Ah, Black Friday, when shoppers go doorbusting for deals and then head to the Fix ‘Em Up Clinic for repairs.
Today’s first wounded bargain hunter, Stephanie, comes in complaining of pain in her left elbow. She apparently elbowed another shopper out of the way to grab the last sweater on the rack. She is also experiencing difficulty when trying to bend her elbow and is wheezing when breathing.
Dr. Donner performs an initial evaluation and then sends Stephanie off for x-rays of her elbow. Dr. Prancer’s x-ray report states that Stephanie suffered a posterior subluxation of the left ulnohumeral joint with no broken bones.
Dr. Donner notes the findings in her notes and also notes that Stephanie has a history of asthma. Dr. Donner documents that Stephanie’s wheezing is due to mild, intermittent asthma without complications.
That gives us the following codes:
- S53.122A, posterior subluxation of left ulnohumeral joint, initial encounter
- J45.20, mild intermittent asthma, uncomplicated
Our next patient, Jane, comes in with a bleeding hand. Apparently Jane snagged the last iPad and another shopper wanted it enough to bite Jane’s hand. Ouch.
Dr. Donner cleans and dresses the wound and documents an open bite of the right hand. She also notes that the bite was a deliberate assault which took place in a shopping mall. That gives us codes:
- S61.451A, open bite of right hand
- Y04.1XXA, assault by human bite, initial encounter
- Y92.59, other trade areas as the place of occurrence of the external cause (the mall)
- Y99.8, other external cause status
If Jane sustained simply a superficial bite, we would have reported code S60.571A (ather superficial bite of hand of right hand, initial encounter).
Our final patient of the day came in for some non-shopping, but still holiday-related, setbacks. Ralph, a 23-year-old, apparently enjoyed Thanksgiving dinner at Mom’s house so much he had seconds, and thirds, and fourths. He now is suffering from a severe stomach ache and feels bloated. He complains of nausea but denies vomiting. He also complains of chest pain and has no history of heart problems.
Dr. Donner orders an EKG to rule out a heart problem as the cause of the chest pain. Dr. Donner rules out an ulcer and cancer as causes of Ralph’s pain. She also rules out a hernia. Dr. Dasher’s EKG report shows no signs of heart problems.
Dr. Donner diagnoses Ralph with functional dyspepsia and advises him to moderate his food intake in the future. That gives us code K30 (functional dyspepsia).
I think it’s time to grab some leftovers and start my Cyber Monday shopping. Happy Thanksgiving!
Farmer Brown came in today to see Dr. Gobbler for some injuries sustained when he tried to prepare his Thanksgiving main course. It seems Farmer Brown’s turkey wasn’t interested in joining him as dinner.
Farmer Brown first attempted to wring the turkey’s neck. After a considerable chase around the yard (and multiple trips and falls by Farmer Brown), he eventually captured the reluctant bird. Unfortunately for Farmer Brown, the turkey pecked his hands until he let go.
That gives us our first code for this encounter: puncture wound of the hand. The question is, which hand? In this case, it’s both hands, so we would report two codes:
- S61.431A, puncture wound without foreign body of right hand, initial encounter
- S61.432A, puncture wound without foreign body of left hand, initial encounter
If the turkey had left part of his beak behind, we would have used the code for puncture wound with foreign body (S61.441A or S61.442A) for the appropriate hand. Notice also that we need a seventh character to denote the encounter.
We can also add some external causes codes to round out our story:
- W61.43XA, pecked by turkey, initial encounter
- Y92.73, farm field as the place of occurrence of the external cause
- Y93.K9, activity, other involving animal care
- Y99.8, other external cause status
Farmer Brown’s attempts don’t stop with interrupted wringing. Next, he tried an axe to cut off the turkey’s head. A chase again ensued, with the turkey neatly tripping Farmer Brown, so he dropped the axe. Unfortunately for Farmer Brown, he dropped the axe onto his foot and crushed two toes.
