The. Coding. Institute
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AVOID AUDITS IMPROVE REIMBURSEMENT REDUCE DENIALS INCREASE REVENUE
ICD-10 Coding Alert
Your monthly guide to ICD-10 coding, training, and reimbursement.
February 2017, Vol. 7, No. 2 (Pages 9-16)
News You Can Use In this issue
Coding Quiz
Test Yourself With 5 Pap Test
Scenarios
 Distinguish reason for
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Training
Top 4 ICD-10 Coding Mistakes
You Cannot Afford To Make p10
 Don’t just correct, perfect
your respiratory failure and
seventh character coding.
Coding Quiz Answers
Grade Your 5 Pap-Test Scenario
Responses
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 Don’t confuse screening
vs. diagnostic tests.
Specialty Corners
 Cauda equina malignancy
 Watch out: Careful of
ICD-10 Glitch Causes CMS to Slacken PQRS
Requirements
The transition from ICD-9 to ICD-10 has had its fair share of ups and downs. But, a recent
CMS release suggests that it might have been rockier than first suspected. Some ICD-CM
(Clinical Modification) and PCS (Procedural Coding System) changes made on Oct. 1,
2016 weren’t updated properly to report measures for CY 2016.
Since these particular ICD-10 codes related to the Physician Quality Reporting System
(PQRS) weren’t adjusted properly, CMS will be waiving penalties for eligible provider
impacted by the glitch.
“CMS will not apply the 2017 or 2018 PQRS payment adjustments, as applicable, to any
EP or group practice that fails to satisfactorily report for CY 2016 solely as a result of the
impact of ICD-10 code updates on quality data reported for the 4th quarter of CY 2016,”
CMS said in a Jan. 11, 2017 release. Read the CMS release here: https://www.cms.gov/
Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/ICD-10_Section.html.
In a fact sheet detailing the issue, CMS listed the following measures groups as being
impacted under PQRS by the ICD-CM updates:
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has defined code though
not all in cranial nerves
have specific codes.
Straining to Find a Neck
Sprain Code? Here are
Your Options
}
Don’t miss this CMS update.
repeat Pap.
Spot the Right Codes for
Malignant Neoplasms
in the Cord, Cauda, and
Cranial Nerves
Also Access Your Alert Online at www.SuperCoder.com
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»
»
»
»
»
Diabetes
Cataracts
Oncology
Cardiovascular Prevention
Diabetic Retinopathy.
Resource: See the CMS ICD-CM update factsheet here: https://www.cms.gov/Medicare/
Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/FAQs_ICD10CM_
Final_20170109.pdf. q
what seventh character
you apply.
Coding Quiz Reader Questions
}
Don’t Be Surprised By Some
CMS ICD-10 Denials
p14
Test Yourself With 5 Pap Test Scenarios
Get Specific with Pharyngitis
Code Choice
p15
Distinguish reason for repeat Pap.
Look Beyond E/M for
Nursemaid’s Elbow
2017
p15
When your lab performs Pap tests, do you know the ins and outs of reporting the proper
procedure and diagnosis codes to make sure you get paid for your services?
Read the following questions and try to answer them, then see how well you know your
stuff by turning to the answers on page 11.
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Scenario 1: We received a Pap test order 13 months after the
previous test due to “high risk sexual behavior.” However, the
ordering physician listed the diagnosis as Z12.4 (Encounter for
screening for malignant neoplasm of cervix), which resulted in
a denial. Is there anything we can do to get this test covered?
Scenario 2: A physician ordered a repeat Pap due to abnormal
findings on a prior screening Pap six months earlier. The
Training The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713
follow-up Pap requires a pathologist’s interpretation. How
should we code the case?
Scenario 3: The lab returned Pap smear results as
“unsatisfactory smear,” so the physician submitted a second
Pap test in three months — sooner than allowable by coverage
rules for either high- or normal-risk patients. Is there any way
to get reimbursement for this test? q
}
Top 4 ICD-10 Coding Mistakes You Cannot Afford To Make
Don’t just correct, perfect your respiratory failure and seventh character coding.
You have now entered the era of hard-core ICD-10 coding. No
more grace period luxuries — you need to tighten your seatbelt
and focus — let specificity guide your path. Take a lesson from
last year’s most common coding mistakes to chart your way to
a denial-free 2017.
When ARF is coexistent with another acute condition, (such as
myocardial infarction [I21.-, I22.-], cerebral infarction [I63.], aspiration pneumonia J69.- [Pneumonitis due to solids and
liquids…], the selection of principal diagnosis will be different
according to the situation.
