All Entries Tagged With: "ICD-10 coding"

ICD-10 on Opening Day

Anytown’s baseball team just completed its home opener and while the team came away with a win, not all of the players made it through the game.

Eddie the outfielder suffered a painful run-in with the left-field fence in the second inning. Eddie raced back to catch a fly ball and jumped up. Unfortunately, he was too close to the fence and ripped his right ear open on the top of the fence.  He cut through the cartilage in his ear and now sports a spiffy row of stitches. Fence 1, Eddie 0.

Dr. Selig documented no foreign body in the laceration and also noted this was Eddie’s first visit. That gives us ICD-10-CM code S01.311A, laceration without foreign body of right ear, initial visit.

We can also add some codes for external causes:

• W18.01xA, striking against sports equipment with subsequent fall, initial encounter (if you consider the fence a piece of baseball equipment)
• Y92.320, baseball field as the place of occurrence of the external cause
• Y93.64, activity, baseball

Eddie’s teammate Ken also suffered a setback in the first game of the season. Ken failed to move out of the path of an oncoming fastball and earned a free base—and a massive bruise to his hip. Fortunately, the pitch wasn’t that fast, so Ken didn’t suffer any breaks, but he’s going to be sore for a while.

When we review Dr. Selig’s note, we find that he did not document laterality or encounter. That means we need to query.

ICD-10-CM does contain a code for contusion to unspecified hip, but in order for any contusion code to be valid, we need a seventh character to denote the encounter. Since we’re asking for one piece of information, we may as well ask for both. That way the record will be more complete and we don’t need to worry about a possible denial for an unspecified code.

Dr. Selig responds (three days later) with a notation of left hip, initial encounter, so we would report:

• S70.02xA, contusion of left hip
• W21.03xA, struck by baseball
• Y92.320, baseball field as the place of occurrence of the external cause
• Y93.64, activity, baseball

Note that we need placeholders for codes for the contusion and the struck by baseball. Without the X placeholder, the seventh character ends up in the sixth position, making the code invalid.

Eddie and Ken will both be back on the field tomorrow, but their teammate Keith is headed for the injured reserve. Keith slid into second and dislocated his right ankle when he hit the bag awkwardly. To add insult to injury, he was out. He had larceny in his heart, but lead in his feet. And now a cast to go with it.

What do we need in Dr. Selig’s documentation to code Keith’s dislocated ankle?

• Laterality (right)
• Encounter (initial)
• Dislocation or subluxation (dislocation)

That gives us:

• S93.04xA, dislocation of right ankle joint, initial encounter
• Y92.320, baseball field as the place of occurrence of the external cause
• Y93.64, activity, baseball

We would not report W18.01xA because Keith didn’t fall. ICD-10-CM does not contain a code for sliding into a base. At least not yet.

A chilling selection of ICD-10-CM external causes codes

So how would you like to explain this accident to your physician? Doctor, I was crossing the street wearing ice skates and was hit by a bicycle.

Believe it or not, there’s an ICD-10-CM code for just such an occasion:

• V06.19, pedestrian with other conveyance injured in collision with other nonmotor vehicle in traffic accident

That code includes a long list of specific circumstances, such as:

• Pedestrian on ice-skates injured in collision with other nonmotor vehicle in traffic accident
• Pedestrian on sled injured in collision with other nonmotor vehicle in traffic accident
• Pedestrian on snowboard injured in collision with other nonmotor vehicle in traffic accident
• Pedestrian on snow-skis injured in collision with other nonmotor vehicle in traffic accident

Odds are, you won’t use code V06.19 often, but it’s there if you need it.

ICD-10-CM contains a wide range of codes for external causes, so let’s look at some of the others you may need during the winter.

New England is bracing for a major snow storm this weekend, so we may see people come in with various injuries caused by activities involving ice and snow (Y93.2). Note that the Y93.2 series excludes injuries related to shoveling ice and snow. They have their own external causes code—Y93.H1.

We’ll also report X37.2 (blizzard [snow][ice]).  Don’t forget the seventh character to denote the encounter.

