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Snow day blues

Penguin with shovelHere in Anytown we are getting blasted by a big winter storm, which means we’re also seeing lots of patients with storm-related injuries at the Fix ‘Em Up Clinic.

Doug came into the clinic complaining of pain and weakness when lifting his right arm. He was out shoveling the snow using the tried-and-true lift, jerk, and fling method. During one of his tosses, he felt a sharp pain in his shoulder and started having trouble lifting his arm. Dr. Frosty examines Doug and diagnoses a torn rotator cuff.

Do we have enough information to code Doug’s injury in ICD-10-CM? If we look up tear, rotator cuff, in the ICD-10-CM Alphabetic Index, we find out very quickly that we need more information. Was this a traumatic tear?

It’s tempting to say yes right off the bat because Dr. Frosty documented that the injury occurred while Doug was shoveling snow. You can tear you rotator cuff by lifting something too heavy with a jerking motion. However, the majority of rotator cuff tears result from a wearing down of the tendon over time. In his chart, Doug’s age is listed as 57, so we could be looking at a nontraumatic tear.

Let’s take a look at the rest of Dr. Frosty’s documentation to see if we can find any indication of whether Doug’s injury is traumatic. As we read further down the note, we see this information:

MRI shows partial tear of right rotator cuff. Doug is a house painter and frequently shovels out neighbor’s driveway in winter. Repetitive motion likely contributed to tear.

ICD-10-CM includes codes for traumatic (S46.01-) and nontraumatic (M75.1-) rotator cuff tears. Dr. Frosty did not specifically indicate which kind Doug suffered, but his documentation seems to lean toward nontraumatic. After all, he is referencing repetitive motion.

We know as coders that we can’t assume and in the case of rotator cuff injuries, ICD-10-CM helps us out a little. The description for codes in the M75.1- subcategory include the words “rotator cuff tear or rupture not specified as traumatic.”

Dr. Frosty didn’t specify a traumatic rupture, so we’re going to use the M75.1- codes. The codes are further subdivided by the degree of the tear:

  • Unspecified
  • Incomplete
  • Complete

We know Doug suffered an incomplete tear, so we’ll go with M75.111 for a right rotator cuff repair. We don’t need a seventh character to specify the encounter because we are using a code from Chapter 13 (diseases of the musculoskeletal system and connective tissue).

If Dr. Frosty documented a traumatic rupture, we would have used a S46.01- code from Chapter 19 (injury, poisoning and certain other consequences of external causes), and we would have needed a seventh character to indicate the encounter.

Dr. Frosty also sees Jocelyn, who comes in complaining of pain on the outside of her left elbow. She is having trouble bending the elbow and she experiences pain when she tries to bend it. She is also unable to turn her forearm to rotate her palm.

Jocelyn was making a last-minute grocery run yesterday to prepare for today’s storm. She slipped and used her left arm to break her fall. She said her arm hurt a little yesterday, but not enough to seek treatment. However, her arm really bothered her today, so she came into the clinic.

Dr. Frosty orders an x-ray that reveals a fracture of the left radial head.

If you look up fracture, radial head, in the ICD-10-CM Alphabetic Index, you see a note to see Fracture, radius, upper end, head. Really? They couldn’t just give me the code?

Well, no, and for good reason it turns out. Once we get to Fracture, radius, upper end, head, we find multiple options:

  • Head
  • Neck
  • Specified NEC
  • Physeal
  • Torus

We know we’re dealing with the head of the radius, which leads us to S52.12-.

The next thing we need to know is whether the fracture is displaced. Dr. Frosty doesn’t specify, but we do have a default in ICD-10-CM.

A note above every section of fracture codes instructs us to code a fracture not indicated as displaced or nondisplaced as displaced.

Is the fracture open or closed? Again Dr. Frosty didn’t specify, but he also did not note any open wounds. Query or guess? We know not to guess, but we don’t have to query either. ICD-10-CM includes another helpful default. This one tells us to code a fracture not indicated as open or closed as closed.

Now we have an initial encounter for a closed, displaced fracture of the left radial head, which gives us code S52.122A.

I certainly hope the maintenance staff clears the parking lot of snow and ice before it’s time for us to go home!

Pick the correct root operation for a biopsy

Bone marrow (1024x1024)We can choose from 31 root operations in the ICD-10-PCS Medical and Surgical section, but biopsy isn’t one of them. So which root operation do we use when a physician performs a biopsy?

The answer is, it depends.

We will select a root operation in ICD-10-PCS based on the intent of the procedure.

For example, Dr. Sharpe documents a thoracentesis, which is a procedure to remove fluid from the space between the lining of the outside of the lungs and the chest wall. For that procedure, we use root operation Drainage (taking or letting out of fluids and/or gases from a body part).

When it comes to coding a biopsy in ICD-10-PCS, we need to look at what the physician is actually removing.

Let’s say Betsy came in with a growth on her thyroid. Dr. Sharpe decides to perform a needle biopsy to see whether the growth is cancerous. For this type of biopsy, Dr. Sharpe is removing a small piece of Betsy’s thyroid for examination.

We would use root operation Excision because Dr. Sharpe’s intent is to cutting out, without replacement, a portion of a body part. We would use the same root operation for liver biopsies, breast biopsies, and so on.

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Step away from the seal

SealSome diseases can cross between species, which can presents a significant problem. Just think back to how quickly avian flu spread starting in 2003.

It turns out that diseases have been crossing that species barrier for quite some time. Researchers just announced that seals first brought tuberculosis (TB) to North America. That’s right, seals.

Europeans brought a second strain of TB to the New World when the Spanish colonized South America in the 16th century.

TB certainly isn’t a new disease. It’s been around for somewhere in the neighborhood of 70,000 years.

Both ICD-9-CM and ICD-10-CM include multiple categories of TB codes depending on where the infection is present. In ICD-9-CM, coders need to choose the appropriate fifth character from:

  • 0, unspecified
  • 1, bacteriological or histological examination not done
  • 2, bacteriological or histological examination unknown (at present)
  • 3, tubercle bacilli found (in sputum) by microscopy
  • 4, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture
  • 5, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically
  • 6, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals)

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A little heat, please!

IciclesEvery have one of those days when you feel like you’ll never be warm? I’m having one of those. One of the downsides to have a window cube is the cold seeps in with the sunshine. Or with the dreary gray day.

Why am I so cold? Maybe I am hypothermic. Hypothermia is a medical emergency that occurs when your body loses heat faster than it can produce it, causing a dangerously low body temperature. Okay, maybe not. Out of curiosity, how would we code hypothermia in ICD-10-CM?

Well, we need to know the age of the patient. ICD-10-CM includes a series of codes for hypothermia in a newborn (P80.-). For adult patients, we need to know the cause of the hypothermia:

  • Hypothermia due to illness (R68.0)
  • Hypothermia, not associated with low environmental temperature (R68.0)
  • Hypothermia NOS (accidental) (T68)
  • Hypothermia due to anesthesia (T88.51)
  • Hypothermia due to low environmental temperature (T68)

If I were in fact hypothermic, it would be because it’s cold out, so T68.XXXA for an initial encounter. Notice you need three placeholder Xs for this code so your seventh character for the encounter is in the seventh position.

Under T68, we also find a note to use an additional code to identify the source of exposure:

  • Exposure to excessive cold of man-made origin (W93)
  • Exposure to excessive cold of natural origin (X31)

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Bundle up

Oh, the joys of being an 8-year-old with a snow day. Joey spent the weekend playing in his newly built snow fort without a hat, scarf, or pair of sunglasses. Now he’s complaining of hot, tender, itchy areas on his cheeks and forehead. Also, his lips and eyelids are really red.

IciclesDr. Frosty examines Joey and diagnoses chilblains and sunburn. That seems like a very odd combination, but is actually not unheard of.

Exposed skin can get sunburned even when the temperatures are below freezing. Apparently the sun doesn’t care how warm out it is. Sunlight reflects off the snow and ice and, as everyone who lives in snowy areas knows, it always finds the unprotected areas.

Sunburn is pretty easy to code in ICD-10-CM. All we need to know is what degree the sunburn is. That’s it. No location, no laterality, no episode of care.

Dr. Frosty documents a first-degree sunburn, so we would report L55.0 (sunburn of first degree).

On to those chilblains. Don’t know the difference between chilblains and frostbite? The big difference is whether the tissue freezes. If it does, the patient likely ends up with frostbite. Frostbite can be superficial or with tissue necrosis.

Chilblains are the painful inflammation of small blood vessels in your skin that occur when you suddenly warm up after being in cold temperatures.

Chilblains usually clear up in one to three weeks, but may reoccur.

This is another easy condition to code in ICD-10-CM. We only have one choice: T69.1.

Hopefully, Joey has learned his lesson and will now listen to his mom when she tells him to bundle up.

Jack Frost is on the prowl

Well, it’s not quite the polar vortex of 2014, but it’s definitely polar bear weather out there. As in, polar bears are the only ones who appreciate this kind of cold.

polar bearWe’re starting to see some casualties of the cold here at the Fix ‘Em Up Clinic, but thankfully, no one appears in imminent danger of death.

Most of our patients spent too long in the cold with inadequate protection and, as a result, developed frostbite. You don’t necessarily need to spend an extended period of time outdoors to develop frostbite. It can happen in 30 minutes when the wind chill is below 0°F.

In ICD-9-CM, we have four total codes for frostbite, depending on the location (face, hand, foot, and other and unspecified sites).

ICD-10-CM divides frostbite into two categories: superficial frostbite and frostbite with tissue necrosis. Each category is further divided by specific site (and we have a lot more than four sites).

If we have a patient with superficial frostbite of the hand, we would need to know which hand, whether any fingers were involved, and whether the wrist is involved. We also need a seventh character to denote the encounter.

You’ll find one Excludes2 note under Frostbite (code categories T33-T34):

  • Excludes2: hypothermia and other effects of reduced temperature (T68, T69.-)

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Volunteer for second end-to-end testing week

news blocksReady to test your ICD-10 systems with CMS? The agency is currently accepting applications for its second end-to-end ICD-10 testing week, scheduled for April 26-May 1.

Each MAC (and Common Electronic Data Interchange with assistance from DME MACs) will randomly select 50 submitters from each jurisdiction to participate in the end-to-end testing. The Railroad Retirement Board contractor will randomly select 50 additional submitters.

CMS hopes to include a broad cross-section of providers in its end-to-end testing weeks. During end-to-end testing, participants will be able to submit ICD-10 claims and receive Remittance Advice that explains the adjudication of the claims.

The agency will conduct its first round of end-to-end testing January 26-30 with the third round scheduled for July 20-24.

Each MAC will post forms for volunteers on its website. Selected participants will be notified in February.

CMS is also conducting ongoing acknowledgement testing. Providers can submit claims for acknowledgement testing at any time until October 1, 2015. CMS is also scheduling a new round of acknowledgement testing weeks with expanded MAC help desk line hours. The first acknowledgement testing week was held in March 2014, with a second in November 2014. The next week of testing is planned for March2015 with a final week scheduled for June.

During acknowledgement testing, MACs will not adjudicate claims, but will return an acknowledgment to the submitter (a 277A or a 999) that confirms whether the submitted test claims were accepted or rejected.

For more information, visit your MAC website or view MLN Matters® SE1409.

So long, 2014!

2014 to 2015We’ve come to the end of another year filled with ICD-10 in the spotlight, for good and bad reasons.

First the bad—we’re still waiting to implement ICD-10. We thought we were all set for October 1, 2014. CMS was standing firm. Healthcare organizations were preparing. And then Congress intervened.

At the end of March, the House and Senate passed the Sustainable Growth Rate (SGR) patch bill that included at least a one-year delay in ICD-10 implementation. President Obama signed the bill into law April 1. Sadly, it wasn’t a joke.

So we’re left with more training costs, more time to worry, and no guarantee 2015 will be the year.

That doubt comes in part because the AMA has continued to beat its “kill ICD-10” drum. According to the AMA, ICD-10 is evil (literally—they claim ICD-10 would serve Darth Vader). The AMA also complained about the cost of implementing ICD-10 again (without noting how much each delay has added to those costs).

AHIMA and 3M offered a rebuttal in the Journal of AHIMA. A group of 3M analysts published a study claiming the costs of ICD-10 implementation are nowhere near what Nachimson Advisors (who were paid by AMA, incidentally) claimed. Nachimson decried the 3M study as flawed, leaving everyone to believe whatever suited their purposes.

The mainstream media (and the AMA) continue to focus on the wrong things in the ICD-10 discussion—namely external cause codes. In the past, they harped on the bitten by duck codes. 2014 was the year of sucked into a jet engine, subsequent encounter. None of them seem to understand the concept of subsequent encounter. It’s not the second time you were sucked into a jet engine (or broke your left index finger). It’s follow-up treatment.

Maybe if physicians took the time to understand ICD-10 they might not be so staunchly opposed. Then again, the AMA represents less than one-third of physicians, so I’m not sure what most physicians think. We just know what the AMA wants us to think they think.

Now for the good news. Yes, we do have good news. One, the ICD-10 date is still standing at October 1, 2015, despite an AMA push over the last couple months for another two-year delay. Congress decided not to include another delay in the massive spending bill it passed earlier this month.

We’re unlikely to see any standalone bill kill ICD-10, even though Republicans in Congress are expected to reintroduce their Cutting Costly Codes bills which previously died in committee. However, we’re not out of the woods yet. Congress could still decide to add a delay into the SGR patch (or permanent fix) next year.

But the pro-ICD-10 crowd seems to have found our voice. AHIMA has been at the forefront of social media and grassroots campaigns to support ICD-10. I don’t know if they are making a difference, but at least we’re getting our side of the story out. AMA’s narrative that ICD-10 won’t improve patient care and will bankrupt physicians has stronger competition than ever.

Even with the latest delay, many organizations continued to train on ICD-10 and dual code, just at a slower pace. That’s better than the near complete stop we had when the previous delay was announced in 2012.

We have a lot of work to do in 2015 (and beyond—implementation problems won’t end when we flip the switch). But we should look forward with optimism and do our best to spread the word about the value of ICD-10.

I’m done with Christmas

On the 12th day of Christmas my true love gave to me 12 drummers drumming and the noise is unbelievable. I’ve got a migraine.

I didn’t see any lights or odd visual disturbances beforehand, so this is a migraine without aura. And that makes the coding pretty simple. Migraines with aura have a lot more choices.12 drummers

For a migraine without aura, we need to know whether it is intractable or not intractable. Intractable means it doesn’t respond to treatment. We’re way too early in the process to know that, so for now, we’ll call it not intractable and see how the medication works.

The other piece of information we need to know is whether the patient is status migrainosus, meaning the migraine has lasted for at least 72 hours. I’m on hour two, so no status migrainosus. That gives us G43.009 (migraine without aura, not intractable, without status migrainosus).

Unfortunately, that’s not our only medical issue in the house today. Several of our drummers have developed carpal tunnel syndrome. This is another easily coded malady. We just need to know laterality to choose from:

  • G56.00, carpal tunnel syndrome, unspecified upper limb
  • G56.01, carpal tunnel syndrome, right upper limb
  • G56.02, carpal tunnel syndrome, left upper limb

How would we code the carpal tunnel surgery in ICD-10-PCS? Granted, most people have this procedure on an outpatient basis, but someone may opt to have this done during a hospital stay for another procedure.

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Two front teeth

11 pipers pipingOn the 11th day of Christmas my true love gave to me 11 pipers piping.

You know that saying about being careful what you wish for? It’s very true. I jokingly told my true love we needed musicians for all of these dancers, and voilà, today we have pipers. Unfortunately, they are very bad pipers. On the bright side, though, the noise from all of the birds currently residing here kind of drowns them out.

Apparently, the birds aren’t fond of the pipers and have been doing everything in their power to disrupt the concert. We’ve got geese weaving between legs, calling birds dive bombing, and hens pecking at feet.

The pipers apparently have had enough and are taking a break. Thank heaven.

Or not. Nick, John, and Steve have appropriated three of the pipes and are using them like lightsabers to see who can claim the title of Jedi Master. Nick just whacked John in the mouth, knocking out his two front teeth.

If you look up Loss, teeth in the ICD-10-CM Alphabetic Index, you are directed to see Absence, teeth, acquired.

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