Critical Limb Ischemia Coding In ICD10- -CM

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Critical Limb IschemiaCoding in ICD-10-CMAdi Renbaum, MBAANR Consulting, LLCLinda Holtzman, MHA, RHIA, CCS, CCS-P, CPC, COCClarity Coding, Incon behalf of

OVERVIEWCritical Limb Ischemia Clinical Nature Treatment ICD-10-CM Coding Sample Coding Scenarios2

BURDEN OF CRITICAL LIMB ISCHEMIA After a diagnosis of critical limb ischemia, risk ofmortality is 24% at 1 year and 60% over 5 years. Inpatient hospitalization is common and up to60% of patients are readmitted within 6 months. About 150,000 amputations occur in the USannually due to critical limb ischemia. Patients with CLI are at increased risk of majorcardiovascular complications, eg, AMI, stroke. The annual US economic burden of CLI wasrecently estimated at over 200 billion.“Overall, the highincidence of critical limbischemia in combinationwith its highly fatal coursemake the disease anunder-recognized majorthreat to public health.”Mustapha JA, Katzen BT, Neville RF,Lookstein RA, et al. Critical limbIschemia: a threat to life and limb.Endovasc Today. 2019;18(5):80-823

CLINICAL NATUREOFCRITICAL LIMBISCHEMIA4

PERIPHERAL ARTERY DISEASE In peripheral artery disease, plaquebuilds up in the peripheral arteriesover time, narrowing or blocking thelumen of the vessel. This reduces or obstructs blood flowthrough the artery, preventing sufficientoxygen from reaching the distalextremities. About 12% of US adults have somedegree of clinically significant peripheralartery disease.5

CRITICAL LIMB ISCHEMIA Of those with peripheral artery disease,about 11% eventually go on to developcritical limb ischemia.Commonly UsedAbbreviations The prevalence of critical limb ischemiain the US is about 1.3% .CLI Critical LimbIschemiaà Critical limb ischemia is essentiallyend-stage peripheral artery disease ofthe lower extremities.CLTI ChronicLimb-ThreateningIschemiaà In critical limb ischemia, the limb isendangered.The abbreviations areinterchangeable.6

CLINICAL DEFINITION OF CLI CLI is characterized by thehallmarks of chronic ischemiawith inadequate blood supplyto the tissues. A diagnosis of CLI requires atleast one of manifestations. By its nature, CLI is a chroniccondition.“Clinically, critical limb ischemia (CLI) isdefined as ischemic rest pain, tissue loss,or gangrene in the presence ofperipheral artery disease (PAD) andhypoperfusion of the lower extremity.”Critical Limb Ischemia: An Expert Statement, MHShishehbor et al, Journal of the American College ofCardiology, 2016, Volume 68, No 18.7

PROGRESSION : PAD è CLIT Asymptomatic peripheral artery diseaseT Intermittent Claudication- Pain affecting the calf, thigh, or buttock,induced by exercise and relieved by restR Rest PainCritical limbischemia does notalways progressthrough the variousstages.- Ischemic pain, usually in the foot andusually at night, when at rest or lying downR Tissue Loss (Ulceration)- Skin breakdown, chronic and non-healingR Gangrene- Tissue death8

OTHER CLASSIFICATIONS Other classifications of critical limb ischemiamay be documented in the medical d claudication2Moderate claudication3Severe claudication4Ischemic rest pain5Minor tissue loss (ulceration,focal gangrene)6Major tissue loss (extensivegangrene, “no option”)SVS WIfI (Wound-Ischemia-Foot emic restpain1Distal, small, shallow, no exposedboneNoMinor tissueloss2Deep ulcer with exposed bone, jointor tendon, except heel / Shallowheel ulcer without calcaneousLimited todigitsMajor tissueloss3Extensive deep ulcer of forefoot ormidfoot / Deep heel ulcer withcalcaneousExtensive,fullthicknessMay not besalvageable9

COEXISTING DIABETES MELLITUS Peripheral artery disease progresses morerapidly in patients with diabetes and the riskof developing CLI is about four times higher. Patients with diabetes often have moreextensive CLI, eg, multiple arteries, long lesions.Patients with CLIwho have coexistingdiabetes are anotable subgroup atparticular risk. They are also more likely to present withhigher severity, ie, ulcers or gangrene. CLI patients with diabetes are also at asignificantly higher risk of major amputationthan CLI patients without diabetes.10

