The document provides updates on ICD-10-CM coding guidelines for 2018, including revisions to the definition of acute myocardial infarction and new codes for pulmonary hypertension and heart failure. Six new codes were added for pulmonary hypertension affecting the arteries of the lungs and heart. A new category was also added for heart failure, including new codes for right ventricular failure and bi-ventricular heart failure.

1. CardiologyCodingUpdatesfor2018
ONLINEAUDIOTRAINING
TerryFletcherConsulting,Inc.
By:TerryFletcherCPC,CCC,CMC,CMSCS,CMCS,CCS-P,CCS,CEMC,ACS-CA,SCP-CA
www.onlineaudiotraining.com
1

2. ICD-10-CM GUIDELINES RELEASED!!
Justreleasedon Thursday, Aug.10 are the OfficialICD-10-CM/PCSCodingandReporting Guidelinesfor the 2018fiscalyear, totaling
117pages.TheNationalCenterfor Health Statistics,via the CDC(Centers for Disease Control andPrevention), hasposted the
guidelineson its websitehere:https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf.
Readersshould notethat the time frameto whichtheseguidelines apply to is Oct.1, 2017to Sept.30, 2018.
Whenyoureview the guidelines for thiscoming fiscal year,pleasetake note the following:
 Narrativechangesappearin boldtext
 Items underlinedhave beenmoved within the guidelines since the FY2017version
 Italics are usedto indicaterevisionstoheadingchanges

Theconventionsfor ICD-10-CMare the generalrules for useof the classification,independentof the guidelines, and there remain19
of theseconventions,asin the FY2017guidelines.ConventionNo. 15, “with,” doeshavesomerevised narrative,soevery coding
professionalshould readthis overcarefully.Here’sa portion of this revision, highlightedin bluefont:
Theword “with” or “in” shouldbe interpreted to mean “associatedwith” or “due to” whenit appears in acode title, the Alphabetic
Index,or aninstructionalnote in the TabularList.
Theseconditionsshould be codedasrelatedevenin the absenceof provider documentationexplicitly linkingthem, unlessthe
documentationclearly statesthe conditionsare unrelatedor when anotherguideline exists that specifically requiresadocumented
linkagebetweentwo conditions(e.g.,sepsisguideline for “acuteorgandysfunctionthat is not clearly associated with the sepsis”).
2

3. ACUTE MYOCARDIAL INFARCTION(AMI)
Definition Change
When documenting anAMI, keep the following inmind:
1. Timeframe: AnAMI is now considered“acute” for 4 weeks from the time of the incident, arevised
time frame from the ICD-9 period of 8 weeks.
2.
3.
4.
Episode of careICD-10-CMdoes not capture episode of care (e.g. initial, subsequent,sequelae).
SubsequentAMI ICD-10 allows coding of a new MI that occurs during the 4 week “acute period” of the
originalAMI.
Type 1 and Type 2Acute Myocardial Infarction Diagnoses to better descript when Ischemic heart
disease is involved. (2018 Update)
ICD-10-CM Code Examples:
I21.-
I21.-
I21.02
I21.4
I21.A1
I21.A9
I22.1
Acute Myocardial Infarction (2018 revision to the definition) (Type1)
Acute Myocardial Infarction (2018 revision to the definition) (Type1)
STelevation(STEMI)myocardial infarctioninvolving left anterior descending coronary artery
Non-STelevation(NSTEMI)myocardial infarction
Myocardial infarction (New 2018)(Type2)
Othermyocardial infarctiontype
SubsequentSTelevation(STEMI)myocardial infarction of inferior wall (no changesto subsequent)
ICD-10-CM2018 will add the new code I21.9 (acute myocardial infarction,unspecified).Thiscould be helpful when apatient is
seenin the ERand it is not clearwhat stage of AMI the patient is in.
3

