Coding Chapters 17-23 Guidelines & Terms

How do you code dominant/non-dominant sides when it is unspecified?

Ambidextrous patients default to dominant, if the right side is affected it defaults to dominant and if the left side is affected it defaults to non-dominant

Acute Traumatic vs Chronic or Recurrent Musculoskeletal Conditions

Any current, acute injury should be coded to the appropriate injury code from Chpt 19. Chronic or Recurrent conditions should generally be coded with a code from Chpt 13. If it is difficult to determine from the documentation in the record which code is best to describe the condition query the provider.

When do you code acute respiratory failure as principal diagnosis?

When it is the condition established after study

When to use G89 codes as principal and first-listed diagnosis codes?

When pain control or pain management is the reason for the encounter. If the patient is admitted for insertion of a neurostimulator for pain control.

How do you code post-operative pain not associated with specific post-operative complication?

With the appropriate G89 code.

What is acute exacerbation?

Worsening or a decompensation of a chronic condition

Atelectasis

a collapse of lung tissue: an integral part of pulmonary disease

Sickle-cell Trait

a condition that occurs when a child receives the trait from only one parent.

Biliary System

a network including the gallbladder and bile ducts

Diverticulum

a small pouch or sac opening from a tubular or saccular organ, considered a medical condition

Bronchospasm

a sudden constriction of the muscles in the walls of the bronchiolesis an integral part of asthma or any other type of chronic airway obstruction, but NO additional coded is assigned to indicate its presence

Legionnaire's disease

a type of pneumonia that is almost always caused by inhalation of aerosols that come from a contaminated water source.

Esophageal varices

abnormally enlarged veins in the lower part of the esophagus

Pleural Effusion

accumulation of fluid within the pleural spacesis almost always integral to the underlying disease and is usually addressed only by treatment of that condition.

Secondary arthritis

also called monoarticular arthritis is confined to the joints of one area and results from some external or internal injury or disease.

Corneal Injury

an external cause code is assigned for the external cause. Example: exposure to sunlight

Cellulitis

an infection of the skin and soft tissues resulting from some sort of break in the skin.

Glaucoma

assign as many codes for category H40 as needed to identify the type of glaucoma, the affected eye and the glaucoma stage.

Urethra

carries urine from the bladder to the outside of the body

Ureter

carries urine from the kidneys to the bladder

COPD

chronic obstructive pulmonary disease; a general term describing conditions that result in an airway obstruction. COPD with exacerbation are also called "exacerbation", "in exacerbation", "decompensation", "acute exacerbation", "exacerbated" or "uncompensated"

Diverticulitis

inflammation of existing diverticula

Esophagitis

inflammation of the lining of the esophagus

Respiratory Failure

is a life-threatening condition that is ALWAYS due to an underlying condition.

Osteoarthritis

is the most common form of arthritis. Also called polyarthritis, degerative arthritis, and hypertrophic arthritis

Status Asthmaticus

is when medication is not working. Do not code unless the provider states "status asthmaticus"

Primary osteoarthritis-

known as polyarticular degenerative arthritis affects joints in the spine, knee, and hip, as well as certain small joints of the hands and feet.

Chronic Kidney Failure

long-term disability of the renal function

Patients admitted with Healed Pressure ulcer

no code is assigned if the documentation states that the pressure ulcer is completely healed.

Acute Kidney Failure

sudden failure of renal function

Central Nervous System

the brain and spinal cord

Diverticulosis

the presence of one or more diverticula of the designated site

Hemiplegia/Hemiparesis

- dominant vs no-dominant. Right side dominant is the default for unspecified or ambidextrous patients. Left is default for non-dominant unless it states Patient is left side dominant.

Site and Laterality

For categories where no multiple site code is provided and more than one bone, joint or muscle is involved, multiple codes should be used to indicate the different sites involved.

Bone vs Joint

For certain conditions, the bone may be affected at the upper or lower end. Though the portion of the bone affected may be at the joint, the site designation will be the bone not the joint.

Sensorineural Hearing Loss

Hearing loss due to a problem with the sensory part of the ear or the nerves associated with hearing.

Pressure Ulcer Stages

ICD 10 CM code category L89 are combination codes that identify the site and stage of the pressure ulcer. Pressure ulcers in ICD 10 CM are categorized in stages of severity 1-4 and un-stageable. Assign as many codes from L89 as needed to identify all pressure ulcers.

Pressure Ulcer Evolving To Another Stage During the Admission

If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, assign the code for the highest stage reported for that site.

When do you code respiratory failure as a secondary diagnosis?

If it happens after admission or is present on admission but does not meet the principal diagnosis.

When not to use the G89 code for pain?

If the pain is not specified as acute or chronic, post-thoracotomy, post-procedural or neoplasm related. Also do not use it if the underlying diagnosis is known unless reason for encounter is pain control/ management.

When do you use G89 codes in conjunction with site specific pain codes?

If they are in conjunction with the site of the pain, if it provides additional information,

When to use the G89 code for pain?