TREATMENTOFCRITICAL LIMBISCHEMIA11

OBJECTIVES OF CLI TREATMENT The overall goal of CLI treatment is to:P Relieve painP Allow wound healingP Improve functionP Preserve limbsP Reduce mortality The specific goal of surgical treatment is toimprove blood flow to the tissues of the limb. Revascularization of the limb is the first-linetreatment for CLI.12

REVASCULARIZATION: APPROACH Revascularization of the lower limb can beperformed by an endovascular approachor an open surgical approach. Which approach is selected depends onmultiple factors, including:P Multilevel diseaseP Length and composition of lesion,eg, calcificationsP Presence of chronic total occlusionP Patient comorbidities13

REVASCULARIZATION: ENDOVASCULAR Common endovascular techniquesinclude:P Angioplasty (plain balloon, drug-eluting)P Stenting (bare metal, drug-eluting)P Atherectomy Other endovascular techniques beingintroduced include:P Endovascular bypassP Venous arterialization14

Open surgical bypass may beperformed when lesionscannot be crossed. It may also be performedwhen endovascularapproaches fail or when thetreated artery is subject tore-occlusion, eg, restenosisof stent.REVASCULARIZATION:OPEN“NO OPTION”AMPUTATION Amputation rates typically exceed15-20% at one year. Rates of amputation rise as theseverity of disease increases. Patients who have undergoneamputation are at heightened riskfor one or more additionalamputations, including thecontralateral limb.15

ICD-10-CMDIAGNOSIS CODESFORCRITICAL LIMBISCHEMIA16

THE TROUBLE WITH ICD-10-CM From its implementation in FY 2016,ICD-10-CM did not contain anyreferences to critical limb ischemia. This created frustration in searchingfor codes for this diagnosis. The ICD-10-CM codes being assigned byphysicians and hospitals for critical limbischemia were inconsistent. The coding inconsistencies carried overto clinical databases.17

ICD-10 C&M COMMITTEE ICD-10 is maintained and updated by the ICD-10Coordination and Maintenance Committee.ICD-10-CM diagnosis codes are managed by CDCICD-10-PCS procedure codes are managed by CMS All requests for new and revised ICD-10-CMdiagnosis codes go to CDC. C&M Committee meetings are held twice a year topublicly review requests, with decisions to follow. If approved, code changes typically take 15 to 22months from submission to implementation.18

CRITERIA FOR CODE CHANGES The C&M Committee looks for multiple elementswhen considering whether to approve a request.P The diagnosis must be understood and appliedconsistently by physicians.P The diagnosis must be useful in broad-baseddata collection and analysis.References toreimbursement,benefits, andclaims processingare consideredoff-topic.P It must be documented distinctly and specificallyin the medical record.µ The proposal must be written in accordancewith ICD-10-CM conventions.19

NATURE OF C&M REQUEST ICD-10-CM already contained codes forperipheral artery disease of the extremitieswith rest pain, ulceration, and gangrene. With this in mind, it was determined that nonew ICD-10-CM codes were needed per se. Instead, the proposal focused on clearlyidentifying existing codes that constitutecritical limb ischemia. This meant focusing on instructional notesin the Tabular and entries in the Index.20

C&M PROPOSAL FOR CLI The proposal requested new inclusion termswithin code category I70, Atherosclerosis.P The inclusion terms were located at thesubcategory level for rest pain, ulceration,and gangrene.P The inclusion terms applied to 144 codes. For the Index, the proposal requested new entriesunder the main term Arteriosclerosis.Both “critical limbischemia” and“chronic limbthreateningischemia” wereproposed termsfor the Tabularand the Index.P Cross-references were proposed under Ischemia.P Over 200 new Index entries were proposed.21

PRESENTATION AT C&M MEETING The proposal was formally presented at theSeptember 11, 2019 meeting of the C&MCommittee. Like all C&M proposals, it was posted to the CDCwebsite and is still available there for review.https://www.cdc.gov/nchs/icd/icd10cm maintenance.htmThe updates forcritical limbischemia wentinto effect onOctober 1, 2020. Approval was made public on June 26, 2020when the ICD-10-CM FY2021 Addenda file wasposted to the CDC website.https://www.cdc.gov/nchs/icd/icd10cm.htm22

