ICD-9-CM Coding for Post Acute Care Presented by: Rhonda Anderson, RHIA, President Anderson Health Information Systems, Inc. AHIS, Inc. 714/558-3887

Objectives Participants will : Correctly assign ICD-9-CM codes to diagnoses Correctly identify primary / Secondary diagnoses Identify correct sequence of diagnoses for coding assignment Identify difference between ICD-9-CM and ICD-10 Learn ICD-10 transition timeline

Purpose of ICD-9-CM Coding Gather statistical data Reporting diagnoses and provides a method for sequencing diagnosis to support billing transactions / reimbursement Ensure compliance with Federal Reporting Standards for diagnoses Provide insight into the types of residents and conditions Health Research AHIS, Inc. 714/558-3887

ICD-9-CM Official Guidelines for Coding and Reporting HIPAA www.cdc.gov/nchs/icd.htm Latest revision October 1, 2011 AHIS, Inc. 714/558-3887

Post Acute Care Skilled Nursing Facility (SNF) Inpatient Rehab Facility (IRF) Home Health Agency (HHA) Long Term Acute Care Hospital (LTACH)

ICD-9-CM Coding book Disease and Procedures (Books 1-3) Alphabetical/Tabular (numeric) Index

Assigning Code Numbers Both the Alphabetic Index and the Tabular List must be used when locating and assigning a code. Do not rely on just one since this can lead to errors in code assignment and a less specific code selection

How to Select Codes Locate each main term and sub term in the alphabetical index, i.e., Chronic Kidney Disease 1. Disease 2. Kidney 3. Chronic Verify the code selected in the Tabular list Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List 585.9 AHIS, Inc. 714/558-3887

Code to the Highest Level of Specificity Assign 3 digit codes only if there are no four digit codes within the category. There are only 100 codes with only 3 digits Assign 4 digit codes only if there is no fifth digit. Assign 5 digit codes when indicated. Samples – 486, 401.x, 250.xx

Types of Codes used in post acute care Settings Aftercare – used when the initial treatment of a disease or injury has been performed and the patients still requires continued care to heal or recover. Categories V51-V58 Late Effects – a late effect is a residual condition that remains and requires medical evaluation, rehab treatments and/or nursing care after the initial illness or injury. AHIS, Inc. 714/558-3887

Types of Codes -2 Chronic Conditions – Conditions that are stable but still require management or treatment. Acute Conditions –acute care codes should only be reported until the condition is resolved. Therapy – Physical, occupational, speech and respiratory therapy.

Types of Codes -3 History of – (Hx) – history codes are acceptable on any Medical record regardless of reason for admission/encounter. A history code is distinct from a “status” code in that history codes indicate that the patient no longer has the condition and “status” codes indicated a present state. There are two types of history V-codes, personal and family.

Examples Status post upper arm fracture V54.11 History of frequent falls V15.88 Admission for physical therapy following hip fracture V57.1 , V54.13

Practice #1 (cont.) Hemiplegia due to recent CVA Total Hip Replacement Acute UTI treated with Cipro. Dementia Late Effect After Care Acute Condition Chronic Condition

What to code? ALL CONDITIONS THAT EXIST AT THE TIME OF ADMISSION, THAT EFFECT TREATMENT RECEIVED

Do NOT Code DIAGNOSES THAT DO NOT AFFECT TREATMENT OR LENGTH OF STAY WHEN CONDITION NO LONGER EXISTS DO NOT ASSIGN PROCEDURE CODES Examples: Fractured forearm 6 years ago, pneumonia, UTI that were resolved (these will only be coded if the Resident is admitted with Antibiotics) FOR EXAMPLE FRACTURED HIP, 7 YEARS AGO, HEALED (DO NOT CODE) STATUS POST PNEUMONIA OR UTI (DO NOT CODE UNLESS RES. IS STILL ON ABT TX) AHIS, Inc. 714/558-3887

Definition of Principal Diagnosis “FIRST LISTED DIAGNOSES” is the diagnosis that is chiefly responsible for the admission to the facility and the diagnosis that supports the reimbursement and should be sequenced first.”

