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Combination codes and comorbidities

Inpatient coders and clinical documentation improvement specialists are very familiar with CCs and MCCs. After all, they help determine the MS-DRG assignment for a particular inpatient stay.

TipsICD-10-CM includes a lot more combination codes than ICD-9-CM, which eliminates the need for multiple codes to report a condition.

Say a type 2 diabetic patient also has gangrene. Dr. Smith documents the gangrene is due to diabetes. In ICD-9-CM, we would report two codes: 250.7x (diabetes with peripheral circulatory disorders) and 785.4 (gangrene). In ICD-9-CM, the gangrene is a CC.

In ICD-10-CM, we only need one code: E11.52 (Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene). What happens to the CC? We no longer have a secondary diagnosis to provide the CC. Do we lose out?

Never fear, the Cooperating Parties came up with a way to solve the case of the disappearing CCs and MCCs. In ICD-10-CM, certain codes, such as E11.52, act as their own CC or MCC. As long as the physician documents enough information for you to report the combination code, this new twist shouldn’t affect coding at all. It might actually make it easier.

Sleuthing for documentation details

Put on your deerstalker hat and grab your magnifying glass. It’s time to do our best Sherlock Holmes impersonation.

detective with footprintsWe just received a chart from Dr. Doolittle and we need to code the procedure. However, some of Dr. Doolittle’s documentation went astray (such as the clinical indications, diagnosis, and history), and this is all the information we have:

Confirmed identity of patient Jill, who was satisfactorily sedated. I used the MFL 1,000 for extracorporeal shock wave lithotripsy, delivering 1,000 shocks to the stone in the lower pole of the right kidney, and 800 shocks to the stone in the upper pole of the same, with change in shape and density of the stone indicating fragmentation. The patient tolerated the procedure well.

Which ICD-10-PCS code would we report?

Let’s start by determining what we know. Well, we’re in the Medical and Surgical section, which means our first character is 0.

The procedure involves the kidneys, which makes our body system the urinary system (second character T).

For the root operation, we need to figure out what Dr. Doolittle did. He documented “extracorporeal shock wave lithotripsy” as the procedure. When we look up lithotripsy in the ICD-10-CM, we find two possible root operations:

  • With removal of fragments, see Extirpation (taking or cutting out solid matter from a body part)
  • See Fragmentation (breaking solid matter in a body part into pieces)

Dr. Doolittle didn’t mention removing fragments, so it’s probably not Extirpation.

If you look up extracorporeal shock wave lithotripsy, ICD-10-PCS directs you to Fragmentation. So Fragmentation it is.

That gives us 0TF as our table. When we get to the table, we notice that the right kidney and the left kidney have their own body part values. We don’t have a bilateral kidney choice, so we’ll be reporting two codes, one for each kidney.

On to the approach. We have six choices in this table and no indication of an approach in the documentation, right? Actually wrong.

An extracorporeal medical procedure is one that is performed outside the body. That makes the approach external.

The table includes only one choice for a device and one for a qualifier, so the little grey cells get a break on the last two characters of our codes. Based on Dr. Doolittle’s documentation and our own sleuthing abilities, we would report:

  • 0TF3XZZ, fragmentation in right kidney pelvis, external approach

Now let’s go see if we can find the rest of Jill’s record.

Them’s the breaks

Julie comes into the Fix ‘Em Up Clinic with a seriously broken arm. Her son Jay left his toy fire engine on the stairs and Julie tripped over it. She threw her arms out to brace her fall. And then snap. Not a good sound to hear. Even worse was when she realized the bone was sticking out of her arm.

Dr. Setter examines Julie and orders x-rays to determine the specific types and locations of the fractures. Because Julie’s fractures are open, he immediately schedules her for surgery at the Stitch ‘Em Up Hospital.woman falling down stairs

When Dr. Setter gets the x-rays back, he determines that Julie suffered diaphyseal fractures involving the right radius and ulna. Hmm, I don’t think that’s enough information to get us to the correct ICD-10-CM codes.

