2. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS CC/MCC Lists: A comparison of ICD-9-CM to ICD-10-CM

3. Objectives Compare key ICD-9-CM diagnoses to ICD-10- CM designated as MCC/CC conditions Identify proactive documentation opportunities to implement now Learn something new and exciting

4. Limitations Please note this comparison and information provided is based on the MS-DRG Conversion Project (V26.0), so it may not represent the final MCC/CC list implemented on October 1, 2013.

5. CC/MCC Basics What are they? – A complication is a condition that develops and is not considered an expected outcome – A comorbidity is a condition that coexists with the principal diagnosis during the specific encounter/admission

6. CC/MCC Basics Complete lists of CC and MCC conditions can be found: – Tables 6I (MCC) and 6J (CC) in the IPPS Final Rule http://www.cms.gov/AcuteInpatientPPS/IPPS2011/list.asp – DRG Expert (Appendix A) Identified individually by code – In your ICD-9-CM manual, identified with the respective “icon” – Encoding software

7. CC/MCC Basics How can MCC/CCs impact reimbursement? – The presence of one MCC/CC condition can impact the overall MS-DRG Exception: hospital-acquired conditions – MS-DRGs 291-293 – Heart Failure and Shock DRG 291 w/MCC - $7630 DRG 292 w/CC - $5087 DRG 293 w/o CC/MCC - $3625 – Based on a wage index of “1”

8. CC/MCC Basics ICD-10 impact on MS-DRGs – 3M Study (October 2010) Only 1.23% of discharges were assigned to a different MS- DRG when converted from ICD-9-CM to ICD-10-CM and ICD- 10-PCS. – Rural hospitals had the least impact (1.14%) “The results of the payment impact analysis show that the conversion to a native ICD-10 version of MS-DRGs will have a minimal impact on aggregate payments to hospitals and the distribution of payments across hospitals.” Optimization was not factored in since the system is not in use currently; therefore, there is not a repository of coded data. – Only translated based off ICD-9 documentation to ICD-10 – MS-DRGs will likely require future revisions to account for added specificity after implementation

9. ICD-10 Convention Basics Placeholders – Some codes within ICD-10-CM have 6th and 7th characters; however, there is not a 5th character. In order to assign a valid code, an “x” is used as a 5th character placeholder. Example: Accidental poisoning of furosemide (i.e., Lasix), initial – Category T50.1x1A

10. ICD-10 Convention Basics Extensions – A – Initial encounter Used when the condition is actively treated during the initial encounter – D – Subsequent encounter Used for encounters after the initial treatment has been performed but the patient continues to receive care during the healing or recovery phase – S – Sequela Used for complications or conditions that arise as a direct result of the condition

11. ICD-10 Convention Basics Excludes1= Not coded here! Indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. Excludes2 = Not included here! Indicates that the condition excluded is not part of the condition represented by the code but can be assigned in addition.

12. Impact on Common MCC/CC Conditions Some key diagnoses may warrant additional documentation to take advantage of the added detail in ICD-10-CM – Urosepsis – Diabetes mellitus – CVAs – CAD with angina – Acute myocardial infarctions – Pressure ulcers – Traumatic fractures – Postoperative complications

13. Urosepsis Urosepsis is a nonspecific term and requires clarification from the provider. There is no default code. – Currently, in ICD-9-CM it defaults to 599.0 (UTI-CC condition) – ICD-10 Alpha Index entry Urosepsis – code to condition – Documentation must identify whether it was a UTI or sepsis due to a urinary origin

14. Diabetes Mellitus Current ICD-9-CM codes – Categories 249–250 Identify type of diabetes mellitus (1 or 2) and secondary diabetes mellitus Fourth digit identifies the presence of manifestations or complications Fifth digit identifies type (or unspecified) as well as whether the diabetes is stated as uncontrolled Additional codes may also be assigned to identify manifestations, as well as use of long-term or current insulin use (i.e., V58.67)

15. Diabetes Mellitus Current ICD-9-CM codes – Type 1, Type 2 and secondary DM with: Ketoacidosis Hyperosmolarity Coma – MCC conditions – Also are MCCs in ICD-10-CM

16. Diabetes Mellitus ICD-10-CM codes – Categories E08–E13 Identify type of diabetes mellitus – DM due to underlying condition – Drug- or chemical-induced DM Specific types of secondary DM – Types 1 and 2 – Other specified DM

17. Diabetes Mellitus ICD-10-CM codes – Fourth digit identifies the presence of manifestations or complications – Fifth and sixth digits identify specific types of manifestation Combination codes Long-term or current insulin use (Z79.4) Inadequately controlled, poorly controlled, out of controlled will be assigned to Diabetes, by type with hyperglycemia

18. Diabetes Mellitus Official Coding Guideline review – See note under Category E08 to “code first the underlying condition” For example: Diabetes mellitus due to cystic fibrosis with Stage II diabetic CKD, initial encounter – E84.8, E08.22, N18.2 – E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease Diabetes mellitus due to underlying condition with chronic kidney disease due to conditions classified to.21 and.22 – Use additional code to identify stage of chronic kidney disease (N18.1–N18.6)