We need to know which toes and which foot was involved. We scan Dr. Gobbler’s notes and find that Farmer Brown crushed two lesser toes on his left foot. That gives us code S97.122A (crushing injury of left lesser toe[s], initial encounter). Regardless of how many lesser toes (one to four) Farmer Brown crushed, we only report one code.
If Farmer Brown had crushed his great toe and one lesser toe, we would need two codes. The great toe has its own code (S97.112A, crushing injury of left great toe, initial encounter).
Farmer Brown’s third and (thankfully) final attempt to bag the bird involved a really big kettle of boiling water. The turkey decided to enlist the aid of a few friendly cows (who never liked Farmer Brown anyway) to tip over the cauldron and drench Farmer Brown.
Fortunately, he suffered only minor first-degree burns to his right leg. We do need some additional specificity in order to code this injury, namely the location of the burns. The following sites on the leg can be coded specifically:
- Lower leg
- Multiple sites
Dr. Gobbler documents burns to the right lower leg, so we would code T24.131A (burn of first degree of right lower leg, initial encounter).
We also spot the note under code T24.1 directing us to report additional external cause codes to identify the source, place, and intent of the burn (X00-X19, X75-X77,X96-X98, Y92), so we also report:
- X12.XXXA, contact with other hot fluids (boiling water), initial encounter
- X98.2XXA, assault by hot fluids, initial encounter (We could make a case that the turkey was only defending himself when he coerced the cows into tipping over the cauldron or that it was an accident.)
- Y92.73, farm field as the place of occurrence of the external cause
Following his latest setback, Farmer Brown has decided to let the turkey live and take his wife out for dinner instead. Let someone else deal with uncooperative poultry.
You may remember that the American Medical Association (AMA) has been pushing for an end to ICD-10 since 2012. During its recent House of Delegates meeting, the AMA reinforced its position that ICD-10 implementation should be delayed by two years. It initially put forth that resolution in June.
The AMA already helped force CMS to delay implementation of ICD-10 from October 1, 2013, to October 1, 2014. That may not have been a great thing for physicians, according to Paul Weygandt, MD, JD, MPH, MBA, CCS, vice president of physician services for J.A. Thomas and Associates in Atlanta.
“The worst thing for physicians was that the AMA delayed ICD-10 by one year,” he told AHIMA Convention attendees. That gave physicians the idea that the AMA will stop ICD-10 implementation again.
How do you get physicians on board for ICD-10 when the AMA is not? Remind them that ICD-10 doesn’t change the way they practice medicine. They will still treat patients the same way they do now. We’re just asking them to document a little more.
Physicians are likely documenting much of the necessary information already, such as laterality, because it’s good patient care. The physician wants to know where an injury occurred so when the patient comes back for a follow up, he or she is checking the correct area.
ICD-10 is also written in more clinical terms and less coder speak, which means docs will need to learn less than coders. For example, many pulmonologists already describe asthma as:
- Mild intermittent
- Mild persistent
- Moderate persistent
- Severe persistent
ICD-10-CM now uses those terms.
For myocardial infarctions, physicians have been documenting STEMI and non-STEMI for years, Weygandt says. In ICD-10-CM, coders will be able to report it that way.
Don’t tell physicians what they need to document. Tell them what they aren’t documenting. Give them a (figurative) pat on the head for the things they are doing correctly. And ask them if they would accept their documentation if it came from a resident.
“Good documentation for ICD-10 is what we should be teaching residents because it’s good clinical care,” Weygandt says.
ICD-10 is coming, whether the AMA wants it to or not. Work with your physicians now so you are all ready for the change.
Conquest, War, Famine, and Death have nothing on the Four Horsemen of the ICD-10 Apocalypse:
How do you tame these terrors? With planning and practice (and some luck thrown in as well). Over the next few weeks, we’ll look at each of these areas in more detail. Today, let’s start with accuracy.
By now, most coders should have started ICD-10 training of some sort. Coding managers should know how well their coders know anatomy and physiology and medical terminology. Ideally, coders should also have started training on the code sets. Some organizations are done training and are onto the practice stage, while others are just compiling the results of their coder assessments.
