3rd Quarter Vol.5 Issue 3. Coding Signs, Symptoms & Abnormal Findings in ICD-10-CM By Connie Calvert RHIA, CCS, CCDS

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1 3rd Quarter 2015 Vol.5 Issue 3 I N S I D E T H I S I S S U E : PCS: An ICD-10 Refresher Tricky Codes: An ICD-10 Refresher CMS Flexibility Policy for Part B Claims ICD-10 Sample Documentation Contact Us Today: Advanced Coding Education customized to take you and your staff to the next level RMC News 6 Coding Signs, Symptoms & Abnormal Findings in ICD-10-CM By Connie Calvert RHIA, CCS, CCDS There s no feeling like perusing a Discharge Summary and coming across a diagnosis of syncope, dizziness, chest pain, or my personal favorite, altered mental status. As coders, we know this chart is going to involve some digging to determine if a related definitive condition is present. Yippee! What a great opportunity to apply our clinical knowledge and delve deeper into the known or suspected etiology of the symptom. OK, did I lose you there? While it may not be fun, in reality, there are times when a patient will be diagnosed with a sign, symptom, or abnormal finding. That won t change in ICD-10-CM. Let s take a look at the Chapter 18 Guidelines in ICD-10-CM, so that when the opportunity presents itself (and we all know it will!) we ll be ready! ICD-10-CM Coding Guideline I.B.4 states that Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Be aware that Chapter 18 of ICD-10-CM contains many, but not all of these codes. Also, remember that, just as with ICD-9-CM, conditions that are an integral part of a disease process are not coded separately in ICD-10. For example, if the patient is experiencing ear pain and the diagnosis is otitis media, the ear pain would be integral to the otitis media and is not separately reported. A symptom code is used with a confirmed diagnosis only when the symptom is not associated with that confirmed diagnosis. Signs and symptoms associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. Conversely, Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present. Example: Pt treated for pneumonia. Provider notes that sputum specimen results indicate abnormally high level of enzymes, with recommendation to follow up with pulmonologist. Code R84.0-, Abnormal level of enzymes in specimens from respiratory organs and thorax, should be assigned as an additional diagnosis. ICD-10-CM contains a number of combination codes that identify both the definitive diagnosis and common symptoms of that diagnosis. When using the combination codes, no additional code for the symptom is assigned. Code R29.6, Repeated falls, is for use when a patient has recently fallen and the reason for the fall is being investigated. History of falling, Z91.81, for use when patient has fallen in the past and is at risk for future falls. When appropriate, both R29.6 and Z91.81 may be assigned together. ICD-10 allows for the incorporation of the Glasgow Coma Scale (GCS) score into coding, either as a whole score (R40.24-) or through use of its individual components (eye-opening, verbal and motor response categories). Documenting and coding the score will help to specify a patient's condition, as well as how it may change over time (if the score is calculated repeatedly). ICD-10-CM also expands coma to include coding for somnolence, stupor, and coma. Somnolence (R40.0) = drowsiness Stupor (R40.1) = catatonic stupor or semi-coma Coma (R40.2-) = unconsciousness Any associated skull fracture or intracranial injury would be coded first 7 th character required Glasgow (coma scale) score available Continued on following page...

