Knowledge Base Category -

The Centers for Medicare and Medicaid Services (CMS) hosted a National Provider Call regarding the 2-Midnight Rule that went into effect on October 1, 2013 with the Fiscal Year (FY) 2014 IPPS Final Rule. For those of you that were unable to attend here is a run-down of 5 key takeaways from the session.

1. CMS is already planning future training sessions for Physician Orders/Certification and Transfers.
2. CMS has acknowledged that there could be times when an inpatient stay would still be appropriate even though an “unforeseen circumstance” occurs and the patient ultimately does not require a 2-Midnight or greater hospitalization. Specific examples from CMS have included patient death, transfer, leaving against medical advice (AMA) or the patient rapidly improving. New to this list is a patient that is admitted, documentation clearly supports a 2-Midnight expectation and the patient / family elect Hospice care and the patient is discharged home to hospice. Key to all of these “unforeseen circumstances” is that documentation in the record clearly supports the physician expectation of a 2-Midnight stay.
3. Effective December 1, 2013, the NUBC redefined Occurrence Span Code 72 to allow “Contiguous outpatient hospital services that preceded the inpatient admission” to be reported on inpatient claims. At this time this is a voluntary code but CMS encourages hospital to use this code.
4. Prior to opening the call up to questions and answers, CMS provided answers to two common questions that they had received prior to this call.
5. Q: How does level of care factor into the 2-Midnight Rule?
6. A: Under the 2014 IPPS Final Rule, the decision to admit is based on medical necessity of hospital care whether it is observation or inpatient care. If the answer is yes then the next question to ask is do you think this patient will be in the hospital for at least 2-Midnights?
7. Q: Can any elective surgeries be ok in Inpatient setting?
8. A: If there is an “unexpected circumstance” requiring 2-Midnights (i.e. a complication) then the stay would be appropriate as an Inpatient admission.
9. During the open Q&A session a question was asked regarding patients staying beyond 2-Midnights and whether or not a hospital would still be able to use InterQual® criteria. CMS responded by indicating that they believe hospitals will not use InterQual® or Milliman. They did go on to indicate that these screening tools could be used to help determine whether a patient should remain in the hospital or is safe for discharge.

The entire slide presentation from this call can be downloaded at http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2014-01-14-Midnight-Presentation.pdf

What do Probe Reviews, the start time for when the 2 midnight benchmark begin, Physician Documentation, automatic denials and Occurrence Span Code 72 have in common? All of these issues were addressed in the CMS Frequently Asked Questions (FAQs) December 23, 2013 update. Let’s break it down be each updated FAQ.

Q1.1: “Will CMS direct the Medicare review contractors to apply the 2-midnight presumption-that is, contractors should not select Medicare Part A inpatient claims for review if the inpatient stay spanned 2 midnights from the time of formal admission?”

• Yes, when a patient has been in your hospital for two midnights AFTER the inpatient order was written review contractors are to presume that the Medicare Part A inpatient admission was reasonable and necessary.
• New to this answer is that for inpatient admissions from October 1, 2013 through March 31, 2014 “CMS will not permit Recovery Auditors to conduct patient status reviews on inpatient claims with dates of admission between October 1, 2013 and March 31, 2014. These reviews will be disallowed permanently; that is, the Recovery Auditors will never be allowed to conduct patient status reviews for claims with dates of admission during that time period.”
• Caution: These same admissions CAN be reviewed for other issues (i.e. medical necessity of a surgical procedure or coding validation).

Q2.1: “Can CMS clarify when the 2 midnight benchmark begins for a claim selected for medical review, and how it incorporates outpatient time prior to admission in determining the general appropriateness of the inpatient admission?

• All time that a Medicare beneficiary is receiving outpatient services at the hospital will be considered in whether or not the 2-midnight benchmark was met.
• Note: “The Medicare review contractor will count only medically necessary services responsive to a beneficiary’s clinical presentation as performed by medical personnel.”
• Services to be included: observation services, treatments in the Emergency Department, and procedures provided in the operating room or other treatment area
• Services not to be included: treatment received in an outlying Emergency Department or in an ambulance en-route to your hospital.

Q4.1: “What documentation will Medicare review contractors expect physicians to provide to support that an expectation of a hospital stay spanning 2 or more midnights was reasonable?”

• Physician complex medical decision making: The expectation of a 2-midnight stay “must be supported by complex medical factors such as history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event.”
• Documentation: Medicare review contractors will expect the Physician’s decision making factors to be documented in the physician assessment and plan of care. “CMS does not anticipate that physicians will include a separate attestation of the expected length of stay, but rather that this information may be inferred from the physician’s standard medical documentation, such as his or her plan of care, treatment orders, and physician’s notes.”

Q4.9: “Under the new guidance, will all inpatient stays of less than 2 midnights after formal inpatient admission be automatically denied?”

• Medicare does anticipate that most stays less than 2 midnights would be as an outpatient. However, “because this is based upon the physician’s expectation, as opposed to a retroactive determination based on actual length of stay, we expect to see services payable under Part A in a number of instances for inpatient stays less than 2 total midnights after formal inpatient admission.”
• CMS has provided specific exceptions to the 2-midnight benchmark when inpatient would still be appropriate:
• Beneficiary death,
• Beneficiary transfer to another acute inpatient facility,
• Beneficiary leaving against medical advice (AMA),
• Beneficiary was admitted for a medically necessary service on the Inpatient-Only List,
• Mechanical ventilation initiated during the present visit (Note: is not intended to apply to anticipated intubations related to minor surgical procedures or other treatment),
• Or a Beneficiary unexpectedly improves and was discharged in less than 2 midnights.
• New to this answer: “Lastly, there may be rare and unusual cases where the physician did not expect a stay lasting 2 or more midnights but nonetheless believes inpatient admission was appropriate and documents such circumstance. The MACs are being instructed to deny these claims and to submit these records to CMS Central Office for further review. If CMS believes that such a stay warrants an inpatient admission, CMS will provide additional subregulatory instruction and the Part A contractors will review any claims that are subsequently submitted for payment in accordance with the most updated list of rare and unusual situations in which an inpatient admission of less than 2 midnights may be appropriate.”

