ICD-9-CM Coding for Post Acute Care

Presented by:

Rhonda Anderson, RHIA, President

Anderson Health Information Systems, Inc.

Objectives

Participants will : Correctly assign ICD-9-CM codes to diagnoses Correctly identify primary / Secondary

diagnoses Identify correct sequence of diagnoses for

coding assignment Identify difference between ICD-9-CM and ICD-

10 Learn ICD-10 transition timeline

Purpose of ICD-9-CM Coding Gather statistical dataReporting diagnoses and provides a

method for sequencing diagnosis to support billing transactions / reimbursement

Ensure compliance with Federal Reporting Standards for diagnoses

Provide insight into the types of residents and conditions

Health Research

ICD-9-CM Official Guidelines for Coding and Reporting

HIPAA www.cdc.gov/nchs/icd.htmLatest revision October 1, 2011

Post Acute Care

Skilled Nursing Facility (SNF) Inpatient Rehab Facility (IRF) Home Health Agency (HHA) Long Term Acute Care Hospital

(LTACH)

ICD-9-CM Coding book

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

Assigning Code Numbers

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

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

How to Select Codes

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

Verify the code selected in the Tabular list

Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List

Code to the Highest Level of Specificity

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

digitsAssign 4 digit codes only if there is

no fifth digit.Assign 5 digit codes when indicated.Samples – 486, 401.x, 250.xx

Types of Codes used in post acute care Settings

Aftercare – used when the initial treatment of a disease or injury has been performed and the patients still requires continued care to heal or recover. Categories V51-V58

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

Types of Codes -2

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

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

Therapy – Physical, occupational, speech and respiratory therapy.

Types of Codes -3

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

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

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

Examples

Status post upper arm fracture V54.11

History of frequent falls V15.88

Admission for physical therapy following hip fracture

V57.1 , V54.13

Practice #1 (cont.)

Hemiplegia due to recent CVA

Total Hip Replacement

Acute UTI treated with Cipro.

Dementia

Late Effect

After Care

Acute Condition

Chronic Condition

What to code?

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

TREATMENT RECEIVED

Do NOT Code

DIAGNOSES THAT DO NOT AFFECT TREATMENT OR LENGTH OF STAY

WHEN CONDITION NO LONGER EXISTS

DO NOT ASSIGN PROCEDURE CODES Examples: Fractured forearm 6 years ago,

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

Definition of Principal Diagnosis “FIRST LISTED DIAGNOSES” is the diagnosis

that is chiefly responsible for the admission to the facility and the diagnosis that supports the reimbursement and should be sequenced first.”

Locating Diagnoses

Transfer RecordsHistory & PhysicalProgress NotesAdmission Orders

Additional Sources of Information

Discharge summary Transfer documentation, Surgical reportsConsultations Physician Progress notes Lab reports and radiological studies

Locating Principal Diagnosis

Principal Diagnosis

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

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

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

Example

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

Choose the Principal Diagnosis

Fall 3 months agoChronic kidney disease Above the knee amputation Rt. Leg

(10 days ago) with infection still on antibiotics

Anemia

Non-Specific Codes

NEC – Not Elsewhere ClassifiedNOS – Not Otherwise SpecifiedCodes are used only when neither

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

Inclusion Terms

The coder must review the titles and inclusions under the three or four digit category to determine if the diagnosis is included in the category; however, the specific diagnosis may not always be listed

Example: Spinal Cord Inflammation 323.9

Combination Codes

Single codes used to classify two diagnosis or a diagnosis with a manifestation

Example: Candidiasis with meningitis 112.83

Combination Codes

Etiology codes – USE ADDITIONAL CODE

Manifestation codes – CODE 1st Underlying Dx.

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

Multiple Coding

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

additional code, if desired, to identify manifestation, as …” “Code also” instructs the coder to:▪ Code the underlying disease, or etiology first as the

primary diagnosis, followed by the code (s) for manifestation (s).

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

Combination Codes

Anosmia following CVA 438.6, 781.1

“with”, “with mention of”, or “associated with” – this code can only be used if both conditions are present

Kidney Infection …..590.9 with Calculus 592.0

Slanted Brackets [ ]

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

is coded first. The code number inside the brackets

is coded second.Codes in brackets in the alphabetic

index can NEVER be sequenced as the principal diagnosis.

EXAMPLES

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

244.9 [713.0]

Multiple Coding

Examples: Aftercare following kidney transplant V58.44 (aftercare involving organ transplant), V42.0 (Organ/tissue replacement by transplant ,

kidney)

Aftercare following arteriocoronary bypass V58.73 (aftercare following surgery of the

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

use aftercare codes to provide better detail

Sequencing Multiple Codes

“Using Additional Codes” When the instructions say “Use

additional code….” the additional code is sequences second.

Example UTI due to E.coli

599.0[041.4]

“Exclusions”

Let’s have a look: See 429 section Under Cardiovascular Disease,

Unspecified ▪ Excludes: That due to hypertension

Diagnosis Sequencing

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

Acute Diagnoses

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

Examples: MRSA Pneumonia UTI

Secondary Diagnoses

May have multiple secondary codes List and code conditions related to

therapy and services provided Review and update as condition changes

– sequence may change over time Billing staff should work with Nursing

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

Secondary Diagnoses

Order by complexity. Assign the condition with the higher

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

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

Late Effects

Residual condition After initial / acute phase of illness

438 Late Effects of CVA

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

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

Let’s Practice

Which of the following is a late effect?

a. End stage renal disease b. Anosmia following recent CVA c. Diabetic retinopathy d. Paraplegia due to polio

Let’s Code

Left hemiplegia secondary to CVA (patient is right handed)

Late Effects Cerebrovascular disease With hemiplegia – nondominant side

Infections

Codes from categories 041 or 079 can be used as principal diagnosis as long as the nature or site of the infection is not specified or when the Alphabetical index instructs you to do so.

Code it

• Gastroenteritis due to E.coli• 008.00

• MRSA infection of Lt. toe • 041.12

• Herpetic septicimia • 054.5

Neoplasms

Go to alphabetic index Look up Ex: fibroma, upper jaw Find “fibroma” Cross reference “see neoplasm, by site,

benign” Turn to neoplasm locate sub term “Jaw / upper” Follow across to Benign Locate code 213.0 Go to Tabular list for any coding

instructions or notes*

Neoplasms of Uncertain Behavior

Only used when stated as such in Alpha Index

Unspecified Behavior – Only used when Neoplasm is not fully

described Or not specified as to behavior Or listed in Alphabetic index

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

see neoplasm, by site, unspecified nature

Neoplasms with Metastasis

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

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

site that has been surgically removed

Neoplasms with Metastasis Determine the primary siteTurn to Neoplasms TableEx: Carcinoma of Rectum (154.1)Find Neoplasm, rectum, malignant,

primary

Neoplasms with MetastasisEx: Secondary malignant neoplasm

of prostate (198.82)Find Neoplasm, prostate, malignant,

secondary Determine the site(s) of metastasis

Turn to Neoplasm tableFind correct sub term(s) for siteCross over to Malignant and column

secondary

Unknown secondary sites

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

Code primary site firstTo code the unknown secondary site

Refer to Neoplasm table Multiple sites NEC Cross over to column for code (199.0)

Unknown Primary Site

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

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

as principle diagnosis in SNF • The metastatic site is coded first

“V” Codes for Cancer

• Primary site must still be identified if removed, eradicated no longer under treatment

• Use a personal history V-code, History, site, malignant neoplasm

• Identify primary site responsible for metastasis but no longer present

• Secondary site code is sequenced first and then the V-code

“V” Codes for Cancer

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

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

V58.42 Neoplasm

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

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

Code It

• History of breast cancer with metastasis to the lung

• 197.0, V10.3

• Carcinoma of prostate with metastasis to spine

• 185, 198.5

• Basal cell carcinoma of chest • 173.5

Endocrine, Nutritional and Metabolic Diseases and immunity disorders

Examples:

HypothyroidismDiabetes Metabolic disorders Obesity

Code It

Hypothyroidism due to history of thyroid cancer (thyroid removed)

244.0, V10.87Uncontrolled, Type II Diabetes 250.01

Manifestations Codes

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

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

Combination Codes

Some Diabetic Conditions Require 2 Codes “Diabetic” or “Due to”▪ One Code for Cause▪ One Code for Complication

Always sequence cause before complication

Combination Codes

Example: Diabetic foot ulcer▪ Diabetes with other manifestation▪ 250.8x

▪ Ulcer of lower limb, except decubitus▪ 707.1x

Manifestation Codes

Diabetic Neuropathy Diabetes with neurological manifestations

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

additional code to identify manifestation, as:”

