Important Billing Coding Updates

Coding updates, Chronic obstructive pulmonary disease (COPD), also known as chronic obstructive lung disease (COLD) and chronic obstructive airway disease (COAD), among others, is a type of obstructive lung disease characterized by chronically poor airflow. It typically worsens over time. The main symptoms include shortness of breath, cough, and sputum production. Most people with chronic bronchitis have COPD.

COPD and Pneumonia The requirement for code J44.0 (chronic obstructive pulmonary disease with an acute lower respiratory infection) are to be coded first when a patient has Pneumonia, and COPD has been eliminated as of October 1.

The 2018 version of ICD-10-CM replaced the “use additional ICD-10.

According to OCG Section I.A.17, the Code Also notes “does not provide sequencing direction. The sequencing depends on the circumstances of the encounter.”

We are now back to where the circumstances of admission, diagnostic workup, or therapy provided will determine the selection of principal diagnosis between COPD and Pneumonia.

Type 2 MI

The supplement for new codes was recently released with many notable additions and deletions. The following articles in this series will address some of these conditions to help us prepare for the October 1 implementation date.

Clinical documentation improvement (CDI) efforts will be well-spent trying to capture the information regarding an acute MI or type 2 MI. When working with physicians, documentation of the five types of MIs (listed below) will help speed code assignments and improve quality reporting.

The new category in ICD-10 went through several rounds of proposals and revisions and is finally debuting. We have several new codes to choose from and some modifications.

Before we go over the coding changes, though, it’s essential to understand the documentation for the different types. This will help coders choose the correct codes and CDI specialists to better assist the physician in documenting these concepts.

The problem with type 2 MIs is that the definition is slightly hard to interpret. According to the American College of Cardiology, it is defined as myocardial infarction secondary to ischemia due to either increased oxygen demand or decreased supply. Examples are coronary artery spasm, coronary embolism, anemia, arrhythmias, hypertension, or hypotension.

Determining the type based on proposed pathological, clinical, and prognostic differentiators helps determine the strategy needed to treat.

Type 1

Spontaneous MI. Ischemia-caused coronary events, such as plaque rupture, erosion, fissuring, or dissection

Type 2

Secondary to ischemia. Ischemia is caused by increased oxygen demand or decreased supply, such as coronary endothelial dysfunction, coronary artery spasm, coronary artery spasm or embolism, tachy- or brady arrhythmias, anemia, respiratory failure, hypotension, and hypertension.

Type 3

Cardiac death due to MI. Sudden unexpected cardiac death with symptoms of suggestive myocardial ischemia accompanied by presumably new ST elevation, new left bundle branch block (LBBB), or evidence of fresh thrombus in a coronary artery by angiography or at autopsy. Death occurs before blood samples can be obtained or before cardiac biomarkers are in the blood.

Type 4a

Percutaneous coronary intervention (PCI) related to MI

Type 4b

MI related to stent thrombosis

Type 5

Coronary artery bypass graft (CABG) related MI

Type 4 and Type 5 MIs related to PCI are further classified as periprocedural MI and stent thrombosis. PCI and CABG-related MIs are defined by specific thresholds in conjunction with evidence of ischemia, demonstrated loss of myocardium, or overt clinical conditions.

Category I21 was changed from ST elevation (STEMI) and non-ST elevation myocardial infarction (NSTEMI) to acute myocardial infarction. The Excludes2 note changes from subsequent myocardial infarction (I22.-) to subsequent type 1 myocardial infarction (I22.-)

Instructional notes at the fourth character designate an anatomical location as before but add the type 1 ST-elevation myocardial infarction designation.

I21.9 is not for acute myocardial infarction, unspecified (NOS).

