New Wound Care ICD-10-CM Codes for Fiscal Year 2018 & Review of Frequently Forgotten Codes

Editor’s Note: Kathleen D. Schaum, MS, author of Business Briefs, will be on extended vacation through early 2018. While she’s away, we will feature guest authors in this column space. Ms. Schaum will return to her column beginning with the February 2018 edition. 

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure information accuracy. However, HMP and the author do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying information accuracy lies with the reader.  

The new year is an excellent time to review some new and frequently forgotten ICD-10-CM codes that are associated with wound care. The new 2018 ICD-10 codes that became effective on Oct. 1, 2017, fit into two major categories: 1) new codes and 2) revised codes. Because readers of Today’s Wound Clinic have submitted many questions regarding the 7th character assignment for ICD-10 codes in Chapter 19 (S00-T98, Injury, Poisoning, and Certain Other Consequences of External Causes), we will also review the coding guidelines for proper 7th character assignment. In addition, because many readers may not be aware of the existence of the aftercare codes and the follow-up codes, we will review their use in wound care businesses as well.  

NEW 2018 ICD-10 CODES

See Table 1, which is divided into four sections of new codes. The new codes in Section 1 have finally cleared up an area of confusion pertaining to the coding of non-pressure ulcers. Remember that the 2017 ICD-10 codes only offered the choice of muscle or bone involvement with necrosis. This caused great confusion if the patient had bone involvement but no necrosis: wound care professionals and coders alike found it difficult to determine exactly what to code, and physicians did not know what was needed to appropriately document the patient’s condition. As Table 1 shows, some unspecified sites are added to the non-pressure ulcers. (Of course, these are not recommended, as one would hope that wound care professionals know whether the ulcer appears on the right or left.)  Most important, new codes are added to all non-pressure ulcer sites to indicate muscle or bone depth without evidence of necrosis. New codes are also added to sites for “other unspecified severity”: they account for severities in wounds that were not reflected in the 2017 ICD-10 codes. 

The new codes in Section 2 are added for diabetes type 2 with ketoacidosis (with and without coma). The new codes displayed in Section 3 are added for dermatomyositis conditions. Section 4 displays the three new unspecified multiple-injury codes. 

REVISED 2018 ICD-10 CODES 

See Table 2 on page 10 for revised codes that may be pertinent to wound care patients. 

• First, revisions are made to the descriptions of the embolism, thrombosis, and varicose vein ICD-10 codes. These revisions change the term “extremities” to the singular term “extremity.”  
• Second, a minor revision is made to the pressure ulcer codes for the elbow and heel: the “unspecified stage” is added.  
• Third, the “Excludes 1” note under the gangrene codes is deleted and replaced with an “Excludes 2” note that reads “gangrene in diabetes mellitus (E08-E13).”  Remember, an “Excludes 2” note means “not included here.” This indicates that the excluded condition is not part of the condition represented by the code, but a patient may be living with both conditions at the same time. When an “Excludes 2” note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate. 

Required Implementation Actions 

After reviewing the new and revised 2018 ICD-10 codes, wound care professionals should:

1. Review the new 2018 ICD-10 code changes with one’s clinical and revenue cycle staff.
2. Ensure that the new 2018 ICD-10 codes are added to one’s electronic billing systems and forms.
3. Review all pertinent national coverage determinations (NCDs) and local coverage determinations (LCDs) — eg, wound care, hyperbaric oxygen therapy (HBOT), cellular and/or tissue-based products for skin wounds (CTPs), electrical stimulation, electromagnetic therapy) — that are updated due to these code changes. The Centers for Medicare & Medicaid Services (CMS) has already updated the NCDs, and most Medicare Administrative Contractors have updated their LCDs. 

Review of Application of 7th Characters in ICD-10 Chapter 19

This author has received numerous questions about the correct use of the 7th character values “A,” “S,” and “D.” Wound care professionals should always remember that 7th character values are only applicable to codes in Chapter 19 of ICD-10. They are not required for non-injury ulcer codes outside of Chapter 19. Some payers are asking for these 7th character values on non-pressure and pressure ulcers. If payers are asking wound care professionals to provide them with the 7th character on these codes, be sure to ask the payer why they are requiring a 7th character on codes that are not in Chapter 19. It may be that the payer is not aware of the Chapter 19 rule.  If this is the case, wound care professionals are encouraged to educate payers on the 7th character ICD-10 requirement and to ask for a copy of any commercial policy(ies) that require this coding. All of the injury and poisoning categories (except for fractures) in Chapter 19 have three 7th character value requirements for each applicable code:

1. “A” - initial encounter,
2. “D” - subsequent encounter, and 
3. “S” - sequela. 

