ACDIS tip: Highlights from AHA Coding Clinic, first quarter 2023

by Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC

The beginning of March brought us the release of the first quarter 2023 Coding Clinic. This release is short (only 39 pages) and brought forth little in surprises. That is a good thing!

The release starts with the announcement about the termination of the COVID-19 public health emergency in May of this year. It forecasts a change in reporting guidelines to go into effect in fiscal year (FY) 2024. Code Z11.52, Encounter for screening for COVID-19, will then be assigned for all encounters for screening for COVID-19 infection. The present Guidelines instruct us that “During the pandemic, a screening code is generally not appropriate. Do not assign code Z11.52, Encounter for screening for COVID-19.” For encounters for testing, we are to report as exposure to COVID-19.

This release also reminds us that new Guidelines will go into effect on April 1, 2023, and 42 new diagnoses codes will be added. The new Guidelines can be accessed at CMS.gov here.

The Guidelines demonstrate a few changes in the chapter specific guidance related to social determinants of health (SDOH). We are to assign SDOH codes to describe social problems, conditions, or risk factors documented during the current episode of care.

An example was offered as to when such codes should be applied. We would not assign Z60.2, Problems related to living alone, merely due to the fact a patient lives alone. This code would be assigned if the documentation indicated the problems related to living alone, such as inability to perform routine activities of daily living.

New codes described as health-related social needs (HRSN) were added to the T74 code grouping classifying adult and child abuse. These codes identify both confirmed and suspected adult and child financial abuse. They include a seventh character extension clarifying if the encounter was related to an initial, subsequent episode, or addressing a related sequela.

The Y07.0 code category classifying spouse or partner, perpetrator of maltreatment and neglect, has been expanded, allowing for capture of increased specificity of the perpetrator.

New codes were added related to problems of the physical environment, inadequate housing, personal history of abuse in childhood, and illiteracy.

The Z91.1 code grouping related to noncompliance with medical treatment has been expanded, adding four codes describing noncompliance with medications regimen and dialysis. These codes specify if the noncompliance was due to a financial reason or other issue.

The expansion of the codes described above is an effort to increase the collection of reliable data to both quantify the prevalence of such social challenges in our patient populations and to identify how such issues impact an individual’s healthcare needs, resource consumption, and risk profiles.

Thirty-four new ICD-10-PCS codes were added as well, these are related to the addition of an open approach when reporting a temporary open balloon occlusion of the descending thoracic and abdominal aortas. New codes were also added to allow reporting of laser interstitial thermal therapy (LITT) of the cervical and thoracic vertebrae.

We are now able to report intraosseous administration of blood products, with the addition of bone marrow to the body systems/region in table 302, Transfusion of the circulatory body system, and 302A3H1, Transfusion of nonautologus whole blood into bone marrow, percutaneous approach.

The question-and-answer section of the Coding Clinic was not extensive. A number of questions were related to sequencing. Two questions were related to sequencing of a GI bleed and associated etiologies. The first describes a situation in which a patient is admitted with acute blood loss anemia (ABLA) due to a GI bleed. Transfusion and EGD were performed with no further interventions, as a non-bleeding gastric ulcer was noted. The guidance stated that it would be appropriate to sequence either the anemia or the GI bleeding as the principal diagnosis. They were both present on admission. Section II.B of the Guidelines was cited:

When there are two or more interrelated conditions (such as disease in the same ICD-10-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.

The second example describes a slightly different scenario. A patient with ABLA was admitted to rule out a GI bleed. Treatment included transfusion and EGD, which revealed bleeding from a duodenal angioectasia and an acute gastric ulcer. Cauterization was performed. The instruction stated that since the primary focus of the admission was to diagnose and treat the bleeding conditions, either the gastric ulcer or the angiodysplasia of the duodenum could be sequenced first.

When present, the staging of chronic kidney disease is a focus of most CDI reviewers. A question describes a nephrologist’s documentation of chronic kidney disease (CKD) G4A3, and asks if this description is sufficient to assign a code for stage four CKD. The answer was to assign N18.4, CKD, stage 4 for a diagnosis of CKD G4A3. The CGA categorization of CKD describes the cause, the glomerular filtration rate, and the extent of albuminuria present. The staging of CKD is based on the glomerular filtration rate.

The Guidelines, section 1.C.2.c.1 speaks to sequencing of anemia when associated with a malignancy. It states, “When the admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for the anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by the appropriate code for the anemia.”  This Coding Clinic guidance reinforces this direction and also confirms that it only pertains to anemia, not the presence and treatment of pancytopenia.

Sequencing guidance was also provided for an encounter in which an end-stage renal disease (ESRD) patient presents in fluid overload, requiring emergent dialysis. The instruction states we are to first sequence the E87.70, code classifying fluid overload, to be followed by the code for ESRD. The guidance clarified that fluid overload is not inherent to ESRD, it is a distinct problem and complication of the kidney disease.

The reporting of “uncertain diagnoses” differs depending upon the setting. An example in the inpatient setting of discharge documentation stating, “Liver mass possibly hepatic cholangiocarcinoma, pending pathology” should be reported with C22.1, Intrahepatic bile duct carcinoma. Citing the Official Guidelines for Coding and Reporting, Section II.H related to the reporting of uncertain diagnoses in the inpatient setting, the Coding Clinic reinforced that this guideline does not make a distinction based upon the type of disease, such as malignancy or other conditions. Many organizations are hesitant to report a malignancy without formal confirmation. This guidance reinforces that indeed it should be reported.

There is also guidance differentiating aftercare Z codes and the seventh character extensions describing a subsequent encounter in injury codes. The Z codes should not be used for aftercare of injuries, the appropriate acute injury code is used with the specification provided by the seventh character extension.

I have only offered you a summary, but there is additional guidance related to PCS coding, the reporting of malignancies, and maggot therapy that you might wish to explore. I always suggest reading through the release in its entirety. You never know what treasures you will find. 

Editor’s note: Prescott is the interim director for ACDIS and director of CDI education for HCPro, based in Middleton, Massachusetts. Contact her at lprescott@acdis.org.