CMS has stopped being nice about ICD10. As of October 1, 2016, the grace period for not using specific codes for certain diagnoses is gone. If you are not precise with these codes, your denial rates will go up. This presentatio helps you learn how you can avoid high denial rates and also explains: - Key changes and revisions - Written guidance from CMS and OIG that may negate a new guideline - Chapter specific changes - How to tell when you need documentation and when you don’t

2. Agenda
• Key changes and revisions
• Written guidance from CMS and OIG that may
negate a new guideline
• Chapter-specific changes
• How to tell when you need documentation and
when you don’t

3. “WITH” – Why It’s Important
With
Means
“associated
with”
or
“due to”
Presumes a
casual
relationship
between two
conditions
linked by these
termsConditions
should be coded
as related, even
if provider
documentation
does not
explicitly link
them
The word
“with” in the
alphabetic index
immediately
follows the
main term

4. 1. amyotrophy E11.44
2. arthropathy NEC E11.618
3. autonomic (poly) E11.43
4. cataract E11.36
5. Charcot's joints E11.60
6. chronic kidney disease E11.22
7. circulatory complication NEC E11.59
8. complication E11.8
9. specified NEC E11.69
10. dermatitis E11.620
11. foot ulcer E11.621
12. gangrene E11.52
13. gastroparalysis E11.43
14. gastroparesis E11.43
15. glomerulonephrosis, intracapillary E11.21
16. glomerulosclerosis, intercapillary E11.21
17. hyperglycemia E11.65
18. hyperosmolarity E11.00
Diabeties, diabetic (mellitius) (sugar) E11.9
-with

5. Code Assignment and Clinical Criteria
The assignment of a
diagnosis code is based
on the provider’s
diagnostic statement
that the condition exists.
The provider’s statement
that the patient has a
particular condition is
sufficient.
Code assignment is not
based on clinical criteria
used by the provider to
establish the diagnosis.

6. 2016 OIG Work Plan
Review the medical record
documentation to ensure
it supports the diagnoses
that MA organizations
submitted to CMS for use
in risk-score calculations.
Medical record
documentation does not
always support the
diagnosis submitted to
CMS by MA organizations.
MA organizations are
required to submit risk
adjustment data to CMS
in accordance with HHS
OIG Work Plan.
Inaccurate diagnoses may
cause CMS to pay MA
organizations improper
amounts.

7. Specific Coding is NOW
Is Medicare going to phase in the requirement to
code to the highest level of specificity?*
No, providers should already be coding to the
highest level of specificity.
As of 10/1/2016, providers are required to code
to accurately reflect the clinical documentation.
*Submitted to CMS 8/8/2016

8. Sequela
Late effects
• There is no time limit for a sequela code.
• The residual effect may be apparent early or may occur months or years later.
• Coding is usually sequenced with two codes:
1. The condition or nature of the sequela
2. The sequela code
• The code for the acute phase of an illness or injury that led to the sequela is
never used with a code for the late effect.
Sequela
a residual effect after the acute
phase of an illness or injury
An exception to the above rule:
If the code for the sequela is followed by a manifestation code identified in the
Tabular list and title, OR the sequela code has been expanded (fourth, fifth, sixth
character levels) to include the manifestation(s).

9. Effective for date of service October 1, 2016
S and T ICD10 CM codes from Chapter 19 requiring a
seventh character of “S” will receive a designation of NPD
in the commercial clinical editor.*
Affects approximately 9,600 diagnosis codes from chapter 19, which
currently do not have the NPD designation.
NPD Designation
*Based on recent clarification from the American Hospital Association.

10. For
 BMI
 Depth of Non-pressure Ulcers
 Pressure Ulcer Stage
 Coma Scale
 NIH Stroke Scale
Code assignment may be based on
the medical record documentation
from clinicians who are not the
patient’s provider.*
*physician, or other qualified health care
practitioner legally accountable for establishing
the patient’s diagnosis
Specific Documentation
The associated diagnosis, i.e.
 Overweight
 Obesity
 Acute stroke
 Pressure ulcer
must be documented by the
patient’s provider.
If there is conflicting medical record
documentation, either from the same
clinician or different clinicians, the
patient’s attending provider should be
asked for clarification.

11. Nurse
documents
patient’s weight,
height, and
BMI data
Physician does
not document
the patient’s
obesity
An obesity
code should
not be used
Examples
Physician
documents the
patient’s
obesity
The obesity
code can be
used

12. • The guideline extends to any complications of care, regardless of the
chapter where the code is located.
• Not all conditions that occur during or following medical care or surgery
are classified as complications.
There must be a cause-and-effect relationship between the care
provided and the condition, plus an indication in the documentation
that it is a complication.
• Query the provider for clarification, if the complication is not clearly
documented.
Documentation of the
Complications of Care
Code assignment is based on the provider’s documentation of the
relationship between the condition and the care or procedure, unless
otherwise instructed by the classification.

13. Excludes1 Exception
When the two conditions are unrelated to each other
For example: Code F45.8 (other somatoform disorders)
Excludes1 note for ”sleep related teeth grinding (G47.63),” because teeth
grinding is an inclusion term under F45.8.
Only one of these two codes should be assigned for teeth grinding.
Psychogenic dysmenorrhea is also an inclusion term under F45.8, and
a patient could have that as well as sleep related teeth grinding.
The two conditions are clearly unrelated,
so both G47.63 and F45.8 can be reported.

