125 Edinburgh South Drive
Cary, NC 27511
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.
A 57-year-old female presents for a biopsy of a very painful quick growing lumbar back mass. The mass definitely involves the subcutaneous tissue. After discussing the risks and alternatives regarding the biopsy, the patient agrees to proceed with the procedure. The surgeon sharply incises with an eleven blade into the subcutaneous tissue to take further specimen here and uses a 3mm punch biopsy to take two good pieces out of the slightly lateral aspect on the right side of the mass.
CPT 11106, Primary incisional biopsy
CPT 11105, Punch biopsy, additional lesion
CPT 11105, Punch biopsy, additional lesion
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.
A 40-year-old transgender man enters an OBGYN office to have a FTM hysterectomy procedure completed. The patient consents to the procedure, and the surgeon proceeds with the operation. An incision is made in the abdomen, and DaVinci robotic camera is inserted for visualization. The uterus and cervix are dissected free from the bladder and surrounding tissues. Coagulation is achieved. The uterus and cervix are removed as well as the fallopian tubes and ovaries. The uterus weighs 205 g. Final diagnosis: gender dysphoria in adulthood.
CPT 58571, laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
Correctly Coding All Components of Spinal ProceduresSeptember 2, 2021
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.
A patient underwent surgery for a transforaminal lumbar interbody fusion. The transverse processes of L5 and the sacral were dissected. Retractors and pedicle screws were placed first and used the gearshift Lenke probe to cannulate each pedicle at L5-S1 bilaterally. Transforaminal approach was performed on the right side. Facet was removed completely off the L5-S1 and harvested the bone for local autograft. A foraminotomy was performed from the outside approach and decompression of any bone was completed at the L5 nerve root. At that point, a complete discectomy was performed from the right side.
0SG30AJ, fusion of lumbosacral joint with interbody fusion device, posterior approach, anterior column, open; 0SG3071, fusion of lumbosacral joint with autologous tissue substitute, posterior approach, posterior column, open; 0ST20ZZ, resection of lumbar vertebral disc, open approach; 01NB0ZZ, release lumbar nerve, open approach
Correct Sequencing of Acute Manifestations of COVID-19August 26, 2021
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.
A patient returns to the ED five weeks after previously being admitted for COVID-19. The presenting signs and symptoms are fever, cough, and pleuritic chest pain. The provider tests the patient once more for COVID-19; however, the test results are negative. The patient is discharged home with a final diagnosis of pneumonia due to COVID-19 virus.
J12.82, Pneumonia due to coronavirus disease 2019
Secondary DiabetesAugust 19, 2021
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.
A 57-year-old woman presents to the ED with complaints of rapid weight loss and fatigue. The patient has chronic pancreatitis. After the provider completes a blood test, the patient is diagnosed with secondary diabetes due to chronic pancreatitis.
K86.1, other chronic pancreatitis
E08.9, diabetes mellitus due to underlying condition without complications (manifestation)
Coronary Artery Disease with AnginaAugust 12, 2021
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.
A 50-year-old patient enters the ED with complaints of chest tightness and discomfort. The provider orders an ECG and x-ray. Results come back positive for coronary artery disease with angina pectoris. Final diagnosis: atherosclerosis coronary artery disease.
I25.119, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
Allergic Reaction to COVID-19 VaccineAugust 5, 2021
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.
A patient presents to the ED with complaints of chest tightness after receiving their first shot of the COVID-19 vaccine. The provider diagnoses the patient with allergic reaction to COVID-19 vaccine and discharges the patient home.
T78.49XA, other allergy, initial encounter; R07.89, other chest pain
Reporting PRN MedicationsJuly 29, 2021
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.
A 40-year-old patient enters the ED with complaints of sore throat, cough, and runny nose. The patient has history of asthma (Fluticasone PRN), GERD (Prilosec once a day), and type 2 diabetes (Metformin once a day). The provider completes a throat swab, which results with a positive status of upper respiratory infection. The provider writes a prescription for Amoxicillin and discharges the patient home.
J06.9, acute upper respiratory infection, unspecified; K21.9, gastro-esophageal reflux disease without esophagitis; J45.909, unspecified asthma, uncomplicated; E11.9, type 2 diabetes mellitus without complications; Z79.84, long term (current) use of oral hypoglycemic drugs
Accurately Reporting Signs and Symptoms When AppropriateJuly 22, 2021
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.
