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.

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.

ICD-10-CM 2017 Guideline Changes: Newborns, Coma Scale, 7th Character, and More!

This issue of “In the kNOW” contains a review of the final Chapter-Specific Coding Guidelines of Section I.C which are applicable to all healthcare settings. 
 
We begin by examining Chapter 16 where there is new guidance at I.C.16.b.1 for observation and evaluation of newborns for suspected conditions not found.  When a healthy infant is evaluated or observed for a suspected condition which is ruled out, coders should assign a code from the Z05 category.  When signs or symptoms of a condition are present, then the signs or symptoms should be coded instead of the Z05 category code.  I.C.16.b.2 states that coders can use the Z05 category code as a principal diagnosis when Z38 codes are not appropriate, such as for readmissions.  I.C.16.b.3 tells coders that Z05 category codes are permitted to be used on the birth record, but only as a secondary diagnosis after the appropriate Z38 code for place of birth and type of delivery is entered as the principal diagnosis.
 
Chapter 18 that covers symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified first revised the coma scale at I.C.18.e.  Here coders are directed that the coma scale can be used in for assessing the central nervous system regardless of the medical condition.  This means that it is applicable for non-trauma conditions.  Also, in Chapter 18 at I.C.18.i, there is discussion of the usage of the NIH stroke scale code.  This code may be used in conjunction with an acute stroke code but should be sequenced secondarily.  Multiple scores may be assigned based on facility protocol, but at a minimum the initial score should be recorded.  Section I.B.14 is referenced for the documentation that is acceptable for assigning this code.

Several revisions occur in Chapter 19 (Injury, poisoning, and certain other consequences of external causes).  The first is I.C.19a where the 3rd and 4th paragraphs discuss the use of the 7th characters “A” and “D”.  The 3rd paragraph clarifies that the “A” 7th character is used for each encounter where the patient is receiving active treatment.  The 4th paragraph states that the “D” 7th character is used when the patient has completed active treatment and is in the healing or recovery phase and receiving routine care.  I.C.19.c.1 has two revisions for initial vs. subsequent encounter for fractures.  The first states that the 7th character for initial encounter is used for each encounter where the patient is receiving active treatment for the fracture.  Also addressed are the 7th character for open fractures of the femur, lower leg (including the ankle) and the forearm which are based on the Gustilo classification.  When the Gustilo classification is not provided for an open fracture, the 7th character assigned should be for Type I or Type II.  Adverse effects, poisoning, underdosing, and toxic effects have a guideline update at I.C.19.e.5.b poisoning.  Here coders are instructed that if the intent of a poisoning is unknown or unspecified, it is to be coded to accidental.  Undetermined intent is only to be used when documentation states the cause cannot be determined.  The last revisions in Chapter 19 occur at I.C.19.f (Adult and child abuse, neglect, and other maltreatment).  The first change expands the code section referenced in paragraph 3 to (X92-Y09).  The other change is the distinction of codes Z04.41 adult rape, and Z04.42 child rape.  

The final chapter-specific guidelines are for Factors Influencing Health Status and Contact with Health Services (Chapter 21).  I.C.21.c.3 is for status codes and there are several changes including the addition of Z19 for hormone sensitivity malignancy status.  Additionally, a note was added at Z68 stating that the assignment of the code for BMI is only to be used when it meets the definition of reportable diagnosis.  Changes were made at I.C.21.c.6 for observation including the insertion of the word “three” when indicating the observation code categories.  Also, mention is made that the observation codes are to be listed as the principal diagnosis only, with the only exception when the Z05 code for observation of a suspected condition for a newborn is ruled out on the infant’s birth record.  In that instance, a code from the Z38 category will be sequenced first followed by the Z05 category code.  At I.C.21.c.7 (aftercare), Z51 was expanded to encounter for other aftercare and medical care.  Encounters for Obstetrical and Reproductive Services (I.C.21.c.11) states that Z3A codes identifying the weeks of gestation are not to be assigned with abortive outcomes, elective termination of pregnancy, or postpartum conditions.  Under Miscellaneous Z-codes (I.C.21.c.14), specifically Prophylactic Organ Removal a new code was added – Z29 encounter for other prophylactic measures.  In the same section, a note was added to Z72 – problems related to lifestyle, that this code is assigned only when documentation specifically states that the patient has an associated problem.  

