FY 2019 ICD-10-CM updates: Returning to the norm (or somewhat)

By Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS

As I sat down to summarize the proposed fiscal year (FY) 2019 ICD-10-CM update, the number of changes are significantly less than the prior two years which makes me think we’re getting back to the norm of expected yearly changes. For the past two years, the amount of additions and revisions were fairly extensive. Although, we are still awaiting the final rule, which should be published in early august, this summary can give you a good idea of what will likely be added to the ICD-10-CM code set.

Here’s what the updates look like as far as numbers go:

• Total changes: 473
  
  • New codes: 279
  • Revised codes: 143
  • Invalidated codes: 51

One downgrade and one upgrade in status

There were many codes added to the CC/MCC lists with the addition of new or revised codes for FY 2019, but there were also a couple of notable changes in “status.”

First, B20, Human immunodeficiency virus (HIV) disease, was downgraded from a major complication/comorbidity (MCC) to a complication/comorbidity (CC) for FY 2019. While this proposal could imply that HIV hospital resource use has lessened since HIV symptoms are better controlled by medications than in the past, it does not mean that diagnosing and coding for HIV has lessened in complexity.

As stated in the FY 2019 IPPS proposed rule, “the data did not strongly suggest that the categorization of HIV as an MCC was inaccurate, our clinical advisors indicated that, for many patients with HIV disease, symptoms are well controlled by medications.” Typically, if a patient has a HIV complicating diagnosis such as pneumocystis pneumonia (B59) or Kaposi’s sarcoma (C46.-), those diagnoses can serve as the MCC or CC condition.

For correct MS-DRG assignment, sequencing for HIV patients is vital. In the MS-DRG classification system, MDC 25 is dedicated to principal diagnoses involving HIV. The MS-DRGs are classified to the following:

• MS-DRGs 969-970, HIV with an Extensive OR Procedure with MCC/without MCC
• MS-DRGs 974-976, HIV with Major Related Condition with MCC/with CC/without MCC/CC
• MS-DRG 977, HIV with or without Other Related Condition

If a patient is admitted for an HIV-related condition, the principal diagnosis should be B20 followed by additional diagnosis codes for all reported HIV-related conditions. The conditions listed under MS-DRG 974 are major HIV-related conditions, therefore, the combination of any of those diagnoses with the principal diagnosis of B20 will be assigned to MS-DRGs 974-976 (unless an extensive OR procedure is coded). If the conditions are not classified as a “major” related condition, the discharge will be assigned to MS-DRG 977.

If a patient is admitted for a non-HIV related condition (e.g. I50.9, Congestive heart failure), the code for the unrelated condition should be assigned as the principal diagnosis. Other diagnoses would be B20 followed by additional diagnosis codes for all reported HIV-related conditions, if applicable. These admissions will likely be the ones that see the most impact in the downgrade from MCC to CC status.

For reporting purposes, only confirmed cases of HIV should be coded. This includes all types of settings, inpatient and outpatient reporting. The provider documentation that the patient is HIV positive is sufficient even in the absence of positive serology.

The other proposed change in status was the elevation of J80, Acute respiratory distress syndrome, to a MCC from a CC status. Per the IPPS proposed rule, “the data suggest that the resources involved in caring for a patient with this condition are 77% greater than expected when the patient has either no other secondary diagnosis present, or all the other secondary diagnoses present are non-CCs.” Based on studying clinical and claims data, the advisors agree the resources required to care for this condition equal that to a MCC condition.

Mental, behavioral, and neurodevelopmental disorders

According to the American Addiction Centers, marijuana is not as physically addictive as drugs like heroin, alcohol, and benzodiazepines. These other drugs have a high potential for the development of both abuse and physical dependence, whereas the level of physical dependence associated with even chronic marijuana usage is comparatively mild. With the most recent release of the Diagnostic and Statistical Manuals of Mental Disorders (DSM-5), the American Psychiatric Association included diagnostic criteria for cannabis withdrawal.

