Presented to the April , 2019... · 1.Navigate the ICD-10 conventions & guidelines, including the...

ICD-10-CM Coding for

Home Health: Basics

Arlynn Hansell, PT, HCS-D, HCS-H, HCS-O, COS-C

Owner

Therapy and More, LLC

Cincinnati, OH1

Presented to the

April , 2019

Coding for Noobs: Objectives1.Navigate the ICD-10 conventions & guidelines, including the use of

laterality, Excludes notes, unspecified codes, sequelae, 7th character

assignment, and key sequencing guidelines.

2.Use the alphabetic index, tabular list and neoplasm table to correctly find

codes.

3.Apply critical thinking in understanding the sequencing of common

diagnoses.

4.Appropriately assign signs and symptoms codes.

5.Understand how to assign codes in M1021 (primary) and M1023 (other).

6.Recognize key coding and OASIS interactions.

7.Apply and reinforce what you’ve learned by working through common

home health scenarios.2

Purpose of Coding

• Provides morbidity and mortality statistical data

• Paints accurate clinical picture of our patients

• Establishes medical necessity for claims

• Contributes to risk adjustment

• Compliance with regulatory requirements

– Applicable coding guidelines

– HIPAA Administrative Simplification Rule 10/16/03

– Every provider/every payor must follow same rules

3

Official Sources

• Official/Approved Coding Sources

• Official Coding Guidelines: published annually; effective every October 1st

• Coding Clinic: published quarterly by the American Hospital Association

• Subscription required

• Official Sources – NOT Official Coding Guidelines. These are

allowed sources, but do not rise to the level of official coding

guidelines.

• OASIS Guidance Manual

• CMS Q&As

• CMS Annual Final Rule4

Official Coding Guidelines

• ICD-10-CM Official Guidelines for Coding and Reporting were

revised for 2019 (effective October 1, 2018) and can be found at:• https://www.cdc.gov/nchs/icd/data/10cmguidelines-FY2019-final.pdf

• The conventions, general guidelines, and chapter-specific

guidelines are applicable to all health care settings, unless

otherwise indicated.

5

Assigning DiagnosesGuidance, tips, and keys

6

The Provider

• In the context of the guidelines, the term provider is used throughout to mean physician or other qualified heath care practitioner who is legally accountable for establishing the patient’s diagnosis.

• Hospice clinicians and coders must work in collaboration with the Hospice medical director and/or attending physician to identify the patient’s related and non-related diagnoses.

• Document all communication with the physician related to diagnoses.

7

The Assessing Clinician

• The assessing clinician is responsible for selecting and sequencing the diagnoses in conjunction with the physician to provide the best description of the patient’s condition.

• The assessing clinician must agree with any changes to the coding made by the coder.

• Documentation of collaboration between the clinician, the physician, and the coder is imperative!

8

Roles and Responsibilities of Coder

• Documentation

• Obtain complete supporting documentation for each patient.

• Ensure that the patient documentation supports the assigned

codes.

• Diagnosis codes

• Assign accurate diagnosis codes from the ICD-10-CM

classification system.

• Sequence the diagnosis codes appropriately.

• Validate diagnosis codes using coding conventions and

guidelines.9

Creating a Compliant Record

• Begins at referral/intake with requests for:• F2F and/or the reason for referral to home care

• If referral from MD office – H&P, current medications, and recent visit notes

• Dates and places of recent inpatient stays/surgeries

• Copies of the H&P, consultations, operative report, if applicable, discharge summary, etc.

• Continues with review of the documentation, the comprehensive assessment, scoring of the OASIS, then determining and coding the diagnoses.

10

Roles and Responsibilities of Coder (cont.)

• Collaboration with clinician, physician, manager, and/or

administrator• Query clinicians, physicians, or managers/administrators about incomplete

information, additional information needed, or documentation deficiencies.

• Obtain clinician agreement with code assignment and sequencing.

• Train clinicians, physicians, and/or managers/administrators about changes to

coding protocols.

• Code in a legal and ethical manner • Conduct activities in a legal, ethical, and professional manner.

• Archive and retrieve patient documentation related to the medical record.

• Adhere to agency policy and regulatory and professional guidelines.

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Documentation, Compliance,Coding, and Billing

12

5 Elements Critical to Compliance and the Final Claim

Documentation

Comprehensive Assessment and OASIS

Diagnosis Codes

Physician Orders

POC13

The OASIS and POC don’t justify care – documentation does!

• All 5 elements of home health care and services must support the claim submitted to Medicare.

• Elements are interrelated and co-dependent.

• Codes or OASIS responses do not automatically support medical necessity.

• Medical necessity is supported by the entirety of the medical record throughout the episode.

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It all must make sense together….

• All progress notes and case management coordination should match the focus of care from SOC through discharge.

• The documentation must support the codes.

• The conditions coded must be addressed in the POC.

• Without consistent and accurate documentation, accurate coding is impossible.

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Coding and Documentation

• Adhere to the Official Coding Guidelines and the OASIS Guidance Manual.

• List only unresolved diagnoses that will be monitored, evaluated, or treated by the agency or those that will impact the treatment of the patient or be impacted by it.

• Documentation must clearly show how the diagnoses affect one another or the home health services/POC being provided.

• Ensure that all diagnoses are confirmed/validated by the physician. If querying the physician for a diagnosis, the documentation in the medical record must support the query and the response.

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Book Tour

17

Alphabetical Index

18

Neoplasm Table

19

Table of Drugs and Chemicals

20

External Causes

21

Tabular List

22

Tabular List

23

Conventions, Guidelines and

Instructions

24

Hierarchy of Importance

Conventions

and

Tabular instructionsChapter-Specific

GuidelinesGeneral Coding

Guidelines25

Conventions

Back it up: what does ICD-10-CM stand for: International Classification of Diseases, 10th Revision, Clinical Modification.

• Conventions are the general rules for use of the classification (again, the ICD-10-CM), independent of the guidelines (see slide 46).

• The conventions are incorporated within the Alphabetic Index and Tabular List as instructional notes.

• Per the ICD-10-CM Guidelines, conventions are defined as:

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Conventions

and

Tabular instructions

Conventions 1-3: Alpha Index, Tabular List, Format and Structure, Use of Codes for reporting purposes

1.The Alphabetic Index and Tabular List

• Alphabetic Index, a list of terms and their corresponding code, consists of:

• Index of Diseases and Injury

• Index of External Causes of Injury

• Table of Neoplasms

• Table of Drugs and Chemicals

• Tabular List is a structured list of codes divided into chapters based on body system or condition.

2.Format and Structure

• Characters may be either a letter or number.

3. Use of codes for reporting purposes

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Conventions

and


Convention 4, 5, 6: Placeholder character and 7th Characters

4. Placeholder character

• The X used as a placeholder at certain codes

• Where required, it must be used in order for the code to be considered a valid code.

5. 7th Characters

• Required where instructed in the notes in the Tabular List.

• 7th character must always be in the 7th character data field – use placeholder X to fill in empty characters as appropriate.

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Conventions

and


7th Character Indicators

29

Convention 6: Abbreviations: NEC and NOS6. NEC and NOS

• NEC = Not elsewhere classifiable; other specified. When a specific code is not available for a condition the Tabular List includes an NEC entry under a code to identify the code as the “other specified” code.

• When a specific code is not available for a condition, the Alpha Index directs the coder to the “other specified” code in the Tabular List.

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Conventions

and


Convention 6: Abbreviations: NEC and NOS6. NEC and NOS

• NOS = Not otherwise specified; unspecified.

• Used when the information in the medical record is insufficient to assign a more specific code.

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Conventions

and


Convention 7: Punctuation• [ ] Brackets are used in the Tabular List to enclose synonyms,

alternative wording or explanatory phrases.

• Used in the Alpha Index to identify manifestation codes.

• ( ) Parentheses used in both Tabular List and Alpha Index.

• Enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. These are referred to as nonessential modifiers.

• : Colons are used in the Tabular List after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category.

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Conventions

and


Conventions 8-11: And, Other, Includes8. Use of “and”. See Convention 14.

9. “Other” and “Unspecified” codes

• “Other”: For use when the information in the medical record provides detail for which a specific code does not exist

• “Unspecified”: for use when the information in the medical record is insufficient to assign a more specific code.

10. Includes Notes – further defines category content

11. Inclusion terms

• Condition for which that code is to be used

• Is not necessarily an exhaustive list

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Conventions

and


Convention 12a, 12b: Excludes 1 & 2

• A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes 1 note indicates that the code excluded should never* be used at the same time as the code above the Excludes 1 note.

• An Excludes 1 note is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

*An exception to the Excludes 1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes 1 note are related or not, query the provider.

• A type 2 Excludes note represents “Not included here”.• The condition excluded is not part of the condition represented by the code

• Patient may have both conditions simultaneously

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Conventions

and


For example…

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Conventions

and


Convention 13: Etiology/manifestation convention (“code first”, “use

additional code” and “in diseases classified elsewhere” notes)

• Instructional notes indicate the proper sequencing order:

etiology followed by manifestation.

• Etiology: the cause of a disease or abnormal condition.

• Manifestation: a sign showing the existence of a particular

condition.

• When one disease or condition causes another disease or

condition, the one that caused the disease or condition is the

etiology, and the disease or condition it caused is the

manifestation.

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Conventions

and


Convention 13: Etiology/manifestation convention (“code first”, “use

additional code” and “in diseases classified elsewhere” notes)

• So how do you know which one you have?

• In the Alpha Index, the etiology is first listed, followed by the manifestation.

• The manifestation will be indicated in brackets and italics

• In the Tabular List, at the category level, there will be a “Use additional

code” convention:

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Etiology Manifestation

– italics, brackets

Conventions

and


“I am a Manifestation”

38

•At the manifestation code, note says, “code first”.• Provides instructions that the underlying condition should

be sequenced first.•May see “in other diseases classified elsewhere” in the code title

•Can NEVER be Primary (M1021) code or listed prior to the

etiology code

Convention 13: Etiology/Manifestation Convention

• Per the Coding Clinic, the instruction to “code first” the underlying condition applies only if an underlying condition is actually present.

• Per the HH PPS Overview, v7218, Oct 2018, “If there is incorrect or invalid pairing of manifestation and etiology diagnosis codes, neither the etiology nor manifestation codes contribute to the score.” (Potential loss of reimbursement $$).

• Meaning the payer will not return your chart and ask you to re-code it – they will simply ignore those codes that are incorrectly sequenced, and look at the rest of the claim.

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Conventions

and


Code First example

40

L97.412 Non-pressure chronic ulcer of right heel and midfoot

with fat layer exposed

Code First (L97)

any associated underlying condition, such as:

any associated gangrene (I96)

atherosclerosis of the lower extremities (I70.23-, I70.24-, I70.33-, I70.34-, I70.43-, I70.44-, I70.53-, I70.54-, I70.63-

, I70.64-, I70.73-, I70.74-)

chronic venous hypertension (I87.31-, I87.33-)

diabetic ulcers (E08.621, E08.622, E09.621, E09.622, E10.621, E10.622, E11.621, E11.622, E13.621, E13.622)

postphlebitic syndrome (I87.01-, I87.03-)

postthrombotic syndrome (I87.01-, I87.03-)

varicose ulcer (I83.0-, I83.2-)

So in this situation, the foot ulcer MAY have an etiology, or underlying

condition present, or it MAY NOT. Would be beneficial to query the

physician.

Conventions

and


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=7&sk=I96

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=7&sk=I70.23














https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=7&sk=E08.621
















Convention 14: “And”

14. “And”. Should be interpreted to mean either “and” or “or” when it appears in a title.

For example, there is code A18.0, Tuberculosis of bones and joints.

• You will use this code, regardless if you are only seeking:• “tuberculosis of bones”

• “tuberculosis of joints”

• as well as “tuberculosis of bones and joints”

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Conventions

and


Convention 15: “With” or “In”• The term “with” or “in” should be interpreted to mean “associated with” or

“due to” when it appears in the code title, the Alphabetic Index, or an instructional note in the Tabular List.

• The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic index or Tabular List.

• These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the provider documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guidelines for “acute organ dysfunction that is not clearly associated with the sepsis”).

• For NEC codes, the specific condition must be linked to the main term and coded.

• Coding guidance states the “with” convention does not apply to “not elsewhere classified (NEC)” index entries that cover broad categories of conditions.

42

Conventions

and


Convention 15: “With” or “In”• For conditions not specifically linked by these relational terms in the

classification or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related.

• The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.

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Conventions

and


Conventions 16 – 19: “See” and “See Also”, “Code Also”, Default codes, Code Assignment and Clinical Criteria

16. “See” and “See Also”.

• When “see” follows a main term in the Alpha Index, this indicates another term should be referenced. You MUST look up the other term.

• “See Also” instruction following a main term in the Alpha Index instructs that there is another main term that may also be referenced that may provide additional Alpha Index entries that may be useful. It is not necessary to follow the “see also” note when the original main term provides the necessary code.

17. “Code Also” note. A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. The sequencing depends on the circumstances of the encounter.

18. Default codes. A code listed next to a main term in the Alpha Index is referred to as a default code. The default code represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition.

19. 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.

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Conventions

and


Chapter-Specific GuidelinesChapter-Specific

Guidelines

45

Chapter-specific coding guidelines are found officially in the

ICD-10-CM Guidelines, Section C.

In this course, they will be discussed as we maneuver our way

through each chapter.

Coding Guidelines• Instructions and conventions of the classification take precedence

over guidelines.

• Guidelines: set of rules to accompany the official conventions and instructions.

• Based on coding and sequencing instructions in the Tabular and Alpha sections.

• Organized into sections:

• Section I: structure and conventions of the classification and general guidelines for the entire classification

• Chapter-specific guidelines

• Section II: guidelines for selection of principal/primary diagnosis for non-outpatient settings

• Section III: guidelines for reporting additional diagnoses in non-outpatient settings

• Section IV: outpatient coding – this area does not apply in home health!

46

General Coding Guidelines

Guidelines 1 - 6

1. Locating a code in the ICD-10-CM.

1. First locate the term in the Alpha Index

2. Then verify the code in the Tabular List.

1. Read and be guided by instructional notes in both locations

2. Level of Detail in Coding

• Codes are to be used and reported at their highest number of characters available (greatest specificity)

• Codes can consist of 3 – 7 alphanumeric characters

3. Code or codes from A00.0 through T88.9, Z00-Z99.8

4. Signs and symptoms. Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. (See Guideline 18, slide 56)

5. Conditions that are an integral part of a disease process. Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

6. Conditions that are not an integral part of a disease process. Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present. 47


Guideline 7

7. Multiple coding for a single condition. “Use additional code” notes are found in the

Tabular List at codes that are not part of an etiology/manifestation pair where a

secondary code is useful to fully describe a condition. The sequencing rule is the same as

the etiology/manifestation pair, “use additional code” indicates that a secondary code

should be added, if known. However, it is not necessary to report the code identified in a

“use additional code” note in the diagnosis field immediately following the primary

code.1

• “Code first” notes are also under certain codes that are not specifically manifestation codes but

may be due to an underlying cause. When there is a “code first” note and an underlying

condition is present, the underlying condition should be sequenced first, if known.

• “Code, if applicable, any causal condition first” notes indicate that this code may be assigned

as a principal/primary diagnosis when the causal condition is unknown or not applicable. If a

causal condition is known, then the code for that condition should be sequenced as the

principal/primary or first-listed diagnosis.

