by Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS
COPD and Pneumonia The requirement for code J44.0 (chronic obstructive pulmonary disease with
acute lower respiratory infection) to be coded first when a patient has
pneumonia and COPD has been eliminated as of October 1.
The 2018 version of ICD-10-CM replaced the “use additional code”
with “code also.” According to OCG Section I.A.17, the Code Also note “does not
provide sequencing direction. The sequencing depends on the circumstances of
the encounter.”
We are now back to where the selection of principal diagnosis
between COPD and Pneumonia will be “determined by the circumstances of
admission, diagnostic workup and/or therapy provided” pursuant to OCG Section
II (Selection of Principal Diagnosis).
Type 2 MI
With the 2018 ICD-10-CM, we finally have codes to identify Type 2 MI (primarily due to supply/demand mismatch) and make the important distinction between it and Type 1 (primarily due to coronary artery disease). In the past, Type 2 was coded as NSTEMI creating many practical problems especially since these two types of MI have completely different causes, pathophysiology, implications, outcomes and management.
With the 2018 ICD-10-CM, we finally have codes to identify Type 2 MI (primarily due to supply/demand mismatch) and make the important distinction between it and Type 1 (primarily due to coronary artery disease). In the past, Type 2 was coded as NSTEMI creating many practical problems especially since these two types of MI have completely different causes, pathophysiology, implications, outcomes and management.
Furthermore, this situation improperly labeled patients with
supply/demand mismatch (Type 2) as having acute coronary thrombosis primarily
due to coronary artery disease causing significant inaccuracy with consequences
for patients, clinicians, and the healthcare data base statistics and analysis.
Type 2 MI (whether new initial or subsequent) is assigned to one
code (I21.A1). The code also includes any description of MI being due to
“demand ischemia” or “ischemic imbalance”. As an MCC, the diagnosis of Type 2
MI has major severity impact affecting DRG assignment and quality reporting,
just like Type 1 MI.
Now that a specific code exists for Type 2 MI, a supply/demand
infarction should not be documented as NSTEMI since that term is reserved for
MI due to coronary artery disease requiring aggressive intervention directed at
thrombosis and occlusion of a coronary artery. Type 2 is managed by treating
the underlying cause.
A diagnosis of “demand ischemia” has always been problematic. It
is still assigned to code I24.8, Other forms of acute ischemic heart disease (a
CC). Demand ischemia is supposed to be reserved for supply/demand mismatch
causing ischemia without necrosis where biomarkers remain below the 99th
percentile of the upper limit of reference range, but is often used by
clinicians to describe what technically Type 2 MI is with biomarkers above the
99th percentile. A clinically correct distinction between demand ischemia and
Type 2 MI is an important diagnostic and coding concern.
Encephalopathy due to Stroke
Coding Clinic Second Quarter 2017 responded to a question regarding whether or encephalopathy would be coded separately or considered inherent to a cerebral infarction when diagnosed with encephalopathy secondary to an acute lacunar infarct.
Coding Clinic Second Quarter 2017 responded to a question regarding whether or encephalopathy would be coded separately or considered inherent to a cerebral infarction when diagnosed with encephalopathy secondary to an acute lacunar infarct.
Coding Clinic instructions were to “Assign code G93.49, other
encephalopathy, for encephalopathy that occurs secondary to an acute
cerebrovascular accident/stroke. Although the encephalopathy is associated with
an acute lacunar infarct, it is not inherent, and therefore is coded when it
occurs.
There are two distinct categories of encephalopathy: acute and
chronic. Many sources confuse and confound these categories, lumping them together
as one. However, the chronic encephalopathies are characterized by a chronic
mental status alteration that, in most cases, is slowly progressive. They
result from permanent, usually irreversible, diffuse structural changes in the
brain.
The vast majority of encephalopathy cases encountered in the
inpatient setting are acute. Acute encephalopathy is characterized by an acute,
diffuse, functional alteration of mental status due to underlying systemic
factors rather than local intracranial processes. It is reversible when these
abnormalities are corrected, with a return to baseline mental status. Acute
encephalopathy may be further identified as toxic, metabolic, or
toxic-metabolic depending on its systemic cause.
Ordinarily, from a clinical standpoint, a mental status change
associated with focal intracranial processes (like CVA) is more an alteration
of consciousness and responsiveness in the spectrum of coma, obtundation, and
lethargy – objectively measured using the Glasgow Coma Scale (GCS) scoring –
and not an encephalopathic process.
The unsettled question remains whether “encephalopathy due to
CVA” is a clinically valid diagnosis that can be compliantly coded on claims,
since Coding Clinic disclaims any authority to assert or establish clinical diagnostic
definitions or standards. Based on the definitions and descriptions above of
what encephalopathy is and is not, the diagnosis of encephalopathy due to CVA
could be challenged. On the other hand, obtaining a GCS may reveal one of the
component scores severe enough to qualify as an MCC.
Functional Quadriplegia
Although the FY 2018 Official Coding Guidelines no longer include a paragraph describing functional quadriplegia, it is still a valid diagnosis and ICD-10-CM code:
Although the FY 2018 Official Coding Guidelines no longer include a paragraph describing functional quadriplegia, it is still a valid diagnosis and ICD-10-CM code:
R53.2 Functional quadriplegia (MCC)
Complete immobility due to severe physical disability or frailty.
Excludes 1: Frailty (R54)
Hysterical paralysis (F44.4)
Immobility syndrome (M62.3)
Neurologic quadriplegia (G82.5-)
Quadriplegia (G82.50)
Complete immobility due to severe physical disability or frailty.
Excludes 1: Frailty (R54)
Hysterical paralysis (F44.4)
Immobility syndrome (M62.3)
Neurologic quadriplegia (G82.5-)
Quadriplegia (G82.50)
Editor’s note: This article originally appeared on Pinson and
Tang’s website, www.pinsonandtang.com/resources. Pinson and Tang are the authors of the 2018
CDI Pocket Guide and the
new Outpatient
CDI Pocket Guide: Focusing on HCCs.
This article originally appeared in the ACDIS CDI Journal on November 1, 2017 and has been reprinted with permission.
