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Risk Adjustment

Risk Adjustment is the method developed and used by the Department of Health & Human Services (HHS) to predict health costs of members enrolling in Affordable Care Act (ACA) or Medicare Advantage (MA) plans. Risk Adjustment prevents health plans from only attracting and enrolling healthy members; or adverse selection. Effective Risk Adjustment programs ensures members are receiving quality care and enable health plans to offer more comprehensive and affordable benefits to members.

Arkansas Health & Wellness is required by law to report complete and accurate diagnostic information on enrollees. This information is gathered from claims data and information obtained from medical record reviews and audits.

We encourage all providers to take every face-to-face encounter as an opportunity to provide comprehensive care and document chronic conditions, co-existing conditions, active status conditions, and pertinent past conditions using the applicable ICD-10 code and supporting the condition with proper documentation in the medical record.

Arkansas Health & Wellness is required to validate member diagnosis annually through Risk Adjustment Data Validation (RADV) audit. Health Plans also engage in chart review projects to ensure member diagnosis are being reported accurately.

Arkansas Health & Wellness engages providers through various incentive programs that reward providers for risk adjustment gap closure.

Cardiac Arrhythmias[1]

An arrhythmia is an abnormal heart rhythm. Arrhythmias occur when the electrical impulses that coordinate your heartbeats don’t work properly, causing your heart to beat too fast, too slow or irregularly.

RISK FACTORS:

  • Hypertension
  • Heart attack
  • Abnormal heart valve
  • Coronary artery disease
  • Emphysema /Lung Disease
  • Stress
  • Congenital defects
  • Viral infections
  • Metabolic imbalance
  • Thyroid disorder
  • Stimulants
  • Smoking

SYMPTOMS:

  • Palpitations
  • Chest pain
  • Weakness / fatigue
  • Confusion
  • Blood pressure change
  • Shortness of breath
  • Lightheadedness
  • No symptoms

Paroxysmal Tachycardia

Tachycardia is a fast heart rate; in adults a rate greater than 100 beats per minute is considered tachycardia. Paroxysmal tachycardia is characterized by periods of rapid heartbeats that start and stop abruptly.

There are 2 types of paroxysmal tachycardia:

  • Supraventricular Tachycardia occurs when the rapid heart rate originates in the heart’s upper chambers (the atria)
  • Ventricular Tachycardia involves a rapid heart rate originating in the lower chambers of the heart (the ventricles). Ventricular tachycardia lasting longer that a few seconds can lead to ventricular fibrillation, the most serious and life-threatening cardiac rhythm disturbance.

Atrial Fibrillation and Flutter

Atrial fibrillation and flutter are arrhythmias involving the atria. They may come and go, or be sustained. Risk of stroke or heart failure is increased if either atrial fibrillation or atrial flutter is not controlled or persist for more than a couple of days.

  • Atrial fibrillation is a rapid, irregular heart rate caused by chaotic electrical impulses in the atria. These cause rapid, uncoordinated, weak contractions of the atria and blood is not moved from the atria into the ventricles effectively. Atrial Fibrillation is the most common type of arrhythmia.
  • Atrial flutter is characterized by a rapid, but regular heartbeat that causes the atria to beat too fast, producing atrial muscle contractions that are faster than and out of sync with the ventricles.

Sick Sinus Syndrome (SSS)

SSS, also known as ‘Sinoatrial node dysfunction’ or ‘Tachycardia-Bradycardia syndrome,’ is the name given to a group of arrhythmias in which the sinus node, the heart’s natural pacemaker, doesn’t send impulses properly. As a result the heart might beat too fast, too slow, or it might speed up and slow down intermittently.

Treatment options depend largely upon the severity of a patient’s symptoms. Many with SSS initially experience few, if any, symptoms. At this stage treatment usually consists of regular checkups and monitoring. Once a patient’s symptoms become more problematic, further treatment is pursued.

Many with sick sinus syndrome eventually need a permanent artificial pacemaker to monitor and regulate the heart’s rhythm and send electrical signals to stimulate the heart when it’s beating too slowly.

A pacemaker controls but does not cure SSS, therefore, it is  a reportable chronic condition.[2]

Patients who have a rapid heart rate as part of their SSS may need additional treatments after pacemaker placement to control fast rhythms.

Treatment Options

  • Anti-arrhythmic drugs
  • Heart-rate control drugs
  • Anticoagulant therapy
  • Electrical cardio conversion
  • Anti-bradycardia pacing
  • Coronary artery bypass
  • Pulmonary vein isolation
  • Catheter ablation
  • Maze procedure
  • Valve surgery

There are many cardiac devices designed to help control irregular heartbeats, such as pacemakers, implantable cardioverter-defibrillators (ICDs) and loop recorders. These are often surgically implanted in the chest or abdominal wall, just below the collarbone.

CARDIAC DEVICES

Coding & Documentation[3]

When documenting cardiac arrhythmias, include the following:

  • Location – atrial, ventricular, supraventricular, etc.
  • Rhythm name – flutter, fibrillation, etc.
  • Acuity – paroxysmal, persistent, longstanding, chronic, etc.
  • Cause – hyperkalemia, hypertension, etc.

ANTICOAGULANT THERAPY

  • Documentation must state the relationship between an­ticoagulation therapy and cardia arrhythmias. It cannot be assumed since anticoagulants are used to manage other conditions.
  • Even when the conditions are linked, document the type, status and severity of the arrhythmia. Anticoagulant therapy is also used to prevent blood clots in patients with a history of cardiac arrhythmias. - Z79.01, Long term (current) use of anticoagulants

HISTORY OF

  • Document “history of” along with a specification that the condition is no longer current in the final assessment.
  • If the condition is currently active and under management do not specify as “history of”, even if stable.
  • There is not a specific code for personal history of cardiac arrhythmia. Use Z86.79, Personal history of other diseases of the circulatory system.

PRESENCE OF CARDIAC DEVICE

  • Z95.0      Presence of a cardiac pacemaker
  • Z95.810  Presence of automatic (implantable) cardiac defibrillator
  • Z95.811  Presence of heart assist device
  • Z95.818  Presence of other cardiac implants and grafts

Reference:

[1] Cardiac Arrhythmias

[2] AHA Coding Clinic, 2019 Q1, Volume 6 pg. 3

ALL21-AR-H-086 Updated October 22, 2021

Chronic Kidney Disease[1]

The clinical criteria for chronic kidney disease (CKD) is either kidney damage or a decreased glomerular filtration rate (GFR) of less than 60 for at least 3 months. When the reduction of functional renal mass reaches a certain point, irreversible sclerosis leads to a progressive decline in the GFR.

ICD-10-CM[2] classifies CKD by the severity level of decreased kidney function. 

STAGE

SEVERITY

GFR

ICD-10

Stage I

Mild kidney damage (normal function)

≥ 90

N18.1

Stage 2

Mildly decreased renal function

60-89

N18.2

Stage 3

Stage 3, unspecified severity

Unspecified

N18.30

Stage 3a

Mild to Moderate

45-59

N18.31

Stage 3b

Moderate to Severe

30-44

N18.32

Stage 4

Severe

15-29

N18.4

Stage 5

Kidney Failure

< 15

N18.5

ESRD

Requires dialysis/transplant

< 15

N18.6

CKD, Unsp.

Renal disease, renal insufficiency or renal failure NOS.

N/A

N18.9

The GFR value may can be used as supporting evidence for renal failure, renal insufficiency, or other renal diseases documented by the provider. It cannot be interpreted to stage CKD or other renal condition. 

Signs and Symptoms

Patients with CKD stages 1-3 are generally asymptomatic. Typically, it is not until stages 4-5 that endocrine/ metabolic derangements or disturbances in water or electrolyte balance become clinically manifested.

When the disease progresses, symptoms presented are:

  • Edema of feet and ankles
  • Need to urinate more often, especially at night
  • Nausea
  • Blood in urine or protein in urine
  • Chest pain
  • Twitching in the muscles and cramps
  • Shortness of breath
  • Erectile dysfunction, amenorrhea, decreased libido
  • Fatigue
  • Platelet dysfunction with tendency to bleed
  • Loss of appetite
  • High blood pressure (hypertension)

Coding & Documentation[3]

Acute vs. Chronic

Acute kidney failure is not an acute exacerbation of chronic kidney failure. They are two separate and distinct conditions. The causes, symptoms, treatments, and outcomes of acute and chronic are different

  • Acute renal failure has an abrupt onset and is potentially reversible.
  • Chronic kidney failure progresses slowly over time and can lead to permanent kidney failure.

If both acute and chronic kidney failure are clearly documented, code both N179 (AKI) and N18.- [4]

End Stage Renal Disease

End-stage renal disease (ESRD) is when the kidneys permanently fail to work. ESRD requires renal dialysis or kidney transplant.

  • N18.6, is assigned when ESRD is documented by provider
  • Also code Z99.2, Dependence on renal dialysis when documentation supports the presence of an arteriovenous shunt/fistula for dialysis
  • Code Z91.15, Patient's noncompliance with renal dialysis when explicitly documented

“With”

Patients with CKD may also suffer from other serious conditions, most commonly diabetes mellitus and hypertension. The sequencing of the CKD code in relationship to codes for other contributing conditions is based on the conventions in the Tabular List.

Diabetes with kidney complications 

Relationship between diabetes and CKD or ESRD (N18.1 - N18.6) is assumed when both conditions are found anywhere in the note as long as there is no conflicting documentation

  • Use an additional code to identify stage of chronic kidney disease (N18.1-N18.6)
  • The ICD-10 “with” guideline only applies to CKD, unspecified (N18.9) when CKD unspecified has been assessed during the encounter

Hypertensive Chronic Kidney Disease

Hypertension and CKD have an assumed relationship unless documentation specifies CKD is caused by a condition other than hypertension.

  • Assign code from category I12
  • Use an additional code to identify stage of chronic kidney disease with I12.0 (N18.1-N18.4,N18.9) or I12.9 (N18.5-N18.6)

Hyperparathyroidism

Hyperparathyroidism is a pathologic manifestations of CKD.  

  • Documentation MUST link the complication and the conditions to assign code N25.81, Hyperparathyroidism of renal origin
  • DO NOT assume causal relationship between these two conditions

Reference:

[1] Chronic Kidney Disease

[2] ICD-10-CM

[3] Coding & Documentation (PDF)

[4] AHA Coding Clinic, Volume 27, Q3, 2010, Pg. 5

ALL21-AR-H-085 Updated October 22, 2021

Chronic obstructive pulmonary disease (COPD) is a progressive chronic respiratory disease that causes blocked airways and breathing-related problems. COPD can be caused by long-term exposure to harmful particles or gases that irritate the lungs such as tobacco smoke and exposure to air pollution.[1]

Types of COPD

Chronic bronchitis - hypersecretion of mucus with chronic productive cough lasting more than 3 months in 2 consecutive years[2]

  • Simple – non obstructive; smokers cough  (J41.0)
  • Mucopurulent -  production of sputum containing mucus and pus  (J41.1)
  • Mixed – chronic simple and mucopurulent bronchitis (J41.8)
  • Chronic bronchitis, NOS  (J42)

Emphysema – enlarged or over inflated air space in the lung due to damaged alveoli (air sacs) or alveolar wall resulting in breathing difficulty and increased risk of respiratory infections.

