OrHIMA



ORHIMA - CERVICAL EXAMSIn regards to annual exams/PAPs, can/should we code for taking the cervical sample as well as the exam? And how does this effect with or without abnormal findings, if at all?(TT: DB, KS 5.2.16) For diagnosis coding - The code screening Z12.4- Screening neoplasm cervix, has an excludes 1 note for a part when screening is part of a gynecological exam then code only Z01.4 (411 or 419 for normal or abnormal findings)???????????????ORHIMA - DISC SPACE NARROWINGDisc space narrowing: a. In ICD-9 you could look up narrowing -> intervertebral disc or space NEC and it would lead you to degeneration, intervertebral space. However, in ICD-10 when you look up narrowing there is no longer an option for narrowing of the intervertebral disc or space. How is disc space narrowing coded in ICD-10?(TT: DB, KS 5.2.16) If you look up narrowing in the ICD-10 code book, it says "see stenosis" Then under stenosis go to intervertebral, disc M99.79- Connective tissue and disc stenosis of intervertebral foramina of abdomen and other regions. Ideally coder would want to identify actual site of spinal stenosis. ???????????????ORHIMA - HYPERTROPHY OF JOINT SPACEHypertrophy of the joint space: a. Although it was not in the code book, in ICD-9 we could enter hypertrophy -> joint into Codefinder/3M encoder and it would lead to osteoarthritis by site. In ICD-10 this is no longer possible. How is the phrase hypertrophy of the joint space coded in ICD-10?(TT: DB, KS 5.2.16) ICD 10 does not have a code for hypertrophy, joint space. Index does notate hypertrophy of bone, some bones are joints. However this is not ideal and a coder cannot assume. This is a great opportunity for provider education. :)???????????????OPEN WOUND We have come across a chart that puts the new coding clinic advice to work. Coder is questioning how to code the open wound noted here – as an unspecified open wound? How about the ulcer & necrosis, should we pick that up as a diabetic complication?FINAL IMPRESSION AND ASSOCIATED CONDITIONS1. OPEN WOUND OF LEFT FOOT, SUBSEQ2. CHRONIC ULCER OF LEFT TOE, MUSCLE NECROSIS (CHRONIC)3. DM 2 W RENAL MANIFESTATION (CHRONIC)4. PERIPHERAL VASCULAR DISEASE (CHRONIC)HPI Comments: Pt is male with a hx of sick sinus syndrome and pacemaker, DM2, atrial flutter, COPD, CHF, PVD, HTN, and dementia. Has chronic wounds to feet. Sent in for worsening wounds and drainage to left foot. Angioplasty left leg xxx followed by wound care and podiatry. Lives in adult foster. Foster provider states in last 24 hours, having to change dressings nearly every hour due to drainage. No fevers. Pt relates no pain. Physical ExamConstitutional: He appears well-developed and well-nourished. No distress.HENT: Head: Normocephalic and atraumatic.Neck: Neck suppleCardiovascular: Normal rate and regular rhythm.Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress.Abdominal: Soft. Bowel sounds are normal. He exhibits no distension. There is no tenderness.Musculoskeletal:Left foot: There is decreased capillary refill.Left second toe with necrosis to dorsum. Dry, no drainage. Dorsal forefoot at base of toes with denuded skin, serous fluid weeping Left third toe with Small open areas, weeping serous fluid. Pulse present with Doppler.Toes cool, but not cold. Decreased cap refill.Neurological: He is alertSkin: Skin is warm and dry.Psychiatric: He has a normal mood and affect.Nursing note and vitals reviewed.Consults Podiatry: Dr consulted. Advises very poor blood flow, would consult vascular.Vascular surgery: Dr. Advises with recent reperfusion after angioplasty increased swelling and serous drainage not unusual after reperfusion of tissues and wounds may temporarily worsen. May consider oral abx with foot redness. Advised f/u vascular clinic this week.ED CoursePlease see H&P for full details of patient’s presenting symptoms and medical history. Pt. with photos taken Able to upload phots to media file today, does not appear significantly changed from prior. Discussed with podiatry and vascular as above. Pt appear nontoxic. Appropriate for DC home with clinic f/u. Has appt with vascular clinic. See no indication for admission, as chronic, ongoing process, does not appear obviously cellulitic. Return precautions discussed and understood. Final answer: Trainers feel based on documentation provided in the Final Impression, there are two wounds: open wound and chronic ulcer. There is no further description of how the open wound occured, and therefore, in absence of a query, Trainers recommend following Index to assign the correct code for open wound, as documented by the provider. Index - Wound, open, foot - S91.302D (subsequent encounter)S91.302D- Open wound of left footE11.621- DM with foot ulcer (Per coding clinic 1Q2016 you would link the diabetes with foot ulcer.)L97.523- Non pressure chronic ulcer other part of foot with necrosis of muscleIn regards to the PVD and DM - Per Index (and recent CC advice), Diabetes with "peripheral angiopathy" would be linked. There is no mention of "PVD" under DM, however, so be aware that PVD codes to peripheral angiography per index. See - Disease, vascular, peripheral - in diabetes, see E08-E13 with .51 - therefore