Good afternoon, everybody. We're going to give it about two more minutes and let everybody that registered today have time to get logged into the webcast. So we'll get started in just a few minutes. All right, we'll go ahead and get started. Good afternoon everyone and thank you for joining us. My name is Jamie Quimby and I'm the Director of Coding with our Revenue Cycle Solutions team here at MedAxiom. Today I'm going to cover the fiscal year 2025 ICD-10-CM coding updates, and we'll do a high focus on cardiovascular today. So we'll do a couple slides with our housekeeping, just as a reminder. So to access the slides for today's presentation, you'll need to click on the chat box to access a link. We do know some people have trouble clicking on that link and accessing it, so you are fine to just type in or send an email if you need a copy of the slides. We do also upload a copy of the slides on our MedAxiom Academy site after we do the live presentation, so a copy can also be found there later. If you do have questions today, please submit those through the Q&A box. Don't do those through the chat. And as always, we do ask that you keep your questions on topic. We will answer questions at the end of the webcast today. And if there are some that we can't get to, we will provide a Q&A document post webcast. All right, for the CEU certificates, you can find those now on your MedAxiom Academy account. We do ask for one to two business days to allow time for our team to get those certificates uploaded to your personal account. If you do not launch the webcast, we cannot give you the CEU credit. That is a strict rule by the AAPC. Also to note, AHIMA does currently accept AAPC certificates. I do hold AHIMA credentials, so I do submit them all the time and know that I don't have any issues. AHIMA is going to be updating their CEU policy starting next year. So they're going to require, I think, 40% of your education credits to come directly from them at that point. But you still will be able to submit some others. You know, just not you'll have to at least meet that 40. I think it's 40% threshold that they're going to be requiring. All right, so to claim your CEU certificate. So you're going to log into your personal account on the MedAxium Academy platform. And this is kind of what the screen looks like. So if you've done this before, this looks familiar to you. If you're new, it'll walk you through the steps. So once you log into your Academy account, you'll click on that presentation and then you'll click on the claim CEU. And then it's going to give you an option to download that PDF or print it. All right, for our agenda today, we're going to start by covering any pertinent ICD-10-CM guideline changes. As you know, they do update the official coding guidelines every year, as well as the actual coding changes. So then once we go through the guidelines, we're going to revisit the cardiovascular chapter guidelines. It's something I like to cover every year. We do do audits for clients throughout the year, and it's certain trends that we always see consistently. So it's stuff I just like to revisit and share that information again. Once we get through that, then we'll go through a summary of the coding changes. There is not a lot of changes in the cardiovascular chapter this year. So we'll just summarize that and then the other chapters, of course. And then I'm going to go through some common cardiovascular diagnosis codes and give some coding tips. And then I'm going to end with a couple slides of us kind of just doing a quick review of ICD-11. So there are some other countries that have already implemented this and are using this new diagnosis coding. U.S. still does not have a set date for implementation, but just kind of want to give a good overview of what the difference looks like. And, you know, we'll cover that when we get to the end. All right. So these are some links. They're very helpful. So back in June of 2024, the CDC did release the coding file updates for the changes. Medicare also will adapt those links and put them on their website as well. I always go to the CDC first because they always release the files first. So this link will take you to that. The nice thing about those files that they upload is if you're not able to get a new coding book every year, these files will give you everything you need related to the changes. So very helpful. And I'll pop open, I'm going to pop something over here real quick on my screen. So this is one of the files within that link here. So this is actually just a summary from the CDC files of the actual changes. So it doesn't give you the full list of all the codes. They do have other files within that link that do that. This one is specific to just the changes for 2025. So it's very helpful. It goes through each chapter and you can see very simply if they added or deleted or revised, it's all marked on here. So very helpful. Highly recommend reviewing that if you weren't able to get a new book. The second link here in the middle is for the official ICD-10 2025 guidelines. So we'll cover a couple slides of that in just a few minutes. And then this is just a summary of the actual changes. So not a ton this year. There was a total of 252 new codes added. There were 36 deletions and 13 revisions. And all the revisions that they did are just typos. They were spelling errors. So that's really the significance of the revisions that they did this year. So now we have a total of 74,260 diagnosis codes. All right. So if you pull up the guidelines from that link and, you know, it's obviously multiple pages. You know, how do you find what's actually changed? So on that very first page, when you open the guidelines, I actually snipped this from the guidelines itself. This is how you can tell when something's been changed. So a narrative change will appear in bold text. Any items that are underlined have been moved within the guidelines since the prior version. And then anything in italics are used to indicate revisions. So they make it very simple, you know, as you go through and want to just kind of see, go to, you know, go to a specific chapter and see if there were any changes made. All right. So I have a couple changes to highlight that are kind of pertinent to our area here. So this first one you can see I highlighted the actual changes. So the first one has to do with sepsis due to a post-procedural infection. I know sometimes we can code sepsis when we're looking at patients in the hospital. This one has to do with, you know, if they've had an infection post-procedure. What they added to that is what's highlighted here that identifies the site of the infection should be sequenced first. So if that is documented in the note and you're able to code that, you should code that and have it sequenced before the sepsis. And then on our myocardial infarctions, they added the if applicable to the guidelines here, and they reference this part to a type 2 MI. What it said before is that the underlying cause should be coded first. So you couldn't code that as a primary diagnosis previously. But now with them adding the if it's applicable. So if the patient doesn't have, you know, an underlying cause documented yet, then you can now code this as primary because you wouldn't have anything applicable to put in front of it. So that those were the only two changes that really affected our cardiology world in the actual guidelines. OK. The excludes notes. This is just something I want to visit as a whole. Again, like I stated earlier, we do audits for our clients and members throughout the year. And