ICD-10-CM For Long Term Care - LeadingAge New York

June 2015Hypertension with Other Conditions ICD-10-CM does not provide combination codes whenhypertension is associated with other conditions thataccelerate its development (e.g., cerebrovasculardisease). Hypertensive cerebrovascular disease (I60-I69): Assign first the appropriate code from categories I60-I69,followed by the appropriate hypertension code I10-I15. Hypertensive retinopathy: Assign subcategory H35.0 with appropriate code fromcategories I10-I15. Sequencing depends on the reason for the encounter.Elevated Blood Pressure versusHypertension Blood pressure readings can vary: Diagnosis of hypertension is based on a series ofreadings, rather than a single reading. Assign code R03.0 for elevated blood pressurewithout hypertension.ICD-10-CM for Long Term Care17

June 2015Respiratory System When a respiratory condition is described asoccurring in more than one site, and is notspecifically indexed (listed in the alphabetical indexas a subterm), it should be classified to the loweranatomical site (eg: tracheobronchitis to bronchitis) Code also, where applicable: Exposure to tobacco smokeExposure to tobacco smoke in perinatal periodHistory of tobacco useOccupational exposure to environmental tobacco smokeTobacco dependenceTobacco useAsthma Coding Notes Wheezing alone is not considered asthma Never assume presence of status asthmaticuswithout a specific statement from the physician. Status asthmaticus means no relieved or managed bytreatments When there is documentation of both acuteexacerbation and status asthmaticus, only thecode with the final character of 2 should beassigned. Example: Acute atopic asthma, status asthmaticus Reference: C.10.a.1ICD-10-CM for Long Term Care18

June 2015Coding Guidelines for Respiratory FailureC.10.b.1: Acute Respiratory Failure as principal diagnosis A code from subcategory J96.0, Acute respiratory failure, orsubcategory J96.2, Acute and chronic respiratory failure, may beassigned as a principal diagnosis when it is the conditionestablished after study to be chiefly responsible for occasioningthe admission to the hospital, and the selection is supported bythe Alphabetic Index and Tabular List. However, chapter-specificcoding guidelines (such as obstetrics, poisoning, HIV, newborn)that provide sequencing direction take precedence.C.10.b.2: Acute respiratory failure as secondary diagnosis Respiratory failure may be listed as a secondary diagnosis if itoccurs after admission, or if it is present on admission, but doesnot meet the definition of principal diagnosis.Coding Guidelines for Respiratory FailureC.10.b.3: Sequencing of acute respiratory failure and another acutecondition When a patient is admitted with respiratory failure and another acutecondition, (e.g., myocardial infarction, cerebrovascular accident,aspiration pneumonia), the principal diagnosis not be the same in everysituation. This applies whether the other acute condition is a respiratoryor nonrespiratory condition. Selection of the principal diagnosis will bedependent on the circumstances of admission. If both the respiratoryfailure and the other acute condition are equally responsible foroccasioning the admission to the hospital, and there are no chapterspecific sequencing rules, the guideline regarding two or more diagnosesthat equally meet the definition for principal diagnosis (Section II, C.) maybe applied in these situations. If the documentation is not clear as to whether acute respiratory failureand another condition are equally responsible for occasioning theadmission, query the provider for clarificationICD-10-CM for Long Term Care19

June 2015InfluenzaC.10.c: Influenza due to certain identified influenza viruses Code only confirmed cases of influenza due to certain identifiedinfluenza viruses (category J09), and due to other identified influenzavirus (category J10). This is an exception to the hospital inpatientguideline Section II, H. (Uncertain Diagnosis). In this context, “confirmation” does not require documentation ofpositive laboratory testing specific for avian or other novel influenza A orother identified influenza virus. However, coding should be based on theprovider’s diagnostic statement that the patient has avian influenza, orother novel influenza A, for category J09, or has another particularidentified strain of influenza, such as H1N1 or H3N2, but not identified asnovel or variant, for category J10. If the provider records “suspected” or “possible” or “probable” avianinfluenza, or novel influenza, or other identified influenza, then theappropriate influenza code from category J11, Influenza due tounidentified influenza virus, should be assigned. A code from categoryJ09, Influenza due to certain identified influenza viruses, should not beassigned nor should a code from category J10, Influenza due to otheridentified influenza virus.Influenza in non-Inpatient setting J11.- (influenza due to unidentified influenzavirus) should not be used in an outpatient orlong term care setting If culture is ordered, do not code suspected orprobable influenza– Code the presenting symptoms as the reason forthe testICD-10-CM for Long Term Care20

