Michelle A. Leppert, CPC, is a senior managing editor for JustCoding.com. 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 firstname.lastname@example.org.
Labor Day marks the unofficial end of summer, and hopefully, the end of patients with picnic-induced problems at the Fix ‘Em Up Clinic.
Dr. Sunni Daze sees Sam and diagnoses Sam with a torn medial collateral ligament and a torn lateral collateral ligament.
Unfortunately, Dr. Daze didn’t specify which knee in the diagnosis. She did, however, document that she examined his left knee, so we have laterality. We also know she is seeing Sam for the first time for these injuries, so we would report:
- S83.412A, sprain of medial collateral ligament of left knee, initial encounter
- S83.422A, sprain of lateral collateral ligament of left knee, initial encounter
She refers Sam to an orthopedist for further treatment. When Sam sees the orthopedist for the first time, we will report the exact same codes, even the same seventh character. Seventh character A is used when the patient is receiving active treatment, including when the patient sees a new physician.
Our second patient, Jake, fell victim to a vengeful squirrel during his family’s picnic in the park. The squirrel made a move to steal Jake’s potato chip for a snack. When Jake reached for it, the squirrel got a mouthful of Jake’s hand instead of the tasty treat. The squirrel took off, leaving Jake with a bleeding bite wound.
Dr. Daze documents the following:
Patient presents for initial treatment of open bite wound on hand caused by squirrel. Cleaned and irrigated wound. Placed five stiches in left hand. Applied sterile bandages. Prescribed antibiotics. Sent patient home with instructions for keeping the wound clean.
Again, we know laterality and encounter, so we would report S61.452A (open bite of left hand, initial encounter).
If your payer requires external cause codes, we do have one for bitten by squirrel (W53.21). Don’t forget the placeholder and seventh character.
Our final Labor Day casualty is Megan, who was taking in her first baseball game. Unfortunately, she forgot to pay attention at all times when the game is going on. Instead of catching that foul ball, she took it on the chin—literally. She suffered a broken jaw as a result.
As you’ve probably heard, ICD-10-CM fracture codes are full of all kinds of details. For a jaw fracture, we first need to know upper jaw (see fracture, maxilla) or lower jaw (see fracture, mandible). Chin is the lower jaw, so we will head to the mandible fractures, where we find these choices:
- S02.600-, fracture of unspecified part of body of mandible
- S02.609-, fracture of mandible, unspecified
- S02.61-, fracture of condylar process of mandible
- S02.62-, fracture of subcondylar process of mandible
- S02.63-, fracture of coronoid process of mandible
- S02.64-, fracture of ramus of mandible
- S02.65-, fracture of angle of mandible
- S02.66-, fracture of symphysis of mandible
- S02.67-, fracture of alveolus of mandible
- S02.69-, fracture of mandible of other specified site
Notice two things—we don’t need laterality, but we do need a seventh character. In order to find out which seventh characters apply, we need to go back to the top of category S02 (fracture of skull and facial bones). We have some additional seventh character choices for this category:
- A, initial encounter for closed fracture
- B, initial encounter for open fracture
- D, subsequent encounter for fracture with routine healing
- G, subsequent encounter for fracture with delayed healing
- K, subsequent encounter for fracture with nonunion
- S, sequela
In addition to knowing the exact site of the fracture, we’ll need to know whether it’s open or closed.
Remember, too, that you can take the specific site from the radiology report as long as the physician documents that the patient has a fracture of the jaw.
Keep your eye on the ball at all times!
Summer is almost over, and so are the summer road trips. Clark, for one, will be very happy about that.
Things got off to a bad start when Clark’s wife Ellen ran over his foot with the family SUV in their driveway before the trip even started. Fortunately for Clark, Ellen wasn’t driving fast and he only suffered a badly bruised foot.
What do we need to know to code Clark’s foot injury? If you said laterality and encounter, move to the head of the line.
