First and Second Quarter Coding Clinic Highlights

By Kelli Horn, RHIT, CCS, and Sandra Smith, RHIA, CCS

 

Keeping up with the American Hospital Association’s (AHA) Coding Clinic for ICD-10-CM and ICD-10-PCS is a good habit for all health information management (HIM) professionals to embrace, as coding touches all facets of our industry. Published quarterly, this official resource answer questions, features topics, and provides clarifications and corrections to complement the official ICD-10-CM/PCS coding conventions and instructions when the ICD-10 classification does not provide specific direction.

Two of many topics below include the posterior capsular opacity and the ureteral stent exchange. First, the ICD-10-CM code book index leads to an incorrect code and this issue of Coding Clinic provides the correct code. Second, a previous Coding Clinic provided an incorrect Reposition root operation for a ureteral stent exchange and this issue provided the correct Repair root operation. Therefore, it is imperative to keep up with this official resource to ensure correct code assignment on patient accounts.

Below are highlights related to the first and second quarter publications.

Alcohol Abuse and Alcohol Withdrawal

  • If after query, a physician documents alcohol abuse with alcohol withdrawal, rather than alcohol dependence, code only the “Alcohol Abuse”. Do not assign a code for alcohol withdrawal

Changes To the ICD-10-CM Official Guidelines for Coding and Reporting

  • New updates were included in the first quarter Coding Clinic

COPD

  • Several topics included COPD and emphysema; exacerbation of COPD and emphysema; acute exacerbation of unspecified asthma with COPD; and emphysema, chronic bronchitis, and COPD; as well as bacterial pneumonia, influenza A, and acute COPD exacerbation

Corrections and Clarifications

  • Previous Coding Clinic advice remains valid for clarifications including coronary artery bifurcation, encephalopathy caused by other conditions, and repair of third and fourth degree lacerations
  • One correction instructed that Repair, not Reposition, is the correct root operation for dismembered pyeloplasty
  • Another correction involved the correct approach for a ureteral stent exchange

Degenerative Changes on Outpatient Radiology Reports

  • M47.812, Spondylosis without myelopathy or radiculopathy, cervical region, is the correct code assignment for “degenerative changes of the cervical spine”
  • M16.0, Bilateral primary osteoarthritis of hip, is the correct code assignment for “advanced degenerative changes of both hips”
  • M51.36, Other intervertebral disc degeneration, lumbar region is the correct code assignment for discogenic degenerative changes of the lumbar spine

Diabetes

  • Do not use the code for diabetes with arthropathy, not elsewhere classified (NEC) when “diabetes with arthritis” is documented since the “with” guidelines should not be applied to NEC codes
  • Peripheral arterial disease, peripheral arteriosclerosis and peripheral arterial disease should be coded to peripheral angiopathy in a diabetic patient

Encephalopathy due to Urinary Tract Infection (UTI)

  • G93.49, Other encephalopathy, is the correct code assignment for encephalopathy due to UTI (with N39.0)
  • G94–, Other disorders of the brain in diseases classified elsewhere, should only be assigned for those conditions with Index entries that directly point to code G94

Healthcare Encounters in Hurricane Aftermath

  • Coding guidance including the use and sequencing of external cause of morbidity codes and use of Z codes during hurricanes was provided

High Transverse Cesarean Section

  • 10D00Z0 Extraction of products of conception classical, open approach, is currently the best available option for coding a high transverse Cesarean section

Hygromas

  • Both traumatic and non-traumatic subdural hygromas are coded to G96.0, Cerebrospinal fluid link

Intra-aortic Balloon Pump (IABP)

  • The IABP may be used pre-, intra-, or postoperatively to support the patient for a few hours or several days. It is used for open surgical procedures, percutaneous coronary interventional procedures, and medical therapy
  • It is not appropriate to report an IABP with the device value for “external heart assist device”
  • ICD-10-PCS does not classify an IABP as a device and therefore, it is not appropriate to report the root operations “insertion” and/or “removal” for the placement or removal of an IABP
  • The use of an IABP is appropriately coded to the root operation “Assistance” (5A02210 – continuous or 5A02110 – intermittent)
  • The intraoperative use of the IABP should be coded

Kennedy Terminal Ulcer

  • Assign the appropriate code for site and stage from category L89, Pressure ulcer for a Kennedy terminal ulcer

Miscellaneous

  • H26.942 is assigned for posterior capsular opacity, a secondary cataract
  • P74.2 is assigned for a sodium balance disturbance
  • Other topics include acute respiratory distress, blindness and low vision, clostridium difficile enterocolitis, coding ruled-out diagnosis, degenerative myopia, dermatomyositis, and more

Observation for Suspected Injuries/No Injury Found

  • Assign Z04.3, Encounter for examination and observation following other accident, for infant with possible hot water burn injury and do not assign an external cause of injury code
  • Assign Z04.1, Encounter for examination and observation following transport accident, for infant in MVA with no signs of injury and do not assign an external cause of injury code

Placement of Bone Morphogenetic Protein and Spinal Fusion Surgery

  • Reporting the placement of bone morphogenetic protein (3E0U0GB) during an open spinal fusion procedure is optional and facilities may code it if desired

Psychoactive Substance use Disorders

  • F14.90, Cocaine use, unspecified, uncomplicated, may be assigned without a related mental, physical, or behavioral disorder unless the provider has stated it is not affecting the pregnancy
  • A code is not assigned for “recreational marijuana use” documented in the history and physical examination or “opioid use” documented for pain management in the chart without a related mental, physical, or behavioral disorder

Social Determinants Using Non-Physician Documentation

  • Codes in Section Z55-Z65, Persons with Potential Health Hazards Related to Socioeconomic and Psychosocial Circumstances, represent social information rather than medical diagnoses. Therefore, codes may be assigned based on information provided by allied health clinicians involved in the care of the patient.

Urinary Tract Infection (UTI)

  • Assign N13.6, Pyonephrosis for UTI with hydronephrosis and obstruction due to ureteral calculus
  • Assign O23.43, Unspecified infection of urinary tract in pregnancy, third trimester during delivery episode

 

Kelli Horn (kelli.horn@ardenthealth.com) is director of coding education at Ardent Health Services. Sandra Smith is director of the health information technology program at Tulsa Community College.

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