Diagnosis Coding
a Little Twisted
Shelley Young, CPC, CEDC
Jennifer Ordner, CPC, CEDC
May 2013
What’s happening in the
Diagnosis World
• Buried info on ICD-10
• HCC coding what is it…
–
–
–
–
–
Hierarchy Condition Coding
PQRS was the first step
ICD-10 is the next step
ICD-10 in the end will change how we determine E/M levels
Physicians will be paid based on condition and severity of what is
being treated vs E/M which will be similar to DRG
WHO
• No, NOT a question WHO stands for the World Health
Organization
• In 1949 they realized that they needed a system in place
to not just track deaths but also track the causes of
disease worldwide
History of Diagnosis
• In 1893, there was a standardized system for tracking
and classifying deaths
• The list was then compiled and sent to a statistician in
Paris by the name of Jacque Bertillon
• Nearly 26 countries began using the Bertillon
Classification method by the 1900s
• In a study, by the Health Organization of the League of
Nations, talked about how the current classification
method could be expanded to include disease tracking
ICD-10
•Go live date is 10-1-2014
•Why convert?
•Many believe that ICD-9 code sets have become too outdated and are no
longer workable for treatment, reporting, and payment processes today
•The belief is that the more specific data will better identify diagnosis trends,
public health needs, epidemic outbreaks and bioterrorism events
•The more precise codes are supported as providing potential benefits through
fewer rejected claims, improved benchmark data, improved quality and care
management and improved public health reporting
(AMA ICD-10 policy statement)
5
What’s happening in the
Diagnosis World
•Partial code freeze for ICD-9
•This will end 1 year after ICD-10 implementation
•The last regular updated made to 9 & 10 were made on
Oct 1, 2011
•Oct 1, 2012 & 2013 there will only be limited code
updates to 9 & 10 code sets to capture new
technologies and diseases
•All other code requests will be processed for
implementation after Oct 1, 2015 in ICD-10
6
Driving Force in Diagnosis Coding?
7
Diagnosis Codes
• Diagnosis and procedure codes must correlate on an outpatient claim
• Medical necessity must be established – Medicare
defines a service as medically necessary if it is needed
for the diagnosis or treatment of a medical condition and
meets the standards of good medical practice
• No correlation = NO reimbursement
Medical Necessity
• Medical Necessity is the overriding factor in determining
whether a service is a covered benefit. You can perform
a complete history and exam but without documenting
that it is medically necessary the OIG would say the case
was over-coded if the level of service provided was more
than what is necessary to evaluate and manage the pt’s
condition that prompted the visit
• USE signs and symptoms that the docs mention within
the chart to support medical necessity of a visit to the ED
In’s & Out’s
•Accurate diagnosis coding helps:
• Avoid rejected claims
•Delays in billing
•Support medical necessity
•There is no such thing as your providers being too specific
•Encourage them more than ever to DOCUMENT down to
the nitty-gritty detail
10
Food for Thought
A CHART IS ONLY AS
STRONG AS THE
WEAKEST COMPONENT
9 VS 10
ICD9
ICD10
• Up to 5 characters
• Up to 7 characters
• No place holders
• X used to fill empty 4th – 7th
character positions
• First character is alpha
(v / e) or numeric
• Subsequent characters (25) are numeric
• 15,000 codes
• First character is alpha
using all but the letter U
• Subsequent characters (27) are alpha or numeric
• 68,000 codes
12
DO NOT CODE
• Do NOT code a dx listed as:
–
–
–
–
–
Probable
Suspected
Questionable
Rule out
Or similar terms indicating uncertainty
– Only code chronic conditions when that chronic condition is
treated or becomes an active factor in the pt’s care… if not do not
code
TRIVIA TIME
• Why are the parts and pieces of ROS important?