Our choices are:
- S90.30-, contusion of unspecified foot
- S90.31-, contusion of right foot
- S90.32-, contusion of left foot
We need a placeholder X and one of the following seventh characters to complete our code:
- A, initial encounter
- D, subsequent encounter
- S, sequela
The term initial is a little misleading, because we will use A as the seventh character when the patient is receiving active treatment, such as:
- Surgical treatment
- ED encounter
- Treatment by a new physician
So much for the foot injury.
During their weeklong odyssey, Clark and the family stopped at Super Fun World Amusement Park. By the end of the day, Clark was far from amused.
While on the roller coaster, Clark was struck in the head by a low-flying (but not slow-flying) bird. He ended up with a concussion, a bruise, and a really bad headache.
In ICD-10-CM, concussion codes live in subcategory S06.0X-. We have nine codes that specify whether the patient lost consciousness, and if so, for how long. We even have two codes to use if the patient dies.
However, Clark did not even suffer a second of unconsciousness following the assault by bird, so we would report S06.0X0A (concussion without loss of consciousness, initial encounter).
Note that we need a seventh character and, in this case, the placeholder is in the fifth spot. ICD-10-CM helpfully includes the placeholder in the Tabular List so we don’t forget it.
If Clark had suffered an open wound to the head or a skull fracture, we would code that separately, per ICD-10-CM guidelines.
We can also add some external cause codes (just because it’s fun and hey, the mainstream media likes to pick on our external cause codes):
- W61.92XXA, struck by other birds, initial encounter (Clark didn’t get the name of the bird that hit him)
- Y92.831, amusement park as the place of occurrence of the external cause
- Y93.I1, activity, roller coaster riding
- Y99.8, other external cause status (leisure activity)
On Day 4 of the trip, Clark and the family were driving through Death Valley (where summer temps routinely top 120°F) when the SUV decided to take a break. And so did the air conditioning. More problematic was the lack of cell reception.
Rather than wait for a passing Good Samaritan, Clark decided to hike back to civilization for assistance. Sadly, he forgot to stock up on water when he exited the vehicle and by the time he made it to the main road, he had a whopper of a sunburn and a case of heatstroke.
ICD-10-CM includes four codes for sunburn, based on degree:
- L55.0, sunburn of first degree
- L55.1, sunburn of second degree
- L55.2, sunburn of third degree
- L55.9, sunburn, unspecified
We don’t need to know the location of the burn, just the degree. Remember to code to the highest degree.
For heatstroke, we only see one choice—T67.0—but we need two X placeholders and a seventh character.
Clark wrapped up his week of woes with a nasty case of food poisoning after chowing down at a roadside taco stand. In order to code Clark’s food poisoning, we need to know the causative organism. Our choices include:
- A02.0, Salmonella enteritis
- A02.9, Salmonella infection, unspecified
- A05.0, foodborne staphylococcal intoxication
- A05.1, botulism food poisoning
- A05.2, foodborne Clostridium perfringens [Clostridium welchii] intoxication
- A05.3, foodborne Vibrio parahaemolyticus intoxication
- A05.4, foodborne Bacillus cereus intoxication
- A05.5, foodborne Vibrio vulnificus intoxication
- A05.8, other specified bacterial foodborne intoxications
- A05.9, bacterial foodborne intoxication, unspecified
Happy trails and safe travels! (And be careful what you eat.)
The ICD-10 transition has been nothing if not contentious. We’ve had delays mandated by both CMS and Congress, as well as ongoing attempts by the AMA to kill ICD-10 altogether.
Both 3M’s Donna Smith, RHIA, and AHIMA’s Angie Comfort, RHIA, CDIP, CCS, say determining the correct code isn’t a sure thing. Coders aren’t always ending up at the same code.
Why? Well, first of all, the system isn’t live so no one is really coding in it. We’re still doing some guess work.
Second, physician documentation is not where we need it to be even for ICD-9. As a result, some coders may be guessing or choosing an incorrect default code.