  • Unilateral pulmonary emphysema MacLeod’s syndrome (J43.0)
  • Panlobular  affecting lower lobes (J43.1)
  • Centrilobular – affecting upper lobes (J43.2)
  • Other & Unspecified (J43.8, J43.9)

Chronic obstructive pulmonary disease – chronic bronchitis and emphysema causing irreversible airflow obstruction

  • With (acute) respiratory infection (J44.0)
  • With (acute) exacerbation (J44.1)
  • COPD, unspecified (J44.9)

Stages of COPD[3]

Stage

Pulmonary Function

Symptoms

I

Mild

80% or greater

Persistent dry cough, shortness of breath during exertion

II

Moderate

79% - 50%

Persistent cough with excess mucus, shortness of breath during mild activity, wheezing, fatigue, sleep disturbance

III

Severe

49% - 30%

Frequent respiratory infections, edema, cyanosis, tightness in chest, trouble breathing while performing basic tasks, difficulty taking a deep breath

IV

End-stage

29% or less

Constant wheezing and shortness of breath, inability to inhale deeply increased heart rate and blood pressure, loss of appetite and weight

COPD Treatment & Management

There is no cure for COPD but early intervention can slow the disease progression and reduce the risk of complications. Treatment for COPD can include:

  • Antibiotics – fights bacterial infection
  • Bullectomy – removal of air space from collapsed air sacs
  • Lung transplant – replace diseased lung with a healthy one
  • Oxygen therapy – reduces shortness of breath
  • Smoking cessation – slows progression
  • Bronchodilators – opens airways
  • Corticosteroids – reduces inflammation
  • Lung volume reduction – removes diseased lung tissue
  • Pulmonary rehabilitation –includes disease management,  exercise, and counseling
  • Vaccines – lower risk of flu or pneumonia

Asthma

Asthma is a chronic lung disease causing inflammation and constriction of the airways that affects the ability to breathe. Asthma triggers may be different for each person and can change over time. Different triggers cause different types of asthma.[4]   

  • Allergic - Dust mites, Mold, Pollen, Pets, Household pests
  • Non-allergic - Cold air, Medications, Household chemicals, Air pollution, Tobacco smoke, Infection
  • Exertional - Induced by exercise or physical activity.
  • Occupational Caused by breathing chemicals or industrial dust particles at work.

Asthma is classified by frequency and severity of symptoms and complications of the disease: (J45.-) 

  • Mild, moderate, severe
  • Intermittent, persistent
  • Uncomplicated, with acute exacerbation, with status asthmaticus  

Diagnostic Testing[5]

Document diagnostic test results and any clinical findings that support the diagnosis along with disease status and treatment plan.

  • Chest x-ray – imaging test to look at the structures and organs of the chest
  • Computed tomography (CT) scan – computerized digital scan that creates two-dimensional, cross-sectional images
  • Bronchoscopy – procedure using a small camera on the end of a long flexible tube, or scope, to look at air passages
  • Endobronchial Ultrasound (EBUS) – bronchoscopy performed using scope with an ultrasound probe attached
  • Lung biopsy – procedure to collect a tissue sample used in disease diagnosis  
  • Spirometry – measures volume capacity and the force of air expelled from the lungs
  • Peak Expiratory Flow (PEF) – measures speed of air blown out of the lungs using maximum effort
  • Fractional exhaled nitric oxide (FeNO) test - measures levels of nitric oxide exhaled from a breath
  • Bronchoprovocation – tests pulmonary response or reaction to the drug methacholine.
  • Pulse oximeter (Pulse Ox) - measures the saturation of oxygen carried in your red blood cells

A diagnosis is not supported by the simple reference of a diagnostic study. The provider must interpret the results and include the clinical significance in the medical record

Coding & Documentation

ICD-10 code assignment depends on documentation detail that should include:

  • Specific diagnosis
  • Severity, frequency or complication
  • Condition status and controlling agents
  • Causal relationships
  • Coexisting and/or underlying conditions

Refer to the tabular list for guidance on diagnosis inclusions, exclusions and additional coding notes.

Use Additional Code to identify:

  • Exposure to environmental tobacco smoke (Z57.31, Z77.22)
  • Tobacco use (Z72.0), tobacco dependence (F17.-), or history of tobacco dependence (Z87.891)
  • Dependence on supplemental oxygen  (Z99.81) - Use of long-term supplemental oxygen regardless of the duration each day[6]
  • Dependence on respirator [ventilator] status (Z99.11) - Use of respirator or ventilator for life support[7]
  • Long-term (current) use of inhaled or systemic steroids (Z79.5-)
  • Other diseases of the pleura (J90-J94)
  • Intraoperative and post procedural complications and disorders of respiratory system (J95)
  • Other diseases of the respiratory system (J96-J99)

Reference:

[1] Basics about COPD

[2] Chronic Bronchitis

[3] What are the Four Stages of COPD?

[4] ICD-10 J45 Asthma

[5] Lung Procedures, Tests & Treatments

[6] AHA Coding Clinic, 2002, Q4,

[7] Ventilator/Ventilator Support

Condition status Z codes are informative and distinct from “history of” codes. “History of” codes indicate a past condition has been resolved and is not present. Condition status codes indicate that a patient is either a carrier of a disease or has the sequela or residual of a past disease or condition. The status can affect the course of treatment and its outcome but they are most commonly overlooked. [1]

Amputation Status – Category Z89

Codes in category Z89 describe traumatic or post-procedural absence of a limb, when there are neither complications of the amputation nor treatment directed toward the site. Documentation should include anatomical location and laterality.

Artificial Opening Status – Category Z93

Codes in category Z93 describe functional artificial opening status. Artificial openings can be permanent or temporary depending on circumstances of creation. These codes are appropriate when no treatment is directed at the site. Documentation should include date of initial procedure and/or reversal, if applicable.

Organ Transplant Status – Category Z94

Category Z94 codes identify post-transplant status when there are no complications of the transplanted organ. A code from this category is appropriate as an additional code when treatment of a condition does not affect the function of the transplanted organ.

Supplemental Oxygen or Respirator Dependence – Category Z99

Category Z99 codes identify supplemental oxygen or ventilator dependence status when there is no complication or malfunction of the equipment on which the patient is dependent.[2] Dependence status can be for a short or long period of time in the hospital, another medical setting, or at home. Dependence on supplemental oxygen status is appropriate for any patient using long-term supplemental oxygen, regardless of the duration of use each day. Use dependence on respirator [ventilator] status codes when respiratory device or equipment is for life sustaining support.

Renal Dialysis Status

ICD-10-CM includes codes for dependence on renal dialysis and noncompliance with renal dialysis. These codes are appropriate when the presence of AV shunt for renal dialysis is indicated.

Lifelong Chronic Conditions[3]

Lifelong chronic conditions often require ongoing medical attention and the associated diagnosis are typically unresolved once diagnosed. It is appropriate to report these conditions, even when stable, if documented in any part of the medical record at the time of the encounter.

Condition Description ICD-10 Diagnosis[4]
HIV/AIDS B20 , Z21
Hemolytic Anemias D56.0, D56.1, D56.5, D57.0-D57.1
Disorders of Immunity D81.0 - D81.7, D81.89, D81.9, D82.0 - D82.1, D83.1, D84.1

Coagulation Defects and Hemorrhagic Conditions

D66, D67
Metabolic Disorders E70.0 - E72.9, E74.0 - E74.2, E74.4 - E74.9, E75.00 - E75.4, E76.01- E77.9, E78.71 - E78.72, E79.1 - E79.9, E80.0 - E80.3, E84 - E85, E88.01, E88.4-, E88.89
Pervasive Developmental Disorders F84.-
Systemic atrophies primarily affecting thecentral nervous system  G10 - G12.9
Extrapyramidal and movement disorders G20 - G23.9
Degenerative diseases of nervous system G31.81 - G31.83
Demyelinating diseases of the central nervoussystem  G36.0, G37.0
Diseases of myoneural junction and muscle G71.0 - G71.11, G71.2
Cerebral Palsy and Paralytic Syndromes G80.-, G82.-
Other Disorders of the nervous system G90.1, G90.3, G93.7
Auto-inflammatory syndromes M04.-
Congenital Malformations Q00.0 - Q02, Q04.0 - Q07.9, Q65.-, Q77.0 - Q78.9, Q79.6-, Q86.-, Q87.1 - Q87.89, Q84.4, Q89.8
Chromosomal Abnormalities Q90.0 - Q93.9, Q95.2 - Q95.3, Q96.0 - Q99.9

It is important to include all condition details in documentation. Report all applicable Z status codes and chronic condition diagnosis codes

  • When presence affects medical decision making or a pertinent factor of overall health; and/or
  • During a wellness or physical exam, at least once per calendar year for as long as they exist

Reference:
[1] ICD-10-CM Chapter 21: Factors influencing health status and contact with health services

[2] ICD-10-CM Codes Lookup

[3] Lifelong Chronic Conditions (PDF)

[4] ICD-10 Diagnosis

Heart Failure is a chronic, progressive condition in which the heart is unable to pump enough blood to meet the body's needs for blood and oxygen. Heart failure is usually caused by another condition that either damaged the heart or caused it to work too hard.

Risk Factors

  • Hypertension
  • Diabetes
  • Endocarditis
  • Coronary artery disease
  • Congenital heart disease
  • Cardiomyopathy
  • Obesity
  • Sleep apnea
  • Severe lung disease

Signs & Symptoms

  • Edema in the feet, ankles and legs
  • Fatigue, weakness, or lightheadedness
  • Irregular or fast heartbeat
  • Dyspnea, orthopnea, or persistent coughing
  • Confusion, impaired thinking, or decreased ability to concentrate

Types of Heart Failure

Heart failure can affect either the heart’s left or right side, or both sides, and it can be acute, chronic, or acute-on-chronic.

  • Left-sided heart failure, or left ventricular (LV) heart failure – Failure of the left ventricle, the main pumping chamber of the heart, to pump blood out to the body effectively. Accumulation of excess fluid behind the left ventricle causes dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and/or acute pulmonary edema.
    There are two different types of left-sided heart failure which call for different treatment approaches:
    • Systolic heart failure - Heart failure with reduced ejection fraction (HFrEF) – the left ventricle loses its ability to contract normally. The heart can’t pump with enough force to push enough blood into circulation.
    • Diastolic heart failure - Heart failure with preserved ejection fraction (HFpEF) – the left ventricle loses its ability to relax normally because the muscle has become stiff. The heart can’t fill properly with blood during the resting period between each beat.

  • Right-sided heart failure, or right ventricular (RV) heart failure - Failure of the right ventricle to move blood returning from systemic circulation into the lungs. Blood backs up in the body’s veins, causing systemic venous congestion (distended neck veins), pitting edema of the lower extremities or other dependent portions of the body, enlarged tender liver, and/or ascites.
  • Chronic heart failure develops slowly and the onset of symptoms may be gradual. Treatment is aimed at managing the underlying cause, minimizing symptoms, and preventing the heart failure from becoming worse.
  • Acute heart failure develops suddenly and symptoms are initially severe which may be experienced until the underlying condition is identified and treated. This can happen with:
    • Severe anemia
    • Hyperthyroidism
    • Pulmonary embolism
    • Arrhythmia
    • Severe infections or allergic reaction
  • Acute on chronic heart failure occurs when there is an acute decompensation of chronic heart failure.

Coding & Documentation

When documenting heart failure, include the following:

  • Type – systolic, diastolic, etc.
  • Acuity – acute, chronic, etc.
  • Disease status – stable, improved, etc.
  • Treatment plan – medicines, lifestyle changes, etc.

Code all documented conditions present at the time of the encounter that require or affect patient care, treatment or management. This includes stable chronic conditions and comorbidities. Include the ICD-10 coded to the highest specificity on the claim.

“Exacerbated” or “Decompensated”

Coding guidelines advise that “exacerbation” and “decompensation” indicate an acute flare-up of a chronic condition. When systolic or diastolic heart failure is described in these terms, the appropriate code indicating acute on chronic heart failure should be assigned.

Congestive heart failure

The term congestive heart failure refers to the back up of fluid into the lungs and tissues. Assign code I50.9, heart failure NOS for a diagnosis of congestive heart failure.

