Kathryn DeVault, RHIA, CCS, CCS-P Director, HIM Solutions, AHIMA
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1 ICD-10-CM: Let s Code, Part II Kathryn DeVault, RHIA, CCS, CCS-P Director, HIM Solutions, AHIMA
2 Agenda Coding questions answered Review of ICD-10-CM coding scenarios
3 ICD-10-CM Coding Questions
4 Coding Questions... Bilateral sudden sensorineural hearing loss The Excludes1 note appears under the codes H91.23 and H90.3. Excludes1 instructs that the code excluded should never be used at the same time as the code above. How should this diagnosis be coded with the Excludes1 notes?
5 Coding Questions... Code H90.3, Sensorineural hearing loss, bilateral, is the correct code for this case. Codes H91.23 and H90.3 cannot be coded together Code H91.23, Sudden idiopathic hearing loss, bilateral, is not coded due to the Excludes1 note The hearing loss is not idiopathic as it is specified as sensorineural
6 Coding Questions... Pregnancy 40+ weeks in labor; post vaginal delivery. GDM and pre-existing hypertension Low forceps delivery a live born male Midline episiotomy; repaired In labor with pre-existing hypertension. According to the index: Hypertensioncomplicating-Childbirth (O10.92-) or Hypertension complicating-pregnancy (O10.91-). Which is correct?
7 Coding Questions... This scenario does not provide enough documentation to determine the correct coding. If the documentation indicates that the preexisting hypertension was complicating the pregnancy, code O should be used If the documentation indicates that the preexisting hypertension was complication the childbirth (labor & delivery), code O should be used.
8 Coding Questions... Pregnancy at 41 weeks with prolonged 1 st stage of labor. Cephalopelvic disproportion, intraabdominal adhesions, and uterine atony with postpartum hemorrhage. Anemia due to acute blood loss Should the anemia due to acute blood loss (D62) be assigned as an additional code?
9 Coding Questions... ICD-10-CM does not provide guidance related to additional codes for specificity in the Obstetrics chapter. Adding code D62 (Acute posthemorrhagic Adding code D62 (Acute posthemorrhagic anemia) provides additional specificity to the case.
10 Coding Questions... O63.0 Prolonged first stage (of labor) O33.9 Maternal care for disproportion O48.0 Post-term pregnancy O99.89 Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium K66.0 Peritoneal adhesions O72.1 Other immediate postpartum hemorrhage O90.81 Anemia of the puerperium D62 Acute posthemorrhagic anemia Z37.0 Single live birth 10D00Z1 Cesarean section
11 Coding Questions... Left side neck metastatic squamous cell carcinoma s/p left side radical neck dissection with right lung metastasis. Pleural effusion, pneumonia (enterobacter cloacae), and pneumothorax Should C80.1 be assigned for unknown primary site when not documented? Yes, C80.1 should be assigned to an unknown primary site
12 Coding Questions... Scrotum mass with debridement of scrotum, excision of scrotum mass Should N50.9 (unspecified) or N50.8 (other specified) be assigned for scrotum mass? Assign code N50.9, Disorder of male genital organs, unspecified for Scrotum mass. Follow the index mass, specified organ, NEC see Disease, by site disease, scrotum N50.9
13 Coding Questions... Prepuce laceration (by dog bite) with debridement and suture of prepuce Should S31.25xA (open bite) or S31.21xA (laceration) be assigned for prepuce laceration by dog bite? Recommend using code S31.25xA, Open bite of penis, to reflect the diagnosis of a dog bite to the prepuce. Add external cause code for additional specificity
14 Coding Questions... Head injury with scalp laceration. Left wrist cutting injury with tendon and muscle lacerations. Debridement of scalp, tendon and muscle repair In this case, would S09.90xA be assigned for the head injury? Yes assign code S09.90xA, Unspecified injury of head, to reflect the diagnosis of the head injury
15 Coding Questions... Traumatic ICH in right occipital lobe, right high frontal lobe, suspected diffuse axonal injury (DAI). Traumatic subarachnoid hemorrhage Excludes1 note under S06.3 instructs that this code is not used at the same time as S06.4-S06.6. Should the S be omitted according to the Excludes1 note? Yes only code S06.6x9A should be coded for the hemorrhage
16 Coding Questions... C-spine injury with cervical spondylotic myelopathy & radiculopathy. Would CSMR be coded with M47.12 or M47.22? Both M47.12, Other spondylosis with myelopathy, cervical region and M47.22, Other spondylosis with radiculopathy, cervical region, should be coded to clearly reflect this diagnosis.
17 ICD-10-CM Coding Scenarios
18 ICD-10-CM Scenario #1 The 25-year-old woman was transferred from an outside facility for treatment of septic shock and acute meningococcal sepsis. The outside facility was unable to manage her severe illness. What diagnosis codes are assigned?
19 Scenario #1 Answer: A39.2 Sepsis (generalized), meningococcal, acute R65.21 Shock, septic (due to severe sepsis) Rationale: The combination code of severe sepsis with septic shock is assigned as a secondary diagnosis although severe sepsis is not documented. The underlying infection, meningococcal sepsis is sequenced first.
20 ICD-10-CM Scenario #2 This 62-year-old male is being seen for mild nonproliferative diabetic retinopathy with macular edema. He has type 2 DM and takes insulin on a daily basis. He also has diabetic cataract in his right eye. What diagnosis codes are assigned?
21 Scenario #2 Answer: E Diabetes, diabetic (mellitus) (sugar), type 2, with retinopathy, nonproliferative, mild, with macular edema E11.36 Diabetes, diabetic (mellitus) (sugar), type 2 with, cataract Z79.4 Long-term (current) (prophylactic) drug therapy (use of), insulin
22 Scenario #2 Answer: Rationale: There is a combination code for the type 2 diabetes with nonproliferative diabetic retinopathy with macular edema. The diabetic cataract was documented and should be coded, but it requires a separate code. Since the patient has type 2 DM, and is on insulin, code Z79.4 should be assigned to indicate that as indicated by the note at category E11: Use additional code to identify any insulin use (Z79.4).
23 ICD-10-CM Scenario #3 This patient is seen for evaluation of his continuing unstable angina. After significant evaluation, his symptoms were found to be due to atherosclerosis of his bypassed graft. This is an autologous arterial graft. Final diagnosis: CAD of bypass graft with unstable angina and hypertensive congestive heart failure. The patient will be scheduled for surgery. What is the correct diagnosis code(s)?
24 Scenario #3 Answer: I Atherosclerosis see also Arteriosclerosis, coronary artery, with angina pectoris, - see Arteriosclerosis, coronary (artery), bypass graft, autologous artery, with, angina pectoris, unstable I11.0 Failure, failed, heart (acute) (senile) (sudden), hypertensive see Hypertension, heart (disease) (conditions in I51.4-I51.9 due to hypertension, with, heart failure (congestive) I50.9 Failure, failed, heart (acute) (senile) (sudden), congestive (compensated)
25 Scenario #3 Answer: Rationale: ICD-10-CM differentiates between the different types of bypassed coronary arteries, including native arteries, autologous vein, autologous artery, and nonautologous graft material. Hypertensive congestive heart failure requires two diagnosis codes to correctly identify the condition. The note at code I11.0 states Use additional code to identify type of heart failure (I50.-)
26 ICD-10-CM Scenario #4 The patient, G1P0, was admitted in active labor at 38 completed weeks of gestation. The patient was dilated to 6 cm approximately 7 hours following admission. Pitocin augmentation was started and she progressed to complete dilation. A second degree perineal laceration occurred during delivery and was repaired. A female infant was delivered with Apgar scores of 9 and 9. Code the diagnosis codes only.
27 Scenario #4 Answer: O70.1 Delivery (childbirth) (labor), complicated, by, laceration (perineal), perineum, perineal, second degree Z3A.38 Pregnancy (single) (uterine), weeks of gestation, 38 weeks Z37.0 Outcome of delivery, single liveborn
28 Scenario #4 Answer Rationale: The patient experienced a second degree perineal laceration (O70.1) during delivery. The outcome of delivery was a single liveborn (Z37.0). The Pitocin augmentation is not coded, only failed medical induction of labor.
29 ICD-10-CM Scenario #5 This is a 50-year-old female who fell down the icy front steps of her singly-family house and sustained trauma to her head as well as a nondisplaced closed trimalleolar fracture of the medial and lateral malleolus of her left leg. The patient denies any loss of consciousness. Attention was directed to her head injury which, after CT scan, revealed a basilar skull fracture and a small subdural hematoma. The neurosurgeon felt that the hematoma currently did not require surgical intervention. What diagnosis codes are assigned?
30 Scenario #5 Answer: S02.10xA Fracture, traumatic (abduction) (adduction) (separation), skull, base S06.5x0A Hematoma (traumatic) (skin S06.5x0A Hematoma (traumatic) (skin surface intact), subdural (traumatic) see Injury, intracranial (traumatic), subdural hemorrhage, traumatic. Review Tabular for complete code assignment
31 Scenario #5 Answer: S82.855A Fracture, traumatic, trimalleolar see fracture, ankle, trimalleolar, nondisplaced. Review Tabular for complete code assignment. W00.1xxA Index to External Causes, Fall, falling (accidental) due to, ice or snow, from one level to another, on stairs or steps Y Index to External Causes, Place of occurrence, residence (non- institutional) (private) house, single family, specified NEC Y99.8 Index to External Causes, External cause status, specified NEC
32 Scenario #5 Answer: In ICD-10-CM, there is not a combination code for a skull fracture with a subsequent subdural hematoma; therefore, the two conditions need to be coded separately. In order to select the correct code for the skull fracture, one would need to know or research that basilar is the base of the skull. The 7 th character A is used to indicate the initial episode of care.
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