Presented byAHIMA Approved ICD-10-CM/PCS Trainers:

Sue Roehl, RHIT, CCSDeb Selland, RHIT, CCS

The presenters have made every reasonable effort to ensure accuracy of the information provided in this material.

The presenters make no guarantee the information compiled or presented is error-free.

8:30 –10:10 What Happened?What’s Next

10:00-10:15 Break

10:15-12:00 Coding and Documentation Tips

12:00-12:30 Roundtable

H.R. 4302 introduced to House at 11:57 p.m. on 3/25/14

1-year patchSection 212-included new “delay in ICD-10” implementation wording

Placed on the “Suspension Calendar”

What is a Suspension Calendar?◦Suspension of rules◦Normally used for benign, noncontroversial bills such as the naming of post offices

◦Voice vote (no roll call)◦No amendments to bills allowed (so Section 212 could not be removed)

◦Allows up to 40 minutes for discussion before vote

11:32 a.m. House was announced in recess

12:08 p.m. House called to order and bill was read

12:09 p.m. Bill passed with no discussion

Members not given usual 15 minute notice that House was calling to order

Members were not notified that vote would take place

Vote was done when most members were out of the room

Estimated only 5 or 6 representatives actually voted

No public records are kept for voice votes so it is not known how many voted or which representatives got to vote

AHIMA had enough votes to kill the bill if all 435 representatives had been aware the vote was taking place

Many members of Congress were outraged by the process used to get the bill passed in the House

3/27 Placed on the Senate schedule

3/31 Passed Senate◦Set to expire on 3/31◦Senate did debate the bill although ICD-10 part of legislation was NOT MENTIONED

Passed 64-35 Senator Hoeven-yeah Senator Heitkamp-did not vote

4/1/2014 Signed into law by President Obama at 5:30 p.m.

AHIMA recommends that organizations continue with preparations under the assumption that next year is the “go live” year.

CCHIIM has determined that all certification exams will continue testing on ICD-9-CM until a new coding classification system is officially implemented.

The Coalition for ICD10 (includes AHIMA) is working on a letter to the Department of Health and Human Services seeking clarification:◦Exact length of delay ◦How new compliance date will be issued

◦Voluntary use of ICD-10

◦Advocacy Assistant http://capwiz/com/ahima/home Let our Legislators know how ICD-10 delay affects your organization

◦Continue dual coding◦Learn to code. Turn off translation tools.

◦Do not lose momentum◦Strengthen clinical documentation improvement programs

◦Work with vendors on transition readiness

◦Train coders and other stakeholders

Q: Can the law be rescinded?A: Not likely. Not enough time between now and 10/1/14 to get it done.

Q: Was this legal?A: Yes. Some Members of Congress have vowed to keep a closer eye on this type of maneuver in the future.

Q: What about the code freeze?A: There were already a few ICD-10 procedure codes being introduced on 10/1/2014. These will still be implemented. Any ICD-9 updates are unknown at this time since it was to be retired this year.

Q: Why not just skip to ICD-11?A: The date to present ICD-11 to the World Health Organization Assembly has been pushed back to 2017 at the earliest. It would then need to be modified to ICD-11-CM for use in the United States which would take many more years.

Sue’s tombstone – “Still Waiting For I-10”

When the admission/encounter is for management of anemia

◦ *Associated with a malignancy Code the malignancy first followed by the anemia

code

◦Associated with adverse effect of chemo, immunotherapy, or radiation therapy Code the anemia first followed by the neoplasm and

adverse effect code

* Change from ICD-9 Coding Guideline

Coding Tips◦Anemia in chronic kidney disease Code first the underlying CKD followed by

the anemia in CKD code D63.1◦Anemia in other chronic diseases Code first the underlying chronic disease

followed by code D63.8, anemia in other chronic diseases classified elsewhere

Documentation Tips◦Type of anemia needs to be documented

Postoperative blood loss Postoperative acute blood loss Acute blood loss Chronic blood loss Aplastic Pernicious Iron deficiency Vitamin deficiency Due to neoplastic disease

Documentation Tips◦ Cannot code anemia from abnormal laboratory

findings, blood loss during a procedure, and/or blood transfusions. It is appropriate to query the provider if findings suggest an anemia diagnosis.

◦ Acute blood loss anemia results from a sudden, significant loss of blood over a brief period of time

◦ Acute blood loss anemia may follow surgery but is not necessarily a complication of the procedure and should not be coded as a postoperative complication unless the physician identifies it as such.

Hypertension◦ No longer classified by benign, malignant or

unspecified

◦ With heart disease codes to hypertensive heart disease when a causal relationship is stated - such as due to …. or hypertensive. If no causal relationship, code each condition separately.

◦ With chronic kidney disease, I-10 assumes a causal relationship even if not stated as such. Assign an additional code to identify the stage of the CKD.

◦ With hypertensive heart and chronic kidney disease assigned combination codes. Assign additional code for type of heart failure if present and stage of CKD.

Hypertension◦ Secondary hypertension requires two codes. One to

identify the underlying etiology and one to identify the hypertension. Sequencing is determined by the reason for the admission/encounter.

◦ Transient codes to R03.0, Elevated blood pressure reading without diagnosis of hypertension

Myocardial Infarctions◦Classified by ST elevation or non-ST elevation

◦Intermediate coronary syndrome (411.1) is now unstable angina (I20.0)

◦Acute coronary occlusion without MI (411.81) is now acute coronary thrombosis not resulting in MI (I24.0)

Myocardial Infarctions◦* Time frame for subsequent MI is 4 weeks

* Different from ICD-9 where time frame was 8 weeks or less

Congestive Heart Failure◦Unspecified heart failure The congestive component of CHF cannot be reported without documentation of diastolic or systolic

Gangrene has moved from the Symptoms and Signs chapter to the Circulatory System chapter.

Combination codes include the type of diabetes and the affected body system.◦ The provider must link the complication with the

diabetes. If the conditions are not linked, the combination codes can not be assigned.

◦ Assign as many codes as necessary to describe all diabetic complications/body systems involved. Sequencing is based on the reason for the encounter

Combination codes include the type of diabetes and the affected body system.◦Coding Guideline A. 15: 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.

◦ Type 2 diabetes is the default when patient is on insulin but the provider does not indicate the type of diabetes. Assign an additional code (Z79.4) for long-term (current) use of insulin. Do not assign code Z79.4 if insulin is given temporarily

to control Type 2 diabetes during an encounter.

◦ Underdose of insulin due to insulin pump failure Assign a code from subcategory T85.6-, mechanical

complication followed by T38.3x6-, underdosing of antidiabetic drugs.

Assign additional codes for the type of diabetes and any associated diabetic complications

◦ Overdose of insulin due to insulin pump failure Assign a code from subcategory T85.6-, mechanical

complication followed by code T38.3x1-, poisoning by antidiabetic drugs, accidental (unintentional).

◦ Secondary diabetes Always caused by another condition or event Sequencing based on Tabular List instructions

E08, code first the underlying condition E09, code first poisoning due to drug or toxin, if

applicable use additional code for adverse effect

Documentation Tips◦Type

Type 1 Type 2 Due to drug or chemical Due to underlying condition Other specified

Documentation Tips◦Uncontrolled No longer coded in ICD-10 Inadequate control, out of control, or poorly controlled codes to diabetes by type with hyperglycemia

Do not assign based on lab test results

Documentation Tips Diabetic nonproliferative retinopathy

Mild Moderate Severe

Diabetic ulcers Site Laterality if applicable

Pathological◦3 causal categories Due to neoplastic disease Due to osteoporosis Due to other specified disease

Pathological◦M80 Osteoporosis with current pathological

fracture Identify the site of the fracture Used for any patient with known

osteoporosis who suffers a fracture, even from a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.

