DIAGNOSIS CODING FOR LONG TERM CARE SETTINGS Presented by: Rhonda Anderson, RHIA President Anderson Health Information Systems, Inc. 940 W. 17th Street, Suite B Santa Ana, California, 92706 Tel. (714) 558-3887 Email: office@ahis.net AHIS, Inc. 714/558-3887

Objectives Participants will identify: Purpose of coding Mechanics of coding 2008 coding updates

Purpose of ICD- 9-CM Coding Gather statistical data Reporting diagnoses and provides a method for sequencing diagnosis to support 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

LTC Issues Listing of diagnoses in LTC setting varies at the point in time when coding is performed: Admission Concurrently Triple Check – verification of diagnosis with documentation at the time of checking Medicare documentation to support billing Discharge/Transfer/Expiration

Definition Principal Diagnosis “FIRST LISTED DIAGNOSES” is the diagnosis that is chiefly responsible for the admissions to, continued residence in the nursing facility and the diagnosis that support the reimbursement and should be sequenced first.”

Types of Codes Used in LTC 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. 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. You may want to make a H.O. that describes these or make a slide that does. They will not remember when they get home or reference in the book and have them Mark it. 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.

Fiscal Intermediary The FI will not accept V-codes as principal diagnosis - is an INCORRECT statement. The Principal DX must be reported according to Official ICD-9-CM guidelines for coding and reporting, as required by HIPAA including any applicable guidelines regarding the use of V-Codes. Please add all the info on a slide here, too and the H.O. refer to from AHIMA or whenever so you can explain V. – codes. Also, be careful To indicate in the slide…that each facility is responsible for checking with their intermediary…also identify risks if do not code correctly, But risks if do code as the intermediary will accept, assure they have documentation to support this on file, etc., doesn’t mean that CMS will Not come back and ask for $$ so you need to be sure there is backup. Make 2 or 3 slides. We need to protect ourselves here, too. AHIS, Inc. 714/558-3887

CMS Transmittal Refer to page 6 of the transmittal Remember that it is your responsibility to verify with your fiscal intermediary if they will accept V-codes as principal diagnoses. Incorrect coding could result not only in lower or higher reimbursements but could also be the cause of claims denials and/or CMS audits.

Medicare Medicare diagnosis needs to be consistent with covered services & MDS. Explain a covered services here and make a slide too….. AHIS, Inc. 714/558-3887

Medicare -2 Resident must have a 3-day qualifying hospital stay. Physician must certify the need for skilled nursing services. Skilled services must be related to the condition treated during the qualifying 3 day hospital stay.

Triple Check What are you looking for during triple check? Proper primary diagnosis Correct ICD-9 codes IMPORTANT – Examine process for how billing dept gets info about when condition resolves. Frequently a weakness in LTC facilities. If done in triple check, who follows up for corrections and updates that are identified and needed?

Examples Resident was treated for dehydration at the hospital and is still on IV therapy. Resident had surgery for a hip replacement and needs aftercare for surgical site and physical therapy.

Discharge Diagnosis If the resident is transferred to an acute care or specialty facility, or died, it would be the condition that caused the resident to be transferred or to die. Went home or to another nursing facility, discharge diagnosis would be the same as the primary diagnosis. AHIS, Inc. 714/558-3887

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 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

Locating Diagnosis 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 Principle 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

Principal Diagnosis-2 The first Dx identifies the main reason for the resident’s admission/encounter The terms Admission and encounter can be used interchangeably and are used all healthcare settings. (they have the same meaning)

Choose the Principal Diagnosis Fall 3 months ago Stage III pressure ulcer Coccyx S/P total knee replacement (Lt. knee) 3 months 24 ago Congestive heart failure

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. A good example of this are diabetes related codes such as diabetic neuropathy Can you take a few words from the sequencing instructions and add to a slide…to review. If a H.O. is helpful or reference them to mark the page In their book and review that with them….this is a big issue. AHIS, Inc. 714/558-3887

Choose the Correct Sequence… Seizure disorder Hx Depression UTI (on antibiotics) Schizophrenia Osteoporosis

