Update ICD 10 Coding Changes and Preview of OASIS D

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The I20 – I25 Issue
                                                                           • Use additional code to identify presence of
                                                                             hypertension (I10‐I16)
       Update ICD‐10 Coding                                                • This is sequencing direction.
                                                                           • This means that if the patient has hypertensive
       Changes and Preview                                                   heart failure as the focus of care, but happens to
                                                                             have CAD or an old MI, that has to be coded prior
            of OASIS D                                                       to the hypertensive heart failure.

             Lisa Selman‐Holman, JD, BSN, RN, HCS‐D, COS‐C, HCS‐O, HCS‐H

      My email to NCHS and their response                                              Related Issue at I60‐I69
• I submitted a proposal regarding the sequencing convention
  found at I20‐I25 indicating that any code in I20‐I25 needed to be        • Use additional code to identify presence of:
  coded prior to hypertension. I noted that it was not included in             • Hypertension (I10‐I15)
  the agenda of last week's meeting, nor was it included in the
  draft changes to the tabular list. Please provide an update to its       • Sequencing direction meaning even if
  status please. Was the agenda too full? Or was the proposal
  denied for some other reason?                                              hypertension, hypertensive heart failure, etc was
                                                                             the focus of care, the old stroke would have to be
• In review of inquires received in this office, it appears there may        coded first.
  have been an oversight in response to you regarding your
  inquiry. Please accept my sincere apologies.                             • This direction, however, is related to the guideline
• Over the next few weeks, the ICD‐10‐CM Classification team will            regarding Hypertensive Cerebrovascular Disease. If
  be reviewing this issue along with new issues / proposals that             that is not documented, do we have to code the
  are for consideration for the upcoming September C&M
  Meeting and possible guideline updates.                                    cerebrovascular disease before the hypertension?
• I will update you accordingly.
• Thank you for bringing this to our attention.
The Resolving Complication without the 7th
                 Character Issue                                    Based on what guideline?
• Body system complications do not have 7th
  characters                                         • 7th character “D” subsequent encounter is used for
• Transplant complications                             encounters after the patient has completed active
                                                       treatment of the condition and is receiving routine
• Amputation complications                             care for the condition during the healing or
                                                       recovery phase.
• Do we continue to code the complication until      • The aftercare Z codes should not be used for
  healed?                                              aftercare for conditions such as injuries or
• Or do we switch to aftercare?                        poisonings, where 7th characters are provided to
                                                       identify subsequent care.
• Answer from CC via letter: switch to aftercare.
                                                     • And if the D is not provided, use aftercare.

                   For example:                                               Diabetes, with

The patient has a bowel obstruction with adhesions   • Skin ulcer NEC
post gastric bypass surgery.                         • Arthropathy NEC
• K95.89 Other complications of other bariatric      • Circulatory NEC
  procedures
                                                     • Do not assume a causal relationship when the
• K56.52 Bowel obstruction                             diabetic complication is “NEC.”
Now, the surgeon has fixed the problem—but there     • Source: AHA Coding Clinic Volume 5 Second Quarter Number 2 2018
is not a D to use until the wound, etc heals.
Revert to aftercare…
Z48.815 Aftercare following GI surgery
Diabetes, with                                                   Examples
                                                                    Diabetic atherosclerosis of the extremities
• Peripheral arteriosclerosis, peripheral vascular                  • E11.51 Diabetes with peripheral angiopathy
  disease and peripheral arterial disease in a diabetic
  patient should be linked and coded as “diabetic                   • I70.2‐ Atherosclerosis of the extremities
  peripheral angiopathy.”                                           Diabetic atherosclerosis with gangrene
• Source: AHA Coding Clinic Volume 5 Second Quarter Number 2 2018   • E11.52 Diabetes with peripheral angiopathy with
                                                                      gangrene
                                                                    • I70.2‐6 Atherosclerosis with gangrene

              Other ‘with’ and ‘in’ issues                                 Diabetes, Hypertension and CKD
• Anemia
   • CKD                                                            • Diabetes and hypertension are assumed related to
                                                                      CKD.
   • Neoplasms
   • Chemotherapy                                                   • What if the physician says ‘diabetic CKD’ or
                                                                      ‘hypertensive CKD’?
• Arthropathy
                                                                    • Code them all related.
                                                                        • Exception is if the physician specifically says the
                                                                          diabetes or the hypertension is NOT related.
Changes in the Code Set                                         Lots of Changes Like This
• Every year effective October 1.                                • Revise from: L98495                          • Revise from: I63219
                                                                   Non‐pressure chronic                           Cerebral infarction due to
• Changes in the code set made by NCHS with input from             ulcer of other sites with                      unspecified occlusion or
  us!                                                              muscle involvement                             stenosis of unspecified
• Some limitations because code set is owned by WHO.               without evidence of                            vertebral arteries
• Types of Changes                                                 necrosis                                     • Revise to: I63219
   1. New codes                                                  • Revise to: L98495 Non‐                         Cerebral infarction due to
   2. Deleted codes                                                pressure chronic ulcer of                      unspecified occlusion or
   3. Changes to the tabular list                                  skin of other sites with                       stenosis of unspecified
                                                                   muscle involvement                             vertebral artery
   4. Changes to the index                                         without evidence of
   5. Guidelines                                                   necrosis

        What? You don’t see the change?                                                        Fixes Like This
                                                                   • Revise from: R402330 Coma scale, best motor response, abnormal, unspecified time
 Revise from: M5001 Cervical disc disorder with myelopathy,        • Revise to: R402330 Coma scale, best motor response, abnormal flexion, unspecified
 high cervical region                                                time
                                                                   • Revise from: R402331 Coma scale, best motor response, abnormal, in the field [EMT
 Revise to: M5001 Cervical disc disorder with myelopathy, high       or ambulance]
 cervical region                                                   • Revise to: R402331 Coma scale, best motor response, abnormal flexion, in the field
 Revise from: M86621 Other chronic osteomyelitis, right              [EMT or ambulance]
 humerus                                                           • Revise from: R402332 Coma scale, best motor response, abnormal, at arrival to
                                                                     emergency department
 Revise to: M86621 Other chronic osteomyelitis, right humerus      • Revise to: R402332 Coma scale, best motor response, abnormal flexion, at arrival to
                                                                     emergency department
                                                                   • Revise from: R402333 Coma scale, best motor response, abnormal, at hospital
                                                                     admission
                                                                   • Revise to: R402333 Coma scale, best motor response, abnormal flexion, at hospital
                                                                     admission
                                                                   • Revise from: R402334 Coma scale, best motor response, abnormal, 24 hours or more
                                                                     after hospital admission
                                                                   • Revise to: R402334 Coma scale, best motor response, abnormal flexion, 24 hours or
                                                                     more after hospital admission
New Postoperative Infection Codes
                        And things like this…
                                                                                           • T81.4xxA, T81.4xxD, T81.4xxS are deleted
                                                                                           • Added (each with a choice of A, D, or S):
  • Medial phalanx changed to middle phalanx of the                                           • T81.40X‐ Infection following a procedure,
    finger                                                                                      unspecified
  • T43641A Poisoning by ecstasy               Who knew
                                              baby stroller
                                                                                              • T81.41X‐ Infection following a procedure, superficial
                                                                                                incisional surgical site
  • V00821S Fall from babystroller, sequela      was 2
                                                words?                                        • T81.42X‐ Infection following a procedure, deep
  • V00821S Fall from baby stroller, sequela                                                    incisional surgical site
  • E671 Hypercarotinemia                                                                     • T81.43X‐ Infection following a procedure, organ and
                                                                                                space surgical site
  • Revise to: E671 Hypercarotenemia                                                          • T81.44X‐ Sepsis following a procedure
                                                                                              • T81.49X‐ Infection following a procedure, other
                                                                                                surgical site