2 Page 2 Coding Signs, Symptoms & Abnormal Findings Continued... In conclusion, Chapter 18 codes are for use in all settings. Know the guidelines for coding signs, symptoms, and abnormal findings. Thoroughly review the chart so that codes may be assigned to the greatest degree of specificity. Know or research the signs and symptoms that are routinely associated with a disease process. If not routinely associated with the disease, and meet the criteria for inclusion as a secondary diagnosis, assign the code. Connie Calvert, RHIA, CCS, CCDS, AHIMA Approved ICD 10 CM/PCS Trainer is RMC s Director of Hospital Coding and Review Services. In this role, she is ultimately responsible for the quality of services supplied by RMC and the excellence in the work provided to RMC clients. Connie has over 20 years of experience in HIM and enjoys coaching and mentoring staff, conducting audits, researching coding issues, developing coding tools, and providing education to coders as well as providers. Clinical Documentation is a particular passion and as such, Connie obtained her CCDS in She is active in AHIMA, SCHIMA, and ACDIS. And is an AHIMA ICD-10-CM & PCS Trainer. PCS: An ICD-10 Refresher by Stacy Hardin, CCS The wait for ICD-10 is almost over and all professionals in the HIM world will be welcoming it with open arms this October 1, One of the biggest changes with ICD-10 is that all hospital facilities will be replacing ICD-9-CM volume 3 with ICD-10-PCS for coding procedures in the inpatient setting. This much needed change provides the specificity that has been lacking in ICD-9-CM. ICD-10-PCS uses a grid system making coding procedures very specific and detailed. The areas for expansion are almost limitless, with our ever changing world and new technologies, ICD-10-PCS will be able to grow with the times. For example, in ICD-9-CM a procedure code could be 3 or 4 characters but a complete ICD-10-PCS code requires 7 characters. This shows how detailed ICD-10-PCS really is! Taking a glance at all the pieces of a PCS code can really explain the story that happens with procedures. It s important to know all the parts of the PCS code and how they all work together. The grid below shows what each character in a PCS code signifies-- each piece is integral part to the procedure telling the story. Character Character 1: Section Character 2: Body System Character 3: Root Operation Character 4: Body Part Character 5: Approach Character 6: Device Character 7: Qualifier Definition General procedure category or section where code is located. General physiological system or anatomical region procedure is performed Objective of procedure Specific body part the procedure performed on Technique of the procedure Describes devices left in body after procedure Unique identifiers per procedure Character 1: There are 3 main sections, Medical and Surgical (0), Medical and Surgical-related (1-9), and Ancillary (B,C,D,F,G,H). Character 2: A strong knowledge of Anatomy becomes a very important requirement as the 2 nd character of a PCS code is the Body System which can be the general physiological system such as Cardiovascular or Respiratory, or it may be the anatomical region such as lower arteries. Character 3: There are 31 different root operations in the Medical/Surgical Section and a coder will need to know all of these root operations and how to apply them to accurately code in ICD-10-PCS. An example of a root operation would be Extirpation: Taking or cutting out solid matter (foreign body, thrombus, calculus, etc) from a body part. Refer to the appendices in the back of the PCS book for definitions of the root operations. Character 4. This is another area that Anatomy becomes extremely important. A coder can also refer to the appendices in the back of the PCS book for the Body Part Key. Character 5: There are 8 different approach values in the Medical and Surgical section such as open, percutaneous, and via natural or artificial opening. Character 6: To code a device, the device must remain at the conclusion of the procedure. There are four basic categories of devices: grafts and prostheses, implants, simple or mechanical appliances, and electronic appliances. If a device is not left in then the 6 th character of Z would be used to indicate no device. Character 7: Qualifiers are unique depending on the procedure and the selection of the previous 6 values. These are special attributes to the procedure such as diagnostic. This character also provides an option of Z for no qualifier. For a more in-depth review of the root operations, including definitions and examples, please join RMC s Refresher Presentation on Inpatient Procedures by Jennifer Jones, CCS. Stacy Hardin, CCS has 15 years experience in the Health Information Management field. She started her career working for a small rural Family Practice Clinic where her duties included coding, transcription and nursing assistant. Stacy moved into the hospital sector over 10 years ago at a small rural hospital performing transcription and coding. With progressive experience, Stacy has held various positions of Coder, Coding Compliance Coordinator and HIM Director. Stacy joined RMC in 2006, and is currently Regional Coding Manager for RMC.