19. Diabetes Mellitus MS-DRG assignment – ICD-9-CM MS-DRG 638 – Diabetes with CC – RW -.8306 (~ $4638) – Cystic fibrosis with manifestation (CC condition) – ICD-10-CM MS-DRG 641 – Nutritional and Misc Metabolic Disorders without MCC – RW -.6916 (~ $3862) – This MS-DRG is only “two-tier” MS-DRG 640 with MCC (RW - 1.1400 ~ $6366)

20. Diabetes Mellitus Drug- or chemical-induced DM (E09) – See note under Category E09 to “code first (T36-T65) to identify drug or chemical” For example: Corticosteroid-induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, initial encounter – T38.0x5A, E09.331 – Adverse effect code is sequenced first

21. Diabetes Mellitus MS-DRG assignment – ICD-9-CM MS-DRG 639 – Diabetes without CC/MCC – RW -.5544 (~ $3096) – ICD-10-CM MS-DRG 923 – Other Injury, Poisoning and Toxic Effect Diagnoses without MCC – RW -.6808 (~ $3802)

22. CVAs/TIAs Current ICD-9-CM codes – Categories – 430–434 – CVA Hemorrhagic vs. occlusive Codes 430–432.1 are MCCs – 432.9 – Unspecified intracranial hemorrhage (CC) – 433–434 – are MCCs “with infarction” – Category – 435.x – TIA (CC) – Category – 438.xx – Late effects of CVA Fourth and fifth digits identify type of late effect (Hemiplegia is the only CC)

23. CVAs/TIAs ICD-10-CM codes – Categories – I60–I69 I60–I62 – Hemorrhagic – Specifies location or source of hemorrhage – Right vs. left artery vs. unspecified – All are MCCs (except I62.9 Nontraumatic intracranial hemorrhage, unspecified) Example: – I60.50 Nontraumatic subarachnoid hemorrhage from unspecified vertebral artery – I60.51 Nontraumatic subarachnoid hemorrhage from right vertebral artery – I60.52 Nontraumatic subarachnoid hemorrhage from left vertebral artery

24. CVAs/TIAs ICD-10-CM codes – I63–I68 – Occlusive Specifies thrombosis vs. embolism or unspecified Infarction vs. not resulting in infarction – All infarctions (I63.xxx are MCCs) Specific location of the occlusion – Example: – I63.311 Cerebral infarction due to THROMBOSIS of right middle cerebral artery – I63.312 Cerebral infarction due to thrombosis of left middle cerebral artery – I63.411 Cerebral infarction due to EMBOLISM of right middle cerebral artery – I63.412 Cerebral infarction due to embolism of left middle cerebral artery – Default for stroke/CVA I63.9 – Cerebral infarction, unspecified

25. CVAs/TIAs ICD-10-CM codes – I69 – Sequelae of cerebrovascular disease Specifies whether the sequelae was a result of a hemorrhagic vs. occlusive CVA Hemiplegia due to CVA- (CC) – Sixth digit indicates dominant vs. nondominant Note: For G81- Hemiplegia, the default is dominant (even in ambidextrous patients). It is not entirely clear whether this rule would also be applied for this section. – Category – G45 – TIA (CC) Placed in the Diseases of the Nervous System chapter

26. CVAs/TIAs Remember! – Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance.

27. CAD with Angina Current ICD-9-CM codes – Category – 414.xx – CAD Assigned based on the vessel involved (native or bypass graft) Bypass vessels and CAD with transplanted hearts (CC) – Category – 411.1 or 413.x – Angina pectoris Coded independently if CAD is present with angina pectoris – Sequencing is usually an issue for inpatient services – Code 411.1 (CC condition) – Code 413.9 (non-CC condition)

28. CAD with Angina ICD-10-CM codes – Categories – I25.1 – CAD of native artery Additional digits identify presence of angina pectoris and type – combination code – I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris Excludes1: unstable angina without atherosclerotic heart disease (I20.0) – I25.110 (non-CC) – I20.0 (CC condition) Default code is Category I25.1 for a native artery

29. CAD with Angina ICD-10-CM codes – Category – I25.7 – CAD of a bypass graft and transplanted hearts Additional digits identify type of bypass (or transplanted heart) and presence of angina pectoris – combination code Only specified bypass types (autologous, nonautologous) are CC conditions – Example I25.700 – Atherosclerosis of CABG, unspecified, with unstable angina pectoris (non-CC) – Example I25.710 – Atherosclerosis of autologous CABG, with unstable angina pectoris (CC condition)

30. Acute MIs Current ICD-9-CM codes – Categories: 410.xx – Acute MI – Fourth digit identifies location – Fifth digit identifies episode of care – Acute is defined as symptoms lasting less than 8 weeks – Initial episode of care (fifth digit “1”) –

31. Acute MIs ICD-10-CM codes – Category – I21.xx Identifies: – ST elevation (STEMI) vs. non-ST elevation (NSTEMI) – Specific coronary artery or wall – Category – I22.x Identifies: – Subsequent MIs STEMI and NSTEMI Specific wall

