Time Waits for No One: Icd-10-Cm Coding for Icd 10

Selman‐Holman & Associates, LLC

2 Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C Home Health Insight—Consulting, Education and Products CoDR—Coding Done Right CodeProUniversity TIME WAITS FOR NO ONE: 606 N. Bell Ave. Denton, Texas 76209 ICD‐10‐CM CODING FOR 214.550.1477 972.692.5908 fax HOME HEALTH [email protected] Teresa@selmanholman. com www.selmanholmanblog.com www.selmanholman.com www. CodeProU. com Teresa Northcutt, BSN, RN, HCS-D, COS-C © 2015, S-H&A AHIMA-Approved ICD-10-CM Trainer

CMS says: Implementation Date

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 Compliance dates are firm and will not change October 1, 2015 There w ill be no de lays There will be no grace period 70 days from today!  If not ready, claims will not be paid.

 Penalties may be incurred for noncompliance with HIPAA. RAPs vs EOEs Comparison

5 6 ICD-9-CM diagnosis codes ICD-1Ø-CM diagnosis codes

 Claims for episodes ending October 1 Limited space for adding new codes Flexible for adding new codes

and later must be coded in ICD-10. Lacks detail Very specific  ICD-10 will not be accepted prior to Lacks laterality Has laterality October 1. Difficult to ana lyze da ta due to non- SifiitiSpecificity improves co ding accuracy  So that means… specific codes and richness of data for analysis Codes do not adequately define Detail improves the accuracy of data …the real beginning of ICD-10 diagnoses needed for medical used for medical research coding is 12 days from today! research Doesn’t support interoperability with Supports interoperability with other other countries countries

Comparison Increase in Number

7 8 ICD-9-CM diagnosis codes ICD-1Ø-CM diagnosis codes  Codes related to musculoskeletal 3-5 characters in length 3-7 characters in length care make up > 50% of ICD-10 First character is numeric or alpha (E or V) First character is alpha (all letters except U) codes. Characters 2-5 are numeric Character 2 is numeric Characters 3-7 are alpha or numeric  Approximately one-third of ICD-10 Use of decimal required after 3 characters Use of decimal required after 3 characters codes are related to fractures No placeholders Use of dummy place holder ‘X’ Alpha characters are case sensitive Alpha characters are NOT case sensitive  25, 000 due to laterality Incomplete code titles Complete code titles

14,,g315 diagnosis codes (Volumes 1 ,),2) 69,,gØ99 diagnosis codes (Volumes 1 ,),2)

3,838 procedure codes (Volume 3) 71,957 procedure codes (Volume 3) Changes Vary by Clinical Area Coding 3 to 7 Characters

9 10 Clinical Area ICD-9 ICD-10

Fractures 747 17099 Alpha 2 - 7 Numeric or Alpha Additional Characters Poisoning and toxic effects 244 4662 (Except U) Brain injury 292 574 Pregnancy-related 1104 2155 MXAS ØX X2 X6 X5 Xx DX Diabetes 69 239 . Migraine 40 44

Bleeding disorders 26 29 Added 7th character) for CtCategory Etiol ogy, anat omi c obstetrics, injuries, and Mood-related disorders 78 71 site, severity external causes of injury Hypertensive disease 33 14 End-stage renal 11 5 3 – 7 Characters Chronic respiratory failure 7 4

Alphabetical Index Tabular List

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 Index to Diseases and Injuries  Within a number of ICD-10-CM chapters, category restructuring and No hypertension table code reorganization have occurred  Neoplasm table is separate resulting in the classification of certain  Table of Drugs and Chemicals diseases and disorders different than what is currently seen in ICD-9-CM.  Index to External Causes  Example: Gout moved to musculoskeletal system chapter  Examppyle: Eyes and ears se parated from the Nervous system chapter Why does diagnosis selection and coding matter? 14

13 Diagnoses and OASIS‐C1  Payment / HHRG calculation (HH)  Support medical necessity and care planning …andthd the Pl an of fC Care  For payment intermediaries and surveyors

 Risk Adjustment (OBQI and HH-CAHPS)

 Resource allocation based on patient acuity

 Completes the patient picture started by your comprehensive assessment and OSSOASIS or HIS responses

OASIS‐C1 Changes CMS Regulation

 OASIS-C1/ICD-9 was implemented The clinician that makes the home visit and performs the comprehensive assessment must Jan. 1, 2015 complete all OASIS items, including identifying the primary and secondary diagnoses for M1020 and  OASIS-C1/ICD-10 will be implemented M1022. A reviewer or coder in the office may add when the ICD-10-CM coding set is the ICD-9-CM numerical codes, but may not change the diagnoses or sequencing in M1020- implemented on Oct. 1, 2015 M1022 without the approval of the author of the assessment. M1011, M1017, M1021, M1023, M1025 On th e oth er h an d, co ding has to be comp lian t w ith will be implemented when ICD-10-CM professional guidelines (Official Guidelines for coding set goes into effect Codinggpg) and Reporting AND CMS) M1010: Inpatient Diagnoses M1011: Inpatient Diagnoses

 Only include diagnoses actively treated  No surgical procedures or Z-codes during the inpatient facility stay within the  May list diagnoses that are only past 14 days allowed in acute care settings (7th  “Actively treated” = receiving something character for injuries, acute CVA) more than the regularly scheduled  “Within th e past 14 d ays ” = treat ed at medications and treatments necessary to maintain or treat an existing condition any facility pt was discharged from any time b e tween d ay 0 an d day 14  OASIS-C1/ICD-10 = M1011 prior to SOC or ROC CMS OCCB April 2010 Q&A #5

M1016: Diagnoses requiring Med/tx M1017: Diagnoses requiring Med/tx Regimen Change Within Past 14 Days Regimen Change Within Past 14 Days 20

 Any changes in treatment regimen , health care  Used in risk adjustment of outcomes to services, or medications within past 14 days identify patient’s recent history, and new or exacerbated diagnoses over past 2 weeks.  Not always the same as M1010/M1011  If at any time in the last 14 days the patient  Mark NA if changes were made because a requires a medical or treatment regimen diagnosis only showed improvement within past change due to development of a new 14 days condition or lack of improvement/worsening of an existing condition, the diagnosis should  Iden tifi es pati en ts th at ar e m or e un stabl e or at btdibe reported in M1017, even if th e conditi on higher risk of complications also showed improvement or stabilization  OASIS-C1/ICD-10 = M1017 during that time, or is improved at the time of the SOC / ROC M1020 and M1022 M1021: Primary Diagnosis

 Report the diagnoses, symptoms, and  Main reason for home care: the focus of conditions that relate to the patient’s care for the home care episode current plan of care, affect patient’ s  Most acute condition requiring the most intensive services and visit frequency response to treatment or prognosis  Mayyy or may not be the reason for the  All repor te d diagnoses mus t be most recent hospitalization supported by documentation in the  No surgical codes, no V,W,X,Y-codes or medica l recordifidbhiid or verified by physician conditions th a t h ave been reso lve d or eliminated by treatment (use Aftercare Z-  OASIS-C1/ICD-10 = M1021 and M1023 codes when appropriate)

Therapy Only: using V57.x M1023: Other ((y)Secondary) Diagnoses

 ICD-9: If therapy is the ONLY discipline  Include co-morbidities: diagnoses that ordered, must use Encounter for affect patient’s response to treatment and Therapy (V57.x ) in M1020 prognosis, even if the conditions are not the  V57.1 =encounter for P.T. focus of the current home health treatment  V57.89 =encounter for multippple therapies  Do not lis t con ditions tha t have reso lve d,  V57.x is never used as a secondary diagnosis (never in M1022) have no current impact on patient progress or outcome, and w ill no t impac t or be  ICD-10: no equivalent to V57 codes for M1021 or M1023! addressed in the plan of care M1023: Co‐morbidities to include Seqqguencing of Secondary Diagnoses

 Diabetes, HTN , COPD , CHF , CAD , PVD  The Symptom Control Rating  MS, Parkinsons, Alzheimers, dementia, should not be used to determine chihronic sys tiditemic diseases order of secondary diagnoses in

 Blindness M1023   Status amputation or ostomy The sequenc ing o f secon dary diagnoses should reflect the  History of neoplasm when care directed at current neoplasm seriousness o fhditidf each condition and support the disciplines and serviihPlfCices in the Plan of Care

M1025: Payment Diagnoses Common Errors Home Health

 A case mix diagnosis contributes points in the clinical  Always listing abnormality of gait , muscle weakness, domain for the Medicare Home Health PPS case-mix difficulty walking, etc. when therapy is involved in POC group assignment.  Listing symptoms instead of identifying and confirming a diagnosis, or separately listing symptoms that are an  It may be a primary diagnosis, secondary (other) integral part of a condition diagnosis, or a manifestation associated with a  Listing diagnoses that are not documented in the primary or secondary diagnosis medical record or confirmed by MD  Indicated in most coding manuals by a symbol ($),  Listing diagnoses in M1023 that are not pertinent to highlighting or color-coding the POC (GERD, without s/sx or interventions/goals)  Listing conditions that are resolved instead of using  OASIS-C1/ICD-10: M1025 not used for payment, Aftercare codes MAY be used for risk adjustment. Physician Confirmation One Clinician Rule Reminder

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 Verifyypyy with physician: you ma y not list a  The clinician that ppperforms the comprehensive diagnosis that is not either documented in assessment is the author of the documentation the medical record by the physician (H&P,  Responsibilities: F2F, progress note, problem list, referral  Complete all OASIS items based on assessment info) or documented as confirmed by the  Identify the primary and other pertinent diagnoses for physician POC  AiAssign the symp tom cont tltitdirol rating to diagnoses  Do not list diagnoses based on  If the coder makes changes in diagnoses or medications, treatments, or sequencing based on CMS rules or official coding patient/caregiver report without contacting guidance, CSCMS requires that the assessing clinician the physician to confirm – document this review and agree to the change(s) confirmation in the record  The origgginal and the changes should be kept b y the agency in the chart (EHR) per OASIS correction policy

Hierarchy of Importance

32 Overview 31 Conventions & Official Guidelines Conventions

General Guidelines

Chapter Specific Guidelines Placeholder ‘X’ Addition of 7th Character

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 Addition of dummy placeholder ‘X’ is  Used in certain chapppters to provide used in certain codes to: information about the characteristic of the encounter  Allow for future expansion th  Must always be used in the 7 position  T42.0x1D Poisoning by hydantoin derivatives,,,q accidental, subsequent  Can be a letter or a number  S02.110B  Fill out empty characters when a code  O65.0xx1 contains fewer than 6 characters and a th 7th character applies  If a code has an applicable 7 character, the code must be reported  W11.xxxD Fall from ladder, subsequent with an appropriate 7th character value  Upper or lower case ‘x’ in order to be valid

7th Character—Injuries 7th Character for Fractures

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 A, initial encounter, is used while the patient is receiving  A = Initial encounter for closed fracture active treatment for the injury. StAy AwAy from A  B = Initial encounter for open fracture

 D = Subsequent encounter for fracture with  D, subsequent encounter, is used for encounters after D is the the patient has received active treatment of the injury routine healing Default and is receiving routine care for the injury during the healing or recovery phase.  G = Subsequent encounter for fracture with D is Default delayed healing  K = Subsequent encounter for fracture with  S, sequelae, is used for complications or conditions that nonunion arise as a direct result of an injury (ICD-10-CM coding gg)uideline I.C.19.a).  P = Subsequent encounter for fracture with S is for Sometimes malunion

 S = Sequela Conventions—Dashes Inclusion Notes

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 ICD-9-CM 250 . xx Inclusion notes contain terms that are the condition for which that code number is to be  ICD-10-CM alpha index utilizes a used. The terms mayyyy be synonyms of the dhtthdfthddash at the end of the code num ber code title, or in the case of “other specified” to indicate the code is incomplete codes, the terms are a list of various conditions assigned to that code. The Fracture, pathologic inclusion terms are not necessarily exhaustive ankle M84.47- (ICD-10-CM coding guideline I.A.11).  A dash preceded by a decimal point ‘Includes’ appears at the category level and applies to the entire cate gor y.  (.-) indicates an incomplete code in the Inclusion notes also appear at subcategory and tabular list. J44.- code levels but ‘includes’ is not there K31.5

Excludes Notes Excludes Note Examples

39 Excludes one— 40 choose one. Excludes 1: J18. Ø Bronchopneumonia, unspecified • An excludes 1 note is a pure excludes note. It means organism “NOT CODED HERE”  • IditIndicates the co de exc lddluded s hou ld never be use d a t Excludes1: the same time as the code above the Excludes 1 hypostatic bronchopneumonia (J18.2) notes. • IdhtdititIs used when two conditions cannot occur tthtogether, lipid pneumonia (J69. 1) such as a congenital form versus an acquired form of the same condition  Excludes2: Excludes 2—Have both? Code both. Excludes 2 acute bronc hio litis (J21.-) • An excludes 2 note represents “not included here”. chronic bronchiolitis (J44.9) • Indicates the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time Laterality Laterality Examples 41 42

 M16.Ø Bilateral ppyrimary osteoarthritis of hip  For bilateral sites, the final character of  M16.11 Unilateral primary osteoarthritis, right the code indicates laterality hip  If no bil at eral cod e i s prov ide d an d the  M16. 12 Unilateral primary osteoarthritis , left hip condition is bilateral, assign separate  Z90.10 Acquired absence of unspecified breast codes for both the left and right side  Z90.11 Acquired absence of right breast  An unspppecified code is also provided  Z90.12 Acquired absence of left breast should the side not be identified in the  Z90.13 Acquired absence of bilateral breasts medical record But do we want to use it?

Sequela Sequela

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Residual effect (condition produced) after the  General Rule: Code what you see first and the acute phase of an illness or injury has ended sequela code (original injury with an S or No time limit on when a sequela code can be original illness, e.g. polio) is listed second used  G81.11 Spastic hemiplegia affecting right dominant side Exception: instances where the code for the  S06.5x9S Traumatic subdural hemorrhage with loss of sequela is followed by a manifestation code, or consciousness of unspecified duration, sequela the sequela code has been expanded (at the  Code the sequela code first when what you 4th, 5th or 6th character levels) to include the ‘see’ cannot go first (manifestation code) manifestation(s)  E64. 3 SlSequelaofiktf rickets  M49.82 Spondylopathy in diseases classified elsewhere The code for the acute phase of an illness or injury that led to the sequela is never used with  Sequel a of cer ebr ov ascul ar acci dent s a code for the late effect  I69.351 Other or Other Specified Unspecified

45 46 Codes titled “other” or “other “Unspecified” codes are used when the specified” are for use when the information in the medical record is information in the medical record insufficient to assiggpn a more specific provides detail for which a specific code (ICD-10-CM coding guideline I.A.9.b). code does not exist (ICD-10-CM coding guideline I.A.9.a). NOS—Not Otherwise Specified J12.9 Viral pneumonia, unspecified NEC—NtNot elhlsewhere class ifie d I25. 89 (contrast that with J12.89) Other forms of chronic ischemic heart th disease 4 digit 9 usuallyyy, but not always 4th digit 8 usually, but not always

Conventions—Relational Terms Conventions Same as ICD‐9

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 And—interpreted to mean ‘and/or’  Parentheses are used in both the Alphabetic Index and Tabular to enclose when it appears in a code title within nonessential modifiers thtblthe tabular litlist  Brackets are used in the Alphabetical Index to identify manifestation codes, and in the  With—interpreted to mean Tabular List to enclose synonyms, alternative wordings, abbreviations, and ‘associated with’ or ‘due to’ when it explanations appears in a code title, the alpha, or  Colons are used in the Tabular List after an incomplete term that needs one or more of an instructional note in the tabular. the modifiers following the colon to make it assignable to a given category Essential Modifiers The Usual Basics

49 50 The indented terms are always read in conjunction with the main term.  Must use the alpha and the tabular Diverticulosis K57.90  Read everything; it all means something With bleeding K57. 91 Large intestine K57.30  CffCode to the level of highest specificity With  Each unique ICD-10-CM diagnosis code Blee ding K57. 31 may be reported only once for an Small intestine K57.50 encounter With bleeding K57.51 Small intestine K57.10  All diagnoses must be confirmed in the With medical record or verified by physician Bleeding K57. 11 except… Large intestine K57.50 With bleeding K57.51

Three Diagnoses coded based on Complications clinician documentation 51 52

 Body Mass Index (BMI)  Code assignment is based on the provider’ s documentation of the relationship between the condition and the care and procedure.  Depth of non-pressure chronic ulcers  Important to note that not all conditions that occur during or following medical care or surgery are class ifie d as comp lica tions.

 Pressure ulcer stages  There must be a cause and effect relationship between the care provided and the condition and an indication in the documentation that it is a complication. If not clearly documented, query the provider for c lar ifica tion. Syndromes Sigg/ypns/Symptoms and Unspecified

 Follow the Alppghabetic Index guidance  Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. Whil e spec ific when coding syndromes. In the absence diagnosis codes should be reported when they are of Alphabetic Index guidance, assign supported by the available medical record codfddes for documen tdted man ifttififestations of documentation and clinical knowledge of the patient’s health condition, there are instances when the syndrome. signs/symptoms or unspecified codes are the best  Additional codes for manifestations that choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be are not an integral part of the disease coded to the level of certainty known for that ppyrocess may also be assi gned when the encounter. condition does not have a unique code.  If a definitive diagnosis has not been established by  the end of the encounter, it is appropriate to report No code for the syndrome? Code all the codes for sign(s) and/or symptom(s) in lieu of a sympt/ttoms/parts separat tlely. definitive diagnosis.

Unspecified

 When sufficient clinical information isn’t known or available about a particular health condition to 56 SiSequencing assign a more specific code, it is acceptable to repppppport the appropriate “unspecified” code (g,(e.g., a diagnosis of pneumonia has been determined, but not the specific type).  Unspecified codes should be reported when they are the codes that most accurately reflects what is known about the patient’s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medica lly unnecessary diagnos tic tes ting in or der to determine a more specific code. Seqqguencing Etiology/Manifestation

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 The Code First/Use Additional Code notes  Need to follow coding conventions provide sequencing order of the codes  Buddy codes—have to be sequenced together (underlying etiology code followed by the with etiology preceding the manifestation manifestat ion co de ).  Conventions • Alphabetical index two codes with second one In contrast: within [italicized brackets] called manifestation  ICD-10-CM coding guideline I.A.17 states a • Tabular List: Code title in italics (a code in italics in “code also” note instructs that two codes may the tabular may NEVER be coded without its cause preceding it). be required to fully describe a condition, but • Tabular List: Code first underlying condition at this note does not provide sequencing manifestation direction. • Tabular List: Use additional code to identify manifestation (not always) at etiology (c)2015, Selman-Holman & Associates, LLC

Teenage Buddy So what does ‘teenage buddy’ mean?

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  “Co de, if app lica ble, any associtdiated condition If cause is known, code with buddy first”, notes indicate that this code may be preceding… assigned as a principal diagnosis when the E11. 621 Type 2 DM with foot ulcer causal condition is unknown or not applicable. L97.421 non-PU of left heel and midfoot If a causal condition is known, then the code for limited to breakdown of skin that condition should be sequenced as the  If cause is unknown, sometimes principal or first -listed diagnosis. teenagers can be alone.  L97 L97.421 non-PU of left heel and midfoo t lim ite d to brea kdown o f skin (c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC Multiple coding for a single condition Multiple coding for a single condition

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 In addition to the etiology/manifestation convention  A “use additional code” note will normally be that requires two codes to fully describe a single found at the infectious disease code, indicating condition that affects multiple body systems, there a need for the organism code to be added as a are other single conditions that also require more secondary code. than one code.  Find acute cystitis – check instructional note!  “Use a dditiona l co de ” no tes are foun d in the Ta bu lar List at codes that are not part of an etiology/manifestation pair where a secondary code is useful to fully describe a condition.

Sequencing Seqqguencing

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 Multiple codes may be needed for  “Code first” notes are also under certain codes that are not specifically manifestation codes but sequela, complication codes and may be due to an underlying cause. When obttibstetric cod es to more f flldully descr ibe there is a “code first” note and an underlying a condition. condition i s present , th e und erl y ing con dition See the specific guidelines for these should be sequenced first. conditions for further instruction.  L89

Chapter 1 Guidelines  65 Localized infection—An infection that A, B Infectious/Parasitic Diseases is limited to a specific part of the body and has local symptoms.

A = Antibiotics  StiiSepticemia—StiiibtiSepticemia is bacteria B = Bacteria in the blood (bacteremia) that often occurs with severe in fec tions. (No separate code in ICD-10)

Definitions Sepsis or Severe Sepsis

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 Sepsis—a potentially life-threatening  ‘A’ codes for sepsis, then code for local infection; complication of an infection. Sepsis occurs sequencing depends on circumstances  A40 Streppptococcal sepsis when chemicals released into the  A41 Other sepsis bloodstream to fight the infection trigger  R65.2- Severe sepsis with or without septic shock iflinflamma tion through ou tthbdt the body. This if acute organ dysfunction is documented (SIRS) inflammation can trigger a cascade of  Septic shock refers to circulatory failure chthtdhanges that can damage mu ltilltiple organ associated with sepsis (cannot be primary) systems, causing them to fail. If sepsis  Add code(s) for associated organ failure or dysdysfunctionfunction progresses ttihkbldto septic shock, blood pressure drops dramatically, may lead to death. Sepsis Severe Sepsis

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Sepsis with localized infection Applies more  Minimum of two (three) codes (pneumonia, UTI) to hospitals than HH Underlying systemic infection ‘A’ code  If ad mitt ed with sepsi s Code from subcategory R65.2- Assign sepsis code first (A40-41) Additional code(s) for associated Then localized infection code organ dysfunction Severe? Add R65.2-  If admitted with localized and develops into sepsis Code localized infection first

More Sepsis Coding HIV and AIDS

71 72 HIV- Code only confirmed cases  PtPostproced ural sepsis—mustbt be documented by the physician—start with  HIV as principal diagnosis—B20 followed the specific postprocedural infection code by manifestations of HIV infection  T81.4-  If reason for admission not related to HIV,  UitA40Use appropriate A40-41 co de nex t. code HIV and related diagnoses as  Patient with postprocedural sepsis secondary related to infected surgical wound caused  Z21 is code for asymptomatic HIV (no by MRSA. symptoms, no AIDS, no treatment for any  T81.4xxD condition for HIV-related illness  A41.02 Infectious agents as the cause of A vs B Simplified diseases classified to other chapters

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 Certain infections are classified in chapters other than Chapter 1 and no organism is identified as part of the  A codes are generally coded first infection code. In these instances, use an additional code (sepsis) from Chapter 1 to identify the organism.  B codes 95, 96 and 97 are sequenced  Use an additional code from category B95, Streptococcus, Staphylococcus, and Enterococcus as the cause of after what is infected. (These diseases classified to other chapters, B96, Other bacterial categories are provided for use as agents as the cause of diseases classified to other chthapters, or B97VilB97, Viral agen ts as the cause o fdif diseases supplementary or additional codes to classified to other chapters. identify the infectious agent in  DO NOT USE A49 codes! diseases classified elsewhere. )

A vs B Simplified Practice

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 Strep sepsis with acute kidney failure  Strep sepsis Acut e cystiti s Sepsis or severe sepsis? Organism? A40.9 caused by E. coli OdftiOrgan dysfunction? Streptococcal N30.00  sepp,sis, B96.20 West Nile Virus unspecified Post op wound with Staph aureus  CMV hepatitis T81.4xxD B95.61 Infections resistant to antibiotics Answers

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 Strep sepsis with acute kidney failure  Many bacterial infections are resistant A40.9 Streptococcal sepsis, unspecified to current antibiotics. Identify all R65. 20 SIRS (severe)without septic infections documented as antibiotic shock resistant. Assign a code from category N17. 9 Acute kidney failure, unspecified Z16, Resistance to antimicrobial drugs,  West Nile Virus following the infection code only if the A92. 30 infection code does not identify drug resistance.  CMV hepatitis Look up resistance, by, name of drug B25.1

MRSA MRSA Examples

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 When a patient is diagnosed with an  Combo codes infection that is due to methicillin resistant Staph aureus and that infection has a Sepsis due to MRSA: A41.02 combination code that includes the causal Colonization by MRSA Z22.322 organism, assign the appropriate combo Colonization = MRSA screen or nasal swab code for the condition. positive but no active infection (can have active infection at same time)  If a combo code is appropriate, do not use an additional code B95.62.  Not all are combo codes  Do not assign a code from Z16.11 to UTI caused byy, MRSA: N39.0, B95.62 MRSA. Resistance More Practice

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Patient admitted with infected surgical  Viral meningitis wound cultured Staph aureus resistant to penic illins and cephlhalospor ins.  Septicemia caused by streptococcus  T81.4xxD infected surgical wound ppeuoneumoni ae  B95.62 MRSA

 Z16. 19 Resistance to specified beta  PidtMRSAPneumonia due to MRSA lactam antibiotics

Answers Information needed

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 Viral meningitis  Intake: A87.9  Infection site, any relation to procedure  Any sepsis or severe sepsis (identify acute  Septicemia caused by streptococcus organ failure) pneumoniae  Iden tify i nf ecti ous organi sm, any resi s tance A40.3 Sepsis due to Strep pneumoniae  Clinician’s assessment:  Pneumonia due to MRSA  Any current antibiotic treatment  J15.212  Fever, response to antibiotics  S/sx residual from any acute organ failure What is a Neoplasm?

86 Chapter 2 Guidelines C and D  Chappgter 2 contains codes for most benign and all 85 malignant neoplasms. Neoplasms and Blood Disorders  Neoplasm is an abnormal mass of tissue as a result of neoplasia (the abnormal proliferation of cells). The growth of cells exceeds and is uncoordinated with that of the normal tissues around it. The growth persists in the same C = Cancer excessive manner even after cessation of the D = Darn, more cancer stimuli. It usually causes a lump or tumor. and Disorders of blood Neoplasms may be benign, pre-malignant or malignant.  In modern medicine, the term ''tumor'' is synonymous with a neoplasm that has formed a lump. (c)2015, Selman-Holman & Associates, LLC

Identify Neoplasm Behavior Neoplasm Table

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 Beniggpn neoplasms do not transform into  Located right after the Alphabetical Index cancer  The Neoplasm Table should be referenced  Potentially malignant neoplasms (pre- cancer)i) inc lu de carc inoma in s itu first (unless histological term documented)  Malignant neoplasms are commonly called  Classifies by site (topography) with broad cancer groupings for behavior (malignant, benign,  Uncertain—neoplasms where histologic etc) confirmation whether maligggnant or benign  Laterality is important!! cannot be made  Ex: Lung CA (primary site, right lung)  Unspecified—growth NOS, neoplasm NOS, new growth NOS, tumor NOS C34. 91  Mass—not a neoplasm Remission Guidelines

 Leukemia and Multiple myeloma and malignant plasma cell neop lasms, have co des in dicat ing w het her or not t he  If treatment is directed at the malignancy, leukemia has achieved remission. Z85.6, Personal list the malignancy as principal diagnosis history of leukemia, and Z85.79, Personal history of other malignant neoplasms of lymphoid, hematopoietic  Exceppgtion to this guideline: if a patient and related tissues. admission/encounter is solely for the  If the documentation is unclear, as to whether the administration of chemotherapy, lkleukem ihia has ac hidhieved rem iiission, the prov idhldbider should be immunotherapy or radiation therapy, assign queried. the appropriate Z51.-- code as the first-  C90-95, for example listed or principal diagnosis, and the  5th digit 0-not having achieved remission, failed remission diagnosis or problem for which the service  5th digit 1-in remission  5th digit 2-in relapse is being performed as a secondary diagnos is (c)2015, Selman-Holman & Associates, LLC

Seqqguencing Maliggynancy vs History

91 92

 Focus of care on treatment of primary  When a ppygyrimary malignancy has been malignancy: list primary site first, excised but further treatment, such as an followed byyy any metastatic sites additional surgery for the malignancy, radia tion therapy or c hemo therapy is  Focus of care directed toward the directed to that site, the primary metastatic ((y)()secondary) site(s) only: the malignancy code should be used until metastatic site(s) is designated as the treatment is completed. principal/first-listed diagnosis. The  Default on the side of coding the cancer primary malignancy is coded as an unless you have documentation that the additional code cancer is eradicated. Primary malignancy previously excised and eradicated Example

93 94  When a primary malignancy has been previously excidised or era ditdfdicated from ititdthiits site and there is no  Small cell CA of right lower lobe of further treatment directed to that site and there is lung with mets to intrathoracic lymph no evidence of any existing primary malignancy, a code fffrom category Z85, Personal history of nodes, brain malignant neoplasm, should be used to indicate C34.31 Malignant neoplasm of lower the former site of the maliggynancy. lobe, right bronchus or lung  Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant C77.1 Secondary malignant neoplasm neoplasm to that site. The secondary site may be of intrathoracic lymph nodes the principal or first-listed with the Z85 code used C79.31 Secondary malignant neoplasm as a secondary code. of brain

Morppghologic Examples to Code Answers

95 96

 Benigg(n carcinoid of the rectum (Tumor,  Benign carcinoid of the rectum carcinoid)  D3A.026  Subacute monocytic leukemia in  Subacute monocytic leukemia in remission remission  C93.91  25 year old received treatment of  25 year old received treatment of malignant melanoma of right breast and malignan t melanoma ofkitihtf skin at right left arm breast and left arm  C43.52  C43. 62

97 98

 Astroglioma of brain  Astroglioma of brain C71.9

 Lymphosarcoma of head, face, and  Lymphosarcoma of head, face, and neck ((g)diffuse large cell) neck ((g)diffuse large cell) C83.31

 Merkel cell carcinoma of left eyelid  Merkel cell carcinoma of left eyelid C4A.12

Diagnostic Statements to Code Answers

99 100

 Squamous cell carcinoma of right ear  Squamous cell carcinoma of right ear C44.222

 Cancer of the labia majorum and  Cancer of the labia majorum and minorus minorus C51.8 Malignant neoplasm of overlapping sites of vulva

101 102 Mr. Lakeford is admitted with Grade 4 Mr. Lakeford: colon cancer excised and eradicated  C78.7 Secondary malignant fdidlfrom ascending and transverse colon neoplasm of liver with metastasis to liver. He has a  Z85. 038 P er son al hi stor y of oth er colostomy, can manage ostomy care, no malignant neoplasm of large intestine further treatment to colon. Currently has  Z93. 3 Colostomy status chemo treatment directed to liver mets.

Primary malignant neoplasms Disseminated malignant neoplasm, overlapping site boundaries unspecified 103 104

 A primary malignant neoplasm that  Code C80. 0, Disseminated malignant overlaps two or more contiguous (next to neoplasm, unspecified, is for use only in each other) sites should be classified to the cases where the patient has advanced subcategory/code .8 ('overlapping lesion') metastatic disease and no known unless the combination is specifically primary or secondary sites are specified. indexed elsewhere (colon w/rectum-C19).  Neoplasm table under “disseminated”  For multiple neoplasms of the same site  It should not be used in place of that are not contiguous such as tumors in different quadrants of the same breast, assigning codes for the primary site and codes for each site should be assigned. all known secondary sites. Symptoms, Signs, and Maliggynancy Site Unknown Ill‐Defined Conditions 105 106

 Code C80. 1, Malignant (primary)  Symptoms, signs, and ill-defined conditions neoplasm, unspecified, should only be listed in Chapter 18 characteristic of, or used when no determination can be made associated with, an existing primary or as to the primary site of a malignancy. secondary site malignancy cannot be used  Cancer NOS, Malignancy NOS to replace the malignancy as principal or first-listed diagnosis, regardless of the  Neoplasm Table under “unknown” site number of admissions or encounters for  Cancer of left kidney but cell type indicates treatment and care of the neoplasm. the cancer originated elsewhere (unknown  Example: weakness primary): C79.02, C80.1

Neoplasm Related Pain Pathologic fracture due to a neoplasm

107 108

 Code G89. 3 is assigned to pain  When an encounter is for a pathological fracture documented as being related, due to a neoplasm, and the focus of treatment is associated or due to cancer, primary the fracture, a code from subcategory M84.5, Pathological fracture in neoplastic disease, should or secondary malignancy, or tumor. be sequenced first, followed by the code for the This code is assigned regardless of neoplasm.

whether:  If the focus of treatment is the neoplasm with an  Tumor is malignant or benign associated pathological fracture, the neoplasm code should be sequenced first, followed by a  Pain is acute or chronic code from M84. 5 for the pathological fracture. Neoplasm Example Neoplasm Answer

109 110

M84. 551D Pathological fracture in  MWMr. West th has a hi hitstory o f prost ttate cancer with mets to the right femur, neoplastic disease, right femur, routine now hthlilhas pathological fxofthtff that femur healing with routine healing. He is admitted to C79.51 Secondary malignant neoplasm, hfPTffiihome care for PT for transfer training bone and strengthening, and SN for pain G89.3 Neoplasm related pain management and assessment. He Z85.46 History of prostate ca continues on Morphine for pain due to Z79.891 Long term (current) use of opiate the bone mets. analgesic

Complications Associated with a Anemia due to Cancer Neoplasm 111 112

 When an encounter is for  Patient admitted for management of management of a complication anemia due to cancer. Anemia is the associtdiated w ith a neop lasm, suc h as fffocus of care.

dehydration, and the treatment is only  Guideline: With anemia due to for the complication, the complication cancer, the cancer is coded first even is coded first,,y followed by the if the anemia is the focus of care appropriate code(s) for the neoplasm. Malignant neoplasm is coded first, then: Exception: Anemia D63. 0 Anemia in neoplastic disease Complications Associated with a Anemia due to Chemo Neoplasm Surgery

 Patient has anemia due to chemotherapy. Is  When an encounter is for treatment of HH treatment for anemia? Or cancer? a complication resulting from a surgical Guideline: When admission is for management of an anemia associated with an adverse effect procedfdfthtttdure performed for the treatment of the administration of chemotherapy or of the neoplasm: immunotherapy and the only treatment is for the anemia, the anemia code is sequenced first Designate the complication as the followed byyppp the appropriate codes for the principal/first-listed diagnosis. neoplasm and the adverse effect… Then code the neoplasm, if not resolved  D64.81 Anemia due to antineoplastic therapy Historyyp of neoplasm should be coded if  T45. 1x 5D Adverse e ffec t o f antineop las tics documentation states CA resolved  Cancer, by site

Code these… Answers

115 116

 Right female breast cancer with mets to R lung  Right female breast cancer with mets to R lung C50. 911  Right female breast cancer with mets to R lung, treatment directed at lung C78.01  Right female breast cancer with mets  Patient with emphysema has history of lung ca and pneumonectomy of left lung to R lung, treatment directed at lung C78. 01  Subacute monocytic leukemia in remission C50.911

117 118

 Patient with emphysema has history  Z85.- for personal history of neoplasm of lung ca and pneumonectomy of left  Also history, personal, benign neoplasm and lung History, personal, in situ neoplasm  Z48.3 Aftercare, following surgery, neoplasm J43.9 Emphysema  Is the neoplasm resolved after the surgery? Z85. 118 History of lung ca  If resolved, do not code the neoplasm as current Z90.2 Acquired absence of lung diagnosis.  If nooesoedout resolved or unkn own at th at tim e,coueoe, continue to  SbSubacu te monocytic lkleukem iiia in code the neoplasm. remission  Is aftercare the focus or the neoplasm the focus? C93.91  Surgical removal – Absence (partial, complete) (c)2015, Selman-Holman & Associates, LLC

Prophylactic Organ Removal Proppyhylactic Organ Removal

  For encounters specifically for prophylactic If the ppgyatient has a malignancy of one site removal of an organ (such as prophylactic and is having prophylactic removal at another site to prevent either a new removal of breasts due to a genetic prilitttidiimary malignancy or metastatic disease, susceptibility to cancer or a family history a code for the malignancy should also be of cancer), the p rinci pal or first-listed code assigned in addition to a code from should be: subcategory Z40.0-, Encounter for  Z40.0- Encounter for pppyrophylactic sur gygery prophylactic surgery for risk factors related tlitto malignant neopl asms.  Followed by the appropriate codes to identify the associated risk factor (such as genetic  A Z40.0- code should not be assigned if susceptibility or f)family history). the patient is having organ removal for treatment of a malignancy Malignant Neoplasm of Transplanted Example Organ 122

The ppyatient was admitted to home care after mastectomy  A malignant neoplasm of a transplanted of right breast for cancer. The left breast was removed prophylactically because of genetic susceptibility. She will organ should be coded as a transplant continue chemotherapy. Aftercare is the focus of care with complication. dressing changes.  Assign first the appropriate code from  Z48.3 Aftercare following surgery for neoplasm category T86.-, Complications of transplanted  C50. 911 Malignant neoplasm right female breast organs and tissue  Z40.01 Encounter for prophylactic removal of breast  Z15.01 Susceptibility to malignant neoplasm of breast  Followed by code C80.2, Malignant neoplasm  Z48.01 Surgical dressing changes associtdiated with itht transpl ant tded organ.  Z90.13 Acquired absence of bilateral breast and nipple  Use an additional code for the specific malignancy site

Example Practice

123 124

 CA in transplanted pancreas  Mrs. Tolson is admitted to home care T86.891 Other transplant tissue failure after hospitalization for heart failure. C80.2 Malignant neoplasm assoc. She h as a hi s tory o f ri g ht breas t w/transplanted organ cancer and is taking Tamoxifen. She C25.9 Malignant neoplasm of pancreas, is on hold for reconstructive surgery unspecified until her heart failure syypmptoms have resolved. Answer Same patient…

125 126

Mrs. Tolson:  Mrs. Tolson has now been resumed  I50.9 Heart failure, unspecified for aftercare following breast  Z79. 810 Long term (curren t) use o f reconstructi on surgery. Sh e i s s till SERMs taking Tamoxifen and her heart failure  Z85.3 Personal history of malignant is stable at this time. SN will provide neoplasm of breast dressinggg changes and monitor  Z90.11 Acquired absence of right healing status. breast and nipple

Answer Anemia Practice

127 128

Mrs. Tolson for ROC:  Mrs. White is admitted to home care  Z42.1 Encounter for breast after a right TKR for OA. She had reconstruction following mastectomy increased bleedinggggy, during surgery,  Z79.810 Long term use of SERMs resulting in acute post-op anemia. She  Z85.3 Personal historyyg of malignant still has OA in the left knee and will have neoplasm of breast surgery for it after her H&H returns to  I50.9 Heart failure, unspecified normal. SN for wound care,  Z48.01 Encounter for surgical dressing assessment, weekl y CBC ; PT for gait changes training and strengthening. Answer Information needed

129 130

Mrs. White:  Intake:  Z47.1 Aftercare following joint  Neoplasm site(s) including laterality replacement  Behavior of neoplasm  D62 Acute post-hemorrhagic anemia  Primary, metastatic  M17.12 Unilateral primary OA, left knee  If post-op, was neoplasm eradicated? Any further treatment or follow up?  Z96.651 Presence of right artificial knee joint  Remission? Failed remission? Relapse?  Clinician assessment:  Z48.01 Encounter for surgical dressing changes  Focus of care  Pain associated with neoplasm

Guidelines

132 Chapter 4 Guidelines E ‐‐Endocrine,  The diabetes mellitus codes are combination 131 codes that include: Metabolic and Nutritional  the type of diabetes mellitus,  the body system affected, and  the complications affecting that body system.  Use as many codes within a particular category E = Endocrine as are necessary to d escrib e a ll o f the complications of the disease  Sequence based on the reason for a particular encounter. Assign as many codes from categories E08 –E13 as needed to identify all of the associated conditions that the patient has.

