RSSArchive for May, 2012

Too many codes? There’s no such thing

A writer paints a picture with words. The English language alone offers somewhere in the neighborhood of a quarter of a million words. But really how many does the average person use? According to Stephen Pinker’s book “The Language Instinct” the average American high-school graduate knows approximately 45,000 words. That’s  a pretty big disparity, but it makes sense.

How many people do you know who use antidisestablishmentarianism in regular conversation? By the way, antidisestablishmentarianism is the longest non-technical and non-coined word in the English language (watching Jeopardy! pays).

Some other odd words that you’ve probably never heard of include:

  • Erinaceous (like a hedgehog)
  • Lamprophony (loudness and clarity of voice)
  • Depone (to testify under oath)
  • Finnimbrun (a trinket or knick-knack)
  • Floccinaucinihilipilification (estimation that something is valueless)
  • Inaniloquent (pertaining to idle talk)

So what does this have to do with coding in general and ICD-10-CM coding in particular? A coder tells a story with codes. Like any good storyteller, you want that story to be as complete and accurate as possible. ICD-10-CM’s increased specificity will help you do that.

A lot of people get hung up on the huge increase in the number of codes. ICD-9-CM includes 14,567 diagnosis codes, while ICD-10-CM offers 69,833. Big, scary difference, right? Yes and no. You’ll have a lot more choices, but that doesn’t mean you’ll use them.

How often does a patient come in for a spacecraft fire injuring occupant (V95.44) or for being bitten by an orca (W56.21)? For that matter, how many cases of light chain deposition disease or variant Creutzfeldt-Jakob disease or Pallister-Killian mosaic syndrome do you see?

If you code for a specialty, you’ll generally use a small fraction of the available codes. Even if you code for several specialties, you still won’t use every code.

And a lot of the codes are just more detailed. They aren’t new conditions or new diseases. For example, look at the codes for serous detachment of retinal pigment epithelium. ICD-9-CM offers one code choice—362.42. So you’re coding this condition now. The difference is when you get to ICD-10-CM, you’ll have four choices:

H35.721, serous detachment of retinal pigment epithelium, right eye

H35.722, serous detachment of retinal pigment epithelium, left eye

H35.723, serous detachment of retinal pigment epithelium, bilateral

H35.729, serous detachment of retinal pigment epithelium, unspecified eye

The additional specificity could be an unexpected aid as well. Because many ICD-10-CM codes include laterality, you shouldn’t have to worry that a payer will reject a claim because of double billing if you can code two separate sites (index finger and middle finger) or different sides of the body (right arm and left arm).

Don’t get stuck on the number of new codes. You don’t need to memorize them and you won’t have to relearn how to code diagnoses from scratch. Probably 90-95% of the coding guidelines remain the same. It’s a big change and will certainly be a challenge, but don’t be afraid of the choices.

Beware of backyard barbeques

Summer semi-officially arrived this week with Memorial Day and that means plenty of sun and sand related illnesses at the Fix ‘Em Up Clinic.

Our first patient is Todd, who was trying to grill up the perfect Memorial Day feast in his backyard. Apparently he turned up the flame on the grill too high and burned not only the burgers, but himself as well. Ouch.

So how do we code Todd’s burns in ICD-10-CM? Burns and corrosions fall under series T20-T32. These codes include thermal burns caused by:

  • Electrical heating appliances
  • Electricity
  • Flame
  • Friction
  • Hot air and hot gases
  • Hot objects
  • Lightning
  • Radiation

Since we know Todd burned himself on a flame, we’re in the right starting place. Next we need to know where specifically did Todd burn himself and how serious the burns are. Dr. Scorcher documents first-degree burns of the right hand and forearm.

Notice that the description of codes for burns of the forearm specify that they do not include the hand or wrist. That tells us we’ll need at least two codes—one for the hand, one for the arm.

We also need to know whether Dr. Scorcher is seeing Todd for the first time (she is according to her notes). That leads us to code T22.111A (burn of first degree of right forearm). Separate codes identify burns to the elbow, shoulder, and maxilla, so make sure your physicians are documenting the exact location. If they aren’t, query, don’t assume or guess.

