A quarterly publication of the Central Office on ICD-10-CM/PCS

[Pages:38]A quarterly publication of the Central Office on ICD-10-CM/PCS

Volume 10 Number 2

Second Quarter 2023

In This Issue

Intraoperative Tibial Fracture

COVID-19 Screening Update

3

During Staple Removal

14

Preoperative Testing and COVID-19

Lichenoid Keratosis

12

Screening

3 Maternal Care Affected by

Umbilical Cord Varix

29

Ask the Editor Anemia due to Chemotherapy Biochemically Recurrent Prostate

Cancer Cerebellar Hemangioblastoma and

Mixed Hyperlipidemia with

17

Hypercholesterolemia Myocardial Infarction and Non-

5

Obstructive Coronary Artery Norwood Procedure with Excision

9 29

Von Hippel-Lindau Syndrome

16

Complication due to Silicone Injection 27

Control of Bleeding with Hemospray? 26

Diabetes with Dysautonomia

Orthostatic Hypotension

Syndrome

8

Direct Endoscopic Necrosectomy 22

Epistaxis Following Nasogastric

Tube Insertion

28

of Thymus Placement of Carillon Mitral

Contour System? Post Abortion Hemorrhage due to

Uterine Atony Post Procedural Seroma Preparation of Donor Organ Before

Transplantation Primary and Secondary Malignancy

22

21

15 13

34

Erosive Duodenitis

11

Excisional Debridement and Non-

Excisional Debridement at

Deeper Layer Same Site

30

Gastrocnemius Equinus

14

Heart Transplantation and Removal

of Right Ventricular Assist Device 6

High Output Ileostomy

20

Hyperglycemia due to Immunotherapy

Diagnosed Concurrently Remplissage of Subscapularis

Tendon Sequencing of Acute Cholecystitis

with Cholelithiasis and Gallstone Pancreatitis Sigmoid Sinus Dehiscence with Mastoidectomy with Resurfacing Spinal Fusion Using Allograft Bone

6 24

11 18

Drugs in Pre-Existing Type 2

Diabetes Mellitus

10

Hypertension and Hypothyroidism 16

Hypertrophy of Ligamentum Flavum 13

Inframammary Fold Adjacent

Tissue Transfer and Deep Inferior

Epigastric Perforator Flap

Breast Reconstruction

30

Graft and Bone Marrow Aspirate Testing of Premature Rupture of

Membranes via Indigo Carmine Injection Thrombus of Aortobifemoral Bypass Graft Venous Thoracic Outlet Syndrome V-Y Anoplasty and Excision of Mucosal Ectropion

25

33 7 8

23

Coding advice or code assignments contained in this issue effective with discharges June 9, 2023.

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 Denene Harper, RHIA Director, Central Office on ICD-10-CM/PCS

Tammy Love, RHIA, CCS, CDIP, Director, Coding Classification, Policy

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

Karen Ayala, RHIT Coding Specialist

Medical Advisors, Centers for Melissa Koehler, DHA, MBA,

Medicare & Medicaid Services RHIA, CHDA, CCS, CCS-P,

Perry Alexion, M.D.

CCDS, CRCR

Edith Hambrick, M.D.

Director, HB Coding Operations

Dorota Marchel, M.D

& Quality, Inova Health System,

Falls Church, VA

Editorial Advisory Board

Tammy Love, Chairman

Mary Bowlan, RHIA, CDIP, CCS Regulatory Audit Manager

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

Jeffrey F. Linzer, M.D., FAAP

University of Arkansas for

Representative, Amer. Academy

Medical Sciences

of Pediatrics, Atlanta, GA

Little Rock, AR

Lee R. Morisy, M.D., FACS

Sue Bowman, MJ, RHIA, CCS, FAHIMA

Representative, Amer. College of Surgeons, Memphis, TN

Senior Director, Coding Policy and Compliance, American Health Information Management Association, Chicago

Bernard Pfeifer, M.D. Representative for American

Medical Assn., Harwich, MA

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

New York, NY

Donna Pickett, RHIA, MPH Chief, Classifications and

Public Health Data Standards,

Centers for Disease Control &

Mady Hue, RHIA

Prevention, Hyattsville, MD

Technical Advisor, Technology, Coding and Pricing Group Centers for Medicare & Medicaid Services, Baltimore

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

of Physicians, Bryn Mawr, PA

Melissa G. Young, MHA, RHIT Director Coding Service Center

Centura Health, Centennial, CO

Kristina Cool, RHIA, CCS Coding Consultant

Subscriptions? Questions? Problems? Call 312-422-3366

Toni Hershey, RHIA, CCS 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

Individual answers within AHA Coding Clinic? are available for reproduction by hospitals and health systems for the purpose of responding to payor audit requests. The answer needs to be reproduced in its entirety, and not edited or altered in any way. Payors, consultants, and other for-profit, commercial entities may only use AHA Coding Clinic? content as an internal reference and for audit purposes. AHA Coding Clinic? content may not be utilized for commercial, for-profit purposes and may not be re-sold, repackaged or distributed without the consent of the American Hospital Association Central Office. The Content may not be compiled, shared, or distributed in a way that circumvents the need for an individual or entity to access, purchase, or obtain a license to utilize Coding Clinic content. The use of usernames and passwords should be limited to the purchaser and/or user and not shared with other individuals or entities to circumvent the purchase of an individual license. For more information on obtaining a license to utilize Coding Clinic beyond what is listed above, please contact Tim Carlson tcarlson@.

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

cooperating parties listed below have final approval of the coding advice

Halima Zayyad-Matarieh, RHIA Coding Consultant

provided in this publication: American Hospital Association, American Health Information Management Association, Centers for Medicare & Medicaid Services (formerly HCFA), National Center for Health Statistics

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

? 2023 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 the publisher. For permission to reprint material from this publication, please write to the Central Office on ICD-10-CM/PCS, American Hospital Association, 155 N. Wacker Drive, Suite 400, Chicago, IL 60606.

Covid-19 Screening

Question: What code will be assigned for COVID-19 screening once the federal Public Health Emergency (PHE) for COVID-19 expires?

Answer: The federal Public Health Emergency (PHE) for COVID-19 expired on May 11, 2023. Based on the ICD-10-CM Official Guidelines for Coding and Reporting, continue to assign code Z20.822, Contact with and (suspected) exposure to COVID-19, for COVID-19 screening that is performed after May 11, 2023.

Note: This advice is consistent with current coding guidance.

Effective October 1, 2023, the ICD-10-CM Official Guidelines for Coding and Reporting for encounters for COVID-19 screening will be revised. For encounters for COVID-19 screening on or after October 1, 2023, assign code Z11.52, Encounter for screening for COVID-19.

Question: Once the federal Public Health Emergency (PHE) for COVID-19 expires, what code should be assigned for COVID-19 screening that is performed during preoperative testing?

Coding Clinic

Second Quarter 2023

3

Answer: For an encounter for COVID-19 screening that is performed as part of preoperative testing after May 11, 2023, continue to assign code Z01.812, Encounter for preprocedural laboratory examination, as the first-listed diagnosis and code Z20.822, Contact with and (suspected) exposure to COVID-19, as an additional diagnosis.

Note: This advice is consistent with current coding guidance.

Effective October 1, 2023, for an encounter for COVID-19 screening that is performed as part of preoperative testing, assign code Z01.812, Encounter for preprocedural laboratory examination, as the first-listed diagnosis and code Z11.52, Encounter for screening for COVID-19, as an additional diagnosis.

4

Second Quarter 2023

Coding Clinic

Coding Clinic

Ask the Editor

Question: A 77-year-old patient diagnosed with biochemically recurrent prostate cancer was seen for a hematology/oncology visit to discuss systemic therapies, such as androgen deprivation therapy (ADT). He had previously undergone prostatectomy and salvage radiation therapy for advanced prostate adenocarcinoma. When a patient is diagnosed with biochemically recurrent prostate cancer, status post prostatectomy, would a code be assigned for recurrent prostate cancer or the rising prostate-specific antigen (PSA) levels? How would this case be coded?

Answer: Assign code C79.9, Secondary malignant neoplasm of unspecified site. Also assign codes R97.21, Rising PSA following treatment for malignant neoplasm of prostate, Z90.79, Acquired absence of other genital organ(s), and Z85.46, Personal history of malignant neoplasm of prostate, as additional diagnoses. While R97.21 is a symptom code, it is appropriate in this case since it provides important clinical information regarding the patient's rising PSA.

Biochemically recurrent prostate cancer is characterized by rising PSA levels in spite of local treatment and prostatectomy. The increasing PSA level is an indicator of disease progression (i.e., local recurrence or

Second Quarter 2023

5

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