RSSAll Entries in the "Coding" Category

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?


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.


Smaller organizations lag in ICD-10 preparation, but it’s not too late

SurveyHow ready are you for ICD-10? The answer might depend on the type and size of your organization.

Eighty-five percent of hospitals reported training staff on ICD-10, according to a recent eHealth initiative survey of 271 providers, while only 41% of physician practices have completed that task.

Practices are also less likely to offer additional training for coders to maintain their skills. The survey found that 74% of all organizations offer additional coding training. Hospitals (80%) are more likely to provide additional training compared to practices (58%).

The survey found that just over half (60%) of small hospitals with less than 100 beds offer additional training to coders.

This makes a certain amount of sense. Small practices and hospitals are less likely to have the time and resources to devote to training and continuing education. But that doesn’t mean it’s too late for them to prepare. CMS just released a guide for organizations to get on track to implementation no matter what step they’re on.

This lack of training could be a problem since smaller organizations are more likely to rely on in-house coders, the survey concluded. Small hospitals (15%) and practices (14%) were the least likely groups to be planning on hiring more coders after the transition.

Smaller practices might have a different focus for the challenges they face in the countdown to ICD-10. According to the survey, the top challenge for all organizations is maintaining clinical workflow and productivity. However, for both practices and small hospitals, the second greatest challenge relates to vendor and partner readiness. Both also say lack of testing is the next top challenge.

Challenges related to testing and vendors shouldn’t be a surprise for providers—we’ve been talking about them for five years. With fewer than 100 days to go until implementation, though, providers of all size must ensure their software can handle ICD-10. CMS is running continuous acknowledgement testing for providers. Even though it’s not as complete as end-to-end testing, providers should take advantage of the opportunity to test their systems ahead of October 1.

ICD-10 is going to the birds

9588217310_a412dbedd0_zMary decided to take advantage of a break in the rainy weather to head out and do some bird watching. The birds, however, were in no mood to be watched.

Mary first came upon a warbler nest with four (almost) cute baby birds. While she was oohing and ahhing over the babies, momma warbler returned (or maybe it was daddy warbler) and attacked. Warblers aren’t very big birds, but they can pack a wallop when they start pecking you.

Mary suffered multiple puncture wounds from the bird’s beak. To code Mary’s puncture wounds, we need to know where they are. ICD-10-CM breaks injuries down by the body area, not the type of injury like ICD-9-CM.

For Mary’s bird attack, we could use the following codes (depending on our physician’s documentation):

  • S01.342A, puncture wound with foreign body of left ear, initial encounter
  • S51.031A, puncture wound without foreign body of right elbow, initial encounter
  • S61.032A, puncture wound without foreign body of left thumb without damage to nail, initial encounter


ICD-10 bill doesn’t account for massive payment, patient implications


Rep. Gary Palmer, R-Alabama, doesn’t want providers penalized for ICD-10 “errors, mistakes, and malfunctions relating to the transition” for two years after implementation. Unfortunately, it doesn’t appear the congressman considered the staggering implications of such a policy.

It was obvious during Congress’ February subcommittee hearing on ICD-10 that most politicians involved didn’t have anything but a cursory understanding of coding, billing, and reimbursement beyond the talking points they were working off.

In the months since, several Congressmen have demonstrated they weren’t listening to the overwhelming support for ICD-10 from the gathered witnesses, with successively unrealistic bills introduced. Palmer’s bill stands alone, however, with the ability to not only remove any incentive for providers to learn ICD-10, but also increase the potential for fraud.


Latest ICD-10 bill shows AMA, Congress flailing to find a way out of implementation

The AMA and Republican congressmen have been working together for quite a wTug of warhile to try and kill ICD-10, but their latest attempt shows not only desperation, but a fundamental misunderstanding of how coding works.

At its annual meeting Sunday, June 7, the AMA’s House of Delegates began a divisive discussion about ICD-10, according to MedPage Today. The Oklahoma delegation reportedly brought a resolution calling for physicians nationwide to simply boycott ICD-10, a proposal so outlandish and dangerous that the House of Delegates didn’t even allow it to be debated or discussed for fear of legal action from the Federal Trade Commission.

The group finally found consensus on a resolution for the Delegation to vote this week regarding a two-year grace period during which providers cannot be penalized for mistakes in ICD-10 code reporting. William Jefferson Terry, MD, proposed the resolution.