Q5.2: “Is there a way for providers to identify any time the beneficiary spent as an outpatient prior to admission on the inpatient claim so that Medicare review contractors can readily identify that the 2-midnight benchmark was met without conducting complex review of claim.”

• “Effective December 1, 2013, Occurrence Span Code 72 was refined to allow hospitals to capture ‘contiguous outpatient hospital services that preceded the inpatient admission’ on inpatient claims.”
• For now, “Occurrence Span Code 72 is a voluntary code, but may be evaluated by CMS for medical review purposes.”

The entire FAQ download can be found at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/QuestionsandAnswersRelatingtoPatientStatusReviews_12232013_508Clean.pdf With the MAC Probe and Educate program just getting underway, you can expect there to be several additional updates to the FAQs.

For the I-10 Corner this week, we’re focusing on diagnostic coding guidelines, plus a few examples,for Chapter 9: Diseases of the Circulatory System (I00-I99)

Quick Tips:

• The types of hypertension (benign, malignant, accelerated, etc.) are all listed as modifiers in I-10. The Hypertension table has been deleted.
• Combination codes include Coronary Artery Disease (CAD) plus all types of Angina. These combination codes include native arteries as well as CAD of bypass graft(s).
• The time frame for Acute Myocardial Infarction (AMI) codes have changed from eight (8) weeks or less to four (4) weeks or less (within 28 days).
• Myocardial Infarction (MI) codes specify ST Elevation (STEMI) Myocardial Infarction, along with the site of the MI, or Non-ST (NSTEMI) Myocardial Infarction, in each descriptive heading.
• Atrial Fibrillation and Atrial Flutter can now be identified as paroxysmal, persistent, typical, atypical, and unspecified.
• For ambidextrous patients, the default should be dominant.
• If the left side is affected, the default is non-dominant.
• If the right side is affected, the default is dominant.

ICD-10-CM Coding Guidelines

9 .a. 1) Hypertension with heart disease

Heart conditions classified to I50.-I51.9, are assigned to a code from category I11, Hypertensive heart disease, when a causal relationship is stated (due to hypertension) or implied (hypertensive). Use an additional code from category I50, Heart failure, to identify the type of heart failure in those patients with heart failure.

The same heart conditions (I50.-, I51.9) with hypertension, but without a stated causal relationship, are coded separately. Sequence according to the circumstances of the admission/encounter.

9. a. 2) Hypertensive chronic kidney disease

Assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension and a condition, classifiable to category N18, Chronic kidney disease (CKD), are present. Unlike hypertension with heart disease, ICD-10-CM presumes a cause-and-effect relationship and classifies chronic kidney disease with hypertension as hypertensive chronic kidney disease.

The appropriate code from category N18 should be used as a secondary code with a code from category I12 to identify the stage of chronic kidney disease.

See Section I.C.14 Chronic kidney disease.

If a patient has hypertensive chronic kidney disease and acute renal failure, an additional code for the acute renal failure is required.

9. a. 3) Hypertensive heart and chronic kidney disease

Assign codes from combination category I13, Hypertensive heart and chronic kidney disease, when both hypertensive kidney disease and hypertensive heart disease are stated in the diagnosis. Assume a relationship between the hypertension and the chronic kidney disease, whether or not the condition is so designated. If heart failure is present, assign an additional code from category I50 to identify the type of heart failure.

The appropriate code from category N18, Chronic kidney disease, should be used as a secondary code with a code from category I13 to identify the stage of chronic kidney disease.

See Section I.C.14 Chronic kidney disease

The codes in category I13, Hypertensive heart and chronic kidney disease, are combination codes that include hypertension, heart disease and chronic kidney disease. The Includes note at I13 specifies that the conditions included at I11 and I12 are included together in I13. If a patient has hypertension, heart disease and chronic kidney disease, then a code from I13 should be used, not individual codes for hypertension, heart disease and chronic kidney disease, or codes from I11 or I12.

Example: CKD, stage 3, with CHF due to Hypertension is coded to I113.0 (Hypertensive heart and chronic kidney disease with CHF, Stage 3 CKD), I50.9 (Heart failure, unspecified), and N18.3 (CKD, Stage 3).

9. a. 4) Hypertensive cerebrovascular disease

For hypertensive cerebrovascular disease, first assign the appropriate code from categories I60-I69, followed by the appropriate hypertension code.

9. a. 5) Hypertensive retinopathy

Subcategory H35.0, Background retinopathy and retinal vascular changes, should be used with a code from category I10-I15, Hypertensive disease to include the systemic hypertension. The sequencing is based on the reason for the encounter.

9. a. 6) Hypertension, secondary

Secondary hypertension is due to an underlying condition. Two codes are required: one to identify the underlying etiology and one from category I14 to identify the hypertension. Sequencing of codes is determined by the reason for admission/encounter.

9. a. 7) Hypertension, transient

Assign code R03.0, Elevated blood pressure reading without diagnosis of hypertension, unless patient has an established diagnosis of hypertension. Assign code O13.-, Gestational [pregnancy-induced] hypertension without significant proteinuria, or O14.-, Pre-eclampsia, for transient hypertension of pregnancy.

9. a. 8) Hypertension, controlled

This diagnostic statement usually refers to an existing state of hypertension under control by therapy. Assign the appropriate code from categories I10-I15, Hypertensive diseases.

9. a. 9) Hypertension, uncontrolled

Uncontrolled hypertension may refer to untreated hypertension or hypertension not responding to current therapeutic regimen. In either case, assign the appropriate code from categories I10-I15, Hypertensive diseases.

9. b. Atherosclerotic coronary artery disease and angina

I-10 has combination codes for atherosclerotic heart disease with angina pectoris. The subcategories for these codes are I25.11, Atherosclerotic heart disease of native coronary artery with angina pectoris and I25.7, Atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris.

When using one of these combination codes it is not necessary to use an additional code for angina pectoris. A causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris, unless the documentation indicates the angina is due to something other than the atherosclerosis.