Perhaps your patient is Lindsey Vonn, the Olympic skier who recently suffered torn knee ligaments in a horrible crash during a race. If we code the activity of skiing, we need to know what type of skiing:

• Y93.23, activity, snow (alpine) (downhill) skiing, snow boarding, sledding, tobogganing, and snowtubing
• Y93.24, activity, cross country skiing

In Lindsey’s case, it’s downhill skiing, so we would code Y93.23 in addition to her injury codes.

What other trouble can we get into in the snow? We could fall because of the snow and ice (it’s not fun, I don’t recommend it). In that case, we would report a code from the W00.- series (fall due to ice and snow):

• W00.0, fall on same level due to ice and snow
• W00.1, fall from stairs and steps due to ice and snow
• W00.2, other fall from one level to another due to ice and snow
• W00.9, unspecified fall due to ice and snow

These codes require a seventh character to denote the encounter, so we’ll need to add two X placeholders so our seventh character ends up in the seventh place.

W00.0 also includes collusions with another person, so when you go sliding across the icy sidewalk straight into an innocent bystander, you get W00.0XXA (for the initial encounter).

If a patient comes in suffering from hypothermia (T68-), we need use additional code to identify source of exposure:

• Exposure to excessive cold of man-made origin (W93)
• Exposure to excessive cold of natural origin (X31)

W93 requires a seventh character to denote the encounter type and includes:

• Excessive cold as the cause of chilblains NOS
• Excessive cold as the cause of immersion foot or hand
• Exposure to cold NOS
• Exposure to weather conditions

W93 specifically excludes:

• cold of man-made origin (W93.-)
• contact with or inhalation of:
• dry ice (W93.-)
• liquefied gas (W93.-)

All of these winter codes are making me cold. Pass the hot chocolate.

Black (and blue) Friday at Fix ‘Em Up Clinic

Black Friday marks the beginning of the holiday shopping season—and the holiday injury season at Fix ‘Em Up Clinic.

Patients started showing up shortly after the stores opened this morning with shopping related injuries.

Heather came in complaining of a sore right wrist after being shoved to the during a midnight madness free-for-all at the local mall.

Dr. Carroll documents a traumatic rupture of tendons in Heather’s wrist, contusions and abrasions to her hand, and contusions to her knees.

Apparently Dr. Carroll enjoyed too much turkey on Thanksgiving because he forgot to document some important information.

We need to know:

• Encounter (initial, subsequent, sequela)
• Laterality for the wrist and hand injuries—we can’t use Heather’s complaint to decide which side she injured. Dr. Carroll must include that information in his documentation
• Specific ligament ruptured –collateral ligament, radiocarpal, ulnocarpal, or other. Other doesn’t not mean unspecified. ICD-10-CM does include a code for unspecified ligament, but we want to avoid unsing unspecified unless absolutely necessary.

We do know the knee contusions are bilateral because Dr. Carroll documented knees.

Let’s see what additional information Dr. Carroll can provide about Heather’s injuries.

In response to our query, Dr. Carroll provides the following:

Initial encounter for traumatic rupture of radiocarpal and collateral ligaments of right wrist; contusions to right hand, abrasions on left palm; contusions on both knees.

Great, now we can report the following codes:

• S63.311A, traumatic rupture of collateral ligament of right wrist, initial encounter
• S63.321A, traumatic rupture of right radiocarpal ligament, initial encounter
• S60.221A, contusion of right hand, initial encounter
• S60.512A, abrasion of left hand, initial encounter
• S80.01XA, contusion of right knee, initial encounter
• S80.02XA, contusion of left knee, initial encounter

If Heather had suffered injuries to her fingers in addition to the abrasions and contusions to her hands, we would need to code those injuries separately by the specific finger injured.

We can also report the following external causes codes if the payer wants them:

• W03.XXXA, other fall on same level due to collision with another person
• Y92.59, other trade areas as the place of occurrence of the external cause (the mall)
• Y93.01, activity, walking, marching and hiking

Sadly, ICD-10-CM does not yet include a code for door-buster shopping, or any shopping for that matter.