NOTE: Categories for traumatic fractures have additional 7th character values. 

Following are a few appropriate-use tips for each of the three 7th character values:

• 7th character “A” - initial encounter: Used for each encounter when the patient is receiving active treatment for the condition. This initial encounter “A” character is based on whether the patient is undergoing active treatment for the condition, not whether the physician or other qualified healthcare professional (QHP) is seeing the patient for the first time. Example: For complication codes, active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier precipitating problem. ICD-10 code “T84.50XA” - infection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter - is used when active treatment is provided for the infection, even though the condition relates to the prosthetic device, implant, or graft that was placed at a previous encounter. NOTE: In wound care, the codes for chronic ulcers and repeat visits while the physician is still providing active treatment, such as debridement, CTPs, and HBOT do not require a 7th character “A” because the chronic ulcer codes are not in Chapter 19. If commercial carriers require the use of these 7th characters, wound care professionals should ask why they are requiring a 7th character when none are required by the ICD-10 classification system. Commercial carriers may also have different definitions than the definitions provided in the official 2018 ICD-10 coding guidelines¹ set forth by CMS, so be sure to verify their definitions for the use of the 7th characters if they are requiring them.

Because this is an area of great confusion, remember that even though a patient may be seen by a new or different physician (or other QHP) over the course of treatment for an injury, assignment of the 7th character value is based on whether the patient is undergoing active treatment for the condition, not whether a patient is being seen for the first time for the condition.

• 7th character “D” - subsequent encounter: Used for encounters after the patient has completed active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. In wound care, this may be a routine postoperative visit after a traumatic wound has closed. The aftercare “Z” codes should not be used to identify subsequent care. Example: assign an acute injury code with the 7th character “D” - subsequent encounter - rather than an aftercare “Z” code. 
•  7th character “S” – sequela: Used for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn. (The scars are sequelae of the burn.) When using the 7th character “S,” it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The “S” is added only to the injury code, not the sequela code. The 7th character “S” identifies the injury responsible for the sequela. The specific type of sequela (eg, scar) is sequenced first, followed by the injury code.

REVIEW OF AFTERCARE CODES

Many wound care professionals are not aware that this category of codes is available. The following list provides aftercare codes that are available for many surgical procedures:

• Z42 - Encounter for plastic and reconstructive surgery following medical procedure or healed injury
• Z43 - Encounter for attention to artificial openings
• Z44 - Encounter for fitting and adjustment of external prosthetic device
• Z45 - Encounter for adjustment and management of implanted device
• Z46 - Encounter for fitting and adjustment of other devices
• Z48 - Encounter for other post-procedural aftercare 
• Z51 - Encounter for other aftercare and medical care 

Example: “Z45” could be used for adjustment and management of an implanted device, such as a tissue expander.

REVIEW of Follow-up Codes 

Follow-up codes are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. They imply that the condition has been fully treated and no longer exists. They should not be confused with aftercare codes or injury codes with a 7th character for subsequent encounter that explain ongoing care of a healing condition or its sequelae. Follow-up codes may be used in conjunction with history codes to provide the full picture of the healed condition and its treatment. The follow-up code is sequenced first, followed by the history code. 

The follow-up “Z” code categories are:

• Z08 - Encounter for follow-up examination after completed treatment for malignant neoplasm 
• Z09 - Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
• Z48 - Encounter for other post-procedural aftercare 
• Z51 - Encounter for other aftercare and medical care

A follow-up code may be used to explain multiple visits. Should a condition be found to have recurred on the follow-up visit, the diagnosis code for the condition should be assigned in place of the follow-up code. Example: “Z48” may be used for post-procedural aftercare for postoperative visits within the global period. 

Donna Cartwright is senior director of strategic reimbursement for Integra LifeSciences Corp., Plainsboro, NJ. She’s approved as a certified trainer on ICD-10 by the American Health Information Management Association and has been designated as a fellow of the American Health Information Management Association.

Reference

1.  ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 (October 1, 2017 - September 30, 2018). CMS. Accessed online: www.cms.gov/medicare/coding/icd10/downloads/2018-icd-10-cm-coding-guidelines.pdf