Learn from Other’s Mistakes
In this situation, selecting the correct code can be a little
tricky, depending on whether the other existing pathology
is respiratory or non-respiratory in nature, and also on the
circumstances of admission. Here’s how to make your decision,
according to the ICD-10 guidelines:
The most common challenge when tackling ICD-10-CM
coding lies in not factoring in all of the available information
before you make your code choice, says Carol Pohlig, BSN,
RN, CPC, ACS, senior coding and education specialist at
the Hospital of the University of Pennsylvania. You’ll need
to consider all the details and the associated complications in
order to choose the correct code.
1. Fight Respiratory Failure Coding Blues with CMS’s 2017
Coding Guidelines
One common mistake coders made in 2017 was inappropriately
reporting respiratory failure as a principal diagnosis, according
to an AHIMA Body of Knowledge article. Fortunately, the new
2017 ICD-10-CM coding guidelines offer some clarity on how
and when to report respiratory failure.
According to the ICD-10 guidelines, if Acute Respiratory
failure (ARF) is the primary reason for the patient’s visit to
the provider, then you may choose an appropriate code from
subcategory J96.0- (Acute respiratory failure…), or subcategory
J96.2-, (Acute and chronic respiratory failure…) as the primary
diagnosis.
But, if the ARF occurs after admission, or even if it exists at the
time of admission, but doesn’t meet the definition of principal
diagnosis above, you will report it as the secondary diagnosis.
» If both ARF and the other acute condition are equally
responsible for patient’s admission, check for any chapter
specific sequencing rules, or any chapter specific guidelines
that lead you to zero in on the primary diagnosis.
» If the documentation does not make it clear whether ARF
and the other condition were equally instru­mental in
effecting the patient’s admission, you may have to ask the
provider for further clarification.
2. Solve Seventh Character Conundrums in Reporting Trauma Cases
Coding up to the seventh character in the acute hospital setting,
especially in trauma and fracture cases, has been amongst top five
recurrent mistakes in coding, according to the AHIMA article.
Example: Suppose a patient has an accident, and faces blunt
trauma to the right front wall of thorax. He also has a fracture
of shaft of right humerus with a single break line that runs
transversely through the central portion of the upper arm bone,
separating the humerus into upper and lower portions with
these fracture fragments remaining in their original alignment,
due to sudden or blunt trauma. Based on the provider’s
documentation, you will code S20.211A (Contusion of right
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front wall of thorax, initial encounter), as well as S42.324A
(Nondisplaced transverse fracture of shaft of humerus, right
arm, initial encounter for closed fracture), as the patient is
seeing the provider for the first time.
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and whether dye was used. Facilities should address their
requirements in the coding policy so the application of codes
for these services is consistent the AHIMA article suggested.
3. Be Sure To Code It Right For Fluoroscopy with Dyes
4. Don’t Forget To Report Precise HCPCS Codes for Devices and
Components
Another recurrent mistake coders make is in coding whether or
not the provider used a dye during the fluoroscopy or ultrasound
procedure. “This can be done on an [outpatient] basis,” says
Sarah Goodman, MBA, CHCAF, CPC-H, CCP, FCS,
president of the consulting firm SLG, Inc., in Raleigh, N.C.
If hope to avoid denials, make sure you capture the device and
the details of its components as impeccably as you code for the
diagnoses and the procedure. Documentation should include
components and grafting material details, according to the
AHIMA article.
Example: Consider the EBUs CPT® code 31654
(Bronchoscopy, rigid or flexible, including fluoroscopic
guidance, when performed; with transendoscopic
endobronchial ultrasound [EBUS] during bronchoscopic
diagnostic or therapeutic intervention[s] for peripheral
lesion[s] [List separately in addition to code for primary
procedure[s]]). There tend to be mistakes around the use
of guidance tools, such as fluoroscopy and ultrasound,
Coding Quiz Answers The bottom line: If you hope to avoid a negative payment
impact, take time to identify and proactively work on your
ICD-10 coding pain points. Contact your payers if you are not
sure about any specific documentation or coding requirements
the payer may have for on accepting a claim.
To know more, go to http://bok.ahima.org/doc?oid=301549#.
WAnkdPkrLIU. q
}
Grade Your 5 Pap-Test Scenario Responses
Don’t confuse screening vs. diagnostic tests.
