ICD-10-CM Updates ICD-10-PCS Updates General guideline updates By chapter: Guidelines Expanded ICD-10-PCS Updates

ICD-10-CM Overview 360 Additions 142 Deletions 226 Revisions 71,704 valid ICD-10-CM codes for 2018

FYI 2018 CM Guidelines Section I: Conventions

Chapter 1-Certain Infectious and Parasitic Diseases

Chapter 1 A04.7 Enterocolitis due to Clostridium difficile A04.71 recurrent A04.72 not specified as recurrent ACG defines recurrence as “episode of CDI that occurs 8 weeks after the onset of a previous episode, provided the symptoms from the previous episode resolved” C-diff is on e of the most common HAI’s (healthcare-associated infection) Significant cause of morbidity and mortality Recurrence is associated with greater morbidity and is managed differently

Chapter 4: Endocrine, Nutritional and Metabolic Diseases Guideline updates: Use of insulin or oral hypoglycemic drugs If these drugs are routinely used the Z79 code(s) should be assigned If the patient routinely uses both, only the long term use of insulin Z79.4 should be reported Do not assign Z79.4 if insulin is given temporarily to control an event during the encounter Applies to secondary diabetes as well I.C.4.a.3. and I.C.6.a.

Added DKA in DM Type II E11.1 Type 2 diabetes mellitus with ketoacidosis E11.10 Type 2 DM with ketoacidosis without coma E11.11 Type 2 DM with ketoacidosis with coma •Type 2 DM with DKA is a rare occurrence but it occurs

Ch 5: Mental, Behavioral & Neurodevelopmental ICD-10-CM has had dependence in remission 2018 introduces ABUSE in remission Better aligns ICD-10 CM with DSM-5 classification and terminology

Ch 7: Disease of the Eye and Adnexa I.C.7.b. Blindness If “blindness” or “low vision” of both eyes is documented but the visual impairment category is not documented, assign code H54.3, Unqualified visual loss, both eyes. If “blindness” or “low vision” in one eye is documented but the visual impairment category is not documented, assign a code from H54.6-, Unqualified visual loss, one eye. If “blindness” or “visual loss” is documented without any information about whether one or both eyes are affected, assign code H54.7, Unspecified visual loss

Ch 9: Disease of the Circulatory System Pulmonary hypertension (PH) I27 is now classified into five groups •Group 1: Pulmonary Arterial Hypertension (PAH) •Group 2: PH due to left heart disease •Group 3: PH due to lung diseases and/or hypoxia •Group 4: Chronic Thromboembolic PH (CTEPH) •Group 5: PH with unclear

Pulmonary HTN New codes were created to better represent the current clinical classification of PH

MI guideline update and new codes I.C.9.e.5. Other types of MI Type 1 assigned to I21.0-I21.4 (depending on site) Type 2 -due to demand ischemia or ischemic balance – I21.A1 Type 2 described as NSTEMI or STEMI assign code I21.A1 Type 3, 4a, 4b, 4c and 5 – I21.A9 Other MI type Acute MI, unspecified I21.9 Code also and code first notes should be followed

MI

Types of MI

Other Forms of Heart Failure added •New codes allocated to: Right heart failure Acute right heart failure Chronic right heart failure Acute on chronic right heart failure Right heart failure due to left heart failure Biventricular heart failure High output heart failure End stage heart failure Also known as Stage D heart failure

Other forms of heart failure New codes provide additional information about heart failure characteristics Code also notes instruct us to use these codes in addition to traditional heart failure codes

Ch 10 Respiratory Tabular change impacts sequencing of COPD with… The change to the COPD and PNA is in the wording at the instructional note for COPD.  J44.0 use to read “use additional code" meaning the COPD had to be the coded first with PNA as a secondary code but the new instructional note says "CODE ALSO" meaning either the PNA or the COPD can be PDX - depending on the reason for admit and the treatment.