“With”

When documentation links either systolic or diastolic dysfunction with heart failure, report as systolic/diastolic heart failure. Link CHF to other associated conditions unless specifically documented as “unrelated”.

  • hypertension
  • chronic kidney disease (CKD)

ALL21-AR-H-084 Updated on October 20, 2021

Diabetes is a disease that occurs when glucose in the blood (blood sugar) is not controlled due to a malfunction of the body’s insulin production. Insulin is necessary to break glucose so that it can enter the body’s cells. High blood sugar from diabetes can lead to other major health problems.

Signs & Symptoms[1]

  • Frequent urination
  • Increased thirst or higher water intake
  • Constant hunger - even after eating
  • Extreme fatigue
  • Slow healing wounds or bruises
  • Unexplained weight loss
  • Tingling, pain, or numbness in hands/feet
  • Blurry vision

Diabetes Type & ICD-10-CM Category[2],[3]

  • Type I – Category E10
    • Insulin-dependent - the body does not produce insulin
    • Sometimes called juvenile diabetes because it usually develops during childhood or adolescence.
    • Sudden onset of symptoms  
  • Type II – Category E11
    • The body does not use the insulin it produces efficiently
    • Symptoms gradually progress
    • Treatment may include a combination of medications, exercise, and diet.[4]
  • Gestational – Category O24
    • Insulin produced by mother is blocked by pregnancy hormones increasing blood sugar.
    • Excess glucose is sent to the fetus and stored as fat.
    • Typically resolves once the baby is born.
  • Glucose intolerance that develops from disorders or conditions other than type 1, type 2 or gestational diabetes.
    • Due to underlying condition (E08.-)
    • Drug or chemical induced (E09.-)
    • Other specified diabetes, NEC (E13.-)

Coding & Documentation[5]

The provider should document all know condition details and the state the specific diagnosis. Document test results and any clinical findings that support diabetes along with disease status and treatment plan.

Assign the ICD-10-CM code to the highest level of specificity found in the medical record.

Combination Codes

Diabetes combination codes include:

  • Type of diabetes
  • Body System  affected
  • Complication/Manifestation affecting the body system

“With”

The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List.

  • Any condition indexed under “with” does not have to be linked by the provider. If the “with” condition is unrelated to diabetes, it must be specifically documented.
  • The link must be documented when a relationship exists between diabetes and another condition not found under “with” before assigning the diabetic complication code.
  • A patient may have diabetic complications in more than one body system. Report as many codes from categories E08 – E13 as are needed to identify all associated conditions.

Follow ICD-10 coding guidelines for code assignment and sequencing. Report codes for diabetic manifestations, underlying conditions, and the controlling agents when instructed.

Complication

Assumed Relationship

Link must be documented

Kidney

chronic kidney disease, glomerulonephritis, glomerulosclerosis, Kimmelsteil-Wilson disease, nephropathy, renal tubular degeneration Renal complications NEC, microalbuminemia, proteinuria

Ophthalmic

Cataract, retinopathy, macular edema, retinal detachment Ophthalmic complication NEC, blindness, glaucoma, Retinal ischemia, vitreous hemorrhage, rubeosis iridis

Neurological

Amyotrophy, autonomic (poly)neuropathy, gastroparalysis, gastroparesis, Loss of Protective Sensation (LOPS), mononeuropathy, myasthenia, neuralgia, neuropathy, polyneuropathy Neurologic complication NEC, cranial nerve palsy, neuropathic ulcer

Circulatory

Gangrene, peripheral angiopathy, (PVD/PAD) with or without gangrene

Circulatory complication NEC, coronary artery disease, hypertension

Other complication

Charcot's joints, dermatitis, foot ulcer, hyperglycemia, hypoglycemia, necrobiosis lipoidica, neuropathic arthropathy, osteomyelitis, periodontal disease

Arthropathy NEC, Oral complication NEC, Skin complication NEC, Other specified complication NEC, cellulitis, erectile dysfunction, obesity, high cholesterol

Code Also

  • Acute renal failure N17.9
  • Chronic Kidney Disease (CKD) N18.-
  • Glaucoma H40-H42

Use Additional Code

  • Use of insulin, Z79.4
  • Use of oral antidiabetic drugs, Z79.84
  • Use of non-insulin injectable drugs, Z79.899

Poor Control & Uncontrolled[6]

The terms “poor control” and “uncontrolled” are not interchangeable. Poorly controlled diabetes refers to diabetic hyperglycemia. There is not an index reference for “uncontrolled” diabetes. If hyperglycemic or hypoglycemic is not specified, the default code, E11.9 (diabetes, unspecified), is assigned.    

Reference:

[1] Signs & Symptoms

[2] Diabetes Type & ICD-10-CM Category

[3] Diabetes Type & ICD-10-CM Category

[4] Understanding Diabetes -- Diagnosis and Treatment

[5] 2021 ICD-10-CM Official Guidelines for Coding and Reporting (PDF)

[6] AHA Coding Clinic, Q1 2017 Pg. 42

ALL21-AR-H-087 Updated October 22, 2021

Occasionally, a reported diagnosis may be omitted from a claim due to errors or limitations of electronic claims submission. Improve the capture of risk adjustment conditions by entering the diagnosis codes on the claim correctly.

Diagnosis “pointers” connect the diagnosis made by the provider to each CPT® code billed on the claim. Only four (4) diagnosis pointers can be listed per CPT® code.

  • Identify the 4 most important or serious diagnoses that the procedure is intended to treat
  • Enter the diagnosis pointers in order of severity.

Maximize reporting opportunities:

Avoid missing eligible risk adjustment conditions by thorough documentation and accurate diagnosis coding.

  • Address all conditions present at the time of the encounter that require treatment or management.
  • Report all chronic conditions that impact treatment or care, even if stable. This includes pertinent status codes.
  • Explicitly state each diagnosis and provide documented evidence of support in the medical record.
  • Capture all valid ICD-10 diagnosis codes in the appropriate order on the claim form. 

Always follow the current ICD-10-CM Official Guidelines for Coding & Reporting[1] Refer to the Medicare Claims Processing Manual2 for additional information.

1500 Claim Form Instructions (PDF) - Coming soon

Health Insurance Claim Form (PDF) - Coming soon

Documentation Requirements[1]

Documentation must:

  • Result from a face-to-face encounter with acceptable provider in an acceptable setting type
  • List the complete date of service (month/day/year)
  • Contain at least two patient identifiers on EACH page of every document (Name, DOB, MRN)
  • Include legible handwritten signature with credentials or proper EMR electronic authentication
  • Explicitly state the diagnosis and clearly document supporting evidence of an active/current condition

Condition Assessment

Assess the status of conditions for which interventions are recommended or underway. Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.  This includes ongoing chronic conditions, even if stable.

Documentation from past dates of service may not be used to report codes for the current date of service.

Current/Active Diagnosis

MEAT & TAMPER are used as tools to help coders determine if a condition can be coded as current or active. At least one of the following elements must be present in at least one section of the medical record (Subjective, Objective, Assessment, Plan) to substantiate the presence of a condition:

  • Monitor, Evaluate, Assess/Address, Treat
  • Treat, Assess, Monitor/Medicate, Plan, Evaluate, Refer

History Of

Do not code conditions that have been treated or no longer exists. Documentation where the provider has used the term(s) “history of” will be coded using the appropriate diagnosis code for the historical condition. The condition should not be referenced as a “history of” if it is a chronic condition currently undergoing treatment.

Condition Lists

Conditions mentioned in Past Medical History or Active Problem List must be supported in another section of the medical record in order to verify the condition is active. The best practice is to include evidence of current review in the form of medication, referrals, order of lab tests, etc. in the assessment and plan.

Specificity

Document to the highest degree and code to the highest specificity. The ICD-10 diagnosis code must match the wording used in documentation. Explicitly state the diagnosis and follow the official conventions and guidelines for coding and reporting.

Consistency

Be clear and consistent throughout the medical record when documenting details of a condition. A diagnosis cannot be validated when the record contains conflicting information.

Reporting

When a condition is assessed and documented in a face-to-face encounter, include the corresponding ICD-10 diagnosis code on the claim form submitted to the health plan.

Telehealth[2],[3]

Telemedicine Visits provided via synchronous audio and video technology meet the face-to-face requirement for risk adjustment. Documentation must include that the visit was performed using interactive audio/video with real-time, two-way communications. Virtual Check-Ins, E-Visits, and Telephone Visits are not acceptable.

Resources

[1] Documentation Requirements (PDF)

[2] Medicare has expanded telehealth coverage and eased current restrictions for the duration of the COVID-19 crisis. During this time, telehealth services that meet the face-to-face documentation requirements can be used for risk adjustment.

[3] Telehealth (PDF)

[4] ICD-10-CM Official Guidelines for Coding and Reporting (PDF)
The Official ICD-10-CM Guidelines[4] are the authoritative source for diagnosis coding and documentation. Please refer to the current year’s guidelines for detailed instructions.  These guidelines and other information about risk adjustment can be found on CMS’s website

Follow the guidelines and assign the appropriate combination codes when reporting hypertension and another condition.[1]

The relationship between hypertension, heart disease and chronic kidney disease is assumed when conditions are found together unless explicitly documented unrelated.

Applies to conditions found in I50.-, I51.4-I51.7, I51.89, I51.9Category I11 - Hypertensive Heart Disease

  • Code separately only if  heart disease stated not due to hypertension
  • Use additional code from category I50, Heart failure, if applicable

Category I12 - Hypertensive Chronic Kidney Disease (CKD)

  • Code separately only if documentation specifies cause other than hypertension
  • Use additional code to identify the stage of the CKD
  • Also code dialysis status, if applicable

Category I13 - Hypertensive Heart & Chronic Kidney Disease

  • Do NOT separately code for hypertension, heart disease, and chronic kidney disease or assign with codes from categories I11 or I12
  • Use additional code for heart conditions I50.-, I51.4-I51.7, I51.89, I51.9
  • Also code the appropriate stage of CKD (N18.- ) and dialysis, if applicable

For conditions not found under the term “with”, the relationship between hypertension and another condition must be specifically documented in order to code them as related.

Category I15 - Secondary Hypertension

Secondary hypertension is due to an underlying condition.

  • Assign the code for the underlying condition and a code from category I15

Category I16 - Hypertensive Crisis

  • Use a code from category I16 when hypertensive urgency, hypertensive emergency or unspecified hypertensive crisis is documented.
  • Code also any identified hypertensive disease (I10- I15)

Category I27 - Pulmonary Hypertension

  • Pulmonary hypertension is classified to category I27, Other pulmonary heart diseases.
  • Code also any associated conditions or adverse effects of drugs or toxins.

Hypertensive Cerebrovascular Disease

  • Assign code from categories I60-I69, followed by the appropriate hypertension code (I10-I15)

Hypertensive Retinopathy

  • Code H35.0, Background retinopathy and retinal vascular changes with the applicable code from category I10-I15

Transient Hypertension

When a hypertension diagnosis has not been established, assign one of the following codes:

  • R03.0, Elevated blood pressure reading without hypertension
  • O13.-, Gestational [pregnancy-induced] hypertension without significant proteinuria
  • O14.-, Pre-eclampsia, for transient hypertension of pregnancy

Reference:

[1] ICD-10-CM Official Guidelines for Coding and Reporting FY 2022

ALL21-AR-H-091 Updated on October 21, 2021

Ischemic Heart Disease[1]

Atherosclerosis

Atherosclerosis is the buildup of fatty deposits, or plaque, within the coronary arteries. Plaque buildup causes narrowed or blocked blood vessels which can lead to more serious conditions such as acute coronary syndrome and myocardial infarction.