Example: A patient is diagnosed with CAD and Angina with no previous history of a CABG. The correct code is I25.19 (ASHD of Native Coronary Artery with other forms of Angina Pectoris).

If a patient with coronary artery disease is admitted due to an AMI, the AMI should be sequenced before the coronary artery disease.

See Section I.C.9. Acute myocardial infarction (AMI)

9. c. Intraoperative and post-procedural cerebrovascular accident

Medical record documentation should clearly specify the cause-and-effect relationship between the medical intervention and the cerebrovascular accident in order to assign a code for intraoperative or post-procedural cerebrovascular accident.

Proper code assignment depends on whether it was an infarction or hemorrhage and whether it occurred intraoperatively or postoperatively. If it was a cerebral hemorrhage, code assignment depends on the type of procedure performed.

9. d. 1(Category I69, sequelae of cerebrovascular disease

Category I69 is used to indicate conditions classifiable to categories I60-I67 as the causes of sequel (neurologic deficits), they themselves classified elsewhere. These “late effects” include neurologic deficits that persist after initial onset of conditions classifiable to categories I60-I67. The neurologic deficits caused by cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition classifiable to categories I60-I67.

Codes from category I69, Sequelae of cerebrovascular disease, that specify hemiplegia, hemiparesis and monoplegia identify whether the dominant or nondominant side is affected. Should the affected side be documented, but not specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows:

9. d. 2) Codes from category I69 with codes from I60-I67

Codes from category I69 may be assigned on a health care record with codes from I60-I67, if the patient has a current cerebrovascular disease and deficits from an old cerebrovascular disease.

9. d. 3) Codes from category I69 and Personal history of transient ischemic attack (TIA) and cerebral infarction (Z86.73)

Codes from category I69 should not be assigned if the patient does not have neurologic deficits.

See Section I.C.21.4 History (of) for use of personal history codes

9. e. 1) Acute myocardial infarction (AMI) --ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI)

The ICD-10-CM codes for AMI identify the site, such as anterolateral wall or true posterior wall. Subcategories I21.0-I21.2 and code I21.3 are used for STEMI. Code I21.4, NSTEMI myocardial infarction, is used for NSTEMI and nontransmural MIs.

If NSTEMI evolves to STEMI, assign the STEMI code. If STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as STEMI.

For encounters occurring while the myocardial infarction is equal to, or less than, four weeks old, including transfers to another acute setting or a post-acute setting, and the patient requires continued care for the myocardial infarction, codes from category I21 may continue to be reported. For encounters after the 4 week time frame and the patient is still receiving care related to the MI, the appropriate aftercare code should be assigned, rather than a code from category I21. For old or healed MIs not requiring further care, code I25.2, Old myocardial infarction, may be assigned.

9. e. 2) Acute myocardial Infarction, unspecified

Code I21.3, STEMI of unspecified site, is the default for the unspecified term acute myocardial infarction. If only STEMI or transmural MI without the site is documented, query the provider as to the site, or assign code I21.3.

9. e. 3) AMI documented as nontransmural or subendocardial but site provided

If an AMI is documented as nontransmural or subendocardial, but the site is provided, it is still coded as a subendocardial AMI.

See Section I.C.21.3 for information on coding status post administration of tPA in a different facility within the last 24 hours.

9. e. 4) Subsequent acute myocardial infarction

A code from category I22, Subsequent STEMI and NSTEMI, is to be used when a patient who has suffered an AMI has a new AMI within the 4 week time frame of the initial AMI. A code from category I22 must be used in conjunction with a code from category I21. The sequencing of the I22 and I21 codes depends on the circumstances of the encounter.

Example: A patient is being treated for an Acute Non-ST Anterior Wall MI which she suffered 5 days ago. The patient also has Atrial Fibrillation. The correct diagnoses are: I21.4 (Non-ST Elevation (NSTEMI) Myocardial Infarction) and I48.91 (Unspecified Atrial Fib).

The next I-10 corner will be featured around a PCS discussion for Chapter 9: Diseases of the Circulatory System (I00-I99)

 

In the last I-10 Corner article we covered Part One of Musculoskeletal System in ICD-10-CM. For this week, Part Two will address the procedures for the Musculoskeletal System. For the PCS portion, we will cover some key points and guidelines that are necessary for you to assign the correct ICD-10-PCS codes.

For those of you who attended AHIMA’s ICD-10-CM/PCS training classes you already know the underlying meaning of the title. In ICD-10-PCS, this sentence helps us to identify the names of the seven characters and what they represent for a code in PCS. Notice below the sharp contrast between ICD-9 and ICD-10-PCS for a left total knee replacement:

ICD-9-CM: Total Knee Replacement, 81.54

ICD-10-PCS: Left Total Knee Replacement, with insertion of total knee prosthesis 0SRD0JZ

‍ICD-10-PCS for the Musculoskeletal System – Part 2

11 of the 31 Body Systems pertain to the MS System                  

• Muscles
• Tendons
• Bursae and Ligaments
• Head and facial bones
• Upper bones
• Lower bones
• Upper joints
• Lower joints
• Anatomical regions general
• Anatomical regions upper extremities
• Anatomical regions lower extremities Example of Root Operation Groups typically seen with Chapter 13
• Excision – Biopsy of muscle
• Detachment – Below knee amputation
• Division - Osteotomy
• Release – Carpal tunnel release
• Reattachment – Reattachment of hand
• Reposition – Fracture reduction
• Transfer – Tendon transfer
• Replacement – Total hip replacement
• Supplement – Placing a new acetabular liner in a previous hip replacement
• Revision – Re-cementing hip prosthesis
• Fusion – Spinal fusion
• Inspection – Diagnostic Arthroscopy
• laterality
• type and material the device is made of, i.e., synthetic substitute or autologous tissue substitute
• specific surface replaced in partial hip and knee replacements
• cemented vs. un-cemented

 

Arthroplasty of Hip and Knee

Often, the hip bearing surface was not known and was not reported. In ICD-10-PCS, you must know the type of surface for arthroplasty of the hips and knees in order to assign the correct procedure code.

