ICD-10 Orientation In Post Acute Care (Part II) Rhonda Anderson, RHIA Anderson Health Information Systems, Inc.

Location, Date, Time Northern California Fairfield Post Acute Rehab March 20, :00am – 3:00pm Southern California Garden View Post Acute Rehab April 9, :00am – 3:00pm 2

Presenters Staci LePage, RHIT Mobile: Khaleelah Wagner, RHIA Mobile:

General Coding Guidelines Locating a code in the ICD-10-CM Level of detail coding Code/codes from A00.0 through Z99.8 Signs and symptoms are acceptable for reporting purposes when a related diagnosis has not been established Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes 4

General Coding Guidelines -2 Acute and Chronic Conditions If the same condition is described as both acute and chronic, and separate subentries exist, code both and sequence the acute code 1st Combination Code Is a single code used to classify two diagnoses, or A diagnosis with an associated complication or manifestation 5

General Coding Guidelines -3 Late Effects (Sequela) Residual effect (condition produced) after the acute phase of an illness/injury has terminated There is no time limit on when a sequela code can be used Coding generally requires two codes Condition/nature of the late effect is sequenced 1st; the sequela code is sequenced 2 nd Exception is when the sequela code is part of the 4th, 5th or 6th character of a code 6

General Coding Guidelines -4 Late Effects (Sequela) The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect 7

General Coding Guidelines -5 BMI & Pressure Ulcer Stages Documentation Assignment may be based on medical record documentation from clinicians who are not the patient’s providers Dietitian often documents the BMI and nurse often documents the pressure ulcer stages The associated diagnosis must be documented by the patient’s provider BMI codes should only be reported as secondary diagnoses 8

Complications Of Care Code assignment is based on the provider’s documentation Not all conditions that occur during or following surgery are classified as complications When admission is for treatment of a complication, the complication code is sequenced as the principal diagnosis 9

Complications of Care -2 Must be a cause-and-effect relationship between the care provided, the condition and an indication in the documentation that it is a complication 10

OSHPD / Principal Diagnosis Definition Uniform Hospital Discharge Data Set (UHDDS)/Principal diagnosis is defined as that condition established, after study, to be the chief cause of the admission of the patient to the facility for care Condition must be identified in the H&P or documented in the current inpatient medical record 11

Acute Hospital – Principal Dx What that means to a SNF Acute hospital diagnosis Late effects of the acute diagnosis Reason for the admission to Acute and the SNF (bundled payments) – one facility gets paid and the other is paid by that facility. 12

Principal Diagnosis Two or more interrelated conditions with each potentially meeting the definition Diseases in the same ICD-10-CM chapter or manifestations characteristically associated with a certain disease, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, or the code book indicate otherwise 13

Principal Diagnosis -2 Two or more interrelated conditions that equally meet the definition When two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the code book does NOT provide sequencing direction, any one of the diagnoses may be sequenced first 14

Other Diagnoses Two or more comparative or contrasting conditions When two or more diagnoses are documented as “either/or”, they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. Either diagnosis may be sequenced first. When a symptom is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. 15

Other Diagnoses -2 Two or more comparative or contrasting conditions (cont.) All the contrasting/comparative diagnoses should be coded as additional diagnoses. These should never be principal diagnoses 16

Signs, Symptoms, Ill-defined Conditions Codes for symptoms, signs, and ill-defined conditions – are NOT to be used as a principal diagnosis when a definitive diagnosis has been established. THIS APPLIES TO SNF, ACUTE and other health-care locations 17

Uncertain Diagnoses If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed/established Applicable only to inpatient admissions to short-term, acute, long-term care & psychiatric hospitals 18

Sequencing Of Codes Determined by the reason for admission/encounter, with the highest acuity diagnoses sequenced 1st 19

Specificity Of Coding With added laterality, need greater documentation from your MD’s Hypertensive Retinopathy H35.03_ H right eye H left eye H bilateral H unspecified (this would be a ?? for billing most likely!!) *code also any associated hypertension (I10) 20

Chapter 1 – Infectious & Parasitic Diseases A00-B99 B95 Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere B96 Other bacterial agents as the cause of diseases classified elsewhere B97 Viral agents as the cause of diseases classified elsewhere 21

Sepsis UROsepsis – The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alpha index. QUERY THE DOCTOR!!! Sepsis with organ dysfunction follow guidelines for severe sepsis 22

Chapter 1 – Infectious & Parasitic Diseases A00-B99 -2 Sepsis (ICD-9 = ) Unspecified organism, A41.9, if type of infection is not specified Severe sepsis R65.2 should not be assigned unless severe sepsis or acute organ dysfunction is documented 23

Sepsis – Severe Requires two codes First code for underlying systemic infection followed by a code from subcategory R65.2, Severe Sepsis Casual organism should be documented; if not – assign A41.9 Sepsis, unspecified organism Where do we look for this information? 24

Sepsis Example This long-term multiple sclerosis patient was admitted for continuing long-term antibiotic therapy for a urinary tract infection due to E. coli. What do we code? 25

Sepsis Answers N39.0 Infection, urinary tract B96.20 Infection, E. coli Z79.2 Long-term use of antibiotics G35 Sclerosis, multiple The long-term use code is assigned for use of the antibiotics. Instructional notes under N39.0 indicate to use an additional code (B95-B97), to identify infectious agent 26

