Coding Heart Failure

This installment of “In the kNOW” is going to review recent Coding Clinic information related to the coding of heart failure.  First, let’s review heart failure in general noting that there are three types of heart failure: left-sided, right-sided, and congestive.

In left-sided heart failure, the blood is not pumped out to the rest of the body efficiently causing the left ventricle to work harder to supply blood flow.  There are two types of left-sided heart failure: heart failure with reduced ejection fraction (HFrEF)(systolic), and heart failure with preserved ejection fraction (HFpEF)(diastolic).  The ejection fraction is a measurement (percentage) of how much blood is being pumped out by the left ventricle with each contraction.  Normal ejection fractions generally run between 50%-70%.  In heart failure with preserved ejection fraction, contraction of heart muscles is normal, but relaxation of the ventricles is abnormal due to stiffness, thus limiting the amount of blood that can fill the heart.  In heart failure with reduced ejection fraction, the contraction part of the process is abnormal and not enough blood enters the circulation.  Because the terminology of HFrER and HFpEF is more widely accepted now, coders may use those terms to assign codes for systolic or diastolic heart failure respectively or a combination of both if applicable.  Keep in mind that additional clarifying terms may impact code assignment, such as acute, chronic, or acute on chronic.   

                                    Acute                   Chronic           Acute on Chronic       Unspecified
Systolic                        I50.21                    I50.22              I50.23                           I50.20
Diastolic                       I50.31                    I50.32              I50.33                           I50.30
Systolic & Diastolic       I50.41                    I50.42              I50.43                           I50.40
Unspecified                                                                                                          I50.9

Left-sided heart failure is often the precursor for right-sided heart failure.  Failure of left ventricular function causes a back-up of pressure to the lungs and ultimately, the right side of the heart.  This domino effect continues with fluid backing-up in the veins.

Congestive heart failure (CHF) (I50.9) is manifested with swelling in bodily tissues, especially legs and ankles.  Shortness of breath may occur when fluid backs-up and collects in lung tissue (pulmonary edema).  CHF happens when the heart is not pumping out blood at a normal rate, and back-up into the veins occurs.  

It is important to note that the American Heart Association has established a classification system for heart failure, A-D.  Class or stage A means that objectively there is no evidence of cardiovascular disease, and that ordinary physical activity is not limited and does not produce any symptoms.  Bearing this in mind, Coding Clinic has indicated that it is inappropriate to code stage A heart failure to I50.9 as the patient does not yet have the disease, even though they have risk factors.  Coders are therefore instructed to use Z91.89, Other specified personal risk factors, not elsewhere classified, to indicate the increased risk status.  Additional codes could be assigned for other conditions which might factor into the risk level such as hypertension or coronary artery disease.

When systolic/diastolic dysfunction is noted along with congestive heart failure, there must be linkage in the documentation to assign systolic or diastolic CHF.  For example, if documentation states chronic CHF with systolic dysfunction, the provider has indicated a relationship using the term “with” so code I50.22 can be assigned.  If on the other hand, the provider stated chronic CHF and systolic dysfunction, there is no linkage and only code I50.9 can be assigned.

Finally, coders have been instructed to assign I11.0 (hypertensive heart disease) in conjunction with an I50.- (heart failure) code to correctly code hypertension and heart failure even in the absence of provider documentation specifically linking the two conditions.  Coders are reminded that there is a presumptive relationship between hypertension and heart involvement, and that these conditions should be coded using the combination code of I11.0 and then the appropriate heart failure code by following the “use additional code” note unless documentation by the provider states that the conditions are unrelated. 

Now you are In the KNOW!! 

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.

Initial, Subsequent, and Sequela 7th Character Assignment for Injuries, Poisonings, and Fractures

Explore the distinction between initial, subsequent, and sequela 7th character assignment for injuries, poisonings, and fractures in this episode of “In the kNOW.”  The usage of these 7th characters is intended to illustrate the care received for a particular patient encounter.  Let’s look at the meaning of each of these terms to help develop a better understanding of their application.

The 7th character used for initial care is “A” for active care which is explained as:

• Emergency room care 
• Surgical care  
• Evaluation/treatment by same/different physician

It is important to remember that not all surgical care will be active treatment however.  Consider a patient who had a Colles fracture with ORIF and now has a nonunion.  The internal fixation device must be removed so that is a procedure that will be performed after the patient had the active (initial) surgery for the repair and will not carry the “A” designation.  

Additionally, not every physician visit will be active care, even it is the first time a physician sees a patient.  For example, a boy had an ankle fracture and received surgical treatment.  Now, his family has moved to a new city and he has to see a new orthopedist in follow-up. That visit will be of a subsequent nature and carry the appropriate 7th character to reflect that status.

