Hi everyone, we'll get started in just a minute to allow time for everybody to get logged in today. We do have a large number of registered attendees so we'll get started in just a few more seconds here. All right, we'll go ahead and get started. Good afternoon everyone and thank you for joining today's webcast. My name is Jamie Quimby and I'm a Revenue Cycle Senior Coding Consultant with MedAxiom. Today's topic is all about diagnosis coding, so I'm going to start with covering some of the official guideline changes as well as revisit our cardiology specific guidelines that we have in ICD-10. Then we'll go over the 2023 code changes, summarizing each chapter before talking about risk adjustment coding and how important this is for our practices. Then we'll end with a little update on what we currently know about ICD-11. All right, we'll start with a little housekeeping. As most of you know that are long term members, we have changed platforms. So now we have a new MedAxiom Academy. So to access your slides for today's presentation, you need to click on the chat box to access the link. Please do not use that chat box for anything else, especially questions. If you do have a question, you will want to submit those through that Q&A box. As always, we ask that you keep your questions on topic and know that we will answer them throughout the end of the webcast. But we do also compile them into a Q&A document that we will upload to our MedAxiom Academy website. Please allow five to seven business days for us to compile that document. Typically, we have a large volume of questions, which we welcome, but it does take us time to get that all typed up and answered and uploaded to our website. So again, just allow five to seven business days and we will get that uploaded to our Academy. So with that being said, with our new education platform, we do have a new CEU process for all our webcasts going forward. So the coding CEU certificate for AAPC will be available to view and download in the transcript section of your MedAxiom Academy account. We do ask that you allow us one to two business days to allow our team time to get those uploaded into the Academy. Please note, though, you do have to launch the webinar in order to obtain your CEU credit. We found that AAPC is performing more audits on vendors, and this is a requirement that we have to show registration attendance. There are also CEU certificates available for BMSC holders. If you do have that credential and need that certificate, please request that directly with Jolene Bruder's email. So this is just a cute little meme I found. Since we're going to be covering ICD-10 today, and you're probably going to see a lot of numbers when you sleep tonight, that is because there were 1,176 new additions. You have 287 deletions this year and 28 revisions. So that brings our total number for 2023 ICD-10-CM to 73,639. So definitely a significant increase from last year's changes. If you recall, last year was very minimal. We only had 159 new additions. There were 32 deletions and only 20 revisions last year. So again, a lot more to cover today. We did have some that actually affect our cardiovascular section, so we are going to cover that in detail. The CDC does release the ICD-10 code changes in June of every year. Again, since this is based on fiscal year, it means these new codes will be effective on October 1st, not January 1st like our CPT coding system is. So again, if you need copies of any of that information, you can go to either link. CMS does also post the same information on their website. I typically go to the CDC first because they have theirs launched before CMS, and that's how I get the updates. I actually print the updates every year from their files. So I actually haven't even opened my actual book yet. It's still wrapped in the package, but I was able to get all the updates from these files from the links that we have here on the slide. So we're going to start with highlighting a couple of the official guideline changes. So this is just a snapshot of what the first page of the guidelines look like. And as you can see, it's detailed in how you can easily find any changes that were made throughout the guidelines. Any narrative changes will appear in a bold text. If you see any items underlined, this means they've been moved within the guidelines since the previous year's version. And anything that you see that's in italics indicates there was a revision. I'm not going to cover all the guideline changes to this section as some are not pertinent to cardiology, but did want to highlight a few that might be important to you. So this is the first one under the conventions for ICD-10. So this guideline updated added language that most of us coders probably already do when we come across a record that maybe doesn't make full sense or kind of might have conflicting information. So what it says is the assignment of a diagnosis code is based on the provider's diagnostic statement that the condition does exist. The provider's statement that the patient has a particular condition is sufficient. The code assignment is not based on clinical criteria used by the provider to establish the diagnosis. If there is conflicting medical record documentation, then you would need to query the provider. So that was the change to this area, what you see in bold and underlined. Next item to point out is under the general coding guidelines. So again, what it states is coding assignment is based on the provider's documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by that classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. So this update points out that there must be a cause and effect relationship between the care provided and the condition. And again, what's bold and underlined is what's in the update. And it says the documentation must support that the condition is clinically significant. It is not necessary for the provider to explicitly document the term complication. For example, if the condition alters the course of a surgery as documented in the operative report, then it would be appropriate to report a complication code. Again, most of us already do this. You would want to query your provider for any additional clarification if that documentation is not clear, especially if it's not clear to that relationship between the condition and then the care or procedure that was provided. So those were the really the two big changes within the guidelines themselves that were changed. There were a couple other chapter guidelines specific changes to some of the other chapters again. So just I recommend just reviewing that. Again, it's easy to point out with everything being bolded or, you know, being in italics for revisions, that kind of stuff. It's easy to find those revisions and updates within the guidelines themselves. So now I want to touch up on our chapter nine, kind of where we live in the cardiovascular world. And one area I like to revisit every year when I give this webcast is the hypertension guideline reporting. This is an area that we do see miscoded often. So, again, this is one that you probably have already heard me talk about because I do talk about it every year. But as we, you know, help practices across the country and do audits and education, this is just such a high area that we see with errors. So to revisit this, the guidelines state that this classification presumes a casual relationship between hypertension and heart involvement and