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: