FY 2024: MDC 22 - Burns

Transcript

1. H I M | C O D I N G & C D I | H E A LT H I T | R E V C Y C L E Empowering Better Health e4health tackles healthcare’s data, quality and revenue challenges empowering your providers to focus on better care.
2. MDC 22 Burns
3. Objectives • Review MDC 22- Burns with a focus on selected diagnoses and procedures • Learner will acquire a basic understanding of the diagnoses and procedures included in MDC-22 • Discuss Query opportunities in MDC-22 • Review coding clinics relevant to the chosen topics in each DRG
4. MDC 22-MS- DRGs (Medical) • 927 EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT • 933 EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT • 928 FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC • 929 FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC • 934 FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY • 935 NON-EXTENSIVE BURNS
5. Chapter Specific Guidelines • The ICD-10-CM makes a distinction between burns and corrosions • The burn codes are for thermal burns, except sunburns, that come from a heat source, such as a fire or hot appliance • The burn codes are also for burns resulting from electricity and radiation • Corrosions are burns due to chemicals • The guidelines are the same for burns and corrosions • Current burns (T20-T25) are classified by depth, extent and by agent (X code) • Burns are classified by depth as first degree (erythema), second degree (blistering), and third degree (full-thickness involvement) • Burns of the eye and internal organs (T26-T28) are classified by site, but not by degree
6. Chapter Specific Guidelines, continued Sequencing of burn and related condition codes • Sequence first the code that reflects the highest degree of burn when more than one burn is present • When the reason for the admission or encounter is for treatment of external multiple burns, sequence first the code that reflects the burn of the highest degree • When a patient has both internal and external burns, the circumstances of admission govern the selection of the principal diagnosis or first-listed diagnosis • When a patient is admitted for burn injuries and other related conditions such as smoke inhalation and/or respiratory failure, the circumstances of admission govern the selection of the principal or first-listed diagnosis
7. Chapter Specific Guidelines Burns of the same anatomic site Classify burns of the same anatomic site and on the same side but of different degrees to the subcategory identifying the highest degree recorded in the diagnosis (e.g., for second and third degree burns of right thigh, assign only code T24.311-) Non-healing burns are coded as acute burns Necrosis of burned skin should be coded as a non-healed burn Infected burn: For any documented infected burn site, use an additional code for the infection
8. Chapter Specific Guidelines Assign separate codes for each burn site When coding burns, assign separate codes for each burn site Category T30, Burn and corrosion, body region unspecified is extremely vague and should rarely be used Codes for burns of "multiple sites" should only be assigned when the medical record documentation does NOT specify the individual sites
9. Chapter Specific Guidelines Burns and corrosions classified according to extent of body surface involved • Assign codes from category T31, Burns classified according to extent of body surface involved, or T32, Corrosions classified according to extent of body surface involved, for acute burns or corrosions when the site of the burn or corrosion is not specified or when there is a need for additional data • It is advisable to use category T31 as additional coding when needed to provide data for evaluating burn mortality, such as that needed by burn units • It is also advisable to use category T31 as an additional code for reporting purposes when there is mention of a third-degree burn involving 20 percent or more of the body surface • Codes from categories T31 and T32 should NOT be used for sequelae of burns or corrosions • Categories T31 and T32 are based on the classic “rule of nines” in estimating body surface involved: head and neck are assigned nine percent, each arm nine percent, each leg 18 percent, the anterior trunk 18 percent, posterior trunk 18 percent, and genitalia one percent (more on this later) • Providers may change these percentage assignments where necessary to accommodate infants and children who have proportionately larger heads than adults, and patients who have large buttocks, thighs, or abdomen that involve burns
10. Chapter Specific Guidelines Encounters for treatment of sequela of burns • Encounters for the treatment of the late effects of burns or corrosions (i.e., scars or joint contractures) should be coded with a burn or corrosion code with the 7th character “S” for sequela • Sequelae with a late effect code and current burn When appropriate, both a code for a current burn or corrosion with 7th character “A” or “D” and a burn or corrosion code with 7th character “S” may be assigned on the same record (when both a current burn and sequelae of an old burn exist) • Burns and corrosions do not heal at the same rate and a current healing wound may still exist with sequela of a healed burn or corrosion • Use of an external cause code with burns and corrosions An external cause code should be used with burns and corrosions to identify the source and intent of the burn, as well as the place where it occurred
11. Burn Coding Coding guidelines, clinical criteria and query opportunities
12. Rule of Nines • Also known as Wallace Rule of Nines is a tool to help physicians estimate the amount of body surface involved in a burn • Categories T31 and T32 are based on the classic "rule of nines" for estimating the amount of body surface involved in a burn. Physicians may modify the percentage assignments for head and neck in infants and small children because young children have proportionately larger heads than do adults. The percentage may also be modified for adults with large buttocks, abdomen, or thighs. • The rule of nines establishes estimates of body surface involved in adults, as follows: Head and Neck 9% Each arm 9% Each leg 18% Anterior trunk 18% Posterior trunk 18% Genitalia 1% • For example, based on this rule a physician can calculate that first-degree burns involve 9% of the body surface, second-degree burns involve 18%, and third-degree burns involve 36%. Adding these together, 63 percent of the body was involved in some type of burn. Code T31.63 (burn of any degree involving 60-69 percent of body surface, with 30-39 percent involved in third-degree burn) could then be assigned.