     Postoperative Infection Definitions                                                                         Tabular Changes
• These are standardized definitions from the CDC:                                         • T81.41‐ (Infection following a procedure, superficial incisional
• Superficial incisional infection                                                           surgical site)
    • Involves only skin & subcutaneous tissue                                                 • Subcutaneous abscess following a procedure
    • May be indicated by localized signs such as redness, pain, heat or                       • Stitch abscess following a procedure
      swelling at the site of the incision or by the drainage of pus                       • T81.42‐ (Infection following a procedure, deep incisional surgical
• Deep incisional                                                                            site)
    • Involves deep tissues, such as fascial and muscle layers                                 • Intra‐muscular abscess following a procedure
    • May be indicated by the presence of pus or an abscess, fever with                    • T81.43‐ (Infection following a procedure, organ and space
      tenderness of the wound, or separation of incision edges exposing                      surgical site)
      deeper tissues
                                                                                               • Intra‐abdominal abscess following a procedure
• Organ and space                                                                              • Subphrenic abscess following a procedure
    • Involves any part of the anatomy in organs and spaces other than
      the incision, which was opened or manipulated during operation,
      such as the joint or the peritoneum                                                  • T81.44‐ (Sepsis following a procedure)
    • May be indicated by the drainage of pus or the formation of an                           • Tabular instruction:
      abscess detected by histopathological or radiological examination                            • Code first the post op infection, e.g. T81.42‐
      or during re‐operation; does not include organ infection.
      Sources: Medscape, NIH, ICD‐10 Coordination & Maintenance Committee September 2017           • Use Additional code to identify the sepsis
      proposal
                                                                                                   • (this is not changed as far as sequencing)
Tabular & Index Updates                                                                       New Neoplasm Codes
• Index entries added or revised:                                                                   • Current codes specify the eyelid for non‐melanoma
    • “Abscess, intra‐abdominal, following procedure” –                                               skin cancer, but not whether the upper or lower is
      T81.43                                                                                          involved.
    • “Abscess, intramuscular, following procedure” –                                               45 new codes:
      T81.42
                                                                                                    • Skin cancers (melanoma, basal cell, squamous cell,
    • “Abscess, stitch” – T81.41
                                                                                                      sebaceous cell, Merkel cell carcinoma, & unspecified,
    • “Cellulitis, drainage site (following operation)” –                                             as well as in situ cancers) affecting the upper and lower
      T81.49                                                                                          eyelid
    • “Fever, due to infection” – T81.40
                                                                                                    • Melanocytic nevi and other benign neoplasms affecting
    • “Infection, postoperative” – T81.40                                                             the upper & lower eyelid
    • “Sepsis, local, in operation wound” –T81.44
    • “Sepsis, postprocedural” – T81.44

           Types of Skin Cancer & Benign Skin
                                                                                                            Examples of New Neoplasm Codes
                       Neoplasms
  • Melanoma – begins in melanocytes cells; the least common but
    most serious type of skin cancer                                                                  • C43.111 (Malignant melanoma of right upper eyelid,
  • Basal cell carcinoma – abnormal, uncontrolled growths or lesions                                    including canthus)
    in the skin’s basal cells, the deepest layer of the epidermis
  • Squamous cell carcinoma – uncontrolled growth in the skin’s                                       • C43.112 (Malignant melanoma of right lower eyelid,
    squamous cells, skin’s outermost layers; second‐most common                                         including canthus)
    skin cancer                                                                                       • C43.121 (Malignant melanoma of left upper eyelid,
  • Sebaceous cell carcinoma – rare skin cancer that mostly begins on                                   including canthus)
    the eyelid
  • Merkel cell carcinoma – rare type of skin cancer that usually                                     • C43.122 (Malignant melanoma of left lower eyelid, including
    appears as a flesh‐colored or bluish‐red nodule, often on your                                      canthus)
    face, head or neck
  • Melanocytic nevi – Moles made up of skin cells that produce
    melanin                                                                                           • Note: C43.11 & C43.12 will both be invalid codes in FY2019
  • Other benign skin neoplasms – other non‐cancerous skin lesions                                       • You’ll need to know whether the melanoma is affecting
                                                                                                           the upper or lower eyelid!
  Sources: American Cancer Society, Skin Cancer Foundation, American Academy of Dermatology, Mayo
  Clinic
G71.0 Muscular dystrophy
     But watch out for those crazy C44 codes
• C44.1121 Basal cell carcinoma of skin of right upper                    • G71.00 Muscular dystrophy, unspecified
  eyelid, including canthus                                               • G71.01 Duchenne or Becker muscular dystrophy
• C44.1122 Basal cell carcinoma of skin of right lower                       • genetic disorder characterized by progressive muscle
  eyelid, including canthus                                                    degeneration and weakness. Starts as early as 3yo
• C44.1191 Basal cell carcinoma of skin of left upper                     • G71.02 Facioscapulohumeral muscular dystrophy
  eyelid, including canthus                                                  • muscles of the face, shoulder blades and upper arms
• C44.1192 Basal cell carcinoma of skin of left lower                          are among the most affected. By the age of 20
  eyelid, including canthus                                               • G71.09 Other specified muscular dystrophies

                                     CADASIL                                                     CADASIL
• I67.850 Cerebral autosomal dominant arteriopathy
  with subcortical infarcts and leukoencephalopathy
                                                                            • Code also any associated diagnoses, such as:
• What is it?
                                                                               • epilepsy (G40.‐)
    • Inherited disorder that causes strokes, brain lesions,
      and other impairments                                                    • stroke (I63.‐)
    • Frequently begins with migraines & mood disorders                        • vascular dementia (F01.‐)
      in 20s & 30s, followed by strokes in 40s & 50s                        • Found in the index under:
    • Epilepsy can occur                                                       • CADASIL
    • Multiple strokes generally leads to vascular                             • Arteriopathy
      dementia
    • Death 10 to 20 years after strokes & dementia begin

Source: ICD‐10 Coordination & Maintenance Committee March 2017 proposal
For example:                                                           Urethral Stricture
                                                         • According to the proposal:
  • The patient has a diagnosis of CADASIL with             • The etiology (i.e. post‐traumatic, post‐infective, etc.) of
    vascular dementia and a recent stroke resulting in        a patient’s urethral stricture is often unknown or
    monoplegia of the right leg.                              unspecified
                                                            • Current codes don’t allow for the specification of the
  • I67.850 CADASIL                                           location of the stricture if the etiology isn’t known
  • F01.50 Vascular dementia                                • Nor do current codes allow for the capture of strictures
                                                              involving overlapping sites
  • I69.341 (I69.841) monoplegia following cerebral
    infarction affecting right dominant side             Source: ICD‐10 Coordination & Maintenance Committee March 2017 proposal

                                                         •   Site
                                                         •   Male, female
                                                         •   Cause
                                                         •   N35 has 16 new codes plus another in N99