4. SixNew Hypertension Codes2018
ICD-10-CM 2018 brings us 6 new codes for pulmonary hypertension, which effects the
arteries of the lungs and the heart.
New codes are as follows:
 I27.20 (Pulmonary hypertension, unspecified)
 I27.21 (Secondary pulmonary arterial hypertension)
 I27.22 (Pulmonary hypertension due to left heart disease)
 I27.23 (Pulmonary hypertension due to lung diseases and hypoxia)
 I27.24 (Chronic thromboembolic pulmonary hypertension)
 I27.29 (Other secondary pulmonary hypertension)
You may see these codes more often with Right Heart Cath coding and possible valve
replacement coding.
4

5. Brand-New Category for Heart Failure
SectionI50- “Heart failure” will add anew category (I50.8-, Otherheartfailure).
The ICD-10- manual will offer new codes to specify when patients have a conditions thatfall under this categorysuch as right
ventricularfailure or BiV heart failure. These additions includethefollowing:
I50.81-(Right heartfailure)
 I50.810(Rightheart failure,unsp)
 I50.811(Acute right heartfailure)
 I50.812(Chronic right heartfailure)
 I50.813(Acute on chronic right heartfailure)
 I50.814 (Rightheartfailuredueto left heart failure)
>>I50.82 (Biventricularheart failure)
>>I50.83 (High output heartfailure)
>>I50.84 (End Stage heartfailure)
>>I50.89 (Otherheart failure)
Therehas beenan increase, within patient medicalrecordsdocumentation, of biventricularheartfailure (new code ICD-10-CM
I50.82). Thiswill make coding a bit more specificwhen ordering tests,labs, visits, etc.Medical Necessity will be easierto
support.
5

6. New Specialty Taxotomy Codes Added for2017
Billing:
CMS adds 3specialtydesignationsstartingOctober 1st, 2017and 2018
Preparefor the addition of three new specialties that will appear under the providerenrollment chain
and
ownership system(PECOS)and that may open up billing opportunities for your providerstaff.
Thesespecialty codes,pertaining to cardiology,medical toxicology and cell transplantation
providers,go into effect Oct.1:
 C7-Advancedheart failure and transplant cardiology
 C8-Medical toxicology
 C9-Hematorpoietic cell transplantation and cellular therapy
Somespecialty groups are saying this is abig win for medical billing staff and someof the denials
that have comefrom the local Medicarecarriers for duplicate billing. Whenacardiologist,for
example,and (heart failure) specialist from the samepractice havebilled for E/M services on the
samedate, denials are going to happen. Hopefully with these new designations, CMSwill allow for
separateservices when appropriate.
6

7. 2018E/Mservicesupdate
Physicianpractices should note several changes to E/M codes, which includes anew
“star”symbol added to CPTto designate possible“Synchronous Telemedicine Health”
code inclusions, and several revised code descriptor sections. Payclose attention to
modifier -95 and -GT
• Plush Care
• VIPCare
• Telehealth
• eVisit
7

8. Coding for TelehealthServices-preview
Reporting Telehealth Serviceswith the appropriate modifiers- Only ½thestory
Submit your Medicare and Medicaid claimsfor telehealth services using the appropriate CPT®orHCPCS
codefor the telehealth servicealong with the modifier GT(via interactive audio and video
telecommunicationssystems)-for example,99202-GT.
Bycoding and billing the GTmodifier with acovered telehealth procedure code,you are certifying that
the beneficiary was present at an eligible originating site when your physician or qualified
approved practitioner furnishesthe telehealth service.Bycoding and billing the GTmodifier with
the covered ESRD-related servicetelehealth code, you are certifying that your provider furnishes
one “hands on” visitper month to examinethe vascularaccesssite.
For Federal telemedicine demonstration programs in Alaska or Hawaii, your submitted claims with the
appropriate CPT®or HCPCScode for the professional service along with the GQmodifier, to certify
aasynchronoustelecommunicationssystem was used.
! Reminder:CMSstates that POS02 is effective January 1st, 2017.ACMStransmittal (R3586CP) mentions that any
time claims for telehealth servicesare reported that include modifier GTor GQon either the CPT®or HCPCScode,
but do not include new POS02, they will be denied. It also mentions that if the new POS02 is used and the
modifiersare not included, the service will be denied by Medicare.
Make sure you attend one of our TelemedicineWebinarsin 2018 to become even more informed on this topic.
*Terry Fletcher is a member of the American TelemedicineAssociation2017
8

9. E/M New vs. Establishedpatient clarification- AVOIDdenials-Cardiology Specialty in
2018
3questions to avoid overpayments anddenials
Wasthe patient seenby:?