hypertension and kidney involvement as the two conditions are linked by the term with in the alphabetic index. These conditions should be coded as related even in the absence of provider documentation linking them together unless that documentation clearly states they are not related. So any time you see hypertension, heart disease, like CHF or kidney disease, unless that physician clearly states they are not related, which I cannot think of one time I've seen that, then you would code them as related. So that's the big thing to point out here. So now we're going to cover them specifically. Hypertension with heart disease involvement. So this is going to be selected from category I-11. You would also code from the heart failure category to identify the type of heart failure that's involved. So example here would be provider documents in their assessment and plan that the patient has hypertension and then documents that the patient has chronic systolic heart failure. So in that category selection, you would select code I-11.0, which is for hypertensive heart disease with heart failure. And then you're going to select code I-50.22, which is that chronic systolic heart failure. You'll notice under the code for I-11.0 in your book that there is instructional notes that tell you to use the additional code to identify the type of heart failure. And it gives you that code range to choose from, that I-50 dash. It goes into the I-51.4 through I-51.7, the I-51.89, and then again that I-51.9, which is unspecified. Now when we're talking about kidney disease involvement, the guidelines here do state that you would assign from category I-12 when there is hypertension and a condition that is classifiable to category N-18, which is our chronic kidney disease. Again, the provider clearly states as an example here that we have hypertension and we have stage four chronic kidney disease. So when you're looking at the correct code assignment here, again, your provider would have to say they are not related to code them separately. So again, most times you're not going to see that. So here, say, you know, we have hypertension, stage four chronic kidney disease. You're going to select code I-12.9, which is your hypertensive chronic kidney disease stage one through four range. It also includes unspecified chronic kidney disease. So if that detail is not within the note, and then you're going to select N-18.4, since in our example here, the provider stated stage four chronic kidney disease. Again, you want to always go to the actual code within the book. Most times there are additional instructional notes within that code set. So, again, with the I-12 series, there's additional notes that state to use an additional code to identify the stage of the chronic kidney disease. So, again, that's why you would code them both. If you do have like a hospital encounter where the patient is hypertensive, they have chronic kidney disease that's known, but say they're also in acute renal failure, the guidelines do state that you would sequence those according to the circumstances of the admission or encounter. So most likely you're probably going to code that acute renal failure primary in front of the chronic kidney failure or kidney disease. But, again, you would sequence them according to the circumstances of how they were, you know, supported within the documentation. And finally, for this section, we have category I-13. So this is a combination that includes both hypertension, heart disease, and chronic kidney disease. So that would include if the patient has all three of those. So, again, the includes notes at I-13 specify that the condition included at I-11 and I-12 are together within that I-13 category. And then so an example here for a patient might be one that has hypertension. Say this patient's in end-stage renal disease. They are currently on dialysis, and maybe they have an acute on chronic combined systolic and diastolic CHF. So for your correct-to-code assignment here, you would select I-13.2, which is that hypertensive heart and kidney disease with heart failure, with stage 5 chronic kidney disease, or that end-stage renal. So with our example, we have end-stage renal. Again, going to those instructional notes within the actual code set, you'll find that under the, where the N18.6 for that end-stage renal disease is, it tells you to code any dialysis status known. So we do know that our patient is currently having dialysis treatment. So you would also want to code that Z99.2, which gives that renal dialysis status. And then for our acute on chronic combined systolic and diastolic heart failure, that would be your I-50.43. So you would code all that as related because our provider did not tell us that they were unrelated. So some other important cardiovascular guidelines to cover. And just to highlight, there were no changes within the guidelines themselves for 2023 for our cardiovascular area. Again, these are areas I want to revisit because we often see sometimes there are some areas of opportunity and sometimes some miscoding that happens. So we're just revisiting these guidelines to cover them. So we're going to start with the coronary artery disease and the angina. So as you all know, ICD-10 does have combination codes to report both coronary artery disease with that angina code. We do occasionally see claims where they are split apart. So we'll see like the I-2510, which is our coronary artery disease without angina. And then we will see coded the I-20.9, which is angina unspecified. So again, there's combination codes to choose from. So you're never going to want to see those split like that when you have options like the combination codes being available. Again, you're going to want to look at like all the different subcategories in this area because there's many codes to choose from now. If the patient has known bypass graphs, say they don't have any disease in the graph. So another area we see that's commonly miscoded is maybe a code from series I-257 is selected. Well, what that ends up telling the insurance carrier is that the patient has coronary artery disease, but that disease is now within a graph that they have. So if you have a claim where you're looking and the patient has CAD, they have known bypass graph, but their graphs are actually patent. So there's no disease within the graphs there. You know, obviously they've helped improve the patient's quality there and they're working. You don't want to code the I-25.7 series because that's telling the carrier that the patient now has disease in that graph. So you would in that kind of case, you would want to code like your I-2510, which is your coronary artery disease. And then you're going to code that Z-95.1, which is that bypass graph status. So that's telling the carrier they have coronary artery disease. They have known bypass graph, but their graphs are still patent. So that's another area. Again, I wanted to kind of point out there again with the angina codes. We have different levels, whether it's stable, unstable, has a spasm, those types of things. There is a new code that we'll be adding to that category, which we will be covering in an upcoming slide. So just kind of keep that in the back of your mind. And when we get to that area, I will definitely point it out. So touch up on our acute myocardial infarction reporting. So for any encounters that are occurring while the M.I. is equal to or less than four weeks old, you would continue to report