            Anal and Rectal Abscesses                                                  Cannabis Withdrawal
• K61.‐ category (Abscess of anal and rectal regions)    • Common among those with cannabis dependence
   • K61.0 Anal abscess                                      • those with cannabis dependence make up a substantial
                                                               percentage of treatment admission for substance use
   • K61.1 Rectal abscess                                      disorders
   • K61.2 Anorectal abscess                             • Symptoms (develop within a week of ceasing heavy,
   • K61.3 Ischiorectal abscess                            prolonged cannabis use) include
      • K61.31 Horseshoe Abscess                             • irritability, anger, or aggression
      • K61.39 Other ischiorectal abscess                    • nervousness or anxiety
                                                             • sleep difficulty
   • K61.4 Intrasphincteric abscess
                                                             • decreased appetite or weight loss
   • K61.5 Supralevator abscess                              • restlessness
                                                             • depressed mood
                                                             • physical symptoms such as abdominal pain,
                                                               shakiness/tremors, sweating, fever, chills, or headache
Cannabis Use, Dependence & Withdrawal                                                   Remember this:
• 2 new codes added to 2 subcategories within F12.‐                       • The Official Guidelines for Coding and Reporting,
  (Cannabis related disorders):                                             Psychoactive Substance (I.C.5.b.3.) state, “As with all
    • Within F12.2‐ (Cannabis dependence)                                   other diagnoses, the codes for psychoactive substance
       • F12.23 (Cannabis dependence with withdrawal)                       use (F10.9‐, F11.9‐ F12.9‐, F13.9‐, F14.9‐, F15.9‐, F16.9‐
       • For cases of cannabis withdrawal in the context                    ) should only be assigned based on provider
         of dependence                                                      documentation and when they meet the definition of a
    • Within F12.9‐ (Cannabis use, unspecified)                             reportable diagnosis (see Section III, Reporting
       • F12.93 (Cannabis use, unspecified, with                            Additional Diagnoses). The codes are to be used only
         withdrawal                                                         when the psychoactive substance use is associated
       • For cases of cannabis withdrawal in contexts                       with a physical, mental or behavioral disorder, and such
         other than dependence                                              a relationship is documented by the provider.”
Source: ICD‐10 Coordination & Maintenance Committee Sept. 2017 proposal

                                                                                                    Sepsis

                                                                            • For infections following a procedure, a code from
                                                                              T81.40, to T81.43 Infection following a procedure,
                                                                              …that identifies the site of the infection should be
                                                                              coded first, if known. Assign an additional code for
                                                                              sepsis following a procedure (T81.44). Use an
                 Guideline Changes                                            additional code to identify the infectious agent
                                                                              (A40 or A41).
Post‐procedural Septic Shock                                                Index
                                                                                         2019 Change
 • If a postprocedural infection has resulted in                                           • List of heart conditions
   postprocedural septic shock, assign the codes                                             excludes I51.81
   indicated above for sepsis due to a postprocedural                                      • Takotsubo Syndrome is
   infection, followed by code T81.12‐,                                                      not related to
   Postprocedural septic shock.                                                              hypertension. It is related
 • Do not assign code R65.21, Severe sepsis with                                             to stress, so it was
   septic shock. Additional code(s) should be                                                omitted from the list of
   assigned for any acute organ dysfunction.                                                 conditions assumed
                                                                                             caused by hypertension.

                    Hypertension                                        Hypertensive Chronic Kidney Disease
• Hypertension with heart conditions classified to I50.‐          • The classification assumes a relationship
  or I51.4‐ I51.7, I51.89, I51.9, are assigned to a code            between hypertension and chronic kidney
  from category I11, Hypertensive heart disease.                    disease.
• Use an additional code from category I50, Heart                 • CKD should not be coded as hypertensive if
  failure, to identify the type of heart failure in those           the provider indicates the CKD is not related
  patients with heart failure.                                      to the hypertension.          2019
• The same heart conditions (I50.‐, I51.4‐I51.7, I51.89,          • Code to I12.‐
  I51.9) with hypertension are coded separately if the              • Stage 5 or ESRD with hypertension I12.0
  provider has specifically documented a different                  • Stage 1‐4 or unspecified CKD with hypertension
  cause.                                                   2018       I12.9
• New language: if the provider has documented they                 • Specific sequencing required with CKD
  are unrelated to the hypertension.                      2019
                                                          39
Documentation by Clinicians Other than
         the Patient's Provider                                 Documentation by Clinicians Other than
• Code assignment is based on the documentation by                     the Patient's Provider
  patient's provider (i.e., physician or other qualified
  healthcare practitioner legally accountable for
  establishing the patient's diagnosis).
• There are a few exceptions, such as codes for the Body      • However, the associated diagnosis (such as
  Mass Index (BMI), depth of non‐pressure chronic               overweight, obesity, acute stroke, or pressure ulcer)
  ulcers, pressure ulcer stage, coma scale, and NIH stroke      must be documented by the patient’s provider.
  scale (NIHSS) codes, code assignment may be based on
  medical record documentation from clinicians who are
  not the patient’s provider (i.e., physician or other
  qualified healthcare practitioner legally accountable for   • BMI codes should only be assigned when the
  establishing the patient’s diagnosis), since this             associated diagnosis (such as overweight or
  information is typically documented by other clinicians
  involved in the care of the patient (e.g., a dietitian        obesity) meets the definition of a reportable
  often documents the BMI, a nurse often documents the          diagnosis (see Section III, Reporting Additional
  pressure ulcer stages, and an emergency medical               Diagnoses).
  technician often documents the coma scale).

  Documentation by Clinicians Other than the                                    Other Changes
             Patient's Provider                               • 2 MIs of 2 different types (Type 1 and Type 2) in the
                                                                same 4 week period
                                                                  • MI due to ischemia I21.A1
• Z55‐Z65, Persons with potential health hazards                  • AMI I21.9
  related to socioeconomic and psychosocial                       • Do not use I22 for the subsequent MI in this
  circumstances, code assignment may be based on                    case.
  medical record documentation from clinicians
  involved in the care of the patient who are not the
  patient’s provider since this information
  represents social information, rather than medical
  diagnoses.
Other Changes                                                  Underdosing
                                                             • Guideline: Codes for underdosing should never be
                                                               assigned as principal or first‐listed codes. If a patient
• Underdosing refers to taking less of a medication            has a relapse or exacerbation of the medical
  than is prescribed by a provider or a                        condition for which the drug is prescribed because of
  manufacturer’s instruction. Discontinuing the use            the reduction in dose, then the medical condition
  of a prescribed medication on the patient's own              itself should be coded.
  initiative (not directed by the patient's provider) is     • Noncompliance or complications of care codes are to
  also classified as an underdosing. For underdosing,          be used with an underdosing code to indicate intent,
  assign the code from categories T36‐T50 (fifth or            if known.
  sixth character “6”).
                                                             • C—Condition
                                                             • T—T code for underdosing of the drug
                                                             • Z—Z code for Underdosing reason (or sometimes Y)
                                                                                                                     46

              Underdosing Example
• Patient with diagnosis of Hypertension continued to
  experience elevated blood pressure while taking blood
  pressure meds. Upon patient interview, it was found
  the patient was taking medication once daily instead of
  twice daily because of the cost of the drug.

