Medtronic Structural Heart ICD-10 Coding for Hospitals Linda Holtzman RHIA, CCS, CCS-P, CPC,COC Clarity Coding January 2016 Disclaimer Reimbursement information provided by Medtronic is for illustrative purposes only and does not constitute legal advice. Information provided is gathered from third party sources and is subject to change without notice due to frequently changing laws, rules and regulations. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other third party payers as to the correct form of billing or the amount that will be paid to providers of service. The provider of service has the responsibility to determine medical necessity and to submit appropriate codes and charges for care provided. Please contact your local payers, reimbursement specialists and/or legal counsel for interpretation of coding, coverage, and payment policies. Medtronic does not promote the use of its products outside FDA-approved labeling. 2 Topics Background and Framework ICD-10-CM Diagnosis Codes ICD-10-PCS Procedure Codes DRG Impact Appendix : Key Resources Questions Attachment : Diagnosis Code Crosswalks 3 Background and Framework 4 Effective Date ICD-10 went into effect October 1, 2015. Use of ICD-10 in the United States was formally proposed in August 2008 and finalized in January 2009. Implementation of ICD-10 was initially scheduled for October 2013 and has been postponed twice since then. ICD-10 is effective by date of discharge, not by date of admission. ICD-10-CM for diagnosis codes and ICD-10-PCS for procedure codes go into effect together on the same date. 5 Who Uses What Hospitals, physicians and all other providers must use ICD-10 diagnosis codes. Hospitals must also use ICD-10-PCS procedure codes for inpatient cases. Implementation of ICD-10 does not affect use of CPT. Provider Setting Diagnoses Procedures Hospitals Inpatient ICD-10-CM ICD-10-PCS Hospitals Outpatient ICD-10-CM CPT Physicians Facility/Office ICD-10-CM CPT ASCs Outpatient ICD-10-CM CPT 6 ICD-10 Coding Guidelines Guidelines for use of ICD-10 are available from multiple credible sources. Instructions within the ICD-10 codebook itself The ICD-10 Official Guidelines for Coding and Reporting Coding Clinic and AHA Coding Clinic Advisor AHA ICD-10-CM and ICD-10-PCS Coding Handbook Minutes from meetings of the ICD-10 Coordination and Maintenance Committee ICD-10-PCS Reference Manual AHIMA ICD-10-PCS: An Applied Approach 7 General Equivalence Mappings General Equivalence Mappings (GEMs) are useful tools for going back-and-forth between ICD-9 and ICD-10 codes, for both diagnoses and procedures. Forward GEMs go from ICD-9 to ICD-10; Backward GEMs go from ICD-10 to ICD-9. The GEMs can be found at: http://www.cdc.gov/nchs/icd/icd10cm.htm#icd2105 http://www.cms.gov/Medicare/Coding/ICD10/ 2015-ICD-10-CM-and-GEMs.html GEMs can be a good starting place. But NCHS and CMS strongly recommend coding directly from the ICD-10 codebooks, as studies have consistently indicated that this is most accurate. 8 ICD-10-CM Diagnosis Codes 9 Diagnosis Code Structure Codes are organized by chapter, mostly by body system. The chapters are virtually identical to those in ICD-9-CM. Codes are alpha-numeric and can be 3 to 7 digits long. CategoryDecimal Details Extension T82.223A T 8 2 2 2 3 A Leakage of biological heart valve graft, initial encounter alpha number alpha or number Q21.3 Q 2 1 3 Tetralogy of Fallot I25.10 Atherosclerotic heart disease I 2 5 1 0 of native coronary artery without angina pectoris 10 Volume of Diagnosis Codes ICD-10-CM has far more diagnosis ICD-9-CM codes than ICD-9-CM and provides a 14,567 codes greater level of specificity. ICD-10-CM Example: Non-rheumatic aortic valve disorders 69,823 codes ICD-9-CM ICD-10-CM I35.0 Non-rheumatic aortic (valve) stenosis I35.1 Non-rheumatic aortic (valve) insufficiency (regurgitation) Aortic valve 424.1 I35.2 Non-rheumatic aortic (valve) stenosis with insufficiency disorders I35.8 Other non-rheumatic aortic valve disorders I35.9 Non-rheumatic aortic valve disorder, unspecified Example: Mechanical complication of coronary artery bypass graft ICD-9-CM ICD-10-CM T82.211A Breakdown (mechanical) of coronary artery bypass graft, initial encounter Mechanical complication T82.212A Displacement of coronary artery bypass graft, initial encounter 996.03 due to coronary artery bypass T82.213A Leakage of coronary artery bypass graft, initial encounter graft T82.218A Other mechanical complication of coronary artery bypass graft, initial encounter 11 Valve Disorders Aortic valve stenosis and pulmonary valve disorders default to non-rheumatic. Mitral valve stenosis and tricuspid valve disorders default to rheumatic. Valve disease with involvement of multiple valves (aortic, mitral, tricuspid) is coded as rheumatic whether documented as rheumatic or not. 12 Angina and Coronary Artery Disease Angina codes (I20) are not assigned separately if