Pathological due to a neoplasm

◦When the focus of treatment is the fracture Subcategory M84.5 - Pathological fracture

in neoplastic disease is sequenced first, followed by a code for the neoplasm

◦When the focus of treatment is the neoplasm The neoplasm code is sequenced first,

followed by a code for the pathological fracture

Pathological fracture codes require a 7th character extension ◦Initial encounter (A) active treatment

Surgical treatment Emergency department encounter Evaluation and treatment by a new physician

◦Subsequent encounter (D) Cast changes, removal Complications of fractures, malunion

Pathological Fractures◦Documentation Site Laterality Etiology (osteoporosis, neoplasm, other)

Encounter (initial, subsequent with routine healing, subsequent with delayed healing, malunion or nonunion, sequela)

Traumatic Fractures◦Documentation Site Laterality Encounter

Initial for closed fracture Initial for open fracture Subsequent with routine healing Subsequent with delayed healing, malunion, or nonunion

Sequela

Traumatic fractures◦Not indicated as open or closed. Code to

closed.◦Not indicated as displaced or not displaced.

Code to displaced.◦Require 7th character extension Initial encounter

Active treatment for the fracture Surgical treatment Emergency department encounter Evaluation and treatment by a new physician Delayed seeking treatment for the fracture

Traumatic fractures◦Require 7th character extension Subsequent encounter

Patient has completed active treatment and is receiving routine care during the healing or recovery phase Cast change or removal Removal of external or internal fixation device Medication adjustment Follow-up visits

Aftercare ◦Aftercare Z codes should NOT be used for aftercare of traumatic fractures. Instead assign the acute fracture code with appropriate 7th character extension.

Open fractures◦Gustilo classification I

Low energy, wound less than 1 cm II

Wound greater than 1 cm with moderate soft tissue damage

Open fractures◦Gustilo classification III

High energy, wound greater than 1 cm. with extensive soft tissue damage IIIA adequate soft tissue cover IIIB inadequate soft tissue cover IIIC associated with arterial injury

Coding Tip◦There is no combination code for fractures of the tibia/fibula. Each bone, each bone site, displaced/non-displaced, open or closed, are assigned separately.

15 point scale for estimating and categorizing the outcomes of brain injury on the basis of overall social capability or dependence on others

Coding tips◦Codes are used with traumatic brain injury, acute cerebrovascular disease or sequelae of cerebrovascular disease codes

◦Sequenced after the diagnosis code◦At a minimum, the initial score documented on presentation to facility should be coded

Coding tips◦7th character indicates where the scale was recorded 0 - unspecified time 1 - in the field (EMT or ambulance) 2 - at arrival to emergency department 3 - at hospital admission 4 - 24 hours or more after hospital admission

Coding tips◦7th character indicates where the scale was recorded 0 - unspecified time 1 - in the field (EMT or ambulance) 2 - at arrival to emergency department 3 - at hospital admission 4 - 24 hours or more after hospital admission

Neoplasm table in the Alphabetic Index is referenced first unless the histological term is documented, then that term is referenced first.

Histology: The study of the form of structures seen under the microscope.

Morphology: The science of structure and form of organisms without regard to function

Examples of Histological/Morphology Types ◦Carcinoma◦Leukemia◦Lymphoma◦Myeloma◦Sarcoma◦Mesothelioma◦CNS (glioma, blastoma)

First listed diagnosis is determined by where the treatment is directed◦If treatment is directed to primary

neoplasm, that site is sequenced first◦If treatment is directed to secondary site,

that site is sequenced first◦If admission/encounter is for administration

of chemo, immunotherapy or radiation therapy, the appropriate Z51.- code is listed first

Primary malignant neoplasms overlapping site boundaries

◦If overlaps two or more contiguous (next to each other) sites classify to the subcategory code .8 (overlapping lesion), unless the combination is specifically indexed elsewhere.

◦For multiple neoplasms of the same site that are not contiguous such as tumors in different quadrants of the same breast, codes for each site should be assigned

Primary malignancy previously excised◦If the primary site has been previously excised or eradicated and there is no further treatment directed to that site, a code from Z85 should be assigned.

Documentation tips◦General Site Example: colon

◦Specific Site Ascending, cecum, descending, with rectum, distal, sigmoid, transverse, etc.