this is something that we do see, you know, issues that practices are having with denials, you know, commonly, obviously with the diagnosis reporting. So with an exclude one note, that's if you see that in the book, it indicates that the code is excluded and should never never be used at the same time as the code that you are reporting. And exclude one is used when two is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. So if you have a bicuspid aortic valve, you wouldn't report non-rheumatic aortic insufficiency with it. Those would be excluded from one another. So that's just an example there. Same with if you look at your unstable or just your angina codes are, you know, the I-20 series. If you go to that in your book, you're going to see an exclude one note with your coronary artery disease codes because those have combination codes that you can report now. So you wouldn't report an I-20 code with an I-25 code together because they, you know, there's a combination code. So crazy enough as it sounds, I do see that these are split up sometimes when I'm doing an audit. So definitely, you know, like I said, just wanted to point that out. If you have a combination code for two conditions, you definitely want to choose that over trying to separate the coding. Now, with an exclude two note, that indicates that the condition is excluded and not part of the condition represented by the code. So that means if you see an exclude one note with two conditions, that means you can't report them together. Exclude two means you can. So an example here. If you go to your heart failure codes in your diagnosis book, in the I-50 series, you're going to see there there's exclude one notes and there's also exclude two. So one of the exclude twos that is listed there is a patient that has had cardiac arrest or in cardiac arrest. So the congestive heart failure and the cardiac arrest, meaning they have an exclude two notes, you would be able to code both of those. So that's the difference there. All right. So another area I like to touch up on every single year when we do the webcast for our coding updates is our chapter nine guidelines. An area that we always see opportunity for improvement is reporting your hypertension codes with your chronic kidney disease and your heart failure. So in the guidelines, what they state is that the classification presumes a casual relationship between that hypertension, the heart involvement and between that hypertension and the kidney involvement, as they link the two conditions with the term with in the alphabetic index. So those conditions should be coded as related in the absence of the provider documentation linking them together. So the provider would have to specifically document that they are not related if you want to code them separately. Otherwise, you're just going to pick your I-11, I-12 or I-13 series for your hypertension and then your applicable chronic kidney disease or your heart failure. So we'll go through what each of those look like because there's different combination reporting just depending on what's documented. So hypertension with the heart disease, those are reported with the I-11 series. So an example here would be you provider documents in their assessment and plan that the patient has hypertension and they also have chronic systolic heart failure. So you're going to code the I-11.0, which is your hypertensive heart disease with heart failure. And then you're going to code your I-50.22, which is your chronic systolic heart failure. And again, when you go to the I-11 series in your book, there's additional instructional notes stating that you would use the additional code to identify that type of heart failure. So again, if you want to report your I-10 and your I-50.22, your provider would have to document that the hypertension is unrelated to that heart failure. And we don't see providers document that they're treating both conditions. So again, you would just report your I-11 with your I-50.22 in that scenario. The I-12 series is for a patient that has hypertension and then they have that chronic kidney disease. So those are those combinations for that. So same setup as what we just covered with the heart failure. You would code your I-12 point whatever the next care applicable character would be, depending on the stage of the chronic kidney disease you have documented. The I-12.0 is for stage five or in stage renal. And then your I-12.9 is with unspecified or you have stage one through four. So again, it's just going to depend on the stage of the chronic kidney disease and then whether or not you're going to pick your I-12.0 or your I-12.9. Again, if you go to the I-12 series, it's going to have further additional instructional notes that tells you to also code the stage of the chronic kidney disease. Now, they did add some additional guidance a couple of years ago to these guidelines. If the patient has acute renal failure, it does state that that should also be coded. It does further state that the guidelines say to you will sequence according to the circumstances of that admission or encounter. So, you know, however, the provider documents it, most likely your acute renal failure is going to be, you know, sequenced first, you know, because that's obviously an acute condition there. But again, it's just going to vary on how the provider documents. All right, so we have hypertensive heart and chronic kidney disease. So this is when the patient has all three of the conditions documented and supported in the note. So the I-13 series is that combination that would include all three. Example here could be a patient that has hypertension. They have that end stage renal disease. The provider does also document the patient is on dialysis and they're also in acute on chronic combined systolic and diastolic heart failure. So in this series, we're going to look at coding the I-13.2, which is that hypertensive heart and chronic kidney disease with that heart failure in stage five or end stage renal disease. We'll also code our I-50.43. That's our acute and chronic combined congestive heart failure. And then we're going to code our N-18.6, which is our end stage renal disease. And then they did also specify the patient was on dialysis. So we will also report that Z-99.2. There again, there's instructional notes under the I-13.2 that do tell you to identify your type of heart failure, your stage of your kidney disease. And then they also state to identify the dialysis status if it's documented. So again, we had all that documented in that example. So you would report all of those codes. Additional hypertension takes up a good chunk of our Chapter 9 guidelines in the ICD-10 official guidelines. So just to revisit again, this is all located within the guidelines, but hypertension, transient hypertension, that's elevated blood pressure reading without a diagnosis of hypertension. That's, you know, a sign that R03.0. If they have controlled or uncontrolled, again, it just the guidelines tell you to report from the appropriate category of the I-10 through I-15 hypertensive disease. I do think there's a need to further specify the hypertensions out, whether or not they're controlled and uncontrolled. But, you know, as of now, they have not made any changes to that. Hypertensive crisis, those are assigned from a category I-16 series. You have the hypertensive urgency, emergency, or the unspecified crisis. The guidelines within the book do also tell you to code the type of hypertension. So, you know, most commonly it's going to just be that I-10 with the I-16 series. Resistant