FY 2024: MDC 23 - Signs and Symptoms

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 23 Signs and Symptoms/Ill- defined Conditions
3. Objectives • Identify the most common diagnoses, comorbidities and complications associated with MDC -23, and what documentation is needed to support each MS-DRG assignment • Identify common secondary diagnoses and query opportunities • Discuss approach and root operations that are found in the surgical DRGs • Review several more challenging surgical procedures
4. MS-DRGs 947-948 Signs and Symptoms with and without MCC
5. MDC 23- MS-DRGs • DRG 939 O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC • DRG 940 O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC • DRG 941 O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC • DRG 947 SIGNS AND SYMPTOMS WITH MCC • DRG 948 SIGNS AND SYMPTOMS WITHOUT MCC • DRG 951 OTHER FACTORS INFLUENCING HEALTH STATUS
6. MS-DRGs 947-948 Signs and Symptoms with and without MCC • Common Principal Diagnoses • G89.3 - Neoplasm related pain (acute) (chronic) • G93.31 - Post-viral fatigue syndrome • P09 category - Abnormal findings on neonatal screenings • Endocrine, Hematologic, Cystic Fibrosis, Hearing Loss • R18 category – Ascites • R41.82 – Altered mental status, unspecified • R53.1 – Weakness • R53.2 – Functional quadriplegia • R53.8 category – Malaise/Fatigue • R60 category – Edema • R64- Cachexia • R84, R85, R87, R89 categories- Abnormal levels of enzymes, hormones, drugs, etc.
7. DEFINITIONS Sign: • Objective evidence of disease observed by the examining physician Symptom: • Subjective observation reported by the patient
8. Use of Signs/Symptom Codes Guideline (see also Official Guidelines for Coding & Reporting Section 1.B.4 and 1.B.18): • Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. • Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. • The definitive diagnosis code should be sequenced before the symptom code. • If the reason for the encounter is a perinatal condition, the code from chapter 16 should be sequenced first. • ICD-10-CM contains several combination codes that identify both the definitive diagnosis and common symptoms of that diagnosis. When using one of these combination codes, an additional code should not be assigned for the symptom.
9. Signs/Symptoms codes are used when... • No more specific diagnosis can be made even after all facts have been investigated • Signs or symptoms existing at time of initial encounter - transient and causes not determined • Provisional diagnosis in patient failing to return • Referred elsewhere before diagnosis made • More precise diagnosis not available • Certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right
10. Coding Guidelines: Signs and Symptoms • I.C.18.a Use of symptom code • Codes that describe symptoms and signs are acceptable for reporting purposes when a relateddefinitive diagnosis has not been established (confirmed) by the provider. • I.C.18.b Symptom code with definitive diagnosis code • Codes for signs & symptoms may be reported in addition to a related definitive diagnosis when that sign or symptom is not routinelyassociated with thatdiagnosis. Definitive diagnosis should be sequenced before the symptom code • Ex: Probably angina pectoris, tachycardia • I.C.18.c Combination codes that include symptoms • ICD-10-CM containsa number of combination codes that identify both the definitive diagnosis and common symptoms of that diagnosis. When using one of these combination codes, an additional code shouldnot be assigned for the symptom. • Ex: Hypoglycemia coma due to Type II DM • I.C.18.d Repeated falls • Code R29.6 (Repeated falls) is used on encounters when a patient has recently fallen & the reason for the fall is being investigated. • Code Z91.81( History of falling), is for use when a patient has fallen in the past and is at risk for future falls.When appropriate, both codes R29.6 and Z91.81 may be assigned together.
11. Coding Guidelines: Signs and Symptoms • I.C.18.e Coma scale • Code R40.20, Unspecified coma, should be assigned when the underlying cause of the coma is not known, or the cause is a traumatic brain injury, and the coma scale is not documented in the medical record. • Do not report codes for unspecified coma, individual or total Glasgow coma scale scores for a patient with a medically induced coma or a sedated patient.. • I.C.18.f Functional quadriplegia • Functional quadriplegia (code R53.2) is the lack of ability to use one’s limbs or to ambulate due to extreme debility. It is not associated with neurologic deficit or injury, and code R53.2 should not be used for cases of neurologic quadriplegia. It should only be assigned if functional quadriplegia is specifically documented in the medical record. • I.C.18.g SIRS due to non-infectious process such as trauma, burns, malignant neoplasm, or pancreatitis • When SIRS is documented w a noninfectious condition, and no subsequent infection is documented, the code for the underlying condition, such as injury, should be assigned, followed by code R65.10 (without organ dysfunction) or code R65.11 (with organ dysfunction). • However, if SIRS due to infection – assign appropriate code for underlying systemic infection. If the type of infection or causal organism is not further specified – assign A41.9 (Sepsis, unspecified organism). A code from subcategory R65.2, severe sepsis, should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented) A code from subcategory R65.2 can never be assigned as a PDx.
