Coding Clinic for ICD-10-CM/PCS Update - wolterskluwerlb.com

1 Libman, MS, RHIA, CDIP, CCS, CCS-P, CICP resident, Libman EducationPresident, Barry Libman Clinic for ICD-10-CM/PCS UpdateWolters Kluwer Law & BusinessOctober 8, 2015 Coding Clinicfor ICD-10- ClinicGuidanceICD-9 Coding Clinics(containing ICD-10 guidance)Q4 2012Q1 2013Q2 2013Q3 2013Q4 2013 ICD-10 Coding ClinicsQ1 2014Q2 2014Q3 2014Q4 2014Q1 2015Q2 2015 (published 7/6/2015)Q3 2015 (any day ) Coding ClinictransitionCoding Clinicfirst Quarter 2013No plans to translate all previous issues ofCodingClinic for ICD-9-CMinto ICD-10-CM/PCS sincemany of the questions published arose out of theneed to provide clarification on the use of ICD-9-CM and would not be readily applicable to ICD-10- of GuidanceConventions of the ClassificationOfficial Coding GuidelinesCoding ClinicOfficial Coding Guidelines page 1 These guidelines are a set of rules that have been developed toaccompany and complement the official conventions and instructionsprovided within the ICD-10-CM itself. The instructions and conventionsof the classification take precedence over guidelines.

2 These guidelinesare based on the Coding and sequencing instructions in the Tabular Listand Alphabetic Index of ICD-10-CM, but provide additional to these guidelines when assigning ICD-10-CM diagnosiscodes is required under the Health Insurance Portability andAccountability Act (HIPAA). Today s topicsCoding ClinicGuidance:..guidance that is the same as in that is drastically to the to CCs allow coders to issues with multiple examplesPlus, brief IPPS 2016 UpdateAssigning Codes Using PriorEncounters Q3 2013 Question:Is there a guideline or rule that indicates that youshould only use the medical record documentationfor that specific visit/admission for diagnosis codingpurposes?Does each visit or admission stand alone?Would the coder go back to previous encounterrecords to assist in the Coding of a current visit oradmission?Assigning Codes Using PriorEncounters Q3 2013 Answer:Documentation for the current encounter should clearly reflect thosediagnoses that are current and relevant for that documented on previous encounters may not be clinicallyrelevant on the current physician is responsible for diagnosing and documenting allrelevant conditions.

3 A patient s historical problem list is notnecessarily the same for every is the physician s responsibility to determine the diagnosesapplicable to the current encounter and document in the patient srecord. When reporting recurring conditions and the recurringcondition is still valid for the outpatient encounter or inpatientadmission, the recurring condition should be documented in themedical record with each Codes Using PriorEncounters Q3 2013 Answer (continued):However, if the condition is not documented in the current healthrecord, it would be inappropriate to go back to previousencounters to retrieve a diagnosis without physician is an area where coders and/or department managers mayneed to educate physicians and/or practice managers on theneed to include complete diagnoses when outpatient services areordered and to continue to document chronic or longstandingconditions on each admission/encounter note this advice applies to both ICD-9-CM and Systolic Heart FailureQ2 2013 Question: Coding Clinic , Third Quarter 2008, p.

4 12, states decompensated indicates that there has been aflare-up (acute phase) of a chronic condition. Should this general definition of decompensated beapplied when assigning ICD-10-CM codes as well?For example, what is the appropriate ICD-10-CMcode assignment for a diagnosis of chronic systolicheart failure, currently decompensated?Decompensated Systolic Heart FailureQ2 2013 Answer:Assign code , Acute on chronic systolic heartfailure, for decompensated systolic heart previously stated decompensated indicates therehas been a flare-up (acute phase) of a Calculi Fragmentation andEvacuation Q2 2015 Question:A patient presents for transurethral treatment of acalculus of the left renal pelvis via endoscope was inserted, the stone was initiallyfragmented by laser lithotripsy, and some of theremaining fragments were removed endoscopicallyby basket via the is the appropriate body part value as well as theroot operation, fragmentation or extirpation ?Urinary Calculi Fragmentation andEvacuation Q2 2015 Answer:Assign the following ICD-10-PCS code for thefragmentation and removal of the stone from theleft renal pelvis:0TC48ZZ Extirpation of matter from left kidney pelvis,via natural or artificial opening endoscopicUrinary Calculi Fragmentation andEvacuation Q2 2015 Fragmentation would not be coded separately since it isinherent to the removal of solid matter such as a calculus or otherabnormal physiological byproduct from a body part is codedto the root operation Extirpation, and includes any previousfragmentation of the solid matter prior to its index to procedures under the term lithotripsy,with removal of fragments instructs see Extirpation.

