Primary Care Coding Alert

This year’s diagnosis code revisions won’t hurt a bit.

The good news about this year’s ICD-10-CM tabular addenda, which highlights changes to the 2020 code set, is that the changes are manageable. “The 2020 Tabular Addenda is only 36 pages, some of which are mostly blank,” notes Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC.

All told, there are seven deleted codes, 328 new subcategories and codes, and 35 revised subcategories and codes. Fortunately, “there are lots of cleanup changes among these. Some are corrections from parentheses, for supplementary words, to square brackets, and for manifestations. Still others are propagation of edits and additions into corresponding advice statements. So, don’t be concerned by the overall number of changes,” says Blanchard.

Even so, there are many revisions that could well affect your coding when they take effect on October 1, 2019. Here are some of the most significant.

Pressure Ulcer Codes Receive New Classification …

ICD-10-CM has made some changes to the L89.- (Pressure ulcer) codes, adding a new classification of pressure injuries: deep tissue damage. This category of injury is different from the ICD-10-CM stage classifications that are currently in use in that it occurs in the deep tissue beneath the skin without an open wound being present.

However, reporting deep tissue pressure damage is easy once you understand the current system of otherwise classifying pressure ulcers. Simply use the appropriate code for the anatomical site, and instead of using one of the existing sixth digits to document an unstageable (0), stage 1 (1), stage 2 (2), stage 3 (3), stage 4 (4), or unspecified (9) pressure ulcer, you will now have the option to use a new sixth digit, 6, to indicate pressure-induced deep tissue damage.

So, to report pressure that has caused deep tissue damage of the left heel, you will report L89.626 (Pressure-induced deep tissue damage of left heel) — starting October 1.

… While Injury Codes Receive Numerous Additions …

Beginning October 1, you’ll also be able to choose several new S02.- (Fracture of skull and facial bones) codes. For example, you will be able to use S02.83- (Fracture of medial orbital wall) and S02.84- (Fracture of lateral orbital wall) along with a new unspecified code, S02.85 (Fracture of orbit, unspecified). “All primary care practices should take a look at all of the revisions and additions to the skull fractures,” notes Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. “While they might not be documenting a lot of these, coders will want to be certain they understand these additions and changes,” Holle adds.  

In addition, ICD-10-CM has introduced new heatstroke codes, expanding heatstroke (T67.0) to three new codes — T67.01 (Heatstroke and sunstroke), T67.02 (Exertional heatstroke), and T67.09 (Other heatstroke and sunstroke). You will still need to add a seventh character to denote an initial encounter (A), subsequent encounter (D), or sequela (S). Thus, an initial encounter for exertional heatstroke would be coded as T67.02XA.

… As Do the Encounter Codes

You will also have some new choices in the Z01.0 (Encounter for examination of eyes and vision) category. ICD-10-CM has introduced separate codes to document an encounter for examination of eyes and vision following a failed vision screening without abnormal findings (Z01.020) and with abnormal finding (Z01.021). Like the current codes, there is also a note that tells you to use an additional code if you do document Z01.021 to specify what those abnormal findings are.

“Practices will need to be certain to add these codes, as they are different from the existing Z01.00 [Encounter for examination of eyes and vision without abnormal findings] and Z01.01 [… with abnormal findings] codes,” says Holle. “The new six-digit codes state that the encounter was specifically for an encounter following a failed vision screening, with or without abnormal findings. These will be very important to use correctly,” Holle cautions.

You’ll also find three new codes that will now enable you to document when a patient with latent, as opposed to active, tuberculosis has encountered health services. ICD-10-CM has added Z11.7 (Encounter for testing for latent tuberculosis infection) to distinguish the encounter from Z11.1 (Encounter for screening for respiratory tuberculosis), which will be accompanied with a note that specifies the code is to be used for patients being screened for the active form of the condition.

You should also take note of Z22.7 (Latent tuberculosis) to identify a patient who is a carrier of the disease. The new code also comes with an Excludes1 note that specifies you cannot use it in conjunction with R76.11 (Nonspecific reaction to tuberculin skin test without active tuberculosis) or R76.12 (Nonspecific reaction to cell mediated immunity measurement of gamma interferon antigen response without active tuberculosis).

And you will also be able to use Z86.15 (Personal history of latent tuberculosis infection) if that is what the patient’s medical history indicates.

Lastly, there is a small but very significant change to the notes for the Z68 (Body mass index [BMI]) codes. ICD-10-CM has now changed the age parameters for both the pediatric and adult BMI codes, with the upper cutoff for the pediatric codes being lowered from 20 years of age to 19, and the corresponding lower cutoff for the adult codes being lowered from 21 years to 20.

Quite why ICD-10-CM has instituted these changes remains a mystery. “I can’t find any rationale for this change,” says Blanchard.

“Coders and billers have to realize that sometimes the changes just don’t make sense!” adds Holle.  

The Last Word

“I encourage coders to get in there and review these changes personally. No one knows your practice like you do, so you should look through the addenda for those special items you alone will notice,” advises Blanchard.

You can review the revisions yourself by going to www.cms.gov/Medicare/Coding/ICD10/2020-ICD-10-CM.html and downloading the zip file labeled 2020 Addenda.