Thesameprovider?
Aprovider of the samespecialty?
Aprovider of the samesub-specialty?
Keepin mind that under the E/M documentation guidelines, if the patient is new to your practice with an
office visit, but was seen in the E/Ror in the hospital within in the past 3-years, they are still consideredan
establishedpatient.
If, for example,apatient seesageneral cardiologist 6-1-2017 in the office for follow up coronary artery
disease but during that encounter an arrhythmia is detected (an abnormality of the computer of the heart)
and the patient needs to be referred to an EP(electrophysiology physician), within the practice.Onadifferent
date, the patient would be considered aNPfor that EPdoctor. It helpsthat EPisaseparate taxotomy code to
differentiate ageneral cardiologist from an EPasa subspecialty.
However, what if the physicianreferral was to aPeripheral Vascular physicianin the samepractice, no
separateTaxID?That is where the debate begins. OIGwill be closely monitoring these claims.They have
alreadysettled a$700,000 claim from 2 medical centers in MASSfor “up-coding” incorrectly from established
patient visit to a new patient visit when it was not supported.
9

10. Modifier 25Alert!-2018
E/M Codeswith modifier -25 may face drastic pay reductions forsome
practices.
Watchyour E/M Claimswhere you append the modifier 25(Significant,separately identifiable E/M service) if your
patients have insurance with aMedicare Advantage carrier that operates in 25 states. This started on August 1st,
when Independence Health Group, which covers almost 9 million people under private health insurance and
Medicare Advantage plans,announced via their website and provider emails,it would apply a“payment
reduction of 50%” to an E/M service when it is billed/reported with amodifier 25 on the samedate asaminor
procedure. The company also said it would cut payment at the same50%rate for E/M servicesbilled with
modifier 25 when apreventative code is also billed. The policy document lists 17 preventative service codesthat
apply, including 99381-99387,99391-99397,G0438 and G0349 the AWV.This revisedpayment policy will
significantly impact reimbursement for many practicesaround the country. I fear this could have physicians
bringing patients back on adifferent day to get paid for both services at 100%.
Westrongly urge providers who are participating with this plan to fight it with the
provider relations department of that payer. There is no basisfor this.
10

11. New Patient relationship Modifiersfor 2018-per CMS
Next year CMSplans to give physicians and somenon-physician
practitioners the opportunity to test drive modifiers that indicate
the relationship between provider andpatient.
CMSwas requiredto createcodesthat will be appended to Medicare claimsto “facilitate the
attribution of patients and episodesto one or more clinicians” ~by MACRA
Hereare the proposed modifiersfor the 2018physician fee schedule:
*X1- (Continuous/broad services) Principal care no plannedendpoint
*X2- (Continuous/focused services) Clinicians whose expertise is needed for ongoing management
*X3- (Episodic/broad services) Clinicians who have broad responsibility for comprehensive needs, i.e. hospitalist
*X4- (Episodic/focusedservices) Specialty clinicians who provide time-limited care, i.e surgery, radiation etc..
*X5- (Only asordered by another clinician) Example aradiologist or cardiologist who interprets adiagnostic test
Thesemodifiers are intended for use by physicians and applicable NPP’s.The Jan1st, 2018 rollout of the codesis
required by law. However the use of the modifierswill not be mandatory in 2018.The modifiers“may be
voluntarily reported on Medicare claims,and will not effect payment”. They should not be used with quality
measures.
11