Key attributes for coders moving forward amidst the 2017 coding guideline changes

by Laura Legg, RHIT, CCS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer

Resiliency is the ability to spring back or rebound. In sports, it’s one of the mental attributes a player must have. Coders are resilient: bouncing back from one change after another, deciding to code smarter and faster, and having the patience to do whatever is expected?even amid closing grace periods and guideline controversies.

The change to ICD-10 in October 2015, was a solid transition, and no one in healthcare was affected by it more than coders. The changes didn’t stop there. The coming months will again prove to be challenging for coders because of the new ICD-10 codes for both CM and PCS beginning October 1, 2016. Along with that, we’ll see the end of the CMS grace period on code specificity for Part B, and updated ICD-10-CM Official Coding Guidelines. Coders have a lot to learn this fall.

The Centers for Disease Control and Prevention published guidelines for discharges effective October 1, 2016, that have been approved by the four organizations that make up the Cooperating Parties for ICD-10-CM: the American Hospital Association, the American Health Information Management Association, CMS, and the National Center for Health Statistics.

The guidelines are available at www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf. In the linked document, the changes are indicated in bold type for easy identification. Below are some of the highlighted changes.

Excludes1

This guideline supports the interim advice published last fall. Here, the Cooperating Parties have given instructions that two conditions unrelated to each other represents an exception to the Excludes1 definition. If it is not clear whether the two conditions are related, coders must query the provider.

With

Under Section I.B.7 of the guidelines, "multiple coding for a single condition" clarification has been added for interpretation of the word "with."

The word "with" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms.

These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by this term in the classification, provider documentation must link the conditions in order to code them as related.

Code assignment and clinical criteria

Also under Section I, the Official Guidelines for Coding and Reporting tell us that the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

Coders are instructed to assign a diagnosis or procedure code according to physician documentation. Coders have been told in the past not to question the physician’s clinical judgment. This appears to be pretty simple until audits from outside the organization place more emphasis on the use of clinical criteria. This use of clinical criteria to assign reported codes is known as "clinical validation." When coders follow the official coding guideline instructing them that a code assignment is not based on clinical criteria used by the provider to establish the diagnosis, they will be caught between following the guideline as instructed and being presented with a claim denial based on the absence of clinical validation.

In today’s healthcare environment, it is essential that organizations face this issue head on and provide coders with guidance on how to solve the dilemma of a record that contains physician documentation but does not contain clinical validation. Clinical documentation improvement efforts to improve upon complex clinical condition documentation must continue to bring the coding and medical records together to allow coders to code correctly and avoid payer denials.

CMS must clarify the reason the Recovery Auditors are allowed to deny claims, whether auditors will bypass this official coding guideline, and how organizations can reconcile the discrepancy.

Laterality coding

This update clarifies that when a patient with a bilateral condition has surgical correction on both sides, the first side corrected is coded with the bilateral code. The second site is not coded using the bilateral code because the condition no longer exists on the corrected side. If the treatment on the first side did not completely resolve the condition, then the bilateral code is used.

Documentation for BMI, non-pressure ulcers, and pressure ulcer stages

Section I.B.14 says for body mass index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH Stroke Scale (NIHSS) codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider. Dietitians often document the BMI, nurses often document pressure ulcer stages, and an emergency medical technician often documents the coma scale. Keep in mind the associated diagnosis must be documented by the patient’s provider. A query should be used to clarify any conflicting medical record documentation.

This guideline shows the addition of the coma scale and NIHSS to conditions where code assignment can be determined from clinicians who are not the patient’s provider. Many coders may not be familiar with the ­NIHSS?it is a 15-item neurologic examination used to evaluate the effect of acute cerebral infarction. The NIHSS evaluates:

• Levels of consciousness
• Language
• Neglect
• Visual field loss
• Extraocular movement
• Motor strength
• Ataxia
• Dysarthria
• Sensory loss

The NIHSS evaluation is often done by nursing staff and can help physicians quantify the severity of a stroke in the acute setting.