Dual coding has been a hot topic in HIM circles for at least a year now. People are trying to figure how and when to start dual coding, which method to use, and how many records to code. Some people think that dual coding or coder training and practice is all they need to get their coders ready for ICD-10.
Not quite. It’s not enough to be able to pick a code in ICD-10. You have to assign the correct code. How do you know if you are assigning the correct code? That’s where things can get tricky.
If you are coding actual records from your facility, you don’t have an answer key to look at to know you came up with the right answer. If you are the only one at your facility coding a particular record in ICD-10, you don’t even have anyone to ask.
Rachel Chebeleu, MBA, RHIA, and her colleagues at the Hospital of the University of Pennsylvania (HOP) came up with a solution. A group of superusers at HOP took a group of actual hospital records and each person coded each record in ICD-10. Then they compared notes to see whether they all arrived at the same codes. If they did, great. If they didn’t, they discussed the case and why each person came up with a specific code.
Consider creating a coding roundtable at your facility to make sure you not only practice coding in ICD-10, but you end up with the correct codes.
One horseman down, keep an eye out for Documentation.
A feral flock of wild turkeys has invaded New York City. Seriously. And with them, they bring all sorts ofcode-ready diseases and mishaps.
When we look up chlamydiosis in the ICD-10-CM Alphabetic Index, we are directed to see chlamydia. That doesn’t sound good.
On a clinical note, however, chlamydiosis in birds is different from the human venereal disease chlamydia. Patients who contract chlamydiosis from birds often experience fever, headache, and loss of appetite. They may also experience painful or difficult breathing.
Chlamydiosis in birds, such as our Big Apple party crashers, is caused by a bacterial organism, Chlamydophila psittaci. And it just so happens we have a specific ICD-10-CM code for it: A70 (Chlamydia psittaci infections).
We all know not to eat raw eggs and I certainly don’t want to fight a wild turkey for one (the grocery store ones come with much less hazard to my hands). Odds are, we won’t contract salmonellosis from the NYC flock.
Colibacillosis is caused by our old friend Escherichia coli. E. coli can cause all sorts of unpleasant conditions, including:
- A04.0, enteropathogenic Escherichia coli infection
- A04.1, enterotoxigenic Escherichia coli infection
- A04.2, enteroinvasive Escherichia coli infection
- A04.3, enterohemorrhagic Escherichia coli infection
- G00.8, meningitis due to Escherichia coli
- J15.5, pneumonia due to Escherichia coli
- P36.4, sepsis of newborn due to Escherichia coli
Those all sound like awesome reasons to avoid the walking turkeys and their droppings.
But what happens when a turkey tries to cross Broadway? Well, if the bird is unlucky, it will get run over. New Yorkers stop for no fowl.
However, if the birds are smart enough to cross en masse, they could cause some serious traffic disruptions and possibly some traffic accidents. We’ll leave the specific injuries (contusions, lacerations, broken bones, etc.) out of the equation for the moment and look at the External Causes codes associated with traffic accidents.
ICD-10-CM includes multiple code possibilities for transport accidents in sections V00-V99. The introductory note for the section states:
This section is structured in 12 groups. Those relating to land transport accidents (V01-V89) reflect the victim’s mode of transport and are subdivided to identify the victim’s ‘counterpart’ or the type of event. The vehicle of which the injured person is an occupant is identified in the first two characters since it is seen as the most important factor to identify for prevention purposes. A transport accident is one in which the vehicle involved must be moving or running or in use for transport purposes at the time of the accident.
