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Jumping for joy?

On the 10th day of Christmas my true love gave to me 10 lords a-leaping. My house isn’t big enough for all of these dancers.

10 lords leapingSeveral of them mistimed their leaps and collided midair and they’re down in a heap with assorted injuries.

Lord Jim twisted his left ankle. Which ligament? ICD-10-CM subcategory S93.4- (sprain of ankle) includes options for:

  • Calcaneofibular ligament
  • Deltoid ligament
  • Tibiofibular ligament
  • Other ligament (specifically the internal collateral and talofibular)

Lord Byron dislocated his right wrist. Is this the first time he’s dislocated his wrist or is it a recurrent injury? ICD-10-CM includes a separate code subcategory for recurrent wrist dislocations.

The Alphabetic Index is a little annoying, though, when it comes to wrist dislocations. Instead of giving you codes to choose from, it lists the different bones and joints and directs you to see Dislocation, metacarpal (bone), proximal end or Dislocation, carpometacarpal (joint).

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High kicks and dislocated hips

On the ninth day of Christmas my true love gave to me nine ladies dancing.

Nine ladies dancingUm, ladies, this isn’t Radio City Music Hall. Please watch where you’re kicking. Don’t look now, but Great Aunt Edna has joined the kick line. Apparently she’s had a little too much holiday cheer. Aunt Edna, I’m really not sure that’s such a good idea. Is her leg supposed to go that way?

Apparently, Aunt Edna kicked a little too vigorously trying to keep up with the chorus line and dislocated her hip.

When we look up Dislocation, hip in the ICD-10-CM Alphabetic Index, we are directed to subcategory S73.0- (subluxation and dislocation of hip).

When we look up S73.0- in the Tabular List, we find an Excludes2 note for dislocation and subluxation of hip prosthesis (T84.020, T84.021).

ICD-10-CM helpfully took the guesswork out of Excludes notes. An Excludes2 note tells us the excluded condition is not part of the condition it is under. However, both conditions can be present and we can code both.

If Aunt Edna dislocated a hip prosthesis, we would report both a code from S73.0- and either code T84.020- (dislocation of internal right hip prosthesis) or T84.021- (dislocation of internal left hip prosthesis).

Fortunately, Aunt Edna has all of her original parts, so we only need to code the hip dislocation. What else do we need to know?

First, as with most codes for musculoskeletal injuries, we need to know laterality. Next, we need to know which type of dislocation Aunt Edna suffered. What it a subluxation or an actual dislocation?

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Watch out for flying hooves

On the eighth day of Christmas my true love gave to me eight maids a-milking.

Why, exactly, has a herd of cows taken up residence in my backyard, True Love? What are we going to do with them and more importantly, how long are they staying? At least the younger kids seem to like them.eight maids a miking

Mr. Whiskers, the cat, does not and the feeling is mutual. When Mr. Whiskers started circling the pear tree to find an angle to attack the partridge, the cows started getting restless. The enthusiastic petting by the children isn’t helping either.

Tommy, I don’t think you should be walking behind that cow. Tommy, seriously, don’t walk behind that…oh, he walked behind the cow and the cow kicked him in the side of the head.

Off to the Acme ED we go with an unconscious 6-year-old and his hysterical mother.

Fortunately, Tommy is awake by the time we arrive at the ED 20 minutes later. Dr. Joe diagnoses a concussion and a fractured parietal bone. Fortunately, Tommy has a hard head and suffered no brain injury beyond the concussion.

To find the code for the fracture of the parietal bone, you can look up either Fracture, skull, parietal, or just Fracture, parietal in the ICD-10-CM Alphabetic Index. Both lead you to code S02.0-.

When you head to the Tabular List, you see that S02.- is a fracture of the vault of the skull and includes both the parietal and frontal bones.

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Swim away swans

On the seventh day of Christmas my true love gave to me seven swans a-swimming.

Seven swansTo be completely accurate, he took a group of us on a road trip to a pond where the swans swam in blissful ignorance of their status as a Christmas present. At least until Chuckie and Ruth went running after them along the shore.

Two screaming children managed to spook all seven swans into taking flight. One swan with poor navigation skills flew right into Chuckie, sending him tumbling and screaming into the really cold pond.

My true love did his best superhero impersonation, wading into the pond to fish out Chuckie. The water was cold, but not very deep. My true love deposited the spluttering child on the bank where his sister Ruth proceeded to mock him for falling into the water. A sibling slugfest ensued with both kids ending up in the pond.