3 Page 3 CMS Flexibility Policy for Part B Claims Keeps ICD-10 Implementation on Target By Connie Eckenrodt RHIT, CHC, CHC-A On July 6, the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) released a joint statement, announcing efforts to work together to help physicians get ready for the U.S. transition to ICD-10 on October 1, In response to physicians concerns regarding inadvertent coding errors or system glitches that could potentially result in audits, claims denials and penalties, CMS said they would work with the physician community and establish a policy of flexibility in the claims auditing and quality reporting process. Simultaneous with the joint statement, CMS released its own guidance, describing the policy in further detail and announcing the establishment of a new ICD-10 Ombudsman to help identify and resolve issues that arise as a result of the transition. The new CMS policy emphasizes that a valid ICD-10 code is a requirement on all claims starting on October 1, Medicare claims with a date of service on or after October 1, 2015, will be rejected if they contain an ICD-9 code. The Medicare claims processing system does not have the capability to accept claims containing both ICD-9 and ICD-10 codes for any dates of service, before or after October 1. CMS further directed that for 12 months after ICD-10 implementation, Medicare review contractors would not deny Part B professional fee billing claims through either automated medical review or complex medical record review solely for lack of diagnosis code specificity as long as a valid code from the right family was applied. This proved to be a point of confusion and caused physicians to ask, What is a valid ICD -10 code? and What is meant by a family of codes? In a Clarifying Questions & Answers document released on July 27, 2015, CMS said a valid code must be coded to the full number of characters required for that code, including the 7 th character, if applicable. Every ICD-10 code belongs to a three-character category, with greater levels of specificity captured by using applicable fourth, fifth, sixth and seventh characters. Three-character codes can only be used if they have not been further sub-categorized. In most cases, a valid code will have 4-7 characters. The code submitted on the claim must be a valid, billable code. The submitted code must also be one from the appropriate family of codes. Family of codes is synonymous with three-character category. Codes within a three-character category are related, which each subsequent fourth, fifth, sixth and seventh character further defining a condition within the category. For example, the three-character code category R22, Localized swelling, mass and lump of skin and subcutaneous tissue, requires additional characters that describe the location of the swelling, such as R22.0, localized swelling, mass and lump, head, or R22.30, localized swelling, mass and lump, unspecified upper limb. It s important to emphasize here that the CMS flexibility policy applies to work performed by the Medicare review contractors, which include Medicare Administrative Contractors (MACs), Recovery Auditors (RACs), Zone Program Integrity Contractors (ZPICs), and the Supplemental Medical Review Contractor. The policy does not preclude a physician or other billing practitioner from reporting the most specific and accurate diagnosis code possible. A claim submitted with R22 will be rejected at the claims level as an invalid code because it requires additional characters to further describe the condition. A claim submitted with R22.30, although valid, might be rejected at the claims level due to lack of specificity if it does not meet a Local or National Coverage Determination policy. Coverage policies that require a specific ICD-9 diagnosis code now will require a specific diagnosis code under ICD-10. The CMS flexibility policy comes into play with the following scenario: The billing practitioner was reimbursed by Medicare for a service claim pertaining to a localized mass of the left lower limb (R22.42). During post-payment medical review, the MAC finds the service to be incorrectly coded to a localized mass, right lower limb (R22.41). Although the code on the claim has an error associated with specificity (laterality), the MAC should not deny this claim solely for code specificity because the code reported was a valid code within the same family of codes (R22). The CMS flexibility policy pertains only to claims paid under the Medicare Fee-for-Service Part B physician fee schedule in the first year post -implementation, and only applies to post payment reviews conducted by the Medicare review contractors. ICD-10 codes with the correct level of specificity will be required for prepayment reviews and prior authorization requests. In all cases, the physician or other billing practitioner should make every effort to report the specific ICD-10 code that most accurately describes the patient s known condition at the time of the encounter. Connie Eckenrodt RHIT, CHC, CHCA has over 15 years in the HIM field. Focusing on outpatient coding, with particular emphasis on professional fee coding and documentation improvement, Ms. Eckenrodt s areas of expertise include: new provider coding orientations; individual and group coding education for providers and professional fee coders; pre-bill and retrospective coding audits; and risk assessment and focus review audits for internal compliance initiatives and compliance initiatives pursuant to federal investigations. Consulting has been provided in myriad settings, from small practices to large multi-specialty practice groups.