The symptoms appear within one week after the individual stops smoking marijuana and may include:

• Feelings of anger, irritability, and/or aggressiveness
• Sensations of extreme nervousness or anxiety
• Disturbances with sleep that can include insomnia or very disturbing dreams and even nightmares
• A decrease in appetite that may or may not be associated with a significant loss of weight
• Feelings of restlessness and general malaise
• The onset of feelings of depression

The two new ICD-10-CM codes are:

• F12.23 – Cannabis dependence with withdrawal
• F12.93 – Cannabis use with withdrawal

Interestingly, these two new “with withdrawal” codes are not considered CCs, whereas almost all other substance dependence categories are classified in such a manner.

Pregnancy, childbirth, and the puerperium

There were a number of codes proposed to identify multiple pregnancies where the number of chorion (outermost sac) and amnion are equal to the number of gestations for triplets, quadruplets, and higher (other multiple births). Currently, ICD-10-CM only provides this type of detail for twin pregnancies.

• Subcategory O30.13 – Triplet pregnancy, trichorionic/triamniotic
  
  • Requires a seventh character to identify the trimester
• Subcategory O30.23 – Quadruplet pregnancy, quadrachorionic/quadra-amniotic
  
  • Requires a seventh character to identify the trimester

All of these codes that identify a specific trimester (first-third) are designated as CCs, however the “unspecified” trimester codes are not. It should be a rarity that documentation is so poor that it is not clear what trimester the condition occurred.

Pregnancy DRGs are admittedly not the forte of CMS. Although, many women are waiting much later to have children, it’s certainly not seen often in the Medicare population unless it’s a disabled patient eligible for Medicare.

The proposed rule included a complete re-do of the MS-DRGs that affect pregnancy since they were always a bit odd with the description of “with complicating diagnoses” for vaginal deliveries. Therefore, CMS proposed to delete the 10 current MS-DRGs (MS-DRGs 765, 766, 767, 774, 775, 777, 778, 780, 781 and 782) and replace them with 18 new MS-DRGs with more logical titles and stratification. Here are the proposed new groupings:

• New MS-DRGs 783-785, Cesarean section with Sterilization with MCC, with CC and without CC/MCC
• New MS-DRGs 786-788, Cesarean section without Sterilization with MCC, with CC and without CC/MCC
• New MS-DRGs 796-798, Vaginal delivery with Sterilization/D&C with MCC, with CC and without CC/MCC
• New MS-DRGs 805-807, Vaginal delivery without Sterilization/D&C with MCC, with CC and without CC/MCC
• New MS-DRGs 817-819, Other Antepartum diagnoses with O.R. Procedure with MCC, with CC and without CC/MCC
• New MS-DRGs 833-825, Other Antepartum diagnoses without O.R. Procedure with MCC, with CC and without CC/MCC

Infection following a procedure

Code category T81.4- was expanded to add specificity to infections following a procedure (type of incision, type of infection).

• T81.40x – Infection following a procedure, unspecified
• T81.41x – Infection following a procedure, superficial incisional surgical site
• T81.42x – Infection following a procedure, deep incisional surgical site
• T81.43x – Infection following a procedure, organ and space surgical site
• T81.44x – Sepsis following a procedure
• T81.49x– Infection following a procedure, other surgical site
  
  • All codes require a seventh characters (A-initial, D-subsequent or S-sequela)

The initial encounter “A” assigned as a seventh character will be considered a CC.

At this point, the revisions to the Official Guidelines for Coding and Reporting have not been released. Stay tuned for any changes to our current guidelines. In the coding industry and related professions, it is helpful to stay abreast of the upcoming changes to the code sets.

We all will have to wait for the release of the final rule in early August, but we can at least prepare ourselves by knowing what is being proposed and will likely come to fruition for FY 2019.

Editor’s note: McCall is the director of HIM and coding for HCPro in Middleton, Massachusetts, and oversees all of the Certified Coder Boot Camp programs. She works with hospitals, medical practices, and other healthcare providers on a wide range of coding-related custom education sessions. Contact her at smccall@hcpro.com. For more information, see www.hcprobootcamps.com.