Cracking the Code


Coding COVID-19 Patient Lung Transplant Status

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.

U07.1, COVID-19


Patient presents to the ED with cough and shortness of breath. The patient has history of lung cancer and lung transplantation. The physician orders a lab to test for COVID-19, and the results are positive for the virus.


T86.812, lung transplant infection

ICD-10-CM Official Guidelines for Coding and Reporting FY 2020, Section I.C.19.g.3.a.

What NOT to Code for a Spinal Fusion

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.


A patient presents to the ED with severe lower back pain that continues to progress in severity. The physician orders a CT scan of the lumbar region. Final impression: degenerative disc disease L2-L5, herniated disc L4-L5, and scoliosis. The patient is admitted to inpatient status, and the physician performs a L2-L5 posterior lumbar interbody fusion using autologous bone graft, L2-L5 discectomy, L2-L5 pedicle screw instrumentation, and harvesting bone graft from right iliac crest through separate incision.


0SG107J, fusion of 2 or more lumbar vertebral joints with autologous tissue substitute, posterior approach, anterior column, open approach 0SB20ZZ, excision of lumbar vertebral disc, open approach 0QB20ZZ, excision of right pelvic bone, open approach

Coding Clinic 3rd Q 2014: Lumbar interbody fusion of two vertebral levels-correction


Coding Consciousness: What’s your GCS?

June 17, 2020

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.


Physician documents GCS 12 = E2 V4 M6 at 5:52 AM at hospital admission.


R40.2423, Glasgow coma scale score 9-12, at hospital admission

Reference: Coding Clinic 4th Quarter 2016, pgs. 64-65: Glasgow coma scale

Spinal Fusion Code Cautions

June 11, 2020

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.”

New Telehealth Therapy Reimbursements

June 4, 2020

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.


A 50-year-old Medicare patient consents to a remote evaluation service with their Physical Therapist. The patient has questions about whether they are performing the recommended exercises correctly. The patient records themselves and sends it off to the Physical Therapist for review via email. After reviewing the video, the Physical Therapist calls the patient on the telephone to provide further instruction on how to properly perform the exercise.


G2010 (remote evaluation of recorded video and/or images submitted by an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment). GP modifier is added to indicate this is a physical therapy service.

Coding CHF with Pleural Effusion

May 28, 2020

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.


A patient is admitted into the inpatient setting with congestive heart failure and pleural effusion. The congestive heart failure is monitored with chest x-rays, and the physician also completes an additional lateral decubitus x-ray to assess the volume of pleural effusion. The patient's final diagnosis is congestive heart failure with pleural effusion.


150.9, heart failure, unspecified J91.8, pleural effusion in other conditions classified elsewhere (acceptable secondary diagnosis because of the additional x-ray to assess the volume)

AHA Coding Handbook Ch. 18: Diseases of the Respiratory System—Pleural Effusion Coding Clinic 2114 Quarter 2015, pg. 16: Heart failure with pleural effusion

Coding Tips: Sequencing Multiple Injuries

May 21, 2020

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.


A 45-year-old patient presents to the ED with complaints of left shoulder, leg and ankle pain after falling off a ladder while painting her home. The physician places orders for x-rays. The imaging results reveal a pilon fracture of the left tibia and a sprain of the left AC joint of the shoulder. The patient is discharged home with a splint applied to the left foot.


S82.872A, Displaced pilon fracture of left tibia, initial encounter for closed fracture - primary diagnosis S43.52XA, Sprain of left acromioclavicular joint, initial encounter - secondary diagnosis

ICD-10-CM Official Guidelines for Coding and Reporting FY 2020 Ch. 19 Section b.

What’s the latest code for Vaping-related disorders?

May 14, 2020

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.


A patient presents to the emergency department with shortness of breath. The patient admits to the physician that they use electronic cigarettes on a regular basis. After a full work-up was completed, the patient was admitted into the hospital. Upon discharge, the physician provides a final diagnosis of acute respiratory distress syndrome due to the electronic cigarette usage.


U07.0, vaping-related disorder J80, acute respiratory distress syndrome Reference: 1st Quarter Coding Clinic 2020 pgs. 3-4: Vaping-related disorder

1st Quarter Coding Clinic 2020 pgs. 3-4: Vaping-related disorder

Coding Changing Severity of Pressure Ulcers

May 7, 2020

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.


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.


L89.314 (pressure ulcer of right buttock, stage 4) L89.313 (pressure ulcer of right buttock, stage 3)

ICD -10-CM Official Coding Guidelines Ch. 12 Section B.3. Coding Clinic 4th Quarter 2016 pg. 124

What modifiers eliminate COVID-19 deductibles?

April 30, 2020

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.


A 30-year-old male presents to the hospital emergency department with a fever, cough, and shortness of breath. The physician orders a CDC COVID-19 lab test, and the results are positive.


L89.314 (pressure ulcer of right buttock, stage 4) L89.313 (pressure ulcer of right buttock, stage 3)

Primary diagnosis: U07.1, COVID-19 CPT for COVID-19 lab test: U0001-CS CMS

When is COVID-19 NOT the primary diagnosis?

April 23, 2020

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:


A 52 year old woman was admitted to the hospital with pneumonia due to COVID-19 virus. During the patient's stay, she developed viral sepsis. What's the correct primary diagnosis?


tJ07.1, COVID-19

References: ICD-IO-CM Official Coding Guidelines section 1_CLd_ Chapter-specific Guidelines: Sepsis, Severe Sepsis, and Septic Shock COVID-19 Guidelines