1. Leon-Chisen, N. ICD-10-CM and ICD-10-PCS Coding Handbook 2019. Chicago: Health Forum, Inc.48


Guideline 8: Acute versus Chronic Condition

• If the same condition is described as both acute and chronic, and there are separate entries for each in the Alphabetic Index at the same indentation level:

• Code both and sequence the acute code first

• Example: patient has both acute and chronic liver failure

49


Guideline 9: Combination Code

• A combination code is a single code used to classify:

• Two diagnoses, or

• A diagnosis with an associated secondary process (manifestation)

• A diagnosis with an associated complication

• Combination codes are identified by referring to subterm entries in

the Alpha Index and by reading the inclusion and exclusion notes

in the Tabular List.

• Use the combination code only if it captures all the necessary

components of the diagnosis. 50


Guideline 10: Sequela (Late Effects)

• Sequela is the residual effect, or condition produced,

AFTER the acute phase of an illness or injury has

terminated.

• No time limit for the occurrence of a sequela.

• General sequela coding (there are exceptions, follow the code notes):

1. Residual condition

2. Sequela code (what caused the sequela/residual condition)

• Examples include:

• Scar formation from a burn

• Abnormal gait from a CVA

• Ex: M24.521, Contracture, right elbow

T22.321S, Burn of third degree of right elbow, sequela51


Guidelines 11 - 13

11. Impending or Threatened Condition: The guideline as written is not

applicable for home health. In home health, we can only code

confirmed (did occur) conditions.

12. Reporting Same Diagnosis Code More than Once. Each unique ICD-

10-CM diagnosis code may be reported only once for an encounter.

13. Laterality: when coding an episode, if a patient has a bilateral

condition, assign the “bilateral” code if one is available. If one is not

available, assign separate codes for both the left and right side.

• Upon recert, if one side has resolved, assign the appropriate unilateral code for

the side where the condition still exists.

52


Guideline 14: Documentation for BMI, Depth of Non-Pressure Ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale

• For the Body Mass Index (BMI), depth of non-pressure chronic ulcers,

pressure ulcer stage,…, code assignment may be based on medical record

documentation from clinicians who are not the patient’s provider (i.e.,

physician or other qualified healthcare practitioner legally accountable for

establishing the patient’s diagnosis).

• The associated diagnosis (such as overweight, obesity,…,or 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 queried for

clarification.

• The BMI codes should only be reported as secondary diagnoses.

• The BMI may be calculated and documented (height and weight used to calculate).

• However, the physician must provide diagnoses, such as overweight, obesity, or underweight in

order to code the BMI.

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Guidelines 15 - 1815. Syndromes. Follow the Alpha Index guidance for coding.

16. Documentation of Complications of Care. Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure. There must be a cause and effect relationship as stated by the provider.

17. Borderline Diagnosis. If a borderline condition has a specific index entry, it should be coded as such. Otherwise, borderline diagnoses cannot be coded as active in home health.

18. Use of Sign/Symptom/Unspecified Codes. There are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter.

• If a definitive diagnosis has not been established, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis.

• Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter.

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PDGM WARNING

The Coding Manual..and how to find the condition!

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The Coding Manual

The ICD-10-CM coding manual consists of: Alphabetic Index

Tabular List


Neoplasm Table

Index to External Cause of Injuries

The format of the coding manual varies by publisher.

Code changes are effective every October 1st.

Always use a current coding manual!

56

So how long is a code?

• Code to the highest level of specificity (maximum # of characters

available) (ICD-10-CM Convention 2).

• All categories are 3 characters. A three-character category that has no

further subdivision is equivalent to a code.

• Subcategories are either 4 or 5 characters. Codes may be 3, 4, 5, 6 or 7

characters. That is, each level of subdivision after a category is a

subcategory.

• The final level of subdivision is a code.

57

Alphabetic Index

• Index of diseases, injuries, symptoms, and other reasons for a patient encounter

• Dash (-) following codes indicates a character for laterality or further specificity is

needed

• e.g., Neoplasm, breast, Benign D24.-

• A-Z index, structured the same by every publisher, including default codes

– Main terms in bold print listed in alphabetical order

– Indented non-bold subterms for more specificity – follow the “with”

– For example:

58

Tabular List

• A chronological numerical listing of codes and their descriptors classified to:

– Etiology of conditions or

– Conditions that affect a specific body system

• Includes notes and Excludes 1 and Excludes 2 notes give more guidance and

can help validate code selection.

• Consult definitions, illustrations, inclusions, exclusions, age, and sex

symbols.

• Note symbols that indicate primary, secondary, or either in the Z codes

section, manifestation codes, and case mix diagnoses.

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Tabular List

60

3 characters = category level4 characters = sub-category level

Code first, code also, includes, excludes notes,

guidelines are all published in the coding manual at the

CATEGORY LEVEL.

So when looking at a specific code, for example

L89.001, you will not see notes. So you must look up

to the nearest category level to find applicable notes

and guidance.

Alpha + Tabular• Use both the Alphabetic Index and the Tabular List when assigning codes.

• First, look up the main term in the Alphabetic Index.

• Next, verify the code in the Tabular List.

• Observe the punctuation, footnotes, cross-references, color-coded prompts, and other

coding conventions.

61


62

• The Table of Drugs and Chemicals is set up in alphabetical order by

the drug or chemical name.

• There are 6 columns of categories: Poisoning (accidental, intentional,

assault, undetermined); Adverse effect, and Underdosing

Using the Table of Drugs and Chemicals

• Patient took a double dosage of Coumadin in error.

• What is the code to use for Coumadin, Poisoning, Accidental?

• Answer: T45.511-

• We will get into later the distinction in the 6 categories.

63

The Neoplasm Table

Neoplasms are listed in alphabetical order by body site with subentry

modifiers for more specificity to site.

64

• The Neoplasm Table has six columns – Malignant Primary, Malignant

Secondary, Ca in situ, Benign, Uncertain Behavior, and Unspecified Behavior.

•Within the Neoplasm Table, the listing is alphabetical by body part.

Using the Neoplasm Table

• Patient has a malignant neoplasm of the lower breast.

• What is the code to use?

• Answer: C50.8-

• What does the (-) indicate in this instance?

• Answer: laterality is needed to further specify the condition

• We will get into later the distinction in the 6 categories.

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Index to External Cause of Injuries

• Classifies environmental events, circumstances, and conditions as the cause of injury, poisoning and other adverse effects.

• Organized by the main term describing the accident, circumstance, etc.

66

Finding the Codes

67

The first step…• Determine the main term in the diagnostic statement.

• The word you’ll look up first

• Think like Yoda (“Look it up, you will”)

• Go to the Alphabetic Index, find the main term.

• Usually a noun

• Name of a person

• Condition, not the body part

• The Index is organized by main terms.

• Diseases – Influenza, Bronchitis, Pneumonia

• Conditions – Fatigue, Fracture, Injury

• Nouns – Disease, Disturbance, Syndrome

• Adjectives – Double, Kink, Large

• Complications – Hemorrhage, Infection, Rupture

68

Identifying the Main TermMedical Diagnoses

Congestive heart failure

Chronic renal insufficiency

Cranial nerve compression

Aortic valve stenosis

Closed fracture of fibula

Myocardial infarction

Staphylococcal infection

Infected joint prosthesis

Vitamin B deficiency

Regional enteritis

Cystic fibrosis

Lyme disease

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Find the Main Term

Z Codes

Attention to surgical dressings

Aftercare following surgery

Fitting of prosthetic device

Status colostomy

History of breast neoplasm

Encounter for palliative care

Resistance to penicillin

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The next step…

• Look for further specifics…

• Are there any indented terms underneath the ones you’ve already found?

• Let’s look at your patient who has a gastric ulcer.

• In the Alphabetic Index:

Ulcer, ulcerated, ulcerating, etc.gastric – see Ulcer, stomachstomach (eroded) (peptic) (round) K25.9

Note for further digit subclassification (with or without obstruction)with

hemorrhage K25.4and perforation K25.6

• Reference the entire “indented” series of subterms following a main term – read

everything from one bold term to the next!71

What will you search for with the following…

Stage 2 pressure ulcer, left hip

Personal history of malignant brain neoplasm

Left total hip replacement

72

AnswersStage 2 pressure ulcer, left hip

Ulcer, Pressure, hip…

Can you search under “Pressure”?

Personal history of malignant brain neoplasm

History, personal, malignant neoplasm….

Left total hip replacement

Aftercare, following surgery for, joint replacement….

Instructions guide to Use Additional Code to identify the joint….

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How do you choose the correct 7th Character…

A, D, or S?

74

“A” (Initial Encounter)

• 7th character “A,” initial encounter, is used for each encounter where the patient is receiving active treatment for the condition.

Examples of active treatment are:

– Antibiotics for an infection

– Wound care using a wound vac

–Patient seen for IV abx for postprocedural septic shock:

–T81.12XA

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“D” (Subsequent Encounter)

• 7th character “D,” subsequent encounter, is used for encounters after

the patient has completed active treatment of the condition and is

receiving routine care for the condition during the healing or

recovery phase.

Examples of subsequent care in home health are:

– Follow-up visits following treatment of an injury or condition

– Therapy following a fracture without complications

Most common in home health: Aftercare following surgery: Z48.81XD

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“S” (Sequela)• A sequela, or late effect, is a residual condition that remains after the acute

phase of an illness or injury has ended.

• Coding of sequela generally requires two codes sequenced in the following order (reminder, this is a Guideline):

• The condition or nature of the sequela is sequenced first.

• The sequela code is sequenced next.

• When using 7th character “S,” it is necessary to use both the injury code (the cause) that precipitated the sequela (residual condition) and the code for the sequela itself.

–Example:– TYPE OF SEQUELA: M24.511, Contracture, right shoulder

– INJURY CODE: T22.351S, Burn of third degree of right shoulder, sequela

• There are exceptions to the guidelines – will be indicated in either the Alpha index or Tabular list. Read everything!

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Sequela (Late Effect)

• There is no time limit for the development of a residual condition or

when a sequela code can be used.

• A residual may be apparent early, such as with a cerebral infarction, or it may occur

months or years later, such as that due to a previous injury.

• There may be more than one residual.

• The sequela may or may not have a 7th character of ‘S’.

• Look for medical terminology such as:• Late

• Old

• Due to previous injury or illness

• Following previous injury or illness

• Traumatic

78

Sequela: when a Convention trumps a Guideline• Exception to the Guideline:

• Happens when a code for the sequela needs to be listed first, as it must be followed by a

manifestation code.

• Scenario: Lumbosacral scoliosis due to rickets

M1021a: E64.3, Sequelae of ricketsM1023b: M49.87, Spondylopathy in diseases classified elsewhere, lumbosacral region

Rationale:

• Even though scoliosis, as the residual condition, would typically get coded first, then followed by the

resolved illness, the scoliosis code is a manifestation code, so it cannot be coded first.

• Rationale: manifestation coding is a Convention, sequela coding is a Guideline.• Conventions always trump Guidelines!

79

“S” (Sequela) and Complications

• A complication is a problem that arises complicating the healing process of the initialillness, injury, or medical/surgical procedure.

• Delayed treatment

• Delayed healing

• Infection

• Foreign body

• Sequela versus Complication• Sequela: occurs after the healing phase of the care or condition is complete.

Think of this as the late effect.

• Complication: occurs while the patient is still healing from the care or condition. Routine care is NOT performed for this condition, so the usual aftercare Z codes and Z codes for wound care are NOT appropriate.

80

OASIS Guidance

81

Code Availability Types

• Diagnosis codes: I73.9, Peripheral vascular disease, unspec.

• Codes to describe:• Aftercare: Z48.812, Aftercare following surgery of the circulatory

system

• Presence of a device: Z93.1, Gastrostomy status

• Attention to artificial opening: Z43.2, Attn to ileostomy

• Long term (current) use of meds: Z79.82, LT use of ASA

• Social conditions: Z60.2, Problems related to living alone

• Medication situations gone awry: T36.0x5, Adverse effect of penicillins

• What will be coded, be it a diagnosis code or other type, depends on the circumstances of the encounter.

82

M1021: Primary Diagnosis

• The chief reason for providing home care and the diagnosis most related to the current plan of care (don’t forget the F2F!).

• The most “serious” condition that requires the most intensive skilled home health services.

• May or may not be related to a recent hospital stay, but must relate to skilledservices (SN, PT, OT, SLP) provided by the home health agency.

83

M1023: Other Diagnosis

• Co-morbid conditions that:

• Exist at the time of the assessment;

• Are actively addressed in the POC; and

• Have the potential to affect the patient’s responsiveness to treatment and/or the rehabilitative process

• Determination of secondary diagnoses is based on:

– Clinician’s assessment of the patient;

– Information in medical record; and

– Input from the patient’s physician.

84

Selection and Sequencing of Diagnoses (cont.)

• Diagnoses that are stable and have no impact on the current POC

should not be coded. For example (typically):

• Anemia

• GERD

• Hypercholesterolemia

• Hypothyroidism

85

M1028: Active Diagnoses

• Identifies whether specific diagnoses are present and active at the SOC/ROC.

• Must be associated with the home health episode of care.

For the guidance and complete list of codes permitted, see the OASIS-D Guidance Manual, item M1028

86

M1028: Guidance (cont.)

• There must be specific documentation in the medical record by a physician of the disease or condition being an active diagnosis.

• The physician may specifically indicate that a diagnosis is active. Specific documentation areas in the medical record may include, but are not limited to, progress notes, admission history and physical, transfer notes, and the hospital discharge summary.

• The physician may, for example, document at the time of assessment that the patient has inadequately controlled diabetes and requires adjustment of the medication regimen.

• This would be sufficient documentation of an active diagnosis and would require no additional confirmation because the physician documented the diagnosis and also confirmed that the medication regimen needed to be modified.

87

General Guidelines

• Z codes are for use in any healthcare setting.

• Z codes may be used as either a first-listed (principal/primary diagnosis) or secondary code, depending on the circumstances of the encounter.

• Hospice can NEVER use a Z code as a principal/primary diagnosis.

• Z codes represent reasons for encounters.

89

Z Code Categories

• Most common categories used in home care are:• Aftercare

• Surgical

• Attention to…

• Encounter for…

• Fitting and adjustment of…

• Adjustment and management of…

• Status

• History

90

Aftercare Codes Z48.-

• Use for situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase; or

• Should not be used if treatment is directed at a current, acute condition.

• For routine care

• Code assigned is based on the body system chapter for the underlying diagnosis –

e.g., aftercare following surgery for an ovarian abscess is coded to Z48.816

(genitourinary system).

• How do you find what system the surgery is? Look up the code for the condition (in this

case, the ovarian abscess), and that condition code chapter indicates the system.

• Includes routine drain care and pain management.

91

Aftercare Codes (cont.)

• Are generally first-listed to explain the specific reason for the encounter, but may be used as an additional code when aftercare is provided in addition to the reason for admission.

• Example: Care of a stage 3 pressure ulcer may be more of a focus than aftercare following surgery.

• Should be used in conjunction with other aftercare or diagnosis codes to provide more detail on the encounter, such as:

• Fitting and adjustment

• Attention to artificial openings

• Encounter for change of surgical dressing

• Sequencing of multiple aftercare codes depends on the circumstances of the encounter.

92

Aftercare Codes (cont.)

• Certain aftercare Z codes require a secondary diagnosis code to describe the resolving condition or sequelae.

• Z48.3, Aftercare following surgery for neoplasm

• Use additional code to identify the neoplasm

• Z47.1, Aftercare following joint replacement surgery

• Use additional code to identify the joint (Z96.6-)

• For others, the condition is included in the code title.

• Z43.6, Encounter for attention to nephrostomy

93

“Attention to”

• Attention to Z codes explain a patient’s medical condition that currently exists, is

receiving treatment, and is affecting the POC. The agency must be actively doing

something related to or about the condition or sequela – cleansing, feeding, or

teaching.