the patient also has CAD. A combination code is used instead. A cause-and-effect relationship between angina and CAD can be assumed.1 To code CAD in ICD-10-CM, the coder must know three things: Does the patient also have angina? What kind of vessel has coronary atherosclerosis? What kind of angina? Code Description Notes Atherosclerotic heart disease of native coronary artery I25.10 Use for CAD or ASHD NOS without angina without angina pectoris Atherosclerotic heart disease of native coronary artery I25.119 Use for CAD or ASHD NOS with angina with unspecified angina pectoris Atherosclerosis of coronary artery bypass graft(s), I25.709 Use for CAD or ASHD with CABG with angina unspecified, with unspecified angina pectoris 1. ICD-10-CM Official Guidelines for Coding and Reporting (Diagnoses), FY 2015, p.42 13 Device Complications Mechanical complication is defined the same way in ICD-10-CM as it is in ICD-9-CM. ICD-10-CM differentiates between mechanical complications of artificial valves and tissue valves. Code Description Notes Breakdown (mechanical) of heart valve prosthesis, initial T82.01xA Artificial valve devices (metallic) encounter Breakdown (mechanical) of biological heart valve graft, Tissue valve devices, including bio- T82.221A initial encounter prosthetics Occlusion of a coronary artery bypass graft due to atherosclerosis is not coded as a complication. Use I25.7 instead.2 ICD-10-CM has a specific code for infection of heart valve device. Code Description Notes Infection and inflammatory reaction due to cardiac valve T82.6xxA Heart valve devices (any type) prosthesis, initial encounter Infection and inflammatory reaction due to other cardiac T82.7xxA All other cardiac devices and vascular devices, implants, and grafts, initial encounter 2. AHA ICD-10-CM and ICD-10-PCS Coding Handbook, FY 2015, p.535 14 Device Complications For other (non-mechanical) complications, ICD-10-CM differentiates the type of complication but not the type of device. ICD-9-CM ICD-10-CM Other complication T82.817A Embolism of cardiac prosthetic devices, implants and grafts, initial encounter 996.71 due to heart valve T82.827A Fibrosis of cardiac prosthetic devices, implants and grafts, initial encounter prosthesis T82.837A Hemorrhage of cardiac prosthetic devices, implants, grafts, initial encounter Other complication T82.847A Pain from cardiac prosthetic devices, implants and grafts, initial encounter 996.72 due to other T82.857A Stenosis of cardiac prosthetic devices, implants and grafts, initial encounter cardiac device, T82.867A Thrombosis of cardiac prosthetic devices, implants, grafts, initial encounter implant and graft (including coronary Other specified complication of cardiac prosthetic devices, implants and T82.897A artery bypass graft) grafts, initial encounter Proposals have already been made to ICD-10 C&M Committee to create new codes that provide more detail on the specific device. 15 Status and Encounter ICD-9-CM ICD-10-CM Z95.3 Presence of xenogenic heart valve V42.2 Heart valve replaced by transplant (tissue) Z95.4 Presence of other heart valve replacement V43.3 Heart valve replaced by other means (artificial) Z95.2 Presence of prosthetic heart valve V45.81 Aortocoronary bypass status Z95.1 Presence of aortocoronary bypass graft Encounter for adjustment and management of V53.39 Fitting and adjustment of other cardiac device Z45.09 other cardiac device Code Z95.2 is used for the presence of a mechanical heart valve. It is also the default code for the presence of any non- native valve. Code Z95.3 is used for the presence of animal tissue valves, including bioprosthetics, eg. CoreValve. Code Z95.4 is used for the presence of a homograft valve. Expected end-of-life for a heart valve graft is not coded as a complication. Use Z45.09 instead.3 3. Coding Clinic, 2nd Q 2008 16 TAVR: Valve-in-Valve In mid-2015, transcatheter aortic valve replacement received a new indication for treatment of “failure” of a previously placed bioprosthetic valve. For coding purposes, the key factor is whether the “failure” is a complication or an expected occurrence. Scenario ICD-10-CM Malposition or displacement of T82.222A Displacement of biological heart valve graft, initial encounter previously placed valve Premature stenosis of the Stenosis of cardiac prosthetic devices, implants and grafts, T82.857A previously placed valve initial encounter Premature regurgitation of the T82.223A Leakage of biological heart valve graft, initial encounter previously placed valve Expected degeneration of Encounter for adjustment and management of other cardiac Z45.09 previously placed valve (end-of-life) device Seventh digit “A” is correct for the complication codes because active treatment is provided for the valve failure.4 4. Coding Clinic, 1st Q 2015 17 ICD-10-PCS Procedure Codes 18 ICD-10-PCS Format Codes are alpha-numeric and are always 7 digits long.