All Entries in the "Coding" Category

ICD-10-PCS adds new codes for 2014

The ICD-10-PCS codes for 2014 are now available on the CMS website. CMS also posted the 2014 ICD-10-PCS guidelines and an ICD-10-PCS reference manual.

You will find four new codes under new technology application, valid October 1, 2013

• 08H005Z, insertion of epiretinal visual prosthesis into right eye, open approach
• 08H105Z, insertion of epiretinal visual prosthesis into left eye, open approach
• 30280B1, transfusion of nonautologous  4-factor prothrombin complex concentrate into vein, open approach
• 30283B1, transfusion of nonautologous  4-factor prothrombin complex concentrate into vein, percutaneous approach

The update also includes three new codes added and three codes deleted, to correct body part value for temporary  occlusion of abdominal aorta.

The new codes are:

• 04V00DJ , restriction of abdominal aorta with intraluminal device, temporary, open approach
• 04V03DJ, restriction of abdominal aorta with intraluminal device, temporary, percutaneous approach
• 04V04DJ
• restriction of abdominal aorta with intraluminal device, temporary, percutaneous endoscopic approach

These three codes were deleted:

• 02VW0DJ, restriction of thoracic aorta with intraluminal device, temporary, open approach
• 02VW3DJ,  restriction of thoracic aorta with intraluminal device, temporary, percutaneous approach
• 02VW4DJ, restriction of thoracic aorta with intraluminal device, temporary, percutaneous endoscopic approach

In addition, the section title for the Radiation Oncology section was revised to Radiation Therapy. No code titles were changed.

Change your EMR to prepare for ICD-10

Do you want to work harder or work smarter? We all know electronic medical records (EMR) are great in some ways, not so great in others. Drop down menus make life easier for physicians, but can also result in physicians choosing the first version of a disease on the list. And that’s usually the most non-specific version of the disease.

EMRs can help improve documentation for ICD-10-CM if you add the correct prompts.

Consider fracture codes. In ICD-10-CM, coders will need more detailed information in order to assign a fracture code, including:

• Specific site (which bone and where on the bone)
• Side (left or right)
• Type of fracture (open or closed, displaced or non-displaced)
• Encounter (initial, subsequent, sequela)

Why not prompt the physician to include that information? Consider adding a drop down for site of the fracture, the encounter, and the type of fracture. Make it easy for the physicians to give coders the information they need.

To assign a code for percutaneous transluminal coronary angioplasty (PTCA), coders need to know the device so add a drop down with these choices:

• Intraluminal Device, Drug-eluting
• Intraluminal Device
• Intraluminal Device, Radioactive
• No Device

Coders need additional information for pregnancy, both trimester and weeks of gestation. Add a drop down so the physician must include that information.

Avoid giving the physicians an easy out in the drop down menus. You want them to be as specific as possible, so force them to be specific.The more information coders have, the fewer queries they’ll need to make. And that saves everyone time.

Remember too that physicians may already be documenting some of this information. Coders just aren’t looking for it. So before you reinvent your EMR, make sure you know which changes will be beneficial.

Don’t burn those ICD-9-CM Manuals just yet

Planning a big bonfire for October 1, 2014, using your ICD-9-CM Manuals? You might want to think again.

Not everyone is required to transition to ICD-10. Only HIPAA covered entities must begin using the ICD-10 code sets. Non-covered entities, such as can workers’ compensation and auto insurance carriers, still use ICD-9 if they choose.

As a result, we may be using ICD-9-CM forever. Or maybe just for a little while. Each non-covered entity will make its own decision on when or if to switch to ICD-10-CM. I wouldn’t be surprised if many of them wait a year (I know, not what you wanted to hear). I think eventually they will start using ICD-10-CM, hopefully before the transition to ICD-11, whenever that comes around.

In the meantime, talk with any workers’ compensation or auto insurance carriers you do business with and find out whether those plans will be moving to ICD-10. If not, you need to determine whether to keep a dual-coding system in place or not accept patients from those carriers.

