DIAGNOSIS CODING FOR DIAGNOSIS CODING FOR LONG TERM CARE LONG TERM CARE

SETTINGSSETTINGS

Presented by:Presented by:

Lizeth Flores, RHIT Lizeth Flores, RHIT & &

Khaleelah Wagner, RHIA Khaleelah Wagner, RHIA

Anderson Health Information Systems, Inc.Anderson Health Information Systems, Inc.940 W. 17940 W. 17thth Street, Suite B Street, Suite B

Santa Ana, California, 92706Santa Ana, California, 92706Tel. (714) 558-3887Tel. (714) 558-3887

Email: office@ahis.netEmail: office@ahis.net

ObjectivesObjectives

Participants will: Participants will: Correctly assign ICD-9-CM codes to diagnosesCorrectly assign ICD-9-CM codes to diagnoses Correctly identify primary / Secondary diagnoses Correctly identify primary / Secondary diagnoses Learn 2009 coding updatesLearn 2009 coding updates

Purpose of ICD- 9-CM CodingPurpose of ICD- 9-CM Coding

Gather statistical dataGather statistical data Reporting diagnoses and provides a method Reporting diagnoses and provides a method

for sequencing diagnosis to support for sequencing diagnosis to support reimbursement reimbursement

Ensure compliance with Federal Reporting Ensure compliance with Federal Reporting Standards for diagnosesStandards for diagnoses

Provide insight into the types of residents and Provide insight into the types of residents and conditionsconditions

Health ResearchHealth Research

Definition Principal DiagnosisDefinition Principal Diagnosis

““FIRST LISTED DIAGNOSES” is the diagnosis that FIRST LISTED DIAGNOSES” is the diagnosis that is chiefly responsible for the admissions to, continued is chiefly responsible for the admissions to, continued residence in the nursing facility and the diagnosis that residence in the nursing facility and the diagnosis that support the reimbursement and should be sequenced support the reimbursement and should be sequenced first.”first.”

Types of Codes Used in LTCTypes of Codes Used in LTC

Aftercare – used when the initial treatment of a Aftercare – used when the initial treatment of a disease or injury has been performed and the disease or injury has been performed and the patients still requires continued care to heal or patients still requires continued care to heal or recover. recover.

Late Effects – a late effect is a residual Late Effects – a late effect is a residual condition that remains and requires medical condition that remains and requires medical evaluation, rehab treatments and/or nursing evaluation, rehab treatments and/or nursing care after the initial illness or injury.care after the initial illness or injury.

Types of Codes Types of Codes -2-2

Chronic Conditions – Conditions that are Chronic Conditions – Conditions that are stable but still require management or stable but still require management or treatment.treatment.

Acute Conditions –acute care codes should Acute Conditions –acute care codes should only be reported until the condition is only be reported until the condition is resolved. resolved.

Therapy – Physical, occupational, speech and Therapy – Physical, occupational, speech and respiratory therapy. respiratory therapy.

Types of Codes Types of Codes -3-3

History of – (Hx) – history codes are acceptable History of – (Hx) – history codes are acceptable on any Medical record regardless of reason for on any Medical record regardless of reason for admission/encounter.admission/encounter.

A history code is distinct from a “status” code in A history code is distinct from a “status” code in that history codes indicate that the patient no that history codes indicate that the patient no longer has the condition and “status” codes longer has the condition and “status” codes indicated a present state.indicated a present state.

There are two types of history V-codes, personal There are two types of history V-codes, personal and family.and family.

MedicareMedicare

Medicare diagnosis needs to be consistent with Medicare diagnosis needs to be consistent with covered services & MDS.covered services & MDS.

Medicare Medicare -2-2

Resident must have a 3-day qualifying hospital Resident must have a 3-day qualifying hospital stay.stay.

Physician must certify the need for skilled Physician must certify the need for skilled nursing services.nursing services.

Skilled services must be related to the Skilled services must be related to the condition treated during the qualifying 3 day condition treated during the qualifying 3 day hospital stay. hospital stay.

ExamplesExamples

Resident was treated for UTI at the hospital Resident was treated for UTI at the hospital and is still on IV antibiotic therapy. and is still on IV antibiotic therapy.

Resident had surgery for a bowel obstruction Resident had surgery for a bowel obstruction and needs care to the surgical site and physical and needs care to the surgical site and physical / occupational therapy / occupational therapy

What to Code?What to Code?

ALL CONDITIONS THAT EXIST AT THE ALL CONDITIONS THAT EXIST AT THE TIME OF ADMISSION, THAT EFFECT TIME OF ADMISSION, THAT EFFECT

TREATMENT RECEIVEDTREATMENT RECEIVED

Do NOT CodeDo NOT Code DIAGNOSES THAT DO NOT AFFECT DIAGNOSES THAT DO NOT AFFECT

TREATMENT OR LENGTH OF STAYTREATMENT OR LENGTH OF STAY WHEN CONDITION NO LONGER EXISTSWHEN CONDITION NO LONGER EXISTS DO NOT ASSIGN PROCEDURE CODESDO NOT ASSIGN PROCEDURE CODES Examples: Fractured forearm 6 years ago, Examples: Fractured forearm 6 years ago,

pneumonia, UTI that were resolved (these will pneumonia, UTI that were resolved (these will only be coded if the Resident is admitted with only be coded if the Resident is admitted with AntibioticsAntibiotics))

Locating DiagnosisLocating Diagnosis

Transfer RecordsTransfer Records History & PhysicalHistory & Physical Progress NotesProgress Notes Admission OrdersAdmission Orders

Additional Sources of InformationAdditional Sources of Information

Discharge summaryDischarge summary Transfer documentation, Transfer documentation, Surgical reportsSurgical reports ConsultationsConsultations Physician Progress notes Physician Progress notes Lab reports and radiological studiesLab reports and radiological studies

Locating Principal DiagnosisLocating Principal Diagnosis

Principal DiagnosisPrincipal Diagnosis

When two or more inter-related conditions When two or more inter-related conditions potentially meet the definition of principal potentially meet the definition of principal diagnosisdiagnosis Either may be sequenced first unless therapy is Either may be sequenced first unless therapy is

being provided, the Tabular list or Alphabetic being provided, the Tabular list or Alphabetic Index indicate otherwise.Index indicate otherwise.