• Z43.-, Encounter for attention to artificial openings

94

“Encounter for”

• Z48.0-, Encounter for attention to dressings, sutures and drains

• Do NOT use this category when the wound is complicated (infection, dehiscence, etc.)

• This should not be the primary/principal code (M1021)

• Z48.00, Encounter for change or removal of nonsurgical wound dressing

• Z48.01, Encounter for change or removal of surgical wound dressing

• Z48.03, Encounter for change or removal of drains

95

History Codes

• Describe medical conditions that:• No longer exist; or

• Are not receiving any treatment; or

• May recur, requiring continued monitoring; or

• May impact the plan of care

• Are important information that may alter treatment

• Two types:1. Family – be careful when reading the alpha index. Be certain you are looking up

the Personal history!

2. Personal

96

Status Codes• Explain a patient’s medical condition that:

• Currently exists and is not receiving any treatment (including intervention or management); but

• Has the potential to affect the POC; and

• May require continued monitoring

• Are informative, because the status may affect the course of treatment and its outcome

• Common:• Z93.-, Artificial opening status

• Z95.-, Presence of cardiac devices

• Z96.-, Presence of orthopedic joint implants

• Z89.-, Z90.-, Acquired absence of …

• Z99.-, Dependence on enabling machines and devices97

Finding Status Codes

Three main terms in the Index:

1. Status

Z93.3, Colostomy status

2. Absence

Z90.410, Acquired total absence of pancreas

3. Presence

Z95.2, Presence of prosthetic heart valve (heart valve NOS)

Index: Presence heart valve prosthetic Z95.2

Status = patient has a device, to which the agency is not providing any care.

98

Status Codes (cont.)

• Status codes should not be used when:

– The aftercare code indicates the type of status, such as:

Z43.0, Encounter for attention to tracheostomy

Z93.0, Tracheostomy status

– There is a related complication: absence of limb would not be coded along with an amputation stump

complication

99

Would not code these both on the claim

Ostomies

• Ostomies are heavy users of Attention to and Status codes

• 3 things must be known to use the correct code:1. Type of opening (colostomy, ileostomy, etc.)

2. Who is providing care to the ostomy – this determines if it is Status or Attention to

3. Is it routine or complicated care – this determines Z code or complication code

100

No Z codes for…

• Z codes are not to be used for:• Traumatic fractures

• Pathological fractures

• Aftercare of an injury

• There is no “Aftercare following surgery on musculoskeletal system”

• Use code Z47.89, Other orthopedic aftercare, NEC

101

Assign the injury code with the appropriate 7th character.

Z Code Quick Codes

• Teaching patient and caregiver on care of new gastrostomy

• Previous diabetic foot ulcer

• New artificial left arm

102

Z Code Quick Codes Answers

• Teaching patient and caregiver on care of new gastrostomy

• Z43.1, Encounter for attention to gastrostomy

• Note: Z43 codes are used for active care to the artificial opening. • For reversal/closure of an ostomy: assign Z48.-. Use the aftercare code for the reason for the

original ostomy.

• Previous diabetic foot ulcer

• Z86.31, Personal history of diabetic foot ulcer

• Do not use for current diabetic ulcer.

• New artificial left arm

• Z97.12, Presence of artificial left arm (complete) (partial)

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Orthopedic Aftercare Codes Z47.-

• Z47 Orthopedic aftercare• Z47.1 Aftercare following joint replacement surgery

• Z47.2 Encounter for removal of internal fixation device (Do NOT use!)

• Z47.3 Aftercare following explantation of joint prosthesis

• Z47.81 Encounter for orthopedic aftercare following surgical amputation

• Z47.82 Encounter for orthopedic aftercare following scoliosis surgery

• Z47.89 Encounter for other orthopedic aftercare

• Use for aftercare following surgery of musculoskeletal system

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Coding Joint Replacements

• When the cause is not an injury, but a condition, such as osteoarthritis:

• Assign Z47.1, Aftercare following joint replacement surgery

• Routine care will be provided

• The status code for the joint replaced (Z96.6-) is also coded per the Use Additional Code convention at Z47.1.

• What if the cause IS an injury, such as a fracture occurs, and the joint is subsequently replaced?

• Code the INJURY

• Code the status code for the joint replaced (Z96.6-)105

Joint Explantations

• Use Z47.3, Aftercare following explantation of joint prosthesis: • The complication has completely resolved

• The entire joint has been removed

• A new one has been inserted via a staged, planned procedure.

For example, patient had an infected joint which was totally

removed, the infection is completely resolved, and a new

joint has been inserted during a planned procedure at a later

date.

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Amputations

• What it is:• the removal of a limb by trauma, medical illness, or surgery.

• Causes:• Trauma

• Surgical due to:

• circulatory disorders

• Diabetic foot infection or gangrene

• Sepsis with peripheral necrosis

• Types of common amputations:• AKA (above-knee amputation), known as transfemoral amputation.

• BKA (below-knee amputation), known as transtibial amputation.

• TMA (transmetatarsal amputation): through the forefoot

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Amputations

• Z47.81, Encounter for orthopedic aftercare following surgical amputation

• Use Additional Code

• code to identify the limb amputated (Z89.-)

• This code is only used for planned amputations. Do not assign Z47.81 for care following a traumatic amputation or when a surgical amputation is complicated by infection, dehiscence, or other complication.

• Amputation not identified as partial or complete should be coded to complete.

108

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=7&sk=Z89

Aftercare Scenario

Patient admitted for aftercare following removal of his gallbladder.

109

Diagnosis ICD-10-CM

M1021a

Aftercare Scenario

Patient admitted for aftercare following removal of his gallbladder.

110

Diagnosis ICD-10-CM

M1021a Encounter for surgical aftercare following surgery on the digestive system

Z48.815

Aftercare Scenario

Patient admitted for aftercare following a CABG due to CAD.

111

Diagnosis ICD-10-CM

M1021a

M1023b

M1023x

Aftercare Scenario

Patient admitted for aftercare following a CABG due to CAD.

112

Diagnosis ICD-10-CM

M1021a Encounter for surgical aftercare following surgery on the circulatory system

Z48.812

M1023b Atherosclerotic heart disease of native coronary artery without angina pectoris

I25.10

M1023x Presence of aortocoronary bypass graft Z95.1

How do you know to include Z95.1? Experience…capture

all the conditions, paint the picture…

Long-Term Drug Use

• Z79.- category (Long term (current) drug therapy)• Indicates patient’s continuous use of a prescribed drug for long-term

treatment or prophylactic use

• Not for use for drug addictions or for medications used to prevent withdrawal symptoms or detoxify (e.g. methadone maintenance).

• Assign the appropriate code for drug dependence instead.

• Do not assign for meds used for a short period of time to treat an acute illness or injury (about 10 days-ish).

113

Understanding the Terms

• Localized infection is an infection that is limited to a specific part

of the body and has localized symptoms, such as cellulitis,

pneumonia, or a UTI.

• Systemic inflammatory response syndrome (SIRS) is an

inflammatory state affecting the whole body, frequently a

response of the immune system to infection.

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Understanding the Terms (cont.)

• Sepsis is SIRS due to infection, which does not have to be proven by a positive culture. This can trigger inflammation throughout the body that may progress in severity causing severe sepsis.

• Severe sepsis is SIRS due to an infection that progresses to organ dysfunction, such as respiratory, kidney, liver, or heart failure, which can result in septic shock.

• Septic shock is a potentially lethal drop in blood pressure due to the presence of bacteria in the blood that causes circulatory failure.

116

Required Documentation

• Frequently, sepsis and the acute infectious process are resolved in the inpatient setting.

• Consider whether sepsis remains unresolved at SOC.• Do not assume this based on the continuation of oral antibiotics. The physician should

be queried.

• The importance of documenting relevant information must be stressed to physicians, which includes:

• The inflammatory condition and if it is infectious or noninfectious;

• If infectious, the causal organism; and

• If noninfectious, what the specific process is.

117

Coding Sepsis

• For a diagnosis of sepsis, assign the appropriate code for the

underlying systemic infection first:• A40.-, Streptococcal sepsis; or

• A41.-, Other sepsis

• A40 and A41 categories are combination codes that describe

both the systemic inflammatory response and the organism

causing it – e.g., A41.52, Sepsis due to Pseudomonas.

• If the type of infection or causal organism is not further

specified, assign code A41.9, Sepsis, unspecified organism.118

Coding: Severe Sepsis and Septic Shock

Coding guidelines instruct to assign:1. Code for the underlying systemic infection;

2. Code from subcategory R65.2-, Severe sepsis;

– R65.20, Severe sepsis without septic shock; or

– R65.21, Severe sepsis with septic shock

3. Additional code(s) for any associated acute organ dysfunction

Exception: If circulatory failure is the only dysfunction, do not code the circulatory failure, as septic shock indicates the presence of circulatory failure.

Note: The codes for severe sepsis and septic shock (R65.2-) can never be listed as primary.

119

Coding Septic Shock

• Septic shock generally refers to circulatory failure associated with severe sepsis, and it represents a type of acute organ dysfunction.

• Sequence as follows:

1. First: the systemic infection code (A40.- or A41.-).

2. Next: code R65.21, Severe sepsis with septic shock or

T81.12-, Postprocedural septic shock, initial encounter

3. Then, assign additional code(s) for any other acute organ dysfunction(s), if applicable.

120

Urosepsis

• Urosepsis is a systemic reaction of the body (SIRS) to a bacterial infection of the urogenital organs.

• Bacteremia: presence of bacteria in the blood (R78.81).

• Per chapter-specific coding guidelines for sepsis:• The term urosepsis is a nonspecific term.

• Urosepsis ≠ Sepsis• It has no default code in the Alphabetic Index.

• Urosepsis - code to condition

• If a provider uses this term, he/she must be queried for clarification.• Is this a UTI, bladder infection, or bloodstream-specific infection?

121

Good Old UTI

• So we understand that when urosepsis is documented, this does

NOT necessarily mean UTI. But when it does….

• Certain codes for localized infections are found outside of

Chapter 1.• Eg: Urinary tract: N39.0 is in Chapter 14

• These infection codes do not include the infectious organism

• Tabular instruction at N39.0:

Use Additional Code

code (B95-B97), to identify infectious agent.

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https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=7&sk=B95-B97

Sepsis in a Nutshell

• Sepsis: need to code for the underlying infection

• SIRS: systemic response to infections. Does not automatically mean Sepsis.

• Severe sepsis: sepsis with associated acute or multiple organ dysfunction.

• May or may not be associated with septic shock

• Septic shock: circulatory failure automatically associated with severe sepsis.

• Organ dysfunction stated: patient has severe sepsis.

123

Finding the Codes… Start in the Alphabetic Index!

1. Look up the condition, such as pneumonia, and then find the subentry “in

(due to)” to find the organism or other cause or look for the organism, if no

combination code.

2. If unable to find the condition, look under Complication(s).

3. Look up the organism, if applicable:

- may have its own entry, such as Staphylococcus, staphylococcal or

- may be listed under Infection or Sepsis

- then find the condition indented under the main term.

Next, verify the code in the Tabular List.124

Code these sepsis scenarios…

• Sepsis due to an acute respiratory infection

• Sepsis due to acute cystitis with hematuria caused by Escherichia coli [E. coli]

125

Coding for sepsis scenarios…

• Sepsis due to an acute respiratory infection

Note: Default is acute lower respiratory infection.

• Sepsis due to acute cystitis with hematuria caused by Escherichia coli [E. coli]

126

Sepsis, unspecified organism A41.9

Unspecified acute lower respiratory infection J22

Sepsis due to E. coli A41.51

Acute cystitis with hematuria N30.01

HIV B20: Use with CAUTION

• Some states and U.S. territories will deny B20 as the primary diagnosis under privacy protection laws, and some prohibit coding it at all.

• In these cases, look for an HIV-related condition, such as B59 Pneumocystis pneumonia, and sequence this as the first-listed diagnosis.

127

States with Restrictions

• Alaska

• Arizona

• California

• Colorado

• Connecticut

• DC

• Delaware

• Hawaii

• Idaho

• Illinois

• Nevada

• New Jersey

• New Mexico

• North Dakota

• Oregon

• Puerto Rico

• South Carolina

• Texas

• Utah

• Washington

• West Virginia

• Wisconsin

• Wyoming

128

These states restrict the coding of B20 as

primary, some prohibit the use of the code

altogether. Contact the state OEC for

specific restrictions.

Coding HIV Disease

• Code only confirmed cases of HIV infection/illness.

• This is an exception to the hospital inpatient guideline Section II, H, which

states if the documentation indicates uncertainty – e.g., “possible,”

“probable,” or “likely” – code the condition as if it existed or was

established.

• The physician’s statement that the patient is HIV positive is not

the same as a confirmation of the condition.

• Use Z21, Asymptomatic HIV status instead.

129

What is a neoplasm?

• “Neoplasm” is an abnormal mass of tissue that results when cells divide more than they should or do not die when they should, which can be either malignant (cancerous), or benign (not cancerous).

• The terms tumor, fibroid, adenoma, myoma, and sarcoma indicate a neoplasm.

• A tumor is an abnormal mass of tissue, which may be solid or fluid-filled. A tumor does notautomatically mean cancer.

• Tumors can be:

• benign (not cancerous)

• pre-malignant (pre-cancerous)

• malignant (cancerous).

• For unspecified terms, such as mass, lesion, lump, or disease, reference the Alphabetic Index.

131

Coding Neoplasms

• To properly code a neoplasm, look in the medical record for terms

the physician has used to describe the patient’s neoplasm, referred

to as the “histology” or “morphology” of the neoplasm. • Neoplasm terms:

• Malignant, benign, in-situ, and uncertain behavior • Carcinoma • Lymphoma• Adenoma• leukemia

• Unspecified terms:• growth NOS • neoplasm NOS • new growth NOS• tumor NOS

132

Types of Neoplasms

• In order to find the right neoplasm code, you must know the

neoplasm’s behavior and what part(s) of the body it is affecting.

Remember, do not assume that a neoplasm is always active, malignant

cancer.

• Neoplasm categories include:

– Malignant neoplasm is cancerous, grows uncontrollably, and may invade

healthy surrounding tissues or spread (metastasize) from the point of origin.

– Primary malignancy is the area where the tumor first developed in the body.

– Secondary malignancy (metastasis) is an area of the body to where the first-

listed (primary) cancer has metastasized or spread.

133

Types of Neoplasms (cont.)

Benign neoplasm is an abnormal growth but is not cancer and does not

invade surrounding tissues or metastasize to other sites in the body.

BUT: the neoplasm may grow to such a size that it impinges on other organs or structures

thereby causing damage or death to those organs/structures. Best example: benign brain

tumor.

Carcinoma in situ (CIS or ca in situ), is a group of abnormal cells that

are found only in the place where they first formed in the body. These

abnormal cells may become cancer and spread into nearby normal tissue.

Also called stage 0 (zero) disease.

Other terms include: noninfiltrating, noninvasive, preinvasive, and intraepithelial.

134


Uncertain behavior describes a neoplasm that is exhibiting characteristics of both

malignant and benign neoplasms, requiring further study to determine the type.

Unspecified behavior describes a neoplasm where there is not enough information

to select the type. This may occur when the physician is waiting for the pathology

report to make a determination of the type of neoplasm.

• Do not code unspecified behavior just because it is unknown whether a cancer is primary

or secondary.

• Codes for these neoplasms should rarely, if ever, be assigned. Query the physician for

more information first.

135

Codes may be assigned for diagnoses listed in pathology or lab reports, if:

the results of the reports have been interpreted by a physician, such as a

pathologist or radiologist,

and that diagnosis has been agreed to by the physician.

Tip


• Primary versus Secondary site• If “metastatic from,” is stated, the “from” refers to the primary site.

• A secondary site is metastatic from a primary site. If the medical record states

“metastatic to,” the “to” refers to the secondary site.

• Primary coding versus Secondary coding• For coding purposes, primary refers to M1021a (principal/primary diagnosis)

• Secondary coding refers to M1023 items

• This is NOT the same as primary or secondary site!

136

Finding the Code in the Index

• If the Alpha Index lists the behavior (morphology or histology) but not the site,

go to the Neoplasm Table to find the code, then verify the code in the Tabular

List – e.g., Adenoma of the colon.

• Index: Adenoma – see also Neoplasm, benign, by site

• There is no indent for Colon, so follow the see also convention.

• Some morphology types, such as melanomas, carcinoid tumors, and neuroendocrine tumors,

are only found in the Alpha Index.

• Follow the notes in the Index.

• If the Alpha Index lists the behavior and the site, go to the Tabular List to verify

the code – e.g., Myoma, prostate: D29.1.

137

Sequencing Guidelines

• Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site, which may be listed as primary orsecondary, depending on the focus of care.

• If there is a primary neoplasm and treatment is directed toward the secondary site, code the secondary site first, even if the primary site is still present.

Example: Colon cancer with focus on metastasis to the liver

‒M1021a: C78.7, Secondary malignant neoplasm of liver

‒M1023 (b-…): C18.9, Malignant neoplasm of colon, unspecified

138

Coding Suspected Neoplasms

Physician documentation of mass, no other information available. Look up ‘mass’ in the Alpha Index, search by site.

Most will land in the R or N chapters

R: Chapter 18, Symptoms, Signs and Abnormal Clinical and Laboratory Findings

N: Chapter 14: Diseases of the Genitourinary System

139

Other Neoplasm-related Complications

• When the admission/encounter is for management of a complication

associated with a neoplasm, such as dehydration, and the treatment is only

for the complication, (e.g., intravenous rehydration), the complication is

coded first, followed by the appropriate code(s) for the malignancy.

1. Complication: E86.0, Dehydration

2. Malignancy: Neoplasm

• When the admission/encounter is for management of a complication

associated with a neoplasm or treatment of a complication resulting from a

surgical procedure, code the complication first, if treatment is directed at

resolving the complication.

140

Other Neoplasm-related Complications

• Neoplasm of a transplanted organ. This is known as a complication.

1. Complication: T86.-

E.g. T86.818 Other complications of lung transplant

2. Next: C80.2, Malignant neoplasm associated with transplanted organ

3. Next: specific malignancy

E.g. C34.91, Malignant neoplasm of unspecified part of right bronchus or lung

141

What to do?

• Example: Patient with a strong family history of breast cancer and positive genetic testing for susceptibility for breast cancer who had a prophylactic bilateral mastectomy is coded:

• M1021a: Z48.89, Aftercare for other specified surgical aftercare

• M1023: Z15.01, Genetic susceptibility to malignant breast neoplasm

• M1023: Z80.3, Family history of malignant neoplasm of breast

• M1023: Z90.13, Acquired absence of bilateral breasts and nipples

142

Neoplasm-related Pain

• G89.3 Neoplasm related pain (acute) (chronic) is used for:

• Cancer associated pain

• Pain due to malignancy (primary)(secondary)

• Tumor associated pain

• Encounter for PAIN MANAGEMENT

• It is not necessary to also code the site of the pain, for example, M79.621, Pain in right upper arm.

143

Anemia

• Decrease in red bloods cells or hemoglobin

• Can be associated to many conditions (CKD, neoplastic diseases, other chronic diseases)

• Code the underlying condition first, then the appropriate anemia code.

• Let’s look up Anemia in the Alpha Index, follow down to “due to (in)(with)”

• Find chronic kidney disease indent: D63.1

• When you follow D63.1 in the Tabular List, it says to Code first the underlying ckd.

• Read everything, follow everything.

145

Anemia

• When the admission/encounter is for management of an anemia associated with the

malignancy and the treatment is only for anemia, sequence the appropriate code for

the malignancy as the principal/primary or first-listed diagnosis, followed by the

appropriate anemia code (such as D63.0).

• Neoplasm

• D63.0, Anemia in neoplastic disease

• When the admission/encounter is for management of an anemia associated with an

adverse effect of the administration of chemotherapy or immunotherapy and the

treatment is only for anemia, the anemia code is sequenced first, followed by the

appropriate codes for the neoplasm and the adverse effect.– D64.81, Anemia due to antineoplastic chemotherapy– Neoplasm– T45.1X5D, Adverse effect of antineoplastic and immunosuppressive drugs, subsequent

encounter146

Anemia (cont.)

• When the admission/encounter is for management of an anemia associated with an adverse effect of radiotherapy, sequence the anemia first, followed by the appropriate neoplasm code and code Y84.2.– D61.2, Aplastic anemia due to radiation

– Neoplasm

– Y84.2, Radiological procedure and radiotherapy as cause of abnormal reaction of patient or of later complication, without mention of misadventure at time of procedure

147

Diabetes

• Diabetes is a disease in which the body cannot process food for use as energy.

• The pancreas beta cells make insulin to process glucose. If insulin doesn’t break

down the glucose so it can reach the cells, glucose builds up in the blood, resulting

in high blood sugar (hyperglycemia).

• There are 5 categories for diabetes:

– Primary (because of the pancreas failure)

• E10 Type 1 diabetes: beta cells are destroyed, so the body does not make insulin

• E11 Type 2 diabetes: body does not make or use insulin well (insulin resistance)

– Secondary (something else caused it to happen)

• E08 Diabetes due to underlying condition

• E09 Drug or chemical induced diabetes

• E13 Other specified diabetes

149

Primary versus Secondary Diabetes

Primary Diabetes Mellitus

(E10 and E11)

• Caused by the inability of the body to produce or properly use insulin –not by another condition.

• Type 1 (E10) always requires insulin – do not code insulin.

• Type 2 (E11) may require insulin –code insulin use if present.

• If the type of diabetes is notstated, the default is Type 2.

Secondary Diabetes Mellitus

(E08, E09, and E13)

• Always caused by another condition or event such as:

• Cystic fibrosis

• Malignant neoplasm of pancreas

• Pancreatectomy

• Adverse effect of drug

• Poisoning

• May require insulin – code insulin use if present.

• Sequencing based on the Tabular List instructions for each of the categories.

150

Diabetes Mellitus, Type 1: E10.-

• Are insulin-dependent

• Includes:• Brittle DM

• DM due to autoimmune process

• DM due to immune mediated pancreatic islet beta-cell destruction

• Idiopathic DM

• Juvenile onset DM

• Ketosis-prone DM

151

Type 1.5 Diabetes

• Type 1.5 is:– A form of diabetes sometimes called “double diabetes,” in which an adult has

aspects of both Type 1 and Type 2 diabetes.

– Have autoimmune destruction of beta cells of Type 1 diabetes

– Have insulin resistance characteristic of Type 2 diabetes

– Also known as Latent Autoimmune Diabetes of Adults (LADA).

• Assign a code from E13.-, Other specified diabetes mellitus

152

Diabetes Mellitus, Type 2: E11.-

• May be on an oral antidiabetic/hypoglycemic med

• May be on insulin

• Includes:

• DM due to insulin secretory defect

• Diabetes NOS

• Insulin resistant DM

153

Secondary Diabetes• E08.-, Diabetes due to underlying condition

• Code 1st underlying condition

• Eg, Cushing's Syndrome, cystic fibrosis, pancreatic cancer

• Use an additional code for insulin (Z79.4) or oral antidiabetic drugs (Z79.84)

• E09.-, Drug or chemical induced diabetes

• Code 1st poisoning T36-T65 due to drug or toxin, if applicable

• Use additional code for adverse effect, if applicable, to identify the drug (T36-T65)


• E13.-, Other specified diabetes


• Includes:

• Postpancreatectomy DM

• Postprocedural DM

• Secondary DM NEC

154

Hypo or Hyperglycemia? Controlled or Out of Control?

• Per Coding Clinic Q1 2017 guidance, diabetes stated as uncontrolled could be either diabetes with hyperglycemia or with hypoglycemia.

• If the record does not indicate which it is, query the physician.

• Hyperglycemia: high blood glucose (5th character of 5).

• Exx.65

• Hypoglycemia: too much insulin and too little glucose in the blood (5th character of 4).

• Exx.64-

• The Alphabetic Index instructs when physician states:

• out of control

• poorly controlled

• E11.65, Type 2 diabetes mellitus with hyperglycemia

155

diabetes, by type, with hyperglycemia

Uncontrolled Flow Sheet

156

Uncontrolled

Out of control

Poorly controlled

Hyperglycemia

Hypoglycemia

Verify

Verify

Use of Insulin and/or Oral Hypoglycemic Drugs

• Code Z79.4, Long-term (current) use of insulin, or code

Z79.84, Long-term (current) use of oral hypoglycemic drugs,

should be assigned if the diabetes mellitus is being treated

with insulin or oral medications.• If the patient is treated with both oral medication and insulin, only the insulin

code should be assigned.

• Do not assign Z79.4:• With type 1 diabetes mellitus, E10.-;

• When a patient receives insulin temporarily to get blood sugar under control

157

Diabetic Manifestations

• Diabetes is the largest and most common group of etiology/manifestation combinations.

• The conditions indented below “with” in the Index are assumed manifestations, even in the absence of physician documentation explicitly linking them, unless it is clearly documented that the conditions are not related.

• Most of these pairings do not require a second code.

• One combination code is required EXCEPT for identifying:– Ulcer site;

– Stage of kidney disease;

– Other specified complication (e.g., osteomyelitis); and

– Insulin use or oral antiglycemic use.

158

Diabetes (Alphabetic Index)

159

The conditions indented below “with” are assumed manifestations, unless documented as due to another cause. Read documentation thoroughly!

For NEC codes, the “with” convention does not apply; the specific condition must be linked to the main term and coded – e.g., CAD and MI are not assumed manifestations of diabetes!

Diabetic Manifestations- CKD, Neuropathy: E11.2-, E11.4-

• If the physician documents both diabetic chronic kidney disease

and nephropathy, code diabetic CKD only, which is more

specific.

• Add the stage of CKD (N18.-) as stated.

160

Diabetic Manifestations- circulatory: E11.5-

• Common circulatory manifestations of diabetes are peripheral angiopathy and gangrene.

• What is peripheral angiopathy? Angiopathy = arterial disease. May be documented as

diabetic PVD, PAD, peripheral atherosclerosis. Peripheral angiopathy is arterial, not

venous, often affecting blood vessels in the legs and feet.

• Blood vessel disease caused by high blood sugar levels.

• Increases risk of atherosclerosis, the build-up of plaque in the arteries. This can limit the blood

supply to a body part, which can create the need for amputation.

• E11.51, add atherosclerosis code (eg, I70.2-)

• Cannot code diabetes with gangrene without “automatically” including peripheral

angiopathy. When you follow the “with” gangrene, you are directed to:

• E11.52, Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene. Add code

for gangrene.

161

Diabetic Manifestations- ulcers

• Common skin manifestations of diabetes are foot ulcers and lower limb ulcers due to the circulatory problems experienced.

162

Diabetic Foot Ulcers E11.621• Ulceration of the foot is assumed related to diabetes unless another cause is

indicated.

• E11.621 has a Use Additional Code convention to identify the site of the ulcer (L97.4-, L97.5-).

• If the patient had a diabetic foot ulcer in the past, either healed or on an

amputated limb, also code Z86.31, Personal history of diabetic foot ulcer.

163

Diabetic Osteomyelitis

• Osteomyelitis is a bone infection

• Can be a complication of diabetes

• E11.69, Type 2 diabetes mellitus with other specified complication

• Has a Use Additional Code convention to identify the complication.

• Use the appropriate code for the osteomyelitis (M86.-) after coding diabetes with other specified manifestation.

• Follow guidance for the addition of other codes as required to specify the complete condition.

164

Let’s take a look…

Nursing is ordered for management of uncontrolled diabetes with hypoglycemia and teaching of insulin administration.

165

Diagnosis ICD-10-CM

M1021a Other specified diabetes mellitus with hypoglycemia without coma

E11.649

M1023x Long-term (current) use of insulin Z79.4

Key Points for the Scenario: Reference “Diabetes with hypoglycemia” in the Alpha Index.

“Uncontrolled” diabetes is coded with “hypoglycemia” or “hyperglycemia.” In this

scenario, the physician stated hypoglycemia.

The insulin code, Z79.4, does not have to immediately follow the diabetes code.

Place it where it needs to be in the order of importance of all conditions present.

Diabetes Scenario #2

Patient has diabetes with polyneuropathy. She was started on Glucophage.

166

Diagnosis ICD-10-CM

M1021a

M1023b

Diabetes Scenario #2 Coding

Patient has diabetes with polyneuropathy. She was started on Glucophage.

167

Diagnosis ICD-10-CM

M1021a Type 2 diabetes mellitus with diabetic polyneuropathy E11.42

M1023b Long-term (current) use of oral hypoglycemic drugs Z79.84

What if the patient was on both an oral antidiabetic medication and insulin?


Patient has Type 1 diabetes with an ulcer on her left midfoot that indicates the fat layer is exposed (code L97.422). She was started on Glucophage along with the insulin she already is taking.

168

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c


Patient has Type 1 diabetes with an ulcer on her left midfoot that indicates the fat layer is exposed (L97.422). She was started on Glucophage along with the insulin she already is taking.

169

Diagnosis ICD-10-CM

M1021a Type 1 diabetes mellitus with foot ulcer E10.621

M1023b Non-pressure chronic ulcer of left heel and midfoot with fat layer exposed

L97.422

M1023x Encounter for change or removal of nonsurgical wound dressing Z48.00

Tabular instructions state to “Use Additional Code”: code to identify site of ulcer (L97.4-, L97.5-)

Why isn’t there any mention of the Glucophage or Insulin?

Documenting Mental and Behavioral Disorders

• Psychiatric/mental disorders should NOT be coded unless documented/confirmed by the physician.

• A psychiatric/mental disorder, which always impacts the care, should be coded as a comorbidity and addressed in the plan of care.

• A primary diagnosis of a psychiatric/mental disorder may require a psychiatric nurse to provide services. However, certain services, such as administration of IM medications for treatment of a psychiatric diagnosis, do not require a psych nurse.

171

DementiaDementia is not a disease; it is a group of symptoms affecting memory, thinking and social abilities that interferes with daily functioning.

• Vascular Dementia: related to different vascular mechanisms.• Result of infarction of the brain due to vascular disease.

• Typically: CVA

• Dementia in other diseases: due to direct physiological effects of a general medical condition

• Example: Alzheimer’s disease, Parkinsons, Huntingtons

• Unspecified dementia: not a manifestation of another condition. No etiology stated by physician.

172

Dementia as a Manifestation

• F02, Dementia in other diseases classified elsewhere

• Code first the underlying physiological condition, such as:

Alzheimer’s, dementia with Lewy bodies, frontotemporal dementia, Huntington’s disease, multiple sclerosis, Parkinson’s disease, Pick’s disease, polyarteritis nodosa, etc.

