Coders and clinical documentation improvement (CDI) specialists have different perspectives and priorities even on common diagnoses.
HCPro boot camp instructors Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Cheryl Ericson, RN, MS, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, are ready to help you bridge the communication gap! Join us at 1 p.m. (Eastern) tomorrow for the live 90-minute webinar, Common Diagnoses in ICD-10-CM: Bring CDI and Coding Together.
Shannon and Cheryl will explain the coding and CDI perspectives on:
- Poisoning/adverse effects/underdosing
- Substance use/abuse/dependence
- Acute respiratory failure
They will also offer tips you can use in your facility to improve communication between coders and CDI specialists.
The program also offers both AHIMA and AAPC credits.
So bring the whole team and build momentum for the final year of ICD-10 preparation.
Can’t get everyone together for the live program? No problem. You get a free on-demand version of the webinar so everyone can listen when it’s convenient and still earn CEUs.
See you at the show!
With flu season just around the corner (hey, where did summer go?), Melissa took her 4-year-old son Andrew to Dr. Spock, the pediatrician, for his flu shot Wednesday.
How would we code this visit in ICD-10-CM? From a diagnosis coding standpoint, it’s pretty easy. If you look up Vaccination in the ICD-10-CM Alphabetic Index, you’re directed to code Z23 (encounter for immunization).
We do need to pay attention to two notes with this code. First, ICD-10-CM instructs us to code for any routine childhood examination. In Andrew’s case, he was just visiting for a flu shot, so no routine exam. If he had gone in for a yearly physical or another problem and just happened to get his flu shot at the same time, we would code the vaccination second.
The other thing to note is Z23 is a very general diagnosis code. We don’t have codes for the specific vaccination. Instead, we need to report the vaccine using a HCPCS code for the drug and a CPT® code (in the outpatient setting) for the actual administration. ICD-10-CM includes a note in the Tabular List stating, “Procedure codes are required to identify the types of immunizations given.”
Andrew weathered his vaccine administration fine, but when it comes to the actual vaccine, things didn’t go as well. When Melissa was getting Andrew ready for preschool Friday, she noticed the injection site was red, inflamed, and hot to the touch. Andrew also reported it was a little itchy.
Back to Dr. Spock they go. Dr. Spock allayed Melissa’s fears of cellulitis and diagnosed an adverse reaction to the vaccine.
What would we code for this visit? Instead of heading to the Alphabetic Index (although we could do that if we wanted to), we’re going to the Table of Drugs and Chemicals. The table is located in the front of the ICD-10-CM Manual, just like it is in the ICD-9-CM Manual and the tables work pretty much the same way.
In the ICD-10-CM Table of Drugs, we find the following headings:
- Poisoning, accidental (unintentional)
- Poisoning, intentional self-harm
- Poisoning, assault
- Poisoning, undetermined
- Adverse effect
The headers in ICD-10-CM differ from those in ICD-9-CM. For example, in ICD-9-CM, any poisoning that was intentional is classified as a suicide attempt. In ICD-10-CM, that category becomes poisoning, intentional, self-harm, which is a little more generic. Some people may intentionally poison themselves with a specific drug, but they are not attempting suicide.
You’ll also notice that the codes now start with T.
Underdosing is a new concept in ICD-10-CM, but it doesn’t really relate to Andrew’s vaccine reaction.
In ICD-9-CM, we don’t have a specific heading for an adverse effect. We use the therapeutic use column, which is a little ambiguous.
However, we know that Andrew suffered an adverse effect from the vaccine, so we would use a code from that column. But which code?
We can find it two ways. First, you can look up “influenza vaccine” and lo and behold, there’s the code. Or you can look up “vaccine,” then scroll through the list to find influenza. Either way you still end up with ICD-10-CM code T50.B95 (adverse effect of other viral vaccines).
Because we know not to code from the Alphabetic Index alone, we check the Tabular List to make sure we have all of the characters we need and that the code actually matches the diagnosis.
We have the correct code, but if you flip all the way back to the start of the T50 series of codes, you’ll see a notation that a seventh character is required for all of the T50 codes. Since this is Andrew’s first visit for his adverse reaction to the flu vaccine, we would use seventh character A. The correct code is T50.B95A.
Without the A, the code is invalid and you won’t get paid.