Inter-related conditions – two or more diagnosis Inter-related conditions – two or more diagnosis that equally meet the definition of principal that equally meet the definition of principal diagnosis. diagnosis.

ExampleExample

Resident admitted with Pneumonia and UTI – Resident admitted with Pneumonia and UTI – either can be used as the principal diagnosis if either can be used as the principal diagnosis if the resident is still receiving antibiotic therapy the resident is still receiving antibiotic therapy

Principal DiagnosisPrincipal Diagnosis-2-2

The first Dx identifies the main reason for the The first Dx identifies the main reason for the resident’s admission/encounterresident’s admission/encounter

The terms Admission and encounter can be The terms Admission and encounter can be used interchangeably and are used all used interchangeably and are used all healthcare settings. (they have the same healthcare settings. (they have the same meaning) meaning)

Choose the Principal Diagnosis Choose the Principal Diagnosis

Fall 3 months agoFall 3 months ago Chronic kidney disease Chronic kidney disease Above the knee amputation Rt. Leg Above the knee amputation Rt. Leg Anemia Anemia MRSA of surgical wound (resolved)MRSA of surgical wound (resolved)

Diagnosis Sequencing Diagnosis Sequencing

The order in which codes are listed is called The order in which codes are listed is called sequencing. The coder should make every sequencing. The coder should make every effort to record the codes in a logical sequence effort to record the codes in a logical sequence that is descriptive of the resident’s condition. that is descriptive of the resident’s condition.

Choose the Correct Sequence…Choose the Correct Sequence…

Diabetes Diabetes Diabetic retinopathy Diabetic retinopathy UTI (on antibiotics)UTI (on antibiotics) Chronic Back Pain Chronic Back Pain Hyperlipidemia Hyperlipidemia Osteoporosis Osteoporosis

Secondary DiagnosesSecondary Diagnoses

To further support Medicare covered skilled To further support Medicare covered skilled services – usually in order of complexity.services – usually in order of complexity. May have multiple secondary codesMay have multiple secondary codes List and code conditions related to therapy and List and code conditions related to therapy and

services providedservices provided Review and update as condition changes – Review and update as condition changes –

sequence may change over timesequence may change over time Billing staff should work with Nursing and Health Billing staff should work with Nursing and Health

Information Department to know which diagnoses Information Department to know which diagnoses are current, which is principal, etc.are current, which is principal, etc.

Secondary DiagnosesSecondary Diagnoses-2-2

Order by complexity.Order by complexity. Assign the condition with the higher complexity Assign the condition with the higher complexity

first. (those that require the most resources i.e. first. (those that require the most resources i.e. wound care vs. hypertension) wound care vs. hypertension)

All conditions present at the time of admission, All conditions present at the time of admission, and that affect the treatment provided and length and that affect the treatment provided and length of stay should be coded. of stay should be coded.

Acute DiagnosesAcute Diagnoses

Acute dx treated in the hospital should be Acute dx treated in the hospital should be coded until the condition is resolved, after the coded until the condition is resolved, after the resident is transferred to the SNFresident is transferred to the SNF

Examples: Examples:

MRSA MRSA

Pneumonia Pneumonia

UTIUTI

ICD-9-CM Official Guidelines for ICD-9-CM Official Guidelines for Coding & ReportingCoding & Reporting

www.cdc.gov/nchs/data/icd9/cdguide.pdfwww.cdc.gov/nchs/data/icd9/cdguide.pdf Latest Revision October 1, 2008Latest Revision October 1, 2008 Codes revised twice per year April and Codes revised twice per year April and

OctoberOctober April codes will come out only if significant or April codes will come out only if significant or

important and can not wait until Octoberimportant and can not wait until October

ICD-9-CM Coding BookICD-9-CM Coding Book

Disease and Procedures (Books 1-3)Disease and Procedures (Books 1-3) Alphabetical/Tabular (numeric) IndexAlphabetical/Tabular (numeric) Index

Assigning Code Numbers Assigning Code Numbers

Both the Alphabetic Index and the Tabular Both the Alphabetic Index and the Tabular List must be used when locating and assigning List must be used when locating and assigning a code. a code.

Do not rely on just one since this can lead to Do not rely on just one since this can lead to errors in code assignment and a less specific errors in code assignment and a less specific code selectioncode selection

How to Select CodesHow to Select Codes

Locate each main term and subterm in the Locate each main term and subterm in the alphabetical index, i.e., Chronic Kidney alphabetical index, i.e., Chronic Kidney Disease Disease Disease Disease 1. Disease 2. Kidney 3. Chronic1. Disease 2. Kidney 3. Chronic

Verify the code selected in the Tabular listVerify the code selected in the Tabular list Read and be guided by instructional notations Read and be guided by instructional notations

that appear in both the Alphabetic Index and that appear in both the Alphabetic Index and the Tabular Listthe Tabular List

Let’s Practice Let’s Practice

Scabies Scabies ColitisColitis MRSA of blood MRSA of blood Hypertension Hypertension Benign prostatic hypertrophy (BPH) Benign prostatic hypertrophy (BPH)

Some HelpSome Help

Scabies - 133.0Scabies - 133.0 Colitis – 558.9Colitis – 558.9 MRSA of blood – 041.12 MRSA of blood – 041.12

Hypertension – 401.9 Hypertension – 401.9 Bening Prostate Hypertrophy 600.00Bening Prostate Hypertrophy 600.00

Tabular ListTabular List

Instructions for conditions that require Instructions for conditions that require multiple coding can appear in the Tabular List.multiple coding can appear in the Tabular List. ““Code also underlying disease”, “Use additional Code also underlying disease”, “Use additional

code, if desired, to identify manifestation, as …” code, if desired, to identify manifestation, as …” “Code also” instructs the coder to:“Code also” instructs the coder to:

Code the underlying disease, or etiology first as the Code the underlying disease, or etiology first as the primary diagnosisprimary diagnosis, followed by the code (s) for , followed by the code (s) for manifestation (s).manifestation (s).

