2020 ACDIS Outpatient Pocket Guide

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2020 ACDIS Outpatient Pocket Guide

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2020 ACDIS Pocket Guide: 

The essential CDI resource for outpatient professionals

CDI professionals need a day-to-day reference when conducting their outpatient medical record reviews – one that can provide trusted clinical indicators for compliant and effective physician clarifications, and at-a-glance, easy-to-use diagnosis and Hierarchical Condition Category (HCC) references. The 2020 ACDIS Outpatient Pocket Guide is the essential resource for outpatient coding guidance, HCC updates, compliant query best practices and standards, E/M requirements, and diagnostic definitions. 

This is the perfect resource as you look to grow your outpatient CDI program and continue to ensure your outpatient coding is in compliance.

Co-written by ACDIS’ CDI Education Director Laurie Prescott, RN, MSN, CCDS, CDIP, CRC, CCDS-O, James Manz, MD, CCDS-O, a practicing physician at the Mayo Clinic steeped in the latest physician documentation terminology, and Karen Newhouser, RN, BSN, CCDS, CCDS-O, CCS, CDIP, CCM, Clinical Documentation Integrity Content Manager for AMN Revenue Cycle Solutions, the 2020 ACDIS Outpatient Pocket Guide is a winning combination of practical, tailored CDI tips and resources, helpful references including ICD-10-CM code mappings organized by HCC, and clinical,  regulatory, and coding guidance adapted from the official sources.

Conditions covered in the 2020 ACDIS Outpatient Pocket Guide are organized by their Hierarchical Condition Category (HHC), and then in alphabetical order. Each condition listed is accompanied by a detailed clinical definition of the condition, clinical indicators that support the presenting condition, including diagnostic criteria and treatment protocols, ICD-10-CM chapter-specific documentation requirements, including the latest coding clinic guidance specific to the condition, CDI critical thinking tips and provider focused education advice related to the diagnoses.


Published: January 2020

Page count: 382 + 5 Tabs
ISBN: 978-1-68308-981-0

Table of Contents

List of Conditions........................................................ ix

Introduction................................................................. 1

Outpatient CDI Functions                                             5

Charge Capture........................................................ 5

Provider Evaluation and Management (E/M)                     8

Quality Metrics......................................................... 8

Risk Adjustment...................................................... 13

Regulatory Guidance................................................ 23

Guidelines Organization                                              23

Official Coding Guidance                                            24

General Coding Guidelines                                          30

Reporting Diagnoses................................................ 34

Diagnostic Coding & Reporting Guidelines for Outpatient Services             36

Selection of the First-Listed Diagnosis.......................... 37

Code Assignment for Special Patient Populations: Pregnancy, Childbirth, and the Puerperium           41

Code Assignment for Special Patient Populations: Congenital Malformations, Deformations, and

Chromosomal Abnormalities....................................... 45

Evaluation and Management Services........................... 46

Elements of an E/M Code.......................................... 49

Components of an E/M Level..................................... 50

Compliant Query Practice                                           57

Why Do We Query?................................................. 60

The Role of Clinical Indicators in Queries                        61

Three Types of Query Formats                                     62

Compliant Verbal Queries                                           64

Use of Query Templates                                              64

Maintaining Compliant Practice                                    65

The Process of Clinical Validation                                  65

Reportability of Diagnoses                                           68

Hierarchical Condition Categories                               71

General Notes and Glossary                                        71

HCC 1 HIV/AIDS...................................................... 73

HCC 2 Septicemia, Sepsis, Systemic Inflammatory

Response Syndrome (SIRS), Shock.............................. 78

HCC 6 Opportunistic Infections................................... 81

Δ HCC 8 Metastatic Cancer and Acute Leukemia............ 84

Δ HCC 9 Lung and Other Severe Cancers..................... 85

Δ HCC 10 Lymphoma and Other Cancers...................... 86

Δ HCC 11 Colorectal, Bladder, and Other Cancers........... 87

Δ HCC 12 Breast, Prostate, and Other Cancers

or Tumors............................................................ 88

Δ HCC 17 Diabetes with Acute Complications................ 97

Δ HCC 18 Diabetes with Chronic Complications.............. 98

Δ HCC 19 Diabetes without Complications.................... 99

HCC 21 Protein-Calorie Malnutrition............................ 111

HCC 22 Morbid Obesity........................................... 120

HCC 23 Other Significant Endocrine and

Metabolic Disorders............................................... 125

Δ HCC 27 End-Stage Liver Disease........................... 128

Δ HCC 28 Cirrhosis of the Liver................................ 130

Δ HCC 29 Chronic Hepatitis..................................... 133

HCC 33 Intestinal Obstruction/Perforation..................... 137

HCC 34 Chronic Pancreatitis.................................... 141

HCC 35 Inflammatory Bowel Disease.......................... 146

HCC 39 Bone/Joint/Muscle Infections/Necrosis.............. 150

HCC 40 Rheumatoid Arthritis and Inflammatory Connective Tissue Disease      151

Δ HCC 46 Severe Hematological Disorders................... 155

HCC 47 Disorders of Immunity.................................. 160

Pancytopenia........................................................ 165

Δ HCC 48 Coagulation Defects and Other

Specified Hematological Disorders............................. 168

Δ HCC 51 Dementia with Complications...................... 171

Δ HCC 52 Dementia without Complications................. 172

Δ HCC 54 Substance Use with Psychotic Complications.... 176

Δ HCC 55 Substance Use Disorder, Moderate/Severe

or Substance Use with Complications......................... 177

Δ HCC 56 Substance Use Disorder, Mild except

Alcohol and Cannabis............................................. 178

Δ HCC 57 Schizophrenia......................................... 185

Δ HCC 58 Reactive and Unspecified Psychoses............. 189

Δ HCC 59 Major Depressive, Bipolar, and

Paranoid Disorders................................................. 190

Δ HCC 60 Personality Disorders................................ 197

Δ HCC 70 Quadriplegia........................................... 199

Δ HCC 71 Paraplegia.............................................. 202

Δ HCC 72 Spinal Cord Disorders/Injuries..................... 203

HCC 73 Amyotrophic Lateral Sclerosis and Other

Motor Neuron Diseases........................................... 204

HCC 74 Cerebral Palsy........................................... 208

HCC 75 Neuromuscular Disorders—Myasthenia Gravis/ Myoneural Disorders and Guillain-Barré Syndrome/ Inflammatory and Toxic Neuropathy........... 212

HCC 76 Muscular Dystrophy.................................... 215

HCC 77 Multiple Sclerosis....................................... 217

HCC 78 Parkinson’s and Huntington’s Disease.............. 219

HCC 79 Seizure Disorders and Convulsions.................. 222

Δ HCC 80 Coma, Brain Compression/Anoxic Damage..... 225

Δ HCC 82 Respirator Dependence/

Tracheostomy Status.............................................. 227

Δ HCC 83 Respiratory Arrest.................................... 229

Δ HCC 84 Cardiorespiratory Failure and Shock............. 230

HCC 85 Congestive Heart Failure............................... 233

Δ HCC 86 Acute Myocardial Infarction........................ 243

Δ HCC 87 Unstable Angina and Other Acute

Ischemic Heart Diseases.......................................... 244

Δ HCC 88 Angina Pectoris....................................... 245

HCC 96 Specified Heart Arrythmias............................ 248

Δ HCC 99 Intracranial Hemorrhage............................ 253

Δ HCC 100 Ischemic or Unspecified Stroke................. 254

Δ HCC 103 Hemiplegia/Hemiparesis........................... 255

Δ HCC 104 Monoplegia, Other Paralytic Syndromes....... 258

Δ HCC 106 Atherosclerosis of the Extremities with

Ulceration and Gangrene......................................... 259

Δ HCC 107 Vascular Disease with Complications.......... 261

Δ HCC 108 Vascular Disease................................... 265

Δ HCC 110 Cystic Fibrosis....................................... 268

Δ HCC 111 Chronic Obstructive Pulmonary Disease....... 271

Δ HCC 112 Fibrosis of Lung and Other Chronic

Lung Disorders..................................................... 276

Δ HCC 114 Aspiration and Other Specified Pneumonias.... 280

Δ HCC 115 Pneumococcal Pneumonia, Empyema,

and Lung Abscess................................................. 281

HCC 122 Proliferative Diabetic Retinopathy and

Vitreous Hemorrhage.............................................. 289

HCC 124 Exudative Macular Degeneration................... 292

Δ HCC 134 Dialysis Status....................................... 295

Δ HCC 135 Acute Renal Failure/Acute Kidney Injury...... 296

Δ HCC 136 Chronic Kidney Disease (CKD) Stage 5....... 302

Δ HCC 137 Chronic Kidney Disease (CKD) Stage 4....... 303

Δ HCC 138 Chronic Kidney Disease (CKD) Stage 3....... 304

Δ HCC 157 Pressure Ulcer of the Skin with Necrosis Through to Muscle, Tendon, or Bone  310

Δ HCC 158 Pressure Ulcer of the Skin with

Full-Thickness Skin Loss......................................... 311

Δ HCC 159 Pressure Ulcer of the Skin with

Partial-Thickness Skin Loss...................................... 312

Δ HCC 161 Chronic Ulcer of the Skin, except Pressure... 313

HCC 162 Severe Skin Burn or Condition...................... 321

Δ HCC 166 Severe Head Injury................................. 326

Δ HCC 167 Major Head Injury.................................. 328

Δ HCC 169 Vertebral Fracture without Spinal

Cord Injury........................................................... 332

HCC 170 Hip Fracture/Dislocation.............................. 336

HCC 173 Traumatic Amputations and Complications....... 337

HCC 176 Complications of Specified Implanted Device

or Graft.............................................................. 338

HCC 186 Major Organ Transplant or Replacement Status.... 339

HCC 188 Artificial Openings for Feeding or Elimination... 341

HCC 189 Amputation Status, Lower Limb,

Amputation Complications........................................ 343

Social Determinants of Health                                   346

HHS-HCCs................................................................ 351

HHS-HCC Diagnostic Classification                              351

Key References....................................................... 359

FY 2020 CMS HCCs............................................... 360

Disease Hierarchies for the 2020 Alternative

Payment Condition Count Model................................ 364

Acceptable Physician Specialty Types......................... 367

List of Conditions

Acute Myocardial Infarction...................................... 243

Acute Renal Failure/Acute Kidney Injury...................... 296

Amputation Status, Lower Limb, Amputation

Complications...................................................... 343

Amyotrophic Lateral Sclerosis and Other Motor

Neuron Diseases.................................................... 204

Angina Pectoris..................................................... 245

Artificial Openings for Feeding or Elimination................ 341

Aspiration and Other Specified Pneumonias.................. 280

Atherosclerosis of the Extremities with Ulceration

and Gangrene....................................................... 259

Bone/Joint/Muscle Infections/Necrosis......................... 150

Breast, Prostate, and Other Cancers or Tumors............... 88

Cardiorespiratory Failure and Shock........................... 230

Cerebral Palsy...................................................... 208

Chronic Hepatitis................................................... 133

Chronic Kidney Disease (CKD) Stage 3....................... 304

Chronic Kidney Disease (CKD) Stage 4....................... 303

Chronic Kidney Disease (CKD) Stage 5....................... 302

Chronic Obstructive Pulmonary Disease....................... 271

Chronic Pancreatitis................................................ 141

Chronic Ulcer of the Skin, except Pressure................... 313

Cirrhosis of the Liver.............................................. 130

Coagulation Defects and Other Specified

Hematological Disorders..................................... 168

Colorectal, Bladder, and Other Cancers................... 87

Coma, Brain Compression/Anoxic Damage........... 225

Complications of Specified Implanted Device or Graft... 338

Congestive Heart Failure..................................... 233

Cystic Fibrosis................................................... 268

Dementia with Complications............................... 171

Dementia without Complications.......................... 172

Diabetes with Acute Complications......................... 97

Diabetes with Chronic Complications...................... 98

Diabetes without Complications............................. 99

Dialysis Status................................................... 295

Disorders of Immunity......................................... 160

End-Stage Liver Disease..................................... 128

Exudative Macular Degeneration.......................... 292

Fibrosis of Lung and Other Chronic Lung Disorders... 276

Hemiplegia/Hemiparesis..................................... 255

Hip Fracture/Dislocation...................................... 336

HIV/AIDS............................................................ 73

Inflammatory Bowel Disease............................... 146

Intestinal Obstruction/Perforation......................... 137

Intracranial Hemorrhage..................................... 253

Ischemic or Unspecified Stroke............................ 254

Lung and Other Severe Cancers............................ 85

Lymphoma and Other Cancers.............................. 86

Major Depressive, Bipolar, and Paranoid Disorders...... 190

Major Head Injury............................................... 328

Major Organ Transplant or Replacement Status...... 339

Metastatic Cancer and Acute Leukemia........................ 84

Monoplegia, Other Paralytic Syndromes....................... 258

Morbid Obesity...................................................... 120

Multiple Sclerosis............................................... 217

Muscular Dystrophy............................................... 215

Myasthenia Gravis/Myoneural Disorders and Guillain-Barré Syndrome/Inflammatory and Toxic

Neuropathy.......................................................... 212

Opportunistic Infections............................................. 81

Other Significant Endocrine and Metabolic Disorders...... 125

Pancytopenia........................................................ 165

Paraplegia........................................................... 202

Parkinson’s and Huntington’s Disease......................... 219

Personality Disorders.............................................. 197

Pneumococcal Pneumonia, Empyema, and

Lung Abscess....................................................... 281

Pressure Ulcer of the Skin with Full-Thickness

Skin Loss........................................................... 311

Pressure Ulcer of the Skin with Necrosis Through to

Muscle, Tendon, or Bone......................................... 310

Pressure Ulcer of the Skin with Partial-Thickness

Skin Loss........................................................... 312

Proliferative Diabetic Retinopathy and

Vitreous Hemorrhage.......................................... 289

Protein-Calorie Malnutrition................................. 111

Quadriplegia...................................................... 199

Reactive and Unspecified Psychoses................... 189

Respirator Dependence/Tracheostomy Status....... 227

Respiratory Arrest.............................................. 229

Response Syndrome (SIRS), Shock, Septicemia, Sepsis, Systemic Inflammatory Rheumatoid Arthritis and Inflammatory Connective Tissue Disease........ 151

Schizophrenia.................................................... 185

Seizure Disorders and Convulsions...................... 222

Severe Head Injury............................................... 326

Severe Hematological Disorders.......................... 155

Severe Skin Burn or Condition............................. 321

Social Determinants of Health.............................. 346

Specified Heart Arrythmias.................................. 248

Spinal Cord Disorders/Injuries............................. 203

Substance Use Disorder, Mild except Alcohol

and Cannabis..................................................... 178

Substance Use Disorder, Moderate/Severe or

Substance Use with Complications....................... 177

Substance Use with Psychotic Complications......... 176

Traumatic Amputations and Complications............ 337

Unstable Angina and Other Acute Ischemic

Heart Diseases.................................................. 244

Vascular Disease with Complications.................... 261

Vascular Disease............................................... 265

Vertebral Fracture without Spinal Cord Injury.......... 332