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Congenital anomaly coding at the carnival sideshow

If you are a fan of American Horror Story (I’m not) or carnival sideshows (again, not my thing, but I’m not judging), you’ve seen some odd creatures. Maybe you’ve wondered if they are real. After all, P.T. Barnum once tried to pass off a monkey body sewn onto a fish as a Feejee mermaid.

"Feejee mermaid" by Original uploader was Chris 73 at en.wikipedia - Originally from en.wikipedia; description page is/was here.. Licensed under Public domain via Wikimedia Commons -

“Feejee mermaid” by Original uploader  Chris 73 at en.wikipedia – Licensed under Public domain via Wikimedia Commons

In the case of American Horror Story, some of the “freaks” are based on people who suffered from actual medical conditions.

Take, for example, the bearded lady. Most women have some facial hair (otherwise we wouldn’t need all of the beauty products promising to do away with the unsightly stuff). However, some women have it worse than most of us. They actually end up with a beard or mustache. This can be the result of the genetic disorder hypertrichosis.

In ICD-10-CM, codes for hypertrichosis appear in three different sections.

The first category, L68 (hypertrichosis), includes excess hair. However, the Excludes1 note tells us that we cannot code these conditions in a patient with hypertrichosis:

  • Congenital hypertrichosis (Q84.2)
  • Persistent lanugo (Q84.2)

Excludes1 means mutually exclusive. You can’t have the two conditions together.

Category L68 includes the following subcategories:

  • L68.0, hirsutism
  • L68.1, acquired hypertrichosis lanuginosa
  • L68.2, localized hypertrichosis
  • L68.3, polytrichia
  • L68.8, other hypertrichosis
  • L68.9, hypertrichosis, unspecified

We’ve already mentioned the second place hypertrichosis codes appear: Q84.2 (other congenital malformations of hair).

The final set of hypertrichosis codes appears in subcategory H02.86 (hypertrichosis of eyelid). The codes are divided by the upper and lower eyelid, as well as laterality.

Another performer in the freak show is lobster boy. Real or fake? Actually, it’s a real condition. In the mid-1900s, Grady Franklin Stiles Jr., suffered from ectrodactyly, in which the fingers and toes are fused together.

If you look up ectrodactyly in the ICD-10-CM Alphabetic Index, you won’t find the condition. You can find it in the ICD-9-CM Alphabetic Index with notes that tell you to see “absence, finger, congenital” and “absence, toe, congenital.”

If we look up “absence, finger” in the ICD-10-CM Alphabetic Index we find two choices:

  • Acquired, Z89.02-
  • Congenital – See Agenesis, hand

Agenesis is simply the failure of a body part to develop. Unfortunately, quite a few body parts can fail to develop, judging by the list of subterms under Agenesis in the ICD-10-CM Alphabetic Index.

For agenesis of the hand, ICD-10-CM includes the nonessential modifiers “and fingers,” “complete,” and “partial.” Nonessential modifiers are just that—nonessential. So you use the same code even if the physician doesn’t document those modifying terms.

We have four code choices based on laterality:

  • Q71.30, congenital absence of unspecified hand and finger
  • Q71.31, congenital absence of right hand and finger
  • Q71.32, congenital absence of left hand and finger
  • Q71.33, congenital absence of hand and finger, bilateral

ICD-10-CM does include an entry for “lobster-claw hand.” It leads you to code Q71.6- (lobster-claw hand). Here’s where physician documentation will really be important. If the physician documents “lobster-claw hand,” use the Q71.6- codes (with an additional digit to specify laterality). If the physician documents “agenesis” or “congenital absence of fingers,” just the Q71.3-.

You can spend a lot of time online searching for the distinctions between the two and you’ll even find “cleft hand,” which creates even more confusion. If you are unsure which condition the patient has based on the documentation, you can always query the physician.

Our final freak show example was commonly referred to as Pinhead. These curiosities were usually people who suffered from microcephaly, a neurodevelopmental disorder that causes abnormal growth of the brain.

