Special Guest Posting by Coding Quality Specialist, Megha Patel, CCS, CPC- Official Coding Guideline Changes

Good afternoon, all.  Today, we're lucky to have a special guest post, by one of SCAN's Coding Quality Specialists, Megha Patel, CCS, CPC.  Megha has done a lot of hard work for us, compiling all the significant changes to the Official Guidelines for Coding and Reporting, beginning with the switch from ICD-9-CM to ICD-10-CM:

ICD -9 to ICD-10 Official Coding Guideline Updates

1.      10/01/2015:

ICD-9 to ICD-10 updated October 1, 2015.

·         CAD with Angina: Use combination codes for CAD with Angina, A causal relationship can be assumed in a patient with both Atherosclerosis and angina pectoris. It is not necessary to code Angina Pectoris separately.

·         Sequelae of CVA: Weakness due to previous CVA should be coded as Hemiplegia/Hemiparesis.

·         Sequelae of CVA: Hemiplegia/Hemiparesis/Monoplegia identify whether the dominant or non-dominant side of affected.  If provider didn’t documented dominant or non-dominant, the default is to assume the right side is the dominant side. If left side affected, the default is non-dominant.

·         DM with Hyperglycemia: Uncontrolled DM, Inadequately Controlled, Out of controlled, Poorly Controlled should be coded as Hyperglycemia.

·         Diabetes Ketoacidosis: ICD-10 CM does not provide a specific code for Type II diabetic Ketoacidosis. Assign code E13.10 Other Specified Diabetes with Ketoacidosis as per Coding Clinic First Quarter of 2013.

2.      03/18/2016:

·         DM with Complications Assumed relationship. The guidelines published in the first quarter 2016 issue of AHA Coding Clinic on pg. 11. According to this clarification, the subterm “with” in the index should be interrupted as a link between diabetes and any of those conditions indented under the word “with”.

** The linkage between diabetes and Osteomyelitis used to be assumed in ICD-9 but it is not assumed in ICD -10 (10/01/2015-10/01/2016 Not coded). There is no assumed relationship till October 1, 2016.

3.      10/01/2016:

·         Uncontrolled DM: Uncontrolled DM is classified by type and whether it is hyperglycemia or hypoglycemia. There is no default code for “uncontrolled DM”. Effective Oct. 1, 2016, uncontrolled diabetes can be referenced as Hyperglycemia or Hypoglycemia.

·          Hypertension with CHF: Presumes a causal relationship between hypertension and heart involvement. 

·         COPD with Asthma: COPD with asthma only coded as J44.9. If type of asthma not documented J45.909 should not be coded.  “Unspecified” is not type of asthma.

4.      10/01/2017:

·         Diabetic Ketoacidosis: October 1, 2017 updated with new codes for Diabetes Ketoacidosis (Type II). E11.10 Type II DM with Ketoacidosis w/o Coma and E11.11 Type II DM with Ketoacidosis w/ Coma.

·         COPD, Emphysema and Chronic Bronchitis all documented: Assign J449 only, because J43.9 Emphysema has Exclude 1 note (Emphysema with chronic bronchitis). J44.9 has Include note Chronic Bronchitis with emphysema. (J439 is Emphysema without Chronic Bronchitis) (J449 is Emphysema with Chronic Bronchitis).

·         COPD with Emphysema: J43.9 Emphysema assigned as Emphysema is specific type of COPD.

·         Emphysema with an Acute Exacerbation of COPD: Assign J43.9. Both codes have Exclude 1 note to each other. J439 is without Chronic Bronchitis and J449 is with Chronic Bronchitis. Emphysema is type of COPD so Acute Exacerbation of COPD is covers in J43.9.

Thanks, Megha--for doing all the heavy lifting!

Remember, you can always download the full text of the ICD-10-CM guidelines on our website, at http://hccuniversity.com/asset/154d663f-95bf-4a59-a1fd-a6e4eb7c8477

Changes to Diabetes Coding Rules Create Challenges

In Q1 2016, Coding Clinic published a question and answer about "Diabetes with Associated Conditions".

On the surface, this new rule seems great--here's an excerpt from AHA's Coding Clinic:


Question:

"The ICD-10-CM Alphabetic Index entry for 'Diabetes with' includes listings for conditions associated with diabetes...Does the provider need to document a relationship between the two conditions or should the coder assume a causal relationship?"

Answer:

"... the term "with" means "associated with" or "due to," when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List,... The classification assumes a cause-and-effect relationship between diabetes and certain diseases of the kidneys, nerves, and circulatory system....

