ICD-10-CM expands codes and necessary documentation for cardiac arrest
by Lolita M. Jones, RHIA, CCS
ICD-10-CM improves the reporting of clinical data for numerous diseases and conditions, including cardiac arrest, which is the sudden, abrupt loss of heart function.
Only 17% of patients who suffer this critical medical condition during hospitalization survive, according to the report, “Cardiopulmonary resuscitation of adults in the hospital: A report of 14,720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation, 2003.”
In the current ICD-9-CM alphabetic index, the main term “arrest,” subterm “cardiac” lists code 427.5 (cardiac arrest). The main term “arrest,” subterms “cardiac, postoperative (immediate)” lists code 997.1 (complications affecting specified body systems, not elsewhere classified, cardiac complications). These same codes also apply for cardiorespiratory arrest, according to the alphabetic index. Editor’s note: For purposes of this article, we will not address the codes for obstetrical and newborn cardiac arrest coding.
Know ICD-9-CM coding guidelines
The American Hospital Association’s Coding Clinic, second quarter, 1988, contains the following official guidelines for reporting cardiac arrest:
- Coders may assign code 427.5 as a principal diagnosis when a patient arrives at the hospital in a state of cardiac arrest and cannot be resuscitated, or is only briefly resuscitated and is pronounced dead with the underlying cause of the cardiac arrest not established (i.e., cause unknown).
- Coders may assign code 427.5 as a secondary diagnosis when a patient arrives at the hospital in a state of cardiac arrest and is resuscitated and admitted with the underlying cause of the cardiac arrest being known (e.g., ventricular tachycardia or trauma). Report the underlying cause as the principal diagnosis, and assign code 427.5 as the secondary diagnosis.
- When cardiac arrest occurs during the hospitalization and the patient is resuscitated, assign code 427.5 as a secondary diagnosis. However, if the cardiac arrest is a complication of a surgical procedure, report code 997.1 as a secondary diagnosis.
- Do not assign code 427.5 or 997.1 to indicate cardiac arrest for a patient who dies during an inpatient stay.
Consider significant reimbursement impact
For most inpatients who are discharged alive, ICD-9-CM code 427.5 represents an MCC under the current MS-DRG system. An MCC classifies a condition as highly likely to extend the inpatient stay and to increase the patient’s utilization of both human and medical resources, thereby increasing the cost of care for the overall admission.
So, although ICD-9-CM provides only two cardiac arrest codes for nonobstetrical and non-newborn cases, the MCC designation carries with it significant reimbursement implications if coding isn’t accurate.
Note significant code expansion
ICD-10-CM, on the other hand, contains seven cardiac arrest codes. The new coding system also provides the following specific surgical complication codes:
- I46.2 (cardiac arrest due to underlying cardiac condition)
- I46.8 (cardiac arrest due to other underlying condition)
- I46.9 (cardiac arrest, cause unspecified)
- I97.120 (postprocedural cardiac arrest following cardiac surgery)
- I97.121 (postprocedural cardiac arrest following other surgery)
- I97.710 (intraoperative cardiac arrest during cardiac surgery)
- I97.711 (intraoperative cardiac arrest during other surgery)
In the 2011 ICD-10-CM tabular list, a note below cardiac arrest code I46.2 states, “Code first underlying cardiac condition.” Similarly, a note below cardiac arrest code I46.8 states, “Code first underlying condition.”
In the ICD-10-CM Official Guidelines for Coding and Reporting for 2011, p. 71, contains the following guideline that applies to cardiac arrest codes I97.120, I97.121, I97.710, and I97.711:
Intraoperative and postprocedural complication codes are found within the body system chapters with codes specific to the organs and structures of that body system. These codes should be sequenced first, followed by a code(s) for the specific complication, if applicable.
To date, these are the only ICD-10-CM official coding guidelines for cardiac arrest.
Recognize cardiac and noncardiac causes
According to the Mayo Clinic website, cardiac arrest can develop from the following cardiac conditions:
- Arrhythmia: abnormal rhythm in the heart’s electrical system
- Coronary artery disease: Arteries in the heart are clogged with cholesterol and other deposits
- Heart attack: Death of heart muscle due to blockage can leave dead scar tissue on the heart
- Cardiomyopathy: Stretching and enlarging or thickening of the heart’s muscular walls
- Heart valve leakage or narrowing
- Congenital heart disease (e.g., hypertrophic cardiomyopathy)
Regarding noncardiac causes, various heart medications and other prescribed medications, as well as abuse of illegal drugs, can lead to arrhythmias that result in cardiac arrest, according to the American Heart Association website.
Institute urges implementation of RRTs
In its 5 Million Lives Campaign from December 2006 to December 2008, the Institute for Healthcare Improvement encouraged hospitals in America to implement rapid response teams (RRT). This designated group of healthcare clinicians can convene quickly to deliver critical care expertise in response to grave clinical deterioration of a patient located outside a critical care unit. For example, an RRT may consist of a physician (e.g., senior resident, intensivist, or hospitalist), physician’s assistant, critical care RN, clinical nurse specialist, and a respiratory therapist.
A hospital usually creates criteria that signify a patient’s condition is deteriorating, for which the staff nurse will activate the RRT. The goal is to treat these warning signs early so that the team can improve the patient’s outcome and prevent a cardiac arrest.
“Research has shown that with RRTs [there is a] 50% reduction in the occurrence of cardiac arrest outside the [intensive care unit] ICU, according to the British Medical Journal article, “Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital.”
Documentation must indicate underlying cause
For coders to achieve accurate ICD-10-CM cardiac arrest coding, physicians must document the underlying cause of the cardiac arrest, whether intraoperative, postoperative, or unassociated with a surgical complication.
Physicians need to document the underlying cause regardless of whether the patient is discharged alive or expires during the stay. A physician should not report cardiac arrest as the cause of death on a death certificate because this does not identify the underlying cause of death. For patients who suffer cardiac arrest and die, cardiac arrest is the mechanism of death or a “mode of dying”—not the underlying cause of death.
Case study illustrates ICD-10-CM/PCS cardiac arrest coding
A 62-year-old Hispanic male with a metastatic bony deposit involving his left proximal femur from a known primary prostatic carcinoma was referred to a provider. Detailed radiological evaluation revealed a large lytic lesion. Due to the high risk of an impending pathological fracture, the provider decides to perform prophylactic intramedullary nailing of the left femur. To reduce the increased intramedullary pressure during nail insertion, the provider performs venting of the distal end of the femur via drilling.
The patient has no other significant past medical history, and documentation did not indicate allergies to any medication. He had undergone previous surgical procedures requiring general anesthesia for other conditions, and each case resulted in an uneventful recovery.
During this procedure described above, the patient suffered a cardiac arrest. The provider initially believed a fat embolism caused this event due to the increased intramedullary pressure during reaming and nail insertion. Following successful cardiopulmonary resuscitation, the provider noticed a marked generalized erythematous rash, which lasted for approximately 30 minutes. This raised the concern of a possible hypersensitivity reaction to one of the anesthetic agents.
The patient received the following eight drugs:
Documentation indicated that the cardiac arrest occurred following a dose of atracurium and an infusion of gelofusine. Consequently, the provider estimated that either one of those two agents could have been responsible for the anaphylactic response.
Serum mast cell tryptase levels taken one hour following the event demonstrated a level of 190 ng/ml, which dropped to 60 ng/ml upon repeating the levels 12 hours later (normal range 3–23 ng/ml). The raised levels of mast cell tryptase were consistent with mast cell degranulation. The latter strongly suggests a hypersensitivity reaction. Furthermore, the provider performed allergy skin prick tests for all the drugs used during the procedure. Test results showed a positive reaction to gelofusine only, confirming it as the causative agent.
- Metastatic bony deposit involving left proximal femur from a known primary prostatic carcinoma.
- Intraoperative cardiac arrest due to anaphylactic reaction to gelofusine
- Prophylactic intramedullary nailing of the left femur
- Allergy skin prick tests
- Cardiopulmonary resuscitation
- C79.51 (secondary malignant neoplasm of bone)
- C61 (malignant neoplasm of prostate)
- I97.711 (intraoperative cardiac arrest during other surgery)
- T45.8x5A (adverse effect of other primarily systemic and hematological agents, initial encounter)
- T88.6xxA (anaphylactic shock due to adverse effect of correct drug or medicament properly, administered, initial encounter)
- 0QH736Z (insertion, upper femur, left, percutaneous, intramedullary fixation device, no qualifier).
- 3E013KZ x 8 (introduction, subcutaneous tissue, percutaneous, other diagnostic substance, no qualifier). Report this code eight times for the skin prick tests performed for the eight drugs.
- 5A12012 (extracorporeal performance and assistance, cardiac, single, output, manual).
Editor’s note: Jones is the principal of Lolita M. Jones Consulting Services in Fort Washington, MD, and an ICD-10-CM/PCS trainer approved by the American Health Information Management Association. She is also author of ICD-10-CM/PCS Implementation Action Plan. Visit her website at www.EZMedEd.com.