◦Histology/Morphology type

Category Z38◦Liveborn infants according to place of birth and type of delivery

◦Always sequenced first◦Used on the initial record of a newborn ONLY, not by the receiving hospital in the event of a transfer

Newborn Disorders Related to Length of Gestation and Fetal Growth◦Codes from P07, Disorders of newborn related to short gestation and low birth weight, NEC, are for use on a child or adult who was premature or had a low birth weight as a newborn and is affecting the patient’s current health status.

Documentation ◦Related to slow fetal growth and fetal malnutrition

◦Related to short gestation and low birth weight

◦Related to long gestation and high birth weight

Documentation ◦Gestational age Light for gestational age (light for dates)

Small for gestational age (small for dates)

◦When birth weight and gestational age are both documented Sequence the code for birth weight first followed by the code for gestational age

Dominant/nondominant side◦If the affected side is documented but not specified as dominant or nondominant and the classification system does not indicate a default, code selection is as follows: For ambidextrous patients, the default should be dominant

If the left side is affected, the default is non-dominant

If the right side is affected, the default is dominant

Documentation◦Hemiplegia Flaccid Spastic Unspecified

◦Dominant/nondominant Unspecified side Right dominant side Left dominant side Right nondominant side Left nondominant side

Code R29.6 Repeated Falls◦Is for use for encounters when a patient has

recently fallen and the reason for the fall is being investigated

Code Z91.81 History of falling◦Is for use when a patient has fallen in the past

and is at risk for future falls

An acute exacerbation is a worsening or decompensation of a chronic condition. It is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection

Acute and chronic respiratory failure may be assigned as principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission.

Respiratory failure may be listed as a secondary diagnosis if it occurs after admission or does not meet the definition of principal diagnosis.

If respiratory failure and another acute condition are equally responsible for occasioning the admission, and there are no chapter- specific sequencing rules, the guideline for two or more diagnoses equally meeting the definition of principal diagnosis may be applied.

If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.

Coding Tips◦Pay close attention to all Includes, Excludes1, and Excludes2 instructional notes within the Respiratory System chapter

◦When a respiratory condition is described in more than one site not specifically indexed, it is classified to the lowest anatomic site (i.e. tracheobronchitis to bronchitis)

Documentation Tips◦Asthma Mild intermittent Mild persistent Moderate persistent Severe persistent

◦Asthma Uncomplicated Acute exacerbation Status asthmaticus

Worldallergy.com

Asthma Severity Frequency of Daytime Symptoms

Intermittent ≤ 2 times per week

Mild Persistent > 2 times per week

Moderate Persistent Daily. May restrict physical activity

Severe Persistent Throughout the day. Frequent severe attacks limiting ability to breathe.

Documentation Tips◦ COPD

Acute lower respiratory infection Acute exacerbation *COPD with asthma assigned to two separate codes

◦ Bronchitis Not specified as acute or chronic Simple chronic Mucopurulent chronic Mixed simple and mucopurulent chronic Unspecified chronic Acute

*Different than ICD-9 where one code (493.22) was assigned

Documentation Tips◦Acute bronchitis Due to mycoplasma pneumonia Due to hemophilus influenza Due to streptococcus Due to coxsackie virus Due to parainfluenza virus Due to rhinovirus Due to echovirus Due to other specified organism Unspecified

Documentation Tips◦Emphysema Unilateral pulmonary Panlobular Centrilobular Other

Documentation Tips

◦Respiratory Failure Acute Chronic Acute and chronic Unspecified

◦Respiratory Failure Unspecified whether with hypoxia or

hypercapnia With hypoxia With hypercapnia

Documentation Tips◦Mechanical ventilation Duration (< 24 hours, 24-96 hours, >96 consecutive hours)

Type (CPAP, IPAP, Continuous negative airway pressure, Intermittent negative airway pressure)

Documentation Tips◦ Mechanical ventilation

Calculation of duration Start time begins when

Endotracheal intubation is performed in the ER or hospital followed by initiation of mechanical ventilation or;

Initiation of mechanical ventilation through tracheostomy was performed in the ER or hospital or;

Patient is admitted already on mechanical ventilation after previous intubation or tracheostomy

Documentation Tips◦Mechanical ventilation Calculation of duration

Ends when Patient is extubated or; Ventilation is discontinued for patient with

tracheostomy after any weaning period is completed or’

Patient is discharged or transferred while still on ventilator

Sepsis, Severe sepsis, septic shock◦ Acute organ dysfunction and sepsis in a patient must be

associated in order to assign a severe sepsis code. If documentation is unclear, query the provider.