You need to know:

• laterality
• type and material the device is made of, i.e., synthetic substitute or autologous tissue substitute
• specific surface replaced in partial hip and knee replacements
• cemented vs. un-cemented

ICD-10-PCS Coding Guideline

Conventions

A11

Many of the terms used to construct PCS codes are defined within the system. It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear.

Example: When the physician documents “partial resection” the coder can independently correlate “partial resection” to the root operation Excision without querying the physician for clarification.

B3. Root Operation

Overlapping Body Layers

B3.5

If the root operations Excision, Repair or Inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded.

Example: Excisional debridement that includes skin and subcutaneous tissue and       muscle is coded to the muscle body part.

Fusion Procedures of the Spine

B3.10a

The body part coded for a spinal vertebral joint(s) rendered immobile by a spinal fusion procedure is classified by the level of the spine (e.g. thoracic). There are distinct body part values for a single vertebral joint and for multiple vertebral joints at each spinal level.

Example: Body part values specify Lumbar Vertebral Joint, Lumbar Vertebral Joints, 2 or More and Lumbosacral Vertebral Joint.

B3.10b

If multiple vertebral joints are fused, a separate procedure is coded for each vertebral joint that uses a different device and/or qualifier.

Example: Fusion of lumbar vertebral joint, posterior approach, anterior column and fusion of lumbar vertebral joint, posterior approach, posterior column are coded separately.

B3.10c

Combinations of devices and materials are often used on a vertebral joint to render the joint immobile. When combinations of devices are used on the same vertebral joint, the device value coded for the procedure is as follows:

• If an interbody fusion device is used to render the joint immobile (alone or containing other material like bone graft), the procedure is coded with the device value Interbody Fusion Device
• If bone graft is the only device used to render the joint immobile, the procedure is coded with the device value Nonautologous Tissue Substitute or Autologous Tissue Substitute
• If a mixture of autologous and nonautologous bone graft (with or without biological or synthetic extenders or binders) is used to render the joint immobile, code the procedure with the device value Autologous Tissue Substitute

Examples: Fusion of a vertebral joint using a cage style interbody fusion device containing morsellized bone graft is coded to the device Interbody Fusion Device.

Fusion of a vertebral joint using a bone dowel interbody fusion device made of cadaver bone and packed with a mixture of local morsellized bone and demineralized bone matrix is coded to the device Interbody Fusion Device.

Fusion of a vertebral joint using both autologous bone graft and bone bank bone graft is coded to the device Autologous Tissue Substitute.

Release procedures

B3.13

In the root operation Release, the body part value coded is the body part being freed and not the tissue being manipulated or cut to free the body part.

Example:         Lysis of intestinal adhesions is coded to the specific intestine body part value.

Release vs. Division

B3.14

If the sole objective of the procedure is freeing a body part without cutting the body part, the root operation is Release. If the sole objective of the procedure is separating or transecting a body part, the root operation is Division.

Examples: Freeing a nerve root from surrounding scar tissue to relieve pain is coded to the root operation Release. Severing a nerve root to relieve pain is coded to the root operation Division.

B4. Body Part

Branches of body parts

B4.2

Where a specific branch of a body part does not have its own body part value in PCS, the body part is coded to the closest proximal branch that has a specific body part value.

Example: A procedure performed on the popliteus tendon is coded to the lower leg tendon body part.

Tendons, ligaments, bursae and fascia near a joint

B4.5

Procedures performed on tendons, ligaments, bursae and fascia supporting a joint are coded to the body part in the respective body system that is the focus of the procedure. Procedures performed on joint structures themselves are coded to the body part in the joint body systems.

Example: Repair of the anterior cruciate ligament of the knee is coded to the knee bursae and ligament body part in the bursae and ligaments body system.

Knee arthroscopy with shaving of articular cartilage is coded to the knee joint body part in the Lower Joints body system.

Skin, subcutaneous tissue and fascia overlying a joint

B4.6

If a procedure is performed on the skin, subcutaneous tissue or fascia overlying a joint, the procedure is coded to the following body part:

• Shoulder is coded to Upper Arm
• Elbow is coded to Lower Arm
• Wrist is coded to Lower Arm
• Hip is coded to Upper Leg
• Knee is coded to Lower Leg
• Ankle is coded to Foot

Fingers and toes

B4.7

If a body system does not contain a separate body part value for fingers, procedures performed on the fingers are coded to the body part value for the hand. If a body system does not contain a separate body part value for toes, procedures performed on the toes are coded to the body part value for the foot.

Example: Excision of finger muscle is coded to one of the hand muscle body part values in the Muscles body system.

ICD-10-CM Chapter 13 Musculoskeletal System – Part 1
In the last I-10 Corner article we covered Infectious and Parasitic Diseases. Our next chapter to review is the Musculoskeletal System which we will cover in two parts. Part one will cover ICD-10-CM and Part two will address ICD-10-PCS. In ICD-10-CM, we will highlight some changes we thought were important for you to be aware of. For instance, The Musculoskeletal System chapter received numerous code expansions partly due to ‘laterality’ being required for code assignment.

Example: Right Medial Epicondylitis

First, take a look below and see how the subchapters or blocks have expanded.

