Coding incision and drainage procedures can often be very frustrating! The key is to break down the procedure(s) into pieces.

Key tips to ask yourself while coding incision and drainage procedures:

• Understand the INTENT of the procedure. What is the physician’s objective?
• Ask yourself how many procedures are being completed. Is it only one or multiple procedures?
• Locate the depth of the procedure. Did it stop at the skin, or did the procedure continue further to the muscle or the joint?
• Ask yourself about the type of device that is being used. What is the device? What is the device’s purpose.

Gastrointestinal (GI) bleeding is not a disease but a symptom of a disorder in a person’s digestive tract. There are many possibilities that may cause GI bleeding, including hemorrhoids, peptic ulcers, diverticulosis/diverticulitis, ulcerative colitis, Crohn’s disease, colonic polyps, or gastritis (just to name a few examples). Per ICD-10-CM Official Guidelines for Coding and Reporting Section I.A.15 “With” guideline, it is safe to presume a causal relationship between two conditions when it is linked by the term “with” or “in” when it appears in a code title. In that case, when a provider documents that a patient has one of the previously mentioned conditions (among other conditions) and GI bleeding, then it is appropriate to assume a relationship between the disorder and bleeding. The ONLY time it is not acceptable is when documentation clearly states that the conditions are unrelated or if the physician documents a different cause of the bleeding.

Selecting the principal (primary) diagnosis is one of the most important steps when coding a medical record. It is very important that a medical coder uses a patient’s entire medical record to determine the selection of a principal diagnosis and not rely solely on the admission information nor discharge summary. Selecting the correct principal diagnosis reduces compliance risk while capturing reimbursement and medical diagnosis codes with integrity. The Uniform Hospital Discharge Data Set (UHDDS) defines principal diagnosis as “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” It is important to review all parts of the medical record (history and physical, progress notes, orders, consultation notes, operative reports, and discharge summary) in order to ensure that the correct principal diagnosis is reported.

“When reviewing medical records where the physician has documented that a patient has both an intrathoracic injury and a rib fracture, it is important to remember that the intrathoracic injury is sequenced first followed by the rib fracture diagnosis. Per instructional note for diagnosis codes that fall under the range of S22, it is advised to code first any associated injury of intrathoracic organ (S27.-) or spinal cord injury (S24.0-, S24.1-).

Wound debridement is a medical procedure that removes infected, damaged, or dead tissue. The physician’s documentation needs to be descriptive enough to create a very clear picture of the procedure performed. Here are some important tips for reporting wound debridement procedures:

• Technique used: scrubbing, brushing, washing, trimming, or excisional
• Instruments used: scissors, scalpel, brushes, curette, etc.
• Nature of tissue removed: necrosis, devitalized tissue, non-viable tissue, slough, etc. (excisional, selective, or nonselective)
• Appearance and size of wound: fresh bleeding tissue, viable tissue, etc.
• Depth of debridement: skin, fascia, subcutaneous tissue, soft tissue, muscle, or bone
  • The depth of debridement is determined by the deepest depth of removed tissue. A patient’s wound may extend to the bone, but the physician may only remove the subcutaneous portion. In this case, the depth of the debridement is to the subcutaneous tissue only.

Sometimes, coders will come across lumbar spinal fusion procedures that involve both anterior and posterior approaches. Typically, there is an incision in the front of the body through the abdomen (anterior) and then another incision in the lumbar or lower back region (posterior).

Are you often stumped with deciding whether to code gastrointestinal (GI) conditions with or without bleeding? The cause for GI bleeding isn’t always easily determined; however, there’s guidance from the coding guidelines that help us with selecting the proper diagnosis codes in these cases. Let’s review…

If two conditions are linked by the terms “with” or “in” in the Alphabetic Index or instructional note in the Tabular List, then there’s a presumed causal relationship between those conditions. The ICD-10-CM Coding Guidelines FY 2020 Section I.A.15 state “these conditions should be interpreted to mean “associated with” or “due to” when it appears in the code title UNLESS the provider documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between the two conditions.

The following are some common conditions that have a causal relationship with GI bleeding: peptic ulcers, varices, gastritis, colitis, duodenitis, diverticulosis/diverticulitis, colon or rectal polyps, angiodysplasia, ulcerative esophagitis or esophageal ulcerations, intestinal tumor or malignancy, and trauma.

History codes are reported when a physician’s documentation specifies that a patient no longer has a condition. There is not a particular timeframe for personal history conditions; if a patient is diagnosed with pneumonia but no longer has pneumonia during a follow-up visit, then a coder would assign a code for personal history of pneumonia. This same rule applies when reporting personal history of COVID-19. U07.1, positive COVID-19 is ONLY reported if documentation supports a confirmed diagnosis. If it is documented that the patient was positive for COVID-19 weeks ago but no longer has the condition during their current encounter, then the coding guidelines state that a personal history code should be reported.

Accurately coding cancer diagnoses all depends on clear documentation from the provider. How do you know when cancer is historical or active? Cancer is considered to be active when the patient is currently and actively being treated and managed for cancer (i.e. current chemotherapy, current pathology revealing cancer, or newly diagnosed patient awaiting treatment).On the other hand, cancer is considered to be historical when the cancer was successfully treated and patient is no longer receiving treatment (i.e. cancer was excised or eradicated, patient using adjuvant therapy for prophylactic purposes, or patient is under surveillance of recurrence).

