FY2013-FY2014 CHANGES TO ICD-9-CM CODING HANDBOOK WITH ANSWERS

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1 FY2013-FY2014 CHANGES TO ICD-9-CM CODING HANDBOOK WITH ANSWERS Narrative changes appear in bold italicized text; deletions show as strike-through text. Revised 4/10/14 Page FY2012 Text Number 39 Because diagnostic statements sometimes include diagnoses that represent past history or existing diagnoses that do not meet the Uniform Hospital Discharge Data Set (UHDDS) guidelines for reportable diagnoses, a review of the medical record is required to determine whether these diagnoses should be coded for this encounter. 57 Borderline Diagnoses... Care should be exercised with diagnoses documented as "borderline." Borderline diagnoses are not the same as an uncertain diagnosis and are therefore handled differently. If the provider documents a "borderline" diagnosis at the time of discharge, the possible/probably guideline to code as if established would not apply in this situation. Instead, provider clarification is required for confirmation of the disease. If, after provider clarification, the disease is not confirmed, a code for abnormal findings may be appropriate such as a code from subcategory 790.2, Abnormal glucose, for a documented diagnosis of "borderline diabetes." This advice is equally applicable to inpatient and outpatient coding. FY2013/14 Correction/Change Because diagnostic statements sometimes include diagnoses that represent past history or existing diagnoses that do not meet the Uniform Hospital Discharge Data Set (UHDDS) guidelines for reportable diagnoses, a review of the medical record is required to determine whether these diagnoses should be coded for this encounter. For example, assigning codes for recurring and/or chronic conditions from a historical problem list may not be appropriate if the condition is not clinically relevant to the current encounter. A patient s historical problem list is not necessarily the same for every encounter/visit. If the condition is not documented in the current medical record, it is not appropriate to go back to previous encounters to retrieve a diagnosis without physician confirmation. Borderline Diagnoses... Care should be exercised with diagnoses documented as "borderline." Borderline diagnoses are not the same as an uncertain diagnosis and are therefore handled differently. Borderline diagnoses are coded as confirmed, unless the classification provides a specific entry (e.g., borderline diabetes). If a borderline condition has a specific index entry in ICD-9-CM, it should be coded as such. Since borderline conditions are not uncertain diagnoses, no distinction is made between the care setting (inpatient versus outpatient). Whenever the documentation is unclear regarding a borderline condition, coders are encouraged to query for clarification. If the provider documents a "borderline" diagnosis at the time of discharge, the possible/probably guideline to code as if established would not apply in this situation. Instead, provider clarification is required for confirmation of the disease. If, after provider clarification, the disease is not confirmed, a code for abnormal findings may be appropriate such as a code from subcategory 790.2, Abnormal glucose, for a documented diagnosis of "borderline

2 diabetes." This advice is equally applicable to inpatient and outpatient coding. 66 It is important to follow UHDDS definitions because It is important to follow UHDDS definitions because... [Insert new paragraph: ] The following additional guidance was released in the Fourth Quarter 2012 issue of Coding Clinic with regards to the selection of principal procedures in relation to the principal diagnosis when more than one procedure is performed: 1. Procedure performed for definitive treatment of both principal diagnosis and secondary diagnosis a. Sequence procedure performed for definitive treatment most related to principal diagnosis as principal procedure. 2. Procedure performed for definitive treatment and diagnostic procedures performed for both principal diagnosis and secondary diagnosis a. Sequence procedure performed for definitive treatment most related to principal diagnosis as principal procedure. 3. A diagnostic procedure was performed for the principal diagnosis and a procedure is performed for definitive treatment of a secondary diagnosis a. Sequence diagnostic procedure as principal procedure, since the procedure most related to the principal diagnosis takes precedence. 4. No procedures performed that are related to principal diagnosis; procedures performed for definitive treatment and diagnostic procedures were performed for secondary diagnosis a. Sequence procedure performed for definitive treatment of secondary diagnosis as principal procedure, since there are no procedures (definitive or nondefinitive treatment) related to principal diagnosis. 109 Tuberculosis of lung with capitation Tuberculosis of lung with capitation cavitation 129 Codes for Nutritional Disorders [Insert 2 new paragraphs at the end] It is possible for a patient s BMI to fluctuate during an inpatient admission. When this occurs and the BMI is linked to a clinical condition such as obesity, malnutrition, anorexia nervosa, etc., the code for the most severe BMI value recorded during the admission is assigned.