This chapter contains the following blocks:

M00-M02        Infectious Arthropathies

M05-M14        Inflammatory Polyarthropathies

M15-M19        Osteoarthritis

M20-M25        Other Joint Disorders

M26-M27        Dentofacial Anomalies [including malocclusion] and Other Disorders of Jaw

M30-M36        Systemic Connective Tissue Disorders

M40-M43        Deforming Dorsopathies

M45-M49        Spondylopathies

M50-M54        Other Dorsopathies

M60-M63        Disorders of Muscles

M65-M67        Disorders of Synovium and Tendon

M70-M79        Other Soft Tissue Disorders   

M80-M85        Disorders of Bone Density and Structure

M86-M90        Other Osteopathies

M91-M94        Chondropathies

New in Chapter 13

• Big code expansion in this chapter to identify type, site and laterality
• Clarifications for coding joint vs. specific affected bone (see coding guideline)
• Acute traumatic vs. chronic/recurrent conditions are defined with coding instructions
• Osteoporosis and Pathological Fracture information now included in ICD-10-CM Coding Guidelines
• Many codes relocated from other chapters in ICD-9-CM, i.e., Gout, Osteomalacia and Malocclusion
• Lots of other instructions such as:
• Use an external cause code
• Code first underlying disease
• Code also any associated underlying condition
• Use additional code to identify
• Code first poisoning due to drug or toxin
• Code first underlying neoplasm
• Use additional code to identify infectious agent
• Instructions for coding pathological fractures, needs 7th digit extension to identify episode of care (see below)
  Example:
  A Initial encounter for fracture
  D Subsequent encounter for fracture with routine healing
  G Subsequent encounter for fracture with delayed healing
  K Subsequent encounter for fracture with nonunion
  P Subsequent encounter for fracture with Malunion
  S Sequela
• Intraoperative and Postprocedural Complications of the Musculoskeletal System located within this chapter
• Acute traumatic fractures reassigned to Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes

ICD-10-CM Coding Guidelines

1. Site and laterality
   Most of the codes within Chapter 13 have site and laterality designations. The site represents the bone, joint or the muscle involved. For some conditions where more than one bone, joint or muscle is usually involved, such as osteoarthritis, there is a “multiple sites” code available. For categories where no multiple site code is provided and more than one bone, joint or muscle is involved, multiple codes should be used to indicate the different sites involved.
2. Bone versus joint
   For certain conditions, the bone may be affected at the upper or lower end, (e.g., avascular necrosis of bone, M87, Osteoporosis, M80, M81). Though the portion of the bone affected may be at the joint, the site designation will be the bone, not the joint.
3. Acute traumatic versus chronic or recurrent musculoskeletal conditions
   Many musculoskeletal conditions are a result of previous injury or trauma to a site, or are recurrent conditions. Bone, joint or muscle conditions that are the result of a healed injury are usually found in chapter 13. Recurrent bone, joint or muscle conditions are also usually found in chapter 13. Any current, acute injury should be coded to the appropriate injury code from chapter 19. Chronic or recurrent conditions should generally be coded with a code from chapter 13. If it is difficult to determine from the documentation in the record which code is best to describe a condition, query the provider.
4. Coding of Pathologic Fractures
   Seventh (7th) character A is for use as long as the patient is receiving active treatment for the fracture. Examples of active treatment are: surgical treatment, emergency department encounter, evaluation and treatment by a new physician. Seventh (7th) character D is to be used for encounters after the patient has completed active treatment. The other 7th characters, listed under each subcategory in the Tabular List, are to be used for subsequent encounters for treatment of problems associated with the healing, such as malunions, nonunions, and sequelae.
   Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes.
   See Section I.C.19. Coding of traumatic fractures.
5. Osteoporosis
   Osteoporosis is a systemic condition, meaning that all bones of the musculoskeletal system are affected. Therefore, site is not a component of the codes under category M81, Osteoporosis without current pathological fracture. The site codes under category M80, Osteoporosis with current pathological fracture, identify the site of the fracture, not the osteoporosis.
6. Osteoporosis without current pathological fracture
   Category M81, Osteoporosis without current pathological fracture, is for use for patients with osteoporosis who do not currently have a pathologic fracture due to the osteoporosis, even if they have had a fracture in the past. For patients with a history of osteoporosis fractures, status code Z87.310, Personal history of (healed) osteoporosis fracture, should follow the code from M81.
7. Osteoporosis with current pathological fracture
   Category M80, Osteoporosis with current pathological fracture, is for patients who have a current pathologic fracture at the time of an encounter. The codes under M80 identify the site of the fracture. A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.

Musculoskeletal System examples of why you need to brush up on your Anatomy and Physiology

Infectious Arthropathy - may also be referred to as Pyogenic or Septic Arthritis. Organisms invade the joint by:

• direct infection of joint; example: infected surgical hip wound
• indirect contamination; infection in bloodstream

Enteropathic Arthropathy - diseases of joints linked to gastrointestinal tract inflammation such as Inflammatory Bowel Disease or Crohn’s Disease.

Palindromic Rheumatism - is a sudden onset of inflammation in one or several joints. Lasts a few hours to a few days and is suddenly gone.

Dorsopathies - is a general term referring to conditions affecting the back or spine. Conditions such as Scoliosis, Spondylosis and Intervertebral disc disorders are included here.

Fragility Fracture -sustained with trauma no more than a fall from a standing height or less that occurs under circumstances that would not cause a fracture in a normal healthy bone.

Skeletal Fluorosis - this is excessive intake of fluoride causing the bones to become hardened and vulnerable to fractures.

In closing, the more you study this chapter the less you will feel overwhelmed. Once you do this, you will become familiar with the clinical information so that you can educate your physicians of what is required for more specific documentation.

Don’t forget to consult Coding Clinic for ICD-10-CM/PCS information!

Methicillin-resistent Staphylococcus Aureus (MRSA) Infection

MRSA is a very tough to treat infection caused by a strain of staph bacteria that has become resistant to commonly used antibiotics generally used to treat ordinary staph infections.

• Can be life threatening.
• MRSA infection can be contagious by:
• Person-to-person / skin-to-skin contact.
• Coming in contact with materials or surfaces touched by a MRSA infected person or carrier

• A “carrier” is a person that that harbors the organism (MRSA) without manifesting symptoms of the infection.
• A carrier (Z22.322) can transmit the MRSA infection.
• Requires “isolation” while being treated.
• Typically causes skin sores and infections such as:
• Abscess
• Boils
• Stys
• Ulcers
• Cellulitis
• Impetigo
• Carbuncles
• MRSA can quickly spread once the germ has entered into the body.
• Bones
• Joints
• Bloodstream (Sepsis - )
• Muscle, Fascia (Necrotizing Fasciitis)
• Organs
• Brain (Meningitis)
• Heart (Endocarditis)
• Lungs (Pneumonia)
• Kidneys (UTI associated with Foley Catheter)

Health Care-Associated MRSA (HA-MRSA)

• Affects people who have been treated in a health-care facility such as:
• Hospitals
• Nursing Homes
• Rehab facilities
• Dialysis center
• Physician’s office
• Commonly seen in patients with:
• Weakened immune system from:
• Illness
• Long term medication therapy
• Cancer treatment
• Surgical history within a year
• Lengthy admissions to hospitals and/or long-term care facilities
• Chronic Kidney Disease on hemodialysis
• History of IV drug use

Community-Associated MRSA (CA_MRSA)

• MRSA showing up in healthy people outside of a health care setting
• Healthy people who may also be at risk:
• Military
• Children at day-care
• Athletes
• Prison inmates
• People who share items such as towels and razors
• People who have gotten tattoos and/or piercings

Signs and Symptoms

• Non-healing wound
• Headache
• Fatigue
• Rash
• Fever and chills
• Low blood pressure
• Shortness of breath
• Chest pain
• Weakness

Treatment

MRSA is resistant to some antibiotics but is still a treatable condition. There are some kinds of antibiotics that still work.

• Treatment often starts with Bactrim and Vancomycin.
• Other antibiotics used are:
• Clindamycin
• Minocycline
• Tygacil
• Cubicin
• Zyvox
• Synercid
• Unfortunately, even with these medications, there is emerging antibiotic resistance developing.
• Antibiotics are not always necessary.
• With early detection, in cases of a skin abscess or boil caused by MRSA, an incision and drainage may be all that is necessary.

Selection and Sequencing of MRSA Codes

Coding Guidelines:

• Section I.C.1.e.1.a. – Combination Codes for MRSA Infection:   When a patient is diagnosed with an infection that is due to Methicillin Resistant Staphylococcus Aureus (MRSA), and that infection has a combination code that includes the causal organism (e.g., Sepsis, Pneumonia) assign the appropriate combination code for the condition (e.g., code A41.02, Sepsis due to Methicillin Resistant Staphylococcus Aureus or code J15.212, Pneumonia due to Methicillin Resistant Staphylococcus Aureus). Do not assign code B95.62, Methicillin Resistant Staphylococcus Aureus Infection as the cause of diseases classified elsewhere, as an additional code because the combination code includes the type of infection and the MRSA organism. Do not assign a code from subcategory Z16.11, Resistance to Penicillins, as an additional diagnosis.
• Section I.C.1.e.1.b. – Other Codes for MRSA Infection:   When there is documentation of a current infection (e.g., wound infection, stitch abscess, urinary tract infection) due to MRSA, and that infection does not have a combination code that includes the causal organism, assign the appropriate code to identify the condition along with code B95.62, Methicillin Resistant Staphylococcus Aureus Infection as the cause of diseases classified elsewhere for the MRSA infection. Do not assign a code from subcategory Z16.11, Resistance to Penicillins.
• Section I.C.e.1.c. – Methicillin Susceptible Staphylococcus Aureus (MSSA) and MRSA Colonization:   The condition or state of being colonized or carrying MSSA or MRSA is called colonization or carriage, while an individual person is described as being colonized or being a carrier. Colonization means that MSSA or MRSA is present on or in the body without necessarily causing illness. A positive “MRSA screen positive” or “MRSA nasal swab positive”.
• Assign code Z22.322, Carrier or suspected carrier of Methicillin Resistant Staphylococcus Aureus, for patients documented as having MRSA colonization. Assign code Z22.321, Carrier or suspected carrier of Methicillin Susceptible Staphylococcus Aureus, for patient documented as having MSSA colonization. Colonization is not necessarily indicative of a disease process or as the cause of a specific condition the patient may have unless documented as such by the provider.

• Section I.C.1.e.1.d. – MRSA Colonization and Infection:   If a patient is documented as having both MRSA colonization and infection during a hospital admission, code Z22.322, Carrier or suspected carrier of Methicillin Resistant Staphylococcus Aureus, and a code for the MRSA infection may both be assigned.

Methicillin-susceptible Staphylococcus Aureus (MSSA) Infection

Another commonly known infection caused by the staph bacteria is Methicillin-susceptible Staphylococcus Aureus (MSSA). MSSA is able to be treated with most penicillin based antibiotics and has yet become resistant to the more common antibiotics enabling the treatment to be cleared up easier than it would be if it was resistant in the case of MRSA.

MSSA can be as serious as MRSA. Signs and symptoms are the same.

The implementation date of ICD-10-CM/PCS is fast approaching. ICD-10-CM/PCS will require coders to possess an in-depth knowledge and understanding of anatomy & physiology and pathophysiology.   Coders’, who are well-versed on how a body in both the healthy state as well as during the disease process should function, will be better prepared to query providers for clarification when additional documentation is required.  In turn, a coder will be able to make appropriate correlations when reviewing documentation and be able to avoid needless queries.

 

This month MMP will focus on some of the important changes and guidelines covering Chapter One “Certain Infectious and Parasitic Diseases”.

Chapter 1 is divided into 22 separate blocks covering two alpha characters A00-B99 and includes:

• Diseases generally recognized as communicable or transmissible as well as a few diseases of unknown but possibly infectious origin.

Type I Excludes:

• Certain localized infections – refer to body system related chapters.
• Influenza and other acute respiratory infections (J00-J22)

Type 2 Excludes:

• Carrier or suspected carrier of infectious disease (Z22.-)

A separate subchapter was created for “Infections with a Predominantly Sexual Mode of Transmission” (A50-A64) to appropriately group these type diseases together:

• Human Immunodeficiency Virus (HIV) is excluded in this range of codes.

For cases with infections shown to have an associated drug resistance, code Z16 should be assigned in addition to the infection code to show the associated drug resistance.                      

• Coding Guideline I.C 1.c. – Infections Resistant to Antibiotics:  Many bacterial infections are resistant to current antibiotics. It is necessary to identify all infections documented as antibiotic resistant.

