ED Coding and Reimbursement Alert

CMS has released the finalized list of 2018 diagnosis codes.

If you've got high hopes that you'll benefit from many new ICD-10 codes starting this fall, CMS delivers, with over 300 new diagnosis codes debuting on Oct. 1. CMS published the full listing of codes on June 13, but we've reviewed the list to identify the changes most relevant to emergency departments.

Myocardial Infarction Coding Is Now Clearer

As you read in last month's issue of Emergency Department Coding Alert, ICD-10 stakeholders requested updates to the myocardial infarction codes, and CMS approved them, finalizing revisions to codes in the I21 range. The name of this category will change from "ST elevation and non-ST elevation myocardial infarction" to the heading, "Acute myocardial infarction," which has several subcodes under it so ED physicians and cardiologists can better specify the type of myocardial infarction that the patient experienced. For instance, I21.0 (ST elevation [STEMI] myocardial infarction of anterior wall) refers to STEMI of the anterior wall, while I21.1 (ST elevation [STEMI] myocardial infarction of inferior wall) describes STEMI of the inferior wall, with notes under both codes indicting that these codes refer to "Type 1" STEMI.

In addition, a new code has been added, which is I21.9 (Acute myocardial infarction, unspecified) and a new subcategory will exist under I21.A (Other type of myocardial infarction), which includes the following new codes:

• I21.A1 -Myocardial infarction type 2
• I21.A9 - Other myocardial infarction type

The ICD-10 manual will include a note under I21.A1 saying, "Code also the underlying cause, if known and applicable." The ICD-10 Coordination and Maintenance Committee chose to include this note rather than a "code first" note. The difference between "code also" and "code first" is a subtle one, involving sequencing, says Sarah Todt, RN, CPMA, CPC, CEDC, director of provider education and audit with LogixHealth in Bedford, Massachusetts. "A 'code first' note would have to be sequenced prior to the MI code," she advises.

Look for Pulmonary Hypertension, Heart Failure Updates

You'll also find new codes effective Oct. 1 for pulmonary hypertension, such as I27.20 (Pulmonary hypertension, unspecified) and I27.21 (Secondary pulmonary arterial hypertension). The ICD-10 manual will further specify this condition noting the cause, such as I27.22 (Pulmonary hypertension due to left heart disease) and I27.23 (Pulmonary hypertension due to lung diseases and hypoxia).

The ICD-10 updates also include new instructions for "Other heart failure," which gets a new category (I50.8). When patients have conditions that fall under this category, such as right ventricular failure or biventricular heart failure, the ICD-10 manual will offer additional new ways to specify these services. These new codes include the following, among many others:

• I50.810 - Right heart failure, unspecified
• I50.813 - Acute on chronic right heart failure
• I50.82 - Biventricular heart failure
• I50.83 - High output heart failure
• I50.84 - End stage heart failure

As demonstrated by the examples above, some of the new codes go out to six characters, while others stop at five - these are important distinctions to note when you're selecting your diagnosis codes. "Coders should pay careful attention to any diagnosis codes that have extra characters because the ICD-10-CM is our road map to coding accurately and correctly," says April Callahan, BA CPC, CPC-I, president and CEO of A&L Medical Coding Consulting, LLC, in Long Beach, Mississippi.

"Using the extra character tells the story of the patient's condition along with what the physician documented, which also leads to coding to the highest specificity," Callahan adds. "This will save a lot of denials when submitting a claim," she adds.

Find Updates to Intestinal Obstruction, Coma Scale

When patients present to the ED with intestinal obstruction, you'll find some new codes to describe these services, such as the following, among others:

• K56.600 - Partial intestinal obstruction, unspecified as to cause
• K56.601 - Complete intestinal obstruction, unspecified as to cause
• K56.691 - Other complete intestinal obstruction

Coma scale changes: The updates to ICD-10 will also add new terminology to clarify age levels under the Pediatric Glasgow Coma Scale. The changes will better allow clinicians to distinguish between the coma levels depending on the patient's age, because clinicians use the Glasgow Coma Scale to assess consciousness of infants and children.

For example, under R40.222 (Coma scale, best verbal response, incomprehensible words), the ICD-10 manual has added "Moans/Grunts to pain; restless (<2 years old)" and "Incomprehensible sounds (2-5 years of age)" so doctors can classify which patients fall into this category depending on whether they are under the age of two or between two and five years of age.

Likewise, under R40.223 (Coma scale, best verbal response, inappropriate words), the manual will add notes such as "Inappropriate crying or screaming (<2 years of age)" and "Screaming (2-5 years of age)."

These types of notes will continue throughout the R40.236 (Coma scale, best motor response, obeys commands) section of ICD-10 to guide physicians in their coma scoring.

Be Ready for Thumb Dislocation Changes: The ICD-10 manual also makes big changes to the subluxation/dislocation codes involving the thumb, deleting two categories that include over a dozen codes. Everything under categories S63.13 (Subluxation and dislocation of proximal interphalangeal joint of thumb) and S63.14 (Subluxation and dislocation of distal interphalangeal joint of thumb) will be deleted effective Oct. 1.

Know Which Proposals Weren't Adopted

Although several of the ICD-10 additions that stakeholders originally recommended were adopted, some were not. For example, you won't find expanded appendicitis codes among the new listings, nor will you see new notes under the diverticulitis codes, which the American Association for the Surgery of Trauma had requested.

Resource: To read the complete list of ICD-10-CM changes, visit https://www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-CM-and-GEMs.html.