• Documentation has to sometimes be pulled from other
areas of the chart to help your docs out
– ROS can come from the HPI or PFSHX also
– A good coder will be able to pull things from HPI that they are not
using in the HPI to add elements to ROS to avoid downcodes
– How much can you save your practice by avoiding
downcodes? (education your coders and docs)
– Allergies are normally listed as part of PFSHX if you aren’t using
it you can count it as an element in ROS
What would you code
• Pt presents with SOB, fever and is HIV positive
780.60, 786.05, 042
042, 780.60, 786.05
042, 780.60, 786.05, v08
Pt involved in MVA with head injury and positive LOC less
than 10 min and is HIV positive
850.11, 042, e812.9
042, 850.11, e812.9
Ch 1: Infectious & Parasitic
•
HIV
– Code only confirmed cases
– The provider’s statement that the pt is HIV positive is sufficient you don’t have to
have documentation of positive serology
– The principal diagnosis should be 042 followed by additional diagnosis codes for
all reported HIV-related conditions
– V08 should only be applied when the pt w/o any documentation of symptoms is
listed as being HIV positive, known HIV, HIV test positive or similar terminology
– 795.71 can be used w/ Inconclusive HIV serology but no definitive dx
– First example 042, 780.60, 786.05 would be the correct sequencing
– If a pt is seen for an unrelated condition such as a traumatic injury the code for
the unrelated condition should be the principal diagnosis followed by 042 and then
any additional diagnosis codes
– Second example 850.11, 042, e812.9 would be the correct sequencing
– There are specific codes for HIV testing and HIV in pregnancy
What would you code
•
Chart Examples: Severe sepsis
– Dx is severe sepsis
– 038.9, 995.92
– 995.92
–
–
–
–
Pt has cellulitis in axilla & dx is sepsis
038.9, 995.91, 682.3
682.3, 995.91
682.3, 038.9, 995.91
–
–
–
–
Pt presents to the ED w/ SOB & cough and dx is sepsis
786.05, 786.2, 038.9
995.91, 786.05, 786.2
038.9, 995.91, 786.05, 786.2
Sepsis
• The coding of SIRS, sepsis & severe sepsis require a minimum of 2
codes: a code for the underlying cause (such as infection or trauma)
and a code from subcategory 995.9 systemic inflammatory response
syndrome (SIRS)
• The code for the underlying cause must be sequenced first
• Sepsis & severe sepsis require a code for the systemic infection
(038.xx-112.5) and either code 995.91, sepsis, or 995.92, severe
sepsis
• If pt has sepsis w multiple organ dysfunctions follow the instructions
for coding severe sepsis
• Example 1 038.9, 995.92, Example 2 038.9, 995.91, 682.3, Example
3 038.9, 995.91, 786.05, 786.2
What would you code
• 70 yr old pt presents to the ED with hip pain and work-up
verified metastatic bone cancer to the hip from an
unknown primary site
• 338.3 – Neoplasm related px
• 199.1 – Malignant neoplasm of unspecified site
• 198.5 – Secondary malignant neoplasm of bone and
bone marrow
• 719.45 – hip px
19
Ch 2: Neoplasms
• This example would be coded
–
–
–
–
338.3 (1st listed diagnosis b/c pain is the reason for the ED encounter)
198.5 (b/c they are concerned w/ the metastatic neoplasm on this visit)
199.1
719.45
• If pt is being treated for anemia associated w/ malignancy then the
anemia 285.22 in neoplastic disease would be sequenced first
followed by the appropriate malignancy code
• If pt presents to the ED for management of dehydration due to the
malignancy and we are rehydrating the pt then the dehydration is
sequenced first followed by the appropriate malignancy code
20
Ch 2: Neoplasm
• Determine first if the neoplasm is:
• Benign – lacks all 3 of the malignant properties of cancer
• In-situ – cancer that is only present in the cells in which it started
and has not spread to any nearby tissues
• Malignant – tumor that tends to grow, invade and metastasize and
tends to spread to other parts of the body
• Metastatic – begins as cancer in another part of the body and the
secondary location of the cancer is the metastatic site
• To code neoplasms use the Neoplasm table in your ICD-9 book
What would you code
• 250.80 – Diabetes w/ hypoglycemia (one code)
• 250.80 + 780.4 – Diabetes w/ dizziness (two codes)
• 250.92 – Diabetes uncontrolled
• 250.13 – DKA, uncontrolled
– Diabetic ketoacidosis by definition is uncontrolled and more
commonly occurs in people with Type I diabetes. Therefore, the
5th digit for 'uncontrolled' should be assigned. If 'unspecified' type
of diabetes was selected, it will default to 250.13 (Type I,
uncontrolled)
– So when would you use 250.11? – DKA not stated as
uncontrolled
Ch 3: Endocrine, Nutritional, & Metabolic
Diseases & Immunity Disorders
• Etiology/ manifestation convention
• For each code under category 250 there is a use additional code
note for the manifestation that is specific for that particular diabetic
manifestation
• The category 250 diabetes codes should be sequenced first,
followed by the manifestation codes
• Be careful when coding complications with diabetes there is usually
always a complicated diabetes code to use with it
What would you code
• The physician documents that the pt has blood loss
anemia. Which diagnosis code is supported by this
documentation?
–
–
–
–
280.0 iron deficiency anemia secondary to blood loss (chronic)
285.1 acute post hemorrhagic anemia
285.8 other specified anemia
285.9 unspecified anemia
Ch 4: Disease of blood & blood forming
organs
• 280.0 is the correct answer: The physician did not
document the type of anemia, w/o that documentation
280.0 is the default for unspecified anemia
• Anemia in chronic illness has codes for anemia in chronic
kidney disease 285.21, anemia in neoplastic disease
285.22, and anemia in other chronic illness 285.29
• These codes can be listed as primary dx but it is also
necessary to use the code for the chronic condition
causing the anemia
Ch 5: Mental Behavior
26
WHAT WOULD YOU CODE
•
HPI:
03/19 This 62 years old Hispanic Female presents to ER via POV with complaints of Emotional
19:46 Problem. Pt's adult child who is her caretaker complains of worsening dementia, wandering
off, combativeness and confusion over last three months. is seeking hospitalization or SNF.
Severity of symptoms: At their worst the symptoms were moderate in the emergency
department the symptoms are unchanged. The patient has experienced similar episodes in
the past.
Disposition:
03/19/13 21:51 Discharged to Home. Impression: Dementia.
- Condition is Stable.
- Discharge Instructions: Dementia.
