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 Part 2 of our Sepsis Series, we are going to focus on sequencing of sepsis when the diagnosis is clearly documented. Later in the series we will look at what to do when the diagnosis is not clearly documented.
In this series, we will learn what sepsis is or causes of sepsis, how to sequence the diagnosis in ICD-10-CM, what are the clinical indicators for sepsis, is a query necessary before reporting the diagnosis of sepsis, and how to prevent denials on sepsis records.
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 FY2020 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2020.
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 FY2020. On August 2, 2019, CMS published the Final Rule for IPPS (CMS-1716) FY2020 IPPS Final Rule.
In Part 1 of this 4 part series we discussed some of the new ICD-10-CM diagnosis changes. In Part 2 we present the significant ICD-10-PCS procedure code changes. There are 72,184 total ICD-10-CM codes for FY2020.
We have finished with the step-by-step coding tidbits on coding of spinal fusions. If you were not able to catch Parts 1-13 of this series focused on spinal fusions, please visit hiacode.com/topics/series/spinal-fusion-coding/.
In Part 12, we focused on intra-operative peripheral neuro monitoring used during spinal fusion surgery. In Part 13, we are going to focus on harvesting of autograft and is it coded. Remember in Part 6, we learned that autograft is bone from the patient.
In Part 11, we focused on identifying the computer assisted navigation used during spinal fusion surgery. In Part 12, we are going to focus on intra-operative peripheral neuro monitoring.
In Part 10, we focused on identifying whether or not hardware from a previous spinal fusion is coded. In Part 11, we are going to discuss computer assisted navigation.
In Part 9, we focused on identifying if decompression was also performed and if so, on which body part. In Part 10, we are going to focus on identifying if hardware was removed from a previous fusion site.
In Part 8, we focused on identifying if a discectomy was performed, and if so, if it was a partial or a total discectomy. In Part 9, we are going to focus on identifying if a decompression was performed, and if so, was it of the spinal cord, spinal nerves or both?
In Part 7, we focused on identifying any instrumentation that may be used during a spinal fusion. In Part 8, we are going to focus on identifying if a discectomy is performed and if this is an excision or a resection of the disc.
In Part 6, we focused on identifying the type of bone graft product used for the spinal fusion. In Part 7, we are going to focus on identifying any instrumentation or device used.
In Part 5, we focused on identifying the approach being used for the spinal fusion. In Part 6, we are going to focus on identifying the type of bone graft used for the spinal fusion.
In Part 4, we focused on determining the spinal column being fused. In Part 5, we are going to focus on identifying what approach is being used to complete the spinal fusion (anterior, posterior or both).
This past year, HIA implemented “Buddy Up,” a program designed to help the new hire have a smooth transition into their new HIA roles with the assistance of a “buddy.” What is a Buddy? The Buddy is simply a peer who can guide the new hire in order to make them feel more comfortable. We are very proud of this program and have many success stories that we would like to share. Take a look at the wonderful feedback we have received below.
In Part 3, we focused on determining the level of the fusion(s) and how to determine the number of vertebrae fused. In Part 4, we are going to focus on identifying which column is being fused (anterior, posterior or both).
Part 3: Spinal Fusion Coding — Determine the Level(s) or Region of Fusion and Number of Vertebrae Fused
In Part 1, we learned the diagnoses associated with the need for spinal fusions, and in Part 2 the need to identify if the fusion is an initial or refusion of the vertebrae. In Part 3, we are going to focus on determining the level(s) of fusion, as well as the number of vertebrae fused.
In Part 2, we are going to look at the differences between initial fusion and a refusion. In ICD-9, there were specific codes to show if the fusion was an initial fusion, or if it was a refusion. In ICD-10-PCS, initial fusions and refusion procedures are coded to the same root operation “fusion.”
This is Part 1 of a 14 part series focusing on education for spinal fusions. Spinal fusion coding is a tough job for coders. There are so many diseases/disorders that result in the need for spinal fusion, and even more choices in reporting the ICD-10-PCS codes.
The official definition from the Centers for Medicare & Medicaid Services (CMS) states that a Medicare overpayment is a payment that exceeds amounts properly payable under Medicare statutes and regulations. When Medicare identifies an overpayment, the amount becomes a debt you owe the Federal government.
The question asked in a physician query may be the most important element of the document. Query questions need to be as simple and concise as possible. The physician should have no doubt what the coder is asking.
Coding complications of transplanted organs has always been a coding dilemma. With the implementation of ICD-10-CM that didn’t change. However, coders have multiple directives to help in determining what a complication of the transplant is vs. non-transplant conditions and diseases.
With the implementation of ICD-10-CM came more codes for reporting many different conditions and diseases, and atrial fibrillation is one of those. For many years there was only one code available for reporting this condition, even when the physician further specified the type of atrial fibrillation that the patient had. In ICD-10-CM, there are four codes to report atrial fibrillation.
We have a case where the physician removes mucoid casts found during bronchoscopy. We have also seen mucus plugs removed during bronchoscopy. The MD performs bronchial washings then removes a large amount of tenacious and thick mucoid casts via bronchoscopy. Is this coded drainage, extirpation or excision? What body part is used?
The key to making the query process more efficient is to look for words or documentation while reviewing the record that may signal a potential query opportunity and to note the finding at that time. By the time a coder reaches the end of a record, documentation may have been found to eliminate the need for the query.
Question: This patient is noted to have “Lymphangitic carcinomatosis of lungs with mediastinal lymph nodes.” How would I code the diagnosis? Would I code metastatic cancer to the lung (C78.01) or metastatic cancer to the lymph nodes (C77.1)?
Coding these can be challenging for coders when trying to decipher the operative notes and terms that are used. The physicians are still using the terms excision and resection interchangeably and review of the entire operative note is required to select the appropriate root operation. Remember, it is the coder’s responsibility to determine the root operation based on the details from the physician in the operative report.
This would be considered a “mechanical” complication of the stent graft since the MD states it is a fracture of the endograft and it is folded over on itself. I would change T82.898A TO T82.598A for Other mechanical complication of other cardiac and vascular devices and implants, initial encounter. I did not use “displacement” because the surgeon did not state that the graft was displaced, only that it collapsed upon itself causing obstruction.