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Take Control of post-operative bleeding in ICD-10-PCS

A patient undergoes a hysterectomy and experiences post-procedural bleeding. The surgeon cauterizes the bleed and evacuates a blood clot.

guidelines01_53597356In ICD-10-PCS, how do you code the cauterization? With the root operation Control (third character 3).

Control (stopping, or attempting to stop, postprocedural bleeding) in ICD-10-PCS represents a very limited set of procedures. You will use root operation Control when the only objective of the procedure is to stop hemorrhaging after a procedure.

Procedures that fall under Control include:

  • Irrigating or evacuating a hematoma at the operative site
  • Ligation of arterial bleeders
  • Cautery with blood clot evacuation
  • Drainage at previous operative site to stop bleeding

The site of the bleeding is coded as an anatomical region and not to a specific body part. For our patient with the post-hysterectomy bleed, we would report 0W3R8ZZ (hysteroscopy with cautery of post-hysterectomy oozing and evacuation of clot).

Other Control procedures include:

  • 0X3F0ZZ, open exploration and ligation of post-op arterial bleeder, left forearm
  • 0W3H0ZZ, control of post-operative retroperitoneal bleeding via laparotomy
  • 0W3C0ZZ, reopening of thoracotomy site with drainage and control of post-op hemopericardium
  • 0Y3F4ZZ, arthroscopy with drainage of hemarthrosis at previous operative site, right knee

What happens when the physician needs to perform a more involved procedure to stop the bleeding? For example, a physician needs to resect the spleen in order to control post-procedural bleeding. Do you report a Control procedure, a Resection procedure, or both?

According to ICD-10-PCS guideline B3.7:

If an attempt to stop post-procedural bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.

So for our patient who lost her spleen, we would report 07TP0ZZ (resection of spleen, open approach) or 07TP4ZZ (resection of spleen, percutaneous endoscopic approach).

Back to infect: mumps and whooping cough

Don’t look now, but mumps are making a comeback. How do we code mumps in ICD-10-CM?

plague germsPretty much the same way we code them in ICD-9-CM. The codes just look a little different.

In ICD-10-CM, we can assign one of the following codes for a patient with mumps:

  • B26.1, mumps orchitis
  • B26.1, mumps meningitis
  • B26.2, mumps encephalitis
  • B26.3, mumps pancreatitis
  • B26.8, mumps with other complications
  • B26.9, mumps without complication

One difference you’ll find is an increase in the named complications of mumps. In ICD-9-CM, we have codes for mumps hepatitis, mumps polyneuropathy, and other.

ICD-10-CM specifies these complications:

  • B26.81, mumps hepatitis
  • B26.82, mumps myocarditis
  • B26.83, mumps nephritis
  • B26.84, mumps polyneuropathy
  • B26.85, mumps arthritis
  • B26.89, other mumps complications

Well, that’s not so bad.

What about whooping cough (also known as pertussis), another reappearing disease?

In ICD-9-CM and ICD-10-CM, we see separate codes for whooping cough due to Bordetella, but ICD-10-CM specifies the type of Bordetella:

  • A37.0, whooping cough due to Bordetella pertussis
  • A37.1, whooping cough due to Bordetella parapertussis
  • A37.8, whooping cough due to other Bordetella species
  • A37.9, whooping cough, unspecified species

Each of those categories includes two subcategory codes to identify whether the patient has pneumonia as well. In ICD-9-CM, we needed a second code to identify the pneumonia.

Don’t worry about getting confused on this change. An Excludes1 note (not coded here) under ICD-10-CM category J17 (pneumonia in diseases classified elsewhere) tells us not to use a code from A37 and one from J17 together.


Take a look around with ICD-10-PCS root operation Inspection

Sometimes a physician just needs to take a look around a body part and see what’s what. If the physician’s sole objective is to examine a body part, either visually or manually, report the procedure using root operation Inspection (third character J).

guidelines01_53597356Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers.

If the physician discontinues a procedure before performing any other root operation, you would also report the procedure using root operation Inspection.

Examples of Inspection include:

  • 0WJ90ZZ, thoracotomy with exploration of right pleural cavity
  • 0CJS8ZZ, diagnostic laryngoscopy:
  • 0SJD0ZZ, exploratory arthrotomy of left knee:
  • 0UJD8ZZ, colposcopy with diagnostic hysteroscopy:
  • 0DJD7ZZ, digital rectal exam

One other thing to keep in mind: if the physician begins a procedure laparoscopically and must convert it to an open procedure, report the laparoscopic procedure is reported as an inspection.

For example, the surgeon begins a cholecystectomy using a laparoscopic approach, but must complete it using an open approach. Report an open cholecystectomy (0FT40ZZ) and a percutaneous endoscopic inspection of the gall bladder (0FJ44ZZ).

If the physician inspects the body part(s) to achieve the objective of a procedure, do not code the inspection separately.

If the physician inspects multiple non-tubular body parts in a region, report the body part that specifies the entire area inspected.

What goes on the baby’s chart?

If you code for pregnant patients and newborns, you may occasionally wonder which record to code a condition on. Is it something you code for the mother or for her offspring?

crying babyICD-10-CM divides the codes into two different chapters:

  • Chapter 15, Pregnancy, Childbirth and the Puerperium (O00-O9A). These codes are only used on the mother’s record.
  • Chapter 16, Certain Conditions Originating in the Perinatal Period (P00-P96). These codes are only reported for the newborn. These codes include conditions that have their origin in the fetal or perinatal period (before birth through the first 28 days after birth) even if morbidity occurs later.

Make sure you code all clinically significant conditions noted on a routine newborn examination. A condition is clinically significant if it requires any of the following:

  • Clinical evaluation
  • Therapeutic treatment
  • Diagnostic procedures
  • Extended length of hospital stay
  • Increased nursing care and/or monitoring
  • Has implications for future health care needs

What types of problems can newborns have? Well, the baby may arrive too early. We would use codes from category P07.3- to report 28 completed weeks or more but less than 37 completed weeks (196 completed days but less than 259 completed days) of gestation.

We have nine different choices to specify exactly how early our bundle of joy arrived, plus an unspecified code. If the newborn arrives at 31 weeks, four days, we would report P07.34.

Maybe our baby is underweight for gestational age. ICD-10-CM includes codes for:

  • P07.0-, extremely low birth weight newborn
  • P07.1-, other low birth weight newborn

The codes in these categories specify weight ranges. So if the newborn weighs 850 grams at birth, we would report P07.03 (extremely low birth weight newborn, 750-999 grams).

So we have a preemie with a low birth weight. Which condition do we sequence as the principal diagnosis for the birth encounter? It’s a trick question because the answer is neither. When coding the birth episode in a newborn record, we will always assign a code from category Z38.- (liveborn infant) as the principal diagnosis. Birth takes precedence.

Z38.- still gives us plenty of options and we need some specific details to choose the correct code. First, how many babies? Where did the baby arrive? How was the baby delivered? You could conceivably have a different place and method if mom is delivering more than one baby.

For example, if mom gives birth to twins in the hospital, she could deliver one vaginally (Z38.30) and one by cesarean (Z38.31).

Alternately, she could have one on the way to the hospital (Z38.4, twin liveborn infant, born outside hospital) and one vaginally in the hospital. Don’t assume it will be the same for each infant in a multiple birth.

Chapter 16 codes may be used throughout the life of the patient if the condition is still present.

Off with his hand: ICD-10-PCS root operation Detachment

Sometimes a surgeon must take drastic action and amputate a patient’s upper or lower extremity. For these cases, we would use ICD-10-PCS root operation Detachment (third character 6).

guidelines01_53597356ICD-10-PCS defines Detachment as cutting off all or part of the upper or lower extremities. You will need to pay close attention to the details of the operative note to determine which specific body part the physician is detaching.

The body part value is the site of the detachment. You may need a qualifier to further specify the level where the extremity was detached.

For example, the physician amputates the patient’s right upper arm. When we look at the table (0X6), we first see body part choices for:

  • Right upper arm
  • Left upper arm
  • Right lower arm
  • Left lower arm

The approach is always open and your only device choice is no device. When we get to the qualifier, we have three options:

  • 1, high
  • 2, mid
  • 3, low

The physician needs to document where he or she performed the detachment. If that information is not in the operative report, query. We do not have unspecified or default codes in ICD-10-PCS. The codes for detachment of the leg include the same choices.

CMS’ ICD-10-PCS Reference Manual defines the qualifiers as:

  • High: amputation at the proximal portion of the shaft of the humerus or femur
  • Mid: amputation at the middle portion of the shaft of the humerus or femur
  • Low: amputation at the distal portion of the shaft of the humerus or femur

We can choose from even more possibilities when it comes to a detachment of the hand. In addition to laterality for the body part (right hand or left hand), we also need to know whether the physician removed the complete hand (qualifier 0) or only part. If only part, which part? Our choices include:

  • 4, complete 1st ray
  • 5, complete 2nd ray
  • 6, complete 3rd ray
  • 7, complete 4th ray
  • 8, complete 5th ray
  • 9, partial 1st ray
  • B, partial 2nd ray
  • C, partial 3rd ray
  • D, partial 4th ray
  • F, partial 5th ray

You’ll see the same options for detachment of the foot (OY6).

Perhaps the surgeon only removes a digit (finger or toe). We need to know the specific digit, such as right thumb or left little toe. We also see these four qualifier choices:

  • 0, complete
  • 1, high
  • 2, mid
  • 3, low

Be sure the physicians are documenting the detail you need to code for a detachment. You should also brush up on your anatomy of the hand and foot (and make sure you know what a ray is) if you see these procedures in your facility.

ICD-10-PCS root operations: Map

Map (third character K) is a very narrowly defined ICD-10-PCS root operation. By definition, Map procedures are used to locate the route of passage of electrical impulses and/or locate functional areas in a body part.

guidelines01_53597356Map only applies to the cardiac conduction mechanism and the central nervous system, so we only have two possible body systems for Map:

  • Central nervous system (00K)
  • Heart and great vessels (02K)

If you look at those tables, you’ll see very few options. The table for the central nervous system offers these body parts:

  • 0, brain
  • 7, cerebral hemisphere
  • 8, basal ganglia
  • 9, thalamus
  • A, hypothalamus
  • B, pons
  • C, cerebellum
  • D, medulla oblongata

For the heart and great vessels, we get only one body part choice: conduction mechanism.

Examples of Map procedures include:

  • 00K83ZZ, percutaneous mapping of basal ganglia
  • 00K00ZZ, intraoperative whole brain mapping via craniotomy
  • 00K74ZZ, mapping of left cerebral hemisphere, percutaneous endoscopic
  • 02K80ZZ, intraoperative cardiac mapping during open heart surgery

Pregnancy codes growing in ICD-10-CM

The codes for complications of pregnancy, childbirth, and the puerperium appear in Chapter 11 in ICD-9-CM. They move to Chapter 15 in ICD-10-CM. But you will find some more significant changes than just where the codes are located.

Pregnant bellyIn ICD-9-CM, you often need a fifth character to denote whether the mother gave birth during the encounter. For example, if a patient is diagnosed with transient hypertension in pregnancy, you would report 642.3x. The fifth digit denotes:

  • 0, unspecified as to episode of care or not applicable
  • 1, delivered, with or without mention of antepartum condition
  • 2, delivered, with mention of postpartum complication
  • 3, antepartum condition or complication
  • 4, postpartum condition or complication

In ICD-10-CM, the codes specify the trimester of the pregnancy in which the condition occurred. For example, if a patient is diagnosed with antepartum transient hypertension (ICD-9-CM code 642.33), you have four choices in ICD-10-CM:

  • O13.1, gestational [pregnancy-induced] hypertension without significant proteinuria, first trimester
  • O13.2, gestational [pregnancy-induced] hypertension without significant proteinuria, second trimester
  • O13.3, gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester
  • O13.9, gestational [pregnancy-induced] hypertension without significant proteinuria, unspecified trimester

Note that the first character is a capital O not a zero. All ICD-10-CM codes start with a letter. However, you may see a zero or two later in some codes.

Coding for multiple fetuses will also present some challenges. ICD-10-CM codes specify the number of fetuses as well as whether the fetuses are monochorionic (share the same placenta) and/or monoamniotic (share the same amniotic sac). The codes are further divided by trimester.

A patient comes in for care related to the fetus and possible delivery problems. She is pregnant with twins and is in her second trimester. Our possible codes include:

  • O30.002, twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, second trimester
  • O30.012, twin pregnancy, monochorionic/monoamniotic, second trimester
  • O30.022, conjoined twin pregnancy, second trimester
  • O30.032, twin pregnancy, monochorionic/diamniotic, second trimester
  • O30.042, twin pregnancy, dichorionic/diamniotic, second trimester
  • O30.092, twin pregnancy, unable to determine number of placenta and number of amniotic sacs, second trimester

Note the difference between O30.002 and O30.092. Use O30.002 if the physician does not specify the number of placentas or amniotic sacs. If the physician documents that he or she cannot tell how many there are, use O30.092.

Another aspect worth noting is the seventh character for complications of labor and delivery (O60-O77). The seventh character identifies the fetus involved. If the mom is only carrying one, the seventh character is always 1. That’s pretty easy.

However, if the mother is carrying multiple fetuses, you need to look for documentation that specifies which fetus is affected. For example, if the physician documents obstructed labor due to breech presentation for one twin, he or she needs to specify fetus 1 or fetus 2. If fetus 2 is involved, report O64.1XX2. The base code is only four characters long, so we need two X placeholders to move the seventh character to the seventh position.

We also need to assign a code from category O30 when multiple fetuses are involved.

ICD-10-CM includes codes that specify when a condition, such as hypertension or diabetes, is pre-existing (meaning before the patient became pregnant) and when it is due to the pregnancy.

Codes from Chapter 15 take precedence over codes from other chapters unless the provider documents that the pregnancy is incidental to the encounter. For example, a pregnant woman cuts her hand on broken glass and needs stitches. The injury has nothing to do with pregnancy. The fact that she is pregnant doesn’t impact care unless, for some reason, she would need anesthesia. In this case, you would report the laceration and also report Z33.1 (pregnant state, incidental).

ICD-10-CM also includes Z codes to denote the weeks of gestation. Codes from category Z3A.- are for use, only on the maternal record, to indicate the weeks of gestation of the pregnancy. Code first complications of pregnancy, childbirth, and the puerperium (O00-O9A).

The specified weeks of gestation go from less than eight (Z3A.01) all the way through more than 42 weeks gestation of pregnancy (Z3A.49).

Begosh and begorrah, we have a rash of St. Paddy’s Day injuries

Holidays are always interesting times here at the Fix ‘Em Up Clinic. We get to see some of the most interesting cases.

1000px-Tux_Paint_shamrock.svgFirst up for St. Patrick’s Day is Sean, who at 8 years old thought it would be great fun to emulate St. Patrick and drive all of the snakes out of Anytown (or at least drive the one snake out of his yard). Said reptile was not pleased to have its sunbathing interrupted and was not the least bit interested in Sean’s St. Patrick’s Day plan. In fact, the snake was so unhappy with Sean that it bite him—repeatedly.

Fortunately for Sean, the snake was not venomous, so all he has to show for his efforts is multiple bite marks (and a slightly hysterical mother).

In order to code Sean’s injuries, we need to know first whether the snake is venomous or non-venomous. If the snake was venomous, we would look up venom, snake, in the Table of Drugs and Chemicals, by animal, poisoning. In case you’re interested, the Table of Drugs and Chemicals names nine different types of snakes, but three include the distinction Not Elsewhere Classified (meaning we know the type of snake, but don’t have a specific code for that species).

We already know the snake was non-venomous, so we look under bite, snake, non-venomous, and the ICD-10-CM Index of Diseases tells us to look up bite, by site.

We will need a separate code for each snake bite, so if the snake bit Sean on the right lower leg, left lower leg, and right hand, we would report:

  • S80.871A, other superficial bite, right lower leg, initial encounter
  • S80.872A, other superficial bite, left lower leg, initial encounter
  • S60.571A, other superficial bite of hand of right hand, initial encounter

These codes include laterality, which is great since the snake bit Sean on both the left and right lower legs. Having laterality tells the payer we didn’t accidentally report the same code twice, our patient did indeed suffer two distinct injuries.

The codes also require a seventh character to denote the encounter. Without the A (initial encounter), D (subsequent encounter), or S (sequela) in the seventh position, the code is invalid.

We can add some External Causes codes to better explain what happened to Sean:

  • W59.11XA, bitten by nonvenomous snake (don’t forget the placeholder and seventh character)
  • Y92.096, garden or yard of other non-institutional residence as the place of occurrence of the external cause
  • Y99.8, other external cause status

Sadly, we do not have an External Causes code for snake herding or religious reenactment.

Liam managed to avoid snakes on St. Patrick’s Day, but alas, he could not forgo the green beer and green cheese. The beer was supposed to be green, but the cheese was not. As a result, poor Liam is suffering from food poisoning. Luckily, he didn’t pick up salmonella or E. coli or any other fungus-borne illness.

Food poisoning is found in the Table of Drugs and Chemicals, where we find options for, among other things:

  • Berries
  • Mushrooms
  • Plants
  • Seafood

Moldy cheese didn’t make the list, but we do have our tried and true standby, specified, not elsewhere classified. So we would assign T62.8X1A (toxic effect of other specified noxious substances eaten as food, accidental [unintentional]). Liam intentionally ate the cheese, but he did not try to poison himself, so we’re going with accidental.

Our final patient for the day is Bridget. She was out scouring the park looking for four-leaf clovers. Instead, she found a patch of poison ivy. Everywhere she came into contact with the pretty plant is now extremely itchy, sports a red, streaky rash, and in some places, grew red bumps and large, weeping blisters.

Fortunately, her illness isn’t fatal. It isn’t even catching. It’s simply contact dermatitis. In ICD-10-CM we need to know what caused the allergic reaction (plant, animal, drugs, etc.). Since poison ivy is the culprit, we would report L23.7 (allergic contact dermatitis due to plants, except food). A little calamine lotion and hydrocortisone cream will help with the itching and blistering, and in no time Bridget will be good as new.

Lá Fhéile Pádraig Sona Daoibh!


Et tu, Brute?

Is this a dagger I see before me? Why, yes, Caesar, that is a dagger aimed at your heart. And your head and just about everywhere else.

Stabbed heartServilius Casca got in the first shot, hitting Caesar in the neck and drawing blood. The other senators all joined in, stabbing the “Dictator for Life” repeatedly about the head. Perhaps the unkindest cut of all came from Caesar’s protégé, Marcus Brutus, who wounded Caesar in the groin.

If Caesar came into the Acme ED for treatment of his wounds, we would first need to identify where the stab wounds occurred.

Dr. M. Antony documents a stab wound to the neck and multiple stab wounds to the head. Can we code that? Let’s start by looking up “stab” in the ICD-10-CM Alphabetic Index. The index directs us to “see also, laceration.”

ICD-10-CM offers us a wealth of laceration codes for laceration of the neck:

  • S11.21, laceration without foreign body of pharynx and cervical esophagus
  • S11.22, laceration with foreign body of pharynx and cervical esophagus
  • S11.81, laceration without foreign body of other specified part of neck
  • S11.82, laceration with foreign body of other specified part of neck
  • S11.91, laceration without foreign body of unspecified part of neck
  • S11.92, laceration with foreign body of unspecified part of neck

The larynx, pharynx, thyroid gland, and trachea have their own laceration codes, so if Casca lacerated Caesar’s trachea and cervical esophagus, we would need two codes.

Two things to notice about the laceration codes for the neck—they don’t specify laterality, but they do require a seventh character. Since the codes are only five characters long, we need to add a placeholder X before our seventh character.

For Caesar’s head wounds, we need to know where the blade struck. ICD-10-CM includes codes for laceration to the:

  • Cheek (which also includes the temporomandibular area)
  • Ear
  • Head
  • Lip
  • Nose
  • Oral cavity
  • Scalp
  • Specified site not elsewhere classified

The codes for lacerations of the cheek and the ear do include laterality, so we’ll need to know which one was involved or if both were injured.

We also need to know if the wound contains a foreign body (a piece of the dagger in Caesar’s case) and the encounter. If Caesar suffered bilateral cheek lacerations without foreign body, we’ll report two codes:

  • S01.411A, laceration without foreign body of right cheek and temporomandibular area, initial encounter
  • S01.412A, laceration without foreign body of left cheek and temporomandibular area, initial encounter

And now for Caesar’s final wound, courtesy of Brutus. Under laceration, groin, we find a note telling us to see laceration, abdomen, wall.