If the turkeys on the Great White Way caused an accident, we would likely head to V40 (car occupant injured in collision with pedestrian or animal). Our choices include:
- V40.0, car driver injured in collision with pedestrian or animal in nontraffic accident
- V40.1, car passenger injured in collision with pedestrian or animal in nontraffic accident
- V40.2, person on outside of car injured in collision with pedestrian or animal in nontraffic accident
- V40.3, unspecified car occupant injured in collision with pedestrian or animal in nontraffic accident
- V40.4, person boarding or alighting a car injured in collision with pedestrian or animal
- V40.5, car driver injured in collision with pedestrian or animal in traffic accident
- V40.6, car passenger injured in collision with pedestrian or animal in traffic accident
- V40.7, person on outside of car injured in collision with pedestrian or animal in traffic accident
- V40.9, unspecified car occupant injured in collision with pedestrian or animal in traffic accident
All of these codes require a seventh character to indicate the encounter type, so you’ll also need two placeholder Xs so the seventh character ends up in the seventh spot.
So if you’re flocking to New York for the holidays, watch out for those wild birds.
Mr. Jack O. Lantern underwent some significant surgery at Stitch ‘Em Hospital back on October 16. Dr. Carver removed Jack’s liver, stomach, large intestine, small intestine, appendix, and gall bladder. Unfortunately, Jack is suffering some complications from his surgery.
Dr. Carver first diagnoses Jack with a fungal infection of the skin due to Podosphaera xanthii. When we look up infection in the ICD-10-CM Alphabetic Index, we find quite a list of potential codes. We know Jack has a skin infection, so if we go to Infection, Skin, we find an entry for “due to fungus.” We actually have two choices:
- B36.8, other specified superficial mycoses
- B36.9, superficial mycosis, unspecified
Since we know the causative organism, we would use B36.8. Remember that other specified is not the same as unspecified. We know the cause, we just don’t have a code for it. Some antibiotics should clear that right up.
Sadly, that is not the extent of Jack’s woes. Dr. Carver also diagnoses him with gangrenous cellulitis, an infection of soft tissue that produces extensive tissue necrosis and local vascular occlusions. Basically, Jack’s rotting from the inside.
If we look up cellulitis, gangrene in the ICD-10-CM Alphabetic Index, we are directed to Gangrene. However, gangrene does not list cellulitis as one of the sub-terms. The main code for gangrene is I96 (gangrene, not elsewhere classified). When we look that up in the Tabular List, we find gangrenous cellulitis listed under I96.
Dr. Carver also documents gangrene of the abdominal wall, which also maps to code I96.
Dr. Carver determines that Jack needs some excisional debridement to remove the gangrene so he can return to health.
In ICD-9-CM procedure coding, we would code excisional debridement using 86.22. How would we code it in ICD-10-PCS?
In order to get to the correct ICD-10-PCS table, we need to know the section, body system, and root operation. Section is easy. We know we are coding for a surgical procedure, which gives us an initial character of 0 (zero, not a capital O).
Let’s skip the body system for a minute and figure out which root operation we’re going to use. When you look up debridement in the ICD-10-PCS Alphabetic Index, you find two choices:
- Excisional, see Excision
- Non-excisional, see Extraction
We need to do a little investigating in Dr. Carver’s operative report to find out exactly what she did, so we know whether we’re coding excisional or non-excisional debridement.
Excisional debridement involves removing or cutting away devitalized tissue, necrosis, or slough. It is always a surgical procedure. Physicians use a recognized sharp instrument, such as a cutting curette, laser, scissors, or scalpel, to perform the excisional debridement.
Dr. Carver documents removal of devitalized tissue using a scalpel, so we are coding an excisional debridement.
On to the body system. Where specifically is Jack’s gangrene? Hopefully, Dr. Carver is very specific in her documentation, otherwise we’ll need to query.
We know some of the gangrene is located in the abdominal wall. ICD-10-PCS classifies the abdominal wall as a general anatomical region, which leads us to table 0WB.
Abdominal wall gives us a fourth character of F.
Now we need the approach. We have three choices:
- Open (0)
- Percutaneous (3)
- Percutaneous endoscopic (4)
Because of the extent of Jack’s abdominal gangrene, Dr. Carver elects an open approach. We have no device choice, which makes the sixth character Z. Our final character can be either X (diagnostic) or Z (no qualifier).
For Dr. Carver’s excisional debridement of Jack’s abdominal gangrene, our code is 0WBF0ZZ.