12. G89.3 - Neoplasm related pain (acute) (chronic) Guidelines General coding information • Codes in category G89, Pain, not elsewhere classified, may be used in conjunction with codes from other categories and chapters to provide more detail about acute or chronic pain and neoplasm-related pain, unless otherwise indicated below. • If the pain is not specified as acute or chronic, post-thoracotomy, postprocedural, or neoplasm-related, do not assign codes from category G89. • A code from category G89 should not be assigned if the underlying (definitive) diagnosis is known, unless the reason for the encounter is pain control/ management and not management of the underlying condition. • When an admission or encounter is for a procedure aimed at treating the underlying condition (e.g., spinal fusion, kyphoplasty), a code for the underlying condition (e.g., vertebral fracture, spinal stenosis) should be assigned as the principal diagnosis. No code from category G89 should be assigned.
13. G89.3 - Neoplasm related pain (acute) (chronic) Guidelines • Category G89 codes are acceptable as principal diagnosis or the first-listed code: • When pain control or pain management is the reason for the admission/encounter (e.g., a patient with displaced intervertebral disc, nerve impingement and severe back pain presents for injection of steroid into the spinal canal). • The underlying cause of the pain should be reported as an additional diagnosis, if known. • When a patient is admitted for the insertion of a neurostimulator for pain control, assign the appropriate pain code as the principal or first-listed diagnosis. • When an admission or encounter is for a procedure aimed at treating the underlying condition and a neurostimulator is inserted for pain control during the same admission/encounter, a code for the underlying condition should be assigned as the principal diagnosis and the appropriate pain code should be assigned as a secondary diagnosis.
14. Post-viral fatigue syndrome Coding Clinic Fourth Quarter ICD-10 2022 • Post-viral and Related Fatigue Syndromes • Subcategory G93.3, Post-viral fatigue syndrome, has been retitled to "Post-viral and related fatigue syndrome" and new codes created as follows: • G93.31, Post-viral fatigue syndrome • G93.32, Myalgic encephalomyelitis/chronic fatigue syndrome • G93.39, Other post infection and related fatigue syndromes • Post-viral fatigue syndrome is a condition represented by an extended period of fatigue that can linger for weeks or months following a viral infection and is not necessarily related to the severity of the initial viral infection. • Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a chronic, multi-system disease affecting millions of people. The syndrome is complex, debilitating and includes the hallmark symptom of post-exertional malaise with a wide spectrum of severity, from mild to very severe. Although the exact cause of ME/CFS is not known, it often follows an infectious-like illness. • Code G93.39 is assigned for post-bacterial fatigue syndrome, postinfectious fatigue syndrome, and other types of fatigue syndromes for which a specific code does not exist.
15. Weakness • Late effect of COVID-19 (Coding Clinic, 4Q, 2021, page 101-111) • Question: The patient presents to the facility with symptoms such as generalized weakness and lack of appetite, and the provider documents a diagnosis of "post COVID-19 syndrome." How should this be coded? • Answer: For discharges/encounters on or after October 1, 2021, assign codes R53.1, Weakness, R63.0, Anorexia, and U09.9, Post COVID-19 condition, unspecified, for a diagnosis of post COVID-19 syndrome with generalized weakness and lack of appetite This is supported by the instructional note at code U09.9 to "code first the specific condition related to COVID-19 if known." • If the provider documents that the symptoms are the result (residual effect) of COVID-19, assign code(s) for the specific symptom(s) and code B94.8, Sequelae of other specified infectious and parasitic diseases. According to the ICD-10-CM Official Guidelines for Coding and Reporting, a sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. • Due to previous CVA (Coding Clinic, 1Q, 2015, page 25) • Question: The patient is a 72-year-old male admitted to the hospital, because of gastrointestinal bleeding. The provider documented that the patient had a history of acute cerebral infarction with residual right-sided weakness (dominant side) and ordered an evaluation by physical and occupational therapy. What is the appropriate code assignment for residual right-sided weakness, resulting from an old CVA without mention of hemiplegia/hemiparesis? • Answer: Assign code I69.351, Hemiplegia and hemiparesis following cerebral infarction, affecting right dominant side, for the residual right-sided weakness due to cerebral infarction. When unilateral weakness is clearly documented as being associated with a stroke, it is considered synonymous with hemiparesis/hemiplegia. Unilateral weakness outside of this clear association cannot be assumed as hemiparesis/hemiplegia, unless it is associated with some other brain disorder or injury.
