Knowledge Base Category -

Did You Know?

There are many new codes for Refractory Angina Pectoris as of October 1, 2022. For example:

• Refractory Angina Pectoris, I20.2
• CAD of Native Coronary Artery with Refractory Angina Pectoris, I25.112

Why Should You Care?

Refractory Angina has been designated as a Complication/Comorbidity. These new codes could impact the Severity of Illness for that admission. Refractory Angina Pectoris is a type of angina present in patients that have irreversible ischemia even though they have been treated with combinations of medications, PCI, or CABG. These patients are difficult to treat as they are already on multiple medications and surgical options would not be appropriate for the patient. In cases where the type of angina is not documented, knowing the types of antianginal medications will help with querying the physician to see if that patient was being treated for Refractory Angina Pectoris. Antianginal medications would be prescribed daily on a long-term basis and not just P.R.N.

Types of Antianginal Drugs with Examples:

• Nitrites – Isosorbide Mononitrate, Nitroglycerin, Isosorbide Dinitrate
• Beta-Blockers – Metoprolol, Carvedilol, Propanolol
• Calcium-Channel Blockers – Diltiazem, Amlodipine, Verapamil
• Metabolic Modulators – Ranolazine

It is important to note that codes for chronic conditions that are currently receiving treatment may be assigned even though symptoms may not be present for that admission.

What Can I Do About It?

Become familiar with the types of antianginal drugs and the definition of Refractory Angina Pectoris. Also review the Coding Clinics listed below.

References:

Coding Clinic, 4th Quarter 2022, page 20

Coding Clinic, 3rd Quarter 1991, page 16

Did You Know?

There are new codes for Respiratory Acidosis as of October 1, 2022.

Why It Matters?

With the code expansion, there was also a change in the Alphabetic Index. Acute Respiratory Acidosis is now assigned to code, J96.02, Acute Respiratory Failure with Hypercapnia, an MCC. >[?

Documentation	ICD-10-CM Code
Respiratory Acidosis	E87.29, Other Acidosis	CC
Acute Respiratory Acidosis	J96.02, Acute Respiratory Failure with Hypercapnia	MCC
Chronic Respiratory Acidosis	J96.12, Chronic Respiratory Failure with Hypercapnia	CC

What Can I Do?

Familiarize yourself with the difference between Acute and Chronic Respiratory Acidosis. Knowing the symptoms will help with compiling a query if needed.

Respiratory Acidosis occurs when natural breathing does not remove carbon dioxide from the body. Carbon dioxide builds up in the blood and causes it to become acidotic. This could be acute or chronic.

Chronic Respiratory Acidosis: People will have excess carbon dioxide in their blood on a chronic basis, but the kidneys work to remove the acid to keep the acid-base balanced. The excess acid still affects the brain and still can cause less notable symptoms such as memory loss, sleep disturbance and anxiety. Treatment is directed towards the underlying cause such as COPD.

Acute Respiratory Acidosis – This type of Respiratory Acidosis is acute with sudden onset and requires immediate medical attention. The symptoms are more severe and can cause heart arrhythmias and hypotension. The patient may experience confusion, stupor, or muscle jerking. In addition to treating the underlying cause, the use of Bipap or mechanical ventilation may be immediately required.

References:

Merck Manual

Medical News Today

Brundage Group – Tip of the Month October 2022 - Acidosis

Question

What is the code assignment for a patient with Type 2 DM with Nephropathy and CKD?

Answer

Assign only one code, Type 2 DM with CKD (E11.22) because CKD is more specific than nephropathy per advice found in Coding Clinic, 3rd Quarter 2019, page 3.

References

Coding Clinic, 3rd Quarter 2019, page 3

Question

The patient presented with seizures and was intubated in the ED. The physician documented "acute respiratory failure" on the H & P, noting "Respiratory failure-intubated in ED for airway protection. Maintain on ventilator overnight. Attempt to wean and extubate when no longer having seizures". On a progress note, "Acute Respiratory Failure” and “Respiratory failure-intubated in ED for airway protection. Maintain on ventilator overnight" was documented. On the Discharge Summary, "Acute Respiratory Failure. Respiratory failure-intubated in ED for airway protection. Now extubated. Doing well" was documented. Based on the documentation, should we code the Acute Respiratory Failure as a secondary diagnosis, query for clarification, or leave it off since it was "for airway protection"?

Answer

If a patient is intubated for airway protection, and Acute Respiratory Failure is documented, a code for the Acute Respiratory Failure can be assigned. However, if a patient is intubated for airway protection and there is no documentation of Respiratory Failure, coders cannot assume or assign a code for Respiratory Failure, just because the patient was intubated and placed on a mechanical vent.

Remember to also code the procedure codes for the Mechanical Ventilation and ETT, if appropriate.