What about the rest of the debridements? Again, we need to know where exactly Dr. Carver is performing the debridements, as well as how deep the debridements are.
ICD-10-PCS guidelines state that an excisional debridement that includes skin, subcutaneous tissue, and muscle is coded to the muscle body part.
Dr. Carver documents the following debridements:
- 13 sq cm of the left quadriceps, percutaneous
- 9 sq cm of the right flexor pollicis longus and pronator quadratus, percutaneous
- 10 sq cm of subcutaneous tissue in the right lower leg, percutaneous
- 8 sq cm of dermis on the scalp, external approach
For each debridement, we need a specific code. Each one will vary based on the body system, the body part, and the approach. All of the codes will include the same section, root operation, device, and qualifier.
If you don’t know where the flexor pollicis longus and pronator quadratus muscles are, check the body part guide in the back of your ICD-10-PCS Manual (For the record, they are arm muscles).
Our codes would be:
- 0KBR3ZZ, excision of left upper leg muscle, percutaneous approach
- 0KB93ZZ, excision of right lower arm and wrist muscle, percutaneous approach
- 0JBN3ZZ, excision of right lower leg subcutaneous tissue and fascia, percutaneous approach
- 0HB0XZZ, excision of scalp skin, external approach
Hopefully, Dr. Carver excised all of the dead tissue and Jack will soon be on the mend.
Poor Mr. Frank N. Stein, he’s literally falling to pieces. Not to worry, though, Dr. Shelly at the Stich ‘Em Up Hospital will have him back together in no time.
Frank’s most obvious problem is that his right hand has come off. Apparently whoever sewed it on the first time didn’t do a very good job. Dr. Shelly documents that she reattached Frank’s own right hand. Her operative note is full of details about the procedure, but for coding purposes, we need to know the objective of the procedure.
ICD-10-PCS root operation Reattachment (M) is defined as “putting back in or on all or a portion of a separated body part to its normal location or other suitable location.” Examples include reattachment of hand and reattachment of avulsed kidney. Dr. Shelly is reattaching a hand, so we know our root operation.
Before we can find the correct table, we need to determine the body system. ICD-10-PCS does not include a body system value for the arm or hand separately. They are rolled into the anatomical region Upper Extremity (X).
Now we can get to the correct ICD-10-PCS table: 0XM. We have lots of choices for specific body parts being reattached, so we need to carefully read the operative report to make sure we choose the correct one.
Dr. Shelly documented reattachment of the right hand, which gives us J as a fourth character. The rest of the characters are easy. We only have one possible approach (open) and no device or qualifiers. That gives us a final code of 0XMJ0ZZ (reattachment of right hand, open approach).
Frank also has several flaps of skin that need to be replaced. Frank does not have the missing skin flaps, so Dr. Shelly is going to use some skin replacements. We’re still in the Medical and Surgical section (0) and our body system is Skin and Breast (H). Now we need to determine the correct root operation. To do that, we need to skim the operative report to determine the objective of the procedure.
In the OP report, Dr. Shelly states she replaced skin on Frank’s left upper leg, abdomen, and scalp with Apligraf®. When we look at our root operation definitions, we see two root operations that could apply to skin grafts.
The first is Repair (restoring, to the extent possible, a body part to its normal anatomic structure and function). Dr. Shelly isn’t really restoring the skin, she is replacing it.
Our second possible root operation looks more promising. Replacement involves 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. Apligraf is a biological material, so it qualifies for replacement, giving us our root operation.
We can now head to table 0HR. We know Dr. Shelly is replacing skin at three sites, so we will report three different codes. We do need to know one other piece of information. Is the replacement partial or full thickness?
If Dr. Shelly doesn’t document this information, we must query. (Yeah, I know, you hate sending doctors queries almost as much as they hate getting them. But without that information we can’t code the procedures.)
