Critical Limb Ischemia Coding in ICD-10-CM, Lecture notes of Cardiology

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Critical Limb Ischemia

Coding in ICD-10-CM

Adi Renbaum, MBA ANR Consulting, LLC

Linda Holtzman, MHA, RHIA, CCS, CCS-P, CPC, COC Clarity Coding, Inc on behalf of

OVERVIEW

• Clinical Nature
• Treatment
• ICD-10-CM Coding
• Sample Coding Scenarios

Critical Limb Ischemia

CLINICAL NATURE

OF

CRITICAL LIMB

ISCHEMIA

PERIPHERAL ARTERY DISEASE

• In peripheral artery disease, plaque builds up in the peripheral arteries over time, narrowing or blocking the lumen of the vessel.
• This reduces or obstructs blood flow through the artery, preventing sufficient oxygen from reaching the distal extremities.
• About 12% of US adults have some degree of clinically significant peripheral artery disease.

CLINICAL DEFINITION OF CLI

• CLI is characterized by the hallmarks of chronic ischemia with inadequate blood supply to the tissues.

“Clinically, critical limb ischemia (CLI) is defined as ischemic rest pain, tissue loss, or gangrene in the presence of peripheral artery disease (PAD) and hypoperfusion of the lower extremity.”

Critical Limb Ischemia: An Expert Statement, MH Shishehbor et al, Journal of the American College of Cardiology, 2016, Volume 68, No 18.

• A diagnosis of CLI requires at least one of manifestations.
• By its nature, CLI is a chronic condition.

PROGRESSION : PAD  CLI

 Intermittent Claudication

 Rest Pain

 Asymptomatic peripheral artery disease

• Pain affecting the calf, thigh, or buttock, induced by exercise and relieved by rest
• Ischemic pain, usually in the foot and usually at night, when at rest or lying down

 Tissue Loss (Ulceration)

• Skin breakdown, chronic and non-healing

 Gangrene

• Tissue death

Critical limb ischemia does not always progress through the various stages.

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COEXISTING DIABETES MELLITUS

• Peripheral artery disease progresses more rapidly in patients with diabetes and the risk of developing CLI is about four times higher.
• CLI patients with diabetes are also at a significantly higher risk of major amputation than CLI patients without diabetes.
• Patients with diabetes often have more extensive CLI, eg, multiple arteries, long lesions.

Patients with CLI who have coexisting diabetes are a notable subgroup at particular risk.

• They are also more likely to present with higher severity, ie, ulcers or gangrene.

TREATMENT

OF

CRITICAL LIMB

ISCHEMIA

REVASCULARIZATION: APPROACH

• Revascularization of the lower limb can be performed by an endovascular approach or an open surgical approach.
• Which approach is selected depends on multiple factors, including:

 Patient comorbidities

 Multilevel disease

 Presence of chronic total occlusion

 Length and composition of lesion, eg, calcifications

REVASCULARIZATION: ENDOVASCULAR

• Common endovascular techniques include:

 Angioplasty (plain balloon, drug-eluting)  Stenting (bare metal, drug-eluting)  Atherectomy

 Endovascular bypass  Venous arterialization

• Other endovascular techniques being introduced include:

ICD-10-CM

DIAGNOSIS CODES

FOR

CRITICAL LIMB

ISCHEMIA

THE TROUBLE WITH ICD-10-CM

• From its implementation in FY 2016, ICD-10-CM did not contain any references to critical limb ischemia.
• This created frustration in searching for codes for this diagnosis.
• The coding inconsistencies carried over to clinical databases.
• The ICD-10-CM codes being assigned by physicians and hospitals for critical limb ischemia were inconsistent.

CRITERIA FOR CODE CHANGES

• The C&M Committee looks for multiple elements when considering whether to approve a request.

 The diagnosis must be understood and applied consistently by physicians.

 The diagnosis must be useful in broad-based data collection and analysis.

 The proposal must be written in accordance with ICD-10-CM conventions.

References to reimbursement, benefits, and claims processing are considered off-topic.

 It must be documented distinctly and specifically in the medical record.

NATURE OF C&M REQUEST

• With this in mind, it was determined that no new ICD-10-CM codes were needed per se.
• Instead, the proposal focused on clearly identifying existing codes that constitute critical limb ischemia.
• ICD-10-CM already contained codes for peripheral artery disease of the extremities with rest pain, ulceration, and gangrene.
• This meant focusing on instructional notes in the Tabular and entries in the Index.