Don’t look now, but the vampires are massing

So we’ve survived the zombie apocalypse, but  we’re not out of the undead woods yet. It seems a group of vampires is trying to one-up the zombies. But, never fear, vampires can actually be regular people suffering from codeable medical illnesses, just like the zombies.

Have you noticed how pale vampires are, especially Robert Pattinson in the ‘Twilight’ movies? Turns out, they could be suffering from anemia. We need a lot more information in order to code anemia in ICD-10-CM.

First of all, what type of anemia is it? ICD-10-CM includes three major categories:

• D50-D53, nutritional anemias
• D55-D59, hemolytic anemias, which involve the premature destruction of red blood cells
• D60-D64, aplastic and other anemias and other bone marrow failure syndromes

So we need to narrow down what type of anemia our vampire has before we can even determine which series of codes to use. Keep in mind that each series of codes includes numerous subcategories that require specific documentation.

For example, if our vampire suffers from hemolytic anemia, we need to know the cause. Is it a hereditary condition or an acquired one? Is it due to an enzyme disorder and if so, which one? Maybe our vampire suffers from thalassemia, in which the body makes an abnormal form of hemoglobin. If it’s thalassemia, we need to know which specific form:

• Alpha
• Beta
• Delta-beta
• Thalassemia minor
• Hereditary persistence of fetal hemoglobin
• Hemoglobin E-beta

Some form of anemia probably accounts for our vampire’s pale complexion, but what about that whole “burst into flames in sunlight” thing?

It’s not as far out as you might think. Our vampire may suffer from porphyria, conditions that can affect the skin and nervous system. People with porphyria have a deficiency in one of the eight enzymes responsible for producing the chemical reactions necessary to produce heme. Of the eight different types of porphyria, four can sometimes cause sensitivity to light, but won’t cause the sufferer to spontaneously combust:

• Erythropoietic protoporphyria or protoporphyria (ICD-10-CM code E80.0)
• Congenital erythropoietic porphyria  (E80.0)
• Porphyria cutanea tarda (E80.1)
• Variegate porphyria, a form of acute intermittent (hepatic) porphyria (E80.21)

Perhaps our vampire suffers from a more common condition, known as polymorphous light eruption, which is characterized by the formation of bumpy and itchy rashes on sun-exposed skin. The symptoms are similar to a sunburn, and you’ll find the ICD-10-CM code (L56.4) in the radiation-related disorders of the skin and subcutaneous tissue series, like sunburn.

For our inpatient coders, ICD-10-CM L56.4 is part of MS-DRG:

• 606 Minor skin disorders with MCC
• 607 Minor skin disorders without MCC

If you’ve ever seen the really old vampire movies (or even just some of the clips), the vampire is often portrayed as being stiff as a board when he rises from his coffin. He also sleeps with his eyes open. And really, if someone was trying to put a stake through your heart, you’d probably sleep with your eyes open too.

However, our vampire may be suffering from an actual medical condition, not just a concern for personal safety. Catalepsy is a nervous condition characterized by muscular rigidity and fixity of posture regardless of external stimuli, as well as decreased sensitivity to pain. A person suffering from catalepsy can see and hear but cannot move. Their breathing, pulse, and other regulatory functions are so slow that the person appears to be  dead.  That explains the rising from the dead without being a zombie.  We have two codes to choose from for catalepsy:

• F20.2, catatonic schizophrenia
• F44.2, catalepsy(hysterical)

Alternately, our vampire may just be hypnotized and wearing stage makeup. In that case, we can put away the garlic and go back to watching Twilight: Breaking Dawn or better yet, The Lost Boys.

It’s never sarcoidosis

Gregory House, MD, is hanging up his stethoscope before the transition to ICD-10-CM. I loved House MD  when Fox first starting airing it in 2005, but the last few seasons, not so much.

Let’s ask Dr. House and his merry band of diagnosticians to treat one more patient and see how we would code for that diagnosis in ICD-10-CM.

