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OASIS Alert

ICD-9 Coding:

Keep Manifestations in Order or Risk Coding Accuracy

Published on Wed May 02, 2012

Know these index cues to find the right manifestation code.

An update to the Home Health Prospective Payment System (HH PPS) Grouper eliminated data validity flags on the etiology/manifestation pairs you list in M1020/M1022, but that doesn't mean there's been a change in the coding guidelines.

A Centers for Medicare & Medicaid spokesperson announced the removal of data validity flags on etiology/manifestation pairs during the Jan. 11 Home Health and Hospice Open Door Forum. The change to the grouper allows points to be captured as long as the manifestation is coded anywhere under the etiology code.

Home health coders were confused and upset by this change, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas. CMS said that the manifestation did not have to be coded directly after the etiology, but the spokesperson was not speaking about the coding guidelines -- this change concerns only the grouper and data validity flags, she explains.

Bottom line: "CMS is not overriding the coding guidelines and making a new rule just for us!" Selman-Holman says.

Follow These Manifestation Coding Guidelines

The guidelines are clear, Selman-Holman says. The ICD-9-CM Official Guidelines for Coding & Reporting advises "Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-9-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a 'use additional code' note at the etiology code, and a 'code first' note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation."

Plus, Appendix D section 6 (December 2011) of the OASIS-C Guidance Manual from CMS says "Criteria associated with etiology/manifestation pairs coding are listed below:

The etiology code is the underlying disease and must be sequenced first, before the code for a related manifestation. When a diagnosis is under consideration as an etiology diagnosis, the HHA is expected to ensure that a valid manifestation code is sequenced immediately following the assignment of the etiology code."

Know How to Spot a Manifestation

In addition to "use additional code" and "code first" notes in the tabular list of your ICD-9 manual, you'll see a specific structure in the alphabetic index for etiology/manifestation pairs. Here, both conditions are listed together with the etiology code first, followed by the manifestation codes in brackets. "The code in brackets is always to be sequenced second," the guidelines state.

Coding example: Mr. E. is being treated for Lyme disease caused by a deer tick bite. He is experiencing pain and immobility in his knee. Upon consultation with an orthopedic surgeon, he was diagnosed with arthritis of knee which is common with Lyme disease. For this patient, list the following etiology/manifestation pair, says Joan L. Usher, BS, RHIA, COS-C, ACE, president, of JLU Health Record Systems in Pembroke, Mass.:

Etiology: 088.81 (Lyme disease)

Manifestation: 711.86 (Arthropathy associated with other infectious and parasitic diseases; lower leg).

When you look up "arthritis, due to or associated with Lyme disease" in the alphabetic index, you'll see "088.81 [711.8]." Checking these codes against the tabular list, you'll see the note "Code first underlying disease as: diseases classified to 080-088, 100-104, 130-136" following 711.8. You'll also see that this code requires a fifth digit to indicate the location of the arthritis.

There are also manifestation codes that appear in the alphabetic index but do not follow the usual format, Usher says. When you locate these etiology codes, you won't find them beside a corresponding manifestation in italic print.

Instead, look up the manifestation and then look for words such as "due to," "with," "associated with," or "in" to find the right code. For example, "Arthritis Due to or Associated With."

Watch Out for Multiple Manifestations

When a disease process has multiple manifestations, you'll need to code for all the manifestations separately, Usher says. This is especially true when coding for patients with diabetic manifestations.

The fourth digit of the diabetes code identifies whether there is a manifestation present. So, for a diabetic patient with multiple manifestations, you'll need to code diabetes multiple times. Each diabetes code will begin with 250 but the fourth digit will change with the manifestation, Usher says.

Constant: The fifth digit which identifies the type of diabetes will be the same for all the patient's diabetic codes.

Coding Example: Your 79-year-old patient has uncontrolled diabetes type I. She is legally blind, has diabetic retinopathy, and peripheral angiopathy due to diabetes. The skilled nursing services include daily wound care to the chronic diabetic ulcer on the right heel; administering insulin every day, fingerstick every week and when needed to check for signs and symptoms of hypo/hyperglycemia; and teaching diabetic foot care regimen. To code for this patient, list the following codes, Usher says:
  • M1020a: 250.83 (Diabetes with other specified manifestations, type I [juvenile type], uncontrolled);
  • M1022b: 707.14 (Ulcer of lower limbs, except pressure ulcer, heel and midfoot);
  • M1022c: 250.73 (Diabetes with peripheral circulatory disorders, type I [juvenile type], uncontrolled);
  • M1022d: 443.81 (Peripheral angiopathy in disease classified elsewhere);
  • M1022e: 250.53 (Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled);
  • M1022f: 362.01 (Background Diabetic Retinopathy); and
  • Other pertinent diagnoses: 369.4 (Legal blindness as defined in U.S.A).

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