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Black Friday with the animals

NY tigerWe’ve survived the holiday feast and decided to skip the doorbusting to head out and visit the cute and fluffy animals at the Anytown Zoo.

Of course, no outing would be complete without some injuries. Oh, the joys of group outings.

Our first stop was the tiger enclosure, where a glass viewing window lets you get up close and personal with the rather large felines. One of the tigers decided it would be fun to play tag with the people and charged the glass. She pulled up in time to avoid giving herself a concussion, but she did send Andrea scrambling away from the glass.

Andrea tripped over a rock and went sprawling. She ended up with lacerations on her palms and a scrapped right knee (her jeans didn’t fare well, either).

Even though we aren’t at work, we’re going to code Andrea’s injuries anyway. We know we’re dealing with lacerations to the right and left hands, but is there any debris remaining in the wounds? Fortunately for Andrea, there isn’t. So our codes would be:

  • S61.411A, laceration without foreign body of right hand, initial encounter
  • S61.412A, laceration without foreign body of left hand, initial encounter

For the knee injury, we need to know the same information. We know it’s the right knee and it looks like some small rocks are embedded in it. Our code for this injury is:

  • S81.021A, laceration with foreign body, right knee, initial encounter

Andrea is all cleaned up and we are off to the reptile house where Steve thought it would be a good idea to smuggle out a baby cobra. Baby cobra was not down with that plan, however, and sank its fangs into Steve’s left hand.

ICD-10-CM includes a plethora of codes for toxic animal bites, including one for a cobra. However, we do need some additional information. Was this accidental, intentional self-harm, assault, or undetermined?

Well, the baby cobra definitely meant to assault Steve, but that’s not what ICD-10-CM means by assault. Assault would be Andrea throwing the cobra at Steve because he made fun of her fall.

Our actual code would be T63.041A, toxic effect of cobra venom, accidental (unintentional), initial encounter.

The reptile house proved to be a very poor choice of place to visit. The Madagascar hissing cockroaches not only gave us all the creeps, they caused Jackee to hyperventilate and have an asthma attack.

The ICD-10-CM asthma codes look very different from their ICD-9-CM counterparts. ICD-10-CM divides asthma into these subcategories:

  • J45.2-, mild intermittent asthma
  • J45.3-, mild persistent asthma
  • J45.4-, moderate persistent asthma
  • J45.5-, severe persistent asthma

Each subcategory includes these options:

  • Uncomplicated
  • With (acute) exacerbation
  • With status asthmaticus

We also have a note in the ICD-10-CM Tabular List to use an additional code to identify:

  • Exposure to environmental tobacco smoke (Z77.22)
  • Exposure to tobacco smoke in the perinatal period (P96.81)
  • History of tobacco use (Z87.891)
  • Occupational exposure to environmental tobacco smoke (Z57.31)
  • Tobacco dependence (F17.-)
  • Tobacco use (Z72.0)

Asthma also has both an Excludes1 (mutually exclusive) note and an Excludes2 (not included, but may also have) note. Be sure you check those when you code asthma.

Sadly, we’re going to have to call a halt to our zoo excursion for the day after we get Steve a fake snake from the gift shop.

Support your turkey

TurkeyTom Turkey has come in to the Stitch ‘Em Up Hospital for a little work before Thanksgiving.

Dr. Carver is going to first take out Tom’s guts, then replace them with stuffing. How would we code Tom’s procedures?

Let’s start with the organ removal. Dr. Carver is removing the entire organs, so we know our root operation will be Resection.

So which body parts are we taking out of Tom? Well, let’s see. We don’t want the heart, lungs, liver, gizzard, gall bladder, crop, duodenum, ileum, jejunum, colon, and kidneys inside Tom.

In ICD-10-PCS, we would report a code for each separate body part. For example, if we are coding for the removal of Tom’s lungs, we would report code:

  • 0BTM0ZZ, Resection of bilateral lungs, open approach

If Dr. Carver only removed one lung, we would use either K (right lung) or L (left lung) as our fourth character.

We will do the same thing for the intestines. ICD-10-PCS includes separate body part values for the small intestine, as well as the duodenum, ileum, and jejunum. Because we are removing the entire small intestine, we would report 0DT80ZZ (Resection of small intestine, open approach).

If Dr. Carver removed part of Tom’s small intestine, we would use the body part character for the appropriate section:

  • 9, duodenum
  • A, jejunum
  • B, ileum

Read the operative report carefully, not only to identify the correct body part, but also to make sure you choose the correct root operation. Dr. Carver may only remove a section of the ileum or duodenum. In that case, we would report the procedure using root operation Excision (cutting out or off, without replacement, a portion of a body part), not Resection.

Once Dr. Carver has completed the internal organ removal, it’s time to replace them with supplemental material (also known as stuffing).

Which root operation would we use to report stuffing Tom? Our possibilities include:

  • Insertion—putting in a non-biological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part
  • Replacement—putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part
  • Supplement—putting in or on biologic or synthetic material that physically reinforces and/or augments the function of a portion of a body part

Since the stuffing is not really taking over the function of Tom’s missing body parts, it looks like Replacement is the closest match by intent. However, if you look at the ICD-10-PCS tables, you will notice that the tables for Replacement don’t include options for the complete organ. That makes sense because we don’t really have functioning artificial organs. And if the patient is receiving a new biologic organ, we would use root operation Transplantation (putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part).

If we were putting in stuffing to help support one of Tom’s organs, we would use root operation Supplement. For example, if we were shoring up his large intestine with stuffing, we would report 0DUE0JZ (Supplement large intestine with synthetic substitute, open approach). I went with a synthetic substance since stuffing isn’t really a biological material.

Again, you need to identify the specific body part because we have body part characters for the:

  • Large intestine as a whole (E)
  • Right large intestine (F)
  • Left large intestine (G)

We also need to look for two other elements for this procedure:

  • The approach
  • The supplemental material

The approach can be:

  • Open (0)
  • Percutaneous endoscopic (4)
  • Via natural or artificial opening (7)
  • Via natural or artificial opening endoscopic (8)

The type of material could be:

  • Autologous tissue substitute (7), which comes from the patient
  • Synthetic substitute (J), which is not biologically derived
  • Nonautologous tissue substitute (K), which comes from someone other than the patient

Once Dr. Carver sews up Tom, he’ll be ready for discharge to the oven, where we can roast him to perfection.

The truth will out

Oh, that Jose Canseco. Such a kidder.

Severed fingerTurns out, his claim that his finger fell off during a poker game was a joke. He did actually shoot part of it off “cleaning” his gun and did indeed have it reattached. However, it’s still attached to his hand and not frozen for posterity (or future sale on eBay).

Why would Jose tell such a whopper? (NOTE: all of the suppositions in this post are just for fun and are not intended to be actual diagnoses of a specific individual. In other words, we’re pretending.)

Maybe he suffers from F60.81 (narcissistic personality disorder). Individuals with narcissistic personality disorder grow up feeling superior and needing to be admired. They have a longstanding pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy. Well, he was an adored pro athlete. He wrote a book about steroids in baseball. He tried to one-up the Philae lander’s touchdown on a comet.

Another possibility is histrionic personality disorder, which is characterized by a pattern of excessive attention-seeking emotions. People with histrionic personality disorder have a high need for attention, make loud and inappropriate appearances, exaggerate their behaviors and emotions, and crave stimulation. That would dovetail nicely with his possible F63.0 (compulsive gambler).

By his own admission, Canseco used anabolic steroids during his playing days, so maybe he is suffering from T38.7X1- (anabolic steroid poisoning). Or perhaps he’s suffering consequences of F55.3 (steroid abuse).

Perhaps Jose is really an F60.2 (pathological liar). Or maybe he has F07.81 (postconcussion syndrome) from the baseball that hit him in the head and bounced over the fence for a home run. The F07.81 could also be a result of his foray into boxing and mixed martial arts.

Most likely, though, he’s not suffering from any clinical condition. He just thought it would be funny.


It’s all fun and games until the finger falls off

Severed fingerBaseball fans may remember Jose Canseco as part of the Oakland A’s slugging duo, the Bash Brothers. He made a lot of money hitting the ball very, very far. I hope he saved some for his medical bills.

