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

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