133 134

 If the type of diabetes mellitus is not documented  E08 DM due to underlyyging condition in the medical record the default is E11.-, Type 2.  Code first underlying condition  If the documentation in a medical record does not  Use additional code to identify insulin use indicate the type of diabetes but does indicate that the patient uses insulin, assign code E11, Type 2.  E09 Drug or c hem ica l in duce d DM  Notice difference between adverse effect and  Code Z79.4, Long-term (current) use of insulin, shldlbhould also be ass igne dtiditthtthd to indicate that the poisoning. patient uses insulin. Code Z79.4 should not be  Use additional code to identify insulin use Z79.4 assigned if the patient has Type 1, or if insulin is  E10 Type 1 DM given temporarily to bring a Type 2 patient’s blood  E11 Type 2 DM sugar under control during an encounter.  Use additional code to identify insulin use  E13 Other speci fied DM (c)2015, Selman-Holman & Associates, LLC  Use additional code to identify insulin use

E09 Drug or chemical induced DM E08 DM due to underlyyging condition Adverse Effect 135 136

 Anyypp condition that impacts the pancreas  Some medications, such as nicotinic acid and function certain types of diuretics, anti-seizure drugs,  Cystic fibrosis- Cystic fibrosis produces psychiatric drugs, and drugs to treat HIV, can abnormally thick mucus , which blocks the impppair beta cells or disrupt insulin action. pancreas. Pentamidine, a drug prescribed to treat a type of pneumonia, can increase the risk of pancreatitis,  Pancreatic cancer, Pancreatitis, and trauma can beta cell damage, and diabetes. Also, all harm the pancrea tic be ta ce lls or impa ir glucocorticoids—steroid hormones that are insulin production, thus causing diabetes. chemically similar to naturally produced  Malnutrition cortisol—may impair insulin action.  Cushing’s syndrome--induces insulin resistance. Glucocorticoids are used to treat inflammatory Cushing’s syndrome is marked by excessive illnesses such as rheumatoid arthritis, asthma, production of cortisol—sometimes called the lupus, and ulcerative colitis. “stress hormone.” (c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC E09 Drug or chemical induced DM Examples Poisoning 137 138

 Many chemical toxins can damage or destroy beta cells  The patient has steroid induced diabetes from iilblfhblikddibin animals, but only a few have been linked to diabetes taking corticosteroids for an upper respiratory in humans. For example, dioxin—a contaminant of the infection last year. herbicide Agent Orange, used during the Vietnam War— may be linked to the development of type 2 diabetes. In  E09. 9 Drug or chemical induced diabetes 2000, based on a report from the Institute of Medicine,  T38.0x5S Adverse effect of glucocorticoids, sequela the U.S. Department of Veterans Affairs (VA) added diabetes to the list of conditions for which Vietnam veterans are eligible for disability compensation. Also, a  The pati ent h as di a be tes from exposure t o chemical in a rat poison no longer in use has been Agent Orange during the Vietnam conflict. shown to cause diabetes if ingested. Some studies  T53.7x1 S T oxi c eff ect of oth er h al ogen deriv ativ es suggest a high intake of nitrogen-containing chemicals of aromatic hydrocarbons, accidental, sequela such as nitrates and nitrites might increase the risk of  E09.9 Drug or chemical induced diabetes diabetes. Arsenic has also been studied for possible links to diabetes. (c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC

E10 Type 1 DM E11 Type II DM

139 140

 Caused by a combination of factors, including insulin  Type 1 diabetes is caused by a lack residiiihihhbd’lfistance, a condition in which the body’s muscle, fat, of insulin due to the destruction of and liver cells do not use insulin effectively. Type 2 diabetes develops when the body can no longer insulin-producing beta cells in the produce enough insulin to compensate for the pancreas. In type 1 diabetes—an impaired ability to use insulin.  The role of genes is suggested by the high rate of autoimmune disease—the body’ s type 2 di ab e tes i n famili es an d iden tica l tw ins an d immune system attacks and destroys wide variations in diabetes prevalence by ethnicity. Type 2 diabetes occurs more frequently in African the beta cells. Americans, Alaska Natives, American Indians, Hispanics/Latinos, and some Asian Americans, Native  Genetic susceptibility Hawaiians, and Pacific Islander Americans than it does in non-Hispanic whites.

141 142

 Genetic defects of beta cell function or  Diabetes with hyperosmolarity insulin action Does not occur with Type 1 DM  Postpancreatectomy/post procedural DM No choice in Type 1 diabetics (no E10.0-)

 Secondary DM, NEC  Diabetes with ketoacidosis Specific guideline postpancreatectomy DM Does not occur with Type 2 diabetics  E89.1 Postprocedural hypoinsulinemia No choice in Type 2 diabetics (no E11. 1-)

 E13 code(s)

Diabetes 4th Characters Diabetes 4th characters 7, 8, 9

143 144

th 2 as 4 ccharacterharacter th • R- Renal/Kidney complications  7—no 4 cht7haracter 7 3 as 4th character  8—unsppp(ecified complications (do • O-Ophthalmic NOT use) 4 as 4th character • N-Neurological  9—without complications (equivalent

5 as 4th character to 250.0x) • C-Circulatory

6 as 4th character • O-Other—arthropathy, skin complications , oral complications , hypoglycemia, hyperglycemia and other (c)2015, Selman-Holman & Associates, LLC Diabetic Manifestation Notables Diabetic Manifestation Notables

 E11.22  E11. 6--  Use additional code note: need stage of CKD Use additional code for ulceration  E11.3- Macular edema includes the type of retinopathy  E11.64 Hypoglycemia  E11.4- includes neuropathy unspecified,  E11.65 Hyperglycemia mononeuropaththy, polthlyneuropathy, etc  E11.69 Other manifestations of  E11.43 Use additional code note for gastroparesis diabetes Use additional code to identify the  E11.5 DM with gangrene includes the peripheral angiopathy specific manifestation  E11.610 Includes Charcot’s

Examples to Code Answers

147 148

 Diabetic macular edema  Diabetic macular edema  E11.311  Diabetic neuralgia  Diabetic neuralgia   Diabetic gangrene E11.42  Diabetic gangrene  Diabetic foot ulcer on toes (rt foot)  E11.52  Diabetic foot ulcer on toes (rt foot)  Diabetic with high blood sugars  E11.621  L97.519  Diabetic chronic osteomyygelitis of right foot

149 150

 Diabetic with high blood sugars  Mr. Hudson is admitted with Type 2 E11.65 DM with angiopathy, and a diabetic ulcer on le ft h ee l tha t is due to the  Diabetic osteomyelitis (chronic) of the right midfoot) diabetic angiopathy. He has a history of right foot amputation due to a prior E11.69 diabetic ulcer. SN for wound care to M86. 671 Chronic osteomyelitis, right ankle and foot the diabetic arterial ulcer. SOC notes ulcer has fat layer visible in wound.

Answer Other types of Diabetes

151 152

Mr. Hudson:  Cystic fibrosis with MRSA pneumonia  E11.51 Type 2 DM with diabetic and diabetes as a result of the CF peripheral angiopathy (no gangrene) E84. 0 CF w ith pu lmonary man ifes ta tion  L97.422 Non-pressure ulcer left heel and J15.212 MRSA pneumonia midfoot, fat layer exposed E84.8 CF with other manifestation  Z48.00 Encounter for non-surgical E08.9 Diabetes due to underlying dressing changes condition  Z89. 431 Acquired absence of right foot E15‐E16 Other disorders of glucose regulation and Special guideline pancreatic internal secretion 153 154

 Pancreatic cancer and  Drug induced hypoglycemia E16. 0

postpancreatecromy diabetes  Hypoglycemia E16.2 C25. 9 pancrea tic cancer Consider that this hypoglycemia is not E89.1 Postprocedural hypoinsulinemia in a diabetic. (See E11.649) E13.9 Other specified diabetes Z90.41 Absence of pancreas Z79.4 Long term use of insulin

Overweight, obesity and other Information needed hyperalimentation 155 156

 Overweight with BMI of 27  Intake:  Type of diabetes, any underlying cause E66.3  Any complications or manifestation Z68.27 BMI 27.0-27.9, adult associated with or due to diabetes, stage of CKD (1-5, not unspecified stage)  The ppyhysician must document  Specific diagnosis of obesity or morbid obesity, overweight before it can be obesity coded. BMI can be coded based on  Clinician assessment: clinician’s documentation.  Blood sugar  Insulin use  Height and weight FØ1‐FØ9‐Mental Disorders due to known physiological reasons 158 Chapter 5 Guidelines 157  Disorders that have an etiology in F –Mental and Behavioral cerebral dysfunction (cerebral disease or in jury )

 Can be primaryyy or secondary F = Freud If there is a ‘code first’ note then these conditions must be coded secondary.

Vascular Dementia Vascular dementia F01.5‐

159 160 Sudden post-stroke changes in  Being rejected as primary diagnosis in HH & hospice  Occurs as a result of infarction of the brain due to thinking and perception may include: vascular disease, including hypertensive vascular disease  Confusion  Autoregulation may be lost in individuals with severe hypertensive arteriosclerotic vascular disease, abrupt  Disorientation lowering of blood pressure may lead to infarct.  Trouble speaking or understanding Coding conventions:  Code first the underlying physiological condition or speech sequelae of cerebrovascular disease. (ICD-10)  Vision loss  Use additional code to identify cerebral atherosclerosis (ICD-9 instruction no longer at the code for the  Changes in a “ladder” fashion underlyyging cause )

(c)2015, Selman-Holman & Associates, LLC Vascular dementia and Example behavioral disorders 161 162  F01.50 Without behavioral disturbances Dementia post CVA, with HTN  F01.51 With behavioral disturbances  Aggressive behavior  I69.31 Cognitive deficits following  Combative behavior cerebral infarction  Violent behavior  …and wandering (use additional code)  F01. 50 v ascul ar dem en ti a  Besides those listed:  I10 Hypertension  Vascular dementia with delirium  Vascular dementia with depression  Vascular dementia with delusions

FØ3.9‐ Unspecified Dementia Unspecified Dementia FØ3.9‐

163 164

 Includes:  FØ3.9Ø - without behavioral disturbances Presenile dementia, NOS  Dementia NOS Presenile psychosis, NOS Primary degenerative dementia, NOS  FØ3.91- with behavioral disturbances Senile dementia, NOS  Unspecified dementia with aggressive Senile dementia depressed or paranoid behavior type  Unspecified dementia with combative behavior Senile psychosis, NOS  Unspecified dementia with violent behavior FØ2‐Dementia in other diseases Senile Dementia classified Elsewhere 165 166 Senile dementia is actually a group of  Excludes 1- dementia with Parkinsonism several different diseases. (G31.83) is a problem.  Code first the underlyygpying physiolo gical  Alzheimer's disease, condition  Vascul ar dem en ti a,  FØ2.8Ø- Without behavioral disturbances  FØ2.81- with behavioral disturbances  Parkinson's disease, and

 Lewy bdbody disease.  This code is a manifestation code and REQUIRES an etiology code

Personality and behavioral Alzheimers G30.‐/F02.‐ disorders due to… 167 168

 Patient admitted for worsening  Code first the underlying dementia related to early onset physiological condition

Alz he imer 's, inc lu ding wandidering.  F07.0 Personality change due to  M1Ø21: G3Ø.Ø Alzheimer's disease early onset known phyygsiological condition  M1Ø23: FØ2.81 Dementia in diseases classified  F07.81 Post concussional syndrome elsewhere with behavioral disturbances

 M1Ø23: Z91.83 Wandering in diseases classified elsewhere

 The patient has explosive personality  When the provider documentation refers to use, disorder due to a TBI 3 years ago. Upon abuse and dependence of the same substance (e.g. alcohol, opioid, cannabis, etc.), only one code further qqg,pyyuestioning, the physician says should be assigned to identify the pattern of use she doesn’t have the specific information based on the following hierarchy: regarding the head injury.  If both use and abuse are documented, assign only the code for abuse  S06.9x0S Sequela, unspecified  If both abuse and dependence are documented, intracranial injury assign only the code for dependence  If use, abuse and dependence are all documented,  F07.0 Personality change due to known assign only the code for dependence ppyhysiolo gical condition  If both use and dependence are documented, assign only the code for dependence.  F60.3 Borderline personality disorder (c)2015, Selman-Holman & Associates, LLC

Practice Answers

171 172

 Chronic alcohol abuse with  Chronic alcohol abuse w/dependence dependence F1Ø.2Ø- Alcohol dependence, uncomplicated  Bipolar disorder, moderate manic  Bipolar disorder, moderate manic episode episode  Mild recurrent major depressive F31.12 disorder  Mild recurren t ma jor depress ive disorder F33.0 Practice Answer

173 174

 Mrs. Allen is admitted with vascular  Mrs. Allen: dementia, query to physician identifies she had a recent CVA that has caused  I69.31 Cognitive deficits following her cognitive changes and resulting cerebral infarction dementia. SN assessment notes patient  F01. 51 V ascul ar dem en ti a wi th tried to bite nurse when attempting to behavioral disturbance check BP, family reports she bites at them wh en s he doesn ’t wan t to participate in care.

Information needed

175 Chapter 6 Guidelines  Cannot accept “dementia” as a 176 terminal diagnosis for hospice G –Nervous System

 Cannot accept senile dementia or vascular dementia as a primary diagnosis for home health or hospice G = Ganglion

 ASK: What caused the dementia? Alzheimer’s early or late onset PkiParkinson ’s vs PkiParkinson ism G00‐G09: Inflammatory Diseases of the General Guidelines Nervous System 177 178

 Hemiplegia/hemiparesis/Monoplegia/  Includes Meningitis, Encephalitis, Monoparesis Abscesses of the CNS, Sequelae of CNS inflammatory disease When r ig ht or le ft is spec ifie d bu t  Bacterial Meningitis (G00.0-G00.9) dominant side is not specified includes causative orgg,anism, if known Default to dominant for the  Sequelae of inflammatory diseases of ambidextrous patient central nervous system (G09) includes Left side defaults to non-dominant conditions whose cause is classifiable to Right side defaults to dominant G00-G08

G10‐G14: Systemic Atrophies primarily Example affecting the Nervous System 179 180 Mrs. Edwards is admitted to home  Includes Huntingg,pton’s, Spinal Muscular Atrophy, Other Motor Neuron diseases, health to treat an extradural intraspinal Post Polio Syndrome abscess due to MRSA. SN ordered for  PtPost-PliPolio syn drome exc ldludes seque lae o f 6 weeks of bid IV antibiotics via PICC. poliomyelitis (B91) G06. 1 Intraspinal Abscess  Huntington’ s disease includes chorea & B95.62 MRSA dementia  Hereditaryy, ataxia include cerebellar ataxia, Z45. 2 Encounter for adjustment and which are further specified as early vs. late management of vascular access device onset or with defective DNA repair Z79. 2 Long Term (current) use of

antibiotics(c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC G20‐26: Extrapyramidal Movement Example disorders 181 182 Mr. Jackson is admitted for progressive  Includes Parkinson’s,,, Parkinsonism, Huntington’s Chorea. He’s had several falls Basal Ganglia disorders, and other movement disorders recently while wandering and his dementia is worsening, with behavior changes  Dementia with Parkinson’s Disease and Dementia with Parkinsonism remain G10 Huntington’ s Disease different/separate F02.81 Dementia with behaviors  Parkinson’s Disease excludes dementia Z91. 83 Wandering with parkinsonism  G31.83 Dementia with Parkinsonism F02.80 R29.6 Repeated Falls  G20 Parkinson’s Disease, F02.80 Dementia without behavioral disturbance

Drug induced Neuro Conditions G35‐37: Demyygelinating diseases of the CNS

183 G40‐47: Episodic and paroxysmal A 56 yypear old male patient is referred to home disorders health for speech and occupational therapy to treat tardive dyskinesia that has begun to significantly impppair his speech and self care abilities. The patient  G35-37 includes multiple sclerosis and has a long-standing diagnosis of schizophrenia with other demyelinating disorders use of phenothiazine class antipsychotic medications, which have resulted in the tardive  G40-47 includes epileptic disorders, dyskinesia. headaches, and sleep disorders  G24.01 Tardive Dyskinesia  T43.3X5D Adverse Effect of phenothiazine  TIAiTIA incl ud e d un der G45 an did is no tft foun d  F20.9 Schizophrenia in the circulatory (I) chapter

185 186 Mr. Parker is referred to home health for Mr. Jones has new onset seizures and is admitted to home health for instruction, increased BLE weakness due to MS. He is assessment and monitoring of no longer able to transfer to toilet or bath anticonvu lsan ts. H&P st at es h e h as without assistance. SN will provide cath idiopathic general epilepsy. His medication changes for neurogenic bladder. is still being monitored and adjusted because he continues to have seizures.  G35- Multiple Sclerosis  G40.319- Generalized idiopathic  N31.9 Neurogenic Bladder epilepsy and epileptic syndromes, intractable, without status epilepticus  Z46.6 Encounter for fittinggj/adjustment of urinary device What d oes i n tract abl e mean ? (c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC

G50‐50.9 –Nerve, Nerve Root, and Neuralgia vs. Neuroppyathy Nerve Plexus Disorders 187

 Cranial nerve disorders are included  Neuralgia= Nerve Pain here  Also includes phantom pain, mononeuropathies, palsy, and neuralgia  Neuropathy = Nerve damage  Facial nerve palsies and disorders must be distinguished from disorders of the These are not the same or cranial nerve itinterch angea bltble terms !  One more reason that diagnoses and documentation MUST be specific!