Chapter 1 – Infectious & Parasitic Diseases A00-B99 -3 When a patient is diagnosed with an infection that is d/t MRSA, and that infection has a combination code that includes the causal organism, assign the appropriate combo code: A41.02 Sepsis d/t MRSA, or J Pneumonia d/t MRSA 27

Chapter 1 -4 When a patient is diagnosed with an infection that is d/t MRSA, and that infection has a combination code that includes the causal organism, assign the appropriate combo code: B95.62 MRSA as the cause of conditions classified elsewhere Only used when the infection does not have a combo code that includes the causal organism 28

Chapter 1 -5 MRSA/MSSA Colonization: A positive MRSA colonization test may be documented by the MD as “MRSA screen positive” or “MRSA nasal swab positive” Assign Z22.322, carrier or suspected carrier of MRSA Colonization is not indicative of a disease process If patient is documented as having both MRSA colonization and infection, code both 29

Chapter 1 -6 HIV infections Code only confirmed cases of HIV infection, MD’s diagnostic statement is sufficient Admit for HIV-related condition, principal diagnosis should be B20, followed by code for HIV-related condition Z21 is assigned when the patient w/o any documentation of symptoms is listed as “HIV positive” or “known HIV” 30

Chapter 2 – Neoplasms C00-D49 Increase in subcategories from 9, to 21 in ICD-10-CM Greater specificity by site and laterality Need to know: upper, lower, overlapping sites, left, right, etc. If cancer treatment is done, then a history code is assigned - Z85. 31

Primary Malignancy Previously Excised When there is no further treatment directed to a primary site and no evidence of any primary malignancy, the following is coded: Z85. Personal history of malignant neoplasm (meant for coding of primary sites only) Any mention of metastasis to another site is coded as a malignant secondary neoplasm to that site. 32

Chapter 3 – Blood and Blood forming Organs, Certain Immune Disorders D50-D89 D50-D53 Nutritional anemias D55-D59 Hemolytic anemias D60-D64 Aplastic and other anemias D65-D69 Coagulation defects D70-D77 Other disorders of the blood D78 Postprocedural complications spleen D80-D89 Disorders involving immunity 33

Chapter 4 – Endocrine, Nutritional, Metabolic E00-E89 Diabetes Mellitus Combination codes Includes the type of diabetes, the body system affected, and the complications affecting that body system Many codes within a particular category as are necessary to describe all of the complications of the disease may be used Sequenced based on the reason for a particular encounter 34

Chapter 4 – Endocrine, Nutritional, Metabolic E00-E89 -2 E08 Diabetes d/t underlying condition E09 Drug or chemical induced diabetes Secondary diabetes is always caused by another condition or event E10 Type I Diabetes Mellitus E11 Type II Diabetes Mellitus E13 Other specified Diabetes Mellitus Z79.4 Long-term use of insulin 35

Type Of Diabetes If the type of diabetes is not documented in the record, the default is E11., Type 2 diabetes If the type is not indicated, but the patient uses insulin, code E11. Type 2 diabetes + Z79.4 long-term use of insulin Need to know: type of DM body system affected + complications 36

Diabetes Example Resident admitted to SNF following foot amputation d/t diabetic PVD. PT and OT ordered with plan for the resident to return home. Staff to change dressings and report any suture site breakdown to MD. Other diagnoses include gastroparesis d/t Type 2 diabetes (receiving insulin), mitral valve regurgitation with aortic stenosis, inguinal hernia, generalized DJD and COPD. 37

Diabetic Answer Z47.81 Aftercare, following surg, amp E11.51 Diabetes, type 2, w/peri angiopath E11.43 Diabetes, type 2, w/gastroparesis I08.0 Regurgitation, mitral, w/aortic valve K40.90 Hernia, inguinal M15.9 Disease, joint, degenerative J44.9 Disease, pulmonary, chronic obstruc Z79.4 Long-term use insulin Z Acquired absence of unspec foot 38

Rationale Both PVD and gastroparesis are d/t type 2 diabetes. Codes assigned for both conditions. Z47.81 has a “use add’l code” note to identify the limb and level of amp Z Documentation doesn’t specify which foot was amp, so 6th digit of 9 is assigned. Pt uses insulin, so Z79.4 is assigned. 39

Dehydration E86.0 Dehydration Need to know if this is a current condition, otherwise do NOT code 40

Chapters 5 – Mental & Behavior Disorders F01-F99 F01. Vascular Dementia F02. Dementia in other diseases classified elsewhere F03. Unspecified Dementia *All of above are coded: with behavioral disturbance, or without behavioral disturbance 41

Key to Psychoactive Drug Use Documentation Make sure each psychoactive drug includes diagnosis for use Behavioral disturbance??? Justification for psychotropic meds??? Documentation of aggressive, combative or violent? Use of antipsychotic meds need specific medical diagnosis to justify use: Schizophrenia - F20., Bipolar – F31., Psychosis (delusions or hallucinations) – F29. 42

Bipolar Disorder – F31 Expanded subcategories: F31.1 Bipolar, current episode manic F31.3 Bipolar, current episode depressed F31.6 Bipolar, current episode mixed F31.7 Bipolar, currently in remission Need to know for above: with or without psychotic features mild, moderate, severe 43

Substance Abuse Codes Expanded to include intoxication and specific mood states that are a result of a variety of substances: Anxiety, sleep disorder, psychosis By drug type: Alcohol, Opioid, Cannabis, Sedative/hypnotic, Cocaine, other stimulant, hallucinogen, nicotine, inhalant) Example: F Alcohol abuse with alcohol- induced anxiety disorder 44