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Let that ulcer bleed

blood dropAlex comes in to see Dr. Guts complaining of fatigue and tiredness, as well as some slight abdominal pain. After performing a complete exam and blood tests, Dr. Guts diagnoses Alex with a bleeding peptic ulcer.

Dr. Guts determines that Alex needs surgery to control the bleeding.

Dr. Guts has plenty of techniques to choose from to stop the bleeding. She can cauterize the ulcer or inject medication. In Alex’s case, she decided to clip the ulcer to stop the blood flow.

Generally, this surgery is performed in the outpatient setting, but our crack coders at Stitch ‘Em Up Hospital are coding it for ICD-10-PCS so they can compare inpatient and outpatient data.

So how are they coding this procedure?

We know we’re in the Medical and Surgical section (first character 0). We know we’re in the gastrointestinal body system (second character D).

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Meet the family

news blocksCMS offered some clarity on what it considers to be a family of codes in ICD-10-CM.

You might remember that CMS struck a deal with the American Medical Association (AMA) to get AMA on board with ICD-10. For the first year of ICD-10 use, CMS will not deny or audit claims based solely on the specificity of diagnosis codes, as long as the codes on such claims are from the correct family of codes.

Unfortunately, CMS didn’t specify at the time what it meant by “family of codes.” Apparently, a lot of people raised questions about just how CMS’ plan would work because the agency released Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities. The document includes 13 questions and answers, including three focused on the family of codes.

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Blame it on the armadillos

ArmadilloLeprosy cases are surging in Florida, with new cases in the first half of 2015 nearing the average total for an entire year. The potential source of this explosion (to use the term very loosely) of cases: armadillos.

Don’t panic, though. Florida typically sees 10 cases of leprosy per year. In the first half of 2015, the number of cases has already reached nine. Nine people does not a real outbreak make, but it is enough to make the national and international news.

Officials are blaming contact with armadillos for the spike in leprosy cases. Personally, I’m not interested in shaking paws with an armadillo (or any wild animal for that matter), but some people just want to embrace nature.

Some armadillos also like to spit at people (usually when the armadillo is in a cage). Mycobacterium leprae bacteria, which causes leprosy, can be transmitted through spit.

Fortunately, leprosy is hard to contract (most people are actually immune to it). However, all nine people who contracted leprosy in Florida this year reported contact with armadillos and some nine-banded armadillos do carry leprosy. They are the only animals that do, by the way. Sadly, they do not also carry signs telling you they are leprosy positive.

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Is that injury acute or chronic?

ICD-10 knee derangementJoe comes into the Fix ‘Em Up Clinic to see Dr. Bones for a problem with his knee. Joe tells Dr. Bones that his right knee locks up occasionally and he often has pain in his knee. Joe denies any traumatic injury. He tells Dr. Bones the knee will lock when he stands up after kneeling on the floor. He’s experienced the problem for almost a year.

Dr. Bones diagnoses Joe with a torn meniscus. But is Joe’s injury acute or chronic?

Meniscal tears are not always necessarily traumatic, and they’re not necessarily acute. According to Dr. Bones’ documentation, Joe has experienced problems with his knee for almost a year and Joe didn’t suffer any trauma at this time that caused him to seek treatment.

Dr. Bones doesn’t specify whether the injury is acute or chronic.

If you look in the ICD-10-CM Alphabetic Index under ”tear, meniscus,” it immediately gives us an S code for a traumatic injury. That makes the traumatic injury the default code.

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So long urosepsis

urosepsis_tombstone (2)Alas, poor urosepsis. I knew him, Horatio, a condition of infinite vagueness. And thankfully, one ICD-10-CM is putting out to pasture. Now, if only the physicians would get on board.

Physicians frequently use the term urosepsis to refer to a systemic inflammatory response initiating from a urinary source, but without further detail in ICD-9-CM this diagnosis defaults to a urinary tract infection (UTI) with code 599.0.

So is the patient septic or does the patient have a UTI? Or does the patient have sepsis secondary to the UTI?

Based on documentation of “urosepsis,” you can’t tell. Coders often query physicians to clarify whether they are documenting a UTI or sepsis.

ICD-10-CM does not include the term urosepsis. The ICD-10-CM Official Guidelines for Coding and Reporting state:

The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification.

Physicians are going to love that (not at all).

Part of the problem may be the way physicians view documentation. Physicians are taught to document for other physicians, not for coders. Physicians can also interpret clinical information that another physician documents, but coders can’t interpret. We can only query for clarification.

Sadly, urosepsis isn’t the only problem term related to sepsis. Physicians often use the terms “bacteremia,” “septicemia,” and “sepsis” interchangeably, even though those terms refer to different clinical conditions.

Learn how sepsis coding will change in ICD-10-CM and when to query physicians for additional information during the live webcast, Prepare for Sepsis Documentation & Coding in ICD-10-CM. During this 90-minute webcast at 1 p.m. (Eastern) Friday, July 31, Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, AHIMA-approved ICD-10-CM/PCS trainer and Robert S. Gold, MD, will review sepsis clinical information as well as the ICD-10-CM guidelines for coding sepsis. In addition, they will offer best practices for coding and documentation in ICD-10-CM, including physician queries.