•
294.20 Dementia, unspecified, w/o behavioral disturbance
•
294.21 Dementia, unspecified, w/ behavioral disturbance
•
294.21 Dementia, unspecified, w/ behavioral disturbance ;
v40.31 Wandering in diseases classified elsewhere (manifestation)
27
Dementia w/ wandering
• Dementia with wandering has a special code set
• 294.21 Dementia w/ behavioral disturbance
•
w/ behavioral disturbance includes aggression, combativeness, violence and
wandering
•
V40.31 Wandering in diseases classified elsewhere (manifestation)
– meaning you would code first the underlying conditions such as:
Alzheimer’s disease (331.0)
Autism or pervasive development disorder (299.0-299.9)
Dementia, unspecified, w/ behavioral disturbance (294.21)
Intellectual disabilities (317-319)
28
WHAT WOULD YOU CODE
•
HPI:
03/19 This 20 years old Male presents to ER via EMS service with complaints of Possible
Overdose. The patient presents to the emergency department with a possible overdose, known
heroin user, was injecting earlier today with his girlfriend.. Context: Method: it is
confirmed or suspected that the patient injected a substance, heroin, Time: just prior
to arrival, the OD/poisoning occurred at home, and was witnessed by family, by a
friend. Associated signs and symptoms: Pertinent positives: decreased level of consciousness,
Pertinent negatives: apnea. Severity of symptoms: At their worst the symptoms were mild
just prior to arrival, in the emergency department the symptoms have improved. The
patient has experienced similar episodes in the past, a few times.
Disposition:
03/19/13 10:01 Discharged to Home. Impression: Heroin Overdose.
•
965.01 Poisoning by Heroin;
E850.0 Accidental poisoning by Heroin
•
965.01 Poisoning by Heroin;
E950.0 Suicide & self inflicted poisoning by analgesic/ antipyretic/ antirheumatic
29
Heroin Overdose
• Accidental vs suicidal/ self inflicted injury
• 965.01 Poisoning by Heroin
• E850.0 Accidental poisoning by Heroin
Even though the pt intentionally injected heroin the suicidal E-code is not appropriate
unless the physician states it that way… always use the accidental code unless
documentation supports the use of a suicidal code
In this case the pt injected himself on purpose but not with the intent to harm himself
30
WHAT WOULD YOU CODE
•
•
Middle ear effusion
•
385.89 Disorder of middle ear & mastoid
31
No good specific code… choices for effusion are
•
Amniotic fluid
•
Brain (serous)
•
Bronchial
•
Cerebral/ Subdural
•
Cerebrospinal
•
Cerebrospinal Vessel
•
Chest
•
Intracranial
•
Joint
•
Meninges
•
Pericardium
•
Peritoneal
•
Pleural/ Pulmonary/ Thorax
•
Spinal
Ch 6: Nervous System
•
HPI:
03/26 This 24 years old Male presents to ER via Walk In with complaints of Allergic
Reaction. The patient presents with muscle spasm in neck. Onset: The symptoms/episode
began/occurred 3 hour(s) ago. Associated signs and symptoms: The patient has no
apparent associated signs or symptoms. Possible causes: Haldol. At home the patient or
guardian has treated the symptoms with nothing. Severity of symptoms: At their worst
the symptoms were moderate in the emergency department the symptoms are unchanged.
The patient has not experienced similar symptoms in the past.
•
Disposition: 03/26/13 17:38 Discharged to Home. Impression: Dystonia- Acute, Due to Drugs
•
333.72 – acute dystonia due to drugs
•
Add e-code e939.2 – tranquilizer causing adverse effects in therapeutic use
What would you code
• Pt presents with high blood pressure. History includes
Dialysis tx
• Diagnosis hypertension w/ ESRD
• 401.9 – unspecified hypertension
• 403.91 – hypertensive chronic kidney disease stage V or
end stage renal disease, unspecified benign or malignant
• 585.6 ESRD
Ch 7: Circulatory System
• Correct code assignment for chart example is 403.91 & 585.6
• Always remember to look and see if there is a combo code for
hypertension there are several for renal diseases, cardiovascular,
encephalopathy, heart disease, retinopathy, cerebrovascular
disease, heart disease, etc
• Assign hypertension to category code 401 w/ the appropriate 4th digit
to indicate malignant (.0), benign (.1) or unspecified (.9)
• Use code 796.2 when the pt has a statement of elevated blood
pressure in chart w/ no diagnosis of hypertension
Ch 7: Circulatory
• Atrial fibrillation – 427.31
• Atrial flutter – 427.32
• Paroxysmal ventricular tachycardia 427.1
– If a chart says w/ RVR (rapid ventricular response) this is the correct
code to add for that
• For MI’s know if they are STEMI or non and identify the site if
documentation tells you such as anterolateral wall or true posterior
wall
• CVA, cerebral infarction & stroke are indexed to the default code
434.91
• V12.54 use for history of cerebrovascular disease when no
neurologic deficits are present
WHAT WOULD YOU CODE
• Intraparenchymal hemorrhage
• 432.9 intracranial hemorrhage
• 432.1 subdural hemorrhage
• 431 intracerebral hemorrhage
36
Intraparenchymal Hemorrhage
431 intracerebral hemorrhage
is the correct code
Intraparenchymal
hemorrhage (IPH) is one
extension of intracerebral
hemorrhage (the other is
intraventricular hemorrhage
(IVH)) with bleeding within
brain
37
Ch 8: Respiratory
• Respiratory Failure – 518.81
• w/ Hypoxia (desaturation) – 799.02
• Respiratory Distress – 518.82
– Not in adult or newborn it codes out to 786.09
• ICD-10 combo code for respiratory failure w/ hypoxia
J96.01
• COPD – 496, w/ exacerbation – 491.21, w/ asthma
exacerbation – 493.22…. Be careful lots of combo codes
What would you code
•
HPI:
04/01 This 47 years old Male presents to ER via EMS service with complaints of Abdominal Pain.
47 year old male who comes in with abdominal pain. He reports he had a hernia repair done one
week ago here. Now he has severe pain all over his abdomen.
ED Workup reveals pt has Hepatitis C and Cirrhosis of the Liver
Disposition: Discharged to Home. Impression: Abdominal Pain.
•
Which diagnosis codes need to be included and how would you sequence them on the claim?
•
070.70 – unspecified viral Hep C w/o hepatic coma
•
571.5 – Cirrhosis of Liver w/o mention of alcohol
•
789.00 – Ab px, unspecified site
•
303.90 – unspecified alcohol dependence
•
571.2 – Alcoholic cirrhosis of liver
•
571.1 – Acute alcoholic hepatitis
Hepatitis
• Do note code what is not in the chart… so do not
diagnose the pt with something they don’t have… if it
doesn’t state that the Cirrhosis is due to alcohol then do
not diagnose as such
• 789.00, 070.70, 571.5
Ch 9: Digestive System
• Persistent/ cyclical vomiting codes out to 536.2
– Helps support medical necessity much more so than just 787.03
or 787.01
• Crohn’s disease – 555.9; ICD-10 K50.90
What would you code
• Urosepsis as Dx… 038.9, 995.91 OR 599.0?
• Dx: UTI (pyelonephritis)… 599.0, 590.80 OR 590.80 only
• Dx: Uremia… codes out to 586 (renal failure)
GU answers
• Example 1: Urosepsis codes out to 599.0… educate your
docs that this dx listed codes out to a UTI not Sepsis
(they don’t always know what is what in the coding world)
• Example 2: Code the pyelonephritis as that is the more
specific of the two
– UTI: infection that infects part of the urinary tract
– Pyelonephritis: when the UTI affects the upper urinary tract AKA
kidney infection
– Cystitis: when the UTI affects the lower urinary tract AKA bladder
infection
Ch 10: Genitourinary
• 592.0 calculus of kidney
• 592.1 calculus of ureter
• 591 hydronephrosis
(literally water in kidneys)
• 592.0 acute cystitis
(bacteria that enters the
urethra and bladder)
HMMMM…
Disposition:
03/13/13 14:04 Discharged to Home. Impression:
Bladder Infection (UTI) - questionable - pt describes a
beautiful UTI but her urine dip came back negative. Will send for
culture..
SIGNS & SYMPTOMS in a chart are your friend… they are
NECESSARY for payment in an ED
45
What would you code
• Pt has RLQ abdominal pain… discharge w/ vaginal
bleeding in pregnancy
• 789.03 – RLQ ab px
• 623.8 – vaginal bleeding
• 646.83 – complication of pregnancy
• 641.93 – unspecified antepartum hemorrhage ,
antepartum
46
Ch 11: Complications of Pregnancy
• The correct way to code it would be 641.93, 789.03
• 646.83, 646.93, 648.93… unspecified pregnancy
complication codes should only be used when there is no
specific pregnancy complication code to use for instance
in this example the 641.93 trumps the use of 646.83
47
What would you code
•
HPI:
01/02 This 30 years old Female presents to ER via POV with complaints of urinary problems.
Onset: The symptoms/episode began/occurred gradually, 5 year(s) ago. Severity of
symptoms: in the emergency department the symptoms are unchanged. The patient has
experienced similar episodes in the past, chronically. The patient has not recently
seen a physician, Patient sees a nurse practitioner in Internal Medicine. Pt had a positive
pregnancy test last week.
Disposition: 01/02/13 13:39 Discharged to Home. Impression: Bacterial Vaginosis
•
646.83 - complication of pregnancy
•
616.10 – vaginosis
•
646.63 – infections of genitourinary tract in pregnancy, antepartum
•
041.9 – unspecified bacterial infection in conditions classified elsewhere
48
Ch 11: Complications of Pregnancy
• The correct way to code it would be 646.63, 616.10,
041.9
• Remember don’t use 646.83 when you have a specific
pregnancy complication code such as 646.63
• 646.63 needs to be listed with any GU complaints in
pregnancy ie: UTI, cervicitis, vaginitis
49
What would you code
•
HPI:
04/23 This 15 years old Female presents to ER via Walk In with complaints of hurts to sit. The patient
presents with pain that is acute, with no known mechanism of injury, and tenderness. The symptoms are
located in the lumbar area. Onset: The symptoms/episode began/occurred 2 day(s) ago. The pain does not
radiate. Associated signs and symptoms: Pertinent positives: none Pertinent negatives: abdominal pain,
constipation, dysuria, fever, hematuria, incontinence, nausea, numbness, vomiting. The
problem was sustained from unknown cause. Modifying factors: The patient symptoms are alleviated by
nothing, the patient symptoms are aggravated by supine position, sitting. Severity of symptoms: At their
worst the symptoms were mild, in the emergency department the symptoms are unchanged. The patient
has not experienced similar symptoms in the past. Patient states that she is currently 25 weeks pregnant.
