Glaucoma

One of the leading causes of blindness in older individuals is glaucoma, so in this edition of “In the kNOW”, we’ll discuss coding for this serious condition.  First, however, let’s get a better understanding of the disease.  In glaucoma, the optic nerve is damaged which results in loss of vision.  This is often the result of increased pressure within the eye due to a buildup of aqueous humor.  The increase in fluid could be a result of poor drainage through the trabecular meshwork or overproduction.  The loss of vision that occurs with glaucoma is irreparable, and there is no cure for glaucoma.  However, early diagnosis of the condition can help prevent or minimize vision loss.  This is one reason why regular ophthalmologic appointments are so important as the vision loss with glaucoma can be insidious, worsening slowly without the patient realizing there is a problem.  Without proper treatment, blindness will result from glaucoma. 

ICD-10-CM addresses glaucoma in the Official Coding Guidelines.  The first guideline related to glaucoma focuses on the fact that there are many types of glaucoma (low-tension, open-angle, angle-closure, etc.), and that to accurately reflect the patient’s condition, coding professionals should assign as many codes from the H40 category as necessary to convey the patient’s diagnosis.  The codes in the H40 category capture the type and stage of the glaucoma, along with the affected eye.

The next guideline revolves around coding for bilateral glaucoma.  When the type and stage of the glaucoma is the same in both eyes, if there is a code for “bilateral”, then that is the code that should be assigned.  However, in the circumstance that the type and stage of the glaucoma are the same in both eyes, but there is no code that reflects “bilateral”, (for example, in subcategories H40.10 and H40.20), then coding professionals are instructed to assign only ONE code.  In both circumstances noted here, the seventh character assigned will indicate the stage of the glaucoma.

Bilateral glaucoma coding continues to be addressed in the third guideline.  While the second guideline dealt with same type and stage of glaucoma, this guideline addresses coding when there is bilateral glaucoma but with different type or stage.  When such is the case, a code should be assigned for each eye based on glaucoma type and stage for the specific eye.  When coding bilateral glaucoma of different types, if laterality is not distinguished in the code (for example, in subcategories H40.10 and H40.20), coding professionals are required to assign one code for EACH type of glaucoma using the seventh character to reflect the stage.  When coding bilateral glaucoma of different stages but the same type, if laterality is not distinguished in the code (for example, in subcategories H40.10 and H40.20), the instruction is to assign a code for the type of glaucoma for each eye using the appropriate seventh character to capture the stage.

The fourth glaucoma guideline provides instruction on how to code glaucoma for an inpatient whose condition has worsened during their stay.  In this instance, the glaucoma code assigned should reflect the highest stage that was documented during the admission.

The final guideline related to glaucoma provides clarification on the term “indeterminate” stage.  Coding “indeterminate” stage for glaucoma means that clinical determination of the glaucoma stage cannot be made by the provider.  It is important for coding professionals to be mindful of the distinction between “indeterminate” and “unspecified” stages.  “Unspecified” is assigned for a glaucoma stage only when there is no documentation at all regarding the glaucoma stage.   

Review of the guidelines will enable coding professionals to correctly apply codes for glaucoma conditions.

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.

Modifiers

This edition of “Spotlight on CPT” will focus on modifiers.  Let’s begin by identifying what a modifier is.  A modifier, in CPT, is comprised of two-characters which acts to supply more detail about a procedure without altering the actual definition of the procedure itself.  For example, modifier 50 will indicate that the procedure being modified was performed bilaterally.  Modifiers are appended to a CPT procedure code with a hyphen.  Look at code 64721-50.  64721 indicates a carpal tunnel release procedure was performed; modifier 50 tells that it was performed bilaterally.    

Modifiers can be found in the CPT manual in Appendix A and inside the front cover of the AMA publication.  Appendix A provides definitions for the modifiers which are only listed inside the cover of the manual.  Modifiers are categorized for use by providers or hospital outpatient facilities.  Additionally, as they relate to hospital outpatient facilities, there are Level I (CPT) modifiers and Level II (HCPCS) modifiers.  The Level II modifiers allow greater specificity when distinguishing between eyelids (E1, E4) or fingers/toes (T4, F5), capturing heart vessels (LD, RC), or establishing laterality (LT, RT).

It’s worth noting that the list of modifiers which apply to providers is different (longer) than the list for hospital outpatient facilities.  Most of the modifiers for hospitals overlap with the list for providers.  However, there are some modifiers which are specific only to hospital outpatient services.  These are modifiers 27, 73, and 74.  Modifier 27 indicates that there are multiple outpatient E/M encounters on the same date of service.  Modifiers 73 and 74 are used in hospital outpatient settings when a procedure is discontinued.  Modifier 73 is assigned if the procedure is discontinued before the patient receives anesthesia, whereas modifier 74 is used once anesthesia has been administered.  

One of the trickiest modifiers to apply is modifier 59.  This modifier is used to indicate a distinct procedural service.  This modifier is often assigned to bypass National Correct Coding Initiative (NCCI) edits.  Unfortunately, its indiscriminate use has led to fraud and abuse prompting the Centers for Medicare and Medicaid Services (CMS) to provide new modifiers to be used in place of modifier 59.  These X modifiers are not mandatory, leaving facilities and providers to make their own determination on whether or not to implement their usage.  The four X modifiers are as follows:

                XE-separate encounter

                XS-separate structure

                XP-separate provider

                XU-unusual non-overlapping service

It is valuable to understand what constitutes a distinct service.  CMS published “Modifier 59 Article” to clarify that term and provide relevant examples with rationales to assist coding professionals in appropriate application of this modifier.  The article can be found at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads/modifier59.pdf

Physical status modifiers (P1-P6) are a specific subset of modifiers for use exclusively with anesthesia codes.  These modifiers give an indication of the patient’s overall health before surgery.  An example is physical status modifier P1 which means that the procedure is performed on a normal, healthy patient. 

