RSSAuthor Archive for Michelle A. Leppert

Michelle A. Leppert

Michelle A. Leppert, CPC, is a senior managing editor for JustCoding provides coders, coding supervisors, and health information management (HIM) directors with educational resources to test their coding knowledge, employ correct coding guidelines, and stay abreast of CMS transmittals.

In addition, she writes and edits the HCPro publication, Briefings on Coding Compliance Strategies. Email her at

Watch your toes

Holly spent the weekend hanging out at the beach, enjoying the sun. The sand was so warm that she slipped off her shoes to stroll near the water. And disturbed a crab in the process. The crustacean, unhappy at being disturbed, clamped down on Holly’s right big toe, partially severing it and sending Holly to the Stitch ‘Em Up Hospital.

Crab madLet’s start with the diagnosis.

ICD-10-CM includes codes for complete and partial traumatic amputations. In Holly’s case, the crab didn’t get the whole toe, so it is a partial amputation. ICD-10-CM further divides toe amputations into the great toe, lesser toes, and more than one toe. And of course we have laterality.

Since this is Holly’s first visit for a traumatic partial amputation of the right great toe, we would report S98.121A.

Holly needs surgery to reattach her toe, so Dr. Shelley is preparing to put Holly back together, and we can build our ICD-10-PCS code at the same time.

First, we know we are in the Medical and Surgical section, which gives us a first character 0 (the number zero, not a capital O).

Our second character is the body system. In this case, we’re going with lower extremities, Y.

The third character is the root operation. Basically what is the surgeon trying to do? Dr. Shelley is putting Holly’s toe back where it belongs, which makes our root operation Reattachment (N).

Note that Reattachment is the root operation of choice whether the surgeon is putting all or a portion of a separated body part to its normal location or another suitable location.

We now have the first three characters of our code, 0YM, so we can go to the ICD-10-PCS table.

The table contains plenty of fourth character options for the body part. We know Dr. Shelley is reattaching Holly’s right great toe, so our fourth character is P (first toe, right). If Dr. Shelley reattached multiple toes, we would code each one separately because each has its own body part.

The rest of the code is a breeze because we only have one choice for each remaining character:

  • 0, open
  • Z, no device
  • Z, no qualifier

That gives us a final code of 0YMP0ZZ.

Holly did get the last laugh on her crustacean attacker. She ate the attacking crab for dinner.

A holiday explosion of injuries

A lot of people are starting their Fourth of July celebrations early. At least it seems that way at the Fix ‘Em Up Clinic.

Shannon took her dog Damian to the park to watch some fireworks last night. Well, Shannon went to watch the fireworks. Damian came along to nap in the grass. The fireworks startled Damian out of his doggy dreams and he decided to take refuge in the car. Unfortunately, Damian wasn’t the only one fleeing from the explosions. He collided with Simon, who tumbled over Damian and hit his head on a rock.

FirewordsSimon is now sporting a lovely bruise and a laceration on his forehead, as well as some scraped palms. His friend warned that he might have a concussion so he came into the clinic to see Dr. Jones.

Dr. Jones examines Simon and does not find evidence of a concussion, just a forehead laceration and lacerations to both palms. Dr. Jones documents that no foreign bodies remain in the head wound or the right palm abrasions, but some gravel is stuck in the left palm.

Our codes for Simon’s visit are:

  • S01.81XA, laceration without foreign body of other part of head, initial encounter (we don’t have a specific code for the forehead, so the ICD-10-CM Alphabetic Index directs us to S01.81-)
  • S61.422A, laceration with foreign body of left hand, initial encounter
  • S61.411A, laceration without foreign body of right hand, initial encounter

We can also add some external cause codes:

  • W01.198A, fall on same level from slipping, tripping and stumbling with subsequent striking against other object, initial encounter
  • Y92.830, public park as the place of occurrence of the external cause
  • Y93.02, activity, running (sadly we don’t have a code to specify fleeing from fireworks)
  • Y99.8, other external cause status (leisure activity)

Damian, by the way, is fine.

Our second patient, Doug, comes in with an eye problem. Doug was running around with a lit sparkler and one of the sparks flew into his eye.

