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

89. V54 Aftercare Healing Traumatic Fracture -2 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” 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. Remember to always refer to the tabular list and carefully read the instructions and exclusions.

90. Aftercare for Healing Pathological Fx Pathological fracture is a fracture in a bone due to weakening of the bone structure by disease process such as osteoporosis. 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 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 A compression fracture of the vertebrae is considered pathologic if it is not caused by trauma

91. V54.81 Joint Replacement Joint replacement of knee for osteoarthritis (V58.78), V54.81, V43.65 Joint replacement of knee for osteoarthritis (V58.78), V54.81, V43.65 Do not code the disease condition that was treated with the surgery 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. 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.

92. Joint Replacement for FX Use multiple coding to fully describe the resident’s condition Use multiple coding to fully describe the resident’s condition FX hip (traumatic) with joint replacement V54.13, V54.81, V43.64 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) 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) (conditions classifiable to 800-999) see excludes note: (V54.10-V54.19)

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

94. V57 Care Involving Rehab -2 Code also the condition requiring the rehab, such as: Code also the condition requiring the rehab, such as: Residuals Residuals Late effects Late effects Aftercare Aftercare symptoms symptoms

95. V58 Aftercare following Surgery The acute dx for which the surgery was preformed is not reported for aftercare encounters or admissions 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 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 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 i.e. aftercare post cataract extraction with lens implant: V58.71, V45.61, V43.1

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

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

98. 2009 ICD-9-CM addenda 2009 code updates effective 10/1/08 2009 code updates effective 10/1/08 041.11 MSSA (susceptible) 041.11 MSSA (susceptible) 041.12 MRSA (combo code) 041.12 MRSA (combo code) V02.53 colonization MSSA V02.53 colonization MSSA V02.54 colonization MRSA V02.54 colonization MRSA V09.0 DELETED CODE – MRSA V09.0 DELETED CODE – MRSA V12.04 personal hx MRSA V12.04 personal hx MRSA

99. New Catagories Category 249. secondary diabetes mellitus Category 249. secondary diabetes mellitus Category 339. other headache syndromes Category 339. other headache syndromes

100. New Codes 403. hypertensive chronic kidney dx (includes 585. with any condition classifiable to 401) 403. hypertensive chronic kidney dx (includes 585. with any condition classifiable to 401) 599.70 hematuria, unspecified 599.70 hematuria, unspecified 599.71 gross hematuria 599.71 gross hematuria 599.72 microscopic hematuria 599.72 microscopic hematuria 780.72 functional quadriplegia 780.72 functional quadriplegia 780.91 functional incontinence 780.91 functional incontinence

101. More new codes 780.60 fever, NOS 780.60 fever, NOS 780.61 fever, with conditions classified elsewhere 780.61 fever, with conditions classified elsewhere 780.62 postprocedural fever 780.62 postprocedural fever 780.63 post vaccination fever 780.63 post vaccination fever 780.64 chills without fever 780.64 chills without fever V45.11 renal dialysis status V45.11 renal dialysis status V45.12 noncompliance with renal dialysis V45.12 noncompliance with renal dialysis

102. Pressure Ulcer Use add’l code to identify pressure ulcer stage Use add’l code to identify pressure ulcer stage 707.20 pressure ulcer, unspecified stage 707.20 pressure ulcer, unspecified stage 707.21 pressure ulcer, stage I 707.21 pressure ulcer, stage I 707.22 pressure ulcer, stage II 707.22 pressure ulcer, stage II 707.23 pressure ulcer, stage III 707.23 pressure ulcer, stage III 707.24 pressure ulcer, stage IV 707.24 pressure ulcer, stage IV 707.25 pressure ulcer, unstageable 707.25 pressure ulcer, unstageable

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

104. Let’s Practice What You Have Learned Today Coding Exercises Coding Exercises Questions for discussion Questions for discussion

105. Thanks for Attending