DIAGNOSIS CODING FOR LONG TERM CARE SETTINGS

Presented by:

Lizeth Flores, RHIT Anderson Health Information Systems,Inc.940 W. 17th Street, Suite BSanta Ana, California, 92706Tel. (714) 558-3887Email: office@ahis.net

Objectives• Participants will:

– Correctly assign ICD-9-CM codes to diagnoses

– Correctly identify primary / Secondary diagnoses

– Be aware of CVHS practice for the use of V-codes

– Learn 2009-2010 coding updates

Purpose of ICD- 9-CM Coding

• Gather statistical data• Reporting diagnoses and provides a

method for sequencing diagnosis to support reimbursement

• Ensure compliance with Federal Reporting Standards for diagnoses

• Provide insight into the types of residents and conditions

• Health Research

• We are changing our practice

Requirements

• Official coding guidelines require the use of V codes for aftercare and specify that applicable aftercare V-codes are to be used for conditions requiring continued / long term care or healing phase of a condition/disease.

• The official coding guidelines are developed by CMS (Centers for Medicare and Medicaid Services) & NCHS (National Center for Health Statistics) and updated in October and April of every year.

Requirements

• Per ICD-9-CM Official Guidelines for Coding and Reporting, aftercare codes are generally first to explain the specific reason for the encounter (admission)

• Certain aftercare code categories need a secondary dx code to describe the resolving condition or sequelae

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

Not So New

Coding clinic Fourth Quarter 1999• Published rules for the use of V codes• Addressed the use of V codes in LTC settings • Coding clinic Fourth Quarter 2003• Clarified the use of aftercare V codes for all

subsequent encounters after the initial treatment for a fracture

• “for statistical purposes, a facture should only be reported once”

CMS Manual System Transmittal 437

• Principal Diagnosis Code - SNFs enter the ICD-9-CM code for the principal diagnosis in FL 67. The code must be reported according to Official ICD-9-CM Guidelines for Coding and Reporting, as required by the Health Insurance Portability and Accountability Act (HIPAA), including any applicable guidelines regarding the use of V codes. The code must be the full ICD-9-CM diagnosis code, including all five digits where applicable.

• Other Diagnosis Codes Required – The SNF enters the full ICD-9-CM codes for up to eight additional conditions in FLs 68-75. Medicare does not have any additional requirements regarding the reporting or sequence of the codes beyond those contained in the ICD-9-CM guidelines.

So What’s Changing???

CVHS will begin implementation of the use of V-codes for principal diagnoses in

compliance with official coding guidelines effective October 2009 with full

compliance by November 1st 2009

What this means to you

• The Principal diagnosis will no longer be an acute diagnosis and it may be a V-CODE

• 800.XX codes for fractures will NO LONGER be used

What you need to do

• When sequencing diagnoses upon admission acute diagnoses will no longer be part of the diagnosis listing, and if they are, you must identify this and discuss with your DNS to ensure correct assignment

• Follow the coding guidelines when assigning diagnosis codes

Ready ……..Set…….Go

What to Code?

ALL CONDITIONS THAT EXIST AT THE TIME OF ADMISSION, THAT EFFECT

TREATMENT RECEIVED

Do NOT Code• DIAGNOSES THAT DO NOT AFFECT

TREATMENT OR LENGTH OF STAY• WHEN CONDITION NO LONGER

EXISTS• DO NOT ASSIGN PROCEDURE CODES• Examples: Fractured forearm 6 years ago,

pneumonia, UTI that were resolved (these will only be coded if the Resident is admitted with Antibiotics)

Types of Codes Used in LTC

• Aftercare – used when the initial treatment of a disease or injury has been performed and the patients still requires continued care to heal or recover.

• Late Effects – a late effect is a residual condition that remains and requires medical evaluation, rehab treatments and/or nursing care after the initial illness or injury.

Types of Codes -2

• Chronic Conditions – Conditions that are stable but still require management or treatment.

• Acute Conditions –acute care codes should only be reported until the condition is resolved.

• Therapy – Physical, occupational, speech and respiratory therapy.

Types of Codes -3

• History of – (Hx) – history codes are acceptable on any Medical record regardless of reason for admission/encounter.

• A history code is distinct from a “status” code in that history codes indicate that the patient no longer has the condition and “status” codes indicated a present state.

