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September 2017

Coding Corner: October Brings Important Updates
By Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA
For The Record
Vol. 29 No. 9 P. 30

When it came time to release the ICD-10 changes for fiscal year 2018, the Centers for Medicare & Medicaid Services (CMS) didn't hold back. As expected, the modifications, set to take effect October 1, were significant. CMS continues to work to ensure both the ICD-10-CM and ICD-10-PCS code sets accurately represent diagnoses and procedures documented for discharges and patient encounters.

Officially, the ICD-10-CM and ICD-10-PCS code sets are only two years old. Their first two years of "life" followed a four-year code set "freeze" while the industry prepared for implementation. During those frozen four years, no major changes could be made prior to the implementation date, which led to an extensive 2017 update containing only the most important updates.

The remainder of the approved changes arrives for 2018. Coders will see more than 700 changes to the ICD-10-CM code set and more than 6,000 changes to the ICD-10-PCS code set. Changes include additions, deletions, and revisions to maintain and improve the accuracy of code assignment.

In addition to code changes in the ICD-10-CM code set, there are 22 Excludes1 notes being converted to Excludes2 notes. In October 2015, AHIMA, CMS, the American Hospital Association, and the National Center for Health Statistics issued interim guidance that acknowledged some modifications were required to the Excludes1 notes within the system. A significant attempt has been made to determine whether an Excludes1 note is always appropriate in the current location, resulting in 22 changes. Besides many Excludes1 notes being changed to Excludes2 notes, the location of the Excludes2 notes have been adjusted to more specific code locations within the category. These changes provide specific guidance on additional code assignment to only some codes within the category rather than the entire category.

In addition, the entire code set has been reviewed for spelling, grammar, and punctuation to allow for easier reading and coding. Additional inclusion terms were added to allow more accurate code assignment.

Highlights from the ICD-10-CM update include the addition of codes for type 2 diabetes mellitus with ketoacidosis, with or without coma, a change that was requested as far back as the initial code set training. Category H54, Blindness and Low Vision, was expanded to provide the ability to code the specifics of blindness or low vision in one eye with the level of impairment in the opposite eye, including laterality.

The most significant ICD-10-CM changes are found within the circulatory system (chapter nine) codes for myocardial infarction, pulmonary hypertension, and right heart failure. These changes all provide the opportunity for coders to gain a greater understanding of the clinical features of these diseases to assist in correct coding. For example, coders should become familiar with terminology related to myocardial infarction types and groups one through five of pulmonary hypertension.

Other updates include two additional severity levels for nonpressure chronic ulcers, both laterality and quadrant designations for breast lumps, expanded locations for undescended testicles, and inclusion terms for pediatrics in the Glasgow Coma Scale codes.

The more than 6,000 code changes for the 2018 ICD-10-PCS code set are due to a table design, where a change in one character value can create a large number of actual code changes. This year's changes involve multiple revisions to body part, device, and qualifier values, creating a large number of deletions, changes, and additions.

As was the case with the ICD-10-CM code set, the use of ICD-10-PCS in daily coding has helped identify areas for improvement. Approximately one-third of this year's changes can be attributed to the miscellaneous fine-tuning of body parts, approaches, devices, qualifiers, and other details. Another one-third involve updates to cardiovascular procedures, with the remaining one-third occurring within pediatric coding.

In addition, there are three guideline changes and one new guideline. Guideline changes were made to identify that device values can be assigned when a device is used temporarily or intraoperatively when a specific qualifier is available, to provide clarity on when to code inspection for discontinued or otherwise not completed procedures, and to further clarify the use of the root operation of Control. The new guideline covers how to code procedures performed on a continuous section of a tubular body part.

Each table with a body system may not contain every available body part. Body part values missing from some tables, such as the peroneal artery for lower leg and foot bypasses, have been added. A number of body part descriptors were collapsed from more detail to less detail. For example, greater and lesser omentum has been collapsed to omentum. The collapsing of laterality was also conducted in body parts where laterality was difficult to determine or not valuable such as anterior or posterior neck subcutaneous tissue and fascia when left or right neck subcutaneous tissue and fascia would provide more valuable data.

Missing approach values were identified and added to various tables, along with a few approach value corrections for certain procedures. Device changes involve the addition of the device value Y, Other device, into many of the tables where this value was missing. This allows for flexibility in coding new devices before a specific device value has been assigned. Substance values were fine-tuned through the consolidation of local, regional, and inhaled anesthetic agents into a single anesthetic agent value. Additional qualifier values were inserted to describe temporary procedures or specific information about a procedure, such as a qualifier for a supracervical hysterectomy.

Review of the code set also identified missing tables, such as Replacement and Extraction tables, from key body systems. Correcting that oversight will enable coders to assign the correct root operation rather than the root operation of Repair. In addition, the Fusion tables were reorganized to allow only device and qualifier combinations that are clinically possible.

The latest edition of ICD-10-PCS codes features important pediatrics updates, most of which are the result of the hard work of the Children's Hospital Association and the coders who meet monthly on a coding roundtable call. Their submissions to the Coordination and Maintenance Committee for corrections and additions have resulted in correct coding for eight common pediatric procedures.

Four body parts were added to selected root operation tables. The body part values for coronary arteries were added to the Release root operation table to allow coding treatment of myocardial bridge. The body part value for left ventricle was added to the Dilation root operation table to allow coding of treatment for left ventricular outflow tract obstruction and subaortic stenosis. The body part value for mitral valve was added to the Restriction root operation table for coding the Alfieri Stitch procedure and body part values for small and large intestine were added to the Reposition root operation table for interventions on the conditions of intussusception and volvulus when individual body part names were not documented.

Other changes include the addition of Z, No Device to the Bypass root operation table in the Central Nervous System and Cranial Nerves body system to allow coding of the Endoscopic third ventriculostomy procedure, and the appropriate qualifier to the Bypass root operation table in the Lower Veins body system to allow appropriate coding of the Fontan procedure.

The percutaneous approach was added to the Bypass root operation table in the Heart and Great Vessels body system to allow correct coding of the Atrial Balloon Septostomy procedure. The approach value of F, Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance, was previously used to code only the laparoscopic-assisted vaginal hysterectomy. For 2018, it's been added to the Excision and Resection tables in the gastrointestinal body system to allow correct coding of the laparoscopic-assisted anal pull-through procedure used to treat Hirschsprung's disease.

The CMS update is vast and varied, requiring coders to investigate the changes and understand the clinical scenarios involved in the code assignments. Coders can prepare by reviewing the addendum documents for each code set.

(The new ICD-10-CM code set files can be obtained from www.cms.gov/Medicare/Coding/
. The new ICD-10-PCS code set files can be obtained from www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-PCS-and-GEMs.html.)

— Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA, is a coding and reimbursement consultant with a particular expertise in ICD-10-PCS, including coding of pediatric services. She is the author of numerous publications for AHIMA as well as multiple online coding courses for Libman Education.