Run, it’s a bull

Angry bullPeople do some strange things on vacation. I mean, really, really strange things.

Take Mike, for example. Mike just returned from his European vacation and has come into the Fix ‘Em Up Clinic for a follow-up visit for injuries suffered during his trip. Did I mention he was in Pamplona, Spain? You know, where they let the bulls chase people through the streets.

Mike thought it would be fun to try and outrun a 2,000-pound enraged bovine through twisty streets in a town he’d never visited before.

This wasn’t Mike’s best plan. In fact, one of the bulls not only caught the fleeing vacationer, he gored Mike in the armpit. The Spanish doctors patched Mike up and sent him back to America.

Dr. Horn is seeing Mike for follow-up treatment of the wound. But what kind of wound is it? Dr. Horn’s notes say Mike was gored by a bull. The ICD-10-CM Alphabetic Index doesn’t include gore or gored as terms.

Fortunately, Dr. Horn also documents that Mike has a deep puncture wound as a result of being gored.

When we look up “puncture” in the ICD-10-CM Alphabetic Index, we find a wonderfully long list of puncture sites. However, the list does not include “armpit.” Okay, thinking back to anatomy class, what is a more clinical term for armpit? Oh, I’ve got it—axilla!

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CMS affirms yearlong ICD-10 transition in accord with AMA

news01After a vigorous, last-ditch push by the AMA for a two-year transition period after implementation to protect physicians from all ICD-CM coding errors and mistakes, CMS and AMA made a joint announcement that appears to signal a burying of the hatchet.

Steven Stack, MD, AMA’s president, touts the changes in a post that begins with a concession his group has resisted stating for years: “Implementation of the ICD-10 code set is just around the corner, with a hard deadline of Oct. 1.”

To gain that admission from the AMA, CMS agreed to a variety of policies involving claim denials, quality reporting, payment disruptions, and navigating the transition.

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Not-so-fabulous Fourth of July

FirewordsThe Fourth of July is in the books for another year and once again, we saw an interesting assortment of patients in the Fix ‘Em Up Clinic over the weekend. Let’s take a look at some of the more challenging cases.

Anytown held a Highland Horribles parade Friday night, complete with the worst-crafted floats (and worst-costumed participants) ever seen. That’s why it’s a “horrible” parade. One of the floats (complete with a fabulously fake Liberty Bell) unfortunately broke down halfway through the parade and several spectators came out to help push it out of the way.

The float collapsed as it was pushed off Main Street, and the bell, now at liberty from the float, went careening into the crowd. Most people were quick enough to get out of the way, but Bob was so busy critiquing the float removal crew that he didn’t see the giant fake bell coming at him.

The bell thankfully was not made of copper and tin, but rather of papier-mâché and chicken wire. Still, it was big enough to knock Bob down and he put out his hand to break his fall. He broke more than that. He also broke his arm.

Not wanting to miss any of the festivities, Bob waited until today to come in the clinic. Dr. Setter sent Bob for x-rays and discovered a Colles’ fracture of the right arm. Hmm, I wonder if we can code that term? Maybe we’ll need to query Dr. Setter. [more]

Here there be monstrous tumors

shutterstock_51169732Jurassic World is ruling the box office, so I thought I would use another blast from the past for the blog. Archeologists in Peru recently uncovered the skeleton of a teenage girl in a historic cemetery of the Chapel of the Divino Niño Serranito de Eten.

Big deal, right? A skeleton in a cemetery. Well, this particular skeleton included something extra—83 strange bits of bone and 37 oddly shaped teeth in her abdominal cavity.

That’s not something you see every day. Archeologists believe the extra bones and teeth represent the remains of an ovarian teratoma, a usually benign tumor in the ovary that contains various tissues including hair, teeth, and bone.

While this teratoma is really old, physicians still see these growths today. In fact, mature cystic teratomas account for 10-20% of all ovarian neoplasms. As a reminder, a neoplasm can be benign or malignant. By definition a neoplasm is new, abnormal growth of tissue.

If this girl came in to the Fix ‘Em Up Clinic, how would we code her condition?

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Disemboweling documentation difficulties

shutterstock_46900594Richard came in to see Dr. Guts complaining of severe abdominal pain, nausea, vomiting, and blood in his stool. Dr. Guts sends Richard for a battery of tests and discovers Richard suffers from a Meckel’s diverticulum.

When we look up diverticulum, Meckel’s in the ICD-10-CM Alphabetic Index, we find two nonessential modifiers with the entry:

  • Displaced
  • Hypertrophic

Nonessential modifiers are supplementary words that may be present or absent in the statement of a disease or procedure without changing code assignment. It doesn’t matter if Dr. Guts includes the words “displaced” or “hypertrophic” in the diagnosis. We’re still reporting the same code (Q43.0).

The only time we would use a different code for Meckel’s diverticulum is if Dr. Guts states the diverticulum is malignant. In that case, the ICD-10-CM Alphabetic Index instructs us to “see Table of Neoplasms, small intestine, malignant.”

You probably noticed that our diagnosis code falls within the congenital malformations, deformations and chromosomal abnormalities chapter of ICD-10-CM. A Meckel’s diverticulum is a pouch on the wall of the lower part of the intestine that is present at birth, making it congenital. Patients may not have symptoms until years later.

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