Codes for fractures of the forearm live in category S52. And you’ll notice a lot of codes under S52. They are broken down into:

  • Ulna and radius
  • Specific part of the bone
  • Displaced and nondisplaced
  • Left and right
  • Type of fracture

However, none of them are for a diaphyseal fracture. Now what? Well, if we check our handy medical dictionary (in book form or online) we can find out that a diaphyseal fracture involves the shaft of a long bone.

We do have codes for fractures of the shaft of the ulna and the radius—many, many codes. So it looks like we’re going to have to query Dr. Setter, unless of course our radiologist documented the details we need.

When we check the radiologist’s report, we find documentation of a displaced transverse fracture of the shaft of the right ulna and a displaced comminuted fracture of the shaft of the right radius. Because Dr. Setter documented the fractures, we can pull additional details from the radiologist’s report.

Dr. Setter also noted this is Julie’s first visit, so we would report codes:

  • S52.221B for the ulna fracture
  • S52.351B for the radius fracture

One thing we don’t have is the extent of the soft tissue damage on the Gustilo-Anderson classification scale. We can query for it or just default to B (initial encounter for open fracture NOS) for our seventh character.

Given the seriousness of Julie’s fractures, Dr. Setter is admitting her to the Stitch ‘Em Up Hospital, where Dr. Breaker will perform surgery to stabilize the fractures.

Dr. Breaker documents an open reduction internal fixation (ORIF) of the right radius and right ulna. Be very careful with ORIF. Sometimes the physician calls it an ORIF, but actually reduces the bone (moves it back into place) before creating the incision to place the fixation device.

In Dr. Breaker’s notes, she documents making the incision prior to reducing the fractures. Note that we need to know this for both fractures. Because the radius and the ulna are separate body parts in ICD-10-PCS, we are going to report separate codes for them. It’s possible that one reduction was open and one was closed. Dr. Breaker documents the same procedure for both bones.

What root operation does ORIF fall under? Well, what is the intent of the procedure? Dr. Breaker is putting the pieces of the bone back into their normal position. Sounds a lot like Reposition (moving to its normal location, or other suitable location, all or a portion of a body part).

Now that we have our root operation (and our section, Medical and Surgical, and our body system, upper bones), we can head to table 0PS (that’s a zero at the beginning of the code, not a capital O—no capital O or I in ICD-10-PCS).

We know the body parts for our two codes: right radius (H) and right ulna (K). Now for the approach. Dr. Breaker documented an open approach, so our fifth character is 0.

Our sixth character is the device and our choices are:

  • 4, internal fixation device
  • 5, external fixation device
  • 6, internal fixation device, intramedullary
  • B, external fixation device, monoplanar
  • C, external fixation device, ring
  • D, external fixation device, hybrid
  • Z, no device

We can eliminate all but two of those choices very quickly because we know Dr. Breaker used an internal fixation device. We just need to know whether it is intramedullary. Remember to look at the device for each bone separately. Each bone gets its own code, so the devices may be different.

In this case, Dr. Breaker documents internal fixation device, but does not mention intramedullary. That makes our sixth character 4 for both codes. The seventh character is easy. We only have one choice—Z (no qualifier).

For Julie’s surgery we would report:

  • 0PSH04Z, reposition right radius with internal fixation device, open approach
  • 0PSK04Z, reposition right ulna with internal fixation device, open approach

When Julie comes back in for routine follow-up care, we will use the same main ICD-10-CM codes we used for the initial fractures, just with a different seventh character. That will help us track how well a specific treatment works for a specific injury and also let us keep track of how well Julie heals.


At least one procedure keeps its name

It turns out that not all eponyms are going away in ICD-10-PCS. The Alphabetic Index still includes an entry for a Roux-en-Y operation.

TipsThe entry directs you to see bypass of the gastrointestinal system or bypass of the hepatobilliary system and pancreas.

Roux-en-Y is a type of gastric bypass surgery. During a Roux-en-Y, the surgeon uses a small part of the stomach to create a new stomach pouch, roughly the size of an egg. The surgeon connects this new, smaller stomach directly to the middle portion of the small intestine (jejunum), bypassing the rest of the stomach and the upper portion of the small intestine (duodenum).