5 Extirpation represents a range of procedures where thebody part itself is not the focus of the , the objective is to remove solid material such as aforeign body, thrombus, or calculus from the body code selection of the body part value is based on thelocation of the stone at the beginning of the ICD-9 2015 Lithotripsyureter removal of obstruction from ureter andrenal pelvisIndex ICD-10-PCS 2016 LithotripsyseeFragmentationwith removal of fragments seeExtirpationDiabetes and Osteomyelitis Q4 2013 Question: Coding Clinic , First Quarter 2004, pages 14-15,indicated that ICD-9-CM assumes a relationshipbetween diabetes and osteomyelitis when bothconditions are present, unless the physician hasindicated in the medical record that the acuteosteomyelitis is totally unrelated to the diabetes. Is the same relationship between diabetes andosteomyelitis true for ICD-10-CM?Diabetes and Osteomyelitis Q4 2013 Answer:No, ICD-10-CM does not presume a linkagebetween diabetes and provider will need to document a linkage orrelationship between the two conditions before itcan be coded as in the IndexOsteomyelitis Cerebral Infarction with Left-SidedWeakness Q1 2015 Question:An 88-year-old male patient is admitted secondary toa cerebral the final diagnostic statement, the providerdocumented acute cerebral infarction involving theright hemisphere with left-sided (nondominant)weakness.

6 How should left-sided weakness due to an acutecerebral infarction be coded when there is nospecific mention of hemiplegia/hemiparesis?Acute Cerebral Infarction with Left-SidedWeakness Q1 2015 Answer:Assign code , Cerebral infarction, unspecified, as theprincipal diagnosis. Assign code , Hemiplegia,unspecified affecting left nondominant side, as an unilateral weakness is clearly documented as beingassociated with a stroke, it is considered synonymouswith weakness outside of this clear association cannotbe assumed as hemiparesis/hemiplegia, unless it isassociated with some other brain disorder or Right-Sided Weakness Due toPrevious Cerebral Infarction Q1 2015 Question:The patient is a 72-year-old male admitted to thehospital, because of gastrointestinal provider documented that the patient had ahistory of acute cerebral infarction with residualright-sided weakness (dominant side), and orderedan evaluation ..What is the appropriate code assignment for residualright-sided weakness, resulting from an old CVAwithout mention of hemiplegia/hemiparesis?

7 Residual Right-Sided Weakness Due toPrevious Cerebral Infarction Q1 2015 Answer:Assign code , Hemiplegia and hemiparesisfollowing cerebral infarction, affecting rightdominant side, for the residual right-sidedweakness due to cerebral unilateral weakness is clearly documented asbeing associated with a stroke, it is consideredsynonymous with weakness outside of this clear associationcannot be assumed as hemiparesis/hemiplegia,unless it is associated with some other braindisorder or Mellitus Type 2 withKetoacidosis Q1 2013 Question:What is the correct code assignment for type 2diabetes mellitus with diabetic ketoacidosis?Diabetes Mellitus Type 2 withKetoacidosis Q1 2013 Answer:Assign code , Other specified diabetes mellitus withketoacidosis without coma, for a patient with type 2 diabeteswith the less than perfect limited choices, it was felt thatit would be clinically important to identify the fact thatthe patient has National Center for Health Statistics (NCHS), who hasoversight for volumes I and II of ICD-10-CM, has agreed toconsider a future ICD-10-CM Coordination and MaintenanceCommittee meeting Mellitus Type 2 withKetoacidosisIndex and DiabetesICD-10-CM Index:out of control code to Diabetes by type withhyperglycemiapoorly controlled code to Diabetes by type withhyperglycemiainadequately controlled code to Diabetes by typewith hyperglycemiaICD-9-CM Index:poorly controlled code to Diabetes by type with 5thdigit for not stated as uncontrolledDM with HypoglycemiaWhat about hypoglycemia ?