Moving on to Todd’s hand, we know we’re dealing with the right hand, first degree burns, and the initial encounter. That leads us to…more questions. We need to know exactly where Todd burned his hand. Palm, back of the hand, or multiple sites? Any fingers involved?

Dr. Scorcher didn’t include that information in her description of the injuries, but in her treatment plan, she instructs Todd to cover the burns on the back of his hand and his index and middle fingers with a sterile gauze bandage. And voilà, we have locations.

In our ICD-10-CM Manual, we find these codes:

  • T23.161A, burn of first degree of back of right hand
  • T23.131A, burn of first degree of multiple right fingers (nail), not including thumb

The codes for the burn to the forearm, hand, and fingers all include the following note: Use additional external cause code to identify the source, place and intent of the burn (X00-X19, X75-X77, X96-X98, Y92). So we know we’ll need some additional codes for Todd’s misadventure.

Our first stop is the X03 (exposure to controlled fire, not in building or structure) series of codes. We know Todd was outside when he burned himself, so we would not use a code from X02 (Exposure to controlled fire in building or structure).  Based on the information Todd gave Dr. Scorcher, we would report:

  • X03.0XXA, exposure to flames in controlled fire, not in building or structure
  • Y93.G2, activity, grilling and smoking food

We do not need any codes from X75-X77 (intentional self-harm) or X96-X98 (assault) because Todd’s injuries were caused by carelessness.

Todd’s cooking proved hazardous to other people’s health as well. His sister Mary, one of his guests, came in with food poisoning caused by undercooked chicken. Apparently Todd turned the flame down a little too much after burning himself.

Food poisoning comes in a lot of forms from a lot of bacteria, including campylobacter, salmonella, shigella, e. coli O157:H7, listeria, and botulism. In this case, we know Mary suffered from a salmonella infection, but we need to know if it’s salmonella enteritis, salmonella sepsis, or a localized salmonella infection. Dr. Scorcher documents salmonella enteritis, which leads us to ICD-10-CM code A02.0.

So much for the food-related mishaps at the Memorial Day cookout. Unfortunately, that doesn’t signal the end of the injuries for Todd’s guests. Several members of the younger crowd decided on a game of volleyball, which ended badly for Andrea and Clara. Andrea suffered a strained her back and ended up at Fix ‘Em Up.

When we look up strain in the ICD-10-CM Manual, we find code S39.012, strain of muscle, fascia and tendon of lower back. We need a seventh character to indicate the encounter in order to make the code valid. Dr. Scorcher documented this as Andrea’s first visit, so the complete code would be S39.012A.

We can also add Y93.68 (activity, volleyball [beach] [court]) to show what Andrea was doing when injured. In looking through Dr. Scorcher’s notes, we learn that the game was played in the backyard of Todd’s single-family house, so we can add Y92.017 (garden or yard in single-family [private] house as the place of occurrence of the external cause).

As a side note, when you look up strain in the ICD-10-CM index, you find some strains listed, but also notes directing you to look up injury, muscle, by site strain, for muscle and tendon strains. So looking up strain may not be your final stop in the index.

That leaves poor Clara. She wasn’t playing volleyball, but the game did her in anyway. She was struck by the volleyball and suffered a broken nose and a mild concussion. Again we need to know the encounter (documented as initial) and we also need to know if Clara lost consciousness (she didn’t).

We would report:

  • S02.2XXA fracture of nasal bones
  • S06.0X0A, concussion without loss of consciousness
  • W21.06XA, struck by volleyball
  • Y92.017, garden or yard in single-family (private) house as the place of occurrence of the external cause

And with that, I am ordering takeout and going inside to watch Frozen Planet. That should be safe, right?

ICD-10-PCS root operations: Restriction

When a physician performs a procedure intended to narrow the diameter of a tubular body part or orifice, coders will select the root operation restriction in ICD-10-PCS. Restriction includes both intraluminal or extraluminal methods for narrowing the diameter. The body part or orifice can be natural or artificially created.

When coding a restriction procedure, coders should report “V” as the third character in medical and surgical codes. Physicians may use these terms when documenting a restriction procedure:

  • Cerclage
  • Banding
  • Restriction
  • Clipping

Examples include esophagogastric fundoplication, banding of pulmonary artery, and clipping of cerebral aneurysm. Specific ICD-10-PCS codes for restriction procedures include:

  • 02VW3DJ, catheter-based temporary restriction of blood flow in descending aorta for treatment of cerebral ischemia
  • 08VX7DZ, non-incisional, trans-nasal placement of restrictive stent in right lacrimal duct
  • 07VK3DZ, restriction of thoracic duct with percutaneous  intraluminal stent
  • 0DV30CZ, restriction of lower esophagus with extraluminal device, open approach
  • 04VP3DZ, restriction of right anterior tibial artery with intraluminal device, percutaneous approach

ICD-10-PCS codes for restriction require documentation of the specific body part or orifice involved. That means physicians will need to be very clear in their documentation, noting laterality and detailed anatomic locations.

A wild time at the zoo

Our Town Zoo hosted its annual black tie fundraiser and things got a little, well, wild as the patients at the Fix ‘Em Up Clinic prove.

Tiffany made a fashion statement with a bright blue shimmering gown that drew plenty of positive comments. Unfortunately for her, she also drew the attention of the zoo’s free-roaming peahen. The peahen was not pleased to discover Tiffany was not a potential mate and decided to peck the dress to pieces.

Watch out for free-roaming peahens!

Dr. Doolittle documents a thigh laceration, finger laceration, and superficial bite of the hand. What do we need to know to code this encounter? First of all, we need to the specific locations of Tiffany’s wounds. Which thigh did the peahen injure? According to Dr. Doolittle’s notes, the right thigh.

Okay, so what about the finger laceration—which hand and which specific finger? Dr. Doolittle documented a laceration of a blood vessel of the index finger. He doesn’t state which side, so we’ll query for that information.

How about the superficial bite of the hand? Again we need to know which hand and Dr. Doolittle didn’t document that information either. So we’ll send another query.

Dr. Doolittle answers our query by stating “right index finger” and “right hand.”  We also need to know what episode of care we are dealing with—initial, subsequent, or sequel? Dr. Doolittle’s notes state Tiffany is seeking treatment for the first time. So we need to append a seventh character of A.

So we would code:

  • S71.111A, laceration without foreign body, right thigh
  • S65.510A, laceration of blood vessel of right index finger
  • S60.371A, other superficial bite of right thumb

We also need to code for the cause of injury, in Tiffany’s case, attack by a peahen. Peafowl do not have their own ICD-10-CM codes, so we need to default to “other birds.” That leads us to:

  • W61.91XA, bitten by other birds
  • W61.92XA, struck by other birds

And since the injuries occurred at the zoo, we would also add:

  • Y92.834, zoological garden (Zoo) as the place of occurrence of the external cause

Ben and Dom got into a slugfest while debating whether gibbons are apes or monkeys. Turns out, they’re apes.

Ben suffered a broken nose, two black eyes, and a broken hand. Ben apparently missed Dom and hit the wall of the gibbons’ exhibit. We need to check for laterality for the broken hand, as well as documentation of which specific bone Ben broke. We also need to know the encounter for all of Ben’s injuries. Dr. Doolittle documents a broken right hand and notes he is seeing Ben for initial treatment of his injuries. Unfortunately, we need more than just “right hand” for Ben’s fracture. So we query Dr. Doolittle and ask for information on which bone Ben broke. Dr. Doolittle documents fractures of the third and fourth metacarpal bones. That’s still not enough information. Are the fractures displaced or non-displaced? Did Ben break the shaft, neck, or base of the bones or more than one area? So we’ll send another query.

By this point, Dr. Doolittle is more than a little annoyed with us. He sends back a note stating: “Non-displaced fracture of shaft of third metacarpal and shaft of fourth metacarpal. Now go away!”

We would report:

  • S02.2XXA, fracture of nasal bones
  • S00.11XA, contusion of right eyelid and periocular area
  • S00.12XA, contusion of left eyelid and periocular area
  • S62.352A, nondisplaced fracture of shaft of third metacarpal bone, right hand
  • S62.354A, nondisplaced fracture of shaft of fourth metacarpal bone, right hand

We also need to add Y92.834 to show Ben suffered his injuries at the zoo.

So what about the fight? Should we code that as well? We certainly can, because ICD-10-CM includes a code for assault by unarmed brawl or fight (Y04.0XXA).

Moving on to the other fight participant, Dr. Doolittle documents Dom suffered contusions to his right hand and a displaced fracture of the right thumb, as well as a laceration to his lip with no foreign body.

As we read through Dr. Doolittle’s notes, we find out this is Dom’s first visit for these injuries, which tells us we’ll use seventh character A. Dr. Doolittle also noted: “Dislocated fracture, distal phalanx, right thumb confirmed by X-ray.” That gives us all of the information we need to code this encounter. We would report:

  • S62.521A, displaced fracture of distal phalanx of right thumb
  • S60.221A, contusion of right hand
  • S01.511A, laceration without foreign body of lip
  • Y92.834, zoological garden (Zoo) as the place of occurrence of the external cause
  • Y04.0XXA, assault by unarmed brawl or fight

Our final casualty from the zoo fundraiser is Blanche, who fell in front of the flamingo exhibit and suffered contusions to her knees and abrasions to her palms, not to mention ruining a lovely dress. Dr. Doolittle documents Blanche’s palm and knee injuries are bilateral and this is her first visit.

  • S80.01XA, contusion of right knee, initial encounter
  • S80.02XA, contusion of right knee, initial encounter
  • S60.511A, abrasion of right hand
  • S60.512A, abrasion of left hand
  • Y92.834, zoological garden (Zoo) as the place of occurrence of the external cause

We do need some additional information in order to code for Blanche’s fall. Did she strike an object when she fell (other than the ground)? Did she fall because she collided with someone else? Did her heel break and cause the fall?

Fortunately, Blanche offered a complete description of her accident and Dr. Doolittle dutifully documented it.  Blanche was trying to get a very close look at the flamingos, struck the glass of the enclosure, and fell. That leads us to W18.02XA (striking against glass with subsequent fall).

The next time you attend a fundraiser at the zoo, be sure to remain alert. It’s a jungle out there.

Multiple coding for a single condition

In ICD-10-CM, coders must report two codes to fully describe certain conditions.  They will find “Use additional code” notes in the Tabular List at codes when they need to report a secondary code to fully describe a condition. Report the “use additional code” as a secondary code.

For example, a patient comes in to the ED for a bacterial infection. Depending on the specific infection, coders may need to include a code from category B95 (Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere) or B96 (other bacterial agents as the cause of diseases classified elsewhere) to identify the bacterial organism causing the infection. Coders will normally find a “use additional code” note at the infectious disease code, indicating a need for the organism code to be added as a secondary code.

ICD-10-CM also includes “code first” notes under certain codes that are not specifically manifestation codes but may be caused by an underlying cause. When coders see a “code first” note and the physician documents the presence of an underlying condition, report the underlying condition first.

For example, the physician documents a major osseous defect of the lower right leg (M89.761). Under the heading “Major osseous defect” (M89.-) coders find a note that instructs them to code first underlying disease, if known, such as:

  • Aseptic necrosis of bone (M87.-)
  • Malignant neoplasm of bone (C40.-)
  • Osteolysis (M89.5)
  • Osteomyelitis (M86.-)
  • Osteonecrosis (M87.-)
  • Osteoporosis (M80.-, M81.-)
  • Periprosthetic osteolysis (T84.05-)

“Code, if applicable, any causal condition first” notes indicate that this code may be assigned as a principal diagnosis when the causal condition is unknown or not applicable. If the physician documents a causal condition, coders should report the code for that condition as the principal or first-listed diagnosis.

For example, a male patient suffers from nocturia caused by an enlarged prostate. The code for nocturia (R35.1) includes a note directing coders to first code any known causal condition, such as an enlarged prostate (N40.1).

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