Coronary atherosclerosis is categorized by the type of vessel in which it occurs.

  • Native coronary artery
  • Coronary artery bypass graft (CABG)
    • Autologous or non-autologous artery or vein
    • Other CABG
  • Artery of transplanted heart

Atherosclerosis is also known as atherosclerotic heart disease (ASHD), coronary artery disease (CAD), or atherosclerotic cardiovascular disease (ASCVD).

RISK FACTORS:

  • Diabetes
  • Hypertension
  • Poor diet
  • Smoking
  • High cholesterol
  • Obesity
  • Lack of exercise
  • Age
  • Gender
  • Family history
  • Poor dental health
  • Stress

When documenting atherosclerosis, include the following:

  • Location –coronary artery involvement, vessel type
  • Symptoms – angina, shortness of breath, etc.
  • Comorbid conditions – hypertension, tobacco use, etc.

Angina

Angina is chest pain or discomfort caused when the heart muscle does not get enough oxygen-rich blood. It is usually a symptom of and underlying heart condition such as coronary artery atherosclerosis.  

SIGNS & SYMPTOMS:

  • Chest pain or discomfort, pressure, squeezing, or fullness in the center of the chest
  • Radiating pain in the arms, neck, jaw, shoulder or back
  • Nausea, fatigue, shortness of breath, sweating, dizziness

TYPES & SEVERITY:

  • Stable – Pain usually caused by exertion or excitement and stops when at rest or with medication.
  • Unstable – Pain changes in frequency, duration and intensity. Does not go away with rest or medicine.
  • Variant – Coronary vasospasm that occurs most often while at rest. Associated with transient ST-segment elevation

When documenting angina, include the following:

  • Type – stable, unstable, etc.
  • Cause – presumed to be ASHD, note if there is another cause
  • Timing/precipitating factors – exercise, emotional stress, etc.
  • Relieving factors – medications, rest, etc.

Not all chest pain is angina.  “Angina” must be explicitly stated. Stable or asymptomatic angina that is controlled by a medication is an active condition and should be assessed, documented, and reported at least once per year. Use “history of” when the condition has resolved and treatment is no longer needed.

Heart Disease Prevention & Management

Heart Disease Prevention & Management

Lifestyle changes:
Medications: Procedures
low-fat and low-sodium diet
statins stents
quit smoking calcium channel blocker angioplasty
limit alcohol intake antianginals bypass
moderate exercise, 30min/day beta blockers implant device

Myocardial Infarction (MI)

Myocardial infarction, known as a heart attack, is the permanent gross necrosis of the myocardium (heart muscle tissue death). An electrocardiogram (ECG) reading will differentiate a ST elevation myocardial infarction (STEMI), or classic heart attack, from a non-ST myocardial infarction (NSTEMI), sometimes called a mild heart attack.

A heart attack occurs when a blocked artery interrupts blood flow to a section of the heart. If the blockage is not treated quickly, that part of the heart begins to die. Symptoms may be immediate and intense but typically start slow and persist for hours, days or weeks before a heart attack. Report in acute/post-acute care setting or following transfer to another acute setting.

CLASSIFICATON[2]

  • Type 1 - Spontaneous
  • Type 2 - Ischemic
  • Type 3 - Unknown
  • Type 4 – (3 subtypes, a-c)
    • a - Due to percutaneous procedure
    • b - Due to stent thrombosis
    • c - Due to restenosis
  • Type 5 - Due to CABG

Cardiac arrest is triggered by an irregular heartbeat (arrhythmia) affecting the heart’s ability to pump blood to other the brain organs.  Cardiac arrest occurs suddenly, often without warning.  It is reversible if treated within the first few minutes but without quick intervention, is fatal.

ICD-10-CM

Category I20 – Angina Pectoris & Category I25 – Chronic ischemic heart disease

ICD-10-CM presumes a causal relationship between ASHD and angina when no other cause has been identified for the angina. These same conditions are coded separately when the provider has specifically documented a different cause for angina.[3]

  • I25.2, old MI – healed myocardial infarction or MI older than 4 weeks (28 days).

Category I21 – Acute MI

  • Type 1 - initial myocardial infarction from onset up to 4 weeks (28 days) old.
  • Unspecified AMI or unspecified type is assigned I21.9
  • Types 3-5 are coded I21.A9

Category I22 – Subsequent MI

  • Occurrence of an acute MI within the four-week time frame of the initial acute MI.
  • Code with a category I21 code

Category I23 – Current complication following MI

  • Must be coded with a Category I21 or Category I22 code
  • "Post-infarction angina” must be stated to assign (I23.7) as a current complication

Category I24 – Acute ischemic heart disease

  • Acute blood clots in the coronary arteries without myocardial infarction
  • Acute coronary syndrome (ACS)[4]

References:

[1] Ischemic Heart Disease

[2] CLASSIFICATON

[3] ICD-10-CM Official Guidelines for Coding and Reporting (PDF)

[4] Acute coronary syndrome (ACS)

ALL21-AR-H-092 Updated on October 21, 2021

Major Depressive Disorder[1]

Major Depressive Disorder, also known as clinical depression, is a common mood disorder characterized by a depressive episode having five or more symptoms causing significant distress or impairment (not caused by substance abuse or other condition) lasting two or more weeks. At least one of the five symptoms must be depressed mood or loss of interest.

Symptoms of Depression: 

  • Depressed Mood
  • Feelings of worthlessness or guilt
  • Fatigue or low energy
  • Insomnia or hypersomnia
  • Significant change in weight or appetite
  • Loss of interest or pleasure in most or all activities
  • Psychomotor retardation or agitation
  • Recurrent thoughts of death or suicidal ideation
  • Poor concentration

Depression screening tools, such as the PHQ-9[2] , are used to identify the presence and level of severity.

PHQ-9 Depression Scoring

SCORE

SEVERITY

PROPOSED TREATMENT

0 – 4

None – Minimal

Education on available supportive services

5 – 9

Mild

Watchful waiting: Repeat PHQ-9 at follow-up Visit

10 – 14

Moderate

Treatment Plan: Consider Counseling and/or medication, follow-up visits

15 – 19

Moderately Severe

Active Treatment: Pharmacotherapy and/or psychotherapy, follow-up visits

20 – 27

Severe

Immediate initiation of pharmacotherapy, expedited referral to mental health specialist for psychotherapy and/or collaborative management 

Bipolar Disorder[3]

Bipolar disorder, sometimes called manic-depressive disorder, causes extreme shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. People with bipolar disorder experience periods of intense emotion, changes in sleep patterns and activity levels, and unusual behaviors. These distinct periods are called “mood episodes.” A provider would have to determine whether they may be the result of another cause (such as low thyroid, or mood symptoms caused by drug or alcohol abuse).

Symptoms of Mania:

  • Talking more/faster than usual
  • Inflated self-esteem (grandiose delusions)
  • Extremely high energy and irritability
  • More easily distracted
  • Increased high-risk /reckless behavior
  • Decreased need to sleep

Symptoms of Hypomania:

  • Increased restlessness and irritability
  • Extreme low energy and fatigue
  • Decreased self-esteem
  • Difficulty concentrating or making decisions
  • Lasting sad, anxious, or empty mood
  • Disturbance in sleep/wake cycle

Symptom Profile[4]

Bipolar Type 1

  • Marked by manic episodes
  • Hospitalization due to mania likely
  • Psychosis may occur during manic episodes

Bipolar Type 2

  • Marked by hypomanic episodes
  • Hospitalization due to hypomania less likely
  • Psychosis UNLIKELY to occur during hypomania

SCHIZOPHRENIA

This disorder affects the way a person thinks, feels and acts. If makes it difficult to differentiate what is real and what is not. Symptoms vary by severity and type. All symptoms may or may not be present in individuals with the condition.[5]

Symptoms of Schizophrenia:

  • Hallucinations
  • Lack of focus
  • Extreme disorganized thoughts
  • Impaired memory
  • Delusions
  • Difficulty completing tasks
  • Movement disorders
  • Unmodulated speech

Coding & Documentation

Major depression and bipolar disorders are classified by their features (type, severity, and presence of psychosis).[2] Symptoms can manifest differently from person to person. A patient’s complete overall health status requires accurate, detailed documentation of the provider’s assessment.[6]

Condition Status

  • ACTIVE/CURRENT - Provider assessment confirms the condition exists and the diagnosis is documented in the medical record. A patient can have a current diagnosis without being actively involved in treatment.
  • “HISTORY OF” - Patient has been previously been diagnosed, condition has completely resolved and treatment is no longer needed. Past medical history (PMH)

Avoid using non-specific terms and unspecified codes when details of the condition are known.

Type[7]

Applicable to the current BIPOLAR EPISODE.

  • MANIC EPISODE (F30.-)
  • Single manic, hypomanic or mixed bipolar episode.
  • TYPE 1, TYPE 2, or MIXED (F31.-)
    • TYPE 1 - Manic episodes (extreme up) lasting 1 week or longer. May also experience depressive episode for at least 2 weeks.
    • TYPE 2- Hypomanic episodes (extreme low) for 4 days and depressive episodes for 2 weeks.
    • MIXED - Meets criteria for manic AND depressive episodes almost every day for AT LEAST one week.

Applicable to the most recent MAJOR DEPRESSIVE EPISODE

  • SINGLE EPISODE (F32.-) – By definition,single episode” applies to the first episode and initial diagnosis of major depressive disorder. Single - only one (1) in number, unique, sole* 
    ICD-10-CM CODE UPDATE
    : [8]
    • F32.A, Depression, unspecified - Applies to Depression, not otherwise specified (NOS)

Report F32.9, only if “major depressive disorder, single episode, unspecified severity, presence of psychosis unspecified” supported by provider documentation in the medical record.

  • RECURRENT EPISODE (F33.-) - “Recurrent”, applies to each subsequent episode and following encounter after the initial episode has resolved. Recurrent – repeated; persistent; intermittent*

* Note: Sourced definitions[9]

Severity

  • MILD - 5 or 6 symptoms with mild disability, normal function requires substantially more effort than usual
  • MODERATE - 7-9 symptoms with moderate functional impairment
  • SEVERE - 7-9 symptoms with major disability, inability to function in relationships with others and/or usual activities of day to day life
  • IN REMISSION - Patient has responded to treatment and no longer meets the criteria for clinical depression. The condition may or may not be currently managed by long term antidepressant medication and/or therapy services.
    • Partial remission – No or minimal symptoms for less than two months
    • Full Remission – No or minimal symptoms for two months until treatment is complete and/or condition has resolved.

With or Without Psychotic Features

Specify the type and nature of the psychotic features.

  • DELUSIONS / HALLUCINATIONS
  • Mood-congruent: Not Consistent with typical depressive themee
    • Thought insertion  –  other persons thoughts in your head
    • Thought broadcasting –  others can hear your thoughts
    • Control - own actions are under outside control
  • Mood-congruent: Not Consistent with typical depressive theme
    • Thought insertion  –  other persons thoughts in your head
    • Thought broadcasting –  others can hear your thoughts
    • Control - own actions are under outside control

Additional Classifications

  • PERSISTENT MOOD DISORDERS (F34.-) - Symptoms present for most days during the past two years not meeting all criteria for major depressive or bipolar disorders
    • Cyclothymia - alternating and recurring periods of depression and hypomania
    • Dysthymia - Persistent depression without psychosis. Mild to moderate chronic depression.
  • SCHIZOPHRENIA (F20.-) - Categorized by the manifestation:
    • Paranoid
    • Catatonic
    • Residual
    • Disorganized
    • Undifferentiated
    • Other and unspecified
  • SCHIZOAFFECTIVE DISORDERS (F25.0) - Characterized by having symptoms of both schizophrenia and mood disorders (depression, bipolar disorder) alternating from delusions or hallucinations to the predominant mood disorder symptoms during the active period of the condition.
  • CATEGORY F01 - F09,  Mental disorders due to known physiological conditions
  • CATEGORY F10 - F19, Mental and behavioral disorders due to psychoactive substance use 

References:
[1] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth edition, 2013
[2] PHQ Screeners Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute
[3] Bipolar Disorder
[4] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth edition, 2013
[5] Schizoaffective disorders
[6] International Classification of Diseases 10th Revision Clinical Modification ICD-10-CM Official Guidelines for Coding & Reporting
[7] Codes for Depression (F32-F33) and Bipolar (F30-F31) are not reported together.  See “Excludes 1 & 2” category guidelines.
[8] Effective 10/1/2021
[9] Dictionary


ALL21-AR-H-090 Updated November 15, 2021

Neoplasms & Cancer[1]

A neoplasm is an abnormal growth or mass of cells called a tumor. Tumor growth, or behavior, can be benign (non-cancerous) or malignant (cancerous). Benign tumors grow in one place and do not spread to other body parts. Malignant tumors grow, spread and invade other body parts (metastasis).