8 2 diabetes mellitus with 2 diabetes mellitus withhypoglycemia with 2 diabetes mellitus withhypoglycemia without comaEndoscopic Banding of EsophagealVarices Q4 2013 Question:A patient with hematemesis presents foresophagogastroduodenoscopy. The patient isfound to have esophageal varices, andtherefore, ligation of esophageal varices wasperformed using bands placed via a bandligation is the appropriate ICD-10-PCS body systemfor esophageal varices: gastrointestinal systemor lower veins?Endoscopic Banding of EsophagealVarices Q4 2013 Question (continued):In ICD-10-PCS, ligation is coded to the root operationocclusion. Therefore, if we use table 06L for occlusionof lower veins, there is the appropriate body part and adevice value for the bands (extraluminal device);However, there is no approach value for via natural orartificial opening , if we use the 0DL table for occlusion ofgastrointestinal system and use esophagus for thebody part, there is the appropriate approach value butthere is no device option for the is the appropriate ICD-10-PCS code assignment forendoscopic banding of esophageal varices?

9 Endoscopic Banding of EsophagealVarices Q4 2013 Answer:Esophageal varices are enlarged veins in the esophagus,which can spontaneously rupture and cause severebleeding. Endoscopic banding of esophageal varicesinvolves completely occluding blood flow and meets thedefinition of root operation occlusion. The lumen of the esophageal vein is being banded, not index under ligation states See occlusion. Endoscopic Banding of EsophagealVarices Q4 2013 Answer (continued):Assign the following ICD-10-PCS code:06L34 CZOcclusion of esophageal vein with extraluminaldevice, percutaneous endoscopic ICD-10-PCS tables currently do not use approachescontaining the phrase via natural or artificial opening forbody part values in the cardiovascular body use of this approach for blood vessel body parts couldchange over time if requests for additional codes aremade through the ICD-10-PCS Coordination andMaintenance Banding of EsophagealVarices Q4 201306L34 CZOcclusion of esophageal vein withextraluminal device, percutaneous endoscopic approachSection0 Medical and surgicalBody system6 Lower veinsRoot operationLOcclusionBody part3 Esophageal veinApproach4 Percutaneous endoscopicDeviceC Extraluminal deviceQualifierZ No qualifierEndoscopic Banding of EsophagealVaricesDevice Character for Port-A-CathPlacement Q4 2013 Question.

10 Venous access port. An incision was made in the anteriorchest wall and a subcutaneous pocket was created. Thecatheter was advanced into the vein, tunneled under theskin and attached to the port, which was anchored in thesubcutaneous pocket. The incision was closed in assigning an ICD-10-PCS code for insertion of a port-a-cath, what device character should we select?Would a port-a-cath be considered a reservoir (character W )or a vascular access device (character X )?Device Character for Port-A-CathPlacement Q4 2013 Answer:Code only the vascular access device (VAD). The device hasa small reservoir, but it does not function as a reservoir tostore medicine during the course of the ICD-10-PCS code as follows:0JH63 XZInsertion of vascular access device into chestsubcutaneous tissue and fascia, ICD-10-PCS, a percutaneous approach is defined as entry,by puncture or minor incision, of instrumentation through theskin or mucous membrane and any other body layersnecessary to reach the site of the Implantable Central VenousAccess Device (Port-a-Cath) Q2 2015 Question:In Coding Clinic , Fourth Quarter 2013, pages 116- 117,information was published about the device character for theinsertion of a totally implantable central venous accessdevice (port-a-cath).