After reading the questions on page 9, now is the time to see if
you’ve mastered the ins and outs of Pap test coding. Here are
the answers, according to our experts:
Solution 1: The denial probably came because the ordering
diagnosis gives no indication that the patient is high risk, and you
exceeded the 2-year frequency limitation for screening Pap tests.
However, Medicare and most other payers will cover screening
Pap tests once every year if the patient is considered “high risk,”
so with proper documentation, this test should be covered.
You’ll need to ask the ordering physician to specify the high risk
sexual behavior that triggered her to order a screening Pap test
earlier than Medicare and other payers typically cover. Then you’ll
need to resubmit the claim with the appropriate diagnosis codes.
Remember: Screening means that the physician orders the test
in the absence of signs or symptoms of the disease. This is still
a screening test if the patient hasn’t had any signs or symptoms
such as an abnormal Pap.
The conditions that Medicare considers valid to justify higher
frequency screening Pap tests include the following, some of
which relate to high-risk sexual activity:
» Early onset of sexual activity (under 16 years of age)
» Multiple sexual partners (five or more in a lifetime)
» History of sexually transmitted disease (including HIV
infection)
» Fewer than three negative or any Pap smears within the
previous seven years
» DES (diethylstilbestrol) exposure of daughters of women
who took DES during pregnancy.
Here are some of the diagnosis codes that ICD-10 provides to
describe these conditions:
»
»
»
»
Z72.51 (High risk heterosexual behavior)
Z72.52 (High risk homosexual behavior)
Z72.53 (High risk bisexual behavior)
Z20.2 (Contact with and [suspected] exposure to infections
with a predominantly sexual mode of transmission)
» Z86.19 (Personal history of other infectious and parasitic
diseases).
Bottom line: Ask the ordering physician to identify the high-risk
sexual behavior factor, and assign one of the preceding codes or
other appropriate code along with the screening Pap test ICD-10
code Z12.4 (Encounter for screening for malignant neoplasm of
cervix). Select the appropriate procedure code that your payer
accepts to describe the Pap test method your lab performs, such
as G0123 (Screening cytopathology, cervical or vaginal [any
reporting system], collected in preservative fluid, automated thin
layer preparation, screening by cytotechnologist under physician
supervision) for Medicare, or 88142 (Cytopathology, cervical
(Continued on next page)
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or vaginal [any reporting system], collected in preservative
fluid, automated thin layer preparation; manual screening under
physician supervision) for other payers that don’t recognize the
HCPCS Level II Pap codes.
Solution 2: You should report the diagnosis from the earlier
abnormal Pap as R87.61- (Abnormal cytological findings in
specimens from cervix uteri…) as the ordering diagnosis. This
code requires a sixth character, points out Peggy Stilley, CPC,
CPC-I, CPMA, CPB, COGBC, revenue integrity auditor in
Norman. If you don’t include the sixth character, this “could be
a reason for a denial,” she adds.
For instance: If the last Pap resulted in a diagnosis of ASCUS, you should report R87.610 (Atypical squamous cells of
undetermined significance on cytologic smear of cervix [ASCUS]) as the ordering diagnosis for the repeat test. Note that this
is now a diagnostic test, not a screening test, so you should not
additionally report the screening code Z12.4 (Encounter for
screening for malignant neoplasm of cervix).
Choose by method: You must always select the procedure
code based on the lab method used for the test. Because this is
a diagnostic test, you should not use one of the HCPCS Level
II procedure codes that Medicare requires for screening Pap
tests, even if Medicare is the payer in this scenario. Choose
the appropriate CPT® code such as 88174 (Cytopathology,
cervical or vaginal [any reporting system], collected in
preservative fluid, automated thin layer preparation; screening
by automated system, under physician supervision).
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Match test and interpretation: You stated that the pathologist
had to interpret this test, which warrants an additional code for
a separate interpretation service. “Because you’ve billed one
of the CPT® Pap test codes, the appropriate interpretation code
is 88141 (Cytopathology, cervical or vaginal [any reporting
system], requiring interpretation by physician),” explains R.M.
Stainton Jr., MD, president of Doctors- Anatomic Pathology
Services in Jonesboro, Ark.
However, if this had been a screening test that you reported
with a HCPCS Level II code, you would choose a different
interpretation code such as one of the following, which matches
the initial test:
» G0124 (Screening cytopathology, cervical or vaginal [any
reporting system], collected in preservative fluid, automated
thin layer preparation, requiring interpretation by physician).