3 142 Drug dependence is a chronic mental and physical condition related to the patient s drug use.... Certain codes indicate a combination of drugs; in particular, code 304.7x is assigned when an opioid drug is involved with other drugs and code 304.8x when no opioid drug is present 154 [Exercise 13.3] 2. Myelophthisic anemia [Exercise 14.7] 3. Acute early stage narrow-angle glaucoma, OD Chronic severe stage narrow-angle glaucoma, OS , , , [Exercise 14.7] 4. Primary openangle glaucoma The duration includes the time the patient is on the ventilator and the weaning period. It ends when the mechanical ventilation is turned off (after the weaning period). Note that some patients do not require this weaning process. Codes 260 through are assigned only when the physician specifically documents malnutrition. Descriptive terms such as emaciation are not assigned a malnutrition code unless the documentation specifically links the descriptive term to the condition (malnutrition). In the absence of such a link, assign a code for the descriptive term. For example, emaciated/emaciation when documented in the absence of malnutrition is assigned code 799.4, Cachexia. Drug dependence is a chronic mental and physical condition related to the patient s drug use.... Certain codes indicate a combination of drugs; in particular, code 304.7x is assigned when an opioid drug is involved with other drugs and code 304.8x when no opioid drug is present. Dependence on prescribed medications is also assigned a code from category 304.xx. However, in the case of prescribed medications, if the provider does not document drug dependence, assign code V58.69, Long-term (current) use of other medications. [Exercise 13.3] 2. Malignant neoplasm of breast with myelophthisic anemia [Exercise 14.7] 3. Acute early stage narrow-angle glaucoma, OD Chronic severe stage narrow-angle glaucoma, OS , , , [Exercise 14.7] 4. Primary open-angle glaucoma , The duration includes the time the patient is on the ventilator and the weaning period. It ends when the mechanical ventilation is turned off (after the weaning period). Some facilities clinical protocols may include a period of weaning trial where the ventilator is turned off, but the patient is continually evaluated. The additional period where the patient is evaluated after the mechanical ventilator is turned off should not be included in the ventilation time. Some patients require intermittent ventilation, for example, ventilation only at night (nocturnal). When weaning patients from intermittent ventilation, count the entire period of weaning, including the time the patient is on the ventilator, and the weaning period up until the mechanical

4 213 [Exercise 16.4] 1. Acute ruptured appendicitis with postoperative paralytic ileus 540.0, 997.4, Documentation of excisional debridement should be specific regarding the type of debridement. If the documentation is not clear or if there is any question about the procedure, the provider should be queried for clarification. 247 [Exercise 18.1] 13. Surgical (excisional) debridement of skin and fascia of foot A 40-year-old female patient with a previous cesarean section.... [Codes: , , V23.82, and 74.0.] 324 [Exercise 23.1] 15. Term birth with severe sepsis due to E. coli caused by amnionitis V30.00, , 762.7, , [Cardiac Arrest] Code 427.5, Cardiac arrest, may be assigned as a principal diagnosis only when a patient arrives at the hospital in a state of cardiac arrest and cannot be resuscitated or is resuscitated briefly and pronounced dead before the underlying cause of the arrest is identified. It may be assigned as a secondary code when cardiac arrest occurs during the hospital episode and the patient is resuscitated (or resuscitation is attempted). In this case, the code for the underlying cause is designated the principal diagnosis, with code assigned as an additional code. Note that codes are not assigned for symptoms ventilation is turned off. Note that some patients do not require this weaning process. [Exercise 16.4] 1. Acute ruptured appendicitis with postoperative paralytic ileus 540.0, 997.4, , Documentation of excisional debridement should be specific regarding the type of debridement. If the documentation is not clear or if there is any question about the procedure, the provider should be queried for clarification. If the debridement of bone, fascia, or muscle is not specified as excisional, assign the code for non-excisional debridement (86.28). Coders cannot assume that the debridement of these deeper layers is always excisional. For example, if a patient suffers a traumatic open wound and fascia, muscle, or bone are exposed, only a nonexcisional debridement is required to clean the wound. [Exercise 18.1] 13. Surgical (excisional) debridement of skin and fascia of foot A 40-year-old female patient with a previous cesarean section.... [Codes , , V23.82, , and 74.0.] [Exercise 23.1] 15. Term birth with severe sepsis due to E. coli caused by amnionitis V30.00, , 762.7, , 041.4, [Cardiac Arrest] Code Cardiac arrest, may be assigned as a principal or first listed diagnosis if the underlying condition is not known. It does not matter whether the patient is resuscitated. The assignment and sequencing of code is dependent upon the circumstances of the hospitalization. If the patient is admitted due to cardiac arrest and an underlying cause is not established before the patient is discharged or expires, it is appropriate to assign code as the principal or first-listed diagnosis. Code should not be sequenced as the principal or firstlisted diagnosis if the underlying condition is known. It may be assigned as a secondary diagnosis code when it meets the definition of a reportable additional diagnosis, regardless of whether the patient is resuscitated. diagnosis only when a patient arrives at the hospital in a