Ch 11: Disease of the Digestive system Expanded Intestinal obstruction categories (cc)---4 codes expanded to 12 (2017 did not describe the severity) K56.5 Adhesions (bands) 5th character K91.3 Postprocedural 0- unspecified 1-partial 2-complete K56.60 Unspecified 6th character K56.69 Other specified 0-partial 1-complete 2-unspecified

Ch 12: Disease of the Skin and Subcutaneous Tissue I.C.12.b. Non-pressure Chronic Ulcers Documented as healed = no code Documented as healing = appropriate severity based on documentation POA but healed on d/c = site and severity at the time of admission Progresses to another severity during the same encounter = two codes, one on admission and one for the highest severity reported during the stay

New codes for Non-pressure ulcers (cc) Non-pressure chronic ulcer severity Expansion within L97 and L98.4 to accommodate non-pressure chronic ulcers WITHOUT necrosis New 6th character for lower extremities 5 – muscle involvement w/o necrosis 6 – bone involvement w/o necrosis 8- other specified severity

New chronic ulcer codes…

Ch 13: Musculoskeletal & Connective Tissue Expanded M48.06 Lumbar Stenosis Without neurogenic claudication – M48.061 With – M48.062

Ch 14 Genitourinary Specific location of breast lump(s) •Proposed by ACOG (American College of Obstetricians) •New codes provide information about laterality and quadrant

Ch 15: Pregnancy, Childbirth and the Puerperium Maternal care for abnormalities of the fetal heart rate or rhythm Previous option only allowed for coding of fetal heart rate/rhythm abnormalities occurring in labor and delivery Follows 7th character conventions for affected fetus O368330 Maternal care for abnormalities of the fetal heart rate or rhythm, third trimester, not applicable or unspecified

Ectopic pregnancy Ectopic pregnancy laterality •Expansion allows for coding of laterality of ectopic pregnancy (e.g. right ovary) •Increased incidence of coexisting intrauterine and ectopic pregnancies

Ch 18: Symptoms, Signs and Abnormal Clinical and Lavatory findings Added R06.03-Acute Respiratory Distress Remains a CDI opportunity if clinically supported

Revised Z Codes Z68.1 Body mass index (BMI) 19 or less, adult –changed to 19.9 or less Z79.890 Hormone replacement therapy (postmenopausal) – removed (postmenopausal)

New Additions to the MCC List Code Description E11.10 Type 2 diabetes mellitus with ketoacidosis without coma E11.11 Type 2 diabetes mellitus with ketoacidosis with coma I21.9 Acute myocardial infarction, unspecified I21.A1 Myocardial infarction type 2 I21.A9 Other myocardial infarction type P29.30 Pulmonary hypertension of newborn P29.38 Other persistent fetal circulation

New additions to the CC list Code Description A04.71 Enterocolitis due to Clostridium difficile, recurrent A04.72 Enterocolitis due to Clostridium difficile, not specified as recurrent C96.20 Malignant mast cell neoplasm, unspecified C96.21 Aggressive systemic mastocytosis C96.22 Mast cell sarcoma C96.29 Other malignant mast cell neoplasm D47.01 Cutaneous mastocytosis D47.02 Systemic mastocytosis D47.09 Other mast cell neoplasms of uncertain behavior E85.81 Light chain (AL) amyloidosis E85.82 Wild-type transthyretin-related (ATTR) amyloidosis E85.89 Other amyloidosis G12.23 Primary lateral sclerosis G12.24 Familial motor neuron disease G12.25 Progressive spinal muscle atrophy

New additions to the CC list Code Description K56.50 Intestinal adhesions [bands], unspecified as to partial versus complete obstruction K56.51 Intestinal adhesions [bands], with partial obstruction K56.52 Intestinal adhesions [bands] with complete obstruction K56.600 Partial intestinal obstruction, unspecified as to cause K56.601 Complete intestinal obstruction, unspecified as to cause K56.609 Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction K56.690 Other partial intestinal obstruction K56.691 Other complete intestinal obstruction K56.699 Other intestinal obstruction unspecified as to partial versus complete obstruction K91.30 Postprocedural intestinal obstruction, unspecified as to partial versus complete K91.31 Postprocedural partial intestinal obstruction

