1. ICD-10 UPDATES & CLINICAL DOCUMENTATION
2016 SC ACDIS
ICD-10 UPDATES & CLINICAL DOCUMENTATION
“Where are we now after ICD-10 Implementation?”
Yvette Book, BS, MBA, CPC
AHIMA Approved Certified Trainer
December 04, 2015

2. Agenda ICD-10 CM Guidelines PCS Codes Updates
New Services and Technology (add on payments)
Section X for New Technology
What we have learned so far and examples?
Coding Clinic Highlights
Education is the KEY!

3. ICD-10- CM Guidelines and Coding Clinic Updates
What we have learned so far - Approach
Specificity
PDX
Root Operation (Resection vs. Excision)
Devices (i.e. what type, cemented vs. un-cemented or unspecified)

4. Applying Past Issues of AHA Coding Clinic for ICD-9 to ICD-10
In general, clinical information and information on documentation best practices published in Coding Clinic were not unique to ICD-9-CM, and remain applicable for ICD-10-CM with some caveats. For example, Coding Clinic may still be useful to understand clinical clues when applying the guideline regarding not coding separately signs or symptoms that are integral to a condition. Users may continue to use that information, as clues—not clinical criteria.
As long as there is nothing new published in Coding Clinic for ICD-10-CM and ICD-10-PCS to replace it, the advice would stand.
Previously published ICD-9-CM advice that is still relevant and applicable to ICD-10 will continue to be re-published in Coding Clinic for ICD-10- CM/PCS. As with the application of any of the coding advice published in Coding Clinic, the information needs to be reviewed carefully for similarities and differences on a case by case basis. Care must be exercised as the codes may have changed. Such change could be related to new codes, new combination codes, code revisions, a change in nonessential modifiers, or any other instructional note. This is particularly true as ICD-10-CM has many new combination codes that were not available in ICD-9-CM. For example, previous Coding Clinic for ICD-9-CM advice has indicated that hypoxia is not inherent in chronic obstructive pulmonary disease (COPD) and it could be separately coded. Coders should not assume this advice inevitably applies to ICD-10-CM. The correct approach when coding with ICD-10-CM is to review the Index entries for COPD, and determine whether or not there is a combination code for COPD with hypoxia, verify the code in the Tabular List, and review any instructional notes. The coder should then determine whether to code the hypoxia separately—and not automatically assume that a separate code should be assigned.
Reference: Coding Clinic, Fourth Quarter ICD Pages: Effective with discharges: November 13, 2015 

5. 2016 ICD-10 CM No new codes/updates for ICD-10 CM for 2016
nes_2016_Final.pdf
Link for current guidelines, effective 10/1/15 there were limited code updates for ICD 10 PCS to capture new technology

6. Secondary Diagnosis
For reporting purposes the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or
therapeutic treatment; or
diagnostic procedures; or
extended length of hospital stay; or
increased nursing care and/or monitoring

7. CM Guidelines Ch. 19

8. CM Guidelines cont.

9. CM Guidelines cont.

10. Excludes Notes Excludes 1 Excludes 2
An Excludes 1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note.
Excludes 2
An Excludes 2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time.
Reference: Section I.A.12.a-b Coding Guidelines

11. Interim Coding Advice on Excludes 1 Notes
The National Center for Health Statistics (NCHS), the Federal agency responsible for use of the ICD-10-CM in the United States, has issued interim advice as it pertains to excludes 1 notes and unrelated conditions. The following information can be found on the NCHS website:
nchs/data/icd/Interim_Coding_advice_on_Excludes_1_note.pdf.
There are circumstances that have been identified where some conditions included in Excludes 1 notes should be allowed to both be coded, and thus might be more appropriate for an Excludes 2 note. However, due to the partial code freeze, no changes to Excludes notes or revisions to the official coding guidelines can be made until October 1, The new guidance concerning Excludes 1 notes is intended to allow conditions to be reported together when appropriate even though they may currently be subject to an Excludes 1 note.
Reference: Coding Clinic, Fourth Quarter ICD Page: 40 Effective with discharges: November 13, 2015

12. Interpretation of Excludes 1 Notes
Question CC 4th QTR 2015:
We have received several questions regarding the interpretation of Excludes 1 notes in ICD-10-CM when the conditions are unrelated to one another.
Reference: Coding Clinic, Fourth Quarter ICD Page: 40 Effective with discharges: November 13, 2015

13. Answer CC 4th QTR 2015:
If the two conditions are not related to one another, it is permissible to report both codes despite the presence of an Excludes1 note. For example, the Excludes1 note at code range R40-R46, states that symptoms and signs constituting part of a pattern of mental disorder (F01-F99) cannot be assigned with the R40-R46 codes. However, if dizziness (R42) is not a component of the mental health condition (e.g., dizziness is unrelated to bipolar disorder), then separate codes may be assigned for both dizziness and the mental disorder.
In another example, code range I60-I69 (Cerebrovascular Diseases) has an Excludes1 note for traumatic intracranial hemorrhage (S06.-). Codes in I60-I69 should not be used for a diagnosis of traumatic intracranial hemorrhage. However, if the patient has both a current traumatic intracranial hemorrhage and sequela from a previous stroke, then it would be appropriate to assign both a code from S06- and I69-. 

