It’s
one of the most important questions coders must ask while using ICD-10: Is
there a single combination code that fully identifies the patient’s relevant
conditions, or is it necessary to report two separate codes?
The
volume of combination codes in ICD-10 has increased, making it imperative for
coders to be alert and aware of instances in which combination codes are
applicable.
Defining Combination Codes
The
ICD-10-CM Official Guidelines for Coding and Reporting describe combination
codes as those used to classify the following:
• Two diagnoses
• A diagnosis with an associated secondary
process (manifestation)
• A diagnosis with an associated
complication
Coders
cannot — and should not — assign multiple diagnosis codes when a single
combination code clearly identifies all aspects of the patient’s diagnosis. For
example, say a patient presents with obstructed and chronic cholecystitis with
cholelithiasis and choledocholithiasis. Assign ICD-10 combination code K80.67
(calculus of gallbladder and bile duct with acute and chronic cholecystitis
with obstruction). All components of the diagnostic statement are captured in
this single code, and no additional codes are required.
Be
on the lookout for instances in which the combination code lacks the necessary
specificity to describe the manifestation or complication. In these instances,
be prepared to assign an additional code. For example, say a physician provides
a diagnostic statement of “undelivered mother in second trimester with Von
Willebrand’s disease.” Assign ICD-10 code O99.112 (other diseases of the blood
and blood-forming organs and certain disorders involving the immune mechanism
complicating pregnancy, second trimester) and ICD-10 code D68.0 (Von
Willebrand’s disease).
The
instructional notes throughout the tabular index remind coders when an
additional code may be necessary. For example, the instructional note “use
additional code to identify the specific condition” located under code category
O99 reminds coders that they must assign a secondary code to identify any
maternal diseases that complicate a pregnancy.
The
alphabetic index also includes helpful hints. Look for subterms such as “with,”
“due to,” “in,” or “associated with” to denote when a combination code may be
applicable.
What’s
Different in ICD-10
As
mentioned above, combination codes are not a new concept, but they have been
expanded in ICD-10. Consider these two important examples of new combination
codes in ICD-10:
1.
Diabetes mellitus. ICD-10 combination codes include both the diabetic
manifestation as well as the diabetes itself. For example, say a physician
provides a diagnostic statement of “type 1 diabetes complicated by
gastroparesis.” In ICD-10, one single combination code, E10.43 (Type 1 diabetes
mellitus with diabetic autonomic [poly]neuropathy), captures the entire
encounter.
2.
Conditions due to drugs, medicaments, and biological substances. ICD-10
combination codes denote whether the patient has experienced a poisoning,
adverse effect, or underdosing as well as the specific substance responsible
for the outcome. For example, say a patient presents with an accidental heroin
overdose. In ICD-10, one single combination code (T40.1X1A, poisoning by
heroin, accidental [unintentional]) captures the entire encounter.
Tips for Compliance
Consider
these tips to ensure accurate application of combination codes:
• Review the diagnostic statement
carefully to determine whether a combination code may be applicable. The
encoder will help guide coders; however, it’s also helpful to check the
alphabetic and tabular indices to look for any instructional notes that may be
applicable.
• Review ICD-10 code categories E10 (Type
1 diabetes mellitus), E11 (Type 2 diabetes mellitus), and E13 (other specified
diabetes mellitus). Familiarize yourself with combination codes for each type
of diabetes, including what documentation may be necessary.
• Review ICD-10 code category T36-T50
(poisoning by, adverse effects of, and underdosing of drugs, medicaments, and
biological substances). Familiarize yourself with combination codes in this
category as well as what additional codes may be necessary.
• Scan other chapters of the ICD-10 book
and circle combination codes that you may report frequently and that previously
required two separate codes in ICD-9.
Consider these examples:
o ICD-10 code I25.110 (arteriosclerotic
heart disease of native coronary artery with unstable angina pectoris). In ICD-9, coders must report both 414.01 (coronary
arteriosclerosis of native coronary artery) and 411.1 (intermediate coronary
syndrome) to denote this condition.
o ICD-10 code A69.23 (arthritis due to Lyme
disease). In ICD-9, coders must report both 088.81
(Lyme disease) and 711.89 (arthropathy associated other infectious and
parasitic diseases) to denote this condition.
• Don’t be afraid to query. When
coders suspect that a combination code may be applicable, but documentation
doesn’t clearly link the two diagnoses, query the physician for more
information. In some cases, the physician must state clearly that a condition
is “due to” another condition. For example, say a patient is admitted with a
gastrointestinal (GI) bleed. Upon evaluation with EGD and colonoscopy, the
patient is found to have acute gastritis, duodenal angiodysplasia, and
diverticulosis. The physician doesn’t identify the source of the GI bleed. All
three conditions can cause bleeding, and all three conditions have a
combination code that includes bleeding. Coders must query the physician to
determine the etiology of the GI bleed, if known.
As
we all continue to focus on coding productivity in ICD-10, it’s also imperative
to ensure data quality and integrity. Don’t be tempted to rush through a record
just for the sake of meeting productivity standards. Coders must take their
time and identify instances in which combination codes are applicable. When
coders incorrectly report two separate codes rather than a single combination
code, not only does data quality suffer, but reimbursement also could be at
risk.
Omitting
a complication entirely also can have a negative effect on quality and
reimbursement. Familiarize yourself now with the combination codes you
anticipate reporting most frequently, and be on the lookout for others.
Hypertension and Combo Coding:
When
a patient has both HTN and heart disease, knowing whether the HTN caused the
heart condition is crucial to proper coding. If a patient’s heart disease is
documented as due to hypertension, report a code from category I11. If there is no causal relationship, code the conditions
separately, sequencing them accordingly.
When
coding hypertension and CKD, chronic kidney disease, we can presume both are connected.
There is no need for explicit statement from the doctor to link the two. So you
report a code from I12 category and add in N18 code for the CKD.
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