• There are two types of history V-codes, personal and family.

Definition Principal Diagnosis

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

Principal Diagnosis

• When two or more inter-related conditions potentially meet the definition of principal diagnosis– Either may be sequenced first unless therapy

is being provided, the Tabular list or Alphabetic Index indicate otherwise.

– Inter-related conditions – two or more diagnosis that equally meet the definition of principal diagnosis.

Principal Diagnosis-2

• The first Dx identifies the main reason for the resident’s admission/encounter

• The terms Admission and encounter can be used interchangeably and are used all healthcare settings. (they have the same meaning)

Examples

• Resident was treated for UTI at the hospital and is still on IV antibiotic therapy.

• Resident had surgery for a bowel obstruction and needs care to the surgical site and physical / occupational therapy

Identify the Principal Diagnosis ……

Locating Diagnosis

• Transfer Records

• History & Physical

• Progress Notes

• Admission Orders

Additional Sources of Information

• Discharge summary• Transfer documentation, • Surgical reports• Consultations

• Physician Progress notes • Lab reports and radiological studies

Secondary Diagnoses

• To further support Medicare covered skilled services – usually in order of complexity.– May have multiple secondary codes– List and code conditions related to therapy

and services provided– Review and update as condition changes –

sequence may change over time– Billing staff should work with Nursing and

Health Information Department to know which diagnoses are current, which is principal, etc.

Secondary Diagnoses-2

• Order by complexity.• Assign the condition with the higher

complexity first. (those that require the most resources i.e. wound care vs. hypertension)

• All conditions present at the time of admission, and that affect the treatment provided and length of stay should be coded.

Acute Diagnoses

• Acute dx treated in the hospital should be coded until the condition is resolved, after the resident is transferred to the SNF

Examples:

MRSA

Pneumonia

UTI

ICD-9-CM Official Guidelines for Coding & Reporting

• www.cdc.gov/nchs/data/icd9/cdguide.pdf

• Latest Revision October 1, 2008

• Codes revised twice per year April and October

• April codes will come out only if significant or important and can not wait until October

Assigning Code Numbers

• Both the Alphabetic Index and the Tabular List must be used when locating and assigning a code.

• Do not rely on just one since this can lead to errors in code assignment and a less specific code selection

How to Select Codes

• Locate each main term and subterm in the alphabetical index, i.e., Chronic Kidney Disease Disease 1. Disease 2. Kidney 3. Chronic

• Verify the code selected in the Tabular list

• Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List

Tabular List

• Instructions for conditions that require multiple coding can appear in the Tabular List.– “Code also underlying disease”, “Use

additional code, if desired, to identify manifestation, as …” “Code also” instructs the coder to:

• Code the underlying disease, or etiology first as the primary diagnosis, followed by the code (s) for manifestation (s).

• It is mandatory to follow the “code also” instructions to assign both codes.

Code to the Highest Level of Specificity

• Assign 3 digit codes only if there are no four digit codes within the category.– There are only 100 codes with only 3 digits

• Assign 4 digit codes only if there is no fifth digit.

• Assign 5 digit codes when indicated.• Samples – 486, 401.x, 250.xx

Non-Specific Codes

• NEC – Not Elsewhere Classified

• NOS – Not Otherwise Specified

• Codes are used only when neither the diagnostic statement nor a thorough review of the clinical record provides adequate information to permit assignment of a more specific code

V Codes

• Per ICD-9-CM Official Guidelines for Coding and Reporting, aftercare codes are generally first to explain the specific reason for the encounter (admission)

• Certain aftercare code categories need a secondary dx code to describe the resolving condition or sequelae

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

V-Codes -2

• V-codes are assigned to problems that affect the patient’s health but are not in themselves a current illness or injury

• V-codes can be used to represent status or history. • Examples:

– Status Cardiac Pacemaker V45.01– Status heart valve prosthesis V43.3– History of falls V15.88– History of alcoholism V11.3

• Remember not to use acute care codes when coding aftercare

Combination Codes

• A single code used to classify TWO (2) diagnoses or a diagnosis with an associated manifestation or complication.

