Opiate Epidemic What is the Medical Coders Role? - PowerPoint Presentation

1. Opiate Epidemic What is the Medical Coders Role?Lisa Phipps, CCS, COC

2. Opiate/Heroin abuse doubled between 2007-2012Heroin overdose deaths not only doubled but increased 5 fold between 2010-2016. A spike of overdose deaths in 2016 of 15,500 people dying from overdose involving Heroin. (from 1999-2016 over 200,000 people died in the US from overdose related to prescription opioids.)In 2016 males aged 25-44 had the highest heroin death rate

3. In 2017, the U.S. Department of Health and Human Services declared a nationwide public health emergency to address the opioid crisis, investing almost $900 million in opioid-specific funding to support treatment and recovery services

4. Goals for the PresentationUnderstand the nature of addiction diseaseCommon complications and co-morbidities Coding Guidelines ReviewedCoding scenariosHow coders can help with this epidemic

5. Short Definition of Addiction:Addiction is a primary, chronic disease of the brain’s reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

6. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.ASAM American Society of Addiction Medicine

7. Genetics account for about half of the likelihood that an individual will develop addiction. Environmental factors interact with the person’s biology and affect the extent to which genetic factors exert their influence. “Life Skills” taught through parenting or later life experiences can affect the extent to which genetic predispositions lead to the behavioral and other manifestation of addiction.Culture also plays a role in actualizing those biological vulnerabilities.What causes some to become addicted?

8. Repeated engagement in drug or other addictive behaviorDisruption of healthy social supports and problems of interpersonal relationshipsExposure to trauma or stressors that overwhelm coping abilityCo–occurring psychiatric disorders Other factors that can lead to addiction….

9. Orally SmokedSnortedInjectedHow opiates are abused

10. Medical Complications in an AbuserOverdose – respiratory failure, organ failurePneumoniaDepression/suicidalAnti social personality DODamaged mucosal tissue in nosePerforated nasal septumCollapsed veinsBacterial infections of the blood vessels, heart valvesSepsisAbscessHepatitis B ,CHIVBlood borne virusesDeath

11. Psychiatrists ordinarily state diagnoses in accordance with the nomenclature used in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5®), published by the American Psychiatric Association (APA). DSM-5 contains criteria used by psychiatrists to diagnose mental disorders, along with extensive descriptive text. ICD contains the code numbers used in DSM-5 and all other areas of medicine for insurance reimbursement and by national and international health agencies for monitoring morbidity and mortality statistics.

12. The terms used in DSM-5 and ICD 10 CM do not always match. Although coders may find it helpful to review the DSM-5 actually coding must be done per ICD 10 CM coding guidelines and codes.The coder will primarily use codes from Chapter 5 for the drug use, abuse, dependency and associated mental disorders codes and Chapter 19 for the poisoning (overdose) coding. Co morbidities , of course, could come from various other chapters in the ICD 10 CM book per your documentation

13. Coding Guidelines for Chapter 5 and Basic TerminologyAbuse = problematic use of drugs or alcohol but without dependenceDependence= increased tolerance to drugs or alcohol with a compulsion to continue taking the substance despite the cost; withdrawal symptoms often occur upon cessationRemission= No longer meeting criteria for drug dependence as defined in the DSM 5

14. The selection of codes for "in remission" for categories F11-F19 with -.21 requires the provider's clinical judgment. The appropriate codes for "in remission" are assigned only on the basis of provider documentation (as defined in the ICD-10-CM Official Guidelines for Coding and Reporting), unless otherwise instructed by the classification. Mild substance use disorders in early or sustained remission are classified to substance abuse in remission. Moderate and severe substance use in early or sustained remission is classified to dependence in remission.

15. Substance related disorders, in remission ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2017 Page: 8 Effective with discharges: October 1, 2017New diagnosis codes have been created to identify "in remission," for abuse of the following substances:Alcohol (F10.11) Opioid (F11.11) Cannabis (F12.11) Sedative, hypnotic or anxiolytic (F13.11) Cocaine (F14.11) Other stimulant (F15.11) Hallucinogen (F16.11) Inhalant (F18.11) Other psychoactive substance (F19.11)Prior to this change, ICD-10-CM included codes for "in remission" for substance dependence, but not for substance abuse. The new codes for substance abuse in remission have inclusion terms for substance use disorder specified as "mild in early remission" and "mild, in sustained remission."