Fortunately, Dr. Shelly documents partial thickness, giving us codes:
- 0HRJXK4, replacement of left upper leg skin with non-autologous tissue substitute, partial thickness, external approach
- 0HR7XK4, replacement of abdomen skin with non-autologous tissue substitute, partial thickness, external approach
- 0HR0XK4, replacement of scalp skin with non-autologous tissue substitute, partial thickness, external approach
Two quick notes: Our only choice for approach is external, which makes perfect sense if you think about it. Procedures performed directly on the skin or mucous membrane use an external approach.
The second thing is we have multiple locations for skin of the leg. ICD-10-PCS includes not just left and right leg, but also upper and lower designations. If your physician isn’t documenting the exact location, you may need to query. Before you do, though, make sure the physician hasn’t documented any anatomical landmarks that you can use to determine the location.
Dr. Shelly also finds that Frank’s right kidney is not working properly, so she is going to transplant a new kidney. It just so happens she has one on hand (Best not to ask where she got it).
ICD-10-PCS defines Transplantation as “putting in or all of a portion of a living body part taken from another individual or animal to physically take the place and/or function of all of a similar body part.”
Dr. Shelly is replacing Frank’s kidney with a live body part, so Transplantation is our root operation. The kidney is part of the urinary system, leading us to table 0TY. We know Dr. Shelly is replacing the right kidney, which gives us 0 for our body part. Our only choice for approach is open (0) and Z is our only choice for a qualifier.
The only other thing we need to know is what type of kidney Dr. Shelly is using:
- 0, allogeneic
- 1, syngeneic
- 2, zooplastic
If you don’t know the difference, now is a good time to learn.
An allogeneic transplant comes from a non-identical donor of the same species—one person donates a kidney to another person. It can be a family member or a complete stranger.
A syngeneic transplant involves an organ from an identical member of the same species (think identical twin).
A zooplastic transplant involves a transplant from one species to another. Pig heart valves implanted into humans is one example.
Dr. Shelly documented that the donor kidney was human, but not from an identical twin, which gives us 0 for our qualifier and a complete code of 0TY00Z0 (transplantation of right kidney, allogeneic, open approach).
Frank is now put back together with fully functioning body parts just in time for trick-or-treating.
Coder productivity was a hot topic of conversation during the AHIMA pre-conference in Atlanta October 26-27.
We all know coders will be less productive initially after the transition to ICD-10. The question is how much less productive?
Different speakers offered different opinions, ranging from a 25% decrease in productivity to 60% decrease in productivity. Some of those estimates are based on Canada’s experience, some are just best guesses, others are based on pilot studies.
Hopefully, most people realize that coders are going to struggle more initially with PCS. It’s a brand new coding system. Inpatient coders are going to have to look for things they don’t look for now, such as laterality and approach.
ICD-10-CM is very similar to ICD-9-CM. You still need to look for more information than you do in ICD-9-CM (laterality again comes to mind). But if you can look up a code in ICD-9-CM, you can look up a code in ICD-10-CM.
The decrease in inpatient productivity remains a great unknown. The best way to combat the productivity decline is make sure you coders are trained and comfortable using ICD-10-CM and PCS before the transition.
Greetings from Atlanta! I spent the weekend collecting all kinds of tips and information about ICD-10 during the AHIMA Conference pre-conference sessions. These are just a few of the best tidbits from the weekend.
I found the absolute best reason to transition to ICD-10, courtesy of Gerri Walk, RHIA, CCS-P, from HRS in Baltimore: We’re staving off dementia! Use your brain or lose it and ICD-10 is going to let us exercise our brains. A lot.
Donna L. Rudolph, RHIT, CCS, and Joanne Schade-Boyce, BSHD, MS, COC, ACS, PCS, from Health Revenue Assurance Associates talked about the hidden impact of ICD-10. For example, the timeframe for an acute MI in ICD-10-CM goes from eight weeks to four weeks. Not only is that going to be a struggle for coders to remember, it can also affect your MS-DRG, Donna says.
Have you thought about how you current coding policies and procedures will have to change under ICD-10? We’re so focused on education right now, we may not be assessing policies and procedures, Joanne says.