Types of Cancer

Cancer can start almost anywhere in the human body. Primary cancer refers to the origin of a malignant neoplasm. Metastatic cancer, or secondary cancer, is the formation of a new tumor in a secondary site from the metastasis of the primary cancer.     

Cancer is usually classified by the location it started (i.e. lung cancer, colon cancer, breast cancer, etc.) or the type of cell where it was formed.

  • Carcinoma – epithelial cells, cells covering inside or outside surfaces
  • Sarcoma – bone and soft tissue, includes muscle, fat, blood & lymph vessels, tendons & ligaments,
  • Leukemia – bone marrow
  • Lymphoma –lymphocytes (T cells & B cells), white blood cells
  • Myeloma – plasma cells
  • Melanoma – melanocytes, melanin producing cells (pigmented tissue such as skin or eyes)

Detection & Staging

Cancer staging is based on the extent of the tumor. Laboratory studies of blood, urine, and stool to detect abnormalities that may indicate cancer. Imaging tests such as X-rays, CT, MRI, ultrasound, and fiber-optic endoscopy help determine the suspected cancer’s location and size. A biopsy can confirm the diagnosis of most cancers and other tests can provide specific information about the cancer.

The stage of cancer indicates information about the location, cell type, size, and grade, and if it has spread to a different part of the body. A cancer is always referred to by the stage it was given at diagnosis regardless of progression or regression.

Carcinoma in situ

Stage I, II, & III

Stage IV

Abnormal cells present but confined to the point of origin without invasion of the surrounding normal tissue

Cancer is present. The higher the number, the larger the cancer tumor and the more it has spread into nearby tissues.

Cancer has grown very extensive and/or has spread to distant parts of the body.

Cancer Treatments

Treatment depends on the cancer type and how advanced it is. Malignant tissue can be removed with surgical excision or treated using targeted therapy, precision medicine, or stem cell transplant.

Targeted Therapy - use of drugs to attack specific types of cancer cells with less harm to normal cells
Precision Medicine – use of genetic and environmental proteins to treat the cancer
Stem Cell Transplant - cancerous bone marrow is replaced with healthy bone marrow from a donor

Coding & Documentation[2]

Clearly document all know details of the patient’s condition. This should include:

  • Behavior - Malignant, Benign,
  • Location – site specific (cell type, anatomical location, laterality)
  • Type – Primary, Secondary, include cancer stage  
  • Status – Active,  In remission, History of

Tips:
For active cancers, document the current treatment. If patient has refused treatment or is under watchful waiting, document the reason and disease progress.

If the patient receives adjuvant therapy, indicate if it is for treatment or prophylactic purposes.

Also report the type of cancer treatment used

Radiation Therapy (Z51.0)
Chemotherapy (Z51.11)
Immunotherapy (Z51.12)
Hormone Therapy (Z79.890)

ICD-10-CM Guidelines[3]

When assigning the diagnosis for neoplasms and cancer, refer to the Neoplasm Table found in the alphabetic index first, unless the histological term is documented (ex. Adenoma). The terms “lump” or “mass” should never be indexed to the neoplasm table. The index directs a coder to see “mass” instead.

  • Neoplasm that overlaps two or more contiguous sites should be coded (overlapping lesion) unless specifically classified elsewhere.
  • When treatment is directed at the malignancy, make the malignancy the principal diagnosis.
  • If the encounter is solely for the administration of chemotherapy, immunotherapy, or radiation therapy, assign a code from category Z51- first.
  • When treatment is directed toward a secondary site only, the secondary neoplasm is designated as the principal diagnosis.

Active vs. Historical

Documentation should clearly indicate and provide support for the current condition.

DO NOT code “history of” when cancer is currently active or assign a code for active cancer if the disease has been treated and no longer exists.

Report a code for active cancer when documentation supports:

  • Current treatment or patient’s refusal of treatment
  • Further treatment is directed towards site of excised malignancy
  • Watchful waiting

History of cancer should be reported as personal history of malignant neoplasm with the appropriate code from category Z85- when documentation supports:

  • Malignancy has been removed, treatment was completed or and/or patient is being monitored for a recurrence.
  • There is no evidence of disease and no further treatment being directed towards site
  • Adjuvant therapy is for prophylactic purposes

Leukemia, multiple myeloma and malignant plasma cell neoplasms, have codes indicating whether the cancer has achieved remission status, or is in remission.

  • Z85.6 Personal history of leukemia is only used when the physician documents that the patient has been completely cured

Reference
[1] National Cancer Institude

[2] The Web's Free 2022 ICD-10-CM/PCS Medical Coding Reference

[3] ICD-10-CM Official Guidelines for Coding and Reporting (PDF)

AMB21-AR-H-109 Updated on October 18, 2021

ALL21-AR-H-089 Updated on October 18, 2021

BMI & Weight Class

Body mass index (BMI) is the ratio between individual’s weight and height. This formula is used to find BMI using pounds and inches: [2]        

BMI = Weight (lb) / [Height (in)]2 x 703.

The BMI value typically corresponds with the amount of fat on an individual’s body and is used to screen for health risks associated with obesity.

Adult Weight Class (Applicable to individuals 20 years of age or older)

  • Underweight: BMI less than 18.5
  • Healthy Weight: BMI 18.5 – 24
  • Overweight: BMI 25 – 29
  • Obese: BMI 30 or higher

Obesity & Morbid Obesity

Obesity is further classified by severity.[3], [4]

Class 1: (high risk) Class 2: (very high risk) Class 3: (extreme risk)
BMI 30 – 34 BMI 35 – 39 BMI 40+

Morbid obesity is defined as

  • Body Mass Index (BMI) of 40 or greater; or
  • BMI of 35 or greater and one or more co-morbid condition; or
  • Being 100 pounds or more above ideal body weight

Risk Factors

Individuals with a high BMI have an increased risk of other chronic conditions. The higher the BMI the greater the chance of having serious complications. 1 including, but not limited to:

  • Cancer
  • Diabetes
  • Emotional/Social issues
  • Heart Disease
  • High Blood Pressure
  • High Cholesterol
  • Mobility Problems
  • Mortality
  • Osteoarthritis
  • Respiratory disorders
  • Sleep apnea
  • Stroke

However, obesity cannot be assumed from a BMI value. The calculation does not account for muscle mass, bone density, body composition, or ethnic and gender differences.

  • Patients with a large waist circumference or excess body fat can be obese even if they have healthy BMI.
  • Healthy patients with more lean muscle mass may have a BMI that falls into the obese range.
  • Multiple patients can have the same BMI value without having the same weight related diagnosis.

Coding & Documentation[5]

The medical record must include the patient’s weight and the calculated BMI as well as the date of the exam. BMI can be documented by any clinician.

  • Physician/Other qualified practitioner
  • Nutritionist
  • Nurse
  • Emergency Medical Technician

A diagnosis associated with BMI (i.e. overweight, obese, morbidly obese, etc.) must be explicitly documented by the treating physician or other qualified provider involved in the patient’s care.

Individuals who are OVERWEIGHT, OBESE, or MORBIDLY OBESE are at an increased risk for certain medical conditions when compared to persons of normal weight. These conditions are always clinically significant and reportable when documented by the provider.6

Documentation should state the clinical significance of obesity to overall health including:

  • Relationship to complications and/or comorbidities
    • Due to
    • Complicated by
  • Causal or contributing factors
    • Excess calories
    • Drug induced
    • Other disorder

Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.

ICD-10-CM codes for Body Mass Index (BMI) found in Category Z687 are to be reported only secondary to a related diagnosis.

 

[1] Managing Overweight and Obesity in Adults (PDF)

[2] How is BMI interpreted for adults?

[3] Defining Adult Overweight & Obesity

[4] Definitions, Classification, and Epidemiology of Obesity

[5] ICD-10-CM Official Guidelines for Coding and Reporting (PDF)

[6] AHA Coding Clinic, 3rd quarter 2011, Vol. 28, Num. 3, pages 4-5

[7] Body mass index [BMI] Z68-

 

ALL21-AR-H-082 Updated October 2021

Preventive visits are an important part of the process of keeping patients healthy. These visits improve quality of care and patient health outcomes by identifying patients who need disease management and intervention.

Annual Physical Exams[1]

Annual Physicals or Routine Comprehensive Physical Exams (CPE) are performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.  The extent and focus of exam depends on the age and gender of the patient. An annual CPE includes an appropriate history/exam with risk counseling and/or intervention

Exam Description and CPT© Code

Patient Age

Initial Exam

Subsequent Exam

Less than 1 year

99381

99391

1 – 4 years

99382

99392

5 – 11 years

99383

99393

12 – 17 years

99384

99394

18 – 39 years

99385

99395

40 – 64 years

99386

99396

65 years and older

99387

99397

How should diagnosis codes be reported?[2]

Category Z00 includes codes for Routine Health Exams “with” or “without” abnormal findings and should be the primary diagnosis. Report additional codes, if applicable, for pre-existing and chronic conditions as well as newly discovered conditions and/or abnormalities documented during the routine exam, regardless of whether the finding requires an additionally reported service.

Description Diagnosis

General adult medical examination

  • without abnormal findings
  • with abnormal findings

Z00.00
Z00.01

Routine child health examination

  • with abnormal findings
  • without abnormal findings


Z00.121
Z00.129

Newborn and infant health examinations
(as appropriate for age)

Z00.11x

Follow the current year’s Official ICD-10-CM Guidelines for Coding and Reporting

What can be reported with the CPE?

Ancillary Studies Screenings Vaccines
• Laboratory
• Radiology
• Other procedures
• Vision
• Hearing
• Developmental
• Toxoid
• Administration
• Risk/Benefit Counseling

Tobacco smoking cessation counseling and substance abuse screening/intervention are included with CPE. Refer the current year’s CPT® Code book for further guidance and to view other services covered at the time of a preventive medicine exam.

Can preventive visits be performed on the same day as another visit?

A separately identifiable E/M service may be performed if prompted by symptoms or chronic conditions assessed during the AWV/CPE. Select the appropriate level of E/M services based on the following:

  • The level of the medical decision making as defined for each service; or
  • The total time for E/M services performed on the date of the encounter.

Append modifier -25 to the E/M service (99202 – 99215) when performed on the same day as CPE (99381 - 99387, 99391 – 99397)

References:
[1] ICD-10-CM Official Guidelines for Coding and Reporting (PDF)

All services provided require medical record authentication. Signatures may be handwritten or electronic. Rubber signature stamps are not acceptable unless an exception has been granted due to a physical disability.