Zika virus infection

The official guidelines instruct coders to code only confirmed cases of the Zika virus with code A92.5 as documented by the provider. Note that this is an exception to the hospital inpatient guidelines. "Confirmation" does not require documentation of the type of test performed; the physician’s diagnostic statement that the condition is confirmed is sufficient. Documentation of "suspected," "possible," or "probable" Zika is not assigned to code A92.5.

Hypertensive crisis

A coding guideline has been added to instruct coders to assign a code from category I16 for hypertensive urgency, hypertensive emergency, or unspecified hypertensive crisis. This may call for some physician documentation education to make physicians aware that these more specific codes are available and can be used instead of documentation of hypertension without any further description.

Coma scale

In addition to using the coma scale codes (R40.2-) for traumatic brain injury codes, acute cerebrovascular disease codes, or sequelae of cerebrovascular disease codes, the coma scale may be used to assess the status of the central nervous system for other non-trauma conditions. Examples include monitoring patients in the ICU regardless of their medical condition.

Observation

One observation Z code category has been added for use when a newborn patient is being observed for a suspected condition that is ruled out. The new code category is Z05: encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out.

Newly added ICD-10 codes

CMS will implement an unprecedented number of new code changes October 1. A partial code freeze prevented regular updates for the last five years, resulting in the release of over 5,000 ICD-10 revisions on that date. The newest coding updates can be found at https://www.cms.gov/Medicare/Coding/ICD10/Latest_News.html.

The new ICD-10 codes come as we thaw out from the code freeze that has been in effect since October 1, 2011. Since that time, we have received only limited code updates to both the ICD-9 and ICD-10-CM/PCS code sets. Now, the long delay is over. ICD-10-CM changes include 1,928 diagnosis code changes with expanded code choices for atrial fibrillation, heart failure, diabetes mellitus Type 2, disorders of the breast, and pulmonary hypertension.

Extensive PCS updates are also being implemented. There are 3,651 new PCS codes, revised code titles, and a grand total of 75,625 valid codes with this update. It is important to note that 87% of the PCS code updates are in the cardiovascular system.

Following adoption of the new codes, review of coding accuracy will be needed. Any misconceptions or incorrect rationale should be recognized and communicated early to prevent ongoing or costly patterns from developing. Remember to ensure software updates are also in place and scheduled on time.

The new cardiovascular PCS codes include:

• Unique codes for unicondylar knee replacement
• Codes involving placement of an intravascular neurostimulator
• Expanded body part detail for the root operations Removal and Revision
• New codes in lower joint body system
• New codes for intracranial administration of substances such as Gliadel chemotherapy wafer using an open approach
• Addition of bifurcation qualifier to multiple root operation tables for all artery body part values
• Specific body part values for the thoracic aorta
• Specific table values to capture congenital cardiac procedures
• Unique device values for multiple intraluminal devices

Other PCS changes include:

• Donor organ perfusion
• Face transplant
• Hand transplant

The impact of the new codes will depend on what you do, so it’s important for hospitals to assess how the changes will affect them specifically. If you don’t deal with the areas where the codes have changed, the updates will be much easier than if your facility uses all the affected codes. Make sure the applicable codes are integrated into your internal applications and processes, while verifying that vendor products support the new codes. You don’t want to have claims rejected because not all of the new codes were incorporated.

Overall, there are moderate changes to the Official Guidelines for Coding and Reporting. The 2017 coding updates, however, are extensive and may seem overwhelming to some coders. The addition of over 10,000 codes after only one year of using ICD-10 will require coder resiliency to learn them all and understand how to apply them.

Editor’s note

Legg is director of HIM optimization at Healthcare Resource Group in Spokane Valley, Washington. For questions, please contact Associate Editor Amanda ­Tyler at [email protected]. Opinions expressed are those of the author and do not represent HCPro or ACDIS.

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