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The big dig (out)

Penguin with shovelWe’re into dig out mode here in Anytown and apparently, not everyone got the memo about proper snow shoveling techniques.

Richard came into the Fix ‘Em Up Clinic complaining of intense pain in his buttocks, right thigh, and right calf. He told Dr. Frosty that he spent six hours shoveling snow yesterday and today can barely stand the pain.

Dr. Frosty sends Richard for an MRI, which reveals a herniated disc. What information do we need to code Richard’s condition?

If you look up herniated disc in the ICD-10-CM Alphabetic Index, you won’t find it. You will find an entry for nucleus pulposus (the fancy medical name for an intervertebral disc). That entry directs you to see Displacement, intervertebral disc.

When we get there, we find that we need some additional information, specifically where in [more]

Snow day blues

Penguin with shovelHere in Anytown we are getting blasted by a big winter storm, which means we’re also seeing lots of patients with storm-related injuries at the Fix ‘Em Up Clinic.

Doug came into the clinic complaining of pain and weakness when lifting his right arm. He was out shoveling the snow using the tried-and-true lift, jerk, and fling method. During one of his tosses, he felt a sharp pain in his shoulder and started having trouble lifting his arm. Dr. Frosty examines Doug and diagnoses a torn rotator cuff.

Do we have enough information to code Doug’s injury in ICD-10-CM? If we look up tear, rotator cuff, in the ICD-10-CM Alphabetic Index, we find out very quickly that we need more information. Was this a traumatic tear?

It’s tempting to say yes right off the bat because Dr. Frosty documented that the injury occurred while Doug was shoveling snow. You can tear you rotator cuff by lifting something too heavy with a jerking motion. However, the majority of rotator cuff tears result from a wearing down of the tendon over time. In his chart, Doug’s age is listed as 57, so we could be looking at a nontraumatic tear.

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Pick the correct root operation for a biopsy

Bone marrow (1024x1024)We can choose from 31 root operations in the ICD-10-PCS Medical and Surgical section, but biopsy isn’t one of them. So which root operation do we use when a physician performs a biopsy?

The answer is, it depends.

We will select a root operation in ICD-10-PCS based on the intent of the procedure.

For example, Dr. Sharpe documents a thoracentesis, which is a procedure to remove fluid from the space between the lining of the outside of the lungs and the chest wall. For that procedure, we use root operation Drainage (taking or letting out of fluids and/or gases from a body part).

When it comes to coding a biopsy in ICD-10-PCS, we need to look at what the physician is actually removing.

Let’s say Betsy came in with a growth on her thyroid. Dr. Sharpe decides to perform a needle biopsy to see whether the growth is cancerous. For this type of biopsy, Dr. Sharpe is removing a small piece of Betsy’s thyroid for examination.

We would use root operation Excision because Dr. Sharpe’s intent is to cutting out, without replacement, a portion of a body part. We would use the same root operation for liver biopsies, breast biopsies, and so on.

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Step away from the seal

SealSome diseases can cross between species, which can presents a significant problem. Just think back to how quickly avian flu spread starting in 2003.

It turns out that diseases have been crossing that species barrier for quite some time. Researchers just announced that seals first brought tuberculosis (TB) to North America. That’s right, seals.

Europeans brought a second strain of TB to the New World when the Spanish colonized South America in the 16th century.

TB certainly isn’t a new disease. It’s been around for somewhere in the neighborhood of 70,000 years.

Both ICD-9-CM and ICD-10-CM include multiple categories of TB codes depending on where the infection is present. In ICD-9-CM, coders need to choose the appropriate fifth character from:

  • 0, unspecified
  • 1, bacteriological or histological examination not done
  • 2, bacteriological or histological examination unknown (at present)
  • 3, tubercle bacilli found (in sputum) by microscopy
  • 4, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture
  • 5, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically
  • 6, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals)

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A little heat, please!

IciclesEvery have one of those days when you feel like you’ll never be warm? I’m having one of those. One of the downsides to have a window cube is the cold seeps in with the sunshine. Or with the dreary gray day.

Why am I so cold? Maybe I am hypothermic. Hypothermia is a medical emergency that occurs when your body loses heat faster than it can produce it, causing a dangerously low body temperature. Okay, maybe not. Out of curiosity, how would we code hypothermia in ICD-10-CM?

Well, we need to know the age of the patient. ICD-10-CM includes a series of codes for hypothermia in a newborn (P80.-). For adult patients, we need to know the cause of the hypothermia:

  • Hypothermia due to illness (R68.0)
  • Hypothermia, not associated with low environmental temperature (R68.0)
  • Hypothermia NOS (accidental) (T68)
  • Hypothermia due to anesthesia (T88.51)
  • Hypothermia due to low environmental temperature (T68)

If I were in fact hypothermic, it would be because it’s cold out, so T68.XXXA for an initial encounter. Notice you need three placeholder Xs for this code so your seventh character for the encounter is in the seventh position.