Get to know ICD-10 codes for wrist and hand conditions

Penny comes in to see Dr. Morang for pain in her wrist. After performing a comprehensive exam and history, Dr. Morang documents the following ICD-9-CM codes:

• 354.0, carpal tunnel
• 715.04, osteoarthrosis, generalized, hand
• 719.43, pain in forearm
• 728.6, contracture of palmer fascia

How would we code Penny’s diagnoses in ICD-10-CM? Let’s start with her carpal tunnel. If we look up syndrome, carpal tunnel in the ICD-10-CM Alphabetic Index, it directs us to G56.0-. The dash tells us the code needs additional characters, so we absolutely must look in the Tabular Index.

You should never code from the Alphabetic Index alone, anyway. That’s one of the many things that won’t change after the transition to ICD-10-CM.

G56.0 gives us three choices:

• G56.00, carpal tunnel syndrome, unspecified upper limb
• G56.01, carpal tunnel syndrome, right upper limb
• G56.02, carpal tunnel syndrome, left upper limb

We need to review Dr. Morang’s documentation to determine the laterality so we can assign the most detailed code. ICD-10-CM does include an unspecified option, but we want to avoid reporting unspecified if at all possible. That means if the physician didn’t document laterality, query!

Moving on to the osteoarthrosis, we find a note in the Alphabetic Index that tells us to see also Osteoarthritis.

Generalized osteoarthrosis of the hand doesn’t really give us much to go on to find the correct ICD-10-CM code. We need more information.

Does Penny suffer from bony bumps on the finger joint closest to the fingernail (Heberden’s nodes), which would lead us to ICD-10-CM code M15.1 (Heberden’s nodes [with arthropathy]).

Or does she have bony bumps on the middle joint of the finger (Bouchard’s nodes)? In that case, we would report M15.2 (Bouchard’s nodes [with arthropathy]).

Does Dr. Morang mean Penny suffers from osteoarthritis of the hand joint or the bones in her hand in general?

We also need to know if the osteoarthrosis is primary, secondary, or post-traumatic.

For the pain in Penny’s forearm, we again need laterality. Our choices are:

• M79.631, pain in right forearm
• M79.632, pain in left forearm
• M79.639, pain in unspecified forearm

We also need to know if the pain is a separate problem or if it is a symptom of one of Penny’s other diagnoses. If it’s a symptom, we don’t code it separately (regardless of what Dr. Morang says).

Finally, we need to code the contracture of palmer fascia. You may be more familiar with the term Dupuytren’s contracture. Both lead us to the same ICD-10-CM code—M72.0 (palmar fascial fibromatosis [Dupuytren]).

Interestingly, M72.0 does not require laterality. We only have one code, which could be a problem if Penny develops the same condition in both hands.

So we’ll wish Penny well, but avoid shaking her hand.

ICD-10-PCS body system, body part: They both sound so simple!

When coders begin using ICD-10-PCS the second and fourth character definitions seem simple enough:

• Second character-Body system
• Fourth character-Body part

However, when coders start assigning codes, they will need to note these things from the ICD-10-PCS General Body Part Rules :

•  The body systems and body parts are specific to ICD-10-PCS and do not represent those typically found in an anatomy.  So don’t expect them to line up perfectly with your anatomy and physiology training. The good news is that they do conform entirely to the body systems and body parts found in ICD-10-CM chapters.
• The body system designations subdivide into smaller components. This makes sense as the ICD-10-PCS system is highly specific. For example, the genitourinary system subdivides into the urinary system, female reproductive system and male reproductive system.
• Sometimes a procedure is performed on a general anatomical region rather than a specific body system. For example a postoperative bleed into the peritoneal cavity is coded to Anatomical region: general and the body part peritoneal cavity.
• The body part designations also are specific to ICD-10-PCS and do not represent body parts as describe in anatomy books.  Example: The liver is one organ but ICD-10-PCS includes three possible body part designations : right lobe, left lobe, and liver.
• ICD-10-PCS also includes “general body part designations” which are considered not otherwise specified codes or NOS.  These designations should only be used when the documentation does not support assignment of a more specific code. For example, liver should be assigned only when the documentation in the medical record does not indicate the part of the liver and the coder cannot obtain the information from the physician.  This could potentially mean a physician query to assign the most specific body part designation.
• When the documentation describes a portion of a body part and ICD-10-PCS does not have a specific designation for that part then the whole body part designation is used. For example, if a procedure is performed on the alveolar process of the mandible the character for mandible is assigned because the alveolar process is not specifically identified as a separate body part.
• Body parts with the prefix “peri” (which means around or surrounding) may have a specific character for the body part. If not report the body part preceded by the prefix “peri” in the operative report with the character for that body part. Example: Pericardium is designated as a specific body part. However, “perirenal” does not have a specific body part and would assigned to the body part renal.

