Revisions Address New ICD-9-CM Codes, Part 1

This month’s CCS Prep! column focuses on some of the revisions to the ICD-9-CM Official Guidelines for Coding and Reporting, which become effective Oct 1. These revisions have been approved by the four cooperating parties for ICD-9-CM, which include the American Hospital Association (AHA), American Health Information Management Association (AHIMA), Centers for Medicare and Medicaid Services (CMS) and National Center for Health Statistics (NCHS).

As indicated in previous CCS Prep! columns, these guidelines are the only official source for coding rules when the ICD-9-CM classification system itself does not provide direction. The conventions, general guidelines and chapter-specific guidelines apply to the proper use of ICD-9-CM, regardless of the health care setting. This column is Part I of II and focuses on the new ICD-9-CM diagnosis codes and related coding guidelines for Methicillin Resistant Staphylococcus aureus (MRSA) and pressure ulcer stage codes. Part II will focus on additional guideline changes as well as those for present on admission reporting.

Methicillin Resistant Staphylococcus aureus (MRSA)
New codes have been created for reporting MRSA, a form of Staphylococcus aureus (S. aureus) that is resistant to treatment with penicillin and cephalosporin antibiotics, which have traditionally been the treatment of choice for S. aureus infections. MRSA accounts for the majority of S. aureus infections acquired in health care settings and contributes to increased morbidity and mortality, and health care costs. Since the late 1990s, MRSA also has caused an increasing number of S. aureus infections occurring in otherwise healthy persons in the general community. The following new codes were created to identify and track MRSA infection and colonization:

038.12 Methicillin resistant Staphylococcus aureus septicemia

041.12 Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site

482.42 Pneumonia due to methicillin resistant Staphylococcus aureus

V02.54 Carrier or suspected carrier of methicillin resistant Staphylococcus aureus

V12.04 Personal history of methicillin resistant Staphylococcus aureus

Along with the above new codes, a section has been added to the Chapter 1 coding guidelines which provide coding and sequencing guidelines:

Combination codes for MRSA infection: When a patient is diagnosed with an infection that is due to MRSA, and that infection has a combination code that includes the causal organism such as septicemia or pneumonia, assign the appropriate code for the condition. For example, septicemia due to MRSA is assigned with new code 038.12, Methicillin resistant Staphylococcus aureus septicemia. Do not assign code 041.12 as an additional code, because code 038.12 includes the type of infection and the MRSA organism.

Other infections due to MRSA: When there is documentation of a current infection due to MRSA, and that infection does not have a combination code that includes the causal organism, select the appropriate code to identify the condition along with new code 041.12, Methicillin resistant Staphylococcus aureus.

MRSA colonization: Colonization means that MRSA is present on or in the body without necessarily causing illness. A positive MRSA colonization test might be documented by the provider as “MRSA screen positive” or “MRSA nasal swab positive.” Assign code V02.54 for patients documented as having MSRA colonization.

MRSA colonization and infection: If a patient is documented as having both MRSA colonization and infection, code V02.54 and a code for the MRSA infection may both be assigned.

Pressure (Decubitus) Ulcer Stages
New codes have been created to report the stages of pressure ulcers. Clinicians characterize pressure or decubitus ulcers by location, shape, depth and healing status. In previous years diagnosis codes were created to report pressure ulcers by site or location. However, no codes were available to report the depth or stage of the ulcer, which is an important element that reflects the clinical services necessary to treat the patient and indicates the quality of care. At the request of the Centers for Disease Control and Prevention (CDC) and CMS, new subcategory 707.2, pressure ulcer stages and six new codes have been created to report the five stages as follows:

707.20 Pressure ulcer, unspecified stage

707.21 Pressure ulcer stage I

707.22 Pressure ulcer stage II

707.23 Pressure ulcer stage III

707.24 Pressure ulcer stage IV

707.25 Pressure ulcer, unstageable

Documentation of pressure ulcer stages:

• Stage I – non-blanching erythema (a reddened area on the skin)

• Stage II – abrasion, blister, shallow open crater, or other partial thickness skin loss

• Stage III – full thickness skin loss involving damage or necrosis into subcutaneous soft tissues

• Stage IV – full thickness skin loss with necrosis of soft tissues through to the muscle, tendons, or tissues around underlying bone

• Unstageable – due to being inaccessible for evaluation (non-removable dressings, eschar, sterile blister, suspected deep injury in evolution).

The following guidelines have been added to Chapter 12 to provide direction for reporting these new pressure ulcer stage codes.

Coding pressure ulcers and their stages:
• Two codes are necessary to completely describe a pressure ulcer: A code from subcategory 707.0, Pressure ulcer, to identify the site of the pressure ulcer, and a code from new subcategory 707.2.

• Codes from category 707.2 may not be assigned as a principal or first-listed diagnosis and should only be used with pressure or decubitus ulcers, and not with other types of ulcers.

Unstageable pressure ulcer: Code 707.25 is used for pressure ulcers whose stage cannot be clinically determined, and pressure ulcers that are documented as deep tissue injury but not documented as due to trauma. This code should not be confused with code 707.20, Pressure ulcer, stage unspecified, which should be assigned when there is no documentation regarding the stage of the pressure ulcer.

Stage progression: If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, assign the code for highest stage.

Bilateral or multiple pressure ulcers:
• When a patient has bilateral pressure ulcers, for example both buttocks, and both are documented as being the same stage, only one code for the site and one code for the stage should be reported.

• When a patient has bilateral pressure ulcers at the same site and each is documented as being at a different stage, assign one code for the site and the appropriate codes for the pressure ulcer stages.

• When a patient has multiple pressure ulcers at different sites and each pressure ulcer is documented as being at different stages, assign the appropriate codes for each site and the appropriate codes for each stage.

Pressure ulcers described as healing: Pressure ulcers described as healing should be assigned the appropriate pressure ulcer stage code based on the documentation in the medical record. If the documentation does not provide information about the stage of the healing pressure ulcer, assign code 707.20, Pressure ulcer stage, unspecified.

If the documentation is unclear as to the stage and whether the patient has a current pressure ulcer or if the patient is being treated for a healing pressure ulcer, query the provider.

Coding Guidelines Changes: In addition to the above chapter-specific guidelines, additional instructions have been added to the coding guidelines section titled “Documentation for BMI and Pressure Ulcer Stages.” Code assignment for Body Mass Index (BMI) and pressure ulcer stage codes may be based on medical record documentation from clinicians who are not the patient’s provider, since this information is typically documented by other clinicians involved in the care of the patient. For example, a dietitian often documents the BMI, and nurses often document the pressure ulcer stages. However, the associated diagnosis, such as obesity or pressure ulcer, must be documented by the patient’s provider. If there is conflicting documentation the attending provider should be queried for clarification.

This new guideline is important because previous Coding Clinic advice only addressed that fact that BMI code assignment could be based on dietitian notes. This new guideline will allow coders to better assign the new stage codes and will decrease the number of potential queries to the attending physician regarding the stage of the pressure ulcer. For more information on pressure ulcers and instructions on determining the stage of the ulcer, refer to the 2007 CCS Prep! column titled “Pressure Ulcers Under Scrutiny” (http://health-information.advanceweb.com/Article/Pressure-Ulcers-Under-Scrutiny.aspx) Information on staging can also be found on the National Pressure Ulcer Advisory Panel Web site at http://www.npuap.org/pr2.htm.

To fully understand all ICD-9-CM Official Guidelines for Coding and Reporting changes effective Oct. 1, coders should carefully review the document at www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide08.pdf.

Additional information presented at the Coordination and Maintenance Meeting on the new MRSA and pressure ulcer stage codes discussed in this column can be found at http://cdc.gov/nchs/about/otheract/icd9/maint/maint.htm.

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After reviewing the new guidelines, test your knowledge with the quiz below.

1. A 56-year-old paraplegic patient is admitted for closure of a recurrent left ischial sinus and residual pressure sore that has been present for many years. Six months prior to admission, the patient had excision and closure of the sinus with good healing. The wound, however, eventually broke down and the sinus recurred. The surgeon excised the left ischial sinus and capsule with rotation flap closure. What is the appropriate diagnosis code assignment for this case?

a. 707.04, 707.20, 344.1,

b. 707.04, 707.25, 344.1,

c. 686.9, 707.04, 707.20, 344.1

d. 686.9, 344.1, 707.04, 707.25

2. A patient admitted with lower back pain is diagnosed with a mycotic aneurysm of the distal descending thoracic aorta. Cultures from the aneurysm site were found to be positive for methicillin resistant Staphylococcus aureus (MRSA). What is the appropriate diagnosis code assignment for this case?

a. 041.12, 441.7

b. 038.12, 441.7

c. 441.7, 041.12

d. 441.7, 038.12

This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix (http://www.ingenix.com/). Ingenix is a leader in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.

Coding Clinic for ICD-9-CM is published quarterly by the AHA.

Answers
1. a. Assign code 707.04, for the residual pressure sore with recurrent ischial sinus. The formation of the ischial sinus in the decubitus ulcer is an integral part of the disease process and no additional code should be assigned. Assign code 707.20, pressure ulcer, stage unspecified because the stage was not documented and code 344.1, paraplegia as secondary diagnoses.

2. c. Assign code 441.7, Thoracoabdominal aneurysm, without mention of rupture, to identify the aneurysm. Assign codes 041.12, Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site, as an additional diagnosis to identify the MRSA infection.

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