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Remember to eat your fiber

Joe came into the Stitch ‘Em Up Hospital for a colonoscopy and therapeutic polypectomy.

HCPro_template-KOnce Joe was under, Dr. Ben E. Full performed a digital rectal exam, which showed good sphincter tone. Dr. Full then advanced a video colonoscope through Joe’s rectum and into the cecum. Dr. Full documented that the mucosa was normal looking throughout, but noted a few diverticula in the sigmoid colon. Dr. Full also identified a rectal polyp in the proximal rectum, approximately 5 mm in size. Dr. Full removed the polyp using hot biopsy technique and sent it off to the lab for a pathology report.

The pathology report stated, “hyperplastic polyp,” which is a benign growth, so Joe doesn’t need to worry about cancer today. However, Dr. Full does prescribe a high-fiber diet for Joe’s diverticulosis and tells Joe to schedule a follow-up colonoscopy in three years.

How would we code Joe’s surgery? Let’s start with the diagnosis codes. The first thing we know is Joe has a polyp. To select the correct ICD-10-CM code, we need to know the location (and we do)—in Joe’s case, in the rectum. When we look up polyp, rectal in the ICD-10-CM Alphabetic Index, we find two choices:

  • Nonadenomatous, polyps with no malignant potential, including hyperplastic polyps, hamartomas, juvenile polyps, pseudopolyps, lipomas, and leiomyomas
  • Adenomatous, benign (noncancerous) growths that may be precursor lesions to colorectal cancer

We know Joe’s polyp is hyperplastic, so we would report K62.1 (rectal polyp). Under K62.1, you’ll see an Excludes1 note. These notes tell you that the two conditions are mutually exclusive. You can’t code one with the other.

So you would never report K62.1 with D12.8 (adenomatous polyp). You always code to severity, so the cancer supersedes a benign polyp.


Next time skip the chips

Tobie comes into the Acme ED Tuesday complaining of stomach cramps, nausea (but no vomiting), light-headedness, and chest pain. What in the world could be wrong with Tobie?

Doritos (800x612)Dr. H.M. Lock examines Tobie and first rules out a myocardial infarction. He also rules out a panic attack. Dr. Lock then considers an allergic reaction or poisoning. The question is, what substance was involved?

Tobie told Dr. Lock that she and her husband went on a date night to a Chinese restaurant Sunday night, then took the kids to a different Chinese restaurant last night. In between, Tobie confessed she consumed two (big) bags of chili cheese Doritos (because they were so tasty) and had leftover Chinese food for lunch.

With that information in hand, Dr. Lock diagnoses MSG poisoning.

If we look in the Table of Drugs and Chemicals in the ICD-10-CM Manual (it looks very similar to the one in the ICD-9-CM Manual), we do find an entry for monosodium glutamate. Note that you have to look for the whole term, not the abbreviation MSG.

We also need to know what type of poisoning Tobie suffered:

  • Accidental
  • Intentional self-harm
  • Assault
  • Undetermined


Documentation details matter for diabetes

Quick, what’s the ICD-9-CM code for diabetes?

blood dropI bet you knew it was 250.00.

What’s the ICD-10-CM equivalent? Does ICD-10-CM even have an equivalent, since 250.00 is very vague?

Yes, we do have a default code in ICD-10-CM for those times the physician just doesn’t document anything more than “diabetes”—it’s E11.9. Just like 250.00, E11.9 (type 2 diabetes mellitus without complications) doesn’t really tell us much.

ICD-10-CM includes a greater number of codes for diabetes than ICD-9-CM (which surprises no one). Many of the ICD-10-CM diabetes codes are combination codes that include information about the patient’s diabetes as well as any complications or manifestations. Obviously, E11.9 doesn’t include a lot of detail.

ICD-10-CM divides diabetes into five categories, up from the two we currently have in ICD-9-CM:

  • E08, diabetes mellitus due to underlying condition
  • E09, drug- or chemical-induced diabetes mellitus
  • E10, type 1 diabetes mellitus
  • E11, type 2 diabetes mellitus
  • E13, other specified diabetes mellitus


Mardi Gras mayhem

Ah, Fat Tuesday (AKA Mardi Gras), the last big blowout before Lent begins. For those not of a religious bent, it’s still a good reason for an all-day party.Mardi gras mask (800x536)

Here at the Fix ‘Em Up Clinic, we have seen quite a few cases of partying gone bad. I’ve lost count of the number of times I have reported T51.0X1A (toxic effect of ethanol, accidental [unintentional], initial encounter), more commonly called alcohol poisoning.

You’ll find this code in the familiar looking Table of Drugs and Chemicals, but be sure you go to the Tabular List for the final code. Codes T51-T65 (Toxic effects of substances chiefly nonmedicinal as to source) include some important notes.

The first involves intent. The ICD-10-CM Table of Chemicals and Drugs clarifies the intent of the poisoning as:

  • Accidental
  • Intentional self-harm
  • Assault
  • Undetermined

When no intent is indicated, code to accidental. You can only report undetermined intent when the provider documents in the record that he or she cannot determine the intent of the toxic effect.


Valentine’s Day Massacre

My true love did his best over the weekend to make up for the 12 days’ worth of bad gift giving at Christmas. Alas, the best(?) laid plans of mice and men often go astray.

CupidMy true love’s first attempt at a Valentine’s Day gift predictably involved chocolate. So far, so good. I love chocolate. I do not love crickets. And apparently crickets (even chocolate-covered ones) don’t like me.

I ate too many of those chocolate covered bugs (before learning they were bugs) and ended up being nauseous. Happy Friday the 13th.

In ICD-10-CM, we would report R11.0 for my nausea because I was not vomiting. Although I thought about barfing up those crickets.

My true love felt really bad about the backfiring crickets so he tried to make it up to me Saturday (actual Valentine’s Day).

My true love brought a lovely bouquet of flowers, although there wasn’t a rose in the bunch. Instead, it was full of chrysanthemums and daisies. A-choo! Now I can’t stop sneezing. Why? I am allergic to chrysanthemums, daisies, jasmine, and wisteria. I now have a raging case of J30.1 (allergic rhinitis due to pollen). A-choo!

The second part of his romantic plans involved him rowing me down a scenic river in the local park. It’s very lovely in the spring and fall, not so great in the middle of winter. When we arrived, the river was iced over in places. Not to be deterred, my true love attempted to free his row boat and ended up in the water. Did I mention it’s really cold?

Fortunately for my true love, he wasn’t in the water long and only ended up with a mild case of T68.XXXA (hypothermia, initial encounter). When we code T68.XXXA, we also need to report a code to identify the source of exposure. For my true love, we would report X31.XXXA (exposure to excessive natural cold, initial encounter).


Check out character meanings in less prominent ICD-10-PCS sections

Most coders will spend their time reporting codes from the Medical and Surgical section (first character 0) and the Obstetrics section (1).

TipsEach character in those sections has the same meaning:

  1. Section
  2. Body System
  3. Root Operation
  4. Body Part
  5. Approach
  6. Device
  7. Qualifier

The meanings of the first (section) and seventh (qualifier) characters of every ICD-10-PCS code represents the same information, regardless of which section you’re using. The meanings of characters two through six, however, vary by section.


Put your ICD-10 coding knowledge through a workout

Codercise-ICD-10-CM-PCS (275x75)“Practice makes perfect” is a well-known adage. How many people can do any new task requiring specific skills successfully without practicing?

We can’t consider the transition to ICD-10-CM/PCS occurring on October 1, 2015 (or we pray anyway) a minor transition for all who code or use codes. I know we probably all feel a little gun-shy after the delay that was announced April 1, 2014. But please don’t just sit idle and not use all that you have learned about ICD-10-CM/PCS because you are worried it will be delayed again. To help keep your ICD-10 muscles in shape, HCPro created a class that is just for those who already learned ICD-10-CM/PCS, but want to practice.

Codercise-Inpatient ICD-10-CM/PCS is a two-day class intended for those who already have completed ICD-10-CM/PCS training. We’re teaching at an intermediate-advanced level because we didn’t want you to duplicate efforts by learning the fundamentals again. You’ve already put in that work. We’re going to help you refine and reinforce your knowledge.


It’s Groundhog Day

groundhogAnd a chilly one it is. It’s also the day after the Super Bowl, which means patients with a variety of injuries arrived at the Fix ‘Em Up Clinic today.

First is Phil, who is convinced he is a groundhog. He’s not. He’s really just a guy in a groundhog suit, but he’s sure he is indeed THE Punxsutawney Phil, seer of seers, sage of sages, prognosticator of prognosticators, and weather prophet extraordinaire. Okay, then. Dr. Jung will see you now.

It turns out that Phil (the person) had a few too many adult beverages while waiting for Phil (the actual groundhog) to make his prediction. It’s six more weeks of winter, in case you missed it. (Stupid rodent.)

Dr. Jung diagnoses Phil (the person) with alcohol poisoning. Off to the Table of Drugs and Chemicals we go. Coding for poisonings in ICD-10-CM is very similar to coding for them in [more]

The big dig (out)

Penguin with shovelWe’re into dig out mode here in Anytown and apparently, not everyone got the memo about proper snow shoveling techniques.

Richard came into the Fix ‘Em Up Clinic complaining of intense pain in his buttocks, right thigh, and right calf. He told Dr. Frosty that he spent six hours shoveling snow yesterday and today can barely stand the pain.

Dr. Frosty sends Richard for an MRI, which reveals a herniated disc. What information do we need to code Richard’s condition?

If you look up herniated disc in the ICD-10-CM Alphabetic Index, you won’t find it. You will find an entry for nucleus pulposus (the fancy medical name for an intervertebral disc). That entry directs you to see Displacement, intervertebral disc.

When we get there, we find that we need some additional information, specifically where in [more]

Snow day blues

Penguin with shovelHere in Anytown we are getting blasted by a big winter storm, which means we’re also seeing lots of patients with storm-related injuries at the Fix ‘Em Up Clinic.

Doug came into the clinic complaining of pain and weakness when lifting his right arm. He was out shoveling the snow using the tried-and-true lift, jerk, and fling method. During one of his tosses, he felt a sharp pain in his shoulder and started having trouble lifting his arm. Dr. Frosty examines Doug and diagnoses a torn rotator cuff.

Do we have enough information to code Doug’s injury in ICD-10-CM? If we look up tear, rotator cuff, in the ICD-10-CM Alphabetic Index, we find out very quickly that we need more information. Was this a traumatic tear?

It’s tempting to say yes right off the bat because Dr. Frosty documented that the injury occurred while Doug was shoveling snow. You can tear you rotator cuff by lifting something too heavy with a jerking motion. However, the majority of rotator cuff tears result from a wearing down of the tendon over time. In his chart, Doug’s age is listed as 57, so we could be looking at a nontraumatic tear.