First of all, the team’s diagnosis of choice at the start is often sarcoidosis (and itnever turned out to be sarcoidosis by the end of the show). For a change, let’s say Dr. House et al actually identified the correct diagnosis at first guess. The first thing we need to know is where is it—lungs, lymph nodes, skin, or maybe somewhere else. The “somewhere else” is where we get lots of choices:

• D86.81, sarcoid meningitis
• D86.82, multiple cranial nerve palsies in sarcoidosis
• D86.83, sarcoid iridocyclitis
• D86.84, sarcoid pyelonephritis
• D86.85, sarcoid myocarditis
• D86.86, sarcoid arthropathy
• D86.87, sarcoid myositis
• D86.89, sarcoidosis of other sites

Okay, it’s really not sarcoidosis, so let’s consider some other possibilities. Perhaps the team mixed up its S diseases and the patient really has scleroderma. Scleroderma by itself doesn’t give us all the information we need to code. In ICD-10-CM, we can choose from two codes (provided Dr. House documents enough information):

• L94.0, localized scleroderma [morphea]
• L94.1, linear scleroderma

Maybe our patient suffers from a systemic connective tissue disorder. An Excludes1 note under Category L94- (other localized connective tissue disorders) directs coders to codes M30-M36. Remember that Excludes1 notes mean “not coded here”. So if Dr. House concludes that the patient actually has lupus, we would look to series M32 (systemic lupus erythematosus).

As you probably guessed, lupus alone isn’t enough to select a code. Even systemic lupus erythematosus doesn’t provide all the detail we need. Although ICD-10-CM does contain an unspecified code, we really should query Dr. House for more information. Is the systemic lupus erythematosus drug-induced? Are systems or organs involved? The answers to those questions will drive code selection. Our choices for systemic lupus erythematosus with organ or system involvement include:

• M32.10, systemic lupus erythematosus, organ or system involvement unspecified
• M32.11, endocarditis in systemic lupus erythematosus
• M32.12, pericarditis in systemic lupus erythematosus
• M32.13, lung involvement in systemic lupus erythematosus
• M32.14, glomerular disease in systemic lupus erythematosus
• M32.15, tubulo-interstitial nephropathy in systemic lupus erythematosus
• M32.19, other organ or system involvement in systemic lupus erythematosus

If we stick with our autoimmune theme, maybe our patient suffers from vasculitis. That’s always popular with Dr. House as a rule out diagnosis. Vasculitis is the name for several diseases that cause an inflammation of the walls of blood vessels, so we need a lot more information from Dr. House and his team.

Unfortunately for our patient, Dr. House documents Churg-Strauss vasculitis, which doesn’t have a cure. Fortunately for us, we only have one possible code: M30.1 (polyarteritis with lung involvement).

If the patient suffered from rheumatoid vasculitis with rheumatoid arthritis (M05.2-) we would need to know where the vasculitis is located:

• M05.21, rheumatoid vasculitis with rheumatoid arthritis of shoulder
• M05.22, rheumatoid vasculitis with rheumatoid arthritis of elbow
• M05.23, rheumatoid vasculitis with rheumatoid arthritis of wrist
• M05.24, rheumatoid vasculitis with rheumatoid arthritis of hand
• M05.25, rheumatoid vasculitis with rheumatoid arthritis of hip
• M05.26, rheumatoid vasculitis with rheumatoid arthritis of knee
• M05.27, rheumatoid vasculitis with rheumatoid arthritis of ankle and foot
• M05.29, rheumatoid vasculitis with rheumatoid arthritis of multiple sites

With the exception of M05.29, we need to report a sixth character to indicate laterality (right, left, bilateral, unspecified) for these codes.

Maybe it isn’t autoimmune after all. What else could Dr. House pull out of his bag of dangerous diagnoses? How about some exotic disease, like leishmaniasis? I’m not sure how a Jersey housewife gets bitten by a sand flea, but stranger things have happened.

