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Stampede to the CDI director

Clinical documentation improvement (CDI) specialists are a passionate group and they love ACDIS director Brian Murphy. They love him so much, in fact, that his appearance in the exhibit hall at the 2015 ACDIS conference in San Antonio this week caused a stampede.

Spectacular CDI specialist Sharme was not quick enough to escape the oncoming masses and was trampled in the rush to Brian.

In addition to being passionate, CDI specialists are also polite and nurturing, so Sharme’s stay at the bottom of the stampede was relatively short. She did come out of it with some minor injuries, though.

At first, she was concerned that she might have a minor concussion, but Dr. Jon quickly ruled that out. Sharme only suffered a contusion on the back of her head. That bump wasn’t the only injury to her skull, however. She also suffered a 2-cm laceration behind her ear.

Sharme did not sustain any broken bones, but she did end up with a nice puncture wound on her hand courtesy of someone’s very high heel. Sharme avoided any more serious injuries and instead has a collection of bruises more colorful than a Texas sunset.

Because she is surrounded by CDI specialists, Sharme decided to appropriate an ICD-10-CM Manual and thrill her audience of assistants with a recitation of the codes for her wounds.

For the contusion to the head, we need to know the exact location. Contenders include:

  • Scalp
  • Eyelid and periocular area
  • Nose
  • Ear
  • Lip and oral cavity
  • Other parts of the head

Sharme ended up with a bump on the back of her head, so we’ll go with S00.83XA (contusion of other part of head, initial encounter).

For the laceration, we have the same options for location. Sharme’s wound falls under scalp, but we need some additional information before we code the injury. Does the wound contain any foreign bodies? Dr. Jon did not locate any, so our code is S01.01XA (laceration without foreign body of scalp, initial encounter).

On to the puncture wound. Without even looking in the ICD-10-CM Alphabetic Index, we know we’ll need laterality. We’ll probably also need to know whether any foreign bodies remained in the puncture.

Sharme’s left hand bore the brunt of the heel, which left a small piece of itself behind, so we would report S61.442A (puncture wound with foreign body of left hand, initial encounter).

We would also report individual codes for all of Sharme’s other contusions.

Sharme shows just how super she is, though, by returning to her duties as a conference room moderator.

Everything’s bigger in Texas, including the food

CatwStomachAcheSuper CDI specialist Cheryl loves Mexican food. Really, she loves it a little too much.

She decided to celebrate the end of her teaching duties at the Association of Clinical Documentation Improvement Specialists’ (ACDIS) annual conference with the super-duper-haven’t-eaten-in-two-months special at Lotsa Enchiladas Mexican Restaurant.

She awoke this morning with severe abdominal pain intensified by movement, nausea, and vomiting. At first, she wasn’t very concerned. She thought it was just the aftermath of a massive Mexican food binge. Then she noticed blood in her vomit and decided it was time to go to the hospital.

Dr. James diagnosed Cheryl with a nontraumatic stomach rupture. Her fellow CDI specialists Laurie and Sharme came to commiserate and wish her well. Then they headed back to the conference where they promptly searched the ICD-10-CM Alphabetic Index for a code for Cheryl’s malady.


Splash goes the CDI

CDI-Journal-ACDIS-2015-ADOur friends at the Association of Clinical Documentation Improvement Specialists (ACDIS) and 1,400 or so of their closest friends have descended on San Antonio for their annual conference. Things did not start off swimmingly.

Peerless CDI Laurie was out for a stroll along the Riverwalk when a very enthusiastic Great Dane decided to say hello, much to his owner (and Laurie’s) chagrin. The very Great Dane knocked Laurie into the San Antonio River. Unfortunately, a boat full of tourists was passing by just as Laurie took her tumble. The boat captain didn’t see Laurie and clipped her shoulder on the way by.


Conference preparation is not for wimps

MattOur friends at the Association of Clinical Documentation Improvement Specialists are putting the final touches on their conference preparations. They have sent off the final shipment to San Antonio (and not a moment too soon!).

Matt, who has been coordinating packing and shipping for the conference, fell afoul of some falling boxes in the warehouse. One of the boxes landed on his foot, squashing it flat. At least, that’s what Matt claimed. It turns out the box only crushed two toes. Still painful and not particularly pleasant, but not as bad as initially thought.