Streptococcal Sore Throat has been relocated from Chapter 1 to Chapter 10 – Diseases of the Respiratory System.

Tuberculosis (TB):  

• ICD-10-CM will not ask for information denoting how the disease was identified.
• The codes for Tuberculosis have been restructured and consolidated. Assignment is now based on anatomical site or type.

Intestinal Infections:

• Codes will now identify type of infection.
• Viral
• Bacterial
• Fungal or parasitic/amebic
• Options available for “Other “ and “Unspecified”

Categories B95.0-B99.9 are supplementary codes to identify the infectious agent(s) in diseases classified elsewhere in which there is no organism identified as part of the infection code.

• Refer to Coding Guideline I.C.1.b.

Human Immunodeficiency Virus (HIV) Infections

HIV is the virus that can lead to AIDS (Acquired Immunodeficiency Syndrome).   People with this illness are much more vulnerable to infections due to the attack and alteration to their immune system. This is prone to get worse as the disease progresses. The human body is not capable of fighting off this virus. Once a person is infected with HIV, it is an affliction for the rest of their life.

HIV is found in the body fluids of an infected person and can be transmitted:

• From one person to another through blood-to-blood and/or sexual contact.
• Newborn infants can acquire HIV:
• During pregnancy
• Through delivery
• Through breast feeding
• Blood transfusion
• Sharing hypodermic needles

There is a subcategory and four codes to classify the HIV virus in ICD-10-CM.

B20 - Human Immunodeficiency Virus (HIV) disease

Assign code B20 as the principal diagnosis when a patient is admitted with an HIV-related condition. An additional diagnosis code should be used to identify all reported manifestations of HIV infection.

• Refer to Coding Guideline I.C.1.a.2.a.
• Code only confirmed cases of HIV infection.
• Confirmation does not require a positive serology or culture for HIV. The physician’s diagnostic statement is sufficient.
• Refer to Coding Guideline I.C. 1.a.1.
• People with HIV can acquire many infections that are called “Opportunistic Infections” or OIs.

Includes:

• Acquired Immune Deficiency Syndrome (AIDS)
• AIDS-related Complex (ARC)
• HIV Infection, Symptomatic

Excludes Type 1:

• Asymptomatic Human Immunodeficiency Virus (HIV) Infection Status (Z21)
• Exposure to HIV virus (Z20.6)
• Inconclusive Serologic Evidence of HIV (R75)

Z21 - Asymptomatic Human Immunodeficiency Virus (HIV) Infection Status

Code Z21 is used for reporting a patient diagnosed with a positive HIV status but has never been diagnosed with any type of manifestation or OI.

• Includes HIV positive NOS
• Once a patient has developed an HIV-related OI, the patient should always be assigned code B20 for any future admission/encounter.
• Code Z21 should never be assigned again for a patient diagnosed with HIV/AIDS even if there is no infection or HIV related condition during that present admission.
• Codes B20 and Z21 should never be assigned together during the same admission.

R75 - Inconclusive laboratory evidence of Human Immunodeficiency Virus (HIV)

• An inconclusive serology test, but no definitive diagnosis or manifestation of the HIV infection.

Z20.6 - Exposure to HIV Virus

This code is assigned only when a patient has been exposed or may have come in contact with the HIV virus.

Some Common HIV Infections:   (this list is not all or inclusive)

• Pneumocystis pneumonia (PCP) - Serious infection which causes inflammation and fluid buildup in the lungs.
• Cytomegalovirus - An opportunistic infection which takes advantage of a patient’s weakened immune system.
• Tuberculosis (TB) - Leading cause of death for people infected with HIV.
• Mycobacterium Avium Complex (MAC) - Usually happens only after a patient has been diagnosed with AIDS and when their CD4 cell counts drop below 50.
• Dementia - AIDS dementia is caused by the HIV virus itself, not by the opportunistic infections.
• AIDS Wasting Syndrome - Occurs when a patient with AIDS has lost at least 10% of their body weight -- especially muscle. The patient could experience at least 30 days of diarrhea, extreme weakness and fever that's not related to an infection.
• Non-Hodgkin’s Lymphoma - As a result of a weakened immune system, a patient is prone to develop certain cancers.
• Lipodystrophy - Also known as “fat redistribution”.   This is when the body has problems in the way it produces, uses, and stores fat.
• Kaposi’s Sarcoma (KS) - Type of cancer affecting mainly the skin, mouth, and lymph nodes (infection-fighting glands). Other organs such as the lungs and gastrointestinal tract can be affected as well.

A list of Meds currently available in the US

‍Note: When coding the HIV Disease and Sepsis, it is very important to read and familiarize yourself with the Coding Guidelines. 

We are now into the second day of the Centers for Medicare and Medicaid Services (CMS) 2014 Fiscal Year. For those that were unable to listen to the CMS Special Open Door Forum (ODF) this past Thursday September 26th, CMS appeared to have heard and has responded to the medical community’s concerns around the education and implementation of the new 2-Midnight Benchmark for inpatient admissions and the Physician Certification of all inpatient admissions.

Clarification of CMS Inpatient Hospital Policy, Why Now?

On the same day as the ODF, CMS also released a letter to the American Hospital Association (AHA). In both this letter and during the ODF, CMS indicated that they have been facing “pressures” that include:

• “An increase in the average length of observation stays;
• An increase in the Comprehensive Error Rate Testing (CERT) error rate for short inpatient stays;
• An increase in the number of inpatient appeals; and
• Requests from the hospital industry requesting clarification on inpatient review policy.”

The two year conversation around these “pressures” between CMS and the hospital industry are what prompted the implementation of the 2-Midnight Benchmark and Physician Certification process. CMS announced that the next three months (October 1, 2013 – December 13, 2013) will be a transition period where they will monitor the impact of the changes to ensure that they result in the best interest for Medicare beneficiaries. Further, they announced a New Probe and Education Program.