4 Page 4 Tricky Codes: An ICD-10 Refresher By Camille Walker, RHIT With ICD-10 fast approaching, many of us in the HIM world are welcoming it with open arms. We have had multiple years to prepare and learn from this new code set. While ICD-10 is much more complex and expansive from ICD-9, it really isn t such a scary thing. Many of the rules and guidelines are very similar to ICD-9 but there are some changes. As coders, it s important to know these changes and differences as we move forward to a much needed expansive code set. From our experiences, we at RMC have found some areas in ICD-10 that we have termed tricky. These are not impossible concepts, just particular areas of ICD-10 that may need some extra attention. Placeholders Within ICD-10 it is important to take codes to the appropriate number of places. Many codes especially in fractures and external causes have codes that require a full 7 digits. Placeholder X is used to fill in for codes that require a 7 th character. Diabetes Pay particular attention to facility guidelines regarding coding of daily use of insulin with Type 1 Diabetes Mellitus. ICD-10 states that code is optional and not necessarily required as insulin is required to sustain life in Type 1. Cardiac Coding New timeframes have been added for coding acute MI and subsequent MI. A subsequent MI is coded if the MI is within 4 weeks of the first MI. Also, coding for STEMI and Non-STEMI for MI is new in ICD-10. Provider documentation is key for accurate coding. Smoking Smoking has been expanded in ICD-10 and has options for use, nicotine dependence, and type. Coders need to follow the index and facility guidelines for accurate coding of smoking. External Cause Index The external cause index has increase in size with many new codes added to it from ICD-9. Be sure to look at all the options for choices in the index. There is probably a code for it! And! Make sure all codes are taken to the appropriate places. This can be tricky here as some require all 7 characters, some codes do not. Z-Codes Locating codes in the index can be tricky for some coders especially for Z-codes. Some hints to locate these codes are knowing the terms to locate them. Key terms for Z-codes are: Anemia Admission Aftercare Examination History Observation Problem Status Use caution when coding anemia especially if a blood transfusion was performed. Providers must document anemia for accurate coding! If you believe a diagnosis of anemia is warranted, query your provider. PCS Root Operations! Know these in and out. Some ideas might be to have note cards or tip sheets with the definition and type of procedures that root operation does nearby. Coders need to know that the root operation of Control is ONLY used for post-procedural bleeding. Also, root operation of Destruction is used only when none of the body part is physically taken out. Coding of biopsies can be tricky in ICD-10. If a biopsy and a more definitive procedure are performed, both are coded. Otherwise a final character of X to identify biopsy is coded on procedures. This is indicated by X for Diagnostic. As you can see there are some concepts in ICD-10 that need a little extra attention. With a little focus and attention these areas are easily understandable. Good luck to all and bring on ICD-10!! Camille Walker, RHIT, joined RMC in 2013 in dual roles of Business Development and Education Services. Camille, with our in-house ICD-10 experts, developed RMC s ICD-10-CM & PCS Training Program 10x. This training program has been exceptional in preparing RMC and client coders for the transition to ICD-10. Holding her Bachelor s degree in Marketing, as well as her RHIT, she brings the perfect blend of skillsets to our team.

5 Page 5 Do you LOVE your job? RMC has taken pride in providing stellar coding compliance services to our clients since We hire only the best in the business, and dedicate ourselves to taking care of our team in every way possible. We offer a friendly staff environment, constant support, ongoing education, and a sense of team work and "family" that is unparalleled in the business. We pride ourselves on being a company that our staff LOVE to work for. RMC is currently looking for experienced, credentialed, hard-working coding experts to join our team. Positions are all remote, and all RMC staff are issued a company laptop. Qualified candidates: Must have a minimum of 5 solid years of coding experience Must be AHIMA/AAPC credentialed Must pass RMC's inpatient coding test Must be reliable, friendly and flexible Must be available FULL-TIME only, please. If you want to join our team and LOVE your job, please send your resume to employment@rmcinc.org Examples: #1 #2 59 year-old pt. with hypertensive and diabetic ESRD is admitted for electrolyte imbalance caused by dialysis. What are the correct diagnosis codes for this case? 29 year-old patient here for routine prenatal exam. She is primigravida in her first trimester. No complications. Normal exam for 10 weeks gestation. What are the correct diagnosis codes for this case? #3 Pt here for follow-up of 2 nd and 3 rd degree burns on right hand and fingers. Pt was canning fruit at home and burned herself with boiling water 3 days ago. Wounds are healing nicely with no signs of infection. Antibiotics are continued and pt. will return in 1 week. What are the correct diagnosis codes for this case?

6 Page 6 Relax. RMC has your training needs covered. 10X Training is comprehensive, methodical, and thoughtfully prepared ICD-10-CM/PCS training with the learner in mind. 10X Training encompasses all of the necessary education AND training to ensure a smooth transition to ICD X Training is 3-fold, utilizing audio conference presentations, real charts for coding, and LIVE interactive webinars. Contact us today or for more info or click here REIMBURSEMENT MANAGEMENT CONSULTANTS, INC. Offering Comprehensive Compliance Review & Coding Services. Nationwide. Hospital Reviews Clinic Reviews Specialized Reviews Coding Support Compliance Programs Education & Training Contact us today for more information: Answers: #1 #2 #3 E87.8 Other disorders of electrolyte and fluid imbalance, NEC I12.0 Hypertensive CKD with stage 5 CKD or ESRD N18.6 ESRD E11.22 Type 2 DM with CKD Z99.2 Dependence on renal dialysis Y84.1 Kidney dialysis as the cause of abnormal reaction of the patient Z34.01 Encounter for supervision of normal first pregnancy, first trimester Z3A weeks gestation T23.391D Burn of third degree multiple sites of right hand and wrist, subsequent encounter X12.xxxD Contact with other hot fluids, subsequent encounter