Our next patient Rex really wanted that jersey at the sporting goods store in the mall, but unfortunately for him, someone else wanted it more. Rex arrived at Fix ‘Em Up with some pretty nasty bruises as well as a broken leg. The other guy really didn’t fight fair it seems.

Dr. Morang documents an initial visit for:

• Contusions to the right periocular area
• Closed, nondisplaced fracture of zygomatic arch (that explains the really nasty bruise on Rex’s face)
• Laceration of the lower lip (no foreign body in wound)
• Open displaced oblique fracture of shaft of right tibia (Gustilo class I)

Apparently Dr. Morang slept off the Thanksgiving turkey better than Dr. Carroll. With this documentation, we can code the following:

• S82.231B, displaced oblique fracture of shaft of right tibia, initial encounter
• S00.11XA, contusion of right eyelid and periocular area, initial encounter
• S02.402, zygomatic fracture, unspecified, initial encounter
• S01.511A, laceration without foreign body of lip, initial encounter

I think I’ll wait for Cyber Monday. It’s way too dangerous out there.

Real goals and benefits of ICD-10-PCS

You need enthusiasm and a desire to keeping learning to tackle the monumental task of learning ICD-10-PCS. In authoring an ICD-10 CM/PCS education program 10 hours per work I learn something new every day. The purpose of this blog is to share along the way with other coders.

This week while preparing a presentation titled “ICD-10-PCS-An Introduction” my research took me to assembling a list of the goals and benefits of ICD-10 PCS. There are so many myths regarding this new coding system that I want to share these REAL GOALS AND BENEFITS.

GOALS

• Improve the accuracy and efficiency of procedure coding
• Replace ICD-9-CM procedure codes with a more logical system
• Improve communication with physicians by developing a code system that aligns more with the clinical aspects of various procedures
• Allow coders to construct accurate codes with minimal effort

BENEFITS:

• Completeness
• Expandability
• Standardized terminology
• Multiaxial
• May reduce coder’s anxiety because it better captures procedural descriptions and details
• Anatomically detailed clinical data

ICD-10-PCS guidelines go right down to our fingers and toes!

ICD-10-PCS includes 31 root operations, but before you go there don’t forget to look at the Official Coding Guidelines for ICD-10-PCS. They are an extensive set of guidelines with instruction on how to use the root operations and cannot be overlooked.  

For example, ICD-10-PCS coding guideline, Body Part Guideline: Fingers and Toes (B4.7), tell us:

If a body system does not contain a separate body part value for fingers, procedures performed on the fingers are coded to the body part value for the hand. If a body system does not contain a separate body part value for toes, procedure performed on the toes are coded to the body part value for the foot.

Example: Excision of finger muscle is coded to one of the hand muscle body part value in the Muscles body system.

Think positively about ICD-10 and consider all the goals and benefits to breathe new life into our profession. For me, choosing to embrace ICD-10 fully and teach it to others has been exciting and fun.

ICD-10 coding for flaming tomato napalm

Over the weekend, Matt decided to grill up dinner, which sounds at first like a good idea.  He started with chicken, then added some vegetables, unfortunately including some cherry tomatoes. While he was grilling dinner, one of the tomatoes made a break for it, rolling off the grill and onto the patio of Matt’s single-family home.

Matt saw it go, considered it a goner, and went back to grilling. The tomato was not prepared to be ignored. It strategically placed itself under Matt’s left sandal. He stepped down and felt “flaming tomato napalm” squirt between his foot and his sandal. When he looked down to verify that the tomato had taken its revenge, he smacked his head into the grill, giving himself a mild concussion and opening a 3-inch gash on his forehead.

When he put his hand up to stem the flow of blood from his forehead, he dropped his grilling fork—straight into the top of his right foot.

After uttering a few choice phrases on the nature of cherry tomato terrorism, Matt arrived at Fix ‘Em Up Clinic for repairs.

So how would we report his multiple injuries? We don’t really have sequencing guidelines for ICD-10-CM that tell us which injury to code first, so let’s look at the injuries in the order Matt sustained them.