Septic shock represents a type of acute organ dysfunction◦ The code for the systemic infection is sequenced first

followed by R65.21, Severe sepsis with septic shock or T81.12, Postprocedural septic shock

A code from subcategory R65.2xx can never be assigned as principal/first-listed diagnosis.

◦ (b) Severe sepsis ◦ The coding of severe sepsis requires a minimum of

2 codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis. If the causal organism is not documented, assign code A41.9, Sepsis, unspecified organism, for the infection. Additional code(s) for the associated acute organ dysfunction are also required.

Sequencing of sepsis, severe sepsis and localized infection◦If both sepsis/severe sepsis and a localized

infection (such as pneumonia) are present on admission, code the underlying systemic infection first followed by the localized infection

◦If a localized infection is POA and sepsis/severe sepsis develops after admission, the localized infection should be first-listed followed by the appropriate sepsis codes.

Sepsis due to a postprocedural infection should be sequenced first, followed by the code for the specific infection. Codes for severe sepsis and any acute organ dysfunction may also be assigned as appropriate.

Severe sepsis and postprocedural septic shock◦The code for the precipitating complication should be sequenced first (such as infection following a procedure or infection of obstetrical wound) followed by the code for severe sepsis with septic shock and a code for the systemic infection.

Documentation Tips◦*Urosepsis directs the coder to “code to

condition”. Urosepsis does not default to UTI.

* Different than ICD-9 guidance

No time limit on when a sequela code can be assigned◦Sequelae includes conditions specified as such or as residuals which may occur at any time after the onset of the causal condition

Coding of sequela generally requires two codes◦Nature of the sequela sequenced first◦Sequela code second

Exception ◦When the code for the sequela is followed by a manifestation code identified in the Tabular List

Exception ◦When the sequela code has been expanded to include the manifestation

A code for the acute phase of illness or injury is never assigned with a sequela code.

Codes from I69, Sequelae of cerebrovascular disease, should NOT be assigned if the patient does not have neurologic deficits.

Documentation Tips◦Specification of cause Nontraumatic subarachnoid hemorrhage

Nontraumatic intracerebral hemorrhage Nontraumatic intracranial hemorrhage Cerebral infarction Other cerebrovascular diseases Unspecified cerebrovascular diseases

Documentation Tips◦Speech and language deficits Aphasia Dysphasia Dysarthria Fluency disorder Other speech and language deficits

Documentation Tips◦Monoplegia, hemiplegia, hemiparesis and other paralytic conditions Unspecified side Right dominant side Left dominant side Right nondominant side Left nondominant side

Documentation of Use, Abuse and Dependence of the same substance◦Only one code is assigned to identify the

pattern of abuse If both use and abuse are documented,

assign only the code for abuse If both abuse and dependence are

documented, assign only the code for dependence

If both use and dependence are documented, assign only a code for dependence

Codes for psychoactive substance abuse should only be assigned based on provider documentation, including a patient “in remission”.

Documentation Tips◦ Blood alcohol level is coded to Y90.-◦ Nicotine dependence

Cigarettes Chewing tobacco product Unspecified

◦ Nicotine dependence Uncomplicated In remission With withdrawal With other nicotine-induced disorders With unspecified nicotine-induced disorders

Documentation Tips◦Tobacco abuse NOS codes to Z72.0◦History of tobacco dependence codes to Z87.891

Sign/symptom codes◦ Can be assigned when a definitive diagnosis has not been established.