You’ll hear lots more from Joanne and Donna’s presentation in an upcoming issue of JustCoding.
When are you planning to start dual coding and which method are you going to use? Are you going to code concurrently or retrospectively? How many records are you going to code in ICD-10 and how will you check the accuracy? Kimberly Carr, RHIT, CCS, CDIP, manager of clinical documentation for HRS, raised all of those questions during her session on justifying the cost of dual coding. One of the biggest advantages to dual coding: reducing your risk for inaccurate coding because coders will be more comfortable in ICD-10. And, oh, by the way, that will reduce your productivity loss as well.
How do you get to the Carnegie Hall of ICD-10? Practice, practice, practice. That’s Donna’s line, but it was a consistent theme across multiple presentations. The best way for coders to learn ICD-10 and get comfortable is to practice coding actual records in ICD-10. The challenge is to find the time.
More on these presentations and other ICD-10 sessions from AHIMA later.
Jacob comes into the Fix ‘Em Up Clinic with a hairy problem—namely too much hair. He’s covered in it, head to tail, I mean toe. He also reports a strange urge to howl at the moon and a severe allergy to silver. And when he smiled, I saw some really long canine teeth.
Dr. Lycan Thrope diagnoses Jacob with hypertrichosis. That’s really just a blanket term for too much hair. ICD-10-CM includes multiple possibilities for coding hypertrichosis (L68):
- L68.0, hirsutism
- L68.1, acquired hypertrichosis lanuginosa
- L68.2, localized hypertrichosis
- L68.3, polytrichia
- L68.8, other hypertrichosis
- L68.9, hypertrichosis, unspecified
A diagnosis just of hypertrichosis isn’t going to get us far. We do have an unspecified code, but at this point, we don’t know if Jacob’s insurance company will pay for unspecified ICD-10-CM codes. So we need to query Dr. Thrope.
Upon further review, Dr. Thrope eliminates all of our potential specific variants of hypertrichosis and instead writes: congenital terminal hypertrichosis.
Being the coding experts we are, we noticed this note under L68:
- Excludes1: congenital hypertrichosis (Q84.2)
ICD-10-CM features two types of Excludes notes so coders no longer have to guess what it means. An Excludes1 note means not coded here. The two codes are mutually exclusive. In this case, you can’t code Q84.2 with any code from the L68 series.
Off to the Q codes we go. Q84.2 represents other congenital malformations of hair, including:
- Congenital hypertrichosis
- Congenital malformation of hair NOS
- Persistent lanugo
Because Dr. Thrope documented congenital terminal hypertrichosis, Q84.2 is our code. Don’t let the term “terminal” throw you off. Terminal is a type of hair, it doesn’t mean Jacob is about to die. Terminal hair is thick, long, and dark.
Now that we’ve got the hair out of the way, we’ll move on to Jacob’s other complaints.
That urge to howl at the moon? It could be delusions that he really is a werewolf. In that case, we would code F22 (delusional disorders). On the other hand, he may just be preparing for National Howl at the Moon Day, slated for October 26. No ICD-10-CM code for that one.
Now the silver allergy. We need to know a little bit more about this condition. In ICD-10-CM, under Allergy, we find a whole list of substances. But if you look at the term Allergy, you’ll see some non-essential modifiers in parentheses: (reaction) (to). These are supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code assigned.
What Jacob really has is an allergic reaction to silver that causes contact dermatitis. That gives us L23.0 (allergic contact dermatitis due to metals).
It turns out Jacob really does have extra-long canine teeth, which Dr. Thrope diagnoses as macrodontia (K00.2). Lots of different conditions fall under K00.2 (abnormalities of size and form of teeth), so you’ll need to carefully read the list of included conditions.
Some of these conditions may actually be symptoms of an underlying disease (or diseases). Delusions could be a sign of a serious mental disorder. The excessive hair could be a sign of too much testosterone (or too much Rogaine). As coders we need to only code what’s in the documentation. Since Dr. Thrope didn’t document any underlying conditions, we’ll go with the ones we have.
Time to go practice my howling.