the code from category I-21. Once the encounter goes past that four week time frame, and if the patient is still receiving active care that is related to that M.I., then you would report the correct aftercare code rather than selecting a code from the I-21 series. Now, for older healed M.I.s that no longer require further active care, that's where you will go and assign that I-25.2, which is for the status of the old myocardial infarction. Now, with our M.I. categories, we have many codes to choose from, and a few years ago, they even added a type two. So we'll cover that next. But just to touch up briefly on how these are defined. So with a spontaneous myocardial infarction, which is our M.I. type one, this is an event related to atherosclerotic plaque rupture, ulceration, fissuring, erosion, or dissection that results in a thrombus in one or more of the coronary arteries, which then leads to that decreased myocardial blood flow, which then can cause that heart attack. So the patient may have an underlying severe coronary artery disease. But on occasion, and what the statistics say is between five and 20 percent, it might be non-obstructive or it may show no coronary artery disease found on the angiography performed. And this is particularly in women from what the studies show. Now, for type two, these are myocardial infarctions that are secondary to an ischemic imbalance. These account for about 25 percent of all M.I.s. So in these circumstances, myocardial injury with necrosis where a condition other than C.A.D. contributes to that imbalance between the myocardial oxygen supply. And then that is when they will add that term M.I. type two. And we see this pretty often, you know, a lot of times with patients coming in through the E.R. and where you'll see that provider specifically state that's a type two non-STEMI. So in critically ill patients or patients undergoing major non-cardiac surgery, sometimes those elevated values of their cardiac biomarkers may appear. And this can be due directly to toxic effects. So, again, it'll be clearly documented. I have seen a lot of improvement with that and the providers reporting. So, again, ICD-10 codes for type one M.I. identify the sites such as anterior lateral wall, true posterior wall, and then subcategories that I21.0 through I21.2 and then the I21.3 are used for a type one STEMI. Code I21.4 is used for that type one non-STEMI. So if a type one STEMI non-STEMI evolves to a type one STEMI, guidelines do state that you would only assign the STEMI code, not the type or the non-STEMI code. So you would if you have a type one non-STEMI that evolves to a type one STEMI, you would only code the STEMI code at that point. So, again, I mentioned a few years ago we did get some changes to this area where they added different definitions and further defined the other different types of M.I.s that now include that type two M.I. So the type two myocardial infarction, again, we covered just a second ago, it accounts for about 25 percent of all M.I.s secondary to an ischemic imbalance. So, again, providers are very clear. There are other types now, too, though. So we're actually going to define these now. So there's a type three M.I., which is the result of coronary thrombus with sudden cardiac death before biomarkers. Results are available. A type four M.I. is caused by complications from a PCI, an intervention. So these get grouped into A, B and C. So a type four A M.I. is a periprocedural M.I. A four B would be related to an instant thrombosis and a four C would be M.I. that is due to restenosis that is greater than 50 percent after an initially successful percutaneous coronary intervention. Again, those these categories were added a couple of years ago. And then finally, we have type five M.I., which is related to complications of a coronary artery bypass surgery. So different types of atrial fibrillation, so again, we had some updates here a couple years ago, just kind of want to revisit this with you guys. They further defined and added additional specificity codes. I do see providers, especially our EP physicians dictate these quite well now, but just so you guys have that anatomy and understand how that's, this is all defined. And to touch up and make sure you guys had copies of this too, so a proximal AFib, you may have symptoms that come and go, usually lasting for a few minutes to hours. Sometimes symptoms occur for as long as a week and episodes can happen repeatedly. Symptoms might go away on their own or the patient may end up needing treatment. For persistent, this often requires a pharmacological or electrical cardioversion. And usually the AFib does not stop within a week. For long-standing persistent AFib, this is persistent and continuous and lasts longer than one year. Chronic AFib or permanent AFib, this is a term that's long been used to describe the condition in people where the abnormal heart rhythm can't be restored, they'll most likely have AFib permanently. It often requires medications to control their heart rate, to prevent blood clots. Usually with chronic or permanent, cardioversion is not even attempted. Sometimes they will attempt it, but more commonly they are unsuccessful. So again, I want to stress to you, provider documentation is very important in this area. If you see a trend with your providers where they're not giving you this level of detail, that might be a good opportunity to meet with them and just kind of go over. Sometimes they may not understand there's so many codes to choose from and having that great specificity is really important to tell the carrier that you're submitting a claim to the most accurate information that you can. Preoperative clearance. So this is another area that we see not miscoded often, but missequenced often. So guidelines do state if the reason for the encounter is for a preoperative visit, then you would code that preoperative diagnosis first. Then you should code the reason the patient's having a surgery. So sometimes it might not be cardiac related, but the surgery provider is requesting cardiac clearance. So they're coming in for that pre-op visit still. Then you would code whatever the reason or condition that's causing the surgery. Then additional diagnoses would be anything cardiac related that your provider is addressing or treating during that visit. There are some carriers that are very strict with this guideline, and they will deny a claim if they see that preoperative diagnosis is not sequenced in that first available diagnosis spot. So again, just keep that in mind. Know your carrier's guidelines. It can vary across the country. So just, again, something I wanted to point out because I do know some practices do have issues with getting denials when it's not sequenced properly. So for congestive heart failure, we kind of touched up on a little bit with the hypertension guidelines, but we know that there are very many codes to choose from in this category. It all varies by location, the cause, and the severity. So again, many codes to choose from. Provider documentation is very important in this area. It should be rare for cardiovascular for us not to know greater specificity here. An example where I can think of where we might have to report unspecified CHF is maybe a new patient to the provider, and they have not yet seen that patient for any congestive heart failure, so they might have to do additional testing and a full workup to kind of further define what all is going on with that patient. Most times, though, your provider should know at least the location and the cause, that kind of stuff. I am starting to see an increased trend where I'm seeing providers not specifically document systolic or diastolic, but what they're documenting now, and that you can see in your slide, I actually put it in parentheses here because I'm seeing this more now than them just saying the words the patient has chronic systolic heart failure. What I'm starting to see a lot now is the patient has chronic HFREF. So just to kind of break these down, so if you go to your ICD-10 book and you go to like the I50.20 where it starts with our systolic heart failure, the ICD-10 book actually defines those abbreviated acronyms right here. So the HFREF, that will code to a systolic heart failure, and it means heart failure with reduced ejection fraction. If you see the HFPEF, that will code to diastolic heart failure, and what that further defines is heart failure with a preserved ejection fraction. So if you're seeing that more now than them actually just specifically stating systolic or diastolic, you can still code it. I wouldn't code it to an unspecified because they are telling you the type of heart failure the patient has. So I found that little tidbit looking in the book a couple years ago, and I was like, oh, it's right there, instead of having to use my friend Google to find out what HFREF meant. So just a little helpful thing I wanted to share in case any of you were not aware that that is in your book. So this calendar year, the stages of heart failure defined were updated from the ACC and the AHA. So I wanted to share this information. It's not anything that us as coders would necessarily use, but again, I always find as a coder it being helpful if you understand more of the anatomy and the disease progression. It just helps you as a stronger coder understand more what your provider's looking at and treating the patient for. So I wanted to add these newly updated defined stages here. So a stage A means the patient is at risk for heart failure. They might not have symptoms, structural heart disease or blood tests indicating any kind of heart muscle injury. This does include people with high blood pressure, diabetes, any metabolic syndrome and obesity, or it could be an exposure to medications or treatments that may damage the heart such as chemotherapy drugs or any hereditary risk for heart failure. A stage B is defined as pre-heart failure. So patients still might not be symptomatic or have any signs of heart failure, but there's evidence of one of the following. Say the patient could have structural heart disease. They may have a reduced ejection fraction, maybe an enlargement of the heart muscle or any abnormalities and heart muscle contractions or valve disease. So those could be putting the patient at risk. Stage three means the patient is now symptomatic heart failure. They could have some structural heart disease or current or previous symptoms of heart failure. Symptoms could include shortness of breath, persistent cough, edema, or any fatigue and nausea. And then finally, with stage D, this is an advanced heart failure. And this means that the symptoms do interfere with the daily life of the patient. It is difficult to control that heart failure and results in recurrent hospitalizations despite continued guideline directed medical therapy. All right, so that kind of touched up on our cardiovascular guideline updates and changes and just revisiting that cardiovascular section. So now we're going to actually get into the chapter coding updates. Since we do specialize in cardiology, some of the chapter updates that I'm going to give are going to be very brief and straight to the point. So we will have time to cover anything more relevant to our specialty in detail. So here I'm just going to kind of summarize some of the other chapters. So chapter one did have one code deletion with two new additions within that same category. Chapter two had 11 revised codes and that revision, sometimes the revisions I chuckle at because I, you know, I'll just look at them and be like, was it really that necessary or that serious? But regardless, this section of chapter two with the 11 revised codes, what they did is they removed the not classified and added revising the language to not elsewhere classified. So not a big revision, but needless to say, you know, wanted to point that out. Chapter three did have three codes that were deleted with the addition of 20 new code additions. So I kind of highlight like those categories within that chapter so you can kind of see what the changes would highlight at. Chapter four had two code deletions with 11 new additions. Chapter five had four codes that were deleted and 83 new code additions along with three that were revised. These were mostly related to dementia and substance use. Chapter six had one code deleted and 14 new code additions with three revisions. One new code to make note of in this chapter is that G90.A. This is for postural orthostatic tachycardia syndrome. So what we commonly refer to as POTS. So this is a condition that causes a number of symptoms when you transition from lying down to a standing up position. Symptoms can range from a fast heart rate, dizziness, fatigue, or shortness of breath. A little fun tidbit to point out here, each word of POTS has a meaning. So postural means related to the position of your body. The orthostatic means relating to a standing upright. The tachycardia means a heart rate that's over 100 beats per minute. And then a syndrome is a group of symptoms that happen together. So we kind of put all that together. It makes sense as they define it, you know, as it's caused from a number of symptoms when you transition from a lying down position to a standing up. All right. Chapter seven and eight had no code changes for 2023. Chapter nine, so this is our chapter. So we did have some significant changes this year to cover. So we're going to start breaking those down in detail. There were 10 deletions total out of chapter nine with 43 new additions. One update here on this slide is the addition of nine new codes, which is related to that refractory angina pectoris, or what they refer to as RAP. So this is defined as the occurrence of frequent angina attacks uncontrolled by optimal drug therapy, significantly limiting the patient's daily activities, and with the presence of coronary artery disease, rendering that percutaneous coronary intervention or bypass surgery unsuitable. So it's going to be important for your doctor if this condition, you know, is existing for this patient for them to be specified in that, since this is going to be a new code. So they added the I20.2, so this is when we don't yet know if the patient has any coronary artery disease, but they do have this symptom. And then with our coronary artery disease code ranges, they did add an additional code that would include this refractory angina pectoris option now. So again, just nine new codes, all related to this one condition, depending if they have that combination with the coronary artery disease or if that's not yet known yet. Additional Chapter 9 updates include the deletion of the I31.0, which is a pericardial infusion. And what they did with deleting that is they expanded it by adding two new codes within that category that give further specificity. So again, it'll just be important for your provider to document whether or not it's going to be malignant or non-malignant or other. Most likely we'll probably be living in this area, the I31.39. Another one to point out is the deletion of the I34.8, and this was for an other non-rheumatic mitral valve disorder. So what they did is expand this code range too. So now we have an I34.81, and this is for if the patient has mitral valve calcification or the I34.89, which is an other non-rheumatic mitral valve disorder. Another big deletion is our I47.2, which is our ventricular tachycardia. And what they did is also expand this area with the addition of three new codes. Again, going to be important for your provider to be specific here on the type of ventricular tachycardia that, you know, they want to define that for that patient. And then there was an addition of the I77.82. This is defined as a group of diseases characterized by destruction and inflammation of small vessels. All right, getting into some of the larger changes, there were some revision or updates to the I71 series. So we're going to break those down in detail. So we're going to start with the I71.01, which is a dissection of the thoracic aorta. That code was deleted but expanded. So they added additional code options available within that category with greater specificity being involved. Looking at the anatomy of that, so an aortic dissection is a serious condition in which there's a tear in the wall of the major artery carrying blood out of the heart, so that aorta. As the tear extends along the wall of the aorta, the blood can flow between the layers of the blood vessels walls, which is also called the dissection. This can lead to an aortic rupture or decreased blood flow to your organs. Next, we have the deletion with the I71.1 and that I71.2, which is for a ruptured or non-ruptured thoracic aortic aneurysm. Again, you can see on the slide here, they just further expanded that code range for greater specificity in both areas. When you're looking again at the anatomy of this, with that thoracic aortic aneurysm, it's the ballooning of the upper aspects of the aorta, which is above your diaphragm. Untreated or unrecognized, they can be fatal due to a dissection or popping of the aneurysm, which can lead to nearly instant death. Thoracic aortic aneurysms are most commonly caused in patients that have high blood pressure or any sudden injury. To continue in our I71 series, we also had deletions with additional codes added for our I71.3 and our I71.4, which is our AAA, depending if it's a ruptured AAA or a non-ruptured AAA. Again, further specificity was added within these categories. Looking at the anatomy of our AAA, an abdominal aortic aneurysm happens below our chest. These do happen more commonly than the thoracic aortic aneurysms. They are more common in men and among people age 65 and older. The AAAs are usually caused from atherosclerosis, but infection or injury can also cause them. Sometimes this condition does not have any symptoms, so if an individual does have symptoms, they could include like throbbing or deep pain in the back or side, or maybe pain in the groin or legs. Okay, so additional changes to our I71 series. You can see that the I71.5 and the I71.6 were deleted with additional revisions that give further clarity, our code options for those two areas. You may see this called a TAAA or like TAAA with the three A's or TAAA wrote out. This is defined as swelling and weakness in the aorta's wall that is extended from the chest all the way to the abdomen. A TAAA can rupture, which results again in life-threatening condition and uncontrollable bleeding. The most prevalent cause is atherosclerosis, which again is stiffening of the arteries, caused from plaque formation. This plaque can stiffen and damage the aorta's wall over time, which would increase that chance of that aneurysm forming. So Chapter 10 had one code addition. Chapter 11 had one code addition with two revised codes. And Chapter 12 had no code changes. Chapter 13 had 35 new code additions with nine revisions. There were new codes added for fractures of the sternum or fractures of one rib, fractures of multiple ribs that are associated with chest compressions from having the patient having to have cardiopulmonary resuscitation. So again, keep that in mind with us being in cardiovascular. I could see where, you know, patient may be getting treatment for something like that. Chapter 14 had seven code deletions with 139 new code additions. These changes were related to endometriosis with them adding further specified code ranges within that category. Chapter 15 had 14 deleted codes with 175 new codes. All these changes were related to maternal care for suspected fetal abnormalities, malformations, or damage. Chapter 16 had two deleted codes with the addition of 10 new codes, and these were all related to a newborn having sleep apnea or another apnea. So Chapter 17 is another area for us as cardiovascular. So we did have some changes here this year as well. There were three deletions with 16 new additions total. So we're going to start with the more significant one. So they deleted the Q21.1, which was our atrial septal defect, and what they did is they further expanded this area, this code range, with eight new codes that further give greater specificity. For me personally, when I saw like an ASD or a PFO documented, I knew it was going to be my Q21.1. I just had that. That was something I had memorized in my brain. So now moving forward come October 1st, we will have to definitely pay attention if the provider gives greater specificity on the type of atrial septal defect, or if they specifically state that patient has a PFO, we now have an actual code specific to the PFO. So definitely want to make sure you watch out for that. Now looking at the anatomy as a whole, an atrial septal defect is a birth defect of the heart in which there's a hole in the wall, which is the septum, that divides our upper chambers, which is our atrium of the heart. The hole can vary in size and may close on its own, or it may end up requiring surgery. An atrial septal defect is one type of congenital heart defect. It's one of the more common defects we see. That hole though increases the amount of blood that flows through the lungs, and over time it can cause damage to the blood vessels in the lungs. So definitely something that needs to be addressed and treated if necessary for that patient. The next deletion was the Q21.2, which was for atrioventricular septal defects. So what they did here is they deleted the Q21.2, but they added further options with greater specificity within that same category. So again, there are different types of the atrioventricular septal defects, so them adding this was definitely something that was needed. Most times providers are detailed in whether the patient has a partial, transitional, or a complete. So again, added the picture here just so you can kind of see what it is for the anatomy wise, but what this is is a heart defect in which there are holes between the chambers of the right and left side of the heart, and the valves that control the flow of the blood between those chambers, which may not be formed correctly. Sometimes it might be called an AV canal, or you just may see it abbreviated as an AVSD for that atrioventricular septal defect. So again, there's different types, just depending on whether it's that complete or that partial or transitional. Lastly, with Chapter 17, they deleted that Q85.8 and added four greater, more specified