When a patient is admitted for management of respiratory manifestations of COVID-19 and is also status-post lung transplant, the coding guidelines state that lung transplant infection diagnosis should be sequenced as the primary diagnosis followed by U07.1, COVID-19 as a secondary diagnosis. It is VERY important to pay attention to the sequencing of the diagnoses. The Tabular List note at the lung transplant infection code states to “use additional code to specify infection”, and coding guidelines state “a transplant complication code is only assigned if the complication affects the function of the transplanted organ.” In this scenario, the COVID-19 infection has affected the function of the transplanted lung.

When coding spinal fusion procedures, it is important to determine which procedures are integral and which are not integral. If the procedure is considered to be integral, then additional, separate codes are NOT assigned. If the procedure is not considered to be integral, then it is appropriate to assign separate codes.

*Pedicle screw instrumentation is included in the spinal fusion.

The Glasgow Coma Scale (GCS) is used to assess reduced levels of consciousness in patients. It is the most reliable way to objectively record the initial and subsequent level of consciousness in a person after a brain injury. It is comprised of three components that are considered separately and summed: eye opening (E), verbal response (V), and motor responses (M). The GCS provides a score in the range of 3 (deep coma or brain death) – 15 (fully awake and aware), and patients that have a score of 3-8 are usually defined as being in a coma. Please pay close attention to physician’s documentation in order to capture the accurate GCS score. If documentation does NOT state the total coma score, then a diagnosis code from subcategory R40.24 should NOT be assigned.

This equation simply states that the eye opening measured at a level 2, verbal response measured at a level 4, and motor response measured at a level 6. The sum of all three components results in a total of 12. The number 12 is the GCS score for this patient.

Spinal Fusion coding can be an area of apprehension for a lot of coders! Coding opportunities sometimes are buried within the body of operative reports which makes it even more challenging. First and foremost, be sure to read the entire report to capture all pertinent codes.

Consider the following snippet, which comes from an actual operative report and supports the assignment of 0SG0071 (fusion of lumbar vertebral joint with autologous tissue substitute, posterior approach, posterior column, open approach):

“I then loaded the tulip-heads onto the screw shanks, and I then placed a Creo addition titanium rod. Posterior instrumentation replaced from the L3-4 interspace modular loading cross connector to L1 pedicle screw. I contoured lordosis in the back table before placement into the Tulip head. Final tightened compressed at L1-2. I used a high-speed bur to decorticate the facet on the left side at L1-2, and the transverse process bilaterally of L1-L2 and placed local bone and osteosurge to complete a posterolateral fusion.”

Telehealth services allow a physician or other approved licensed care provider with the ability to provide services and effectively communicate with their patients via secure telecommunication devices. As of April 30, 2020, CMS has expanded the list of approved telehealth services to include physical therapy (PT), occupational therapy (OT), and speech therapy (ST). Please be sure to check with individual third-party payers about their policies in order to receive full reimbursement.

Pleural effusion is a typical disorder that is seen in patients who have congestive heart failure. It is an abnormal accumulation of fluid within the pleural space. If the physician completes therapeutic intervention or diagnostic testing for the pleural effusion, then it is acceptable to report it as a secondary diagnosis. If the physician does NOT specifically evaluate or treat the pleural effusion separately from the congestive heart failure, then it should NOT be reported as a secondary diagnosis.

When a patient presents to the hospital for treatment of multiple injuries, it is appropriate to code all of the injuries for accurate reporting purposes. All of the injuries should be reported separately unless there is a combination diagnosis code provided for those conditions. The injury that is sequenced first is the injury that is determined by the physician and focus of treatment to be the most serious.

Starting April 1, 2020, the World Health Organization (WHO) implemented a brand new ICD-10-CM diagnosis code: U07.0, vaping-related disorder. This is being implemented now due to the recent occurrences of vaping related disorders. For all discharge dates on or after April 1, U07.0 will be sequenced as the primary diagnosis IF the physician’s documentation states that the vaping caused the patient’s current condition. It is then followed by that condition as a secondary diagnosis code.

If a patient is admitted to a hospital with a pressure ulcer that progresses during the patient’s stay to another severity, then it’s appropriate to report two separate diagnosis codes. The first code is for the site and severity of the ulcer that was present on admission, and the second one is for the severity level that was reported during the stay.

On April 7, 2020, CMS proposed a new Families First Coronavirus Response Act. This act waives co-insurance and deductibles for additional COVID-19 related services. Under this act, CMS requires modifier CS applied to applicable institutional and non-institutional claim lines to identify that the service is subject to the cost-sharing waiver for COVID-19 testing-related services. This ensures that Medicare members are NOT charged any co-insurance or deductibles for those services as well.

When COVID-19 meets the definition for principal diagnosis, it should be sequenced first followed by all other appropriate secondary diagnoses. There is an exception for sepsis, obstetric, and newborn patients. However, if sepsis does NOT meet the guidelines for principal diagnosis, it should be sequenced as a secondary diagnosis. Please see the example below: