Part 1: New ICD-10 Codes and IPPS Changes
Pat Maccariella‑Hafey
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.
Injuries Chapter
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.
Happy Coding!
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.
Download 4-Part Series
Popular Posts
Coding Tip: Cardiac Arrest and Cardiac Shock
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.
Client X: Let’s Talk Numbers
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.
Coding Tip: Endarterectomy During Coronary Artery Bypass
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.
Coding Tip: Update – Coding COVID-19 When the Test is Negative
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.
New ICD-10-PCS Procedure Codes for COVID-19
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.
Subscribe to our weekly newsletter
Latest News
Coding Tip: Cardiac Arrest and Cardiac Shock
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.
Client X: Let’s Talk Numbers
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.
Coding Tip: Endarterectomy During Coronary Artery Bypass
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.
Coding Tip: Update – Coding COVID-19 When the Test is Negative
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.
New ICD-10-PCS Procedure Codes for COVID-19
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.
New Rule Helps Medicare ACOs During COVID-19 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.
Part 5: Reasons for AKI Denials and Prevention | AKI Series
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.
Part 4: Is Documentation Present to Report Acute Kidney Injury/Failure? | AKI Series
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.
Coding Tip: Z Code Reporting for COVID-19
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).
Part 3: Clinical Indicators for Acute Kidney Injury/Failure | AKI Series
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.
FY2021 Proposed Rule and Code Changes Highlights
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.
Part 2: Specificity Coding of Acute Kidney Injury (AKI) and Sequencing | AKI Series
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.
Part 1: What is Acute Kidney Injury (AKI)? | AKI Series
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.
Coding Tip: Covid-19 Diagnosis Coding Common Scenarios
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.
Reporting Telehealth Services During the COVID-19 Emergency
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.
Coding Tip: What is Single Path Coding?
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.
Coding Tip: Reporting Vaping in ICD-10-CM | Effective on 4/1/2020
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.
Telehealth and the Coronavirus
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
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.
Part 3: Coder and CDI Communication Example | CDI Series
This is the final part of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. In this part, we provide an actual example of an effective communication response to CDI.
Part 2: How Coders Can Address Coding Mismatches | CDI Series
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.
Part 1: How Coders Can Better Interact with CDI Teams | CDI Series
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.
Coding Tip: Coding Diagnoses on Outpatient Encounters
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.
Part 4: Top 5 ICD-10-CM Chapters 2019 | Acute Care Reviews
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.
Part 3: Top 5 ICD-10-CM Chapters 2019 | Acute Care Reviews
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.
Part 2: Top 5 ICD-10-CM Chapters 2019 | Acute Care Reviews
For Part 2 of this 5-part series, we will look at Chapter 1 within ICD-10-CM—A00-B99—Certain Infectious and Parasitic 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.
Part 1: Top 5 ICD-10-CM Chapters 2019 | Acute Care Reviews
For Part 1 of this 5-part series, we will look at Chapter 21 within ICD-10-CM—Z00-Z99—Factors influencing health status and contact with health services. There is no possible way to include every guideline or coding reference for this chapter, but I’ll do my best to touch on some off the most common issues.
Coding & Quality Measures Tip: Social Determinants of Health
The HIM world has been buzzing recently with discussion of “Social Determinants of Health” and coded data. What does this mean for coders and the HIM field?
New ICD-10-CM Code for Vaping-Related Disorder
In response to the recent occurrences of vaping related disorders and in consultation with the World Health Organization (WHO) Framework Convention on Tobacco Control, the WHO Family of International Classifications (WHOFIC) Network Classification and Statistics Advisory Committee (CSAC) was convened to discuss a diagnosis code for vaping related illness for immediate use.