This condition is pretty easy to code. We have one choice in ICD-10-CM: Q02 (microcephaly), which also includes hydromicrocephaly and micrencephalon.

Mad cow disease anyone?

You’ve probably heard that you need to beef up your clinical knowledge for ICD-10-CM and ICD-10-PCS coding. And you’re probably wondering when you have time to do that.

26707_MB318719_CCE_Cover_135x135 (3)We’re here to help. We’ve researched 140 clinical conditions and collected them in JustCoding’s Clinical Conditions Encyclopedia. Each entry includes clinical information, such as signs and symptoms, types or stages, and treatment, along with coding and documentation for both ICD-9-CM and ICD-10-CM.

Mad cow disease, more properly called Creutzfeldt-Jakob disease (CJD), is one of the conditions the encyclopedia covers. CJD is divided into three major categories:

  • Sporadic CJD
  • Hereditary CJD
  • Acquired CJD

On October 1, 2008, the Cooperating Parties revised and expanded the ICD-9-CM codes for CJD to include:

  • Variant Creutzfeldt-Jakob disease: Report code 046.11
  • Other and unspecified Creutzfeldt-Jakob disease: Report code 046.19
  • Dementia in conditions classified elsewhere without behavioral disturbance: Report code 294.10
  • Dementia in conditions classified elsewhere with behavioral disturbance: Report code 294.11

The revised code description for code 046 includes slow virus infections and prion diseases of the central nervous system. The fifth digit represents the form of the disease. Currently, only variant CJD has a fifth digit of a 1. Report code 046.19 for all other forms.

When a patient develops dementia with or without behavioral disturbance, report an additional code to represent the dementia.

When we get to ICD-10-CM, our coding will look like this:

  • Creutzfeldt-Jakob disease, unspecified, or Jakob-Creutzfeldt disease, unspecified: A81.00
  • Variant Creutzfeldt-Jakob disease: A81.01
  • Other Creutzfeldt-Jakob disease including familial Creutzfeldt-Jakob disease, iatrogenic Creutzfeldt-Jakob disease, sporadic Creutzfeldt-Jakob disease, and subacute spongiform encephalopathy (with dementia): A81.09

Category A81 (atypical virus infections of central nervous system) still includes diseases of the central nervous system caused by prions.

And we will still use an additional code to identify:

  • Dementia with behavioral disturbance (F02.81)
  • Dementia without behavioral disturbance (F02.80)

While you’re unlikely to see a large number CJD diagnoses, you probably code for patients with anemia, hypertension, heart failure, migraine, stroke, and syncope. All of those conditions are part of the encyclopedia as well.

You’ll also find some less common conditions such as hungry bone syndrome, blue diaper syndrome, and kabuki syndrome.

Order your copy of JustCoding’s Clinical Conditions Encyclopedia today!

Eyes on the migraine

Jeff, an 18-year-old male, came into the Fix ‘Em Up Clinic with complete left oculomotor palsy. Jeff stated he had a severe, throbbing headache around his eye yesterday. He took some aspirin and went to sleep.

Swollen eye_tired eyeWhen he woke up this morning, he had troubled seeing out of his left eye because his left eyelid was drooping so much. He says overall his vision is blurry and the area around his left eye is very painful.

Fortunately for Jeff, Dr. Achy is on the case. Dr. Achy documented that Jeff’s left pupil was 6 mm in diameter and reactive to light. She performed a neurological exam and ordered x-rays, both of which were normal.

To be on the safe side, Dr. Achy ordered an MRI and magnetic resonance angiography to rule out really bad things such as tumors and aneurysms. Again, the tests came back normal. Dr. Achy also ruled out glaucoma.

Dr. Achy prescribed two aspirin and Jeff’s symptoms almost completely resolved. It’s a miracle, but what on earth is wrong with Jeff?

He has an ophthalmoplegic migraine, a very rare headache that tends to occur in younger adults.

The pain centers around one eye and is usually less intense than in a standard migraine. It may be accompanied by vomiting, double vision, a droopy eyelid, and paralysis of eye muscles. Attacks can last from hours to months.

In ICD-9-CM, we would report code 346.20 (variants of migraine, not elsewhere classified, without mention of intractable migraine without mention of status migrainosus). That doesn’t really tell us much about Jeff’s specific condition. “Without mention” appears twice in the code description and it’s a not elsewhere classified code—we have information, but no specific code available.

ICD-10-CM resolves part of that problem. We will have a code for ophthalmoplegic migraine. In fact, we have two:

  • G43.B0, ophthalmoplegic migraine, not intractable
  • G43.B1, ophthalmoplegic migraine, intractable

We know the migraine is not intractable because it resolved with standard treatment. First, Dr. Achy didn’t document it as intractable. Second, “intractable” means the headache doesn’t resolve with the usual treatment. Jeff’s condition improved after he took some aspirin.

That gives us G43.B0.

If you see a lot of migraine patients in your facility or organization, check the physician documentation to make sure he or she is noting the type of migraine, e.g., with aura, without aura, with status migrainosus, persistent.

ICD-10-CM includes much more detailed choices for migraines so if your physicians aren’t documented to the level of specificity you need in ICD-10-CM, start working with them now. Implementation is less than a year away.

The tell-tale chart

Saturday marks the 165th anniversary of the death of Edgar Allan Poe, but sadly, we’re still not sure of the cause of Poe’s demise. We do, however, have plenty of theories.

RavenFirst is the popular “he drank himself to death” theory that many people have heard. Poe was found “in great distress” outside of a polling place in Baltimore and died four days later.

If Poe, who couldn’t really hold his liquor, did succumb to alcohol poisoning, how would we code it? First, we head to the Table of Drugs and Chemicals, then find alcohol and its 28 related entries. Apparently you can be poisoned by a lot of different types of alcohol.

In Poe’s case, it was probably ethanol (T51.0X-). In fact, 13 of the terms under alcohol in the Table of Drugs direct you to T51.0X-.

Now we need the intent behind the poisoning. We have specific codes for:

  • Accidental (unintentional)
  • Intentional self-harm
  • Assault
  • Undetermined

We also need a seventh character to denote the encounter. We have three choices:

  • A, initial encounter
  • D, subsequent encounter
  • S, sequela

Most likely, the alcohol poisoning (if that’s what put an end to the poet) was accidental, so we would report T51.0X1A.

However, we are faced with a more sinister possibility. Some have speculated that Poe was actually the victim of cooping, a method of voter fraud practiced by gangs in the 19th century. The gangs would kidnap people and take them around to various polling places so they could vote multiple times. After each successful casting of the ballot, the gang would reward their victim with alcohol.

You might be able to make a case for this being an assault, although that is probably a tough sell. You could also make a case for undetermined.

You’ll also find the following note under T51.01X-:


  • Acute alcohol intoxication or ‘hangover’ effects (F10.129, F10.229, F10.929)
  • Drunkenness (F10.129, F10.229, F10.929)
  • Pathological alcohol intoxication (F10.129, F10.229, F10.929)

An Excludes2 note tells us that the conditions listed are not part of T50.1X-, but a patient could be suffering from one of these conditions as well. So if Poe’s doctor documented pathological alcohol intoxication, we would code it in addition to the alcohol poisoning.

Not everyone is convinced that Poe died from too much drink. Another popular theory is rabies. Many of Poe’s symptoms fit. He was admitted to a hospital due to “lethargy and confusion.”

Once admitted, his condition rapidly declined and he exhibited:

  • Delirium
  • Visual hallucinations
  • Wide variations in pulse rate and rapid
  • Shallow breathing

Four days after being admitted, Poe died. Four days is the median survival rate after the onset of serious rabies symptoms.

Rabies, however, is not a perfect fit. Poe did not display hydrophobia, which commonly afflicts those with rabies. He also didn’t have signs of an animal bite.

ICD-10-CM offers three codes for rabies:

  • A82.0, sylvatic rabies
  • A82.1, urban rabies
  • A82.9, rabies, unspecified

We would probably go with unspecified rabies because we don’t know where Poe was infected (if he even was). The author was missing for several days before he was found lying in the street incoherent.