Third, not everyone is finding the same information in the record. In many cases physicians already document laterality, Donna says; it’s just that coders might not know where to look for it.
Fourth, we still don’t have a ton of guidance for the grey areas. We have 30 years’ worth of Coding Clinic advice for ICD-9. We have a few issues for ICD-10.
Many organizations are doing some type of dual or double coding. I’m not sure how many are actually checking to make sure coders are coming up with the correct answer. And that’s another problem. How do you decide who got the correct answer?
You need a plan, Donna says. Part of that plan should include identifying the top diagnoses and procedures at your organization. Pull actual cases that include those conditions or procedures and have all of your coders code the record.
Once you’ve done that, compare the results, Angie says. Did you all come up with the same answer? Probably not. Agreement rates are pretty low right now, according to Donna.
So you came up with one code and your coworker came up with a different one. Maybe a third coworker came up with something completely different. Now what?
Sit down and talk about it, both Angie and Donna say. No one knows everything about ICD-10 yet (no one knows everything about ICD-9 either and it’s been around way longer). Try to figure out why you came up with different codes. Did someone miss a piece of information in the documentation? Did someone make an assumption based on his or her knowledge of the physician’s habits? Is the physician’s documentation so vague that everyone was just guessing?
If you can’t come to an agreement among yourselves, ask Coding Clinic. Send the de-identified record to AHA and ask them how to code it. Coding Clinic loves real-life examples, Donna says. So send them in. The more actual documentation they can look at, the better they can answer questions for everyone.
ICD-10-PCS requires coders to possess strong clinical knowledge as well as a solid foundation in anatomy and physiology. Coders need to understand what physicians are actually doing in certain procedures. Without an understanding of what is being done, coders can’t assemble the correct ICD-10-PCS code.
A Billroth II procedure is a surgical procedure in which an anastomosis is created between the stomach and the proximal loop of the jejunum. In case you’re wondering, a Billroth procedure involves removing the pylorus and creating an anastomosis of the proximal stomach directly to the duodenum.
If you know that a Billroth II is also called a gastrojejunostomy, or if your surgeon documents gastrojejunostomy, you’re in luck. ICD-10-PCS includes two listings for gastrojejunostomy in the Alphabetic Index.
Of course, two is not as good as one, but it gives us a place to start. Our two choices according to the Alphabetic Index are:
- Bypass, stomach 0D16
- Drainage, stomach 0D96
The only difference between the first four characters of the code is character three, the root operation. We determine the root operation based on the intent of the procedure. So in a gastrojejunostomy, what is the physician doing? He or she is creating an anastomosis, basically a surgical connection between two structures.
Look at the definitions of Bypass and Drainage. Bypass involves altering the route of passage of the contents of a tubular body part. Drainage involves taking or letting out fluids and/or gases from a body part. Based on the intent of the procedure, Bypass is our root operation.
In ICD-10-PCS, we assign codes based on the body part bypassed from to the body part bypassed to. Confused? Don’t be. The fourth character in the code is where the bypass began, in this case the stomach. The seventh character is where the bypass ends up, in this case, the jejunum.
We also need to know the approach:
- Via a natural or artificial opening endoscopic
We also need to know what type of device was used. Remember, in ICD-10-PCS you only code devices that are left in the patient after the procedure. For an anastomosis, we are connecting one body part to another. The physician probably isn’t placing a device, but read the operative report to be sure.
For an open Billroth II without a device, we would report: 0D160ZA (bypass stomach to jejunum, open approach).
If you aren’t sure what a physician is doing during a common procedure, ask the physician to explain it or make friends with your clinical documentation improvement specialists. They can probably help you out as well. You still have time to figure out what clinical information you don’t know and what procedures you commonly code. Make the most of that time.
We hear a lot about the projected productivity declines after ICD-10 implementation. And coders will be less productive initially. That only makes sense because ICD-10 is new, coders will need to look for additional information, they (or their clinical documentation improvement specialist coworkers) may be sending more queries.