It turns out we have multiple choices even for leishmaniasis:

• B55.0, visceral leishmaniasis
• B55.1, cutaneous leishmaniasis
• B55.2, mucocutaneous leishmaniasis
• B55.9, leishmaniasis, unspecified

Maybe it was just a regular flea that bit the patient and she actually suffers from tularemia. In that case, we need enough documentation to choose from these codes:

• A21.0, ulceroglandular tularemia
• A21.1, oculoglandular tularemia
• A21.2, pulmonary tularemia
• A21.3, gastrointestinal tularemia
• A21.7, generalized tularemia
• A21.8, other forms of tularemia
• A21.9, tularemia, unspecified

Perhaps it’s actually schistosomiasis, another disease that often shows up in the differential at Princeton Plainsboro. If it actually is schistosomiasis, we would choose from these codes:

• B65.0, Schistosomiasis due to Schistosoma haematobium [urinary schistosomiasis]
• B65.1, Schistosomiasis due to Schistosoma mansoni [intestinal schistosomiasis]
• B65.2, Schistosomiasis due to Schistosoma japonicum
• B65.3, Cercarial dermatitis
• B65.8, Other schistosomiasis
• B65.9, Schistosomiasis, unspecified

Well, we’re down to the last commercial break and our patient still doesn’t have a definitive diagnosis. Things aren’t looking good, until Dr. House comes up with a brilliant deduction just in time to save the patient. She’s actually suffering from West Nile virus (those pesky mosquitoes!).

Again we need additional documentation  so we can code the correct form of West Nile virus:

• A92.30, West Nile virus infection, unspecified
• A92.31, West Nile virus infection with encephalitis
• A92.32, West Nile virus infection with other neurologic manifestation
  • Use additional code to specify the neurologic manifestation
  • A92.39, West Nile virus infection with other complications
    • Use additional code to specify the other conditions

Notice that two of the codes include notes to use additional codes to specify the neurologic manifestation or other conditions. Make sure you don’t forget those codes.

And with that brilliant, last-minute save, Dr. House hangs up his stethoscope, fires up his motorcycle, and heads off into the sunset.

Is the sign or symptom integral to the disease?

Coders often report signs and symptoms when physicians document them in the patient’s medical record. However, coders should not always report additional codes for signs and symptoms. How can coders make this determination?

Refer to the ICD-10-CM Official Guidelines for Coding and Reporting. The guidelines instruct coders not to report signs and symptoms routinely associated with a disease process, unless otherwise instructed by the classification.

Coders should report additional signs and symptoms that may not be routinely associated with a disease process when present, and of course, documented.

For example, a physician may document that a patient suffered from nausea and vomiting. Does this necessitate code assignment?  Unfortunately for coders, the answer is sometimes yes, sometimes no. If a physician diagnoses a patient with allergic and dietetic gastroenteritis and colitis (ICD-10-CM code K52.2), coders shouldn’t report a code for nausea and vomiting. These symptoms are integral parts of the disease.

Consider what happens if a physician diagnoses a patient with irritable bowel syndrome without diarrhea (ICD-10-CM code K58.9) and documents nausea and vomiting. In this case, coders should report nausea and vomiting with the appropriate code from the R11- series. Nausea and vomiting are not common symptoms of irritable bowel syndrome.

ICD-10-CM coding conventions for etiology and manifestations

Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. ICD-10-CM coding conventions for such conditions require coders to report the underlying condition first followed by the manifestation.

Wherever such a combination exists, coders will notice a “use additional code” note for the etiology code, and a “code first” note for the manifestation code. These instructional notes indicate the proper sequencing order of the codes, which is etiology followed by manifestation.

Manifestation code titles generally will include “in diseases classified elsewhere.” The following example includes a code title that is indicative of  a manifestation code.

E35, disorders of endocrine glands in diseases classified elsewhere

Code first underlying disease, such as:

late congenital syphilis of thymus gland [Dubois disease] (A50.5)

tuberculous calcification of adrenal gland (B90.8)

Coders may not report  “in diseases classified elsewhere” codes as first-listed or principal diagnosis codes. Coders may report them only in conjunction with an underlying condition code and must always sequence them after the underlying condition.

Some manifestation code titles don’t include “in diseases classified elsewhere.”  However, these codes include a “use additional code” note and they are subject to the same sequencing rules.

For example, ICD-10-CM code A48.52 (wound botulism) does not include “in diseases classified elsewhere,” but a note instructs coders to “use additional code for associated wound”.

These conditions also have a specific Alphabetic Index entry structure. The ICD-10-CM Alphabetic Index lists both codes together with etiology codes first followed by manifestation codes in brackets. Coders must always report etiology codes first.

“Code first” and “Use additional code” notes also serve as sequencing rules in the classification of certain codes that are not part of an etiology/ manifestation combination.

ICD-10-PCS root operations: Dilation

When a physician performs a procedure to enlarge the diameter of a tubular body part or orifice, coders will report root operation dilation with 7 as the third character in the medical and surgical section of ICD-10-PCS. The orifice can be natural or artificially created.

Coders will report dilation when a physician uses either intraluminal or extraluminal methods of enlarging the diameter. Percutaneous transluminal angioplasty, pyloromyotomy, and cystoscopy are among the procedures reported as dilation.

A device placed to maintain the new diameter is an integral part of the dilation procedure. Coders will report the device with the appropriate sixth-character device value in the dilation procedure code.

Other examples of dilation procedures include:

• 0F798ZZ, endoscopic retrograde cholangiopancreatography with balloon dilation of common bile duct
• 0D717ZZ, dilation of upper esophageal stricture, direct visualization, with bougie sound
• 087Y7DZ, transnasal dilation and stent placement in left lacrimal duct
• 047D04Z, dilation of left common iliac artery with drug-eluting intraluminal device, open approach

The dangers of do-it-yourself

Home repair and improvement can be hazardous to your health. Just ask the residents of Calamity Condos who are visiting the Fix ‘Em Up Clinic.

Tom and Wendy decided to repaint the living room of their condo. When it came time to paint the ceiling, Wendy picked up Hawkeye the cat to make things safer for Tom on the ladder. Alas, Tom leaned too far back on the ladder, overbalanced, and crashed to the floor. The thump scared Hawkeye, who clawed his way out of Wendy’s grip and headed off for parts unknown (and presumably quieter).

Dr. Crusher notes that she is seeing Tom for the first time for injuries suffered during the fall from the ladder. She documents Tom sustained a concussion, lower back contusion, and sprained wrist in the fall.

So how do we code Tom’s injuries? First we need to know if he lost consciousness when he fell and if so, for how long. ICD-10-CM includes 10 codes for concussions, from no loss of consciousness to loss of consciousness of any duration, with death due to other cause prior to regaining consciousness.

We don’t see any documentation of loss of consciousness in Dr. Crusher’s note, but we send a query just to make sure that means Tom didn’t lose consciousness. Dr. Crusher confirms he did not, so we would report S06.0X0A (concussion without loss of consciousness).

For Tom’s contusion of the lower back, we would report S30.0XXA. Note that we need two placeholders in this code because we need a seventh character to denote the encounter type.

That brings us to Tom’s sprained wrist. Sprained wrist is not going to cut it as far as coding goes. We need to know which wrist and which joint Tom sprained.  When we look through Dr. Crusher’s notes, we find documentation stating a sprain of the left radiocarpal joint, which leads to code S63.522A.

And let’s not forget the code for falling from the ladder. In ICD-9-CM, we would look for an E code, but in ICD-10-CM, we head to Chapter 20, External causes of morbidity (V00-Y99). Tom’s tumble from the ladder leads us to code W11 (fall on or from ladder). The category doesn’t include any additional subcodes, but it does include a note to add the appropriate seventh character. Since Dr. Crusher is treating Tom for the initial visit for the fall, we would report W11.XXXA.