New additions to the CC list Code Description L97.**5 Non-pressure chronic ulcer of (lower extremity)with muscle involvement without evidence of necrosis L97.**6 Non-pressure chronic ulcer of (lower extremity)with bone involvement without evidence of necrosis L97.**8 Non-pressure chronic ulcer of (lower extremity)with other specified severity L98.4*5 Non-pressure chronic ulcer of skin NEC with muscle involvement without evidence of necrosis L98.4*6 Non-pressure chronic ulcer of skin NEC with bone involvement without evidence of necrosis L98.4*8 Non-pressure chronic ulcer of skin NEC with other specified severity Note: All ulcers classifiable to category L97 are designated CCs Note: Only ulcers classifiable to 6th character 5, 6, or 8 in subcategory L98.4 are designated CCs!

New additions to the CC list CODE DESCRIPTION M33.03 Juvenile dermatomyositis without myopathy M33.13 Other dermatomyositis without myopathy M33.93 Dermatopolymyositis, unspecified without myopathy O00.101 Right tubal pregnancy without intrauterine pregnancy O00.102 Left tubal pregnancy without intrauterine pregnancy O00.109 Unspecified tubal pregnancy without intrauterine pregnancy O00.111 Right tubal pregnancy with intrauterine pregnancy O00.112 Left tubal pregnancy with intrauterine pregnancy O00.119 Unspecified tubal pregnancy with intrauterine pregnancy O00.201 Right ovarian pregnancy without intrauterine pregnancy O00.202 Left ovarian pregnancy without intrauterine pregnancy O00.209 Unspecified ovarian pregnancy without intrauterine pregnancy O00.211 Right ovarian pregnancy with intrauterine pregnancy O00.212 Left ovarian pregnancy without intrauterine pregnancy O00.219 Unspecified ovarian pregnancy with intrauterine pregnancy

ICD-10 PCS CHANGES 3562 new codes 1821 revised codes 646 deleted codes

Update to general guidelines B4.1c body part If a procedure is performed on a continuous section of a tubular body part, code the body part value corresponding to the furthest anatomical site from the point of entry. Example: A procedure performed on a continuous section of artery from the femoral artery to the external iliac artery with the point of entry at the femoral artery is coded to the external iliac body part.

Guideline B4.1c Application Read the documentation to determine the point of entry Determine the direction in which procedure performed such as distal from entry, proximal from entry, or both Locate the furthest anatomical site from the point of entry in each direction. Use an anatomical drawing of body parts if needed Select the code for each of the furthest anatomical sites

Update to general guidelines B6.1a A device is coded only if a device remains after the procedure is completed. If no device remains, the device value No Device is coded. In limited root operations, the classification provides the qualifier values Temporary and Intraoperative, for specific procedures involving clinically significant devices, where the purpose of the device is to be utilized for a brief duration during the procedure or current inpatient stay.

Guideline Changes Short term external heart assist system is a device found in the 02H and 02P tables New qualifier for J, Intraoperative New qualifier for S, Biventricular

Example Section 0 Medical and Surgical Body System 2 Heart and Great Vessels Operation H Insertion: Putting in a nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part Body Part Approach Device Qualifier A Heart 0 Open Q Implantable Heart Assist System Z No Qualifier 3 Percutaneous Y Other device 4 Perc endoscopic A Heart 0 Open R Short-term external Heart Assist J Intraoperative 3 Percutaneous System S Biventricular 4 perc endoscopic Z No Qualifier

IMPACTFUL CHANGES (root operation) EXTRACTION PROCEDURES (ASPIRATIONS AND BRUSH BIOPSY) • CMS added the root operation Extraction to the lymphatic, respiratory and gastrointestinal body systems to capture additional detail, including percutaneous aspiration biopsies and brush biopsies FY 2018 Example: FNA of right cervical LN and Endoscopic brush biopsy of lower esophagus • Will supersede CC guidance advising the use of other root operations (e.g. Excision) for these types of procedures