• Key words:– “AND”, “AND/OR”– “WITH”, “WITH MENTION OF” OR “ASSOCIATED

WITH”– “EXCLUDES”

Examples

• 1. Chronic Peptic Ulcer with Hemorrhage • 2. Cerebral thrombosis with cerebral

infarction • 3. Diverticulitis of Duodenum “with”

bleeding

Combination Codes-2

• Certain conditions have both underlying etiology and multiple body system manifestations, due to the underlying etiology. Code the underlying etiology first, followed by the manifestation.

Combination Codes-3

• Etiology codes – USE ADDITIONAL CODE

• Manifestation codes – CODE 1st Underlying Dx.

• Codes in parentheses identify conditions that require multiple coding. Also, codes in parentheses CAN NOT be sequenced as PRINCIPAL Dx.

Manifestation Codes

• There are written instructions in ICD-9-CM coding books for sequencing codes.

• The underlying Dx (cause/s) coded first, followed by codes for manifestations.

Manifestation Codes -2

• Diabetic Neuropathy • Diabetes with neurological manifestations

must be coded first (250.60) • The tabular list will guide you to “Use

additional code to identify manifestation, as:” • Polyneuropathy in diabetes (357.2) • The tabular section will tell you that this code

is not allowed as a principal Dx and will guide you to code underlying disease, as (Diabetes with complication…)

Multiple Coding

• Multiple Coding of Diagnoses– Find the main term in the Alphabetical Index

to locate the code number reference. Check the reference in the Tabular List for notes and instructions “associated with”, “due to”, “secondary to”, etc. are clues that multiple coding may be necessary.

Multiple Coding -3

• “Associate with”, “Due to”, or “Secondary to”…– Frequently needed to completely identify

diagnosis of resident’s in long term care facilities.

– Residents are often treated for the functional manifestations of a disease. Multiple coding is needed to identify both the underlying disease and the manifestations.

Multiple Coding -4

• Examples:– Aftercare following kidney transplant – V58.44 (aftercare involving organ transplant), – V42.0 (Organ/tissue replacement by transplant ,

kidney)– Aftercare following arteriocoronary bypass – V58.73 (aftercare following surgery of the circulatory

system), V45.81(aortocoronary bypass status)

use aftercare codes to provide better detail

Multiple Coding -5

• “Code, if applicable any causal condition first” notes indicate that the code may be assigned as a principal diagnosis when the underlying cause is not known.

• Example: – Lt. heel ulcer 707.14

Multiple Coding -6

• When the causal condition is known, that code should be sequenced as the principal diagnosis and the manifestation as second.

• Example: – Atherosclerotic ulcer of Lt. heel 440.23,

707.14

Chronic Illnesses Under Treatment

• Chronic illnesses that are managed with medication or treatments, such as hypertension, hypothyroidism, diabetes mellitus, atrial fibrillation, assign the appropriate ICD 9 code

• The chronic condition exists, but is under control by medication

Chronic Conditions

• Chronic conditions under treatment are coded even though the condition is under control with medication

• 250.xx Diabetes is a common chronic condition that is treated and controlled with medication or diet

• Code diabetes even though it is under control and the resident has no complications

Combination Codes

• Some Diabetic Conditions Require 2 Codes– “Diabetic” or “Due to”

• One Code for Cause• One Code for Complication

– Always sequence cause before complication

Combination Codes -2

• Example:– Diabetic foot ulcer

• Diabetes with other manifestation– 250.8x

• Ulcer of lower limb, except decubitus– 707.1x

Skin Ulcers

• Pressure Ulcer is a synonym for decubitus ulcer – due to prolonged pressure

• Subcategory 707.0x has fifth digits to identify site

• New last year - additional code must be used to identify stage

Skin Ulcers of Lower Limbs

• Non pressure ulcers of lower leg

• Fifth digits to identify site

• Multiple coding, code first the underlying dx, such as arteriosclerosis, diabetes, venous hypertension– i.e. diabetic ulcer of left fifth toe 250.80,

707.15

Stasis Ulcers

• The most common type of vascular ulcers– In Alphabetical index under “ulcer” , the index

lists “venous” as a non-essential modifier under the subterm “stasis” that refers to code 459.81.

– Under section 459.81 in the Tabular List you will be instructed to code any associated ulceration from category 707.0-707.9

Wounds

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

Skin Tears and Abrasions

• Abrasions and skin tears are found in the Alphabetical Index under “injury, superficial”

• The fourth digit assignment identifies: – Abrasions– Insect bites– Infections– Superficial foreign body– Blisters

Cellulitis

• Skin tears or ulcers may become reddened, infected or swollen. Do not assume the diagnosis of cellulitis unless it is documented by a physician.

