For inpatient coders, it is imperative that medical diagnoses are coded correctly and in proper sequence due to the importance of the correct diagnosis-related group (DRG) assignment. It is the coder’s responsibility to be sure all the reported procedures are fully supported by the documentation. Coders must verify whether a procedure was performed as planned because this directly impacts the DRG and reimbursement. When reviewing the provider’s operative report, coders should make note of key words throughout the documentation, such as aborted, attempted, abandoned, failed, incomplete, unsuccessful, etc. These key terms alert the coder that a procedure was canceled or discontinued. Per coding guidelines, coders are instructed to code the procedure to the root operation that was successfully performed. If the procedure was canceled before any other root operation was performed, then it is appropriate to code to the root operation Inspection of the body part or anatomical region inspected.

The thoracentesis was aborted, but the provider was able to successfully complete imaging.

AMA and the CDC have been working very closely together to continue accurately tracking, reporting, and analyzing the administration of COVID-19 vaccinations. It is their belief that data-driven planning and resources allocation is vital for effective immunization programs that will hopefully bring the coronavirus pandemic to an end. Per CPT updates for FY 2022, there are new CPT codes that are effective immediately for use now that a third dose shot of the Pfizer and Moderna COVID-19 vaccines have received emergency use authorization for certain patients with compromised immune systems. The vaccine administration CPT code and long descriptor reads as follows:

0003A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; third dose.

0013A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; third dose.

Per Official Guidelines for Coding and Reporting, there is updated guidance in section I.B.14. “Documentation by Clinicians Other than the Patient’s Provider”. This updated guidance states that medical coders may capture diagnosis codes based on medical record documentation from clinicians who are not the patient’s provider. In these instances, documentation from clinicians (such as dietitians, nurses, or emergency medical technicians just to provide a few examples) may provide more specific information that is missing in the attending provider’s notes. For example, if the attending provider documents that the patient has morbid obesity but does not include the body mass index (BMI), then it is appropriate to capture the BMI code assignment if it is located elsewhere such as in the dietitian’s documentation. However, if the attending provider did NOT document morbid obesity, then it is NOT appropriate to capture the associated diagnosis (morbid obesity) from the dietitian’s documentation. That diagnosis must be documented by the patient’s provider. Whenever there is conflicting documentation from the patient’s provider and other clinicians, then the patient’s provider must be queried for clarification.

It is important for medical coders to code diagnoses to the highest level of specificity. This guidance also pertains to laterality diagnosis codes. Per ICD-10-CM Official Guidelines for Coding and Reporting FY 2022, medical coders are instructed to assign separate codes for both the left and right side when the condition is bilateral but there is not a bilateral code available. If the side is not identified in the medical record, then coders should assign the code for the unspecified side. New updated guidance for FY 2022 states that it is appropriate for coders to base the laterality diagnosis code on medical documentation from other clinicians if the patient’s provider is missing this information. When coders are presented with conflicting medical record documentation, they should query the attending provider for clarification.

Starting January 1, 2021, AMA implemented new guidelines for Evaluation and Management (E/M) coding. These changes ONLY pertain to office/outpatient visits that fall within CPT code range 99202-99205 and 99211-99215. Per the new guidance, providers will have the opportunity to report their E/M level based on medical decision making (MDM) or time. When selecting an E/M level based on MDM, it is very important that their documentation supports that E/M code pertaining to the revised MDM chart. Coders are responsible for validating this information on the front-end, which helps to avoid unnecessary denials.

Leveling for MDM is based on 2 out of 3 elements. Documentation supports moderate number of problems addressed with 2 stable chronic illnesses and moderate risk of complications with prescription drug management. This constitutes a level 4 E/M service.

Per coding guidelines, it is accurate to interpret the word “with” or “in” as “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note. Therefore, conditions that fall under this guideline have an assumed causal relationship and should be reported as related even if the provider does not specifically link the two conditions together. For example, diabetes and chronic kidney disease are two conditions that should be linked together unless a provider’s documentation clearly states that they are not related to one another. If a provider documents a patient having diabetes and chronic kidney disease, then a coder should report E11.22, diabetes with chronic kidney disease and N18.9, chronic kidney disease, unspecified. It is important for coders to understand this guideline pertaining to the word “with” in order to report diagnoses as accurately as possible and ensure clean claims before proceeding to billing.

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.

J91.8 is an acceptable secondary diagnosis because of the additional x-ray to assess the volume

A deep inferior epigastric perforator (DIEP) flap procedure is a type of breast reconstruction surgery that does not require incisions to be made within the muscles. Instead, surgeons use a free flap of complete tissue from the blood vessels (perforators), skin, and fat from the lower abdomen. Sometimes, a surgeon may complete a mastectomy prior to completing a DIEP procedure. Other times, a surgeon may remove a tissue expander prior to completing a DIEP procedure.

