Coding for Antibiotic Resistant Infections
There are three guidelines to consider.
What are the ICD-10 coding guidelines related to superbug infections and medication resistance?
Answer: A recent Nevada case has reignited national concern about antibiotic-resistant infections. A woman in her 70s died from an infection resistant to every known antibiotic. More than 26 antibiotics were tested during her one-month hospitalization. In the end, the Centers for Disease Control and Prevention (CDC) determined that no drug currently on the market would have stopped the bacteria’s spread.
This case—and many more like it—present challenging scenarios for hospitals, health systems, and other providers. Not only do patients require costly isolation protocols, but the nuances for coding the superbugs can significantly impact revenue streams—especially if these infections are contracted during a hospital stay.
Given the high cost of these cases and risk factors for contamination, ensuring correct identification, coding, and nationwide tracking of superbug infections is critical. Bacteria such as enterococcus, staphylococcus, klebsiella, acinetobacter, pseudomonas, and enterobacter wreak havoc on hospital care teams and bottomline budgets.
The CDC considers antimicrobial resistance “one of the most serious health threats” currently facing the United States, according to its website, which frequently updates the list of superbugs for ongoing monitoring and surveillance (“ Antibiotic/Antimicrobial Resistance: Biggest Threats,” CDC.gov). One common hospital-acquired infection, Clostridium difficile, contributed an average of $7,286 per hospitalized patient in additional cost according to a recent American Journal of Infection Control study.
To further complicate such cases, most patients who contract superbugs are already immunocompromised due to cancer, long-term medication protocols, extended inpatient admissions, or other factors. The progression of infection in these cases must be carefully noted and coded to ensure proper reimbursement. Here are three specific guidelines to follow when coding antibiotic-resistant cases.
Assign all available codes. Coders should assign all available ICD-10 codes to reflect medication resistance. There are ICD-10 codes for resistance to 22 different types of medications including codes for resistance to multiple medications, which could include antibiotics, narcotics, and other drugs. While the codes for medication resistance don’t impact the DRG, they are usually assigned in high-dollar cases with long lengths of stay. Coders should do the following:
- Code the infection and type of bacteria.
- Assign a Z code to describe the resistance (e.g., resistance to antimicrobial drugs—Z16.10-Z16.39).
- If the patient has been on long-term antibiotics, this should also be coded.
Review all supporting documentation. Coders are also advised to consider all supporting documentation, including culture reports, physician progress notes, medication administration records, and any other ancillary testing used to identify resistance.
Because resistance codes do not impact the DRG, a coding query is not applicable. However, it is critical to properly identify and code antibiotic-resistant cases for national reporting and statistics. We expect future guidance from CMS to open the door for CDI and coding queries where resistance occurs but is not documented by the physician.
Pay attention to MRSA. Because MRSA is so resistant to treatment, there are added precautions and costs. Clinical documentation must prove that the patient contracted MRSA while in the hospital for the case to be coded as an active infection and hospital-acquired condition (HAC), leading to a complication and comorbidity.
MRSA should also be coded if the patient is a carrier. Carrier status is usually a note in the chart as either carrier or suspected carrier of MRSA (Z22.32), colonization status, or personal history. MRSA is the onlyorganism that has a specific code identifying both the bacteria and the antibiotic it is resistant to (B95.62—MRSA infections as the cause of diseases classified elsewhere).
For inpatients with resistant infections, hospitals must identify, document, treat, and code cases as early as possible. Some superbugs can grow faster than new antibiotics become available to eradicate them.
From a coding and billing perspective, hospital departments should keep current with the latest changes and announcements through published literature and partnership with infectious disease clinicians. Keep a close eye on new bacteria and annual ICD-10 code updates. With so many new infections appearing on the U.S. healthcare scene, we expect every annual ICD-10 code update to include at least one or two new superbug codes.