Locating Diagnoses Transfer Records History & Physical Progress Notes Admission Orders Add abnormal ancillary reports, x-rays, etc. also look at consultations. Mark that as secondary review. AHIS, Inc. 714/558-3887

Additional Sources of Information Discharge summary Transfer documentation, Surgical reports Consultations Physician Progress notes Lab reports and radiological studies

Locating Principal Diagnosis

Principal Diagnosis When two or more inter-related conditions potentially meet the definition of principal diagnosis Either may be sequenced first unless therapy is being provided, the Tabular list or Alphabetic Index indicate otherwise. Inter-related conditions – two or more diagnosis that equally meet the definition of principal diagnosis. I would add a slide abut inter-related conditions and explain in a slide, too. These are not experienced people usually even if they Have coded, AHIS, Inc. 714/558-3887

Example Resident admitted with Pneumonia and UTI – either can be used as the principal diagnosis if the resident is still receiving antibiotic therapy

Choose the Principal Diagnosis Fall 3 months ago Chronic kidney disease Above the knee amputation Rt. Leg (10 days ago) with infection still on antibiotics Anemia

Non-Specific Codes NEC – Not Elsewhere Classified NOS – Not Otherwise Specified Codes are used only when neither the diagnostic statement nor a thorough review of the clinical record provides adequate information to permit assignment of a more specific code

Inclusion Terms The coder must review the titles and inclusions under the three or four digit category to determine if the diagnosis is included in the category; however, the specific diagnosis may not always be listed Example: Spinal Cord Inflammation 323.9

Combination Codes Single codes used to classify two diagnosis or a diagnosis with a manifestation Example: Candidiasis with meningitis 112.83

Combination Codes Etiology codes – USE ADDITIONAL CODE Manifestation codes – CODE 1st Underlying Dx. Codes in parentheses identify conditions that require multiple coding. Also, codes in parentheses CAN NOT be sequenced as PRINCIPAL Dx. 331.0 Alzheimer's Disease 294.10 Dementia in conditions classified elsewhere *Dementia of the Alzheimer’s Type* Tabular list directs you to code underlying physical condition first as: Alzheimer’s disease (331.0) AHIS, Inc. 714/558-3887

Multiple Coding Instructions for conditions that require multiple coding can appear in the Tabular List. “Code also underlying disease”, “Use additional code, if desired, to identify manifestation, as …” “Code also” instructs the coder to: Code the underlying disease, or etiology first as the primary diagnosis, followed by the code (s) for manifestation (s). It is mandatory to follow the “code also” instructions to assign both codes.

Combination Codes Anosmia following CVA 438.6, 781.1 “with”, “with mention of”, or “associated with” – this code can only be used if both conditions are present Kidney Infection …..590.9 with Calculus 592.0

Slanted Brackets [ ] Indicate proper sequencing for the two codes listed. The code number before the bracket is coded first. The code number inside the brackets is coded second. Codes in brackets in the alphabetic index can NEVER be sequenced as the principal diagnosis. AHIS, Inc. 714/558-3887

EXAMPLES 1.Arthritis, arthritic --- due to or associated with hypothyroidism 244.9 [713.0]

Multiple Coding Examples: Aftercare following kidney transplant V58.44 (aftercare involving organ transplant), V42.0 (Organ/tissue replacement by transplant , kidney) Aftercare following arteriocoronary bypass V58.73 (aftercare following surgery of the circulatory system), V45.81(aortocoronary bypass status)  use aftercare codes to provide better detail AHIS, Inc. 714/558-3887

Sequencing Multiple Codes “Using Additional Codes” When the instructions say “Use additional code….” the additional code is sequences second. Example UTI due to E.coli 599.0 [041.4]