So what kind of injury does Doug have? If the little metal shaving from the sparkler is still in his eye, he may have a foreign body in the cornea (T15.0-) or a foreign body in the conjunctival sac (T15.1-). Alternately, he could have a corneal abrasion without a foreign body (S05.0-).

The code we choose will ultimately depend on the physician’s documentation, but we should note that S05.0- has an Excludes1 note for codes T15.0- and T15.1-, meaning those codes cannot be reported together.

That makes sense if you think about it. S05.0- specifies no foreign body, while both T codes indicate the presence of a foreign body.

We hope you have a safe and happy holiday and don’t end it at the Fix ‘Em Up Clinic!

Anatomy matters

Go to your local bookstore, pick up a copy of Gray’s Anatomy (the book, not the television show), and flip though the illustrations. Alternately, you can Google “Gray’s anatomy illustrations.” They are in the public domain. Some of them are pretty good, especially considering it was first published in 1858.image505

Not surprisingly, anatomy hasn’t really changed since then. Our understanding of certain things–like what parts of the brain are involved in which functions—has changed, but the structures themselves have stayed the same for the last many thousands of years.

So why do you need to brush up on anatomy and physiology before ICD-10? The best reason I’ve heard so far comes from Gerri Walk, RHIA, CCS, senior manager of technical training for HRS in Baltimore.

“The vessels of the heart are like roads in Texas,” Gerri says. “Turn a corner and you’re on a different road or in a different vessel.”

ICD-10-CM and ICD-10-PCS both require specific vessels for cardiac conditions and procedures. For example, a patient suffers an acute MI. Where was the infarction? ICD-10-CM includes specific sites, such as:

  • Left main coronary artery
  • Left anterior descending coronary artery
  • Diagonal coronary artery
  • Other coronary artery of anterior wall
  • Right coronary artery
  • Other coronary artery of inferior wall

Some of those are easy (if the physician documents it). Some could be a little trickier. Do you know which smaller arteries are on the inferior wall and which are on the anterior wall?

For Dilation procedures (balloon angioplasty and stents) in ICD-10-PCS, you only need to know the number of coronary sites treated. For Bypass procedures, you need to know the number of sites bypassed from and where the bypass is going:

  • 3, coronary artery
  • 8, internal mammary, right
  • 9, internal mammary, left
  • C, thoracic artery
  • F, abdominal artery
  • W, aorta

Don’t code cardiac cases? You still need to know arteries. For a procedure involving an artery, for example, you will need to know which artery is involved, where it is located in the body, what approach the physician used, what type of repair he or she performed, and whether the physician used a device.

Consider a patient with septic thrombosis of the choroid vein. If you know that the choroid vein is an intracranial vein, you’re all set. You can report ICD-10-CM code G08 (intracranial and intraspinal phlebitis and thrombophlebitis). You’ll notice all of the intracranial veins and sinuses are lumped into this one code. If you don’t know where the vein belongs and your physician simply documents septic thrombosis of the choroid vein, you’ll need to research the vein. This decreases productivity, which slows down cash flow and so on and so forth.

If you code for the ED or orthopedics, you definitely need to know your bones (not just where they are, but what kind of sections they have) and muscles.

For example, where would you find the navicular bone? It’s kind of a trick question because humans have a navicular bone in the foot as well as the wrist. The one in the wrist is also called the scaphoid bone. ICD-10-CM lists it as the navicular (scaphoid).

The navicular bone in the wrist can be fractured in the distal pole, middle third, or proximal third. Each has a separate subcategory in ICD-10-CM that includes options for laterality and displaced vs. nondisplaced.

The navicular of the foot doesn’t have those location differences. Your choices are displaced or nondisplaced, left or right.

If you only code one type of record all the time—for example, if you work for a pulmonologist—you probably only really need to brush up on the anatomy for that body system or area. If you work at a hospital or are part of a pool of coders, you might see a wide range of cases. Then you’re going to need to understand a wider range of anatomy.