You might remember Terry, a representative of the American Urological Association (AUA), as the only voice of dissent among witnesses during February’s House of Representatives hearing on ICD-10. He memorably complained that ICD-10 was too confusing and too extensive for physicians to ever adapt to—until another witness pointed out that the AUA had lobbied for 200 new codes for its specialty in the first ICD-10 update.

Terry’s resolution goes so far as to ask the AMA to find a way for physicians to opt out of contracts with Medicare and all other payers after implementation if they cannot figure out the codes, MedPage Today reports.


Learn from your peers

guy with question marks (2)One of the best parts of attending the Association of Clinical Documentation Improvement Specialists’ (ACDIS) 8th Annual Conference is talking with others in the field to find out what documentation shortcomings they see in their organization.

Sometimes you learn very unexpected things. For example, I thought most physicians already documented laterality. To me, that’s a no-brainer. You should be documenting which side an injury is on. However, in talking with two CDI specialists from one facility, I found out that’s not always the case. When they conducted documentation audits for ICD-10-CM, they found that laterality was the most common piece of information missing. I was absolutely floored.

You can also pick up some good ideas just by chatting with your peers. During the ACDIS conference, Cheree A. Lueck, RN, BSN, and Megan Buyrn, RN, shared flip cards their team created for each surgical specialty to help capture all of the information coders need to code in ICD-10-PCS. Session attendees couldn’t wait to get an up-close look at the cards and many were talking about how to create something similar at their facilities.

The transition to ICD-10 is a huge undertaking and we have 117 days to prepare. Talk to others in your organization or your area. Reach out to people you’ve met, either at conferences or through professional organizations.

You can also sign up for our free 100 days to ICD-10 implementation webcast June 22.

CMS’ second end-to-end testing week a success

news blocksCMS declared its second week of ICD-10 end-to-end testing, held from April 27 through May 1, a success.

Approximately 875 participants submitted 23,138 test claims during the week and CMS accepted 88% of the claims. CMS rejected only 2% of claims for an incorrect ICD-10 code and less than 1% for an incorrect ICD-9-CM code. During the first week of end-to-end testing, CMS rejected 3% of claims for incorrect ICD-10 codes and 3% of claims for incorrect ICD-9-CM codes.

CMS rejected the remaining claims for errors not related to coding, such as:

  • Incorrect National Provider Identifiers, Health Insurance Claim Number, or Submitter ID
  • Dates of service outside the range valid for testing
  • Invalid HCPCS codes
  • Invalid place of service

These types of errors also accounted for the majority of rejected claims during the first end-to-end testing week in January.

Half of the test claims came from professional services, 43% from institutions, and 7% from suppliers. During the first testing week, which CMS also declared a success, 56% of the claims fell under professional services and 38% were institutional claims. Suppliers submitted 6% of the claims.

CMS identified one system error for institutional claims. CMS’ system inappropriately processed certain inpatient hospital test claims due to a systems issue with codes that are exempt from Present on Admission reporting. CMS plans to resolve this error before the final week of end-to-end testing in July.


No summer vacation from ICD-10

dont miss itAh, summer—sand, surf, and…ICD-10 education?

That’s right. Summer, especially this summer, is no time to stop your ICD-10 education. We have 125 days left until ICD-10 implementation, so we need to fine-tune our coding and documentation. We also need to update queries and educate physicians.

Let’s start with the easiest piece—ICD-10-CM coding. You probably think I am suffering from F22 (I’m not telling you what that is. You have to look it up.).

Summer is primetime for outdoor injuries and ICD-10-CM includes plenty of specificity for reporting sprains, strains, fractures, allergic reactions to bug bites, and so on and so forth.

Coding sunburns in ICD-10-CM is pretty easy. We just need to know the degree:

  • 0, sunburn of first degree
  • 1, sunburn of second degree
  • 2, sunburn of third degree


Post-conference breakdown

headacheOur friends at the Association of Clinical Documentation Improvement Specialists (ACDIS) held their 8th annual conference last week. Aside from a few mishaps involving their crack team of CDI specialists, Cheryl, Laurie, and Sharme, everyone survived the actual conference.

However, some of the planning staff are starting to feel the effects of all the intense work to prepare for and staff the conference.

Jessica suffered a nervous breakdown after building the conference app and overseeing all of the multimedia work. It’s worth noting that “nervous breakdown” isn’t actually a medical term or a psychiatric disorder. It’s a colloquial term. So can we code a nervous breakdown in ICD-10-CM?

You’re probably saying, well of course we can code it! The real question is what information do we need to code it?

As always, we’ll start in the Alphabetic Index. You won’t find anything applicable under nervous, although you do find:

  • Heart
  • Stomach
  • Tension