26 Dec 2017

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 acute lower respiratory infection) to be coded first when a patient has pneumonia and COPD has been eliminated as of October 1.pulmonary billing coding

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

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

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

Type 2 MI

The addendum for new codes coming out was recently released with many notable additions and deletions. The next several articles in this series will address some of these conditions in order to help us get ready 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 the 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 as well as some revisions.

Before we go over the coding changes though, it’s important to understand the documentation for the different types. This will help coders to 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. It is defined, according to the American College of Cardiology, as myocardial infarction secondary to ischemia due to either increased oxygen demand or decreased supply. Examples given are coronary artery spasm, coronary embolism, anemia, arrhythmias, hypertension or hypotension.

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

Type 1
Spontaneous MI
Ischemia-caused coronary event, such as plaque rupture, erosion, fissuring or dissection

Type 2
Secondary to an ischemia
Ischemia 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 that is 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 the time that cardiac biomarkers in the blood.

Type 4a
Percutaneous coronary intervention (PCI) related MI

Type 4b
MI related to stent thrombosis

Type 5
Coronary arterial 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 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.A Other type of myocardial infarction

I21.A1 Myocardial infarction type 2

Myocardial infarction due to demand ischemia

Myocardial infarction secondary to 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 Other myocardial infarction type

Myocardial infarction associated with revascularization

Myocardial infarction type 3

Myocardial infarction type 4a

Myocardial infarction type 4b

Myocardial infarction type 4c

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-)

(acute) stent stenosis (T82.857-)

(acute) stent thrombosis (T82.867-)

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

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 reference range, but is often used by clinicians 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 important diagnostic and coding concern.

Coding Update for Encephalopathy due to Stroke
Coding Clinic Second Quarter 2017 responded to a question regarding whether or encephalopathy would be coded separately or considered inherent to a cerebral infarction when diagnosed with encephalopathy secondary to an acute lacunar infarct.Neurology billing coding
Coding Clinic instructions were to “Assign code G93.49, other encephalopathy, for encephalopathy that occurs secondary to an acute cerebrovascular accident/stroke. Although the 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, the chronic encephalopathies are characterized by a chronic 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 an acute, 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 further identified 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 definitions 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 your medical billing software you are using such as Medisoft, Lytec or Primesuite by Greenway you can be getting your latest ICD-10 and CPT codes for 2018 automatically as apart of your updates. Check with your medical billing service company (AKA revenue cycle management)when are you getting your 2018 codes update.