» P3001 (Screening Papanicolaou smear, cervical or vaginal,
up to three smears, requiring interpretation by physician)
» G0141 (Screening cytopathology smears, cervical or
vaginal, performed by automated system, with manual
rescreening, requiring interpretation by physician).
Solution 3: If the patient requires a second Pap smear because
the first sample was inadequate (that is, the lab did not have
enough cells in the specimen to interpret the results), you
need to “report the appropriate diagnosis,” says Shannon
McKendall, CPC with TUMG Business Services, which is
R87.615 (Unsatisfactory cytologic smear of cervix).
Unsatisfactory smear: Several conditions can result in a Pap
smear that does not yield enough cells for the cytopathologist
or automated system to reach a determination. For example,
the physician may not reach the transformation zone to acquire
enough cervical cells, or the lab analyst may not be able to see
enough cells due to contamination from blood, inflammation,
or mucous. When the Pap test results in an inadequate
specimen for analysis, the physician likely would require
another Pap. In the absence of an abnormal diagnosis, the
repeat Pap would still be a screening test, not a diagnostic test.
Remember: If Medicare is the payer, you’ll need to avoid
CPT® Pap test codes and instead use one of the HCPCS Level
II codes to report the screening procedure, such as G0143
(Screening cytopathology, cervical or vaginal [any reporting
system], collected in preservative fluid, automated thin layer
preparation, with manual screening and rescreening by
cytotechnologist under physician supervision).
Use modifier: Repeating a screening Pap test more frequently
than allowed by coverage rules can result in a denial. To
alert your payer that the repeat test is medically necessary,
you’ll need to bill the second screening procedure code with
a modifier. Different payers may expect different modifiers
in this scenario, but many Medicare payers and others accept
76 (Repeat procedure or service by same physician or other
qualified health care professional). You may want to contact
your payer for instruction. q
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}
Oncology & Hematology:
Spot the Right Codes for Malignant Neoplasms in the Cord,
Cauda, and Cranial Nerves
Cauda equina malignancy has defined code though not all in cranial nerves have specific codes.
Having reported the ICD-10-CM codes for many months
now, you would have identified the key codes that make
routine for your practice. It is good to periodically review
how you are submitting the diagnosis codes on claims. In this
issue, we will reiterate the codes for malignant neoplasms in
the spinal cord, cauda equina, and the cranial nerves.
respectively. Metastatic neoplasms can also be rarely
seen,” says Gregory Przybylski, MD, director of
neurosurgery, New Jersey Neuroscience Institute, JFK
Medical Center, Edison. “Fortunately, most spinal
cord neoplasms are benign, including astrocytoma and
ependymoma.”
Target C72.0 for Spinal Cord Tumors
Spot the Specific Codes for 3 Cranial Nerves
When reporting a diagnosis of malignant neoplasm in
the spinal cord, you submit the ICD-10-CM code C72.0
(Malignant neoplasm of spinal cord). This is a single
simple code that leaves you little room for confusion.
CPT® has specific codes for neoplasms only in the cranial
nerves I, II, and VIII, i.e. the olfactory, optic, and acoustic
cranial nerves. The three code series for these cranial
nerves are: C72.2 (Malignant neoplasm of olfactory
nerve), C72.3 (Malignant neoplasm of optic nerve), and
C72.4 (Malignant neoplasm of acoustic nerve).
Spinal cord vs. spinal meninges: Note that spinal cord
and spinal meninges are not the same. These are two
distinct anatomical structures and you have a distinct code
for malignant neoplasms arising in the spinal meninges,
i.e., C70.1 (Malignant neoplasm of spinal meninges).
Cauda Equina is not the Same as Spinal Cord
Cauda equina is not a nerve and is not same as the spinal
cord. When your physician documents a diagnosis of
malignant neoplasm in the tuft of nerves at the terminal
end of the spinal cord, you should code C72.1 (Malignant
neoplasm of cauda equina).
What is cauda equina? Cauda equina is the bundle of
spinal nerves and spinal nerve roots that originate in the
tip of the spinal cord. This bundle consists of nerve pairs
that originate from second lumbar level to fifth sacral
level, and the coccygeal nerve. This bundle has both
sensory and motor nerves and supplies the pelvic organs,
perineum, and lower limbs.