A 20-year-old patient came into the ED with complaints of chest pain. The patient has history of GERD, which is maintained with Prilosec. The provider orders an xray to determine if the chest pain is related to the GERD. Results come back negative. The provider cannot determine the cause of the chest pain. The patient is provided counseling in regards to their condition and discharged home. Final impression: chest pain and GERD.
R07.9, chest pain unspecified
K21.9, gastro-esophageal reflux disease without esophagitis
Reporting an Additional Diagnosis with a Combination Diagnosis CodeJuly 15, 2021
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.
A 28-year-old obese woman comes into the ED with complaints of fatigue and weakness. She is currently 24 weeks pregnant. The physician orders a CBC, which results with a final impression of iron deficiency anemia. Upon discharge, the physician counsels the patient about taking prenatal vitamins daily and maintaining a healthy diet. Final diagnoses: obesity and anemia.
O99.012, anemia complicating pregnancy, second trimester
D50.9, iron deficiency anemia
O99.212, obesity complicating pregnancy, second trimester
Diabetes with Long-term Insulin and Oral MedicationsJuly 8, 2021
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.
A 34-year-old male patient has type 2 diabetes mellitus and is being evaluated for a chronic diabetic left foot ulcer. The patient also takes insulin and Metformin daily.
E11.621, type 2 diabetes mellitus with foot ulcer
L97.529, non-pressure chronic ulcer of other part of left foot with unspecified severity
Z79.4, long-term (current) use of insulin
Biopsy Followed By Definitive ProcedureJuly 1, 2021
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.
A 40-year-old male patient was admitted with cough, blood-stained sputum and a mass in the left lung. He underwent a percutaneous needle biopsy of the upper left lung lobe. Results of the tissue biopsied revealed Adenocarcinoma of the lung. During that same admission, he underwent an open resection of the left upper lung lobe.
0BTG0ZZ, resection of left upper lung lobe, open approach
0BBG3ZX, excision of left upper lung lobe, percutaneous approach, diagnostic
Screening Diagnosis CodeJune 24, 2021
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.
A 52-year-old woman presents to the outpatient radiology department for a mammogram. The provider orders a breast cancer screening. The screening reveals a breast mass in the left breast.
Z12.31, encounter for screening mammogram for malignant neoplasm of breast
N63.20, unspecified lump in the left breast, unspecified quadrant
Etiology Followed By ManifestationJune 17, 2021
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.
A patient presents to the ED with complaints of pain surrounding her index finger. The area is also red and swollen. The provider orders an x-ray to determine the cause of the pain and swelling. In conclusion, the patient has a final diagnosis of cellulitis due to a staph infection.
L03.011, Cellulitis of right finger
B95.8, Unspecified staphylococcus as the cause of diseases classified elsewhere
Coding Depression and AnxietyJune 10, 2021
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.
A 20-year-old college male reports to the ED with complaints of feeling depressed and stressed about school. He has concerns with flunking out and spends a lot of time playing video games to distract himself from experiencing chaotic thoughts. He rarely attends class and avoids interacting with people. A psychiatric evaluation is completed, and the patient has a final diagnosis of depression and anxiety.
F32.9, major depressive disorder, single episode, unspecified
F41.9, anxiety disorder, unspecified
Coding Excision of a TumorJune 3, 2021
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:
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.
What is the appropriate CPT code?
Coding Diagnoses to the Highest SpecificityMay 27, 2021
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.
A 25-year-old woman presents to the ED with complaints of lower abdominal pain on the left side of the body. She also has nausea but no vomiting. Her last menses was two weeks ago and normal. The provider orders a urine test, which results in negative status for pregnancy. The provider also orders a CT scan to evaluate the abdominal pain; however, the results are negative for a cause of the abdominal pain. Final impression: abdominal pain, unspecified.
R10.32, left lower quadrant pain
2021 Revised E/M Guidelines for Medical Decision Making (MDM)May 20, 2021
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.
Dr. Jones performs a follow-up visit for a 68-year-old male Medicare patient in his office for low back pain that is radiating towards the left leg. While deciding how to treat the patient, Dr. Jones performs an independent interpretation of prior x-ray results performed at an outside facility. The x-ray results provided a final impression of sciatica and herniated disc at L5-S1. With this information provided, Dr. Jones prescribes the patient with an NSAID for pain management. What is the most appropriate E/M level for this scenario?
Coding Signs and Symptoms with Definitive DiagnosesMay 13, 2021
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.
A 5-year-old child presents to the ED setting with complaints of abdominal pain, nausea, vomiting, and headache. The physician performs an abdominal x-ray, which confirms that the patient has appendicitis. The physician also performs a MRI to determine the cause of the patient’s headache, but the results come back negative for any definitive diagnosis. Final assessment of this visit: appendicitis.
K37, unspecified appendicitis
R51.9, headache, unspecified
IVR Intracardiac Echocardiography ProcedureMay 6, 2021
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).”References: CPT Book-Cardiovascular-Intracardiac Electrophysiological Procedures/Studies
Complications After Receiving Brachytherapy TreatmentApril 29, 2021
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.
A 57-year-old woman with cervical cancer presents to the cancer treatment center for brachytherapy radiation. After receiving the treatment, the patient started experiencing diarrhea and nausea.
C53.9, malignant neoplasm of cervix uteri, unspecified, R19.7, diarrhea, unspecified, and R11.0, nausea
Signs and symptoms vs pain related to neoplasm conditionsApril 22, 2021
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.References: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 Section I.C.2.g. and I.C.6.b.5.
Coding Atherosclerosis with Angina and Acute Myocardial InfarctionApril 15, 2021
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.
A 37-year-old patient arrives to the ED with complaints of dyspnea on exertion and sharp chest pain and tightness. The physician performed a chest x-ray to determine the cause of the chest pain. In the final impression, the physician notates coronary artery disease with unstable angina. Final diagnoses: acute AMI due to CAD and unstable angina pectoris
I21.9, acute myocardial infarction, unspecified I25.110, atherosclerotic heart disease of native coronary artery with unstable angina pectoris
Coding Procedures for Inpatient AccountsApril 8, 2021
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:
Sequencing Rules for Child and Adult AbuseApril 1, 2021
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.
A 15-year-old patient arrives to the emergency department with complaints of physical assault. The patient is accompanied by their grandmother who confirms that the patient’s boyfriend was the perpetrator. The physician confirms this information to be true and provides treatment to the patient.
T74.12XA, child physical abuse, confirmed, initial encounter; Y04.2XXA, assault by strike against or bumped into by another person, initial encounter; and Y07.03, male partner, perpetrator of maltreatment and neglect
Insulin Pump Malfunction Sequencing GuidanceMarch 25, 2021
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).
A type 1 diabetic patient is seen in the emergency department for an initial encounter to evaluate the leakage of their insulin pump. The patient is experiencing underdosing of insulin due to the leakage.
T85.633A, leakage of insulin pump, initial encounter; T38.3X6A, underdosing of insulin and oral hypoglycemic [antidiabetic] drugs, initial encounter; and E10.9, type 1 diabetes mellitus without complications
DIEP Breast ReconstructionMarch 18, 2021
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.
A 42-year-old female patient who is post mastectomy secondary to breast cancer was admitted for left breast DIEP flap reconstruction with nerve conduit neurotization. The surgeon dissects the abdominal fascia and harvests the perforator flap. The nerve repair is accomplished using a Neurogen alloplastic conduit. The ends of the nerves were secured to the conduit with a suture. Patient tolerated procedure well.
0HRU077, replacement of left breast using deep inferior epigastric artery perforator flap, open approach and 01U80KZ, supplement thoracic nerve with nonautologous tissue substitute, open approach; CPT 19364, breast reconstruction with free flap
Acute Respiratory Failure as Principal DiagnosisMarch 11, 2021
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 57-year-old patient presents to the emergency department with acute hypoxic respiratory failure and was admitted as inpatient status with pulseless electrical activity (PEA) cardiac arrest. The patient was also hypoglycemic with a low blood glucose level of 32. During the hospital course, the patient is admitted to the intensive care unit on mechanical ventilation. Final discharge diagnoses: PEA cardiac arrest possibly due to hypoglycemia and acute respiratory failure post arrest and heart failure. What is the primary diagnosis for this encounter?