Perhaps flu felled the master of the macabre. Poe may have been suffering from influenza, which may have turned into pneumonia. Poe is reported to have been ill before he left Richmond, Virginia, to travel to Philadelphia. A high fever might account for his hallucinations and his confusion and the rain in Baltimore may explain his second-hand clothes.

If this was indeed Poe’s cause of death, we would code both the influenza and the pneumonia. And we can probably code it with a single combination code.

Poe’s pneumonia was likely either bacterial or viral. Code categories J13 (pneumonia due to Streptococcus pneumonia), J14 (pneumonia due to Hemophilus influenza), J15 (bacterial pneumonia, not elsewhere classified), and J16 (pneumonia due to other infectious organisms, not elsewhere classified) all instruct codes to first code any associated influenza.

However, when you look up “influenza” in the ICD-10-CM Alphabetic Index, you will find a listing for “influenza with pneumonia.” The index entry leads to you a very non-specific code: J11.00 (influenza due to unidentified influenza virus with unspecified type of pneumonia).

That’s probably the code we need to report because we don’t have any additional information (and we can’t query the physician. At this point, he’s dead too).

Keep in mind that the ICD-10-CM Official Guidelines for Coding and Reporting tell us it’s okay to report unspecified codes. Guideline B.18 in fact uses pneumonia as an example:

When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type).

The guidelines also state that the physician shouldn’t perform tests just for more specificity.

Poe’s official cause of death, the one on his death certificate, is phrenitis, or swelling of the brain.

If you look up “phrenitis” in the ICD-10-CM Alphabetic Index, you’re directed to “see encephalitis.”

Not surprisingly, we find a plethora of choices, including alcoholic encephalopathy (G31.2). We would need the physician to document alcoholic encephalopathy before we can code it.

Sadly Poe’s medical records have gone missing and shall be seen nevermore.

Brain injury coding can be complex

Today we’re going to look at a real-life injury, but I will say up front that I don’t have all of the information about this particular patient’s injuries.

6_BrainWithArteries-no labelF1 racecar driver Jules Bianchi was involved in a pretty horrible crash over the weekend in Japan. He is currently in intensive care after suffering a diffuse axonal injury.

Let’s start at the very beginning. A diffuse axonal injury is a severe traumatic brain injury or severe closed head injury. That tells us we will not be coding for an open head injury. Diffuse also tells us that the injury does not involve one specific area of the brain like a focal brain injury (ICD-10-CM includes specific codes for focal injuries). Instead a diffuse axonal injury affects a widespread area of the brain.

How will we look up a diffuse axonal injury in the ICD-10-CM Alphabetic Index? The place to start is Injury. We have pages and pages of injury codes in ICD-10-CM.

Would you look under “axonal” or “brain”? If you said brain, you’re correct. I tried looking up Injury, axonal and got nowhere. I also tried diffuse axonal with no luck.

Under injury, brain (traumatic), we have an entry for diffuse (axonal), which directs us to S06.2X-.

A quick aside before we head to the Tabular List. As with ICD-9-CM, in ICD-10-CM when words appear in parentheses, they are nonessential modifiers. That means we don’t need them to code, but they help tell us we’re in the right place.

Off to the Tabular List to identify our additional characters. We find the following choices, broken down by the length of any associated loss of consciousness (LOC):

  • S06.2X0-, diffuse traumatic brain injury without loss of consciousness
  • S06.2X1-, diffuse traumatic brain injury with loss of consciousness of 30 minutes or less
  • S06.2X2-, diffuse traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes
  • S06.2X3-, diffuse traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes
  • S06.2X4-, diffuse traumatic brain injury with loss of consciousness of 6 hours to 24 hours
  • S06.2X5-, diffuse traumatic brain injury with loss of consciousness greater than 24 hours with return to pre-existing conscious levels
  • S06.2X6-, diffuse traumatic brain injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving
  • S06.2X7-, diffuse traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness
  • S06.2X8-, diffuse traumatic brain injury with loss of consciousness of any duration with death due to other cause prior to regaining consciousness
  • S06.2X9-, diffuse traumatic brain injury with loss of consciousness of unspecified duration

Note that these are not complete codes. We need a seventh character to indicate the encounter. You’ll need to go back to the beginning of category S06 (intracranial injury) to find that information.

Category S06 also includes these notes:

Code also any associated:

  • Open wound of head (S01.-)
  • Skull fracture (S02.-)

We face two challenges whenselecting the correct code. First, does the documentation specify the length of the LOC? Based on information in the media right now, we’re looking at an LOC of greater than 24 hours. That eliminates the first five codes.

And it brings us to the second challenge—how well did the patient return to pre-existing conscious level? We may not know the final amount of recovery at the time of discharge (assuming the patient survives—the prognosis for diffuse axonal injuries isn’t very good). Brain injuries are complex and can take a significant amount of time to heal.

The code we assign at discharge will be based on the patient’s status at that time.

Use GEMs as a starting point, not an end point

The Workgroup for Electronic Data Interchange’s (WEDI) most recent survey on ICD-10 readiness included a particularly alarming (at least to me) statistic: Approximately 25% of the 324 providers who responded to the survey plan only to do crosswalking from ICD-9 to ICD-10.

detective with footprintsThat percentage roughly doubled in a year and it represents a pretty big concern for anyone interested in data integrity and getting paid.

Here’s why. General Equivalence Mapping (GEMs) like those CMS posts and other crosswalks are tools to help coders and, like any tool, they have their good points and bad points. Good point: they give coders a place to start. Bad point: they don’t get you to the final code.

Put another way: GEMs will get you to the correct neighborhood, but they won’t get you to the front door.

CMS even admits the limitations of the GEMs, stating: “There is no simple crosswalk from I-9 to I-10 in the GEM files.”

In some cases, you will find a one-to-one correlation from ICD-9-CM to ICD-10-CM (forget about it when it comes to ICD-9-CM procedure codes and ICD-10-PCS).

For example, Salmonella meningitis translates cleanly from 003.21 in ICD-9-CM to A02.21 in ICD-10-CM. Those cases are the exception. We wouldn’t need to move to ICD-10-CM if all codes were one-to-one matches.

In many cases, one ICD-9-CM code translates to multiple ICD-10-CM codes. Consider ICD-9-CM code 733.93 (stress fracture of tibia or fibula).

ICD-10-CM contains five choices that could match 733.93:

  • M84.361-, stress fracture, right tibia
  • M84.362-, stress fracture, left tibia
  • M84.363-, stress fracture, right fibula
  • M84.364-, stress fracture, left fibula
  • M84.369-, stress fracture, unspecified tibia and fibula

Odds are, the GEM will take you to M84.369, which really tells you nothing about the actual fracture. No laterality, no specific bone.

It’s also not a valid code as is. It requires one of these seventh character to denote the encounter:

  • A, initial encounter for fracture
  • D, subsequent encounter for fracture with routine healing
  • G, subsequent encounter for fracture with delayed healing
  • K, subsequent encounter for fracture with nonunion
  • P, subsequent encounter for fracture with malunion
  • S, sequela

That information is not included in the ICD-9-CM code you’re crosswalking.

GEMs have other drawbacks as well. By now, you’ve probably heard that diabetes codes in ICD-10-CM no longer specify controlled or uncontrolled. ICD-10-CM also includes five subcategories of diabetes codes compared to two in ICD-9-CM. No way those codes will match up.

ICD-10-CM also includes different ways of classifying conditions. Consider complications of pregnancy. ICD-9-CM classifies them as:

  • Unspecified episode of care
  • Delivered
  • Antepartum

ICD-10-CM codes instead classify them by trimester:

  • First trimester
  • Second trimester
  • Third trimester
  • Unspecified trimester

An antepartum episode of care could fall into any of those trimesters. The OB/GYN is probably documenting somewhere in the patient’s record which trimester she is in. By just using a crosswalk, you lose that detail and likely end up with an unspecified code.

Unspecified codes aren’t the end of the world, but they do defeat part of the purpose for moving to ICD-10-CM. They could also result in denials. We don’t know for sure yet, but why take the chance?

ICD-10-CM includes a few different guidelines from ICD-9-CM (not many, but you still need to know them). GEMs won’t take those guideline changes into account. And you may or may not end up at the correct combination codes (ICD-10-CM includes a lot of those).

The best way to learn to code in ICD-10-CM is to actually code the record using the ICD-10-CM Manual. In fact, almost half of the providers responding to the WEDI survey plan to do just that. If your organization is using just GEMs, you may need to do a little work on your own or explain why GEMs alone aren’t the answer. It’s more work now, but it will pay off after the transition.


New ICD-10-CM guidelines are out

We’re still living under a code freeze as we (eagerly) await ICD-10 implementation. However, the four Cooperating Parties are still tweaking the ICD-10-CM guidelines. Both the Centers for Disease Control and Prevention and CMS posted the new guidelines on their websites. You can also download PDFs of the codes and indexes as well.

guidelinesNot surprisingly, the guidelines don’t contain major changes. However, you should download the guidelines and read through them (if you haven’t already). You’ll notice that most of the guidelines are the same as those we currently use in ICD-9-CM, but you still need to spot the differences.

New for 2015 are these specific examples of sequelae:

  • Scar formation resulting from a burn
  • Deviated septum due to a nasal fracture
  • Infertility due to tubal occlusion from old tuberculosis

The Cooperating Parties also updated the guidelines for sepsis, specifically the guideline for postprocedural infection and postprocedural septic shock.

When the patient develops a postprocedural infection and severe sepsis, first report the code for the precipitating complication, such as code T81.4 (infection following a procedure). You should also report R65.20 (severe sepsis without septic shock) and a code for the systemic infection.

If the postprocedural infection leads to septic shock, you still code the precipitating complication first, but now report code T81.12- (postprocedural septic shock) and a code for the systemic infection.

ICD-10-CM now includes additional information on the seventh character for pathologic fractures. The seventh character denotes the episode of care.

Use seventh character A when the patient is undergoing active treatment, which now includes evaluation and continuing treatment by the same or a different physician.

The guidelines further state:

While the patient may be seen by a new or different provider over the course of treatment for a pathological fracture, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time.

You’ll find the same information under the guidelines for chapter 19, Injury, poisoning, and certain other consequences of external causes. You’ll also see some additional information on complications:

For complication codes, active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier precipitating problem.

The guidelines further clarify that seventh character D is used when the patient has an x-ray to check the healing status of a fracture.

When it comes to external cause codes, the guidelines now specify that the seventh character for external cause should be the same as the one for the code assigned for the associated injury or condition for the encounter.

You probably know that you only assign a place of occurrence code once. Well, most of the time. ICD-10-CM now specifics that when the patient suffers a new injury during hospitalization (which should be rare), you can assign an additional place of occurrence code.

We’re one year from implementation…again

I don’t know about you, but I’m starting to feel a little like Chicken Little, yelling, “ICD-10 is coming!” instead of “The sky is falling!” And we’re all probably being met with the same polite (or not so polite) skepticism from our colleagues each October 2015 calendartime the ICD-10 implementation date changes.

Never fear, ICD-10 will be here no matter how much fuss the AMA and Congress put up. Why? Because ICD-9-CM isn’t getting it done anymore. ICD-9-CM is vague, out of room, and quite frankly, out of date.

Think about this: The National Committee on Vital and Health Statistics actually sent a letter to the Secretary of Health and Human Services recommending the U.S. move to ICD-10 more than 10 years ago.

How do we make sure we actually implement ICD-10 next year instead of talking about another delay?

Talk about the specific benefits of ICD-10 as they relate to your audience. Don’t talk to brain surgeons about the incredible amount of data you’ll be able to collect on fractures. They don’t care. Instead point out that ICD-10-CM includes more detailed codes for cerebral infarctions.

ICD-10-CM includes subcategories for cerebral infarction due to:

  • Thrombosis of precerebral arteries
  • Embolism of precerebral arteries
  • Unspecified occlusion or stenosis of precerebral arteries
  • Thrombosis of cerebral arteries
  • Embolism of cerebral arteries
  • Unspecified occlusion or stenosis of cerebral arteries

Think how much better, Doctor, you will be able to follow your patient’s progress and track how well different treatment methods work with all of these additional details (ICD-10-CM also includes more detailed codes for sequela from a cerebral infarction). Image the research possibilities. Consider the medical and treatment advances you can make.

And isn’t it all about better patient care? So let’s tell a better story about our patients. While we’re at it, let’s tell a better story about ICD-10 so everyone (or the majority at least) is on board with the transition.

ICD-10 is not harder to use. ICD-10-CM is similar in many ways to ICD-9-CM. You look up codes the same way, you still follow guidelines (90%-95% of the time it’s the same guidelines), you still code from the Tabular List, not the Alphabetic Index.

Clinicians have provided input into ICD-10. In fact, the vast majority of ICD-10 updates come from physician groups, according to Sue Bowman, RHIA, CCS, senior director of coding policy and compliance for AHIMA in Chicago. No one is freezing the physicians out.

On the subject of physician misconceptions, doctors don’t need to learn to code in ICD-10. They just need to document better (really they need to document better in ICD-9, but that’s another story). Instead of hitting them with codes, introduce them to new concepts in ICD-10, says Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, vice-president of ICD-10 training and education for AAPC in Salt Lake City. Those concepts include:

  • Laterality (which they should already be documenting)
  • Episodes of care
  • Anatomical location
  • Cause/type
  • Complication/manifestation

SNOMED CT and ICD-11 are NOT viable alternatives. I’ve heard people push for use of SNOMED CT instead of ICD-10. That’s not going to work because they are complimentary systems, not interchangeable ones. SNOMED CT is designed for the primary documentation of clinical care. The ICD system defines the universe of diseases, disorders, injuries, and other related health conditions. And we’d have to figure out how to pay based on SNOMED CT. Any idea how long that will take?

And for those who want to use ICD-11—honestly, we can’t wait that long. ICD-11 is still two to three years away from beta testing. Who knows how long it will take to modify for use in the U.S. We’ve been modifying ICD-10 for 20 years. Many of the concepts in ICD-11 are based on those in ICD-10. If you skip ICD-10, you miss that intermediate step. Never a good idea.

Look for ways to get accurate information out about ICD-10. You can find plenty of resources online (just make sure they are reputable sources). Let’s make this the last year we’re planning to implement ICD-10.

Bring the differing CDI and coder perspectives into focus

Coders and clinical documentation improvement (CDI) specialists have different perspectives and priorities even on common diagnoses.

dont miss itHCPro boot camp instructors Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Cheryl Ericson, RN, MS, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, are ready to help you bridge the communication gap! Join us at 1 p.m. (Eastern) tomorrow for the live 90-minute webinar, Common Diagnoses in ICD-10-CM: Bring CDI and Coding Together.

Shannon and Cheryl will explain the coding and CDI perspectives on:

  • Cardiovascular
  • Complications
  • Poisoning/adverse effects/underdosing
  • Substance use/abuse/dependence
  • Acute respiratory failure

They will also offer tips you can use in your facility to improve communication between coders and CDI specialists.

The program also offers both AHIMA and AAPC credits.

So bring the whole team and build momentum for the final year of ICD-10 preparation.

Can’t get everyone together for the live program? No problem. You get a free on-demand version of the webinar so everyone can listen when it’s convenient and still earn CEUs.

See you at the show!

When good vaccines lead to bad reactions

With flu season just around the corner (hey, where did summer go?), Melissa took her 4-year-old son Andrew to Dr. Spock, the pediatrician, for his flu shot Wednesday.

Vaccine needleWith a minimum of fuss (and a small bribe by mom), Andrew took his shot and headed home with Melissa.

How would we code this visit in ICD-10-CM? From a diagnosis coding standpoint, it’s pretty easy. If you look up Vaccination in the ICD-10-CM Alphabetic Index, you’re directed to code Z23 (encounter for immunization).