codes in that same category. Continuing with our chapter touch-ups here, Chapter 18 had no code changes this year. Chapter 19 had 104 new codes added. So there were lots of new codes that were added that were related to injuries for concussions, traumatic, contusion, lacerations, hemorrhage, and it's always related to cerebral injuries, brain injuries, or carotid arteries. So again, 104 new codes in that category, all related to injuries of those specific areas that I just mentioned. There were also additional new codes that were added for poisoning, adverse effects, and underdosing of methamphetamines. So that was the significance of the 104 codes that were added there. Chapter 20 had significant changes here also. It's probably the largest chapter that had the most changes out of all the chapters. So they had 237 codes they deleted with the addition of 477 new additions. So they took certain codes, deleted, but further expanded their specificity. These were all related to an electric-assisted bicycle injury, motorcycle driver injury, or motorcycle passenger injuries. Again, if you ever looked at Chapter 20, sometimes we chuckle at some of the code options that are available there. And in cardiovascular, we don't typically have to code much from this chapter, but that 477 new codes literally broke down with those three areas right there. Chapter 21 had three deleted codes with the addition of 45 new codes. There were some new codes that were added for long-term current use of different therapies, such as inhibitors. There were also some new codes added for personal history of corrected conditions, mostly in the congenital area. These were not congenital cardiac area, though. There were other congenital conditions that a patient may have had corrected. So again, just additional personal history codes added of corrected conditions. There were some new codes also added for patient and caregiver non-compliance. There were quite a few codes added in that section. These were all related to non-compliance, related to diet, medical treatment, and then underdosing of medication. And then finally, chapter 22, we know this was added two years ago with the pandemic happening. So it's categories codes for special purposes. There were no code changes made this year to this category. All right. So with that, that ends our updates with the 2023 fiscal year ICD-10-CM updates. So now we're going to touch up on some other topics that are all related to diagnosis coding. So again, with those updates coming for our ICD-10-CM coming October 1st, CMS does review and update and release any pertinent national coverage determinations that are needed with the upcoming changes. You are going to also want to check with your local carriers on any updated policies and your local Medicare carrier for any updated local coverage determinations or what we commonly refer to as an LCD. Some relevant cardiovascular changes to point out here in this MLN Matters 12822, there's going to be some revisions related to medical nutrition therapy if you're providing that service, our VAD devices, ECP, and then our intensive cardiac rehab. And then what I did is I kind of highlighted in the slide what specifically those revisions to that NDC are. So as you can see, this one was an error that was added to the NDC. So what they did was just correct that error on that medical nutrition therapy. For the, oh, I'm sorry, clicking too fast. For our VADs, our ECP, and our cardiac rehab, you can see what they did is instruct the contractors to add any of the new codes upcoming to be effective October 1st, and end any that will no longer be effective as of September 30th. So you can see our example, our ventricular tachycardia is instructed to end with an effective date September 30th. But then down here, they're adding those new additional ventricular tachycardia coding options. So same thing with our ECWs or ECP, they're adding the additional, the refractory angina pectoris codes additions, and same with our cardiac rehab. Another MLN matters relevant to our cardiovascular coding changes is for our transcatheter aortic valve replacement and any heart transplant NDCs. So again, you can see here, the TAVR just had an instruction on an ICD-10 PCS code to be effective October 1st. And then with our heart transplants, again, they're instructing the contractors to end the soon to be deleted codes with the addition of the more specified code options. All right, so now we're going to touch up on risk adjustment coding. This is another topic I like to touch up on every year when we cover our diagnosis changes, because risk adjustment is so important to our practices. If you are new to risk adjustment coding, we're going to kind of, I'll give a basic breakdown of what it is and how it's used and the goals and all that. So just to define it, risk adjustment is defined as a statistical process that takes into account the underlying health status and health spending of the enrollee and an insurance plan when looking at their health care outcomes or health care costs. It's a process involving diagnosis reporting to measure a patient's health status. The diagnosis codes are used to adjust a potential risk for that patient. It's also used to forecast trends and future needs of that patient. This affects payment as well as quality, which quality is just a big thing that we've been talking about for many years now with the MIPS and the cost category and all that stuff. So how risk adjustment works is it's used to determine the financial risk of various diseases and their manifestations. It's composed of five main elements. It has the health condition the beneficiary may have, specifically those that will fall within an HCC category. It also factors in the age and disability status of the patient, their gender, their insurance status, and then that socioeconomic status. The overall goal of risk adjustment is to mitigate the impacts of potential adverse selection. So, for example, insurers that are refusing coverage to higher risk individuals and to stabilize health insurance premiums so those premiums better reflect differences in the patient's benefit and plan efficiencies. Again, rather than that health status of the enrolled population. So basically what this does and the goal of what it does is level the playing field. There are many different type of risk adjustment models out there depending on the payer. So the most common that we see in cardiovascular is that Medicare HCC model. Some models were developed as early as the 1990s, but the Medicare HCC model began back in 2004 and then they expanded it with the Medicare Part D prescription model that followed going back to 2006. So Medicare's HCC model and our diagnosis related groups, the DRG programs, are the most recognized models out there. Again, private payers also have developed their own models. There's also a model for Medicaid. Your different state Medicades will have their own model. So again, it's definitely something you want to be familiar with. We're going to focus primarily on that Medicare HCC model since that is the bigger model that we see in our cardiovascular world. So just to kind of break it down in steps here with Medicare's risk adjustment model, it all starts with that diagnosis portion of what you're reporting. Each code is then grouped together into what they call a diagnosis group, which is then used to determine the condition category that then feeds into an HCC code assignment. Then