5 integral to the condition, such as bradycardia and hypotension. Cardiac arrest that occurs as a complication of surgery is coded as 997.1, Cardiac complications. Code 669.4x is assigned for cardiac arrest complicating abortion, ectopic pregnancy, or labor and delivery. None of these codes are assigned to indicate that a patient has died. Do not code cardiac arrest to indicate the patient s death. 346 [Exercise 24.5] 3. Admission for treatment of new cerebral infarction... dysphagia , 784.3, , [Exercise 24.7] 5. Pulmonary hypertension 373 [Exercise 24.9] 16. Cerebrovascular accident, acute, with thrombosis Coders may use the completed cancer staging form for coding purposes when it is authenticated by the attending physician. 411 Abuse often results in physical injuries state of cardiac arrest and cannot be resuscitated or is resuscitated briefly and pronounced dead before the underlying cause of the arrest is identified. It may be assigned as a secondary code when cardiac arrest occurs during the hospital episode and the patient is resuscitated (or resuscitation is attempted). In this case, the code for the underlying cause is designated the principal diagnosis, with code assigned as an additional code. Note that codes are not assigned for symptoms integral to the condition, such as bradycardia and hypotension. Cardiac arrest documented as occurring during or following that occurs as a complication of surgery is coded as 997.1, Cardiac complications, and as additional diagnoses, regardless of outcome (successfully resuscitated or not resuscitated). Code 669.4x is assigned for cardiac arrest complicating abortion, ectopic pregnancy, or labor and delivery. None of these codes are assigned to indicate that a patient has died. Do not code cardiac arrest to indicate the patient s death. [Exercise 24.5] 3. Admission... dysphagia , 784.3, , , [Exercise 24.7] 5. Primary pulmonary hypertension [Exercise 24.9] 16. Cerebrovascular accident, acute, with thrombosis Coders may use the completed cancer staging form for coding purposes when it is authenticated by the attending physician. If staging classes are being documented in the hospital medical record, the coding staff should obtain copies of the current classifications for use in decoding the numerical/alphabetic designations. [Insert new paragraph:] ICD-9-CM does not specify the age limit for the assignment of child abuse codes , versus adult abuse codes The age of majority varies among states. If the patient has reached the age of majority per state guidelines, it would be appropriate to assign the adult abuse codes ( ). In some states, an emancipated

6 minor is considered an adult. For example, if a judge declares a minor emancipated, he or she is usually granted majority status at the same time. Other factors may influence the age of majority, such as minors who marry or who join the armed forces. In some instances, when it is not documented, the provider will need to be queried to determine if the patient is an emancipated minor. 450 Alcoholic hepatitis; chronic alcohol dependence, episodic Malignant neoplasm of transplanted kidney The occurrence of unintended retention of objects at any point after surgery ends should be captured regardless of setting or whether the object is removed.... The surgeon decided that further search for the needle would cause the patient harm, so the chest was closed, and the patient was transferred to the ICU in stable condition. Assign code 998.4, Foreign body accidentally left during a procedure. Although the surgeon made the decision to leave the needle to avoid harm to the patient, it was not the intent of the original procedure to leave a foreign body behind. 464 Admitted for replacement of knee prosthesis following explantation of infected joint prosthesis V The compliance date for implementation of these two classification systems in the United States is October 1, The compliance date for implementation in the United States is October 1, Abuse often results in physical injuries... Alcoholic hepatitis; chronic alcohol dependence, episodic Malignant neoplasm of transplanted kidney The occurrence of unintended retention of objects at any point after surgery ends should be captured regardless of setting or whether the object is removed. However, when the provider intentionally leaves a foreign body during surgery in order to prevent additional risk to the patient that the removal may cause, do not assign code Instead, code E871.0, Foreign object left in body during procedure, surgical operation, is assigned.... The surgeon decided that further search for the needle would cause the patient harm, so the chest was closed, and the patient was transferred to the ICU in stable condition. Assign code 998.4, Foreign body accidentally left during a procedure. Although the surgeon made the decision to leave the needle to avoid harm to the patient, it was not the intent of the original procedure to leave a foreign body behind. E871.0, Foreign object left in body during procedure, surgical operation, to show that there was a problem with a foreign body left during the procedure. Admitted for replacement of knee prosthesis following explantation of infected joint prosthesis V54.81 V54.82 The compliance date for implementation of these two classification systems in the United States is may not be prior to October 1, The compliance date for implementation in the United States is may not be prior to October 1,