J96.01, acute respiratory failure with hypoxia
Incisions and DrainageMarch 4, 2021
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.
A patient presents with right neck swelling, redness, and drainage. The surgeon confirms that the patient has a neck abscess and decides to perform an incision and drainage procedure to treat the abscess. A skin incision in the right neck is completed. There is purulent drainage followed by blunt dissection until the cavity was visualized. At the completion of surgery, a Penrose drain was placed and secured. The patient tolerated the procedure well and is discharged home.
0J940ZZ, drainage of right neck subcutaneous tissue and fascia, open approach 10060, incision and drainage of abscess; simple or single
Overlapping Body LayersFebruary 25, 2021
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.
A surgeon performed an open incision and debridement of the right knee anterior soft tissues and prepatellar bursal area to include excision of compromised skin and subcutaneous tissue and superficial fascia with placement of wound VAC.
0JBL0ZZ, excision of right upper leg subcutaneous tissue and fascia, open approach and 0S9C3ZX, drainage of right knee joint, percutaneous approach, diagnostic
Newborn Patient Admitted to Observation with Ruled-Out ConditionFebruary 18, 2021
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.
0-hour-old, 39 weeks gestation male newborn who was delivered vaginally presents with fast breathing. The provider admits the newborn into observation to study the breathing. The newborn stayed for three days before the provider confirmed to rule out the condition.
Z38.00, single liveborn infant, delivered vaginally and Z05.3, observation and evaluation of newborn for suspected respiratory condition ruled out
IV Hydration GuidanceFebruary 11, 2021
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.References: Coding Clinic for HCPCS First Quarter 2012 pages 1-4: IV push, infusion vs hydration
Discontinued ProceduresFebruary 4, 2021
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.
A 27-year-old patient with known history of intravenous drug abuse and asthma is admitted for acute hypoxemic respiratory failure secondary to severe asthma exacerbation. Per ED provider’s notes, the patient was coughing up large amounts of phlegm with a possibility of aspiration. Thus, the patient was intubated, and bronchoscopy was performed. Bronchoscopy findings showed that there were inflammations of bronchial mucosa, and both lungs with the presence of secretion were suctioned. However, the procedure was aborted because of significant desaturation and evidence of bronchospasm. (Coding tip: suctioning of the secretions was performed prior to the discontinuation of the procedure, so it should be coded to the root operation “drainage.”)
0BH17EZ, insertion of endotracheal airway into trachea, via natural or artificial opening and 0B9M8ZZ, drainage of bilateral lungs, via natural or artificial opening endoscopic
Principal diagnosis for observation converted to inpatient statusJanuary 27, 2021
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.
A patient is admitted to Observation status after being evaluated in the ED for chest pain, shortness of breath, and cough. The physician orders a chest x-ray and results show that the patient has right lower lobe pneumonia. Upon these results, the physician decides to convert the patient to Inpatient status to run more in-depth tests and provide extra treatment for the pneumonia.
J18.9, pneumonia, unspecified organism
Principal Diagnosis Guidelines – Two Interrelated ConditionsJanuary 20, 2021
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.
A 63-year-old female with a past medical history significant for congestive heart failure with EF of 35-40%, severe aortic stenosis status post TAVR, cardiac arrest post AICD implantation, type 2 diabetes, is admitted for pre-syncope and hypotension. Hypotension – secondary to diuretic use, decreased oral intake, and daughter reported possible laxative abuse to the ED provider. Per discharge summary, patient has a final diagnosis of hypotension-hypovolemia due to poor PO intake and diuretic use.
Per coding guideline section II.B., either the hypotension or the hypovolemia can be sequenced as the primary diagnosis.
I95.9, hypotension, unspecified
PFIZER & MODERNA CPT Vaccination CodesJanuary 13, 2021
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).References: American Medical Association
Updated COVID-19 DiagnosisJanuary 8, 2021
Effective immediately as of January 1st, 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.References: AHA Frequently Asked Questions
Discontinued Procedures for PCS CodesDecember 16, 2020
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:
Accurately Reporting Newborn with ComplicationsDecember 10, 2020
The perinatal period is defined as before birth through the 28th 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.
0-hour-old birth weight TBD. AGA 39 weeks gestation male newborn presents asymptomatic.
