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

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

3. FYI 2018 CM Guidelines Section I: Conventions

4. Chapter 1-Certain Infectious and Parasitic Diseases

5. 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

6. 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.

7. 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

8. 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

9. 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

10. 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

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

12. 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

13. MI

14. Types of MI

15. 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

17. 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

18. 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.

19. 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) th 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

20. 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

21. 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

22. New chronic ulcer codes…

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

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

25. 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
O Maternal care for abnormalities of the fetal heart rate or rhythm, third trimester, not applicable or unspecified

26. 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

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

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

29. 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
I 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

30. New additions to the CC list
Code Description
A Enterocolitis due to Clostridium difficile, recurrent
A Enterocolitis due to Clostridium difficile, not specified as recurrent
C Malignant mast cell neoplasm, unspecified
C Aggressive systemic mastocytosis
C Mast cell sarcoma
C Other malignant mast cell neoplasm
D Cutaneous mastocytosis
D Systemic mastocytosis
D Other mast cell neoplasms of uncertain behavior
E Light chain (AL) amyloidosis
E Wild-type transthyretin-related (ATTR) amyloidosis
E Other amyloidosis
G Primary lateral sclerosis
G Familial motor neuron disease
G Progressive spinal muscle atrophy

31. 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
K Partial intestinal obstruction, unspecified as to cause
K Complete intestinal obstruction, unspecified as to cause
K Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction
K Other partial intestinal obstruction
K Other complete intestinal obstruction
K 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

32. 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!

33. 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
O Right tubal pregnancy without intrauterine pregnancy
O Left tubal pregnancy without intrauterine pregnancy
O Unspecified tubal pregnancy without intrauterine pregnancy
O Right tubal pregnancy with intrauterine pregnancy
O Left tubal pregnancy with intrauterine pregnancy
O Unspecified tubal pregnancy with intrauterine pregnancy
O Right ovarian pregnancy without intrauterine pregnancy
O Left ovarian pregnancy without intrauterine pregnancy
O Unspecified ovarian pregnancy without intrauterine pregnancy
O Right ovarian pregnancy with intrauterine pregnancy
O Left ovarian pregnancy without intrauterine pregnancy
O Unspecified ovarian pregnancy with intrauterine pregnancy

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

35. 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.

36. 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

37. 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.

38. 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

39. Example Section 0 Medical and Surgical
Body System 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

40. 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

41. 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

42. 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

43. 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.

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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”

50. 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

51. 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

52. 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

53. 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

54. 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

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

56. 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

57. 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

58. 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

59. IMPACTFUL CHANGES (simplification)
Diaphragm-laterality no longer needed
Section 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

60. IMPACTFUL CHANGES (simplification)
Omentum – laterality no longer needed
Section Medical and Surgical
Body System D Gastrointestinal System
Operation 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

61. IMPACTFUL CHANGES (simplification)
Saphenous - no longer need to specify greater or lesser saphenous vein
Section 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

62. 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