hypertension, that refers to blood pressure of a patient with hypertension that remains above goal in spite of the use of the antihypertensive medications. You would assign that I-1A.0 as an additional code on top of your appropriate hypertension code. And, okay, so coronary artery disease. So, again, I know we touched up on this previously a little bit, but as I stated when we do reviews, we do still see these actually not coded together. We'll see the I-20 series coded and then the I-25 series coded separately. So, just remember, if you do have that supported in your documentation, you definitely want to choose the combination codes. There are many to choose from just depending on, you know, that patient's circumstances. So, you know, the I-2510 series is your, you know, coronary artery disease. And then once you get over into the I-257 and I-258, that's where the patient's had history of bypass graft. And just depending on the type of graft that they have can vary on the coding within that I-257 series if they have symptoms. If they don't have symptoms and the documentation shows they have disease within that graft, then you're going to be looking at the I-25810 for that. So, again, just lots of options for reporting. Again, provider documentation is big key here. You know, what type of symptoms are they having? Are they unstable? Are they stable? You know, sometimes we don't have all that. So, you know, there is an unspecified also option. So, again, level of documentation is definitely key to accurately report those. Now, if a patient has had history of bypass graft, you're not automatically going to code an I-25810 because what you're doing there is telling the carrier that the patient has disease within that graft. So, if they have had bypass graft but their grafts are patent, that means they don't have disease within that graft. So, you're going to report your I-2510, and then you would report your Z95.1, which is showing that history of that bypass graft. All right, so, again, guidelines within our Chapter 9. If there are acute myocardial infarctions for any encounters occurring while the MI is equal to or less than four weeks old, you would continue to report the appropriate code from that category I-21 series. Once the encounter goes past that four-week time frame and the patient is still receiving care related to that MI, then you would report the correct aftercare code. But if, you know, they're stable, it's post four weeks, they're doing fine, that's when you're going to report that I-25.2, which is for that old MI. And we'll cover the different types of myocardial infarctions later in the presentation. I kind of have, I have a couple slides that break down, like, type 1, type 2, you know, and type 3. There's several different types that got redefined several years ago. All right, so now we're going to go over the, we'll summarize the actual coding changes in the next several slides. So, Chapter 1 just had one revision. Again, that was related to a typo where they misspelled something, so they fixed that. Chapter 2 was, is our neoplasms. There were 14 deletions and 63 new codes in this chapter. Most of those changes are related to lymphoma. And what they did was delete some codes, and then they further specified. So, they really grew the chapter in that sense to give more specification. Chapter 3 just received one new code for Fanconi anemia. Chapter 4, we did get a new code for type 1 diabetes that is pre-symptomatic. I do know in our cardiovascular world, we do code diabetes pretty often. So, again, this is, that'll be a new code. There's also hypoglycemia that they've added further specification to where you can code it by level 1, 2, or 3. And then they did add some new obesity codes. So, the E66.8, which was for other obesity, that is going to be deleted. And they added four new specified codes in that category. So, you can, it'll have obesity class 1, 2, or 3. And then there's an unspecified. So, it's other obesity not elsewhere classifiable. So, there's, that's where those four new codes for the obesity came from. Chapter 5 had four deletions, 26 new codes, and one revision. Again, that revision had to do to a typo. The deletions were related to these four areas, the anorexia, the bulimia, the binge. And then they added further specification to those conditions with the specific types. So, whether or not the condition is mild, moderate, severe, extreme, in remission, or unspecified. And then Chapter 6, that had one deletion, seven new codes, and then again one revision to a typo. So, and then these are the areas where we have the coding. Most of the changes here, they added new codes related to this epilepsy. All right, Chapter 7 just had some revisions. The five revisions in this chapter were then just removing the word I from a description of those five codes. And it's because the description of the actual codes made it obvious it was related to the I, so they took the word I out of the actual description. Chapter 8 had no coding changes. All right, so our Chapter 9, so very minimal changes this year. So we did have four new codes added related to this cement embolism of the pulmonary artery. So this is a rare but potentially severe complication after a patient has a vertebroplasty procedure, and it can result in this patient developing this condition. So again, it's just going to depend on whether they have that acute core pulmonale or without, so only difference there. But we do have four new codes for that category. And then we had some revisions, we only had two revised codes in our area here. And all they did was they revised these two codes and added the word thrombotic to it. So that's it. Those were our revisions. And then Chapter 10 had seven new codes that had to do with the nasal valve collapse. Chapter 11 had three deletions, 27 new codes, and one revision. And again, you can see they deleted these three codes here, and then they added more specified codes to these three areas. So just further specificity within that chapter. And then our Chapter 12 for our skin, they had three deletions with eight new codes, all related to these three areas here. I'm not going to try to pronounce them because I will probably butcher them. And let's see, Chapter 13 had three deletions with 33 new codes, and these all had to do with some type of degeneration. So again, you can see the areas where there's the lumbar, the lumbosacral, or unspecified. Chapter 14 had no changes. Chapter 15 and 16 also had no changes. Chapter 17 did have a couple of things I wanted to point out because, you know, especially in our congenital world, we definitely will see these. So there was one spelling revision that had to do to a typo, but then they added a couple new codes that I definitely know we'll be using. So we have now an actual specific code for a bicuspid aortic valve. So we'll have a new code for that. That's going to be the Q23.81. And then we're going to be getting a new code for a congenital mitral valve cleft leaflet. And then a new code for other congenital malformations of the aortic and mitral valves. So three new codes there to our congenital world. Chapter 18 had one new code added that is related to a neurological condition. Chapter 19, this chapter is always a little entertaining when I'm going through the changes. This is where they kind of add some of that crazy stuff, you know, whether you got injured by, you know, an alligator or something crazy, you know. So I usually get a chuckle when I'm looking at them. But this year, nothing crazy jumped out at me. So they did do three deletions, added 30 