•
Disposition:
04/23/13 19:20 Discharged to Home. Impression: Discomfort of Pregnancy.
- Condition is Stable. - Discharge Instructions: BACK PAIN (Acute or Chronic).
•
724.2 – low back pain
•
646.83 – complication of pregnancy, antepartum
•
648.73 - Bone/joint disorder of back/pelvis/lower limb complicating pregnancy, antepartum
50
Ch 11: Complications in Pregnancy
• In this example you would code the pregnancy
complication code 648.73 for the disorder of back along
with the 724.2 for low back pain code
– 648 has a note that says use additional code to identify the
condition so this would need both codes to be properly coded
51
What would you code
•
HPI:
01/05 This 29 years old African American Female presents to ER via POV with complaints of ER to ER Transfer,
Abdominal Pain. The patient presents with abdominal pain in the lower abdomen. Onset: The symptoms/episode
began/occurred 1 day(s) ago. The symptoms do not radiate. Associated signs and symptoms Pertinent negatives:
chest pain, diarrhea, dysuria, fever, headache, hematuria, nausea, palpitations, shortness of breath, vomiting,
vomiting blood. The symptoms are described as crampy, intermittent. Modifying factors: The symptoms are
alleviated by bringing legs to chest. the symptoms are aggravated by coughing, pressure. Severity of pain: At its
worst the pain was moderate in the emergency department the pain is unchanged.
Procedures:
06:36 The staff physician who was present for and supervised the key portions of the procedure was Scott McAninch
MD. I performed a transvaginal ultrasound to rule out ectopic pregnancy and to assess fetal viability. Probe used was
a tightly curved transcavitary probe. Interpretation: Empty uterus without signs of intrauterine pregnancy. FHT: 176
beats per minute. Other: Concern for an ectopic pregnancy, pt sent for formal OB US.
Disposition:
01/05/13 08:12 Discharged to OR. Impression: Ectopic Pregnancy
633.90 – unspecified ectopic pregnancy w/o intrauterine pregnancy
52
Ch 11: Complications in Pregnancy
• Threatened abortion – 640.03 (includes vaginal bleeding)
• All of the abortion codes will ask if it is complete or
incomplete or unknown… the majority of the time in the
ED it’s unknown
• All OB ultrasounds done in the ED need to be supported
w/ pregnancy complication codes if applicable….
– What if dx is ab px and vaginal bleeding but doesn’t mention pregnancy? In the procedure
note for the ultrasound it says FHT (fetal heart tone) 154… CODE the pregnancy complication
– What if dx is UTI w/ IUP, but ultrasound shows empty uterus without signs of pregnancy? We
get this quite often in our ED… after speaking with numerous docs, they have stated that it is
difficult for them to determine miscarriages in the ED and if the pt is pregnant no matter what
the U/S reveals b/c it doesn’t always show them everything then the chart needs to be coded
as a pregnancy chart
53
Abortions
Spontaneous Abortion
Unspecified Abortion
•
634.0X
•
637.0X
•
634.0 complicated by genital tract & pelvic
infection
•
637.0 complicated by genital tract & pelvic
infection
•
634.1 complicated by delayed or excessive
hemorrhage
•
637.1 complicated by delayed or excessive
hemorrhage
•
634.8 with unspecified complication
•
637.8 with unspecified complication
•
634.9 w/o mention of complication
•
637.9 w/o mention of complication
5th digit
0- unspecified
1- incomplete
2- complete
54
Vomiting in Pregnancy
•
643.93 – unspecified vomiting in pregnancy, antepartum
– Prenatal & antepartum mean before giving birth and refer to the
period during pregnancy
•
643.91 – unspecified vomiting in pregnancy, delivered
•
643.90 – unspecified vomiting in pregnancy, unspecified episode of care
•
643.03 – mild hyperemesis gravidarum, antepartum
– Hyperemesis gravidarum is extreme, persistent nausea and vomiting
during pregnancy… can lead to dehydration
•
643.01 – mild hyperemesis gravidarum, delivered
•
643.00 – mild hyperemesis gravidarum, unspecified episode of care
55
Ch 11: Complications of Pregnancy
• Chapter 11 codes have sequencing priority over codes from other
chapters
• Should the provider document that pregnancy is incidental (not what
they are being seen for at the time of the visit) to the encounter, then
code v22.2 should be used in place of any chapter 11 codes… it is
the docs responsibility to state that the condition being treated is not
affecting the pregnancy and if that is not stated then a code from
chapter 11 would be appropriate
• Postpartum period is from the time immediately following delivery
and continues for six weeks… after the six week period chapter 11
codes can still be used if the provider documents that a condition is
pregnancy related
56
Pregnancy Trimesters
• If you know the trimester of pregnancy, use the codes
that specify that… again in the ED it is usually not
specified
• First Trimester:
– Weeks 1-13
– Months 1-3
• Second Trimester:
– Weeks 14-26
– Months 4-6
• Third Trimester:
– Weeks 27-40
– Months 7-9
57
Ch 12: Skin
Two codes are needed to completely
describe a pressure ulcer.