Secondary Diagnoses To further support Medicare covered skilled services – usually in order of complexity. 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. Handout #1 If you have a H.O, include that H.O. and # in the slide, AHIS, Inc. 714/558-3887

Secondary Diagnoses-2 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, that develop during the resident’s stay and that affect the treatment provided and length of stay should be coded. Describe how you determine that again.//// AHIS, Inc. 714/558-3887

Example Handout #1 IDENTIFY PRINCIPAL DIAGNOSIS IDENTIFY OTHER MEDICARE COVERED DIAGNOSES SEQUENCE BASED ON COMPLEXITY

Acute Diagnoses Acute dx treated in the hospital should be coded until the condition is resolved, after the resident is transferred to the SNF Exercise: Using the Transfer H&P from the hospital, identify and code acute diagnoses still under treatment upon admission

ICD-9-CM Official Guidelines for Coding & Reporting www.cdc.gov/nchs/data/icd9/cdguide.pdf Latest Revision October 1, 2007 Codes revised twice per year April and October April codes will come out only if significant or important and can not wait until October

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 subterm in the alphabetical index, i.e., Peripheral Vascular Disease 1. Disease 2. Vascular 3. Peripheral 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

Let’s Practice COPD Pressure Ulcer (Left Elbow) Alzheimer’s Disease Hypertension Urinary Retention NEC

Some Help COPD- Disease, Pulmonary Obstructive, chronic 496 Pressure Ulcer (Elbow) – Ulcer, Pressure, Elbow 707.01 Alzheimer’s Disease – Disease, Alzheimer’s 331.0

Tabular List 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. AHIS, Inc. 714/558-3887

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. EXAMPLE: Arthritis, arthritic --- due to or associated with acromegaly 253.0 [713.0] Codes in brackets in the alphabetic index can NEVER be sequenced as the principal diagnosis. See pp. 100 Gangrene, diabetic, any site 250.7x [785.4] See decubital, above 707.0 [785.4] AHIS, Inc. 714/558-3887

Slanted Brackets -2 “Excludes” can be found at the beginning of chapters, at the beginning of coding categories or under subcategories. “Excludes” means “the code is found elsewhere”. The coder is instructed to select another code for the specified condition. The condition must be coded to a different code number. See pp.331 c0de 196 excludes… AHIS, Inc. 714/558-3887

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

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

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

Non-Specific Codes -2 When the alphabetical index assigns a code to a category labeled “other (NEC)” refer to the Tabular list. Review the titles and inclusions terms in the subdivisions, under that category to determine if the information available can be appropriately assigned to a more specific code. AHIS, Inc. 714/558-3887

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 sequelae For others (V codes) the condition is inherent in code title 2. For example when a resident is admitted for physical therapy (aftercare) following a hip fracture (V57.1 physical therapy, V54.13 fracture, hip, healing, traumatic) 3. For example aftercare for healing traumatic facture of upper arm (V54.11), status post prostatectomy for BPH (V58.76) AHIS, Inc. 714/558-3887

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 History of falls V15.88 Remember not to use acute care codes when coding aftercare

Handout #2 Identify history of falls (Face Sheet) Is the code E888.9 correct ? What is the correct code ?

Combination Codes A single code used to classify TWO (2) diagnoses or a diagnosis with an associated manifestation or complication. Key words: “AND”, “AND/OR” “WITH”, “WITH MENTION OF” OR “ASSOCIATED WITH” “EXCLUDES” For example AHIS, Inc. 714/558-3887

Let’s Practice 1. Chronic Peptic Ulcer with Hemorrhage 2. Senile Dementia “with” Delirium 3. Diverticulitis of Duodenum “with” bleeding

Combination Codes-2 Certain conditions have both underlying etiology and multiple body system manifestations, due to the underlying etiology. Code the underlying etiology first, followed by the manifestation.

Combination Codes-3 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

Manifestation 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.

Manifestation Codes -2 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 2. DIABETIC GLAUCOMA

Multiple Coding Multiple Coding of Diagnoses Find the main term in the Alphabetical Index to locate the code number reference. Check the reference in the Tabular List for notes and instructions “associated with”, “due to”, “secondary to”, etc. are clues that multiple coding may be necessary. AHIS, Inc. 714/558-3887

Multiple Coding -2 Alphabetic Index: Instructions for conditions that require multiple coding appear in the Alphabetical Index. Codes for both etiology and manifestations of a disease appear following the sub-term entry with the second code italicized and in slanted brackets. Assign both codes in the same sequence in which they appear in the Alphabetical Index. AHIS, Inc. 714/558-3887

Multiple Coding -3 “Associate with”, “Due to”, or “Secondary to”… Frequently needed to completely identify diagnosis of resident’s in long term care facilities. Residents are often treated for the functional manifestations of a disease. Multiple coding is needed to identify both the underlying disease and the manifestations.

Multiple Coding -4 Example: BLADDER INFECTION DUE TO FOLEY CATHETER (996.64, 595.9) The infection is a complication DUE TO the use of the catheter When you look up complications – infection and inflammation due to Indwelling urinary catheter it will guide you to tabular section 996.64 the tabular list then guides you to Use additional code to identify specified infections such as Cystitis (595.0-595.9) AHIS, Inc. 714/558-3887

Multiple Coding -5 “Code, if applicable any causal condition first” notes indicate that the code may be assigned as a principal diagnosis when the underlying cause is not known. Example: Lt. heel ulcer 707.14

Multiple Coding -6 When the causal condition is known, that code should be sequenced as the principal diagnosis and the manifestation as second. Example: Atherosclerotic ulcer of Lt. heel 440.23, 707.14 In the Alphabetic Index Arteriosclerosis with ulceration will refer you to 440.23 in the Tabular list The tabular section will then instruct you to “Use additional code for any associated ulceration (707.10-707.9) Section 707.XX will also instruct you to “code if applicable any causal condition first” referring to the arteriosclerosis AHIS, Inc. 714/558-3887

Chronic Illnesses Under Treatment 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

Diabetes – Type I Insulin Dependent – 250.01 Type I – Body does not produce any insulin Most often occurring in children young adults Daily insulin injections to stay alive This accounts for 5-10% of diabetes American Diabetes Association AHIS, Inc. 714/558-3887

Acute and Chronic Complications Acute complications Need Immediate treatment/life threatening Diabetic Ketoacidosis Hyperosmolar/Hyperglycemic Nonketotic Coma Hypoglycemia AHIS, Inc. 714/558-3887

Chronic Complications Develop over time Effect systems such as: Eyes Kidneys Blood Vessels Nerves Skin Bone Muscle AHIS, Inc. 714/558-3887

Chronic Conditions Chronic conditions under treatment are coded even though the condition is under control with medication 250.xx Diabetes is a common chronic condition that is treated and controlled with medication or diet Code diabetes even though it is under control and the resident has no complications

250 Diabetes Mellitus Fifth digits identify the type of DM Ask the MD to ID type of DM The administration of insulin has no affect on the coding assignment The administration of insulin is assigned the code V58.67 (Long Term (current) use of insulin)

Reviewing Documentation Reviewing documentation for DX of DM and type Look for documentation on: H&P Discharge summary Surgical reports Physicians’ progress notes Clarify with attending physician AHIS, Inc. 714/558-3887

How/Why to Ask for Clarification? Diabetes Mellitus Type I or Type II? Controlled or Uncontrolled? Casual relationship MD doesn’t realize need to link Documentation must support the diagnosis Ask nursing to clarify with MD Establish a process for physician query when diagnoses are too general or incomplete. AHIS, Inc. 714/558-3887

Coding Diabetes Metabolic manifestations of the disease – require only one code Examples: Diabetes with ketoacidosis 250.1x Diabetes with osmolarity 250.2x Diabetes with other coma 250.3x AHIS, Inc. 714/558-3887

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 -2 Example: Diabetic foot ulcer Diabetes with other manifestation 250.8x Ulcer of lower limb, except decubitus 707.1x 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

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 subterm “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

Skin Tears and Abrasions Abrasions and skin tears are found in the Alphabetical Index under “injury, superficial” The fourth digit assignment identifies: Abrasions Insect bites Infections Superficial foreign body Blisters

Cellulitis Skin tears or ulcers may become reddened, infected or swollen. Do not assume the diagnosis of cellulitis unless it is documented by a physician. If cellulitis is present code both the cellulitis and skin ulcer or skin tear to describe the cellulitis as a complication of a skin ulcer or skin tear

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 -2 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

Neoplasms Go to alphabetic index Look up Ex: angiofibroma, pharynx Find “angiofibroma” Cross reference “see neoplasm, by site,benign” Turn to neoplasm locate subterm “pharynx” Follow across to Benign Locate code 210.9 Go to Tabular list for any coding instructions or notes* NO Notes AHIS, Inc. 714/558-3887

Neoplasms of Uncertain Behavior Only used when stated as such in Alpha Index Ex: Gastrinoma of Duodenum (235.2) Look up: Gastrinoma, specified site States to see Neoplasm,by site, uncertain behavior Uncertain behavior = difficult to distinguish from malignant behavior AHIS, Inc. 714/558-3887

Unspecified Behavior 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 Malignant Neoplasm from primary site Invade or spread via the Blood Lymphatic system Tissue to secondary metastatic site

Neoplasms with Metastasis -2 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 -3 Determine the primary site Turn to Neoplasms Table Ex: Carcinoma of Rectum (154.1) Find Neoplasm, rectum, malignant, primary Find Neoplasm, prostate, malignant, secondary Determine the site(s) of metastasis AHIS, Inc. 714/558-3887

Neoplasms with Metastasis -4 Turn to Neoplasm table Find correct subterm(s) for site Cross over to Malignant and column secondary Ex: Secondary malignant neoplasm of prostate (198.82) 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 (199.1) 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 AHIS, Inc. 714/558-3887

Handout #3 Look for the Neoplasm history and code it

V codes for Neoplasms 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

V58.42 Neoplasm -2 A primary malignancy Previously excised or eradicated from its site And there is no further tx directed to that site And there is no evidence of any existing primary malignancy, A code from Category V10 is used to identify the former site of malignancy

V-Codes -2 V12.41 Personal history of benign neoplasm of the brain. Previously, no code to indicate that the patient had benign growth. These can cause serious symptoms in the patient.

Long Term (Current) Drug Use Receives the drug on a regular basis and has multiple refills available for RX Hx of deep vein thrombosis, resident on coumadin, monitoring for dose adjustments V58.83 (encounter for therapeutic drug monitoring), V58.61(Long Term (current) use of anticoagulants and V12.51(venous thrombosis and embolism) AHIS, Inc. 714/558-3887

Late Effects of CVA’s (438.0-438.9) Rather than code the residual condition AND the late effect, combination codes that include the late effect should be used. Additionally, these can be used with a new CVA. DO NOT code 436 for CVA codes from categories 430-436 are used for the initial episode of care for an acute CVA at the hospital AHIS, Inc. 714/558-3887

Late Effect -2 A late effect is a residual condition that remains and requires nursing care after the initial phase of an illness or injury has passed Locate the codes in the Alphabetical Index under the main term “Late, effect (s)(of) No example AHIS, Inc. 714/558-3887

Late Effect -3 The residual condition is coded first and the late effect is sequenced second Multiple coding is required for most late effects A late effect is not used as a principal dx, except for Category 438 Late Effect of CVA i.e. Left Hemiplegia due to CVA 438.20

438 Late Effect 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

438 Combination/Multiple Coding Category 438 includes combination codes that describe both the cause and the residual deficit Right hemiplegia due to old CVA 438.20 More than one code my be used from category 438 to identify multiple residuals from a CVA Dysphagia and left hemiplegia post CVA 438.82, 438.20

438 Use additional codes with category 438 if the combination code does not address all elements of diagnostic statement Multiple coding is used to identify residuals of CVA that do not have a specific code Seizure disorder following CVA 438.89, 780.39 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 -2 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 Aftercare 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 Aftercare Healing Traumatic Fracture -2 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 Fx 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

Malunion vs. Nonunion of Fx Malunion (733.81) is the improper joining of bone following a fracture Nonunion (733.82) is the failure of bone to join together following a fracture Both conditions are residual effects of a fracture and should be coded with the “late effect” code (905.X) as secondary diagnosis.