IMPACTFUL CHANGES (device) OXIDIZED ZIRCONIUM ON POLYETHYLENE BEARING SURFACE FOR HIP & KNEE ARTHROPLASTY Oxidized zirconium on polyethylene is a type of ceramic bearing surface Fracture resistance benefits of a traditional metal implant Reduced friction of ceramic implants • Distinct from conventional ceramic • Used in over 90K hip and knee replacements annually

IMPACTFUL CHANGES (body part) COMMON HEPATIC DUCT PROCEDURES Body part value 7, Common Hepatic Duct was added to 15 Root Operations in the Hepatobiliary System and Pancreas Body System

IMPACTFUL CHANGES body part LOWER ARTERY BYPASS Allows for coding of arterial bypass procedures performed on distal lower extremities Decreases need to refer to Body Part Key Much less common than bypass procedures on proximal lower extremities B3.6a Bypass procedures are coded by identifying the body part bypassed “from” and the body part bypassed “to.” The fourth character body part specifies the body part bypassed from, and the qualifier specifies the body part bypassed to.

IMPACTFUL CHANGES (approach) PERCUTANEOUS HEART VALVE PROCEDURES Allows for coding of trans-catheter tricuspid valve replacements Tricuspid valve is least treated of the four heart valves valve revisions

IMPACTFUL CHANGES (body part) EXTIRPATION FROM SPINALCANAL Added Body Part value U, Spinal Canal Allows for coding of spinal epidural hematoma evacuation SHE/PSEH usually the consequence of surgical intervention of the spine Evacuation involves re-exploring the operative site and removing clot/hematoma

IMPACTFUL CHANGES (body part) CRANIAL MENINGEAL SPACE Revised the title of the body part values: 3, Epidural Space to Epidural Space, Intracranial 4, Subdural Space to Subdural Space, Intracranial 5, Subarachnoid Space to Subarachnoid Space, Intracranial

IMPACTFUL CHANGES (device) VASCULAR ACCESS RESERVOIR Device title revisions make PCS terminology more consistent with clinical terminology Codes describe proximal aspect of CVC TIVAD = no part of CVC is external to body Use tunnel or implanted for long term use (>30 days) of IV drugs therapy such as chemo, or therapeutic infusions for CF patients

IMPACTFUL CHANGES (qualifier) DRUG-COATED BALLOON DILATION OF LOWER ARTERIES Expanded use of Qualifier ‘Drug Coated Balloon’ across additional lower arteries FDA approved drug-coated balloons (DCB)  Lutonix® (CR Bard) Drug-coated Balloon (DCB) Percutaneous Transluminal Angioplasty (PTA) Catheter  In.Pact™ Admiral (Medtronic), Paclitaxel Coated Percutaneous Transluminal Angioplasty (PTA) Balloon  StellarexTM Drug-coated Angioplasty Balloon arteries

IMPACTFUL CHANGES (qualifier) TIPS PROCEDURE Transjugular intrahepatic portosystemic shunt Reduces portal HTN and associated complications Performed by interventional radiologists Added qualifier for “hepatic vein” Added device “synthetic substitute”

IMPACTFUL CHANGES (qualifer) SUPRACERVICAL HYSTERECTOMY Created new qualifier value L Supracervical within Root Operation Resection Allows for code level differentiation of hysterectomy procedures independent of other procedure codes

IMPACTFUL CHANGES (qualifier) INSERTION OF EXTERNAL HEART ASSIST DEVICES Device title change reflects short term nature of these external devices Qualifier ‘Intraoperative’ allows for identification of procedures where procedure is removed at the conclusion of the procedure Qualifier ‘Biventricular’ added to coding path for Removal and Revision for short term external heart assist systems

IMPACTFUL CHANGES (qualifier) TRAM FLAP Added new qualifier values for Latissimus Dorsi Myocutaneous Flap, Deep Inferior Epigastric Artery Perforator Flap, Superficial Inferior Epigastric Artery Flap, and Gluteal Artery Perforator Flap, for root operation Transfer Provides additional information about pedicled breast reconstruction flaps using trunk muscles More specificity

IMPACTFUL CHANGES (qualifier) The HeRO Graft is a hemodialysis access graft for patients who are failing fistulas or grafts or are catheter-dependent due to the blockage of veins leading to the heart Addition of Body Part Value V, Superior Vena Cava allows for appropriate coding of the venous outflow component

IMPACTFUL CHANGES (qualifer) ADMINISTRATION OF INFLUENZA VACCINE Added Qualifier value 0, Influenza Vaccine Allows for influenza vaccinations to be coded (and tracked) separately Provides another data point to help understand vaccination efficacy and ideal vaccination Previously pneumonoccla, mmr, influenza etc were coded to same code

IMPACTFUL CHANGES (qualifer) MANUAL REMOVAL OF RETAINED POC Allows for differentiation of manual removal of products of conception (e.g. placenta) vs other techniques

IMPACTFUL CHANGES (administration) MEDICAL INDUCTION OF LABOR Added Substance value V, Hormone Captures detail for administration of substances for medical induction of labor Dinoprostone (Cervidil) and Misoprostol (Cytotec, more commonly used in the US) are two types of prostaglandins used for labor induction*** Administered in gel form or as a pessary

IMPACTFUL CHANGES (new technology) SPINAL FUSION WITH RADIOLUCENT INTERBODY FUSION DEVICE Added multiple codes to describe spinal fusion using a radiolucent porous interbody fusion device Examples: COHERE by Vertera Spine, COALESCE by Vertera Spine

IMPACTFUL CHANGES (performance) RENAL PLACEMENT THERAPY New Duration Values allow for the coding and specification of RRT type 7, Intermittent, Less than 6 Hours Per Day: This is your routine dialysis, normally performed 3-4 hours per treatment, every other day 8, Intermittent, 6-18 hours Per Day: Used to code PIRRT or Prolonged Intermittent Renal Replacement Therapy, is administered between 8-12 hours per day on several or all days of the week 9, Continuous, Greater than 18 Hours Per Day: Used to code CRRT or Continuous Renal Replacement-administered 24 hrs per day Current ICD-10-PCS codes categorize hemodialysis as a "single" episode of treatment, or "multiple" treatments

IMPACTFUL CHANGES (simplification) Diaphragm-laterality no longer needed Section 0 Medical and Surgical Body System B Respiratory System Operation B Excision: Cutting out or off, without replacement, a portion of a body part Body Part Approach Device Qualifier T Diaphragm 0 Open Z No Device X Diagnostic 3 Percutaneous Z No Qualifier 4 Percutaneous Endoscopic

IMPACTFUL CHANGES (simplification) Omentum – laterality no longer needed Section 0 Medical and Surgical Body System D Gastrointestinal System Operation 5 Destruction: Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent Body Part Approach Device Qualifier U Omentum 0 Open Z No Device Z No Qualifier 3 Percutaneous 4 Percutaneous Endoscopic greater or lesser----deleted

IMPACTFUL CHANGES (simplification) Saphenous - no longer need to specify greater or lesser saphenous vein Section 0 Medical and Surgical Body System 6 Lower Veins Operation B Excision: Cutting out or off, without replacement, a portion of a body part Body Part Approach Device Qualifier P Saphenous vein, right 0 Open Z No Device X Diagnostic Q Saphenous vein, left 3 Percutaneous Z No Qualifier 4 Percutaneous Endoscopic No longer greater or lesser needed

References Center for Medicare and Medicaid Services (CMS) MedLearn Media, INC. ICD University Optum 360 ICD-10-PCS Official Coding Guidelines FY2018 ICD-10-CM Official Coding Guidelines FY2018 ICD-10 Coding Clinic