When coding DIEP procedures, it is important for medical coders to read the entire operative report. Be sure to thoroughly review each sentence in the provider’s note so that all components are fully captured.

When multiple biopsy techniques are performed during the same encounter, it is important to understand the guidance pertaining to proper sequencing of the CPT codes. It is appropriate to only report ONE primary lesion biopsy CPT code (11102, 11104, or 11106). Additional biopsy codes should be assigned as well as proper add-on codes. Incisional biopsies take precedence over punch and tangential biopsy procedures. When reporting these three procedures, coders should report CPT 11106 first for the primary incisional biopsy. CPT 11105 or 11103 should be reported secondly as additional add-on codes.

When coding medical cases pertaining to transgender individuals, there is certain criteria that a provider must meet within their documentation for the patient to have the medical procedure fully covered by their insurance. There must be a final diagnosis in the provider’s documentation for gender dysphoria. The formal diagnosis is gender identity disorder (GID), which is when a person experiences significant gender dysphoria. If this information is missing, then it is highly likely that the encounter will result in a denial. Please be sure to read the provider’s documentation fully to ensure all important information is captured when reporting final diagnoses and procedures for that encounter.

When coding spinal procedures in the inpatient setting, it is important that coders be sure to read the operative report in its entirety. There are missed coding opportunities that are buried in the body of the operative note, which makes it even more challenging for medical coders as they are reading medical cases. Be sure to code for all levels, approaches, discectomy, and harvesting of the autograft if it’s removed from a different site than the spinal fusion.

It is important for medical coders to adhere to all current coding guidelines pertaining to COVID-19 medical scenarios. Please remember that coding guidance for COVID-19 is very fluent. There are specific instructions on how to correctly sequence diagnoses for COVID-19 cases. Currently, when a patient is treated for COVID-19, returns to the hospital for further signs and symptoms (i.e. coughing), and has negative subsequent COVID-19 tests BUT provider documents a final diagnosis of Pneumonia due to COVID-19 virus, it is accurate to code that final diagnosis as it is documented. The coding guidelines state to sequence U07.1, COVID-19 as the principal diagnosis and J12.82, Pneumonia due to coronavirus disease 2019 as a secondary diagnosis. In this scenario, the pneumonia is an acute manifestation of COVID-19. Regardless of the patient’s current COVID-19 test results, U07.1 is sequenced first.

When coding diabetes, it is important that medical coders read the provider’s documentation thoroughly and understand what condition is being listed. In some cases, providers may state that patients have secondary diabetes. Secondary diabetes is a diabetic condition that develops after the destruction of pancreatic beta cells and/or hormonal syndromes that interfere with insulin secretion. A patient may have a disorder such as pancreatitis, cystic fibrosis, or pancreatic cancer that causes secondary diabetes. Pay close attention to sequencing instructions per coding guidelines. Per instructions under the Tabular index for category E08, it is accurate to report the underlying condition as the primary diagnosis and secondary diabetes (E08.-) as a secondary diagnosis. Before assigning the secondary diabetes diagnosis, be sure that the provider EXPLICITLY links the two conditions together.

It is important for medical coders to understand how to accurately assign atherosclerosis coronary artery disease (CAD) with angina. If the provider’s documentation states a patient has CAD with angina, then it is NOT appropriate to capture a diagnosis for both conditions separately. Per coding guidelines, it is appropriate to report the combination diagnosis code for CAD with angina pectoris. So since the combination diagnosis code is reported, there is no need to report the separate diagnosis code for angina pectoris.

There has been confusion across the board when it comes to correctly coding COVID-19. A lot of medical coders are not sure which diagnoses to assign nor how to appropriately assign them. When a provider documents that a patient has an allergic reaction to COVID-19 vaccine, it is NOT appropriate to assign a diagnosis from subcategory T80.62XA-, other serum reaction due to vaccination, initial encounter because the current approved COVID-19 vaccines in the United States are not serum based. For these encounters, it is appropriate to assign T78.49XA, other allergy, initial encounter as the primary diagnosis followed by any signs, symptoms, or definitive conditions as secondary diagnoses. Please keep in mind that COVID-19 guidance is fluid, so it may change in the future. However, this is proper protocol for now.

It is important for medical coders to understand when to accurately assign codes from category Z79, long-term (current) drug therapy. In order to assign a diagnosis from this subcategory, the provider’s documentation must support a patient receiving a medication for an extensive amount of time. If the provider’s documentation states a patient is receiving medication briefly to treat an acute illness or an as-needed basis (PRN), then it is NOT appropriate to capture a diagnosis from subcategory Z79.