It is mandatory to follow the “code also” instructions to It is mandatory to follow the “code also” instructions to assign both codes.assign both codes.

Slanted Brackets Slanted Brackets [ ][ ]

Indicate proper sequencing for the two Indicate proper sequencing for the two codes listed.codes listed. The code number before the bracket is The code number before the bracket is

coded first.coded first. The code number inside the brackets is The code number inside the brackets is

coded second.coded second.

Codes in brackets in the alphabetic index can Codes in brackets in the alphabetic index can NEVER be sequenced as the principal NEVER be sequenced as the principal diagnosis.diagnosis.

EXAMPLES EXAMPLES

1.Arthritis, arthritic --- due to or associated 1.Arthritis, arthritic --- due to or associated with hypothyroidism with hypothyroidism

244.9 244.9 [713.0][713.0]

2. UTI due to E.coli 2. UTI due to E.coli

599.0, [041.4]599.0, [041.4]

Let’s have a look Let’s have a look

See 429 section See 429 section Under Cardiovascular Disease, Unspecified Under Cardiovascular Disease, Unspecified

Excludes: That due to hypertension Excludes: That due to hypertension

Code to the Highest Level of Code to the Highest Level of SpecificitySpecificity

Assign 3 digit codes only if there are no four Assign 3 digit codes only if there are no four digit codes within the category.digit codes within the category. There are only 100 codes with only 3 digitsThere are only 100 codes with only 3 digits

Assign 4 digit codes only if there is no fifth Assign 4 digit codes only if there is no fifth digit.digit.

Assign 5 digit codes when indicated.Assign 5 digit codes when indicated. Samples – 486, 401.x, 250.xxSamples – 486, 401.x, 250.xx

Non-Specific CodesNon-Specific Codes

NEC – Not Elsewhere ClassifiedNEC – Not Elsewhere Classified NOS – Not Otherwise SpecifiedNOS – Not Otherwise Specified Codes are used only when neither the Codes are used only when neither the

diagnostic statement nor a thorough review of diagnostic statement nor a thorough review of the clinical record provides adequate the clinical record provides adequate information to permit assignment of a more information to permit assignment of a more specific codespecific code

V CodesV Codes

Per ICD-9-CM Official Guidelines for Coding Per ICD-9-CM Official Guidelines for Coding and Reporting, aftercare codes are generally and Reporting, aftercare codes are generally first to explain the specific reason for the first to explain the specific reason for the encounter (admission)encounter (admission)

Certain aftercare code categories need a Certain aftercare code categories need a secondary dx code to describe the resolving secondary dx code to describe the resolving condition or sequelaecondition or sequelae

For others (V codes) the condition is inherent For others (V codes) the condition is inherent in code title in code title

V-Codes V-Codes -2-2

V-codes are assigned to problems that affect the V-codes are assigned to problems that affect the patient’s health but are not in themselves a current patient’s health but are not in themselves a current illness or injuryillness or injury

V-codes can be used to represent status or history. V-codes can be used to represent status or history. Examples:Examples:

Status Cardiac Pacemaker V45.01Status Cardiac Pacemaker V45.01 Status heart valve prosthesis V43.3Status heart valve prosthesis V43.3 History of falls V15.88History of falls V15.88 History of alcoholism V11.3History of alcoholism V11.3

Remember not to use acute care codes when coding Remember not to use acute care codes when coding aftercare aftercare

Combination CodesCombination Codes

A single code used to classify TWO (2) A single code used to classify TWO (2) diagnoses or a diagnosis with an associated diagnoses or a diagnosis with an associated manifestation or complication.manifestation or complication.

Key words:Key words: ““AND”, “AND/OR”AND”, “AND/OR” ““WITH”, “WITH MENTION OF” OR “ASSOCIATED WITH”, “WITH MENTION OF” OR “ASSOCIATED

WITH”WITH” ““EXCLUDES”EXCLUDES”

Let’s Practice Let’s Practice

1. Chronic Peptic Ulcer 1. Chronic Peptic Ulcer with with Hemorrhage Hemorrhage 2. Cerebral thrombosis with cerebral 2. Cerebral thrombosis with cerebral

infarction infarction 3. Diverticulitis of Duodenum “with” 3. Diverticulitis of Duodenum “with”

bleeding bleeding

Combination CodesCombination Codes-2-2

Certain conditions have both underlying Certain conditions have both underlying etiology and multiple body system etiology and multiple body system manifestations, due to the underlying manifestations, due to the underlying etiology. Code the underlying etiology etiology. Code the underlying etiology first, followed by the manifestation.first, followed by the manifestation.

Combination CodesCombination Codes-3-3

Etiology codes – USE ADDITIONAL Etiology codes – USE ADDITIONAL CODECODE

Manifestation codes – CODE 1Manifestation codes – CODE 1stst Underlying Underlying DxDx..

Codes in parentheses identify conditions that Codes in parentheses identify conditions that require multiple coding. Also, codes in require multiple coding. Also, codes in parentheses CAN NOT be sequenced as parentheses CAN NOT be sequenced as PRINCIPAL Dx.PRINCIPAL Dx.

Manifestation Codes Manifestation Codes

There are written instructions in ICD-9-CM There are written instructions in ICD-9-CM coding books for sequencing codes. coding books for sequencing codes.

The underlying Dx (cause/s) coded first, The underlying Dx (cause/s) coded first, followed by codes for manifestations. followed by codes for manifestations.

Manifestation Codes Manifestation Codes -2-2

Diabetic Neuropathy Diabetic Neuropathy Diabetes with neurological manifestations must Diabetes with neurological manifestations must

be coded first (250.60) be coded first (250.60) The tabular list will guide you to “Use additional The tabular list will guide you to “Use additional

code to identify manifestation, as:” code to identify manifestation, as:” Polyneuropathy in diabetes (357.2) Polyneuropathy in diabetes (357.2) The tabular section will tell you that this code is The tabular section will tell you that this code is

not allowed as a principal Dx and will guide you not allowed as a principal Dx and will guide you to code underlying disease, as (Diabetes with to code underlying disease, as (Diabetes with complication…)complication…)

Let’s Code Let’s Code

1. ALZHEIMER’S DEMENTIA 1. ALZHEIMER’S DEMENTIA

2. DIABETIC GLAUCOMA 2. DIABETIC GLAUCOMA

Multiple CodingMultiple Coding

Multiple Coding of DiagnosesMultiple Coding of Diagnoses Find the main term in the Alphabetical Index to Find the main term in the Alphabetical Index to

locate the code number reference. Check the locate the code number reference. Check the reference in the Tabular List for notes and reference in the Tabular List for notes and instructions “associated with”, “due to”, instructions “associated with”, “due to”, “secondary to”, etc. are clues that multiple coding “secondary to”, etc. are clues that multiple coding may be necessary.may be necessary.

Multiple Coding Multiple Coding -3-3

““Associate with”, “Due to”, or “Secondary Associate with”, “Due to”, or “Secondary to”…to”… Frequently needed to completely identify diagnosis Frequently needed to completely identify diagnosis

of resident’s in long term care facilities.of resident’s in long term care facilities. Residents are often treated for the functional Residents are often treated for the functional

manifestations of a disease. Multiple coding is manifestations of a disease. Multiple coding is needed to identify both the underlying disease and needed to identify both the underlying disease and the manifestations.the manifestations.

Multiple Coding Multiple Coding -4-4

Examples:Examples: Aftercare following kidney transplant Aftercare following kidney transplant V58.44 (aftercare involving organ transplant), V58.44 (aftercare involving organ transplant), V42.0 (Organ/tissue replacement by transplant , kidney)V42.0 (Organ/tissue replacement by transplant , kidney) Aftercare following arteriocoronary bypass Aftercare following arteriocoronary bypass V58.73 (aftercare following surgery of the circulatory V58.73 (aftercare following surgery of the circulatory

system), V45.81(aortocoronary bypass status) system), V45.81(aortocoronary bypass status)

use aftercare codes to provide better detail use aftercare codes to provide better detail

Multiple Coding Multiple Coding -5-5

““Code, if applicable any causal condition first” Code, if applicable any causal condition first” notes indicate that the code may be assigned as notes indicate that the code may be assigned as a principal diagnosis when the underlying a principal diagnosis when the underlying cause cause is notis not known. known.

Example: Example: Lt. heel ulcer 707.14Lt. heel ulcer 707.14

Multiple Coding Multiple Coding -6-6

When the causal condition When the causal condition isis known, that code known, that code should be sequenced as the principal diagnosis should be sequenced as the principal diagnosis and the manifestation as second. and the manifestation as second.

Example: Example: Atherosclerotic ulcer of Lt. heel 440.23, 707.14Atherosclerotic ulcer of Lt. heel 440.23, 707.14

Chronic Illnesses Under TreatmentChronic Illnesses Under Treatment

Chronic illnesses that are managed with Chronic illnesses that are managed with medication or treatments, such as medication or treatments, such as hypertension, hypothyroidism, diabetes hypertension, hypothyroidism, diabetes mellitus, atrial fibrillation, assign the mellitus, atrial fibrillation, assign the appropriate ICD 9 codeappropriate ICD 9 code

The chronic condition exists, but is under The chronic condition exists, but is under control by medication control by medication

Acute and Chronic ComplicationsAcute and Chronic Complications

Acute complications Acute complications Need Immediate treatment/life threateningNeed Immediate treatment/life threatening

Diabetic KetoacidosisDiabetic Ketoacidosis Hyperglycemia / Hypoglycemia Hyperglycemia / Hypoglycemia Hypokalemia Hypokalemia

Chronic ConditionsChronic Conditions

Chronic conditions under treatment are coded Chronic conditions under treatment are coded even though the condition is under control even though the condition is under control with medicationwith medication

250.xx Diabetes is a common chronic 250.xx Diabetes is a common chronic condition that is treated and controlled with condition that is treated and controlled with medication or dietmedication or diet

Code diabetes even though it is under control Code diabetes even though it is under control and the resident has no complications and the resident has no complications

Reviewing DocumentationReviewing Documentation

Reviewing documentation for DX of DM and Reviewing documentation for DX of DM and type type

Look for documentation on:Look for documentation on: H&PH&P Discharge summary Discharge summary Surgical reports Surgical reports Physicians’ progress notes Physicians’ progress notes

Clarify with attending physicianClarify with attending physician

Coding DiabetesCoding Diabetes

Metabolic manifestations of the disease – Metabolic manifestations of the disease – require only one coderequire only one code Examples:Examples:

Diabetes with ketoacidosis 250.1x Diabetes with ketoacidosis 250.1x Diabetes with osmolarity 250.2xDiabetes with osmolarity 250.2x Diabetes with other coma 250.3xDiabetes with other coma 250.3x

Combination CodesCombination Codes

Some Diabetic Conditions Require 2 CodesSome Diabetic Conditions Require 2 Codes “ “Diabetic” or “Due to”Diabetic” or “Due to”

