Cardiology Coding Alert

Watch for Index hints to help with etiology/manifestation codes.

How did you fare when ICD-10 replaced ICD-9 on October 1? For the most part, coders are reporting that pinpointing the code for a specific diagnosis isn’t too tough, but applying guidelines adds some unexpected complications.

“Code first” instructions and conflicting ICD-10/payer policy rules are two of the areas coders are reporting issues with, says Jamie Cassella, billing manager for The Huntington Heart Center in New York.

Cardiology Coding Alert consulting editor Christina Neighbors, MA, CPC, CCC, offers this advice on handling these two areas of concern.

Look Into Etiology/Manifestation for Code First

Question: If ICD-10-CM code “X” has a “code first” rule, but the patient doesn’t have any of the conditions listed under “code first,” can you sequence code X first? In particular, can you sequence I50.- (Heart failure) codes first despite the instructions to “code first” other conditions?

Response: Whether you may sequence first an ICD-10 code that has a “code first” instruction depends upon whether the code is part of an etiology/manifestation pair.

According to the ICD-10 Official Guidelines, some conditions have both an underlying cause (etiology) and multiple manifestations of that underlying disease. For those conditions, an ICD-10 convention requires you to code the etiology first followed by the manifestation. The etiology code will have a “use additional code” note with it for the manifestation, and the manifestation code will have a “code first” note for the etiology.

You can usually, but not always, identify manifestation codes by the phrase in the descriptor, “in diseases classified elsewhere.” Another clue that you’re dealing with an etiology/manifestation pair is that in the Index, you’ll find the conditions listed together. The etiology code will be first with the manifestation code in brackets.

But the ICD-10 Official Guidelines also state, “‘Code first’ notes are also under certain codes that are not specifically manifestation codes but may be due to an underlying cause. When there is a ‘code first’ note and an underlying condition is present, the underlying condition should be sequenced first” (www.cdc.gov/nchs/data/icd/10cmguidelines_2016_Final.pdf).

For this rule, which applies to non-etiology/manifestation pairs, the wording “may be due to” and “when ... an underlying condition is present” suggests you apply the “code first” note only when there is documentation of an underlying condition.

Heart failure: You should be able to sequence the I50.- codes first if there is no documentation that the patient has one of the conditions listed under the code first instructions with I50.-.

The instruction is to “code first”:

• Heart failure complicating abortion or ectopic or molar pregnancy (O00-O07, O08.8)
• Heart failure following surgery (I97.13-)
• Heart failure due to hypertension (I11.0)
• Heart failure due to hypertension with chronic kidney disease (I13.-)
• Obstetric surgery and procedures (O75.4)
• Rheumatic heart failure (I09.81).

If you look up Failure in the ICD-10 Index, you will see that there are no bracketed codes with the heart failure entries. This suggests heart failure is not part of a so-called etiology/manifestation pair.

Let Payers Know When They Conflict With ICD-10

Question: Suppose a patient has hypertensive heart disease with left ventricular failure and requires a test. According to the ICD-10 instructions you should “code first” I11.0 (Hypertensive heart disease with heart failure) followed by I50.1 (Left ventricular failure). The payer policy lists I50.1 as a code that supports medical necessity, but not I11.0. Despite the ICD-10 rule, should you report I50.1 in the first position rather than I11.0 to meet payer requirements?

Response: If you’re encountering situations where an LCD or other payer policy conflicts with ICD-10 instructions or Official Guidelines, you should let the payer know they need to revise the policy. You can send in a scan of the official rule from the code set and also remind the payer that page 1 of the Official Guidelines states, “Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA).”

Neighbors advises following the ICD-10 rules with the expectation that you’ll have to appeal denials until the payer updates its policy.