 Includes neuropathies, polyneuropathies Johnny Walker is referred for home health due to alcoholic polyneuropathy. He is 67 years old and and other disorders. was drinking daily until last week. His physician  Causes of neuropathic conditions must lists “alcohol dependence and use”. He has also received a concurrent diagnosis of alcoholic be determined cirrhosis and withdrawal.  Hereditary G62.1 Alcoholic Polyneuropathy  Idiopathic K70.30 Alcoholic cirrhosis of liver- no ascites  Drug induced F10.230 Alcohol dependence with withdrawal  Inflammatory F10.288 Alcohol dependence with other  Do not code these when caused by alcohol-induced disorder???

Pain Codes (Category G89) More Pain Coding Specifics General Guidelines 191 192

 Provide more specific info on pain in a  Pain codes (G89) may be used as primary patient when the POC is addressing pain when a focus of care management  Must be specified as Acute, Chronic, Post-  Pain codes (G89) may be used in Thoracotomy, Post-Procedural, or Neoplasm- conjunction with site specific codes when related pain code provides greater detail  DO NOT assign when an underlying cause of the pp(pain is known (i.e. a more specific,  Sequencing is dependent on focus of care definitive dx like osteoarthritis) If pain control is focus of care then G89  Assign when nature of pain is not part of the code is assigned first dfiitidefinitive diagnos is, i.e. acu te, c hron ic. (c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC Example Example

193 194

Mr. Smith is admitted to the agency for  Mrs. Smith fell off the porch and hurt therapy (PT & OT) to treat a decline in her neck. PT and OT will treat her mobility related to primary osteoarthritis of decreased mobility and SN will the bilateral knees. He has pain daily that manage pain. ranges from 2-7 in the joints. M54. 2 Pain in the neck  Code only the osteoarthritis M17.0 G89.11 Acute pain due to trauma  The pai n i s rel at ed t o th e ost eoarth riti s  The pain code adds information condition—will not code the pain separately regarding the nature and cause of the pain. (c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC

More Pain Coding Specifics More Pain Coding Specifics

195 196

 Codinggp Postoperative Pain  Coding Chronic Pain (subcategory  Default is acute when not specified  Used alone when NOT associated with a post- G89.2) operative complication; may use with Time frame not tdfidbt defined, but ph ys iiician complication code if related to complication  i.e.- Post-operative pain alone is not a complication must specify as “Chronic”  Coding Neoplasm-Related Pain Chronic Pain Syndrome (G89.4) and  Pain documented as being related, associated Central Pain Syndrome (G89.0) require with or due to cancer, primary or secondary malignancy or tumor. that the physician specify the syndrome.  May be acute or chronic  MbMay be use d as a pr imary co difiifde if pain is focus of care (c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC When Pain is a Complication Scenario

197 198

  Mrs. Williams has had a bilateral knee replacement T code is used first to report the perfd6kformed 6 weeks ago. ShididhhlhShe is admitted to home health complication for therapy and pain management. Despite orders for Percocet, she reports ongoing pain in the joints replaced  Pain is post procedural and G code is of 8-10 at all times, which impairs mobility. Physician used to provide additional information documents pain due to the prosthesis.  T84.84xD Pain due to internal orthopedic prosthetic  Default to acute devices…,  Must use a Z code to define the  G89.18 Other acute post-procedural pain presence of joint replaced  Z96.653 Presence of Artificial Knee joint, bilateral  With complication of joint replaced, Z code  Use additional code to identify the specified condition resulting from the complication (found at the beginning of the mayyp still be used if complication code complication codes above T80). doesn’t identify the joint (c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC

Scenario Information needed

199 200

Sam Adams is referred to hospice with a  Intake: terminal diagnosis of anoxic brain damage For meningitis, encephalitis, CNS following an extended submersion when abscess: identify infectious organism his sailboat overturned. He is in a For drug-induced neuro conditions, ppgersistent vegetative state and ex pected to identify drug causing adverse effect live less than 1 month. For seizures, identify if intractable G93.1 Anoxic brain damage Neuralgia vs neuropathy V90.04xS Drowning and submersion For pain, identify if acute/chronic, post- due to sailboat overturning, sequelae op, neoplasm related, etc.

201

 Chapter 9 Guidelines Intake, con’ t: 202 For neuropathies, identify cause: I –Circulatory System hereditary, drug-induced, inflammatory, idiopathic (do not code here when caused by diabetes) IIhI = Ischemi a  Clinician assessment: For MS, identify if treating overall condition or one aspect For hemiplegia/monoplegia, identify if side affected is dominant or non-dominant side

Hypertension Hypertension

204

 Includes Essential Hypertension,  I10 Essential hypertension Hypertensive Heart Disease,  I11 Hypertensive heart disease Hypertensive Chronic Kidne y disease ,  I11.0 with heart failure and secondary hypertension  I11.9 without heart failure  No Hypertension table in ICD-10  I12 Hypertensive chronic kidney disease  No distinction between malignant and  I12.0 with stage 5 or ESRD benign hypertension in ICD-10  I12.9 with stage 1-4 or unspecified  I13 Hypertens ive heart an d c hron ic  Guidelines are unchanged from ICD-9- CM kidney disease  I13.0 -I13.2 Variety with or without heart failure and stage of CKD General Guidelines General Guidelines Hypertensive Heart Disease Hypertensive Chronic Kidney Disease 205 206

 Heart conditions classified to I50.- or I51.4-I51.9 are assidigned to a co dfI11hde from I11 when a causa l  May assume a relationship between relationship is STATED or IMPLIED hypertension and chronic kidney  Physician MUST state or imply relationship disease  I51.4-I51.9 are included however use an additional code for heart failure, if present.  Code to I12.-  Specific sequencing required  For patients who do NOT have a stated or implied Stage 5 or ESRD w ith hyper tens ion relationship between the same heart conditions (I50-, I12.0 I51.4-I51.9) and hypertension, the conditions are coddded separa tltely (no spec ific sequenc ing requ ire d Stage 1-4 or unspecified CKD with with hypertension and the heart disease) hypertension I12.9  I10 Essential Hypertension OR  I12.- HtiChiKidDi(ifCKDt)Hypertensive Chronic Kidney Disease (if CKD present) Specific sequencing required with CKD

General Guidelines Name that categgyory Hypertensive Heart and CKD 207 208

 I13—combination code when  Hypertension and  I10 hypertensive heart disease is verified ESRD (I11) an d the pa tien t a lso has CKD  Hypertension and CHF  I11 (I12).  Systolic heart failure Use additional code for heart failure dthtdue to hypertens ion when present.  Malignant hypertension  I12 Use additional code for CKD stage.  Patient has CKD and hypertensive  I13 cardiomegaly (c)2015, Selman-Holman & Associates, LLC Name that categgyory Answers

209 210

 Hypertension and  I10  Hypertension and ESRD I12 .0 , N18 . 6 ESRD  Hypertension and CHF I10, I50.9 or  Hypertension and CHF  I11 I50.9, I10  Systolic heart failure  Systolic hea rt fa ilu re due to dthtdue to hypertens ion hypertension I11.0, I50.20  Malignant hypertension  I12  Malignant hypertension I10  Patient has CKD and  Patient has CKD and hypertensive hypertensive  I13 cardiomegaly Now let’s cardiomegaly I13.10, N18.9 (c)2015, Selman-Holman & Associates, LLC code (c)2015, Selman-Holman & Associates, LLC

Heart Failure Heart Failure

211 212 When the rigg,ht side of the heart starts to fail, fluid 428. 0 = congestive heart failure, unspecified (I50. 9) collects in the feet and lower legs. As the heart failure becomes worse, the upper legs swell and eventually the 428.1 = I50.1 = left ventricular heart failure abdomen collects fluid (ascites). Weight gain 428.2 = I50.2 = systolic HF (includes CHF in ICD-10) accompanies the fluid retention. 428.3 = I50.3 = diastolic HF (includes CHF in ICD-10) Systolic HF: pumping action of the heart is reduced or 428.4 = I50.4 = combined HF (includes CHF in ICD-10) weakened measured by the left ventricular ejection means systolic and diastolic fraction (LVEF); typically, systolic heart failure has a decreased ejection fraction of less than 50%. 428.9 = I50.9 = HF unspecified Diastolic HF: heart can contract normally but is stiff and 429.0 = I51.4 = myocarditis unspecified less able to relax and fill with blood. This impedes blood 429.1 = I51.5 = myocardial degeneration flow into heart chambers, produces backup into the lungs 429.3 = I51.7 = cardiomegaly and CHF symptoms. Diastolic heart failure is more common ititldth75in patients older than 75 years, espec illiially in 429. 9 = I51. 9 = heart disease, unspecified women with high blood pressure. LVEF is normal. Scenario What about this?

213 214

 Mr. Richards is admitted to hospice  The patient has a history of CHF and following an exacerbation of his chronic systolic heart failure. He has Stage IV now is documented as having acute CKD. Physician documented hypertensive systlifiltolic failure. systolic heart failure.  2 codes OR  I13.0 H yper tens ive hear t an d c hron ic kidney disease with heart failure and Stage IV CKD  1 code??  I50.23 Acute on chronic systolic heart failure  N18.4 CKD Stage IV

I20‐25 Ischemic heart disease Angina Example

215 216

 Angina is considered integral to Mr. Parker is referred to home health ASHD unless otherwise noted due to increased recurrent chest pain Angina alone = I20.- reltdtlated to angi na an did increase d use o f Angina with dx of ASHD = I25.- nitroglycerine tablets. He has a comorbid diagnosis of hypertension.  Post infarction angina is considered a complication of the MI if specifically  I20.9 Angina pectoris, unspecified documented in medical record  I10 Hypertension

217 218

Mr. Kinsey has new onset chest pain  Initial MI coded to I21 for 4 weeks with pre-existing diagnosed CAD and  Any subsequent MI within the same 4 hypertension. weeks is coded to I22 Sequencing by plan of care I25. 119 – Atheroscl eroti c h eart di sease Site i s more i mport ant th an STEMI/ non- of native coronary artery with STEMI unspecifie d ang ina pec tor is Care setting does not change code I10- Hypertension  Old MIs not requiring further care— code to I25 . 2 (c)2015, Selman-Holman & Associates, LLC

STEMI vs non‐STEMI STEMI vs non‐STEMI

219 220

 NSTEMI account for about 30% and STEMI  NSTEMI does not show ST segment elevation in ECG about 70% of all myocardial infarction. (due to part ilhikial thickness damage o fhf heart musc l)le) an d later does not progress to a Q-wave pattern on ECG.  NSTEMI occurs by developing a complete For this reason, it is also called a non–Q-wave occlusion of a minor coronary artery or a partial myocardial infarction (NQMI). occlusion of a major coronary artery previously  STEMI shows ST segment elevation in ECG (due to affected by atherosclerosis. This causes a full thickness damage of heart muscle) and later partial thickness myocardial infarction (partial progress tQto a Q-wave myocardia l in farc tion (QWMI). thickness damage of heart muscle).  Cardiac markers including CK-MB (creatine kinase  STEMI occurs by developing a complete myocardial band), troponin I and troponin T, all elevate occlusion of a major coronary artery previously bo th in cases. Bu t the e leva tion o f these mar kers is affected by atherosclerosis. This causes a often mild in NSTEMI compared with STEMI. transmural myy(ocardial infarction (full thickness damage of heart muscle). (c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC I21 vs. I22 Defaults Scenarios to Code

222

 I21. 3 STEMI of unspecified site (also Michael Isaac was referred to the AMI NOS) agency 3 weeks after he was diagnosed with an inferior wall MI.  I21.4 non-STEMI of unspecified site Mr. Isaac has a diagnosis of post infarction angina  I22.2 Subsequent non-STEMI Mr. Isaac was resumed after  I22.9 Subsequent STEMI of unspecified hitliti2dltithhospitalization 2 days later with site ((qSubsequent MI NOS ) another inferior wall MI. Codes for inpa tien t diagnoses (M1011)? (c)2015, Selman-Holman & Associates, LLC

Answers Scenario to Code

223 224

Michael Isaac was referred to the agency  Mrs. Lambert is referred to home 3 weeks after he was diagnosed with an care after a STEMI involving the LAD inferior wall MI. Code? I21.19 coronary artdbttery and subsequent Mr. Isaac has a diagnosis of post infarction angg,ina. I23.7, I21.19 CABG. CAD is documented. She also Mr. Isaac was resumed after has atrial fibrillation and hospitalization 2 days later with another hypertension. inferior wall MI. Codes for inpatient diagg()noses (M1011)? I23.7, I21.19, I22.1 (c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC Answers Home Health MI Example

225 226

 Z48.812 Aftercare following surgery on the  Mrs Sepulveda is admitted to home health circulatory system for nursing and therapy following a Non-ST elevation Myocardial Infarction (NSTEMI)  I25.1 0 Ath eosceocerosclerotic h eart dseaseodisease of n ativ e occurring 3 weeks prior to admission. The coronary artery without angina pectoris patient has a longstanding history of  I21.02 STEMI involvinggg left anterior descending coronary atherosclerosis and angina but no coronary artery coronary bypass surgery. She had angioplasty with stent.  I10 Hypertension

 I48.91 Unspecified atrial fibrillation  MIs are sequenced prior to ASHD when  Z95.1 aortocoronary bypass status admitted for the MI.

Hospice MI Example Home Health Answer

227 228 Mrs Sepulveda is admitted to home health for  PtitPatient was t reat tdfed for an i ifnferi or wall nursing and therapy following a Non-ST elevation MI in the last 14 days and then was Myocardial Infarction (NSTEMI) occurring 3 weeks readmitted to hospital for anterior wall pritior to a diidmission. ThtithThe patient has a longs tditanding history of coronary atherosclerosis and angina but MI. He is beinggp admitted to hospice no coronary bypass surgery. She had angioplasty for unstable angina and his ASHD with stent. because he is not a surgical I21.4- NSTEMI candidate. I25.119-Atherosclerosis with Angina Z95.5 Presence of coronary angioplasty implant and graft (c)2015, Selman-Holman & Associates, LLC Category I69, Sequelae of Hospice MI Answers Cerebrovascular disease 229 230

 I25. 11Ø AHD with unstable angina  CtCategory I69 is use d to in dica te con ditions  I21.19 MI other coronary artery classifiable to categories I60-I67 as the inferior wall causes of sequela (neurologic deficits).  The neurologic deficits, or “late effects”  I22.ØØoateoa MI of anterior wall caused by cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition.  It i s most i mport ant t o cod e l ocati on.  Personal history of transient ischemic attack (TIA) and cerebral infarction (Z86.73)

Sequela of CVAs Sequela of Strokes

231 232

NON-traumatic bleeds  I69. 3-  CVA due to subarachnoid hemorrhage—I69.0- Which ones require more info?  CVA due to intracerebral hemorrhage—I69. 1- Other paralytic syndrome  CVA due to intracranial hemorrhage—I69.2- Dysphagia  If NOT a bleed (most strokes are caused by a clot), then: Seizures  If just documented as a ‘stroke’—I69.3- Muscle weakness  Do NOT use I69.9  Reference ‘Sequela’ in the index

233 234 Mr. Jarvis was referred to home care after a stroke for right sided hemiplegia, dysphasia and  Mrs. Parker is admitted from a 3 cognitive changes. week stay in rehab for a CVA with in farcti on. She has r ig ht s ide  I69.351 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side hemiplegia, dysphagia (pharyngeal  I69.321 Dysphasia following cerebral infarction phase), and a peripheral visual field  I69.31 Cognitive deficits following cerebral infarction deficit ((gright ey y)e).

CVA Answer Extremity Circulatory Disorders

235 236

Mrs. Parker:  Atherosclerosis is coded with or without  I69.351 Hemiplegia following CVA complications, such as ulceration: affecting right dominant side  I70.2 - requires identification of artery  I69.391 Dysphagia following CVA affected, native or graft, site of ulcer, and depth of tissue damage  R13.13 Dysphagia, pharyngeal phase  Venous stasis disease, insufficiency,  I69.398 Other sequela of CVA chronic venous hypertension, varicose  H53.451 Other localized visual field veins, with or without ulceration defect, right eye  I87.- requires s idhflite, depth of ulcer I95‐99: Other and unspecified Venous Stasis Example disorders of the vascular system 237 238

 Patient has venous stasis disease.  Includes hypotension , gangrene (not  I87.2 Venous insufficiency (chronic) elsewhere classified), Intraoperative (peripheral) and post-procedural complication,  Patient has chronic venous hypertension with ulceration at right ankle (fatty tissue post-mastectomy lymphedema visible).  Note that the gangrene listed in I95-  I87.311 Chronic venous HTN with ulcer of 99 is for gangrenous cellulitis not RLE classifiable to other causes such as  L97.312 Non-pressure chronic ulcer of right ankle with fat layer exposed atherosclerosis or diabetes.