the PVD when present with DM would be linked. You may want to make a note of this in your book as certain book based encoders may not lead you there directly when searching under other terms (such as PVD).???????????????"PREGNANCY?" I have a chart with “pregnancy” noted in the clinical impression with symptoms & PMH that would be coded as complications, however, in the MDM our provider indicates that it is a surprisingly positive hCG and US reveals no pregnancy. Should this be coded as pregnancy with complications? For example, O012.01, edema in pregnancy, O10.911, pre-existing HTN, & O99.331, smoking in pregnancy, and more. Or is it possible to use Z32.01, or another route?Past Medical History:Has a past medical history of HTN (hypertension); Blighted ovum (xxxx); Acid reflux; Previous recurrent miscarriages affecting pregnancy, antepartum; and renal insufficiency. Has past surgical history that includes none.Social history: reports that she has been smoking cigarettes. She has been smoking about .50 packs per day. She has never used smokeless tobacco. She reports that she does not drink alcohol or use ilicit drugs. Medical decision making: female who is presenting for multiple nonspecific symptoms including lightheadedness, pedal edema, fatigue, reminiscent of prior episode of renal failure. IV was placed and blood work obtained which showed normal renal function, normal electrolytes, normal CBC, normal BNP. She did have a surprisingly positive HCG however. Quantitative HCG is only elevated at 18 and her last menstrual period was less than a month ago. She does have some mild flank pain bilaterally however nothing to suspect pyelonephritis or renal colic. She did undergo an ultrasound which was nondiagnostic for intrauterine or extrauterine pregnancy. I discussed the need for follow-up to for serial HCG/ ultrasoundsClinical impression:1. Lightheadedness2. Peripheral edema3. Pregnancy(TT: CC, MC, KS 3.22.16) Trainers recommend coding the lightheadedness- R42, (Index= light - R42 - lightheadedness), Peripheral edema- R60.9, and Z32.01- Encounter for positive pregnancy test.Rationale: conflicting documentation and patient was presenting with pregnancy for the first time. The positive HCG (low) could possibly be a early pregnancy not confirmed by the US, or a miscarriage that hormones have not gone back down to normal levels. Provider recommends follow up for the pregnancy. ???????????????OSTEOMYELITISHope I am missing the boat in I-10 coding on this one and will have an Ah-ha moment.How would you code osteomyelitis toe?No documentation to support acute or chronic or subacute.The best I am coming up with is M86.9. Unfortunately the providers I am dealing with are used to the unspecified osteomyelitis I-9 codes (730.20 to 730.26) On their best days they are not open to questions/comments from the coders and certainly not education so this is all I have to work with. Since this is a bread and butter dx for them, I hope I am missing the boat and have missed some guidance or documentation that would allow me to use a more descriptive code. (often they don’t even document cellulitis or diabetes or ulcers--L )(TT: KS, DB, SH 10.28) You can only code what is specifically documented, in this particular case correct code would be Osteomyelitis unspecified M86.9. Unfortunately since not documented acute or chronic you cannot get to toe, CDI issue. ???????????????ABSCESS AND CELLULITISIn ICD10- if both abscess and cellulitis of the site is documented, you code both the abscess & the cellulitis, correct?(TT:) ICD10 now includes codes for abscess and cellulitis separately when both occur at same site, codes from each may be assigned. ???????????????ACUTE BRONCHOSPASMER chart w/ diagnosis “Acute bronchospasm”. COPD is listed under PMHx, which I would pick up & code because it’s a chronic systemic condition. In ICD9, I would only code the COPD 496 per CC 3rd Qtr 1988 pp 6 that states that bronchospasm is included in the COPD code.Is this still relevant in ICD10 coding? There are no excludes notes so do I code both the J98.01 Acute bronchospasm & J44.9 COPD?(TT: MC, KS, CC 1.6.16) No- acute bronchospasm is an integral part of COPD and Asthma. See reference below.Per ICD-10 CM/PCS Coding Handbook (old Faye Brown) Chapter 19Bronchospasm Bronchospasm is an integral part of asthma or any other type of chronic airway obstruction, but no additional code is assigned to indicate its presence. Code J98.01, Acute bronchospasm, is assigned only when the underlying cause has not been identified.???????????????ACUTE ON CHRONIC RESPIRATORY FAILURE WITH HYPOXIA AND HYPERCAPNIAI cannot remember if this question has been brought up before, this patient comes in with COPD exacerbation and Acute on Chronic respiratory failure with hypoxia and hypercapnia. will this need both codes? J96.01—acute RF with hypoxia J96.02—acute RF with hypercapnia(TT: CC, MC 1.12.16) The definition of hypoxia is a deficiency in the amount of oxygen that reaches the tissues and hypercapnia is excessive carbon dioxide in the blood stream. These conditions are not synonymous and can occur together. Therefore if documented as such, both conditions would be coded. J96.01 and J96.02???????????????ALCOHOL INTOXICATIONAlcohol intoxication is only documented with no mention of dependence or abuse- is this alcohol use or abuse? 