14. Unspecified/Other Specified
“Other” codes
“Unspecified Codes”
The medical record provides detail for which a specific code does not exist.
The information in the medical record is insufficient to assign a more specific code.
For those categories for which an unspecified code is not provided, the “other specified” code may represent both other and unspecified

15. Tobacco – Use, Abuse, Dependence
“SMOKER” = code as
Nicotine dependence F17.2-
“Tobacco Use” (NOS)= Z72.0

16. Alcohol – Use, Abuse, Dependence

17. Alcohol – Use, Abuse, Dependence
Per CC 2nd Qtr.,2015 p query the provider for clarification when alcohol abuse and alcohol dependence is documented.

18. Use of imaging reports for greater specificity
Question:
Previous Coding Clinic advice has supported the assignment of a more specific fracture code in ICD- 9-CM and ICD-10-CM based on findings in imaging reports when a physician has documented a diagnosis of fracture. Does this advice hold true for other conditions that may be further specified based on imaging reports? For example, if a patient is diagnosed with a cerebral infarction or hemorrhagic stroke, can the imaging results be used to identify the specific vessel associated with these conditions?
Reference: Coding Clinic, Third Quarter ICD Page: 5 Effective with discharges: September 15, 2014

19. Answer:
It is appropriate to utilize imaging reports to provide greater specificity of the anatomic site as documented by the physician. Therefore, if a patient is diagnosed with a cerebral infarction or hemorrhagic stroke, it would be appropriate to utilize the imaging report to determine the location of the stroke or infarction.
Reference: Coding Clinic, Third Quarter ICD Page: 5 Effective with discharges: September 15, 2014

20. Diabetes and Osteomyelitis Change
Coding note – Osteomyelitis is not a symptom of DM; however patients with DM are at higher risk in developing infection.
Per Coding Clinic 4th Qtr 2013 p
ICD-9 CM assumed relationship between DM and osteomyelitis when both conditions were present.
ICD-10 CM does NOT presume linkage between DM and osteomyelitis. The physician will need to document a linkage/relationship in order to code as such.

21. Neutropenia and Acute Kidney Injury
If both Neutropenia and Acute Kidney Injury/Complication of Transplant are present on admission and……
Both conditions meet Coding Guidelines Section II.C - Two or more diagnoses that equally meet the definition for principal diagnosis.
Having neutropenia instead of kidney transplant failure as PDX changes to a higher DRG

22. Example
H&P: Patient noted to have neutropenia with ANC of .28 on 6/3 given neupogen and myfortic, valcyte and septra held. Repeat labs on 6/4 showed ANC of .26, pt. sent back to ED for another dose of neupogen. Patient presents today with continued low ANC of admitted for Neutropenia
Patient given additional dose of neupogen. Myfortic, Valcyte and Bactrium were held as meds. believing to be an underlying cause of neutropenia. Hematology was consulted to rule out any viral syndrome, autoimmune condition or leukemia and recommended a bone marrow biopsy. Patient lost IV and refused BM aspiration procedure.
On admission the patient did have elevated creatinine (1.4) thought secondary to dehydration. If the focus of treatment was to correct the Neutropenia and find an underlying cause but patient refused further workup - Neutropenia and AKI both equally treated in this example.
Assign D70.8 Other neutropenia as PDX and N17.9 AKF as secondary

23. Remember!
Manifestation codes are not allowed as principal diagnosis. A manifestation code represents a part of an underlying disease. Example: Uremic Pericarditis N18.9 [I32]

24. ICD-10-PCS Updates and Challenges

25. Top 10 Documentation Tips
Laterality (side) i.e., left or right – 25,000+ codes!
Stage of Care, i.e., initial, subsequent, sequelae
Specific Diagnosis
Specific Anatomy
Associated and/or Related Conditions
Cause of Injury
Documentation of Additional Symptoms or Conditions
Dominant vs. Non-dominant Side
Tobacco Exposure or Use
Gustilo-Anderson scale

26. Body System: General Guidelines
B2.1a
The procedure codes in the general anatomical regions body systems should only be used when the procedure is performed on an anatomical region rather than a specific body part (e.g., root operations Control and Detachment, drainage of a body cavity) or on the rare occasion when no information is available to support assignment of a code to a specific body part.
Example: Control of postoperative hemorrhage is coded to the root operation Control found in the general anatomical regions body systems.