You don’t need to take a full-blown anatomy course. Figure out what anatomy you already know well. Odds are you know some of it very well. Identify areas where you aren’t as strong and do some focused training. It can be as simple as looking at Gray’s Anatomy (again, the book, not the TV show).

Find ways to make it fun. An anatomy version of Jeopardy! could be interesting. You can find a lot of free resources online, just make sure you choose ones from a reputable source.

ICD-10 and value-based healthcare

CMS and Obamacare have increasingly been moving healthcare toward a more value-based model. They want to pay physicians for how well they treat patients and not by the volume of services they provide. Even outpatient hospital services are moving that way as CMS increasingly packages services into one payment.

TipsWhat happens when ICD-10 enters this value-focused mix? Imagine how much information physicians and coders can’t capture today because we just don’t have the codes to represent the true clinical picture of the patient’s illness.

For example, in ICD-9, we have no way of knowing whether a patient broke his or her right or left arm. We can code for the specific bone (radius or ulna) and the area of the bone (upper end, shaft, or lower end). We can even specify open or closed.

What we can’t tell is which side. Why does that matter? Well, consider this scenario. George comes in with a closed fracture of the distal end of the radius (In ICD-9-CM, you would use code 813.43. In ICD-10-CM, we would use a code from the S52.5- series, but we need a lot more information to select the most specific code).

Dr. Bones treats George and sends him on his way. Unfortunately for George, he is back in three weeks with another fracture. Suppose Dr. Bones documents a closed fracture of the distal end of the radius, our 813.43 ICD-9-CM code again. Do you think our payer might be a little suspicious about that?

However, in ICD-10-CM, you could show that George broke the right radius first, then was unlucky enough to break the left one. We’ll have separate codes for each fracture. For example, if George suffered a displaced oblique fracture of the shaft of the right radius, we would report S52.331A for the initial encounter.

When Dr. Bones sees him for the left radial fracture, she documents a nondisplaced comminuted fracture of the shaft of the radius of the left arm (S52.355A). Two different injuries, two different codes.

We’ll also be able to track how well an injury is healing. ICD-10-CM includes seventh characters that specify the encounter. The three most common are:

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

Those choices expand for fractures that include:

  • D, routine healing
  • G, delayed healing
  • K, nonunion
  • P, malunion

The main code will stay the same; the seventh character will tell you how well the fracture is healing. Suppose George’s right arm fracture was showing malunion when he came in for the initial treatment of the left arm fracture. We could report two codes for that visit and those codes will tell our payer that Dr. Bones treated two separate injuries on that day. If you’re wondering, the codes would be S52.331P and S52.355A.

Notice that the code for the malunion is almost exactly the same as the code for the initial visit for the right arm fracture. In ICD-10-CM that fracture code will run through the entire course of treatment for the injury. That will make it easier to pull data about how well a treatment works, how a patient responds to a particular treatment, and what the physician does to treat that particular injury over the course of healing.

And all of that leads us back to quality measures. If you see a patient who suffers a lot of fractures, the physician should look for an underlying reason. Is George clumsy? Does he work in a high-risk environment? Does he have another condition that makes him more susceptible to fractures?

On the other hand, if George keeps coming in for treatment of the same fracture over and over, maybe Dr. Bones isn’t doing a good job.

ICD-10-CM will make it easier to figure that out because we will have more granular data and we’ll actually be able to tell (to some extent) what quality of treatment a physician is providing.

“We can’t pay for value if we don’t know the outcomes and what the value of the treatment really is,” says Sue Bowman, MJ, RHIA, CCS, FAHIMA, senior director of coding policy and compliance for AHIMA in Chicago.

“ICD-10 will really help give us more specific data, so we can see what the outcomes really are and we can judge what is good value.”

Latest ICD-10 survey shows positives, negatives

More healthcare providers would have been ready for an October 1, 2014 ICD-10 implementation date than people may have realized, according to a survey by Edifecs, eHealth Initiative (eHI) and AHIMA.

news blocksA total of 349 people responded to the survey, which was conducted in May and June to assess the anticipated impact of ICD-10. Of the respondents, 27.5% worked in acute care hospitals with an equal number working in clinics and physician practices.

