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ICD-9-CM and ICD-10-CM/PCS are currently under a code freeze as the industry prepares for ICD-10 implementation. As a result, CMS has made only minimal changes to the CC and MCC lists for the past several years.

Coders and CDI specialists still need to pay attention to what conditions are considered CCs and MCCs, as well as sequencing rules which could affect MS-DRGs.

The MS-DRG system requires only one MCC to maximize the relative weight and reimbursement, says Laurie L. Prescott, MSN, RN, CCDS, CDIP, AHI-MA-approved ICD-10-CM/PCS trainer, CDI education specialist with HCPro, a division of BLR, in Danvers, Massachusetts. No matter how many CCs or MCCs are added to the account, it will remain at that level.

For example, an admission for aspiration pneumonia with the single MCC of acute respiratory failure leads to MS-DRG 177 with a relative weight of 2.0549. “Even if this patient developed a pulmonary embolus and suffered from end-stage renal disease, which are both MCCs, the DRG would remain at 177 with the same relative weight,” Prescott says.

Refresh your knowledge of CC/MCCs

Take a high level look at CMS’ PSI 90Learn the components of the measure and how it relates to coders and CDI specialists

Aftercare codes get a makeover in ICD-10-CMFind out what changes are coming soon

Clinically SpeakingRobert S. Gold, MD, discusses hypertension in its various forms

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Inside: Coding Q&A insert

APRIL 2015Volume 18Issue No. 4

Coders and CDI specialists should not focus just on maximizing revenue, Prescott cautions. CDI specialists typically work to identify all significant and report-able secondary diagnoses within the record, no matter whether the MS-DRG was maximized.

Recovery Auditors and private payer auditors often review records with only one CC or MCC on the claim. The reason many organizations work to identify a sec-ond (or more) MCC or CC is that if one is denied, the second would still support the assigned MS-DRG and payment would not change, Prescott says. “We would not be required to return a portion of the reimburse-ment back. This makes our level of reimbursement for the case much less vulnerable.”

When to report additional diagnosesThe Uniform Hospital Discharge Data Set

(UHDDS) defines “other diagnoses” as all conditions that:• Coexist at the time of admission• Develop subsequently• Affect the treatment received and/or length of stay

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April 2015Briefings on Coding Compliance Strategies

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That definition may not be particularly helpful, says William E. Haik, MD, FCCP, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, director with DRG Review, Inc., in Fort Walton Beach, Florida.

Instead, consider the “general rule,” which defines “other diagnoses” as affecting patient care in terms of requiring any of the following:• Clinical evaluation • Therapeutic treatment • Diagnostic procedures • Extended length of hospital stay • Increased nursing care and/or monitoring • Implications for future healthcare needs

In a nutshell, any condition that affects the patient’s care would be considered clinically significant and reported as an additional diagnosis, Haik says.

Many conditions can qualify as a CC, and the ICD-9-CM Manual includes a notation of potential CC and MCC conditions in the Tabular List. The ICD-10-CM Manual for Hospitals also includes the CC and MCC notations.

Acute respiratory insufficiencyPhysicians frequently document acute respiratory

insufficiency (ICD-9-CM code 518.82) in patients with exacerbation of chronic obstructive pulmonary disease (COPD). Don’t report it in that instance, even though the physician documented it. In this case, it is considered integral to the disease process, Haik says. It however is not integral in a patient who has pneumonia, and should be reported as an additional diagnosis.

AnginaPre-infarction or unstable angina (411.1), is considered

the most severe type of angina. Attending physicians will often use softer terms in the record, like “accelerated,” in situations when a myocardial infarction is not imminent (such as, in a patient who presents with atrial fibrilla-tion with a rapid ventricular response and accelerated angina), Haik says. As a result, coders may not realize the patient has pre-infarction or unstable angina. If they don’t code it, they don’t get credit for the CC.

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Briefings on Coding Compliance Strategies (ISSN: 1098-0571 [print]; 1937-7371 [online]) is published monthly by HCPro, a division of BLR®. Subscription rate: $269/year. • Briefings on Coding Compliance Strategies, 100 Winners Circle, Suite 300, Brentwood, TN 37027. • Copyright © 2015 HCPro, a division of BLR. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, a division of BLR, or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email [email protected]. • Visit our website at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing depart-ment at the address above. • Opinions expressed are not necessarily those of BCCS. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

EDITORIAL ADVISORY BOARDLori Belanger, RN, BSN, RHITInpatient Coder/CDI SpecialistNorthern Maine Medical Center Fort Kent, Maine

Paul Belton, RHIA, MHA, MBA, JD, LLMVice President Corporate ComplianceSharp HealthCare San Diego, California

Gloryanne Bryant, RHIA, CCS, CDIP, CCDS HIM ConsultantFremont, California

William E. Haik, MD, FCCP, CDIPDirectorDRG Review, Inc. Fort Walton Beach, Florida

James S. Kennedy, MD, CCSPresidentCDIMD Smyrna, Tennessee

Laura Legg, RHIT, CCS HIM and Coding Consultant Renton, Washington

Monica Lenahan, CCSManager of Coding Education and ComplianceRevenue Management Centura Health Englewood, Colorado

Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDSDirector of Coding and HIMHCPro Danvers, Massachusetts

Jean Stone, RHIT, CCS, CDIPManager of Clinical Documentation Integrity Program/HIMSLucile Packard Children’s Hospital at Stanford Palo Alto, California

Senior Managing EditorMichelle Leppert, [email protected]

This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission.

Briefings on Coding Compliance StrategiesApril 2015

3HCPRO.COM© 2015 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

sive, combative, or violent behavior, or wandering off. Even if the patient has an unspecified form of de-

mentia, it is considered a CC if it is associated with behavioral disturbances.

These conditions are clinically significant and should be captured to impact the MS-DRG, Haik says.

