Part 1: New ICD-10 Codes and IPPS Changes
RHIA, CDIP, CCS, CCS‑P, CIRCC
Executive Director Of Education
AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador
New ICD-10-CM Codes
This is Part 1 of a 4 part series on the FY2020 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:
72,184 total ICD-10-CM codes for FY2020
- 324 changes all together (2019 had 473 changes)
- 273 new codes (2019 had 279 new codes)
- 21 deleted codes (2019 had 51 deleted codes)
- 30 revised codes (2019 had 143 revised codes)
Most of the changes occurred in the circulatory system, skin and subcutaneous system, congenital malformations, injuries, external causes and status codes chapters. The major changes will be discussed below.
Circulatory System Chapter
The first big change involves Type 2 Myocardial Infarction (MI). The OCG and notes in the tabular have been revised to state that the coder must CODE FIRST the underlying cause of the Type 2 MI such as: anemia (D50.0-D64.9); COPD (J44.-); paroxysmal tachycardia (I47.0-I47.9), shock (R57.0-R57.9). Code I21.A1 should never appear as a principal diagnosis.
Type 2 MI (myocardial infarction) is marked by non-ST elevation, and occurs secondary to cardiac stress due to other causes (i.e., ischemia resulting from a supply-and-demand mismatch), without atherosclerotic plaque rupture, but with myocardial necrosis.
Type 2 MI patients may have elevated troponin but no real clinical features of a Type I MI. The underlying cause usually is increasing the oxygen demand or decreasing the oxygen supply. Treating the underlying cause corrects this.
Troponin can be elevated by non-cardiac causes such as renal failure, significant age and other conditions listed. An elevated troponin and a normal ECG or nonspecific changes should raise suspicion of an alternate diagnosis. Elevated troponin (R79.89) does not always equal Type 2 or other MI. The coder may need to query if this is the case.
The second major change is the addition of various codes for different types of atrial fibrillation.
I48.1 Persistent atrial fibrillation
Add Excludes1: Permanent atrial fibrillation (I48.21)
Add I48.11 Longstanding persistent atrial fibrillation (CC)
Add I48.19 Other persistent atrial fibrillation (CC)
Add Chronic persistent atrial fibrillation
Add Persistent atrial fibrillation, NOS
I48.2 Chronic atrial fibrillation
Delete Permanent atrial fibrillation
Add I48.20 Chronic atrial fibrillation, unspecified (CC)
Add Excludes1: Chronic persistent atrial fibrillation (I48.19)
Add I48.21 Permanent atrial fibrillation (CC)
Atrial Fibrillation definitions are categorized by duration, and can change over time.
Persistent Atrial Fibrillation (I48.19)
Usually, this lasts longer than a week. It could stop on its own, or patient may need medicine or treatment to stop it. Doctors can use medicine such as Amiodarone to treat this type of AFib. If that doesn’t work, they might use a low-voltage current to reset the heart’s rhythm to normal (called electrical cardioversion.) Pacemaker is sometimes placed.
Long-Standing Persistent Atrial Fibrillation (I48.11)
This means the AFib has lasted for more than a year and doesn’t go away. Medicine and treatment such as electrical cardioversion may not stop the AFib. Doctors can use another kind of treatment, such as ablation (which burns certain areas of your heart’s electrical system) to restore patient to normal heart rhythm. Or can try the MAZE procedure. Pacemaker sometimes placed.
Permanent Atrial Fibrillation (I48.21)
This can’t be corrected by treatments. Patient and doctor will decide if patient needs long-term medication to control heart rate and lower odds of having a stroke. Usually nothing can correct it.
Paroxysmal Atrial Fibrillation (I48.0)
This is an episode of atrial fibrillation that lasts less than a week. Patient might feel it happening for a few minutes or for several days. May not need treatment with this type of AFib, but you should see a doctor. Sometimes Beta Blockers, pulmonary vein isolation or radiofrequency ablation used.
Chronic Atrial Fibrillation (I48.20)
The MD documents ‘chronic’ but does not know exact type. Usually means more than 1 week although there are more precise definitions above. The physician can be queried.
The question comes up as to what to do when a physician documents two types of atrial fibrillation, such as paroxysmal atrial fibrillation (PAT) and persistent atrial fibrillation. Since the definitions are by duration, best practice would be to query and educate physicians on new codes and importance of discerning the exact type of atrial fibrillation. Since it can change over time, the patient may have had paroxysmal atrial fib in the past in the history section that now has persistent atrial fibrillation. Also the abbreviation of PAT must be reviewed as it may stand for paroxysmal or persistent or even permanent atrial fibrillation. This abbreviation is best avoided.
Skin and Subcutaneous System Chapter
The most prominent change here is the addition of “Pressure-induced deep tissue damage” codes of the various sites of the body to include elbow, upper/lower back, sacrum, hip, buttock, ankle, heel, other, unspecified. All are “CCs” and have the sixth character of “6.” These were previously indexed to “Unstageable” ulcers. Pressure-induced deep tissue damage is also referred to as Deep Tissue Pressure Injury (DTPI) is now defined as “intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This condition results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss.” Coders will need to be especially careful in indexing these codes. The index under injury, deep tissue meaning pressure ulcer states to code to the ulcer, pressure unstageable. However, if deep tissue injury is present, the L89 codes should be used, not the unstageable codes. The index entry will be revised in the future. Please refer to 4Q2019 Coding Clinic page 11.
