Transcript ICD-9-CM Coding for Post Acute Care

ICD-9-CM Coding
for
Post Acute Care
Presented by:
Lizeth Flores, RHIT
Anderson Health Information Systems, Inc.
Ontario
September 1, 2010
Dublin
September 2, 2010
Objectives
• Participants will:
– Correctly assign ICD-9-CM codes to diagnoses
– Correctly identify primary / Secondary diagnoses
– Identify correct sequence of diagnoses for coding
assignment
– Learn 2010-2011 coding updates
Purpose of ICD-9-CM Coding
• Gather statistical data
• Reporting diagnoses and
provides a method for
sequencing diagnosis to
support billing transactions /
reimbursement
• Ensure compliance with Federal
Reporting Standards for
diagnoses
• Provide insight into the types of
residents and conditions
• Health Research
ICD-9-CM Official Guidelines for
Coding and Reporting
• HIPAA
• www.cdc.gov/nchs/icd.ht
m
• Latest revision October 1,
2010
Post Acute Care
• Skilled Nursing Facility (SNF)
• Inpatient Rehab Facility
(IRF)
• Home Health Agency
(HHA)
• Long Term Acute Care
Hospital (LTACH)
ICD-9-CM Coding book
• Disease and Procedures
(Books 1-3)
• Alphabetical/Tabular
(numeric) Index
Assigning Code Numbers
• Both the Alphabetic Index
and the Tabular List must
be used when locating
and assigning a code.
• Do not rely on just one
since this can lead to errors
in code assignment and a
less specific code selection
How to Select Codes
• Locate each main term
and subterm in the
alphabetical index, i.e.,
Chronic Kidney Disease
Disease
1. Disease 2. Kidney 3. Chronic
• Verify the code selected in
the Tabular list
• Read and be guided by
instructional notations that
appear in both the
Code to the Highest Level of
Specificity
• Assign 3 digit codes only if there are no four
digit codes within the category.
– There are only 100 codes with only 3 digits
• Assign 4 digit codes only if there is no fifth
digit.
• Assign 5 digit codes when indicated.
• Samples – 486, 401.x, 250.xx
Let’s Practice
•
•
•
•
•
Scabies
Colitis
MRSA of blood
Hypertension
Benign prostatic
hypertrophy (BPH)
Some
•
•
•
•
•
Scabies - 133.0
Colitis – 558.9
MRSA of blood – 041.12
Hypertension – 401.9
Bening Prostate
Hypertrophy 600.00
Types of Codes used in post acute
care Settings
• Aftercare – used when the
initial treatment of a
disease or injury has been
performed and the
patients still requires
continued care to heal or
recover. Categories V51V58
• Late Effects – a late effect
is a residual condition that
remains and requires
medical evaluation, rehab
treatments and/or nursing
Types of Codes -2
• Chronic Conditions –
Conditions that are stable
but still require
management or
treatment.
• Acute Conditions –acute
care codes should only be
reported until the condition
is resolved.
• Therapy – Physical,
occupational, speech and
Types of Codes -3
• History of – (Hx) – history codes are acceptable
on any Medical record regardless of reason for
admission/encounter.
• A history code is distinct from a “status” code in
that history codes indicate that the patient no
longer has the condition and “status” codes
indicated a present state.
• There are two types of history V-codes, personal
and family.
Examples
• Status post ORIF of hip fracture
• V54.11
• History of frequent falls
• V15.88
• Admission for physical therapy
following hip fracture
• V57.1 , V54.13
Practice #1
Chose from the following
and assign the correct
category:
•
•
•
•
After Care
Late Effect
Chronic Condition
Acute Condition
Practice #1 (cont.)
• Hemiplegia
following due
to recent
CVA
• Total Hip
Replacement
• Acute UTI
treated with
Cipro.
• Dementia
• Late Effect
• After Care
• Acute
Condition
• Chronic
Conditon
What to code?
ALL CONDITIONS THAT EXIST
AT THE TIME OF ADMISSION,
THAT EFFECT TREATMENT
RECEIVED
Do NOT Code
DIAGNOSES THAT DO NOT AFFECT TREATMENT
OR LENGTH OF STAY
• WHEN CONDITION NO LONGER EXISTS
• DO NOT ASSIGN PROCEDURE CODES
• Examples: Fractured forearm 6 years ago,
pneumonia, UTI that were resolved (these will
only be coded if the Resident is admitted with
Antibiotics)
Definition of Principal Diagnosis
• “FIRST LISTED DIAGNOSES” is the
diagnosis that is chiefly
responsible for the admission to
the facility and the diagnosis
that supports the
reimbursement and should be
sequenced first.”