ICD-10 should actually speed up claims processing, according to Donna Smith, RHIA, project manager and senior consultant with 3M Health Information Systems in Salt Lake City.
For one thing, ICD-10-CM codes will better support medical necessity because they include more information, Donna points out. Right now, hospitals spend a lot of time copying records and shipping them off to payers because the ICD-9-CM codes are just so vague.
ICD-10 will also tell a better patient story. With the seventh character, you can actually follow a patient’s injury all the way through and see what kind of outcome the patient experienced.
A better, more complete picture of the patient’s severity of illness should also help reduce denials, Donna says. If Dr. Adams says her patients are really sicker than Dr. Smith’s, ICD-10 will allow her to show it. And if you don’t have to appeal denials, you get paid faster and you spend less time fighting with the payers.
Let’s not forget laterality. Joe comes in with a lacerated left index finger with injury to the nail. We have one code in ICD-9-CM (883.2). We’re reporting that same code for all 10 fingers.
In ICD-10-CM, we have separate codes for every finger, plus codes that specify whether the nail is involved and whether any foreign bodies remain in the wound. For our lacerated left index finger, we would choose between:
- S61.311-, laceration without foreign body of left index finger with damage to nail
- S61.321-, laceration with foreign body of left index finger with damage to nail
Both codes require a seventh character to denote the encounter.
The next day, Joe comes in with another finger laceration, this time of the left ring finger. In ICD-9-CM, we’re still reporting 883.2 and the insurance company may think we’re double billing or we did something wrong.
However, in ICD-10-CM, we will report one of these codes:
- S61.215-, laceration without foreign body of left ring finger without damage to nail
- S61.225-, laceration with foreign body of left ring finger without damage to nail
- S61.315-, laceration without foreign body of left ring finger with damage to nail
- S61.325-, laceration with foreign body of left ring finger with damage to nail
Again, we need a seventh character for encounter.
The payer can see that Joe injured a different finger, so we should be quickly reimbursed, which will save time (and aggravation).
What constitutes good documentation? The next physician treating the patient should be able to pick up the medical record and know exactly what happened in the previous encounter.
How often does this happen now? Sadly, not very. The fact is, most documentation doesn’t meet the current standards for ICD-9-CM coding, according to Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC, vice president of ICD-10 education and training for AAPC in Salt Lake City. Rhonda discussed documentation during an AAPC webinar August 15.
Think about how many times you assign an unspecified code because the physician hasn’t documented the information you need. In coding we are not allowed to assume or guess or suppose. If the physician didn’t document it, we can’t code it.
Good documentation isn’t about the code set. It’s about patient care. Physicians shouldn’t be documenting for payment. They should be telling the patient’s story.
What should you tell physicians about documentation improvement?
Start with the patient’s story. Would the physician know what went on with that patient based on his or her documentation alone? Physicians probably won’t remember specifics of a patient encounter three months down the road, so they need to document everything that happened in the encounter.
Check to make sure you can read the physician’s writing if you are still using paper charts. If you can’t read it, you can’t code it.
Eliminate the abbreviations. The physician might know what that shorthand note means, but coders and other clinicians might not. Ask the physician to clearly spell out the information.
Focus on what they aren’t doing. If the physician is already documenting laterality, don’t spend time discussing it in training. Give them a “Great job on documenting laterality. That’s one of the elements we need in ICD-10” and move on.
Remember that physicians can’t improve their documentation if they don’t know what we need. Show them the ICD-10-CM Manual. Then show them their documentation and point out what’s missing. Maybe the information isn’t missing, you just don’t know where to find it.
We don’t want physicians to write reams of additional information. They don’t have time to write an epic and we don’t have time to read one. In some cases, we only need a few extra words. One example Rhonda gave involves a superficial foreign body in a finger of the left hand. If the physician doesn’t say which finger, we need to use a default code. All we need is which finger and we can get to a more specific code. The physician only needs to add one word. Documentation improvement can be that simple.