• If cellulitis is present code both the cellulitis and skin ulcer or skin tear to describe the cellulitis as a complication of a skin ulcer or skin tear

Myocardial Infarction

• A code from category 410.XX must be assigned if the admission is strictly for rehabilitation within eight weeks of the acute MI.

• The fifth digit 2 would be used in LTC to designate observation, treatment or evaluation of MI within eight weeks of onset, following the acute phase or in the healing state.

Myocardial Infarction -2

• The fifth digit “1” should be used if the acute myocardial infarction occurred at the nursing facility and was the reason for transfer to the hospital or the cause of death.

• If the admission takes place after eight weeks assign code (412) Old Myocardial Infarction

Neoplasms

Neoplasms of Uncertain Behavior

• Only used when stated as such in Alpha Index– Ex: Gastrinoma of Duodenum (235.2)

• Look up: Gastrinoma, specified site• States to see Neoplasm,by site, uncertain

behavior• Uncertain behavior = difficult to distinguish

from malignant behavior

Unspecified Behavior

• Unspecified behavior – only used when Neoplasm is not fully described– Or not specified as to behavior– Or listed in Alphabetic index

• Ex: Neoplastic Cyst of Tongue– Cross reference Alpha Index Under Cyst,

neoplastic see neoplasm,by site, unspecified nature

Neoplasms with Metastasis

• Malignant Neoplasm from primary site

• Invade or spread via the – Blood– Lymphatic system– Tissue to secondary metastatic site

– Example: Lymphoma with malignant pleural effusion 202.80, 511.81

Neoplasms with Metastasis -2

• Two codes– One for primary (original site)– One for each secondary site

• Code primary before secondary– Except when using “V” code for primary site

that has been surgically removed

Neoplasms with Metastasis -3

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

primary

Neoplasms with Metastasis -4

• Ex: Secondary malignant neoplasm of prostate (198.82)

• Find Neoplasm, prostate, malignant, secondary Determine the site(s) of metastasis

• Turn to Neoplasm table• Find correct subterm(s) for site• Cross over to Malignant and column

secondary

Unknown Primary Site

• Refer to neoplasm table • Unknown or Unspecified primary site• Cross over to primary column 199.1• Sequence after secondary site(s)• Ex: abdominal metastasis from unknown

origin (198.89, 199.1)• Unknown primary would not be used as

principle diagnosis in SNF • The metastatic site is coded first

Unknown Secondary Sites

• Ex: Cancer of Lower lobe of lung with metastases (162.5, 199.1)

• Code primary site first

• To code the unknown secondary site– Refer to Neoplasm table– Multiple sites NEC– Cross over to column for code (199.1)

“V” Codes for Cancer

• Primary site must still be identified

• If removed, eradicated no longer under treatment

• Use a personal history V-code, History,site, malignant neoplasm

• Identify primary site responsible for metastasis but no longer present

V codes for Cancer

• Do not use codes from category V10 for secondary metastatic sites removed or not

• ICD-9-CM does not provide code numbers for “history of secondary neoplasm site

V58.42 Neoplasm

• Official coding guidelines for neoplasm apply when using the aftercare following surgery for neoplasm V58.42

• Aftercare code V58.42 may be used with either the current neoplasm code or a code from category V10, whichever is applicable

V58.42 Neoplasm -2

• A primary malignancy – Previously excised or eradicated from its site – And there is no further tx directed to that site – And there is no evidence of any existing

primary malignancy,– A code from Category V10 is used to identify

the former site of malignancy

Late Effects of CVA’s (438.0-438.9)

• Rather than code the residual condition AND the late effect, combination codes that include the late effect should be used. Additionally, these can be used with a new CVA.