The next posting of “In the kNOW” will look at the remainder of the guideline changes for ICD-10-CM 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.

ICD-10-CM 2017 Guideline Changes: Ulcers, Fractures, High-Risk Pregnancies

The 6th edition of “In the kNOW” continues the review of I.C (Chapter-Specific Coding Guidelines) which are applicable to all healthcare settings. 
 
Chapter 12 (Diseases of the Skin and Subcutaneous Tissue) saw revisions to pressure ulcer guidelines.  These are very significant changes for coders to be aware of.  I.C.12.a.5 is the guideline for patients admitted with pressure ulcers documented as healing.  For pressure ulcers that were present on admission (POA) but healed at the time of discharge, coders are to assign the code for the site and stage of the ulcer at the time of admission.   The biggest change is seen in I.C.12.a.6 for patients admitted with pressure ulcers that evolve into another stage during the admission.  Coders are now being directed that to appropriately capture that condition will require two codes; one for the site and stage of the pressure ulcer at the time of admission, and one for the same ulcer site and highest stage reported during the patient’s stay.  

Chapter 13 (Diseases of the Musculoskeletal System and Connective Tissue) had one update at I.C.13.c under Coding of Pathological Fractures.  This guideline expands the description of the 7th character to include “routine care of the fracture during the healing and recovery phase as well” as treatment of complications of fractures such as malunions or nonunions, as well as sequela.

There are several guideline updates in Chapter 15 (Pregnancy, Childbirth, and Puerperium).  Supervision of high-risk pregnancy at I.C.15.b.2 states that O09 category codes are only for use during the prenatal period.  High-risk pregnancies that result in a complication arising during labor or delivery should be coded with the appropriate complication code(s).  If no complications occur, then O80 for uncomplicated delivery should be assigned.  I.C.15.b.4 provides guidance for an obstetric patient who is admitted and then delivers.  In cases like that, the condition that necessitated the admission should be the principal diagnosis, and in a case where multiple conditions caused the admission, the diagnosis most related to the delivery should be assigned as the principal diagnosis.  Any complications should be assigned secondarily.  I.C.15.h looks at long-term use of insulin and oral hypoglycemic drugs for OB patients who are diabetic.  This reiterates the new guidance in I.C.4.a.3 and I.C.4.a.6 for using Z79.84 for long-term use of oral hypoglycemic drugs just as Z79.4 is used for long-term insulin use.  Here there is additional information given that says if a patient’s diabetes is said to be controlled with both oral hypoglycemic drugs and insulin, then only code the insulin control.  I.C.15.i goes on to address gestational diabetes.  Codes in O24.4 are for diet controlled, insulin controlled, or oral hypoglycemic controlled diabetes.  If there is documentation of both diet and insulin control, only code the insulin.  If there is documentation of both diet and oral control, code only the oral.  The codes Z79.84 and Z79.4 are NOT to be used in addition to codes from O24.4.

Our next issue will explore the final Chapter-specific guideline changes to ICD-10-CM 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.

ICD-10-CM 2017 Guideline Changes: Zika, Hypertension, STEMI and more!

Issue 5 of “In the kNOW” will be reviewing I.C (Chapter-Specific Coding Guidelines).  These are the guidelines that address specific issues relevant to a particular ICD-10-CM chapter and are to be applied in all healthcare settings.  Some chapters may have no updates, while others will have a number of revisions.  So let’s begin.

First, there are 11 chapters that had no coding guideline changes for 2017.  They are chapters: 2, 3, 5, 6, 7, 8, 10, 11, 14, 17, and 20.

The addition to Chapter 1 guidelines for “Certain Infectious and Parasitic Diseases” (I.C.1.f) deals with the Zika virus.  Under this new guideline, coders are instructed to assign the code for Zika virus infection only for confirmed cases of the disease.  This is an exception to the inpatient guideline that states for suspected, possible, probable, or rule out diagnoses to code them as if they exist.  For Zika infections, only code confirmed cases.  A confirmed case can rely solely on the provider’s diagnostic statement and does not require documentation of the test.  If the physician documents suspected, possible, probable, or rule out Zika, then code the symptoms or Z20.828 for contact or exposure to other viral communicable diseases.  

