Updates to ICD-10 Coding Guidelines and Code Sets for 2018

1. Texas ACDIS Fall MeetingCoding Roundtable

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

3. FY 2018 ICD-10-CM Coding Guideline Updates • Narrative changes appear in bold text • Items underlined have been moved within the guidelines since the FY 2017 version • Italics are used to indicate revisions to heading changes • Notable changes take place mostly in Section I. • The complete guidelines may be downloaded by visiting: • https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf

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

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

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

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

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

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

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

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

12. FY 2018 ICD-10-PCS Coding Guideline Updates • Section B4.1.c *new* • If a procedure is performed on a continuous section of a tubular body part, code the body part value corresponding to the furthest anatomical site from the point of entry. Example: A procedure performed on a continuous section of artery from the femoral artery to the external iliac artery with the point of entry at the femoral artery is coded to the external iliac body part. • Section B6.1a *expanded* • In limited root operations, the classification provides the qualifier values Temporary and Intraoperative, for specific procedures involving clinically significant devices, where the purpose of the device is to be utilized for a brief duration during the procedure or current inpatient stay.

13. FY 2018 ICD-10-CM Code Updates • ICD-10-CM Change Summary • Notable changes: • Chapter 4 – Endocrine, Nutritional, and Metabolic diseases • Chapter 5 – Mental, Behavioral, and Neurodevelopmental disorders • Chapter 7 – Diseases of the Eye and Adnexa • Chapter 9 – Diseases of the Circulatory system • Chapter 12 – Diseases of the Skin and Subcutaneous Tissue

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

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

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

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

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

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

20. Notable ICD-10-CM Changes • Chapter 9 (continued) • I50.8 – Other heart failure • Expanded to include: • Right heart failure • Acute right heart failure • Chronic right heart failure • Acute on chronic right heart failure • Right heart failure due to left heart failure • Biventricular heart failure • High output heart failure • End stage heart failure • Other heart failure

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

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

23. FY 2018 ICD-10-PCS Code Updates • ICD-10-PCS Change Summary • Change Highlights • Medical Surgical section – body part values revised or streamlined for clarity and usefulness of coded data • Endoscopic approaches added to various tables throughout the system for completeness

24. Notable ICD-10-PCS Changes • Cranial Nervous System and Cranial Nerves, Tables 001-00X • Body System Heading changed to: • Central Nervous System and Cranial Nerves • Body Parts added to some tables • Device Codes added to some tables • Qualifier X = Diagnostic, was removed on some tables

25. Notable ICD-10-PCS Changes • Lower Veins, Tables 061-04W • Deleted body part • Lessor Saphenous Vein • Added body part • Hepatic Vein • Added 2 Qualifiers to some tables • Pulmonary Trunk • Pulmonary Artery (L/R)

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

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

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

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

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

31. QUESTIONS?!