New Probe and Education Program

This new program will begin with dates of admission on or after October 1, 2013 through December 31, 2013. Specific instructions for Contractors include the following:

• Medicare Administrative Contractors (MACs)
• MACs will shift their pre-payment focus to admissions on or after October 1st through December 31st with “0” or “1” midnight lengths of stay.
• The focus of these reviews will be to “determine the medical necessity of the patient status in accordance with the two midnight benchmark.”
• The Pre-payment Probe limit has been set at 10-25 claims per hospital.
• If a MAC completes a probe and finds no issues they will “cease further such reviews for that hospital from October – December 2013, unless there are significant changes in billing patterns for admissions.”
• If a MAC does identify issues, education will be provided to the hospital and then the MAC will conduct further follow-up as necessary.
• Since these will be pre-payment reviews, a hospital could re-bill any denied claims in accordance with the Part A to Part B rebilling Final Rule.
• MACs will use their review findings to determine a hospital’s compliance with the new inpatient rules and provide feedback to CMS for development of joint education and guidance.

• Recovery Auditors (RAs)
• During this same 90 days, “CMS will not permit Recovery Auditors to review inpatient admissions of one midnight or less that begin on or after October 1, 2013.”
• The RA Pre-payment Demonstration will be suspended during the 90 day period for the 11 states that are participating in this demonstration (FL, CA, MI, TX, NY, LA, IL, PA, OH, NC, and MO).
• RAs will continue pre-payment reviews for Therapy Caps.

• Caution:
• CMS reminds providers that “physicians should make inpatient admission decisions in accordance with the 2 midnight provisions in the final rule. If at any time there is evidence of systematic gaming, abuse or delays in the provision of care in an attempt to surpass the 2-midnight presumption could warrant medical review.”
• During this transition period MACs can continue to perform coding validation reviews.
• The CERT contractor, Zone Program Integrity Contractors (ZPICs), Office of Inspector General (OIG), etc. are not limited by this 90 day time period and can continue to pick any claims for review.
• Contractor reviews specifically supporting the medical necessity of a surgery (i.e. total knee replacement) and correct coding reviews can continue during this time.

Dress Rehearsal

Moving forward, CMS has set up an Inpatient Hospital Reviews webpage on their website under Medical Review and Education and encourages hospitals to check this site frequently for updates.

Hospitals should take this time to use the next three months as a dress rehearsal to continue with staff education, proceed with your plans to be compliant with the 2-Midnight Benchmark and develop processes to ensure completion of the Physician Certifications prior to beneficiaries being discharged.

2014 IPPS Final Rule Resources:

Link to the Final Rule:  http://www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf

Link to September 5, 2013 Guidance - Hospital Inpatient Admission Order and Certification:  http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-09-05-13.pdf

Link to MLN Matters: SE1333 – Temporary Instructions for Implementation of Final Rule 1599-F for Part A to Part B Billing of Denied Hospital Inpatient Claims

 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1333.pdf

Link to CMS Open Door Forums webpage:  http://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/ODFSpecialODF.html

‍

Hospitals are facing significant changes with the implementation of the 2014 IPPS Final Rule. Beyond medical necessity guidance, physician certification and recertification for a Part A inpatient admission and the Part A to Part B rebilling, the National Uniform Billing Committee (NUBC) developed and approved new discharge status codes that were finalized for use in the Final Rule.

An interesting twist is that these codes are to be used specifically for DRG 280 (Acute Myocardial Infarction, Discharged Alive with MCC), DRG 281 (Acute Myocardial Infarction, Discharged Alive with CC), DRG 282 (Acute Myocardial Infarction, Discharged Alive without CC/MCC) and DRG 789 (Neonates, Died or Transferred to Another Acute Care Facility).

DRGs 280, 281 and 282:

The finalized rule added one new code for this DRG group.

• New Code: 69 - Discharged/transferred to a designated disaster alternative care site
• Purpose: “Is to identify those patients diagnosed with an acute myocardial infarction (AMI) who were discharged/transferred to a designated disaster alternative care site alive.”
• Final Rule Comments: Most people that commented on this proposal were supportive of adding this new code and anticipate that it will be used infrequently.

The 15 remaining discharge status codes were proposed and finalized to identify planned readmissions after an AMI index admission. The new codes will replace codes already in place. In response to a comment CMS clarified that “at this time, these new discharge status codes are not related in any way to the Hospital Readmission Reduction Program and will not be taken into account in the readmission measures for that program.” The following table is a crosswalk from the current code to the new code. (This table can be found in the Final Rule on pages 50533 – 50534).

‍DRG 789:

Three new discharge status codes have been added to this DRG “to identify neonates that are transferred to a designated facility with a planned acute care hospital inpatient readmission.” The new codes can be found on page 50538 of the final rule and include:

Suggestions to prepare for the new discharge status codes:

• Work with your IT Department to ensure that your systems have been updated to reflect these changes,
• Provide physician education to help ensure that there is clear documentation in the Index admission that he/she is planning on readmitting the patient; and
• Educate HIM and Case Management staff.

The Medicare Hospital Conditions of Participation (CoPs) allow stamped signatures but Medicare conditions of payment do not allow stamped signatures and now there is an exception to the conditions of payment that does allow stamped signatures. Are you confused yet? Let’s see if we can sort this out.

Section 3.3.2.4 of the Medicare Program Integrity Manual addresses signature requirements for Medicare medical review purposes. This section states:

“For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable.” (emphasis added)

This means that for services to be approved for payment by Medicare, they must contain a legible handwritten or electronic signature. Stamped signatures are generally not acceptable for Medicare payment purposes. However, under the Rehabilitation Act of 1973 a stamped signature will be accepted in the case of an author with a physical disability.

Change Request 8219 (MLN Matters Article MM8219) clarifies that CMS will permit the use of a rubber stamp for signature when the author has a disability that prevents him/her from physically signing documentation. These providers must be able to provide proof to the Medicare contractor of their inability to sign their signature due to their disability. By affixing the rubber stamp, the provider is certifying that they have reviewed the document. So if your hospital has a provider that uses a rubber stamp due to a physical disability remember to include the required proof of their inability to sign when you submit medical records containing their stamped signature to a Medicare review contractor.