To use ICD-10-PCS effectively and efficiently, coders will need to learn the ICD-10-PCS Body Part Rules for four body systems:

• Cardiovascular
• Nervous
• Musculoskeletal
• Integumentary

Computer-assisted coding another tool to help in ICD-10

Any healthcare organizations are considering computer-assisted coding (CAC) to help minimize the expected coder productivity decline in ICD-10. Lisa Knowles-Ward, RHIT, coding and reimbursement for the Cleveland Clinic, reported on her organization’s success with a CAC during the AHIMA ICD-10-CM/PCS and CAC Summit in Baltimore.

The Cleveland Clinic saw a 16% increase in coder productivity for records coded by a coder using the CAC within six weeks of enabling the auto suggest feature on the CAC. After coders spent an additional five months using the CAC, productivity rose by 22%.

Knowles-Ward said her goal is to see a 30% increase in productivity to offset the expected decline in productivity in ICD-10.

Cleveland Clinic is only using the CAC for ICD-9 diagnosis and procedure codes and CPT codes. The clinic has not started using it to code in ICD-10.

Cleveland Clinic is not planning to use CAC to replace codes, Knowles-Ward said. “CAC is a tool. It’s meant to be a tool.”

In fact, the CAC does not select the principle diagnosis. Certified coders do that.

In addition to the coders, clinical documentation improvement (CDI) specialists at Cleveland Clinic also use the CAC during inpatient stays. CDI specialists are generating a higher volume of concurrent queries by using the CAC, with a  decrease in retroactive queries.

Another danger of unspecified ICD-10-CM codes: Fraud

How often do you default to an unlisted code or a non-specific code in ICD-9 because the physician just didn’t document enough information? For example, how many times do you see documentation stating simply “diabetes” and nothing else? Probably more than you would like.

So what happens when we start using ICD-10-CM? One of the perks of the new system is the increased specificity ICD-10-CM offer. A physician documenting just “diabetes” won’t cut it October 1, 2014.

ICD-10-CM does include unspecified codes (which seems to defeat the purpose). No one is quite sure whether payers will reimburse for the unspecified codes or how long they will allow providers to slide by without the additional details.

Here’s something else to consider (in case a lack of money doesn’t motivate your docs). Reporting unspecified codes could result in False Claims Act violations and post-payment liability, according  to Michael Miscoe, Esq., CPC, CPCO, CASCC, CCPC, CUC. I don’t know about you, but I don’t look good in orange jumpsuits or stripes.

Start working with physicians now to educate them about the additional documentation requirements for ICD-10-CM. Hopefully, the physicians will get on board with better documentation. If they don’t, start dropping gentle (or not so gentle) hints about fraud and reduced reimbursement. Don’t scare them if you don’t have to, but if all else fails, drastic action could be required.

Putting a broken jaw back together in ICD-10

Editor’s note: For purposes of today’s example, we are ignoring medical necessity. We’re going to say Sidney is an inpatient. In the real world, he would need to meet the criteria for an inpatient admission. This example is for educational purposes.

Sidney is admitted to Stitch ‘Em Up Hospital after being hit in the mouth with a hockey puck during a hockey game. The injury occurred at the rink. In addition to a broken jaw, Sidney also lost several teeth.

Dr. Coffey performed surgery to repair Sidney’s broken teeth two days ago and is now preparing to insert a plate and screws to stabilize Sidney’s broken jaw.

If we look at the ICD-10-CM coding for Sidney’s injuries, his broken teeth look pretty easy to code. We only have one code choice: S02.5 (fracture of tooth [traumatic]).

However, we do need to add a seventh character to denote the encounter.  Since the code only has four characters, we need to add two placeholders so the encounter ends up in the seventh spot.

Before working on Sidney’s jaw, Dr. Francis examines Sidney’s teeth and documents routine healing. We would report S02.5XXA. We are using the seventh character A because Dr. Francis is a new physician. If Dr. Coffey had seen Sidney to evaluate the healing of the tooth fractures, we would use seventh character D.