Example Information needed

239 240

Mr. Tripper admitted following repeated falls  Intake: and progressively worsening orthostatic For HTN and heart disease, identify if hypotension. He has severe volume de pletion causing the orthostasis, related to his reduced reltdlated and difh if hear tfilt failure presen t oral intake. He has no appetite. For HTN and CKD, identify CKD stage I95.1 Orthostatic hypotension For heart failure, identify type of HF E86.9 Volume depletion CHF? Query if systolic/diastolic R63.0 Anorexia For AMI, identify date, site of infarction, R29.6 Repeated falls STEMI or NSTEMI Z91.81 History of falls (c)2015, Selman-Holman & Associates, LLC Information needed Information needed

241 242

 Intake, con’ t:  Clinician assessment: For ASHD, identify if native coronary Any angina present artftifittery or graft, if angina present For CffCVA, any residual deficits present, if For CVA, identify specific artery affected, patient is left or right side dominant sififiite of infarction, cause (bld(bleed, For CVA with dysphagia, identify type of thrombosis, embolism), and the residual dysphagia dfiideficit present Depth of tissue damage for any non- Etiology of any circulatory ulcerations pressure ulcers

General Guidelines

Chapter 10 Guidelines  243 ICD-10 removes instructions related J –Respiratory System to the classification of COPD All components covered under J44.-  For infectious disease processes, J = Junk in the coder is to include infectious lungs organism Use a dditional cod e f or th e causa tive microorganism if known Acute exacerbation of chronic obstructive General Guidelines bronchitis and asthma 245 246

 COPD J44 .-  An acutbtiiite exacerbation is a worsening or ICD-10 coding broken up into a decompensation of a chronic condition. exacerba ted , no t oth erwi se spec ifie d, AtAn acute exacerb btiitiltation is not equivalent and with acute lower respiratory to an infection superimposed on a infection chronic condition, though an Extremely important to note the exacerbation may be triggered by an excldludes 1 an d exc ldludes 2 notes infection.

 See difference between J44.0 and J44.1

J44 Other chronic obstructive What is an exacerbation? pulmonary disease 247 248

 Increased s/sx of COPD for 3+ days  J44.0 COPD with acute lower resppyiratory infection  Coughing, sputum production, change in  Coded by location (if multiple areas, code colitdiO2tlor or consistency, drop in O2 sat, tthlto the lowest anat omi cal lit) site) more shortness of breath, decreased  Use additional code to identify the infection activ ity tolerance  J44. 1 COPD with (acute) exacerbation  Decompensated COPD  Requires change in treatment  Decompensated COPD w/acute Additional medication, using inhaler or exacerbation O2 more,,y curtailed activity level  J44.9 COPD, NOS J44—Conventions Scenario

249 250

 Although asthma is included, if Mr. Winston is admitted for IV antibiotic information is provided on type of and PICC line care to treat pneumonia asthma, code also the specific J45 code dtMRSAHdue to MRSA. He alhlso has a hitfhistory of  Use additional code to report tobacco COPD with chronic obstructive use, his tory o f use, or exposure bronchitis, and is oxygen dependent.  Remember guidance

 May add additional code for oxygen dependence when known.

Scenario Coded Other Notes

251 252  J44.0 COPD with lower resppyiratory infection A patient with COPD (of any type) who  J15.212 MRSA pneumonia also has a lower respiratory infection is not  Z99.81 Oxygen de pendence assumed exacerbated. If Mr. Winston is  Z45.2 Fitting and adjustment of vascular also documented as exacerbated, then: catheter  J44.0 COPD with lower resppyiratory  Z79. 2 Long term curren t use o f antibi o tic infection medication  J15.212 MRSA pneumonia

 COPD code used indicates presence of  J44.1 Exacerbation of COPD lower resppyiratory infection  See Excludes 2 note  Note sequencing instruction at J44.0 (c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC Practice Answers

253 254  An 80 year old female is admitted due to J20. 2 Acute Bronchitis due to a recent onset of bronchitis caused by Streptococcus streppgtococcus. She has been discharged home with 10 days of antibiotics and G30.9 Alzheimer’s Disease oxygen. In addition, she has a history of F02. 80 D em en ti a wi th out beh avi or al Alzheimer’s dementia and is bedbound. disturbance Z74. 01 Bed Confinement status  Note the difference between chronic and infectious bronchitis

Use additional code… Practice

255 256  Exposure to environmental tobacco Mr. Mathers has been admitted due to smoke (Z77.22) recently diagnosed chronic obstructive  Exposure to tobacco smoke in the asthma, with use of oxygen. His history and perinatal period (P96.81) physical states he has been hospitalized for  History of tobacco use (Z87.891) an exacerbation and has exercise induced  Occupational exposure to environmental bronchospasm. SN will assess and instruct in tobacco smoke (Z57.31) disease process and medication. The patient has no history of tobacco use, but his wife of  TbTobacco depen dence (F17.-) 35 years is a smoker. His history reports he  Tobacco use (Z72.0) also has congestive heart failure.

257 258

 J44.1 Chronic Obstructive Asthma Exacerbated  Mrs. Green is admitted following  J45.990 Exercise Induced Bronchospasm  I50.9 Congestive Heart Failure diagnosis of a pseudomonas lung  Z77.22 Contact with and exposure to abShi30dflbscess. She is on 30 days of oral environmental tobacco smoke antibiotic therapy and will receive  Z99.81 Dependence on supplemental oxygen skilled nursing and therapy. She has Chronic Obstructive asthma classified under J44.- also been a smoker for 30 years. Type of asthma is specified ICD-10 requires the additional coding of any exposure to tobacco smoke, if known

J95 Intraoperative and postprocedural Scenario Coded complications and disorders of the 259 respiratory system, not elsewhere J85.2 Abscess of the lunggp without pneumonia B96.5 Pseudomonas class ifie d F17.210 Nicotine dependence, cigarettes, uncomplicated  Includes pulmonary insufficiency following Z79.2 Long Term use of antibiotic surgery, tracheostomy complications,  B96.5 additional code is used for pseudomonas pneumonitis d ue t o anesth esi a, I nt raoperati ve  Additional code for tobacco use as the patient is a smoker hemorrhage of a respiratory organ.  Excessive length of antibiotic therapy so use of  Post operative infections of respiratory organs antibiotic also coded coded here including tracheostomy infection

(c)2015, Selman-Holman & Associates, LLC 260 (c)2015, Selman-Holman & Associates, LLC J96‐J99: Other diseases of the J95 Intraoperative and postprocedural Respiratory system complications and disorders of the 262 respiratory system, not elsewhere classified  Includes Respiratory Failure, Pulmonary  Excludes 2: aspiration pneumonia, emphysema collapse, Compensa tory emp hysema resulting from procedure, hypostatic pneumonia,  Respiratory Failure Excludes (1) ARDS, pulmonary manifestations due to radiation Cardiorespiratory Failure, Respiratory Arrest, Post Procedural Respiratory Failure **Excludes 2 means these conditions should be  *These should not be concurrently coded additionally coded if they exist concurrently. They are not considered included under J95 block 261 (c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC

Scenario Scenario Coded

263 264 Mr. James is referred to home health J96.21 Acute and Chronic Respiratory Failure for skilled nursing care following with Hypoxia hitlitiftithospitalization for acute respiratory J44.1 COPD exacerbated Z99.81 Dependence on Supplemental Oxygen failure with hypoxia. He has just been Acute condition is superimposed on chronic. started on oxygen. He has additional Physician has specified both the acute and diaggpynoses of chronic respiratory failure chronic respiratory failure and COPD which is noted as Physician has specified “with hypoxia” exacerbated in the clinical record. COPD is reported as exacerbated so J44. 1

265

 Intake: Chapter 11 Guidelines 266  For infectious processes, identify causative K ‐ Digestive organism KSK = Spec ilKiial K is good dfth for the  Any exacerbation digestive system!  For asthma and bronchitis,,yyp identify type  Tobacco abuse or dependence  Clinician assessment:  If s/sx, query for exacerbation  Any tobacco use or exposure  Any supplemental oxygen

Guidelines Ulcers of the GI System

268

 General guidelines for this chapter are  The followinggp indicates the specific site reserved for future expansion of the ulcer, with or without hemorrhage and perforation  Laterality and specificity guidelines are  Esophageal ulcer K22.- in effect in this chapter.  Gastric Ulcer-K25.-  Pay cl ose a ttenti on t o use additi onal  Duodenal Ulcer- K26.- code when documentation present,  Peptic Ulcer- K27.- Eld1Excludes 1 an dEld2d Excludes 2 no tes.  Gastrojejunal ulcer-K28.-  The indented terms are always read in  Without bleeding vs with conjunction with the main term. bleeding (case mix) (c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC K31.84 Gastroparesis Hernias (K4Ø‐K46)

269 270

 Gastroparesis: delayed gastric emptying,  Includes acqq,guired hernias, congenital consisting of partial paralysis of the hernia (except hiatal), and recurrent stomach,,g resulting in the food stay yging in hernias. the stomach longer than normal  Remember, if a hernia is noted to have obstruction (strangulation) and  Code first anyyyg underlying disease, if known gangrene, code to the gangrene. These such as: would likely be used in the acute  Anorexia nervosa (F5Ø.Ø-) conditions in M1011 and M1017.  Diabetes Mellitus (EØ8.43, EØ9.43, E1Ø.43,  Location includes type of hernia and E11.43, E13.43) laterality.  Sc lero derma (M34.-) (c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC

Code the Scenario Answers

271 272

 Patient admitted to home health with a  Patient admitted to home health with a diagnosis of diagnosis of GERD with esophagitis for GERD with esophagitis for teaching and teaching and observation and observation and assessment. assessment. K21. Ø-GERD with esophagitis  Patient was admitted to home health with acute gastric ulcer with perforation which resulted in  Pati ent was ad mitt ed t o h ome h ealth with blee ding an d SN to mon itor for con tinue d blee ding acute gastric ulcer with perforation which and teach s/s of exacerbation and medication resulted in bleeding and SN to monitor teaching. for continued bleeding and teach s/s of K25.2-Acute gastric ulcer with both hemorrhage exacerbation and medication teaching. and perforation

 Also known as Crohn syndrome or  K57.- Diverticular disease of the regional enteritis intestine th th th  4 , 5 , and 6 character identifies small intestine, large intestine or 4th and 5th character identifies the areas both, and any complication manifested. of the intestine (small or large), with or without perforation and bleeding.  Example: K5Ø.812 -Crohn’s disease of both small and large intestine with intestinal obstruction

Diseases of the Liver Diseases of the Liver K7Ø‐K77 K70‐K77 275 276

 K7Ø.- Alcoholic liver disease with specific  K73.- Chronic hepatitis, NEC complications  K74.- Fibrosis and cirrhosis of the liver  K71.- Toxic liver disease Code also, if applicable, viral hepatitis  Code 1st poisoning due to drug/toxin, if applicable  K75.- Other inflammatory liver diseases  Use additional code for adverse effect, if  Abscess applicable, to identify drug  Phlebitis  K72.-Hepatic failure, NEC  Autoimmune  Incl u des hepa titis, NEC w ith hepa tic fa ilure  Hepatic encephalopathy, NOS  NASH  Yellow liver atrophy or dystrophy  Hepatitis, NOS

(c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC Complications of artificial openings of Hepatitis the digestive system K94.‐ 277 278 Although viruses are the most common Complications include hemorrhage, cause of hepatitis, other causes include autoimmune liver disease, obesity, alcohol, infection, malfunction, and unspecified titoxins, or m isuse o f cer titain prescr itiiptions  K94.Ø- Colostomy complications drugs and over-the-counter drugs such as Tylenol. These forms of hepatitis can  K94.1- Enter ostomy comp licat i on s cause the same symptoms and liver  K94.2- Gastrostomy complications inflammation that result from viral hepatitis, bu t are not cont agi ous. (Vi ral hepa titis is  K94. 3- EhEsophagos tomy complicati ons coded in the infectious disease chapters)

Complications of Bariatric Procedures Practice (K95.‐) 279 280

 K95. 0- Complications of gastric band  Patient admitted to home health for procedure B12 injections weekly x 4, then  K95.01: Infection due to gastric band monthly for new diagnos is o f  Infection: use additional code to specify type of infection or or ganism, (bacterial and malabsorption syndrome viral infectious agents) (B95-. B96)  Cellulitis of abdominal wall (LØ3.311)  Chronic bleeding duodenal ulcer  Sepsis (A4Ø.-, A41.-)  K95.8- Complications of other bariatric procedures (c)2015, Selman-Holman & Associates, LLC Answers Information needed

281 282

Patient admitted to home health for B12  Intake: injections weekly x 4, then monthly for new Identify site or part of GI tract affected diagnosis of malabsorption syndrome. Identify any bleeding, obstruction,  K90.9-intestinal malabsorption, perforation, infection unspecifie d  Clinical assessment: Chronic bleeding duodenal ulcer Any s/sx bleeding or obstruction  K26.4-chronic or unspecified duodenal ulcer with hemorrhage

Diseases of the Skin and Subcutaneous Tissues 284 Chapter 12 Guidelines 283  Includes diseases : L –Skin and Subcutaneous Pressure ulcers Non Pressure ulcers Chronic skin ulcers L = you have lovely skin Atypical skin ulcers Cutaneous abscesses Cellulitis Infections of the skin and subcutaneous tissue LØØ‐LØ8 Abscess 285 286

 Use an additional code to identify any  Collection of pus that has accumulated infectious agent. within a tissue because of an inflammatory  LØØ Staphylococcal scalded skin process in response to either an infectious syndrome (SSSS)-also known as Ritter’s process or foreign object. It is a defensive disease and localized bullous imppgetigo reaction of the tissue to prevent the  Use additional code to identify percentage spread of infectious materials to other of skin exfoliation (L49-) parts of the body.  Excludes 1- impetigo (LØ1.Ø3)

LØ2‐Cutaneous abscess, furuncle and Furuncles and Carbuncles carbuncle 287 288

 Furuncle- (boil)infection of the hair follicle and sebaceous gland, and  4th, 5th, and 6th character identifies appears as a pus filled red whether the area is an abscess, a inflammation. carbuncle or a furuncle and the area of the body it is located.

 Use additional code to identify  Carbuncle-Group of furuncles that extend deeper into the skin. organism

289 290 th th  4 and 5 characters define if the  Staphylococcal boil , left groin patient has a cyst, or a sinus, or both, andithd with or w ithtithout an a bscess.

 Use additional code to define  Pilonidal fistula with abscess organism, if known.

Answers L22 Diaper dermatitis

291 292

 Staphylococcal boil , left groin  Generic term applied to skin rashes L02.224-Furuncle of groin in the diaper area that are caused by B95.8-Unspecified staphylococcus varikididd/iittious skin disorders and/or irritants, as th e cause di seases cl assifi ed often prolonged contact with urine or stool.  Pilonidal fistula with abscess L05. 02—Pilonid al si nus w ith a bscess

293 294

 L23. Ø- Due to metals  L23.4- Due to dyes  L23.5- other chemical products  L23.1- Due to adhesives  Cement,,p pesticide ,p, plastic, rubber  L23. 2- DtDue to cosmeti cs  L23.6- food in contact with the skin  L23.3-Due to drugs in contact with  L23.7-due to pp,lant, excep t foods skin  L23.8- Due to other allergens Use additional code for adverse effect, if  L23.81-animal dander applicable to identify drug (T36-T5Ø with  L23.89- other agents th th 5 or 6 character 5)  L23.9- Unspecified

L27.‐ Dermatitis due to substances Practice taken internally 295 296

 Use additional code for adverse Dermatitis covering entire body due to effects, if applicable, to identify drug antibiotics (penicillin) taken correctly as (T36-T50 w ith 5th or 6th cht5)haracter 5) prescribed.

 L27.Ø Generalized skin eruption

 L27.1- Localized skin eruption

 L27. 2- Ingested food

297 298

Dermatitis covering entire body due to  Pressure ulcers (L89 .-) antibiotics (penicillin) taken correctly as Combination codes that indicate location prescribed. (lat eralit y) and st agi ng of ul cer. Th ey do no t  L27.Ø-Generalized skin eruption require a second code to describe the due to drugs and medicaments taken stage. The 6th character indicates stage. internally ICD-10-CM classifies pressure ulcers from  T36. Øx 5D-Adverse e ffect s of stages 1-4ifidd4, unspecified, and unstageable. penicillin Assign as many codes in L89.- category that are needed to identify all the pressure (c)2015, Selman-Holman & Associates, LLC ulcers the patient has.

Pressure Ulcer Guidelines Pressure Ulcer Guidelines

299 300

 If a patient is admitted with a pressure  Assigggpnment of stages of pressure ulcers ulcer at one stage, and it progresses to a can be based on:  Documentation from the provider higher stage, assign the code for the  Documentation from the agency clinician. highest stage reported for that site.  NPUAP and WOCN guidance:  Also a new ca tegory o f pressure ul cers  Reverse staging is not allowed of contiguous sites are included in the  Stage III and Stage IV ulcers never “heal”, (L89.-)lt) pressure ulcer category. but close , and therefore will always be coded based on interventions the agency may be performing (assessment and prevention are i n terventi ons!) Pressure Ulcer Guidelines Pressure Ulcer Example

301 302  Unstageable pp(ressure ulcers (L89.- -0) The patient has a pressure ulcer to the  Ulcer whose stage can not be clinically sacrum with an area that is to the determined due to:  EhEschar bone. The remainder of the area is  Skin or muscle graft shown to be full thickness with good  Deep tissue injury (not due to trauma) granulation tissue. SN for wound care  Do not confuse this with unspecified stage 2-3x week for wound vac placement. (L89.- -9)  When there is no spec ific documen ta tion on w ha t L89. 154-Pressure ulcer of sacral stage the ulcer is. THIS SHOULD NOT BE USED SINCE YOU CAN DERIVE STAGES FROM THE region, stage IV ASSESSMENT BY AGENCY CLINICIANS!