It can be confusing for medical coders to know when it is appropriate to report a sign or symptom for outpatient encounters when a definitive diagnosis is listed. When deciding whether it is appropriate or not to report a sign or symptom, it is important to have a clear understanding of the provider’s documentation. Be sure to read the provider’s documentation fully to ensure the sign or symptom can be supported as a final diagnosis. If so, then it is accurate to report that sign or symptom.

It can be confusing for medical coders to know when it is appropriate to report an additional diagnosis when a combination diagnosis code is already reported. When reporting a combination diagnosis code, instructions in the tabular index may state “use additional code to identify specific condition”. The keyword in this guidance is SPECIFIC. If the documentation does not provide specificity, then the additional diagnosis is NOT appropriate for reporting along with the combination diagnosis code.

Anemia was specified, so the additional diagnosis is reported. Obesity was not specified, so only the pregnancy diagnosis for obesity is reported.

The ICD-10-CM Official Guidelines for Coding and Reporting has specific instructions pertaining to correctly reporting long term use of insulin and oral hypoglycemics. When a provider documents that a patient receives long term insulin or oral medications, it is appropriate to report either Z79.4, long-term (current) use of insulin or Z79.84, long-term (current) use of oral hypoglycemic drugs. However, when the provider documents that a patient receives both insulin and oral medications, it is appropriate to ONLY report a diagnosis code for the long-term use of insulin. It is important for coders to remember this guidance to prevent unnecessary errors when reporting all final secondary diagnoses.

For inpatient medical coders, it is important to follow the ICD-10-PCS coding guidelines when reporting medical procedures. Per coding guidelines, if a diagnostic biopsy is followed by a more definitive procedure, then it is appropriate to report both the biopsy and the more definitive treatment. When a provider’s documentation states that an excision, extraction, or drainage procedure (biopsy) was performed and a destruction, excision, or resection is completed as well at the same procedure site, then both procedures should be reported.

Chapter 21 of the ICD-10-CM coding guidelines houses the “Z” codes for medical coding. This chapter provides specific information and instructions about how to properly report factors that influence health status and contact with health services. In this chapter, there is direct guidance for how to accurately report screening diagnosis codes.

A screening involves testing for disease or disease precursors so that early detection and treatment can be provided for people who test positive for a disease. With screening exams, the patient is asymptomatic. Per guidelines, a screening code may be a first-listed code if the reason for the visit specifically pertains to the screening exam. When there are positive findings, this should be listed as secondary diagnoses. Please be sure to read a provider’s documentation in its entirety to determine the proper sequencing of the screening diagnosis code.

It is important for coders to remember this rule of thumb: etiology followed by manifestation. Coders are instructed by the coding guidelines to sequence the underlying condition first as the primary diagnosis (if applicable) followed by the manifestation. It is proper protocol for coders to follow the “use additional code” noted under the etiology code and the “code first” code noted under the manifestation code. These instructional notes were created to ensure that there is proper sequencing order of the diagnosis codes: etiology followed by manifestation. Think of it as a dream you want to manifest. The dream/desire/need is created first and then you follow that with manifesting it into your life.

When a patient has both depression and anxiety, it is important to remember that there is not an assumed relationship between the two conditions. If a provider’s documentation has not established a linkage between the depression and the anxiety, then it is appropriate to report F32.9, major depressive disorder, single episode, unspecified and F41.9, anxiety disorder, unspecified to capture both conditions. However, if a provider’s documentation DOES establish a linkage between the two conditions, then it is appropriate to assign the combination diagnosis code F41.8, other specified anxiety disorders to capture both conditions. This code assignment also includes anxiety depression and mixed anxiety and depressive disorder.

CPT Assistant indicates that when a lipoma is removed from the deeper subcutaneous layer, or beyond (fascia or muscle) then the appropriate code for removal will be found in the musculoskeletal section of the CPT manual. The index entry would be:
Excision
Tumor
Specific location

If the lipoma were located superficially, the removal of the lipoma would be coded to excision of a benign lesion. The appropriate code would fall into the CPT code range 11400-11446 based on location and size of the lipoma removed.

Coding specificity is a shared responsibility between the provider and the coding professional. As a medical coder, it is important to code to the highest level of specificity. This is a requirement for all medical coders. For example, if documentation states that a patient’s final diagnosis is myalgia – unspecified, but the history of present illness provides the anatomical site of the myalgia, the coder should assign the most specific code, using all pertinent documentation available in the note. Often, medical claims are denied by payers due to lack of specificity. To ensure that facilities avoid unnecessary denials, it is imperative to remember this rule of thumb about reporting diagnoses to the highest level of specificity supported by the documentation.

