1. Texas ACDIS Fall Meeting Coding Roundtable

2. Coding Roundtable Objectives
Review the key updates to the ICD-10-CM/PCS Official Coding Guidelines for Coding and Reporting
Review key code changes for the FY 2018 ICD-10-CM/PCS code sets
Review highlights of the FY 2018 MS-DRG changes

3. FY 2018 ICD-10-CM Coding Guideline Updates
Narrative changes appear in bold text
Items underlined have been moved within the guidelines since the FY 2017 version
Italics are used to indicate revisions to heading changes
Notable changes take place mostly in Section I.
The complete guidelines may be downloaded by visiting:

4. Section I. Conventions, general coding guidelines and chapter specific guidelines
I.A.15 – “With”
The word “with” or “in” should be interpreted to mean “associated with” or “due to”….
These conditions should be coded as related even without an explicit link or when another guideline exists that specifically requires a documented linkage between two conditions
I.A.17 – “Code also”
Sequencing depends on the circumstances of the encounter

5. Section I. Conventions, general coding guidelines and chapter specific guidelines
I.C.2.a – Treatment directed at the malignancy
External beam is the exception to this guideline which states that the malignancy should be the principal diagnosis when treatment is directed towards it.
I.C.4.a.3 & I.C.4.a.6.a – DM and use of insulin/oral hypoglycemic
Use additional code to identify long-term use of insulin or oral hypoglycemic drugs; if both types of drugs are used, only use code for insulin

6. Section I. Conventions, general coding guidelines and chapter specific guidelines
I.C.7.b – Blindness
If “blindness” or “low vision” of both eyes is documented but the visual impairment category is not documented, assign “Unqualified visual loss, both eyes”.
If “blindness” or “low vision” in one eye is documented but the visual impairment category is not documented, assign “Unqualified visual loss, one eye”.
If “blindness” or “low vision” is documented without any further information about whether one or both eyes are affected, assign “Unspecified visual loss”.

7. Section I. Conventions, general coding guidelines and chapter specific guidelines
I.C.9.a.10 – Pulmonary Hypertension
Pulmonary hypertension is classified to category I27, Other pulmonary heart diseases.
For secondary pulmonary hypertension, code also any associated conditions or adverse effects of drugs or toxins. The sequencing is based on the reason for the encounter.

8. Section I. Conventions, general coding guidelines and chapter specific guidelines
I.C.9.e.1 & I.C.9.e.2 – Acute myocardial infarction (AMI)
“Type 1” is inserted throughout these two guidelines
I.C.9.e.4 – Subsequent AMI
Do not assign code I22 for subsequent MIs other than type 1 or unspecified
For subsequent type 2 AMI, assign only code I21.A1
For subsequent type 4 or type 5 AMI, assign only code I21.A9

9. Section I. Conventions, general coding guidelines and chapter specific guidelines
I.C.9.e.5 – Other types of MIs
Assign type 1 MI to codes I21.0-I21.4
Assign type 2 MI and MI due to demand ischemia to I21.A1
Code for underlying cause should also be assigned
Sequencing of underlying cause and type 2 MI is dependent on the circumstances of the admission
Assign type 3, 4a, 4b, 4c, and 5 MI to code I21.A9

10. Section I. Conventions, general coding guidelines and chapter specific guidelines
I.C.12.b.1-3 – Non-Pressure Chronic Ulcers
1) Patients admitted with non-pressure ulcer documented as healed
No code is assigned
2) Patients admitted with non-pressure ulcer documented as healing
Assign appropriate non-pressure ulcer code
For ulcers POA but healed prior to discharge, assign the code for the site and severity of the non-pressure ulcer at the time of admission
3) Patients admitted with non-pressure ulcer that progresses to another severity level during the admission
Assign two codes – one for the severity at the time of admission, and a second code at the highest level of severity reported during the hospital stay

11. Section I. Conventions, general coding guidelines and chapter specific guidelines
I.C.18.f – Functional quadriplegia
This guideline has been DELETED effective 10/1/2017
It previously stated: “Functional quadriplegia (code R53.2) is the lack of ability to use one’s limbs or to ambulate due to extreme debility. It is not associated with neurologic deficit or injury, and code R53.2 should not be used for cases of neurologic quadriplegia. It should only be assigned if functional quadriplegia is specifically documented in the medical record.”

12. FY 2018 ICD-10-PCS Coding Guideline Updates
Section B4.1.c *new*
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.
Section B6.1a *expanded*
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.

13. FY 2018 ICD-10-CM Code Updates
ICD-10-CM Change Summary
Notable changes:
Chapter 4 – Endocrine, Nutritional, and Metabolic diseases
Chapter 5 – Mental, Behavioral, and Neurodevelopmental disorders
Chapter 7 – Diseases of the Eye and Adnexa
Chapter 9 – Diseases of the Circulatory system
Chapter 12 – Diseases of the Skin and Subcutaneous Tissue
New Codes
Revised Codes
Deleted Codes
Total Changes
~363
~142
250+
755+

14. Notable ICD-10-CM Changes
Chapter 1 – Certain Infectious and Parasitic Diseases
A04.7, Enterocolitis due to Clostridium difficile (C-Diff) – now specified as recurrent vs not recurrent
Added to CC list
Chapter 3 – Diseases of the blood and blood-forming organs
D63.0, Anemia in neoplastic disease – change from Excludes 1 to Excludes 2 note meaning anemia and the neoplastic disease can be coded together
Chapter 4 - Endocrine, Nutritional, and Metabolic diseases
E11.1, Type 2 DM w/ketoacidosis (with and without coma)
Added to MCC list

15. Notable ICD-10-CM Changes
Chapter 5 - Mental, Behavioral, and Neurodevelopmental disorders
New abuse codes for “in remission”
Abuse
In early remission
In sustained remission
Expanded definitions for dependence “in remission”
Nicotine dependence – no abuse code, just dependence now with “in remission”

16. Notable ICD-10-CM Changes
Chapter 5 (continued)
New abuse codes for “in remission”
Alcohol
Opioid
Cannabis
Sedative, hypnotic or anxiolytic
Cocaine
Other stimulant
Hallucinogen
Inhalant
Other psychoactive substance abuse

17. Notable ICD-10-CM Changes
Chapter 7 - Diseases of the Eye and Adnexa
Degenerative Myopia – need to know type and laterality
Type: Choroidal neovascularization, macular hole, retinal detachment, foceoschisis, other maculopathy
Laterality: right eye, left eye, bilateral, unspecified.
Blindness – need to know what category of blindness of each eye (category 3,4,or 5); can be different for each eye

18. Notable ICD-10-CM Changes
Chapter 9 - Diseases of the Circulatory system
MI Types
Type 1: Spontaneous myocardial infarction due to a primary coronary event like plaque rupture.
Type 2: Myocardial infarction secondary to an ischemic imbalance as in coronary vasospasm, anemia or hypotension.
Type 3: Myocardial infarction resulting in death when biomarker values are unavailable
Type 4a: Myocardial infarction related to percutaneous coronary intervention (PCI)
Type 4b: Myocardial infarction related to stent thrombosis
Type 4c: Myocardial infarction due to restenosis ≥50% after an initially successful PCI
Type 5: Myocardial infarction related to coronary artery bypass grafting (CABG)

19. Notable ICD-10-CM Changes
Chapter 9 (continued)
I21.A1 – MI type 2
MI due to demand ischemia – code also note to code also the underlying condition
I21.A9 – Other MI types
Includes types 3, 4a, 4b, 4c, 5
I27.2 – Other secondary pulmonary hypertension
Expanded to 5 characters to include:
Pulmonary HTN, unsp
Secondary pulmonary arterial HTN
Pulmonary HTN due to left heart disease
Pulmonary HTN due to lung diseases and hypoxia
Chronic thromboembolic pulmonary HTN
Other secondary pulmonary HTN

20. Notable ICD-10-CM Changes
Chapter 9 (continued)
I50.8 – Other heart failure
Expanded to include:
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
Other heart failure

21. Notable ICD-10-CM Changes
Chapter 10 – Diseases of the Respiratory System
J44.0 – COPD w/acute lower respiratory infection
Note changed from “use additional code” to “code also” meaning sequencing is no longer mandated and either may be principal depending on circumstances of admission
Chapter 11 – Diseases of the Digestive System
Intestinal Obstructions are now defined as
Unspecified
Partial
Complete

22. Notable ICD-10-CM Changes
Chapter 12 – Diseases of the Skin and Subcutaneous Tissue
Seventy-three new codes for non-pressure chronic ulcers!
Added to CC list
Chapter 18 – Signs and Symptoms
R06.0, Dyspnea
Excludes 1 – Tachypnea, NOS
R06.03, Acute respiratory distress (new!)

23. FY 2018 ICD-10-PCS Code Updates
ICD-10-PCS Change Summary
Change Highlights
Medical Surgical section – body part values revised or streamlined for clarity and usefulness of coded data
Endoscopic approaches added to various tables throughout the system for completeness
New Codes
Revised Titles
Deleted Codes
Total Codes
% increase
3,562
1,821
646
78,705 4%

24. Notable ICD-10-PCS Changes
Cranial Nervous System and Cranial Nerves, Tables X
Body System Heading changed to:
Central Nervous System and Cranial Nerves
Body Parts added to some tables
Device Codes added to some tables
Qualifier X = Diagnostic, was removed on some tables

25. Notable ICD-10-PCS Changes
Lower Veins, Tables W
Deleted body part
Lessor Saphenous Vein
Added body part
Hepatic Vein
Added 2 Qualifiers to some tables
Pulmonary Trunk
Pulmonary Artery (L/R)

26. Notable ICD-10-PCS Changes
Gastrointestinal System, Tables 0D0-0DW
Deleted body part
Greater Omentum
Lesser Omentum
Added body part
Omentum

27. Notable ICD-10-PCS Changes
Procedure codes proposed to change from O.R. to Non-O.R. Status
Percutaneous/diagnostic drainage
Percutaneous insertion
Percutaneous removal
Percutaneous revision
External/diagnostic drainage
Endoscopic/transorifice drainage
Endoscopic/transorifice revision
External division and excision of skin

28. Notable ICD-10-PCS Changes
Procedure codes proposed to change from O.R. to Non-O.R. Status
Open drainage
Percutaneous extraction
Open extraction
Percutaneous/open repair
External release
External repair
Percutaneous transfer
External/percutaneous/transorifice introduction

29. FY 2018 MS-DRG Changes Multiple title changes
DRG 984 re-classed to DRG 987
DRG 985 re-classed to DRG 988
DRG 986 re-classed to DRG 989

30. Submitted Coding Questions
What is your organization's timeline for d/c summary to be completed, and what is the timeline for dropping the final bill?
What is the sequence for coding the following conditions on hypertension, CKD, chronic diastolic heart failure and diabetes?
How you are handling the new heart failure code assignments?
Sepsis, surgical code 
HTN urgency / crisis/ emergency in the setting of stable CHF - do these terms unlink it to the combo code hypertensive heart disease with heart failure?

31. QUESTIONS?!