◦ Should NOT be assigned if routinely associated with the disease process

◦If not routinely associated with the disease process they may be coded with the definitive diagnosis code sequenced first

Contrasting/comparative diagnoses◦ When a symptom code is followed by contrasting/comparative diagnoses, the symptom code is sequenced first followed by the contrasting/comparative diagnoses codes

Outpatient coding◦Do NOT code “probable”, “suspected”,

“questionable”, “rule out”, or “working diagnosis” or other similar terms indicating uncertainty. Code the condition to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal results, or other reason for the visit.

If a combination code exists that identifies both the diagnosis and common symptoms of that diagnosis, NO additional code is assigned for the sign/symptom.

Circumstances when to use a sign/symptom code◦ A more specific diagnosis can not be determined

even after all investigation◦ Sign or symptom was transient with no cause

determined◦ Provisional diagnosis in a patient who fails to return◦ Referred elsewhere before diagnosis determined◦ More precise diagnosis not available◦ Certain symptoms that in their own right represent

important problems in medical care

Factors influencing health status and contact with health services◦Used in all health care settings◦May be used as principal/first-listed diagnosis or as secondary codes, depending on the circumstances of the visit/encounter.

Factors influencing health status and contact with health services◦Certain Z codes may only be used as first-

listed diagnosis Z38 Liveborn infants according to place of

birth and type of delivery Z51.0 Encounter for antineoplastic

radiation therapy Z51.1- Encounter for antineopolastic

chemo and immunotherapy Z76.2 Encounter for health supervision

and care of other healthy infant or child

Factors influencing health status and contact with health services◦Status codes are different than History of codes History of codes indicate the patient no

longer has the condition

Factors influencing health status and contact with health services◦Two types of History of Z codes Personal- patient has a past medical condition that no longer exists and is not receiving treatment for

Family- a patient’s family member(s) has had a particular disease that causes the patient to be at a higher risk

Factors influencing health status and contact with health services◦Common status codes Z33.1 Pregnant state, incidental Z68.- Body mass index Z79.-Long-term (current) drug therapy Z89.-Acquired absence of limb Z90.- Acquired absence of organs, NEC Z95.- Presence of cardiac and vascular

implants and grafts

Factors influencing health status and contact with health services◦Aftercare Z codes

Used in situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase.

Are NOT used for aftercare of injuries. The acute injury code is assigned with the appropriate 7th character extension for subsequent encounter.

Factors influencing health status and contact with health services◦Body Mass Index (BMI) Separated into adult, persons 21 years of age or older or pediatric, persons 2-20 years of age.

Factors influencing health status and contact with health services◦Body Mass Index (BMI) Adult Range

≤ 19 to ≥70 Pediatric Range

< 5th percentile for age 5th percentile to <85th percentile for age 85th percentile to <95th percentile for age ≥ 95th percentile for age

Factors influencing health status and contact with health services◦Persons Encountering Health Services for Examinations (Z00-Z13) Codes have been expanded to allow for

capturing an exam with abnormal findings These codes have instructional notes to

assign an additional code to identify the abnormal findings.

Factors influencing health status and contact with health services◦Persons Encountering Health Services for Examinations (Z00-Z13) Z00.00 Encounter for general adult medical examination without abnormal findings

Z00.01 Encounter for general adult medical examination with abnormal findings

Question:◦With the new respiratory failure codes, hypoxia

vs hypercapnia-some of our physicians are using Type I and Type II-we think we can take it to the appropriate code based on its description. We would like confirmation of that as we cannot index type I or type II in the codebook.

Answer (from AHIMA audit seminar Coding for Respiratory Services August 2009):◦ Type 1 Respiratory failure◦ Hypoxemic respiratory failure Decreased arterial oxygen level with normal

or low arterial carbon dioxide level and normal or elevated pH level

◦Type 2 Respiratory failure Hypercapneic respiratory failure

Increased arterial carbon dioxide level and decreased pH level with or without decreased arterial oxygen level

Also known as ventilatory failure or pump failure

Answer:◦Acute or chronic

Type 1 (hypoxemic) Virtually always acute Rarely chronic

Type 2 (hypercapneic) May be acute or chronic Acute: Elevated PaCO2 and low pH levels Chronic: pH levels higher than expected

Answer:ICD-10 does not provide codes for Type 1 or Type

2 respiratory failure.Options are:J96.00 acute respiratory failure unspecified with

hypoxia or hypercapniaJ96.01 acute respiratory failure with hypoxiaJ96.02 acute respiratory failure with hypercapniaJ96.90 respiratory failure, unspecified, unspecified

whether with hypoxia or hypercapniaJ96.91 respiratory failure, unspecified, with

hypoxiaJ96.92 respiratory failure, unspecified with

hypercapnia

Answer:◦Coding Clinic 1st Quarter 2014◦Associated conditions & documentation linkage

Do two conditions have to be listed together in the diagnostic statement in order to assume an association?

