CCS Preparation Readiness W k h Workshop May 2013
Transcription
CCS Preparation Readiness W k h Workshop May 2013
IOD Incorporated May 2013 CCS Preparation Readiness W k h Workshop May 2013 Presented by: Kim Felix, RHIA, CCS Director of Education IOD Incorporated www.iodincorporated.com • Full suite of HIM solutions including: – – – – – – Release of Information (ROI) Document Conversion Coding/Abstracting/Auditing ICD-10 Consulting g RAC Services Training/Education www.iodincorporated.com 2 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 1 IOD Incorporated May 2013 Where to begin? • Organize and review the following: – AHIMA Candidate Handbook for the CCS Exam – Official Coding Guidelines (inpt and outpt) – Coding books – Coding Clinic from the past 2-3 years (make notes in ICD-9 book) – CPT Assistant from the past 2-3 years – Personal textbooks, class notes, tests, etc. 3 General Information • Inpatient rules versus Outpatient rules – i.e. possible/probable • Do not overcode! – signs/symptoms integral to a disease process – Personal and family ‘history of’ codes that have no bearing on the stay • Pharmacology – what drugs treat what condition? • When to query? – abnormal lab findings not correlated by the physician in the record • Reimbursement and Billing 4 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 2 IOD Incorporated May 2013 General Information • 2013 CCS exam will launch on June 1, 2013 Candidates 2013. C did t will ill b be required i d tto b bring i the 2012 OR 2013 versions of ICD-9-CM Volumes 1 through 3 and the 2013 AMA CPT coding books to the testing center – Per AHIMA’s website – You can use your code books for the entire exam 5 Exam Specifications • • • • • Total Testing Time= Four HOURS Multiple Choice Section – 81 single response multiple-choice items (63 "scored" and 18 "pre-test" items) – Pre Pre-test test items are unscored items that are included in the examination to assess the item's performance prior to using it for operational use in a future examination – The pre-test items are scrambled randomly throughout the examination and do not count toward the candidate's score. Multiple Select Section – more than one response required – The multiple select section will consist of 8 multiple response items (6 "scored" and 2 "pre-test" items). Pre-test items are unscored items. Fill in the Blank Section (Medical Record Cases) - The fill in the blank section will consist of 12 medical record cases, which contains six outpatient records and six inpatient records. Inpatient diagnoses and procedures are to be coded with ICD-9-CM volumes 1-3; ambulatory care diagnoses are to be coded with ICD-9-CM volumes 1 and 2; and ambulatory care procedures with CPT. 6 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 3 IOD Incorporated May 2013 Exam Specifications • Candidates will be instructed on exactly how many codes are required – By diagnosis and procedure • If a candidate did t d does nott enter t an answer in i one off the required boxes, they will NOT be allowed to move to the next question • Scoring: – If the question has 2 answers and the candidate gets both codes correct, they will receive 2 points – If they get one correct and one incorrect, they will receive 1 point – Not ‘all or nothing’ questions. – Partial credit is given. 7 What to expect on the test TOPIC % of questions Health information documentation 10 Diagnosis and procedure coding 64 Regulatory Guidelines & Reporting Requirements for Inpatient 5 Regulatory Guidelines & Reporting Requirements for Outpatient 6 Data Quality 4 Information and Communication Technologies 3 Privacy, Confidentiality, Legal and Ethical Issues 4 Compliance 4 8 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 4 IOD Incorporated May 2013 BOOKS • http://www.ahima.org/certification • Candidate Exam available – Candidates who report to the test center with incorrect code books will not be permitted to test and will forfeit their exam application fee. 9 Inpatient p Guidelines 10 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 5 IOD Incorporated May 2013 Selection of Principal Diagnosis • Codes for signs/symptoms are not to be used as principal dx when a related definitive diagnosis has been established • When Wh th there are 2 or more iinterrelated t l t d conditions that potentially meet the definition of principal diagnosis, either condition may be sequenced first • When there are 2 or more diagnoses that equally q y meet the criteria for p principal p diagnosis, any one of the diagnoses may be sequenced first 11 Selection of Principal Diagnosis • When 2 or more contrasting or comparative diagnoses are documented as ‘either/or’, they are coded as if they were confirmed and sequenced according to the circumstances of admission • When a symptom is followed by contrasting/ comparing (either/or) diagnoses, the symptom code is sequenced first followed by all the contrasting/ comparative diagnoses • Sequence the condition that meets the definition of principal diagnosis even though treatment may not have been carried out due to unforeseen circumstances 12 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 6 IOD Incorporated May 2013 Selection of Principal Diagnosis • When the admission is for treatment of a complication resulting from surgery or other medical care,, the complication p code is sequenced q as the principal diagnosis. Add an additional code to further describe the complication if the complication code lacks specificity • If the diagnosis is qualified as ‘probable, suspected, likely, questionable, possible, still to be ruled out’ or other similar terms indicating uncertainty, code the condition as if it existed or was established 13 Sample Question • The coding supervisor conducts weekly quality controls to assess the accuracy of coded data. Which of the following codes listed as the principal diagnosis is the only code appropriate for principal diagnosis assignment? A. 321.2 Meningitis due to viruses, not elsewhere classified B. E855.0 Accidental poisoning by anticonvulsant and anti-Parkinsonism drugs C. V27.0 Outcome of delivery, single liveborn D. V71.1 Observation for suspected malignant neoplasm 14 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 7 IOD Incorporated May 2013 Answer D. V71.1 Observation for suspected malignant neoplasm 15 Additional Diagnoses • • • • • • • Clinical evaluation Therapeutic treatment Diagnostic procedures Extended LOS Increased nursing care/monitoring Previous conditions, if pertinent to current stay Abnormal findings, if provider documents their clinical significance • Uncertain diagnoses (probable, suspected, likely, questionable, possible, still to be ruled out) are coded as if they existed or established 16 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 8 IOD Incorporated May 2013 Additional Diagnoses • AHIMA’s website: Procedures for Coding Part II of the CCS Exam • Highlights: – Code diagnoses of chronic systemic or generalized conditions that are not under active management when a physician documents them in the record and that may have a bearing on the management of the patient. • For example: Admission for breast mass; diagnosis is carcinoma. Patient is blind and requires increased care. Code the breast carcinoma and blindness. Additional Diagnoses • More highlights: – Code status post previous surgeries or conditions likely to recur that may have a bearing on the managementt off the th patient ti t • For example: Admission for pneumonia; status post cardiac bypass surgery. Code the pneumonia and status post cardiac bypass surgery (V code). – Do not code status post previous surgeries or histories of conditions that have no bearing on the management of the patient. • For example: Admission for pneumonia; status post hernia repair six months prior to admission. Code only the pneumonia. • Previous surgeries involving transplants, internal devices, and prosthetics should be coded. CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 9 IOD Incorporated May 2013 Additional Diagnoses • More highlights: • Do not assign External Cause of Injury and Poisoning Codes C ((E codes), ) except those that identify the causative substance for an adverse effect of a drug that is correctly prescribed and properly administered and/or p poisoning g ((E850E982). Procedures • Do not code procedures that fall within the code range 87.01 through 99.99. But code procedures in the following ranges: – – – – – – – – – – – 87.51 87.54 Cholangiograms 87.51-87.54 87.74 and 87.76 Retrogrades, urinary systems 88.40-88.58 Arteriography and angiography 92.21-92.29 Radiation therapy 94.24-94.27 Psychiatric therapy 94.61-94.69 Alcohol/drug detoxification and rehabilitation. 96.04 Insertion of endotracheal tube 96 56 Other lavage of bronchus and trachea 96.56 96.70-96.72 Mechanical ventilation 98.51-98.59 ESWL 99.25 Chemotherapy CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 10 IOD Incorporated May 2013 Coding from Pathology/Lab/Radiology Reports • In the inpatient setting, coders should not assign g codes from the p pathology gy report p alone, without the provider’s input • When available, the coder may use x-ray results to provide greater specificity • Abnormal findings alone should not be coded d d unless l th the provider id d documents t th their i clinical significance 21 Coding abnormal finding from the pathology report • Abnormal findings on the pathology report are not coded and reported unless the provider indicates their clinical significance. This ensures that the documentation and the codes reported are consistent with the attending physician’s interpretation since he or she is responsible for the clinical management of the case. It is the responsibility of the attending physician to gather and collate all of the findings from the consultants and other providers involved in the care for the patient. The plan of care is based on the attending’s evaluation, interpretation and collation of all the findings (i.e.. pathology radiology, pathology, radiology and laboratory results) results). Although the pathologist provides a written interpretation of a tissue biopsy, this is not equivalent to the attending physician’s medical diagnosis based on the patient’s complete clinical picture. Coding Clinic 2008 22 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 11 IOD Incorporated May 2013 Infectious and Parasitic Diseases • HIV – Code only confirmed cases – V08 = asymptomatic y p HIV infection who have never had an HIV-related illness – HIV-related condition = Code 042 as principal – Previous diagnosis of AIDS/HIV related illness is always coded as 042 from then on – PREGNANCY is the exception- Use code from pregnancy chapter as principal diagnosis if pregnant woman has HIV-related illness – Patient here to determine HIV status = V73.89 23 Infectious and Parasitic Diseases • Septicemia, Systemic Inflammatory Response Syndrome (SIRS), Sepsis, Severe Sepsis Sepsis, and Septic Shock Bacteremia→→→Septicemia→→→Sepsis↓ ↓Severe Sepsis w/shock←←Severe Sepsis←← →→Multiple p Organ g Dysfunction→→Death y 24 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 12 IOD Incorporated May 2013 Sepsis/SIRS • Bacteremia- bacteria in the blood (790.7) • Septicemia- systemic disease with presence of organisms in the blood (038.x) – Do NOT need a positive blood culture to code septicemia • SIRS – systemic response to infection, trauma/burns, cancer WITH symptoms (fever, tachycardia, tachypnea, leukocytosis) (995.90) progresses quickly to….. • Sepsis – SIRS due to infection (995 (995.91) 91) • Severe sepsis – sepsis with associated acute organ dysfunction (995.92) 25 Bottom Line… • Coding of SIRS, sepsis and severe sepsis requires a minimum of 2 codes: – One for underlying cause (infection, trauma) Thi iis sequenced This d fi firstt – One for SIRS code (995.9x) as secondary dx – Severe sepsis also requires a code for the associated organ dysfunction EXCEPTION: If the patient has sepsis and an acute organ g dysfunction, but the documentation indicates that the acute organ dysfunction is related to a medical condition other than sepsis, do not assign code 995.92 26 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 13 IOD Incorporated May 2013 Septic Shock • Code first the systemic infection, followed by 995.92 and 785.52 • Septic S ti Shock Sh k cannott b be assigned i d as principal diagnosis • Must use code 995.92 with 785.52 even if the term ‘severe sepsis’ is not documented 27 Sepsis and Severe Sepsis with Non-infectious process • SIRS can develop due to trauma, malignant neoplasm or pancreatitis • If no infection is documented as the cause of SIRS, code the underlying condition (such as the injury) followed by 995.93 or 995.94. • Additional Additi l codes d ffor organ d dysfunction f ti should also be assigned as secondary diagnosis 28 28 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 14 IOD Incorporated May 2013 Sepsis Example • Septicemia due to methicillin-resistant Staph A. Patient was also admitted with septic shock and Stage 3 decubitus ulcer of the sacrum. Patient had a central line inserted in the ICU for medication administration. 038.12, 995.92, 785.52, 707.03, 707.23 38 93 38.93 29 Sample Question • The following ICD-9-CM index entries appear: Encephalitis infectious (acute) (virus) NEC 049.8 postinfectious NEC 136.9 136 9 [323.6] [323 6] The diagnosis listed by the physician is encephalitis after infection. Which of the following represents the correct coding and sequencing? A. 049.8 B. 323.6 C. 136.9; 323.6 D. 049.8; 136.9 30 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 15 IOD Incorporated May 2013 Answer • C. 136.9; 323.6 31 Neoplasms • Treatment directed at malignancy= code malignancy as principal diagnosis • Treatment directed at complication associated with malignancy (i.e. anemia) anemia)= code associated complication as principal diagnosis • Primary malignancy previously excised and NO further treatment = V code – There is no code for a history of metastatic site(s) • Admission for chemotherapy/radiation = V58.1x as principal diagnosis, then code malignancy as secondary • Signs/symptoms associated with or related to the malignancy= use malignancy as principal diagnosis 32 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 16 IOD Incorporated May 2013 Neoplasms • Question: Patient admitted with weakness, fatigue and weight loss. Hepatomegaly and jaundice are found on PE. CT is compatible with extensive t i metastatic t t ti di disease iinvolving l i th the llungs, liver and intra-abdominal lymph nodes. Primary tumor was not identified although the possibility of a pancreatic mass was considered. Discharge diagnoses included “the liver and lung masses, probably metastatic disease”. How should this be coded? 33 Neoplasms • ANSWER: Assign code 197.0, secondary neoplasm of lung and 197.7, secondary neoplasm of liver and 199.1, malignant neoplasm, unspecified site. In this case the Official Guideline for Coding and Reporting Uncertain Diagnoses would apply. • The Cooperating parties for ICD-9-CM have thoroughly examined this issue and decided NOT to change or make an exception to the existing guideline for uncertain diagnoses. If the diagnosis documented at the time of discharge (inpatient) is qualified as ‘probable probable, suspected, likely, possible or still to be ruled out’, code the condition as if it existed or was established. – Coding Clinic, 2006 34 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 17 IOD Incorporated May 2013 Neoplasms • Tumor lysis syndrome • Effective October 1, 2009, subcategory 277.8, Other specified disorders of metabolism, has been expanded to uniquely describe tumor lysis syndrome. This new code (277.88) captures both tumor y syndrome y following g cancer therapy py and spontaneous p tumor lysis y lysis syndrome. Previously, the tumor lysis syndrome was not specifically indexed in ICD-9-CM. • Tumor lysis syndrome (TLS) refers to a group of serious, potentially lifethreatening metabolic disturbances that can occur after antineoplastic therapy. TLS usually occurs following the administration of anti-cancer drugs; however, it can also develop spontaneously or as a result of radiation or corticosteroid therapy. It is often associated with leukemias and lymphomas, but is also seen in other hematologic malignancies and solid tumors. Since anti-cancer therapy can result in the quick breakdown of tumor cells, some malignancies with rapidly dividing cells that are very responsive to therapy are at an increased risk for TLS. When cancer cells are destroyed, they can release intracellular ions and metabolic byproducts into the circulation leading to TLS. 35 Neoplasms • Tumor lysis syndrome • Clinically, the syndrome is characterized by a number of effects from tumor cell breakdown and as phosphate levels increase, serum calcium decreases; if the levels are both high, calcium phosphate may precipitate in tissues tissues. – These disturbances can lead to acute renal failure due to uric acid nephropathy and/or xanthine nephropathy, or due to precipitation of calcium phosphate in renal tubules or interstitium. • Although TLS is commonly a complication of cancer therapy, the syndrome may rarely develop spontaneously before treatment is initiated. Pretreatment spontaneous tumor lysis syndrome is generally associated with acute renal failure due to uric acid nephropathy. • An additional E code should be assigned to identify the cause when tumor lysis syndrome is drug-induced. 