June 2015Tracheostomy Complications—Subcategory J95.0 Classified to subcategory J95.0 in chapter 10 of ICD-10-CM. Infection of a tracheostomy is classified to code J95.02,with an additional code to identify the type of infectionand/or a code from category B95-B97 to identify theorganism, or sepsis, A40.-, A41.-. Mechanical complications are coded to J95.03. Other complications, such as: Hemorrhage of tracheostomy, which is coded to J95.01. Trachea-esophageal fistula following tracheostomy, which iscoded to J95.04. Alphabetical index: Complications, tracheostomyCaution Notes for Respiratory System: Do not assume a respiratory infection or condition from alaboratory or radiology report without physician concurrence. However, infection may be assigned without laboratoryevidence when supported by clinical documentation. Ventilator-associated pneumonia must have correlationdocumented by physician. Cannot code just because patienthas pneumonia and is on a ventilator.– Note there are specific coding guidelines for Ventilatorassociated pneumonia (ref: C. 10.d.1) Code J98.11, Atelectasis, should not be assigned on the basisof an x-ray finding alone; it should be coded only when thephysician identifies it as a clinical condition that meets thecriteria for a reportable diagnosis.ICD-10-CM for Long Term Care21

June 2015ICD-10-CMPart IIISkin & Subcutaneous Disorders (L00-L99) Need to look for instructional notes,Excludes1 and Excludes2 Many notes stating to code also infectiousagent (B95-B97)ICD-10-CM for Long Term Care22

June 2015Coding Guidelines: Pressure Ulcer Stage CodesC.12.a.1) Pressure ulcer stagesCodes from category L89, Pressure ulcer, arecombination codes that identify the site of the pressureulcer as well as the stage of the ulcer.The ICD-10-CM classifies pressure ulcer stages basedon severity, which is designated by stages 1-4,unspecified stage and unstageable.Assign as many codes from category L89 as needed toidentifyC.12.a.2) Unstageable pressure ulcersAssignment of the code for unstageable pressure ulcer (L89.--0) shouldbe based on the clinical documentation. These codes are used forpressure ulcers:whose stage cannot be clinically determined (e.g., the ulcer iscovered by eschar orhas been treated with a skin or muscle graft) andpressure ulcers that are documented as deep tissue injury but notdocumented as due to trauma.This code should not be confused with the codes for unspecified stage(L89.--9). When there is no documentation regarding the stage of thepressure ulcer, assign the appropriate code for unspecified stage (L89.-9).ICD-10-CM for Long Term Care23

June 2015C.12.a.3) Documented pressure ulcer stageAssignment of the pressure ulcer stage code should be guided by clinicaldocumentation of the stage or documentation of the terms found in theAlphabetic Index. For clinical terms describing the stage that are notfound in the Alphabetic Index, and there is no documentation of thestage, the provider should be queried.C.12.a.4) Patients admitted with pressure ulcers documented as healedNo code is assigned if the documentation states that the pressure ulcer iscompletely healed.C.12.a.5) Patients admitted with pressure ulcers documented as healingPressure ulcers described as healing should be assigned the appropriatepressure ulcer stage code based on the documentation in the medicalrecord. If the documentation does not provide information about the stageof the healing pressure ulcer, assign the appropriate code for unspecifiedstage.If the documentation is unclear as to whether the patient has a current(new) pressure ulcer or if the patient is being treated for a healing pressureulcer, query the provider.C.12.a.6) Patient admitted with pressure ulcer evolving into another stageduring the admissionIf a patient is admitted with a pressure ulcer at one stage and it progressesto a higher stage, assign the code for the highest stage reported for thatsite.ICD-10-CM for Long Term Care24

