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We can rebuild his elbow

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

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

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

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

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

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

While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time. [more]

Unlucky roll of the dice

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

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

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

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

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


Dangers lurk in your sleep

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

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

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

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


Beware of infectious toddlers

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

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

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

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

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


Another reason for better documentation

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

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

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

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

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

Perils peeping up all day

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

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

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

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

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

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

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

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


Things that go boom in the night

One of the great things about healthcare and medicine is you can always learn something new. Today’s odd but true condition is exploding head syndrome. (I love the Internet.)

monter under bedIf you have ever experienced a loud bang in your head like a bomb exploding, a gun firing, a clash of cymbals or any other form of loud, indecipherable noise, you may have suffered from exploding head syndrome.

You’re more likely to experience it just before deep sleep or just after coming out of a deep sleep. But don’t worry, you won’t feel any pain or other physical manifestations of the syndrome. Just that loud noise inside your head.

Doctors don’t know for sure what causes exploding head syndrome, but it may be related to stress and fatigue, according to the American Sleep Association. Doctors also aren’t sure what causes the noise.

If we have a patient suffering from exploding head syndrome, how would we code it?

I looked up syndrome, head, and syndrome, exploding head, in the ICD-10-CM Alphabetic Index. No luck. I tried exploding (no listing at all with that as the first tern) and head, which told me to “see condition.”


A little clarity on seventh characters

question marksJeff went on vacation to Hawaii three weeks ago to enjoy some sun, sand, and surfing. He came back with some cool photos and a broken ankle. Apparently, the parking lot at the beach did him in even before he hit the surf.

Jeff saw an ED physician in Hawaii, who diagnosed a non-displaced trimalleolar fracture of the left ankle. The physician treated Jeff and instructed him to follow up with his primary care physician on the mainland.

The coder reported ICD-10-CM code S82.855A for Jeff’s ED visit.

Jeff came in to see Dr. Breaker at the Fix ‘Em Up Clinic for follow-up care for the fracture. Dr. Breaker ordered x-rays to check the healing of the fracture and documented:

Saw patient three weeks post non-displaced trimalleolar fracture of the left ankle. Ordered x-rays. Bone shows normal healing. Instructed patient to return in three weeks.


Nonunion, malunion, or delayed healing?

FeetPoor Wendy. Shortly before Christmas, she stubbed her toe, really hard. However, no bruise appeared and her toe didn’t swell up, so she thought nothing of it. Three weeks later, she stretched her feet in bed and felt excruciating pain in the toe.

She came into the Fix ‘Em Up Clinic to see Dr. Setter, who confirmed that Wendy had fractured her toe. Dr. Setter provided a special shoe for Wendy to wear and told her to rest the foot as much as possible.

Three months later, Wendy’s broken toe hasn’t healed so she is back to see Dr. Setter. Wendy told Dr. Setter that because of the bad winter weather she was unable to wear the special shoe all of the time. She also stated that she is occasionally bothered by pain in the toe.

Dr. Setter ordered a new set of x-rays to make sure Wendy did not fracture the toe a second time. After comparing the old and new x-rays, Dr. Setter documents that the fracture is the same one Wendy suffered in December. He noted that the fracture is non-healing and is considering more aggressive treatment, including possible surgery.

How would we code Wendy’s fracture in ICD-10-CM? Basically, the same way we would have coded it in December, just with a new seventh character.

For fractures, we need to know:

  • Laterality
  • Specific site
  • Encounter
  • Open or closed
  • Displaced or non-displaced

We can gather some of this information from the x-ray that Dr. Setter reviewed. For example, the x-ray report identifies the fracture as a non-displaced fracture of the medial phalanx of the second right toe.

We don’t have any documentation that identifies the fracture as open or closed, but we do have a default (closed) in ICD-10-CM.

For a closed, non-displaced fracture of the medial phalanx of a right lesser toe, we would report S92.524-.

Now we have to decide which seventh character to use. For all codes in category S92 (fractures of the foot and toe, except ankle) we have seven possible seventh characters:

  • 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
  • P, subsequent encounter for fracture with malunion
  • S, sequela

We can eliminate B (we’re dealing with a closed fracture) and D (obviously, the fracture isn’t healing normally).

What about A? The Official Guidelines for ICD-10-CM Coding and Reporting instruct us to use A (and B) when the patient is receiving active treatment, such as:

  • Surgical treatment
  • Emergency department encounter
  • Evaluation and treatment by a new physician

Dr. Setter documents that he may need to operate on Wendy’s toe, but he isn’t doing it at this visit. He is also not a new physician and Wendy is not in the ED. So we can eliminate A.

A sequela is a late effect, something that shows up after an injury heals. It also isn’t a choice in this case because Wendy’s fracture hasn’t healed.

That leaves us with three choices for a subsequent visit:

  • Delayed healing
  • Nonunion
  • Malunion

We can also eliminate malunion. A malunion is a fracture that healed but in less than an optimal position. Again, Wendy’s fracture hasn’t healed so it can’t be a malunion.

Now things get tricky. Delayed healing and nonunion are very close in definition.

A nonunion occurs when a fracture fails to heal, according to the American Academy of Orthopedic Surgeons. Delayed union or healing is when a fracture takes longer than usual to heal.

Dr. Setter documented “non-healing” which is kind of a hybrid term. We may need to query Dr. Setter for clarification because ICD-10-CM doesn’t give us any information on how to differentiate between the two.

No pot of gold for you

Pot of goldLiam spent this St. Patrick’s Day on a fruitless quest for a pot of gold.

He powered up for his quest by having a few glasses of green Guinness beer for breakfast. Turns out it’s not a good idea to try and make Guinness green. It requires an excessive amount of green dye.

As a result, Liam ended up suffering from:

  • 0X1A, toxic effect of ethanol, accidental (unintentional), initial encounter
  • 6X1A, toxic effect of paints and dyes, not elsewhere classified, accidental (unintentional), initial encounter

You’ll find those codes by looking in the Table of Chemicals and Drugs, just like you do in ICD-9-CM.

However, Liam decided a little poisoning was not going to deter him from his pursuit of fame and fortune (mostly fortune). So he headed back out to follow the rainbow only he could see. Hmm, perhaps Liam also has a little R44.1 (visual hallucinations) going on.

The (imaginary) rainbow leads him into the deep, dark woods, where instead of finding a friendly leprechaun, he encounters some decidedly less friendly woodland creatures. Or at least that’s his story when he arrives back at the Fix ‘Em Up Clinic with numerous bite marks, abrasions, and lacerations.