Part 2: 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
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. 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)
Official Guidelines for Coding and Reporting ICD-10-PCS
There are several minor changes to the guidelines that include adding more descriptive terms, and adding examples. An exception was added to B3.1b Multiple Procedures in that mastectomy followed by breast reconstruction, both resection and replacement of the breast are coded separately. Likewise, in guideline B3.9 for Excision of Graft, clarification of DIEP was added: Replacement of breast with autologous deep inferior epigastric artery perforator (DIEP) flap, excision of the DIEP flap is not coded separately. The seventh character qualifier value Deep Inferior Epigastric Artery Perforator Flap in the Replacement table fully specifies the site of the autograft harvest.
A brand new Section D – Radiation Therapy has been added. This will help coders to know when to report an “Insertion” code with device value “radioactive element” in addition the modality in the radiation therapy section, and when not to. For example, brachytherapy with implantation of a low dose rate brachytherapy source left in the body at the end of the procedure is coded to the applicable treatment site in section D, Radiation Therapy, with the modality Brachytherapy, the modality qualifier value Low Dose Rate, and the applicable isotope value and qualifier value. The implantation of the brachytherapy source is coded separately to the device value “radioactive element” in the appropriate Insertion table of the Medical and Surgical section (0). The Radiation Therapy section code identifies the specific modality and isotope of the brachytherapy, and the root operation Insertion code identifies the implantation of the brachytherapy source that remains in the body at the end of the procedure. There is an exception to this for Cesdium-131 Collagen implant in that this procedure identifies both the implantation and brachytherapy, so only one code is needed. There is also guidance on placing temporary applicators for delivering brachytherapy.
Guidelines for Section E – New Technology Section (X codes) was updated to state that Section X codes fully represent the specific procedure described in the code title, and do not require additional codes from other sections of ICD-10-PCS. So all the coder needs to assign is the new technology code.
Major Changes to the ICD-10-PCS Tables
Coders will notice than there were many deleted ICD-10-PCS codes for FY2020. This is primarily because of the removal of “Bifurcation” as a qualifier in all upper and lower artery tables. However it remains as a choice for the coronary arteries. That change eliminated quite a few codes. This was a troublesome area for coders as many did not know when to assign the bifurcation qualifier.
ICD-10-PCS also removed approach “external” from all breast procedures. The index has been updated to indicate that procedures performed on the skin of the breast be coded to body part “Skin, chest” and not to breast.
In the Administration Section, body part value for peripheral or central “artery” was removed, eliminating many ICD-10-PCS codes. This was done because transfusions are done through veins, not arteries.
A device value for Internal fixation device, intramedullary limb lengthening for insertion of upper or lower bones was added. This includes the PRECICE intramedullary limb lengthening system. This would be coded to root operation “Insertion” and not “Reposition” as the surgeon is lengthening the bone, not repositioning a fracture.
A new device for Intraluminal Device, Flow Diverter for Restriction in Upper Arteries was added for the Pipeline™ and Surpass Streamline ™ Flow Diverter devices. The flow diverter, sometimes called a stent is designed to reliably open and provide consistent mesh density across the neck of the aneurysm to aid in aneurysm occlusion while maintaining perforator artery patency. Coders will need to be sure to research these types of devices that the proper device value is assigned.
A new device value for Subcutaneous Defibrillator Lead in Subcutaneous Tissue and Fascia for the S-ICD ™ lead was added. The EMBLEM S-ICD System is an innovative and truly novel ICD. Unlike traditional ICDs that require placement of at least one lead in or on the heart, the S-ICD System is implanted just under the skin and provides the patient protection from sudden cardiac arrest without invading the heart and blood vessels. It is the only fully subcutaneous (under the skin) ICD available at the current time. However coders should be on the look out for new S-ICDs.