Of course, not all documentation improvement involves adding a single word. But knowing the ICD-10-CM codes and the guidelines won’t help you if the information you need is not in the record.
It’s a texting world, and more and more we use shorthand in our everyday lives. What about shorthand in a medical record? Can you code from it?
First, let’s look at what kind of shorthand you might see. Physicians may use a +, ↑, or ↓. Those symbols could mean positive (like a pregnancy test), increased level, or decreased level, respectively. The problem is, they aren’t very clear or specific.
Na↑ could mean hypernatremia (elevated sodium) or it could just mean the sodium level has increased. Maybe the patient has a low sodium level and the physician is simply indicating that treatment to raise the level is working. It could mean the sodium level is a little high or significantly elevated. Maybe the physician just documented a slight elevation so he or she remembers to have it rechecked during the patient’s next encounter.
Bottom line: you just don’t know, so you can’t code from it.
So that means it’s time to query the physician, right? Well, it depends. First, make sure you review the entire record and see if the physician documented the information anywhere else more specifically. Maybe BP↑ was just a note on a summary sheet and in the history of present illness, the physician stated, “Patient’s blood pressure elevated.” No query needed. We have the information.
Maybe the physician didn’t document it more completely elsewhere. Is the condition clinically significant?
Hypernatremia is a CC, so it could affect MS-DRG assignment and the patient’s care. You should probably query.
↓BP could also be clinically significant because a low blood pressure could cause other health problems, such as dizziness, weakness, and fainting. Again, probably worth a query.
↓low chloride is probably not worth querying, because it isn’t associated with any adverse health effects.
If you have providers who routinely seem to document using symbols, work with them to eliminate the symbols and document in clear words. (because we can’t code from symbols in any coding system). The better the physician documents, the better the story of the patient becomes.
Take it from today’s victims, er, patients, at the Fix ‘Em Up Clinic: not every idea is a good idea.
Jeff was so determined to claim the s’mores title that he ate a few marshmallows that were a little too hot. As in, they were on fire. And while fire eating is fine for professionals, for a kid at camp, it’s not such a great idea.
Dr. Sunni Daze examines Jeff and documents burns to the mouth, pharynx, tongue, and lips.
The burns of the mouth, pharynx, and tongue are easy. One code covers all three and it does not specify degree of the burn. Since this is Jeff’s initial visit, we would report T28.5XXA.
The lip burns require a little more information. We need to know what degree of burns Jeff suffered on his lips. Fortunately for him, Dr. Daze notes the burns are first degree, so we would report T20.12XA (burn of first degree of lip[s]).
ICD-10-CM does not include separate codes for the upper and lower lip, so T20.12XA covers one lip or both.
We also find the following note under pretty much all of the burn codes:
- Use additional external cause code to identify the source, place and intent of the burn (X00-X19, X75-X77,X96-X98, Y92)
We definitely need an X00-X19 code, which in Jeff’s case is X10.1XXA (contact with hot food, initial encounter).
The X75-X77 codes are for intentional self-harm. Overeating burning marshmallows doesn’t quite qualify as planning to hurt yourself. Jeff just got caught up in the moment.
The X96-X98 are codes for assault. Again, not applicable in Jeff’s case.
For our place of occurrence, we’ll use Y92.833 (campsite as the place of occurrence of the external cause). Notice we do not need a seventh character for this code.
Our second patient Grace tried to change the direction of the fan by grabbing the cage that houses the blades. Turns out that wasn’t the best plan. That “squeeze” caused the blades to hit the cage and Grace’s fingers.
Fortunately, the fan wasn’t going fast enough to sever any of Grace’s fingers, but she does have some wicked-looking lacerations.
ICD-10-CM finger laceration codes are very specific, as in you need to know which hand and which finger is involved. You also need to know whether the nail is damaged and whether any foreign body remains in the laceration.
Let’s see what Dr. Daze documented:
14-year-old female with lacerations to the palm side of the right index, middle, ring fingers, no nail involvement. No foreign bodies remain in wounds. Flexor digitorum profundus tendon of index finger severed.