ultimately what that risk adjustment factor is assigned for that HCC. That risk adjustment factor will impact the individual patient score and that's the risk score that's used to measure and determine the healthcare resources that will likely be necessary to take care of that patient with future visits. So what do we mean by this term risk adjustment factor? This risk adjustment is calculated using a tool developed to predict the cost of healthcare for covered beneficiaries. A risk adjustment score is determined by using a combination of the demographic information along with the disease information to predict that future healthcare costs for that patient. The score is highest for the sickest patients as determined by a combination of those factors. That risk adjustment factor is a relative measure of the probable costs to meet the healthcare needs of that individual patient. So that risk adjustment factor is then used to adjust that capitated payments again for that beneficiary's enrollment in the Medicare Advantage Plan and certain demonstration projects. Payment rates are going to vary based on the patient's predicted level of risk. So again, being as specific as possible and you know just to think about like how they apply all this. So not every single diagnosis that we have and I think for 2023 we said there's 73,000 something. Not every single one of those codes is going to map to an HCC category and be counted for risk adjustment purposes. So if you have something that is unspecified it may not map to anything, but if you have something that is does have more specificity that could map to an HCC code which again was is going to affect all this. So what CMS states with all this is diagnosis codes have a direct relation to the risk involved in caring for a patient. These costs for caring for the patient's diseases are how Medicare Advantage organizations are reimbursed. So once you start combining that main disease and any manifestations that arise, you will increase that reimbursement since you're now treating and addressing multiple conditions. Status codes such as amputations, artificial openings, our old acute MIs, those are also calculated into HCCs. So again, important that you're reporting these services. It's done on a yearly calendar basis. So we know our ICD-10 updates are effective fiscal year October 1st, but with our risk adjustment reporting, Medicare has this updated yearly on a calendar year basis. So every January 1st. So definitely want to make sure if a patient has any conditions like that old MI or any amputations, say you have a patient, a vascular surgeon that is seeing a patient further peripheral vascular disease and patient has a known amputation to one of their extremities, you're going to want to make sure you're reporting that at least yearly because those will map to an HCC code and your provider is still treating that patient for their vascular disease. So again, how the HCCs are determined and released through CMS, they're going to type it out with the type of condition and then map it to a specific HCC category. As an example, some high cost conditions or cancers that are being actively treated, heart disease is a high risk, sepsis, HIV, other acute conditions and chronic conditions, some status codes that we've talked up on and so forth, those will all map to an HCC code. Again, not every single diagnosis code will though. So again, just keep that in mind. An example I can tell you off the top of my head, say a patient has obesity, but your provider did not specify it, that unspecified obesity will not map to an HCC category. But if they say morbid obesity, that will map to a code. So that level of detail can be important when you're trying to apply this risk adjustment to each patient chart. These are some common HCCs that we see common on our cardiovascular. You can see they're given different weight values, depending on the type of category they fall in. So like with our peripheral artery disease, for example, you can see one that's just documented as PAD, we don't really have anything further specified, you can see what its weight value is at. But say we have a patient that has ulcer or gangrene, you can see how significant that weight value will jump, because obviously this patient is going to require a lot more treatment and management to get them more stable and back into a healed stage versus as a patient that is in a healed stage and not requiring much follow up at that current time frame. So again, since these are based on calendar year, these do need to be reported and recaptured from January 1st to December 31st. And you know, Medicare has this little fun saying that every January 1st, all risk adjusted members are completely healed of all their conditions, according to Medicare. So we know that's not accurate. But that's why it's important to make sure you're reporting these services at least once yearly on a claim. Because that's going to factor into the overall level of care that patient will be required to have. Some key documentation points. So when looking at education, both for clinicians and coders, definitely need to understand the basics of accurately reporting a diagnosis code, you cannot accurately capture a diagnosis code if it's just simply listed with no known status or management of the condition. So it's not enough just to simply say in your assessment and plan that the patient has hypertension. Okay, well, is that hypertension stable? Or is it controlled on any type of medication? Who's the treating provider for that hypertension? Is it the patient's primary care provider? Or is the cardiologist involved now because there's other diseases manifesting from that hypertension being present. So those types of details are important. Definitely don't want to code anything that has no status whatsoever. So if you see a condition listed in your assessment and plan, and that's literally all you have, you would want to query your provider or not code it at all, because you can't code anything, you don't have proof that it was addressed during the visit. Two helpful acronyms when you're looking at applying risk adjustment coding. The first is the MEAT acronym. So this is Monitor, Evaluate, Assess, and Treat. And the second is TAMPER. And that's for Treatment, Assessment, Monitor, or Medicaid, Plan, Evaluate, or a Referral. So the TAMPER was created to assist coders when faced with when looking at a diagnosis list as a past medical history or that problems list that we commonly see in our notes. It was created as a way to help determine if those diagnoses should or shouldn't be submitted. So one thing you want to ask yourself when you're looking at a note and you're applying your diagnosis code, you want to look for evidence of treatment or ask yourself, did the provider TAMPER with that condition listed? If they did, then you want to make sure you report and code it on your claim. Now with our MEAT acronym, this is the more common one that is used from coders. So again, Monitor shows any signs or symptoms of a complaint or maybe a referral to a specialist. Evaluate is obvious. Did the provider evaluate the condition? Are they reviewing any labs or other test results? How's the patient responding to current treatment that's already in place? Those types of things. Assess, again, are they ordering any additional testing or labs? Is the patient now describing their symptom or condition as a stable or improving or worsening? And then