Heart failure Heart failure can be either a CC or an MCC depend-

ing on the type and severity. It may help to understand a little bit of the clinical information about the different types of heart failure.

Systolic heart failure relates to the failure of the ventricle to contract normally, sometimes referred to by physicians with the term “reduced ejection fraction heart failure,” Haik says.

Diastolic heart failure relates to the inability of the ventricle to relax and fill normally, referred to by physi-cians with the updated terminology of “preserved ejec-tion fraction heart failure.”

Current American Hospital Association Coding Clinic for ICD-9-CM/ICD-10-CM/PCS advice does not recognize these as synonymous terms, so coders must query the physician to determine whether he or she meant systolic or diastolic heart failure.

Left heart failure (428.1) can only be a CC. However, systolic heart failure (428.2x), diastolic heart failure (428.3x), and combined systolic and diastolic heart failure (428.4x) are CCs when the physician does not specify whether the condition is acute or chronic.

If the physician documents any of these conditions as acute or acute on chronic, they become MCCs.

Neither congestive heart failure (428.0) nor heart failure unspecified (428.9) are classified as CCs or MCCs.

HemiplegiaWhen hemiplegia (342.xx) is a late effect of a cere-

brovascular accident (CVA) or acute effect of CVA, coders should report it as an additional diagnosis. Physicians will sometimes only document left-sided weakness. Weakness has its own ICD-9-CM code.

In this case, query the physician to determine wheth-er the patient just has weakness or in fact suffers from hemiplegia.

This is especially important because hemiplegia is a CC, and weakness is not. For quality reporting

Physicians may also use the term “ACS,” which, from a physician perspective, can mean any spectrum of acute ischemic heart disease (unstable angina, submyocardial, or transmural myocardial infarction), Haik says. The term “ACS” codes to unstable angina in ICD-9-CM. Cod-ers or CDI specialists should consider querying a physi-cian if the patient has increased troponin levels because this could be a sign of a myocardial infarction.

AsthmaAsthma (493.xx) is another condition that may be

missed. Coders should note that asthma is only a CC when the physician documents with status asthmaticus (fifth digit 1) or with acute exacerbation (fifth digit 2). Also note that 493.8 (other forms of asthma) is not a CC or MCC.

Be on the lookout for patients with pneumonia suffer-ing from exacerbation of asthma, Haik says. Physicians may not document exacerbation of asthma or acute asthma. If an asthmatic patient is wheezing on admis-sion to the hospital, has pneumonia, and is treated for asthma (for example, with steroids) in addition to receiv-ing antibiotics for pneumonia, then coders can consider the asthma an additional diagnosis. However, they may need to query the physician for additional clarity.

Chronic respiratory failure Physicians will often document COPD oxygen de-

pendent, or COPD with chronic hypoxemia. If a patient receives ongoing oxygen paid by Medicare, his or her partial pressure of oxygen level must be less than 60, which is consistent with chronic respiratory failure. Query whether the patient suffers from chronic respi-ratory failure (518.83) and be sure the query provides reasonable options to remain compliant.

Dementia Certain forms of specified dementia without behav-

ioral disturbances are CCs, such as alcohol-induced dementia (291.2) and drug-induced dementia (292.82). The more common forms of dementia, such as senile dementia (290.0), must be associated with some altera-tion of mental status, such as delirium or confusion, to be a CC, Haik says.

Other forms of dementia, such as Alzheimer’s (331.0) and Parkinson’s disease (331.82), are only CCs when associated with behavioral disturbances such as aggres-



purposes, if the patient has hemiplegia as an additional diagnosis, it negates or severely adjusts patient safety indicators that assume poor quality, such as a hospital-acquired decubitus ulcer. This, in turn, affects both CC capture and quality reporting.

Cerebral edemaCoders and CDI specialists frequently omit cerebral

edema (348.5), Haik says. “If it’s only on the CT scan, you can’t report it. But if it’s on the CT scan, and you see the physician treating it with Decadron®, then this is obviously a place where you want to query the at-tending physician regarding its clinical significance for reporting purposes,” he says. See Coding Clinic, Third Quarter 2009, p. 8, and First Quarter 2010, p. 8, for more information.

Decubitus ulcerStages III (full-thickness skin loss, 707.23) and IV

(skin ulcer with necrosis of soft tissue to bone, 707.24) are MCCs. A wound care nurse can document the stage of the ulcer, but a physician must document the ulcer’s site and type.

“If the wound care nurse does not document the [specific] stage, but rather describes the stage, and that description is similar to the inclusion term in the tabular part of the code book, then you can report that stage,” says Haik.

Remember that if the decubitus ulcer isn’t present on admission (POA) it won’t act as an MCC. “One caveat is that you would code to the highest level of evolution of a decubitus ulcer if it’s present on admission, and you would assign Y rather than N,” says Haik. Thus, when a Stage I ulcer POA evolves to Stage III, coders should report a stage III ulcer POA. See Coding Clinic, First Quarter 2009, p. 19.

QuadriplegiaFunctional quadriplegia is defined as an inability

to move. The patient cannot carry out daily activities and is considered bedridden. Functional quadriplegia is different from quadriplegia that occurs from a central nervous system (CNS) lesions or spinal cord lesion. Patients with functional quadriplegia do not have a CNS lesion, but are not able to move either because of dementia or severe contractures, or arthritis, Haik says. Query the physician to see if functional quadriplegia is present in a bed-bound patient, who cannot perform basic activities such as feeding or dressing themselves.

Renal failurePhysicians often document acute tubular necrosis

(ATN). To determine ATN, the most important criteria is whether a urinalysis shows a tubular cast. H

Take a high level look CMS’ PSI 90Editor’s note: This is the first of a series of four

articles on Patient Safety Indicator 90.

Since the implementation of the Hospital Value-Based Purchasing Program (HVBP) in 2013, CMS has adjusted the MS-DRG payment for each traditional Medicare discharge.