When coding professional evaluation and management (E/M) cases for office and other outpatient visits (CPT code range 99202-99205; 99212-99215), it is important to understand the revised 2021 guidelines for medical decision making (MDM).

Rationale: low number and complexity of problems being addressed with acute, uncomplicated illness; moderate amount of data to be reviewed and analyzed with independent interpretation of prior x-ray performed at an outside facility; lastly, moderate risk of complication with prescription drug management. Based on 2/3 for MDM elements, this would constitute as a level 4 visit.

As a medical coder, it is important to understand disease processes to accurately report diagnosis codes. Per the coding guidelines, signs and symptoms that are routinely associated with a disease process should NOT be captured when they are present in the documentation. However, if a sign or symptom is not routinely associated with a disease process, then it is appropriate to report that sign or symptom as an additional diagnosis.

Abdominal pain, nausea, and vomiting are all routinely associated with appendicitis. Since the headache is not associated with the disorder, then it is appropriate to assign it as a secondary diagnosis.

When reviewing operative notes for IVR procedures, it is extremely important that coders understand what is being completed and CPT guidelines about how to accurately report the procedures. Please review the scenario below and pay close attention to the bolded phrases that capture the corresponding CPT procedures.

“Ultrasound guided femoral vein access was performed bilaterally. A 10F and a 7F short sheath were placed on the left side. The intracardiac ultrasound was introduced into the 10F sheath and positioned in the right atrium. Echocardiographic study was performed and was completed a view of the interatrial septum was stabilized for referenced (CPT 93662). 3D electroanatomical mapping was performed using the St Jude Precision mapping system (CPT 93613).

Once all pulmonary veins and left atrial tissue geometry and voltage were collected, the veins were segmented. The HD GRID catheter was placed into each vein of interest. Wide area circumferential ablation was performed over the left and the right pulmonary veins. The posterior wall was isolated by connecting the superior and inferior pulmonary vein WACA lines (CPT 93656). Cardioversion was performed at 200J but was unsuccessful, and therefore a second cardioversion at 360J was performed. This successfully returned the patient to sinus rhythm, but he then developed atrial flutter.  Flutter appeared 2-1 and concentric. The ablation catheter was brought back to the right atrium and a long CTI line was performed at 30 W (CPT 93655). This was greater than 6 cm long line.  Tachycardia cycle length altered during the procedure.  Propagation mapping with the HD GRID in the left atrium showed mitral flutter. Therefore, the ablation catheter was brought back to the left atrium and a long mitral isthmus ablation line was performed at 35 W (CPT 96355).

IV adenosine bolus was administered and pacing from within each pulmonary vein was performed to ensure pulmonary vein exit block and lack of reconnection (CPT 93623).”

There are times where a cancer patient may be admitted for chemotherapy, radiation therapy, or immunotherapy and develops complications after admission. Coding instructions from ICD-10-CM Official Guidelines for Coding and Reporting state that the principal diagnosis is the encounter for the chemotherapy, radiation therapy, or immunotherapy followed by any codes for the complications as secondary diagnoses.

However, there are other times when a cancer patient may be admitted for insertion or implantation of radioactive elements (i.e. brachytherapy or external beam radiation) and develops complications after admission. For these types of encounters, coding guidelines instructs coders to list the appropriate code for malignancy followed by any codes for the complications as secondary diagnoses.

It is very important for coders to pay attention to the documentation when coding neoplasm accounts. There are two sets of instructions in the coding guidelines specifically pertaining to how to report signs and symptoms associated with neoplasms and pain associated with neoplasms. Section I.C.2.g. of the coding guidelines state symptoms, signs, and ill-defined conditions that are listed in Chapter 18 or are associated with an existing primary or secondary malignancy site CANNOT be used to replace the malignancy as principal diagnosis.  It does not matter how many times the patient is admitted or treated for the sign or symptom. The malignancy should be reported as the principal diagnosis.

However, if the patient has related pain associated or due to primary or secondary malignancy, then this condition CAN be assigned as the principal diagnosis when the reason for the admission is documented as pain control/management. Per coding guidelines in section I.C.6.b.5., if the documentation supports the patient being admitted and treated for the pain of the neoplasm, then it is appropriate to assign G89.3 as the principal diagnosis followed by the underlying neoplasm as a secondary diagnosis. If the documentation supports the neoplasm as the reason for admission and treatment and the pain is also documented, then it is appropriate to assign the neoplasm as the principal diagnosis followed by the associated pain as a secondary diagnosis.

