Complications of Care

Coding Complications may be complicated!

ICD-10-CM Coding Guidelines state:

• The code assignment is based on the provider's documentation of the relationship between the condition and the medical care or procedure
• Not all conditions that occur during or following medical care or a procedure are complication
• There must be a cause-and-effect relationship between the care that was provided and the condition that occurred during or after the complication
•  The condition cannot be routinely expected after a procedure 

Some conditions that can be routinely expected after a procedure and would not be coded as a complication are:

• Some level of pain is an expected condition after surgery
• Fatigue and lack of energy
• Sore throat after anesthesia
• Nausea and vomiting from general anesthesia
• Restlessness and sleeplessness
• Flatulence

 When not sure, query the provider for clarification, if the complication is not clearly documented.

External Cause in ICD-10-CM
Chapter 20, External Causes of Morbidityy

 There is no national requirement for mandatory ICD-10-CM external cause code reporting just as there was none in ICD-9-CM. However, a provider may be subject to a state-based external cause code reporting mandate or a provider may be required by a particular payer to report external cause codes.

Even though a provider may not be mandated to report these codes, providers are encouraged to report external cause codes as the codes provide beneficial information to areas such as research.

There are four different types of external cause codes with each code answering one of the following questions:

·         How did the injury or condition happen?

·         Where did it happen?

·         What was the patient doing when it happened?

·         Was it intentional or unintentional?        

• As many external cause codes as necessary to explain the patient’s condition to the fullest extent possible may be reported. 
• The external cause codes only need to be reported for the initial encounter with each provider or provider group
• The first cause code that should be reported is the one describes the cause or intent most closely related to the principal diagnosis. 
• The external cause codes for the following events take precedence over all other external cause codes, in the following order of importance:

1.      Child and adult abuse

2.      Terrorism events

3.      Cataclysmic events

4.      Transport accidents

 

 REFERENCE: ICD-10-CM Official Guidelines for Coding and Reporting

FY 2015

Some Neoplasm Q & A 

ICD-CM-10

Q. What if the documentation states malignant neoplasm, but the site is not documented?

A. Then you would code C80.1, Malignant (primary) neoplasm, unspecified. Note, this code should only be reported when no determination can be made as to the primary site of the neoplasm.

Q. What is metastatic cancer?

A. Metastatic cancer is cancer that has spread from the place where it first started (primary site) to another place in the body (secondary site). 

Q. What if the treatment is directed toward the metastatic site, how is that coded?

A. The metastatic site(s) is designated as the principal/first-listed diagnosis. The primary malignancy is coded as an additional code.

Q. How do you code a neoplasm if the patient is pregnant?

A. See subcategory O9A.1 and sequence first, followed by a code from Chapter 2 to indicate the type of neoplasm.

Q. What if there is a complication associated with a neoplasm and the treatment is only for the complication?

A. The complication is coded first, followed by the code for the neoplasm. The exception to this guideline is anemia. When the admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by code D63.0, Anemia in neoplastic disease. 2016-ICD-10-CM-Guidelines

                                                              Lung Cancer

Coding "Syndromes"
Have you wondered how to code syndromes such as Cushing's Syndrome, Alcohol Withdrawal Syndrome, Budd-Chiari Syndrome, Wolf-Parkinson White Syndrome, Meigs’ Syndrome, Marfan Syndrome?

1. Start with the Alphabetic Index when coding syndromes. 
2. In the absence of Alphabetic Index listing, assign codes for the documented manifestations of the syndrome. 
3. Additional codes for manifestations that are not an integral part of the disease process may be assigned in addition when the condition does not have a unique code. GUIDELINES FOR CODING SYNDROMES

Chronic Pain Syndrome

Chronic Pain Syndrome (CPS) is the combination of chronic pain and the secondary complications that make the original pain worse. It is like saying, one thing leads to another. Chronic pain can lead to some common problems over time. Pain can cause sleep problems, stress, emotional issues, etc. CPS has a complex natural history, unclear etiology, and does not respond well to  therapy.




Central pain syndrome (G89.0) and chronic pain syndrome (G89.4) are different than the term “chronic pain,” and therefore codes should only be used when the provider has specifically documented this condition. ICD-10-CM Official Guidelines for Coding and Reporting FY 2016

Pressure Ulcer Stage ICD-10-CM Official Guidelines

L00-L99

Pressure Ulcer Stages
Codes from ICD-10-CM category L89 are combination codes that identify the site of the pressure ulcer and the stage of the ulcer.
ICD-10-CM classifies pressure ulcer stages based on severity, which is designated by stages 1-4, unspecified stage and unstageable.
Assign as many codes from category L89 as needed to report all the pressure ulcers the patient has.

Unstageable Pressure Ulcers
Assignment of the ICD-10 CM codes for unstageable pressure ulcer (L89.--0) is based on documentation. These codes are used for pressure ulcers whose stage cannot be clinically determined perhaps because the ulcer is covered by eschar or for some other reason and pressure ulcers that are documented as deep tissue injury but not documented as due to trauma.
Do not confuse "unstageable" pressure ulcer with "unspecified stage" when there is no documentation regarding the stage of the pressure ulcer.

Documented Pressure Ulcer Stage
Assignment of the ICD-10-CM pressure ulcer stage code is based on documentation of the stage or documentation of the terms found in the Alphabetic Index.
For clinical terms describing the stage that are not found in the Alphabetic Index, and there is no documentation of the stage, the provider should be queried.

Healed Pressure Ulcers
No ICD-10-CM code is assigned if the documentation states that the pressure ulcer is completely healed.

Healing Pressure Ulcers
Pressure ulcers documented as healing should be assigned the pressure ulcer stage code based on the documentation in the medical record.
If the documentation does not state the stage of the healing pressure ulcer, assign the appropriate code for unspecified stage.
If the documentation is unclear as to whether there is a current (new) pressure ulcer or if there is a healing pressure ulcer, query the provider.

Pressure Ulcer Evolving 
If a pressure ulcer at one stage progresses to a higher stage, then report the code for the highest stage for that site. 
ICD-10-CM Official Guidelines for Coding and Reporting

ICD-10-CM Dental Screening Codes 

Screening Codes
Z01.20-Encounter for dental exam and cleaning without abnormal findings.
Z01.21-Encounter for dental exam and cleaning with abnormal findings

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The Most Critical Rule In the Medical Coding World

Begin your search for the correct code assignment through the Alphabetic Index. Never begin searching initially in the Tabular List as this will lead to coding errors

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ICD-10-PCS CODING TIP
If multiple coronary artery sites are bypassed, a separate procedure code is required for each coronary artery site that uses a different device and/or qualifier.
ICD-10-PCS Official Guidelines for Coding and Reporting 2015