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

**********************************************************************

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

ICD-10-CM CODING TIP

 CODES

Z codes can be used in any health care setting and may be first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. Certain Z codes may only be listed as first-listed or principal diagnosis.  There are 20 of these first listed/principal Z codes and they are listed in your  ICD-10-CM manual in the front of the book under the Official Guidelines for Coding and Reporting for Chapter 21-16.

First listed Z codes indicate:
• that a person with a resolving disease or injury or chronic is being seen for specific aftercare, such as the removal of internal fixation devices such as orthopedic pins

• that the patient is seen for the sole purpose of special therapy, such as radiotherapy or chemotherapy.

• that a person not currently ill is encountering the health service for a specific reason, such as to act as an organ donor, to receive prophylactic care, or to receive counseling

•  the birth status of newborns

Additional codes indicate:

• that a patient has a history, a health status, or another problem that is not in itself an illness or injury but may influence patient care.

CODING FRACTURES IN ICD-10

ICD-10 & Orthopedic Coding 

Documentation is the

 for specificity

• ·         Type of fracture (Open, closed, pathological, neoplastic disease, stress)
• ·         Pattern (Comminuted, oblique, segmental, spiral, transverse)
• ·         Etiology to document in the external cause codes
• ·         Encounter of care (Initial, subsequent, sequelae)
• ·         Healing status, if subsequent encounter (normal or delayed healing, nonunion, malunion)
• ·         Localization (Shaft, head, neck, distal, proximal, styloid)
• ·         Displacement (Displaced, non displaced)
• ·         Classification (Gustilo-Anderson, Salter-Harris)
• ·         Any complications, whether acute or delayed (Direct result of trauma sustained)
• ·         Intra-articular or extra-articular involvement ICD-10 Clinical Concepts  

Some Traumatic Fracture Coding Tips

A fracture not documented as open or closed should be coded to closed. 

A fracture not documented as displaced or not displaced should be coded to displaced.

Traumatic fractures are coded using the appropriate 7th character for initial encounter (A, B, C) while the patient is receiving active treatment for the fracture. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician. 

The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.

Fractures are coded using the appropriate 7th character for subsequent care for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase. Examples of fracture aftercare are: cast change or removal, removal of external or internal fixation device, medication adjustment, and follow-up visits following fracture treatment.

Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes.

Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7th character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R)

The aftercare Z codes would not be used for aftercare for traumatic fractures. For aftercare of a traumatic fracture, assign the acute fracture code with the appropriate 7th character. ICD-10-CM Official Guidelines for Coding and Reporting

WELL IT'S HERE..................

The Arrival of ICD-10

For several years, there was so much anticipation for ICD-10 like a roaring lion getting ready to attack. I went to bed about 10:00 PM on September 30, 2015 and work up at 6:00 AM on October 1, 2015 to meet a calm lamb. Not sure if this is the calm before the storm, time will tell. Everyone is just getting started so not sure how it will go.

How to Proceed

So in the mean time, stay calm and forge ahead, you got this! Remember the basics of coding:

• Review the documentation
• Abstract the information needed to select the correct diagnosis and procedure code
• Determine the "reason" for the encounter
• Determine the procedure performed
• Start with the index of the coding book
• Look up the term
• Make notes of the recommended codes 
• Go to the Tabular for ICD or the main part of the CPT book
• Review the codes
• Read all notes, instructions, section guidelines
• Review any additional references such as coding guidelines, Coding Clinic, CPT Assistant or Coder's Desk Reference to select the correct code
• Link the codes correctly
• If applicable, apply modifiers

Sound familiar?

ICD-10-CM Coding Tip

Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. The aftercare Z code should not be used if treatment is directed at a current, acute disease. The diagnosis code is to be used in these cases. Exceptions to this rule are codes Z51.0, Encounter for antineoplastic radiation therapy, and codes from subcategory Z51.1, Encounter for antineoplastic chemotherapy and immunotherapy. The aftercare Z codes should also not be used for aftercare for injuries. For aftercare of an injury, assign the acute injury code with the appropriate 7th character (for subsequent encounter). The aftercare codes are generally first-listed to explain the specific reason for the encounter. An aftercare code may be used as an additional code when some type of aftercare is provided in addition to the reason for admission and no diagnosis code is applicable. Aftercare codes should be used in conjunction with other aftercare codes or diagnosis codes to provide better detail on the specifics of an aftercare encounter visit, unless otherwise directed by the classification. 
ICD-10-CM Official Guidelines for Coding and Reporting

Medical Necessity & Medical Coders

Medical  necessity, what is it?

CMS defines medical necessity/medical necessary as "

"Services or supplies that: are proper and needed for the diagnosis or treatment of your medical condition, are provided for the diagnosis, direct care, and treatment of your medical condition, meet the standards of good medical practice in the local area, and aren't mainly for the convenience of you or your doctor." Definition Medical Necessity

It Is Not the Medical Coder's Responsibility......

It is not the responsibility of the medical coder to make up a diagnosis to meet medical necessity, however, it is the responsibility of the  medical coder to verify the diagnosis, select the correct code to he highest level of specificity, follow Coding Guidelines, follow coding instructions in the ICD-CM Tabular, use all available resources, and link the ICD-CM code to the CPT code correctly.

The Responsibility of Establishing Medical Necessity Belongs to the Ordering Provider

Documentation supporting the medical necessity such as diagnosis or procedure codes must be submitted with each claim. Without such evidence, the claim will be denied as being not medically necessary. The medical record must include documentation of the signs, symptoms, and conditions associated with the billed diagnosis and procedure codes. Documentation

Remember--
If it is not documented, it was not done

"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record."CMS & MEDICAL NECESSITY

Evaluation & Management (E/M) Coding Overview

The Story Behind Evaluation & Management  CPT Codes

Today, we have over 38 pages of Evaluation and Management codes in our CPT Manual, well it was not always that way, in 1991, there was a simple medical billing system that included levels of evaluation and management medical services that took up only four pages in the CPT Manual. 

In 1992, the Health Care Financing Administration (HCFA), mandated by congress, introduced a new, and complicated set of physician billing codes. In May 1997, the version of the Documentation Guidelines for Evaluation & Management Services  included 54 pages covering patient history, clinical exam, family history, decision complexity, body areas, organ systems, physical exam types, diagnostic tests, and management options. 

There are two different sets of Evaluation and Management guidelines; 1995 and 1997. The 1997 guidelines were introduced by the Centers for Medicare & Medicaid Services (CMS) to address some of the problems that were found with the 1995 guidelines at the time. The main difference between the two guidelines is in the  examination part of the evaluation and management service.

  

Evaluation and Management CPT Codes are a medical billing system that healthcare providers in the United States use so that they are able to be reimbursed by private insurance companies and other payers such as Medicare and Medicaid. 

Instructions for Selecting a Level of E/M Service

The CPT codes in the Evaluation & Management section are 99201-99499. The Evaluation and Management section is the first section in the CPT Manual. There are categories and subcategories to the Evaluation and Management codes.

In the Current Procedural Terminology (CPT®) Manual, the following instructions are found:

• Review the instructions for the selected category or subcategory.
• Review the level of E/M Service Descriptors & examples in the selected category or subcategory.
• Determine the extent of history obtained.
• Determine the extent of examination performed.
• Determine the Complexity of medical decision making.

Key Components

There are three key components in choosing an evaluation and management code. The history, examination, and medical decision making.

• Select the appropriate level of E/M service based on all the key components for initial hospital care, office consultation, initial inpatient consultation, office new patient, hospital observation, emergency department, initial nursing facility care, domiciliary care, new patient & home new patient.
• OR
• Select the appropriate level of E/M service based on two of the three components for office established, subsequent hospital; care, subsequent nursing facility care, domiciliary care established, & home established patient.
• OR
• Select the appropriate level of E/M when counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family (face-to-face in the office or other outpatient setting or floor/unit time in the hospital or nursing facility) then time shall be considered the key or controlling factor to qualify for a particular level of E/M services.

Want to read more?

1995 EM Guidelines

1997 EM Guidelines

Medical Necessity

"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record."CMS & MEDICAL NECESSITY

In future post, I will expand upon evaluation and management coding.

ICD-10-CM-Highlight

V97.33XD-Sucked into jet engine, subsequent encounter

Funny

Statistically…. 9 out of 10 injections are in vein.”

Highlight On Three Codes

Current Procedural Terminology (CPT) 51798

As stated in the AMA Professional Edition of Current Procedural Terminology Manual, CPT code 51798 describes measurement of post voiding residual urine (PVR), and/or bladder capacity by ultrasound, non-imaging.

Urodynamics

CPT 51798 comes under the section of Urodynamics. 
What is urodynamics? 
Urodynamics is a group of tests performed on a patient’s lower urinary tract when a patient is experiencing such conditions as frequent urination, urgency of urination, weak stream, intermittent stream, frequent urinary tract infection, incomplete bladder emptying, and/or urinary incontinence.

In the CPT manual, under the section of Urodynamics, the section guidelines state that:

• ·         The tests in this section may be used separately or in combination with each other
• ·         When multiple tests are performed at the same session, modifier 51 should be appended
• ·         All the tests are performed by, or are under the direct supervision of a physician or other qualified health care professional
• ·         All the instruments, equipment, supplies, technical assistance, and other sterile supplies are bundled into the CPT code
• ·         If the physician performs the professional service only, (interpretation of the tests), modifier 26 (professional component) is appended to the CPT codes for the tests if Professional fees are applicable to the CPT code.

Coder’s Desk Reference-51798

After the patient has voided, the ultrasound measures the residual urine and/or bladder capacity. The ultrasound machine used for this procedure is an ultrasound scanner. The scanning head is directed over the suprapubic area while the patient is lying down in the supine position. The calculation of the residual urine is performed by the software in the scanner and provides immediate results.

Some specifics to CPT 51798--

• ·         There are no Professional fees associated with CPT code 51798.
• ·         If an interpretation is performed, the results can be included in an Evaluation and Management service.
• ·         When reporting an Evaluation and Management CPT code with CPT code 51798, modifier 25 may need to be appended to the Evaluation and Management CPT code.
• ·         It is in the “scope of duty” of most Ancillary providers (e.g. registered nurse, medical assistant) to perform a PVR.

Current Procedural Terminology (CPT) Category II

2000F

On one my pages on this Blog site, entitled “Current Medical Coding Classification Systems”-I explained that Category II codes were “performance measurement codes.” Category II codes are used to track the performance of certain tests and or test results. Category II CPT® codes are used for information purposes only, their usage is optional, and no payment is associated with these codes. 

CPT II codes consist of five alphanumeric characters in a string, ending with the letter “F.”

• 1.    Category II codes describe clinical components that may be included in evaluation and management services or clinical services and this is why there is no relative value associated with them.
• 2.    As stated in the AMA Professional Edition of Current Procedural Terminology Manual, code 2000F, located under Physical Exam, describes “blood pressure measured.
• 
  
• If No Money, Why Use?

• ·         Improve performance in healthcare organizations
• ·         Medicare may pay an incentive to report Category II codes
• ·         Identify opportunities for improvement in healthcare organizations

How to Bill Category II Codes

Category II codes are billed in the same code field as CPT category I codes.

Current Procedural Terminology (CPT) Category III

 0355T

Also known as a “local” code or “temporary,” this code is used to designate an emerging technology and to track the usage of the code. Visit my page on this blog entitled “Current Medical Coding Classification Systems” to read more.

1.    Category III CPT® codes must be used in place of an unlisted procedure code. The reimbursement for these codes is determined by the carrier. By using a Category III code instead of a Category I unlisted code, data will be collected on the Category III code to show how often the emerging technology is used.

2.    As stated in the AMA Professional Edition of Current Procedural Terminology Manual, code 0355T describes “extra-osseous subtalar joint implant for talotarsal stabilization.”

3.    Code 0335T will “sunset” January 2019

What Is The Life Span Of A Category III Code?

·         Not all Category III codes will become a Category I code.

·         If a Category III code does not become a Category I code within five years, the code will “sunset” unless it is determined that the code needs to continue as a temporary Category III code.

Highlight

September 2015

Welcome to my medical coding blog, it is my hope that you will find valuable information in every blog post including this one. I also have several pages for you to read and plan on adding additional pages.

As we all know, The ICD-9 code sets that we currently use to report medical diagnoses and inpatient procedures is scheduled to be replaced by ICD-10 code sets on October 1, 2015. 

ICD-10 will consist of two parts:

1. ICD-10-CM diagnosis coding which is for use in all U.S. health care settings.
2. ICD-10-PCS for inpatient procedure coding which is for use in U.S. hospital settings.

ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by the Health Insurance Portability Accountability Act (HIPAA), not just those who submit Medicare or Medicaid claims:

• Claims for services provided on or after October 1, 2015 should be submitted with ICD-10 diagnosis codes.
• Claims for services provided prior to October 1, 2015 should be submitted with ICD-9 diagnosis codes.

The change to ICD-10 codes does not affect CPT coding for outpatient procedures.

Good luck!

In the next post, the following codes will be highlighted:

Current Procedural Terminology (CPT) 51798

Current Procedural Terminology (CPT) Category II 2000F

Current Procedural Terminology (CPT) Category III 0355T

Healthcare Common Procedure Coding System II (HCPCS)-G0105