Congenital Malformations and Abnormalities Chapter
Many new codes were added to describe the laterality of congenital disorders of talipes equinovarus, talipes calaneovarus, metatarsus primus varus, metatarsus adductus, varus deformities, talipes calcaneovalgus, pes cavus, and deformity of feet.
New codes were added for the various types of Ehlers-Danlos Syndromes. This affects 1 in 5000 individuals. Ehlers-Danlos syndrome is a group of disorders that affect connective tissues supporting the skin, bones, blood vessels, and many other organs and tissues. Defects in connective tissues cause the signs and symptoms of these conditions, which range from mildly loose joints to life-threatening complications such as aortic root issues. Subtypes usually diagnosed by knowing the gene mutation.
Most of the new codes in this chapter have to do with a creation of 60 new codes for fractures of the orbital roof, medial orbital wall, lateral orbital wall and orbital floor (S02.121-29, S02.8-). This can be confusing to coders as different bones make up each designation:
Orbital Roof: frontal bone, lesser wing of sphenoid
Lateral Orbital Wall: zygomatic bone, greater wing of sphenoid
Orbital Floor: maxillary, zygomatic, and palatine bones
Medial Orbital Wall: maxillary, lacrimal, ethmoid and sphenoid bones
18 new codes in the T50.91- category were created for poisoning by, adverse effect of and underdosing of multiple unspecified drugs, medicaments and biological substances. There is a note to assign codes for individual specific drug codes in addition to the T50.91- codes when applicable. The intent of creation of this code was to allow coding of poisoning and adverse effects when the specific drugs are not known by the patient, or maybe one or some drugs are known but not all that were taken. In that case the individual drug codes would be coded along with a code from T50.91-. There is no sequencing directive.
External Causes Chapter
New codes created in this chapter are for identification of an “Unspecified person” in the legal intervention codes Y35.00-Y35.99. This choice was not available when the person injury was unknown. A new subsection for “legal intervention involving conduction energy device” such as stun gun or taser was added.
Factors Influencing Health Status Chapter
There are various new “Z” codes for encounter for exam of eyes and vision following failed vision screening, latent tuberculosis encounter, carrier or personal history; and Encounter for health counseling related to travel.
Z45.42 was revised to Encounter for adjustment and management of NEUROSTIMULATOR to accommodate any type of neurostimulator such as brain, gastric, peripheral nerve, spinal cord, vagus nerve and sacral nerve. Code Z96.82 Presence of neurostimulator as added.
Official Guidelines for Coding and Reporting
Most of the changes and updates have to do with the tabular changes this year such as sequencing rule for Type 2 MI and Pressure-induced deep tissue damage. There was an addition to Chapter 19 guidelines for
3) Iatrogenic injuries. It states “Injury codes from Chapter 19 should not be assigned for injuries that occur during, or as a result of, a medical intervention. Assign the appropriate complication code(s).” What this means is don’t assign a traumatic laceration “S” code when the laceration is due to surgeon such as K91.71, laceration of digestive organ during digestive system procedure.
At the beginning of Chapter 19 is this: Note: The chapter uses the S-section for coding different types of injuries related to single body regions and the T-section to cover injuries to unspecified body regions as well as poisoning and certain other consequences of external causes. Consequently under guideline g for
“Complications of care, this note was added: Complication codes from the body system chapters should be assigned for intraoperative and postprocedural complications (e.g., the appropriate complication code from chapter 9 would be assigned for a vascular intraoperative or postprocedural complication) unless the complication is specifically indexed to a T code in chapter 19.
For section III and IV, C. Uncertain Diagnosis, the terms “compatible with” and “consistent with” were added as terms that indicate the same meaning as “probable,” “likely,” and “questionable.”
So that about sums it up. No real earth shattering changes to ICD-10-CM except for maybe the new atrial fibrillation codes and Type 2 MI sequencing directives. Be sure to review all the other changes in the addenda.
In Part 2 of this series, we will look at some highlights of the new ICD-10-PCS codes and changes.
The information contained in this coding advice 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.
In June CMS released the final ICD-10-PCS codes for FY2022, which begins October 1, 2021. We are giving you a sneak peek at the changes. HIA will have a full educational module on these changes available later this summer.
CMS released the IPPS proposed rule on 4/27/21 outlining the proposed changes to the Inpatient Prospective Payment System for FY2022, which begins October 1, 2021. Later this year, sometime in August, CMS will release the Final Rule. Currently CMS is reviewing responses to their proposed rule and will address them in the final rule.
A medical coding audit is a process that includes internal or external reviews of medical coding and billing accuracy, procedures or policies in place, and any other component that affects the medical record documentation. Medical coding audits…
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 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)…
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.
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.