1st code the site
2nd code the stage
Unstageable pressure ulcers:
707.25- the stage cannot be
determined (e.g., the ulcer has been
treated by skin graft)
707.20 – should be assigned if there
is no documentation regarding the
stage.
This code is also used for a healing
pressure ulcer and no stage is given
Unstageable pressure ulcers - until enough
slough and/or eschar is removed to expose
the base of the wound, the true depth and
stage cannot be determined. However, it will
be either a Stage III or IV.
Let’s have a little fun
• Skeleton Bone Dance
59
Ch 13: Musculoskeletal
• Coding of pathological fractures: 733.1X
– A pathological fracture is a broken bone caused by disease
leading to weakness of the bone as opposed to direct physical
trauma
– Most pathological fractures occur spontaneously during normal
activity, or after a mild injury that wouldn’t ordinarily lead to a
broken bone in most people
Ch 14 Congenital Anomalies
• What is a congenital anomaly?
– A condition that is present at the time of birth
• Assign a code 740-759 when an anomaly is present
• Ch 14 codes can be used through the life of the pt
• If a congenital anomaly has been corrected, a personal
history code should be used to identify the history of the
anomaly
What would you code
• HPI: This 8 day old female presents w complaints of
respiratory symptoms – grunting. The pt has SOB for
approx 3 days. Mom says she had two episodes of
projectile vomiting today 1-2ft.
• Diagnosis is Sepsis
• 038.9, 995.91, 786.05, 787.03
• 771.81, 041.9, 779.33, 786.05
• 771.81, 779.33, 786.05
Ch 15: Newborn
• Newborn Sepsis
• Code 771.81 Septicemia of newborn should be assigned w/ a
secondary code from category 041, bacterial infections in conditions
classified elsewhere and of unspecified site to identify the organism
• A code from 038, septicemia, should not be used on a newborn
record
• Do not assign code 995.91, sepsis, as code 771.81 describes the
sepsis
• Previous example would code out to: 771.81, 041.9, 779.33, 786.05
What would you code
•
HPI:
04/07 This 10 months old Male presents to ER with complaints of Fever. Presents with 2 day
history of r/c/c/ and 1 day history of increased work of breathing and fever (101.8). Pt uses
occasional O2 at home but has not in the past 3 weeks. Patient has maintained good po intake and
UOP. No vomiting or diarrhea. Mom has been giving patient albuterol treatments which seems to
help..
ROS:
01:45 Eyes: Negative for injury, pain, redness, and discharge. Cardiovascular: Negative for cs5
history of heart murmur. Abdomen/GI: Negative for vomiting, diarrhea. Skin: Negative
for injury, rash, and discoloration, Neuro: Negative for weakness and seizure.
Constitutional: Positive for fever, Negative for poor PO intake. ENT: Positive for
nasal discharge, rhinorrhea. Respiratory: Positive for cough, shortness of breath,
wheezing.
Disposition:
04/07/13 01:58 Admit ordered for Saenz, Paulina. Diagnosis is Bronchopulmonary Dysplasia exacerbation.
•
770.7 – chronic respiratory disease arising in the perinatal period
•
OR code signs & symptoms 780.60 – fever, 786.05 - SOB
Bronchopulmonary Dysplasia
• Bronchopulmonary Dysplasia always originates in the
perinatal period; therefore; regardless of the pt's age it is
coded 770.7 chronic respiratory disease arising in the
perinatal period... the age at which the diagnosis was
established or age at continuing tx does not affect the
assignment of code 770.7
Common Newborn Codes in ED
• Newborn w/ Jaundice – 774.6…w/ preterm delivery 774.2
• Vomiting in Newborn – 779.33
• Fever in Newborn – 778.4
• Dehydration in Newborn – 775.5(transitory neonatal
electrolyte disturbances) & 276.51(dehydration)
• Respiratory Failure in Newborn – 770.84
• Respiratory Distress in Newborn – 770.89
• UTI in Newborn – 771.82
Ch 15: Newborn
• Generally codes from Ch 15 should be sequenced as the
principal dx
• If the index does not provide a specific code for a
perinatal condition, assign code 779.89, other specified
conditions originating in the perinatal period, followed by
the code from another chapter that specifies the condition
67
Ch 16: Signs, Symptoms & Ill Defined
Conditions
• ALTE
– What is it? – Apparent Life Threatening Event … the sudden
occurrence of certain alarming symptoms such as
– Prolonged periods of no breathing
– Changes in color or muscle tone
– Coughing or gagging
– ALTE is not a specific disorder it is a group of symptoms
that occur suddenly in young children
– ALTE ICD-9 code is for infants only 799.82 so up to one
year in age
– If your doc has ALTE listed in as dx in a pt over 1 yr old
then you would need to code the signs and symptoms in
the chart
WHAT WOULD YOU CODE
• Spell or spells of uncertain etiology
• 780.39??? Code for seizure
• 780.2?? Syncope and collapse
• 781.0??? Code for involuntary movement
• Do you really want to give a pt a dx of seizure just b/c the
doc doesn’t know that there isn’t a good code for spells?
