A quarterly publication of the Central Office on ICD-10 …

[Pages:33]A quarterly publication of the Central Office on ICD-10-CM/PCS

Volume 9 Number 2

Second Quarter 2022

In This Issue

Obesity Designated by Class

9

New Frequently Asked

Osmotic Demyelination

Questions Regarding

Syndrome

10

Coding for COVID-19

28 Palatoplasty with Intravelar

Veloplasty

24

Ask the Editor

Postpartum Sepsis Due to

Ankle Distraction Procedure

22 Postpartum Urinary Tract

Congenital Nasal Pyriform

Infection

5

Aperture Stenosis and Repair 17 Post-Term Pregnancy

3

COVID-19 Pre-Exposure

Pressure Injury of Mucosal Lip 7

Prophylactic Treatment

27 Pressure Injury of Penile Mucosal

Deep Tissue Pressure Injury

Membrane

7

Revealed to be Stage IV

Radioembolization of Right

Pressure Ulcer

8

Hepatic Lobe

26

Determining Completed Weeks

Sacroiliac Joint Fusion

23

of Gestation

3 Segmental and Subsegmental

Encounter for In Vitro Fertilization

Pulmonary Emboli

13

due to Congenital Vaginal

Serotonin Syndrome

11

Anomaly

15 Sternal Non-Union and

Encounter for In Vitro Fertilization

Pseudoarthrosis Following

due to Polycystic Ovarian

Sternotomy

14

Syndrome

16 Temporary-Permanent

Hiatal Hernia with

Pacemaker Placement

25

Esophagogastric Junction

Transbronchial Lung Biopsy

Outflow Obstruction

13 Using Alligator Forceps

19

Hyperlipidemia Not Specified

Ventricular Fibrillation

14

with Hypercholesterolemia

5 Vestibular Ataxia

12

Light Meconium Stained Fluid 16

Limb Lengthening Surgery Long-Term Use of Eliquis? Metabolic Bone Disease Mixed Hyperlipidemia with

Hypercholesterolemia

19 Clarifications

17 Hierarchical Condition Category

10 (HCC) Coding

30

Reporting Additional Diagnoses

6

in Outpatient Setting

30

Coding advice or code assignments contained in this issue effective with discharges June 3, 2022

Coding Clinic for ICD?10?CM/PCS

Published quarterly by the American Hospital Association Central Office on ICD-10-CM/PCS 155 N. Wacker Drive Chicago, IL 60606.

ISSN 0742-9800

Coding Clinic for ICD-10-CM/PCS Online subscription information can be found at Click Help Center then subscriptions for more information.

Executive Editor Nelly Leon-Chisen, RHIA Director, Central Office on ICD-10-CM/PCS

Editorial Staff, AHA Central Office on ICD-10-CM/PCS

Karen Ayala, RHIT Coding Specialist

Kristina Cool, RHIA, CCS Coding Consultant

Medical Advisors, Centers for Mady Hue, RHIA

Medicare & Medicaid Services Technical Advisor, Technology,

Perry Alexion, M.D.

Coding and Pricing Group

Edith Hambrick, M.D.

Centers for Medicare &

Karen Nakano, M.D.

Medicaid Services, Baltimore

Editorial Advisory Board Donna Ganzer, Chairman President, Ganzer Network Corporation, Great Neck, NY

Chrystel Barron, MHI, RHIA, CPHIMS, CCS, CCS-P, CDIP, CHTS-TR, CICA, CHRI Coding Education Instructor Cleveland Clinic

Edward A. Liechty, M.D. Representative, Amer. Academy of Pediatrics, Indianapolis, IN

Jeffrey F. Linzer, M.D., FAAP Representative, Amer. Academy of Pediatrics, Atlanta, GA

Lee R. Morisy, M.D., FACS Representative, Amer. College of Surgeons, Memphis, TN

Sue Bowman, MJ, RHIA, CCS, FAHIMA Senior Director, Coding Policy and

Compliance, American Health

Bernard Pfeifer, M.D. Representative for American

Medical Assn., Harwich, MA

Information Management Association, Chicago

Donna Pickett, RHIA, MPH Chief, Classifications and

Jonathan Gal, M.D., FASA Mount Sinai Health System

New York, NY

Public Health Data Standards, Centers for Disease Control & Prevention, Hyattsville, MD

Yvonne E. Henderson, CCS, CCS-P, CDIP HIM Coding Quality Supervisor

Evan Pollack, M.D., FACP Representative for Amer. College

of Physicians, Bryn Mawr, PA

Sutter Health Shared Services Melissa G. Roberts, MHA, RHIT

Fairfield, CA

Director Coding Service Center

Centura Health, Centennial, CO

Denene Harper, RHIA Senior Coding Consultant

Diane Komar, RHIT Coding Consultant

Susan Latham, RHIT, CCS Coding Consultant

Anita Rapier, RHIT, CCS Managing Editor Senior Coding Consultant

Cherrsse Ruffin, RHIT Coding Consultant

Kathy White, RHIA Coding Consultant

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Gretchen Young-Charles, RHIA Senior Coding Consultant

Coding Clinic is the official publication for ICD-10-CM/PCS coding guidelines and advice as designated by the four cooperating parties. The

Halima Zayyad-Matarieh, RHIA cooperating parties listed below have final approval of the coding advice

Coding Consultant

provided in this publication: American Hospital Association, American

Health Information Management Association, Centers for Medicare &

CDC Medical Officer

Medicaid Services (formerly HCFA), National Center for Health Statistics

David Berglund, M.D. Medical Officer, Centers for Disease Control & Prevention

? 2022 by the American Hospital Association. All rights reserved. Reproduction or use of this publication in any form or in any information storage or retrieval system is forbidden without express permission of

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please write to the Central Office on ICD-10-CM/PCS, American Hospital

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Coding Clinic

Ask the Editor

Question: An obstetrical patient is admitted to labor and delivery for a planned cesarean section due to breech presentation. The provider documents the gestational weeks as "40 weeks and 2 days." Is it appropriate to assign code O48.0, Post-term pregnancy, based on the documentation of gestational weeks alone without documentation of "post-term" or "postdates"?

Answer: Yes. When provider documentation indicates the patient is over 40 completed weeks to 42 completed weeks gestation, it is appropriate to assign code O48.0, Post-term pregnancy, based on the inclusion term that specifically states: "Pregnancy over 40 completed weeks to 42 completed weeks gestation." The provider does not have to document "post-term" or "post-dates." Assign also the appropriate code from category Z3A, Weeks of gestation.

Question: Please clarify "completed weeks of gestation" when assigning codes: O48.0, Post-term pregnancy, O48.1, Prolonged pregnancy, O75.82, Onset (spontaneous) of labor after 37 completed weeks of gestation but before 39 completed weeks gestation, with delivery by (planned) cesarean section, O02.1, Missed abortion, and O36.4, Maternal care for intrauterine death.

Second Quarter 2022

3

Answer: In ICD-10-CM, "completed week of gestation" refers to a full week. For example, if the provider documents gestation at 39 weeks and 6 days, 39 weeks of gestation is assigned, as the patient has not yet reached 40 completed weeks.

When the provider's documentation in the medical record indicates that the patient's pregnancy is over 40 completed weeks to 42 completed weeks (40 weeks 1 day - 42 weeks 0 days), it is appropriate to assign code O48.0, Post-term pregnancy. If the documentation indicates that the pregnancy has advanced beyond 42 completed weeks of gestation (42 weeks 1 day), it would be appropriate to assign code O48.1, Prolonged pregnancy.

Code O75.82, Onset (spontaneous) of labor after 37 completed weeks of gestation but before 39 completed weeks of gestation, with delivery by (planned) cesarean section, may be assigned for a patient with weeks of gestation of 37 weeks 0 days up to 38 weeks and 6 days.

Code O02.1, Missed abortion, refers to fetal death that occurs prior to the completion of 20 weeks of gestation, thus including up to 19 weeks and 6 days.

Code O36.4, Maternal care for intrauterine death, is assigned for maternal care for intrauterine fetal death after completion of 20 weeks 0 days of gestation or later.

When assigning codes for obstetric conditions, assign also the appropriate code from category Z3A to indicate the weeks of gestation of the pregnancy.

4

Second Quarter 2022

Coding Clinic

Question: A 24-year-old patient was admitted with shortness of breath and fever due to postpartum sepsis and postpartum urinary tract infection (UTI). The patient had a history of spontaneous vaginal delivery one week ago. In the Tabular List an Excludes1 note under code O85, Puerperal sepsis, prohibits assigning code O86.20, Urinary tract infection following delivery, unspecified. What are the diagnosis codes for postpartum sepsis and UTI?

Answer: Assign codes O98.83, Other maternal infectious and parasitic diseases complicating the puerperium, A41.9, Sepsis, unspecified organism, since the causal organism was not specified and O86.20, Urinary tract infection following delivery, unspecified, for postpartum sepsis and UTI. In this case, code O85, Puerperal sepsis, is not appropriate, as puerperal sepsis implies an infection of the genital tract, not an infection of the urinary tract.

The Centers for Disease Control and Prevention's National Center for Health Statistics (CDC/NCHS) is considering a future Coordination and Maintenance (C&M) proposal to expand code O85 to differentiate puerperal sepsis NOS (that is puerperal sepsis with infection of the genital tract) and postpartum systemic sepsis without infection of the genital tract, and other puerperal sepsis, as well as deleting the Excludes1 note.

Question: What is the appropriate ICD-10-CM code(s) for a diagnosis of unspecified hyperlipidemia and hypercholesterolemia?

Coding Clinic

Second Quarter 2022

5

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