When coding medical diagnoses such as atherosclerotic coronary artery disease with angina pectoris and acute myocardial infarction (AMI), it is important to remember the instructions from the coding guidelines. When a patient is admitted for atherosclerotic heart disease with angina pectoris, coders should use a combination diagnosis code from subcategories I25.11, atherosclerotic heart disease of native artery with angina pectoris and I25.7, atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris. It is incorrect to report a separate, additional code for the angina. The guidelines assume a causal relationship with both atherosclerosis and angina pectoris unless the provider specifically states that the angina is due to another disorder.

When a patient is admitted for atherosclerotic coronary artery disease due to an AMI, then it is proper protocol to sequence the AMI before the coronary artery disease.

When coding inpatient procedures, it is very possible that a coder will have to report multiple procedures for one encounter. It is important for coders to remember the directive about how to properly capture multiple procedures. Per the ICD-10-PCS Official Guidelines for Coding and Reporting FY 2021 Section B3.2, multiple procedures are reported if:

• The same root operation is performed on different body parts as defined by distinct values of the body part character (i.e. excision of
• The same root operation is repeated in multiple body parts, and those body parts are separate and distinct body parts classified as a single ICD-10-PCS body part value
• Multiple root operations with distinct objectives are performed on the same body part
• The intended root operation is attempted using one approach but is converted to a different approach

When coding adult and child abuse, neglect, and other maltreatment, it is important to understand the proper sequencing of the diagnoses. Per ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, it is appropriate to assign a diagnosis from subcategory T74, adult and child abuse, neglect, and other maltreatment, confirmed or T76, adult and child abuse, neglect, and other maltreatment, suspected as the primary diagnosis. All other mental health or injury codes should be sequenced as secondary diagnoses. Be sure that the documentation clearly states whether the abuse was confirmed or suspected. For confirmed cases, it is appropriate to report an external cause code from the assault section (X92-Y09) and a perpetrator code (Y07) when the perpetrator of abuse is known. This guidance ONLY applies to confirmed cases.

The coding guidelines provide specific guidance on how to accurately report complications of diabetes mellitus due to insulin pump malfunction. For an underdose of insulin due to insulin pump failure, a diagnosis from subcategory T85.6, mechanical complication of other specified internal and external prosthetic devices, implants, and grafts should be sequenced as the principal diagnosis followed by code T38.3X6-, underdosing of insulin and oral hypoglycemic [antidiabetic] drugs as a secondary diagnosis. It is appropriate to assign additional diagnoses for the type of diabetes and any associated complications due to the underdosing as well. For an overdose of insulin due to insulin pump failure, a diagnosis from T85.6 should be reported as the principal diagnosis as well followed by code T38.3X1-, poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentional).

With a deep inferior epigastric perforator (DIEP) procedure, fat, skin, and blood vessels are cut from the wall of the lower belly and moved up through a person’s chest to rebuild the breast. When coding a DIEP procedure, it is important to remember that the harvesting of the flap is NOT coded separately. With this procedure, the “Replacement” code fully specifies the fact that an autograft was harvested, and the qualifier value describes the DIEP flap.

Acute respiratory failure occurs when fluid builds up in the air sacs in the lungs. During this occurrence, lungs are unable to release oxygen into the blood. In return, the organ cannot get enough oxygen-rich blood to function properly. With a lot of medical scenarios, it is common to see acute respiratory failure listed as a secondary diagnosis; however, there are some cases where this condition can be sequenced as the principal diagnosis. Acute respiratory failure can be coded as the principal diagnosis if it meets the definition and is clinically supported in the medical record. It all boils down to the circumstances of admission, any diagnostic workup and/or therapy provided, and whether there are any coding conventions or guidelines that give direction to code otherwise.

A lot of incision and drainage procedures involve draining areas of the skin and subcutaneous tissues; however, there are some cases where the surgeon goes deeper into the fascia, muscle, bone, joint, or internal organ. When reviewing the operative report, it is important to understand the intent of the procedure, how many procedures are being completed, the depth of the procedure, and the type of device that is being used during the treatment.

When reviewing medical records pertaining to incision and drainage/excision procedures, it is very important for a coder to locate documentation supporting the depth of the procedure. For ICD-10-PCS procedure codes, there are different codes provided for incision and drainage of skin and incision and drainage of subcutaneous tissue and fascia. To ensure that a coder is selecting the most appropriate code, it is imperative to have a firm understanding of skin vs subcutaneous tissue.

The skin is the outer layer of the body. The subcutaneous tissue is the deepest layer underneath the skin. When coding incision and drainage/excision procedures, it is important to code to the deepest layer. If a provider’s documentation states that an incision and drainage/excision was performed on skin and subcutaneous tissue, then it is appropriate to report the PCS code for the subcutaneous layer.

Sometimes, newborns are admitted for observation and evaluation of suspected conditions. Per ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, it is appropriate to report a diagnosis code from category Z05, observation and evaluation of newborns and infants for suspected conditions ruled out. A code from this category identifies when a healthy newborn is evaluated for a suspected condition that is determined to not be present after the provider completes a full study of the newborn. Z05 should ONLY be reported if the newborn does not have any signs and symptoms. If the newborn has confirmed signs and symptoms of a suspected problem, then it is appropriate to report the signs and symptoms instead. Lastly, when Z05 is reported on a birth record, it is important to sequence the diagnoses correctly. A diagnosis from category Z38, liveborn infants should be reported as the primary diagnosis followed by a code from category Z05 as a secondary diagnosis.

When a patient enters the emergency department (ED), an intravenous (IV) site full of pre-packaged fluids and electrolytes is typically started for the purpose of providing hydration. Hydration is basically the replacement of necessary fluids. As a medical coder, it is very important to have a firm understanding of when to report and how to accurately report hydration procedures. Some of the solutions that are administered for hydration are saline solutions, dextrose 5% water (D5W), hypotonic solution, ringer lactate, and distilled water (DW).

In order to properly report hydration procedures, it is important to have a firm understanding of when and how to report them. Hydration services are NOT reportable when the fluid is used to flush an IV line prior or subsequent to another infusion; when the fluid is used as the diluent to mix the drug; and when the hydration’s purpose is to accommodate a therapeutic IV piggyback through the same IV site as a free-flowing IV.

On the other hand, hydration services can be reported if the hydration is administered before or after a therapeutic or prophylactic drug infusion and chemotherapeutic service. It is very important that there is clear supporting documentation from the provider showing medical necessity for the hydration. Signs and symptoms such as dehydration or nausea with vomiting needs to be documented for proper reporting of a hydration procedure.

Per ICD-10-PCS Official Guidelines for Coding and Reporting FY 2021, section B3.3 instructs to code the procedure to the root operation performed if the intended procedure is discontinued or otherwise not completed. Furthermore, the code root operation Inspection of the body part or anatomical region inspected should be reported if a procedure is discontinued before any other root operation is performed.

Selection of the principal diagnosis is crucial for correct DRG assignment and reporting of the patient’s condition. When a patient is converted from a medical or surgical Observation status to an Inpatient, the principal diagnosis should be the condition that necessitated Inpatient admission. Per ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, the principal diagnosis is defined as “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” This diagnosis may be different from the reason for the initial Observation care.

Direct guidance from the coding guidelines state that either condition may be sequenced first when two or more interrelated conditions potentially meet the definition of principal diagnosis. The interrelated conditions refer to diseases in the same ICD-10-CM chapter or manifestations characteristically associated with a certain disease. The ONLY exception to this rule is when the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise. If there are no chapter-specific guidelines or instructional notes under the code description for sequencing, then either condition can be listed as the primary diagnosis.

Effective December 2020, The U.S. Food and Drug Administration (FDA) issued the first emergency use authorization for a vaccine for the prevention of COVID-19 in individuals 16 years of age and older. During the clinical trials, The Pfizer/BioNTech was 95% effective at preventing laboratory-confirmed COVID-19 illness in people without evidence of previous infection. Currently, the FDA is working on approving a second vaccine for immediate emergency use called Moderna. It is hopeful that this vaccine will have the same outcome as the Pfizer vaccine.

Both vaccinations have their own unique vaccine and administration codes. Both vaccines have two administration codes since they both will be administered in two doses via intramuscular method. The American Medical Association (AMA) has already created CPT codes for reporting the COVID-19 vaccines.

The vaccine code for Pfizer/BioNTech is 91300, and the administration codes are 0001A (for the first dose) and 0002A (for the second dose). The vaccine code for Moderna is 91301, and the administration codes are 0011A (for the first dose) and 0012A (for the second dose).

Effective immediately as of January 1^st, 2021, there are new diagnosis codes pertaining to COVID-19!

Z11.52, encounter for screening for COVID-19 (previously used Z11.59; reported for people who are asymptomatic and test negative)

Z20.822, contact with and (suspected) exposure to COVID-19 (previously Z20.828)

Z86.16, personal history of COVID-19 (previously used Z86.19)

J12.82, pneumonia due to coronavirus disease 2019 (previously used J12.89). Includes the inclusion terms, “pneumonia due to COVID-19” and “pneumonia due to severe acute respiratory syndrome coronavirus 2”. Existing coding guidance (prior to 1/1/21) for COVID-19-related pneumonia instructs coders to report two ICD-10-CM codes for the condition: U07.1 (COVID-19) and J12.89 (other viral pneumonia). As of 1/1/21, AHA now recommends that BOTH U07.1 and J12.82 be reported for viral pneumonia due to COVID-19.