again, treatment, are they ordering or refilling any medications? Are they going to maybe order any upcoming diagnostic surgery like a coronary angiography? Those types of things. So again, how do you apply this concept? You want to allow to report all diagnosis codes that are current and addressed by that documentation. This applies to your ICD-10-CM reporting though, not to your CPT. So again, when you're determining a level of care of service, you only can consider those conditions which were treated and addressed that would impact the complexity of that medical decision making. The assessment and plan should describe the status of the conditions listed. Again, stressing simply listing that condition and not commenting or giving any type of update does not allow you to report that code. So definitely want to make sure you're watching out for that and educating your providers when you see trends like that. So let's look at an example real quick. So here you can see we have a member with no known conditions coded and reported to the health plan. You'll also see an interaction that is when a known disease and a known complication of another or has a bearing of an outcome of the disease. You'll also notice when some type of the known conditions are coded, the risk adjustment factor score increases and that payment will obviously increase as well. So again, looking at the three categories here, you have chronic conditions that are not documented or encoded, chronic conditions not documented and not specified, and then all conditions are documented properly and addressed and coded appropriately. So you can see the difference in that overall risk adjustment factor score and the reimbursement assigned to it. So here we have the same patient, 76-year-old female, Medicaid female, aged, their demographic information is recorded. So all of this is the same in these top three boxes. Now you start factoring in their conditions. Patient in our first category doesn't show they have diabetes. It's not documented or clinically supported. Same with their CHF. There's no disease interaction, obviously. So we can see our total weighted value is 5,200. Now with our middle column here, we have disease or diabetes with chronic manifestation, which maps to an HCC-19. So you can see it has a weight value. Again, no further specificity on any other diseases being present or interactions. So you can see it brings it up to 6,300. But here we had a very good detailed documented note, provider address, all conditions documented. Everything's mapped to an HCC code. You can see how significant it increased that value just based on having that detailed documented note available. All right. So let's briefly touch up on ICD-11. So this is something that's on the radar. Not so much for the United States yet, but it is on the radar across the world here. It was released in this calendar year. So what we currently know is it is now live as the beginning of this year. There are 35 countries that are currently reporting ICD-11. Current implementations and improvements with reporting include cause of death, cancer registrations, rare disease coding, patient safety. There's a data dictionary guideline that's now available. There's a lot of detail that's now available with ICD-11. So again, we don't have any type of update as far as what the goal is for the United States. But just to recap, if you can believe it, ICD-10 is now over 25 years old. I can still remember, obviously we didn't implement it 25 years ago, but I remember when we went through that implementation and transition from ICD-9 to ICD-10. So ICD-11 is something that will be on the horizon. Again, we just don't have that detail known yet for the United States. I did try to look and see if there's anything posted recent, but there's not been. So last goal that I saw was with a goal to implement no later than 2027. So if that does happen, that gives us five years. So definitely want to just start talking about this. I want to show you the difference in how it looks. There is a link here where you can go to it. It breaks down ICD-11 beautifully. It even gives you the codes that are currently available in the current book that other countries are using. So just to kind of show you how they differ. So you can see with ICD-10 and then I've hit with ICD-11, the same code categories. So you can see here with our coronary artery disease that we currently use that has no symptoms present, that's our I25.10. Same code in ICD-11 though is going to look different. It's going to start with two letters, then the numbers. So VA80.0. Same thing. I didn't update this with the ICD-10 changes, but our I47.2 for our ventricular tachycardia, that's going to look like the BC71 in ICD-11. Same with our murmur code. Again, you can just see how different the codes. Obviously with us having more digits here, it's going to mean that there are a lot more codes in ICD-11 than what we have currently in ICD-10, which is a little scary to think about considering we know we have 73,000 codes in ICD-10 currently. You know, ICD-11 is obviously going to be a lot bigger when looking at that. This is our MedAxiom disclaimer. It just states this for informational purposes only. It does not constitute legal reimbursement or coding advice. We always recommend you check with your local carriers directly on any policies they have. Check with your practice's legal counsel if you need to on any type of policies. Again, if you have a compliance department, you definitely want to check with them and follow up any rules and stuff like that that they may have in place. All right. So bringing us to the end of our webcast, I do see there are multiple questions asked and answered. So what I will do is get those added into that Q&A document. That way, they're shared with everybody that was able to attend today. Again, please allow five to seven business days and we will get that uploaded to our MedAxiom Academy website. Again, give one to two business days for our team to get your CEU certificate uploaded to your academy site. If you have any general case coding questions, say you have a case that you're stumped on and you need a second opinion on, instead of emailing us individually for something like that, if you email it to this RCS at MedAxiom.com, it's going to come up with a list of all the questions that it's going to come to our entire team. We have grown our team within the last year, and we've added some very, very talented coding experts that live in the cardiovascular world. So they are more than capable of also helping with any case code questions that you have. So we definitely encourage you to send any questions like that to the RCS email directly. We will be not having a webcast for October, but we will be back in November. Jolene will be hosting one, and then we will also cover, once the final rule is released, we'll put a webcast out for that. Then look for future dates in December for our coding bootcamp series that we do every year. We're still in the process of trying to pick those topics, but once we get all that put together and we launch the registrations for all that, we will definitely let all of our members know. All right. Well, I thank you so much for joining us today, and we will talk to you in November.

diagnosis coding

ICD-10-CM codes

updates

code categories

accurate documentation

risk adjustment coding

healthcare costs

diagnosis codes impact

risk adjustment

ICD-11 implementation

Q&A document