Manual Signatures

  • Legible hand written signature with credential – No date of signature required
  • Hand written signature or initials if provider name/credential on pre-printed progress note
  • If the names of two or more physicians are listed on the note, then the provider must have his/her name identified, such as pre-printed name/credential
  • Initials over a typed or pre-printed name with credential
  • “Scribble”-as long as acceptable provider name with credentials is indicated.
  • Digitalized signature: handwritten and scanned into computer must be legible or provider name with credentials must be on record.

Electronic Signature Elements

  • Authentication    
  • Practitioner’s name
  • Credentials noted
  • Date signed *must be within 180 days of date of service
  • “Last Updated” is an approved electronic signature date as long as the Electronic signature wording is an approved authentication.    
    • If elements of the electronic signature are not met in its entirety, an attestation is needed.
    • Practitioner credentials can be pre-printed anywhere within the DOS.

Transcribed Records

  • Provider Signature authentication statement
  • Provider name
  • Provider credentials
  • Date note signed
    • Note: To identify a transcribed note, look for indicators such as “Transcribed by”, “Date dictated (DD)”, and/or “Date Transcribed (DT)”.

Authentication Examples
(Not all inclusive)

  • Accepted by
  • Completed by
  • Electronically signed by
  • Released by
  • Acknowledged by
  • Confirmed by
  • Electronically verified by
  • Reviewed by
  • Approved by
  • Digitally signed by
  • Encounter sign off by
  • Signature on file
  • Authenticated by
  • E-Authenticated by
  • Finalized by
  • Signed
  • Authorized by
  • Edited by
  • Generated by
  • Signed by
  • Closed by
  • Electronically generated
  • Performed by
  • Validated by

Reference: Medicare Program Integrity Manual (PDF)

Rheumatoid Arthritis & Other Inflammatory Connective Tissue Disorders [1], [2]

Rheumatoid arthritis (RA) is a systemic autoimmune disease where the body’s immune system attacks its own joints, causing inflammation and joint damage. RA can occur at any age. Juvenile arthritis is a form of RA that develops in childhood that can carry into adulthood.

Signs & Symptoms

Symptoms of RA can come and go for some, and be severe and continuous for others. The condition can lead to serious joint damage and disability in severe cases.

  • Joint pain, stiffness, & swelling
  • Warmth & redness of joints
  • Nodules under skin near joints
  • Frequent fatigue
  • Loss of appetite & weight loss
  • Occasional fever

Clinical Criteria for RA Diagnosis

  • Inflammatory arthritis of 3 or more joints
  • Positive RF testing
  • Elevated levels of CRP or ESR
  • Symptoms greater than six weeks
  • Other similar diseases have been ruled out
  • Rheumatology consultation

Diagnostic Tests

  • Rheumatoid factor test (RF)
  • Anti-citrullinated peptide antibody test (ACPA)
  • C-reactive protein test (CRP)
  • Erythrocyte sedimentation rate (ESR)
  • X-ray, MRI, and ultrasound

Diagnostic tests can provide support for a specific diagnosis. Test results cannot be used to assume a diagnosis more specific than the provider documents in the medical record.

Manifestations & Complications

RA is commonly known as a joint disease but it can also involve multiple organ systems.

Heart

  • Accelerated atherosclerosis
  • Pericarditis

Nerves

  • Cervical myelopathy
  • Neuropathy

Eyes

Episcleritis/scleritis Keratoconjunctivitis sicca Peripheral ulcerative keratitis

Lungs

  • Caplan syndrome
  • Interstitial lung disease
  • Pleural effusion
  • Pulmonary nodules

Blood

  • Amyloidosis
  • Felty’s syndrome

Skin

  • Rheumatoid nodules
  • Vasculiti

Increased risk of complications can arise as a result of the disease or the treatment of the disease such as depression, infection, or malignancy.

Treatment

The treatment of RA should begin as soon as the diagnosis has been made and symptoms will need to be frequently monitored in order to minimize joint pain and swelling, prevent deformity, control manifestations, and maintain quality of life.

Treatments may include DMARDS, NSAIDS, corticosteroids, dietary changes, and physical therapy or exercise training.

Coding & Documentation

A provider must actively consider chronic comorbidities and their effect in the medical decision making process. This consideration to appropriate to document in the medical record and should be reported on claims.[3]

Documentation should include:

  • Etiology[4]
  • Onset, frequency and severity of symptoms
  • Joint(s) affected, progression and any deformities, if applicable
  • Test results used to confirm diagnosis
  • Associated complications
  • Treatment used to control symptoms and/or prevent joint damage

ICD-10-CM[5]

Category M05-M06, M08

Combination codes for Rheumatoid arthritis specify:

  • Presence of rheumatoid factor
  • Organ or system affected
  • Site & Laterality

Other Inflammatory Connective Tissue Disorders[6]

  • Psoriatic arthritis (L04.5-)
  • Reiter’s Disease (M02.3-)
  • Auto inflammatory Syndromes (M04.-)
  • Systemic Connective Tissue Disorders (M30-M35)
  • Spondylopathies (M45-M46, M48.8x-, M49.8-)

References:

[1]  Diagnosis and Management of Rheumatoid Arthritis

[2]  What Are the Types of Spondyloarthropathies?

[3] Johnston G. HCC coding and the importance of documenting comorbidities. Presented at: United Rheumatology National Meeting. April 20-21, 2018; San Diego.

[4] When arthritis is not specified further, ICD-10-CM defaults to osteoarthritis, unspecified site.

[5] Diseases of the musculoskeletal system and connective tissue M00-M99

[6] Condition categories applicable to Medicare Advantage risk adjustment HCC model v24

 

ALL21-AR-H-083 Updated on October 20. 2021

Sepsis, Severe Sepsis, & Septic Shock[1]

Sepsis is the immune systems extreme response to an infection. The chemical released into the bloodstream by the immune system attack the body instead of fighting the infection.  Sepsis can quickly lead to tissue damage, organ failure and death. Early identification and treatment is critical.

  • Septicemia or sepsis – Bacterial, viral or fungal infection in the bloodstream, also called blood poisoning
  • Inflammatory Response Syndrome (SIRS) - Systemic inflammation due to a blood born infection or other non-infectious cause such as trauma or injury
  • Severe Sepsis – Sepsis with systemic organ dysfunction, hypoperfusion (reduced blood flow) or hypotension (low blood pressure)
  • Septic Shock – Severe sepsis with extreme, persistent hypotension and circulatory failure  

Signs & Symptoms

Sepsis may cause any of the following:

  • Rapid breathing and heart rate
  • Extreme pain or discomfort
  • Shortness of breath 
  • Fever, shivering, or feeling very cold
  • Confusion or disorientation 
  • Clammy or sweaty skin
  • Nausea and vomiting 
  • Blotchy, pale or discolored skin

Coding & Documentation

There is no single diagnostic test or comprehensive clinical criteria for sepsis.  The diagnosis requires clinical judgment of the provider based on evidence of infection and organ dysfunction.[1]

The level of detail in the documentation impacts coding and reporting accuracy.

  • Identify the infectious agent or causal organism as well as the related infectious or non-infectious condition
  • Document the severity of the condition and including the organ(s) affected with the nature and severity of dysfunction
  • Specially state the causal relationship (due to/cause of) between sepsis and
    • other infectious conditions
    • non-infectious conditions
    • post-procedural infections

To determine the proper code sequencing.

  • Clearly state the reason for the hospital admission or the primary diagnosis.
  • Note whether sepsis is present on admission or if it developed after admission if not the cause.

 

Sepsis would not typically be assigned in the outpatient setting due to the acute nature of the condition.

With Localized Infection
 

FIRST

SECOND

USE

ADD’L

CODE

WITH SEVERE SEPSIS

WITH SEPTIC SHOCK

OTHER ADD’L

CODE

Present on admission

Sepsis Local Infection > R65.2-

R65.21

Acute organ dysfunction

Develops after admission

Local Infection

Sepsis > R65.2- R65.21 Acute organ dysfunction

With Non-Infectious Condition

 

FIRST

SECOND

USE

ADD’L

CODE

WITH SEVERE SEPSIS

WITH SEPTIC SHOCK

OTHER ADD’L

CODE

Do not code SIRS of non-infectious origin when infection and condition are related Trauma/Injury
Sepsis > R65.2- R65.21 Acute organ dysfunction
Due to Post-procedural Infection
 

FIRST

SECOND

USE

ADD’L

CODE

WITH SEVERE SEPSIS

WITH SEPTIC SHOCK

OTHER ADD’L

CODE

Following infusion, transfusion & therapeutic injections T80.2- Sepsis > R65.2- T81.12X- Acute organ dysfunction
Following immunization T88.0- Sepsis > R65.2- T81.12X- Acute organ dysfunction
Following a procedure T81.4-
(code to depth)
T81.44 Sepsis R65.2- T81.12X- Acute organ dysfunction
Infection of obstetrical surgical wound O86.0-
(code to depth)
O86.04 Sepsis R65.2- T81.12X- Acute organ dysfunction

DIAGNOSIS CODE SEQUENCE

With Non-Infectious Condition

Do not code SIRS of non-infectious origin when infection and condition  are related

Trauma/Injury

Sepsis

R65.2-

R65.21

Acute organ dysfunction

Due to Post-procedural Infection

Following infusion, transfusion & therapeutic injections

T80.2-

Sepsis

R65.2-

T81.12X-

Acute organ dysfunction

Following immunization

T88.0-

Sepsis

R65.2- T81.12X- Acute organ dysfunction

Following a procedure

T81.4-

(code to depth)

T81.44

Sepsis

R65.2- T81.12X- Acute organ dysfunction

Infection of obstetrical surgical wound

O86.0-

(code to depth)

O86.04

Sepsis

R65.2- T81.12X- Acute organ dysfunction

ICD-10-CM GUIDELINES[2]

Refer to ICD-10-CM Official Guidelines for Coding & Reporting and review conventions in the tabular list.

  • First, code for the underlying systemic infection. Use A41.9 Sepsis, unspecified organism, when the infection is not identified.
  • Then use the appropriate codes to identify severe sepsis and septic shock.
  • Additional code(s) for the associated acute organ dysfunction are required.
  • Never assign severe sepsis or septic shock as principal diagnosis.
  • Do not code severe sepsis unless severe sepsis or associated acute organ dysfunction is documented.
  • Negative labs do not rule out sepsis when there is clinical evidence of the condition.
  • Query provider when:
    • clinical evidence of sepsis is present with negative or inconclusive labs
    • “urosepsis” is documented

References:

[1] Hospital Toolkit for Adult Sepsis Surveillance (PDF)

[2] ICD-10-CM Official Guidelines for Coding and Reporting FY2022 (PDF)

ALL21-AR-H-108 Updated November 15, 2021

A Cerebrovascular accident (CVA), also known as a stroke, occurs when there is an interruption to blood flow that supplies oxygen to the brain.[1] There are two different types of strokes:

  • Ischemic Stroke  - blockage of blood vessel in the brain due to a blood clot or stenosis
  • Hemorrhagic Stroke - bleed into the brain caused by a broken blood vessel

A stroke is an emergent event that requires treatment in an acute care setting.[2]

Residual or late effects (sequelae) caused by a stroke may be present from the onset of a stroke or arise at ANY time after the onset of the stroke. Some conditions develop slowly and exist over extended periods. Others develop suddenly and last only a few days or weeks.

A transischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without acute infarction. It is sometimes referred to as a mini stroke because the symptoms are similar to that of a stroke. The symptoms can resolve within minutes, or can last up to 24 hours.

Documentation

Detailed documentation is necessary for proper code selection.

