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December 2015

Old Dog, New Tricks
By Judy Sturgeon, CCS, CCDS
For The Record
Vol. 27 No. 12 P. 6

The adage about not being able to teach new tricks to an old dog had better not be true, because a whole lot of new tricks have to be learned in order to become proficient in ICD-10-CM.

Many of the ICD-9-CM Official Coding Guidelines have been incorporated into ICD-10 without perceptible change. However, there also are changes in the new coding system that may be considered improvements over ICD-9, others that involve a different way of coding, and still others that run the gamut from confusing to incomprehensible.

As an old-school inpatient coder, the following examples stand out. It's by no means a complete list, but it does provide a snapshot into several significant new rules while touching on whether the code may be reported, major changes in sequencing instructions, and potential impact to diagnosis-related group (DRG) assignments and public data reporting.

The diagnosis "SIRS [systemic inflammatory response syndrome] due to Pneumonia" is no longer presumed to include sepsis. If the documentation clinically indicates the presence of sepsis symptoms, the coder must query for clarification, according to the third quarter 2014 edition of Coding Clinic.

An ICD-9 official coding guideline for neonates that required the coder to report any diagnosis documented at discharge by the provider is not included in the ICD-10-CM guidelines. Secondary conditions will not be valid for reporting unless there is an associated effect on care, or the condition is also a congenital anomaly or meets some other exception to the basic requirement for coding and reporting of secondary diagnoses.

In the past, only overdosing could be coded; prescription drug underdosing can now be reported when it causes morbidity or mortality.

When both are present, osteomyelitis is no longer presumed to have an association with diabetes. In ICD-9-CM, the provider was obliged to document specifically if this infection was not due to the diabetes, while in ICD 10, the inverse is true, according to the fourth quarter 2013 edition of Coding Clinic.

The index and tabular directions of Official Coding Guidelines state that the term urosepsis no longer defaults to the code for a urinary tract infection, requiring coders to query for clarification on whether the patient has a bladder or kidney infection, sepsis, or a combination of infections.

Previously, coders were prohibited from reporting that a maternal condition had affected a newborn based only on workup; the baby had to exhibit some kind of symptom due to the mother's problem. Modification of the baby's care alone did not justify reporting the issue. In the new code sets, any time a maternal condition affects the baby or the baby's care, a representative code is reported. The definition of category P00- codes permits both suspected and confirmed conditions, according to ICD-10 Coding Handbook.

If a patient is admitted for end stage renal disease (ESRD) caused by systemic lupus erythematosis, the ESRD is now sequenced first, according to the fourth quarter 2013 edition of Coding Clinic. Also, unilateral weakness due to stroke is now presumed to be hemiplegia, according to the first quarter 2015 edition of Coding Clinic. Official Coding Guidelines state that in ICD-10, if a patient is admitted for anemia due to cancer, the principal diagnosis is the cancer rather than the anemia.

In ICD-9-CM, nearly every procedure performed on a pregnant patient was reported with a code from the pregnancy chapter. Now, only procedures performed on products of conception are reported with obstetric chapter codes, according to Official Coding Guidelines.

Codes for all external causes of injury continue to be reported as long as the injury—or its late effect—still exists and is receiving care or evaluation. ICD-9 had allowed only acute fracture care to have an external cause coded on subsequent encounters or by subsequent providers. ICD-10 adds a seventh character to indicate whether it's an initial injury, subsequent care, or a sequela of the original injury. One might expect this additional character to prevent the same injury from being counted multiple times in public data reporting. However, the definition of the term "initial" in the first quarter 2015 edition of Coding Clinic is not used for only the initial episode of care; it is used any time the initial injury is receiving active treatment rather than maintenance or aftercare.

These coding examples should serve as cautionary tales for those who report from coded data. For reports to be accurate, the creator must understand the definition of the external cause codes, and the person using the report must be careful to correctly represent the number and type of injuries. Failure to do so may result in skewed facts regarding the frequency of motor vehicle accidents, assaults, or work-related injuries. In fact, these incidents may not be increasing, but instead are being tracked each time care is administered.

Surgical debridement continues to require a precise description of the procedure in order to be coded correctly based on numerous examples found in both the 2014 and 2015 editions of Coding Clinic. However, ICD-10-PCS terminology does provide directions for how the coder should proceed. Excision or no excision? What was the deepest tissue debrided? Was the approach open or percutaneous or percutaneous endoscopic/arthroscopic?

Incision and drainage of skin of a trunk abscess does not create a surgical Medicare severity DRG (MS-DRG) for an inpatient admission. However, incision and drainage of subcutaneous tissue and fascia of a trunk abscess can move over to the surgical MS-DRGs. Anatomical details are critical to correctly report these formerly simple procedure codes and ensure appropriate reimbursement.

Say What?
Even though ICD-10-CM and PCS have been scheduled to become a reality for decades, it apparently was not sufficient time to fully prepare the new system. For example, not all surgical approaches or common variations of diagnoses have been included. Perhaps annual coding updates will identify and correct many of these gaps, but until that time, several accommodations have been published in Coding Clinic for ICD-10-CM.

Endoscopic banding of esophageal varices, open resection of brain tumor with placement of chemotherapy wafer, transbronchial needle aspiration biopsy of a mediastinal lymph node, and open placement of an intrauterine device during a C-section delivery are examples in which ICD-10-PCS fails to correctly report all components of the procedure. Several 2013 and 2014 Coding Clinic publications suggest temporary workarounds until the system can be updated for technical accuracy.

Surprisingly, procedures that are clinically diagnostic in nature are not necessarily reported as diagnostic procedures. For example, a diagnostic lumbar puncture is reported with a "diagnostic" seventh character if it's performed for biopsy. However, if the diagnostic evaluation includes only laboratory chemistries or cultures, it's not defined or reported with the seventh character X.

Work Together
ICD-10 is a new frontier. Surprises and unexpected findings are part of the deal. To help navigate tricky terrain, coders who identify significant changes, and new rules and coding options should share them with colleagues and professional associations. Work together, communicate with peers, and take advantage of the professionals who staff the American Hospital Association's Coding Clinic Advisor (www.codingclinicadvisor.com) to help make the transition as smooth, productive, and painless as possible.

— Judy Sturgeon, CCS, CCDS, is the clinical coding/reimbursement compliance manager at Harris County Hospital District in Houston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and compliance for 26 years.