• DO NOT code 436 for CVA codes from categories 430-436 are used for the initial episode of care for an acute CVA at the hospital

Late Effect -2

• A late effect is a residual condition that remains and requires nursing care after the initial phase of an illness or injury has passed

• Locate the codes in the Alphabetical Index under the main term “Late, effect (s)(of)

Late Effect -3

• The residual condition is coded first and the late effect is sequenced second

• Multiple coding is required for most late effects

• A late effect is not used as a principal dx, except for Category 438 Late Effect of CVA – i.e. Left Hemiplegia due to CVA 438.20

438 Late Effect of CVA

• Official coding guidelines state that Category 438 is used for admission and encounter for post acute care following treatment of the CVA in the acute hospital

• Codes from categories 430 to 436 are reserved for the “initial” (first) episode of care for an acute CVA that was provided in the qualifying hospital stay and should not be used in SNF

438 Combination/Multiple Coding

• Category 438 includes combination codes that describe both the cause and the residual deficit

• Right hemiplegia due to old CVA 438.20• More than one code my be used from

category 438 to identify multiple residuals from a CVA

• Dysphagia and left hemiplegia post CVA 438.82, 438.20

438

• Use additional codes with category 438 if the combination code does not address all elements of diagnostic statement

• Multiple coding is used to identify residuals of CVA that do not have a specific code

• Seizure disorder following CVA 438.89, 780.39

V54.1 Aftercare for Healing Traumatic Fracture

• For residents admitted to a SNF for care following treatment in the acute hospital for a traumatic fx use the aftercare codes from Subcategory V54.1

• Do not code the (acute) fracture

• Coding Guidelines require an aftercare code be used after the initial encounter for care of a fx.

V54.1 Aftercare for Healing Traumatic Fracture -2

• For statistical purposes, a fracture should only be coded once. If the same fx is coded for all encounters, it makes collection of fracture statistics difficult

• The V54.1 identifies that the fracture is in the healing phases and the 5th digit identifies the site.

• Aftercare for Fractures; Pathologic and Traumatic

V54 Aftercare Healing Traumatic Fracture

• The fifth digits identify the specific site of the healing fracture

• The fifth digit 9 is used for other specified sites

• If there are several bones that would be classified to the other specified site, only one code is used

V54 Aftercare Healing Traumatic Fracture -2

• DO NOT code V58.43 Aftercare following surgery for injury and trauma (conditions classifiable to 800-999) Exclusion note states “Excludes: aftercare for healing traumatic fracture”

• Remember to always refer to the tabular list and carefully read the instructions and exclusions.

Aftercare for Healing Pathological Fx

• Pathological fracture is a fracture in a bone due to weakening of the bone structure by disease process such as osteoporosis.

• For admissions in LTC following a hospital stay for treatment of a pathological fracture assign a code from Subcategory V54.2 Aftercare for healing pathologic fracture

• A compression fracture of the vertebrae is considered pathologic if it is not caused by trauma

V54.81 Joint Replacement

• Joint replacement of knee for osteoarthritis (V58.78), V54.81, V43.65

• Do not code the disease condition that was treated with the surgery

• 2008 had a change in the tabular list for V58.78 that excludes it when there is orthopedic aftercare; and directs that codes from section V54.01-V54.9 should be used.

Joint Replacement for FX

• Use multiple coding to fully describe the resident’s condition

• FX hip (traumatic) with joint replacement V54.13, V54.81, V43.64

• Do not use V58.43 Aftercare following surgery for injury and trauma-(not for fx)

(conditions classifiable to 800-999) see excludes note: (V54.10-V54.19)

V57 Care Involving Rehab

• Category V57 does not indicate that rehab services were provided, only that the resident was admitted for this purpose

• Use only one code from Category V57 for an admission

• If the resident is admitted for multiple therapies, use V57.89

V57 Care Involving Rehab -2

• Code also the condition requiring the rehab, such as:– Residuals– Late effects– Aftercare– symptoms

V58 Aftercare following Surgery

• The acute dx for which the surgery was preformed is not reported for aftercare encounters or admissions

• Use other aftercare or symptom codes to provide better detail

• Note the instructions with each code that identifies the range of conditions that are included in the aftercare code number– i.e. aftercare post cataract extraction with lens

implant: V58.71, V45.61, V43.1

Hypertension

• Unless the diagnosis statement specifies as “benign” or “Malignant”

• “unspecified” code (401.9) must be assigned

Heart Conditions Due to HTN

• When there is a casual relationship is states as “hypertensive” or “due to hypertension” heart conditions are assigned by Category 402 Hypertensive Heart Disease

• Arteriosclerotic disease due to hypertension 402.90

2009 ICD-9-CM addenda

• Handout # 1

• 2009 -2010 Invalid Codes

• Handout # 2

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