Chattering teeth resolve family disputes and Chuckie and Ruth are back to being friends. But they have an assortment of injuries, including:

  • T33.011A, superficial frostbite of right ear, initial encounter
  • T33.012A, superficial frostbite of left ear, initial encounter
  • T33.531A, superficial frostbite of right finger(s), initial encounter
  • T33.532A, superficial frostbite of left finger(s), initial encounter
  • T33.831A, superficial frostbite of right toe(s), initial encounter
  • T33.832A, superficial frostbite of left toe(s), initial encounter

Notice that we need a code for each area affected by frostbite, as well as a seventh character to indicate the encounter. We don’t have codes for individual fingers or toes, so we use the same code regardless of whether it’s one finger or five.

For frostbite with tissue necrosis, we would report codes from category T34. Patients may have frostbite with tissue necrosis at one site and without tissue necrosis at another site, so you need to carefully read the documentation. And when in doubt, query.

Our little angels are all bundled up for the ride home, where we will investigate the healing properties of hot chocolate.

No fresh eggs for you

On the sixth day of Christmas my true love gave to me six geese a-laying.

Six geeseMy favorite Uncle Ted was so excited about this gift that he rushed right over to relieve those geese of their eggs. Bad idea, Uncle Ted. The geese were so outraged by Uncle Ted’s presumption that they attacked en masse.

Luckily for Uncle Ted, geese don’t have teeth so he only ended up with lots of bruises from goose beaks. In ICD-10-CM, we will report a separate code for each bite site, so if the geese bit his right forearm, left lower leg, and his right pinkie, we would report:

  • S50.871A, other superficial bite of right forearm, initial encounter
  • S80.872A, other superficial bite, left lower leg, initial encounter
  • S60.476A, other superficial bite of right little finger, initial encounter

Note that all of these codes require a seventh character for the encounter. They are all also “other specified” codes. We know what bit Uncle Ted, but since it was not an insect, we go with “other specified.”

We can add some external cause codes to further flesh out Uncle Ted’s travails:

  • W61.51XA, bitten by goose, initial encounter
  • Y92.010, kitchen of single-family (private) house as the place of occurrence of the external cause
  • Y99.8, other external cause status

Only the first code requires a seventh character to specify the encounter, so don’t add As to the other codes. They’ll be invalid.

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Now, this is a good gift

On the fifth day of Christmas my true love gave to me five golden rings. Hey wait, there are only four rings here. Where did the other one go?

Oh no, little Andrew shoved it up his nose.Five gold rings

Time to remove the ring from the child’s nose and then disinfect it (kid boogers—gross).

If we are removing something in ICD-10-PCS, which root operation would we use? (Keep in mind, ICD-10-PCS is really for inpatient procedures. Outpatient facilities and physicians will still use CPT®. But this is a fun exercise.)

ICD-10-PCS does feature root operation Removal. Fortunately for Andrew, pulling a ring out of his nose does not meet the ICD-10-PCS definition of Removal. In ICD-10-PCS, we only use Removal for taking out or off a device from a body part. No device, no Removal.

What other root operations could it be? Extraction perhaps? ICD-10-PCS defines Extraction as “pulling or stripping out or off all or a portion of a body part by the use of force.” That ring is not a body part so we can eliminate Extraction.

How about Extirpation? I’ve always wanted to code Extirpation. The ICD-10-PCS definition of Extirpation is “taking or cutting out solid matter from a body part.” The ring is solid matter (at least it better be).

The ICD-10-PCS Reference Manual provides the following additional information about Extirpation:

The solid matter may be an abnormal byproduct of a biological function or a foreign body; it may be imbedded in a body part or in the lumen of a tubular body part. The solid matter may or may not have been previously broken into pieces.

Winner! Extirpation it is. Our table in ICD-10-PCS is 09C.

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We need a new gift theme

On the fourth day of Christmas my true love gave to me four calling birds.

Four calling birdsI’m starting to think he raided a pet shop. Or maybe he captured these in the park. He says they’re calling birds. They look more like blackbirds to me.

And they act like blackbirds. Right now they are fighting for the prime nesting spot in my Christmas tree. More alarmingly, Mr. Whiskers has abandoned his partridge vigil to try and catch the calling birds.

My true love better put a stop to that, but alas, numbers more than made up for the size disparity, especially when Mr. Whiskers turned on my true love.

In an effort to flee his feathered and feline attackers, my true love tripped over the coffee table. He made a valiant effort to keep his balance, but just before he could completely right himself, he crashed into the glass sliding door to the patio. Make that crashed through the glass sliding door.

My true love lives a charmed life, however, and suffered only lacerations from the glass. How he managed that, I will never know.

How would we code his misfortune this time? ICD-10-CM groups injuries by body area instead of type of injury. So we can’t turn to a category of codes and find all of the laceration codes. Instead, we’ll find lacerations grouped with all of the other injuries to the hand or leg or whichever body part is affected.

For example, my true love suffered lacerations to his right forearm (thankfully he missed the big arteries). We would look up laceration, forearm in the ICD-10-CM Alphabetic Index. If you look up laceration, arm, the index specifies upper arm.

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A hat trick of feathered friends

On the third day of Christmas my true love gave to me, three French hens.

Three french hensAwesome, more birds. My house is starting to look like an aviary. I’m also not sure why my true love thought it necessary to import hens. What to do with the hens?

Well, it seems little Cindy Lou has decided to play tag with the hens. The birds don’t seem to be enjoying the game nearly as much as the 2-year-old. I wonder why they don’t just fly off?

I spoke too soon. The birds have taken flight and Cindy Lou thought she could too. She just jumped off the couch flapping her arms in imitation of the French ladies. Not surprisingly, she didn’t do as well. She just hit the floor and commenced wailing. I guess we should see what sort of injuries she has incurred.

Fortunately, the couch wasn’t high off the ground and Cindy Lou is sort of an expert at falling. Did I mention she’s 2?

Other than some minor bumps and bruises (and a good scare), she seems to be OK. And then she stood up and immediately crumpled to the ground with a fresh screech and more tears. Cindy Lou did not stick a perfect landing after all.

What misfortune befell our little angel? Did she break her ankle? Sprain her ankle? Heaven forbid, dislocate her ankle?

Dr. Joe at the Acme ED believes she just sprained her ankle. He is sending her for a rule-out x-ray just to be sure.

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Oh, look, a bird in a tree

On the first day of Christmas, my true love gave to me, a partridge in a pear tree. How…nice.

Partridge in a pear treeFortunately, the tree is way too big for the living room (it also clashes with my real Christmas tree). The pear tree is potted, so out it goes to the patio.

Unfortunately, Mr. Whiskers spotted the partridge before I could get the pear tree out of the house. Mr. Whiskers thinks the bird is his Christmas present. (Not that he should get presents. He’s been a bad kitty.)

Mr. Whiskers prepared a sneak attack on his presumed snack, but the partridge was prepared. It launched a barrage of pears at the cat as he attempted to climb the tree. (The bird couldn’t have just relocated?)

Sadly the bird’s aim was a little off (which is only to be expected when one is hurling pears with talons) and Mr. Whiskers escaped unscathed (but motivated to devise a new plan). One of the projectile pears did find a target—it hit my true love right between the eyes. Oh, honey, that looked like it hurt. (Maybe the bird’s aim isn’t so bad after all.)

My true love suffered a contusion of the forehead. In ICD-10-CM, we would report S00.83XA (contusion of other part of head) for the initial encounter. You’ll notice the placeholder X to make sure the seventh character is in the seventh position. It doesn’t matter if you capitalize the X or not when you report the code on the claim.

You’ll also notice the code description states, “other part of the head.” Underneath the code are these two included conditions:

  • Bruise of other part of head
  • Hematoma of other part of head

Other part of the head does not mean this is an unspecified code. We know the part of the head involved. We just don’t have a code for it. This is a “not elsewhere classified” code, not a “not otherwise specified” code.

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Those pesky earaches

Poor Finn. He’s heading for his first birthday, but he may not be in a partying mood. After Finn developed his fifth ear infection in six months, mom Melissa decided it was time to put tubes in his ears. Three days before his birthday. Bummer little dude, but this will be way better in the long run.

crying babyIn the real world, myringotomy is an outpatient procedure. It usually takes 10-15 minutes. However, for instructional purposes, we’re going to admit Finn to the Stitch ‘Em Up Hospital for his myringotomy.

In ICD-9-CM Volume 3, we would report code 20.01 (myringotomy with insertion of tube). What would this look like in ICD-10-PCS?

We know our first character will be 0 for the Medical and Surgical section of ICD-10-PCS. The second character is the body system. In this case, we’ll use 9 (ear, nose sinus).

Now the fun part—determining the root operation. Coders get to choose the root operation (sorry, docs) based on the intent of the procedure. What is the purpose of putting tubes in Finn’s ears?

The idea behind a myringotomy is to drain excess fluid or pus from the middle ear, usually by making a small incision in the ear drum. The tympanostomy tubes keep the middle ear aerated for a few months or years to stop the fluid from building up again.

So the physician is putting in a tube to drain fluid. Insertion maybe? That might be your first guess, but ICD-10-PCS defines root operation Insertion as “putting in a nonbiological appliance that monitors, assists, performs, or prevents a biological function, but does not physically take the place of a body part.”

That doesn’t really match what our physician is doing. When you look at the root operation definitions, Drainage (taking or letting out fluids and/or gases from a body part) is a better fit.

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