The type and amount of the adjustment, which could be a financial penalty and/or an incentive payment, is determined by the hospital’s performance for defined quality measures, such as risk-adjusted mortality.

Since that time, the number of pay for performance (P4P) programs and quality measures has expanded.

By 2017, P4P payment adjustments will impact up to 6% of traditional Medicare revenue.

Why is this relevant to the coding and CDI team? Because many of the P4P measures are claims-based, the performance for claims-based measures is derived from diagnosis codes submitted on claims.

CDI roleThe CDI team members are the subject matter experts

on the accurate and complete assignment of diagnoses, and on the provider documentation requirements to sup-port code assignment. The CDI team must understand CMS P4P measures in order to improve data quality.



The types of diagnoses that can impact these measures are typically chronic conditions, many of which have been off the radar in the inpatient acute care setting, such as restless leg syndrome or loss of weight.

In this article series, we will take a closer look at one of the CMS claims-based P4P measures: Patient Safety Indicator (PSI) 90. We’ll do so from a CDI team per-spective. We’ll learn about the measure, common cod-ing and documentation vulnerabilities, and approaches the team might consider to strengthen the reporting of impactful diagnoses and procedures with ICD codes on submitted claims.

Introduction to PSI 90PSI 90 evaluates hospital performance for defined

in-hospital complications and adverse events. The measure was developed by the Agency for Healthcare Research & Quality (AHRQ) and adopted by CMS for inclusion as a measure in two P4P programs: • Hospital Value-Based Purchasing Program (HVBP) • Hospital-Acquired Condition Reduction Program

(HACRP)

PSI 90 is referred to as a composite measure because eight different PSIs are rolled up to provide an overview of hospital performance. The eight PSIs included in the CMS PSI 90 composite measure include:• PSI 03, pressure ulcer• PSI 06, iatrogenic pneumothorax• PSI 07, central venous catheter-related

bloodstream infections• PSI 08, postoperative hip fracture• PSI 12, postoperative pulmonary embolism or deep

venous thrombosis• PSI 13, postoperative sepsis• PSI 14, postoperative wound dehiscence• PSI 15, accidental puncture or laceration

CMS provides each hospital with an annual re-port, referred to as a Hospital Specific Report, that provides feedback on PSI 90 performance for the HVBP Program and HACRP. Feedback provided by the HACRP Hospital Specific Report is more mean-ingful for the CDI team than that provided for the HVBP.

Unlike the HVBP Program, the HACRP uses the most recent version of the measures. Different measure versions affect how the PSIs are weighted in PSI 90. For example, PSI 15 is weighted at 49% in the HACRP vs. 42% in the HVBP Program.

In addition, the HACRP uses 25 diagnoses and pro-cedure codes, while the HVBP Program uses only nine diagnoses and six procedure codes.

The time period of data included in the performance evaluation differs as well. For FY 2015, the HACRP time period is two years (07/01/2011–06/30/2013) vs. nine months (10/15/2012–06/30/2013) for the HVBP Program.

The HACRP scoring methodology requires continual improvement across all measures to avoid a financial penalty. Each year, hospitals are ranked based on PSI 90 risk-adjusted performance. Hospitals with perfor-mance that falls into the worst quartile are penalized with a 1% reduction in the MS-DRG payment for each discharge the next fiscal year.

The hospital’s quality department is typically respon-sible for obtaining and analyzing this report to identify organizational improvement priorities within PSI 90. Given that CMS has adopted this measure for two dif-ferent P4P programs, PSI 90 performance is of signifi-cant importance to most hospitals.

Get engaged in PSI 90 data quality improvementThe following key steps can position the CDI team for

successful engagement:• Meet with the quality department to learn about

PSI 90 improvement priorities – Heighten awareness of the quality department on CDI team contributions to measure performance with improved data quality

– Get a seat at the table for existing organizational improvement initiatives

• Identify coding and documentation vulnerabilities for each PSI

• Develop an action plan to strengthen documenta-tion capture and code assignment for conditions pertinent to the PSI measure(s), including:

– Coding and documentation query processes – Provider educational initiatives – Documentation infrastructure refinements – Additional performance metrics



Identify PSI coding and documentation vulnerabilities

The CDI team (and inpatient coders) must under-stand PSI measure structure in order to identify data quality vulnerabilities. Three key concepts are associ-ated with the structure of PSIs.

The first is inclusions. These variables trigger a discharge to be counted in one of the measures. Inclu-sions consist of ICD-9-CM codes for diagnoses and/or procedures.

The second is exclusions. These variables cause a discharge triggered for inclusion in the measure to be excluded from the measure; they will not count.

Exclusions exist to improve capture of the intended population and enhance face validity of the measures with clinicians. As an example, a patient with a stage III, IV, or unstageable pressure ulcer would be included in the PSI 3 measure unless:• The diagnosis was present on admission • The patient had a length of stay less than five days;

it is unlikely that a patient would develop a stage III, IV, or unstageable pressure ulcer during the course of a five-day stay

Exclusions consist of ICD-9-CM diagnosis and pro-cedure codes, admission source codes, and discharge disposition codes.

The third concept is risk adjustment. Twenty-five dif-ferent comorbid categories impact PSI risk adjustment.

Some comorbid categories have a positive impact on risk adjustment, while others can negatively impact (or weaken) risk adjustment.

ICD-9-CM codes are mapped to each comorbid cat-egory. The number of ICD-9-CM codes mapped to each comorbid category ranges from a low of 1 to a high of approximately 800.

The capture of one ICD-9-CM code for each comor-bid category with a positive impact on risk adjustment would optimize risk adjustment for the PSI.

The impact that a comorbid category has on the risk adjustment is PSI specific. As an example, the capture of restless leg syndrome has a positive risk-adjustment impact of 10% on PSI 3 (pressure ulcers).