One Code for CauseOne Code for Cause One Code for ComplicationOne Code for Complication

Always sequence cause before complicationAlways sequence cause before complication

Combination Codes Combination Codes -2-2

Example:Example: Diabetic foot ulcerDiabetic foot ulcer

Diabetes with other manifestationDiabetes with other manifestation 250.8x250.8x

Ulcer of lower limb, except decubitusUlcer of lower limb, except decubitus 707.1x707.1x

Skin UlcersSkin Ulcers

Clarification of clinical terms related to skin Clarification of clinical terms related to skin ulcers ulcers www.cms.hhs.gov/manuals/pm trans/r4som.pdfwww.cms.hhs.gov/manuals/pm trans/r4som.pdf

Pressure Ulcer is a synonym for decubitus ulcer Pressure Ulcer is a synonym for decubitus ulcer – due to prolonged pressure– due to prolonged pressure

Subcategory 707.0x has fifth digits to identify Subcategory 707.0x has fifth digits to identify sitesite

New- additional code must be used to identify New- additional code must be used to identify stage stage

Skin Ulcers of Lower LimbsSkin Ulcers of Lower Limbs

Non pressure ulcers of lower legNon pressure ulcers of lower leg Fifth digits to identify siteFifth digits to identify site Multiple coding, code first the underlying dx, Multiple coding, code first the underlying dx,

such as arteriosclerosis, diabetes, venous such as arteriosclerosis, diabetes, venous hypertensionhypertension i.e. diabetic ulcer of left fifth toe 250.80, 707.15i.e. diabetic ulcer of left fifth toe 250.80, 707.15

Stasis Ulcers Stasis Ulcers

The most common type of vascular ulcersThe most common type of vascular ulcers In Alphabetical index under “ulcer” , the index In Alphabetical index under “ulcer” , the index

lists “venous” as a non-essential modifier under lists “venous” as a non-essential modifier under the subterm “stasis” that refers to code 459.81. the subterm “stasis” that refers to code 459.81.

Under section 459.81 in the Tabular List you will Under section 459.81 in the Tabular List you will be instructed to code any associated ulceration be instructed to code any associated ulceration from category 707.0-707.9from category 707.0-707.9

Wounds Wounds

Category 870-897 Codes for wounds are not to Category 870-897 Codes for wounds are not to be used for normal, healing surgical wounds or be used for normal, healing surgical wounds or to identify complications of surgical woundsto identify complications of surgical wounds

Skin Tears and Abrasions Skin Tears and Abrasions

Abrasions and skin tears are found in the Abrasions and skin tears are found in the Alphabetical Index under “injury, superficial” Alphabetical Index under “injury, superficial”

The fourth digit assignment identifies: The fourth digit assignment identifies: AbrasionsAbrasions Insect bitesInsect bites InfectionsInfections Superficial foreign bodySuperficial foreign body BlistersBlisters

CellulitisCellulitis

Skin tears or ulcers may become reddened, Skin tears or ulcers may become reddened, infected or swollen. Do not assume the infected or swollen. Do not assume the diagnosis of cellulitis unless it is documented diagnosis of cellulitis unless it is documented by a physician.by a physician.

If cellulitis is present code both the cellulitis If cellulitis is present code both the cellulitis and skin ulcer or skin tear to describe the and skin ulcer or skin tear to describe the cellulitis as a complication of a skin ulcer or cellulitis as a complication of a skin ulcer or skin tear skin tear

Myocardial InfarctionMyocardial Infarction

A code from category 410.XX must be A code from category 410.XX must be assigned if the admission is strictly for assigned if the admission is strictly for rehabilitation within eight weeks of the acute rehabilitation within eight weeks of the acute MI. MI.

The fifth digit 2 would be used in LTC to The fifth digit 2 would be used in LTC to designate observation, treatment or evaluation designate observation, treatment or evaluation of MI within eight weeks of onset, following of MI within eight weeks of onset, following the acute phase or in the healing state. the acute phase or in the healing state.

Myocardial Infarction Myocardial Infarction -2-2

The fifth digit “1” should be used if the acute The fifth digit “1” should be used if the acute myocardial infarction occurred at the nursing myocardial infarction occurred at the nursing facility and was the reason for transfer to the facility and was the reason for transfer to the hospital or the cause of death.hospital or the cause of death.

If the admission takes place after eight weeks If the admission takes place after eight weeks assign code (412) Old Myocardial Infarction assign code (412) Old Myocardial Infarction

NeoplasmsNeoplasms

Go to alphabetic indexGo to alphabetic index Look up Ex: fibroma, upper jaw Look up Ex: fibroma, upper jaw Find “fibroma”Find “fibroma” Cross reference “see neoplasm, by site,benign”Cross reference “see neoplasm, by site,benign” Turn to neoplasm locate subterm Turn to neoplasm locate subterm ““Jaw / upper”Jaw / upper” Follow across to Benign Follow across to Benign Locate code 213.0Locate code 213.0 Go to Tabular list for any coding instructions or Go to Tabular list for any coding instructions or

notes*notes*

Neoplasms of Uncertain BehaviorNeoplasms of Uncertain Behavior

Only used when stated as such in Alpha IndexOnly used when stated as such in Alpha Index Ex: Gastrinoma of Duodenum (235.2)Ex: Gastrinoma of Duodenum (235.2)

Look up: Gastrinoma, specified siteLook up: Gastrinoma, specified site States to see Neoplasm,by site, uncertain States to see Neoplasm,by site, uncertain

behaviorbehavior Uncertain behavior = difficult to distinguish Uncertain behavior = difficult to distinguish

from malignant behaviorfrom malignant behavior

Unspecified BehaviorUnspecified Behavior

Unspecified behavior – only used when Unspecified behavior – only used when Neoplasm is not fully describedNeoplasm is not fully described Or not specified as to behaviorOr not specified as to behavior Or listed in Alphabetic indexOr listed in Alphabetic index