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 -2 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

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

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

2008 Effective 10/1/07 - implementation date for new codes 389 – Hearing Loss Category 488 – Influenza due to Avian virus (bird flu) Dysphagia 5th digits 787.2X Hx of cardiac arrest V12.53 Hx of TIA V12.54

2009 ICD-9-CM addenda 2009 code updates effective 10/1/08 041.11 MSSA (susceptible) 041.12 MRSA (combo code) V02.53 colonization MSSA V02.54 colonization MRSA V09.0 DELETED CODE – MRSA V12.04 personal hx MRSA

New Catagories Category 249. secondary diabetes mellitus Category 339. other headache syndromes

New Codes 403. hypertensive chronic kidney dx (includes 585. with any condition classifiable to 401) 599.70 hematuria, unspecified 599.71 gross hematuria 599.72 microscopic hematuria 780.72 functional quadriplegia 780.91 functional incontinence

More new codes 780.60 fever, NOS 780.61 fever, with conditions classified elsewhere 780.62 postprocedural fever 780.63 post vaccination fever 780.64 chills without fever V45.11 renal dialysis status V45.12 noncompliance with renal dialysis

Pressure Ulcer Use add’l code to identify pressure ulcer stage 707.20 pressure ulcer, unspecified stage 707.21 pressure ulcer, stage I 707.22 pressure ulcer, stage II 707.23 pressure ulcer, stage III 707.24 pressure ulcer, stage IV 707.25 pressure ulcer, unstageable

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 subcatagory 733.0 -use add’l code to identify personal hx of pathologic (healed) fx (V13.51)

Let’s Practice What You Have Learned Today Coding Exercises Questions for discussion

ICD-9 Coding Exercises #1 Please code the following: Stage IV decubitus of the coccyx with gangrene - XXX.XX, XXX.X. Arterioslerotic ulcer of the left foot with gangrene- XXX.XX, XXX.XX. Venous stasis ulcer of right calf – XXX.XX, XXX.XX Ulcerated varicose veins of right calf – XXX.XX Diabetic ulcer of the left fifth toe- XXX.XX, XXX.XX Osteoarthritis of the hip – XXX.XX Cervical arthritis – XXX.X Gouty arthritis – XXX.X Nonunion fracture of Tibia – XXX.XX, XXX.X

ICD-9 Coding Exercises #2 Please code the following: Primary Secondary _____ _____ Adenocarcinoma of breast with metastasis to axillary lymph glands. Metastatic carcinoma of brain from nasal septum. Ewing’s sarcoma of mandible with spread to maxilla. Carcinoma of prostate metastasizing to spine.

ICD-9 Coding Exercises #3 Please code the following: Knee pain due to osteoarthritis – XXX.XX Coma – XXX.XX Hepatic coma – XXX.XX Azotemia – XXX.X Persistent vegetative state – XXX.XX Failure to thrive in a 95 year old female – XXX.X

V Coding Exercises #4 Please code the following: MRSA colonization (no symptoms) – V_ _._ _, V_ _._ Post hysterectomy for cancer three years ago V_ _._ _ Recurrent cancer of liver, primary site in lung removed (1year ago) _ _ _. _ , V_ _._ _

V Coding Exercises #4 -2 Above the knee amputation status V_ _. _ _ Status post amputation of thumb (5 years ago) V_ _._ _ Chronic obstructive pulmonary disease, Palliative care. _ _ _, V_ _._ Post cataract extraction aftercare Status cardiac pacemaker

Late Effects Coding Exercises #5 Please code the following: Seizure disorder following viral encephalitis treated. *Hint: 6 month ago Post CVA with dominant side hemiparesis and aphasia. *Hint: (6months ago) Malunion fracture of ankle *Hint: See Fx in tabular.

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