However, we’re not done coding just yet. If you look at the very beginning of the Poisoning by, adverse effects of and underdosing of drugs, medicaments and biological substances (T36-T50) category, you’ll see several more notes, including:
Code first, for adverse effects, the nature of the adverse effect, such as:
- Adverse effect NOS (T88.7 )
- Aspirin gastritis (K29.-)
- Blood disorders (D56-D76 )
- Contact dermatitis (L23-L25 )
- Dermatitis due to substances taken internally (L27.-)
- Nephropathy (N14.0-N14.2)
What adverse effects did Andrew suffer? We know he had a rash and pain. If we look up rash, we find a code for rash following immunization:
- T88.1, other complications following immunization, not elsewhere classified
- Generalized vaccinia
- Rash following immunization
Again we need our seventh character for the encounter, but we also need two placeholder Xs. Our final code is T88.1XXA.
The itch is a symptom that rolls into the rash code, so we don’t need to code it separately.
Fortunately, Andrew will soon be on the mend (vaccine reactions typically clear up in a few days).
Some days I swear I have the attention span of a hyperactive hummingbird or Dug the talking dog from the movie “Up.” Maybe what I really have is attention deficit disorder (ADD). How would you code ADD in ICD-10-CM?
If you look up “attention” in the ICD-10-CM Alphabetic Index, you will indeed find an entry for “deficit disorder or syndrome” and code F98.8 (other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence).
F98.8 is a pretty general code. In the Tabular List, F98.8 does not specify ADD, but does provide these conditions:
- Excessive masturbation
I know a lot of people who bite their nails (everyone I know has given up thumb-sucking and nose-picking though).
I wonder if ICD-10-CM might have a better code for a short attention span. It doesn’t really seem to fit with the other listed conditions.
Back to the Alphabetic Index. Under “attention, deficit disorder,” we find a subentry specifying “with hyperactivity.” For patients with attention deficit hyperactivity disorder (ADHD), we are instructed to “see Disorder, attention-deficit hyperactivity.”
When we get to that listing in the Alphabetic Index, we find out that ICD-10-CM includes codes for several types of ADHD:
- F90.0, attention-deficit hyperactivity disorder, predominantly inattentive type
- F90.1, attention-deficit hyperactivity disorder, predominantly hyperactive type
- F90.2, attention-deficit hyperactivity disorder, combined type
- F90.8, attention-deficit hyperactivity disorder, other type
- F90.9, attention-deficit hyperactivity disorder, unspecified type
In the Tabular List (remember we should never code from the Alphabetic Index alone), we also find two notes.
The Includes note tells us that attention deficit disorder with hyperactivity and attention deficit syndrome with hyperactivity fall under category F90.
The Excludes2 note tells us that the following conditions are not included in F90:
- anxiety disorders (F40.-, F41.-)
- mood [affective] disorders (F30-F39)
- pervasive developmental disorders (F84.-)
- schizophrenia (F20.-)
Because this is an Excludes2 note, we can code both ADHD and these disorders in the same patient as long as the physician documents both conditions.
After doing a little more research on ADHD, I’m pretty sure that’s actually not my problem. Well, at least I…oh, look, a squirrel!
CMS is currently hosting an ICD-10 “Code-a-thon” (a title which instantly brings to mind all of the PBS pledge drives I’ve unwittingly watched). One of the questions that has come up repeatedly is when to use A as the seventh character in an ICD-10-CM code.
I think part of the confusion comes from the quick definition of A: initial encounter. You will use seventh character A for more than the first time the patient sees a physician for treatment of an injury.
According to the ICD-10-CM Official Guidelines for Coding and Reporting, coders should use seventh character A when the patient is receiving active treatment, including:
- Surgical treatment
- ED encounter
- Evaluation and treatment by a new physician
James comes into the ED after breaking his arm. Dr. Bones evaluates James and diagnoses a nondisplaced fracture of the neck of the right radius. Dr. Bones stabilizes the injury and sends James home with instructions to see an orthopedist.
ED coders would report S52.134A (A for the initial encounter).
The following day, James sees Dr. Stetter, an orthopedist. Dr. Setter determines that James does not require surgery on his arm and instead immobilizes it in a cast. Dr. Setter’s coder will report S52.134A, exactly the same code that the ED coder reported.
Instead of thinking A for initial encounter, think of it as A for active treatment. If the patient is being actively treated and is not in the healing phase, use seventh character.
Ebola has been in the news quite a bit recently and it’s actually a good global case study for why we should be using ICD-10-CM codes.