  • Specify the location or source of hemorrhage and its laterality
  • Specify the source of occlusion and the vessel affected
  • If applicable, identify the specific neurologic or cognitive deficit, identify the affected extremity and laterality and whether dominant or non-dominate side, and specify the type of event as the causing the sequelae

Key Terms:[3]

  • Stenosis – narrowing
  • Occlusion – complete or partial obstruction
  • Thrombosis – stationary blood clot lodged in vessel
  • Embolism – blood or other clot carried through vessel
  • Meninges – protective membranes surrounding the cerebral cortex (brain)
    • Dura matter (outer), Arachnoid (middle), Pia matter (inner)
  • Epidural - between dura matter and skull
  • Subdural - between dura matter and arachnoid
  • Subarachnoid - between arachnoid and pia matter
  • Precerebral arteries – vertebral, basilar, carotid
  • Cerebral arteries – anterior, middle, and posterior

Coding

Assign the most specific code as appropriate according to documentation. More than one code may be assigned if specific code is available for separate locations. Watch for parenthetical notes found in the tabular list (e.g. excluded conditions, coding sequence).

Acute conditions must only be reported when present and actively being treated. Chronic conditions should be reported when treatment is required and/or affects care.  Once a condition has resolved, it should no longer be reported as active.

ICD-10-CM Codes[4]

  • Category I60 – I62: Non-traumatic cerebral hemorrhage
  • Category I63: Cerebral Infarction
  • Category I65 – I68: Other cerebrovascular disorders and diseases
  • Category I69: Sequelae of cerebrovascular disease

Acute conditions found in Category I60 – I67 are applicable to the initial event.

After discharge from acute care, the condition is classified by:

Sequela (late effects) found in Category I69; or

Personal history of CVA or TIA without residual deficits, Z86.73

  • Transient cerebral ischemic attack, G45.9 should be reported at the time of initial diagnosis. Refer to personal history of TIA and CVA without residual deficits,  Z86.73 for subsequent encounters
  • See Category S06 for Intracranial hemorrhage due to accident or injury (traumatic)
  • See Category I97 & G97 for guidance on intraoperative and postoperative events. Causal relationships must be clearly documented.
  • Use Additional code to identify presence of:
    • alcohol abuse and dependence (F10.-)
    • exposure to environmental tobacco smoke (Z77.22)
    • history of tobacco dependence (Z87.891)
    • hypertension (I10-I16 )
    • occupational exposure to environmental tobacco smoke (Z57.31)
    • tobacco dependence (F17.-)
    • tobacco use (Z72.0)

NOTE: The information listed here is not all inclusive and is to be used as a reference only. Please refer to applicable coding and documentation resources for the current year. [5]

Referneces:

[1] Medical Definition of Cerebrovascular accident

[2] Cerebrovascular Disease

[3] Stroke

[4] The Web's Free 2022 ICD-10-CM/PCS Medical Coding Reference

[5] ICD-10

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the American Society of Addiction Medicine created a category called “Substance Use Disorders.” This category combines the concepts of “substance abuse” and “substance dependence” into a single disorder, measured on a continuum from mild to severe.

Diagnostic Criteria[1]

DSM-5 defines substance use disorder as a problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least two of the following occurring in a 12-month period:

DSM-5 Criteria for Substance Use Disorders

  1. Substance is often taken in larger amounts or over a longer period of time than was intended
  2. Persistent desire or unsuccessful efforts to cut down or control substance use
  3. Great deal of time spent in activities to obtain the substance, use the substance, or recover from its effects
  4. Craving or strong desire to use the substance
  5. Recurrent use resulting in failure to fulfill major role obligations at work, school, home
  6. Continued substance use despite persistent or recurrent social or interpersonal problems
  7. Important social, occupational, or recreational activities are given up or reduced because of substance use
  8. Recurrent substance use in situations in which it is physically hazardous
  9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
  10. Tolerance, as defined by either of the following:
  • A need for markedly increased amounts of the substance to achieve desired effect
  • A markedly diminished effect with continued use of the same amount of substance 11.Withdrawal, as manifested by either of the following:
    • Characteristic withdrawal syndrome for the substance
    • Use of the substance or closely related substance is taken to relieve or avoid withdrawal symptoms

Note: Symptoms of tolerance and withdrawal occurring in the context of appropriate medical treatment with prescribed medications (e.g., opioid analgesics, sedatives, stimulants) are specifically not counted when diagnosing a substance use disorder. Furthermore, the DSM states:

“The appearance of normal, expected pharmacological tolerance and withdrawal during the course of medical treatment has been known to lead to an erroneous diagnosis of “addiction,” even when these were the only symptoms present.”

Use, Abuse, & Dependence

Unlike DSM-5, ICD-10-CM continues to employ the concepts of “substance abuse” and “substance dependence.”

Substance abuse represents a maladaptive pattern of drug-taking, which may include detriments to social functioning, to physical well-being and/or to mental health in patients who have not yet reached a state of physical dependence.

Substance dependence is defined as a chronic mental and physical condition related to the patient's pattern of drug-taking that is characterized by behavioral and physiological responses, which may include:

  • A compulsion to take the drug in order to experience its psychic effects, or to avoid the discomfort of its absence
  • An inability to stop the use of the drug despite strong incentives
  • Physical dependence (i.e., tolerance and withdrawal)

When documenting substance use disorders, include the following:

  • Severity – mild, moderate, etc.
  • Pattern of use – continuous use, in remission, relapsed, etc.
  • Substance-induced mood/psychotic symptoms – depression, hallucinations, anxiety, etc.
  • Current presentation – intoxication, drunkenness, withdrawal
  • Treatment plan – rehabilitation, maintenance therapy (specify drug), AA, etc.

Drug dependence in context of appropriate medical treatment – Physical dependence (i.e., tolerance and withdrawal) can develop with the chronic use of many drugs: this can include prescription drugs, even if taken as instructed. ICD-10-CM does not distinguish between this normal, expected response and other forms of drug dependence. Any type of drug dependency (i.e., prescribed, non-prescribed [illicit], physiological and/or behavioral) is coded similarly.

The “substance use disorders” of DSM-5 are reported in ICD-10 as follows:

DSM-5 Diagnosis

ICD-10 Category

Substance use disorder, mild

Substance abuse

Substance use disorder, moderate

Substance dependence

Substance use disorder, severe (addiction) [2]

Substance dependence

When use, abuse and dependence of the same substance are documented in the encounter note, only one code should be assigned based on the following hierarchy:

If…

Then report…

Both use and abuse are documented

Abuse

Both abuse and dependence are documented

Dependence

Use, abuse and dependence are documented

Dependence

Both use and dependence are documented

Dependence

ICD-10-CM Code Selection

The presence of a condition can’t be assumed even if evidence is present in the medical record. It requires the provider’s clinical judgment & explicitly stated diagnosis. The diagnosis code reported must match the documented diagnosis assessed by the provider.

Identify the substance:[3]

  • Alcohol (F10)
  • Stimulant (F15) non-cocaine
  • Opioid (F11)
  • Hallucinogen (F16)
  • Cannabis (F12)
  • Nicotine (F17)
  • Sedative/Hypnotic/Anxiolytic (F13)
  • Inhalant (F18)
  • Cocaine (F14)
  • Other Psychoactive Substance (F19)

The severity is determined by the number of symptoms present in the individual.

  • Mild – 2 to 3
  • Moderate – 4 to 5
  • Severe – 6 or more
  • In remission - Remission occurs when none of the criteria for substance use disorder (except craving) for at least three months.
    • Early remission: more than 3 to less than 12 months
    • Sustained remission: more than 12 months

Further specify any applicable detail:

  • Environment or method of achieved remission
    • In a controlled environment” – When the individual in remission is in a supervised residential setting where access to alcohol and controlled substances is restricted
    • On maintenance therapy” – When the individual in remission is being maintained on a prescribed medication (e.g., agonist, partial agonist, agonist/antagonist, or full antagonist)
  • Association with intoxication or withdraw
  • Presence of induced manifestation or complication
    • delirium
    • perceptual disturbance
    • anxiety
    • sexual dysfunction
    • sleep or mood disorder
    • persisting amnestic disorder or dementia
  • Detailed clinical diagnosis and treatment plan/condition management

References:

[1] American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.

[2] DSM-5 Criteria for Addiction Simplified

[3] 2022 ICD-10-CM CODES FOR MENTAL AND BEHAVIORAL DISORDERS DUE TO PSYCHOACTIVE SUBSTANCE USE (F10-F19)

ALL21-AR-H-107 Updated on November 15, 2021

Telehealth refers to a broad collection of electronic and telecommunications technologies that support delivery of healthcare services from distant locations. Forms of telehealth include telemedicine, virtual check-ins, e-visits and telephone visits, among others.[1]

Risk adjustment requires that reported diagnoses stem from face-to-face visits between patients and providers. Telehealth services that employ synchronous audio and video technology permitting real- time communication between patients and providers, meet the face-to-face requirement.[2]

Telemedicine

Telemedicine visits are the same as in-person visits when synchronous communications based technology is used for between distant and originating sites. This includes outpatient office visits, annual wellness visits, emergency department or inpatient consultations, and individual psychotherapy.

  • Technology: Interactive audio & video with real-time two-way communication
  • Originating Site:
    • Rural health professional shortage area or
    • County outside a metropolitan statistical area
  • Distant Site:
    • Medical facility (i.e.  Hospital, health clinic, physician’s office, etc.) or
    • Home of beneficiary receiving dialysis for ESRD or treatment for substance use disorder

Virtual Check-Ins

Virtual check-ins are short, patient-initiated communications with a provider to determine if an office visit or remote evaluation of a store and forward submitted by the patient is needed.

  • Technology: Audio/video, audio-only, digital image/video, secure text messaging, email, or patient portal
  • Originating Site:  Any location, including patient’s home

E-Visits

E-visits are non-face-to-face, patient-initiated digital communications via an online portal. Once a patient generates the initial inquiry, communications can occur over a seven-day period.

  • Technology: Patient portal
  • Originating Site:  Any location, including patient’s home

Telephone Visits

Telephone visits are non-face-to-face, patient-initiated services over the telephone.

  • Technology: Telephone

A provider must have an established relationship[3]  with a patient before utilizing telehealth services to treat a patient.

  • Provider has previously conducted an in-person exam available to provide follow-up care;
  • On-call or cross-coverage arrangement exists with the patient's regular provider; or
  • A consulting provider agreed to supervise treatment, including follow-up care

Key Terms[4]

  • Distant site - Site at which the provider is located at the time of service
  • Originating site - Location of the patient at the time of service
  • Asynchronous or "Store and Forward" - Transfer of data from one site to another that has been recorded (stored) and sent (forwarded) via telecommunications device.

Coding & Documentation

  • Verbal consent for the service should be noted and, if applicable, a statement that the patient does not require a visit unless there is a problem.
  • Communications should not be related to a medical visit within the past seven days and should not lead to a medical visit within the next 24 hours (or soonest available appointment).
  • All chronic, active, or status conditions (amputations, dialysis status etc.) that impact the current date of service should be clearly documented.
  • Document start and stop times and/or the total visit time to meet applicable CPT requirements.
CPT©/HCPCS Codes

Code

Description

G2010, G2250

Remote evaluation of pre-recorded  image/video (e.g., store & forward)

G2012, G2251-G2252

Non-face-to-face brief medical discussion (e.g., virtual check-in)

G0071

RHC/FQHA communications services

99421-99423,

G2061-G2063,

98970-98972*

Non-face-to-face Online digital E/M (E-Visit)

99441-99423,

98966-98968*

Audio-only, Telephone E/M service

Telemedicine does not require a distinct set of CPT®/HCPCS codes. Report with same CPT© and Place of Service (POS) codes as the in-person visit using the 95 or GT modifier

Telehealth during the Public Health Emergency (PHE) COVID-19

Telehealth flexibilities allow safe access to important health care services during the COVID-19 PHE. This document provides a broad overview of common telehealth services and is for informational purposes only. Stay informed about current state telehealth policies and waivers. Up-to-date information can be found at the Center for Connected Health Policy https://www.cchpca.org/[5].

