Coding Clinic for CDI: Fourth Quarter 2019 release highlights 2020 code changes

CDI Journal - Volume 14, Issue 1

by Sharme Brodie, RN, CCDS, CCDS-O
As is typical with fourth quarter Coding Clinic releases, this most recent offering mainly contains information about fiscal year (FY) 2020 coding and Official Guidelines for Coding and Reporting changes. By now, most CDI professionals should have reviewed the major changes, which include 273 added codes, 21 deleted codes, and 30 revised codes.

Let’s go ahead and take a look at what the Fourth Quarter 2019 issue of Coding Clinic has to offer in terms of CDI-related information.

Segmental pulmonary embolisms
Over the years, there has been a lot of conversation about the treatment of segmental pulmonary embolisms, whether these patients should be put on anticoagulants, and how long they should remain on them if so. The FY 2020 IPPS final rule added codes I26.93, Single subsegmental pulmonary embolism with acute cor pulmonale, and I26.94, Multiple submental pulmonary emboli without acute cor pulmonale.

According to this issue of Coding Clinic, these changes will “enable important clinical differentiation and will be beneficial for hospital quality measures, as well as for research and evaluation of treatment efficacy.”

Atrial fibrillation
On p. 6, Coding Clinic discusses atrial fibrillation (A-Fib) coding, which in code category I48 was expanded by four codes to include:

  • I48.11, Longstanding persistent atrial fibrillation
  • I48.19, Other persistent atrial fibrillation
  • I48.20, Chronic atrial fibrillation, unspecified
  • I48.21, Permanent atrial fibrillation

Coding Clinic goes on to describe the different types of A-Fib on p. 7, reminding us that chronic persistent A-Fib has no widely accepted clinical definition or meaning and that it is coded to I48.19, Other persistent atrial fibrillation.

Phlebitis and thrombophlebitis
The next topic of conversation is phlebitis and thrombophlebitis. Coding Clinic lists eight additional codes added to code category I80 to capture whether phlebitis or thrombophlebitis involves the peroneal vein or muscular branch veins, and to differentiate proximal from distal.

New codes were also added to identify acute and chronic venous embolism and thrombosis of deep vessels of the distal lower extremities, including the peroneal vein and calf muscular vein.

The calf veins are made up of three paired veins—posterior tibial, peroneal, and anterior tibial—along with two sets of muscular veins, soleal and gastrocnemial. A calf vein thrombosis is a clot affecting deep veins of the calf.

Sixteen codes were added to code category I82, Other venous embolism and thrombosis, which are listed on pp. 9–10 of this edition of Coding Clinic. The new codes will differentiate acute and chronic thrombosis involving deep veins of the proximal lower extremity from acute and chronic thrombosis involving deep veins of the distal lower extremity. Previously, ICD-10-CM did not provide specific codes to capture deep vein thrombosis of the peroneal vein or muscular branch veins; coding professionals were instructed to use to nonspecific codes.

Pressure-induced deep tissue damage
On pp. 10–11, Coding Clinic tells us about the 11 added codes to category L89 to capture pressure-induced deep tissue damage of various sites and align with updates to National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer staging. Prior to this change, deep tissue pressure injuries were coded to unstageable. Changes to the NPUAP pressure ulcer staging were made based on recent clinical literature and expert consensus; however, they resulted in minor inconsistencies with ICD-10-CM. The new codes will help resolve the discrepancy.

CDI professionals should clarify whether the term “deep tissue injury” is described in the setting of trauma to accurately capture the provider’s intent or meaning. If due to trauma, the codes added to the L89 code category would be inappropriate.

Breast lump in overlapping quadrants
On p. 12, we learn that category N63, Unspecified lump in breast, includes two new codes to identify unspecified lumps in the right or left breast that are of overlapping quadrants:

  • N63.15, Unspecified lump in the right breast, overlapping quadrants
  • N63.25, Unspecified lump in the left breast, overlapping quadrants

Providers should be educated to clearly describe the location to include laterality and the appropriate quadrant or quadrants.