Our crack staff of CDI specialists immediately pulled out their ICD-10-CM Manuals to check on what documentation they need to code Matt’s injury.

We know Matt suffered a crush injury, so we start in the Alphabetic Index under crush, crushed, crushing. Judging by the list of options, you can crush a lot of body parts. ICD-10-CM does include an entry for foot, but also includes a more specific entry for toe(s)—S97.1-.

The dash tells us we need more characters for our code and we can find one of them in the Alphabetic Index. ICD-10-CM divides the toes into the great toe and the lesser toe(s). Which ones did the box crush?

Super CDI specialist Cheryl (a former ED nurse) identifies the great toe and one lesser toe as the injured parties. That means we’ll report two codes:

  • S97.11-, crushing injury of great toe
  • S97.12-, crushing injury of lesser toe(s)


A plague upon you and your pit bill

plague germsIn case getting allergic rhinitis from your dog wasn’t bad enough, a Colorado man contracted the plague from his pit bull. And then he may have passed it on to another person. Person-to-person transmission of the plague last happened in 1924.

In all, four people became infected with plague in 2014 through contact with the dog or his owner.

Eight Americans, mainly in the desert Southwest, contract plague each year on average. Fortunately, medical science has come a long way since the Middle Ages, and we can now successfully treat plague.

Because of its relative rarity here in the U.S., doctors don’t always suspect plague. In fact, physicians initially diagnosed the dog owner with pneumonia due to Pseudomonas (J15.1) before correctly diagnosing the plague.


April showers bring May flowers

And the flowers bring pollen. Achoo!

Allergy guy (1500x1136)Allergies are a fact of life for millions of Americans—approximately 30% of adults and 40% of children suffer from allergies, according to the American College of Allergy, Asthma and Immunology. That’s a lot of sniffling and sneezing.

What are all of these people allergic to? Just about everything:

  • Bee stings
  • Cat dander
  • Cockroaches
  • Dust
  • Grain
  • Grass
  • Peanuts
  • Pollen
  • Ragweed
  • Rose pollen
  • Shellfish
  • Wheat


ICD-10 is better in Texas

CDI-Journal-ACDIS-2015-ADOur friends at the Association of Clinical Documentation Improvement Specialists hold their annual conference next month in San Antonio, Texas. And like everything in Texas, it’s going to be BIG.

And ICD-10 will play a big part in the conference from the start. In fact, one of the three pre-conferences May 17-18 is the ICD-10 for CDI Boot Camp. (If you are interested in the Boot Camp, but can’t make the conference, you can attend other live programs across the country or take the Boot Camp online.)

Its focus on ICD-10 documentation improvement continues to the general session on Day 1 (May 19) of the main conference when Donna Smith, RHIA, discusses how ICD-10 will affect APR-DRGs using real-world examples.

Then James S. Kennedy, MD, CCS, CDIP, gets things rolling in the Clinical and Coding track with his session on Coding Clinic. As you probably know, the AHA started answering only ICD-10 related questions in first quarter 2014. We have six issues under our belts and lots of advice to digest before October 1.


Game over

Video game guyYou learn something new every day. Today’s new fact: you can be a professional video game player. I’m not sure why that surprises me. After all, video games have come a long way from the Atari and Pong days (Or so I hear. I stopped playing video games around the time Pac-Man became passé).

Like anyone who performs repetitive movements over and over, gamers can develop repetitive strain injuries (RSI). Gamers can develop Nintendo thumb where the base of the thumb meets the wrist.

Sadly, we do not have ICD-10-CM codes for Nintendo thumb or gamer’s grip. I also doubt that you see physicians documenting Nintendo thumb.

This particular RSI can be a form of tendinitis, tenosynovitis, or a combination of both.

ICD-10-CM offers plenty of codes for those injuries. But what is the difference?

Tendonitis means inflammation of a tendon. The term tendonitis is usually used for tendon injuries that involve acute injuries accompanied by inflammation.

Tenosynovitis means inflammation of the sheath that surrounds a tendon. (The sheath is called the synovium.)

Patients may also suffer from tendinosis (chronic degeneration of a tendon without inflammation) or tendinopathy (a more general term that just means tendon injury). Make sure you pay close attention to what the physician actually documents.


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.