Cracking the Code


Coding Obstetric Complications That Span Trimesters

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.



A patient who is currently 13 weeks pregnant arrives to the ED complaining of cough and shortness of breath. The physician is made aware that the patient has been in contact with someone who previously had COVID-19. The patient is admitted and tested for COVID-19. The results are positive for Coronavirus and pneumonia. The patient is treated for their diagnoses. At the time of discharge, the patient is now 14 weeks pregnant.


O98.511, other viral diseases complicating pregnancy, first trimester O99.511, diseases of the respiratory system complicating pregnancy, first trimester U07.1, COVID-19 J12.89, other viral pneumonia Z3A.13, 13 weeks of gestation of pregnancy

ICD-10-CM Guidelines for Coding and Reporting FY 2020 Section I.C.15.a.4

Principal diagnosis with POA “N”

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


AHA Coding Clinic Fourth Quarter 2016: Changes to the ICD-10-CM Official Guidelines for Coding and Reporting; Appendix I; Present on Admission Reporting Guidelines


Coding Incision and Drainage Procedures

September 3, 2020

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.



Coding GI Conditions with Bleeding

August 27, 2020

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.




A 65-year-old patient arrived at the hospital with complaints of weakness and fatigue. The patient also complains of GI bleeding over the past few days. The physician performs an EGD to determine the cause of bleeding. In conclusion, the EGD does not provide a specific source of the bleeding; however, gastric ulcers were revealed.


K25.4, chronic or unspecified gastric ulcer with hemorrhage

Coding Clinic 3rd Quarter 2017 pg. 27: Gastrointestinal bleeding secondary to gastric ulcer

Selecting the Appropriate Primary Diagnosis

August 20, 2020

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.




A 62-year-old patient with a personal history of chronic anemia, upper gastrointestinal (GI) bleed, and Barrett’s esophagus presented for bloody stools. The patient was admitted for further treatment and care. During the patient’s stay, an EGD was completed. The results for the EGD stated that the patient had non-bleeding esophageal ulcers at the esophagogastric junction (GEJ), two gastrojejunal anastomotic ulcers (one with a visible vessel; coagulation for hemostasis), and status-post gastric bypass with patent Roux-en-Y anastomosis. The physician plans to repeat the upper EGD in two months to check the healing process and advises the patient not to take any aspirin, ibuprofen, naproxen, or other non-steroidal anti-inflammatory drugs.


K95.89, other complications of other bariatric procedure K28.4, chronic or unspecified gastrojejunal ulcer with hemorrhage K22.10, ulcer of esophagus without bleeding

ICD-10-CM Coding and Reporting Guidelines FY2020 Section II. Selection of Principal Diagnosis

Intrathoracic injuries with rib fractures

August 13, 2020

“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-).



A 64-year-old patient presents to the ED with complaints of significant pain over the left side of his body (including the shoulder and left posterior chest wall) after a fall from a ladder while painting the outside of their home. The patient was admitted for further trauma evaluation and care. The physician orders a CT of the chest, abdomen, and pelvis, and the final impression states that the patient has a comminuted nondisplaced fracture of the posterior left sixth and seventh ribs. There is also tracing of left pneumothorax.


S27.0XXA, traumatic pneumothorax, initial encounter S22.42XA, multiple fractures of ribs, left side, initial encounter for closed fracture W11.XXXA, fall on and from ladder, initial encounter Y92.007, garden or yard of unspecified non-institutional (private) residence as the place of occurrence of the external cause

Instructional “Code First” Note under S22 (rib fractures)”

Coding Wound Debridement Procedures

August 6, 2020

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.

Reference: Coding Clinic for HCPCS First Quarter 2018, pgs. 6-9: Debridement procedures, clarification.

Lumbar Coding From Front to Back

July 30, 2020

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).


A woman is admitted to the hospital with lumbar spondylolisthesis and lumbar spinal stenosis. The surgeon performs a lumbar laminectomy. He used up ankle curettes to release the dura from its attachment to the medial facet capsule. Foraminotomies were then performed. From a left-sided approach, the surgeon placed a Trelloss transforaminal lumbar interbody fusion spacer. Pars interarticularis on the left side was resected along with the superior aspect of the L3-4 and L4-L5 facets. Trelloss banana-shaped titanium cages were then placed into the disc space and tapped as anterior as possible toward the anterior part of the disc space. Behind the cages morselized local autograft bone was then packed into the disc space. A Trocar was advanced into the iliac crest on the right side. Bone marrow was harvested and iliac crest bone marrow was mixed with the morselized local autograft bone and was laid over the decorticated posterolateral gutters for purposes of arthrodesis from L3-L5 bilaterally.


0SG10AJ, fusion of 2 or more lumbar vertebral joints with interbody fusion device, posterior approach, anterior column, open approach 0SG1071, fusion of 2 or more lumbar vertebral joints with autologous tissue substitute, posterior approach, posterior column, open approach 01NB0ZZ, release lumbar nerve, open approach 0SB20ZZ, excision of lumbar vertebral disc, open approach 07DR3ZZ, extraction of iliac bone marrow, percutaneous approach.

ICD-10-PCS Coding Guideline B3.10b, Coding Clinic 4th Quarter 2010 pgs. 125-129: Spinal fusion and refusion, and Coding Clinic 3rd Quarter 2013 pgs. 25-26: 360-degree spinal fusion.

Coding Gastrointestinal Conditions with Bleeding

July 23, 2020

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.


A patient who previously tested positive for COVID-19 is seen for a follow-up exam. The physician orders lab testing once again, and the results are now negative for COVID-19.


Z09, Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm

AHA Coding Clinic Third Quarter 2018 pages 21-22:Gastrointestinal bleeding due to multiple possible sources.

Historical Versus Active COVID 19 Codes

July 16, 2020

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.


A patient who previously tested positive for COVID-19 is seen for a follow-up exam. The physician orders lab testing once again, and the results are now negative for COVID-19.


Z09, Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm

Z86.19, personal history of other infectious and parasitic diseases

Coding Cancer Correctly

July 9, 2020

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).


A 41-year-old woman with a history of breast cancer and status-post double mastectomy in 2016 comes in today for chemotherapy treatment for metastatic cancer to the hip and femur bone.


Z51.11, encounter for antineoplastic chemotherapy C79.51, secondary malignant neoplasm of bone Z85.3, personal history of malignant neoplasm of breast

ICD-10-CM Official Guidelines for Coding and Reporting FY 2020, Section I.C.2.m.

Coding COVID-19 Patient Lung Transplant Status

July 2, 2020

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.



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 U07.1, COVID-19

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

June 25, 2020

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