A review of the measure specifications (www.quali-tynet.org) can then be conducted to identify inclusions, exclusions, and risk-adjustment variables for each PSI.

To support identification of data quality vulnerabilities, this analysis is best performed by someone on the CDI team who understands the coding classification system, coding guidelines, documentation requirements, and associated documentation improvement strategies. Consider the following examples:

For PSI 8, which measures in-house hip fractures, patients are excluded from this measure if the fracture is pathologic.

Patients are excluded from PSI 13 if secondary diagnoses reported are considered an immunocompro-mised state. Chronic kidney disease (CKD) stage V and malnutrition are examples.

Patients have a strengthened risk adjustment for PSI 15 if secondary diagnoses are reported for defined risk-adjustment variables. The capture of obesity, CKD, and peripheral vascular disease would optimize risk adjust-ment for this PSI.

Leverage your EHR to improve documentation capture

A broad range of ICD codes impact each PSI as part of an inclusion, exclusion, or risk-adjustment comor-bid category. Leveraging the EHR to automate capture of critical diagnoses is an essential component of best practice CDI programs under CMS P4P measures.

As an example, PSI 3 measures the frequency of pressure ulcers (stage III, IV, or unstageable) which are not present on admission:• The presence of any pressure ulcer (regardless of

stage) on admission will exclude a discharge from counting in the measure.

• Medicare data shows a pressure ulcer rate of only .20%, but surveillance data suggests an actual rate 10 times higher than that. This discrepancy indicates that coders are either missing provider documentation related to pressure ulcers, or that providers are under-documenting this condition.

• The capture of pressure ulcers (regardless of stage) is also important to the risk-adjustment methodol-ogy for other CMS P4P measures such as readmis-sions, mortality, and complications.

Let’s look at ways to customize the EHR to efficiently and consistently support the capture of pressure ulcer documentation in provider notes.



Partnership with subject matter experts to design how and what documentation must be captured is critical to effective leverage of the EHR. For pressure ulcers, this partnership would consist of EHR design and build staff, a representative from the CDI team, and the clinical subject matter expert(s).

Identify the clinical subject matter experts: Wound care nurses are considered the subject matter experts to assess, stage, and recommend treatment for pressure ulcers.

Embed informational text in your wound care documentation tools: The IT team would embed pressure ulcer documentation requirements wherever nurses can document pressure ulcer assessments in the EHR (e.g., flow sheets). Requirements would include site, laterality, stage, present on admission status, and the presence of (any) gangrene.

Provide wound care nurses with ability to manually update the problem list: The wound care nurses would be provided with EHR access to add a predefined set of pressure ulcer problems to the problem list. Nurses would add the appropriate problem to the problem list after completing their pressure ulcer docu-mentation. It is important to understand that the addi-tion of the condition to the problem list does not mean that the wound care nurse is diagnosing the patient. As a subject matter expert, they are using the problem list to communicate the condition to the provider.

In addition to wound care nurses, provide floor nurs-es with access to update the problem list if they assess the majority of pressure ulcers. If floor nurses assess, but do not always stage, pressure ulcers, consider con-figuring your EHR so that the capture of pressure ulcer documentation by a floor nurse triggers the patient to be added to a custom work list. Wound care nurses monitoring this work list can then assess the patient, document an ulcer stage, and update the problem list after that.

Link the problem list to the provider note: The IT team would embed a link to the problem list in all provider note templates. The pressure ulcer diagno-sis and associated information are then automatically integrated into the provider progress note. The pro-vider then signs off on this documentation by filing the note to the patient’s chart.

Links are tools available in many EHR systems.

Links allow providers to pull information into their notes from elsewhere in the patient’s chart.

Note templates are another tool available in many EHR system support tools. Note templates can include links to important patient clinical information such as recent vitals, lab results, and current home medications.

Coders typically are restricted from assigning codes to diagnoses on problem lists. However, they can code diagnoses included in physician’s notes.

Coming upNext month, we’ll review the measure specifications

variables pertinent to PSI 15, which has the biggest impact on the PSI 90 composite weight. We’ll discuss coding and documentation vulnerabilities, and provide additional examples to leverage the EHR to systemize documentation capture. We’ll also discuss ways to customize the EHR so that it encourages better adop-tion and maintenance of the problem list, leading to more accurate, up-to-date, and less-cluttered problem lists across your patient population. H

Editor’s note: Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer, is a director with CCDI-DQ. Newell provides consulting services to hos-pitals interested in strengthening their coding and CDI programs to support accurate, optimal DRG assign-ment and claims-based quality outcomes such as those measured by CMS P4P programs. She specializes in building sustainable programs designed to identify and address organizational priorities for documenta-tion and coding improvement. You can reach Newell at (704) 931-8537 or [email protected].

Steve Weichhand and Sean Johnson lead the pro-vider documentation improvement service line at Fal-con Consulting Group. Falcon Consulting is an EHR consultancy specializing in EHR planning, implemen-tation, optimization, and support. Weichhand and Johnson are both former Epic employees with years of technical experience, and their service line has been proven to improve physician efficiency, enhance docu-mentation specificity, and create a structured process for future optimization. For inquiries, call (312) 751-8900 and ask for Steve or Sean. Email Steve at [email protected]. Email Sean at [email protected].



Aftercare codes get a makeover in ICD-10-CMOne of the new concepts in ICD-10-CM is the seventh

character to denote the encounter type. In ICD-10-CM, coders will use the same basic diagnosis code throughout treatment, with only the seventh character changing.

In ICD-9-CM, coders report a code from V54 for orthopedic aftercare. For example, if a patient is being seen for aftercare for a healing traumatic fracture of the hip, coders would report V54.13.

The ICD-9-CM Official Guidelines for Coding and Reporting instruct coders to report the aftercare codes (subcategories V54.0x, V54.2x, V54.8x, or V54.9) for encounters after the patient has completed active treat-ment of the fracture and is receiving routine care dur-ing the healing or recovery phase. Examples of fracture aftercare include: • Cast change or removal• Removal of external or internal fixation device• Medication adjustment• Follow-up visits following fracture treatment

Coders generally report the aftercare code as the first listed or principal diagnosis. Coders may also use an aftercare code as an additional code when the physician provides some type of aftercare in addition to treating the main problem necessitating the admission.

Consider a patient with a traumatic finger ampu-tation who presents with an amputation stump and concern for infection at the amputation site.

The physician finds no obvious signs and symptoms of infection at the amputation site, and the patient is receiving antibiotics presumably as a prophylactic measure for infection. In this case, the aftercare code V54.89 (other specified rehabilitation procedure) is the most appropriate ICD-9-CM code to report for this encounter, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, C-DAM, executive director of the Foundation for Physician Documentation Integrity.

The patient’s status is post initial treatment of the traumatic amputation, and he or she is currently in the healing or recovery phase. The physician isn’t directing the current treatment toward a current injury. There-fore, report only code V54.89, Krauss says.

However, in some cases, coders run into problems with payers when they follow the ICD-9-CM sequenc-ing rules for aftercare codes. “I’ve heard of horror stories of hospital billing departments resequencing the codes because the insurance company won’t pay for that V code,” says Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-approved ICD-10-CM/PCS trainer, AHIMA ICD-10 ambassador, and senior consultant with the Haugen Consulting Group in Denver. “But the guidelines in ICD-9 specifically tell us to do that.”

Change for ICD-10-CMCoders won’t face that problem in ICD-10-CM be-

cause they won’t be reporting specific aftercare codes. They will continue to report the injury code with differ-ent seventh characters to identify what type of treat-ment the patient is receiving.

ICD-10-CM does include a code for orthopedic aftercare in ICD-10: Z47.89 (encounter for orthopedic aftercare). “However, we do not use this code for or-thopedic aftercare for injuries,” Pollard says. “What we code instead is the code for the injury with the seventh character for subsequent care.”

Coders will also report a Z code when a condition is no longer present, says Anita Rapier, RHIT, CCS, senior coding consultant for the American Hospital Association in Chicago.

For example, a patient suffering from severe os-teoarthritis of the hip undergoes a hip replacement procedure. The patient then comes in for rehabilitation. Coders should report code Z47.1 (aftercare following joint replacement surgery) and not a code for osteoar-thritis, Rapier says.

The aftercare changes don’t apply solely to fractures or other injuries. They also apply for admissions or en-counters for rehabilitation for sequelae of a cerebrovas-cular accident (CVA), Rapier says. ICD-10-CM includes a category of codes (I69) specifically for reporting sequelae of a CVA.

For example, a patient suffered a CVA two months ago and is experiencing right-sided dominant hemiplegia following a CVA. The patient is admitted for rehabilitation services. Coders would report I69.351



(hemiplegia and hemiparesis, following cerebral infarction affecting right dominant side), Rapier says.

Seventh charactersWhen a patient comes in for treatment of injuries,

poisonings, and certain other consequences of external causes, coders will usually find the appropriate code in Chapter 19 in ICD-10-CM. Many of the codes in this chapter require a seventh character, with most codes only including three choices:• A, initial encounter• D, subsequent encounter• S, sequela

For certain closed fractures, coders have three or four additional seventh character choices. ICD-10-CM also includes 10 seventh characters for open fractures of the femur, lower leg, and forearm.

Don’t confuse initial encounter with first visit. Coders will assign seventh character A when the patient is

ICD-10-CM seventh characters

Certain ICD-10-CM codes require a seventh character to de-

note the encounter. These characters fall into three basic groups.

This list details the possible seventh characters for fractures.

Initial encounters are used while the patient is receiving

active treatment for the injury.

• A, initial encounter for closed fracture

• B, initial encounter for open fracture type I or II

• C, initial encounter for open fracture type IIIA, IIIB, or IIIC

Subsequent encounters are used for encounters after the

patient has received active treatment of the injury and is receiving

routine care for the injury during the healing or recovery phase.

• D, subsequent encounter for closed fracture with routine

healing

• E, subsequent encounter for open fracture type I or II with

routine healing

• F, subsequent encounter for open fracture type IIIA, IIIB,

or IIIC with routine healing

• G, subsequent encounter for closed fracture with delayed

receiving active treatment, such as an ED visit, surgery, or evaluation and treatment by a new physician.

Coders will use seventh character D when the patient is receiving basically the same routine aftercare identi-fied by the V codes in ICD-9-CM.

A sequela (seventh character S) is the same as a late effect in ICD-9-CM. “Whatever was a late effect in ICD-9 is now a sequela in ICD-10,” Pollard says.

Fracture aftercare exampleA patient comes into the ED with a displaced frac-

ture of the right intertrochanteric femur. Coders would report S72.141A (displaced intertrochanteric fracture of right femur, initial encounter), Rapier says.

The physician determines that the patient requires surgery for the fracture. Coders will again report S72.141A because surgery is considered active treat-ment, Pollard says.

The patient is then admitted for an inpatient rehabilitation stay following the surgery. During the

healing

• H, subsequent encounter for open fracture type I or II with

delayed healing

• J, subsequent encounter for open fracture type IIIA, IIIB, or

IIIC with delayed healing

• K, subsequent encounter for closed fracture with nonunion

• M, subsequent encounter for open fracture type I or II with

nonunion

• N, subsequent encounter for open fracture type IIIA, IIIB,

or IIIC with nonunion

• P, subsequent encounter for closed fracture with malunion

• Q, subsequent encounter for open fracture type I or II with

malunion

• R, subsequent encounter for open fracture type IIIA, IIIB,

or IIIC with malunion

Sequelae are the ICD-10-CM equivalent of late effects in

ICD-9-CM.