In October, Jose was cleaning a gun and accidentally shot off part of his left middle finger. According to Jose’s girlfriend, the finger was hanging on by a thread because Jose blew away an artery and a chunk of bone.

If we were to code Jose’s mishap, we would need some additional information. We already know the laterality and the specific finger. We also know it’s a partial amputation and it’s pretty traumatic. With that information, we can head to category S68 (traumatic amputation of wrist, hand, and fingers). Note that if the physician does not specify whether the amputation is complete or partial, you default to complete.

The next piece of information we need is where on the finger the partial amputation occurred. We have two choices:

  • S68.123-, partial traumatic metacarpophalangeal amputation of left middle finger
  • S68.623-, partial traumatic transphalangeal amputation of left middle finger

We also need a seventh character to denote the encounter.

We can also add some external cause codes to explain what happened to Jose:

  • W32.0XXA, accidental handgun discharge, initial encounter (this was operator error, not a mechanical failure)
  • Y92.019, unspecified place in single-family (private) house as the place of occurrence of the external cause (We know from media reports that he was home, but we don’t know which room. Really, it doesn’t matter much for our purposes, but his insurance company may want to know.)
  • Y99.8, other external cause status

We don’t know what specific treatment Jose had for his finger (I wasn’t interested enough to really dig in). So instead we’re going to look at how you would code a finger reattachment in ICD-10-PCS. For purposes of today’s post, we’re going to pretend Jose lost the whole finger (just make sure you don’t pretend or assume when you’re coding in the real world).

When we code for reattaching a body part, we’re going to use root operation Reattachment. That makes sense.

Our body system will be the upper extremities, which leads us to table 0XM.

ICD-10-PCS includes a body part character to each finger on each hand, so we know exactly which finger we’re dealing with. We’ll look for left middle finger, which gives us fourth character R. The rest of the code is a cakewalk because we only have one choice for each of the final three characters:

  • Open approach (0)
  • No device (Z)
  • No qualifier (Z)

That makes our reattachment of the left middle finger code 0XMR0ZZ.

Sadly, Jose’s finger decided it didn’t want to stick around. Late last week, Jose noticed the finger was starting to smell bad. Um, Jose, that’s probably gangrene. You should go to a doctor.

Instead, he went to a poker tournament in Las Vegas and claims the finger fell off. That probably falls under T87.2 (complications of other reattached body part). Note this is a not elsewhere classified code. We know the body part, we just don’t have a more specific code.

We also don’t have an external cause code for playing cards. Maybe they’ll add that in the first round of ICD-10-CM updates.

Even the rich and famous get sick

As healthcare professionals, we’re all familiar to some degree with HIPAA. You know, the law that makes it illegal to release protected health information, among other things. Hospital employees have been fired for snooping into celebrities’ records. So it’s always interesting to see what health information celebs voluntarily share.

Sick starAngelina Jolie went very public with her decision to undergo a double mastectomy because of a higher likelihood she would get breast cancer.

Actor Hugh Jackman has been equally candid about his repeated bouts of skin cancer. How would we code Jackman’s cancer? First we need to know what kind of cancer he’s had. Luckily for us, he’s told the world it’s basal cell carcinoma (BCC).

BCC is the most common type of skin cancer, so in the Table of Neoplasms, we would look under skin. Not surprisingly, we see we need to know where on the skin his cancer was. Through the magic power of the Internet, we know it was on his nose—all three times.

Scanning down the many rows of skin cancer, we finally find nose, which gives us C44.301 (unspecified malignant neoplasm of skin of nose). Well, that’s not right. We know what kind of cancer it is.

Let’s go back to the table and look up nose. Okay, we have lots of choices under nose, including skin. And under skin, we find a specific entry for BCC—C44.311 (basal cell carcinoma of skin of nose).

The Table of Neoplasms has six columns to describe the nature of the neoplasm (neoplasm does not equal cancer). You probably noticed, though, that BCC only has one possible code and it’s under Malignancy, primary. That’s because a carcinoma by definition is cancer. Neoplasm is not necessarily cancer, carcinoma is definitely cancer.

Fortunately for Jackman, BCCs are easily treated and are rarely, if ever, fatal.

