I D-10 Roundtable 139 - Ciox

ICD-10 Roundtable 139

October 12, 2021

In the news....

Announcement Addition of April 1st Maintenance of the ICD-10-CM and ICD-10-PCS Coding Systems

In the fiscal year 2022 Hospital Inpatient Prospective Payment System final rule published on August 2, 2021, the Centers for Medicare & Medicaid Services (CMS) announced it is adopting an April 1 implementation date for ICD-10-CM and ICD-10-PCS code updates, in addition to the annual October 1 update, beginning with April 1, 2022. This April 1 code update would be in addition to the existing April 1 update under section 1886(d)(5)(k)(vii) of the Act for diagnosis or procedure code revisions needed to describe new technologies and medical services for purposes of the new technology add-on payment process. The April 1 implementation will use a phased-in approach, such that initially, the number and nature of the code updates would be fewer and less comprehensive as compared to the existing October 1 update.

Earlier recognition of diagnoses, conditions, and illnesses as well as procedures, services, and treatments in the claims data would be beneficial for purposes of reporting, data collection, tracking clinical outcomes, claims processing, surveillance, research, policy decisions and data interoperability.

The existing established process for code maintenance will be used, meaning that the codes will be presented at the ICD-10 Coordination and Maintenance Committee meeting with opportunity for public comment. Coding guidelines and coding advice will be updated as needed. Any new ICD-10 code updates finalized for implementation on the following April 1 would be announced in November of the prior year.

CM Guidelines Changes

Please note anything in bold in new for FY 2022

Section 1: Conventions

Laterality When laterality is not documented by the patient's provider, code assignment for the affected side may be based on medical record documentation from other clinicians. If there is conflicting medical record documentation regarding the affected side, the patient's attending provider should be queried for clarification. Codes for "unspecified" side should rarely be used, such as when the documentation in the record is insufficient to determine the affected side and it is not possible to obtain clarification

Documentation by Clinicians Other than the Patient's Provider

Code assignment is based on the documentation by the patient's provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis). There are a few exceptions when, such as codes for the Body Mass Index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes, code assignment may be based on medical record documentation from clinicians who are not the patient's provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis). since this In this context, "clinicians" other than the patient's provider refer to healthcare professionals permitted, based on regulatory or accreditation requirements or internal hospital policies, to document in a patient's official medical record. These exceptions include codes for:

? Body Mass Index (BMI) ? Depth of non-pressure chronic ulcers ? Pressure ulcer stage ? Coma scale ? NIH stroke scale (NIHSS) ? Social determinants of health (SDOH) ? Laterality ? Blood alcohol level This information is typically, or may be, documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale). However, the associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer, or a condition classifiable to category F10, Alcohol related disorders) must be documented by the patient's provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient's attending provider should be queried for clarification.

For social determinants of health, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient's provider since this information represents social information, rather than medical diagnoses.

The BMI, coma scale, NIHSS codes, blood alcohol level and codes for social determinants of health categories Z55-Z65 should only be reported as secondary diagnoses.

See Section I.C.21.c.17 for additional information regarding coding social determinants of health. . . . For social determinants of health, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient's provider since this information represents social information, rather than medical diagnoses. Patient self-reported documentation may also be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the health record by either a clinician or provider.

Section 1.C: Chapter-Specific Coding Guidelines

Chapter

Description

Chapter 1: Certain Infectious and Parasitic Diseases

(d) Asymptomatic human immunodeficiency virus (i) History of HIV managed by medication (g) Signs and symptoms without definitive diagnosis of COVID-19 (l) Multisystem Inflammatory Syndrome (m)Post COVID-19 Condition

Chapter 2: Neoplasms (C00-D49)

s. Breast Implant Associated Anaplastic Large Cell Lymphoma

Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89)

Diabetes mellitus and the use of insulin, oral hypoglycemics, and injectable noninsulin drugs (also applies to secondary diabetes)

Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01 ? F99)

Psychoactive Substance Use, Unspecified Medical Conditions Due to Psychoactive Substance Use, Abuse and Dependence Blood Alcohol Level

Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99)

Unstageable pressure ulcers

Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A)

Final character for trimester

Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

e. Coma 1) Coma Scale

Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00T88)

Burns and corrosions classified according to extent of body surface involved

Chapter 21: Factors influencing health status and contact with health services (Z00Z99)

History (of) Counseling Social Determinants of Health

Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99), U07.1, U09.9

a. Human Immunodeficiency Virus (HIV) Infections

2)Selection and sequencing of HIV codes (d)Asymptomatic human immunodeficiency virus

Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, is to be applied when the patient without any documentation of symptoms is listed as being "HIV positive," "known HIV," "HIV test positive," or similar terminology. Do not use this code if the term "AIDS" or "HIV disease" is used or if the patient is treated for any HIV-related illness or is described as having any condition(s) resulting from his/her HIV positive status; use B20 in these cases

(h)Encounters for testing for HIV Use additional codes for any associated high-risk behavior, if applicable.

(i) History of HIV managed by medication If a patient with documented history of HIV disease is currently managed on antiretroviral medications, assign code B20, Human immunodeficiency virus [HIV] disease. Code Z79.899, Other long term (current) drug therapy, may be assigned as an additional code to identify the long-term (current) use of antiretroviral medications

Related Coding clinics Anemia admission with history of HIV, correct reporting

ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2020 Page: 97 Effective with discharges: October 2, 2020

Question: A 68-year-old male was admitted due to anemia. The patient also has a past medical history of HIV disease, currently on antiretrovirals (ARVs). The patient had a history of CD4 count less than 200 with a current CD4 of 335. The provider's diagnostic statement listed, "HIV disease on ARVs (CD4 335, VL undetectable)" as a secondary diagnosis. What is the appropriate HIV code for this patient?

Answer: Assign code B20, Human immunodeficiency virus [HIV] disease, for this patient. The provider documented HIV disease, which is specifically classified to code B20. As with any other condition, query the provider for clarification when there is conflicting documentation.

Influenza admission with history of HIV, correct reporting ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2020 Page: 97,98 Effective with discharges:

October 1, 2020

Question: A 55-year-old with a personal history of end-stage renal disease (ESRD) and long-standing history of HIV disease presented due to influenza. The provider documented HIV disease on current treatment with a CD4 level over 1,000 and an undetectable viral load. What is the appropriate HIV code for this patient?

Answer: Assign code B20, Human immunodeficiency virus [HIV] disease, for this patient. Provider documentation indicated HIV disease, which is specifically classified to code B20. As with any other condition, query the provider for clarification when there is conflicting documentation.

Cryptococcal meningitis in HIV positive patient ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2019 Pages: 9-10 Effective with discharges: March

20, 2019 Related Information

Question:

Current literature states that cryptococcal meningitis is a major HIV-related infection. When a patient who is HIV positive presents due to this condition, is it appropriate to assume a linkage between the HIV and the meningitis and assign code B20, Human immunodeficiency virus [HIV] disease? How should HIV be coded in a patient with cryptococcal meningitis?

Answer:

The ICD-10-CM classification does not assume a relationship between cryptococcal meningitis and HIV. Therefore, do not assume that cryptococcal meningitis is an HIV-related infection without provider documentation linking the two conditions. If the medical record documentation does not indicate AIDS, HIV-related infection or other similar terminology indicating the patient has AIDS, it is not appropriate to assign code B20, Human immunodeficiency virus [HIV] disease.

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