• F02.80, Dementia in other diseases classified elsewhere withoutbehavioral disturbance

• F02.81, Dementia in other diseases classified elsewhere with behavioral disturbance

Use additional code, if applicable, to identify wandering in conditions classified elsewhere (Z91.83)

173

Unspecified Dementia

• F03, Unspecified dementia, has the following code options:• F03.90, Unspecified dementia without behavioral disturbance

• Dementia NOS

• F03.91, Unspecified dementia with behavioral disturbance• “Use additional code, if applicable, to identify wandering in unspecified

dementia (Z91.83)”

Note:

– There is no “Code first” instruction.

– May be assigned as the primary diagnosis, except in hospice.

174

Depression

• Depression: no further information available, the default is F32.9,

Major depressive disorder, single episode, unspecified.

• Physician must confirm diagnosis; cannot be coded based upon the

presence of symptoms alone, or on positive depression screen (PHQ-

2©), etc.

• Depression NOS

• Depressive disorder NOS

• Major depression NOS

175

Mental and Behavioral Disordersdue to Psychoactive Substance Use

• When the provider documentation refers to use, abuse, and/or dependence of the same substance, only one code should be assigned to identify the pattern of use, based on the following hierarchy:

• Use + abuse = abuse• Abuse + dependence = dependence• Use + dependence = dependence• Use + abuse + dependence = dependence

Code the longest word!

176

Tip

Coding Practice for Mental Disorders

• Caffeine use and abuse• What are you going to look up?

• Depression and dementia with wandering• Are the depression and dementia covered under one code?

177

Coding Practice Answers• Caffeine use and abuse

- F15.10, Other stimulant abuse, uncomplicated

• Depression and dementia with wandering– F32.9, Major depressive disorder, single episode, unspecified

– F03.91, Unspecified dementia with behavioral disturbance

– Z91.83, Wandering in diseases classified elsewhere

178

Systemic Atrophies Primarily Affecting the CNS

• G14 Postpolio syndrome• Documentation must specifically state “post polio syndrome.”

• This is different than sequelae of poliomyelitis or residual deficits related to resolved poliomyelitis.

• When the medical record only specifies residual deficits due to resolved poliomyelitis, assign B91, Sequelae of poliomyelitis.

180

Parkinson’s vs Parkinsonism

Parkinson’s disease and Parkinsonism are different conditions

• Parkinson’s is “a progressive disorder of the nervous system”• Essentially normal MRI that excludes other causes for the symptoms

• Parkinsonism is a reference “to symptoms of Parkinson’s disease (e.g., slow movements and tremors), regardless of the cause”

• Can be caused by several conditions (eg, Muhammad Ali)

181

Coding Dementia in Parkinson’s versus Parkinsonism

• Dementia in Parkinson’s‒ G20, Parkinson’s disease

‒ F02.80, Dementia in other diseases classified elsewhere without behavioral disturbance

Note: There is no instructional note in the Tabular list at G20 to use an additional code for the dementia. But if you look up Dementia in Parkinson’s disease it is indicated as G20 [F02.80].

• Dementia in Parkinsonism‒ G31.83, Dementia with Lewy bodies (Parkinsonism)

‒ F02.80, Dementia in other diseases classified elsewhere without behavioral disturbance

Look up the manifestation (dementia) in the Index.

182

Degenerative Diseases of the Nervous System

• G30 Alzheimer’s Disease

Includes: Alzheimer’s dementia senile and presenile forms

Excludes 1: senile degeneration of brain NEC (G31.1)

senile dementia NOS (F03)

senility NOS (R41.81)

Use additional code to identify: delirium, if applicable (F05); dementia with behavioral disturbance (F02.81); dementia without behavioral disturbance (F02.80)

183

Code this scenario…

Patient with new diagnosis of Alzheimer’s is admitted for teaching of disease process and new medication regimen to his wife.

184

Diagnosis ICD-10-CM

M1021a

M1023b

Coding for scenario…

Patient with new diagnosis of Alzheimer’s is admitted for teaching of disease process and new medication regimen to his wife.

185

Diagnosis ICD-10-CM

M1021a Alzheimer's disease, unspecified G30.9

M1023b Dementia in other diseases classified elsewhere without behavioral disturbance

F02.80

Why did we add the Dementia?

Because it is part of the disease per the Coding Tips, and G30.9

has a Use Additional Code convention.

Multiple Sclerosis (MS) (G35)

• If the POC addresses only one MS-related problem:

–List that problem first. For example:1. Fitting and adjustment of urinary catheter (Z46.6)

2. Urinary incontinence (R32)

3. Multiple sclerosis (G35)

• When focus of the POC – new onset or exacerbation or more than one aspect is being addressed:

–List MS first. For example:1. Multiple sclerosis (G35)

2. Urinary incontinence (R32)

3. Fitting and adjustment of urinary catheter (Z46.6)

186

Hemiplegia and Monoplegia

• Codes from category G81, Hemiplegia and hemiparesis, and subcategories G83.-, Monoplegia, identify whether the dominant or non-dominant side is affected.

• Hemiplegia = paralysis of the same side of the body

• Monoplegia = paralysis of one limb or region of the body

• Hemiparesis = weakness of one side of the body

• If the affected side is documented, but not specified as dominant or non-dominant, and the classification system does not indicate a default, code as follows:

• If the right side is affected, the code default is dominant.

• If the left side is affected, the code default is non-dominant.

• For ambidextrous patients, the code default is dominant.

187

Hemiplegia and Monoplegia

G81, Hemiplegia and hemiparesis, and subcategories G83.-, Monoplegia, are used for patients with causative injuries OTHER THAN cerebrovascular disease (eg, CVA).

• Resultant of brain or spinal cord injuries

1. Code the paralysis/paresis

2. Code the injury with the 7th character “S” to report a sequela of the injury

They have an Excludes 1 note: hemiplegia and hemiparesis due to sequela of cerebrovascular disease (I69.-)

188

CVA

Spinal Cord Injuries (SCI)

• Paralysis from a SCI is also known as:• Paraplegia: This paralysis affects all or part of the trunk, legs and pelvic organs.

ARMS are NOT involved.

• Tetraplegia/Quadriplegia: arms, hands, trunk, legs and pelvic organs are all affected

by the spinal cord injury.

189

More SCI coding guidance

• If there are multiple levels of injury, code the highest anatomical injury level only for each section of the spine.

• E.g.: Injured at C7, T1, T2, T12, L3: code only the C7, T1, L3 injuries.

• Code also any vertebral fractures that occurred (S##.-)

• Code also any open wounds that occurred (S##.-)

190

SCI Sequela

• These are sequela OF the SCI, meaning “…complications or conditions that arise”:

• Contractures

• Quadriplegia

• Paraplegia

• Rule (reminder):1. Code FIRST the sequela (resulting condition) (for example paraplegia)

2. Then code the injury that precipitated the sequela (eg. SCI that caused the paraplegia). The 7th character “S” is added here to the injury code.

191

Basic Rules for Coding Pain

• Determine if the pain code provides additional information, or, is the pain integral to the condition.

• If it does provide additional information, decide whether it should be primary or secondary.

• If the pain code does not provide additional information, or is integral to the condition, do not use it.

• Code as primary when the reason for the encounter is pain management and not management of the underlying condition.

192

Coding Pain

• Pain codes may be used to provide more detail about: – Acute (G89.1-) pain

– Chronic (G89.2-) pain

– There is no time frame for chronic pain, but MD must document or confirm the diagnosis.

– Neoplasm related (G89.3) pain (acute) (chronic)

– G89.4 Chronic pain syndrome– Not the same as chronic pain

– May be associated with significant psychosocial dysfunction

– Must be specified by the physician

• Routine or expected postoperative pain immediately after surgery should not be coded.

• When the definitive diagnosis is known and the focus of care is not pain management, do not assign G89.-, e.g., knee pain due to osteoarthritis.

193

Common Hypertensive Diseases at a glance

• Essential Hypertension (I10): high blood pressure. Force of blood flowing

through the veins is consistently too high. Includes HTN described as: arterial,

benign, essential, malignant, primary, systemic.

• Hypertensive Heart Disease (I11.-)

• Hypertensive Chronic Kidney Disease (CKD) (I12;-)

• Hypertensive Heart and Chronic Kidney Disease (I13.-)

195

Notes at the top of the Category

196

Causal Relationships

• The classification presumes a causal relationship between hypertension and

heart involvement and between hypertension and kidney involvement, as the

two conditions are linked by the term “with” in the Alphabetic Index. These

conditions should be coded as related, even in the absence of provider

documentation linking them, unless the documentation clearly states the

conditions are unrelated.

197

Hypertensive Heart Disease (I11)

• Hypertension with heart conditions classified to I50.- (Heart failure) are assigned to a code from category I11.

• Use additional code(s) from category I50, Heart failure, to identify the type(s) of heart

failure in those patients with heart failure.

198

Hypertensive Chronic Kidney Disease (I12)

• Assign code from I12, Hypertensive chronic kidney disease, when both

hypertension and a condition classifiable to category N18, Chronic kidney

disease, are present.• CKD will still be coded as hypertensive even if the physician has specifically

documented a different cause due to the “with” convention. The physician would

have to state as well that the CKD was NOT related to HTN to not make the link.

• The appropriate code from category N18 should be used as a secondary code to

identify the stage of the CKD.

• For patients with both acute renal failure and chronic kidney disease, an

additional code for acute kidney failure (N17.-) is required.

199

What if the patient also has diabetes along with HTN and CKD?

• Diabetes or hypertension may be coded first, depending on which is the focus of care.

• The codes for diabetic CKD and hypertensive CKD instruct to use a additional code for the stage of CKD.

• Code N18, Chronic kidney disease, instructs to code first any associated diabetic CKD or hypertensive CKD.

200

Let’s take a look…Patient was hospitalized with an exacerbation of his HTN and is referred to home care

for blood pressure monitoring and teaching of disease process and new medication regimen. He has co-morbid conditions of diabetes, managed with an oral med, and stage 3 CKD (N18.3).

201

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

M1023x

Let’s take a look…Patient was hospitalized with an exacerbation of his HTN and is referred to home care

for blood pressure monitoring and teaching of disease process and new medication regimen. He has co-morbid conditions of diabetes, managed with an oral med, and stage 3 CKD (N18.3).

202

Diagnosis ICD-10-CM

M1021a Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I12.9

M1023b Type 2 diabetes mellitus with diabetic CKD E11.22

M1023c Chronic kidney disease, stage 3 N18.3

M1023x Long-term use of oral hypoglycemic drugs Z79.84

A different look…Patient was hospitalized with an exacerbation of his diabetes and is referred to home

care for teaching of disease process. He has co-morbid conditions of HTN and stage 3 CKD (N18.3), and his diabetes is managed with an oral med.

203

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

M1023x

A different look…Patient was hospitalized with an exacerbation of his diabetes and is referred to home

care for teaching of disease process. He has co-morbid conditions of HTN and stage 3 CKD (N18.3), and his diabetes is managed with an oral med.

204

Diagnosis ICD-10-CM

M1021a Type 2 diabetes mellitus with diabetic CKD E11.22

M1023b Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I12.9

M1023c Chronic kidney disease, stage 3 N18.3

M1023x Long-term use of oral hypoglycemic drugs Z79.84

Hypertensive Heart and CKD (I13)

• When both hypertensive heart disease (I11) AND hypertensive chronic kidney disease (I12) are stated in the diagnosis (e.g., HTN, CHF and CKD), assign a combination code from I13.

• Assign additional codes to identify:

• Type(s) of heart failure (I50.-), if present

• Stage of chronic kidney disease

205

Acute Myocardial Infarction (MI)

• An MI is considered “acute” 4 weeks (28 days) or less from the onset and still requires care. Codes from category I21 are assigned.

• For MIs older than 4 weeks that still require care related to the MI, the appropriate aftercare code (Z51.89, Encounter for other specified aftercare) should be assigned, rather than an I21 code.

• For healed or old MIs, which are older than 4 weeks and do not require further care, assign code I25.2, Old myocardial infarction.

– Index: Infarction Myocardium healed or old I25.2

• If a patient with CAD is admitted due to an acute MI, the MI should be sequenced before the CAD.

206

Coronary Artery Disease (CAD)

• CAD is atherosclerosis, a build-up of fatty deposits in the coronary arteries, resulting in ischemia (the heart muscle can’t get adequate oxygen).

• Again, if a patient with CAD is admitted for an MI, code the MI first.

• CAD is in the I25.- category

207

Coding Heart Failure

If unknown, query the physician as to the type.

• If there is more than one type of heart failure, code them all.

• Do NOT code CHF in addition to other types of heart failure.• Is a nonessential modifier – e.g., acute systolic (congestive) HF

• Code acute before chronic.

• If one type of heart failure is acute and another type is chronic, such as acute

systolic heart failure and chronic diastolic heart failure, code the conditions

separately – not acute on chronic.

208

Coding Heart Failure

• Do not code integral symptoms if due to heart failure:

• pulmonary congestion

• dependent and pulmonary edema

• Note: fluid overload ≠ edema. Fluid overload might still be coded.

• fluid retention

• SOB

• cough

• fatigue

• pleural effusion

209

Classification of Stages

• Per the ABCD Classification of the American College of Cardiology (ACC)/American Heart Association (AHA):

• Stage A is the presence of heart failure risk factors but no heart disease and no symptoms. Do not code as heart failure.

• Code to Z91.89, Other specified personal risk factors, not elsewhere classified.

• Stage B is where heart disease is present but there are no symptoms. Thus, there are structural changes in the heart before symptoms occur.

• Stage C involves structural heart disease, with symptoms.

• Stage D is end stage heart failure (I50.84).

210

I50 Heart Failure - More inclusion Terms

• Diagnostic terms clarified by Coding Clinic in 2016 are now added to heart failure

terms under I50:

• I50.2 Systolic (congestive) heart failure

• Heart failure with reduced ejection fraction [HFrEF]

• Systolic left ventricular heart failure

• Code also end stage heart failure, if applicable (I50.84)

• I50.3 Diastolic (congestive) heart failure

• Diastolic left ventricular heart failure

• Heart failure with normal ejection fraction

• Heart failure with preserved ejection fraction [HFpEF] p d(iastolic)


• I50.4 Combined systolic (congestive) and diastolic (congestive) heart failure

• Combined systolic and diastolic left ventricular heart failure

• Heart failure with reduced ejection fraction and diastolic dysfunction


211

Hint to remember

More Heart Failure Codes (I50.8)

I50.84 End stage heart failure

Stage D heart failure

Code also the type of heart failure as systolic, diastolic, or combined, if known (I50.2-I50.43)

I50.89 Other heart failure

I50.9 Heart failure, unspecified

Note: There are many additional INCLUDES terms, EXCLUDES 1 and EXCLUDES 2 notes, "Code first” and “Code also” notes, and other notations throughout Chapter 9. Be sure to pay close attention to these!

212

Heart Failure Quick Coding

• HTN, CHF, and acute systolic heart failure, and pulmonary edema

• End stage heart failure with preserved ejection fraction

• Hypertension and stage 5 CKD (N18.5)

213

Heart Failure Quick Code Answers

• HTN, CHF, acute systolic heart failure, with pulmonary edema– I11.0, Hypertensive heart disease with heart failure

– I50.21, Acute systolic (congestive) heart failure

• End stage heart failure with preserved ejection fraction– I50.30, Unspecified diastolic (congestive) heart failure

– I50.84, End stage heart failure

• Hypertension and stage 5 CKD (N18.5)– I12.0, Hypertensive chronic kidney disease with stage 5 chronic

kidney disease or end stage renal disease

– N18.5, Chronic kidney disease, stage 5

214

Cerebrovascular Disease

• Codes from category I69 (Sequelae of cerebrovascular disease) include neurological deficits that persist after the initial onset of conditions.

• Categories I60-I67 are for the acute phase, for hospital use typically.

