MDS Alert

How coding of aftercare and ‘late effects’ will change drastically.

Ready or not, here comes ICD-10 — your facility must begin using ICD-10 codes on Oct. 1, 2015, or you’ll suffer denied claims and rejected MDS records. Here’s what you need to know to make sure you’re prepared for the big diagnoses-coding conversion.

Brace Yourself for More Complicated Coding

The biggest differences between ICD-9-CM codes and ICD-10-CM is that the new codes contain expanded detail and far more specificity, according to a recent Centers for Medicare & Medicaid Services (CMS) tutorial by Sue Bowman, MJ, RHIA, CCS, FAHIMA, senior director of coding policy and compliance for the American Health Information Management Association (AHIMA). The concept of laterality (relating to the actual “side” that the injury or pressure ulcer is located) has been added to some chapters.

“The use of combination codes has been expanded, such as the creation of combination codes for certain conditions and their associated common symptoms or manifestations, or combination codes for poisonings and the associated external cause,” Bowman said.

And because ICD-10 codes are more abundant and more specific than ICD-9 codes, they are also longer. ICD-10 codes are up to seven characters long and are alphanumeric. ICD-10 codes have three characters before the decimal, with the first character always alpha, and up to four characters after the decimal.

The new seventh character “has a different meaning depending on the section where it is being used,” Bowman noted. “It must always be used in the seventh character position, and when a seventh character applies, codes that are missing this character are considered invalid.” 

In some cases, for instance, you may need to use the seventh character in a code to identify the type of encounter (initial, subsequent, or sequelae), Bowman said. “Encounters for therapy, such as physical and occupational therapy, are examples of the use of the subsequent encounter seventh character.”

Pay attention: For nursing facilities, “ICD-10 will eliminate a vast majority of common coding practices currently utilized, including the utilization of the V-code to identify encounters for therapy, the 18 aftercare codes for fractures, the ‘late effects’ codes, and the hypertension table,” noted Kris Mastrangelo, president and CEO of Harmony Healthcare International in a recent company blog posting. “It will add the ‘X’ placeholder and change the timeframe in the reporting for a myocardial infarct.”

V Codes are Now Z Codes

“ICD-10 eliminates the use of the [therapy] V codes due to the fact that they provide no clinical information about the patient other than the fact that therapy services are being provided,” Mastrangelo explained. “ICD-10 will require much more specificity related to the medical condition resulting in the need for the therapy encounter.” 

Under ICD-10, you’ll report V-code services under a new set of codes — Z codes, wrote Karen Kostick, RHT, CCS, CCS-P in a recent Journal of AHIMA article. And beware that, unlike other ICD-10 codes that have three to seven characters, Z code categories Z00 through Z99 consist of three to six characters. 

Important: Pay special attention to the aftercare codes, which identify specific types of continuing care after the initial treatment of an injury or disease. You cannot use ICD-10’s Z codes — specifically, the orthopedic aftercare visit codes — if treatment is directed at the injury, Kostick warned. “Coding guidelines state that a fracture code from the main classification can be used only for an initial encounter.” 

SNFs “will no longer use aftercare codes when coding fractures, but instead will utilize the specific acute fracture code followed by the appropriate seventh digit extension to indicate a Subsequent Episode of Care,” Mastrangelo instructed. “For therapy delivery, the specific medical diagnosis should be coded in combination with any applicable treatment diagnosis.”

‘Late Effects’ Codes Replaced with I69 Category

Also under ICD-10, the sequelae codes utilizing the I69 category will replace the “late effects” codes, such as the late effects of cerebrovascular disease (CVA) “previously coded under ICD-9 in the 438.XX category,” according to Mastrangelo. “Under ICD-9 coding, the late effects category included neurological deficits that persisted after the initial onset of conditions.”

Under ICD-10, however, your documentation should “clearly indicate whether the neurologic deficits were present from the onset or were identified at any time after the onset of the primary neurological condition,” Mastrangelo said. In some cases, you may need to also include an additional code to identify the type of sequelae when coding the sequelae of cerebrovascular disease. 

Example: For dysphagia following a CVA, you would code the appropriate I69 code with an additional code included from R13.19 to identify the specific type of dysphagia, Mastrangelo illustrated.

Take ‘GEMs’ with a Grain of Salt

CMS, AHIMA and other industry organizations joined together to develop General Equivalence Mappings (GEMs) to help providers understand how ICD-9 codes relate to the new ICD-10 codes and code categories.

Downside: “Unfortunately, there are no perfect crosswalks to convert from ICD-9 to ICD-10,” Mastrangelo pointed out. “GEMs provide plausible conversions, not equivalent conversions. GEMs do not provide an exact match and in most cases translation may require the selection of the best alternative code from among all plausible coding options.”

When you’re “forward-mapping” from ICD-9 to ICD-10, expect only about 5 percent of all codes to accurately map one-to-one. Mastrangelo provided the following forward-mapping scenario:

Old way: When coding pressure ulcers under ICD-9, you have nine possible coding options that identify the location but not the stage (707.00 – 707.99). To identify the stage, you would use a second code from the 707.20 through 707.25 series.

New way: Under ICD-10, there are 125 possible coding options for pressure ulcers (L89.00–L89.95). You will use one ICD-10 code to provide all pertinent information related to the pressure ulcer’s depth, severity and occurrence.

Resources: You can find a treasure trove of ICD-10 resources at www.roadto10.org, a website that CMS has created specifically for ICD-10 transition-related training, tools, and information.