Agenda

• Key changes and revisions

• Written guidance from CMS and OIG that may negate a new guideline

• Chapter-specific changes

• How to tell when you need documentation and when you don’t

“WITH” – Why It’s Important

With

Means“associated

with”or

“due to”

Presumes a casual

relationship between two

conditions linked by these

termsConditions should be coded as related, even

if provider documentation

does not explicitly link

them

The word “with” in the

alphabetic index immediately follows the main term

1. amyotrophy E11.442. arthropathy NEC E11.6183. autonomic (poly) E11.434. cataract E11.365. Charcot's joints E11.606. chronic kidney disease E11.227. circulatory complication NEC E11.598. complication E11.89. specified NEC E11.69

10. dermatitis E11.62011. foot ulcer E11.62112. gangrene E11.5213. gastroparalysis E11.4314. gastroparesis E11.4315. glomerulonephrosis, intracapillary E11.2116. glomerulosclerosis, intercapillary E11.2117. hyperglycemia E11.6518. hyperosmolarity E11.00

Diabeties, diabetic (mellitius) (sugar) E11.9 -with

Code Assignment and Clinical Criteria

The assignment of a diagnosis code is based

on the provider’s diagnostic statement

that the condition exists.

The provider’s statement that the patient has a particular condition is

sufficient.

Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

2016 OIG Work Plan

Review the medical record documentation to

ensure it supports the diagnoses that MA

organizations submitted to CMS for use in risk-

score calculations.

Medical record documentation does not

always support the diagnosis submitted to

CMS by MA organizations.

MA organizations are required to submit risk

adjustment data to CMS in accordance with HHS

OIG Work Plan.

Inaccurate diagnoses may cause CMS to pay

MA organizations improper amounts.

Specific Coding is NOW

Is Medicare going to phase in the requirement to code to the highest level of specificity?*

No, providers should already be coding to the highest level of specificity.

As of 10/1/2016, providers are required to code to accurately reflect the clinical documentation.

*Submitted to CMS 8/8/2016

SequelaLate effects

• There is no time limit for a sequela code.• The residual effect may be apparent early or may occur months or years later.• Coding is usually sequenced with two codes:

1. The condition or nature of the sequela2. The sequela code

• The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect.

Sequela

a residual effect after the acute phase of an illness or

injury

An exception to the above rule: If the code for the sequela is followed by a manifestation code identified in the Tabular list and title, OR the sequela code has been expanded (fourth, fifth, sixth character levels) to include the manifestation(s).

Effective for date of service October 1, 2016S and T ICD10 CM codes from Chapter 19 requiring a seventh character of “S” will receive a designation of NPD in the commercial clinical editor.*

Affects approximately 9,600 diagnosis codes from chapter 19, which currently do not have the NPD designation.

NPD Designation

*Based on recent clarification from the American Hospital Association.

For BMI Depth of Non-pressure

Ulcers Pressure Ulcer Stage Coma Scale NIH Stroke ScaleCode assignment may be based on the medical record documentation from clinicians who are not the patient’s provider.* *physician, or other qualified health care practitioner legally accountable for establishing the patient’s diagnosis

Specific Documentation

The associated diagnosis, i.e. Overweight Obesity Acute stroke Pressure ulcer must be documented by the patient’s provider.

If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be asked for clarification.

Nurse documents

patient’s weight, height, and

BMI data

Physician does not document the patient’s

obesity

An obesity code

should not be used

Examples

Physician documents the

patient’s obesity

The obesity code can be

used

• The guideline extends to any complications of care, regardless of the chapter where the code is located.

• Not all conditions that occur during or following medical care or surgery are classified as complications.

There must be a cause-and-effect relationship between the care provided and the condition, plus an indication in the

documentation that it is a complication.

• Query the provider for clarification, if the complication is not clearly documented.

Documentation of the Complications of Care

Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless

otherwise instructed by the classification.

Excludes1 ExceptionWhen the two conditions are unrelated to each other

For example: Code F45.8 (other somatoform disorders) Excludes1 note for ”sleep related teeth grinding (G47.63),” because teeth

grinding is an inclusion term under F45.8.

Only one of these two codes should be assigned for teeth grinding.

Psychogenic dysmenorrhea is also an inclusion term under F45.8, and a patient could have that as well as sleep related teeth grinding.

The two conditions are clearly unrelated, so both G47.63 and F45.8 can be reported.

Laterality

• If no bilateral code is provided, and the condition is bilateral, assign separate codes for the right and left side.

• If the side is not identified in the medical record, assign code for Unspecified.

• If a patient has a bilateral condition, and each side is treated during separate encounters, assign the bilateral code.

