Updated on: November 29, -0001

Coding Clinic Solves Documentation Issues, Changes Paradigm for Diabetes and Heart Failure Coding

Original story posted on: April 11, 2016
As many of you may know by now, the often-discussed question of what to do about physicians’ use of new clinical practice terms that do not correspond to ICD-10 codes was recently addressed in the Coding Clinic for the first quarter of 2016.

Heart failure with “reduced ejection fraction” or “preserved ejection fraction” now can be coded without further specification by the physician.

Additionally, terms such as heart failure with “preserved systolic function” or “reduced systolic function” and “other such terms” now can be assigned without further clarification from the attending physician. What’s more, the abbreviations “HFpEF” and “HFrEF” also officially now are being accepted as documentation specifying type of heart failure. The terms “acute” or “chronic” still will need to be present in the chart somewhere, of course. This is a full reversal of previous Coding Clinic advice indicating just the opposite.

For those of you who may not know how those terms translate, the following terms should be helpful: a) reduced ejection fraction = systolic heart failure; b) preserved ejection fraction = diastolic heart failure; c) preserved systolic function = diastolic heart failure; d) reduced systolic function = systolic heart failure; e) HFrEF = systolic heart failure; and f) HFpEF = diastolic heart failure. There isn’t a version that translates into combined systolic and diastolic heart failure.

This change of heart apparently came after review of “additional information from the American Cardiology Association.”

Perhaps even more interesting, however, is something that appears in another section of the same issue of Coding Clinic. As you may recall, the linkage between diabetes and osteomyelitis used to be assumed in ICD-9, but it is not an assumed relationship in ICD-10 – meaning that for ICD-10, there are no assumed relationships. That was only true up until the discharges that became effective March 18. In a section of Coding Clinic titled “diabetic foot,” the language reads “ICD-10 assumes a causal relationship between the diabetes mellitus.”

The same passage then proceeds to name three body systems: a) the foot ulcer (diabetes and foot ulcers are now automatically linked); b) polyneuropathy (diabetes and polyneuropathy are now automatically linked as diabetes with neurological manifestations); and c) chronic kidney disease (diabetes and chronic kidney disease are automatically linked as diabetes with renal manifestations).

This raises several interesting issues, most notably that in ICD-10, chronic kidney disease now automatically will be linked to not one, but two diagnoses (diabetes and hypertension), meaning the data now automatically will trend towards multifactorial ckd caused by two conditions. This could have interesting ramifications in the analysis of metadata. Another question that undoubtedly is going to be asked is this: if diabetes is automatically linked to polyneuropathy, can it also be linked to the more commonly used term “neuropathy” or “lower leg neuropathy”? I believe most coders only will want to link diabetes to the specific term “polyneuropathy,” which will drastically change coding queries. Instead of querying a physician simply if neuropathy is “diabetic neuropathy,” we could see queries asking physicians if a patient’s neuropathy is “polyneuropathy,” since the vast majority of diabetic neuropathy cases do involve more than one isolated body part; polyneuropathy is in fact very common.

The fun doesn’t stop there. In a section of Coding Clinic titled “duodenal ulcer with hemorrhage due to anticoagulant therapy,” we have moved far away from the old paradigm of ignoring the effects of anticoagulant therapy impacting an inpatient stay, instead referring to this as an abnormal lab value. Coding Clinic specifically instructs us to use code D68.32, “Hemorrhagic disorder due to extrinsic circulating anticoagulant.”

The Coding Clinic goes on to note that this would be the code even when the anticoagulant was given according to prescription; this is not limited as an additional code to be assigned only when a poisoning or overdose has occurred. Another source of confusion is that the Coding Clinic seems to indicate that D68.32 is to be used when hemorrhage has occurred, but it makes no such indication regarding situations in which an elevated PT/INR simply occurred without hemorrhage. The language notes an increased risk for bleeding as a “side effect,” but coders are instructed to assign the code when hemorrhage has occurred. D68.32 holds DRG value as a CC. The includes notes for D68.32, which includes the term “hyperheparinemia.” Take that for what you will.

Last but not least, and perhaps the biggest “facepalm” moment of the review is this: bronchoalveolar lavage with a brushing is to be coded as “excisions” on the grounds that there is no root operation for “extraction.” As you may recall from your skin debridement training, the term “brushing” does not meet the ICD-10 definition of “excision.” The results are predictable; in addition to a simple BAL with lavage and washings (root operation “drainage”) moving you to DRG 165, if the coder does not choose the modifier for “diagnostic,” we also get moved to DRG 168, using the root word “excision” (brushings) if the coder does not chose the modifier for “diagnostic” also.

This means if BAL with brushing is done for any therapeutic reason whatsoever (and depending on your coder), you could end up with a surgical DRG. Basically, any BAL procedure ending in letter Z (not diagnostic) puts you into a surgical DRG.

The Coding Clinic does however use the modifier “X” for all of the examples given, which do not impact the DRG in anyway.
Allen R. Frady, RN, BSN, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer

With 20 years in healthcare, Allen R. Frady provides clients assistance in the areas of documentation, program implementation and compliance. His background includes critical care nursing, coding, auditing, utilization review, and documentation improvement.