INDEX: NEW ENTRIES The index now explicitly citescritical limb ischemia and chroniclimb-threatening ischemia. Exhaustive new index entriesdirect users to all 144 codes.ICD-10-CM Index 202123

TABULAR: NEW NOTES The tabular notes now display criticallimb ischemia and chronic limbthreatening ischemia as equivalentterms to the code definitions. Rest pain is set as the default.24

CODING POINTS The codes are organized into six categories by the type of vessel affected:I70.5 bypass graft, nonautologous biologicalI70.2 native arteryI70.3 bypass graft, unspecified type I70.6 bypass graft, nonbiologicalI70.4 bypass graft, autologous vein I70.7 bypass graft, other Each category then has the same coding structure:CLI manifestationrest painulcerationgangreneLocationright leg, left legbilateral legsadditional sites forulceration, if applicableCLI Coding Logic- Type of vessel?- Manifestation?- Which leg?- Location of ulcer?25

KEY IN CRITICAL LIMB ISCHEMIA! Use of ICD-10-CM is specifically mandated by HIPAA. Index and tabular changes for critical limb ischemiawere officially adopted as part of ICD-10-CM by HHS. The new index entries and tabular notes are mandated toappear in all versions of ICD-10-CM as of October 1, 2020. Coding software and EHRs must now recognize “criticallimb ischemia” and “chronic limb-threatening ischemia”as codable diagnoses.WI70.9, Otherand unspecifiedatherosclerosis When these terms are entered, coding software will presentchoices based on vessel type, manifestation, and location.26

SAMPLE CODINGSCENARIOSFORCRITICAL LIMBISCHEMIA27

SAMPLE CASE 154 year old Black male who presented with claudication fivemonths ago. Diagnostic angiography showed a chronic totalocclusion of the distal popliteal artery on the left with thelesion extending into the anterior tibial artery and tibioperoneal trunk. He has recently been complaining ofintermittent rest pain, placing him at Rutherford class 4.Given his rapid progression to critical limb ischemia, decisionwas made to proceed with endovascular atherectomy to tryto preserve the tibial vessels.I70.222, Atherosclerosis of native arteries of extremities withrest pain, left legI70.92, Chronic total occlusion of artery of the extremities28

SAMPLE CASE 1: NATIVE ARTERY, CTO Default tonative artery(Index) Additionalcode for CTO(Tabular)29

SAMPLE CASE 2A patient with long history of type 2 diabetes presents with critical limb ischemia,ulceration of right big toe to the subcutaneous tissue with gangrene. Whenqueried, the physician says that the ulcer and gangrene are associated with bothdiabetic neuropathy and peripheral artery disease.E11.52, Type 2 diabetes mellitus with diabetic peripheral angiopathy withgangreneE11.621, Type 2 diabetes mellitus with foot ulcerE11.40, Type 2 diabetes mellitus with neurological complicationsL97.512, Non-pressure chronic ulcer of other part of right foot with fat layerexposedI70.261, Atherosclerosis of native arteries of extremities with gangrene, right leg30

SAMPLE CASE 2: CONSIDERATIONS When both are present, diabetes and critical limbischemia are assumed to be related. Arteriosclerotic peripheral artery disease I70.2is coded separately with diabetes. Coding PAD separately provides “specificity aboutthe atherosclerosis such as laterality, affectedvessel as well as additional manifestations of thedisease (ie, claudication, rest pain, etc).” “(A)lthough diabetes mellitus may increase the riskof pressure ulcers because of its association withneuropathy and angiopathy,” ICD-10-CM does notclassify pressure ulcers as diabetic ulcers.AHA ICD-10-CM and ICD-10-PCSCoding Handbook 2020“Diabetic CirculatoryComplications”“Other Manifestations of DiabetesMellitus”Coding Clinic, 3rd Q 2018“Diabetes Mellitus withArteriosclerotic Peripheral ArteryDisease”Coding Clinic, 3rd Q 2018“Necrotic Pressure Ulcer of Heelwith Diabetic Peripheral VascularDisease and Neuropathy”31

Critical Limb IschemiaCoding in ICD-10-CMQUESTIONS?

Mar 05, 2021 · Index and tabular changes for critical limb ischemia were officially adopted as part of ICD-10-CM by HHS. The new index entries and tabular notes are mandated to appear in all versions of ICD-10-CM as of October 1, 2020. Use of ICD-10-CM is specifically mandated by HIPAA

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