Locating Diagnoses
•
•
•
•
Transfer Records
History & Physical
Progress Notes
Admission Orders
Additional Sources of
Information
•
•
•
•
•
•
Discharge summary
Transfer documentation,
Surgical reports
Consultations
Physician Progress notes
Lab reports and
radiological studies
Locating Principal Diagnosis
Principal Diagnosis
• When two or more inter-related conditions
potentially meet the definition of principal
diagnosis
– Either may be sequenced first unless therapy is
being provided, the Tabular list or Alphabetic
Index indicate otherwise.
– Inter-related conditions – two or more diagnosis
that equally meet the definition of principal
diagnosis.
Example
• Resident admitted with
Pneumonia and UTI – either
can be used as the
principal diagnosis if the
resident is still receiving
antibiotic therapy
Choose the Principal Diagnosis
• Fall 3 months ago
• Chronic kidney disease
• Above the knee
amputation Rt. Leg (10
days ago)
• Anemia
• MRSA of surgical wound
(resolved)
Non-Specific Codes
• NEC – Not Elsewhere
Classified
• NOS – Not Otherwise
Specified
• Codes are used only when
neither the diagnostic
statement nor a thorough
review of the clinical
record provides adequate
information to permit
assignment of a more
Inclusion Terms
The coder must review the
titles and inclusions under
the three or four digit
category to determine if
the diagnosis is included in
the category; however,
the specific diagnosis may
not always be listed
• Example:
• Spinal Cord Inflammation
323.9
Combination Codes
• Single codes used to
classify two diagnosis or a
diganosis with a
manifestation
• Example:
• Candidiasis with meningitis
112.83
Combination Codes
• Etiology codes – USE
ADDITIONAL CODE
• Manifestation codes –
CODE 1st Underlying Dx.
• Codes in parentheses
identify conditions that
require multiple coding.
Also, codes in parentheses
CAN NOT be sequenced
as PRINCIPAL Dx.
Combination Codes
• Anosmia following CVA
• 438.6, 781.1
• “with”, “with mention of”,
or “associated with” – this
code can only be used if
both conditions are
present
• Kidney Infection …..590.9
with Calculus 592.0
Multiple Coding
• Instructions for conditions
that require multiple
coding can appear in the
Tabular List.
– “Code also underlying
disease”, “Use additional
code, if desired, to identify
manifestation, as …” “Code
also” instructs the coder to:
• Code the underlying disease, or
etiology first as the primary
diagnosis, followed by the
code (s) for manifestation (s).
• It is mandatory to follow the
Slanted Brackets [ ]
• Indicate proper sequencing for the
two codes listed.
– The code number before the bracket is
coded first.
– The code number inside the brackets is
coded second.
Codes in brackets in the alphabetic index
can NEVER be sequenced as the
principal diagnosis.
EXAMPLES
1.Arthritis, arthritic --- due to
or associated with
hypothyroidism
244.9 [713.0]
Multiple Coding
• Examples:
– Aftercare following kidney
transplant
– V58.44 (aftercare involving organ
transplant),
– V42.0 (Organ/tissue replacement
by transplant , kidney)
– Aftercare following arteriocoronary
bypass
– V58.73 (aftercare following surgery
of the circulatory system),
V45.81(aortocoronary bypass
status)
–  use aftercare codes to provide
Sequencing Multiple Codes
• “Using Additional Codes”
– When the instructions say
“Use additional code….” the
additional code is
sequences second.
Example
UTI due to E.coli
599.0, [041.4]
Let’s Practice
• 1. Chronic Peptic Ulcer
with Hemorrhage
• 2. Cerebral thrombosis
with cerebral infarction
• 3. Diverticulitis of
Duodenum “with”
bleeding
“Exclusions”
Let’s have a look:
• See 429 section
• Under Cardiovascular
Disease, Unspecified
• Excludes: That due to
hypertension
Diagnosis Sequencing
• The order in which codes
are listed is called
sequencing. The coder
should make every effort to
record the codes in a
logical sequence that is
descriptive of the resident’s
condition.
Choose the correct
sequence…
•
•
•
•
•
Diabetic retinopathy
UTI (on antibiotics)
Chronic Back Pain
Hyperlipidemia
Osteoporosis
Acute Diagnoses
• Acute dx treated in the hospital should be
coded until the condition is resolved, after
the resident is transferred to the SNF
Examples:
MRSA
Pneumonia
UTI
Secondary Diagnoses
– May have multiple secondary codes
– List and code conditions related to therapy and
services provided
– Review and update as condition changes –
sequence may change over time
– Billing staff should work with Nursing and Health
Information Department to know which
diagnoses are current, which is principal, etc.
Secondary Diagnoses
• Order by complexity.
• Assign the condition with the higher
complexity first. (those that require the
most resources i.e. wound care vs.
hypertension)
• All conditions present at the time of
admission, and that affect the treatment
provided and length of stay should be
coded.
V- Codes
• Per ICD-9-CM Official
Guidelines for Coding and
Reporting, aftercare codes
are generally first to explain
the specific reason for the
encounter (admission)
• Certain aftercare code
categories need a
secondary dx code to
describe the resolving
condition or sequelae
• For others (V codes) the
condition is inherent in
Coding Clinic Fourth Quarter
1999
• Published rules for the use
of V codes
• Addressed the use of V
codes in LTC settings
• Coding clinic Fourth
Quarter 2003
• Clarified the use of
aftercare V codes for all
subsequent encounters
after the initial treatment
for a fracture
V- Codes -2
• V-codes are assigned to
problems that affect the
patient’s health but are not
in themselves a current illness
or injury
• V-codes can be used to
represent status or history.
• Examples:
– Status Cardiac Pacemaker
V45.01
– Status heart valve prosthesis
V43.3
– History of falls V15.88
– History of alcoholism V11.3
Let’s Practice
• Admitted for physical
therapy, status post total
knee replacement due to
arthritis
1) Admission –
rehabilitation
–
physical
2 ) Aftercare – following surgery for –
joint replacement
3) Replacement –
Knee
joint –
• Post hysterectomy for
uterine cancer three years
ago (no further treatment)
• History – personal –
malignant neoplasm –
uterus
• V10.42
Select the correct Code
• Fracture of upper arm due
to fall, resident wearing a
sling, admitted for ADL
assistance.
V54.11
905.2
812.20
Late Effects
• Residual condition
• After initial / acute phase
of illness
438 Late Effects of CVA
• Official coding guidelines
state that Category 438 is
used for admission and
encounter for post acute
care following treatment of
the CVA in the acute
hospital
• Codes from categories 430
to 436 are reserved for the
“initial” (first) episode of
care for an acute CVA
that was provided in the
Let’s Practice
• Which of the followign is a
late effect?
a. End stage renal disease
b. Anosmia following recent
CVA
c. Diabetic retinopathy
d. Paraplegia due to polio
Let’s Code
• Left hemiplegia secondary
to CVA (patient is right handed)
• Late Effects
• Cerebrovascular disease
• With hemiplegia –
nondominant side
Code it
• Dysphagia and residual
hemiparesis due to CVA
• Ataxic gait followin
traumatic brain injury
Infections
• Codes from categories 041
or 079 can be used as
principal diagnosis as long
as the nature or site of the
infection is not specified or
when the Alphabetical
index instructs you to do so.
Code it
• Gastroenteritis due to E.coli
• MRSA infection of Lt. toe
• Herpetic septicimia
Neoplasms
• Go to alphabetic index
• Look up Ex: fibroma, upper
jaw
• Find “fibroma”
• Cross reference “see
neoplasm, by site,benign”
• Turn to neoplasm locate
subterm
• “Jaw / upper”
• Follow across to Benign
• Locate code 213.0
• Go to Tabular list for any
coding instructions or notes*
Neoplasms of Uncertain
Behavior
• Only used when stated as such
in Alpha Index
• Unspecified Behavior –
• Only used when Neoplasm is
not fully described
– Or not specified as to behavior
– Or listed in Alphabetic index
• Ex: Neoplastic Cyst of Tongue
– Cross reference Alpha Index Under
Cyst, neoplastic see neoplasm,by
site, unspecified nature
Neoplasms with Metastasis
• Malignant Neoplasm from
primary site
• Invade or spread via the
– Blood
– Lymphatic system
– Tissue to secondary
metastatic site
Neoplasms with Metastasis
• Two codes
– One for primary (original
site)
– One for each secondary site
• Code primary before
secondary
– Except when using “V” code
for primary site that has been
surgically removed
Neoplasms with Metastasis
• Determine the primary site
• Turn to Neoplasms Table
• Ex: Carcinoma of Rectum
(154.1)
• Find Neoplasm, rectum,
malignant, primary
Neoplasms with Metastasis
• Ex: Secondary malignant
neoplasm of prostate
(198.82)
• Find Neoplasm, prostate,
malignant, secondary
Determine the site(s) of
metastasis
• Turn to Neoplasm table
• Find correct subterm(s) for
site
• Cross over to Malignant
and column secondary
Unknown secondary sites
• Ex: Cancer of Lower lobe
of lung with metastases
(162.5, 199.0)
• Code primary site first
• To code the unknown
secondary site
– Refer to Neoplasm table
– Multiple sites NEC
– Cross over to column for
code (199.0)
Unknown Primary Site
• Refer to neoplasm table
• Unknown or Unspecified
site
• Cross over to primary
column 199.1
• Sequence after secondary
site(s)
• Ex: abdominal metastasis
from unknown origin
(198.89, 199.1)
• Unknown primary would
not be used as principle
“V” Codes for Cancer
• Primary site must still be
identified if removed,
eradicated no longer
under treatment
• Use a personal history Vcode, History,site,
malignant neoplasm
• Identify primary site
responsible for metastasis
but no longer present
• Secondary site code is
“V” Codes for Cancer
• Do not use codes from
category V10 for
secondary metastatic sites
removed or not
• ICD-9-CM does not provide
code numbers for “history
of secondary neoplasm
site
V58.42 Neoplasm
• Official coding guidelines
for neoplasm apply when
using the aftercare
following surgery for
neoplasm V58.42
• Aftercare code V58.42
may be used with either
the current neoplasm
code or a code from
category V10, whichever is
applicable
V-Codes
• (2010) V12.41 Personal
history of benign neoplasm
of the brain.
– Previously, no code to
indicate that the patient had
benign growth. These can
cause serious symptoms in
the patient.
Code It
• History of breast cancer
with metastasis to the lung
• Carcinoma of prostate
with metastasis to spine
• Basal cell carcinoma of
chest
Endocrine, Nutritional and
Metabolic Diseases and immunity
disorders
Examples:
•
•
•
•
Hypothyroidism
Diabetes
Metabolic disordes
Obesity
Code It
• Hypothyroidism due to
history of thyroid cancer
(thyroid removed)
• Uncontrolled, Type II
Diabetes
Manifestations Codes
• There are written
instructions in ICD-9-CM
coding books for
sequencing codes.
• The underlying Dx
(cause/s) coded first,
followed by codes for
manifestations.
Combination Codes
• Some Diabetic Conditions
Require 2 Codes
– “Diabetic” or “Due to”
• One Code for Cause
• One Code for Complication
– Always sequence cause
before complication
Combination Codes
• Example:
– Diabetic foot ulcer
• Diabetes with other
manifestation
– 250.8x
• Ulcer of lower limb, except
decubitus
– 707.1x
Manifestation Codes
• Diabetic Neuropathy
• Diabetes with neurological
manifestations must be
coded first (250.60)
• The tabular list will guide you
to “Use additional code to
identify manifestation, as:”
• Polyneuropathy in diabetes
(357.2)
• The tabular section will tell
you that this code is not
allowed as a principal Dx
and will guide you to code
Let’s Code
• 1. ALZHEIMER’S DEMENTIA
• 2. DIABETIC GLAUCOMA
Chronic Illnesses
• Chronic illnesses that are
managed with medication
or treatments, such as
hypertension,
hypothyroidism, diabetes
mellitus, atrial fibrillation,
assign the appropriate ICD
9 code
• The chronic condition
exists, but is under control
by medication
Myocardial Infarction
• A code from category
410.XX must be assigned if
the admission is strictly for
rehabilitation within eight
weeks of the acute MI.
• The fifth digit 2 would be
used in LTC to designate
observation, treatment or
evaluation of MI within
eight weeks of onset,
following the acute phase
or in the healing state.
Myocardial Infarction
• The fifth digit “1” should be
used if the acute
myocardial infarction
occurred at the nursing
facility and was the reason
for transfer to the hospital
or the cause of death.
• If the admission takes
place after eight weeks
assign code (412) Old
Myocardial Infarction
Hypertension
• Unless the diagnosis
statement specifies as
“benign” or “Malignant”
• “unspecified” code (401.9)
must be assigned
Heart Conditions Due to
Hypertension
• When there is a casual
relationship is states as
“hypertensive” or “due to
hypertension” heart
conditions are assigned by
Category 402 Hypertensive
Heart Disease
• Arteriosclerotic disease
due to hypertension 402.90
Circulatory System
• Let’s Code
1. Chronic hypertensive
kidney disease
2. Deep vein thrombosis
patient on Coumadin
Respiratory System
• Let’s Code
• Aspiration Pneumonia
• Chronic bronchitis with
emphysema
Skin Ulcers
• Clarification of clinical
terms related to skin ulcers
www.cms.hhs.gov/manual
s/pm trans/r4som.pdf
• Pressure Ulcer is a synonym
for decubitus ulcer – due to
prolonged pressure
• Subcategory 707.0x has
fifth digits to identify site
•
New- additional code
must be used to identify
Skin Ulcers of Lower Limbs
• Non pressure ulcers of
lower leg
• Fifth digits to identify site
• Multiple coding, code first
the underlying dx, such as
arteriosclerosis, diabetes,
venous hypertension
– i.e. diabetic ulcer of left fifth
toe 250.80, 707.15
Stasis Ulcers
• The most common type of
vascular ulcers
– In Alphabetical index under
“ulcer” , the index lists
“venous” as a non-essential
modifier under the subterm
“stasis” that refers to code
459.81.
– Under section 459.81 in the
Tabular List you will be
instructed to code any
associated ulceration from
category 707.0-707.9
Wounds
• Category 870-897 Codes
for wounds are not to be
used for normal, healing
surgical wounds or to
identify complications of
surgical wounds
V54.1 Aftercare for healing
traumatic fracture
• For residents admitted to a
SNF for care following
treatment in the acute
hospital for a traumatic fx
use the aftercare codes
from Subcategory V54.1
• Do not code the (acute)
fracture
• Coding Guidelines require
an aftercare code be used
after the initial encounter
V54.1 Aftercare for healing
traumatic fracture
• For statistical purposes, a
fracture should only be
coded once. If the same
fx is coded for all
encounters, it makes
collection of fracture
statistics difficult
• The V54.1 identifies the site
of the fracture and that it is
in the healing phases
• Aftercare for Fractures;
V54.1 Aftercare for healing
traumatic fracture
• The fifth digits identify the
specific site of the healing
fracture
• The fifth digit 9 is used for
other specified sites
• If there are several bones
that would be classified to
the other specified site,
only one code is used
V54.1 Aftercare for healing
traumatic fracture
• DO NOT code V58.43
Aftercare following surgery
for injury and trauma
(conditions classifiable to
800-999) Exclusion note
states “Excludes: aftercare
for healing traumatic
fracture”
• Remember to always refer
to the tabular list and
carefully read the
instructions and exclusions.
Aftercare for healing
Pathological fracture
• Pathological fracture is a
fracture in a bone due to
weakening of the bone
structure by disease process
such as osteoporosis.
• For admissions in LTC
following a hospital stay for
treatment of a pathological
fracture assign a code from
Subcategory V54.2 Aftercare
for healing pathologic
fracture
Hx of Fracture
• V13.51 personal hx of
healed pathologic fx
• V13.52 personal hx of
healed stress fx
• V15.51 personal hx of
healed traumatic fx
• Note added to
subcatagory 733.0
-use add’l code to identify
personal hx of pathologic
V54.81 Joint replacement
• Joint replacement of knee
for osteoarthritis (V58.78),
V54.81, V43.65
• Do not code the disease
condition that was treated
with the surgery
• 2008 will have a change in
the tabular list for V58.78
that will exclude it when
there is orthopedic
aftercare; codes from
Joint Replacement for Fx
• Use multiple coding to fully
describe the resident’s
condition
• FX hip (traumatic) with joint
replacement V54.13,
V54.81, V43.64
• Do not use V58.43
Aftercare following surgery
for injury and trauma-(not
for fx)
(conditions classifiable to
V57 Care Involving Rehab
• Category V57 does not
indicate that rehab
services were provided,
only that the resident was
admitted for this purpose
• Use only one code from
Category V57 for an
admission
• If the resident is admitted
for multiple therapies, use
V57.89
V57 Care Involving Rehab
• Code also the condition
requiring the rehab, such
as:
–
–
–
–
Residuals
Late effects
Aftercare
symptoms
V58 Aftercare Following
Surgery
• The acute dx for which the surgery was
preformed is not reported for aftercare
encounters or admissions
• Use other aftercare or symptom codes to
provide better detail
• Note the instructions with each code that
identifies the range of conditions that are
included in the aftercare code number
– i.e. aftercare post cataract extraction with lens
implant: V58.71, V45.61, V43.1
2009 ICD-9-CM addenda
• Implementation date of
new, revised and invalid
codes October 1, 2010
• See handout for code
details
Thanks for attending