• I10 Essential (primary) hypertension
• T46.5x6D Underdosing of other antihypertensive
  drugs, subsequent encounter
                                                              Changes to the OASIS!!!!
• Z91.120 Patient's intentional underdosing of
  medication regimen due to financial hardship

                                                        47
How OASIS Changes Affect Coding
       How OASIS Changes Affect Coding                      • Only items that cannot be updated in the 5 day
Effective Now (as of August 2017)                             timeframe for SOC
• Extension of the one clinician rule                           • Pressure Ulcers
    • First clinician may not complete the assessment and       • When did the skin assessment occur?
      wait for someone else to complete (team
      assessments)
    • May collaborate more on assessment findings
    • Skin assessment is biggest impact

                       Example                                                     Example

  1. RN says that patient wouldn’t allow him to look at      • 2. RN says that the patient wouldn’t allow him to
  her bottom when he did skin assessment. Female               assess her bottom and so he did not complete the
  nurse visits on day 3 and documents pressure ulcer           skin assessment. Female nurse visits on day 3 and
  on coccyx.                                                   completes skin assessment and documents
      • Pressure ulcer marked in M1300 items?                  pressure ulcer on the coccyx.
      • Should it still be coded (considering physician          • Pressure ulcer marked in M1300 items?
        verified)?                                               • Should it still be coded (considering physician
      • Can the care still be added to the POC?                    verified)?
                                                                 • Can the care still be added to the POC?
How OASIS Changes Affect Coding

Effective January 1         BAM!
• M1011                    They’re
• M1017                     gone!
• M1025
• PDGM – up to 25 diagnoses
But also items like: M1350
• Tracking down the etiology of wounds
• Should still be there

       Conventions—Relational Terms                                                  With
• And—interpreted to mean ‘and/or’ when it                      The classification presumes a causal relationship
  appears in a code title within the tabular list               between the two conditions linked by these terms
  (C34 Malignant neoplasm of bronchus and                       in the Alphabetic Index or Tabular List. These
  lung)                                                         conditions should be coded as related even in the
                       2018
                                                                absence of provider documentation explicitly linking
                                                                them, unless the documentation clearly states the
• The word “with” or “in” should be                             conditions are unrelated or when another guideline
  interpreted to mean “associated with” or                      exists that specifically requires a documented
  “due to” when it appears in a code title, the                 linkage between two conditions (e.g., sepsis
  Alphabetic Index, (either under a main term            2019   guideline for “acute organ dysfunction that is not
  or subterm) or an instructional note in the                   clearly associated with the sepsis”).
  Tabular List.
                                                    55                                  56
“With” or “in”                                                 Examples of ‘With’
                                                                   • Reference diabetes in the index AS AN EXAMPLE
       For conditions not
                                                                   • Diabetes
      specifically linked by                                            with
   these relational terms in        If the condition is not                 amyotrophy
      the classification or        specifically listed under                arthropathy NEC
       when a guideline            with or in, then it cannot
    requires that a linkage         be linked without the
                                                                            autonomic (poly) neuropathy
   between two conditions             physician’s say‐so.                   cataract (yes, even cataracts)
          be explicitly                                                     Charcot’s joints
                                    Does a guideline say it
    documented, provider                                                    And so on…
                                      requires physician
   documentation must link
   the conditions in order to
                                       documentation?              • Not limited to diabetes…see dementia, with…
     code them as related.                                            • Dementia, with, Parkinson’s
                                                                      • Anemia in…
                                                                      • Arthropathy in…
                                                                                                                       58

    Diabetic Manifestations (and Others)                                                    Examples
• It’s not the coder that assumes—the classification
  assumes a cause and effect relationship between                   • The physician documents foot ulcer on a diabetic
  diabetes and the listed manifestations                              patient.
• The only time you do not code those manifestations                • The physician documents pressure ulcer on the right
  specifically listed, as diabetic is if the physician has            buttock on a diabetic patient.
  documented a different cause it is unrelated.                     • The patient has diabetes and also has
    • It is imperative that all documentation be                      polyneuropathy.
      reviewed for indications that there is another                • The patient has diabetes and also has alcoholic
      cause before assigning the manifestation to                     polyneuropathy documented.
      diabetes.
                                                                    • The diabetic has a gangrenous pressure ulcer.

                                                              59                                                       60
Examples
• The diabetic patient has PVD                              •   Arthropathy NEC                     • For conditions not
• The diabetic patient has arterial ulcers.                 •   Circulatory complication NEC          specifically linked by
                                                                                                      these relational
                                                            •   Complication, specified NEC           terms in the
• The diabetic has an ulcer                                 •   Kidney complications NEC              classification,
                                                                                                      provider
on his lower leg associated                                 •   Neurologic complication NEC           documentation must
                                                            •   Oral complication NEC                 link the conditions in
with stasis dermatitis with                                                                           order to code them
                                                            •   Skin complication NEC
hemosiderin staining and a                                                                            as related.
                                                            •   Skin ulcer NEC
beefy wet appearance.
    • Know when you should really                           CC Q4 2017 Do NOT link conditions
   ask                                                      not specifically listed!
                                                       61                                      62

• The patient has diabetes and OA. Do we code that
  as diabetic arthropathy?
• What about if the physician documents
  arthropathy?                                                   E ‐‐Endocrine, Metabolic
• The patient has diabetes and CAD. Is that diabetic
  CAD? No, but…                                                       and Nutritional
   • (If diabetic CAD is documented: E11.59, I25.10)

                                                       63                                      64
Diabetes Categories                                                              E08 DM due to underlying condition
    E08 DM due to underlying condition
    • Code first underlying condition (e.g., pancreatitis, pancreatic cancer, injury to
      pancreas, cystic fibrosis, malnutrition, Cushing’s)
    • Use additional code for insulin (Z79.4) or oral antiglycemics (Z79.84)                   • Any condition that impacts the pancreas function
    E09 DM due to drug or chemical                                                             • Cystic fibrosis‐ Cystic fibrosis produces abnormally
    • Sequencing depends on adverse effect or poisoning (Adverse Effect—e.g.,
      steroids, pentamidine; E09.‐, then T code for drug) (Poisoning—e.g., Dioxin,               thick mucus, which blocks the pancreas.
      arsenic; T code for drug or chemical, then E09.‐)
    • Use additional code for insulin (Z79.4) or oral antiglycemics (Z79.84)                   • Pancreatic cancer, Pancreatitis, and trauma can all
    E10 DM Type I                                                   No insulin coded             harm the pancreatic beta cells or impair insulin
    • Brittle, ketosis prone
                                                                                                 production, thus causing diabetes.
     E11 DM Type II
    • Use additional code for insulin (Z79.4) or oral antiglycemics (Z79.84)                   • Malnutrition
    • Includes unspecified diabetes
    E13 Other specified DM                                                                     • Cushing’s syndrome‐‐induces insulin resistance.
    • Secondary diabetes NEC                                                                     Cushing’s syndrome is marked by excessive
    • Use additional code for insulin (Z79.4) or oral antiglycemics (Z79.84)
    • Special sequencing when caused by removal of pancreas (E89.1, E13.‐,
                                                                                                 production of cortisol—sometimes called the “stress
      Z90.41‐, Z79.4 or Z79.84)                                                                  hormone.”
                                                                                          65                                                            66

      E09 Drug or chemical induced DM                                                                  E09 Drug or chemical induced DM
               Adverse Effect                                                                                      Poisoning
                                                                                               • Many chemical toxins can damage or destroy beta cells in
• Some medications, such as nicotinic acid and                                                   animals, but only a few have been linked to diabetes in
  certain types of diuretics, anti‐seizure drugs,                                                humans. For example, dioxin—a contaminant of the
  psychiatric drugs, and drugs to treat HIV, can impair                                          herbicide Agent Orange, used during the Vietnam War—
  beta cells or disrupt insulin action. Pentamidine, a
  drug prescribed to treat a type of pneumonia, can                                              may be linked to the development of type 2 diabetes. In
  increase the risk of pancreatitis, beta cell damage,                                           2000, based on a report from the Institute of Medicine,
  and diabetes. Also, glucocorticoids—steroid                                                    the U.S. Department of Veterans Affairs (VA) added
  hormones that are chemically similar to naturally                                              diabetes to the list of conditions for which Vietnam
  produced cortisol—may impair insulin action.                                                   veterans are eligible for disability compensation. Also, a
  Glucocorticoids are used to treat inflammatory                                                 chemical in a rat poison no longer in use has been shown
  illnesses such as rheumatoid arthritis, asthma,                                                to cause diabetes if ingested. Some studies suggest a high
  lupus, and ulcerative colitis.                                                                 intake of nitrogen‐containing chemicals such as nitrates
                                                                                                 and nitrites might increase the risk of diabetes. Arsenic
                                                                                          67     has also been studied for possible links to diabetes. 68
Examples                                                  Coding Clinic
                                                             • How do you code a patient with chronic respiratory
• The patient has steroid induced diabetes from taking         failure due to a valium overdose 3 months ago?
  corticosteroids for an upper respiratory infection last
  year.                                                          • Chronic respiratory failure
   • E09.9 Drug or chemical induced diabetes                     • Poisoning by valium, sequela
   • T38.0x5S Adverse effect of glucocorticoids,
     sequela                                                 • Wait! Isn’t this a poisoning? Shouldn’t this be
                                                               coded:
• The patient has diabetes from exposure to Agent               • Poisoning by valium, sequela
  Orange during the Vietnam conflict.                           • Chronic respiratory failure
   • T53.7x1S Toxic effect of other halogen derivatives      Response: Code it as a sequela (without
     of aromatic hydrocarbons, accidental, sequela           explanation).
   • E09.9 Drug or chemical induced diabetes
                                                        69