“Malignant tumors of the spinal cord and cauda equina
are typically glioblastoma and malignant ependymoma
Find the fifth character: For malignant neoplasms in the
olfactory, optic, and acoustic cranial nerves, you should
describe the fifth character depending upon the laterality
of the neoplasm. Table 2 lists the codes for the right and
left sided involvement of these cranial nerves. In addition,
you have specific codes which you can submit when your
physician does not specify the laterality of the neoplasm.
Code for Other Cranial Nerves
Your claims are not limited to only olfactory, optic, and
acoustic cranial nerves. When your physician documents
neoplasm in a cranial nerve other than these three nerves,
you can prepare a claim with code C72.59 (Malignant
neoplasm of other cranial nerves).
Don’t have a name or number for cranial nerve?
When your physician does not document the name or
number of the cranial nerve involved with the neoplasm,
you submit CPT® code C72.50 (Malignant neoplasm of
unspecified cranial nerve). q
Table 2: CPT® codes for malignant neoplasms in the olfactory, optic, and acoustic cranial nerves
Code
Descriptor
Code
Descriptor
Code
Descriptor
C72.20
C72.30 Malignant neoplasm of
C72.40 Malignant neoplasm of
Malignant neoplasm of
unspecified olfactory nerve
unspecified optic nerve
unspecified acoustic nerve
C72.21
Malignant neoplasm of right C72.31 Malignant neoplasm of right C72.41 Malignant neoplasm of
olfactory nerve
optic nerve
right acoustic nerve
C72.22
C72.42 Malignant neoplasm of left
Malignant neoplasm of left C72.32 Malignant neoplasm of left
olfactory nerve
optic nerve
acoustic nerve
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Orthopedics:
Straining to Find a Neck Sprain Code? Here are Your Options
Watch out: Careful of what seventh character you apply.
Neck sprain means that the patient presents with damage
to the ligaments of the neck. To report the correct code
you must specify which ligaments/joints were sprained in
the neck.
Injury (see also specified injury type) T14.90
Here are your options:
- anterior longitudinal, cervical S13.4
- atlas, atlanto-axial, atlanto-occipital S13.4
- cervical, cervicodorsal, cervicothoracic S13.4
- neck S13.9
- - anterior longitudinal cervical ligament S13.4
- - atlanto-axial joint S13.4
- - atlanto-occipital joint S13.4
- - cervical spine S13.4
- - specified site NEC S13.8
- spine
- - cervical S13.4
» S13.4xx-, Sprain of ligaments of cervical spine
» S13.8xx-, Sprain of joints and ligaments of other
parts of neck
» S13.9xx-, Sprain of joints and ligament of
unspecified parts of neck.
Each of these codes requires a 7th character: A (initial
counter), D (subsequent encounter), or S (sequela),
says Peggy Stilley, CPC, CPC-I, CPMA, CPB,
COGBC, revenue integrity auditor for Oklahoma Sports
Orthopedics Institute in Norman.
Sprain (joint) (ligament)
Documentation: The provider probably already
specifies which ligaments/joints were sprained in the
neck, but now you have codes to reflect that.
Syndrome —see also Disease
The provider may simply document sprain of ligaments
of cervical spine as “sprain of anterior longitudinal
(ligament), cervical,” “sprain of atlanto-axial (joints),”
“sprain of atlanto-occipital (joints),” or “whiplash injury
of cervical spine.”
Torticollis (intermittent) (spastic) M43.6
Heads up: Don’t always reach for the unspecified code.
You should always code to the highest specificity.
Locate This Condition in Alphabetic Index
Here is how you will locate this code in the Alphabetical
Index:
Reader Questions - whiplash S13.4
- traumatic, current S13.4
Whiplash injury S13.4
Coding tips: You will see an Exclude2 note under S13
stating that you may report this code with a strain of
muscle or tendon at neck level (S16.1) code, but your
physician needs to document both conditions.
If you’re seeing a patient for a worker’s compensation
claim, you may have to apply an old ICD-9 code, which
would be 847.0 (Neck sprain). q
}
Don’t Be Surprised By Some CMS ICD-10 Denials
Question:
Are other coders receiving denials fora PSA claim after
10/1/2016 for using the new ICD-10 code R97.20?
Kansas Subscriber
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- whiplash (cervical spine) S13.4
Answer:
Yes, physicians are getting denials for claims with ICD-10
diagnosis R97.20 (Elevated prostate specific antigen [PSA]).
Here’s why: Medicare’s lab system is not accepting the new
diagnosis codes until either January 1 or April 1 of 2017. The
new ICD-10 codes will be backdated to their effective date
once that shift takes place.