Polyneuropathy in diabetes (357.2) The tabular section will tell you that this

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

Let’s Code

1. ALZHEIMER’S DEMENTIA 331.0, 294.10

2. DIABETIC GLAUCOMA 250.50, 365.9

Chronic Illnesses

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

The chronic condition exists, but is under control by medication

Myocardial Infarction

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

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

Myocardial Infarction

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

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

Hypertension

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

“unspecified” code (401.9) must be assigned

Heart Conditions Due to Hypertension

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

Arteriosclerotic disease due to hypertension 402.90

Circulatory System

Let’s Code 1. Chronic hypertensive kidney

disease 2. 403.9, 585.93. Deep vein thrombosis patient on

Coumadin 4. 453.40, V58.61

Respiratory System

Let’s Code

Aspiration Pneumonia 507.0

Chronic bronchitis with emphysema 491.20

Skin Ulcers

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

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

• Subcategory 707.0x has fifth digits to identify site

2009- New- additional code must be used to identify stage

Skin Ulcers of Lower Limbs

Non pressure ulcers of lower legFifth digits to identify siteMultiple coding, code first the

underlying dx, such as arteriosclerosis, diabetes, venous hypertension i.e. diabetic ulcer of left fifth toe 250.80,

707.15

Stasis Ulcers

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

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

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

Wounds

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

V- Codes

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

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

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

Coding Clinic Fourth Quarter 1999

Published rules for the use of V codes

Addressed the use of V codes in LTC settings

Coding clinic Fourth Quarter 2003Clarified the use of aftercare V codes

for all subsequent encounters after the initial treatment for a fracture

“for statistical purposes, a facture should only be reported once”

V- Codes -2

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

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

Examples: Status Cardiac Pacemaker V45.01 Status heart valve prosthesis V43.3 History of falls V15.88 History of alcoholism V11.3▪ Remember not to use acute care codes when

coding aftercare

To “V” or not to “V”Scenario # 1

A resident is admitted for physical therapy following a hip replacement for an inter-trochanteric right hip fracture due to a fall.

To ‘V’ or Not to ‘V’: Scenario #1

Physical therapy:▪ V57.1 Physical Therapy

Intertrochantic right hip fracture due to a fall:▪ V54.13 Aftercare following traumatic hip fracture

Hip replacement:▪ V54.81 Aftercare following joint replacement▪ V43.64 Joint replacement, hip

To ‘V’ or Not to ‘V’: Scenario #2

A resident is admitted for P.T. & O.T.following a hip fracture after a fall.The physician indicated that the fracture was due to osteoporosis. The Discharge Summary stated that old compression fractures of the vertebrae due to osteoporosis were present on x-ray.

To ‘V’ or Not to ‘V’: Scenario #2

Physical Therapy and Occupational Therapy▪ V57.89 Multiple therapies

Hip Fracture (due to osteoporosis)▪ V54.23 Aftercare for continuing treatment of

healing pathologic fracture of hipOsteoporosis

▪ 733.00 OsteoporosisCompression fractures of vertebrae

▪ 733.13 Pathologic fractures of vertebrae

Let’s Practice

Admitted for physical therapy, status post total knee replacement due to arthritis

1) Admission – rehabilitation – physical

2 ) Aftercare – following surgery for – joint replacement 3) Replacement – joint – Knee

V57.1, V54.81 , V43.65

Post hysterectomy for uterine cancer three years ago (no further treatment)

History – personal – malignant neoplasm – uterus

V10.42

Select the correct Code Fracture of upper arm due to fall,

resident wearing a sling, admitted for ADL assistance.

V54.11 812.20 (NO)

V54.1 Aftercare for healing traumatic fracture

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

Do not code the (acute) fractureCoding Guidelines require an

aftercare code be used after the initial encounter for care of a fx.

V54.1 Aftercare for healing traumatic fracture

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

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

Aftercare for Fractures; Pathologic and Traumatic

V54.1 Aftercare for healing traumatic fracture

The fifth digits identify the specific site of the healing fracture

The fifth digit 9 is used for other specified sites

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

V54.1 Aftercare for healing traumatic fracture

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

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

Aftercare for healing Pathological fracture

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

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

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

Hx of Fracture

V13.51 personal hx of healed pathologic fx

V13.52 personal hx of healed stress fx

V15.51 personal hx of healed traumatic fx

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

V54.81 Joint replacement

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

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

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

Joint Replacement for Fx

Use multiple coding to fully describe the resident’s condition

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

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

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

V57 Care Involving Rehab

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

Use only one code from Category V57 for an admission

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

V57 Care Involving Rehab

Code also the condition requiring the rehab, such as: Residuals Late effects Aftercare symptoms

V58 Aftercare Following Surgery The acute dx for which the surgery

was preformed is not reported for aftercare encounters or admissions

Use other aftercare or symptom codes to provide better detail

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

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

2011 ICD-9-CM UPDATES

Implementation date of new, revised and invalid codes October 1, 201

Chart # 1

Chart # 2

Important Points

Provide a roadmap back to the qualifying stay

Paint a clear picture of your patient

Pay attention to details

Go beyond the code and communicate through documentation

Questions and Answers

Thanks for attending