69
WHAT WOULD YOU CODE
• Pulmonary Nodule
• 492.8 Nodule; lung; emphysematous nodule…
Emphysema
• 793.11 Nodule; lung, solitary nodule… nonspecific
abnormal findings on radiological/ other examination of
solitary pulmonary nodule
• 786.6 Swelling/ Mass/ Lump in chest
70
Pulmonary Nodule
793.11 would be the correct
code to use for the solitary
pulmonary nodule
Solitary means ONE and
that it stands alone
A solitary pulmonary nodule is
defined as a single nodule
(abnormality) seen on an x-ray
or CT scan, that is less than or
equal to 3 cm (1 ½ inches) in
diameter. If a "spot" on the
lung is larger than 3 cm it is
considered a lung mass
71
Ch 17: Injury & Poisoning
•
Superficial injuries such as abrasions or contusions are not coded when associated
with more severe injuries of the same site
•
When an injury results in damage to nerves or blood vessels the primary injury is
sequenced first w/ additional codes from categories 950-957, injury to nerves and
spinal cord, and/or 900-904, injury to blood vessels… unless the primary injury is to
the nerve or blood vessel then it would be sequenced first
•
Never use the multiple injury codes unless the information for a more specific code is
not available
•
Assign separate codes for each injury unless a combination code is provided in which
case you would use the combo code
73
What would you code
HPI:
03/19 This 90 years old Female presents to ER via EMS service with complaints of Arm Injury.
Nursing home called daughter and told daughter that her Mother's arm started hurting and that pt had
had an XR that showed L arm fx. Pt has not been able to give adequate hx given dementia. Nursing
home unaware of recent fall per daughter. Pt has also complained of "bottom pain". Pt is not on blood
thinners. Pt is non-ambulatory. .
Procedures:
Splinting: Splint applied to left arm using Thumb
Spica Splint applied by myself. Examined by me, post splint application: neurovascular
intact, brisk capillary refill noted, Patient tolerated well.
There was concern for scaphoid fx per report done at OSH. Imaging was
repeated in the ED and radiologist denies seeing any fracture in the scaphoid but pt
have confirmed spiral fx of humerus. Pt has swelling in L wrist and is tender to
palpation at snuff box. Pt was put in thumb spica splint and cuff and collar
Disposition:
03/19/13 17:15 diagnosis Humerus Fx, Possible scaphoid fracture.
74
What would you code
• When documentation is lacking in the physician note look on the radiology report for
more specific findings
• Here is what is found on the radiology report
IMPRESSION:
Humeral diaphysis fracture.
•812.20 Closed fx, unspecified part of humerus
•812.21 Closed fx, shaft of humerus
•812.44 Closed fx, unspecified condyle of humerus (epiphysis)
75
Humeral diaphysis fx
•What does diaphysis mean?
•Mid Shaft of long bone
•What does physis mean?
•AKA growth plate
•What does metaphysis mean?
•The wider portion of a long bone adjacent to the epiphyseal plate
•Part of bone that grows during childhood
•What does epiphysis mean?
•End part of long bone
• 812.21 Closed fx, shaft of humerus
would be the proper code for this example
76
Types of Fx’s
• Complete fx: fx in which bone segments separate completely
• Incomplete fx: fx in which the bone fragments are still partially joined
• Linear fx: fx that is parallel to the bone’s long axis
• Transverse fx: fx that is at a rt angle to the bone’s long axis
• Oblique fx: fx that is diagonal to a bone’s long axis
• Spiral fx: fx where at least one part of the bone is twisted
• Comminuted fx: fx in which bone has broken into several pieces
• Impacted fx: fx caused when bone fragments are driven into each other
• Avulsion fx: fx where a fragment of bone is separated from the main mass
77
FUNKY FX’S!!!
•
Blowout fx: a fx of the walls or floor of the orbit
•
Holstein-Lewis fx: a fx of the distal third of the humerus resulting in entrapment of the radial nerve
•
Colle’s fx: distal fx of the radius w/ dorsal (posterior) displacement of the wrist and hand
•
Smith’s fx: distal fx of the radius w/ volar (ventral) displacement of the wrist and hand
•
Boxer’s fx: fx at the neck of the metacarpal
•
Toddler’s fx: undisplaced & spiral fx of the distal half of the tibia
•
Trimalleolar fx: involving the lateral malleolus, medial malleolus and the distal posterior aspect of
the tibia
•
Bimalleolar fx: involving the lateral malleolus and the medial malleolus
•
Jone’s fx: fx of the proximal end of the fifth metatarsal
•
Salter-Harris fx: fx that involves the epiphyseal plate or growth plate of a bone
•
Greenstick fx: fx in a young, soft bone in which the bone bends and partially breaks
78
Ch 18: V-Codes
• V codes may be used as either a first listed or secondary
code, depending on the circumstances of the encounter.
• Certain V codes may only be used as first listed, others
only as secondary codes, and others either or.