16. In addition, new inclusion terms have been added to the existing codes for substance dependence in remission, to indicate that substance use disorder described in the following terms are classified to dependence in remission:Moderate, in early remission Moderate, in sustained remission Severe, in early remission, and Severe, in sustained remissionThese inclusion terms harmonize with the Fifth Edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) clinical terminology and classifications to indicate substance use disorder in remission and severity.The Official Guidelines for Coding and Reporting for Mental and Behavioral Disorders due to psychoactive substance use have also been revised to: "The appropriate codes for "in remission" are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting), unless otherwise instructed by the classification."

17. Alcohol abuse & alcohol withdrawal ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2018 Page: 16 Effective with discharges: February 18, 2018Related Information Question: A 21-year-old was admitted due to alcohol abuse and the provider documented alcohol withdrawal. The physician was queried and clarified that the patient had alcohol withdrawal, but was not alcohol dependent. We are not able to code a diagnosis of alcohol withdrawal without dependence. How can we accurately code this case?Answer: In ICD-10-CM, alcohol withdrawal is categorized as alcohol dependence. ICD-10-CM does not classify alcohol withdrawal with alcohol abuse. If the physician has been queried and confirmed alcohol abuse, rather than dependence, code only "alcohol abuse" and do not assign a code for withdrawal.

18. Psychoactive Substance Use, Abuse, and Dependence Code Hierarchy When the provider documentation refers to use, abuse, and dependence of the same substance (e.g., alcohol, opioid, cannabis), only one code should be assigned to identify the pattern of use, based on the following hierarchy:If both use and abuse are documented, assign only the code for abuse. If both abuse and dependence are documented, assign only the code for dependence. If use, abuse, and dependence are all documented, assign only the code for dependence. If both use and dependence are documented, assign only the code for dependence.

19. Selection of the Principal Diagnosis The designation of the principal diagnosis for patients with either substance abuse or substance dependence is determined by the circumstances of the admission, as defined in the following examples:When a patient is admitted for detoxification or rehabilitation for both drug abuse or dependence and alcohol abuse or dependence, and both are treated, either condition may be designated as the principal diagnosis.When a patient with a diagnosis of substance abuse or dependence is admitted for treatment or evaluation of a physical complaint related to the substance use, follow the directions in the Alphabetic Index for conditions described as alcoholic or due to drugs; sequence the physical condition first, followed by the code for abuse or dependence.When a patient with a diagnosis of alcohol or drug abuse or dependence is admitted because of an unrelated condition, follow the usual guidelines for selecting a principal diagnosis.

20. Coding Guidelines Chapter 19Chapter 19 e. b PoisoningPoisoning vs adverse effectPoisoning = Error made in prescription, overdose of drug taken intentionally or unintentionally, non prescribed drug taken with prescribed drug even if prescribed drug is taken correctly, and interaction of drug and alcoholUse as many codes as needed to describe completely all drugs or biological substances

21. If the same code would describe the causative agent for more than one adverse effect or poisoning assign the code only once. Intent of the poisoning indicated in the 5th or 6th character (accidental, intentional self harm, assault, and undetermined) if the intent is unknown or unspecified use default accidental intent. Only use undetermined if this is documented in the record. If there is also a diagnosis of abuse of or dependence on the substance, the abuse or dependence is also coded

22. Coding Scenario #1Patient transfer to acute care hospital for vent and toxicology management. Patient was transferred from a rural critical access hospital where patient was revived with naloxone from heroin OD and intubated for respiratory failure . Critical access hospital did not have equipment to manage the vent. Upon admission to the acute care hospital the physician documents patient has respiratory failure, sepsis, renal failure . The vent was managed and patient was weaned off the vent within 24hrs and was in stable condition . Labs also were all back to normal. Patient was discharged home .What steps do CDI need to take??What steps does Coding take??

23. CDI query for :1. Did the patient have sepsis ( medical criteria)2. Was respiratory failure due to overdose or sepsis?3. Was renal failure due to overdose or sepsis

24. Respiratory failure due to poisoning ICD-9-CM Coding Clinic, Third Quarter 2007 Page: 7 to 8 Effective with discharges: September 14, 2007 Question: A 60-year-old female attempted suicide by taking an overdose of amitriptyline, hydrocodone and tramadol. She was initially seen in the emergency department at another facility in a coma and in acute respiratory failure, intubated, and placed on mechanical ventilation. The patient was then transferred to our hospital for continued toxicology management and for treatment of acute respiratory failure. The patient remained on the ventilator for three days. According to coding guidelines, when acute respiratory failure is due to poisoning, the poisoning is assigned as the principal diagnosis. How should this case be coded?

25. Answer: Note from 3M :As of October 1, 2009, code 969.0, Poisoning by psychotropic agent, Antidepressants, has been further expanded to provide a unique code for each of the common current classes of antidepressants.Assign code 969.0, Poisoning by psychotropic agents, Antidepressants, for the amitriptyline overdose, as the principal diagnosis. Codes 518.81, Acute respiratory failure; 965.09, Poisoning by analgesics, antipyretics, and antirheumatics, Other; for the hydrocodone poisoning, and 965.00, Poisoning by analgesics, antipyretics, and antirheumatics, Opiates and related narcotics, Opium (alkaloids), unspecified, should be assigned as additional diagnoses. Assign code 96.71, Continuous mechanical ventilation for less than 96 consecutive hours, for the mechanical ventilation.

26. The poisoning code is sequenced first, because there is a chapter-specific guideline (Section 1, C 17, e, 2, d) that provides sequencing directions specifying that the poisoning code is sequenced first, followed by a code for the manifestation. The acute respiratory failure is a manifestation of the poisoning. This advice is consistent with information previously published in Coding Clinic First Quarter 2005, pages 3-8, and First Quarter 2006, pages 66-72.In addition, the general E-code guidelines state that the external cause of injury code should only be assigned for initial encounters for treatment of an injury, poisoning, or adverse effect of drugs, not for subsequent treatment. The exception to this guideline is acute fracture. For fractures, the E-code may be assigned while the acute fracture codes are still applicable

27. Chronic Respiratory Failure due to Poisoning - Clarification ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2016 Page: 38 Effective with discharges: March 18, 2016Question: Coding Clinic First Quarter 2015, page 21, advised the assignment of code J96.10, Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, as the principal diagnosis for a patient who was transferred to a long term care hospital for continued care of chronic respiratory failure following an accidental drug overdose. In this case, shouldn't the poisoning guideline be applied rather than the one for sequela?

28. Answer: The chronic respiratory failure was the reason for the admission and was appropriately sequenced as the principal diagnosis. After treatment, the patient's respiratory issue did not resolve. The chronic respiratory failure is a sequela, not a manifestation of the poisoning. In this circumstance, the sequela guideline is more relevant than the poisoning guideline, and takes precedence, because the reason for admission was for treatment of the sequela. The poisoning code is sequenced as an additional diagnosis.

29. Mechanical ventilation for airway protection ICD-9-CM Coding Clinic, Third Quarter 2012 Page:21 Effective with discharges: September 15, 2012Question: A patient presents to the Emergency Department (ED) due to an overdose of Ambien and is intubated and placed on mechanical ventilation. The attending physician admits the patient to the intensive care unit (ICU) and documents that the patient was intubated for airway protection because of the drug overdose. There was no documentation of respiratory failure and the patient was weaned from the ventilator the following next day. Can the coder assume that the patient was in respiratory failure and report code 518.81, Acute respiratory failure, based on the fact that the patient was intubated and placed on mechanical ventilation for airway protection?

30. Answer: Do not assign code 518.81, Acute respiratory failure, simply because the patient was intubated and received ventilatory assistance. Documentation of intubation and mechanical ventilation is not enough to support assignment of a code for respiratory failure. The condition being treated (e.g., respiratory failure) needs to be clearly documented by the provider.

31. Coding Scenario #227 yo male After fighting with wife and threatening self harm, the patient spent the night drinking alcohol and took unknown number of oxycotin. Patient was found unresponsive but revived with naloxone. Admitted with diagnosis of acute respiratory failure with hypoxia due to overdose , AKI, severe sepsis with septic shock, aspiration pneumonia, and intentional self harm overdose of oxycontin while drinking Bourbon. Alcohol abuse currently intoxicated. Patient remained on the vent but was eventually weaned and was back to baseline. Patient was discharged to rehabilitation facility.

32. Coding Guidelines Chapter 19, Section e section 5b

33. Coding Guideline Chapter 1 section d1.)b 2.)

34. Sepsis and Severe Sepsis with a Localized Infection When the reason for admission is both sepsis, or severe sepsis, and a localized infection (e.g., pneumonia or cellulitis), the code(s) for the underlying systemic infection should be assigned first and the code for the localized infection should be assigned as a secondary diagnosis. If the patient has severe sepsis, a code from subcategory R65.2 should also be assigned as a secondary diagnosis. On the other hand, if the patient is admitted with a localized infection, such as pneumonia, and the sepsis/severe sepsis does not develop until after admission, the code for the localized infection should be assigned first, followed by the appropriate sepsis/severe sepsis codes.When the code for sepsis identifies the organism and the patient also has a localized infection due to the same organism, it is not necessary to separately assign a code for the organism responsible for the localized infection because the sepsis code clearly identifies the causal organism. For example, for a diagnosis of sepsis due to Escherichia coli urinary tract infection, assign code A41.51, Sepsis due to Escherichia coli [E. coli], and code N39.0, Urinary tract infection, site not specified. Code A41.51 clearly identifies the causal bacterium for both the sepsis and the urinary tract infection. Although there is a "Use additional code (B95-B97), to identify infectious agent" instructional note at code N39.0, assigning B96.20 as an additional code is redundant in this case

35. Codes Assigned and SequencingT402X2A Poisoning by other opioids intentional self harm, initial encounterA419 Sepsis unspecified organismR65.21 Severe sepsis with septic shockJ9601 Acute respiratory failure with hypoxiaN17.0 Acute kidney failure with tubular necrosisJ96.0 pneumonitis due to inhalation of food and vomitF10129 alcohol abuse with intoxication unspecified

36. Many new coders or CDI specialist try to re-sequence the sepsis to capture the vent in the DRG. However, the guidelines are clear and unless the physician documents that the sepsis is not related to the OD but rather to another infectious process such as abscess, UTI, etc. the poisoning would be sequenced as pdx

37. Coding Scenario #3Patient admitted with fractured ulnar shaft left arm following a fall from ladder while at work. Patient is on methadone maintenance , History of opiate dependency.

38. Codes Assigned and SequencingS52255A nondisplaced comminuted fracture of shaft of ulna, left arm initial encounter for closed fx.W11XXA Fall from ladder initial encounterY99.0 Civillian activity done for income or payF1120 Opioid dependence, uncomplicated

39. Methadone maintenance for heroin dependence ICD-9-CM Coding Clinic, Second Quarter 2010 Page: 13 Effective with discharges: July 7, 2010Question: Which code should we use to capture patients who are heroin addicts and are being maintained on methadone? Coding Clinic Fourth Quarter 1988, page 8, advised coders to use code 304.01 for patients who are receiving methadone maintenance; however, code V58.69 appears more appropriate.Answer: Assign code 304.00, Opioid type dependence, unspecified, for patients who are receiving methadone maintenance because of heroin dependence. Code V58.69, Long-term (current) use of other medications, is not appropriate since it should not be used for patients who have addictions to drugs. The Official Guidelines for Coding and Reporting state that subcategory V58.6 is not used for medications for detoxification or maintenance programs to prevent withdrawal symptoms in patients with drug dependence (e.g., methadone maintenance for opiate dependence).

40. Newborn with in-utero drug exposure to cocaine and heroin exhibiting symptoms of NASCoding Scenario #4

41. Neonatal Abstinence Syndrome – this occurs when heroin passes through the placenta to the fetus during pregnancy causing the baby to become dependent on the drug as well.Symptoms of NAS include: excessive crying, fever, irritability, seizures, slow weight gain, tremors, diarrhea, vomiting, and possibly death.Treatment for NAS: treating the symptoms of withdrawal and weaning the infant off the drug until it adjusts to being opioid free.

42. Codes Assigned and SequencingZ38.00 Single liveborn infant, delivered vaginallyP96.1 Neonatal withdrawal symptoms from maternal use of drug of addictionP04.49 Newborn affected by maternal use of other drugs of addiction

43. Young women presented to hospital 24 weeks pregnant. Long term IVDU and diagnosed with endocarditis and, sepsis due to endocarditis (documented grew MRSA), severe sepsis, respiratory failure with hypoxia, poly substance abuse most recent heroin abuse, Delivered nonviable baby during stay.Coding Scenario #5

44. O75.3 Other infection during laborA41.02 Sepsis due to MRSAR65.20 Severe Sepsis w/o septic shockI33.0 acute and subacute infective endocarditisO99.42 Dz of the circulatory system complicating childbirthO99.52 Dz of the respiratory system complicating childbirthJ96.01 Acute Respiratory failure w/ hypoxiaO99324 Drug use complicating childbirthF1110 Opioid abuseZ3A24 24 weeks gestationZ37.1 single stillbirthCodes Assigned and sequencing

45. What role do medical coders play in this epidemic?Coding professionalStatisticsHumanitarian Role – Be a part of the culture of change to stop this epidemic.Understand it is a chronic diseaseShow Respect and Compassion (but not enabling)Socially acceptable to get helpBe responsible with your own medicationsTalk to your children and young family membersIf someone you know needs help – Don’t wait

46. Resources usedICD 10 CM Coding GuidelinesAHA Coding ClinicsASAM website for addiction statistics ICD 10 CM Coding HandbookContact information: lisa.phipps@nortonhealthcare.org