It is not required that two conditions be listed together in the health record. However, the provider needs to document the linkage, except in situations where the classification assumes an association (e.g. hypertension with chronic kidney involvement). When the provider establishes a linkage or relationship between two conditions, they should be coded as such.

Answer:◦US National Library of Medicine National

Institutes of Health Several articles on this site define Type I and II

respiratory failure. With documentation of hypercapnia or hypoxia; and respiratory failure, acute respiratory failure, chronic respiratory failure in the medical record- it appears appropriate to use the definitions of type I and II respiratory failure in the code assignment.

Question:◦When orthopedic coding initial vs subsequent

encounters, our orthopedic surgeon says he considers recasting a fracture as part of the acute phase of treatment, yet the descriptions we have seen say the casting would be subsequent. What is correct, initial or subsequent?

Answer:◦If the documentation supports that frequent

casting is part of the active treatment of the fracture, initial encounter may be the appropriate 7th character.

◦However, per the coding guidelines cast change or removal would typically be assigned the 7th character for subsequent encounter.

Coding guideline: Initial encounter

Active treatment for the fracture Surgical treatment Emergency department encounter Evaluation and treatment by a new physician Delayed seeking treatment for the fracture

Subsequent encounter Patient has completed active treatment and is

receiving routine care during the healing or recovery phase Cast change or removal Removal of external or internal fixation device Medication adjustment Follow-up visits

Question:◦How do the professional coders code trimester

for the global billing of OB patients since it could cross several trimesters?

Answer:◦3) Final character for trimester

The majority of codes in Chapter 15 have a final character indicating the trimester of pregnancy. The timeframes for the trimesters are indicated at the beginning of the chapter.

Assignment of the final character for trimester should be based on the provider’s documentation of the trimester (or number of weeks) for the current admission/encounter.

Answer:◦4) Selection of trimester for inpatient

admissions that encompass more than one trimester In instances when a patient is admitted to a

hospital for complications of pregnancy during one trimester and remains in the hospital into a subsequent trimester, the trimester character for the antepartum complication code should be assigned on the basis of the trimester when the complication developed, not the trimester of the discharge. If the condition developed prior to the current admission/encounter or represents a pre-existing condition, the trimester character for the trimester at the time of the admission/encounter should be assigned.

Answer:◦If there is one claim submitted and the patient

has delivered, submit the codes as appropriate for the time of delivery (i.e. 3rd trimester if the code requires a trimester).

Question:◦Can we code from the nurses notes for

dominant vs. nondominant or does it have to be documented by a physician? Coding guidelines don’t seem to address it.

Answer:◦There is no information available to indicate

the dominant vs nondominant specification may be assigned from documentation other than provided by a physician. See previous slides for default code assignment of dominant vs. nondominant.

http://www.cdc.gov/nchs/icd/icd10cm.htm or or http://www.cms.hhs.gov/ICD10

2014 ICD-10-CM Index to Diseases and Injuries 2014 ICD-10-CM Tabular List of Diseases and Injuries

◦ Instructional Notations 2014 Official Guidelines for Coding and Reporting 2014 Table of Drugs and Chemicals 2014 Neoplasm Table 2014 Index to External Causes 2014 Mapping ICD-9-CM to ICD-10-CM and

ICD-10-CM to ICD-9-CM

AHIMA.org Advance for Health Information Professionals

AHIMA audio seminar Coding for Respiratory Services August 2009

Coding Clinic 1st Quarter 2014 Page 15

US National Library of Medicine National Institutes of Health