• S, sequela



stay, the patient received physical and occupational therapy and fracture aftercare. Assign code S72.141D, (displaced intertrochanteric fracture of right femur, subsequent encounter), Rapier says.

Reimbursement impactFacilities will see a change in MS-DRG assign-

ment and consequently a change in reimbursement when they begin reporting ICD-10-CM codes for fractures.

Currently in ICD-9-CM, the above case would be reported with V57.89 as the principal diagnosis and 820.21 for the intertrochanteric fracture, Pollard says. That groups to MS-DRG 945 (rehabilitation with CC/MCC). Using an average hospital’s blended rate of $4,556 times the MS-DRG relative weight (1.3804) equals $6,289 in reimbursement, Pollard says.

In ICD-10-CM, coders will no longer report a Z code. Instead, they will use a code from category S72, which now groups to MS-DRG 561 (aftercare, musculoskeletal system and connective tissue without CC/MCC), Pol-lard says. MS-DRG 561 has a relative weight of 0.6408, leading to a payment of $2,919.

That’s probably not the best news for hospitals with rehabilitation units paid on the MS-DRG system, Pol-lard says.

Data considerationsICD-10-CM codes are designed to follow a patient all

the way through treatment, which raises several data considerations. “This sounds great on paper,” Pollard says. “You’re able to know that the patient came in with a fracture, then went to physical therapy.” In addition, if the patient comes back with a sequela, facilities will be able to track that.

The problems start with documentation. “How often do you get documentation down to the specific part of the bone and laterality on a sequela?” Pollard says. How often is the physician documentation that good?

The physician’s documentation is likely to be much more specific on the initial encounter than it would be for subsequent encounters and sequelae, Pollard says. Physicians don’t always identify sequelae as such, which means coders won’t be able to assign the fracture code with a seventh character S.

Another problem arises for patients who suffered their initial injury prior to ICD-10-CM implementa-tion. The ICD-9-CM codes don’t provide as much detail as the ICD-10-CM codes, so coders may not have the level of detail necessary in documentation for subsequent encounters to report the most specific code. H

Tension over hypertension as we transition from ICD-9-CM to ICD-10-CM By Robert S. Gold, MD

Hypertension can have so many mean-ings, so many organs involved, so many causes, and so many effects. We get stuck in a rut, thinking of “hypertension” and sometimes, we lose sight of what’s wrong

with patients. Additionally, when we do discover the word refers to arterial blood pressure, we go to coding guidelines and rules, which can confuse us more.

Hypertension means “straining beyond,” according to vocabulary.com. A patient may have elevated pressure in the eyeball (ocular hypertension), which can lead to glaucoma. The patient may have elevated pressure in the venous system draining blood from the

intestines into the liver as in cases of cirrhosis. This can lead to bleeding esophageal or hemorrhoidal varices and is called hepatic portal hypertension.

Pressures can be elevated in the skull, leading to headaches, nausea, and vomiting in the absence of tu-mor or other disease such as intracranial bleed. This is pseudotumor cerebri or benign intracranial hyperten-sion. Cases of compartment syndrome can occur with crush injuries of the arm with intact skin or in vascular insufficiency to a limb. As a result, the patient may develop intramuscular or fascial hypertension.

We can see elevated pressures in the arterial sys-tem to the lungs as in cases of obesity hypoventilation



syndrome. Newborns may experience congenital or secondary elevations in pressure in the right side of the circulation, occasionally with left-to-right shunts. That’s pulmonary hypertension, or pulmonary artery hypertension.

Patients can suffer from a variety of hypertensions, so don’t automatically ask if the hypertension is malignant or benign just because you see the word “hypertension.”

Before we go any further, patients may have an elevated blood pressure without any disease of hyper-tension. It could be due to nervousness about undergo-ing surgery, or fear caused by watching A Nightmare on Elm Street, or anxiety about presenting their report card with their first F to their parents.

It could be related to ingestion or injection of cor-ticosteroids, or use of epinephrine-like drugs for an acute asthma flare (beta agonists). These situations are “elevated blood pressure” (ICD-9-CM code 796.2 or ICD-10-CM code R03.0) without a disease of hyperten-sion. Even if the physician calls it “hypertension,” it isn’t. How can you know? If the patient is not on any long-term medication associated with hypertension, maybe it isn’t hypertension.

What we will concentrate on right now is systemic arterial hypertension. Systemic arterial hypertension can have several presentations.

Secondary hypertensionAs we see in a limited way in ICD-9-CM and more ex-

panded in ICD-10-CM, systemic arterial hypertension can have acute presentations in a patient who has no hypertensive disease at all. It can also happen acutely due to one cause in a patient with chronic essential hypertensive disease.

The causes of acute hypertension include endocrine disorders (405.x9 in ICD-9-CM and I15.2 in ICD-10-CM), such as thyrotoxicosis or pheochromocytoma or, occasionally, carcinoid syndrome.

The changes in hormonal excretion during pregnancy can lead to episodes of sustained hypertension, as can occur in eclampsia.

These secondary causes of hypertension are usually transient episodes of high blood pressure, but they may have been around for a long time without treatment, until the patient appeared with an acute decompensa-

tion of a target organ of the hypertension. These target organs include the kidneys, the heart, and the brain.

Episodes of extreme elevations of blood pressure in the range of 240/120 are called hypertensive emergen-cies. Hypertensive emergency is defined as extremely high levels of blood pressure associated with target organ damage. The manifestations of acute episodes of extremely high blood pressure are:• Acute kidney injury• Acute pulmonary edema (acute diastolic heart

failure) • Acute hypertensive encephalopathy • Acute hypertensive stroke

Notice the word “acute” is included in all of the con-ditions. Physicians sometimes use the term “pulmonary edema” in such circumstances and forget to provide the adjective “acute.” Generally, when you see “pulmonary edema” in an ED record other than on an x-ray report, it is worthwhile to get clarification if the physician means acute pulmonary edema.

