Codes That Keep You On Your Toes

Since the launch of ICD-10-CM/PCS, AHIMA has been offering a service called Code-Check where members and nonmembers can seek help from professional coders to solve challenging coding questions concerning ICD-10-CM, ICD-10-PCS, CPT, and HCPCS codes.

The service was designed for physicians, coders, coding managers, clinical documentation improvement specialists, and revenue cycle managers. Code-Check is monitored and staffed by experienced, credentialed coding experts who respond to questions within one business day. This slideshow features five questions submitted to Code-Check on ICD-10-PCS, ICD-10-CM, and CPT coding. Learn more about Code-Check here.

Question

A patient had an ECMO inserted at another hospital and they were unable to remove prior to transfer. The patient was transferred to our hospital and remained on the ECMO for a few days prior to removal. What PCS code(s) would you assign to show the patient is on ECMO and for the removal of it?

Code-Check Response

Only the code for ECMO is assigned, as PCS does not have a code for the insertion and removal of the ECMO device. See Coding Clinics referenced below. However, you do need to verify if the ECMO is central, veno-arterial, or veno-venous.

Question

Patient is admitted with neutropenia fever. MD also documents secondary diagnosis as pancytopenia due to leukemia and chemotherapy. He also states patient has neutropenia fever and neutropenia secondary to chemotx. There is ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2014 regarding neutropenia fever with anemia and thrombocytopenia and it states to code them individually due to pancytopenia has Exclude 1 exclusion with neutropenia a PDX.

My question is admitted with neutropenia fever and MD clearly states pancytopenia. Do I code each individually per 4th qt 2014? Would I code neutropenia fever secondary chemo?

Code-Check Response

We recommend assignment of a code for neutropenia, anemia, and thrombocytopenia.

Rationale

Pancytopenia includes deficiency of all blood constituents, so if the patient had neutropenia, anemia, and thrombocytopenia, a single code for pancytopenia would be assigned. However, neutropenic fever is a more serious condition that is not accounted for solely by reporting neutropenia as part of the pancytopenia code. Coding neutropenic fever requires two codes, a code for neutropenia (agranulocytosis) and a code for fever presenting with conditions classified elsewhere.

The ICD-10-CM Code book, Tabular has an Excludes 1 note at the code for pancytopenia indicating it cannot be assigned with the code for neutropenia (agranulocytosis). Since the classification will not allow assignment of the codes needed to report neutropenic fever along with a code for pancytopenia to cover the additional anemia and thrombocytopenia, codes for each individual condition are assigned rather than the pancytopenia code.

The codes for adverse effect of chemotherapy and the malignancies are also assigned as appropriate.

Question

If the MD states the patient has nonrheumatic aortic valve disease and the patient also has mitral disease what is the appropriate diagnosis code assigned? Does ICD-10 assume the patient is rheumatic and we assign code I08.0? Or do we code them both or separately as nonrheumatic heart disease?

Code-Check Response

We recommend assignment of these codes:

I35.9 Nonrheumatic aortic valve disorder, unspecified

I05.9 Rheumatic mitral valve disease, unspecified

Question

I have a provider report that reads as follows and could use some guidance.

“The Sural nerve was injected with 0.5 cc of Kenalog and 0.25 cc of 0.5% Marcaine plain. The dorsal medial nerve was also injected, just proximal to the left great toenail. Patient tolerated the injections very well.” This is what I understand, if injecting the nerves it would be 64450 x 2 but when injecting in the interspace or other areas, then 64455 x 1. Please advise.

Code-Check Response

We recommend assignment of codes: 64450 Injection(s), anesthetic agent; other peripheral nerve or branch; 64455 Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s).

Question

Our question is about making queries for specific types of encephalopathy, metabolic in particular. We see documentation of encephalopathy as multifactorial or due to infections such as pneumonia. We know from Coding Clinic that when encephalopathy is linked to a specific condition such as UTI or stroke, we code “other” (G93.49). Would it be appropriate to query for the type of encephalopathy in cases where encephalopathy is linked to a specific condition such as a UTI, pneumonia, or multifactorial?

Code-Check Response

A query is appropriate if the clinical indicators supporting a diagnosis are present in the medical record or if there is a need to clarify documentation present in the record.

Rationale

Coding Clinic directs code G93.49, Other encephalopathy be assigned when the documentation indicates encephalopathy is linked to a condition, but a specific encephalopathy (i.e., metabolic, toxic, hypertensive, etc.) is not documented. A specific encephalopathy may not be documented for several reasons including:

  • The patient did not have a specific encephalopathy
  • The physician failed to document the specificity of the encephalopathy

If the clinical data indicates a more specific encephalopathy, it is appropriate to query for a diagnosis or to clarify a less specific diagnosis in order to most accurately paint the patient’s clinical picture. AHIMA guidelines for compliant query indicate queries may be necessary to:

  • Support documentation of medical diagnoses or conditions that are clinically evidentand meet Uniform Hospital Discharge Data Set (UHDDS) requirements but without the corresponding diagnoses or conditions stated.

Establish the acuity or specificity of a documented diagnosis to avoid reporting a default or unspecified code.

Mary Butler is associate editor at Journal of AHIMA.

1 Comment

  1. Are all of your responses published so that other members can benefit from info?

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