While we can’t say that all eponyms depart ICD-10-PCS (I suspect one or two more may be lurking in the index), the vast majority of them do. If your physicians common document a procedure using an eponym, make sure you know exactly what they are doing.

Also be sure to read the operative report. The physician may be (hopefully is) documenting the elements you need to build an ICD-10-PCS code, such as approach, root operation (intent of the procedure), and body part.

Watch your toes

Holly spent the weekend hanging out at the beach, enjoying the sun. The sand was so warm that she slipped off her shoes to stroll near the water. And disturbed a crab in the process. The crustacean, unhappy at being disturbed, clamped down on Holly’s right big toe, partially severing it and sending Holly to the Stitch ‘Em Up Hospital.

Crab madLet’s start with the diagnosis.

ICD-10-CM includes codes for complete and partial traumatic amputations. In Holly’s case, the crab didn’t get the whole toe, so it is a partial amputation. ICD-10-CM further divides toe amputations into the great toe, lesser toes, and more than one toe. And of course we have laterality.

Since this is Holly’s first visit for a traumatic partial amputation of the right great toe, we would report S98.121A.

Holly needs surgery to reattach her toe, so Dr. Shelley is preparing to put Holly back together, and we can build our ICD-10-PCS code at the same time.

First, we know we are in the Medical and Surgical section, which gives us a first character 0 (the number zero, not a capital O).

Our second character is the body system. In this case, we’re going with lower extremities, Y.

The third character is the root operation. Basically what is the surgeon trying to do? Dr. Shelley is putting Holly’s toe back where it belongs, which makes our root operation Reattachment (N).

Note that Reattachment is the root operation of choice whether the surgeon is putting all or a portion of a separated body part to its normal location or another suitable location.

We now have the first three characters of our code, 0YM, so we can go to the ICD-10-PCS table.

The table contains plenty of fourth character options for the body part. We know Dr. Shelley is reattaching Holly’s right great toe, so our fourth character is P (first toe, right). If Dr. Shelley reattached multiple toes, we would code each one separately because each has its own body part.

The rest of the code is a breeze because we only have one choice for each remaining character:

  • 0, open
  • Z, no device
  • Z, no qualifier

That gives us a final code of 0YMP0ZZ.

Holly did get the last laugh on her crustacean attacker. She ate the attacking crab for dinner.

A holiday explosion of injuries

A lot of people are starting their Fourth of July celebrations early. At least it seems that way at the Fix ‘Em Up Clinic.

Shannon took her dog Damian to the park to watch some fireworks last night. Well, Shannon went to watch the fireworks. Damian came along to nap in the grass. The fireworks startled Damian out of his doggy dreams and he decided to take refuge in the car. Unfortunately, Damian wasn’t the only one fleeing from the explosions. He collided with Simon, who tumbled over Damian and hit his head on a rock.

FirewordsSimon is now sporting a lovely bruise and a laceration on his forehead, as well as some scraped palms. His friend warned that he might have a concussion so he came into the clinic to see Dr. Jones.

Dr. Jones examines Simon and does not find evidence of a concussion, just a forehead laceration and lacerations to both palms. Dr. Jones documents that no foreign bodies remain in the head wound or the right palm abrasions, but some gravel is stuck in the left palm.

Our codes for Simon’s visit are:

  • S01.81XA, laceration without foreign body of other part of head, initial encounter (we don’t have a specific code for the forehead, so the ICD-10-CM Alphabetic Index directs us to S01.81-)
  • S61.422A, laceration with foreign body of left hand, initial encounter
  • S61.411A, laceration without foreign body of right hand, initial encounter

We can also add some external cause codes:

  • W01.198A, fall on same level from slipping, tripping and stumbling with subsequent striking against other object, initial encounter
  • Y92.830, public park as the place of occurrence of the external cause
  • Y93.02, activity, running (sadly we don’t have a code to specify fleeing from fireworks)
  • Y99.8, other external cause status (leisure activity)

Damian, by the way, is fine.

