Coding Tip: Cerebral Infarction When Patient Has Carotid Stenosis
RHIA, CDIP, CCS, CCS‑P, CIRCC
Executive Director Of Education
AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador
Coders have struggled for some time with the dilemma of when to assign the combination code of carotid stenosis, with cerebral infarction (i.e.I63.231) and when to assign separate codes for the specific cerebral infarction and carotid stenosis. (i.e. I66.01 and I65.21). The problem is with how the coder looks at the index and also where the carotid stenosis is, as opposed to where the cerebral infarction is. Also, occlusion is not the same as stenosis in that a patient can have a minimally stenotic carotid that would not cause occlusion of an artery.
What the Index Revels:
When the coder indexes stenosis, carotid the index states “See occlusion carotid.” The coder can see that “with” is linking the cerebral infarction with carotid stenosis in the index:
When the coder indexes infarction, cerebral, there is the term “due to” listed.This means there must be a link by the physician documented. “Due to” is not assumed to exist without physician documentation.
But there is a “see also” note right next to cerebral (cerebral (see also Occlusion, artery cerebral or precerebral, with infarction) I63.9-). If the coder follows that, they will end up with the combination code.
cerebral (see also Occlusion, artery cerebral or precerebral, with infarction) I63.9-
cerebral venous thrombosis, nonpyogenic I63.6
cerebral arteries I63.4-
precerebral arteries I63.1-
cerebral arteries I63.5-
precerebral arteries I63.2-
cerebral arteries I63.5-
precerebral arteries I63.2-
cerebral artery I63.3-
precerebral artery I63.0-
The tabular has this note:
I63 Cerebral infarction
Includes: occlusion and stenosis of cerebral and precerebral arteries, resulting in cerebral infarction
This note is including both occlusion AND stenosis causing cerebral infarction.
Also in the AHA handbook is an example number 28.5 in which a cerebral infarction is linked “with carotid stenosis” and the one combination code, I63.231 is assigned.
What should the coder do?
In reviewing the case from 3Q2018 Coding Clinic page 5, the MI is not coded as associated with a totally occluded coronary artery because the MI is in a different artery. The MI is coded separately from the total occlusion and is not assumed to be related.
Similarly in a case of cerebral infarction with carotid stenosis, the coder should look at CT scans or MRIs to find the location of the cerebral infarction. If the origination is from the carotid stenosis, and it is documented as such, then the combination code would be assigned. However, if the coder sees that the cerebral infarction is in a different artery than the carotid stenosis, or due to another cause, the cerebral infarction would be coded separately with an additional code for the carotid stenosis. The combination code would NOT be assigned. (i.e. I66.01 and I65.21). Cerebral infarctions can be due to other causes such as a thrombus or embolus that are not related to carotid stenosis. Many patients have minimal carotid stenosis but have cerebral infarctions due to other causes.
When it is unclear, and if the facility allows, best practice would be to query the physician to see if the cerebral infarction is related or unrelated to the carotid stenosis. In the interim, if the record is unclear of a relationship between the cerebral infarction and the carotid stenosis, and the facility does not allow query in these cases, it may be best to assign separate codes for the carotid stenosis and cerebral infarction. This is because the code description itself states “Due to” within it. (i.e. Cerebral infarction due to unspecified occlusion or stenosis of unspecified precerebral arteries). HIA is seeking official guidance on this situation.
Coding Clinic 3rd Quarter 2018
ICD-10-CM Official Guidelines for Coding and Reporting
The information contained in this post is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
This is Part 1 of a 4 part series on the FY2021 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. Here is the breakdown: 72,616 total ICD-10-CM codes for FY2021; 490 new codes (2020 had 273 new codes); 58 deleted codes (2020 had 21 deleted codes); 47 revised codes (2020 had 30 revised codes)
Acute pulmonary edema is the rapid accumulation of fluid within the tissue and space around the air sacs of the lung (lung interstitium). When this fluid collects in the air sacs in the lungs it is difficult to breathe. Acute pulmonary edema occurs suddenly and is life threatening.
“Client S” is a small, not-for-profit, 40 bed micro-hospital in the Southeast. HIA performed a 65-record review this year for Client S and found an opportunity with 15 of them. 9 had an increased reimbursement with a total of $43,228 found.
The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition.
In the past, there had been an Excludes1 note at I46.- Cardiac arrest that excluded R57.0, Cardiac shock. HIA had also received a letter from AHA on a case in the past that had stated that only I46.- Cardiac arrest would be coded if both were documented. In addition, the Third Quarter Coding Clinic page 26 had a similar case that asked if both could be coded, and AHA had instructed that only I46.9, cardiac arrest, cause unspecified would be coded if both were documented and that the CDC would be looking at possible revision to the Excludes1 note.
A higher CMI corresponds to increased consumption of resources and increased cost of patient care, resulting in increased reimbursement to the facility from government and private payers, like CMS. We know that documentation directly impacts coding.
Lately we have seen several cases where the endarterectomy was assigned along with the coronary artery bypass (CABG) procedure when being performed on the same vessel to facilitate the CABG. A coronary artery endarterectomy is not always performed during a CABG procedure, so when it is performed it becomes confusing as to whether to code it separately or not.