                    Compare                                                    E10 Type 1 DM
   Poisoning Guideline       Sequela Guideline (option)

    T53.7x1S Toxic effect       E09.9 Drug or                • Type 1 diabetes is caused by a lack of insulin
      of other halogen          chemical induced               due to the destruction of insulin‐producing
        derivatives of          diabetes                       beta cells in the pancreas. In type 1
          aromatic                                             diabetes—an autoimmune disease—the
       hydrocarbons,            T53.7x1S Toxic effect          body’s immune system attacks and destroys
     accidental, sequela        of other halogen               the beta cells.
                                derivatives of               • Genetic susceptibility
        E09.9 Drug or           aromatic
      chemical induced          hydrocarbons,
          diabetes              accidental, sequela
                                                                                                                 72
E11 Type II DM                                         E13 Other Specified Diabetes
• Caused by a combination of factors, including insulin
  resistance, a condition in which the body’s muscle,         • Genetic defects of beta cell function or insulin action
  fat, and liver cells do not use insulin effectively. Type   • Postpancreatectomy/post procedural DM
  2 diabetes develops when the body can no longer
  produce enough insulin to compensate for the                • Secondary DM, NEC
  impaired ability to use insulin.                            • Specific guideline postpancreatectomy DM
• The role of genes is suggested by the high rate of          • E89.1 Postprocedural hypoinsulinemia
  type 2 diabetes in families and identical twins and
  wide variations in diabetes prevalence by ethnicity.        • E13 code(s)
  Type 2 diabetes occurs more frequently in African           • Z90.41‐ Acquired absence of pancreas
  Americans, Alaska Natives, American Indians,
  Hispanics/Latinos, and some Asian Americans, Native         • Z79.4 insulin or Z79.84 anti‐glycemics
  Hawaiians, and Pacific Islander Americans than it
  does in non‐Hispanic whites.
                                                        73                                                            74

                   Type 1.5 LADA                                          Type 3 Alzheimers Disease
• Latent autoimmune diabetes in adults (LADA) is a
  slow progressing form of autoimmune diabetes.                • Pronounced insulin resistance in the brain
  Like type 1 diabetes, LADA occurs because your               • Code? E13 Other specified diabetes
  pancreas stops producing adequate insulin, most
  likely from some "insult" that slowly damages the
  insulin‐producing cells in the pancreas.
• Unlike type 1 diabetes, with LADA, insulin will not
  be needed for several months up to years after
  diagnosis.
• Code? E13
Diabetes Categories                                           Diabetes Categories
                                                                 • Diabetes                           E11
• Diabetes
• Diabetes as an adverse effect of steroids with
                                                         • E08   • Diabetes as an adverse effect of
                                                                   steroids with hyperglycemia        E09
  hyperglycemia
                                                         • E09   • Diabetes as a result of cystic     E08
• Diabetes as a result of cystic fibrosis                          fibrosis

                                                         • E10   • Diabetes after a pancreatectomy    E13
• Diabetes after a pancreatectomy

                                                         • E11   • Ketosis prone diabetes             E10
• Ketosis prone diabetes
                                                                 • Diabetes as a result of arsenic
                                                         • E13     poisoning                          E09
• Diabetes as a result of arsenic poisoning
                                                                 • Type II DM with hyperglycemia
                                                                   due to taking steroids             E11
• Type II DM with hyperglycemia due to taking steroids

                       Which one is it?                                               Which one is it?
 • Steroid induced diabetes • Other types of diabetes            • Diabetes as a result of            • Diabetes as a result of
   E09                        with hyperglycemia                   pancreatitis, pancreatic             removing the pancreas
 • The patient did not have   because of taking                    cancer of other injury               (E13)
   diabetes prior to taking   steroids is not steroid              to the pancreatic beta
   the medication impacting induced diabetes—                      cells (E08)
   the pancreatic beta cells. continue to code the
 • Hyperglycemia with         specific type with .65 as
   taking the medication      4th and 5th digits.
   may be temporary—
   before coding the patient
   as diabetic, ask the
   physician!!
Guidelines                                                                            Guidelines
• The diabetes mellitus codes are combination codes                          • If the type of diabetes mellitus is not documented
  that include:                                                                in the medical record the default is E11.‐, Type 2
    • the type of diabetes mellitus (E08‐E13),                                 diabetes mellitus.
    • the body system affected, (4th character) and                          • Old policy:
    • the complications affecting that body system (5th,                         • If the documentation in a medical record does
      6th characters).                                                             not indicate the type of diabetes, code E11,
• Diabetes codes should be sequenced based on the                                  Type 2 diabetes mellitus, should be assigned.
  reason for a particular encounter.                                             • (Type 2 is the DEFAULT—do NOT code Type I just
• Assign as many codes from the appropriate category                               because the patient takes insulin)
  (E08 –E13) as needed to identify all of the associated                         • Physician says insulin dependent diabetes
  conditions that the patient has. (MANY Assumptions)                              mellitus—code type 2
                                                                    81                                                                                        82

                 Now code these…                                                             Now code these…answers
• Secondary Diabetes
                                                                         • Secondary Diabetes                                • E13.9
• Diabetes as an adverse effect of steroids with hyperglycemia
                                                                         • Diabetes as an adverse effect of steroids with
                                                                           hyperglycemia                                     • E09.65, T38.0x5D
• Diabetes as a result of cystic fibrosis and CKD
                                                                         • Diabetes as a result of cystic fibrosis and CKD   • E84.8, E08.22, N18.9
• Diabetes after a pancreatectomy taking insulin
                                                                         • Diabetes after a pancreatectomy taking insulin
                                                                                                                             • E89.1, E13.9, Z90.410, Z79.4