June 2015Make sure your codes represent the fact you do know your residents!Coding Caution Notes – PressureUlcers Assign code I96.- if gangrene is present withulceration. The code assignment for the pressure ulcer stagemay be based on nursing documentation oncethe physician has documented the presence ofthe pressure ulcer of the site. Recommend facility-specific internal coding policyconfirming use of nursing documentation andspecific formICD-10-CM for Long Term Care25

June 2015Coding Caution Notes - Dermatitis Dermatitis and ecxzema are used synonymously andinterchangeably For many skin conditions, it is important to determine if it is due toan adverse effect of a medication or due to a poisoning. If dermatitis is a poisoning (due to incorrect use of the drug):– Assign the category T36-T65 code first. T36.0x1A L27.0, Initial encounter for dermatitis due to accidental ingestionof mother’s penicillin tablets If dermatitis is an adverse effect (due to proper administration of adrug):– Assign category T36-T65 as an additional code. L27.0 T36.0x5A, Initial encounter for dermatitis due to penicillin tabletstaken as prescribedMusculoskeletal disordersCG C.13.a: Site and laterality Most of the codes within Chapter 13 have site and lateralitydesignations. The site represents the bone, joint or the muscleinvolved. For some conditions where more than one bone, joint or muscle isusually involved, such as osteoarthritis, there is a “multiple sites” codeavailable. For categories where no multiple site code is provided and more thanone bone, joint or muscle is involved, multiple codes should be usedto indicate the different sites involvedI.C.13.a.(1) Bone versus joint For certain conditions, the bone may be affected at the upper orlower end, (e.g., avascular necrosis of bone, M87, Osteoporosis, M80,M81). Though the portion of the bone affected may be at the joint,the site designation will be the bone, not the jointICD-10-CM for Long Term Care26

June 2015Acute Traumatic versus Chronic or RecurrentMusculoskeletal ConditionsI.C.13.bMany musculoskeletal conditions are a result of previous injury ortrauma to a site, or are recurrent conditions. Bone, joint or muscleconditions that are the result of a healed injury are usually found inchapter 13. Recurrent bone, joint or muscle conditions are alsousually found in chapter 13.Any current, acute injury should be coded to the appropriate injurycode from chapter 19. Chronic and recurrent conditions shouldgenerally be coded with a code from chapter 13.If it is difficult to determine from the documentation in the recordwhich code is best to describe a condition query the provider.Musculoskeletal conditions Placeholders in use! Laterality codes in use! Several codes contain letters in the categorycode– M1a. – Idiopathic gouty arthritisICD-10-CM for Long Term Care27

June 2015Pathological Fractures Pathological fractures due to osteoporosis are coded toM80.-, while traumatic fracture are coded in Chapter19 under injuries, by site. Care must be used to ensure you are in the appropriatesection. I often suggest to my students to highlight the termsPathological and Traumatic in their Alphabetical Index tomake sure they code from the correct term. A seventh character is required when codingpathological or stress-related fractures Never code traumatic fracture with a pathologicalfracture of the same bone.OsteoporosisI.C.13.dOsteoporosis is a systemic condition, meaning all bonesof the musculoskeletal system are affected. Therefore,site is not a component of the codes under categoryM81, Osteoporosis without current pathologicalfracture.The site codes under category M80, Osteoporosis withcurrent pathological fracture, identify the site of thefracture, not the osteoporosis.ICD-10-CM for Long Term Care28

June 2015Osteoporosis without pathological fractureI.C.13.d.(1)Category M81, Osteoporosis without current pathologicalfracture, is for use for patients with osteoporosis who do notcurrently have a pathological fracture due to theosteoporosis, even if they have had a fracture in the past.For patients with a history of osteoporosis fractures, statuscode Z87.310, Personal history of (healed) osteoporosisfracture should follow the code from M81.Pathological FracturesI.C.13.c.7th character A is for use as long as the patient is receiving activetreatment for the fracture. Examples of active treatment are:surgical treatment, emergency department encounter, evaluationand treatment by a new physician.7th character D is to used for encounters after the patient hascompleted active treatment.The other 7th characters, listed under each subcategory in theTabular List, are to be used for subsequent encounters fortreatment of problems associated with the healing such asmalunions, nonunions, and sequelae.Care for complications of surgical treatment for fracture repairsduring the healing or recovery phase should be coded with theappropriate complication code.ICD-10-CM for Long Term Care29