For a laceration of the abdominal wall, we need to know which quadrant was involved, whether a foreign body remains in the wound, whether the laceration penetrated the peritoneal cavity, and the encounter. All for one code.

So if Dr. Antony documented an initial visit for a laceration to the lower right quadrant, without foreign body and without penetration into the peritoneal cavity, we would report S31.123A.

We can add some External Causes codes so history knows what happened to poor Caesar. Keep in mind that External Causes codes are not mandatory in most cases. They just tell a more complete story. So for Caesar’s assassination, we would report:

  • X99.2XXA, assault by sword or dagger, initial encounter
  • Y92.29, other specified public building as the place of occurrence of the external cause (the Senate)
  • Y99.0, civilian activity done for income or pay (ruling Rome is a big job after all)

You could make a case for Y99.1 (military activity) since Caesar was Rome’s supreme military commander, but overseeing the Senate is more of a civilian job.

Remember to beware the Ides of March and avoid sharp objects!


Gestational diabetes expands in ICD-10-CM

In ICD-9-CM, we have one base code for gestational diabetes: 648.8x (abnormal glucose tolerance). We need a fifth digit to specify the episode of care:

  • Tips0, unspecified as to episode of care or not applicable
  • 1, delivered, with or without mention of antepartum condition
  • 2, delivered, with mention of postpartum complication
  • 3, antepartum condition or complication
  • 4, postpartum condition or complication

Things look a little different in ICD-10-CM. First, ICD-10-CM distinguishes between pre-existing conditions and those caused by pregnancy.

A patient may be diabetic and become pregnant or the patient may develop gestational diabetes. We will use different codes to report those conditions.

If a pregnant patient has pre-existing type 2 diabetes mellitus and is in her second trimester, report O24.112.

Note that the first character is a capital letter O, not a zero. All ICD-10-CM codes begin with letters. However, zeroes will appear in other places in the codes.

Codes for pre-existing type I diabetes are found under O24.0-. However, if the physician does not denote the type of pre-existing diabetes, use a code from O24.3-.

The Official ICD-10-CM Guidelines for Coding and Reporting instruct us to first assign the code from O24 (diabetes mellitus in pregnancy, childbirth, and the puerperium), followed by the appropriate diabetes code(s) from E08-E13.

If the patient is controlling her diabetes with insulin, we also need to report Z79.4 (long-term use of insulin).

Gestational diabetes generally occurs in the second or third trimester and can cause the same problems as pre-existing diabetes.

ICD-10-CM divides gestational diabetes into three time periods of the pregnancy:

  • O24.41-, gestational diabetes mellitus in pregnancy
  • O24.42, gestational diabetes mellitus in childbirth
  • O24.43, gestational diabetes mellitus in the puerperium

Code O24.41- is further subdivided by how the patient is controlling her diabetes:

  • O24.410, gestational diabetes mellitus in pregnancy, diet controlled
  • O24.414, gestational diabetes mellitus in pregnancy, insulin controlled
  • O24.419, gestational diabetes mellitus in pregnancy, unspecified control

If the patient controls her diabetes with both diet and insulin, we only need to report the insulin controlled code.

When we report a code from O24.4-, we will not report any other code from O24, according to the official guidelines.

We also will not report Z79.4.

What happens if our physician doesn’t tell us whether the diabetes is pre-existing or gestational? ICD-10-CM has a code set for that:

  • O24.91-, unspecified diabetes mellitus in pregnancy
  • O24.92, unspecified diabetes mellitus in childbirth
  • O24.93, unspecified diabetes mellitus in the puerperium

O24.91- is further divided by trimester:

  • O24.911, unspecified diabetes mellitus in pregnancy, first trimester
  • O24.912, unspecified diabetes mellitus in pregnancy, second trimester
  • O24.913, unspecified diabetes mellitus in pregnancy, third trimester
  • O24.919, unspecified diabetes mellitus in pregnancy, unspecified trimester

For these codes, we would report long-term insulin use when appropriate.