• Ketosis prone diabetes                                                 • Ketosis prone diabetes
                                                                                                                             • E10.9
                                                                         • Diabetes as a result of arsenic poisoning years
• Diabetes as a result of arsenic poisoning years ago and chronic          ago and chronic osteomyelitis of the 5th
  osteomyelitis of the 5th lumbar vertebrae (patient had post              lumbar vertebrae                                  • T57.0x1S, E09.9, M46.26
  op infection after laminectomy 5 years ago) NEED to QUERY
                                                                         • Type II DM with hyperglycemia due to taking
                                                                           steroids                                          • E11.65, T38.0x5D
• Type II DM with hyperglycemia due to taking steroids
Diabetes 4th characters 0 and 1                                              Example
• Diabetes with hyperosmolarity                             • The patient is admitted to home care after a
    • Does not occur with Type 1 DM                           hospitalization for episode of diabetic ketosis with
        • No choice in Type 1 diabetics (no E10.0‐)           blood sugar of 857. The physician documents type
                                                              2 DM, polyneuropathy and CKD. The neuropathy
• Diabetes with ketoacidosis                                  required pain management and the CKD required
    • Occurs rarely with Type 2 diabetics                     dialysis for 2 days as a precaution. Codes for M1011
        • New choice in Type 2 diabetics (E11.1‐)             include:
• Type 2 DM with ketoacidosis E11.10                        a. E10.10, E10.65, E10.42, N18.9
• Do not code hyperglycemia with ketoacidosis.
                                                            b. E11.10, E11.65, E11.42, E11.22, N18.9
• If the type of diabetes is unspecified but
  documented with ketoacidosis, do not code Type 2.         c. E13.10, E11.42, E11.22, N18.9
  Query physician.                                          d. E11.10, E11.42, E11.22, N18.9
                                                       85

                   Explanation:                                              Diabetes 4th Characters
                                                              2 as 4th character
• Do not code hyperglycemia with ketoacidosis.                • R‐ Renal/Kidney complications
• Neuropathy and CKD are assumed related to                   3 as 4th character
  diabetes.                                                   • O‐Ophthalmic
                                                              4 as 4th character
                                                              • N‐Neurological
                                                              5 as 4th character
• Remember that diabetes type is unspecified, then
                                                              • C‐Circulatory
  type 2 is coded?
                                                              6 as 4th character
• Diabetic ketoacidosis is not assumed to be type 2
                                                              • O‐Other—arthropathy, skin complications, oral
  because the type of diabetes is unspecified. Query            complications, hypoglycemia, hyperglycemia and
  the physician for type.                                       other
                                                                                                                 88
Diabetes (Other)                                     Diabetic Manifestation Notables
                                                                 • E11.22 Use additional code for CKD (N18.1‐ N18.6)
• 7—no 4th character 7                                              • Use additional code note (OK to code N18.9, but this
                                                                      may change)
• 8—unspecified complications (do NOT use)                       Patients with CKD may also suffer from other conditions,
• 9—without complications (equivalent to 250.00)                 most commonly diabetes and hypertension. The
                                                                 sequencing of the CKD in relationship to codes for other
                                                                 contributing conditions is based on the coding conventions.
                                                                 FOLLOW THE TABULAR INSTRUCTIONS
                   NOT Diabetes
• Borderline diabetes                     Do not mark            • The classification assumes a relationship between CKD
                                                                   and HTN.
• Latent diabetes, and                    diabetes on
                                                                 • The classification assumes a relationship between CKD
• Prediabetes                               M1028.                 and Diabetes.
                         R73.03                                  • Diabetes, CKD and HTN
                                                            89   • E11.22, I12.9, N18.9 OR I12.9, E11.22, N18.9            90

           N18‐Chronic kidney disease                                     Related Except If They’re Not
 • If the physician says diabetic CKD and the patient            • The ICD‐10‐CM classification makes a linkage between
   also has hypertension, code BOTH as related to                  hypertension with CKD and also makes a link between
   CKD.                                                            diabetes and CKD. If there is no documentation clearly
                                                                   stating that the hypertension nor diabetes mellitus is
 • If the physician says hypertensive CKD and the                  the cause of the CKD, codes I12.0, Hypertensive chronic
                                                                   kidney disease and code E11.22, Type 2 diabetes
   patient also has diabetes, code BOTH as related to              mellitus with diabetic chronic kidney disease, may be
   CKD.                                                            reported.
 • The only time you do not code one or the other as             • However, if provider documentation were to clearly
                                                                   state that the CKD is due to a different cause such as
   related is if the physician specifically says they are          diabetes mellitus, and was not due to hypertension, a
   not related.                                                    code from category I12 would not be assigned.
                                                                   Likewise, if provider documentation were to clearly
                                                                   state that the CKD is not due to diabetes mellitus but
                                                                   was due to a different cause, such as hypertension,
 • If the physician documents diabetic nephropathy                 code E11.22 would not be reported.
   (E11.21) and CKD (E11.22), code E11.22.                       • Coding Clinic Letter December 2017
                                                            91
Diabetic Manifestation Notables                                          Diabetes, with
• E11.3‐ Macular edema includes the type of            • Peripheral arteriosclerosis, peripheral vascular
  retinopathy                                            disease and peripheral arterial disease in a diabetic
• E11.4‐ includes neuropathy unspecified,                patient should be linked and coded as “diabetic
  mononeuropathy, polyneuropathy, etc                    peripheral angiopathy.”
                                                       • Source: AHA Coding Clinic Volume 5 Second Quarter Number 2 2018
    • E11.43 Includes gastroparesis/gastroparalysis
• E11.5 DM with gangrene includes the peripheral       • A letter from Coding Clinic
  angiopathy (disease of the peripheral arteries)         • E11.51 Diabetes with peripheral angiopathy
    • atherosclerosis is related to diabetes…             • I170.2‐ Atherosclerosis of lower extremity
• E11.610 Includes Charcot’s
    • Not M14.6
    • Neurogenic arthropathy

  Diabetes with Atherosclerosis of Lower
                                                                Diabetic Manifestation Notables
               Extremities
Other issues without resolution:
Atherosclerotic ulcer in a diabetic????
                                                       • E11.621        or E11.622 (ankle and above)
• E11.51
                                                          • Use additional code for ulceration
• I70.2‐                                MMTA
• L97.‐                                                • E11.64‐ Hypoglycemia
Diabetic ulcer in a patient with atherosclerosis????   • E11.65 Hyperglycemia
• E11.62‐                                                 • Remember not to use this with ketoacidosis.
• L97.‐                                                • E11.69 Other manifestations of diabetes
• E11.51                                                  • Use additional code, e.g. osteomyelitis
                                       Wound
• I70.2‐
                                                                                                                           96
Sequencing Several Diabetic                             Sequencing Several Diabetic
              Complications/Manifestations                            Complications/Manifestations
                                                              Mrs Wolfe:
 • Mrs. Wolfe has diabetic ulcers on three toes of her        • E11.621 DMII with foot ulcers
   right foot (muscle necrosis on the worst), diabetic
   gangrene on a 4th toe and poorly controlled blood          • L97.513 Ulcer other part of foot (toes), right,
   sugars.                                                      muscle necrosis
 • She also had CHF and hypertension.                         • E11.65 DMII with hyperglycemia
 • The ulceration and the blood sugars are the focus          • E11.52 DMII with peripheral angiopathy with
   of care. The physician says we’re going to let the           gangrene
   toe fall off.
                                                                                   Where do we put the
                                                                                  CHF and hypertension?
                                                         97                                                          98

                                                                                Hyperglycemia
                                                              • With, Hyperglycemia
                                                              • Inadequately controlled –code to diabetes, by type
                                                                with hyperglycemia
 Diabetes
 with foot        E11 6 2 1
                                                              • Out of control –code to diabetes, by type with
                                        Symptom
   ulcer                                 control
                                                                hyperglycemia
                                       required on            • Poorly controlled –code to diabetes, by type with
 Foot ulcer
                                           all.                 hyperglycemia
                  L9 7 5 1 3

     DM           E1 1 6 5                                    • Uncontrolled
hyperglycemia
                  E11 5 2
                                                                    ‐ meaning
 Hypertension                                                              hyperglycemia ‐ see Diabetes, by
                                                                           type, with, hyperglycemia
     CHF
                                                                           hypoglycemia ‐ see Diabetes, by type,
DM angiopathy                                            99
                                                                                 with, hypoglycemia                100
M1028 Active Diagnoses                                           Applicable Codes

•   “-” means unable to assess
•   Leave blank if the patient doesn’t have either diagnosis.
    • 3 None of the Above will be added with OASIS D

•   Mark 1 and 2 if the patient has diabetic PVD (e.g.,
    E11.51)

    101                                                                                                              102

                                                                           Guideline: Hypertension
                                                                • The classification presumes a causal relationship
                                                                  between hypertension and heart involvement and
                                                                  between hypertension and kidney involvement, as
                                                                  the two conditions are linked by the term “with” in
                                                                  the Alphabetic Index.
                                                                • These conditions should be coded as related even in
                                                                  the absence of provider documentation explicitly
                                                                  linking them, unless the documentation clearly states
          Hypertension “with”                                     the conditions are unrelated.
                                                                • For hypertension and conditions not specifically
                                                                  linked by relational terms such as “with,” “associated
                                                                  with” or “due to” in the classification, provider
                                                                  documentation must link the conditions in order to
                                                                  code them as related.
                              103                                                                                    104
Index                                                   Hypertension
                           2019 Change                    • Hypertension with heart conditions classified to I50.‐
                                                            or I51.4‐ I51.7, I51.89, I51.9, are assigned to a code
                           • List of heart conditions
                                                            from category I11, Hypertensive heart disease.
                             excludes I51.81
                                                          • Use an additional code from category I50, Heart
                           • Takotsubo Syndrome is
                                                            failure, to identify the type of heart failure in those
                             not related to
                                                            patients with heart failure.
                             hypertension. It is
                             related to stress, so it     • The same heart conditions (I50.‐, I51.4‐I51.7, I51.89,
                             was omitted from the           I51.9) with hypertension are coded separately if the
                             list of conditions             provider has specifically documented a different
                             assumed caused by              cause.
                             hypertension.                • New language: if the provider has documented they
                                                            are unrelated to the hypertension.
                                                                                                                106

              Significant Change?                                     Hypertensive Heart Disease
• Just a clarification?                                       Look at I11
• The patient has documented rheumatic heart                  • I51.4‐I51.9 (but not I51.81) are included
  failure. The patient also has hypertension.                   however use an additional code for heart
• specifically documented a different cause: code
                                                                failure, if present.
  rheumatic heart failure followed by the appropriate         • Specific sequencing required
  heart failure code. Code hypertension separately.
• documented they are unrelated to the                        • The hypertension must be coded prior to the
                                                                heart failure.
  hypertension: Code hypertension with I11.0, and
                                                                 • Note the ‘code first’ note at I50
  rheumatic heart failure, and appropriate heart
  failure code.                                               • The conditions included in I11 are not coded
                                                                separately.
                                                                 • Patient has hypertension and cardiomegaly
                                                    107            (I51.7), then code I11.9 ONLY
Practice                                               Practice
• Hypertensive left ventricular hypertrophy           • Hypertensive left ventricular hypertrophy
   a. I11.9                                              a. I11.9
   b. I11.9, I51.7                                       b. I11.9, I51.7
• End stage heart disease patient also has            • End stage heart disease patient also has
  hypertension                                          hypertension
   a. I11.9                                              a. I11.9
  b. I11.9, I51.9                                        b. I11.9, I51.9
• Senile cardiomyopathy with hypertension             • Senile cardiomyopathy with hypertension
  a. I11.9                                              a. I11.9
  b. I11.9, I51.5                                       b. I11.9, I51.5

      Hypertensive Chronic Kidney Disease                     Hypertensive Heart and Kidney
• The classification assumes a relationship           • Assign codes from combination category I13,
  between hypertension and chronic kidney               Hypertensive heart and chronic kidney disease, when
  disease.                                              there is hypertension with both heart and kidney
• CKD should not be coded as hypertensive if            involvement.
  the provider indicates the CKD is not related       • If heart failure is present, assign an additional code
  to the hypertension.          2019                    from category I50 to identify the type of heart failure.
• Code to I12.‐                                       • The appropriate code from category N18, Chronic
   • Stage 5 or ESRD with hypertension I12.0            kidney disease, should be used as a secondary code
   • Stage 1‐4 or unspecified CKD with hypertension     with a code from category I13 to identify the stage of
     I12.9                                              chronic kidney disease.
   • Specific sequencing required with CKD
                                                                                                            112
Still there in the guidelines                            Diabetes, Hypertension and CKD
Chronic kidney disease with other conditions                • Diabetes and hypertension are assumed related to
                                                              CKD.
• Patients with CKD may also suffer from other serious
  conditions, most commonly diabetes mellitus and           • What if the physician says ‘diabetic CKD’ or
  hypertension. The sequencing of the CKD code in             ‘hypertensive CKD’?
  relationship to codes for other contributing              • Code them all related.
  conditions is based on the conventions in the Tabular         • Exception is if the physician specifically says the
  List.                                                           diabetes or the hypertension is NOT related.

                                                     113

                     Examples                                           Name that category
• The patient has diabetes, HTN and CKD
   • E11.22, I12.9, N18.9 OR
                                                            • Hypertension and ESRD             • I10
   • I12.9, E11.22, N18.9                                   • Hypertension and CHF
   These are coded like this even if the physician states   • Systolic heart failure due        • I11
   “diabetic CKD” or “hypertensive CKD”                       to hypertension
• The patient has diabetes, HTN, heart failure and CKD      • Malignant hypertension            • I12
   • E11.22, I13.0, I50.9, N18.9 OR
   • I13.0, E11.22, I50.9, N18.9 OR maybe
                                                            • Patient has CKD and
                                                              hypertensive                      • I13
   • I13.0, I50.9, E11.22, N18.9
                                                              cardiomegaly
                                                            • “Diabetic hypertension”           • I15
                                                     115                                116
Name that category                                  Answers

• Hypertension and ESRD        I12   • Hypertension and ESRD I12.0, N18.6
• Hypertension and CHF         I11   • Hypertension and CHF I11.0, I50.9
• Systolic heart failure due   I11   • Systolic heart failure due to hypertension
  to hypertension                      I11.0, I50.20
• Malignant hypertension       I10   • Malignant hypertension I10
• Patient has CKD and                • Patient has CKD and hypertensive
  hypertensive                 I13     cardiomegaly I13.10, N18.9
  cardiomegaly                       • Diabetic hypertension E11.59, I15.2
• Diabetic hypertension        I15
                        117                                                                         118

                                                             Definitions
                                     • Sepsis—Sepsis is a potentially life‐threatening complication
                                       of an infection. Sepsis occurs when chemicals released into
                                       the bloodstream to fight the infection trigger inflammation
                                       throughout the body. This inflammation can trigger a
                                       cascade of changes that can damage multiple organ
                                       systems, causing them to fail. If sepsis progresses to septic
                                       shock, blood pressure drops dramatically, which may lead to
                                       death.

                                     • Localized infection—An infection that is limited to a specific
                                       part of the body and has local symptoms.

                                     • Septicemia—Septicemia is bacteria in the blood
                                       (bacteremia) that often occurs with severe infections. (No
                                       separate code)
                                                                                                    120
Sepsis                                                           Why is Sepsis becoming more common?
• Becoming more common in home care                                                                  • Aging population. Americans are living longer, which is
                                                                                                       swelling the ranks of the highest risk age group — people
• Sepsis                          Coded the
                                  same way
                                                                                                       older than 65.
• Septicemia                                                                                         • Drug‐resistant bacteria. Many types of bacteria can resist
                                     Add R65.2‐ and organ                                              the effects of antibiotics that once killed them. These
• Severe sepsis                             failure
                                                                                                       antibiotic‐resistant bacteria are often the root cause of the
                                                                                                       infections that trigger sepsis.
• Sepsis from a localized infection        Sequencing
                                                                                                     • Weakened immune systems. More Americans are living
• Postprocedural sepsis                                                                                with weakened immune systems, caused by HIV, cancer
                                                                                                       treatments or transplant drugs.

                                                                                               121   •    Source: http://www.mayoclinic.org/diseases‐conditions/sepsis/symptoms‐causes/dxc‐20169787

                               More on Sepsis                                                                       Example of Sepsis vs Septicemia
 • Many doctors view sepsis as a three‐stage syndrome,
   starting with sepsis and progressing through severe sepsis                                            • Sepsis from Strep pneumoniae
   to septic shock. The goal is to treat sepsis during its early
   stage, before it becomes more dangerous.
                                                                                                            • A40.3 Sepsis due to Strep pneumoniae
 Sepsis
 To be diagnosed with sepsis, you must exhibit at least two of                                           • Septicemia from Strep pneumoniae
 the following symptoms, plus a probable or confirmed                                                       • A40.3
 infection:
 • Body temperature above 101 F (38.3 C) or below 96.8 F (36                                                  • Index directs to A41.9 (Septicemia NOS)
   C)
 • Heart rate higher than 90 beats a minute
 • Respiratory rate higher than 20 breaths a minute
                                                                                                         • A41.9 is also used when the physician documents
 • Source: http://www.mayoclinic.org/diseases‐conditions/sepsis/symptoms‐causes/dxc‐20169787
                                                                                                           sepsis without the bacteria
                                                                                                                                                                                                      124
Coding Sepsis                                                                  Septic Shock
‘
                                                             • Septic shock generally refers to circulatory failure
• A’ codes for sepsis. Sequencing depends on                   associated with severe sepsis, and therefore, it
  circumstances. See the codes.                                represents a type of acute organ dysfunction.
• A40 Streptococcal sepsis                                   • Low BP that does not respond to treatment.
• A41 Other sepsis                                           • Not usually a home care diagnosis, but could be a
• And others                                                   hospice diagnosis.
• R65.20 Severe sepsis without septic shock
• R65.21 Severe sepsis with septic shock
(if acute organ dysfunction is documented).            125

                  Severe Sepsis                                          Severe Sepsis Guidelines
• In severe sepsis the patient will also exhibit at least    • If a patient has sepsis and an associated acute
  one of the following signs and symptoms, which               organ dysfunction or multiple organ dysfunction,
  indicate an organ may be failing:                            follow the instructions for coding severe sepsis.
                                                                 • Query if not clear whether the organ dysfunction
• Significantly decreased urine output                             is related to the sepsis.
• Abrupt change in mental status                                 • The ‘with’ doesn’t count.
• Decrease in platelet count                                 • Minimum of two (but usually three) codes
• Difficulty breathing                                           • Underlying systemic infection
                                                                 • Code from subcategory R65.2‐
• Abnormal heart pumping function                                • Additional code for the associated organ
• Abdominal pain                                                   dysfunction.
• Source: http://www.mayoclinic.org/diseases‐                        • No need to code circulatory collapse if
  conditions/sepsis/symptoms‐causes/dxc‐20169787                       present
                                                                                                                      128
Examples                  Severe because
                                                                        Sepsis with localized infection
                                                of associated
                                                organ failure   • Such as pneumonia, UTI
• Strep sepsis with acute kidney failure                        • If admitted with sepsis        Usually this one
    • A40.9 Streptococcal sepsis, unspecified                       • Assign sepsis code first (A40‐41)
    • R65.20 SIRS (severe) without septic shock                     • Then localized infection
    • N17.9 Acute kidney failure, unspecified                       • Severe? Add R65.2‐ & organ dysfunction
                                                                • If admitted with localized and develops into sepsis
• Strep sepsis with septic shock                                    • Code localized infection first
   • A40.9 Streptococcal sepsis, unspecified
   • R65.21 SIRS (severe) with septic shock                             Sequencing is dependent on whether the
                                                  This counts         patient was admitted with sepsis or developed
                                                   as organ
                                                    failure.
                                                                                  sepsis after admission.
                                                                                                                      130

        Sepsis with localized infection                                                Code it
                                                                • Patient was admitted with sepsis due to
 • Sepsis due to Serratia from a UTI
                                                                  MRSA pneumonia with continued IV
    • Sepsis A41.53
    • Localized infection, UTI N39.0
                                                                  antibiotics

    • SIRS (R65.2‐) if organ dysfunction is related
      (severe sepsis)
    • Organ dysfunction, if applicable.

                                                        131
Sepsis due to MRSA pneumonia                                           Code it:
• A41.02 MRSA sepsis                                    • Patient was admitted for E coli sepsis due to acute
                                                          cystitis.
• J15.212 MRSA pneumonia                                    N30.00, B96.20
• Z45.2 Management of vascular device                       A41.51, N30.00, B96.20
                                                            A41.51, N30.00
                                                            A49.51, N39.0, B96.20

      E coli sepsis due to acute cystitis                                    Urosepsis
• Patient was admitted for E coli sepsis due to acute
  cystitis.                                             • The term urosepsis is a
    N30.00, B96.20                                        nonspecific term. It is not to
    A41.51, N30.00, B96.20
                                                          be considered synonymous
                                                          with sepsis. It has no default
    A41.51, N30.00                                        code in the Alphabetic Index.
    A49.51, N39.0, B96.20                                 Should a provider use this
                                                          term, he/she must be
                                                          queried for clarification.
Reminder‐‐7th Character A                            Postprocedural Sepsis (until September 30)

• 7th character “A”, initial encounter is used while the
                                                                • Must be documented by the physician—
  patient is receiving active treatment for the condition.      • Start with the specific postprocedural infection code
  Examples of active treatment are: surgical treatment,           (e.g., T81.4‐)
  emergency department encounter, and evaluation and
  continuing treatment by the same or a different               • Use appropriate A40‐41 code next.
  physician

                                                                • Patient with postprocedural sepsis related to infected
• Additional examples of “initial” encounter (examples of
  active treatment)                                               surgical wound caused by MRSA. IV antibiotics.
• Antibiotic therapy for postoperative infection                   • T81.4xxA Post‐op sepsis
• Wound vac treatment of wound dehiscence                          • A41.02 MRSA sepsis
                                                                   • Z45.2 Management of vascular device
                                                                   • Z79.2 LT use antibiotics                        138

      Postprocedural Sepsis (October 1)                                        Change in Guideline
                                                                As with all postprocedural complications, code
• Must be documented by the physician—                          assignment is based on the provider’s documentation of
• Start with the specific postprocedural infection code         the relationship between the infection and the
  (e.g., T81.4‐)                                                procedure.
• Code the T81.44x‐ next.
• Use appropriate A40‐41 code next.                             For infections following a procedure, a code from
                                                                T81.40, to T81.43 Infection following a procedure, … that
• Patient with postprocedural intramuscular abscess             identifies the site of the infection should be coded first,
  resulting in sepsis caused by MRSA. IV antibiotics.           if known.
    • T81.42xA Post surgical infection, deep incisional         Assign an additional code for sepsis following a
      surgical site                                             procedure (T81.44)... Use an additional code to identify
    • T81.44xA Post‐op sepsis                                   the infectious agent.
    • A41.02 MRSA sepsis                                        If the patient has severe sepsis, the appropriate code
    • Z45.2 Management of vascular device                       from subcategory R65.2 should also be assigned with the
    • Z79.2 LT use antibiotics                                  additional code(s) for any acute organ dysfunction.
                                                          139
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