Inpatient coders are used to being able to code conditions documented as possible, probable, suspected, or rule out, as if they were in fact confirmed. Outpatient coders can’t do that. They need a confirmed diagnosis.
However, in one case, inpatient coders always must have a confirmed diagnosis in order to report the condition: HIV. Regardless of setting, coders can only code confirmed cases of HIV. You don’t need a diagnostic lab test for a confirmation. In this context, you just need the provider’s diagnostic statement that the patient is HIV-positive, or has an HIV-related illness.
Patients with HIV can suffer from a host of related conditions, so you need to know the sequencing guidelines. Here’s the good news: the guidelines in ICD-10-CM are the same as the guidelines in ICD-9-CM. They just look different.
So, a quick review of HIV coding guidelines.
If the patient is admitted for an HIV-related condition, report B20 (human immunodeficiency virus [HIV] disease) as the principal diagnosis, followed by additional diagnosis codes for all reported HIV-related conditions.
If the patient is admitted for an unrelated illness or injury, such as a traumatic fracture, sequence the unrelated condition as the principal diagnosis, followed by B20 and coders for any reported HIV-related conditions.
Remember that whether the patient is newly or previously diagnosed does not affect sequencing. You go by the reason for the admission.
What happens when a physician documents that a patient is HIV-positive, but has no symptoms? Report Z21 (asymptomatic human immunodeficiency virus [HIV] infection status). You would not use the Z code if the physician documents that the patient has AIDS, or is treating the patient for any HIV-related illness, or describes the patient as having any condition(s) resulting from his/her HIV-positive status. Z21 is only for asymptomatic cases of HIV.
Once a patient has developed an HIV-related illness, you will always assign code B20 on every subsequent admission/encounter. Never report R75 (inconclusive laboratory evidence of human immunodeficiency virus [HIV]) or Z21 for patients previously diagnosed with any HIV illness. Once a patient has HIV, he or she always has HIV. We haven’t cured it yet.
Brush up on your knowledge of cardiovascular system anatomy as you learn how to code cardiovascular diseases in ICD-10-CM during the live, 90-minute webcast Reduce the Fear of ICD-10-CM Cardiovascular Coding!
Join JustCoding at 1 p.m. (Eastern) Thursday, March 6, as expert speakers Gerri Walk, RHIA, CCS-P, and Laura Legg, RHIT, CCS, give you the inside track on codes and guidelines for cardiovascular conditions in ICD-10-CM. They will discuss what you need to see in the documentation in order to assign the most appropriate code.
Gerri and Laura will present a companion webcast, Reduce the Fear of ICD-10-PCS Cardiovascular Procedures, April 10 to give you the ins and outs of cardiovascular procedure coding in ICD-10-PCS. They will address documentation requirements and provide tips and takeaways to assist
inpatient coders in preparation for this new coding system.
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Can’t join us live? No problem! You can order both webcasts on-demand, meaning you can watch whenever it’s convenient for you. And you can train your entire team, live, on-demand, or both!
I really want the t-shirt that says, “I only do what the voices in my head tell me” and its companion shirt, “The voices in my head don’t like you.” Sadly too many people I know might believe it.
It depends on why you’re hearing voices. People hear voices all the time, sometimes for totally benign reasons. For example, you may hear voices when you fall asleep. Not to worry, they’re just hypnagogic hallucinations, part of falling asleep.
ICD-10-CM includes six different codes for hallucinations, including one for auditory hallucinations (R44.0). You’ll find these codes under category R44 (other symptoms and signs involving general sensations and perceptions). You would only report these codes if the physician doesn’t know why the patient is hallucinating.
However, plenty of medical conditions also cause hallucinations. For example, people who abuse drugs and alcohol can experience hallucinations. For these patients, you would need to know whether their drug or alcohol use falls under:
This is a new concept in ICD-10-CM. Use, abuse, and dependence even have their own hierarchy. The ICD-10-CM guidelines tell us the following:
- If both use and abuse are documented, assign only the code for abuse
- If both abuse and dependence are documented, assign only the code for dependence
- If use, abuse and dependence are all documented, assign only the code for dependence
- If both use and dependence are documented, assign only the code for dependence
Dependence, when documented, always trumps use and abuse.
In ICD-10-CM, you’ll find the code broken out by substance causing the psychotic disorder (i.e. hallucinations). Our choices include:
- F10.251, alcohol dependence with alcohol-induced psychotic disorder with hallucinations
- F11.151, opioid abuse with opioid-induced psychotic disorder with hallucinations
- F12.951, cannabis use, unspecified with psychotic disorder with hallucinations
- F13.251, sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with hallucinations
- F14.951, cocaine use, unspecified with cocaine-induced psychotic disorder with hallucinations
We need documentation of the substance and the level of use, as well as the specific psychotic symptom.
Alternately, a patient may be suffering from a mental illness that is causing his or her hallucinations. Schizophrenia may be the mental illness that comes to mind. If the patient does indeed suffer from schizophrenia, we need to know the type in order to choose from these codes:
- F20.0, paranoid schizophrenia
- F20.1, disorganized schizophrenia
- F20.2, catatonic schizophrenia
- F20.3, undifferentiated schizophrenia
- F20.5, residual schizophrenia
- F20.81, schizophreniform disorder
- F20.89, other schizophrenia
Many of these codes feature a list of inclusive terms underneath them. For example, catatonic schizophrenia includes:
- Schizophrenic catalepsy
- Schizophrenic catatonia
- Schizophrenic flexibilitas cerea
Patients with major depressive disorder may also hear voices. In order to code this condition, we need to know whether the patient is suffering from a single episode with psychotic features (F32.3) or recurrent major depressive disorder with psychotic symptoms (F33.3).
Bipolar patients may also suffer from auditory hallucinations. ICD-10-CM breaks down the bipolar disorder codes to identify the type of episode the patient has:
- F31.2, bipolar disorder, current episode manic severe with psychotic features
- F31.5, bipolar disorder, current episode depressed, severe, with psychotic features
- F31.64, bipolar disorder, current episode mixed, severe, with psychotic features
Patients suffering from post-traumatic stress disorder (PTSD) may also hallucinate. The ICD-10-CM codes for PTSD do not specify whether the patient is suffering from psychotic symptoms. They are divided into:
- Acute (F43.11)
- Chronic (F43.12)
- Unspecified (F43.10)
A range of organic brain disorders, such as brain tumors, temporal lobe epilepsy, and viral encephalitis, can also cause hallucinations. If the hallucinations are integral to the disease process, we don’t code them separately. You may need to ask a clinician or clinical documentation improvement specialist if you’re not sure.
If you’ll excuse me, I hear a cookie calling my name.
One of the things that drives me crazy about how media, Congress, and the AMA discuss ICD-10 codes is their focus on the External Causes codes. Granted some of those codes are silly or strange or seem pointless.
The ICD-10-CM guidelines point out that coders are not to report External Causes codes. Some states or payers may require External Causes, but reporting these codes is otherwise optional. However, the guidelines recommend reporting these codes anyway because they provide valuable data.
So you don’t need to report W58.11XA (bitten by crocodile, initial encounter) or X06.1XXA (exposure to melting of plastic jewelry, initial encounter). The codes are there, they help tell a better story about the patient, and they can be useful for data collection.
External Causes codes include some very detailed codes for injuries involving motor vehicles, such as:
- V39.50-, passenger in three-wheeled motor vehicle injured in collision with unspecified motor vehicles in traffic accident
- V43.42-, person boarding or alighting a car injured in collision with other type car
- V65.00, driver of heavy transport vehicle injured in collision with railway train or railway vehicle in non-traffic accident
Those aren’t the codes you need to worry about, though. Instead of focusing on the External Causes codes, coders (and the AMA, media, and Congress) should be looking at the injury and illness codes. For example, in Chapter 19 (Injury, poisoning and certain other consequences of external causes [S00-T88]), we find six choices in category S90.1- (contusion of toe without damage to nail):
- S90.111-, contusion of right great toe without damage to nail
- S90.112-, contusion of left great toe without damage to nail
- S90.119-, contusion of unspecified great toe without damage to nail
- S90.121-, contusion of right lesser toe(s) without damage to nail
- S90.122-, contusion of left lesser toe(s) without damage to nail
- S90.129-, contusion of unspecified lesser toe(s) without damage to nail
In order to be valid codes, each of those choices needs a seventh character:
- A, initial encounter
- D, subsequent encounter
- S, sequela
So in reality, we have 21 possible codes for a contusion of the toe without damage to the nail. In ICD-9-CM, we have one possible code: 924.3 (contusion of toe). We also have 21 codes for contusion of a toe with damage to nail. Still reporting 924.3 in ICD-9-CM.
If you want to talk about the increased number of codes and the increased specificity and granularity of ICD-10-CM, those are the kind of codes you should be discussing. Those are the codes that are clinically significant and describe the patient’s condition. Those are the codes we need better documentation to report. Those are the codes that will get us paid.
Worry about those codes and their details and leave the External Causes alone.
What did you get for Valentine’s Day? Flowers? Chocolate? Mono? It is the kissing disease after all.
ICD-9-CM includes only one code for infectious mononucleosis: 075. That code includes glandular fever, monocytic angina, and Pfeiffer’s disease. Prepare to be shocked: ICD-10-CM offers many more choices for mono. The new codes identify the cause of the patient’s mononucleosis:
- B27.0, gammaherpesviral mononucleosis (also known as the Epstein-Barr virus)
- B27.1, cytomegaloviral mononucleosis
- B27.8, other infectious mononucleosis
- B27.9, infectious mononucleosis, unspecified
Those four codes are not reportable codes. If you try to report B27.0, you will either hit an edit or get the bill back from the insurance company. Why? Because each of those four codes includes four additional subcategories of codes to denote:
- Without complications
- With polyneuropathy
- With meningitis
- With other complication
Not only do we need to know the causative organism for mono, we also need to know what complications are present.
Keep in mind though that we can report a code from the B27.9- series if the physician does not know the causative organism. You always want to report the most specific code, which would be from the B27.0-, B27.1-, or B27.8- series. However, the physician may be unable to determine the type of mono without additional tests. The ICD-10-CM Official Guidelines for Coding and Reporting tell us not to conduct medically unnecessary diagnostic testing in order to determine a more specific code.
Poor Paul, he just wanted to take his black Labrador Molly to the vet for her checkup. Instead he ended up needing a doctor.
Paul put down a sheet in his truck so Molly wouldn’t have to sit on the cold leather seat. To make sure the sheet didn’t slip, he tucked it in. And in the process, he injured the middle finger on his right hand.
Undeterred by the drooping finger, Paul took Molly to the vet, where she got a clean bill of health, then left her with his friend Bruce while he took himself off to Fix ‘Em Up Clinic.
Dr. Neefe examined Paul’s finger and diagnosed mallet finger. Mallet finger is an injury of the extensor digitorum tendon of the finger at the distal interphalangeal joint. Fortunately, the ICD-10-CM Alphabetic Index lists mallet finger with three potential codes:
- Acquired, see Deformity, finger, mallet finger
- Congenital, Q74.0
- Sequelae of rickets, E64.3
We know Paul suffered an injury, which makes it acquired mallet finger. So off we go to deformity. Not surprisingly, we have three code choices for an acquired mallet finger:
- M20.011, mallet finger of right finger(s)
- M20.012, mallet finger of left finger(s)
- M20.019, mallet finger of unspecified finger(s)
ICD-10-CM only requires laterality, not specificity for the individual finger. If Paul had developed mallet finger on more than one finger, we would still report the same code and only report it once.
You will need to check the record for some additional information, because mallet finger can simply be a tendon injury treated with a splint or it can be serious enough to require surgery.
In some cases, the tendon may pull a piece of the bone away when it breaks. If a patient has large fracture fragments or the joint becomes misaligned, the patient may require surgery.
In other cases, the nail may become detached. Fortunately, Paul only needs a splint and Dr. Neefe expects Paul will regain acceptable function and appearance with this treatment plan.
Molly was very happy to see Paul return, even if he has a funny cover on his finger.
Is this love that I’m feeling? Or do I have some deadly disease?
When we look up Sickness, mountain, in the ICD-10-CM Alphabetic Index, we find two options:
- T70.29-, other effects of high altitude, which includes both alpine and mountain sickness
- D75.1, secondary polycythemia, increased red blood cells, white blood cells, and platelets
Well, I haven’t been to the mountains or any other high-altitude place recently, so I don’t think it’s mountain sickness.
It feels like a swarm of butterflies has taken up residency in my stomach every time I hear my beloved’s name mentioned. Could be love or generalized anxiety disorder. We can’t code love in ICD-10-CM, but we can code anxiety. In fact, we can code a lot of anxiety in ICD-10-CM. Just look at our choices:
- F41.0, panic disorder [episodic paroxysmal anxiety] without agoraphobia
- F41.1, generalized anxiety disorder
- F41.3, other mixed anxiety disorders
- F41.8, other specified anxiety disorders
- F41.9, anxiety disorder, unspecified
We also have an Excludes2 note under Other Anxiety Disorders (F41):
- Acute stress reaction (F43.0)
- Transient adjustment reaction (F43.2)
- Neurasthenia (F48.8)
- Psychophysiologic disorders (F45.-)
- Separation anxiety (F93.0)
An Excludes2 note means not included here. The condition excluded is not part of the condition under which it is listed, but a patient may have both conditions at the same time. So a patient could have both generalized anxiety disorder and an acute stress reaction. It’s okay to report both.
I never thought of myself as the anxious type. What other symptoms do I have? I can’t sleep. Love or insomnia?
What is the cause of my insomnia? Is it due to an anxiety disorder (there’s that word again)? If so, we would report F51.05 (insomnia due to other mental disorder). Note that we also need to code the specific mental disorder. ICD-10-CM says so.
Maybe I had too much caffeine last night (F15.982). Hopefully this is a short-term situation (F51.02, adjustment insomnia).
Moving on, my heart is all aflutter and my pulse is literally racing. Is it love or atrial fibrillation? (Please be love, please be love.)
With my luck, it’s atrial fibrillation. We need some more specific information to choose from these codes:
- I48.0, paroxysmal atrial fibrillation
- I48.1, persistent atrial fibrillation
- I48.2, chronic atrial fibrillation
- I48.3, typical atrial flutter
- I48.4, atypical atrial flutter
- I48.9, unspecified atrial fibrillation and atrial flutter
I48.9- actually has two subcategory codes (odd since it’s an unspecified code). They are also unspecified, but give a little more detail:
- I48.91, unspecified atrial fibrillation
- I48.92, unspecified atrial flutter
Maybe it’s just R00.2 (palpitations, awareness of heart beat).
On second thought, maybe I don’t want to be in love. I can’t handle the stress (and the palpations and butterflies and anxiety).
It turns out that Punxsutawney Phil seeing his shadow, and thereby forecasting six more weeks of winter, wasn’t the most painful part of Groundhog Day.
Phil decided his didn’t want to make a prediction and attempted to flee the scene. He clawed his handler, who promptly dropped Phil to the platform in front of a collected assortment of national media.
Caught in the glare of the spotlights, Phil froze, suffering temporary paralysis. As soon as he spotted his handler coming to collect him, he regained his motor skills and headed into the woods.
During the ensuing chase, Bill tripped over some tree roots and went flying through the air with the greatest of ease, until he hit a tree. That left him with a concussion and a broken nose.
Another searcher, Tom, stepped in a cleverly disguised hole and twisted his ankle. Phil can create some quick booby traps on the fly, it seems.
Finally, after an exhausting groundhog hunt, the mob was able to recapture Phil. Phil didn’t go down without a fight, however, biting several of his would-be wranglers.
So how would we code these Groundhog Day wounds? Let’s start with Phil (after all, he started the whole thing).
We would report Phil’s panic attack with code F41.0 (panic disorder [episodic paroxysmal anxiety] without agoraphobia). Enochlophobia is a social phobia, which leads us to F40.11 (social phobia, generalized).
Phil’s handler escaped with some minor lacerations to his hands. In order to code his injuries, we need to know which hand. If both are involved, we would report a separate code for the right hand (S61.411-) and the left hand (S61.412-). We would also add additional codes for any fingers or wrists injured.
In order to code Bill’s concussion, we need to know if he suffered any loss of consciousness (LOC). ICD-10-CM includes 10 codes to specify the length of the LOC, from none to death. Pretty wide time range. ICD-10-CM also offers a code for LOC of unspecified duration.
If Bill suffered only a five-minute LOC, we would report S06.0X1A (concussion with loss of consciousness of 30 minutes or less, initial encounter). Note that a concussion with other intracranial injuries is classified in category S06-. Report the code for the specified intracranial injury instead of a concussion code.
Bill also broke his nose. I’m going out on a limb to say it’s a traumatic fracture, which leads us to S02.2- (fracture of nasal bones). Don’t stop there. S02.2 is not a valid ICD-10-CM code. You also need a seventh character to indicate the encounter and whether the fracture is open or closed.
Bill suffered a closed fracture and this is his initial encounter, which gives us seventh character A. In order to make sure A shows up in the seventh spot in the code, we need to add a pair of X placeholders, giving us S02.2XXA.
We can also add some External Causes codes to better explain what happened to Bill:
- W22.09XA, striking against other stationary object, initial encounter
- Y92.821, forest as the place of occurrence of the external cause
- Y93.02, activity, running (chasing an escaped groundhog is not an option unfortunately)
- Y99.8, other external cause status
What is the exact nature of Tom’s ankle injury? Is it a fracture? A dislocation? Or merely a sprain? Which ankle did he injure?
If Tom dislocated his left ankle, we would report S93.05XA (dislocation of left ankle joint, initial encounter). If he only sprained his left ankle, we would need to know which ligament(s) he injured. ICD-10-CM includes codes for:
In case the physician isn’t sure which ligament is involved, we have the option for unspecified ligament.
We could report the same External Causes codes for Tom, since he was running after the fleeing rodent.
Our final group of wounded hunters suffered open bite injuries. We need to know where the bites are in order to select the correct codes. ICD-10-CM divides codes by the area of injury, not by the type of injury. So an open bite to the right hand is reported with S61.451-, which is in the same series as the earlier lacerations of the hand.
If Phil took a chunk out of a pursuer’s left leg, we would report S80.872- (other superficial bite, left lower leg).
We would report almost the same External Causes codes, except we would report W53.81 (bitten by other rodent) instead of Y93.02
Phil is now safely behind bars in a little, tiny groundhog jail while we enjoy six more weeks of winter.
Shoveling snow can be great exercise. You can burn a lot of calories (depending on how much snow you’re shoveling and how much effort you’re putting into it).
Or like Cliff, you could suffer a myocardial infarction.
Cliff presents to the Acme ED with chest pain and shortness of breath. Dr. Hart performs an EKG and other lab tests and diagnosis Cliff with a myocardial infarction (MI).
In ICD-10-CM, we have separate codes for STEMI and non-STEMI MIs. A STEMI is due to a sudden occlusion of a coronary artery and is usually treated with thrombolytic therapy.
An NSTEMI is generally due to unstable plaque with an accumulation of platelets and treated with anticoagulants and platelet inhibitors.
If Cliff suffered an acute non-STEMI MI, our only code choice is I21.4 (non-ST elevation [NSTEMI] myocardial infarction).
If Cliff suffered an acute STEMI MI, we need to know the specific area involved. ICD-10-CM first breaks the areas down to:
- Anterior wall (I21.0-)
- Inferior wall (I21.1-)
- Other site (I21.2-)
Each subcategory is further broken down into specific arteries. For example, if Cliff suffered an acute STEMI of the anterior wall, we would choose between these codes:
- I21.01, ST elevation (STEMI) myocardial infarction involving left main coronary artery
- I21.02, ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery
- I21.09, ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall
You’ll need a solid foundation in cardiac anatomy if you’re coding MIs.
So far we’ve been looking at acute MIs. Here’s where things will get a little tricky. In ICD-9-CM, an MI is considered to be acute when stated as such or when the patient has been symptomatic for a stated duration of eight weeks or less. In ICD-10-CM, that timeframe shrinks to four weeks.
How long has Cliff experienced symptoms? And is this his first MI or a subsequent MI?
ICD-10-CM uses initial and subsequent differently than ICD-9-CM does. In ICD-9-CM, initial and subsequent used in the code description refer to the episode of care. In ICD-10-CM, initial refers to the patient’s first MI and subsequent refers to additional MIs the patient suffers during the acute phase.
If Cliff suffered an acute STEMI three weeks ago and suffered another STEMI today, we would report a code from I21.- for the initial STEMI and assign a code from category I22.- for the subsequent MI.
Before assigning a code from category I22, we need to confirm that the patient suffered two MIs within four weeks.
Subsequent MI codes don’t drill down to the vessel level like the initial codes do, so we have fewer choices:
- I22.0, subsequent ST elevation (STEMI) myocardial infarction of anterior wall
- I22.1, subsequent ST elevation (STEMI) myocardial infarction of inferior wall
- I22.2, subsequent non-ST elevation (NSTEMI) myocardial infarction
- I22.8, subsequent ST elevation (STEMI) myocardial infarction of other sites
- I22.9, subsequent ST elevation (STEMI) myocardial infarction of unspecified site
Both codes must be assigned and sequencing can vary on the circumstances of the admission, but remember per the Official Guidelines for Coding and Reporting that I22 cannot be used alone.
So to offset the cold this morning (and motivate myself to crawl out from under the warm covers), I decided to make some hot tea. I don’t own a tea kettle to boil water. The microwave is much faster.
I nuked my water in a Pyrex glass measuring cup until it boiled (boiling water makes better tea). I took the water out of the microwave—and promptly dropped the measuring cup. In case you didn’t know, Pyrex will shatter if it hits the floor at just the right angle and in the process send that nice boiling water all over the person who dropped it.
So now I am sporting some nice first-degree burns on my lower legs. They’re not bad enough to go to the doctor, but we can code them.
I suffered first-degree burns of multiple sites on both the right and left leg (I was planning on a really big cup of tea). ICD-10-CM includes codes for first-degree burns of the:
- Lower leg
Of course, ICD-10-CM also includes laterality and an unspecified choice. Don’t report unspecified laterality. The physician should tell you which side. If not, query.
In my case, it’s bilateral, so we’ll need codes for the left lower leg and the right lower leg. Also note that I have burns on multiple sites. ICD-10-CM has a code for that. Well, numerous codes actually.
For this accident, we would report:
- T24.191A, burn of first degree of multiple sites of right lower limb, except ankle and foot, initial encounter
- T24.192A, burn of first degree of multiple sites of left lower limb, except ankle and foot, initial encounter
We also need to use additional external cause code to identify the source, place and intent of the burn (X00-X19, X75-X77, X96-X98, Y92). This note shows up at the beginning of each category of burn codes. Just like in ICD-9-CM, you need to look for these notes when you code.
I was burned by boiling water, which gives us X12.XXXA (contact with other hot fluids, initial encounter). Don’t forget your placeholders so the seventh character ends up in the seventh position.
We don’t need a code from X75-X77 because I was not trying to burn myself. I was just trying to make tea.
We also don’t need a code from X96-X98 because no one assaulted me.
The incident occurred in the kitchen, so we would add Y92.010 (kitchen of single-family [private] house as the place of occurrence of the external cause).
That alone would be a bad enough start to the morning, but I seem to be a perpetual victim of Murphy’s Law. While cleaning up the hot water and broken glass on the kitchen floor, I stepped on a small sliver of glass. And it embedded itself in my foot. What fun.
So now we have another injury to code—laceration of the foot. We need to know which foot (left) and whether a foreign body remained in the wound (sadly, yes).
That gives us S91.322A (laceration with foreign body, left foot). Again, we have an option for unspecified foot, but don’t use it. Sometimes unspecified codes are the best available to report the encounter. That doesn’t apply to laterality. On the bright side, most physicians are probably already documenting laterality.
If the injury was to my ankle or toes we would have assigned different codes.
So the kitchen is cleaned up, I slapped a Band-Aid on my foot (after removing the glass, of course), and put burn cream on my legs. Now I am going back to bed. Wake me when it’s Wednesday.