new codes here, mostly poisoning by that immune checkpoint inhibitors. And then there was some disruption of a closure, meaning, you know, patients having a complication with an operation wound. So that that was mostly what those new codes were related to. Chapter 20 had no changes. Chapter 21 had two deletions, 25 new codes, and again, one revision for a typo. And I just kind of summarize what some of the new codes were related to. Nothing much that we will probably code in cardiology. Maybe the encounter for sepsis after care. You know, it just depends. I know we do see patients, obviously, in the hospital that are, you know, in septic shock and that kind of stuff. So might be, you know, a new Z code there that you might report. But everything else, you know, I didn't see it affecting cardiology too much. Chapter 22 was that new chapter they added during the pandemic. And there hasn't been any changes made to it in the last several years. So no changes again this year. And then that is the summary of the actual coding changes. So nothing too crazy, you know, coming up with our new fiscal year. And all right, so now we're going to move on to just reviewing some common cardiovascular diagnosis and some coding tips for those areas. One area is our preoperative clearances. So if you're reporting this code and it's the primary reason your provider is seeing that patient, it has to be sequenced first. Guidelines state to sequence that Z code first. Then you should report the reason for the pre-op clearance. And, you know, sometimes it may be unrelated to cardiology. Maybe they're getting pre-op clearance for, you know, knee surgery or something like that. So guidelines state you should report the reason for the pre-op clearance second and then any cardiac conditions you're treating, you know, third and so on. Again, so you don't if you have it listed and it's not in that primary position, your carrier most likely is going to deny because they do want that in the primary position if you are reporting it. So just keep that in mind because I do see issues with that. Valve disease, this is an area I wish they would fix the guidelines on. I do know some practices that we work with have implemented internal policies on this. So if your provider does not document that the valve disease is non-rheumatic and they have multi-valve disease, meaning they have maybe they have mitral and tricuspid valve disease, when you go to your index, you know, you let your index guide you to the appropriate code. Well, the index is going to guide you to report it as rheumatic because of it being a combination code. If it's truly non-rheumatic disease, you know, and the provider doesn't document that, just depending. So we work with some groups that have put in a policy internally where all their valve diseases is assumed non-rheumatic unless the provider specifies it's rheumatic. And the reason for that is rheumatic disease is not that common in the United States. But again, we're not the only country that, you know, is using this ICD-10 coding book. So that's why the guidelines are the way that they are. So, again, some practices, like I said, they have policies where unless that provider specifically states it's rheumatic, they code all their valve disease non-rheumatic. And that's a great policy to put into place. But if you don't have a policy like that, then, you know, the index, if you have multivalve disease, the index is going to guide you to code it as rheumatic. So, you know, just keep that in mind. And when you code rheumatic disease, if you have a patient that has left ventricular hypertrophy, you know, that will crosswalk you to the I-51.7 diagnosis code. You cannot report that code with any rheumatic valve disease code. So you got to make sure you're looking at those excludes notes, because that is definitely a big one. You know, say you report this I-08.1, which is that mitral and tricuspid disease. You would not be able to report your I-517 with that per the ICD-10 rules. All right, so now let's define all of our myocardial infarctions, because we've got several types. So a type one is when an event related to atherosclerotic plaque rupture, ulceration, fissuring, erosion, or dissection, excuse me, with resulting in that intraluminal thrombus in one or more of the coronary arteries. This leads to decreased myocardial blood flow or distal platelet emboli with ensuing microcyte necrosis. The patient may have underlying severe coronary artery disease, but on occasion in just, you know, how the studies show about anywhere from 5 to 20 percent may be non-obstructive or have no CAD that is actually found on the angiography. And they do, in the studies, it does show that particularly in women. So myocardial infarction secondary to an ischemic imbalance, which they call our MI type two, those do account for about 25 percent of all of our MIs. So, you know, if you're like me and look at, you know, coronary angiographies a lot, you do tend to see a high number of those type two MIs documented. All right. So, again, the ICD-10 codes for type one acute MIs identify the site, so whether it's the anterior or lateral wall or the posterior wall, they also reference the actual vessel, whether it's like the LAD, the left circumflex, the right coronary. So, again, just make sure you're coding the appropriate code, you know, pending your documentation, guiding you to that appropriate code. So a few years ago, we did get new MI codes that further define the different types, so that included this type two. So remember, that is accounting for up to about 25 percent of the MIs that we see. So in certain, an instance of a myocardial infarction with that necrosis, where a condition other than CAD contributes to that imbalance between the myocardial oxygen supply and or demand, that's when they deploy that type two MRI condition. So in critically ill patients or in patients undergoing major non-cardiac surgery, elevated values of those cardiac biomarkers may appear due to the direct toxic effects. So, you know, you'll see them doing the troponin labs a lot with that. So, again, just depending on what your provider documents. And so these were the further specified codes that we got here are the defining types of MIs. So a type three MI is the result of a coronary thrombus that with sudden cardiac death before those biomarker results are available. I cannot think of one time I've reported this type three because I don't typically see that specified of documentation, you know, put in the note. A type four MI is caused by complications of a PCI. So a four A is a periprocedural MI. A four B is related to an instant thrombus. A four C is an MI due to restenosis that is greater than 50% after an initially successful PCI. So, again, I don't, I have seen the four B documented well before, but, you know, not the four A or the four C. So, again, it's just going to depend on the level of detail your provider gives you. A type five MI is related to complications of a patient having that coronary artery bypass surgery. All right. So then we have demand ischemia. So this is a mismatch or imbalance due to an underlying cause. And then these were added so that myocardial injury was fairly new too within the last couple of years. So that's an acute myocardial injury is characterized by the rise and or fall of the cardiac troponin levels with at least one value above the 99th percentile. So, again, your provider will specifically document this condition in order for you to accurately report it. So, again, we've touched up on the coronary artery disease, which is kind of a snapshot of these codes. So as you can see in the I-257 series, it's just going to depend on the type of graft or if they've had transplanted heart on what you report. You can see here your I-2510 series is just your coronary artery disease and your native arteries without having those symptoms. The I-25810 is that patient having that disease within that bypass graft. I do see that reported a lot in error just because the patient has had bypass doesn't mean they have disease in those bypass grafts. So, again, you just want to make sure you're reporting the appropriate. And then the coronary instant restenosis that's reported with the T-82855 and then your appropriate character. If it's the initial visit, you're going to be adding the eight to that. All right, so different types of bradycardia, obviously. I code EP a lot and it really drives me nuts when I see an operative report for pacemaker implant and my indications just say bradycardia. And I'm like, that's not going to pay. I need to know what type of bradycardia the patient has. So then, you know, you have to either query the provider or go to the H&P and see what's in the documentation. So they're never going to just put in a pacemaker with just bradycardia. There's the provider knows the more specificity that you need. So does the patient have six sinus syndrome, tachybradysyndrome? Do they have a type one, type two, type three heart block? You know, do they have a bifascular block? You know, you need to know what type of bradycardia. One thing to point out, too, is you're not going to code these further specified conditions with an R001. An R001 is a symptom of these conditions. So, again, that's another example of those exclude one notes that you definitely want to pay attention to because you wouldn't want to report these two things together. But knowing the type of bradycardia is important, especially when you're looking at an operative note. Different types of SVT. So these did get some changes last year. You probably have dealt with some painful denials because the carriers did not recognize initially or update their systems with the new I-4710 series. I still occasionally see denials with clients that they're still dealing with. And I'm like, you know, we're about to get the new 2025 fiscal year codes in effect and they're still denying this code an error. So but we did get in further specificity last year with the I-4710 series. And then they also added this inappropriate sinus tachycardia. One thing to point out here, again, with the exclude one notes is the SVT diagnosis codes, the I-47 series here specifically have an exclude one notes with just tachycardia. So that R00.0, you cannot report that code with the SVT code. So, again, just keeping that in mind there. Different types of flutter. So typical flutter, which is defined as type one, that's localized to the right atrium. This type of atrial flutter can be cured with a short outpatient catheter ablation. Normally we see that documented as our CTI ablation. That's that cavo tricuspid flutter ablation. And that is a typical flutter. Atypical flutter is your type two. That refers to an atrial flutter arising to the left atrium. Most times that atypical flutter can be treated with an ablation, but it's a more severe flutter than the typical and it's harder to treat. So a lot of times I see these where the patient's getting a pulmonary vein isolation for AFib. And, you know, the providers on that left side of the atrium and then the patient goes into an atypical flutter. So then they have to do another ablation to get rid of that arrhythmia. So that is common that I see. Different types of AFib. So several years ago they did add these new codes. So we've had these for, you know, two or three years now for sure. But proximal AFib is when 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 may go away on their own or a patient obviously may need treatment. Persistent AFib. This one often requires a pharmacological or electrical cardioversion and does not stop within a week. That long standing persistent AFib is persistent and continuous and lasts longer than one year. And then when you get into your chronic or permanent, it's really up to the provider to document that level of specificity. But this is a term that has long been used to describe the condition of people where the abnormal heart rhythm cannot be restored. They'll most likely have that AFib permanently and often require medications to control their heart rate. As you know, AFib can cause a patient to have blood clots, which can cause them to have a stroke. So it is a serious arrhythmia that they definitely, you know, don't just sit by and let happen. So once they're in that chronic to permanent, though, they it's really a struggle for them to try to keep that patient out of that arrhythmia. So sometimes they may decide to do a pacemaker implant where they're planning an AV node ablation. And the purpose of that AV node ablation is to put that patient in a complete heart block, which at that point would render them pacemaker dependent. And the hopes is so they can control that AFib through that pacemaker system itself. So, you know, if you code EP, you probably see reports like that often. So that that is another option for the providers to treat the patient once they're in that chronic or permanent phase. Cardioversion usually is not attempted once they're in that permanent to chronic phase of the condition. There's occasions where they may try, but a lot of times they're not successful. So, again, it's really up to your provider to document that level of specificity. Again, there's there may be occasions where you may have to report unspecified. It could be the first time the patient's ever been in AFib, you know, so you don't really have a specified, you know, whether it's proximal, persistent, that type of thing. And there actually is some patients that don't know they're in AFib when when they're, you know, having issues with the condition. Some patients have no symptoms of it. So, again, you know, lean on your provider for that level of specificity. VTAC also had some updates a couple of years ago. So there's different levels that we can code now, just depending on what the documentation shows. So it is a rapid heart rate. It's one of our more serious arrhythmias that definitely needs to be treated. It occurs in the lower chambers of the heart. So when that heart beats too fast, there's inadequate time for the chambers to fill between the beats, which results in less oxygenated blood being pumped to the body. So, again, it's a pretty serious condition. If it's not treated, it can go into, you know, like your ventricular fibrillation, which is a very serious condition and can put the patient in that sudden cardiac death, you know, where they're having to be shocked. And so, again, these are ventricular flutter, ventricular fibrillation. So these are definitely life-threatening conditions with the arrhythmias, and they have to be addressed immediately. Congestive heart failure, we have so many coding options to choose from with this category now. So really, level specificity is definitely important here. The location of the heart failure, the cause, the severity, you know, those level details, there's so many reporting options. There's different stages also. So this was some redefined stages from the ACC and the AHA several years ago. So they go through each stage and, you know, just define it. So stage A means they're at risk for that heart failure. They may be without symptoms, but they do have structural heart disease or blood testing that may be, you know, consistent with showing heart muscle injury. Patients could have, you know, other underlying conditions like high blood pressure, diabetes, obesity, you know, just so on. Stage B is defined as pre-heart failure. So they may still have no symptoms or signs, but they do have evidence of having that structural heart disease again. Their ejection fraction is reduced. So a lot of times when you do an echocardiogram, they do do that ejection fraction on that study. So that may be showing it's reducing enlargement of the heart muscle, abnormalities in the heart muscle, valve disease. Those types of things can show that they could possibly be in that pre-heart failure. Stage three means they have symptomatic heart failure. So it's structural heart disease with current or previous symptoms of heart failure. And some of those symptoms could be shortness of breath, persistent cough, swelling in their legs, feet or abdomen, fatigue and nausea. Those are just some examples of symptoms patients might be feeling. And then stage D is advanced heart failure. So that's where their symptoms are interfering with their daily life. It's difficult to control. It may result in the patient in having recurrent hospitalizations and just with that continued directed medical therapy and all that. And then this was a slide that I found very helpful. Actually, this was put together from a physician. And it's just super helpful. It just defines. So in your actual coding book, you may see sometimes in the documentation, like the HFREF. I see that a lot now. And when I first started seeing it, I was like, what is that? Like, I don't know what that means. Well, if you go to your coding book, go to systolic heart failure, the I50.2 series, you will see in the description, this is documented. So I was like, oh. After talking with the clinician, I was like, heart failure reduced EF. So that's systolic heart failure. That's how systolic heart failure is defined. So then that started making sense to me. The P is for preserved heart failure or that preserved EF. So that correlates to diastolic heart failure. And then you have an MR, which is mildly reduced or improving EF. So again, it just depends. And where that EF is at, it was really just gonna depend on the type of heart failure it can correlate to. So obviously if it's a reduced EF, that's a systolic heart failure. If it's above 50%, then that means their ejection fraction is preserved. So that would be diastolic. So again, just some helpful tips there. If you see like HFREF documented in your note, don't code unspecified. You do have a specified that would correlate to systolic. Combined heart failure, really your clinicians have to document if they have both that acute and diastolic, or the systolic and diastolic. Bi-V heart failure, that's when a patient also has right heart failure with the left heart failure. So again, this is just kind of like a guiding chart that can help. It has some coding clinic references from the AHA. So just to help for resource. End stage is where they are in that stage D heart failure. And documentation would have to show that. I don't see that documented to that level too often, but if you do see that in your notes, then you're in the end stage area. Right heart failure only, that's gonna just go to your I5 0.8 series. And then high output is another coding option. So lots of heart failure coding options we have. So again, this chart I find to be very helpful when looking at documentation. All right, so another area that I see coded wrong is a CVA. So if the patient is coming into your office for follow-up, they were in the hospital recently, had a CVA, made a recovery, they're coming back in your office to be seen, you would not code that as an acute CVA. So, and this is per the coding clinic fourth quarter of 2012. So you would code that as the Z86.73 at that point. So when they're in the acute phase of the CVA, you would report it as acute. But once they've recovered and they're stable and they don't have those residual effects, you're gonna look at reporting your Z series from there. All right, so let's touch up on risk adjustment just a little bit. If this is not a topic we've talked about in a while. So with us talking, all things diagnosis reporting today, I just wanted to touch up on this and cover a few slides. So what is risk adjustment? It's defined as a statistical process that takes into account the underlying health status and health spending of the enrollees in an insurance plan when looking at their healthcare outcomes or healthcare costs. Risk adjustment is a process that involves diagnosis reporting to measure a patient's health status. The diagnosis codes are used to adjust potential risk. It's also used to forecast trends and future needs of a patient. And this affects payment as well as that quality. So how it works, it's used to determine the financial risk of the various diseases and their manifestations. It's composed into five main elements. It has the health condition the beneficiary has and specifically those that would fall within an HCC category. It also factors in their age and disability status, their gender, their insurance status and then the socioeconomic status. So those are the five main elements when you're looking at risk adjustment. The goal of this is to mitigate the impacts of the potential adverse selection and to stabilize the health insurance premium so that the premiums better reflect differences in benefits and plan efficiency rather than the health status of the enrolled population. So basically the goal of this is to level the playing field. So this is just a snapshot of some of the diagnosis-based programs. The most common one we see is the HCC one which is the Medicare program. But as you see, Medicaid has its own program. The Affordable Care Act also has their own program. Your inpatient DRGs have theirs, the ACGs for outpatient has. So it's just depending on the type of program. But again, the most common one that we see is that HCC program. The most common one that we see is that HCC one with Medicare. So with that, we'll just kind of go look at, what's Medicare's model? What does it look like? So it starts with that diagnosis portion of the calculation. It all starts with that code that you're reporting. And then each code is then grouped together into a diagnosis group, which is then used to determine the condition categories that feed into an HCC code correlated that code too. And then ultimately the risk adjustment factor that they have assigned it. The risk adjustment factor will impact the individual patient risk score. And that's the score that is used to measure and determine those healthcare resources that will likely be necessary in the future to take care of that patient. So what do we mean by this term with the risk adjustment factor? So that risk adjustment is calculated using a tool developed to predict the cost of the healthcare for that covered beneficiary. The risk adjustment score is determined by using a combination of that demographic information that we covered with their socioeconomic status, their gender, all that stuff. And then they try to predict the future healthcare costs for that patient with that diagnosis code being reported. The score is the highest for the sickest patients as determined by a combination of those factors. So the risk adjustment factor is a relative measure of the probable costs to meet the healthcare needs of that patient. So it's important that all conditions be accurately documented and addressed during each patient encounter. So why does a risk adjustment and risk scoring matter? Diagnosis codes have a direct relation to the risk involved in caring for a patient. The cost for caring for the patient's diseases are how Medicare Advantage organizations are reimbursed. So once you start combining the main disease along with the manifestations that arise, you increase the reimbursement since you are now treating multiple diseases. Status codes such as amputations, artificial openings, old MIs, et cetera, those are also calculated into an HCC. These conditions still cost money to treat and are rehabilitate the patient. So Medicare states risk adjustment relies on physicians to perform accurate medical record documentation and coding practices in order to capture the complete risk of each patient. CMS requires that a qualified healthcare provider identify all chronic conditions and severe diagnoses for each patient to substantiate a base year health profile for those individuals. Documentation in the medical record must support the presence of the condition and indicate the provider's assessment and plan for management of that condition. This must occur at least once each calendar year for CMS to recognize that the individual continues to have the condition. So example here is maybe you have a patient coming in to your peripheral vascular clinic. They have had a right leg amputation due to their peripheral vascular disease. If you don't report at least once per year that amputation status, Medicare states at the beginning of every year that all patients are cured of all their conditions. So that's where they're saying it's important for you to accurately report at least once per year to show that that patient still needs that treatment for that condition. Otherwise, at the beginning of every year, Medicare wipes the slate clean for all patients and you have to re-report those codes accurately for them to recognize that that patient still needs that continued care. It's definitely a silly saying in my opinion from Medicare's perspective on like, patients are not just cured every year of all their chronic conditions, but you have to accurately report them at least once per year. So HCCs are determined or released through Medicare. So what types of conditions may map to an HCC? Examples are some high cost conditions like cancers, obviously, heart disease is a big one, sepsis, HIV, also other acute conditions, chronic conditions, status codes against those amputations, old MIs, those types of things. Some diagnosis, not all diagnoses map to an HCC though. So example diagnosis codes that may be used for labs, radiology and home health claims are not used because they are not reliable and they sometimes indicate a rule out diagnosis rather than a confirmed. Also some symptom diagnoses don't correlate to an HCC. So not all, you know, 74,000 or whatever it was that we have now of our diagnosis because they don't all map to an HCC category is really key there to point out. So again, since this is based on a calendar year, they have to be accurately reported and recaptured from January 1st to December 31st from a Medicare perspective. Because again, Medicare states all patients are completely healed according to Medicare every January 1st. So again, you have to re-report those and make sure you're capturing everything. All right, so some key documentation points. So when looking at education, both clinicians and coders need to understand the basics of accurately reporting a diagnosis code. You cannot accurately capture a diagnosis code if it is just simply listed with no known status or management. So this is where you get to your assessment and plan. Your provider lists, you know, maybe 10 different conditions, but they don't, you have nothing further. You know, whether the condition's stable, if it's unstable, if it's managed on a certain medication, who manages it, you know, do they have diabetes and it's managed by their primary care provider, but their diabetes is affecting their cardiac conditions you're treating. So again, just, you can't just list a condition and plan and report it. You have to have a status of that condition where it shows they've addressed the condition. So again, some helpful acronyms when looking at risk adjustment and whether or not you should be reporting those diagnosis codes. The most common one used is MEET, and that's whether monitor, evaluate, assess, or treat. So again, you're monitoring, that's any signs or symptoms of a diagnosis listed, you know, is it, you know, do they have coronary artery disease and now the patient's been having chest pain and shortness of breath recently, you know, those types of things. Evaluate, are they gonna review labs or order further testing? You know, are they gonna order a nuclear stress test, a echocardiogram? How are they responding to current treatment in place? So again, are they evaluating the condition? Now you don't have to meet all four of these when you're looking at your assessment and plan. It only has to meet one bullet to show that they address the condition, you know, as a whole. The second term is TAMPER. This one was created to assist coders when faced with diagnosis lists that, you know, are located within the past medical history or the favorite problems list that we see sometimes in our notes. So this TAMPER acronym is a way to help determine if those diagnoses should be or should not be submitted. So it just depends. So what they did when they created this, they said, did the provider tamper with that condition that is listed? If they meet one bullet, then that means you can't code it. So again, you have treatment, assessment, monitor or Medicaid, plan, evaluate or referral. So again, if they tampered with the condition in the note, then you can still report it. Now, whether or not you're reporting the diagnosis codes related to risk adjustment does not mean that it may correlate with your medical decision-making level. So that's totally separate. We're just talking about whether or not you can report a diagnosis code for that risk adjustment purpose. All right, so how do you apply this? You are allowed to report all diagnosis codes that are current and addressed by the documentation. Again, this applies to the ICD-10 reporting, though not CPT. So again, two separate things we're talking about. So when determining your level of service, you can only consider those conditions which were treated and addressed that would impact the complexity of the medical decision-making. The assessment and plan should describe the status of the conditions listed. Again, simply listing that condition and not further commenting on that does not mean you can report it. So again, keep that in mind. That's very important. All right, with that, let's talk about ICD-1011 real quick. So this actually went into effect January 1st of 2022. So there are some countries right now that have already implemented this and are using it. And if you can believe it, the ICD-10 classification is now 25 years old, which is just crazy to believe, is now considered outdated both clinically and from a classification perspective. If you're old school like me, you probably still have some ICD-9 codes still memorized crazy enough. And never thought you would have any ICD-10 codes memorized, but now you do. So eventually we'll be working on implementing this ICD-11. So again, just a little history. Decision was made back in 2007 to begin work on developing this new ICD-11. It was released in June of 2018 to allow member states to prepare for implementation and also to develop it in their national languages. The version given to the World Health Assembly will go into, it went into effect January 1st of 2022. The United States, for us, the committee sees implementation required use for reporting morbidity in the United States without ACM version as early as, they stated this back in 2020, or the goal was to do it, implement it in 2025, but don't see that happening. I've seen some articles that said maybe 2027 would be the goal. That doesn't mean it's gonna be in full effect like we're using it day to day. It just may be used for reporting for that morbidity. We know how long it took for ICD-10 to be implemented if you went through that transition several years ago. So pretty expect the same thing to happen with ICD-11, but eventually we will be implementing this. So wanted to kind of just give an outlook of what it looks like. You can go to the World Health Organization website. You can actually look at all the codes, like the whole reference guide is there. You can search for stuff by the index. It'll take you straight to that chapter. And then you can see all the coding options available for that specific category. It's pretty neat. So just the difference with how it looks. So our current ICD-10 with our chapter nine, you know, our chapter nine is our diseases of circulatory system. Well, in ICD-11, it's chapter 11, which is our circulatory system. And the difference between how the coding looks is like our I2510 series, which is our coronary artery disease of that native artery. In ICD-11, the difference with the coding is everything starts with a letter, not, you know, you have two letters, then you have some numbers. So you can see the difference in how it looks. So same code as I2510 in ICD-11 would be BA52.0. And then again, same thing with our VTAC. You can see the difference in the coding, benign and innocent murmurs, again, difference in the coding. So coding is definitely gonna look a lot different. And just thinking about it now, you know, like same thing when we implemented ICD-10, I was like, I'm never gonna have these codes memorized. And now I do have a lot of them memorized. So looking at 11 though, I'm just like, I don't know about this. I don't know if I'll ever have those memorized because, you know, it's a lot different than what we do now. And with that, that brings us to the end. Let me go look at our questions real quick and see if there's anything. Somebody asked, do they have that for ICD and CPT books? I'm guessing that is those files I pulled up at the beginning. So CPT does not have anything that nice. The AMA did release the CPT changes, but when you click on the article to read it, it basically guides you to buy a book. So once we get our books and Medicare has released the final rule, you know, we'll have those confirmed changes at that time. It's not as nice as the ICD-10 stuff where the CDC releases that file and you can literally download the file and see the actual changes. I wish it was as glorious with the CPT stuff as it is for the ICD-10. All right. If a patient has hypertension and chronic kidney injury, if they don't state the two conditions are related, are we to code hypertension as I1-2.9, meaning does the I1-2.9 always include acute kidney failure? So if it's an acute kidney failure and they don't have known chronic kidney disease, then you're gonna code your I10 with your acute kidney failure, which is your N179. If they have that chronic kidney disease known, then that's when you're gonna code that I12 series with that chronic kidney disease. Now, if they're in the hospital and they're also in acute kidney failure, then you're also gonna code your acute kidney failure at that time too. Okay. If they're getting, like you said, knee surgery and they want to do a pre-op visit for their cardiovascular system first, should we code the Z01810 even if there turns out to be fine? Yeah, if your provider's still seeing that patient for that cardiac clearance, you're still gonna report your cardiac clearance code. If you know the type of condition that they need the surgery for, you would code that second and then any related cardiovascular conditions your provider may be addressing at that time, you would report further. So when there is no policy in place, is it appropriate to code non-rheumatic tricuspid insufficiency, but non-rheumatic tricuspid insufficiently, sorry, but non-rheumatic tricuspid insufficiency with non-rheumatic mitral insufficiency with the I8 series. So when they have single valve disease, and this is where the guidelines, or I should say the index. So if it's a single valve disease and you're in your index, it's gonna guide you to non-rheumatic. It's when they have the multivalve disease and it's not specified as non-rheumatic, your index and your diagnosis book will guide you to code it as rheumatic. So that's the difference there. So if you only have the tricuspid insufficiency and you go to your index, just let it guide you to the appropriate code. It's multivalve, then yes, if you have the mitral and the tricuspid, it's gonna be that I08.1 series code. Again, unless you implement that policy, which we know several practices that have. So again, it's just gonna depend. Let's see, if your provider documents intraoperative self-limited AFib and you are using that for an ablation, which AFib diagnosis would you use? Your provider would have to specify whether it's proximal, persistent, that type of thing. There's no specific code that would correlate to an intraoperative self-limited AFib. So again, if you don't have that further specificity, you would just be using the unspecified. All right, how do I code chest pain, not cardiac related and CAD? Well, your CAD is going to be your I-2510 code if they didn't document any, you know, further specificity to symptoms. Chest pain, just depending on, you know, just off the top of my head, RO-79 is just unspecified chest pain. It might correlate to that if it's not cardiac related. I can't think off the top of my head if there's one more specified. I think there's one for another chest pain, but I just don't have that one memorized. But you would code the CAD separately if it was addressed. Somebody said the slide link is not downloading. So if you're having issues with that, you can, again, we'll upload a copy of the presentation to our Medaxim Academy site. It should be up within a few days. Or you could send an email to our Academy team and they'll be able to get you a copy of that. CPT changes for this fiscal year, will there be a webinar? I have not seen anything. So CPT, so ICD-10 is released for fiscal year. So it's effective October 1st. Our CPT changes are effective on a calendar year. So those will be effective January 1st. And we do an annual boot camp series in December. It's usually a four webcast series and we will address the CPT changes and the Medicare final rule in that series in December. Okay, I'll grab one more. Some of these are specific examples. Some of these are a little bit more in depth, so I would have to review them more in detail. So I will look at those and get a document uploaded to our site. We'll further look into those more specified questions. But with that, we'll give you about 15 minutes of your time. We will be doing a webcast. We'll announce our next webcast coming up. We'll post it to our listserv so everybody can get registered for that. But I hope you enjoyed today's content, and everybody has a great rest of your day.

ICD-10-CM

coding updates

cardiovascular coding

Jamie Quimby

MedAxiom

hypertension

heart disease

chronic kidney disease

diabetes

ICD-11

revenue cycle management