The new subcategories for “other type of myocardial infarction” include:

I21.Another type of myocardial infarction

I21.A1 Myocardial infarction type 2

Myocardial infarction due to demand ischemia

Myocardial infarction secondary to an ischemic imbalance

Code also the underlying cause, if known and applicable, such as:

Anemia (D50.0–D64.9)

Chronic obstructive pulmonary disease (J44)

Heart failure (I50-)

Paroxysmal tachycardia (I47.0–I47.9)

Renal failure (N17.0–N19)

Shock (R57.0–R57.9)

I21.A9, another myocardial infarction type

Myocardial infarction associated with revascularization

The Myocardial infarction type 3

Myocardial infarction type 4a

The Myocardial infarction type 4b

Myocardial infarction type 4c

The Myocardial infarction type 5

Code first, if applicable, postprocedural myocardial infarction following cardiac surgery

(I97, I90), or postprocedural myocardial infarction during cardiac surgery (I97.790)

Code also complication, if known and applicable, such as:

(acute) stent occlusion (T82.897-)

The (acute) stent stenosis (T82.857-)

(acute) stent thrombosis (T82.867-)

cardiac arrest due to underlying cardiac condition (I46.2)

the complication of percutaneous coronary intervention (PCI) (I97.89)

occlusion of coronary artery bypass graft (T82.218-)

A diagnosis of “demand ischemia” has always been a challenge. It is still assigned to ICD-10 code I24.8, Other forms of acute ischemic heart disease (a CC). Demand ischemia is supposed to be reserved for supply/demand mismatch causing ischemia without necrosis, where biomarkers remain below the 99th percentile of the upper limit of the reference range. Still, clinicians often use it to describe what technically Type 2 MI is with biomarkers above the 99th percentile. A clinically correct distinction between demand ischemia and Type 2 MI is an effective diagnostic and coding concern.

Coding Update for Encephalopathy due to Stroke

Coding Clinic Second Quarter 2017 addressed whether encephalopathy would be coded separately or considered inherent to a cerebral infarction when diagnosed with encephalopathy secondary to an acute lacunar infarct. The Coding Clinic instructions were to “Assign Code G93.49, another encephalopathy, for encephalopathy secondary to an acute cerebrovascular accident/stroke. Although encephalopathy is associated with an acute lacunar infarct, it is not inherent and therefore is coded when it occurs.

There are two distinct categories of encephalopathy: acute and chronic. Many sources confuse and confound these categories, lumping them together as one. However, chronic encephalopathies are characterized by a regular mental status alteration that, in most cases, is slowly progressive. They result from permanent, usually irreversible, diffuse structural changes in the brain.

The vast majority of encephalopathy cases encountered in the inpatient setting are acute. Acute encephalopathy is characterized by a sharp, diffuse, functional alteration of mental status due to underlying systemic factors rather than local intracranial processes. It is reversible when these abnormalities are corrected, with a return to baseline mental status. Acute encephalopathy may be classified as toxic, metabolic, or toxic-metabolic, depending on its systemic cause.

Ordinarily, from a clinical standpoint, a mental status change associated with focal intracranial processes (like CVA) is more an alteration of consciousness and responsiveness in the spectrum of coma, obtundation, and lethargy – objectively measured using the Glasgow Coma Scale (GCS) scoring – and not an encephalopathic process.

The unsettled question remains whether “encephalopathy due to CVA” is a clinically valid diagnosis that can be compliantly coded on claims since Coding Clinic disclaims any authority to assert or establish clinical diagnostic definitions or standards. Based on the purposes and descriptions above of what encephalopathy is and is not, the diagnosis of encephalopathy due to CVA could be challenged. On the other hand, obtaining a GCS may reveal one of the component scores severe enough to qualify as an MCC.

Coding Update Functional Quadriplegia

Although the FY 2018 Official Coding Guidelines no longer include a paragraph describing functional quadriplegia, it is still a valid diagnosis and ICD-10-CM Code:

R53.2 Functional quadriplegia (MCC)

Complete immobility due to severe physical disability or frailty.

Excludes 1:

Frailty (R54)

Hysterical paralysis (F44.4)

Immobility syndrome (M62.3)

Neurologic quadriplegia (G82.5-)

Quadriplegia (G82.50)

Coding updates inside your medical billing software, depending on the medical billing software you are using, such as Medisoft, Lytec, or Primesuite by Greenway, you can get your latest ICD-10 and CPT codes for 2018 automatically as a part of your updates. Check with your medical billing service company (AKA revenue cycle management)when you get your 2018 codes updated.