It is not required that two conditions be listed together in the health record. However, the provider needs to document the linkage, except for situations where the classification assumes an association ...When the provider establishes a linkage or relationship between the two conditions, they should be coded as such. .... The fact that a patient has two conditions that commonly occur together does not necessarily mean they are related...."

All of this sounds like it should make things easier for both physicians and coders.  However, the opposite can be true.

As coders, it's our job to educate physicians on coding rules.  But I think this Coding Clinic ruling, and other similar ones, as potential minefields.  Physicians, by the very nature of their jobs, have to keep current with a large amount of very complex information.  Educating physicians on a rule like this has the potential to backfire.

The physician is unlikely to go to the ICD-10 and check the code title, then to the Alphabetic Index, and  continue on to search for instructional notes in the Tabular list to determine if the term "with" is present.  That may lead them to assume that the rule applies in cases where it doesn't.

There is no harm in documenting the association between two diseases, but there can be tremendous harm (in an audit situation) in failing to document that association if the rule does not apply.

So, how can we best educate our physicians?  I think that explaining that there are some limited cases where a causal relationship is assumed is a good approach.  But with that explanation, physicians must also be told that the majority of the time, a  causal relationship is NOT assumed, and that trying to remember which is which is difficult for coders who do this all day long.  The safest approach is to state the causal relationship, which ensures that coders can code what the physician actually means.  Give them examples--and make sure those examples demonstrate how this can be done without significantly increasing their workload.  By simply adding a few words, the physician can convey their clinical judgement that one disease cause another--for example "CKD 4 2^o DM2" clearly shows the physician's diagnosis that type 2 diabetes mellitus caused the patient's stage 4 kidney disease.  And it means that doctors don't have one more thing to remember.

While telling our physicians about these rules in detail may seem like a good idea, it can increase the likelihood of errors.


What coding and educational challenges do you face?  Do you have ideas for helping providers navigate documentation issues?  Be sure to leave us a comment, or send ideas you would like to share to coding@scanhealthplan.com.

Coding Clinic Q1 2016 Addresses Diabetic Complications

In the Q1 2016,  AHA Coding Clinic addresses a number of issues--two of which are hot topics for coders in risk adjustment.

Most of the questions we get in the Coding Inbox (coding@scanhealthplan.com) deal with "Diabetes and ______________", and whether or not the ICD-10CM assumes a causal relationship.  Usually, this is because the physician has not made a link in the medical record, and the coder is unsure whether or not they can code the diabetic complication.

In ICD-9, the question also came up a lot--and most often, the answer was NO.

Coding Clinic took this subject on once again, for ICD-10CM..  In Section I. Conventions, general coding guidelines and chapter specific guidelines of the Official Guidelines for Coding and Reporting, the ICD-10 describes how the word "with" is to be interpreted:



15.     “With”

The word “with” should be interpreted to mean “associated with” or “due to”
when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular 
List.

In a code title, the association might look like this:

E11.31  Type 2 diabetes mellitus with unspecified diabetic retinopathy

This tells you that there is an association between the two diseases.
_____________________________________________________________

The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in
alphabetical order.

In part, the Alphabetic Index under "Diabetes" looks like this:

Diabetes, diabetic (mellitus) (sugar) E11.9
- with
- - amyotrophy E11.44,- - arthropathy NEC E11.618
- - autonomic (poly)neuropathy E11.43
- - cataract E11.36
- - Charcot's joints E11.610
- - chronic kidney disease E11.22
- - circulatory complication NEC E11.59
- - complication E11.8
- - - specified NEC E11.69
- - dermatitis E11.620
- - foot ulcer E11.621
- - gangrene E11.52
- - gastroparesis E11.43
- - glomerulonephrosis, intracapillary E11.21
- - glomerulosclerosis, intercapillary E11.21
- - hyperglycemia E11.65
- - hyperosmolarity E11.00
- - - with coma E11.01
- - hypoglycemia E11.649
- - - with coma E11.641
- - kidney complications NEC E11.29
- - Kimmelsteil-Wilson disease E11.21
- - loss of protective sensation (LOPS) —see Diabetes, by type, with neuropathy
- - mononeuropathy E11.41
- - myasthenia E11.44
- - necrobiosis lipoidica E11.620
- - nephropathy E11.21
- - neuralgia E11.42
- - neurologic complication NEC E11.49
- - neuropathic arthropathy E11.610
- - neuropathy E11.40
- - ophthalmic complication NEC E11.39
- - oral complication NEC E11.638
- - periodontal disease E11.630
- - peripheral angiopathy E11.51

With this new Coding Clinic clarification, when the physician documents and another disease, you need to check the Alphabetic Index first, to see if the problem/complication is listed there, and then as always, go to the code itself.  If the condition is qualified by the term diabetes with ____, the you can code the complication.  The doctor does not have to state the complication--it is assumed.   If you don't find that causal relationship is supported, then the two diseases are coded as unrelated.