Now let’s turn our attention to Sidney’s jaw. The first thing we need to know is what specific part of the jaw is fractured. ICD-10-CM includes the following codes for fracture of the mandible:

• S02.60, 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 that these codes do not contain laterality. They do require a seventh character for the encounter, and because they are only five characters long, they also need one placeholder. That seventh character will also detail whether the fracture is open or closed.

Dr. Francis documents an initial encounter for treatment of a closed fracture of the alveolus following traumatic impact of a hockey puck.

That gives us code S02.67XA.

We can also include these codes for external causes:

• W21.220A, struck by ice hockey puck, initial encounter
• Y92.330, ice skating rink (indoor) (outdoor) as the place of occurrence of the external cause
• Y93.22, activity, ice hockey

Now, let’s move on to the actual surgical procedure. Time to turn to ICD-10-PCS (again, in the real world we would probably use CPT codes for an outpatient procedure, but we’re pretending.)

We know our first character will be 0 for medical and surgical.

Next, we need the body system. In Sidney’s case, it’s the mandible, which falls under head and facial bones (second character N).

Now we need the root operation. What is the intent of the procedure? Dr. Francis is inserting a metal (non-biological) plate and screws into Sidney’s jaw to stabilize the fracture. We know the fracture is closed, but is it also displaced? That information will affect the root operation. Displaced fractures require manipulation to put the bone(s) back into place before inserting the plate and screws.

Dr. Coffey documented a displaced fracture during Sidney’s initial treatment and Dr. Francis confirms this information in his operative note.

Dr. Francis also documents performing an open reduction with internal fixation. He does document making the incision prior to repositioning the bone.

That gives us root operation reposition and a third character S. If the fracture had been non-displaced, we would use root operation insertion.

With this much of the code—0NS—we can get to the correct table in ICD-10-PCS and finish building our code.

The fourth character denotes the body part. For Sidney’s surgery, it’s the mandible. However, in order to select the correct ICD-10-PCS code, we need the laterality. The right and left sides of the mandible have separate body part characters. So even though we don’t need laterality for the ICD-10-CM code, we do need it in ICD-10-PCS.

Dr. Francis’ operative note states “right side of mandible” which makes our fourth character T.

For the fifth character, we need to know what approach Dr. Francis used:

• Open (0)
• Percutaneous (3)
• Percutaneous endoscopic (4)

We know this is an open procedure, so our fifth character is 0. Dr. Francis documented an internal fixation device, making our sixth character 4. The seventh character will always be Z (no qualifier) because that’s our only option for this table.

Our final code is 0NST04Z, reposition right mandible with internal fixation device, open approach.

That brings our case to a close and we’ll discharge Sidney with the advice to duck next time a puck comes flying at his face.

ICD-10 on Opening Day

Anytown’s baseball team just completed its home opener and while the team came away with a win, not all of the players made it through the game.

Eddie the outfielder suffered a painful run-in with the left-field fence in the second inning. Eddie raced back to catch a fly ball and jumped up. Unfortunately, he was too close to the fence and ripped his right ear open on the top of the fence.  He cut through the cartilage in his ear and now sports a spiffy row of stitches. Fence 1, Eddie 0.

Dr. Selig documented no foreign body in the laceration and also noted this was Eddie’s first visit. That gives us ICD-10-CM code S01.311A, laceration without foreign body of right ear, initial visit.

We can also add some codes for external causes:

• W18.01xA, striking against sports equipment with subsequent fall, initial encounter (if you consider the fence a piece of baseball equipment)
• Y92.320, baseball field as the place of occurrence of the external cause
• Y93.64, activity, baseball

Eddie’s teammate Ken also suffered a setback in the first game of the season. Ken failed to move out of the path of an oncoming fastball and earned a free base—and a massive bruise to his hip. Fortunately, the pitch wasn’t that fast, so Ken didn’t suffer any breaks, but he’s going to be sore for a while.

When we review Dr. Selig’s note, we find that he did not document laterality or encounter. That means we need to query.

ICD-10-CM does contain a code for contusion to unspecified hip, but in order for any contusion code to be valid, we need a seventh character to denote the encounter. Since we’re asking for one piece of information, we may as well ask for both. That way the record will be more complete and we don’t need to worry about a possible denial for an unspecified code.

Dr. Selig responds (three days later) with a notation of left hip, initial encounter, so we would report:

• S70.02xA, contusion of left hip
• W21.03xA, struck by baseball
• Y92.320, baseball field as the place of occurrence of the external cause
• Y93.64, activity, baseball

Note that we need placeholders for codes for the contusion and the struck by baseball. Without the X placeholder, the seventh character ends up in the sixth position, making the code invalid.