3M encoder puts it to abuse(TT:) If only alcohol intoxication is documented without any conflicting documentation I would code to F10.129 which automatically defaults to alcohol abuse with intoxication per the Alphabetic Index. However, if alcohol dependence was documented then based on the hierarchy, dependence would be used which is code F10.229.Follow index for guidance. If ETOH intoxication is solely documented, this leads to F10.129, Alcohol Abuse with Intoxication???????????????CHRONIC HEADACHE DISORDERI was wondering how you would capture “chronic headache disorder” would you use the headache syndrome code or the regular headache code? Am I missing a different pathway to a different code? I just checked in the book.(TT: JJ, KS, DB, CC 1.22.16) Trainers feel you cannot code syndrome since it is not stated in record and there is no entry for disorder therefore, trainers recommend R51 - headache. *Chronic headache also codes to R51???????????????CLEARANCE FOR INCARCERATIONClearance for incarceration? How do you code?? Is it Z02.89? Z02 block are administrative codes. Z04 are for medicolegal reasons, Z04.8 for specified Z04.9 unspecified. I'm not sure how to decide what constitutes specified but I think that would be a more concise code to use. (TT::)Index: Examination, Medical, Admission to, Prison or Examination, Medical Prisoners, for entrance into prison = Z02.89???????????????CRUSH INJURIESPt is seen for a Crushing Injury of the R index finger and a deep laceration was sutured. The code used for the injury was S67.190A for this initial visit. Several days later pt comes in for wound check and is diagnosed with cellulitis in the wound but the accident/injury is not addressed in the documentation for this DOS. The instinct is to use Z48.817 for f/u care but the coding guidelines state not to use a Z code for aftercare if the injury code includes 7th characters to describe the subsequent care. In this case the original injury code does have a 7th character to describe subsequent care, but the documentation for the care being provided in this subsequent visit doesn’t include documentation of the injury/accident. So therefore, that coding guideline no longer applies – correct? If they don’t document the original injury in the second follow-up visit, we would be unable to assign a more specific code for the injury. We are not allowed to look at previous visits, so you would only be able to go off of the documentation from the follow-up encounter. If they documented “cellulitis of the wound”, code:L03.011 cellulitis, finger, rightS61.200D wound, finger, right???????????????CURRENT VERSUS OLD INJURYPATIENT COMES IN FOR Lt knee medial meniscus tear that happened 4 months ago from a car accidentToday coming in to have a Lt. knee arthroscopic partial medial menisectomy. The question is regarding old verses current injury….M23204 is s derangement due to old tear/injuryS83242A is a current injuryAAPC states that the definition of current is “now”Which is the proper way to code these??(TT:CC, MC 1.12.16) It would be coded as current unless documentation states "old" "chronic" "degenerative" In the absence of such documentation the default is S83.242A- Current injury of left knee, initial???????????????DELIRIUM SECONDARY TO MEDICATIONSIn I-10 how would you code delirium secondary to Ditropan given in the hospital. I-9 takes it to a drug induced delirium code 292.81 but I-10 want to take it to drug use/intoxication/dependence. The coder is using F05. Is this what you would use?(TT: CC, MC 1.12.16) R41.0 would be the most appropriate in this case as the delirium resulted from an adverse effect of a medication taken as prescribed. An F code is not appropriate, as this drug was taken as prescribed.Need to add T code for AE, Ditropan, aka oxybutynin = T44.3X5A. F codes would not apply in cases of Adverse Effects, as only if there is abuse or dependence of the substance, is the abuse or dependence is coded as an additional code. See OCG on page 71 for further information. ???????????????DIABETES WITH NEUROPATHYChart documents "severe diabetes with neuropathy". The patient developed a pressure ulcer of the heel from wearing poorly fitting shoes. (this is not linked to the diabetes) Since E11.621 directs you to also code L97.4>> (which is a non-pressure ulcer), should E11.621 not be used at all? I’m thinking of using E11.40 instead and then assign the pressure ulcer code of L89.623. "Developed a pressure of the heel with full-thickness skin loss"E11.621 = Type 2 DM with foot ulcer. However the provider does not make a link between DM and ulcer so therefore this cannot be coded. Diabetic neuropathy, unspecified type 2 DM -- E11.40 and pressure ulcer of heel (heel indicated in document) L89.603- pressure ulcer, unspecified, heel stage 3 would be correct CM codes for this case. See OCG for Pressure ulcer staging pg. 48. IS THIS CORRECT????????????????E CODESWhen coding striking against furniture, a bed rail, dresser etc, when you code it out it takes to you “walked into furniture” that’s what 3M leads you to, Are we to use this or use striking against object? I have used the striking against other objects. The narrative on the walked into doesn’t fit the situations. I looked it up in the book as well but wanted additional opinion. The striking against code seems more appropriate to me.(TT: CC, MR, KS 2.11.16) Trainers agree with the encoder logic and feel this would be the most appropriate.???????????????EAR WAX On Ear wax there is no code for just ear wax- the codes for ear wax takes you too H61.20 Impacted cerumen Unspecified earo H61.21 Impacted cerumen , Right earo H61022 Impacted cerumen Left earo H61.23 Impacted cerumen Bilateralo Is any ear wax present considered Impacted? I have one coder who works for another facility as well AS ABC HOSPITAL and she was told that the impaction codes were wrong if the doctor does not specify as impacted. What other coder would be used? Or do we just not code for the wax in the ear unless it is impacted.( TT: MR, JJ, CC 4.21.16) RMC recommends using H61.2X- Ear Wax in ear, Per Index "wax in ear" leads to H61 with "impacted" as a non essential modifier. RMC recommends coding ear wax only if it meets the criteria of a code able diagnosis. ???????????????ESOPHAGEAL VARICESIn coding an EGD I came across the diagnosis of Esophageal varices and liver cirrhosis based on this information can we link the varices and the cirrhosis and code K74.60 and I85.10? There does not seem to be any other information stating the varices are a result of the cirrhosis in the record.(TT: CC, KS 11.17.15) There has to be documentation to link the two conditions together. Coders are not to assume. See Index- Esophageal (in or due to) cirrhosis. You can use K74.60 and I85.00 for correct coding in this case. But the sequencing is coded according to circumstances of the visit.???????????????EXTERNAL CAUSEIn ER charts, often I only see "fall." How would I code that? My facility does not approve of many queries in ER accounts. (TT::) Please use W19.xxxA for Fall, Unspecified???????????????EXTERNAL CAUSEI have a question on an ED visit. Patient had a fall from her bed hitting night stand and then fell again at school. Would both falls be coded (W06XXXA, W228XXA & W19XXXA) and classified as initial encounter if the ED visit was after the 2nd fall at school?Code the appropriate injury codes/external cause codes as per provider documentation. If documentation states both falls resulted in injury, code both falls. ICD 10 CM guidelines state that as many external cause codes may be used as necessary in order to accurately reflect the activity(ies) in which the patient was engaged at the time of the injury(ies). ???????????????EXTERNAL CAUSE CODEpt was riding bicycle, got cut off by a car, bicycle went up onto sidewalk, front tire slipped and pt went down on left side sliding across cement into grass. Was not wearing helmet, but head did not hit, but rather grazed across ground. Most of his pain is in Left shoulder and knee. Unable to move left shoulder, heard a pop. Grip normal for him, no numbness or tingling.I am looking for an external cause code for the attached situation, the V19.9xxa does not seem appropriate.(TT:DB, SH, KS 1.18.16)Trainers feel that V19.9XXA isn't necessarily incorrect but trainers feel that V18.4XXA - Pedicycle driver injured in noncollision transport accident in traffic accident, might be a better description of the incident???????????????FOREIGN BODY IN EYEWhich E code would you assign for foreign body in the eye? (TT::)The most appropriate code we could find is X58.XXXA Coding Index: External cause, Injury, NOS Agree, also be sure to review the entire record for clues to code more specific external cause.???????????????FUNGAL RASHHow would code an ER with a final dx of fungal rash? (location on skin on leg)(TT: KS, MC, CC 1.19.16) B36.9 Superficial mycoses would be the best code for this. see Infection, fungus. Infection, fungus, skin = B36.9.???????????????MARIJUANA USEShould we code marijuana use now that it is legal (Oregon or other states that made legal)?(TT: MR, CC, KS 10.29.15) Marijuana use needs to meet the criteria for inclusion of secondary diagnoses per Official Coding Guidelines to be coded. If so, just as with alcohol or tobacco then it would be appropriate to code it. OCG C.5 B.3 As with all other diagnoses, the codes for psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). The codes are to be used only when the psychoactive substance use is associated with a mental or behavioral disorder, and such a relationship is documented by the provider.Marijuana use is F12.90???????????????BACK INJURYI am not getting to a code with “back injury” pathway is asking for upper or lower information. Also there is no mid or upper option. How would one go about coding “back injury”?(TT: SH, KS, DB 11/4/15) Per the book index look up "injury, lower, back" S39.92XA, If you are using 3M and some thing doesn't make sense - check a code book. ???????????????ECGIf documentation states from an ECG report states “inferior infarct-age undetermined” and “Abnormal ECG” would diagnosis codes R94.31 & I25.2 be correct? During an audit, the diagnosis R94.31 was coded and I suggested to add I25.2. (TT: DB, KS, SH 3.28.16) Trainers do not recommend coding the I25.2 as the "age undetermined" is not clear for being an "old MI" as time is not defined. REMINDER: old MI in ICD10 is coded after 4 weeks. ???????????????PHYSICAL THERAPYHow to code physical therapy accounts , as in Ancillary coding. (Do trainers agree?)(TT: MC, KS, CC 2.10.16 ) Refer to OCG, Coding Clinic and previous trainers advice on rehab coding. See below.See Official Coding Guideline pg. 98 4th quarter 2012When the purpose for the admission/encounter is rehabilitation, sequence first the code for the condition for which the service is being performed. For example, for an admission/encounter for rehabilitation for right-sided dominant hemiplegia following a cerebrovascular infarction, report code I69.351, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, as the first-listed or principal diagnosis. If the condition for which the rehabilitation service is no longer present, report the appropriate aftercare code as the first-listed or principal diagnosis. For example, if a patient with severe degenerative osteoarthritis of the hip, underwent hip replacement and the current encounter/admission is for rehabilitation, report code Z47.1, Aftercare following joint replacement surgery, as the first-listed or principal diagnosis.Coding Clinic 4th quarter, 2012 page 90When a patient is admitted to the LTC specifically for rehabilitative physical therapy following an injury, assign the acute injury code with the appropriate 7th character (for subsequent encounter), as the first-listed diagnosis. In this example, assign code S32.9XXD, Fracture of unspecified parts of lumbosacral spine and pelvis, subsequent encounter for fracture with routine healing, or S42.009D, Fracture of unspecified part of unspecified clavicle, subsequent encounter for fracture with routine healing, as the reason for the admission. Assign the appropriate procedure code to show that the physical therapy was provided. It is inappropriate to assign aftercare Z codes for aftercare for traumatic fractures in ICD-10-CM. Refer to Section I.C.19.c., of the Official Guidelines for coding and Reporting for the Application of 7th characters for Chapter 19. There is no catch-all ICD10 code for physical therapy like the ICD9 V57x codes. If a patient has had an injury then we need to use the injury code with the appropriate 7th letter code (A-D-S). Never A and followed by the appropriate aftercare code. Aftercare codes are used for PT – i.e.: Aftercare following joint replacement – Z47.1 with the appropriate Z96.6x code. See the code book for “aftercare following surgery for . . “ codes The closest thing to a generic PT code is Z51.89 –“Encounter for specified aftercare” OR Z47.89 “Encounter for other orthopedic aftercare”. ???????????????GALLSTONECODER had an account where “gallstone” is documented on the x-ray report. When you go to ‘gallstone, unspecified’ in 3M, it takes you to K80.80. AUDITOR brought up a good point on CODERS’s audit that in the book, gallstone takes you to “calculus of gallbladder” which is code K80.20. The only way you can get to this code in 3M is to choose “other gallstone”. The question is: When would you use K80.80 vs. K80.20? Gallstone is documented, not calculus.(TT: SH, DB, KS 3.14.16) Trainers reviewed this and this appears to be a 3M issue and not a book issue. 3M is not consistent with the book. The correct code for gallstone is K80.20 per ICD10 Code book index. Please have all coders note not to rely on encoders as the book is the most accurate way for coding in ICD10.???????????????7TH CHARACTER IN ANCILLARYWhen coding ancillary charts, what is the appropriate 7th character? Often times there is no other documentation for X-ray. Would it be A or D? I understand querying facility for their guidelines would be appropriate but what if there is no policy in effect? What would the RMC guideline be in these instances? Assume A? Or?(TT:) Managers should check each facility's policy. (TT:)RMC stance: In absence of facility specific policy, recommend coding to 7th character of D. Coder will add notation in Comments section of Coding Log. ???????????????CADA patient with known coronary artery disease presents with crescendo angina concerning for progressive coronary artery disease. Patient undergoes angiography and it shows that his CAD is stable, not much progression to explain his ongoing symptoms. (He has non-obstructive CAD.) Since his symptoms are not cardiac in nature, how do I code this? Would I assign I25.110 for CAD with unstable angina? I would think that would imply that his angina is ischemic, which it is not.(TT: KS, CC, MR 1.7.16) Based on the information provided, the documentation is not clear as to whether the provider is stating that the angina/symptoms is not due to CAD. Did the provider document that the symptoms are non cardiac in nature? CAD and angina would be reported as a combination code, correct, however, the question in this case is whether, after study, the patient truly was felt to have had crescendo angina, or if the symptoms were not due to the angina/CAD at all. Query the provider for clarification.???????????????CHFIf patient has a history of A. Fib on anticoagulants do you take that to mean chronic A. Fib. I have been coding as unspecified atrial fibrillation but then today I had one and started thinking that when a patient has a history of say diastolic CHF I normally code that to chronic diastolic CHF which is something other auditors advised. I have never gotten dinged for doing that. So can we use the same premise for A. Fib?? (TT: KS, DB, SH 10.28) In the Alphabetic Index, when looking up atrial fibrillation it has "established" in parentheses which we know are nonessential modifiers and then chronic is listed as a subterm. To me, based off the Alphabetic Index, and in light of any I-10 Coding Clinic reference, I would code to unspecified atrial fibrillation or I would suggest to query the MD if the atrial fibrillation is chronic. Not sure if that will necessarily impact the DRG but it will help us assign the most specific code. ???????????????DIABETESI see in 4Q2013 that ICD10 does not assume the relationship between DM and osteomyelitis as was the case in ICD9. ICD9 also assumed a relationship between DM and PVD. What is ICD10’s stand on PVD and DM. Is there an automatic relationship or does the provider need to document this in ICD10.(TT: SH, KS, DB, CW 11.4.15): You are correct in ICD-10 there is now no assumed relationship with DM & Osteomyelitis (as there was in 9). Per CC 1994 2nd Qtr. it specifically states there is NOT an assumed relationship between DM & PVD. ICD-10 has not addressed this issue, until it does coders are to not assume a relationship.ICD-10 does not contradict this advice. Therefore, coders are to not assume a relationship. ICD 10 Coding Handbook p 164 states PVD and DM are "coded separately unless the physician documents a causal relationship." Regarding osteomyelitis, per CC 4Q 2013 pg. 114, ICD-10-CM does not assume a relationship between the two conditions. Therefore, the physician must document a cause and effect relationship in order to code diabetic osteomyelitis using the diabetic code E10.69, Type 1 diabetes with other specified complication or E11.69, for Type 2 diabetes with other specified complication. If no relationship is documented, code the conditions separately using the code for DM without complications, or query the physician for clarification. SEE NEW CC ON ASSUMING A RELATIONSHIP W DM AND SOME CONDITIONS - FOLLOW THE INDEX. ???????????????GESTATIONAL DIABETESHow would you code Gestational DM controlled on Metformin? From what I read on line Metformin is not insulin, and our only choice in ICD-10 is diet or insulin controlled. If we choose unspecified it comes up with unspecified control. (TT: CC, KS, JJ, DB, CW 11.6.15): Coder must code to unspecified O24.419 Gestational DM unspecified - cannot code any more specific because there is nothing more specified in the example.???????????????REHABI have a question. What would be the correct code selection for a patient admitted to rehab after a hernia repair? (NO CHART AVAILABLE, HYPOTHETICAL QUESTION PER CODER)(TT: JJ, KS, CC, DB 1.22.16) Trainers recommend an aftercare code Z48.8__ would be appropriate for a patient who is admitted after surgery. Hernia is part of digestive system- therefore Z48.815 - surgical aftercare following surgery on digestive system would be the appropriate code. Refer to Coding Clinic for Rehab coding 4th quarter 2012 pgs 90-98 and many more. ???????????????SCLERAL ABRASIONHow to code a scleral abrasion?! The exam states “Sclera: abrasion, of the medial aspect of conjunctiva of right eye and lateral aspect of conjunctiva of right eye.” You can’t get a specific code for scleral/conjunctival abrasion. The patient reports that he woke up in the morning with right eye pain, tearing and redness. Pt states it does not feel like there is something in his eye, it just feels like he scratched his cornea.(TT: KS, MC, CC 1.19.16) S05.01XA- Injury of conjunctiva and corneal abrasion without foreign body, right eye, initial encounter. Per guidelines, the word “and” should be interpreted to mean either “and” or “or” when it appears in a title.???????????????SCREENING MAMMOI am coding a screening mammo and one of the statements in the clinical history is “She had bilateral collapsed implants in both breasts.” I’m not sure how to code this or if I should code this. I could code implant status (Z98.82) but they are collapsed. I could use a complication code but it sounds like they have been collapsed for a while. The patient is xx years old. She doesn’t seem to have any sequela from them being collapsed. The body of the report states “The right implant is totally collapsed with calcification of the surface.” On the left “Collapsed implant is noted with the shell located posteriorly.” If I do code a complication, do I use 7th character A, D or S??? Or do I not code anything for this example?(TT: CC, KS 11.17.15) T85.49XD- Mechanical complication of breast prosthesis, subsequent encounter. D is appropriate because the documentation indicates that the physician is aware of the bilateral implants and no evidence of active treatment.???????????????SMOKINGHow would you code the following scenario. The H&P documents patient is a former smoker/ex- smoker but still “takes” a cigarette socially. Would this be hx dependence with a tobacco use code? Z87.891 (personal history of nicotine dependence) and Z72.0 (Tobacco use).(TT: MC, CC, KS 12.15.15) Trainers feel that you would want to code the history of smoking and-- if it is clinically significant to the reason for visit/admission, then a code for tobacco use would be appropriate. Providers documentation will be the best resource for coding.???????????????SMOKINGCould someone tell me what the guideline is for coding vapor cigarettes as tobacco use, I know we just talked about this in the last couple weeks.(TT: )If "smoker" is not specifically documented, then use index - Use, Tobacco - Z72, or Tobacco, Use - Z72.0. Vape is an inhalant system, but when tobacco use is documented via vapor, code to the documentation/terms available (in this case tobacco use).???????????????SMOKINGI do not understand when to use Personal history of nicotine dependence (Z87.891) vs. Nicotine dependence, cigarettes, in remission (F17.211). The documentation I consistently see looks just like this:Smoking status: Former smoker – 1.00 packs/day for 15 years; Types: Cigarettes; Quit date: xx/xx/xxxx3M codes this to Z87.891 every time (it’s picking up “former smoker”). Like ICD-9 and other substance abuse, does the term “in remission” have to be specifically stated by the provider? (MR::) According to the I-10 Guidelines “Selection of codes for “in remission” for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use (categories F10-F19 with -.21) requires the provider’s clinical judgment. The appropriate codes for “in remission” are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting).” Tobacco dependence falls in the category F17. To me, and this is only my opinion on how I have interpreted the guidelines, I would only code remission if it is documented specifically by the physician. I would code “history of” if the patient is a former smoker even if the type of nicotine is specified. I would only code “in remission” if it is documented as such. (CC::)There are currently no codes for history of tobacco "use" or "abuse" in patient who is no longer smoking. Code Z87.891 is defined as history of nicotine "dependence" (TT: )In ICD10, smoker is classified as nicotine dependence. Therefore, logic would direct you to use Z87.891 for former smoker. See index: History, Personal, Nicotine dependence (Tobacco dependence) Z87.891. The appropriate codes for “in remission” are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting)???????????????SPRAIN VS. STRAIN I cannot get to a code for “strain of knee” I can with sprain but not strain. What should I do in the case? Is there a pathway I am missing?(TT: CC,MC,KS 11.3.15) Please use code S86.919APer the book index= Injury, muscle, leg - Strain (need to know L or R above is unspecified) initial encounter???????????????SUBSEQUENT ENCOUNTER?When a patient was seen by the surgeon in his clinic for a meniscus tear (or any injury) and then is admitted to the hospital (physician is not a hospital employee) for surgery is that surgery considered initial care or subsequent care. If it is subsequent would we code the external causes?(TT: MR, CC, KS, 12.17.15) Trainers feel that this would still be considered initial encounter "A "as the final character of the code. Refer to OCG- pg.65 2016,7th character “A”, initial encounter is used while the patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician. If it was subsequent, the final character would be "D" for both the injury and the external cause. ???????????????SUTURE REMOVALPt had a Basal Cell Carcinoma removed from the nose and sutures placed. Coming in to a different provider/facility today for suture removal. Sutures are removed and gauze packing is replaced in the wound. Would you code Z48.02 for suture removal or use the S01.20xD for open wound, subsequent encounter? With the gauze repacking just listing the Z48.02 doesn’t seem sufficient. The provider is coding both which we know is wrong per coding guidelines. TT(CC, JJ, KS, DB) 10-30-15: #1 Should be Z48.817 Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (we feel this code is best because Z48.02 was aftercare for Suture Removal only whereas this code also will cover the packing.) #2 is The BCC=C44.311.???????????????TACHYCARDIAI have a coding question; one that forever keeps tripping me up and I can’t find anything concrete on the subject.Documented Atrial Fib with tachycardia or Tachycardia secondary to A. Fib. These need to be coded separate if Doctor states it in those two ways correct? And a query would be generated to ask more specifics on the Tachycardia? A coder can’t assume linking it and calling it Atrial Tachycardia can they?TT: MR, CC, KS 2.4.16) If tachycardia unspecified due to atrial fibrillation, it would not be coded separately as the tachycardia, is a symptom code R00.0 (chapter 18 symptom code). See also instructional notes at the beginning of chapter 18. As per OCG a symptom is not coded if a definitive diagnosis is present. A query would not be indicated in this instance and a coder cannot assume linking it to be Atrial Tachycardia without specific documentation supporting that diagnosis.Tachycardia is a general term; atrial fibrillation is a type of tachycardia. ???????????????UNDERDOSINGwhen to use, ‘underdosing’chart I have now:She has had recurrent a fib, a large component of which is due to fear about taking any medications and then adjusting them at home. For example, she said that over the past week, she was taking 1/2 tablet some mornings, and a full tablet on other mornings. She is supposed to be on metoprolol tartrate 25 BID, but hasn't taken BID dosing until last night, and then she took extra tablets.is this underdosing? Then you have the choices: intentional, unintentional, other noncompliance by patient(TT::) This was underdosing until noted she took "extra tablets" trainers feel need to know if she took more than prescribed or correct amount? This would be considered intentional..???????????????USE, ABUSE AND DEPENDENCEDocumentation in the history states cocaine & heroin abuse in remission last 2 months, however, in the final impression, it is documented differently as dx #4 & 5 - “opioid dependence (severe use disorder)” and “cocaine abuse”. Throughout the ED stay there is no mention or testing for drugs, so there really is no further indication that the patient is not in remission besides the final impression statement. How do we deal with these discrepancies?The entire document must be reviewed in order to correctly assign a code. In this case, since the pattern of use is documented "in remission" and there is no conflicting documentation, assign appropriate code for abuse/dependence with final character of "in remission." Remember the hierarchy, which reminds us that if both abuse and dependence are documented, only dependence would be coded.???????????????UTI IN PREGNANCYQ: 34 week Obstetric patient presented in labor. On admission it was documented the patient had a GBS UTI (bacteuria since X/XXXX) and antibiotics were started. When indexing UTI complicating pregnancy per TruCode and “infection, urinary, tract, complicating pregnancy” per the Alphabetic index in the ICD-10-CM book I am given diagnosis code O23.4- with a final character of “3” since this is the third trimester. There is no option for “in childbirth”. Patient delivered on this admission.Coder wants to use diagnosis code O75.3 (Other infection during labor) and N39.0 (Urinary tract infection, unspecified). Her argument is that “The 3M Encoder leads me to O75.3 + B95.1 when I code out a GBS UTI. I tried coding it several ways and I keep getting O75.3 + B95.1. In the text there is a note to use additional code B95-B97 along with O75.3. I see what you're saying, but I thought if they delivered during the current admission we should be choosing "in childbirth" when it's available...so when I code this I chose UTI complicating Childbirth and I come up with O75.3.”If you add O75.3 this changes the DRG from 775 to 774. My rationale was per the Alphabetic index and also that the infection during labor would be for more of a sepsis or choramniotis that develop during the labor and delivery process but instead this was more of an infection of the pregnancy. Also, per the ICD-10 Guidelines, Whenever delivery occurs during the current admission, and there is an "in childbirth" option for the obstetric complication being coded, the "in childbirth" code should be assigned. However, there was not an “in childbirth” option for UTI complicating pregnancy per TrucCode/Book. I did not check this is 3M so I’m not sure if this is a 3M error or maybe 3M is right. Please let me know which code you think is more appropriate O23.43 (Unspecified infection of urinary tract in pregnancy, third trimester) or O75.3 (Other infection during labor)?(TT: DB, SH, KS 2.15.16)“In childbirth” is only used when there is that option. Therefore recommend coding to O23.43, Unspecified infection of urinary tract in pregnancy, third trimester. Rationale: The UTI is more specific and we have a code that indicates that condition. The O75.3 would not be appropriate because “in labor” is stated and this infection incurred prior to admission. Reference OCG c.15.a.3 “For final character for trimester…” **Reminder to all coders that encoders are a tool and following an index in a code book and official coding guidelines is the best for the most accurate coding.** ???????????????RMC DISCLAIMER:Every reasonable effort has been taken to ensure that the educational information provided in this presentation is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital/facility situation. A thorough individual review of the information is recommended and to establish individual facility guidelines. ??RMC makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. RMC has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this presentation material, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this presentation. RMC makes no guarantee that the use of this presentation material will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to providers of service.If there are any questions or concerns – please contact us at 800-538-5007 or Dana Brown at dana@THANKS!! ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download