Breaking News regarding Z45.2

Lisa Selm an-H olm an, JD , BSN , RN ,

H CS-D , H CS-O , CO S-C

Z45.2 Management of vascular catheter

Coding Clinic guidance

How it has been traditionally used

Update from CMS

Coding Clinic Guidance

Z45.2 Management of vascular access deviceQuestion: If a home health agency is providing intravenous therapy for an identified condition, should the agency report the condition being treated, or should they report code Z45.2, Encounter for adjustment and management of vascular access device?

Answer: Do not report code Z45.2, Encounter for adjustment and management of vascular access device, if the only service provided is administration of intravenous therapy. According to the Official Guidelines for Coding and Reporting, Section I.C.21.c.7, “The aftercare Z code should not be used if treatment is directed at a current, acute disease. The diagnosis code is to be used in these cases.” Assign the appropriate code for the condition being treated. Coding Clinic 3rd Q 2018

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Z45.2 Management of vascular access device• May be primary when the only care provided is care of the device—changing dressings,

flushing, etc.

• SN is ordered for care of the central line including one time per week flush with NS to keep open for every 3 week chemo to be administered in physician clinic.

• Z45.2• May not be used when an IV is used in the treatment of an acute condition.• Patient has MRSA pneumonia. Orders are to continue IV antibiotics for 8 more days.

Administer…. Flush with normal saline. Dressing change QOD. Teach patient/caregiver IV administration and care of central line.

• J15.212• Z79.2

Source: Coding Clinic + examples from me

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Why is that a problem?

Z45.2 Traditional Use

• Patient has MRSA pneumonia and is admitted with IV antibiotics. Also has COPD, hypertension and diabetes.

• J15.212 MRSA pneumonia• J44.0 COPD with lower respiratory infection• I10 Hypertension• E11.9 Diabetes• Z45.2 management of vascular access• Z79.2 antibiotics

The Grouper

• Z45.2 is in the clinical grouper as complex nursing.• Z45.2 also changes any primary diagnosis to complex nursing

if it is sequenced second.

• There is a long paragraph in the final rule regarding Z45.2 and the use of the code as primary or the first secondary.

Resolution

Email received 2/19/2020

• The reasoning for looking at the first secondary diagnosis for Z45.2 was to ensure that the complexity of services inherent with a patient who has an IV or is receiving IV therapy was captured for the clinical group assignment under the PDGM in the event that the primary reason for home health services is for IV therapy or management of a patient with an IV line. Currently, the home health grouper will look for the presence of Z45.2 as a first reported secondary diagnosis and would group into the Complex Nursing Interventions clinical group. That will not change in this current grouper even though this is not in accordance with the current coding guidance. We will continue to consider alternatives going forward.

Email received 2/19/2020• I will note that the principal diagnosis is reported on the final claim which generates the appropriate

payment for the home health services provided during a 30-day period of care. Therefore, it is possible that there may have been visits during the course of that 30-day period in which the home health nurse administered the IV drug and other visits where the purpose of the visit may have been solely for the maintenance of the IV line. As you know, there is not a diagnosis reported for each nursing visit during a home health period of care. The principal diagnosis represents the primary reason for home health services over the course of the 30-day period. Therefore, the principal diagnosis code reported on the 30-day claim should reflect the primary reason for home health services which could mean Z45.2 to account for the IV line care and maintenance with the condition necessitating the need for IV therapy as a reported secondary diagnosis or the condition reported as principal and Z45.2 reported as secondary. As noted in the CY 2020 final rule, we will continue to look at the ICD-10 diagnoses and their clinical group assignments each year to determine if any changes are warranted. While we recommend adherence to the coding guidelines, we recognize that there may be changes along the way to those guidelines that may warrant some modifications to the clinical group assignments under the PDGM case-mix model.

Email received 2/19/2020

• Therefore, to answer your question below, currently Z45.2 can be reported as the principal diagnosis or the first

reported secondary diagnosis to be assigned to the Complex

Nursing Interventions group.

• Kelly Vontran• CMS

So what does that mean to you?

• J15.212 MRSA pneumonia• J44.0 COPD with lower

respiratory infection• I10 Hypertension• E11.9 Diabetes• Z45.2 management of

vascular access• Z79.2 antibiotics

• J15.212 MRSA pneumonia• Z45.2 management of

vascular access• J44.0 COPD with lower

respiratory infection• I10 Hypertension• E11.9 Diabetes• Z79.2 antibiotics

Effectively Immediately

MMTA- RespComplex Nursing

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QuestionsLisa@selmanholman.com