Delivery type: spontaneous vaginal delivery
Assessment: term newborn delivered vaginally, current hospitalization
Passage of meconium during delivery affecting newborn
Z38.00, single liveborn infant, delivered vaginally
P03.82, meconium passage during delivery
ICD-10-CM Guidelines for DiabetesDecember 2, 2020
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.”References: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section I.C.4.a.
Initial vs Subsequent: The 7th CharacterNovember 17, 2020
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.References: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section I.C.19.a.
NIH VS GCS Stroke ScoringNovember 11, 2020
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).References: FY2021 ICD-10-CM Official Guidelines for Coding and Reporting Sections I.C.18.e. and i
Observation Service Code ObservationsNovember 5, 2020
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:
References: https://www.cgsmedicare.com/partb/mr/pdf/observation_serv_factsheet.pdf CPT Assistant June 2011 pages 3-7: Observation care reporting
Coding Permanent Dual-chamber PacemakersOctober 29, 2020
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
A patient presents to the ED with complaints of sick sinus syndrome. The physician admits the patient and determines that surgery intervention is necessary. A permanent dual chamber pacemaker with atrial and ventricular leads was implanted. An incision was made into the left chest wall with the dual chamber pacemaker being placed in the subcutaneous pocket. Next, a small incision was made into the skin and the leads were percutaneously passed into the right ventricle and right atrium
I49.5, sick sinus syndrome
Getting to the Point of an IVR Lumbar PunctureOctober 22, 2020
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.
A patient enters an orthopedic office with complaints of muscle spasms/pain, stiffness, and weakness. The physician performs a fluoroscopic lumbar puncture in order to collect spinal fluid to test for certain antibodies. The patient tolerates the procedure well and is instructed to return in two months in order to review the findings.
ICD-10-PCS Code: 009U3ZX, Drainage of Spinal Canal, Percutaneous Approach, Diagnostic CPT Code: 62328, Spinal puncture, lumbar, diagnostic; with fluoroscopic or CT guidance
Updated Glasgow Coma Scale Guidance for FY2021October 15, 2020
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 1st, 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.Reference: ICD-10-CM Official Guidelines for Coding and Reporting Section I.C.18.e: Coma scale
Coding Diagnostic vs Therapeutic ProceduresOctober 8, 2020
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.
A patient comes in for a biopsy of their left pleural cavity via thoracentesis. During the same encounter, the physician also performs a therapeutic thoracentesis from the right side of the patient's chest.
0W9B3ZX, drainage of left pleural cavity, percutaneous, diagnostic 0W993ZX, drainage of right pleural cavity, percutaneous
Coding for CirrhosisOctober 1, 2020
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.
A 73-year-old male with history of cirrhosis and colon cancer (status-post resection and colectomy) presents with episodes of hematemesis and blood in colostomy bag. The provider performs an EGD and finds bleeding esophageal varices. The provider performs esophageal banding in order to stop the bleeding.
K74.60, cirrhosis of liver I85.11, secondary esophageal varices with bleeding Z85.038, personal history of other malignant neoplasm of large intestine Z93.3, colostomy status 06L38CZ, occlusion of esophageal vein with extraluminal device, via natural or artificial opening endoscopic 43244; EGD, flexible, transoral; with band ligation of esophageal/gastric varices
Coding Obstetric Complications That Span TrimestersSeptember 24, 2020
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
Principal diagnosis with POA “N”September 17, 2020
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 ProceduresSeptember 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:
Coding GI Conditions with BleedingAugust 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
Selecting the Appropriate Primary DiagnosisAugust 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
Intrathoracic injuries with rib fracturesAugust 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
Coding Wound Debridement ProceduresAugust 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:
Lumbar Coding From Front to BackJuly 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.
Coding Gastrointestinal Conditions with BleedingJuly 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
Historical Versus Active COVID 19 CodesJuly 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
Coding Cancer CorrectlyJuly 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
Coding COVID-19 Patient Lung Transplant StatusJuly 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
What NOT to Code for a Spinal FusionJune 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 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
Spinal Fusion Code CautionsJune 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 ReimbursementsJune 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 EffusionMay 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)
Coding Tips: Sequencing Multiple InjuriesMay 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
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
Coding Changing Severity of Pressure UlcersMay 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)
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)
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?