New ICD Codes and IPPS Changes for FY2021 (ICD-10-CM Diagnoses changes) – Part 2
RHIA, CDIP, CCS, CCS‑P, CIRCC
Executive Director Of Education
AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador
This is Part 2 of a 4 part series on the FY2021 ICD-10 Code and IPPS changes. In this part, the ICD-10-PCS procedure codes are presented.
For FY2021 ICD-10-PCS there are 78,115 total codes (FY2020 total was 77,571)
556 new codes (734 new last year in FY2020)
0 deleted codes (2.056 last year in FY2020)
0 revised codes (2 last year in FY2020)
Official Guidelines for Coding and Reporting ICD-10-PCS
There were only a few changes to the procedure guidelines with addition of two new guidelines. The first change addresses fusions. The change is in bold text and strikethrough text:
B3.10c Combinations of devices and bone grafts
Combinations of devices and materials are often used on a vertebral joint to render the joint immobile. When combinations of devices are used on the same vertebral joint, the device value coded for the procedure is as follows:
- If an interbody fusion device is used to render the joint immobile (alone or containing other material like bone graft) (containing bone graft or bone graft substitute), the procedure is coded with the device value Interbody Fusion Device
A second change involved the addition of a new guideline as below. It explains when and when not to code multiple codes.
NEW – B3.18 Excision/Resection followed by replacement
- If an excision or resection of a body part is followed by a replacement procedure, code both procedures to identify each distinct objective, except when the excision or resection is considered integral and preparatory for the replacement procedure.
- Mastectomy followed by reconstruction, both resection and replacement of the breast are coded to fully capture the distinct objectives of the procedures performed.
- Maxillectomy with obturator reconstruction, both excision and replacement of the maxilla are coded to fully capture the distinct objectives of the procedures performed.
- Excisional debridement of tendon with skin graft, both the excision of the tendon and the replacement of the skin with a graft are coded to fully capture the distinct objectives of the procedures performed.
- Esophagectomy followed by reconstruction with colonic interposition, both the resection and the transfer of the large intestine to function as the esophagus are coded to fully capture the distinct objectives of the procedures performed.
- Resection of a joint as part of a joint replacement procedure is considered integral and preparatory for the replacement of the joint and the resection is not coded separately.
- Resection of valve as part of valve replacement and procedure is considered integral and preparatory for the valve replacement and the resection is not coded separately.
Coders will need to pay attention to the objectives of procedures that involve replacement to determine if the excision/resection is integral or not.
The third change is another new guideline was added as below:
NEW – B5.2b Percutaneous endoscopic approach with extension of incision
Procedures performed using the percutaneous endoscopic approach, with incision or extension of an incision to assist in the removal of all or a portion of a body part or to anastomose a tubular body part to complete the procedure, are coded to the approach value Percutaneous Endoscopic.
Examples: Laparoscopic sigmoid colectomy with extension of stapling port for removal of specimen and direct anastomosis is coded to the approach value percutaneous endoscopic.
- Laparoscopic nephrectomy with midline incision for removing the resected kidney is coded to the approach value percutaneous endoscopic.
- Robotic-assisted laparoscopic prostatectomy with extension of incision for removal of the resected prostate is coded to the approach value percutaneous endoscopic.
Major Changes to the ICD-10-PCS Tables
I won’t discuss every change however will review major changes to the codes in the tables.
In many of the body systems, device “1-Radioactive Element” was added in root operation “Insertion” to allow for reporting of radioactive elements left in at the end of brachytherapy procedures. Internal radiation therapy is also called “brachytherapy.” Roughly translated, it means “short distance therapy” – it’s a short distance between the radiation and the tumor. A small thin tube – called a catheter – is used to deliver radioactive solids to the site of the cancer. Solids can be capsules, seeds, micro-spheres, or ribbons about the size of a grain of rice. Other methods of internally delivering radioactive material to the site of the disease/tumor include ingestion of a pill (ex., for thyroid cancer) or injection/infusion through an IV (ex., for bone cancer). These last methods are NOT coded to insertion. Permanent Brachytherapy means the radioactive elements are inserted and remain in the patient – giving off helpful radiation for weeks or months. They don’t cause discomfort, remain in place, and over time lose their radioactivity. This is the type the new device was added for coding.
For Heart and Great Vessels under “Bypass,” qualifier “Atrium, Right” was added to accommodate percutaneous left atrium to right atrium shunt creation using the new Corvid and V-Wave devices. Creation of a left to right atrial shunt will lower left atrial pressure at rest and during exercise and in turn reduce symptoms in patients with HFpEF. Coders may see these devices described as “IASD” or “InterAtrial Shunt Device.”