Actor Michael J. Fox has been suffering from Parkinson’s disease since 1991. ICD-10-CM includes multiple codes for Parkinsonism, but only one for Parkinson’s disease—G20. Numerous conditions fall under G20, including:

  • Hemiparkinsonism
  • Idiopathic Parkinsonism or Parkinson’s disease
  • Paralysis agitans
  • Parkinsonism or Parkinson’s disease NOS
  • Primary Parkinsonism or Parkinson’s disease

If the physician documents any of those terms, you’ll report G20.

Actor and comedian Robin Williams also suffered from Parkinson’s disease, as well as depression throughout his lifetime. He also reportedly suffered from delusions and/or hallucinations caused by Lewy bodies dementia.

If we look up dementia in the ICD-10-CM Alphabetic Index, we find a large number of choices depending on the type of dementia. Lewy bodies show up twice in the list, first under the subterm “with,” then as a standalone entry, “Lewy bodies.” Both entries lead you to the same code, G31.83 (dementia with Lewy bodies).

You’ll also notice codes F02.80 (dementia in other diseases classified elsewhere without behavioral disturbance) and F02.81 (dementia in other diseases classified elsewhere with behavioral disturbance) appear in brackets after G31.83. The specific code depends on whether the patient is exhibiting behavioral disturbances, including:

  • Aggressive behavior
  • Combative behavior
  • Violent behavior

Wandering has its own code—Z91.83.

Codes that appear in brackets in the Alphabetic Index are manifestation codes.

Certain conditions have both an underlying cause and multiple body system manifestations due to that cause. In most cases, the manifestation codes will have in the code title, “in diseases classified elsewhere.” Codes with this title are a component of the etiology/manifestation convention.

“In diseases classified elsewhere” codes cannot be the first-listed or principal diagnosis. You can only report them with the code for the underlying condition and you always report it after the underlying condition.

Note that you would not code the delusions and/or hallucinations because they are an integral part of the dementia.

Sew up your knowledge of root operation Repair

Welcome to OR 13 at the Stitch ‘Em Up Hospital, where Dr. Hack N. Slash is preparing for today’s procedure. And what is today’s procedure? Dr. Slash is performing a cut down and suturing of a pseudoaneurysm.

Example of an aneurysm bulging out a blood vessel.

Example of an aneurysm bulging out a blood vessel.

OK, what’s that? Well, a pseudoaneurysm is a hematoma adjacent to a hole or other disruption of the arterial wall. If you know your Greek, you know that “pseudo” means false. An aneurysm is a balloon-like bulge in an artery. So instead of the pseudoaneurysm being a bulge in an artery, the blood is actually collecting outside the arterial wall. Not a good thing.

A pseudoaneurysm is caused by blood slowly leaking into the surrounding tissue. It can happen pretty much anywhere you have an artery (which is pretty much everywhere in your body).

Pseudoaneurysms can also occur in the heart after damage from a heart attack causes blood to leak and pool outside the injured heart muscle.

The first thing we need to know is where the pseudoaneurysm is. That will give us our second character for our ICD-10-PCS code. The first character will be a 0 (zero, not a capital letter o) for the Medical and Surgical section. This is the biggest section of the ICD-10-PCS Manual and the one most non-OB coders will use the most.

Dr. Slash documents that the patient’s left leg is prepped and draped in a sterile fashion and he makes an incision to expose the femoral artery. That gives us lower artery as the body system (second character 4) and left femoral artery for the body part (fourth character L).

But we still need a third character, which is our root operation. What is the intent of this procedure? Well, Dr. Slash is attempting to remove blood from the patient’s leg, so maybe it’s Drainage (third character 9).

ICD-10-PCS defines Drainage as “taking or letting out fluids and/or gases from a body part.” Is Dr. Slash’s intention really just to remove the blood? Let’s check the OP report.

Under objective, Dr. Slash states he is suturing the artery to return it to its normal function. OK, so not Drainage. Dr. Slash’s objective isn’t to remove the blood flow. It’s to suture the hole in the artery to stop the leak. Which other root operation fits?

Turns out, it’s the “not elsewhere classified” (NEC) root operation Repair (restoring, to the extent possible, a body part to its normal anatomic structure and function).