We know Matt’s burn is to the left foot, which takes us to ICD-10-CM code series T25 (burn and corrosion of ankle and foot). The first thing we notice is the entire series of codes needs a seventh character to specify the encounter—initial, subsequent, or sequela. We look to Dr. Tom A. Toe’s documentation and see that this is Matt’s first visit.

The next thing we need to know is the degree of the burn—first, second, third, or unspecified. Try to avoid unspecified even if you need to query. We also need to know where specifically the burn is—ankle, foot, toes, or multiple sites. Back to the documentation, when Dr. Toe has documented a second degree burn to the bottom of the foot. That leads us to T25.222A, burn of second degree of left foot.

But we aren’t done with this injury yet. Under T25.2 (burn of second degree of ankle and foot) we find this note: Use additional external cause code to identify the source, place, and intent of the burn (X00-X19, X75-X77,X96-X98, Y92). Fortunately, we have that information in our narrative of the accident:

• X12.XXXA, contact with other hot fluids (the liquid inside the tomato)
• Y92.018, other place in single-family (private) house as the place of occurrence of the external cause
• Y93.G2, activity, grilling and smoking food

ICD-10-CM does not specify a patio as a place of occurrence (hence Y92.018), but does include a code for garden or yard. Since we don’t know where the patio is located (and it’s a patio, not the garden or yard), we’ll go with other place. “Other place” is not the same as “unspecified place.” We know where specifically Matt suffered his injuries, we just don’t have a code for it.

That takes us to Matt’s concussion and forehead laceration. Dr. Toe documented no loss of consciousness, so we would report S06.0X0A (concussion without loss of consciousness, initial encounter).

For the laceration, we need to know whether Matt had any foreign body in the wound (a check of the documentation says, no). When we look up laceration, forehead in the ICD-10-CM Alphabetic Index, we are directed to S01.81, laceration without foreign body of other part of head. When we go to the Tabular Index, we see that we need a seventh character to denote the encounter type, so our final code would be S01.81XA.

That brings us to Matt’s final injury, the fork to the foot. Matt removed the fork before coming to Fix ‘Em Up, and fortunately, nothing stayed behind in the punctures. Again, we need to know which foot (right), with or without foreign body (without), foot itself or toes (foot itself), and encounter type (initial). All of that brings us to: S91.331A (puncture wound without foreign body, right foot, initial encounter).

And with that, Dr. Toe is done with Matt and we are done with his diagnostic record. So it’s time to head home and fire up the grill. I will not be adding any cherry tomatoes though.

Too many codes? There’s no such thing

A writer paints a picture with words. The English language alone offers somewhere in the neighborhood of a quarter of a million words. But really how many does the average person use? According to Stephen Pinker’s book “The Language Instinct” the average American high-school graduate knows approximately 45,000 words. That’s  a pretty big disparity, but it makes sense.

How many people do you know who use antidisestablishmentarianism in regular conversation? By the way, antidisestablishmentarianism is the longest non-technical and non-coined word in the English language (watching Jeopardy! pays).

Some other odd words that you’ve probably never heard of include:

• Erinaceous (like a hedgehog)
• Lamprophony (loudness and clarity of voice)
• Depone (to testify under oath)
• Finnimbrun (a trinket or knick-knack)
• Floccinaucinihilipilification (estimation that something is valueless)
• Inaniloquent (pertaining to idle talk)

So what does this have to do with coding in general and ICD-10-CM coding in particular? A coder tells a story with codes. Like any good storyteller, you want that story to be as complete and accurate as possible. ICD-10-CM’s increased specificity will help you do that.

A lot of people get hung up on the huge increase in the number of codes. ICD-9-CM includes 14,567 diagnosis codes, while ICD-10-CM offers 69,833. Big, scary difference, right? Yes and no. You’ll have a lot more choices, but that doesn’t mean you’ll use them.

How often does a patient come in for a spacecraft fire injuring occupant (V95.44) or for being bitten by an orca (W56.21)? For that matter, how many cases of light chain deposition disease or variant Creutzfeldt-Jakob disease or Pallister-Killian mosaic syndrome do you see?