The results of the survey show both concern and optimism.

First the not-so-good view. A little more than one-third of respondents (38%) believe revenue will decrease in the first year of ICD-10. Only 6% believe revenue will go up and 14% think it will stay the same. More than a quarter of respondents (26%) haven’t done any financial projections.

The majority of respondents (61%) believe coding patient encounters will be harder immediately after implementation, which makes sense and fits with the coder productivity declines seen in other countries.

Forty-four percent said documentation will be more difficult. I’m not sure what to think about that aspect of the transition. Coders and CDI specialists will tell you physicians don’t document well in ICD-9. The diseases aren’t changing, but the documentation requirements for many are. I suspect we will see plenty of additional documentation shortcomings in ICD-10.

That’s not to throw physicians under the bus and blame them. We need to educate them on what we need to see in the documentation. They’re taught to document for other physicians. We need to show them how to document for coding.

Other areas where respondents think things will get more difficult initially include:

  • Adjudicating reimbursement claims (including historical analysis of ICD-9 codes), 41%
  • Analyzing and reporting measures on performance, quality, and safety, 24%
  • Collecting and exchanging health information, 20%
  • Negotiating contracts between health plans and providers, 20%

One-third also believe the efficiency of reimbursement will worsen long term.

So that all seems pretty grim, but you’ll notice a light at the end of the tunnel with some other responses. Forty-one percent of respondents think coding will be more accurate in the long term (although they don’t specify what “long term” is).

Quality of care will improve, according to 27% of respondents, and 25% believe patient safety will improve.

Respondents believe the increased specificity will help improve research, population health management, and quality and performance measurement in the long term.

A whopping 68% of the respondents are planning additional training during the delay, which sounds like a wonderful idea. The better coders, CDIs, and physicians understand the requirements of ICD-10, the sooner we will realize the long-term benefits.

Score a few more famous deaths

Composers lead pretty safe lives, right? They compose music, conduct the symphony, and hang out at post-show parties. And we’re not talking rock star parties.

Grim reaper sillySometimes, though, that job isn’t so safe. Take, for example, Jean-Baptiste Lully, King Louis XIV’s favorite and main court composer. In January 1687, Lully inadvertently struck his foot with the pointed staff he had been using to keep time while conducting his Te Deum for Louis.

Healthcare being what it was in the 17th century, Lully developed gangrene. He refused to have the foot amputated (no super antibiotics in those days) and subsequently died.

Since we don’t have an exact cause of death (my guess is septic shock), let’s code his gangrene instead.

When we look up gangrene in the ICD-10-CM Alphabetic Index, we see a nice long list of potential codes, some of which specify a type and some that specify location. For example, we would use K35.80 for gangrene of the appendix. For gas gangrene, we would report A48.0.

Many of the terms direct you to other terms. For example, gangrene with diabetes directs you to see Diabetes, gangrene.

We know Lully’s gangrene started in his foot (although we don’t know which one). Foot is not one of our choices for a gangrene location, but we do have extremities. The foot counts as an extremity and both upper and lower extremities lead to the same code: I96 (gangrene, not elsewhere classified).

That’s a nice vague code, but it is not an unspecified code. It’s a NOC code—we have the information, we just don’t have a more specific code. It’s worth noting that I96 includes a long list of Exclude1 codes (meaning don’t code together):

  • Gangrene in atherosclerosis of native arteries of the extremities (I70.26)
  • Gangrene in diabetes mellitus (E08-E13)
  • Gangrene in hernia (K40.1, K40.4, K41.1, K41.4, K42.1, K43.1-, K44.1, K45.1, K46.1)
  • Gangrene in other peripheral vascular diseases (I73.-)
  • Gangrene of certain specified sites – see Alphabetical Index
  • Gas gangrene (A48.0)
  • Pyoderma gangrenosum (L88)

Acne appears to have done in Alexander Scriabin. The Russian composer-pianist noticed a pimple on his upper lip, which became infected. The infection progressed to a fatal case of septicemia.