The first injury we’ll code is the severed tendon, because it is the most severe injury. If you look under laceration (because the tendon was lacerated, right?), the entry for tendon directs you to see Injury, muscle, by site, laceration.
Okay, so off to Injury, muscle, finger we go. And find all sorts of code options. The codes are divided into the forearm and hand level. We don’t have a code for finger level, so we’ll go with hand level.
However, we can code to the specific finger. In Grace’s case, that’s the right index finger and code S66.120A (laceration of flexor muscle, fascia, and tendon of right index finger at wrist and hand level, initial encounter).
The other codes for Grace’s misadventure would be laceration codes for the middle and ring fingers:
- 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
Dr. Daze is done for the day and so are we. Remember to make sure your food isn’t on fire before you eat it.
ICD-10-CM includes 68,000 codes and ICD-10-PCS features 71,924 code choices. Scary numbers, right?
All of those codes will actually make it easier to find the code that best represents either the patient’s diagnosis or the procedure the physician performed.
Some ICD-9-CM codes are vague. By now, you’ve probably seen the comparisons for fracture codes. ICD-9-CM may include only two code choices for a particular fracture (open or closed), while ICD-10-CM can offer more than 100 (sometimes more than 200) codes, which include laterality, specific site of the fracture, type of fracture, and encounter.
Sue likes to compare the code book to a phone book. If you look at the New York City phone book, you’ll find lots and lots of names. More than 8 million people call the Big Apple home. By contrast, Schenectady, New York, is home to slightly more than 66,000 people and requires a much smaller phone book.
You’ll still look up a name the same way. You just have more names to sort through in New York City.
Same holds true for ICD-10-CM. (ICD-10-PCS is very different than ICD-9-CM Vol. 3).
You still look in the Alphabetic Index, you still go to the Tabular List to double check the code. The only difference is you have more code choices.
Increase specificity makes it easier to assign a code because it takes some of the guess work out of the process, Sue says.
That’s especially true in ICD-10-PCS. The ICD-9-CM Vol. 3 codes are so vague that one code could represent more than 100 procedures. That about ambiguity!
With all of the code choices in ICD-10-PCS, you’re more likely to find a code that represents what the physician actually did. And that should save time in the long. It will certainly give us more accurate data about the patient and allow us to tell a better story about the patient’s health.
“It’s never too early to start learning,” says Jillian Harrington, MHA, CPC, CPC-I, CPC-P, CCS, CCS-P, MHP. “By keeping the ball rolling, staff can continue to drive home those documentation improvement aspects to providers.”
Another advantage to starting now: “We as coders and CDI specialists can become experts in ICD-10-CM coding ourselves,” Jillian says. By becoming experts, we’ll know what is needed from a documentation standpoint and we’ll also know the coding guidelines before ICD-10-CM implementation.
Diabetes coding won’t really be harder in ICD-10-CM, Jillian says, but it will be different. The codes will look different, the documentation requirements will change, and you can’t use 250.00 after October 1, 2015. (Don’t worry, though, ICD-10-CM does have an equivalent code.)
Jillian will gives coders, CDI specialists, and clinicians the inside scoop on how to code for diabetes in ICD-10-CM during the live 60-minute webinar, ICD-10-CM Diabetes: Combine Coding and Documentation for Greater Specificity.
She will reveal how the new codes better represent a patient’s clinical picture and what information coders and CDI specialists need to see in the documentation to assign the most specific code. She’ll also review what the ICD-10-CM guidelines and Coding Clinic have to say about ICD-10-CM diabetes coding and offer some tips on getting physicians to improve their documentation.
Be sure to join us at 1 p.m. Thursday, August 14, for the live webinar. Come ready with questions for Jillian! She’ll answer live questions after her presentation.
And if everyone at your organization can’t make it to the live show, don’t worry, you get a free on-demand version of the webinar!