•
How do you know which one’s can be listed as first or
have to be listed second (refer to v-code handout)
Ch 18: V-Codes
•
Contact/ Exposure – may be used as first listed to explain an encounter for testing, or more
commonly, as secondary to identify a potential risk… v01.6 STD exposure
•
Inoculations/ Vaccines – codes from v03-v06 may be used as a secondary code if the inoculation is
given as a routine part of preventative health care such as well-baby visit or tetanus in a trauma
•
Status codes – should NOT be used w/ a code from one of the body system chapters
– V42.1 heart transplant status should not be used in conjunction w/ 996.83 complications of
transplanted heart
– Status codes are important b/c they may affect the course of a treatment and its outcome
– Different than a history code … history indicates that the pt no longer has the condition
•
History codes – two types:
–
–
personal : explain a pt’s past medical condition that no longer exists and is not receiving any tx, but has potential for
reoccurrence, and therefore may require continued monitoring (exception allergies… a person who has an allergic
episode should always be considered allergic to the substance)
Family: to be used when a pt has a family member who has had a particular disease that causes the pt to be at higher
risk of also contracting the disease
•
Screening – testing of a person to rule out or confirm a suspected dx
•
Other v-code categories observation, aftercare, follow-up, donor, counseling, obstetrics and related
conditions, newborn (infant & child), routine & administrative examinations, miscellaneous, non-specific
80
Fracture aftercare codes
• Fractures are coded using the aftercare codes for
encounters after pt has completed active treatment of the
fx and is receiving routine care for the fx during the
healing or recovery phase (v54.0, v54.2, v54.8 or v54.9)
• Ie: cast change or removal, removal of external or
internal fixation device, medication adjustment and follow
up visits
– Pain management is not an example of fracture aftercare that is
considered treatment received outside of the customary global
period of fracture care and is separately reportable
81
Ch 19: E-Codes
•
E-codes are intended to provide data for injury research and evaluation of injury prevention
strategies.
•
Everyone knows they are never listed FIRST!
•
Always use an E code if there is an injury being reported!!
– When you code an injury and do not list an e-code it holds up the processing of claims… the
insurance carrier will always send the claim back for lack of an e-code to identify what
happened and to place the liability for payment where it should fall… so stay a step ahead
and be as specific as possible in listed the correct e-code for the encounter
•
You can use more than one.
•
Here is a short list of common categories of E-codes:
–
–
–
–
–
–
–
Transport accidents
Poisoning and adverse effects of drugs, medicinal substances
Accidental falls
Accidents caused by fire
Accidents due to natural environmental factors
Late effects of accidents, assaults or self-injury
Suicide or self inflicted injury
Claim Forms
• Do your docs list tons of signs and symtpoms and then
have a large list of diagnosis codes… (this makes it hard
to pull signs and symptoms to support medical necessity
due to lack of space on the claim form)?
– The coder is stuck muddling through which ones to choose from,
especially in a trauma when you only have space for 4 dx codes
– SOLUTION… the 1500 form will allow you to list 8 diagnosis
codes… June 1st insurance carriers will be ready to accept the
revised 1500 claim form
83
Help your docs get paid in ICD10
•
Documentation is going to have to be a lot more specific even in the ED’s in order for coders to
come up with good dx codes to support the emergency visits
•
laterality: bilateral, right, left… not only pertaining to injuries ie: otitis media, left ear: ICD9 382.9;
ICD10 H66.92 (2 for the left ear)
•
Anatomic specificity
•
Obstetric codes: the 5th digit episode of care (delivered, antepartum, postpartum) has been
removed from the code description in ICD10 and replaced w/ trimester
– ie: UTI in pregnancy, first trimester ICD9 646.63, 599.0; ICD10 O23.01 (1 for first trimester), w UTI code
– You can see you will have to distinguish between a O and a 0(zero)
•
phase of care: (7th character extensions for injuries)
– S: sequela: meaning complications or conditions that arise as a direct result of an injury, such as scar
formation after a burn (e.g., S65.009S, unspecified injury of ulnar artery at wrist and hand level of unspecified
arm)
– A: initial encounter: meaning the physician is actively treating the patient for the injury (ie: code M84.322A,
stress fracture, left humerus, initial encounter)
– D: subsequent encounter: meaning the patient has received active treatment for the injury, and the physician
is providing routine care for the injury during the healing or recovery phase (ie: code T50.B96D, under dosing
of other viral vaccines, subsequent encounter)
84
The skinny on 10
• What is the meaning for alpha characters?
– At the beginning of the code: it identifies what chapter it is in
– In the middle of the code: they don’t have a specific meaning they
just expand the code set
– At the end of the code: it usually means episode of care or
different types of fractures and/or the episode of care of a fracture
YOUR DOCS DON’T KNOW WHAT YOU DON’T TELL THEM….
ICD-10 is new for everyone…
know it, own it and pass it on
85
Tools & Resources to have handy
• Mercks Manual http://www.merckmanuals.com/professional/index.html
• WebMD - http://www.webmd.com/
• ICD-9 Documentation guidelines http://www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_20
11.pdf
• MAC carrier – Novitas for TX - https://www.novitassolutions.com/
87