ED Coding and Reimbursement Alert

Myocardial infarction, diverticular disease are also diagnosis codes to watch.

Appendicitis coding could be set for a pretty big overhaul as part of the Oct. 1, 2017, ICD-10 update. That’s the word from the proposed changes that the ICD-10 Coordination and Maintenance Committee discussed during its March meeting.

The Committee will not make final decisions until later this year, but the following proposals are on the table and could impact emergency departments nationwide if they are approved.

Focus on Appendicitis Expansion

The proposal includes potential codes that would allow additional specificity in appendicitis coding. If confirmed, the codes open up the options for reporting appendicitis with peritonitis depending on whether or not the patient had an abscess, perforation, or gangrene. The changes, proposed by the American Association for the Surgery of Trauma, include eight new codes and almost as many revisions to codes and subcategories in the K35 (Acute appendicitis) range.

For instance:  The proposed changes would expand the current appendicitis codes out to a fifth, and sometimes sixth, character, including the following, among others:

• K35.20 — Acute appendicitis with generalized peritonitis, without abscess
• K35.21 — Acute appendicitis with generalized peritonitis, with abscess
• K35.30 — Acute appendicitis with localized peritonitis, without perforation or gangrene
• K35.891 — Other acute appendicitis without perforation, with gangrene

If the ICD-10 Committee approves the new codes, emergency departments will need to be increasingly specific in their documentation so coders know when appendicitis patients have peritonitis, abscess, perforation, or gangrene, because the coding choice will depend upon those facts.

This change is significant enough to warrant coders to speak with their ED physicians about it in-depth if the ICD-10 committee ultimately approves it, because specifying the appendicitis to this level of clinical detail is not always a part of the documentation, says Michael Granovsky, MD, FACEP, CPC, President of LogixHealth, a national ED coding and billing company in Bedford, MA.

Recognize Potential Myocardial Infarction Updates

Another group of proposed codes focuses on myocardial infarction, and the updates would revise codes in the I21 range, which would change from “ST elevation and non-ST elevation myocardial infarction” to the heading, “Acute myocardial infarction,” which would have several subcodes under it so ED physicians and cardiologists could be more specific about the type of MI that the patient experienced. For instance, I21.0 would refer to STEMI of the anterior wall, while I21.1 would describe STEMI of the inferior wall.

In addition, a new code would be added, which is I21.9 (Acute myocardial infarction, unspecified) and a new subcategory would debut under I21.A (Other type of myocardial infarction), which would include the following new codes: 

• I21.A1 – Myocardial infarction type 2
• I21.A9 – Other myocardial infarction type

The Committee also proposed a note under I21.A1 saying, “Code also the underlying cause, if known and applicable,” rather than including a “code first” note, the ICD-10-CM Coordination and Maintenance Committee says in the proposal.

Possible New Subcategories for Pediatric Glasgow Coma Scale

The American Academy of Pediatrics asked the ICD-10 Committee to add new terminology to clarify age levels under the Pediatric Glasgow Coma Scale. The updates would better allow physicians to make distinctions between the coma levels depending on the patient’s age, because clinicians use the Glasgow Coma Scale to assess consciousness of infants and children.

For example, under R40.222 (Coma scale, best verbal response, incomprehensible words), the ICD-10 manual would add “Moans/Grunts to pain; restless (<2 years old)” and “Incomprehensible sounds (2-5 years of age)” so doctors would be able to classify which patients fall into this category depending on whether they are under the age of two or between two and five years of age.

Likewise, under R40.223 (Coma scale, best verbal response, inappropriate words), the manual would add notes such as “Inappropriate crying or screaming (<2 years of age)” and “Screaming (2-5 years of age).”

These types of notes would continue throughout the R40.236 (Coma scale, best motor response, obeys commands) section of ICD-10 to guide physicians in their coma scoring.

Follow the Proposed Changes to Diverticular Disease

Emergency room physicians could be positively impacted if the proposed changes to diverticular disease are finalized, since the notes accompanying the codes could better explain when to use each code.

The American Association for the Surgery of Trauma requested tabular changes “to better distinguish the severity of diverticulitis” in notes following K57 (Diverticular disease of intestine). If the proposals are adopted, the ICD-10 manual would advise coders to “code also if applicable peritonitis, K65.-)” and would guide coders to use an additional code from the B95-B97 range “to identify infectious agent, if known.” The underlined “if known” segment is new.

By underlining “if known,” that sends a message to the coder that it might not be known, and therefore that detail might not be apparent, says Susan Stovall, COC, CPC, AAS, medical billing and coding instructor with the Southwest Skill Center in Avondale, Ariz. She advises that if the physician didn’t document the infectious agent, didn’t have that information available at the time of treatment, you don’t need to add anything from the B95-B97 range.

Resources: These proposals were discussed at the ICD-10 Coordination and Maintenance Committee Meeting March 7-8, 2017. You can review the proposals at https://www.cdc.gov/nchs/data/icd/topic-packet_03_07_17.pdf.