Complications’ twist: ICD-10 codes that act as their own CC or MCC
July 16, 2014
CDI Blog - Volume 7, Issue 10
A diabetic patient is admitted with gangrene. The physician does not specifically link the diabetes and the gangrene, but alsodoes not document any other potential cause of the gangrene. Should you code both conditions?
In ICD-9-CM, coders can assume a cause-and-effect relationship between the diabetes and the gangrene as long as the physician does not document any other causes of the gangrene (Coding Clinic, First Quarter 2004, pp. 14-15).
That guidance allows coders to report the gangrene, which is a CC, even if the physician does not state that the gangrene is due to diabetes. "Physicians are not always good at documenting cause-and-effect relationships," says Jennifer Avery, CCS, CPC-H, CPC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, senior coding instructor for HCPro, a division of BLR, in Danvers, Massachusetts.
Coders cannot report the combination codes for diabetes and a complication, such as osteomyelitis, gangrene, or renal failure, unless the physician specifically documents the relationship between the diabetes and the condition, adds Christina Benjamin, RHIA, CCS, CCS-P, an independent coding and education consultant in Jesup, Georgia. Per Coding Clinic, Third Quarter 2008, p. 5, the phrase "diabetes with [a certain condition]" satisfies this requirement.
Combination codes
In ICD-9-CM, coders need two codes to describe the patient's condition: 250.7x (diabetes with peripheral circulatory disorders) and 785.4 (gangrene). In ICD-9-CM, the gangrene is a CC.
In ICD-10-CM, coders will only need one code: E11.52 (Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene). Because it's a combination code in ICD-10-CM, facilities would lose the CC. So ICD-10-CM includes a new wrinkle—codes that act as their own CC or MCC. E11.52 is one of those codes.
"For the most part, this shouldn't impact coders at all as long as the documentation is appropriate for them to report the combination code," Avery says.
Gangrene is still a CC, but in order to report the combination code in ICD-10-CM, the physician must establish the cause-and-effect relationship, she says.
If the physician does not link the diabetes and the gangrene, coders would report two ICD-10-CM codes: one for the diabetes (categories E10-E11) and one for the gangrene (code I96). Gangrene is still a CC even without the link.
"Regardless of whether we get the cause-and-effect relationship, we'll still get credit for the CC," Avery says.
From a CDI perspective, people are going to have to go back and question what they are doing, Avery notes. In ICD-9-CM, coders and CDI specialists did not have to query the physician for the relationship between the gangrene and the diabetes--they could assume the two conditions were related. In ICD-10-CM, physicians will need to document the relationship in order for coders to report the combination code.
Although gangrene would still be a CC without the physician documenting the cause-and-effect, facilities could still see a potential change in MS-DRG assignment.
If the patient is admitted for gangrene and the diabetes isn't linked, diabetes becomes the secondary condition, Avery says. "Potentially, you could lose your CC."
Codes as their own MCC
A total of 244 ICD-10-CM codes serve as their own CC, while an additional 82 codes work as their own MCC when reported as a principal diagnosis. Of those codes, 50 fall in the L89.- series (pressure ulcer). This category also includes:
- Bed sore
- Decubitus ulcer
- Plaster ulcer
- Pressure area
- Pressure sore
In ICD-9-CM, a wound care nurse can document the stage of the ulcer, but the physician must document the site and the type, says William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Florida. The same holds true in ICD-10-CM.
"If the wound care nurse does not document the stage, but rather describes the stage and that description is similar to the inclusion term in the tabular part of the code book, then you can report that stage without the wound care nurse actually saying the stage," Haik says.
In ICD-9-CM, coders need two codes to report the location and stage of the ulcer. For example, if a patient has a stage 4 pressure ulcer of the hip, coders would report 404.04 (pressure ulcer of the hip) and 707.24 (pressure ulcer stage 4).
The stage code is an MCC. An instructional note under category 707.0x (pressure ulcer) reminds coders to use an additional code to identify the pressure ulcer stage.
Coders also need to report whether the pressure ulcer is present on admission (POA) or is a hospital-acquired condition. If the ulcer is not POA, then it is not an MCC, Haik says.
Coders should also code to the highest level of evolution of a decubitus ulcer if it's POA, he adds. If a patient comes in with a stage 1 pressure ulcer (not a CC or MCC) and it evolves to a stage 3 pressure ulcer, report the code for a stage 3 ulcer (which is an MCC).
In ICD-10-CM, coders will only need one code to report both the location and stage of the ulcer, Avery says. For a stage 4 pressure ulcer of the hip, coders have three choices:
- L89.204, pressure ulcer of unspecified hip, stage 4
- L89.214, pressure ulcer of right hip, stage 4
- L89.224, pressure ulcer of left hip, stage 4
If the physician or nurse does not stage the ulcer, then coders will default to unspecified stage (ICD-9-CM code 707.20). Each ICD-10-CM category includes a separate code for unspecified stage. For example, coders would report L89.329 for a pressure ulcer of the left buttock, unspecified stage.
Both ICD-9-CM and ICD-10-CM include codes for an unstageable ulcer. In ICD-9-CM, coders would report 707.25. In ICD-10-CM, they would use the code listed for the specific site—for example, L89.320 (pressure ulcer of left buttock, unstageable).
When coders report unspecified stage or unstageable ulcer in both ICD-9-CM and ICD-10-CM, they lose the MCC, Avery says.
Editor’s note: This article was originally published in the May issue of Briefings on Coding Compliance Strategies. Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.
Found in Categories:
Clinical & Coding