Ehlers-Danlos Syndrome (EDS)
Ehlers-Danlos Syndrome (EDS) is a group of inherited disorders that mostly affect the skin, joints, and blood vessels. EDS is a lifelong progressive condition that has a major effect on a person’s life and daily function. The most prevalent and common types of EDS include:

  • Classical (Q79.61): These patients have wounds that split open with little bleeding; the wounds leave scars that widen over time to create “cigarette paper” scars. Typically, these patients have loose skin that sags and wrinkles.
  • Hypermobile (Q79.62): A certain set of criteria must be met for a patient to be diagnosed with EDS. Some common symptoms include joint hypermobility, somewhat elastic (stretchy) skin, easy bruising, and chronic musculoskeletal pain.
  • Vascular EDS (Q79.63; vEDS): Can cause unpredictable tearing (rupture) of blood vessels, leading to internal bleeding and other potential life-threatening complications. It is also associated with an increased risk of organ rupture, including tearing of the intestine and rupture of the uterus during pregnancy. The long-term outlook for vEDS is generally poor. The median life expectancy for people affected by vEDS is 48 years.

There are also codes for EDS unspecified (Q79.60) and for other EDS (Q79.69).

Prader-Willi Syndrome (PWS)
A unique code Q87.11 was created in this year’s IPPS to capture Prader-Willi Syndrome (PWS), a rare complex genetic neurodevelopmental disorder that results in a number of physical, mental, and behavioral problems. Signs and symptoms vary among individuals and may slowly change over time from childhood to adulthood. The new code will hopefully facilitate communication and research related to PWS.

Providers caring for this population, including neurologists, who assign codes as part of their documentation should be educated that there is a new code available.

Cyclical vomiting syndrome
On p. 15, we find that code R11.15, Cyclical vomiting syndrome unrelated to migraine, has been created to identify cases in which a patient has cyclical vomiting that is totally unrelated to a migraine. Cyclical vomiting not otherwise specified (NOS) and persistent vomiting are inclusion terms at code R11.15.

In addition, the titles for codes in subcategory G43.A, Cyclic vomiting, have been revised, and “in migraine” was added to codes G43.A0 and G43.A1. Cyclical vomiting syndrome is described as episodes of severe vomiting that have no noticeable cause. Episodes can last for days or hours and alternate with symptom-free periods. Each episode tends to start at the same time of day, lasts the same length of time, and occurs with the same symptoms and level of intensity. Treatment usually involves medications, including anti-nausea and migraine therapies that may lessen symptoms.

Pyuria (p. 16) is a lab finding of white blood cells (WBC) in the urine and is commonly associated with a urinary tract infection (UTI), but a UTI is not the only reason that WBCs might be present in a person’s urine—kidney stones, tumors, and inflammation could also cause this finding. According to Coding Clinic, when a patient has pyuria without a UTI present, code R82.1, Pyuria, would be assigned. Subcategory R82.8, Abnormal findings on cytological and histological examination of urine, was expanded, and two codes were created to uniquely capture pyuria and other abnormal findings on cytological and histological examination of urine as follows:

  • R82.81, Pyuria
  • R82.89, Other abnormal findings on cytological and histological examination of urine

CDI record reviews should evaluate the need for query to capture a UTI if supported by clinical criteria, including the presence of localized genitourinary symptoms, urinary tract inflammation as demonstrated by pyuria, and a urine culture with an identified urinary pathogen.

Fracture of orbit
On pp. 16–17, Coding Clinic discusses changes made to subcategory S02.1, Fracture of base of skull, and subcategory S02.8, Fractures of other specified skull and facial bones. These new codes were created to provide additional detail on fractures of the orbital roof. The codes also specify the right, left, or unspecified side. These changes to subcategory S02.1 and S02.8 resulted in 60 new codes, including the seventh character extensions. CDI specialists, particularly those working with trauma patients, will need to query to capture the additional level of specificity if it’s not clear in the medical record.

Multiple drug ingestion
A new subcategory (T50.91.-) has been created for poisoning by, adverse effect of, and underdosing of multiple unspecified drugs, medications, and biological substances. A total of 18 codes have been added to better identify and track these episodes of care. Unfortunately, in the past it has been difficult to identify everything a patient may have ingested. CDI professionals should educate providers to identify any and all substances involved to allow for proper code assignment.