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According to the National Coverage Determination, “Please
note that due to this being the first regular ICD-10 code update
since the partial code freeze October 1, 2011, (there were
limited new codes introduced in fiscal years 2012, 2013, 2014,
and 2015), and the voluminous number of new codes involved,
the Medicare shared systems will split implementation of the
new codes over the January 1, 2017 and April1, 2017 quarterly
updates. While the implementation dates will be in January
1 and April 1, 2017, the effective dates of the new codes will
still be October 1, 2016. All deleted codes will not be valid
for payment after September 30, 2016. Contractors will be
instructed to adjust claims brought to their attention.” q
Get Specific with Pharyngitis Code Choice
Question:
When our otolaryngologist diagnoses acute pharyngitis, how
should I choose an ICD-10 code for the condition?
Michigan Subscriber
Answer:
Your final diagnosis code choice will depend on encounter
specifics. If you want to choose the most accurate acute
pharyngitis ICD-10 code, you’ll need to go to the notes and get
more information on the patient’s specific complaints. Then,
you’ll be able to make a more informed decision on the specific
type of acute pharyngitis the patient is suffering from.
Pharyngitis types: According to ICD-10, you could diagnose
acute pharyngitis with one of the following ICD-10 codes:
» J02.0 (Streptococcal pharyngitis): Use this diagnosis
if the patient suffers from conditions such as septic
pharyngitis or streptococcal sore throat.
» J02.8 (Acute pharyngitis due to other specified
organisms): Use this diagnosis if the patient suffers from
pharyngitis brought on by an infectious agent. Also,
include an additional code from the B95.- (Streptococcus,
Staphylococcus, and Enterococcus as the cause of
We Want to Hear From You
Tell us what you think about ICD-10
Coding Alert.
• What do you like?
• What topics would you like to see us cover?
• What can we improve on?
We’d love to hear from you.
Please email Suzanne Burmeister at
[email protected]
Thank you in advance for your input!
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diseases classified elsewhere) through B97.- (Viral agents
as the cause of diseases classified elsewhere) ICD-10
code set to identify the infectious agent.
» J02.9 (Acute pharyngitis, unspecified): Use this diagnosis
if the patient suffers from pharyngitis not otherwise
classified in the other pharyngitis codes. As examples of
possible J02.9 sufferers, ICD-10 offers patients afflicted
with acute attacks of gangrenous pharyngitis, suppurative
pharyngitis, and ulcerative pharyngitis. ICD-10 also
wants you to report J02.9 when a patient has one of the
following conditions: acute infective pharyngitis, NOS
(not otherwise specified); acute pharyngitis, NOS; and
acute sore throat, NOS
Although providers are encouraged to avoid unspecified
diagnoses as much as possible, it is likely that the organism
will be unknown when the otolaryngologist first sees the
patient with his complaints. A swab is sent out for culturing
during that visit and the exact organism should be known by
the time the patient comes for follow-up visits. q
Look Beyond E/M for Nursemaid’s Elbow
Question:
Which code applies to nursemaid’s elbow treatment? Our
pediatrician just marked an E/M code but we think there’s more
we can report.
Supercoder.com Subscriber
Answer:
You’ll report the procedure with 24640 (Closed treatment of radial
head subluxation in child, nursemaid elbow, with manipulation).
Link the correct diagnosis code to 24640 to represent the patient’s
affliction. Under ICD-10, you need to know whether the left or
right arm is impacted before you choose your code. You’ll report
S53.031A for the initial encounter to treat nursemaid’s elbow of
the right elbow, and S53.032A for the left elbow.
Because these are ‘S’ codes from Chapter 19 of the ICD-10
manual, you should also report ‘V,’ ‘W,’ ‘X’ or ‘Y’ codes from
Chapter 20 to describe “Occurrence, Activity and Place.”
You’ll typically be able to report a separate evaluation and
management code along with 24640, assuming that the
pediatrician documents an appropriate history, examination of
the patient, and medical decision-making that he performed
before treating the injury.
If the procedural notes justify a separate E/M along with
24640, be sure to attach modifier 25 (Significant, separately
identifiable evaluation and management service by the same
physician or other qualified health care professional on
the same day of the procedure or other service) to the E/M
code. Optimal documentation would be to provide separate
evaluation/management and procedure notes. Distinct
diagnoses linked to each CPT® code, although not absolutely
necessary, would be best. q
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