Innominate artery, also known as the brachiocephalic artery was added as a qualifier under the Bypass root operation in the Heart and Great Vessels body system In addition, coronary arteries were added to the “Insertion” and “Supplement” root operations. Coders must be careful not to use “Insertion” and the coronary artery body part for PCI stent insertion. PCI angioplasties are still coded to root operation Dilation. The root operation for “Insertion” of device in coronary artery is for s stent insertions DURING TAVR OR VALVE REPLACEMENTS to help prevent the risk of coronary obstruction following valve insertion. So this type of stent is not really treating a condition such as CAD, it is a preventative device at time of other surgery. Supplement of coronary arteries is done to reinforce or augment coronary arteries, such as a stent graft placed to seal and reinforce a perforated/dissection of artery status post atherectomy. The objective is to supplement the wall of the artery.
Coders can not code EGD with occlusion of gastric vein as “Gastric Vein” was added as body part value for procedures done via natural or artificial opening and natural or artificial opening endoscopic.
Under Performance, Circulatory a new Duration of “Intraoperative” was added so coders could code ECMO done intraoperatively. In recent years, providers are increasingly performing short-term, percutaneous ECMO procedures in addition to open-chest ECMO. ECMO was originally only used for respiratory support, but today, ECMO is commonly used for respiratory and cardiac support. CentralECMO cannulation involves sternotomy and direct surgical cannulation of the right atrium and aorta. This involves two open insertions; arterial and venous and provides cardiorespiratory support.
V A Peripheral ECMO cannulation involves two femoral percutaneous insertions; arterial and venous. This type of ECMO support provides respiratory and circulatory support.
V V ECMO requires two venous insertions, one in the upper veins and one in the lower veins. This provides respiratory support only.
For “Other Procedures,” a new method of “Fluorescence Guided Procedure” was added. An example is a fluorescent label attached to a marker (e.g. a monoclonal antibody) that binds specifically and selectively to tumor cells, helping the surgeon ‘see’ the tumor and metastatic tissue in real time. Fluorescent markers can be used with a wide range of procedures, including classic (‘open’) surgery, laparoscopic surgery, and diagnostic procedures such as colonoscopy.
A new device for dilation of artery with sustained release drug-eluting intraluminal device was added as a New Technology X code, X27. The Eluvia and SAVAL stents are two such devices.
Another new device called a cerebral embolic filtration, single deflection filter was added to new technology table X2A. One example is the Embrella Embolic Deflector (Embrella Cardiovascular Inc, Wayne, Pa) which was designed to meet the need for embolic protection during procedures on the heart or involving the passage of catheters over the aortic arch. Emboli may arise from manipulation of the heart valves or atria and aorta and this device deflects them. There are several types of aortic arch filters that the coder must become familiar with. They include: a single filter but not a deflection filter (Embol-X)
Two single deflection filters called Embrella, TriGuard to the right. (Device 2 – Cerebral Embolic Filtration, Single Deflection Filter) and a third one called Sentinel which is a dual filter (Device 1 – Cerebral Embolic Filtration, Dual Filter)
In Part 3, the pertinent IPPS changes will be presented. In the final Part 4, New Technologies (X codes) and payment impacts will be presented and discussed in detail.
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.
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 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.
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.
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.
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.
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.
The Centers for Disease Control and Prevention (CDC) is in process of developing a new code for the COVID-19 (coronavirus) that will be released October 1, 2020. In the meantime, the CDC has provided advice on coding the COVID-19 coronavirus.
We’re finally at the #1 most common DRG with recommendations by HIA for 2019. Just to recap, HIA reviewed over 50,000 inpatient records in 2019. Most have probably already guessed what the correct DRG would be with the most recommendations. There are just some diagnoses and DRG’s that will always be a thorn in the side for coders. #1 DRG with the most recommendations during HIA reviews : DRG 871—Septicemia or severe sepsis w/o mechanical ventilation >96 hours with MCC
We’re now at the second most common DRG with recommendations by HIA for 2019. Just to recap, HIA reviewed over 50,000 inpatient records in 2019. We are counting down to # 1. #2 DRG with the most recommendations during HIA reviews: DRG 872—Septicemia or severe sepsis w/o mechanical ventilation >96 hours w/o MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #3 DRG 190—Chronic obstructive pulmonary disease with MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #4 is DRG 193—Simple pneumonia & pleurisy with MCC.