36 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 18 IOD Incorporated May 2013 Neoplasm examples • Patient with h/o malignant neoplasm of lung is admitted with seizures. W/U revealed mets to the brain. 198.3, 780.39, v10.11 • Patient admitted for dehydration following chemotherapy as treatment for ovarian CA 276.51, 183.0 37 Neoplasms • Question: The patient is a 48-year-old male with glioblastoma multiforme status post two surgeries. The tumor has recurred with massive growth since debulking one month ago. The provider indicated that there was a significant amount of surrounding vasogenic edema and mass effect. Is it appropriate to assign a code for cerebral edema when it is due to a primary intracranial process such as a brain tumor and the provider has indicated that it is clinically significant? 38 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 19 IOD Incorporated May 2013 Neoplasms • Answer: Assign code 348.5, Cerebral edema, as an additional diagnosis, since the provider has evaluated and documented the clinical significance of the vasogenic edema. • Patients with glioblastoma commonly develop vasogenic edema. Vasogenic edema is an accumulation of fluid in the brain (due to the tumor’s disruption of the blood-brain barrier). The surrounding edema can increase the mass effect of the tumor and is considered an irreversible process. Tumor-related vasogenic edema may disrupt synaptic transmission and alter neuronal excitability, leading to headaches, seizures, focal neurological g deficits, and encephalopathy. The condition can contribute to morbidity, resulting in fatal brain herniation. – Coding Clinic, Third Quarter 2009 39 Neoplasm examples • Pt admitted with abdominal pain. Needle biopsy of liver reveals secondary malignancy of the liver liver. Pt has an exploratory laparotomy to determine primary site. Primary site is unknown at time of discharge. 197.7, 199.1, 54.11, 50.11 40 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 20 IOD Incorporated May 2013 Neoplasms • Malignant Pleural Effusion – Code 511.8, other effusion has been further expanded to differentiate between malignant pleural effusion (511.81) and other specified forms of pleural effusion (511.89) – Previously malignant pleural effusion defaulted to secondary neoplasm of pleura (197 2) (197.2) 41 Neoplasms • Question: The patient was admitted for heminephrectomy due to bilateral renal masses. Pathologic analysis confirmed renal cell carcinoma. The provider listed “bilateral renal masses,” in the final diagnostic statement since the pathological results were not available at the time. However, the cancer staging form that the provider has completed and signed is available in the health record. Our medical staff leadership has deemed this confirmation of the pathologic diagnosis of renal cancer and sufficient documentation for coding. Is the completed and signed cancer staging form appropriate documentation for coding and reporting purposes? • Answer: Yes, it is appropriate to use the completed cancer staging form for coding purposes when it is authenticated by the attending physician. p y As stated in Coding g Clinic, Second Quarter 2000, p pages g 17- 18, “Documentation is not limited to the face sheet, discharge summary, progress notes, history and physical, or other report designed to capture diagnostic information. This advice refers only to inpatient coding.” Coding Clinic, 2nd quarter 2010, p. 7-8 42 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 21 IOD Incorporated May 2013 Sample Question • A patient is admitted to the hospital to undergo a radical mastectomy for recurrent carcinoma of the breast (Previously, she had elected to have a lumpectomy). The attending physician lists a history of atrial fibrillation as a secondary di diagnosis. i Th The patient ti t iis currently tl nott on any medication. di ti F For medical clearance prior to surgery, the patient is seen by a consultant, who says that the patient was satisfactory for the procedure. The coder should: A. Report atrial fibrillation as a current condition, because it was documented by the physician in the history. B. Code atrial fibrillation as a current condition, because the patient was seen by a consultant for surgical clearance. C Add th C. the code d ffor observation b ti ffor suspected t d cardiovascular di l condition diti D. Omit reporting the code for atrial fibrillation, because it was not treated and did not affect the course of treatment. 43 Answer D. Omit reporting the code for atrial fibrillation because it was not treated and fibrillation, did not affect the course of treatment. 44 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 22 IOD Incorporated May 2013 Diabetes • Type I versus Type II – Type I is always insulin-requiring (usually a jjuvenile onset)) and is much less common than Type II – Type II CAN be insulin- requiring or can be managed with medication. Add v58.67 for patients that are Type II and who routinely use insulin – If the type of DM is not documented in the medical record the default is type II 45 Diabetes • Fifth digits must be consistent for Diabetes coding. • If DM is out of control, control all manifestation codes must have the same fifth digit of uncontrolled. – Example: Patient has Type II Diabetes with numbness due to peripheral neuropathy. Patient also has retinopathy. Patient becomes uncontrolled on Day 3. Final Dx: 250.62, 357.2, 250.52, 362.01 46 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 23 IOD Incorporated May 2013 Diabetes • Question: Previously published Coding Clinic advice instructed coders not to assume a causal relationship between diabetes and certain manifestations The physician documentation manifestations. should establish the relationship with terms such as “due to diabetes” or “diabetic.” However, recent advice published in Coding Clinic Third Quarter 2008, pages 5-6, is not consistent with this advice. Additionally, in ICD-9- CM’s Alphabetic Index, there is no entry for diabetes with ith neuropathy. th C Could ld you please l clarify l if thi this new instruction? 47 Diabetes • Answer: In ICD-9-CM’s Alphabetic Index, the subentry term “with” means associated with or due to. to If the provider documents “diabetes with neuropathy,” assign code 250.6X, Diabetes with neurological manifestations, and code 357.2, Polyneuropathy in diabetes. • Coding Clinic, Second Quarter 2009 48 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 24 IOD Incorporated May 2013 Sample Question • A patient with out-of-control • Type I Diabetes was admitted with diabetic retinopathy. ti th Th The correctt coding and sequencing for • this case is… Select ONE of the following options a. 250.53, 362.02 • b. 250.53, 362.01 c. 250.51, 362.01 • d. 250.51, 362.02 250.51- Type I DM with ophthalmic manifestations,, not stated as uncontrolled 250.53- Type I DM with ophthalmic manifestations, uncontrolled 362 01 Background 362.01diabetic retinopathy 362.02- Proliferative diabetic retinopathy Answer b. 250.53, 362.01 250.53 Type I DM, OOC 362 01 Background diabetic retinopathy 362.01 Diabetes with retinopathy 250.5 [362.01] background d e to secondary due secondar diabetes due to secondary diabetes nonproliferative CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 25 IOD Incorporated May 2013 Diabetes • How should ‘brittle’ diabetes be coded? – 250.0x, DM without mention of complication. Brittle is a nonessential modifier under diabetes. Code 250.90 is NOT an appropriate code assignment. • Coding Clinic, 2006 • Review the record for documentation of ‘out of control’ diabetes 51 Diabetes • Question: How should a diagnosis of borderline diabetes be coded? • Answer: Code assignment for borderline diabetes mellitus should be based on physician documentation and will require clarification in some cases. If the attending physician has confirmed a diagnosis of diabetes mellitus, assign the appropriate code from category 250, Diabetes mellitus. Otherwise, a diagnosis of “borderline diabetes” without further confirmation of the disease should be assigned the appropriate code from subcategory 790.2, Ab Abnormal l glucose. l Coding Clinic, First Quarter, 2011 52 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 26 IOD Incorporated May 2013 Diabetes Question: How is diabetes with ketoacidosis coded? Answer: Assign code 250.13, Diabetes with ketoacidosis type I [juvenile type] ketoacidosis, type], uncontrolled, for diabetic ketoacidosis. Diabetic ketoacidosis by definition is uncontrolled and code 250.13 is the default, unless the MD specifically documents type II. • Coding Clinic, 2006 • This advice is inconsistent with our ‘normal’ normal diabetes guidelines that states Type II is the default! 53 Sample Question • A patient was admitted to the hospital with severe dehydration and malnutrition. His blood sugar was elevated. The patient is a known alcohol abuser. Intravenous fluid replacement was given to hydrate the patient, who signed out against medical advice after two days. Final diagnoses were: severe dehydration with malnutrition and adult-onset diabetes vs. early cirrhosis associated with alcoholism. The principal diagnosis is: A. Adult-onset diabetes B. Alcohol abuse C. Cirrhosis of liver due to alcoholism D. Severe dehydration 54 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 27 IOD Incorporated May 2013 Answer • D. Severe dehydration 55 Insulin Pump • Any insulin pump malfunction resulting in overdose or underdose of insulin= mechanical complication due to insulin pump (996.57). If overdose, add 962.3 as secondary diagnosis for the poisoning by insulin and the correct DM code as well. 56 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 28 IOD Incorporated May 2013 Blood and Blood forming organs • Use of 286.5 – Do not use 286.5 if patient has a h hemorrhagic h i di disorder d and d iis on an anticoagulant drug. – 286.5 is very rarely used and is an inherent condition of clotting factors, not one that is a result of drug g usage. g 57 Anemia • Anemia of chronic disease – 285.2x can be used as principal if the encounter is for the treatment of anemia – Code also the chronic condition causing the anemia • 285.21- anemia in chronic kidney disease • 285.22- anemia in neoplastic disease • 285.29- anemia in other chronic illness 58 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 29 IOD Incorporated May 2013 Anemia • Question: The provider’s final diagnostic statement listed “chronic anemia.” Should code 285.9, Anemia, unspecified, or code 281.9, U Unspecified ifi d d deficiency fi i anemia, i b be assigned i d since i code 281.9 includes “chronic simple anemia”? • Answer: Assign code 285.9, Anemia, unspecified, for chronic anemia not otherwise specified. Coding Clinic, First Quarter 2011 59 Mental Disorders • Abuse versus Dependence – Abuse = take drugs to excess but has not yet reached a state of dependence • 305.x – Dependence = chronic condition of patient developing a pattern of drug abuse with increased tolerance and is unable to stop using the drug, even while health, social interactions and jjob p performance are impaired p • 303.xx and 304.xx 60 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 30 IOD Incorporated May 2013 Mental Disorders • 5th digits associated with abuse and dependence – 1 ContinuousContinuous Daily (or almost daily) use of drug/alcohol – 2 Episodic- ‘Binging’ lasting weeks or months followed by no use – 3 Remission- Complete cessation of drug/alcohol or period which decrease towards cessation is taking place 61 Mental Disorders • Be aware of current status of condition – i.e. acute, chronic, exacerbations, with/without psychosis – Bipolar d/o, mixed, currently depressed with moderate stress Final dx: 296.50- bipolar I disorder, most recent episode (or current) depressed, unspecified Coding Clinic, 2006 62 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 31 IOD Incorporated May 2013 Mental Disorders • Question: Which code should we use to capture patients who are heroin addicts and are being maintained on methadone? Coding Clinic Fourth Quarter 1988, page 8, advised coders to use code 304.01 for patients who are receiving methadone maintenance; however however, code V58 V58.69 69 appears more appropriate. • Answer: Assign code 304.00, Opioid type dependence, unspecified, for patients who are receiving methadone maintenance because of heroin dependence. Code V58.69, Long-term (current) use of other medications, is not appropriate since it should not be used for patients who have addictions to drugs. The Official Guidelines for Coding and Reporting state that subcategory V58.6 V58 6 is not used for medications for detoxification or maintenance programs to prevent withdrawal symptoms in patients with drug dependence (e.g., methadone maintenance for opiate dependence). Coding Clinic, 2nd quarter 2010, p. 13 63 Nervous System • Clarification of ‘Pain’ Codes – If the pain is not specified as ‘acute’ or ‘chronic’ do not assign codes from 338.x, except for postthoracotomy pain pain, post- op pain, pain neoplasm pain or central pain syndrome – These include: • • • • • Central pain syndrome Acute pain Chronic pain Neoplasm related pain (acute or chronic) Chronic pain syndrome 64 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 32 IOD Incorporated May 2013 Nervous System • 338.1x- Acute pain • 338.2x- Chronic pain • There is no time frame defining when pain becomes chronic. Provider documentation should define the pain as chronic 65 Nervous System • 338 codes as Principal Diagnosis – When pain control or pain management is the reason for admission • Code the underlying cause of the pain as an additional diagnosis, if known. – Insertion for neurostimulator for pain control 66 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 33 IOD Incorporated May 2013 Nervous System • When NOT to use 338 codes as principal – Admission is for a procedure aimed at treating the underlying condition • Code the condition as principal diagnosis 67 Nervous System • Neoplasm Related Pain – 338.3 is assigned when pain is related to or associated with anyy type yp of cancer, regardless g if the pain is documented as acute or chronic – 338.3 may be assigned as principal when the patient is admitted for pain control purposes. Code the neoplasm as a secondary diagnosis. – ‘Chronic pain syndrome’ is different than ‘chronic pain’. 68 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 34 IOD Incorporated May 2013 Nervous System • Accidental Dural Tear – New codes have been created for intraoperative incidental/inadvertent dural tear (349.31) and other dural tear (349.39) in order to distinguish dural tears from other h types off accidental id l surgical i l llacerations. i Th The d dura mater covers the spinal cord and spinal nerves. A tear in the dura that occurs during spinal surgery is not unusual and is typically repaired intra-operatively when identified. Primary closure of the dural tear is usually accomplished. Dural tears that are not discovered during surgery can result in leakage of CSF, leading to CSF headache,, caudal displacement p of the brain,, subdural hematoma, spinal meningitis, pseudomeningocele and/or a dural cutaneous fistula. – Coding Clinic 2008 69 Sample Question • A patient was admitted with complaints of severe vertigo, headache, and nausea of two weeks’ duration. The patient had a malignant melanoma of the face removed two y years ago. g An MRI ordered during g this stay showed no sign of malignancy; however, toxicology studies indicated high levels of insecticide in the blood, which the physician documented as being toxic neuropathy. • Which of the following represents the conditions to be coded? A. Toxic neuropathyy due to insecticide B. Toxic neuropathy due to insecticide; history of malignant melanoma C. Vertigo; headaches; nausea; malignant melanoma D. Vertigo; headaches; nausea; insecticide poisoning 70 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 35 IOD Incorporated May 2013 Answer • B. Toxic neuropathy due to insecticide;history of malignant melanoma 71 Circulatory System • Hypertension • Presume a cause and effect relationship with HTN and Chronic Kidney Disease (CKD) unless it is documented that the CKD is due to another cause (i.e. DM) – Use 403.xx for Hypertensive CKD – There is NO cause and effect relationship with HTN and Acute Renal Failure • Use 2 codes 584.9 and 401.9 72 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 36 IOD Incorporated May 2013 Circulatory System • Hypertension – Do NOT presume cause and effect relationship l ti hi with ith HTN and dh heartt di disease. Must be documented as ‘hypertensive’ or ‘due to’ – Use additional code from category 428 to identify the type of heart failure, if documented 73 Circulatory System • Hypertension – Uncontrolled HTN≠ Malignant/Accelerated HTN – There is no code for uncontrolled ncontrolled hypertension. Do NOT assume this is malignant. – Elevated BP or transient hypertension without a diagnosis of HTN = 796.2 74 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 37 IOD Incorporated May 2013 Circulatory System • Question: What is the correct code assignment for pulmonary hypertension? The default for pulmonary hypertension is code 416.8, Other chronic pulmonary heart diseases, but the inclusion term for 416.8 is “pulmonary hypertension, secondary.” Code 416.0, Primary pulmonary hypertension, seems to be appropriate for an unspecified pulmonary hypertension since “pulmonary hypertension” is listed as an inclusion term. • Answer: Assign code 416.8, Other chronic pulmonary heart diseases, for pulmonary hypertension that is not documented as primary or secondary. Since secondary pulmonary hypertension is the most common type of pulmonary hypertension, it is the default. Code 416.0, Primary pulmonary hypertension, is only y assigned g when the p provider has specifically p y diagnosed g primary pulmonary hypertension. Coding Clinic, 2nd quarter 2010, p. 10-11 75 Circulatory System • CVA = Stroke = Cerebral Infarction • All default to 434.91,, cerebral arteryy occlusion, unspecified, with infarction • Do NOT use code 436, Acute, but illdefined, cerebrovascular disease, when the documentation states stroke or CVA 76 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 38 IOD Incorporated May 2013 Circulatory System • Question: According to Coding Clinic, Second Quarter 1989, page 8, hospitals are not to report hemiplegia as an additional diagnosis for patients who present with acute CVA if the hemiplegia resolves prior to hospital discharge. Therefore, hemiplegia is not being reported even though these patients receive physical therapy or other treatment, which would ordinarily signify reporting the hemiplegia based on the General Rule for Reporting additional diagnoses. Could consideration be given to allow coding this clinically significant diagnosis? • Answer: Hemiplegia is not inherent to an acute cerebrovascular accident (CVA). Therefore, it should be coded even if the hemiplegia resolves, with or without treatment. The hemiplegia p g affects the care that the p patient receives. Report p any y neurological deficits caused by a CVA even when they have been resolved at the time of discharge from the hospital. This current advice supersedes information previously published in Coding Clinic. Coding Clinic, First Quarter 2010, p. 5 77 Circulatory System • Aborted Stroke – Patient has still suffered a stroke and an acute stroke (434.91) should be coded, even if tPA was given – Selection of the correct code assignment for a condition described as averted or p on whether the aborted depends condition actually occurred. 78 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 39 IOD Incorporated May 2013 Circulatory System • Late effects of CVA – Neurological deficits that persist after the initial onset of the stroke. – May need a second code to describe the remaining deficit if not clear in 438.xx code • Patient with seizures s/p stroke 3 years ago. – Use code 438.89 (other late effect) and 780.39 (seizures) • Old CVA with no residuals – Code v12.54 79 Circulatory System • Myocardial Infarction – Fifth digits • 1- the FIRST episode of care, regardless of the number of times a patient is transferred to and from acute care facilities and occurring within the 8 week time frame • 2- the subsequent episode of care, following the initial episode. The patient has been discharged from acute care (to home or long term care facility) and returns for further observation, evaluation or treatment for an MI and is still within the h 8 week k time i fframe • If the patient is readmitted more than 8 weeks after the onset of the MI, do not use code 410.xx 80 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 40 IOD Incorporated May 2013 Circulatory System • Question: A patient with an acute ST elevation lateral wall myocardial infarction (STEMI) was initially seen at Hospital A and was immediately transferred to Hospital B for an emergency cardiac catheterization and percutaneous transluminal coronary angioplasty (PTCA) with stent insertion. What is the appropriate principal diagnosis for Hospital B? 81 Circulatory System • Answer: Assign code 410.51, Acute myocardial infarction, Of other lateral wall, initial episode of care, as the principal diagnosis. The acute STEMI of the lateral wall had not resolved and was still being treated at Hospital B. Assign code 414.01, Coronary atherosclerosis, of native coronary artery, as a secondary diagnosis. This advice is consistent with that previously published in Coding Clinic Fifth Issue 1993, page 14. – Coding Clinic, Third Quarter 2009 82 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 41 IOD Incorporated May 2013 Circulatory System • Heart failure – If congestive heart failure is documented along with diastolic and/or systolic, systolic 2 codes must be used. There is no ‘combo’ code • One code for CHF • One code for diastolic and/or systolic heart failure (determine if acute, chronic, acute on chronic or unspecified) 83 Circulatory System • Question: when a patient has a known history of diastolic congestive heart failure (CHF), how would this be coded? • Answer: Assign code 428.32, diastolic heart failure, chronic, and code 428.0, CHF unspecified. This is coded as chronic due to the patient’s know history. – Coding Clinic 2008 84 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 42 IOD Incorporated May 2013 Circulatory System • Question: Is a diagnosis of systolic or diastolic dysfunction coded the same as heart failure? • Answer: No,, diastolic dysfunction y without mention of heart failure is indexed to 429.9, Heart disease, unspecified. It is not appropriate to assume a patient is in heart failure when only “diastolic dysfunction” or “systolic dysfunction” is documented. – Coding Clinic Clinic, First Quarter 2009 85 Circulatory System • Question: The patient is documented as having systolic dysfunction with acute exacerbation of congestive heart failure (CHF). Can this be coded as acute t systolic t li heart h t failure f il with ith congestive ti heart failure? • Answer: Assign code 428.0, Congestive heart failure, unspecified and code 428.23, Systolic heart failure, Acute on chronic. Acute exacerbation of a chronic condition ((heart failure)) is coded as acute on chronic. – Coding Clinic First Quarter 2009 86 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 43 IOD Incorporated May 2013 Circulatory System • Question: A patient had an acute exacerbation of chronic systolic congestive heart failure and severe mitral regurgitation and aortic stenosis. How should this be coded coded? • Answer: Assign codes 428.23, Acute on chronic systolic heart failure; 428.0, Congestive heart failure, unspecified; and 396.3, Mitral valve insufficiency and aortic valve stenosis. As stated in Coding Clinic, Second Quarter 2000, pages 16-17, “Do not make an assumption that the congestive heart failure is rheumatic in nature.” Unless ICD-9-CM directs the coder to assign the code for “rheumatic” it is inappropriate to assign a code for rheumatic congestive heart failure. Coding Clinic, 1st qtr 2009, p. 18 87 Circulatory System • Aborted/Impending MI – If there is no myocardial injury/infarction documented use 411 documented, 411.1 1 for an aborted or impending MI. If there has been myocardial injury/infarction, code the MI • Selection of the correct code assignment for a condition described as ‘averted’ or ‘aborted’ depends p on whether the condition actually occurred. 88 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 44 IOD Incorporated May 2013 Circulatory System • Chronic total occlusion of coronary artery 414.2 – Complete blockage of a coronary artery that has been present for an extended period of time (months years) (months, years). – May be treated with angioplasty or stent placement (usually drug-eluting) – When total chronic coronary occlusion is present with coronary atherosclerosis, assign code 414.2 as an additional code. Do not assign 414.2 for an acute coronary occlusion • Coding Clinic, 2007 89 Circulatory System • Endovascular Bioactive Coil • Two new codes have been created to identify endovascular embolization or occlusion of head or neck vessels using bare metal coils (39 (39.75) 75) and bioactive coils (39.76). Prior to this change, these procedures were indexed to code 39.72, Endovascular repair or occlusion of head and neck vessels. • Currently, there are two classes of coils: bare platinum coils (BPCs) and bioactive coils. 90 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 45 IOD Incorporated May 2013 Circulatory System • New code 39.75 Endovascular embolization or occlusion of vessel(s) of head or neck using bare coils Bare metal coils Bare p platinum coils [[BPC]] That for treatment of aneurysm, arteriovenous malformation[AVM] or fistula performed. • New code 39.76 Endovascular embolization or occlusion of vessel(s) of head or neck using bioactive coils Biodegradable inner luminal polymer coils Coil embolization or occlusion utilizing g bioactive coils Coils containing polyglycolic acid [PGA] That for treatment of aneurysm, arteriovenous malformation [AVM] or fistula 91 Circulatory System • Question: A 64-year-old patient with a right internal carotid artery aneurysm underwent endovascular embolization with six bioactive coils in the standard as o until u t complete co p ete occ occlusion us o o of tthe ea aneurysm eu ys was as fashion obtained. What is the appropriate code for the coil embolization? Answer: Assign code 39.76, Endovascular embolization or occlusion of vessels(s) of head or neck using bioactive coils, for the procedure Coding Clinic, Fourth Quarter 2009 92 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 46 IOD Incorporated May 2013 Circulatory System • Don’t forget procedure codes 00.4x for specific vascular procedures • To be used in conjunction with other therapeutic procedures d tto provide id additional dditi l iinformation f ti (00 (00.6161 00.62, 00.66, 39.50, 38.10-38.18, 00.55, 00.63-00.65, 36.06-36.07, 39.90, 3609) – 00.40-00.44 number of vessels treated or vessel bifurcation – 00.45-00.48 number of stents inserted 93 Circulatory System • Question: this patient presented with femoral artery aneurysm and underwent repair of the femoral artery aneurysm with Dacron graft. During the surgery the femoral artery was opened and a a thrombus was evacuated. ICD-9C provides unique codes ffor femoral CM f artery aneurysm and femoral artery thrombus. Would the thrombus and aneurysm be reported separately? • Answer: Assign code 442.3, other aneurysm of Lower extremity for the femoral artery aneurysm. Do not assign an additional code for the thrombus found during surgery. A thrombus found and evacuated during aneurysm repair is inherent in the diagnosis of aneurysm aneurysm. Assign code 38 38.48, 48 resection of vessel with replacement, lower limb artery, for the repair of the femoral artery aneurysm with Dacron graft replacement – Coding Clinic 2008 94 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 47 IOD Incorporated May 2013 Circulatory System • Question: Given the codes for chronic venous embolism and thrombosis, when does DVT become chronic? • Answer: There are no specific timelines for when DVT or any other condition becomes chronic. The assignment of chronic DVT should be based on provider documentation. Coding Clinic, First Quarter, 2011 95 Respiratory System • COPD – Include obstructive chronic bronchitis (491.2x) and emphysema (492.x) (492 x) – Unspecified COPD = 496 • Asthma – Included in category 493.xx 96 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 48 IOD Incorporated May 2013 Respiratory System • Acute exacerbation of asthma versus status asthmaticus – Acute exacerbation = increased severityy of asthma such as wheezing and SOB – Status asthmaticus (intractable, refractory)= failure to respond to therapy during an asthmatic episode and is life threatening. Status asthmaticus supercedes any type of COPD and should be sequenced first if both conditions are present. 97 Respiratory System • Acute bronchitis with COPD – Code 491.22 (Obstructive chronic bronchitis with acute bronchitis). Do NOT code 466.0 • Acute bronchitis with COPD with acute exacerbation – Code 491.22 (Acute bronchitis supercedes the acute exacerbation) • Acute exacerbation of COPD – Code 491.21 only 98 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 49 IOD Incorporated May 2013 Respiratory System • Acute Respiratory Failure – Code 518.81 can be used as principal diagnosis when it meets the definition of principal diagnosis. This is a significant change for some of the ‘old-time coders’. • However, chapter-specific coding guidelines take precedence (such as Obstetrics, Poisoning, HIV, Newborn) 99 Respiratory System Question: Is it appropriate to assign a code for hypoxemia as an additional diagnosis when it is associated with acute respiratory failure? Answer: Do NOT assign hypoxemia as an additional diagnosis when it is present or associated with acute respiratory failure. Hypoxemia would be considered inherent in acute respiratory failure. • Coding Clinic, 2006 100 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 50 IOD Incorporated May 2013 Respiratory System • Question: When a patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD) and an infection such as pneumonia, is pneumonia always sequenced as the principal diagnosis? • Answer: Sequence either code 486, Pneumonia, organism unspecified, or code 491.21, Obstructive chronic bronchitis, with (acute) exacerbation, as the principal diagnosis, when the patient is admitted with both conditions. The pneumonia and COPD are two separate conditions that presented simultaneously. The pneumonia is not the exacerbation of the COPD. • The Official Guidelines for Coding and Reporting previously published in Coding Clinic, Fourth Quarter 2008, page 303, states “In those rare instances when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.” Coding Clinic, First Quarter 2010, page 12-13 101 Respiratory System • Pleural effusion – Often is integral to an underlying condition and is usually not coded • EXCEPT when it is treated. – i.e. Thoracentesis done for treatment of pleural effusion 102 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 51 IOD Incorporated May 2013 Respiratory System • Effective October 1, 2009, code 488 has been revised and expanded to create a new subcategory with two unique codes for: – influenza due to identified avian influenza virus (488.0) – influenza due to identified novel H1N1 influenza virus (488.1) • These codes have been created to provide data capture for the novel H1N1 influenza virus (swine flu virus), which was first identified in April, after the March 2009 ICD-9-CM Coordination and Maintenance Committee meeting. • Similar to the guidelines for coding HIV infection, codes 488.0 and 488.1 should be assigned only for confirmed cases of avian flu or H1N1 flu. Codes 488.0 and 488.1 are not assigned when the final diagnostic statement indicates that the infection is “ “suspected,” t d ” “possible,” “ ibl ” “lik “likely,” l ” or ““questionable.” ti bl ” Thi This iis an exception to the hospital inpatient guideline that directs the coder to assign a code for a diagnosis qualified at the time of discharge as suspected or possible as if it were established. 103 Respiratory System • New code 488.0 Influenza due to identified avian influenza virus Avian influenza d flu u Bird Influenza A/H5N1 • New code 488.1 Influenza due to identified novel H1N1 influenza virus 2009 H1N1 [swine] influenza virus Novel 2009 influenza H1N1 Novel H1N1 influenza N Novel l iinfluenza fl A/H1N1 Swine flu 104 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 52 IOD Incorporated May 2013 Respiratory System • Procedures – Code 33.27, Closed [endoscopic] biopsy of lung, is assigned when the biopsy is taken endoscopically (through the bronchus) into the lung alveoli (i.e. t transbronchial b hi l bi biopsy)) – Code 33.24, Closed [endoscopic] biopsy of bronchus, is assigned when the biopsy is taken endoscopically within the lumen of the trachea and bronchus. – Fiberoptic bronchoscopy with brushings and biopsies. The pathology report describes bronchus and lung tissue tissue. • Code 33.27 and 33.24 since both biopsies were performed. – Coding Clinic, 2002 105 Respiratory System • Procedures – Question: The patient has complaint of fevers, cough and an abnormal CT of the chest. The bronchoscope was wedged d d iin th the lleft ft llower llobe, b superior i segmentt and da bronchoalveolar lavage (BAL) was performed. Transbronchial lung biopsies were performed in the left lower lobe under fluoroscopic guidance where two biopsies were taken. Endobronchial biopsies were taken at the superior segment. – Answer: Assign g code 33.24,, Closed [endoscopic] [ p ] biopsy p y of bronchus, for the BAL and endobronchial biopsies, and code 33.27, Closed endoscopic biopsy of lung, for the transbronchial biopsies. Coding Clinic, 3rd Qtr. 2011, p. 8 106 106 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 53 IOD Incorporated May 2013 Respiratory System • Mechanical Ventilation • Question: Our question relates to patients admitted to a long term care hospital on a T-piece or tracheostomy collar the day of the transfer, but placed on mechanical ventilation that evening. How are the hours of g counting g hours at the mechanical ventilation counted? Should we begin start of the admission even though the patient is breathing through the T-piece without mechanical ventilation, or are the hours counted from the time the patient is on the vent? • Answer: Yes, you should begin counting hours at the start of the admission. All of the period of weaning is counted during the process of withdrawing the patient from ventilatory support. The duration includes the time the patient is on the ventilator, the weaning period and ends when the mechanical ventilation is turned off (after the weaning period). The fact that a T-piece is being used during the day does not affect code assignment. A T-piece (trachcollar) trial involves the patient breathing through a T-piece without ventilatory assistance for a set period of time. Coding Clinic, 3rd Qtr 2010, p. 4 107 Sample Question • A patient was discharged from the hospital with a diagnosis of bronchial asthma. Upon reviewing the record, the coder notes the patient was described as having prolonged and intractable wheezing, airway obstruction not relieved by bronchodilators, and a decreased PAO2 lab value. The physician should be queried to determine whether the code for ___________is appropriate as the principal diagnosis: A. Acute viral Bronchitis B. COPD C. Respiratory failure D. Status asthmaticus 108 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 54 IOD Incorporated May 2013 Answer • D. Status asthmaticus 109 Digestive System • When minor adhesions are present and lysed but do not cause symptoms or increase the difficulty of the procedure, do not code the lysis of adhesions • When adhesions are strong, dense or create problems or lengthen the operation, it is appropriate to code the lysis of adhesions 110 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 55 IOD Incorporated May 2013 Sample Question • A patient was being treated for gastric ulcer with hemorrhage, cirrhosis of liver, portal hypertension, and esophageal varices. Of the following medications, di ti which hi h would ld iindicate di t a possible ibl complication or comorbid condition that would impact DRG reimbursement? A. Bactrim®, 1 tablet q.i.d. B. Darvocet-N®, 100 mg prn C. HydroDIURIL®, 50 mg PO daily D. Tagamet®, 300 mg IM q 6 hrs 111 Answer • A. Bactrim®, 1 tablet q.i.d. 112 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 56 IOD Incorporated May 2013 Genitourinary System • Urosepsis – Defined as bacteria in the urine. Coded as 599.0 – Confusion as to whether this represents a true UTI or septicemia from f a urinary source – A diagnosis of septicemia can neither be assumed nor ruled out on the basis of lab values alone (positive blood culture) – Signs/symptoms of septicemia where a query could be necessary: • Fever (or hypothermia), hypothermia) malaise, malaise fatigue, fatigue hyperventilation, tachypnea, tachycardia, change in mental status, hypotension, metabolic acidosis, high white cell count 113 Genitourinary System • Question: What is the correct code assignment for a urinary infection due to a suprapubic catheter? Would it be classified differently than a urinary infection due to an indwelling urethral catheter? There are no includes notes or subterms in ICD ICD-9-CM 9 CM that direct the coder to the proper code assignment. • Answer: Assign code 996.64, Infection and inflammatory reaction due to indwelling urinary catheter along with code 599.0, Urinary tract infection, site not specified, for a UTI due to suprapubic catheter infection. A suprapubic catheter is an indwelling catheter that is placed directly into the bladder through g the abdomen. The catheter is normally y placed by an urologist and is inserted above the pubic bone and attached to a drainage bag. • Coding Clinic, Third Quarter 2009 114 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 57 IOD Incorporated May 2013 Genitourinary System • CKD – Chronic kidney disease • Stages II-IV, IV ESRD (585 (585.x) x) • Renal Insufficiency – Acute = 593.9 – Chronic = 585.9 – Unspecified p = 593.9 115 Genitourinary System • Question: Clinical laboratory findings for sodium and creatinine were elevated. After workup, p the MD diagnosed g acute kidney y injury j y (AKI) secondary to volume depletion. How should a non-traumatic AKI be coded? • Answer: assign code 584.9, acute renal failure, for a nontraumatic acute kidney injury (AKI). – Coding Clinic 2008 116 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 58 IOD Incorporated May 2013 Genitourinary System • BEWARE: – AKI = acute kidney injury • 584.9 – AKI = acute kidney insufficiency • 593.9 117 Genitourinary System • Uterine Artery Embolization (UAE) • Question: Please provide clarification on the correct code assignment for a percutaneous uterine artery embolization. We find the existing Index and Tabular instructions confusing. The recent advice published in Coding Clinic, Clinic Second Quarter 2009 2009, page 7 7, for transcatheter embolizations seemed to be limited to coil embolizations. We’re unsure whether a percutaneous transcatheter uterine embolization using embospheres should be coded to 99.29, Injection or infusion of other therapeutic or prophylactic substance; or code 39.79, Other endovascular repair (of aneurysm) of other vessels. • Answer: Assign code 99.29, Injection or infusion of other therapeutic or prophylactic substance, for uterine artery embolization. The advice published in Coding C C Clinic, S Second Quarter 2009 was specific to transcatheter coil embolizations. Coding Clinic, First Quarter 2010, p. 21-22 118 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 59 IOD Incorporated May 2013 Sample Question • A patient undergoing hemodialysis for renal disease in the outpatient unit of a hospital develops what is believed to be heartburn. After a few hours of observation,, he is admitted to the hospital for further care. The consulting cardiologist diagnoses this patient’s condition as unstable angina. What is the principal diagnosis for the hospital stay? A. Complication of dialysis B. Heartburn C. Renal disease D. Unstable angina 119 Answer • D. Unstable angina 120 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 60 IOD Incorporated May 2013 Obstetrics • 650- What is considered ‘normal’? – Full term pregnancy – Vaginal g delivery y w/cephalic presentation, no fetal rotation. No use of instruments – Single, healthy infant – No antepartum, delivery or postpartum complications – Artificial rupture of membranes (73.09), other manually assisted delivery (73.59), episiotomy (73.6), other fetal monitoring g ((75.34), ) injection j into spinal canal, anesthetic (03.91), sterilization (66.21-66.29, 66.31-66.39) 121 Obstetrics • With every delivery, the mom’s chart must have a V27.x code. Not to be used on subsequent visits or on newborn record • 655.xx category (fetal abnormality affecting the management of the mother) – Assigned only when the fetal condition is modifying the management of the mother 122 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 61 IOD Incorporated May 2013 Obstetrics • HIV Infection in Pregnancy – Use 647.6x as principal dx if patient is admitted with HIV-related illness followed by 042 and the code for the HIV-related illness – Patients with asymptomatic HIV, admitted during pregnancy should use 647.6x as principal dx and V08 as a secondary dx 123 Obstetrics • New codes as of October 1, 2008 for Maternal and fetal complications due to In Utero Procedures • To be used on a mother’s mother s record when the management of a current pregnancy is affected due to a complication of in utero surgery performed during the current pregnancy. – 679.0x- Maternal complications from in utero procedure – 679.1x- fetal complications from in utero procedure 124 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 62 IOD Incorporated May 2013 Obstetrics • Question: the patient had a normal spontaneous vaginal delivery at 40 weeks gestation. The patient had an episiotomy, which extended to a second-degree perineal laceration The laceration was repaired with sutures laceration. sutures. How should this be coded? • Answer: Assign code 664.11, second-degree perineal laceration as the principal diagnosis. Code v27.0 for the outcome. Assign code 73.6, episiotomy and 75.69, repair of OB laceration for the procedure performed. When an episiotomy extends spontaneously to become a perineal l laceration, ti assign i code d 73 73.6 6 ttogether th with ith code d 75 75.69. 69 Both codes are needed to completely describe this situation – Coding Clinic 2008 125 Abortion • Less than 22 weeks OR less than 500 gms – Patient expels part or all of products of conception – Missed abortion abortion- less than 22 weeks and fetus is retained in the uterus • AKA blighted ovum • Completed medically or surgically by MD as soon as diagnosis is certain – Threatened abortion- less than 22 weeks with bleeding, without expulsion of fetus, without dilation of cervix, so pregnancy continues 126 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 63 IOD Incorporated May 2013 Musculoskeletal & Connective Tissue • Pathologic fractures – May be described as ‘spontaneous’ – Code 733.1x first with the etiology of the fracture as secondary (i (i.e. e osteoporosis) • Aftercare – Use aftercare codes (v54.xx) for encounters after the patient has completed active treatment of the fracture and is receiving routine care during healing/recovery • Active treatment includes: surgical treatment, ER encounter, evaluation and treatment by a new physician removal, • Aftercare treatment includes: cast change or removal removal of external or internal fixation device, medication adjustment, and follow-up visits following fracture treatment 127 Pathologic Fracture • • • Question: The patient is a 46-year-old man with multiple myeloma who was admitted to the hospital for management of pathologic fracture of the proximal shaft of the humerus. He also has impending pathologic fractures in multiple places of his left femur, which are very painful. CT scan of the femur demonstrated significant thinning of the medial wall, multiple cortical permeative changes involving the femur neck and permeative changes of the ischium ischium. The patient is unable to bear weight; therefore the decision was made to undergo prophylactic cephalomedullary trochanteric nail fixation of the left femur as well as intramedullary nail fixation of the right humerus. How should this case be coded? Answer: Assign code 733.11, Pathologic fracture of humerus, as the principal diagnosis. Codes 203.00, Multiple myeloma, without mention of having achieved remission, 731.8, Other bone involvement in disease classified elsewhere, and V07.8, Other specified prophylactic measure, should be assigned as additional diagnoses. It is not uncommon to perform prophylactic orthopedic procedures for bone malignancies. However, it would be inappropriate to report code 733.15, Pathologic fracture of other specified part of femur, femur since it is not a confirmed diagnosis. If an impending condition is not listed in the ICD-9-CM Alphabetic Index, the condition described as impending or threatened is not coded. For the procedures, assign codes 78.55, Internal fixation of bone without fracture reduction, femur, and 78.52, Internal fixation of bone without fracture reduction, humerus. Coding Clinic, 2nd Quarter 2010, p. 6 128 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 64 IOD Incorporated May 2013 Musculoskeletal & Connective Tissue • DJD – 715.36, Osteoarthrosis, localized, not specified whether primary or secondary, lower leg is assigned for DJD of knee. When DJD affects only one site but is not identified as primary or secondary, it is assigned to 715.3x. • Coding Clinic, 2003 • Note: Localized DJD includes bilateral involvement of the same site 129 Musculoskeletal & Connective Tissue • Kyphoplasty w/vertebral biopsy – Should Sh ld a vertebral t b l bi biopsy b be coded d d separately t l when performed during a kyphoplasty? – The biopsy is not an inherent part of the procedure (kyphoplasty) and should be coded separately if performed. Code 81.66, kyphoplasty and 77.49, 77 49 biopsy of bone bone, other other. • Coding Clinic, 2006 130 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 65 IOD Incorporated May 2013 Musculoskeletal & Connective Tissue • Be careful coding – Knee/Hip replacements • Partial versus Total – Knee/Hip revisions • Revision of previous replacement or another total replacement being done? p ( ) of the jjoint is/are being g • Which component(s) revised? • If known, code type of components used (metal, ceramic, polythylene) 131 Musculoskeletal & Connective Tissue • Spinal Fusions – Site? (cervical, thoracic, lumbar, sacral) – Technique? (anterior, posterior or both) – How many # of vertebrae fused? – Bone graft? – Interbody spinal fusion device? 132 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 66 IOD Incorporated May 2013 Sample Question • The following is an operative report to be coded: Preoperative Diagnosis: Nonossifying fibroma Postoperative Diagnosis: Aneurysmal bone cyst Procedure: Excisional bone biopsy The patient was brought to the operating room room, and after adequate spinal anesthesia, the right lower extremity was prepped and draped. A transverse incision was carried down through the skin and subcutaneous tissue. The soft tissues were dissected. The lesion was curetted from the bone, revealing a cavity approximately 5.0 cm in length and 2.5 cm in width. The cavity was irrigated and the margins electrocauterized. A specimen that was sent for frozen section was consistent with aneurysmal bone cyst. The subcutaneous tissue was closed with 2-0 Vicryl, and the skin was closed with 4-0 nylon. A sterile dressing was applied. The patient tolerated the procedure well. Which of the following CPT procedures is to be coded? A Arthrotomy of ankle A. ankle, with biopsy for removal of loose body B. Bone biopsy of leg or ankle area, deep C. Curettage of bone cyst or benign tumor, tibia or fibula D. Resection of tumor, radical; tibia 133 Answer • C. Curettage of bone cyst or benign tumor tibia or fibula tumor, 134 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 67 IOD Incorporated May 2013 Decubitus/Pressure Ulcer • New subcategory (707.2x) for stage – Stage I-IV and unstageable – The diagnosis of “pressure/decubitus ulcer” should be based on the provider’s documentation. However, the associated code assignment may be based on other clinicians (nursing, PT). • Site of pressure ulcer should also be coded (707.00-707.09) 135 Congenital Anomalies • Codes from this chapter can be used throughout a patient’s life – Not N t just j t as newborn/infant b /i f t – May be identified later in life 136 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 68 IOD Incorporated May 2013 Newborn/Perinatal • V30-V39 should always be sequenced as principal diagnosis for all birth admissions and will only be used once in a patient’s life. – Not to be used on subsequent q visits or on the mother’s record • If the newborn is transferred to another institution, V30-V39 is not used at the receiving hospital. Code the reason for the transfer. • For coding and reporting purposes, the perinatal period is defined as BEFORE birth through the 28th day y of life. – If a condition begins before the 28th day of life and continues after that, it can still be coded as a perinatal condition. 137 Newborn/Perinatal • Code all clinically significant conditions: – – – – – – Clinical evaluation Therapeutic treatment Diagnostic procedures Extended LOS Increased nursing care/monitoring Implications for future health care needs (not used for adult patients) 138 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 69 IOD Incorporated May 2013 Newborn/Perinatal • Perinatal Morbidity due to maternal causes – Code 760-763 are assigned ONLY when the f t is fetus i affected ff t d by b the th maternal t l condition diti • The fact that the mother has a medical condition or experiences a complication of pregnancy or delivery does NOT justify the routine assignment of codes 760-763 139 Newborn/Perinatal • Newborn Sepsis – 771.81 (Septicemia/sepsis of newborn) should be assigned to describe sepsis • Not necessary to assign a code from 995.9x and/or 038.xx for a newborn record • Add code from 041.xx as a secondary diagnosis to identify the organism 140 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 70 IOD Incorporated May 2013 Newborn/Perinatal • Apparent Life Threatening Event in Infant (ALTE) • According to the National Institutes of Health, ALTE is an episode that is frightening to the observer and is characterized by some combination of – Apnea (central or obstructive) – Color change (cyanotic, pallid, erythematous or plethoric) – Change in muscle tone (usually diminished), and – Choking or gagging • Previously used terminology such as near-miss sudden infant death syndrome (SIDS) or aborted crib death is outdated. • A variety of congenital or acquired conditions can cause ALTE episodes. Some of these conditions included GERD, pertussis, lower respiratory tract infection, seizure, and UTI. In approximately half the ALTE cases, no discrete cause can be identified despite extensive workup. A unique code is important in order to track the true incidence of ALTE. 141 Newborn/Perinatal • New code• 799.82 Apparent life threatening event in infant f • Since the term ALTE describes a clinical syndrome, additional code(s) should be reported for associated signs and symptoms as noted in the Tabular instructions. This code is intended for use only when no underlying diagnosis has been identified. – Coding Clinic, fourth quarter 2009 142 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 71 IOD Incorporated May 2013 Newborn/Perinatal • Question: a baby was delivered at 39.2 weeks with vacuum extraction. The delivery record indicates bag/mask ventilation and oxygen were provided for 1 minute. Should a procedure code for the bag ventilation and oxygen be reported? • Answer: A Th use off supplemental The l t l oxygen and d bag b ventilation til ti is an integral part of the care of a newborn. Do not assign additional codes for the brief use of bag/mask ventilation and oxygen. Some newborns may experience difficulty transitioning to extrauterine life and may require a period of supplemental oxygen, and spontaneous respirations can often be stimulated using a manual resuscitation bag and face-mask (BMV). In most cases, infants respond to these measures with no further interventions. interventions In cases where they do not respond and mechanical ventilation is required, the mechanical vent codes should be used. – Coding Clinic 2008 143 Signs and Symptoms • When to use signs/symptom codes: – No more specific diagnosis can be made – Sign/symptom existed at time of initial encounter that was transient and cause not determined (fever, resolved after one day) – Provisional diagnosis was made in patient who failed to return for further care – Case was referred elsewhere for treatment before diagnosis was made (transfers) (chest pain, transferred to Hosp A for cardiac cath) – A more precise diagnosis was not available – Sign/symptom that is present that represent important problems in medical care, not routinely associated with a disease process (seizures) – When a symptom is followed by a comparing/contrasting diagnosis, the symptom code is sequenced first as principal diagnosis(i.e. abd pain due to either GE or pancreatitis) – When a sign/symptom is NOT integral to the disease process – When its presence is significant in relationship to the condition or care given (cirrhosis with ascites. Paracentesis is done for ascites) 144 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 72 IOD Incorporated May 2013 Signs and Symptoms • Patient admitted to the hospital with chest pain. In the final diagnostic statement, the provider documented chest pain pain, most likely of GI origin. – Query the MD regarding the specific GI condition. If the MD cannot provide a definitive answer regarding the nature of the GI condition, assign code 786.50 (chest pain, unspecified) ifi d) as the th principal i i l di diagnosis i • Coding Clinic, 2007 145 Signs and Symptoms • Ascites – Code 789.5 has been expanded to separately identify y malignant g ascites ((789.51)) and other ascites (789.59) – The term ‘malignant ascites’ had previously been an inclusion term at code 197.6. Now under code 789.51 (Malignant ascites), code first malignancy, such as 183.0, Ovarian CA, 197 6 Peritoneal CA 197.6, 146 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 73 IOD Incorporated May 2013 Injuries • Assign separate codes for each injury unless l a combination bi ti code d iis provided id d • Multiple injury/fracture codes should only be assigned if there is no specific code or documentation available 147 Injuries • Fractures – Open fracture (open wound at fracture site) • Compound, C d iinfected, f t d missile, i il puncture t and d with foreign body – Closed fracture • Comminuted, depressed, elevated, greenstick, spiral and simple • If a fracture is not identified as ‘open’ or ‘closed’, the code for a closed fracture is used 148 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 74 IOD Incorporated May 2013 Injuries • Fracture treatment – Reduction – Internal fixation • Screws, pins, rods, staples or plates – External fixation • Casts, splints 149 Injuries • Open wounds are considered complicated when there is: – Delayed D l dh healing li – Delayed treatment – Infection – Foreign body in wound 150 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 75 IOD Incorporated May 2013 Burns • Sequence first the code that reflects the highest degree of burn when more than one burn is present • Burns of the same local site (3 digit category 940947) but different degrees should be coded to the highest degree recorded in the record • Non-healing burns are coded as acute burns • Code 958.3 (post-traumatic wound infection) as an additional code for any infected burn site site. 151 Debridement • Excisional debridement (86.22) – “Surgical” removal or cutting away of tissue (often done with a scalpel) – NOT defined by the term ‘sharp’ sharp – Can be done in OR, ER or at bedside – Can be performed by nurse, therapist, physician assistant or physician • Nonexcisional debridement (86.28) – Brushing, scrubbing, irrigating, flushing or washing of tissue, minor scissors removal of loose fragments • (i.e. (i versajet, j t whirlpool) hi l l) – NONOPERATIVE in nature – Minor ‘snipping’ of tissue/loose fragments with scissors 152 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 76 IOD Incorporated May 2013 Debridement • The use of a scalpel (or blade) does NOT indicate ‘excisional’ debridement • The Th description d i ti off th the procedure d performed must support the type of debridement performed • When multiple layers are debrided (skin, muscle,, fascia,, bone), ), code ONLY the deepest layer debrided 153 Debridement • Question: The Arobella Qoustic Wound Therapy System uses an ultrasonic assisted curette to debride wounds. How should the use of this device be coded? • Answer: Assign code 86.28, Non-excisional debridement of wound, infection, or burn. The device is used for mechanical debridement. If, however, the provider documents that excisional debridement was also performed in addition to the use of this device, then code the excisional d b id debridement t separately. t l Coding Clinic, 2nd quarter 2010, p. 11-12 154 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 77 IOD Incorporated May 2013 Debridement • Question: The provider indicated that the patient was admitted for IV antibiotic therapy, as well as incision and drainage of a chronic nonhealing ulceration on the plantar aspect of the right foot with recent development of cellulitis and abscess in the area. The patient underwent incision and drainage (I&D) of the right foot ulceration, with insertion of vancomycin antibiotic tibi ti b beads. d Th The surgeon noted t d th thatt th the ulceration l ti on th the plantarl t lateral aspect of the heel had a sinus tract, which tracked laterally. The surgeon made an incision utilizing a #15 blade through the skin layers, down to the sinus tract to open up the area. The ulceration, sinus tract, and all fibrotic/necrotic and infected looking tissues were sharply excised. The surgeon noted that the excisional debridement encompassed the plantar fascial layer of the heel, but did not extend into bone or capsular tissue. The area was packed with vancomycin-impregnated antibiotic beads. What are the appropriate procedure codes for this case? • Answer: Assign code 83 83.39, 39 Excision of lesion of other soft tissue tissue, for the excisional debridement of the fascia. Code 99.21, Injection of antibiotic, may be assigned as an additional code for the use of antibioticimpregnated beads. Coding Clinic, 3rd quarter 2010, p. 11 155 Debridement- Versajet • Question: A patient with a stage III sacral pressure ulcer undergoes a Versajet debridement which includes skin, subcutaneous fat and muscle. Previous Coding Clinic advice published on Versajet debridement assigned code 86.28, Nonexcisional debridement of wound, infection, or burn, for the Versajet debridement of skin and subcutaneous tissue. Are all debridements performed with the Versajet considered “nonexcisional”? What is the appropriate procedure code assignment in this case? • Answer: Assign code 86.28, Nonexcisional debridement of wound, d infection, i f ti or burn, b ffor the th Versajet V j td debridement. b id t Versajet V j t debridement is always considered nonsurgical mechanical debridement. It does not involve cutting away or excising devitalized tissue. – Coding Clinic, Third Quarter 2009 156 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 78 IOD Incorporated May 2013 Adverse Effects, Poisonings, Toxic Effects • Adverse effect – Drug correctly prescribed and properly administered – Code the reaction first (tachycardia) plus the E-code • Poisoning – Error in prescription, overdose of drug intentionally taken, nonprescribed drug taken with correctly prescribed and properly administered drug (wrong dose, wrong substance, wrong route of administration) – Code the poisoning code first followed by a code for the manifestation. Add drug abuse or dependence if documented • Toxic effect – Harmful substance is ingested or comes in contact with a person – Code the toxic effect first (980-989) followed by the code that identifies the result/manifestation of the toxic effect and the E-code 157 Sample Question • A patient came to the emergency department with hypotension and tachycardia. Upon examination, the patient’s condition was determined to be the result of a tetanus teta us to toxoid o d vaccine acc e ad administered ste ed four ou hours ou s ea earlier. e Which of the following is the appropriate sequencing? A. Hypotension; tachycardia; and accidental poisoning E code, tetanus toxoid B. Hypotension; tachycardia; and therapeutic use E code, tetanus toxoid C. Poisoning due to tetanus toxoid and therapeutic use E code, tetanus toxoid D. Unspecified adverse reaction and undetermined cause E code, tetanus toxoid 158 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 79 IOD Incorporated May 2013 Answer • B. Hypotension; tachycardia; and th therapeutic ti use E code, d ttetanus t t toxoid id 159 Complications • Transplant complications – Only assigned if the complication affects the function of the transplanted organ • Complications due to implant/device – If a patient is admitted with an infection, malfunction, etc due to a device, code the complication code as principal diagnosis 160 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 80 IOD Incorporated May 2013 Complications • Question: a septic patient with respiratory failure, underwent multiple attempts to insert a peripheral IV for fluid resuscitation and frequent blood draws. After multiple failed attempts attempts, the patient subsequently had ultrasound guidance to help with the placement of a central venous catheter. The MD’s diagnosis was “poor IV access”. What is the diagnosis code for “poor IV access”? • Answer: “Poor IV access” is not a medical diagnosis. Assign a code for the underlying condition that is being treated (e (e.g. g sepsis sepsis, respiratory failure, etc.) – Coding Clinic 2008 161 Sample Question • What is the diagnosis code assignment for contraction of the anterior capsule causing the intraocular lens implant to be displaced following extraction t ti off a cataract? t t? Th The physician h i i uses a laser to repair the torn capsule and reposition the lens. A. 996.69 B. 996.53 C. 998.82 998 82 D. 998.89 162 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 81 IOD Incorporated May 2013 Answer • B. 996.53 163 Late Effects • Residual condition that remains after the acute phase of the illness/injury has passed d • No time periods • Code first the residual condition then the cause of the late effect 164 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 82 IOD Incorporated May 2013 V codes Admission Counseling History of (personal and family) Resistance Aftercare Dependence Maintenance Screening Att ti Attention to t Di l i Dialysis M l dj t Maladjustment t St t Post Status P t Boarder Donor Newborn Supervision of Care (of) Encounter for Observation Test (s) Carrier of Examination Outcome of delivery Therapy Checking Exposure Pregnancy Transplant(ed) Contact Fitting (of) Problem Unavailablity of medical facilities Contraception Follow-up Prophylactic Vaccination Convalescence Health Replacement 165 V code categories • • • • • • • • Contact/exposure – Exposure to TB V01.1 Inoculations/vaccinations – Flu shot V03.81 Status – S/P CABG V45.81 History (of) – History of lung cancer V10.11 Screening – Mammography screening V76.12 Observation – Observation after MVA V71.4 Aftercare – Colostomy takedown V55 V55.3 3 Follow-up – Follow-up after surgery V67.09 • • • • • • • Donor – Kidney donor V59.4 Counseling – Genetic counseling V26.33 Obstetrics and related conditions – History of pre-term labor V23.41 Newborn, infant/child – Normal newborn V30.00 Routine/administrative examinations – Vision testing V20.2 Miscellaneous – Prophylactic breast removal V50.41 Nonspecific (limited use in outpatient setting) – History of arthritis V13.4 166 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 83 IOD Incorporated May 2013 BMI • BMI should only be reported as secondary diagnoses – For the BMI, code assignment may be based on medical record documentation from clinicians who are NOT the patient's provider (i.e. physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis) • This information is typically documented by other clinicians involved in the care of the patient (e.g. a dietician often documents the BMI BMI. • However, the associated diagnosis (such as overweight or obesity) must be documented by the patient's provider 167 Let’s Have Some Fun! What’s wrong with these codes? 1. 174.4, V58.11, 197.0 2 357 2. 357.2, 2 250 250.60, 60 401 401.9 9 3. V27.0, 654,21, 644.21 4. 403.91, 585.6, 401.9, 562.10 5. 774.2, V30.00, V05.3 6. 250.70, 443.81, 250.62, 357.2 7 041 7. 041.11, 11 599 599.0, 0 401 401.9 9 8. 644.21, 650, v27.0 168 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 84 IOD Incorporated May 2013 This is what she calls FUN? 1. 174.4, V58.11, 197.0- V58.11 must be principal dx 2. 357.2, 250.60, 401.9- 357.2 cannot be principal 3. V27.0, 654,21, 644.21- v27.0 cannot be principal 4. 403.91, 585.6, 401.9, 562.10- do not use 403.xx and 401.9 together 5. 774.2, V30.00, v05.3- V30.00 must be principal dx 6. 250.70, 443.81, 250.62, 357.2- inconsistent fifth digits on DM codes 7. 041.11, 599.0, 401.9- 041.11 cannot be used as principal dx 8. 644.21, 650, v27.0- cannot use 650 with complication code from pregnancy chapter 169 Present on Admission (POA) • Y = Yes (present at the time of inpatient admission) • N = No (not present at the time of inpatient admission) • U = Unknown (documentation is insufficient to determine if condition is present on admission • W = Clinically undetermined (provider is unable to clinically determine whether condition was present on admission) 170 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 85 IOD Incorporated May 2013 POA • Assign ‘Yes’ in the following examples: • Condition present on admission: Patient admitted with lethargy, fever, tachycardia, hypotension and altered mental status. Blood culture grew out pseudomonas on day of admission. MD d documents t ‘sepsis ‘ i was presentt on admission d i i as evidenced id db by the presenting signs and symptoms’. • Condition diagnosed PRIOR to admission: Patient has a PMH of angina and is treated with Imdur during the hospital stay. • Condition diagnosed during the admission that was clearly present before admission but not diagnosed until after the admission occurred: Patient is admitted with cough and difficulty breathing. After study, the final diagnosis is lung cancer. • Condition confirmed after admission but documented as suspected, possible, rule out, probable for a final diagnosis and the diagnosis was suspected at the time of the inpatient admission: Patient admitted with chest pain, rule out MI. Diagnostic w/u could not confirm the MI. Final diagnosis is chest pain, possible MI. 171 POA Assign ‘Yes’ in the following examples: • Final diagnosis is documented as impending or threatened and the diagnosis is based on the symptoms or clinical findings that were present on admission: Patient is admitted with chest pain, rule out MI Final diagnosis is documented as impending MI MI. MI. • Condition that develops during an outpatient encounter prior to a written order for inpatient admission: Patient undergoes outpatient surgery. During recovery, patient develops A fib and patient is admitted as inpatient. • Any acute condition present at time of admission: Patient admitted from the ER. MD documents respiratory failure, pneumonia, ARF and dehydration. • Any A chronic h i condition diti even th though h th the condition diti may nott be b diagnosed until after admission: ECHO is performed during hospital stay and shows mitral regurgitation. MD confirms the diagnosis of mitral regurgitation in the progress notes and discharge summary. • 172 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 86 IOD Incorporated May 2013 POA • Assign ‘Yes’ in the following examples: • Combination code only identifies the chronic condition and not the acute exacerbation: Patient admitted with decompensated CHF. • Combination code where all parts of the combination code are presentt on admission: d i i P ti t admitted Patient d itt d with ith GI bl bleed. d EGD demonstrates gastritis and MD documents GI bleed due to gastritis. • Comparative/contrasting diagnoses when both are present or suspected at the time of admission: Abdominal pain documented in the ER. MD documents abdominal pain may be due to either pancreatitis or cholecystitis. • Infection code that includes the causal organism when infection (or signs i off iinfection) f ti ) were presentt on admission: d i i P ti t in Patient i ER iis diagnosed with pneumonia. Sputum culture taken in the ER eventually grows out Klebsiella. • Pregnancy complications/obstetrical conditions present on admission: Patient admitted in labor and positive group B strep culture was noted. Patient was treated with IV abx prior to delivery. 173 POA • Assign ‘Yes’ in the following examples: • Newborn condition present at birth or developed in utero including any condition that occurred during delivery: Fetal bradycardia documented during labor and is included in the final diagnosis on the NB record. • Any congenital condition/anomaly: Baby delivered and Tetralogy of Fallot was noted by the MD throughout the record. • Any E code representing external cause of injury/poisoning that occurred prior to admission: Patient admitted with fracture of femur due to fall down stairs. 174 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 87 IOD Incorporated May 2013 POA • Assign ‘No’ in the following examples: • Any condition the provider explicitly documents as NOT present at time of admission: Patient admitted with fever, elevated WBCs and hypoxemia. yp Pneumonia is documented. Patient progressively gets worse and on day 3 has hypotension, tachycardia, pulse 132. Blood cultures grew out pseudomonas on hospital day 5. MD documents ‘sepsis did not develop until after admission’. Pneumonia = Y, Sepsis = N • Diagnosis contains the term possible, probable, suspected or rule out for a final diagnosis and the diagnosis, symptoms or clinical findings were NOT present on admission: On day 2, patient develops chest pain pain. MD documents chest pain due to possible MI as final diagnosis. • Final diagnoses is documented as impending or threatened and the diagnosis is based on symptoms or clinical findings that were NOT present on admission: On day 2, patient develops chest pain. MD documents impending MI as final diagnosis. 175 POA • Assign ‘No’ in the following examples: • Acute conditions NOT present at the time of admission: Patient develops V-tach on hospital day 3. • Combination code where ALL parts of the combination code were NOT present on admission: Patient with DM developed OOC DM on hospital day 3. Patient has gastric ulcer that does not start bleeding until after admission. • Pregnancy complications/OB conditions NOT present on admission: Patient delivers baby and has second degree laceration 176 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 88 IOD Incorporated May 2013 POA • Assign ‘No’ in the following examples: • OB code including more than one diagnosis and all parts of the diagnosis were NOT present on admission: Patient with pre-existing pre existing HTN is admitted and developed pre-eclampsia after admission. • Newborn condition that developed after admission/delivery: NB developed diarrhea which was believed to be due to hospital baby formula. • Any E code representing an external cause of injury/poisoning that occurred DURING the inpatient stay: Patient experienced an adverse reaction to med given on day 3. 177 POA • Assign ‘U’ in the following example: • *NOTE: ‘U’ should not be routinely used and only in very limited circumstances.* When the documentation is unclear if the condition was present on admission: Patient admitted with fever and pneumonia. Patient rapidly deteriorates and becomes septic. Discharge diagnosis lists sepsis and pneumonia. Documentation is unclear as to whether the sepsis was present on admission or developed shortly after admission. Pneumonia = Y, Sepsis = U • Assign ‘W’ in the following example: • When the documentation indicates that it cannot be clinically determined whether or not the condition was present on admission: Patient admitted in active labor. During the stay, a breast abscess is noted when the mother attempts to breast feed. MD is unable to determine whether the abscess was present on admission. 178 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 89 IOD Incorporated May 2013 POA • Question: a patient is admitted to the hospital with a stage II pressure ulcer of the heel. During the hospitalization, the pressure ulcer worsens and becomes a stage III. Based on the new Official Coding Guidelines, we would be assigned the code for the highest stage for that site. What would be the correct POA indicator assignment for the stage III code? • Answer: Assign ‘Y’ to the pressure ulcer stage III code since this code is referring to a pressure ulcer l th thatt was presentt on admission d i i rather th th than a new ulcer. – Coding Clinic 2008 179 POA • Question: A patient is admitted with a subarachnoid hemorrhage following an injury. At the time of admission there was no mention of loss of consciousness. However, after admission the patient lost consciousness for several hours. We assigned code 852.03, Subarachnoid hemorrhage following injury without mention of open intracranial wound, with moderate [1-24 hours] loss of consciousness, as the principal diagnosis. What is the appropriate POA indicator since the patient lost consciousness after admission? • Answer: Assign POA indicator “Y” since the injury occurred prior to admission. Loss of consciousness is part of the natural history of the disease process. In addition, the POA guideline governing combination codes does not apply pp y here, since this is not a combination of diagnoses. The skull fracture (800- 804) and intracranial injury (850-854) categories are unique, so this advice only applies to these categories. Coding Clinic, 2nd Quarter, 2010, p. 17 180 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 90 IOD Incorporated May 2013 New Codes- Valid October 2012 • 041.4x E. coli expanded • 173.xx basal cell, squamous cell and unspecified malignant neoplasms of skin (by site) • 282.4x thalassemias • 284.1x pancytopenias • 365.7x mild, moderate, severe and indeterminate stages of glaucoma • 415.13 saddle embolus of pulmonary artery • 425.1x cardiomyopathies • 444.01 saddle embolus of abdominal bd i l aorta t • 512.8x various pneumothorax • 516.3x various interstitial pneumonitis • 516.31 idiopathic pulmonary fibrosis • 518.51 acute respiratory failure following trauma/surgery pulmonary y • 518.52 other p insufficiency, NEC, following trauma/surgery • 518.53 Acute and chronic respiratory failure following trauma/surgery • 539.0x Complications of gastric band surgery • 539.8x Complications of bariatric procedure • 747.3x pulmonary artery malformations • 998.0x Post operative shock 181 New Codes- Valid October 2012 • 02.21 Insertion or replacement of external ventricular drain • 02.22 Intracranial ventricular shunt or anastomosis • 17.53-17.54 17 53 17 54 Percutaneous atherectomy of extra- and intracranial vessels • 17.55 Transluminal coronary atherectomy • 17.56 Atherectomy of noncornonary vessel(s) • 35.05 Endovascular replacement of aortic valve • 35.06 Transapical replacement of aortic valve • 35.07 Endovascular replacement of pulmonary valve CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer • 35.08 Transapical replacement of pulmonary valve • 35.09 Endovascular replacement of unsp heart valve • 39.77 Temporary therapeutic endovascular occlusion of vessel • 39.78 Endovascular implantation of branching or fenestrated graft(s) in aorta • 43.82 Laparoscopic vertical (sleeve) gastrectomy • 68.24 68 24 Uterine artery embolization [UAE] with coils • 68.25 Uterine artery embolization [UAE] without coils 91 IOD Incorporated May 2013 Admission from Observation Unit • When a patient is admitted to an observation unit for a medical condition that requires an inpatient admission, the principal diagnosis would be the medical condition which led to this hospital admission • When a patient is admitted from outpatient surgery due to a complication, assign the complication code as principal dx • If there is no complication or other condition after outpatient surgery and the patient requires an inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis p admission is another condition • If the reason for the inpatient unrelated to the surgery, assign the unrelated condition as principal dx 183 183 Outpatient p Guidelines 184 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 92 IOD Incorporated May 2013 Selection of First-listed Condition • The term ‘first-listed’ condition is used in lieu of principal dx • Diagnosis are often not established at the time of the initial encounter/visit May take 2 or more visits before the encounter/visit. diagnosis is confirmed. • Outpatient surgery – Code reason for the surgery as first-listed diagnosis, even if the surgery is not performed due to contraindication • Observation stay – Assign g code for the medical condition as first-listed diagnosis g – When patient develops complications after outpatient surgery, requiring observation, code the reason for surgery as the first-reported diagnosis followed by the complications as secondary diagnoses 185 Uncertain Diagnosis • DO NOT CODE diagnoses documented as ‘probable, suspected, questionable, rule l outt or working ki di diagnosis’ i ’ or other th similar term. Rather, code the condition to the highest degree of certainty, such as signs, symptoms, or abnormal test results. 186 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 93 IOD Incorporated May 2013 Diagnostic Services • For diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding coding, code any confirmed or definitive diagnoses documented in the interpretation. Do not code any related signs/symptoms as additional diagnoses. 187 Preoperative Evaluations (only) • Sequence first a code from category v72.8, 72 8 other th specified ifi d examinations, i ti tto describe pre-op consultations. Assign a code for the condition to describe the reason for surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation 188 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 94 IOD Incorporated May 2013 Ambulatory Surgery • Code the diagnosis for which the surgery is performed. If the postoperative dx diff differs from f the th preoperative ti dx, d select l t th the postoperative dx for coding since it is the most definitive. 189 Modifiers (Level I) – Bilateral procedure was performed (-50) • Caution: some codes describe bilateral procedures • Typically NOT used for integumentary codes – Reduced services (-52) • No other code to accurately reflect the service provided • Physician-directed reduction – Distinct procedural service (-59) • Used to report services not normally reported together • Different session/encounter, different procedure, different site (i (i.e. e removal of lesions from leg and biopsy of back lesion. – Excision of lesion code + biopsy code -59 190 190 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 95 IOD Incorporated May 2013 Modifiers (Level I) – Discontinued outpatient hospital procedure PRIOR to administration of anesthesia (-73) • Procedure stopped due to patient’s condition • After surgical prep and sedation • Prior to administration of anesthesia – Discontinued outpatient hospital procedure AFTER administration of anesthesia (-74) • Procedure stopped due to patient’s condition • After administration of anesthesia • i.e. Intubation started or incision was made 191 Modifiers (Level II) Anatomical Modifiers – – – – – – – – LT left side RT right g side E1 upper left, eyelid E2 lower left, eyelid E3 upper right, eyelid E4 lower right, eyelid FA left hand, thumb F1 left hand hand, second digit – F2 left hand, third digit – – – – – – – F5 right hand, thumb F6 right hand, second digit TA left foot, great toe T1 left foot, second digit T5 right foot, great toe T6 right foot, second digit LC left circumflex, coronary artery t – RC right coronary artery 192 192 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 96 IOD Incorporated May 2013 Surgical Package (Global Surgery Payment) • Surgical procedure • Local, digital or topical anesthesia • One related E/M encounter on date of, or immediately prior to date of procedure (includes H & P) • Immediate postoperative care • Preparation of orders • Evaluation E al ation of patient in postanesthesia recovery reco er area • Typical postoperative follow-up care 193 Mutually Exclusive • Applies to improbable or impossible combination of codes – Example: E l 69601 69601- revision i i mastoidectomy, t id t resulting in complete mastoidectomy used with code: 69604- Revision mastoidectomy; resulting in tympanoplasty 194 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 97 IOD Incorporated May 2013 E & M Coding • Determine: – Place of service (office, ER, nursing home) – Type of service (consult, admission, NB) – Patient status (new, (new unless patient seen in last 3 years by MD or MD or same specialty in same group) – 3 key components • History (problem focused, expanded, detailed, comprehensive) • PE (problem focused, expanded, detailed, comprehensive) • Medical decision making (straightforward, low, moderate, high) – New patients require all 3 above components – Established E t bli h d patients ti t usually ll require i 2 or 3 off above b components – Some codes are based on time: critical care, prolonged services 195 Integumentary Procedures • Types of repairs (12001-13160) – Simple repair: used when the wound is superficial; eg, involving primarily epidermis, dermis, and subcutaneous tissue and no deeper structures. The wound closure involves closing one layer, and includes local anesthesia, and chemical or electrocauterization of unclosed wounds wounds. – Intermediate repair: includes requires layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (nonmuscle) fascia. Single-layer closure of heavily contaminated wounds, which required extensive cleaning or removal of particulate matter also constitutes as intermediate repair. – Complex repair: requires more than layered closure, such as scar revision, debridement (eg, traumatic lacerations or avulsions), extensive undermining, stents or retention sutures sutures. Necessary preparation includes creation of a defect for repairs (eg, excision of a scar requiring a complex repair) or the debridement of complicated lacerations or avulsions. Steri-strips or bandages only are reported with the appropriate E/M code (no separate CPT code) 196 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 98 IOD Incorporated May 2013 Integumentary Procedures • Lesions (10040-11646) – – – – Benign or malignant? What site/body yp part is involved? Biopsy, excision, destruction, shaving? How large is excised area? Not just lesion size • Report each lesion excised separately • Includes margins excised • The size of the lesion is best found on the OPERATIVE REPORT • Excisional biopsy used when entire lesion is removed – What type of closure was performed? • Advancement flap codes include excision of lesions 197 197 Integumentary Procedures • Integumentary Lesion Excisions • The Integumentary System guidelines listed in the CPT 2010 codebook define an excision as the removal of a lesion, including margins, through the full thickness of the dermis, and including simple (nonlayered) closure and local anesthesia. • Code selection is determined by measuring the greatest clinical diameter of the apparent g pp lesion, plus the margin required for complete excision, prior to the procedure. 198 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 99 IOD Incorporated May 2013 Integumentary Procedures • Integumentary excision procedures may require simple, intermediate, or complex closures. Simple repair is included in the lesion excision and is not reported separately. However, repair by intermediate or complex closures should be reported separately. example if a malignant skin lesion on the left arm measuring 1 1.0 0 • For example, cm is excised with 0.3cm margins (excised diameter 1.6 cm), and requires a complex closure of the wound of 3.0cm length after accounting for manipulation of the wound for closure, report CPT code 11602, Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm, for the excision; for the repair, report code 13121, Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm. • Note that when the excision of benign or malignant skin lesions (codes 11400-11446 11400 11446 and 11600-11646) 11600 11646) is performed in conjunction with an adjacent tissue transfer (codes 14000-14302), only the adjacent tissue transfer should be reported, as the excision is included in this procedure. 199 Sample Question • A patient has six actinic keratoses destroyed cryosurgically. What should be referenced under the CPT index? A. Excision, lesion, skin (malignant) B. Excision, lesion, skin (benign) C. Lesion, skin, excision D Lesion D. Lesion, skin, skin destruction 200 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 100 IOD Incorporated May 2013 Answer • D. Lesion, skin, destruction 201 Integumentary Procedures • Debridement – Percentage of body surface debrided – Extent of skin debrided (full or partial thickness) – Depth of debridement (subcutaneous, muscle, bone) 202 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 101 IOD Incorporated May 2013 Integumentary Procedures • Breast lesions – Pre-op radiological markers (localization wires) i ) often ft used d prior i tto biopsies bi i and d excisions • Use codes 19290-19291 for placement • Use codes 19125-19126 for excision of breast lesion with pre-op marker previously placed 203 Integumentary Procedures • Skin replacement/substitutes – Surgical preparation • 15002-15005 15002 15005 • Does donor site require repair? – Grafts (Split-thickness, full-thickness, allograft/donor, autograft, skin substitute, xenograft/nonhuman donor) • 14000-14350 14000 14350 – Tissue-cultured Epidermal Autograft • 15150-15157 204 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 102 IOD Incorporated May 2013 Integumentary Procedures • Example: – 10 sq cm epidermal autograft to face from back. • 15115 205 Musculoskeletal System • Whether reporting the excision or radical resection of soft tissue tumors from the subcutaneous, fascial or subfascial layer, appreciable vessel exploration and/or neuroplasty should be reported separately. Simple and intermediate repair closures are included in the excision procedures,, but if complex p p repairs p with extensive undermining g or other techniques are performed to close a defect created by a lesion excision, the complex repair codes are reported separately. • The excision of musculoskeletal lesions (tumors), includes the dissection or elevation of tissue planes in order to allow resection of the tumor, and therefore, those services are not reported separately. The code selection for musculoskeletal lesion excisions is determined by measuring the greatest diameter of the tumor, in addition to the narrowest margin required for the complete excision of the tumor, based on the p physician's y jjudgment, g at the time of the excision. • The radical resection of soft tissue tumors may be confined to a specific layer, for instance the subcutaneous or subfascial tissue, or it may involve the removal of tissue from one or more layers. Radical resection of soft tissue tumors is most commonly used for malignant or very aggressive benign tumors. 206 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 103 IOD Incorporated May 2013 Musculoskeletal System • Musculoskeletal Lesion Excisions • Musculoskeletal lesion excision codes pertain to subcutaneous, superficial, or deep soft tissues under the skin which may include subcutaneous fat skin, fat, fascia fascia, muscle and bone. Soft tissue excision codes are dispersed throughout the CPT 2010 musculoskeletal section and are categorized by anatomic site. • When coding musculoskeletal procedures, it is important to note that the excision must meet the criteria listed in the code descriptor. For example, in order to report code 26116 Excision, 26116, E i i tumor, t soft ft tissue, ti or vascular l malformation, of hand or finger; subfascial (eg,intramuscular); less than 1.5 cm, the tumor must be down to the muscle (ie, located between the fascia and muscle) or be intramuscular, such as a muscle sarcoma. 207 Examples • The following are the different types of excisions, as listed in the guidelines: • Subcutaneous soft tissue tumors: involve the simple or marginal resection of tumors confined to subcutaneous fatty tissue below the skin, skin but above the deep fascia fascia. • Fascial or subfascial soft tissue tumors: involve the resection of tumors confined to the tissue within or below the deep fascia, but not involving the muscle or bone. Included are digital (ie, fingers and toes) subfascial tumors that involve the tendons, tendon sheaths, or joints of the digit. • Radical resection of soft tissue tumors: involve the resection of a tumor, usually malignant, with wide margins of normal tissue. • Radical R di l resection ti off bone b tumors: t i involve l th the resection ti off th the tumor with wide margins of normal tissue. Radical resection of bone tumors is usually performed for malignant tumors or very aggressive tumors. (See CPT Assistant February 2010.) 208 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 104 IOD Incorporated May 2013 Examples • Subcutaneous soft tissue tumors: usually benign and resected without removing a significant amount of surrounding normal tissue. • Fascial or subfascial soft tissue tumors: usually benign, i involve l ffascia i and/or d/ muscle, l and d resected t d without ith t removing i a significant amount of surrounding normal tissue. • Digital (ie, fingers and toes) subcutaneous tumors: adjacent to but not breaching the tendon, tendon sheath, or joint capsule. • Digital (ie, fingers and toes) fascial or subfascial tumors: involve the tendon, tendon sheath, or joint capsule capsule. • Radical resection of soft tissue tumors: most commonly used for malignant tumors, and extremely aggressive benign tumors in which wide margins of normal tissue are excised. 209 Examples • Question: May I report code 19260, Excision of chest wall tumor including ribs with Modifier 52 appended, if the excision of a 10cm chest wall mass did not include removing the ribs? • Answer: No. It would not be appropriate to report code 19260, Excision of chest wall tumor including ribs, with Modifier 52 appended, as the procedure did not involve removal of the ribs. If the procedure involves removing a chest wall tumor without the ribs, it would be more appropriate to report a musculoskeletal tumor excision code, d such h as code d 21557, 21557 Radical R di l resection ti off tumor t (eg, malignant neoplasm), soft tissue of neck or anterior thorax; less than 5 cm, depending on the depth, size, and malignant or benign nature of the lesion. 210 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 105 IOD Incorporated May 2013 Examples • Question: What would be the appropriate CPT code for excision of a sebaceous cyst on the scalp or on the face that is subdermal or deeper? • Answer: Integumentary lesion excision codes pertain to the epidermis, dermis and subcutaneous tissue dermis, tissue, while musculoskeletal lesion excision codes pertain to subcutaneous, superficial or deep soft tissues. Code ranges 11400-11446 and 11600-11646 represent lesions that normally occur on the surface of the skin (epidermis) or near the surface of the skin (dermis), compared to the type of lesion (or tumor) that occurs in the subfascial or fascial tissue, muscles and joints, as listed in the musculoskeletal section. A sebaceous cyst is a skin lesion and may be very large, distending the skin and pushing into the subcutaneous fatty tissue, but it is a skin lesion, and therefore, should be coded using the g y lesion excision codes, depending p g on the size of the cyst. y integumentary • Code range 21011-21016 lists the excision codes for soft tissue tumors subcutaneous and subfascial on the face or scalp. When coding musculoskeletal procedures, it is important to note that the excision must meet the criteria listed in the code descriptor. The physician must determine and document the depth of the excision to determine whether the integumentary system or musculoskeletal system CPT codes are appropriate. 211 Sample Question • The following CPT codes appear: 19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple, or areolar lesion (except 19140), male or female, one or more lesions 19125 Excision of breast lesion identified by preoperative placement of radiological marker; single lesion 19290 Preoperative placement of needle localization wire, breast The patient underwent a needle localization with excision of a right breast lesion. Pathology revealed diffuse fibrocystic disease. Which of the following is the appropriate coding for this procedure? A. 19125; 19290 B 19125 B. C. 19120; 19125 D. 19120; 19290 212 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 106 IOD Incorporated May 2013 Answer • A. 19125; 19290 – Notice there are no modifiers??? 213 213 Fractures/Dislocations • Treatment can be open, closed/percutaneous • Closed treatment – Fracture/dislocation site is not surgically opened • Open treatment – Surgically opened to visualize and allow treatment • Skeletal fixation – Neither open nor closed. Pins placed across fracture using x-ray guidance • Manipulation M i l ti – Reduction or restoration of a fracture/dislocation 214 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 107 IOD Incorporated May 2013 Fractures/Dislocations • Example: – Patient arrives to ER with left intertrochanteric fracture and left tib/fib fracture. ORIF was performed on both fractures • 27244 -LT, 27758 -LT 215 Bronchoscopy and Biopsy • • • • Endobronchial Biopsy: 31625 Transbronchial Biopsy: 31628 Transbronchial needle aspiration biopsy: 31629 Catheter aspiration of tracheobronchial tree at bedside: 31725 • NOTE: Cell washings/brushings are NOT considered biopsies 216 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 108 IOD Incorporated May 2013 Nasal Procedures • Hemorrhage control (30901-30999) – Packing, ligation, cauterization – Anterior: was hemorrhage simple or complex? • Inserts gauze packing or performs cauterization – Posterior: was control of hemorrhage initial or subsequent procedure? • Typically a more severe bleed • Inserts nasal stents,, tampons, p , balloon catheters or patient taken to OR for ligation 217 Cardiac Pacemakers/ Defibrillators (33202-33249) • Questions to ask: – – – – – Permanentt or temporary? P t ? Approach? (transverse or thoracotomy) Type of device? (electrodes and/or generator) Electrode placement? (atrial and/or ventricle) Initial placement, revision, removal, or replacement? l t? – Skin pocket revision? 