• These may be present from the onset or arise at any time after the onset of the condition.

• Codes from category I69 should not be assigned, if the patient does not have neurologic deficits. Instead, code Z86.73, Personal history of transient ischemic attack (TIA) and cerebral

infarction without residual deficits.

215

Cerebrovascular Disease

• There are six I69.- subcategories to identify sequelae of specific non-traumaticconditions.

The 4th character defines a specific underlying cause.

5th and 6th characters provide information on the type of sequela, laterality, and whether

the affected side of the body is dominant or non-dominant. If the dominant side is

unknown, in coding:

Default to dominant if the right side is affected or the patient is ambidextrous

Default to non-dominant if the left side is affected.

• Assign as many of the combination codes in I69 that apply. Most of the codes are fully descriptive combination codes, and do not need further codes for sequelae:

• Examples:

• I69.020, Aphasia following nontraumatic subarachnoid hemorrhage

• I69.363, Hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side

216

Categories of CVA

I69.3 Sequelae of cerebral infarction

• I69.30 Unspecified sequelae of cerebral infarction

• I69.31 Cognitive deficits following cerebral infarction

• I69.32 Speech and language deficits following cerebral infarction

• I69.33 Monoplegia of upper limb following cerebral infarction

• I69.34 Monoplegia of lower limb following cerebral infarction

• I69.35 Hemiplegia and hemiparesis following cerebral infarction

• I69.36 Other paralytic syndrome following cerebral infarction

• I69.39 Other sequelae of cerebral infarction

217

https://codingcenter.decisionhealth.com/MVC/icd10/Details/I69.3









Coding Practice - CVAPatient is admitted to home care with left-sided weakness due to a right

CVA. He is left handed. He also has oropharyngeal dysphagia (R13.12) due to the CVA. Therapy has stated the weakness is the greater issue.

218

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

Coding Practice - CVAPatient is admitted to home care with left-sided weakness due to a right CVA. He is

left handed. He also has oropharyngeal dysphagia (R13.12) due to the CVA. Therapy has stated the weakness is the greater issue.

Should we also code weakness M62.81?

Why did we also code the dysphagia phase?219

Diagnosis ICD-10-CM

M1021a Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side

I69.352

M1023b Dysphagia following cerebral infarction I69.391

M1023c Dysphagia, oropharyngeal phase R13.12

PVD, PAD, Atherosclerosis

• Atherosclerosis: build-up of fatty material inside the blood vessels. Cause of PVD/PAD.

• Atherosclerosis of the extremities is a specific diagnosis: I70.-

• I73.9, PVD = Peripheral Vascular Disease. Disease or disorders of the circulatory system outside of the brain and heart.

• Inclusion terms:

• Intermittent claudication

• Peripheral angiopathy NOS

• Spasm of artery

• Often used as a synonym for peripheral artery disease PAD (I73.9). This is a form of arterial insufficiency – blood circulation is decreased in the vessels that carry blood away from the heart.

220

Venous Diseases

• Venous circulation: blood vessels (veins) carry blood back to the heart.

• Venous diseases:• Venous insufficiency – commonly caused by blood clots (DVT) or varicose veins.

• Venous hypertension – high blood pressure in the veins, can lead to skin problems like leg ulcers.

• Varicose veins – enlarged, dilated veins, overfilled with blood. Due to vein valve failure.

• Phlebitis – inflammation of a vein

• Venous stasis – slow blood flow in the veins.

• Due to different pathologies, each condition must be looked up in the Alpha Index to locate the correct disease process.

221

I96 (Gangrene)

• I96, Gangrene, not elsewhere classified

• There is an Excludes I note at I96 for gangrene in other

peripheral vascular diseases (I73.-).

• Can assume that if a patient has gangrene, they also have PVD, but it does

not mean that if a patient has PVD, they also have gangrene. All beagles

are dogs, but not all dogs are beagles!

• The physician should specify the type of PVD.

222

I96 (Gangrene)

• When diabetes and gangrene are both indicated in the documentation, the classification makes the related link.

• Can get to the correct code by looking up:

Gangrene with diabetes: See Diabetes, gangrene

Diabetes with gangrene

• Diabetes and a gangrenous pressure ulcer? NO LINK.

• Code: - I96 (gangrene)

- L89.- (ulcer location & stage)

- E11.9 (DM)

223

General Respiratory Chapter Notes

• Refer to the beginning of Chapter 10, Diseases of the Respiratory System, for notes that apply to all codes within this chapter.

• When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site (e.g., tracheobronchitis bronchitis in J40).

Pay close attention to the many inclusions and exclusions!

225

COPD

• COPD is a generic term that represents any form of unspecified chronic obstructive lung disease with irreversible airway obstruction

• Comprised primarily of 3 related conditions:• Chronic obstructive bronchitis

• Chronic obstructive asthma

• Chronic obstructive emphysema

• The default code for COPD is J44 with 3 subcategories:

• J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection

• Use additional code to identify the infection

• J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation

• J44.9 Chronic obstructive pulmonary disease, unspecified 226

Chronic Lower Respiratory Diseases (cont.)

• J44 Other chronic obstructive pulmonary disease

– asthma with COPD– chronic asthmatic (obstructive) bronchitis– chronic bronchitis with airways obstruction– chronic bronchitis with emphysema– chronic emphysematous bronchitis– chronic obstructive asthma– chronic obstructive bronchitis– chronic obstructive tracheobronchitis

Code also, if applicable, type of asthma (J45-)

Note: If the type of asthma is specified by the physician – mild, moderate, severe

intermittent or persistent, or other (J45.2-, J45.3-, J45.4-, J45.5-, J45.99-), also code

J45 for the type of asthma.

If not specified, do not add code J45.909, Unspecified asthma, uncomplicated. 227

INCLUDES

Exacerbation of COPD

• An acute exacerbation is a worsening or decompensation of a chronic condition and is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection.

Per the Coding Clinic…– When assigning a code for end-stage chronic obstructive pulmonary

disease (COPD), coders should not assume that “exacerbation” is synonymous with end stage.

– Therefore, in the absence of a specifically assigned code, when the physician documents end-stage lung disease, it would not be appropriate to assign a code for COPD exacerbation.

Code assignment for exacerbation is solely based upon the physician’s documentation of the condition!

228

Emphysema

• Emphysema with unspecified COPD, whether chronic or an

acute exacerbation, is coded to J43. • If the COPD is further specified, such as chronic obstructive bronchitis or chronic

obstructive asthma, assign a code from category J44.

229

Asthma J45.-

• Asthma is a condition in which your airways narrow and swell and produce extra mucus. This can make breathing difficult and trigger coughing, wheezing and shortness of breath.

• Reversible airway obstruction (vs. COPD, which is irreversible)

• Can have both asthma and other types of COPD • When documentation indicates COPD of any type + any specified type of

asthma, or exacerbation of asthma, the asthma should also be coded (J45.-).

• If the physician has not specified the type of asthma, do not add the J45 code for asthma. Example, do not add J45.909, Unspecified asthma, as unspecified is not a type of asthma.

230

Coding Practice

Patient admitted following hospitalization for an exacerbation of COPD. She also has emphysema. While in the hospital, she was treated for recurrent Clostridium difficile, and will continue on oral antibiotics for 5 more days. COPD is the focus of care.

231

Diagnosis ICD-10-CM

M1021a

M1023b

Coding Practice - answerPatient admitted following hospitalization for an exacerbation of COPD. She also has

emphysema. While in the hospital, she was treated for recurrent Clostridium difficile, and will continue on oral antibiotics for 5 more days. COPD is the focus of care.

232

Diagnosis ICD-10-CM

M1021a Emphysema, unspecified J43.9

M1023b Enterocolitis due to Clostridium difficile, recurrent A04.71

Emphysema and unspecified COPD, whether chronic or an acute exacerbation, is coded to J43. See Index – Disease – lung – obstructive (chronic) – emphysema. This was also confirmed by the Coding Clinic.

Short-term use of antibiotics to treat an infection is not coded.

Gastroparesis• K31.84 Gastroparesis

• Inclusion term: gastroparalysis

• Code first underlying disease, if known, such as:• anorexia nervosa (F50.0-)

• diabetes mellitus (E08.43, E09.43, E10.43, E11.43, E13.43)

• scleroderma (M34.-)

Note: There is no instructional note in the Index or Tabular List at diabetes to use an additional code for gastroparesis. Coding Clinic has stated a separate code for DM is optional, but not required since the combination code under diabetes includes both conditions. However, if you look at these codes, the description does not specifically state gastroparesis – it is a clarifying term. It is recommended to add the K code to “paint the picture”.

234

Digestive System Code Practice

• Chronic bleeding duodenal ulcer

• Alcoholic cirrhosis of liver with ascites

235

Digestive System Coding

• Chronic bleeding duodenal ulcer• K26.4, Chronic or unspecified duodenal ulcer with hemorrhage

• Alcoholic cirrhosis of liver with ascites • K70.31, Alcoholic cirrhosis of liver with ascites

236

Ostomy Complications• All colostomy, gastrostomy, enterostomy, and esophagostomy complications are coded

to category K94.

• Complications include:• Mechanical complications

• e.g. excoriation and denuding of the skin surrounding the ostomy • Infection of the ostomy site • Hemorrhage of the ostomy site• other complications

• No additional code should be used when coding skin complications – the complication code covers that.

• Unless an infection is present – e.g., cellulitis:• An additional code should be used to specify the infection and also the organism, if known.

• When there is an ostomy complication, do not also assign a code for the ostomy status,

since it is included in the complication code.237

Abscesses and Cellulitis

• Cellulitis = bacterial skin infection

• Abscess = tender mass full of pus and debris. So by definition, they are infected, so follow the “use additional code” convention to identify the organism.

• There is an instructional note for categories L00-L08 to: Use additional code (B95-B97) to identify infectious agent

• Sequence the organism after the infection.

• If you don’t know the organism, don’t code it.

239

Cellulitis (L03)

• L03 Cellulitis • Cellulitis: A spreading bacterial infection of connective soft tissue extending into

deep dermal and subcutaneous layers; produces circumscribed swelling, fever, and swollen lymph glands.

• To find the codes, look under each main term in the Index.• Use additional code (B95-B97) to identify organism (for L00-L08)

• The 4th, 5th, and 6th character identifies cellulitis and the location.

• If cellulitis is associated with a wound or ostomy, sequence the wound or ostomy complication first.

240

Question from a coder…

How should I code a patient with CHF who has edema, redness, and draining blisters on her lower legs? Would this be cellulitis?

• This is known as weeping edema, and the blisters are vesicular eruptions.

• Look in the Index under Blister, multiple, skin, nontraumatic R23.8 or Eruption, vesicular R23.8.

• Sequence the CHF, I50.9, first.

I50.9, CHF

R23.8, Other skin changes241

What if the patient also has cellulitis?Patient has exacerbated CHF and cellulitis of her lower legs with

worsening edema and weeping blisters due to her CHF, which is the focus of care. Wound care and 7 days of oral antibiotics ordered.

242

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

M1023d

What if the patient also has cellulitis?Patient has exacerbated CHF and cellulitis of her lower legs with worsening

edema and weeping blisters due to her CHF, which is the focus of care. Wound care and 7 days of oral antibiotics ordered.

243

Diagnosis ICD-10-CM

M1021a Heart failure, unspecified I50.9

M1023b Cellulitis of right lower limb L03.115

M1023c Cellulitis of left lower limb L03.116

M1023d Other skin changes R23.8

Edema is integral to heart failure, so it is not coded.

If the causative organism of the cellulitis is known, it would be

sequenced immediately after the cellulitis codes.

Short-term use of antibiotics is also not coded.

Should we also use the Z48.00, Attn to nonsurgical wound dressings?

Pressure Ulcers

• There is no code for bilateral or infected pressure ulcers.• Assign codes for both right and left.

• For infections, code the organism, if known, immediately after the pressure ulcer code.

A pressure ulcer on the ischial tuberosity is coded to the buttock.

244

Contiguous Site

• A pressure ulcer that is contiguous (adjacent) to the surface area of the back, buttock, and/or hip.

• A code from L89.4- should be assigned.

• 2 pressure ulcers on a surface connected by tunneling should be coded individually.

• 2 pressure ulcers with overlapping edges where there is no defined intact skin separating them is coded as a single pressure ulcer, coded to the area at the worst stage.

• The stage of the ulcer should be assigned as the worst stage identifiable – the area of the ulcer which has deteriorated to its worst stage.

245

Official Guidelines: Pressure Ulcers

• Codes from category L89.-, Pressure ulcers, are combination codes that identify the site as well as the stage.

• Pressure ulcer stages are classified according to severity:

• stage 1-4

• unspecified stage

• unstageable

• Assign as many codes from L89.- as needed to identify all the pressure ulcers the patient has, if applicable.

• List in the order of medical severity, not necessarily the worst stage.

• Code first any associated gangrene (I96).

246

Unstageable vs. Unspecified

• Unstageable pressure ulcers (L89._ _0)

• Should be based on clinical documentation and coded when the stage cannot be clinically determined due to:

• Eschar/slough

• Skin or muscle graft

• Deep tissue injury not due to trauma

• Unspecified stage (L89._ _9)

• Intended for when there is no clinical documentation regarding the stage

Should not be used, since the stage can be coded based on the assessing clinician’s documentation

247

More Pressure Ulcer Guidelines

• The provider must diagnose the type of ulcer.

• Clinical documentation should guide the stage/severity of the ulcer.

• No code is assigned if the documentation states that the pressure ulcer is completely healed, however:

• Healed stage 3 and stage 4 pressure ulcers typically continue to require skilled intervention/assessment.

• Include an intervention on the POC

248

More guidance…

• A healing pressure ulcer may have previously been at a worse

stage. Code the ulcer at its worst stage.

• NEVER reverse stage!

249

Coding and OASIS guidance are not always consistent, but coding should be consistent with documentation in the medical record.

More guidance…

• Per WOCN guidance, stage 2 pressure ulcers do NOT include:

• Moisture associated skin damage (code as diaper rash)• Incontinence associated dermatitis

• Intertriginous dermatitis

• Medical adhesive related skin injury

• Traumatic wounds

• Medical Device related Pressure Ulcer• Code as a pressure ulcer

• Code also Y79.2, Prosthetic and other implants, materials and accessory orthopedic devices associated with adverse incidents

250

Pressure ulcer scenario…

Patient admitted for wound care to a gangrenous stage 3 pressure ulcer on the left hip. He also has diabetes, which is well-controlled with Metformin.

251

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

M1023x

Coding for scenario…Patient admitted for wound care to a gangrenous stage 3 pressure ulcer

on the left hip. He also has diabetes, which is well-controlled with Metformin.

252

Diagnosis ICD-10-CM

M1021a Gangrene, not elsewhere classified I96

M1023b Pressure ulcer of left hip, stage 3 L89.223

M1023c Type 2 diabetes mellitus without complications E11.9

M1023x Long-term (current) use of oral hypoglycemic drug Z79.84

There is an instructional note at L89 to “Code first any associated gangrene (I96).” This is not diabetic gangrene. The gangrene is linked to the pressure ulcer. Encounter for nonsurgical dressing would NOT be coded for the complicated ulcer.

Chronic Ulcers Lower Extremity (L97)

• The Coding Clinic believes that all lower extremity ulcers require a minimum of two codes.

• If the medical record does not describe the underlying etiology, the physician should be queried.

• Clinicians are permitted to determine the severity of non-pressure ulcers based on clinical documentation.

• For all non-pressure chronic ulcers of the lower extremity, not elsewhere classified:

• Code first the underlying etiology;

• Followed by the code for the location and severity of ulcer.