Active care may also be staged or necessitate multiple visits/physicians.

“D” is the 7th character used to show subsequent care for routine healing and recovery.  This can be used in a variety of circumstances such as:

• X-rays to monitor fracture healing
• Cast change/removal
• Internal/external fixation device removal
• Adjustment of medication
• Other types of aftercare or follow up visits

The 7th character for sequela is “S”.  A sequela is a condition/complication that is a direct result of another condition.  Think scar as a result of a burn.  The scar is the sequela.  An important note for sequelae is that there is no time table for a sequela.  It can be evident immediately after an injury or condition like dysphagia following a stroke, or it can take years to manifest such as the development of pleural calcifications years after TB.

The number of 7th characters expands when we talk about fractures.  Here the 7th character will tell if the fracture is:

• Closed/open  (A, B)
• Routine/delayed healing  (D, G)
• Nonunion/malunion  (K, P)
• Sequela  (S)

We’ll find another layer of specificity for those fractures that are designated with the Gustilo classification; open fractures of the forearm, femur, and lower leg.  These 7th characters take into consideration which type of Gustilo classification fits the fracture as outlined below:

• B=initial, open, type I or II
• C=initial open, type IIIA, IIIB, or IIIC
• E=subsequent, open, type I or II routine healing
• F=subsequent, open, type IIIA, IIIB, or IIIC routine healing
• H=subsequent, open, type I or II delayed healing
• J=subsequent, open, type IIIA,IIIB, or IIIC delayed healing
• M=subsequent, open, type I or II nonunion
• N=subsequent, open, type IIIA, IIIB, or IIIC nonunion
• Q=subsequent, open, type I or II malunion
• R=subsequent, open, type IIIA, IIIB, or IIIC malunion

With one exception, aftercare codes should not be assigned when coding care related to injuries, poisonings, and fractures because the 7th characters that have been discussed above provide a more specific indication of the type of aftercare given.  The exception is when a joint prosthesis has been previously removed due to a complication and now, at the episode of care when the replacement prosthesis will be inserted, an aftercare code is appropriate (Z47.3X)-aftercare following explantation of joint prosthesis (staged procedure).   

A final thought, for complications, active treatment relates to the treatment directed to the condition described by the code, not the problem that caused the condition which may have occurred earlier.  For instance, if a patient had a hip fracture and had to have a joint prosthesis which became infected, the code would be for the complication of the joint prosthesis which is infected, not the hip fracture which no longer exists but caused the need for the joint prosthesis. 

Now you are In the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.

Epidural Steroid Injection (ESI) Codes

This installment of “In the kNOW” focuses on the changes to epidural steroid injection (ESI) codes.  Previous codes that identified ESIs have been deleted (62310, 62311, 62318, and 62319) and have been replaced with new codes ranging from 62320-62327. 

ESIs are a common, minimally invasive, treatment method for addressing pain that is the result of inflammation of spinal nerves.  Causes of the pain can be the herniation of an intervertebral disc, spinal stenosis or spondylolysis.  Two medications work in tandem when an ESI is administered.  The first component is a local anesthetic which will work to provide immediate symptom (pain) relief while the second is a corticosteroid which works to reduce the inflammation over time thus affording longer pain relief.  

Until the 2017 CPT update, ESI coding was based on:

the injection site: cervical/thoracic or lumbar/sacral,
            and
the method of administration: injection or injection with indwelling catheter.   

The new 2017 CPT codes for ESIs now include whether or not the ESI was administered with imaging guidance.
–    62320 injection C or T without Imaging Guidance
–    62321 injection C or T with Imaging Guidance
–    62322 injection L or S without Imaging Guidance
–    62323 injection L or S with Imaging Guidance
–    62324 injection with catheter C or T without Imaging Guidance
–    62325 injection with catheter C or T with Imaging Guidance
–    62326 injection with catheter L or S without Imaging Guidance
–    62327 injection with catheter L or S with Imaging Guidance

As coders begin the process of coding for ESIs now, the first consideration will be to determine where the needle or catheter enters the body.  Coders should note that the threading of the catheter into the epidural space, the injection of one or more levels, and the subsequent catheter removal are all components of a single injection.  The ESI should be considered a single injection even if the administered agent spreads to another level or the catheter tip moves into another region.  

When a catheter is placed for an ESI and is used on a single calendar day, coders should report ONE injection only, even if more than one injection is given.  Catheters that are left in place for more than one day in order to provide a bolus or continuous treatment will be coded to the new codes 62324-62327.

Now you are In the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.