All of the pulmonary artery body parts were added to root operation “Fragmentation” within the Heart and Great Vessels body system to enable capture of fragmentation within the pulmonary arteries and veins, i.e., ultrasonic thrombolysis or “intravascular lithotripsy” (IVL) or “acoustic pulse lithotripsy.” This was also added to body systems “Upper and Lower Arteries/Veins” to allow ultrasonic fragmentation of all vessels. An infusion catheter is introduced into the vessel and thrombolysis is accomplished via ultrasound, acoustic or other methods to fragment the thrombus. “EkoSonic” is one vendor. It treats thrombus in the conditions deep vein thrombosis and pulmonary embolism. A link below has more info.
“Transapical” has been added as a qualifier for “Supplement of mitral valve.”
In the Hepatobiliary and Pancreas body system, the qualifier “stomach” was added so that pancreatic duct to stomach bypass for pancreaticogastrostomy can be coded. This is done for decompression of the pancreatic ductal system.
“Other device” was added to the “subcutaneous tissue and fascia, abdomen” so that the totally implantable drainage pump used in the “Alfapump” placement, which directs ascites fluid from the peritoneal cavity to the bladder and be coded. Another code is needed for this procedure for the bypass of peritoneal cavity to bladder (0W1G-J6).
“External Fixation Device” was added as a device under root operation “Removal” from lower bones, lumbar vertebra, sacrum, acetabulum R/L, and coccyx.
Under “Fusion” of upper/lower joints, “3-Internal Fixation Device, Intramedullary Sustained Compression” was added to allow for coding of fusions with the DynaNail® Fusion System or DynaNail Mini® Fusion System. DynaNail is made by MedShape and maintains compression used for degenerative conditions, joint deformities and revised failed total ankle replacements or arthrodesis non-unions. The Mini is used for subtalar fusions many times.
In the Male Reproductive System, Transplantation of scrotum or penis was added.
Two new approaches of “Via natural or artificial opening/Via natural or artificial opening endoscopic” were added to “Drainage” in Anatomical Regions, General to allow for pelvic cavity drainage via these approaches.
“Open” and “Percutaneous endoscopic” approaches for Extraction of Ectopic Products of Conception were added.
Substance ‘C-Hematopoietic Stem/Progenitor Cells, Genetically Modified” was added for administration of OTL-101 in the “Administration, Circulatory, Transfusion” table. Hematopoietic stem cell transplant (HSCT) is a potentially curative treatment for ADA-SCID. Adenosine deaminase severe combined immunodeficiency (ADA-SCID) is a rare autosomal recessive, monogenic, inherited immune disorder. ADA is a ubiquitously expressed purine salvage enzyme, which metabolizes adenosine and deoxyadenosine.
For section “Extracorporeal or Systemic Assistance and Performance,” added “High Nasal Flow/Velocity” to ASSISTANCE, Respiratory, Ventilation.’ This will allow capture ventilatory assistance provided by high flow or high velocity nasal cannula devices. This device sits under the nose, much like an oxygen tube and helps to treat respiratory failure. Link to the device is in references below.
Added “External” as an approach for Near-Infrared Spectroscopy (NIRS) in “Other Procedures.”
Broadly speaking, it can be used to assess oxygenation and microvascular function in the brain (cerebral NIRS) or in the peripheral tissues (Peripheral NIRS). NIRS can be used as a quick screening tool for possible intracranial bleeding cases by placing the scanner on four locations on the head.
A totally new table for “Other Imaging of Hepatobiliary System and Pancreas was added to capture imaging using Indocyanine Green Dye fluorescing agent. Indocyanine green (ICG) (IC Green) is a cyanine dye which is used in medicine as an indicator substance (e.g. for photometric hepatic function diagnostics and fluorescence angiography) in cardiac, circulatory, hepatic and ophthalmic conditions.
Indocyanine green is administered as a rapid IV bolus.
New table for bacterial autofluorescence imaging was added as well. This is used to identify the use of portable real-time imaging of an acute or chronic wound and surrounding tissue for the presence, location, and load of bacteria using autofluorescence detection. The MolecuLight i:X® is a handheld imaging tool used in this type of imaging.
Added Cesium 131 (Cs-131) as an Isotope to allow capture of this to all applicable treatment sites in the tables for Brachytherapy.
Added Intraoperative Radiation Therapy (IORT) to enable the capture of intraoperatively administered radiation for targeted therapy of intracranial tumors or tumor beds to “Radiation Therapy, Other Radiation.”
A new device for “Cerebral Embolic Filtration, Extracorporeal Flow Reversal Circuit” has been added to New technology section, cardiovascular assistance. During the Reverse Flow Embolic Neuroprotection procedure performed with TCAR, an extracorporeal circuit is created intraoperatively to temporarily redirect and reverse blood flow away from the carotid artery during placement of the stent. Flow reversal keeps debris moving away from the brain, protecting it from emboli.