Episodes of sustained high blood pressure, as well as extremes in elevation leading to hypertensive emer-gency, can happen with renal artery stenosis (405.x1 in ICD-9-CM and I15.0 in ICD-10-CM), as well, with the same type of target organ damage. These are also acute conditions.

In ICD-9-CM, we had the series of codes in the 401 through 404 series, with fourth digits of 0 for malig-nant hypertension. These are all acute events with acute organ damages and are the equivalent of hyper-tensive emergencies when associated with acute organ damage. ICD-10-CM does not include an equivalent code, or one for hypertensive emergency either.

All of these causes of acute hypertension can poten-tially be cured—totally. Remove the endocrine tumor, stent the renal artery, deliver the baby, and it’s gone.

Primary (essential) hypertensionPrimary or essential hypertension is the chronic

disease of hypertension that can have no identifiable cause. Children with chronic kidney disease (CKD) are often identified as having hypertension, but this is secondary hypertension caused by CKD. In the pediatric population, we are not usually dealing with renovascular disease, but rather hypertension due to



whatever destroyed renal function over time, and led to chemicals released in the bloodstream that raised blood pressure.

In ICD-9-CM, it’s 405.9x, the same grouping as hy-pertension caused by endocrine disorders, but we will have them separated in ICD-10-CM. Hypertension in children due to CKD may resolve with renal transplant. Adult-onset essential hypertension cannot be cured, but it can be controlled.

Essential hypertension, whether you call it benign or don’t specify it as benign when it is benign, is the same chronic disease. It’s a chronic condition that over a prolonged period of time can lead to CKD, chronic heart disease, and chronic brain disease. In ICD-9-CM, these were grouped together with no con-sideration that the malignant hypertension can cause acute disease and the essential can cause the chronic disease. The code sets don’t match what physicians see with patients.

When essential hypertension causes CKD, it can progress rapidly or slowly. Such a patient may ul-timately decompensate to end-stage renal disease (ESRD) and require a kidney transplant or lifelong dialysis.

When essential hypertension causes chronic heart disease, it most often leads to left ventricular hypertro-phy, which leads to inadequate filling of the left ven-tricle during the diastolic period of the heart cycle. It can progress to left ventricular chronic diastolic failure. Sometimes, at end-stage chronic hypertensive cardio-myopathy, the left ventricle dilates, ejection fraction drops, and the patient progresses to chronic systolic (and diastolic) heart failure. The patient may also suf-fer strokes, but these are more associated with chronic pressure on weak spots in the blood vessels and intra-cranial bleeding.

In ICD-10-CM, I10 is essential hypertension. I11 is the equivalent of 402. I11.0 is for hypertensive

heart disease with heart failure, while I11.9 denotes hypertensive heart disease without heart failure. I12.- is the equivalent of 403. Use I12.0 for hypertensive CKD with stage 5 CKD or ESRD, I12.9 for hypertensive CKD with stage 1 through stage 4 CKD, or unspecified CKD. These are all chronic conditions.

I13.- is the ICD-10-CM equivalent of 404 and includes four codes:

• I13.0, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

• I13.10, hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

• I13.11, hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease

• I13.2, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease

These codes all denote chronic hypertensive heart and renal disease with chronic renal disease and with or with-out chronic heart failure. There’s no acute anywhere.

ConundrumIn ICD-9-CM, we are told that CKD and acute kidney

injury are different and, if a patient is admitted with AKI and has CKD due to hypertension, sequence the acute first and follow that with the 403 code. Why? Because the patient is admitted for the acute problem and not for the chronic one. You wind up with MS-DRG 683 (renal failure with CC).

Similar advice does not follow through to hyper-tensive heart disease when a patient is admitted with congestive heart failure and also has CKD. Here, we are told to sequence the chronic hypertensive heart disease and renal disease with heart failure, followed by the acute heart failure code. That’s an MCC when the physician documents systolic or diastolic heart failure because of sequencing.

If you sequence the acute heart failure first, you wind up with a CC, comparable with acute renal disease in a patient with hypertensive CKD. That’s the way it should be (acute sequenced first) to follow all of the other rules of coding disease of virtually all other organs. I’m interested to see if this is corrected in ICD-10-CM. H

EDITOR’S NOTEDr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician CDI programs, including needs for ICD-10. Contact him at 770-216-9691 or [email protected]. If you have a specific procedure or condition you would like Dr. Gold to address in his column, contact senior managing editor Michelle Leppert at [email protected].

A supplement to Briefings on Coding Compliance Strategies

A monthly service of Briefings on Coding Compliance Strategies

APRIL 2015

Coding Q&A

Q Our facility is considering having our coders and CDI specialists “go live” with ICD-10-CM/PCS on

July 1, in order to practice and help offset the impact of ICD-10. The system would then code backward into ICD-9-CM for billing. Is this “backward mapping” method appropriate?

A The biggest issue is how your ICD-10-CM/PCS coding will be “translated” into ICD-9-CM for

claims processing until CMS accepts ICD-10-CM/PCS codes to process claims. If your system is coding back-ward, the resulting code will likely be based on General Equivalence Mapping (GEMs), which CMS discourages.

CMS specifically states the GEMS are not for cod-ing purposes, but rather to help build coding databases. Backward mapping—going from an ICD-10-CM/PCS code to an ICD-9-CM code—could be problematic, and could result in assigning many nonspecific codes, which may have reimbursement ramifications. The GEM mappings were not intended to be used for coding pur-poses, but rather to help build coding databases.

Many codes have a “one to many” ratio, resulting in either a nonspecific code or, in some cases, a “no map” option. Ideally, we would like to think if we convert documentation to ICD-10-CM/PCS that it would auto-matically backward map to the correct ICD-9-CM code, but it may not.

