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CODING
CLINIC
E F F E C T I V E W I T H D I S C H A RG E S : O C T O B E R 1 , 2 0 1 2
PRESENTED BY
STEPHANIE CARLISTO, RHIT, CCS
CODE SET FREEZE
There is a partial code set freeze in preparation for ICD-10-CM/PCS implementation, there are
no new or revised ICD-9-CM diagnosis codes, or ICD-9-CM changes to the Official Guidelines
for Coding and Reporting for Fiscal Year 2013.
CMS announced on September 15, 2010, that a partial freeze of both ICD-9-CM and ICD-10CM/PCS codes (ICD-10 code sets) would be implemented as follows:
The last regular annual update to both ICD-9-CM and ICD-10 code sets was made on October 1,
2011.
On October 1, 2012, there will be only limited code updates to both ICD- 9-CM and ICD-10 code
sets to capture new technology and new diseases.
On October 1, 2013, there were to be only limited code updates to ICD-10 code sets to capture
new technology and new diseases. There were to be no updates to ICD-9-CM on October 1,
2013, as the system would no longer be a HIPAA standard and, therefore, no longer be used for
reporting. With the proposed ICD-10 implementation delay, there will be only limited code
updates to both ICD-9-CM and ICD-10 to capture new technology and new diagnoses on
October 1, 2013.
Regular updates to ICD-10-CM and ICD-10-PCS will begin one year after the implementation of
ICD-10. October 1, 2015.
CRESCENDO ANGINA
PRINCIPAL PROCEDURE
A patient had a percutaneous transluminal coronary angioplasty (PTCA)
with administration of thrombolytic agent in an effort to prevent an
impending myocardial infarction after presenting with severe crescendo
angina. What should be the principal procedure?
Assign code 00.66, percutaneous transluminal coronary angioplasty
[PTCA], as the principal procedure. Assign code 99.10, Injection or
infusion of thrombolytic agent, as a secondary procedure.
DECOMPENSATED
CHF W/ PLEURAL EFFUSION PRINCIPAL
PROCEDURE
A patient is admitted for decompensated congestive heart failure (CHF)
with pleural effusion. The patient also has type 2 diabetes mellitus with
peripheral vascular disease with a chronic foot ulcer. Due to the pleural
effusion patient has a thoracentesis to drain fluid. During the course of
the hospital stay, the patient’s diabetic foot ulcer worsens and must be
surgically debrided down to muscle and bone.
How would you sequence the procedures performed on this encounter?
34.91, Thoracentesis, as the principal procedure, since it is the
procedure is associated with the principal diagnosis.
77.68, Local excision of lesion or tissue of bone, tarsals and
metatarsals, as a secondary procedure, since it was performed for a
condition that developed after admission.
PRINCIPAL PROCEDURE FOR
MALIGNANT NEOPLASM OF OVARY
A patient with a malignant neoplasm of the ovary is admitted for
surgery. A bilateral salpingo-oophorectomy and hysterectomy are
performed. Which procedure code should be listed as the principal
procedure on the record, 65.61, Other removal of both ovaries and
tubes at same operative episode, or 68.49, Total abdominal
hysterectomy?
Assign code 65.61, Other removal of both ovaries and tubes at same
operative episode, as the principal procedure, since it is the
procedure most closely related to the principal diagnosis. Assign
code 68.49, Total abdominal hysterectomy, as a secondary
procedure.
CEREBRAL NEOPLASM
PRINCIPAL PROCEDURE
A patient with a cerebral neoplasm is admitted for surgery. An
open biopsy of the brain is performed and the neoplasm is
found to be an inoperable and malignant. During the procedure,
an artery is accidentally lacerated and is sutured to control the
bleeding. Which procedure code should be listed as the
principal procedure on the record, 01.14, Open biopsy of brain
or 39.31, Suture of artery?
01.14, Open biopsy of brain, as the principal procedure. Even
though the biopsy is a diagnostic procedure, rather than a
treatment, it is the procedure that is related to the principal
diagnosis.
39.31, Suture of artery, as a secondary procedure, since it was
performed for the complication during surgery.
PACEMAKER LEAD
DISPLACEMENT PRINCIPAL
PROCEDURE
A patient with displacement of a cardiac pacemaker lead is
admitted for revision of the lead. The patient also has internal
hemorrhoids. The pacemaker lead is repositioned. During the
recovery period, the patient has significant rectal bleeding from the
internal hemorrhoids. A hemorrhoid ligation is performed to
control the bleeding. Which procedure code should be listed as the
principal procedure on the record, 37.75, Revision of lead, or 49.45,
hemorrhoid ligation?
37.75, Revision of lead, as the principal procedure, since it was the
procedure most closely related to the principal diagnosis
49.45, Hemorrhoid ligation as a secondary procedure.
INJECTION
OR INFUSION OF
GLUCARPIDASE
Effective October 1, 2012, a new procedure code (00.95) was created to describe
the administration of glucarpidase (Voraxaze®) used to treat cancer patients
with toxic levels of methotrexate in their blood due to renal impairment which
prevents clearance of the drug from their systems. Prior to this, the injection or
infusion of glucarpidase was coded to 99.29, Injection or infusion of other
therapeutic or prophylactic substance
Methotrexate is one of the most commonly used anti-cancer agents. The
administration of high dose methotrexate is an important component in the
treatment of a variety of cancers.
Voraxaze® is not indicated for use in patients who display the expected
outcome of methotrexate or those with normal or mildly impaired renal function
because of the potential risk of subtherapeutic exposure to methotrexate.
(Meaning if your renal function is adequate, the Methotrexate levels may not be
high enough to be effective to treat the cancer.)
New code
00.95 Injection or infusion of glucarpidase
PLACEMENT OF
SUBCUTANEOUS IMPLANTABLE
CARDIOVERTER DEFIBRILLATOR
What are the correct code assignments for implantation, replacement, or
revision of a totally subcutaneous implantable defibrillator system? Use
the existing defibrillator codes as follows, as ICD-9-CM does not
distinguish the location of cardioverter/defibrillator implantations:
Implantation:
37.94, Implantation or replacement of automatic cardioverter/defibrillator,
total system [AICD]
37.95, Implantation of automatic cardioverter defibrillator lead(s) only
37.96, Implantation of automatic cardioverter/ defibrillator pulse generator
only
Replacement:
37.97, Replacement of automatic cardioverter defibrillator lead, only
37.98, Replacement of automatic cardioverter/ defibrillator pulse generator
only
Revision:
37.79, Revision or relocation of cardiac device pocket
37.75, Revision of lead [electrode]
DIAGNOSTIC PROCEDURE OR
DEFINITIVE TREATMENT AS
PRINCIPAL PROCEDURE
A patient is admitted for biopsy of a cerebral neoplasm. During
the encounter, the patient has significant rectal bleeding due to
internal hemorrhoids. A hemorrhoid ligation is performed to
control the bleeding. Which procedure code should be listed as
the principal procedure, 01.14, Open biopsy of brain, or 49.45,
hemorrhoid ligation?
Assign code 01.14, Open biopsy of brain, as the principal
procedure. Code 49.45, hemorrhoid ligation should be added as
a secondary procedure. Although the biopsy is a diagnostic
procedure, rather than definitive treatment, it is sequenced as
the principal procedure, since it’s the procedure most closely
related to the principal diagnosis.
LUMBAR VERTEBRAE
FRACTURE W/ ASPIRATION
PNEUMONIA AND ARDS
PRINCIPAL PROCEDURE
A patient with compression fracture of the first lumbar vertebrae is admitted.
Percutaneous vertebroplasty using methylmethacrylate is performed. Several
days after the procedure, the patient is diagnosed with aspiration pneumonia with
acute respiratory failure. The patient cannot be intubated due to severe edema of
the airway so a tracheostomy is done. The patient is on mechanical ventilation for
48 hours, and is eventually discharged after the pneumonia is resolved and the
tracheostomy removed. Which procedure code should be listed as the principal
procedure on the record, 81.65, Percutaneous vertebroplasty, or 31.29, Other
permanent tracheostomy?
81.65, Percutaneous vertebroplasty, as the principal procedure, since it is the
procedure most closely related to the principal diagnosis.
31.29, Other permanent tracheostomy, as a secondary procedure, since it was
performed for a condition that developed after admission.
ESOPHAGEAL
VARICES PRINCIPAL
PROCEDURE
A patient with alcoholic liver disease and portal hypertension is
admitted with bleeding esophageal varices. The patient undergoes
esophagogastroduodenoscopy (EGD) with an attempted banding of the
varices. The banding procedure is discontinued due to patient
becoming agitated, the varices stop oozing during the hospital stay with
medical management. The patient then developed chest pain with an
elevation of troponin. The patient also has a history coronary artery
disease and coronary bypass surgery. During this admission, a 90%
blockage is discovered in the native obtuse marginal artery, and
percutaneous transluminal coronary angioplasty (PTCA) is successfully
performed.
Which procedure code should be listed as the principal procedure on
the record, 45.13, Other endoscopy of small intestine, or 00.66,
Percutaneous transluminal coronary angioplasty [PTCA]?
Assign code 45.13, Other endoscopy of small intestine, as the principal
procedure, since it is the procedure most closely related to the principal
diagnosis, even though the procedure was discontinued. Assign code
00.66, Percutaneous transluminal coronary angioplasty [PTCA] as a
secondary diagnosis.
ESOPHAGEAL VARICES
PRINCIPAL PROCEDURE
A patient with hepatic encephalopathy and alcoholic cirrhosis is
admitted. During the encounter, the patient had hemoptysis and
underwent an esophagogastroduodenoscopy (EGD) for
suspected esophageal varices, they were confirmed to be
present, but not bleeding. However, a few days later, the varices
ruptured and the patient required endoscopic banding of the
esophageal varices. What should be the principal procedure?
Assign code 42.33, Endoscopic excision or destruction of lesion
or tissue of esophagus, for the endoscopic banding of
esophageal varices, as the principal procedure. There were no
procedures performed related to the principal diagnosis and the
banding of the esophageal varices was the procedure performed
for definitive treatment of the secondary diagnosis. Assign code
45.13, Other endoscopy of small intestine, as a secondary
procedure.
CODING CLINIC FOR ICD10-CM INTRODUCTION
From CC 4th 1. 2014, “Although ICD-10-CM and ICD-10-PCS have not
been implemented yet, in response to requests from the coding
community, the AHA Central Office announced last November that
interested parties may start sending ICD-10- CM/PCS questions to the
AHA Central Office. However, just as with ICD- 9-CM, inquirers must
have a working knowledge of ICD-10-CM and ICD- 10-PCS coding
when submitting a question. The service is limited to providing
coding advice and not advice on the General Equivalence Mappings
(GEMs) or implementation issues. Please refer to the AHA’s website
for information on submission of requests for coding advice:
www.ahacentraloffice.org”
“The following ICD-10-CM and ICD-10-PCS coding questions have
been reviewed and approved through the same process used for all
Coding Clinic issues. Future issues of Coding Clinic will continue to
include ICD-10-CM/ PCS issues as approved by the Editorial Advisory
Board.”
ACUTE EXACERBATION OF
ASTHMA AND STATUS
ASTHMATICUS
The question posed to CC was as follows:
“Are we to assume that ICD-9-CM guidelines not included in ICD-10-CM will
not be valid beginning when ICD-10-CM is implemented? For example, ICD-9CM guideline Section I.C8.a.4, "Acute exacerbation of asthma and status
asthmaticus" does not have a counterpart in the ICD-10-CM guidelines.”
Their response was:
“Every effort was made to carry over the ICD-9-CM guidelines and concepts
into ICD-10-CM, unless there was a specific change in ICD-10-CM that
precluded the incorporation of the same concept into ICD-10-CM. However,
some of the guidelines in ICD-9-CM included information that may have been
clinical in nature (as in the example noted in the question) and therefore not
appropriate for coding guidelines.”
As far as coding of acute exacerbation of asthma and status asthmaticus
together in ICD-10-CM, CC’s advice is “only the code for the more severe
condition (i.e., status asthmaticus) should be assigned.”
ACUTE EXACERBATION OF
ASTHMA AND STATUS
ASTHMATICUS
Asthma, asthmatic (bronchial) (catarrh) (spasmodic) J45.909
-
With
-
exacerbation (acute) J45.901
-
- - - status asthmaticus J45.902
CROHN’S DISEASE WITH
RECTAL ABSCESS
The following ICD-10-CM codes K50.014, K50.114, K50.814 and
K50.914 are used to identify Crohn’s disease with intestinal
abscess. If a patient presents with Crohn’s disease of the small
intestine with a rectal abscess, should we assign an additional
code for the rectal abscess?
It is appropriate to assign code K50.014, Crohn’s disease of
small intestine with abscess, along with code K61.1, Rectal
abscess, the additional code provides more information
regarding the site of the abscess. Codes in category K50
describe intestinal abscess only.
INITIAL
ENCOUNTER FOR
FRACTURE MALUNION
A patient fell and sustained a fracture of his left wrist but did not
seek medical treatment for some time. He now seeks treatment for
the first time and he is diagnosed with malunion of closed fracture
of the navicular bone, left wrist. What is the appropriate seventh
character since the patient is only now seeking treatment for the
fracture?
Code S62.002A, Unspecified fracture of navicular [scaphoid] bone
of left wrist, initial encounter for closed fracture should be
assigned. According to the Official Guidelines for Coding and
Reporting, "the appropriate 7th character for initial encounter
should be assigned for a patient who delayed seeking treatment
for the fracture or nonunion."
OPEN DISLOCATION
OF ELBOW
A patient was seen in the emergency department after sustaining an
open anterior dislocation of the right elbow, with no associated
vascular or neural injury due to crashing into her partner and falling
while at a school dance.
Code S53.114A, Anterior dislocation of right ulnohumeral joint, initial
encounter, as the first-listed diagnosis
Code S51.001A, Unspecified open wound of right elbow, initial
encounter;
W03.XXXA, Other fall on same level due to collision with another
person, initial encounter
Y92.213 High school as the place of occurrence of the external cause;
Y99.8, Other external cause status
Y93.41, Activity, dancing.
CATEGORY I69 -DOMINANT
VERSUS NON-DOMINANT SIDE
For late effects of CVA the same rule applies for distinguishing
between dominant and non-dominant side as when the patient has
the initial CVA and deficits.
If the affected side documented, but not specified as dominant or
non-dominant, and the classification system does not indicate a
default, code selection is as follows:
• For ambidextrous patients, the default should be dominant.
• If the left side is affected, the default is nondominant.
• If the right side is affected, the default is dominant.
RESECTION OF RIB W/
RECONSTRUCTION OF
ANTERIOR CHEST WALL
A patient with right anterior fourth rib low grade chondrosarcoma
underwent resection of a 7 cm. segment of the right fourth rib and
reconstruction of anterior chest wall using methylmethacrylate Marlex
overlay plate which was sutured into the
Would it be coded to the root operations excision and supplement, or
the root operation replacement?
Coding Clinic advice:
“Assign code 0PB10ZZ, Excision of right rib, open approach, for
removal of the rib. In addition, assign code 0WU80JZ, Supplement chest
wall with synthetic substitute, open approach, for the insertion of the
Marlex and methylmethacrylate composite plate. Even though the
physician referred to the procedure as "resection," the root operation
"excision" should be selected.”