We do need to pay attention to two notes with this code. First, ICD-10-CM instructs us to code for any routine childhood examination. In Andrew’s case, he was just visiting for a flu shot, so no routine exam. If he had gone in for a yearly physical or another problem and just happened to get his flu shot at the same time, we would code the vaccination second.

The other thing to note is Z23 is a very general diagnosis code. We don’t have codes for the specific vaccination. Instead, we need to report the vaccine using a HCPCS code for the drug and a CPT® code (in the outpatient setting) for the actual administration. ICD-10-CM includes a note in the Tabular List stating, “Procedure codes are required to identify the types of immunizations given.”

Andrew weathered his vaccine administration fine, but when it comes to the actual vaccine, things didn’t go as well. When Melissa was getting Andrew ready for preschool Friday, she noticed the injection site was red, inflamed, and hot to the touch. Andrew also reported it was a little itchy.

Back to Dr. Spock they go. Dr. Spock allayed Melissa’s fears of cellulitis and diagnosed an adverse reaction to the vaccine.

What would we code for this visit? Instead of heading to the Alphabetic Index (although we could do that if we wanted to), we’re going to the Table of Drugs and Chemicals. The table is located in the front of the ICD-10-CM Manual, just like it is in the ICD-9-CM Manual and the tables work pretty much the same way.

In the ICD-10-CM Table of Drugs, we find the following headings:

  • Poisoning, accidental (unintentional)
  • Poisoning, intentional self-harm
  • Poisoning, assault
  • Poisoning, undetermined
  • Adverse effect
  • Underdosing

The headers in ICD-10-CM differ from those in ICD-9-CM. For example, in ICD-9-CM, any poisoning that was intentional is classified as a suicide attempt. In ICD-10-CM, that category becomes poisoning, intentional, self-harm, which is a little more generic. Some people may intentionally poison themselves with a specific drug, but they are not attempting suicide.

You’ll also notice that the codes now start with T.

Underdosing is a new concept in ICD-10-CM, but it doesn’t really relate to Andrew’s vaccine reaction.

In ICD-9-CM, we don’t have a specific heading for an adverse effect. We use the therapeutic use column, which is a little ambiguous.

However, we know that Andrew suffered an adverse effect from the vaccine, so we would use a code from that column. But which code?

We can find it two ways. First, you can look up “influenza vaccine” and lo and behold, there’s the code. Or you can look up “vaccine,” then scroll through the list to find influenza. Either way you still end up with ICD-10-CM code T50.B95 (adverse effect of other viral vaccines).

Because we know not to code from the Alphabetic Index alone, we check the Tabular List to make sure we have all of the characters we need and that the code actually matches the diagnosis.

We have the correct code, but if you flip all the way back to the start of the T50 series of codes, you’ll see a notation that a seventh character is required for all of the T50 codes. Since this is Andrew’s first visit for his adverse reaction to the flu vaccine, we would use seventh character A. The correct code is T50.B95A.

Without the A, the code is invalid and you won’t get paid.

However, we’re not done coding just yet. If you look at the very beginning of the Poisoning by, adverse effects of and underdosing of drugs, medicaments and biological substances (T36-T50) category, you’ll see several more notes, including:

Code first, for adverse effects, the nature of the adverse effect, such as:

  • Adverse effect NOS (T88.7 )
  • Aspirin gastritis (K29.-)
  • Blood disorders (D56-D76 )
  • Contact dermatitis (L23-L25 )
  • Dermatitis due to substances taken internally (L27.-)
  • Nephropathy (N14.0-N14.2)

What adverse effects did Andrew suffer? We know he had a rash and pain. If we look up rash, we find a code for rash following immunization:

  • T88.1, other complications following immunization, not elsewhere classified
    • Generalized vaccinia
    • Rash following immunization

Again we need our seventh character for the encounter, but we also need two placeholder Xs. Our final code is T88.1XXA.

The itch is a symptom that rolls into the rash code, so we don’t need to code it separately.

Fortunately, Andrew will soon be on the mend (vaccine reactions typically clear up in a few days).