• For the 2nd encounter after one side has already been treated, and the condition NO longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists.

NOTE: If treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate

Some codes specify whether the condition is on the left, right, or bilateral

RL

Laterality Example

Patient has been evaluated for cataracts

in both eyes. The right eye was previously fixed via

surgical interventionPatient now presents to

have the left eye re-evaluated for surgery.

Initial visit: - Cataracts are diagnosed as

bilateral - Bilateral code is chosen

In the re-evaluation visit: - Condition only exists in the left

eye - Report as such

Chapter Specific Changes

Zika Virus

• Code only confirmed case of Zika virus as documented by the provider.

• In this context, “confirmation” does not require documentation of the type of test performed

• The physician’s diagnostic statement that the condition is confirmed is sufficient

• This code should be assigned, regardless of the stated mode of transmission

• If the provider documents “suspected,” “probable,” or “possible” Zika, do not use the code A92.5. Only code associated signs and symptoms

Hypertension Crisis

Assign a code from category I16, Hypertensive crisis, for:

• Documented hypertensive urgency

• Hypertensive emergency • Unspecified hypertensive

crisis

Code any identified hypertensive disease (I10-I15). Sequencing is based on the reason for the encounter.

Acute Myocardial Infarction

Encounters occurring while the myocardial infarction is < 4 weeks old, including transfers to another acute setting or a postacute setting, and the myocardial infarction meets the definition for “other diagnoses” (see Section III, Reporting Additional Diagnoses), codes from category I21 may continue to be reported.

Pressure Ulcers

For ulcers that were present on admission, but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission.

Supervision of High-Risk Pregnancy

High-risk pregnancy complications during labor and delivery Assign the applicable complication codes from Chapter 15.

No complications during the labor and delivery Assign code O80, Encounter for full-term

uncomplicated delivery.

Codes from category O09, Supervision of high-risk pregnancy, are intended for use only during the prenatal period.

When a Delivery Occurs

An obstetric patient is admitted & delivery occurs during that admission The condition prompting the admission Is sequenced as the principal diagnosis.

Multiple conditions prompted the admission Sequence the one most related to the delivery as the principal diagnosis.

Any complication of the delivery Should be assigned as an additional diagnosis.

Gestational (pregnancy-induced) Diabetes

Should not be assigned with codes from subcategory O24.2:Code Z79.4, Long-term (current) use of insulin Code Z79.84, Long term (current) use of oral hypoglycemic drugs

The codes under subcategory O24.4 include: - Diet controlled - Insulin controlled - Controlled by oral hypoglycemic drugs

If a patient with gestational diabetes is treated with both diet and insulin, only the code for insulin controlled is required.

If a patient with gestational diabetes is treated with both diet and oral hypoglycemic medications, only code for “controlled by oral hypoglycemic drugs” is required.

Observation and Evaluation of Newborns for Suspected

Conditions not Found

Assign a code from category Z05, Observation and evaluation of newborns and infants for suspected conditions ruled out, to identify instances when a healthy newborn is evaluated for a suspected condition that is not found.

If the patient has signs and symptoms of suspected problem do not use Z05.

Only code the sign or symptom

Coma Scale

Should be sequenced after the diagnosis code(s).

The coma scale codes (R40.2-) can be used in conjunction with:

- Traumatic brain injury codes - Acute cerebrovascular disease codes- Sequela of cerebrovascular disease

codes

May also be used to assess the status of the central nervous system for other non-trauma conditions (i.e., monitoring patients in the ICU regardless of the medical condition).

NIHSS Stroke Scale

The NIH stroke scale NIHSS codes

(R29.7-) can be used in

conjunction with acute stroke code (I63) to identify

the patient’s neurological status and the severity of

the stroke.

The stroke scale codes should be sequenced

after the acute stroke

diagnosis code.

At a minimum, report the

initial score documented.

You may choose to capture

multiple stroke scale codes.

NIHSS Stroke Scale

R29.700

R29.701

R29.702

R29.703

NIHSS score 0

NIHSS score 1

NIHSS score 2

NIHSS score 3

7th Character A

Used for each encounter where the patient is receiving active treatment for the condition

7th character “A,” initial encounter

Initial vs. Subsequent Encounter for Fractures

The open fracture designations in the assignment of the 7th character for fractures of the forearm, femur, and lower leg (including ankle) are based on the Gustilo open fracture classification.

When the Gustilo classification type is not specified for an open fracture, the 7th character for open fracture should be assigned (B,E,H,M,O).

?Questions

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References

www.aapc.comwww.cdc.govwww.cms.govwww.hhs.gov