27. Body System General Guidelines cont.
B2.1b
Body systems designated as upper or lower contain body parts located above or below the diaphragm respectively.

28. ICD -10 PCS Reminder Discontinued procedures B3.3.
If the intended procedure is discontinued, code the procedure to the root operation performed.
If a procedure is discontinued before any other root operation is performed, code the root operation inspection of the body part or anatomical region.
See CC, 1st Qtr pg. 22

29. PCS Guideline Revisions
B3.2b: Multiple procedures – The same root operation is repeated in multiple body parts, and those body parts are separate and distinct body parts classified to a single ICD-10 PCS body part value.
B3.11b: Inspection procedures – If multiple tubular body parts are inspected, the most distal body part (the body part furthest from the starting point of the inspection) is coded.

30. PCS Reminder Convention
Convention A10. “AND”, when used in a code description means “and/or”
Ex: Lower Arm and Wrist Muscle means Lower Arm and/or Wrist Muscle

31. Groin: Inguinal Region vs. Femoral Region
PCS Reminders cont.
Groin: Inguinal Region vs. Femoral Region
Groin can refer to either the inguinal region or the femoral region.
The inguinal region is above the inguinal ligament.
The femoral region is below the inguinal ligament.
Per CC 1st Qtr. 2015, pg. 22
Default ICD-10 PCS body part value for groin as inguinal region.

33. Root Operation: General Guidelines (cont.)
B3.1b
Components of a procedure specified in the root operation definition and explanation are not coded separately. Procedural steps necessary to reach the operative site and close the operative site are also not coded separately.

34. Chemotherapy Infusion
High Dose Infusion Interleukin-2 (IL-2) type chemotherapy this procedure will affect the DRG. (i.e. 3E04302)
MS-DRG: 837 Chemo w acute leukemia as SDX or high dose chemo agent with MCC.
As secondary DX

35. Coding additional Procedures – Missed Revenue
Coding Laparoscopic Gastrostomy
Addition of the Nissen Fundoplication code changed the DRG from 391 to 326 which results in an increase in payment.

36. Coding Hip Replacement
Documentation requirements:
If it is not clear from the operative note if the device is cemented, un-cemented then you must use no qualifier.
Physician could be queried for additional information, however this will not change the DRG.
CDI and our team has educated our providers on this issue.

37. Total Hip Replacement Cont.

38. TKR – Total Knee replacement Look for documentation cement in note Brief Op note

39. DRG Shift example
Procedure: 1) PTA thrombectomy av fistula with composite graft segment left upper arm. 2) fistulogram 3) 6mm balloon angioplasty arterial 6mm,8mm venous plasty. 4) angioplasty arterial RS Findings: 1) Initial fistulogram demonstarted complete thrombosed fistula left upper arm. After PTA thrombectomized venous limb, 6mm and 8mm balloon angioplasty axillary vein 90% tight stenosis with significant improvement. Remainder of axillary vein, subclavian vein, brachiocephalic vein and SVC are patent. 2) reflux images demonstrated patent arterial anastomosis but sclerotic juxta arterial segment before the large pseudoaneurysm. After thrombectomized the arterial limb, 6mm balloon angioplasty arterial anastomosis and juxta segment with minimum residual stenosis. Pseudoaneurysm was free of thrombus. No evidence of extravasation.

40. 05CY3CC - Extirpation vein 03CY3ZZ - Extirpation artery
DRG shifts from 808 to 981 with an increase in payment/relative value when thrombosed left upper arm AV fistula (T82.868A) and PCS codes for removal of AV fistula thrombosis and angioplasty shifting DRG 808 to 981.
05CY3CC - Extirpation vein
03CY3ZZ - Extirpation artery
057F3ZZ - Dilation vein
03783ZZ - Dilation artery
DRG shifts from 808 to 981 with an increase in payment/relative value
808- MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W MCC
981 -EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MC
Big change about $24K

41. Totally Implantable central Venous Access Device
Per coding clinic, totally implantable central venous access device is a two-part device and two ICD-10-PCS codes are required to capture insertion of the device. The appropriate code assignment for placement of the infusion portion of the device is based on end placement.
Port-a-cath is placed into the chest via an open approach and the catheter tip is placed percutaneously in the right atrium, assign codes 02H633Z, Insertion of infusion device into right atrium, percutaneous approach, and 0JH60XZ, Insertion of vascular access device into chest subcutaneous tissue and fascia, open approach. If, however, the infusion portion of the port-a-cath ends up in the superior vena cava, assign codes 02HV33Z, Insertion of infusion device into superior vena cava, percutaneous approach, and 0JH60XZ, Insertion of vascular access device into chest subcutaneous tissue and fascia, open approach.
Reference: Coding Clinic, Fourth Quarter ICD Pages: Effective with discharges: November 13, 2015