32. Acute MIs I21 – Includes note: – Acute MIs are defined as a stated duration of 4 weeks (28 days) or less from onset ICD-9-CM was 8 weeks I22 – Includes note: – AMI occurring within four weeks (28 days) of a previous AMI, regardless of site – Mandatory instructional note I22 must be used in conjunction with a code from I21 Sequencing depends on circumstances of admission Both I21 and I22 are MCC conditions – It is unclear whether the presence of both codes will be an MCC exclusion since an MCC/CC Exclusion list is not available currently

33. Pressure Ulcers Current ICD-9-CM codes – Category – 707.0x and 707.2x Identify: – Location – Stage Stages III and IV are MCCs – Unless HAC

34. Pressure Ulcers ICD-10-CM codes – Category – L89.xxx Identify: – Very specific location (right elbow, right upper back) – Stage Combination codes Added new codes for head, sacral, contiguous sites (back, buttock, hip) – All Stage III and IV sites are MCCs

35. Traumatic Fractures Current ICD-9-CM codes – Fractures (800–829) – Organized by site and type of fracture (open vs. closed) Fractures not indicated as open or closed should be classified as closed Examples of descriptors for open and closed are found preceding category 800 – E.g., Closed (comminuted, greenstick, spiral, etc.) – E.g., Open (compound, infected, etc.) Many fracture codes are MCC or CC conditions (in ICD-10-CM too) – Except if HAC

36. Traumatic Fractures ICD-10-CM codes – Traumatic fractures (S00–S99) – Interspersed throughout chapter (by site) Additional information – Type of fracture (closed, open, displaced, nondisplaced, comminuted, oblique, transverse) Default is displaced Fractures not indicated as open or closed should be classified as closed (same as ICD-9-CM) – Encounter type (initial, subsequent, sequela) For subsequent encounters (routine healing, delayed healing, nonunion, malunion) No default currently – Location (right, left, unspecified)

37. Traumatic Fractures ICD-10-CM codes – Examples S42.312 Greenstick fracture of shaft of humerus, left arm S42.321 Displaced transverse fracture of shaft of humerus, right arm S42.334 Nondisplaced oblique fracture of shaft of humerus, right arm – All require a seventh character extension

38. Fractures ICD-10-CM codes – Three fracture categories will utilize the Gustilo-Anderson classifications (Type I, II, IIIA, IIIB, IIIC) Forearm (S52) Femur (S72) Lower leg, including ankle (S82) – This classification is used to identify the extent of soft tissue injury, arterial injury, as well as contamination

39. Fractures Gustilo-Anderson example – S72.322 Displaced transverse fracture of shaft of left femur Seventh character extension is required Examples: – C – Initial encounter for open fracture type IIIA, IIIB, or IIIC – F – Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing – J – Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing

40. Postoperative Complications Current ICD-9-CM codes – Categories: 996 – Complications of artificial substitutes, internal devices, and prosthetics – Example – Infection and inflammatory reaction, due to vascular device (996.62 – CC) 997 – Complications affecting specified body systems – Use additional code to identify complication – Example – Postoperative cardiac arrest (997.1-CC, 427.5-MCC only if discharged alive) 998 – Other complications of procedures, NEC – Example – Accidental puncture or laceration during a procedure (998.2-CC) 999 – Complications of medical care, NEC – Example – Air embolism (999.1-MCC)

41. Postoperative Complications Intraoperative and postprocedural complication codes are found within the body system chapters with codes specific to the organs/structures within that body system.

42. Postoperative Complications ICD-10-CM codes – Infection and inflammatory reaction, due to vascular dialysis catheter, initial E.g., T82.7xxA (Infection and inflammatory reaction due to other vascular devices, implants, and grafts) – Additional code should be assigned for the infection – Non-CC in ICD-10 – Postprocedural cardiac arrest (I97.12) E.g., I97.120 (Postprocedural cardiac arrest following cardiac surgery) E.g., I97.121 (Postprocedural cardiac arrest following other surgery) – Additional code for cardiac arrest not necessary – Non-CC in ICD-10

43. Postoperative Complications ICD-10-CM codes – Accidental puncture or laceration during a procedure What was punctured? During a procedure of the same system? – E.g., I97.51 (Accidental puncture during a circulatory system procedure) – E.g., I97.52 (Accidental puncture during other procedure) – Both CC conditions – Example – Air embolism, initial E.g., T80.0xxA (Air embolism following infusion, transfusion, and therapeutic injection) – MCC condition

44. CC/MCC Which ones are essentially identical? – Pneumonia (J12–J18) and Aspiration (J69) – Acute blood loss anemia (D62) – CHF (I50) – CKD (N18.x)

45. Sources 3M – ICD-10 MS-DRG Conversion Project – http://www.cms.gov/ICD10/17_ICD10_MS_DRG_Conversion_ Project.asp 2010 Ingenix ICD-10-CM manual ICD-10-CM Official Guidelines – http://www.cms.gov/ICD10/Downloads/7_Guidelines10cm2010.pdf ICD-9-CM Official Guidelines (October 2010 version) – http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm

46. Questions? Have a common CC/MCC not included in the presentation? – ASK ME