June 2015Arthritis (M19.-) In ICD-10, arthritis and osteoarthritis are thesame code Need to review all subterms under arthritis toensure appropriate coding Primary axis– Site—whether it involves multiple sites (M15.-,Osteoarthritis) or single joints. Verification of the arthritis code in the TabularListing is necessary for correct fifth and sixthcharacter assignment.Gait Abnormality (R26.-) Has been expanded to include:– Ataxia R26.0– Falling R29.6– Paralytic R26.1– Spastic R26.1– Staggering R26.0– Unsteadiness R26.81– Walking Difficulty R26.2ICD-10-CM for Long Term Care30

June 2015Congenital Anomalies Codes from Chapter 17 can be used throughoutthe life of the patient and may need continuedcare after admission to a long-term care facility. If a congenital malformation or deformity hasbeen corrected, a personal history code shouldbe used to identify the history of themalformation or deformity. Whenever the condition is diagnosed by thephysician, it is appropriate to assign a code fromcodes Q00- Q99.Coding Injuries Two axes for coding injuries: Anatomical site Type of injuryImportant to review instructional notes: Instructional notes (i.e., inclusion and exclusion notes) are used extensively inchapter 19. These notes assist in correct code assignment. Many sections also contain Excludes 1 and Excludes 2 notes7th Character value If a seventh character is required, and the code is not six characters: a placeholder “x” must be used to fill in empty spaces. Most categories in this chapter have three 7th character values (with theexception of fractures): A, initial encounter, D, subsequent encounter and S,sequelaICD-10-CM for Long Term Care31

June 2015C.19.a Application of 7th Characters in Chapter 19 7th character “A”, initial encounter is used while the patient isreceiving active treatment for the condition. Examples ofactive treatment are: surgical treatment, emergencydepartment encounter, and evaluation and treatment by anew physician. 7th character “D” subsequent encounter is used forencounters after the patient has received active treatment ofthe condition and is receiving routine care for the conditionduring the healing or recovery phase. Examples of subsequentcare are: cast change or removal, removal of external orinternal fixation device, medication adjustment, otheraftercare and follow up visits following treatment of theinjury or condition.C.19.a Application of 7th Characters in Chapter 19 The aftercare Z codes should not be used for aftercare forconditions such as injuries or poisonings, where 7thcharacters are provided to identify subsequent care. For example, for aftercare of an injury, assign the acuteinjury code with the 7th character “D” (subsequentencounter). 7th character “S”, sequela, is for use for complications orconditions that arise as a direct result of a condition, such asscar formation after a burn. The scars are sequelae of theburn. When using 7th character “S”, it is necessary to useboth the injury code that precipitated the sequela and thecode for the sequela itself. The “S” is added only to the injurycode, not the sequela code. The 7th character “S” identifies the injury responsible forthe sequela. The specific type of sequela (e.g. scar) is sequenced first,followed by the injury code.ICD-10-CM for Long Term Care32

June 2015C.19.b.Coding of Injuries When coding injuries, assign separate codes for each injuryunless a combination code is provided, in which case thecombination code is assigned. Code T07, Unspecified multipleinjuries should not be assigned in the inpatient setting unlessinformation for a more specific code is not available. Traumatic injury codes (S00-T14.9) are not to be used fornormal, healing surgical wounds or to identify complications ofsurgical wounds. The code for the most serious injury, as determined by theprovider and the focus of treatment, is sequenced first.C.19.c Coding of Traumatic Fractures The principles of multiple coding of injuries should be followedin coding fractures. Fractures of specifie

ICD-10-CM for Long Term Care 14 Hypertension (I10) Hypertension described as accelerated, benign, essential, idiopathic, malignant, or systemic is assigned to code I10, Essential (primary) hypertension. Whether hypertension is controlled or uncontrolled does not affect code assignment. Secondary