42. Totally Implantable central Venous Access Device Cont.

43. Use of imaging reports for greater specificity
Question:
Previous Coding Clinic advice has supported the assignment of a more specific fracture code in ICD- 9-CM and ICD-10-CM based on findings in imaging reports when a physician has documented a diagnosis of fracture. Does this advice hold true for other conditions that may be further specified based on imaging reports? For example, if a patient is diagnosed with a cerebral infarction or hemorrhagic stroke, can the imaging results be used to identify the specific vessel associated with these conditions?
Reference: Coding Clinic, Fourth Quarter ICD Pages: Effective with discharges: November 13, 2015

44. Also – reference guideline B3.11b

45. Root Operation Guidelines: Multiple Procedures
B3.2 During the same operative episode, multiple procedures are coded if: The same root operation is performed on different body parts as defined by distinct values of the body part character. b. The same root operation is repeated at different body sites that are included in the same body part value. c. Multiple root operations with distinct objectives are performed on the same body part. d. The intended root operation is attempted using one approach, but is converted to a different approach.

46. Root Operation Guidelines: Excision vs. Resection
B3.8
PCS contains specific body parts for anatomical subdivisions of a body part, such as lobes of the lungs or liver and regions of the intestine.
Resection of the specific body part is coded whenever all of the body part is cut out or off, rather than coding Excision of a less specific body part.

47. Excision vs. Resection
Excision is defined as: cutting out or off, without replacement, a PORTION of a body part.
Ex: partial nephrectomy, left kidney
Resection is defined as: Cutting out or off, without replacement, ALL of a body part.
Ex: lobectomy, right lobe of liver

48. Example – The Whipple Procedure
A Whipple procedure is known as a pancreaticoduodenectomy.
In ICD-9-CM this procedure is coded to 52.7, radical
pancreaticoduodenectomy. This one ICD-9 code includes all components of the procedure: the pancreaticojejunal anastomosis, choledochojejunal
anastomosis, and gastrojejunostomy.
In ICD-10-PCS, the a “whipple”procedure requires the assignment of five separate procedure codes
0FBG0ZZ for the excision of the pancreas, open approach
0DBA0ZZ for the excision of the jejunum, open approach
0DB90ZZ for the excision of the duodenum, open approach
0F1G0ZB for the bypass of the pancreas to the small intestine, open approach
0D160ZA for the bypass of the stomach to jejunum, open approach.
Use of path report will help

49. Revision vs. Change
Revision is defined as: Correcting, to the extent possible, a portion of a malfunctioning DEVICE or the position of a displaced device.
Ex: Adjustment of a pacemaker lead
Change is defined as: Taking out or off a device from a body part and putting back an IDENTICAL OR SIMILAR device in or on the same body part without cutting or puncturing the skin or mucous membrane.
Ex: Urinary catheter change

50. Remember!
When it comes to Revision a complete re-do of the original root operation is coded to the root operation that is performed and not to revision.

51. Dural Patch Clarification
Question:
In the Q&A published in Coding Clinic,Third Quarter 2014, page 24, a Durepair® patch graft was sewn in to cover the wide opening at the site in which a lipoma was removed. Should the fourth character for body part be "2" for dura mater instead of "T" for spinal meninges?
Answer:
The Coding Clinic advice is accurate. The body part value "Spinal Meninges" was intentionally chosen. In the Central Nervous System, the body part value dura mater refers exclusively to the dura mater covering the brain. The body part value Spinal Meninges includes all meningeal layers covering the spinal cord. The exclusive use of the dura mater body part value to refer to the brain produces clearer coded data, because it is more important to know whether the procedure was performed on the brain or the spinal cord than it is to know that a procedure was performed on the dura mater meningeal layer. The body part key has been revised to reflect this.
Reference:       Coding Clinic, Fourth Quarter ICD Page:39 Effective with discharges: November 13, 2015

52. Section X Guidelines General guidelines D1. Section X codes are:
Standalone codes
Not supplemental codes
Fully represent the specific procedure
Ex: XW04321 Introduction of Ceftazidime-Avibactam Anti-infective into Central Vein, Percutaneous Approach
A separate code from table 3E0 in the Administration section is not coded in addition to this code.
1 Represents group 1 new technology for this year next year it will change to #27th character is used to indicated the new technology group.
Ex: Section X codes added for this year have 7th character value 1, New Technology Group 1 and the next year new ones that are added will have 7th character value 2

53. CC/MCC Changes
Principal diagnosis codes that can act as their own CC for DRG grouping
Hydronephrois due to Ureteral Stricture (N13.1)
Hydronephrosis w/ Renal and Ureteral Calculous Obstruction (N13.2)