This clarification should help make coding more accurately reflect what the physician is trying to convey to the coder.  As always, we as coders have to be careful to ensure that we double check the ICD-10CM to be sure we're coding it right.

So, I recently read a funny blog....

About Coding of all things.  It's called Coder Coach.  And the author does a code for the day, with a focus on humor.  I'm not as funny as she is, so I'm not even going to try.  But I think that I will try to be more diligent about posting--and I think I'll try to do a code a day (or week...or something).

Let's face it--ICD-10 has been a royal pain of an implementation.  So, by focusing on a new code with some regularity, I might be able to lend a hand.  No time like the present!

We'll start off, not with a code, but with at category.  This category may be the most misused category of codes I've ever seen.

I've been coding for more years than I like to admit.  Let's say north of 30.  While I've seen instances where these codes (and their predecessors in ICD-9) could have been used correctly, I've never actually seen them used correctly.  They are: Neoplasms of  Uncertain Behavior.  In ICD-10 they are found in the section Neoplasms of Uncertain Behavior, Polycythemia Vera and Myelodysplastic Disorders (D37-D48).

When I see a code for neoplasm of uncertain behavior submitted, no matter the body area, it's always because:

1. The physician hasn't biopsied the lesion yet, and so he/she is uncertain of the histology; or
2. The physician has biopsied the lesion, but hasn't yet received the pathology report

Neither of these is the correct usage of the code.  The beginning of the code section explains the correct use of the codes, but unfortunately, one of the downsides of Electronic Health Records (EHRs) is that none of these instructions are visible to most users.  Here's the instruction, straight from the ICD-10:

Note: Categories D37-D44, and D48 classify by site neoplasms of uncertain behavior, i.e., histologic confirmation whether the neoplasm is malignant or benign cannot be made.

As you might guess, the instances where you can correctly use these codes are relatively rare.  So, unless the pathologist cannot tell you whether to neoplasm is benign or malignant, these codes should not be used. 

This code category points out the importance of the coding instructions and guidelines.  As noted, these are generally lost in an EHR--that's not to say EHRs are bad, simply that they have their limitations.   So, what's a coder (or the physician who is coding) to do?  I strongly recommend that coders AND physicians read the sections of the Coding Guidelines that apply to them.  That means any specialty specific guidelines, and the entire Outpatient coding section.  You should also review the section of the code book that includes common codes you use.  And, when faced with the new and unusual (like these), take a quick glance at the book to see if there are special instructions like we found here. 

Now, if you have an EHR, you don't have to buy the code book to do that.  Every year, we post a full text copy of the ICD-10 on HCC University.

I'm going to do my best to keep posting these coding tips.  If I fall behind, feel free to email me at Coding@scanhealthplan.com to remind me.  I sometimes suffer from mild memory loss, NOS (R41.3)

New Content on HCCUniversity.com

There’s been a lot of activity on HCC University!  Since my last email, we’ve posted several new things:

First, an updated Pocket Documentation Tip Sheet, which includes instructions for ICD-10 guidelines.  This tip sheet can be printed and folded to fit in a lab coat pocket, and will help clinicians meet some of the documentation challenges they face on a daily basis.

Next, we’ve updated the Primary Care Superbill.  As before, it includes CPT  II codes that help you meet both 5 Star AND Fee-for-service PQRS requirements!  Now, it’s been updated to include ICD-10 codes for many common illnesses seen in a Primary Care practice.

Finally, we’ve posted a new presentation on ICD-10 Guidelines.  This brief, physician oriented presentation will help providers understand the rules of ICD-10, where to find them, and why they must be followed.  It shouldn’t take any more than 20 minutes to go through, but provides a wealth of information to help you choose the correct ICD-10 code. 

For all of you who have asked---yes, the Risk Score Calculator will be updated for 2016 payment year.  We’re in the midst of doing that now, and hope to have it available right after the first of the year.  

As always, if you have suggestions for tools for HCC University, please let me know. 

If you have coding questions, please contact us at Coding@scanhealthplan.com.

Happy Holidays all!  And a wonderful 2016!

Best,

Stacey