218 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 109 IOD Incorporated May 2013 Venous Access Devices • Insertion (36555-36571) – – – – – Tunneled (under skin), Hickman, Broviac, Groshong Non tunneled , triple lumen, PICC Centrally placed placed, subclavian subclavian, jugular jugular, IVC Peripheral Age? • Repair (36575, 36576) – Without replacement • Replacement (36578-36585) – Partial versus complete – With/without port or pump • Removal (36589, 36590) – Use for tunneled catheters only, non-tunneled cath removals are NOT reported separately • Guidance (77001-fluoro, 76937- ultrasound) 219 Digestive Procedures • Hernias (49491-49611) – Initial vs. recurrent – Reducible vs. strangulated – Use code 49568 for incisional and ventral hernia repairs 220 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 110 IOD Incorporated May 2013 Digestive Procedures • Code biopsy if single lesion is biopsied (but not excised) • Code biopsy once if multiple biopsies are done (from same or different lesions) and none of the lesions are excised • Code only the excision if a biopsy of lesion is done and the balance of the same lesion is then excised • Code both the biopsy and excision if both are performed and if the biopsy is taken from a lesion DIFFERENT from that which is excised; AND if the code for the excision does not include the phrase ‘with or without biopsy’. If that is the case, then a separate biopsy code should not be used • Use Modifier -59 to explain when coding both biopsy and removal of a different lesion 221 Genitourinary • Different approaches include: – Cystoscopy, urethroscopy, cystourethroscopy ureteroscopy cystourethroscopy, ureteroscopy, pyeloscopy, renal endoscopy • BEWARE: – Ureteral versus Urethral procedures! 222 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 111 IOD Incorporated May 2013 Abortion • Spontaneous abortion in any trimester and completed surgically: 59812 • Missed abortion occurring in the first f trimester: 59820 • Induced abortion with curettage and evacuation: 59851 • Induced abortion evacuation: 59841 • Abortion by D & C : 59840 – Nonobstetrical D & C : 58120 223 Spinal Procedures • Epidural injections are just that- injection into the epidural space space. • Root injections differ in that the approach is more difficult. It is through the nerve root foramen versus translaminer. • In addition, addition add fluoroscopy code when performed. Approach Site CPT Epidural Injection Cervical/ Thoracic 62310 Epidural Injection Lumbar/ Sacral 62311 Root Injection (Lt and Rt) Cervical/ 64479-1st level Thoracic 64480- each (Lt and Rt) addt’l level Root Injection (Lt and Rt) Lumbar/ 64483- 1st level Sacral 64484- each (Lt and Rt) addt’l level 224 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 112 IOD Incorporated May 2013 Eye Procedures • Cataract extraction – ICCE Intracapsular cataract extraction – ECCE Extracapsular cataract extraction – Anterior chamber intraocular lens (IOL) – Posterior chamber intraocular lens (IOL) • Do NOT code injection done in conjunction with cataract surgery. g y Considered p part of the procedure. 225 Eye Procedures • Cataract removal includes codes: 6683066984 – DO NOT code d the th following f ll i procedures d separately: • • • • • Anterior/Posterior capsulotomy Enzymatic zonulysis Iridectomy/iridotomy Lateral canthotomy Subconjunctival/sub-tenon injections 226 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 113 IOD Incorporated May 2013 Infusions/Injections • Injection = 15 minutes or less • Infusion (one hour) = 31-90 minutes – 30 minutes or less- do not report – “Each Each additional additional” must be 31 minutes or greater • Report only 1 initial infusion (even if multiple infusion, injections or a combination of both are performed), unless 2 separate IV sites are used – Choose the initial code that best describes the key reason for the encounter versus the ‘order’ in which they occurred – Therapy infusions take precedence over ‘hydration’ – Therefore, any hydration therapy administered subsequent to the initial drug/substance infusion, only ‘each additional’ hydration code(s) should be used 227 Infusions/Injections • Hydration infusion note – Hydration codes are NOT reported when IV hydration is running while the therapeutic agent infusion. – In other words, hydration codes can only be sequential (pre- and post-) but NOT concurrent 228 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 114 IOD Incorporated May 2013 Infusions/Injections • Example: – For example, if intravenous hydration as d described ib d b by codes d 96360 and d 96361 iis given i from 11:00 pm to 2:00 am, code 96360 would be reported once for the first hour and code 96361 would be reported twice (once for each additional hour of hydration intravenous infusion) infusion). 229 Infusions/Injections • Question: On the basis of the infusion guidelines for facilities, in the following scenario, is IV hydration primary to an IV push in the hierarchy? A patient receives an IV hydration from 1:00 pm to 3:00 pm and two IV pushes of the same drug d att 1:30 1 30 pm and d3 3:30 30 pm. • No. The guidelines indicate that "therapeutic, prophylactic, and diagnostic services are primary to hydration services." Therefore, the intravenous push administrations of the same drug are primary to the hydration service.For facility reporting pertaining to this specific scenario, the intravenous push drug administration performed at 1:00 pm, code 96374 is considered the "initial" service and is primary to the hydration service. service Code 96376 is for the 1:30 pm IV push. The 3:30 pm IV-push administration of the same drug is reported with code 96376. 230 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 115 IOD Incorporated May 2013 Infusions/Injections • More on the answer: – The 2-hour duration of the intravenous "hydration" infusion from 1:00 pm to 3:00 pm is provided as a secondary service to a different initial service (code 96374). However, hydration may not be a concurrent service. In this instance, some portion less than 16 minutes of the 2 hours of "hydration" infusion, was concurrent. Therefore, the hydration is reported using code 96361 once. This reporting instruction is outlined i th in the parenthetical th ti l note t ffollowing ll i code d 96361 96361, where h users are directed to report add-on code 96361 in conjunction with code 96374 and beneath code 96360, whereby it notes that hydration is not a concurrent service. 231 Infusions/Injections • The Q&A was offered to clarify that while some portion of the IVpush administration may occur concurrent to the hydration infusion, it is not appropriate to report code 96368. Instead, code 96361 should be reported. The instruction does not suggest or infer that the time of the IV-push IV push administration is to be deducted from the total hydration infusion interval. • To further clarify, for facility reporting specific to this scenario, the intravenous-push drug administration performed at 1:30 pm, is considered the initial service, ie, primary to the hydration service. Therefore, code 96374, Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug, is reported for the 1:30 pm IV-push administration of the same drug. g Add-on code 96376, Therapeutic, p prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure) is reported for the 3:30 pm push of the same drug. 232 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 116 IOD Incorporated May 2013 Infusions/Injections • Furthermore, the 2-hour duration of the intravenous hydration infusion from 1:00 pm to 3:00 pm is provided as a secondary service to a different initial service (96374). In this instance, the 2 hours of hydration infusion is reported twice using code 96361 (2 units) as it is reported once for each hour of the 2-hour infusion. This reporting instruction is outlined in the parenthetical note following code 96361, in which users are directed to report add-on code 96361 in conjunction with code 96374. Nevertheless, hydration y may y not be a concurrent service and, therefore, the duration of the pushes could affect the units reported for hydration. Note that overlapping time may not be included. • **CPT Assistant, May 2010, page 8 233 Cardiac Catheterization • CPT Definition of cardiac catheterization: – Introduction, positioning, repositioning of catheter – Recording of intracardiac/intravascular pressure – Obtaining blood samples for blood gases or dilution curves – Cardiac C di output t t measurements t with ith or without ith t electrode catheter placement – Final evaluation and report of procedure 234 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 117 IOD Incorporated May 2013 Cardiac Catheterization • • • • • 93451 Right heart catheterization 93452 Left heart catheterization including injection(s) for LVgram, imaging S&I 93453 Combined right and left heart catheterization including intraprocedural injection(s) for LVgram, imaging S&I 93454 Catheter placement in coronary artery(s) for coronary angiography, including injection(s) for coronary angiography, imaging S&I 93455 with catheter placement(s) in bypass graft(s) (internal mammary, free arterial venou grafts) including injection(s) for bypass graft angiography 93456 with right heart cath 93457 with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization 93458 with left heart cath including injection(s) for LVgram, when performed 93459 with left heart cath including injection(s) for LVgram, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with yp g graft angiography g g p y bypass 93460 with right and left heart cath including injection(s) for LVgram 93461 with right and left heart cath including intraprocedural iniection(s) for LVgram, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts with bypass graft angiography 93462 Left heart cath by transseptal puncture through intact septum or by transapical puncture (List separately in addition to code for primary procedure) 235 Cardiac Catheterization • Most common procedures: – Right and left heart cath with coronary angiography and LVgram 93460 – Left heart cath with coronary angiography 93458 – Left heart cath with coronary angiography and LVgram 93458 – Left L ft heart h t cath th with ith LVgram LV 93452 – Left heart cath 93452 – Right heart cath 93451 236 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 118 IOD Incorporated May 2013 PTCA/Stent/Atherectomy Procedure Single Vessel Each addt’l vessel **Assigned PER VESSEL, even when St t 92980 92891 multiple strictures are Stent treated within the same vessel Coronary 92982 92984 angioplasty** **Include when performed with a ‘ tti b ‘cutting balloon’ ll ’ Coronary atherectomy 92995 92996 237 Sample Question • A cardiovascular procedure that is unfamiliar to the coder is performed, and the procedural name used by the physician does not appear in the CPT index. In such a situation situation, what should the coder do first? A. Ask the physician to review the codes in the cardiovascular section of CPT B. Assign a similar cardiovascular procedure code C. Postpone coding the specific procedure until a code is established by the AMA D. Use an unlisted procedure code from the cardiovascular section 238 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 119 IOD Incorporated May 2013 Answer • A. Ask the physician to review the codes d iin th the cardiovascular di l section ti off CPT 239 Other Tidbits of Info 240 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 120 IOD Incorporated May 2013 Rule Out • Rule out pneumonia – Outpatient - do NOT code pneumonia. Code to the highest degree of certainty (often a sign/symptom). i.e. cough, fever – Inpatient - code pneumonia as if it existed because the evaluation and management of the suspected condition is equal to the treatment of the same condition that has been confirmed 241 Ruled Out • Ruled Out designates the fact that the condition does NOT exist and should not b coded. be d d – Code the preceding signs, symptoms or abnormal test results instead. 242 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 121 IOD Incorporated May 2013 Sample Question • A patient with a complaint of cough(786.2) was referred by his physician to the outpatient department for a chest x-ray (V72.5) to rule out pneumonia (486). (486) The results were negative. negative Which of the following is the appropriate sequencing? A. V72.5; 786.2 B. 786.2 C. V72.5; 486 D. V72.5 243 Answer • B. 786.2 244 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 122 IOD Incorporated May 2013 Cancelled procedures • If the original treatment plan cannot be carried out due to unforeseen circumstances the criteria for designation circumstances, of principal diagnosis does not change. • Example: Pt with BPH admitted for TURP. After admission, the patient fell and sustained a fracture of the femur. TURP was canceled canceled, hip pinning done the following day. Principal dx: BPH, even though it was not treated, it was the reason for the admission. Sample question • The patient with a history of esophageal reflux is prepared for an EGD. While infusing Fentanyl and Versed for sedation, the patient developed sinus bradycardia and the physician cancelled the procedure. Assign the diagnosis code(s). Select THREE of the following options a. b. c. d. e. 427.81 (sinoatrial node dysfunction) 427.89 (other cardiac dysrhythmias) 530.11 (reflux esophagitis) 530.81 (GERD) V64.1 (surgery not carried out because of contraindication) f. V64.3 (surgery not carried out for other reasons) CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 123 IOD Incorporated May 2013 Answer b. 427.89 (other cardiac dysrhythmias) d. 530.81 (GERD) f. V64.3 (surgery not carried out for other reasons) All those acronyms • DSM = Psych/Behavioral health • ICD-O = Oncology/Neoplasms • SNOMED = Systemized Nomenclature of M di i Medicine • SNOP = Standard Nomenclature of Pathology • LOINC = Logical Observation Identifiers Names and Codes (labs) • AHA = Coding Clinic • AMA = CPT • ACOS = Cancer program • Level II HCPCS = Medicare/Medicaid 248 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 124 IOD Incorporated May 2013 More acronyms • • • • • • • CMI= Case Mix Index RW = Relative weight OASIS = PPS for home health APC = PPS for outpatient DRG = PPS for inpatient QIO = Peer review (PEPPER reports) RBRVs = Payment to MD for outpatient surgery • OIG Workplan • NCHS = ICD-9-CM 249 Case Mix Index #of patients DRG 10 20 10 5 222 232 451 530 Relative Weight 3.00 2.00 2.00 1.00 Calculations 10 x 3.00= 30 20 x 2.00= 40 10 x 2.00= 20 5 x 1.00= 5 • MULTIPLY # patients by relative weight for each DRG in aqua • ADD Relative weights (30+ 40+ 20+ 5 = 95) • ADD # of patients (10+ 20+ 10+ 5= 45 ) • DIVIDE Total Relative Weights by # of patients 95 (total RW) ÷ 45 (# patients) = 2.111 2.111 is the CMI 250 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 125 IOD Incorporated May 2013 Medical Science Technology/Pharmacology • • • • Anatomy and Physiology Causes of disease processes Diagnostic tests performed to work up Treatment/Medication for specific diagnoses 251 Physician Queries • When is a query appropriate? – Information in the record is conflicting, ambiguous or incomplete regarding SIGNIFICANT reportable conditions or procedures • When is a query not necessary? – If there is no conflicting documentation from one physician to another – When a physician has documented a final diagnosis and clinical indicators do not appear to support this diagnosisg this is a p physician’s y medical jjudgment g 252 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 126 IOD Incorporated May 2013 Recommended “practice exercises” • Professional Review Guide for the CCS examination (PRG Publishing, Inc) – CD-ROM CD ROM is i like lik ttaking ki th the actual t l CCS exam • Clinical Coding Workout (AHIMA) 253 Websites • CCS examination details – www.ahima.org • POAs – http://www.cms.hhs.gov/HospitalAcqCond • Updated coding guidelines – http://www.cms.gov/ICD9ProviderDiagnostic Codes/07 summarytables asp Codes/07_summarytables.asp 254 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 127 IOD Incorporated May 2013 Thank You & Good Luck! Kim Felix, RHIA, CCS, AHIMA-Approved ICD-10 Trainer Director of Education For further information on IOD and how we can help you: www.iodincorporated.com 255 CCS Prep Workshop Kim Felix, RHIA, CCS AHIMA Approved ICD-10 Trainer 128