ICD-10 Coding Corner: Recap of
Coding Clinic, First Quarter 2013
W h ite paper
E
ditor’s note: AHA Coding Clinic for ICD-9-CM released its second round
of ICD-10 coding guidance in its First Quarter 2013 issue. HCPro CDI
Education Director Cheryl Ericson, MS, RN, CCDS, CDIP, says the guidance
contains information regarding diagnosis clarification, but also instances in which
a CDI specialist may be called upon to clarify a procedure. Other than debridement of pressure ulcers, procedures rarely need to be clarified in ICD-9, but this
paradigm may be changing under ICD-10.
The following is a recap of the issue with an eye toward what it means for CDI
specialists.
Methamphetamine abuse
Cheryl Ericson, MS, RN,
CCDS, CDIP,
HCPro CDI Education
Director
In this entry, Coding Clinic states to assign Z87.898 (Personal history of other
specified conditions) to a patient with a past history of methamphetamine
abuse. This entry serves as a reminder for CDI specialists to educate physicians about documentation of abuse vs. dependence. Physicians are often
hesitant to document abuse as they often worry about being judgmental,
Ericson says, but there are strategies to overcome this resistance.
F E AT U R E S
■■ ST elevation (STEMI)
myocardial infarction
2
■■ Type 2 diabetes ■
mellitus with diabetic ■
ketoacidosis 2
■■ Use of radiology report
for coding/specifying
fractures
3
■■ ICD-10-PCS guidance
3
“Physicians need to become more comfortable with using the term ‘dependent’ for example long-term cancer patients dependent on opioids. Also, it
is helpful if you involve the pain management team. They’re more likely to
highlight that someone is on long-term medication,” she says. “It is always
helpful to interact with as many members of the healthcare umbrella as possible—they can become good advocates.”
Left atrial appendage thrombus
Coding Clinic for ICD-9-CM states to assign code I51.3 (Intracardiac thrombus, not elsewhere classified) for a left atrial appendage thrombus. This entry
highlights the need for a strong understanding of anatomy and physiology
in mastering ICD-10 coding.
“This demonstrates the continued need for the partnership between CDI
and coding, because CDI has clinical expertise to know that you wouldn’t
© 2013 HCPro, Inc.
­2 ICD-10 Codi ng Corner: Recap of Coding Cl inic, First Quarter 2013
June 2013
equate a thrombus in an atrial appendage to a cardiac type event that’s similar to a myocardial infarction [MI]. Coronary arteries aren’t the same as an
atrial appendage,” Ericson says.
If your hospital has an internal Internet firewall that doesn’t allow for
Internet use/search by employees, ask to have it disabled prior to the ICD-10
go-live date.
“If you search the Internet for left atrial appendage, you’ll see that it’s different from a left atrial thrombus,” Ericson says. “Staff members needs to have
access to electronic resources for anatomy to expedite code assignment.”
ST elevation myocardial infarction (STEMI)
In this entry, Coding Clinic states to assign I21.02, ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery, for an AMI
unspecified as either STEMI or non-STEMI of the left anterior descending
coronary artery (stated duration of four weeks or less). This piece of guidance
reinforces that STEMI—a more severe type of AMI—is the default for AMIs.
“If you look at the coding guidelines, you’ll see a hierarchy that STEMI
supersedes a non-STEMI,” Ericson explains. “If a patient starts out as nonSTEMI, and their heart attack progresses, you code to a STEMI. If they start
as STEMI, get TPA, and their blockage clears, you still code it as a STEMI.”
One problem with this default hierarchy is that the American Heart
Association runs a program called Mission: Lifeline®, which only tracks
STEMIs. If physicians don’t understand that the default AMI is a STEMI—in
other words, if they document “AMI” without specifying it as STEMI or nonSTEMI—it defaults to STEMI and skews the Mission: Lifeline data.
“You may have more Mission: Lifeline failures—coding will be picking up
more STEMIs than actually occurred,” Ericson says.
ICD-9 did not use STEMI vs. non-STEMI for coding purposes. In ICD-9,
everything was an AMI. In short, ask your physicians to clarify non-STEMIs
vs. STEMIs in ICD-10.
Type 2 diabetes mellitus with diabetic ketoacidosis
In this entry, Coding Clinic for ICD-9-CM states that a coder must assign
E13.10, Other specified diabetes mellitus with ketoacidosis without coma, for
a patient with type 2 diabetes with ketoacidosis. This advice highlights the
unfortunate shortcomings of the ICD-10 code set.
“Type 2 diabetes should be an E11 code, but ketoacidosis rarely occurs in
type 2 diabetes,” says Ericson, noting that MedlinePlus has a helpful reference for type 2 diabetes with ketoacidosis. “So we need to use an ‘Other
specified diabetes’ E13 code.”
© 2013 HCPro, Inc.
June 2013
ICD-10 Codi ng Corner: Recap of Coding Cli nic, Fi rst Quarter 2013 ­3
Coding Clinic for ICD-9-CM states that this issue will go before the ICD-10
Coordination and Maintenance Committee for reclassification in order that
patients with ketoacidosis can be properly identified.