Our second patient, Doug, comes in with an eye problem. Doug was running around with a lit sparkler and one of the sparks flew into his eye.

So what kind of injury does Doug have? If the little metal shaving from the sparkler is still in his eye, he may have a foreign body in the cornea (T15.0-) or a foreign body in the conjunctival sac (T15.1-). Alternately, he could have a corneal abrasion without a foreign body (S05.0-).

The code we choose will ultimately depend on the physician’s documentation, but we should note that S05.0- has an Excludes1 note for codes T15.0- and T15.1-, meaning those codes cannot be reported together.

That makes sense if you think about it. S05.0- specifies no foreign body, while both T codes indicate the presence of a foreign body.

We hope you have a safe and happy holiday and don’t end it at the Fix ‘Em Up Clinic!

Anatomy matters

Go to your local bookstore, pick up a copy of Gray’s Anatomy (the book, not the television show), and flip though the illustrations. Alternately, you can Google “Gray’s anatomy illustrations.” They are in the public domain. Some of them are pretty good, especially considering it was first published in 1858.image505

Not surprisingly, anatomy hasn’t really changed since then. Our understanding of certain things–like what parts of the brain are involved in which functions—has changed, but the structures themselves have stayed the same for the last many thousands of years.

So why do you need to brush up on anatomy and physiology before ICD-10? The best reason I’ve heard so far comes from Gerri Walk, RHIA, CCS, senior manager of technical training for HRS in Baltimore.

“The vessels of the heart are like roads in Texas,” Gerri says. “Turn a corner and you’re on a different road or in a different vessel.”

ICD-10-CM and ICD-10-PCS both require specific vessels for cardiac conditions and procedures. For example, a patient suffers an acute MI. Where was the infarction? ICD-10-CM includes specific sites, such as:

  • Left main coronary artery
  • Left anterior descending coronary artery
  • Diagonal coronary artery
  • Other coronary artery of anterior wall
  • Right coronary artery
  • Other coronary artery of inferior wall

Some of those are easy (if the physician documents it). Some could be a little trickier. Do you know which smaller arteries are on the inferior wall and which are on the anterior wall?

For Dilation procedures (balloon angioplasty and stents) in ICD-10-PCS, you only need to know the number of coronary sites treated. For Bypass procedures, you need to know the number of sites bypassed from and where the bypass is going:

  • 3, coronary artery
  • 8, internal mammary, right
  • 9, internal mammary, left
  • C, thoracic artery
  • F, abdominal artery
  • W, aorta

Don’t code cardiac cases? You still need to know arteries. For a procedure involving an artery, for example, you will need to know which artery is involved, where it is located in the body, what approach the physician used, what type of repair he or she performed, and whether the physician used a device.

Consider a patient with septic thrombosis of the choroid vein. If you know that the choroid vein is an intracranial vein, you’re all set. You can report ICD-10-CM code G08 (intracranial and intraspinal phlebitis and thrombophlebitis). You’ll notice all of the intracranial veins and sinuses are lumped into this one code. If you don’t know where the vein belongs and your physician simply documents septic thrombosis of the choroid vein, you’ll need to research the vein. This decreases productivity, which slows down cash flow and so on and so forth.

If you code for the ED or orthopedics, you definitely need to know your bones (not just where they are, but what kind of sections they have) and muscles.

For example, where would you find the navicular bone? It’s kind of a trick question because humans have a navicular bone in the foot as well as the wrist. The one in the wrist is also called the scaphoid bone. ICD-10-CM lists it as the navicular (scaphoid).

The navicular bone in the wrist can be fractured in the distal pole, middle third, or proximal third. Each has a separate subcategory in ICD-10-CM that includes options for laterality and displaced vs. nondisplaced.

The navicular of the foot doesn’t have those location differences. Your choices are displaced or nondisplaced, left or right.

If you only code one type of record all the time—for example, if you work for a pulmonologist—you probably only really need to brush up on the anatomy for that body system or area. If you work at a hospital or are part of a pool of coders, you might see a wide range of cases. Then you’re going to need to understand a wider range of anatomy.

You don’t need to take a full-blown anatomy course. Figure out what anatomy you already know well. Odds are you know some of it very well. Identify areas where you aren’t as strong and do some focused training. It can be as simple as looking at Gray’s Anatomy (again, the book, not the TV show).

Find ways to make it fun. An anatomy version of Jeopardy! could be interesting. You can find a lot of free resources online, just make sure you choose ones from a reputable source.

ICD-10 and value-based healthcare

CMS and Obamacare have increasingly been moving healthcare toward a more value-based model. They want to pay physicians for how well they treat patients and not by the volume of services they provide. Even outpatient hospital services are moving that way as CMS increasingly packages services into one payment.

TipsWhat happens when ICD-10 enters this value-focused mix? Imagine how much information physicians and coders can’t capture today because we just don’t have the codes to represent the true clinical picture of the patient’s illness.

For example, in ICD-9, we have no way of knowing whether a patient broke his or her right or left arm. We can code for the specific bone (radius or ulna) and the area of the bone (upper end, shaft, or lower end). We can even specify open or closed.

What we can’t tell is which side. Why does that matter? Well, consider this scenario. George comes in with a closed fracture of the distal end of the radius (In ICD-9-CM, you would use code 813.43. In ICD-10-CM, we would use a code from the S52.5- series, but we need a lot more information to select the most specific code).

Dr. Bones treats George and sends him on his way. Unfortunately for George, he is back in three weeks with another fracture. Suppose Dr. Bones documents a closed fracture of the distal end of the radius, our 813.43 ICD-9-CM code again. Do you think our payer might be a little suspicious about that?

However, in ICD-10-CM, you could show that George broke the right radius first, then was unlucky enough to break the left one. We’ll have separate codes for each fracture. For example, if George suffered a displaced oblique fracture of the shaft of the right radius, we would report S52.331A for the initial encounter.

When Dr. Bones sees him for the left radial fracture, she documents a nondisplaced comminuted fracture of the shaft of the radius of the left arm (S52.355A). Two different injuries, two different codes.

We’ll also be able to track how well an injury is healing. ICD-10-CM includes seventh characters that specify the encounter. The three most common are:

  • A, initial encounter
  • D, subsequent encounter
  • S, sequela

Those choices expand for fractures that include:

  • D, routine healing
  • G, delayed healing
  • K, nonunion
  • P, malunion

The main code will stay the same; the seventh character will tell you how well the fracture is healing. Suppose George’s right arm fracture was showing malunion when he came in for the initial treatment of the left arm fracture. We could report two codes for that visit and those codes will tell our payer that Dr. Bones treated two separate injuries on that day. If you’re wondering, the codes would be S52.331P and S52.355A.

Notice that the code for the malunion is almost exactly the same as the code for the initial visit for the right arm fracture. In ICD-10-CM that fracture code will run through the entire course of treatment for the injury. That will make it easier to pull data about how well a treatment works, how a patient responds to a particular treatment, and what the physician does to treat that particular injury over the course of healing.

And all of that leads us back to quality measures. If you see a patient who suffers a lot of fractures, the physician should look for an underlying reason. Is George clumsy? Does he work in a high-risk environment? Does he have another condition that makes him more susceptible to fractures?

On the other hand, if George keeps coming in for treatment of the same fracture over and over, maybe Dr. Bones isn’t doing a good job.

ICD-10-CM will make it easier to figure that out because we will have more granular data and we’ll actually be able to tell (to some extent) what quality of treatment a physician is providing.

“We can’t pay for value if we don’t know the outcomes and what the value of the treatment really is,” says Sue Bowman, MJ, RHIA, CCS, FAHIMA, senior director of coding policy and compliance for AHIMA in Chicago.

“ICD-10 will really help give us more specific data, so we can see what the outcomes really are and we can judge what is good value.”

Score a few more famous deaths

Composers lead pretty safe lives, right? They compose music, conduct the symphony, and hang out at post-show parties. And we’re not talking rock star parties.

Grim reaper sillySometimes, though, that job isn’t so safe. Take, for example, Jean-Baptiste Lully, King Louis XIV’s favorite and main court composer. In January 1687, Lully inadvertently struck his foot with the pointed staff he had been using to keep time while conducting his Te Deum for Louis.

Healthcare being what it was in the 17th century, Lully developed gangrene. He refused to have the foot amputated (no super antibiotics in those days) and subsequently died.

Since we don’t have an exact cause of death (my guess is septic shock), let’s code his gangrene instead.

When we look up gangrene in the ICD-10-CM Alphabetic Index, we see a nice long list of potential codes, some of which specify a type and some that specify location. For example, we would use K35.80 for gangrene of the appendix. For gas gangrene, we would report A48.0.

Many of the terms direct you to other terms. For example, gangrene with diabetes directs you to see Diabetes, gangrene.

We know Lully’s gangrene started in his foot (although we don’t know which one). Foot is not one of our choices for a gangrene location, but we do have extremities. The foot counts as an extremity and both upper and lower extremities lead to the same code: I96 (gangrene, not elsewhere classified).

That’s a nice vague code, but it is not an unspecified code. It’s a NOC code—we have the information, we just don’t have a more specific code. It’s worth noting that I96 includes a long list of Exclude1 codes (meaning don’t code together):

  • Gangrene in atherosclerosis of native arteries of the extremities (I70.26)
  • Gangrene in diabetes mellitus (E08-E13)
  • Gangrene in hernia (K40.1, K40.4, K41.1, K41.4, K42.1, K43.1-, K44.1, K45.1, K46.1)
  • Gangrene in other peripheral vascular diseases (I73.-)
  • Gangrene of certain specified sites – see Alphabetical Index
  • Gas gangrene (A48.0)
  • Pyoderma gangrenosum (L88)

Acne appears to have done in Alexander Scriabin. The Russian composer-pianist noticed a pimple on his upper lip, which became infected. The infection progressed to a fatal case of septicemia.

Ah, septicemia, one of the problem children of the coding world (largely because doctors don’t document it well). In ICD-9-CM, our septicemia choices include:

  • 038.0, streptococcal septicemia
  • 038.1x, staphylococcal septicemia
  • 038.2, pneumococcal septicemia [Streptococcus pneumoniae septicemia]
  • 038.3, septicemia due to anaerobes
  • 038.4x, septicemia due to other gram-negative organisms
  • 038.8, other specified septicemias
  • 038.9, unspecified septicemia

In ICD-10-CM, we have no codes for septicemia. Huh?

In ICD-10-CM, we will not have codes with septicemia in the code title but will code it as sepsis since it is the body’s systemic reaction to infection.

If you look up septicemia in the ICD-10-CM Alphabetic Index, you find one code—A41.9 (Sepsis, unspecified organism)—and a note: meaning sepsis—see Sepsis.

We should not be at a loss for options when it comes to sepsis. ICD-10-CM includes codes for

  • Anaerobic A41.4
  • Bacillus anthracis A22.7
  • Brucella (see also Brucellosis) A23.9
  • Candidal B37.7
  • Cryptogenic A41.9
  • Due to device, implant or graft T85.79
  • Enterococcus A41.81
  • Erysipelothrix (rhusiopathiae) (erysipeloid) A26.7
  • Escherichia coli (E. coli) A41.5
  • Extraintestinal yersiniosis A28.2
  • Gangrenous A41.9
  • Gonococcal A54.86
  • Gram-negative (organism) A41.5

And so on and so forth. What we really need is for the physician to specify the causative organism. Otherwise, we’re back to A41.9. Before you prepare to bombard your physicians with a bazillion queries for causative organisms, take a look at ICD-10-CM guideline B18:

When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type).

The guideline goes on to state:

It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.

Consider carefully whether the physician can provide additional details before you send that query. If you see that Dr. Germ wrote an order for a lab test that should provide the information, by all means, politely ask him or her to provide details.

Our final musically inclined casualty is something of a mystery (or a conspiracy, depending on who you believe). Pyotr Ilyich Tchaikovsky, who composed the perennial Christmas classic The Nutcracker, died of either cholera or suicide.