Device “5-Synthetic Substitute, Mechanically Expandable (Paired) was added to New Technology, Bones, Supplement to allow coding of the SpineJack® System. The Stryker SpineJack implantable fracture reduction system is based on a modifiable titanium expander designed to realize the biomechanical restoration of a VCF by simultaneously restoring sagittal and coronal balance, coronal angulation, and endplate restoration.
Several new drugs were added to the XW0-Introduction tables for FY2021. They include Remdesivir anti-infective, Sarilumab, and Tocilizumab, Brexanolone, Ceftazidime-Avibactam anti-infective, Nerinitide, Idarucizumab, Dabigatran Reversal agent, Durvalumab antineoplastic along with “Other new therapeutic substance into Subcu.” Transfusion of convalescent plasma (nonautologous) was also added for someone who receives blood from someone with antibodies to COVID-19 and has donated blood.
In Part 4 of this series, I will provide a detailed table and discussion of many of these drugs, what they are used for, and the new technology payment, if applicable.
Keep an eye out for Part 3 of this 4 part series where the major FY2021 IPPS DRG and other changes will be discussed.
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.
Anticoagulants and antiplatelets are used for the prevention and treatment of blood clots that occur in blood vessels. Oftentimes, anticoagulants and antiplatelets are referred to as “blood thinners,” but they don’t actually thin the blood at all. These drugs slow down the body’s process of making clots. Their main function is to keep the patient’s blood from clotting or turning into solid clumps of cells. These drugs do this by interfering with either fibrin or platelets in the blood.
Carotid artery disease is a vague category that can incorporate many different carotid artery issues. Some physicians may feel that they are being clear the patient has plaque, stenosis, or occlusion of the artery, but in ICD-10-CM the specificity must be included in the documentation.
10 ICD-10 Codes for Superheroes. Superman: T78.2XXA Anaphylactic reaction; substance: kryptonite. Batman: F44.81 Dissociative identity disorder. Robin: F60.7 dependent personality. The Hulk: L30.4 Erythema intertrigo. Wonder Woman: T24.032A Burn of unspecified degree of left lower leg. Black Panther S93.401A Sprain…
Practices have not seen many revisions to the Evaluation and Management (E/M) office / outpatient visit guidelines in three decades – until now. As of January 1, there are new E/M coding guidelines. We’ll get to those in a bit, but first let’s look at why they changed.
Pseudoseizures are a form of non-epileptic seizure. These are difficult to diagnose and oftentimes extremely difficult for the patient to comprehend. The term “pseudoseizures” is an older term that is still used today to describe psychogenic nonepileptic seizures (PNES).
With the implementation of ICD-10-CM came different codes and coding rules for many diagnoses. One of these is the coding of bowel obstruction when the patient presents for this condition that is caused by another condition.
This is Part 5 of a five part series on the new 2021 CPT codes. For the remaining areas we will just briefly summarize the section. Due to the intricate nature of these sections in CPT, it is recommended that the coder read the entire section notes associated with the new codes.
This is Part 4 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes in the urinary, nervous, ocular and auditory systems. There are 2 new urinary/male reproductive system codes with no revisions or deletions; 3 new female reproductive codes with 2 deletions, 0 new with 4 deleted nervous system codes with 5 revisions; 5 new eye category III codes; and finally a 2 new auditory codes with one deletion.
This is Part 3 of a five part series on the new 2021 CPT codes. In this series we will explore the cardiovascular system CPT changes. There are 5 new cardiovascular CPT codes added with 0 deletions and 4 revisions.
This is Part 2 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include some examples to help the coder understand the new codes. There are 0 new musculoskeletal CPT codes added with 0 deletions and 2 major revisions along with an extensive update to arthroscopic loose body removal requirements. For the respiratory system, there were 2 new codes, one code deletion and no revisions.
This is Part 1 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include examples to help the coder understand the new codes. For 2021 in general, there were 199 new CPT codes added, 54 deleted and 69 revised.
In January, new CPT codes were released. There were 248 new CPT codes added, 71 deleted and 75 revised. Most of the surgery section changes were in the musculoskeletal and cardiovascular subsections. These included procedures such as skin grafting, breast biopsies, deep drug delivery systems, tricuspid valve repairs, aortic grafts and repair of iliac artery.
We have seen many updates and changes to COVID-19 (SARS-CoV-2) since the pandemic started. On January 1, 2021 we will see even more changes as outlined in this post. Also the CMS MS-DRG grouper will be updated to version 38.1 to accommodate the changes.
In the previous three parts of this four-part series, we discussed the new ICD-10-CM diagnosis code changes, ICD-10-PCS procedure code changes and FY2021 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2021.
In the previous two parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes and ICD-10-PC procedure code changes. In this session we will review the major IPPS changes for FY2021.
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.
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.