• If there is gangrene, it should be coded first (I96) – see the code first note

• If the etiology code includes gangrene, do not add I96 as well.253

What is NOT a non-pressure chronic ulcer:• Traumatic wounds

• Pemphigoid lesions

• Cancerous lesions

• Blisters, scabs, keloids, keratosis

• Maceration due to incontinence, friction or irritants

• Breakdown of a surgical wound

• Drained/incised hematoma

• Cellulitis

• Abscess

• Dermatitis

• Eczema

254

Venous Stasis Ulcers

• Venous stasis ulcers are thought to occur due to improper functioning of venous valves, usually of the legs. Index: Ulcer Stasis (venous) – See Varix, leg, with ulcer without

varicose veins I87.2 I87.2 = Venous insufficiency (chronic) (peripheral)

• There is no instructional note to use an additional code for the ulcer at I87.2, but there is at I83.2 (varicose veins), I70.- (arterial ulcers) and other codes.

• However, L97.-, with the location and severity, should be coded for all non-pressure ulcers and has the instruction to “Code first any associated underlying condition.”

255

Arterial Ulcers

• Arterial ulcers, also known as ischemic ulcers, are caused by a

lack of blood flow due to blocked arteries in the lower

extremities (atherosclerosis/arteriosclerosis), which are mostly

located on the lateral surface of the ankle or the distal digits.• Index: Atherosclerosis (see also arteriosclerosis) Arteriosclerosis

extremities (native arteries) leg with: (gangrene, and intermittent

claudication, rest pain and ulcer)

• Use additional code to identify severity of ulcer (L97.-).

256

Quick Codes

• Diabetic ulcer left great toe with fat exposure

• Stage 3 pressure ulcer of left ankle

• Stasis ulcer of right calf with muscle involvement

257

Quick Code Answers

• Diabetic ulcer left great toe with fat exposure

• E11.621, Type 2 diabetes mellitus with foot ulcer

• L97.522, Non-pressure chronic ulcer of other part of left foot with fat layer exposed

• Stage 3 pressure ulcer of left ankle

• L89.523, Pressure ulcer of left ankle, stage 3

• Stasis ulcer of right calf with muscle involvement

• I87.2, Venous insufficiency

• L97.215, Non-pressure chronic ulcer of right calf with muscle

involvement without evidence of necrosis

258

Musculoskeletal Disorders vs Injuries –are you looking in the correct chapter?

Chapter 13 Musculoskeletal

• Healed injuries that cause bone, joint or muscle conditions

• Chronic or recurrent bone, joint or muscle conditions

• Chronic conditions induced by a traumatic event (traumatic arthritis)

Chapter 19 Injuries

• Current, acute injuries

• Current condition caused by trauma

• Sequela of traumatic injury

260

Osteoarthritis• What it is:

• Sometimes called degenerative joint disease or “wear and tear” arthritis, osteoarthritis (OA) is the most common chronic condition of the joints.

• It occurs when the cartilage or cushion between joints breaks down leading to pain, stiffness and swelling.

• Also known as:

• degenerative joint disease or degenerative arthritis

• Code osteoarthritis (OA) in a patient’s joint as primary osteoarthritis if the type of

OA, such as primary, secondary or generalized, is not specified, according to the Q4 2016 Coding Clinic update.

“When the type of osteoarthritis is not specified, “primary” is the default.” For example, you should assign M16.0 (Bilateral primary osteoarthritis of hip) for a patient documented as having bilateral osteoarthritis of the hips.

261

+ primary M19.91

• Well, the Coding Clinic said if the osteoarthritis is unspecified, we can code

primary as the default. So can I just use M19.91? When we expand this code:

• primary M19.91

ankle M19.07

elbow M19.02

foot joint M19.07

+ hand joint M19.04

+ hip M16.1

+ knee M17.1

shoulder M19.01

spine See Spondylosiswrist M19.03

262

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=primary

https://codingcenter.decisionhealth.com/MVC/ICD10/Details/M19.91?includeResults=true

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=ankle


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=elbow


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=foot joint


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=hand joint


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=hip


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=knee


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=shoulder


https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=spine

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=Spondylosis

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=8&sk=wrist


M15 vs M19

M15.0 Primary generalized (osteo)arthritis

• Includes (M15)• arthritis of multiple sites

M19.90 Unspecified osteoarthritis, unspecified site

• Clarifying Terms• Arthrosis NOS

• Arthritis NOS

• Osteoarthritis NOS

263

Osteomyelitis• What it is:

• Osteomyelitis is a bone infection. It is mainly caused by bacteria or other

germs.

• Osteomyelitis can be assumed to be related to diabetes mellitus, unless

another cause is stated (e.g., injury).

• The location of the osteomyelitis is coded to the type of osteomyelitis (acute,

subacute, chronic, hematogenous, specified type, etc.)

264

Coding Osteomyelitis

• Get as much information as possible:• The causative organism

• Specific site

• Acute versus chronic (chronic must be confirmed by the physician)

• Has a Use Additional Code convention:• Infectious agent (B95-B97) (causative organism)

• Identify any major osseous defect prn (M89.7-)

• Major osseous defect: absence or imperfection of bony structure as a result of extensive bone loss

265

Osteoporosis, NO Pathological Fracture

• Osteoporosis is a systemic condition, meaning all the bones of the musculoskeletal system are affected.

• M81, Osteoporosis without current pathological fracture, does not require a specific code for location.

• Default code is M81.0, Age-related osteoporosis without current pathological fracture, if the type of osteoporosis is not identified.

• M81.8-, Other osteoporosis without current pathological fracture

• Drug-induced, post-traumatic, idiopathic, etc.

• Add a code for personal history of healed osteoporosis fracture (Z87.310), if applicable.

266

Osteoporosis WITH Pathological Fracture

• Site codes under M80, Osteoporosis with current pathological fracture, are combination codes that identify the site of the fracture due to osteoporosis.

• A code from category M80 should be used when:• Patient with known osteoporosis who suffers a fracture, even if the patient had a

minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.

• Do not use a traumatic fracture code.

• Add a code for personal history of healed osteoporosis fracture (Z87.310), if

applicable.

267

Other Pathological Fractures• Due to cancer:

• M84.5-, Pathological fracture in neoplastic disease

• Code also underlying neoplasm

• Due to other disease• M84.6-, Pathological fracture in other disease

• Code also underlying condition

• Pathological fractures NEC• M84.4-, Pathological fracture, NEC

• Code also underlying cause if able to determine

• Stress fractures • M84.3-, Stress fracture

• Code also external cause

268

Chronic Kidney Disease

• Chronic Kidney Disease (CKD) is coded by the stage of the disease as stated by the physician.

• Codes are in the N18.- category: • N18.1 = stage 1

• N18.2 = stage 2, mild CKD

• N18.3 = stage 3, moderate CKD

• N18.4 = stage 4, severe CKD

• N18.5 = stage 5, not requiring dialysis. If dialysis is required, code N18.6.

• N18.6 = End stage CKD (ESRD)

• N18.9 = CKD, unspecified stage

270

CKD

• If the patient is receiving dialysis (HDU or peritoneal), code as ESRD: N18.6.

• Add code for dialysis (peritoneal or hemodialysis): Z99.2, Dependence on renal dialysis

• If both a stage of CKD and ESRD are documented, assign code N18.6 only.

• ESRD N18.6 can NOT be coded as primary in home health, as this would be a duplication of services (of the HDU facility).

• The stage may not be coded based on lab data such as the glomerular filtration rates (GFR).

271

Kidney Transplants

• Patients who have had kidney transplants may still have some degree of CKD, as the transplant might not fully restore kidney function.

• This is NOT considered a complication

• Code from N18.- for the stage of CKD

• Code also Z94.0, Kidney transplant status

272

Symptom Codes

274

PDGM WARNING

Symptoms

Guidelines

Section I.C.18.a-c

• Codes that describe symptoms and signs are acceptable for reporting purposes when

a related definitive diagnosis has not been established (confirmed) by the provider.

• 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 that diagnosis,

such as the various signs and symptoms associated with complex syndromes.

• The definitive diagnosis code should be sequenced before the symptom code.

• Signs or symptoms that are associated routinely with a disease process should not

be assigned as additional codes, unless otherwise instructed by the classification.

275

The Falling Codes

• R29.6, Repeated Falls, has clarifying terms of:• Falling

• Tendency to fall

• Used for encounters when a patient has recently fallen, and the reason for the fall is being investigated, home safety is assessed, methods to reduce falls is being addressed.

• Z91.81, History of falling, is for use when a patient has fallen in the past, and is at risk for future falls.

• Both R29.6 and Z91.81 may be assigned together when appropriate.

276

R53.0 Neoplastic (malignant) related fatigue

• Has a code first note for “associated neoplasm”

• Take-away message: if the chart speaks of fatigue, and the patient has a neoplasm, before doing a knee-jerk insertion of R53.83, Fatigue, query the physician if the fatigue is related to the cancer.

277

Chapter-Specific Guidance

• The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent care.– For example, for aftercare of an injury, assign the acute injury code with

the appropriate 7th character “D”.

279

Coding Injuries

• Assign separate codes for each injury, unless there is a combination code.

• Do not code surgical wounds, whether healing or complicated, as traumatic injuries.

• Even if the traumatic injury received sutures, it is still coded as a traumatic injury.

• Do not code superficial injuries, such as abrasions or contusions, when associated with more severe injuries of the same site.

• Sequence the code for the most serious injury first.

280

Open Wounds

• Trauma wound = Open wound

• Open wound codes are meant only for traumatic injuries.

• NEVER code medically caused wounds as open wounds.

• Includes:

• Animal bites (venomous and nonvenomous)

• Abrasions, avulsions, contusions, skin tears

• Lacerations and cuts, puncture wounds

• Traumatic amputations

• 7th character is required.

• No aftercare Z code for surgery for injury / trauma.

Always ask: What kind of trauma is this?281

Bites

• Coding bites depends on the kind of bite:• Venomous bites: look up under the Table of Drugs & Chemicals

• Nonvenomous bites (insect, snake): code as Injury

• Animal bites: code as Injury:

• Contusion (superficial injury) if skin is intact

• Trauma wound (open wound) if skin is not intact

282

Superficial Injuries

• Superficial: the injury involves the superficial structures, such as the first layer of epidermis.

• Includes:• Abrasions

• Blisters

• Contusions

• Uncomplicated skin tears

• Classified by body site, search in Alpha under “Injury, superficial”, then to body site

283

Superficial Injuries

• Be sure you are getting the distinction between superficial injuries and trauma wounds correct.

• For correct coding, know:• Correct wound assessment, thorough documentation that further

describes the home health interventions

• Knowledge of the Payne-Martin skin tear classification tool

• Adherence to your MAC guidelines for what constitutes a need for skilled nursing care

284

Skin Tears

• Most skin tears are partial thickness wounds, superficial injuries.• Require only simple wound care

• Not covered under the MCR benefit – NOT SKILLED CARE

• Even though it may have been caused by trauma, if the wound itself does not meet open wound criteria, it CANNOT be coded as a trauma wound.

• You MAY code it as a trauma wound if:• The skin tear is extensive – i.e., extends into the dermis, or it no longer

has a flap

• The wound is complicated – i.e., delayed healing, foreign body present, is infected

285

Traumatic Fractures• All injuries are grouped together in Chapter 19 by anatomical

location and then by type of injury, within that location, with traumatic fractures integrated by location.

• Fracture coding requires documentation of:• Site;

• Laterality;

• Type of fracture;

• Whether it is displaced or not displaced;

• The encounter – initial, subsequent, or sequela; and

• The stage of healing.

• The fracture is coded with the appropriate 7th character. 286

7th Characters for Traumatic Fractures

• The 7th character identifies:

– Fracture type;

– Whether healing is routine, delayed, malunion; and

– Encounter type

• initial encounter (A, B, C) is used for each encounter where the patient is receiving active treatment for the fracture.

287

Subsequent Encounter for Fractures

Fractures are coded using the appropriate 7th character for subsequent care for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase.

288

Traumatic Fractures (cont.)

• Multiple fractures are coded individually and sequenced according to the severity of the fracture.

• A fracture not indicated as “displaced” or “not displaced” should be coded to displaced, when an option.

• A fracture not indicated as open or closed should be coded to closed.

• Therefore, the default is Displaced, closed

• Do not code the wound additionally when the bone breaks through the skin in an open fracture.

• Complications of fractures should be reported with the appropriate 7th character for:Delayed healing;

Malunion; or

Nonunion.

289

Code the complication first!

Code this scenario…

Patient was admitted for SN, PT, and OT following a right total hip replacement due to a traumatic fracture he sustained when he fell from his chair at home.

290

Diagnosis ICD-10-CM

M1021a

M1023x

M1023x

Coding for scenario…

Patient was admitted for SN, PT, and OT following a right total hip replacement due to a traumatic fracture he sustained when he fell from his chair at home.

291

Diagnosis ICD-10-CM

M1021a Fracture of unspecified part of neck of (R) femur S72.001D

M1021x Presence of right artificial hip joint Z96.641

M1023x Fall from chair W07.xxxD

The fracture is coded, NOT aftercare following the joint replacement (Z47.1).

The code indicating the joint replaced is indicated (Z96.6-.)

The 7th character for rehab is “D” (subsequent encounter).

The cause of the injury (fall) should be coded.

Planned vs. Traumatic Amputation

Planned

Patient’s right great toe was amputated due to severe diabetic PVD.

• Z47.81 Aftercare following surgical amputation

• E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene

• Z89.411 Acquired absence of right great toe

Traumatic

Patient’s right great toe was cut off when mowing the lawn with a power mower.

• S98.111D Complete traumatic amputation of right great toe, subsequent encounter

• W28.xxxD Contact with powered lawn mower, subsequent encounter

The status code for absence is not used, because the traumatic amputation code provides the information.

The 7th character “D” is assigned, since active care is not being provided.

The 7th character for the external cause code is the same as the 7th character for the injury.

292

Expand Complication to find Amputation Complications

+ Complication (s) (from) (of)amputation stump NEC (surgical) (late) T87.9

dehiscence T87.81

+ infection or inflammation T87.40

+ necrosis T87.50

+ neuroma T87.30

specified type NEC T87.89

• T87.8-, Other complications of amputation stump• amputation stump contracture

• contracture of next proximal joint

• flexion

• edema

• hematoma

293

Burns and Corrosions

• There is a distinction between burns and corrosions.• Burns:

• Thermal from heat source:

• Fire

• Hot appliance

• Electricity

• Radiation

• Not sunburn

• Corrosions:• Burns due to chemicals

• Use an external cause code to identify the source and intent of the burn, and the place (not body location) where it occurred.

294

Classification of Burns

• Current burns are classified by depth as first, second, and third degree.

• First degree burns include only the dermis and usually result in red and painful skin.

• Second degree burns can cause partial thickness (may present with blisters) or full thickness tissue loss (extend into the dermis).

• Third degree burns involve destruction of all levels of the skin, and are not painful, as the nerves have been destroyed.

295

Guidelines for Coding Burns• Assign separate burn codes for a patient who suffers multiple burns to multiple

body sites. • Codes for burns of “multiple sites” should only be assigned when the medical record

documentation does not specify the individual sites.

• However, if a patient has multiple burns to the same body site, but the burns are of different degrees (for example, second and third degree burns to the left thigh), code only the most severe burns (for example, the third degree burns.)

• Sequence first the code that reflects the highest degree of burn when more than one burn is present.

• Non-healing burns are coded as acute burns.

• Necrosis of burned skin should be coded as an acute burn.