16. Glasgow Coma Scale This Photo by Unknown author is licensed under CC BY-NC-ND.
17. Coding Guidelines: Coma Scale • I.C.18.e.1 Coma scale • The coma scale codes (R40.21- to R40.24-) can be used in conjunction with traumatic brain injury codes. • These codes cannot be used with code R40.2A, Nontraumatic coma due to underlying condition. They are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis code(s). • These codes, one from each subcategory, are needed to complete the scale. The 7th character indicates when the scale was recorded. The 7th character should match for all three codes. • At a minimum, report the initial score documented on presentation at your facility. This may be a score from the emergency medicine technician (EMT) or in the emergency department. If desired, a facility may choose to capture multiple coma scale scores. • Assign code R40.24-, Glasgow coma scale, total score, when only the total score is documented in the medical record and not the individual score(s) • If multiple coma scores are captured within the first 24 hours after hospital admission, assign only the code for the score at the time of admission. ICD-10-CM does not classify coma scores that are reported after admission but less than 24 hours later
18. Glasgow Coma Scale – Coding Clinics Coding Clinic for ICD-10-CM/PCS, Second Quarter 2021: Page 4 - Multiple Glasgow Coma Scale Scores Pre and Post Admission •"ICD-10-CM does not classify scores that are reported after admission but less than 24 hours later. •Therefore, only assign one code that represents the GCS score at the time of admission with a POA of "Y." Coding Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2017: Page 95 - Medically Induced Coma and Glasgow Coma Score •"Do not report individual or total GSC scores codes for a patient with a medically induced coma. This type of reversible coma is induced with drugs to help protect the brain from swelling by decreasing blood flow as well as the metabolic rate of brain tissue." Coding
19. Glasgow Coma Scale – Coding Clinics – Pediatrics, Verbal response • Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2017: Page 23 – Pediatric Glasgow Coma Scale (PGCS) • New inclusion terms have been added to codes in subcategories of the Coma Scale for verbal response and motor response to clarify the usage for pediatric patients. • The Pediatric Glasgow Coma Scale (PGCS) is used to assess the mental state of child patients. As with the Glasgow Coma Scale (GCS), the PGCS is comprised of three tests: eye, verbal, and motor responses. • No changes were made for subcategory R40.21, Coma scale, eyes open. • The following new inclusion terms are provided at the corresponding codes from subcategory R40.22, Coma scale, best verbal response, for newborns and children through 5 years of age: • R40.222, Coma scale, best verbal response, incomprehensible words ▪ Incomprehensible sounds (2-5 years of age) ▪ Moans/grunts to pain; restless (<2 years old) ▪ R40.223, Coma scale, best verbal response, inappropriate words ▪ Screaming (2-5 years of age) ▪ Inappropriate crying or screaming (< 2 years of age) • R40.224, Coma scale, best verbal response, confused conversation ▪ Inappropriate words (2-5 years of age) ▪ Irritable cries (< 2 years of age) • R40.225, Coma scale, best verbal response, oriented ▪ Cooing or babbling or crying appropriately (< 2 years of age) ▪ Uses appropriate words (2-5 years of age) This Photo by Unknown author is licensed under CC BY.
20. Glasgow Coma Scale – Coding Clinics – Pediatrics, Motor response • Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2017: Page 23 – Pediatric Glasgow Coma Scale (PGCS) • New inclusion terms have been added to codes in subcategories of the Coma Scale for verbal response and motor response to clarify the usage for pediatric patients. • The Pediatric Glasgow Coma Scale (PGCS) is used to assess the mental state of child patients. As with the Glasgow Coma Scale (GCS), the PGCS is comprised of three tests: eye, verbal, and motor responses. • No changes were made for subcategory R40.21, Coma scale, eyes open. • The following new inclusion terms are provided at the corresponding codes from subcategory R40.23, Coma scale, best motor response, for newborns and children through 5 years of age: • R40.232, Coma scale, best motor response, extension ▪ Abnormal extensor posturing to pain or noxious stimuli (< 2 years of age) ▪ Extensor posturing to pain or noxious stimuli (2-5 years of age) • R40.233, Coma scale, best motor response, abnormal ▪ Abnormal flexure posturing to pain or noxious stimuli (0-5 years of age) ▪ Flexion/decorticate posturing (< 2 years of age) • R40.234, Coma scale, best motor response, flexion withdrawal ▪ Withdraws from pain or noxious stimuli (0-5 years of age) • R40.235, Coma scale, best motor response, localizes pain ▪ Localizes pain (2-5 years of age) ▪ Withdraws to touch (< 2 years of age) • R40.236, Coma scale, best motor response, obeys commands ▪ Normal or spontaneous movement (< 2 years of age) ▪ Obeys commands (2-5 years of age)
21. MS-DRGs 947-948 Signs and Symptoms with and without MCC Do not necessarily have ‘clinical indicators’ because there is no definitive diagnosis ‘after study’. The coder should always do a second review of the record if these MS-DRGs are encountered. Is there a definitive diagnosis given? Opportunity to query the MD for the root cause of symptom
22. Query Opportunities Clarify suspected causative nature of: • Fall or weakness • Coma, stupor • Abnormal labs with treatments • Mental status changes Although these two diagnoses do not fall in DRG 947-948, they are usually symptoms that would need to be clarified the suspected root cause: • Syncope (DRG 312) - usually there is a suspected root cause such as an arrhythmia, dehydration, TIA, etc. • Chest pain (DRG 313) - usually there is a suspected root cause such as costochondritis, arrhythmia, MI, etc. • Pain – usually there is a suspected root cause such as spinal stenosis, gait abnormalities, complication of prosthesis, etc.
23. A patient is seen complaining of right upper quadrant abdominal pain. In addition, the patient is having nausea and vomited several times. Patient has elevated blood pressure readings but no history or diagnosis of HTN. What is the diagnosis codes reported? R10.11 Pain(s) (see also Painful), abdominal, upper, right quadrant R11.2 Nausea, with vomiting R03.0 Elevated, elevation, blood pressure, reading (incidental) (isolated) (nonspecific), no diagnosis of hypertension Rationale: No conclusive diagnosis was documented from the scenario; therefore, the symptoms are coded. SIGN AND SYMPTOM EXAMPLE
24. A patient with a history of chronic back pain comes into the ED for complaints of intense back pain. Patient with a history of lumbar spinal stenosis, congenital hip dysplasia, and osteoarthritis of bilateral hips. After receiving pain medication, muscle relaxants, and a consult to pain management, the patient is discharged with back pain. M54.9 Pain, back (postural) G98.29 Pain, Chronic M48.061 Spinal stenosis, lumbar region without neurogenic claudication Q65.89 Other specified congenital deformities of hip M16.0 Bilateral primary osteoarthritis of hip Query: Recommended to query the physician for the suspected cause of back pain. Rationale: Potential diagnosis change to reflect the causative nature of back pain. SIGN AND SYMPTOM EXAMPLE
25. Diagnoses that may impact SOI/ROM Symptom diagnoses can affect SOI/ROM, such as cachexia, anorexia, tachycardia, coma HOWEVER, keep in mind the following: Not every secondary diagnoses affects the SOI/ROM in relation to the principal diagnosis. There should be an attempt to see if there is a more specific diagnosis that is the root cause and being treated: Cachexia = is there treatment for a certain degree of malnutrition? Tachycardia = is there a specific treatment for the type of arrhythmia, such as atrial flutter? Coma = is there a root cause for reason of coma or the cause of the coma?
26. MS-DRGs 939, 940, 941 O.R. Procedures with Diagnoses of Other Contact with Health Services with MCC/CC, without CC/MCC
27. MS-DRGs 939, 940, 941 • The coder should always do a second review of the record if these MS-DRGs are encountered • Is there a definitive reason given for the symptom? • Opportunity to query the MD for the root cause of symptom
28. A patient with a history of multiple sclerosis is admitted as a direct admission for elective surgery for ORIF of his left acetabulum. Documentation in the OR report states "functional quadriplegia" s/p left acetabulum ORIF. The patient's follow up x-ray shows osteoporosis of the bilateral hips, but is not mentioned in the progress notes or discharge summary. R53.2 Quadriplegia, functional G35 Sclerosis, multiple (brain stem) (cerebral) (generalized) (spinal cord) Query: Recommended to query the physician for the suspected reason for the ORIF Rationale: Potential diagnosis change if the underlying cause is the osteoporosis SIGN AND SYMPTOM EXAMPLE
29. References • ICD-10-CM/PCS MS-DRG v40.0 Definitions Manual • ICD-10-CM Guidelines April 1 2023 FY23 (cms.gov) • AHA ICD-10-CM and ICD-10-PCS Coding Handbook • ICD-10-PCS: An Applied Approach 2023 • Cengage: 3-2-1 CODE IT!
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