Ex: Neoplastic Cyst of TongueEx: Neoplastic Cyst of Tongue Cross reference Alpha Index Under Cyst, Cross reference Alpha Index Under Cyst,

neoplastic see neoplasm,by site, unspecified natureneoplastic see neoplasm,by site, unspecified nature

Neoplasms with MetastasisNeoplasms with Metastasis

Malignant Neoplasm from primary siteMalignant Neoplasm from primary site Invade or spread via the Invade or spread via the

BloodBlood Lymphatic systemLymphatic system Tissue to secondary metastatic siteTissue to secondary metastatic site

Example: Lymphoma with malignant pleural Example: Lymphoma with malignant pleural effusion 202.80 (old code 197.2 after Oct. 1effusion 202.80 (old code 197.2 after Oct. 1stst, , 511.81 will be used) 511.81 will be used)

Neoplasms with Metastasis Neoplasms with Metastasis -2-2

Two codesTwo codes One for primary (original site)One for primary (original site) One for each secondary siteOne for each secondary site

Code primary before secondaryCode primary before secondary Except when using “V” code for primary site that Except when using “V” code for primary site that

has been surgically removedhas been surgically removed

Neoplasms with Metastasis Neoplasms with Metastasis -3-3

Determine the primary siteDetermine the primary site Turn to Neoplasms TableTurn to Neoplasms Table Ex: Carcinoma of Rectum (154.1)Ex: Carcinoma of Rectum (154.1) Find Neoplasm, rectum, malignant, primaryFind Neoplasm, rectum, malignant, primary

Neoplasms with Metastasis Neoplasms with Metastasis -4-4

Ex: Secondary malignant neoplasm of prostate Ex: Secondary malignant neoplasm of prostate (198.82(198.82

Find Neoplasm, prostate, malignant, secondary Find Neoplasm, prostate, malignant, secondary Determine the site(s) of metastasisDetermine the site(s) of metastasis

Turn to Neoplasm tableTurn to Neoplasm table Find correct subterm(s) for siteFind correct subterm(s) for site Cross over to Malignant and column Cross over to Malignant and column

secondarysecondary

Unknown Secondary SitesUnknown Secondary Sites

Ex: Cancer of Lower lobe of lung with Ex: Cancer of Lower lobe of lung with metastases (162.5, 199.0)metastases (162.5, 199.0)

Code primary site firstCode primary site first To code the unknown secondary siteTo code the unknown secondary site

Refer to Neoplasm tableRefer to Neoplasm table Multiple sites NECMultiple sites NEC Cross over to column for code (199.1)Cross over to column for code (199.1)

Unknown Primary SiteUnknown Primary Site

Refer to neoplasm table Refer to neoplasm table Unknown or Unspecified siteUnknown or Unspecified site Cross over to primary column 199.1Cross over to primary column 199.1 Sequence after secondary site(s)Sequence after secondary site(s) Ex: abdominal metastasis from unknown Ex: abdominal metastasis from unknown

origin (198.89, 199.1)origin (198.89, 199.1) Unknown primary would not be used as Unknown primary would not be used as

principle diagnosis in SNF principle diagnosis in SNF The metastatic site is coded firstThe metastatic site is coded first

““V” Codes for CancerV” Codes for Cancer

Primary site must still be identifiedPrimary site must still be identified If removed, eradicated no longer under If removed, eradicated no longer under

treatmenttreatment Use a personal history V-code, History,site, Use a personal history V-code, History,site,

malignant neoplasmmalignant neoplasm Identify primary site responsible for metastasis Identify primary site responsible for metastasis

but no longer presentbut no longer present

V codes for Neoplasms V codes for Neoplasms

Do not use codes from category V10 for Do not use codes from category V10 for secondary metastatic sites removed or notsecondary metastatic sites removed or not

ICD-9-CM does not provide code numbers for ICD-9-CM does not provide code numbers for “history of secondary neoplasm site“history of secondary neoplasm site

V58.42 NeoplasmV58.42 Neoplasm

Official coding guidelines for neoplasm apply Official coding guidelines for neoplasm apply when using the aftercare following surgery for when using the aftercare following surgery for neoplasm V58.42neoplasm V58.42

Aftercare code V58.42 may be used with Aftercare code V58.42 may be used with either the current neoplasm code or a code either the current neoplasm code or a code from category V10, whichever is applicablefrom category V10, whichever is applicable

V58.42 Neoplasm V58.42 Neoplasm -2-2

A primary malignancy A primary malignancy Previously excised or eradicated from its site Previously excised or eradicated from its site And there is no further tx directed to that site And there is no further tx directed to that site And there is no evidence of any existing primary And there is no evidence of any existing primary

malignancy,malignancy, A code from Category V10 is used to identify the A code from Category V10 is used to identify the

former site of malignancy former site of malignancy

V-Codes V-Codes -2-2

V12.41 Personal history of benign neoplasm V12.41 Personal history of benign neoplasm of the brain.of the brain. Previously, no code to indicate that the patient had Previously, no code to indicate that the patient had

benign growth. These can cause serious symptoms benign growth. These can cause serious symptoms in the patient.in the patient.

Late Effects of CVA’s Late Effects of CVA’s (438.0-438.9)(438.0-438.9)

Rather than code the residual condition AND Rather than code the residual condition AND the late effect, combination codes that include the late effect, combination codes that include the late effect should be used. Additionally, the late effect should be used. Additionally, these can be used with a new CVA.these can be used with a new CVA.

DO NOTDO NOT code 436 for CVA codes from code 436 for CVA codes from categories 430-436 are used for the initial categories 430-436 are used for the initial episode of care for an acute CVA at the episode of care for an acute CVA at the hospitalhospital

Late Effect Late Effect -2-2

A late effect is a residual condition that A late effect is a residual condition that remains and requires nursing care after the remains and requires nursing care after the initial phase of an illness or injury has passedinitial phase of an illness or injury has passed

Locate the codes in the Alphabetical Index Locate the codes in the Alphabetical Index under the main term “Late, effect (s)(of)under the main term “Late, effect (s)(of)

Late Effect Late Effect -3-3

The residual condition is coded first and the The residual condition is coded first and the late effect is sequenced secondlate effect is sequenced second

Multiple coding is required for most late Multiple coding is required for most late effectseffects

A late effect is not used as a principal dx, A late effect is not used as a principal dx, except for Category 438 Late Effect of CVA except for Category 438 Late Effect of CVA i.e. Left Hemiplegia due to CVA 438.20i.e. Left Hemiplegia due to CVA 438.20

438 Late Effect of CVA438 Late Effect of CVA

Official coding guidelines state that Category Official coding guidelines state that Category 438 is used for admission and encounter for 438 is used for admission and encounter for post acute carepost acute care following treatment of the following treatment of the CVA in the acute hospitalCVA in the acute hospital

Codes from categories 430 to 436 are reserved Codes from categories 430 to 436 are reserved for the “initial” (first) episode of care for an for the “initial” (first) episode of care for an acute CVA that was provided in the qualifying acute CVA that was provided in the qualifying hospital stay and should not be used in SNFhospital stay and should not be used in SNF

438 Combination/Multiple Coding438 Combination/Multiple Coding

Category 438 includes combination codes that Category 438 includes combination codes that describe both the cause and the residual deficitdescribe both the cause and the residual deficit

Right hemiplegia due to old CVA 438.20Right hemiplegia due to old CVA 438.20 More than one code my be used from category More than one code my be used from category

438 to identify multiple residuals from a CVA 438 to identify multiple residuals from a CVA Dysphagia and left hemiplegia post CVA Dysphagia and left hemiplegia post CVA

438.82, 438.20 438.82, 438.20

438438

Use additional codes with category 438 if the Use additional codes with category 438 if the combination code does not address all combination code does not address all elements of diagnostic statementelements of diagnostic statement

Multiple coding is used to identify residuals of Multiple coding is used to identify residuals of CVA that do not have a specific codeCVA that do not have a specific code

Seizure disorder following CVA 438.89, Seizure disorder following CVA 438.89, 780.39 780.39

V54.1 Aftercare for Healing V54.1 Aftercare for Healing Traumatic FractureTraumatic Fracture

For residents admitted to a SNF for care For residents admitted to a SNF for care following treatment in the acute hospital for a following treatment in the acute hospital for a traumatic fx use the aftercare codes from traumatic fx use the aftercare codes from Subcategory V54.1Subcategory V54.1

Do not code the (acute) fractureDo not code the (acute) fracture Coding Guidelines require an aftercare code be Coding Guidelines require an aftercare code be

used after the initial encounter for care of a fx.used after the initial encounter for care of a fx.

V54.1 Aftercare for Healing V54.1 Aftercare for Healing Traumatic Fracture Traumatic Fracture -2-2

For statistical purposes, a fracture should only For statistical purposes, a fracture should only be coded once. If the same fx is coded for all be coded once. If the same fx is coded for all encounters, it makes collection of fracture encounters, it makes collection of fracture statistics difficultstatistics difficult

The V54.1 identifies the site of the fracture The V54.1 identifies the site of the fracture and that it is in the healing phasesand that it is in the healing phases

Aftercare for Fractures; Pathologic and Aftercare for Fractures; Pathologic and TraumaticTraumatic

V54 Aftercare Healing Traumatic V54 Aftercare Healing Traumatic FractureFracture

The fifth digits identify the specific site of the The fifth digits identify the specific site of the healing fracturehealing fracture

The fifth digit 9 is used for other specified The fifth digit 9 is used for other specified sitessites

If there are several bones that would be If there are several bones that would be classified to the other specified site, only one classified to the other specified site, only one code is usedcode is used

V54 Aftercare Healing Traumatic V54 Aftercare Healing Traumatic Fracture Fracture -2-2

DO NOT code V58.43 Aftercare following DO NOT code V58.43 Aftercare following surgery for injury and trauma (conditions surgery for injury and trauma (conditions classifiable to 800-999) Exclusion note states classifiable to 800-999) Exclusion note states “Excludes: aftercare for healing traumatic “Excludes: aftercare for healing traumatic fracture” fracture”

Remember to always refer to the tabular list Remember to always refer to the tabular list and carefully read the instructions and and carefully read the instructions and exclusions. exclusions.

Aftercare for Healing Pathological Aftercare for Healing Pathological FxFx

Pathological fracture is a fracture in a bone due to Pathological fracture is a fracture in a bone due to weakening of the bone structure by disease weakening of the bone structure by disease process such as osteoporosis. process such as osteoporosis.

For admissions in LTC following a hospital stay For admissions in LTC following a hospital stay for treatment of a pathological fracture assign a for treatment of a pathological fracture assign a code from Subcategory V54.2 Aftercare for code from Subcategory V54.2 Aftercare for healing pathologic fracture healing pathologic fracture

A compression fracture of the vertebrae is A compression fracture of the vertebrae is considered pathologic if it is not caused by traumaconsidered pathologic if it is not caused by trauma

V54.81 Joint ReplacementV54.81 Joint Replacement

Joint replacement of knee for osteoarthritis Joint replacement of knee for osteoarthritis ((V58.78)V58.78), V54.81, V43.65, V54.81, V43.65

Do not code the disease condition that was Do not code the disease condition that was treated with the surgerytreated with the surgery

2008 will have a change in the tabular list for 2008 will have a change in the tabular list for V58.78 that will exclude it when there is V58.78 that will exclude it when there is orthopedic aftercare; codes from section orthopedic aftercare; codes from section V54.01-V54.9 will be used. V54.01-V54.9 will be used.

Joint Replacement for FXJoint Replacement for FX

Use multiple coding to fully describe the Use multiple coding to fully describe the resident’s conditionresident’s condition

FX hip (traumatic) with joint replacement FX hip (traumatic) with joint replacement V54.13, V54.81, V43.64V54.13, V54.81, V43.64

Do not use V58.43 Aftercare following Do not use V58.43 Aftercare following surgery for injury and trauma-(not for fx)surgery for injury and trauma-(not for fx)

(conditions classifiable to 800-999) see (conditions classifiable to 800-999) see excludes note: (V54.10-V54.19)excludes note: (V54.10-V54.19)

V57 Care Involving RehabV57 Care Involving Rehab

Category V57 does not indicate that rehab Category V57 does not indicate that rehab services were provided, only that the resident services were provided, only that the resident was admitted for this purposewas admitted for this purpose

Use only one code from Category V57 for an Use only one code from Category V57 for an admissionadmission

If the resident is admitted for multiple If the resident is admitted for multiple therapies, use V57.89 therapies, use V57.89

V57 Care Involving Rehab V57 Care Involving Rehab -2-2

Code also the condition requiring the rehab, Code also the condition requiring the rehab, such as:such as: ResidualsResiduals Late effectsLate effects AftercareAftercare symptomssymptoms

V58 Aftercare following SurgeryV58 Aftercare following Surgery

The acute dx for which the surgery was The acute dx for which the surgery was preformed is not reported for aftercare preformed is not reported for aftercare encounters or admissionsencounters or admissions

Use other aftercare or symptom codes to Use other aftercare or symptom codes to provide better detailprovide better detail

Note the instructions with each code that Note the instructions with each code that identifies the range of conditions that are identifies the range of conditions that are included in the aftercare code numberincluded in the aftercare code number i.e. aftercare post cataract extraction with lens i.e. aftercare post cataract extraction with lens

implant: V58.71, V45.61, V43.1 implant: V58.71, V45.61, V43.1

HypertensionHypertension

Unless the diagnosis statement specifies as Unless the diagnosis statement specifies as “benign” or “Malignant” “benign” or “Malignant”

““unspecified” code (401.9) must be assigned unspecified” code (401.9) must be assigned

Heart Conditions Due to HTNHeart Conditions Due to HTN

When there is a casual relationship is states as When there is a casual relationship is states as “hypertensive” or “due to hypertension” heart “hypertensive” or “due to hypertension” heart conditions are assigned by Category 402 conditions are assigned by Category 402 Hypertensive Heart Disease Hypertensive Heart Disease

Arteriosclerotic disease due to hypertension Arteriosclerotic disease due to hypertension 402.90402.90

2009 ICD-9-CM addenda2009 ICD-9-CM addenda

2009 code updates effective 10/1/082009 code updates effective 10/1/08 041.11 MSSA (susceptible) 041.11 MSSA (susceptible) 041.12 MRSA (combo code)041.12 MRSA (combo code) V02.53 colonization MSSAV02.53 colonization MSSA V02.54 colonization MRSAV02.54 colonization MRSA V09.0 DELETED CODE – MRSAV09.0 DELETED CODE – MRSA V12.04 personal hx MRSAV12.04 personal hx MRSA

New CatagoriesNew Catagories

Category 249. secondary diabetes mellitusCategory 249. secondary diabetes mellitus

Category 339. other headache syndromesCategory 339. other headache syndromes

New CodesNew Codes

403. hypertensive chronic kidney dx (includes 403. hypertensive chronic kidney dx (includes 585. with any condition classifiable to 401)585. with any condition classifiable to 401)

599.70 hematuria, unspecified599.70 hematuria, unspecified 599.71 gross hematuria599.71 gross hematuria 599.72 microscopic hematuria599.72 microscopic hematuria 780.72 functional quadriplegia780.72 functional quadriplegia 780.91 functional incontinence780.91 functional incontinence

More new codesMore new codes

780.60 fever, NOS780.60 fever, NOS 780.61 fever, with conditions classified 780.61 fever, with conditions classified

elsewhereelsewhere 780.62 postprocedural fever780.62 postprocedural fever 780.63 post vaccination fever780.63 post vaccination fever 780.64 chills without fever780.64 chills without fever V45.11 renal dialysis statusV45.11 renal dialysis status V45.12 noncompliance with renal dialysisV45.12 noncompliance with renal dialysis

Pressure UlcerPressure Ulcer

Use add’l code to identify pressure ulcer stageUse add’l code to identify pressure ulcer stage 707.20 pressure ulcer, unspecified stage707.20 pressure ulcer, unspecified stage 707.21 pressure ulcer, stage I707.21 pressure ulcer, stage I 707.22 pressure ulcer, stage II707.22 pressure ulcer, stage II 707.23 pressure ulcer, stage III707.23 pressure ulcer, stage III 707.24 pressure ulcer, stage IV707.24 pressure ulcer, stage IV 707.25 pressure ulcer, unstageable707.25 pressure ulcer, unstageable

Hx of FractureHx of Fracture

V13.51 personal hx of healed pathologic fxV13.51 personal hx of healed pathologic fx V13.52 personal hx of healed stress fxV13.52 personal hx of healed stress fx V15.51 personal hx of healed traumatic fxV15.51 personal hx of healed traumatic fx

Note added to subcatagory 733.0Note added to subcatagory 733.0-use add’l code to identify personal hx of -use add’l code to identify personal hx of pathologic (healed) fx (V13.51)pathologic (healed) fx (V13.51)

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Coding Exercises Coding Exercises Questions for discussionQuestions for discussion

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