Exertional heatstroke
If you live in one of the warmer states like I do, you might appreciate the new codes created to identify heatstroke and sunstroke (T67.01-), exertional heatstroke (T67.02-), and other heatstroke and sunstroke (T67.09-). The hope is that the new codes will improve tracking of these conditions.

One of the questions in this Coding Clinic asks how to code when a patient is admitted with seizures related to heatstroke while playing basketball. The answer is to assign code T67.02XA, Exertional heatstroke, initial encounter, and code R56.9, Unspecified convulsions for the seizures. The instructional note at T67.0 directs the coder to “use additional code(s) to identify any associated complications of the heatstroke.” Lastly, code Y93.67 is assigned for Activity, basketball.

History (of)
On p. 20, Coding Clinic discusses seven new personal history codes. Six of them are for personal history of in-situ neoplasms (Z86.002–Z86.007), and one is for personal history of latent tuberculosis infection (Z86.15). These codes will allow for the reporting of personal history of carcinoma in situ of other additional specific sites that do not have specific codes in ICD-10-CM:

  • Z86.002, Personal history of in-situ neoplasm of other and unspecified genital organs
  • Z86.003, Personal history of in-situ neoplasm of oral cavity, esophagus and stomach 
  • Z86.004, Personal history of in-situ neoplasm of other and unspecified digestive organs 
  • Z86.005, Personal history of in-situ neoplasm of middle ear and respiratory system 
  • Z86.006, Personal history of in-situ neoplasm of melanoma
  • Z86.007, Personal history of in-situ neoplasm of skin

Sepsis and organ dysfunction
“Ask the Editor,” starting on p. 64, once again speaks to the issue of whether there is an assumed relationship between sepsis and any acute organ dysfunction because of the subentry “with” and the advice given in Coding Clinic, Fourth Quarter 2017. This new edition of Coding Clinic answers that “the exception to the ‘with’ guideline which said ‘unless the documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for ‘acute organ dysfunction that is not clearly associated with the sepsis’)” was added for FY 2018. The answer reiterates this Official Guidelines update and confirms the need to acute link organ dysfunction to the sepsis to allow accurate capture of the presence of severe sepsis.

Social determinants
Coding Clinic instructs, “If the patient self-reported information is signed-off and incorporated into the health record by either a clinician or provider, it would be appropriate to assign codes from categories Z55-Z65, describing social determinants of health.” A question asks for a definition of the word “clinician,” and Coding Clinic answers that “The ICD-10-CM Official Guidelines for Coding and Reporting do not have a unique definition of the term ‘clinicians.’ In the context of code assignment for social determinants of health Z codes, documentation deemed meeting the requirements for inclusion in the patient’s official medical record based on regulatory or accreditation requirements or internal hospital policies, could be utilized since the information pertains to social rather than medical information.”

CDI professionals should determine whether social determinants of health represent a record review priority, understand their program’s acceptable definition of “clinician” for the purposes of reporting Z codes, and perform an audit to identify the most common Z scores for the team to review and query on.

Mesenteric vein thrombosis
The last bit of information under “Ask the Editor” answers a question about how a diagnosis of acute ischemia of the ascending colon due to mesenteric vein thrombosis, which is attributed to antithrombin III deficiency, would be coded. The problem seems to be that the Alphabetic Index to Diseases references code I81, Portal vein under Thrombosis, mesenteric, vein. Mesenteric thrombosis is, however, included in the inclusion terms under subcategory K55.0, Acute vascular disorders of intestine.

So, the question asks, how would this mesenteric vein thrombosis be coded? Coding Clinic answers that code K55.039, Acute (reversible) ischemia of large intestine, extent unspecified, should be assigned for the mesenteric vein thrombosis, as the provider did not document focal or diffuse. As of October 1, 2019, the Alphabetic Index has been revised and coding professionals are directed to subcategory K55.0 for a diagnosis of mesenteric thrombosis. The specific code assignment would be based on the provider’s documentation.

Editor’s note: Brodie is a CDI education specialist with HCPro/ACDIS in Middleton, Massachusetts. Contact her at To learn more about our Boot Camps, click here.

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