M35.81, multisystem inflammatory syndrome (previously used M35.8)

The information is fluid, and we are currently staying abreast. We will be sure to distribute more details once we discover more information.

A discontinued procedure is one that is canceled or not fully accomplished under the procedure definition. Per ICD-10-PCS Coding Guidelines Section B3.3, it is appropriate to code the procedure to the root operation performed if the intended procedure is discontinued. If a procedure is discontinued before any other root operation is performed, then the code root operation Inspection of the body part or anatomical region inspected. It is the coder’s responsibility to recognize whether a procedure was performed in its entirety in order to properly code it.

When reviewing the provider’s documentation, it is important to look for key words that highlight a discontinued procedure (such as aborted, attempted, abandoned, failed, incomplete, or unsuccessful). Here are a couple of helpful coding tips when reviewing medical record documentation:

• Read the operative report fully to see if the planned procedure was performed.
• If the planned procedure was not performed, then be sure to code the procedure to the root operation performed. Be sure that the root operation identifies the main objective of the procedure.

The perinatal period is defined as before birth through the 28^th day following birth. Coders should utilize chapter 16 ICD-10-CM coding guidelines when coding newborn records. When coding the birth episode in a newborn record, a code from category Z38, liveborn infants should be assigned as the principal diagnosis. Coding guidelines also instruct coders to code all clinically significant conditions noted on routine newborn examinations. A condition is clinically significant if it requires clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, increased nursing care, or implications for future health care needs.

Per FY 2021 ICD-10-CM Guidelines for Coding and Reporting, there is updated information in the section pertaining to the chapter specific guidelines for coding diabetes mellitus. This information can be reviewed under section I.C.4.a.3. titled “Diabetes mellitus and the use of insulin, oral hypoglycemics, and injectable non-insulin drugs” and section I.C.4.a.6. titled “Secondary diabetes mellitus”.

“If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11-, Type 2 diabetes mellitus, should be assigned. An additional code should be assigned from category Z79 to identify the long-term (current) use of insulin or oral hypoglycemic drugs. If the patient is treated with both oral medications and insulin, only the code for long-term (current) use of insulin should be assigned. If the patient is treated with both insulin and an injectable non-insulin antidiabetic drug, assign codes Z79.4, Long-term (current) use of insulin, and Z79.899, Other long term (current) drug therapy. If the patient is treated with both oral hypoglycemic drugs and an injectable non-insulin antidiabetic drug, assign codes Z79.84, Long-term (current) use of oral hypoglycemic drugs, and Z79.899, Other long-term (current) drug therapy. Code Z79.4 should not be assigned if insulin is given temporarily to bring a type 2 patient’s blood sugar under control during an encounter.”

Sometimes, there is confusion about when to assign the seventh character for diagnosis codes S00-T88 with “A” for initial encounter or “D” for subsequent encounter. “Initial encounter” for an injury does not always equate to an “initial visit.” Per Chapter 19 of FY2021 ICD-10-CM Official Guidelines for Coding and Reporting, assignment of the seventh character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time.

Some examples of active treatment are surgical treatment, emergency department encounter, and evaluation and treatment by a new physician. Some examples of routine care during the recovery phase are cast change or removal, removal of external or internal fixation device, medication adjustment, and other aftercare and follow up visits following injury treatment.

In conclusion, active treatment occurs when the provider sees the patient and develops a plan of care. The patient following that plan is when a subsequent encounter occurs. If the patient is receiving active treatment for their condition, then it is appropriate to assign “A” for the seventh character. If the patient has completed active treatment for their condition but is receiving routine care during the healing or recovery phase, then it is appropriate to assign “D” for the seventh character.

In the medical coding field, there is often confusion about when to report the National Institutes of Health Stroke Scale (NIHSS) and Glasgow Coma Scale (GCS) scores. Per FY2021 ICD-10-CM Official Guidelines for Coding and Reporting, a GCS score (R40.2-) is used in conjunction with traumatic brain injury to identify the severity of an acute brain injury. On the other hand, a NIHSS score (R29.7–) is used in conjunction with acute stroke codes (I63) to identify the patient’s neurological status and severity of the stroke.

Both scores are to be sequenced after the traumatic brain injury code (for GCS) or acute stroke code (for NIHSS).