In conjunction with codes form other categories and chapters to provide more detail about acute/chronic and neoplasm-related pain.

Osteoporosis

Is a systemic Condition, meaning that all bones are affected.

How do you sequence G89 codes with site specific pain codes?

It depends on the circumstances of the encounter, if the encounter is for pain control/management assign code from G89 followed by code identifying specific site and if encounter is for any other reason code site first followed by a code from G89.

Unstageable Pressure Ulcers

L89.-0 codes should be based on clinical documentation. These codes are used for pressure ulcers whose stage cannot be clinically determined and pressure ulcers that are documented as deep tissue injury but not documented as due to trauma. Do not confuse this code with L89.--9 which is unspecified stage. When their is no documentation regarding the stage of the pressure ulcer codes from unspecified stage L89.--9 should be used.

Do you code routine pain associated with surgery?

No

Can you code avian flu based on labs?

No only based on physicians diagnostic statement.

Is there a time frame for chronic pain?

No there is no time frame for when pain becomes chronic. Use physician's documentation to guide use of these codes.

Are central pain syndrome and chronic pain syndrome the same as chronic pain?

No, and there for they should only be coded when physician specifically documents the condition.

What takes precedence over coding acute respiratory failure as principal?

Obstetrics, poisoning, HIV and newborn

How do you code pneumonia if on a ventilator?

Only code ventilator associated pneumonia if provider documents VAP. Do not code as VAP if patient has pneumonia and is on a ventilator but they are not related.

How do you code influenza due to certain viruses?

Only if confirmed

Coding of Pathological Fractures

7th Character A is for use as long as the patient is receiving active treatment for the fracture. 7th character D is to be used for encounters after the patient has completed active treatment. The other 7th characters listed are to be used for subsequent encounters for treatment of problems associated with healing.

Anemia

A condition in which blood is deficient in the amount of hemoglobin in red blood cells or in the volume of red blood cells.

Aplastic Anemia

A condition in which there is a deficiency of red blood cells because the bone marrow is failing to produce them.

Thrombocytopenia

A deficiency in platelets, the cells that are important in blood clotting.

Sickle-cell Anemia

A hereditary disease of the red blood cells passed to a child when both parents carry the genetic trait.

Pancytopenia

A type of aplastic anemia in which red blood cells, white blood cells, and platelets are all deficient.

Peripheral Nervous System

All elements of the nervous system except the brain and spinal cord.

Chronic Kidney Disease and Kidney Transplant Status

Assign the appropriate N18 code for the CKD and Z94.0 code for the transplant status

Osteoporosis with Current Pathological Fracture

Category M80 is for patients who have a current pathological fracture at the time of encounter. These codes are NOT used for traumatic fractures.

Osteoporosis without Pathological Fracture

Category M81 is for use for patients with osteoporosis who do not currently have a pathological fracture. History of Osteoporosis Fracture use code Z87.31 Personal History of Pathological Fracture, should follow code from M81.

If patient is seen for pain management due to a neoplasm how do you code it?

Code G89.3 followed by the underlying neoplasm regardless if the pain is acute or chronic.

How do code if the post-operative pain associated with post-operative complication?

Code correct code from chapter 19 (injury, poisoning and other external causes)

What is the default for post-thoracotomy and other post-operative pain not specified as acute or chronic?

Code it as acute

Documented Pressure Ulcer Stage

Code only based on clinical documentation. The provider should be queried clinical terms used in documentation cannot be found in alphabetic index and there is no documentation regarding stage.

How do you code if patient is admitted for pneumonia then develops VAP?

Code pneumonia then code VAP as additional diagnosis.

Patients admitted with a Pressure ulcer Documented as Healing

Pressure Ulcers described as healing should be assigned the appropriate pressure ulcer stage coded based on documentation or the appropriate unspecified stage code. If the documentation is unclear query the provider for clarification.

Chronic kidney Disease

Stages: ICD 10 CM classifies CKD based on severity. Stages I-V. Stage II, code N18.2 equates to mild, stage III, code N18.3 equates to moderate. Stage IV, code N18.4 equates to severe and code N18.6 is end stage renal disease. If both a stage of CKD and ESRD are documented assign code N18.6 only.

How do you sequence acute respiratory failure and another acute condition?

The principal will vary. The selection of principal will depend on the circumstances of admission. If both are equally responsible for admission code either first. If documentation is unclear query.

Chronic Kidney Condition with Other Complications

When coding CKD with other conditions follow the notes in the tabular in regards to sequencing etc

Myelopathy

damage to the myelinated fiber tracts that carry information to the brain

Acute Pulmonary Edema

excessive fluid in the tissue and alveolar spaces of the lung

Nephropathy

general term indicating that renal disease is present

Status Migrainosus

generally refers to a sever migraine attack that lasts for more than 72hrs When a physician mentions a history of seizure in the workup but does not include any mention of seizures in the diagnostic statement, NO code should be assigned unless cleat documentation indicates that the criteria for reporting the condition has been met and physician agrees that a code should be added.

Conductive Hearing Loss

hearing loss due to a problem with a part of the ear