Eddie and Ken will both be back on the field tomorrow, but their teammate Keith is headed for the injured reserve. Keith slid into second and dislocated his right ankle when he hit the bag awkwardly. To add insult to injury, he was out. He had larceny in his heart, but lead in his feet. And now a cast to go with it.

What do we need in Dr. Selig’s documentation to code Keith’s dislocated ankle?

• Laterality (right)
• Encounter (initial)
• Dislocation or subluxation (dislocation)

That gives us:

• S93.04xA, dislocation of right ankle joint, initial encounter
• Y92.320, baseball field as the place of occurrence of the external cause
• Y93.64, activity, baseball

We would not report W18.01xA because Keith didn’t fall. ICD-10-CM does not contain a code for sliding into a base. At least not yet.

Meanwhile out in the swamps of Dagobah ….

When last we left our intrepid hero, Luke Skywalker, he was well on the road to recovery after being bashed by a wampa and spending the night in the belly of a Tauntaun.

Now he’s off to the Dagobah system to meet a little green guy who talks funny and maybe listen to those voices in his head some more.

Luke survives his crash landing in the swamp without injury and promptly finds Yoda rifling through his belongings.

In addition to being green (sadly ICD-10-CM does not contain a code for green skin discoloration), Yoda also suffers from a speech problem, namely mixing up the order of words in his sentence. For example, “away put your weapon, I mean you no harm.”

Could Yoda be suffering from aphasia, a disturbance of the comprehension and formulation of language caused by dysfunction in specific brain regions? If so, how would we code it in ICD-10-CM?

The first thing we need to know is the cause of the aphasia. Is it a developmental disorder (F80.2, mixed receptive-expressive language disorder)?

Or is it the result of a degenerative brain disorder?

Perhaps it’s really a sequela of a non-traumatic subarachnoid hemorrhage (I69.020) or some other brain injury.  Coders should report a code from category I69 to indicate conditions in I60-I67 as the cause of sequelae. The ‘sequelae’ include conditions specified as such or as residuals which may occur at any time after the onset of the causal condition.

If the cause is not classified elsewhere, we would look to R47.01 (aphasia). Pay attention to the Excludes1 note:

• aphasia following cerebrovascular disease (I69. with final characters -20)
• progressive isolated aphasia (G31.01)

Yoda also walks with a limp. And really, considering he’s 800 years old, he’s in pretty good shape. But what causes him to limp? Perhaps, given his age, he suffers from osteoarthritis.

You’ll find the ICD-10-CM codes for osteoarthritis in categories M15-M19. The codes are divided by the location of the osteoarthritis. For example, category M16 covers osteoarthritis of the hip, which can be:

• Bilateral
• Unilateral
• Unilateral resulting from hip dysplasia
• Bilateral post-traumatic
• Unilateral post-traumatic
• Other bilateral secondary
• Other unilateral secondary

If the osteoarthritis is only present unilaterally, you will need to specify the laterality when you chose your code.

Luke, meanwhile, seems to weather his time in the swamp relatively well until Yoda sends him into a hollow tree and a dark underground labyrinth. That’s when Luke’s hallucinations return with a vengeance, making that schizophrenia diagnosis look better and better. Actually, to be fair, Luke’s been hallucinating a lot on Dagobah from the day he crash-landed.

In the tree, Luke thinks he sees Darth Vader and cuts off Vader’s helmet which cracks open after hitting the ground to reveal…Luke’s face. Freud would have a field day with that imagery.

Suppose Luke really does suffer from schizophrenia. How do we code it in ICD-10-CM?

First, we need to know what type of schizophrenia Luke has:

• F20.0, paranoid schizophrenia
• F20.1, disorganized schizophrenia
• F20.2, catatonic schizophrenia
• F20.3, undifferentiated schizophrenia
• F20.5, residual schizophrenia
• F20.8, other schizophrenia

Maybe Luke is just delusional (F22, delusional disorders). Or it could be a schizoaffective disorder (F25).

Or it could be delusions brought on by some swamp-borne illness.

Regardless, I think it’s time for Luke to head off to the Cloud City and leave the swamp in his rearview mirror.