13. Rule of Nines, continued • Children tend to have different body proportions than adults do, including larger heads and smaller legs • These estimates of TBSA involved can be referenced by specific age of a child vs. an overall criteria for children via different methods of calculation: • Wallace Rule of Nine • Lund and Browder Chart - a more accurate method, especially in children, to calculate TBSA % by age • Palmar Surface - For small burns • The rule of nines establishes estimates of body surface involved in infants, for example: Head and Neck 18% Each arm 9% Each leg 14% Anterior trunk 18% Posterior trunk 18%
14. Rule of Nines
15. Rule of Nines Query Opportunity Coding professionals are not expected to calculate the extent of a burn, but understanding the rule of nines may help them recognize when burns are so extensive that the physician should be asked for additional information.
16. Depth of burn • For categories T20 through T25, the fourth-character axis indicates the type of burn or corrosion according to depth or degree, as follows: • First degree (erythema)- Damage from first-degree burns is limited to the outer layer of the epidermis, with erythema and increased tenderness. First-degree burns have good capillary refill and do not represent significant injury in terms of fluid replacement need. • Second degree (blistering) - Second-degree burns represent a partial-thickness injury to the dermis, which may be either superficial or deep. Deep second-degree burns heal much more slowly than first-degree burns and are prone to developing infection. The end result of second-degree burns may be hypertrophic scarring. • Third degree (full-thickness involvement)- In third-degree burns, the dermal barrier is lost, and the presence of necrotic tissue creates fluid volume loss with systemic effects on capillaries well away from the burn site. In addition, the burn site establishes an ideal culture medium for infection, which may be life threatening. Blood supply is the critical factor in healing of third-degree burns. Areas rich in blood supply, such as hair follicles and sweat glands, have a better chance for reepithelialization. • Deep third-degree burns are characterized by an underlying necrosis with thrombosed vessels. Codes for burns of this depth are assigned only on the basis of a specific diagnosis made by the physician.
17. Depth of burn
18. Depth of burn Query Opportunity Documentation in the chart should be consistent on the depth of burn. If there is inconsistency, query the provider for clarity
19. Seventh Character Values • Like other injury codes, categories T20 through T28 require the following seventh-character values A - Initial Encounter D - Subsequent Encounter S - Sequela • Value "A" (initial encounter) is used for each encounter in which the patient is receiving active treatment for the injury. Examples of active treatment are surgical treatment, emergency department encounter, and evaluation and management of acute injuries. Although the patient may be seen by a new or different provider over the course of treatment for the injury, assignment of the seventh character is based on whether the patient is undergoing active treatment—not on whether the provider is seeing the patient for the first time. • Value "D" (subsequent encounter) is used for encounters after the patient has completed active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase. Examples of subsequent care are medication adjustment, other aftercare, and follow-up visits following injury treatment. The aftercare Z codes should not be used for aftercare for injuries. For aftercare of an injury, assign the acute injury code with the seventh character "D" (subsequent encounter). • Value "S" (sequela) is for use for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn; the scars are sequelae of the burn. When using value "S," it is necessary to use both the code for the sequela itself and the injury code that precipitated the sequela. The specific type of sequela (e.g., scar) is sequenced first, followed by the injury code. The "S" value identifies the injury responsible for the sequela and is added only to the burn or corrosion code, not the sequela code. • Note that using code Z41.1, Encounter for cosmetic surgery, is inappropriate for burn patients admitted for repair of scar tissue, skin contracture, or other sequelae. For such patients, a code should be assigned for the condition being treated.