If you code for a specialty, you’ll generally use a small fraction of the available codes. Even if you code for several specialties, you still won’t use every code.

And a lot of the codes are just more detailed. They aren’t new conditions or new diseases. For example, look at the codes for serous detachment of retinal pigment epithelium. ICD-9-CM offers one code choice—362.42. So you’re coding this condition now. The difference is when you get to ICD-10-CM, you’ll have four choices:

H35.721, serous detachment of retinal pigment epithelium, right eye

H35.722, serous detachment of retinal pigment epithelium, left eye

H35.723, serous detachment of retinal pigment epithelium, bilateral

H35.729, serous detachment of retinal pigment epithelium, unspecified eye

The additional specificity could be an unexpected aid as well. Because many ICD-10-CM codes include laterality, you shouldn’t have to worry that a payer will reject a claim because of double billing if you can code two separate sites (index finger and middle finger) or different sides of the body (right arm and left arm).

Don’t get stuck on the number of new codes. You don’t need to memorize them and you won’t have to relearn how to code diagnoses from scratch. Probably 90-95% of the coding guidelines remain the same. It’s a big change and will certainly be a challenge, but don’t be afraid of the choices.

Don’t look now, but the vampires are massing

So we’ve survived the zombie apocalypse, but  we’re not out of the undead woods yet. It seems a group of vampires is trying to one-up the zombies. But, never fear, vampires can actually be regular people suffering from codeable medical illnesses, just like the zombies.

Have you noticed how pale vampires are, especially Robert Pattinson in the ‘Twilight’ movies? Turns out, they could be suffering from anemia. We need a lot more information in order to code anemia in ICD-10-CM.

First of all, what type of anemia is it? ICD-10-CM includes three major categories:

• D50-D53, nutritional anemias
• D55-D59, hemolytic anemias, which involve the premature destruction of red blood cells
• D60-D64, aplastic and other anemias and other bone marrow failure syndromes

So we need to narrow down what type of anemia our vampire has before we can even determine which series of codes to use. Keep in mind that each series of codes includes numerous subcategories that require specific documentation.

For example, if our vampire suffers from hemolytic anemia, we need to know the cause. Is it a hereditary condition or an acquired one? Is it due to an enzyme disorder and if so, which one? Maybe our vampire suffers from thalassemia, in which the body makes an abnormal form of hemoglobin. If it’s thalassemia, we need to know which specific form:

• Alpha
• Beta
• Delta-beta
• Thalassemia minor
• Hereditary persistence of fetal hemoglobin
• Hemoglobin E-beta

Some form of anemia probably accounts for our vampire’s pale complexion, but what about that whole “burst into flames in sunlight” thing?

It’s not as far out as you might think. Our vampire may suffer from porphyria, conditions that can affect the skin and nervous system. People with porphyria have a deficiency in one of the eight enzymes responsible for producing the chemical reactions necessary to produce heme. Of the eight different types of porphyria, four can sometimes cause sensitivity to light, but won’t cause the sufferer to spontaneously combust:

• Erythropoietic protoporphyria or protoporphyria (ICD-10-CM code E80.0)
• Congenital erythropoietic porphyria  (E80.0)
• Porphyria cutanea tarda (E80.1)
• Variegate porphyria, a form of acute intermittent (hepatic) porphyria (E80.21)

Perhaps our vampire suffers from a more common condition, known as polymorphous light eruption, which is characterized by the formation of bumpy and itchy rashes on sun-exposed skin. The symptoms are similar to a sunburn, and you’ll find the ICD-10-CM code (L56.4) in the radiation-related disorders of the skin and subcutaneous tissue series, like sunburn.

For our inpatient coders, ICD-10-CM L56.4 is part of MS-DRG:

• 606 Minor skin disorders with MCC
• 607 Minor skin disorders without MCC

If you’ve ever seen the really old vampire movies (or even just some of the clips), the vampire is often portrayed as being stiff as a board when he rises from his coffin. He also sleeps with his eyes open. And really, if someone was trying to put a stake through your heart, you’d probably sleep with your eyes open too.

However, our vampire may be suffering from an actual medical condition, not just a concern for personal safety. Catalepsy is a nervous condition characterized by muscular rigidity and fixity of posture regardless of external stimuli, as well as decreased sensitivity to pain. A person suffering from catalepsy can see and hear but cannot move. Their breathing, pulse, and other regulatory functions are so slow that the person appears to be  dead.  That explains the rising from the dead without being a zombie.  We have two codes to choose from for catalepsy:

• F20.2, catatonic schizophrenia
• F44.2, catalepsy(hysterical)

Alternately, our vampire may just be hypnotized and wearing stage makeup. In that case, we can put away the garlic and go back to watching Twilight: Breaking Dawn or better yet, The Lost Boys.

ICD-10-PCS root operations: Dilation

When a physician performs a procedure to enlarge the diameter of a tubular body part or orifice, coders will report root operation dilation with 7 as the third character in the medical and surgical section of ICD-10-PCS. The orifice can be natural or artificially created.

Coders will report dilation when a physician uses either intraluminal or extraluminal methods of enlarging the diameter. Percutaneous transluminal angioplasty, pyloromyotomy, and cystoscopy are among the procedures reported as dilation.

A device placed to maintain the new diameter is an integral part of the dilation procedure. Coders will report the device with the appropriate sixth-character device value in the dilation procedure code.

Other examples of dilation procedures include:

• 0F798ZZ, endoscopic retrograde cholangiopancreatography with balloon dilation of common bile duct
• 0D717ZZ, dilation of upper esophageal stricture, direct visualization, with bougie sound
• 087Y7DZ, transnasal dilation and stent placement in left lacrimal duct
• 047D04Z, dilation of left common iliac artery with drug-eluting intraluminal device, open approach

The dangers of do-it-yourself

Home repair and improvement can be hazardous to your health. Just ask the residents of Calamity Condos who are visiting the Fix ‘Em Up Clinic.

Tom and Wendy decided to repaint the living room of their condo. When it came time to paint the ceiling, Wendy picked up Hawkeye the cat to make things safer for Tom on the ladder. Alas, Tom leaned too far back on the ladder, overbalanced, and crashed to the floor. The thump scared Hawkeye, who clawed his way out of Wendy’s grip and headed off for parts unknown (and presumably quieter).

Dr. Crusher notes that she is seeing Tom for the first time for injuries suffered during the fall from the ladder. She documents Tom sustained a concussion, lower back contusion, and sprained wrist in the fall.

So how do we code Tom’s injuries? First we need to know if he lost consciousness when he fell and if so, for how long. ICD-10-CM includes 10 codes for concussions, from no loss of consciousness to loss of consciousness of any duration, with death due to other cause prior to regaining consciousness.

We don’t see any documentation of loss of consciousness in Dr. Crusher’s note, but we send a query just to make sure that means Tom didn’t lose consciousness. Dr. Crusher confirms he did not, so we would report S06.0X0A (concussion without loss of consciousness).

For Tom’s contusion of the lower back, we would report S30.0XXA. Note that we need two placeholders in this code because we need a seventh character to denote the encounter type.

That brings us to Tom’s sprained wrist. Sprained wrist is not going to cut it as far as coding goes. We need to know which wrist and which joint Tom sprained.  When we look through Dr. Crusher’s notes, we find documentation stating a sprain of the left radiocarpal joint, which leads to code S63.522A.

And let’s not forget the code for falling from the ladder. In ICD-9-CM, we would look for an E code, but in ICD-10-CM, we head to Chapter 20, External causes of morbidity (V00-Y99). Tom’s tumble from the ladder leads us to code W11 (fall on or from ladder). The category doesn’t include any additional subcodes, but it does include a note to add the appropriate seventh character. Since Dr. Crusher is treating Tom for the initial visit for the fall, we would report W11.XXXA.

What about poor Wendy? She ended up with lacerations in multiple locations as a result of Hawkeye’s getaway. We need to report each location that Dr. Crusher documented, which include the right upper arm and forearm, left forearm, right thumb, and right index finger. Hawkeye also bit Wendy’s right index finger in his bid for freedom. So we would code:

• S41.111A, laceration without foreign body of right upper arm
• S51.811A, laceration without foreign body of right forearm
• S51.812A, laceration without foreign body of left forearm
• S60.470A, other superficial bite of right index finger
• S61.011A, laceration without foreign body of right thumb without damage to nail
• S61.210A, laceration without foreign body of right index finger without damage to nail

If Hawkeye had scratched more fingers and Dr. Crusher had documented it, we would continue to add codes. Because Dr. Crusher documented lacerations to both the right and left forearms, we code for both. If she didn’t specify which arm was involved, we would query and if we weren’t able to get clarification, we would be forced to report the unspecified code S51.819 (laceration without foreign body of unspecified forearm).

That might not make much of a difference initially, but at some point, third-party payers may decide not to pay for unspecified laterality. And really, physicians should know where the specific injury is located. We just need to get them to write in down.

Here’s the other problem with that unspecified code. In our example, Wendy suffered lacerations to both arms and Dr. Crusher documented those injuries. As a result, we report two codes and should be reimbursed for both. Different sides of the body, different injuries. However, if we report the unspecified code, we’re missing out on half of the reimbursement because we’re only getting paid for the lacerations on one arm. Think about pointing that out to your physicians, in a polite way.

As we continue reading through Dr. Crusher’s notes, we find this notation: “Patient complains of nausea from paint fumes, no vomiting. Patient says smell of paint often makes her nauseous.” That means we need to check the Table of Drugs and Chemicals to find a code for poisoning by paint fumes.

In the Table of Drugs and Chemicals, under paint, we find five choices:

• Cleaner
• Fumes NEC
• Lead (fumes)
• Solvent NEC
• Stripper

Dr. Crusher documented that the paint fumes made Wendy sick. Clearly this is an accidental poisoning, so we would report T59.891 (toxic effect of other specified gases, fumes and vapors, accidental [unintentional]). We also report code R11.0 (nausea without vomiting).

Dr. Crusher is also seeing Roger, another resident of Calamity Condos. Two weeks ago, Roger cut off part of his left thumb with a table saw. Ouch. Today he’s back for a routine follow up for the partial traumatic metacarpophalangeal amputation of left thumb. Dr. Crusher documents the injury is healing well, so we would report S68.022D (partial traumatic metacarpophalangeal amputation of left thumb). Notice the seventh character in this case is D for a subsequent encounter. If Dr. Crusher had documented some type of adverse after effect, we would have used S for the seventh character for sequela.

Our final victim of the Calamity Condo fixing up, Steve, comes in with crushed toes. He dropped a sink on his foot while he was trying to lift it into place. Dr. Crusher documents crush injuries to the great toe and two of the lesser toes on Steve’s right foot. She also documents this is an initial visit.

• S97.111A, crushing injury of right great toe
• S97.121A, crushing injury of right lesser toe(s)

We would only report two codes, even though three toes are involved because S97.121A specifies toe or toes. So even if Steve crushed all four of the lesser toes, we would still only report one code.

We would also want to report the falling sink as the cause of Steve’s injuries, so we would also report W20.8XXA (other cause of strike by thrown, projected or falling object).

That appears to be our last do-it-yourself project injury. Just remember if you undertake any home repairs or improvements, watch out for falling objects, falling people, and easily startled felines.

Coding for the zombie invasion

Braaaaains!

Braaaaains!

Don’t look now, but the Centers for Disease Control and Prevention was right about the zombie apocalypse. It’s here! Run for your lives!

Okay, we’re not about to be overrun by brain-munching undead. But as it turns out, several diseases could turn you into a zombie, if you got them all at once. Really, what are the chances of that happening? Let’s look at the diseases and see how we would code them in ICD-10-CM. Then we’ll be prepared when the zombie do eventually attack.

First up is sleeping sickness. Odds are you won’t see these cases very often because it is more prevalent in Africa. Sleeping sickness is caused by the parasite Trypanosoma brucei and transmitted by the tsetse fly.

When we look up sleeping sickness in the ICD-10-CM alphabetic index, we’re directed to sickness, sleeping. Really? They couldn’t just include it under sleeping sickness? Oh well, it’s only one page away in the 2012 index. It turns out we have three choices for sleeping sickness:

• B56.0, Gambiense trypanosomiasis
  • Infection due to Trypanosoma brucei gambiense
  • West African sleeping sickness
• B56.1, Rhodesiense trypanosomiasis
  • East African sleeping sickness
  • Infection due to Trypanosoma brucei rhodesiense
• B56.9, African trypanosomiasis, unspecified
  • Sleeping sickness NOS

So we need to know where our patient was when bitten by the tsetse fly. Avoid the unspecified unless you have no choice.

Although no current medically recognized disease causes cannibalism, rabies could cause a zombie wannabe to seek out brains. Here again we need to know where our patient was when infected—an urban environment or a wooded one.

• A82.0, sylvatic rabies
• A82.1, urban rabies
• A82.9, rabies, unspecified

We also have some other choices under rabies when we look in the alphabetic index. The patient could have been exposed to rabies or come into contact with it, but not contracted it. In that case, we would report code Z20.3. Maybe our patient is trying to avoid becoming a zombie and received a rabies vaccine. That could lead to an inoculation reaction. The ICD-10-CM index directs us to complications, vaccination to find the code for the adverse reaction.

What about the rotting flesh look most zombies fashion? That can be explained by necrosis. Technically, it’s not a disease but a condition with a lot of different possible causes—cancer, poison, injury, and infection among them.

But just to be sure we’re prepared; we’ll consider this as a cause of zombie-itis. We need a lot of information in order to code necrosis. The codes for necrosis are spread throughout the ICD-10-CM manual, depending on where the condition occurs.

For example, if our zombie showed necrosis of the jaw, which would explain the gaping mouth, we would report M27.2. If the necrosis occurred in the cornea (hence the poor eyesight), we would code H18.40 (unspecified corneal degeneration).  Even though the code doesn’t require laterality, it’s a good idea for the physician to document it. After all, you never know when your zombie will return.

The physician also needs to document all of the sites where necrosis occurs so we can report all of them, internal and external.

What is causing our zombie’s shuffling gait? Could it be Hansen’s disease, aka leprosy? And yes, if you look up Hansen’s disease, the index directs you to leprosy, but if you look up leprosy, you’re in the right place. Assuming of course, the physician documents the type of leprosy our zombie contracted.

• A30.0, indeterminate leprosy
• A30.1, tuberculoid leprosy
• A30.2, borderline tuberculoid leprosy
• A30.3, borderline leprosy
• A30.4, borderline lepromatous leprosy
• A30.5, lepromatous leprosy
• A30.8, other forms of leprosy
• A30.9, leprosy, unspecified

Remember that other forms of leprosy and unspecified leprosy are two different things. If we code A30.8, we know what type of leprosy our zombie has, but ICD-10-CM doesn’t include a code for it. We would only report A30.9 if the physician didn’t document the type of leprosy and our query was unsuccessful.

Let’s move on to our final sign of zombie-itis, the noises emulating from our zombie, specifically those moans and grunts. Turns out our zombie could be suffering from dysarthria, which is a disorder affecting the motor controls of human speech.

Before we can code, we need to know what caused it. A complete medical history is a must. So is complete documentation. It doesn’t do us any good if the physician knows this information but doesn’t write it down.

Did our zombie suffer a nontraumatic intracerebral hemorrhage? If so, we would code I69.122. Maybe the dysarthria developed after a nontraumatic subarachnoid hemorrhage (I69.022), some other nontraumatic intracranial hemorrhage (I69.222), or possibly a cerebral infarction (I69.322).

So basically, as long as none of your patients come in with sleeping sickness, rabies, necrosis , leprosy, and dysarthria, you should be safe from zombies. But it wouldn’t hurt to put together one of the CDC’s zombie preparedness kits.