ORHIMA - CERVICAL EXAMS / In regards to annual exams/PAPs, can/should we code for taking the cervical sample as well as the exam? And how does this effect with or without abnormal findings, if at all? / (TT: DB, KS 5.2.16) For diagnosis coding - The code screening Z12.4- Screening neoplasm cervix, has an excludes 1 note for a part when screening is part of a gynecological exam then code only Z01.4 (411 or 419 for normal or abnormal findings)
ORHIMA - DISC SPACE NARROWING / Disc space narrowing:
a. In ICD-9 you could look up narrowing -> intervertebral disc or space NEC and it would lead you to degeneration, intervertebral space. However, in ICD-10 when you look up narrowing there is no longer an option for narrowing of the intervertebral disc or space. How is disc space narrowing coded in ICD-10? / (TT: DB, KS 5.2.16) If you look up narrowing in the ICD-10 code book, it says "see stenosis" Then under stenosis go to intervertebral, disc M99.79- Connective tissue and disc stenosis of intervertebral foramina of abdomen and other regions. Ideally coder would want to identify actual site of spinal stenosis.
ORHIMA - HYPERTROPHY OF JOINT SPACE / Hypertrophy of the joint space:
a. Although it was not in the code book, in ICD-9 we could enter hypertrophy -> joint into Codefinder/3M encoder and it would lead to osteoarthritis by site. In ICD-10 this is no longer possible. How is the phrase hypertrophy of the joint space coded in ICD-10? / (TT: DB, KS 5.2.16) ICD 10 does not have a code for hypertrophy, joint space. Index does notate hypertrophy of bone, some bones are joints. However this is not ideal and a coder cannot assume. This is a great opportunity for provider education. :)
OPEN WOUND / We have come across a chart that puts the new coding clinic advice to work. Coder is questioning how to code the open wound noted here – as an unspecified open wound? How about the ulcer & necrosis, should we pick that up as a diabetic complication?
FINAL IMPRESSION AND ASSOCIATED CONDITIONS
1. OPEN WOUND OF LEFT FOOT, SUBSEQ
2. CHRONIC ULCER OF LEFT TOE, MUSCLE NECROSIS (CHRONIC)
3. DM 2 W RENAL MANIFESTATION (CHRONIC)
4. PERIPHERAL VASCULAR DISEASE (CHRONIC)
HPI Comments: Pt is male with a hx of sick sinus syndrome and pacemaker, DM2, atrial flutter, COPD, CHF, PVD, HTN, and dementia. Has chronic wounds to feet. Sent in for worsening wounds and drainage to left foot. Angioplasty left leg xxx followed by wound care and podiatry. Lives in adult foster. Foster provider states in last 24 hours, having to change dressings nearly every hour due to drainage. No fevers. Pt relates no pain.
Physical Exam
Constitutional: He appears well-developed and well-nourished. No distress.
HENT:
Head: Normocephalic and atraumatic.
Neck: Neck supple
Cardiovascular: Normal rate and regular rhythm.
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress.
Abdominal: Soft. Bowel sounds are normal. He exhibits no distension. There is no tenderness.
Musculoskeletal:
Left foot: There is decreased capillary refill.
Left second toe with necrosis to dorsum. Dry, no drainage. Dorsal forefoot at base of toes with denuded skin, serous fluid weeping Left third toe with Small open areas, weeping serous fluid. Pulse present with Doppler.
Toes cool, but not cold. Decreased cap refill.
Neurological: He is alert
Skin: Skin is warm and dry.
Psychiatric: He has a normal mood and affect.
Nursing note and vitals reviewed.
Consults
Podiatry: Dr consulted. Advises very poor blood flow, would consult vascular.
Vascular surgery: Dr. Advises with recent reperfusion after angioplasty increased swelling and serous drainage not unusual after reperfusion of tissues and wounds may temporarily worsen. May consider oral abx with foot redness. Advised f/u vascular clinic this week.
ED Course
Please see H&P for full details of patient’s presenting symptoms and medical history. Pt. with photos taken Able to upload phots to media file today, does not appear significantly changed from prior. Discussed with podiatry and vascular as above. Pt appear nontoxic. Appropriate for DC home with clinic f/u. Has appt with vascular clinic. See no indication for admission, as chronic, ongoing process, does not appear obviously cellulitic. Return precautions discussed and understood. / Final answer: Trainers feel based on documentation provided in the Final Impression, there are two wounds: open wound and chronic ulcer. There is no further description of how the open wound occured, and therefore, in absence of a query, Trainers recommend following Index to assign the correct code for open wound, as documented by the provider. Index - Wound, open, foot - S91.302D (subsequent encounter)
S91.302D- Open wound of left foot
E11.621- DM with foot ulcer (Per coding clinic 1Q2016 you would link the diabetes with foot ulcer.)
L97.523- Non pressure chronic ulcer other part of foot with necrosis of muscle
In regards to the PVD and DM -
Per Index (and recent CC advice), Diabetes with "peripheral angiopathy" would be linked. There is no mention of "PVD" under DM, however, so be aware that PVD codes to peripheral angiography per index. See - Disease, vascular, peripheral - in diabetes, see E08-E13 with .51 - therefore the PVD when present with DM would be linked. You may want to make a note of this in your book as certain book based encoders may not lead you there directly when searching under other terms (such as PVD).
"PREGNANCY?" / I have a chart with “pregnancy” noted in the clinical impression with symptoms & PMH that would be coded as complications, however, in the MDM our provider indicates that it is a surprisingly positive hCG and US reveals no pregnancy. Should this be coded as pregnancy with complications? For example, O012.01, edema in pregnancy, O10.911, pre-existing HTN, & O99.331, smoking in pregnancy, and more. Or is it possible to use Z32.01, or another route?
Past Medical History:
Has a past medical history of HTN (hypertension); Blighted ovum (xxxx); Acid reflux; Previous recurrent miscarriages affecting pregnancy, antepartum; and renal insufficiency. Has past surgical history that includes none.
Social history: reports that she has been smoking cigarettes. She has been smoking about .50 packs per day. She has never used smokeless tobacco. She reports that she does not drink alcohol or use ilicit drugs.
Medical decision making: female who is presenting for multiple nonspecific symptoms including lightheadedness, pedal edema, fatigue, reminiscent of prior episode of renal failure. IV was placed and blood work obtained which showed normal renal function, normal electrolytes, normal CBC, normal BNP. She did have a surprisingly positive HCG however. Quantitative HCG is only elevated at 18 and her last menstrual period was less than a month ago. She does have some mild flank pain bilaterally however nothing to suspect pyelonephritis or renal colic. She did undergo an ultrasound which was nondiagnostic for intrauterine or extrauterine pregnancy. I discussed the need for follow-up to for serial HCG/ ultrasounds
Clinical impression:
1. Lightheadedness
2. Peripheral edema
3. Pregnancy / (TT: CC, MC, KS 3.22.16) Trainers recommend coding the lightheadedness- R42, (Index= light - R42 - lightheadedness), Peripheral edema- R60.9, and Z32.01- Encounter for positive pregnancy test.
Rationale: conflicting documentation and patient was presenting with pregnancy for the first time. The positive HCG (low) could possibly be a early pregnancy not confirmed by the US, or a miscarriage that hormones have not gone back down to normal levels. Provider recommends follow up for the pregnancy.
OSTEOMYELITIS / Hope I am missing the boat in I-10 coding on this one and will have an Ah-ha moment.
How would you code osteomyelitis toe?
No documentation to support acute or chronic or subacute.
The best I am coming up with is M86.9.
Unfortunately the providers I am dealing with are used to the unspecified osteomyelitis I-9 codes (730.20 to 730.26) On their best days they are not open to questions/comments from the coders and certainly not education so this is all I have to work with. Since this is a bread and butter dx for them, I hope I am missing the boat and have missed some guidance or documentation that would allow me to use a more descriptive code. (often they don’t even document cellulitis or diabetes or ulcers--L ) / (TT: KS, DB, SH 10.28) You can only code what is specifically documented, in this particular case correct code would be Osteomyelitis unspecified M86.9. Unfortunately since not documented acute or chronic you cannot get to toe, CDI issue.
ABSCESS AND CELLULITIS / In ICD10- if both abscess and cellulitis of the site is documented, you code both the abscess & the cellulitis, correct? / (TT:) ICD10 now includes codes for abscess and cellulitis separately when both occur at same site, codes from each may be assigned.
ACUTE BRONCHOSPASM / ER chart w/ diagnosis “Acute bronchospasm”. COPD is listed under PMHx, which I would pick up & code because it’s a chronic systemic condition. In ICD9, I would only code the COPD 496 per CC 3rd Qtr 1988 pp 6 that states that bronchospasm is included in the COPD code.
Is this still relevant in ICD10 coding? There are no excludes notes so do I code both the J98.01 Acute bronchospasm & J44.9 COPD? / (TT: MC, KS, CC 1.6.16) No- acute bronchospasm is an integral part of COPD and Asthma. See reference below.
Per ICD-10 CM/PCS Coding Handbook (old Faye Brown) Chapter 19
Bronchospasm
Bronchospasm is an integral part of asthma or any other type of chronic airway obstruction, but no additional code is assigned to indicate its presence. Code J98.01, Acute bronchospasm, is assigned only when the underlying cause has not been identified.
ACUTE ON CHRONIC RESPIRATORY FAILURE WITH HYPOXIA AND HYPERCAPNIA / I cannot remember if this question has been brought up before, this patient comes in with COPD exacerbation and Acute on Chronic respiratory failure with hypoxia and hypercapnia. will this need both codes? J96.01—acute RF with hypoxia J96.02—acute RF with hypercapnia / (TT: CC, MC 1.12.16) The definition of hypoxia is a deficiency in the amount of oxygen that reaches the tissues and hypercapnia is excessive carbon dioxide in the blood stream. These conditions are not synonymous and can occur together. Therefore if documented as such, both conditions would be coded. J96.01 and J96.02
ALCOHOL INTOXICATION / Alcohol intoxication is only documented with no mention of dependence or abuse- is this alcohol use or abuse? 3M encoder puts it to abuse / (TT:) If only alcohol intoxication is documented without any conflicting documentation I would code to F10.129 which automatically defaults to alcohol abuse with intoxication per the Alphabetic Index. However, if alcohol dependence was documented then based on the hierarchy, dependence would be used which is code F10.229.
Follow index for guidance. If ETOH intoxication is solely documented, this leads to F10.129, Alcohol Abuse with Intoxication
CHRONIC HEADACHE DISORDER / I was wondering how you would capture “chronic headache disorder” would you use the headache syndrome code or the regular headache code? Am I missing a different pathway to a different code? I just checked in the book. / (TT: JJ, KS, DB, CC 1.22.16) Trainers feel you cannot code syndrome since it is not stated in record and there is no entry for disorder therefore, trainers recommend R51 - headache.
*Chronic headache also codes to R51
CLEARANCE FOR INCARCERATION / Clearance for incarceration? How do you code?? Is it Z02.89?
Z02 block are administrative codes. Z04 are for medicolegal reasons, Z04.8 for specified Z04.9 unspecified. I'm not sure how to decide what constitutes specified but I think that would be a more concise code to use. / (TT::)Index: Examination, Medical, Admission to, Prison or Examination, Medical Prisoners, for entrance into prison = Z02.89
CRUSH INJURIES / Pt is seen for a Crushing Injury of the R index finger and a deep laceration was sutured. The code used for the injury was S67.190A for this initial visit.
Several days later pt comes in for wound check and is diagnosed with cellulitis in the wound but the accident/injury is not addressed in the documentation for this DOS. The instinct is to use Z48.817 for f/u care but the coding guidelines state not to use a Z code for aftercare if the injury code includes 7th characters to describe the subsequent care. In this case the original injury code does have a 7th character to describe subsequent care, but the documentation for the care being provided in this subsequent visit doesn’t include documentation of the injury/accident. So therefore, that coding guideline no longer applies – correct? / If they don’t document the original injury in the second follow-up visit, we would be unable to assign a more specific code for the injury. We are not allowed to look at previous visits, so you would only be able to go off of the documentation from the follow-up encounter.
If they documented “cellulitis of the wound”, code:
L03.011 cellulitis, finger, right
S61.200D wound, finger, right
CURRENT VERSUS OLD INJURY / PATIENT COMES IN FOR Lt knee medial meniscus tear that happened 4 months ago from a car accident
Today coming in to have a Lt. knee arthroscopic partial medial menisectomy. The question is regarding old verses current injury….M23204 is s derangement due to old tear/injury
S83242A is a current injury
AAPC states that the definition of current is “now”
Which is the proper way to code these?? / (TT:CC, MC 1.12.16) It would be coded as current unless documentation states "old" "chronic" "degenerative" In the absence of such documentation the default is S83.242A- Current injury of left knee, initial