For example, if the documentation states “severe persistent intrinsic asthma,” the ICD-10-CM assigned code would be to J45.50 (severe persistent asthma, uncomplicated), because the term “intrinsic” in ICD-10-CM/PCS is now an included term not previously factored into category selection in ICD-9-CM. So, if you backward map J45.50, it will translate to 493.00 or 493.10 in ICD-9-CM.

Unfortunately, this does not translate to a direct match: 493.00 is for extrinsic asthma and 493.10 is for intrinsic asthma. The ICD-10-CM/PCS code translates to two possible ICD-9-CM codes, and only one can be chosen. But it has to backward map to both because the code for severe persistent asthma does not identify ex-trinsic or intrinsic in ICD-9-CM.

Most organizations are dual-coding: coding in ICD-9-CM so their claims can be reimbursed appropriately, and in ICD-10-CM/PCS so they can practice the code set and identify improvement opportunities. However, not all organizations have software that can “hold” both code sets simultaneously. If your software allows you to hold both codes, even though it is time-consuming, the best suggestion is to natively code in both ICD-9-CM and ICD-10-CM/PCS. If you rely merely on the back-ward mapping, it may not achieve the desired result. The systems are not identical, and very few codes have exact maps.

Cheryl Ericson, MS, RN, CCDS, CDIP, AHI-

MA-approved ICD-10-CM/PCS trainer, associate di-rector for education at ACDIS and CDI education director, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS director of HIM and coding at HCPro, a division of BLR, in Danvers, Massachu-setts, contributed to this response.

Q How should the diagnosis of urinary tract infec-tion (UTI) and encephalopathy be sequenced?

Specifically, which diagnosis should be the principal? If physician documentation indicates that the patient came in with confusion, can encephalopathy be assigned as the principal diagnosis if it is due to the UTI and no other contributing issues are present?

We want your coding and compliance questions!The mission of Coding Q&A is to help you find an swers to your urgent coding/compliance questions.

To submit your questions, contact Briefings on Coding Compliance Strategies Senior Managing Editor Michelle Leppert, CPC, [email protected].

A monthly service of Briefings on Coding Compliance Strategies

tus” (was a CT scan performed, etc.), or was it on a UTI?Not every patient with a UTI has encephalopathy.

However, if they are sick enough to need inpatient care, they likely have more going on.

Encephalopathy also isn’t as big of an audit target as UTI is. Yes, auditors do deny encephalopathy claims since it is an MCC—but so is severe malnutrition, acute respiratory failure, etc. Think about what type of claim is usually more vulnerable.

When the UTI is the principal diagnosis and enceph-alopathy is the MCC, there is only one MCC in the re-cord. When encephalopathy is the principal diagnosis, the UTI can be added as a CC.

When the encephalopathy is a principal diagno-sis, auditor denials are not the issue; the real con-cern is with the documentation not supporting it as a reportable condition. Think of encephalopathy on a continuum with acute confusion, delirium, and en-cephalopathy, because everything isn’t encephalopa-thy. It can, oftentimes, only be accurately diagnosed when working backward by asking, “When does the patient return to baseline?” and “What treatment was necessary?”

It would be interesting to find out if the infection control team supports the diagnosis of a UTI, as often the UTI is a process of elimination diagnosis because the urine is “dirty.” But it doesn’t always clinically meet the definition of a UTI by Centers for Disease Control guidelines. If that is the case, what is the provider re-ally treating? They could be treating the altered mental status. However, that is only a symptom, and the goal of clinical documentation improvement is to find a di-agnosis associated with that symptom. That diagnosis could be acute confusion, delirium, or, in some cases, encephalopathy.

Cheryl Ericson, MS, RN, CCDS, CDIP, AHI-MA-approved ICD-10-CM/PCS trainer, answered this question.

A Assigning the UTI as the principal diagnosis makes the claim more vulnerable to denial than

the encephalopathy does. If you look at the big picture, a UTI does not support inpatient care. Additionally, there is no coding rule that requires the UTI to be cod-ed as the principal diagnosis because it is not part of an etiology/manifestation pair. According to the Uniform Hospital Discharge Data Set (UHDDS) definition of the principal diagnosis, it is the condition (after study) that occasioned the admission.

The inclusion of the term “after study” is often what throws off accurate principal diagnosis assignments, because people don’t look at the totality of the coding guidelines. At times symptoms present at the time of admission require further “study” in order for the phy-sician to find a definitive diagnosis.

Symptoms may be reported when no other definitive diagnosis can be identified, but this leads to assignment of lower weighted MS-DRGs, less specificity in assign-ment, and vague medical records overall. So, the pref-erence is to avoid reporting symptoms as a principal diagnosis.

For example, the provider often describes encepha-lopathy instead of diagnosing it; documenting the pa-tient as having altered mental status. If the patient has encephalopathy, they usually need inpatient care, not just supportive care, because the goal is to stop the pro-gression of the encephalopathy by finding and treating the cause.

When looking at the record, think about the pa-tient’s continuum of care. Ask yourself, at what point is the patient safe for discharge? In this case, would it be when the physician treats the encephalopathy or the UTI? Clinically speaking, this patient would be safe to discharge when he or she returns to baseline in mental functioning, not when the UTI is resolved.

A UTI (even a complicated one) can be treated in the outpatient setting. Also, look at the totality of the record: Was the focus of the treatment the “altered mental sta-

Coding Q&A is a monthly service to Briefings on Coding Compliance Strategies subscribers. Reproduction in any form outside the subscriber’s institution is forbidden without prior written permission from HCPro, a division of BLR®. Copyright © 2015 HCPro, a division of BLR. Telephone: 781-639-1872; fax: 781-639-7857. CPT codes, de scriptions, and mate-rial only are Copyright © 2015 American Medical Association. CPT is a trademark of the American Medical As sociation. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The American Medical Association assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

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