We only use Repair (third character Q) when the method to accomplish the restoration is not one of the other root operations. That’s what makes it the NEC of root operations. If you’ve worked in the outpatient world at all, you are familiar with modifier -59 (distinct procedural service). You only append that modifier if no other modifier is more appropriate. Repair is the same way. You only report Repair when none of the other root operations describe the procedure.

Now we can head to the table because we have our first three characters: 04Q.

We already know the body part, so our code so far is 04QL. Notice that we have a different body part for the right femoral artery, along with:

  • Abdominal aorta
  • Celiac artery
  • Gastric artery
  • Hepatic artery
  • Splenic artery
  • Superior mesenteric artery
  • Colic artery (right, left, and middle)
  • Renal artery (right and left)
  • Inferior mesenteric artery
  • Common iliac artery (right and left)
  • Internal iliac artery( right and left)
  • External iliac artery (right and left)
  • Popliteal artery (right and left)
  • Anterior tibial artery (right and left)
  • Posterior tibial artery (right and left)
  • Peroneal artery (right and left)
  • Foot artery (right and left)

That is not by any means an exhaustive list of lower arteries, so we also have a body part character for “lower artery.”

You need to carefully read the body of the OP report to make sure the physician is actually performing the procedure he or she listed in the objective section. Sometimes surgeons need to change the procedure or sometimes they need to add a procedure.

The artery list is very specific, so if your surgeons are not this precise in their documentation, start working with them now on the added specificity. Chances are surgeons are documenting this somewhere in the OP report. You just may need to dig for it. (And make sure you scour the record before you fire off that query for location. No need to unnecessarily anger the surgeon.)

Back to our code. We have three choices for the approach:

  • 0, open
  • 3, percutaneous
  • 4, percutaneous endoscopic

Dr. Slash documented making an incision down to the artery to visualize the hole, so our approach is open (cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure).

Our final two characters are a snap because we only have one option for each:

  • Z, no device
  • Z, no qualifier

Our final code is 04QL0ZZ (repair left femoral artery, open approach).

All that’s left now is to sew up the patient and send him off to recovery.

Party til the ghosts come home

Ghosties and ghoulies and long-legged beasties are parading through the Fix ‘Em Up Clinic. It must be Halloween and the staff Halloween party.

Even the best planned Halloween party can go astray (especially with imps running around the building). Fortunately we know how to code the mishaps.

Our first bump in the night came during the bobbing for apples activity. Shannon and Wendy both went for the same apple and instead of a bite of juicy fruit, they cracked their heads together. Such a wailing you have never heard.

They both ended up with contusions (and Shannon inhaled some water), but otherwise, they’re fine.Pumpkin scary

To code their contusions, we need to know where they occurred. ICD-10-CM includes specific codes for contusions of the:

  • Forehead (S00.83-)
  • Ear (S00.43-)
  • Eyebrow (S00.1-)
  • Cheek (S00.83-)
  • Nose (nasal, S00.33-)
  • Jaw (S00.83-)
  • Scalp (S00.03)

You’ll notice code S00.83- shows up several times. It’s a not elsewhere classified code, specifically contusion of other part of the head. We know where the contusion occurred, we just don’t have a code for that specific body part.

Don’t confuse that with the not elsewhere classified code, S00.93- (contusion of unspecified part of head). You will report S00.93- when the physician doesn’t tell you where the contusion occurred other than the patient’s head.

Wendy and Shannon smacked foreheads, so we would report S00.83XA (contusion of other part of head, initial encounter) for both.

Make sure a ghost doesn’t make off with your placeholder X. S00.83A is not a valid ICD-10-CM code.

Speaking of ghosts making off with things, John decided to decamp with an entire pizza that was intended for the party. He consumed all of said pizza, making the evidence disappear—until he barfed it back up. (Yuck. I’m glad I don’t have to clean that up.)

ICD-10-CM contains multiple codes for vomiting, depending on the type and cause, including:

  • Bilious
  • Cyclical
  • Functional
  • Hysterical
  • Nervous
  • Periodic
  • Projectile
  • Psychogenic

Fortunately, John’s vomiting is solely due to excess pizza consumption. He also claims to be nauseous (no wonder), so we will report R11.2 (nausea with vomiting, unspecified).

