March 23, 2015

Take Heart in ICD-10: New Codes Prove Sometimes They Listen

By Robert S. Gold, MD

The transition to ICD-10 is a needed one – not for the reasons that the folks who have dollars and time invested into it worry about, but for the needs of patient care. In order for it to be a worthwhile change, mistakes from ICD-9 have to be corrected in ICD-10. And some of these will, indeed, be corrected.

As I’ve been writing for a decade, the chronic disease of hypertension (which can be controlled by medication, diet, and exercise) was linked inappropriately with the acute events that happen in the malignant hypertension codes in ICD-9 – and that needed a fix.

I was disturbed to find that there was no way to identify people with malignant or accelerated hypertension in ICD-10. I studied the condition and communicated with the president-elect of the American Society of Hypertension, who wrote the classic article on hypertensive emergency and hypertensive urgency (read it online at http://emedicine.medscape.com/article/241640-overview). I also discussed the situation with the current president of the American Society of Hypertension, who agreed with the strategy that his confrere and I came up with.

We recommended that ICD-10-CM codes for chronic hypertension and chronic disease related to chronic hypertension (chronic hypertensive heart disease, chronic hypertensive kidney disease) should remain as they are in the I10 to I15 series, but that in the I16 and I17 series these should be identified as hypertensive crisis without acute organ dysfunction, hypertensive urgency and hypertensive crisis with acute organ dysfunction, and hypertensive emergency, respectively, with instructions as follows:

Name and code the acute dysfunction additionally, such as hypertensive encephalopathy or hypertensive seizure or hypertensive stroke, as the manifestations of brain as a target organ, acute kidney injury with the kidney as a target organ, and acute (usually diastolic) heart failure with the heart as a target organ; and

Name the chronic hypertensive disease that the patient has, if the patient has chronic hypertensive disease, and its organ manifestations as they exist.

Well, the agenda for the Coordination and Maintenance Committee for March 19-20, 2014 came up with virtually the same model, that is:

I16 is hypertensive crisis with

I16.0 indicating hypertensive urgency and

I16.2 indicating hypertensive emergency with instruction to code also the acute damage

Cool. It’s there.

Now all we have to do is to use these new codes correctly in ICD-10, according to the definitions and clinical circumstances, as we completely blew it with ICD-9.

Also, at the request of the coders for the cardiology department of one of the hospitals in the country that was distressed by the Coding Clinic citation published in the 2006 piece on stent stenosis, we prepared a position paper to ask for consideration of some modification of codes to reflect their unhappiness. It seems that Coding Clinic only allowed for continuation of progress of coronary artery disease as an explanation for stenosis of a patient with a vascular stent exhibiting late narrowing or occlusion, either due to progression of coronary atherosclerosis or as a complication of technique. However, the folks who cited this condition recognized that the major part of this event’s frequency of occurrence was caused by neointimal hyperplasia as the body’s natural reaction to a metallic stent in the vessel rather than atherosclerosis. We suggested that codes be developed to reflect this event, as the only options in ICD-9 were progressive CAD or a complication of the procedure indicating poor technique. I sent the issue to Sue Bowman in April 2012 asking for her help, and it looks like we have it.

This new code set in the T82.85 set is designed to reflect instent restenosis caused by this process rather than atherosclerosis.

Again, it becomes important for us to recognize that this is the intent of the code and to watch out for inadequate directions on proper assignment of this series.

Finally, a whole bunch of codes and instructions came out in a recent Coordination and Maintenance Committee for correction of congenital heart disease, as we introduced that deficiency in ICD-10 to ICD-10monitor last year.

See? They do listen!

About the Author

Robert S. Gold, MD, is a nationally known physician, responsible for having championed clinical documentation with a peer-to-peer educational approach in hospital organizations. Dr. Gold is a cofounder and the CEO for DCBA, Inc., a consulting firm that concentrates on development of Clinical Documentation Improvement (CDI) programs that aid in proper data streams, proper communication within the medical records and proper reimbursement.

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