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
www.BarryLibmanInc.com
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
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AHA Coding Clinic Advisor
• Coding Clinic question submission
• 1) Visit www.CodingClinicAdvisor.com
• 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
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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-10PCS was published; Second Quarter 2014 also available
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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.
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CMS statement
• “On April 1, 2014, the Protecting Access to Medicare Act
of 2014 (PAMA) (Pub. L. No. 113-93) was enacted, which
said that the Secretary may not adopt ICD-10 prior to
October 1, 2015.
• 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, 2015.
• The rule will also require HIPAA covered entities to
continue to use ICD-9-CM through September 30, 2015.”
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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 ICD10-CM and PCS
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Today’s Coding Clinic topics
– ICD-10 Coding Clinics:
– Assigning Codes Using Prior Encounters Q3 2013
– Decompensated Systolic Heart Failure Q2 2013
– Diabetes and Osteomyelitis Q4 2013
– Diabetic Mellitus with Hyperglycemia Q3 2013
– Diabetes with Ketoacidosis Q3 2013
– Diabetes Mellitus Type 2 with Ketoacidosis Q1 2013
– Pneumonia and Hemoptysis Q4 2013
– Healthcare Acquired (Nosocomial) Condition Q4 2013
– Endoscopic Banding of Esophageal Varices Q4 2013
– Root Operation for Bone Marrow Biopsy Q4 2013
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Today’s Coding Clinic topics
• ICD-9 Coding Clinics:
• History of Ductal Carcinoma Q1 2012
• Heart Failure with Preserved or Reduced Ejection Fraction Q1 2014
• Immune Thrombocytopenic Purpura and Pancytopenia Q1 2014
• Traumatic Urinary Catheterization Q1 2014
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Assigning Codes Using Prior
Encounters Q3 2013
• 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?
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Assigning Codes Using Prior
Encounters Q3 2013
• 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.
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Assigning Codes Using Prior
Encounters Q3 2013
• 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-10CM.
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Decompensated Systolic
Heart Failure Q2 2013
• Question:
• Coding Clinic, Third Quarter 2008, p. 12, states
“decompensated indicates that there has been a flareup (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?
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Decompensated Systolic
Heart Failure Q2 2013
• 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.
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Diabetes and Osteomyelitis Q4 2013
• 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?
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Diabetes and Osteomyelitis Q4 2013
• 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.
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Diabetes and Osteomyelitis
•
•
•
•
250.80 with 730.27 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
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Osteomyelitis in the Index
• Osteomyelitis M86.9
•
acute M86.10
•
carpus M86.14-
•
clavicle M86.11-
•
femur M86.15-
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Diabetic Mellitus with Hyperglycemia
Q3 2013
• 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?
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Diabetic Mellitus with Hyperglycemia
Q3 2013
• 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.
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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
5th digit for not stated as uncontrolled
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Diabetes with Ketoacidosis Q3 2013
• 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-10CM?
• 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.
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Diabetes with Ketoacidosis Q3 2013
• Answer:
• No, in this case, it is not appropriate to assign
code E10.65, Type 1 diabetes mellitus with
hyperglycemia, together with code E10.10.
• Assign only code E10.10, Type 1 diabetes
mellitus with ketoacidosis without coma.
• Ketoacidosis signifies uncontrolled diabetes.
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Diabetes Mellitus Type 2 with
Ketoacidosis Q1 2013
• Question:
• What is the correct code assignment for type 2
diabetes mellitus with diabetic ketoacidosis?
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Diabetes Mellitus Type 2 with
Ketoacidosis Q1 2013
• 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.
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Pneumonia and Hemoptysis Q4 2013
• 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?
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Pneumonia and Hemoptysis Q4 2013
• 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.
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Healthcare Acquired (Nosocomial)
Condition Q4 2013
• 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?
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Healthcare Acquired (Nosocomial)
Condition Q4 2013
• 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.”
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Endoscopic Banding of Esophageal
Varices Q4 2013
• 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?
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Endoscopic Banding of Esophageal
Varices Q4 2013
• 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?
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Endoscopic Banding of Esophageal
Varices Q4 2013
• 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.”
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Endoscopic Banding of Esophageal
Varices Q4 2013
• 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.
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Endoscopic Banding of Esophageal
Varices
• MS-DRG 432 Cirrhosis & alcoholic hepatitis w/
MCC
• Cost weight: 01.7150
• 571.2 Alcoholic cirrhosis
• 456.20 bleeding esophageal varices
•
42.33 endoscopic ligation esophageal varices
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Endoscopic Banding of Esophageal
Varices
• MS-DRG 981 Extensive O.R. procedure
unrelated to principal diagnosis w/ MCC
• Cost weight: 4.9319
• 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.
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Root Operation for Bone Marrow
Biopsy Q4 2013
• Question:
• What is the ICD-10-PCS root operation for bone
marrow biopsy?
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Root Operation for Bone Marrow
Biopsy Q4 2013
• 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.
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Bone Marrow Biopsy
• Biopsy
• see Drainage with qualifier Diagnostic
• see Excision with qualifier Diagnostic
• Bone Marrow see Extraction with qualifier
diagnostic
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History of Ductal Carcinoma in Situ
Q1 2012
• Question:
• Should code V10.3, Personal history of malignant
neoplasm, Breast, be reported for history of
ductal carcinoma in situ (DCIS) of the breast?
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History of Ductal Carcinoma in Situ
Q1 2012
• 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.
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Heart Failure with Preserved or Reduced
Ejection Fraction Q1 2014
• 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?
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Heart Failure with Preserved or Reduced
Ejection Fraction Q1 2014
• 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.
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Immune Thrombocytopenic Purpura and
Pancytopenia Q1 2014
• 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?
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Immune Thrombocytopenic Purpura and
Pancytopenia Q1 2014
• Answer:
• Assign both codes 287.31, Immune
thrombocytopenic purpura, and 284.19, Other
pancytopenia, for immune thrombocytopenic
purpura and pancytopenia. Although code
284.19 includes a deficiency in the number of
platelets in the body, it does not identify that the
patient has immune thrombocytopenic purpura.
• Therefore, code 287.31 is needed to identify this
condition.
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Traumatic Urinary Catheterization Q1 2014
• 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?
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Traumatic Urinary Catheterization Q1 2014
• 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.
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Traumatic Urinary Catheterization Q1 2014
• 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.
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Traumatic Urinary Catheterization Q1 2014
• 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?
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Traumatic Urinary Catheterization Q1 2014
• 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.
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Questions?
Barry Libman, MS, RHIA, CDIP, CCS, CCS-P
President, Barry Libman Inc.
President, Libman Education
978-369-7180
barry@barrylibmaninc.com
www.BarryLibmanInc.com
www.LibmanEducation.com
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