“Exclusions” Let’s have a look: See 429 section Under Cardiovascular Disease, Unspecified Excludes: That due to hypertension

Diagnosis Sequencing The order in which codes are listed is called sequencing. The coder should make every effort to record the codes in a logical sequence that is descriptive of the resident’s condition. AHIS, Inc. 714/558-3887

Acute Diagnoses Acute dx treated in the hospital should be coded until the condition is resolved, after the resident is transferred to the SNF Examples: MRSA Pneumonia UTI

Secondary Diagnoses May have multiple secondary codes List and code conditions related to therapy and services provided Review and update as condition changes – sequence may change over time Billing staff should work with Nursing and Health Information Department to know which diagnoses are current, which is principal, etc. AHIS, Inc. 714/558-3887

Secondary Diagnoses Order by complexity. Assign the condition with the higher complexity first. (those that require the most resources i.e. wound care vs. hypertension) All conditions present at the time of admission, and that affect the treatment provided and length of stay should be coded. AHIS, Inc. 714/558-3887

Late Effects Residual condition After initial / acute phase of illness

438 Late Effects of CVA Official coding guidelines state that Category 438 is used for admission and encounter for post acute care following treatment of the CVA in the acute hospital Codes from categories 430 to 436 are reserved for the “initial” (first) episode of care for an acute CVA that was provided in the qualifying hospital stay and should not be used in SNF

Let’s Practice Which of the following is a late effect? a. End stage renal disease b. Anosmia following recent CVA c. Diabetic retinopathy d. Paraplegia due to polio B&C AHIS, Inc. 714/558-3887

Let’s Code Left hemiplegia secondary to CVA (patient is right handed) Late Effects Cerebrovascular disease With hemiplegia – nondominant side 438.22 AHIS, Inc. 714/558-3887

Infections Codes from categories 041 or 079 can be used as principal diagnosis as long as the nature or site of the infection is not specified or when the Alphabetical index instructs you to do so.

Code it Gastroenteritis due to E.coli 008.00 MRSA infection of Lt. toe 041.12 Herpetic septicimia 054.5 008.00 2. 041.12 3. 054.5 AHIS, Inc. 714/558-3887

Neoplasms Go to alphabetic index Look up Ex: fibroma, upper jaw Find “fibroma” Cross reference “see neoplasm, by site, benign” Turn to neoplasm locate sub term “Jaw / upper” Follow across to Benign Locate code 213.0 Go to Tabular list for any coding instructions or notes*

Neoplasms of Uncertain Behavior Only used when stated as such in Alpha Index Unspecified Behavior – Only used when Neoplasm is not fully described Or not specified as to behavior Or listed in Alphabetic index Ex: Neoplastic Cyst of Tongue Cross reference Alpha Index Under Cyst, neoplastic see neoplasm, by site, unspecified nature AHIS, Inc. 714/558-3887

Neoplasms with Metastasis Two codes One for primary (original site) One for each secondary site Code primary before secondary Except when using “V” code for primary site that has been surgically removed

Neoplasms with Metastasis Determine the primary site Turn to Neoplasms Table Ex: Carcinoma of Rectum (154.1) Find Neoplasm, rectum, malignant, primary AHIS, Inc. 714/558-3887

Neoplasms with Metastasis Ex: Secondary malignant neoplasm of prostate (198.82) Find Neoplasm, prostate, malignant, secondary Determine the site(s) of metastasis Turn to Neoplasm table Find correct sub term(s) for site Cross over to Malignant and column secondary AHIS, Inc. 714/558-3887

Unknown secondary sites Ex: Cancer of Lower lobe of lung with metastases (162.5, 199.0) Code primary site first To code the unknown secondary site Refer to Neoplasm table Multiple sites NEC Cross over to column for code (199.0) pp. 155, 156 AHIS, Inc. 714/558-3887

Unknown Primary Site Refer to neoplasm table Unknown or Unspecified site Cross over to primary column 199.1 Sequence after secondary site(s) Ex: abdominal metastasis from unknown origin (198.89, 199.1) Unknown primary would not be used as principle diagnosis in SNF The metastatic site is coded first AHIS, Inc. 714/558-3887

“V” Codes for Cancer Primary site must still be identified if removed, eradicated no longer under treatment Use a personal history V-code, History, site, malignant neoplasm Identify primary site responsible for metastasis but no longer present Secondary site code is sequenced first and then the V-code AHIS, Inc. 714/558-3887

“V” Codes for Cancer Do not use codes from category V10 for secondary metastatic sites removed or not ICD-9-CM does not provide code numbers for “history of secondary neoplasm site

V58.42 Neoplasm Official coding guidelines for neoplasm apply when using the aftercare following surgery for neoplasm V58.42 Aftercare code V58.42 may be used with either the current neoplasm code or a code from category V10, whichever is applicable AHIS, Inc. 714/558-3887

Code It History of breast cancer with metastasis to the lung 197.0, V10.3 Carcinoma of prostate with metastasis to spine 185, 198.5 Basal cell carcinoma of chest 173.5 197.0, V10.3 185, 198.5 173.5 AHIS, Inc. 714/558-3887

Endocrine, Nutritional and Metabolic Diseases and immunity disorders Examples: Hypothyroidism Diabetes Metabolic disorders Obesity

Code It Hypothyroidism due to history of thyroid cancer (thyroid removed) 244.0, V10.87 Uncontrolled, Type II Diabetes 250.01 244.0, V10.87 250.02 AHIS, Inc. 714/558-3887

Manifestations Codes There are written instructions in ICD-9-CM coding books for sequencing codes. The underlying Dx (cause/s) coded first, followed by codes for manifestations.

Combination Codes Some Diabetic Conditions Require 2 Codes “Diabetic” or “Due to” One Code for Cause One Code for Complication Always sequence cause before complication AHIS, Inc. 714/558-3887

Combination Codes Example: Diabetic foot ulcer Diabetes with other manifestation 250.8x Ulcer of lower limb, except decubitus 707.1x AHIS, Inc. 714/558-3887

Manifestation Codes Diabetic Neuropathy Diabetes with neurological manifestations must be coded first (250.60) The tabular list will guide you to “Use additional code to identify manifestation, as:” Polyneuropathy in diabetes (357.2) The tabular section will tell you that this code is not allowed as a principal Dx and will guide you to code underlying disease, as (Diabetes with complication…)

Let’s Code 1. ALZHEIMER’S DEMENTIA 331.0, 294.10 2. DIABETIC GLAUCOMA 250.50, 365.9 331.0, 294.10 250.50, 365.9 AHIS, Inc. 714/558-3887

Chronic Illnesses Chronic illnesses that are managed with medication or treatments, such as hypertension, hypothyroidism, diabetes mellitus, atrial fibrillation, assign the appropriate ICD 9 code The chronic condition exists, but is under control by medication

Myocardial Infarction A code from category 410.XX must be assigned if the admission is strictly for rehabilitation within eight weeks of the acute MI. The fifth digit 2 would be used in LTC to designate observation, treatment or evaluation of MI within eight weeks of onset, following the acute phase or in the healing state.

Myocardial Infarction The fifth digit “1” should be used if the acute myocardial infarction occurred at the nursing facility and was the reason for transfer to the hospital or the cause of death. If the admission takes place after eight weeks assign code (412) Old Myocardial Infarction

Hypertension Unless the diagnosis statement specifies as “benign” or “Malignant” “unspecified” code (401.9) must be assigned

Heart Conditions Due to Hypertension When there is a causal relationship stated as “hypertensive” or “due to hypertension” heart conditions are assigned by Category 402 Hypertensive Heart Disease Arteriosclerotic disease due to hypertension 402.90

Circulatory System Let’s Code Chronic hypertensive kidney disease 403.9, 585.9 Deep vein thrombosis patient on Coumadin 453.40, V58.61 403.9, 585.9 453.40, V58.61 AHIS, Inc. 714/558-3887

Respiratory System Let’s Code Aspiration Pneumonia 507.0 Chronic bronchitis with emphysema 491.20 507.0 491.20 AHIS, Inc. 714/558-3887

Skin Ulcers Clarification of clinical terms related to skin ulcers www.cms.hhs.gov/manuals/pm trans/r4som.pdf Pressure Ulcer is a synonym for decubitus ulcer – due to prolonged pressure Subcategory 707.0x has fifth digits to identify site 2009- New- additional code must be used to identify stage

Skin Ulcers of Lower Limbs Non pressure ulcers of lower leg Fifth digits to identify site Multiple coding, code first the underlying dx, such as arteriosclerosis, diabetes, venous hypertension i.e. diabetic ulcer of left fifth toe 250.80, 707.15

Stasis Ulcers The most common type of vascular ulcers In Alphabetical index under “ulcer” , the index lists “venous” as a non-essential modifier under the sub term “stasis” that refers to code 459.81. Under section 459.81 in the Tabular List you will be instructed to code any associated ulceration from category 707.0-707.9

Wounds Category 870-897 Codes for wounds are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds

V- Codes Per ICD-9-CM Official Guidelines for Coding and Reporting, aftercare codes are generally first to explain the specific reason for the encounter (admission) Certain aftercare code categories need a secondary dx code to describe the resolving condition or sequela For others (V codes) the condition is inherent in code title AHIS, Inc. 714/558-3887

Coding Clinic Fourth Quarter 1999 Published rules for the use of V codes Addressed the use of V codes in LTC settings Coding clinic Fourth Quarter 2003 Clarified the use of aftercare V codes for all subsequent encounters after the initial treatment for a fracture “for statistical purposes, a facture should only be reported once”

V- Codes -2 V-codes are assigned to problems that affect the patient’s health but are not in themselves a current illness or injury V-codes can be used to represent status or history. Examples: Status Cardiac Pacemaker V45.01 Status heart valve prosthesis V43.3 History of falls V15.88 History of alcoholism V11.3 Remember not to use acute care codes when coding aftercare

To “V” or not to “V” Scenario # 1 A resident is admitted for physical therapy following a hip replacement for an inter-trochanteric right hip fracture due to a fall. AHIS, Inc. 714/558-3887

To ‘V’ or Not to ‘V’: Scenario #1 Physical therapy: V57.1 Physical Therapy Intertrochantic right hip fracture due to a fall: V54.13 Aftercare following traumatic hip fracture Hip replacement: V54.81 Aftercare following joint replacement V43.64 Joint replacement, hip

To ‘V’ or Not to ‘V’: Scenario #2 A resident is admitted for P.T. & O.T. following a hip fracture after a fall. The physician indicated that the fracture was due to osteoporosis. The Discharge Summary stated that old compression fractures of the vertebrae due to osteoporosis were present on x-ray.

To ‘V’ or Not to ‘V’: Scenario #2 Physical Therapy and Occupational Therapy V57.89 Multiple therapies Hip Fracture (due to osteoporosis) V54.23 Aftercare for continuing treatment of healing pathologic fracture of hip Osteoporosis 733.00 Osteoporosis Compression fractures of vertebrae 733.13 Pathologic fractures of vertebrae

Let’s Practice Admitted for physical therapy, status post total knee replacement due to arthritis 1) Admission – rehabilitation – physical 2 ) Aftercare – following surgery for – joint replacement 3) Replacement – joint – Knee V57.1, V54.81 , V43.65

Post hysterectomy for uterine cancer three years ago (no further treatment) History – personal – malignant neoplasm – uterus V10.42

Select the correct Code Fracture of upper arm due to fall, resident wearing a sling, admitted for ADL assistance. V54.11 812.20 (NO) V54.11 AHIS, Inc. 714/558-3887

V54.1 Aftercare for healing traumatic fracture For residents admitted to a SNF for care following treatment in the acute hospital for a traumatic fx use the aftercare codes from Subcategory V54.1 Do not code the (acute) fracture Coding Guidelines require an aftercare code be used after the initial encounter for care of a fx.

V54.1 Aftercare for healing traumatic fracture For statistical purposes, a fracture should only be coded once. If the same fx is coded for all encounters, it makes collection of fracture statistics difficult The V54.1 identifies the site of the fracture and that it is in the healing phases Aftercare for Fractures; Pathologic and Traumatic Remember that only the physician can indicate whether or not the fracture was pathological. AHIS, Inc. 714/558-3887

V54.1 Aftercare for healing traumatic fracture The fifth digits identify the specific site of the healing fracture The fifth digit 9 is used for other specified sites If there are several bones that would be classified to the other specified site, only one code is used AHIS, Inc. 714/558-3887

V54.1 Aftercare for healing traumatic fracture DO NOT code V58.43 Aftercare following surgery for injury and trauma (conditions classifiable to 800-999) Exclusion note states “Excludes: aftercare for healing traumatic fracture” Remember to always refer to the tabular list and carefully read the instructions and exclusions.

Aftercare for healing Pathological fracture Pathological fracture is a fracture in a bone due to weakening of the bone structure by disease process such as osteoporosis. For admissions in LTC following a hospital stay for treatment of a pathological fracture assign a code from Subcategory V54.2 Aftercare for healing pathologic fracture A compression fracture of the vertebrae is considered pathologic if it is not caused by trauma

Hx of Fracture V13.51 personal hx of healed pathologic fx V13.52 personal hx of healed stress fx V15.51 personal hx of healed traumatic fx Note added to subcategory 733.0 -use add’l code to identify personal hx of pathologic (healed) fx (V13.51)

V54.81 Joint replacement Joint replacement of knee for osteoarthritis (V58.78), V54.81, V43.65 Do not code the disease condition that was treated with the surgery 2008 will have a change in the tabular list for V58.78 that will exclude it when there is orthopedic aftercare; codes from section V54.01-V54.9 will be used. AHIS, Inc. 714/558-3887

Joint Replacement for Fx Use multiple coding to fully describe the resident’s condition FX hip (traumatic) with joint replacement V54.13, V54.81, V43.64 Do not use V58.43 Aftercare following surgery for injury and trauma-(not for fx) (conditions classifiable to 800-999) see excludes note: (V54.10-V54.19) 54.15 ex healing of traumatic fx pp.650 AHIS, Inc. 714/558-3887

V57 Care Involving Rehab Category V57 does not indicate that rehab services were provided, only that the resident was admitted for this purpose Use only one code from Category V57 for an admission If the resident is admitted for multiple therapies, use V57.89 AHIS, Inc. 714/558-3887

V57 Care Involving Rehab Code also the condition requiring the rehab, such as: Residuals Late effects Aftercare symptoms

V58 Aftercare Following Surgery The acute dx for which the surgery was preformed is not reported for aftercare encounters or admissions Use other aftercare or symptom codes to provide better detail Note the instructions with each code that identifies the range of conditions that are included in the aftercare code number i.e. aftercare post cataract extraction with lens implant: V58.71, V45.61, V43.1 AHIS, Inc. 714/558-3887

2011 ICD-9-CM UPDATES Implementation date of new, revised and invalid codes October 1, 201

Chart # 1

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Chart # 2

Important Points Provide a roadmap back to the qualifying stay Paint a clear picture of your patient Pay attention to details Go beyond the code and communicate through documentation

Questions and Answers

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