What about poor Wendy? She ended up with lacerations in multiple locations as a result of Hawkeye’s getaway. We need to report each location that Dr. Crusher documented, which include the right upper arm and forearm, left forearm, right thumb, and right index finger. Hawkeye also bit Wendy’s right index finger in his bid for freedom. So we would code:

• S41.111A, laceration without foreign body of right upper arm
• S51.811A, laceration without foreign body of right forearm
• S51.812A, laceration without foreign body of left forearm
• S60.470A, other superficial bite of right index finger
• S61.011A, laceration without foreign body of right thumb without damage to nail
• S61.210A, laceration without foreign body of right index finger without damage to nail

If Hawkeye had scratched more fingers and Dr. Crusher had documented it, we would continue to add codes. Because Dr. Crusher documented lacerations to both the right and left forearms, we code for both. If she didn’t specify which arm was involved, we would query and if we weren’t able to get clarification, we would be forced to report the unspecified code S51.819 (laceration without foreign body of unspecified forearm).

That might not make much of a difference initially, but at some point, third-party payers may decide not to pay for unspecified laterality. And really, physicians should know where the specific injury is located. We just need to get them to write in down.

Here’s the other problem with that unspecified code. In our example, Wendy suffered lacerations to both arms and Dr. Crusher documented those injuries. As a result, we report two codes and should be reimbursed for both. Different sides of the body, different injuries. However, if we report the unspecified code, we’re missing out on half of the reimbursement because we’re only getting paid for the lacerations on one arm. Think about pointing that out to your physicians, in a polite way.

As we continue reading through Dr. Crusher’s notes, we find this notation: “Patient complains of nausea from paint fumes, no vomiting. Patient says smell of paint often makes her nauseous.” That means we need to check the Table of Drugs and Chemicals to find a code for poisoning by paint fumes.

In the Table of Drugs and Chemicals, under paint, we find five choices:

• Cleaner
• Fumes NEC
• Lead (fumes)
• Solvent NEC
• Stripper

Dr. Crusher documented that the paint fumes made Wendy sick. Clearly this is an accidental poisoning, so we would report T59.891 (toxic effect of other specified gases, fumes and vapors, accidental [unintentional]). We also report code R11.0 (nausea without vomiting).

Dr. Crusher is also seeing Roger, another resident of Calamity Condos. Two weeks ago, Roger cut off part of his left thumb with a table saw. Ouch. Today he’s back for a routine follow up for the partial traumatic metacarpophalangeal amputation of left thumb. Dr. Crusher documents the injury is healing well, so we would report S68.022D (partial traumatic metacarpophalangeal amputation of left thumb). Notice the seventh character in this case is D for a subsequent encounter. If Dr. Crusher had documented some type of adverse after effect, we would have used S for the seventh character for sequela.

Our final victim of the Calamity Condo fixing up, Steve, comes in with crushed toes. He dropped a sink on his foot while he was trying to lift it into place. Dr. Crusher documents crush injuries to the great toe and two of the lesser toes on Steve’s right foot. She also documents this is an initial visit.

• S97.111A, crushing injury of right great toe
• S97.121A, crushing injury of right lesser toe(s)

We would only report two codes, even though three toes are involved because S97.121A specifies toe or toes. So even if Steve crushed all four of the lesser toes, we would still only report one code.

We would also want to report the falling sink as the cause of Steve’s injuries, so we would also report W20.8XXA (other cause of strike by thrown, projected or falling object).

That appears to be our last do-it-yourself project injury. Just remember if you undertake any home repairs or improvements, watch out for falling objects, falling people, and easily startled felines.

Coding for the zombie invasion

Braaaaains!

Braaaaains!

Don’t look now, but the Centers for Disease Control and Prevention was right about the zombie apocalypse. It’s here! Run for your lives!

Okay, we’re not about to be overrun by brain-munching undead. But as it turns out, several diseases could turn you into a zombie, if you got them all at once. Really, what are the chances of that happening? Let’s look at the diseases and see how we would code them in ICD-10-CM. Then we’ll be prepared when the zombie do eventually attack.

First up is sleeping sickness. Odds are you won’t see these cases very often because it is more prevalent in Africa. Sleeping sickness is caused by the parasite Trypanosoma brucei and transmitted by the tsetse fly.

When we look up sleeping sickness in the ICD-10-CM alphabetic index, we’re directed to sickness, sleeping. Really? They couldn’t just include it under sleeping sickness? Oh well, it’s only one page away in the 2012 index. It turns out we have three choices for sleeping sickness:

• B56.0, Gambiense trypanosomiasis
  • Infection due to Trypanosoma brucei gambiense
  • West African sleeping sickness
• B56.1, Rhodesiense trypanosomiasis
  • East African sleeping sickness
  • Infection due to Trypanosoma brucei rhodesiense
• B56.9, African trypanosomiasis, unspecified
  • Sleeping sickness NOS

So we need to know where our patient was when bitten by the tsetse fly. Avoid the unspecified unless you have no choice.

Although no current medically recognized disease causes cannibalism, rabies could cause a zombie wannabe to seek out brains. Here again we need to know where our patient was when infected—an urban environment or a wooded one.

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

We also have some other choices under rabies when we look in the alphabetic index. The patient could have been exposed to rabies or come into contact with it, but not contracted it. In that case, we would report code Z20.3. Maybe our patient is trying to avoid becoming a zombie and received a rabies vaccine. That could lead to an inoculation reaction. The ICD-10-CM index directs us to complications, vaccination to find the code for the adverse reaction.

What about the rotting flesh look most zombies fashion? That can be explained by necrosis. Technically, it’s not a disease but a condition with a lot of different possible causes—cancer, poison, injury, and infection among them.

But just to be sure we’re prepared; we’ll consider this as a cause of zombie-itis. We need a lot of information in order to code necrosis. The codes for necrosis are spread throughout the ICD-10-CM manual, depending on where the condition occurs.

For example, if our zombie showed necrosis of the jaw, which would explain the gaping mouth, we would report M27.2. If the necrosis occurred in the cornea (hence the poor eyesight), we would code H18.40 (unspecified corneal degeneration).  Even though the code doesn’t require laterality, it’s a good idea for the physician to document it. After all, you never know when your zombie will return.

The physician also needs to document all of the sites where necrosis occurs so we can report all of them, internal and external.

What is causing our zombie’s shuffling gait? Could it be Hansen’s disease, aka leprosy? And yes, if you look up Hansen’s disease, the index directs you to leprosy, but if you look up leprosy, you’re in the right place. Assuming of course, the physician documents the type of leprosy our zombie contracted.

• A30.0, indeterminate leprosy
• A30.1, tuberculoid leprosy
• A30.2, borderline tuberculoid leprosy
• A30.3, borderline leprosy
• A30.4, borderline lepromatous leprosy
• A30.5, lepromatous leprosy
• A30.8, other forms of leprosy
• A30.9, leprosy, unspecified

Remember that other forms of leprosy and unspecified leprosy are two different things. If we code A30.8, we know what type of leprosy our zombie has, but ICD-10-CM doesn’t include a code for it. We would only report A30.9 if the physician didn’t document the type of leprosy and our query was unsuccessful.

Let’s move on to our final sign of zombie-itis, the noises emulating from our zombie, specifically those moans and grunts. Turns out our zombie could be suffering from dysarthria, which is a disorder affecting the motor controls of human speech.

Before we can code, we need to know what caused it. A complete medical history is a must. So is complete documentation. It doesn’t do us any good if the physician knows this information but doesn’t write it down.

Did our zombie suffer a nontraumatic intracerebral hemorrhage? If so, we would code I69.122. Maybe the dysarthria developed after a nontraumatic subarachnoid hemorrhage (I69.022), some other nontraumatic intracranial hemorrhage (I69.222), or possibly a cerebral infarction (I69.322).

So basically, as long as none of your patients come in with sleeping sickness, rabies, necrosis , leprosy, and dysarthria, you should be safe from zombies. But it wouldn’t hurt to put together one of the CDC’s zombie preparedness kits.

The clock strikes twelve…

…and the documentation coach will turn into a pumpkin if you’re not on time. As a CDI specialist, what has been your approach to ICD-10? Are you hoping it will go away? Are you waiting for 2014? Are you preparing now?

Although the official start date for ICD-10 CM and ICD-10 PCS is expected to move out to October 1, 2014, the start of fiscal year 2015, most hospitals should be, and are, preparing now. AHIMA has produced an ICD-10 checklist, with a detailed timeline and suggestions as to who should be involved at what stage of the process. CDI specialists aren’t specifically mentioned until the very end, as one group of the many users who will need ICD-10 education, but their role will be critical.

According to the timeline, you should have already looked at your physicians’ documentation to see if it will stand up to ICD-10 coding requirements, and should be developing and implementing strategies to address any weaknesses in that documentation. You can’t do that if you don’t know ICD-10. If you are not expert in anatomy and physiology (A&P), get refresher training now. While you are likely not coding the chart, you are ensuring that the documentation is sufficiently detailed to meet ICD-10 (especially PCS) coding requirements, and that means having expert understanding of A&P.

If your hospital hasn’t decided what changes to it needs to make in its electronic documentation processes, get involved. You are the experts on documentation requirements. It will be much easier to work the documentation requirements into the system before implementation than to try to retrofit a process into an existing system later.

You may think it is too early to learn about ICD-10, or that if you learn it now, you will forget it by the implementation date because you are still using ICD-9.  Think back to when you first learned the MS-DRG system and ICD-9-CM codes. How long did that take?  Aren’t you still learning? Don’t you have to give yourself time to become competent so that you can educate your doctors?

Consider this:  Everything you teach physicians about documentation for ICD-10 will improve their documentation under ICD-9. Your coders are not going to complain that you enabled the physician to be too accurate.  When you send a query, physicians generally doesn’t know or care about the coding rule or the classification system that triggered the query. They just know they have to answer to the level of detail you’re asking, so start sending questions that generate ICD-10 compliant answers. When you learn ICD-10, you can start guiding your physicians in the right direction, and the official transition in 2014 will be much less painful.

I liken the preparation for ICD-10 to that, a little more than a decade ago, for Y2K.  Some people feared disasters including nuclear holocaust, and when nothing happened on 1/1/2000, they were almost disappointed. In reality, the preparation had been impressively thorough and left nothing to chance. Although the world might not end if we aren’t ready for ICD-10, getting all the details covered before the official implementation date can make the actual conversion a burp instead of an explosion.

Training seminars, boot camps, and books abound. Take advantage of everything that’s offered, and ask for training if you haven’t received any. If you’re just starting to train, review CMS’s overview of ICD-10. The World Health Organization offers an ICD-10-CM online training tool that’s free and easy to use.

As a CDI consultant, I knew that at some point I would be required to provide ICD-10 documentation education to new CDI specialists. So I decided to pull out the ICD-10-CM official guidelines and actually compare them side by side with the ICD-9 CM guidelines . Not only did I learn about ICD-10-CM, but I refreshed my knowledge of ICD-9-CM.

Then I began putting together a presentation on ICD-10-PCS, and by working my way through the definitions and the rules, I educated myself. By the time I finished the PowerPoint, not only did I have a greater understanding of the complexity of the documentation requirements, but I was able to code a simple procedure. I was very proud of myself, too! Now, I didn’t become an ICD-10 expert that day, but by challenging myself to work with it, I found it much less frightening and mystifying.

Please don’t wait for education to come to you.  Please don’t wait for someone else to tell you what your CDI process should be.  Put the “special” in CDI specialist.

Editor’s note: We borrowed this post from our friends at the Association for Clinical Documentation Specialists and Linda Renee Brown, RN, CCRN, CCDS, MA. She is a clinical documentation improvement consultant with Jacobus Consulting, Inc. An RN since 1985, she has experience in critical care, nursing education, case management, and long-term care. She thinks the only thing better than writing for ACDIS is snuggling with her cat Thomas. Contact Renee at catladyrn@gmail.com.

It’s Monday at the Fix ‘Em Up Clinic

Happy Monday! I hope you had a great weekend because it’s time to dive into coding for today’s visitors to the Fix ‘Em Up Clinic.

Our first patient, nine-year-old Chris, arrived with a really nasty case of chicken pox. Dr. Killdare doesn’t document whether Chris suffered any complications with his chickenpox, so we need to query. Chris could suffer from encephalitis, myelitis, or encephalomyelitis along with his chickenpox (B01.1-) or he could have other complications (B01.8-). Fortunately for Chris, he avoided complications, so we would report code B01.9 (varicella without complication).

If you don’t know varicella is the official name of chickenpox, don’t worry. In the ICD-10-CM alphabetic index, under chickenpox, it says, see varicella.

Our next patient, Nancy, is back for a follow up visit with Dr. Killdare after fracturing her right ulna. When we look up her initial injury, we find that Dr. Killdare treated Nancy for a displaced fracture of olecranon process without intraarticular extension of right ulna (S52.021A) last month. In his documentation for today’s visit, Dr. Killdare notes Nancy’s fracture is not healing correctly.

So we still need to know whether it’s delayed healing, nonunion, or malunion. By reading further in Dr. Killdare’s note, we find documentation of malunion, so we would report S52.021P. That’s almost the exact same code we reported during Nancy’s initial visit. The only difference is the seventh character. For her first visit we used ‘A’ for initial, while this visit, we used ‘P’ for malunion.

If Dr. Killdare documented delayed healing, we would use ‘G’ for the seventh character. For a nonunion, we would use ‘K’ as the seventh character extension. Keep in mind the majority of the code—those first six characters—don’t change. Anytime Nancy comes in for treatment of that same fracture, we would code S52.021 with the appropriate seventh character.

Bill, an unlucky cave explorer, rounds out our Monday at Fix ‘Em Up.

A falling rock hit Bill in the back during a cave-in, leaving some nasty bruises. Bill also scrapped both palms. Dr. Killdare documented this as the first encounter. What should we report?

Let’s start with the bruised back. Where specifically are the bruises—shoulder, neck, lower back, or multiple sites? In his notes, Dr. Killdare documents multiple lower back contusions, which leads us to S30.0xxA (contusion of lower back and pelvis).

Moving on, we next look at Bill’s scrapped palms. Are they lacerated, bruised, abraded, or all of the above? Also, did Bill injure any of his fingers? In his notes, Dr. Killare specifies a lacerated right palm with rocks in the cut, code S61.421A, (laceration with foreign body of right hand) and abrasions to the left hand, code S60.512A (abrasion of left hand).

Dr. Killdare also documents that he found a tiny piece of rock in the cornea of Bill’s right eye, so we would add code T15.01xA (foreign body in cornea, right eye).

Don’t forget to add W20.0xxA (struck by falling object in cave-in).

That’s all for Monday at Fix ‘Em Up. Remember to watch out for those falling rocks!

ICD-10 root operations: Reposition

A surgeon performs an open reduction of right tibia fracture for an inpatient. Which ICD-10-PCS root operation should be reported?

In this case, it’s fairly easy: reposition. In a reposition procedure, the physician moves a body part to a new location, either its normal location or a new location to enhance its ability to function. Since the physician is putting the bone back where it belongs, we would code a reposition. For our right tibia open reduction, we would report code 0QSG0ZZ.

• 0DS64ZZ, laparoscopy with gastropexy for malrotation
• 0MSP4ZZ, left knee arthroscopy with reposition of anterior cruciate ligament
• 01S40ZZ, open transposition of ulnar nerve
• 0QS634Z, closed reduction with percutaneous internal fixation of right femoral neck fracture

Most of these codes denote laterality, the exception in this list being the ulnar nerve transposition. So make sure the physician documents which side he or she operated on. Also, be sure to read the entire operative report, not just the summary. Sometimes a physician may title a procedure as an open reduction, when in fact, the physician performed a closed reduction.