ICD-9-CM does not include a specific code for Ebola. It gets lumped in with other specified viral infections in code 079.89. So in the U.S., we have no idea how many people suffer from Ebola (I think the last confirmed count was three).
In many other countries, they can monitor the rates of Ebola, along with a host of other infectious diseases. The code for Ebola in ICD-10-CM is A98.4, in case you’re wondering.
You may be thinking, who cares? Three cases of Ebola aren’t many. Why do we need to know?
The world is becoming a smaller place every day. Travel is faster and cheaper, and while security will pat you down looking for weapons, nobody checks to see if you are infected with a potentially fatal disease.
Still don’t think it’s important to know what’s making people sick? Harken back to the glory days of 2002 when a new virus know as severe acute respiratory syndrome (SARS) hit the world stage. SARS took only a few weeks to infect people in 37 countries.
The fatality rate for SARS was a little under 10%. Ebola is fatal in more than half of the cases.
More specific codes allow for better public health monitoring and better disease tracking. Without effecting tracking and monitoring, we can’t effectively identify and try to contain an outbreak.
We also can’t tell how well a particular treatment is working or even if it is working at all. And you certainly can’t determine how many people are dying from a disease like Ebola.
Maybe you don’t care about swapping stats with other countries (I’ve heard that from a few people who are not in favor of moving to ICD-10). Personally, I’d like to know what’s out there that could kill me so I know what to avoid.
The truth is often stranger than fiction because fiction has to make sense.
Apparently a panda in China figured out that pregnant pandas get better treatment, so she pretended to be expecting.
Instead of hearing the pitter-patter of baby panda paws, her keepers discovered they were dealing with a master deceiver.
Fake pregnancies do occur in humans, but they are more likely to happen in animals. If we had a patient who was faking a pregnancy, how would we code it?
It depends on our patient’s symptoms.
A fake pregnancy in humans can be an outright lie, which could mean you are dealing with a patient who suffers from a mental disorder. In those cases, the patient may have a factitious disorder (deliberately and consciously acting as if you have an illness when you aren’t sick).
ICD-10-CM includes four code choices for factitious disorder:
- F68.10, factitious disorder, unspecified
- F68.11, factitious disorder with predominantly psychological signs and symptoms
- F68.12, factitious disorder with predominantly physical signs and symptoms
- F68.13, factitious disorder with combined psychological and physical signs and symptoms
Since the panda in question was only displaying pregnancy behaviors, we would code F68.11.
Sometimes, though, a woman may believe she is pregnant when she’s not. False pregnancy, clinically termed pseudocyesis, is the belief that you are expecting a baby when you are not really carrying a child. In ICD-10-CM, we would report F45.8 (other somatoform disorders).
The ICD-10-CM Alphabetic Index includes the term pseudocyesis, but it’s not explicitly listed as one of the included terms under F45.8.
Not every physician will diagnose a false pregnancy as pseudocyesis. Instead the physician may simply document the patient’s symptoms, such as lack of appetite, nausea and vomiting, enlarged breasts, milk production, and interruption of the menstrual period.
The physician may think the patient is pregnant, but orders a pregnancy test to be sure. If the physician orders a blood test, you won’t know the results when the patient leaves the office after the visit. If the physician documents “possible pregnancy” in the outpatient record, we can’t code pregnancy. We have to code the signs and symptoms.
ICD-10-CM includes two possible codes for lack or loss of appetite:
- R63.0, anorexia (loss of appetite)
- F50.8, other eating disorders (psychogenic loss of appetite)
For the nausea and vomiting, we would report R11.2 (nausea and vomiting, unspecified).
Make sure you are not coding the conditions separately, since ICD-10-CM also includes these codes:
- R11.0, nausea
- R11.10, vomiting
- R11.11, vomiting without nausea
- R11.12, projectile vomiting
- R11.13, vomiting of fecal matter
If our patient is an inpatient, we should know at the time of discharge whether she is pregnant. However, if the physician documents “possible pregnancy” for an inpatient, we would report the pregnancy code as if the pregnancy was confirmed.
You should already be used to that distinction because we have the same rule in ICD-9-CM. No coding of possible, probably, suspected, or rule out diagnoses on the outpatient. On the inpatient side, report them as if they were present.
On a happier note, another Chinese panda recently gave birth to triplets. Hopefully, all three will survive.
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.