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Medical Coding News Archives

Updates to ICD-10-CM Alter Approach to Coding Certain Conditions

April 19, 2016:

Over 2,500 ICD-10-CM codes are being added, revised, or deleted for the 2017 update, effective October 1, 2016. The changes range from minor code revisions, such as the addition or removal of a dash between certain terms in a code title, to more complex revisions such as changes to laterality and/or site specificity.

Below we summarize some of the changes for 2017 that will require coders to learn new terms and concepts, or alter the way they think about a condition.

Chapter 9: Diseases of the Circulatory System

Hypertension: ICD-10-CM for 2017 provides specific codes for hypertensive urgency and emergency, which are both considered hypertension crises. In the switch to ICD-10-CM, hypertension stopped being classified as malignant, benign, or unspecified, as it was in ICD-9-CM, and the terms “emergency” and “urgency” disappeared. The update for 2017 adds these two terms back in and goes one step further by having specific codes for the concepts.

  • I16.0 Hypertensive urgency
  • I16.1 Hypertensive emergency
  • I16.9 Hypertensive crisis, unspecified

Correct coding now depends on knowing what constitutes an urgent versus an emergent case of hypertension:

Crisis: Blood pressure rises quickly and high enough to potentially damage organs. Hypertensive crisis can be either urgent or emergent.

Urgency: Systolic blood pressure greater than 180 or a diastolic pressure greater than 110, without associated progressive organ dysfunction. The patient may have severe headache, shortness of breath, nosebleeds, or severe anxiety. The condition calls for immediate evaluation to assess organ function to determine appropriate treatment.

Emergency: Blood pressure reaches levels indicating impending or progressive organ damage. Such levels usually exceed 180 systolic and 120 dystolic, but could be lower in patients without previous high blood pressure. The patient is at risk for stroke, loss of consciousness, memory loss, acute myocardial infarction or angina, aortic dissection, damage to the eyes and kidneys, and pulmonary edema. For pregnant patients, a hypertensive emergency could lead to eclampsia.

For children, hypertensive urgencies and emergencies are indicated by systolic blood pressure greater than the 99th percentile for age and sex, and symptoms such as headache (urgent) or seizure (emergent).

Cognitive deficits from cerebrovascular disease: The 2017 update to ICD-10-CM will include specific codes for cognitive deficits arising from particular cerebrovascular diseases in category I69 (Sequelae of cerebrovascular diseases). The new codes appear under subcategory codes I69.01, I69.11, I69.21, I69.31, I69.81, and I69.91. Until now, the only codes for deficits associated with such diseases have been related to motor and speech/language skills. Cognitive deficits had to be described in the past using symptom codes, such as those in subcategory R41.84- (Other specified cognitive deficit).

The codes were created at the urging of the American Academy of Neurology. It pointed out that the code system needed a way to describe deficits affecting the frontal lobe, attention and concentration, visuospatial perception, psychomotor skills, and executive functions. The academy also explained that those surviving cerebrovascular disease may have memory deficits and cognitive social or emotional deficits that should be reflected in the code system. For example, some patients have trouble with memory recall but their symptoms do not rise to the level of vascular dementia and cannot be coded as such. Cerebrovascular disease can also lead to a patient’s inability to understand or behave appropriately in social situations or relationships. For instance, they may not be able to interpret facial expressions, body language, or speech intonation.

Chapter 16: Certain Conditions Originating in the Perinatal Period

Observation and evaluation of newborns for suspected conditions ruled out: Currently, the only way for a coder to indicate that a suspected condition in a newborn was the reason for an encounter but that it had been ruled out is to use a code from P00.0-P04.9. This is problematic, as the use of these codes often pushes the admission into a higher-paying MS-DRG but without any resource consumption to justify the higher payment. For fiscal 2017, however, a new category of codes, beginning with Z05, can be used to describe such a circumstance. In addition, the nonessential modifier “(suspected to be)” has been removed from the code descriptions of P00.0-P04.9. The observed conditions described by the new Z05 codes are widely varied, from cardiac and immunological conditions to connective tissue disorders.

Chapter 18: Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified

NIH Stroke Scale: More than 10 medical associations and federal agencies were successful in lobbying for 43 new ICD-10-CM codes under category code R29 (Other symptoms and signs involving the nervous and musculoskeletal systems). These codes reflect National Institutes of Health Stroke Scale (NIHSS) scores, which have been successful in predicting 30-day mortality risk in stroke patients. Both the American Heart Association and the American Stroke Association name the NIHSS as the preferred scoring tool for evaluating the major components of a neurological exam.

Scoring stroke patients is voluntary for the most part and is done by hospitals participating in special initiatives, such as the American Heart Association’s Get with the Guidelines-Stroke program. As of January 15, 2016, the Joint Commission mandated the use of the NIHSS to assess ischemic stroke patients for hospitals to qualify for Disease-Specific Care Comprehensive Stroke Center (CSC) advanced certification.

The stroke scale is based on a 15-item exam measuring neurological status and stroke severity. It measures things like level of consciousness, facial palsy, best gaze, motor skills, limb ataxia, language, and visual fields. The scale goes up to a value of 42, which indicates the most severe and devastating stroke.

The new codes directly relate the NIHSS score starting at R29.700 (indicating an NIHSS score of 0) all the way up to R29.742 (indicating an NIHSS score of 42).

Time of assessment using the Glasgow coma scale: Code R40.24- (Glasgow coma scale, total score) was added to the list of codes requiring a seventh character to describe where the patient was assessed (in the field [EMT or ambulance], at arrival to the emergency department, at hospital admission, or 24 hours or more after hospital admission). Before this update, codes R40.21-, R40.22-, and R40.23-, which describe use of a coma scale, required the seventh character but R40.24- did not. The American Academy of Neurology pointed out that the seventh character provides useful data and is appropriately used with R40.24-.

Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes

Concussion codes: Twenty-one codes from subcategory S06.0 (Concussion) have been deleted for fiscal 2017. The Department of Veterans Affairs pointed out that the existing codes describing loss of consciousness for periods longer than 30 minutes and LOC with death were inconsistent with a diagnosis of concussion. The agency commented that mild intracranial injury is synonymous with concussion but that moderate and severe forms would be more appropriately coded using subcategories S06.8 Other specified intracranial injuries, or S06.9 Unspecified intracranial injury.


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