CPT Code Changes for 2017

This “In the kNOW” topic addresses a major change in CPT coding for 2017 regarding moderate (conscious) sedation.  This type of sedation allows a patient to purposefully respond when given verbal commands after being medicated.  It is not necessary to provide airway or cardiovascular support, and the patient’s own breathing is sufficient.  In the past, moderate sedation was considered part of select CPT codes and identified by the presence of an encircled bullet symbol, like this:

Effective January 1, 2017, there is a new way to code for moderate sedation thus resulting in revisions to many codes.  
 

A review of Appendix B indicates a large number of codes impacted by this change which is also reflected by review of Appendix G which has been removed from CPT.  Review of the explanatory note found under Appendix G provides coders with the information that the moderate sedation symbol, has been removed from the codes it was previously associated with and that is confirmed in Appendix B, where we see the codes preceded by the moderate sedation symbol with a strikethrough, like this: 

Appendix G now refers coders to new CPT codes 99151-99157 in order to capture moderate sedation, and Appendix B indicates that codes 99143-99150 which applied to procedures where it was appropriate to code moderate sedation separately have been deleted.  These new moderate sedation codes are inclusive of preservice, intraservice, and postservice work.  However, the code selection is solely based on the intraservice time as the pre and post work are included in the codes.  Components of the intraservice time include:

• Starts with administration of sedation
• Ends with completion of procedure, determination that patient is stable, and provider face-to-face time concludes
• Initial and subsequent orders and administration of sedation are included
• Continuous face-to-face time by provider is required
• Patient is monitored for sedation response

The new section of moderate sedation codes (99151-99157) are based on 15 minute increments of time as well as the age of the patient, and whether or not the sedation is provided by the same individual who is performing the diagnostic or therapeutic service.  For example, code 99151 is for the first 15 minutes of conscious sedation on a patient who is younger than 5 years old by the same provider performing the diagnostic or therapeutic service.  Add-on codes 99153 and 99157 are for each additional 15 minutes of intraservice time regardless of age.    

Further information on this important change in CPT can be found in the 2017 CPT Manual under Appendices B and G, and in the notes preceding the new CPT codes 99151-99157.  

Now you are In the kNOW!!

If you are interested in learning more about the CPT code updates coming in 2017, register for our webinar on this topic!  

Dianna Foley, the author of this article, will be the presenter on the webinar.  

 See our website for registration and details.

 
About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.

ICD-10-CM 2017 Guideline Changes: Abnormal Findings, Present on Admission Findings

"In the kNOW" has been presenting a review of the ICD-10 Coding Guidelines and this edition is focusing on ICD-10-CM changes in Section II, Section III, Section IV, and Appendix A.   

The only changes to Section II: Selection of Principal Diagnosis and Section III: Reporting Additional Diagnoses guidelines is the addition in paragraph three of the sentence that instructs coders that the Uniform Hospital Discharge Data Set (UHDDS) definitions are applicable to all levels of hospice care in addition to acute care, short term, long term, psychiatric hospitals, home health agencies, rehab facilities, nursing homes, etc. 

Section IV: Diagnostic Coding and Reporting Guidelines for Outpatient Services presents an addition in the first paragraph which states that the guidelines in Section I are applicable to outpatient services including office visits.  There is also an addition to the variations between inpatient and outpatient coding guidelines which states for hospital-based outpatient services and provider-based office visits, the UHDDS definition of principal diagnosis is not applicable.  The final change to Section IV is under P. Encounters for general medical examinations with abnormal findings.  Here the definition of abnormal findings is clarified by stating the meaning is identification of a new condition or diagnosis or the worsening of a chronic condition.  The coding direction remains the same, with assignment of the code for general medical exam with an abnormal finding coded first and an additional code assigned for the specific abnormal finding.

Appendix I which addresses Present on Admission Reporting Guidelines has a few updates.  The first addition is the identification of the CDC website locating all ICD-10-CM codes where Present on Admission (POA) indicator assignment is not necessary.  The codes that are exempt from POA assignment are either always present on admission, or are not considered a current disease or injury.  Two other clarifications to POA guidelines were made.  Under Acute and Chronic Conditions, clarification was added stating that the guideline for codes that contain multiple clinical concepts should be used if one code identifies both an acute and chronic condition.  An additional paragraph was then added to Codes that Contain Multiple Clinical Concepts indicating that the POA assignment “Y” should be entered if all the concepts included in a code were present on admission.  Previous information stating that POA indicator “N” was to be used if even one concept in a multiple concept code was not present on admission still stands.  

This concludes our review of the ICD-10 guideline changes for 2017.  The next posting of “In the kNOW” will look a major CPT coding change for moderate (conscious) sedation upcoming for 2017.

This link will direct you to the CMS webpage for everything ICD-10-CM related:
https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-CM-and-GEMs.html

Now you are In the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.