Ah, septicemia, one of the problem children of the coding world (largely because doctors don’t document it well). In ICD-9-CM, our septicemia choices include:

  • 038.0, streptococcal septicemia
  • 038.1x, staphylococcal septicemia
  • 038.2, pneumococcal septicemia [Streptococcus pneumoniae septicemia]
  • 038.3, septicemia due to anaerobes
  • 038.4x, septicemia due to other gram-negative organisms
  • 038.8, other specified septicemias
  • 038.9, unspecified septicemia

In ICD-10-CM, we have no codes for septicemia. Huh?

In ICD-10-CM, we will not have codes with septicemia in the code title but will code it as sepsis since it is the body’s systemic reaction to infection.

If you look up septicemia in the ICD-10-CM Alphabetic Index, you find one code—A41.9 (Sepsis, unspecified organism)—and a note: meaning sepsis—see Sepsis.

We should not be at a loss for options when it comes to sepsis. ICD-10-CM includes codes for

  • Anaerobic A41.4
  • Bacillus anthracis A22.7
  • Brucella (see also Brucellosis) A23.9
  • Candidal B37.7
  • Cryptogenic A41.9
  • Due to device, implant or graft T85.79
  • Enterococcus A41.81
  • Erysipelothrix (rhusiopathiae) (erysipeloid) A26.7
  • Escherichia coli (E. coli) A41.5
  • Extraintestinal yersiniosis A28.2
  • Gangrenous A41.9
  • Gonococcal A54.86
  • Gram-negative (organism) A41.5

And so on and so forth. What we really need is for the physician to specify the causative organism. Otherwise, we’re back to A41.9. Before you prepare to bombard your physicians with a bazillion queries for causative organisms, take a look at ICD-10-CM guideline B18:

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

The guideline goes on to state:

It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.

Consider carefully whether the physician can provide additional details before you send that query. If you see that Dr. Germ wrote an order for a lab test that should provide the information, by all means, politely ask him or her to provide details.

Our final musically inclined casualty is something of a mystery (or a conspiracy, depending on who you believe). Pyotr Ilyich Tchaikovsky, who composed the perennial Christmas classic The Nutcracker, died of either cholera or suicide.

Cholera is Tchaikovsky’s official cause of death. Witnesses, including his brother, said Tchaikovsky drank a glass of unboiled water during a cholera outbreak in St. Petersburg.

ICD-10-CM includes three codes for cholera, and they are actually the first three codes in the Tabular List:

  • A00.0, cholera due to Vibrio cholerae 01, biovar cholerae
  • A00.1, cholera due to Vibrio cholerae 01, biovar eltor
  • A00.9, cholera, unspecified

If we know the causative organism, we’ll go with a specific code. If our physician doesn’t document it, we’ll go with A00.9.

Baby blues turned pink

Poor Finn is having a rough week. It started out well as he spent Sunday with his folks and older brother at an amusement park being as amused as a 6-month-old can be.

crying babyThings started going downhill Monday when mom Melissa had to wipe off a thick yellow discharge crusting over Finn’s eyelashes when she woke him up. She also noticed the whites of Finn’s eyes were now red.

She brought Finn into the Fix ‘Em Up Clinic to see Dr. Spock, who diagnosed bilateral acute bacterial conjunctivitis and prescribes eye drops. Dr. Spock expects Finn to be on the mend soon.

When we look up conjunctivitis, acute, we find choices for:

  • Atopic
  • Chemical
  • Mucopurulent
  • Pseudomembranous
  • Serous except viral
  • Toxic

Which one do we use? Since we are super coders, we know bacterial conjunctivitis falls under serous not viral, which takes us to code H10.23-. Ah, the dash. That tells us we need more characters for our code.

When we visit the Tabular List, we find the additional character we need identifies laterality. Dr. Spock documented bilateral, so we would use H10.233 (serous conjunctivitis, except viral, bilateral).

Off Finn went with some eye drops and antibiotics and things should have ended well enough there.