We ended the Halloween party with a recitation of the classic Edgar Allen Poe poem, The Raven. Our performer turned out to be a little too terrifying for some of the smaller children. In fact, several suffered from:

  • Generalize anxiety (F41.1)
  • Excessive crying (R45.83)
  • Fear of birds (F40.218)

Well, that was a good party. Now it’s time to scare the trick-or-treaters.

Nevermore a delay

Once upon a midnight dreary, as I labored on a query

RavenTo send to the doc whose documentation was a source of constant woe

As I nodded, nearly napping (that darn G47.411 again)

Suddenly there came a tapping

As of someone gently rapping, rapping at my cubicle wall

Tis just my manager, I muttered, coming for the query

Only this and nothing more


The silken, sad, muffled rustling of each chart that I sat shuffling

Thrilled me—filled me with fantastic terrors never felt before (oh wait, that’s just F41.1);

So that now, to still the beating of my heart, I stood repeating,

“Tis just my manager coming for the query

Just my manager looking for the query”

This it is and nothing more.


Presently my soul grew stronger; hesitating then no longer,

“Jill,” said I, “or Shannon, truly your forgiveness I implore;

But you know my lack of hearing (H90.0) caused by this incessant ringing (H93.13)

Left me thinking there was no one tapping at my cubicle door,

I scarce was sure I heard you”—here I opened wide the door—

Darkness there and nothing more.


Deep into that darkness peering, long I stood there wondering, fearing (more F41.1),

Doubting, dreaming dreams no mortal ever dared to dream before;

But the silence was unbroken (or am I just suffering H91.23?), and the stillness gave no token,

Until I heard this one word spoken—ICD-10

This I whispered and an echo murmured back—ICD-10

Merely this and nothing more.

Back into the chamber turning, all my soul within me burning (maybe it’s really R12 and not my soul),

Soon again I heard a tapping somewhat louder than before.

Open here I flung the door, to see a Raven of the days of yore;

Perched above the neighboring cubicle door

Perched contently above my next-door neighbor’s cubicle door

Then he spoke—ICD-10—and nothing more.


Wonderful, I muttered, now I’m seeing birds, I shuttered

I’ve started hallucinating a creepy bird of yore (R44.1, too bad it doesn’t specify what I’m seeing)

I really want to write this query

So I can code this record, I am weary (R53.83)

Weary of worrying when ICD-10 will be implemented

Quoth the raven, 2015

This he said and nothing more.


Listen bird, I said with feeling, please don’t let me be dreaming

Please tell me that ICD-10 is really coming soon

Currently our codes are lacking

We can’t even tell what’s catching

We don’t know what diseases we’re not tracking

Quoth the raven, 2015

This he said and nothing more.


“Be that word our sign of parting, bird my friend!” I grinned, upstarting—

“Get thee back into the tempest and spread the word to every coder!

Leave one black plume as a token of that joy thy beak hath spoken!

Leave my hopefulness unbroken!—quit the perch above my neighbors door!

Take thy beak from out my heart (S26.19, W61.99XA), and take thy form from off my neighbor’s door!”

Quoth the raven, 2015

This he said and nothing more.

Trick or treat, smell my feet

Ewww, I don’t think so. Your feet stink. What could be causing that foul odor to emanate from your feet?

FeetThe most common cause is sweat. Just sniff your old gym sneakers and you’ll see what I mean.

Sweat by itself is odorless, but when it comes into contact with bacteria it begins to smell bad. Usually, the bacteria are harmless, but some, such as necrotizing fasciitis, can eat through the skin.

Maybe you have necrotizing fasciitis. How would we code that in ICD-10-CM?

If you look up fasciitis, necrotizing, in the ICD-10-CM Alphabetic Index, you are directed to code M72.6. Pretty easy at first glance. We only have one code, so we don’t need to know what area the necrotizing fasciitis affected.

We do, however, need to use additional code (B95.-, B96.-) to identify causative organism. Is the necrotizing fasciitis caused by a form of Streptococcus, Staphylococcus, and Enterococcus or by some other bacterial agent, such as E. coli or Klebsiella pneumonia?