Use of radiology report for coding/specifying fractures
This entry seems to be a welcome relief for coders (and CDI specialists) in that
it allows coders to assign a more specific fracture code based on documentation in a radiology report, rather than clarifying with the attending physician.
This was permitted in ICD-9-CM, but Coding Clinic for ICD-9-CM stated previously that ICD-9-CM guidance will not apply to ICD-10. In this case, it will.
Ericson anticipates the guidance could prove troublesome. The question
writer refers to “coding guidelines in ICD-10” rather than Coding Clinic for
ICD-9-CM. It is important to remember that Coding Clinic for ICD-9-CM
and the Official Guidelines for Coding and Reporting are different documents.
Ericson also wonders whether this advice is limited to radiology reports, or
whether it can be interpreted to include any diagnostic imaging.
“Right now Coding Clinic for ICD-9-CM just says radiology reports, but computed tomography [CT] scans of the head are done for stroke. It would be
nice to be able to extrapolate the exact location of the blockage from the CT,
and the affected artery,” she says. “Right now we don’t know if physicians
need to document to this level of specificity, or if we can get this detail from
the CT report.”
Ericson also wonders how Coding Clinic for ICD-9-CM considers laterality
(which is needed to code fractures and other procedures in ICD-10). For
example, is laterality part of the location, which has to be documented by the
provider, or is laterality considered specificity, in which case it could be taken
from radiological imaging?
“It may seem like I’m splitting hairs, but consider pressure ulcers. Can we
obtain laterality from other sources that are already allowed to define specificity, like wound care notes? Do you really want to have to query physicians
for laterality?” Ericson says.
ICD-10-PCS guidance
Organizations must decide whether their CDI specialists will review/clarify
procedures. Outside of debridement, CDI specialists typically do not review
operative procedures in ICD-9 because they don’t add a complication and
comorbidity (CC) or major CC (MCC). However, this issue of Coding Clinic
for ICD-9-CM reinforces the complexity of coding under PCS, which may
require CDI involvement.
“We don’t know how PCS will affect coder productivity, but it’s likely to have
a significant impact, much more than is being anticipated,” Ericson says.
© 2013 HCPro, Inc.
­4 ICD-10 Codi ng Corner: Recap of Coding Cl inic, First Quarter 2013
June 2013
“Organizations may want to consider hiring CDI staff with surgical experience to assist coding with querying and/or accurately assigning PCS codes.”
For example, Coding Clinic for ICD-9-CM states on p. 27 that a coder should
assign ICD-10-PCS code 031C0ZF (Bypass left radial artery to lower arm
vein, open approach) for creation of a left proximal radial artery fistula. The
question asks,“How does the coder know which direction the blood is flowing (‘from’ what body part, ‘to’ what body part)?”—which is needed in order
to correctly assign the 4th character of body part and the 7th character qualifier with the root operation bypass. A CDI specialist is more likely to know
this information, eliminating the need for a physician query.
The elements of a PCS code are intertwined. The first three characters (i.e.,
section, body system, and root operation) of a PCS code are necessary to
identify the correct table that will be used to assign the additional characters;
however, assignment of the root operation often depends on the possible
table values for body part and device.
“The problem is the root operation is dependent upon knowledge of the body
part and/or device, which forces you to work backwards,” Ericson says. “I can
see where it may be problematic to accurately assign a PCS code if the encoder
forces code assignment to proceed sequentially based on character order.”
This issue of clinical knowledge is further reinforced with Coding Clinic for
ICD-9-CM’s advice on p. 27 regarding ICD-10 code assignment for injection
of a sclerosing agent into an esophageal varix of the lower esophagus. The
correct code is 3E0G8TZ (Introduction of destructive agent into upper GI),
clarifying the use of “introduction” vs. “destruction.”
“This highlights that root operations will be a trial-and-error process. Again,
this is why you might want CDI with a surgical background, because a physician doesn’t have to use root operation terminology per ICD-10-PCS coding guidelines—they just have to describe the procedure as such that a root
operation can be correctly assigned,” Ericson says. “I think there will be a lot
of struggle with PCS—you can’t bill a procedure without all seven characters
and there are no default codes.
“Remember, coder productivity is expected to decrease under ICD-10-CM/
PCS, so the coding department may not have the resources to query for PCS
codes—so this job may default to CDI,” she adds. “Failing to assign a PCS
code significantly impacts reimbursement, as surgical DRGs are typically
paid at a higher rate compared to medical DRGs. Hospitals need to develop
an action plan to address PCS querying.”
06/13
This special report is published by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA 01923. • Copyright 2013 HCPro, Inc. All rights reserved. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance
Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872 or fax
­781-639-7857. • Opinions expressed are not necessarily those of the editors. Mention of products and services does not constitute endorsement. Advice given is general,
and readers should consult professional counsel for specific legal, ethical, or clinical questions. HCPro, Inc., is not affiliated in any way with The Joint Commission, which
owns the JCAHO and Joint Commission trademarks.
© 2013 HCPro, Inc.