Finn was back at the Clinic Thursday for his six-month well baby checkup. Right off the bat, we know our first code with be one of these:

  • Z00.121, encounter for routine child health examination with abnormal findings

Use additional code to identify abnormal findings

  • Z00.129, encounter for routine child health examination without abnormal findings

In order to choose, we need to know if Dr. Spock found anything wrong with Finn (other than the previously diagnoses pinkeye). Sadly for Finn, Dr. Spock also identified an ear infection. That means we’re going with Z00.121. We also need to add additional codes to report what’s wrong with Finn.

To code his ear infection, we need to know:

  • Where is the infection—outer, middle, or inner ear?
  • Which side (or both)?
  • Acute or chronic?
  • Suppurative or nonsuppurative?

Let’s see what Dr. Spock documented. As we scan through the documentation, we see:

  • Acute
  • Nonsuppurative
  • Bilateral
  • Secretory otitis media

With that information, we can report code H65.03 (acute serous otitis media, bilateral).

We also see two notes under H65, Nonsuppurative otitis media:

  • Use additional code for any associated perforated tympanic membrane (H72.-)
  • Use additional code to identify:

exposure to environmental tobacco smoke (Z77.22)

exposure to tobacco smoke in the perinatal period (P96.81)

history of tobacco use (Z87.891)

occupational exposure to environmental tobacco smoke (Z57.31)

tobacco dependence (F17.-)

tobacco use (Z72.0)


Dr. Spock did not document any tobacco exposure or a perforated ear drum, so we don’t need any additional codes.

However, when we continue reading the office visit note, we find that Finn received four vaccinations:

  • DTaP
  • Hib
  • PCV
  • Rota

When we look up vaccination in the Alphabetic Index, we find codes for

  • Complication or reaction
  • Delayed
  • Encounter for
  • Not done

We already have an encounter code for the well baby visit. Do we still code an encounter for the vaccinations? Yes. In fact, when we look up code Z23 (encounter for immunization), ICD-10-CM tells use to code first any routine childhood examination. Not only do we know we need both codes, but we even get the sequencing.

One other thing to note under Z23:

  • Note: procedure codes are required to identify the types of immunizations given

So don’t forget your CPT codes for vaccine administration and HCPCS codes for the specific vaccines.

Hopefully, Finn will be feeling better soon!

Linking smoking and COPD

Jeff comes in to the Fix ‘Em Up Clinic complaining of shortness of breath, a persistent cough, tightness in his chest, and frequent respiratory infections. He tells Nurse Nosey that he smokes a pack of cigarettes a day and has for the past 20 years.

shutterstock_73841773 After examining Jeff, Dr. Sniffle diagnoses chronic obstructive pulmonary disease (COPD). He also notes that Jeff is a smoker. No wonder Jeff has trouble breathing.

When we look up COPD in the ICD-10-CM Alphabetic Index (under disease, pulmonary, chronic), we are directed to the J44 (other chronic obstructive pulmonary disease) code series. We find lots of interesting notes under J44. We have Includes, Excludes1, Code also, and Use additional code notes.

We’re going to just look at the Use additional code notes.

Use additional code to identify:

  • exposure to environmental tobacco smoke (Z77.22)
  • history of tobacco use (Z87.891)
  • occupational exposure to environmental tobacco smoke (Z57.31)
  • tobacco dependence (F17.-)
  • tobacco use (Z72.0)

We know Jeff is a smoker, but which additional code should we use? Dr. Sniffle didn’t document dependence, use, or abuse, just that Jeff was a smoker.

The ICD-10-CM Alphabetic Index to the rescue! If you look up smoker in the index, you are directed to see dependence, drug, nicotine. It doesn’t matter how much Jeff smokes, just that he is a smoker, according to Nelly Leon-Chisen, RHIA, director of coding and classification for the American Hospital Association in Chicago.

What does matter is whether Dr. Sniffle documents a link between Jeff’s smoking and his COPD. If Dr. Sniffle notes that Jeff’s smoking caused his COPD, we would report:

  • J44.9, chronic obstructive pulmonary disease, unspecified
  • F17.218, nicotine dependence, cigarettes, with other nicotine-induced disorders

However, if Dr. Sniffle does not document a link between Jeff’s smoking and COPD, we cannot assume one (Coding Clinic, Fourth Quarter 2013, p. 109). That changes our codes to:

  • J44.9, chronic obstructive pulmonary disease, unspecified
  • F17.210, nicotine dependence, cigarettes, uncomplicated

The main cause of COPD is smoking (according to WebMD and the Mayo Clinic). Even so, we can’t assume the connection. Jeff’s COPD could possibly be caused by something else. If you aren’t sure, drop Dr. Sniffle a query and ask whether he can specify the cause of Jeff’s COPD.

Dodge ball death match

Dodge ball is not a game for wimps or the uncoordinated. Even master ball dodgers can end up in the Fix ‘Em Up Clinic.

Steve engaged in a spirited game of dodge ball over the weekend, which resulted in him coming in to see Dr. Howard T. Duck.

Steve planted his foot to pivot out of the way of the speeding ball and heard a pop in his knee, followed by excruciating pain. He thought he sprained his knee and was prepared to shake off the injury with some rest and icDodgeball kide. Sadly, this morning his knee locked up, thus convincing him of the need to come to the clinic.

Dr. Duck performs some preliminary tests and sends Steve for an MRI. After reviewing the results, Dr. Duck has to break some bad news to Steve: he has osteochondritis dissecans of the knee.

What is osteochondritis dissecans, you ask. It’s a joint condition in which a piece of cartilage, along with a thin layer of the bone beneath it, comes loose from the end of a bone. In some people, the fracture heals with no problem. For other people, like poor Steve, the piece of bone comes loose and gets stuck in the moving parts of the joint.

How would we code Steve’s injury? As a fracture since a piece of his kneecap came off? Or as something else?

If you look in the ICD-10-CM Alphabetic Index, you will find osteochondritis has its own index entry, which includes multiple subterms, such as Brailsford’s, dissecans, juvenile, and syphilitic.

We know Steve has osteochondritis dissecans, which is further divided by site. We know the site is the knee, which leads us to M93.26-.

The dash tells us we need more characters in our code. I’m guessing we’ll need laterality. Off to the Tabular List we go to find that we have three choices:

  • M93.261, osteochondritis dissecans, right knee
  • M93.262, osteochondritis dissecans, left knee
  • M93.269, osteochondritis dissecans, unspecified knee

Notice that we don’t need a seventh character to denote the encounter. That’s because osteochondritis dissecans does not fall under chapter 19 (injury, poisonings, and other complications of external causes). It’s considered a disease of the musculoskeletal system and connective tissue.

If you are like me and you want to know why, it’s because Dr. Duck and his colleagues in the medical profession aren’t completely sure what causes osteochondritis dissecans. Potential causes include:

  • A reduction of blood flow to the end of the affected bone
  • Repetitive trauma—small, multiple episodes of minor unrecognized injury that damage the end of the affected bone
  • A possible genetic component, making some people more inclined to develop the disorder

They do know that younger males involved in sports are more likely to develop the condition and it also increases their risk of developing osteoarthritis down the road. We’ll have to keep tabs on Steve to see how he’s doing down the road.

It’s Friday the 13th: Avoid black cats and falling paint cans

What do you get when you combine a full moon and Friday the 13th? Some really odd injuries at the Fix ‘Em Up Clinic. Fortunately, we here at the clinic suffer from neither paraskevidekatriaphobia (fear of Friday the 13th), nor selenophobia (fear of the moon).

Black catWe’ll start with Damian, who came into the clinic covered in scratches and hives. Apparently Damian saw a black cat on the stoop outside his apartment and tried to pick it up and move it so his elderly neighbor wouldn’t trip. Said cat was happy where it was and scratched Damian repeatedly when he tried to evict it. That explains the lacerations.

In order to code them, we need to know the specific locations and whether any foreign body remains in the laceration. If the lacerations are to Damian’s fingers, we also need to know whether the nails are damaged as well.

So if Damian suffered lacerations on his right index, middle, and ring fingers with no foreign bodies or nail damage, we would report:

  • S61.210A, laceration without foreign body of right index finger without damage to nail, initial encounter
  • S61.212A, laceration without foreign body of right middle finger without damage to nail, initial encounter
  • S61.214A, laceration without foreign body of right ring finger without damage to nail, initial encounter

Each finger gets its own code and you could have some fingers with nail damage and/or foreign bodies remaining in the wound. Make sure you read the documentation closely to find these details.