Categories B95 and B96 do include unspecified options in case the physician doesn’t know whether the patient’s necrotizing fasciitis is caused by group A strep or group B strep. And you can use those unspecified codes. They are completely legitimate. The ICD-10-CM Official Guidelines for Coding and Reporting even tell us that performing a medically unnecessary lab test just to arrive at a more specific code is inappropriate. (It’s guideline I.B.18 in case you’re interested.)

Perhaps you have gangrene instead of necrotizing fasciitis. Gangrene reeks. The ICD-10-CM codes for gangrene are more specific than those for necrotizing fasciitis. We need to know where the gangrene is before we can code it.

ICD-10-CM does not include a separate listing for gangrene of the feet. It falls under gangrene of the upper and lower extremities, which leads to I96 (gangrene, not elsewhere classified).

Before you report I96, make sure you review the Excludes1 note. Excludes1 in ICD-10-CM means the two conditions are mutually exclusive. A patient can’t have both at the same time. Under I96, the Excludes1 note specifies:

  • Gangrene in atherosclerosis of native arteries of the extremities (I70.26)
  • Gangrene in diabetes mellitus (E08-E13)
  • Gangrene in hernia (K40.1, K40.4, K41.1, K41.4, K42.1, K43.1-, K44.1, K45.1, K46.1)
  • Gangrene in other peripheral vascular diseases (I73.-)
  • Gangrene of certain specified sites – see Alphabetical Index
  • Gas gangrene (A48.0)
  • Pyoderma gangrenosum (L88)

If a patient suffers from atherosclerosis of native arteries of the extremities or diabetes mellitus, you may need to query the provider to make sure the two conditions aren’t causally related. In ICD-9-CM, we can assume a relationship between diabetes mellitus and gangrene if the physician does not document any other cause of the gangrene.

Coders cannot report the combination codes for diabetes and a complication, such as gangrene, unless the physician specifically documents the relationship between the diabetes and the condition.

Maybe the cause of your foul feet is something a little less life-threatening. You could just suffer from hyperhidrosis (aka sweaty feet).

The default code in ICD-10-CM is R61 (generalized hyperhidrosis). However, again we find some important Exludes1 notes:

  • Focal (primary) (secondary) hyperhidrosis (L74.5-)
  • Frey’s syndrome (L74.52)
  • Localized (primary) (secondary) hyperhidrosis (L74.5-)

These conditions are all more specific than the generalized hyperhidrosis.

When excessive sweating affects the hands, feet, and armpits, it is called primary or focal (local) hyperhidrosis. Since we know the hyperhidrosis is of the feet, we would look to L74.5-.

The only code in this subcategory that applies is L74.513 (primary focal hyperhidrosis, soles). Again, the physician will need to documents that specific information in the medical record or you may need to query.

In the meantime, might I suggest some extra strength Odor Eaters?


Coding Clinic caveats

guidelinesWhen coders run into a tough coding question, they often look for guidance in the AHA’s Coding Clinic. Coding Clinic is a resource, but it’s not always the final word.

The AHA publishes Coding Clinic on a quarterly basis and addresses questions submitted to Coding Clinic by stakeholders in the healthcare industry.

Coders, as well as payers, use Coding Clinic advice to determine accurate code assignment.

However, Coding Clinic does not provide clinical criteria for establishing diagnoses and has no authority to provide clinical definitions, nor does it replace physician documentation regarding the clinical significance of a patient’s condition.

Coding Clinic does provide guidance on what codes can be reported based on already-documented diagnoses.

Coding Clinic information may still be useful to understand clinical clues regarding signs or symptoms that may be integral (or not) to a condition.

The Coding Clinic editorial staff is not updating past guidance for ICD-9-CM to ICD-10, just like CMS is not transitioning all National Coverage Determinations from ICD-9-CM to ICD-10.

Coding Clinic staff members are only answering ICD-10 questions going forward, but the editors can only answer question that you ask. So if you are practicing (or learning) ICD-10 and something seems wrong or you’re confused, submit a question to Coding Clinic.

They don’t guarantee they will answer your question, but odds are, someone else has the same question. The more questions we raise before implementation, the more information we will have when we start assigning ICD-10 codes for real. Remember, though, that the Coding Clinic editors are new to ICD-10 as well. Some of the answers they publish now may need to be updated as more information becomes available and coders actually use the new codes.