20. Initial, Subsequent, or Sequela Query Opportunity Documentation should be clear if a condition is associated with the burn as well as if it is a sequela of that burn. If unsure, query the physician for clarity
21. Sunburn Sunburn and other ultraviolet radiation burns are classified in Chapter 12, Diseases of Skin and Subcutaneous Tissue Category L55, Sunburn, is assigned for first-degree (L55.0), second-degree (L55.1), and third-degree sunburns (L55.2) or for sunburn of an unspecified degree (L55.9) Sunburn due to other ultraviolet radiation exposure, such as a tanning bed, is classified to category L56, Other acute skin changes due to ultraviolet radiation, or category L57, Skin changes due to chronic exposure to nonionizing radiation
22. External Causes of Burns • External cause codes, including codes from category Y92, Place of occurrence of the external cause, are assigned for burns and corrosions, as discussed in chapter 29 of this handbook, which covers other injuries. The following External cause categories should be used to report source and intent: X00-X08 Exposure to smoke, fire and flames X10-X19 Contact with heat and hot substances X75 Intentional self-harm by explosive material X76 Intentional self-harm by smoke, fire and flames X77 Intentional self-harm by steam, hot vapors and hot objects X96 Assault by explosive material X97 Assault by smoke, fire and flames X98 Assault by steam, hot vapors and hot objects
23. Associated Injuries and Illnesses Coding guidelines, clinical criteria and query opportunities
24. Infected Burn When a burn is described as infected, two codes are required The code for the burn is sequenced first, with an additional code for the infection
25. Other Injuries associated with Burns • Smoke inhalation often occurs in cases of burns due to combustible products (category T59). It is caused by inhalation or exposure to hot gaseous products of combustion and can cause serious respiratory complications. • Code J68.9 is assigned for smoke inhalation due to chemical fumes and vapors. Code J70.5 is assigned to describe a smoke inhalation injury not otherwise specified. • Use an additional code to identify any associated respiratory conditions, such as acute respiratory failure. • The selection of the principal diagnosis is determined by the circumstances of admission
26. Smoke Inhalation and Acute Respiratory Failure Coding Clinic Fourth Quarter 2013 Page 121 ▪ Question: In ICD-10-CM, under code J70.5, Respiratory conditions due to smoke inhalation, there is no instructional note indicating "use additional code" to describe acute respiratory failure due to smoke inhalation. The patient is admitted through the emergency department for smoke inhalation with acute respiratory failure. Should acute respiratory failure (J96.0) be assigned as an additional code to specify the type of respiratory condition since the index does not provide direction? ▪ Answer: Assign code J96.00, Acute respiratory failure, unspecified whether with hypoxia or hypercapnia, as the principal diagnosis. The acute respiratory failure, resulting from smoke inhalation, is the primary problem. Assign also code T59.811A, Toxic effect of smoke, accidental (unintentional), Initial encounter, and code J70.5, Respiratory conditions due to smoke inhalation.
27. Other Injuries associated with Burns ELECTRICAL BURNS, SUCH AS THOSE CAUSED BY HIGH-TENSION WIRES, MAY CAUSE VENTRICULAR ARRHYTHMIAS (I49.-) THAT REQUIRE IMMEDIATE ATTENTION CERTAIN SUBSTANCES FROM PLASTIC PRODUCTS MAY PRODUCE HYDROGEN CYANIDE. TOXIC EFFECT OF HYDROGEN CYANIDE IS CODED TO T57.3- TRAUMATIC SHOCK (T79.4-) IS OFTEN PRESENT AT THE TIME OF ADMISSION OR MAY OCCUR LATER
28. Pre-existing Conditions • Pre-existing conditions may also have an impact on the burn patient's prognosis and care management and therefore should be coded as additional diagnoses when they otherwise meet criteria for reportable diagnoses. Examples of potentially harmful pre- existing conditions that should be reported include the following: • Cardiovascular disorders (such as angina, congestive heart failure, or valvular disease) may increase ischemia and precipitate myocardial infarction in a patient with extensive second-degree or third-degree burns. Pulmonary wedge monitoring may be necessary in these cases. • Asthma, chronic bronchitis, and other chronic obstructive pulmonary diseases may require ventilation therapy • Peptic ulcers, either gastric or duodenal, and ulcerative colitis are pre-existing conditions that may lead to gastrointestinal bleeding and require treatment along with the burn • Pre-existing kidney disease increases the risk of tubular necrosis and renal failure in patients with third-degree burns or extensive second-degree burns • Alcoholism may pose a threat of alcohol withdrawal syndrome, requiring prophylactic treatment for delirium tremens • Diabetes mellitus slows the healing process, and diabetes mellitus with stated manifestations can further complicate the management of burn cases
29. Application of bioabsorbable wound dressing Coding clinic third quarter 2021 pages 13-14 • Question: A patient presents for debridement of a full-thickness burn to the left lower leg. The provider performs excisional debridement down to and including fascia, and then covers the wound bed with a bioabsorbable wound dressing. The dressing consists of a biocompatible synthetic matrix placed onto the wound to provide a framework for the tissue to regenerate, temporarily closing the wound. Is this classified as wound dressing, skin replacement or other therapeutic substance? What is the appropriate ICD-10-PCS code for the application of a biodegradable wound dressing? • Answer: This wound dressing consists of a synthetic bioabsorbable matrix. In ICD-10-PCS, wound dressings are considered surgical supplies, and surgical supplies are not coded separately in an inpatient setting.
30. Burns – Query opportunity • Type: • Corrosion • Thermal • Site: • Specify body part • Include laterality • Degree: • First • Second • Third  Document total body surface area (TBSA) burned percentage  Specify the percentage of third-degree burns  Include the external cause of the burn, such as house fire, stove, acid, etc.  Document any associated diagnoses/conditions, such as:  Acute organ injury, specify organs  Cellulitis  Sequela of burns  Child/adult abuse  Noncompliance
31. ICD-10-PCS Review Coding guidelines, clinical criteria and query opportunities
32. Anatomy Review- Skin Layers
33. Non-Excisional Debridement Non-excisional • Involves the nonoperative brushing, irrigating, scrubbing, or washing of devitalized tissue, necrosis, slough, or foreign material • Classified to the root operation “Extraction” (the “pulling or stripping out or off all or a portion of a body part by use of force”) except when performed by irrigating the tissue, which is coded to “Irrigation” in the Administration Section of ICD-10-PCS • Performed by a physician or other health care personnel • Versajet is an example of non-excisional debridement • Consists of an ultra–high pressure generator with a console and disposable attachments • A natural vacuum created by the jet stream removes tissue fragments • Specialized features allow physicians to debride traumatic wounds, chronic wounds, or other soft tissue lesions and to aspirate and remove contaminants or other debris • Another example of non-excisional debridement is ultrasonic debridement
34. Excisional debridement Excisional • Surgical removal or cutting away of tissue, necrosis, or slough • Classified to the root operation “Excision” • May be performed by a physician or another health care provider • Involves an excisional as opposed to a mechanical (brushing, scrubbing, or washing) debridement • Uses a scalpel to remove devitalized tissue • Documentation of excisional debridement should be specific regarding the type of debridement • Query the physician if the documentation is not clear
35. Debridement Coding Clinic advice indicates that the phrase "debridement" alone is not sufficient to assign a procedure to the root operation of Excision • Documentation of sharp debridement only is not always indicative of excisional debridement • The description of debridement performed must be documented as definite cutting away of tissue before excisional debridement can be assigned Coding Clinic advice further states, "Clear and concise documentation is needed in order to accurately report excisional debridement" • "If the documentation is not clear or there is any question about the procedure, the physician/provider should be queried for clarification" Documentation of debridement needs to be descriptive enough to create a clear picture of procedure performed. Documentation should include: • Method of debridement: Should be descriptive, painting a clear picture of the type of debridement performed • Depth of debridement: Did the physician/provider debride beyond the dead or damaged tissue down to healthy, viable tissue? • Instruments used to perform the debridement: While the type of instrument used to perform the procedure is not the determining factor in deciding whether the procedure was excisional or non-excisional, the instrument used is one component that helps support the type of debridement reported. However, use of a sharp instrument does not always indicate that an excisional debridement was performed. Excisional debridement is reported when the physician/provider documents "excisional debridement" and/or the documentation meets the root operation definition of excision Documentation of the procedure must be in the body of medical record such as progress notes or operative report
36. Debridement query opportunity • Review documentation for depth of debridement and method or technique used to accomplish the debridement. If the documentation is not clear as to the type, depth of debridement, then query the physician/provider for clarification. • Excision debridement of skin (excision of skin) is an extremely rare procedure as typically the surgeon needs to debride down below the dermal layer • Soft tissue is a part of the subcutaneous tissue and fascia body system • Coding Clinic 2020 2nd Quarter p. 19 clarified that for a chronic non-pressure ulcer documented as necrotic with exposed subcutaneous tissue, subcutaneous tissue includes the fat layer • Root operation "excision" is defined as "cutting out or off, without replacement, a portion of a body part" This Photo by Unknown author is licensed under CC BY-SA-NC.
37. Graft procedures- Transfer vs Replacement • Transfer: Moving, without taking out all or a portion of a body part to another location to take over the function of all or a portion of a body part • Blood vessels and nerves stay attached • Includes: Pedicle grafts, pedicle transfer, rotating flap graft, and advancement flaps • For Transfer procedures involving more than one layer • Character 4 for body part is for the deepest tissue layer in the flap • Character 7 for the qualifier indicates other layer(s) in the flap involved in the Transfer • Qualifiers to specify when a transfer flap is composed of more than one tissue layer, such as a musculocutaneous flap • For procedures involving transfer of multiple tissue layers including skin, subcutaneous tissue, fascia or muscle • Body part value = deepest tissue layer in the flap • Qualifier to describe the other tissue layer(s) in the transfer flap  Replacement: putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part  Includes free grafts  Approach is always ‘External’  Device choices:  Synthetic substitutes (sixth character "J")  Autologous tissue substitutes (sixth character 7)  Non-autologous tissue substitutes (sixth character "K")  The following guidance should be followed when selecting the device character for grafts:  If the material used is derived from a living or biologic basis, it should be coded as "nonautologous tissue substitute"; otherwise, it is considered synthetic  If living or biologic material is mixed with synthetic material, the graft should be coded as "nonautologous tissue substitute“  If two separate products are used (synthetic and biologic), code each separately
38. Graft procedures- Transfer vs Replacement • ICD-10-PCS Table Example: This Photo by Unknown author is licensed under CC BY-NC-ND.
39. Graft procedures- Transfer vs Replacement • Transfer Example: • A musculocutaneous flap transfer is coded to the appropriate body part value in the body system "muscles," and the qualifier is used to describe the additional tissue layer(s) in the transfer flap  Replacement Example:  Radical excision of scar from previous left hand burn was performed, and the defect was covered with a full- thickness graft taken from the left upper arm Documentation requirements: Provider documentation needs to be specific as to graft being free or pedicle as well as specific to location of donor site
40. Skin Grafts Dermal regenerative graft - Root operation “Replacement” Clinical concepts • Includes: • Artificial skin • Creation of "neodermis" • Integumentary matrix implant • Prosthetic implant of dermal layer of skin • Regenerate dermal layer of skin
41. Polarity Skin TE Application Coding Clinic First Quarter 2020 Page 30 • Question: The patient had previously undergone placement of autograft and homograft due to full thickness burns and is now admitted for failure of the previously placed autograft and homograft. During surgery, the affected areas were excised and debrided, a new homograft was placed, and full thickness skin was harvested for anticipated Polarity SkinTE grafting. During this admission, the patient also underwent removal of the homograft, debridement of the affected areas and placement of full thickness Polarity SkinTE graft. What is the appropriate root operation for application of the full thickness Polarity SkinTE graft? • Answer: Assign the appropriate code for the full-thickness autologous tissue substitute, with the root operation "Replacement," for the placement of the full thickness Polarity SkinTE graft. • The excision of failed autograft and homograft, followed by replacement with full thickness Skin TE graft, support the root operation "Replacement" - Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part.
42. Skin graft procedures •Clinical concepts •Typically, an autograft and includes all dermal layers •Documentation requirements/ query opportunity •Specificity is required to distinguish between full thickness and partial thickness. In addition, specificity is required to identify the tissue substitute used (e.g., autologous tissue, nonautologoustissue or synthetic substitute) •Notes •Root operation "replacement" is defined as "putting in or on biological or synthetic material that physically takes the place and/or function of all, or a portion of, a body part" Full-thickness skin graft •Documentation requirements/ query opportunity •Specificity is required to distinguish between full thickness and partial thickness. In addition, specificity is required to identify the tissue substitute used (e.g., autologous tissue, nonautologoustissue or synthetic substitute) •Notes •Root operation "replacement" is defined as "putting in or on biological or synthetic material that physically takes the place and/or function of all, or a portion of, a body part" Skin Graft
43. References • AHA ICD-10-CM and ICD-10-PCS Coding Handbook • ICD-10-PCS: An Applied Approach 2023 • Cengage: 3-2-1 CODE IT! • Medical Terminology Systems, 8th Edition • Burns - Injuries; Poisoning - Merck Manuals Professional Edition • Burn Evaluation and Management - StatPearls - NCBI Bookshelf (nih.gov) • Consider Depth and Other Factors when Coding for Burns - AAPC Knowledge Center • Public Resources – American Burn Association (ameriburn.org)
44. Thank you! To learn more, please visit: e4.health