• Pay close attention to the many instructional notes!296

Categories T31 and T32

• Assign codes from category T31, Burns classified according to extent of body surface involved, or T32, Corrosions classified according to body surface involved, as a supplementary code with categories T20-T25.

• T31 and T32 are assigned for patients who have third degree burns over 20% or more of their bodies.

• Codes are based on the classic “rule of nines” in estimating body surface involved.

297

Sequelae of Burns

• Encounters for the treatment of the sequelae (late effects) of burns or corrosions (e.g., scars or joint contractures) should be coded with a burn or corrosion code with the 7th character “S” for sequela.

• Code the sequela first, followed by the burn.

• Current acute burns or corrosions may be assigned to the same record as a sequela of a burn with the appropriate 7th character of “A,” “D,” or “S”.

• Burns and corrosions do not heal at the same rate. Therefore, a healing wound may still exist with a sequela of a healed burn or corrosion.

298

Code this burn scenario…Patient admitted with a non-healing 3rd degree burn on the back of her right hand

and severe scarring of her right wrist from a healed 3rd degree burn, which both resulted from spattered hot oil while she was cooking. SN for wound care and OT for wrist mobility.

299

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

M1023x

M1023x

Coding for burn scenario

Patient admitted with a non-healing 3rd degree burn on the back of her right hand and severe scarring of her right wrist from a healed 3rd degree burn, which both resulted from spattered hot oil while she was cooking. SN for wound care and OT for wrist mobility.

300

Diagnosis ICD-10-CM

M1021a Burn of 3rd degree of back of right hand T23.361D

M1023b Scar conditions and fibrosis of skin L90.5

M1023c Burn of 3rd degree of right wrist, sequela T23.371S

M1023x Contact with fats and cooking oils X10.2xxD

M1023x Kitchen in private house, place of occurrence of the external cause

Y92.010D

302

Substance

Poisoning, Accidental

(unintentional)

Poisoning, Intentional self-

harmPoisoning,

AssaultPoisoning,

Undetermined Adverse effect Underdosing

Opiate NEC T40.601 T40.602 T40.603 T40.604 T40.605 T40.606

The Table contains a classification of drugs and other

chemical substances associated with poisoning and external

causes of adverse effects.

https://codingcenter.decisionhealth.com/MVC/ICD10/Search?cst=10&sk=Opiate NEC

https://codingcenter.decisionhealth.com/MVC/ICD10/Details/T40.601/2019






Medications

• Let’s review, from a clinician and OASIS standpoint, what we know about the proper assessment of medication usage:

• RIGHT person

• RIGHT medication

• RIGHT dose

• RIGHT time

• RIGHT route

• So if any of these points goes wrong, the result may either be a poisoning or an adverse effect.

303

Table of Drugs and Chemicals• Poisoning:

• (Accidental, Intentional, Assault, Undetermined)• Overdose of substance

• Wrong substance given or taken in error

• Adverse effect:

• Hypersensitivity, reaction, drug toxicity, etc., of correct substance properly

prescribed and administered

• Underdosing:

• Taking less of a medication than is prescribed or instructed by a manufacturer,

whether inadvertently or deliberately, including discontinuing the use of a

prescribed medication willingly

• Codes require a 7th character extension of “A”, “D”, or “S304

Adverse Effect versus Poisoning

Adverse Effect

Drug correctly prescribed and properly administered

• First…assign the code for the adverse effect(s) – e.g., rash, slow pulse, confusion, dehydration, etc.

• Next…assign the med code(s) indicating adverse effect of the drug (T36-T50).

Sequencing:

1. E = Effect

2. T = T code

Poisoning

Something wrong happened, such as wrong drug, wrong dose, or wrong person

• First…assign a code from categories T36-T50. If the intent is unknown or unspecified, code as accidental.

• Next…code effect(s) of the poisoning.

Sequencing

1. T = T code

2. E = Effect

305

ScenarioPatient has been taking the prescribed amount of Lanoxin (Digoxin) for

atrial flutter. However, he now has bradycardia and is toxic according to lab values. SN ordered for monitoring and lab draws.

Is this a poisoning or an adverse effect?

306

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

M1023x

M1023x

ScenarioPatient has been taking the prescribed amount of Lanoxin (Digoxin) for atrial

flutter. However, he now has bradycardia and is toxic according to lab values. SN ordered for monitoring and lab draws.

This is an adverse effect.

307

Diagnosis ICD-10-CM

M1021a Bradycardia R00.1

M1023b Adverse effect of cardiac-stimulant glycosides T46.0X5D

M1023c Unspecified atrial flutter I48.92

M1023x Encounter for therapeutic drug monitoring Z51.81

M1023x Long-term (current) use of other high risk med Z79.899

E

T

Scenario

Patient has been taking Lasix 40mg every morning and night for CHF. The prescription bottle instructions reads 40mg daily. Now he is dehydrated and hypokalemic.

Is this a poisoning or an adverse effect?

308

Diagnosis ICD-10-CM

M1021a

M1023b

M1023c

M1023d

ScenarioPatient has been taking Lasix 40mg. every morning and night for CHF. The

prescription bottle instructions reads 40mg. daily. Now he is dehydrated and hypokalemic.

This is a poisoning (wrong dose).

309

Diagnosis ICD-10-CM

M1021a Poisoning by diuretics, subsequent encounter T50.1X1D

M1023b Dehydration E86.0

M1023c Hypokalemia E87.6

M1023d Heart failure, unspecified I50.9

T

E

E

Underdosing

Guideline: Codes for underdosing should never be assigned as principal/primary or first-listed codes. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded.

• For underdosing, assign:

• C = Condition caused by the underdosing

• T = T code from categories T36-T50, with 5th or 6th character of 6 for underdosing

of the drug

• Z = Z code for the reason for underdosing (Z91.1-)

310

Underdosing Scenario

Patient with a diagnosis of hypertension continued to experience elevated blood pressure while taking her blood pressure medication. Upon patient interview, it was found she was taking it only once a day, instead of twice, as prescribed, because she couldn’t afford the cost of the drug.

311

Diagnosis ICD-10-CM

M1021a

M1023b

M1023x

Underdosing Scenario

Patient with a diagnosis of hypertension continued to experience elevated blood pressure while taking her blood pressure medication. Upon patient interview, it was found she was taking it only once a day, instead of twice, as prescribed, because she couldn’t afford the cost of the drug.

312

Diagnosis ICD-10-CM

M1021a Essential hypertension I10

M1023b Underdosing of other antihypertensive drugs, subsequent encounter

T46.5x6D

M1023x Patient's intentional underdosing of medication regimen due to financial hardship

Z91.120

Coding Complications

• There is no time limit.• Reference the main term in the Index for the condition, and look for a

subentry indicating the complication, such as:• Adhesions postoperative (gastrointestinal tract)

• Colostomy malfunctioning

• Infection bacterial NOS

• If no entry is found, go to Complications in the Index and look for the appropriate subentry:

• Nature of complication (catheter, hemorrhage, vascular)

• Type of procedure (surgical, postprocedural, transplant)

• Anatomical site or body system (cardiac, endocrine, respiratory)

• Verify the code in the Tabular List and follow instructions for any additional codes.

314

Types of Complications

Medical complications

• Infection and inflammation• Hemorrhage• Problems related to an injection, infusion, or transfusion – e.g.,

phlebitis, infection, or sloughing

Complications of surgical procedure

• Post-surgical infection of wounds, amputation stumps• Infection of grafts, devices, and prosthetics• Complication of transplanted organs• Disruption of surgical or trauma wounds

Mechanical complications

• Ostomies – e.g., malfunctioning• Grafts, devices, and prosthetics – e.g., insulin pump, dialysis

catheter, urinary catheter, prosthetic joint

315

Location in the Alpha Index

316

Location in the Tabular List

• Chapter 19 (T80-T88) includes complications of surgical and medical care, not elsewhere classified.

• There are instructional notes at the beginning of the section which state to “Use an additional code.”

• For adverse effect, if applicable, to identify the drug

• To identify the specified condition resulting from the complication

• To identify devices involved and details of circumstances•

• Each body system chapter includes post-procedural and intra-operative complications related to the structures and functions within those body systems – e.g., digestive chapter.

317

Key Points for Complications

• The complication is sequenced first.

• A code to identify the specified condition resulting from the complication is coded next.

• Coding the cause of the injury, found in the Index to External Causes of Injuries, is optional, in this case. The fall requires a 7th

character – A, D, or S.

• Assign the 7th character the same as the complication code’s 7th

character.

• The place of occurrence is only coded at the initial encounter, which is not home care. 318

Requirement for Reporting

• Reporting ICD-10 external cause codes is not required:‒ Unless a provider is subject to a state-based external cause code reporting mandate

or these codes are required by a particular payer.

Exception: Burns

• In the absence of a mandatory reporting requirement, providers are encouraged to report them, as they provide valuable data for injury research and evaluation of injury prevention strategies.

• They are located in the Index to External Causes of Injury.

320

Purpose of External Cause Codes

These codes capture:• How the injury or health condition happened (cause)

• The intent:

• unintentional or accidental

• intentional, such as suicide or assault

• The place where the event occurred (Y92)• Typically used only once, at initial encounter for treatment

• The activity of the patient at the time of the event (Y93) • Used only once, at initial encounter for treatment

• The person’s status (e.g., civilian, military) (Y99)

321

Use of External Cause Codes

• If a home agency chooses to report external cause codes, only the codes for the intent and cause should be reported, except for burns.

• External cause codes for the place of encounter, activity, and status are used only once at the initial encounter for treatment (e.g., the patient was seen by a physician in the ER or urgent-care center to diagnose and order treatment first).

• Most often used for injuries

• Valid for use with:

• Infections

• Diseases due to an external source

322

Use of External Cause Codes (cont.)

• Assign the external cause code with the applicable 7th character –“A,” “D,” or “S” for most categories.

• The 7th character for the external cause should match the 7th

character of the code assigned for the associated injury or condition for the encounter.

• An external cause code can never be the primary diagnosis.

• No external cause code from Chapter 20 is needed, if the external cause and intent are included in a code from another chapter – e.g., T36.0X1-, Poisoning by penicillins, accidental (unintentional).

323

TEST TIME!!!!!Putting it all Together

324

Putting it all Together: Test Question #1

• Patient sustained a left femoral shaft fracture while skiing. An OREF was

performed. The patient has comorbidities of osteoporosis, HTN, and frequent falls.

Nursing will be addressing the pin care of the fixation device. Therapy will be

addressing his falls risk and safety with the walker. He is taking ASA only.

325

M item Diagnosis ICD-10-CM code

M1021a

M1023

M1023

M1023

M1023

M1023

M1023

M1023

Putting it all Together: Test Question #1 What do we need to know?

• Is this a traumatic fracture or a pathological fracture?

• What comorbidities should we also code?

• Do we code for abnormal gait?

• Do we code for the aspirin use?

• Is using an external cause code mandatory?

326

Putting it all Together: Test Question #1• Patient sustained a left femoral shaft fracture while skiing. An OREF was performed. The patient has

comorbidities of osteoporosis, HTN, and frequent falls. Nursing will be addressing the pin care of the

fixation device. Therapy will be addressing his falls risk and safety with the walker. He is taking ASA

only.

M1021a: S72.302D, Unspecified fracture of shaft of left femur, subsequent encounter for closed fracture with routine healing

M1023b: M81.0, Age-related osteoporosis without current pathological fracture

M1023c: I10, HTN

M1023d: R29.6, Repeated falls

M1023x: Z91.81, History of falling

M1023x: Z48.01, Encounter for change or removal of surgical wound dressing

M1023x: Z79.82, Long term (current) use of aspirin

M1023x: Y93.23, Activity, snow (alpine) (downhill) skiing, snowboarding, sledding, tobogganing and snow tubing

327


• Patient has a diagnosis of Multiple Sclerosis. She was recently admitted to the hospital for urinary retention, and now requires a Foley catheter. She is taking steroids and Glucophage. She is wheelchair dependent.

328


M1021a

M1023

M1023

M1023

M1023

M1023

M1023


• What is the focus of care?• Foley

• What is the Glucophage for?• Physician confirmed diagnosis of DM2.


• Do we code for the steroids and Glucophage use?

• Do we code for abnormal gait?

• Do we code for the wheelchair dependence?

329

Putting it all Together: Test Question #2 • Patient has a diagnosis of Multiple Sclerosis and DM2. She was recently admitted to

the hospital for urinary retention, and now requires a Foley catheter. She is taking steroids and Glucophage. She is wheelchair dependent.

M1021a: Z46.6, Encounter for fitting and adjustment of urinary device

M1023b: R33.9, Retention of urine, unspecified

M1023c: G35, Multiple sclerosis

M1023d: E11.9, Type 2 diabetes mellitus without complications

M1023x: Z99.3, Dependence on wheelchair

M1023x: Z79.52, Long term (current) use of systemic steroid

M1023x: Z79.84, Long term (current) use of oral hypoglycemic drugs

330


• Patient has a diagnosis of neoplastic disease in her transplanted right kidney. She is

on dialysis. She has HTN and chronic diastolic CHF. Therapy is seeing her for

weakness from the surgeries. Nursing is seeing her for disease management of the

neoplasm. She is taking opiates as well as antirejection medications.

331


M1021a

M1023

M1023

M1023

M1023

M1023

M1023

M1023

M1023


• What is the focus of care?

• Disease management of the kidney transplant. But can we code that as PRIMARY?

• Why is she on dialysis?

• Physician confirmed diagnosis of ESRD.


• Do we have any combination code situations?

• HTN + CKD + Heart failure. Do we code CHF as well as chronic diastolic heart

failure?

• Do we code for the opiates and antirejection meds?

• Do we code for weakness?

332

Putting it all Together: Test Question #3 • Patient has a diagnosis of neoplastic disease in her transplanted right kidney. She is on

dialysis due to ESRD. She has HTN and chronic diastolic CHF. Therapy is seeing her for

weakness from the surgeries. Nursing is seeing her for disease management of the neoplasm.

She is taking opiates as well as antirejection medications.

M1021a: T86.19, Other complication of kidney transplant

M1023b: C80.2, Malignant neoplasm associated with transplanted organ

M1023c: C64.1, Malignant neoplasm of right kidney, except renal pelvis

M1023d: I13.2, Hypertensive heart and chronic kidney disease with heart failure and with stage 5

chronic kidney disease, or end stage renal disease

M1023e: I50.32, Chronic diastolic (congestive) heart failure

M1023f: N18.6, End stage renal disease

M1023x: Z99.2, Dependence on renal dialysis

M1023x: Z79.891, Long term (current) use of opiate analgesic

M1023x: Z79.899, Other long term (current) drug therapy

333

Thank you. Questions?

[email protected](513) 432-2111

334

Presented By

Arlynn Hansell, PT, HCS-D, HCS-H, HCS-O, COS-C, has been a

Physical Therapist in both the home health and SNF settings since October

1998, holding positions of therapist, rehab manager, and quality/compliance

assurance. She is the owner of Therapy and More, LLC, where services

consist of OASIS auditing, ICD-10 coding for home health and hospice,

therapy visit note audits and end of episode quality reviews. In addition, she

assists agencies in achieving therapy documentation and practice excellence

in order to better position themselves against auditors.

Arlynn is appointed to the BMSC Home Health Advisory Panel, where she

serves as Vice Chair. She is a past member of the American Physical

Therapy Association, where she served as the past Vice President of the

Home Health Section. She is involved in the creation and editing of the

HCS-D, HCS-O, HCS-H certification exams, and is the editor of the Home

Care Clinical Specialist – OASIS D online guidance.

335

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