Now, light has been shed on modifiers.

 

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.

New Year, New ICD-10-CM Codes?

by June Bronnert, MSHI, RHIA, CCS, CCS-P

This year, 2020, provided new and extraordinary situations due to 2019 novel coronavirus or COVID-19.  Healthcare continues to manage surges in demands for certain services while balancing other elective services.  All of this brought many new challenges to the industry ranging rapid establishment of field hospitals to accurate reflection of the pandemic through industry standard code sets. 

Activating COVID-19 related codes occurred internationally and domestically in various unprecedented off-cycle releases.  The codes reflect COVID-19 procedures and diagnoses.  Procedure code systems such as LOINC, CPT, HCPCS, and ICD-10-PCS released codes supporting laboratory tests, treatment, and vaccination codes to keep pace with industry activities.  Diagnostic code systems such as ICD also released codes across the globe.  The World Health Organization (WHO) originally activated two emergency use U codes related to COVID-19. 

Those codes are as follows:

• U07.1 COVID-19, virus identified
• U07.2 COVID-19, virus not identified

In the United States, the ICD-10 Coordination and Maintenance Committee implemented U07.1 COVID-19, effective April 1, 2020. The ICD-10-CM Official Coding and Reporting Guidelines were updated to reflect the new U COVID-19 code along with other various clinical COVID-19 related scenarios. 

The medical understanding of COVID-19 continues to advance.  Other associated conditions and long- term effects from COVID continue to manifest, such as multisystem inflammatory syndrome or persistent fatigue and require healthcare services.  The need for ICD codes to reflect the conditions remains a top priority domestically and internationally.  The WHO has activated additional emergency use U codes to capture the different conditions.  The codes are as follows:

• U08.9 Personal history of COVID-19, unspecified
• U09.9 Post COVID-19 condition, unspecified
• U10.9 Multisystem inflammatory syndrome associated with COVID-19

In the United States, the committee, based upon input from the community, proposed new codes during the September 8-9, 2020 meeting to reflect data capture and the evolving clinical picture of COVID-19.  The proposed effective date is January 1, 2021.

The following new codes were proposed:

• J12.82    Pneumonia due to coronavirus disease 2019
• M35.81     Multisystem inflammatory syndrome
• M35.89 Other specified systemic involvement of connective tissue
• Z11.52    Encounter for screening for COVID-19
• Z20.822     Contact with and (suspected) exposure to COVID-19
• Z86.16    Personal history of COVID-19

The ICD-10 Coordination and Maintenance Committee received multiple requests to create unique codes of screening, exposure, and personal history of COVID-10 due to the significant public health impact from the virus.  The committee announced at the end of November further COVID-19 related additions to ICD-10-CM.

The new codes support ongoing data needs for healthcare due to the pandemic in a variety of fashions.  The codes identify a variety of clinical situations.  As individuals are receiving tests for a variety of reasons the codes distinguish the reasons, such as a suspected exposure versus a screening.  Another scenario is individuals who have had COVID.  A personal history specific to COVID-19 supports identification of individuals who have had COVID-19.  Identifying this patient cohort with a unique code can support ongoing research efforts.  The research will continue to advance the medical understanding of the disease process.  

The two additional requests, M35.81 Multisystem inflammatory syndrome (MIS) and J12.82 Pneumonia due to coronavirus disease 2019 captures associated COVID-19 conditions.  MIS associated with COVID-19 is a new condition, M35.81 uniquely identifies the condition and support ongoing surveillance efforts.  The request for code J12.82 to capture pneumonia due to COVID-2019 was based upon review of Centers for Medicare and Medicaid (CMS) and Centers for Disease Control (CDC) data.  The data suggests under reporting of the two codes identified in the current coding guidelines to report the condition.

The current 1.g.1.c.i guideline for pneumonia directs one to assign U07.1, COVID-19 and J12.89, Other viral pneumonia for confirmed pneumonia due to the 2019 novel coronavirus.  The guidelines will need revised not only indicate the new code (J12.82) but also if U07.1 is still appropriate to report as the code descriptor for J12.82 indicates the connection to the 2019 coronavirus.

The ICD-10-CM Official Coding and Reporting Guidelines were revised to provide coding advice for a variety of clinical situations related to COVID-19.  The guidelines were updated when U07.1, COVID-19 was implemented.  As the new codes are implemented, watch for updates to the coding guidelines to reflect the clinical scenarios to apply the new codes.   

The effective date is January 1, 2021 for the new COVID-19 related codes.  Keep watching the ICD-10-CM Coordination and Maintenance website for additional details regarding guidance and the new codes:  https://www.cdc.gov/nchs/icd/icd10cm.htm
 

About the Author 

June Bronnert, MSHI, RHIA, CCS, CCS-P is the Senior Director of Informatics at Intelligent Medical Objects Inc. (IMO) where she provides health information management subject matter expertise internally and externally for IMO’s terminology solutions.  She serves as a Committee Member on OHIMA’s Blog Committee in FY2020-21.