14. Laterality
• If no bilateral code is provided, and the condition is bilateral,
assign separate codes for the right and left side.
• If the side is not identified in the medical record, assign code for
Unspecified.
• If a patient has a bilateral condition, and each side is treated
during separate encounters, assign the bilateral code.
• For the 2nd encounter after one side has already been treated,
and the condition NO longer exists on that side, assign the
appropriate unilateral code for the side where the condition still
exists.
NOTE: If treatment on the first side did not completely resolve the condition, then
the bilateral code would still be appropriate
Some codes specify whether the condition
is on the left, right, or bilateral
RL

15. Laterality Example
Patient has been
evaluated for cataracts
in both eyes.
The right eye was
previously fixed via
surgical intervention
Patient now presents to
have the left eye re-
evaluated for surgery.
Initial visit:
- Cataracts are diagnosed as
bilateral
- Bilateral code is chosen
In the re-evaluation visit:
- Condition only exists in the left eye

16. Chapter
Specific
Changes

17. Zika Virus
• Code only confirmed case of Zika virus as documented by the
provider.
• In this context, “confirmation” does not require
documentation of the type of test performed
• The physician’s diagnostic statement that the condition is
confirmed is sufficient
• This code should be assigned, regardless of the stated
mode of transmission
• If the provider documents “suspected,”
“probable,” or “possible” Zika,
do not use the code A92.5. Only code associated
signs and symptoms

18. Hypertension Crisis
Assign a code from category I16,
Hypertensive crisis, for:
• Documented hypertensive
urgency
• Hypertensive emergency
• Unspecified hypertensive
crisis
Code any identified hypertensive
disease (I10-I15).
Sequencing is based on the
reason for the encounter.

19. Acute Myocardial Infarction
Encounters occurring while the myocardial infarction is < 4
weeks old, including transfers to another acute setting or a
postacute setting, and the myocardial infarction meets the
definition for “other diagnoses” (see Section III, Reporting
Additional Diagnoses), codes from category I21 may
continue to be reported.

20. Pressure Ulcers
For ulcers that were present on
admission, but healed at the
time of discharge, assign the
code for the site and stage of
the pressure ulcer at the time
of admission.

21. Supervision of High-Risk Pregnancy
High-risk pregnancy complications during labor
and delivery
Assign the applicable complication codes from
Chapter 15.
No complications during the labor and delivery
Assign code O80, Encounter for full-term
uncomplicated delivery.
Codes from category O09, Supervision of high-risk pregnancy,
are intended for use only during the prenatal period.

22. When a Delivery Occurs
An obstetric patient is admitted & delivery
occurs during that admission
The condition prompting the admission
Is sequenced as the principal diagnosis.
Multiple conditions prompted the admission
Sequence the one most related to the delivery
as the principal diagnosis.
Any complication of the delivery
Should be assigned as an additional diagnosis.

23. Gestational (pregnancy-induced)
Diabetes
Should not be assigned with codes from subcategory O24.2:
Code Z79.4, Long-term (current) use of insulin
Code Z79.84, Long term (current) use of oral hypoglycemic drugs
The codes under subcategory O24.4 include:
- Diet controlled
- Insulin controlled
- Controlled by oral hypoglycemic drugs
If a patient with gestational diabetes is treated with both diet
and insulin, only the code for insulin controlled is required.
If a patient with gestational diabetes is treated with both diet
and oral hypoglycemic medications, only code for
“controlled by oral hypoglycemic drugs” is required.

24. Observation and Evaluation of Newborns
for Suspected Conditions not Found
Assign a code from category Z05, Observation and evaluation
of newborns and infants for suspected conditions ruled out, to
identify instances when a healthy newborn is evaluated for a
suspected condition that is not found.
If the patient has signs and symptoms of suspected problem do
not use Z05.
Only code
the sign or
symptom

25. Coma Scale
Should be sequenced after the
diagnosis code(s).
The coma scale codes (R40.2-) can be used in
conjunction with:
- Traumatic brain injury codes
- Acute cerebrovascular disease codes
- Sequela of cerebrovascular disease codes
May also be used to assess the status of the
central nervous system for other non-trauma
conditions (i.e., monitoring patients in the ICU
regardless of the medical condition).

26. NIHSS Stroke Scale
The NIH stroke
scale NIHSS codes
(R29.7-) can be
used in conjunction
with acute stroke
code (I63) to
identify the
patient’s
neurological status
and the severity of
the stroke.
The stroke scale
codes should be
sequenced after
the acute stroke
diagnosis code.
At a minimum,
report the initial
score
documented.
You may choose
to capture
multiple stroke
scale codes.

27. NIHSS Stroke Scale
R29.700
R29.701
R29.702
R29.703
NIHSS score 0
NIHSS score 1
NIHSS score 2
NIHSS score 3

28. 7th Character A
Used for each encounter where
the patient is receiving active
treatment for the condition
7th character “A,” initial encounter

29. Initial vs. Subsequent
Encounter for Fractures
The open fracture designations in
the assignment of the 7th character
for fractures of the forearm, femur,
and lower leg (including ankle) are
based on the Gustilo open fracture
classification.
When the Gustilo classification type
is not specified for an open fracture,
the 7th character for open fracture
should be assigned (B,E,H,M,O).

30. Questions
Please email your questions to:
ashley.giaquinta@careoptimize.com
To learn even more about CareOptimize and how
we can help your bottom line, please visit our
newly updated website: www.careoptimize.com

31. References
www.aapc.com
www.cdc.gov
www.cms.gov
www.hhs.gov