7 474 Full compliance is expected for claims received for encounters and discharges occurring on or after October 1, 2013 (FY 2014). 475 October 1, 2014: Regular updates to ICD-10-CM/PCS will begin. 477 The use of a dummy place holder ( x as the fifth character) allows for further expansion without a disruption of the six-character structure. 478 The dummy placeholder in ICD-10- CM is the character "x." At press time, the date for full Full compliance has been delayed to after October 1, 2015 (FY 2016). is expected for claims received for encounters and discharges occurring on or after October 1, 2013 (FY 2014). October 1, 2014: Regular updates to ICD-10- CM/PCS will begin. No updates to ICD-9-CM. Limited code updates to ICD-10-CM/PCS to capture new technology and new diseases. October 1, 2015: Regular updates to ICD-10- CM/PCS will begin. [At press time, announcements had not been made regarding changes to the timelines for code updates.] The use of a dummy place holder ( x as the fifth character) allows for further expansion without a disruption of the six-character structure. The dummy placeholder in ICD-10-CM is the character "x." 480 Table 31.1 Dummy placeholders Table 31.1 Dummy p Placeholders 486 A revised set of guidelines was released by the ICD-9-CM cooperating parties in The complete 2011 version of the guidelines may be found by visiting the Web site m.htm#10update. 489 ICD-10-PCS is divided into Index, Tables, and List of Codes. 492 The 2012 version is available on the CMS Web site at The ICD-10-PCS is divided into Index, Tables, and List of Codes.... The List of Codes allows for direct lookup of each code, with a short description of each code being provided. 498 [List of Codes] The ICD-10-PCS List of Codes displays all valid codes... can be found online at the following Web site: A revised set of guidelines was released by the ICD-9-CM cooperating parties in is available.... The complete 2011 most recent version of the guidelines may be found by visiting the Web site date. ICD-10-PCS is divided into Index and Tables. and List of Codes. The 2012 most recent version is available on the CMS Web site at The ICD-10-PCS is divided into Index and Tables. and List of Codes. The complete list of ICD-10-PCS long and abbreviated code titles is available online from the CMS Web site ( 014-ICD-10-PCS.html)... The List of Codes allows for direct lookup of each code, with a short description of each code being provided. [List of Codes] The ICD-10-PCS List of Codes displays all valid codes... can be found online at the following Web site: Click on the 2012 ICD-10-PCS and Click on the ICD-10-PCS and GEMS link

8 GEMS link in the left-hand column and select the PDF link titled 2012 Official ICD-10-PCS Coding Guidelines. 499 In addition, a documentation and user s guide has been made available online at 012_ICD10PCS.asp#TopOfPage. 503 Although the compliance date for national implementation of ICD-10- CM and ICD-10-PCS is not until October 1, 2013, individuals and provider organizations must start preparing now. 503 American Hospital Association (AHA) acentraloffice_app/icd-10/icd-10.jsp 503 Sign up for the free CMS service... rvice/subscribe.html?code=uscms_ Inpatient Admission:... A colonoscopy was done because of a past history of polyps, with no recurrence found. in the left-hand column and select the PDF link titled Official ICD-10-PCS Coding Guidelines. In addition, a documentation and user s guide has been made available online at S.asp#TopOfPage 14-ICD-10-PCS.html. Although the compliance date for national implementation of ICD-10-CM and ICD-10-PCS is not until after October 1, , individuals and provider organizations must start preparing now. American Hospital Association (AHA) _app/icd-10/icd-10.jsp. tml Sign up for the free CMS service... e.html?code=uscms_608 /subscriber/new?topic_id=uscms_ Inpatient Admission:... A colonoscopy was done due to the abdominal pain and because of a past history of polyps, with no recurrence found Codes 318.0, 133.0, 132.1, Codes 318.0, V40.31, 133.0, 132.1, [Add to comments:] Code V40.31 may be used when wandering related to a disease or condition is documented by the provider, and such documentation reflects that the wandering is clinically relevant. Note that the underlying disorder (i.e., intellectual disabilities) should be coded first according to the Tabular List instructions Comments:... (4) Code V12.72 is assigned because the history of polyps was the reason for the colonoscopy , , Comments:... (4) Code V12.72 is assigned because the history of polyps and the abdominal pain were the reasons for the colonoscopy.