What about Damian’s hives? It turns out he is allergic to cats (but didn’t know it) and the hives are a reaction to the cat dander. Dr. Scratchy documents contact dermatitis due to an allergic reaction to cats.

In the ICD-10-CM Alphabetic Index, we look up dermatitis, contact, allergic, and we find an entry for dander (cat) (dog). The index lists the code as L23.81 with no dashes indicating extra characters are needed. However, because we are expert coders, we check the Tabular List just to be sure. Turns out we don’t need any additional characters, so L23.81 it is.

We can also add some external cause codes if our payer wants them:

  • W55.09XA, other contact with cat, initial encounter
  • Y92.038, other place in apartment as the place of occurrence of the external cause
  • Y99.8, other external cause status

Our second patient, Gabriel, walked under a ladder on the sidewalk and was hit on the head by a falling paint can. The blow caused a small skull fracture.

For the skull fracture, we need to know the bone(s) involved and whether it is open or closed. As an aside, we don’t need to know whether a skull fracture is displaced.

When we look under category S02 (fracture of the skull and facial bones) we find the following note:

Code also any associated intracranial injury (S06.-)

So that’s another piece of information we need.

Let’s check out Dr. Scratchy documentation and see what we can find:

Patient struck on head with paint can, suffered closed fracture of parietal bone, subdural hematoma noted on x-ray. Patient also suffered concussion with LOC of 14 minutes. Initial visit for injuries.

With that information, we can report:

  • S02.0XXA, fracture of vault of skull, initial encounter (notice that we need two placeholder Xs)

If we look up hematoma, subdural (traumatic), in the ICD-10-CM Alphabetic Index, we are directed to injury, intracranial, subdural hemorrhage. That leads us to code subcategory S06.5X-. This subcategory of codes is broken down to include a time element. For Gabriel, who lost consciousness for 14 minutes, we would report:

  • S06.5X1A, traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, initial encounter

You have to go all the way back to the beginning of category S06 (intracranial injury) to find out that you need a seventh character. We currently do the same thing in ICD-9-CM, so you should be used to looking for those additional character notations.

Again, we can add some external cause codes if our payer wants them:

  • W20.8XXA, other cause of strike by thrown, projected, or falling object, initial encounter (the paint can)
  • Y93.01, activity, walking, marching and hiking
  • Y92.480, sidewalk as the place of occurrence of the external cause
  • Y99.8, other external cause status

Our final patient, Marion, was talking on her cell phone while walking in the mall when she suddenly lost service. (Apparently the full moon is playing havoc with communications.) As she was trying to reconnect her call, she failed to pay proper attention to where she was going and she walked into a department store mannequin. The mannequin was unable to maintain its balance and toppled onto Marion.

Marion suffered a concussion and a bruised cheek in the scuffle (she maintains that the mannequin started it). She also experienced a severe panic attack (which is also apparently the mannequin’s fault).

The first thing we need to know is whether Marion suffered any loss of consciousness. Dr. Scratchy notes a brief LOC of less than five minutes. We also need to know which cheek was contused. Dr. Scratchy says left.

That gives us codes:

  • S06.0X1A, concussion with loss of consciousness of 30 minutes or less, initial encounter
  • S00.83XA, contusion of other part of head, initial encounter (the cheek does not have its own specified body part)
  • F41.0, panic disorder [episodic paroxysmal anxiety] without agoraphobia (panic attack)

We run into a small dilemma when it comes to our external cause codes. Marion walked into a stationary object, which then fell on her. W22.8XXA (striking against or struck by other objects) is probably our best bet.

We can also add:

  • Y93.C2, activity, hand held interactive electronic device (I choose this one because she was distracted by her phone)
  • Y92.513, shop (commercial) as the place of occurrence of the external cause (because she was in a store when she fell afoul of the mannequin)
  • Y99.8, other external cause status

How much longer until Saturday?