Practice Pressure Ulcer Answer

303 304  Patient admitted with a stage III Pati ent ad mitt ed with a s tage III pressure ulcer to left heel, stage II pressure ulcer to left heel, stage II pressure ulcer to r ig ht hee l. Stage III pressure ultihthllcer to right heel. Stage III wound is gangrenous wound is gangrenous  M1Ø21: I96 Gangrenous cellulitis Tip: watch for instructional note!  M1Ø23: L89.623 Pressure ulcer of left heel, stage 3  M1Ø23: L89.612 Pressure ulcer of right heel, stage 2 L97 Non‐pressure chronic ulcer of the Non‐pressure Ulcer Guidelines lower limb, not elsewhere classified 305 306

 Non Pressure ulcers (L97.-)  Code first any associated conditions Based on site and laterality such as: Any associated gangrene Based on depth offf wound, defined by anatomical depth including: skin only, Atherosclerosis of the lower extremities subil(flbcutaneous tissue layer (fat layer Chronic venous hypertension exposed), muscle tissue layer necrosis, Diabetic ulcers andbd bone necros is. May be co de dbd base d Pos tphl e bitic syndrome on clinician documentation Postthrombotic syndrome ViVaricose u lcer (c)2015, Selman-Holman & Associates, LLC

Non pressure ulcer limited to Non pressure ulcer with fat layer breakdown of the skin (subcutaneous layer) exposed 307 308

Patient admitted with arterial skin ulcer of left calf due to atherosclerosis

 I7Ø.242 Atherosclerosis of native arteries of left leg with ulceration of calf

 L97.221 Non pressure ulcer of left calf limited to skin

Ulcer Severity Coding Example

311 312 L97. 22- Non-pressure chronic ulcer of left calf  Mrs. Beasleyyp is an obese female patient who has a non-pressure wound to her left calf. It is draining a large amount of serous fluid, which 1Non-pressure chronic ulcer of left calf limited to often drippps down into her shoes. The patient has breakdown of skin DM, venous hypertension, and edema. The 2Non-pressure chronic ulcer of left calf with fat patient is not noted to have varicose veins. The layer exposed physician is queried and agrees that the ulcer is due to the chronic venous hypertension. She 3Non-pressure chronic ulcer of left calf with necrosis of muscle has co-morbidities of DM, CAD and HTN. On admission, the SN noted that the wound was 4Non-pressure chronic ulcer of left calf with shallow, with wound bed with some granulation. necrosis of bone 9Non-pressure chronic ulcer of left calf with unspecified severity (c)2015, Selman-Holman & Associates, LLC Coding Example Scenario

313 314

 I87.312-Chronic venous HTN with ulcer  Mr Stubbs pp,resents with edema, of left LE redness, and pain of the left big toe. He  L97.222-Non-pressure ulcer left calf with did not seek treatment because he fat layer exposed thoug ht it wou ld improve on its own. He does not remember any injury, but the  I25.10-Atherosclerotic heart disease of native coronary art ery with out angi na pain has gotten progressively worse for pectoris the past week.  Diagggnosis: Gangrenous abscess of the  I10-primary HTN entire left big toe.  E11.9-Type II DM without complications  E66. 9 Obesity, unspecified

Answer Information needed

315 316

Mr Stubbs:  Intake: Site of wound, laterality  L02.612-Cutaneous abscess of left foot Etiology of wound, complicating factors  I96- Gangrene, NEC If an area is an abscess, carbuncle, furuncle, and infectious organism.  Clinician assessment: Stage of pressure ul cer Depth of tissue damage for non-pressure ulcer

318 Chapter 13 Guidelines  Bone, joint or muscle conditions that 317 M –Musculoskeletal are the result of a prior healed injury  Chronic or recurrent bone, joint or muscle conditions M = Musculoskeletal Any current, acute injury should be coded to the appropriate injury code from chapter 19.  Site by the bone, joint or muscle involved, multiple sites code for some conditions

7th Characters for Pathological Osteoporosis with current Fractures pathological fracture 319 320

 7th character A is for use as longgp as the patient is  Categgyory M80,,p Osteoporosis with current receiving active treatment for the fracture. pathological fracture, is for patients who Examples of active treatment are: surgical have a current pathologic fracture at the treatment,,gyp emergency department encounter , time of an encounter . The codes under M80 evaluation and treatment by a new physician. identify the site of the fracture. A code from  7th character, D is to be used for encounters after category M80, not a traumatic fracture the patient has completed active treatment. code, should be used for any patient with D is the Default known osteoporosis who suffers a fracture,  The other 7th characters, listed under each even if the patient had a minor fall or subcategory in the Tabular List, are to be used for trauma, if that fall or trauma would not subsequent encounters for treatment of problems usually break a normal, healthy bone. associated with the healing, such as malunions, nonunions, and sequelae. Osteoporosis without current Osteoporosis With Fracture pathological fracture Example 321 322

 Patient admitted for aftercare of  Category M81, Osteoporosis without current pathological fracture, is for use for pathological fractured vertebra due patients with osteoporosis who do not tltdtito age related osteoporosis. currently have a pathologic fracture due to Documentation indicates patient had the osteoporosis, even if they have had a fracture in the past. For patients with a previous healed pathological fracture historyyp of osteoporosis fractures , status of humerus due to osteoporosis code Z87.310, Personal history of (healed) osteoporosis fracture, should follow the code from M81.

Osteoporosis With Fracture Osteomyelitis Answer 323 324

 M80.08xD Aggpe related osteoporosis with  Notable Omissions: current pathological fracture, vertebra  No mention of osteomyelitis in diabetes in the subsequent encounter Osteoporosis alpha index or the tabular list.  ONE code for unspecified  Z87.310 Personal history of healed  Specify as acute, subacute or chronic osteoporosis fracture  Osteomyelitis of vertebra is in different location from other sites.  Note: Age related osteoporosis is separate category from other osteoporosis  Osteomyelitis  Use additional code to identify infectious agent  Note: Pathological fracture is separate category from osteoporosis fracture  Use additional code to identify major osseous defect, if applicable Osteomyelitis Example Osteoarthritis

325 326

 Acute osteomyelitis of the R thumb  Most common DJD  Many differences between ICD-9 and cultured Strep D ICD-10  M86. 141 Other acu te os teomye litis ,  Types right hand  Polyosteoarthritis (generalized) B95.2 Enterococcus as the cause of  Osteoarthritis, coded by site diseases classified elsewhere  M16.-OA of hip  M17.-OA of knee  Primary or secondary  Post-traumatic  Unspecified OA M19.90 – don’t use! (c)2015, Selman-Holman & Associates, LLC

Infectious Arthropathies Other Items to Note

327 328

 Direct infection --invasion by infective  Gout—M10.- organisms (organisms invade the Code chronic gout with tophi synovial tissue) M1A.9xx1  Indirect infection-Microbial infection of the body is established however  Charcot’s joint, R foot M14. 671 organisms can not be identified or is Check out the Excludes 1 inconsistent in the joints.  JitdJoint derangement s and dli ligamen t  What kind of codes are included in issues are due to OLD injuries or are M01? M02? spontaneous, i.e. without injury (c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC Information needed

329 Chapter 14 Guidelines  Intake: 330  Site of disease or condition N –Genitourinary  Type of arthritis or osteoarthritis  For osteomyelitis, identify if acute or chronic, ifinfec tious organi sm N = Naughty parts  For osteoporosis, identify site, history of any pathol og ica l frac ture (s )

 Clinician assessment:  Obtain history and query physician to verify

N17‐N19‐Acute kidney (renal) failure N18‐Chronic kidney disease and chronic kidney disease 331 332

Acute kidney failure is the rapid loss of the kidneys'  Code first any associated: ability to remove waste and help balance fluids  Diabetic chronic kidney disease (does not presume a and electrolytes in the body. In this case, rapid cause-effect relationship and must be documented) means less than 2 days. Many causes, may include:  Hypertensive chronic kidney disease (DOES assume a decreased blood flow due to hypotension, infections cause-effect relationship and if the patient has HTN and that directly injure the kidney, urinary tract blockage, CKD documented, code as such) medications, among other reasons .  Use additional code to identify kidney transplant status, if applicable (Z94.Ø) If documentation of Acute and chronic kidney  If ESRD i s docum en ted, th en use N1 8. 6 failure, code both. (regardless whether receiving dialysis). Code also associated underlyyging condition  If stage V, use N18.5 unless undergoing dialysis, then use N18. 6. (use additional code to identify dialysis status-Z99.2) N18‐Chronic kidney disease Other Urinary Conditions

333 334

 N18.1- Stage I  N20-N23: Urolithiasis  N18.2- Stage II (mild) N20.- Calculus of kidney, ureter, or both,  N18. 3- Stage III (moderate) and unspecified (upper tract)  N18.4- Stage IV (severe) N21.- Calculus of bladder, urethra, other  N18. 5- Stage V without mention of dialysis lower tract or unspecified (lower)   N18.6- ESRD, or Stage V with dialysis N3Ø.- Cystitis-has 5 characters to identify s pecific t ype of c ystitis  N18. 9- Unspecified degree of chronic Use additional code to identify infectious kidney disease agent (B95-B97)  Uremia NOS

N31‐Neuromuscular dysfunction of N3Ø‐N39‐Other diseases of the urinary system bladder, NEC 335 336

 N3Ø.- Cystitis-has 5 characters to identify  Excludes 1-neurogenic bladder due to specific type of cystitis cauda equina syndrome, neuromuscular  Use additional code to identify infectious agent dysfunction due to spinal cord lesion (B95-B97)  Use a dditiona l co de to iden tify any associated urinary incontinence (N39.3-  Cystitis refers to inflammation of the N39.4-) bladder, specifically, inflammation of the wall of the bladder. Cystitis usually occurs when the urethra and bladder, which are normally sterile  Neuroggy,enic bladder dysfunction, (microbe free) become infected by bacteria - the sometimes referred to as neurogenic area becomes irritated and inflamed. More bladder is a dysfunction of the nervous common among females system or peripheral nerves involved in the control of urination (micturition). (c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC N39‐Other disorders of urinary N39.4‐ other specified urinary system incontinence 337 338

 N39.41-Urge incontinence  N39. Ø-Urinary tract infection , site not  N39.42-Incontinence without sensory specified awareness  Use additional code (B95-B97) to identify infectious agent  N39. 43- Post-void dribbling  N39.3-stress incontinence (male)  N39.44- Nocturnal enuresis (female)  N39. 45- Continuous leakage   Code also any associated overactive bladder (N32.81) N39.46- Mixed incontinence (urge and stress incontinence)  N39. 4- other specified urinary  N39.49Ø-Overflow incontinence incontinence  N39.498-other specified urinary incontinence  Code also any associated overactive bladder (N32. 81)  Reflex incontinence  Total incontinence (c)2015, Selman-Holman & Associates, LLC

Practice ANSWERS

339 340

 Acute suppurative cystitis, with  Acute suppurative cyy,stitis, w/ hematuria hematuria due to E coli. due to E coli. N3Ø.Ø1-Cystitis, acute with hematuria B96.2Ø- E Coli, as cause of disease  Chronic kidney disease, stage III classified elsewhere  Chronic kidney disease, stage III  Kidney stone N18.3  Kidney stone N20.0  CKD Stage V, on dialysis  CKD Stage V, on dialysis N18.6, Z99.2

341 Chapter 17 Guidelines  Intake: 342 Any relationship between CKD and Q –Congenital Malformations under ly ing HTN, DM, or o ther con dition Stage of CKD History of acute renal failure Q = Quirky conditions Sppypecific type of incontinence

 Clinician assessment: If eGFR known, query stage of CKD

Conventions and Guidelines Conventions and Guidelines

343 344

 May be the principle/first listed diagnosis  If congenital malformation has been or secondary diagnosis corrected, code history code, not the  When a malformation/deformation/or malformation chromosomal activity does not have a  Although present at birth, abnormality uniqqg,gue code assignment, assign may not be identified until later in life, additional code(s) for any manifestations that may be present. and diagnosed by physician.  Co des can be use d throug hou t the  Components of the anomaly that are inherent should not be seppyarately coded life of the patient.

 QØ5-Spina Bifida  Use additional code to identify any associated physical conditions and Further defined by location deggyree of intellectual disability Further defined with or without  Down’s syndrome, also known as hydrocephalus Trisomyyg 21 is a genetic disorder caused by the presence of all or part of a third Use additional code for any associated copy of Trisomy 21. It is the most paraplegia (paraparesis) (G82.2-) common chromosome abnormality in humans.

Information needed

347 Chapter 18 Guidelines R –Symptoms,  Intake: 348 Identify any congenital malformations, Signs, Abnormal Clinical/LabFindings dfdeformati ons and c hromosoma l abnormalities VifVerify con diiditions are congen ilital an d not RtdiR = symptom coding acquired after birth should be rare

 Clinician assessment: Obtain history, query physician to verify Code the Symptoms Do not code the syypmptoms

349 350

Codes that describe symptoms and signs are acceptable  Siggypns or symptoms that are associated for reporting purposes when a related definitive diagnosis routinely with a disease process should has not been established (confirmed) by the provider. not be assigned as additional codes, unlthiittdbthless otherwise instructed by the  Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the s/sx classification. ittilis not routinely assoc itdiththtiated with that diagnos is.  ICD-10-CM contains a number of

 The definitive diagnosis code should be sequenced combination codes that identify both the before the symptom code. definitive diagnosis and common symptoms of that diagnosis. When using  Remember the proximate diagnosis vs underlying condition rule? one of these combination codes, an additional code should not be assigned

Syndromes Guideline

351 352

 Follow the Alppghabetic Index guidance  Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. Whil e spec ific when coding syndromes. diagnosis codes should be reported when they are  In the absence of Alphabetic Index supported by the available medical record documentation and clinical knowledge of the patient’s guidance, assign codes for the health condition, there are instances when documented manifestations of the signs/symptoms or unspecified codes are the best syndrome. choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be  Additional codes for manifestations that coded to the level of certainty known for that are not an integral part of the disease encounter. process may also be assigned when the  If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report condition does not have a unique code. codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. (c)2015, Selman-Holman & Associates, LLC (c)2015, Selman-Holman & Associates, LLC Guideline Falls

353 354

 When sufficient clinical information isn’t known or  availa ble ab out a parti cul ar h ea lt h con dit ion to ass ign Code R29. 6, Repeated falls, is for use a more specific code, it is acceptable to report the for encounters when a patient has appropriate “unspecified” code (e.g., a diagnosis of recently fallen and the reason for the fall pneumonia has been determined , but not the specific type). Unspecified codes should be reported when is being investigated. they are the codes that most accurately reflects what is known about the patient’ s condition at the time of  Code Z91.81,,y History of falling, is for use that particular encounter. It would be inappropriate to when a patient has fallen in the past and select a specific code that is not supported by the medical record documentation or conduct medically is at risk for future falls. When unnecessary diagnostic testing in order to determine a appropriate, both codes R29.6 and more specific code. Z91.81 may be assigned together.

Functional qqpguadriplegia SSI Equivalent Codes

355 356

 783.41 (()R62.51) Failure to thrive  Functional quadriplegia (code R53.2) is  783.7 (R62.7) Adult failure to thrive the lack of ability to use one’s limbs or  799.3 (()ypR53.81) Debility Unspecified to amb ul a te d ue to ex treme d e bility. It i s  799.89 Other ill-defined conditions not associated with neurologic deficit or  799.9 (R99) Other unknown and inju ry, and code R53. 2 shou ld not be unspecified cause of morbidit y or mor talit y used for cases of neurologic  (ICD-10—used only for those who have already quadriplegia. It should only be assigned died) if functional quadriplegia is specifically  R54 Age related physical debility (old age) documented in the medical record.  Don’t use as terminal dx for hospice

357 358

 R26 Abnormalities of Gait and Mobility  Abnormalityyg of gait  Excludes 1  Usually neuro when the definitive diagnosis is  R26.0 Ataxic gait unknown or resolved  R26.1 Paralytic gait  Difficulty in walking  R26.2 Difficulty in walking, NEC  Chronic condition of the bone and joint  R26. 8 Other a bnorma lities o f gait and  (moved from MS chapter) mobility  But where does that definition come from?**  R26. 81 Unsteadiness on feet  R26.89 Other abnormalities of gait and mobility  R26.9 unspecified abnormalities of gait and mobility (c)2015, Selman-Holman & Associates, LLC

Will the definitions still stand? Information needed

359 360

 Weakness, generalized—R53. 1  Intake:  Asthenia NOS (malaise, fatigue, dizziness) If you get a symptom at referral, ask for  Excludes 1  age related weakness* the un der ly ing con dition tha t is caus ing  Muscle weakness M62.8- (symptom of a the symptom(s) muscular condition)  Clinician assessment:  Muscle weakness (generalized)—M62.81 Do not list syypmptoms that are inte gral to the condition on the diagnosis list

Chapter 19 Guidelines  NO aftercare codes . 361 S,T –Injury and Poisoning  All kinds of injuries  Organized by body part (instead of type of injury) with the exception of burns and SSthiS = Strychnine corrosions T = Trauma  Superficial  Contusions  Open wounds  Fractures

This chapter consists of: This chapter consists of:

364

 All kinds of injj()uries (con’t)  Complications of surgical and  Dislocations and sprains medical care, NEC  Traumatic hemorrhages T81 Complications of procedures, NEC  Traumatic amputations T84 Complications of internal orthopedic  Blast injuries prosthetic devices, implants and grafts  ChiCrushing   Burns and Corrosions T86 Complications of transplanted organs and tissue  PiPoison ing by, a dverse e fftffects o f and underdosing T87 Complications peculiar to reattachment and amputation Application of 7th Characters in External Cause Codes Chapter 19 365 366

Most (but not all) categories in chapter  In the absence of a mandatory 19 have a 7th character requirement reporting requirement, providers fhlibldfor each applicable code. are encouragedtd to vol unt aril y No aftercare code for injuries report external cause codes, as they provide valuable data for  A = Initial encounter injjyury research and evaluation of  D = Subsequent encounter injury prevention strategies.  S = Sequela (p.55) Different 7th characters for fractures

Guidelines: Trauma Injjyury Trauma Wound Example

 Traumatic injjyury codes (S00-T14.9) are Patient admitted for wound care to not used for normal, healing surgical wounds or to identify complications of lacerated right forearm due to falling from surgilical woun ds. moving motorized mobility scooter.  Alphabetic index—Wound, open, by site,  S51.811D Laceration, without foreign by type of injury bdbody, ofihtff right forearm  Amputation  V00.831D Fall from moving motorized  Bite  Laceration--A jagged wound or cut mobility scooter  Puncture  look up accident, transport, pedestrian… Burn Guidelines Burn Guidelines

369

 Burns=Thermal Burns , except sunburns (see  Burns of the eye and internal organs (T26- includes note for T20-T32) T28) are classified by site, but not by degree.

 Corrosions= chemical burns  Do NOT use T30! Assign separate codes for

 First degree (erythema), second degree (blistering), each burn site and third degree (full-thickness involvement)  Non-healing burns are coded as acute burns

 Classify burns of the same local site but different  Necrosis of burned skin should be coded as a degr ees to th e hi gh est degr ee burn i den tifi ed of th at non-healed burn site  If infected, add the ‘B’ code  Code the worst ((ghighest de gree ) burn first  No aftercare codes for burns

Burn Guidelines Non‐Healing Burn Example

 Use category T31 as an additional code Patient has an ulcer on his left lower leg where for reporting purposes when there is he left a heating pad and burned his leg. Because of his atherosclerosis (with mention of a third-degree burn involving clau dication) the second degree bu rn has nev er 20 percent or more of the body surface. healed. The focus of home care is the care of Use Rule of Nines the ulcer/burn.  T24.232D Burn of second degree left lower  May code a sequela of a burn and a leg current burn at the same time  I70.212 Atherosclerosis of native arteries  The external cause code should be extremities w/intermittent claudication, left leg usedithbd with burns an d corros ions  Y63. 5 Inappropriate temp in local application (optional) Sequela of Burn Example Acute burn and sequela of burn

Patient had a burn of right wrist last year. The burn  When appropriate, both a code for a current has healed but the patient has a skin contracture at burn or corrosion with 7th character “A” or the wrist. PT/OT are ordered. “D” and a burn or corrosion code with 7th  L90. 5 Scar con ditions an d fibros is o f s kin character “S” may be assigned on the same  T23.371S Burn of 3rd degree of R wrist, sequela record (when both a current burn and sequelae of an old burn exist). Burns and Encounters for treatment of the late effects of burns corrosions do not heal at the same rate and or corrosions (i.e., scars or joint contractures) a current healing wound may still exist with shou ld be co de d w ith a burn or corros ion co de w ith the 7th character “S” for sequela. sequela of a healed burn or corrosion.

Remember the sequela sequencing rule?

Example Information Needed ‐ Wounds

376 Patient had third degree burns on back of right  Type of injury hand and wrist. Burn on back of hand has  Location, including laterality never healed, burn on wrist has healed but there is a skin contracture. Nursing will provide  BdBurns: degree, comp litilications wound care to burn and OT will work on  Any infection, causative organism contttracture.  How injury happened  T23.361D Burn of 3rd degree of R dorsum of Extern al cause code opti on al but hand recommended  L90.5 Scar conditions and fibrosis of skin  Treatment orders  T23.371S Burn o f 3r d degree o f R wr is t, sequela Traumatic Fracture Guideline 7th Character for Fractures

 A = Initial encounter for closed fracture  Classifications of fractures:  B = Initial encounter for open fracture  Open or closed  D = Subsequent encounter for fracture with  Default is closed routine healing  Gustilo grade, if open  G = Subsequent encounter for fracture with  Displaced or non-displaced delayyged healing  Default is displaced  K = Subsequent encounter for fracture with nonunion  Traumatic or pathological  P = Su bsequ ent encou nter for fractu re w ith  Traumatic: bone breaks due to fall or injury malunion  Pathological: bone breaks due to a  S = Sequela disease of the bone, a tumor or infection

7th Character Open Fractures Gustilo Grades for Fractures Gustilo Grade Definition th I Open fracture, clean wound, wound <1 cm in length Look at 7 character for S72 II Open fracture, wound > 1 cm in length without extensive soft- tissue damage, flaps, avulsions  Type I III Open fracture with extensive soft-tissue  laceration/damage/loss or an open segmental fracture; also Type II includes open fractures caused by farm injuries, fractures requiring vascular repair, or fractures that have been open for  Type IIIA 8 hhr pritttior to treatment IIIA Type III fracture with adequate periosteal coverage of the  Type IIIB fracture bone despite the extensive soft-tissue laceration or damage  Type IIIC IIIB Type III fracture with extensive soft-tissue loss and periosteal stripping and bone damage. Usually associated with massive contamination. Will often need further soft-tissue coverage procedure (i.e. free or rotational flap) IIIC Type III fracture associated with an arterial injury requiring repair, irrespective of degree of soft-tissue injury Traumatic Hip Fracture Example Trauma vs Fraggyility Fracture

Patient admitted for aftercare of traumatic  A code from M80, not a trauma right hip (neck of femur) fracture after fracture code, should be used for any falling out of wheelchair patient with k nown ost eoporosi s wh o  S72.001D Subsequent encounter for suffers a fracture, even if the patient cldftlosed fracture o f unspecifi ifidtfed part of had a minor fall or trauma if that fall neck of right femur with routine healing or trauma would not usually break a  W05.0xxD Fall from wheelchair normal, healthy bone. (optional)

Fracture Example Fracture Answer

M1020/22 Description ICD-10 65 year old male fell down 7 stairs at home M1021 Tibia upper end unspecified S82. 101D twisting his right leg, which resulted in fractures closed at the ppgroximal and distal ends of the right tibia M1023 Tibia medial malleolus closed S82. 51XD (medial malleolus). He has a non-wt bearing cast on the right leg. The doctor expects to M1023 Fall down steps, stairs W10.8xxD itincrease to wt bear ing w ithin 10 days. He has a M1023 Diabetes type 2 with E11.40 history of type II diabetes (insulin dependent) unspecified neuropathy with neuropathy and has had 4 toes (all except M1023 Amputation status toes, left Z89.422 great toe) previously amputated on his left foot as a result. He is receiving home health M1023 Long term use of insulin Z79.4 physical therapy for gait training. M1023 M1011/M1017 Fracture of Hip Example

386 Patient fell off the bed when his foot got M1011 M1017 caught in the covers and he has a fracture  Fx Tibia  Fx Tibia of the riggght greater trochanter. unspecified upper unspecified upper

end closed end closed  S72. 111D Fracture of greater trochanter S82.101A S82.101A of right femur, subsequent encounter for  Fx Tibia medial  Fx Tibia medial closed fracture with routine healing malleolus closed malleolus closed  W06.xxxD Fall from bed, subsequent S82.51XA S82.51XA encounter (optional)

Fracture of the Hip, Sequela Fracture with Spinal Cord Injyjury

387 388 The patient with the broken hip refused a Patient had an unstable burst fracture of the 1st lumbar joint replacement. His fracture has healed vertebra resulting in a complete lesion at L1. He is but his right leg is significantly shorter than paraplegic as a result. He is being discharged home after his le ft. rehab.  G82.21 Complete paraplegia

 S34.111S Complete lesion of L1 level of lumbar spinal  M21.751 Unequal limb length ()(acquired), cord right femur  S32.012S Unstable burst fracture of 1st lumbar vertebra  S72. 111S Fracture of greater trochanter  Code first any associated spinal cord and spinal nerve of right femur, sequela injury (S34.-)  W06. xxxS Fall from bed, sequela

 Patient’s right great toe  Patient’s riggght great toe was  Code assignment is based on the provider’ s is amputated because of cut off when mowing the documentation of the relationship between the a diabetic ulcer that lawn (powered lawnmower). condition and the care or procedure. won’ t heal. He also has  S98. 111D Trauma tic diabetic PVD.  The guid e line ex ten ds to any comp lica tions o f care, amputation of right great toe regardless of the chapter the code is located in.  Z47.81 Aftercare  W28. xxxD Contact with  Not all conditions that occur during or following following amputation powered lawn mower medical care or surgery are classified as  E11.51 Diabetes with complications. There must be a cause-and-effect  (Status code for absence is peripheral angiopathy relationship between the care provided and the not used because the condition, and an indication in the documentation  Z89.411 Acquired traumatic amputation code that it is a complication. absence of right great pp)rovides the information) toe  Query th e provid er for c lar ifica tion, if the complication is not clearly documented.

Amputation and Surgical Amputation Complications Complications

 Surgical complications are coded to  Infected R BKA (surgical): T87. 43 category T81.- complications of  Dehiscence of amputation stump T87.81 procedures NEC  PiPrevious Toe ampu ttitation-NhliNon healing  Amputation complications are NOT with eschar T87.54 appro priatel y coded with T81 codes  IfInfect tded and dDhi Dehisce d(d (ex terna l)  Alphabetical index: Complication, Surgical Wound T81.31xD, T81.4xxD amputation stump, by type of complication (infection, dehiscence, necrosis, etc.)  DhiDehiscence (int ernal) post CABG  Amputation complications are coded to T81.32xD T87.-  Non-hlihealing surg ilical woun d - ??? Mechanical Complication Complication

The pppatient’s peritoneal dial ysis catheter is infected with MRSA and  The patient has a muscle flap on a stage has been abandoned. Home health is ordered to change dressings to the infected site. The patient has a new AV fistula and a central line IV pressure ulcer. The flap is not healing (triple lumen). Home health will teach the patient/caregiver how to and is breaking down. administer IV antibiotics through new central line.  Infection, due to…,device, catheter, dialysis, intraperitoneal  Complication, graft, muscle, breakdown  MRSA, infection, as the cause of diseases classified elsewhere  Admission, adjustment, device, specified NEC, vascular access

 T85.71xD-infection and inflammatory reaction due to  T84.410D peritoneal dialysis catheter  B95.62 MRSA  Z45.2 Encounter for adjustment and management of vascular access device

Complication of Transplant Complication of Joint Prosthesis

The patient ’ s new right hip prosthesis is  The patient has a rejection of his infected with Staph aureus. bone marrow transplant due to graft- versu s-host disease.  Complication, joint prosthesis, infection, hip  Complication, transplant, bone marrow  T84.51xD Infection and inflammatory reaction due to internal riggppht hip prosthesis T86.01 Bone marrow transplant rejection  B95.61 Staph aureus D89.813 Graft-versus-host disease, unspecified Complication of Internal Fixation Complication of Internal Fixation Device Device

Patient suffered a comminuted fracture of the  T84. 120D Displacement of internal right humerus at mid shaft in a 4-wheeler fixation device of right humerus accident when riding with her grandson. She ha d an ORIF and th e fi xati on d evi ce has  S42. 351K Displaced comminuted come loose resulting in a nonunion of the fracture of shaft of humerus, right fracture. arm, nonunion  Should you code the nonunion or the complication first?  V86.69xD Passenger of other special  Instructional note: Use additional code to all-titerrain or oth thffdter off road motor identify the specified condition resulting from vehicle injured in nontraffic accident the complication.

Intracranial Injjyury Example

 Difference between a traumatic Patient fell out of bed and received a subdural intracranial bleed and a CVA type bleed hemorrhage. The doctor documented that the wife states that the patient was out for less than  External vs internal 5 minutes. He was admitted for observation and  Coding the acute injury OR the sequela of now comes home for further observation. an injury?  Injury, intracranial  What is the focus of your Plan of Care?  Seizures, coma and not woken up?  S06.5x1D Traumatic subdural hemorrhage with  Stable? loss of consciousness of 30 minutes or less  Residual neurological deficits?  W06.xxxD Fall out of bed Information Needed –Fractures Example and Complications 402

Patient fell off the steps at the WWII Memorial when  Fractures he was visiting. He sustained a subdural hemorrhage and was comatose for 28 days. He has left dominant Bone affected, laterality spastic hemiplegia and speech problems and is Traumatic or pathological etiology coming home after 2 months in rehab. Open/closed, displaced/non-displaced  G81.12 spastic hemiplegia affecting left dominant side Gustillo Grade if open  Dysphasia Any complications of healing  S06.5x5S traumatic subdural hemorrhage with loss of consciousness greater than 24 hours with return  Complications to pre-existing conscious level, sequela Requires physician documentation  W10. 8xx S Fa ll from s teps

Poisoning Differences

Poisoning, adverse effects, ICD-9-CM ICD-10-CM underdosing  Poisoning requires  Poisoning requires Still i n th e T cod es 3 codes 2 codes  Adverse Effect  Therapeutic use  Underdosing a new  No underdosing concept  Use of external  No use of external cause codes (E cause codes codes) (V,W,X,Y) Table of Drugs and Chemicals Table of Drugs and Chemicals

 Combination codes—no need for external cause code  Poisoning is defined as:  Look up by name of drug or chemical  overdose of substances  Determine circumstances or intent  wronggg substance given or taken in error  PiPoison ing, acc idtl(dflt)idental (default)  Poisoning intentional self-harm  Adverse effect is defined as:  Poisoning assault  'hyyypersensitivity', 'reaction', etc. of correct  Poisoning undetermined substance properly administered to correct  Adverse effect (therapeutic use in ICD-9) patient  Underdosing th   Add appropriate 7 character Underdosing is defined as:  A - Initial encounter  taking less of a medication than is prescribed or  D - Subsequent encounter instructed by the manufacturer, whether  S - Sequela inadvertently or deliberately

Poisoning Adverse Effect

 Guideline: When coding a poisoning or  Guideline: When coding an adverse improper use of a medication first assign effect of a drug that has been correctly the appro priate code from cate gories prescribed and properly administered, assithign the appropr itdfthiate code for the T36-T5Ø. Use additional code(s) for nature of the adverse effect followed by manifestations of poisonings. the appropriate code for the adverse  T—code for poisoning, accidental effect of the drug (T36-T5Ø with a 5th or (unless the physician has documented 6th character of 5). something specific)  E—Effect  E—Effect(()s) of the poisonin g  T—T code for adverse effect of drug Underdosing Underdosing Example

 Guideline: Codes for underdosing should Patient with diagnosis of Hypertension never be assigned as principal or first-listed codes. If a patient has a relapse or continued to experience elevated blood exacerbtibation o fthf the medi dilcal con dition for pressure while taki ng bl oo d pressure which the drug is prescribed because of the reduction in dose, then the medical condition meds. Upon patient interview, it was itself should be coded. found the patient was taking medication once daily instead of twice  C—Condition daily because of the cost of the drug.  T—T code for underdosing of the drug  Z—ZdfZ code for unddderdos ing reason

Underdosing Answer Poisoning Example

 I1Ø Essential (primary) hypertension Patient has taken his Lasix 4Ømg every morning and night. The  T46.5x6D Underdosing of other prescription bottle reads 4Ømg daily. antihypertensive drugs, subsequent Patient is dehydrated and encounter hypokalemic.  Z91.12Ø Patient's intentional T-- T5Ø.1x1D poisoning by diuretics underdosing of medication regimen E--E86. Ø de hy dra tion due to financial hardship E87.6 hypokalemia Adverse Effect Example Practice

414

Patient has been taking the prescribed  Mrs. Thompson is admitted after amount of Lanoxin, however his pulse rate is now 42 and he is toxic according to lab hospitalization for Strep B values. SfSN for observation and assessment, pneumonia. She is ta king pen ic illin, teaching and venipuncture for monitoring and at SOC the nurse identifies a levels. raised rash over patient’s trunk, back  R00.1 Bradycardia  T46.Øx5D cardiotonic glycosides and extremities. On repp,pyort, physician  Z51.81 Encounter for monitoring diagnoses the rash as due to the  Z79.899 Longg( term (current ) use of other penicillin and changes the antibiotic. high risk medication

Answer

415 Chapter 21 Guidelines Mrs. Thompson: 416 Z –Factors Influencing…  J15.3 Strep B pneumonia

 L27.0 Generalized dermatitis due to dr ugs an d m edi cam en ts tak en Z = codes of last resort, internally last chapter

 T36. 0x5D Adverse effect of penicillin General Guidelines General Guidelines

417 418

 These codes represent reasons for  These codes are provided for occasions when circumstances other than a disease, encounters. A corresponding injury or external cause classifiable to proceddtdure code must accompany a Z catiAØØtegories AØØ-Y89 are recor de d as code if a procedure is performed “diagnoses” or “problems”. They can arise in 2 ways: • Doesn’t apply for Home Health or  Patient not sick but requires health services for Hospice. a specific purpose  When problem is present which influences the person’s health status, but is not a current illness/injury

Guidelines Guidelines

419 420

 May be first listed or secondary  History—past medical condition that depending on circumstances. no longer exists and is not receiving  Status—either a carrier or has the any treatment, bhhbut that has a potent ilial sequelae or residual of a past disease or condition for recurrence and therefore may  Informative—may affect the course of require continued monitoring. treatment/outcome Watch out for personal vs family history  Should not be used if diagnosis code History may alter treatment/outcome. includes the info (status transplant with transplant complication) Guidelines Guidelines

421 422

 Aftercare—initial treatment of a  Aftercare codes should be used in disease has been performed and the conjunction with other aftercare codes patient req u ires continu ed care du ring (dZd)dii(read Z codes) or diagnosis co des to the healing or recovery phase, or for provide better detail on the specifics ltlong term consequences of fdi disease. of an aftercare encounter visit… The Aftercare code should not be used if sequencing of multiple aftercare tttreatment tiditdt is directed at a current , acut e disease. codes depends on the circumstances Not to be used for injuries. of the encounter.

Attention to….. How to Find Z Codes

423 424

 Attention Z Codes explain a patient’ s Look for: medical condition that currently  Absence  History exists, is receiving treatment , and is  Admission  Observation affecting the plan of care  Aftercare  Presence  Feeding/Cleansing/Teaching  Attention  Problem  Encounter  Resistance  Examination  Status  Must be doing something to or about the condition or sequelae  Exposure Common categories in Home Health Aftercare

425 426

 Aftercare  No aftercare codes for aftercare following an injury or fracture Surgical  Certain aftercare (()Z) code cate gories need Attention to…. a secondary diagnosis code to describe the Fitting and adjustment.... resolving condition or sequelae  Z48. 3-Aftercare following surgery for the neoplasm  Status  Use additional code to identify the neoplasm  FthZdthditiiilddFor other Z codes, the condition is included in the code title.  History  Z43. 3-Encounter for attention to colostomy

Orthopedic aftercare Orthopedic Example

427 428

 Z47. 1- Aftercare following joint Patient admitted for surgical aftercare replacement surgery for a right shoulder joint prosthesis  Z47. 3- Aftercare fo llow ing explttilantation itiflliinsertion following an explttilantation of a of joint prosthesis prosthesis due to mechanical failure. 5th character designates location  Z47.31 Aftercare following explantation  Z47.81- Encounter for orthopedic of shoulder joint prosthesis aftercare following surgical amputation  Z96.612-Presence of left artificial  Use additional code to identify the limb shoulder joint amputated (Z89.-) Z48.‐ Status Codes

429 430

 Z48. 3-Aftercare following surgery for  3 main terms in alphabetical index neoplasm Status  Use additional code to identify the neoplasm Absence Presence  Z48.81- Encounter for surgical aftercare fllfollow ing surgery on spec ifidbdified body sys tems Z95.810-presence of automatic  6th character to note system implantable cardiac defibrillator  No more “Conditions classifiable to…” Not listed under status; but listed under  What happened to musculoskeletal?? ‘presence’

Status Codes History

431 432

 Non compliance codes greatly  Two types of history Z codes expanded  Personal Z91. 11- Patient’ s noncompliance with  Family dietary regimen  Personal History of Malignant neoplasm codes Z91. 12-Patient’ s intentional underdosing expanded to specifically capture: of medication regimen  Carcinoid tumors Z91.12Ø-Patient’ s unintentional underdosing  Small intestine of medication regimen due to financial  Pancreas hardship.  In-situ neoplasms  Neoplasm of uncertain behavior  Prostatic dysplasia Z43‐Encounter for attention to Z43 vs. Z93 artificial openings 433 434

 Includes:  Z93 codes are for artificial opening Closure of artificial openings status Passage of sounds or bougies through  Is the patient receiving treatment or artificial openings attention to the ostomy site? If so, Reforming artificial openings use a Z43 code instead of Z93 Removal of catheter form artificial Excludes 1 under each category to openings exclude the other category Toilet or cleansing of artificial openings.

Z45 vs Z95 More Common Z codes

435 436

Cardiac pacemaker attention to OR status  Z45. 2-Encounter for adjustment and management of vascular access device  Z46. 6 Encounter for fitting and  Z45.Ø - AiAgency is reprogramm ihing the adjustment of urinary device device either manually or via computer  Z46. 82- Encounter for fitting and adjustment of non-vascular catheter  Z95.- Status or presence: stating as a fact  Z91. 83: Wandering in diseases classified the patient has the device, but agency is elsewhere not doing anything with it  Z66 – Do not resuscitate Z74.‐ Problems related to care Z72.‐Problems related to lifestyle provider dependency 437 438

 Z72. Ø- Tobacco Use  Z74.Ø1- Bed confinement status  Z72.3- Lack of physical exercise  Z74. Ø9- Other re duce d mo bility  Z72.4 Inappropriate diet and eating habi ts Chair ridden

Z79.‐ Long term (current) drug Look up Z63.1 therapy 439 440

 To indicate any long term current use that affects the plan of care

 Length of time for “long term” is up to clinical jjgudgment

441 442

Patient had left BKA for diabetic gangrene. SN is  amputation site infected (MRSA) necrosed providing aftercare, observation and assessment  care to surgical wound, dressing changes. and dressing changes. ICD-10-CM Description M1025 ICD-10-CM Description

Z47.81 Aftercare amputation E11.52 T87.54 Necrosis of amp stump, LLE ()(optional) E11.51 DM w/peripheral angiopathy T87.44 Infection of amp stump, LLE without gangrene Z89.512 Acquired absence of left leg B95.62 MRSA (cause of diseases classified below knee elsewhere) Z48.01 Encounter for surgical E11.51 DM with periph angiopathy w/o gangrene dressing changes

Are you ready to dual code?

 Practice in ICD-10 coding is essential to be prepared for the implementation date OPERATIONAL PREPARATION October 1, 2015  Home care will actually start dual coding cases on Augg,ust 3, 2015 for any yp episodes that will extend past 9/30/15. What did we do  RAP will be filed in ICD-9 prior to 10/1/15 with an extra  End of Episode final claim will bill in ICD-10 year? on or after 10/1/15 ICD‐10‐CM Challenges What are some of the issues now?

445 446

 Increased concern for:  Little to no clinical information available  Claims and denials at referral/intake.  Documentation  More difficult to identifyyp patient issues  More difficult to develop POC meaningful to  Loss of productivity by coders the patient  “Unlearninggg” Coding Clinic rules for ICD-9  More difficu lt to prov ide s kille d care tha t w ill  Time! withstand the scrutiny  Operational focus:  How do we get better information to  Gap analysis begin with AND  Process updates  Hoodoegetteccastow do we get the clinicians to  Back-up plan for cash flow disruptions assess/document better?

What are some of the issues? Key Factors on HH Claims

447 448

 Coders will be 20-30% slower even if well Three factors affect how ICD-10-CM must trained and practiced. be used on these episodes for services that span the October 1 date:  What is the productivity level you expect 1. The claim “From” date (episode start now? date);  Hospice coverage and related vs 2. The Out come and A ssessment unrelated conditions will compound the Information Set (OASIS) assessment reduction in productivity completion date (OASIS item M0090 date); and  What can you do to improve the whole process now and with implementation of 3. The claim “Through” date. ICD-10? Episodes Starting Before October 1, 2015, with Episodes Starting Before October 1, 2015, with OASIS Completion Dates Before October 1, 2015 OASIS Completion Dates Before October 1, 2015

449 450

 For HH claims ((yptype of bill 032x ), ICD-10-CM  In the case of initial HH episodes, the OASIS assessment must be completed within 5 days of reporting is required based on the claim the start of care. “Through” date.  On Requests for Anticipated Payment (RAPs),  The assessment compl eti on d at e (M0090 d at e) determines whether the HH Grouper software that Medicare billing instructions require that the determines the ppyayment grou p for the e pisode will “From” and “Through” dates are the same. So if apply ICD-9-CM or ICD-10-CM codes to the the episode begins in September 2015, the episode. “From” and “Through” dates on the RAP would report the same date in September.  In the case where the episode start of care date is before October 1, 2015 and the M0090 date is also  These RAPs would report ICD-9-CM diagnosis before October 1, 2015, ICD-9-CM codes will be codes using codes matching the OASIS used on the OASIS and to determine the payment assessment. group code (the Health Insurance Prospective Payment System (HIPPS) code.

Episodes Starting Before October 1, 2015, with Episodes Starting Before October 1, 2015, with OASIS Completion Dates Before October 1, 2015 OASIS Completion Dates Before October 1, 2015

451 452

 If the HH epppisode spans into October 2015, the  “Allow HHAs to use the ppyayment grou p code corresponding final claim for the episode will be derived from ICD-9-CM codes on claims which required to report ICD-10-CM codes. span 10/1, but require those claims to be  HH claims cannot be split into periods before submitted using ICD-10-CM codes.” and after October 1, 2015, so these claims will  This means that HHAs do not have to re-group have claim “Through” dates of October 1, 2015, the episode based on the ICD-10-CM codes. or later. But this could result in some inconsistency  The HIPPS code on the final claim must match between the HIPPS code and the ICD-10-CM the HIPPS code that was reported on the RAP. codes on the claim. CMS will alert medical The HIPPS code on the RAP was based on the reviewers at our MACs to ensure that the ICD- ICD-9-CM codes matching the OASIS 10-CM codes on these claims are not used in assessment. making determinations. CMS will also alert researchers us ing CMS d at a fil es of thi s inconsistency. Episodes Starting Before October 1, 2015, with Episodes Starting Before October 1, 2015, with OASIS Completion Dates Before October 1, 2015 OASIS Completion Dates in October 2015

453 454

 The codinggpppy used to support the payment of  There mayyp be cases where the episode start of care date the HIPPS code will be the ICD-9-CM is before October 1, 2015, and, due to the 5 day codes that were used on the RAP and completion window, the M0090 date is in October 2015. For example, an initial episode with a start of care date of which are stored in the OASIS system . September 28, 2015, could have an M0090 date of  These same procedures will apply to October 2, 2015. In these cases, ICD-10-CM codes will resum pti on of car e assessm ent s (M 01 00 = be used on the OASIS and to determine the HIPPS code. 03) and to recertification (M0100 = 04) and  The RAP for this example would have “From” and “Through” dates of September 28, 2015. As a result, follow-up (M0100 = 05) assessments when these RAPs would need to report ICD-9-CM diagnosis the episode start date and the M0090 date codthhICDdes even though ICD- 10-CM cod es were used on the on those assessments are both before OASIS assessment. October 1, 2015 but the episode ends in  The ICD-9-CM codes are required in order for the RAP to October 2015 (see table below). be processe d. The correspon ding fi nal c la im for the episode will report ICD-10-CM codes matching the OASIS assessment.

Recertification Episodes Beginning in CMS Table the First Days of October 2015 455 456

 In the case of recertification episodes, the M0090 date can be up to 5 days earlier than the episode start date. So, a recertification episode starting on October 2,,, 2015, could have an M0090 date of September 28, 2015. ICD-9-CM codes are used on the OASIS assessment and will be used to determine the HIPPS code. But in this case, both the RAP and claim will require ICD-10-CM codes since the “Through” date on both will be after October 1, 2015.  The coding used to support the payment of the HIPPS code will be the ICD-9-CM codes which are stored in the OASIS syst em. What is dual coding? And why is it CMS Table (()Revised) important?

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 Coding in ICD-9 and ICD-10 Keeping in mind that everything has to be in ICD-9 now OASIS C-1/9  Faster and more accurate OASIS C-1/9  AlAnalyze w htdhat documen ttiitation is

OASIS needed for better coding/better C-1/10 assessments. OASIS C-1/9 Make changes to forms Make list for intake personnel Combination of SOE and M0090

Dual Coding Plan Sample Dual Coding Plan

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 Do you outsource your coding? Are  Start by running a report on top 20 diagnoses your agency uses. they ready?  Not jjpust primar ygy diagnoses.  Do NOT depend on the GEMs.  Evaluate whether your list needs to include more than 20.  Cannot dual code until the coders  CdCode thtthe top 20di20 diagnoses in ICD-10-CM have had training.  Category enough? When w ill tha t be ?  What additional information do you need from your referral source and your clinicians 50 HOURS OF TRAINING AND to code these well? PRACCCTICE RE COMMENDED  Start NOW with a percentage of cases Sample Dual Coding Plan Plan Your JJyourney

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 Now: dual code 25-50% of assessments  Pinpoint where diagnosis codes are used in ICD-9 and ICD-10 in your processes  Intake  August 3: dual code all assessments that you anticipate will be final billed on or after  Assessment October 1, 2015  POC  Billing  October: code only in ICD-10  Prepare an ICD-10 transition budget.  Quality audits of all coders  Training  Software-EMR and billing  Forms revision

Identify your Team Prepare Your Budget

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 Evaluate the performance of your  Budget for the following expenses: Transition Team  EHR, and/or other system upgrades or Do you need to make changes? ppyypyurchases you may need to help you achieve ICD-10 compliance.  Establish accountability for the  ICD-10 code selection support tools, books, processes, forms, and information and software you intend to purchase. systems affected by ICD-10 and  ICD-10 updates to paper forms and assign specific responsibilities to the documents which reference diagnosis codes. members of your team.  ICD-10 overview, documentation, and coding training for your practice staff. Prepare Your Budget Train Your Team

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 Budgggpet for the following expenses:  Intake personnel on referral  User training on the ICD-10 functionality included with system upgrades. information to request  Temporary staffing if you anticipate a large  Coders on coding training reduction in productivity. The productivity factors  Physyscaician sas an dcd clini cacian sos on you use are subjective and will vary depending upon the: documentation required  PfiiProficiency an d spee dfd of co ders  Overview training for staff members  Improvements in clinical documentation engaged in administrative functions.

Update Your Processes Update Your Processes

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 Obtain this information (run reports  Pinpoint the ICD-9 codes with the highest rate of rejections and denials for each of from your software, ask your billing your largest payers: company)  CihiCategorize the primary reasons fhfor the denials and rejections. Your claim rejections and denials by  Note changes you can make to your ICD-9 diagnosis code and payer. documentation and billing processes to The most common unspecified ICD-9 address the causes for denials / rejections. codes you submit by payer.  Identify your commonly billed unspecified ICD-9 codes Update Your Processes Clinical Documentation

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 Evaluate a samppyle of your clinical  Clinical Documentation Improvement documentation. The sample should include common conditions seen where the for ALL KINDS of reasons underlying ICD-9 codes map to multiple ICD- 10 codes. Determine if all key concepts  Preliminary assessments of A&P, relevant to patient care were captured in pathophyygysiology, pharmacolo gy for sufficient detail within the sample to support the selection of appropriate ICD-10 codes. clinicians, coders, QA  Increase your level of documentation in those  Evaluate the documentation details instances where key concepts are not being needed to code diagnoses in ICD-10 capppptured in sufficient detail to support the selection of a specific ICD-10 code.

Revise Paper Forms Modify Processes

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 Incorporate ICD-10 codes into paper  Track payment delays, denials, and forms and tools which reference increases in authorization volume for diagnos is codes atlt least t(3) (3) month s b eg inn ing on the Patient Intake and History compliance date. By logging this Assessments information, you will be in a better Car e Pl an s ppposition to spot and address Other forms and templates problems more quickly. Technology Medicare

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 Evaluate yygyour technology vendor contracts to understand  Review your MAC’ ssICD ICD-10 website. the type of ICD-10 expenses which may be separate from regular fees. Clarify with each vendor the additional ICD- Updated LCDs 10 related technology expenses. CfCCheck results of ICD-10 end-to-end  Verify that your key systems are, or will soon be, ICD-10 compliant. Most HIPAA covered entities that receive data testing from your systems will not translate ICD-9 diagnosis Watch for tools and tips for ICD-10 codes into ICD-10. The expectation is that you will be able transition plans to submit ICD-10 codes for claims having a date of service greater than or equal to the compliance date.

 Set training dates for software updates.

Medicaid Gap Analysis

475 476  Review ICD-10 information on your Definition: “ …the comparison of state agency’s website actual performance with potential  Note ICD-10 related deadlines, performance. Gap analysis testing information, and FAQs. provides a foundation for  CltComplete tktasks that will ensure measuring investment of time, compliance and compatibility with the money and human resources ICD-10 up da tes your Me dica id required to achieve a particular agency is instituting. outcome.”

477 478 1. Analyze your current situation for 2. Identify the objectives that must be achieved to each process and system by collecting achieve the overall goal. (where we need to be) a) What are your goals now for days to POC? information and data. (where we are now). b) How long does it ta ke to ge t assessmen ts a. What are we currently doing? complete? How many assessments are acceptable when first submitted and how many times does the bWhob. Who has the knowledge that we need? coder have to go back to the clinician for additional c. Is the information documented information? anywhere? c) How much time for calls to physician to get POC and med list finalized? d. What is the best way to obtain the d)What are achievable objectives for each issue information? Software reports? Interviews? iden tifie d? Document review? Observation?

Steps in a Gap Analysis Areas to be addressed in Gap Analysis

479 480 3. Identify how to bridge the gap from Financial Operational the current situation to the desired Billing/Revenue Intake/referral cycle IT/Outside Vendors outcome (how do we get there). Consider Cash Flow what resources you w ill nee d to ta ke to Budget Coding reach the objective, and then take action! Training a. People Clin ica l Competency b. Processes Clinical Speed documentation Determining primary c. Technology POC development diagnosis and secondary d. Time Case Management diagnoses with potential to impact care. e. Materials and Equ ipment Sample Gap Analysis‐‐Intake Sample Gap Analysis‐‐Clinicians

Personnel take Intake will obtain better Intake needs to have some information from referral clinical information so education in coding to ensure Assessing clinicians Improved Have clinician/coder that clinical information is as complete OASIS and team review current source and directed to that assessments, comppplete as possible at intake documentation to ask certain questions if documentation and stage. sequence diagnoses support skilled care assessments to ensure information is not coding can be more based on the proposed adequate prompts are in Provide list of questions based POC—assessments are place for improving offered, such as accurate and complete. on common diagnoses for Improved mostly checklists and documentation. demographic infffo, next of referral source so that clinical cues/prompts for kin, who will sign F2F, etc information is as complete as do not provide a lot of Transfer information to possible, e.g., osteomyelitis— narrative clinical gathering new OASIS C-1. acute or chronic. information. information on the Query the physicians and assessment Evaluate knowledge of discharge planners for additional pathophysiology and diagnosis information beginning pharmacology. iditltfICDimmediately as part of our ICD- 10 Readiness Training. Develop POC based on Develop form for querying diagnosis information physicians to identify missing and patient need. diagnosis information based on description of patient, pharmacology, etc

Sample Gap Analysis‐‐Coders Sample Gap Analysis‐‐QA Develop POC based Develop patient Review the completed Review history and Increased amount of See above for improved on completed OASIS centered POC based OASIS for accuracy and physical (when information documentation to support information at referral within ______hours. on completed OASIS available), assessment skilled care. Compliant, accurate within 48 hours and proposed POC to coding based on ICD-10 comprehensive determine appropriate training (improved Ensure that the documentation sequencing has been done sequencing taking into individualization of the available. correctly to support account coding Evaluate knowledge of POC for the patient) services provided. Consult Coding within 24-48 guidelines. pathophysiology and with coders on sequencing Coding within hours of receipt of pharmacology. questions. ______hours of OASIS receipt of OASIS Dual coding plan to Ensure that correction improve efficiency and policy is followed. accuracy of coders once Ensure that if F2F is not training has taken place. completed prior to SOC, that POC is available to physician when encountering the patient. (Communicate with physician) Sample Gap Analysis‐‐Billing Gap Analysis on Communication ______days to RAP. 5-7 days to RAP Evaluate coders/QA for speed of completion of 486 coding, ‘locking’ the OASIS and POC development. Gathering more information Evaluate ‘bottle necks’ in process and develop plan  Referring physicians to resolve any issues.  Indications of other illnesses: Once RAP has been submitted, evaluate any  Medications RTPs and status in DDE. Follow up immediately to  Treatments Final claim within ___ days correct any claims issues.  of EOE except in cases in Identify who to go to for Interview of patient/caregiver Final claim within 10 which the orders are RTPs related to coding .  And verifying those findings with the missing or F2F is not days of EOE except in present on SOC. cases in which the Identify responsibility for physician and/or medical director orders are missing or pre-billing audit and  SBAR F2F is not present on identif y cri teri a f or pre- SOC. billing audit. Identify who will review the coding.

Resources Resources

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 ICD-10-CM Coding Manual for Home  MLN SE 1410 Health and Hospice  ICD-10-CM page on cms.gov  CMS Final Rule for case-mix diagnoses  Information is all ppyhysician/hos pital ifinforma tion  ftp://ftp.cdc.gov/pub/Health_Statistics/NCH  OASIS-C1/ICD-10 Guidance Manual, S/Publications/ICD10CM/2015/ quarterly Q&A’s  http:// cms.gov/Me dicare /Co ding /ICD10/201  Education on A&P&P, diagnosis selection, 5-ICD-10-CM-and-GEMs.html assessment,,,, documentation, intake cues,  Since coding involves clinical analysis, coding in ICD-10, any software upgrades, providers should code accurately and according OASIS updates, SBAR and communication to the guidelines, rather than depending on code crosswalks or equivalence mapping. Tips for Change What questions do you have?

489  Make a ppypglan, set very specific goals [email protected]  Stay focused on the steps of the plan [email protected]  Believe you will succeed, but know success will not come easily  Selm an-Holm an & A ssoci ates, LL C   It’s about making progress, not doing everything Home Health Insight ppyerfectly from the start  CoDR—Coding Done Right—home  You can develop new abilities through work and health and hospice outsource for coding practice, so push through the setbacks and and coding audits challenges  CodeProUniversity—role based  Focus on what you will do, not what you won’t or can’t do comprehensive online ICD-10-CM training for home health and hospice