References

Coding Clinic for ICD-10-CM/PCS, Third Quarter 2012: Page 21

Did You Know?

The way brush biopsy is coded changed October 1, 2017.

Why It Matters?

Prior to 2017 ICD -10 did not have the option to choose Extraction for the Root Operation. At that time, the only option was to select “Excision”.

Definitions of Excision and Extraction:

1. Excision is the cutting out or off, without replacement, a portion of a body part
2. Extraction is the pulling or stripping out or off all or a portion of a body part with the use of force.

Physicians like to use the “brush” technique as it is low risk and the least invasive, but still provides enough cells to the Pathologists to make a diagnosis.

In addition, it is important to note the difference between the two approaches because the physician may obtain a specimen using both Excision and Extraction during an operative episode.

For example, during a Bronchoscopy, the physician may perform a brush biopsy of the bronchus and a transbronchial lung biopsy. To obtain a lung biopsy, tiny forceps are used to remove lung tissue, so this would be coded to the approach Excision. The lung biopsy carries a higher risk because there is a chance a pneumothorax will occur. The endoscopic lung biopsy will also group the DRG to a higher weight, which is another reason for being aware of these two approaches.

What Can I Do?

Review Coding Clinic, 4th Quarter 2017, page 41. Closely review the Op Report documentation and note the root operations used during the procedure.

References

• Coding Clinic, 4th Quarter 2017, page 41
• PCS Coding Guidelines

Did you know?

Did you know that a new code has been created to identify unspecified Depression, NOS, effective October 1, 2021?

Previously in ICD--10, when a provider documented Depression, NOS, it was assigned to Major Depression, Single Episode, code (F32.9); however, only 10% out of 30% of patients that report symptoms of Depression, have Major Depression. Therefore, a new code has been created to capture Depression NOS.

• Depression, Unspecified (F32.A) • Depression NOS (F32.A) • Depressive Disorder NOS (F32.A)

Major Depression, Single Episode, Unspecified and Major Depression NOS is still assigned to code (F32.9).

Why it matters.

You may not be capturing the most accurate severity of illness of the patient.

What can I do?

Read Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2021: Page 9

Question

Do you know when the COVID-19 Public Health Emergency (PHE) will end?

Answer

The COVID-19 PHE declaration was last renewed on January 14, 2022 with an effective date of January 16th (link). When the Secretary of the Department of Health and Human Services (HHS) makes a PHE declaration, it lasts for the duration of the PHE or 90 days but may be extended by the Secretary for as long as the PHE continues to exist. The most recent declaration is set to end April 16, 2022.

Further, in January 2021, acting HHS Secretary Norris Cochran sent a letter to governors across the country to share details about the COVID-19 PHE and indicated in the letter that HHS “has determined that the PHE will likely remain in place for the entirety of 2021, and when a decision is made to terminate the declaration or let it expire, HHS will provide states with 60 days’ notice prior to termination.”

Question

Our gastroenterologists rarely state if a patient’s personal history of colon polyps is adenomatous in nature or hyperplastic, or both. Typically, the documentation only reflects that the patient has a “history of colon polyps”. If the physician specifies the patient’s previous colon polyps as being hyperplastic, what ICD-10-CM diagnosis code should be assigned?

Answer

For a personal history of hyperplastic colon polyps, assign ICD-10-CM diagnosis code Z87.19 (personal history of other diseases of the digestive system).

Did You Know?

The advice from Coding Clinic, First Quarter 2021, page 12 advises that medications prescribed on a “PRN” or “as needed” basis are not considered to be long term drug therapy. This means that Z79, Long Term Drug Therapy would not be assigned for these medications.

Why It Matters?

Coding long term medication use for a drug that is given only on an “as needed” basis would be contradictory to the Z79 code description as it implies continuous use of a drug for an extended period of time.

What Can I Do?

Review Coding Clinic, 1ST Quarter 2021, page 12. Read the medication list, determine the medications to be coded and then look to see how they are prescribed.

Coding Clinic, 1ST Quarter 2021, page 12.

Question

Has Palmetto GBA finalized its coverage determination for Cardiac Resynchronization Therapy (CRT)?

Answer

Yes. The coverage determination became effective December 12, 2021 and can be found in Palmetto GBAs’ Local Coverage Article A58821 (link) and Palmetto GBAs’ Local Coverage Determination L39080 (link).

As with most of the other Medicare coverage guidelines, CRT has specific diagnosis codes that must be submitted on the claim to support medical necessity. In addition, the medical record must have documentation of the patient’s QRS duration - reflected in milliseconds - from the EKG, as well as documentation of QRS morphology such as right / left bundle branch block. Check the LCA and LCD for complete coverage requirements.