Assign code Z20.828, “Contact with and (suspected) exposure to other viral communicable diseases” for all patients who are tested for COVID-19 and the results are negative, regardless of symptoms, no symptoms, exposure or not as we are in a pandemic.
The Centers for Medicare & Medicaid Services (CMS) announced new procedure codes for treatments of COVID-19 – effective as of August 1, 2020. Among the new codes are Section X New Technology codes for the introduction or infusion of therapeutics including Remdesivir, Sarilumab, Tocilizumab, transfusion of convalescent plasma, as well as introduction of any other or new therapeutic substances for the treatment of COVID-19.
One common element in many value-based programs is risk adjustment using Hierarchical Condition Categories (HCCs) to create a Risk Adjustment Factor (RAF) score. This method ranks diagnoses into categories that represent conditions with similar cost patterns.
Why are so many AKI records being denied? It’s hard to give one answer for why so many AKI records are being denied lately, but most appear to be due to the multiple sets of criteria available for use in determining if a patient has AKI, as well as physician documentation. As stated in Part 3 of this series, there are three main criteria/classifications used to diagnose AKI.
In previous parts of this series we looked at the definitions of AKI/ARF, causes, coding and sequencing, and the common clinical indicators that patients present with that are diagnosed with this condition. In Part 4, we will look at the documentation that should be present to report the diagnosis without fear of denial, as well as when a query is needed to clarify the diagnosis.
If the facility does a COVID-19 test, and test is negative, do I need a diagnosis code. The answer is yes, you will report a Z-code. The Z-code depends on the record documentation and circumstances of testing. For any patient receiving a COVID-19 test, if negative, there MUST e a Z-code to describe why the test was taken. (Test negative for COVID-19 and MD does not override negative results).
In the first parts of this series we looked at definitions of AKI/ARF, causes, coding and sequencing. In Part 3, we will look at what clinical indicators would possibly be present to support the diagnosis of AKI/ARF.
The FY2021 IPPS Proposed Rule is out and here are some highlights from it regarding ICD-10 Code proposals. We will know if these changes are permanent after the public comment period is over on July 10, 2020 and CMS prepares the Final Rule, usually out by August 1.
As discussed in Part 1 of this series, AKI/ARF is a common diagnosis that coders see daily. In Part 2, we are going to focus on the different types/specificity of AKI/ARF. We’ll learn what they mean, as well as how to code the diagnosis.
This is part 1 in a series focused on coding of acute kidney injury (AKI) and/or acute renal failure (ARF). AKI/ARF is reported often, but is also one of the most common diagnosis found in denials.
With the proliferation of COVID-19 cases, we thought we would put together a quick reference listing of some of the common scenarios that coders have asked about. As with all coding, coders should follow Official Guidelines for Coding and Reporting and the COVD-19 Frequently Asked Questions document by the AHA.
Effective March 1, Medicare will pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, not just services related to COVID-19. This great for providers whose patients are reluctant to visit the office.
The biggest reasons why some hospital systems are moving to single path coding is to eliminate duplicative processes and to optimize productivity. In addition, costs are reduced when only one coder “touches” the record and completes both types of coding.
Effective with 4/1/2020 discharges, ICD-10-CM code U07.0 is used to report vaping -related disorders. ICD-10-CM code U07.0 (vaping related disorder) should be used when documentation supports that the patient has a lung-related disorder from vaping. This code is found in the new ICD-10-CM Chapter 22. U07.0 will be in listed in the ICD-10-CM manual under a new section: Provisional assignment of new disease of uncertain etiology or emergency use.
The US government and public-health officials are urging consumers to utilize telemedicine for remote treatment, fill prescriptions and get medical attention during the new coronavirus pandemic. The goal is to keep people with symptoms at home and to practice social distancing if their condition doesn’t warrant more intensive hospital care.
Coronavirus: Tips for working from home. Companies around the world have told their employees to stay home and work remotely. Whether you’re a new to this concept or a work from home veteran, here’s some tips to staying productive from our #HIAfamily.
This is part two of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. In this part, we discuss mismatches and how to best go about resolving them. In part three we will provide a case example of best practice interaction.
This is part one of a three part series in which we address how coders can better interact with Clinical Documentation Integrity (CDI) professionals. Many times these departments are separate and the remote environment makes it difficult to interact efficiently between the two departments. In part one, we will discuss the history and objectives of CDI so the coder has a better understanding of CDI’s role.
One reason that coders should report chronic conditions (including history and status codes) on outpatient records is the HCC’s—Hierarchical Condition Categories. The quick and easy explanation of what HCC’s are is each HCC is mapped to certain ICD-10-CM codes or code ranges. HCC coding is designed to estimate future health care costs for patients.
For Part 5 of this 5-part series, we will look at Chapter 4 within ICD-10-CM—E00-E89—Endocrine, Nutritional, and Metabolic Diseases. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 4 of this 5-part series, we will look at Chapter 10 within ICD-10-CM—J00-J99—Diseases of the Respiratory System. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 3 of this 5 part series, we will look at Chapter 9 within ICD-10-CM—I00-I99—Diseases of the Circulatory System. This chapter contains so many of the everyday diagnoses that we code such as hypertension, heart disease and stroke.