DOMINO
LIVER TRANSPLANT
A patient with familial amyloid polyneuropathy needs to have a liver transplant due
to worsening of his condition. Since his liver function was good with no cirrhosis,
he was determined to be a good candidate for liver transplant and in turn his
explanted liver transplanted into another patient. The physician used the term
"domino liver transplant" to describe the chain of events occurring during
transplantation. A new liver from a live nonrelative was donated and transplanted.
The patient’s old liver was removed for donation.
Per CC advice:
“Assign code E85.1, Neuropathic heredofamilial amyloidosis, as the principal
diagnosis along with code G63, Polyneuropathy in diseases classified elsewhere,
as an additional diagnosis.”
“Assign code 0FY00Z0, Transplantation of liver, allogeneic, open approach, and
code 0FT00ZZ, Resection of liver, open approach, for the procedures performed.
Currently, neither ICD-10- PCS nor ICD-9-CM has a specific code to describe a
domino liver transplant.”
SEQUENCING OF ACUTE AND
SUBSEQUENT MYOCARDIAL
INFARCTIONS
A patient was discharged from the hospital after being
hospitalized for treatment of an acute transmural myocardial
infarction of the anterior wall. A week after discharge, he back in
the emergency department for chest pain and was admitted for a
subsequent acute transmural myocardial infarction of the
posterior wall. How should the second admission be coded?
The sequencing of the I22 and I21 codes depends on the
circumstances of the encounter. The reason for the admission
was the subsequent MI, so code I22.1, Subsequent ST elevation
(STEMI) myocardial infarction of inferior wall, would be assigned
as the principal diagnosis.
Code I21.09, ST elevation (STEMI) myocardial infarction
involving other coronary artery of anterior wall, as a secondary
diagnosis.
SEQUENCING OF ACUTE AND
SUBSEQUENT MYOCARDIAL
INFARCTIONS
The sequencing of the I22 and I21 codes depends on the
circumstances of the encounter. Should a patient who is in the
hospital due to an AMI have a subsequent AMI while still in the
hospital code I21 would be sequenced first as the reason for
admission, with code I22 sequenced as a secondary code.
Should a patient have a subsequent AMI after discharge for care
of an initial AMI, and the reason for admission is the subsequent
AMI, the I22 code should be sequenced first followed by the I21.
An I21 code must accompany an I22 code to identify the site of
the initial AMI, and to indicate that the patient is still within the 4
week time frame of healing from the initial AMI.
The guidelines for assigning the correct I22 code are the same
as for the initial AMI.
SEQUENCING OF
MYOCARDIAL INFARCTION
CODES
A patient was admitted to the hospital due to an acute
transmural myocardial infarction of the anterior wall. A week
after admission, while the patient was still in the hospital, the
patient suffered another acute myocardial infarction (AMI),
this time, a transmural infarction of the inferior wall.
Code I21.09, ST elevation (STEMI) myocardial infarction
involving other coronary artery of anterior wall, as the
principal diagnosis.
Code I22.1, Subsequent ST elevation (STEMI) myocardial
infarction of inferior wall, as a secondary diagnosis.
SEVENTH CHARACTER FOR
FETUS IDENTIFICATION
Twins are often documented as fetus A and fetus B. Fetal
extensions in chapter 15, Pregnancy, childbirth and the
puerperium, for codes related to complications of multiple
gestation (e.g., O31, O32, etc.) use fetus 1, fetus 2, and so on.
Is it okay to assume based on how they are referred to in I-10,
can we assume fetus A is the same as fetus 1, and so on.
Fetus A should be equated with fetus 1, fetus B should be
equated with fetus 2, and so on. There is no guarantee that
the same fetus number or alphabetical character will be
always carried over from one admission to the next.
Identification of the fetus, whether by number or alphabetical
character, is based on the documentation in the chart.
RESOURCES
http://www.ncbi.nlm.nih.gov/pubmed/18555132
ICD-10 Official Coding Guidelines 2013
Coding Clinic AHA
QUESTIONS?

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