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We can rebuild his elbow

Ulnar collateral ligamentYou may recall that Steve’s super streak at the Vegas craps table ended with a torn right ulnar collateral ligament.

On the recommendation of his primary care physician, Steve consulted an orthopedic surgeon, Dr. Frank Jobe, who agreed that surgery was Steve’s best treatment option. Dr. Jobe is set to perform the surgery today at the Stitch ‘Em Up Hospital.

A side note before we go any further. Tommy John surgery is generally performed in the outpatient setting. It generally takes 60 to 90 minutes to complete. A patient who needs Tommy John surgery probably doesn’t meet the criteria for inpatient admission. Because the Stitch ‘Em Up Hospital likes to compare data between inpatient and outpatient procedures, our coders code all surgeries using ICD-10-PCS. We’re overachievers that way.

On to Steve’s procedure. Well, actually, let’s take a look at Steve’s diagnosis code for this visit. We need to show the medical necessity of the procedure before our payer will reimburse us.

Dr. Jobe documents a traumatic rupture of the right ulnar collateral ligament. When we look up Rupture, traumatic, ligament, ulnar collateral in the ICD-10-CM Alphabetic Index, we are directed to S53.3-. Further investigation in the Tabular List leads us to S53.31XA.

We’re back to seventh character A because on this visit, Steve is receiving active treatment. Surgery is one of the examples the ICD-10-CM Official Guidelines for Coding and Reporting cite as active treatment. If Dr. Jobe was just evaluating Steve’s elbow and not treating it, our seventh character would be D for subsequent encounter. In fact, the guidelines state:

While the patient may be seen by a new or different provider over the course of treatment for an injury, 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. [more]

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Good news on implementation

news blocksI spent the weekend reading the 2016 Inpatient Prospective Payment System (IPPS) proposed rule. Not the most thrilling reading ever (government-ese should be classified as a foreign language). I did not read all 1,526 page word for word, in part because of the number of tables included in the proposed rule. Those tables offer a pretty strong indication that CMS believes ICD-10 will be implemented this October.

In the IPPS proposed rule, CMS discusses requests for changes to MS-DGRs. What makes the discussion interesting this year is CMS refers mainly to ICD-10-CM and ICD-10-PCS codes. Last year, CMS used ICD-9-CM codes. (If you are interested, the discussion of requested MS-DRG changes begins on page 143.)

If CMS is going through the trouble of justifying why it is not (or in a few cases is) changing MS-DRG assignment based on ICD-10 codes, the agency must feel pretty confident about implementation this year. Otherwise, the staff would have used ICD-9-CM codes.

So that’s the good news. The bad news is we’re down to 163 days until implementation.

Unlucky roll of the dice

Purple diceLast week, Steve spent some serious time at the craps table in Las Vegas. He was on a real roll with those dice, racking up a 14-hour winning streak. However, on that last throw, something went very wrong. Steve flicked the dice with his patented curveball throw and felt something pop in his elbow. He suffered excruciating pain and could not throw the dice again.

So much for that winning streak. Steve went to a Las Vegas ED, where Dr. Siegfried diagnosed a torn right ulnar collateral ligament. There goes Steve’s pitching career.

When we look up torn in the ICD-10-CM Alphabetic Index, we are directed to see Tear. Okay, let’s go to Tear, ligament. And we’re sent elsewhere again, this time to Sprain. We’ve got it this time—Sprain, ulna, collateral ligament. But no, success eludes us once again. We need to see Rupture, traumatic, ligament, ulnar collateral.

I think I’m spending more time looking for this code than Dr. Siegfried spent examining Steve. Under Rupture, traumatic, ligament, ulnar collateral, we find, S53.3-. The dash tells us we need more characters, so off to the Tabular List we go.

We need two pieces of information to complete our code: laterality and encounter. We know Steve tore his right ulnar collateral ligament and we know this is his first visit. That makes our code S53.31XA (traumatic rupture of right ulnar collateral ligament, initial encounter). Don’t forget your placeholder X.


Good news from Congress

news blocksThe endless last-minute patches for the Sustainable Growth Rate (SGR) are almost history. Late last night, the Senate overwhelmingly passed H.R. 2, which repeals the SGR. The House overwhelmingly passed the bill two weeks ago. President Obama plans to sign it.

That’s great news for physicians and for the industry as a whole. We won’t be faced with 11th hour deal each year to patch the SGR. Those patch bills lead to all sorts of sneaky amendments being passed as well. Last year, the ICD-10 delay was included in the patch bill.

The final SGR fix did not include any mention of ICD-10 or another delay. So it’s looking more and more like October 1, 2015 will be THE day.

Thunderclap coming for ICD-10

CMS is asking for some social media help in support of ICD-10. The agency is planning a social media rally to encourage the healthcare community to get ready for the ICD-10 transition.dont miss it

You can sign up to take part in the Thunderclap on the CMS website and sign in with your Facebook, Twitter, or Tumblr account.

A message will be automatically released from participants’ selected accounts at 9 a.m. (Eastern) Thursday. The result will be a “thunderclap” of simultaneous Twitter, Facebook, and Tumblr posts about ICD-10 that will reverberate across social media.

Dangers lurk in your sleep

monter under bedI’m always fascinated by new medical research and information about diseases I’ve never heard of. They also make great fodder for this blog.

I recently came across an article on REM sleep behavior disorder (RBD) and its link to later neurological diseases. If you suffer from RBD, you’re pretty much doomed to a disease like Parkinson’s if you live long enough. It’s also worth mentioning that if you live long enough, you’re almost assured of developing cataracts. Old age is not for wimps.

What is RBD? It’s basically moving around during REM sleep (that really, really deep sleep when you’re not supposed to be able to move). It’s not the same as sleepwalking.

Doctors think people with RBD have a brain-stem malfunction that allows them to move during REM sleep, and thus act out their dreams, according to a study published in JAMA Neurology.


Beware of infectious toddlers

crying babyFifteen-month-old Finn is back at the Fix ‘Em Up Clinic today to see Dr. Spock. Finn is currently suffering from a fever, reduced appetite, and sore throat, according to his mom Melissa. Finn just developed painful sores near his mouth and a skin rash with flat red spots on the palms of his hands and soles of his feet. Melissa is worried that Finn caught some horrible disease at daycare.

Dr. Spock examines Finn and diagnoses hand, foot, and mouth disease (HFMD). Although it is highly contagious, HFMD is not usually life-threatening. In fact, most patients get better in seven to 10 days without treatment. HFMD is most commonly caused by a coxsackievirus.

How would we code little Finn’s visit? If we look up “hand, foot, and mouth disease” in the Alphabetic Index, we find an entry for “hand-foot syndrome,” which sends us to L27.1 (localized skin eruption due to drugs and medicaments taken internally). Clearly that is the wrong condition because Dr. Spock didn’t document any drugs being ingested.

Let’s head back to the ICD-10-CM Alphabetic Index and try “Disease, diseased” as our main term. The index does contain an entry for hand, foot, and mouth—B08.4.

When we go to the Tabular List to double-check our code, we notice that the code description is “enteroviral vesicular stomatitis with exanthema.” Fortunately, underneath that, we see “hand, foot, and mouth disease.”


Another reason for better documentation

guy with question marks (2)As we continue to move closer to ICD-10 implementation (still set for October 1, 2015), I keep finding more reasons why we need better documentation. I am not trying to pick on physicians (really), but everything we do as coders depends on what the physician includes in the chart.

We know we can’t go back to a previous encounter and pick up details about a patient’s illness in ICD-9-CM. For example, the physician documents that a patient has Type 2 diabetes, is insulin-dependent, and suffers from peripheral neuropathy. On the next visit, the physician simply documents “diabetes.” We can’t look back at the previous note and add all of the additional detail.

The same will hold true in ICD-10-CM. No looking back in the record for information. We can only code what the physician documented for that particular encounter.

Why is that such a big deal in ICD-10-CM? Because of the increased specificity (obviously), but also because of the seventh character.

Codes in chapters 19 (Injury, Poisoning, and Certain Other Consequences of External Causes) and 20 (External Causes of Morbidity) use seventh characters to denote the encounter. In most cases, ICD-10-CM gives us three choices for that seventh character: [more]

Perils peeping up all day

Dogs and peepsRuth and Gary thought it would be great fun to give their nieces Amanda and Rachel some peeps for Easter. Amanda and Rachel thought they were getting marshmallow treats (so did their parents) so it came as something of a surprise when Ruth and Gary arrived with real, live baby chickens.

Being relatively young kids, Amanda and Rachel decided to embrace this twist and the peeps. Unfortunately, Amanda embraced some of the peeps a little too tightly and they pecked her hand repeatedly until they gained their freedom.

Amanda now has multiple puncture wounds on her hands. Those birds may be small, but their beaks are mighty.

To code Amanda’s injuries in ICD-10-CM, we need to know some additional information about those punctures.

Are they limited to the hand or hands? If fingers are involved, we need to report additional codes. The same goes for the wrists.

Which side is injured—left hand, right hand, or both? Each had has its own set of codes.

Did any part of the bird’s beak remain in the wound? ICD-10-CM includes different codes for wounds with foreign body and those without.

Is this an initial encounter, subsequent encounter, or visit for sequela?