Cholera is Tchaikovsky’s official cause of death. Witnesses, including his brother, said Tchaikovsky drank a glass of unboiled water during a cholera outbreak in St. Petersburg.

ICD-10-CM includes three codes for cholera, and they are actually the first three codes in the Tabular List:

  • A00.0, cholera due to Vibrio cholerae 01, biovar cholerae
  • A00.1, cholera due to Vibrio cholerae 01, biovar eltor
  • A00.9, cholera, unspecified

If we know the causative organism, we’ll go with a specific code. If our physician doesn’t document it, we’ll go with A00.9.

Baby blues turned pink

Poor Finn is having a rough week. It started out well as he spent Sunday with his folks and older brother at an amusement park being as amused as a 6-month-old can be.

crying babyThings started going downhill Monday when mom Melissa had to wipe off a thick yellow discharge crusting over Finn’s eyelashes when she woke him up. She also noticed the whites of Finn’s eyes were now red.

She brought Finn into the Fix ‘Em Up Clinic to see Dr. Spock, who diagnosed bilateral acute bacterial conjunctivitis and prescribes eye drops. Dr. Spock expects Finn to be on the mend soon.

When we look up conjunctivitis, acute, we find choices for:

  • Atopic
  • Chemical
  • Mucopurulent
  • Pseudomembranous
  • Serous except viral
  • Toxic

Which one do we use? Since we are super coders, we know bacterial conjunctivitis falls under serous not viral, which takes us to code H10.23-. Ah, the dash. That tells us we need more characters for our code.

When we visit the Tabular List, we find the additional character we need identifies laterality. Dr. Spock documented bilateral, so we would use H10.233 (serous conjunctivitis, except viral, bilateral).

Off Finn went with some eye drops and antibiotics and things should have ended well enough there.

Finn was back at the Clinic Thursday for his six-month well baby checkup. Right off the bat, we know our first code with be one of these:

  • Z00.121, encounter for routine child health examination with abnormal findings

Use additional code to identify abnormal findings

  • Z00.129, encounter for routine child health examination without abnormal findings

In order to choose, we need to know if Dr. Spock found anything wrong with Finn (other than the previously diagnoses pinkeye). Sadly for Finn, Dr. Spock also identified an ear infection. That means we’re going with Z00.121. We also need to add additional codes to report what’s wrong with Finn.

To code his ear infection, we need to know:

  • Where is the infection—outer, middle, or inner ear?
  • Which side (or both)?
  • Acute or chronic?
  • Suppurative or nonsuppurative?

Let’s see what Dr. Spock documented. As we scan through the documentation, we see:

  • Acute
  • Nonsuppurative
  • Bilateral
  • Secretory otitis media

With that information, we can report code H65.03 (acute serous otitis media, bilateral).

We also see two notes under H65, Nonsuppurative otitis media:

  • Use additional code for any associated perforated tympanic membrane (H72.-)
  • Use additional code to identify:

exposure to environmental tobacco smoke (Z77.22)

exposure to tobacco smoke in the perinatal period (P96.81)

history of tobacco use (Z87.891)

occupational exposure to environmental tobacco smoke (Z57.31)

tobacco dependence (F17.-)

tobacco use (Z72.0)


Dr. Spock did not document any tobacco exposure or a perforated ear drum, so we don’t need any additional codes.

However, when we continue reading the office visit note, we find that Finn received four vaccinations:

  • DTaP
  • Hib
  • PCV
  • Rota

When we look up vaccination in the Alphabetic Index, we find codes for

  • Complication or reaction
  • Delayed
  • Encounter for
  • Not done

We already have an encounter code for the well baby visit. Do we still code an encounter for the vaccinations? Yes. In fact, when we look up code Z23 (encounter for immunization), ICD-10-CM tells use to code first any routine childhood examination. Not only do we know we need both codes, but we even get the sequencing.

One other thing to note under Z23:

  • Note: procedure codes are required to identify the types of immunizations given

So don’t forget your CPT codes for vaccine administration and HCPCS codes for the specific vaccines.

Hopefully, Finn will be feeling better soon!