Additional Resources

Centers for Medicare & Medicaid Services (CMS):

  • General Provider Telemedicine and Telehealth Toolkit[6]
  • Medicare Telehealth Frequently Asked Questions[7]
  • Medicare Learning Network (MLN) Booklet: Telehealth Services[8]

U.S. Department of Health & Human Services (DHHS):

  • Notification of Enforcement Discretion for Telehealth Remote Communications[9]

Federal Register:

  • Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency[10]

U.S. Department of Justice Drug Enforcement Administration:

  • Telemedicine[11]

References

[1] MEDICARE TELEMEDICINE HEALTH CARE PROVIDER FACT SHEET

[2] Applicability of diagnoses from telehealth services for risk adjustment (PDF)

[3]  Stricken language would be deleted from and underlined language would be added to present law (PDF)

[4] Telemedicine

[5] The Center for Connected Health Policy is a program of the Public Health Institute. The National Telehealth Policy Resource Center project is made possible by Grant #GA5RH37470 from the Office for the Advancement of Telehealth, Health Resources and Services Administration, DHHS. © 2010-2021 Public Health Institute Center for Connected Health Policy

[6] General Provider Telehealth and Telemedicine Tool Kit (PDF)

[7]  COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing (PDF)

[8]  Telehealth Services (PDF)

[9]  Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency

[10] Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency

[11] Telemedicine

 

ALL21-AR-H-088 Updated on October 18, 2021

Peripheral Vascular Disease (PVD) describes any disorder of the blood vessels outside the heart and chest or disorders that affect blood flow through the arteries and/or veins.

Peripheral Vascular Disease (PVD) is also known as:

  • Peripheral artery disease (PAD)
  • Peripheral arterial insufficiency
  • (Intermittent) claudication
  • Peripheral angiopathy
  • Spasm of artery

ICD-10-CM code I73.9 - Peripheral vascular disease, unspecified is assigned for all conditions listed above when documented in the medical record.[1]

Arteriosclerosis is the hardening of the arteries. Atherosclerosis is a pattern of arteriosclerosis in which the artery narrows due to the buildup of plaque (fatty deposits) inside the artery the wall.[2]

These conditions are applicable to ICD-10-CM Category I70:

  • Arteriolosclerosis
  • Arterial degeneration
  • Arteriosclerosis
  • Arteriosclerotic vascular disease
  • Arteriovascular degeneration
  • Atheroma
  • Endarteritis deformans or obliterans
  • Senile arteritis
  • Senile endarteritis
  • Vascular degeneration

PVD due to atherosclerosis should be documented, if applicable, to correctly assign codes with higher specificity. Note: Atherosclerosis of extremities; unspecified refers to type, not location.

Signs & Symptoms[3]

Examples include:

  • Claudication - foot, calf, buttock, hip or thigh pain or discomfort when walking that is relieved by rest.
  • Cyanosis - bluish discoloration of the skin resulting from poor circulation.
  • Femoral or Carotid bruit - vascular murmur sound heard over a partially occluded blood vessel on auscultation.
  • Slow healing wound or skin infection
  • Slow capillary refill
  • Numb/painful sensations in extremities
  • Atrophic skin changes
  • Decreased nail growth
  • Abnormal or diminished pedal pulses
  • Non-pressure ulcer
  • Toes or feet appear pale or discolored
  • Ischemic rest pain

Abnormal physical exam findings must be confirmed with diagnostic testing.[4]

  • Ankle brachial index (ABI)
  • CT angiogram (CTA)
  • Doppler ultrasound
  • MRI

Other vascular diseases:

  • Aneurysm
  • Deep vein thrombosis
  • Varicose veins
  • Chronic venous insufficiency
  • Critical limb-threatening ischemia

Complications & Interventions

Early interventions can the lower the risk of complications.[5]

Complications

  • Limited mobility
  • Infection
  • Amputation
  • Heart attack

Interventions[6]

Lifestyle Changes

  • Healthy diet
  • Regular exercise
  • Lose weight
  • Quit smoking

Medications

  • Statins
  • Vasodilators
  • Anticoagulants

Procedures

  • Angioplasty
  • Stents
  • Endarterectomy
  • Thrombolysis (CDT)

Coding & Documentation

Include the following details in the medical record:

  • Cause (e.g., atherosclerosis, stenosis)
  • Location of vein/artery affected (leg, foot, heal, ankle, calf, thigh)
  • Laterality – specify left, right or bilateral
  • Status of the artery (e.g., native, bypass graft, autologous, non-autologous biological)
  • Complications such rest pain, intermittent claudication, ulceration (document ulcer site) or gangrene.

Document diagnostic test results and any clinical findings that support PVD along with disease status and treatment plan.

Also include the following details, when applicable:

  • Risk factors (e.g., tobacco use, high cholesterol, morbid obesity)
  • Counseling provided to patient (e.g., smoking cessation)
  • Co-morbidities such as HTN, DM, and CAD with disease status and treatment plan.

References:

[1] 2022 ICD-10-CM Diagnosis Code I73.9

[2] Atherosclerosis

[3] What Is Vascular Disease?

[4] Everett Stephens, MD. Peripheral Vascular Disease Guidelines. [Updated 2017 Dec. 31]. In: Medscape [Internet]. 1994–2020 by WebMD LLC. Peripheral Vascular Disease Guidelines 

[5] Smith DA, Lillie CJ. Arterial Occlusion, Acute. [Updated 2020 Apr. 23]. In: StatPearls [Internet]. Treasure Island (FL): Stat Pearls Publishing; 2020 Jan. Acute Arterial OcclusionAttribution 4.0 International (CC BY 4.0) 

”Hepatitis” means inflammation of the liver. Toxins, certain drugs, some diseases, heavy alcohol use, bacterial or viral infections can cause hepatitis. Hepatitis is also the name of a family of viral infections that affect the liver.

 Viral Hepatitis Types[1]

Acute viral hepatitis generally resolves within a few months from the date of onset. In other cases, the disease becomes a long-term or chronic illness.

Chronic hepatitis is classified as inflammation caused by viral hepatitis lasting longer than six months. If left untreated, chronic hepatitis can cause serious health problems, including liver damage, cirrhosis, liver cancer, and even death

  • Hepatitis A – caused by ingesting contaminated water or food. Highly contagious, can also be contracted from close contact with an infected person or object.
  • Hepatitis B – spread through bodily fluids during sexual contact or through blood transfusions
  • Hepatitis C – blood-borne, spread through direct contact with infected blood. Primarily transmitted by needles shared among drug abusers, blood transfusion, hemodialysis and needle sticks, can also be transmitted by sexual contact
  • Hepatitis D – also known as delta, cannot occur in the absence of hepatitis B.  Hepatitis B with delta agent is the most severe form of (acute and chronic) hepatitis[2]
  • Hepatitis E – acute condition caused by ingesting contaminated food or water, which does not lead to chronic hepatitis

The most common types are Hepatitis A, Hepatitis B, and Hepatitis C. Hepatitis A and E are acute in nature and do not lead to chronic hepatitis. Hepatitis B, C and D viruses can cause chronic, sometimes lifelong conditions.

Signs & Symptoms

Signs and symptoms of viral hepatitis may or may not be present. Only lab tests can confirm which viral agent is present.

  • Nausea          
  • Vomiting       
  • Loss of Appetite
  • Jaundice        
  • Abdominal pain       
  • Dry mucous membranes
  • Malaise/fatigue        
  • Anorexia        
  • Ascites
  • Hepato-jugular reflex          
  • Firm/enlarged liver
  • Palmar erythema

Diagnostic Testing

Hepatitis A (HAV)

  • Hepatitis A surface antibody (HAV IgM) test detects the first antibody produced by the body when it is exposed to hepatitis A. It detects early or recent infections and diagnoses the disease in people with systems of acute hepatitis.

Hepatitis B (HBV)

  • Hepatitis B surface antigen (HBsAg) is present in acute and chronic infection.
  • Anti-Hepatitis B core antigen (Anti-HBc IgM) is only positive during the acute phase of the infections.

Hepatitis C (HCV)

  • There is no acute infectious phase serological testing available.
  • Confirmation of infection determined by Anti-Hepatitis C (Anti-HCV) for initial screening, which can be confirmed with more specific testing through polymerase chain reaction (PCR) and/or nucleic acid testing (NAT).

HCV Screening &Test Results[3]

HCV Antibody Test 

Non-reactive/Negative, HCV not present

  • Never had HCV
  • Recent HCV infection
    • 2–9 mos. to produce antibodies
  • Weak immune system
    • Unable to produce antibodies

Reactive/Positive,  HCV present (need add’l test) 

  • Possible current HCV infection
  • History of HCV
    • Virus cleared naturally
    • Virus medically treated/cured

HCV RNA Viral Load Test

Undetectable, No HCV found in bloodstream 

  • Spontaneously cleared
  • Medically cured
  • Recently infected,  less than 2wks
  • Within lower limit of detection (LLOD)
    • varies, can be as low as <5 IU/mL

Detectable < LLOQ, HCV present in bloodstream less than lower limit of quantification (LLOQ) 

  • Amount too small to measure

Detectable

  • HCV present in bloodstream

Other Chronic Hepatitis & Related Conditions

  • Autoimmune hepatitis — caused by the body’s own immune system attacking hepatic cells of the liver, typically due to genetic predisposition or environmental exposure
  • Lobular Hepatitis — affects one or more of the four lobes (caudate, quadrate, left, right) of the liver
  • Hepatomegaly — enlarged liver
  • Hepatic fibrosis — chronic injury or inflammation causes a buildup of scar tissue
  • Hepatic cirrhosis — late stage of hepatic fibrosis with changes to the organ structure –Caused by many liver diseases and conditions, such as hepatitis and chronic alcoholism
  • Hepatocellular carcinoma — most common form of liver cancer, which is caused either by genetic predisposition, hepatitis, or underlying cirrhosis

Coding & Documentation

 Detailed documentation is necessary for proper code selection.

  • Identify the type of hepatitis
  • Indicate the acuity – chronic, acute, with/without hepatic coma, with/without delta agent
    • If viral hepatitis is not specified as acute or chronic, assign the appropriate code for unspecified viral hepatitis from Category B19
    • Viral Hepatitis in remission, any type, code to Hepatitis chronic, by type
    • For patients who have had a liver transplant, document and report the appropriate transplant status code and document any anti-rejection drugs if appropriate
  • Specify the causal agent or behavior that led to the acquisition of hepatitis
  • Refrain from using the term “History of” if a patient still has an active viral infection.
  • Document treatment and follow up.

ICD-10-CM Code Selection[4]

Chronic hepatitis NEC 

(see Category K73) 

  • Persistent
  • Lobular
  • Active 
  • Other

Hepatic Failure

(see Category K70 – K72, K76)

  • Acute, Chronic, Alcoholic, Unspecified
  • Portal hypertension 
  • Hepatorenal syndrome
  • Hepatopulmonary syndrome

Cirrhosis

(see Categories K70, K74)

  • Primary/Secondary biliary
  • Alcoholic with/without ascites
  • Unspecified

Related Conditions

  • Auto-immune hepatitis (K75.4)
  • Jaundice (R17)
  • Malignant neoplasm of liver (C22-)
  • Alcoholic liver disease (K70.9)
  • High risk sexual behavior (Z72-)

Reference:

[1] What is Viral Hepatitis?

[2] Hepatitis D

[3] Hepatitis C Virus (HCV) Diagnostics (PDF)

[4] Diseases of Liver

 

Allwell Coding Tip Sheets And Forms