ED Coding and Reimbursement Alert

Read on for ED Relevant ICD-10 Tips To Prepare For The Big Transition

Need to jumpstart your ICD-10 coding training, now that the Oct. 1, 2014 implementation date is less than year away? Chances are good you’re looking for help. Use these ICD-10 coding strategies on reporting neoplasms, diseases of the blood and blood-forming organs, and endocrine, nutritional and metabolic diseases (Chapters 2, 3 and 4 of the ICD-10-CM manual), provided by Caral Edelberg, CPC, CMPA, CAC, CCS-P, CHC, an AHIMA Certified ICD-10 Instructor and President, Edelberg and Associates. 

Best practices: As we move closer to implementation of ICD-10, you might want to start parallel coding of common ED problems and begin working through the various code choices depending on the detail provided in your ED provider documentation, says Edelberg.  Many of the ED diagnoses default to non-specific diagnosis codes and this may effect payment.  We won’t know for some time how payers will react to this new coding system with determining medical necessity, so it’s best to work with providers now to educate them on increasing the specificity of diagnoses, she advises.

Primary Site and Behavior Drive Neoplasm Code Choices

ICD-10 Chapter 2, Neoplasms, contains numerous broad groups of neoplasms, whether functionally active or not.  Check the chart documentation to help you determine the primary site and nature if the neoplasm. When functionally active, an additional code from Chapter 4 – Endocrine, Nutritional and Metabolic Diseases E00 – E89, can be used to identify the activity associated with the neoplasm.  The morphology contained in Chapter 2 classifies neoplasms primarily by site, with groupings for behavior, malignant, in situ, benign, etc.  Two key points to remember are that primary malignant neoplasms that overlap site boundaries are classified as overlapping lesions and that malignant neoplasm of ectopic tissue is coded to the site/location of the tissue. If a malignancy results in dehydration, and the dehydration is being managed in the ED, the admission/encounter is considered management of dehydration due to malignancy, says Edelberg. 

What to document: ED providers need to document dehydration when applicable to avoid the less specific codes involving NEC (Not elsewhere classified) descriptors.  When sequencing dehydration resulting from malignancy, the dehydration needs to be sequenced first, followed by the code(s) for the malignancy.  If an admission/encounter is for a neoplasm-related pain (G89.3), this should be specified by the ED provider as well. The pain code will be sequenced first if the sole purpose of the encounter is for pain control/pain management, says Edelberg. 

Malignant neoplasms of liver are included in the malignant neoplasm of digestive organs section (C15-C26).  This broader section includes;

• malignant neoplasms of esophagus;
• malignant neoplasm of stomach;
• malignant neoplasm of small intestine, colon, recto-sigmoid junction, rectum anus and anal canal, liver and intrahepatic bile ducts, gallbladder;
• other unspecified part of biliary tract, pancreas;
• other and ill-defined digestive organs. 

Liver neoplasm excludes:

• malignant neoplasm of biliary tract;
• secondary malignant neoplasm of liver and intrahepatic bile duct. 

Common to emergency medicine, coding of alcohol abuse/dependence will require additional codes to identify:

• alcohol related disorders(F10);
• hepatitis B (B16-, B18-0-B18-1); and
• hepatitis C (B17.1-,  B18.2). 

Liver includes liver cell carcinoma, intrahepatic bile duct carcinoma and hepatoblastoma, angiosarcoma of liver.

Common ED Hemorrhage Presentations Require More Specifc Codes Under ICD-10

You must specify hemorrhagic conditions using codes from Chapter 3,  Diseases of the Blood and Blood-forming Organs and Certain Disorders Involving the Immune Mechanism, includes codes from D50-D89.  D69. This chapter includes conditions common to the emergency department and associated with puerperal and other hemorrhagic conditions. 

Watch for terminology as ICD-10 includes under purpura and other hemorrhagic conditions like allergic purpura, qualitative platelet defects, other nonthrombocytopenic purpura, immune thrombocytopenic; purpura, other primary thrombocytopenia, secondary thrombocytopenia to include post-transfusion purpura, warns Edelberg.

Example:

C22.0 liver cell carcinomaD69.6 Thrombocytopenia, unspecified

Don’t Forget to Follow Up Active Neoplasm Codes With A Chapter 4 Diagnosis

Chapter 4.  Endocrine, Nutritional and Metabolic Diseases (E00-E89) does not contain neoplasms classified in Chapter 2.  Rather, codes in this chapter are used as additional codes to indicate either functional activity by neoplasms and ectopic endocrine tissue or hyperfunction and hypofunction of endocrine glands associated with neoplasms and other conditions classified elsewhere Edelberg explains.

What to look for: Conditions common to emergency medicine contained in this section are diabetes mellitus with additional classifications for disorders of glucose regulation and pancreatic internal secretions, disorders of other endocrine glands, malnutrition, other nutritional deficiencies, overweight, obesity and other hyperalimentation and metabolic disorders.

How to code: For diabetes mellitus, code first the underlying condition then use additional codes to identify any insulin use. For example, Type 1 diabetes with other specified complication (E11.69).  For Type 2 diabetes mellitus with left heel and mid foot ulcer (E11.621) limited to breakdown of skin,  the location of the foot ulcer would be required (L97.421).  The numerous listings in this section often require special attention to additional conditions.  Laterality is generally included in the code set as well, Edelberg adds.

If the physician states “chronic kidney disease” as a complication, it will be necessary to identify the stage of chronic disease:

• stage 1 – (N18.1)
• stage 2 – mild (N18.2)
• stage 3 – moderate  (N18.3)
• stage 4 -  severe (N18.4)
• stage 5 – N18.5

Don’t Get An Ulcer Over Underlying Conditions

When an underlying condition exists, such as a foot ulcer, remind ED providers to identify site, e.g. ankle, heel, mid-foot, calf, thigh, or other part of foot. 

Also identify the ulcer type e.g., limited to breakdown of skin, with fat layer exposed, with necrosis of muscle, with necrosis of bone or unspecified severity. 

As always, medical necessity for emergency department treatment requires as much detail as possible.  Encourage providers to provide detailed information about wounds of any kind, Edelberg warns.

Types of ulcers include: 

Pressure ulcers include bed sores, decubitus ulcers, pressure areas and pressure sores.  

Non-pressure include examples such as:  chronic ulcers of skin NOS (not otherwise specified), non-healing ulcer of skin, non-infected sinus of skin, and  trophic ulcer NOS

If the complication is a drug or chemically induced, code first the drug or chemical and use an additional code to identify insulin use.  If complication stems from drug or chemical induced diabetes, use an additional code to identify the complication.

Get Control Of Your Diabetes Coding

When coding for the diagnosis of diabetes, we no longer classify it as controlled or uncontrolled, says Edelberg.  We are able to code diabetes mellitus with hyperglycemia when it is associated with the following statements;

- Out of control

- Inadequately controlled

- Poorly controlled