Under T68, we also find a note to use an additional code to identify the source of exposure:

  • Exposure to excessive cold of man-made origin (W93)
  • Exposure to excessive cold of natural origin (X31)

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Bundle up

Oh, the joys of being an 8-year-old with a snow day. Joey spent the weekend playing in his newly built snow fort without a hat, scarf, or pair of sunglasses. Now he’s complaining of hot, tender, itchy areas on his cheeks and forehead. Also, his lips and eyelids are really red.

IciclesDr. Frosty examines Joey and diagnoses chilblains and sunburn. That seems like a very odd combination, but is actually not unheard of.

Exposed skin can get sunburned even when the temperatures are below freezing. Apparently the sun doesn’t care how warm out it is. Sunlight reflects off the snow and ice and, as everyone who lives in snowy areas knows, it always finds the unprotected areas.

Sunburn is pretty easy to code in ICD-10-CM. All we need to know is what degree the sunburn is. That’s it. No location, no laterality, no episode of care.

Dr. Frosty documents a first-degree sunburn, so we would report L55.0 (sunburn of first degree).

On to those chilblains. Don’t know the difference between chilblains and frostbite? The big difference is whether the tissue freezes. If it does, the patient likely ends up with frostbite. Frostbite can be superficial or with tissue necrosis.

Chilblains are the painful inflammation of small blood vessels in your skin that occur when you suddenly warm up after being in cold temperatures.

Chilblains usually clear up in one to three weeks, but may reoccur.

This is another easy condition to code in ICD-10-CM. We only have one choice: T69.1.

Hopefully, Joey has learned his lesson and will now listen to his mom when she tells him to bundle up.

Jack Frost is on the prowl

Well, it’s not quite the polar vortex of 2014, but it’s definitely polar bear weather out there. As in, polar bears are the only ones who appreciate this kind of cold.

polar bearWe’re starting to see some casualties of the cold here at the Fix ‘Em Up Clinic, but thankfully, no one appears in imminent danger of death.

Most of our patients spent too long in the cold with inadequate protection and, as a result, developed frostbite. You don’t necessarily need to spend an extended period of time outdoors to develop frostbite. It can happen in 30 minutes when the wind chill is below 0°F.

In ICD-9-CM, we have four total codes for frostbite, depending on the location (face, hand, foot, and other and unspecified sites).

ICD-10-CM divides frostbite into two categories: superficial frostbite and frostbite with tissue necrosis. Each category is further divided by specific site (and we have a lot more than four sites).

If we have a patient with superficial frostbite of the hand, we would need to know which hand, whether any fingers were involved, and whether the wrist is involved. We also need a seventh character to denote the encounter.

You’ll find one Excludes2 note under Frostbite (code categories T33-T34):

  • Excludes2: hypothermia and other effects of reduced temperature (T68, T69.-)

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I’m done with Christmas

On the 12th day of Christmas my true love gave to me 12 drummers drumming and the noise is unbelievable. I’ve got a migraine.

I didn’t see any lights or odd visual disturbances beforehand, so this is a migraine without aura. And that makes the coding pretty simple. Migraines with aura have a lot more choices.12 drummers

For a migraine without aura, we need to know whether it is intractable or not intractable. Intractable means it doesn’t respond to treatment. We’re way too early in the process to know that, so for now, we’ll call it not intractable and see how the medication works.

The other piece of information we need to know is whether the patient is status migrainosus, meaning the migraine has lasted for at least 72 hours. I’m on hour two, so no status migrainosus. That gives us G43.009 (migraine without aura, not intractable, without status migrainosus).

Unfortunately, that’s not our only medical issue in the house today. Several of our drummers have developed carpal tunnel syndrome. This is another easily coded malady. We just need to know laterality to choose from:

  • G56.00, carpal tunnel syndrome, unspecified upper limb
  • G56.01, carpal tunnel syndrome, right upper limb
  • G56.02, carpal tunnel syndrome, left upper limb

How would we code the carpal tunnel surgery in ICD-10-PCS? Granted, most people have this procedure on an outpatient basis, but someone may opt to have this done during a hospital stay for another procedure.

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Two front teeth

11 pipers pipingOn the 11th day of Christmas my true love gave to me 11 pipers piping.

You know that saying about being careful what you wish for? It’s very true. I jokingly told my true love we needed musicians for all of these dancers, and voilà, today we have pipers. Unfortunately, they are very bad pipers. On the bright side, though, the noise from all of the birds currently residing here kind of drowns them out.

Apparently, the birds aren’t fond of the pipers and have been doing everything in their power to disrupt the concert. We’ve got geese weaving between legs, calling birds dive bombing, and hens pecking at feet.

The pipers apparently have had enough and are taking a break. Thank heaven.

Or not. Nick, John, and Steve have appropriated three of the pipes and are using them like lightsabers to see who can claim the title of Jedi Master. Nick just whacked John in the mouth, knocking out his two front teeth.

If you look up Loss, teeth in the ICD-10-CM Alphabetic Index, you are directed to see Absence, teeth, acquired.

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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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