Chapter 4 (Endocrine, Nutritional, and Metabolic Diseases) also saw revisions.  I.C.4.a.3 (Diabetes and use of insulin and oral hypoglycemics) and I.C.4.a.6 (Secondary diabetes) were both revised to include the new code Z79.84 (long-term use of oral hypoglycemic drugs).  This is to be used much like Z79.4 which depicts a patient’s long-term use of insulin.  

Several revisions occur in Chapter 9 (Diseases of the Circulatory System).  The first is under Hypertension at I.C.9.a that states that because the word “with” is used in the Alphabetic Index, a causal relationship can be assumed between hypertension and kidney involvement and hypertension and heart involvement.  Based on that direction (see further discussion of this topic in “In the kNOW- 3”), unless specifically stated in the documentation that the conditions are unrelated, those conditions are to be coded as related even if there is no physician documentation linking them.  For any other conditions that are not linked to hypertension by phrases such as associated with, due to, or with, there must be specific physician documentation that links them in order to be coded as related.  

I.C.9.a.1 Hypertension with heart disease reiterates the above point by restating that the conditions are coded as related unless the physician has specifically documented a different cause.  I.C.9.a.2 directs coders not to CKD (chronic kidney disease) as hypertensive if the physician has identified a different cause.  I.C.9.a.3 states that hypertensive heart and CKD are assigned using a combination code when the hypertension occurs with both heart and kidney disease.  I.C.9.a.10 is a new guideline addressing the coding of hypertensive crisis with codes from the I16 category.  An additional code should be used to code an identified hypertensive disease with the sequencing then based on the circumstances of the admission.  

A final change to the Chapter 9 guidelines is a small one at I.C.9.e.1 which addresses ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI).  The third paragraphs talks about assigning I21 category codes if, within or equal to four weeks from the onset of the MI, the MI meets the definition for “other diagnoses” as outlined in Section III- Reporting Additional Diagnoses”.  

Our next issue will continue to explore the Chapter-specific guideline changes to ICD-10-CM 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.

ICD-10-CM 2017 Guideline Changes: Laterality, Coma and Stroke Scale, and Complications of Care

In the last edition of “In the kNOW”, the spotlight was on the ICD-10-CM guideline changes from Section I.A addressing conventions for the ICD-10-CM.  This included the expanded guideline concerning the term “with” and a new guideline on diagnosis code assignment and clinical criteria.  The next part of conventions, general coding guidelines, and chapter specific guidelines that will be reviewed will cover I.B (General Coding Guidelines).
 
The first guideline with an update in Section I.B is 13 which focuses on laterality.  Coders are instructed on the appropriate way to code bilateral conditions when that condition is treated in separate encounters.  This revised guideline states that the bilateral condition should be coded as such even during the first encounter to treat the condition, as at that time both side are still affected.  After treatment of one side which corrects the condition, only a unilateral code should be assigned for a second visit, since the condition is now only present on one side.  The exception to this is if the original treatment did not completely resolve the condition, then the bilateral code assignment would still be warranted.

Section I.B.14 presents the next guideline change and discusses the inclusion of the coma scale and NIH stroke scale (NIHSS) documentation.  This is the same guideline that provides information for BMI, pressure ulcer stages, and depth of non-pressure ulcers.  Under the revision, coders are instructed that they may take the documentation of the coma scale from an emergency medical technician, much as they might take the BMI from a dietitian.  There is a reminder that the diagnosis of acute stroke must be provided by the physician.  Further, coders are reminder that the diagnoses of coma scale and NIHSS-like BMI- may only be used as secondary diagnoses.
 
The final guideline change to Section I.B is to guideline 16 where documentation of complications of care is outlined.  A small change was made to the wording in this guideline which explains that the coding of a complication of care must be based on the physician’s documentation indicating a relationship between the condition and the care or procedure provided, unless otherwise instructed by the classification.  Those final words presented in bold are the revision to the guideline and simply allow coders to assign complications if directed by the classification system.
 
The next “In the kNOW” will begin to highlight changes under the chapter specific guidelines.   

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.