Observation care reporting can be a challenging area of medical coding. Patients are commonly ordered for observation services when they present to the emergency department and then require an extensive period of treatment/monitoring in order to determine their admission or discharge. Here are some helpful tips on how to successfully report observation service codes:

1. Initial observation services are per calendar date, not per 24-hour period. Do not rely on length of stay in making determination of the correct CPT code.
2. Confirm patient status. It is important to know whether the patient is in the hospital under “observation” status or “inpatient” status.
3. The second day of observation begins at 12 A.M. even if the initial observation services were provided just an hour earlier. Second day of observation care should be reported with office or other outpatient visit codes 99211-99215.
4. Physician documentation is key! Be sure that the provider’s documentation is concise and supports the observation service codes that are being reported.

Sick sinus syndrome (SSS) is a disorder of the heart’s natural pacemaker. Typically, SSS is treated with an implanted pacemaker. A pacemaker consists of a small, battery-powered generator and one or more leads. With a single-chamber system, only one lead is used. With a double-chamber system, two leads are used and placed in the right atrium and right ventricle.

ICD-10-PCS Codes: 0JH606Z, Insertion of pacemaker generation, 02H63JZ, insertion of device in atrium, and 02HK3JZ, insertion of device in ventricle

CPT Codes: 33208, insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular

Interventional radiology (IVR) uses minimally invasive image-guided procedures (such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound) to diagnose and treat diseases inside of the body. There is much less risk, pain, and recovery time for IVR procedures compared to open surgeries. A lumbar puncture (sometimes referred to as a spinal tap) is an example of an IVR procedure that reveals if the amount of protein, white blood cells, or myelin is too high in your body. It can also reveal if the fluid in your spine contains an abnormal level of antibodies. By analyzing this fluid, the physician can diagnose the patient with a condition.

For FY2021 ICD-10-CM Official Guidelines for Coding and Reporting, CMS revised the guideline for the Glasgow Coma Scale (GCS). Per the updated guidance, “The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes. These codes are primarily use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis code(s).”

Per the updated guidelines, the GCS score will NO longer be applicable to acute cerebrovascular disease or sequelae of cerebrovascular disease codes starting with October 1^st, 2020 discharges. Furthermore, the GCS score may NOT also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition.

There may be further clarification with this updated guidance in the AHA Coding Clinic for Fourth Quarter 2020. However, for now, these are the official updated guidelines for GCS score.

The main factor when considering whether a procedure is diagnostic or therapeutic is to determine the objective of the procedure. If the main objective is to establish a diagnosis for the patient prior to starting any kind of treatment, then it is considered to be a diagnostic procedure. If a diagnosis is already established and a procedure is completed in order to eradicate a problem, then it is considered to be a therapeutic procedure. For drainage root operations, the ICD-10-PCS guidelines state that if a diagnostic procedure is followed by a more definitive procedure (therapeutic) then both the diagnostic and more definitive treatment are coded.

Cirrhosis is the most common type of liver disease. Most of the patients who have cirrhosis develop esophageal varices due to scarring throughout the liver. Since the esophageal varices are due to the scarring (which is caused by cirrhosis), cirrhosis is sequenced as the primary diagnosis followed by varices as a secondary diagnosis. Also, coders should be sure to follow the instructional note under I85.11 that states to “code first underlying disease”.

When reviewing cases with esophageal varices, please be sure to look for documentation specifying the underlying cause. If the provider does NOT document the etiology of the varices, please query for clarification.

When an obstetric patient is admitted to a hospital for complications of pregnancy during one trimester and remains in the hospital into a subsequent trimester, then it is appropriate to report the trimester character for when the complication developed. For example, if a patient is admitted into inpatient status for a complication during their second trimester but is in their third trimester at the time of discharge, then the correct character assignment for the antepartum complication code should be for the second trimester.

It is the responsibility of the inpatient coder to assign a Present on Admission (POA) Indicator for all principal and secondary diagnosis codes as defined in Section II of the Official Coding Guidelines. The “Y” indicator is for when a diagnosis is present at the time admission while the “N” indicator is for when a diagnosis is not present at the time of inpatient admission. The “U” indicator is for when documentation insufficient to determine if condition is present at the time of inpatient admission. Lastly, the “W” indicator is for when a provider is unable to clinically determine whether the condition was present at the time of inpatient admission.

According to the POA Reporting Guidelines, the coder should assign “N” if at least ONE part of the clinical concepts included in the code was NOT present on admission. This would also be appropriate for primary diagnoses. Here are a few examples of these instances below:

Alcohol dependence when withdrawal symptoms occur after admission

Chronic obstructive pulmonary disease when exacerbation occurs after admission

Gastric ulcer when bleeding occurs after admission

Asthma when asthmaticus occurs after admission

Duodenal ulcer when the perforation occurs after admission

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: