Let's Code It!
Let's Code It!
All credits appearing on page or at the end of the book are considered to be an extension of the copyright page.
Library of Congress Cataloging-in-Publication Data
Names: Safian, Shelley C., author. | Johnson, Mary A. (Medical record coding
program manager) author.
Title: Let’s code it! / Shelley C. Safian, PhD, RHIA, MAOM/HSM, CCS-P, CPC-H,
CPC-I, AHIMA-Approved ICD-10-CM/PCS Trainer, Mary A. Johnson, CPC, Central
Carolina Technical College.
Description: First edition. | New York, NY : McGraw-Hill Education, [2019] |
Includes index.
Identifiers: LCCN 2017025623 | ISBN 9781259828737 (alk. paper)
Subjects: LCSH: Nosology—Code numbers.
Classification: LCC RB115 .S24 2019 | DDC 616.001/2—dc23 LC record available at https://lccn.loc.gov/2017025623
The Internet addresses listed in the text were accurate at the time of publication. The inclusion of a website does not indicate an
endorsement by the authors or McGraw-Hill Education, and McGraw-Hill Education does not guarantee the accuracy of the information
presented at these sites.
mheducation.com/highered
ABOUT THE AUTHORS
Shelley C. Safian
Shelley Safian has been teaching medical coding and health information management
for more than 15 years, at both on-ground and online campuses. In addition to her
regular teaching responsibilities at University of Central Florida and Berkeley College
Online, she often presents seminars sponsored by AHIMA and AAPC, writes regu-
larly about coding for the Just Coding newsletter, and has written articles published in
AAPC’s Healthcare Business Monthly, SurgiStrategies, and HFM (Healthcare Finan-
cial Management) magazine. Safian is the course author for multiple distance educa-
tion courses on various coding topics, including ICD-10-CM, ICD-10-PCS, CPT, and
HCPCS Level II coding.
Safian is a Registered Health Information Administrator (RHIA) and a Certified
Coding Specialist–Physician-based (CCS-P) from the American Health Information
Management Association and a Certified Outpatient Coder (COC) and a Certified Courtesy of Shelley C. Safian
Professional Coding Instructor (CPC-I) from the American Academy of Professional
Coders. She is also a Certified HIPAA Administrator (CHA) and has earned the desig-
nation of AHIMA-Approved ICD-10-CM/PCS Trainer.
Safian completed her Graduate Certificate in Health Care Management at Keller
Graduate School of Management. The University of Phoenix awarded her the
Master of Arts/Organizational Management degree and a Graduate Certificate in
Health Informatics. She earned her Ph.D. in Health Care Administration with a focus
in Health Information Management.
Mary A. Johnson
Mary Johnson is currently the Medical Record Coding Program Director at Central
Carolina Technical College, Sumter, South Carolina. Her background includes cor-
porate training as well as on-campus and online platforms. Johnson also designs and
implements customized coding curricula. Johnson received her Bachelor of Arts dual
degree in Business Administration and Marketing from Columbia College, and earned
a Masters of Business Administration with a dual focus in Healthcare Management
and Health Informatics from New England College. Johnson is a Certified Profes-
sional Coder (CPC) credentialed through the American Academy of Professional Cod-
ers and is ICD-10-CM proficient.
Acknowledgments
—This book is dedicated to all of those who have come into my life sharing encour-
agement and opportunity to pursue work that I love; for the benefit of all of my stu- Courtesy of Mary A. Johnson
dents: past, present, and future.—Shelley
—This book is dedicated in loving memory of my parents, Dr. and Mrs. Clarence
J. Johnson Sr., for their love and support. Also, to those students with whom I have
had the privilege to work and to those students who are beginning their journey into
the world of medical coding.—Mary
BRIEF CONTENTS
Appendix 1216
Glossary 1218
Index 1229
Let’s Code It! is the comprehensive title in a series of four books. The other titles are:
Let’s Code It! ICD-10-CM: includes Parts 1, 2 and 6
Let’s Code It! ICD-10-CM, ICD-10-PCS: includes Parts 1, 2, 5 and 6
Let’s Code It! Procedure: includes Parts 1 and 3-6
x CONTENTS
12.6 Respiratory Conditions Requiring External 16 CODING INJURY, POISONING, AND EXTERNAL
Cause Codes 345 CAUSES 429
Chapter Summary and Review 347 16.1 Reporting External Causes
of Injuries 429
13 CODING DIGESTIVE SYSTEM CONDITIONS 356 16.2 Traumatic Injuries 432
13.1 Diseases of Oral Cavity and Salivary 16.3 Using Seventh Characters to Report
Glands 356 Status of Care 439
13.2 Conditions of the Esophagus and 16.4 Using the Table of Drugs and
Stomach 360 Chemicals 440
13.3 Conditions Affecting the Intestines 364 16.5 Adverse Effects, Poisoning, Underdosing,
13.4 Dysfunction of the Digestive Accessory and Toxic Effects 444
Organs and Malabsorption 370 16.6 Reporting Burns 450
13.5 Reporting the Involvement of Alcohol in 16.7 Abuse, Neglect, and Maltreatment 457
Digestive Disorders 373 16.8 Complications of Care 458
Chapter Summary and Review 374 Chapter Summary and Review 460
xii CONTENTS
25 CPT SURGERY SECTION 717 27 CPT PATHOLOGY & LAB SECTION 828
25.1 Types of Surgical Procedures 718 27.1 Specimen Collection and Testing 828
25.2 The Surgical Package 720 27.2 Testing Methodology and Desired
25.3 Global Period Time Frames 724 Results 830
25.4 Unusual Services and 27.3 Panels 833
Treatments 725 27.4 Blood Test Documentation 835
25.5 Integumentary System 728 27.5 Clinical Chemistry 838
25.6 Musculoskeletal System 739 27.6 Molecular Diagnostics 839
25.7 Respiratory System 747 27.7 Immunology, Microbiology, and
25.8 Cardiovascular System 749 Cytopathology 840
25.9 Digestive System 759 27.8 Surgical Pathology 843
25.10 Urinary System 762 27.9 Modifiers for Laboratory Coding 848
25.11 The Genital Systems: Male and 27.10 Pathology and Lab Abbreviations 849
Female 765 Chapter Summary and Review 851
25.12 Nervous System 769
25.13 The Optical and Auditory 28 CPT MEDICINE SECTION 859
Systems 773 28.1 Immunizations 859
25.14 Organ Transplantation 779 28.2 Injections and Infusions 862
25.15 Operating Microscope 784 28.3 Psychiatry, Psychotherapy, and
Chapter Summary and Review 786 Biofeedback 865
28.4 Dialysis and Gastroenterology
26 CPT RADIOLOGY SECTION 797 Services 867
26.1 Types of Imaging 797 28.5 Ophthalmology and Otorhinolaryngologic
26.2 Purposes for Imaging 801 Services 870
26.3 Technical vs. Professional 803 28.6 Cardiovascular Services 872
26.4 Number of Views 805 28.7 Pulmonary 876
26.5 Procedures With or Without 28.8 Allergy and Clinical Immunology 877
Contrast 807 28.9 Neurology and Neuromuscular
26.6 Diagnostic Radiology 809 Procedures 879
26.7 Mammography 813 28.10 Physical Medicine and Rehabilitation 880
26.8 Bone and Joint Studies 814 28.11 Acupuncture, Osteopathic, and
26.9 Radiation Oncology 815 Chiropractic Treatments 882
26.10 Nuclear Medicine 818 28.12 Other Services Provided 884
Chapter Summary and Review 819 Chapter Summary and Review 886
29 PHYSICIANS’ SERVICES CAPSTONE 895 33.5 Medical/Surgical Devices: Character 6 993
33.6 Medical/Surgical Qualifiers:
PART IV: DMEPOS & Character 7 995
TRANSPORTATION 905 33.7 Multiple and Discontinued Procedures in
30 HCPCS LEVEL II 906 Medical and Surgical Cases 996
33.8 Medical/Surgical Coding: Putting It All
30.1 HCPCS Level II Categories 906
Together 999
30.2 The Alphabetic Index 908
Chapter Summary and Review 1003
30.3 The Alphanumeric Listing Overview 910
30.4 Symbols and Notations 923 34 OBSTETRICS SECTION 1015
30.5 Appendices 931 34.1 Obstetrics Section/Body System:
Chapter Summary and Review 932 Characters 1 and 2 1015
34.2 Obstetrics Root Operations:
31 DMEPOS AND TRANSPORTATION
Character 3 1016
CODING CAPSTONE 941
34.3 Obstetrics Body Parts: Character 4 1021
PART V: Inpatient (Hospital) 34.4 Obstetrics Approaches:
Reporting 949 Character 5 1022
34.5 Obstetrics Devices: Character 6 1024
32 INTRODUCTION TO ICD-10-PCS 950
34.6 Obstetrics Qualifiers: Character 7 1024
32.1 The Purpose of ICD-10-PCS 950 34.7 Obstetrics Coding: Putting It All
32.2 The Structure of ICD-10-PCS Codes 950 Together 1028
32.3 The ICD-10-PCS Book 959 Chapter Summary and Review 1030
32.4 ICD-10-PCS General Conventions 964
32.5 Selection of Principal Procedure 967 35 PLACEMENT THROUGH CHIROPRACTIC
Chapter Summary and Review 968 SECTIONS 1040
35.1 Reporting Services from the Placement
33 ICD-10-PCS MEDICAL AND SURGICAL Section 1040
SECTION 975 35.2 Reporting Services from the
33.1 Medical/Surgical Section/Body Systems: Administration Section 1046
Characters 1 and 2 975 35.3 Reporting Services from the Measurement
33.2 Medical/Surgical Root Operations: and Monitoring Section 1050
Character 3 978 35.4 Reporting from the Extracorporeal
33.3 Medical/Surgical Body Parts: or Systemic Assistance and
Character 4 987 Performance Section 1054
33.4 Medical/Surgical Approaches: 35.5 Reporting Services from the Extracorporeal
Character 5 989 or Systemic Therapies Section 1058
xiv CONTENTS
35.6 Reporting Osteopathic Services 1063 38 INPATIENT CODING CAPSTONE 1140
35.7 Reporting from the Other Procedures
Section 1066 PART VI: Reimbursement, Legal, and
35.8 Reporting Inpatient Chiropractic Ethical Issues 1155
Services 1070
39 REIMBURSEMENT 1156
35.9 Sections 2–9: Putting It All
39.1 The Role of Insurance in
Together 1074
Health Care 1156
Chapter Summary and Review 1076
39.2 Types of Insurance Plans 1158
36 IMAGING, NUCLEAR MEDICINE, AND 39.3 Methods of Compensation 1163
RADIATION THERAPY SECTIONS 1087 39.4 NCCI Edits and NCD/LCD 1165
39.5 Place-of-Service and Type-of-Service
36.1 Reporting from the Imaging Section 1087
Codes 1167
36.2 Reporting from the Nuclear Medicine
39.6 Organizing Claims: Resubmission,
Section 1092
Denials, and Appeals 1172
36.3 Reporting from the Radiation Therapy
Chapter Summary and Review 1180
Section 1096
36.4 Sections B, C, and D: Putting It All 40 INTRODUCTION TO HEALTH CARE LAW AND
Together 1101 ETHICS 1185
Chapter Summary and Review 1104
40.1 Sources for Legal Guidance 1185
37 PHYSICAL REHABILITATION AND DIAGNOSTIC 40.2 Rules for Ethical and Legal Coding 1190
AUDIOLOGY THROUGH NEW TECHNOLOGY 40.3 False Claims Act 1193
SECTIONS 1111 40.4 Health Insurance Portability and
Accountability Act (HIPAA) 1195
37.1 Reporting Services from the Physical
Rehabilitation and Diagnostic Audiology 40.5 Health Care Fraud and Abuse Control
Section 1111 Program 1205
37.2 Reporting Services from the Mental 40.6 Codes of Ethics 1206
Health Section 1115 40.7 Compliance Programs 1208
37.3 Reporting from the Substance Abuse Chapter Summary and Review 1209
Treatment Section 1119 Appendix 1216
37.4 Reporting from the New Technology Glossary 1218
Section 1123 Index 1229
Each chapter begins by clearly identifying the 1 Introduction to the written or dictated, recounting
Languages of Codingstatement, in these notes will ex
The physician’s notes explai
Learning Outcomes students need to master along Key Terms
Classification Systems
Learning Outcomes
The notes may document a sp
with the Key Terms that they need to learn. Condition After completing this chapter, the student should be able to:
Diagnosis LO 1.1 Explain the four purposes of medical coding. a yet-unnamed problem, or an
Eponym
LO 1.2 Identify the structure of the ICD-10-CM diagnosis coding
External Cause
Inpatient
Medical Necessity
manual. service. As a coding specialist,
LO 1.3 Differentiate between the types of procedures and the
Nonessential Modifiers
Outpatient
various procedure coding manuals. nosis code (or codes) so that ev
LO 1.4 Examine the HCPCS Level II coding manual used to report
Procedure
Reimbursement
Services
the provision of equipment and supplies.
particular patient at a particular
Treatments
The International Classificat
1.1 The Purpose of Coding
CODING BITES (ICD-10-CM) code book cont
Around the world, languages exist to enable clear and accurate communication
We use the concept of
“languages” to help you report the reason why the healt
between individuals in similar groups or working together in similar functions. The
purpose of using health care coding languages is to enable the sharing of information,
in a specific and efficient way, between all those involved in health care.
cific encounter.
relate medical coding—
and its code sets—to Coding languages are constructed of individual codes that are more precise than
an idea you already words. (You will discover this as you venture through this textbook.) By communicat-
understand. In the health ing using codes rather than words, you can successfully convey to others involved (1)
care industry, however, exactly what happened during a provider-patient encounter and (2) why it occurred.
Coding Bites
CODING BITES
A diagnosis explains
WHY the patient CODING BITES
Medical Necessity
sections to determine the most
requires the attention of
a health care provider encounter occurred.
The diagnosis codes that you report explain the justification for the procedure, service,
or treatment provided to a patient during his or her encounter. Every time a health
and a procedure
explains WHAT the
This is just an overview
These appear throughout the text to highlight key
physician or health care
provider did for the to help you orient your- Index to Diseases and In
patient.
self to the structure of
concepts and tips to further support understanding the code book. You will
The Alphabetic Index [Index t
terms used by the physician to
2
ICD-10-CM
LET’S CODE IT! SCENARIO
CHAPTER
Abby Shantner, a 41-year-old female, comes to see Dr. Branson to get the results 6 | CODING
of her biopsy. NEOPLA
Dr. Bra
Examples are included throughout each chapter to help explains that Abby has an alpha cell adenoma of the pancreas. Dr. Branson spends 30 minutes discussing t
ment options.
students make the connection between theoretical and Let’s Code It!
Rev
it—benign or malignant? To help you determine this, instead of going to neoplasm, let’s see if there is a listing
through abstracting and the coding process, step-by- the Alphabetic Index under adenoma. When you find adenoma, the book refers you to
Adenoma (see also Neoplasm, benign, by site)
step, to determine the correct code. And You Code It! This tells you an adenoma is a benign tumor. Or you can continue down this list to the indented term, and find
EXAMPLE
Adenoma
Case Studies provide students with hands-on practice alpha-cell,
pancreas D13.7
N30 Cystitis
Also,
Use additional read
code the next
to identify notation
infectious carefully:
agent (B95-B97)
coding scenarios and case studies throughout each Turn to the Tabular List and read the complete description of code category D13:
D13
Very often, the ICD-10-CM will tell you that you will need this second code
Benign neoplasmtify the specific
of other
Use additional code to identify any fam
pathogen.
and ill-defined parts of digestive system
chapter. In addition, You Interpret It! questions present The note does not relate to this patient’s diagnosis for this encounter, so continue rea
ICD-10-CM reminds you that an additional
ing down the column to review all of the choices for the required fourth character.
factor for the screening is not age but family
opportunities for students to use critical-thinking skills YOUD13.7 Benign neoplasm of endocrine pancreas
INTERPRET IT!
That matches Dr. Branson’s diagnosis. in the patient’s past bloodline had been diag
to identify details needed for accurate coding.
Check the top of this subsection and the head of this chapter in ICD-10-CM. There are several NOTES. Re
What is the mode of transmission for eachand ofitAbby?
condition?
carefully. Do any relate to Dr. Branson’s diagnosis is known
No. Turnthat
to thethis places
Official theandpatient
Guidelines a
read Secti
1. 1.c.2.
Hepatitis
There B ___________
is nothing specifically applicable here, either. 4. Insect bites ___________
2. Measles
Good job! ___________ 5. Influenza ___________
3. Cholera ___________
EXAMPLE
You would report code:
5.2 Bacterial
Malignant Primary Infections
The termof
Types primary
Bacteria Z80.42
indicates Family
the anatomical history
site (the ofthe
place in malignan
body) whe
malignant neoplasm was first seen and identified. If the physician’s notes do no
Bacteria Bacteria areor single-celled
ify primary secondary, organisms
in addition
then the site named by
tomentioned
code Z12.5their shape
for an
is primary. (see Figure
encoun
Single-celled microorganisms shaped bacteria, called bacilli, are responsible for the development of d
that cause disease. a screening
tetanus, and tuberculosis, prostate
among others. exam
Spirilla, because
bacterial organismshis
shaf
150 PART II | REPORTING DIAGNOSES with prostate cancer, dramatically increa
GUIDANCE
Guidance Connections CONNECTION
A personal history code (Z85.-) shoul
Read the ICD-10-CM receive screening tests more frequently tha
Official Guidelines
saf28735_ch06_145-172.indd 150 for tory of breast cancer may get mammogram 07/08/1
Each of these boxes connects the concepts Coding and Reporting, personal history of breast cancer code will
section I. Conventions, in the frequency of testing.
students are learning in the chapter to the General Coding Guide-
EXAMPLE
saf28735_ch05_101-144.indd 104 You would report code: 07
Confirming a Diagnosis
Once the patient exhibits signs, such as a
or an abnormality identified during a scree
essence of the neoplasm. This is the only w
cells and malignant cells.
saf28735_ch06_145-172.indd 146
Revised Pages
CHAPTER 39 REVIEW
Reimbursement Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
Part I
ment types to reinforce the chapter learning 1. LO 39.2 A physician, typically a family practitioner or an internist, who serves
as the primary care physician for an individual. This physician is
A. Automobile Insurance
lines; Let’s Check It! Rules and Regulations; tral health care supervisor. E. Disability
Compensation
3. LO 39.2 A type of health insurance that uses a primary care physician, also
known as a gatekeeper, to manage all health care services for an F. Discounted FFS
Revised Pages
7. Follicular grade III lymphoma lymph nodes of 11. Malignant odontogenic tumor, upper jaw bone:
Gain real-world experience by using ac- a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
physicians’ notes documenting real patient blood. After a thorough examination, Dr. Benson notes stridor and orders an MRI scan. The results of the
MRI confirm the diagnosis of bronchial adenoma.
encounters in order to code those scenarios. 6. Elizabeth Conyers, a 56-year-old female, presents with unexplained weakness, weight loss, and dizziness.
Dr. Amos completes a thorough examination and does a work-up. The protein electrophoresis (SPEP) and
Both of these types of exercises can be quantitative immunoglobulin results confirm the diagnosis of Waldenström’s macroglobulinemia.
7. James Buckholtz, a 3-year-old male, is brought in by his parents. Jimmy has lost his appetite and is los-
found at the end of most chapters. Capstone ing weight. Mrs. Buckholtz tells Dr. Ferguson that Jimmy’s gums bleed and he seems short of breath.
Dr. Ferguson notes splenomegaly and admits Jimmy to Weston Hospital. After reviewing the blood tests,
Chapters come at the end of Parts II–V and MRI scan, and bone marrow aspiration results, Jimmy is diagnosed with acute lymphoblastic leukemia.
8. Kelley Young, a 39-year-old female, presents to Dr. Clerk with the complaints of sudden blurred vision, dizzi-
include 15 additional real-life outpatient ness, and numbness in her face. Kelley states she feels very weak and has headaches. Dr. Clerk admits Kelley
to the hospital. After reviewing the MRI scan, her hormone levels from the blood workup, and urine tests,
and inpatient case studies to help stu- Kelley is diagnosed with a primary malignant neoplasm of the pituitary gland.
9. Ralph Bradley, a 36-year-old male, comes to see Dr. Harper because he is weak, losing weight, and vomiting
dents synthesize and apply what they have and has diarrhea with some blood showing. Ralph was diagnosed with HIV 3 years ago. Dr. Harper completes
an examination noting paleness, tachycardia, and tachypnea. Ralph is admitted to the hospital. The biopsied
learned through hands-on coding practice tissue from an endoscopy confirms a diagnosis of Kaposi’s sarcoma of gastrointestinal organ.
xviii
saf28735_ch06_145-172.indd 168
CHAPTER 4 REVIEW
15. Paul Plum, an 8-month-old male, is brought in by his mother to see Dr. Wallace, Paul’s pediatrician. Paul’s
stomach feels hard and he is also having some diarrhea and vomiting. Dr. Wallace notes Paul is failing to
thrive and hospitalizes him. After blood tests and a hydrogen breath test are completed, Paul is diagnosed
with congenital lactase deficiency.
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: DAVIS, HELEN
ACCOUNT/EHR #: DAVIHE001
DATE: 10/21/18
Attending Physician: Renee O. Bracker, MD
Welcome to Let’s Code It! This product is part of a multipart series that instructs
students on how to become proficient in medical coding—a health care field that con-
tinues to be in high demand. The Bureau of Labor Statistics notes the demand for
health information management professionals (which includes coders) will continue to
increase incredibly through 2024 and beyond.
Let’s Code It! provides a 360-degree learning experience for anyone interested in
the field of medical coding, with strong guidance down the path to coding certification.
Theory is presented in easy-to-understand language and accompanied by lots of exam-
ples. Hands-on practice is included with real-life physician documentation, from both
outpatient and inpatient facilities, to promote critical thinking analysis and evaluation.
This is in addition to determination of accurate codes to report diagnoses, procedures,
and ancillary services. All of this is assembled to support the reader’s development of
a solid foundation upon which to build a successful career after graduation.
The Safian/Johnson Medical Coding series includes the following products:
Let’s Code It!
Let’s Code It! ICD-10-CM
Let’s Code It! ICD-10-CM/PCS
Let’s Code It! Procedure
You Code It! Abstracting Case Studies Practicum, 3e
The different solutions are designed to fit the most common course content selections.
Let’s Code It! is the comprehensive offering with coverage of ICD-10-CM, ICD-10-
PCS, CPT, and HCPCS Level II.
These products are further designed to give your students the medical coding experi-
ence they need in order to pass their first medical coding certification exams, such as the
CCS/CCS-P or CPC/COC. The products offer students a variety of practice opportuni-
ties by reinforcing the learning outcomes set forth in every chapter. The chapter materi-
als are organized in short bursts of text followed by practice—keeping students active
and coding! These products were developed based on the 2017 code sets, with 2018
updates implemented as much as possible prior to publication. Updates will be made to
the answer keys and Connect exercises on an annual basis.
xxii PREFACE
∙ Codes of Ethics from both AHIMA and AAPC are included as well as information
on compliance plans.
∙ You Interpret It! questions present students with opportunities to use critical-thinking
skills to identify details required for accurate job performance.
∙ Chapter Reviews include assessments of chapter concepts:
∙ Let’s Check It! Terminology
∙ Let’s Check It! Concepts
∙ Let’s Check It! Which Type of Insurance?
∙ Let’s Check It! Rules and Regulations
∙ You Code It! Application Case Studies
McGraw-Hill Connect® is a highly reliable, easy-to-
use homework and learning management solution
that utilizes learning science and award-winning
adaptive tools to improve student results.
73% of instructors
who use Connect
Quality Content and Learning Resources require it; instructor
satisfaction increases
Connect content is authored by the world’s best subject by 28% when Connect
matter experts, and is available to your class through a is required.
simple and intuitive interface.
The Connect eBook makes it easy for students to
access their reading material on smartphones
and tablets. They can study on the go and don’t
need internet access to use the eBook as a
reference, with full functionality.
Multimedia content such as videos, simulations,
and games drive student engagement and critical
thinking skills. ©McGraw-Hill Education
Robust Analytics and Reporting
Connect integrates with your LMS to provide single sign-on and automatic syncing
of grades. Integration with Blackboard®, D2L®, and Canvas also provides automatic
syncing of the course calendar and assignment-level linking.
Connect offers comprehensive service, support, and training throughout every
phase of your implementation.
If you’re looking for some guidance on how to use Connect, or want to learn
tips and tricks from super users, you can find tutorials as you work. Our Digital
Faculty Consultants and Student Ambassadors offer insight into how to achieve
the results you want with Connect.
www.mheducation.com/connect
CONNECT FOR YOU CODE IT!
McGraw-Hill Connect for You Code It! will include:
∙ All end-of-chapter questions
∙ CodePath versions of You Code It! practice questions, in which students are pre-
sented with a series of questions to guide them through the critical thinking process
to determine the correct code
∙ Interactive Exercises, such as Matching, Sequencing, and Labeling activities
∙ Testbank questions
∙ Lecture-style videos, which will provide additional guidance on challenging coding
questions
INSTRUCTORS’ RESOURCES
You can rely on the following materials to help you and your students work through
the material in the book; all are available in the Instructor Resources under the Library
tab in Connect (available only to instructors who are logged in to Connect).
Supplement Features
Instructor’s Manual (organized by Learning ∙ Lesson plans
Outcomes) ∙ Answer keys for all exercises
PowerPoint Presentations (organized by ∙ Key terms
Learning Outcomes) ∙ Key concepts
∙ Accessible
Electronic Testbank ∙ Computerized and Connect
∙ Word version
∙ Questions are tagged with learning out-
comes; level of difficulty; level of Bloom’s
taxonomy; feedback; and ABHES,
CAAHEP, and CAHIIM competencies.
Tools to Plan Course ∙ Correlations by learning outcomes to
accrediting bodies such as ABHES,
CAAHEP, and CAHIIM
∙ Sample syllabi
∙ Asset map—recap of the key instructor
resources as well as information on the
content available through Connect
Want to learn more about this product? Attend one of our online webinars. To learn
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xxvi PREFACE
ACKNOWLEDGMENTS
Board of Advisors
A select group of instructors participated in our Coding Board of Advisors. They pro-
vided timely and focused guidance to the author team on all aspects of content devel-
opment. We are extremely grateful for their input on this project.
Christine Cusano, CMA (AAMA), CPhT, Tatyana Pashnyak, CHTS-TR, Bainbridge
Lincoln Technical Institute State College
Gerry Gordon, BA, CPC, CPB, Daytona Patricia Saccone, MA, RHIA, CCS-P,
College Waubonsee Community College
Shalena Jarvis, RHIT, CCS Stephanie Scott, MSHI, RHIA, CDIP,
CCS, CCS-P, Moraine Park Technical
Jan Klawitter, AS, CPC, CPB, CPC-I, College
San Joaquin Valley College
Reviews
Many instructors reviewed the manuscript while it was in development and provided
valuable feedback that directly affected the product’s development. Their contribu-
tions are greatly appreciated.
Julie Alles-Grice, MSCTE, RHIA Rashmi Gaonkar, BS, MS, MHA/
Informatics, ASA College
Alicia Alva, AS, San Joaquin Valley
College Savanna Garrity, MPA, CPC,
Madisonville Community College
Kelly Berge, MSHA, CPC, CCS-P,
Berkeley College Deborah Gilbert, RHIA, MBA, CMA,
Dalton State College
Valerie Brock, EdS, MBA, RHIA, CDIP,
CPC, Tennessee State University Terri Gilbert, MS, ECPI University
William Butler, MHA, UNC Gerry Gordon, BA, CPC, CPB, Daytona
Healthcare College
Heather Copen, RHIA, CCS-P, Ivy Tech Michelle A. Harris, CPC, CPB, CPC-I,
Community College Bossier Parish Community College
Gerard Cronin, MS, DC, Salem Susan Hernandez, B.S.B.A., San Joaquin
Community College Valley College
Christine Cusano, CMA (AAMA), Judith Hurtt, MEd, East Central
CPhT, Lincoln Technical Institute Community College
Patti Fayash, CCS, ICD-10-CM/PCS Beverlee Jackson, BA, RHIT, CCS,
AHIMA Approved Trainer, Luzerne AHIMA Ambassador, Central Oregon
County Community College Community College
Shalena Jarvis, RHIT, CCS Melissa Oelfke, RHIA, HIT Program
Coordinator, Rasmussen College
Mary Z. Johnston, RN, BSN, RHIA,
CPC, CPC-H, CPC-I, Ultimate Medical Barbara Parker, CPC, CCS-P, CMA
Academy (AAMA), Olympic College
Jan Klawitter, AS, CPC, CPB, CPC-I, Brenda Parks-Brown, MHS, HCA, CCS,
San Joaquin Valley College CMA, Miller-Motte Technical College
Jennifer Lamé, MPH, RHIT, Southwest Tatyana Pashnyak, CHTS-TR,
Wisconsin Technical College Bainbridge State College
Jorell Lawrence, MSA, CPC, Stratford Staci Porter, AA, San Joaquin Valley
University College
Tracey Lee, MSA, CPC, Vista College Terri Randolph, MBA/HCM, CAHI,
CBCS, CEHRS, Eagle Gate College
Angela Leuvoy, AAS, CMA, CPT,
CBCS, Fortis College Lisa Riggs, CPC, CPC-I, Ultimate
Medical Academy
Glenda Lloyd, MBA, BS, RHIA,
Rasmussen College, Vista College Rolando Russell, MBA, RHIA, CPC,
CPAR, Ultimate Medical Academy
Lynnae Lockett, RN, RMA, CMRS,
MSN, Bryant & Stratton College Patricia Saccone, MA, RHIA, CCS-P,
Waubonsee Community College
Marta Lopez, MD, BXMO, RMA,
Miami Dade College Georgina Sampson, RHIA, Anoka
Technical College
JanMarie Malik, MBA, RHIA, CCS-P,
National University Stephanie Scott, MSHI, RHIA, CDIP,
CCS, CCS-P, Moraine Park Technical
Barbara Marchelletta, BS, CMA
College
(AAMA), CPT, CPC, AHI, Beal College
Mary Jo Slater, MS, MIE, Community
David Martinez, MHSA, RHIT, RMA,
College of Beaver County
University of Phoenix
Karen K. Smith, MEd, RHIA, CDIP,
Jillian McDonald, BS, RMA (AMT),
CPC, University of Arkansas for Medical
EMT, CPT(NPA)
Sciences
Cheryl Miller, MBA/HCM, Westmoreland
Kameron Stutzman, MEd, CMBS, IBMC
County Community College
College
Robin Moore, CPC, CCMA, Davis
Stephanie Vergne, MAEd, RHIA, CPC,
College
Hazard Community & Technical College
Lisa Nimmo, CPC, CFPC, Central
Carolina Technical College
xxviii ACKNOWLEDGMENTS
Ajay Mehra, BSc, RT(R), CCS-P, RHIT, Barbara Parker, CPC, CCS-P, CMA
Rochester Community & Technical (AAMA), Olympic College
College
Jerri Rowe, MBA, CFE, RHIA, CPC,
Corina Miranda, CMPC-I, CMRS, CPC, CRC, Allen School of Health Sciences
Northwest Vista College/Alamo Kathy J Ware, MCLS, RHIT, CPC, CPB,
Community Colleges CPC-I, Lord Fairfax Community College
Robin Moore, CPC, CCMA, Davis Deborah Zenzal, RN, MSHIM, MS,
College CPC, CCS-P, RMA
2
care professional provides care to a patient, there must be a valid medical reason. Diagnosis
Patients certainly want to know that health care professionals performed procedures A physician’s determination of
or provided care for a specific, justified purpose, and so do third-party payers! This is a patient’s condition, illness,
referred to as medical necessity. Requiring medical necessity ensures that health care or injury.
providers are not performing tests or giving injections without a good medical reason. Procedure
Diagnosis codes explain why the individual came to see the physician and support the Action taken, in accordance
physician’s decision about what procedures to provide. with the standards of care, by
Medical necessity is one of the reasons why it is so very important to code the diag- the physician to accomplish
nosis accurately and with all the detail possible. If you are one number off in your code a predetermined objective
selection, you could accidentally cause a claim to be denied because the diagnosis, (result); a surgical operation.
identified by your incorrect code, does not justify the procedure. Medical Necessity
Let’s analyze an example: The determination that the
health care professional was
acting according to standard
EXAMPLE practices in providing a
Dr. Justini performs a colonoscopy on Shoshanna because a lab test identified particular procedure for an
that she had blood in her feces (melena). individual with a particular
diagnosis. Also referred to as
medically necessary.
A colonoscopy involves the insertion of a camera, with surgical tools, into the patient’s
anus, rectum, and up through the large intestine. If you are Shoshanna, or if you are
the one paying for this procedure, you want to make certain that this colonoscopy was CODING BITES
done to support Shoshanna’s good health and not any other reason. This is clearly The WHY justifies the
communicated when you report the code: K92.1 Melena (the presence of blood in WHAT.
feces). Now, whether for resource allocation or reimbursement, it is understood that
Dr. Justini was caring properly for Shoshanna and her good health.
Statistical Analyses
Research organizations and government agencies statistically analyze the data pro-
vided by codes to develop programs, identify research areas, allocate funds, and write
public health policies that will best address areas of concern for the health of our
nation. For example, we can only know that a disease such as Alzheimer’s needs diag-
nostic tests, treatments, and possibly a vaccine or a cure by studying statistics to see
what individual signs and symptoms are being identified and treated around the coun-
try and around the world. Reimbursement
The process of paying for
health care services after they
Reimbursement have been provided.
In most cases, there are three parties involved in virtually every encounter: the health
care provider, the patient, and the person or organization paying for the care provided
(frequently, a health care insurance company). However, the insurance company is not CODING BITES
CPT © 2017 American Medical Association. All rights reserved.
always an actual insurance company, so the broader term “third-party payer” is used. In most cases, there are
Third-party payers use our coding data to determine how much they should pay health three parties involved in
care professionals for the attention and services they provide patients. This is the role reimbursement:
that coding plays in the reimbursement process. The codes make it easier for the
organizations involved to evaluate and manage all their data. • The health care
provider = First party
• The patient =
Resource Allocations
Second party
Whether a health care facility is a one-physician office or a large hospital, there are • The insurance
not unlimited resources available. Administrators and managers must ensure that all company or other
resources are employed in the most efficient and effective manner. Computer pro- organization
grams can easily and quickly organize data (the codes) to identify the largest patient financially
population’s diagnoses and the most frequently provided treatments and services. With responsible =
these details, staff members, equipment, and money can be directed to those patients Third-party payer
and locations that need them the most.
CHAPTER 1 |
1.2 Diagnosis Coding
When a person goes to see a health care provider, he or she must have a reason—a
health-related reason. After all, as much as you might like your physician, you prob-
ably wouldn’t make an appointment, sit in the waiting room, and go through all the
paperwork just to say, “hello.” Whether the reason is a checkup, a flu shot, or some-
thing more serious, there is always a reason why. The physician will create notes, either
written or dictated, recounting the events of the visit. The diagnosis, or diagnostic
statement, in these notes will explain the reason why the patient was seen and treated.
The physician’s notes explain, in writing, the reasons why the encounter occurred.
The notes may document a specific condition or illness, the signs or symptoms of
a yet-unnamed problem, or another reason for the encounter, such as a preventive
service. As a coding specialist, it is your job to translate this explanation into a diag-
nosis code (or codes) so that everyone involved will clearly understand the issues of a
particular patient at a particular time.
The International Classification of Diseases – 10th Revision – Clinical Modification
(ICD-10-CM) code book contains all of the codes from which you will choose to
report the reason why the health care professional cared for the patient during a spe-
cific encounter.
FIGURE 1-1 ICD-10-CM Alphabetic Index, partial listing under main term Abnormal
CHAPTER 1 |
Malignant Malignant Ca in Uncertain Unspecified
Primary Secondary situ Benign Behavior Behavior
Neoplasm, neoplastic C80.1 C79.9 D09.9 D36.9 D48.9 D49.9
-abdomen, abdominal C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
--cavity C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
--organ C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
--viscera C76.2 C79.8- D09.8 D36.7 D48.7 D49.2
--wall—see also Neoplasm, C44.509 C79.2- D04.5 D23.5 D48.5 D49.2
abdomen, wall, skin
---connective tissue C49.4 C79.8- - D21.4 D48.1 D49.2
---skin C44.509
----basal cell carcinoma C44.519 - - - - -
----specified type NEC C44.599 - - - - -
----squamous cell carcinoma C44.529 - - - - -
FIGURE 1-3 The Neoplasm Table from ICD-10-CM, listings for abdominal neoplasms
Poisoning, Poisoning,
Accidental Intentional Poisoning, Poisoning, Adverse
Substance (Unintentional) Self-harm Assault Undetermined Effect Underdosing
Acefylline piperazine T48.6X1 T48.6X2 T48.6X3 T48.6X4 T48.6X5 T48.6X6
Acemorphan T40.2X1 T40.2X2 T40.2X3 T40.2X4 T40.2X5 T40.2X6
Acenocoumarin T45.511 T45.512 T45.513 T45.514 T45.515 T45.516
Acenocoumarol T45.511 T45.512 T45.513 T45.514 T45.515 T45.516
Acepifylline T48.6X1 T48.6X2 T48.6X3 T48.6X4 T48.6X5 T48.6X6
Acepromazine T43.3X1 T43.3X2 T43.3X3 T43.3X4 T43.3X5 T43.3X6
Acesulfamethoxypyridazine T37.0X1 T37.0X2 T37.0X3 T37.0X4 T37.0X5 T37.0X6
Acetal T52.8X1 T52.8X2 T52.8X3 T52.8X4 — —
Acetaldehyde (vapor) T52.8X1 T52.8X2 T52.8X3 T52.8X4 — —
- liquid T65.891 T65.892 T65.893 T65.894 — —
P-Acetamidophenol T39.1X1 T39.1X2 T39.1X3 T39.1X4 T39.1X5 T39.1X6
Acetaminophen T39.1X1 T39.1X2 T39.1X3 T39.1X4 T39.1X5 T39.1X6
FIGURE 1-4 The Table of Drugs and Chemicals from ICD-10-CM, listings from Acefylline piperazine to Acetaminophen
be reviewed in the Tabular List to ensure completeness and accuracy before you can
report it.
You will learn how to use the Table of Drugs and Chemicals in the chapter Coding
Injury, Poisoning, and External Causes.
FIGURE 1-5 The Index to External Causes, first listings including main terms
Abandonment, Abuse, and Accident
progress through your learning experience, particularly in the chapter Coding Injury,
Poisoning, and External Causes.
CHAPTER 1 |
EXAMPLE
The Tabular List shows you which details to abstract from the documentation. All you
have to do is keep reading. The portion of the ICD-10-CM Tabular List below shows
options for additional characters and the information these characters convey.
S43.3 Subluxation and dislocation of other and unspecified parts of shoulder
girdle
CODING BITES S43.30 Subluxation and dislocation of unspecified parts of shoulder girdle
Dislocation of shoulder girdle NOS
You will learn many
Subluxation of shoulder girdle NOS
more details about
reporting diagnoses S43.301 Subluxation of unspecified parts of right shoulder girdle
in Part II: Reporting S43.302 Subluxation of unspecified parts of left shoulder girdle
Diagnoses, with more S43.303 Subluxation of unspecified parts of unspecified shoulder girdle
in-depth introduction to S43.304 Dislocation of unspecified parts of the right shoulder girdle
ICD-10-CM as well as S43.305 Dislocation of unspecified parts of the left shoulder girdle
details by body system. S43.306 Dislocation of unspecified parts of unspecified shoulder girdle
ICD-10-CM
LET’S CODE IT! SCENARIO
MCGRAW GENERAL HOSPITAL
DATE OF ADMISSION: 05/27/18
DATE OF DISCHARGE: 05/28/18
PATIENT: YOUNG, MATTHEW JAMES
HISTORY: Neonate is male, delivered 05/27/2018 at 1915 hours by C-section due to previous C-section. Mother is:
• gravida 2, para 2, AB 1
• blood type B positive
• GBS negative
• hepatitis B surface antigen negative
• rubella immune
• VDRL nonreactive
VITAL SIGNS:
Weight: 6 pounds 9 ounces
Height: 10-1/2 inches
CHAPTER 1 |
These actions provided by the physician, or other health care professional, are done for
one of three reasons:
Diagnostic tests or procedures are performed to provide the physician with addi-
tional information required to determine a confirmed diagnosis.
Preventive procedures and services are provided to keep a healthy patient healthy.
In other words . . . to avoid illness or injury. These also include early detection test-
ing, known as screenings.
Therapeutic procedures, treatments, and services are performed with the intention
of removing, correcting, or repairing an abnormality or condition.
There are three different code sets available for you to use to translate health care
procedures, services, and treatments into codes. These three code sets are
Current Procedural Terminology (CPT)
International Classification of Diseases – 10th Revision – Procedure Coding System
(ICD-10-PCS)
Healthcare Common Procedure Coding System (HCPCS) Level II
(Report 10030 for each individual collection drained with 10121 complicated
a separate catheter) CPT Assistant Spring 91:7, Dec 06:15. Sep 12:10, Dec 13:16
(Do not report 10030 in conjunction with 75989, 76942, (To report wound exploration due to penetrating trauma
77002, 77003, 77012, 77021) without laparotomy or thoracotomy, one 20100-20103, as
appropriate)
FIGURE 1-6 CPT main section, showing codes 10030–10121 Source: American Medical
Association, CPT Professional Manual
Pelvic
Acylcarnitines . . . . . . . . 82016, 82017 Lysis. . . . . . . . . . . . . . . . . . . . . . . .58660, 58740 Tendon
Penile Tibia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28238
Adamantinoma, Pituitary Lysis
See Craniopharyngioma Post-circumcision. . . . . . . . . . . . . . . . . . .54162
Advancement Flap
See Skin, Adjacent Tissue Transfer
Preputial
Addam Operation
See Dupuytren's Contracture
Lysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54450 Aerosol Inhalation
Urethral See Pulmonology, Therapeutic
Adductor Tenotomy of Hip Lysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53500 Pentamidine. . . . . . . . . . . . . . . . . . . . . . . . . . . 94642
See Tenotomy. Hip, Adductor
Adipectomy AFB
Adenoidectomy See Lipectomy See Acid-Fast Bacilli (AFB)
Index
FIGURE 1-7 CPT Alphabetic Index, partial listings from Activity, Glomerular
Procoagulant to Agglutinin Source: American Medical Association, CPT Professional Manual
CHAPTER 1 |
CPT
LET’S CODE IT! SCENARIO
Corey Carter, a 55-year-old male, came to the McGraw Ambulatory Surgery Center, an outpatient facility, so Dr.
Lucano could perform a percutaneous core needle biopsy on his thyroid. Corey’s primary care physician referred
him to Dr. Lucano after noting a lump on his thyroid during an annual physical.
codes under special circumstances, such as the use of unusual anesthesia, two sur-
CODING BITES geons working on the same patient at the same time, or a multipart procedure per-
You will learn many formed over time. When required, a modifier is added after the main CPT code with a
more details about hyphen. Example: 47600-54 Cholecystectomy, surgical care only.
reporting procedures
in Part III: Reporting International Classification of Diseases – 10th Revision –
Physicians Services and Procedure Coding System (ICD-10-PCS)
Outpatient Procedures.
The International Classification of Diseases – 10th Revision – Procedure Coding Sys-
tem (ICD-10-PCS) codes are used to describe the contribution made by the hospital to
inpatient a procedure provided to an inpatient (a patient admitted into an acute care facility).
These are known as “facility charges” because they report what the hospital provided
CPT © 2017 American Medical Association. All rights reserved.
A patient admitted into a
hospital for an overnight stay during a specific procedure, service, or treatment, such as the skilled nursing staff, the
or longer. operating room, the equipment, and whatever else is required.
ICD-10-PCS contains an Alphabetic Index and a Tables section (Figure 1-8).
The Alphabetic Index is used in the same way you use this part of the other code
books—to get an idea of where in the Tables section to find codes. However, the
Tables section of this code set is very different. Rather than a listing of the codes in
numeric or alphanumeric order, you will find Tables listing various characters and
their meanings. Then, you will actually build the code, according to the physician’s
documentation.
FIGURE 1-8 Table 025, one of the tables from ICD-10-PCS Tables section
CPT © 2017 American Medical Association. All rights reserved.
change for each section of the codebook. But don’t worry. No memorization is
required . . . the code book provides you with what you need to know. All you have to
do is read carefully.
For example, in the Medical and Surgical Section, each character reports the:
1. Section of the ICD-10-PCS code set.
2. Body system upon which the procedure or service was performed.
3. Root operation, which explains the category or type of procedure.
4. Body part, which identifies the specific anatomical site involved in the procedure.
5. Approach, which reports which method was used to perform the service or
treatment.
6. Device, which reports, when applicable, what type of device was involved in the
service or procedure.
7. Qualifier, which adds any additional detail.
CHAPTER 1 |
EXAMPLE
0DQ48ZZ Repair of the esophagogastric junction, via natural opening
endoscopic
0RRJ0J6 Replacement of shoulder joint humeral surface with synthetic
substitute, right side, open approach
EXAMPLE
B31M110 Intraoperative fluoroscopy of the spinal arteries, low osmolar
contrast, laser
BB24ZZZ Bilateral CT scan of lungs, no contrast
ICD-10-PCS
LET’S CODE IT! SCENARIO
Marlena Takamoto, a 37-year-old female, contracted hepatitis seven years ago. The disease severely damaged her
liver. She was admitted to Carolina Brookdale Hospital today so Dr. Lewis and his team can perform a liver trans-
plantation, open approach. The liver donor was killed in a car accident early this morning.
Now, with all of this information, let’s build the correct code:
1. Section of the ICD-10-PCS code set = Medical and Surgical 0
2. Body system upon which the procedure was performed = Hepatobiliary F
Remember, the liver is an organ that is part of the Hepatobiliary System.
3. Root operation: the type of procedure = Transplantation Y
4. Body part: the specific anatomical site involved in the procedure = Liver 0
5. Approach: method used to perform the transplant = Open 0
6. Device, when applicable = No Device Z
7. Qualifier: any additional detail = Allogeneic 0
Before reporting this code . . . check the Official Guidelines, specifically B3.16 Transplantation vs. Administration.
This confirms that you used the correct root operation term of Transplantation.
Good job! Now you have built the ICD-10-PCS code for this procedure: 0FY00Z0.
It would not be unusual for one patient encounter, for a patient admitted into
the hospital, to ultimately require interpretation into all three coding languages: CODING BITES
ICD-10-CM, CPT, and ICD-10-PCS.
Use a medical
dictionary whenever
EXAMPLE you do not know the
Injured in an accident, Terence McCarthy was admitted into McGraw General meaning of a term:
Hospital with a major contusion of the spleen. Terence was brought into the Allogeneic means
operating room, he was placed in the supine position, and general anesthesia coming from a different
was administered by Dr. London. Dr. Berring performed a total splenectomy. individual of the same
Together, let’s review all of the codes that will be reported for this surgical species.
procedure: Syngeneic means
• The professional coding specialist for Dr. Berring, the surgeon, will report: coming from a genetic
identical, such as from
S36.021A Major contusion of spleen, initial encounter an identical twin.
38100 Splenectomy; total Zooplastic means
• The professional coding specialist for Dr. London, the anesthesiologist, will report: the tissue or organ is
CPT © 2017 American Medical Association. All rights reserved.
CHAPTER 1 |
HCPCS (pronounced “hick-picks”) is the abbreviation for Healthcare Common
Procedure Coding System.
∙ HCPCS Level I codes are actually called CPT codes. While CPT codes are main-
tained by the American Medical Association (AMA), this code set was adopted by
our industry as the first level of HCPCS.
∙ HCPCS Level II codes are referred to as HCPCS Level II codes.
For the most part, health care services are listed in the HCPCS Level II section
titled Procedures/Professional Services (Temporary) G0008–G0151 [but not exclu-
sively, so be certain to check the Alphabetic Index first]. As always, reading carefully
and completely is required. However, as you scan the codes and their descriptions
in this section of HCPCS Level II, you may find some are very close to CPT code
descriptions. But . . . not exactly. Let’s look at the simple repair of a 2.1 cm superficial
laceration on the patient’s left hand being repaired with tissue adhesive.
In CPT, under REPAIR (CLOSURE), the in-section guidelines state: “Use the
codes in this section to designate wound closure utilizing sutures, staples, or tissue
adhesives, either singly or in combination with each other or in combination with
adhesive strips.”
The definition in CPT of a simple repair includes “. . . requires simple one layer
closure.” With this scenario, this would lead to code
12001 Simple repair of superficial wounds of scalp, neck, axillae,
external genitalia, trunk and/or extremities (including hands
and feet); 2.5 cm or less
Compare this with the most appropriate HCPCS Level II code:
G0168 Wound closure utilizing tissue adhesive(s) only
Which code reports the repair more accurately? You must go back to the documenta-
tion and read carefully, looking for the additional details included in the definition
of Simple Repair in CPT. Was a one-layer closure performed? Was local anesthesia
used? Was anything else done by the physician in addition to the application of the
tissue adhesive?
If the answer to any of these questions is Yes, then you need to report the CPT code
12001. If the answers to all of these questions are No, then report G0168.
Let’s look at an example that is perhaps a bit less complex. Compare and contrast
these two codes, both of which are used for reporting speech therapy services:
92507 Treatment of speech, language, voice, communication, and/or
auditory processing disorder; individual
CODING BITES S9128 Speech therapy, in the home, per diem
Learn about the other These two codes report similar services: speech therapy provided to an individual.
CPT © 2017 American Medical Association. All rights reserved.
types of HCPCS However, they differ with regard to location, length of the session, and possibly the pro-
Level II codes in the fessional providing the therapy. Be certain to read the CPT in-section Guidelines related
section Equipment and to the reporting of 92507 (and other codes in this subsection) before you decide. And, of
Supplies in this chapter. course, you need to carefully abstract the details within the documentation from which
And learn more you are coding and compare the specifics to each of the code descriptions, and perhaps
about the HCPCS to any others available. Then, and only then, can you determine which code to report.
Level II code set in the Don’t worry . . . one item, one detail, one concept at a time. It will take time, but we
chapter HCPCS Level II. are confident you will be able to understand, learn, and master coding for health care
services.
FIGURE 1-9 HCPCS Level II Alphabetic Index, partial listing from Cyclosporine to
Dactinomycin
CHAPTER 1 |
2017 HCPCS Level II J7628
J7512 — J7628
CODING BITES AHA: 2Q, ’13, 3 J7628 Bitolterol mesylate, inhalation solution, compounded
product, administered through DME, concentrated form, per mg
Inhalation Drugs
You will learn many J7604 Acetylcysteine, Inhalation solution, compounded product,
administered through DME, unit dose form, per g
more details about J7605 Arformoterol, inhalation solution, FDA approved final product,
using the HCPCS noncompounded, administered through DME, unit dose form,
15 mcg
Level II code set in
Part IV: DMEPOS &
Transportation. FIGURE 1-10 One page from the HCPCS Level II Alphanumeric Listing, showing
codes J7512–J7628 Center for Medicare and Medicaid Services (CMS)
HCPCS Level II
LET’S CODE IT! SCENARIO
Rita Widden, a 92-year-old female, was being transferred from Hampton Medical Center to the Sunflower Nursing
Home across town. Cosentti Ambulance Service provided nonemergency transportation prepared with basic life
support (BLS) services.
This code set often will require some patience as you read through all of the code options, which were sug-
gested by the Alphabetic Index, until you find the one that matches the services for which you are reporting:
A0428 Ambulance service, basic life-support, nonemergency transport, (BLS)
Good work! You got it!
CHAPTER 1 REVIEW
Essentially, the process of coding begins with the physician’s documentation stating
why the patient needed care and what was done for this patient during this visit. As
a professional coding specialist, you will interpret the documentation in the patient’s
record from medical terminology into codes: diagnosis codes to explain why, along
with how and where if the patient is injured; and procedure codes to report what the
physician or facility did for the patient during this encounter. You will need to confirm
that the diagnosis code or codes support medical necessity for the procedures, ser-
vices, and treatments provided. As you proceed through this textbook, read carefully
and completely. Coding is like nothing you have experienced before, and you want to
learn how to be proficient.
CODING BITES
ICD-10-CM . . . Diagnosis Codes
• Used by all health care providers and facilities
• Report WHY the patient needed care [medical necessity]
• ICD-10-CM diagnosis codes = A12.3K5A (up to 7 alphanumeric)
CPT . . . Procedure Codes
• Used by physicians to report services provided at any/all facilities
• Also used by outpatient care facilities [i.e., ambulatory surgery centers, hospital
emergency rooms, hospital outpatient surgery centers, etc.]
• Report WHAT was done for the patient
• CPT procedure codes = 12345 (five numbers always)
ICD-10-PCS . . . Procedure Codes
• Used only by hospitals for reporting facility services to inpatients
• ICD-10-PCS procedure codes = 012B4LZ (seven characters always)
HCPCS Level II . . . Services and Supplies Codes
• Used to report services and supplies not already represented by a code in CPT
[i.e., transportation, drugs administered by a health care professional, durable
medical equipment, etc.]
• Used by any facility or provider
• Not all third-party payers accept the use of HCPCS Level II codes
• HCPCS Level II codes = A1234 (one letter, four numbers always)
CPT © 2017 American Medical Association. All rights reserved.
CHAPTER 1 REVIEW
Enhance your learning by
A. Classification System
Let’s Check It! Terminology B. Condition
Match each key term to the appropriate definition. C. Diagnosis
1. LO 1.3 The provision of medical care for a disorder or disease. D. Eponym
2. LO 1.2 The state of abnormality or dysfunction. E. External Causes
CHAPTER 1 |
3. LO 1.1 The determination that the health care professional was acting according F. Inpatient
CHAPTER 1 REVIEW
CHAPTER 1 REVIEW
a. injuries and poisoning b. diseases and syndromes
c. injuries d. poisoning
10. LO 1.2 An example of an ICD-10-CM code is
a. H2031 b. 85460 c. H61.022 d. 08NTXZZ
11. LO 1.1 When ICD-10-CM codes support medical necessity, this means that
a. there was a valid medical reason to provide care.
b. a preexisting condition was treated.
c. the patient was seen in a hospital.
d. a licensed health care professional was involved.
12. LO 1.1 The why justifies the
a. who b. where c. what d. when
13. LO 1.3 Surgical removal of a skin tag is an example of a
a. treatment b. procedure c. service d. diagnosis
14. LO 1.3 ___________ tests or procedures are performed to provide the physician with additional information to
support the determination of a confirmed diagnosis.
a. Diagnostic b. Preventive c. Therapeutic d. Conditional
15. LO 1.3 The code set(s) available for the coding specialist to use to translate health care procedures, services, and
treatments into codes is/are
a. CPT code book. b. ICD-10-PCS code book.
c. HCPCS level II code book. d. all of these.
16. LO 1.3 The main body of the CPT book has ___________ sections.
a. 5 b. 6 c. 7 d. 8
17. LO 1.3 An example of a Category II code is
a. 89398 b. 1134F c. V95.9 d. 0241T
18. LO 1.3 The code set used for hospital facility reporting of procedures, services, and treatments provided to a
patient who has been admitted as an inpatient is
a. ICD-10-CM code book. b. CPT code book.
c. ICD-10-PCS code book. d. HCPCS Level II code book.
19. LO 1.4 HCPCS Level II codes are presented as
a. five numbers. b. one letter followed by four numbers.
c. four numbers followed by two letters. d. one letter, a dash, and four numbers.
CPT © 2017 American Medical Association. All rights reserved.
CHAPTER 1 |
2
Key Terms
Abstracting Clinical
Documentation
Learning Outcomes
Abstracting After completing this chapter, the student should be able to:
Assume
Co-morbidity LO 2.1 Identify which health care professional for whom you are
Demographic coding.
Interpret LO 2.2 Describe the process of abstracting physician documenta-
Manifestation tion and operative notes.
Query LO 2.3 Recognize the terms used to describe diagnoses in
Sequela documentation.
Signs
Symptoms LO 2.4 Distinguish between co-morbidities, manifestations, and
sequelae.
LO 2.5 Determine those conditions that require external cause
codes to be reported.
LO 2.6 Recognize the terms used to describe procedures, services,
and treatments provided.
LO 2.7 Create a legal query to obtain documentation about a miss-
ing, ambiguous, or contradictory component in the existing
documentation.
22
Therefore, the first question you, as the professional coder, will need to ask is . . .
for whom are you reporting? Only then will you know which key terms to look for as CODING BITES
you abstract the operative notes, the physician’s notes, and the reports. Patient = Who is pro-
There may also be many professionals providing different types of care for one vided with care
patient for different reasons. For example . . . Physician = Who is the
Allen Davidson, a 59-year-old male, was admitted to the hospital due to a myocar- health care provider you
dial infarction (heart attack). Allen has type 2 diabetes mellitus. are representing
∙ A cardiologist (heart specialist) will diagnose and treat Allen’s heart problem. Diagnosis = Why the
∙ An endocrinologist will diagnose and treat Allen’s diabetes mellitus. provider is caring for
this individual during
∙ The facility, such as a hospital, will provide care for Allen and all of his health this encounter
concerns.
External Cause = How
For all professionals involved in the care of a patient, the reason or reasons why and Where the patient
(diagnosis code or codes) care was required are critical to establishing medical neces- became injured
sity for the what (specific procedures, services, and treatments) provided. Yet, in a Procedure = What the
location, such as an acute care facility (hospital), there may be many issues for you to provider did for the
evaluate and connect. individual
Facility = Where the ser-
2.2 The Process of Abstracting vices were provided
You are learning that documentation about the encounter between physician and
patient will be your primary source for details that you will use to determine the most Abstracting
accurate codes to report. Physicians, though, do not write their documentation solely Identifying the key words or
terms needed to determine
for coding; therefore, there will be pieces of information included that you will not use
the accurate code.
in your coding process. Reading the entire patient record and pulling out the details
necessary for determining the correct codes is known as abstracting. Assume
Suppose to be the case, with-
Assume or Interpret out proof; guess the intended
details.
Always keep in mind the professional coding specialists’ motto: “If it isn’t docu-
mented, it didn’t happen. If it didn’t happen, you can’t code it!” Interpret
If it is documented appropriately, there is no reason for you to assume any details; Explain the meaning of; con-
vert a meaning from one lan-
you only need to interpret what is documented.
guage to another.
One of the most challenging aspects of coding is the very fine line between assum-
ing and interpreting. Yes, professional coding specialists must interpret the physician’s
documentation. This does not include assuming in any way. Assuming is making up CODING BITE
details, filling in the blanks with your own specifics, guessing, or substituting your Keep a medical dictionary
own knowledge for missing facts. Interpreting is an exact science; it involves chang- by your side so that the
ing information from one language to another. Just like casa = house (Spanish-to- minute you come upon
English), fine needle aspiration = 10021 (medical terminology-to-CPT). This is why a word you don’t under-
coding can be so challenging. We are responsible for not only translating from one stand for an absolute fact,
CPT © 2017 American Medical Association. All rights reserved.
language (medical terminology) to another (medical codes) but also for accurately you can look it up right
figuring out into which language (CPT or ICD-10-CM or ICD-10-PCS or HCPCS away. If you don’t under-
Level II) medical terminology must be translated. Another major factor is that no one stand what you are read-
is a natural-born speaker of medical terminology, so you are required to learn a new ing, you will not be able
language to understand the languages of medical coding. Imagine if you were born to interpret it accurately.
speaking English, but you had to learn to speak French before achieving your ultimate
goal of interpreting French words into Spanish. EXCELLENT RESOURCE:
MedlinePlus, an online
Source Documents medical dictionary and
encyclopedia, is an excel-
The patient’s health care record is at the center of health information management lent and reliable source
in general as well as the primary focus for you, as the professional coding specialist. created and maintained
Within this record, whether it is written on paper or typed into an electronic health by the US National
record (EHR), are several important components that you will use to gather details Library of Medicine.
necessary to determine the correct code or codes.
CHAPTER 2 |
Virtually every patient record should include all, or most, of these pages or sections:
∙ Patient’s Registration Form: This document or section includes the patient’s
Demographic demographic information, as well as health insurance policy numbers and the
Demographic details include name of the individual who will be financially responsible for the patient’s care.
the patient’s name, address,
∙ Referral Authorization Form: If another physician or health care provider referred
date of birth, and other per-
sonal details, not specifically
this patient for a consultation, you will need to know this to determine the correct
related to health. evaluation and management code.
∙ Physician’s Notes/Operative Reports: Written documentation of what occurred
during the encounter between physician and patient is also known as clinical doc-
umentation. The physician’s notes or operative reports are your most important
source for details required to determine the most accurate code or codes. Your job
is to interpret the words—medical terminology—into codes. Your ability to inter-
pret accurately is dependent upon your knowledge of anatomy and physiology, as
well as medical terminology.
∙ Pathology and Laboratory Reports: Results of testing performed on blood, tissue,
and other specimens hold important keys to the patient’s condition. The results can
provide you with important details necessary for you to determine a specific, accu-
rate code.
∙ Imaging Reports: Similar to pathology reports, these are reports written by a radi-
ologist containing his or her interpretations of images taken of the patient [e.g.,
x-ray, CT scan, MRI, etc.].
∙ Medication Logs: If the facility is residential, such as an acute care hospital, skilled
nursing facility, long-term care facility, etc., the nursing staff must record every
time they administer a medication to a patient, including the drug name, dosage,
time administered, and route used for administration. All data must be reported.
∙ Allergy List: This list is included for the patient’s safety so health care professionals
can avoid giving the patient any substance to which he or she may be allergic.
∙ History and Physical (H&P): Essentially, this document, written by the admitting
physician, explains the background and current issues used to make the decision to
admit the patient into the hospital.
∙ Consultations Reports: When a specialist is asked by an attending physician to
evaluate a patient’s condition, a report is written and sent over to be included in the
patient’s medical record in the requesting physician’s files, as well as those belong-
ing to the consulting physician.
∙ Discharge Summary: At the time a patient is released from a facility, such as a hos-
pital, the Discharge Summary provides the conclusions and results of the patient’s
stay in the facility in addition to follow-up advice.
CODING BITE CPT © 2017 American Medical Association. All rights reserved.
Principles of Documentation for Medical Records
Adapted from the Centers for Medicare and Medicaid Services
. The documentation of each patient encounter should include:
1
∙ the date;
∙ the reason for the encounter;
∙ appropriate history and physical exam in relationship to the patient’s chief
complaint;
∙ review of lab, x-ray data, and other ancillary services, where appropriate;
∙ assessment; and
∙ a plan for care (including discharge plan, if appropriate).
2. Past and present diagnoses should be accessible.
There are times when an individual comes to see a health care provider without hav-
ing a particular illness or injury. In such cases, you might assign a diagnosis code that
explains why the patient was seen that is not a current health condition or injury. A
healthy person might go to see a physician for preventive care, for routine and admin-
istrative exams, or for monitoring care and screenings for someone with a personal CODING BITE
CPT © 2017 American Medical Association. All rights reserved.
history or family history of a condition. As you read through the documentation, you Every health care
may discover that the reason why the encounter was necessary may be wellness, rather professional/patient
than illness or injury. encounter must have
In the same fashion, the description of what the physician provided may not be a at least one reportable
procedure, service, or treatment. It may be advice or a second opinion. The physician [codeable] reason why
and patient may meet to discuss previously done test results, a recommendation for a and at least one report-
specific treatment plan, suggestions for risk-factor reduction (e.g., stop smoking), or a able [codeable] explana-
referral to another physician or facility. tion of what.
CHAPTER 2 |
medical necessity for a procedure, service, or treatment performed, determining the
diagnosis code to report will vary slightly, depending on whether you are coding for
an inpatient or outpatient encounter.
∙ In an outpatient encounter, if there is no confirmed diagnostic statement, you will
Signs code the patient’s signs and/or symptoms that led to the physician’s decision for the
Measurable indicators of a next step in care.
patient’s health status.
∙ When an inpatient (admitted into the hospital) is being discharged with-
Symptoms out a confirmed diagnosis, you will code the suspected conditions listed on the
A patient’s subjective descrip- discharge summary as if they were confirmed. You will not code the signs and
tion of feeling. symptoms.
CODING BITE
A diagnostic term might have a suffix like:
Dermatitis derma = skin + -itis = inflammation (a condition)
Acrophobia acro = heights + -phobia = fear (a condition)
A procedural term might have a suffix like:
Pancreatectomy pancreat = pancreas + -ectomy = to surgically remove
(an action)
Conjunctivoplasty conjunctivo = conjunctiva (part of the eye) + -plasty = to
repair (an action)
NOTE: These first three steps will get you started when it comes to determining the correct diagnosis code in
ICD-10-CM. You will learn more about this beginning in the chapter Introduction to ICD-10-CM.
Also . . .
NOTE: These first three steps will get you started when it comes to determining the correct drug code in
HCPCS Level II. You will learn more about this beginning in the chapter HCPCS Level II.
GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section
I. Conventions, General Coding Guidelines and Chapter Specific Guidelines;
subsections
• B.4 Signs and Symptoms
• B.5 Conditions that are an integral part of a disease process
• B.6 Conditions that are not an integral part of a disease process
CHAPTER 2 |
LET’S CODE IT! SCENARIO
Ralph Carbonna, a 61-year-old male, came into the Emergency Department of McGraw General Hospital. Earlier
in the day, Ralph felt lightheaded and a little dizzy. In addition, he complained that his heart was beating so wildly
that he thought he may have had a heart attack. When interviewed by the nurse, Ralph revealed his previous diag-
nosis of type 1 diabetes mellitus, prompting Dr. Geller to order a blood glucose test. Dr. Geller also ordered an EKG
(ECG) to check Ralph’s heart. After getting the results of the tests, Dr. Geller determined that Ralph’s lightheadedness
and dizziness were a result of his abnormal glucose level. He spoke with Ralph about how to bring his diabetes
mellitus under control and informed Ralph that the EKG was negative [normal], meaning there were no signs of a
heart attack.
GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I. Con-
ventions, General Coding Guidelines and Chapter Specific Guidelines; subsection
B.18. Use of Sign/Symptom/Unspecified Codes. “If a definitive diagnosis has not
been established by the end of the encounter, it is appropriate to report codes for
sign(s) and/or symptoms in lieu of a definitive diagnosis.”
Section II. Selection of Principal Diagnosis, subsection H. Uncertain
Diagnosis. “If the diagnosis documented at the time of discharge is qualified as
‘probable’, ‘suspected’, ‘likely’, ‘questionable’, ‘possible’, or ‘still to be ruled out’, or
other similar terms indicating uncertainty, code the condition as if it existed or was
established.” NOTE: This guideline is applicable only to inpatient admissions to CPT © 2017 American Medical Association. All rights reserved.
short-term, acute, long-term care, and psychiatric hospitals.
Co-morbidities
A co-morbidity is a condition that is present in the same body at the same time as Co-morbidity
another problem or disease, but the two conditions are unrelated—there is no docu- A separate diagnosis exist-
mented cause-and-effect relationship. These “other diagnoses” may be referred to in the ing in the same patient at the
physician’s documentation. However, only those conditions that the physician has spe- same time as an unrelated
cifically evaluated, treated, or ordered additional testing for or those requiring additional diagnosis.
monitoring, nursing care, or more time in the hospital should be reported with a code.
EXAMPLE
Lindsey, 28 weeks pregnant, fell and broke her leg. So, the pregnancy and the
fracture are co-morbidities—they are two conditions present in the same patient
at the same time. You know that being pregnant does not cause a fracture and a
fracture does not cause pregnancy.
Which code will you report first? The code that is the reason for the encounter with
CPT © 2017 American Medical Association. All rights reserved.
the physician. You are coding for Dr. Kessler, an orthopedist, and Lindsey comes in
because her leg hurts. Dr. Kessler confirms her leg is fractured, so the fracture will be
reported first because this is Dr. Kessler’s primary concern—caring for the fracture.
However, Dr. Kessler MUST take the pregnancy into consideration because pregnancy
is a systemic condition and will impact the treatment plan for the fracture. The preg-
nancy code will also be reported (after the fracture code).
EXAMPLE
Mary-Ellen’s history includes asthma. She is here to see the dermatologist to have
a benign mole removed from her arm. Dr. Callen does not ask about Mary-Ellen’s
asthma. The asthma does not have any relationship at all to the benign mole or
the care/treatment of the mole. You will only determine the correct diagnosis code
for the benign mole. The asthma will NOT be reported at all.
CHAPTER 2 |
GUIDANCE EXAMPLE
CONNECTION Paul’s history includes asthma. He is here to see Dr. Hannah, his family physician,
Read the ICD-10-CM for his annual checkup. Dr. Hannah asks Paul about his asthma and writes a pre-
Official Guidelines for scription for a refill for his inhaler. In addition to the annual exam code, you will
Coding and Reporting, also need to report the code for the asthma because the physician paid attention
section III. Reporting to it during this encounter.
Additional Diagnoses.
Sequelae
Sequela A sequela is the residual impact of a previous condition or injury that may need the
A cause-and-effect relation- attention of a physician. When the patient has come to see the health care professional
ship between an original con- for the treatment of a sequela (also known as a late effect), you must code the particu-
dition that has been resolved lar problem as a sequela only in the following situations:
with a current condition; also
known as a late effect. ∙ Scarring
∙ Nonunion of a fracture
∙ Malunion of a fracture
∙ When the connection is specifically documented by the physician or health care
professional confirming the new condition as a sequela (a late effect) of a previous
condition
Coding a sequela requires at least two codes, in the following order:
1. The sequela condition, which is the condition that resulted and is being treated,
such as a scar or paralysis.
2. The sequela (late effect) or original-condition code with the seventh character “S.”
EXAMPLE
Jenna Malaletto, an 18-year-old female, was using a hydrofluoric acid mixture to
etch glass for an art class last spring and got some on her left forearm, causing
a corrosion burn of the third degree. She came in today to see Dr. Rosen to dis-
cuss treatment options for the adherent scarring.
CODING BITES Dr. Rosen is discussing treatment options of the scars that were left behind
after the third-degree corrosion burn had healed. This is known as a sequela, and
You will learn a lot
it is the reason for this encounter. However, as you learned, you will also need to
more about reporting
report what caused the scar—the corrosion burn.
co-morbidities, manifes-
tations, and sequelae L90.5 Scar conditions and fibrosis of skin (adherent scar)
in Part II: Reporting T22.712S Corrosion of third degree of left forearm, sequela
There are thousands of different ways a patient can become injured, and there is
a different code for almost every incident: the typical, the silly, the unusual, and the
surprising.
ICD-10-CM provides a separate Index to External Causes, usually found between
the Index to Diseases and Injuries (Alphabetic Index) and the beginning of the Tabular
List. This index will point you to the correct subsection in the Tabular List, within the
code range of V00–Y99.
You will learn more details about how to code external causes later in this textbook
in the chapter Coding Injury, Poisoning, and External Causes.
EXAMPLES
i. Neuroplasty: neuro = nerves + -plasty = repair
ii. Thrombolysis: thrombo = blood clot + -lysis = dissolving
iii. Gastrectomy: gastr = stomach + -ectomy = surgical removal
CODING BITE
Other times, the procedure will be identified by its name. This name may be Only the procedures,
∙ a description of the action, such as ablation, debridement, or injection services, and treatments
actually provided dur-
∙ an eponym (named after the individual who invented it), such as Abbe-Estlander
ing a specific encounter,
procedure, Swan-Ganz catheter, or Dupuy-Dutemps operation
by a specific physician,
∙ an abbreviation or acronym, such as ECG = electrocardiography; GTT = glucose health care professional,
tolerance test; PET = positron emission tomography; TAVR = transcatheter aortic or facility, will be coded.
valve replacement
CHAPTER 2 |
Review and practice your medical terminology and keep a medical dictionary close
at hand. As you gain more experience, the process of deconstructing the statements
in the various types of documentation will become easier (not really easy, but easier).
You learned about the part of this career that involves interpreting and you cannot
interpret the words if you don’t know what they mean.
CPT ICD-10-PCS
LET’S CODE IT! SCENARIO
McGRAW HILL HOSPITAL
DATE OF PROCEDURE: 08/18/2018
PATIENT: Christine Gordon
PREOPERATIVE DIAGNOSIS: Acute right lower abdominal pain.
POSTOPERATIVE DIAGNOSIS: Acute appendicitis.
OPERATION PERFORMED: Laparoscopic appendectomy.
SURGEON: Charles E. Manchester, MD
SEDATION: General endotracheal anesthetic.
PROCEDURE:
This 47-year-old female presented with signs and symptoms consistent with acute appendicitis. Preoperative
CT scan indicates an inflamed appendix, rupture not probable. Patient signed written consent for a laparoscopic
appendectomy.
Turn to the Main Section of CPT to find code 44970 because Dr. Manchester specifically documented that the
appendectomy was done laparoscopically. So, now you have found the correct code to report for Dr. Manches-
ter’s work:
44970 Laparoscopy, surgical, appendectomy
*-*-*
Now, if you were the coder for the hospital at which the surgery occurred, you would need to report this same
procedure using the ICD-10-PCS code set.
CHAPTER 2 |
2.7 How to Query
Once you have completed abstracting the documentation, you may find that details
needed to determine a specific code are not included. Should this happen, you
Query should query the physician who wrote the documentation to ask him or her to provide
To ask; an official request to clarification or additional specifics. Every day, coders and health information man-
the attending physician for agement specialists find documentation with information that is
more specific information
related to a patient’s condition ∙ Missing or incomplete
or treatment. ■ for example, What specific type of fracture?
∙ Ambiguous or inconsistent
■ for example, Procedure notes state a single lead pacemaker was inserted; how-
ever, the equipment list states the pacemaker was dual lead.
∙ Contradictory
■ for example, In first paragraph, notes state, “Patient denies any cough or chest
congestion.”; however, last paragraph states patient was prescribed Tessalon (a
cough suppressant).
In Section 2.2 The Process of Abstracting, you learned the difference between
assuming and interpreting. Therefore, you will need to ask the physician to add the
details you need to the patient’s record so you can move forward and determine the
correct code. This process is known as creating a query, and it must be done in a very
specific manner so as not to break the law.
EXAMPLE
Dr. Osage saw Jose Ramirez and documented him to have a displaced fracture of
the metatarsal bone of the right foot.
After rereading the operative notes again, and reviewing the entire patient
record, you discover that the detail of which specific bone was fractured is miss-
ing. Therefore, you need to query Dr. Osage.
Open-ended query: CPT © 2017 American Medical Association. All rights reserved.
The query you write to request the specific details needed should be accompanied
by the pertinent clinical information from the patient’s chart. You want to make it
clear to the physician what you need clarified or supported with more details. There
are many query templates available and often larger organizations have their own ver-
sions, already approved by attorneys.
Query Pathways
The specific details will need to be added to the chart in a time-efficient man-
ner; therefore, the way you deliver the query to the physician is important. Most
facilities have an existing process for delivering a query to the attending physician.
Certainly, in a physician’s office or small clinic, it may be easier than in a hospital
to connect with the physician to ask a question or questions and obtain a response
or responses.
Some electronic health record software programs include a query feature. Alter-
natively, using a secure, encrypted e-mail system can provide a swift route for ask-
ing for the details required as well as a written response. Remember our creed: “If
it’s not documented, it didn’t happen. If it didn’t happen, you cannot code it!” This
reinforces the importance of obtaining those additional specifics in writing from
the physician.
For those facilities still using paper patient records, query notes should be attached
to the front of charts, so all relevant information about that patient, for that encounter,
is at hand and easy for the physician to reference and annotate.
CPT © 2017 American Medical Association. All rights reserved.
Chapter Summary
In preparation for you to learn the process of determining the specific code or codes,
you must be able to gather the required information from the clinical documentation.
You must read through the clinical documentation in the patient’s record and under-
stand everything you read so you can collect the specifics you need. If details are
missing, ambiguous, or conflicting, you will need to query the physician to have the
documentation amended. This is your responsibility and a critical part of the coding
process.
CHAPTER 2 |
CHAPTER 2 REVIEW
CHAPTER 2 REVIEW
CHAPTER 2 REVIEW
d. Read the patient’s registration form.
7. LO 2.2 Every patient encounter must have at least _____ reportable [codeable] reason why and at least _____
reportable [codeable] explanation of what.
a. 1, 1 b. 2, 1 c. 1, 2 d. 3, 1
8. LO 2.3 All of the following would be considered a diagnostic “main term” except
a. herpes. b. acute. c. spasm. d. infarction.
9. LO 2.3 The patient has been diagnosed with hypersecretion of thyroid stimulating hormone. Identify the
condition.
a. hormone b. thyroid c. stimulating d. hypersecretion
10. LO 2.3 Which official guideline is concerned with conditions that are an integral part of a disease process?
a. Section 1.B.4 b. Section 1.B.5 c. Section 1.B.6 d. Section 1.B.7
11. LO 2.4 A manifestation is a _____ condition caused by the _____condition.
a. first, second b. third, fourth c. second, first d. second, third
12. LO 2.4 Coding a sequela requires at least _____ codes.
a. 1 b. 2 c. 3 d. 4
13. LO 2.5 External causes explain _____ and _____ the patient became injured.
a. why, what b. what, where c. how, where d. why, how
14. LO 2.5 Which of the following would be an example of an external causes code?
a. H26.053 b. M62.831 c. S00.03A d. Y92.838
15. LO 2.6 The suffix -plasty means
a. to dissolve. b. to repair. c. to crush. d. to remove.
16. LO 2.6 The abbreviation ECG stands for
a. electrocardiography. b. electroencephalography.
c. electroconvulsive therapy. d. electrocautery.
17. LO 2.7 When you find missing or incomplete information in the physician’s notes, you should
a. place the file at the bottom of the pile.
b. figure out the information yourself; you should know what the doctor is thinking.
c. ask a coworker.
d. query the physician.
18. LO 2.7 Before using an unspecified or NOS (not otherwise specified) code(s), you should
a. code the case as unspecified and move to the next file.
CPT © 2017 American Medical Association. All rights reserved.
CHAPTER 2 |
Let’s Check It! A Diagnosis or Procedure
CHAPTER 2 REVIEW
First, identify the following statements as a diagnosis or a procedure, and then identify the main term.
Example: Factitial dermatosis:
a. diagnosis or procedure: diagnosis b. main term: dermatosis
4. LO 2.4 Discuss the ICD-10-CM Official Guidelines concerning Sequela—Section 1.B.10; include where the
guideline directs you.
5. LO 2.4 Discuss co-morbidity and the correct coding sequence for the encounter.
Laryngoplasty
Repair
Supplement
In HCPCS Level II’s Alphabetic Index, you will see terms such as:
Commode
IPPB machine
Nebulizer
Wheelchair
Once you find the main term that matches the word or words that you abstracted
from the medical documentation, you may find an indented list containing adjectives
providing more detail about that specific main term. It may be an additional descrip-
tion, such as chronic or laparoscopic, or it may be the anatomical site that was involved.
EXAMPLES
ICD-10-CM: ABDOMINAL ABSCESS
Abscess
Abdominal
CPT: INSERTION OF A GASTROSTOMY TUBE
Insertion
Gastrostomy Tube
ICD-10-PCS: REPAIR OF MAXILLA
Repair
Maxilla
HCPCS LEVEL II: NEBULIZER FILTER
Nebulizer
Filter
Often, you will find that further details will be necessary, and options will be pro-
vided in another list, indented from the previous indented list.
EXAMPLES
ICD-10-CM: ABSCESS IN THE WALL OF THE ABDOMINAL CAVITY
Abscess
Abdominal
Cavity
Wall
CPT: PERCUTANEOUS INSERTION OF GASTROSTOMY TUBE
Insertion
Gastrostomy Tube
Laparoscopic
Percutaneous
ICD-10-PCS: REPAIR OF THE RIGHT MAXILLA
Repair
Maxilla
Left
Right
HCPCS LEVEL II: NON-DISPOSABLE NEBULIZER FILTER
Nebulizer
You are required to keep making choices, matching the documentation, all the way
to the most specific detail. Once at the most specific level, you will see that the Alpha-
betic Index will suggest a code or codes.
EXAMPLES
ICD-10-CM: ABSCESS IN THE WALL OF THE ABDOMINAL CAVITY
Abscess
Abdominal
(continued)
ICD-10-CM
The Alphabetic Index gave you:
Abscess, Abdominal, Cavity K65.1
Abscess, Abdominal, Wall L02.211 (continued)
Rev. Confirming Pages
Look at all the additional details provided in the complete code descriptions. As
you can see with just our few examples, there are specifics that may require you to go
back to the documentation to confirm these additional details are still accurate. While
you are here, you also need to read the complete code descriptions for all of the other
codes in this code category. It is not uncommon that you may find another code that is CPT © 2017 American Medical Association. All rights reserved.
ICD-10-CM
In the Tabular List above K65.1 is a notation that states:
Use additional code to identify infectious agent
K65.1 Peritoneal abscess (mesenteric abscess)
A “Use additional code” notation reminds you that you will need to include a second
code reporting the detail identified in the notation. This notation helps you ensure you CODING BITES
are reporting complete information about a patient’s diagnosis that will support medi- You will learn more
cal necessity for the appropriate treatment. about ICD-10-CM con-
ventions, notations, and
CPT symbols in the chapter
In the Main Section to the left of code 97803 is a star symbol: titled Introduction to
⋆97803 Medical nutrition therapy; re-assessment and intervention, individual, ICD-10-CM.
face-to-face with the patient, each 15 minutes
Both at the bottom of the page in CPT and in the “Introduction” in the front of the CPT
code book, you can see that this symbol ⋆ informs you, the coder, that if this service CODING BITES
was provided using audio/video synchronous equipment (i.e., Skype, FaceTime), you You will learn more
will need to append modifier 95 to this code. This small symbol helps you avoid com- about CPT conventions,
mitting fraud. notations, and symbols
in the chapter titled
ICD-10-PCS Introduction to CPT.
The majority of the codes suggested in the Alphabetic Index of ICD-10-PCS are not
complete codes. This fact will not let you forget that you have to go into the Tables sec-
tion to build the code out to seven (7) characters (based on the additional details in the
operative notes). To report a complete, valid code, you must go into the Tables section. CODING BITES
0NQQ0ZZ Repair of orbit, left side, open approach You will learn more
about ICD-10-PCS con-
0NQRXZZ Repair of maxilla, external approach
ventions in the chapter
NOTE: Even in those occasions when the Alphabetic Index provides you with all titled Introduction to
seven characters for the code, you still should go to the appropriate Table to confirm. ICD-10-PCS.
It will only take a few seconds, and you can be certain you are reporting the complete
and accurate code.
With all these code sets and all these codes, you can see that the process to get from
documentation to code is more complicated than simply finding a word here and a
code there. Coding is important work, so you want to get it accurate every time. To
accomplish this, it is essential to have help and support exactly when you need it.
And you have that help right at your fingertips within each code set’s book. Always
there, just the turn of a few pages, is the guidance from those who created these code
sets and who oversee their legal and correct use. These are the published Official Official Guidelines
Guidelines with which you must comply. You don’t need to memorize them; you A listing of rules and regula-
just need to remember they are there and refer to them every time you are working to tions instructing how to use a
determine a code. specific code set accurately.
ICD-10-CM
Usually in the front of this code book, you will find the section titled “ICD-10-CM
Official Guidelines for Coding and Reporting.”
ICD-10-PCS
Usually in the front of this code book, you will find the section titled “ICD-10-PCS
Official Guidelines for Coding and Reporting.”
Guidance Connection
Throughout this book, you will see special boxes titled GUIDANCE CONNEC-
TION that will point you to a specific guideline in that particular code set directly
related to whatever concept or aspect is being discussed. Take a minute and turn to
that Guideline in your personal code book and read it, think about it, and identify how
you would apply this guideline to your work as a professional coding specialist. There
is no need to memorize these details because they will always be there for you, right
inside your code book, at your fingertips.
CPT
LET’S CODE IT! SCENARIO
DATE OF PROCEDURE: 08/18/2018
PATIENT: ARTHUR FERGUSON
PREOPERATIVE DIAGNOSIS: Acute upper abdominal pain
POSTOPERATIVE DIAGNOSIS: Liver tumor
OPERATION PERFORMED: Diagnostic laparoscopy; Laparoscopic ablation, using radiofrequency
SURGEON: Harrison Brusk, MD
SEDATION: General endotracheal anesthetic
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None. CPT © 2017 American Medical Association. All rights reserved.
(continued)
Turn to the Main Section of CPT to find code 47370 because Dr. Brusk specifically documented that the abla-
tion was done laparoscopically. Directly above code 47370 are some official guidelines that provide important
direction:
“Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (perito-
neoscopy) (separate procedure), use 49320.”
Without this direction, you might have gone to the trouble to report both 49320 and 47370. So, now you
saved yourself some time and found the correct code to report for Dr. Brusk’s work:
Good work!
do whatever they want to a patient without a valid reason. In our industry, this valid
reason is known as medical necessity, and you learned about it in the Introduction to
the Languages of Coding chapter. The code or codes that you report to identify the
reasons why the patient required the attention of a health care professional justify what
the physician or health care professional did to the patient or for the patient . . . but
only when they are in accordance with the standards of care.
Outpatient Settings
In an outpatient setting, once you have determined the accurate diagnosis codes and
procedure codes, you must confirm that you are reporting at least one diagnosis code Linking
to identify medical necessity by linking it to at least one procedure code. Multiple Confirming medical necessity
procedure codes can link to one diagnosis code, and multiple diagnosis codes can by pairing at least one diagno-
link to one procedure code. But there must be at least one of each to support the sis code to at least one proce-
encounter. dure code.
You must take this action to ensure that the diagnosis codes you are reporting accu-
rately represent the documented reasons why the physician made the decisions he or
she made and provided care to this patient, based on those reasons. You must make
certain you did not miss anything in the documentation. You must make certain you
did not jot down, or enter, the code incorrectly [a typo?].
CPT
LET’S CODE IT! SCENARIO
Ahmed Obodeh, a 23-year-old male, came in to see Dr. Starkey because he hit his head on a cabinet and has had a
headache for 2 days nonstop. Dr. Starkey examined Ahmed and ordered an MRI of his brain to be taken. Just before
the nurse took him down to imaging, Ahmed told Dr. Starkey that he also banged his left knee and was having pain
when walking. So Dr. Starkey told the nurse to have radiology take an x-ray of his left knee while he was there. After-
wards, Dr. Starkey gave Ahmed instructions for care of a mild concussion, and suggested an ace bandage for his
knee and over-the-counter pain relievers for 1 week.
Inpatient Setting
In an inpatient setting, the diagnosis code or codes reported must support the medical
necessity for the patient to require acute care in a hospital setting—24-hour care from
trained health care professionals.
CPT © 2017 American Medical Association. All rights reserved.
For example, uncomplicated mild intermittent asthma [J45.20], occasional narrow-
ing of the bronchi causing diminished breathing, relieved with a prescription inhaler,
is not a reason to admit a patient into the hospital to receive round-the-clock care;
however, mild intermittent asthma with status asthmaticus [J45.22], a life-threatening
asthma attack that is not responding to normal treatments such as an inhaler or nebu-
lizer, certainly might be.
ICD-10-CM
LET’S CODE IT! SCENARIO
DATE OF ADMISSION: 09/18/2018
ADMITTING DIAGNOSIS: Suspected bowel obstruction
CHIEF COMPLAINT: Severe abdominal pain, vomiting, bloating (continued)
Chapter Summary
In this chapter, you learned how to take the data culled from the physician’s documen-
tation and interpret the data into another language, a medical code (ICD-10-CM, CPT,
HCPCS Level II, or ICD-10-PCS). Following each and every one of the six actions
required will help you ensure that you are accurately interpreting what occurred
between physician and patient during a specific encounter or during a patient’s stay
in a hospital. In the next part of this book, you will delve more deeply into diagnosis
coding using the language of ICD-10-CM.
CODING BITES
Action 1. Abstract the documentation
Action 2. Query, if necessary
Action 3. Code the diagnosis or diagnoses
Action 4. Code the procedure or procedures
Action 5. Confirm medical necessity
Action 6. Double-check your codes
CPT © 2017 American Medical Association. All rights reserved.
CHAPTER 3 REVIEW
CHAPTER 3 REVIEW
CHAPTER 3 REVIEW
a. ICD-10-CM b. CPT
c. ICD-10-PCS d. HCPCS Level II
8. LO 3.2 IPPB machine would be an example of a term found in which Alphabetic Index?
a. ICD-10-CM b. CPT
c. ICD-10-PCS d. HCPCS Level II
9. LO 3.2 The Main Section and Tabular List of the code books all contain additional _____ and _____ to help you
determine the most accurate code.
a. notations, modifiers b. symbols, notations
c. figures, icons d. transformers, symbols
10. LO 3.3 Which of the following code books lists the codes in numeric order?
a. ICD-10-CM b. HCPCS Level II c. CPT d. ICD-10-PCS
11. LO 3.3 Which of the following is a full code description?
a. Carbuncle of trunk L02.23 b. Furuncle of trunk L02.22
c. Cutaneous abscess of chest wall L02.213 d. Impetigo L01.0
12. LO 3.3 In the ICD-10-CM Tabular List above code K70.31 there is a notation. What is the notation?
a. Use additional code to identify alcohol abuse and dependence
b. Code first underlying diseases
c. Code also, if applicable, viral hepatitis
d. Code first poisoning due to drug or toxin, if applicable
13. LO 3.3 If you see this symbol in the CPT code book’s main section beside a code, it tells you that
a. the code is a revised code. b. moderate sedation is included in this code.
c. the code is an add-on code. d. the code is a new code.
14. LO 3.3 Which code set requires you, the coder, to build the code out to seven characters?
a. ICD-10-CM b. HCPCS Level II
c. CPT d. ICD-10-PCS
15. LO 3.3 What is the correct ICD-10-PCS code for the Repair of maxilla, left side, open approach?
a. 0NQT0ZZ b. 0NQRXZZ
c. 0NQR0ZZ d. 0NQV0ZZ
16. LO 3.3 What is the correct CPT code for a Laparoscopy, surgical; gastrostomy, without construction of gastric
tube?
a. 43246 b. 43653
CPT © 2017 American Medical Association. All rights reserved.
3. LO 3.3 Explain the ICD-10-CM Tabular List, how the codes are listed, and why it is important.
4. LO 3.4 Describe what the Official Guidelines are, why they are important, where they are located, and if you are
required to comply with these guidelines.
5. LO 3.5 Discuss the importance of linking a diagnosis code to a procedure code.
54
Punctuation
CODING BITES
Punctuation in ICD-10-CM adds information and helps you further your quest for the
best, most appropriate code. NOTE: This code set is
maintained by the U.S.
Brackets [ ] federal government;
however, there are
Found in the Tabular List, brackets will show you alternate terms, alternate phrases, and/
many different publish-
or synonyms to provide additional detail or explanation to the description. In the follow-
ers. Each publisher may
ing example, the provider may have diagnosed the patient with food-borne intoxication
present the symbols
due to either Clostridium perfringens or C. welchii. In either case, A05.2 would be the
and notations in its own
correct code. The same for our other examples: If the documentation reads either “benign
way. Don’t worry. The
recurrent meningitis” or “Mollaret’s,” code G03.2 can be reported, and if either “third
conventions section in
nerve palsy” or “palsy of the oculomotor nerve” is documented, code H49.02 is valid.
the very front of your
code book, in Section
1.A of the Official Guide-
EXAMPLES lines, as well as the leg-
A05.2 Food-borne Clostridium perfringens [Clostridium welchii] intoxication end along the bottom of
G03.2 Benign recurrent meningitis [Mollaret] every page will always
H49.02 Third [oculomotor] nerve palsy, left eye explain what means
what. All you have to do
is read.
Italicized or Slanted Brackets [ ]
Italicized, or slanted, brackets, used in the Alphabetic Index, will surround an addi-
tional code or codes (i.e., secondary codes) that must be included with the initial code.
It is the Alphabetic Index’s way of telling you that you may need to report more than
one code, as well as in what order to sequence these codes.
The italic brackets tell you that if the patient has been diagnosed with schistosomia-
sis due to granuloma, you have to use two codes: first, B65.9 for the underlying condi-
tion (the schistosomiasis) and, second, G07 for the granuloma itself.
EXAMPLE
Granuloma L92.9
brain (any site) G06.0
schistosomiasis B65.9 [G07]
Parentheses ( )
Throughout the code set, parentheses show you additional terms or phrases that are
also included in the description of a particular code. The additional terms are called
nonessential modifiers. The modifiers can be used to provide additional defini- Nonessential Modifiers
tion but do not change the description of the condition. The additional terms are not Descriptors whose inclusion in
required in the documentation, so if the provider did not use the additional term, the the physician’s notes are not
code description is still valid. absolutely necessary and that
Take a look at the first example below. Whether the physician wrote the diagnosis as are provided simply to further
clarify a code description;
“malaria,” “malarial,” or “malarial fever,” code B54 would still be a valid suggestion.
optional terms.
In the Tabular List example, code H18.52 would be valid for a diagnosis written by
the physician as “epithelial corneal dystrophy” or “juvenile corneal dystrophy.”
EXAMPLES
In the Alphabetic Index:
Malaria, malarial (fever) B54
Injury, thyroid (gland) NEC S19.84 (continued)
In the Tabular List:
H18.52 Epithelial ( juvenile) corneal dystrophy
H44.631 Retained (old) magnetic foreign body in lens, right eye
Colon :
A colon (two dots, one on top of the other), used in the Tabular List, emphasizes that
one or more of the following descriptors are required to make the code valid for the
diagnosis.
EXAMPLES
K72.- Hepatic failure, not elsewhere classified
Infection, coronavirus NEC B34.2
NOS
Not Otherwise Specified Not otherwise specified (NOS) means that the physician did not document any addi-
(NOS) tional details that are identified in any of the other available code descriptions. On
The absence of additional occasion, you may find an NOS in the Alphabetic Index, but most often, you will see
details documented in the these notations in the Tabular List.
notes. Before reporting a code with NOS in the description, you need to reread the phy-
sician’s documentation and complete patient chart to make certain the specifics you
need to report a more complete code are not there. And, even then, you should query
the physician to obtain the details, as you learned in the chapter Abstracting Clinical
Documentation. An NOS code should be a very last resort to report.
EXAMPLES
R10.811 Right upper quadrant abdominal tenderness NOS
Z30.09 Encounter for other general counseling and advice on contraception
(Encounter for family planning advice NOS)
EXAMPLE
Turn in your ICD-10-CM code book, Tabular List, and find code:
J99 Respiratory disorders in diseases classified elsewhere
respiratory disorders in:
amebiasis (A06.5)
blastomycosis (B40.0–B40.2)
You would read the excluded diagnoses as . . .
respiratory disorders in ambeiasis (A06.5)
respiratory disorders in blastomycosis (B40.0–B40.2)
EXCLUDES2
An notation is a warning to STOP AND DOUBLE- CHECK THE DOCUMENTA-
TION so you don’t report the code above the notation when a code shown in the notation
may be more accurate. You will see specific conditions listed in the notation that are
GUIDANCE not a part of the code above and a suggestion for an alternate code that may be a more
CONNECTION accurate match to the physician’s notes. In some cases, the notation may be
Read the ICD-10-CM
alerting you that an additional code may be needed to complete telling the story about
Official Guidelines for
the patient’s condition. Using our example, you can see that the notation
Coding and Report-
tells you that F34.0 Cyclothymia is not the same as F31 Bipolar disorder. Now you can
ing, section I. Con-
go back to the physician’s notes, double-check the information, and determine which
ventions, General
is the more accurate code to report, or if you need to report both codes.
Coding Guidelines
and Chapter Specific EXAMPLE
Guidelines, subsection
Turn in your ICD-10-CM Tabular List to:
A. Conventions for
the ICD-10-CM, para- M66.1 Rupture of synovial cyst
graphs 10. Includes rupture of popliteal cyst (M66.0)
notes; 11. Inclusion
The notation alerts you to STOP AND DOUBLE-CHECK THE DOCUMENTATION to
terms; and 12. Excludes
confirm which type of cyst the physician documented. If the documentation states
notes.
a synovial cyst, then continue determining the correct additional characters for
M66.1. If the documentation states that the cyst was a popliteal cyst, then you
need to report M66.0 to be more accurate.
Code First
Certain conditions and diseases can cause other problems in the body. Individuals
with diabetes, for example, are known to have problems with their eyes or circulation,
just to name a few, as a direct result of having diabetes. Patients found to be HIV-
positive are prone to conditions such as pneumonia, again as a direct result of the fact
that they have human immunodeficiency virus infection. In these examples, diabetes
Underlying Condition and HIV are what are known as underlying conditions. The resulting conditions (e.g.,
One disease that affects circulation problems, pneumonia) are called manifestations.
or encourages another The Code first notation is a reminder that you are going to need another code to
condition. identify the underlying disease that caused the diagnosed condition. This notation
Manifestation also tells you the sequence in which to report the two codes: the underlying condition
A condition caused or devel- first followed by the manifestation (see Figure 4-1). Often, the notation will reference
oped from the existence of the most common underlying diseases for a manifestation (along with their codes)!
another condition. Cool!
EXAMPLE
G00.2 Streptococcal meningitis
Use additional code to further identify the organism (B95.0–B95.5)
(continued)
This notation tells you that
1. You need to report both code G00.2 and a code from the range B95.0-B95.5
(as per the physician’s notes).
2. You need to report G00.2 first, followed by the code from B95.0-B95.5.
Code Also
The Code also notation is similar to the Code first and Use additional code nota-
tions, just without the predetermination of sequencing. ICD-10-CM is alerting you that
GUIDANCE the physician’s notes may contain some additional condition or issue that should be
CONNECTION reported with a separate code, in addition to the code above this notation. This nota-
Read the ICD-10-CM tion leaves it up to you to decide whether or not the additional code is needed to tell
Official Guidelines for the whole story. If it is needed, you will need to use the Official Guidelines, Sections
Coding and Report- II and III, to determine the reporting order.
ing, section I. Con-
ventions, General
Coding Guidelines EXAMPLE
and Chapter Specific H18.041 Kayser-Fleischer ring, right eye
Guidelines, subsection
Code also any associated Wilson’s disease (E83.01)
A. Conventions for the
ICD-10-CM, paragraph This Code also notation alerts you to check the documentation to see if there is a
17. “Code also note.” diagnosis of Wilson’s disease mentioned in connection with the Kayser-Fleischer
ring of the patient’s right eye.
If so, then . . .
1. You need to report both code H18.041 and code E83.01 (as per the physi-
CODING BITES cian’s notes).
Sometimes notations 2. You need to determine from the physician’s documentation, and using the Offi-
appear under the three- cial Guidelines, Section II. Selection of Principal Diagnosis, and Section III.
character code at the Reporting Additional Diagnoses, which code to report first.
top of a category but are
not repeated after each
additional code in its
Category Notes
section. This is another
reason why it is impor- Occasionally, you may see informational notes under the description of a three-
tant to start reading at character code or at the top of a subsection in the Tabular List. These notes share
the three-character code, important information and clarifications that you need to know before you determine
even when the Alpha- the code or codes to report.
betic Index directs you to
a code with more char-
acters. You don’t want to EXAMPLES
miss any important direc-
tives, such as , I69 Sequelae of cerebrovascular disease
, Code first, or Note: Category I69 is to be used to indicate conditions in I60–I67 as the cause of
Use additional code sequelae. The “sequelae” include conditions specified as such or as residuals that
notations. may occur at any time after the onset of the causal condition.
*-*-*
Chapter 15. Pregnancy, Childbirth and the Puerperium (O00–O9A)
Sequela
A cause-and-effect relation- Note: Codes from this chapter are for use only on maternal records, never on
ship between an original con- newborn records. Codes from this chapter are for use for conditions related to or
dition that has been resolved aggravated by the pregnancy, childbirth, or by the puerperium (maternal causes or
with a current condition; also obstetric causes).
known as a late effect.
With
The term “with” can be seen in both the Alphabetic Index and the Tabular List, and GUIDANCE
you should read this as a connection confirmed by the physician. A phrase you may
CONNECTION
see in the physician’s documentation is “associated with.” To use a combination code
containing “with,” you do not need the physician to document the connection between Read the ICD-10-CM
the two diagnoses. The Official Guidelines direct us to avoid using a combination Official Guidelines for
code when the physician’s documentation specifies that the conditions are not related Coding and Report-
or associated with each other. ing, section I. Con-
ventions, General
Coding Guidelines
EXAMPLE and Chapter Specific
Lorrie Demming, a 31-year-old female, G1, P0, came to see Dr. Southland because Guidelines, subsection
of bleeding. She is in her third trimester and very worried about the baby. Dr. A. Conventions for the
Southland confirmed the hemorrhage was associated with her placenta previa. ICD-10-CM, paragraph
15. “With.”
O44.13 Placenta previa with hemorrhage, third trimester
Confirmed
Other Specified Found to be true or definite.
The phrase other specified means the same thing as NEC: The physician specified Other Specified
additional information that the ICD-10-CM book doesn’t have in any of the other Additional information the
codes in the category. physician specified that isn’t
included in any other code
description.
EXAMPLE
Dr. Josephs diagnosed Allen Halverson with portal cirrhosis of the liver. Turn to the
ICD-10-CM Tabular List code category:
K74 Fibrosis and cirrhosis of liver
K74.3 Primary biliary cirrhosis
K74.4 Secondary biliary cirrhosis
K74.6 Other and unspecified cirrhosis of liver
K74.60 Unspecified cirrhosis of liver
K74.69 Other cirrhosis of liver
You can see that Portal cirrhosis of the liver is not specified in codes K74.3 or
K74.4. You cannot honestly report K74.60 because the physician DID specify the
type of cirrhosis. Therefore, to be accurate, you must report K74.69 Other
cirrhosis of liver.
Unspecified
Unspecified Unspecified has the same meaning as NOS, explaining that the physician did not
The absence of additional provide more details in his or her notes. Query the physician for specifics so you can
specifics in the physician’s avoid using an unspecified code. Using these codes should always be a last resort.
documentation.
EXAMPLES
K64.9 Unspecified hemorrhoids
Tumor, yolk sac, unspecified site, male C62.90
See
CODING BITES In the Alphabetic Index of ICD-10-CM, you may look up a term and notice that the
Before choosing any book instructs you to see another term. This is an instruction in the index that the
code with NOS or information you are looking for is listed under a different term.
unspecified in the
description, double-
check the notes and EXAMPLES
patient record to be
Entamoeba, entamebic—see Dysentery, amebic
certain you cannot
Dysentery, dysenteric
find specific details to
amebic (see also Amebiasis) A06.0
support a specific code.
acute A06.0
If not, then query the
chronic A06.1
provider and ask for
the additional details *-*-*
you need to determine Glue
a more accurate code. sniffing (airplane)—see Abuse, drug, inhalant
An unspecified or NOS Abuse
code should always be drug
a last resort. inhalant F18.10
See Also
GUIDANCE
In other places in the Alphabetic Index, you may see that the instruction see also is
CONNECTION next to the term you are investigating. See also explains that additional details may be
Read the ICD-10-CM found under a different term. The index is providing you with an alternate main term
Official Guidelines for that may show descriptions more accurate to the physician’s documentation.
Coding and Report-
ing, section I. Con-
ventions, General EXAMPLE
Coding Guidelines Angiofibroma (see also Neoplasm, benign, by site)
and Chapter Specific juvenile
Guidelines, subsection
A. Conventions for specified site—see Neoplasm, benign, by site
the ICD-10-CM, para- unspecified site D10.6
graph 16. “See” and You can see that the See Also notation provides you with an additional path to get
“See Also.” to the correct code.
See Condition
The Alphabetic Index may also point you in a less concrete way, such as when you look
up a term and the notation tells you to see condition. This can be confusing. The index
Anatomical Site is not telling you to look up the term condition. What it is instructing you to do is to
A specific location within the find the term that describes the health-related situation involved with this diagnosis and
anatomy (body). look up that term. You will see this most often next to the listing for an anatomical site.
This instruction comes back to the reason you are looking for a code in the first
place. Remember, you are looking for a code to explain why the physician cared for the
patient during the encounter. Using our example, having a heart is not a reason for a
physician to meet with a patient. Everyone has a heart. Therefore, the index is telling
you to look, instead, for the term that describes the condition of this patient’s heart—
the problem or concern about his or her heart that brought the patient together with the
physician at this time. So, as an example, instead of heart, cervix, or lung, you need to
look up atrophy, fracture, or deformity . . . whatever the reason why the patient would
need the care of a health care professional.
EXAMPLE
H20 Iridocyclitis
H20.0 Acute and subacute iridocyclitis
H20.01 Primary iridocyclitis
H20.013 Primary iridocyclitis, bilateral
You can see that, as each additional character is added to the code, more specific
details are included in the code description. As a professional coding specialist, it
is your obligation to always report the most detail possible. This is referred to as
the “highest level of specificity.” Therefore, when the ICD-10-CM code book directs
you to keep reading to find an additional character, you are required to do this.
Hyphen -
A hyphen is used in the Alphabetic Index to indicate that additional characters are
required. This alerts you to an incomplete code.
EXAMPLES
Cogan’s syndrome H16.32-
Discontinuity, ossicles, ear H74.2-
Fahr Volhard disease (of kidney) I12.-
FIGURE 4-2 An excerpt from the Official Guidelines for Coding and Reporting,
section 1.C. Chapter-Specific Coding Guidelines, chapter 4. Endocrine, Nutritional,
and Metabolic Diseases (E00-E89), subsection a. Diabetes Mellitus, parts
1 through 3 Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and
Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)
Dr. Jackson noted that Jenna’s sinusitis was recurrent, leading you to J01.11 as the
correct code. However, this does not tell the WHOLE story, does it? You need to also
explain the cause of the sinusitis.
Take a look at the notations beneath J01:
Use additional code (B95–B97) to identify infectious agent
This tells you that the second code to report will explain the cause of the sinusitis. You
are already using what you have learned in just this short amount of time. You can find
the correct second code by turning in your Tabular List to B95 and read all of the code
descriptions in these code categories carefully. Did you find: CODING BITES
The sinusitis is con-
B95.3 treptococcus pneumoniae as the cause of diseases classified
S
sidered a “disease
elsewhere
classified elsewhere”
So, you will report: because it is a condition
that is reported with a
J01.11 Acute recurrent frontal sinusitis
B95.3 Streptococcus pneumoniae as the cause of diseases classified code from elsewhere in
elsewhere this code set. The word
“classified” is used to
Now you can see that, with these two codes, you and anyone reading these codes mean assigned a code
clearly can understand that Dr. Jackson cared for Jenna because she had a recurring in this code set.
acute frontal sinus infection caused by Streptococcus pneumoniae. Without BOTH
codes, you don’t have the whole story. So, for every case, every encounter, every sce-
nario, you are responsible for telling the WHOLE STORY about the encounter.
CODE SEQUENCING
When more than one diagnosis code is required to tell the whole story of the encounter
accurately, you then must determine in which order the codes should be listed. [Yes, it
does matter!] The code reporting the most important reason for the encounter is called
Principal Diagnosis the principal diagnosis.
The condition, after study, that Sometimes the ICD-10-CM book will tell you which code should come first and
is the primary, or main, reason which should come second with the Code first and Use additional code notations.
for the admission of a patient Section II and Section III of the Official Guidelines will help you with those instances
to the hospital for care; the when there are no notations to guide you with sequencing.
condition that requires the
largest amount of hospital
resources for care. EXAMPLE
Carl Rossen was diagnosed with myocarditis due to E. coli. You will find notations
directing you on how to sequence these two codes.
I40.0 Infective myocarditis
Use additional code (B95–B97) to identify infectious agent
I41 Myocarditis in diseases classified elsewhere
Code first underlying disease, such as: typhus (A75.0–A75.9)
In cases when there are multiple confirmed diagnoses identified, the guidelines
CODING BITES instruct you to list the codes in order of severity from the most severe to the least
If two (or more) diagno- severe. Take a look at the encounter Dr. Jackson documented with Jenna Wilson. You
ses are of equal sever- knew to report B95.3 AFTER J01.11 because the notation beneath J01 directed you
ity, then report them to Use additional code, providing you with the detail that you (1) needed a second
in order of anatomical code to complete your explanation of why Jenna required treatment and that (2) clari-
site—head to toe. fied the order in which to place the codes.
ICD-10-CM
YOU CODE IT! CASE STUDY
Lorraine Pankow has acute lymphoblastic leukemia and chronic lymphocytic leukemia of B-cell type, now in remis-
sion. She is seeing Dr. Huang today for a checkup of this condition.
Combination Codes
If one code exists with a description that includes two or more diagnoses identified in
one patient at the same time, you must choose the code that includes as many condi-
tions as available. You may not code each separately.
When the physician’s notes indicate that the patient suffered with both acute respi- Acute
ratory failure and chronic respiratory failure, you must use the code J96.2-. You are Severe; serious.
not allowed to use J96.0- and J96.1-, even though, technically, you are reporting the Chronic
patient’s conditions accurately. It is required that you use the combination code, as Long duration; continuing over
discussed in the Official Guidelines. an extended period of time.
EXAMPLES
J96.0- Acute respiratory failure GUIDANCE
J96.1- Chronic respiratory failure CONNECTION
J96.2- Acute and chronic respiratory failure
Read the ICD-10-CM
Official Guidelines for
Also, there are combination codes throughout ICD-10-CM that enable you to report Coding and Reporting,
an underlying condition along with a manifestation. section I. Conven-
tions, General Coding
Guidelines and Chapter
EXAMPLES Specific Guidelines,
E10.21 Type 1 diabetes mellitus with diabetic nephropathy subsection B. General
. . . This one code reports two diagnoses: type 1 DM + diabetic nephropathy. Coding Guidelines,
I73.01 Raynaud’s syndrome with gangrene paragraphs 8. Acute
. . . This one code reports two diagnoses: Reynaud’s syndrome + gangrene. and Chronic Conditions
and 9. Combination
K55.21 Angiodysplasia of colon with hemorrhage
Code.
. . . This one code reports two diagnoses: Angiodysplasia of colon + hemorrhage.
ICD-10-CM
LET’S CODE IT! SCENARIO
Cahlen Achmed, a 61-year-old male, came to see Dr. Miller. Earlier in the day, he was lightheaded and a little
dizzy. In addition, he complained that his heart was beating so wildly that he thought he was having a heart attack.
(continued)
Due to his previous diagnosis of type 1 diabetes, Dr. Miller ordered a blood glucose test. He also performed an EKG to
check Cahlen’s heart. After getting the results of the tests, Dr. Miller determined that Cahlen’s lightheadedness and dizziness
were a result of his glucose being too high and administered a shot of insulin subq, 5U. He spoke with Cahlen about how to
bring his diabetes under control. He also told him that the EKG was negative and that there were no signs of a heart attack.
CODING BITES
Cahlen Achmed’s case illustrates that sometimes asking yourself, “Why did the physician provide a specific
test, treatment, or service?” can help you find the necessary diagnostic key words for an encounter.
Type 1 diabetes mellitus seems to be the only confirmed diagnosis in Dr. Miller’s notes. However, the doctor
performed an EKG. A diagnosis for diabetes does not provide any medical necessity for doing an EKG. In addi-
tion, the test was negative and, therefore, provided no diagnosis. So you still need a diagnosis code to report
the medical necessity for running the EKG. Why did Dr. Miller perform the EKG? Because Cahlen complained of a
rapid heartbeat. The Alphabetic Index suggests:
Rapid, heart (beat) R00.0
The Tabular List confirms
R00 Abnormalities of heart beat
R00.0 Tachycardia, unspecified
CODING BITES
An electrocardiogram may be referred to as either an ECG or an EKG. Tachycardia is the medical term for
rapid heartbeat.
For the encounter, you have one confirmed diagnosis (the diabetes) and one symptom (rapid heartbeat).
Check the top of this subsection and the head of this chapter in ICD-10-CM. There is a NOTE, an
notation, and an notation. Read carefully. Do any relate to Dr. Miller’s diagnosis of Cahlen? No. Turn
to the Official Guidelines and read Section 1.c.4, particularly a. Diabetes mellitus. There is nothing specifically
applicable here either.
The guidelines state that a confirmed diagnosis should precede a sign or symptom, so you will list the diabe-
tes code first and then the tachycardia.
E10.9 Type 1 diabetes mellitus without complications
R00.0 Tachycardia, unspecified
Differential Diagnosis
When the physician indicates
Differential Diagnosis
that the patient’s signs and
symptoms may closely lead to In the case where a provider indicates a differential diagnosis by using the word
two different diagnoses; usu- versus or or between two diagnostic statements, you need to code both as if they were
ally written as “diagnosis A vs. confirmed, and either may be listed first. This means that the physician has deter-
diagnosis B.” mined that the patient’s signs and symptoms lead equally to two different diagnoses.
ICD-10-CM
YOU CODE IT! CASE STUDY
Deanna Franklin, a 45-year-old female, came to see Dr. Carter for a follow-up on a previous diagnosis of paroxysmal
atrial fibrillation. Dr. Carter examined Deanna and did a blood test to monitor the effectiveness of the prescription
medication Coumadin, a blood thinner. Dr. Carter told Deanna he was very pleased with her progress and that she
was doing well. Before leaving, Deanna asked Dr. Carter for a refill of trinalin, her allergy medication. This time of
year typically provoked her allergy to pollen, which caused a lot of inflammation and irritation in her nose (rhinitis).
Dr. Carter wrote the refill prescription.
(continued)
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine the correct codes?
I48.0 Paroxysmal atrial fibrillation
J30.1 Allergic rhinitis, due to pollen (hayfever)
Z79.01 Long-term (current) use of anticoagulants
The code for the atrial fibrillation supports the office visit and exam, the code for long-term use of the Coumadin
(an anticoagulant) justifies the blood test, and the code for the allergic rhinitis supports the medical necessity for
the trinalin prescription.
Placeholder Character
There are times when a fifth, sixth, or seventh character is required, yet there are no
fourth, fifth, or sixth characters. In these cases, ICD-10-CM uses a placeholder char-
GUIDANCE acter, the letter “x,” so the following characters will fall into their correct locations.
CONNECTION The symbols in the Tabular List will lead you to filling out your code accurately. Just
pay attention to each character as well as in what position each character belongs. Let’s
Read the ICD-10-CM look at as an example. This symbol tells you that you will need to add a place-
Official Guidelines for holder x in the fifth position and a placeholder x in the sixth position before determin-
Coding and Report- ing which of the seventh character options to place at the end of the code.
ing, section I. Conven-
tions, General Coding
EXAMPLES
Guidelines and Chapter
Specific Guidelines, sub- S02.611A Fracture of condylar process of right mandible, initial encounter
section A. Conventions T47.2x2D Poisoning by stimulant laxatives, intentional self-harm, subsequent
for the ICD-10-CM, para- encounter
graph 4. Placeholder W89.1xxS Exposure to tanning bed, sequela
character.
W85.xxxA Exposure to electric transmission lines, initial encounter
As you can see, all of these codes require a seventh character, yet the initial
codes were shorter. These codes are examples of how the placeholder character
GUIDANCE “x” is used so that all of the characters fall into their proper placement.
CONNECTION
Seventh Character
Read the ICD-10-CM
Official Guidelines for
Some ICD-10-CM codes require a seventh character. Different subsections of the code
Coding and Report-
book use this position—the seventh character—to add varying types of information.
ing, section I. Con-
Most often, the character choices are listed at the top of the code category to be used
ventions, General
for all codes within that category. With this in mind, you must always begin reading at
Coding Guidelines
the top of the code category or subsection for this information.
and Chapter Specific
The Tabular List contains all the details you need. All you have to do is read the
Guidelines, subsection
options and determine which is the most accurate, as per the physician’s documentation.
A. Conventions for the
Section I.C. Chapter-Specific Coding Guidelines
ICD-10-CM, paragraph
5. 7th Characters. This subsection of the Official Guidelines is further divided and sorted by the chap-
ters in the Tabular List. The process of determining the code or codes for a specific
Section IV. Diagnostic Coding and Reporting Guidelines for Principal Diagnosis
The condition, after study, that
Outpatient Services is the primary, or main, reason
This section of the Official Guidelines covers specific differences when reporting for for the admission of a patient
to the hospital for care; the
an outpatient service, including a hospital emergency department, same-day surgical
condition that requires the
center, walk-in clinic, or physician’s office. largest amount of hospital
Essentially, the guidelines for inpatient and outpatient coding are the same or simi- resources for care.
lar when it comes to reporting the reasons why a patient needs care except for one main
difference—unconfirmed diagnoses. First-Listed
“First-listed diagnosis” is used,
Unconfirmed Diagnoses when reporting outpatient
encounters, instead of the
The Official Guidelines are different for reporting unconfirmed diagnoses for patients
term “principal diagnosis.”
who are treated as outpatient versus inpatient.
Outpatient
Outpatient Services An outpatient is a patient who
The guideline Section IV.H, Uncertain diagnosis states that you are to use the code receives services for a short
or codes that identify the condition to its highest level of certainty. This means that amount of time (less than 24
you code only what you know for a fact. You are not permitted to assign an ICD- hours) in a physician’s office
or clinic, without being kept
10-CM diagnosis code for a condition that is described by the provider as probable,
overnight. An outpatient
suspected, possible, questionable, or to be ruled out. If the health care professional facility includes a hospital
has not been able to confirm a diagnosis, then you must code the signs, symptoms, emergency room, ambulatory
abnormal test results, or other element stated as the reason for the visit or service. care center, same-day surgery
center, or walk-in clinic.
EXAMPLE
Ellyn Cragen, a 27-year-old female, came to see Dr. Jenisha in his office because
of nausea and absence of her period for 2 months. After doing a thorough exami- GUIDANCE
nation, Dr. Jenisha suspects that Ellyn may be pregnant, so he orders a blood test. CONNECTION
If the blood test comes back positive to confirm her pregnancy (after the physician
documents it in the file), you would use the following code: Read the ICD-10-CM
Official Guidelines for
Z32.01 Encounter for pregnancy test, result positive Coding and Reporting,
If the blood test comes back negative, this confirms that Ellyn is not pregnant. section IV. Diagnostic
Therefore, you would need to report what you know to be true: Coding and Report-
ing Guidelines for
N91.2 Amenorrhea, unspecified Outpatient Services,
R11.0 Nausea paragraph H. Uncertain
Z32.02 Encounter for pregnancy test, results negative Diagnosis.
Inpatient Services
The rules for coding uncertain diagnoses for patients of an inpatient facility are dif-
ferent from those for outpatients. As directed by the guideline Section II.H, Uncertain
Inpatient Facility diagnosis, if the diagnosis is described as probable, possible, suspected, likely, or still
An establishment that pro- to be ruled out at the time of discharge, you must code that condition as if it existed.
vides health care services to This directive applies only when you are coding services provided in a short-term,
individuals who stay overnight acute, long-term care, or psychiatric hospital or facility. It is one of the few circum-
on the premises.
stances in which you will find the guidelines differ between coding for outpatient and
inpatient services.
ICD-10-CM
YOU CODE IT! CASE STUDY
Howard Tamar, a 61-year-old male, was admitted to the hospital for observation after he complained of having
severe chest pain radiating to his left shoulder and down his left arm. After 24 hours in the telemetry unit, Dr. Norwalk
discharged him with a diagnosis of suspected variant angina pectoris.
FIGURE 4-3 Example from ICD-10-CM Alphabetic Index: Main terms Aarskog’s
syndrome through Abduction contracture, hip or other joint Source: ICD-10-CM Official
Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Services (CMS) and the National Center
for Health Statistics (NCHS)
FIGURE 4-4 ICD-10-CM, Alphabetic Index, partial, from Torture to Toxemia Source:
ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Services (CMS) and
the National Center for Health Statistics (NCHS)
Abrasion T14.8
- abdomen, abdominal (wall) S30.811
- alveolar process S00.512
- ankle S90.51-
- antecubital space—see Abrasion, elbow
- anus S30.817
- arm (upper) S40.81-
- auditory canal—see Abrasion, ear
- auricle—see Abrasion, ear
- axilla—see Abrasion, arm
- back, lower S30.810
- breast S20.11-
- brow S00.81
- buttock S30.810
- calf—see Abrasion, leg
- canthus—see Abrasion, eyelid
- cheek S00.81
-- internal S00.512
- chest wall—see Abrasion, thorax
- chin S00.81
- clitoris S30.814
- cornea S05.0-
- costal region—see Abrasion, thorax
- dental K03.1
- digit(s)
-- foot—see Abrasion, toe
-- hand—see Abrasion, finger
- ear S00.41-
- elbow S50.31-
- epididymis S30.813
- epigastric region S30.811
- epiglottis S10.11
- esophagus (thoracic) S27.818
-- cervical S10.11
- eyebrow—see Abrasion, eyelid
(continued)
FIGURE 4-5 ICD-10-CM Alphabetic Index, partial, from Abrasion to Abrasion, fore-
head Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid
Services (CMS) and the National Center for Health Statistics (NCHS)
It is important for you to remember that the ICD-10-CM code book has informa-
tion that can really help you do your job well. Consider Dr. Johnson, a pediatrician,
caring for Melinda, who has a problem with her right eye. Dr. Johnson documents
that Melinda has “pink eye.” Pink eye is not actually a medical term. It is a common
term. But this is all you have to go on, so let’s take a chance with this in the Alphabetic
Index. Eye is an anatomical site, so you know that having an eye is not a reason to see
the physician. Look for the term “pink” and find, not a suggested code, but a reference
(see Figure 4-6).
The ICD-10-CM Alphabetic Index actually tells you the medical term for “pink
eye” and that you need to look this up using this term. Turn in the Alphabetic Index to
find the main term, Conjunctivitis (see Figure 4-7).
Similar to the situation with Abrasion, you see a long list indented beneath
this main term, meanin, you need more details from the documentation, or in this
case, the previous Alphabetic Index notation. Check back to what you read when
you looked at Pink, eye—see Conjunctivitis, acute, mucopurulent. Now, read the
indented list beneath Conjunctivitis carefully and find acute. Then, indented
beneath that, find:
Conjunctivitis, acute, mucopurulent H10.02-
You may find that a medical dictionary can also help you find synonyms for terms
used in the physician documentation that does not match an item in the Alphabetic
Index. Build the habit to use all of your resources to help you determine the accurate
code.
FIGURE 4-6 ICD-10-CM Alphabetic Index, partial, from Pinhole meatus through
Pinkus’ disease Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare
and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)
CODING BITES Conjunctiva—see condition
Never, never, never Conjunctivitis (staphylococcal) (streptococcal) NOS H10.9
code only from the - Acanthamoeba B60.12
Alphabetic Index. You - acute H10.3-
are required to check -- atopic H10.1-
every code in the Tabu- -- chemical (see also Corrosion, cornea) H10.21-
lar List. Only then can -- mucopurulent H10.02-
you read the entire --- follicular H10.01-
code description and all -- pseudomembranous H10.22-
notations to determine -- serous except viral H10.23-
the most accurate code. --- viral—see Conjunctivitis, viral
-- toxic H10.21-
- adenoviral (acute) (follicular) B30.1
- allergic (acute)—see Conjunctivitis, acute, atopic
-- chronic H10.45
--- vernal H10.44
- anaphalactic—see Conjunctivitis, acute, atopic
- Apollo B30.3
- atopic (acute)—see Conjunctivitis, acute, atopic
CODING BITES - Béal’s B30.2
Neoplasm Table: A - blennorrhagic (gonococcal) (neonatorum) A54.31
table that lists the - chemical (acute) (see also Corrosion, cornea) H10.21-
suggested codes for
benign and malignant FIGURE 4-7 ICD-10-CM Alphabetic Index, partial, Conjuctiva to Conjunctivitis,
neoplasms (tumors). chemical Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medic-
The list is organized in aid Services (CMS) and the National Center for Health Statistics (NCHS)
alphabetic order by the
anatomical location of
the neoplasm.
Neoplasm Table
Neoplasm Table The Neoplasm Table is a breakout section of the Alphabetic Index, listing the sug-
The Neoplasm Table lists all gested codes for benign and malignant neoplasms. These pages are set up as a seven
possible codes for benign (7) column table (Figure 4-8) organized by the information in column 1—the ana-
and malignant neoplasms, in tomical location of the tumor, in alphabetic order. Moving to the right, the following
alphabetic order by anatomi- six columns show the suggested code in the following order:
cal location of the tumor.
Malignant, Primary
Malignant, Secondary
FIGURE 4-8 Excerpt from the Neoplasm Table, partial listing for Abdominal neo-
plasm Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid
Services (CMS) and the National Center for Health Statistics (NCHS)
Poisoning, Assault
Poisoning, Undetermined CODING BITES
Adverse Effect Table of Drugs and
Chemicals : A table that
Underdosing lists pharmaceuticals
Later in this book, the chapter titled Coding Injury, Poisoning, and External Causes and chemicals that may
will provide you with full explanations for using this table. cause poisoning or
adverse effects in the
Index to External Causes human body.
To make it easier to determine the correct code or codes to report how the patient
became injured or poisoned, and where the patient was (Place of Occurrence) when Adverse Effect
An unexpected bad reaction
to a drug or other treatment.
FIGURE 4-9 Excerpt from Table of Drugs and Chemicals, Acetomorphine through
Acetosulfone (sodium). Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for
Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)
Fall, falling (accidental) W19
- building W20.1
-- burning (uncontrolled fire) X00.3
- down
-- embankment W17.81
-- escalator W10.0
-- hill W17.81
-- ladder W11
-- ramp W10.2
-- stairs, steps W10.9
- due to
– bumping against
CODING BITES --- object W18.00
Index to External ---- sharp glass W18.02
Causes : The alphabetic ---- specified NEC W18.09
list with short descrip- ---- sports equipment W18.01
tions of the external
causes of injury and
FIGURE 4-10 An excerpt from the Index to External Causes, main term Fall Source:
poisoning. ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Services (CMS) and
the National Center for Health Statistics (NCHS)
Index to External Causes the injury or poisoning occurred, you can use the Index to External Causes (see
The alphabetic listing of the Figure 4-10) to find a suggested code for the main terms you abstract from the physi-
external causes that might cian’s documentation.
cause a patient’s injury, poi- Later in this book, the chapter titled Coding Injury, Poisoning, and External Causes
soning, or adverse reaction.
will provide you with full explanations for using this index.
External Cause
An event, outside the body,
that causes injury, poisoning, 4.4 The Tabular List
or an adverse reaction.
Once you have a suggested code from the Alphabetic Index, Neoplasm Table, Table of
Drugs and Chemicals, and/or the Index to External Cause Codes, you will need to find
Tabular List of Diseases and that code in the Tabular List of Diseases and Injuries. Remember, you may never
Injuries report a code directly from the Alphabetic Index without checking it in the Tabular List.
The section of the ICD-10-CM This suggested code will point you to a section or subsection inside a chapter of the
code book listing all of the Tabular List (see Table 4-1 for a list of the Tabular List chapters).
codes in alphanumeric order. Beginning at the top of each chapter and subchapter, you will need to carefully read
all associated code descriptions. This part of the process helps you ensure that you
determine the most accurate code to the highest level of specificity:
∙ Matching the details in the physician’s documentation
∙ Regarding only one particular encounter
∙ In compliance with the rules and guidelines
The Tabular List section of the ICD-10-CM book lists every code and its complete
description in alphanumeric order by code. Starting at A00, the codes go all the way through
to Z99.89 (see Figure 4-11). Let’s investigate the various components of this section.
Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Services
(CMS) and the National Center for Health Statistics (NCHS)
CODING BITES
The Alphabetic Index will suggest a possible diagnosis code. Then you must find
the code suggested by the Alphabetic Index in the Tabular List. This step is not
a suggestion—it is mandatory. The Tabular List provides more detail in the code
description as well as additional notations such as includes and excludes notes and
directives for the requirement of additional characters and codes. NEVER, NEVER,
NEVER code from the Alphabetic Index.
CODING BITES
Different publishers do things differently. So, your specific version of the ICD-
10-CM code book may provide you with the meanings of the symbols in other
ways, and other places. Be certain to spend a few minutes becoming familiar
with YOUR code book and where things are placed. Inserting tabs on specific
pages may help you find quick access to the details you need when you need
them.
B68 Taeniasis
cysticercosis (B69.-)
B68.0 Taenia solium taeniasis
Pork tapeworm (infection)
B68.1 Taenia saginata taeniasis
Beef tapework (infection)
Infection due to adult tapeworm Taenia saginata
B68.9 Taeniasis, unspecified
B69 Cysticercosis
cysticerciasis infection due to larval form of Taenia solium
B69.0 Cysticercosis of central nervous system
B69.1 Cysticercosis of eye
B69.8 Cysticercosis of other sites
B69.81 Myositis in cysticercosis
B69.89 Cysticercosis of other sites
B69.9 Cysticercosis, unspecified
B70 Diphyllobithriasis and sparganosis
B70.0 Diphyllobothriasis
Diphyllobothrium (adult) (latum) (pacificum) infection
Fish tapeworm (infection)
larval diphyllobothriasis (B70.1)
B70.1 Sparganosis
FIGURE 4-11 Example of a page from ICD-10-CM Tabular List: code categories
B67 through B70 Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare
and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)
Chapter 1
Certain infectious and parasitic diseases (A00-B99)
diseases generally recognized as communicable or transmissible
Use additional code to identify resistance to antimicrobial drugs (Z16.-)
certain localized infections—see body system-related chapters
carrier or suspected carrier of infectious disease (Z22.-)
infectious and parasitic diseases complicating pregnancy, childbirth,
and the puerperium (O98.-)
infectious and parasitic diseases specific to the perinatal period
(P35-P39)
influenza and other acute respiratory infections (J00-J22)
The Legends
Across the bottom of every page throughout the Tabular List you will find short expla-
nations for many of the symbols you will see among the codes and their descriptions.
These legends are an abbreviation of the more complete explanations of each symbol
in the front of your code book, found on the pages titled Overview of ICD-10-CM
Official Conventions and Additional Conventions. Once you become familiar with
FIGURE 4-13 Example of a subchapter section note, from above code F90 Source:
ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Services (CMS) and
the National Center for Health Statistics (NCHS)
FIGURE 4-14 Chapter opening notations, example from chapter 5 Source: ICD-10-CM
Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Services (CMS) and the National
Center for Health Statistics (NCHS)
Again, good information, but none of these notations related to reporting Belinda’s
diagnosis. One more step to take—check the ICD-10-CM Official Guidelines for
Coding and Reporting, Section 1.c.5. Mental, Behavioral, and Neurodevelopmen-
tal Disorders (F01-F99). Read all of the guidelines in this section to see if there is any
guidance you need to properly report code F95.2. No? Great.
Now . . . you can report code F95.2 with confidence that it is accurate and correct to
report why Dr. Gaseor cared for Belinda during this encounter. Good work!
Case #2 Abrasion
Let’s look at the second case we covered in the section The Alphabetic Index and Ancil-
laries, “Dr. Mulford noted that Charlie has suffered an abrasion on his chin.” And
you found code Abrasion, chin S00.81. Turn in your ICD-10-CM Tabular List to the
code category:
S00 Superficial injury of head
diffuse cerebral contusion (S06.2-)
focal cerebral contusion (S06.3-)
injury of eye and orbit (S05.-)
open wound of head (S01.-)
The appropriate 7th is to be added to each code from category S00.
A Initial encounter
D Subsequent encounter
S Sequela
None of these diagnoses in the notation relate to Charlie’s case; however, it
is a good thing you started reading here because there is a box containing the available
seventh characters for you to use in this code category.
Read down through all of the available fourth characters in this code category to
ensure you don’t find something more accurate than that suggested by the Alphabetic
Index:
S00.0 Superficial injury of scalp
S00.1 Contusion of eyelid and periocular area
S00.2 Other and unspecified superficial injuries of eyelid and periocular area
S00.3 Superficial injury of nose
S00.4 Superficial injury of ear
S00.5 Superficial injury of lip and oral cavity
S00.8 Superficial injury of other parts of the head
S00.9 Superficial injury of unspecified part of head
It looks like the Alphabetic Index was sending us in the right direction. S00.8 is the
best option. A fifth character is needed. Read all of the options carefully. Did you
determine this?
S00.81 Abrasion of other part of head
You see how different this code description is from what you read in the Alphabetic
Index? This is one reason why it is important to use both the Alphabetic Index and the
Tabular List. Each has its own details to share. Good. However, one thing the Alpha-
betic Index didn’t let you know is that this code must have a seventh character. Turn
back to that box at the beginning of this subsection. Which is the correct character to
report for Charlie’s encounter with Dr. Mulford for care related to his abrasion?
The appropriate 7th is to be added to each code from category S00.
A Initial encounter
D Subsequent encounter
S Sequela
Did you abstract from the scenario that this was the first encounter? And you
noticed that you will need to insert a placeholder letter x after the fifth character, so
that the seventh character A lands in the correct spot.
S00.81xA Abrasion of other part of head, initial encounter
Look back to the beginning of this ICD-10-CM chapter to check for any notations
that you might need to consider before you report this code (see Figure 4-15).
This is important information, but none of it relates to Charlie’s abrasion.
One more step, check the ICD-10-CM Official Guidelines for Coding and
Reporting, Section 1.c.19. Injury, Poisoning, and Certain Other Consequences of
External Causes (S00-T88). Read all of the guidelines in this section to see if there
is any guidance you need to properly report code S00.81xA. No? Great. Good work!
FIGURE 4-16 Tabular List, chapter 7, Diseases of the Eye and Adnexa, opening
notations Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medic-
aid Services (CMS) and the National Center for Health Statistics (NCHS)
Go back to the documentation and read: “Dr. Johnson . . . caring for Melinda, who has
a problem with her right eye.”
H10.021 Other mucopurulent conjunctivitis, right eye
Good work! Check the beginning of the subsection. There are no notations at all. Now,
check the very beginning of this ICD-10-CM chapter (see Figure 4-16).
A lot of good information here, yet it is not related to Melinda’s diagnosis, so you
have only one more place to check: the ICD-10-CM Official Guidelines for Coding
and Reporting, Section 1.c.7. Diseases of the Eye and Adnexa (H00-H59). Read
GUIDANCE all of the guidelines in this section to see if there is any guidance you need to properly
CONNECTION report code H10.021. No? Great. You can now report H10.021 Other mucopurulent
conjunctivitis, right eye with confidence.
Read the ICD-10-CM
Official Guidelines for
Coding and Reporting,
section I. Conven-
4.5 Which Conditions to Code
tions, General Coding As you abstract the provider’s notes, you are looking for the information that will
Guidelines and Chapter direct you to those codes that explain or describe the answer to the question, “Why did
Specific Guidelines, this health care provider care for and treat this individual during this encounter?” That
subsection B. General is it. The codes do not report the individual’s complete medical history.
coding guidelines, spe-
cifically subsections Unrelated Conditions
4. Signs and symptoms,
5. Conditions that are The attending physician may include information in his or her documentation that
an integral part of a reports a condition or diagnosis that is unrelated to this encounter. Remember that
disease process, and the physician does not write the notes just for you to code from. The notes have other,
6. Conditions that are important purposes, such as documenting past history. You must learn to distinguish
not an integral part of a among notations. You will code only those diagnoses, signs, and/or symptoms related
disease process. to procedures, services, treatments, and/or medical decision making occurring dur-
ing this visit. ICD-10-CM guidelines specifically direct you to omit (do not code) any
ICD-10-CM
LET’S CODE IT! SCENARIO
MaeBelle Abernathy, a 29-year-old female, came to see Dr. Cypher complaining of severe pain in her shoulder. She
stated that she was working in the garden and a loose branch fell out of her magnolia tree onto her left shoulder.
MaeBelle is 15 weeks pregnant. Normally, Dr. Cypher would have sent MaeBelle for an x-ray. However, because
she is pregnant, he decided to examine her, diagnosed her with a sprained corahumeral shoulder, and strapped her
shoulder and arm. He also double-checked the pain medication he prescribed to ensure that it was safe for preg-
nant women.
(continued)
that her pregnancy was a factor included in the patient’s treatment plan but not a part of the principal diagnosis.
Perfect!
Do you remember when you read the chapter Abstracting Clinical Documentation that you will need external
cause codes for this encounter between MaeBelle and Dr. Cypher because she was injured? Therefore, you
would also include three other codes:
W20.8xxA Other cause of strike by thrown, projected or falling object
Y93.H2 Activity, gardening and landscaping
Y99.8 Other external cause status (leisure activity)
[Don’t worry . . . more details about determining external cause codes are in the upcoming chapter titled Cod-
ing Injury, Poisoning, and External Causes.]
Check the top of each subsection and the head of each chapter in ICD-10-CM. There are notations at the
beginning of this chapter: an notation, a Use Additional Code note, an notation, and an
notation. Read carefully. Do any relate to Dr. Cypher’s diagnosis of MaeBelle? No. Turn to the Official
Guidelines and read Section 1.c.19, 1.c.20, and 1.c.21. There is nothing here that will change what you have
already determined, this time.
The bottom line . . . there will be five codes to report the reasons why Dr. Cypher needed to care for MaeBelle
at this encounter:
S43.412A Sprain of left corahumeral (ligament), initial encounter
Z33.1 Pregnant state, incidental
W20.8xxA Other cause of strike by thrown, projected or falling object
Y93.H2 Activity, gardening and landscaping
Y99.8 Other external cause status (leisure activity)
In some encounters you will not report a condition, just because there was a men-
tion of it in the documentation.
ICD-10-CM
LET’S CODE IT! SCENARIO
Arthur Fleurs, a 47-year-old male, came to Dr. Davenport at the clinic because he was having a nosebleed that
wouldn’t stop. Arthur was in a single-car accident and his airbag expanded, hitting him in the nose, causing it to
bleed. He is otherwise healthy with a history of allergic asthma. Dr. Davenport examined Arthur’s nasal passages
and packed the nostrils. The doctor then told Arthur to go home and rest and return the next day for a follow-up.
(continued)
EXAMPLES
Z00.00 Encounter for general adult medical examination without abnormal
findings
. . . this code reports what is commonly known as an annual physical, which is
an encounter prompted by the calendar to ensure preventive measures and
early detection testing are employed to support good health.
Z02.1 Encounter for pre-employment examination
. . . some employers require a candidate to have a physical prior to being offi-
cially hired. This code is used to report this reason why the individual would
see the physician.
Z12.31 Encounter for screening mammogram for malignant neoplasm of
breast
. . . every woman over the age of 40 should be doing this annually, or every
other year, to identify the presence of a malignancy at the earliest possible
time, when treatment is less invasive, less intensive, and less costly. This code
explains that this woman has no signs or symptoms; she and her physician just
want to be smart about her health.
Test Results
Even though you didn’t go to medical school, you still need to know the difference
between a positive test result and a negative test result. However, you are not permitted
to affirm a diagnosis from a test result without the physician’s documentation. This rule
applies to laboratory tests, x-rays and other imaging, pathology, and any other screening
or diagnostic testing done for a patient. In such cases, especially when the health care pro-
fessional has ordered additional tests based on an abnormal finding, you should query, or
ask, the physician whether or not you should document the results. Be certain to get your
answer in writing in the patient’s record. If it’s not in writing, you can’t code it!
EXAMPLE
Laboratory report in patient’s file shows:
Glucose 155 Norm Range: 65–105 mg/dL
You can see that the patient’s glucose is abnormally high. However, you cannot code
hyperglycemia without a physician’s written interpretation and diagnostic statement.
If a physician or other health care professional has already interpreted the test
results and the final report has been placed in the patient’s file with a diagnostic state-
ment, you should include the code.
EXAMPLE
Report from radiology states: “X-ray shows an open fracture of the anatomical
neck of the humerus, right arm. Signed: Flor Rodriquez, MD, Chief of Radiology.”
The report, signed by a physician, includes a specific diagnostic statement that
should be coded. However, you should always check with the attending physician
and permit him or her the opportunity to update the patient’s chart with the con-
firmed diagnosis. You should do this as a sign of respect.
Preoperative Evaluations
Whenever a patient is scheduled for a surgical procedure (on a nonemergency basis),
there are typical tests that must be done to ensure that the patient is healthy enough to
have the operation. Cardiovascular, respiratory, and other examinations are often done
a couple of days prior to the date of surgery. Often these tests do not necessarily relate
directly to the diagnostic reason the surgery will be performed. Therefore, they will
need a different diagnosis code to report medical necessity.
Coding those encounters carries a specific guideline. In such cases, the principal, or
first-listed, diagnosis code will be from the following category:
Z01.8 Encounter for other specified special examinations
Follow that code with the code or codes that identify the condition(s) documented as
the reason for the upcoming surgical procedure.
EXAMPLE
Kenzie Hannon was diagnosed with carpal tunnel syndrome in her right wrist. Dr.
Isaacs recommended a surgical solution. Because of her history of atrial fibrilla-
tion, Kenzie was required to get approval from her cardiologist before she could
have the procedure.
G56.01, Carpal tunnel syndrome, right upper limb, is the code that will be used
to report the medical necessity for the surgery on Kenzie’s wrist. However, it will
not support the examination performed by her cardiologist. Think about it . . . who
would agree to pay for a cardiologist to examine a patient with a diagnosis of car-
pal tunnel syndrome? The cardiologist is not qualified to do the job; that is better
suited for an orthopedist.
GUIDANCE Z01.810, Encounter for preprocedural cardiovascular examination will support
the cardiologist’s time and expertise to clear Kenzie for the procedure on her
CONNECTION wrist.
Read the ICD-10-CM
Official Guidelines for
Coding and Reporting, Preoperative/Postoperative Diagnoses
section II. Selection of You may have already noticed that procedure and operative reporting usually include
Principal Diagnosis and both a preoperative diagnosis and a postoperative diagnosis. For cases where the two
section III. Reporting statements differ, the guidelines state that you should code the postoperative diagnosis
Additional Diagnoses. because it is expected that it is the more accurate of the two.
Fever (inanition) (of unknown origin) (persistent) (with chills) (with rigor) R50.9
- abortus A23.1
- Aden (dengue) A90
- African tick-borne A68.1
- American
-- mountain (tick) A93.2
-- spotted A77.0
- aphthous B08.8
- arbovirus, arboviral A94
-- hemorrhagic A94
-- specified NEC A93.8
- Argentinian hemorrhagic A96.0
- Assam B55.0
- Australian Q A78
- Bangkok hemorrhagic A91
- Barmah forest A92.8
- Bartonella A44.0
- bilious, hemoglobinuric B50.8
- blackwater B50.8
- blister B00.1
- Bolivian hemorrhagic A96.1
- Bonvale dam T73.3
- boutonneuse A77.1
- brain—see Encephalitis
- Brazilian purpiric A48.4
- breakbone A90
- Bullis A77.0
- Bunyamwera A92.8
- Burdwan B55.0
- Bwamba A92.8
(continued)
- Cameroon—see Malaria
- Canton A75.9
- catarrhal (acute) J00
-- chronic J31.0
- cat-scratch A28.1
- Central Asian hemorrhagic A98.0
- cerebral—see Encephalitis
- cerebrospinal meningococcal A39.0
- Chagres B50.9
- Chandipura A92.8
- Changuinola A93.1
- Charcot’s (biliary) (hepatic) (intermittent)—see Calculus, bile duct
- Chikungunya (viral) (hemorrhagic) A92.0
- Chitral A93.1
- Colombo—see Fever, paratyphoid
- Colorado tick (virus) A93.2
- congestive (remittent)—see Malaria
- Congo virus A98.0
- continued malarial B50.9
- Corsican—see Malaria
- Crimean-Congo hemorrhagic A98.0
- Cyprus—see Brucellosis
- dandy A90
- deer fly—see Tularemia
- dengue (virus) A90
-- hemorrhagic A91
You can see the long, long list of types of fevers that a person can have. Notice these additional terms are
shown in alphabetic order, so . . . what kind of fever did Michael have? Cypress Fever. Read carefully down the
long list and see if you can find Cypress.
Fever
- Cyprus—see Brucellosis
Still in the Alphabetic Index, turn to find the main term, Brucellosis.
There are several choices here as well. Go back to Dr. Opell’s notes. Are there any terms that will help with
this decision?
(continued)
A23 Brucellosis
Malta fever
Mediterranean fever
undulant fever
A23.0 Brucellosis due to Brucella melitensis
A23.1 Brucellosis due to Brucella abortus
A23.2 Brucellosis due to Brucella suis
A23.3 Brucellosis due to Brucella canis
A23.8 Other brucellosis
A23.9 Brucellosis, unspecified
Check the notation. This does not relate to this case. Check for any other notations. There are none.
Do you need a second code to identify the specific bacteria that caused Michael’s infection? No, because this is
a combination code and it already includes that detail.
One final step . . . turn to the ICD-10-CM Official Guidelines for Coding and Reporting, Section 1.c.1. Certain
Infectious and Parasitic Diseases (A00-B99). Read through the subsections. Are there any related to Cypress
Fever or Brucellosis? No.
Terrific! Now you can feel confident that reporting A23.1 Brucellosis due to Brucella abortus will justify
Dr. Opell’s care for Michael.
Good job! You are really learning.
Chapter Summary
As you look back over this chapter, you should notice one very important thing: The
ICD-10-CM book will almost always guide you to the correct code. The Alphabetic
Index will guide you to the correct chapter and subsection in the Tabular List, so you
can read all of the notations and symbols, evaluate all the options, and determine the
best, most accurate code. If no codes seem to match the attending physician’s notes, CODING BITES
just go back and keep looking.
ICD-10-CM CODE
Two principles important to becoming a good ICD-10-CM coder:
BOOK CONTENTS
1. Abstract the main term(s) from the physician’s documentation so that you can deter- Introduction
mine the best, most accurate code or codes. Official Conventions
2. In case of an injury, poisoning, or adverse effect, you will need to add an external Official Guidelines
cause code. for Coding and
Reporting
The Official Coding Guidelines are always there, at your fingertips in the book for The Alphabetic Index
you to reference—no memorization! All the information can point you in the right The Neoplasm Table
direction toward the best, most accurate code. Just look and read. And when the time The Table of Drugs
comes, you will have no problem transitioning from student to professional coding and Chemicals
specialist. The Index to External
The ICD-10-CM code book will lead you, step-by-step, to the correct, complete Causes
code to report medical necessity—why the health care provider cared for the patient— The Tabular List
for this encounter with the highest level of specificity. However, not all diagnostic
statements follow a straight line. Sometimes, you have to really read carefully and use
CHAPTER 4 REVIEW
your critical thinking skills to interpret accurately. Other times, you may have to use
alternate terms from those used in the notes to determine the correct code description.
A medical dictionary will help you, so it is recommended that you keep one by your
side (especially now, while you are early in your learning). Familiarize yourself with
the terms used as well as the critical thinking and interpretation skills that are part of
the coding process.
CHAPTER 4 REVIEW
Introduction to ICD-10-CM Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
Part I
1. LO 4.4 The section of the ICD-10-CM code book listing all of the codes in A. Alphabetic Index
alphanumeric order. B. Index to External
2. LO 4.3 The section of a code book showing all codes, from A to Z, by the short Causes
code descriptions. C. Neoplasm Table
3. LO 4.3 The section of the ICD-10-CM code book listing drugs, chemicals, D. Table of Drugs and
and other biologicals that may poison a patient or result in an adverse Chemicals
reaction.
E. Tabular List of Diseases
4. LO 4.3 A list of all possible codes for benign and malignant neoplasms, in and Injuries
alphabetic order by anatomical location of the tumor.
5. LO 4.3 The alphabetic listing of the multitude of external causes that might
result in a patient’s injury.
Part II
1. LO 4.1 A specific location or part of the human body. A. Adverse Effect
2. LO 4.1 Found to be true or definite. B. Anatomical Site
3. LO 4.3 A condition named after a person. C. Condition
4. LO 4.5 A condition that affects the entire body and virtually all body systems, D. Confirmed
therefore requiring the physician to consider this in his or her medical E. Eponym
decision making for any other condition.
F. External Cause
5. LO 4.2 An establishment that provides acute care services to individuals who
G. Inpatient Facility
stay overnight on the premises.
H. Outpatient Services
6. LO 4.1 Cause-and-effect relationship between an original condition, illness, or
injury and an additional problem caused by the existence of that original I. Sequela (Late Effect)
condition. J. Systemic Condition
7. LO 4.2 Health care services provided to individuals without an overnight stay in
the facility.
8. LO 4.3 The state of abnormality or dysfunction.
9. LO 4.3 An unexpected, bad result.
10. LO 4.3 An event, outside the body, that causes injury, poisoning, or an adverse
reaction.
CHAPTER 4 REVIEW
1. LO 4.1 Descriptors that are not absolutely necessary to have been included in A. Acute
the physician’s notes and are provided simply to further clarify a code B. Chronic
description; optional terms.
C. Differential Diagnosis
2. LO 4.1 Specifics that are not described in any other code in the ICD-10-CM
D. Manifestation
book.
E. Nonessential Modifier
3. LO 4.2 Long duration; continuing over a long period of time.
F. Not Elsewhere Classifi-
4. LO 4.1 A condition caused or developed from the existence of another
able (NEC)
condition.
G. Not Otherwise Speci-
5. LO 4.1 One disease that affects or encourages another condition.
fied (NOS)
6. LO 4.1 The absence of additional specifics in the physician’s documentation.
H. Other Specified
7. LO 4.1 Additional information that the physician specified and isn’t included in
I. Principal Diagnosis
any other code description.
J. Underlying Condition
8. LO 4.2 The condition that is the primary, or main, reason for the encounter.
K. Unspecified
9. LO 4.1 An indication that more detailed information is not available from the
physician’s notes.
10. LO 4.2 Severe; serious.
11. LO 4.2 When the physician indicates that the patient’s signs and symptoms may
closely lead to two different diagnoses.
1. The ICD-10-CM is divided into the _____ Index, an alphabetic list of terms and their corresponding code, and the
______ List, a structured list of codes divided into chapters based on body system or condition.
2. The Alphabetic Index consists of the following parts: the Index of _____ and Injury, the Index of _____ of Injury,
the Table of _____, and the Table of _____ and Chemicals.
3. All categories are _____ characters.
4. A code that has an applicable seventh character is considered _____ without the seventh character.
5. The “x” is used as a _____ at certain codes to allow for future _____.
6. Codes titled _____ are for use when the information in the medical record is _____ to assign a more specific
code.
7. A type _____ note is a pure excludes note. It means “NOT CODED HERE!”
8. A type _____ note represents “Not included here.”
9. To select a code in the classification that corresponds to a diagnosis or reason for a visit documented in a medical
record, _____ locate the term in the Alphabetic Index, and then _____ the code in the Tabular List.
10. Diagnosis codes are to be used and _____ at their _____ number of characters available.
11. Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a
_____ definitive diagnosis has _____ been _____ (confirmed) by the provider.
CHAPTER 4 REVIEW
_____ subentries exist in the Alphabetic Index at the _____ indentation level,
code _____ and sequence the _____ code first.
13. Each unique ICD-10-CM diagnosis code may be reported only _____ for an
encounter.
14. If no bilateral code is provided and the condition is bilateral, assign separate
codes for both the _____ and _____ side.
15. If the provider documents a “borderline” diagnosis at the time of _____, the
diagnosis is coded as _____, unless the classification provides a specific entry
(e.g., borderline diabetes).
ICD-10-CM
ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case.
1. Ralph Flower, a 27-year-old male, presents today for his annual flu vaccination.
2. Erina Castles, a 43-year-old female, presents today with a few pimples on her chest. Dr. Moss noted some
slight redness and swelling in the area and orders blood tests. The results of the blood tests confirm the diag-
nosis that Erina is a carrier of staphylococcal, methicillin resistant (MRSA).
3. Herman Carson, a 32-year-old male, presents with a severe headache and occasional nosebleeds. Dr. Wells
completed an examination recording a blood pressure reading of 180/110. Herman is hospitalized, where an
ECG and echocardiogram confirm the diagnosis of malignant hypertension.
4. Anna Blanks, a 68-year-old female, presents with a cyst on the anterior wall of her vagina. After an examina-
tion, Dr. Hervey takes a tissue biopsy and orders a CT scan. Anna is diagnosed with a primary malignant neo-
plasm of the Skene’s gland.
5. Jan McKenzie, a 68-year-old female, presents today to see Dr. McLeod due to restlessness and being anxious.
Jan retired 3 months ago. Dr. McLeod notes Jan is having difficulty adjusting to retirement.
6. Margaret Carll, a 28-year-old female, presents today with the complaint of feeling dizzy and has some head-
aches. Dr. Dithomas notes a fever and completes an ECG, which shows an ST depression. PMH and PFH are
noncontributory. Margaret is admitted to the hospital, where further blood tests, a chest CT scan, and a venti-
lation scan confirm the diagnosis of hyperventilation (tetany).
7. Elizabeth Hagun, a 35-year-old female, spent yesterday afternoon outside in the full sun; now she is experi-
encing severe itching. She comes to see Dr. Jerod, who completes an examination and notes skin redness and
blistering. Elizabeth is diagnosed with acute dermatitis due to solar radiation. Code the dermatitis.
8. Audrey Harkey, a 33-year-old female, comes to see Dr. Blankenship. Audrey is accompanied by her husband,
Henry. Audrey complaints of fever, a stiff neck, and headaches. Henry states he is concerned because he has
noticed some confusion. Audrey is admitted to the hospital, where a lumbar puncture is performed; 5 ml of
cerebrospinal fluid is drawn. Test results confirm Dr. Blankenship’s diagnosis of tuberculous meningitis.
9. Gloria Leugers, a 37-year-old female, comes to see Dr. Lewis with a fever, weakness, and abdominal pain.
Blood tests reveal a hemoglobin of 8.6 and UA is positive for blood. Gloria is admitted to Weston Hospital
and diagnosed with schistosomiasis disorder in the kidney.
10. Lauren Wheatle, a 68-year-old female, presents today with chest discomfort when resting. Dr. Billings com-
pletes an examination with ECG. The ECG reveals an elevated ST segment. Lauren is admitted to the hospital,
where blood tests show elevated cardiac enzymes and a cardiac echo confirms the diagnosis of variant angina.
11. Carolyn Mann, a 34-year-old female, presents today with intense itching and a burning sensation of her anus.
Dr. Neal completes an examination and diagnoses her with pruritus ani, stage 2.
12. Sylvia McCray, a 17-year-old female, presents today with a headache and dull facial pain between and behind
her eyes. Dr. Clayton orders a CT scan, which confirms the diagnosis of acute ethmoidal sinusitis, infection
due to staphylococcus.
13. Shawn Phillips, a 6-year-old male, is brought in by his parents to see Dr. Smoak, his pediatrician. Shawn
was eating his lunch and swallowed a piece of chicken bone, which is stuck in his throat. Shawn is having
difficulty breathing. Dr. Smoak notes that the bone is causing tracheal compression. Dr. Smoak was able to
remove the bone and Shawn’s breathing returned to normal.
14. Christopher Crawford, a 47-year-old male, presents today with swollen, red gums that are painful to touch,
but are not bleeding. Dr. Hubert diagnosed Christopher with acute gingivitis, non-plaque induced.
ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physician documentation from our health care facility,
Prader, Bracker, & Associates. These case studies are modeled on real patient encounters. Using the techniques
described in this chapter, carefully read through the case studies and determine the most accurate ICD-10-CM
code(s) for each case study. Remember to include external cause codes, if appropriate.
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: DAVIS, HELEN
ACCOUNT/EHR #: DAVIHE001
DATE: 10/21/18
Attending Physician: Renee O. Bracker, MD
CHAPTER 4 REVIEW
Patient, an 82-year-old that presents today to see Dr. Newson. Dr. Newson saw this patient 10 days ago
in office, where she was diagnosed with a UTI and prescribed nitrofurantoin po. Today she presents
with the complaints of dysuria, low back pain, abdominal pain, nausea, and diarrhea. After a positive UA
she was admitted to Weston Hospital.
PE: Ht: 5′3″, Wt: 112 lb., T: 97.3, P: 70, R: 19, BP: 133/62, O2 sat 97%. Dr. Newson notes LLQ tender-
ness and poor nutritional intake. Blood work results: WBC-16.5, RBC-5.70, HCT-50.5 indicating infec-
tion. Urine culture showed Staphylococcus. CT scan of abdomen and pelvis reveals mild diverticulitis.
Chest clear, lungs clear—sounds bilaterally S1 & S2 heard. Active bowel sound. Strong muscle strength
in all extremities. Pulse is regular. Skin is intact, noted redness in coccyx area. Mucous membrane is
moist and pink. Functioning independently.
Laboratory results:
Sodium—133 (L); Potassium—4.7
Chloride—95 (L); CO2—23
Glucose-Serum—122 (H); BUN—16
Creatinine—0.8; Protein—8.2
Albumin—4.7; Total Bilirubin—1.3
WBC—15.5 (H); RBC—5.70 (H)
HGB—15.9; HCT—50.5 (H)
Platelet—326; Neutrophils—65.4
Lymphocytes—27.0; Monocytes—6.3
Eosinophils—0.4; Basophils—0.9
ALT—13; AST—31; Alkaline Phosphatase—106
Patient was started on Vancomycin 200mg/IV q 6 hr, Docusate sodium 100mg/hr, and Zofran 24mg po.
Patient responded to treatment and is alert & oriented x 3. If she continues to improve, she will be dis-
charged home tomorrow.
Dx: Staphylococcal UTI, Large intestine diverticulitis
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: FLORA, VINCENT
ACCOUNT/EHR #: FLORVI001
DATE: 11/19/18
Attending Physician: Oscar R. Prader, MD
S: Pt is a 37-year-old female who was on vacation with friends. On a wager she parachuted from a plane
and landed in a tree. She hit her head against a rock when she fell from the tree and lost consciousness
for approximately 5 minutes. She says she has a headache and is a bit nauseated.
O: Ht 5′6″ Wt. 130 lb. R 18. T 98.1. BP 122/83. HEENT unremarkable. PERRLA. Dr. Prader notes slight
slurred speech. EEG shows indication of a head trauma. CT scan confirmed the brain concussion.
Patient was admitted to the hospital for observation.
A: Concussion with brief loss of consciousness
P: 1. Watch for 24 hours
2. Discharge home if no further complications.
Tuberculosis
learning experience. Viruses
Human Immunodeficiency
Infections and Inflammation Virus (HIV)
A condition affecting the
There are wars going on constantly throughout your body as pathogens (vehicles of immune system.
disease) insert themselves into your cells and multiply. There are many types of patho-
gens and each carries its own threat to your health. Infection happens once a patho- Pathogen
gen successfully invades the body and begins to replicate. This multiplication of the Any agent that causes dis-
organism, known as colonization, causes damage to cell structures and can remain ease; a microorganism such
localized in one area (such as an infected toe), spread to a larger area (such as infection as a bacterium or virus.
of the foot and leg), or become systemic (spreading throughout the entire body). The Infection
human body is designed to alert the individual and the doctor to the existence of infec- The invasion of pathogens
tion by exhibiting specific signs and symptoms: into tissue cells.
Systemic ∙ Increased body temperature (commonly known as a fever)
Spread throughout the entire ∙ Increased white blood cell count
body.
∙ Increase (tachycardia) or decrease (bradycardia) in heart rate
Asymptomatic
∙ Increase (hyperventilation) or decrease (dyspnea) in respiratory rate
No symptoms or
manifestations. In some cases, a patient might not be aware that there is an infection in his or
Acute
her body. This is known as a subclinical or asymptomatic infection. In other cases,
Severe; serious. the condition can become acute (severe) and a specific area may show signs of
inflammation. When located in the epidermis, inflammation can be visible; it causes
Inflammation signs and symptoms, such as erythema (reddening), swelling, warmth to the touch,
The reaction of tissues to and often pain. When located internally, the inflammation can cause lack of func-
infection or injury; character- tion, especially when found within a joint. When inflammation is left untreated, or if
ized by pain, swelling, and
treatment is ineffective, the condition can become chronic (ongoing). Any of these
erythema.
details may be required to determine an accurate code. You will know by reading the
Chronic complete code descriptions in the Tabular List.
Long duration; continuing over
an extended period of time.
EXAMPLE
CODING BITES A39.2 Acute meningococcemia
Keep references close B39.1 Chronic pulmonary histoplasmosis capsulati
at hand. Bookmark Z21 Asymptomatic human immunodeficiency virus [HIV] infection status
or mark as a favorite
reliable sources such
as the MedlinePlus
online medical ency- Communicable Diseases
clopedia. This will help
People interact in society, and, therefore, the transmission of pathogens cannot be
you increase your
avoided. The level of interaction and the severity of the pathogen (how aggressive it
understanding of any
may be) will impact how many individuals are infected. There are many ways that
infectious disease, and
patients can be exposed to an infection and become ill.
its inclusive signs and
Health care–acquired infections (HAIs), also known as nosocomial infections,
symptoms, that you
are those conditions that are contracted solely due to interactions with a health
encounter in physician
care facility, during which exposure to various types of pathogens occurs. Take
documentation.
note that HAIs are infections that occur in hospitals, nursing homes, and other
health care provider locations. HAIs are not just the concern of inpatient acute
Nosocomial
care facilities.
A hospital-acquired condition; A cough or a sneeze may send pathogens into the air, and a doorknob or a tele-
a condition that develops as a phone receiver easily transfers pathogens to the skin that touches it next—these are
result of being in a health care methods of transportation for bacteria or viruses to travel from an infected person
facility. to another soon-to-be-infected person. Some diseases require more intimate con-
tact, such as the exchange of bodily fluids (during sex, exposure to blood, or contact
with mucus).
∙ Touch exposure: Physical interaction with blood, bodily fluids, nonintact skin, and
mucous membranes can enable a long list of bloodborne pathogens to make their
way from one person to another.
∙ Airborne exposure: Some pathogens travel in small particles that remain contagious
CODING BITES in the air, such as chickenpox. Measles can live in the air of a room for 2 hours after
Later on, in the chapter the infected person leaves. Breathing in contaminated air by merely entering an
titled Inpatient (Hospital) examination room or patient area can expose someone to the disease.
Diagnosis Coding, you
∙ Droplet exposure: Some diseases, such as influenza, can be dispersed in large drop-
will learn how to use
lets, such as those transmitted by coughing, spitting, talking, and sneezing.
Present-On-Admission
indicators to report nos- ∙ Contact exposure: As with touch exposure, some infections, such as herpes simplex
ocomial conditions. virus, are communicated by skin-to-skin contact or skin to other surfaces (e.g., coun-
tertops, paper).
EXAMPLE
Tuberculosis (A15-A19)
infections due to Mycobacterium tuberculosis and Mycobacterium bovis
Sometimes, you will find a combination code that includes the name of the patho-
gen in the code description.
EXAMPLE
J02.0 Streptococcal pharyngitis
J09.x3 Influenza due to identified novel influenza A virus with gastrointesti-
nal manifestations
These code descriptions are known as combination codes because they include
both the condition and the specific pathogen.
Other times, an infection might be caused by any one of several different pathogens.
In these cases, you will need to report a second code to specify the bacterial or viral
infectious agent.
EXAMPLES
B95.2 Enterococcus as the cause of diseases classified elsewhere
B96.3 Hemophilus influenzae [H. influenzae] as the cause of diseases clas-
sified elsewhere
B97.11 Coxsackievirus as the cause of diseases classified elsewhere
These code descriptions identify the specific pathogen to be reported along with
the code describing the condition caused.
The part of the code description that states “diseases classified elsewhere” means
that the condition has its own code within this code set. This underscores the fact that
this is not a combination code and you will need two codes to report the condition.
CHAPTER 5
EXAMPLE
N30 Cystitis
Use additional code to identify infectious agent (B95-B97)
Very often, the ICD-10-CM will tell you that you will need this second code to iden-
tify the specific pathogen.
(a) (c)
(b) (d)
FIGURE 5-1 Types of bacteria: (a) coccus, (b) bacillus, (c) spirillum, and (d) vibrio (a) Source: CDC/Janice Carr;
(b) Source: CDC/Janice Carr; (c) ©MELBA PHOTO AGENCY/Alamy Stock Photo RF; (d) Source: CDC/Janice Carr
EXAMPLE
A05.4 Foodborne Bacillus cereus intoxication
A27.9 Leptospirosis, unspecified
A49.1 Streptococcal infection, unspecified site
This is a great example of why professional coders-to-be need to know these
details . . . so you can recognize the name of a bacterium in diagnostic terms and
phrases. Until you learn them, use your medical dictionary to confirm.
EXAMPLE
A specific, complete diagnostic statement is required to determine an accurate
code for a case of impetigo:
L01.01 Non-bullous impetigo
L01.02 Brockhart’s impetigo
L01.03 Bullous impetigo
L01.09 Other impetigo [ulcerative impetigo]
Yet, notice . . . not all impetigo diagnoses are reported from this one code
category . . .
L40.1 Generalized pustular psoriasis [impetigo herpetiformis]
Foodborne Illness
Some bacterial infections that you will encounter in a typical health care facility are
those that are foodborne, commonly called food poisoning. Do not let the word “poison-
ing” fool you. These diagnoses are not poisonings; they are actually infections. Some of
the most frequently seen bacterial infections, and their sources, are shown in Table 5-1.
EXAMPLES
Clostridium botulinium is the bacterium that causes A05.1 Botulism food poisoning
Foodborne Clostridium perfringens, the bacterium that causes enteritis necroti-
cans, is reported with code A05.2
(continued)
CHAPTER 5
Foodborne staphylococcal intoxication is reported with A05.0
Salmonella foodborne intoxication and infection are reported from code category
A02, which requires additional information related to the infection resulting from
this bacterium.
Listeriosis [listerial foodborne infection] is reported from code category A32 and
requires additional detail about the patient’s condition.
TABLE 5-1 Common Bacterial Infections, Their Sources, and Their Codes
Almost all infections shown in Table 5-1 induce symptoms of diarrhea, abdominal
pain, nausea, fever, and vomiting. Other serious effects include dehydration, head-
ache, and kidney damage or failure. Therefore, you must be careful not to report
unnecessary codes for signs and symptoms that are actually included in a definitive
diagnosis that has been made.
ICD-10-CM
LET’S CODE IT! SCENARIO
Francie Holland, a 23-year-old female, came to see Dr. Kensington due to severe abdominal pain. She had a fever
and stated that she has had bloody diarrhea for the past 2 days. Dr. Kensington’s examination revealed that she was
dehydrated as well. Francie stated she ate at a new restaurant at the beach where she had a salad and a vegetable
plate. After taking some tests, he diagnosed Francie with Shigella dysenteriae (bacillary dysentery).
Cellulitis
Cellulitis is a serious infection of the skin that may be either a staph infection (the
staphylococcal bacteria) or a strep infection (the streptococcal bacteria). These patho-
gens typically enter the body through an abnormal opening in the epidermal layer of
the skin—for example, a burn, puncture wound, abrasion (also known as a scrape), or
even a bite—either animal or human.
Cellulitis begins with the typical signs of inflammation: erythema (redness), heat
arising from the area of infection, pain, and edema (swelling). Vesicles or bullae may
appear in the infected area. In addition, the patient may develop a fever with chills,
experience tachycardia (a rapid heartbeat), suffer a headache, have hypotension (low
blood pressure), and, at times, become mentally confused.
Report a diagnosis of cellulitis with a code—in many cases—from code category
L03. You will need specific information on the precise anatomical site affected by the
condition.
EXAMPLES
L03.012 Cellulitis of left finger
L03.113 Cellulitis of right upper limb
L03.314 Cellulitis of groin
These are examples of the need to identify the specific anatomical site of the cel-
lulitis to determine an accurate code.
CHAPTER 5
as stepping on a rusty nail, report it with code A35 plus an external cause code. Should
this disease occur with or following an abortion or ectopic pregnancy, then you will
report it as a complication of pregnancy, using A34 or O08.89. And in cases where the
tetanus is affecting a neonate, it will be reported with code A33.
Tuberculosis
Mycobacterium tuberculosis, the causative agent of tuberculosis (TB), is a bacte-
rial infection that is transmitted through the air. One version of TB is called latent
tuberculosis infection (LTBI) because it is dormant and may not show symptoms
right away. Not everyone who has been infected is symptomatic, so a test is required
to confirm the diagnosis. Most types of TB and LTBI are successfully treated with
medication.
There is a specific cultural group of people who will get a positive result to the skin
test but not actually have the disease. A simple chest x-ray confirms that situation.
Should you have a patient in such a circumstance, you will use this code:
R76.11 Nonspecific reaction to tuberculin skin test without active
tuberculosis
When the documentation confirms a diagnosis of TB, you will choose the best, most
appropriate code from the range A15–A19 Tuberculosis based on the specific anatomi-
cal site affected.
EXAMPLE
A15.0 Tuberculosis of lung
A17.1 Meningeal tuberculoma
A18.81 Tuberculosis of thyroid gland
A19.1 Acute miliary tuberculosis of multiple sites
The codes in these four code categories illustrate the extensive list of anatomical
sites that may be affected with TB. Read the documentation and diagnosis care-
fully (as always).
As you look through the section, you will notice that TB is a disseminated disease.
While most people think of TB as a pulmonary infection, infiltrating only the lungs, it
can actually leach throughout the body and be identified in many different anatomical
sites. You have to abstract which anatomical site is infected with the TB bacterium so
that you can find the most accurate code.
ICD-10-CM
YOU CODE IT! CASE STUDY
Audra Swenson was brought into the emergency department (ED) by ambulance because she was having suprapu-
bic pain, pain in her lower back, and nocturia. Dr. Balthazar diagnosed Audra with renal tuberculosis, also known as
urogential TB, confirmed histologically, with pyelonephritis.
FIGURE 5-2 Types of viruses: (a) influenza, (b) hepatitis, and (c) warts (a) Source: CDC/F.A. Murphy; (b) ©BSIP/UIG/Universal
Images Group/Getty Images; (c) ©James Cavallini/Science Source
CHAPTER 5
Wart (due to HPV) (filiform) (infectious) (viral) B07.9
- anogenital region (venereal) A63.0
- common B07.8
- external genital organs (venereal) A63.0
- flat B07.8
- Hassal-Henle’s (of cornea) H18.49
- Peruvian A44.1
- plantar B07.0
- prosector (tuberculosis) A18.4
- seborrheic L82.1
-- inflamed L82.0
- senile (seborrheic) L82.1
-- inflamed L82.0
- tuberculosis A18.4
- venereal A63.0
FIGURE 5-3 ICD-10-CM Alphabetic Index, partial listing under the main term
Wart Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Ser-
vices (CMS) and the National Center for Health Statistics (NCHS)
Viral Hepatitis
Hepatitis (hepat = liver; -itis = inflammation) actually refers to several different viral
infections. According to the Centers for Disease Control and Prevention (CDC), viral
hepatitis is the most prevalent cause of malignant neoplasms of the liver. As you know,
prevention is a much better path than treatment. For those coming to your facility to
get a hepatitis vaccine, you will report one of these codes:
Z20.5 Contact with or (suspected) exposure to other viral hepatitis
Z22.330 Carrier of Group B Streptococcus
Z23 Encounter for immunization
For those who are already infected with one of the strains of hepatitis, it’s critical to
understand the different types in order to code the encounter(s) correctly.
CHAPTER 5
ICD-10-CM
LET’S CODE IT! SCENARIO
David Tranccione, a 55-year-old white male, came into our office. He complains that he feels tired all the time, no
matter how much he sleeps. His muscles are sore, his stomach is upset, and he has experienced frequent bouts of
diarrhea. He made an appointment with his regular physician, Dr. Cameron, when he noticed his urine was dark.
Dr. Cameron ordered blood tests, and the pathology report confirmed the diagnosis of acute hepatitis B virus.
Influenza
There is a reason why so much commotion is made annually about individuals getting
their flu shots. A seemingly ordinary infection, influenza (commonly called the flu)
can be deadly. It is caused by the influenza A or B virus and can be transmitted by
casual contact, such as a handshake or touching a contaminated doorknob. It is esti-
mated that as many as 36,000 people die in the United States each year from influenza.
The most common symptoms of the flu are
∙ Body or muscle aches
∙ Chills
∙ Cough
∙ Fever
∙ Headache
∙ Sore throat
EXAMPLE
J09.X1 Influenza due to identified novel influenza A virus with pneumonia
J10.2 Influenza due to other identified influenza virus with gastrointestinal
manifestations
J11.1 Influenza due to unidentified influenza virus with other respiratory
manifestations
The physician’s documentation, along with the pathology report, should provide
you with the details you need.
Varicella
Varicella, commonly known as chickenpox, is generally not perceived to be serious,
most particularly for children. Complications from varicella, however, may include
pneumonia in adults and bacterial infections of the skin and soft tissue in affected
children. The infections can be severe and can lead to septicemia, toxic shock syn-
drome, necrotizing fasciitis, osteomyelitis, bacterial pneumonia, and septic arthritis. CODING BITES
There may also be a connection between varicella and development of herpes zoster, Varicella is commonly
also known as shingles, later in life. The availability of the varicella vaccine has made called chickenpox.
the risk of contracting the infection almost nil.
Code varicella from B01.- if the patient has been diagnosed. If the patient has come
to receive a varicella vaccine, then use code Z23. However, if the patient has been
exposed to varicella, the code will change to Z20.820.
Rubeola
The risk of catching the childhood illness of rubeola, commonly referred to as mea-
sles, is very low because of the success of the measles vaccine. Your coding experience
relating to measles should be limited to office visits for administering the vaccine.
When an individual has come to get vaccinated against rubeola only, code the
encounter using Z23. However, a patient who is seeing a health care professional
because of having been exposed to rubeola will be reported with Z20.828. A diagnosis
of rubeola (measles) should be reported with code B05.-.
ICD-10-CM
YOU CODE IT! CASE STUDY
Gregg Espinoza brought his 3-year-old son, Raymond, to his pediatrician, Dr. Nunez, with complaints of a 102
degree F fever for 3 days’ duration. The boy was coughing, had signs of a runny nose, and had conjunctivitis in both
eyes. Upon examination, Dr. Nunez notes Koplik’s spots inside his checks and lips. Also noted are small, generalized,
maculopapular erythematous rashes on his scalp. When asked, the father agreed that the boy had been scratching
his head and he had been tugging at his ears.
Dr. Nunez confirmed that Raymond had measles keratoconjunctivitis.
(continued)
CHAPTER 5
You Code It!
Read the scenario carefully and determine the diagnosis code or codes to report for this encounter with Dr.
Nunez.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the code?
B05.81 Measles keratitis and keratoconjunctivitis
Good job!
Rubella
Rubella, an acute viral disease that can affect anyone of any age, is thought of by
many to be a children’s disease known as the German measles. While the symptoms
are most often not more than a mild rash, the health danger of rubella can be serious
to a pregnant woman in her first trimester. When contracted during the early months
of pregnancy, rubella can be associated with a condition known as congenital rubella
syndrome (CRS). CRS may cause any of a large number of birth defects, including
deafness and possibly fetal death. The rubella vaccine has almost eliminated CRS.
Rubella is coded with B06.- when it has been diagnosed. For those cases in which
a patient is being vaccinated against rubella alone, you will use Z23, and if the patient
has been exposed to rubella, report this with code Z20.4.
EXAMPLE
B00 Herpesviral [herpes simplex] infections
congenital herpesviral infections (P35.2)
anogenital herpesviral infection (A60.-)
gamaherpesviral mononucleosis (B27.0-)
herpangina (B08.5)
Herpes Zoster
Herpes zoster or postherpetic neuralgia is commonly known as shingles. Herpes zos-
ter is an infection of the varicella zoster virus—the same pathogen that causes chick-
enpox. Those patients who actually had chickenpox previously are at the greatest risk
for developing this painful disease. Patients will feel a burning sensation or shooting
pain, accompanied often by tingling or itching on only one side of the body.
Finding shingles in the ICD-10-CM Alphabetic Index will require you to search
for Herpes, zoster . . . reported with a code from code category B02. The required
additional characters will identify specific details about the anatomical location and
activity of the virus.
EXAMPLE
B02 Zoster [herpes zoster]
shingles
zona
B02.0 Zoster encephalitis
B02.24 Postherpetic myelitis
You may be aware of the shingles vaccine, made recently available. For those
patients coming to your health care facility to take advantage of this preventive medi-
cine, the likely ICD-10-CM diagnosis code to provide medical necessity will be
Z86.19 Personal history of other infectious and parasitic diseases.
Of course, the specific disease would be varicella—commonly known as chicken- GUIDANCE
pox. The documentation will need to specify this personal history to support the provi- CONNECTION
sion of this vaccine. Also, make note of any other qualifiers set forth by third-party
Read the ICD-10-CM
payers. Some require the patient to be aged 65 or over.
Official Guidelines for
Coding and Reporting,
Zika Virus Infections section I. Conven-
When a physician documents a confirmed diagnosis of the Zika virus, you are going tions, General Coding
to report code A92.5 Zika virus disease. However, if the physician includes any terms Guidelines and Chapter
of doubt, such as describing this diagnosis as “suspected” or “possible,” do not report Specific Guidelines,
the A92.5 code. Instead, you must report either: subsection C. Chapter-
Specific Coding Guide-
∙ the codes for the specific symptoms that are included in the documentation, such as lines, chapter 1. Certain
joint pain, fever, etc. Infectious and Parasitic
or Diseases, subsection
f. Zika virus infections.
∙ Z20.828 Contact with and (suspected) exposure to other viral communicable diseases
CHAPTER 5
5.4 Parasitic and Fungal Infections
Parasitic Infestations
Parasites Parasites are tiny living things that can invade and feed off other living things—like
Tiny living things that can humans. They are one-celled organisms (protozoa), insects (lice and mites), and worms
invade and feed off other liv- (helminths) among others (see Figure 5-4) that can interfere with a healthy body. Tape-
ing things. worms, hookworms, and pinworms are internal parasites. Parasites can be transmitted
in food (e.g., protozoa like Giardia intestinalis and Cyclospora cayetanensis); spread
by mosquitoes and other insects through the bloodstream (as in malaria and leishmani-
asis); or ingested in contaminated water (as in amebiasis and schistosomiasis).
EXAMPLE
B86 Scabies
B71.9 Cestode infection, unspecified
B87.2 Ocular myiasis
Diagnoses with a pathogen that is parasitic may not always be clearly defined.
Keep that medical dictionary close at hand.
(a)
(d)
(b)
(e)
FIGURE 5-4 Parasitic worms: (a) tapeworms and (b) Trichinella. Parasitic
insects: (c) mosquitoes, (d) deer ticks, and (e) mites (a) ©Mediscan/Alamy Stock
Photo; (b) ©Dickson Despommier/Science Source; (c) Source: CDC/James Gathany; (d) ©Svetoslav Radkov/
(c) Shutterstock.com RF; (e) Source: USDA/Scott Bauer
Protozoal diseases are caused by a single-celled, microscopic organism. There are CODING BITES
several types of diagnoses that fall into this category:
These terms from Greek
B50-B54 Malaria and Latin can be com-
B57 Chagas’ disease (infection due to Trypanosoma cruzi) plex. However, physi-
B58 Toxoplasmosis (infection due to Toxoplasma gondii) cians are more likely
Helminths (from the Greek word for worms) are large organisms that grow to be to use these terms in
visible with the naked eye. (See Figure 5-5.) Platyhelminths (flatworms) are com- documentation. There-
monly called tape worms, like acanthocephalins, which seek out the gastrointestinal fore, keep that medical
tract. Ascariasis is the medical term used to describe a case of roundworm infection. dictionary close at hand.
You will need the sup-
B68.1 Taenia saginata taeniasis (infection due to adult port and accuracy of the
tapeworm Taenia saginata) definitions to help you
B76 Hookworm diseases determine the correct
B77 Ascariasis (roundworm infection) code.
B85.3 Phthiriasis (infestation by crab-louse)
ICD-10-CM
YOU CODE IT! CASE STUDY
Michael McCarthey brought his 6-year-old daughter, Johannah, to see Dr. Benzzoni, complaining that his daughter
keeps scratching her head. After a thorough exam, Dr. Benzzoni explains that Johannah has a case of head lice.
He instructs Michael to buy Nix, an over-the-counter permethrin, and provides an instruction sheet on how to rid his
child and their household of the parasites.
CHAPTER 5
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine the correct code?
B85.0 Pediculosis due to Pediculus humanus capitis [head louse infestation]
Great work!
Fungal Infections
Fungi There are many versions of fungi (the plural form of fungus) in our lives. Mushrooms
Group of organisms, includ- on your pizza or in your salad and yeast in your bread or beer are tasty. Mold, a form
ing mold, yeast, and mildew, of fungus, can be delicious when it is called blue cheese or feta cheese, and it can
that cause infection; fungus be helpful when developed in a pill containing penicillin. Then there are fungi that
(singular). cause illness, such as Aspergillus, which may cause lower respiratory tract dysfunc-
tion, or Candida albicans, which causes infection in the oral mucosa and the walls of
the vagina. Onychomycosis is the most common nail fungal infection.
EXAMPLE
P37.5 Neonatal candidiasis
B44.81 Allergic bronchopulmonary aspergillosis
B40.3 Cutaneous blastomycosis
With fungal infections, it may not be easy or straightforward from reading the diagnos-
tic statement. You may need to do some research, or check in your medical dictionary.
Except in patients with compromised immune systems, fungal infections are not
life-threatening.
B35 Dermatophytosis
Ectoparasites are organisms that attach, or burrow, into the epidermis and dermis and
remain there, such as ticks, fleas, lice, and mites. Often, the medical term “tinea” is
used in the diagnostic statement, such as tinea pedis (commonly known as athlete’s
foot) or tinea cruris (also known as jock itch).
B44 Aspergillosis
There can be serious concerns with a fungal infection when it affects the pulmonary
organs, skin, or adrenal glands, known as histoplasmosis.
B38.0 Acute pulmonary coccidioidomycosis (also known as Valley Fever, this is
an infection of the lungs)
B39.3 Disseminate histoplasmosis capsulati
Pneumonia
Pneumonia is not an uncommon infection of the lungs. Actually, it is estimated that CODING BITES
more than 3 million diagnoses of pneumonia are made each year in the U.S. Yet, as The incidence of
a professional coder, you need to know the specific type of pathogen that caused this pneumonia is also cat-
infection before you can accurately determine the code. egorized by the envi-
ronment in which the
Types of Pneumonia patient may have con-
tracted this condition.
Several different types of pathogens can result in fluid and pus filling the air sacs
Community-acquired
(alveoli)—the underlying cause of pneumonia. Integral signs and symptoms include
pneumonia (CAP) identi-
cough with phlegm or pus, fever, chills, and difficulty breathing. When you look
fies that pneumonia has
under the main term PNEUMONIA in the ICD-10-CM Alphabetic Index, you can
developed in a patient
see the very long list of additional descriptors needed to get to a specific code
who has not recently
recommendation.
been in the hospital
or another health care
Bacterial Pneumonia facility such as a nursing
The Streptococcus pneumoniae bacterium, also known as pneumococcus, causes home or rehab facility.
the most common type of pneumonia. Atypical pneumonia, commonly referred to as Hospital-acquired
walking pneumonia, is also caused by bacteria, but different bacteria, including Legi- pneumonia identifies
onella pneumophila, Mycoplasma pneumoniae (M. pneumoniae), and Chlamydophila those patients who con-
pneumoniae. tract pneumonia while in
Aspiration pneumonia is a bacterial infection that develops after the patient has a residential health care
inhaled food, a liquid, or vomit. The particles deteriorate and bacteria grow, causing facility.
the infection and inflammation.
ICD-10-CM
LET’S CODE IT! SCENARIO
Anna Carland, an 81-year-old female, was admitted to the hospital with pneumonia. She was placed on oxygen to
help her breathe while labs were done to determine the type of pneumonia. Dr. Premin diagnosed her with strepto-
coccal pneumonia. The pathology report specifies Streptococcus pneumoniae group B.
(continued)
CHAPTER 5
Pneumonia
in (due to)
all the way down this list to . . .
Streptococcus J15.4
group B J15.3
pneumoniae J13
specified NEC J15.4
Knowing that Anna has “Streptococcus pneumoniae” is not enough. Remember that we are required to always
code to the greatest specificity, and the code book is reminding you that you need additional details. Go back
to the documentation, not only the physician’s notes but the pathology report, too. Aha! The pathology report
specifies “Streptococcus group B.” Now, turn to the Tabular List to the code category J15.
J15 Bacterial pneumonia, not elsewhere classified
Code First associated influenza, if applicable (J09.X1, J10.0-, J11.0-)
Code Also associated lung abscess, if applicable (J85.1)
chlamydial pneumonia (J16.0)
congenital pneumonia (P23.-)
Legionnaires’ disease (A48.1)
spirochetal pneumonia (A69.8)
Read these notations carefully and determine if any of them relate to Anna’s case. Not this time. Good! So, read
down all of the fourth-character options and determine which matches Dr. Premin’s documentation.
J15.3 Pneumonia due to streptococcus, group B
Check the head of this chapter in ICD-10-CM. There are notations at the beginning of this chapter: a NOTE, a
Use Additional Code notation, and an notation. Read carefully. Do any relate to Dr. Premin’s diagno-
sis of Anna? No. Turn to the Official Guidelines and read Section 1.c.1. There is nothing specifically applicable
here either.
Now you can report J15.3 for Anna’s diagnosis with confidence.
Good coding!
Viral Pneumonia
There are some viruses that are known to cause inflammation and swelling in the
lungs. The influenza A and B viruses, as well as Hemophilus influenzae (H. influ-
enzae), can develop into viral pneumonia if not treated quickly. Cytomegalovirus
(CMV) is most often seen in patients with a suppressed immune system, such
as one going through chemotherapy or one suffering with an immunodeficiency
condition.
EXAMPLES
J11.0 Influenza due to unidentified influenza virus with pneumonia
J12 Viral pneumonia not elsewhere classified
J14 Pneumonia due to Hemophilus influenzae
Secondary Pneumonia
There are some diseases that can manifest a case of pneumonia. These conditions
include rheumatic fever, schistosomiasis, and Q fever. There is a difference between
this type of pneumonia and those we have just been discussing, so read carefully and
possibly query the physician. This diagnosis is reported with the following code:
J17 Pneumonia in diseases classified elsewhere
Meningitis
Meningitis is the inflammation of the meningeal membranes of the brain and/or the
spinal cord. Meningitis can be caused by a bacterial pathogen, such as Meningococ-
cus; however, it is more often the result of a viral infection. When meningitis is caught
early, the prognosis is good and complications are rare.
In order to code a diagnosis of meningitis, you have to know the specific virus or
bacterium at the core of the inflammation. This will typically be found in the patholo-
gist’s report as well as the physician’s documentation.
EXAMPLES
Some bacterial causes of meningitis would be reported with
A39.0 Meningococcal meningitis
A54.81 Gonococcal meningitis
G00.2 Streptococcal meningitis
Use additional code to further identify organism
(B95.0-B95.5)
EXAMPLES
Some viral causes of meningitis would be reported with
A87.1 Adenoviral meningitis
A87.0 Echoviral meningitis
B26.1 Mumps (virus) meningitis
EXAMPLES
Meningitis due to poliovirus A80.9 [G02]
A80.9 Acute poliomyelitis, unspecified
G02 Meningitis in other infectious and parasitic diseases
classified elsewhere
G00.2 Streptococcal meningitis
Use additional code to further identify organism (B95.0-B95.5)
CHAPTER 5
CODING BITES 5.6 Immunodeficiency Conditions
In some states, infor- Some conditions cause the body’s immune system to stop working, meaning that infec-
mation in the patient’s tion and pathogens cannot be fought off effectively. You may remember learning about
record relating to HIV T cells, B cells, and lymphoid tissues from your physiology class. A defect involv-
testing (positive or ing any of these is known as a primary (congenital) immunodeficiency condition. A
negative result), HIV secondary (acquired) immunodeficiency is a manifestation caused by something that
AIDS status, sexually is blocking the proper immune response or depressing the response to an ineffective
transmitted diseases, level. There are some viruses that trigger secondary immunodeficiency, such as with
genetic information acquired immunodeficiency syndrome (AIDS). However, there are a number of poten-
(such as the results of tial external causes of secondary immunodeficiency, ranging from exposure to an
any genetic testing), infection, a toxic chemical, or radiation to suffering severe burns.
mental health condi- Primary immunodeficiency disorders include
tions, and substance ∙ X-linked agammaglobulinemia (XLA)
abuse is categorized as
superconfidential infor-
∙ Common variable immunodeficiency (CVID)
mation. This information ∙ Severe combined immunodeficiency (SCID), also known as “boy in a bubble”
has additional legal disease
protection, above the ∙ Alymphocytosis (deficiency of lymphocytes in the blood)
requirements of HIPAA,
with regard to disclo-
Secondary immunodeficiency conditions include
sure and use. Be certain ∙ AIDS
to find out if your state ∙ Leukemia and other cancers of the immune system
has this additional pro-
tection for patients as
∙ Viral hepatitis and other immune-complex diseases
well as the requirements ∙ Multiple myeloma (a cancer of the plasma cells)
for compliance.
Human Immunodeficiency Virus
Human immunodeficiency virus (HIV) infection is a serious illness. Sadly, as if
GUIDANCE this illness were not enough for a patient to deal with, it also carries a huge societal
stigma. Therefore, whether you are coding for an inpatient facility (an exception
CONNECTION
to the guideline discussed earlier) or an outpatient facility, you will code this ill-
Read the ICD-10-CM ness only when it has been clearly specified in the physician’s notes that the patient
Official Guidelines for is HIV-positive.
Coding and Reporting, Anyone possibly exposed to HIV should be tested. Similar to so many other con-
section I. Conven- ditions, like malignancies, the earlier a diagnosis is made, the sooner treatment can
tions, General Coding begin. Early treatment translates into a longer, better-quality life for the patient.
Guidelines and Chapter
Specific Guidelines, Coding HIV Testing, Test Results, and Symptoms
subsection C. Chapter-
Specific Coding Guide-
Documenting Medical Necessity of HIV Testing
lines, chapter 1. Certain When an individual with no symptoms comes to a health care facility to be tested for
Infectious and Parasitic a condition, you will need a diagnosis code to provide medical necessity for the test.
Diseases, subsections As with other preventive health care encounters, you will use a Z code to document the
a. Human immuno- need for HIV testing. For a first office visit to discuss possible exposure to HIV, you
deficiency virus (HIV) will use this code:
infections and a.2)(h) Z20.6 Contact with and (suspected) exposure to human
Encounters for testing immunodeficiency virus [HIV]
for HIV.
For the diagnosis code used to support the actual test, generally, you will use this
code:
Z11.4 Encounter for screening for human immunodeficiency virus [HIV]
However, if the patient is documented by the physician as a member of a known high-
risk group, you may use one of these codes:
ICD-10-CM
LET’S CODE IT! SCENARIO
Michael Callahan got drunk and had unprotected intercourse last night. He comes to Dr. Ansara’s office to discuss
his concerns about possible exposure to HIV.
Test Negative
There are rapid HIV tests using oral swabs or finger sticks that can provide results in
minutes. Other HIV tests may take several days to provide an answer. Therefore, a
return visit to the health care provider will sometimes be required.
CHAPTER 5
The entire experience of being tested and then having to wait for the results can be psy-
chologically difficult, even when the news is good and the test is negative. It is the health
care professional’s responsibility to counsel the patient on how to prevent future risk.
Therefore, when an individual returns to get the results of an HIV test, even when the results
are negative, counseling should be provided. For that reason, when documented, report:
Z71.7 Human immunodeficiency virus [HIV] counseling
Test Inconclusive
CODING BITES It can happen that the serology (pathology testing) comes back inconclusive for HIV.
Once a patient has There can be no specific diagnosis for HIV or any direct manifestations of the illness
been diagnosed with because there is nothing to confirm or deny HIV-positive status. In such cases, you
manifestations of HIV- have to use this code:
positive status, you are R75 Inconclusive laboratory evidence of human immunodeficiency virus [HIV]
no longer permitted to
use code Z21, even Test Positive but Asymptomatic
when the manifestations
Thanks to research and the development of new drug therapies, patients who have HIV
are no longer present.
are living longer and with a better quality of life. Therefore, testing positive for HIV is
not quite as devastating as it was years ago. When a patient comes to receive the HIV
test results that are positive but the patient has no signs, symptoms, or manifestations,
Asymptomatic the patient is asymptomatic. You will assign this code:
No symptoms or
manifestations. Z21 Asymptomatic human immunodeficiency virus [HIV] infection status
When the physician provides counseling for the patient, discusses therapeutic treat-
ments, and/or any other elements of dealing with the disease, you should report the
counseling code as well.
CODING BITES
Test Positive with Symptoms or Manifestations
Positive status means
that laboratory tests Once the individual has been diagnosed and exhibits any manifestations associated
have confirmed that the with HIV, the code to report the condition will change from Z21 to
patient does have the B20 Human immunodeficiency virus [HIV] disease
virus in his or her sys-
tem (positive status). Code B20 includes a diagnosis of acquired immune deficiency syndrome (AIDS),
Asymptomatic means which is essentially HIV with manifestations. When you use code B20, you have to
that the patient is cur- follow it with a code or codes to identify the specific manifestations, such as pneu-
rently not exhibiting any monia or HIV-2 infection. There is a notation in the ICD-10-CM book, below code
signs or symptoms of B20’s description in the Tabular List, reminding you to do this. If the patient is seen
the disease. for a condition or illness directly related to his or her HIV-positive status, list code B20
first, followed by the code or codes for the conditions.
ICD-10-CM
LET’S CODE IT! SCENARIO
Alfredo Zimoso has been HIV-positive for 10 years. He comes to see Dr. Chang because of severe headaches and
vision problems. After a complete physical examination (PE) and appropriate tests, Dr. Chang diagnoses Alfredo with
noninfectious acute disseminated encephalomyelitis, secondary to HIV.
CHAPTER 5
HIV Status with Unrelated Conditions
GUIDANCE
An individual who is HIV-positive can still be affected by conditions, illnesses, or inju-
CONNECTION ries that have nothing to do with his or her HIV status. As you have learned, the first-
Read the ICD-10-CM listed code should answer the question, “Why did the health care provider care for the
Official Guidelines for patient at this encounter?” Therefore, the code for the condition that caused the patient
Coding and Reporting, to visit the physician should come first. Because HIV is a systemic disease, affecting
section I. Conven- the entire body, you have to include a code for that condition as well. Even if it has
tions, General Coding nothing to do with the services or treatment provided by the physician, it will have an
Guidelines and Chapter impact on the physician’s decision making and therefore must be included.
Specific Guidelines,
subsection C. Chapter- GUIDANCE CONNECTION
Specific Coding Guide-
lines, chapter 1. Certain Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I. Conven-
Infectious and Parasitic tions, General Coding Guidelines and Chapter Specific Guidelines, subsection C.
Diseases, subsec- Chapter-Specific Coding Guidelines, chapter 1. Certain Infectious and Parasitic Dis-
tion a. 2)(f) Previously eases, subsection a.2)(b): “If a patient with HIV disease is admitted for an unrelated
diagnosed HIV-related condition (such as a traumatic injury), the code for the unrelated condition (e.g., the
illness. nature of injury code) should be the principal diagnosis. Other diagnoses would be
B20 followed by additional diagnosis codes for all reported HIV-related conditions.”
EXAMPLE
Gayle Robbins came to see Dr. Tigliano because she slipped on the ice this morn-
ing and hurt her ankle. Dr. Tigliano examined her and took x-rays that confirmed
a sprain of the deltoid ligament of the left ankle. Gayle was diagnosed with HIV 2
years ago and is asymptomatic.
S93.422A Sprain, of deltoid ligament of left ankle, initial encounter
Z21 Asymptomatic human immunodeficiency virus [HIV]
EXAMPLE
Yuri Kastachen fell off a ladder and hurt his lower back. Dr. Lang determined that Yuri
had a fractured coccyx. Last year, Yuri was hospitalized with HIV-related pneumonia.
S32.2xxA Fracture of coccyx, initial encounter
B20 Human immunodeficiency virus [HIV] disease
ICD-10-CM
YOU CODE IT! CASE STUDY
Maureen Dunbar, a 27-year-old female, 23 weeks pregnant, was playing tennis when she felt a pain in her right knee.
She went to see her physician, Dr. Rummur, who diagnosed her problem as a derangement of the anterior horn of the
lateral cystic meniscus. Maureen has been HIV-positive and asymptomatic for 5 years.
Are you wondering why the knee condition is listed first when the guideline for
HIV infection in pregnancy states the O98.7- code category should be listed first? In
this case, you have two guidelines that need to be followed:
Section I.C.1.a.2)(b) Patient with HIV disease admitted for unrelated condition
Section I.C.1.a.2)(g) HIV infection in pregnancy, childbirth, and the puerperium
To break the tie, let’s look at one more guideline, either
Section II. Selection of Principal Diagnosis (for inpatient encounters)
or
ection IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services,
S
Subsection H (for outpatient encounters)
Whether you are coding for outpatient or inpatient services, the guidelines agree that
the principal, or first-listed, diagnosis code should be the condition “chiefly responsible”
for the encounter. In Maureen’s case, the reason she went to the doctor for care was the
pain in her knee—not the pregnancy and not the HIV. Then why code them at all? Because
Dr. Rummur must take Maureen’s pregnant status and her HIV status into consideration
in his medical decision-making process to determine the best way to treat her knee.
CHAPTER 5
5.7 Septicemia and Other Blood Infections
Blood infections are very dangerous, as you might imagine, because of their poten-
tial effect on the entire body. Blood circulates through the body and touches all the
cells and organs in some fashion. So you can understand that if the blood circulat-
ing through the body is carrying a disease, it can have the potential to cause serious
problems. There are several types of blood infections, and each needs to be coded
Septicemia differently.
Generalized infection spread
through the body via the
bloodstream; blood infection. Septicemia
Systemic Inflammatory Essentially, septicemia is identified as the presence of a microorganism or toxin in the
Response Syndrome (SIRS) bloodstream. The organism might be a virus, a fungus, a bacterium, or another patho-
A definite physical reaction, logic substance. Septicemia is very serious. A physician may refer to this condition as
such as fever, chills, etc., to an bacteremia; however, they are really not the same. Bacteremia may not be clinically
unspecified pathogen. significant, but septicemia is always significant.
The code used for a diagnosis of septicemia may be taken from category
A41.9 Sepsis, unspecified sepsis (Septicemia NOS)
GUIDANCE
CONNECTION You will need to determine a more accurate code by the pathogen or toxin found in the
blood, such as streptococcus or staphylococcus.
Read the ICD-10-CM A diagnosis of systemic inflammatory response syndrome (SIRS) is used when
Official Guidelines for the basic cause, or pathogen, is unknown. The human body is amazing and is designed
Coding and Reporting, to fight any and all intruders (disease or infection). The system’s response to infection
section I. Conven- may be
tions, General Coding
Guidelines and Chapter
∙ Increased body temperature.
Specific Guidelines, ∙ Change in heart rate.
subsection C. Chapter- ∙ Change in respiratory rate.
Specific Coding Guide- ∙ Increased white blood cell count.
lines, chapter 1. Certain
Infectious and Parasitic Systemic inflammatory response syndrome (SIRS) of non-infectious origin
Diseases, subsection d. R65.10
Sepsis, severe sepsis, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with
and septic shock. acute organ dysfunction R65.11
ICD-10-CM
YOU CODE IT! CASE STUDY
Priscilla Christopher, a 17-year-old female, was brought by her mother to see Dr. Fasold. Priscilla claimed that her
muscles ache, she has been sweating, and she has chills at the same time. She stated that she has been cough-
ing and short of breath for several days. After running some tests, Dr. Fasold diagnosed Priscilla with sepsis due to
Hemophilus influenzae.
Sepsis Sepsis
Condition typified by two or
When an individual exhibits two or more systemic responses or when the presence of more systemic responses
a specific pathogen has been identified in the bloodstream, the diagnosis is typically to infection; a specified
sepsis. pathogen.
Reporting a diagnosis of sepsis will begin with the identification of the underlying
systemic infection—the pathogen that initiated the septic condition. This code will
come from category A40.- or A41.-. You may find this detail in the physician’s docu- GUIDANCE
mentation or the pathology report.
On occasion, a physician might diagnose a patient with urosepsis. This is not a syn- CONNECTION
onym for sepsis and cannot be coded as sepsis. Should you find this term used in the Read the ICD-10-CM
documentation, you will need to query the physician for clarification. Official Guidelines for
A patient may be diagnosed with sepsis and acute organ failure during the same Coding and Reporting,
encounter, without a relationship (or cause and effect) between the two. In these situ- section I. Conven-
ations, the organ failure is a co-morbidity and is reported separately from the sepsis. tions, General Coding
Guidelines and Chapter
Specific Guidelines,
EXAMPLE subsection C. Chapter-
Bernard Madison was in the hospital and diagnosed with group A streptococcus Specific Coding Guide-
sepsis. lines, chapter 1. Certain
A40.0 Sepsis due to streptococcus, group A Infections and Parasitic
Diseases, subsec-
tion d.3) Sequencing
Severe Sepsis of severe sepsis, which
warns you that a code
When left untreated, sepsis may become severe and cause an organ to fail—a life- from subcategory
threatening condition. In some cases, this can occur when treatment is provided but R65.2 Severe sepsis is
is ineffective. A diagnosis of sepsis in combination with acute organ failure due to the never permitted to be
septic condition is reported as severe sepsis. The physician’s notes that contain a diag- the first-listed or prin-
nosis of severe sepsis will be reported with cipal diagnosis code
∙ First: the code for the underlying systemic infection, such as streptococcus or other reported.
bacteria (e.g., a code from A40.- or A41.-). If the organism is not known, you may
report A41.9 Sepsis, unspecified organism.
Severe Sepsis
∙ Followed by: a code from subcategory R65.2 Severe sepsis. An additional char-
Sepsis with signs of acute
acter is required to report whether or not the physician has documented that the organ dysfunction.
patient is in “septic shock.”
∙ Followed by: a code to report the specific organ failure caused by the septic condi-
tion. To remind you, code subcategory R65 has a Use additional code notation.
CHAPTER 5
ICD-10-CM
LET’S CODE IT! SCENARIO
Dr. Kahanni admitted Burton Chapel with acute renal failure due to severe sepsis resulting from pneumonia.
Sepsis
Pneumococcal A40.3
Turn to the Tabular List to confirm this code:
Next, let’s turn to R65.2- and see what will accurately report Dr. Kahanni’s diagnosis for Burton.
The notations above this code help you further. They remind you to “Code first underlying infection,” which you
have done already with the pneumococcal sepsis code. The second notation directs you to
Use additional code to specify acute organ dysfunction, such as: acute kidney failure (N17.-)
Next, confirm the code for the acute renal (kidney) failure:
Carefully read the Code also and notes. There is no relevance here to Burton’s diagnosis at this
encounter, so read down the column to review all of your choices for the required fourth character. With no docu-
mentation of any lesions on Burton’s kidneys, the best choice is
Check the top of this subsection and the head of this chapter in ICD-10-CM. There are notations at the beginning
of this chapter: an notation, a Use additional code note, an notation, and an nota-
tion. Read carefully. Do any relate to Dr. Kahanni’s diagnosis of Burton? No. Turn to the Official Guidelines and
read Section 1.c.1, particularly d. Sepsis, severe sepsis, and septic shock.
Now you can report, with confidence, these codes in the order specified by the guidelines: A40.3,
R65.20, N17.9 . . .
Good job!
Neonatal Sepsis
A fetus may contract an infection in utero, during the birth process (delivery),
or during the first 28 days after birth. In these cases, when a neonate is diag-
nosed with sepsis, the code will be reported from category P36 Bacterial sepsis of
newborn. An additional character is required to identify the pathogen that caused
the infection. If severe sepsis is documented, a code from R65.2- should also be
reported.
CHAPTER 5
Next, carefully read the three diagnoses listed in the note.
bleb associated endophthalmitis (H59.4-)
infection due to infusion, transfusion and therapeutic injection (T80.2-)
infection due to prosthetic devices, implants and grafts (T82.6-T82.7, T83.5-
T83.6, T84.5-T84.7, T85.7)
Don’t forget the Use Additional Code notations, also:
Use additional code to identify infection
Use additional code (R65.2-) to identify severe sepsis, if applicable
Then, continue with the usual coding sequence for sepsis, as reviewed earlier in this
section. Remember to refer to the physician’s documentation and the pathology report
to gather all of the details you need to code accurately.
ICD-10-CM
YOU CODE IT! CASE STUDY
Gregory Parrale, a 31-year-old male, had his appendix taken out last week. He comes to Dr. Gorman’s office for his
postsurgical follow-up visit. Dr. Gorman finds the surgical wound is erythematous, swollen, and painful to the touch.
He takes a swab of the fluid oozing from the site. The lab confirms a postoperative staph infection.
CHAPTER 5
Primarily, one code category is used to report AMR. There is a note and a notation
for you:
Z16 Resistance to antimicrobial drugs
CODING BITES NOTE: The codes in this category are provided as Use additional codes to iden-
A Physician’s Desk Ref- tify the resistance and non-responsiveness of a condition to antimicrobial drugs.
erence (PDR) or a Drug Code first the infection.
Guide can help you
connect the name of a
specific drug to a fam-
Clostridium difficile (C. diff)
ily name of drugs. For C. diffis a spore-forming, gram-positive anaerobic bacillus that causes life-threatening
example, the quinolones diarrhea and that has been documented as causing about 250,000 infections each year,
are a family of synthetic which have resulted in about 14,000 deaths. Of those patients aged 65 and older infected
broad-spectrum antibi- with C. diff, more than 90% died. In total, C. diff costs us an estimated $1 billion
otics. Ciprofloxacin, also in excess health care costs. At greatest risk for contracting C. diff are hospitalized
known as Cipro, and patients, those who have been recently hospitalized, and those who have recently
levofloxavin, also known received medical care with a course of antibiotic therapy.
as Levaquin, are part of The CDC is calling for more data as they track these AMRs. ICD-10-CM gives us
the quinolones family of the tools to collect and submit these details. For example, these codes may be reported
drugs. for a patient with C. diff who is not responding to antibiotics:
Z16.23 Resistance to quinolones and fluoroquinolones
Z16.24 Resistance to multiple antibiotics
CHAPTER 5
The coding guidelines state that it is possible for one patient to be a MRSA carrier
and have a current MRSA infection at the same encounter. When this is the case, you
are permitted to report code Z22.322 and a code for the MRSA infection.
ICD-10-CM
YOU CODE IT! CASE STUDY
REFERRING PHYSICIAN: Audra Starch, MD
REASON FOR CONSULTATION: MRSA pneumonia, fever.
HISTORY OF PRESENT ILLNESS: This 77-year-old male has a history of recent stroke. Garden Nursing Home, where
he is a resident, requested a consultation due to his increased cough, along with some pulmonary congestion. Dr.
Starch prescribed an extended spectrum penicillin (Zosyn, 4.5g q 6hr via IV bedside) for the patient’s low-grade
fever. Sputum cultures evidenced MRSA, leading to the request for this consultation.
Patient is post-CVA aphasic. Daughter is present and serves as primary relator. Nurse’s notes document that the
patient has been aspirating in conjunction with the increasing frequency of cough. Overall status has decreased due
to these situations. At this time, the patient appears to be resting comfortably without any complaints.
ASSESSMENT AND PLAN:
1. Pathology report shows: positive sputum cultures with methicillin-resistant Staphylococcus aureus.
2. Fever, most likely secondary to pneumonia.
RX: Vancomycin, 500mg q 6hr IV x 10 days to treat MRSA
ceftriazone, 2 g q 12, IM x 7 days to treat UTI/E. coli
CHAPTER 5 REVIEW
The contagious nature of infectious diseases makes them very serious. The coding of
such conditions, and their treatments, has statistical significance, in addition to the
importance of reimbursement.
Ordinary day-to-day activities, such as sneezing, coughing, having sex, or play-
ing baseball, may pass an infectious disease from one person to another. Health care
advancements have enabled the use of vaccines to prevent such conditions as measles,
mumps, varicella, or human papillomavirus (HPV). Other conditions require behav-
ioral or lifestyle changes to prevent their spread.
In any case, the health care industry is charged with helping patients, and it is, or
will be, your job to code all of these infectious diseases correctly.
CODING BITES
Did you know . . .?
• Number of visits to physician offices for infectious and parasitic diseases: 20.2
million (2012)
• Number of new tuberculosis cases: 9,582 (2013)
• Number of new salmonella cases: 50,634 (2013)
• Number of new Lyme disease cases: 36,307 (2013)
• Number of new meningococcal disease cases: 556 (2013)
CHAPTER 5 REVIEW
Coding Infectious Diseases Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
Part I A. Acute
1. LO 5.1 A hospital-acquired condition. B. Asymptomatic
2. LO 5.2 A singxle-celled microorganism that causes disease. C. Bacteria
3. LO 5.1 A condition that can be transmitted from one person to another. D. Chronic
4. LO 5.1 Long-lasting; ongoing. E. Fungi
5. LO 5.1 A condition affecting the immune system. F. Human Immunodefi-
6. LO 5.4 Group of organisms, including mold, yeast, and mildew, that cause infection. ciency Virus (HIV)
7. LO 5.1 Severe. G. Infection
8. LO 5.1 The invasion of pathogens into tissue cells. H. Infectious
9. LO 5.1 No symptoms or manifestations. I. Inflammation
10. LO 5.1 The reaction of tissues to infection or injury; characterized by pain, J. Nosocomial
swelling, and erythema.
CHAPTER 5
Part II
CHAPTER 5 REVIEW
1. LO 5.3 Microscopic particles that initiate disease, mimicking the characteris- A. Parasites
tics of a particular cell, and can reproduce only within the body of the
B. Pathogen
cells that they have invaded.
C. Sepsis
2. LO 5.4 Tiny living things that can invade and feed off of other living things.
D. Septic Shock
3. LO 5.1 Any agent that causes disease; a microorganism such as a bacterium or
virus. E. Septicemia
4. LO 5.7 Generalized infection spread through the body via the bloodstream; F. Severe Sepsis
blood infection. G. Systemic
5. LO 5.7 Sepsis with signs of acute organ dysfunction. H. Systemic Inflammatory
6. LO 5.7 A definite physical reaction, such as fever, chills, etc., to an unspecified Response Syndrome
pathogen. (SIRS)
7. LO 5.1 Spread throughout the entire body. I. Tuberculosis
8. LO 5.2 An infectious condition that causes small rounded swellings on mucous J. Viruses
membranes throughout the body.
9. LO 5.7 Condition typified by two or more systemic responses to infection; a
specified pathogen.
10. LO 5.7 Severe sepsis with hypotension; unresponsive to fluid resuscitation.
CHAPTER 5 REVIEW
a. the first-listed diagnosis code.
b. an additional code.
c. used to identify the inclusion of hypotension.
d. added to the codes required for severe sepsis.
10. LO 5.8 Methicillin-resistant Staphylococcus aureus (MRSA) is spread from one person to another by
a. direct contact.
b. indirect contact.
c. both direct and indirect contact.
d. none of these.
CHAPTER 5
3. LO 5.1 What is a nosocomial infection, and where do such infections occur?
CHAPTER 5 REVIEW
ICD-10-CM
YOU CODE IT! Basics
First, identify the main term in the following diagno- 8. Kaposi’s sarcoma of the lymph nodes:
ses; then code the diagnosis. a. main term: _____ b. diagnosis: _____
Example: Neonatal candidiasis: 9. Cellulitis of upper right limb:
a. main term: candidiasis b. diagnosis: P37.5 a. main term: _____ b. diagnosis: _____
10. Generalized blastomycosis:
1. Allergic bronchopulmonary aspergillosis:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
11. Acute disseminated, noninfectious,
2. Chronic active hepatitis:
encephalomyelitis:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
3. Sepsis, streptococcal, group B:
12. Laryngeal diphtheria:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
4. Pulmonary cryptococcosis:
13. Retroperitoneal tuberculosis:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
5. Herpes zoster meningitis:
14. Shigellosis, group C:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
6. Chronic otitis media, right ear:
15. Ringworm honeycomb:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
7. Jungle yellow fever:
a. main term: _____ b. diagnosis: _____
ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case.
1. Ben Kenton, a 49-year-old male, presents today with a high fever, chills, nausea, and diarrhea. After an exam-
ination and reviewing the results of the blood tests, Dr. Daniels diagnoses Ben with West Nile fever.
2. Robin Pullen, a 36-year-old female, comes to see Dr. Ditolla because she is running a fever and has a sore
throat and overall body aches. Test results are positive for H1N1. Robin is diagnosed with swine influenza.
3. Joan Kenney, a 27-year-old female, is having difficulty breathing. Dr. Aung documents a fever of 101 F and
facial edema. Joan recently returned home from a trip to Asia. Joan said they were contending with some sort
of larval infestation in Asia. Joan is diagnosed with nasopharyngeal myiasis.
CHAPTER 5
CHAPTER 5 REVIEW
ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ documentation from our textbook’s health care
facility, Prader, Bracker, & Associates. These case studies are modeled on real patient encounters. Using the tech-
niques described in this chapter, carefully read through the case studies and determine the most accurate ICD-10-
CM code(s) for each case study.
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: GALEANA, ROBERT
ACCOUNT/EHR #: GALERO001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
This 33-year-old male was admitted for a high fever, abdominal pain, and a noted moderate decrease in
alertness. Robert has been on oral antibiotics for a left ear infection for approximately 7 days. I last saw
the patient in the office four days ago when his left ear spontaneously drained.
PE: Ht: 5’ 11”, Wt: 194, T: 101.2, R: 19, BP: 134/86. Pt seems confused. Left ear drainage continues.
CSF analysis reveals normal pressure, a slightly thicker viscosity with a cloudy appearance. Results of
CSF exam showed 6875 WBC, 35 g/L protein, and 23 mg/dL glucose.
Arbovirus is identified in two blood cultures. Pt responds positively to antimicrobial therapy.
DX: Meningitis due to arbovirus, urban yellow fever; acute suppurative otitis media.
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: MURPHY, ADRIENNE
ACCOUNT/EHR #: MURPAD001
DATE: 08/11/18
Attending Physician: Renee O. Bracker, MD
Pt is admitted with a chief complaint of shortness of breath of approximately 7 to 10 days duration and
a feeling of uneasiness and discomfort. Pt was found to be HIV-positive in May 2014, and diagnosed
with AIDS in February 2016. Patient also complains of vision loss. She states she can’t see and it hurts
when you touch her eyes and face.
PE: Ht: 5’4”, Wt: 126, T: 101.6. The physician notes pustules on forehead, right eye, and bridge of nose.
A Tzanck smear with methylene blue stain was performed; results positive.
DX: Herpesviral keratoconjunctivitis (simplex), secondary to AIDS
Plan: Acyclovir, IV: 10mg/kg q 8 hr
CHAPTER 5
CHAPTER 5 REVIEW
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: SAMUELS, BERNARD
ACCOUNT/EHR #: SAMUBE001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
This 82-year-old male was admitted to the hospital with high fever, myalgia, headache, rhinitis, and a
nonproductive cough. He also shows signs of confusion.
PE: Ht: 5’9”, Wt: 173, T: 103.2, R: 22, BP: 90/59. Pt’s condition deteriorated with definite signs of septic
shock, pneumonia, and hypotension. He is now in acute renal failure.
DX: Influenza with pneumonia due to E. coli; septic shock, acute renal failure.
Learning Outcomes
6
Key Terms
After completing this chapter, the student should be able to: Benign
Carcinoma
LO 6.1 Identify the medical necessity for screenings and diagnostic Ectopic
testing for malignancies. Functional Activity
LO 6.2 Discern the various types of neoplasms. Malignant
LO 6.3 Interpret the Table of Neoplasms accurately. Mass
LO 6.4 Employ the directions provided in the Chapter Notes at the Metastasize
Morphology
head of the Neoplasms section of the Tabular List.
Neoplasm
LO 6.5 Apply the guidelines for sequencing admissions due to com- Overlapping
plications of neoplasms and/or their treatments. Boundaries
Topography
EXAMPLE
You would report code:
Z12.5 Encounter for screening for malignant neoplasm of prostate
for an encounter when a 59-year-old man goes in for a screening prostate exam,
as per recommendations for men aged 55 to 69 years of age.
EXAMPLE
You would report code:
Z80.42 Family history of malignant neoplasm of prostate
in addition to code Z12.5 for an encounter when a 44-year-old man goes in for
a screening prostate exam because his father and brother were both diagnosed
with prostate cancer, dramatically increasing his risk.
GUIDANCE
CONNECTION
A personal history code (Z85.-) should be reported for those patients who may
Read the ICD-10-CM receive screening tests more frequently than others. For example, a woman with a his-
Official Guidelines for tory of breast cancer may get mammograms every 6 months rather than annually. The
Coding and Reporting, personal history of breast cancer code will support medical necessity for this increase
section I. Conventions, in the frequency of testing.
General Coding Guide-
lines and Chapter
Specific Guidelines, EXAMPLE
subsection C. Chapter- You would report code:
Specific Coding Guide-
Z85.3 Personal history of malignant neoplasm of breast
lines, chapter 21.
Factors influencing in addition to code Z12.31 Encounter for screening mammogram for m alignant
health status and neoplasm of breast for an encounter when a 57-year-old female goes in for a
contact with health screening mammogram every 6 months, instead of the usual (once a year), because
services (Z00-Z99), sub- the fact that she had a malignant neoplasm of her breast a few years ago dramati-
section c.4) History (of). cally increases her risk for a recurrence.
The Z12 code category also carries an notation to remind you of the
difference between a diagnostic test, which is performed when a patient does exhibit
signs or symptoms, and a screening test, which is performed with the intention of early
detection of disease without signs or symptoms.
encounter for diagnostic examination—code to sign or symptom
EXAMPLE
You would report code:
N63.- Unspecified lump in breast
for an encounter when a 62-year-old female goes in for a mammogram because
she felt a lump in her breast during her monthly self-check and her gynecologist
confirmed it was suspicious.
Confirming a Diagnosis
Once the patient exhibits signs, such as a lump found during a physical examination
or an abnormality identified during a screening test, a pathologist must determine the
essence of the neoplasm. This is the only way to factually distinguish between benign
cells and malignant cells.
Test Results
You will see pathology reports in the patient’s chart, whether you work in a hospital or
a physician’s office. Some examples of reports include
∙ Histopathology: A punch biopsy of the overlying skin reveals an adenocarcinoma
with diffuse involvement of the dermis and extensive invasion of the dermal lym-
phatics. The adenocarcinoma is composed of irregular nests with some areas form-
ing tubercles. Mitotic figures, including atypical forms, are seen. The tumor was
ER −, PR −, Her2 +, CK7 +, and CK 20 −.
∙ Tissue biopsy culture: Negative for any growth
∙ Lumbar puncture: negative for organisms
∙ Blood culture: 2/2 positive for Neisseria meningitidis
∙ Labs: WBC: 8.6, Hgb/Hct: 9.4/26.3, Platelets: 222, BUN: 71, Creatinine: 6.8, U/A:
2+ protein, 3+ blood, ANA: negative, Hepatitis B surface antigen: negative, Hepatitis
C antibody: negative, Serum cryoglobulins: negative, HIV: negative, cANCA: posi-
tive (1:1280), Tissue culture: negative, Initial blood cultures: negative, CXR: bilat-
eral opacities.
Pathology reports may also provide information on the grading and/or staging of the
tumor. Grading a tumor is the microscopic analysis of the tumor cells and tissue to describe
how abnormal they appear. Staging, however, evaluates the size and location of the tumor,
as well as determination of any signs or evidence of metastasis. In some cases, you will
need to know the grade of a patient’s tumor so you can determine the correct code.
EXAMPLES
C82.07 Follicular lymphoma grade 1, spleen
C82.16 Follicular lymphoma grade II, intrapelvic lymph nodes
These two codes are examples of those with code descriptions that require you to
check the physician’s documentation and pathology reports to identify the grade
of the tumor.
TABLE 6-1 Some Common Tests Performed When Various Types of Malignan-
cies Are Suspected
Malignant Neoplasm of the Cervix
∙ Abdominal ultrasound
∙ Cervical biopsy
∙ Colposcopy
∙ CT scan of the abdomen and pelvis
Malignant Neoplasm of the Colon and Rectum
∙ Barium enema
∙ Carcinoembryonic antigen (CEA)
∙ Colonoscopy
∙ Stool for occult blood
Leukemia/Lymphoma
∙ Blood smear
∙ Bone marrow biopsy
∙ Cell surface immunophenotyping
∙ Cryoglobulins
Malignant Neoplasm of the Lung
∙ Alpha-1 antitrypsin
∙ Bone scan
∙ Bronchoscopy
∙ Chest x-ray
∙ Lung biopsy
Malignant Neoplasm of the Ovary
∙ CA-125
∙ Laparoscopy
∙ Paracentesis
∙ Pyelography
Malignant Neoplasm of the Prostate
∙ Acid phosphatase
∙ CT scan of the pelvis
∙ Cystoscopy
∙ MRI of the prostate
∙ Prostate specific antigen (PSA)
FIGURE 6-1 Types of skin cancer: (a) squamous cell carcinoma, (b) basal cell carcinoma, and (c) malignant melanoma
When the physician uses a term such as adenoma, melanoma, or other specific
CODING BITES name rather than the more generic term of neoplasm, it is more efficient for you to
In medical terminology, look for that specific term in the Alphabetic Index first, before looking under the term
the suffix -oma means neoplasm. At the very least, the Alphabetic Index can tell you if that type of tumor is
tumor. known to be malignant or benign.
Often, when you look up one of these specific neoplasm terms in the Alpha-
betic Index, it will provide you with some specific information about the tumor.
Let’s take a look in the ICD-10-CM Alphabetic Index under the term written by the
physician . . .
Fibroxanthoma (see also Neoplasm, connective tissue, benign)
atypical — see Neoplasm, connective tissue, uncertain behavior
malignant — see Neoplasm, connective tissue, malignant
Fibroxanthosarcoma — see Neoplasm, connective tissue malignant
You can see that while you might not know if a fibroxanthoma is malignant or benign,
the Alphabetic Index will tell you.
ICD-10-CM
LET’S CODE IT! SCENARIO
Abby Shantner, a 41-year-old female, comes to see Dr. Branson to get the results of her biopsy. Dr. Branson
explains that Abby has an alpha cell adenoma of the pancreas. Dr. Branson spends 30 minutes discussing treat-
ment options.
Malignant Primary
The term primary indicates the anatomical site (the place in the body) where the
malignant neoplasm was first seen and identified. If the physician’s notes do not spec-
ify primary or secondary, then the site mentioned is primary.
Ca in Situ Metastasize
To proliferate, reproduce, or
The term Ca in situ indicates that the tumor has undergone malignant changes but is spread.
still limited to the site where it originated (i.e., it has not spread). Ca is short for carci-
noma, and you can remember situ as in the word situated. So think of it as a cancerous
tumor that is staying in place. CODING BITES
To determine the code
Benign to report a neoplasm,
The term benign means there is no indication of invasion of adjacent cells. Essentially, you need to know
benign means not cancerous. 1. Where in the body
(specifically, which
Uncertain anatomical site) is the
The classification uncertain indicates that the pathologist is not able to specifically deter- neoplasm located?
mine whether a tumor is benign or malignant because indicators of both are present. 2. Is the neoplasm
benign, malignant,
Unspecified Behavior in situ, or uncertain?
Choose codes that describe “Unspecified Behavior” when the physician’s notes do Uncertain is a patho-
not include any specific information regarding the nature of the tumor. Before choos- logic determination
ing one of these codes, please query the physician and make certain that a laboratory and is not the same
report is not available or on its way with the information you need. as unspecified.
3. If the neoplasm is
malignant, is this
YOU INTERPRET IT! the first diagnosis of
malignancy for this
patient? If so, this
What type of neoplasm is this: benign or malignant; primary or secondary?
is the primary site.
5. Metastatic lung cancer ___________ If not, this is a sec-
6. Melanoma ___________ ondary malignancy
7. Squamous cell carcinoma ___________ because it metas-
8. Pancreatic lymph gland neoplasm ___________ tasized from the
9. Adenoma ___________ primary.
CODING BITES
6.3 Reporting the Neoplastic Diagnosis
If you turn to the term
Once you have determined the anatomical location and type of tumor that has been Neoplasm in the Alpha-
documented, you will need to find a suggested code in the ICD-10-CM Neoplasm betic Index in the regu-
Table, found directly after the Alphabetic Index. lar alphabetic order, you
The Neoplasm Table is a seven-column table set in alphabetic order by the ana- will see the notation (see
tomical site (the part of the body where the tumor is located), shown in the first also Table of Neoplasms).
column. To the right of the first column, there are six columns across: Malignant
Malignant Malignant Uncertain Unspecified
Primary Secondary Ca in situ Benign Behavior Behavior
Neoplasm, neoplastic C80.1 C79.9 D09.9 D36.9 D48.9 D49.9
- abdomen, abdominal C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
-- cavity C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
-- organ C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
-- viscera C76.2 C79.8- D09.8 D36.7 D48.7 D49.89
-- wall — see also Neoplasm, C44.509 C79.2- D09.5 D23.5 D48.5 D49.2
abdomen, wall, skin
--- connective tissue C49.4 C79.8- — D21.4 D48.1 D49.2
--- skin C44.509
---- basal cell carcinoma C44.519 — — — — —
---- specified type NEC C44.599 — — — — —
---- squamous cell carcinoma C44.529 — — — — —
- abdominopelvic C76.8 C79.8- — D36.7 D48.7 D49.89
FIGURE 6-2 The Neoplasm Table, in part, showing codes for various abdominal neoplasms and abdominopelvic
neoplasms
EXAMPLE
Epiglottis
anterior aspect or surface
cartilage
free border (margin)
junctional region
posterior (laryngeal) surface
You can see in this one example that knowing the anatomical site of the tumor—
the epiglottis—is not enough information. You need to identify, from the documen-
tation, where the tumor is located on the epiglottis.
Once you have found the most specific match for the anatomical site identified
as the location of the tumor in the documentation, go back to the physician’s notes.
This time, look for the type of neoplasm in the diagnosis: Malignant Primary, Malig-
nant Secondary, Ca in situ, Benign, Uncertain, or Unspecified Behavior. Now, back
in the Neoplasm Table, read straight across to the right of the anatomical site line.
At the top of the page, each of these six columns has a title. Find which column has
the title that matches the diagnosis, and then go down until you hit the conjunction
of the anatomical site line and the type of neoplasm in question. This is your sug-
gested code.
In the Neoplasm Table, in the first column, find Abdomen, then indented below that the specific site -- viscera.
Then, across to the right you can see suggested codes for each type of tumor. For Elsa’s diagnosis, code D09.8
is suggested.
Next, turn in the Tabular List to check this code, and all of the notations. Because
the Neoplasm Table is a part of the Alphabetic Index, the rule still applies . . . never,
never report a code directly from here. You must check the suggested code in the
Tabular List, read the symbols and notations, read the complete code description and
all of the options, and check the Official Guidelines before you can confirm and report
a code.
ICD-10-CM
LET’S CODE IT! SCENARIO
Aaron Docker, a 65-year-old male, returns to see Dr. Cabrera. The results of his colonoscopy and laboratory tests on
the biopsy have come back. Dr. Cabrera confirms Aaron has a benign neoplasm of the ascending colon.
(continued)
Check the top of this subsection and the head of this chapter in ICD-10-CM. There are several NOTES at the
beginning of this chapter. Read carefully. Do any relate to Dr. Cabrera’s diagnosis of Aaron? No. Turn to the Offi-
cial Guidelines and read Section 1.c.2. There is nothing specifically applicable here, either.
Now you can report D12.2 for Aaron’s diagnosis with confidence.
Good coding!
EXAMPLE
Fran has been diagnosed with malignant melanoma on her right shoulder. She is
CODING BITES 21 weeks pregnant.
ICD-10-CM
LET’S CODE IT! SCENARIO
PATIENT: Roberta Wolfe
DATE OF CONSULTATION: 05/25/2018
CONSULTING PHYSICIAN: Oliver Cannon, MD
REQUESTING PHYSICIAN: Theresa Calabressi, MD
Thank you for referring the patient for medical oncology consultation.
PHYSICAL EXAMINATION
GENERAL: The patient is well developed, well nourished, in no acute distress.
VITAL SIGNS: Temperature 98.8, heart rate 63, blood pressure 110/81, weight 135.4 pounds, and height 57 inches.
SKIN: Skin clear. No visible rash, ecchymosis or petechia.
HEENT: Normocephalic. No scleral icterus. No mucosal lesions.
NECK: Supple without thyromegaly.
LYMPH NODES: No secondary neck, axillary, or inguinal nodes.
BREASTS: Without dominant mass bilaterally. There is moderate induration of approximately 2.8 cm across, underly-
ing the left upper outer quadrant incision. There is no fluctuance or erythema and patient denies significant tender-
ness to the area.
CHEST: Clear to auscultation and percussion.
CARDIAC: Regular rate and rhythm. No murmur, rub, or gallop.
ABDOMEN: Soft and nontender. No masses or hepatosplenomegaly.
RECTAL AND GENITAL: Deferred.
EXTREMITIES: No clubbing, cyanosis, or edema.
MUSCULOSKELETAL: No back tenderness. No bony or joint deformity.
NEUROLOGIC: Alert and oriented. Cranial nerves, sensory and motor system, and gait are normal.
IMPRESSION: Ductal carcinoma in situ, left breast, stage 0 (Tis N0 M0), ER positive, PR positive, status post lumpec-
tomy to negative surgical margins and has set up breast radiation. Overall prognosis is excellent with estimated risk
of local recurrence in the 5% range. Risk of systemic metastasis is negligible. Thus, adjuvant systemic therapy is not
warranted. She is, of course, at increased risk for second malignancy; thus tamoxifen chemoprevention would be a
reasonable option.
RECOMMENDATIONS AND PLAN: Diagnosis, prognosis, and management options were discussed in detail with
the patient and questions were answered. Tamoxifen chemoprevention was discussed in detail and she, at this time,
appears agreeable to initiation of therapy. I provided a prescription for tamoxifen 20 mg daily. On the assumption that
(continued)
she desires continuing oncologic follow-up, any follow-up appointment will be made in 6 months. Alternatively, if she
should decline tamoxifen chemoprevention or if her gynecologic physician, Dr. Calabressi, would be willing to prescribe
tamoxifen and provide continuing oncologic follow-up, then medical oncology follow-up will be on an as-needed basis.
Functional Activity
The functional activity of a neoplasm notes whether or not the tumor is causing the
secretion of hormones. This would be documented in the pathology report and may
need to be reported.
The first note in the Neoplasms chapter of ICD-10-CM helps you when certain
Functional Activity neoplasms require an additional code to report functional activity. This note states:
Glandular secretion in abnor-
mal quantity. “All neoplasms are classified in this chapter, whether they are functionally active
or not. An additional code from chapter 4 may be used to identify such func-
tional activity associated with any neoplasm.”
EXAMPLES
Catecholamine-producing malignant pheochromocytoma of thyroid
C73 Malignant neoplasm of thyroid gland
E27.5 Adrenomedullary hyperfunction
Ovarian carcinoma, right side, with hyperestrogenism
C56.1 Malignant neoplasm of right ovary
E28.0 Estrogen excess
Basophil adenoma of pituitary with Cushing’s disease
C75.1 Malignant neoplasm of pituitary gland
E24.0 Pituitary-dependent Cushing’s disease
Daniel Coleman, a 41-year-old male, came to see Dr. Lucano for a checkup. He was diagnosed with functioning thy-
roid carcinoma. Dr. Lucano reviews with Daniel the results of his latest thyroid scan, TSH and TRH stimulation tests,
and an ultrasonogram. Dr. Lucano informs Daniel that he has developed hyperthyroidism.
(continued)
Let’s Code It!
Dr. Lucano has diagnosed Daniel with functioning thyroid carcinoma and hyperthyroidism. The hyperthyroidism
is the functional activity of the thyroid carcinoma. Turn to the Alphabetic Index and look for
Carcinoma — see also Neoplasm, by site, malignant
Look down the list. Neither the term functioning nor the term thyroid is shown here, so you will need to turn to
the Neoplasm Table and find
Neoplasm, thyroid, malignant, primary C73
Let’s go to the Tabular List, to confirm:
C73 Malignant neoplasm of thyroid gland
Use additional code to identify any functional activity
This code is correct, and the ICD-10-CM book is telling you that you need an additional code to report the
functional activity. The only other detail Dr. Lucano included in her diagnostic statement is hyperthyroidism. Turn
back to the Alphabetic Index and look up hyperthyroidism:
Hyperthyroidism (latent) (preadult) (recurrent) E05.90
Turn to the Tabular List to confirm this suggested code.
E05 Thyrotoxicosis [hyperthyroidism]
The note mentions nothing that relates to this encounter for our patient, so read down the column to
review the choices for the required fourth character.
E05.9 Thyrotoxicosis unspecified
This matches the notes, so you are in the correct place. The symbol to the left of the code tells you that an addi-
tional character is required.
E05.90 Thyrotoxicosis unspecified without mention of thyrotoxic crisis or storm
Did you notice that this code is located in Chapter 4 and is describing the functional activity of the neo-
plasm? Great!
Check the top of this subsection and the head of this chapter in ICD-10-CM. A NOTE and an
notation are shown at the beginning of this chapter. Read carefully. Do any relate to Dr. Lucano’s diagnosis of
Daniel? Yes. Both chapters have NOTES regarding the coding of neoplasms and functional activity. Double-
check to make certain you are complying with these directions. Next, turn to the Official Guidelines and read
both Sections 1.c.2 and 1.c.4. There is nothing specifically applicable here either.
Now, you can report C73 and E05.90 for this encounter with Daniel with confidence.
Good coding!
Morphology (Histology)
The second note at the top of Chapter 2 relates to the classifications of neoplasms.
Topography Chapter 2 classifies neoplasms primarily by site (topography) with broad group-
The classification of neo- ings for behavior, malignant, in situ, benign, etc. The Table of Neoplasms should
plasms primarily by anatomi- be used to identify the correct topography code. In a few cases, such as for
cal site. malignant melanoma and certain neuroendocrine tumors, the morphology (histo-
Morphology
logic type) is included in the category and codes.
The study of the configura- In addition to the code for a neoplasm, you may be required to include a separate code
tion or structure of living with additional information about the tumor’s morphology. “Morphology of Neo-
organisms. plasms” is available as a separate book, the International Classification of Diseases
EXAMPLE
C05.8 Malignant neoplasm of overlapping sites of palate
C17.8 Malignant neoplasm of overlapping sites of small intestine
C57.8 Malignant neoplasm of overlapping sites of female genital organs
For cases in which the physician cannot identify a specific site, usually because
the malignancy has metastasized so dramatically, the code category C76 enables you
to report the malignancy by identifying only the section of the patient’s body, such as
head, abdomen, or lower limb.
EXAMPLE
C76.0 Malignant neoplasm of head, face, and neck
C76.51 Malignant neoplasm of right lower limb
EXAMPLE
Warren Spencer was admitted to McGraw Hospital for his third chemotherapy
infusion . . . treatment for the malignant neoplasm on the tail of his pancreas.
Z51.11 Encounter for antineoplastic chemotherapy
C25.2 Malignant neoplasm of tail of pancreas
Because Warren was admitted for the purpose of receiving his chemotherapy
treatment, his chemotherapy is reported first (the principal diagnosis code), fol-
lowed by the reason Warren needs this chemotherapy—pancreatic cancer.
EXAMPLE
GUIDANCE
Ronald Albertson was diagnosed with prostate cancer. It spread to his liver before
he was able to have surgery. The diagnosis codes, in this sequence, are
CONNECTION
Read the ICD-10-CM Offi-
C61 Malignant neoplasm of the prostate
cial Guidelines for Coding
C78.7 Secondary malignant neoplasm of liver, and intrahepatic bile duct
and Reporting, section
Dr. Isaacson removes Ronald’s prostate successfully. He no longer required any I. Conventions, General
treatment. The new codes are Coding Guidelines and
Chapter Specific Guide-
C78.7 Secondary malignant neoplasm of liver, and intrahepatic bile duct
lines, subsection C.
Z85.46 Personal history of malignant neoplasm, prostate
Chapter-Specific Coding
Once Ronald has the site of his primary malignancy removed, his prostate condi- Guidelines, chapter 2.
tion becomes “history.” The code for his secondary malignancy in the liver moves Neoplasms, subsection
up in order, but it will always be the secondary site at which Ronald developed a b. Treatment of second-
malignancy. ary site.
ICD-10-CM
YOU CODE IT! CASE STUDY
Frederick Westchester, a 53-year-old male, came to see Dr. Henner, his dermatologist, for an annual checkup.
Two years ago, Dr. Henner removed a malignant melanoma from Frederick’s left forearm. The malignancy was
totally removed, but he comes to see his physician for a checkup once a year.
Chapter Summary
In this chapter, you learned how to identify the key words in physicians’ documen-
tation and test results reports that can guide you toward the most accurate code
or codes. You learned the differences in the types of neoplasms and the proper
sequencing of codes. In addition, you reviewed the correct way to sequence the
codes when a patient has had a malignant site excised or been admitted for treat-
ment or a complication.
There have been, and continue to be, incredible advancements made in the treat-
ments of all types of neoplasms, as well as modifications to sociological behaviors
to help prevent the development of those insidious health concerns. As a professional
coding specialist, your ability to properly code the medical necessity for diagnostic
tests and therapeutic procedures used in the care of individuals can open many job
opportunities for you.
CHAPTER 6 REVIEW
Coding Neoplasms Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
where it originated.
a. uncertain b. Ca in situ c. benign d. secondary
4. LO 6.4 Morphology codes are used
a. for reimbursement. b. to describe treatment.
c. to describe the topography and histology of the neoplasm.
d. for identification of manifestations.
5. LO 6.5 At subsequent encounters after the surgical removal of a neoplasm and no additional treatment, the diag-
nosis code changes to a
a. personal history of malignancy code. b. malignancy code.
c. late effects code. d. co-morbidity code.
6. LO 6.5 When a patient is admitted for chemotherapy to treat a malignant neoplasm and that is the extent of treat-
ment, the first code listed is the code for
a. the primary malignancy. b. the secondary malignancy.
c. the chemotherapy. d. observation in a hospital.
7. LO 6.5 When a patient is admitted for treatment for a complication, such as anemia or dehydration, as the result
of a neoplastic treatment, the code for this complication should be listed
a. after the primary malignancy. b. first.
c. after the chemotherapy or radiation code. d. as a Z code.
8. LO 6.3 The correct code for a solitary plasmacytoma in remission is
a. C90.3 b. C90.30 c. C90.31 d. C90.32
9. LO 6.1 All of the following are common diagnostic tests for a suspected malignancy of the lung except
a. alpha-1 antitrypsin. b. CA-125 c. bronchoscopy. d. bone scan.
10. LO 6.2 When coding a neoplasm, you must know
a. the anatomical site. b. whether it is primary or secondary.
c. whether it is benign or malignant. d. all of these.
CHAPTER 6 REVIEW
only for anemia, the appropriate code for the malignancy is sequenced as the principal or _____ diagnosis fol-
lowed by the appropriate code for the anemia.
5. When the admission/encounter is for management of _____ due to the malignancy and only the dehydration is
being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the _____.
6. When a primary malignancy has been previously _____ or eradicated from its site and there is no further treat-
ment directed to that site and there is no evidence of any existing primary malignancy, a code from category
_____, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.
7. If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy, or radiation
therapy assign code _____, Encounter for antineoplastic radiation therapy, or _____, Encounter for antineoplastic
chemotherapy, or _____, Encounter for antineoplastic immunotherapy as the first-listed or principal diagnosis.
8. When the reason for admission/encounter is to determine the _____ of the malignancy or for a procedure such as
paracentesis or thoracentesis, the primary malignancy or appropriate metastatic site is designated as the principal
or first-listed diagnosis, even though chemotherapy or radiotherapy is administered.
9. If the reason for the encounter is for treatment of a primary malignancy, assign the malignancy as the _____
diagnosis.
10. When an encounter is for a _____ fracture due to a neoplasm, and the focus of treatment is the fracture, a code
from subcategory _____, Pathological fracture in neoplastic disease, should be sequenced _____, followed by the
code for the neoplasm.
ICD-10-CM
YOU CODE IT! Basics
First, identify the main term in the following diagno- 3. Papillary adenocarcinoma, intraductal, left
ses; then code the diagnosis. breast:
Example: Malignant primary neoplasm of lung, right a. main term: _____ b. diagnosis: _____
upper lobe: 4. Malignant carcinoid tumor of the colon:
a. main term: neoplasm b. diagnosis C34.11 a. main term: _____ b. diagnosis: _____
5. Hemangioma of intra-abdominal structures:
1. Acute megakaryocytic leukemia in relapse:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
6. Adenoma of the liver cell:
2. Benign neoplasm of uterine ligament, broad:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
CHAPTER 6 REVIEW
7. Follicular grade III lymphoma lymph nodes of 11. Malignant odontogenic tumor, upper jaw bone:
inguinal region and lower limbs: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 12. Secondary malignant neoplasm of vallecula:
8. Acral lentiginous, right heel melanoma: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 13. Carcinoma in situ neoplasm of left eyeball:
9. Lipoma of the kidney: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 14. Benign neoplasm of cerebrum peduncle:
10. Primary malignant neoplasm of right male breast, a. main term: _____ b. diagnosis: _____
upper-outer quadrant: 15. Myelofibrosis with myeloid metaplasia:
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. George Donmoyer, a 58-year-old male, presents today with a sore throat, persistent cough, and earache.
Dr. Selph completes an examination and appropriate tests. The blood-clotting parameters, the thyroid function
studies, as well as the tissue biopsy confirm a diagnosis of malignant neoplasm of the extrinsic larynx.
2. Monica Pressley, a 37-year-old female, comes to see Dr. Wheaten today because she has been having diarrhea
and abdominal cramping and states her heart feels like its quavering. The MRI scan confirms a diagnosis of
benign pancreatic islet cell adenoma.
3. Suber Wilson, a 57-year-old male, was diagnosed with a malignant neoplasm of the liver metastasized from
the prostate; both sites are being addressed in today’s encounter.
4. William Amerson, a 41-year-old male, comes in for his annual eye examination. Dr. Leviner notes a benign
right conjunctiva nevus.
5. Edward Bakersfield, a 43-year-old male, presents with shortness of breath, chest pain, and coughing up
blood. After a thorough examination, Dr. Benson notes stridor and orders an MRI scan. The results of the
MRI confirm the diagnosis of bronchial adenoma.
6. Elizabeth Conyers, a 56-year-old female, presents with unexplained weakness, weight loss, and dizziness.
Dr. Amos completes a thorough examination and does a work-up. The protein electrophoresis (SPEP) and
quantitative immunoglobulin results confirm the diagnosis of Waldenström’s macroglobulinemia.
7. James Buckholtz, a 3-year-old male, is brought in by his parents. Jimmy has lost his appetite and is los-
ing weight. Mrs. Buckholtz tells Dr. Ferguson that Jimmy’s gums bleed and he seems short of breath.
Dr. Ferguson notes splenomegaly and admits Jimmy to Weston Hospital. After reviewing the blood tests,
MRI scan, and bone marrow aspiration results, Jimmy is diagnosed with acute lymphoblastic leukemia.
8. Kelley Young, a 39-year-old female, presents to Dr. Clerk with the complaints of sudden blurred vision, dizzi-
ness, and numbness in her face. Kelley states she feels very weak and has headaches. Dr. Clerk admits Kelley
to the hospital. After reviewing the MRI scan, her hormone levels from the blood workup, and urine tests,
Kelley is diagnosed with a primary malignant neoplasm of the pituitary gland.
9. Ralph Bradley, a 36-year-old male, comes to see Dr. Harper because he is weak, losing weight, and vomiting
and has diarrhea with some blood showing. Ralph was diagnosed with HIV 3 years ago. Dr. Harper completes
an examination noting paleness, tachycardia, and tachypnea. Ralph is admitted to the hospital. The biopsied
tissue from an endoscopy confirms a diagnosis of Kaposi’s sarcoma of gastrointestinal organ.
ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ documentation from our health care facility,
Prader, Bracker, & Associates. These case studies are modeled on real patient encounters. Using the techniques
described in this chapter, carefully read through the case studies and determine the most accurate ICD-10-CM
code(s) and external cause code(s), if appropriate, for each case study.
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: KAHN, SERENA
ACCOUNT/EHR #: KAHNSE001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
HPI: This patient is being admitted to Weston Hospital for wide excision of a level 2 melanoma, right
side of the face. She was referred from Dr. Robinson. Patient states she has had the lesion forever.
Dr. Robinson found it disturbing and decided to take a biopsy; results, melanoma, level 2.
This lesion is located just anterior to the ear on the right zygomatic region; we should get a reasonably
good margin.
PAST MEDICAL HISTORY: Hypothyroidism and takes thyroid replacement medication.
CHAPTER 6 REVIEW
PAST SURGICAL HISTORY: The patient had carcinoma of the breast and underwent a left mastectomy in
2012. She had a hysterectomy for benign ovarian tumors in 2015.
ALLERGIES: NKA
SOCIAL HISTORY: Nonsmoker. Drinks alcohol socially.
FAMILY HISTORY: The patient’s sister is diabetic.
ROS: Negative.
PHYSICAL EXAMINATION: Ht: 5’6”, Wt: 142, T: 98.6, R: 18, BP 170/70. HEENT: Head is atraumatic, nor-
mocephalic; there is a pigmented lesion just anterior to the right ear over the zygomatic region, which
is slightly irregular in shape and different shades of brown. Biopsied site is noted and healing within
normal limits.
NECK: Negative.
CHEST: Clear and symmetrical
HEART: Regular rhythm, no murmurs
ABDOMEN: Soft, nontender, no masses or organomegaly
EXTREMITIES: No cyanosis, clubbing, or edema
NEUROLOGIC: Grossly intact
IMPRESSION: Melanoma of the right cheek, level 2
PLAN: Wide excision with flap advancement closure
ORP/pw D: 9/16/18 09:50:16 T: 9/18/18 12:55:01
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: DAWSON, WILSON
ACCOUNT/EHR #: DAWSWI001
DATE: 08/11/18
Attending Physician: Renee O. Bracker, MD
Pt is a 47-year-old male with left breast carcinoma, terminal stage, metastatic to the brain and liver.
Wilson is undergoing chemotherapy and has become dehydrated, showing signs of confusion and dis-
orientation. He is admitted to Weston Hospital for rehydration. Procalamine 3%, IV, 50mL/hr was given
for 12 hours. Patient stabilized and was discharged home with no other treatment.
ROB/pw D: 08/11/18 09:50:16 T: 08/13/18 12:55:01
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: BENTONN, VERNON
ACCOUNT/EHR #: BENTVE001
DATE: 09/16/18
Attending Physician: Oscar R. Prader, MD
PREOP DIAGNOSIS: Lower extremity ischemia with rest pain and gangrene of the right third toe, prob-
able atheroembolic disease to the right lower extremity.
POSTOP DIAGNOSIS: Atheroembolic disease to the right lower extremity.
PROCEDURE: Right, axillary femoral-femoral bypass utilizing an 8.0-mm ringed Gore-Tex axillary-to-
femoral graft and a 6.0-mm ringed Gore-Tex femoral cross-over graft, right third toe amputation.
OPERATIVE INDICATIONS: This is a 69-year-old male, presenting with local rectal carcinoma, recurrent,
with miliary metastases to the liver.
PATHOLOGICAL FINDINGS: Specimen: Third right toe consistent with ischemic necrosis.
PLAN/RECOMMENDATIONS: At this time, given known early liver metastases and extensive local
regional recurrence in the pelvis, I do not feel that further antineoplastic therapy will be of great benefit.
Specifically, patient has had chemotherapy up until September of this year and this disease has
recurred. In addition, he has a history of full radiotherapy to the pelvis.
Secondly, evidence-based medicine for recurrent colorectal cancer has shown that secondline chemo-
therapy has been of little to no value.
Pain management: I would recommend continuing his Duragesic patch, advise the addition of a low
dose of Elavil to help reduce neurogenic pain. Efforts will be made to improve mobility.
ORP/pw D: 9/16/18 09:50:16 T: 9/18/18 12:55:01
Blood
7.1 Reporting Blood Conditions Fluid pumped throughout
the body, carrying oxygen
As with any other part of the body, malfunction of the blood-forming organs, the and nutrients to the cells and
blood itself, or one of its components can result in problems affecting the entire body. wastes away from the cells.
Blood is actually a type of connective tissue consisting of red blood cells (RBCs), Red Blood Cells (RBCs)
white blood cells (WBCs), and platelets (PLTs)—all contained within liquid Cells within the blood that con-
plasma. It is the transportation system used to deliver oxygen (nourishment) for cells tain hemoglobin responsible
throughout the body and to carry carbon dioxide (cell waste products) so it can be for carrying oxygen to tissues;
expelled from the body. The average adult has between 5 and 6 liters of blood con- also known as erythrocytes.
stantly circulating throughout.
White Blood Cells (WBCs)
Cells within the blood that help
The Formation of Blood to protect the body from patho-
Blood is created in the red bone marrow (see Figure 7-1) during a series of steps called gens; also known as leukocytes.
hematopoiesis. During gestation, blood cells originate in the yolk sac from the mesen- Platelets (PLTs)
chyme (the section of the embryo in which blood, lymphatic vessels, bones, cartilage, Large cell fragments in the bone
and connective tissues form). As the fetus continues to develop, the liver, spleen, and marrow that function in clotting;
thymus begin to produce blood cells. Then, at about the 20th week of gestation, the red also known as thrombocytes.
bone marrow also begins to contribute to production. Once the baby is born, blood cell
formation becomes the responsibility of the red bone marrow only, specifically in the Plasma
The fluid part of the blood.
sternum, ribs, and vertebrae. Red bone marrow produces red blood cells (erythrocytes)
through a process called erythropoiesis and white blood cells (leukocytes) through a Hematopoiesis
process called leukopoiesis. The formation of blood cells.
Epiphyseal plates
Articular cartilage
Proximal
Spongy bone epiphysis
Space containing
red marrow
Compact bone
Medullary cavity
Yellow marrow
Periosteum Diaphysis
Distal
epiphysis
Femur
FIGURE 7-1 Bone marrow Source: David Shier et al., Hole’s Human Anatomy & Physiology, 12/e. ©2010
McGraw-Hill Education. Figure 7.2, p. 194. Used with permission.
How many blood cells does a healthy body need? Normal counts (per microliter of
blood) are
∙ Red blood cell count: 4 to 6 million cells.
Hemoglobin (hgb or Hgb) ∙ White blood cell count: 4,000 to 11,000 cells.
The part of the red blood cell
that carries oxygen. ∙ Platelet count: 150,000 to 400,000 platelets.
Too many cells or too few cells may indicate a problem. This is why one of the first
diagnostic tests run when a physician is trying to figure out what is wrong with the
patient is a complete blood count (CBC).
CODING BITES
While professional cod-
Blood Roles
ing specialists are not Blood’s primary job is transporting oxygen from the lungs and delivering it to tissue
permitted to diagnose cells throughout the body. As the oxygen passes from the lungs to the blood, it binds
a patient, understand- to the red blood cells and the hemoglobin (hgb or Hgb) inside those RBCs (see
ing these details from a Figure 7-2), so it can travel through the heart and out through the body via the arteries.
pathology or lab report After delivering the oxygen (O2) to the cells, the blood picks up carbon dioxide (CO2)
can support your under- and carries it back to the lungs for expulsion from the body.
standing of the docu-
mentation or explain Anemias
medical necessity—or
it may alert you, as the While many believe anemia is the result of an iron deficiency, this is only one cause
coder, to query the phy- of an abnormally low count of hemoglobin, hematocrit, and/or RBCs. The low volume
sician about missing or of RBCs reduces the amount of oxygen being transported, causing tissue hypoxia (low
ambiguous notes. levels of oxygen). Blood loss, lack of red blood cell production, and high rates of red
blood cell destruction are the three most common causes of anemia. Classic signs and
symptoms include tachycardia, dyspnea, and sometimes fatigue.
CO2 O2
Internal
respiration
Tissue cells
Nutritional anemia, reported with a code from the D50–D53 range, is caused by an
insufficient intake or absorption into the body of certain key nutrients. For example,
pernicious anemia is a genetic condition that causes dysfunction of the ileum so it
cannot properly absorb vitamin B12; iron deficiency anemia may be caused by a diet
lacking iron-rich foods.
EXAMPLES
D50.0 Iron deficiency anemia secondary to blood loss (chronic)
D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency
(pernicious (congenital) anemia)
D52.0 Dietary folate deficiency anemia
D53.2 Scorbutic anemia
Specific details about the underlying cause of the anemia are required to report
an accurate code.
CHAPTER 7 |
Hemolytic anemia (codes D55–D59) results from an insufficient number of healthy
red blood cells due to abnormal or premature destruction, thereby retarding the deliv-
ery of oxygen to the tissues throughout the body. This premature destruction of the
red blood cells may be caused by a genetic defect, an infection, or exposure to certain
toxins. Hemolytic anemia can also be caused by a mismatched blood transfusion.
EXAMPLES
D55.1 Anemia due to other disorders of glutathione metabolism
D56.4 Hereditary persistence of fetal hemoglobin
Sickle-cell disorders are included in this subsection. See upcoming section for
more on these diagnoses.
Aplastic anemia (code category D61) is the inability of the bone marrow to manu-
facture enough new blood cells required by the body for proper function.
EXAMPLES
D61.01 Constitutional (pure) red blood cell aplasia
D61.2 Aplastic anemia due to other external agents
Code first, if applicable, toxic effects of substances chiefly non-
medicinal as to source (T51-T65)
Sickle-cell disorders are included in this subsection. See upcoming section for
more on these diagnoses.
ICD-10-CM
LET’S CODE IT! SCENARIO
Carter McMannus, an 18-month-old male, was brought by his mother to Dr. Hampshire, a pediatrician specializing
in hematologic (blood) disorders. Dr. Hampshire noted jaundice, an enlarged spleen on palpation, and other signs
of failure to thrive. Dr. Hampshire recognized these signs and symptoms and confirmed with blood tests a diagnosis
of Cooley’s anemia.
CHAPTER 7 |
This form of SCD manifests when the patient inherits one sickle cell gene (“S”) from
one parent and the gene for beta thalassemia from the other parent.
Hematologic Malignancies
Both lymphomas and leukemias are included in this category. Leukemia is the pres-
ence of malignant cells within the bone marrow that produces blood cells (hema-
topoietic tissues), causing a reduction in the production of RBCs, WBCs, and
platelets. This anemic state makes the patient very susceptible to infections and
hemorrhaging.
There are several types of leukemia reported from several ICD-10-CM code
categories:
code category C92 Myeloid leukemia
code category C93 Monocytic leukemia
code category C94 Other leukemia of specified cell type
code category C95 Leukemia of unspecified cell type
The aspiration of bone marrow (known as a bone marrow biopsy) is typically taken
from the posterior superior iliac spine. This specimen is tested to quantify the white
blood cells. When a rapid reproduction of immature WBCs is evidenced, this confirms
a diagnosis of acute leukemia. In addition, the results of a differential leukocyte count
can specifically identify the type of cell and a lumbar puncture (aka spinal tap) can
reveal whether or not there is involvement of the meninges.
Vessel Collagen
injury fibers
Endothelial cells Platelet plug Blood clot Fibroblasts
(a) Blood vessel spasm (b) Platelet plug formation (c) Blood clotting (d) Fibrinolysis
Hemophilia
Hemophilia is a genetic mutation that establishes a deficiency lacking a protein (clot-
ting factor) in the blood necessary in the clotting process. Therefore, the patient’s
blood will not clot when needed to prevent hemorrhaging. The lower the quantity of
the clotting factor, the higher the probability that the patient might hemorrhage and
have it become life-threatening.
The majority of patients diagnosed with hemophilia have a deficiency of either fac-
tor VIII or factor IX.
Types of Hemophilia
There are four types of Hemophilia: A, B, C, and Acquired.
CHAPTER 7 |
Hemophilia C (Rosenthal’s Disease) . . . deficiency of clotting factor XI.
D68.1 Hereditary factor XI deficiency
(Hemophilia C)
Plasma thromboplastin antecedent [PTA} deficiency
(Rosenthal’s disease)
Acquired hemophilia (secondary hemophilia) . . . actually an autoimmune disease that
occurs when antibodies are created that mistakenly attack healthy tissue, specifically
clotting factor VIII. In these cases, the bleeding pattern is quite different from classi-
cal hemophilia. With acquired hemophilia, spontaneous hemorrhaging moves into the
muscles, skin, soft tissue, and mucous membranes. Bleeding episodes are frequently
acute and can become life-threatening.
D68.311 Acquired hemophilia
(Secondary hemophilia)
D68.4 Acquired coagulation factor deficiency
(Deficiency of coagulation factor due to liver disease)
(Deficiency of coagulation factor due to vitamin K deficiency)
ICD-10-CM
LET’S CODE IT! SCENARIO
Dr. Victor ordered a coagulation profile, including a partial thromboplastin time (PTT) and prothrombin time (PT), to
be done on Louis Langer prior to scheduling his surgery. The pathology report showed an abnormally prolonged
PTT. The surgery will be delayed until Dr. Victor can confirm the cause.
This is going to take some analysis. There is no listing under Abnormal for Test or Coagulation. Think about this.
What is the body’s reason for coagulation? To stop bleeding. Look for Blood or Bleeding. Did you find
Abnormal
Bleeding time R79.1
Now let’s go into the Tabular List to check this out. Remember, always begin reading at the three-character
category.
R79 Other abnormal findings of blood chemistry
ICD-10-CM
YOU CODE IT! CASE STUDY
Marissa Rubine, a 27-year-old female, came to see Dr. Post with complaints of bruising “suddenly appearing” on her
arms and legs. She states she had two recent episodes of epistaxis but denies any other bleeding. She denied tak-
ing any drugs or smoking, and states she has no risk factors for HIV. Physical examination revealed the spleen was
not palpable. Petechiae are noted scattered on her legs bilaterally.
Blood work results:
• hemoglobin (138 g/L)—normal
• white cell count—normal
• platelet count of 10 × 109/L—low (normal >150 × 109/L)
• erythrocyte sedimentation rate was 6 mm/h
• direct Coombs’ test—negative
• antinuclear—absent
• DNA-binding antibodies—absent
• rheumatoid factor—absent
Bone marrow aspiration: high number of normal megakaryocytes but otherwise normal
Dx: Immune thrombocytopenia purpura
She is placed on a short course of prednisolone.
(continued)
CHAPTER 7 |
Answer:
Did you determine this to be the correct code?
D69.3 Immune thrombocytopenic purpura
Great work!
Rh Factor
Another antigen that may or may not be present on the surface of a red blood cell is
Rh (Rhesus) Factor called Rh (Rhesus) factor. This is also an inherited situation.
An antigen located on the
red blood cell that produces ∙ An individual identified as Rh-negative does not have the Rh antigen.
immunogenic responses in ∙ An individual identified as Rh-positive does have the Rh antigen.
those individuals without it.
Because Rh factor is inherited, there is concern about additional complications if
an Rh-negative woman becomes pregnant with a Rh-positive fetus (the father is Rh-
positive). The good news is, often, the placenta will prevent the mother’s blood from
mixing with the baby’s blood, keeping both mother and baby safe.
EXAMPLE
O36.012 Maternal care for anti-D (Rh) antibodies, second trimester
Z31.82 Encounter for Rh incompatibility status
When the mother is seen so Rh compatibility can be determined and, if necessary,
dealt with, these codes are examples for reporting why the encounter was medi-
cally necessary.
When the mother is Rh-negative and her body makes antibodies to her fetus’s Rh-
positive blood cells, and the antibodies cross the placenta, it can result in Rh incom-
patibility, resulting in a large number of red blood cells in the fetus’s bloodstream that
may be destroyed, known as hemolytic disease of the newborn.
When proper precautions have not been taken while the baby is in utero, hydrops
fetalis due to hemolytic disease, also known as immune hydrops fetalis, can develop.
This is a known complication of Rh incompatibility and leads the neonate’s entire
body to swell, interfering with the proper function of body organs and systems.
P56.0 Hydrops fetalis due to isoimmunization
ICD-10-CM
LET’S CODE IT! SCENARIO
Neonate Alvarez, male, was born vaginally yesterday, 09/05/2018, at 15:25 without incident. Apgar scores: 1 min.—
10, 5 min.—10.
Four hours later, extensive purpura became visible on his abdomen, arms, and legs. No jaundice was observed.
His 29-year-old mother was given a blood transfusion for a postpartum hemorrhage after her first pregnancy 3
years earlier. The mother’s serum was found to contain IgG antibodies to the father’s platelets and to some of a
panel of platelets from normal, unrelated donors. These antibodies were typed as specific anti-HPA-1A antibodies
and had been incited by the previous pregnancy and transfusion.
These antibodies crossed the placenta, manifesting as alloimmune thrombocytopenia in this neonate. Addition-
ally, the neonate was found to have red cell incompatibility.
An exchange transfusion was performed to compensate for hemolysis. While it is unusual for an ABO incompat-
ibility to require an exchange transfusion, it worked. The neonate’s platelet count returned to normal quickly due to
free reactant antibody to platelets having been removed by the exchange.
We kept the neonate for observation for another 48 hours and then discharged him to his mother. She was told
to follow up in 1 week at the office or phone PRN.
Congenital means “present at birth,” and this condition was. However, the patient is a neonate, and the docu-
mentation states that this condition is due to the exchange with his mother. One thing to always remember: You
can always look up both terms in the Tabular List. So let’s do just that—take a look at them both:
D69.42 Congenital and hereditary thrombocytopenia purpura
P61.0 Transient neonatal thrombocytopenia
(continued)
CHAPTER 7 |
Let’s go back to the documentation. The physician notes that the baby contracted this condition as a result
of the transfusion his mother received previously. So, this is not actually inherited because it is not the result
of genetics; it is the result of circumstances. In addition, the treatment worked, so the baby no longer has the
blood problem, meaning the thrombocytopenia was temporary (transient). This points us toward the accurate
code of
P61.0 Transient neonatal thrombocytopenia
Check the top of this subsection as well as the head of this chapter in ICD-10-CM. You will find a NOTE, an
notation, and an notation at the beginning of this chapter. Read carefully. Do any relate to this
neonate’s diagnosis? No. Turn to the Official Guidelines and read Section 1.c.16. There is nothing specifically
applicable here either.
Now you can report P61.0 for baby boy Alvarez’s diagnosis with confidence.
Good work!
Transfusions
Due to the existence of antigens located on the surface of the patient’s red blood cells,
Transfusion any time a patient requires a transfusion of blood, it must be checked for compatibil-
The provision of one person’s ity with regard to type and Rh factor; otherwise, serious consequences could occur.
blood or plasma to another People with type O blood have neither antigen; anyone can accept this blood type.
individual. Individuals with type O blood are known as universal donors. So, a patient with type
A blood can receive a transfusion of only type A or type O blood. An individual with
type B blood can receive only type B or type O blood. Those with type AB blood
have both types of antigens, so they can receive type A blood, type B blood, or type O
blood. For this reason, they are known as universal recipients.
However, attention must still be paid to Rh factor compatibility. A patient with Rh-
positive blood can receive either Rh-positive or Rh-negative blood. However, patients
with Rh-negative blood should only receive Rh-negative blood. Because of these facts,
Agglutination in an emergency, when time cannot be taken to test the patient’s blood, Rh-negative
The process of red blood cells blood is used.
combining together in a mass The concern about both blood type and Rh factor compatibility arises from the
or lump. dangers that can happen when the correct antibodies and antigens are not in place.
Hemolysis For example, if an Rh-negative patient receives Rh-positive blood, anti-Rh antibodies
The destruction of red blood would be created, causing red blood cell agglutination and hemolysis. Agglutina-
cells, resulting in the release tion occurs when antibodies merge with antigens, causing red blood cells to clump
of hemoglobin into the together. Hemolysis is the process of cells rupturing—destroying red blood cells and
bloodstream. releasing hemoglobin into the bloodstream.
EXAMPLES
Complications of incompatibility can occur when a transfusion is administered
without a valid match to the patient. Because this condition is a complication of
the transfusion, this diagnosis is not reported from Chapter 3 in ICD-10-CM. As the
result of an External Cause, this is reported from the following code category:
T80 Complications following infusion, transfusion, and therapeutic
injection
T80.411A Rh incompatibility with delayed hemolytic transfusion reaction, ini-
tial encounter
T80.310A ABO incompatibility with acute hemolytic transfusion reaction
T80.A10A Non-ABO incompatibility with acute hemolytic transfusion reaction
Neutropenia
Neutropenia is a condition when the patient’s bone marrow produces an abnormally
low number of white blood cells. This may be an ineffective number of cells being
created or a loss of neutrophils at a rate faster than they can be replaced by new cells.
Remember that white blood cells fight infection. Once created in the bone marrow,
these cells are released into the bloodstream, so they can move about the body to
wherever they are needed.
A diagnosis of neutropenia may be a congenital condition, an adverse reaction to
chemotherapy or other medications, or a malfunction of the hematopoiesis process.
D70.0 Congenital agranulocytosis
(congenital neutropenia)
(Kostmann’s disease)
D70.1 Agranulocytosis secondary to cancer chemotherapy
Code also underlying neoplasm
Use additional code for adverse effect, if applicable, to identify
drug (T45.1X5)
D70.2 Other drug-induced agranulocytosis
Use additional code for adverse effect, if applicable, to identify
drug (T36-T50 with fifth or sixth character 5)
D70.3 Neutropenia due to infection
D70.4 Cyclic neutropenia
CHAPTER 7 |
Monocytic, Eosinophilic, and Basophilic Conditions
CODING BITES It is logical that the malfunctions causing too few, or too many, neutrophils and leuko-
Leukemia is a malig- cytes might also occur to the other types of white blood cells.
nancy of the white
blood cells, resulting in D72.818 Other decreased white blood cell count
the bone marrow pro- (Basophilic leukopenia)
ducing abnormal white (Eosinophilic leukopenia)
blood cells that do not (Monocytopenia)
function as needed. This D72.821 Monocytosis (symptomatic)
is why it is reported from D72.823 Leukemoid reaction
the Neoplasms section (Basophilic leukemoid reaction)
of ICD-10-CM, specifi- (Monocytic leukemoid reaction)
cally the C91–C95 code (Neutrophilic leukemoid reaction)
categories.
Splenic Dysfunction
The spleen is part of the lymphatic system, but it contains white blood cells that work
to fight infection. Damage to this organ can be caused by disease or trauma. Problems
with the spleen caused by pathogens are reported from this section of ICD-10-CM.
EXAMPLES
D73.0 Hyposplenism (Atrophy of spleen)
D73.3 Abscess of spleen
A pathogen or other disease that interferes with the proper function of the spleen
is reported from this chapter of ICD-10-CM.
EXAMPLES
S36.021A Major contusion of spleen, initial encounter
S36.030A Superficial (capsular) laceration of spleen, initial encounter
Even though the spleen is part of the immune system, traumatic injuries are still
reported from the appropriate chapter in ICD-10-CM.
When the problem with the spleen is a congenital anomaly, the appropriate codes
will be found in the Congenital Malformations, Deformations, and Chromosomal
Abnormalities chapter of ICD-10-CM.
EXAMPLES
Q89.01 Asplenia (congenital)
Q89.09 Congenital malformations of spleen
These codes explain that the malfunction of this organ (the spleen) occurred in utero.
PROCEDURES PERFORMED:
1. Two-view chest x-ray.
2. One unit of PRBC transfusion.
HOSPITAL COURSE: The patient is a very pleasant 54-year-old male with acute myelogenous leukemia who has
undergone three cycles of high-dose Ara-C. He was transferred here after he presented to an outside facility with a
1-day onset of fevers and chills. He had a measured temperature at the outside hospital at that time of 102 degrees.
He was transferred to this facility and admitted to the oncology service.
He was initially placed on cefepime, and blood cultures were drawn. All cultures throughout the course of his hos-
pitalization turned out to be negative. He, however, remained febrile for the majority of his hospitalization. Upon
presentation, he did complain of 1-day onset of profuse watery diarrhea that was extremely foul smelling. Of note, he
was on p.o. prophylactic Levaquin due to his neutropenia. He was also on prophylactic acyclovir. Due to his being on
antibiotics and history of diarrhea, a stool PCR was collected but resulted negative. Before the stool PCR resulted, he
was placed on Flagyl as empiric coverage for suspected C. diff colitis. After the stool PCR resulted negative, Flagyl
was discontinued.
During the short 24 hours when he was on Flagyl, he seemed to have defervesced, and his fever curve trended
down. However, after the Flagyl was discontinued, he started having worsened diarrhea and the fevers went back
up again. For this reason, a C. diff PCR was ordered and the Flagyl was resumed. The C. diff PCR was also negative.
Until that point, he remained on cefepime and the Flagyl was also decided to be continued since the patient seemed
to improve with it. The thinking was that he may have had some colitis that was not related to C. diff.
Six days into his hospitalization, he continued to have fever. At this juncture, vancomycin was added to see if this
would help. Repeat blood cultures were negative. Cultures were even drawn from the port that he had. There was
some discussion as to whether his fevers may have been caused by the cefepime. The cefepime was discontin-
ued. At this time, however, his fever curve had already started slightly trending down. Over the next 48 hours, he
remained afebrile.
The vancomycin and Flagyl were discontinued the day before discharge, and he remained afebrile that night. His
diarrhea had resolved over the last 4 to 5 days of his hospitalization and he received Imodium for this. The remainder
of his hospitalization was unremarkable and he felt well. Of note, he did complain of poor appetite. We advised him
to try to eat as much as he can and at the very least remain hydrated with Gatorade, and he understood that it may
take some time for his appetite to completely return to normal.
He did frequently have hypokalemia and hypomagnesemia. This was presumed to be secondary to the diarrhea.
Both of these electrolytes were replaced appropriately. However, even after the diarrhea resolved, he continued
to have hypokalemia despite replacement. He later notified us that this issue is not new and that he actually takes
potassium supplementation at home. He reported that he had p.o. potassium chloride at home and that he did not
need medication or a refill for this. He could not, however, recall the dosage. We do not know the etiology of his
(continued)
CHAPTER 7 |
hypokalemia as this was not worked up while he was inpatient due to again thinking that his hypokalemia was a
result of his diarrhea.
On the day of discharge, he was also instructed to resume his prophylactic Levaquin and acyclovir.
DISCHARGE MEDICATIONS:
1. Acyclovir 400 mg p.o. b.i.d.
2. HCTZ 25 mg p.o. daily.
3. Lopressor 25 mg p.o. b.i.d.
4. Pravastatin 10 mg p.o. at bedtime.
5. Norethindrone 5 mg p.o. daily.
6. Levaquin 500 mg p.o. daily.
7. Zofran 4 mg sublingually q.8 hours p.r.n. nausea.
8. Norco 5/325 one tablet p.o. q.4 hours p.r.n. pain.
FOLLOWUP APPOINTMENT: Dr. Constantine Revorsky in 1 week for followup for chemotherapy.
FOLLOWUP LABS AND STUDIES: CBC, CMP before appointment with Dr. Revorsky.
DISCHARGE DIET: Regular as tolerated.
DISCHARGE ACTIVITY: As tolerated.
Allergies
An allergy is actually an immune system false alarm, responding to something as if it
were a pathogen able to harm the body, when, in reality, it is not. In medical terminol-
ogy, this is known as a hypersensitivity reaction. These reactions are divided into four
classes. Classes I, II, and III are caused by antibodies, IgE or IgG, which are produced
by B cells in response to an allergen. Class IV reactions are caused by T cells. In these
cases, the T cells might turn traitor and cause damage to the body, or they may ignite
macrophages and eosinophils, which, in turn, may damage host cells.
Sarcoidosis
The specific etiology of sarcoidosis is still unknown; however, most researchers believe it
is a combination of a genetic susceptibility with a certain exposure to something that trig-
gers the immune system to release chemicals that are ineffective at combating inflamma-
tion. Instead, the cells clump together and become granulomas (tumors that result from an
ulcerated infection) situated within certain organs throughout the body, such as the lungs,
liver, or skin. This diagnosis is reported with a code from category D86 Sarcoidosis.
EXAMPLES
D86.0 Sarcoidosis of lung
D86.3 Sarcoidosis of skin
D86.84 Sarcoidosis pyelonephritis
As you can see from these three examples, you will need to know the specific
anatomical site of the sarcoidosis before you can determine an accurate code.
Wiskott-Aldrich Syndrome
When a patient suffers from Wiskott-Aldrich syndrome, this genetic mutation causes
white blood cells to malfunction, increasing the body’s susceptibility to inflammatory
diseases and other immunodeficiency disorders. Eczema, thrombocytopenia, and pyo-
genic infections often develop and put the patient at a higher-than-normal risk of autoim-
mune diseases. This condition is reported with code D82.0 Wiskott-Aldrich syndrome.
CHAPTER 7 |
ICD-10-CM
YOU CODE IT! CASE STUDY
Carol-Anne Nieman, a 41-year-old female, came in complaining of discomfort and tenderness under her arms and
in her neck. Dr. Rothenberg performed a physical exam, revealing swollen lymph nodes. Lab work showed she was
suffering with sarcoidosis of her lymph nodes.
CHAPTER 7 REVIEW
Coding Blood Conditions Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
CHAPTER 7 |
5. LO 7.1 Which type of anemia results from an insufficient number of healthy red blood cells due to abnormal or
CHAPTER 7 REVIEW
premature destruction?
a. aplastic anemia c. nutritional anemia
b. hemolytic anemia d. hemorrhagic anemia
6. LO 7.2 _____ is a low platelet count most often due to increased platelet destruction, decreased platelet produc-
tion, or malfunctioning platelets.
a. Pancytopenia c. Thrombocytopenia
b. Leukocytopenia d. Erythrocytopenia
7. LO 7.1 Donny Cobin, a 19-year-old male, has been diagnosed with sickle-cell thalassemia with acute chest syn-
drome. How would you code this?
a. D57.40 b. D57.411 c. D57.811 d. D57.812
8. LO 7.3 Antigens are _____ that sit on the surface of red blood cells.
a. proteins b. sugars c. markers d. chromosomes
9. LO 7.5 Typically, immunodeficiency disorders occur when _____ do not work properly.
a. T lymphocytes c. T or B lymphocytes
b. B lymphocytes d. None of these
10. LO 7.5 The genetic mutation causing white blood cells to malfunction, increasing the body’s susceptibility to
inflammatory diseases and other immunodeficiency disorders, is known as _____.
a. Clarke-Hadfield Syndrome c. Wiskott-Aldrich Syndrome
b. Heubner-Herter Syndrome d. Lennox-Gastaut Syndrome
ICD-10-CM
YOU CODE IT! Basics
First, identify the main term in the following diagnose; 2. Purpura fulminans:
then code the diagnosis. a. main term: _____ b. diagnosis: _____
Example: Posthemorrhagic anemia, chronic 3. Anemia due to vitamin B12 intrinsic factor
deficiency:
a. main term: anemia b. diagnosis D50.0
a. main term: _____ b. diagnosis: _____
1. Hemoglobin H disease:
a. main term: _____ b. diagnosis: _____
ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. James Abney, a 7-month-old male, is brought in by his parents to see Dr. Fay, his pediatrician. Dr. Fay notes
a temperature of 106 F, jaundice, and generalized weakness and admits James to Weston Hospital for a full
work-up. The CBC and Coombs’ test results confirm the diagnosis of favism anemia.
2. Sam Goodman, a 9-year-old male, presents today for a sports physical in order to play on his school baseball
team. Dr. Inabinet notes splenomegaly. The results from the CBC test and peripheral blood smear confirm a
diagnosis of Hb-C disease.
3. Arthur Hylton, a 45-year-old male, presents today with the complaint of general weakness and overall tiredness.
Arthur works for an industrial factory and has been exposed to a large quantity of benzene. Dr. Burger completes
an examination, noting an irregular heartbeat and hand tremors. Arthur is admitted to the hospital. The results of
the bone marrow biopsy confirm a diagnosis of aplastic anemia due to accidental poisoning by benzene.
4. Rosalyn Burkett, a 37-year-old female, presents today with the complaint of migraines and blurred vision.
After an examination and a review of the laboratory tests, Dr. Flick diagnoses Rosalyn with Lupus anticoagu-
lant syndrome.
5. Tilley Cabe, a 9-month-old female, is brought in to see Dr. Peterson, her pediatrician. Tilley has had a per-
sistent low-grade fever for 4 days that has not diminished. Dr. Peterson notes a temperature of 100.2 and
splenomegaly. Tilley is not thriving. Dr. Peterson admits her to the hospital. The laboratory results reveal
Tilley has a low natural killer cell activity and cytopenia, which confirm the diagnosis of hemophagocytic
lymphohistiocytosis (HLH).
6. Glenn Carballero, a 15-year-old male, presents today with the complaint of weakness and generalized muscu-
lar pains. Dr. Douglass notes an erythematous periorofacial macular rash. After a thorough examination and
laboratory tests are completed, Glenn is diagnosed with biotinidase deficiency.
7. Sadie Thompson, an 18-month-old female, was born with TAR syndrome (thrombocytopenia with absent
radius). Sadie is brought in today by her mother with the complaint of excessive bruising without significant
trauma. After an examination and the laboratory tests are completed, Dr. Dotson diagnosis Sadie with con-
genital thrombocytopenia purpura.
CHAPTER 7 |
CHAPTER 7 REVIEW
8. Victor Motts, a 6-month-old male, is brought in by his mother to see his pediatrician, Dr. Stewart. Victor
experienced a type of spasm. Dr. James notes skeletal abnormalities and cyanosis as well as some hearing
difficulties and admits him to Weston Hospital. A fluorescence in situ hybridization (FISH) blood test
confirms a diagnosis of Di George’s syndrome.
9. Lindsey Williams, a 33-year-old female, has not been feeling well and is seen by Dr. Goldburg, who notes
jaundice. Lindsey admits to feeling weak and being dizzy. Blood tests return a hemoglobin of 6.3 g/dL.
Lindsey is admitted to the hospital for a blood transfusion; while there, a peripheral blood smear was
performed that showed echinocytes, confirming a diagnosis of pyruvate kinase deficiency anemia.
10. Antonio Scott, a 47-year-old male, presents today with the complaint of a cough, runny nose, and a sore
throat. Dr. Benton completes an examination and reviews the results of the CBC test and diagnoses Stanley
with lymphocytopenia.
11. Ivory Presnell, a 75-year-old female, comes in today complaining of fever, chills, and night sweats. She says she
feels tired and has lost 5 lbs. within a week. Dr. Shirley notes nail clubbing and completes an in-house CBC test;
results: hemoglobin of 7.9 g/dL. Ivory is admitted to Weston Hospital, where a tissue biopsy is taken, returning
a positive reading for extra-pulmonary tuberculosis. Ivory is diagnosed with anemia due to tuberculosis.
12. Buddy Dent, a 59-year-old male with chronic kidney disease, stage 4, comes to see Dr. Wilberly complaining
of extreme weakness. Dr. Wilberly completes a full blood workup and notes the following results:
hemoglobin—8.2 g/dL, creatinine—52 mg/dL, and BUN—102 mg/dL. Buddy is diagnosed with anemia due
to chronic kidney disease and is scheduled for a transfusion.
13. Juanita Ilderton, a 41-year-old female, received a blood transfusion 12 hours ago; now she is experiencing
fever, chills, and dizziness. A direct Coombs’ test is performed, which confirms a diagnosis of acute Rh blood
transfusion incompatibility after a transfusion.
14. Richard Greene, 33-year-old male, comes to see Dr. Walter with the complaints of tiredness and weakness.
Dr. Walter completes bloodwork and a bone marrow biopsy. Richard is diagnosed with chronic lymphocytic,
B-cell type leukemia.
15. Billy Stevenson, a 10-year-old-male, is brought in by his father to see Dr. Loveichelle. Billy has developed
a cough and fever. Billy says he feels really tired. Mr. Stevenson also stated they can’t get Billy to eat.
Dr. Loveichelle completes an examination and an in-house CBC. Billy’s hemoglobin is 7.4 g/dL. Billy is
admitted to the hospital for a full workup. Once all the laboratory results have been reviewed, Billy is
diagnosed with hookworm anemia.
ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ documentation from our health care facility,
Prader, Bracker, & Associates. These case studies are modeled on real patient encounters. Using the techniques
described in this chapter, carefully read through the case studies and determine the most accurate ICD-10-CM
code(s) and external cause code(s), if appropriate, for each case study.
PATIENT: KRIESEL, BROOKE
ACCOUNT/EHR #: KRIEBR001
DATE: 09/23/18
CHAPTER 7 |
CHAPTER 7 REVIEW
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: FUENTES, ERIN
ACCOUNT/EHR #: FUENER001
DATE: 09/16/18
Attending Physician: Renee O. Bracker, MD
Pt is a 9-year-old female brought in by her parents to see Dr. Bracker. I last saw Erin 6 months ago, at
which time she was thriving. Erin has experienced several nosebleeds over the last week. After ques-
tioning Erin, she admits she gets tired easily and doesn’t feel much like eating.
PE: Ht: 52.5”, Wt: 60 lb., T: 101.2, R: 18, HR: 81, BP: 125/70. Dr. Bracker notes that Erin is having dif-
ficulty focusing and articulating. Weight loss of 3 lb. since last visit. A CBC is performed; results show a
hemoglobin of 6.8 g/dL. Erin is admitted.
CV: Normal S1, S2, regular.
Pulm: Unlabored respiration, clear, bilaterally.
Abd: Soft, nontender, nondistended, without organomegaly or mass.
Extr: Warm, well perfused, no edema, notable for several 3 cm ecchymoses on the forearms and thighs
bilaterally; in addition, there is a petechial rash over the ankles and feet bilaterally.
Neuro: Alert and oriented
Laboratory results:
Hemoglobin—6.7 g/dL
Platelet count—35 × 10/L
Leukocyte count–3.1 × 10/L
Neutrophil count—1.4 × 10/L
INR—1.5
PT—16.2
Bone marrow aspirate was performed—20% promyelocytes.
Dx: Acute promyelocytic leukemia (APL)
P: Chemotherapy with ATRA
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: FLOWERS, CATLYNNE
ACCOUNT/EHR #: FLOWCA001
DATE: 09/16/18
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: ARNOLD, CAMERON
ACCOUNT/EHR #: ARNOCA001
DATE: 08/11/18
Attending Physician: Oscar R. Prader, MD
Cameron Arnold, a 39-year-old female, comes in to see Dr. Prader with complaints of weakness and
several spontaneous nosebleeds that last approximately 10 minutes—10 days duration. She states that
she bruises easily without any injury—3 times in the last month alone—and her menstrual periods have
been notably heavier. Dr. White, the referring physician, asks that we rule out coagulopathy. PMH: non-
contributory. PFH: no history of family bleeding.
Preliminary laboratory results reveal a hemoglobin of 6.7 g/dL. The mean corpuscular volume (MCV) is
71 fl. PT and APTT are within normal range.
A von Willebrand factor antigen assay, a von Willebrand factor activity assay, and factor VIII measure-
ment were ordered; results confirm the diagnosis of von Willebrand disease.
CHAPTER 7 |
8
Key Terms
Coding Endocrine
Conditions
Learning Outcomes
Cushing’s Syndrome After completing this chapter, the student should be able to:
Diabetes Mellitus
(DM) LO 8.1 Identify the various disorders affecting the thyroid gland.
Dyslipidemia LO 8.2 Evaluate the details about a diabetes mellitus diagnosis to
Gestational Diabetes determine the correct code.
Mellitus (GDM) LO 8.3 Assess the relationship between diabetes mellitus and its
Hyperglycemia manifestations.
Hypoglycemia LO 8.4 Interpret the documentation related to the reporting of other
Hypoglycemics
Hypothyroidism endocrinologic diseases.
Parathyroid Glands LO 8.5 Identify the aspects of nutrition and weight required for accu-
Polydipsia rate code determination.
Polyuria LO 8.6 Analyze the details related to metabolic disorder diagnoses
Secondary Diabetes to determine the correct code.
Mellitus
Thyroid Gland
Type 1 Diabetes
Mellitus Remember, you need to follow along in
Type 2 Diabetes
Mellitus
ICD-10-CM
EXAMPLES
E03.1 Congenital hypothyroidism without goiter
E07.81 Sick-euthyroid syndrome
Parathyroid Glands
Four small glands situated
on the back of the thyroid
Parathyroid Glands
gland that secrete parathyroid In the posterior aspect of the thyroid gland are four partially embedded parathy-
hormone. roid glands. When stimulated by hypocalcemia (too little calcium in the blood), they
198
Pharynx
(posterior view)
Thyroid gland
Parathyroid
glands
Esophagus
produce parathyroid hormone (PTH). PTH works in the opposite way of how calcito-
nin (produced by the thyroid) works.
EXAMPLES
E20.1 Pseudohypoparathyroidism
E21.0 Primary hyperparathyroidism
Hypothyroidism (Adults)
Hypothyroidism is caused by an insufficient production of thyroid hormone (TH). Hypothyroidism
When a patient has hypothyroidism, the thyroid converts energy more slowly than A condition in which the thy-
normal, resulting in an otherwise unexplained weight gain and fatigue. In addition, roid converts energy more
hypercholesterolemia, unexplained increase in weight, forgetfulness, and even unusual slowly than normal, resulting
sensitivity to colder temperatures may be evidence of early signs of this condition. in an otherwise unexplained
weight gain and fatigue.
This might be the result of irradiation therapy, infection, Hashimoto’s disease
(chronic autoimmune thyroiditis), or pituitary failure to produce the required amount
of thyroid-stimulating hormone (TSH).
To confirm this diagnosis, radioimmunoassay and/or lab tests are performed to look
at the levels of TSH. Lab tests can identify the patient’s TSH levels; however, refer-
ence ranges may fluctuate depending upon the patient’s age and family history. Treat-
ment for hypothyroidism includes medication, such as levothyroxine, to replace TH.
EXAMPLES
E03.1 Congenital hypothyroidism without goiter
E03.2 Hypothyroidism due to medicaments and other exogenous
substances
ode first poisoning due to drug or toxin, if applicable (T36-T65
C
with fifth or sixth character 1-4 or 6)
Use additional code for adverse effect, if applicable, to identify
drug (T36-T50 with fifth or sixth character 5)
(continued)
CHAPTER 8 |
CODING BITES E03.3 Postinfectious hypothyroidism
If you recognize a As you can see, the underlying cause of the hypothyroidism is key to determining
patient’s condition from an accurate code.
a lab report, but the
physician did not docu-
ment a confirmed diag- Hyperthyroidism
nosis, you must query
the physician. You may Hyperthyroidism, also known as thyrotoxicosis, is a condition in which the thyroid
not code from the lab secretes too many hormones, more than the body needs to function properly. Inter-
report. estingly, hyperthyroidism is most often a manifestation of another disease, including
Graves’ disease or thyroiditis.
Signs and symptoms include unexplained weight loss, rapid heart rate, and sensitivity
to heat. Also, because the body systems are faster due to the excess of these hormones,
irritability, trouble sleeping, hand tremors, and mood swings may also be exhibited.
EXAMPLES
E05.00 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm
(Graves’ disease)
E05.11 Thyrotoxicosis with toxic single thyroid nodule with thyrotoxic crisis
or storm
E05.20 Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis
or storm
As you can see from these few examples, the term thyrotoxicosis is used by the
code descriptions, rather than the more common term hyperthyroidism.
Graves’ Disease
Graves’ disease (toxic diffuse goiter) is an autoimmune disorder. This malfunction of
the immune system creates an antibody called thyroid stimulating immunoglobulin
(TSI) that affixes itself to thyroid cells. TSI then accelerates the overproduction of the
thyroid hormone.
Thyroid Nodules
Thyroid nodules are adenomas, benign neoplasms that grow in the thyroid. These nod-
ules may stimulate the thyroid to become overactive. A toxic multinodular goiter is an
accumulation of several thyroid nodules multiplying the effects, and the quantity of
thyroid hormone that is overproduced.
Thyroiditis
Thyroiditis is an inflammation of the thyroid that causes thyroid hormone stored
within the thyroid gland to leak out. Initially, the leakage can be identified by
increased hormone levels showing in the blood. If the leak continues, this can cause
hyperthyroidism.
E06.0 Acute thyroiditis
(Abscess of thyroid)
(Pyogenic thyroiditis)
Use additional code (B95–B97) to identify infectious agent
E06.1 Subacute thyroiditis
(de Quervain thyroiditis)
(Giant cell thyroiditis)
: autoimmune thyroiditis (E06.3)
ICD-10-CM
LET’S CODE IT! SCENARIO
PATIENT: Angela Tanner
Preprocedural Diagnosis: Right thyroid tumor
Postprocedural Diagnosis: Benign tumor of right thyroid
Procedure: Isthmectomy, Right thyroidectomy
Surgeon: Samuel Rodriguez, MD
DESCRIPTION OF OPERATION: The patient was intubated with a Xomed nerve monitor endotracheal tube. The
neck was extended with a shoulder roll and a transverse cervical incision was made along the skin crease, leaning
to the right side. The skin incision was made and the platysma was divided. A superior flap was developed to the
thyroid notch and inferior flap to the sternal notch. Crossing jugular veins were ligated with 2-0 and 3-0 silk ties. The
strap muscles were separated in the midline. The right strap muscles were then lifted off of a markedly enlarged right
thyroid gland. The lateral border of the gland was identified. The middle thyroid vein and its branches were doubly
ligated with 3-0 silk ties and divided. The recurrent laryngeal nerve was identified at the base of the neck and we
traced this superiorly. The inferior thyroid vascular bundle was noted to be quite anterior to this. We doubly ligated
this with 2-0 silk ties and divided it as it entered the thyroid gland. The inferior right parathyroid gland was identified.
It was noted to be adherent to the thyroid gland. We separated the two glands and placed the right inferior parathy-
roid gland in the base of the neck. We then identified the superior pole of the right thyroid gland. The superior thyroid
vascular bundle was doubly ligated with 2-0 silk ties and divided. The right upper parathyroid gland was separated
from the thyroid gland. This was also adherent to the thyroid gland. We then mobilized the gland medially. A small
amount of thyroid tissue was left behind in the upper pole. The stump was doubly ligated with 2-0 silk ties and
divided. This allowed us to mobilize the thyroid gland medially, and we slowly separated the nerve from the posterior
surface of the thyroid gland. This nerve was adherent to the thyroid gland. The gland was left intact as we separated
the thyroid gland from it, and then we lifted the thyroid gland off of the trachea. Dissection was then carried beyond
the isthmus, and with the right thyroid gland in the isthmus lifted off of the trachea, we then clamped the medial
(continued)
CHAPTER 8 |
aspect of the right thyroid lobe and we then excised the specimen. The stump was then suture ligated with running
2-0 silk stitch. Specimen was sent for pathology, and on analysis, there was no evidence of a malignancy. The thy-
roid stump was inspected. No bleeding was noted. No bleeding was noted from the right upper or lower parathyroid
glands. The recurrent laryngeal nerve was noted to be functional throughout its course, and the inferior and superior
vascular bundles were noted to be hemostatic. With assurance of hemostasis, the strap muscles were closed with
running 4-0 Vicryls, platysma was closed with interrupted 4-0 Vicryls, and 5-0 Monocryls were used for subcuticular
skin closure. Local anesthesia was infiltrated. The patient tolerated the procedure well. Sponge and needle counts
were correct. Blood loss was minimal. The patient was extubated and taken to the recovery room in stable condition.
CHAPTER 8 |
∙ Frequent vaginal infections (females)
∙ Yeast infections (both males and females)
∙ Dry mouth
∙ Slow-healing sores or cuts
∙ Itchy skin, especially in the groin or vaginal area
Measures for detecting diabetes include a glucose tolerance test (GTT) and evaluation
of the results. Diabetes may be indicated by
∙ A casual plasma glucose value greater than or equal to 200 mg/dL
∙ A fasting plasma glucose level greater than or equal to 126 mg/dL
∙ A plasma glucose value in the 2-hour sample of the oral glucose tolerance test
greater than or equal to 200 mg/dL
(Note: Normal blood glucose levels are less than 110 mg/dL)
There are four types of diabetes mellitus:
Type 1 Diabetes Mellitus ∙ Type 1 DM: The malfunction of the pancreatic beta cells, resulting in no production
A sudden onset of insulin of insulin naturally, is the underlying cause of type 1 (juvenile) diabetes mellitus,
deficiency that may occur at although there is no documented known etiology for idiopathic DM. Therapeuti-
any age but most often arises cally, type 1 DM patients must administer insulin every day in addition to follow-
in childhood and adoles- ing specific diet and exercise programs. Implanted insulin pumps may be used for
cence; also known as insulin-
those requiring multiple dose regimens. This diagnosis will be reported from ICD-
dependent diabetes mellitus
(IDDM), juvenile diabetes,
10-CM code category E10 with additional characters required to identify specific
or type I. information about complications (manifestations).
∙ Type 2 DM: In type 2 patients, the pancreatic beta cells do produce insulin; however,
Type 2 Diabetes Mellitus
the glucose transport is ineffective, thereby failing to deliver the required amount
A form of diabetes mellitus
with a gradual onset that may
to the rest of the body. Type 2 diabetics often suffer pathologic effects, including
develop at any age but most increased body fat (obesity), especially when the individual does not exercise regu-
often occurs in adults over the larly. Family history of DM, co-morbidities of hypertension or dyslipidemia, or a
age of 40; also known as non- personal history of gestational DM will increase the likelihood of developing this
insulin-dependent diabetes condition. In addition, patients of African-American, Latino, or Native American
mellitus (NIDDM) or type II. heritage are found to have a high risk. Diet and exercise are the first level of treat-
ment and may resolve the condition. However, oral antidiabetic medications, such
Dyslipidemia
Abnormal lipoprotein
as sulfonylureas, may be prescribed to stimulate pancreatic beta cell function if diet
metabolism. and exercise fail to show sufficient improvement. Some type 2 DM patients require
the administration of insulin. A type 2 diagnosis will be reported from ICD-10-CM
code category E11 with additional characters required to identify specific informa-
tion about complications (manifestations).
Secondary Diabetes Mellitus ∙ Secondary DM: Certain drugs or chemicals can negatively affect the pancreatic
Diabetes caused by medica- beta cells and may prevent them from producing the required amount of insulin.
tion or another condition or Also, other diseases and conditions, such as Cushing’s syndrome, can cause the
disease. patient to develop diabetes mellitus. This diagnosis is reported from code category
E08 Diabetes mellitus due to underlying condition, E09 Drug or chemical induced
diabetes mellitus, or E13 Other specified diabetes mellitus; additional characters
are required to provide specific information about complications. The underlying
condition, drug, or chemical causing the secondary DM will be reported first, and
any codes required to identify specific manifestations will be reported following
the E08, E09, or E13 code.
Gestational Diabetes Mellitus
(GDM) ∙ Gestational DM (GDM): When a woman is pregnant, the weight gain, along with
Usually a temporary diabe- the higher levels of estrogen and the increase of placental hormones, may retard the
tes mellitus occurring during production of insulin. This is considered a temporary type of DM due to the fact
pregnancy; however, such that, typically, the problem with the pancreatic beta cells resolves itself after the
patients have an increased baby is delivered. Report this with a code from the ICD-10-CM code subcategory
risk of later developing type 2 O24.4 Gestational diabetes mellitus, with an additional character to report addi-
diabetes. tional details.
Neurologic Manifestations
Uncontrolled diabetes can cause damage to the patient’s nerves, causing diabetic
neuropathy—in particular, sensory diabetic neuropathy, or a lack of feeling. Sensory
diabetic neuropathy can be dangerous because the damaged nerves do not transmit
feelings of heat, cold, or pain. Such a patient might be burned or cut and not know it.
The injuries might become infected, causing additional health problems. In addition,
the nerve damage can retard healing, making additional complications more viable.
Renal Manifestations
Diabetic nephropathy develops due to the reduced control of blood sugar. Almost 30%
of diabetics develop diabetic nephropathy (kidney disease) or other kidney-related
problems, such as bladder infections and nerve damage to the bladder. The nephrons
within the kidneys thicken, and the scarring that forms results in leakage of albumin
(protein) into the urine. Quantitative lab tests examine the levels of albumin in the
patient’s urine (microalbuminuria), as well as other levels such as blood urea nitrogen
(BUN) and serum creatinine. Diabetic kidney disease can cause severe illness and
possibly death. Therefore, early diagnosis and treatment to prevent the progression of
the condition are important. Angiotensin-converting enzyme (ACE) inhibitors as well
as angiotensin receptor blockers (ARB) are considered the best medications in these
cases. A diagnosis of type 2 diabetic nephropathy is reported from ICD-10-CM sub-
category E11.2 Type 2 diabetes mellitus with kidney complications, with an additional
character to report a chronic or other condition.
You may need a second code to identify the exact nature of the renal complication,
such as the stage of the chronic kidney failure. Type 2 diabetes–related chronic kidney
disease may be reported with E11.22 Type 2 diabetes mellitus with diabetic chronic
kidney disease; diabetic nephropathy may be reported with E10.21 Type 1 diabetes
mellitus with diabetic nephropathy.
CHAPTER 8 |
Circulatory Manifestations
Peripheral vascular disease is another likely complication because diabetes mellitus
disturbs the blood flow, increasing the development of ulcers. It is estimated that as
many as 10% of diabetics develop foot ulcers. Gangrene, a condition by which necrosis
(tissue death) occurs as a result of lack of blood, is another relatively common mani-
festation. When gangrene is not caught early enough, the resulting treatment to stop
the spread of the necrosis is often amputation. You might report one of these diagnoses
with code E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral
angiopathy with gangrene or E11.51 Type 2 diabetes mellitus with diabetic peripheral
angiopathy without gangrene.
ICD-10-CM
LET’S CODE IT! SCENARIO
Brittany Hatthaway, a 53-year-old female, came to see Dr. DeRupo for her annual checkup. She is a type 1 insulin-
dependent diabetic and has been feeling fine. There are no diabetic-related manifestations noted.
GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I.
Conventions, General Coding Guidelines and Chapter Specific Guidelines,
subsection C. Chapter-Specific Coding Guidelines, chapter 4. Endocrine,
Nutritional, and Metabolic Diseases (E00–E89), subsection a.3) Diabetes
mellitus and the use of insulin and oral hypoglycemics and a.6)(a) Secondary
diabetes mellitus and the use of insulin or hypoglycemic drugs.
ICD-10-CM
YOU CODE IT! CASE STUDY
Alec Kustra, a 37-year-old male, was diagnosed with type 2 diabetes a year ago. Dr. Lockhart had prescribed tolbu-
tamide to stimulate his pancreatic insulin release. However, 6 months ago, he became concerned that the medica-
tion was not working and started Alec on a regime of insulin injections. Alec is here today for Dr. Lockhart to check
his insulin levels.
CHAPTER 8 |
8.3 Diabetes-Related Conditions
ICD-10-CM
LET’S CODE IT! SCENARIO
Jessica Gundersen, a 61-year-old female, has been feeling excessively tired and irritable. She tells Dr. Vickers
that she has felt edgy and nervous while experiencing cold sweats and trembling. Dr. Vickers performs a glucose-
screening test using a reagent strip, resulting in a reading of less than 45 mg/dL. He orders a lab test to confirm a
diagnosis of reactive hypoglycemia and provides Jessica with a diet to follow and a referral to a nutritionist.
Insulin Pumps
Technology has provided patients with an easier and more controlled manner by which
to get their insulin: an insulin pump. However, nothing is perfect, so there may be a
concern with the patient as a result of the insulin pump not working correctly.
Underdose of Insulin
It can be very dangerous for a patient to receive less than the proper amount of insulin,
as prescribed by the physician, on schedule. If that occurs and is the reason the physi-
cian is caring for the patient at the encounter, your first-listed code should be this:
ICD-10-CM
YOU CODE IT! CASE STUDY
Tori Anderson, a 19-year-old female, was diagnosed with type 1 diabetes 2 years ago. Starting college, Tori
kept forgetting to take her insulin as prescribed. She comes into the University Health Center because she feels
dizzy, weak, and confused. Dr. Griffith, the on-call physician, finds her to have poor skin turgor and dry mucous
membranes. He diagnoses her with dehydration caused by insulin deficiency and diabetes mellitus, type 1,
uncontrolled.
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically
necessary.
Answer:
CHAPTER 8 |
Overdose of Insulin
Patients with an insulin pump that malfunctions can dose with a higher quantity of
insulin than prescribed by the attending physician. For such a case, you will use the
following code (which is the same as the code for an underdose):
T85.614A Breakdown (mechanical) of insulin pump, initial encounter
Follow that code with a poisoning code, for example:
T38.3x1A Poisoning by insulin and oral hypoglycemic (antidiabetic) drugs,
accidental (unintentional), initial encounter
Follow that code with the appropriate diabetes mellitus code and any other appropri-
ate codes, including the codes identifying the reaction or conditions caused by the
overdose.
If the patient delivers a dose of insulin manually and suffers an overdose,
you will code it the same way you do any other poisoning, including the deter-
mination of the cause of the overdose (such as accident, attempted suicide, or
assault). Unless the health concern with the patient is an adverse reaction to the
insulin and not related to the actual dosage, you will not use the code reporting
therapeutic usage.
ICD-10-CM
YOU CODE IT! CASE STUDY
Roy Holvang, a 25-year-old male, comes to see Dr. Fletcher with complaints of extreme thirst and muscle weakness.
During examination, Dr. Fletcher identifies that Roy has poor tissue turgor, dry mucous membranes, and hypoten-
sion. UA results show urine of low osmolality at 75 mOsm/kg. Dr. Fletcher diagnoses Roy with diabetes insipidus and
prescribes vasopressin IM qid.
Good job!
Cushing’s Syndrome
Cushing’s syndrome is caused by excessive production of corticotropin (ACTH) in Cushing’s Syndrome
the hypothalamus and too much secretion from the adenohypophysis (pituitary gland). A condition resulting from the
This may be caused by a tumor in another organ affecting this process—possibly a hyperproduction of corticoste-
bronchogenic tumor or a malignant neoplasm of the pancreas. Approximately 30% of roids, most often caused by
such cases are the result of a benign neoplasm of the adrenal gland. an adrenal cortex tumor or a
Cushing’s syndrome may cause diabetes mellitus, hypokalemia (low potassium in tumor of the pituitary gland.
the blood), pathologic fractures, slow wound healing, hypertension, irritability, and
other conditions. Lab tests for plasma steroid levels measured by 24-hour urine sam-
ples can be used to confirm a diagnosis of Cushing’s syndrome. An adrenal tumor
can be seen on an ultrasound, CT scan, or angiography, while MRI and CT scans can
illuminate the presence of a pituitary tumor.
Administration of radiation therapy, drug therapy with a medication such as
aminoglutethimide, or surgery to remove the tumor can be successful to control or
reverse the effects of Cushing’s syndrome. ICD-10-CM code category E24 Cushing’s
syndrome requires an additional character to provide more specific information about
the condition.
EXAMPLES
E24.0 Pituitary-dependent Cushing’s disease
E24.2 Drug-induced Cushing’s disease
Use additional code for adverse effect, if applicable, to identify
drug (T36-T50 with fifth or sixth character 5)
E24.4 Alcohol-induced pseudo-Cushing’s disease CODING BITES
As you can see, you will need to abstract additional details related to the diagno- The postprocedural time
sis of Cushing’s disease in order to determine a specific code. frame is generally con-
sidered the time from
the surgical procedure’s
Postprocedural Endocrine System Complications conclusion until the
physician releases the
Due to the incredible connections between all aspects of the human body, there are patient from care. This
times when a procedure employed to treat one condition results in a malfunction else- typically aligns with the
where in the body. global period standard
Should a malfunction in the endocrine system be a documented postprocedural for the specific proce-
complication, you must report this using a designated code category: E89 Postproce- dure provided.
dural endocrine and metabolic complications and disorders, not elsewhere classified.
CHAPTER 8 |
EXAMPLES
E89.0 Postprocedural hypothyroidism
E89.3 Postprocedural hypopituitarism
E89.5 Postprocedural testicular hypofunction
These complications may be predictable. For example, it would be expected, after
the surgical removal of the patient’s thyroid, that hypothyroidism would develop.
However, this is not always the case.
CODING BITES
Remember, in earlier chapters you learned the difference between a manifestation
and a sequela. When a patient is diagnosed with a sequela of malnutrition or other
nutritional deficiency, report the condition (the sequela) first, followed by a code
from the E64 code category:
E64.0 Sequela of protein-calorie malnutrition
E64.1 Sequela of vitamin A deficiency
E64.2 Sequela of vitamin C deficiency
E64.3 Sequela of rickets
E64.8 Sequela of other nutritional deficiencies
ICD-10-CM
YOU CODE IT! CASE STUDY
Shakeia and Robert Malabwa just adopted Benjamin, a 3-year-old male, from an orphanage in Africa. They brought
him in to see Dr. D’Onofrio, a pediatrician, for this first American checkup. After reviewing what was available about
his history, and a complete physical examination, Dr. D’Onofrio diagnosed Ben with moderate protein-energy mal-
nutrition. They sat together and discussed a treatment plan and diet to help him improve. Lactose intolerance can
manifest, so he suggested that they avoid foods with lactose.
Obesity
The definitions of overweight, obese, and morbidly obese can get lost in societal
norms and self-perception. Of course, the health care industry has its own official
determinations of these conditions, further specified by reporting the patient’s body
mass index (BMI).
Overweight merely means weighing too much. This can be a reference to the indi-
vidual’s muscles, bones, fat, or fluid retention when calculated along with the person’s
height. This condition is calculated as a BMI of 25 to 29.9.
Obesity is a condition calculated as a body mass index of 30 to 38.9. Typically, a
person becomes obese when more calories are consumed than expended. While some
critics believe extra pounds are caused only by eating too much and not exercising
enough, the facts are that one’s genetics and current medications (including herbal
supplements) can also influence this condition.
Being diagnosed as obese is a true health condition that not only can result in self-
esteem problems and social anxiety but also may increase the risk of developing dia-
betes, heart disease, arthritis, stroke, and even certain malignancies.
Morbid obesity is diagnosed when a patient’s current overweight status increases
to the extent that it actually interferes with normal, daily activities. This condition is CODING BITES
calculated as a BMI over 39.
Several different types
of health care profes-
EXAMPLES sionals, such as a dieti-
code category E66 Overweight and obesity tian or a nutritionist,
may be involved in the
Use additional code to identify Body Mass Index (BMI) if known (Z68.-)
care of a patient deter-
E66.01 Morbid (severe) obesity due to excess calories mined to be overweight,
E66.09 Other obesity due to excess calories obese, or morbidly
E66.1 Drug-induced obesity obese. However, the
E66.2 Morbid (severe) obesity with alveolar hypoventilation first time this diagnosis
E66.3 Overweight code is reported, it may
E66.8 Other obesity be coded only from phy-
E66.9 Obesity, unspecified sician documentation.
CHAPTER 8 |
As you can see, ICD-10-CM reminds you to use an additional code to specify the
patient’s BMI.
Underweight
With all the discussion regarding how many people in the United States are over-
weight or clinically obese, the opposite—being underweight—can also cause health
concerns. Unlike the codes for overweight conditions, codes for reporting an abnormal
weight loss or underweight condition are listed in the Symptoms, Signs, and Abnor-
mal Clinical and Laboratory Findings section of ICD-10-CM. In certain cases, the
BMI will also need to be reported.
EXAMPLES
R63.4 Abnormal weight loss
R63.6 Underweight
se additional code to identify Body Mass Index (BMI) if
U
known (Z68.-)
CODING BITES
While you may see
issues of overweight When a patient is diagnosed with anorexia, you may need more information from
status accompany- the physician before determining the correct code.
ing diagnoses such as
diabetes mellitus or R63.0 Anorexia
hypertension, in cases (This is used when the cause of the anorexia has not been determined as organic [phys-
of underweight patients, iological] or nonorganic [psychological].)
be alert to initial or
additional diagnoses of F50.0- Anorexia nervosa
malnutrition. F50.2 Bulimia nervosa
F50.8- Other eating disorders
(continued)
CHAPTER 8 |
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
E66.01 Morbid (severe) obesity due to excess calories
E11.9 Type 2 diabetes mellitus without complications
I10 Essential (primary) hypertension
E78.5 Hyperlipidemia, unspecified
Z68.42 Body mass index [BMI] 45.0-49.9, adult
Cystic Fibrosis
Cystic fibrosis (CF) is a hereditary malfunction of the secretory glands. Many lay-
people think of this as a malfunction of the pulmonary system. However, as you can
see by the code descriptions, the effects of this genetic condition reach to other body
systems as well.
A defect in the CFTR gene affects the glands that produce mucus and sweat, result-
ing in the creation of thick, sticky mucus and very salty sweat. There are manifesta-
tions that can develop in the respiratory, digestive, and reproductive systems, as well
as other maladies.
E84.0 Cystic fibrosis with pulmonary manifestations
se additional code to identify any infectious organism present,
U
such as Pseudomonas (B96.5)
E84.11 Meconium ileus in cystic fibrosis
E84.19 Cystic fibrosis with other intestinal manifestations
E84.8 Cystic fibrosis with other manifestations
Other manifestations, reported with E84.8, include male neonates born without a vas
deferens or females who may have an overproduction of mucus blocking the cervix.
Dehydration may result due to the large loss of salt in the CF patient’s perspiration;
clubbing and low bone density may both occur later in life.
ICD-10-CM
YOU CODE IT! CASE STUDY
Rachel Ward brought her 3-year-old son Ethan to his pediatrician, Dr. Inger. She was very distressed because Ethan
had eruptions on his arms, legs, and face that appeared after he had spent the day at the beach. She had also
noticed that his urine appeared to be reddish in color. Dr. Inger examined Ethan and discovered that he had sple-
nomegaly (enlargement of the spleen). The blood test came back positive for hemolytic anemia. Both of these con-
ditions are signs of erythropoietic porphyria, also known as Gunther’s disease. Dr. Inger diagnosed Ethan with this
condition.
(continued)
CHAPTER 8 |
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
E80.0 Hereditary erythropoietic porphyria
Good job!
Lactose Intolerance
If you know anyone with a lactose intolerance, you understand how challenging this
can be to quality of life. While the symptoms of this condition evidence in the diges-
tive system, this is a metabolic disorder because a lactose intolerance develops after
the small intestine is unable to digest lactose due to abnormally low production of
lactase (also known as lactase deficiency).
As you have learned many times, while this sounds like a complete diagnostic state-
ment, you will need to abstract the type of lactase deficiency before you will be able to
determine the accurate code.
∙ Congenital lactase deficiency is an extremely rare, genetic disorder in which there
is a failure of the small intestine to produce any, or enough, of the lactase enzyme.
This diagnosis is reported with code E73.0 Congenital lactase deficiency.
∙ Secondary lactase deficiency manifests when an infection or disease causes the
small intestine to malfunction in this way. These cases can be reversed with success-
ful treatment of the underlying disease. This diagnosis is reported with code E73.1
Secondary lactase deficiency.
∙ Other lactose intolerance may be prompted by developmental lactase deficiency,
a short-term condition seen in premature neonates, or primary lactase deficiency
(lactase nonpersistence), the most frequently seen type of lactase deficiency. Typi-
cally, in these patients, the small intestine’s production of lactase begins to decline
around 2 years of age. Any of these diagnoses are reported with code E73.8 Other
lactose intolerance.
Chapter Summary
The glands of the endocrine system produce and release various types of hormones
that are used by numerous organs throughout the body—all a part of the function of a
healthy body. When a component of this system does not function properly, the harm
can cascade and reveal itself as signs and symptoms evident with other body systems,
such as the urinary system or reproductive system. Diabetes mellitus is probably the
most common of the conditions and diseases affecting the endocrine system. From the
hypothalamus of the brain to the genitals, every part of this system, like all of the oth-
ers that make up the human body, can malfunction or become diseased.
Testes (male)
Testosterone
Ovaries (female)
Estrogen
Progesterone
CHAPTER 8 |
CHAPTER 8 REVIEW
CHAPTER 8 REVIEW
CHAPTER 8 REVIEW
a. background. b. maculopathy. c. proliferative. d. neurologic.
4. LO 8.2 Gestational diabetes is a condition that can affect only an individual
a. over the age of 65. b. under the age of 4. c. who is pregnant. d. with hypertension.
5. LO 8.5 What are the correct codes for a patient with type 1 DM who is overweight and has been diagnosed with
Refsum’s disease?
a. E10.51, E66.00, G60.8
b. E11.9, E66.3, G60.2
c. E11.49, E66.01, G60.0
d. E10.9, E66.3, G60.1
6. LO 8.1 Amanda is being seen today for her hypothyroidism, which was induced when she took sulfonamide as
prescribed by her physician, initial encounter. What is/are the correct code(s) for this condition?
a. E03.2, T37.0X1A b. T37.0X5A, E03.2 c. E03.2, T37.0X5A d. T37.0X5A
7. LO 8.1 When a patient has _____, the thyroid converts energy more slowly than normal, resulting in an other-
wise unexplained weight gain and fatigue.
a. hypothroidism b. myxedema c. hyperthyroidism d. thyroidits
8. LO 8.4 Which of the following conditions is a disorder of water metabolism that is the result of an ADH
deficiency?
a. Type I DM b. Diabetes insipidus c. Secondary DM d. Gestational DM
9. LO 8.5 When the patient is diagnosed with obesity, his or her body mass will be between
a. 20 and 24.9 b. 25 and 29.9 c. 30 and 38.9 d. 40 and 45.0
10. LO 8.6 Which of the following is a metabolic diagnosis?
a. G6PD deficiency b. Mucopolysaccharidoses c. Hyperoxaluria d. All of these
1. The diabetes mellitus codes are _____ codes that include the type of diabetes mellitus, the _____ affected, and the
complications affecting that body system.
2. Assign as many codes from categories _____ as needed to identify all of the associated conditions that the patient
has.
3. The _____ of a patient is not the sole determining factor, though most type 1 diabetics develop the condition
before reaching _____.
4. If the _____ of diabetes mellitus is not documented in the medical record, the default is _____, type 2 diabetes
mellitus.
CHAPTER 8 |
5. An underdose of insulin due to an insulin pump failure should be assigned to a code from subcategory _____,
CHAPTER 8 REVIEW
Mechanical complication of other specified internal and external prosthetic devices, implants and grafts, that
specifies the type of pump malfunction, as the principal or first-listed code, followed by code _____, Underdosing
of insulin and oral hypoglycemic [antidiabetic] drugs.
6. The principal or first-listed code for an encounter due to an insulin pump malfunction resulting in an overdose of
insulin should also be _____, Mechanical complication of other specified internal and external prosthetic devices,
implants and grafts, followed by code _____, Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs,
accidental (unintentional).
7. Codes under categories _____, Diabetes mellitus due to underlying condition, _____, Drug or chemical induced
diabetes mellitus, and _____, Other specified diabetes mellitus, identify complications/manifestations associated
with secondary diabetes mellitus.
8. For patients who routinely use insulin or hypoglycemic drugs, code _____, Long-term (current) use of insulin, or
_____, Long term (current) use of oral hypoglycemic drugs should also be assigned.
9. Code Z79.4 should _____ be assigned if insulin is given _____ to bring a patient’s blood sugar under control dur-
ing an encounter.
10. For postpancreatectomy diabetes mellitus (lack of insulin due to the surgical removal of all or part of the pan-
creas), assign code _____, Postprocedural hypoinsulinemia.
2. LO 8.2 Explain the difference between diabetes mellitus type 1 and diabetes mellitus type 2; include the ICD-
10-CM category code for each.
3. LO 8.3 How would you code an overdose of insulin caused by a malfunction of an insulin pump?
4. LO 8.4 Explain Cushing’s syndrome, including the ICD-10-CM code category as well as an example of another
diagnosis that may result from having Cushing’s.
5. LO 8.6 What is cystic fibrosis and what gene is defective? Include an example of where manifestations can
appear.
ICD-10-CM
YOU CODE IT! Basics
First, identify the main term in the following diagno- 3. Abscess of the thyroid:
ses; then code the diagnosis. a. main term: _____ b. diagnosis: _____
Example: Diabetes mellitus, type 1, with dermatitis: 4. Type I glycogen storage disease:
a. main term: diabetes b. diagnosis E10.620 a. main term: _____ b. diagnosis: _____
1. Endemic hypothyroid cretinism: 5. Urea cycle metabolism disorder:
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
2. Diabetes mellitus with hyperglycemia: 6. Thyroid nodules with thyrotoxicosis:
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. Jason Peak, a 33-year-old male, comes to see Dr. James with the complaint that he is having difficulty sleep-
ing, is sweating a lot, and has diarrhea. Dr. James completes an examination and notes muscle weakness and
skin warmth with moistness. Dr. James also notes eyelid retraction with exophthalmos. Jason is diagnosed
with Graves’ disease.
2. Pauline Allyson, a 2-week-old female, is brought in by her mother to see her pediatrician, Dr. Goldburg.
Pauline is having feeding difficulties with vomiting. She also has diarrhea. Dr. Goldburg notes the child is
failing to thrive, as well as hepatosplenomegaly and abdominal distention. Pauline is admitted to the hos-
pital, where lab tests confirm the absence of lysosomal lipase acid (LIPA). Pauline is diagnosed with Wol-
man’s disease.
3. Joyce Meadows, a 42-year-old female, was found unconscious by her husband, George, who rushed his wife
to the nearest ED. Dr. Herald asked about her medical history and George said she was diagnosed with type
2 diabetes about 3 years ago. After lab work, Joyce is admitted in a diabetic hypoglycemic coma.
4. Richard Sullivan, a 12-year-old male, presents with the complaint of tiredness. Richard is accompanied by his
mother. Mrs. Sullivan tells Dr. Gilbert that Richard has been clumsy lately and seems confused. After a thor-
ough examination, Dr. Gilbert notes slight muscle stiffness and Kayser–Fleischer rings bilaterally. Richard is
admitted to Weston Hospital, where a liver biopsy confirmed the diagnosis of Wilson’s disease.
5. April Sundell, a 48-year-old female, presents today with the complaint of generally being “out of sorts” or
a feeling of uneasiness. Dr. Loveichelle notes muscle weakness and mild hyperventilation. The laboratory
results confirm the diagnosis of hyperkalemia.
6. Latoya Nexsen, a 61-year-old female with diabetes type 1, presents today with the complaint that her left
lower leg is cold and she has a sore that won’t heal. Dr. Benson notes gangrene in Latoya’s left extrem-
ity and admits her to Weston Hospital. After a thorough physical exam, lab workup, and an angiography,
Latoya is diagnosed with atherosclerosis and gangrene of the left lower extremity due to type 1 diabetes
mellitus.
CHAPTER 8 |
CHAPTER 8 REVIEW
7. Lee Summers, a 3-year-old male, is brought in by his parents for a checkup. The parents have no specific
concerns. Lee does have a history of ear infections and colds. Dr. Shirley, his pediatrician, notes a prominent
forehead, a flattened nose bridge, and a slightly enlarged tongue. Dr. Shirley completes a urine test, which
reveal the presence of mucopolysaccharides. Lee is admitted to the hospital, where further laboratory tests
confirm the diagnosis of Hunter’s syndrome.
8. Loretta Sims, a 14-year-old female, presents today with the complaint of abdominal bloating and cramps with
vomiting. Mrs. Sims, her mother, says this usually occurs shortly after Loretta has drunk milk or eaten yogurt.
Dr. Albany completes an examination and the hydrogen breath test confirms the diagnosis of primary lactose
intolerance.
9. Billy Siau, an 8-month-old male with a congenital cataract, was referred to an ophthalmologist by his pedia-
trician, Dr. Wilberly. Billy and his mother present today to discuss the results of Billy’s tests. Dr. Wilberly
also notes that Billy has hypotonia and below-normal reflexes. The ophthalmologist’s report confirms glau-
coma. Dr. Wilberly diagnoses Billy with Lowe’s syndrome.
10. Anita Kucherin, a 27-year-old female, is at 29 weeks gestation. This is Anita’s first baby and she has not felt
the baby move all day, so she presents to the ED. Anita was diagnosed with diabetes type 2 approximately
3 years ago. Anita states she has tried to keep her diabetes under control. Anita is admitted to the hospital
for observation.
11. James Bucklew, a 38-year-old male, presents for the results of the blood tests taken last week. Dr. Walter
documents central obesity, hypertension, decreased serum HDL cholesterol (fasting), elevated serum triglyc-
eride level (fasting), and pre-diabetes. James’s BMI is 35.4. Dr. Walter diagnoses James with Dysmetabolic
syndrome X.
12. Diana Gamble, a 56-year-old female, had her pancreas removed and is now experiencing headaches, blurred
vision, and weight loss. Diana admits she has not been taking her medications as prescribed. Dr. Caldwell
notes a blood sugar of 305 mg/dL postprandial and admits Diana. After a complete workup, Diana is diag-
nosed with postpancreatectomy hyperglycemia.
13. Mark Hennecy, a 32-year-old male, presents today with the complaints of feeling tired all the time, difficulty
concentrating, and abdominal pain. Dr. Mather notes mild jaundice. After a thorough examination and review
of the laboratory results, Mark is diagnosed with Gilbert’s syndrome.
14. Erica Lamotte, a 63-year-old female, has been diagnosed with insulin-dependent (type 1) diabetic nephropa-
thy and chronic renal failure, stage 4. She is now requiring regular dialysis treatments.
15. Sue Pittman, a 46-year-old female, presents today with the complaints of tiredness and numbness. Sue was
diagnosed with hypertension 2 years ago. Dr. Charmers notes muscle weakness with slight paralysis. Sue is
admitted to the hospital, where blood tests reveal a high level of calcium. After a complete workup, Sue is
diagnosed with familial aldosteronism, type I.
ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ documentation from our health care facility,
Prader, Bracker, & Associates. These case studies are modeled on real patient encounters. Using the techniques
described in this chapter, carefully read through the case studies and determine the most accurate ICD-10-CM
code(s) and external cause code(s), if appropriate, for each case study.
CHAPTER 8 |
CHAPTER 8 REVIEW
CHAPTER 8 |
9 Coding Mental,
Behavioral, and
Neurological Disorders
Key Terms Learning Outcomes
Abuse After completing this chapter, the student should be able to:
Acute
Anxiety LO 9.1 Determine underlying conditions that affect mental health.
Behavioral LO 9.2 Distinguish mood and nonmood disorders.
Disturbance LO 9.3 Apply the guidelines for reporting nonpsychotic mental
Chronic conditions.
Dependence LO 9.4 Identify conditions affecting the central nervous system.
Depressive LO 9.5 Interpret details regarding peripheral nervous system
Manic
Phobia conditions into accurate codes.
Schizophrenia LO 9.6 Assess the diagnosis of pain and report it with accurate codes.
Somatoform Disorder
Use
228
Dementia is included in this subsection of the chapter on mental and behavioral dis-
orders in ICD-10-CM. This diagnosis can be identified by evidence of both neurologic
and psychological signs and symptoms, such as differences in personality, altered
thoughts and feelings, and behavioral changes.
When it comes to reporting diagnoses for mental disorders that are manifestations
of physiological conditions, you need to identify from the documentation the specific
known etiology in cerebral disease, brain injury, or other insult leading to this cerebral
dysfunction.
Vascular Dementia
A patient may develop vascular dementia after having experienced an infarction of
the brain that is known to be a manifestation of a previously existing vascular disease.
In ICD-10-CM, code category F01 also includes a diagnosis of hypertensive cerebro-
vascular disease as well as arteriosclerotic dementia. A cerebrovascular disease and
ischemic or hemorrhagic brain injury can often result in cognitive impairment known
as vascular dementia.
EXAMPLE
At the code category F01, you can see the definition, along with some important
notations:
F01 Vascular dementia
Vascular dementia as a result of infarction of the brain due to vascular disease,
including hypertensive cerebrovascular disease.
arteriosclerotic dementia
Code first the underlying physiological condition or sequelae of cerebrovas-
cular disease.
EXAMPLES
F01.50 Vascular dementia without behavioral disturbance
F01.51 Vascular dementia with behavior disturbance
Use additional code, if applicable, to identify wandering in vascular demen-
tia (Z91.83)
As you read down this code category listing, you can see that, in addition to identi-
fying the underlying physiological condition, you will also need to identify whether or
not the patient is documented as having behavioral disturbance. If so, has the patient Behavioral Disturbance
also been documented as having episodes of “wandering”? These details will guide A type of common behavior
you toward the correct code or codes to accurately report this patient’s condition. that includes mood disorders
(such as depression, apathy,
Amnestic Disorder Due to Known Physiological Condition and euphoria), sleep disorders
(such as insomnia and hyper-
Reporting amnestic disorder due to known physiological condition will take you to somnia), psychotic symptoms
code category F04 Amnestic disorder, with the additional descriptions of Korsakov’s (such as delusions and hallu-
psychosis and Syndrome, nonalcoholic. You can see that the Code first underlying cinations), and agitation (such
condition notation requires that the underlying condition be physiological, thereby as pacing, wandering, and
eliminating any psychological underlying conditions from qualifying for this code. aggression).
CHAPTER 9 |
Note that ICD-10-CM reporting of this diagnosis has an notation. An
notation identifies other diagnoses that are mutually exclusive to the diag-
nosis above the notation (in this case, F04). This is the absolute statement that the
excluded code can never be used at the same time because the two conditions cannot
occur together in one patient at one time.
amnesia NOS (R41.3)
anterograde amnesia (R41.1)
dissociative amnesia (F44.0)
retrograde amnesia (R41.2)
F04 also carries an notation identifying several amnestic disorders that are
not included in F04, therefore requiring either a different code or an additional code:
alcohol-induced or unspecified Korsakov’s syndrome (F10.26,
F10.96)
Korsakov’s syndrome induced by other psychoactive substances
(F13.26, F13.96, F19.16, F19.26, F19.96)
EXAMPLES
F06.30 Mood disorder due to known physiological condition, unspecified
F06.31 Mood disorder due to known physiological condition, with depres-
sive features
F06.32 Mood disorder due to known physiological condition, with major
depressive-like episode
F06.33 Mood disorder due to known physiological condition, with manic
features
F06.34 Mood disorder due to known physiological condition, with mixed
features
As you abstract documentation related to a mood disorder, you must be alert to
mentions of any additional signs and symptoms.
Depressive features include decrease in interest in hobbies or favorite activi-
ties, hypersomnia, or insomnia virtually every day.
Manic features are identified by documented episodes of intensely disruptive
and exaggerated behaviors of heightened mood.
Mixed features refer to documented and regular (virtually every day within 1 week)
meeting of the criteria of both depressive and manic features. Also known as
roller-coastering.
EXAMPLE
F07.0 Personality change due to known physiological condition (Fron-
tal lobe syndrome) (Organic pseudopsychopathic personality)
(Postleucotomy syndrome)
Code first underlying physiological condition
mild cognitive impairment (G31.84)
postconcussional syndrome (F07.81)
postencephalitic syndrome (F07.89)
signs and symptoms involving emotional state (R45.-)
specific personality disorder (F60.-)
ICD-10-CM
LET’S CODE IT! SCENARIO
Eboni O’Neal, a 37-year-old female, came with her husband, Carl, to see Dr. Annikah, a psychiatrist, on a referral
from her regular physician. She complains about unusual fatigue and problems remembering things. Her husband
has complained that she has been unusually irritable. Carl stated that he has found Eboni wandering the neighbor-
hood several times over the last few weeks. Eboni admitted to being on a new dairy-free, animal product–free diet.
After a complete physical examination, Dr. Annikah performed a complete psychology exam and ordered blood
work, which confirmed his diagnosis of dementia caused by vitamin B12 deficiency.
(continued)
CHAPTER 9 |
Let’s Code It!
Dr. Annikah diagnosed Eboni with dementia caused by vitamin B12 deficiency. You also read that she did have
incidents of wandering. When you turn to the Alphabetic Index, you see
Dementia (degenerative (primary)) (old age) (persisting) F03.90
In (due to)
Vitamin B12 deficiency E53.8 [F02.80]
With behavioral disturbance E53.8 [F02.81]
You should remember from the chapter The Coding Process that the second code, in italicized brackets, tells you
that you will need two codes for this diagnosis and in which order to report these two codes. Turn to the Tabular
List to read the first suggested code:
E53 Deficiency of other B group vitamins
Read down and review all of the fourth-character choices to determine the most accurate code:
E53.8 Deficiency of other specified B group vitamins
Next, you know that you will need to follow this code with a code from F02—either F02.80 or F02.81. Let’s take
a look at both codes and see what exactly is meant by behavioral disturbance:
F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance
Did you notice the notation beneath F02.81?
Use additional code, if applicable, to identify wandering in dementia in conditions classified elsewhere
(Z91.83)
Aha! This tells you that “wandering” is considered a behavioral disturbance. Dr. Annikah documented that Eboni
had been wandering, so you will need one more code:
Z91.83 Wandering in conditions classified elsewhere
Good job! You determined the three codes required to accurately report Dr. Annikah’s encounter with Eboni.
Check the top of all three chapters in ICD-10-CM. Check them all for an notation, a Use additional
code note, an notation, and an notation. Read carefully. Do any relate to Dr. Annikah’s diag-
nosis of Eboni? No. Turn to the Official Guidelines and read Section 1.c.4, 1.c.5, and 1.c.21. There is nothing
specifically applicable here either.
Now you can report these three codes with confidence.
E53.8 Deficiency of other specified B group vitamins
F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance
Z91.83 Wandering in conditions classified elsewhere
Good coding!
The first thing you might notice about these codes is that details are required from
the documentation to identify use of, abuse of, or dependence on the psychoactive
substance. Also, there are codes for specifically reporting the use of alcohol and drugs
that enable the tracking of the patient’s behavior, which often will ultimately have a
negative impact on his or her health. These details can give providers and researchers
a great deal of useful information as they look for better ways to care for patients and
their maladies.
What is the clinical difference between these terms?
Use: Consumption of a substance without significant clinical manifestations. Use
Abuse: Ongoing, regular consumption of a substance with resulting clinical Occasional consumption of
a substance without clinical
manifestations.
manifestations.
Dependence: Ongoing, regular consumption of a substance with resulting signifi-
cant clinical manifestations and a dramatic decrease in the effect of the substance Abuse
with continued use, therefore requiring an increased quantity of the substance to Regular consumption of a sub-
achieve intoxication. In addition, the patient will require continued consumption of stance with manifestations.
the substance to avoid withdrawal symptoms and other serious behavioral effects, Dependence
occurring at any time in the same 12-month period. Ongoing, regular consump-
tion of a substance with
All of these codes require additional characters to identify details from the documen-
resulting significant clinical
tation about manifestations and co-morbidities. Let’s take alcohol abuse as an exam- manifestations, and a dramatic
ple of what details you may need to abstract from the clinical documentation. decrease in the effect of the
substance with continued
use, therefore requiring an
EXAMPLES increased quantity of the sub-
F10.1 Alcohol abuse stance to achieve intoxication.
F10.10 Alcohol abuse, uncomplicated
F10.120 Alcohol abuse with intoxication, uncomplicated
F10.121 Alcohol abuse with intoxication delirium
F10.14 Alcohol abuse with alcohol-induced mood disorder
F10.150 Alcohol abuse with alcohol-induced psychotic disorder with delusions
F10.180 Alcohol abuse with alcohol-induced anxiety disorder
F10.181 Alcohol abuse with alcohol-induced sexual dysfunction
F10.182 Alcohol abuse with alcohol-induced sleep disorder
F10.188 Alcohol abuse with other alcohol-induced disorder
CHAPTER 9 |
As you can see, ICD-10-CM requires an understanding of the psychological and
behavioral impacts of the use, abuse, or dependence. Signs, symptoms, manifestations,
GUIDANCE and co-morbidities such as delirium, mood disorder, and hallucinations will be reported
with one combination code from this subsection.
CONNECTION
In the subcategories for alcohol use and dependence, you will also find codes
Read the ICD-10-CM including a state of withdrawal, again providing one combination code to report this
Official Guidelines for condition.
Coding and Reporting,
section I. Conven-
tions, General Coding EXAMPLE
Guidelines and Chapter
F10.231 Alcohol dependence with withdrawal delirium
Specific Guidelines,
subsection C. Chapter-
Specific Coding Guide-
The extended descriptions and combination-code choices include those codes used
lines, chapter 5. Men-
to report the use of other nontherapeutic substances as well. Take, for example, caf-
tal, Behavioral, and
feine use, hallucinogens, and inhalant use.
Neurodevelopmental
disorders (F01–F99),
subsection b. Mental
and behavioral dis- EXAMPLES
orders due to psy- F15.120 Other stimulant abuse with intoxication, uncomplicated
choactive substance F15.920 Other stimulant use, unspecified with intoxication, uncomplicated
use, 2) Psychoactive F16.1- Hallucinogen abuse
substance use, abuse F16.2- Hallucinogen dependence
and dependence and F16.9- Hallucinogen use, unspecified
3) Psychoactive sub- F18.1- Inhalant abuse
stance use. F18.9- Inhalant use, unspecified
ICD-10-CM code descriptions separate inhalant abuse and dependence into its
own specific code category (F18), and caffeine (yes, this is considered a substance)
is included in the “Other” code category, now combined with amphetamine-related
disorders.
As with the previous code categories in this subsection, the additional characters
required for these ICD-10-CM codes include abstracting documentation for details
on accompanying intoxication, delirium, perceptual disturbance, mood disorder, psy-
Anxiety chotic disorder with delusions or hallucinations, anxiety disorder, flashbacks, and
The feelings of apprehension other manifestations.
and fear, sometimes mani- One more addition to this subsection of ICD-10-CM’s Chapter 5, Mental, Behavioral,
fested with physical manifes- and Neurodevelopmental disorders, is code category F17 Nicotine dependence.
tations such as sweating and The note reminds you that nicotine dependence is not the same d iagnosis
palpitations.
as tobacco use (Z72.0) or history of tobacco dependence (Z87.891). Therefore, the
documentation will need to specifically discern between tobacco use and nicotine
dependence.
EXAMPLES
F17.210 Nicotine dependence, cigarettes, uncomplicated
F17.211 Nicotine dependence, cigarettes, in remission
F17.213 Nicotine dependence, cigarettes, with withdrawal
F17.218 Nicotine dependence, cigarettes, with other nicotine-induced
disorders
F17.220 Nicotine dependence, chewing tobacco, uncomplicated
F17.221 Nicotine dependence, chewing tobacco, in remission
The bottom line is that ICD-10-CM has organized these codes in a logical and effi-
cient order and provided you with many combination codes.
ICD-10-CM
LET’S CODE IT! SCENARIO
Jason Hurst, a 63-year-old male, has been a salesman for the last 30 years. He travels throughout the Midwest
and has had a less-than-stellar career. Very often, he has come close to being fired for not making quota, but his
supervisor takes pity on him because he has been with the company for so long. He is at the medical office today by
court order after being arrested for his third DUI in the last 6 months. Seeking treatment is part of his plea deal so he
doesn’t lose his driver’s license. He needs to be able to drive to see his customers.
Jason states he has tried to stop drinking but can’t because it is part of his job. He must take customers out for
a drink. And when he is back at his office, all the guys go out for drinks after work. When he is on the road, he finds
nothing to do in the motel at night, so he drinks away the loneliness. The one time he tried to quit drinking, he got
really sick. The only thing that helped him feel better was a little “hair of the dog.”
He states that at times he is very sad and hopeless, while other times, especially when he is with clients, he is the
life of the party and knows some of the best jokes. He pleads for help and begins to cry.
Dr. Walkowicz diagnoses Jason with alcohol dependence with alcohol-induced mood disorder.
CHAPTER 9 |
In Remission
GUIDANCE
The determination of whether a patient who has been diagnosed with a mental or
CONNECTION behavioral disorder due to the use of a psychoactive substance is in remission is in the
Read the ICD-10-CM judgment of the attending physician. Therefore, report the appropriate character iden-
Official Guidelines for tifying the state of remission only when the physician has specifically documented
Coding and Reporting, this condition.
section I. Conven-
tions, General Coding
Guidelines and Chapter EXAMPLES
Specific Guidelines, F11.21 Opioid dependence, in remission
subsection C. Chapter- F14.21 Cocaine dependence, in remission
Specific Coding
Guidelines, chapter 5.
Mental, Behavioral, and
Neurodevelopmental
9.2 Mood (Affective) and Nonmood
disorders (F01–F99), (Psychotic) Disorders
subsection b. Mental
and behavioral disor- Mood (Affective) Disorders
ders due to psychoac-
tive substance use, 1)
Bipolar Disorders
In remission. The etiology of bipolar disorders is uncertain and complex. The strongest evidence
leads to the belief that many factors act together to activate the signs and symptoms.
While some evidence exists that the condition tends to have familial connections,
there have been studies of identical twins in which only one twin is affected.
Bipolar disorder is categorized as a “mood disorder” identified by acute swings
exhibited by the patient, ranging from euphoria and hyperactivity to depression and
Manic lethargy. An overly elated or overexcited state is called a manic episode, and an acute
An emotional state that sad or hopeless state is known as a depressive episode. Bipolar disorder may also be
includes elation, excitement, present in a mixed state, during which the patient experiences both mania and depres-
and exuberance. sion simultaneously.
Depressive Bipolar disorder is a chronic illness, therefore requiring long-term, continuous
An emotional state that treatment to control symptoms. Mood stabilizers (e.g., lithium carbonate), atypical
includes sadness, hopeless- antipsychotics (e.g., clozapine), and antidepressants are most commonly prescribed in
ness, and gloom. combination.
This diagnosis is categorized into two types: Type I bipolar disorder is identified
as alternating between manic episodes and depressive episodes, while type II bipolar
patients deal with recurring depressive episodes with occasional mania.
EXAMPLES
F31 Bipolar disorder
F31.0 Bipolar disorder, current episode hypomanic
F31.11 Bipolar disorder, current episode, manic without psychotic features,
mild
F31.12 Bipolar disorder, current episode, manic without psychotic features,
moderate
F31.13 Bipolar disorder, current episode, manic without psychotic features,
severe
F31.2 Bipolar disorder, current episode, manic, severe, with psychotic
features
F31.31 Bipolar disorder, current episode, depressed, mild
F31.32 Bipolar disorder, current episode, depressed, moderate
F31.4 Bipolar disorder, current episode, depressed, severe, without psy-
chotic features
EXAMPLES
F31.7- Bipolar disorder, currently in remission
F31.71 Bipolar disorder, in partial remission, most recent episode hypomanic
F31.72 Bipolar disorder, in full remission, most recent episode hypomanic
F31.73 Bipolar disorder, in partial remission, most recent episode manic
F31.74 Bipolar disorder, in full remission, most recent episode manic
F31.75 Bipolar disorder, in partial remission, most recent episode depressed
F31.76 Bipolar disorder, in full remission, most recent episode depressed
F31.77 Bipolar disorder, in partial remission, most recent episode mixed
F31.78 Bipolar disorder, in full remission, most recent episode mixed
A patient in full remission has not experienced any significant mood fluxuataion for
at least 2 months, virtually always during treatment.
A patient in partial remission has experienced reduced episodes or has had no
episodes for less than 60 days.
EXAMPLES
F32.- Major depressive disorder, single episode
F33.- Major depressive disorder, recurrent
(continued)
CHAPTER 9 |
You will need an additional character to identify the current episode as mild, mod-
erate, severe without psychotic features, or severe with psychotic features.
F32.4 Major depressive disorder, single episode, in partial remission
F33.41 Major depressive disorder, recurrent, in partial remission
A patient in partial remission has experienced reduced episodes or has had no
episodes for less than 60 days.
F32.5 Major depressive disorder, single episode, in full remission
F33.42 Major depressive disorder, recurrent, in full remission
A patient in full remission has not experienced any significant depressive symp-
toms for at least 2 months, virtually always during treatment.
ICD-10-CM
YOU CODE IT! CASE STUDY
Sherri L., a 23-year-old female, came in to see Dr. Keel, a psychiatrist. She has a very demanding and high-stress
life, being a second-year law student. In addition, she is clerking for a judge, and she is planning her wedding for this
coming summer. She states that she has always been highly motivated to achieve her goals. After graduating with
top honors from college, she went on to achieve a 3.95 GPA in her first year in law school. She admits that she can
be very self-critical when she is not able to achieve perfection, even though, intellectually, she knows that perfec-
tion is not necessary for success. Recently, she has been struggling with considerable feelings of worthlessness and
shame due to her inability to perform as well as she has in the past.
For the past few weeks, Sherri has noticed that she is constantly feeling fatigued, no matter how much she has slept.
She also states that it has been increasingly difficult to concentrate at work and pay attention in class. Her best friend,
RaeAnn, who works with her at the courthouse, stated that, recently, Sherri is irritable and withdrawn, not at all her typi-
cal upbeat and friendly disposition. While she has always prided herself on perfect attendance at school and at work,
Sherri has called in sick on several occasions. On those days she stayed in bed all day, watching TV and sleeping.
At home, Sherri’s fiancé has noticed changes in her as well. He states that, in the last 6 months, it seems that she
has lost interest in sex despite a very healthy sex life during the previous 2 years they had been together. He also
has noticed that she has had difficulties falling asleep at night. Her tossing and turning for an hour or two after they
go to bed has been keeping him awake. He confesses that he overheard her having tearful phone conversations
with RaeAnn and her sister that have worried him. When he tries to get her to open up, she denies anything is wrong,
emphatically stating, “I’m fine,” and walking away.
Sherri states that she has found herself increasingly dissatisfied with her life. She admits to having frequent
thoughts of wishing she was dead, yet denies ever considering suicide. She gets frustrated with herself because she
feels that she has every reason to be happy yet can’t seem to shake the sense of a heavy dark cloud enshrouding
her. Dr. Keel diagnosed Sherri with major depressive disorder, single episode, moderate severity.
EXAMPLES
F20.0 Paranoid schizophrenia
F20.1 Disorganized schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia (Atypical schizophrenia)
F20.5 Residual schizophrenia
F20.81 Schizophreniform disorder
F20.89 Other schizophrenia (Simple schizophrenia)
F21 Schizotypal disorder (Latent schizophrenia)
F25.0 Schizoaffective disorder, bipolar type
F25.1 Schizoaffective disorder, depressive type
F25.8 Other schizoaffective disorders
Coders working with health care professionals caring for patients diagnosed with
schizophrenia should be aware of the known adverse effects of the antipsychotic drugs
most often used to treat this condition. Also known as neuroleptic drugs, antipsychot-
ics (such as haloperidol) are known to result in a high incident rate of extrapyramidal
effects, including
CHAPTER 9 |
∙ Drug-induced parkinsonism [G21.11] with signs of propulsive gait, stooped posture,
muscle rigidity, tremors
∙ Drug-induced acute dystonia [G24.02] showing signs of severe muscle contractions
∙ Drug-induced akathisia [G25.71] showing signs of restlessness and pacing
Some low-potency drugs in this category have been known to cause orthostatic
hypotension [I95.2]—a sudden drop in blood pressure when the patient changes posi-
tion quickly, such as standing up. A development of malignant neuroleptic syndrome
[G21.0] has been reported in as many as 1% of patients taking antipsychotics.
Remember that when these adverse effects have been diagnosed, you will need to
include an external cause code to identify the “drug taken for therapeutic purposes” as
the reason for this condition. You would choose a code from category T43 Poisoning
by, adverse effect of and underdosing of psychotropic drugs, not elsewhere classified in
ICD-10-CM.
ICD-10-CM
YOU CODE IT! CASE STUDY
Gary R., a 20-year-old male, is a junior at a state university. Over the past month, his parents have noticed that his
behavior has become quite peculiar. Several times, his mother has overheard him speaking in a quiet yet angry
tone, even though no one was in the room with him. Over the past 7 to 10 days, Gary has refused to answer or
make calls on his cell phone, stating that he knows if he uses the phone, it will activate a deadly chip that has been
implanted in his brain by evil men from space.
Gary’s parents, as well as his brother and his best friend, have attempted to convince him to join them at an
appointment with a psychiatrist for an evaluation, but he adamantly refused, until today. Several times, Gary has
accused his parents of conspiring with the aliens to steal his brain. He no longer attends classes and will soon flunk
out unless he can get some help.
Other than a few beers with his friends, Gary denies abusing alcohol or drugs. There is a family history of psychiatric
illness; an estranged aunt has been in and out of psychiatric hospitals over the years due to erratic and bizarre behavior.
Dr. Zavakos diagnosed Gary with paranoid schizophrenia.
ICD-10-CM
YOU CODE IT! CASE STUDY
Brian B., a 52-year-old divorced father of two teenagers, states he has a successful, financially rewarding career.
He has been with this company for the last 15 years, the last 5 as vice president of his division. Even though his job
performance evaluations are good and he has been lauded by his boss, he is overwrought with worry constantly
(continued)
CHAPTER 9 |
about losing his job and being unable to provide for his children. This worry has been troubling him for about the last
8 or 9 months. Despite really trying, he can’t seem to shake the negative thoughts.
Over these last months, he noticed that he feels restless, tired, and stressed out. He often paces in his office
when he’s alone, especially when not deeply engaged in tasks. He’s found difficulty in expressing himself and has
been humiliated in a few meetings when this has occurred. At night, when attempting to go to sleep, he often finds
that his brain won’t shut off. Instead of resting, he finds himself obsessing over all the worst-case scenarios, includ-
ing losing his job and ending up homeless.
Dr. Burnett diagnoses Brian with generalized anxiety disorder and discusses a treatment plan with him.
Stress-Related Disorders
Post-traumatic stress disorder (PTSD) is a condition in which a horrible experience
leaves a lasting imprint on the patient’s sense of danger. Normally, when an individual
senses danger, a “fight or flight” response initiates feelings of worry and fear. For
those suffering from PTSD, the harmful or dangerous situation is gone, yet the sensa-
tion of fear continues.
Situations that may ignite PTSD can affect more individuals than just our wonderful
military personnel returning from the horrors of war. Sadly, it has become far too typical
to read about a shooting at a school or restaurant, rape, abuse (child, spouse, elder), trans-
portation accidents (car, truck, train, airplane), natural disasters (hurricane, earthquake,
flood), or other terrifying ordeals occurring in an all-American neighborhood. As health
information management professionals and professional coding specialists, we should
be aware, empathetic, and accurate. PTSD affects an estimated 7.5 million adults in the
United States.
Signs and symptoms typically appear within 3 months of the event; however, in
some cases, they can be internalized and take longer to recognize. Flashbacks, hyper-
arousal (overreactions), and avoidance are the most frequently experienced behaviors.
When the symptoms are acute but then dissipate after a few weeks, this may be diag-
nosed as acute stress disorder (ASD), reported with ICD-10-CM code F43.0 Acute
stress reaction, also known as crisis state or psychic shock.
When the patient experiences at least one flashback or “re-experiencing” symp-
tom (including diaphoresis (sweating) and tachycardia (rapid heart rate)), at least
EXAMPLES
All of these codes require additional characters to complete a valid code.
X34.xxx- Earthquake
X37.0xx- Hurricane (storm surge) (typhoon)
X96.3xx- Assault by fertilizer bomb
X99.1xx- Assault by knife
Y36.- Operations of war
Y37.- Military Operations
EXAMPLES
Y92.133 Barracks on military base as the place of occurrence of the external
cause
Y92.212 Middle school as the place of occurrence of the external cause
Y92.26 Movie house or cinema as the place of occurrence of the external
cause
Y92.821 Forest as the place of occurrence of the external cause
∙ Activity during the occurrence, such as almost drowning while SCUBA diving or
being involved in a construction accident.
EXAMPLE
Y93.15 Activity, underwater diving and snorkeling
Y93.34 Activity, bungee jumping
Y93.H3 Activity, building and construction
CHAPTER 9 |
9.4 Physiological Conditions Affecting the
Central Nervous System
Inflammatory Conditions of the Central Nervous System
Bacteria and viruses can invade the nervous system and cause infection, malfunction,
and, in some cases, death. Examples include encephalitis (inflammation of the brain
tissue), myelitis (inflammation of the spinal cord), intracranial abscess, and, probably
the most well-known condition, meningitis.
Meningitis is an inflammatory disease of the CNS. However, as a professional
coder, you must know more than the fact that the patient is diagnosed with meningitis.
Meningitis can be caused by a virus or a bacterial invader that you will need to identify
from the documentation; this may be a virus such as enterovirus, herpes zoster, or lep-
tospira or a bacteria such as Haemophilus influenzae, streptococcus, pneumococcus,
staphylococcus, or E. coli, to name just a few. Each specific detail may lead you to a
different code or require a second code.
EXAMPLES
G00.1 Pneumococcal meningitis
G00.8 Other bacterial meningitis (Meningitis due to Escherichia coli)
G03.0 Nonpyogenic meningitis
ICD-10-CM
LET’S CODE IT! SCENARIO
Lamonte Millwood went to see Dr. Vaughn after returning home from college on spring break. He stated that
his new dorm room is a small suite and he has three roommates. He said that the last couple of days before he
left to come home, two of his roommates were coughing and sneezing. Lamonte tells Dr. Vaughn that he has
been nauseous and vomiting, he has become very sensitive to light, and he feels a bit confused, having trou-
ble concentrating on his school work. Tests confirmed Dr. Vaughn’s diagnosis of bacterial meningitis caused by
Neisseria meningitidis.
CHAPTER 9 |
ICD-10-CM
LET’S CODE IT! SCENARIO
Nate Mercado, an 81-year-old male, came to see Dr. Bronson with complaints of increasing forgetfulness and dif-
ficulty remembering new information. He states virtually no ability to focus or concentrate. His presentation confirms
a deterioration in personal hygiene, and his appearance is somewhat disheveled. Nate’s daughter insisted that he
come to the doctor. After a neurologic exam, psychometric testing, a PET scan, and an EEG, Dr. Bronson diagnosed
Nate with late-onset Alzheimer’s disease.
Migraine Headaches
Medical researchers have been trying to determine the cause of migraine headaches
for quite a long time. According to the U.S. National Library of Medicine, cur-
rently the theory is that genes related to the control of some brain cell function are
the cause.
While the genetic potential for having migraines may be congenital, generally, this
pain is not constant, but caused by specific actions or events in one’s life. These are
known as triggers, and they include
∙ Stress or anxiety
∙ Insufficient sleep
∙ Lack of food
∙ Fluctuations in hormone levels (specifically in females)
There are several different types of migraine headaches, and these details should be
available to you when you abstract the documentation.
Aura: The aura connected with a migraine is actually a sequence of neurologic
symptoms that occur within the hour prior to the onset of the migraine itself (in adults).
These experiences may affect their vision, such as the appearance of dark or colored
spots; their physical sensations, such as tingling or numbness, possibly vertigo; or
their senses, such as difficulty with speech or hearing.
Intractable: An intractable migraine may also be described in the documentation as
pharmacologically resistant, treatment resistant, medically induced (refractory), and/
or poorly controlled by treatment.
CHAPTER 9 |
Status migrainosus: This term is used to identify that the patient’s migraine head-
ache has lasted more than 72 continuous hours.
Chronic: A diagnosis of chronic migraine is documented as the patient reporting
more than 15 headache days within a 30-day period, with more than half of these
described as migraines.
Other types of migraines: There are many more categories of migraine headaches
that you may abstract from the documentation, such as cyclical vomiting, abdomi-
nal, or menstrual. Each of these has its own specific code within code category G43
Migraine.
Be alert to these terms, in connection with a migraine diagnosis. The absence of
a term, such as aura or intractable, can be used as an indicator that the patient was
“without” that aspect of the condition. What this means is that, if the physician does
not specifically document that the patient had aura with his or her migraine, you are
permitted to use a code that states, “without aura.” It is not expected that the physician
would necessarily document elements that are not present. However, if the detail is
documented, a code that includes that detail must be reported.
ICD-10-CM
LET’S CODE IT! SCENARIO
Jeffrey Himes was referred to Dr. Jonas, a neurosurgeon, after his last brain MRI came back showing signs of an
abundance of cerebrospinal fluid (CSF) in the ventricles of his brain. After taking a full history and examination,
Dr. Jonas determined that there was malabsorption of CSF in the brain—an official diagnosis of communicating
hydrocephalus. Dr. Jonas discussed the treatment options with Jeffrey and his family.
This seems to match the notes, except included in the parenthetical nonessential modifiers is the term noncom-
municating. When you look back at the notes, you can see that Dr. Jonas diagnosed Jeffrey with communicating—
the opposite. So, you know that this code cannot be correct. There is still a long list of additional modifying
terms indented below hydrocephalus. Read through all of the choices and see if you can determine which one
matches the documentation. Did you find this?
Hydrocephalus
communicating G91.0
This matches the notes, so let’s turn to the Tabular List and begin reading at the three-character code:
G91 Hydrocephalus
Carefully read the note that identifies acquired hydrocephalus and the note citing three diag-
noses that are not reported from this code category. Do you see any of these diagnoses included in Dr. Jonas’s
documentation? No. Read all of the choices for the fourth character available in this code category and deter-
mine which one best matches what Dr. Jonas wrote in Jeffrey’s notes:
EXAMPLES
G81.12 Spastic hemiplegia affecting left dominant side
G83.14 Monoplegia of lower limb affecting left nondominant side
Remember that the laterality refers to the patient’s right or left, not that of the
writer of the documentation.
Plexus Disorders
Many plexus disorders are the result of a specific point in the peripheral neural path-
way for that plexus becoming compressed. Typically, something causes the nerve to
be pinched between muscle and bone, such as the thoracic outlet syndrome (brachial
CHAPTER 9 |
plexus disorder) occurring from the muscles of the neck and shoulder squeezing
CODING BITES down on the nerve. See code G54.0 Brachial plexus disorders or G54.1 Lumbosacral
Four nerve plexuses plexus disorders.
branch from the spinal
cord off into the periph- Complex Regional Pain Syndrome
eral nerve network:
After a traumatic injury, complex regional pain syndrome (CRPS) may develop in the
• The cervical plexus damaged extremity (arm/hand, leg/foot). Signs and symptoms include chronic (ongo-
branches nerves to ing) pain; dramatic changes to the color, texture, or temperature of the epidural sur-
the head, neck, and face; a burning sensation; and edema and stiffness in involved joints, which often
shoulder. results in decreased mobility.
• The brachial plexus There are two types of CRPS: CRPS-I and CRPS-II.
branches nerves to CRPS-I used to be called reflex sympathetic dystrophy syndrome. Physicians clas-
the chest, shoulders, sify this diagnosis when the patient denies the occurrence of any nerve injury.
upper arms, fore-
G90.511 Complex regional pain syndrome I of right upper limb
arms, and hands.
G90.512 Complex regional pain syndrome I of left upper limb
• The lumbar plexus G90.513 Complex regional pain syndrome I of upper limb, bilateral
branches nerves to G90.521 Complex regional pain syndrome I of right lower limb
the back, abdomen, G90.522 Complex regional pain syndrome I of left lower limb
groin, thighs, knees, G90.523 Complex regional pain syndrome I of lower limb, bilateral
and calves.
• The sacral plexus CRPS-II has been previously documented as causalgia, for patients who have a
branches nerves to confirmed nerve injury prior to this diagnosis.
the pelvis, buttocks, G56.41 Causalgia of right upper limb
genitals, thighs, G56.42 Causalgia of left upper limb
calves, and feet. G56.43 Causalgia of bilateral upper limbs
G57.71 Causalgia of right lower limb
G57.72 Causalgia of left lower limb
G57.73 Causalgia of bilateral lower limbs
ICD-10-CM
YOU CODE IT! CASE STUDY
Simon Clossberg is a 37-year-old architect. While on a business trip to Los Angeles, Simon and guys on his
team decided to have some fun and rented some motorcycles. Taking a turn too wide, Simon was involved in a
one-vehicle motorcycle accident. In the accident, Simon was pinned and slid between the bike and the pave-
ment, ultimately landing on his back. A police officer witnessed the accident and immediately called for medical
assistance.
EMTs arrived within minutes and immediately immobilized Simon’s neck and secured him to a rigid board prior
to transporting him to the emergency department of the nearest hospital. Upon arrival at the ED, Simon was con-
scious and complained of pain in his lower back. ED physician Dr. NeJame examined Simon and found numer-
ous abrasions and contusions, in addition to a loss of both sensation and motor control of his legs. After he was
stabilized, Dr. NeJame admitted Simon and called for a neurologic consult. Dr. Cheslea completed the neurologic
assessment.
The neurologic exam revealed the following: Simon demonstrated normal or near normal strength in flexing and
extending his elbows, in extending his wrists, and when flexing his middle finger and abducting his little finger on
both hands. However, he exhibited no movement when medical personnel tested his ability to flex his hips, extend
his knees, and dorsiflex his ankles.
Stretch reflexes involving the biceps, brachioradialis, and triceps muscles were found to be normal, while those
involving the patella and ankle were absent. In addition, Simon was found to have normal sensitivity to pin prick
and light touch in areas of his body above the level of his inguinal (groin) region, but not below that region of
the body.
Dr. Cheslea diagnosed Simon with lumbosacral plexus disorder.
CHAPTER 9 |
TABLE 9-1 Numeric Rating Scale for Pain
EXAMPLES
1. Megan slipped during ice skating practice and broke her right ankle. After
x-raying the ankle and applying the cast, Dr. Hustey gave her a prescription
for pain medication. In this case, only the fractured ankle would be reported
(S82.64xA, Nondisplaced fracture of lateral malleolus of right fibula, initial
encounter for closed fracture). The pain is an inclusive symptom of the fracture.
2. Megan came back to Dr. Hustey 10 days later complaining of unbearable pain
and stating that the prescribed medication was not “doing the trick.” Dr. Hustey
discussed with Megan several management treatments for the acute pain, and
she agreed to try a different medication. This encounter was only for pain man-
agement. Dr. Hustey did not attend to the fracture at all. Therefore, this encoun-
ter would be reported with two codes:
G89.11 Acute pain due to trauma
S82.64xD Nondisplaced fracture of lateral malleolus of right fibula, sub-
sequent encounter for fracture with routine healing
A code from category G89 is reported to add details about the reason for this
encounter with Dr. Hustey. The code for the fracture explains why Megan had pain.
3. Phillip is diagnosed with chronic tension headaches due to the extreme
pressures of his job. He told the doctor he could not stand the pain anymore and
he needed help. This diagnosis would be reported with both of these codes:
G89.29 Other chronic pain
G44.229 Chronic tension-type headache, not intractable
The official guidelines state that if the pain is not specifically documented as
acute or chronic, it should not be reported separately. The exceptions to this guide-
line include
ICD-10-CM
LET’S CODE IT! SCENARIO
Patti Moscowicz came in to see Dr. Levine with complaints of extreme pain in her head. She stated that she was nau-
seous and irritable and that light made the pain even worse. Patti stated that these headaches seemed to happen
every month, right before she got her menstrual period, and she couldn’t take it anymore. She begged for something
to help with the pain. After a full examination, Dr. Levine diagnosed her with chronic premenstrual migraine.
(continued)
CHAPTER 9 |
There is a list of additional descriptors indented below this. Go back to the physician’s notes. Did he describe the
migraine with more detail? Yes, he stated her migraine was premenstrual. So look down the list and see if you
can find a suggested code:
Migraine (idiopathic) G43.909
Premenstrual—see Migraine, menstrual
Menstrual G43.829
Perfect! Now, let’s turn to code category G43 in the Tabular List:
G43 Migraine
There is no mention of any drugs or adverse reactions in Dr. Levine’s documentation, so let’s continue. Read the
and notes. Nothing there matches the physician’s notes, so continue down the column and
review all of the choices for the mandatory fourth character. Which one matches what Dr. Levine wrote?
There are fifth-character choices listed below this code, so you will have to look down the column and find the
box containing the fifth-character choices. You will see the box directly below the three-character code category.
Review the four choices. Which one matches?
Good. There was no mention that Patti was having an intractable migraine. Read the notation beneath this code
classification:
There was no mention of this in Dr. Levine’s notes on Patti. Review the choices for the sixth character:
Do you also need to include a code from the G89 code category? Check the Official Guidelines, specifically
Section 1.c.6.b.1)(b), Use of category G89 codes in conjunction with site specific pain codes. You will
see that it states, “If the code describes the site of the pain, but does not fully describe whether the pain
is acute or chronic, then both codes should be assigned.” Terrific! Dr. Levine documented that Patti’s pain
was chronic, and code G43.829 does not include that specific detail. That’s the answer to that question,
so go and review all of the possible codes from code category G89 to determine the most accurate code
to report:
You have one last task to complete. Now that you have two codes to report Dr. Levine’s reasons for caring
for Patti during this encounter, you need to determine the correct sequence in which to report these codes.
Refer again to that guideline, and the next part tells you, “If the encounter is for pain control or pain man-
agement, assign the code from category G89 followed by the code identifying the specific site of pain.”
You know from the notes that the reason for this encounter was pain management, so now you know the
correct codes and the correct order in which to report the reason why Dr. Levine cared for Patti during this
encounter:
G89.29 Other chronic pain
G43.829 Menstrual migraine, not intractable, without mention of status migrainosus
Good job!
CHAPTER 9 REVIEW
Due to an increase in available care, more patients are receiving treatment for mental
and behavioral disorders. Therefore, it is important for professional coding specialists
to understand both psychological and physiological concerns. Through education and
understanding, these patients can receive treatment and their providers can receive
accurate reimbursement.
Many different circumstances and situations can be the cause of malfunction any-
where in the nervous system. As with any other organ system or diagnosis, professional
coding specialists should never assume. Everything you need to report these conditions
accurately is in the physician’s documentation. If it is not, you must query the physician.
CODING BITES
Did you know there are hundreds of named phobias . . . such as
Acrophobia = fear of high places
Aerophobia = fear of air travel
Apiphobia = fear of bees
Bromidrosiphobia = fear of body odor
Claustrophobia = fear of enclosed places
Gephyrophobia = fear of bridges
Haemophobia = fear of blood
Kakorrhaphiaphobia = fear of failure
Linonophobia = fear of string
Phasmophobia = fear of ghosts
Scotophobia = fear of the dark
Taphephobia = fear of being buried alive
Triskaidekaphobia = fear of the number 13
CHAPTER 9 REVIEW
Coding Mental, Behavioral, Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
CHAPTER 9 |
8. LO 9.3 Irrational and excessive fear of an object, activity, or situation.
CHAPTER 9 REVIEW
CHAPTER 9 REVIEW
Refer to the Official Guidelines and fill in the blanks according to the Chapter 5, Mental, Behavioral, and
Neurodevelopmental Disorders, and Chapter 6, Diseases of the Nervous System, Chapter-Specific Coding
Guidelines.
G89 default G89.2 cancer psychological
relationship one acute pain associated
G89.4 G89.0 F45.41 G89.3 only
documentation F45.42 mental appropriate
1. Assign code _____, for pain that is exclusively related to _____disorders. As indicated by the Excludes 1 note
under category G89, a code from category G89 should not be assigned with code F45.41.
2. Code _____, Pain disorders with related psychological factors, should be used with a code from category _____,
Pain, not elsewhere classified, if there is documentation of a psychological component for a patient with acute or
chronic pain.
3. The _____ codes for “in remission” are assigned only on the basis of provider _____ (as defined in the Official
Guidelines for Coding and Reporting).
4. When the provider documentation refers to use, abuse and dependence of the same substance, only _____ code
should be assigned to identify the pattern of use.
5. The codes are to be used only when the psychoactive substance use is _____ with a _____ or behavioral disorder,
and such a _____ is documented by the provider.
6. Codes in category G89, Pain, not elsewhere classified, may be used in conjunction with codes from other catego-
ries and chapters to provide more detail about acute or chronic _____ and neoplasm-related pain, unless otherwise
indicated below.
7. The _____ for post-thoracotomy and other postoperative pain not specified as acute or chronic is the code for the
_____ form.
8. Chronic pain is classified to subcategory _____.
9. Code _____ is assigned to pain documented as being related, associated or due to _____, primary or secondary
malignancy, or tumor.
10. Central pain syndrome _____ and chronic pain syndrome _____ are different than the term “chronic pain,” and
therefore codes should _____ be used when the provider has specifically documented this condition.
4. LO 9.4 Differentiate between an inflammatory and a hereditary/degenerative type of disease of the nervous
system. Give an example of each type.
5. LO 9.5 Why is it important to know which side is dominant when coding weakness or paralysis? How do the
guidelines help us if the dominant side is not documented in the patient’s chart? How do the guidelines
direct the coder for a patient who has been documented as being ambidextrous?
CHAPTER 9 |
CHAPTER 9 REVIEW
ICD-10-CM
YOU CODE IT! Basics
First, identify the main term in the following diagno- 8. Infantile autism:
ses; then code the diagnosis. a. main term: _____ b. diagnosis: _____
Example: Korsakoff’s alcoholic psychosis 9. Bacterial meningitis, E. coli:
a. main term: psychosis b. diagnosis F10.96 a. main term: _____ b. diagnosis: _____
10. Acute disseminated encephalitis:
1. Nicotine dependence:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
11. Early-onset cerebellar ataxia:
2. Generalized anxiety disorder:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
12. Amyotrophic lateral sclerosis:
3. Vascular dementia:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
13. Postencephalitic parkinsonism:
4. Mild cognitive impairment:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
14. Generalized idiopathic epilepsy:
5. Cocaine abuse:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
15. Congenital dystonic cerebral palsy:
6. Schizoaffective manic type disorder:
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
7. Delirium with multiple etiologies:
a. main term: _____ b. diagnosis: _____
ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. Albert Goings, a 54-year-old male, presents today with abdominal cramping and diarrhea. Albert had knee
surgery 6 months ago and the surgeon prescribed oxycodone for pain control. Albert has stopped taking the
medication but is having difficulty. Dr. Kenneth documents dilated pupils as well as goose bumps. Albert is
diagnosed with oxycodone dependence, uncomplicated.
2. Charles Homer, a 6-year-old male, is brought in by his parents to see his pediatrician, Dr. Freibert. Mrs.
Homer is concerned because Charles has been eating dirt and sand and he has tried to eat paper for approxi-
mately 1 month. Dr. Freibert completes a thorough examination and notes paleness and failure to thrive.
Charles is admitted to Weston Hospital for a full workup. After reviewing the laboratory and developmental
test results, Charles is diagnosed with pica.
3. Kelley Dumont, a 19-year-old female, comes in to see Dr. Molusky. Kelley complains that she feels powerless
and depressed. Kelley is accompanied by her mother. Mrs. Dumont states that Kelley has given up activi-
ties and has become fearful. Dr. Molusky completes a psychological examination and diagnoses Kelley with
chronic paranoid reaction.
4. Kevin Genutis, a 24-year-old male, presents with the complaint of experiencing early orgasm and ejacula-
tion, usually a minute or two after beginning sexual activity. Dr. Fox completes an examination and diagnoses
Kevin with premature ejaculation.
ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documentation
from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient encoun-
ters. Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
CHAPTER 9 |
CHAPTER 9 REVIEW
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: LYNCH, VICTOR
ACCOUNT/EHR #: LYNVIC001
DATE: 10/16/18
Attending Physician: Renee O. Bracker, MD
S: This is a 3-year-old male who is recovering from a mild case of the Flu and suddenly began vomit-
ing. The babysitter may have given him aspirin by accident instead of acetaminophen. Luke’s mother
brought him to the ED for unexplained irritability and restlessness. He later develops convulsions, which
are treated with anticonvulsants. He is admitted to PICU.
CHAPTER 9 |
CHAPTER 9 REVIEW
O: T: 36.7, P: 102, R 48, BP 115/69, oxygen saturation 99% in room air. Height, weight, and head cir-
cumference are all at the 50th percentile. PERRLA. No signs of external trauma. Sclera nonicteric. EOMs
cannot be fully tested, but they are conjugate. TMs are normal. Neck reveals no adenopathy. He is agi-
tated and uncooperative. Heart regular without murmurs or gallops. Lungs are clear. Abdomen—normal
bowel sounds. No definite tenderness. No inguinal hernias are present. He moves all extremities.
LABS: Serum bilirubin: normal. Serum AST and ALT: increased. Serum ammonia: increased. Prothrombin
time: prolonged. A CT scan of the brain shows cerebral edema. Neurologic symptoms rapidly deterio-
rate and he becomes unresponsive. Patient is intubated and put on mechanical ventilation and IV fluid
is started. A liver biopsy reveals diffuse, small lipid deposits in the hepatocytes (microvesicular steatosis)
without significant necrosis or inflammation.
A: Reye’s syndrome.
P: Continue to follow and treat.
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: YAN, MARANDA
ACCOUNT/EHR #: YANMAR001
DATE: 10/16/18
Attending Physician: Oscar R. Prader, MD
S: This is a 23-year-old female who presents with a chief complaint of clumsiness and blurred vision.
Patient states she had been feeling fine until about 10 days ago when she noticed some numbness and
weakness in her right leg, and suddenly her vision became blurry.
O: VS are normal. She is alert but subdued, afebrile with some ataxia noted. HEENT exam is notable for
severe visual loss and pale optic discs on funduscopy. Her heart, lungs, and abdomen are normal. She
is noted to have a hyporeflexive paraparesis noted on the right.
I decided to admit her to the hospital. An MRI scan shows multiple lesions in the periventricular white
matter and cerebellum. Pattern visual evoked responses showed markedly delayed latencies. Cortico-
steroids are prescribed. Prognosis—a full recovery within 10–14 days.
A: Multiple sclerosis (MS)
P: Continue to follow and treat with traditional medication.
Lacrimal Apparatus
learning experience. Lens
Meibomian Glands
Moll’s Glands
Orbit
10.1 Diseases of the External Palpebrae
Palpebral Conjunctiva
Optical System Proptosis
The Exterior of the Eye Pupil
Retina
The palpebrae (eyelids) cover the eyeballs to protect them from injury and envi- Retinal Detachment
ronmental invaders as well as to maintain the proper level of moisture. Some peo- Retinopathy
ple think eyelids are made of epidermis, like regular skin; however, they are really Rod
composed of connective tissue. The levator palpebrae muscle superioris (levator = Sclera
lift; palpebrae = eyelids; muscle; superioris = above) is responsible for opening Uveal Tract
and closing the upper eyelid, while the fascia behind the orbicularis oculi muscle Vitreous Chamber
(the orbital septum) creates a barrier between the lids and the orbit. There is a
thin mucous membrane that lines the inside of the eyelid, known as the palpebral
Palpebrae
conjunctiva; this lines the eyelid internally, creasing over at the fornix, and covers The eyelids; singular palpebra.
the surface of the eyeball. At that point, it becomes known as the bulbar conjunctiva
(see Figure 10-1). Orbit
Within the palpebrae (eyelids), there are three types of glands: The bony cavity in the skull
that houses the eye and
∙ Moll’s glands: ordinary sweat glands. its ancillary parts (muscles,
∙ Meibomian glands: sebaceous glands that secrete a tear film component that pre- nerves, blood vessels).
vents tears from evaporating so that the area stays moist. Palpebral Conjunctiva
∙ Glands of Zeis: altered sebaceous glands that are connected to the eyelash A mucous membrane that
follicles. lines the palpebrae.
Upper eyelid
Upper lacrimal
punctum Pupil
Superior Limbus
canaliculus Iris
Lacrimal sac
Sclera
Inferior canaliculus
Lower eyelid
Lower lacrimal
punctum
Nasolacrimal duct
Bulbar Conjunctiva
A mucous membrane on the EXAMPLES
surface of the eyeball. H00.024 Hordeolum internum left upper eyelid
H00.15 Chalazion left lower eyelid
Moll’s Glands
H01.112 Allergic dermatitis of right lower eyelid
Ordinary sweat glands.
H02.031 Senile entropion of right upper eyelid
Meibomian Glands H02.131 Senile ectropion of right upper eyelid
Sebaceous glands that
You may be thinking, “Hey, wait a minute. You just taught us that palpebra is the med-
secrete a tear film compo-
nent that prevents tears from ical term for eyelid. And yet here in the code descriptions, they each state ‘eyelid,’ the
evaporating so that the area English word.” That’s very true. However, the reason you need to learn that the term
stays moist. palpebra means eyelid is because when your physician is writing operative notes or
procedure notes, he or she may use the term palpebra, and if you’re not familiar
Glands of Zeis with that and you don’t know what it means, you won’t know how to code this.
Altered sebaceous glands that
are connected to the eyelash
follicles. Blepharitis
Blepharitis Staphylococcal blepharitis, also known as ulcerative blepharitis, is a condition in
Inflammation of the eyelid. which the rims of the eyelids become inflamed and appear red. Most often, this condi-
tion is chronic and affects bilaterally, as well as simultaneously to the upper and lower
lids. In addition to the redness, dry scales and ulcerations may form.
Squamous blepharitis is similar, with inflammation of the glands of Zeis. Signs
and symptoms include itching, burning, photophobia, mucous discharge, and a crusty
formation on the eyelids.
As you abstract documentation with a confirmed diagnosis of blepharitis, you will
need to confirm the specific eye involved (right or left) as well as the specific lid
(upper or lower). Code subcategory H01.0- Blepharitis.
ICD-10-CM
YOU CODE IT! CASE STUDY
Rosemary Seaborn, a 25-year-old female, came to see Dr. Spencer, an ophthalmologist, with complaints of itching
and a burning sensation in both of her eyes. She stated her upper eyelids looked like they had “dandruff” with a
crusty appearance, and she noted an increased sensitivity to light. After examinations and testing, Dr. Spencer docu-
mented a confirmed case of bilateral squamous blepharitis on her upper palpebrae.
Exophthalmic Conditions
Exophthalmos, also known as proptosis, is an abnormal displacement of the eyeball. Proptosis
Most often, ophthalmic Graves’ disease is the underlying condition that results in the Bulging out of the eye; also
eyeball bulging outward while the eyelids retract backward, bilaterally. Trauma, such as known as exophthalmos.
ethmoid bone fracture, may cause a unilateral diagnosis. Edema, hemorrhage, throm-
bosis, or varicosities may also cause exophthalmos, either unilaterally or bilaterally.
As you abstract the documentation, note the difference between the displacement of
CODING BITES
the orbit, or eyeball, and whether or not the exophthalmos is constant, intermittent, or
pulsating so you can determine the accurate code: NOTE: All of these
codes [in the H05 code
H05.21- Displacement (lateral) of globe category] require a sixth
H05.24- Constant exophthalmos character to specify
H05.25- Intermittent exophthalmos right eye, left eye, or
H05.26- Pulsating exophthalmos bilateral (both eyes)
involved.
Disorders of the Lacrimal Apparatus
The lacrimal glands, the upper canaliculi, the lower canaliculi, the lacrimal sac, and
the nasolacrimal duct are together known as the lacrimal apparatus. Tears are cre- Lacrimal Apparatus
ated in the main lacrimal gland and then flow through several excretory ducts, pass A system in the eye that con-
through the canaliculi and the lacrimal sac, and continue down the nasolacrimal duct sists of the lacrimal glands,
into the nasal cavity—the nose. This is why when you cry, your nose runs. the upper canaliculi, the lower
Signs and symptoms of an obstructed lacrimal apparatus include recurring conjunc- canaliculi, the lacrimal sac,
and the nasolacrimal duct
tivitis (pink eye), discharge of pus or mucus from the eyelids and/or the conjunctiva,
blurred vision, and excessive tearing.
Congenital nasolacrimal duct anomalies: A neonate may be born with a duct
abnormality, an obstruction, or a lacrimal apparatus that is not fully developed. This is
reported with one of these codes:
Q10.4 Absence and agenesis of lacrimal apparatus
or
CHAPTER 10 |
Q10.5 Congenital stenosis and stricture of lacrimal duct
or
Q10.6 Other congenital malformations of lacrimal apparatus
Neonatal lacrimal duct (passages) obstruction: An infant born with a healthy lac-
rimal apparatus may still develop an obstruction of the nasolacrimal duct. As you are
abstracting the documentation, confirm that this condition is acquired and not con-
genital so you can determine the accurate code:
H04.531 Neonatal obstruction of right nasolacrimal duct
or
H04.532 Neonatal obstruction of left nasolacrimal duct
or
H04.533 Neonatal obstruction of bilateral nasolacrimal ducts
Dacryops, also known as lacrimal gland cyst or lacrimal duct cyst, is reported with
one of these codes:
H04.111 Dacryops of right lacrimal gland
or
H04.112 Dacryops of left lacrimal gland
or
H04.113 Dacryops of bilateral lacrimal glands
Dacryocystitis
Dacryocystitis Dacryocystitis is lacrimal gland inflammation (dacry/o = lacrimal sac or duct + cyst =
Lacrimal gland inflammation. sac + itis = inflammation). This may be a manifestation of a nasolacrimal duct obstruc-
tion and can be acute and/or chronic. Research shows that Staphylococcus aureus—
or, on occasion, beta-hemolytic streptococci—is the pathogen responsible for acute
dacryocystitis inflammation, whereas the chronic condition is more often caused by
Streptococcus pneumoniae or, on occasion, a fungal infection such as Actinomyces or
Candida albicans.
Signs and symptoms include pain, redness, and swelling over the inner aspect of the
lower eyelid and epiphora. As you are abstracting the documentation, confirm whether
the patient is a neonate or not, so you can determine the accurate code:
H04.321 Acute dacryocystitis of right lacrimal passage
or
H04.322 Acute dacryocystitis of left lacrimal passage
or
H04.323 Acute dacryocystitis of bilateral lacrimal passages
or
P39.1 Neonatal conjunctivitis and dacryocystitis
ICD-10-CM
YOU CODE IT! CASE STUDY
Raven Mercado, a 27-year-old female, came in to see Dr. Garner complaining of swelling, pain, and redness on her
left eyelid. She was pretty certain it was a stye, but it was so painful, she had to ask for help. Dr. Garner examined her
and confirmed a diagnosis of hordeolum externum of the left lower eyelid (commonly known as a stye).
CHAPTER 10 |
Ora serrata
Ciliary muscle
Hyaloid canal Ciliary body
Ciliary process
Lacrimal sac
Central retinal
artery and vein
Limbus
Scleral venous sinus
CN II (optic) (canal of Schlemm)
Suspensory ligament
Lens
Iris
Cornea
Optic disc (blind spot)
Pupil
Fovea centralis
FIGURE 10-2 The anatomical components of the orbital septum (view from the right side)
Pupil
Anterior chamber
Anterior cavity
Posterior chamber
CHAPTER 10 |
When caused by herpes simplex virus, type 1, the diagnosis is dendritic corneal
ulcer (herpesviral keratitis). Typically it is a unilateral condition, and initial signs and
symptoms include reduced visual clarity, tearing, photophobia, and varying levels of
pain (anywhere from mild discomfort to acute pain). As you can see, there are several
different viruses that cause keratitis. You should find this detail in the documentation
and the pathology report.
B00.52 Herpesviral keratitis
B01.81 Varicella keratitis
B02.33 Zoster keratitis
Corneal Dystrophy Corneal dystrophy occurs when one or more parts of the cornea develop an accu-
Growth of abnormal tissue on mulation of cloudy material, resulting in the loss of normal clarity. There are over
the cornea, often related to a 20 varieties of corneal dystrophies, all of which share several characteristics:
nutritional deficiency.
∙ Genetic (inherited)
∙ Bilateral
∙ Not the result of external causes, such as injury or diet
∙ Develop gradually
∙ Onset limited to a single layer of the cornea, with the disorder spreading later to the
others
Some of the most common corneal dystrophies include Fuchs’ dystrophy (endothe-
lial corneal dystrophy), keratoconus, lattice dystrophy, and map-dot-fingerprint (epi-
thelial corneal) dystrophy.
H18.51 Endothelial corneal dystrophy
Fuchs’ dystrophy
H18.52 Epithelial ( juvenile) corneal dystrophy
H18.53 Granular corneal dystrophy
H18.54 Lattice corneal dystrophy
H18.55 Macular corneal dystrophy
ICD-10-CM
LET’S CODE IT! SCENARIO
Jessica Harvey, a 41-year-old female, came in to see Dr. Loughlin with complaints of pain in her left eye upon blink-
ing, photophobia, and increased tearing. She has also noticed some blurring. She states she hasn’t been able to put
her contact lenses in for several days. Dr. Loughlin examined Jessica and dropped fluorescein dye into the conjuncti-
val sac, which stained the outline of the ulcer, the entire outer rim of the cornea. Dr. Loughlin diagnosed Jessica with
a ring corneal ulcer of the left eye.
Whew! Now review the options for the fifth and sixth characters to see if you can determine an accurate
code:
H16.022 Ring corneal ulcer, left eye
That matches perfectly!
Check the top of this subsection and the head of this chapter in ICD-10-CM. There are notations at the begin-
ning of this chapter: a NOTE and an notation. Read carefully. Do any relate to Dr. Loughlin’s diagnosis
of Jessica? No. Turn to the Official Guidelines and read Section 1.c.7. There is nothing specifically applicable
here either.
Now you can report H16.022 for Jessica’s diagnosis with confidence.
Good coding!
CHAPTER 10 |
ICD-10-CM
YOU CODE IT! CASE STUDY
Nicholas McCord, a 45-year-old male, was tightening the rope holding a load on the bed of his pickup truck
when the rope broke suddenly. His fist, clenching the rope, snapped backward, hitting him in the right eye. The
pain was difficult for him to deal with, so his friends brought him to the emergency department. After examina-
tion, Dr. Espinal diagnosed Nicholas with an anterior dislocation of his right eye lens. He was taken up to the
procedure room.
Vascular tunic
Iris
Ciliary body
Choroid
Neural tunic
Retina
really only interpret up to 150? The eye combines the light wavelengths to enable rod
perception of a multitude of colors. An elongated, cylindrical cell
Retinal detachment is the separation of the outer RPE from the neural retina, cre- within the retina that is photo-
ating a space immediately beneath the retina. This subretinal space then fills with fluid sensitive in low light.
(liquid vitreous) and obstructs the flow of choroidal blood (which supplies oxygen and Cone
nutrients to the retina). Signs and symptoms include floaters (floating black spots) as A receptor in the retina that is
well as photopsia (recurring flashes of light). responsible for light and color.
H33.012 Retinal detachment with single break, left eye Retinal Detachment
H33.021 Retinal detachment with multiple breaks, right eye A break in the connection
H33.21 Serous retinal detachment, right eye between the retinal pigment
epithelium layer and the neu-
ral retina.
CHAPTER 10 |
ICD-10-CM
YOU CODE IT! CASE STUDY
PATIENT NAME: Peter Calvern
DATE OF OPERATION: 10/05/2018
PREOPERATIVE DIAGNOSIS: Narrow-angle glaucoma, right eye.
POSTOPERATIVE DIAGNOSIS: Narrow-angle glaucoma, right eye.
OPERATION PERFORMED: Laser iridotomy, right eye.
SURGEON: JoAnn Hannigan, MD
ANESTHESIA: Topical proparacaine.
INDICATIONS FOR PROCEDURE: The patient is a 67-year-old male with a history of narrow-angle glaucoma, at high
risk for blindness or angle-closure glaucoma, diagnosed on physical examination by gonioscopy. Risks, benefits, and
alternatives of laser iridotomy were discussed with the patient preoperatively. The patient agreed and signed appro-
priate consent preoperatively.
DESCRIPTION OF PROCEDURE: On the day of the procedure, the right eye was identified as the operative eye.
The patient received 3 sets q. 5 minutes of the following drops: proparacaine, pilocarpine, and Iopidine. Appropri-
ate constriction and anesthesia were achieved. The patient was then brought back to the laser suite, where first
the argon laser was used to pretreat the iris superiorly in an area that was covered by the lid with the following set-
tings: 800 milliwatts, 0.06 second duration and 50 micron spot size. Then, the YAG laser was used to complete the
iridotomy with the following settings: 5 millijoules, 2 pulses and a total of 2 pulses applied. Good flow of aqueous
was noted from the posterior chamber to the anterior chamber and a patent iridotomy was obtained. The patient
was given the following postoperative instructions: No bending, coughing, lifting, straining, or sneezing. Return to
the clinic for further followup care, and the patient is to use prednisolone acetate 1 drop, left eye, 4 times a day
for 1 week.
Good work!
EXAMPLES
E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinop-
athy with macular edema
E11.36 Type 2 diabetes mellitus with diabetic cataract
Remember, whenever a combination code is available that includes the underlying GUIDANCE
condition and the manifestation in one code, you must use this to report the diag-
nosis. If no combination code is accurate, then you will probably need to report
CONNECTION
multiple codes to provide the whole picture. Read the ICD-10-CM
Official Guidelines for
Coding and Report-
Hypertensive Retinopathy ing, section I. Conven-
tions, General Coding
Patients with hypertension (high blood pressure) can develop damage to the retina
Guidelines and Chapter
because of the unusually high pressure of the blood traveling through the vessels.
Specific Guidelines,
This condition is known as hypertensive retinopathy. The higher the pressure and the
subsection C.
longer this condition has been ongoing, the more severely the retina may be harmed.
Chapter-Specific
Signs and symptoms most evident for those with hypertensive retinopathy include
Coding Guidelines,
∙ Double vision chapter 9. Diseases of
∙ Dimmed vision the Circulatory System,
subsection a. 5) Hyper-
∙ Blindness (vision loss)
tensive retinopathy.
∙ Headaches
CHAPTER 10 |
EXAMPLES
H35.031 Hypertensive retinopathy, right eye
H35.032 Hypertensive retinopathy, left eye
Did you notice that, with diabetic retinopathy, the combination codes are available
to you in the subsection for the underlying condition, diabetes mellitus? However,
with hypertensive retinopathy, these combination codes are with the ophthalmic
codes—the manifestation. You always need to read carefully and completely.
ICD-10-CM
LET’S CODE IT! SCENARIO
PATIENT’S NAME: Arlene Masconetti
MRN: ALMAS0122
DATE OF PROCEDURE: 07/22/2018
PRE/POSTOPERATIVE DIAGNOSIS: Cataract, traumatic and mature, right eye.
PROCEDURE PERFORMED: Phacoemulsification and implantation of intraocular lens, right eye.
SURGEON: Jason Britemann, MD
ANESTHESIA: MAC with retrobulbar
PREPROCEDURE: Patient is a 37-year-old female who had been playing softball with co-workers and got hit by a ball
in the right eye, causing a total traumatic cataract. She tried to ignore the discomfort, but it was interfering with her
doing her work, and she was afraid to drive. Patient was given the complete information on this procedure, possible
outcomes, and projected outcomes, and she signed consent. Prior to bringing the patient to the operating room, the
patient received three sets of topical dilating, antibiotic drops.
DESCRIPTION OF OPERATION: The patient was brought to the procedure room and placed in a supine position on
the operating table, and was prepped and draped in a sterile manner. She was sedated and retrobulbar injection of
0.75% Marcaine and 1% lidocaine was made. No complications were evident. A lid speculum was inserted to part
the eyelid. A paracentesis was made infratemporally. The anterior chamber was filled with air and then indocyanine
green to stain the anterior capsule. The cataract was noted to be extremely mature. A small capsulorrhexis was initi-
ated. Immediately, milky white fluid extruded from the capsulorrhexis opening. A 27-gauge cannula was then used
to aspirate this fluid. The cystotome was then used to complete the capsulorrhexis. The nucleus was gently rocked
to facilitate mobility. The phacoemulsification apparatus was introduced into the eye. The nucleus was phacoemulsi-
fied and removed without any complications. The remaining cortex was removed with irrigation and aspiration. An
SA60 AC 21-diopter lens was placed in the bag and the remaining viscoelastic was removed. One interrupted 10-0
nylon suture was placed in the cornea. The patient tolerated the procedure well. The lid speculum was removed.
One drop of Betadine, one drop of Ciloxan, and bacitracin ointment were placed into the eye and patch and shield
were applied. The patient was returned to postanesthesia care in satisfactory condition. The patient was instructed to
take the eye patch off at 6 p.m. and use the topical Vigamox and Pred Forte eye drops every 2 hours until bedtime.
CHAPTER 10 |
10.4 Dysfunctions of the Auditory System
Auditory Diseases
Otitis media is the inflammation of the middle ear. There are various types of this
condition: suppurative and nonsuppurative, acute and chronic. While otitis media
is common in children, it is not exclusively a childhood condition. Interestingly, the
cases of this diagnosis increase during the winter, while there is an increase of otitis
externa (inflammation of the external ear) in the summer. ICD-10-CM code category
H66.- Suppurative and unspecified otitis media requires additional characters to report
details including acute or chronic, suppurative or nonsuppurative, and with or without
rupture of the eardrum, as well as laterality.
Endolymphatic hydrops (Ménière’s disease) is a dysfunction of the labyrinth (semicir-
cular canals). Signs and symptoms include vertigo, sensorineural hearing loss, and tinnitus.
A feeling of fullness within the ear is not uncommon. Report this diagnosis with ICD-
10-CM code H81.0- Ménière’s disease, with an additional character to identify laterality.
ICD-10-CM
LET’S CODE IT! SCENARIO
Kaitlyn Logan, a 27-year-old female, was at a club and met a guy doing ear piercings. She got a piercing through
the cartilage of her upper left ear. Now, 3 days later, her ear is erythematous (red), swollen, and painful to the touch.
Dr. Sweeting examined her ear and diagnosed her with acute perichondritis of the left pinna. He prescribed fluoro-
quinoline with a semisynthetic penicillin and told her to come back in 2 weeks.
ICD-10-CM
LET’S CODE IT! SCENARIO
Alexis Acosta, a 33-year-old female, was having a terrible time with dizziness. She states that she has also had
a problem keeping her balance. A complete examination by Dr. McQuaig confirmed a diagnosis of bilateral aural
vertigo.
Tumors of the ear canal include osteomas and sebaceous cysts and can grow large
enough to interfere with hearing. Should the growth become infected, the patient may
develop a fever and other signs of inflammation, including pain. While these tumors
rarely become malignant, pain might indicate a malignancy. Examination with an oto-
scope can typically confirm this diagnosis, although a biopsy would be required to
confirm benign or malignant status.
EXAMPLES
C30.1 Malignant neoplasm of middle ear (malignant neoplasm of inner ear)
C44.212 Basal cell carcinoma of skin of right ear and external auricular canal
D14.0 Benign neoplasm of middle ear, nasal cavity and accessory sinuses
D23.22 Other benign neoplasm of skin of left ear and external auricular canal
CHAPTER 10 |
Labyrinthitis is an infection within the inner ear’s labyrinth. The most evident
symptom is incapacitating vertigo that may last as long as 5 days. Sensorineural hear-
ing loss may also occur. Viral labyrinthitis can be a manifestation of some upper respi-
ratory tract infections, or caused by trauma or toxic drug ingestion. In some cases,
cholesteatoma may form on the bone of the labyrinth and erode it. Labyrinthitis may
be described as circumscribed, destructive, diffused, latent, purulent, or suppurative.
Report H83.0- Labyrinthitis with an additional character to identify laterality.
ICD-10-CM
YOU CODE IT! CASE STUDY
Rebekka Keith, a 9-year-old female, was brought to her pediatrician, Dr. Granberry, because her right ear was very
painful and inflamed, and there was presence of both blood and fluid in her ear canal. She had suffered with the Flu
(upper respiratory infection), which had resolved last week. Physical examination revealed blebs and evidence that
one or two had ruptured spontaneously causing the presence of fluid and blood. Culture identified the pathogen as
Haemophilus influenzae. Dr. Granberry diagnosed Rebekka with acute infectious bullous myringitis of the right ear
and prescribed antibiotic ear drops.
EXAMPLES
Z01.10 Encounter for examination of ears and hearing without abnormal
findings
Z13.5 Encounter for screening for eye and ear disorders
Here are two examples of code you might report to explain the reason why the
physician or audiologist met with the patient for this encounter.
EXAMPLES
P00.2 Newborn (suspected to be) affected by maternal infectious and
parasitic diseases
Q16.5 Congenital malformation of inner ear
H91.1- Presbycusis
H93.25 Central auditory processing disorder (Congenital auditory
imperception)
CHAPTER 10 |
Psychogenic (Hysterical) Hearing Loss
Sometimes a traumatic event can be so upsetting to an individual that it results in neu-
rologic symptoms that have no organic cause. This is a psychiatric disorder that was
formerly called “hysteria.”
EXAMPLE
F44.6 Conversion disorder with sensory symptom or deficit (psychogenic
deafness)
EXAMPLES
H61.22 Impacted cerumen, left ear
H91.21 Sudden idiopathic hearing loss, right ear
ICD-10-CM
YOU CODE IT! CASE STUDY
Tatiana Clayton, a 39-year-old female, felt something in her ear. She was having problems hearing in her left ear
and felt very uncomfortable. When Dr. Silver asked her, she stated that it felt like something was inside her ear. Upon
inspection with the otoscope, Dr. Silver diagnosed a polyp in her middle ear.
EXAMPLES
H83.3x1 Noise effects on right inner ear
H91.03 Ototoxic hearing loss, bilateral
S09.21xA Traumatic rupture of right ear drum
Remember, whenever an external cause is documented, you must include the addi-
tional codes to explain how the injury or poisoning occurred.
EXAMPLES
T36.8x5A Adverse effect of other systemic antibiotics, initial encounter
W36.1xxA Explosion and rupture of aerosol can, initial encounter
EXAMPLE
When the physician documents that sound has caused the patient’s hearing loss,
you may report an external cause code from the W42 Exposure to noise code
category.
CHAPTER 10 |
TABLE 10-2 Common Sounds
Sound Noise Level (dB) Effect
Boom cars 145
Jet engines (near) 140
Shotgun firing 130
Jet takeoff (100–200 ft)
Rock concerts (varies) 110–140 Threshold of pain begins around 125 dB.
Oxygen torch 121
Discotheque/boom box 120 Threshold of sensation begins around 120 dB.
Thunderclap (near)
Stereos (over 100 watts) 110–125
Symphony orchestra 110 Regular exposure to sound over 100 dB for more
Power saw (chainsaw) than 1 minute risks permanent hearing loss.
Pneumatic drill/jackhammer
Snowmobile 105
Jet flyover (1,000 ft.) 103
Electric furnace area 100 No more than 15 minutes of unprotected exposure rec-
Garbage truck/cement mixer ommended for sounds between 90 and 100 dB.
Farm tractor 98
Newspaper press 97
Subway, motorcycle (25 ft) 88 Very annoying.
Lawn mower, food blender 85–90 85 dB is the level at which hearing damage
Recreational vehicles, TV 70–90 (8 hr) begins.
Diesel truck (40 mph, 50 ft) 84
Average city traffic 80 Annoying; interferes with conversation; constant
Garbage disposal exposure may cause damage.
Washing machine 78
Dishwasher 75
Vacuum cleaner, hair dryer 70 Intrusive; interferes with telephone conversation.
Normal conversation 50–65
Source: Decibel table developed by the National Institute on Deafness and Other Communication Disorders, National Institutes of Health. January 1990.
nidcd.nih.gov
GUIDANCE
CONNECTION
Chapter Summary
Read the ICD-10-CM Offi-
cial Guidelines for Coding One of the five senses, vision is involved in virtually every aspect of one’s life.
and Reporting, section I. This incredible complex organ system captures light and transmits it via inter-
Conventions, General active anatomical sites to the optic nerve and into the brain for evaluation and
Coding Guidelines and interpretation. Even though it is protected by the skull, the optical system is still
Chapter Specific Guide- susceptible to the invasions of pathogens (bacteria, viruses, fungi); can be dam-
lines, subsection C. aged by trauma; and can be impacted by other environmental issues, such as UV
Chapter-Specific light rays from the sun.
Coding Guidelines, The auditory (hearing) system enables the human body to hear—one of only two
chapter 20. External senses that have their own organ systems. The auditory system passes along sound
Causes of Morbidity. vibrations captured by the external ear, through the middle ear and the inner ear, to the
cerebellum for interpretation.
CHAPTER 10 REVIEW
Coding Dysfunction of the Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
Part I
1. LO 10.2 A membrane in the back of the eye that is sensitive to light and A. Choroid
functions as the sensory end of the optic nerve. B. Cones
2. LO 10.2 An elongated, cylindrical cell within the retina that is photosensitive in C. Cornea
low light.
D. Iris
3. LO 10.2 A receptor in the retina that is responsible for light and color.
E. Lens
4. LO 10.2 The membranous tissue that covers the entire eyeball (except the cor-
nea); also known as the white of the eye.
5. LO 10.2 Transparent tissue covering the eyeball; responsible for focusing light
into the eye and transmitting light.
CHAPTER 10 |
6. LO 10.2 The vascular layer of the eye that lies between the retina and the sclera. F. Orbit
CHAPTER 10 REVIEW
7. LO 10.1 A transparent, crystalline segment of the eye, situated directly behind G. Pupil
the pupil, that is responsible for focusing light rays as they enter the eye H. Retina
and travel back to the retina.
I. Rod
8. LO 10.2 The opening in the center of the iris that permits light to enter and con-
J. Sclera
tinue on to the lens and retina.
9. LO 10.1 The bony cavity in the skull that houses the eye and its ancillary parts
(muscles, nerves, and blood vessels).
10. LO 10.2 The round, pigmented muscular curtain in the eye.
Part II
1. LO 10.1 The eyelids. A. Accommodation
2. LO 10.1 Sebaceous glands that secrete a tear film component that prevents tears B. Bulbar Conjunctiva
from evaporating so that the area stays moist. C. Ciliary body
3. LO 10.2 The vascular layer of the eye that lies between the sclera and the crys- D. Extraocular Muscles
talline lens.
E. Glands of Zeis
4. LO 10.2 The interior segment of the eye that contains the vitreous body.
F. Lacrimal Apparatus
5. LO 10.1 Altered sebaceous glands that are connected to the eyelash follicles.
G. Meibomian Glands
6. LO 10.1 A system in the eye that consists of the lacrimal glands, the upper cana-
H. Moll’s Glands
liculi, the lower canaliculi, the lacrimal sac, and the nasolacrimal duct.
I. Palpebral Conjunctiva
7. LO 10.1 A mucous membrane that lines the palpebrae.
J. Palpebrae
8. LO 10.1 Adaptation of the eye’s lens to adjust for varying focal distances.
K. Uveal Tract
9. LO 10.1 Ordinary sweat glands.
L. Vitreous Chamber
10. LO 10.2 The muscles that control the eye.
11. LO 10.1 A mucous membrane on the surface of the eyeball.
12. LO 10.2 The middle layer of the eye, consisting of the iris, ciliary body, and
choroid.
Part III
1. LO 10.1 Inflammation of the eyelid. A. Blepharitis
2. LO 10.3 Degenerative condition of the retina. B. Conjunctivitis
3. LO 10.2 A break in the connection between the retinal pigment epithelium layer C. Corneal Dystrophy
and the neural retina. D. Dacryocystitis
4. LO 10.2 An inflammation of the cornea, typically accompanied by an E. Glaucoma
ulceration.
F. Keratitis
5. LO 10.1 Bulging out of the eye; also known as exophthalmos.
G. Proptosis
6. LO 10.2 Inflammation of the conjunctiva.
H. Retinal Detachment
7. LO 10.1 Lacrimal gland inflammation.
I. Retinopathy
8. LO 10.3 The condition that results when poor draining of fluid causes an abnor-
mal increase in pressure within the eye, damaging the optic nerve.
9. LO 10.2 Growth of abnormal tissue on the cornea, often related to a nutritional
deficiency.
CHAPTER 10 REVIEW
Choose the most appropriate answer for each of the following questions.
1. LO 10.1 All of the following are layers of the cornea except
a. epithelium. b. conjunctiva. c. stroma. d. endothelium.
2. LO 10.1 Tears are created in the main
a. lacrimal gland. b. upper canaliculi. c. lacrimal sac. d. lower canaliculi.
3. LO 10.2 _____ is commonly known as pink eye.
a. Keratitis b. Dacryocystitis c. Conjunctivitis d. Blepharitis
4. LO 10.2 The muscles that control the eye are known as
a. intraocular. b. palpebrae. c. vitreous. d. extraocular.
5. LO 10.3 What is the correct diagnosis code for intermittent angle-closure glaucoma, left eye?
a. H40.23 b. H40.231 c. H40.232 d. H40.233
6. LO 10.3 Signs and symptoms of diabetic retinopathy include all of the following except
a. double vision. b. flashing lights. c. rings around lights. d. headaches.
7. LO 10.4 Auditory dysfunction of the labyrinth is known as
a. otitis media. b. otosclerosis.
c. endolymphatic hydrops. d. tumors of the ear canal.
8. LO 10.4 ________ is an infection within the inner ear’s labyrinth.
a. Labyrinthitis b. Otitis media c. Chondritis d. Perichondritis
9. LO 10.5 Too much cerumen can build up in the canal and form an obstruction, blocking the entrance of sound
waves and causing sudden
a. inner ear hearing loss. b. sensorineural hearing loss.
c. organ of Corti hearing loss. d. conductive hearing loss.
10. LO 10.5 The hearing threshold for moderately severe hearing loss is
a. 20 dB and below. b. 40 to 55 dB. c. 56 to 70 dB. d. 90 dB and above.
1. Assign as many codes from category _____, Glaucoma, as needed to identify the type of _____, the affected eye,
and the glaucoma stage.
2. When a patient has _____ glaucoma and both eyes are documented as being the same type and _____, and there is
a code for bilateral glaucoma, report only the code for the type of glaucoma, bilateral, with the seventh character
for the stage.
CHAPTER 10 |
3. When a patient has bilateral glaucoma and _____ eyes are documented as being the same _____ and stage, and
CHAPTER 10 REVIEW
the classification does not provide a code for bilateral glaucoma report only _____ code for the type of glaucoma
with the appropriate seventh character for the stage.
4. When a patient has bilateral glaucoma and each eye is documented as having a _____ type or stage, and the
classification distinguishes _____, assign the appropriate code for _____ eye rather than the code for bilateral
glaucoma.
5. If a patient is _____ with glaucoma and the stage _____ during the admission, assign the code for _____ stage
documented.
6. Assignment of the _____ character “_____” for “indeterminate stage” should be based on the _____
documentation.
ICD-10-CM
YOU CODE IT! Basics
First, identify the condition in the following diagnoses; 8. Chronic perichondritis of external ear, left:
then code the diagnosis. a. main term: _____ b. diagnosis: _____
Example: Hordeolum externum, left upper eye 9. Labyrinthine dysfunction, right ear:
a. main term: Hordeolum b. diagnosis: H00.014 a. main term: _____ b. diagnosis: _____
10. Bullous keratopathy, left ear:
1. Stenosis of lacrimal sac, bilateral:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
11. Mechanical entropion of eyelid, right lower:
2. Transient ischemic deafness, bilateral:
a. main term _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
12. Total attic perforation of tympanic membrane,
3. Retinal telangiectasis, bilateral:
right ear:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
4. Ulcerative blepharitis, right upper eyelid:
13. Recurrent bilateral mastoiditis:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
5. Cholesteatoma of attic, left ear:
14. Senile ectropion of eyelid, left lower:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
6. Subluxation of lens, left eye:
15. Vestibular neuronitis, left ear:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
7. Granuloma of right orbit:
a. main term: _____ b. diagnosis: _____
CHAPTER 10 |
CHAPTER 10 REVIEW
hearing loss is verified by audiometry; MRI scan and electrocochleography confirm the final diagnosis of
bilateral Ménière’s disease.
14. Tamika Robinson, a 12-year-old female, is having difficulty hearing at school. Dr. Zaprzalka uses an otoscope
to visualize the tympanic membrane, noting left and right are within normal range without indication of
inflammation. The results of audiometry suggest conductive hearing loss. The CT scan confirms the diagno-
sis of cochlear otosclerosis, right ear.
15. Rodney Sabido, a 49-year-old male, is suddenly having difficulty with his hearing. Rod describes it as the
pitch is higher in one ear than the other. Dr. Butterfield completes an examination and the audiometry con-
firms a diagnosis of diplacusis, right ear.
ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documenta-
tion from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient
encounters. Using the techniques described in this chapter, carefully read through the case studies and determine
the most accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
O: History of Present Illness: A 69-year-old male presented to our office with a 1-day history of conjunc-
tival injection and mild discomfort in his right eye (OD). He had a known history of pigmentary glaucoma
that was treated with PCIOL and trabeculectomy with mitomycin C in the right eye 5 years earlier. His
visual acuity had decreased from 20/120 to 20/250 OD.
Past Ocular History: Pigmentary glaucoma (OD), age-related macular degeneration in both eyes (OU).
The patient had suffered a severe retinal detachment in the left eye (OS).
Medical History: Hypertension, thyroidectomy.
Medications: Latanoprost OD qhs, Synthroid, and Buspar.
Family History: Noncontributory.
Social History: The patient denies alcohol and tobacco use.
Exam, Ocular:
∙ Visual acuity, with correction: OD—20/250; OS—Light perception.
∙ Intraocular pressure: OD—8 mmHg.
∙ External and anterior segment examination, OD: Conjunctival hyperemia with papillary reaction.
There were 4+ cells (per high-power field) visible in the anterior chamber with a small (0.75-mm)
hypopyon. The right eye had an elevated, thin avascular bleb with a small infiltrate visible within
the bleb. The bleb had a positive Seidel test.
∙ Dilated fundus exam (DFE), OD: 3+ vitreous cell with a hazy view. Visible retina appeared to be
normal.
Course: Performed aqueous and vitreous taps; administered intravitreal vancomycin and ceftazidime;
and prescribed hourly topical, fortified gentamycin and vancomycin drops.
The patient responded well to treatment. His visual acuity has returned to baseline, and the bleb leak
resolved in 6 weeks.
A: Bleb-related endophthalmitis
P: Next appointment 2 months or earlier prn
ROB/pw D: 10/17/18 09:50:16 T: 10/18/18 12:55:01
CHAPTER 10 |
CHAPTER 10 REVIEW
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: SIMONSON-WALKER, SIERRA
ACCOUNT/EHR #: SIMOSI001
DATE: 10/17/18
Attending Physician: Oscar R. Prader, MD
S: Sierra Simonson-Walker, a 61-year-old woman, presented with left ear discharge with some bleeding.
Sierra has a 4-year history of progressive hearing loss in the left ear. She denied any pain, numbness, or
weakness.
O: Upon examination, her right ear is within normal limits and the left ear canal is completely blocked
with skin debris not consistent with cerumen. An attempt was made to remove the debris in the office,
but the patient could not tolerate the severe discomfort.
Medical History: Progressive hearing loss, no ear surgery, no reoccurring ear infections, no prolonged
exposure to sun, no head and neck malignancies.
Family History: Noncontributory
Social History: The patient denies alcohol and tobacco use.
Maximum conductive hearing loss on the left and normal hearing on the right is verified by the
audiometry.
CT scan showed opacification of the external ear canal with no evidence of bone erosion.
The patient is admitted and taken to the operating room; the debris is visualized to be flaky and kerati-
naceous. A portion of this was traced back to the anterior portion of the cartilaginous ear canal, where
it appeared to be adherent to the skin. This lesion was removed en block and sent to frozen pathology,
resulting in no identified carcinoma. There was also some irregular-appearing tissue along the tympanic
membrane, which was also removed and sent with the specimen. The patient underwent a tympano-
plasty without complication.
Final pathology, however, shows squamous cell carcinoma. The patient was then taken for a lateral tem-
poral bone resection and external ear canal closure.
A: Squamous cell carcinoma of the external ear canal, left
P: Will continue to follow patient closely
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: RIVERA, WALTER
ACCOUNT/EHR #: RIVEWA001
DATE: 10/16/18
Attending Physician: Renee O. Bracker, MD
CHAPTER 10 |
11
Key Terms
Coding Cardiovascular
Conditions
Learning Outcomes
Angina Pectoris After completing this chapter, the student should be able to:
Atherosclerosis
Atrium LO 11.1 Abstract the documentation accurately to report heart
Cerebral Infarction dysfunction.
Cerebrovascular Acci- LO 11.2 Discern the specifics of cardiovascular disease.
dent (CVA) LO 11.3 Evaluate documentation to determine details about abnormal
Edema blood pressure diagnoses.
Elevated Blood LO 11.4 Identify known manifestations of hypertension.
Pressure
Embolus LO 11.5 Interpret the details of cerebrovascular disease.
Gestational LO 11.6 Distinguish the sequelae of cerebrovascular disease and
Hypertension report them accurately.
Hypertension
Hypotension
Infarction
Myocardial Infarction Remember, you need to follow along in
(MI)
STOP! your ICD-10-CM code book for an optimal
ICD-10-CM
NSTEMI
Secondary learning experience.
Hypertension
STEMI
Thrombus
Vascular 11.1 Heart Conditions
Ventricle At the center of your body is the heart. Like the engine in a car, this small organ
pumps oxygen-rich blood through your arteries to every cell in your body, from your
head to your toes. The heart beats approximately once every second (60 beats per min-
ute). Each beat is a compression—the heart contracting to force blood through it and
out through the aorta to travel through the body delivering oxygen (see Figure 11-1).
Heart Disorders
Cardiac Arrest
Cardiac arrest means the heart actually stops beating. Typically, this happens suddenly.
The key factor that you need to know about this condition is that it must be caused
by something else. Possible causes of cardiac arrest include an underlying condition
such as a myocardial infarction (dead tissue within the heart), an arrhythmia (abnormal
heartbeat), electric shock (such as from wiring or lightning), a drug interaction, a drug
overdose, a medical procedure, or a trauma. Therefore, along with abstracting this spe-
cific diagnosis, you will also need to look for the underlying cause (Figure 11-2).
There are several codes available to report this condition, specifying the underlying
cause; here are some of the codes shown in the Tabular List:
I46.2 Cardiac arrest due to underlying cardiac condition
Code first underlying cardiac condition
I46.8 Cardiac arrest due to other underlying condition
Code first underlying condition
I97.710 Intraoperative cardiac arrest during cardiac surgery
294
I97.711 Intraoperative cardiac arrest during other surgery
I97.120 Postprocedural cardiac arrest during cardiac surgery CODING BITES
I97.121 Postprocedural cardiac arrest during other surgery In reality, there is a code
O75.4 Other complications of obstetric surgery and procedures available with no spe-
cific underlying cause:
As you can interpret from these code descriptions, you would have to go back to the I46.9 Cardiac arrest,
physician’s documentation and specifically identify the underlying condition (that caused cause unspecified
As you learned in
Abstracting Clinical
Documentation, you
are required to query
Superior vena cava the physician to obtain
Aorta the details about the
Aortic valve cause of this patient’s
Left pulmonary
artery cardiac arrest to be
Right pulmonary added to the documen-
artery Pulmonary trunk
Left pulmonary tation so the code you
veins report is accurate.
Branches of Left atrium
right pulmonary
veins
Bicuspid (mitral) valve
Right atrium
Chordae tendineae
Left ventricle
Opening of coronary
sinus Papillary muscle
Tricuspid valve
Septum
Right ventricle
Inferior vena cava
FIGURE 11-1 The anatomical components of the heart David Shier et al., HOLE’S HUMAN
ANATOMY & PHYSIOLOGY, 12/e. ©2010 McGraw-Hill Education. Figure 15.6b, p. 558. Used with permission.
Arrest, arrested
- cardiac I46.9
-- complicating
--- abortion — see Abortion, by type, complicated by, cardiac arrest
--- anesthesia (general) (local) or other sedation — see Table of Drugs and
Chemicals, by drug,
---- in labor and delivery O74.2
---- in pregnancy O29.11-
---- postpartum, puerperal O89.1
--- delivery (cesarean) (instrumental) O75.4
-- due to
--- cardiac condition I46.2
--- specified condition NEC I46.8
-- intraoperative I97.71-
FIGURE 11-2 ICD-10-CM, Alphabetic Index, partial, from Cardiac Arrest to Intra-
operative Arrest Source: ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare
and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)
CHAPTER 11 |
the cardiac arrest). You need this information so you can determine which of these two
GUIDANCE codes to report, and so you will know what that other (principal) diagnosis code should be.
CONNECTION
Dysrhythmia/Arrhythmia
Read the ICD-10-CM
Dysrhythmia, or arrhythmia, refers to an irregular heartbeat. Signs include tachycar-
Official Guidelines for
dia (rapid heartbeat, more than 100 beats per minute) or bradycardia (abnormally slow
Coding and Reporting,
heartbeat, less than 60 beats per minute). A short-term version of tachycardia may be pal-
section II. Selection of
pitations, a condition in which the patient feels a very rapid heartbeat that lasts only a
Principal Diagnosis,
few minutes. Palpitations are a temporary condition that may be caused by another con-
as well as section III.
dition, such as anxiety, whereas tachycardia is an ongoing malfunction of the heart.
Reporting Additional
Diagnoses. R00.0 Tachycardia, unspecified
R00.1 Bradycardia, unspecified
I49.8 Other specified cardiac arrhythmias
I49.9 Cardiac arrhythmia, unspecified
I97.89 Other postprocedural complications and disorders of the circulatory
system, not elsewhere classified
When you search for dysrhythmia or arrhythmia, the ICD-10-CM Alphabetic Index
directs you to I49.9. You can see that there are no codes specific to dysrhythmia.
Notice that other codes are suggested when this condition is diagnosed in a newborn or
occurring postoperatively. These details are a tip for you to go back to the documenta-
tion and check the patient’s age or if the patient was in the postoperative period when
the dysrhythmia occurred. Essentially, this diagnosis is vague, as it expresses what is
wrong (irregular heartbeat) but does not relate the reason or reasons why the heartbeat
is abnormal. You will need more specific information about the patient’s condition,
from either the documentation or the physician, to determine the correct code(s).
Mitral Valve Prolapse
Mitral valve prolapse is a rather common abnormality that prevents the mitral valve
Atrium from closing properly (the mitral valve is the gateway between the left atrium and the
A chamber that is located in left ventricle). A prolapse may develop or be influenced by other conditions, including
the top half of the heart and hyperthyroidism, congenital heart lesions, or Marfan syndrome.
receives blood. In the Alphabetic Index, find
Ventricle Prolapse, prolapsed
A chamber that is located in mitral (valve) I34.1
the bottom half of the heart
and receives blood from the When you turn to the code category in the Tabular List, you will see
atrium.
I34 Nonrheumatic mitral valve disorders
I34.1 Nonrheumatic mitral (valve) prolapse
The inclusion of the term “nonrheumatic” is a tip to go back into the documentation to
ensure that the physician did not state that the patient’s condition was caused by rheu-
matic fever. Rheumatic fever can manifest heart inflammation as well as affect joints
and other parts of the body. Rheumatic fever with heart involvement as well as chronic
rheumatic heart diseases are reported from code categories I01– I09.
Atrial Fibrillation
Atrial fibrillation is a condition in which atria shudder or tremble in the heart instead
of contracting to push blood through to the ventricles. This results in incomplete emp-
tying of the atria, leaving blood to collect and sometimes clot. Episodes of paroxysmal
atrial tachycardia (PAT), a rapid heart rate that can go as high as 150 or 200 beats per
minute, can occur. Anticoagulants (drugs that prevent clotting) and/or thrombolytics
(clot-dissolving drugs) are often prescribed.
I48.2 Chronic atrial fibrillation
I47.1 Supraventricular tachycardia (Atrial (paroxysmal) tachycardia)
ICD-10-CM
LET’S CODE IT! SCENARIO
Sara Cohen, a 73-year-old woman, was brought to the ED via ambulance after a witnessed cardiac arrest at the local airport.
Past medical history included hypertension, elevated cholesterol, and obstructive sleep apnea. She wore CPAP
nightly but continued to experience daytime somnolence. She has smoked half a pack of cigarettes a day for the past
40 years and drank no alcohol. She had a chronic daily cough. She walked 2 miles daily without dyspnea or other
limitation. She had never experienced chest pain, palpitations, presyncope, or syncope and had no known history of
CAD. Current medications included nifedipine 30 mg orally once daily and simvastatin 20 mg orally once daily.
On the day of presentation, she was at the airport waiting for a flight to visit her grandchildren. Bystanders at the
airport reported that they saw her suddenly drop to the floor while walking in the terminal. At a subsequent interview,
the first lay responder described that the woman collapsed abruptly without any vocalization and was found to be
unresponsive, pulseless, and without respirations. This lay responder, along with another bystander who was a nurse
without formal training in advanced resuscitation, began CPR. This particular airport had recently instituted a policy of
providing public access defibrillators in the terminals. Bystanders notified airport security staff, who brought a defibril-
lator to the scene and also called the EMTs. The woman was revived and brought to the hospital.
After examination, Dr. Troy diagnosed Sara with sudden cardiac arrest. He admitted her to the hospital for further
testing to determine the cause of this event.
CHAPTER 11 |
Heart Failure
CODING BITES
To determine the diag-
A diagnosis of heart failure is serious; however, it does not mean the heart has totally
nosis code for heart fail-
“failed” to function. This condition, also known as congestive heart failure (CHF),
ure, you need to know:
is characterized by the inability of an individual’s heart to pump a sufficient quantity
of blood throughout the body. Congestive heart failure can cause fluid to back up into
• What type of heart the lungs, resulting in respiratory problems such as shortness of breath and fatigue. In
failure? addition, fluid might build up in the lower extremities, causing edema (swelling) in the
• Is it acute or chronic? feet, ankles, and legs. In some patients, the edema can become so acute (severe) that
they may have pain and trouble walking.
The National Heart, Lung, and Blood Institute reported in November 2015 that
approximately 5.7 million people in the United States currently have a diagnosis of
heart failure. The institute estimates that this condition contributes to as many as
30,000 deaths each year.
Right heart failure, secondary to left heart failure, is diagnosed when the heart
cannot pump and circulate the blood needed throughout the body. Patients with this
diagnosis may develop hypertension, congestion, edema, and fluid collection in the
lungs.
Systolic heart failure occurs when the contractions of the ventricles are too weak to
push the blood through the heart. The documentation should include the specific detail
Secondary Hypertension that the condition is acute, chronic, or acute on chronic.
The condition of hypertension
caused by another condition I50.21 Acute systolic (congestive) heart failure
or illness. I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
Diastolic heart failure is the result of a ventricle of the heart being unable to fill as
CODING BITES it should. The documentation should include the specific detail that the condition is
When a condition, such acute, chronic, or acute on chronic.
as right heart failure,
causes the patient I50.31 Acute diastolic (congestive) heart failure
to develop another I50.32 Chronic diastolic (congestive) heart failure
condition, such as I50.33 Acute on chronic diastolic (congestive) heart failure
hypertension, that
other condition may be Combined systolic and diastolic heart failure means that the function of the heart
referred to as a second- is weak and unable to process blood properly. The documentation should include the
ary condition. specific detail that the condition is acute, chronic, or acute on chronic.
For example, if Ralph
developed hypertension I50.41 Acute combined systolic (congestive) and diastolic (congestive)
due to his right heart fail- heart failure
ure, you would report the I50.42 Chronic combined systolic (congestive) and diastolic (congestive)
hypertension as second- heart failure
ary hypertension. I50.43 Acute on chronic combined systolic (congestive) and diastolic
(congestive) heart failure
CHAPTER 11 |
GUIDANCE CODING BITES
CONNECTION A thrombus is a blood clot that has attached itself to the wall of a blood vessel. If
Read the ICD-10-CM Offi- left untreated, it may cause a blockage, preventing blood from flowing through
cial Guidelines for Coding the artery or vein. In addition, there is always concern that the clot will detach and
and Reporting, section float through the vessel and pass through an organ. A detached clot is known
I. Conventions, General as an embolus; it can get stuck as it passes through an organ and can com-
Coding Guidelines and pletely prevent blood from moving through. The greatest danger occurs when an
Chapter Specific Guide- embolus travels into the lung or the heart, potentially causing death.
lines, subsection C.
Chapter-Specific Cod- I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary
ing Guidelines, chapter artery
9. Diseases of the Circu- I21.02 ST elevation (STEMI) myocardial infarction involving left anterior
latory System, subsec- descending coronary artery
tion e. Acute myocardial I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery
infarction (AMI). I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex
coronary artery
CODING BITES Subsequent MI
If the physician docu- Another important aspect of a diagnosis of MI is whether or not this is the first time a
ments this encounter patient has experienced this event. When a patient is documented as having had an acute
has focused on the myocardial infarction (AMI) within the last 4 weeks (28 days) and is at your facility for
patient’s subsequent or a second event, this current MI is reported with a code describing a “subsequent” MI:
second MI and the . . .
I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall
• Previous MI was I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
within the last 4 I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction
weeks = code from I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites
category I22
When the previous MI is documented either as a “healed MI” or as a past MI with-
• Previous MI was out any current signs or symptoms, it is reported with this code:
more than 4 weeks
ago = code I25.2 I25.2 Old myocardial infarction
GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I.
Conventions, General Coding Guidelines and Chapter Specific Guidelines, sub-
section C. Chapter-Specific Coding Guidelines, chapter 9. Diseases of the Circu-
latory System, subsection e. Acute myocardial infarction (AMI), 4) Subsequent
acute myocardial infarction.
ICD-10-CM
YOU CODE IT! CASE STUDY
Mark is sitting in the stands watching his son play softball when all of a sudden he feels a severe pain in his chest.
He is having difficulty taking a breath, and the pain is radiating down his left arm. He arrives at the ED via ambu-
lance, and Dr. Constantine and nurses work on him, taking blood and doing an EKG. Dr. Constantine determines that
Mark had an ST elevation myocardial infarction (STEMI) of the inferolateral wall. Once he is stabilized, Mark is admit-
ted into the hospital and transferred to the ICU.
Carotid
artery Superior
vena cava CODING BITES
Jugular
vein
Cardiovascular: car-
Pulmonary dio = heart + -vascu-
Heart trunk
lar = vessels (veins and
Brachial
Aorta arteries)
artery Arteries = blood
Femoral vessels that carry oxy-
Inferior artery and genated blood from the
vena vein
cava heart to the tissues and
cells throughout the
body.
Veins = blood ves-
sels that carry deoxy-
genated blood, along
with carbon dioxide and
cell waste, away from
the tissues and cells
throughout the body
FIGURE 11-3 The cardiovascular system, highlighting major vessels Booth et al., Medi- and back to the heart.
cal Assisting, 5e. Copyright ©2013 by McGraw-Hill Education. Figure 22-6b, p. 479. Used with permission.
CHAPTER 11 |
Deep Vein Thrombosis
Earlier in this chapter, you learned about thrombi and emboli—blood clots that develop
within the blood vessels. Deep vein thrombi can block the blood flow, causing venous
insufficiency and affecting the ability of oxygen to get to the tissues throughout the body.
A lack, or reduction, of blood flow can cause edema, congestion, necrosis, and pain. In
addition, there is the danger that the blood clot can break loose and travel within the
veins and arteries (embolism), causing damage to internal organs, blocking oxygen from
the lungs (pulmonary embolism), or blocking off blood flow through the heart.
Reporting a diagnosis of deep vein thrombosis (DVT) [the presence of a blood clot
attached to the wall of an interior vein] will require you to know a few specifics to
determine the most accurate code:
∙ Is the condition identified as acute or chronic?
∙ Where (the specific anatomical site) has the thrombus been located?
I82.412 Acute embolism and thrombosis of left femoral vein
I82.543 Chronic embolism and thrombosis of tibial vein, bilateral
ICD-10-CM
YOU CODE IT! CASE STUDY
Dr. Victorelli examined Carter Franchez and diagnosed him with a chronic thrombosis of the right popliteal vein.
ICD-10-CM
YOU CODE IT! CASE STUDY
PATIENT: Basti, Carl
REASON FOR CONSULTATION: Surgical evaluation for coronary artery disease.
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old male who has a known history of coronary artery
disease. He underwent previous PTCA and stenting procedures in December and most recently in August. Since
that time, he has been relatively stable with medical management. However, in the past several weeks, he started to
notice some exertional dyspnea with chest pain.
For the most part, the pain subsides with rest. For this reason, he was reevaluated with a cardiac catheterization.
This demonstrated 3-vessel coronary artery disease with a 70% lesion to the right coronary artery; this was a proximal
lesion. The left main had a 70% stenosis. The circumflex also had a 99% stenosis. Overall left ventricular function was
mildly reduced with an ejection fraction of about 45%. The left ventriculogram did note some apical hypokinesis. In
view of these findings, surgical consultation was requested and the patient was seen and evaluated by Dr. Isaacson.
PAST MEDICAL HISTORY:
1. Coronary artery disease as described above with previous PTCA and stenting procedures.
2. Dyslipidemia.
3. Hypertension.
ALLERGIES: None.
(continued)
CHAPTER 11 |
MEDICATIONS: Aspirin 81 mg daily, Plavix 75 mg daily, Altace 2.5 mg daily, metoprolol 50 mg b.i.d., and Lipitor 10 mg q.h.s.
SOCIAL HISTORY: He quit smoking approximately 8 months ago. Prior to that time, he had about a 35- to 40-pack-
per-year history. He does not abuse alcohol.
FAMILY MEDICAL HISTORY: Mother died prematurely of breast cancer. His father died prematurely of gastric carcinoma.
REVIEW OF SYSTEMS: There is no history of any CVAs, TIAs, or seizures. No chronic headaches. No asthma, TB, hemop-
tysis, or productive cough. There is no congenital heart abnormality or rheumatic fever history. He has no palpitations.
He notes no nausea, vomiting, constipation, diarrhea, but immediately prior to admission, he did develop some diffuse
abdominal discomfort. He says that since then, this has resolved. No diabetes or thyroid problem. There is no depression
or psychiatric problems. There are no musculoskeletal disorders or history of gout; no hematologic problems or blood
dyscrasias; no bleeding tendencies; and no recent fevers, malaise, changes in appetite, or changes in weight.
PHYSICAL EXAMINATION: His blood pressure is 120/70; pulse is 80. He is in a sinus rhythm on the EKG monitor.
Respirations are 18 and unlabored. Temperature is 98.2 degrees Fahrenheit. He weighs 260 pounds and is 5 feet
10 inches. In general, this was a pleasant male who currently is not in acute distress. Skin color and turgor are good.
Pupils were equal and reactive to light. Conjunctivae clear. Throat is benign. Mucosa was moist and noncyanotic.
Neck veins not distended at 90 degrees. Carotids had 2+ upstrokes bilaterally without bruits. No lymphadenopathy
was appreciated. Chest had a normal AP diameter. The lungs were clear in the apices and bases; no wheezing or
egophony appreciated. The heart had a normal S1, S2. No murmurs, clicks, or gallops. The abdomen was soft, non-
tender, nondistended. Good bowel sounds present. No hepatosplenomegaly was appreciated. No pulsatile masses
were felt. No abdominal bruits were heard. His pulses are 2+ and equal bilaterally in the upper and lower extremi-
ties. No clubbing is appreciated. He is oriented x3. Demonstrated a good amount of strength in the upper and lower
extremities. Face was symmetrical. He had a normal gait.
IMPRESSION: This is a 47-year-old male with significant multivessel coronary artery disease. The patient also has a left
main lesion. He has undergone several PTCA and stenting procedures within the last year to year and a half. At this point,
in order to reduce the risk of any possible ischemia in the future, surgical myocardial revascularization is recommended.
PLAN: We will plan to proceed with surgical myocardial revascularization. The risks and benefits of this procedure
were explained to the patient. All questions pertaining to this procedure were answered.
Vaughn Pronder, MD
You Code It!
Carefully review Dr. Pronder’s documentation after his evaluation of Carl Basti, and determine the correct diag-
nosis code or codes to report.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
I10 Essential (primary) Hypertension
Z87.891 Personal history of nicotine dependence
Z79.82 Long term (current) use of aspirin
Good work!
Blood Pressure
The force with which blood travels through your veins and arteries must create enough
pressure to ensure the cycle of oxygenation and carbon dioxide is maintained properly.
Blood pressure that is too low—a condition known as hypotension (hypo = low or Hypotension
under + tension = pressure)—can result in organs and tissue cells being unable to Low blood pressure; systolic
function. In hypotension, the patient has lower-than-normal blood pressure. Low blood blood pressure below
pressure indicates an inadequate flow of blood and, therefore, inadequate oxygen to 90 mmHg and/or diastolic
the brain, heart, and other vital organs. Lightheadedness and dizziness can occur in measurements of lower than
60 mmHg.
a person with hypotension. Some medications, such as antianxiety drugs and diuret-
ics, can cause hypotension, as can alcohol and narcotics. Conditions such as advanced
diabetes, dehydration, or arrhythmia can also result in a patient suffering from hypo-
tension. Code category I95 will provide you with the details you will need to abstract
from the documentation about this diagnosis:
CHAPTER 11 |
Diastolic pressure (DP) is the measure of the pressure of blood left in the arteries
in between ventricular contractions. This is the bottom number of a reported blood
pressure.
Hypertension is a condition that millions of people must deal with every day and is
a major cause of death. According to the Centers for Disease Control and Prevention
(CDC), 29% of all American adults—70 million people—have high blood pressure.
These numbers include more women than men and a greater prevalence in individu-
als over 65 years of age. There are estimates that only about one-third of hypertensive
people have been officially diagnosed and are getting treatment. It is believed that as
many as 50% of all people over age 60 are included in these numbers.
The CDC also determined that high blood pressure was a primary or contributing
cause of death for more than 360,000 people in the United States in 2013. The risk of
heart disease is increased 300% by the presence of hypertension, and the risk of stroke
is increased 700%. Research also proves that African-Americans are at a much higher
risk of hypertension and its effects than any other racial or ethnic group.
Primary Hypertension
Hypertension frequently shows no signs and symptoms, other than continuous high
Vascular blood pressure measurements, until the condition alters vascular function in the heart,
Referring to the vessels (arter- brain, and/or kidneys. This effect is similar to what would happen if the pressure level
ies and veins). at which water flows through the pipes in your home increased: High pressure can
break a dish in your kitchen sink and make a mess. Patients with high blood pres-
sure specifically diagnosed as hypertension are known to suffer manifestations of this
condition, including damage to the heart and kidneys. Hypertension causes the heart
to work harder than normal and can result in left ventricular hypertrophy, which can
subsequently cause left-sided heart failure or right-sided heart failure as well as pul-
Edema monary edema (excess fluid in the tissues).
An overaccumulation of fluid There are many risk factors that promote the development of hypertension. Here are
in the cells of the tissues. a few of the most common:
∙ An underlying disorder such as renal disease or Cushing’s syndrome
∙ Chronic emotional stress
∙ A sedentary lifestyle
∙ Excessive sodium in diet
∙ Family history of hypertension
∙ Postmenopausal state
∙ Advancing age
∙ Excessive use of alcohol
∙ Obesity
∙ African-American ancestry
ICD-10-CM
LET’S CODE IT! SCENARIO
Anna Epstein, a 63-year-old female, came to see Dr. Tanner. She was complaining of occasional dizziness and a
headache. After a complete examination, Dr. Tanner diagnosed Anna with idiopathic systemic hypertension.
CHAPTER 11 |
Secondary Hypertension
There are occasions when another condition or a medication may cause hypertension
instead of hypertension causing other conditions (manifestations) in the patient. Medica-
tions, such as corticosteroids (e.g., prednisone), antidepressants (e.g., Sinequan), and hor-
mones (e.g., Estrace), or diseases, such as Cushing’s syndrome or scleroderma, may trigger
a hypertensive condition. When the hypertensive condition is generated by, or secondary
Secondary Hypertension to, another disease or medication, the condition is called secondary hypertension.
The condition of hypertension The involvement of renal disease as an underlying cause of hypertension, also
caused by another condition known as renovascular hypertension, may be diagnosed as a result of testing including:
or illness.
∙ Urinalysis, which shows protein levels and red and white blood cells indicating
glomerulonephritis (inflammation of small blood vessels in the kidneys).
∙ Excretory urography, which reveals renal atrophy (wasting away of a kidney),
pointing to chronic renal disease, or a shortening of one kidney, which may indicate
unilateral renal disease.
∙ Blood tests for serum potassium levels (measuring the levels of potassium in the
blood), which show levels below the normal measure of 3.5 mEq/L, which can indicate
primary hyperaldosteronism (hyper = high or over + aldosterone = a hormone pro-
duced by the adrenal cortex that prompts the kidney to preserve sodium and water).
Hypertension is coded as secondary when the physician uses terms such as “due
to” an underlying disease, “resulting from” another condition, or other descriptors that
GUIDANCE point to another disease or condition. In such cases, you will need two codes:
CONNECTION 1. The underlying condition
Read the ICD-10-CM 2. The type of secondary hypertension (I15.x)
Official Guidelines for
There is a notation to “Code also underlying condition.” Note that sequencing is
Coding and Report-
not identified in this notation. Therefore, you will need to report the two codes based
ing, section I. Con-
on the sequencing guidelines in the Official Guidelines, Section II, which will guide
ventions, General
you in determining the principal diagnosis code. So the order in which you will list the
Coding Guidelines
two codes is determined by the answer to the question, “Why did the patient come to
and Chapter Specific
see the physician today?”
Guidelines, subsec-
tion C. Chapter-Specific
Coding Guidelines, EXAMPLES
chapter 9. Diseases I15.0 Renovascular hypertension
of the Circulatory I15.1 Hypertension secondary to other renal disorders
System, subsection I15.2 Hypertension secondary to endocrine disorders
a.6) Hypertension, I15.8 Other secondary hypertension
secondary. I15.9 Secondary hypertension, unspecified
ICD-10-CM
LET’S CODE IT! SCENARIO
Breanna Payne, a 67-year-old female, came to see Dr. Lebonna in his office. She was having headaches and bouts
of dizziness. After a physical examination, a urinalysis, and blood work, he diagnosed her with benign hyperten-
sion. Dr. Lebonna’s notes stated that Breanna’s hypertension was the result of her existing diagnosis of pituitary-
dependent Cushing’s disease.
That’s right—a code for the Cushing’s disease. In the Alphabetic Index, you see the following under Cushing’s:
Cushing’s
Syndrome or disease E24.9
Pituitary-dependent E24.0
Hypertensive Crisis
Code category I16 provides three codes for reporting a hypertensive crisis. This is
when a patient suffers an acute and dramatic increase in blood pressure, measuring
approximately 180/120. This situation can result in blood vessels becoming dam-
aged and leaking, as well as dysfunction of the heart’s ability to pump blood through
the body.
A hypertensive crisis is categorized as either urgent or emergency.
CHAPTER 11 |
∙ I16.0 Hypertensive urgency identifies a patient with an extremely high spike of
CODING BITES blood pressure, with the belief that the vessels have not yet been damaged.
Code category I16 ∙ I16.1 Hypertensive emergency documents that the patient’s extraordinarily high
includes a notation blood pressure has caused damage to blood vessels and/or organs. This diagnosis
applicable to all codes can be associated with life-threatening complications.
in this category: ∙ I16.9 Hypertensive crisis, unspecified is a code that should rarely be reported.
Code also any identi- Instead, as you have learned, you should query the physician to determine what
fied hypertensive dis- type of crisis it is and have the documentation amended.
ease (I10-I15)
Hypertension and Pregnancy
When a pregnant woman has a diagnosis of hypertension, you will first need to determine
from the documentation whether she developed hypertension before or after conception.
A woman with a preexisting diagnosis of hypertension who then becomes pregnant
will be reported with the appropriate code from the O10 Pre-existing hypertension
complicating pregnancy, childbirth, and the puerperium code category. A code from the
Gestational Hypertension O10 code category reports this situation clearly with additional details, provided by
Hypertension that devel- the fourth character, to report the specific hypertensive manifestation, if any:
ops during pregnancy and
typically goes away once the O10.0- Pre-existing essential hypertension complicating pregnancy, child-
pregnancy has ended. birth, and the puerperium
O10.1- Pre-existing hypertensive heart disease complicating pregnancy,
childbirth, and the puerperium
GUIDANCE O10.2- Pre-existing hypertensive chronic kidney disease complicating preg-
CONNECTION nancy, childbirth, and the puerperium
O10.3- Pre-existing hypertensive heart and chronic kidney disease compli-
Read the ICD-10-CM cating pregnancy, childbirth, and the puerperium
Official Guidelines for O10.4- Pre-existing secondary hypertension complicating pregnancy, child-
Coding and Report- birth, and the puerperium
ing, section I. Con-
ventions, General However, if the hypertension is diagnosed as gestational hypertension, or tran-
Coding Guidelines sient hypertension, you will report a code from O13 Gestational [pregnancy-induced]
and Chapter Specific hypertension without significant proteinuria. This is not unusual and generally means
Guidelines, subsec- that the hypertension will go away after the baby is born.
tion C. Chapter-Specific O13.1 Gestational [pregnancy-induced] hypertension without significant
Coding Guidelines, proteinuria, first trimester
chapter 9. Diseases O13.2 Gestational [pregnancy-induced] hypertension without significant
of the Circulatory proteinuria, second trimester
System, subsec- O13.3 Gestational [pregnancy-induced] hypertension without significant
tion a.7) Hypertension, proteinuria, third trimester
transient.
Should the woman’s diagnosed hypertension cause problems directly related to the
pregnancy or complicating the pregnancy, you will choose the best, most appropriate code
from ICD-10-CM’s Chapter 15, Pregnancy, Childbirth, and the Puerperium (O00–O9A).
ICD-10-CM
LET’S CODE IT! SCENARIO
Zena Browning, a 23-year-old female, is 20 weeks pregnant. Dr. Shinto diagnoses her with gestational hyperten-
sion. Even though there is no evidence of proteinuria, he is concerned about the effect of the condition on her preg-
nancy and writes a prescription.
GUIDANCE
11.4 Manifestations of Hypertension CONNECTION
Read the ICD-10-CM
Hypertensive Heart Disease Official Guidelines for
When a patient has heart disease or heart failure and also has hypertension, you must Coding and Reporting,
carefully examine the words used by the physician in the description. section I. Conven-
tions, General Coding
1. Heart condition due to hypertension
Guidelines and Chapter
2. Hypertensive heart condition Specific Guidelines,
3. Heart condition with hypertension subsection C. Chapter-
Specific Coding Guide-
If the physician states that the patient has both hypertension and heart disease,
lines, chapter 9. Dis-
a combination code from code category I11 Hypertensive heart disease must be
eases of the Circulatory
recorded.
System, subsection
I11.0 Hypertensive heart disease with heart failure a.1) Hypertensive with
Use additional code to identify type of heart failure (I50.-) heart disease.
I11.9 Hypertensive heart disease without heart failure
CHAPTER 11 |
EXAMPLE
Acute congestive heart failure due to benign hypertension
You will report two codes, in this sequence: I11.0, I50.31
I11.0 Hypertensive heart disease with heart failure
I50.31 Acute diastolic (congestive) heart failure
ICD-10-CM
LET’S CODE IT! SCENARIO
Colin Fahey, a 53-year-old male, was diagnosed with chronic diastolic congestive heart failure due to benign hyper-
tension. Dr. Engman wrote a prescription for medication and scheduled follow-up tests.
ICD-10-CM
YOU CODE IT! CASE STUDY
Matthew Spencer, a 69-year-old male, is admitted to Franklin General Hospital for observation with a diagnosis of
stage 3 chronic renal disease due to benign hypertension.
(continued)
CHAPTER 11 |
Answer:
Did you determine these to be the diagnosis codes?
I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease or
unspecified chronic kidney disease
N18.3 Chronic kidney disease, stage 3 (moderate)
ICD-10-CM
YOU CODE IT! CASE STUDY
Clarissa Bennelli, a 71-year-old female, is seen at Weston Hospital with a diagnosis of acute systolic congestive
heart failure due to hypertensive heart disease. Ms. Bennelli responds positively to Lasix therapy. She is also diag-
nosed with stage 1 chronic renal disease.
ICD-10-CM
YOU CODE IT! CASE STUDY
Denise Argudin, a 53-year-old female, came to see Dr. Fenwick because she was experiencing headaches and
problems with her vision. Denise was diagnosed with essential benign hypertension 3 years ago. After a thorough
physical examination and further questioning about her visual disturbances, Dr. Fenwick ordered a CT scan of her
head and a few other tests. The test results indicate that Denise has hypertensive encephalopathy.
(continued)
CHAPTER 11 |
You Code It!
Carefully review Dr. Fenwick’s notes on his visit with Denise, along with the test results. Determine the best, most
appropriate diagnosis code or codes.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Infarction
Tissue or muscle that has
deteriorated or died (necrotic).
GUIDANCE
CONNECTION
Read the ICD-10-CM
Official Guidelines for
Coding and Report-
ing, section I. Con-
ventions, General
Coding Guidelines
and Chapter Specific
Guidelines, subsec-
tion C. Chapter-Specific
Coding Guidelines,
chapter 9. Diseases of
the Circulatory System,
subsection c. Intraop-
erative and postproce-
dural cerebrovascular
accident.
FIGURE 11-5 Illustration highlighting an aneurysm causing a hemorrhagic stroke
CHAPTER 11 |
You will need specific details about the patient’s condition, abstracted from the
documentation, to determine the correct code category, and then the correct code to
report:
∙ Was the attack a result of a hemorrhage from a cerebral aneurysm or an obstruction
from a thrombus or embolism?
∙ What is the specific anatomical site of the attack?
I61.- Nontraumatic intracerebral hemorrhage
I63.- Cerebral infarction (occlusion and stenosis of cerebral arteries,
resulting in cerebral infarction)
I65.- Occlusion and stenosis of precerebral arteries, not resulting in cere-
bral infarction
I66.- Occlusion and stenosis of cerebral arteries, not resulting in cerebral
infarction
It can happen that a cerebrovascular hemorrhage or infarction is brought about by a
GUIDANCE medical procedure, most typically surgery. When the procedure is plainly identified as
the cause of the infarction, you have to use two codes. The first code will be
CONNECTION
I97.810 Intraoperative cerebrovascular infarction during cardiac surgery
Read the ICD-10-CM I97.811 Intraoperative cerebrovascular infarction during other surgery
Official Guidelines for I97.820 Postprocedural cerebrovascular infarction following cardiac surgery
Coding and Reporting, I97.821 Postprocedural cerebrovascular infarction following other surgery
section I. Conven-
tions, General Coding As noted below code I97.8, you will need an additional code to identify the exact
Guidelines and Chapter complication. The second code will identify the exact nature of the infarction, and you
Specific Guidelines, will choose it from the I60–I67 range, as appropriate, according to the documentation.
subsection C. Chapter-
Specific Coding Guide- NIH Stroke Scale
lines, chapter 18.
Symptoms, signs, and
The National Institutes of Health Stroke Scale (NIHSS) is used to assess a patient’s
abnormal clinical and
cerebral activity and function after a cerebrovascular accident (CVA—also known as a
laboratory findings, not
stroke). The assessment tool provides health care professionals with a numeric (quan-
elsewhere classified,
tifiable) way to measure impairment.
subsection i. NIHSS
Code category R29.7 National Institutes of Health Stroke Scale (NIHSS) score pro-
Stroke Scale.
vides you with 43 codes from which to choose to accurately report the score. Notice
that this code is reported after the code to report the type of cerebral infarction (code
category I63).
ICD-10-CM
YOU CODE IT! CASE STUDY
Ruben Sackheim, a 55-year-old male, was brought into the recovery room after having a craniectomy for the drain-
age of an intracranial abscess. Dr. Turner’s notes indicate that Ruben had a postoperative cerebrovascular infarc-
tion with intracranial hemorrhage and an acute subdural hematoma.
CHAPTER 11 |
ICD-10-CM
LET’S CODE IT! SCENARIO
Arlene Williams goes to see Dr. McGovern. She was diagnosed with a cerebral embolism 3 months ago that has now
been resolved. She explains that she has been having difficulty putting words together to make a sentence and it
seems to be getting worse. After examination, Dr. McGovern diagnoses her with post-cerebral embolic dysphasia.
CODING BITES
Read carefully! Dysphasia (ending in “sia”) means impaired speech and dyspha-
gia (ending in “gia”) means difficulty swallowing. Another word that is close is dys-
plasia, which means abnormal cell growth. Big difference!
Chapter Summary
Cardiovascular conditions may initially be treated within the specialty of a cardiologist.
However, the manifestations of heart failure and heart disease can affect the patient any-
where in the body—from the brain to the feet. Blood vessels extend throughout the body,
from the large aorta to the tiny capillaries, delivering oxygen and transporting carbon
CHAPTER 11 REVIEW
the entire body, as well as the patient’s quality of life, can be negatively affected.
Hypertension is a condition that you may encounter as a professional coder while work-
ing for a family physician, an internist, a gerontologist, or a cardiologist. It can be a very
dangerous condition and can cause many co-morbidities and manifestations. As complex
as the condition is, so is the coding of the diagnosis. As with all other situations, it must be
diagnosed and documented by the attending physician. Read the notes carefully, and query
the physician when necessary to get all the specifics that you need to code accurately.
Source: http://www.cdc.gov/vitalsigns/heartdisease-stroke/infographic.html
CHAPTER 11 REVIEW
Coding Cardiovascular Conditions Enhance your learning by
completing these exercises
and more at connect.mheducation.com!
Part I
1. LO 11.2 Chest pain. A. Angina Pectoris
2. LO 11.3 An occurrence of high blood pressure; an isolated or infrequent reading B. Atherosclerosis
of a systolic blood pressure above 140 mmHg and/or a diastolic blood C. Atrium
pressure above 90 mmHg.
D. Cerebral Infarction
3. LO 11.5 A stroke.
E. Cerebrovascular
4. LO 11.5 An area of dead tissue (necrosis) in the brain caused by a blocked or Accident (CVA)
ruptured blood vessel.
F. Edema
5. LO 11.2 A condition resulting from plaque buildup on the interior walls of the
G. Elevated Blood
arteries, causing reduced blood flow.
Pressure
6. LO 11.1 A thrombus that has broken free and is traveling freely within the vas-
H. Embolus
cular system.
7. LO 11.1 A chamber that is located in the top half of the heart and receives blood.
8. LO 11.3 An overaccumulation of fluid in the cells of the tissues.
Part II
1. LO 11.1 A chamber that is located in the bottom half of the heart and receives A. Gestational
blood from the atrium. Hypertension
2. LO 11.3 High blood pressure, usually a chronic condition; often identified by a B. Hypertension
systolic blood pressure above 140 mmHg and/or a diastolic blood pres-
sure above 90 mmHg.
CHAPTER 11 |
3. LO 11.3 Hypertension that develops during pregnancy and typically goes away C. Hypotension
CHAPTER 11 REVIEW
CHAPTER 11 REVIEW
disease (which has since resolved) should be reported from
a. the I60–I69 range. b. the I69 code category.
c. the Z86.7- code subcategory. d. none of these.
9. LO 11.3 According to ICD-10-CM Official Guidelines section I.C.9.a.7 “Assign code _____, Elevated blood
pressure reading without diagnosis of hypertension, unless patient has an established diagnosis of
hypertension.”
a. R03.1 b. I15.1 c. R03.0 d. I10
10. LO 11.3 A physician can support a diagnosis of hypertension with all of the following data except
a. auscultation over the abdominal aorta. b. EKG.
c. chest x-ray. d. ACE.
CHAPTER 11 |
2. LO 11.3 What is the difference between hypertension and elevated blood pressure?
CHAPTER 11 REVIEW
ICD-10-CM
YOU CODE IT! Basics
First, identify the main term in the following diagno- 8. Chronic embolism of superior vena cava:
ses; then code the diagnosis. a. main term: _____ b. diagnosis: _____
Example: Acute rheumatic myocarditis: 9. Rupture of pulmonary vessels:
a. main term: myocarditis b. diagnosis: I01.2 a. main term: _____ b. diagnosis: _____
10. Nonrheumatic pulmonary valve stenosis:
1. Acute diastolic (congestive) heart failure:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
11. Arteriosclerotic endocarditis:
2. Secondary hypertension due to
pheochromocytoma: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 12. Giant cell myocarditis:
3. Left posterior fascicular block: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 13. Cardiac arrest due to cardiac condition:
4. Aneurysm of heart, 6 weeks’ duration: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 14. Ventricular fibrillation:
5. Ischemic cardiomyopathy: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 15. Neurogenic orthostatic hypotension:
6. Chronic total occlusion of coronary artery: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
7. Atherosclerosis of bypass graft of coronary artery
of transplanted heart:
a. main term: _____ b. diagnosis: _____
ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. Kitty Hearn, a 63-year-old female, presents today with the complaint of chest tightness. She also states that her left
jaw and shoulder hurt. Dr. Kickey notes diaphoresis. Kitty has smoked cigarettes for 40 years. Dr. Kickey com-
pletes an examination and reviews blood test results, which reveal a high level of creatine phosphokinase (CPK).
Kitty is admitted to the hospital, where a coronary angiography confirms the diagnosis of crescendo angina.
2. Calvin Ballew, an 8-year-old male, is brought in by his parents with the complaint that Calvin has been
“out of sorts” for the last day or two and has not been eating well. Dr. Barfield notes a cough and labored
CHAPTER 11 |
CHAPTER 11 REVIEW
ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documenta-
tion from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient
encounters. Using the techniques described in this chapter, carefully read through the case studies and determine
the most accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: CROWDER, CHRISTOPHER
ACCOUNT/EHR #: CROWCH001
DATE: 11/04/18
ATTENDING PHYSICIAN: Oscar R. Prader, MD
ADMITTING DIAGNOSES: Deep venous thrombosis (DVT) right leg
Urinary tract infection (UTI)
Parkinson’s disease
FINAL DIAGNOSES: Acute DVT, right
UTI
Parkinson’s disease
HOSPITAL COURSE: The patient presented to the office with left leg pain, and uneasiness as well as
cloudy urine. He was evaluated, and Doppler studies of the leg confirmed DVT. Urinalysis reveals infec-
tion and the patient was started on Levaquin and Lovenox subcu 1 mg per kg twice a day; after 3 days
patient asymptomatic for both with his urinary symptoms and calf pain. Patient’s vital signs are stable.
He is afebrile. Lungs clear. Heart rhythm regular.
CHAPTER 11 |
CHAPTER 11 REVIEW
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: WEINER, PHILLIP
ACCOUNT/EHR #: WEINPH001
DATE: 08/03/18
Attending Physician: Oscar R. Prader, MD
Pt is a 73-year-old male who was admitted to the hospital because of asthenia, xerostomia, fatigue. The
patient states he is very weak, drinks a lot of water, but has not been urinating much. His blood pressure
was 165/91, and he has been having pain in the left jaw and neck.
PMH: 2003 he had bladder suspension operation and has a history of PVCs.
The patient has had trouble with some edema of the ankles and feet.
The electrocardiogram shows a sinus rhythm with premature ventricular contractions.
FH: Father died of CVA. Mother died of stomach cancer.
CURRENT MEDICATIONS: Inderal; Ativan; Zestril
ALLERGIES: NKA
FINAL DIAGNOSES:
1. Acute myocardial infarction—anterior wall
2. Systemic arterial hypertension
3. Cardiomegaly with chronic systolic CHF
4. Cardiac arrhythmia
learning experience.
Congenital Anomalies
Respiratory distress and cyanosis are the two most frequent manifestations of congeni-
tal anomalies of the lungs and are usually identified within the child’s first 24 months.
The most common congenital respiratory disorder is pulmonary hypoplasia, a situa-
tion in which the lung does not form completely or forms improperly. When you are
reporting this condition, ICD-10-CM requires you to determine from the documenta-
tion whether the pulmonary hypoplasia is a result of short gestation (i.e., prematu-
rity) or not. If the gestation is short, it is reported with code P28.0 Primary atelectasis
of newborn (pulmonary hypoplasia associated with short gestation). If it is not, it is
reported with code Q33.6 Congenital hypoplasia and dysplasia of lung.
The most common cause of neonate mortality is respiratory distress syndrome (RDS)
and it is seen most often in premature births. RDS can be fatal within 72 hours if not
treated. Mechanical ventilation improves patient outcomes. Idiopathic RDS is reported
with code P22.0 for a newborn or code J80 for acute RDS in a child or adult patient.
Remember, the definition of a neonate (newborn) is one who is age 28 days or younger.
Genetic Disorders
CODING BITES
Congenital anomalies
Alpha-1 antitrypsin deficiency is a genetic condition that may cause respiratory dysfunc-
occur during gestation.
tion as well as liver disease. Individuals with an alpha-1 antitrypsin deficiency often will
However, the problem
develop emphysema, with the first signs and symptoms appearing in adulthood (between
may not be diagnosed
ages 20 and 50). Cystic fibrosis is another genetic condition that causes malfunction of the
until later on in the
mucous glands and results in progressive damage to the lungs. A mutation of the BMPR2
patient’s life.
gene causes pulmonary arterial hypertension, a genetic condition with extremely high
hypertension specifically in the pulmonary artery. Dyspnea and fainting are symptoms
of this condition. Primary pulmonary arterial hypertension is reported with code I27.0,
while secondary pulmonary arterial hypertension is reported with code I27.21.
Trauma
Car accidents and other activities can result in trauma to the chest, throat, or nose that
can interfere with a patient’s ability to breathe. Traumatic pneumothorax (S27.0xx-)
may result from a penetrating chest wound or can occur due to a medical misadven-
ture during the insertion of a central venous line or during thoracic surgery. During
a pneumothorax, air accumulates between the parietal and visceral pleurae, reducing
the space in the chest cavity and thereby limiting the room the lungs have to expand
during inhalation. When the lungs cannot expand properly, oxygen cannot be brought
down into the lungs far enough, so breathing becomes difficult and the exchange of
gases (oxygen and carbon dioxide) is hindered. Blunt trauma to the chest, or a pen-
etrating wound, can also cause hemothorax, in which blood (instead of air, as in pneu-
mothorax) fills the pleural cavity. Report this condition with code J94.2 Hemothorax.
ICD-10-CM
LET’S CODE IT! SCENARIO
Vincent Perdimo, a 17-year-old male, decided he wanted to audition for the State Fair. After watching some videos
online, he decided that he could do a fire-eating act. As he was practicing in his backyard, he accidentally aspirated
some of the isopropyl alcohol he poured in his mouth. After he began having problems breathing, his parents took
him to the ED. Dr. Van Hooven documented that Vincent had severe pulmonary complications, and appeared to
have pneumonitis with partial respiratory insufficiency. After a workup and testing, Vincent was admitted into the
hospital with a diagnosis of acute respiratory distress syndrome.
Environment
Respiratory dysfunction can be caused by elements in the world around us. Those
elements can be natural, like volcanic dust from an erupting volcano or dander from
cats, or human-made, such as asbestos in the ceiling (J61). Legionnaires’ disease, an
CHAPTER 12 |
aerobic Gram-negative bacillus, is transmitted through the air—for example, through
air-conditioning systems (J67.7). Men are more susceptible than women. Administra-
tion of antibiotics, specifically erythromycin, is the primary treatment, along with
fluid replacement and oxygen administration, if necessary. When a patient is diag-
nosed with coal worker’s pneumoconiosis, another environmentally caused lung dis-
ease, this is reported with code J60 Coal worker’s pneumoconiosis, along with code
Y92.64 Mine or pit as the place of occurrence of the external cause and Y99.0 Civilian
activity done for income or pay.
Some patients may suffer respiratory problems from air contaminants at work, which
would be reported with a subsequent code; for example: Z57.31 Occupational expo-
sure to environmental tobacco smoke; Z57.39 Occupational exposure to other air con-
taminants; Z77.110 Contact with and (suspected) exposure to air pollution; or Z77.22
Contact with and (exposure to) environmental tobacco smoke (acute) (chronic).
Lung Infections
Both bacteria and viruses can cause respiratory disorders. Bacterial pneumonia
(J15.-), community-acquired pneumonia, nosocomial (originating in a hospital) pneu-
monia, viral pneumonia (J12.-), and opportunistic pneumonia (affecting individuals
with compromised immunities) are common examples of respiratory infection. In
addition, bronchitis (inflammation of the bronchi) (J20.-) and influenza (J09.- or J10.-)
are also frequently seen, particularly in children and the elderly. Viruses affecting the
pulmonary parenchyma result in interstitial pneumonia (J84.9). Mycobacterium tuber-
culosis, acquired by inhaling aerosols, has been seen more often in the last several
years, especially in patients who are HIV-positive and have developed AIDS. When an
HIV-positive patient is diagnosed with tuberculosis affecting the lungs, this condition
would be reported with code B20 HIV, followed by code A15.0 Tuberculosis of the lung.
Lifestyle Behaviors
Smoking cigars and cigarettes is known to cause respiratory disorders, including lung
cancer. In addition, sedentary lifestyles can encourage the creation of thrombi in the
legs. What does that have to do with the lungs? A dislodged thrombus becomes an
embolus that can travel through the pulmonary artery into the lungs, becoming a pul-
monary embolus. An acute pulmonary embolism NOS is reported with code I26.99;
however, several other details are required for a complete code.
GUIDANCE CONNECTION
At the very beginning of this chapter in ICD-10-CM, there is a Use additional code
notation. It states:
Use additional code, where applicable, to identify:
exposure to environmental tobacco smoke (Z77.22)
exposure to tobacco smoke in the perinatal period (P96.81)
history of tobacco use (Z87.891)
occupational exposure to environmental tobacco smoke (Z57.31)
tobacco dependence (F17.-)
tobacco use (Z72.0)
This applies to all codes in this chapter of ICD-10-CM, which makes sense, right?
It has been proven that inhaling tobacco has a negative effect on the pulmonary
system. If the physician’s documentation is not clear on this detail, you must query
the physician to have it added, if applicable, so you can report this code, as well
as the specific respiratory diagnosis.
See more details about this later in this chapter, in the section Reporting
Tobacco Involvement.
CHAPTER 12 |
∙ Pleural effusion: The presence of excess fluid in the pleural cavity, frequently a
manifestation of congestive heart failure.
J94.0 Chylous effusion
J91.0 Malignant pleural effusion
P28.89 Newborn pleural effusion
Pneumothorax ∙ Pneumothorax: The presence of excess air or gases in the pleural space, typi-
A condition in which air or gas cally caused by respiratory disease such as chronic obstructive pulmonary disorder
is present within the chest (COPD) or tuberculosis (TB).
cavity but outside the lungs.
J93.81 Chronic pneumothorax
J86.9 Pyothorax without fistula (empyema) [an infection within the
pleural space]
∙ Hemothorax: An accumulation of blood in the pleural cavity, most often caused by
an injury to the thoracic cavity (the chest).
J94.2 Hemothorax
Pulmonary Embolism
As you probably remember, an embolus is the medical term for a blood clot (thrombus)
CODING BITES or other tiny piece of bone marrow fat (most often created by high cholesterol) that
Why is a hemothorax travels within the bloodstream. During its passage through the body, this embolus can
coded as a type of pleu- get stuck in an artery and block the flow of blood through that area. When this occurs
ral effusion? Remember in the lungs, it is called a pulmonary embolism.
that a pleural effusion The presence of a pulmonary embolism can create serious problems for the patient,
is the accumulation of including dyspnea (shortness of breath), pain, and/or hemoptysis (coughing up blood).
excessive fluid in the Over the course of time, a pulmonary embolism can result in permanent damage to the
pleural space. Blood is a lung as well as damage to the organs being denied oxygen because of the blockage. A
type of fluid. pulmonary embolism can also cause an infarction (necrotic tissue) due to the lack of oxy-
gen to the cells. A large clot, or cluster of several clots, can result in the patient’s death.
I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale
I27.82 Chronic pulmonary embolism
ICD-10-CM
LET’S CODE IT! SCENARIO
Fawn Springwater, a 3-year-old female, was brought to her pediatrician, Dr. Canterberg, with an odd-sounding
cough and chest congestion. She had the measles just a short time prior. After a complete PE and the appropriate
tests, Dr. Canterberg diagnosed Fawn with the croup.
Pulmonary Fibrosis
Fibrosis is the creation of extra fibrous tissue (also known as scar tissue) in response to
inflammation or irritation. When this abnormal process occurs in the lungs, it is called
pulmonary fibrosis. This development of thickened tissue reduces the flexibility of
the lung sac, making it harder for the lungs to expand with inspiration and contract
for expiration. Idiopathic pulmonary fibrosis may also be referred to as cryptogenic
fibrosing alveolitis, diffuse interstitial fibrosis, idiopathic interstitial pneumonitis, and
Hamman-Rich syndrome.
Pulmonary fibrosis may be caused by another disease, such as tuberculosis, or
develop as a result of debris inhaled from an environment, such as the dust that may
be breathed in by sand blasters or coal miners during their work. Pulmonary fibrosis is
also associated as a side effect of certain medications.
J84.10 Pulmonary fibrosis, unspecified
ICD-10-CM
YOU CODE IT! CASE STUDY
Hans Surgesson, a 47-year-old male, has been suffering with chronic inflammation of his left bronchus. He admits to
previous crack cocaine use but denies current use. He complains of a dry, hacking, paroxysmal cough and occasional
dyspnea lasting at least 5 months. Chest x-ray and pulmonary function tests lead Dr. Mellville to diagnose Hans with
idiopathic pulmonary fibrosis due to mucopurulent chronic bronchitis. Hans is placed on oxygen therapy immediately.
(continued)
CHAPTER 12 |
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine these to be the correct codes?
J84.112 Idiopathic pulmonary fibrosis
J41.1 Mucopurulent chronic bronchitis
Terrific!
GUIDANCE
EXAMPLES
CONNECTION
J12.0 Adenoviral pneumonia
J15.0 Pneumonia due to Klebsiella pneumoniae Read the ICD-10-CM
Official Guidelines
Note that these examples of pneumonia codes are both combination codes,
for Coding and
reporting both the condition (pneumonia) and the pathogen (adenovirus or Kleb-
Reporting, section I.
siella). Not all pneumonia codes are combination codes, so you may need to
Conventions, General
remember to use an additional code to identify the pathogen.
Coding Guidelines
and Chapter Specific
Pneumonia as a Manifestation of HIV Guidelines, subsec-
tion C. Chapter-Specific
In some cases, pneumonia may be a manifestation of HIV infection. Therefore, if the Coding Guidelines,
notes report that the patient has also been diagnosed with HIV-positive status, you chapter 10. Diseases
have to include of the Respiratory
B20 Human immunodeficiency virus (HIV) disease System, subsec-
tion c. Influenza due
Code B20 should be listed first, followed by the appropriate pneumonia code. There to certain identified
are other types of pneumonia that may have other underlying diseases. Read the nota- influenza viruses.
tions carefully.
ICD-10-CM
LET’S CODE IT! SCENARIO
Craig Alaksar, a 13-year-old male, came to see Dr. Winston with a complaint of a sore throat, fever, cough, chills,
and malaise. Dr. Winston examined Craig, took a chest x-ray, and did a WBC count. After reviewing the results of the
exam and tests, Dr. Winston diagnosed Craig with adenovirus pneumonia.
(continued)
CHAPTER 12 |
Will the Tabular List confirm that it is the correct code? Turn to
J12 Viral pneumonia, not elsewhere classified
There are no notations or directions, so keep reading to review all of the choices for the required fourth character:
J12.0 Adenoviral pneumonia
You will remember that when there is an infectious organism involved, you must code it. Dr. Winston’s notes
identify it as the adenovirus. Should you use an additional code or not?
Professional coding specialists are responsible for relating the entire story with all specific details applicable
to the diagnosis. This one combination code tells both the condition and the infectious organism. There is no
reason to provide a second code to repeat the same information. Therefore, the code on Craig’s claim form will
be J12.0 alone.
(continued)
CHAPTER 12 |
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the code?
J09.X3 Influenza due to identified novel influenza A virus with gastrointestinal manifestations
EXAMPLES
J40 Bronchitis, not specified as acute or chronic
J41.- Simple and mucopurulent chronic bronchitis
J42 Unspecified chronic bronchitis
J43.- Emphysema
J44.- Other chronic obstructive pulmonary disease
J45.- Asthma
Diagnoses in the COPD section can be particularly complex. You will need to be
very diligent as you read the terms in the physician’s notes and those included in the
code descriptions. It is, as always, crucial that you refer to the index and then verify
the code in the Tabular List.
Let’s look at some of the diagnostic statements that might be used in the documen-
tation, by reading through the note under J44.
J44 Other chronic obstructive pulmonary disease
asthma with chronic obstructive pulmonary disease
chronic asthmatic (obstructive) bronchitis
chronic bronchitis with airways obstruction
chronic bronchitis with emphysema
ICD-10-CM
LET’S CODE IT! SCENARIO
Tiffany Burnstein, a 57-year-old female, quit smoking 2 years ago after a two-pack-a-day habit that lasted 40 years.
She came to see Dr. Mercado with an insidious onset of dyspnea, tachypnea, and malaise. PE showed use of her
accessory muscles for respiration. Dr. Mercado took a chest x-ray, EKG, RBC count, and pulmonary function test. The
results directed a diagnosis of panlobular emphysema.
CHAPTER 12 |
and follows the sequencing rules that you learned earlier. In addition, status asthmati-
CODING BITES cus, being the more severe condition, will override an additional diagnosis of acute
If both diagnoses are exacerbation of asthma.
included in the notes—
status asthmaticus and
acute exacerbation of
asthma—use only one GUIDANCE CONNECTION
asthma code, for status
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I.
asthmaticus. Do not use
Conventions, General Coding Guidelines and Chapter Specific Guidelines,
two asthma codes.
subsection C. Chapter-Specific Coding Guidelines, chapter10. Diseases of the
Respiratory System, subsection a. Chronic Obstructive Pulmonary Disease
[COPD] and Asthma.
ICD-10-CM
LET’S CODE IT! SCENARIO
Isabella LaVelle, a 41-year-old female, has a history of intermittent dyspnea and wheezing. She comes today to see
Dr. Slater with complaints of tachypnea, chest tightness, and a cough with thick mucus. The results of Dr. Slater’s PE,
the chest x-ray, sputum culture, EKG, pulmonary function tests, and an arterial blood gas analysis indicate moderate,
persistent asthma with COPD, with exacerbation.
CHAPTER 12 |
agent may impact the patient. When it comes to health care issues, this would
apply to an individual who does not use tobacco products but lives or works
with someone who smokes, resulting in the patient’s breathing in secondhand
tobacco smoke on an ongoing basis. If this individual develops a respiratory
disease as a result of this environment, you would include a code to report this
exposure.
EXAMPLE
Z77.22 Contact with and (suspected) exposure to environmental tobacco
smoke (acute) (chronic) [Exposure to second hand tobacco smoke]
∙ Use is the term that identifies that the patient smokes tobacco on a regular basis,
taken by his or her own initiative, even though the substance is known to be a detri-
ment to one’s health. There are no obvious clinical manifestations.
EXAMPLE
Z72.0 Tobacco use
∙ Abuse describes the patient’s habitual smoking of tobacco, taken by his or her own
initiative, even though the substance is known to be a detriment to one’s health.
Clinical manifestations are evident as signs and symptoms develop. The patient
deals with a daily fixation on obtaining and smoking tobacco with virtually every-
thing else in life becoming secondary.
EXAMPLE
F17.218 Nicotine dependence, cigarettes, with other nicotine-induced
disorders
EXAMPLE
F17.220 Nicotine dependence, chewing tobacco, uncomplicated
∙ History describes a patient who has successfully quit using tobacco products.
EXAMPLE
Z87.891 Personal history of tobacco dependence
CHAPTER 12 |
an external cause, you will need to report the details of the event so that you tell the
CODING BITES whole story. In addition to reporting the other codes, you will also need to report codes
Refer back to that explain
the Abstracting Clinical ∙ Cause of the injury, such as a car accident or a fall off a ladder.
Documentation chapter
to remind yourself about ∙ Place of the occurrence, such as the park or the kitchen.
reporting external cause ∙ Activity during the occurrence, such as playing basketball or gardening.
codes whenever you ∙ Patient’s status, such as paid employment, on-duty military, or leisure activity.
are reporting an injury
or poisoning.
ICD-10-CM
LET’S CODE IT! SCENARIO
Amanda Bleigh, a 33-year-old female, works in a veterinary clinic. After a very sick stray animal was brought in, she
was instructed by her boss to disinfect the floor of the clinic by mopping it with straight bleach. It was cold outside,
so all the doors and windows were closed tightly. Amanda began to have trouble breathing. She went immediately
to Dr. Litzkom’s office, where, after examination and tests, he diagnosed her with acute chemical bronchitis.
Chapter Summary
Sadly, most people take breathing for granted . . . until they cannot do it without
difficulty or pain. You have to know how to code respiratory conditions accurately
whether you are working for a family physician, a pediatrician, respiratory therapist,
or a pulmonologist. In addition, respiratory conditions might be present in a patient of
an immunologist; allergist; or ear, nose, and throat (ENT) specialist.
CODING BITES
Did you know . . . ?
• The average healthy adult’s respiration rate is 12 to 15 per minute. Adult men
breathe more slowly than adult women. Neonates breathe 30 to 60 times per
minute.
• The entire surface area of both lungs combined is approximately the same sur-
face area as a tennis court.
• Expiration (breathing out) not only expels carbon dioxide from the body, but
water as well—an estimated 12 ounces a day.
• A yawn is an autonomic response when your brain determines the body needs
more oxygen.
• The left lung is smaller than the right lung to accommodate the placement of the
heart in the thoracic cavity.
CHAPTER 12 |
CHAPTER 12 REVIEW
CHAPTER 12 REVIEW
CHAPTER 12 REVIEW
d. these two diagnoses cannot be in the same patient at the same time.
7. LO 12.2 Jake Phillipson, a 59-year-old male, presents with dyspnea, tachypnea, and chest pain. After an exami-
nation, Jake is diagnosed with a saddle embolus of pulmonary artery with acute cor pulmonale. How
would this be coded?
a. I26.09 b. Z86.711 c. I26.92 d. I26.02
8. LO 12.6 Respiratory conditions need external cause codes
a. never. b. sometimes.
c. always. d. only if there is an external cause for the condition.
9. LO 12.5 _____ is the term that identifies that the patient smokes tobacco on a regular basis, taken by his or her
own initiative, even though the substance is known to be a detriment to one’s health. There are no obvi-
ous clinical manifestations.
a. Exposure b. Use c. Abuse d. Dependence
10. LO 12.3 Code the diagnosis of pneumonitis due to inhalation of lubricating oil, unintentional, initial encounter.
a. T52.0X1A b. J69.1 c. T52.0X1A, J69.1 d. J69.1, T52.0X1A
admission
CHAPTER 12 |
Let’s Check It! Rules and Regulations
CHAPTER 12 REVIEW
Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 12.2 What is pleural effusion? What is the correct ICD-10-CM code for malignant pleural effusion?
2. LO 12.3 Explain what ventilator-associated pneumonia is. Include the correct ICD-10-CM code you would use
to report VAP.
3. LO 12.4 Differentiate between exacerbation and status asthmaticus.
4. LO 12.5 In relation to tobacco involvement, explain the difference between exposure,use,abuse,dependence, and
history.
5. LO 12.6 Explain why a respiratory condition might require an external cause code. Include an example.
ICD-10-CM
YOU CODE IT! Basics
First, identify the condition in the following diagnoses; 8. Bronchitis due to rhinovirus:
then code the diagnosis. a. main term: _____ b. diagnosis: _____
Example: Acute nasopharyngitis: 9. Cellulitis of nose:
a. main term: Nasopharyngitis b. diagnosis: J00 a. main term: _____ b. diagnosis: _____
10. Polypoid sinus degeneration:
1. Vasomotor rhinitis:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
11. Adenoid vegetations:
2. Nasal catarrh, acute:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
12. Abscess of lung:
3. Acute recurrent empyema of sphenoidal sinus:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
13. Bronchiectasis with exacerbation:
4. Hypertrophy of tonsils:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
14. Seropurulent pleurisy with fistula:
5. Obstructive laryngitis:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
15. Pulmonary gangrene:
6. Chronic laryngotracheitis:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
7. Aspiration pneumonia due to solids and liquids:
a. main term: _____ b. diagnosis: _____
ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate ICD-10-CM code(s) and external cause codes, if appropriate, for each case study.
1. Fred Draper, a 39-year-old male, is HIV-positive, asymptomatic. Fred was just admitted with organic
pneumonia.
2. Rebecca Key, a 21-year-old female, presents with a fever and sore throat. Dr. Brice notes large lymph nodes.
The throat culture confirms a diagnosis of streptococcal pharyngitis.
CHAPTER 12 |
CHAPTER 12 REVIEW
ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documentation
from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient encoun-
ters. Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: YOUNG, ELIAS
ACCOUNT/EHR #: YOUNEL001
DATE: 07/16/18
Attending Physician: Oscar R. Prader, MD
Elias Young, a 71-year-old male, is brought to the ED by EMS. Elias is on ACUD mode on ventilator with
a respiration of 11 breaths per minute. No cyanosis is noted. Pt is currently alert and oriented and able
to answer some questions. Dr. Prader notes as time progresses patient is showing signs of confusion
and disorientation. He is admitted to the hospital.
The patient’s blood gases showed a compensated respiratory acidosis, VS are stable, and patient is
afebrile. BP: 148/83. Sinus tachycardia on the monitor at about 131 beats per minute. Lung fields are
clear to auscultation and percussion.
DIAGNOSES: 1. Respiratory failure, chronic
2. Sinus tachycardia
PLAN/RECOMMENDATIONS:
1. 100% ventilator support for the time being
2. Nutrition with PulmoCare at 60 cc an hour
3. Follow up laboratory
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: SMUTH, SARAH
ACCOUNT/EHR #: SMUTSA001
DATE: 07/16/18
Attending Physician: Renee O. Bracker, MD
Sarah Smuth, a 52-year-old female, underwent total knee replacement surgery 5 days ago. Patient is
alert and oriented, but began to complain of chest pain and dyspnea 3 days after surgery. Laboratory
tests reveal a WBC of 15, HR: 101, R: 20 and shallow, P: 56, BP: 135/85, T: 98.9 F, SpO2 is 95% receiv-
ing oxygen via nasal cannula at 2 Lpm. VS have remained stable. Diminished sounds and fine crackles
are noted on auscultation. Post-op day 3—CXR confirms atelectasis; pneumonia is ruled out. Post-op
day 4—patient has not improved; a repeat CXR shows no improvement of atelectasis and a bronchos-
copy was performed and mucus plugs were removed. Post-op day 5—patient begins to show improve-
ment and full resolution is expected.
CHAPTER 12 |
CHAPTER 12 REVIEW
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: ALBERTSON, JONAH
ACCOUNT/EHR #: ALBEJO001
DATE: 09/15/18
Attending Physician: Renee O. Bracker, MD
Jonah Albertson, a 62-year-old male, was transported to the ED by EMS after an MVA. Patient was
involved in a three-car accident while driving home. Patient does not appear to have any injuries.
Patient denies any pain or discomfort at this time. Patient is alert and oriented, but appears anxious.
VS: H: 6’ 1”, W: 192 lb., P: 94, R: 24, T: 99.1 F, BP: 90/60, SpO2 100% on room air.
Laboratory results 25 minutes after arrival:
pH: 7.5
PaO2: 195 mmHg
PaCO2: 32 mmHg
SaO2: 90%
HCO3: 20 mEq
Hgb: 13.9 gms
COHgb: 11.2%
With the level of carbon monoxide on the hemoglobin, the patient is placed on a nonrebreathing
mask. COHgb has decreased to 7.1% and patient is breathing comfortably 4 hours after arrival. Patient
is admitted for observation.
Three hours later, respiration becomes more rapid and labored. Patient shows extreme fatigue. Auscul-
tation reveals fine crackles throughout both lungs. CXR shows bilateral infiltrates extending into all four
lung quadrants.
Arterial blood gases are rechecked:
pH: 7.31
PaO2: 71 mmHg
PaCO2: 43 mmHg
SaO2: 89%
HCO3: 22 mEq
COHgb: 3.9%
Heart Rate: 79
Blood Pressure: 88/57
Dx: ARDS
P: Intubation and mechanical ventilation
CHAPTER 12 |
13 Coding Digestive
System Conditions
Learning Outcomes
Key Terms
Accessory Organs After completing this chapter, the student should be able to:
Anus
LO 13.1 Analyze the documentation for applicable details needed
Ascending Colon
Cecum to report diseases affecting the mouth and salivary glands
Cholelithiasis accurately.
Common Bile Duct LO 13.2 Interpret documentation to determine necessary details
Descending Colon to report conditions affecting the esophagus and stomach
Duodenum correctly.
Edentulism
LO 13.3 Apply your knowledge to identify main terms relating to
Esophagus
Fundus intestinal disorders.
Gallbladder LO 13.4 Evaluate the specifics from the documentation related to
Gangrene digestive accessory organs and malabsorption disorders
Hemorrhage accurately.
Hernia LO 13.5 Determine when additional codes are required to report the
Ileum
involvement of alcohol.
Jejunum
Liver
Mesentery
Obstruction
Oral Cavity
Pancreas Remember, you need to follow along in
Pancreatic Islets
ICD-10-CM
356
Lip
Hard palate
Soft palate
Uvula
Palatine tonsils
Tongue
Vestibule
Lip
EXAMPLE
Perry brought his 8-month-old son, Benjamin, to Dr. Reddington, his pediatrician,
because he had been crying all night long. It seemed nothing he or his wife did
calmed him. After examination, Dr. Reddington diagnosed Benjamin with teething
syndrome and provided Perry with several ways to help the family through this
experience. This diagnosis is reported with the following code:
K00.7 Teething syndrome
Diagnoses, related to the teeth, range from everything from baby’s first tooth to
dental caries (commonly known as a dental cavity) to issues of the surrounding tissue,
such as gingivitis and other periodontal diseases, to edentulism (tooth loss). Edentulism
When you are abstracting the documentation regarding acquired loss of teeth, you Absence of teeth.
will need to identify three specified details from the notes:
1. Is the loss complete or partial?
K08.1 Complete loss of teeth
K08.4 Partial loss of teeth
2. What is the cause of this loss?
K08.11 Complete loss of teeth due to trauma
K08.12 Complete loss of teeth due to periodontal diseases
K08.13 Complete loss of teeth due to caries
K08.41 Partial loss of teeth due to trauma
K08.42 Partial loss of teeth due to periodontal diseases
K08.43 Partial loss of teeth due to caries
CHAPTER 13 |
3. What class classification is documented?
∙ Class I describes the stage of edentulism believed to have the best prognosis to have
successful treatment using conventional prosthodontic techniques.
∙ Class II identifies a patient with deterioration of the gums and other supporting
structures, along with systemic disease interactions, soft tissue concerns, as well as
patient management and/or lifestyle considerations affecting the prognosis of the
treatment.
∙ Class III establishes the existence of other factors significantly affecting the out-
comes of treatment and the need for surgical revision of the supporting structures
(gums and bone) to create an opportunity for prosthodontics.
∙ Class IV reports a severely compromised condition of the supporting structures
requiring surgical reconstruction. If due to the patient’s health, personal prefer-
ences, past dental history, along with financial considerations, a customized prosth-
odontic technique may need to be created for an acceptable outcome.
Remember that ICD-10-CM diagnosis codes provide the explanation of why a par-
ticular procedure, treatment, or service is provided. You can see that the descriptions
of each of these class classifications provides the justification for the treatment plan.
ICD-10-CM
LET’S CODE IT! SCENARIO
Hannah Kim, a 49-year-old female, comes in to see her dentist, Dr. Morrison. She knew that she had periodontitis
for a while, but now the teeth on the lower right side of her mouth are really bothering her. Dr. Morrison did a full
evaluation and found that five teeth on the lower right were so loose that they came out with little encouragement.
Dr. Morrison determined that Hannah has partial loss (edentulism) of teeth due to periodontal disease, class I.
Salivary Glands
As the teeth and tongue are breaking down food in preparation for the journey down
the alimentary canal, three sets of major salivary glands (the parotid, submandibu- Salivary Glands
lar, and sublingual glands) secrete saliva to moisten and bind the food particles. This Three sets of bilateral exo-
begins the chemical digestion of carbohydrates, dissolves foods so their flavor can crine glands that secrete
be appreciated, and helps enable swallowing of the food particles. In addition, saliva saliva: parotid glands, sub-
helps to clean the teeth and mouth after the particles leave the oral cavity. maxillary glands, and sublin-
gual glands.
As with almost any other part of the body, these glands can become infected. The
salivary glands may be negatively impacted by either a bacterium or a virus, so be
alert to check the pathology report.
Sialoadenitis, also known as parotitis, is described as acute, acute recurrent, or
chronic. Note that chronic means ongoing (typically lasting more than 3 months),
whereas acute recurrent means that the condition is severe, it clears up, and everything
is fine for a while, but then it comes back again.
K11.21 Acute sialoadenitis
K11.22 Acute recurrent sialoadenitis
K11.23 Chronic sialoadenitis
ICD-10-CM
YOU CODE IT! CASE STUDY
Isaac McNealy, a 37-year-old male, came in with complaints of pain in his face and mouth. He states that the pain
becomes worse just before and during meals. He also claims that he has trouble swallowing and when he went to
the dentist, he couldn’t open his mouth very wide at all. Dr. Randolph did an ultrasound of Isaac’s face and neck and
confirmed that he was suffering with calculus of the salivary duct.
(continued)
CHAPTER 13 |
Answer:
Did you determine this to be the code?
K11.5 Sialolithiasis
(Calculus of salivary gland or duct)
Epiglottis
Esophagus
Trachea
Bronchi
Lung
Diaphragm
Gastroesophageal
junction Stomach
FIGURE 13-2 An illustration showing the anatomical sites from the epiglottis to
the gastroesophageal junction
EXAMPLES
K21.0 Gastro-esophageal reflux disease with esophagitis
K21.9 Gastro-esophageal reflux disease without esophagitis
Stomach
The next organ along the alimentary canal is the stomach. As stated earlier, the stom- Stomach
ach connects to the esophagus at the lower esophageal sphincter in the cardiac region A saclike organ within the
of the stomach, also known as the cardia. To the left, the stomach curves upward, alimentary canal designed to
creating the fundic region, or fundus. A fundus is defined as a domed portion of a contain nourishment during
hollow organ that sits the farthest from, above, or opposite an opening. As you can see the initial phase of the diges-
tive process.
in Figure 13-3, the fundus of the stomach is located superior to (above) the opening to
the esophagus. Fundus
The lining of the stomach, a mucous membrane, contains gastric glands that The section of an organ far-
secrete gastric juices. As with the function of saliva in the processing of food in thest from its opening.
the mouth, the gastric juices support the extraction of nutritional elements in the
contents that entered from the esophagus. Mucous cells coat the internal wall of the
stomach to prevent the gastric juices from digesting it. When this coating is flawed,
the patient might develop a gastric (peptic) ulcer, a condition in which the acids in
the stomach actually eat a hole in the lining and wall of the stomach. This diagnosis
is reported with code K25.9 Gastric ulcer, unspecified as acute or chronic, without
hemorrhage or perforation.
As the shape of the stomach’s body curves downward, the inside of the curve on the
side of the cardia is referred to as the lesser curvature, and the outside curve, coming
down from the fundus, is referred to as the greater curvature. The lower portion of the
stomach narrows as it nears the duodenum and connects to the small intestine. The
pyloric sphincter is located here to control the emptying of the contents of the stomach
into the lower half of the digestive system.
Lower esophageal
(cardiac) sphincter
Fundus
Esophagus
Cardiac region
of stomach
Pyloric canal
Pylorus
FIGURE 13-3 An illustration identifying the specific anatomical sites of the stomach
David Shier et al., HOLE’S HUMAN ANATOMY & PHYSIOLOGY, 12/e. ©2010 McGraw-Hill Education. Figure 17.17,
p. 666. Used with permission.
CHAPTER 13 |
EXAMPLES
K31.1 Adult hypertrophic pyloric stenosis
K31.3 Pylorospasm, not elsewhere classified
Perforation
An atypical hole in the wall of
an organ or anatomical site.
Ulcers
Hemorrhage
Excessive or severe bleeding. An ulcer is a sore or hole in the tissue. Ulcers can occur externally, such as a decubitus
ulcer, or they can form internally. The terms used to document an internal ulcer in the
digestive system may include
∙ Ulcer of esophagus
CODING BITES ∙ Gastric ulcer (in the lining of the stomach)
If a medication caused
∙ Duodenal ulcer
the ulcer, an external
cause code will be ∙ Gastrojejunal ulcer
required to identify the You will notice that these descriptors identify the location of the ulcer, such as the
specific drug and whether esophagus, the stomach, or the jejunum.
or not it was taken for Further description of these ulcers may include known complications resulting
therapeutic purposes. from an ulcer in this segment of the upper digestive system: perforation and
hemorrhage.
ICD-10-CM
LET’S CODE IT! SCENARIO
Pauline Ochoa had been taking aspirin several times a day every day for pain in her knees. Her husband, John,
came home and found her lying on the kitchen floor. Emergency medical services (EMS) brought her to the ED. Tests
revealed an acute perforated, hemorrhaging peptic ulcer due to chronic use of aspirin.
Beneath peptic is another indented list. Is there anything here that matches the physician’s notes?
Ulcer, ulcerated, ulcerating, ulceration, ulcerative
peptic (site unspecified) K27.9
with
hemorrhage K27.4
and perforation K27.6
acute K27.3
with
hemorrhage K27.0
and perforation K27.2
Hernia
Hernias A condition in which one
A hernia is a condition that is created when a tear or opening in a muscle permits anatomical structure pushes
a part of an internal organ to push through. Due to the nature of one anatomical through a perforation in the wall
part squeezing through a hole in another site, the blood supply can be cut off to of the anatomical site that nor-
the section stuck in that opening. When that happens, the tissue might become mally contains that structure.
necrotic (deteriorate and die) and/or develop gangrene. In addition, this condition Gangrene
can create an obstruction in the structure or organ, preventing the normal flow of Necrotic tissue resulting from
material. a loss of blood supply.
CHAPTER 13 |
Obstruction There are several types of hernias, or anatomical sites that can be susceptible to
A blockage or closing. herniation:
∙ Hiatal (esophageal) hernia may occur when a portion of the stomach pokes
CODING BITES through an opening in the diaphragm; congenital diaphragmatic hernias are con-
If an activity, such as lifting sidered birth defects and reported from the congenital malformations section of
something very heavy, ICD-10-CM.
causes an inguinal hernia, ∙ Umbilical hernia may occur when the muscle around the navel (belly button) does
or if a surgical procedure not close completely, permitting an internal organ to protrude.
causes an incisional her- ∙ Incisional hernia is a defect that may occur at the site of a previous abdominal sur-
nia, additional codes may gical opening (scar tissue).
be required to tell the
∙ Inguinal hernias, more common in men, appear in the groin area.
whole story.
∙ Femoral hernias, more common in women, appear in the upper thigh.
ICD-10-CM
YOU CODE IT! CASE STUDY
Jeffrey Gilberts, a 3-hours-old male, is brought in for Dr. Gensin to surgically repair his diaphragmatic hernia. He was
born with this abnormal fistula in the diaphragm, diagnosed at 28 weeks gestation, but it was determined that he
was not a candidate for in utero surgery.
Duodenum
Jejunum
Ascending colon
Cecum
Mesentery
Appendix
Ileum
CHAPTER 13 |
3. Has the ulcer perforated the wall of the small intestine?
K28.1 Acute gastrojejunal ulcer with perforation
K28.5 Chronic or unspecified gastrojejunal ulcer with perforation
4. Are hemorrhage and perforation both documented?
K28.2 Acute gastrojejunal ulcer with both hemorrhage and perforation
K28.6 Chronic or unspecified gastrojejunal ulcer with both hemorrhage and
perforation
5. Has either hemorrhage or perforation been documented individually? If not . . .
K28.3 Acute gastrojejunal ulcer without hemorrhage or perforation
K28.7 Chronic or unspecified gastrojejunal ulcer without hemorrhage or
perforation
Of course, be certain to read the notations at the top of this code category:
Use additional code to identify alcohol abuse and dependence (F10.-)
primary ulcer of small intestine (K63.3)
Read the documentation carefully, again, to determine if the physician noted whether
the patient suffers with alcohol abuse or alcohol dependence. If so, you will need to
code this, as well.
The jejunum is one specific part of the small intestine. The small intestine includes
the duodenum, jejunum, mesentery, ileum, and cecum.
ICD-10-CM
YOU CODE IT! CASE STUDY
Bernadette Bowers, a 29-year-old female, came to see Dr. Grandem with symptoms of persistent diarrhea and
ongoing right lower quadrant (RLQ) abdominal pain. Lab work showed an increased white blood cell count and
erythrocyte sedimentation rate. A barium enema showed string sign. A biopsy confirmed a diagnosis of Crohn’s
disease of the jejunum.
Good job!
Muscular layer
Mucous membrane
Serous layer
Transverse colon
Ascending colon
Tenia coli
Ileum
Descending colon
Ileocecal sphincter
Orifice of appendix
Haustra
Cecum
Vermiform appendix
Anal canal
FIGURE 13-5 An illustration identifying the anatomical sites of the large intestine David Shier et al., HOLE’S HUMAN ANAT-
OMY & PHYSIOLOGY, 12/e. ©2010 McGraw-Hill Education. Figure 17.43, p. 687. Used with permission.
CHAPTER 13 |
Transverse Colon because of the proximity to the liver) and runs across to the left side. This section is
The portion of the large known as the transverse colon because it traverses across the abdomen (transverse
intestine that connects the = across). On the left side, the colon turns downward at a curve known as the splenic
hepatic flexure to the splenic flexure (named because of the proximity to the spleen), becoming the descending
flexure.
colon. It continues down until it slightly curves, just above the pelvis, and becomes the
Descending Colon sigmoid colon.
The segment of the large The large intestine turns again, downward. This area is called the rectum (rectal
intestine that connects the vault), and it leads directly into the anal canal. At the distal end of the anal canal, the
splenic flexure to the sigmoid internal and external anal sphincters form the anus—the opening to the outside.
colon.
Sigmoid Colon
The dual-curved segment of EXAMPLES
the colon that connects the K51.20 Ulcerative (chronic) proctitis without complications
descending colon to the rec- K56.41 Fecal impaction of the intestine
tum; also referred to as the K35.3 Acute appendicitis with localized peritonitis
sigmoid flexure.
ICD-10-CM
YOU CODE IT! CASE STUDY
Gerald Candahar, a 51-year-old male, was brought into the procedure room so Dr. Avalino could remove his anal
polyps.
ICD-10-CM
YOU CODE IT! CASE STUDY
Lisa Begas, a 63-year-old female, came in complaining of a low-grade fever with chills for 3 days, nausea and vomit-
ing, and cramps. Dr. Allendale did a CT scan of her abdomen and pelvis, and determined that she had diverticulitis
without perforation or bleeding of the colon.
CHAPTER 13 |
13.4 Dysfunction of the Digestive Accessory
Organs and Malabsorption
Accessory Organs
Organs that assist the diges- The digestive accessory organs play a role in the way the body processes food
tive process and are adja- and water so that each tissue and organ system has the fuel to function. These
cent to the alimentary canal: organs secrete enzymes, alkalis, and other substances that are required for the
the gallbladder, liver, and process of digestion, and they include the gallbladder, liver, and pancreas. The
pancreas. accessory organs connect to the alimentary canal and support it, but they are not
a part of it.
Gallbladder
A pear-shaped organ that
stores bile until it is required Gallbladder
to aid the digestive process.
In the top left corner of Figure 13-6, the pear-shaped pouch is the gallbladder. This
Common Bile Duct sac is a storage tank for bile, a yellow-green liquid created by the liver and used by
The juncture of the cystic duct the body to assist in the digestive process. When required, the gallbladder contracts
of the gallbladder and the
to release bile into the duodenum via the common bile duct and the hepatopancreatic
hepatic duct from the liver.
ampulla. The common bile duct is the juncture where the hepatic duct (which comes
from the liver) meets the cystic duct (which comes from the gallbladder). At the hepa-
topancreatic sphincter, both the common bile duct and the pancreatic duct meet to
CODING BITES continue into the duodenum.
Due to the interactive
nature of the anatomical
organs in this small area EXAMPLES
of the body, you may
K81.0 Acute cholecystitis
notice long, complex
medical terms used in K82.3 Fistula of gallbladder
diagnostic statements.
Don’t be intimidated;
just use your knowledge Right hepatic duct Left hepatic duct
from medical terminol- Cystic duct Common hepatic duct
Common
ogy class and parse bile duct
the terms. For example: Gallbladder
choledocholithiasis: Pancreatic duct
chole = bile + docho
Pyloric sphincter
= common bile duct +
lith = calculus + iasis =
Minor duodenal
pathologic condition. papilla
Duodenum
Tail of pancreas
Major duodenal Common Pancreatic
papilla bile duct duct
Sphincter muscles
Head of pancreas
Duodenal papilla
Intestinal lumen
Hepatopancreatic Hepatopancreatic
ampulla sphincter
FIGURE 13-6 An illustration identifying the anatomical sites within the accessory
organs David Shier et al., HOLE’S HUMAN ANATOMY & PHYSIOLOGY, 12/e. ©2010 McGraw-Hill Education.
Figure 17.23, p. 672. Used with permission.
EXAMPLES
K80.70 Calculus of gallbladder and bile duct without cholecystitis without
obstruction
K81.1 Chronic cholecystitis
Pancreas
Situated posterior to the stomach, tucked inside a curve of the duodenum, is the
pancreas. The section of the pancreas adjacent to the duodenum, called the head of Pancreas
the pancreas, extends to the center section (the body of the pancreas), which extends to A gland that secretes insulin
the tail of the pancreas, which forms almost a fingerlike shape. The pancreatic islets and other hormones from the
(the islets of Langerhans) create glucagon and insulin, as well as other hormones, and islet cells into the bloodstream
secrete them into the bloodstream. Similar to the gallbladder, the pancreas manufac- and manufactures digestive
enzymes that are secreted
tures certain digestive enzymes that pass into the duodenum via the pancreatic duct
into the duodenum.
(see Figure 13-6).
Malfunction of the pancreas may lead to various health problems, including pancre- Pancreatic Islets
atic cancer, pancreatitis, cystic fibrosis, and diabetes mellitus. One of the most danger- Cells within the pancreas that
ous concerns about the impact on the body of conditions of the pancreas is that signs secrete insulin and other hor-
and symptoms are few and nonspecific, making diagnosis difficult. For example, there mones into the bloodstream.
is actually a treatment for pancreatic cancer. However, due to lack of signs and symp- Liver
toms that typically promote early identification and treatment, diagnosis is not often The organ, located in the
realized until the malignancy has metastasized to other organs and cannot be halted. upper right area of the
abdominal cavity, that is
Pancreatitis responsible for regulating
Acute pancreatitis occurs suddenly and usually goes away in a few days with treat- blood sugar levels; secret-
ing bile for the gallbladder;
ment. However, when you are determining the correct code for this diagnosis, you
metabolizing fats, proteins,
must abstract the underlying cause of the pancreatitis: and carbohydrates; manufac-
K85.0- Idiopathic acute pancreatitis turing some blood proteins;
K85.1- Biliary acute pancreatitis and removing toxins from the
K85.2- Alcohol-induced acute pancreatitis blood.
K85.3- Drug-induced acute pancreatitis
CODING BITES
Note that alcohol-induced acute pancreatitis and alcohol-induced chronic pancreatitis
are reported from different code categories. The medical root hepa-
or hepat- is used in
K86.0 Alcohol-induced chronic pancreatitis most diagnoses and
other descriptive terms
Liver to refer to the liver as
the anatomical site
The liver is an almost triangular-shaped organ (see Figure 13-7) located in the right involved. For example,
upper quadrant (RUQ) of the abdominal cavity, beneath the diaphragm, anterior to the the term hepatic failure
stomach and pancreas. As the largest gland in the body, it performs many functions, identifies a condition
including regulating blood sugar levels and aiding the digestive process by secreting that has rendered the
bile to the gallbladder. The liver cleans the blood of toxins; metabolizes proteins, fats, liver ineffective.
and carbohydrates; and manufactures some blood proteins.
CHAPTER 13 |
Inferior
Right lobe vena cava Left lobe
Cirrhosis
After a person suffers with chronic hepatic disease, fibrotic tissue may form on hepatic
cells causing scarring, known as cirrhosis of the liver. This condition may be caused
by injury as well. The scar tissue impairs the normal function of the liver and can
result in easy bruising or bleeding, abdominal swelling, lower extremity edema, and
possibly kidney failure. There is evidence that approximately 5% of patients suffering
with cirrhosis will develop liver cancer.
EXAMPLES
K74.3 Primary biliary cirrhosis
K74.69 Other cirrhosis of liver
ICD-10-CM
YOU CODE IT! CASE STUDY
After struggling to deal with a sharp pain that went from his stomach area straight through to his back, Saul Braver-
man went to see Dr. Spiegel. After a full examination and an ultrasound, Dr. Spiegel confirmed Saul’s cholelithiasis
and they discussed plans for surgery.
Celiac Disease
While you may see a great deal in the news and advertisements about gluten-free
products, the facts support that celiac disease, also known as gluten enteropathy, is
uncommon. This condition is suffered by twice as many women than men, and has
been seen to be familial (common in families).
Recurrent attacks of diarrhea, abdominal distention due to flatulence, stomach
cramps, and weakness are some of the most frequently experienced signs and symp-
toms. When diagnosed in adults, celiac disease may be the underlying cause of mul-
tiple ulcers forming within the lining of the small intestine. Biopsies from the small
bowel, identifying histologic changes, would confirm this diagnosis.
EXAMPLE
K90.0 Celiac disease
Use additional code for associated disorders including:
dermatitis herpetiformis (L13.0)
gluten ataxia (G32.81)
Code also exocrine pancreatic insufficiency (K86.81) CODING BITES
In some cases, through-
out the ICD-10-CM Tab-
13.5 Reporting the Involvement of Alcohol ular List will remind you
in Digestive Disorders that the involvement of
alcohol abuse must also
Alcohol abuse can increase the risk of developing several serious disorders of the be reported:
digestive system. When the documentation includes a connection of alcohol abuse in K05 Gingivitis and
the diagnosis, you will need to report this with an additional code. periodontal diseases
When reading the documentation for digestive system disorders, be aware of these
Use additional code
diagnoses which are known to be connected to alcohol abuse. If there is any indica-
to identify:
tion, you might need to query the physician.
alcohol abuse and
∙ Mouth cancer and gum disease: Alcohol abuse increases the risk, second only to dependence (F10.-)
tobacco abuse.
CHAPTER 13 |
∙ GERD and gastritis: Excessive use of alcohol can damage the sphincter between
the esophagus and the stomach, permitting stomachs acids to backwash into the
esophagus. The lining of the stomach can also become irritated.
∙ Malabsorption and malnutrition: The consistent and excessive intake of alcohol
can interfere with the body’s ability to absorb nutrients.
∙ Pancreatitis: Alcohol abuse can cause inflammation in the pancreas and interfere
with the proper function of the digestive process.
∙ Alcoholic liver disease: Alcohol abuse can cause this condition, a precursor to
cirrhosis.
ICD-10-CM
YOU CODE IT! CASE STUDY
Noel Cooper, a 43-year-old male, came to see Dr. Briscow with complaints of epigastric discomfort, nausea, and
indigestion, over the last several days. He admits to drinking alcohol at lunch and dinner daily. He states he often
has a couple in the evening as well. A gastroscopy was performed, and Dr. Briscow confirmed a diagnosis of acute
gastritis due to alcohol abuse.
Chapter Summary
The organs included in the digestive system run from the head to the bottom of the
torso. Therefore, several different health care specialists may be involved in car-
ing for patients with digestive disorders, depending upon where the abnormality is
located. Health care issues within the digestive system can occur as the result of a
congenital anomaly, a traumatic event, or dietary influence. This means that there
may be times when an external cause code is required to be included so that you can
tell the whole story about the reasons why (the medical necessity) this patient was
cared for.
Part I
1. LO 13.1 Small, calcified protrusions with roots in the jaw. A. Anus
2. LO 13.4 Cells within the pancreas that secrete insulin and other hormones into B. Duodenum
the bloodstream. C. Esophagus
3. LO 13.4 A large gland responsible for creating digestive enzymes. D. Ileum
4. LO 13.3 The last segment of the small intestine. E. Jejunum
5. LO 13.2 A saclike organ within the alimentary canal designed to contain nour- F. Liver
ishment during the initial phase of the digestive process.
G. Pancreas
6. LO 13.3 A long, narrow mass of tissue attached to the cecum; also called
H. Pancreatic Islets
appendix.
I. Rectum
7. LO 13.3 The last segment of the large intestine, connecting the sigmoid colon to
the anus.
8. LO 13.2 The tubular organ that connects the pharynx to the stomach for the pas-
sage of nourishment.
9. LO 13.4 The organ, located in the upper right area of the abdominal cavity, that
is responsible for regulating blood sugar levels; secreting bile for the
gallbladder; metabolizing fats, proteins, and carbohydrates; manufac-
turing some blood proteins; and removing toxins from the blood.
CHAPTER 13 |
10. LO 13.3 The portion of the large intestine that leads outside the body. J. Stomach
CHAPTER 13 REVIEW
11. LO 13.3 The first segment of the small intestine, connecting the stomach to the K. Teeth
jejunum. L. Vermiform Appendix
12. LO 13.3 The segment of the small intestine that connects the duodenum to the ileum.
Part II
1. LO 13.3 A pouchlike organ that connects the ileum with the large intestine; the A. Ascending Colon
point of connection for the vermiform appendix. B. Cecum
2. LO 13.3 The segment of the large intestine that connects the splenic flexure to C. Common Bile Duct
the sigmoid colon.
D. Descending Colon
3. LO 13.3 The portion of the large intestine that connects the hepatic flexure to
E. Oral Cavity
the splenic flexure.
F. Salivary Glands
4. LO 13.4 The juncture of the cystic duct of the gallbladder and the hepatic duct
from the liver. G. Sigmoid Colon
5. LO 13.3 The portion of the large intestine that connects the cecum to the hepatic H. Transverse Colon
flexure.
6. LO 13.3 The dual-curved segment of the colon that connects the descending
colon to the rectum.
7. LO 13.1 The opening in the face that begins the alimentary canal and is used for
the input of nutrition; also known as the mouth.
8. LO 13.1 Three sets of bilateral exocrine glands that secrete saliva: parotid
glands, submaxillary glands, and the sublingual glands.
Part III
1. LO 13.2 A blockage or closing. A. Accessory Organs
2. LO 13.2 An atypical hole in the wall of an organ or anatomical site. B. Cholelithiasis
3. LO 13.4 Organs that assist the digestive process and are adjacent to the alimen- C. Edentulism
tary canal: the gallbladder, liver, and pancreas. D. Fundus
4. LO 13.4 Gallstones. E. Gallbladder
5. LO 13.3 A fold of a membrane that carries blood to the small intestine and con- F. Gangrene
nects it to the posterior wall of the abdominal cavity.
G. Hemorrhage
6. LO 13.2 A circular muscle that contracts to prevent passage of liquids or solids.
H. Hernia
7. LO 13.4 A pear-shaped organ that stores bile until it is required to aid the
I. Mesentery
digestive process.
J. Obstruction
8. LO 13.2 The section of an organ farthest from its opening.
K. Perforation
9. LO 13.1 Absence of teeth.
L. Sphincter
10. LO 13.2 A condition in which one anatomical structure pushes through a perforation
in the wall of the anatomical site that normally contains that structure.
11. LO 13.2 Necrotic tissue resulting from a loss of blood supply.
12. LO 13.2 Excessive or severe bleeding.
CHAPTER 13 REVIEW
a. esophagus. b. liver. c. small intestine. d. large intestine.
3. LO 13.1 When you are abstracting the documentation regarding acquired loss of teeth: Class _____ establishes
the existence of other factors significantly affecting the outcomes of treatment and the need for surgical
revision of the supporting structures (gums and bone) to create an opportunity for prosthodontics.
a. I b. II c. III d. IV
4. LO 13.4 Cirrhosis of the liver can be caused by
a. abuse of alcohol. b. trauma. c. disease. d. all of these.
5. LO 13.2 A hiatal hernia occurs at the
a. esophagus. b. small intestine. c. surgical site. d. groin.
6. LO 13.3 What is the correct code for an acute appendicitis with localized peritonitis?
a. K35.2 b. K35.3 c. K35.8 d. K35.89
7. LO 13.3 The transverse colon lies between the
a. ascending colon and the hepatic flexure. b. hepatic flexure and the splenic flexure.
c. splenic flexure and the sigmoid colon. d. sigmoid colon and the anus.
8. LO 13.4 Cholelithiasis is commonly known as
a. disease of the liver. b. disease of the colon. c. gallstones. d. pancreatic cancer.
9. LO 13.2 Necrotic tissue resulting from a loss of blood supply is known as
a. obstruction. b. hemorrhage. c. perforation. d. gangrene.
10. LO 13.5 All of the following are known be diagnoses that could be connected to alcohol abuse except
a. GERD. b. pancreatitis.
c. malabsorption and malnutrition. d. all of these could be connected to alcohol abuse.
ICD-10-CM
YOU CODE IT! Basics
First, identify the condition in the following 2. Acute generalized periodontitis severe:
diagnoses; then code the diagnosis. a. main term: _____ b. diagnosis: _____
Example: Acute pulpitis 3. Odontogenic cyst:
a. main term: Pulpitis b. diagnosis: K04.0 a. main term: _____ b. diagnosis: _____
4. Exfoliative cheilitis:
1. Dental caries on pit and fissure surface, penetrat-
ing into dentin: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
CHAPTER 13 |
CHAPTER 13 REVIEW
ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. Dorothea Greig, a 26-year-old female, presents with the complaint of persistent pain in her lower left abdo-
men, 1 week duration. Dorothea says she has also experienced nausea and vomiting. Dr. Hendrix notes
weakness and a temperature of 102.2 F. The decision is made to admit the patient. Following a review of the
laboratory tests, liver function tests, and the CT scan, Dorothea is diagnosed with diverticulitis of both the
small and large intestines; abscess is noted.
2. Kent Rhodes, a 28-month-old male, is brought in by his parents for a checkup. Dr. Washington notes Kent’s
deciduous teeth are smaller than normal and widely spaced with notches on the biting surface. Kent is diag-
nosed with Hutchinson’s teeth.
3. Leigh Norman, a 37-year-old female, comes in today with the complaint of shortness of breath. Dr. Schimek
notes tachypnea, tachycardia, and cyanosis. Upon auscultation, bowel sounds are heard in the chest area.
Leigh is admitted to Weston Hospital. After reviewing the arterial blood gases, laboratory results, and CT
scan, Leigh is diagnosed with a diaphragmatic hernia with obstruction. Surgery is scheduled.
4. John Bandings, a 53-year-old male, presents today with fever and jaundice. John admits to drinking alcohol for
decades. After reviewing the test results, Dr. Fong diagnoses John with alcoholic cirrhosis of the liver with ascites.
5. Maxine Weber, a 42-year-old female, comes in today with the complaint of severe pain in the right side of her
lower abdomen. Maxine also says she has vomited. Dr. Jefferson documents a temperature of 101 F. Maxine is
admitted to the hospital, where a CT scan confirms the diagnosis of acute appendicitis with localized peritonitis.
6. Archie Blume, a 41-year-old male, presents with the complaint of swollen tender gums and bleeding after he
brushes his teeth. Dr. Day notes Archie uses tobacco. After an examination and x-rays, Archie is diagnosed
with acute gingivitis, non-plaque induced.
7. Allen Klebb, a 36-year-old male, comes in today complaining of diarrhea and vomiting. Allen just finished his
radiation treatments for his hand malignancy. Dr. Ard diagnoses Allen with gastroenteritis due to radiation.
8. Paula Dent, a 3-year-old female, is diagnosed with a congenital trachea-esophageal fistula with atresia of the
esophagus. Paula is admitted to Weston Hospital for surgical repair.
9. Walter Logan, a 59-year-old male, presents today with a yellow brownish tongue. Walter admits to a bad taste
in his mouth. Dr. Roche completes an examination, noting hypertrophy of the central dorsal tongue papillae.
The biopsy confirms a diagnosis of black hairy tongue.
ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documentation
from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient encoun-
ters. Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: UMBRELL, MORGAN
ACCOUNT/EHR #: UMBRMO001
DATE: 09/16/18
Attending Physician: Renee O. Bracker, MD
S: Patient is a 41-year-old female complaining of localized pain in the upper right quadrant radiating to
the right scapular tip. Pain usually begins postprandial and is intense for approximately a 5-hour dura-
tion and then subsides. Pain is not relieved by emesis, flatus, or position change.
O: H: 5’3”, Wt: 146 lb., R: 19, HR: 125, BP: 135/73, T: 102.4 F. Dr. Bracker notes diaphoresis, slight jaundice,
as well as hypoactive bowel sound. CT scan confirms a bile duct calculus. Morgan is admitted for surgery.
A: Choledocholithiasis, acute with cholangitis, and obstruction
P: Laparoscopic cholecystectomy
CHAPTER 13 |
YOU CODE IT! Practice
CHAPTER 13 REVIEW
CHAPTER 13 |
14
Key Terms
Coding Integumentary
Conditions
Learning Outcomes
Blister After completing this chapter, the student should be able to:
Bulla
Carbuncle LO 14.1 Apply the guidelines for reporting conditions of the skin.
Cyst LO 14.2 Analyze disorders of the nails, hair, glands, and sensory
Decubitus Ulcer nerves.
Dermis LO 14.3 Determine the specific characteristics of a lesion as they
Epidermis relate to coding.
Furuncle LO 14.4 Abstract the reasons for preventive care and report them
Gangrene
Hair accurately to support medical necessity.
Hair Follicle
Macule
Nevus
Nodule
Papule Remember, you need to follow along in
Patch
Phalanges
ICD-10-CM
382
Epidermis
Dermis
Subcutaneous
layer
FIGURE 14-1 An illustration identifying the layers of the skin David Shier et al., Hole’s
Human Anatomy & Physiology, 12/e. ©2010 McGraw-Hill Education. Figure 6.2a, p. 172. Used with permission.
affects infants (1 month to 1 year of age) with family histories of atopic conditions
such as allergic rhinitis and bronchial asthma. Signs and symptoms include erythema-
tous areas on extremely dry skin, appearing as lesions on the forehead, cheeks, arms,
and legs. The pruritus nature of this condition results in scratching that induces scaling
and edema.
Seborrheic dermatitis (category L21) includes seborrhea capitis and seborrheic
infantile dermatitis, commonly affecting the scalp and face. Symptoms include itch-
ing, erythematous areas, and inflammation, characterized by lesions covered with
brownish gray or yellow scales in areas in which sebaceous glands are plentiful.
Diaper dermatitis (category L22), commonly referred to as diaper rash, is caused
by continuously wet skin. Often, this develops when diapers are not changed frequently
enough to permit the area to dry out.
Allergic contact dermatitis (category L23) is the result of the skin touching a mate-
rial or substance to which the patient is sensitive. In addition to erythematous areas,
vesicles develop that itch, scale, and may ooze.
Irritant contact dermatitis (category L24) is caused by exposure of the skin to
detergents, solvents, acids, or alkalis. Blisters and/or ulcerations may appear in the
area that came in contact with the chemical.
Exfoliative dermatitis (category L26) is an acute and chronic inflammation with
widespread erythema and scales. The loss of the stratum corneum (the outermost layer
of the epidermis) is at the heart of this condition, along with hair loss, fever, and
shivering.
Dermatitis due to substances taken internally (category L27) would include an
inflammatory eruption of the epidermis in reaction to medications, drugs, ingested
food, or other substances. It may be easy to think that this might be limited to a
response only to oral medicines, but, technically, a drug injected, infused, or delivered
via subcutaneous patch also places the pharmaceutical internally. Keep a watchful eye
on the Use additional code notations within this code category, which remind you to
include an external cause code.
CHAPTER 14 |
Psoriasis
Identified by epidermal erythematous papules and plaques covered with silvery scales,
psoriasis is a chronic illness. Exacerbations (flare-ups) can be treated to relieve the
symptoms. Patients can inherit the tendency to develop psoriasis because it is geneti-
cally passed from parent to child. Its pruritic nature can sometimes result in pain along
with itching in the areas covered with dry, cracked, encrusted lesions appearing on
the scalp, chest, elbows, knees, shins, back, and buttocks. The silver scales may flake
away easily or create a thickened cover over the lesion. There are several types of pso-
riasis, including the following:
Psoriasis vulgaris, also known as nummular psoriasis or plaque psoriasis, is the
most common type of psoriasis. It usually causes dry, red skin lesions (plaques)
covered with silvery scales. Reported with code L40.0 Psoriasis vulgaris.
Guttate psoriasis appears more often in young adults (under the age of 30) as well as
children. Lesions covered by a fine scale will typically develop as small, teardrop-
shaped sores on the scalp, arms, trunk, and legs. Reported with code L40.4 Guttate
psoriasis.
Psoriatic arthritis mutilans presents with pain, edema, and/or loss of flexibility
in at least one joint. When affecting the fingers or toes, the nails may show pit-
ting or begin to separate from the nail bed. Reported with code L40.52 Psoriatic
arthritis mutilans.
Soft
tissue
Pinching off of
Blood blood vessels
vessels
Skin
layers
FIGURE 14-2 An illustration identifying the etiology of pressure ulcers including the layers of the skin affected
■ Stage 4 indicates the skin layers are necrotic and the ulcer reaches down into
muscle and possibly bone. Stage 4 pressure ulcers have become so deep that there
is damage to the muscle and bone, sometimes along with tendon and joint dam-
age. While the depth of the ulcer varies on the basis of the anatomical site, there
is full-thickness tissue loss with bone, tendon, or muscle exposed.
■ An unstageable ulcer is not an unspecified stage. There are times when slough
and eschar must be removed to reveal the base of the wound before the true
depth, or stage, can be accurately determined. The lesion may be inaccessible—
because it is covered by a wound dressing that has not been removed or by a GUIDANCE
sterile blister or because of some other documented reason. CONNECTION
ICD-10-CM has created combination codes, therefore requiring only one code to Read the ICD-10-CM
identify both the anatomical site and the stage of the ulcer. Official Guidelines for
Coding and Reporting,
section I. Conven-
EXAMPLE tions, General Coding
Holder Pronce has a stage 3 pressure ulcer on his left hip. Guidelines and Chapter
Specific Guidelines,
L89.223 Pressure ulcer of left hip, stage 3 subsection C. Chapter-
Specific Coding Guide-
lines, chapter 12. Dis-
Healing Pressure Ulcers eases of the Skin and
It is logical that a patient will be attended to by a health care professional during Subcutaneous Tissue,
the time the pressure ulcer is healing. Typically, the documentation will identify the subsection a.5) Patients
original stage and describe the ulcer as “healing.” For example, “Harvey Rhoden was admitted with pressure
seen today by Dr. Steelman to follow up on his stage 2 pressure ulcer. Dr. Steelman ulcers documented as
documented that the ulcer is healing nicely.” In this case, you would continue to code healing.
this as a stage 2 pressure ulcer.
CHAPTER 14 |
GUIDANCE
CONNECTION Skin
layers
Read the ICD-10-CM
Official Guidelines for Subcutaneous
Coding and Reporting, soft tissue
section I. Conven- Bone
tions, General Coding
Guidelines and Chapter
Stage 1 Stage 2
Specific Guidelines,
subsection C. Chapter-
Specific Coding Guide-
lines, chapter 12.
Diseases of the Skin
and Subcutaneous
Tissue, subsection
a.6) Patients admitted
with pressure ulcer
evolving into another
stage during the Stage 3 Stage 4
admission. FIGURE 14-3 An illustration showing each of the four pressure ulcer stages
At the time of discharge, if the patient’s pressure ulcer has healed, and is documented
as healed, you will need to report the stage and site of this ulcer as described in the
admissions documentation. This will provide the medical necessity for the treatment of
this condition while the patient was in the facility and resulted in the healed outcome.
ICD-10-CM
LET’S CODE IT! SCENARIO
After attempting to jump his motorcycle over five barrels and crashing on the other side, Hunter Massler ended up
in the hospital for 6 weeks with a left, closed, transverse fractured femur, shaft; a right, closed, oblique fractured
CHAPTER 14 |
Stratum
corneum Radix
Unguis (nail) (cuticular fold) (nail root)
Phalanx
Stratum Nail (bone)
germinativum matrix
(nail bed)
FIGURE 14-4 An illustration identifying the anatomical sites of the basic parts
of a human nail: nail plate, lunula, root, sinus, matrix, nail bed, hyponychium, free
edge Booth et al., Medical Assisting, 5e. Copyright ©2013 by McGraw-Hill Education. Figure 23-4, p. 501. Used
with permission.
of the nail is the nail plate, the main part of the nail, which lies upon a layer of skin (nail
bed). At the point where the nail plate goes beneath the skin [eponychium = nail fold +
cuticle (lunula)] of the finger (or toe) is the lunula, a white area shaped like a crescent
moon (therefore, the term lunula, from luna, meaning moon). As the nail grows over the
tip of the phalange, the area of epidermis beneath is called the hyponychium.
Nail Disorders
The human body has 20 nails—10 fingernails and 10 toenails—and as with any other
anatomical site, things can go wrong.
∙ Onycholysis: This is a detachment of the nail from the bed of the nail. Onset occurs
at either the distal or lateral attachment. Patients previously diagnosed with psoria-
sis or thyrotoxicosis are most often seen with this condition. Reported with code
L60.1 Onycholysis.
∙ Beau’s lines: These are deeply grooved, horizontal lines (from side to side) on either
a fingernail or a toenail. Previous infection, injury, or other disruption to the nail
fold, the location of nail formation, may be the cause. Reported with code L60.4
Beau’s lines.
∙ Yellow nail syndrome: A thickened nail that has become yellowed is typically seen
in patients previously diagnosed with a systemic disease, such as lymphedema or
bronchiectasis. This is reported with code L60.5 Yellow nail syndrome.
You have learned, with many diseases in various body systems, that a disease in one
location of the body may negatively impact another part of the body. This can happen
with the nails as well, so ICD-10-CM provides a specific code to report this:
L62 Nail disorders in diseases classified elsewhere
Code first underlying disease, such as: pachydermoperiostosis (M89.4-)
ICD-10-CM
LET’S CODE IT! SCENARIO
Priscilla Ablerts, an 83-year-old female, was brought in with toenails that had grown out of normal shape. It had got-
ten to the point that she could no longer wear closed shoes, and her daughter was concerned. After examination, Dr.
Terranzo diagnosed Priscilla with onychogryphosis.
Hair
Hair is a pigmented (colored), hard keratin that grows from the hair follicle—the Hair
location of the hair root. As you can see in Figure 14-5, the follicle is embedded in the A pigmented, cylindrical
dermis and fatty tissue of the skin layers. As you probably know from your own body, filament that grows out from
hair may grow externally, such as on your scalp, as well as internally, such as inside the hair follicle within the
the nasal or ear cavity. The hairs in the nose help to prevent certain particles from epidermis.
entering the respiratory system. Hair Follicle
A saclike bulb containing the
Disorders of the Hair hair root.
For some patients, a bad hair day can be much more serious than a cowlick or frizz.
∙ Alopecia mucinosa: This skin disorder may first be identified by erythematous
plaqueing of the skin without any hair growth. The flat patches of hairlessness may
occur on the scalp, face, or legs. Reported with code L65.2 Alopecia mucinosa.
∙ Trichorrhexis nodosa: Evidenced by a hair shaft defect that causes weak spots, this
disorder results in hair that easily breaks. Most often, this condition is caused by
environmental factors such as blow drying, permanent waves, or excessive chemi-
cal exposure. Reported with code L67.0 Trichorrhexis nodosa.
∙ Hirsutism: Women with this condition have excessive hair growth on anatomical
sites where hair does not typically occur, such as the chest or chin. It is believed
to be caused by an abnormal hormonal level, particularly male hormones such as
testosterone. Reported with code L68.0 Hirsutism.
Glands
Three different types of glands are located within the skin:
∙ Sebaceous glands produce an oil-rich element, known as sebum, that lies on the
outer surface of the epidermis and along the hair. The substance has a waterproof-
ing effect. Individuals with oily skin may have overly active sebaceous glands.
CHAPTER 14 |
Hair shaft
Sebaceous
gland
Hair root
(keratinized
cells)
Hair follicle
Region of
cell division
Hair papilla
FIGURE 14-5 An illustration identifying the anatomical parts of a hair; from papilla
to shaft David Shier et al., Hole’s Human Anatomy & Physiology, 12/e. ©2010 McGraw-Hill Education.
Figure 6.7a, p. 178. Used with permission.
∙ Eccrine glands are sweat glands that are responsible for maintaining proper body
temperature by excreting sweat (water, salt, and wastes) via the pores in the skin. Pro-
duction of more sweat is the reaction to cool an overheated body (see Figure 14-6).
∙ Apocrine glands release a discharge that is high in protein. Located in the axilla
(armpits), anal, and genital areas, bacteria interact with the protein and create an odor.
Sebaceous gland
Sweat gland
FIGURE 14-6 An illustration identifying the anatomical sites of sweat glands Booth
et al., Medical Assisting, 5e. Copyright ©2013 by McGraw-Hill Education. Figure 23-1, p. 497. Used with permission.
ICD-10-CM
YOU CODE IT! CASE STUDY
Ellyn Pacard, a 41-year-old female, presents to Dr. Grall with what she believes to be nonscarring male-pattern
alopecia. Examination reveals small patches of scalp, with some limited mild erythema. “Exclamation point” hairs
are located on the periphery with some indication of new patches and regrowth. Explained to patient that complete
regrowth is possible in this diagnosis.
Diagnosis: alopecia capitis
Treatment plan: intralesional corticosteroid injections followed by minoxidil applications.
(continued)
CHAPTER 14 |
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically
necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
L63.0 Alopecia (capitis) totalis
Good work!
Sensory Nerves
In a part of the nervous system known as the somatic (relating to the body) sensory
system, sensory nerve endings are located in the layers of the skin to provide sensory
feedback—the sense of touch. These nerves enable you to feel pressure, pain, tempera-
ture (hot and cold), textures (rough and smooth), and more.
There is more about the nervous system in this book’s chapter titled Coding Men-
tal, Behavioral, and Neurological Disorders.
ICD-10-CM
LET’S CODE IT! SCENARIO
Serena Brynner is a 19-year-old female who came in to see Dr. Trenton with thickened, hardened skin and subcu-
taneous tissue on her forearms, bilaterally. Examination shows Addison’s keloid present. She is given a referral to a
plastic surgeon.
CHAPTER 14 |
PRIMARY LESIONS
Flat, discolored, nonpalpable changes in skin color Elevation formed by fluid in a cavity
SECONDARY LESIONS
VASCULAR LESIONS
FIGURE 14-7 An illustration showing the various types of skin lesions Booth et al., Medical Assisting, 5e. Copyright ©2013 by
McGraw-Hill Education. Figure 23-2, p. 498. Used with permission.
Malignant Lesions
The majority of skin lesions diagnosed are benign. However, there are certain skin
lesions that are pathologically identified as malignant.
Malignant melanoma is the most deadly type of skin malignancy, causing 80%
of all skin malignancy fatalities. The most frequently identified sites of melanoma
ICD-10-CM
YOU CODE IT! CASE STUDY
Carlos Monteverde, a 63-year-old male, comes in to see Dr. Harris, complaining of an extremely painful spot on his
thigh. He states he has been very tired lately, especially since he noticed this bump. Patient history reveals a preex-
istent furunculosis.
Examination shows deep follicular abscess of several follicles with several draining points. CBC shows an ele-
vated white blood cell count. Wound culture identifies Staphylococcus aureus.
Area is cleaned thoroughly. Instructions given to patient to apply warm, wet compresses at home.
A: Carbuncle of the thigh, left
P: Rx for erythromycin, q8h and mupirocin ointment
CHAPTER 14 |
14.4 Prevention and Screenings
The most frequently diagnosed malignancy in the United States is skin cancer. While
some individuals have a higher risk of developing this type of malignant neoplasm, the
truth is that anyone can find himself or herself with this diagnosis.
The best way to prevent skin lesions is to avoid known causes. Of course, some sug-
gest staying out of the sun altogether, but this could decrease a patient’s exercise and out-
door activities, which are also good for one’s health. Therefore, protective clothing and
use of sunscreen with a sun protection factor (SPF) of 15 or higher is strongly recom-
mended prior to going out into the sun. Tanning beds also may cause an increased risk.
The Centers for Disease Control and Prevention (CDC) suggests ways to protect
yourself from UV rays that can cause harm:
∙ Stay in the shade as much as possible, especially during the hours of 10 a.m. through
4 p.m.
∙ Keep your extremities (arms and legs) covered with clothing.
∙ Use a wide-brimmed hat to shade and protect your head, face, neck, and ears.
∙ Wear sunglasses to protect your eyes (and reduce your risk for cataracts).
∙ Apply sunscreen with an SPF of 15 or higher.
∙ Avoid the use of any indoor tanning beds or booths including sunlamps.
Physicians are encouraged by the CDC to perform an annual exam of all patients,
especially those who are older and higher at risk. The scalp, ears, nasolabial folds, and
wrinkles are key points.
EXAMPLES
There can be other reasons for a healthy patient to see a physician about skin-
related issues:
Z12.83 Encounter for screening for malignant neoplasm of skin
Z20.7 Contact with and (suspected) exposure to pediculosis, acariasis
and other infestations
Z52.11 Skin donor, autologous
Z52.19 Skin donor, other
Z84.0 Family history of diseases of the skin and subcutaneous tissue
Z86.31 Personal history of diabetic foot ulcer
Z87.2 Personal history of disease of the skin and subcutaneous tissue
Z94.5 Skin transplant status
Z96.81 Presence of artificial skin
ICD-10-CM
YOU CODE IT! CASE STUDY
PATIENT NAME: Christopher Flemming
SUBJECTIVE: The patient is a 54-year-old male who presents for his annual preventive screening of moles. He has
no particular lesions he is concerned about, although he states his wife has told him that he has a lot of moles on his
back. He does not think any of them are changing. He did have an atypical nevus removed from one of the toes on
his left foot about 3 years ago. He did not require re-excision after the biopsy. He was told to have annual skin exams
and he just has not followed through with it. His other complaint is acne on his chest and back.
PAST MEDICAL HISTORY: Negative for skin cancer.
MEDICATIONS: None.
Chapter Summary
With all the advertising about lotions to preserve youthful skin, shampoos and con-
ditioners for soft hair, and manicures and pedicures for nails, you may forget that
the elements of the integumentary system (skin, hair, nails) are not just cosmetic or
CHAPTER 14 |
decorative elements of our bodies. In addition, the glands embedded in the skin sup-
CHAPTER 14 REVIEW
CODING BITES
Early detection is the best, most effective way to deal with any malignancy, includ-
ing skin cancer. This means that a regular habit of self-examination is wise. The
CDC developed a five-point checklist to help you check yourself for melanoma.
“A” stands for Asymmetrical. Does the mole or spot have an irregular shape
with two parts that look very different?
“B” stands for Border. Is the border irregular or jagged?
“C” is for Color. Is the color uneven? Do you see variations of brown, black,
blue, or white?
“D” is for Diameter. Is the mole or spot larger than the size of a pea (6 mm)?
“E” is for Evolving. Has the mole or spot changed during the past few weeks or
months?
If the answer to any of these steps is Yes, the patient should contact a dermatolo-
gist for a complete screening.
CHAPTER 14 REVIEW
Coding Integumentary Conditions Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
Part I
1. LO 14.1 A bubble or sac formed on the surface of the skin, typically filled with A. Blister
a watery fluid or serum. B. Carbuncle
2. LO 14.1 An open wound or sore caused by pressure, infection, or inflammation. C. Decubitus Ulcer
3. LO 14.2 Death and decay of tissue due to inadequate blood supply. D. Dermis
4. LO 14.1 The layer beneath the dermis; also known as the hypodermis. E. Epidermis
5. LO 14.3 A painful, pus-filled boil due to infection of the epidermis and underly- F. Gangrene
ing tissues, often caused by staphylococcus.
G. Hair
6. LO 14.1 A skin lesion caused by continuous pressure on one spot, particularly
H. Hair Follicle
on a bony prominence.
I. Phalanges
7. LO 14.2 A saclike bulb containing the hair root.
J. Skin
8. LO 14.2 Fingers and toes.
K. Subcutaneous
9. LO 14.2 A pigmented, cylindrical filament that grows out from the hair follicle
within the epidermis. L. Pressure Ulcer
10. LO 14.1 The external layer of the skin, the majority of which is squamous cells.
11. LO 14.1 The internal layer of the skin; the location of blood vessels, lymph ves-
sels, hair follicles, sweat glands, and sebum.
12. LO 14.1 The external membranous covering of the body.
CHAPTER 14 REVIEW
1. LO 14.3 An erosion or loss of the full thickness of the epidermis. A. Bulla
2. LO 14.3 A large macule. B. Cyst
3. LO 14.3 A raised lesion with a diameter of less than 5 mm. C. Furuncle
4. LO 14.3 An abnormally pigmented area of skin. A birthmark is an example. D. Macule
5. LO 14.3 A flat lesion with a different pigmentation (color) when compared with E. Nevus
the surrounding skin. F. Nodule
6. LO 14.3 A papule larger than 5 mm. G. Papule
7. LO 14.3 A fluid-filled or gas-filled bubble in the skin. H. Patch
8. LO 14.3 A boil. I. Pustule
9. LO 14.3 Flaky exfoliated epidermis. J. Scale
10. LO 14.3 A large vesicle that is filled with fluid. K. Ulcer
11. LO 14.3 A vesicle filled with pus.
3. LO 14.3 Latoya Gregson was diagnosed with a left hand nevus. The correct code would be
a. D22.6 b. D22.60 c. D22.61 d. D22.62
4. LO 14.2 Women with this condition have excessive hair growth on anatomical sites where hair does not typically
occur, such as the chest or chin. This condition is known as
a. trichotillomania. b. hirsutism.
c. alopecia. d. cilia.
5. LO 14.1 Kathy Harrington, a 17-year-old female, comes in today complaining of red, tender skin and having
chills. Kathy admits to sun bathing all day yesterday. After an examination, Dr. Dills diagnoses Kathy
with a 2nd degree sunburn. What is the correct code?
a. L55.9 b. L55.0 c. L55.1 d. L55.2
6. LO 14.2 _____ are sweat glands that are responsible for maintaining proper body temperature by excreting sweat
(water, salt, and wastes) via the pores in the skin.
a. Sebaceous glands b. Eccrine glands
c. Apocrine glands d. Holocrine glands
CHAPTER 14 |
8. LO 14.1 When skin layers are lost through and including the subcutaneous tissue, this is a _____ pressure ulcer.
CHAPTER 14 REVIEW
9. LO 14.1 _____ presents with pain, edema, and/or loss of flexibility in at least one joint. When affecting the fin-
gers or toes, the nails may show pitting or begin to separate from the nail bed.
a. Psoriatic arthritis mutilans b. Psoriasis vulgaris
c. Guttate psoriasis d. Plaque psoriasis
10. LO 14.4 All of the following are ways to protect yourself from UV rays that can cause harm except
a. keep your extremities covered with clothing.
b. use indoor tanning beds regularly.
c. use a wide-brimmed hat to shade and protect your head, face, neck, and ears.
d. wear sunglasses to protect your eyes (and reduce your risk for cataracts).
1. Codes from category L89, Pressure _____, identify the _____ of the pressure ulcer as well as the stage of the
ulcer.
2. Assign as many codes from category _____ as needed to identify _____ the pressure ulcers the patient has, if
applicable.
3. When there is _____ documentation regarding the _____ of the pressure ulcer, assign the appropriate code for
unspecified stage (L89.--9).
4. Assignment of the pressure ulcer stage code should be guided by _____ documentation of the stage or documen-
tation of the _____ found in the Alphabetic Index.
5. No code is assigned if the documentation states that the pressure ulcer is _____ healed.
6. Pressure ulcers described as _____ should be assigned the appropriate pressure ulcer stage code based on the
_____ in the medical record.
7. If a patient is _____ with a pressure ulcer at one stage and it _____ to a higher stage, _____ separate codes should
be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site
and the _____ stage reported during the stay.
CHAPTER 14 REVIEW
5. LO 14.3 List two types of malignant lesions; describe each one, including the category code.
ICD-10-CM
YOU CODE IT! Basics
First, identify the condition in the following 8. Psoriasis vulgaris:
diagnoses; then code the diagnosis. a. main term _____ b. diagnosis: _____
Example: Bullous impetigo 9. Psoriatic arthritis mutilans:
a. main term: impetigo b. diagnosis: L01.03 a. main term _____ b. diagnosis: _____
10. Lichen nitidus:
1. Carbuncle of perineum:
a. main term _____ b. diagnosis: _____
a. main term _____ b. diagnosis: _____
11. Telogen effluvium:
2. Acute lymphangitis:
a. main term _____ b. diagnosis: _____
a. main term _____ b. diagnosis: _____
12. Alopecia universalis:
3. Coccygeal fistula with abscess:
a. main term _____ b. diagnosis: _____
a. main term _____ b. diagnosis: _____
13. Acne conglobata:
4. Pemphigus vulgaris:
a. main term _____ b. diagnosis: _____
a. main term _____ b. diagnosis: _____
14. Pilar cyst:
5. Flexural eczema:
a. main term _____ b. diagnosis: _____
a. main term _____ b. diagnosis: _____
15. Livedoid vasculitis:
6. Seborrhea capitis:
a. main term _____ b. diagnosis: _____
a. main term _____ b. diagnosis: _____
7. Irritant contact dermatitis due to cosmetics:
a. main term _____ b. diagnosis: _____
ICD-10-CM
CHAPTER 14 |
CHAPTER 14 REVIEW
6. Matt Kicklighter, an 18-year-old male, presents today with fluid-filled blisters on his back. Matt states that
the blisters are easily broken. After an examination and testing, Dr. Gardener diagnoses Matt with staphylo-
coccal scalded skin syndrome with 14% exfoliation due to erythematosis.
7. Judy Shirer, a 48-year-old female, comes in today with swollen, red, and painful skin on her face. Judy says
she also feels nauseous. Dr. Lee notes red streaking around the cheeks and eyes and a temperature of 103 F.
After examining Judy, Dr. Lee admits her to the hospital, where further laboratory test results confirm the
diagnosis of facial cellulitis, MRSA.
8. Aaron Ragin, a 17-year-old male, presents today with a painful red lump on his chest. Dr. Godwin com-
pletes an examination and the appropriate laboratory tests. Aaron is diagnosed with a furuncle due to
staphylococcus.
9. Harriett Mooney, a 6-year-old female, is brought in by her parents. Harriett has dry scaly skin. Dr. Lebrun
completes an examination and a patch test, which confirms the diagnosis of infantile eczema.
10. Kathy Neal, a 56-year-old female, presents today with an itchy purple-colored lower lip. Dr. Grimsley notes
flat-topped papules intermingled with lacy white lines. Kathy is diagnosed with bullous lichen planus.
11. Brenda Mets, a 32-year-old female, was diagnosed with basal cell carcinoma on her nose 10 days ago. Brenda
is admitted to the hospital today for electrodesiccation and curettage by Dr. Dease.
12. Donald Ross, a 33-year-old male, presents today with raised bumps on his back. Dr. Margroff notes pustules.
Don admits to skin tenderness. Dr. Margroff completes an examination and diagnoses Donald with general-
ized pustular psoriasis.
13. Beth Whitman, an 81-year-old female, presents with a sore on the medial side of her right calf. After examin-
ing the area and documenting edema and ulceration, Dr. Sanoski decides to admit Beth to the hospital. After a
workup, Beth is diagnosed with a venous stasis ulcer with muscle necrosis, right calf. A possible skin graft is
discussed with the patient.
14. Eugene Sanford, a 49-year-old male, comes in today with the complaint of a small red prickly rash under his scro-
tum. Dr. Kimrey completes an examination and the appropriate tests. Eugene is diagnosed with apocrine miliaria.
15. Gary Sanders, a 78-year-old male, comes in today with the complaint that the mole on his right ankle has
begun to rapidly change in shape and color. Dr. Jones completes an examination noting ABCD - asymmetry,
elevation above skin surface with an irregular border, blue-grey in color, firm to the touch, and a diameter of
8 mm and thickness of 1.63 mm. Gary is admitted to Weston Hospital. Skin and lymph node biopsies were
ordered as well as imaging studies and blood tests. After reviewing the results of the pathology report and
other tests, Gary is diagnosed with a malignant nodular melanoma. Excision of lesion is scheduled.
ICD-10-CM
CHAPTER 14 |
CHAPTER 14 REVIEW
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: MEDINA, LEAH
ACCOUNT/EHR #: MEDILE001
DATE: 09/16/18
Attending Physician: Renee O. Bracker, MD
S: Leah Medina, a 6-year-old female, was at home helping her father clean out the attic when she was
bitten by a black spider. Her father, Jacob, thought quickly and captured the spider in an old jar. Leah
began to run a fever and vomited several hours later, so her father rushed her to the ED.
O: H: 50.5”, Wt: 58.0 lbs., T: 102 F, R: 22, P: 90, BP: 127/88. Leah says she feels really tired and hurts all
over. She has constantly scratched the bite area since arriving at the ED. She appears lethargic; rash is
noted over body; heart is regular with no gallops or murmurs; lungs are clear; a dark blue/purple wound
is noted on the right thigh. PMH and FH are both noncontributory. Dr. Bracker was able to identify the
spider as a black widow spider and admits Leah to the hospital.
A: Black widow spider bite
P: Anitvenom 6000 units IV in 50 mL of normal saline over 15 minutes
CHAPTER 14 |
15
Key Terms
Coding Muscular
and Skeletal Conditions
Learning Outcomes
Arthropathy After completing this chapter, the student should be able to:
Articulation
Chondropathy LO 15.1 Code accurately arthropathic conditions of the muscles.
Dorsopathy LO 15.2 Determine the proper way to report dorsopathies and
Intervertebral Disc spondylopathies.
Laterality LO 15.3 Interpret the details required to report soft tissue disorders.
Myopathy LO 15.4 Identify the specifics of diseases that affect the musculoskel-
Site etal system reported from other areas of ICD-10-CM.
Spondylopathy
Vertebra LO 15.5 Report diagnoses related to pathological fractures
accurately.
15.1 Arthropathies
As you can see in Figure 15-1, the entire skeleton appears to be wrapped with muscles
from top to bottom and all the way around. Each muscle has a specific function.
Injuries are not the only concern that can affect an individual’s musculoskeletal
health. Diseases, infections, and other problems can occur. There are pathogens (bac-
teria, viruses, and fungi) that directly attack the muscles of the body. The physician’s
Myopathy notes might identify the patient’s condition as myopathy, arthropathy, chondropathy,
Disease of a muscle [plural: dorsopathy, or spondylopathy. Some of these conditions are described in this list:
myopathies].
Arthropathy
Disease or dysfunction of a CODING BITES
joint [plural: arthropathies]. Myopathy: myo = muscle + -pathy = disease.
Chondropathy Arthropathy: arthro = joint + -pathy = disease.
Disease affecting the cartilage Chondropathy: chondro = cartilage + -pathy = disease.
[plural: chondropathies]. Dorsopathy: dorso = back + -pathy = disease.
Spondylopathy: spondylo = vertebra + -pathy = disease.
Dorsopathy
Disease affecting the
back of the torso [plural:
Rheumatoid arthritis (RA) is an autoimmune systemic inflammatory disease that
dorsopathies].
affects joints as well as the surrounding muscles, tendons, and ligaments. Report a
Spondylopathy code from category M05 Rheumatoid arthritis with rheumatoid factor or M06 Other
Disease affecting the verte- rheumatoid arthritis. To determine the complete valid code, you will need to iden-
brae [plural: spondylopathies]. tify, from the documentation, the specific anatomical site. Be alert because more than
one anatomical site may be involved, and ICD-10-CM provides you with combination
codes to report the complete story of this patient’s condition.
406
Frontalis
Orbicularis Temporalis
oculi
Occipitalis
Zygomaticus
Masseter Sternocleidomastoid
Orbicularis oris
Trapezius Trapezius Infraspinatus
Sternocleido-
mastoid
Deltoid Rhomboid
Deltoid
Pectoralis Teres minor Latissimus
major dorsi
Serratus Teres major
anterior Biceps brachii Brachialis
Brachialis Triceps
External External
brachii
oblique oblique
Rectus Brachioradialis Gluteus
abdominis medius
Tensor Gluteus
maximus
fasciae
latae
Sartorius
FIGURE 15-1 An illustration identifying the muscles of the body: anterior and posterior David Shier et al., Hole’s Human
Anatomy & Physiology, 12/e. ©2010 McGraw-Hill Education. Figure 9.23 and 9.24, p. 305–306. Used with permission.
EXAMPLES
CODING BITES
M05.151 Rheumatoid lung disease with rheumatoid arthritis of right hip
Many people confuse
M05.242 Rheumatoid vasculitis with rheumatoid arthritis of the left hand
RA (rheumatoid arthritis)
M05.361 Rheumatoid heart disease with rheumatoid arthritis of right knee
with OA (osteoarthritis).
M06.022 Rheumatoid arthritis without rheumatoid factor, left elbow
RA is a condition that
M06.071 Rheumatoid arthritis without rheumatoid factor, right ankle
affects the muscles,
and foot
joints, and/or connec-
tive tissue, whereas OA Rheumatoid factor (RF) is a test that quantifies the amount of the RF antibodies in
is the deterioration of the blood. A positive RF is the abnormal result indicating a higher number of anti-
cartilage within joints as bodies have been detected—confirmation of the autoimmune response mecha-
well as spinal vertebrae. nism. You would find the data on the pathology report.
CHAPTER 15 |
ICD-10-CM
YOU CODE IT! CASE STUDY
Gary Simmons, a 19-year-old male, came in with complaints of intense pain and swelling of his left elbow. Vital signs
evidence a low-grade fever. Gary states that he injured his forearm in hockey practice and it got infected, but he
was too busy with classes and practice to go to the medical clinic on campus. Now, all of a sudden, he has pain in
his elbow that he cannot ignore. Dr. Lannahan applied a local anesthetic and used fine needle aspiration to extract
some synovial fluid. Analysis shows gross pus and testing shows a high white blood cell count. The synovial fluid glu-
cose is 55 mg/dL. This confirmed a diagnosis of acute septic arthritis, due to gram-positive Staphylococcus aureus.
Genu recurvatum, the backward curving of the knee joint, as well as other bowing
of the long bones of the leg, may be treated with braces, casting, and/or orthotics. Con-
genital genu recurvatum is reported with code Q68.2 Congenital deformity of knee.
When this condition is the sequela (late effect) of rickets, it is reported with M21.26-
Flexion deformity, knee, followed by code E64.3 Sequela of rickets.
Gout, also known as gouty arthritis, is the result of the buildup of uric acid in the
body; caused by either a malfunction that produces too much uric acid or an anomaly
that makes it difficult for the body to get rid of uric acid. The specific underlying cause
may be idiopathic or secondary, as a manifestation of renal impairment, adverse reaction
to a drug, or a toxic effect. Gout presents in the joints, most often a toe, knee, or ankle,
and begins with a throbbing or extreme pain in the middle of the night. The joint will
be tender, warm to the touch, and erythematous (red). The most common treatment is a
prescription for NSAIDs (nonsteroidal anti-inflammatory drugs). In ICD-10-CM, gout
is reported from code category M10- Gout or from code category M1A- Chronic Gout,
with additional characters required to report the underlying cause (i.e., drug-induced,
idiopathic, etc.) as well as the specific anatomical location (i.e., ankle, elbow, foot, etc.).
Osteoarthritis is a chronic degeneration of the articular cartilage simultaneous with
the formation of bone spurs on the underlying bone within a joint. The cause of the
osteoarthritis might be an idiomatic condition (such as code M17.11 Unilateral pri-
mary osteoarthritis, right knee); secondary to another underlying condition (such as
ICD-10-CM
LET’S CODE IT! SCENARIO
Timothy Metrosky, a 55-year-old male, came to see Dr. Weingard with complaints of acute pain in his left hip. He had
been diagnosed with stage 1 chronic kidney disease about 1 year ago, but it has been under control with medica-
tion. Dr. Weingard aspirated synovial fluid from his hip, and the pathology report confirmed that Timothy had devel-
oped secondary gout in his hip.
(continued)
CHAPTER 15 |
Make certain to check the top of both subsections and the head of both chapters in ICD-10-CM. There are nota-
tions at the beginning: an notation, a Code first notation, a Use additional code notation, NOTEs at
the head of both chapters, and notations. Read carefully. Do any relate to Dr. Weingard’s diagnosis of
Timothy? No. Turn to the Official Guidelines and read Section 1.c.13 (for the musculoskeletal system) and 1.c.14
(for the renal disease). There is nothing specifically applicable here, either. Now you can report N18.1, M10.352
for Timothy’s diagnosis with confidence. Good coding!
Systemic lupus erythematosus (SLE) is an autoimmune disease affecting the joints, kid-
neys, brain, skin, and other organs. Interestingly, ICD-10-CM places this code category
within the musculokeletal system chapter. SLE may be an adverse effect of certain drugs.
When this is documented, you will code M32.0 Drug-induced systemic lupus erythemato-
sus, as well as an additional external cause code to identify the specific drug involved. If
the etiology of the SLE is unknown, you will need to abstract from the physician’s notes if
any organ or organ system is specifically affected. When this is documented, use a combi-
nation code from subcategory M32.1- Systemic lupus erythematosus with organ or system
involvement, with the fifth character naming that system or issue, such as
M32.11 Endocarditis in systemic lupus erythematosus
M32.13 Lung involvement in systemic lupus erythematosus
ICD-10-CM
LET’S CODE IT! SCENARIO
Manuel Daniels, a 43-year-old male, came to see Dr. Biehl complaining of pain and stiffness in his lower jaw. Upon
examination, Dr. Biehl noted swelling and erythema at the temporomandibular joint. Dr. Biehl diagnosed Manuel with
arthralgia of temporomandibular joint, right side.
Posterior
Anterior Posterior
Spinal cord
Spinous
process Spinal cord
Vertebral
foramen Transverse Facet of superior
process articular process
Intervetebral
Facet for head
disc
of rib
Facet of Vertebral arch:
superior
articular Lamina
Inferior articular
process process
Pedicle
Facet for
head of rib Body
Spinous process
Spinal nerve
Anterior exiting through
intervertebral Left posterolateral view
foramen of articulated vertebrae
Superior view
FIGURE 15-2 An illustration identifying the aspects of the vertebrae: anterior and posterior
CHAPTER 15 |
Cervical Cervical
curvature vertebrae
Vertebra
prominens
Rib facet
Thoracic Thoracic
curvature vertebrae
Intervertebral
discs
Intervertebral
Lumbar foramina Lumbar
curvature vertebrae
Sacrum
Pelvic
curvature
Coccyx
(a) (b)
FIGURE 15-3 An illustration identifying the anatomical sites of the spinal column
Source: David Shier et al., Hole’s Human Anatomy & Physiology, 12/e. ©2010 McGraw-Hill Education. Figure 7.32,
p. 219. Used with permission.
EXAMPLE
In all scoliosis diagnoses, you will need to abstract the specific region of the spine
affected.
M41.02 Infantile idiopathic scoliosis, cervical region
M41.115 Juvenile idiopathic scoliosis, thoracolumbar region
M41.127 Adolescent idiopathic scoliosis, lumbosacral region
ICD-10-CM
YOU CODE IT! CASE STUDY
Marci Wakefield started having pain in her back, after completing a full course of radiation treatments for a malig-
nant tumor. Dr. Diaz diagnosed her with scoliosis of the thoracic region as a result of the radiation.
Spinal ankylosis is the fusion within a vertebral joint caused by disease. This is not
a procedure where the physician may fuse a joint. Code subcategory M43.2 Fusion of
spine requires a fifth character to report the specific region affected.
Ankylosing spondylitis (AS) is actually a type of inflammation within the vertebral
joint (arthritis). This may also be seen in the joints between the spine and the pelvic
girdle. AS affects men more than women. Code category M45 Ankylosing spondylitis
is used to report AS, with a fourth character to specify the region affected.
Intervertebral disc infection is caused by a pathogen and is different from the
inflammation of arthritis because it is suppurative (produces pus). Code subcategory
CHAPTER 15 |
CODING BITES
Why is Marci’s condition coded as secondary scoliosis and not . . .
M41.24 Other idiopathic scoliosis, thoracic region
Idiopathic means with no known cause. But the notes do state a cause of her
scoliosis—the radiation. So this cannot be correct.
What about this code:
Q67.5 Congenital deformity of spine (Congenital scoliosis)
Congenital means present at birth. But Marci was not born with scoliosis—it devel-
oped as a result of her having radiation treatments.
Secondary means that something else (other than nature or something
unknown) caused this condition. In this case, the radiation caused the scoliosis.
The radiation came first, and the scoliosis came second.
ICD-10-CM
LET’S CODE IT! SCENARIO
George Cornelius came to see Dr. Rymer with complaints of sudden-onset, severe low back pain. He states that the
pain is in the left side of his buttocks, his left leg, and sometimes his left foot. At times, he states that his leg seems
weak as well. Dr. Rymer takes a complete patient history, including specific times and actions that intensify the pain.
Then x-rays, followed by an MRI, are taken of George’s spine, showing a herniated (intervertebral) disc at L3–L4.
CHAPTER 15 |
ball of the foot rather than the heel while jogging or is a manifestation of cerebral palsy or
poliomyelitis. Use code M67.0 Short Achilles tendon (acquired), with a fifth character to
identify the right or left ankle, or Q66.89 Other specified congenital deformities of feet.
Torticollis is a condition in which the sternocleidomastoid muscle becomes spasmed
(shortened), causing the head to bend to one side and the chin to the opposite side. This
condition may be acquired, reported with code M43.6 Torticollis, unless the documen-
tation states Q68.0 Congenital deformity of sternocleidomastoid muscle, F45.8 Other
somatoform disorders, G24.3 Spasmodic torticollis, or other diagnosis shown in the nota-
tion beneath M43.6.
Muscle spasms, commonly known as muscle cramps, are involuntary twitches and
are often caused by myositis or fibromyositis. Sometimes these spasms are caused
by metabolic or mineral imbalances. Abstract the documentation to identify the ana-
tomical site. Use code M62.830 Muscle spasm of back, M62.831 Muscle spasm of calf
(Charley-horse), M62.838 Other muscle spasm, or R25.2 Cramp and spasm.
Type III traumatic spondylolisthesis of the axis (C2) is a displacement of the ver-
tebra anteriorly over the vertebra below it. An open reduction of the C2 vertebra fol-
lowed by a posterior spinal fusion with a pedicle lag screw is used to repair the injury.
Report this with code M43.12 Spondylolisthesis, cervical region.
ICD-10-CM
LET’S CODE IT! SCENARIO
Elliott Carlyle, a 17-year-old male, is believed to be an up-and-coming star on the golf course. He explains to Dr. Carole
that the pain in his left elbow has become severe and his ability to grasp the club is weakened. Physical exam included
flexion and pronation, confirming medial epicondylitis.
ICD-10-CM
LET’S CODE IT! SCENARIO
Everett Rotarine, a 43-year-old male, was having pain in his left thigh, which his orthopedist, Dr. Nixon, identified
as excessive bone resorption, the osteoclastic phase of Paget’s disease. X-rays and a urinalysis showing elevated
levels of hydroxyproline confirmed the osteoclastic hyperactivity. Everett comes in today to discuss the test findings
and treatment options.
CHAPTER 15 |
15.4 Musculoskeletal Disorders from Other
Body Systems
Acquired Conditions
Muscle tumors do not occur frequently and can often be malignant. Use code catego-
ries C49 Malignant neoplasm of other connective and soft tissue, C79.89 Secondary
malignant neoplasms of other specified sites, or D21 Other benign neoplasms of con-
nective and other soft tissue.
Duchenne’s muscular dystrophy (DMD) is caused by a mutation of the DMD gene
within the X chromosome, resulting in the body’s inability to create the dystrophin
protein within the muscles. Due to this, males are more likely to contract the condition
because females have an additional X chromosome that may counteract the mutated
gene, as long as the second X chromosome is not damaged as well. Initial signs and
symptoms of DMD include leg muscle weakness followed by weakness of the shoul-
der muscles. DMD is most often diagnosed in early childhood and may be terminal by
age 21 should the weakness spread to either heart or respiratory muscles. New trials
using gene therapy are hopeful. Use code G71.0 Muscular dystrophy.
Myasthenia gravis is a chronic autoimmune condition that causes muscle weak-
ness, primarily in the face and neck, due to the immune system incorrectly attacking
the muscle cells in the body. It may progress and involve additional weakness in the
muscles of the extremities (arms and legs). Use code G70.00 Myasthenia gravis with-
out (acute) exacerbation or G70.01 Myasthenia gravis with (acute) exacerbation.
Paralytic syndromes are conditions in which muscle control is reduced or non-
existent. Cerebral palsy (code category G80), hemiplegia and hemiparesis (code
category G81), and paraplegia (paraparesis) and quadriplegia (quadriparesis) (code
category G82) are some of the conditions that may interfere with the activities of
daily living.
Congenital Disorders
Congenital myopathies include minicore disease, nemaline myopathy, and fiber-type
disproportion. One code, G71.2, reports several muscle abnormalities diagnosed in a
neonate or infant. Most often, the infant will not meet normal developmental mile-
stones, particularly those involving muscular actions, such as sitting up or rolling over.
CODING BITES Such babies may also have problems feeding.
NOTICE that these Developmental dysplasia of the hip (DDH), also known as congenital hip dyspla-
conditions—congenital sia, is most common in a baby born breech, a large neonate, or a multiparity baby.
myopathies, muscular DDH is a condition in which the head of the femur is displaced from the acetabulum.
dystrophy, myasthe- Use code Q65.89 Other specified congenital deformities of hip (congenital acetabular
nia gravis, and para- dysplasia).
lytic syndromes—are Ectromelia or hemimelia can occur in either the upper or lower limb. Ectromelia
reported with codes is the congenital absence or imperfection of one or more limbs. Hemimelia is a con-
from the Diseases of genital abnormality affecting only the distal segment of either the upper or lower limb.
the Nervous System This condition is reported with code Q73.8 Other reduction defects of unspecified limb
chapter of ICD-10-CM. (ectromelia of limb NOS) (hemimelia of limb NOS).
Remember that the Klippel-Feil syndrome is a condition characterized by the development of a short,
nerves signal the wide neck due to either an abnormal number of cervical vertebrae or fused hemiverte-
muscles to function. brae (the incomplete development of one side of a vertebra). Use code Q76.1 Klippel-
Therefore, paralysis is Feil syndrome (cervical fusion syndrome).
actually a dysfunction of Spina bifida is a condition in which the bony encasement of the spinal cord fails to
the nerves that commu- close. Surgical repair is done as soon as possible in an effort to reduce serious handi-
nicate with the affected caps. There have been some successful cases of in utero surgical repair. This condition
specific muscles. is reported from code category Q05- Spina bifida, with an additional character to iden-
tify the specific area of the spine that is affected.
CHAPTER 15 |
Site Skull
The specific anatomical loca- Cranium
tion of the disease or injury. Spinal
column
Laterality Cervical Mandible
The right or left side of ana- vertebrae
Clavicle
tomical sites that have loca-
Scapula
tions on both sides of the
body; e.g., right arm or left Manubrium
Thoracic
arm; unilateral means one Ribs
vertebrae
side and bilateral means both Sternum
sides. Humerus
Ulna
Lumbar
Radius
vertebrae
GUIDANCE Sacrum
Pelvic girdle
Carpals
CONNECTION
Metacarpals
Read the ICD-10-CM
Official Guidelines for Coccyx Phalanges
Coding and Reporting,
section I. Conven-
tions, General Coding Femur
Guidelines and Chapter
Specific Guidelines, Patella
subsection C. Chapter- Tibia
Specific Coding
Fibula
Guidelines, chapter
13. Diseases of the
Musculoskeletal Sys- Tarsals
tem and Connective Metatarsals
Tissue, subsection a.1) Phalanges
Bone versus joint.
FIGURE 15-4 An illustration identifying the major bones of the human skeleton
Treatment for pathological fractures may be similar to that for a traumatic fracture.
GUIDANCE However, not always. In virtually all cases, the underlying condition is treated as well.
CONNECTION
Read the ICD-10-CM
Official Guidelines for EXAMPLES
Coding and Report- Pathological fractures are reported from these code subcategories:
ing, section I. Con-
M84.4- Pathological fracture, not elsewhere classified
ventions, General
M84.5- Pathological fracture in neoplastic disease
Coding Guidelines
M84.6- Pathological fracture in other diseases
and Chapter Specific
Guidelines, subsec-
tion C. Chapter-Specific When reporting a code for a pathologic fracture, you will need to assign a seventh
Coding Guidelines, character to identify the point in the treatment for this condition.
chapter 13. Diseases
of the Musculoskeletal A Use the seventh character A for the entire scope of time that the patient is receiving
System and Connec- active treatment for this fracture. This seventh character reports the status of “active
tive Tissue, subsection treatment,” not the relationship between physician and patient (new patient).
c. Coding of Pathologic D Once the patient has completed active treatment, this character should be reported to
Fractures. identify follow-up for routine healing.
G The seventh character G would be reported for subsequent care for a pathological
fracture with delayed healing.
K Subsequent care provided for a nonunion would be identified with a seventh charac-
ter of K.
GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I.
Conventions, General Coding Guidelines and Chapter Specific Guidelines, sub-
section C. Chapter-Specific Coding Guidelines, chapter 13. Diseases of the Mus-
culoskeletal System and Connective Tissue, subsection c. Coding of Pathologic
Fractures, and chapter 2. Neoplasms, subsection l.6) Pathologic fracture due to
a neoplasm.
ICD-10-CM
YOU CODE IT! CASE STUDY
Deliah Livingston, a 49-year-old female, was diagnosed with breast cancer a year ago. She had a double mas-
tectomy 6 months ago. She came to see Dr. Wells for a checkup and he discovered that Deliah’s malignancy had
metastasized to the proximal portion of her right femur. Dr. Wells suggested surgery to insert a metal rod to support
the bone. She told him she would think about it. Yesterday, she was walking down her driveway and all of a sudden
her thighbone splintered and she fell. In the Emergency Department, Dr. Travers diagnosed Deliah with a pathologi-
cal fracture of the proximal femur, just below the hip joint, due to metastatic malignancy.
Chapter Summary
The entire body is wrapped from head to toe and all the way around by muscles: vol-
untary muscles that assist movement of the skeleton and involuntary muscles that are
CHAPTER 15 |
controlled by the nervous system. Each muscle has its specific function and they are
CHAPTER 15 REVIEW
CODING BITES
Interesting Facts about Human Muscles
Longest muscle = Sartorious (thigh) muscle
Smallest muscle = Stapedius (in the ear)
Largest muscle = Gluteus maximus (buttocks)
Strongest muscle = Masseter (chewing)
Busiest muscles = Eye muscles
Goosebump muscles = Tiny muscles in the hair root
Smiling requires 17 facial muscles.
Frowns require 42 facial muscles.
CHAPTER 15 REVIEW
Coding Muscular and Skeletal Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
Conditions
Let’s Check It! Terminology
Match each key term to the appropriate definition.
1. LO 15.2 A fibrocartilage segment that lies between vertebrae of the spinal col- A. Articulation
umn and provides cushioning and support. B. Intervertebral Disc
2. LO 15.5 A joint. C. Laterality
3. LO 15.5 The specific anatomical location of the disease or injury. D. Site
4. LO 15.2 A bone that is a part of the construction of the spinal column. E. Vertebra
5. LO 15.5 The right or left side of anatomical sites that have locations on both
sides of the body.
CHAPTER 15 REVIEW
head to bend to one side and the chin to the opposite side.
a. Bursitis b. Epicondylitis
c. Achilles tendon contracture d. Torticollis
5. LO 15.2 Sammie Blane was diagnosed with cervicothoracic postural kyphosis. How is this coded?
a. M40.209 b. M40.202 c. M40.03 d. M40.12
6. LO 15.3 A systemic rheumatic disorder characterized by inflammatory and degenerative changes in the skin and
muscles is known as
a. myositis.
b. juvenile dermatomyositis.
c. osteochondrosis.
d. dermatopolymyositis.
7. LO 15.4 Myotonic muscular dystrophy is coded
a. G71.11 b. G71.0 c. G71.12 d. G71.13
8. LO 15.4 ____ is a chronic autoimmune condition that causes muscle weakness, primarily in the face and neck,
due to the immune system incorrectly attacking the muscle cells in the body.
a. Duchenne’s muscular dystrophy
b. Myasthenia gravis
c. Ectromelia
d. Paralytic syndromes
9. LO 5.5 Ben Watson is diagnosed with a malunion. It will be reported with which seventh character?
a. A b. G c. P d. K
10. LO 15.5 When disease deteriorates the structure of a bone so much that it breaks under the slightest pressure,
this is known as a ____ fracture.
a. malformation b. traumatic
c. congenital d. pathologic
1. Most of the codes within Chapter 13 have ____ and ____ designations. The site ____ the bone, joint or the mus-
cle involved.
2. For categories where ____ multiple site code is provided and more than ____ bone, joint or muscle is involved,
____ codes should be used to indicate the different sites involved.
3. For certain conditions, the bone may be affected at the upper or lower end (e.g., avascular necrosis of bone, M87,
Osteoporosis, M80, M81). Though the portion of the bone ____ may be at the ____, the site designation will be
the ____, not the joint.
4. Bone, joint, or muscle conditions that are the result of a ____ injury are usually found in Chapter 13.
5. 7th character ____ is for use as long as the patient is receiving ____ treatment for the fracture.
CHAPTER 15 |
6. Osteoporosis is a ____ condition, meaning that all bones of the ____ system are affected.
CHAPTER 15 REVIEW
7. Category M81, Osteoporosis ____ current pathological fracture, is for use for patients with osteoporosis who do
____ currently have a pathologic fracture due to the osteoporosis, even if they have had a ____ in the past.
8. For patients with a ____ of osteoporosis fractures, status code ____, Personal history of (healed) osteoporosis
fracture, should follow the code from M81.
9. Category M80, Osteoporosis with ____ pathological fracture, is for patients who have a current pathologic frac-
ture at the ____ of an encounter.
10. A code from category M80, not a ____ fracture code, should be used for any patient with ____ osteoporosis who
suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a
normal, healthy bone.
ICD-10-CM
YOU CODE IT! Basics
First, identify the condition in the following diagnoses; 8. Osteomyelitis neonatal jaw:
then code the diagnosis. a. main term: ____ b. diagnosis: ____
Example: Trigger thumb, right: 9. Infantile idiopathic scoliosis, lumbosacral:
a. main term: Trigger b. diagnosis: M65.311 a. main term: ____ b. diagnosis: ____
10. Contracture of right ankle:
1. Infective myositis, left foot:
a. main term: ____ b. diagnosis: ____
a. main term: ____ b. diagnosis: ____
11. Atrophy of left lower leg:
2. Pyogenic arthritis, left knee:
a. main term: ____ b. diagnosis: ____
a. main term: ____ b. diagnosis: ____
12. Ankylosis of right wrist:
3. Foreign body granuloma of soft tissue, right thigh:
a. main term: ____ b. diagnosis: ____
a. main term: ____ b. diagnosis: ____
13. Abscess of tendon sheath, right forearm:
4. Juxtaphalangeal distal osteoarthritis:
a. main term: ____ b. diagnosis: ____
a. main term: ____ b. diagnosis: ____
14. Spinal stenosis, cervicothoracic region:
5. Nontraumatic rupture of muscle, left shoulder:
a. main term: ____ b. diagnosis: ____
a. main term: ____ b. diagnosis: ____
15. Calcific tendinitis, left pelvic region:
6. Hallux valgus, left foot:
a. main term: ____ b. diagnosis: ____
a. main term: ____ b. diagnosis: ____
7. Ischemic infarction of muscle, left hand:
a. main term: ____ b. diagnosis: ____
CHAPTER 15 |
CHAPTER 15 REVIEW
13. Valerie Halsey, a 51-year-old female, complains of lower back pain and numbness. Valerie also admits it is
sometimes difficult to control her left leg. Dr. Spratt completes a physical examination and history of the
symptoms. Dr. Spratt has Valerie perform the straight leg raise test, which was positive for Lasegue’s sign.
Valerie is diagnosed with wallet sciatica, left side.
14. James Ard, a 31-year-old male, comes in today to see Dr. Smyth. Jim complains his head is tilting and he
can’t control it. He also admits to neck spasms and it seems to him that it is worse after he has taken his after-
noon run. After a thorough examination and testing, Dr. Smyth diagnoses Jim with spasmodic torticollis.
15. Marygrace Fuller, a 16-year-old female, participated in rhythmic gymnastics yesterday at the local gym. She
woke up this morning and her left ankle was stiff and aches. After an examination, Dr. Jefferson diagnosed
Marygrace with Achilles tendinitis.
ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documentation
from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient encoun-
ters. Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
CHAPTER 15 |
CHAPTER 15 REVIEW
Perfect! That is exactly what she was doing. Let’s take a look in the Tabular List:
(continued)
CHAPTER 16 |
Y93 Activity codes
Y93.3 Activities involving climbing, rappelling, and jumping off
The note lists activities not related to Phyllis’s injury, so keep reading down the list:
Y93.31 Activity, mountain climbing, rock climbing and wall climbing
A code is needed to report the place of occurrence. Where was Phyllis when she got injured? At her gym.
Y92 Place of occurrence of the external cause
Y92.39 Other specific sports and athletic area as the place of occurrence of the external cause
(Gymnasium)
One more thing: What was Phyllis’s status, which you can describe using the codes within Y99 External cause
status? The wall climbing was a leisure activity for Phyllis, so you will report
Y99.8 Other external cause status (hobby not done for income)
Now you have all of the codes you need to tell the whole story about Phyllis’s injury and why Dr. Dellin treated
her:
S43.034A Inferior dislocation of right humerus, initial encounter
Y93.31 Activity, mountain climbing, rock climbing and wall climbing
Y92.39 Other specific sports and athletic area as the place of occurrence of the external cause
(Gymnasium)
Y99.8 Other external cause status (hobby not done for income)
Good work!
Traumatic Fractures
Fracture Both bone and cartilage can break—that is, become fractured. Fractures can be the
Broken cartilage or bone. result of trauma, such as a fall or car accident, or they can be the result of a pathologic
condition (underlying disease), such as osteoporosis, that causes the bone to weaken so
much that it breaks. This is important information for you to abstract from the physi-
cian’s documentation because traumatic fractures and pathologic fractures are coded
differently. Actually, they have separate listings in the Alphabetic Index: Fracture,
pathological, and Fracture, traumatic.
When a fracture of a bone occurs, the coder must identify the segment of the bone
that was affected. For example: The sternal end of the clavicle is called this because it
is the end that connects to the sternum (ICD-10-CM code S42.011 Anterior displaced
fracture of sternal end of right clavicle). The acromial or lateral end of the clavicle con-
nects to the acromioclavicular joint (ICD-10-CM code S42.031 Displaced fracture of
lateral end of right clavicle).
Types of Fractures
One of the first factors needed for accurate coding of a fracture is whether the fracture
is open or closed (see Figure 16-1).
An open fractured bone is found in conjunction with an open wound through which
the bone may or may not extend. A closed, or simple, fracture has no accompany-
ing wound and remains within the confines of the body. Some types of fractures are
explained in the following paragraphs.
Avulsion fractures happen when a tiny bone piece breaks off at the point where a
ligament or tendon attaches to the bone. This is an occurrence of a piece of bone that
has broken away at a tubercle. When the fracture is not displaced, treatment is similar
to that for a soft tissue injury. In severe cases, surgery may be required to realign and
stabilize an affected growth plate.
Burst fractures occur when a vertebra has been crushed in all directions. This frac-
ture may be described as stable or unstable. Imaging (x-rays, CT scan, or MRI), as
well as physical and neurologic exams, typically will support a diagnosis. Stable burst
fractures may be treated with a molded turtle shell brace or a body cast. If neurologic
damage is identified, then the fracture is considered unstable and will require surgery.
An anterior or posterior approach may be used to insert internal fixation, a bone graft,
and/or fusion. The specific bone affected will determine the code.
Comminuted fracture identifies the breaking of the bone into several pieces.
A closed reduction may be required prior to immobilization by cast or splint. Internal
fixation may be necessary to correct an impacted fracture with an open reduction.
Depressed fracture indicates that the bone has been displaced inward. CODING BITES
Fatigue fractures occur most often in the second or third metatarsal shaft and are typi- Open fractures may
cally the result of continuous weight-bearing activities such as long-distance running, ballet also be documented as
dancing, or sports. An example is M48.4- Fatigue fracture of vertebra. Additional names for infected, missile, punc-
this type of fracture include march fracture, Deutschlander’s disease, and stress fracture— ture, compound, or with
reported from subcategory M84.3- Stress fracture (fatigue fracture) (march fracture). a foreign body.
Fissured (linear) fracture is a break that runs along the length of a long bone. Closed fractures
Greenstick fracture is one in which the fracture exists on one side of the bone while may also be docu-
the other side is not broken but bent. Example: S42.311A Greenstick fracture of shaft mented as comminuted,
of humerus, right arm, initial encounter for closed fracture. depressed, elevated,
Impacted fracture occurs when a fragment from the broken bone embeds itself into fissured, greenstick,
the body of another. impacted, linear, simple,
Infected fracture documents that there is presence of an infection at the fracture site. slipped epiphysis, or
This often will require additional codes to report the underlying bacterium or virus, as spiral.
well as the infection itself.
CHAPTER 16 |
Lateral mass fracture of the atlas (C1), as the name implies, involves the lateral
masses. These are the sturdiest sections of the C1 vertebra and include a superior facet
and an inferior facet. This fracture occurs at the point where the spine meets the base
of the cranium. A stable fracture means the transverse ligament is still intact, and a
cervical collar or cervicothoracic brace is the first course of treatment. For unstable
fractures, cranial traction will support a reduction of the displaced bone. After time, a
halo vest can be used. Fusion of C1–C3 may be required for more severe subluxation.
Use code S12.040 Displaced lateral mass fracture of first cervical vertebra or S12.041
Non-displaced lateral mass fracture of first cervical vertebra.
Maisonneuve’s fracture is a spiral fracture of the proximal portion of the fibula.
This type of fracture includes a disruption of ligaments. Stable fractures can be treated
with a long leg cast. Internal fixation may be required in more severe cases.
Oblique fracture is a fracture line that runs at an angle to the axis of the bone. Cast-
ing is the typical first course of treatment. In severe cases, an open reduction and pos-
sibly internal fixation will be used. Repair to surrounding ligaments may be required
as well.
Periosteal fractures occur below the periosteum (membrane covering the bone sur-
face) and are usually not displaced.
Pilon fracture is an oblique, comminuted fracture of the distal tibia. Treatment may
begin with stabilization, using external traction to permit the soft tissue injuries to heal
prior to surgical intervention. Open reduction with internal fixation, as well as external
fixation and percutaneous plating, may be used once the soft tissue has recovered.
Puncture fracture can identify that a puncture from outside the body penetrated
to cause the fracture or that the broken bone has punctured the skin after the fracture
occurred. Example: S91.231A Puncture wound without foreign body of right great toe
with damage to nail, initial encounter.
Segmental fracture is similar to the comminuted fracture; however, the broken
pieces of the bone separate. Internal fixation with open reduction is used to prevent
misalignment of the bone fragments. In some cases, bone cement is included in the
repair. Some surgical procedures also include attachment of external fixation.
Salter-Harris physeal fracture is a fracture of the epiphyseal plate (a thin layer of
bone; a growth plate, an area near the end of a long bone that contains growing tissue,
also known as the physis), and it is commonly found in children. ICD-10-CM sepa-
rately codes four of the nine types of Salter-Harris fracture: Salter-Harris type I is a
transverse fracture of the growth plate; type II is a fracture of the growth plate and the
metaphysis; type III is a fracture of the growth plate and the epiphysis; and type IV is a
fracture line that travels through all three: the growth plate, metaphysis, and epiphysis.
Closed reductions and traction can be used for less severe cases. Types III and IV more
GUIDANCE often will require surgical intervention using open reduction and internal fixation. For
CONNECTION example: S79.011A Salter-Harris type I physeal fracture of upper end of right femur,
Read the ICD-10-CM initial encounter for closed fracture.
Official Guidelines for Spiral fracture happens when a twisting force causes the bone to break around a
Coding and Reporting, long bone in a spiral direction. Example: S52.244A Nondisplaced spiral fracture of
section I. Conven- shaft of ulna, right arm, initial encounter for closed fracture.
tions, General Coding Torus fracture is also known as a buckle fracture; it is a compression of one side of
Guidelines and Chapter a bone’s protrusion, also known as the torus, while the other side is bent. This fracture
Specific Guidelines, is typically nondisplaced and, therefore, is correctable with a cast or splint.
subsection C. Chapter- Transverse fracture is a fracture line that runs across the bone; it may be an open or
Specific Guidelines, closed fracture. An open reduction with internal fixation may be required if the bone
chapter 19. Injury, has separated. A closed reduction might alternatively be employed. Casting is typical.
poisoning, and certain Transcondylar fracture is a fracture that runs through a condyle (a rounded knoblike
other consequences of prominence at the end of a bone). Such fractures are categorized as flexion or exten-
external causes, sub- sion fractures. Treatment can begin with immobilization for nondisplaced injury. How-
section c. Coding of ever, treatment for this type of fracture can be difficult due to the break’s location and
Traumatic Fractures. the lack of bone available for successful union. Example: S42.431A Displaced fracture
(avulsion) of lateral epicondyle of right humerus, initial encounter for closed fracture.
Maxillary Fracture
Facial trauma might result in a LeFort fracture, which is a bilateral maxillary frac-
ture with involvement of the surrounding bone, including the zygomatic bones. Such
fractures are identified by type: A LeFort I fracture (code S02.411-) is a downward
horizontal facial fracture and typically involves the maxillary alveolar rim and infe-
rior nasal aperture. A LeFort II fracture (code S02.412-) is more triangular, involving
the inferior orbital rim, the nasal bridge, and the frontal processes of the maxilla.
A LeFort III fracture (code S02.413-) is a transverse fracture, sometimes referred to
as a craniofacial dissociation. This fracture involves the zygomatic arch, the nasal
bridge, and the upper maxilla and extends along the orbit floor (posteriorly).
EXAMPLES
S02.402A Zygomatic fracture, unspecified side, initial encounter for closed
fracture
S02.413D LeFort III fracture, subsequent encounter for fracture with rou-
tine healing
CHAPTER 16 |
Laceration Traumatic Wounds
Damage to the epidermal
and dermal layers of the skin Lacerations (Superficial Wounds)
made by a sharp object.
Each one of us has had a laceration at some time or another. Perhaps it was a paper
cut or a cut from a knife while chopping vegetables. This smooth slit or opening in the
GUIDANCE epidermal layer is typically superficial and does not bleed. A laceration caused by a
CONNECTION sharp object is generally a ragged wound (see Figure 16-2). Unlike a superficial cut,
a laceration is deeper, damaging the dermal layer of the skin. It penetrates the blood
Review the ICD-10-CM
vessels, resulting in bleeding. These more severe injuries may also be vulnerable to
Official Guidelines for
infection and pain. Depending upon the specific object or event that caused the lacera-
Coding and Report-
tion, the physician may order an x-ray to determine whether any foreign bodies, such
ing, section I. Conven-
as shards of glass or splinters from wood, are lodged within the wound.
tions, General Coding
Guidelines and Chapter
Contusions and Hematomas
Specific Guidelines, sub-
section C. Chapter- A contusion, commonly known as a bruise or “black-and-blue mark,” is an injury to
Specific Coding the body that typically does not break the skin but that does damage to the underlying
Guidelines, chapter blood vessels. The bleeding in the dermal layer is seen only through the epidermis as a
13. Diseases of the dark color. As the contusion heals, the colors change until the collected blood is dissi-
Musculoskeletal System pated and everything has healed. When the bleeding coagulates into a blood clot, this
and Connective Tissue, is called a hematoma. The seriousness of these injuries largely depends on the ana-
subsection b, Acute trau- tomical site where the bleeding and/or clot is located. A contusion or hematoma on the
matic versus chronic or leg or arm is typically a minor event that rarely requires a physician’s skill, whereas a
recurrent musculoskel- contusion to the brain or a subdural hematoma could be life-threatening.
etal conditions, in addi-
tion to chapter 19. Injury, Puncture Wounds
poisoning, and certain When a pointed, narrow object enters deeply into the visceral (inside) aspects of the
other consequences of body, the injury is known as a puncture wound (see Figure 16-2). A carpenter’s nail,
external causes, subsec- a knife, scissors, and a fishhook are just a few items that can cause an injury of this
tion b. Coding of Injuries. nature. Due to the characteristics of this type of wound, infection and internal damage
Puncture Abrasion
FIGURE 16-2 Illustrations of different types of wounds, including lacerations and puncture wounds Booth et al., Medi-
cal Assisting, 5e. Copyright ©2013 by McGraw-Hill Education. Figure 57-7, p. 1191. Used with permission.
Avulsions
The medical term avulsion describes a situation in which all layers of the skin (epidermis Avulsion
and dermis) are forcibly torn away from the body, typically a surface trauma. Due to the Injury in which layers of skin
pulling off of the dermal layers, the underlying structures, including adipose tissue, mus- are traumatically torn away
cles, tendons, and bone, become open to the outside. Rock climbers may suffer “flappers,” from the body.
an avulsion of the fingertip pad. When this occurs to a fingernail or toenail, it is known
as a nail avulsion—the nail plate is torn off the nail bed. Unlike the case with avulsions
at other anatomical sites, in nail avulsions the nail is not reattached. Instead, the fingertip
and nail bed are covered to protect the area until the keratin has formed a new nail.
ICD-10-CM
LET’S CODE IT! SCENARIO
Nathan Kirchner, an 8-year-old male, was hiking in a public park with his Boy Scout troop when they came to a clearing
and he saw a foal and its mother looking over the fence in a corral in the northeast edge of the park. He reached out
his left hand to pet the foal, and the mother horse bit his thumb. His scout leader took him to the emergency room. After
examination and some tests, Dr. Clifton cleaned the wound, applied a sterile dressing, and gave Nathan an antibiotic.
(continued)
CHAPTER 16 |
S61.052A Open bite of left thumb without damage to nail, initial encounter
Perfect! Yet you have not explained the whole story about why Dr. Clifton cared for Nathan. This code states he
was bitten on the left thumb, but not by whom or what. To report how Nathan got bitten and by what, you will
need external cause codes. Turn to the Alphabetic Index to External Causes and look up
Bite
horse W55.11
Turn in the Tabular List to
W55 Contact with other mammals
Of course, you are going to read this code’s notation carefully. None of the exclusions apply to this
case. And there are your options for the seventh character. But, first, read down to determine the correct fourth,
fifth, and sixth characters:
W55.1 Contact with horse
W55.11x- Bitten by horse
And now, go back up for the seventh character:
W55.11xA Bitten by horse, initial encounter
Terrific! You will also need to determine the codes to report the place of occurrence, activity, and the external
cause status. Try this on your own. Did you determine that these are the codes?
Y92.830 Public park as the place of occurrence of the external cause
Y93.01 Activity, walking, marching and hiking
Y99.8 Other external cause status
You are really getting to be a great coder!
Myalgia
Pain in a muscle. Traumatic Injury to the Muscles
A muscle injury is most often the result of some type of trauma or overexertion dur-
CODING BITES ing exercise or sports. Traumatic injuries to muscles may be described in a number of
Remember that when- ways:
ever you are reporting ∙ Strain is a tearing of the fibers of the muscle involved, most often the result of over-
an injury, you will also stretching the muscle during movement.
need to report external
∙ Sprain is a partially torn or overstretched ligament.
cause codes to explain
how the patient got ∙ Contusion is usually the result of a minor trauma to a muscle, causing a bruise.
injured and identify the ∙ Tear (muscle tear) is a separation within the muscle fibers. A bowstring tear, also
place of occurrence. To known as a bucket-handle tear, occurs longitudinally in the meniscus.
learn more, see the sec- ∙ Myalgia is the medical term for muscle pain.
tion Reporting External
∙ Rupture is the tear in an organ or tissue.
Causes of Injuries in this
chapter. Also, many of the
codes from ICD-10-CM
code book’s Chapter 19, EXAMPLES
Injury, poisoning, and S53.21xA Traumatic rupture of right radial collateral ligament, initial
certain other conse- encounter
quences of external S76.122A Laceration of left quadriceps muscle, fascia, and tendon, initial
causes require seventh encounter
characters for reporting S83.211A Bucket-handle tear of medial meniscus, current injury, right
the type of encounter. knee, initial encounter
CHAPTER 16 |
Skeletal Fractures
GUIDANCE
Character Description
CONNECTION
A Initial encounter for closed fracture
Read the ICD-10-CM Offi- B Initial encounter for open fracture
cial Guidelines for Coding D Subsequent encounter for fracture with routine healing
and Reporting, section
G Subsequent encounter for fracture with delayed healing
I. Conventions, Gen-
eral Coding Guidelines K Subsequent encounter for fracture with nonunion
and Chapter Specific P Subsequent encounter for fracture with malunion
Guidelines, subsection C. S Sequela
Chapter-Specific Cod-
ing Guidelines, chapter
19. Injury, poisoning, CODING BITES
and certain other con- Example of a subsequent encounter for fracture care might include a cast change,
sequences of external removal of a cast, x-ray to evaluate healing of a fracture, or adjusting a patient’s
causes, subsection a. medication.
Application of 7th Char-
acters in Chapter 19.
Fracture of Forearm, Femur, and Lower Leg (Including Ankle)
Character Description
GUIDANCE A Initial encounter for closed fracture
CONNECTION B Initial encounter for open fracture type I or II (or NOS)
C Initial encounter for open fracture type IIIA, IIIB, or IIIC
Read the ICD-10-CM Offi-
cial Guidelines for Coding
D Subsequent encounter for closed fracture with routine healing
and Reporting, section E Subsequent encounter for open fracture type I or II with routine healing
I. Conventions, Gen- F Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with
eral Coding Guidelines routine healing
and Chapter Specific G Subsequent encounter for closed fracture with delayed healing
Guidelines, subsection C. H Subsequent encounter for open fracture type I or II with delayed healing
Chapter-Specific Cod- J Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with
ing Guidelines, chapter delayed healing
19. Injury, poisoning,
K Subsequent encounter for closed fracture with nonunion
and certain other con-
sequences of external M Subsequent encounter for open fracture type I or II with nonunion
causes, subsection c.1) N Subsequent encounter for open fracture type IIIA, IIIB, or IIIC wtih
Initial vs. Subsequent nonunion
Encounter for Fractures. P Subsequent encounter for closed fracture with malunion
Q Subsequent encounter for open fracture type I or II with malunion
R Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with
malunion
S Sequela
CODING BITES
Aftercare codes from ICD-10-CM’s Chapter 21 (Z codes) should NOT be reported
when the injury or poisoning code uses a 7th character.
(continued)
CHAPTER 16 |
Poisoning, Poisoning,
Accidental Intentional Poisoning, Poisoning, Adverse
Substance (unintentional) self-harm Assault Undetermined Effect Underdosing
-- with sodium acetate
(ointment) T49.3X1 T49.3X2 T49.3X3 T49.3X4 T49.3X5 T49.3X6
-- ester (solvent) (vapor) T52.8X1 T52.8X2 T52.8X3 T52.8X4 – –
-- irrigating solution T50.3X1 T50.3X2 T50.3X3 T50.3X4 T50.3X5 T50.3X6
-- medicinal (lotion) T49.2X1 T49.2X2 T49.2X3 T49.2X4 T49.2X5 T49.2X6
- anhydride T65.891 T65.892 T65.893 T65.894 – –
FIGURE 16-3 ICD-10-CM Table of Drugs and Chemicals, in part, from 1-propanol through acetic anhydride Source:
ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)
ICD-10-CM
LET’S CODE IT! SCENARIO
Kurt Hershey found an unmarked barrel in the back of the warehouse where he works. He opened the top and
leaned over to see what was inside. Vapors from the benzene solvent being stored in that barrel overcame Kurt.
He had difficulty breathing because he accidentally inhaled the chemical. He was taken to the doctor immediately.
Dr. Blanchard diagnosed Kurt with respiratory distress syndrome, a toxic effect from inhaling the benzene.
(continued)
CHAPTER 16 |
This matches!
Two more codes—remember, you also need external cause codes to report where the accident occurred
and Kurt’s status (why he was doing this). In the Index to External Causes, turn to “Place of occurrence.”
The notes state that Kurt was in a warehouse when this accident happened, so read down the list, and you
will see
Place of occurrence
warehouse Y92.59
Go to the Tabular List, beginning with the code category:
Y92 Place of occurrence of the external cause
Read down the column to review your choices for the required fourth and fifth characters.
Y92.59 Other trade areas as the place of occurrence of the external cause (warehouse as the
place of occurrence of the external cause)
Your last code will report Kurt’s status. You know he was at work, so you will use this code:
Y99.0 Civilian activity done for income or pay
This completes the report.
The patient then has an unexpected bad reaction to that drug. There may have been
no way to know the patient was allergic to this medication because he had never taken CODING BITES
it before. Unpredictable reactions to drugs can be prompted by genetic factors, other Think P.E. for Poison
conditions or diseases, allergies, or other issues. P = poison code is
When an adverse reaction has occurred, you will need a minimum of two codes. reported first [the code
First, code for the effect. The code or codes will report exactly what the reaction suggested by the
was, such as a rash, vomiting, or unconsciousness. When you abstract the physician’s appropriate column of
documentation, you may find this is a confirmed diagnosis, or signs and symptoms the Table of Drugs and
experienced by the patient as a result of taking the medication. Chemicals]
Second, code for the external cause. The external cause code will explain that the
patient took the drug for therapeutic use. You can find this code in the Table of Drugs E = effect of the poison-
and Chemicals by first locating the name of the drug (either the brand name or the ing is reported next [the
generic name) in the first column and then reading across that row to the column under bad reaction the patient
the heading “Adverse Effect.” had to the substance,
such as a rash, vomiting,
or unconsciousness]
EXAMPLE The effect of the poi-
Giana Roman took her prescription for amoxicillin exactly as the doctor and the soning might be a
pharmacist instructed. She broke out in a rash because it turned out she was aller- confirmed diagnosis
gic to this antibiotic and no one knew. or documentation of
The “effect” is the rash “dermatitis due to drugs taken internally” = L27.0 Gen- signs and/or symptoms.
eralized skin eruption due to drugs and medicaments taken internally You may need more
than one code to tell
+
the whole story about
The external cause code explains “therapeutic use of amoxicillin” = T36.0x5A how this poisoning has
Adverse effect of penicillins, initial encounter affected the patient.
Poisoning GUIDANCE
Most people think of poisoning as something from a great detective novel or movie; CONNECTION
however, a poisoning can happen under many different circumstances. In reality, when
a person comes in contact with a drug (not prescribed by a physician or not taken as The ICD-10-CM guide-
prescribed) or a chemical and a health problem results, it is called a poisoning. lines reduce the num-
The drug or substance might have been ingested, inhaled, absorbed through the ber of codes you will
skin, injected, or taken by some other method. Remember that this may be a drug, or need to report some
it may be a chemical, such as cleaning supplies, gasoline, or other type of poison or conditions. Codes in
toxic substance. Your first step is to abstract the name of the substance that poisoned categories T36–T65 are
the patient so you can look it up on the Table of Drugs and Chemicals. combination codes that
Next, you will need to discover the circumstances under which this patient came to include the substances
be poisoned. Was it . . . related to adverse
effects, poisonings, toxic
∙ An accident (unintentional). Things happen, such as a child finding a bottle of effects, and underdos-
medication and thinking it’s candy or finding cleaning spray and thinking it would ing, as well as the exter-
be fun to wash his face with it. A patient mistakenly took the wrong amount of nal cause.
a medication or the clinician mistakenly administered the wrong quantity to the
CHAPTER 16 |
wrong patient (if this was a drug). Two substances could also be taken that contra-
GUIDANCE dicted each other.
CONNECTION ∙ A suicide attempt (intentional self-harm). Sadly, a person might take an overdose
Read the ICD-10-CM while trying to harm himself or herself, intentionally.
Official Guidelines for ∙ An assault. This occurs when someone tries to cause intentional harm to someone
Coding and Report- else. It sounds like a scene from that detective movie, but it does happen in real life.
ing, section I. Conven- ∙ Underdosing. Most often, this occurs when the patient cannot afford the medica-
tions, General Coding tion, so he or she takes less each time so one prescription will last longer. Or, this
Guidelines and Chapter may occur because a label is misread or an implanted medication pump malfunc-
Specific Guidelines, tions. In any of these situations, the patient is not receiving the quantity necessary
subsection C. Chapter- for therapeutic value and thus does not improve as expected due to the medication’s
Specific Coding Guide- ineffectiveness.
lines, chapter 19. Injury,
poisoning, and certain Underdosing and Patient Noncompliance
other consequences of
Sometimes, a patient has an adverse effect because he or she did not take the medica-
external causes, subsec-
tion as ordered by the physician or didn’t take the drugs at all. Some patients forget,
tion e.5)(b) Poisoning.
some are resistant to needing a drug, and some cannot afford the required number of
pills. When taking too little of the quantity prescribed (underdosing) is the patient’s
action, rather than an error on the part of a health care professional, this is considered
CODING BITES noncompliance and is reported with an additional code to explain:
Code subcategories
Z91.120 Patient’s intentional underdosing of medication regimen due to
Z91.12- and Z91.13-
financial hardship
both have a Code first
Z91.128 Patient’s intentional underdosing of medication regimen for other
notation, so you don’t
reason
have to wonder about
Z91.130 Patient’s unintentional underdosing of medication regimen due to
proper sequencing.
age-related debility
Z91.138 Patient’s unintentional underdosing of medication regimen for
other reason
CODING BITES Z91.14 Patient’s other noncompliance with medication regimen
The difference between
a poisoning and a toxic Toxic Effects
effect is the substance.
A toxic effect, such as irritation or carcinogenicity, may result from a part of the
A poisoning or adverse
human body interacting with a chemical or other nonmedicinal substance. When an
effect is a reaction to
individual comes in contact with a toxic substance, whether ingested (such as liquid
a natural or medicinal
window cleaner), inhaled (such as asbestos), or touched (such as acid), you will report
substance, whereas a
this using the same coding process as reporting a poisoning. The external cause code
toxic effect is a reaction
will come from a different range of codes, that’s all.
to a harmful substance.
T51-T65 Toxic effects of substances chiefly nonmedicinal as to source
ICD-10-CM
LET’S CODE IT! SCENARIO
Dr. Barry, a pediatrician, was called in to see Abigail Scanter, a 3-year-old female, brought in by her mother after she
discovered Abigail on the floor with part of a detergent pod in her mouth, half empty. Abigail was having difficulty
breathing; she had vomited; and her mouth, throat, and esophagus were erythmatous, swollen, and irritated. Dr.
Barry ordered blood tests and immediately began to pump Abigail’s stomach based on his diagnosis of a toxic effect
of the accidental ingestion of detergent.
Substance Interactions
When the cause of the poisoning or toxic effect is the interaction between two sub-
stances (e.g., drugs and alcohol), then you will need to report both substances involved.
You will need one poisoning code for each substance causing the reaction, as well as
one or more codes to accurately report the effect of the interaction.
Interactions can occur between two or more drugs, drugs and alcohol or other
drinks, drugs and food, or many other combinations. For example, you might notice
a warning “Don’t take this drug with milk or other dairy products.” This is a warn-
ing provided to prevent an interaction—the mixture of two or more substances that
changes the effect of any of the individual substances.
ICD-10-CM
LET’S CODE IT! SCENARIO
Meryl Brighton was prescribed Zyprexa (olanzapine), a psychotropic, by her psychiatrist, Dr. Cauldwell, for treatment
of her bipolar disorder. Meryl mentioned that her family doctor, Dr. Wall, had her on Norvasc (amlodipine), an anti-
hypertensive, for her high blood pressure. Dr. Cauldwell told Meryl to stop taking the Norvasc while on the Zyprexa.
Meryl forgot and took both medicines at the same time. Meryl suffered a dangerous case of severe hypotension and
was rushed to the ED by ambulance.
(continued)
CHAPTER 16 |
Let’s Code It!
Meryl was diagnosed with severe hypotension as a result of taking both Zyprexa and Norvasc. She was told not
to take both medications, but she forgot and took them both anyway. This means that this was an accidental
drug interaction.
First, you will need to determine the codes for the substances and intent. Open your ICD-10-CM code book
to the Table of Drugs and Chemicals and look for
Zyprexa
Move across the row to find the suggested code in the first column for Poisoning, Accidental (Unintentional) . . .
T43.591
Turn in the Tabular List to code category
T43 Poisoning by, adverse effect of and underdosing of psychotropic drugs, not elsewhere
classified
Carefully read the and notes. Do they have any connection to Meryl’s diagnosis? Not this
time, so read down and review all of the fourth-character options.
T43.5 Poisoning by, adverse effect of and underdosing of other and unspecified antipsychot-
ics and neuroleptics
Carefully read the note. Meryl did not become poisoned by rauwolfia, so continue reading to find the
appropriate fifth character.
T43.59 Poisoning by, adverse effect of and underdosing of other antipsychotics and
neuroleptics
Next, find the appropriate sixth character for Meryl’s accidental ingestion of Zyprexa.
T43.591 Poisoning by, adverse effect of and underdosing of other antipsychotics and neurolep-
tics, accidental (unintentional)
Almost done; find the appropriate seventh character. You will find the box with the options at the top of this sub-
section, right under the T43 code.
T43.591A Poisoning by, adverse effect of and underdosing of other antipsychotics and neuroleptics,
accidental (unintentional), initial encounter
Good job! Now, you need to go back to the Table of Drugs and Chemicals, and look for
Norvasc
It is not listed. So, use a PDR (Physicians’ Desk Reference) or the website [www.pdr.net] and learn that the
generic name for Norvasc is amlodipine besylate and it is an antihypertensive.
Antihypertensive drug NEC
Move across the row to find the suggested code in the first column for Poisoning, Accidental (Unintentional) . . . T46.5x1
Turn in the Tabular List to code category
T46 Poisoning by, adverse effect of and underdosing of agents primarily affecting the cardio-
vascular system
Carefully read the note. Meryl did not become poisoned by metaraminol, so continue reading to find
the appropriate fourth character.
T46.5 Poisoning by, adverse effect of and underdosing of other antihypertensive drugs
Carefully read the notes. Meryl did not become poisoned by any of these, so continue reading to find
the appropriate fifth character.
T46.5x Poisoning by, adverse effect of and underdosing of other antihypertensive drugs
CHAPTER 16 |
16.6 Reporting Burns
A patient can sustain a burn or corrosion to any part of the body in many different
ways. It can be the result of the skin coming near to or in actual contact with a flame,
such as a candle or the flame on a gas stove. A burn can happen when contact is made
with a hot object, such as a hot plate or curling iron. Chemicals, such as lye or acid,
can cause a corrosion upon contact with a person’s skin. As a professional coding spe-
CODING BITES cialist, you may need to code the diagnosis of a burn or corrosion.
When a patient has suffered a burn, virtually every case will require multiple codes to
A burn is caused by tell the whole story. So, we came up with a memory tip to help you remember the details
fire or heat, while a cor- you need, the minimum number of codes you need, and the sequencing of (the order in
rosion is caused by a which to report) the codes. To report these diagnoses correctly, you have to S/S.E.E. the
chemical. burn. You need at least three codes to properly report the diagnosis of a burn:
First-listed code(s): S/S = site and severity (from categories T20–T25)
Next-listed code: E = extent (from code category T31)
GUIDANCE Last-listed code(s): E = external cause code(s)
CONNECTION
Let’s look at these components and what they mean.
Read the ICD-10-CM
Official Guidelines for Site and Severity
Coding and Reporting,
section I. Conven- Site
tions, General Coding Your first-listed code or codes will be combination codes that report both the site and
Guidelines and Chapter severity of the injury. Site refers to the anatomical site that is affected by the burn.
Specific Guidelines, When you look at the descriptions for the codes in range T20–T28, you see that each
subsection C. Chapter- code category is first defined by a general part or section of the human body:
Specific Coding Guide-
T20 Burn and corrosion of head, face, and neck
lines, chapter 19. Injury,
T21 Burn and corrosion of trunk
poisoning, and certain
T22 Burn and corrosion of shoulder and upper limb, except wrist and hand
other consequences of
T23 Burn and corrosion of wrist and hand
external causes, sub-
T24 Burn and corrosion of lower limb, except ankle and foot
section d. Coding of
T25 Burn and corrosion of ankle and foot
Burns and Corrosions.
T26 Burn and corrosion confined to eye and adnexa
T27 Burn and corrosion of respiratory tract
T28 Burn and corrosion of other internal organs
GUIDANCE
CONNECTION EXAMPLE
Read the ICD-10-CM Offi- Hope Rockfield suffered a burn to her left knee. Lower limb is the general ana-
cial Guidelines for Coding tomical site, and knee is the specific site of the burn.
and Reporting, section
I. Conventions, General
Coding Guidelines and Severity
Chapter Specific Guide- The fourth character for each category (except categories T26–T28) identifies the severity.
lines, subsection C. Using the layers of the skin, the severity of a burn is identified by degree (see Figure 16-4):
Chapter-Specific Cod-
∙ First-degree burns are evident by erythema (redness of the epidural layer).
ing Guidelines, chapter
19. Injury, poisoning, ∙ Second-degree burns are identified by fluid-filled blisters in addition to the
and certain other con- erythema.
sequences of external ∙ Third-degree burns have damage evident in the epidermis, dermis, and fatty tis-
causes, subsections sue layers and can involve the muscles and nerves below.
d.2) Burns of the same ∙ Deep third-degree burned skin will show necrosis (death of the tissue) and at times
local site and d.5) Assign may result in the loss (amputation) of a body part.
separate codes for each
burn site. The fourth characters available in this section give you the ability to report the
documented severity of the burn or corrosion:
Specific Site
The fifth character gives you the opportunity to report additional details regarding the CODING BITES
anatomical site of the burn. Of course, these details will change in accordance with The code descriptions
the anatomical region of the code category. Let’s take a look at samples from code in this section all include
category T23 Burn and corrosion of wrist and hand: both the medical terms
T23.-1 Burn . . . of thumb (nail) (such as blisters) and
T23.-2 Burn . . . of single finger (nail) except thumb the degree (such as
T23.-3 Burn . . . of multiple fingers (nail), not including thumb second degree), so you
T23.-4 Burn . . . of multiple fingers (nail), including thumb can match either to the
T23.-5 Burn . . . of palm documentation.
T23.-6 Burn . . . of back of hand
T23.-7 Burn . . . of wrist
T23.-9 Burn . . . of multiple sites of wrist and hand CODING BITES
The description of the
EXAMPLE fifth character 0 (zero)
Troy was talking to his buddy and stepped back, hitting the back of his right calf on states “unspecified site.”
the hot tailpipe of his motorcycle. The doctor at the emergency room documented Use this character very,
second-degree burns. very rarely. Think about
it: How can a physi-
The first three characters = T24 Burn and corrosion of lower limb, except
cian diagnose and treat
ankle and foot.
a burn and not know
The fourth character = T24.2 Burn of second degree of lower limb, except
exactly where it is?
ankle and foot.
The fifth character = T24.23 Burn of second degree of lower leg.
The sixth character = T24.231 Burn of second degree of right lower leg.
The seventh character = T24.231A Burn of second degree of right lower leg,
initial encounter.
And there you have the complete code to report Troy’s injury. Of course, as you
remember, you will also need to report an external cause code to explain how
Troy’s leg became burned.
CHAPTER 16 |
ICD-10-CM
LET’S CODE IT! SCENARIO
Anthony, a 15-year-old male, was working on a school project in the basement and accidentally released the hot
glue gun onto the palm of his left hand. Dr. Clermont treated him for third-degree burns of the palm of his hand.
ICD-10-CM
LET’S CODE IT! SCENARIO
Damien Connell opened the cover of the bar-b-que to see how the coals were doing. He decided to add some
lighter fluid to hurry it along, and the flames roared up into his face. Gina, his wife, rushed him to the emergency
department. After an exam, Dr. Hawks diagnosed Damien with a third-degree burn on his chin and second-degree
burns on his nose and cheek.
Extent
The next code you have to report indicates the extent, or percentage, of the body Extent
involved. The three-character category for reporting the extent of a burn is T31 and the The percentage of the body
extent of a corrosion is T32. Either of these codes requires a total of five characters to that has been affected by the
be valid, no matter what the extent of the burn or corrosion. burn or corrosion.
CHAPTER 16 |
GUIDANCE 41/2% 41/2%
head and neck posterior trunk
CONNECTION 9% and buttocks
anterior trunk 18%
Read the ICD-10-CM 18%
Official Guidelines for
Coding and Reporting,
arms, hands,
section I. Conven- and shoulders
tions, General Coding 18% 18% 18%
Guidelines and Chapter
41/2% 41/2% 41/2% 41/2%
Specific Guidelines,
subsection C. Chapter-
Specific Coding Guide-
lines, chapter 19. Injury, 9% 9% 9% 9%
poisoning, and certain genitals
other consequences of 1%
anterior posterior
external causes, sub- legs and feet
legs and feet
section d.6) Burns and 18% 18%
Corrosions Classified
According to Extent of
Body Surface Involved.
Anterior Posterior
FIGURE 16-5 An illustration identifying the rule of nines, which can be used to
estimate the extent of burns
you the information you need to find the correct fourth character for code T31 or T32.
However, other times, the physician may not use a number, and you will have to calcu-
Rule of Nines late the percentage yourself. To calculate, you can use the rule of nines.
A general division of the whole The rule of nines is used to estimate the total body surface area that has been
body into sections that each affected by the burns. The body is divided into sections, each section representing 9%
represents 9%; used for esti- of the human body (see Figure 16-5):
mating the extent of a burn.
Head and neck 9%
Arm, right 9%
GUIDANCE Arm, left 9%
CONNECTION Chest 9%
Abdomen 9%
Read the ICD-10-CM
Official Guidelines for Upper back 9%
Coding and Reporting, Lower back 9%
section I. Conven- Leg, right, anterior (front) 9%
tions, General Coding
Leg, right, posterior (back) 9%
Guidelines and Chapter
Specific Guidelines, Leg, left, anterior (front) 9%
subsection C. Chapter- Leg, left, posterior (back) 9%
Specific Coding Guide- Genitalia 1%
lines, chapter 19. Injury,
poisoning, and certain As you read through the physician’s notes, be aware of the anatomical site, not only
other consequences of for your site code but also for your calculation of the extent of the body involved in
external causes, sub- the burns.
section d.1) Sequenc- Next, you must determine the most accurate fifth character for this code. The fifth
ing of burn and related character identifies the percentage of the patient’s body that is suffering with third-
condition codes. degree burns only. You can also use the rule of nines to calculate the percentage of
area affected by third-degree burns to find the best fifth character.
EXAMPLE
Celia suffered third-degree burns on her lower back and the back of her left leg
and second-degree burns on her anterior forearm, wrist, and hand:
Lower back (9%) + left leg, back (9%) + anterior forearm (2%) + wrist and
hand (1%) = total body surface (21%)
T31.2 Burns involving 20%–29% of body surface
Only her back and leg had third-degree burns:
Lower back (9%) + left leg, back (9%) = 18%
T31.21 Burns involving 20%–29% of body surface with 10–19% third-
degree burns
ICD-10-CM
LET’S CODE IT! SCENARIO
Eli Glosyck, a 28-year-old male, was trying to start a campfire when the flames flared and burned him on the back
of his right hand, right forearm, and right elbow. He was rushed to the emergency room, where Dr. Compton deter-
mined that he had third-degree burns on his hand and forearm and second-degree burns on his elbow.
(continued)
CHAPTER 16 |
T23.361A Burn of third degree of back of right hand, initial encounter
This code tells the whole story about the burn to Eli’s hand. Now look at the other codes suggested by the Alpha-
betic Index:
Burn, forearm, third degree T22.319
Burn, elbow, second-degree T22.229
Did you notice that both of these burns are reported using the same three-character code category, T22?
T22 Burn and corrosion of shoulder and upper limb, except wrist and hand
You have two codes with the same three-character code category. The guidelines state that you must combine
these into one code, T22, but which fourth character should you use? Remember, the guidelines also direct you
to use the character that reports the greatest severity (the highest degree) of the burn. Third degree is more
severe than second degree, so you will use
T22.3 Burn of third-degree of shoulder and upper limb, except wrist and hand
Read the fifth-character choices for this code category. Which one code can report the burn to both Eli’s forearm
and his elbow?
T22.39 Burn of third-degree of multiple sites of shoulder and upper limb, except wrist and hand
The sixth character will report which forearm and elbow were burned:
T22.391 Burn of third-degree of multiple sites of right shoulder and upper limb, except wrist
and hand
And the seventh character will report which encounter this is:
T22.391A Burn of third-degree of multiple sites of right shoulder and upper limb, except wrist
and hand, initial encounter
Good! Next, you need a code to report the extent of the burns. Eli was burned on the following sites:
Hand (part of the arm), 9%
Forearm (part of the same arm), 9%
Elbow (also part of the same arm), 9%
The rule of nines states that one arm represents 9%. Eli had burns on his hand, forearm, and elbow of the same
arm. You can see that it would not make sense to add 9% for each of these injuries, as it is still only one arm, so
you get a TBSA of 9%. Of this 9%, you must note that only an estimated 4% of his body (his hand and forearm)
suffered third-degree burns. Therefore, the next code on Eli’s chart will be:
T31.0 Burns involving less than 10% of body surface
The codes you have for Eli’s burns are T23.361A, T22.391A, and T31.10 (plus the external cause codes, of course!).
Good work!
GUIDANCE
CONNECTION
Read the ICD-10-CM
Official Guidelines for Infection in the Burn Site
Coding and Reporting,
section I. C. 19. Injury, If not treated properly, a burn site can become infected. This can happen because
poisoning, and certain the inner layers of the tissue are exposed, and it might be difficult to keep the
other consequences of wound clean and sterile. If an infection occurs, you should add a code for the spe-
external causes, subsec- cific pathogen. Sequence the infection code after the burn code but before the T31
tion d.4) Infected Burn. or T32 code.
CHAPTER 16 |
professionals to report any instances of abuse or neglect, even if it is just a suspicion
at this point.
When applicable, the code from T74 or T76 should be the first-listed or principal
diagnosis, followed by the injury code and/or mental health code. For cases in which
the circumstances have been confirmed, a code to report the specific cause of the
injury should be included, most often from code range X92–Y08. In any case of abuse,
neglect, or maltreatment, if the perpetrator is known, an additional code from category
Y07 should be included.
ICD-10-CM
YOU CODE IT! CASE STUDY
Judah Messner, a 5-month-old male, was brought into the ED with third-degree burns on all five fingers of his left
hand and both second-degree and third-degree burns on the back of his left hand. His aunt brought him in after
visiting the home and seeing her sister’s boyfriend stick the baby’s hand into a pot of boiling water on the stove.
She states she quickly grabbed the baby from this man and rushed him here. She stated that she did not want to
risk staying on the premises awaiting the ambulance. When asked about the baby’s mother, the aunt stated she
just stood there, crying, and did not come with the child. The child was taken into treatment and the police were
notified.
ICD-10-CM
YOU CODE IT! CASE STUDY
Dr. Prentiss ordered 1 pint of A+ to be transfused into Sami Yariz in the postoperative area. The nurse was in a hurry
and did not read carefully when she grabbed the blood and hung it on the IV pole. A few hours later, the patient
began to complain of feeling very hot (temperature of 103 F) and pain in his back. At that time, one of the assistants
noticed that the patient was given AB+ blood. The patient was treated immediately for ABO incompatibility. Hemo-
lytic transfusion reaction was confirmed.
CHAPTER 16 |
Chapter Summary
CHAPTER 16 REVIEW
People injure themselves in many different ways under many different circumstances,
or others may harm someone—by accident or on purpose. Some patients may try to
hurt themselves. Whether a fractured bone, a third-degree burn, a pulled muscle, or an
adverse effect of a medication, when something like this happens, those of us working
in health care help them.
As professional coding specialists, you must remember that, in these situations, you
not only need to determine the code or codes to explain why the patient needs health
care services, you also must explain how the patient got hurt and where the injury
occurred.
CODING BITES
External cause codes explain
• Cause of the injury, such as a car accident or a fall off a ladder.
• Place of the occurrence, such as the park or the kitchen.
• Activity during the occurrence, such as playing basketball or gardening.
• Patient’s status, such as paid employment, on-duty military, or leisure activity.
CHAPTER 16 REVIEW
Coding Injury, Poisoning, Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
Part I
1. LO 16.2 Layers of skin traumatically torn away from the body. A. Avulsion
2. LO 16.5 Redness of the epidermis (skin). B. Burn
3. LO 16.5 A burn caused by a chemical;chemical destruction of the skin. C. Corrosion
4. LO 16.5 Destruction of all layers of the skin, with possible involvement of the D. First-Degree Burn
subcutaneous fat, muscle, and bone. E. Laceration
5. LO 16.5 Injury by heat or fire. F. Rule of Nines
6. LO 16.5 The level of seriousness. G. Second-Degree Burn
7. LO 16.5 Blisters on the skin; involvement of the epidermis and the dermis H. Severity
layers.
I. Site
8. LO 16.5 A general division of the whole body portioned out to each represent
J. Third-Degree Burn
9%; used for estimating the extent of a burn.
9. LO 16.2 Damage to the epidermal and dermal layers of the skin made by a
sharp object.
10. LO 16.5 The location on or in the human body; the anatomical part of the body.
CHAPTER 16 REVIEW
1. LO 16.6 This term is used in different manners: (a) extreme use of a drug or A. Abuse
chemical; (b) violent and/or inappropriate treatment of another person. B. Dislocation
2. LO 16.5 The percentage of the body that has been affected by the burn or C. Extent
corrosion.
D. Fracture
3. LO 16.2 A fractured bone that did not heal correctly; healing of bone that was
E. Malunion
not in proper position or alignment.
F. Myalgia
4. LO 16.1 The displacement of a limb, bone, or organ from its customary
position. G. Nonunion
5. LO 16.2 Broken cartilage or bone. H. Physicians’ Desk Refer-
ence (PDR)
6. LO 16.2 Pain in a muscle.
7. LO 16.3 A series of reference books identifying all aspects of prescription and
over-the-counter medications, as well as herbal remedies.
8. LO 16.2 A fractured bone that did not heal back together; no mending or joining
together of the broken segments.
CHAPTER 16 |
10. LO 16.6 Jennie James, a 28-year-old female, is pregnant and in her third trimester. Jennie presents today with the
CHAPTER 16 REVIEW
complaint that her right forearm hurts. Upon examination, bruises are noted. When asked how she got
the bruises, Jennie stated that her husband came home upset and twisted her arm because dinner was not
ready. What is the correct code for the physical abuse complicating the pregnancy?
a. O9A.311 b. O9A.312 c. O9A.313 d. O9A.319
1. Most categories in chapter 19 have a _____ character requirement for each applicable code.
2. The aftercare _____ codes should not be used for _____ for conditions such as injuries or poisonings, where 7th
characters are provided to identify _____ care.
3. _____ injuries such as abrasions or contusions are not coded when associated with more severe injuries of the
same site.
4. When a primary injury results in _____ damage to peripheral nerves or blood vessels, the _____ injury is
sequenced _____ with additional code(s) for injuries to nerves and spinal cord (such as category S04), and/or
injury to blood vessels (such as category S15).
5. Traumatic fractures are coded using the appropriate 7th character for _____ encounter (A, B, C) for each encoun-
ter where the patient is receiving _____ treatment for the fracture.
6. Multiple fractures are sequenced in accordance with the _____ of the fracture.
7. When the reason for the admission or encounter is for treatment of _____ multiple burns, sequence first the code
that reflects the burn of the _____ degree.
8. Classify burns of the same _____ site (three-character category level, T20-T28) but of different _____ to the sub-
category identifying the highest degree recorded in the diagnosis.
9. Non-healing burns are coded as _____ burns.
10. When coding burns, assign _____ codes for each burn site.
11. Assign codes from category _____, Burns classified according to extent of body surface involved, or _____, Cor-
rosions classified according to _____ of body surface involved, when the site of the burn is not specified or when
there is a need for additional data.
12. Encounters for the treatment of the _____ effects of burns or corrosions (i.e., scars or joint contractures) should
be coded with a burn or corrosion code with the 7th character _____ for sequela.
Part II
Refer to the Official Guidelines and fill in the blanks according to the Chapter 19, Injury, poisoning, and certain other
consequences of external causes, Chapter-Specific Coding Guidelines.
external adverse many assault properly sequelae
improper toxic current Underdosing Z04.71 complication
confirmed correctly individually suspected source T36-T50
CHAPTER 16 REVIEW
sion code with 7th character “S” may be assigned on the same record (when both a current burn and _____ of an
old burn exist).
2. An _____ cause code should be used with burns and corrosions to identify the _____ and intent of the burn, as
well as the place where it occurred.
3. Use as _____ codes as necessary to describe completely all drugs, medicinal or biological substances.
4. If two or more drugs, medicinal or biological substances are reported, code each _____ unless a combination code
is listed in the Table of Drugs and Chemicals.
5. When coding an _____ effect of a drug that has been _____ prescribed and _____ administered, assign the appro-
priate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug
(T36-T50).
6. When coding a poisoning or reaction to the _____ use of a medication (e.g., overdose, wrong substance given or
taken in error, wrong route of administration), first assign the appropriate code from categories _____.
7. _____ refers to taking less of a medication than is prescribed by a provider or a manufacturer’s instruction.
8. When a harmful substance is ingested or comes in contact with a person, this is classified as a _____ effect.
9. For cases of _____ abuse or neglect an external cause code from the _____ section (X92-Y09) should be added to
identify the cause of any physical injuries.
10. If a _____ case of abuse, neglect, or mistreatment is ruled out during an encounter code _____, Encounter for exami-
nation and observation following alleged physical adult abuse, ruled out, or code Z04.72, Encounter for examination
and observation following alleged child physical abuse, ruled out, should be used, not a code from T76.
11. Intraoperative and postprocedural _____ codes are found within the body system chapters with codes specific to
the organs and structures of that body system.
Part III
Refer to the Official Guidelines and fill in the blanks according to the Chapter 20, External Causes of Morbidity,
Chapter-Specific Coding Guidelines.
A00.0-T88.9 never Y92 encounter
secondary assault data Y38.9
Y93 “S” full initial
completely Y99 once status
1. External cause codes are intended to provide _____ for injury research and evaluation of injury prevention
strategies.
2. An external cause code may be used with any code in the range of _____, Z00-Z99, classification that is a health
condition due to an external cause.
3. Assign the external cause code, with the appropriate 7th character (initial encounter, subsequent encounter or
sequela) for each _____ for which the injury or condition is being treated.
4. Use the _____ range of external cause codes to _____ describe the cause, the intent, the place of occurrence, and
if applicable, the activity of the patient at the time of the event, and the patient’s status, for all injuries, and other
health conditions due to an external cause.
5. An external cause code can _____ be a principal (first-listed) diagnosis.
6. Codes from category _____, Place of occurrence of the external cause, are secondary codes for use after other
external cause codes to identify the location of the patient at the time of injury or other condition.
7. Generally, a place of occurrence code is assigned only _____, at the _____ encounter for treatment.
8. Assign a code from category _____, Activity code, to describe the activity of the patient at the time the injury or
other health condition occurred.
CHAPTER 16 |
9. Adult and child abuse, neglect, and maltreatment are classified as _____.
CHAPTER 16 REVIEW
10. Sequela are reported using the external cause code with the 7th character _____ for sequela.
11. Assign code _____, Terrorism, _____ effects, for conditions occurring subsequent to the terrorist event.
12. Assign a code from category _____, External cause status, to indicate the work _____ of the person at the time
the event occurred.
ICD-10-CM
YOU CODE IT! Basics
First, identify the condition in the following diagnoses; 8. Second degree burn of the right axilla, initial
then code the diagnosis. encounter:
Example: Abrasion of scalp, initial encounter: a. main term: _____ b. diagnosis: _____
9. Displaced shaft fracture of the left clavicle (trau-
a. main term: Abrasion b. diagnosis: S00.01XA
matic), subsequent encounter for fracture with
1. Underdosing of succinimides, initial encounter: malunion:
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
2. External constriction of left eyelid, initial 10. Concussion with loss of consciousness of
encounter: 35 minutes, initial encounter:
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
3. Laceration without foreign body of nose, initial 11. Contusion of left ear, subsequent encounter:
encounter a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 12. Crushing injury of larynx:
4. Open bite of left cheek, subsequent encounter: a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____ 13. Corrosion of third degree of left shoulder, initial
5. Corrosion of trachea, sequela: encounter:
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
6. Toxic effect of ethanol, assault, subsequent 14. Adverse effect of antimycobacterial drugs,
encounter: combination:
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
7. Puncture wound with foreign body of scalp, initial 15. Pathological fracture of right tibia due to neoplas-
encounter: tic disease, delayed healing:
a. main term: _____ b. diagnosis: _____ a. main term: _____ b. diagnosis: _____
CHAPTER 16 |
CHAPTER 16 REVIEW
baseball field and got hit by the ball. She was in obvious pain, and the wrist was swollen and too painful upon
attempts to flex. After Dr. Rodgers reviewed the x-ray Carolina is diagnosed with a Salter-Harris, type II frac-
ture of the distal radius, left.
13. Tricia Thornwell, a 68-year-old female, was going walking when she fell down the icy front steps of her
house; now she can’t bear weight on her right leg. She is brought into the ER by ambulance. After the ER
physician completed a thorough exam and reviewed the x-ray, he diagnosed her with a femoral neck base
fracture, nondisplaced.
14. Paula Caine, a 41-year-old female, was deep-frying fish and the kettle fell over and burned her right thigh.
Paula was rushed to the ER by her husband, where the ER physician, Dr. Dinkins, diagnosed her with a sec-
ond degree burn on her right thigh. Dr. Dinkins dressed the wounds and sent her to the burn unit.
15. Helen Carrizo, an 18-year-old female, presents to the ED with a painful left ankle. Helen is accompanied by
her mother. Helen had been rollerblading and tripped, falling on the sidewalk. Helen is unable to flex her ankle,
which has begun to swell. Dr. Webber gathered a brief history of the incident that caused the injury, as well
as any history relating to her legs and feet. He then performed a limited examination of her left leg, ankle, and
foot. The imaging confirmed a sprained calcaneofibular ligament and a sprained anterior tibiofibular ligament.
ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documenta-
tion from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient
encounters. Using the techniques described in this chapter, carefully read through the case studies and determine
the most accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: TRUMAN, HERBERT
ACCOUNT/EHR #: TRUMHE001
DATE: 07/16/18
Attending Physician: Oscar R. Prader, MD
S: Pt is a 47-year-old male brought in by ambulance accompanied by his wife. Wife states he has been
confused, dizzy, and vomiting all morning.
O: Ht. 5′11″, Wt. 187 lb., R 16. During the physical examination, the patient has a dramatic drop in vital
sign measurements and suffers cardiac arrest. The crash team takes over and patient is successfully
resuscitated. Blood work reveals overdose of digoxin. After Pt is stabilized, he states he was rushing to
get to work this morning and couldn’t remember if he had taken his medication, so he took it again.
A: Cardiac arrest due to overdose of digoxin, accidental
P: Admit for stabilization
Oxygenation
Hydration IV fluids
Monitor electrolyte balance
CHAPTER 16 |
CHAPTER 16 REVIEW
S: This new Pt is a 56-year-old male who was involved in an accident when the motorcycle he was driv-
ing was struck by a car on a street near his house. Cyrus admits to riding motorcycles for recreation.
He is complaining about some neck pain. He has tingling into his hand and feet. He states that his left
arm hurts when he tries to pull it overhead. PMH is remarkable for kidney trouble. Past bronchoscopy,
laparoscopy, and kidney stone surgery, otherwise noncontributory as per the medical history form com-
pleted by the patient and reviewed this encounter.
O: Ht. 5′9″, Wt. 181 lb., R 18. On exam, the left shoulder demonstrates full passive motion. He has nor-
mal strength testing. He has no deformity. He has some tenderness over the trapezial area. The reflexes
are brisk and symmetric. X-rays of his chest 2 views and C spine AP/LAT are relatively benign, as are
complete x-rays of the shoulder.
A: Anterior displaced type II dens fracture of the second cervical vertebra, and an anterior dislocation of
the proximal end of the left humerus.
P: 1. Rx Naprosyn
2. Referral to PT
3. Referral to orthopedist
CHAPTER 16 |
17 Coding Genitourinary,
Gynecology, Obstetrics,
Congenital, and
Pediatrics Conditions
Key Terms Learning Outcomes
Abortion After completing this chapter, the student should be able to:
Anemic
Anomaly LO 17.1 Identify the details required to accurately report renal and
Benign Prostatic urologic malfunctions.
Hyperplasia (BPH) LO 17.2 Explain the conditions affecting the male genital system.
Bladder Cancer LO 17.3 Abstract the components for reporting sexually transmitted
Chronic Kidney Dis- diseases accurately.
ease (CKD)
Clinically Significant
LO 17.4 Enumerate the reasons for gynecologic care.
Congenital LO 17.5 Apply the guidelines for coding routine obstetrics care.
Deformity LO 17.6 Determine the correct codes for reporting complications of
Genetic Abnormality pregnancy.
Gestation LO 17.7 Utilize the official guidelines for well-baby encounters and
Glomerular Filtration congenital anomalies.
Rate (GFR)
Gynecologist (GYN)
Low Birth Weight
(LBW)
Malformation Remember, you need to follow along in
Morbidity
STOP! your ICD-10-CM code book for an optimal
ICD-10-CM
Mortality
Obstetrics (OB) learning experience.
Perinatal
Prematurity
Prenatal
Prostatitis
Puerperium 17.1 Renal and Urologic Malfunctions
Urea Components of the Urinary System
Urinary System
Urinary Tract Infection The components of the urinary system (see Figure 17-1) are the same in both men
(UTI) and women. This organ system is responsible for removing waste products (known
as urea) that are left behind by protein (food), excessive water, disproportionate
amounts of electrolytes, and other nitrogenous compounds from the blood and the
Urinary System
body. A failure to eliminate these wastes from the body in a timely fashion may actu-
The organ system responsible ally result in the body poisoning itself. The organ components of the urinary system
for removing waste products include
that are left behind in the ∙ Kidney (right and left), each leading to a
blood and the body.
∙ Ureter (right and left), each leading to the
Urea
A compound that is excreted
∙ Urinary bladder, which then passes urine through the
in urine. ∙ Urethra, to travel outside the body.
470
Kidney
Renal
Renal artery
vein
Inferior
Hilum vena cava
Abdominal
aorta
Ureters
Urinary
bladder
Urethra
FIGURE 17-1 An illustration identifying the anatomical sites of the urinary sys-
tem David Shier et al., Hole’s human anatomy & physiology, 12/e. ©2010 McGraw-Hill Education. Figure 20.1, p.
776. Used with permission.
Diagnostic Tools
A patient history of hypertension, diabetes mellitus, and/or bladder infections may
also be indicative of urinary system conditions. Genetic predispositions can be identi-
fied with family histories that include glomerulonephritis or polycystic kidney disease.
Nephrotoxicity can be caused by the patient’s abuse of antibiotics or analgesics.
Blood tests can measure the levels of uric acid, creatinine, and blood urea nitro-
gen (BUN), providing insight into kidney function. Of course, urinalysis can add data
about pH as well as clarity, color, and odor of the specimen. Measurement of urine
output may require 24-hour specimen collection. Checking levels of antidiuretic hor-
mone (ADH), produced by the pituitary gland, and/or levels of aldosterone, a hormone
produced by the adrenal cortex, may also indicate kidney concerns.
Kidney-ureter-bladder (KUB) radiography can measure the size, shape, and posi-
tion of these organs, as well as identify any possible areas of calcification.
Ultrasonography, fluoroscopy, computerized tomography (CT) scans, and/or mag-
netic resonance imaging (MRI) of the urinary system may also be appropriate to sup-
port the confirmation of a diagnosis.
An intravenous pyelogram (IVP) records a series of x-ray images, taken rapidly, as
contrast material injected intravenously passes through the urinary tract. A retrograde
pyelogram also uses contrast material; however, this iodine-based fluid is injected
through the ureters to investigate a suspicion of an obstruction, such as kidney stones
(calculi).
CHAPTER 17 |
ICD-10-CM
LET’S CODE IT! SCENARIO
Nila Taglia, a 33-year-old female, just returned from her honeymoon in the islands. She is feeling a burning sensa-
tion and some pain on urination, so she came to see Dr. Slater. After exam and urinalysis, Nila was diagnosed with
acute cystitis due to E. coli.
ICD-10-CM
YOU CODE IT! CASE STUDY
Shane Moyet, a 41-year-old male, was tested as part of his annual physical. He came in today with his wife to get his
test results. Dr. Contreras diagnosed him with moderate chronic kidney disease. She sat and discussed treatment
options with Shane and his wife.
Step #2: Abstract the scenario. Which key words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
CHAPTER 17 |
Diabetes with Renal Manifestations
A patient who has been diagnosed with diabetes may develop problems with his or her
kidneys, such as chronic kidney disease, diabetic nephropathy, or Kimmelstiel-Wilson
syndrome. When this is documented, regardless of the specific reason for the encoun-
ter, you will report a code from one of the following code categories, depending upon
the type of diabetes mellitus:
E08.2- Diabetes mellitus due to underlying condition with kidney
complications
E09.2- Drug or chemical induced diabetes mellitus with kidney complications
E10.2- Type 1 diabetes mellitus with kidney complications
E11.2- Type 2 diabetes mellitus with kidney complications
E13.2- Other specified diabetes mellitus with kidney complications
In all of these code categories, if the patient’s kidney complication is CKD, you will
need to report an additional code to identify the stage of the disease. You will see the
Use additional code notation.
ICD-10-CM
LET’S CODE IT! SCENARIO
Sergio Prisma, a 21-year-old male, was diagnosed with type 1 diabetes mellitus when he was 7 years old. He has
been lax about testing his glucose and giving himself his insulin shots because he has been so busy with his courses
and activities at Hillgraw University. After a complete HPI and exam, Dr. Allenson performed a glucose test and a
urinalysis. The results showed the early signs of type 1 diabetic nephrosis.
Anemic
Any of various conditions
Anemia in CKD
marked by deficiency in red The malfunction of the kidneys as they attempt to filter out the impurities in the body
blood cells or hemoglobin. may trigger an anemic condition in the body. This condition can leave the patient
Dialysis
There are two types of dialysis that may be used to treat a patient with renal malfunc-
tion: peritoneal dialysis and hemodialysis.
Peritoneal dialysis infuses a dialysate solution into the peritoneal cavity. Subse-
quently, the solution passes through the peritoneal membrane (which lines the abdom-
inal cavity), collecting waste. The solution is then drained and thereby removes the
waste.
Hemodialysis draws blood out of the body via an intravenous tube and passes the
blood through a machine that removes waste products and returns clean blood to the
body via a second intravenous connection.
When the patient is preparing for the dialysis treatments, you will need to know
which type of dialysis the patient will be receiving:
Z49.01 Encounter for fitting and adjustment of extracorporeal dialysis
catheter
or
Z49.02 Encounter for fitting and adjustment of peritoneal dialysis catheter
Plus, note the reminder directly beneath the code category:
Code also associated end stage renal disease (N18.6)
Within the first few weeks after beginning the series of dialysis treatments, the physician
will want to have the patient come in for an efficiency or adequacy test. The purpose of the
test is to measure the exchanges to ensure that the treatments are removing enough urea. The
test results enable the health care professionals to adjust the dose, or amount, of the dialysis
in each treatment. To report the reason for the encounter, report one of these codes:
Z49.31 Encounter for adequacy testing for hemodialysis
or
Z49.32 Encounter for adequacy testing for peritoneal dialysis
Most patients will need to receive dialysis several times each week, usually until a GUIDANCE
transplant is available. For each of these encounters, the diagnosis codes to report will CONNECTION
include this code: Read the ICD-10-CM
Z99.2 Dependence on renal dialysis (hemodialysis status) (peritoneal dialy- Official Guidelines for
sis status) (presence of arteriovenous shunt for dialysis) Coding and Reporting,
section I. Conven-
Sadly, some patients cannot deal with an ongoing need for treatment and may tions, General Coding
not come in for their sessions. As you learned, this can have a negative impact on Guidelines and Chapter
their health, and it must be documented. The diagnosis codes to report will include Specific Guidelines,
this: subsection C. Chapter-
Z91.15 Patient’s noncompliance with renal dialysis Specific Coding Guide-
lines, chapter 14.
Diseases of Genitouri-
Transplantation
nary System, subsec-
At the point when the kidney is so severely damaged that it cannot be rehabilitated, a tion a.2) Chronic kidney
transplant may be the only solution to improve the patient’s health and possibly save disease and kidney
his or her life. A patient receiving a transplant must deal with the challenge of need- transplant status.
ing lifelong medication as well as follow-up care. However, great success has been
CHAPTER 17 |
achieved in increasing transplant patients’ quality of life. Of course, there is always
CODING BITES the possibility that the patient’s body might reject the new organ, but the greatest road-
Code category T86 block for these patients is the long wait for a donor:
Complications of trans- Z76.82 Awaiting organ transplant status
planted organs and
tissue has a Use addi- Of course, a donor is needed. With kidney transplants, the donor may be either a live
tional code notation individual or a cadaver. If the donor is live, the individual will need this diagnosis
to remind you to also code to support medical necessity for the preoperative testing, the procedure itself to
report any other trans- remove the donated organ, and the postoperative care:
plant complications, Z52.4 Kidney donor
such as
Organ transplantation is an incredible health care procedural accomplishment, giv-
Graft-versus-host dis- ing thousands of individuals with previously terminal conditions a second chance to
ease (D89.81-) live a normal and productive life. Patients who have received an organ transplant will
Malignancy associated typically need to take antirejection medication and receive regular checkups. There-
with organ transplant fore, after the transplant has taken place, the patient’s posttransplant status may need
(C80.2-) to be reported:
Post-transplant lympho- Z94.0 Kidney transplant status
proliferative disorders
(PTLD) (D47.Z1) Transplanting an organ from one person into another person is not always a per-
fect cure. There may be several issues that may require additional treatment. In some
cases, the transplant does not eliminate all of the kidney disease. One kidney may
have a milder case of CKD and not need transplantation, whereas the other kidney
CODING BITES does. Therefore, it is acceptable to report both posttransplant status and current CKD
in the same patient at the same time when the physician documents both conditions
Infections can occur concurrently.
commonly, particularly When a transplanted organ begins to show signs of rejection, failure, infection, or
in an organ system that other complication, this will need to be treated and, in some cases, the transplanted
is open to the outside organ will need to be removed.
of the body. Conditions
such as a kidney infec- T86.11 Kidney transplant rejection
tion, cystitis (bladder T86.12 Kidney transplant failure
infection), or a urinary T86.13 Kidney transplant infection
tract infection (UTI) are (use additional code to report specific infection)
certainly not exotic T86.19 Other complication of kidney transplant
infectious conditions. Z98.85 Transplanted organ removal status
In these cases, you will
need to
Acute Renal Failure
se additional code
U
to identify organism. Acute renal failure (ARF) is a sudden malfunction of the kidney often caused by an
obstruction, a circulatory problem, or possible renal parenchymal disease. This condi-
You may have to check tion is often reversible with medical treatment.
the pathology report The most typical cause of ARF in critically ill patients and the cause of approxi-
to determine what the mately 75% of all cases of ARF is a condition known as acute tubular necrosis
organism is if it is not (ATN), also called acute tubulointerstitial nephritis (ATIN)—code N10. Nephro-
specified in the physi- toxic injury, such as that caused by the ingestion of certain chemicals, can cause
cian’s notes. ATN but is reversible when diagnosed and treated early. Ischemic ATN may be
the result of an injury to the glomerular epithelial cells causing cellular collapse
or injury to the vascular endothelium, resulting in cellular swelling and therefore
obstruction.
Report this condition with a code from category N17 Acute kidney failure, with an
additional character to identify accompanying tubular necrosis, acute cortical necrosis,
or medullary necrosis.
Treatment typically includes the provision of diuretics and fluids to flush the sys-
tem. Electrolyte and fluid balances must be maintained to avoid fluid overload. Some
cases require peritoneal dialysis.
Renal Calculi
Renal calculi, commonly known as kidney stones, might actually form anywhere
within the urinary system; however, formation in the renal pelvis or the calyces of the
kidneys is most common. While the precise cause of these uncomfortable formations
is not known, decreased urine production, infection, urinary stasis, and metabolic con-
ditions, such as gout, are considered predispositions. Code category N20 Calculus of
CHAPTER 17 |
kidney and ureter, N21 Calculus of lower urinary tract, or N22 Calculus of urinary tract
in diseases classified elsewhere would be appropriate for reporting this diagnosis.
When the individual stones are small, hydration is prescribed to enable natural
passage of the calculi. Larger stones may need to be removed surgically, most often
using a cystoscope or using lithotripsy to break up the larger pieces to permit natural
passage.
ICD-10-CM
YOU CODE IT! CASE STUDY
Brandon Markinson, a 51-year-old male, was in so much pain that he was doubled over. He went to the emergency
department at the hospital near his house. Dr. Deitz took an x-ray and determined that Brandon had nephrolithiasis.
She discussed treatment options with him.
ICD-10-CM
YOU CODE IT! CASE STUDY
Corneilus St. Augusteine contracted syphilis of his kidney, and now Dr. Acosta determines that an anterior urethral
stricture has developed as a result.
Serous coat
Urinary bladder
Ureter
Vas
deferens
Seminal
vesicle
Prostate gland
Urethra
FIGURE 17-2 An illustration identifying the anatomical sites of the prostate Booth et al., Medical Assisting, 5e. Copyright ©2013
by McGraw-Hill Education. Figure 31-6 (b), p. 616. Used with permission.
CHAPTER 17 |
culture of specimens collected using a four-step process known as the Meares and
Stamey technique provides the best data for a confirmed diagnosis. Antibiotics are the
standard-of-care treatment. Code category N41 Inflammatory diseases of the prostate
requires a fourth character to identify whether the inflammation is acute, chronic, an
abscess, or another issue.
Benign Prostatic Hyperplasia Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy,
(BPH) most often diagnosed in men over 50 years of age, is a condition in which the prostate
Enlarged prostate that results enlarges and results in depressing the urethra. This interferes with the flow of urine
in depressing the urethra. from the bladder to the outside. Code category N40 Enlarged prostate with a fourth
character would be used to report this condition. BPH can also result in urine reten-
tion, severe hematuria (blood in urine), or hydronephrosis.
Hydrocele is a condition that occurs when fluid collects within the tunica vaginalis
of the scrotum, the testis, or the spermatic cord. The physician will not only diagnose
and treat this condition, but also needs to investigate to determine the underlying cause,
especially when associated with pathology that is considered clinically significant. As
you abstract the documentation, you will need to identify if the hydrocele is congeni-
tal, encysted, infected, or other type, as well as any identified underlying conditions.
N43.0 Encysted hydrocele
N43.1 Infected hydrocele
Use additional code (B95-B97), to identify infectious agent
N43.2 Other hydrocele
P83.5 Congenital hydrocele
ICD-10-CM
YOU CODE IT! CASE STUDY
PATIENT NAME: Walter Primiera
PREOPERATIVE DIAGNOSES:
1. Left hydrocele, possible right.
2. Urethral meatal stenosis.
POSTOPERATIVE DIAGNOSES:
1. Left encysted hydrocele.
2. Urethral meatal stenosis.
OPERATIONS PERFORMED:
1. Left hydrocelectomy.
2. Diagnostic laparoscopy.
3. Urethral meatoplasty.
ANESTHESIA: General and caudal.
DESCRIPTION OF PROCEDURE: After informed consent was acquired, the patient was brought into the surgical
suite. The patient was placed on the table in a supine position, and prepped and draped in the usual sterile manner.
General anesthesia was accomplished, and a caudal block was administered. A left inguinal skin crease incision was
made and the dissection proceeded to expose the external oblique fascia. After placing self-retaining retractors, the
external oblique was opened in the direction of its fibers. The external ring was opened. The ilioinguinal nerve was
identified and moved away to avoid any injury. The cord was then isolated and a vessel loop placed around it. The
fibers of cord were separated and hydrocele sac was identified. This was carefully dissected away from the cord
structures, taking care to identify and avoid any injury to the vas or vessels.
Once the sac was completely isolated, bladder was doubly clamped and divided on the proximal aspect as well as
up to the internal ring. The sac was then opened, 5 mm laparoscopic trocar sheath was placed under vision into the
peritoneum, and a 2-0 silk stitch was secured in order to maintain the pneumoperitoneum. CO2 was then insufflated to
CHAPTER 17 |
Erectile dysfunction is broadcast in television and Internet ads as easily solved by
a little blue pill. However, whether or not it is that simple to cure, the reporting of the
diagnosis is complex. As you will discover turning to code category N52 Male erectile
dysfunction, you will need to determine, from the documentation, the underlying cause
because all of these code options are combination codes.
N52.01 Erectile dysfunction due to arterial insufficiency
N52.02 Corporo-venous occlusive erectile dysfunction
N52.03 Combined arterial insufficiency and corporo-venous occlusive erec-
tile dysfunction
N52.1 Erectile dysfunction due to diseases classified elsewhere
Code first underlying disease
N52.31 Erectile dysfunction following radical prostatectomy
N52.32 Erectile dysfunction following radical cystectomy
N52.33 Erectile dysfunction following urethral surgery
N52.34 Erectile dysfunction following simple prostatectomy
N52.39 Other and unspecified post-surgical erectile dysfunction
Bacterial Vaginosis
Bacterial vaginosis (BV)—the most common vaginal infection in women 16 to 45
years of age, often affecting pregnant women—is caused by an overgrowth of bacteria.
Symptoms include odor, itching, burning, pain, and/or a discharge. Code N76.0 Acute
vaginitis would be reported, along with a second code to identify the infectious agent.
Chlamydia
Caused by a bacterium (Chlamydia trachomatis), chlamydia can result in infertility
or other irreversible damage to a woman’s reproductive organs. The symptoms are
mild or absent, so most women don’t know they have a problem unless their partner is
diagnosed. Chlamydia can cause a penile discharge in men. It is the most commonly
reported bacterial STD in the United States, according to the CDC. In ICD-10-CM,
code A55 Chlamydial lymphogranuloma (venereum) is reported for chlamydia that is
transmitted by sexual contact. Note: Do not confuse this with A70 Chlamydia psit-
taci infections, A74.0 Chlamydial conjunctivitis, A74.81 Chlamydial peritonitis, A74.89
Other chlamydial diseases, or A74.9 Chlamydial infection unspecified, all of which are
reported when chlamydia causes another disease.
Genital Herpes
Genital herpes is caused by one of the herpes simplex viruses: type 1 (HSV-1) or type
2 (HSV-2). In this STD, one or more blisters may appear on or in the genital or rectal
area. Once the blister bursts, it can take several weeks for the ulcer to heal. The virus
will remain in the body indefinitely, even though no more breakouts may be experi-
enced, because there is no cure. Treatment can reduce the number of outbreaks and
diminish the opportunity of transmission to a partner. To code from category A60
Anogenital herpesviral [herpes simplex] infections, you must know the specific ana-
tomical site, such as penis or cervix, to determine the additional characters required.
Human Papillomavirus
There are over 40 different types of human papillomavirus (HPV) that can infect the gen-
ital regions, mouth, and/or throat of both men and women. This infection will not cause
any signs or symptoms; however, it is known to contribute to the development of genital
warts as well as cervical cancer (in women). A connection has also been made between
HPV and malignancies in the penis, anus, vulva, vagina, and oropharynx. A patient get-
ting a test to screen for HPV will be reported with code Z11.51 Encounter for screening
for human papillomavirus (HPV). Reporting for a female patient with a positive test result
will come from subcategory R87.8 Other abnormal findings in specimens from female
genital organs. Additional characters are required based on the anatomical location (cer-
vix or vagina) and on whether the patient is identified as high risk or low risk. Male and
female patients would both be reported with a code from subcategory R85.8 Other abnor-
mal findings in specimens from digestive organs and abdominal cavity for HPV-positive
results in the anus. A confirmed diagnosis for either a male or female patient would be
reported with A63.0 Anogenital (venereal) warts [due to (human) papillomavirus (HPV)].
Syphilis
In its early stages, syphilis, caused by a bacterium (Treponema pallidum), is easy
to cure. Signs and symptoms include a rash, particularly on the palmar and plantar
CHAPTER 17 |
surfaces, as well as a small, round, painless sore on the genitals, anus, or mouth. How-
ever, these symptoms mimic many other diseases, often resulting in delayed diagno-
sis. Code category A50 Congenital syphilis, A51 Early syphilis, A52 Late syphilis, or
A53 Other and unspecified syphilis would be reported when this condition is sexually
transmitted.
Trichomoniasis
Trichomoniasis (trich), a protozoan parasitic (Trichomonas vaginalis) STD, is more
common in older women than in men. Most individuals do not know they are infected
because only approximately 30% develop any symptoms, such as a genital discharge.
While the condition is curable, a person who has trich and goes without treatment
increases his or her risk of getting human immunodeficiency virus (HIV). Trich, when
present in a pregnant woman, can cause premature delivery of low-birth-weight neo-
nates. Code category A59 Trichomoniasis requires additional characters to identify the
specific anatomical site of the infection.
ICD-10-CM
YOU CODE IT! CASE STUDY
PATIENT: AMELIA MADISON
DATE OF OPERATION: 05/22/2018
PREOPERATIVE DIAGNOSES:
1. Severe pelvic pain.
2. History of pelvic inflammatory disease and pelvic adhesion.
3. Probable left hydrosalpinx.
POSTOPERATIVE DIAGNOSES:
1. Chronic pelvic inflammatory disease.
2. Extensive pelvic adhesion and left hydrosalpinx.
PROCEDURES PERFORMED:
1. Pelvic examination under anesthesia.
2. Total abdominal hysterectomy.
3. Bilateral salpingo-oophorectomy.
4. Lysis of adhesions.
SURGEON: Gabriel Underwood, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 100 mL.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient was taken to the operating room, where general anesthesia was admin-
istered without complication. The patient was placed in the dorsal lithotomy position, and examination under anes-
thesia revealed a normal-appearing vagina and cervix. Bimanual exam reveals a normal-sized uterus with no right
adnexal pathology noted. There was an adnexal mass in the left adnexa of approximately 4–5 cm. The patient was
placed in the supine position. She was prepped and draped in the usual fashion.
A Pfannenstiel skin incision was performed and carried down to the fascial layer. The fascia was transected. The
rectus muscles were retracted laterally, and the peritoneum was entered under direct visualization. The pelvic cav-
ity was inspected, and there were extensive pelvic adhesions noted. The bowel was packed into the upper abdo-
men using moist laps. There was a large left hydrosalpinx present with bilateral tubal-ovarian adhesions. The left
CHAPTER 17 |
Obstetrics (OB) specialization of obstetrics (OB), which focuses on care during pregnancy and the
A health care specialty focus- puerperium, and gynecology. Concerns and disorders relating to other aspects of the
ing on the care of women female anatomy are not always related to pregnancy. Let’s investigate some of the most
during pregnancy and the common reasons a woman would seek the care of a gynecologist and how to report them.
puerperium.
Endometriosis
Endometriosis (code category N80) is an inflammation or swelling of the tissue that lines
the uterus. The condition is estimated to affect 2% to 10% of women of childbearing age
in the United States. Although the disorder is identified as being within the uterus, endo-
metriosis can be observed in a woman’s ovary, cul-de-sac, uterosacral ligaments, broad
ligaments, fallopian tube, uterovesical fold, round ligament, vermiform appendix, vagina,
and/or rectovaginal septum. This means that a diagnosis of endometriosis is not sufficient
to determine the most accurate code. You have to know the specific site of the condition.
Uterine Fibroids
Also known as uterine leiomyoma or uterine fibromyoma, uterine fibroids (code cate-
gory D25 Leiomyoma of uterus) are tumors located in the female reproductive system.
Only about one-third of women with these tumors are actually diagnosed. Uterine
fibroids are not related to cancer, do not increase the patient’s risk of developing can-
cer later, and are found to be benign 99% of the time.
Pelvic Pain
Female pelvic and perineal pain (code R10.2) may be related to a specific genital
organ or an area around a genital organ or may be psychological in nature. The physi-
cian may be able to diagnose a particular cause, such as sexual intercourse or men-
struation, or the source of the pain may remain unknown.
ICD-10-CM
YOU CODE IT! CASE STUDY
Clarisse Battle, a 31-year-old female, came to see Dr. Legg with complaints of feeling bloated. She stated that she has
felt this way for over a month and cannot connect it to anything she has been eating. After taking a complete history,
doing an exam, and performing an ultrasound, Dr. Legg explained that Clarisse had a simple cyst on her right ovary.
Procreative Management
A woman may want to see her doctor regarding her desire to have children now or in
the future. Code category Z31 Encounter for procreative management is used only
for testing conducted with anticipation of procreation (having children). Code subcat-
egory Z31.6 Encounter for general counseling and advice on procreation will provide
you with a few fifth-character options to include additional details.
Perhaps a patient comes in for a test to determine whether or not she is a carrier
of a genetic disease before getting pregnant. Most often, such a woman wants to be
aware of the possibilities of passing inherited diseases, such as sickle cell anemia
or Tay-Sachs, to her baby. The code or codes to report her encounter would be
code(s):
Z31.430 Encounter of female for testing for genetic diseases carrier status
for procreative management
and/or
Z31.438 Encounter for other genetic testing of female for procreative
management
Code Z31.5 Encounter for genetic counseling would be used after a genetic test has
been done and shown positive results.
With good news so far, our female patient may come in next time for fertility testing
or, perhaps, a pregnancy test:
Z31.41 Encounter for fertility testing
Z32.00 Encounter for pregnancy test, result unknown
Z32.01 Encounter for pregnancy test, result positive
Z32.02 Encounter for pregnancy test, result negative
CHAPTER 17 |
ICD-10-CM
LET’S CODE IT! SCENARIO
Priscilla Sharp, a 25-year-old female, came to see Dr. Trenton to have an intrauterine device (IUD) inserted. She and
her husband, Eli, want to wait a while before having children.
Normal Pregnancy
Routine outpatient prenatal checkups are very important to the health and well-being Prenatal
of both the mother and the baby. For a healthy pregnant woman, the visits are typically Prior to birth; also referred to
scheduled at specific points throughout the pregnancy, as determined by the number as antenatal.
of weeks of gestation.
When coding routine visits, with the patient having no complications, you will
choose from the available Z codes. Remember that you will use a Z code when the
CHAPTER 17 |
patient is not encountering the health care provider because of any current illness or
GUIDANCE injury. A healthy, pregnant woman has neither a current illness nor a current injury.
CONNECTION
Z34.01 Encounter for supervision of normal first pregnancy, first trimester
Read the ICD-10-CM Z34.82 Encounter for supervision of other normal pregnancy, second
Official Guidelines for trimester
Coding and Report-
ing, section I. Con-
As you can see, you will need to determine which code to use on the basis of the physi-
ventions, General
cian’s notes on the woman’s gravida.
Coding Guidelines
High-Risk Pregnancy
and Chapter Specific
Guidelines, subsec- In cases where the pregnancy is considered to be medically high risk, you will use a
tion C. Chapter-Specific code from category O09 Supervision of high-risk pregnancy for the routine visit.
Coding Guidelines, You will determine the fourth digit for the O09 code according to the reason stated
chapter 15. Pregnancy, in the physician’s notes that the pregnancy is considered high risk. The reason might
Childbirth, and the be a history of infertility (O09.0-), a very young mother (O09.61-), an older mother
Puerperium, subsection (O09.51-), or another issue.
b.1) Routine outpatient The fifth or sixth character is used to report which trimester the patient is in at the
prenatal visits. encounter.
EXAMPLES
GUIDANCE O09.211 Supervision of pregnancy with history of pre-term labor, first trimester
CONNECTION O09.32 Supervision of pregnancy with insufficient antenatal care, second
trimester
Read the ICD-10-CM
Official Guidelines for
Coding and Report- Incidental Pregnant State
ing, section I. Con- You may be in an office when a pregnant woman comes in for services or treatment
ventions, General from a physician for a reason that has nothing to do with her pregnancy at all. Even
Coding Guidelines though the actual treatment or service is not related to her pregnancy, the fact that she
and Chapter Specific is pregnant will affect the way the doctor treats her condition. Therefore, you must
Guidelines, subsec- always include code Z33.1 Pregnant state, incidental, to indicate the pregnancy. It will
tion C. Chapter-Specific never be a first-listed code.
Coding Guidelines,
chapter 15. Pregnancy,
EXAMPLE
Childbirth, and the
Puerperium, subsec- Wendy Weingarter is 15 weeks pregnant and works at a bank. As she was walk-
tion b.2) Supervision of ing to her car, she slipped and fractured her toe. Dr. Stewart prescribed one pain
High-Risk Pregnancy. medication rather than another because Wendy was pregnant. He also took extra
precautions while x-raying her foot. You will report these codes:
S92.424A Nondisplaced fracture of distal phalanx of right great toe, initial
encounter
Z33.1 Pregnant state, incidental
ICD-10-CM
YOU CODE IT! CASE STUDY
Genesa Thurston, a 31-year-old female, G1 P0, came to see Dr. Mallard for her routine 20-week prenatal checkup.
Dr. Mallard noted that Genesa’s blood pressure was elevated and told her to come back in 10 days for a recheck.
Normal Delivery
When a baby comes by the old-fashioned route—spontaneous, full-term, vaginal, live-
born, single infant—and there are no current complications or issues related to the
pregnancy, your principal diagnostic code will be
GUIDANCE
O80 Encounter for full-term uncomplicated delivery
CONNECTION
Amniotic sac Read the ICD-10-CM
Official Guidelines for
Coding and Reporting,
Umbilical cord
section I. Conven-
tions, General Coding
Urethra Guidelines and Chapter
Specific Guidelines,
Vagina
subsection C. Chapter-
Placenta
Cervix Specific Coding Guide-
lines, chapter 15. Preg-
Rectum nancy, Childbirth, and
the Puerperium, sub-
sections b.4) When a
delivery occurs and
FIGURE 17-3 An illustration identifying the anatomical sites of a pregnant uterus n. Normal Delivery,
and related parts of the female anatomy Roiger, Deborah, Anatomy & Physiology: Foundations for Code O80.
the Health Professions, 1/e. ©2013 McGraw-Hill Education. Figure 16.20, pg. 619. Used with permission.
CHAPTER 17 |
Vertex presentation Breech presentation
ICD-10-CM
LET’S CODE IT! SCENARIO
Annette Spearman, a 33-year-old female, G1 P0, is in the birthing room and in full labor, ready to give birth to her
baby vaginally. All of a sudden, Dr. Tatum tells her to stop pushing. The umbilical cord has prolapsed, and they can-
not seem to move it. Dr. Tatum immediately orders Annette into the OR, where he performs a c-section. Annette’s
baby girl was born without further incident.
Outcome of Delivery
GUIDANCE
As stated earlier in this chapter, every time a patient gives birth during an encounter,
you have to code the birth process (the delivery code) and you have to report the result
CONNECTION
of that birth process (the outcome-of-delivery code). Read the ICD-10-CM
The very last code on the mother’s chart that will have anything to do with the baby Official Guidelines for
is a code chosen from the Z37 Outcome of delivery category. The fourth character for Coding and Report-
the code is determined by two elements: ing, section I. Con-
ventions, General
1. How many babies were born during this delivery.
Coding Guidelines
2. Live-born, stillborn (dead), or, if a multiple birth, a combination. and Chapter Specific
Guidelines, subsec-
CODING BITE tion C. Chapter-Specific
Coding Guidelines,
Once a baby is born, the baby gets his or her own chart. From that point forward,
chapter 15. Pregnancy,
anything having to do with the baby is coded for the baby and stays off the moth-
Childbirth, and the
er’s chart.
Puerperium, subsec-
Remember that the very last code directly relating to the baby that is placed
tion b.5) Outcome of
on the mother’s chart is a code from category Z37 Outcome of delivery. The very
delivery.
first code on the baby’s chart will be from code category Z38 Liveborn infants
according to place of birth and type of delivery. This Z code is used to report that
a newborn baby has arrived, and it is always the principal (first-listed) code. A code
from this category can be used only once, for the date of birth.
ICD-10-CM
LET’S CODE IT! SCENARIO
Shoshanna Betterman, a 29-year-old female, had some third-trimester bleeding, so she went to her doctor. Dr. Patterson
performed a pelvic examination and was concerned. A transvaginal ultrasound scan confirmed that she was suffer-
ing from total placenta previa. Because she is in her 36th week, Dr. Patterson arranged to do a c-section immediately.
Shoshanna’s baby girl was born without further incident.
(continued)
CHAPTER 17 |
Let’s Code It!
Dr. Patterson performed a c-section on Shoshanna because she had total placenta previa with bleeding. Go to
the Alphabetic Index and look up
Placenta, placental — see Pregnancy, complicated by (care of) (management affected by), specified
condition
So let’s turn to
Pregnancy
complicated by (care of) (management affected by)
placenta previa O44.0-
In the Tabular List, you confirm it is an appropriate code. Start reading at
O44 Placenta previa
There are no notations or directives, so keep reading down the column to determine the most accurate fourth
character:
O44.0- Complete placenta previa NOS or without hemorrhage
O44.1- Complete placenta previa with hemorrhage
Be certain not to go too fast, or you might miss that the first code, O44.0, states, “without hemorrhage.”
Shoshanna was hemorrhaging (bleeding). This makes O44.1 more accurate.
Now, you need to determine the required fifth character. As with all codes in this chapter of ICD-10-CM, you
will need to determine, from the documentation, which trimester Paula was in at this encounter. Dr. Patterson
stated, “some third-trimester bleeding.”
Put it all together and your code for this encounter is
O44.13 Complete placenta previa with hemorrhage, third trimester
That’s good. But coding for the encounter with Shoshanna is not complete.
Shoshanna is in only her 36th week of gestation. Therefore, you need to include this detail. Turn to the Alpha-
betic Index and look up weeks—nothing there. Try gestation—not there either. Let’s turn to
Pregnancy
weeks of gestation
36 weeks Z3A.36
Turn to the Tabular List to confirm, as is required by the Official Guidelines:
Z3A Weeks of gestation
Z3A.36 36 weeks gestation
Terrific! You need one more code, to report the outcome of delivery. Shoshanna had one live-born baby.
Z37 Outcome of delivery
There are no notations or directives, so read down the column to determine the required fourth character that
will accurately report Shoshanna’s outcome of delivery:
Z37.0 Outcome of delivery, single live birth
Excellent!
O44.13 Placenta previa with hemorrhage, third trimester
Z3A.36 36 weeks gestation
Z37.0 Outcome of delivery, single live birth
ICD-10-CM
YOU CODE IT! CASE STUDY
Charles Wallace drove his wife, Angela, a 30-year-old female, to the hospital. She had gone into labor, but she was
only at 35 weeks gestation. Dr. Callahan assisted in the delivery of her twin girls. However, there was a problem, and
one of the twins was stillborn.
CHAPTER 17 |
ICD-10-CM
YOU CODE IT! CASE STUDY
Vitalita Meadows, a 31-year-old female, G2 P1, is 17 weeks pregnant. Dr. Kramer is meeting with her to discuss her
lab test results, which indicate that Vitalita has anemia. Dr. Kramer is concerned about how the anemia will affect
her pregnancy.
EXAMPLES
O36.593- Maternal care for other known or suspected poor fetal growth,
third trimester
This diagnosis would explain the medical necessity for the mother
being referred to a nutritionist for a special diet.
O35.3XX- Maternal care for (suspected) damage to fetus from viral disease
in mother
This diagnosis would explain the medical necessity for the mother
to have special laboratory tests or an amniocentesis.
Note: The seventh character reports which fetus is, or may be, damaged or abnor-
mal. The number 0 (zero) is used for a single gestation, the number 1 for the first
of a multiple gestation, the number 2 for the second fetus, and so on.
Seventh Character
You may have noticed that many pregnancy complication codes require a seventh
character. If the pregnancy is a single gestation, you will report a zero (0). However,
when there is more than one fetus, you will need to determine, from the documenta-
tion, which specific fetus is having the problem described by the code. For example:
O64.2xx3 Obstructed labor due to face presentation, fetus 3
O69.1xx2 Labor and delivery complicated by cord around neck, with com-
pression, fetus 2
CHAPTER 17 |
Routine postpartum care, just like routine prenatal care, is reported with a Z code:
GUIDANCE
CONNECTION Z39.0 Encounter for care and examination of mother immediately after
delivery
Read the ICD-10-CM Z39.1 Encounter for care and examination of lactating mother
Official Guidelines for Z39.2 Encounter for routine postpartum follow-up
Coding and Reporting,
section I. Conven- Whenever the health care concern arises—even if the diagnosis falls outside the
tions, General Coding 6-week period—if the physician’s notes document that it is a postpartum complica-
Guidelines and Chapter tion, or pregnancy-related, you are to code it as a postpartum condition.
Specific Guidelines,
subsection C. Chapter- Sequelae (Late Effects) of Obstetric Complications
Specific Coding Guide-
Late effects of obstetric complications, as identified by the attending physician in his
lines, chapter 15. Preg-
or her notes, are coded the same way as all other sequelae. The late effect code— O94
nancy, Childbirth, and
Sequelae of complication of pregnancy, childbirth, and the puerperium—is added
the Puerperium, sub-
when a condition begins during pregnancy but requires continued treatment. The code
section o. The Peripar-
is placed after the code describing the actual health condition. Notice the notation
tum and Postpartum
beneath this code:
Periods.
Code first condition resulting from (sequela) of complication of pregnancy, child-
birth, and the puerperium
ICD-10-CM
YOU CODE IT! CASE STUDY
Marjorie Ableman, a 31-year-old female, gave birth, vaginally, to a beautiful baby girl 3 weeks ago. She comes
today to see Dr. Beale because of feelings of fatigue. After exam and blood tests, Dr. Beale diagnoses her with post-
partum cervical infection caused by Enterococcus.
ICD-10-CM
LET’S CODE IT! SCENARIO
Tristan Allen Montegro was born via vaginal delivery in the McGraw Birthing Center at 10:58 a.m. on September
1. He weighed 8 pounds 5 ounces and was 21 inches long, with Apgar scores of 9 and 9. Dr. Grall, a pediatrician,
performed a comprehensive examination immediately following Tristan’s birth. Baby Tristan was sent home at 6:30
p.m. in the care of his mother, Arashala.
(continued)
CHAPTER 17 |
Let’s Code It!
Tristan was just born, and this is his first health care chart. As you learned, his very first code must be from the
Z38 range. As with all other cases, begin in the Alphabetic Index. What should you look up? Birth would be a
logical choice. However, when you turn to this term in the Alphabetic Index, you are going to see a long list of
adjectives, none of which applies to Tristan, or any other baby being born without a problem. As you look down
the list, you may notice this item:
Birth
There is nothing here that fits. Let’s go look up the term newborn.
Newborn (infant) (liveborn) (singleton) Z38.2
Check Dr. Smith’s notes. It is documented that Tristan was a single, liveborn baby.
Let’s go to the Tabular List and look at our choices. Begin with
Z38 Liveborn infants according to place of birth and type of delivery
As you read down, you can see that code Z38.2 reports Single liveborn infant, unspecified as to place of birth.
The documentation clearly indicates where Tristan was born—in the McGraw Birthing Center (not a part of a
hospital). So this code is not accurate. Keep reading. The answer from the documentation will bring you to the
correct code:
Z38.1 Single liveborn infant, born outside the hospital
Good work!
When a congenital or perinatal condition has been resolved and no longer has an Prematurity
Birth occurring prior to the
impact on the child’s health and well-being, you will need to assign a code from the
completion of 37 weeks
range Z85–Z87, Personal history of . . . .
gestation.
CHAPTER 17 |
Mortality Respiratory distress syndrome (RDS) is the leading cause of mortality and morbidity
Death. of premature neonates. The immature lungs have an insufficient quantity of surfactant—
Morbidity the secretion within the lungs that supports the alveoli and keeps them from collapsing.
Unhealthy. Maternal diabetes and neonatal asphyxia are known contributing factors. RDS causes
hypoxia, which can then lead to pulmonary ischemia, pulmonary capillary damage, and
fluid leaking inappropriately into the alveoli. Cyanosis, increased respiratory effort,
anoxia, and acidosis are signs and complications. Report a diagnosis of RDS with code
CODING BITES P22.0 Respiratory distress syndrome of newborn.
Codes from category You will find the codes needed to report an infant’s prematurity and/or LBW, as
P05 and category P07 well as long gestation and high birth weight, as documented in the physician’s notes,
may not be reported on within these code categories:
the same claim at the
same time. P05 Disorders of newborn related to slow fetal growth and fetal malnutrition
P07 Disorders of newborn related to short gestation and low birth weight,
not elsewhere classified
P08 Disorders of newborn related to long gestation and high birth weight
GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I. Con-
ventions, General Coding Guidelines and Chapter Specific Guidelines, subsec-
tion C. Chapter-Specific Coding Guidelines, chapter 16. Certain Conditions
Originating in the Perinatal Period, subsections d. Prematurity and Fetal Growth
Retardation and e. Low birth weight and immaturity status.
ICD-10-CM
YOU CODE IT! CASE STUDY
Harper Anne Glosick was born today at 27 weeks 2 days gestation by cesarean section at Hillside Hospital. She
weighed 945 grams at birth, and her lungs are immature. Dr. McArthur admits Harper into the neonatal intensive
care unit (NICU) with a diagnosis of extreme immaturity.
ICD-10-CM
LET’S CODE IT! SCENARIO
Roseanna Glassman brought her 39-day-old daughter, Marisol, to Dr. Granger for her routine health check. During the
examination, Roseanna related that Marisol’s head accidentally was banged into the table and she was worried about
neurologic problems. Dr. Granger checked her head and found no bruise or laceration. To calm Roseanna, he took Mari-
sol down the hall to have a special neurologic screening for traumatic brain injury. Fortunately, the scan was negative.
(continued)
CHAPTER 17 |
Go back to the notes and see that Dr. Granger wrote “neurologic screening for traumatic brain injury.” There-
fore, you know that Z13.850 Encounter for screening for traumatic brain injury is accurate and matches what
Dr. Granger wrote in the notes.
One more code—remember, you need to report a code for the bang on the head because this led Dr. Granger
to do the screening. Check the notes and see that Dr. Granger found no bruises or lacerations and that Roseanna
did not report any other signs or symptoms, such as vomiting or seizure. The bang on the head will have to be
reported with an external cause code because it is an external factor that explains why Dr. Granger screened
Marisol for a TBI. Check the External Causes Code Alphabetic Index and look up strike, striking because Marisol’s
head struck the table (furniture). Code W22.03 is suggested. Let’s check the Tabular List:
W22 Striking against or struck by other objects
W22.03x- Walked into furniture
This cannot be accurate because Marisol is only 39 days old and she cannot walk yet. Review all of the other
codes in this subsection to determine the code that will report what happened:
W22.8xxA Striking against or struck by other objects, initial encounter
So for Marisol’s visit to Dr. Granger, you have three codes to report:
Z00.129 Encounter for routine child health examination without abnormal findings
Z13.850 Encounter for screening for traumatic brain injury
W22.8xxA Striking against or struck by other objects, initial encounter
ICD-10-CM
YOU CODE IT! CASE STUDY
Ines Nancy Mulle was born, full term, vaginally at Barton Hospital. Her mother has been an alcoholic for many years
and would not stop drinking during the pregnancy. Ines weighed only 1,575 grams, small for a full-term neonate.
After testing, she was diagnosed at birth with fetal alcohol syndrome and admitted into the NICU.
Inherited Conditions
Your blue eyes and brown hair are the products of genetics—qualities in the chromo-
somes you received from your father and mother. Sadly, a genetic abnormality will
negatively affect the health of a child. An inherited mutation in the DNA causes a
permanent alteration that will affect each and every cell as it multiplies during the
GUIDANCE
maturation of the zygote to embryo to fetus to neonate. There is also a strong probabil-
ity that this person will pass this condition along to his or her children. CONNECTION
Read the ICD-10-CM
Congenital Anomalies Official Guidelines for
A congenital malformation, also known as a birth defect, is a permanent physical Coding and Reporting,
defect—the incomplete development of an anatomical structure—that is identified in section I. Conven-
a neonate. It may be the effect of a genetic mutation, or it may have been caused by tions, General Coding
a prenatal event. The fetal development of many organs, including the brain, heart, Guidelines and Chapter
lungs, liver, bones, and/or intestinal tract, may have been altered by alcohol or drugs Specific Guidelines,
used by the mother at a particular point during gestation, by exposure to an environ- subsection C. Chapter-
mental factor, or by an injury sustained during delivery. Specific Coding
Guidelines, chapter
EXAMPLES 17. Congenital malfor-
mations, deformations,
Q14.1 Congenital malformation of retina and chromosomal
Q64.4 Malformation of urachus abnormalities.
CHAPTER 17 |
Testing
Health care research has found ways to identify the presence or the likelihood of
genetic disorders and congenital anomalies.
Genetic testing can be performed prior to fertilization so the potential parents can
gain insights on the possibility of passing along certain diseases to their future chil-
dren. A family tree analysis, called a pedigree, is a diagram of the individual’s family
that includes diseases and causes of death. A geneticist (a physician specializing in
the study of genetics) can use this diagram to identify inheritance patterns and prob-
abilities. In addition, a blood test known as a karyotype can be used. During this test,
multiple staining techniques can illuminate each chromosomal band to enable visual-
ization of a mutation.
Prenatal blood and DNA tests can currently detect more than 600 genetic disorders
prior to the baby’s birth. This information can allow parents to make informed deci-
sions and to become prepared emotionally, intellectually, and financially for the birth
of a child with a genetic disorder. In addition, the physician can make certain appropri-
ate arrangements, such as method of delivery and timing of delivery, that may reduce
the severity or impact of the condition.
Amniocentesis is the process of collecting a sample of amniotic fluid via needle
aspiration from a pregnant uterus. Chorionic villus sampling is the process of obtain-
ing tissues from the placenta for prenatal testing by passing a catheter through the
vagina and threading it up to the placenta.
Genetic tests are not limited to potential or impending parents. Adults can use this
information as well. For example, many women are tested for the BRCA1 or BRCA2
gene that identifies a potential for the development of breast and/or ovarian cancer.
EXAMPLES
Z14.1 Cystic fibrosis carrier
Z15.01 Genetic susceptibility to malignant neoplasm of breast
Gene Therapy
Researchers continue to experiment with gene therapy to prevent or treat these types
of diseases. The goal is to find a safe and effective way to correct a malfunctioning
gene. Methods currently being investigated include
∙ Placing a normal gene into the genome in a nonspecific place so it can provide the
correct function of the nonfunctional gene.
∙ Using homologous recombination to remove the abnormal gene and replace it with
a normal gene.
∙ Using selected reverse mutation to actually repair the gene so it will function properly.
In such cases, the term placed or inserted does not mean the same as it typically does
in the context of other health care procedures. One method is to put the therapeutic
gene into a carrier molecule, known as a vector, which is a genetically altered virus.
Nonviral methods include the injection of the therapeutic gene directly into its target
cell. However, this can be accomplished only with a limited number of tissue types.
Studies are being conducted on the effectiveness of using an artificial liposome and/or
certain chemicals to achieve the successful delivery of the therapeutic gene.
Genetic Abnormality
An error in a gene (chromo- Genetic Disorders
some) that affects develop-
ment during gestation; also
Chromosomal Abnormalities
known as a chromosomal Down syndrome (trisomy 21) is a spontaneous genetic abnormality and is not inher-
abnormality. ited. Manifestations include mental retardation, unusual facial features including
Multifactorial Abnormalities
Cleft lip and cleft palate are malformations of the upper lip and/or palate that occur
during the first 2 months of gestation. This deformity may be seen unilaterally or Deformity
bilaterally (medial is rare) and may extend into the nasal cavity and/or the maxilla A size or shape (structural
(upper jaw). Use code categories Q35 Cleft palate (additional character to identify hard design) that deviates from that
palate, soft palate, etc.), Q36 Cleft lip (additional character to specify laterality), and which is considered normal.
Q37 Cleft palate with cleft lip (additional character to specify laterality).
CHAPTER 17 |
injury or surgical procedure. On occasion, spontaneous bleeding may occur, causing
damage to the brain, nerves, or muscle function, depending upon the location of the
hemorrhage. Treatment can extend life expectancy. Report code D66 Hereditary factor
VIII deficiency (hemophilia NOS).
Fragile X syndrome is the most frequently diagnosed underlying cause of inher-
ited mental retardation, and it affects both males and females. An accurate pedigree
would be important in predicting the likelihood of this condition because probabili-
ties increase with each generation. Males display profound mental retardation, while
females may or may not reveal this dysfunction. Use code Q99.2 Fragile X chromo-
some to report this condition.
Congenital Malformations
Spina bifida is a condition that results from an incomplete closure of the vertebral col-
umn, the spinal cord, or both. Presented often by a hole in the skin covering the area
of the spine, it is an abnormality in the development of the central nervous system.
In the 1990s, researchers discovered that folic acid (a B vitamin), when taken before
and during the first trimester of pregnancy, could actually prevent some cerebral and
spinal birth defects. In 1996, the U.S. Food and Drug Administration ordered that folic
acid be added into breads, cereals, and other grain products. The number of cases of
spina bifida dropped from 2,490 in 1995–1996 to 1,640 in 1999–2000. Spina bifida is
sometimes accompanied by hydrocephalus. Code category Q05 Spina bifida (aperta)
(cystica) requires an additional character to report the location on the spine (cervical,
thoracic, lumbar, sacral), as well as to report the presence or absence of hydrocepha-
lus. Spina bifida occulta is reported with Q76.0 Spina bifida occulta. This version of
spina bifida is evidenced by a tiny gap between vertebrae with no involvement of the
nervous system. It can be seen only on an x-ray of the affected area and generally has
no signs or symptoms.
Congenital hernia can occur in several locations in the body, just as with adult
hernias. The difference with reporting such conditions is the specification in the docu-
mentation that the hernia is congenital. Some of the codes include Q79.0 Congenital
diaphragmatic hernia, Q40.1 Congenital hiatus hernia, and Q79.51 Congenital hernia
of bladder.
Congenital heart defects have been determined by the CDC to affect close to
400,000 babies born in the United States each year. They are the most common type of
congenital anomaly and one of the most common causes of death in infants. Research
has proved a strong connection between cigarette smoking, especially during the first
trimester of gestation, and neonates with pulmonary valve stenosis and type 2 atrial
septal defects, among other congenital heart malformations. Code from categories
Q20 Congenital malformations of cardiac chambers and connections, Q21 Congeni-
tal malformations of cardiac septa, Q23 Congenital malformations of aortic and mitral
valves, and Q24 Other congenital malformations of heart. Additional characters are
required to provide specific details, such as Q21.1 Atrial septal defect and Q22.1 Con-
genital pulmonary valve stenosis.
Chapter Summary
The urinary system is designed to remove the urea from the blood, manufacture urine,
and perform waste removal by eliminating the urine. It supports many of the other
body systems by ensuring fluid balance and eliminating waste products to avoid tox-
icity. Understanding the components of this system and their functions will help you
correctly interpret the documentation to determine the most accurate code or codes.
Some conditions affecting organs in the urinary system are the manifestations of other
diseases, such as hypertension or diabetes, whereas others may be the result of an
infectious organism. Coders must read carefully (as always) to determine the correct
coding process.
CHAPTER 17 REVIEW
phrase “private places.” These organs have important functions and are susceptible to
disease and injury, as with other body systems. Female anatomy includes many organs
and anatomical sites that can be subject to health concerns. Well-woman exams and
preventive tests should be annual events in every woman’s life. Each time, a medical
necessity for the visit must be documented. Remember that staying healthy or catching
illness or disease early is a medical necessity.
Babies are precious and should always be treated with tender loving care. From the
moment they are born, babies receive a special version of health care services created
especially for them, due to their size and growth patterns. The guidelines for coding
the reasons for these services are very specific. Congenital anomalies, whether inher-
ited or caused by an interaction with a chemical, drug, or other environmental factor
during gestation, can have a lifelong effect on the child as well as the family. Con-
genital deficits can cause a minor inconvenience, present a challenge, require years of
health care treatments, or result in premature death.
CODING BITES
The Apgar test is named for Virginia Apgar, but it also has come to stand for the
following:
Activity (muscle tone)
Pulse rate (heart rate)
Grimace (reflex response)
Appearance (skin color)
Respiratory (breathing effort)
Apgar Scoring for Newborns
Score Interpretation
0–3 Baby needs immediate lifesaving procedures
4–6 Baby needs some assistance; requires careful monitoring
7–10 Normal
Part I
1. LO 17.1 The organ system responsible for removing waste products that are A. Anemic
left behind by protein, excessive water, disproportionate amounts of B. Benign Prostatic
electrolytes, and other nitrogenous compounds from the blood and the Hyperplasia (BPH)
body.
2. LO 17.1 Inflammation of any part of the urinary tract: kidney, ureter, bladder, or
urethra.
CHAPTER 17 |
3. LO 17.7 An error in a gene that affects development during gestation. C. Bladder Cancer
CHAPTER 17 REVIEW
4. LO 17.2 Enlarged prostate that results in depressing the urethra. D. Chronic Kidney Dis-
5. LO 17.1 Ongoing malfunction of one or both kidneys. ease (CKD)
6. LO 17.7 A size or shape that deviates from that which is considered normal. E. Deformity
7. LO 17.1 Glomerular filtration rate, the measurement of kidney function; used to F. Genetic Abnormality
determine the stage of kidney disease. G. GFR
8. LO 17.2 Inflammation of the prostate. H. Malformation
9. LO 17.7 An irregular structural development. I. Prostatitis
10. LO 17.1 Malignancy of the urinary bladder. J. Urea
11. LO 17.1 A compound that results from the breakdown of proteins and is K. Urinary System
excreted in urine. L. Urinary Tract Infection
12. LO 17.1 Suffering from a low red blood cell count. (UTI)
Part II
1. LO 17.4 A health care specialty focusing on the care of women during preg- A. Abortion
nancy and the puerperium. B. Gestation
2. LO 17.4 A physician specializing in the care of the female genital tract. C. Gynecologist
3. LO 17.5 The length of time for the complete development of a baby from con- D. Obstetrics
ception to birth; on average, 40 weeks.
E. Prenatal
4. LO 17.4 The time period from the end of labor until the uterus returns to normal
F. Puerperium
size, typically 3 to 6 weeks.
5. LO 17.5 Prior to birth; also referred to as antenatal.
6. LO 17.6 The end of a pregnancy prior to or subsequent to the death of a fetus.
Part III
1. LO 17.7 An abnormal, or unexpected, condition. A. Anomaly
2. LO 17.7 A condition existing at the time of birth. B. Clinically Significant
3. LO 17.7 A baby born weighing less than 5 pounds 8 ounces, or 2,500 grams. C. Congenital
4. LO 17.7 Unhealthy, diseased. D. Low Birth Weight
5. LO 17.7 The time period from before birth to the 28th day after birth. (LBW)
6. LO 17.7 Birth occurring prior to the completion of 37 weeks gestation. E. Morbidity
7. LO 17.7 Signs, symptoms, and/or conditions present at birth that may impact F. Mortality
the child’s future health status. G. Perinatal
8. LO 17.7 Death. H. Prematurity
2. LO 17.2 _____ is a condition that occurs when fluid collects within the tunica vaginalis of the scrotum, the testis,
or the spermatic cord.
a. Erectile dysfunction b. Oligospermia
c. Hydrocele d. Benign prostatic hyperplasia
CHAPTER 17 REVIEW
a. A51.9 b. A52.06 c. A52.03 d. A51.2
CHAPTER 17 |
7. If both a stage of CKD and ESRD are documented, assign code _____ only.
CHAPTER 17 REVIEW
8. Patients who have undergone kidney transplant may still have some form of _____ because the kidney transplant may
not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complica-
tion. Assign the appropriate _____ code for the patient’s stage of CKD and code _____, Kidney transplant status.
9. If a transplant complication such as _____ or other transplant complication is documented, see section _____ for
information on coding complications of a kidney transplant. If the documentation is unclear as to whether the
patient has a complication of the transplant, _____ the provider.
10. Patients with _____ may also suffer from other serious conditions, most commonly _____.
11. The _____ of the CKD code in _____ to codes for other contributing conditions is _____ on the conventions in
the Tabular List.
Part II
Refer to the Official Guidelines and fill in the blanks according to the Chapter 15, Pregnancy, Childbirth, and the
Puerperium, Chapter-Specific Coding Guidelines.
never fetus every complications
7th O09 “in childbirth” “unspecified trimester”
prompted Z37 priority Z34
antepartum trimester insufficient maternal
no
1. Chapter 15 codes have sequencing _____ over codes from other chapters.
2. Chapter 15 codes are to be used only on the _____ record, _____ on the record of the newborn.
3. The majority of codes in Chapter 15 have a final character indicating the _____ of pregnancy.
4. Whenever delivery occurs during the current admission, and there is an “in childbirth” option for the obstetric
complication being coded, the _____ code should be assigned.
5. In instances when a patient is admitted to a hospital for _____ of pregnancy during one trimester and remains
in the hospital into a subsequent trimester, the trimester character for the _____ complication code should be
assigned on the basis of the trimester when the complication developed, not the trimester of the discharge.
6. The _____ code should rarely be used, such as when the documentation in the record is _____ to determine the
trimester and it is not possible to obtain clarification.
7. Where applicable, a _____ character is to be assigned for certain categories to identify the _____ for which the
complication code applies.
8. For routine outpatient prenatal visits when no complications are present, a code from category _____, Encounter
for supervision of normal pregnancy, should be used as the first-listed diagnosis.
9. For routine prenatal outpatient visits for patients with high-risk pregnancies, a code from category _____, Super-
vision of high-risk pregnancy, should be used as the first-listed diagnosis.
10. In episodes when _____ delivery occurs, the principal diagnosis should correspond to the principal complication
of the pregnancy which necessitated the encounter.
11. When an obstetric patient is admitted and delivers during that admission, the condition that _____ the admission
should be sequenced as the principal diagnosis.
12. A code from category _____, Outcome of delivery, should be included on _____ maternal record when a delivery
has occurred.
Part III
Refer to the Official Guidelines and fill in the blanks according to the Chapter 16, Certain Conditions Origination in
the Perinatal Period, Chapter-Specific Coding Guidelines.
CHAPTER 17 REVIEW
life originate definitive once
place before newborn first
continue not default Z38
never clinically should
1. For coding and reporting purposes the perinatal period is defined as _____ birth through the _____ day following birth.
2. Codes in this chapter are _____ for use on the maternal record.
3. Codes from Chapter 15, the obstetric chapter, are never permitted on the _____ record.
4. Chapter 16 codes may be used throughout the _____ of the patient if the _____ is still present.
5. When coding the birth episode in a newborn record, assign a code from category _____, Liveborn infants accord-
ing to _____ of birth and _____ of delivery, as the principal diagnosis.
6. A code from category Z38 is assigned only _____, to a newborn at the time of birth.
7. Codes for signs and symptoms may be assigned when a _____ diagnosis has _____ been established.
8. If the reason for the encounter is a _____ condition, the code from Chapter 16 should be sequenced _____.
9. Should a condition _____ in the perinatal period, and _____ throughout the life of the patient, the perinatal code
should continue to be used regardless of the patient’s age.
10. If a newborn has a condition that may be either due to the birth process or community acquired and the documenta-
tion does not indicate which it is, the _____ is due to the birth process and the code from Chapter 16 should be used.
11. All _____ significant conditions noted on routine newborn examination _____ be coded.
ICD-10-CM
YOU CODE IT! Basics
First, identify the condition in the following diagnoses, 2. Recurrent hematuria with membranoproliferative
then code the diagnosis. glomeruloephritis:
Example: Glaucoma of newborn: a. main term: _____ b. diagnosis: _____
3. Chronic interstitial nephritis, reflux associated:
a. main term: Glaucoma b. diagnosis: Q15.0
a. main term: _____ b. diagnosis: _____
1. Acute nephritic syndrome with dense deposit
4. Stricture of ureter:
disease:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
CHAPTER 17 |
CHAPTER 17 REVIEW
ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. Sean Dollarson, an 8-year-old male, is brought in by his parents to see Dr. Greenburg, his pediatrician. Sean
has not been feeling well and has had some pinkish colored urine. Dr. Greenburg completed a physical exam
noting elevated blood pressure and periobrbital puffiness. Sean is admitted to the hospital. The laboratory
tests reveal azotemia, a BUN:Cr ratio of 18, proteinuria of 2.1 g/day, and that RBCs are dysmorphic. After
reviewing the results of the tests, Sean is diagnosed with chronic nephritic syndrome with diffused mesangial
proliferative glomerulonephritis.
2. Sally Hyman, a 37-year-old female, presents with the complaint of restlessness, nausea, and vomiting. Sally
also admits to intermittent abdominal pain. Dr. Moye completes an examination and orders a noncontrast CT
scan followed by an intravenous contrast CT scan. The CT results confirmed the diagnosis of a staghorn cal-
culus of kidney.
3. Murphy Jorganson, a 42-year-old male, presents with the complaint of frequent and painful urination. Dr. Reddy
completes a physical examination and notes swelling of the testicles. Murphy admits to some soreness and a
whitish discharge. Dr. Reddy inserts a cotton swab approximately 3.5 cm into the urethra and rotates it once.
Microscopic examination confirmed the diagnosis of non-gonococcal urethritis due to methicillin-resistant
Staphylococcus aureus.
4. Eugene Applewhite, a 5-year-old male, is brought in by his parents. Eugene is losing weight and his parents are
concerned because Eugene prefers drinking water to eating food. Eugene has also been wetting his bed. Dr. Ryant
completes a clinical examination and notes mild dehydration and decides to admit Eugene to the hospital. After
reviewing the MRI scan and laboratory results, Eugene is diagnosed with nephrogenic diabetes insipidus.
5. Larry Tucker, a 24-year-old male, presents today to see Dr. Dawkins, a urologist, with the complaint of low
level of semen with ejaculation. Dr. Dawkins completes a medical history, a physical examination, and the
appropriate tests. Larry is diagnosed with azoospemia due to obstruction of efferent ducts.
6. Pamela Cain, a 34-year-old female, presents today 23 weeks pregnant. Pamela has no complaints and states
she is feeling well. Pamela was diagnosed with essential hypertension 1 year ago.
7. Gladys Shull, a 17-year-old female, comes in today to see Dr. Henson. Gladys thinks she may be pregnant.
Dr. Henson performs a pregnancy test, results positive.
ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documenta-
tion from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient
encounters. Using the techniques described in this chapter, carefully read through the case studies and determine
the most accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: OTTMAN, BELINDA
ACCOUNT/EHR #: OTTMBE001
DATE: 10/17/18
Attending Physician: Renee O. Bracker, MD
S: This 71-year-old female was diagnosed with end-stage renal disease requiring regular dialysis main-
tenance 6 months ago. She presents today with shortness of breath, nausea, hiccups, and overall weak-
ness. She admits to noncompliance with her dialysis plan.
O: Ht. 5′4″, Wt. 134 lb., P 81, R 28, BP 170/92. HEENT: unremarkable. Serum creatinine of 1.7 mg/dL,
GFR 14 mL/min/1.73 m, hemaglobin 6.4, edema pitting 2+.
CHAPTER 17 |
CHAPTER 17 REVIEW
A: End-stage renal disease with regular dialysis, noncompliance; anemia due to ESRD
P: Admit to inpatient with immediate hemodialysis session and transfusion
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: TERRY, MARIANNA
ACCOUNT/EHR #: TERRMA001
DATE: 9/17/18
Operative Report
Preoperative DX: 1. First trimester missed abortion; 2. Undesired fertility
Postoperative DX: Same
Operation: 1. Dilation and curettage with suction; 2. Laparoscopic bilateral tubal ligation
using Kleppinger bipolar cautery
Surgeon: Oscar R. Prader, MD
Assistant: None
Anesthesia: General endotracheal anesthesia
Findings: Pt had products of conception at the time of dilation and curettage. She also had
normal-appearing uterus, ovaries, fallopian tubes, and liver edge.
Specimens: Products of conception to pathology
Disposition: To PACU in stable condition
Procedure: The patient was taken to the operating room, and she was placed in the dorsal supine posi-
tion. General endotracheal anesthesia was administered without difficulty. The patient was placed in
dorsal lithotomy position. She was prepped and draped in the normal sterile fashion. A red rubber tip
catheter was placed gently to drain the patient’s bladder. A weighted speculum was placed in the pos-
terior vagina and Deaver retractor anteriorly. A single-tooth tenaculum was placed in the anterior cervix
for retraction. The uterus sounded to 9 cm. The cervix was dilated with Hanks dilators to 25 French.
This sufficiently passed a #7 suction curet. The suction curet was inserted without incident, and the
products of conception were gently suctioned out. Good uterine cry was noted with a serrated curet. No
further products were noted on suctioning. At this point, a Hulka tenaculum was placed in the cervix for
retraction. The other instruments were removed.
Attention was then turned to the patient’s abdomen. A small vertical intraumbilical incision was made
with the knife. A Veress needle was placed through that incision. Confirmation of placement into the
abdominal cavity was made with instillation of normal saline without return and a positive handing drop
test. The abdomen was then insufflated with sufficient carbon dioxide gas to cause abdominal tympany.
The Veress needle was removed and a 5-mm trocar was placed in the same incision. Confirmation of
CHAPTER 17 |
CHAPTER 17 REVIEW
placement into the abdominal cavity was made with placement of the laparoscopic camera. Another
trocar site was placed two fingerbreadths above the pubic symphysis in the midline under direct visual-
ization. The above-noted intrapelvic and intraabdominal findings were seen. The patient was placed in
steep trendelenburg. The fallopian tubes were identified and followed out to the fimbriated ends. They
were then cauterized four times on either side. At this point, all instruments were removed from the
patient’s abdomen. This was done under direct visualization during the insufflation. The skin incisions
were reapproximated with 4-0 Vicryl suture. The Hulka tenaculum was removed without incident.
The patient was placed back in the dorsal supine position. Anesthesia was withdrawn without difficulty.
The patient was taken to the PACU in stable condition. All sponge, instrument, and needle counts were
correct in the operating room.
ORP/pw D: 9/17/18 09:50:16 T: 9/19/18 12:55:01
GUIDANCE
18.1 Preventive Care CONNECTION
In several chapters throughout this textbook, you got an overview of Z codes, which Read the ICD-10-CM
are codes used to report a reason for a visit to a physician for something other than an Official Guidelines for
illness or injury. As you have learned, there must always be a valid, medical reason Coding and Reporting,
for a patient’s encounter with a health care professional. And there are occasions for section I. Conventions,
patients to seek attention even when they are not currently ill. These codes give you General Coding Guide-
the opportunity to explain. lines and Chapter
Science and research have provided us with a better understanding of disease and Specific Guidelines,
disease progression, as well as etiology (underlying cause of disease). This knowledge subsection C. Chapter-
has resulted in improved preventive care services to stop the onset of illness or injury. Specific Coding
The provision of preventive care services is likely to increase. The enacting of the Guidelines, chapter
Affordable Care Act enables more patients to take advantage of more preventive ser- 21. Factors influenc-
vices than ever before. Since September 2010, new health insurance policies must ing health status and
cover preventive services, with no copayment, no coinsurance payments, and no contact with health
requirement for deductible fulfillment. services, subsection
Reporting the provision of preventive care will require a Z code to explain the spe- c.2) Inoculations and
cific reason for the encounter, such as a flu shot or measles vaccination (Z23 Encoun- vaccinations.
ter for immunization).
The physician or other health care professional may also be able to provide counsel-
ing for the patient and/or family members. This type of counseling is not the same as
that provided by a psychiatrist or psychologist; instead, the physician would take the
time to discuss options for preventing the development of disease or injury. Perhaps
this may include dietary counseling and surveillance (Z71.3) to prevent the onset of
hypertension, heart disease, obesity, or other nutrition-related conditions, or a discus-
sion about the patient’s tobacco use (Z72.0) could focus on various methodologies
available to quit smoking to prevent the patient from developing lung disease. Couples
may come in for genetic counseling (Z31.5) to prevent passing chromosomal abnor-
malities to their future children; for those who do not want to have children yet, gen-
eral counseling and advice on contraception (Z30.09) may be provided.
ICD-10-CM
LET’S CODE IT! SCENARIO
Bonnie Poggio, a 15-year-old female, came into the clinic with her mother. While searching for seashells at the
beach, she went up on the boardwalk barefooted to get ice cream and stepped on a nail, puncturing the sole of her
left foot. After checking the puncture wound, cleaning it, and dressing it, Dr. Baldwin gave Bonnie a tetanus shot as
a precaution.
ICD-10-CM
YOU CODE IT! CASE STUDY
Kathryn Rogers, a 49-year-old female, came in to see Dr. Apter to get a colonoscopy. Dr. Apter explained last week
that this was an important screening for malignant neoplasms of the colon and was recommended for all adults
aged 50 and over. After the screening, Dr. Apter told Kathryn she was fine and there were no abnormalities.
(continued)
CHAPTER 18 |
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which main words or terms describe why the physician cared for the patient dur-
ing this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Check for any relevant guidance, including reading all of the symbols and notations in the Tabular List
and the appropriate sections of the Official Guidelines.
Step #5: Determine the correct diagnosis code or codes to explain why this encounter was medically necessary.
Step #6: Double-check your work.
Answer:
Did you determine this to be the correct code?
Z12.11 Encounter for screening for malignant neoplasm of colon
Screening A screening is a test or examination, such as routine lab work or imaging services,
An examination or test of administered when there are no current signs, symptoms, or related diagnosis. Report
a patient who has no signs a visit for a screening with a Z code such as code Z13.22 Encounter for screening for
or symptoms that is con- metabolic disorder or Z13.820 Encounter for screening for osteoporosis.
ducted with the intention The standards of care have established important examinations and tests to detect
of finding any evidence of
illnesses at the earliest possible time. However, these tests are typically recommended
disease as soon as possible,
thus enabling better patient
for specific population subgroups determined to be at the greatest risk, such as mammo-
outcomes. grams for women over 40 or prostate examinations for men over 50. These encounters
would be reported with a Z code such as code Z12.5 Encounter for screening for malig-
nant neoplasm of prostate or Z13.6 Encounter for screening for cardiovascular disorders.
Society, especially in the United States, is designed for interaction between indi-
viduals. Shopping malls, concert halls and festival venues, public transport sites, class-
rooms, playgrounds, and other locations draw friends, families, and strangers together
in close proximity to one another. Close physical proximity can put someone in contact
with a potential health hazard and facilitate (suspected) exposure to a communicable
disease. Think of this: Two children, Jane and Mary, were playing together, and the
next day Jane is diagnosed with rubella. This means that Mary was exposed. When
Mary’s mom takes her to the doctor, this visit will include code Z20.4 Contact with and
(suspected) exposure to rubella. Another example: Kenny works for County Animal
Control. As he was placing a wild raccoon into his vehicle, the raccoon bit him. Kenny
went to the emergency clinic immediately, and code Z20.3 Contact with and (suspected)
exposure to rabies was included on the claim.
With all these tests being done to confirm the patient’s good health, there are times
Abnormal Findings when the documentation includes abnormal findings, meaning the results indicate
Test results that indicate a something is wrong. This is not the same thing as a confirmed diagnosis, necessar-
disease or condition may be ily. It may be a signal that a condition is potential or that more extensive and specific
present. examinations must be done.
EXAMPLES
Z00.01 Encounter for general adult medical examination with abnormal
findings
Z01.411 Encounter for gynecological examination (general) (routine) with
abnormal findings
ICD-10-CM
YOU CODE IT! CASE STUDY
Dallas Rossi, a 66-year-old male, came in to see his regular physician, Dr. DeGusipe, for his annual physical. Dallas
said he has been feeling great and working out about twice a week. During the digital rectal exam, Dr. DeGuisipe
noted a palpable nodule on the posterior of Dallas’s prostate. Dr. DeGuispe told Dallas that he appears in good
health except for the nodule. They discussed this and scheduled an appointment for a biopsy.
CHAPTER 18 |
mellitus. In these cases, no additional genetic testing may be done. However, the knowledge
GUIDANCE of family members with a particular condition could support more frequent screenings,
CONNECTION such as a patient getting a mammogram every 6 months instead of the standard annual test.
Read the ICD-10-CM
A patient may have reason to believe he or she is the carrier of a disease, such as
Official Guidelines for
diphtheria (Z22.2) or viral hepatitis B (Z55.51). A carrier is an individual who has
Coding and Report-
been infected with a pathogen yet has no signs or symptoms of the disease. Carriers,
ing, section I. Conven-
while not ill themselves, are still able to pass the condition to another person.
tions, General Coding
Guidelines and Chapter
EXAMPLE
Specific Guidelines, sub-
section C. Chapter- Cystic fibrosis, the result of mutations in the CFTR gene, is a common genetic dis-
Specific Coding Guide- ease. Due to its nature, both parents must each carry a copy of the mutated gene
lines, chapter 21. Fac- in order for the child to inherit and develop the disease. However, the parents may
tors influencing health not show any signs or symptoms.
status and contact with Risk is measured by family history and ethnic background. If the patient has a
health services, subsec- family history of CF, then the probability of being a carrier is increased above the
tions c.3), Status and risk based on ethnicity alone. The probability increases if the patient is a close
c.14) Miscellaneous Z relative of an individual with CF, such as a parent, sibling, or child.
codes—Prophylactic To report medical necessity to perform the genetic testing:
Organ Removal. Z84.81 Family history of carrier of genetic disease
Z13.71 Encounter for nonprocreative screening for genetic disease
carrier status
CODING BITES
or
Notice that these codes
are used when the phy- Z31.430 Encounter of female for testing for genetic diseases carrier
sician determines obser- status for procreative management
vation is required “to be
or
sure” and the result is
nothing is wrong [ruled Z31.440 Encounter of male for testing for genetic diseases carrier
out]. If the determina- status for procreative management
tion is that there is a
If the woman is currently pregnant and needs to be screened, use this code:
problem, you would
then report the code Z36.- Encounter for antenatal screening of mother
for the problem, not the
If the test is positive, report
observation.
Z14.1 Cystic fibrosis carrier
GUIDANCE
CONNECTION You may have heard about genetic susceptibility to malignant neoplasm of the breast
(Z15.01) and genetic susceptibility to malignant neoplasm of the ovary (Z15.02), iden-
Read the ICD-10-CM tified by the BRCA1 and BRCA2 tests. These tests may be used to confirm, or deny,
Official Guidelines for the presence of an abnormality in a gene that may have been inherited, which can
Coding and Reporting, serve as a prediction of the potential for developing a disease—in these cases, cancer.
section I. Conven- Some patients have opted for prophylactic (preventive) surgery after a positive finding
tions, General Coding of an abnormal gene. If a patient had this procedure, you would report it with code
Guidelines and Chapter Z40.01 Encounter for prophylactic removal of breast.
Specific Guidelines,
subsection C. Chapter-
Specific Coding Guide- 18.4 Observation
lines, chapter 21. Fac- There might be a reason that a physician suspects a patient may be ill despite the
tors influencing health absence of signs and symptoms. Code categories Z03 and Z04 enable you to report the
status and contact reason these types of encounters are medically necessary.
with health ser-
vices, subsection c.6) Z03 Encounter for medical observation for suspected diseases and
Observation. conditions ruled out
Z04 Encounter for examination and observation for other reasons
ICD-10-CM
YOU CODE IT! CASE STUDY
Tracey Morales, a 33-year-old male, was brought into the ED after an accident on his construction job site. He
tripped and hit his head against a pile of bricks. There was a 3 cm laceration on his temporal lobe scalp, but he did
not lose consciousness. CT scan of his head was inconclusive. After the laceration was stitched up with a simple
repair, Dr. Tribow placed Tracey into observation status so they could watch for signs of a concussion. After 20 hours
with normal vital signs and a normal neurologic exam, he was determined to not have suffered a concussion and
released.
CHAPTER 18 |
effective. When coding an encounter for such monitoring, you may begin with Z51.81
GUIDANCE Encounter for therapeutic drug level monitoring, along with a code to identify the
CONNECTION type of therapeutic drug, such as Z79.01 Long term (current) use of anticoagulants or
Z79.811 Long term (current) use of aromatase inhibitors.
Read the ICD-10-CM
Official Guidelines for
Of course, the physician-patient relationship in treating a specific illness or injury
Coding and Reporting,
does not end at the end of a surgical procedure or other type of therapeutic service.
section I. Conven-
A healing illness or injury may require aftercare, reported with a code such as Z47.1
Aftercare following joint replacement surgery, Z48.00 Encounter for change or removal
tions, General Coding
of nonsurgical wound dressing, or Z45.24 Encounter for aftercare following lung
Guidelines and Chapter
transplant.
Specific Guidelines,
subsection C. Chapter-
Patients with implanted medical devices may need more frequent encounters to
Specific Coding Guide-
check the device to ensure it is working properly, as is the case with a patient with a
lines, chapter 21. Fac-
cardiac pacemaker (Z45.01) or a patient with a cochlear implant (Z45.321).
tors influencing health
Follow-up examinations may be necessary for a condition that has already been
status and contact with
treated or no longer exists. Examples of such follow-ups include an encounter for the
health services, subsec-
removal of sutures (stitches), reported with code Z48.02, or an encounter after the
tion c.7) Aftercare.
patient has completed treatment for a malignant neoplasm (Z08), once the patient has
finished the chemotherapy or radiation treatment plan.
GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section I. Con-
ventions, General Coding Guidelines and Chapter Specific Guidelines, subsec-
tion C. Chapter-Specific Coding Guidelines, chapter 21. Factors influencing
health status and contact with health services, subsection c.8) Follow-up.
ICD-10-CM
LET’S CODE IT! SCENARIO
Adelina Plenner, a 43-year-old female, came in to see Dr. Buldar, her gastroenterologist. She had a colostomy
6 weeks ago, and this is a standard post-procedural follow-up. He noted that there was some irritation and he applied
some ointment and gave Adelina a prescription for more ointment. Dr. Buldar examined the area and told Adelina
to return prn.
Prosthetic Lost tissue is replaced with synthetic material such as metal, plastic, or
ceramic.
CHAPTER 18 |
ICD-10-CM
YOU CODE IT! CASE STUDY
Ilani Marhefka, a 31-year-old female, came in to donate her eggs. Her sister, Serita, had lesions on her ovaries and
had to have them removed many years ago. Dr. Stark is going to harvest eggs from Ilani to implant in Serita so she
and her husband, Jude, can have children. Ilani wanted to help her sister and brother-in-law by donating her eggs.
Of course, prior to the actual procedure to harvest the organ or tissue, an examina-
tion will need to be done, reported with code Z00.5 Encounter for examination for
potential donor of organ or tissue.
ICD-10-CM
YOU CODE IT! CASE STUDY
PATIENT: Paulina Stohl
DATE OF CONSULTATION:011/09/2018
PHYSICIAN REQUESTING THE CONSULT: Ada Carole, MD
REASON FOR CONSULTATION: Resistant infection.
CHIEF COMPLAINT: Fatigue.
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old female with a history of type 2 diabetes mellitus, pan-
creatitis, and chronic hepatitis C who presented with complaints of fever and generalized malaise. She was seen and
evaluated by Dr. Koehler in the ED and subsequently admitted. Vital signs identified a low grade fever [99.8 F] and
blood cultures taken in ED were positive for gram-positive cocci. In addition, urinalysis was positive for MRSA. Patient
was given Zosyn, 3.375g q 6 hr. Infectious disease was requested in for a consultation.
(continued)
CHAPTER 18 |
At bedside, the patient stated a cystoscopy was performed by her urologist for chronic obstructive uropathy. The
following biopsy was negative for malignancy. A few days later, the patient began to experience generalized malaise
and then experienced fever and chills. The urine culture taken in ED was noted to be positive for MRSA and one of
two blood cultures was positive. Since admission 1 day ago, blood cultures were repeated, with positive results in
both tests for gram-positive cocci in clusters.
FAMILY HISTORY: No immune dysfunction other than diabetes.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: A 14-system review is as per history of present illness, otherwise negative.
CURRENT MEDICATIONS: List is reviewed.
PHYSICAL EXAMINATION:
VITAL SIGNS: Upon my initial evaluation, patient has T 100.2 degrees Fahrenheit, pulse 104, respirations 20, and
blood pressure 120/70.
GENERAL: Patient is alert and oriented x3, in no apparent distress at rest.
HEENT: Head is normocephalic and atraumatic. Extraocular muscle movements are intact. No scleral icterus. Oro-
pharynx is clear.
NECK: Free of palpable adenopathy.
HEART: Regular at 100. No auscultated rub.
LUNGS: Clear to auscultation and percussion bilaterally. No rhonchi and no wheezing.
ABDOMEN: Positive bowel sounds, soft, nontender, and nondistended. No rebound, rigidity, or guarding.
EXTREMITIES: Lower extremities are without clubbing or cyanosis.
NEUROMUSCULAR: Neurologically, patient is nonfocal with normal cranial nerves. Muscle strength is normal in the
upper extremities.
LABORATORY STUDIES: A complete blood count, basic metabolic profile, full microbiologic database, all of which
have been reviewed.
IMPRESSION:
1. Methicillin-resistant Staphylococcus aureus urinary tract infection in a patient who has recently undergone a geni-
tourinary procedure for outlet obstruction.
2. Type 2 diabetes mellitus with poor control.
3. Fever.
RECOMMENDATIONS:
1. Place the patient in contact isolation.
2. Repeat blood cultures x2.
4. Start vancomycin.
5. Discontinue Zosyn [the extended-spectrum penicillin that has proved ineffective to patient’s MRSA].
Thank you for this interesting consult and allowing us to participate in this patient’s care.
Allen B. Dechante, MD
You Code It!
Read Dr. Dechante’s notes regarding his evaluation of Paulina Stohl and determine the accurate ICD-10-CM
diagnosis codes for this encounter.
Step #1: Read the case carefully and completely.
CHAPTER 18 |
ICD-10-CM
LET’S CODE IT! SCENARIO
Alfredo “Al” Martinelli, a 43-year-old male, was admitted to the hospital today because he is donating one of his
kidneys to his son, Anthony. The surgery is scheduled for this afternoon.
Chapter Summary
As a professional coder, you are responsible to ensure that every physician-patient
encounter is supported as medically necessary. You probably know from your own
personal experience that there are legitimate reasons for a healthy person to seek the
attention of a physician or other health care professional. In ICD-10-CM, virtually all
of the codes used to explain these valid reasons are found in the Z code chapter. Here,
you will find codes to report the medical necessity for providing preventive care ser-
vices, performing a screening, observing a patient, and checking for the viability of a
potential organ donor.
CODING BITES
Free Preventive Services under Affordable Care Act
All marketplace plans and many other plans must cover the following list of pre-
ventive services without charging you a copayment or coinsurance. This is true
even if you haven’t met your yearly deductible. This applies only when these ser-
vices are delivered by a network provider.
CHAPTER 18 REVIEW
Factors Influencing Health Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
Status (Z Codes)
Let’s Check It! Terminology
Match each key term to the appropriate definition.
1. LO 18.6 The donor and recipient individuals are genetically identical.
2. LO 18.3 An individual infected with a disease who is not ill but can still pass A. Abnormal Findings
it to another person; an individual with an abnormal gene that can be B. Allogeneic
passed to a child, making the child susceptible to disease.
CHAPTER 18 |
3. LO 18.2 Test results that indicate a disease or condition may be present. C. Autologous
CHAPTER 18 REVIEW
CHAPTER 18 REVIEW
Part I
Refer to the Official Guidelines and fill in the blanks according to the Chapter 21, Factors influencing health status and
contact with health services, Chapter-Specific Coding Guidelines.
first-listed secondary any
screening present past
potential Z carrier
procedure specifically higher
depending Family no
sequelae not
1. _____ codes are for use in _____ health care setting.
2. Z codes may be used as either a _____ (principal diagnosis code in the inpatient setting) or secondary code,
_____ on the circumstances of the encounter.
3. Z codes are _____ procedure codes.
4. A corresponding _____ code must accompany a Z code to describe any procedure performed.
5. Contact/exposure codes may be used as a first-listed code to explain an encounter for testing, or, more commonly,
as a _____ code to identify a potential risk.
6. Status codes indicate that a patient is either a _____ of a disease or has the _____ or residual of a past disease or
condition.
7. Personal history codes explain a patient’s _____ medical condition that _____ longer exists and is not receiving
any treatment, but that has the _____ for recurrence, and therefore may require continued monitoring.
8. _____ history codes are for use when a patient has a family member(s) who has had a particular disease that
causes the patient to be at _____ risk of also contracting the disease.
9. A _____ code may be a first-listed code if the reason for the visit is _____ the screening exam.
10. The observation codes are not for use if an injury or illness or any signs or symptoms related to the suspected con-
dition are _____.
Part II
Z40 routine support
surveillance continued living
multiple prophylactic inital
aftermath Z52 risk
1. Aftercare visit codes cover situations when the _____ treatment of a disease has been performed and the patient
requires _____ care during the healing or recovery phase, or for the long-term consequences of the disease.
2. The follow-up codes are used to explain continuing _____ following completed treatment of a disease, condition,
or injury.
3. A follow-up code may be used to explain _____ visits.
4. Codes in category _____, Donors of organs and tissues, are used for _____ individuals who are donating blood or
other body tissue.
5. Counseling Z codes are used when a patient or family member receives assistance in the _____ of an illness or
injury, or when _____ is required in coping with family or social problems.
6. The Z codes allow for the description of encounters for _____ examinations, such as, a general checkup, or, exam-
inations for administrative purposes, such as, a pre-employment physical.
7. For encounters specifically for _____ removal of an organ (such as prophylactic removal of breasts due to a
genetic susceptibility to cancer or a family history of cancer), the principal or first-listed code should be a code
CHAPTER 18 |
from category _____, Encounter for prophylactic surgery, followed by the appropriate codes to identify the associ-
CHAPTER 18 REVIEW
ICD-10-CM
YOU CODE IT! Basics
First, identify the condition in the following diagnoses; 8. Encounter for procreative management:
then code the diagnosis. a. main term: _____ b. diagnosis: _____
Example: Awaiting organ transplant status: 9. Encounter for fitting and adjustment of external
right breast prosthesis:
a. main term: Status b. diagnosis: Z76.82
a. main term: _____ b. diagnosis: _____
1. Encounter for disability limiting activities:
10. Aftercare following explantation of knee joint:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
2. Encounter for screening for human
11. Cornea donor:
papillomavirus:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
12. High-risk bisexual behavior:
3. Personal history of leukemia:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
13. Acquired absence of left upper limb below elbow:
4. Genetic susceptibility to malignant neoplasm:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
14. Encounter for examination of blood pressure with-
5. Contact with and suspected exposure to rubella:
out abnormal findings:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
6. Carrier of diphtheria:
15. Presence of heart assist device:
a. main term: _____ b. diagnosis: _____
a. main term: _____ b. diagnosis: _____
7. Encounter for surveillance of injectable
contraceptive:
a. main term: _____ b. diagnosis: _____
ICD-10-CM
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
1. Donald DuFour, an 8-month-old male, is brought in by his mother and Kent Fuller to determine if Kent is
the biological father. Don’s mother is applying for child support and social welfare benefits and needs proof
ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documentation
from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on real patient encoun-
ters. Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
CHAPTER 18 |
CHAPTER 18 REVIEW
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: GALLOP, MICHAEL
ACCOUNT/EHR #: GALLMI001
DATE: 10/16/18
Attending Physician: Renee O. Bracker, MD
S: Neonate was born 8 hours ago via spontaneous vaginal delivery, full-term, this hospital.
O: Newborn screening exam performed in the well-baby nursery included pulse oximetry showing
normal percentage of hemoglobin in his blood that is saturated with oxygen. However, the test for
hypothyroidism was positive. Prior to discharge, I met with the parents and explained this condition and
discussed thyroxine, the medication required so the baby can avoid problems such as slowed growth
and brain damage.
A: Congenital hypothyroidism without goiter
P: Rx: Thyroxine
Follow-up in office in 2 days
CHAPTER 18 |
CHAPTER 18 REVIEW
learning experience.
ICD-10-CM
LET’S CODE IT! SCENARIO
The attending physician, Raymond Morrison, MD, included this in the discharge summary:
Admission Diagnosis: Abdominal pain, status post appendectomy
Final Diagnosis: Abdominal pain, unknown etiology, status post appendectomy
Brief History: Patient underwent an appendectomy for perforated appendicitis 6 weeks ago. . . . Three days prior to
admission, she had a recurrent bout of diffuse, dull abdominal pain in the right upper quadrant with associated
nausea and anorexia. She was admitted to the hospital at the time for workup of this pain.
At this time, the patient has just had a regular meal without difficulty and feels like returning home. She will be dis-
charged home at this time and can follow up with her primary MD. We will see her on an as-needed basis.
Appendectomy is not listed. What can you look up? Think about the patient status post: What exactly is an
appendectomy? Surgery. No, surgery is not listed in this index either. Hmmmm. Try looking at postsurgical.
Aha!
Status (post) – see also Presence (of)
postsurgical (postprocedural) NEC Z98.890
(Postoperative NEC is also shown, leading to the same code.)
Let’s turn to the Z code section and check this code out:
Z98 Other postprocedural states
The notes don’t relate to this discharge summary, so continue reading down the column to find the
correct fourth character. No other fourth character is accurate to report postappendectomy, so let’s take a look
at what the Alphabetic Index suggested:
Z98.8 Other specified postprocedural status
Z98.89 Other specified postprocedural states
Z98.890 Other specified postprocedural states
When you review the other procedures included in this classification, none seem to relate to an appendectomy.
This code description is the most accurate of those available. Therefore, these are the diagnosis codes you will
report for this case:
R10.11 Right upper quadrant pain
Z98.890 Other specified postprocedural states
Good job!
CHAPTER 19 |
CODING BITES
What about the part of the diagnosis where Dr. Morrison wrote “Abdominal pain,
unknown etiology”? How is that reported? Notice that the code R10.11 for the
abdominal pain is located in Symptoms, signs, and abnormal clinical and labora-
tory conditions, not elsewhere classified (ICD-10-CM’s chapter 18). This is the
part that reports the physician could not determine the cause (etiology) of the
pain. Had the cause of the pain been identified, you would be reporting that with a
different code.
Uncertain Diagnosis
Remember, you learned for outpatient coding (as shown in Section IV, Subsection H.
Uncertain diagnosis) that you are not permitted to ever code something identified by
the physician in his or her documentation as “rule out,” “probable,” “possible,” “sus-
pected,” or other similar terms of an unconfirmed nature.
For inpatient coding, this guidance (as shown in Section II, Subsection H. Uncer-
tain diagnosis) is different.
GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section
II. Selection of Principal Diagnosis, subsection H. Uncertain diagnosis.
The guidance for inpatient coders is that you are permitted to “code the condi-
tion as if it existed or was established.” This is done so that medical necessity can be
reported for tests, observation, or other services and resources used to care for the
patient whether or not these efforts resulted in a confirmed diagnosis.
GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section
III. Reporting Additional Diagnoses, subsection B. Abnormal findings.
When you are coding for inpatient services, abnormal test results are not reported
unless the physician has documented the clinical significance of those results. Interest-
ingly, in this section of the guidelines, it is reiterated that if the coding professional
ICD-10-CM
YOU CODE IT! CASE STUDY
The attending physician, Thomas Talbott, MD, included this in the discharge summary:
Admission Diagnosis: Acute cervical pain, admitted through ED after MVA
Final Diagnosis: Acute cervical pain and radiculitis secondary to degenerative disc disease with posttraumatic acti-
vation of pain
Brief History: Patient is a 41-year-old male who was involved in a motor vehicle accident, admitted after being
brought to the ED by the ambulance that responded to the accident scene. Patient showed signs of neck and arm
pain associated with cervical radiculopathy, radiating into the shoulders along with constant headaches. He has
numbness and tingling into the hands and fingers.
Radiology: X-rays AP and lateral cervical spinal x-rays demonstrate evidence of significant degenerative disc dis-
ease at C5–6 and C6–7 levels. MRI of cervical spine demonstrates evidence of significant degenerative disc
disease at the C5–6 and C6–7 levels with osteophyte formation and canal compromise with the spinal canal
diameter reduced to approximately 9 mm. Lumbar spine MRI demonstrates mild degenerative disc disease; oth-
erwise normal.
Recommendation to patient is to undergo an anterior cervical diskectomy and fusion utilizing an autologous iliac
bone grafting and placement of anterior titanium plate. After reviewing with patient regarding risks and benefits of
surgery, the patient refused and requested to be discharged immediately.
GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, Appendix
I. Present on Admission Reporting Guidelines.
CHAPTER 19 |
CODING BITES FIGURE 19-2 An example of an admitting history and physical (H&P) (Page 1 of 2)
A POA indicator is
required to be assigned
to the principal diagno- General Reporting Guidelines
sis codes as well as all According to CMS Publication 100-04, “Present on admission is defined as present
secondary diagnoses, at the time the order for inpatient admission occurs—conditions that develop during
including external cause an outpatient encounter, including emergency department, observation, or outpatient
of injury codes. surgery, are considered as present on admission.”
What does this mean? This means professional coders must carefully review the
admitting physician’s history and physical (H&P)—the documentation that supports
Hospital-Acquired Condition
(HAC)
the order to admit the patient into the hospital (see Figure 19-2 for an example)—
A condition, illness, or injury to determine whether or not the condition was identified at that time. Then you will
contracted by the patient dur- assign the POA indicator to report this fact: Yes—this diagnosis was present when the
ing his or her stay in an acute patient was admitted; No—it was not present; and so on.
care facility; also known as One reason for the importance of gathering POA data is to identify hospital-
nosocomial condition. acquired conditions (HACs). A hospital-acquired condition is exactly what it sounds
like: an illness or injury that the patient contracted solely due to the fact that he or she
was in the hospital at the time. HAC data are used for many different purposes, includ-
ing evaluating patient safety directives and limiting payment to a facility for errors it
may have made that caused the problem.
GUIDANCE CONNECTION
Go to:
www.cms.gov
> Medicare
. . . scroll down to . . .
> Hospital-Acquired Conditions (Present on Admission Indicator)
(continued)
CHAPTER 19 |
On the next screen, on the left side, click on the link: Hospital-Acquired Con-
ditions and then click on ICD-10 HAC LIST for a current list of the conditions
included in this program.
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/icd10_hacs.html
The ICD-10 HAC LIST actually shows you the diagnosis and then the procedures,
with ICD-10-PCS codes included. Very interesting!
POA Indicators
The POA indicators are used to clearly identify whether or not the signs, symptoms,
and diagnoses reported on the claim form were documented by the admitting physi-
cian at the time the patient was admitted into the hospital.
CODING BITES
POA indicators are not required for external cause codes unless the code is being
reported as an “other diagnosis.”
CODING BITES
If any part of the diagnosis code description was NOT present at the time of
admission, report this with an N.
CODING BITES
It is the responsibility of the physician or health care provider admitting the patient
into the hospital to clearly document which conditions are POA. However, it is the
professional coder’s responsibility to query the physician if the documentation is
incomplete with regard to this issue.
GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, Appendix I,
Present on Admission Reporting Guidelines, subsection Condition is on the
“Exempt from Reporting” list.
∙ 1 Exempt
You can find a list of the conditions, and their diagnosis codes, that are exempt
from POA reporting in the Official Coding Guidelines in your ICD-10-CM book or on
the CMS website. (Note: Some third-party payers prefer this box remain blank instead
of using the numeral 1.)
CHAPTER 19 |
CODING BITES
The CDC website has the detailed list of ICD-10-CM codes that are exempt from
(do not require) the use of a POA indicator:
ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2017/
The conditions on this exempt list represent categories and/or codes for cir-
cumstances regarding the health care encounter or factors influencing health
status that do not represent a current disease or injury or are always present on
admission.
ICD-10-CM
LET’S CODE IT! SCENARIO
Kimberly Byner was admitted into the hospital because she was suffering acute exacerbation of her obstructive
chronic bronchitis. After 2 days of treatment, while still in the hospital, she tried to get out of bed without help, fell,
and broke her left wrist.
EXAMPLE
There are several other versions of DRG systems that focus on different details:
APR-DRG = All-Patient Refined Diagnosis-Related Group
APS-DRG = All-Patient Severity-Adjusted DRG
MS-LTC-DRG = Medicare-Severity—Long-Term Care DRG
R-DRG = Refined DRG
AP-DRG = All Patient DRG
S-DRG = Severity DRG
IR-DRG = International-Refined DRG
CHAPTER 19 |
You have learned that a patient may have, or end up with, several different condi-
tions treated during a stay in the hospital. The individual may also have preexisting
conditions that have nothing to do with the reason for admission but still need atten-
tion by hospital personnel.
EXAMPLE
Henry was admitted into the hospital with appendicitis. During his stay, the physi-
cian had to order and the nurses had to continue to give Henry his Lipitor, pre-
scribed for his preexisting hypercholesterolemia (high cholesterol). Even though
this condition has nothing to do with the appendicitis or the appendectomy
Co-morbidity (surgery to remove the infected appendix), this co-morbidity must be coded
A separate condition or illness and reported to support the medical necessity for the hospital supplying the
present in the same patient medication.
at the same time as another,
unrelated condition or illness.
Major Complications and Co-morbidities
Conditions, illnesses, and injuries come in all shapes and sizes, as well as severities,
Major Complication and and so do complications and co-morbidities. Typically, a major complication and co-
Co-morbidity (MCC) morbidity (MCC) is a condition that is systemic, making treatment for the principal
A complication or co-morbidity diagnosis more complex and/or making the health concern life-threatening.
that has an impact on the
treatment of the patient and
makes care for that patient
more complex.
EXAMPLES
MS-DRG 799 Splenectomy with MCC Weight: 4.7488
MS-DRG 800 Splenectomy with CC Weight: 2.7250
MS-DRG 801 Splenectomy without CC or MCC Weight: 1.7473
You can see how the presence, or absence, of MCC and/or CC alters the weight
applied to the reimbursement for this procedure.
GUIDANCE CONNECTION
Read the ICD-10-CM Official Guidelines for Coding and Reporting, section
III. Reporting Additional Diagnoses.
CHAPTER 19 REVIEW
∙ Total charges billed by the hospital for this admission (this will not include physi-
cian and other professional services billed).
Clinical data collected evaluate
∙ Type of admission, described as scheduled (planned in advance with preregistration
at least 24 hours prior) or unscheduled.
∙ Diagnoses, including principal and additional diagnoses.
∙ Procedures, services, and treatments provided during this admission period.
∙ External causes of injury, determined by the reporting of external cause codes.
Definitions of these, and other, categories as determined by the UHDDS are used
by ICD-10-CM in the Official Coding Guidelines. Over the years that the UHDDS
has been in place, these definitions have been used to assist the reporting of patient
data not only in acute care facilities (hospitals) but also for inpatient short-term care,
long-term care, and psychiatric hospitals. Outpatient providers including home health
agencies, nursing homes, and rehabilitation facilities also use these definitions for
their data.
Chapter Summary
The coding process remains the same for inpatient and outpatient services for which
coders are determining and reporting accurate diagnosis codes. The same code set,
ICD-10-CM, is used; the same guidelines are used (with the exception of the two spe-
cific guidelines). Therefore, with the additional knowledge provided in this chapter, a
professional coder can be successful in any type of facility.
CODING BITES
POA Reporting Options
Y = Yes
N = No
U = Unknown
W = Clinically undetermined
Unreported/Not used = Exempt from POA reporting
CHAPTER 19 REVIEW
Inpatient (Hospital) Diagnosis Coding Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
CHAPTER 19 |
1. LO 19.4 A complication or co-morbidity that has an impact on the treatment of A. Co-morbidity
CHAPTER 19 REVIEW
the patient and makes care for that patient more complex. B. Complication
2. LO 19.4 A separate condition or illness present in the same patient at the same C. Concurrent Coding
time as another, unrelated condition or illness.
D. Diagnosis-Related
3. LO 19.5 A compilation of data collected by acute care facilities and other desig- Group (DRG)
nated health care facilities.
E. Hospital-Acquired Con-
4. LO 19.1 System in which coding processes are performed while a patient is still dition (HAC)
in the hospital receiving care.
F. Major Complication
5. LO 19.3 A condition, illness, or injury contracted by the patient during his or and Co-morbidity
her stay in an acute care facility; also known as a nosocomial condition. (MCC)
6. LO 19.4 An unexpected illness or other condition that develops as a result of a G. Present-On-Admission
procedure, service, or treatment provided during the patient’s hospital (POA)
stay.
H. Uniform Hospital
7. LO 19.4 An episodic-care payment system basing reimbursement to hospitals Discharge Data Set
for inpatient services upon standards of care for specific diagnoses (UHDDS)
grouped by their similar usage of resources for procedures, services,
and treatments.
8. LO 19.3 A one-character indicator reporting the status of the diagnosis at the
time the patient was admitted to the acute care facility.
CHAPTER 19 REVIEW
during his stay, he developed pneumonia. The POA indicator for the pneumonia is
a. Y.
b. 1.
c. W.
d. N.
6. LO 19.4 An example of a complication is a
a. known allergy to penicillin.
b. family history of breast cancer.
c. high-risk pregnancy.
d. postoperative wound infection.
7. LO 19.2 Inpatient coders are not permitted to ever code something identified in the physician’s notes as “sus-
pected” or “probable.”
a. True
b. False
8. LO 19.5 The UHDDS collects all of these data elements except
a. gender.
b. credit card number.
c. geographic location.
d. age.
9. LO 19.1 Once a patient is discharged, the coder will go through the complete patient record. The most important
documentation to look for includes all of the following except
a. the discharge summary.
b. the hospital course.
c. the discharge disposition.
d. all of these documentations are important.
10. LO 19.4 DRGs are used for reimbursement from Medicare to
a. physician offices.
b. acute care facilities.
c. ambulatory surgical centers.
d. walk-in clinics.
CHAPTER 19 |
1. The circumstances of _____ admission always govern the selection of principal diagnosis.
CHAPTER 19 REVIEW
2. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition
_____ after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
3. The importance of consistent, _____ documentation in the medical record cannot be _____.
4. Codes for symptoms, signs, and ill-defined conditions from Chapter 18 are _____ to be used as _____ diagnosis
when a related definitive diagnosis has been established.
5. In the _____instance when two or more diagnoses _____ meet the criteria for principal diagnosis as determined
by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabu-
lar List, or another coding guidelines does not provide sequencing direction, any _____ of the diagnoses may be
sequenced first.
6. If the diagnosis documented at the time of _____ is qualified as “probable,” “suspected,” “likely,” “questionable,”
“possible,” or “still to be ruled out,” or other similar terms indicating uncertainty, code the condition as if it _____
or was established.
7. When a patient is _____ to an observation unit for a medical condition, which either _____ or does not improve,
and is subsequently admitted as an inpatient of the same hospital for this same medical condition, the principal
diagnosis would be the medical condition which _____ to the hospital admission.
8. If the provider has included a diagnosis in the final _____ statement, such as the discharge summary or the face
sheet, it should ordinarily be coded.
9. _____ findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the
provider indicates their clinical significance.
10. If the findings are _____ the normal range and the attending provider has ordered other tests to evaluate the con-
dition or prescribed treatment, it is appropriate to _____ the provider whether the abnormal finding should be
added.
Part II
Go to www.cms.gov and click on the Medicare tab in the upper yellow navigation bar. In the right column, look for
Medicare Fee-for-Service Payment. Under this subtitle you will see Acute Inpatient PPS. Now click on it and fill in the
blanks accordingly.
(IPPS) add-on approved prospectively
census diagnosis-related group unusually outlier
multiplied added divided low-income
inpatient qualify wage ratio
disproportionate prospective cost of living average
1. Section 1886(d) of the Social Security Act (the Act) sets forth a system of payment for the operating costs of
acute care hospital _____ stays under Medicare Part A (Hospital Insurance) based on _____ set rates.
2. This payment system is referred to as the inpatient _____ payment system _____.
3. Under the IPPS, each case is categorized into a _____ (DRG). Each DRG has a payment weight assigned to it,
based on the _____ resources used to treat Medicare patients in that DRG.
4. The base payment rate is _____ into a labor-related and nonlabor share.
5. The labor-related share is adjusted by the _____ index applicable to the area where the hospital is located, and if
the hospital is located in Alaska or Hawaii, the nonlabor share is adjusted by a _____ adjustment factor.
6. This base payment rate is _____ by the DRG relative weight.
CHAPTER 19 REVIEW
DRG-adjusted base payment rate.
8. This add-on, known as the _____ share hospital (DSH) adjustment, provides for a percentage _____ in Medicare
payment for hospitals that _____ under either of two statutory formulas designed to identify hospitals that serve a
disproportionate share of low-income patients.
9. Also if the hospital is an _____ teaching hospital it receives a percentage add-on payment for each case paid
through IPPS.
10. This add-on known as the indirect medical education (IME) adjustment, varies depending on the _____ of
residents-to-beds under the IPPS for operating costs, and according to the ratio of residents-to-average daily
_____ under the IPPS for capital costs.
11. Finally, for particular cases that are _____ costly, known as _____ cases, the IPPS payment is increased.
12. Any outlier payment due is _____ to the DRG-adjusted base payment rate, plus any DSH or IME adjustments.
ICD-10-CM
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documenta-
tion from our health care facility, Westward Hospital. These case studies are modeled on real patient encounters.
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-CM code(s) and external cause code(s), if appropriate, for each case study.
WESTWARD HOSPITAL
Masters, FL 33955
DISCHARGE SUMMARY
CHAPTER 19 |
CHAPTER 19 REVIEW
DISCHARGE DIAGNOSIS: Malignant neoplasm of areola, right breast, estrogen receptor status negative;
postsurgical respiratory congestion
This 52-year-old African American male was admitted to the hospital with a palpable 2.25-cm
nodule in the right breast in the superficial aspect of the right breast in the 4 o’clock axis near the
periphery.
Excision of the right breast mass with an intermediate wound closure of 3 cm was accomplished. Patient
tolerated the procedure well; however, some respiratory complications were realized as a result of the
general anesthesia so the patient was kept in the facility for an extra day.
Patient is discharged home with his wife. Discharge orders instruct him to make a follow-up appoint-
ment with Dr. Facci, the oncologist, to discuss treatment.
Benjamin Johnston, MD
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
DISCHARGE SUMMARY
PATIENT: FRIZZELLI, ALLISON
DATE OF ADMISSION: 07/15/18
DATE OF DISCHARGE: 08/01/18
ADMITTING DIAGNOSIS: Schizoaffective disorder
DISCHARGE DIAGNOSIS: Schizoaffective disorder; hypothyroidism; hypercholesterolemia; borderline
hypertension
The patient is a 34-year-old white female with a long history of schizoaffective disorder with numer-
ous hospitalizations, brought in by ambulance for increasing paranoia; increasing arguments with other
people; and, in general, an exacerbation of her psychotic symptoms, which had been worsening over
the previous 2 weeks.
She is now discharged to return to her home at the YMCA and also to return to her weekly psychiatric
appointments with Dr. Mulford. The patient also is advised to follow up with her medical doctor for her
hypertension.
The patient was advised during this admission to start on hydrochlorothiazide 12.5 mg daily, but she
refused.
Roxan Kernan, MD
556848/mt98328: 08/01/18 09:50:16 T: 08/01/18 12:55:01
WESTWARD HOSPITAL
Masters, FL 33955
DISCHARGE SUMMARY
DISCHARGE DIAGNOSIS: Alcohol dependence; cocaine dependence; major depressive disorder, recur-
rent; HIV positive; hepatitis C; and history of asthma
This 39-year-old single male was referred for this admission, his second lifetime rehabilitation. The
patient has a history of alcohol and cocaine dependence since age 17.
During the course of admission, the patient was placed on hydrochlorothiazide 25 milligrams for hyper-
tension, to which he responded well. He participated in this rehabilitation program and worked rigor-
ously throughout.
On discharge, the patient is alert and oriented ×3. Mood is euthymic. Affect is full range. The patient
denies SI, HI, denies AH, VH. Thought process is organized. Thought content—no delusions elicited.
There is no evidence of psychosis. There is no imminent risk of suicide or homicide.
Benjamin Johnston, MD
WESTWARD HOSPITAL
Masters, FL 33955
DISCHARGE SUMMARY
CHAPTER 19 |
CHAPTER 19 REVIEW
DISCHARGE DIAGNOSIS: High-grade transitional cell carcinoma of the left bladder wall; low-grade tran-
sitional cell carcinoma in situ, bladder; underlying mild chronic inflammation,
bladder
This 59-year-old male was admitted with a suspicious mass identified in the lateral bladder wall. Biopsy
was performed, and upon pathology report of malignancy, a transurethral resection of the bladder
tumors was performed. Patient was kept overnight. Foley catheter removed second day, and dis-
charged with orders to make appointment to be seen in the office in about 2 weeks to start weekly BCG
bladder installation treatments for recurrent bladder tumors.
Kenzi Bloomington, MD
WESTWARD HOSPITAL
Masters, FL 33955
DISCHARGE SUMMARY
This 51-year-old male had a transurethral resection of prostate 10 years ago, complicated by a post-
operative bleed as well as evaluation with an attempted ureteroscopy. This hematuria is secondary to
prostatic varices.
Flexible cystoscopy demonstrated a normal urethra and obstructed bladder outlet secondary to a very
large nodular regrowth of the prostate at the medium lobe.
Phillip Carlsson, MD
Masters, FL 33955
ADMITTING DIAGNOSES:
1. Dyspnea
2. Congestive heart failure (CHR) exacerbation
3. Hypertension
4. Heart murmur
5. Inferior vena cava filter placed July 2010 secondary to lower extremity deep venous thrombosis
(DVT)
6. Hypothyroidism with TSH 9.1
7. Peripheral vascular disease—peripheral arterial disease
DISCHARGE DIAGNOSES:
1. Dyspnea, resolved
2. Diastolic CHR, ejection fraction 70%
3. Hypertension, controlled
4. Aortic stenosis with insufficiency
5. Catheter placed secondary to deep venous thrombosis, on Coumadin, INR in 2 on discharge
6. Hypothyroidism
7. Peripheral vascular disease
8. Renal ultrasound with medical disease
HISTORY: A 76-year-old male was admitted with dyspnea. He was found with diastolic CHF exacerba-
tion. The patient was seen by Dr. Shah, vascular surgeon, who believed that he had some mild arterial
insufficiency and continued anticoagulation. He wants to see him in his office as an outpatient. During
admission, on and off he was having numbness in bilateral feet and hands and cyanosis that resolved
by themselves with no problems. Probably Raynaud phenomenon. During the admission he also was
seen by cardiologist, who diuresed the patient with no complications. He believes that the patient
needs to be started on 1 mg po Bumex. Weigh every day. If the weight gain is more than 3 pounds,
Bumex is to be increased by 1 mg po. The patient also was seen by Dr. Almeada, who believed that the
patient can go home and continue follow-up as an outpatient. Pulmonology saw the patient as well and
believed the same thing. The patient has been stable. Vital signs stable, afebrile, 98% O2 stat on room
air. He was complaining of some biting itching. The daughter had taken him to the dermatologist and
wants to continue follow-up with the dermatologist as an outpatient.
CHAPTER 19 |
CHAPTER 19 REVIEW
RECOMMENDATIONS: Discharge patient home. Follow up with Dr. Yablakoff in the nursing home.
DISCHARGE MEDICATIONS
1. The patient is going with alendronate 70 mg every week, bumetanide 1 mg twice a day if the weight
gain is more than 3 pounds
Keith Kappinski, MD
WESTWARD HOSPITAL
Masters, FL 33955
ADMITTING DIAGNOSIS: Ischemia, transient ischemic attack, rule out myocardial infarction, arrythmia
CONSULTATIONS: Dr. Jenson for neurology and Dr. Balmer for cardiology
COMPLICATIONS: None
INFECTIOUS: None
HISTORY: Eighty-one-year-old white male with significant history of coronary artery disease, status post
coronary artery bypass graft 3 years ago and cardioversion in February 2016, who presented with dif-
ficulty speaking. He stated that he had difficulty obtaining the right words when he spoke. This lasted
about 15 minutes; however, when the patient came to the emergency room he was completely okay.
He did not have any deficits. The patient was admitted and consultants were called in to provide evalu-
ation of possible TIA with rule out cardiac source. Carotid Doppler was done. Echocardiogram was
done. This showed dilated left ventricle, severe global left ventricular dysfunction, estimated ejection
fraction 20% and left atrial enlargement, mitral annular calcification with severe mitral regurgitation,
aortic sclerosis with moderate aortic insufficiency, and severe tricuspid regurgitation with estimated pul-
monary study pressure of 70 mm. Thallium stress test was uneventful. Persantine infusion protocol and
no clinical EKG changes of ischemia and radionuclide showed fixed defect anteroseptal, anteroapical,
and adjacent inferior wall with hypokinesis; no ischemia seen. The ejection fraction was calculated 40%.
CT of the brain showed white matter ischemic changes and atrophy, no acute intracranial abnormalities.
MRI showed extensive periventricular white matter ischemia changes. MRA was normal. EKG was within
normal limits, showing sinus bradycardia with average of 50 to 56.
The patient went to TEE to rule out cardiac source. The TEE was not conclusive and there was no hypo-
kinesis, as described in the previous echocardiogram, and it was considered the patient needs to have
lifetime Coumadin because of previous events.
The hospital course was uneventful. He never presented with any other new deficit or any new
symptoms.
Today, the patient is asymptomatic; vital signs are stable. Monitor shows sinus rhythm, and he is dis-
charged in stable condition to be followed by Dr. Curran in 1 week, by Dr. Jenson in 2 weeks, and by
Dr. Balmer in 2 weeks. He will have home health nurse to inject him Lovenox until PT and INR reach
therapeutic levels of 2/3. He will be on Coumadin 5 mg po qd, and home health nurse will draw PT and
INR daily until Dr. Roman thoroughly assesses the patient. He will receive the last dose of Bactrim today
for urine; however, urine culture has been negative.
Rudolph Langer, MD
WESTWARD HOSPITAL
Masters, FL 33955
CHAPTER 19 |
CHAPTER 19 REVIEW
BRIEF HISTORY: The patient is a 21-year-old female who, 6 weeks ago, underwent an appendec-
tomy for perforated appendicitis. About 3 weeks following that, she had episodes of nausea and
vomiting and diffuse abdominal pain. This was worked up at Kinsey Urgent Care Center, including
CT scan, Meckel scan, and laboratory, which were unremarkable. It resolved spontaneously over
a 3-day period. Three days prior to admission, she had a recurrent bout of diffuse, dull, abdominal
pain with associated nausea and anorexia. She was admitted to our hospital at the time for workup
of this pain.
CLINICAL COURSE: On examination, the patient was found to have a diffuse, mild tenderness with-
out any rebound or peritoneal signs. Plain radiographs of the abdomen were obtained, which were
within normal limits. A CT scan of the abdomen and pelvis was also obtained, which was unremark-
able. She was without leukocytosis. Dr. Pointer of GI saw the patient in consultation, and an upper
GI with small bowel follow-through was obtained. This was performed today and was found to be
normal.
At this time, the patient has just had a regular meal without difficulty and feels like returning home. She
will be discharged home at this time and can follow up with her primary MD. We will see her on an as-
needed basis.
Robyn Charne, MD
WESTWARD HOSPITAL
Masters, FL 33955
FINAL DIAGNOSES:
3. HIV
5. Hepatitis C, chronic
DISCHARGE MEDICATIONS:
2. Seroquel 50 mg po qhs
7. Hydrochlorothiazide 25 mg po qam
DISPOSITION: The patient will return to his residence at the Daylight Hotel. He will attend the hospital
continuing day treatment program.
PROGNOSIS: Guarded
HISTORY: He is noted to have significant immunosuppression related to his HIV. Currently there is no
stigmata of opportunistic infection.
During the course of admission, the patient was placed on hydrochlorothiazide 25 mg for hypertension,
which he responded well to.
CONDITION ON DISCHARGE: The patient is a 43-year-old single black male referred for his first BRU
admission, his second lifetime rehabilitation. The patient has a history of alcohol and methamphetamine
dependence since age 21. Prior to this admission, he had attained no significant period of sobriety
other than time spent incarcerated.
The patient participated in a 21-day MICA rehabilitation program. He worked rigorously throughout the entire
program. He had perfect attendance and participated well as a peer support provider. The patient attended
eight groups daily. He worked well in individual therapy with his nurse practitioner and social worker.
On discharge, the patient is alert and oriented ×3. Mood is euthymic. Affect is full range. The patient
denies SI, HI, denies AH, VH. Thought process is organized. Thought content—no delusions elicited.
There is no evidence of psychosis. There is no imminent risk of suicide or homicide.
Kelsey Berge, MD
CHAPTER 19 |
CHAPTER 19 REVIEW
WESTWARD HOSPITAL
Masters, FL 33955
This is a 36–37-week-old female neonate delivered to a 25-year-old, gravida 2, para 1, who was a
known breech presentation. Mother presented with complaint of vaginal bleeding, rupture of mem-
branes, and abdominal pain and cramping. On exam found to be complete with large fecal impaction.
Fetal heart rate 120 by monitor. To c-section room for disimpaction and cesarean section for breech.
Delivered precipitously immediately after impaction was removed, breech presentation. OB moved
baby to warmer. She was pale with no respiratory effort or heart rate. Ambu bagged with mask for
30 seconds. Intubation attempted. Code called. UAC was placed. ENT in place and bagged. No heart
rate, no breath sounds, pale, cyanotic. Reintubated with chest rise, heart rate about 60. Chest compres-
sion stopped when heart rate above 120, color improved. Apgar 0 at 1 minute, 1 at 5 minutes, and 4 at
10 minutes. No spontaneous respiratory effort. Received sodium bicarbonate, epinephrine, and calcium.
No grimace, no spontaneous movements. Pupils midpoint, nonreactive to light. NG placed for distended
abdomen. Cord pH 7.33. Mother noted to have 50% abruptio placenta. Transferred to Neo. UAC was
removed and replaced. UVC also placed.
Physical exam: weight 2,620 grams, pink, fontanelle soft, significant clonus of extremities, tone
decreased. Pupils 2 cm and round, nonreactive to light. No movement, no grimace, no suck, good chest
rise. Equal breath sounds, no murmur. Pulses 2+. Perfusion good. Abdomen soft and full. No masses.
Normal female genitalia externally. Anus patent. Extremities no edema. Skin—Mongolian spot sacrum
and both arms, single café-au-lait spot left flank 1.5 cm × 0.5 cm. Palate intact.
IMPRESSION:
PHYSICAL EXAM: 23 days of age, weight 2,520 grams, head circumference 35, pink. Anterior fonta-
nelle soft. Heart—II/VI murmur radiating to the axilla. Chest clear. Abdomen soft, positive bowel sounds,
gastrostomy tube intact, wound is okay. Neuro—irritable. The infant has an anal fissure at 12 o’clock that
has caused some blood streaks in the stool.
FINAL DIAGNOSES:
3. Respiratory arrest
6. Seizures
Nancy Odom, MD
CHAPTER 19 |
20 Diagnostic Coding
Capstone
Learning Outcomes
After completing this chapter, the student should be able to:
LO 20.1 Apply the techniques learned, carefully read through the
case studies, and determine the accurate ICD-10-CM code(s)
and the external cause code(s), as required.
As you worked your way through the last 19 chapters, you have learned how to abstract
documentation and interpret the reasons WHY a physician needed to care for a patient—
known as the diagnosis—into ICD-10-CM codes. You also learned to distinguish signs
and symptoms, and other conditions, and when to code those—or not. Now, this chap-
ter provides you with case studies so you can get some hands-on practice.
For each of the following case studies, read through the documentation and:
∙ Determine what code or codes report these reasons, to their most specific level.
∙ Determine how many ICD-10-CM codes you will need to tell the whole story as to
WHY the patient required care.
∙ Identify external cause codes in cases of injury or poisoning.
∙ If more than one code is required, determine the sequence in which to report the codes.
Remember, the notations, symbols, and Official Guidelines are there to help you get
it correct.
Harris Teal, a 19-year-old male, reports to the hospital-based urgent care clinic for
headache and wheezing. Following examination, he is discharged with an acute frontal
sinus infection, recurrent, and exacerbated asthma due to environmental dust allergies.
Roger Gill, a 39-year-old retired professional athlete, comes in with complaints of inter-
mittent joint pain, particularly in his left shoulder. He was a pitcher on a AA league base-
ball team. He also states he feels tenderness at the outer aspect of the left shoulder,
568
most often when he raises his arm. He states that simply putting on his shirt is very
painful. Dr. Jeaneau asks Roger if he suffered any shoulder injuries while playing base-
ball. Roger admitted that his left proximal humerus was fractured when hit by a thrown
ball during a game. Roger quickly added that it healed OK. Dr. Jeaneau confirms a
diagnosis of abscess of the bursa of his shoulder.
Angel Dunbar, a 27-year-old male, presents to see his physician, Dr. Davison, with the
complaints of difficulty breathing, muscle weakness, and fatigue. Following a com-
plete examination, Dr. Davison notes ataxia and sudden muscle spasms in Angel’s
legs. The lab results are positive for lactic acidosis. CSF results show elevated protein
and the muscle biopsy is positive for ragged red fiber. Angel is diagnosed with MERRF
syndrome.
Renay Griffith, a 25-year-old female, recently returned from working for the Red Cross
overseas. She presents to the clinic for an evaluation of a rash. Dr. Leisom evaluates
the patient and diagnoses her with cutaneous leishmaniasis related to her recent
deployment to Iraq.
CHAPTER 20 |
In March of 2018, the patient was seen in the office. She is still very emotionally
unstable. She is crying, depressed (not suicidal), and stressed about her new home.
She wants to move to a different Senior Housing unit because it would be on the bus
route, making it easier to get around. She has also hired a middle-aged woman as a
caregiver.
In November 2018, 9 months after moving to the new facility, she becomes acutely
ill with psychotic symptoms and severe paranoia. She hallucinates that men and women
are in her bed and calls others all hours of the day. I admitted her into a hospitalized
psychiatric unit and she shows improvement over about 14 days without antipsychotic
medication.
Today, 1 week following discharge from the hospital, symptoms rapidly recurred
when she returned to the senior apartment. She was disruptive and threatened with
eviction unless something was done rapidly. An emergency petition was prepared
because she refused medical care. With the help of her companion, we were finally
able to persuade her to take a neuroleptic drug (Haloperidol 0.025 – 1.0 mg/day)
for her recurrent incapacitating hallucinations. Initial injection was administered IM
5 mg. Our office nurse and staff called her later in the day to guide her through
the process of taking her medicines. She slowly but steadily improved and became
stabilized.
Diagnosis: Chronic Post Traumatic Stress Disorder
Rx: Haloperidol 0.025 – 1.0 mg/day
Examination
While he was there he was noted to have symptoms consistent with mild depression,
as well as a prior history of a major depressive episode in 2016. Mirtazapine (Remeron)
25 mg/day was started.
He was transferred to a skilled nursing unit for another month of rehabilitation man-
agement of his medical conditions and then discharged home to the care of his wife.
CHAPTER 20 |
CASE STUDY 9: GERALD YOUNG
PATIENT: Carolina Spencer
REASON FOR ENCOUNTER: Assistance with tracheostomy management.
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old female admitted to McGraw
Hospital on July 17th with acute ischemic CVA and DKA. The patient has a very compli-
cated medical history, including respiratory failure, on prolonged mechanical ventilation.
She underwent tracheostomy placement on July 19th and was weaned from mechanical
ventilation within 12 hours. She was also diagnosed with hospital-acquired pneumonia,
multi-organism, and pulmonary embolism by CTPA. She is currently on heparin drip, while
started on Warfarin. She also has end-stage renal disease and is on hemodialysis.
PAST MEDICAL HISTORY: In addition to the above, the patient was found to have some
type of intracardiac shunt per echocardiogram, not otherwise defined; atherosclerosis
of the internal carotid arteries; positive lupus anticoagulants; and long-standing history
of diabetes mellitus, type II.
SOCIAL HISTORY: Tobacco and alcohol use are unknown.
MEDICATIONS: Sliding scale insulin, Reglan, Lantus insulin, diltiazem, Timentin, heparin
drip, Warfarin, Bactrim, Pepcid, and iron sulfate.
ALLERGIES: No known allergies.
REVIEW OF SYSTEMS: Not available.
FAMILY HISTORY: Not available.
PHYSICAL EXAMINATION:
GENERAL: She is an unresponsive female, in no acute distress.
VITAL SIGNS: Temperature is 98.6 degrees; respiratory rate is 21 to 25, somewhat
irregular; pulse is 102; blood pressure is 122/80; and pulse oximetry is 97% on 50%
cuffless tracheostomy.
HEENT: Unable to visualize posterior pharynx secondary to the patient’s resistance to
mouth opening. The patient does have some natural dentition anteriorly. No coating of
the tongue is appreciated. The patient has an eschar on the left upper lip, presumably
secondary to ET tube. Conjunctivae are clear. Gaze is conjugate. The patient has a size
8 Portex cuffless tracheostomy tube in the midline.
CHEST: The patient has a few crackles at the right base, few anterior coarse rhonchi.
No wheeze or stridor with the tracheostomy tube, patent. With finger occlusion of the
CHAPTER 20 |
cuffless #8 Portex, the patient does have stridor and increased respiratory rate. Unable
to adequately percuss the chest.
CARDIOVASCULAR: The patient has regular rate and rhythm. No murmur or gallop is
appreciated. No heaves or thrills.
ABDOMEN: Soft and obese. The patient has G-tube in position and normoactive bowel
sounds. No guarding.
EXTREMITIES: She has decreased pulse in lower extremities bilaterally. No discrepancy
in calf size is appreciated. No clubbing, cyanosis, or edema.
NEUROLOGIC: The patient does withdraw, on the left side; grimaces to pain. She is not
cooperative with exam at this time.
LABORATORY DATA: BUN 16 and creatinine 3.3 on July 18th with venous CO2 of 24,
calcium 9.1, white count 9200, hemoglobin 9.2, and platelets 515,000. Chest x-ray is
not available for review.
IMPRESSION: The patient is a 73-year-old female, status post respiratory failure, pro-
longed mechanical ventilation, necessitating tracheostomy tube placement. She has
had multiple complications including pulmonary embolism, for which she is now antico-
agulated with heparin and reportedly intracardiac shunt, which would help explain her
Aa gradient. She also reported she had a right-sided cavitary lesion and had negative
AFB on bronchoalveolar lavage.
RECOMMENDATIONS:
1. Change to #8 Portex cuffless tracheostomy tube. Would not plan on downsizing,
capping tracheostomy at this time secondary to poor patient cough, decreased
mental status, and inability to protect airway. She does have some evidence with
occlusion of the tracheostomy of possible upper airway obstruction, and so, if her
ability to protect her airway improves, she may need evaluation of the upper airway
before considering progressing toward decannulation as well.
2. Repeat chest x-ray to evaluate right cavitary lesion and obtain films from the primary
care physician for comparison.
This is a 33-year-old female, primigravida, who came in experiencing early labor. The
patient had been scheduled for a cesarean section due to breech presentation.
This patient has had no significant problems during first, second, or third trimes-
ter. The patient’s past medical history is noncontributory. The patient’s LMP was
06/22/2017, placing her EDC at 04/05/2018. Ultrasounds were performed throughout
the pregnancy and revealed adequate growth during the pregnancy and EDC remained
technically the same.
The patient’s initial blood work showed blood type to be A positive, VDRL was non-
reactive, rubella titer indicated immunity, hepatitis B surface antigen (HbsAg) was nega-
tive, HIV screen was negative, GC and Chlamydia cultures were negative. Pap smear
was normal. Her 1-hour glucose tolerance test was within normal parameters. The
patient’s blood count also remained well within normal parameters. Her quad screen
for maternal serum alpha-fetoprotein (MSAFP) was normal. Strep culture was likewise
negative at 34–35 weeks.
The patient, upon admission, was having contractions approximately every 4–5
minutes, moderate in intensity. The patient had no dilation; presenting part was still in
a breech presentation, per bedside ultrasound; and the patient was therefore made
ready for primary cesarean section.
DISCHARGE DIAGNOSES:
AXIS I:
. Bipolar disorder, depressed, with psychotic features, symptoms in remission.
1
2. Attention deficit hyperactivity disorder, symptoms in remission.
AXIS II: Deferred.
AXIS III: None.
AXIS IV: Moderate.
AXIS V: Global assessment of functioning 65 on discharge.
REASON FOR ADMISSION: The patient was admitted with a chief complaint of suicidal
ideation. The patient was brought to the hospital after his guidance counselor found a
note the patient wrote, which detailed to whom he was giving away his possessions
when he dies. The patient told the counselor that he hears voices telling him to hurt
himself and others. The patient reports over the last month these symptoms have exac-
erbated. The patient had a fight in school recently, which the patient blames on the
voices. Three weeks ago, he got pushed into a corner at school and threatened to
shoot himself and others with a gun. The patient was suspended for that remark.
PROCEDURES AND TREATMENT:
. Individual and group psychotherapy.
1
2. Psychopharmacologic management.
3. Family therapy with the patient and the patient’s family for the purpose of education
and discharge planning.
HOSPITAL COURSE: The patient responded well to individual and group psychotherapy,
milieu therapy, and medication management. As stated, family therapy was conducted.
DISCHARGE ASSESSMENT: At the time of discharge, the patient is alert and fully ori-
ented. Mood euthymic. Affect broad range. He denies any suicidal or homicidal ide-
ation. IQ is at baseline. Memory intact. Insight and judgment good.
CHAPTER 20 |
PLAN: The patient may be discharged as he no longer poses a risk of harm towards
himself or others.
The patient will continue on the following medications: Ritalin LA 60 mg q.a.m.,
Depakote 500 mg q.a.m. and 750 mg q.h.s., Abilify 20 mg q.h.s. Depakote level on date
of discharge was 110. Liver enzymes drawn were within normal limits.
The patient will follow up with Dr. Wallace for medication management and Dr. Deiter for
psychotherapy. All other discharge orders per the psychiatrist, as arranged by social work.
Outpatient Facility
EXAMPLES
An outpatient facility includes
a hospital emergency room, Outpatient Facilities
ambulatory care center, same- • Physicians’ offices
day surgery center, or walk-in • Urgent care and walk-in clinics
clinic.
578
• Ambulatory care centers CODING BITES
• Same-day surgery centers
CPT codes explain what
• Emergency departments
the physician or health
care professional did to
When you are abstracting the physician’s documentation to collect the details, you or for the patient.
need to determine the codes that report what actions the physician accomplished for
the patient during this encounter. This is a different perspective from when you are
abstracting for diagnosis coding. As you read through the case, look for action verbs:
inserted; excised; administered; discussed; dilated; and many, many more. Then, you
will be able to identify which terms to interpret into CPT codes.
Identify the term that explains WHAT the physician did for the patient and from which SECTION that
would be reported.
4. Dr. Harper excised a mole from Katrina’s arm.
5. Dr. Aubrey administered general anesthesia prior to the beginning of the surgery.
6. Dr. Davine took and evaluated the MRI images of Lawrence’s head after the car accident.
EXAMPLE
Directly after code 46200 is code
46220 Code is out of numerical sequence. See 46200–46255
You can actually find code 46220 with its description between codes 46946 and
46230.
EXAMPLES
The codes in the subsection for Anus, Excision are listed:
46221 Hemorrhoidectomy, internal, by rubber band ligation(s)
# 46945 Hemorrhoidectomy, internal, by ligation other than rubber band;
single hemorrhoid column/group
# 46946 2 or more hemorrhoid columns/groups
EXAMPLE
Find “excision” in the Alphabetic Index:
Excision
Abdomen
Tumor . . . . . . . . . . 49203-49205
of codes 49203–49205. This means that you are required to investigate ALL of these
codes before making a decision as to which code will accurately report what the physi-
cian did.
As you compare these three code descriptions in the Main Section of CPT, you can
identify which additional specific detail or details you will need to abstract from the
documentation. Continue to the Main Section as you learn the steps to determine an
accurate CPT code.
ICD-10-CM
LET’S CODE IT! SCENARIO
Dr. Cragen performed a second pericardiocentesis on Lucy Brockton. Her initial procedure was 10 days ago.
Good job!
In these situations, report the unlisted code and attach a special report to the claim that
includes the specific details of the procedure or service. Make certain you, as the profes-
sional coder, have done everything possible, including querying the physician, to confirm
there are no other codes that will sufficiently or accurately report what was done.
Throughout the CPT book, you will see notations and symbols. Let’s review them
together.
See
A “see” reference is found under a heading in the Alphabetic Index. Let’s review again
an earlier example to better understand this reference.
EXAMPLE
Leukocyte
See White Blood Cell
In this example, under the heading “Leukocyte,” the notation “See White Blood
Cell” provides an alternate term that the physician may have used in his or her notes.
The CPT book is suggesting that, if you cannot find a match to the documentation
under “Leukocyte,” you might find it under the heading “White Blood Cell.”
Plus Sign
GUIDANCE
CONNECTION The plus symbol ( ) identifies an add-on code. An add-on procedure is most often
performed with a main procedure. These services or treatments are in addition to,
Read the CPT Introduc- and associated with, the main procedure and are never performed or reported alone
tion, subsection Instruc- (without the main procedure). Due to this relationship with the main procedure, add-
tions for Use of the on codes never use the modifier 51 Multiple Procedures. (You will learn all about
CPT Codebook—Add- modifiers later in this book.) All the add-on codes are grouped and listed in Appendix
on Codes. D for additional reference.
EXAMPLE
Add-On Code Listing—the Plus Symbol
22328 each additional fractured vertebra or dislocated segment (List sepa-
rately in addition to code for primary procedure)
EXAMPLE
Add-On Code Listing—the Parenthetical Notations
22630 Arthrodesis, posterior interbody technique, including laminectomy
and/or discectomy to prepare interspace (other than for decom-
pression), single interspace; lumbar
22632 each additional interspace (List separately in addition to code for
primary procedure)
(Use 22632 in conjunction with 22612, 22630, or 22633 when performed at a
different level.)
CPT © 2017 American Medical Association. All rights reserved.
Bullet Symbol
The bullet symbol ( ) identifies a new code, one that is in the CPT book for the first
time. During the annual update of the CPT book, various codes and guidelines are
added, deleted, or revised. The new, updated, printed version of CPT is effective every
January 1.
You can see that it is helpful to have this new notation here, should the physician
document an open procedure, and you ended up here, for the endoscopic proce-
dure, by mistake. Now, the CPT book tells you which code is more accurate.
Star Symbol
The star symbol ( ), new beginning with the 2017 edition of CPT, is placed to the left of
those procedure codes that are permitted to be reported when the service has been pro-
vided using synchronous telemedicine services, and appended with modifier 95. These
synchronous (real-time) telemedicine services engage physician and patient by use of
CPT © 2017 American Medical Association. All rights reserved.
equipment with functioning audio and video. These codes are listed in Appendix P.
EXAMPLE
90832 Psychotherapy, 30 minutes with patient
The star lets you know that if this physician and patient met in person, you can
report this code. And if this physician and patient met via telemedicine (such as
FaceTime or Skype), you can report this same code, appended with modifier 95.
There will be more about modifiers in CPT and HCPCS Level II Modifiers.
EXAMPLE
44500 Introduction of long gastrointestinal tube (eg, Miller-Abbott) (sepa-
rate procedure)
Hashtag
When you see this symbol, a hashtag ( ), to the left of a CPT code, this identifies a
code that has been added and placed into the code set out of numeric order. For more
on this, see the section on the CPT Resequencing Initiative in the section CPT Code
Book of this chapter.
Open Circle
An open circle ( ) identifies a recycled or reinstated code, which is a code that was
CODING BITES previously deleted and now is found to be necessary, so it has been reactivated.
There is a legend across
the bottom of the pages Arrow in a Circle
throughout the CPT
code book to remind Some versions of the CPT book may also include a circle with an arrow symbol ( ). This
you what each symbol symbol ( ) points you toward an AMA-published reference that may be of additional guid-
represents, so you don’t ance. The notation may direct you toward a particular edition of either the CPT Assistant
have to worry about newsletter or the book CPT Changes: An Insider’s View. The American Medical Associa-
memorizing all of these tion (AMA) describes this subscription-only publication, CPT Assistant, as “instrumental
notations and symbols. to many in their appeal of insurance denials, validating coding to auditors, training their
staff and simply making answering day-to-day coding questions second nature.”
ICD-10-CM
LET’S CODE IT! SCENARIO
Kevin Kewly was in a fight with a member of his rival company’s softball team. The other player took out a knife and
stabbed him. When he arrived at the Emergency Department, Dr. Jarrenson repaired his 12 cm laceration, including
debridement and retention sutures, on his lower right arm.
Let’s Code It! CPT © 2017 American Medical Association. All rights reserved.
Dr. Jarrenson stitched a 12 cm laceration on Kevin’s arm. You learned in medical terminology class that this is
known in health care services as a wound repair. Turn to the Alphabetic Index in your CPT code book and find
Wound
Read down the list to find Repair, and indented beneath this, Arms.
Wound
Repair
Arms
Complex. . . . . . 13120-13122
Intermediate. . . 12031, 12032, 12034-12037
Simple. . . . . . . . 12001, 12002, 12004-12007
∙ Surgery Guidelines
∙ Surgery Numerical Listings
∙ Radiology Guidelines
∙ Radiology Numerical Listings
∙ Pathology and Laboratory Guidelines
∙ Pathology and Laboratory Numerical Listings
∙ Medicine Guidelines
∙ Medicine Numerical Listings
The guidelines identify important rules and directives that coders must follow when
assigning codes from each section—for example:
∙ Evaluation and management services guidelines include the definitions of com-
monly used terms.
Surgery Guidelines
Guidelines to direct general reporting of services are other concomitant conditions is not included and may be
presented in the Introduction. Some of the listed separately.
commonalities are repeated here for the convenience of
hose referring to this section on Surgery. Other
definitions and items unique to Surgery are also listed.
Follow-Up Care for
Therapeutic Surgical
Services Procedures
Services rendered in the office, home, or hospital,
Follow-up care for therapeutic surgical procedures
Surgery
consultations, and other medical services are listed in the
includes only that care which is usually a part of the
Evaluation and Management Services section (99201-
surgical service. Complications, exacerbations, recurrence,
99499) beginning on page 11. “Special Services and
or the presence of other diseases or injuries requiring
Reports” (99000-99091) are listed in the Medicine
additional services should be separately reported.
section.
FIGURE 21-1 A portion of the Surgery Guidelines in the CPT code book, includ-
ing the CPT Surgical Package Definition Source: CPT Professional Manual, American Medical
Association
∙ Surgery guidelines include a listing of services that are bundled into the surgical
package definition (see Figure 21-1).
∙ Medicine guidelines include instructions on how to code multiple procedures and
CPT © 2017 American Medical Association. All rights reserved.
the proper use of add-on codes.
In-Section Guidelines
There are additional guidelines and instructions throughout each section, shown in
paragraphs under various subheadings. These instructional notations, ranging from a
short sentence to several paragraphs, provide specific information regarding the proper
coding appropriate to that anatomical site or type of procedure. (See Figure 21-2.)
EXAMPLES
Instructional Notations in a Subsection
Biopsy
Identify the pre-section or in-section Guideline that you need to report the procedure accurately.
7. Dr. Singer documented that he debrided Jesse’s abdominal wall. What specific details do you need
to know to determine this code?
8. Dr. Trenton documented performing a sleep study with simultaneous recording of vital signs for
Kent Burlington. The CPT code description is
95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart
rate, and oxygen saturation, attended by a technologist
What does “attended by” mean?
9. Dr. Obatunda completed his documentation on his evaluation of Adam. To determine the correct
Evaluation and Management code, you must determine the level of history documented in the
notes. What exactly is included in a problem-focused history?
EXAMPLES
CPT © 2017 American Medical Association. All rights reserved.
0015F Melanoma follow-up completed (includes assessment of all of the
following components): history obtained regarding new or changing
moles, complete physical skin exam performed, and patient coun-
seled to perform a monthly self-skin examination.
1220F Patient screened for depression
As you can see from these examples, category II codes provide detailed informa-
tion about the encounter between physician and patient . . . details that are impor-
tant to research.
Each code’s description explains clinical fundamentals (such as vital signs), lab
test results, patient education, or other facets that might be provided within a typical
office visit. However, individually, these component services do not have any billable
value and, therefore, are not assigned a code from Category I CPT codes. Assigning
ICD-10-CM
LET’S CODE IT! SCENARIO
Michael Catapano, a 71-year-old male, comes to see Dr. Sheridan, his primary care physician for the last 5 years,
for his annual checkup. Michael has a family history of cardiac disease, so Dr. Sheridan takes extra care to examine
Michael and speak with him about angina (severe acute chest pain caused by inadequate supply of oxygen to part
of the heart). Dr. Sheridan documents that angina is absent.
NOTE: You will learn more about annual physical exam coding in the chapter on CPT Evaluation and Manage-
ment Section, Section 23.5.
The use of Category III codes is mandatory, as appropriate, according to the physi-
cian’s notes. If there aren’t any accurate Category I codes in the CPT book to report the
physician’s services, you must check the Category III section for an appropriate code
Unlisted Codes before you are permitted to use a Category I unlisted code. The good news is that the
Codes shown at the end of CPT book will continue to help you. Category III codes are included in the Alphabetic
each subsection of the CPT Index. In addition, there are notations throughout the main sections that will direct you
used as a catch-all for any to a Category III code, if applicable.
procedure not represented by It is important that you are aware of the fact that Category III codes represent up-
an existing code.
and-coming technology. Because of this, the third-party payers from whom you seek
Experimental reimbursement may consider some services experimental. When you work in a health
A procedure or treatment that care facility that uses any procedures or services reported with a Category III code, it
has not yet been accepted by is critical that you determine the carrier’s rules and coverage with regard to the treat-
the health care industry as the ment or test. Should the carrier exclude it and refuse to pay, both the patient and your
standard of care. facility are better off knowing this as soon as possible.
Keep good communication open with the physicians for whom you code. There are
multiple benefits for this, including you finding out about a new technique or proce-
dure before it is provided to any patient. Then, you can determine if this procedure will
require a Category III code. Knowing this before a patient is involved will give you
time. You may be able to petition the payer to convince them of the medical necessity
and the cost efficiency of the new technology, and you may receive an approval after
all. Waiting for a denial notice is not an efficient way to handle the situation. That is
also not respectful to the patient.
A particular Category III code, once assigned, is reserved for 5 years, whether the
code is upgraded to a Category I code or deleted altogether. It allows for the fact that
certain technologies or procedures may take time to find acceptance.
YOU CODE IT! CASE STUDY CPT © 2017 American Medical Association. All rights reserved.
ICD-10-CM
Grace Emerson, a 55-year-old female, had a heart transplant 2 months ago. She has not been feeling well, so
Dr. Rasmussen performs a breath test for heart transplant rejection. This test is experimental, but it is noninvasive.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Chapter Summary
In this chapter, you learned about the important role that coding plays in our health
care system, with specific focus on procedure codes used to report physician services
and outpatient facility services. As an up-and-coming professional coding specialist,
you must strive to accurately report the procedure, services, and treatments provided
to every patient using CPT codes. Health care professionals are responsible for ensur-
ing that the supporting documentation is complete so that you have the information
necessary to find the most accurate code or codes.
CODING BITES
Steps to Coding Procedures
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service
the physician provided to the patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to
query the physician? [If so, ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the
CPT © 2017 American Medical Association. All rights reserved.
details about what was provided to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and
notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate
information is provided?
Step #7: Double-check your work.
cal removal . . . report a code from the Surgery section. 5. Anesthesia . . . report a code
from the Anesthesia section. 6. MRI (Magnetic Resonance Imaging) = imaging . . .
report a code from the Radiology section. 7. Inside the Surgery section of CPT, above
the many codes available to report debridement, are in-section guidelines that include
Debridement. Wound debridements (11042–11047) are reported by depth of tissue that
is removed and by surface area of the wound. 8. 95807 Sleep study, simultaneous
recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation,
attended by a technologist. What does “attended by” mean? The CPT book includes
this definition right there, along with in-section guidelines for Sleep Medicine Testing:
“Attended: a technologist or qualified health care professional is physically pres-
ent.” 9. Turn to the Evaluation and Management (E/M) Services Guidelines directly
in front of the Evaluation and Management code section in CPT and find this subsec-
tion: Determine the Extent of History Obtained. Problem focused: Chief complaint;
brief history of present illness or problem.
CHAPTER 21 REVIEW
Introduction to CPT Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
CHAPTER 21 REVIEW
indented description to it.
a. up to the comma b. up to the semicolon
c. up to the period d. up to the hyphen
4. LO 21.5 CPT guidelines
a. must be memorized by professional coders.
b. can be found in the front of every CPT section.
c. can be found in a separate guidelines book.
d. change every 2 months.
5. LO 21.4 The plus symbol identifies
a. a new code. b. a revised code.
c. an add-on code. d. a code that includes conscious sedation.
6. LO 21.4 The star symbol identifies
a. a new code. b. an add-on code.
c. a revised code. d. a telemedicine encounter.
7. LO 21.4 The bullet symbol identifies
a. a new code. b. an add-on code.
c. a revised code. d. a code that includes conscious sedation.
8. LO 21.4 The hashtag symbol identifies
a. a reinstated or recycled code. b. a product pending FDA approval.
c. an out-of-numeric-sequence code. d. an exemption from modifier 51.
9. LO 21.3 An unlisted code should only be used when
a. an accurate Category I code is not available.
b. an accurate Category I code is not available and an accurate Category III code is not available.
c. an accurate Category III code is not available.
d. an accurate Category I code is not available or an accurate Category III code is not available.
10. LO 21.6 The _____ program provides for a bonus payment to those eligible professionals who meet the criteria
for successful reporting, and a negative payment adjustment is applied when reporting is not submitted
as required.
a. MIPS b. AMA c. RVU d. PQRS
Part I
Match each symbol to the appropriate definition.
1. LO 21.4 Add-on code A.
2. LO 21.4 New or revised codes B.
3. LO 21.4 Telemedicine C.
4. LO 21.4 Out-of-numeric-sequence code D.
5. LO 21.4 New code E.
6. LO 21.4 Revised code F.
7. LO 21.4 Exempt from modifier 51 G.
8. LO 21.4 Reinstated or recycled code H.
Part II
CHAPTER 21 REVIEW
The main body of the CPT book has six sections. Match the code range to the correct
A. 99201–99499
section name.
B. 00100–01999 and
1. LO 21.2 Surgery 99100–99140
2. LO 21.2 Pathology and Laboratory C. 10021–69990
3. LO 21.2 Evaluation and Management D. 70010–79999
4. LO 21.2 Medicine E. 80047–89398,
5. LO 21.2 Anesthesia 0001U-0017U
6. LO 21.2 Radiology F. 90281–99199,
99500–99607
CPT
YOU CODE IT! Basics
First, identify the procedural main term in the follow- 8. Anesthesia for ear biopsy:
ing statements; then code the procedure or service. a. main term: _____ b. procedure: _____
Example: Drainage of eyelid abscess 9. Data analysis of implantable defibrillation, wear-
able device:
a. main term: Drainage b. procedure: 67700
a. main term: _____ b. procedure: _____
1. Ligation salivary ducts, intraoral:
10. Keratoplasty, anterior lamellar:
a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____
2. Carpal scaphoid fracture manipulation:
11. Lower arm x-ray:
a. main term: _____ b. procedure: _____
CPT © 2017 American Medical Association. All rights reserved.
a. main term: _____ b. procedure: _____
3. Cardiac massage:
12. Kidney cyst injection:
a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____
4. Ureter meatotomy:
13. Lithotripsy with cystourethroscopy:
a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____
5. Intraocular pressure monitoring for 36 hours:
14. Percutaneous spinal cord biopsy:
a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____
6. Tendon sheath incision, finger:
15. Pediatric gastroenteritis education, individual:
a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____
7. Immunoassay antigen detection influenza B:
a. main term: _____ b. procedure: _____
and examined the area. He then applied a topical anesthetic and removed the foreign body from the superfi-
cial conjunctiva of her eye. Code the removal of the foreign body only.
15. Michael Munsey, an 84-year-old male, was seen by his physician at an ambulatory surgical center for the
insertion of a temporary transvenous single-chamber cardiac electrode. The patient tolerated the procedure
well.
CPT
SOAP notes are a standardized documentation method used by health care providers to build a patient’s chart. The
SOAP note has 4 parts and each part will vary in length depending on the patient’s encounter for that day.
So, what does the acronym SOAP stand for?
S = subjective
O = objective
A = assessment
P = plan
What does the subjective portion of the SOAP note include?
The chief complaint, a short statement in the patient’s own words as to the reason for the encounter.
What does the objective portion of the SOAP note include?
The results of the physical examination and any measurable result; a few examples are vital signs, height,
weight, and lab and diagnostic results.
What does the assessment portion of the SOAP note include?
A brief summation of the physician’s diagnosis.
What does the plan portion of the SOAP note include?
The physician’s plan of care (treatment) for the patient’s encounter.
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: WOODARD, HOPE
CPT © 2017 American Medical Association. All rights reserved.
ACCOUNT/EHR #: WOODHO001
DATE: 3/19/18
Attending Physician: Oscar R. Prader, MD
The patient is a 54-year-old female with a very long history of schizoaffective disorder with numerous
hospitalizations who was brought in by ambulance due to increasing paranoia; increasing arguments
with other people; and, in general, an exacerbation of her psychotic symptoms, 14-day duration.
I am here to provide psychoanalysis.
Initially, the patient was very agitated and uncooperative. She refused medications. A 2PC* was done
and the patient had a court hearing that results in retention. Eventually, the patient agreed to a trial of
CHAPTER 21 REVIEW
a Risperdal; she fairly rapidly improved once she was started on Risperdal 2 mg twice daily. At the time
of discharge compared with admission, the patient is much improved. She is usually pleasant and coop-
erative, with occasional difficult moments and some continuing mild paranoia. She has no hallucinations.
She has no thoughts of harming herself or anyone else. She has been compliant with her medication
until she recently refused hydrochlorothiazide. She is irritable at times, but overall she is redirectable
and is considered to be at or close to her best baseline. She is considered no imminent danger to her-
self or to others at this time.
FINAL DX: Schizoaffective disorder; hypothyroidism; hypercholesterolemia; borderline hypertension.
Prescriptions for 30-day supplies were given:
Ativan 2 mg po tid; Celexa 40 mg po daily; Risperdal 2 mg po bid; Synthroid 0.088 mg po qam; Zocor
40 mg po qhs
ORP/mg D: 03/19/18 09:50:16 T: 03/20/18 12:55:01
*2PC stands for “two physicians certify”—a medical certification testifying that an individual requires involuntary
treatment at a psychiatric facility.
Determine the most accurate CPT code(s).
602
reporting what was actually provided to the patient during the encounter. Some modifiers
GUIDANCE
will result in the physician or facility getting paid more money because the circumstances
resulted in their having to do more work than usual. For example, modifier 22 Increased CONNECTION
Procedural Service reports that the procedure was more complex than usual. Read the CPT Introduc-
Some modifiers will result in the physician or facility getting paid less money for tion, subsection Instruc-
the typical procedure but truthfully and accurately report that less work than usual was tions for Use of the CPT
provided. For example, modifier 52 Reduced Services reports fewer services were Codebook—Modifiers
provided. on how to properly use
Other modifiers will prevent a claim for reimbursement from being denied because modifiers.
it brings attention to the fact that unusual circumstances required unusual work. For
example, modifier 23 Unusual Anesthesia alerts that a procedure that typically only
uses a local anesthetic, for example, required general anesthesia. In these cases, you
will also need to provide a supplemental report to explain what those circumstances
were so that they will understand because you are telling the whole story. CODING BITES
As you go through the lists, you will find there are modifiers that have no effect Bookmark Appendix A
at all on reimbursement but provide specific details about the procedure that will be in your CPT code
important for continuity of care, as well as for research and statistics. An example is book. This is the sec-
modifier RC Right Coronary Artery to identify the specific anatomical site upon which tion containing the CPT
the procedure was completed. modifiers and their full
You will find many modifiers listed in Appendix A, their own section of the CPT descriptions. It is impor-
book. Listed in numeric order, each modifier is shown by category, accompanied by an tant that you reference
explanation of when and how you should use that modifier. The rest can be found in these prior to using any
the separate HCPCS Level II code book. modifier. Your HCPCS
Level II book has its own
Types of Modifiers section that lists those
There are five categories of modifiers: modifiers with their
complete descriptions.
∙ CPT code modifiers are two characters that can be attached to regular codes from
the main portion of the CPT book and to HCPCS Level II codes.
CPT Code Modifier
A two-character code that may
EXAMPLE: CPT Modifiers be appended to a code from
23 Unusual Anesthesia the main portion of the CPT
66 Surgical Team book to provide additional
information.
∙ Anesthesia Physical Status Modifiers consist of two characters and are Physical Status Modifier
alphanumeric. They are used only with CPT codes reporting anesthesia services. A two-character alphanumeric
code used to describe the
condition of the patient at the
time anesthesia services are
CPT © 2017 American Medical Association. All rights reserved.
CHAPTER 22 |
HCPCS Level II Modifier ∙ HCPCS Level II modifiers are two characters and alphabetic or alphanumeric.
A two-character alphabetic They are used to provide additional information about services when appended to
or alphanumeric code that CPT and HCPCS Level II codes.
may be appended to a code
from the main portion of the
CPT book or a code from the
HCPCS Level II book. EXAMPLE: HCPCS Level II Modifiers
E1 Upper left eyelid
RT Right side (of body)
Category II Modifiers ∙ Category II modifiers are two characters: a number followed by the letter P. Only
Modifiers provided for use appended to Category II codes, these modifiers provide explanations as to why a
with Category II CPT codes particular service should not be included in the qualifications for a specific perfor-
to indicate a valid reason for mance measure.
a portion of a performance
measure to be deleted from
qualification.
EXAMPLES
1P Performance Measure Exclusion Modifier due to Medical Reasons
2P Performance Measure Exclusion Modifier due to Patient Reasons
Using Modifiers
CODING BITES
Using modifiers is, most often, a judgment that you, the coding specialist, will have
HCPCS Level II modi-
to make as you review the details of each case. As you analyze the descriptions of the
fiers can be appended
procedures performed, as documented by the physician, and compare them with the
to either CPT codes or
descriptions of the codes in the CPT book, you may find that there is more to the story
HCPCS Level II codes.
than the code description provides. This is important because it is a coding profes-
sional’s job to relate the whole story of the encounter.
EXAMPLE
Dr. Kennedy determined that Patricia’s tear ducts were blocked. He dilated and
irrigated both the right and left eyes.
[Remember from medical terminology class, the medical term for the tear duct =
lacrimal punctum (plural = puncta). If you don’t remember, it is important to use
your medical dictionary to ensure you can determine the accurate code or codes.]
CODING BITES Modifier 50 is used to identify that a service or procedure was performed bilater-
ally (both sides). If the physician’s documentation states that this procedure was
On occasion, the CPT done on both sides, you can see that the code description does not include this
book will remind you of detail. Therefore, you must add a modifier . . . to tell the whole story.
a special circumstance
that requires a modifier.
However, most of the
time, it is you who must EXAMPLE
determine when to use
Jason has been deaf in his left ear since he was 16. Today, Dr. Sangar is perform-
a modifier and which
ing a Bekesy audiometry screening test on his right ear.
modifier or modifiers to
append to the code. 92560 Bekesy audiometry; screening
CPT
LET’S CODE IT! SCENARIO
Dinah Chen, a 21-year-old female, came into the emergency clinic with two lacerations: one on her right hand and
the second on her right arm. Dr. Padmore debrided and provided a complicated repair of the 3.1 cm laceration on
her upper right arm and a layered closure of a 2.5 cm laceration on her right hand, proximal to the second digit.
Directly above this first code, starting on the previous page, are Official Guidelines under the subheading Repair
(Closure). These in-section Guidelines explain the definitions of Simple Repair, Intermediate Repair, and
Complex Repair, along with other important details that you need to report these repairs accurately.
The chapter CPT Surgery Section will provide you with more in-depth instruction about this.
For this chapter, on Modifiers, you want to focus on paragraph 2 of these in-section Guidelines. It tells you that,
when multiple wounds are repaired, reported with different levels of repair, you will need to append modifier 59
Distinct Procedural Service to the second code and all thereafter. This will help you understand that, to report
Dr. Padmore’s services to Dinah Chen, you will submit these codes:
CHAPTER 22 |
22.2 Personnel Modifiers
As you read through the descriptions of the modifiers, most of them will seem very
Personnel Modifier straightforward. Personnel modifiers explain special circumstances relating to the
A modifier adding informa- health care professionals involved in the treatment of the patient. These modifiers spe-
tion about the professional(s) cifically identify the qualifications of the health care professional who provided the
attending to the provision of service reported by the code to which this modifier is being attached, while other
this procedure or treatment modifiers identify the provider’s special training. You will note that some of the modi-
to the patient during this
fier descriptions also include a location as a part of their meaning.
encounter.
CPT
LET’S CODE IT! SCENARIO
CPT © 2017 American Medical Association. All rights reserved.
Valerie Ferguson, a 43-year-old female, has been diagnosed with endometriosis and is admitted to Midtown Hospi-
tal to have Dr. Lissard perform a vaginal, radical hysterectomy. While Valerie is in the operating room (OR) and under
anesthesia, Dr. Rasmussen is going to perform an open sling operation for stress incontinence on her bladder, and
Dr. Barlow is an assistant surgeon who is there to assist Dr. Lissard. She tolerates both procedures well and is taken
back to her room.
(continued)
CHAPTER 22 |
Dr. Rasmussen’s coder sent the claim for her work performed for Valerie 2 days later. This claim also fails to
include any modifiers.
Now, Bernice Cannaloni, claims adjuster for Valerie’s health insurance company, looks at Dr. Rasmussen’s
claim. Wait a minute. We just paid a claim for two other physicians who stated a totally different surgical proce-
dure was provided to the same patient on the same date! Perhaps someone is trying to defraud this company!
An investigation begins, delaying payment by several months until it is all straightened out.
If there were modifiers that could explain what role each of these surgeons played, working side-by-side to
care for this patient, the entire fraud investigation and delay in payment could be prevented.
Open your CPT code book to Appendix A and read through the list of modifiers to see if any might enable
Dr. Lissard’s coder and Dr. Rasmussen’s coder to more clearly explain the whole story. Take a look at
62 Two Surgeons: When 2 surgeons work together as primary surgeons performing distinct
part(s) of a procedure, each surgeon should report his/her distinct operative work by adding
modifier 62 to the procedure code . . .
This looks perfect to explain this unusual situation, doesn’t it?
Now what about Dr. Barlow? How do we explain his role during this procedure? Review the modifiers in
Appendix A to determine if there are any that will help explain. Take a look at
80 Assistant Surgeon: Surgical assistant services may be identified by adding modifier 80 to the
usual procedure number(s).
So, Dr. Lissard’s coder would report this code:
tered but is indicative of the patient’s overall health. You can see that, without under- and their descriptions in
standing the difference between treatment issue and overall health, it might be hard for the Official Guidelines
you to identify a patient as “P1 A normal healthy patient” when the person is in your located immediately
facility to have a diseased gallbladder removed. However, if the patient is otherwise prior to the Anesthesia
healthy, P1 is the correct status modifier. code section in the main
The Physical Status Modifiers, P1–P6, may be appended only to codes from the part of CPT and/or in
Anesthesia section of the CPT book, codes 00100–01999. Appendix A.
All anesthesia codes
and only anesthesia
EXAMPLE: Use of a Physical Status Modifier codes are appended
with a Physical Status
Anesthesia for a diagnostic arthroscopy of the knee on a 67-year-old male with Modifier, immediately
diabetes mellitus, controlled well with medication. following the anesthesia
01382-P2 code.
CHAPTER 22 |
There may be a case when a CPT modifier must also be used with an anesthesia
code. When this is done, the Physical Status Modifier is to be placed closest to the
anesthesia code.
You will read more about the anesthesia physical status modifiers in the chapter
CPT Anesthesia Section.
CPT
LET’S CODE IT! SCENARIO
Carson Crosby, a healthy and fit 18-year-old male, fell from a girder on a construction site, fracturing three ribs and
two vertebrae, and sustaining a hairline fracture of his pelvis. Dr. Pollack, an anesthesiologist, was brought in to
administer general anesthesia so the body cast could be applied by Dr. Abrams, an orthopedist.
EXAMPLE
Alexandra Benson, a 41-year-old female, cut her hand and went to the Mulford
General Hospital clinic. After Dr. Williams evaluated her hand, he sent her to the
CPT © 2017 American Medical Association. All rights reserved.
emergency department (ED) because the cut was so deep it needed more intense
care. Dr. Kinsey evaluated the injury and repaired Alexandra’s laceration in the ED.
As the coding specialist for the hospital, you would be responsible for coding
the services provided in all your facilities, including the clinic as well as the ED.
Alexandra Benson was seen in two different facilities on the same day for the
same injury. First, you would code the services that Dr. Williams did—the E/M of
Alexandra’s injury and his decision to send her to the ED for a higher level of care.
Second, you would report the services that Alexandra received in the ED, which
certainly included additional evaluation and then the repair of her wound.
For Dr. Williams, report: 99201-27
For Dr. Kinsey, report: 99281-27
Without the use of modifier 27, you would have difficulty in getting the claim paid
because the third-party payer may think that this is a case of duplicate billing, an
error, or fraud.
CHAPTER 22 |
Modifiers 73 and 74
Occasionally, a planned surgical event is not performed due to circumstances that might
put the patient in jeopardy. In such cases, all the preparation was done, the team was
ready, and your facility needs to be reimbursed, even though you have not performed
the service or treatment. Modifiers 73 and 74 will identify these unusual circumstances.
73 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC)
Procedure Prior to the Administration of Anesthesia: Due to extenuat-
ing circumstances or those that threaten the well-being of the patient, the
physician may cancel a surgical or diagnostic procedure subsequent to the
patient’s surgical preparation (including sedation when provided, and being
taken to the room where the procedure is to be performed), but prior to the
administration of anesthesia (local, regional block(s) or general). Under these
circumstances, the intended service that is prepared for but canceled can
be reported by its usual procedure number and the addition of modifier 73.
74 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC)
Procedure After Administration of Anesthesia: Due to extenuating circum-
stances or those that threaten the well-being of the patient, the physician
may terminate a surgical or diagnostic procedure after the administration of
anesthesia (local, regional block(s) or general), or after the procedure was
started (incision made, intubation started, scope inserted, etc.). Under these
circumstances, the procedure started, but terminated can be reported by its
usual procedure number and the addition of modifier 74.
The extenuating circumstances mentioned are generally accepted situations that would
be reasonable to stop a procedure at this late point in time. Prior to the a dministration
of anesthesia, it might be that the nurse, while taking the patient’s vital signs, docu-
ments that the patient has a fever. It is the standard of care to avoid surgical procedures
on a patient with a fever, so the proper thing to do would be to postpone. Once the
patient is in the procedure room, and anesthesia has been administered, there may be a
need to stop the procedure, such as the patient experiencing a seizure or dramatic drop
in blood pressure. Make certain that you not only append one of these modifiers, when
appropriate, but also include a special report to explain exactly what happened to make
cancelling the procedure the right action to take.
CPT
LET’S CODE IT! SCENARIO
Cole Dennali, a 59-year-old male, was brought into Room 5 to be prepared for a bunionectomy. He changed into a
gown, he got into bed, and the nurse took his vital signs. Cole’s breathing was labored—it appeared he was having
an asthma attack. Dr. Fraumann ordered respiratory therapy to come in and provide a nebulizer treatment. Because
general anesthesia could not be administered, the bunionectomy was canceled. CPT © 2017 American Medical Association. All rights reserved.
EXAMPLE
28008 Fasciotomy, foot and/or toe
Adding a modifier such as T7 would include very important information for the
claim, especially if the patient had a preexisting condition involving a different toe.
T7 Right foot, third digit
Therefore, you would report: 28008-T7 Fasciotomy, right foot, third digit.
(continued)
CHAPTER 22 |
TABLE 22-3 Anatomical Sites Modifiers (continued)
CPT
YOU CODE IT! CASE STUDY
Beatrice Burmuda, a 37-year-old female, came to the Upton Ambulatory Surgery Center so that Dr. Thomas could
excise a benign tumor from her left foot’s big toe (known medically as the great toe). She tolerated the procedure
well and was discharged.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
CPT © 2017 American Medical Association. All rights reserved.
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
EXAMPLE
Dr. Lappin has been working with Louisa providing psychotherapy to help her deal
CPT © 2017 American Medical Association. All rights reserved.
with panic attacks. Today, they had a good, 30-minute session in the office.
90832 Psychotherapy, 30 minutes with patient
Dr. Lappin has been working with Louisa providing psychotherapy to help her
deal with panic attacks. Today, Louisa is on a plane, traveling to visit her parents in
another state. As she feels a panic attack coming on, she uses the airplane’s WiFi
system to Skype with Dr. Lappin. They spend 30 minutes talking things through
and helping Louisa get through.
90832-95 Psychotherapy, 30 minutes with patient, synchronous
telemedicine service rendered via a real-time interac-
tive audio and video telecommunications system
By appending modifier 95, you are clearly communicating the difference in
Dr. Lappin’s service to her patient.
CHAPTER 22 |
TABLE 22-4 Modifiers for Multiple Wounds
Wound Care
Typically, a dressing change is required for a wound many times throughout the heal-
ing process. In addition, it is not unusual that a patient might have more than one
wound that needs care at the same time. Therefore, to make the coding process easier
and more efficient, one modifier can explain the extent of such care so that listing the
same code multiple times is not necessary. The list in Table 22-4 contains the modi-
fiers for multiple wounds.
CB Service ordered by a renal dialysis facility (RDF) physician as part of the beneficiary’s benefit is not part of the
composite rate and is separately reimbursable
CD AMCC test has been ordered by an ESRD facility or MCP physician that is part of the composite rate and is
not separately billable
CE AMCC test has been ordered by an ESRD facility or MCP physician that is a composite rate test but is beyond
the normal frequency covered under the rate and is separately reimbursable based on medical necessity
CF AMCC test has been ordered by an ESRD facility or MCP physician that is not part of the composite rate and
is separately billable
EM Emergency reserve supply (for ESRD benefit only)
G1 Most recent urea reduction ratio (URR) reading of less than 60
G2 Most recent URR reading of 60 to 64.9
G3 Most recent URR reading of 65 to 69.9
G4 Most recent URR reading of 70 to 74.9
G5 Most recent URR reading of 75 or greater
G6 ESRD patient for whom less than six dialysis sessions have been provided in a month
Ophthalmology/Optometry AMCC
Automated Multi-Channel
Sometimes, when ophthalmic or optometric services are provided, more detail is nec- Chemistry—Automated organ
essary to ensure proper reimbursement. Following are the HCPCS Level II modifiers disease panel tests performed
used with these services: on the same patient, by the
same provider, on the same day.
AP Determination of refractive state was not performed in the course of diagnostic
ophthalmologic examination
Urea Reduction Ratio (URR)
LS FDA-monitored intraocular lens implant
A formula to determine the
PL Progressive addition lenses
effectiveness of hemodialysis
VP Aphakic patient treatment.
Amie Gander, a 39-year-old female, was diagnosed with ESRD. Dr. Linnger prescribed her treatments to begin on
May 29 at the Southside Dialysis Center (SDC). Code for the services provided at SDC for the month of May.
(continued)
CHAPTER 22 |
After reading the complete code descriptions in the suggested range, you find the best procedure code to be this:
90970 End-stage renal disease (ESRD) related services (less than full month), per day; for patients
twenty years of age and over
This means you will have to list the code three times because the code description says per day. Are there any
modifiers than can help you communicate this situation?
G6 ESRD patient for whom less than six dialysis sessions have been provided in a month
The modifier that will complete this report is G6 because she has had fewer than six sessions in 1 month:
90970-G6; 90970-G6; 90970-G6 or 90970-G6 × 3.
Good job!
Pharmaceuticals
Pharmaceuticals, the industry term for medications, are items that must be monitored
very carefully: the purchase, the storage, and the dispensing. The modifiers in Table 22-6
provide important information that must be tracked.
Modifier RD Drug provided to beneficiary, but not administered “incident to” indi-
cates that a particular pharmaceutical was provided to the patient but not administered.
For example, the nurse brings the patient’s pills into his room to administer them when
she notices he has a rash. She notifies the physician on call and he orders the medica-
tion stopped to investigate if the patient is allergic. Once the pills have been taken out
of the pharmacy, they cannot be returned. If the patient does not take them, they must
be discarded but still accounted for in the system and billing.
Modifier SV Pharmaceuticals delivered to patient’s home but not utilized might
be used by a mail-order pharmaceutical service to show that the medications were
shipped and delivered to the patient’s house but have nothing to do with how, when, or
if the patient uses those drugs.
EXAMPLES
RD Drug provided to beneficiary, but not administered “incident to”
SV Pharmaceuticals delivered to patient’s home but not utilized
Oscar Barkley, a 57-year-old male, was diagnosed with type 2 diabetes mellitus. Dr. Habersham wants to try a new
medication to control Oscar’s blood glucose levels and delay, or avoid, putting him on insulin. Dr. Habersham gives
Oscar the prescription for the medication and a second prescription for a home blood glucose monitor.
CHAPTER 22 |
TABLE 22-8 Purchase/Rental Items Modifiers
BP The beneficiary has been informed of the purchase and rental options and has elected to purchase the item
BR The beneficiary has been informed of the purchase and rental options and has elected to rent the item
BU The beneficiary has been informed of the purchase and rental options and after 30 days has not informed the supplier
of his/her decision
KH DMEPOS item, initial claim, purchase or first month rental
KI DMEPOS item, second or third month rental
KJ DMEPOS item, parenteral enteral nutrition (PEN) pump or capped rental, months four to fifteen
KR Rental item, billing for partial month
LL Lease/rental (use when DME rental payments are to be applied against the purchase price)
MS Six-month maintenance and servicing fee for reasonable and necessary parts and labor not covered under any manu-
facturer or supplier warranty
NR New when rented
RR Rental DME
Purchase/Rental Items
Often, when durable medical equipment (DME) is supplied, the patient has a choice to
rent the equipment or purchase it outright. This will depend upon the patient’s personal
situation. A modifier (see Table 22-8) provides important details, especially to the payor.
CC Procedure code change (used to indicate that a procedure code previously submitted was changed either for an admin-
istrative reason or because an incorrect code was filed)
GA Waiver of liability statement issued, individual case
GB Claim being resubmitted for payment because it is no longer covered under a global payment
KB Beneficiary requested upgrade for ABN, more than four modifiers identified on claim
KX Requirements specified in the medical policy have been met
QP Documentation is on file showing that the laboratory test(s) was ordered individually or ordered as a CPT-recognized
panel other than automated profile codes 80002–80019, G0058, G0059, and G0060
Deceased Patient
Should a patient expire (die) while services are in the process of being rendered, cer-
tainly the situation changes and there must be some indication of the death. The fol-
lowing modifiers are used in such circumstances:
CA Procedure payable only in the inpatient setting when performed emergently on an
outpatient who expires prior to admission
QL Patient pronounced dead after ambulance called
67810-E1-CC Incisional biopsy of eyelid skin including lid margin; upper left, eyelid, Pro-
cedure code change because an incorrect code was filed
Good job!!
Family Services
Services provided under Medicaid’s Early and Periodic Screening, Diagnostic, and Early and Periodic Screening,
Treatment (EPSDT) program must be identified with the EP modifier, shown in Diagnostic, and Treatment
Table 22-10. In addition, other family services may benefit from further explanation (EPSDT)
by the use of one of the modifiers found in that list. A Medicaid preventive health
program for children under 21.
Treatments/Screenings
The modifiers shown in Table 22-11 are directly related to the provision of mammog-
raphy and infusion therapeutic services.
CHAPTER 22 |
TABLE 22-10 Family Services Modifiers
EP Service provided as part of Medicaid early periodic screening diagnosis and treatment (EPSDT) program
FP Service provided as part of family planning program
G7 Pregnancy resulted from rape or incest or pregnancy certified by physician as life threatening
TL Early intervention/individualized family service plan (IFSP)
TM Individualized education plan (IEP)
TR School-based individualized education program (IEP) services provided outside the public school district
responsible for the student
GG Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day
GH Diagnostic mammogram converted from screening mammogram on same day
SH Second concurrently administered infusion therapy
SJ Third, or more, concurrently administered infusion therapy
Funded Programs
When a service or treatment is provided under the terms or conditions of a formal-
ized program or plan, the services must be identified so that statistical tracking can
be accomplished accurately and reimbursement is not received from two sources. The
modifiers shown in Table 22-13 enable such tracking.
H9 Court-ordered
HA Child/adolescent program
CHAPTER 22 |
TABLE 22-13 Funding Modifiers (continued)
HQ Group setting
HR Family/couple with client present
HS Family/couple without client present
TJ Program group, child and/or adolescent
TT Individualized service provided to more than one patient in same setting
UN Two patients served
UP Three patients served
UQ Four patients served
UR Five patients served
US Six or more patients served
Individual/Group
Most often, modifiers for individuals or groups are going to be used in conjunction
with psychiatric and psychotherapeutic codes to clarify how many patients were
involved in the session. The modifiers shown in Table 22-14 relate to the number, and
sometimes the type, of patient(s) being helped at one time.
Prosthetics
When services are provided relating to the supply or adjustment of a prosthetic device,
you might have to include additional information by using one of the modifiers shown
in Table 22-15.
K0 Lower extremity prosthesis functional level 0—does not have the ability or potential to ambulate or transfer safely with
CPT © 2017 American Medical Association. All rights reserved.
or without assistance and prosthesis does not enhance his or her quality of life or mobility
K1 Lower extremity prosthesis functional level 1—has the ability or potential to use a prosthesis for transfers or ambulation
on level surfaces at fixed cadence, typical of the limited and unlimited household ambulatory
K2 Lower extremity prosthesis functional level 2—has the ability or potential for ambulation with the ability to traverse low-
level environmental barriers such as curbs, stairs, uneven surfaces, typical of limited community ambulatory
K3 Lower extremity prosthesis functional level 3—has the ability or potential for ambulation with variable cadence. Typi-
cal of the community ambulatory who has the ability to traverse most environmental barriers and may have vocational,
therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion
K4 Lower extremity prosthesis functional level 4—has the ability or potential for prosthetic ambulation that exceeds the
basic ambulation skills, exhibiting high impact, stress, or energy levels, typical of the prosthetic demands of the child,
active adult, or athlete
KM Replacement of facial prosthesis including new impression/moulage
KN Replacement of facial prosthesis using previous master model
CHAPTER 22 |
HCPCS Level II
YOU CODE IT! CASE STUDY
On January 5, a respiratory suction pump was provided to Teresa Christley, who was diagnosed with emphysema.
On January 6, another suction pump was delivered to Teresa. The first unit had to be replaced because of a defec-
tive piece.
Location
The following modifiers describe situations when you will need to clarify the location
at which services were provided:
PN Non-excepted service provided at an off-campus, outpatient, provider-based depart-
Class A Finding ment of a hospital
Nontraumatic amputation of PO Expected services provided at off-campus, outpatient, provider-based department
CPT © 2017 American Medical Association. All rights reserved.
a foot or an integral skeletal of a hospital
portion. SG Ambulatory surgical center (ASC) facility service
Class B Finding SU Procedure performed in physician’s office (i.e., to denote use of facility and equipment)
Absence of a posterior tibial TN Rural/outside providers’ customary service area
pulse; absence or decrease of
hair growth; thickening of the
nail, discoloration of the skin, Podiatric Care
and/or thinning of the skin
There are times when particular services are recategorized, determined by certain
texture; and/or absence of a
posterior pedal pulse. signs and/or symptoms that the patient may be exhibiting. The following list identifies
modifiers used to indicate some of these circumstances when a podiatrist provides
Class C Finding treatment to a patient:
Edema, burning sensation,
temperature change (cold feet), Q7 One class A finding
abnormal spontaneous sensa- Q8 Two class B findings
tions in the feet, and/or limping. Q9 One class B and two class C findings
Other Services
The modifiers shown in Table 22-17 do not seem to fit into any of the other categories
we have established. Review all the modifiers in the list, and see if you can come up
with examples of how and when they would be used.
Medicaid Services
Each state administers its own version of the federal Medicaid program and deter-
mines its own specific descriptions of the different levels of care. To maintain con-
sistency, HCPCS Level II has the modifiers shown in Table 22-18 that can be used
nationwide—even though the description of each modifier will change, as defined by
each state.
SY Persons who are in close contact with member of high-risk population (use with immunization codes only)
TC Technical component
TG Complex/high-tech level of care
TH Obstetrical treatment/services, prenatal or postpartum
TS Follow-up service
UF Services provided in the morning
UG Services provided in the afternoon
UH Services provided in the evening
UJ Services provided at night
UK Services provided on behalf of the client to someone other than the client (collateral relationship)
CHAPTER 22 |
TABLE 22-18 Medicaid Services Modifiers
Special Rates
The following two modifiers are used to indicate that a service or procedure was provided
to a patient during an unusual time frame, that is, not during regular working hours:
TU Special payment rate, overtime
TV Special payment rates, holidays/weekends
EXAMPLE
Dr. Weaver, and his surgical team, began the pancreatic transplantation procedure on
Kenneth. Once the incision had been made, the patient’s heartbeat became erratic
and could not be brought back under control, so the procedure was discontinued.
The procedure code reported requires two modifiers: 48554-53-66.
When a HCPCS Level II modifier is used in addition to a CPT modifier, the CPT
modifier is placed closest to the procedure code, and the HCPCS Level II modifier
follows.
EXAMPLE
24201-76-LT Removal of foreign body, upper arm or elbow area; deep,
repeat procedure by same physician, left side
There is an exception to this rule when reporting anesthesia services. The physical
status modifier always is reported closest to the anesthesia procedure code.
EXAMPLE
Dr. Cowles administered the general anesthesia when Dr. Dean had to take the
patient back into the surgery unexpectedly to attend to a problem with the replan-
tation procedure for the patient’s index finger of his right hand. For Dr. Cowles, the
code is 01810-P1-76.
CPT
LET’S CODE IT! SCENARIO
Dr. Tuders performed a bilateral osteotomy on the shaft of Arlis Richardson’s femur. Another surgeon performed the
same procedure on Jack 2 weeks ago but was unsuccessful, so Dr. Tuders repeated the procedure. As an expert in
CPT © 2017 American Medical Association. All rights reserved.
this procedure, he was brought in to perform the surgery only and will not be involved in any preoperative or post-
operative care of the patient.
CHAPTER 22 |
More Than Three Modifiers Needed
The outpatient claim form, upon which you will record your chosen codes and other
information to request reimbursement from the third-party payer, has a limited amount
of space in which to place the necessary information, particularly when it comes to the
inclusion of modifiers. Some third-party payers do not permit multiple modifiers to be
listed on the same line as the CPT code. Therefore, should your case require three or
more modifiers to completely explain all of the circumstances involved, you can use
modifier 99.
99 Multiple Modifiers: Under certain circumstances two or more modifiers may
be necessary to completely delineate a service. In such situations modifier
99 should be added to the basic procedure, and other applicable modifiers
may be listed as part of the description of the service.
CPT
YOU CODE IT! CASE STUDY
Dr. Cabbot drained an abscess on Mark Swanson’s left thumb and another on his second finger. Both were simple
procedures.
10060-FA Incision and drainage of abscess, simple or single; left hand, thumb
10060-F1-59 Incision and drainage of abscess, simple or single; left hand, second digit;
separate procedure
Without the modifiers FA for left hand, thumb; F1 for left hand, second digit; and 59 for distinct procedural
service, the claim form could not clearly communicate that Dr. Cabbot did work on two different fingers.
EXAMPLES
Just a few of the modifiers that might need a supplemental report to ensure com-
plete communications.
22 Increased Procedural Services . . . what was it that required the addi-
tional time and effort?
23 Unusual Anesthesia . . . why was this necessary?
52 Reduced Services . . . why couldn’t the physician complete the planned
procedure in full?
53 Discontinued Procedure . . . why did the physician have to stop?
CPT
LET’S CODE IT! SCENARIO
Aden Carrington, a 9-year-old boy, had a superficial cut, about 3.3 cm, on his left cheek, after being in a car accident
and hit by broken glass. Dr. Kern is ready to perform a simple repair of the wound, but she is very concerned. Aden
has Tourette’s syndrome, which causes him to jerk or move abruptly, especially when nervous. Although anesthe-
sia is not typically used for a simple repair of a superficial wound, Dr. Kern administers general anesthesia. Sharon
Haverty, a CRNA, assists Dr. Kern with monitoring Aden during the procedure.
12011 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mu-
cous membranes; 2.5 cm or less
The basic description matches the notes exactly. However, several choices are determined by the size of the
wound. The notes state that Aden’s wound was 3.3 cm. This brings you to the correct code:
12013 Simple repair of superficial wounds of face, ears, eyelids,
nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm
Great! Now, you have to address the fact that Dr. Kern gave Aden general anesthesia. This was done for a very
valid medical reason, and Dr. Kern (and her facility) should be properly reimbursed for the service. Anesthesia
is not included with code 12013 because it is not normally required. Aden’s case is unusual. Unusual circum-
stances often require modifiers, so let’s look at CPT’s Appendix A to see if there is an applicable modifier. Modi-
fier 23 seems to fit.
(continued)
CHAPTER 22 |
23 Unusual Anesthesia: Occasionally, a procedure, which usually requires either
no anesthesia or local anesthesia, because of unusual circumstances must be
done under general anesthesia. This circumstance may be reported by add-
ing modifier 23 to the procedure code of the basic service.
So modifier 23 should be appended, or attached, to the procedure code.
12013-23
You know that you have to code the anesthesia service as well.
00300 Anesthesia for all procedures on the integumentary system, muscles
and nerves of head, neck, and posterior trunk, not otherwise specified
Let’s look to see if there is an applicable CPT modifier to explain that an anesthesiologist was not involved. Modi-
fier 47 seems to fit.
47 Anesthesia by surgeon: Regional or general anesthesia provided by the
surgeon may be reported by adding modifier 47 to the basic service. (This
does not include local anesthesia.) Note: Modifier 47 would not be used as a
modifier for the anesthesia procedures.
Well, the note within the description of modifier 47 tells you that this modifier is necessary but that it cannot be
used with code 00300. You have to attach the modifier to the procedure code. Therefore, you submit the claim
with one CPT code and two modifiers: 12013-23-47. In addition, it is smart to include a supplemental report with
the claim to explain the use of general anesthesia. You are aware that the insurance company needs to know
the details before paying the claim.
Chapter Summary
Modifiers provide additional explanation to the third-party payer so that it can fully
appreciate any special circumstances that affected the procedures and services pro-
vided to the patient. In health care, as well as in so many other instances of our lives,
most things do not fit neatly into predetermined descriptions. By using modifiers
correctly, you provide an additional explanation and promote the efficient and more
accurate reimbursement of your facility.
CODING BITES
CPT MODIFIER REFERENCES:
Inside the front cover of your CPT code book: CPT modifiers and short
descriptions
Appendix A: CPT modifiers, some Level II (HCPCS/National) Modifiers, and full
descriptions
HCPCS LEVEL II MODIFIER REFERENCE:
Appendix 2: Modifiers
[NOTE: Different publishers may place the Modifier listing in different locations of
the HCPCS Level II code book.]
CHAPTER 22 REVIEW
CPT and HCPCS Level II Modifiers Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
Part I
1. LO 22.1 Containing both letters and numbers. A. Alphanumeric
2. LO 22.1 A two-character alphabetic or alphanumeric code that may be B. Ambulatory Surgery
appended to a code from the main portion of the CPT book or a code Center (ASC)
from the HCPCS Level II book. C. CPT Code Modifier
3. LO 22.8 A letter or report written by the attending physician or other health care D. HCPCS Level II
professional to provide additional clarification or explanation. Modifier
4. LO 22.1 A modifier relating to a change or adjustment of a procedure or service E. Modifier
provided.
F. Nonphysician
5. LO 22.2 A nurse practitioner, certified registered nurse anesthetist, certified reg-
G. Personnel Modifier
istered nurse, clinical nurse specialist, or physician assistant.
H. Physical Status
6. LO 22.1 A two-character code that affects the meaning of another code; a code
Modifier
addendum that provides more meaning to the original code.
I. Service-Related
7. LO 22.1 A facility specially designed to provide surgical treatments without an
Modifier
overnight stay; also known as a same-day surgery center.
J. Supplemental Report
8. LO 22.2 A modifier adding information about the professional(s) attending to
the provision of this procedure or treatment to the patient during this
encounter.
9. LO 22.1 A two-character code that may be appended to a code from the main
portion of the CPT book to provide additional information.
10. LO 22.1 A two-character alphanumeric code used to describe the condition of
the patient at the time anesthesia services are administered.
A. Automated Multi-
Part II Channel Chemistry
1. LO 22.6 Nontraumatic amputation of a foot or an integral skeletal portion. (AMCC)
CPT © 2017 American Medical Association. All rights reserved.
2. LO 22.6 A Medicaid preventive health program for children under 21. B. Class A Finding
3. LO 22.6 Nourishment delivered using a combination of means other than the gas- C. Class B Finding
trointestinal tract (such as IV) in addition to via the gastrointestinal tract. D. Class C Finding
4. LO 22.6 Edema, burning sensation, temperature change (cold feet), abnormal E. Clinical Laboratory
spontaneous sensations in the feet, and/or limping. Improvement
5. LO 22.6 Chronic, irreversible kidney disease requiring regular treatments. Amendment (CLIA)
6. LO 22.6 Absence of a posterior tibial pulse; absence or decrease of hair growth; F. Early and Periodic
thickening of the nail, discoloration of the skin, and/or thinning of the Screening, Diagnostic,
skin texture; and/or absence of a posterior pedal pulse. and Treatment (EPSDT)
7. LO 22.6 The measurement of how many liters of a drug or chemical are pro- G. End-stage renal disease
vided to the patient in 60 seconds. (ESRD)
8. LO 22.2 A physician who fills in, temporarily, for another physician. H. Locum Tenens Physician
CHAPTER 22 |
9. LO 22.6 Federal legislation created for the monitoring and regulation of clinical I. Liters Per Minute (LPM)
CHAPTER 22 REVIEW
CPT
HCPCS Level II
Part I
1. LO 22.1 A modifier explains
a. the reason a procedure was performed.
b. an unusual circumstance.
c. the date of service.
d. the level of education of the physician.
2. LO 22.1 CPT code modifiers are appended to
a. policy numbers. b. diagnosis codes. c. procedure codes. d. pharmaceuticalcodes.
3. LO 22.2 Service performed by a resident without the presence of a teaching physician under the primary care
exception is identified with modifier
a. AG b. AK c. GC d. GE
4. LO 22.3 A physical status modifier may only be appended to
a. surgical codes. b. radiology codes.
c. anesthesia codes. d. evaluation and management codes.
5. LO 22.1 An example of a HCPCS Level II modifier is
a. 23 b. LT c. P4 d. 99
6. LO 22.2 An example of a personnel modifier is
a. 81 b. 47 c. LC d. 57
7. LO 22.7 If a third-party payer limits your use of multiple modifiers, you should use
a. no modifiers b. 91 c. 51 d. 99
8. LO 22.3 P5 is an example of a
a. HCPCS Level II modifier.
b. CPT modifier.
c. physical status modifier. CPT © 2017 American Medical Association. All rights reserved.
d. personnel modifier.
9. LO 22.7 When appending both a CPT modifier and a HCPCS Level II modifier to a procedure code,
a. the HCPCS Level II modifier comes first.
b. the CPT modifier comes first.
c. it doesn’t matter which comes first.
d. use neither—they cancel each other out.
10. LO 22.8 A(n) _______ is a letter or report written by the attending physician or other health care professional to
provide additional clarification or explanation.
a. supplemental report b. service-related report
c. ambulatory surgery report d. personnel report
CHAPTER 22 REVIEW
1. LO 22.6 Appending modifier A7 identifies a(n)
a. aphakic patient.
b. most recent URR reading of 65 to 69.9
c. state-supplied vaccine.
d. dressing for seven wounds.
2. LO 22.4 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration
of anesthesia is identified with modifier
a. 27 b. 73 c. 74 d. AJ
3. LO 22.6 LPM stands for
a. local procedure modality.
b. licensed practical medicine.
c. local patient median.
d. liters per minute.
4. LO 22.4 Multiple outpatient hospital E/M encounters on the same date are identified by modifier
a. 27 b. 73 c. 74 d. 82
5. LO 22.6 An example of DME is
a. an aspirin.
b. the administration of a vaccination.
c. a wheelchair.
d. the removal of a cyst.
6. LO 22.6 CLIA is identified with modifier
a. BL b. QW c. SQ d. AV
7. LO 22.6 EPSDT for school-based individualized education program (IEP) services provided outside the public
school district responsible for the student is identified by
a. TR b. EP c. G7 d. TM
8. LO 22.5 Dr. Fullmark repairs a laceration on Johnny’s left lower eyelid. What modifier would be appended?
a. E4 b. E3 c. E2 d. E1
9. LO 22.5 Which of the following modifiers identifies the right foot, third digit?
a. T2 b. T7 c. T8 d. T9
10. LO 22.8 Which of the following modifiers may need a supplemental report?
CPT © 2017 American Medical Association. All rights reserved.
a. 50 b. 57 c. 66 d. 53
CHAPTER 22 |
CHAPTER 22 REVIEW
Part I
1. Dr. Clayton removed Ricky Pujara’s gallbladder 10 days ago. Today, he comes to see Dr. Clayton because of a
problem with his knee. Which modifier should be appended to the encounter’s E/M code?
2. Dr. Smyth performed an appendectomy on Lynda Lyman. However, the operation took twice as long as usual
because Lynda weighs 356 pounds.
3. Dr. Julienne performed a biopsy on the left external ear of Ben Maas, a 69-year-old male.
4. Christopher Slice, a 17-year-old male, was brought into the OR in the Bracker ASC to have a programmable
pump inserted into his spine for pain control. After the anesthesia was administered and Chris was fully
unconscious, Dr. Sutton made the first incision. Chris began to hemorrhage. The bleeding was stopped, the
incision was closed, and the procedure was discontinued.
5. Glenda Roberts, a 61-year-old female, goes to see Dr. Zentz at the referral of her family physician,
Dr. Younts, for his opinion as to whether or not she should have surgery. After the evaluation and Glenda’s
agreement, Dr. Zentz schedules surgery for Thursday. Which modifier should be appended to Dr. Zentz’s
consultation code for today’s evaluation?
6. Patricia Harris, an 82-year-old female, is having Dr. Harmon remove a cyst from her left ring finger.
7. Charles McBroom, a 4-week-old male, was rushed into surgery for repair of a septal defect. If the repair is not
completed successfully, he may not survive. What is the correct anesthesia physical status modifier?
8. Dr. Shull is preparing to perform open-heart surgery on Fred Faulkner. Dr. Lowell is asked to assist because a
surgical resident is not available. Which modifier should be appended to the procedure code on Dr. Lowell’s
claim for services?
9. Carolyn Lovett, a 37-year-old female, comes to see Dr. Richardson for a complete physical examination,
required by her insurance carrier.
10. George Carlos, a 9-week-old male, was born prematurely and weighs 3.8 kg. Dr. Wilson performs a cardiac
catheterization on George.
11. Dr. Kelley excised an abscess on Clyde Hawken’s great toe, right foot.
12. Annie Mathewson, a 12-year-old female, has been complaining of hearing a constant ringing in her right ear.
Dr. Burwell performs an assessment for tinnitus in the right ear only.
13. Dr. Maxwell performed a percutaneous transluminal coronary atherectomy, by mechanical method, on Ronald
Yates’s left circumflex artery.
CPT © 2017 American Medical Association. All rights reserved.
14. John Davis, a 25-year-old male, came to Dr. Browne to have corrective surgery on both of his eyes.
15. Tamara Connelly, a 16-year-old female, hurt her shoulder while camping. The clinic in the area took an x-ray
but did not have a radiologist, so Tamara brought the films to Dr. Evely for interpretation and evaluation.
Which modifier should Dr. Evely’s coder append to the code for the x-rays?
Part II
1. Dr. White performed a blepharotomy on Vanetta Regis, draining the abscess on her upper left eyelid.
2. Stacey Maxell, a nurse midwife, helped Janise Edge deliver her first baby, a girl.
3. Wilfred Edmonds, a 67-year-old male diagnosed with terminal bone cancer, has been in the hospice facility
for 3 weeks and is showing signs of an ear infection. Dr. Johns was called in to attend Wilfred’s ear problem.
CHAPTER 22 |
CHAPTER 22 REVIEW
PROCEDURE: Pt is a 43-year-old female. Patient was placed into position. Digital examination revealed
no masses. The pediatric variable flexion Olympus colonoscope was introduced into the rectum and
advanced to the cecum. A picture was taken of the appendiceal orifice and the ileocecal valve.
The scope was then carefully extubated. The mucosa looked normal. Random biopsies were taken from
the ascending colon, the transverse colon, the descending colon, the sigmoid colon, and the rectum.
There was a 3-mm sessile polyp in the mid-sigmoid colon that a hot biopsy destroyed.
CHAPTER 22 |
CHAPTER 22 REVIEW
Evaluation and Management (E/M) is the first section in the CPT book and lists codes System Review
numbered 99201–99499. These codes are used to report and reimburse physicians for Relationship
their expertise and thought processes involved in diagnosing and treating patients, Risk Factor Reduction
such as Intervention
∙ Talking with the patient and his or her family. Transfer of Care
∙ Reviewing data such as complaints, signs, symptoms, and examination results.
∙ Doing research in medical books and journals.
∙ Consulting with other health care professionals.
All these elements, including the training and education that this health care profes-
sional has had, go into the decision of what to do next for the patient—what advice,
what prescription, what test, what treatment, what procedure. E/M codes provide a
way to reimburse the health care professional for his or her assessment and supervision
of the patient and the determination of the best course for his or her care.
Preventive Evaluation and management (E/M) services go beyond those included in the typical
A type of action or service that office or hospital visit. Preventive medicine assessments—more commonly called
stops something from hap- annual physicals or wellness visits, evaluations of patients in short-term and long-term
pening or from getting worse. care facilities, counseling, and critical care—are just some of the areas of focus that
might be required of the attending physician. This chapter reviews these subcategories
GUIDANCE of E/M codes.
As you just read, E/M codes are used to describe specifically the physician’s exper-
CONNECTION tise and assessment that was provided during an encounter between him or her and a
When a specific code patient. There are many different types of E/M codes, as you will learn throughout
is approved for use this and the next chapter. Let’s begin by reviewing the pieces of information you will
in reporting services need to abstract from the physician’s documentation to code the E/M portion of the
provided using syn- encounter properly.
chronous, audiovisual,
telecommunications Face-to-Face (Office and Other Outpatient Visits)
equipment [indicated
by a star ( ) symbol to
You may have noticed the phrase face-to-face in the code description qualification
the left of the code],
about time. CPT is very specific about what is included in this element of E/M ser-
face-to-face may also
vices provided by a physician to a patient, such as the time it takes to collect health
occur electronically.
care–related history, perform the physical examination, and counsel the patient (as
Refer to the chapter
discussed previously).
CPT and HCPCS Level
Everyone understands that most physicians will spend time, before and after their
II Modifiers, where
encounters with patients, reviewing records, going over test results, conferencing with
you will find a section
other professionals and the patients by writing letters and reports, making phone calls,
on Service-Related
and performing other non–face-to-face tasks. Officially, these are not included in the
Modifiers, specifically
time component of the E/M codes.
modifier 95.
Unit/Floor Time (Hospital and Other Inpatient Visits)
When a physician attends to a patient in a facility, such as a hospital or nursing home,
GUIDANCE the measure of time, for purposes of E/M coding, is described a bit differently than for
CONNECTION outpatient encounters.
In outpatient encounters, time is measured by face-to-face—the number of minutes
Read the additional spent with the patient. With inpatient services, in addition to the face-to-face time that
explanations in the the physician may spend at bedside examining the patient, there are additional com-
Evaluation and Manage- ponents included in the measure of time. These additional components are known as
ment (E/M) Services unit/floor time, which include
Guidelines, subhead
Time, paragraphs ∙ Meeting with nursing staff and other health care professionals.
Face-to-face . . . and ∙ Speaking with family members.
Unit/floor time . . . , in ∙ Time the physician spends going over the patient’s chart and reviewing notes
your CPT book directly in by other professionals caring for the patient while the physician is still physically
front of the E/M section present in the hospital unit.
CPT © 2017 American Medical Association. All rights reserved.
that lists all the codes.
CHAPTER 23 |
CPT
LET’S CODE IT! SCENARIO
Suzette Kabole, an 87-year-old female, broke her hip 1 month ago. She has been a patient of Dr. Okine for several
years. Since her release from the hospital, Suzette has been homebound until her hip completely heals. Therefore,
Dr. Okine went to her home to check on her progress.
Match the E/M subsection code range for each of these locations:
.
1 Preventive Medicine Services a. 99201–99205
2. Telephone with patient b. 99217–99226
3. Emergency Department c. 99381–99429
4. Hospital Observation d. 99441–99443
5. Walk-in Clinic e. 99281–99288
Relationship
23.3 Relationship between Provider
The level of familiarity
between provider and patient.
and Patient
Throughout the E/M section of the CPT book, subheadings identify the relationship
New Patient
between the provider and the individual. E/M codes use different types of relation-
A person who has not
received any professional ser-
ship for determining the best, most appropriate code. You may have to identify, from
vices within the past 3 years the documentation, if the relationship between the physician and patient is as a new
from either the provider or patient or established patient; if this is initial care or subsequent care; or if this
another provider of the same qualifies as a temporary relationship—a consultation.
specialty who belongs to the
same group practice. New or Established Patient
Established Patient In many cases, you must know the relationship between the patient and the provider so
EXAMPLE
Barry Balmer is admitted to the hospital on Saturday after having a myocardial
infarction (MI) while playing tennis. His regular cardiologist, Dr. Hamilton, is out of
CPT © 2017 American Medical Association. All rights reserved.
town for the weekend, so Dr. Zenbar admits Barry to the hospital on Saturday and
checks in on his care on Sunday. Monday, when Dr. Hamilton returns, she goes to
see Barry in the hospital and takes charge of his care.
• On Saturday, an initial hospital care visit is reported for Dr. Zenbar because this
is his first time seeing Barry during this course of treatment at the hospital.
• On Sunday, a subsequent hospital care visit is reported for Dr. Zenbar because
this is his second time seeing Barry during this course of treatment at the hospital.
• On Monday, an initial hospital care visit is reported for Dr. Hamilton because
this is her first time seeing Barry during this course of treatment at the hospital,
even though it is Barry’s third day in the hospital.
• On Tuesday, a subsequent hospital care visit is reported for Dr. Hamilton
because this is her second time seeing Barry during this course of treatment at
the hospital.
CHAPTER 23 |
Consultations
There are times when the relationship between a patient and a health care provider is
expected to be temporary, typically lasting only one visit. In such cases, one physi-
cian or health care professional will ask another physician to meet with a patient and
evaluate a patient’s condition only to offer his or her own professional opinion about
the patient’s diagnosis and/or treatment options. This temporary relationship is known
GUIDANCE as a consultation.
When a patient goes to a physician for a consultation because the first physician is
CONNECTION merely seeking a second opinion from the consulting physician regarding diagnosis
Read the additional and/or treatment of the patient, it will be reported from the Consultations subsection
explanations in the of E/M. Different than other subsections, the consultation codes 99241–99255 are sep-
in-section guidelines arated into two parts on the basis of the location of where the consultation took place:
located within the Office and Other Outpatient Consultations and Inpatient Consultations.
Evaluation and
Management (E/M)
section, subhead EXAMPLE
Consultations, directly
Dr. Gail reviews Derita Beck’s lab tests and notices that her lipase level is very
above code 99241 in
high. This may indicate a problem with the patient’s pancreas. While Derita is
your CPT book.
healthy overall, Dr. Gail does not want to take any chances, so he refers Derita to
If the second opin-
Dr. Keith, a gastroenterologist, for a second opinion. Derita goes to see Dr. Keith,
ion is requested by the
who examines her, reviews the test results, and writes a letter to Dr. Gail agreeing
patient or a family mem-
with his assessment. Derita goes back to Dr. Gail and does not see Dr. Keith again.
ber instead of another
health care professional,
this is not reported as
a Consultation. It would The relationship between Dr. Keith and Derita Beck is not defined as new or
be reported as a New established but as a consultation—a second opinion requested by another physician.
Patient encounter. Therefore, Dr. Keith’s coder will report this one encounter from the Consultations
subsection, codes 99241–99255.
CPT
LET’S CODE IT! SCENARIO
Denny Rossman, a 49-year-old male, was having pain in his lower abdomen, especially when going to the bath-
room. His primary care physician, Dr. Lein, did a PSA and was not very concerned, so he told Denny to come back in
6–8 months for a follow-up. Denny did not feel comfortable about Dr. Lein’s decision and made an appointment for
a second opinion with Dr. Ellis, a urologist.
Referral or Consultation?
Referral and consultation are two terms that are commonly used and confused. When
one physician transfers the care and treatment for a patient (in total or for one par-
ticular issue) to another physician, this is a referral. The patient is merely being rec-
ommended to see another physician and is expected to become a patient of the other
physician. These visits are reported using the regular E/M codes, based on the loca-
tion of the encounter between the new physician (the specialist) and the patient—for
example, physician’s office 99201–99205, etc.
If the patient goes back to see the “consultant” again, this second E/M encounter will
be reported as an established patient encounter because this means that the “consultant”
Level of Service
While accurately reporting the level of expertise and knowledge used by the physician
during a visit may seem intangible, the Evaluation and Management (E/M) Services
Guidelines provide you with a checklist type of criteria—very specific and tangible
measurements to help you determine the appropriate level of service based on the doc-
umentation for the encounter. Let’s begin this step of E/M by discussing the elements
you need to determine what level of each component has been provided.
∙ Patient history taken
∙ Physical examination performed
∙ Medical decision making required to determine a diagnosis, or possible diagnoses,
and a treatment plan or next step
CHAPTER 23 |
Level of Patient History
As you look at the codes shown in the E/M Section of CPT, under the header Office or
Other Outpatient Services, you can see that included in the code description is a list
Level of Patient History with three bullets. Notice that the first key component (bullet) describes the level of
The amount of detail involved patient history taken during this encounter by the physician.
in the documentation of There are four levels of patient history. You can measure the level of patient history
patient history. taken by the physician by reading the notes and matching the documentation to this
list. Gathering information from the patient is an important part of the evaluation pro-
cess for the physician to complete. This is the portion of the visit where the physician
Chief Complaint (CC) asks the patient questions about his or her health and the situations surrounding the
The primary reasons why health concern that brought him or her to see this doctor.
the patient has come for this
encounter, in the patient’s Problem-Focused History
own words. a. A discussion of the patient’s chief complaint (CC)
History of Present Illness (HPI) b. A brief history of present illness (HPI) or concern
The collection of details Taking a problem-focused history from the patient is going to gather information about
about the patient’s chief
only the reason the patient came to this physician today. The physician and patient are
complaint, the current issue
that prompted this encounter:
not discussing anything else—no other concern, just this one aspect.
duration, specific signs and
symptoms, etc.
EXAMPLE: ANTONIO 1
Antonio goes to Dr. Grace because he has a cough. [Antonio’s chief complaint (CC)]
Dr. Grace documents that Antonio explained what type of cough (dry or wet),
how long he has been coughing, whether the cough is worse when lying down,
and the color of any mucus that may be coughed up. [Documentation of the
history of Antonio’s present illness (HPI)]
Detailed History
a. A discussion of the patient’s chief complaint.
b. An extended history of this present illness or concern.
c. A problem-pertinent system review extended to include some additional systems.
d. A pertinent past, family, and social history (PFSH). Past, Family, and Social
History (PFSH)
Collection of details, related
CODING BITES to the chief complaint, regard-
ing possible signs, symptoms,
A PFSH has three key components that that you should be watching for while
behaviors, genetic connec-
abstracting that will help you differentiate a detailed history: Past history, Family
tion, etc.
history, and Social History.
Past History [Patient’s Medical History (PMH)]
• Prior major illnesses and injuries
• Prior operations
• Prior hospitalizations
• Current medications
• Allergies (e.g., drug, food)
• Age-appropriate immunization status
• Age-appropriate feeding/dietary status
Family History
• The health status or cause of death of parents, siblings, and children
• Specific diseases related to problems identified in the chief complaint, history
of present illness, and/or system review
• Diseases of family members that may be hereditary or place the patient at risk
Social History
• Marital status and/or living arrangements
CPT © 2017 American Medical Association. All rights reserved.
• Current employment
• Occupational history
• Use of drugs, alcohol, and tobacco
• Level of education
• Sexual history
• Other relevant social factors
EXAMPLE: ANTONIO 3
In addition to the previous questions for both problem-focused and expanded
problem-focused histories, the documentation for the visit between Antonio and
Dr. Grace may show information about whether Antonio ever had a cough like this
(continued)
CHAPTER 23 |
before; whether he has a history of sinus problems, heart problems, respiratory
problems, and/or throat problems; whether anyone in his family ever suffered a
cough like this; whether he smokes or lives/works/socializes with anyone who
smokes; and in what type of environment he works. [Dr. Grace is now asking
more questions, seeking a potential connection to a chronic problem (had this in
the past); genetics (anyone in the family have this); and social (behaviors that are
known to contribute to the chief complaint).]
Comprehensive History
CODING BITES a. A discussion of the patient’s chief complaint.
A complete PFSH would b. An extended history of this present illness or concern.
cover details about the c. A review of systems related to the problem.
patient’s health that cov-
ers all or most body sys- d. A review of all additional body systems.
tems and health-related e. A complete PFSH.
behaviors.
EXAMPLE: ANTONIO 4
In addition to the previous questions, the documentation for the visit between
Antonio and Dr. Grace may show information about Antonio’s complete medi-
cal history beyond those issues related to the respiratory system, to include his
entire body; about his allergies, vaccinations, vacations or other travel, general
GUIDANCE health, weight gain or loss, history of hypertension, diabetes; about the health of
his parents, siblings, etc. [Dr. Grace is now asking more questions, to get specific
CONNECTION knowledge about Antonio’s overall health as well as the health of his family. This
Read the additional broader understanding of Antonio’s health can provide important clues to his cur-
explanations in the rent diagnosis.]
Evaluation and Manage-
ment (E/M) Services
Guidelines, subhead
Table 23-1 may provide you with help to determine what level of history is
Determine the Extent
documented.
of History Obtained, in
your CPT book directly in Level of Physical Examination
front of the E/M section
that lists all the codes. The second key component (bullet) describes the level of physical examination
that was performed during an encounter with the physician. There are four levels of
physical examination. You can measure the level of examination performed by the
Level of Physical
Examination
physician by reading the notes and matching the documentation to the following list.
The extent of a physician’s CPT © 2017 American Medical Association. All rights reserved.
clinical assessment and Problem-Focused Examination
inspection of a patient. a. A limited examination of the affected body area or organ system.
EXAMPLE: ANTONIO 6
An expanded problem-focused exam during the visit between Antonio and
Dr. Grace may indicate that Dr. Grace also looked up his nose, palpated his cheeks
(sinuses), and perhaps listened to his lungs. [Dr. Grace does a more in-depth exam
of those anatomical sites directly related to Antonio’s chief complaint.]
Detailed Examination
a. An extended examination of the affected body area(s) or organ system(s).
b. An examination of any other symptomatic or related body area(s) or organ system(s).
EXAMPLE: ANTONIO 7
In addition to looking at Antonio’s throat, nose, and lungs, Dr. Grace may also have
listened to his heart; manually palpated his lymph nodes and neck; and palpated
his abdomen, specifically the upper middle (stomach area). [Dr. Grace expands his
exam to include other anatomical sites that may relate to a cough.]
The CPT book categorizes 7 body areas and 11 organ systems in its determination
of the best, most appropriate level of physical examination. The CPT definitions of
each body area and each recognized organ system are a bit different than you learned
in anatomy class:
BODY AREAS
1. Head, including the face
CPT © 2017 American Medical Association. All rights reserved.
2. Neck
3. Chest, including breasts and axilla
4. Abdomen
5. Genitalia, groin, buttocks
6. Back
7. Each extremity (arms and legs)
ORGAN SYSTEMS
1. Eyes
2. Ears, mouth, nose, and throat
3. Cardiovascular
CHAPTER 23 |
4. Respiratory
GUIDANCE
5. Gastrointestinal
CONNECTION
6. Genitourinary
Read the additional 7. Musculoskeletal
explanations in the
Evaluation and Man-
8. Skin
agement (E/M) Services 9. Neurologic
Guidelines, sub- 10. Psychiatric
head Determine the 11. Hematologic/lymphatic/immunologic
Extent of Examination
Performed, in your CPT
Comprehensive examination
book directly in front of
the E/M section that lists a. A general, multisystem examination—or—
all the codes. b. A complete examination of a single organ system
Table 23-2 may provide you with help to determine what level of physical examina-
tion is documented.
EXAMPLE: ANTONIO 8
In addition to all of the above, Dr. Grace may have taken a chest x-ray, done a
respiratory efficiency test, and taken a sputum culture and/or throat cultures.
Straightforward MDM
a. A small number of possible diagnoses
b. A small number of treatment or management options
c. A low to no risk for complications
d. Little to no data or research to be reviewed
EXAMPLE: ANTONIO 10
If Dr. Grace observed Antonio had a different type of inflammation (other than
tonsillitis), such as some indication that his condition might be strep throat or
pharyngitis, the process of determining what is best to do is slightly more complex.
If so, then a culture would need to be taken for a lab test.
Moderate-complexity MDM
a. A multiple number of possible diagnoses
b. A multiple number of treatment or management options
c. A moderate amount of data to be reviewed
d. A moderate level of risk for complications, possibly due to other existing diagnoses CODING BITES
or medications currently being taken Certain terms in the
physician’s notes may
indicate a more com-
plex process of MDM
EXAMPLE: ANTONIO 11 on the physician’s part.
In addition to the inflammation Dr. Grace observed, he also noted worrisome Orders for several tests
sounds in Antonio’s lungs. This complicates matters because the diagnosis with terms such as
possibilities now extend from tonsillitis to strep throat to asthma, bronchitis, or rule out, possible, and
pneumonia. Or perhaps Antonio has a history of asthma or previous bouts with likely might indicate the
pneumonia. Or perhaps Antonio has other known current illnesses, such as physician is looking for
hypertension or diabetes, which may make diagnosing and treating this condition evidence of several pos-
much more complicated. sible diagnoses.
High-complexity MDM
a. A large number of possible diagnoses
b. A large number of treatment or management options
CPT © 2017 American Medical Association. All rights reserved.
EXAMPLE: ANTONIO 12
In highly complex cases, the documentation will show issues such as multiple
co-morbidities (other conditions or diseases), current multiple medications that
may make determining the best treatment for a problem more dangerous for fear
of adverse interactions, perhaps allergies to medications under consideration, or
other factors that make the determination of the best course of treatment for the
patient incredibly complicated.
CHAPTER 23 |
TABLE 23-3 Determine Level of Medical Decision Making Documented
Table 23-3 may provide you with help to determine what level of MDM is
documented.
EXAMPLE
Bernard Clinton comes in to his physician’s office with a large shard of glass in his
hand. You can see that the number of potential diagnoses is very small: a foreign
body in his hand. There are a small number of treatment options: remove the
shard. There are no real health complications, and the physician should not have
GUIDANCE to research Bernard’s condition before deciding what to do. This is a straightfor-
CONNECTION ward level of MDM.
Read the additional
explanations in Evalua-
tion and Management
(E/M) Services Guide- EXAMPLE
lines, subhead Deter- Karen Potts comes to see her family physician, Dr. Seridan, and complains of mal-
mine the Complexity of aise and fatigue. She denies any major changes in her diet or lifestyle prior to the
Medical Decision Mak- onset of her symptoms. This is a complex situation that will take a lot of investiga-
ing, in your CPT book tion and knowledge on the part of the physician to determine Karen’s underlying
directly in front of the condition. There are numerous possible diagnoses and, therefore, a large number
E/M section that lists all of management options. Dr. Seridan may have to perform several diagnostic tests
the codes. to help him determine the problem. This is a highly complex case.
CODING BITES
When the patient history, examination, and MDM are not performed at the same
level, the guidelines instruct you to choose the one code that identifies the required
key components that have been met or exceeded by the physician’s documentation.
CPT © 2017 American Medical Association. All rights reserved.
But what about when the three levels point toward different E/M codes? How do
you mesh them all into one code? The CPT guidelines state, “. . . must meet or exceed
the stated requirements to qualify for a particular level of E/M service.” Let’s use a
scenario to figure this out together.
CPT
LET’S CODE IT! SCENARIO
Sadie Adanson, an 89-year-old female, was admitted today into McGraw Skilled Nursing Facility (SNF) by Dr. Domino
for rehabilitation and care. She suffered a stroke 2 weeks ago and was just discharged from the hospital. Dr. Domino
documented a comprehensive level of history. She performed a detailed level of physical exam. Due to the patient’s
advanced age, co-morbidities, and long list of current medications, as well as the late effects of the stroke, Dr. Domino’s
MDM was of high complexity.
(continued)
CHAPTER 23 |
Let’s Code It!
First, identify the location where the encounter between Dr. Domino and Sadie Adanson occurred. The notes state,
“admitted into McGraw Skilled Nursing Facility.” Turn in the CPT book, E/M section, to Nursing Facility Services. This
subsection of E/M is divided into two parts: Initial Nursing Facility Care and Subsequent Nursing Facility Care.
The documentation states that Sadie was admitted today, so this must be the first time Dr. Domino is caring
for Sadie at this nursing home. Now you know that the correct code for Dr. Domino’s evaluation of Sadie for this
visit must be within the Initial Nursing Facility Care 99304–99306 range.
Next, you need to check the requirements for this range of codes. The code descriptions tell you that ALL
THREE key components—level of history, exam, and MDM—must be met or exceeded to qualify. In a full case,
you will go back and read through the physician’s notes to determine the level provided for each of the three
components, as you learned earlier in this chapter. This scenario is provided with a shortcut, indicating the levels
for you: “comprehensive history . . . detailed exam . . . MDM high complexity.”
Comprehensive history meets the descriptions for 99304, 99305, and 99306.
Detailed exam only meets the description of 99304. Codes 99305 and 99306 both require a comprehen-
sive exam to have been performed.
MDM high complexity meets the description of 99306 and exceeds (a higher level was actually docu-
mented) for codes 99304 and 99305.
You must find the one code that is satisfied by ALL THREE levels of care.
99304:
You have documentation that is equal to this level of history.
You have documentation that is equal to this level of exam.
You have documentation that is greater than this level of MDM.
99305:
You have documentation that is equal to this level of history.
You do NOT have documentation that is equal to this level of exam.
You have documentation that is greater than this level of MDM.
99306:
You have documentation that is equal to this level of history.
You do NOT have documentation that is equal to this level of exam.
You have documentation that is equal to this level of MDM.
The only code that has ALL THREE levels equal to or greater than its requirements is 99304, so this is the code
that must be reported.
Now, let’s take a look at another scenario that requires only two of the three
components. CPT © 2017 American Medical Association. All rights reserved.
CPT
LET’S CODE IT! SCENARIO
Patrick Chapman, a 77-year old male, has been living at Northside Assisted Living Facility for 6 months. Dr. Colon, his
primary physician since he moved in, comes in today to see Patrick because of a complaint of leg pain. Dr. Colon docu-
ments a problem-focused interval history, an expanded problem-focused exam, and MDM of moderate complexity.
99335:
You have documentation that is NOT equal to this level of history.
You have documentation that is equal to this level of exam.
You have documentation that is greater than this level of MDM.
99336:
You have documentation that is NOT equal to this level of history.
You have documentation that is NOT equal to this level of exam.
You have documentation that is equal to this level of MDM.
Now, you must report the highest level of code that has at least TWO levels equal to or greater than its require-
ments. The only choice is 99335.
GUIDANCE CONNECTION
Read the list of these elements, body areas, and organ systems found in the Evalua-
CPT © 2017 American Medical Association. All rights reserved.
tion and Management (E/M) Services Guidelines, subhead Select the Appropriate
Level of E/M Services Based on the Following, in your CPT book directly in front of
the E/M section that lists all the codes.
CPT
YOU CODE IT! CASE STUDY
Daman Cordero, a 41-year-old male, came to see Dr. Decklin in her office for the first time because of a cough, fever,
excessive sputum production, and difficulty in breathing. He had been reasonably well until now. Dr. Decklin did an
expanded problem-focused exam of the patient’s respiratory system and took Daman’s personal, family, and social
history in detail. After a chest x-ray was taken to rule out pneumonia, Dr. Decklin’s straightforward MDM led her to
diagnose him with bronchitis and prescribe an antibiotic and a steroid.
(continued)
CHAPTER 23 |
You Code It!
Go through the steps of E/M coding, and determine the E/M code that should be reported for this encounter
between Dr. Decklin and Daman Cordero.
Step #1: Read the case completely.
Step #2: Abstract the notes: Which key words can you identify relating to the E/M service performed?
Step #3: What is the location?
Step #4: What is the relationship?
Step #5: What level of patient history was taken?
Step #6: What level of physical examination was performed?
Step #7: What level of MDM was required?
Step #8: What is the most accurate E/M code for this encounter?
Step #9: Double-check your work.
Answer:
Did you determine the correct code to be 99202? Good work!
You know, from the notes, that Daman saw the doctor “in her office.” This tells you the location. You also can
detect that Daman is a new patient because Dr. Decklin is seeing him “for the first time.”
You would need to use code 99203 because the physician documented “history in detail.” However, the level
of physical examination performed would better match code 99202 because she performed only “an expanded
problem-focused exam.” Code 99202 is also supported by the “straightforward medical decision making.” So when
you examine the requirements to meet or exceed the key components of code 99202, you consider the following:
• Expanded problem-focused history: Exceeded.
• Expanded problem-focused exam: Met.
• Straightforward decision making: Met.
The correct E/M code for this scenario is 99202.
CPT
LET’S CODE IT! SCENARIO
Rafael Soriano, a 17-year-old male, was brought into the ED by ambulance after being involved in a motorcycle
accident. He was not wearing a helmet, and his head hit a brick wall. After initial evaluation and testing by the ED
physician, Rafael was sent to the CCU and Dr. Haung spent 2 hours reviewing test results, performing a complete
physical exam of Rafael, and discussing a care management plan with the rest of the medical team.
CHAPTER 23 |
Note that these code descriptions report a day of E/M service, not just history/exam/
GUIDANCE MDM or even time spent.
CONNECTION
Intensive Care Services—Child
Read the additional
explanations in the There is a difference between a patient who is critically ill and one who requires inten-
in-section guidelines sive care services, such as intensive observation, cardiac and respiratory monitoring,
located within the vital sign monitoring, and other services detailed in the guidelines for this subsection
Evaluation and Man- (shown above code 99477).
agement (E/M) section, Determining the most accurate code in this subsection will require you to have two
subhead Initial and essential pieces of information:
Continuing Intensive ∙ 99477 reports the initial hospital care for a neonate, 28 days of age or younger, who
Care Services, directly requires intensive care, as per those services identified in the guidelines.
above code 99477 in
∙ Subsequent intensive care codes 99478–99480 are distinguished by the present
your CPT book.
weight of the neonate.
Note that these code descriptions report a day of E/M service, not just history/exam/
MDM or even time spent.
GUIDANCE
CONNECTION Time
Read the additional Under certain circumstances, the correct E/M code is not determined by the key com-
explanations of these ponents of history, physical exam, and MDM but is based on the amount of time the
elements used to deter- physician spent evaluating the patient’s condition and managing his or her care. In
mine the most accurate these cases, the time shown in the last paragraph of the E/M code description is used
E/M code involving the as a guide. This detail can be found following the three bullets for the key compo-
measurement of time nents. You will see that the last sentence reads something like Typically, 20 minutes
spent with the patient are spent face-to-face with the patient and/or family (found in the last portion of the
in the Evaluation and code 99202 description). This gives you an approximate time frame that may be used
Management (E/M) Ser- instead of the other key components to determine the appropriate level. In order to
vices Guidelines, sub- use this guideline to choose a code, the documentation must contain the appropriate
head Time, in your CPT specific information.
book directly in front of
the E/M section that lists Counseling between Physician and Patient
all the codes.
If the physician spends more than half (51% or more) of the total time counseling the
patient, then time spent shall be used as the key element in determining the best, most
appropriate E/M code. This is not psychological counseling with a therapist (reported
with codes 90804–90857) but the physician’s discussing diagnosis and treatment with
the patient. It might be to review test results or to go over care options with a family
member. The CPT guidelines specify the following:
∙ The results of recommendations for diagnostic tests and/or the review of the results
of tests and impressions already gathered.
CPT © 2017 American Medical Association. All rights reserved.
EXAMPLE
The doctor writes, “I discussed with the patient that the MRI shows an area of
concern. . . .”
EXAMPLE
The doctor writes, “I explained to the patient that his condition can be treated
with medication or surgery. The research shows that this new drug has been quite
effective; however, there are some side effects. . . .”
EXAMPLE
The doctor writes, “Prescription provided with instructions to take one tablet three
times a day. I want to see you in 1 week.”
EXAMPLE
The doctor writes, “I informed the patient that she needs to take all of the pills in
this pack. Even if she is feeling better, I instructed her to keep taking them until
they are all gone.”
CHAPTER 23 |
Long-Term Care Services
Specific codes are used to report E/M services provided to patients in residential care
facilities.
Use 99304–99318 and 99379–99380 for reporting services to patients in the
following places:
∙ Skilled nursing facilities (SNF)
∙ Intermediate care facilities (ICF)
∙ Long-term care facilities (LTCF)
∙ Psychiatric residential treatment centers
Use 99324–99340 for reporting services to patients in locations where room, meals,
Basic Personal Services and basic personal services are provided, but medical services are not included:
Services that include washing/
bathing, dressing and undress-
∙ Assisted living facilities
ing, assistance in taking medi- ∙ Domiciliaries
cations, and assistance getting ∙ Rest homes
in and out of bed.
∙ Custodial care settings
∙ Alzheimer’s facilities
GUIDANCE EXAMPLE
CONNECTION Dr. Banks goes to see Peter Lister at the halfway house where he resides. Peter is
autistic, and Dr. Banks wants to examine him and adjust his medication for asthma.
Read the additional
You should report Dr. Banks’s visit to Peter with code 99334.
explanations in the
in-section guidelines
located within the
Evaluation and Man-
Care Plan Oversight Services
agement (E/M) section,
subhead Nursing Facil- When a physician provides care plan oversight services, you have to use the appro-
ity Services, directly priate code determined by the length of time involved and the type of facility in which
above code 99304 in the patient is located.
your CPT book. 99339–99340 for patients in assisted living or domiciliary facility
99374–99375 for home health care patients
99377–99378 for hospice patients
Care Plan Oversight Services
E/M of a patient, reported 99379–99380 for residents in a nursing facility—but only if the manage-
in 30-day periods, includ- ment of the patient involves repeated direction of therapy by the attending
ing infrequent supervision physician
CPT © 2017 American Medical Association. All rights reserved.
along with preencounter and
postencounter work, such
as reading test results and Admission to a Nursing Facility
assessment of notes. When a patient is admitted into a nursing facility as a continued part of an encounter
at the physician’s office or the emergency department (ED) (on the same day by the
same physician), you report only one code (from the Nursing Facility section of the
E/M codes) that will include all the services provided from all the locations on that
day. The admission to the hospital from the physician’s office or ED is reported all in
the one hospital admission E/M code. The same rule also applies to admission to a
nursing facility.
However, if the patient has been discharged from inpatient status on the same day
as being admitted to a nursing facility, you code the physician’s discharge services
separately from the admission.
Three key components, similar to other E/M codes, are used to determine the
appropriate level of E/M service provided by the attending physician to a patient on
CPT
LET’S CODE IT! SCENARIO
Mara Morietty, a 55-year-old female, was diagnosed with advanced pancreatic cancer and is being cared for at her
home by her family, with the help of a home health agency. Dr. Clarke is providing care plan oversight services for
the first month of care. The plan includes home oxygen, IV medications for pain control management, and diuretics
for edema and ascites control. Dr. Clarke also discusses end-of-life issues, living will directive, and other concerns
with the family, the nurse, and the social worker. Dr. Clarke includes documentation of his 45-minute assessment,
as well as notes on modifications to the care plan. Certifications of care from the nursing staff, the social worker, the
pharmacy, and the company supplying the durable medical equipment for support are also in the record.
Now, let’s turn to code 99374 to read the entire code description:
99374 Physician supervision of a patient under care of home health agency (patient not
present) in home, domiciliary or equivalent environment requiring complex and multi-
disciplinary care modalities involving regular physician development and/or revision
of care plans; 15–29 minutes
99375 30 minutes or more
Dr. Clark’s notes report that he spent 45 minutes. Therefore, the correct code is 99375.
CHAPTER 23 |
GUIDANCE Case Management Services
CONNECTION If a patient has several or complex health issues or diagnoses, a team of health care
professionals may have to work together to provide proper management and treatment.
Read the additional The team may involve several physicians or the attending physician and a physical
explanations in the therapist, for example, conferencing together. To properly reimburse the health care
in-section guidelines professional for the time and expertise spent on the patient’s behalf with other profes-
located within the Evalu- sionals, you report such services using codes from ranges
ation and Management
(E/M) section, subheads 99366–99368 Medical Team Conferences
Case Management 99441–99443 Telephone Services
Services, directly above 99444 On-Line Medical Evaluation
code 99363, and Medi- 99446–99448 Interprofessional Telephone/Internet Consultations
cal Team Conferences,
directly above code
99366, in your CPT book.
CPT
YOU CODE IT! CASE STUDY
Scott Germain, an 81-year-old male, is still having pain and swelling in his hands. Dr. Daniels, an orthopedist, came
in to evaluate Scott 2 weeks ago, and Ira Hansrani’s last physical therapy session with Scott was yesterday.
Dr. Rubine, the gerontologist and primary care physician for Scott, reads the up-to-date notes and test results,
and sets up a meeting in the conference room with Ira Hansrani, the physical therapist, and Dr. Daniels to discuss
adjusting Scott’s therapy plan, based on current test results. The meeting lasts 45 minutes.
EXAMPLE
Dr. Baldwin is a neonatologist. Dr. Matthews, an obstetrician, asked Dr. Baldwin to
be in attendance during the delivery of Anita Mescale’s baby because of a con-
cern over her excessive alcohol consumption during pregnancy. Dr. Baldwin was
there and stabilized the baby after birth. You would report Dr. Baldwin’s service
with code 99464.
Home Services
If a physician provides E/M services to a patient at his or her private residence, use
codes 99341–99350. Determine the most appropriate code by using the same key com-
ponents as those for E/M services provided in the physician’s office.
Some home health agencies employ physicians, some physicians may volunteer
to see homebound patients, while others visit only established patients who are
homebound.
When a health care professional other than the physician—such as a nurse or respi-
ratory therapist—cares for a patient at the patient’s home, report these services with a
CPT © 2017 American Medical Association. All rights reserved.
CPT
LET’S CODE IT! SCENARIO
Jules Paganto, a 39-year-old male, suffers from agoraphobia and cannot leave his home. Dr. Volente went to the
house to examine Jules because he was complaining of chest congestion. Dr. Volente took a problem-focused his-
tory, as this was the first time he had seen Jules. The doctor examined Jules’s HEENT and chest and concluded that
Jules had a chest cold. He told Jules to get some over-the-counter cold medicine and to call if the symptoms did not
go away within a week.
(continued)
CHAPTER 23 |
Let’s Code It!
You need to find the appropriate code to reimburse Dr. Volente for his E/M services to Jules Paganto. You know
that “Dr. Volente went to the house,” so the location section is titled Home Services. The notes say that “this
was the first time he had seen Jules,” meaning that Jules is a new patient, narrowing the choices to codes
99341–99345. The book tells us that a new patient home visit requires three key components: history, exami-
nation, and MDM. According to the notes, Dr. Volente
1. Took a problem-focused history.
2. Examined the patient’s head, ears, eyes, nose, throat (HEENT), and chest: expanded problem-focused
because the doctor examined the affected body system and other related organ systems.
3. Concluded, without tests or additional resources: straightforward.
When you assess the levels and use the meet or exceed rule, the most accurate code for the visit is 99341.
Good job!
Non-Face-to-Face
Everyone is trying to work more efficiently by using the telephone or the Internet to
communicate with an established patient and/or the patient’s family, coordinate care,
discuss test results, or answer a question. This makes good sense.
To report E/M services provided by the physician over the telephone, a code from
the range 99441–99443 should be used. The different codes are distinguished by the
GUIDANCE
length of time of the call. However, before you report one of these codes, there are
CONNECTION restrictions. If the phone call is a follow-up to an E/M service provided for a related
Read additional expla- problem or concern that occurred within the previous 7 days, none of these codes can
nations in the in-section be reported because the phone call is considered part of that service. In the same light,
guidelines within if the phone call results in the decision for the patient to come in to see the physician
the Evaluation and as soon as possible, this phone call is considered a part of that future E/M service, so
Management (E/M) one of these codes would not be used, either.
Services section, sub- Code 99444 is used to report an online E/M service to an established patient, a
head N on-Face-to-Face guardian, or a health care provider as a response to a patient’s question. Similar to
Services, related to the restriction on the reporting of a telephone call, code 99444 should not be reported
codes 99441–99449 in when this e-mail or Internet communication is connected to an E/M service provided
your CPT book. for a related concern that occurred within the previous 7 days or within a surgical pro-
cedure’s postoperative period.
EXAMPLE
Dr. Herbert provides anticipatory guidance to Kenneth Simons with regard to
being careful about protecting his respiratory health. Kenneth works at an auto-
mobile paint shop, and the fumes are very dangerous if a breathing mask is not
worn.
CHAPTER 23 |
Specific Preventive Medicine codes are determined first by New Patient or
Established Patient, and second by the patient’s age:
∙ Infant (age younger than 1 year)
∙ Early childhood (age 1 through 4 years)
∙ Late childhood (age 5 through 11 years)
∙ Adolescent (age 12 through 17 years)
∙ 18–39 years
∙ 40–64 years
∙ 65 years and older
You may be familiar with the standards of care that have physicians check different
parts of the body in different ways, determined by the patient’s age, such as:
∙ Behavioral assessments for children ages 0 to 11 months, 1 to 4 years, 5 to 10 years,
11 to 14 years, and 15 to 17 years.
∙ Hearing screening for all newborns.
∙ Diabetes (type 2) screening for adults with high blood pressure.
If elements such as risk factor reduction intervention or counseling occur during
a separate visit (not at the same time as the physical examination), you have to code
them separately with a code from the 99401–99412 range.
If, during the course of the preventive medicine examination, the physician finds
something of concern that warrants special and extra attention involving the key com-
ponents of a problem-oriented E/M service, the extra work should be coded with a
separate E/M code appended with modifier 25. It is applicable only when the same
physician does the extra service on the same date.
CPT
LET’S CODE IT! SCENARIO
Kensie Hamilton, a 47-year-old female, comes to see her regular physician, Dr. Granger, for her annual physical. Dur-
ing the examination, Dr. Granger finds a mass in her abdomen that concerns him. After the exam, he sits and talks
with Kensie about past or current problems with her abdomen, including pain, discomfort, and other details regard-
ing her abdominal issue. He asks whether any family members have had problems in that area, as well as about
her alcohol consumption and sexual history as they relate to this concern. Dr. Granger then goes into his office to
analyze the multiple possibilities of diagnoses, evaluates the information in Kensie’s chart, and reviews the moder-
ate risk of complications that might occur due to her current list of medications. He orders an abdominal CT scan,
blood work, and a UA for further input.
Let’s Code It! CPT © 2017 American Medical Association. All rights reserved.
According to the notes, Dr. Granger performed an “annual physical exam,” also known as a preventive medicine
exam, on Kensie, a “47-year-old.” Go to the Alphabetic Index and look up Evaluation and Management, Preventive
Services, or go directly to the E/M section and look for the Preventive Medicine Services subheading. The phrase
“her regular physician” reveals that Kensie is an established patient, helping you to determine to report code
99396 Periodic comprehensive preventive medicine, established patient, 40–64 years
Dr. Granger’s notes also reveal that during the exam he found a mass in Kensie’s abdomen that he felt needed
further investigation. He spent additional time getting details about her personal, family, and social history
regarding abdominal problems; he reviewed concerns about multiple possible diagnoses, complications, and
treatments. As per the guidelines, this is extra work done on Dr. Granger’s part, and therefore he is entitled to
additional reimbursement, reported with a separate E/M code. As you review the notes, you should be able to
GUIDANCE
23.6 Abstracting the Physician’s Notes CONNECTION
You learned about abstracting clinical documentation in the chapter Abstracting Read additional explana-
Clinical Documentation. Abstracting for details regarding evaluation and manage- tions in the in-section
ment (E/M) is a bit different because you have to cull out details about the physi- guidelines located
cian’s thought processes, in addition to specifically what was done and why. Very within the Evaluation
rarely will physicians actually identify the level of MDM in their notes with a state- and Management (E/M)
ment such as “MDM was low complexity.” So, you really need to hone your inter- section, subhead Preven-
pretative skills. tive Medicine Services,
directly above code
99381 in your CPT book.
CPT
YOU CODE IT! CASE STUDY
Gloria Merro, a 33-year-old female, comes to see Dr. Feldner at his office with complaints of severe pain in her right
wrist and forearm. She just moved to the area, and this is the first time Dr. Feldner has seen her. Gloria sees Dr. Feldner
for a very specific concern. The doctor asks Gloria about any medical history she may have related to her arm
(diagnosed osteoporosis, previous broken bones, etc.). Next, Dr. Feldner examines Gloria’s arm. He suspects that the
arm is broken and orders an x-ray to be taken.
CHAPTER 23 |
Answer:
Did you determine this to be the correct code?
99201 Office or other outpatient visit, new patient
Let’s carefully review the physician’s notes.
• Where did the encounter occur? Gloria went “to see Dr. Feldner at his office.” This will lead us to the first sub-
heading in the E/M section, Office or Other Outpatient Services.
• What is the relationship? The notes state, “She just moved to the area, and this is the first time Dr. Feldner has
seen her.” This brings us to the category of New Patient, and the code range 99201–99205.
• What is the level of history? The notes state, “The doctor asks Gloria about any medical history she may have
related to her arm,” meaning that all the history he took was problem-focused.
• What is the level of exam? You will see that “Dr. Feldner examines Gloria’s arm.” This means only one body
area (each extremity) or one organ system (musculoskeletal) was examined. That’s problem-focused.
• What is the level of MDM? In this case, did you analyze the situation and determine that the MDM was straight-
forward? However, you can see that the documentation supports the definition of this level: There is only
one diagnosis, the management options are limited (put a cast on it), there are very few complications, and
Dr. Feldner didn’t really have to do any research to recommend a course of treatment.
This brings you to the best, most appropriate E/M code: 99201.
Please understand that the physicians will not come right out and use the same
words as the code descriptions to describe what occurred during the encounter. Let’s
inspect various statements from patients’ charts and identify the key words that lead to
the correct E/M code.
1. George Semple, a 57-year-old male, was seen for the first time by Dr. Brieo in the
office for a contusion of his hand. Dr. Brieo asked questions about the bruise on
George’s hand and examined his hand thoroughly.
a. Location: Office tells us where the encounter took place.
b. Relationship: First time tells us this is a new patient.
c. Key components: History—problem-focused, physical examination—problem-
focused, medical decision making—straightforward. Therefore, the correct
code is 99201.
2. Dr. Fein performed an initial observation at the hospital of Lois Martin, a 31-year-old
female. After asking about her personal medical history, including pertinent history
of stomach problems, digestive problems, and pertinent family and social history
CHAPTER 23 |
CPT
YOU CODE IT! CASE STUDY
Ten days after Dr. Rollins performed a carpal tunnel revision on Nicole Letchin’s left hand, Nicole, a 23-year-old
female, came to see him in his office, as instructed when he discharged her. He asked how she was feeling, checked
the flexibility of the wrist, removed the stitches, and checked the healing of the incision. She was doing fine, so
Dr. Rollins told her to come in only if she needed anything.
by the same physician on the same day of the procedure of other ser-
vice. It may be necessary to indicate that on the day a procedure or service
identified by a CPT code was performed, the patient’s condition required a
significant, separately identifiable E/M service above and beyond the other
service provided or beyond the usual preoperative and postoperative care
associated with the procedure that was performed. A significant, separately
identifiable E/M service is defined or substantiated by documentation that
satisfies the relevant criteria for the respective E/M service to be reported.
The E/M service may be prompted by the symptom or condition for which
the procedure and/or service was provided. As such, different diagnoses
are not required for reporting of the E/M services on the same date. This
circumstance may be reported by adding modifier 25 to the appropriate
level of E/M service. Note: This modifier is not used to report an E/M ser-
vice that resulted in a decision to perform surgery. See modifier 57. For
significant, separately identifiable non-E/M services, see modifier 59.
CHAPTER 23 |
CODING BITES
In order for modifier 25 to be used correctly, it is best if the E/M code links or
relates to a different diagnosis from the procedure performed that day. So there
would be at least two diagnosis codes on the same claim form before you con-
sider using this modifier. Although different diagnoses are not required, there is
concern in the industry about overuse of modifier 25, so this may trigger an audit
without a separately identifiable diagnosis.
Certainly this happens quite frequently: A patient goes to see the doctor for a minor
procedure in the office. Then the patient says, “Oh, Doc, while I’m here, I want to talk
to you about . . . .” Should that happen, you have to append the E/M code with modi-
fier 25 to explain that there were two visits in one at this encounter.
CPT
LET’S CODE IT! SCENARIO
Gladys Topfer goes to see her dermatologist for a scheduled appointment to have a 1.5-cm mole removed from her
cheek. Once Dr. Assanti completes the procedure, Gladys asks the doctor to look at a cyst that has developed under
her arm. Dr. Assanti discusses the presence of the cyst with her (How long has it been there? Does it hurt? etc.), and
then he examines her underarm area and determines that the best course of action is to wait and see what happens
with the cyst. He advises Gladys to keep the area clean and to come back in 3 weeks if the cyst has not gone away.
CPT
LET’S CODE IT! SCENARIO
Alene Morgen, a 49-year-old female, went to see Dr. Blume for a comprehensive physical assessment, as a require-
ment for her special coverage application. The insurance carrier would not consider the policy without the examina-
tion. She had never seen Dr. Blume before today’s visit.
CPT
LET’S CODE IT! SCENARIO
Dr. Richards referred Timothy Dunne, a 67-year-old male, to Dr. Eliot for a consultation to determine whether he
needs a prostatectomy. After taking a comprehensive history, performing a comprehensive examination, and review-
ing all the previous test results, Dr. Eliot informs Timothy that he recommends the procedure. Timothy agrees, and
they select a date the following week for the surgery to be performed.
the amount of time represented by standard E/M codes. These codes may be reported Read the additional
in addition to standard E/M codes at any level, as appropriate. explanations in the
To determine the best, most appropriate code from this subcategory, you have to in-section guidelines
calculate the total number of minutes that the physician spent with, or on behalf of, the located within the Evalu-
patient, during one date of service. The codes will be calculated as follows: ation and Management
(E/M) section, subhead
∙ The first code would be the standard evaluation and management code (such as 99213). Prolonged Services,
∙ Then, depending upon how long the physician spent with the patient, you would directly above code
also report code . . . 99354 in your CPT book.
99354 or 99356 for the time spent lasting at least 30 minutes over the standard
evaluation and management service and includes time spent up to 74 minutes.
99355 or 99357 for each 30 minutes additionally spent, over the 74 minutes
reported by 99354 or 99356, until the total amount of time spent by the physi-
cian is represented.
CHAPTER 23 |
CODING BITES EXAMPLE
When the health care Dr. Alfredo spent a total of 2 hours, in his office, with Mona Catzer working with her
provider has spent more to stabilize her diabetes mellitus. The codes used to report this E/M encounter are
than the standard time
99214 Office visit, established patient, detailed 25 min.
but less than 30 minutes
99354 Prolonged physician service in the office; first hour 60 min.
with the patient, it is not
99355 additional 30 minutes 30 min.
reported separately.
TOTAL 115 min
∙ Communicating with home health agencies and other community services available
and used by the patient.
∙ Communicating aspects of care to the patient, family, and/or caregiver.
∙ Collecting health outcomes data and registry documentation.
Services identified by code 99487 overlap longstanding E/M codes. Therefore, when
reporting 99487, (to set off clause) do not separately report the following:
∙ Care plan oversight services (CPT codes 99339, 99340, 99374–99378)
∙ Prolonged services without direct patient contact (99358, 99359)
∙ Anticoagulant management (99363, 99364)
∙ Medical team conferences (99366–99368)
∙ Education and training (98966–98968, 99441–99443)
∙ Online medical evaluation (98969, 99444)
CHAPTER 23 |
∙ Preparation of special reports (99080)
∙ Analysis of data (99090, 99091)
∙ Transitional care management services (99495, 99496)
∙ Medication therapy management services (99605–99607)
Code 99487 should not be reported separately, nor should it include the time spent
when reporting the following:
∙ End-stage renal disease services (ESRD) (90951–90970) during the same month
∙ Postoperative care services during the global period
∙ E/M services (99211–99215, 99334–99337, 99347–99350)
∙ E/M services while patient is an inpatient or in observation (99217–99239,
99241–99255, 99291–99318)
∙ Transitional care management services (99495, 99496)
As you can see, 99487 would be reported only once per month by the physician or
health care professional who has taken on the role of coordinator for this patient for the
first 60–89 minutes of services.
Add-on code 99489 can be reported in conjunction with either 99487 to represent
time greater than 89 minutes during the month.
CHAPTER 23 |
TCM may be reported only once within 30 days of discharge by only one health
care professional, even if there is a subsequent discharge within that time. This profes-
sional is permitted to report hospital or observation discharge services concurrently
with TCM services, but not within the global period of postoperative care.
Chapter Summary
Evaluation and management (E/M) codes report the energy and knowledge a health
care professional puts into gathering information, reviewing data, and determining the
best course of treatment for the patient’s current condition. Many health information
management professionals find these difficult to correctly determine due to the com-
plex formula of such codes. Don’t become overwhelmed. Once you get a job, you will
find that a particular portion of this section will become your main focus.
EXAMPLE
• If you work for a provider in a private medical office, most of your E/M codes will
be found under the Office heading on the first two pages of the section.
• If you work for a physician who cares for patients at a skilled nursing facility, you
will use codes from under the Nursing Facility Services heading.
So in the real world, most of the time, you will be using the same small set of codes
over and over again. But because you don’t know where you will be working in the
CHAPTER 23 REVIEW
CPT Evaluation and Management Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
Coding
Let’s Check It! Terminology
Match each key term to the appropriate definition.
Part I
1. LO 23.3 The level of familiarity between provider and patient. A. Chief Complaint
2. LO 23.3 An encounter for purposes of a second physician’s opinion or advice, B. Consultation
requested by another physician, regarding the management of a C. Established Patient
patient’s specific health concern.
D. Evaluation and
3. LO 23.4 The extent of a physician’s clinical assessment and inspection of a patient. Management (E/M)
4. LO 23.4 The collection of details about the patient’s chief complaint, the current E. History of Present
issue that prompted this encounter: duration, specific signs and symp-
CPT © 2017 American Medical Association. All rights reserved.
Illness
toms, etc.
F. Level of Patient History
5. LO 23.4 The level of knowledge and experience needed by the provider to
determine the diagnosis and/or what to do next. G. Level of Physical
Examination
6. LO 23.4 The amount of detail involved in the documentation of patient history.
H. Medical Decision
7. LO 23.4 Collection of details, related to the chief complaint, regarding possible
Making (MDM)
signs, symptoms, behaviors, genetic connection, etc.
I. New Patient
8. LO 23.3 A person who has received professional services within the last 3 years
from either this provider or another provider of the same specialty
belonging to the same group practice.
9. LO 23.3 A person who has not received any professional services within the
past 3 years from either the provider or another provider of the same
specialty who belongs to the same group practice.
CHAPTER 23 |
10. LO 23.2 Specific characteristics of a face-to-face meeting between a health care J. PFSH
CHAPTER 23 REVIEW
Part II
1. LO 23.7 A group of services already included in the code for the operation and A. Anticipatory Guidance
not reported separately. B. Basic Personal Services
2. LO 23.5 Action taken by the attending physician to stop or reduce a behavior or life- C. Care Plan Oversight
style that is predicted to have a negative effect on the individual’s health. Services
3. LO 23.4 An organization that provides services to terminally ill patients and D. Critical Care Services
their families. E. ESRD
4. LO 23.4 Services that include washing/bathing, dressing and undressing, assis-
F. Global Surgical
tance in taking medications, and getting in and out of bed.
Package
5. LO 23.1 A type of action or service that stops something from happening or
G. Hospice
from getting worse.
H. Interval
6. LO 23.2 A facility that provides skilled nursing treatment and attention along
with limited medical care for its (usually long-term) residents, who do I. Nursing facility
not require acute care services (hospitalization). J. Preventive
7. LO 23.4 The time measured between one point and another, such as between K. Risk Factor Reduction
physician visits. Intervention
8. LO 23.4 Services for a patient who has a life-threatening condition expected to L. Transfer of Care
worsen.
9. LO 23.10 Chronic, irreversible kidney disease requiring regular treatments.
10. LO 23.4 E/M of a patient, reported in 30-day periods, including infrequent
supervision along with pre-encounter and post-encounter work, such
as reading test results and assessment of notes.
11. LO 23.5 Recommendations for behavior modification and/or other preventive
measures.
12. LO 23.3 When a physician gives up responsibility for caring for a patient, in
whole or with regard to one specific condition, and another physician
accepts responsibility for the care of that patient.
CPT © 2017 American Medical Association. All rights reserved.
CPT
Part I
1. LO 23.1 E/M codes enable the physician to be reimbursed for all of these services except
a. talking with the patient and his or her family. b. taking continuing education classes.
c. consulting with other health care professionals. d. reviewing data such as test results.
2. LO 23.2 Often, finding the correct E/M code begins with knowing
a. where the patient met with the physician.
CHAPTER 23 REVIEW
c. what type of insurance policy is held by the patient.
d. what the patient does for an occupation.
3. LO 23.3 A patient who has not seen a particular physician in the last 3 years is categorized as
a. an established patient. b. a referral.
c. a consultation. d. a new patient.
4. LO 23.4 The three key components of many E/M codes include all of these except
a. history. b. exam. c. chief complaint. d. MDM.
Part II
1. LO 23.5 A preventive medical E/M encounter may include any of these services except
a. counseling. b. admission into the hospital.
c. anticipatory guidance. d. risk factor reduction intervention.
2. LO 23.8 If the physician finds a health concern during a preventive medicine examination requiring additional
CPT © 2017 American Medical Association. All rights reserved.
E/M services and the extra service is performed by the same physician on the same day, then the extra
service should be coded with
a. the preventive medicine code only. b. the additional E/M code.
c. whichever code is reimbursable at a higher rate. d. a separate E/M code appended with modifier 25.
3. LO 23.4 E/M services provided to a patient in an assisted living facility are reported from the subsection
a. Nursing Facility.
b. Home Services.
c. Domiciliary, Rest Homes, and Custodial Care Settings.
d. Care Plan Oversight Services.
4. LO 23.4 If a patient is discharged from the hospital and admitted into a skilled nursing facility (SNF) on the
same day by the same physician, report the E/M services with
CHAPTER 23 |
a. an admission to the nursing facility E/M code only.
CHAPTER 23 REVIEW
1. Solely for the purposes of distinguishing between new and established patients, professional services are those
_____ services rendered by physicians and other qualified health care professionals who may report evaluation
and management services reported by a specific CPT code(s).
2. An established patient is one who has received professional services from the physician/qualified health care
professional or another physician/qualified health care professional of the _____same specialty and _____ who
belongs to the same group practice, within the past 3 years.
3. A _____ is a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the
reason for the encounter, usually stated in the patient’s words.
CHAPTER 23 REVIEW
other qualified health care professional on the same day.
5. Levels of E/M services are _____interchangeable among the different categories or subcategories of service.
6. The E/M codes recognize _____types of presenting problems.
7. Time is not a descriptive component for the _____ levels of E/M services because emergency department services
are typically provided on a variable intensity basis, often involving multiple encounters with several patients over
an extended period of time. Therefore, it is often difficult to provide accurate estimates of the time spent face-to-
face with the patient.
8. Intraservice times are defined as face-to-face time for _____ and other _____ visits and as unit/floor time for
_____ and other _____ visits.
9. The extent of the _____ is dependent upon clinical judgment and on the nature of the presenting problem(s).
10. The extent of the _____ performed is dependent on clinical judgment and on the nature of the presenting problem(s).
11. _____ refers to the complexity of establishing a diagnosis and/or selecting a management option.
12. When _____ and/or _____ of care dominates (more than 50%) the encounter with the patient and/or
family (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility),
then _____ shall be considered the key or controlling factor to qualify for a particular level of E/M services.
CPT
YOU CODE IT! Basics
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate E/M code(s) for each case study.
1. Makayla Sorensen, a 4-year-old female, sees Dr. Pitassin, a pediatrician, for the first time with itchy spots all
over her body. After a detailed history and a detailed examination, his MDM is of a low complexity. Dr. Pitassin
diagnoses her with chickenpox.
CPT © 2017 American Medical Association. All rights reserved.
2. Loretta Stabler, an 81-year-old female, comes to see Dr. Gilman for her semi-annual check-up Dr. Gilman notes
he last saw the patient 6 months ago for a regular checkup. Dr. Gilman completes a detailed interval history with
a comprehensive head-to-toe physical exam. He reviews and affirms the present medical plan of care. Loretta’s
condition is stable, her hypertension and diabetes (type 2) are in good control, and she has no new problems.
There are minimal data for Dr. Gilman to review and several diagnoses to consider. The MDM is moderate.
3. George Terazzo, an 81-year-old male, collapsed at church during services and was brought to the ED.
Dr. Horatio took a comprehensive history, performed a comprehensive examination, and made the decision to
admit George into the observation unit of the hospital due to an irregular heartbeat with an unknown cause.
MDM is of moderate complexity.
4. Sue Appleton, a 46-year-old female, was admitted this morning for observation after an MVA. Dr. Rhodes
documents a detailed history and a comprehensive exam with a straightforward MDM. Sue is doing fine; all
test results are within normal range. Dr. Rhodes discharges Sue the same afternoon.
CHAPTER 23 |
CHAPTER 23 REVIEW
5. Reisa Haven, a 39-year-old female, was sent by Dr. Alfaya to Dr. Avery, an OB-GYN, for an office consultation.
She had been suffering with moderate pelvic pain, a heavy sensation in her lower pelvis, and marked discomfort
during sexual intercourse. In a detailed history, Dr. Avery noted the location, severity, and duration of her pelvic
pain and related symptoms. In the review of systems, Reisa had positive findings related to her gastrointestinal,
genitourinary, and endocrine body systems. Dr. Avery noted that her past medical history was noncontributory
to the present problem. The detailed physical examination centered on her gastrointestinal and genitourinary
systems with a complete pelvic exam. Dr. Avery ordered lab tests and a pelvic ultrasound in order to consider
uterine fibroids, endometritis, or other internal gynecologic pathology. MDM complexity was moderate.
6. Catalina King came into the ED with what appeared to be a wrist sprain that she sustained during a baseball
game when she slid into home base. She was in obvious pain, and the wrist was swollen and too painful upon
attempts to flex. Dr. Ervin performed an expanded problem-focused history and exam before he ordered
x-rays. Reports confirmed a simple fracture of the distal radius. MDM was low.
7. George Carter was discharged today from the Bracker Nursing Center after Dr. Mintz spent 25 minutes perform-
ing a final examination, discussing George’s stay, and providing instructions to George’s wife for continuing care.
8. Heather Swann, a 68-year-old female, in good health, is a new patient at Victors Boarding Home. Dr. Cannon
comes by to complete Heather’s evaluation and documents an expanded problem-focused history and exam
with an MDM of low complexity.
9. Marla Olden, a 38-year-old female, G2 P1, was admitted to Weston Hospital to deliver. Marla is considered a
high-risk delivery. Dr. Kucherin was on standby for 30 minutes in the event a c-section was necessary. Marla
delivered vaginally. Marla and baby are doing well. Code Dr. Kucherin’s services.
10. Loretta Reubens, an 18-month-old female, is admitted today by Dr. Smallerman into the pediatric critical care
unit because of severe respiratory distress.
CPT
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate E/M code(s) and modifier(s), if appropriate, for each case study.
1. Zena Awtrey, a 58-year-old female, sees Dr. Lunden for the first time for a variety of medical problems. She
was diagnosed 5 years ago with insulin-dependent diabetes mellitus with complicating eye and renal prob-
lems. In addition, she suffers from hypertensive heart disease with episodes of congestive heart failure. Her
peripheral vascular disease has worsened, and she can walk only a block before being crippled with extreme
leg pain. The patient reports that a new problem has surfaced: throbbing headaches with radiating neck pain.
Dr. Lunden and Zena thoroughly discuss her health concerns and issues. In order to manage and investigate
the multiplicity of problems, Dr. Lunden takes a complete PFSH. A complete review of systems (ROS) is CPT © 2017 American Medical Association. All rights reserved.
performed and comprehensive physical exam is completed. Dr. Lunden has to take a multitude of factors into
consideration, as the patient’s problems are highly complex.
2. Jamie Farmer, a 32-year-old male, goes to his family physician, Dr. Mitchell, for a tetanus shot after stepping
on a rusty nail at the beach. While there, he asks Dr. Mitchell to look at a cut on his left hand. Dr. Mitchell
examines the wound and tells him to keep the wound clean and bandaged. Dr. Mitchell documents a brief HPI
and performs a limited exam of the left hand, MDM straightforward. Code only the E/M.
3. Owen Unger, a 19-month-old male, is admitted to the hospital by his pediatrician, Dr. Curtis, after a chest
x-ray confirmed the child has pneumonia. Dr. Curtis and Mrs. Unger, Owen’s mother, discuss the child’s
fever, cough, and diarrhea. Mrs. Unger provides a pertinent PFSH. An extended problem-focused ROS is
completed and an extended examination of the cardiovascular and respiratory systems is performed. The
course of treatment planned by Dr. Curtis is straightforward as the child’s condition is of low severity.
12. Raymond Catertell, a 23-year-old male, is the son of two alcoholics. Dr. Lowen spends 40 minutes with him
providing risk factor reduction behavior modification techniques to help him avoid becoming an alcoholic
himself.
13. Premier Life & Health Insurance Company required David Harrison, a 39-year-old male, to get Dr. Dijohn,
his regular physician, to complete a certificate confirming that David’s current disability prevents him from
working at his regular job and makes him eligible for disability insurance.
14. Dr. Anderson works in a very small town in Ohio and travels up to 200 miles to see his patients in the sur-
rounding rural areas. His patient Brenda Viard gave birth at her home the previous day to a 6-lb 3-oz baby
girl, Alice Rose. Dr. Anderson sees Alice Rose for the first time today, does a complete history and exam, and
prepares her medical chart. Alice Rose is a healthy newborn.
15. Petula Carter, a 4-day-old female, currently weighs 2,000 grams and requires intensive cardiac and respiratory
monitoring. This is her third day in the NICU, and Dr. Wadhwa comes in to do his E/M of her condition.
CHAPTER 23 |
CHAPTER 23 REVIEW
CPT
YOU CODE IT! Application
The following exercises provide practice in the application of abstracting the physicians’ notes and learning
to work with documentation from our health care facility, Prader, Bracker, & Associates. These case studies
are modeled on real patient encounters. Using the techniques described in this chapter, carefully read through
the case studies and determine the most accurate E/M code(s) and modifier(s), if appropriate, for each case
study.
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: TURNER, CHARLES
ACCOUNT/EHR #: TURNCH001
DATE: 10/01/18
Attending Physician: Renee O. Bracker, MD
S: This 27-year-old male was brought to the ED by ambulance after he was found unconscious on the
living room floor. He regained consciousness within several minutes but complained of a severe head-
ache and nausea. Pt states that the last thing he remembers he was on a ladder, changing a light bulb.
He believes he lost his balance trying to reach too far and fell, hitting his head on the end-table.
O: Ht 5’10”, Wt 195 lb., R 16. Head: Scalp laceration on the right posterior parietal bone. Bruise indi-
cates trauma to this area. Eyes: PERRLA. Neck: Neck muscles are tense; there is minor pain upon rota-
tion of the head. Musculoskeletal: All other aspects of the shoulders, arms, and legs are unremarkable.
X-rays of skull, two views, and soft tissue of the neck are all benign.
A: Concussion
P: 1. MRI to rule out subdural hematoma
2. Repair laceration and bandage
ROB/mg D: 10/01/18 09:50:16 T: 10/05/18 12:55:01
CHAPTER 23 |
CHAPTER 23 REVIEW
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: LEAMAN, HESTER
ACCOUNT/EHR #: LEAMHE001
DATE: 10/01/18
Attending Physician: Renee O. Bracker, MD
This 18-month-old female is being admitted to the pediatric critical care. Mother claims onset of symp-
toms was sudden. She states that she rushed the child to the ED immediately.
Child is unresponsive. Respiration is shallow. B/P 85/60 mmHg, T 102.
refers to the dulling of feeling in a limited area of the body. The application of a drug to
Topical anesthesia is applied directly to the skin or mucous membranes, using a the skin to reduce or prevent
liquid or gel form. Typically, this is administered prior to very minor procedures on sensation in a specific area
the epidural layer of the skin, or the eye, anus, vagina, mouth, gums, eardrum, or nose. temporarily.
Local anesthetics are most often administered by injection, directly into the anatomi- Local Anesthesia
cal site that is the object or target of the procedure. Lidocaine is one of the frequently The injection of a drug to pre-
used anesthetics. vent sensation in a specific
portion of the body; includes
local infiltration anesthesia,
EXAMPLE digital blocks, and pudendal
Dr. Victors, a general dentist, rubbed a topical anesthetic onto Walter’s gum to blocks.
prevent him from feeling any pain from the injection of the local anesthetic. The
local anesthetic will prevent him from feeling pain while the doctor drills the cavity
that Walter has in his left, lower molar.
Regional Anesthesia
CODING BITES
Topical: Think top, for
Regional anesthesia prevents a section of the body from transmitting pain and
the top layer of skin
includes epidural, caudal, spinal, axillary, stellate ganglion blocks, regional blocks,
Local: The effect of the
and brachial anesthesia.
anesthesia stays close
Regional anesthesia is most often used when the procedure
to the injection site ∙ Is focused on a specific region of the body.
Neither of these types ∙ Involves a larger area of the body than could be treated with a local injection.
of anesthesia is sepa- ∙ Does not require general anesthesia.
rately reported. They
are already included in In these cases, the chosen anesthetic is injected directly into a nerve, nerve plexis, or
the procedure code. the spinal cord. There are two types of regional anesthesia:
∙ Peripheral nerve blocks, which are typically used for procedures performed on the
Regional Anesthesia extremities: arms or legs, or the groin, or the face.
The administration of a drug
in order to interrupt the nerve ∙ Epidural and spinal anesthesia, which employs an anesthetic injected into the spinal
impulses without loss of cord, most often to numb the lower abdomen, pelvic area, or the lower extremities.
consciousness.
EXAMPLE
Dr. Carloni, an anesthesiologist, was paged to come to the maternity ward to
administer epidural anesthesia for Kimberly Saunders. After the epidural was
given, Kimberly was able to proceed with the birth of her baby without the pain of
childbirth. The loss of sensation was only from the waist down. She was otherwise
awake and alert.
General Anesthesia
General Anesthesia General anesthesia, also called surgical anesthesia, creates a total loss of conscious-
The administration of a drug in ness and sensation. General anesthesia is given to the patient by inhalation, intrave-
order to induce a loss of con- nous (IV) injection, or, on rare occasions, intramuscular (IM) injection.
sciousness in the patient, who Propofol is the drug most commonly used, administered by slow intravenous infu-
is unable to be aroused even sion. In some cases, a slow inhalation of anesthetic vapors is administered using a
by painful stimulation.
face mask.
EXAMPLE
Dr. Carver, an anesthesiologist, administered general anesthesia to Darnell Liberty
after he was brought into the operating room (OR) and positioned on the table.
Dr. Mendosa was preparing to remove Darnell’s gallbladder because of the collec-
CPT © 2017 American Medical Association. All rights reserved.
tion of stones in that organ, and everyone wanted to be certain that Darnell would
not feel anything during the surgical procedure.
EXAMPLES GUIDANCE
99151 Moderate sedation services provided by the same physician or CONNECTION
other qualified health care professional performing the diagnos- Read the additional
tic or therapeutic service that the sedation supports, requiring explanations in the
the presence of an independent trained observer to assist in the in-section guidelines
monitoring of the patient’s level of consciousness and physiologi- located within the
cal status; initial 15 minutes of intraservice time, patient younger Medicine section,
than 5 years of age subhead Moderate
99152 initial 15 minutes of intraservice time, patient age 5 years or older (Conscious) Sedation,
99153 each additional 15 minutes intraservice time (List separately in directly above code
addition to code for primary service) 99151 in your CPT book.
CPT
LET’S CODE IT! SCENARIO
Caterina Zingler, a 41-year-old female, came into the same day surgery center to Certified Registered Nurse
have Dr. Freeman perform a hemorrhoidopexy by stapling. She was very nervous Anesthetist (CRNA)
because she had never had this procedure before. Raymond Elvers, a certified reg- A registered nurse (RN) who
istered nurse anesthetist (CRNA), administered Versed, IV, a sedative to relieve her has taken additional, special-
anxiety. The procedure is not really painful, so there was no need for a full anes- ized training in the administra-
thetic or painkiller. Raymond sat with Caterina throughout the procedure to ensure tion of anesthesia.
her safety and comfort level. Dr. Freeman accomplished the procedure in one stage,
taking 30 minutes.
Moderate Sedation
See Sedation
Turn to Sedation, where you find:
Sedation
Moderate . . . . . . . . . . . 99151–99153, 99155–99157
with independent observation. . . . . 99151–99153
Read, carefully, the complete descriptions of all of these codes in the Main Section of the CPT book and analyze
the details within each.
Code 99151 requires the physician who performed the procedure to administer the moderate sedation,
whereas 99155 requires another physician or health care professional. Which is correct? Go back to the docu-
mentation, which states, “Raymond Elvers, a certified registered nurse anesthetist (CRNA), administered Versed,
IV, a sedative to relieve her anxiety.” This would lead you to 99155.
You will see that code 99155 is the more accurate. This identifies moderate sedation, administered by a
different health care professional [Raymond Elvers, CRNA] than the professional who performed the
procedure [Dr. Freeman], initial 15 minutes intraservice, patient younger than 5 years of age.
Wait a minute; the documentation states the patient is “a 41-year-old female.” Take a look at code 99156
initial 15 minutes intraservice time, patient age 5 years or older. That’s more accurate.
Are you done? Not yet. Code 99156 only reports 15 minutes. The documentation states, “taking 30 minutes.”
You will need to also report code 99157 for the next 15 minutes, so Dr. Freeman and Raymond Elvers can be
accurately reimbursed for all of the time they spent.
CPT © 2017 American Medical Association. All rights reserved.
So, in addition to the code for the hemorrhoidopexy (46947), you need to include two additional codes for
the moderate sedation (99156 and 99157) on the report and claim form.
Good job!
EXAMPLE
Anesthesia
Skull. . . . . . . . 00190
5. Turn to the Main Section of the CPT book, Anesthesia section, and find the subsec-
tion identifying that anatomical site.
EXAMPLES
00212 Anesthesia for intracranial procedures; subdural taps
00216 vascular procedures
6. Read the descriptions written next to each code option suggested in the Alphabetic
Index carefully. Then compare them with the terms used by the physician in his or
her notes documenting the procedure. This will lead you to the best, most appropri-
ate code available.
CPT
LET’S CODE IT! SCENARIO
Dr. Fonda is called in to administer general anesthesia to Morgan Saffire, a 6-month-old female, diagnosed with
congenital tracheal stenosis. Dr. Caudwell performs a surgical repair of her trachea.
CPT © 2017 American Medical Association. All rights reserved.
The physician’s notes state that Dr. Caudwell performed a “repair,” not a reconstruction, so focus on the codes
shown next to Trachea. Turn to the Main Section of the CPT book to find the codes 00320, 00326, and 00542.
Read the descriptions written next to each code, as well as the others found in the subsection, in order to deter-
mine the best, most appropriate code available.
Neck
00320 Anesthesia for all procedures on esophagus, thyroid, larynx, trachea and lymphatic system of
neck; not otherwise specified, age 1 year or older
00322 Anesthesia for all procedures on esophagus, thyroid, larynx, trachea and lymphatic system of
neck; needle biopsy of thyroid
00326 Anesthesia for all procedures on the larynx and trachea in children less than 1 year of age
00542 Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum
(including surgical thoracoscopy); decortication
As you review the code descriptions, you can identify which terms or words are most important in matching the
code to the physician’s documentation of the procedure. Look at the physician’s notes one more time and iden-
tify the key terms.
Dr. Fonda is called in to administer general anesthesia to Morgan Saffire, a 6-month-old female, diag-
nosed with congenital tracheal stenosis. Dr. Caudwell performs a surgical repair of her trachea.
The combination of all these terms matches only one of our available code descriptions, doesn’t it?
00326 Anesthesia for all procedures on the larynx and trachea in children younger than 1 year
of age
You found the best, most appropriate code for the administration of general anesthesia for Morgan’s surgery.
EXAMPLE
Dr. Tristan administered general anesthesia to Austin Berger, a 15-year-old oth-
erwise healthy female gymnast, before Dr. Armaden performed an arthroscopic
extensive debridement of her shoulder joint. The correct code is 01630-P1.
EXAMPLE
Dr. Steiner administered general anesthesia to Venice Binle, a 41-year-old female
with controlled type 1 diabetes mellitus, for her radical mastectomy with internal
mammary node dissection, to be performed by Dr. Cabara. The correct code is
00406-P2.
P3 (a patient with severe systemic disease). In this case, the patient’s disease is seri-
ous throughout his or her body and is an important factor for the anesthesiolo-
gist to contend with, in addition to the reason for the procedure.
EXAMPLE
Dr. Jeffries administered general anesthesia to Wilson Meyers, a 62-year-old
male with benign hypertension due to Cushing’s disease. Wilson came today for
Dr. Ephron to perform a laparoscopic cholecystectomy with cholangiography for
acute cholecystitis. The correct code is 00790-P3.
P4 (a patient with severe systemic disease that is a constant threat to life). Modifier
P4 describes any patient having medical problems that have invaded or affected
multiple systems of the body. The large number of issues regarding the effects
of the disease, along with existing medications and treatments that have been
ongoing in the patient’s system, and the potential interactions with the anes-
thetic make it a very complex case.
EXAMPLE
Dr. Rockenbach administers general anesthesia to Ethan Vox, a 71-year-old male.
Ethan has advanced esophageal cancer that has metastasized throughout his
body. Dr. Glasser will be performing a partial esophagectomy. The correct code is
00500-P4.
GUIDANCE
P5 (a moribund patient who is not expected to survive without the operation). This CONNECTION
CPT © 2017 American Medical Association. All rights reserved.
is a life or death situation, but not necessarily an emergency. In such cases, the Read the additional
patient is in critical condition, and there are serious medical complications that explanations in the
make administering anesthesia more challenging. Anesthesia Guidelines,
subsection Anesthesia
Modifiers, in your CPT
EXAMPLE book directly in front of
Dr. Jeppapi administered general anesthesia to Zena Afronski, a 31-year-old the Anesthesia section
female with acute arteriosclerosis. Dr. Able was called back in from vacation to that lists all the codes,
perform a heart/lung transplant this morning. The correct code is 00580-P5. and read the entire
descriptions in
Appendix A, subsection
P6 (a declared brain-dead patient whose organs are being removed for donor pur- Anesthesia Physical
poses). This modifier is provided by the ASA for use with brain-dead patients. Status Modifiers in your
Individuals in this condition need to have anesthesia administered to slow CPT book.
bodily functions and give the transplant team time to harvest the viable organs.
YOU INTERPRET IT!
Determine which Physical Status Modifier is most accurate from the descriptions below of the patients’
conditions.
1. Usual preoperative visits. Most of the time, the anesthesiologist will stop in to
interview the patient, in addition to taking the time to thoroughly read the chart
and patient history, before administering the anesthesia. It gives the physician
the opportunity to discuss any potential reactions or other considerations with
CPT © 2017 American Medical Association. All rights reserved.
the patient.
2. Anesthesia care during the procedure. The time and expertise the anesthesiolo-
gist spends in addition to administering the actual anesthetic, including observing
the patient throughout the procedure, are very important parts of his or her job
responsibilities.
3. Administration of fluids. The anesthesiologist gives the patient fluids as well as
analgesics (liquid form) as needed during the procedure.
4. Usual monitoring services (such as ECG [electrocardiogram], temperature, BP
[blood pressure]). As a part of the natural course of the anesthesiologist’s duties,
he or she must monitor the patient’s vital signs throughout the procedure and make
certain that there are no unexpected effects from the anesthesia.
5. Usual postoperative visits. The anesthesiologist normally visits the patient while he
or she is in recovery to ensure that there are no lingering effects of the anesthesia
and there are no other concerns as a result of the anesthesia.
CPT HCPCS Level II
YOU CODE IT! CASE STUDY
PATIENT: DARLENA ESKINE
DATE OF OPERATION: 02/17/2018
PREOPERATIVE DIAGNOSIS: Avascular necrosis, right hip.
POSTOPERATIVE DIAGNOSIS: Avascular necrosis, right hip.
OPERATION PERFORMED: Right total hip arthroplasty.
SURGEON: Arthur Hunter, MD
ANESTHESIOLOGIST: Samuel Samahdi, MD
INDICATIONS FOR OPERATION: The patient is an overall healthy 39-year-old former athlete, who presents for hip
arthroplasty having failed nonoperative treatment options. The risks, benefits, and treatment alternatives were dis-
cussed including, but not limited to, infection, bleeding, blood clots, nerve injury, dislocation, leg length inequal-
ity, prosthetic wear, loosening, need for further surgery, failure to relieve pain, etc. The patient’s questions were
answered, and the surgical plan was approved.
DESCRIPTION OF OPERATION: The patient was taken into the operating room, the appropriate extremity was iden-
tified, and the patient was positioned with appropriate padding to all pressure areas. After sterile skin preparation
and draping, a posterior incision was performed. The skin and subcutaneous tissues were divided to the level of the
fascia, which was then incised along the course of its fibers for a posterior approach. Leg lengths were measured
prior to dislocation and then the hip capsule was excised, and a femoral neck cut was made. The acetabulum was
then exposed and examined. No significant osteophytes were found. No significant acetabular defect was found.
The acetabulum was prepared. The last reamer used was 51 mm. No bone graft was used to reconstruct the
acetabular defect. The acetabular component, 52 mm Pinnacle, was positioned appropriately and impacted into
position, and mechanical stability was achieved. Supplemental screw fixation was not used. A neutral 36 liner was
then appropriately chosen and positioned and the device assembled. Femoral exposure was obtained and the femo-
ral canal was prepared. A trial reduction was performed and hip stability was assessed.
After the appropriate component position was determined, final canal preparation was completed. The compo-
nent was then impacted into position, and mechanical stability was achieved. A trial reduction was performed, leg
length and hip stability were assessed, and the appropriate neck length was chosen, and a +8.5 ceramic head was
impacted into position. The final reduction was performed, and hip stability was assessed. The hip was stable to
90 degrees of internal rotation, 20 degrees of abduction, 20 degrees of extension, 20 degrees of adduction, and
60 degrees of external rotation really with no tendency to dislocate.
The wound was irrigated profusely, a final inspection was performed, and bleeding was controlled and the wound
was closed in layers. The hip capsule was not sutured. A drain was not placed. Sterile dressings were applied, and
a radiograph was ordered. The components were found to be in appropriate alignment. The plan is for a routine
postoperative course with weightbearing as tolerated and ambulation. Sciatic nerve was explored at the end of the
procedure and found to be intact.
You Code It! CPT © 2017 American Medical Association. All rights reserved.
Read this operative report and determine what code or codes should be reported for Dr. Samadhi’s services.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so, ask
your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided to
the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Here are the facts as reported by Dr. Haverall’s sedation record of general anesthesia administered to
Allen Dagmar for his perineal prostatectomy, performed by Dr. Kessler.
Base unit(s): 6
Time: 60 minutes [15 minutes × 4]
Modifying factors: None
Conversion factor: 21.9935
4. Determine the compensation the anesthesiologist should receive.
Remember . . . (B + T + M) × CF = Compensation
FIGURE 24-1 Anesthesiologist’s sedation record
99100 Patient of extreme age . . . younger than 1 year or older than 70 years
—This add-on code is not to be used when the code description already
includes an age definition, such as code 00326, 00834, or 00836.
99116 Anesthesia complicated by total body hypothermia
—Hypothermia is defined as extremely low body temperature, below
36.1°C (97°F). Because monitoring vital signs, including body temper-
ature, is an important part of the anesthesia process, a very low
body temperature would make the safe administration of anesthesia
more complex.
99135 Anesthesia complicated by controlled hypotension
—Hypotension is defined as abnormally low blood pressure. The critical
connection between blood pressure and heart rate makes this situation
CPT
YOU CODE IT! CASE STUDY
Arlena Smithson, a 77-year-old female, comes to see Dr. Beele for a total knee arthroplasty due to acute arthritis.
Dr. Knight is called in to administer the general anesthesia for the procedure. Arlena is in otherwise good health.
CPT
LET’S CODE IT! SCENARIO
Louisa Cabaña, a 61-year-old female, arrived for the insertion of a permanent pacemaker, atrial with transvenous
electrodes. Dr. Snyder, knowing that Louisa has been diagnosed with Parkinson’s disease, causing her to have
uncontrollable tremors, decided that conscious sedation (which is the standard of care) was insufficient to ensure
the patient’s safety. He called Dr. Corman to administer general anesthesia.
GUIDANCE
CONNECTION
CPT © 2017 American Medical Association. All rights reserved.
Read the additional
Same Physician Administering Anesthesia and Performing
explanations in the
Anesthesia Guidelines, the Procedure
first column, last para- If the physician performing the procedure also administers either regional or general
graph, in your CPT book anesthesia, the modifier 47 Anesthesia by Surgeon must be appended to the procedure
directly before the code for that basic service (not to the anesthesia code). In such cases, an anesthesia
Anesthesia section that code would not be reported. However, it is permissible to report a code for the injec-
lists all the codes, and tion of the anesthetic drug.
read the entire descrip- Turn to Appendix A and read the CPT modifier description:
tion of modifier 47 in
Appendix A, subsection 47 Anesthesia by Surgeon: Regional or general anesthesia provided by the
Modifiers, in your surgeon may be reported by adding modifier 47 to the basic service.
CPT book. (This does not include local anesthesia.) NOTE: Modifier 47 would not be
used as a modifier for the anesthesia procedures.
25270-47 Repair, tendon or muscle, extensor, forearm and/or wrist; primary, single, each tendon
or muscle, regional anesthesia administered by surgeon
64450 Injection, anesthetic agent; other peripheral nerve or branch
Excellent!
00170 Anesthesia for intraoral procedures, including biopsy; not otherwise specified
00172 Anesthesia for intraoral procedures, including biopsy; repair of cleft palate
Chapter Summary
For the most part, anesthesia coding is for the purposes of submitting health insurance
claim forms on behalf of the anesthesiologist or a member of his or her staff, such as
a CRNA.
To find the best, most appropriate code that accurately represents the anesthesia
services administered, you must first know which type of anesthesia was used. Then
you must determine the anatomical site upon which the procedure was performed and
exactly which procedure was provided to the patient. In addition, you must know who
administered the anesthesia to the patient: Was it the physician who also performed
that procedure, or was it a different health care professional? When using HCPCS
Level II modifiers, you also need to know whether the physician who administered the
anesthetic was an anesthesiologist.
Once you determine the best, most appropriate code for the dispensation of the
anesthesia, you also have to append the correct modifiers, when applicable.
CPT © 2017 American Medical Association. All rights reserved.
CODING BITES
Physical Status Modifiers
CHAPTER 24 REVIEW
CPT Anesthesia Section Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
CHAPTER 24 REVIEW
cally requires either local anesthesia or no anesthesia. What modifier would be appended to the proce-
dure code in these circumstances?
a. 23 b. QZ c. 47 d. G9
4. LO 24.1 MAC is an acronym that stands for
a. medically administered care. c. monitored anesthesia care.
b. mutually accessible care. d. medical anesthetic characters.
5. LO 24.7 All of the following are HCPCS Level II modifiers except
a. AD b. G8 c. 57 d. QX
6. LO 24.2 When the physician performing the procedure also administers regional or general anesthesia, modifier
47 should
a. be appended to the correct anesthesia code.
b. be appended to the correct procedure code.
c. be appended to either the correct anesthesia code or the correct procedure code.
d. not be used in this circumstance.
7. LO 24.3 The anesthesia code package includes all except
a. preoperative visits. c. usual monitoring services.
b. postoperative visits. d. home health follow-up.
8. LO 24.4 When reporting anesthesia services using time reporting, the formula used is
a. (B + T + M) × CF b. (B + Q + CF) × T c. (Q + T + CF) × B d. (CF + B + T) × M
9. LO 24.5 Qualifying circumstances are conditions that might require more work on the part of the anesthesiolo-
gist, including all except
a. extreme age. c. severe systemic disease.
b. emergency conditions. d. total body hypothermia.
10. LO 24.2 A Physical Status Modifier describes issues that may increase the complexity of delivering anesthetic
services, including
a. emergency situations. c. extreme age.
b. mild systemic disease. d. controlled hypotension.
1. Services involving administration of _____ are reported by the use of the anesthesia _____ procedure code plus
modifier codes.
2. To report _____ (conscious) sedation provided by a physician also performing the service for which conscious
sedation is being provided, see codes _____.
3. When a second physician other than the health care professional performing the diagnostic or therapeutic services
CHAPTER 24 REVIEW
provides moderate (conscious) sedation in the _____ setting, the second physician reports the associated moderate
sedation procedure/service _____; when these services are performed by the second physician in the _____
setting, codes 99155, 99156, 99157 would _____ be reported.
4. Moderate sedation does not include _____ sedation (anxiolysis), _____ sedation, or _____ anesthesia care.
5. Anesthesia _____ begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia
in the operating room and _____ when the anesthesiologist is no longer in personal attendance, that is, when the
patient may be _____ placed under postoperative supervision.
6. “Special Services and Reporting” are listed in the _____ section.
7. Supplies and materials provided _____ and _____ those usually included in the office visit or other services
rendered may be listed _____. Drugs, tray supplies, and materials provided should be listed and identified with
_____ or the appropriate supply code.
8. When _____ surgical procedures are performed during a _____ anesthetic administration, the anesthesia code
representing the most _____ procedure is reported. The time reported is the combined _____ for all procedures.
9. _____ anesthesia services are reported by use of the anesthesia five-digit procedure code _____ the addition of a _____.
10. Physical Status modifiers are represented by the initial letter _____ followed by a single digit from _____.
Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 24.2 List the six steps to coding anesthesia.
2. LO 24.3 What is included in the anesthesia code package?
3. LO 24.4 Why is time important to coding anesthesia? When does the clock start and stop?
4. LO 24.5 List the qualifying circumstance add-on codes with their description.
5. LO 24.7 Explain the difference between HCPCS Level II modifiers QX, QY, and QZ.
neoplasm of the uterus. Her gynecologist, Dr. Ramage, performed a vaginal hysterectomy.
5. Dr. Billingsworth administered anesthesia to Ralph Skipper, a 7-month-old male requiring a hernia repair
in the lower abdomen. Dr. Sims, the neonatologist, noted that, without the surgery, Ralph was not expected
to survive.
6. Martha Gantt, a 76-year-old female with a history of hypertension and diabetes mellitus, is brought into
the OR for Dr. Brunson to perform a corneal transplant. Dr. Williams, the anesthesiologist, administers the
anesthesia.
7. Dr. Elliston is preparing to perform a ventriculography with burr holes on Daniel Ewing, a 12-year-old male,
who fell off the monkey bars onto a cement floor yesterday. Dr. Hallbeck administers the anesthesia. Daniel is
otherwise healthy.
8. Dr. Hanh administers anesthesia so that Dr. Lindholm can perform a diagnostic lumbar puncture on Keith
Franklin, a 56-year-old male. Over the course of the last year, Keith, a construction worker, has developed
CHAPTER 24 REVIEW
essential hypertension, which is currently controlled by diet. This lumbar puncture is to confirm the suspected
diagnosis of bacterial meningitis.
9. Gerry Sherman, a healthy 28-year-old male, plays professional basketball and is given anesthesia by
Dr. Wallace before having a diagnostic arthroscopy of his right knee by Dr. Hook.
10. Carlton Dazquez, a 17-year-old male, was in a go-kart accident and fractured his upper arm 3 months ago.
Today, Dr. Hytower operated on him to repair the malunion of his humerus. Dr. Murphy administered the
anesthesia. Carl is otherwise healthy.
11. Trisha Moultrie brought her 3-year-old daughter, Tamara, into the emergency room with a deep laceration
of her scalp above her right ear, measuring 2.25 cm. Tamara was distraught, crying, and combative, kicking
at the physician and the nurse as they attempted to clean the wound. At the recommendation of Dr. White,
Trisha held Tamara in her lap, while the physician administered 1 mg of Versed, IM. Once the sedation took
effect, Dr. White was able to perform a layered repair of the laceration while the nurse monitored Tamara’s
vital signs. The entire procedure took 25 minutes. Code the moderate sedation only.
12. Regina Weyeneth, a healthy 23-year-old female, was given an epidural during labor, with the expectations of
a vaginal delivery. After a time, Dr. Bedenbaugh, her obstetrician, determined that the labor was obstructed
and notified the hospital staff, that they would have to do a cesarean (c-section).
13. Dr. Anderson administered anesthesia to Barbara Brooks, a 52-year-old female, in preparation of the breast
reconstruction with TRAM flap to be performed by Dr. Mocase. Barbara has a history of breast cancer and is
postmastectomy; she is otherwise healthy.
14. Dr. Solington brought Howard Chen, a 10-month-old male, into the OR for repair of his complete transpo-
sition of the great arteries under cardiopulmonary bypass. Pump oxygenation was used. Howard was not
expected to survive without the surgery. Dr. Misher, the anesthesiologist, administered the anesthesia.
15. Meredith Susswell, a 79-year-old female, was given anesthesia by Dr. Yabsley, the anesthesiologist, in prepa-
ration for the repair of her ventral hernia in her lower abdomen, to be performed by Dr. Carrouth. Meredith
has uncontrolled diabetes mellitus and essential hypertension.
The following exercises provide practice in the application of abstracting the physicians’ notes and learning to
work with documentation from our health care facility, Anytown Anesthesiology Associates. These case studies are
modeled on real patient encounters. Using the techniques described in this chapter, carefully read through the case
studies and determine the most accurate anesthesia code(s) and modifier(s), if appropriate, for each case study.
prepped and draped in the usual fashion. The patient had several previous lower midline incisions and
right flank incision; therefore, the pneumoperitoneum was created via epigastric incision to the left of
the midline with a Verres needle. After adequate pneumoperitoneum, the 11-mm trocar was placed
through the extended incision in the left epigastrium just to the left of the midline, and the laparoscope
and camera were in place. Inspection of the peritoneal cavity revealed it to be free of adhesions, and
another 11-mm trocar was then placed under direct vision through a small infraumbilical incision. The
scope and camera were then moved to this position, and the gallbladder was easily visualized. The
gallbladder was elevated, and Hartmann’s pouch was grasped. Using a combination of sharp and
blunt dissection, the cystic artery was identified. The gallbladder was somewhat tense and subacutely
inflamed. Therefore, a needle was passed through the abdominal wall into the gallbladder, and the gall-
bladder was aspirated free until it collapsed. One of the graspers was held over this region to prevent
any further leakage of bile. Again, direction was turned to the area of the triangle of Calot. The cystic
duct was dissected free with sharp and blunt dissection. A small opening was made in the duct, and the
CHAPTER 24 REVIEW
cholangiogram catheter was passed. The cholangiogram revealed no stones or filling defects in the bile
duct system. The biliary tree was normal. There was good flow into the duodenum, and the catheter
was definitely in the cystic duct. The catheter was removed, and the cystic duct was ligated between
clips, as was the cystic artery. The gallbladder was then dissected free from the hepatic bed using
electrocautery dissection, and it was removed from the abdomen through the umbilical port. Inspection
of the hepatic bed noted that hemostasis was meticulous. The region of dissection was irrigated and
aspirated dry. The trocars were removed, and the pneumoperitoneum was released. The incisions were
closed with Steri-Strips, and the umbilical fascial incision was closed with 2-0 Maxon. The patient toler-
ated the procedure well; there were no complications. She was returned to the recovery room awake
and alert.
Learning Outcomes
25
Key Terms
After completing this chapter, the student should be able to: Allotransplantation
Arthrodesis
LO 25.1 Distinguish among the types of surgical procedures. Closed Treatment
LO 25.2 Determine which services are included in the global surgi- Complex Closure
cal package. Donor Area (Site)
LO 25.3 Interpret the impact on coding of the global time frames. Excision
LO 25.4 Identify unusual services and treatments and report them Fornix
Full-Thickness
accurately.
Global Period
LO 25.5 Abstract physician documentation of procedures on the Harvesting
integumentary system. Intermediate Closure
LO 25.6 Apply the guidelines, accurately, for coding procedures on Laminectomy
the musculoskeletal system. Manipulation
LO 25.7 Recognize the details required to accurately report proce- Open Treatment
Percutaneous Skeletal
dures on the respiratory system.
Fixation
LO 25.8 Identify guidelines to correctly report services to the car- Recipient Area
diovascular system. Saphenous Vein
LO 25.9 Distinguish the various procedures on the digestive Simple Closure
system. Standard of Care
LO 25.10 Ascertain the elements of coding services to the urinary Surgical Approach
Transplantation
system.
LO 25.11 Determine how to accurately report procedures on the
genital systems: male and female.
LO 25.12 Interpret documentation to accurately report procedures
on the nervous system.
LO 25.13 Recognize the necessary details to report procedures on
the eye, ocular adnexa, and auditory system.
LO 25.14 Report accurately the different services provided during an
organ transplant.
CPT © 2017 American Medical Association. All rights reserved.
EXAMPLE
For a surgical procedure performed in a hospital operating room (OR), there may
be as many as three coders involved:
1. The hospital’s coder codes for the support personnel, facilities, and supplies.
2. The surgeon’s coder codes for his or her professional services.
3. The anesthesiologist’s coder codes for his or her professional services.
Coding operative reports and procedure notes becomes easier with experience
because the longer you work for a physician or facility, the more you will learn about
the procedures and services he or she performs. Experience will train you to decipher
which services are included in procedures and which are not. Throughout this chapter
and the next, the guidelines and specifications for coding the various types of surgical
and nonsurgical procedures are reviewed.
In CPT, the term surgery is not limited to only those services and treatments per-
formed in an operating room (OR) or even in a hospital. Within this section of the CPT
book, codes are listed that report
∙ Incision and drainage of a cyst
∙ Debridement
∙ Simple repair of a superficial wound
All these services can easily be performed in a physician’s office. In addition,
many procedures are now performed at an ambulatory surgical center or outpatient
department.
When hearing the word surgery, most people picture an all-white room with health
care professionals dressed in masks, gowns, and gloves and a patient under general
anesthesia. However, this is a very narrow perspective on surgical procedures. You, as
a professional coding specialist, need to understand the various types of surgical pro-
CPT © 2017 American Medical Association. All rights reserved.
cesses because this detail may be important for determining the most accurate code.
There are times when, for the safety of the patient, a procedure begins as a diag- GUIDANCE
nostic examination and turns into a therapeutic procedure. Generally, a therapeutic or CONNECTION
surgical procedure will include the diagnostic portion, thereby requiring only one code
when both are done during the same encounter. Read additional expla-
Above, in both of the two laparoscopic codes (49320 and 50541), CPT includes nations in the Surgery
the guideline “Surgical laparoscopy always includes diagnostic laparoscopy.” There- Guidelines, subheads
fore, if the physician performed a diagnostic laparoscopy solely to determine what was Follow-Up Care for
wrong with the patient, the correct code might be 49320. However, if while the physi- Diagnostic Proce-
cian was performing the diagnostic laparoscopy, he observed a renal cyst and decided dures and Follow-Up
to ablate the cyst at the same time, this would mean that a diagnostic procedure (to Care for Therapeutic
discover the cyst) and a therapeutic procedure (ablation of the cyst) were done at the Surgical Procedures, in
same time. In that case, only 50541 might be reported, as it is one code that includes your CPT book directly
both the diagnostic and therapeutic portions of the procedure. in front of the Surgery
section that lists all the
Surgical Approaches codes.
Procedure coding requires that you understand the various surgical approaches a Follow-Up Care for
physician can take to provide care for a patient: Diagnostic Procedures
When a diagnostic pro-
∙ A noninvasive, or external, procedure is one that does not enter the patient’s body;
cedure is performed,
these are procedures that are applied or performed directly to the skin without
the code includes only
physical entry into the visceral (internal) part of the body. An example of a nonin-
that care related to the
vasive procedure is a shave biopsy, a technique to acquire pathology specimens of
recovery from this pro-
an elevated growth on the skin by razor.
cedure, not any treat-
∙ Minimally invasive procedures are becoming more and more available as health ment for the condition
care researchers continue to find methods to diagnose and correct problems with identified. Care for the
the least amount of trauma to the patient. Although there is a big difference in our condition (therapeutic
perception between a patient being stabbed by a mugger and a patient being cut services) is not included.
open by a physician during a surgical procedure, the human body knows only that
it is being invaded by a sharp piece of metal. It is traumatic, and healing must occur Follow-Up Care for
at the point of the incision as well as to whatever was done to internal organs. Therapeutic Surgical
Procedures
CPT © 2017 American Medical Association. All rights reserved.
∙ The percutaneous approach uses instruments inserted into the body by way of a
puncture or small incision to access the intended anatomical site. Example: needle The code report-
biopsy. ing the provision of a
therapeutic procedure
∙ The percutaneous endoscopic approach uses instruments inserted into the body by
only includes the care
way of a puncture or small incision to access and visualize the intended anatomical
related to that proce-
site. Example: diagnostic anoscopy.
dure. Complications,
∙ The via natural or artificial opening approach involves instrumentation entered exacerbations, recur-
into the body through a natural opening (such as the vagina) or an artificial open- rence, or the presence
ing (such as a stoma) to visualize the intended anatomical site. Example: flexible of other diseases or
esophagoscopy. injuries requiring addi-
∙ The via natural or artificial opening endoscopic approach involves insertion of a tional services should
scope through a natural opening (such as the mouth) or an artificial opening (such be separately reported.
as a stoma) to visualize and aid in the performance of a procedure on the intended
anatomical site. Example: colonoscopy with polyp removal.
∙ Open approach procedures are fully invasive, as the surgeon cuts the body open
to enable access to internal tissues and organs. These procedures involve using a
scalpel or laser to cut through the skin, membranes, and body layers to access the
intended anatomical site.
EXAMPLES
Surgical procedures on a woman’s uterus can be performed using
• The vaginal canal as the entry point (endoscopic using a natural opening) to
avoid surgical entry through the abdomen, reported with
58262 Vaginal hysterectomy, for uterus 250g or less; with removal of
tube(s) and/or ovary(s)
• Laparoscopy (a minimally invasive procedure through the abdominal cavity) via
small incisions into the patient’s skin and muscle, reported with
58542 Laparoscopy, surgical, supracervical hysterectomy, for uterus
250g or less; with removal of tube(s) and/or ovary(s)
• Open procedure with a longer incision through the abdominal wall, reported
with
58150 Total abdominal hysterectomy (corpus and cervix), with or with-
out removal of tube(s), with or without removal of ovary(s)
You can see that all three of these codes accurately report a hysterectomy (the
surgical removal of the uterus) with the removal of the fallopian tubes and ovaries.
The difference between these codes is the surgical technique reported: 58150
reports an open abdominal procedure using an incision through the patient’s
abdominal wall, 58262 reports a procedure using a natural orifice (the vagina) so
that no surgical incision was required, and 58542 reports a laparoscopic proce-
dure that uses three tiny incisions in the patient’s abdomen. The information pro-
vided by the reporting of these different versions of this procedure includes not
only the level of work required by the physician to perform the procedure but also
the level of postoperative care that the patient will require.
Interpret each of these procedural statements to determine the type of procedure being documented:
Diagnostic, Prophylactic, or Therapeutic.
1. Biopsy was performed to determine if mass is benign or malignant. _____________
CPT © 2017 American Medical Association. All rights reserved.
2. Lithotripsy to destroy kidney stones. _____________
3. Cholecystectomy. _____________
4. Pneumonia vaccine administered. _____________
Interpret each of these procedural statements to determine the type of surgical approach being docu-
mented: Open, Percutaneous, or Endoscopic/Laparoscopic.
5. A 7 cm incision was made. _____________
6. A needle-biopsy was performed. _____________
7. The scope was passed through the patient’s mouth into the stomach. _____________
minor procedures.
had, surgery are not included in the surgical package. When such services and/or pro-
cedures are performed, you must code them separately.
1. Diagnostic tests and procedures. Tests or procedures that the physician needs to
confirm the medical necessity for the surgery or investigate other issues related to
the surgery are coded separately.
EXAMPLE
Diagnostic tests and procedures, such as biopsies, blood tests, and x-rays.
4. Staged or multipart procedures. Each stage or operation has its own surgical pack-
CODING BITES age and global period for aftercare. You must add modifier 58 to the second proce-
There are some codes dure code and all additional procedure codes reported for the same encounter.
that are exempt from
58 Staged or Related Procedure or Service by the Same Physician During
using modifier 58.
the Postoperative Period. It may be necessary to indicate that the perfor-
Take a look at codes
mance of a procedure or service during the postoperative period was: (a)
67141–67229 for some
planned or anticipated (staged); (b) more extensive than the original proce-
examples. Notice that
dure; or (c) for therapy following a surgical procedure. This circumstance
each code’s descrip-
may be reported by adding modifier 58 to the staged or related procedure.
tion includes the phrase
“one or more sessions.”
EXAMPLE
Albert Rodgers, a 31-year-old male, suffered a fracture to his upper arm that
severely damaged the shaft of his right humerus. Dr. Curran decides to first do a
bone graft to support the healing process of the fracture and to follow that with a
second surgical procedure—an osteotomy—in about 4 weeks. This is a staged, or
multipart, surgical procedure.
24516 Treatment of humeral shaft fracture, with insertion of intramedul-
lary implant, with or without cerclage and/or locking screws
24400-58 Osteotomy, humerus, with or without internal fixation, staged pro-
cedure by the same physician during the postoperative period
5. Management of postoperative complications that require additional surgery. As CPT © 2017 American Medical Association. All rights reserved.
you may remember about the surgical package from Services Always Included
(earlier in this section), the physician’s attention to any postoperative complications
is included in the original package unless those complications require the patient to
return to the operating room. In such cases, you must use a modifier with the CPT
code for the procedure performed.
76 Repeat Procedure by the Same Physician. It may be necessary to indicate
that a procedure or service was repeated subsequent to the original proce-
dure or service. This circumstance may be reported by adding modifier 76
to the repeated procedure or service.
78 Unplanned Return to the Operating/Procedure Room by the Same Physi-
cian Following Initial Procedure for a Related Procedure During the Post-
operative Period. It may be necessary to indicate that another procedure
was performed during the postoperative period of the initial procedure
EXAMPLE
Lilly Drummond, a 14-year-old female, was burned on her left forearm when she
missed catching a flaming baton during cheerleading practice. Five days ago, Dr.
Cheng applied a skin allograft to the burned area. Lilly is admitted today because
the graft is not healing properly, and Dr. Cheng is going to apply a new allograft of
20 sq. cm.
15271-76 Application of skin substitute graft to trunk, arms, legs, total
wound surface area up to 100 sq. cm.; first 25 sq. cm. or less
wound surface area; repeat procedures by the same physician
EXAMPLE
Ray DeVilldus, an 18-year-old male, was stabbed in the chest during a fight. Dr.
Swartz performed a complex repair of a 6-cm laceration of the chest. The next day,
Dr. Swartz left for a medical conference. The guy who stabbed Ray showed up at the
hospital, and Ray got out of bed, against doctor’s orders, and engaged in another
fight, ripping open his stitches. Dr. Tyson, filling in for Dr. Swartz, had to take Ray back
into the OR and redo the repair. Dr. Tyson will send the claim with the following code:
13101-77 Repair, complex, trunk; 2.6 cm to 7.5 cm; repeat procedure by
another physician
6. Unrelated surgical procedure during the postoperative period. If the same physician
must perform an unrelated surgical procedure during the postoperative period, you
have to include a modifier to explain that this procedure has nothing to do with the first.
79 Unrelated Procedure or Service by the Same Physician During the Post-
operative Period. The physician may need to indicate that the performance
of a procedure or service during the postoperative period was unrelated to
the original procedure. This circumstance may be reported by using modi-
fier 79.
CPT © 2017 American Medical Association. All rights reserved.
EXAMPLE
Judith Conchran, a 41-year-old female, had a gastric bypass performed by Dr.
Fellowes 10 days ago. She comes to see him today because she has a fever and
pain radiating across her abdomen. Dr. Fellowes examines her, calls an ambu-
lance, and takes her to the hospital and up to the operating room, where he
performs an appendectomy to remove her ruptured appendix. The global post-
operative period for a gastric bypass is 90 days. Dr. Fellowes performed Judith’s
appendectomy during the postoperative period for the bypass, and it had nothing
to do with the first procedure. Therefore, our correct code would be
44960-79 Appendectomy; for ruptured appendix with abscess or general-
izedperitonitis;unrelatedprocedureorservicebythesamephysicianduring
the postoperative period
7. Supplies. In certain cases, for certain procedures performed in a physician’s office,
a separate code is permitted for supplies, such as a surgical tray, casting supplies,
splints, and drugs. You have to check the reimbursement rules for the specific third-
party payer.
EXAMPLE
Illea Beurus was prepped and ready for the procedure to begin. Dr. Hernandez
performed the closed manipulation of the fracture. Instead of the usual plaster
cast, fiberglass was used.
99070 Supplies and materials (except spectacles), provided by the physician
or other qualified health care professional over and above those usu-
ally included with the office visit or other services rendered (list drugs,
trays, supplies, or materials provided)
Determine if the service or procedure provided in these statements is Included in the Surgical code
(package) or Reported with a separate code.
8. Jeanine came to see Dr. Kidmon in his office 1 week after he performed her hysterectomy, as he
instructed her to do. He wanted to check her sutures and healing progress. __________________
9. While at Dr. Kidmon’s office, Jeanine asked him to check her left breast because she felt a lump. He
was concerned and performed a biopsy on the lump. __________________
10. After Dr. Kidmon performed a mastectomy on Jeanine’s left breast, he explained to her that
they would need to complete a series of skin grafts. One graft would be done each month
for 3 months. All are part of the postoperative care for mastectomy patients. Jeanine agreed.
__________________
CPT
LET’S CODE IT! SCENARIO
Nadia Forrester, a 37-year-old female, was on vacation, hiking through the mountains, when she fell over a log and
wrenched her knee very badly. She was flown to the nearest hospital and placed under the care of Dr. Petrone.
After the diagnostic tests were completed, Dr. Petrone recommended arthroscopic surgery to treat the knee. Dr.
Petrone called in Dr. Wellington, an orthopedic surgeon, to perform the procedure. Dr. Wellington performed a surgi-
cal arthroscopy and repaired the medial meniscus. Immediately after the surgery, Nadia flew home, and she went to
her family physician, Dr. Shields, for the follow-up appointments.
CPT
YOU CODE IT! CASE STUDY
Fredrick Stiner, a 15-year-old male, is 5 ft. 6 in., 365 lb. Dr. Girst performs a partial colectomy with anastomosis. The
procedure, however, takes several hours longer than usual due to the fact that Frederick is morbidly obese.
GUIDANCE
CODING BITES CONNECTION
Read the entire description of these modifiers, and all others, in your CPT book, Read the additional
Appendix A. explanations in the
Surgery Guidelines,
subhead Separate
Separate Procedure Procedure, in your CPT
book directly in front of
Throughout the CPT book, you will see code descriptions that include the notation “sep- the Surgery section that
arate procedure.” Such services and treatments are generally performed along with a lists all the codes.
group of other procedures. When this happens, you will be able to find a combination, or
bundled, code that includes all the treatments together. However, this particular procedure
can also be performed alone. If so, you would use the code for the “separate procedure.”
CPT
LET’S CODE IT! SCENARIO
Dr. Capella performed a repair of the secondary tendon flexor in Bruce Roden’s right foot. He first performed an
open tenotomy and then did the repair with a free graft.
Incision and Drainage (I&D) CPT © 2017 American Medical Association. All rights reserved.
CODING BITES A cyst, an abscess, a furuncle (boil), or a paronychia (infected skin around a finger-
Remember: there is a nail or toenail) can harbor infection. When this happens, most often a physician will
difference between inci- perform an incision (cut into the tissue) and drainage (I&D) to extract the infectious
sion and excision. material.
Incision means cut into,
while excision means Debridement
cut out.
The process of carefully cleaning out a wound to encourage the healing process is
called debridement. The basis of this term comes from the word debris, meaning
wreckage or rubble, and relates to the process of taking away necrotic (dead or dying)
tissue that can impede the creation of new, healthy tissue. This may be necessary
for burn patients, for victims of penetrating wounds, and sometimes for patients with
complex wounds such as an open, penetrating fracture.
You can see, from the descriptions of the codes in this subsection, that you will
need to identify the total body surface area (TBSA) that was debrided, in order to
determine an accurate code.
Biopsies
Biopsies are performed, most often, for diagnostic purposes. These procedures are
done to obtain a sampling of cells or piece of tissue from the body that can then
be pathologically analyzed. Although a specimen of tissue may be excised, shave
removed, or lased and then sent to pathology for testing, this does not automatically
indicate the need for a separate biopsy code. The guidelines state that you should
use a biopsy procedure code only when the procedure is conducted individually, or
distinctly separate, from any other procedure or service performed at the same time.
EXAMPLE
Paula had a rash that would not go away. So, she went to see Dr. Denardo, a der-
matologist, who took a biopsy of one of the pustules in an effort to diagnose
the cause of her rash. Dr. Denardo closed the small defect with one stitch.
Dr. Denardo’s coder would report
11100 Biopsy of skin, subcutaneous tissue and/or mucous membrane
(including simple closure), unless otherwise listed; single lesion
There are many different types of biopsies, and you will need to know the details
(from the documentation) to help you determine the correct code: GUIDANCE
CONNECTION
∙ Fine-needle aspiration biopsy: the physician uses a thin needle to draw out—or
drain—a specimen (some fluid or gas) to be used for pathology testing. Read the additional
∙ Core-needle biopsy: the physician uses a hollow needle, a bit larger than the needle used explanations in the
during a fine-needle biopsy, to extract a cylindrical section of tissue to be analyzed. in-section guidelines
located within the
∙ Excisional biopsies and incisional biopsies: a sampling of tissue of the abnormal area;
Surgery section, sub-
an entire organ or tumor is taken during the procedure and sent to the pathology lab.
head Biopsy, directly
∙ Endoscopic biopsy: during a percutaneous endoscopy or via a natural or artificial above code 11100 in
opening endoscopic procedure, a specimen of an abnormal or suspicious tissue is
CPT © 2017 American Medical Association. All rights reserved.
CPT
LET’S CODE IT! SCENARIO
Seth Berensen, a 69-year-old male, came to see Dr. Tyner to get rid of some skin tags on his left cheek. After apply-
ing a local anesthetic, Dr. Tyner removed nine tags and sent them to the lab.
(continued)
are 11200–11201. Turn to the numeric listing of the book, in the Surgery section, and look for those codes. You
will see
11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions
11201 each additional 10 lesions or part thereof (list separately in addition to code for primary
procedure)
(Use 11201 in conjunction with 11200)
The next question is . . . How many skin tags (lesions) did the physician remove from Seth’s face? When you
reread the notes, you will see that he removed nine tags. This confirms the correct code is 11200.
The notes also indicate that the lesions were sent to pathology, meaning a biopsy. Should we add another
code for the biopsy? Remember that the guidelines state that a separate code for the biopsy is used only when
the biopsy is a procedure distinctly separate from other procedures and not a part of another service. In this
case, the biopsy is a part of the removal of the skin tags and does not require a second code.
Excisions
Excision When the physician removes a lesion from a patient, you must code the excision of each
The full-thickness removal of lesion separately. Codes for the excision, or full-thickness removal (Figure 25-1), of a
a lesion, including margins; lesion are determined first by the anatomical site from where the lesion was removed
includes (for coding purposes) and then by the size of the lesion removed. The code for the excision includes the
a simple closure. administration of a local anesthetic and a simple closure of the excision site, as men-
Full-Thickness tioned in the definition.
A measure that extends from To correctly measure what was excised, you must look at the dimensions of the
the epidermis to the connec- lesion itself plus a proper margin around the lesion. That will give you the total amount
tive tissue layer of the skin. actually excised by the physician and lead you to the correct code. In order to find the
correct size of the lesion excised, we must do the following: Add the size of the lesion
Simple Closure
A method of sealing an open- to the size of the margin doubled (margins all around mean that the diameter will have
ing in the skin (epidermis or a margin on each side).
dermis), involving only one The formula is
layer. It includes the admin-
Coded size of lesion = size of lesion + (size of margins × 2)
istration of local anesthesia
and/or chemical or electro- As always, you must read carefully. Some surgeons include the measurement of the
cauterization of a wound not margins in their operative notes. In other cases, you may need to review the patholo-
closed. gist’s report to determine an accurate measurement. And, typically, the measurements
will be presented in centimeters (cm). Just in case:
1 centimeter (cm) = 10 millimeters (mm) = 0.4 inch (in.)
1 millimeter (mm) = 0.1 centimeter (cm) = 0.04 inch (in.)
GUIDANCE
CPT © 2017 American Medical Association. All rights reserved.
1 inch (in.) = 2.54 cm
CONNECTION
Read the additional
explanations in the in-
section guidelines within
the Surgery section,
subheads Excision—
Benign Lesions, directly
above code 11400; Incision
Excision—Malignant Safety margin
of normal skin
Lesions, directly above
Skin lesion
code 11600; and Exci-
sion, directly above
code 19081, in your
CPT book. FIGURE 25-1 This illustration shows how you will determine the size of the lesion
for coding
You may find that the physician’s notes indicate that the excision of the lesion was
complicated or unusual in some way. Should this be the situation, remember to add
modifier 22 Increased Procedural Services to the procedure code. The difficulty is
CPT © 2017 American Medical Association. All rights reserved.
CPT
LET’S CODE IT! SCENARIO
Dr. Samsune excised a lesion that measured 2.1 by 3.0 cm, with 0.5-cm margins on each side, from Sally Hardy’s
abdomen. Sally is diagnosed clinically obese and the excess fatty tissue around the lesion required a complex clo-
sure of the excision site. The pathology report confirmed that the lesion was malignant.
(continued)
11600 Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 0.5 cm or less
The abdomen is a part of the trunk, so this code is OK. Next, you will need to add up the size of the lesion.
Coded size of lesion = 3.0 cm + (0.5 cm × 2) = 4.0 cm
The answer 4.0 cm leads to the code
11604 Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 3.1 to
4.0 cm
Excellent! Sally’s case was not as complicated as Anson’s, so modifier 22 will not be required. However, Dr. Samsune
did note that Sally’s procedure “required a complex closure of the excision site.” The guidelines tell you that only a
simple closure is included in the excision code. A complex closure, just like an intermediate closure, is coded in addi-
tion to the code for the excision. So let’s code it!
Let’s go back to the Alphabetic Index and find the key term closure. None of the indented descriptors seem to
match, so you should investigate the code range shown next to the word closure: 12001–13160.
You will notice the heading immediately above the first code in the range: 12001. It reads “Repair–Simple.”
But you are looking for a complex closure, so continue down the page. The next section, above code 12031, is
“Repair–Intermediate.” This is closer to what you need, but not exactly. Above code 13100 you find the heading
you have been looking for: “Repair–Complex.”
Remember that Sally’s lesion was located on her abdomen (trunk). Look at the codes in this section, and find
the best code for the complex closure of her excision site.
13100 Repair, complex, trunk; 1.1 cm to 2.5 cm
Excellent! You have found the correct level of closure (repair) for the correct anatomical site (trunk). Now, you
must find the correct size of the excision site. Your calculation totaled 4.0 cm, which brings you to the correct
code:
13101 Repair, complex, trunk; 2.6 cm to 7.5 cm
Excellent! You now know that, for this one procedure on Sally, the claim form will include these codes:
11604 Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 3.1 to 4.0 cm
13101 Repair, complex, trunk; 2.6 cm to 7.5 cm
Good job!
Reexcision
When the pathology report indicates that the physician did not excise around the lesion
(the margins) widely enough to get all the malignancy, an additional excision proce-
Intermediate Closure
A multilevel method of sealing
dure may be needed.
CPT © 2017 American Medical Association. All rights reserved.
an opening in the skin involv- If the reexcision is performed during the same operative session, adjust the total
ing one or more of the deeper size of the lesion being coded to include the new total measurement. Report just the
layers of the skin. Single-layer one code, with the largest measurement shown in the operative or procedure notes.
closure of heavily contami- If the reexcision is performed during a subsequent encounter during the postopera-
nated wounds that required tive period, you should attach modifier 58 Staged Procedure to the procedure code for
extensive cleaning or removal that second excision. The reexcision to remove additional tissue around the original
of particulate matter also con- site during the postoperative period would directly apply to modifier 58’s description:
stitutes intermediate closure. (b) more extensive than the original procedure.
Complex Closure
A method of sealing an open- Repair (Closures)
ing in the skin involving a
multilayered closure and a Simple closure is included in the excision code. However, if the closure of the excision
reconstructive procedure such site becomes more involved and is described as an intermediate closure or a complex
as scar revision, debridement, closure, the repair is no longer included in the code for the excision procedure. You
or retention sutures. need to report an additional code.
GUIDANCE CONNECTION
In-section Guidelines (above code 12001 in the Surgery section)
The multiple wound repair guideline is different from the guideline for multiple
lesions. Remember that, with lesions, each lesion is coded separately. With
wounds, you will report one code for the total length of all wounds being repaired CODING BITES
on the same anatomical site with the same level of repair (simple, intermediate, Modifier 59 is used
complex). to report multiple
When more than one level of wound repair is used during the same encounter procedures that are
for the same patient, list the more complicated as the primary procedure and the performed at the same
less complicated as the secondary procedures, using modifier 59. encounter by the same
provider. This modifier is
appended to the codes
Debridement or decontamination of a wound is included in the code for the repair reporting the second
of that wound. However, if the contamination is so extensive that it requires extra time and additional services,
and effort, it should be coded separately. Also, if the debridement is performed and not the primary proce-
the wound is not closed or repaired during the same session, code the debridement dure code.
separately.
CPT
LET’S CODE IT! SCENARIO
Fiona Curtis, a 27-year-old female, got into a bar fight and sustained multiple wounds to her hand and arm.
CPT © 2017 American Medical Association. All rights reserved.
Dr. Rockville performed intermediate repair of a 5- by 2-cm wound and a 3.1- by 1-cm wound on Fiona’s right hand
and a simple repair to a 3.2- by 1-cm wound to her right forearm.
(continued)
There were two wounds on Fiona’s right hand (the first is 5 × 2 cm and the second 3.1 × 1 cm). The guide-
lines state that, because the wounds are on the same anatomical site as per the code description (hands) and
received the same level of repair (intermediate), you must add them together. Let’s add the two longest mea-
surements together (5 cm + 3.1 cm) for a total of 8.1 cm. This brings us to the correct code:
12044 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 7.6 cm to
12.5 cm
Good job! Now, the last wound on Fiona’s forearm is different. It is a simple repair rather than an intermediate repair,
and the wound is on her arm, not her hand. Therefore, this wound repair will have its own code. Follow the code
descriptions and see if you can come up with the most accurate code. Did you determine this to be the correct code?
12002 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or
extremities (including hands and feet); 2.6 cm to 7.5 cm
Now that you know the guideline regarding multiple wound repairs, do you think any adjustments should be
made to the claim form you are preparing for Dr. Rockville to be reimbursed for his work on Fiona? You need to
report them in the correct sequence and append a modifier:
12044 (The intermediate repair tells us this was the more severe or complicated procedure.
Therefore, this code is reported first.)
12002-59 (This was the simple repair of a smaller wound. This was less complicated and, therefore,
the code is listed second and appended with the modifier 59.)
That’s great! You did excellent work!
A woman was screaming in a parking lot and calling for help. She had accidentally locked her keys in the car, along with
her infant son. It was a hot day, and she was quite concerned about her child. Alex Franklin came along and used a rock
to break a window on the other side of the car, reached in through the broken glass, and unlocked the door. Without
question, Alex is a hero, but he also cut his wrist on the broken glass. At the ED, Dr. Zander discovered that the subcu-
taneous tissue at the laceration site was littered with tiny shards of glass. Dr. Zander administered a local anesthetic. It
took Dr. Zander quite a long time to debride the 5.3- by 1.6-cm wound of all the glass before he was able to suture it.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
∙ Anatomical site: The anatomical location of the primary defect—the skin opening
that needs to be repaired—as well as the location of the secondary defect—the skin
area from where the surgeon took the skin being transferred.
∙ Size of the defect: Add together the sizes of the primary defect and the secondary defect.
∙ For all defects over 30 sq. cm, all anatomical sites are reported with the same
codes—code 14301 with code 14302, depending upon the total size.
CPT
LET’S CODE IT! SCENARIO
CPT © 2017 American Medical Association. All rights reserved.
Larissa Cheek had a 2.5 cm × 1 cm contracted scar on the back of her hand, making it difficult to use her fingers
completely. Dr. Villa performed a Z-plasty tissue transfer to disrupt the scar tissue and elongate the transferred tis-
sues. He notes that the secondary defect was 3 sq. cm.
(continued)
Adjacent
Skin . . . . . . . . . . 14000–14350
As you review the guidelines in this subsection, shown above code 14000, you can see that Z-plasty is included
in this section, confirming that you are in the right area. Next, you can see that the code descriptions require you
to know the anatomical location of the procedure.
14000 Adjacent tissue transfer or rearrangement, trunk
14020 Adjacent tissue transfer or rearrangement, scalp, arms, and/or legs
14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genita-
lia, hands and/or feet
14060 Adjacent tissue transfer or rearrangement, eyelids, nose, ears, and/or lips
Go back to the scenario and identify the anatomical site: “on the back of her hand.” This leads you to code
14040. You must now choose between the following two codes determined by the size of the defects:
14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genita-
lia, hands and/or feet; defect 10 sq. cm or less
14041 defect 10.1 sq. cm to 30.0 sq. cm
How big was the defect? In the guidelines above code 14000, it says, “The primary defect resulting from the
excision and the secondary defect resulting from flap design to perform the reconstruction are measured
together to determine the code.”
Larissa’s original scar—the primary defect—is noted to be 2.5 cm × 1. Multiply these two numbers to get
2.5 sq. cm. The secondary defect, the source of the tissue transfer, is noted to be 3 sq. cm. Add 2.5 sq. cm to
3 sq. cm and get a total of 5.5 sq. cm. Compare this measurement to the measurements included in the code
descriptions for tissue transfers done on the hands. This confirms the correct code for the procedure Dr. Villa did
for Larissa:
14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genita-
lia, hands and/or feet; defect 10 sq. cm or less
Good job!
CPT
YOU CODE IT! CASE STUDY
Evan Riggs, an 11-year-old male, had burn eschar on his face from an accident. Dr. Charne performed a surgical
preparation of the area. Two days later, Dr. Charne applied a dermal autograft to the 30-sq.-cm area.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
(continued)
Answer:
Did you determine the following codes?
15004 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar,
or scar (including subcutaneous tissues), or incisional release of scar contracture, face,
scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first
100 sq cm or 1% of body area of infants and children
15135-58 Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/
or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children; staged
procedure
Great work!
Destruction
GUIDANCE
CONNECTION Destruction is the term used for the removal of diseased or unwanted tissue from the
body by surgical or other means, such as surgical curettement (also known as curet-
Read additional expla- tage), laser treatment, electrosurgery, chemical treatment, or cryosurgery. Ablation is
nations in the in-section the surgical destruction of tissue or a body part. When the tissue is destroyed rather
guidelines located than excised, there is nothing left. Therefore, there will be no specimens sent to pathol-
within the Surgery sec- ogy for analysis. The codes in the destruction subheading of the surgical section
tion, subhead Destruc- include the administration of local anesthesia.
tion, directly above There are several methods that a physician can use to destroy tissue.
code 17000 in your
CPT book. ∙ Cauterization is the process of destroying tissue with the use of a chemical or elec-
tricity to seal a wound and stop bleeding. Some cauterizations can be accomplished
with extreme heat or cold. For example, you might see physician’s notes document
the removal of an internal polyp with the use of hot forceps.
∙ Cryosurgical or cryotherapy techniques use liquid nitrogen or freezing carbon
dioxide to destroy the tissue of concern.
∙ Curettage is the method of using a special surgical tool, called a curette, to scrape
an organ, a muscle, or other anatomical site.
∙ Electrosurgical methods use high-frequency electrical current instead of a scalpel
to separate and destroy tissue. One example of this is electrolysis, which removes
hair by using electricity to destroy the hair follicle.
∙ Laser surgery uses light to cut, separate, or destroy tissue. The term laser is actu-
ally an acronym for “light amplification by stimulated emission of radiation.”
CPT
LET’S CODE IT! SCENARIO
Derrick Franks, a 54-year-old male, came to see Dr. Johnston, his podiatrist, for the removal of a benign plantar wart
from the sole of his left foot. Dr. Johnston administered a local anesthetic and then destroyed the wart using a che-
mosurgical technique. A protective bandage was applied to the foot, and Frank was sent home with an appointment
to return in 1 week for a follow-up check.
CPT book.
25.6 Musculoskeletal System
The musculoskeletal system subsection of codes reports procedures and treatments
performed on the bones, ligaments, cartilage, muscles, and tendons in the human body
(Figure 25-2).
Cast Application
Earlier in this chapter, you learned about the Surgical Package, and all of the services
it includes. In addition, codes in this subsection already include the application and
removal of a cast or traction device as a part of the procedure performed.
So, when would you report a code from the subsection Application of Casts and
Strapping, codes 29000 through 29799? There are times when no other procedure
is performed. When the only service provided is the cast application, this will be
reported from here.
FIGURE 25-2 These illustrations show some of the over 600 muscles and 206 bones in the human body
GUIDANCE EXAMPLES
CONNECTION Dr. Philphot performed a closed realignment, manipulating the fractured calcaneal
Read additional expla- bone back together, and applied a foot-to-knee plaster cast.
nations in the in-section • The application of this cast would be included in the code for the treatment of
guidelines located the fracture:
within the Surgery sec-
28405 Closed treatment of calcaneal fracture; with manipulation
tion, subhead Appli-
cation of Casts and Justine had fractured her ulna and radius after falling off her skateboard. She
Strapping, directly got caught in an unexpected rainstorm that drenched her, and her cast. Dr. Keller
above code 29000 in replaced the long-arm cast.
your CPT book.
• The application of this cast was the only service provided for the treatment of
Justine’s fracture; therefore, it would be reported separately.
29065 Application, cast; shoulder to hand (long arm)
Fracture Reduction
A fracture reduction is the process of returning the bone fragments back to their origi-
nal and correct location and configuration. The type of fracture will determine the CPT © 2017 American Medical Association. All rights reserved.
specific components of this procedure. For example, a simple fracture might possibly
be reduced with a closed treatment, while a multifragmentary fracture or one with
bone loss may require an open treatment with additional work, such as a bone graft or
internal fixation, to restore the bone to its previous length, alignment, and ability to
Manipulation rotate (such as with an articulation). Reduction or manipulation may be necessary to
The attempted return of a realign the bone pieces so that union can occur properly. This may be done externally
fracture or dislocation to its (closed reduction, known as manipulation) or surgically (open reduction).
normal alignment manually by Details from the CPT Coding Guidelines, found at the beginning of the Musculo-
the physician. skeletal System section of the Surgery section of CPT, remind you that
“Manipulation is used throughout the musculoskeletal fracture and dislocation
subsections to specifically mean the attempted reduction or restoration of a frac-
ture or joint dislocation to its normal anatomic alignment by the application of
manually applied forces.”
EXAMPLES
23525 Closed treatment of sternoclavicular dislocation; with manipulation
27178 Open treatment of slipped femoral epiphysis; closed manipulation
with single or multiple pinning
The key terms you will need to identify from the documentation will also vary
depending upon the particular fractured bone that is being treated. For example:
Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), pos-
terior approach, 1 fractured vertebra or dislocated segment;
Lumbar............................................................22325
Cervical...........................................................22326
Thoracic..........................................................22327
Additional fractured vertebra................. +22328
When the fractured bone is a segment of the spinal column, you will need to abstract
three key important pieces of information: the location of the bone on the vertebral
column (i.e., cervical, thoracic, lumbar), the number of fractured vertebrae reduced,
and the approach—posterior or anterior. The codes shown above (22325–22328) are
only to be reported when the physician used a posterior, or back, approach. When the
approach used to visualize and reduce the fracture was from the front—an anterior
approach—codes 63081–63091 are used instead.
Open Treatment
CPT defines open treatment as a procedure provided to treat a fractured bone that is Open Treatment
either Surgically opening the frac-
ture site, or another site in the
Surgically opened, so that the fracture can be visualized and internal fixation may body nearby, in order to treat
be applied. the fractured bone.
or
Not opened surgically, but the fractured bone is opened remotely from the site to
enable the surgeon to insert an intramedullary nail.
Closed Treatment
The treatment of a fracture
Closed Treatment without surgically opening the
According to CPT, the closed treatment of a fracture is performed affected area.
∙ With or without manipulation.
GUIDANCE
∙ With or without traction.
CONNECTION
∙ Without the fracture being opened and visualized.
Read the additional
explanations in the
Penetrating Trauma Wounds
in-section guidelines
located within the Sur- The CPT book distinguishes between wounds and penetrating trauma wounds. A pen-
gery section, subhead etrating trauma wound requires
Musculoskeletal Sys-
1. Surgery to explore the wound.
tem, subsection Wound
Exploration—Trauma 2. Determination of the depth and complexity of the wound.
(e.g., Penetrating Gun- 3. Identification of any damage created by the penetrating object (such as the stabbing
shot, Stab Wound), from a knife or the wound from a bullet).
directly above code 4. Debridement of the wound to remove any particles, dirt, and foreign fragments.
20100 in your CPT
5. Ligation or coagulation of minor subcutaneous tissue, muscle fascia, and/or muscle
book.
(not severe enough to require a thoracotomy or laparotomy).
You will use codes 20100–20103 to report the exploration of such wounds. Then, code
whichever repair the physician actually performs, as documented in the notes.
Laminotomy
CPT © 2017 American Medical Association. All rights reserved.
CODING BITES A laminotomy is a partial laminectomy used to treat lumbar disc herniation. Remov-
ing a portion of the lamina is often sufficient to access the affected nerve root. Then,
CPT describes a verte-
the disc herniation can be visualized and accessed from beneath the nerve root. This
bral interspace as the
procedure should be reported with the most accurate code, based on the details in the
nonbony compartment
documentation:
between two adjacent
vertebral bodies. This 63020 Laminotomy (hemilaminectomy), with decompression of nerve root(s),
space houses the including partial facetectomy, foraminotomy and/or excision of herni-
intervertebral disc and ated intervertebral disc, including open or endoscopically-assisted
includes the nucleus approach; one interspace, cervical
pulposus, the annulus 63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s),
fibrosus, and two carti- including partial facetectomy, foraminotomy and/or excision of herni-
laginous endplates. ated intervertebral disc, including open or endoscopically-assisted
approach; one interspace, lumbar
You can see that the only difference between the two code descriptions is the location L1
of the vertebra being treated. This is a piece of information you will need to determine L2
the correct code.
Then, depending upon how many discs were involved, you might add L3
L5
Arthrodesis
Arthrodesis is the surgical immobilization of a joint so that the bones can heal, or Os sacrum
grow solidly, together. While this is most often performed on the spine, it can also be
done on any joint in the body, including ankle, elbow, shoulder, etc.
When coding arthrodesis, you will need to identify the approach technique used by Coccyx
the physician, such as
FIGURE 25-3 The verte-
∙ Lateral extracavitary technique.
brae of the spinal column
∙ Anterior transoral or extraoral technique. are numbered from the
∙ Anterior interbody technique. head to the coccyx Source:
www.boundless.com
∙ Posterior technique: craniocervical or atlas-axis.
∙ Posterior or posterolateral technique. Arthrodesis
∙ Posterior interbody technique with number of interspaces treated. The immobilization of a joint
using a surgical technique.
Arthrodesis can be performed alone or in combination with other procedures such
Laminectomy
as bone grafting, osteotomy, fracture care, vertebral corpectomy, or laminectomy.
The surgical removal of a ver-
When arthrodesis is done at the same time as another procedure, modifier 51 Multiple tebral posterior arch.
CPT © 2017 American Medical Association. All rights reserved.
Procedures should be appended to the code for the arthrodesis. This applies to almost
all procedures, with the exception of bone grafting and instrumentation. Modifier
51 Multiple Procedures is not used in those cases because bone grafts and instrumenta-
tion are never performed without arthrodesis.
CPT
LET’S CODE IT! SCENARIO
Caryn Philips, a 51-year-old female, was diagnosed with degenerative disc disease 3 months ago. She is admit-
ted today for Dr. Cheffer to perform a posterior arthrodesis of L5–S1 (transverse process), utilizing a morselized
autogenous iliac bone graft harvested through a separate fascial incision. Caryn tolerates the procedure well and is
returned to her hospital room after 2 hours in recovery.
(continued)
Let’s Code It!
Pull out the description of the procedures that Dr. Cheffer performed. First, note the “posterior arthrodesis of
L5–S1” and then the “morselized autogenous iliac bone graft harvested through a separate fascial incision.”
Let’s begin in the Alphabetic Index with the listing for arthrodesis. The designation of L5–S1 tells you this
was done to Caryn’s spine. However, spine isn’t listed under arthrodesis. Keep reading and you will see vertebra
listed, lumbar underneath that, and posterior beneath that. However, the physician noted “transverse process,”
which is listed here as well. Let’s investigate code 22612, as suggested by the Alphabetic Index.
22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lat-
eral transverse technique)
This matches the physician’s notes.
Now, let’s move to the next procedure performed. Look in the Alphabetic Index under bone graft. Read
through the list until you reach the item that reflects what was done for Caryn: spine surgery. Indented below
that you will see autograft (the same as autogenous) and then morselized. The index suggests code 20937.
Turn to the numeric list and take a look at the code’s description:
20937 Autograft for spine surgery only (includes harvesting the graft); morselized (through sepa-
rate skin or fascial incision)
Notice the symbol to the left of code 20937: . The plus sign means this is an add-on code and it cannot be used
alone. However, the notation below 20937 indicates that you are permitted to use this code along with 22612.
In addition, the guidelines state that when arthrodesis is performed with another procedure, you need to add
modifier 51 to the arthrodesis code except when the other procedure is a bone graft. This is the case in Caryn’s
record, so the claim form for Caryn Phillip’s surgery will show procedure codes 22612 and 20937—with no
modifiers. Great job!
GUIDANCE
CONNECTION
Skeletal Fixation
Whether the fracture is open or closed, it may require fixation. Internal fixation is the
Read the additional
process of placing plates and screws, or pins, or other devices directly onto or around
explanations in the
the bone, inside of the patient. When external fixation is used, a device—such as a
in-section guidelines
brace, cast, or halo—prevents motion in a certain area of the body. The care for a frac-
within the Surgery sec-
ture may also include the external application of traction.
tion, subhead Spine,
It is not always necessary for the physician to visualize the specific fracture directly,
subsection Arthrodesis,
yet some type of immobilization is required to ensure proper healing. X-ray imaging
directly above code
is used to provide guidance so pins or other fixation can be accurately applied. This is
22532 in your CPT
known as percutaneous skeletal fixation because the procedure is not an open proce-
book.
dure, yet it is not completely closed either.
Percutaneous Skeletal CPT © 2017 American Medical Association. All rights reserved.
Fixation EXAMPLE
The insertion of fixation instru- 25606 Percutaneous skeletal fixation of distal radial fracture or epiphyseal
ments (such as pins) placed separation
across the fracture site. It may
be done under x-ray imaging
for guidance purposes. External fixation, as the name implies, is the attachment of skeletal pins along with
a device to provide stability and corrective action on either a permanent or temporary
basis. This is only reported separately when this portion of the process is not already
part of the procedure.
EXAMPLE
21454 Open treatment of mandibular fracture with external fixation
EXAMPLE
29855 Arthroscopically aided treatment of tibial fracture, proximal (pla-
teau); unicondylar, includes internal fixation, when performed
(includes arthroscopy)
GUIDANCE CONNECTION
Read the additional explanations in the in-section guidelines located within the
Surgery section, subhead Spine (Vertebral Column), subsection Fracture and/or
Dislocation, directly above code 22310 in your CPT book.
CPT
LET’S CODE IT! CASE SCENARIO
Peter Kessler, a 17-year-old male, plays basketball on his high school team. While practicing in his driveway, he fell
and fractured the shaft of his tibia. Dr. Warden, the orthopedist on duty at the emergency room, is able to use a per-
cutaneous fixation using pins.
Spinal Procedures
There are several procedures often performed on patients with spinal concerns:
∙ Arthrodesis is the surgical immobilization of a joint.
∙ Arthroplasty is the insertion of an artificial disc.
CPT © 2017 American Medical Association. All rights reserved.
Spinal Fusion
Spinal fusion permanently locks two or more spinal vertebrae together so that they
move as a single unit utilizing bone grafts, with or without screws, plates, cages, or
other devices. The bone grafts are placed around the problem area of the spine during
surgery. As the body heals itself, the graft helps join the bones together.
Performed under general anesthesia, fusion of lumbar vertebrae is generally done
GUIDANCE using a posterior lumbar approach, whereas cervical vertebrae are accessed using an
CONNECTION anterior cervical approach. An anterior thoracic approach is normally used for fusion
Read the additional
of thoracic vertebrae.
explanations in the
Spinal fusion is known to diminish mobility because of the connections made
in-section guidelines
between the individual vertebrae involved in the procedure. This is one of the primary
located within the Sur-
reasons health care technology has been working diligently on an artificial interverte-
gery section, subhead
bral disc that can continue to permit individual vertebral motion. Artificial discs have
Spine (Vertebral Col-
been evidenced to allow for six degrees of freedom.
umn), subsection Spinal
After removing the ineffective or damaged disc, two metal plates are pressed into the
Instrumentation, directly
bony endplates above and below the interspace and held into place by metal spikes. A
above code 22840 in
plastic spacer, usually made of a polyethylene core, is inserted between the plates. The
your CPT book.
patient’s own body weight compresses the spacer after the surgery is complete.
CPT
YOU CODE IT! CASE STUDY
Allyssa Erickson, an 83-year-old female, fell and sustained a fracture to the C4 vertebral body. Due to the position of
the fracture, Dr. Rubbine was able to use a closed treatment without having to put her through a surgical procedure.
Dr. Rubbine then put Allyssa into a brace.
22310 Closed treatment of vertebral body fracture(s), without manipulation, requiring and including
casting or bracing
Great job!
CPT
LET’S CODE IT! SCENARIO
Epharim Habbati, a 41-year-old male, had been diagnosed with chronic sinusitis many years ago and has tried
everything. He told Dr. Tolber that no medication has worked and the inflammation just won’t go away. Dr. Tolber
performed a nasal/sinus diagnostic endoscopy via the inferior meatus, with a maxillary sinusoscopy.
descriptions.
31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)
31233 Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine
fossa puncture)
31235 Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of sphenoidal face
or cannulation of ostium)
Let’s go back to the physician’s notes to confirm exactly what was done for Mr. Habbati.
diagnostic endoscopy . . . all three code choices include this term
via the inferior meatus . . . only code 31233 mentions the inferior meatus specifically
with a maxillary sinusoscopy . . . only code 31233 mentions the maxillary sinusoscopy
The code description for 31233 matches the notes and is our most accurate code to report.
Pleural and Lung Biopsies
A biopsy of the pleural tissue or lung tissue may be accomplished in one of several
different ways.
Percutaneous Needle
When a percutaneous needle biopsy is performed, a hollow needle is inserted through
a tiny incision and directed toward the internal area, typically with the support of
imaging guidance. Only local anesthesia is used, and with only tiny incisions to mend,
getting back to normal daily activities is quick.
32400 Biopsy, pleura, percutaneous needle
32405 Biopsy, lung or mediastinum, percutaneous needle
CPT
YOU CODE IT! CASE STUDY
Harrison Matthews, a 37-year old male, was having frequent nosebleeds. Finally, after all other methods failed to
provide relief, Dr. French performed an endoscopic surgical procedure to control his nasal hemorrhages.
Pacemakers
When a physician inserts a standard pacemaker system (CPT codes 33202–33273), the
procedure includes the placement of a pulse generator into a subcutaneous envelope
that has been created beneath the abdominal muscles distally to the ribs or placement
in a subclavicular site. The generator itself contains a battery and one or more leads
(electrodes) that are inserted transvenously (through a vein) or epicardially (on the
surface of the heart). (See Figure 25-4.)
When the epicardial placement is used, a thoracotomy or thoracoscopy is necessary
to insert the electrodes accurately.
33202 Insertion of epicardial electrode(s); open incision (eg, thoracotomy,
median sternotomy, subxiphoid approach)
33203 Insertion of epicardial electrode(s); endoscopic approach (eg, thora-
coscopy, pericardioscopy)
When a physician inserts a single-chamber pacemaker system into a patient, it includes
the pulse generator and one electrode inserted into either the atrium or the ventricle.
When a dual-chamber pacemaker system is placed, the system includes the pulse
generator and one electrode into both the right atrium and the right ventricle.
When the pulse generator is inserted at the same encounter, report 33202 or 33203
in addition to
33212 Insertion of pacemaker pulse generator only; with existing single lead
33213 Insertion of pacemaker pulse generator only; with existing dual leads
33221 Insertion of pacemaker pulse generator only; with existing multiple
leads
In addition to the insertion method (epicardial or transvenous), coders must abstract
from the physician’s documentation the specific chamber or chambers of the heart
affected. These codes include the insertion of the pulse generator subcutaneously,
the transvenous placement of the electrode or electrodes, and moderate (conscious)
CPT © 2017 American Medical Association. All rights reserved.
Pacemaker
Pacemaker
leads
Right atrium
Right ventricle
Implantable Defibrillators
Pacing cardioverter-defibrillator systems are similar to pacemaker systems. While
they also consist of a pulse generator and electrodes, the units may use several leads
inserted into a single chamber (ventricle) or into dual chambers (atrium and ventricle)
(Figure 25-4). The system is actually a combination of antitachycardia pacing, low-
energy cardioversion, and/or defibrillating shocks to address a patient’s ventricular
tachycardia or ventricular fibrillation.
In some cases, an additional electrode may be needed to regulate the pacing of the
left ventricle, called biventricular pacing. When this occurs, the placement of the elec-
trode transvenously should be coded separately, just as the pacemaker is coded, with
either 33224 or 33225.
Leadless Pacemakers
An intracardiac pacemaker functions in much the same way as other pacemakers to
regulate heart rate. However, these newly FDA-approved units are self-contained, one-
inch-long devices that are implanted directly into the right ventricle chamber of the
CPT © 2017 American Medical Association. All rights reserved.
heart, and have no leads and no pockets. This pulse generator has an internal battery
and electrode and is inserted into a cardiac chamber by transfemoral catheter (through
an artery in the thigh). No incision or creation of a pocket reduces the opportunity
for infection and eliminates unsightly scars. No leads avoid the repercussions of lead
failure and result in no possible discomfort when moving, increasing mobility for the
patient.
These units are still considered new technology, so their codes will be found in the
Category III section of CPT.
These codes are used to report the evaluation of the patient so the physician can
determine if this type of pacemaker is feasible. This would be reported instead of a
typical E/M code, as long as this is the total focus of the encounter.
0390T Peri-procedural device evaluation (in person) and programming of
device system parameters before or after a surgery, procedure, or
test with analysis, review and report, leadless pacemaker system
0391T Interrogation device evaluation (in person) with analysis, review, and
report, includes connection, recording and disconnection per patient
encounter, leadless pacemaker system
A code for insertion and/or replacement of this unit and a separate code for the removal
of the unit will report the specific services provided by this physician.
0387T Transcatheter insertion or replacement of permanent leadless pace-
maker, ventricular
0388T Transcatheter removal of permanent leadless pacemaker, ventricular
Leadless pacemakers use technology to direct their function, and the physician can ensure
that the unit is adjusted and set to provide the best possible outcomes for the patient.
0389T Programming device evaluation (in person) with iterative adjustment
of the implantable device to test the function of the device and select
optimal permanent programmed values with analysis, review and
report, leadless pacemaker system
Bypass Grafting
Saphenous Vein Venous Grafts
Either of the two major veins
in the leg that run from the When a venous graft is performed, use codes from the range 33510–33516. All these
foot to the thigh near the sur- codes include a saphenous vein graft.
face of the skin. However, if the graft is harvested from an upper extremity (arm) vein, you need to code
this separately, using code 35500, in addition to the code for the bypass procedure itself.
35500 Harvest of upper extremity vein, one segment for lower extremity or
CODING BITES coronary artery bypass procedure (List separately in addition to code
The same exceptions for primary procedure.)
apply as before: If the 35572 Harvest of femoropopliteal vein, one segment, for vascular recon-
graft is harvested from struction procedure (e.g., aortic, vena caval, coronary, peripheral
an upper extremity artery) (List separately in addition to code for primary procedure.)
artery, code it sepa-
rately from the bypass Combined Arterial-Venous Grafts
procedure, using code
When both venous grafts and arterial grafts are used during the same procedure, you
35600. And if the graft
will use two codes. First, code the combined arterial-venous graft from the range
is obtained from the
33517–33523. Just like the codes for the venous grafts, these include getting the graft
femoropopliteal vein,
from the saphenous vein. Second, code the appropriate arterial graft from the range
code it with 35572 in
33533–33536. Harvesting the arterial vein section is included in those codes.
addition to the code for
the bypass procedure.
Arterial Grafts
When an arterial graft is performed, use codes from the range 33533–33536. All these
CPT © 2017 American Medical Association. All rights reserved.
codes include the use of grafts from the internal mammary artery, gastroepiploic
GUIDANCE
artery, epigastric artery, radial artery, and arterial conduits harvested from other sites.
CONNECTION For example, examine the following code descriptions:
Read the additional 33533 Coronary artery bypass, using arterial graft(s); single arterial graft
explanations in the in- 33534 Coronary artery bypass, using arterial graft(s); 2 coronary arterial grafts
section guidelines within 33535 Coronary artery bypass, using arterial graft(s); 3 coronary arterial grafts
the Surgery section, 33536 Coronary artery bypass, using arterial graft(s); 4 or more coronary
subhead Cardiovascu- arterial grafts
lar System, subsection
Venous Grafting Only Use one of the following codes (in addition to the code for the bypass procedure) if
for Coronary Artery the graft is harvested from another site:
Bypass, directly above ∙ From an upper extremity artery, add code 35600.
code 33510 in your
∙ From an upper extremity vein, add code 35500.
CPT book.
∙ From the femoropopliteal vein, use code 35572.
Right internal
iliac artery
Femoral arteries
GUIDANCE
CONNECTION
Read the additional FIGURE 25-5 An illustration showing some of the arteries and veins of the body
information in the in-
section guidelines within
Endovascular Repair of Abdominal Aorta and/or Iliac Arteries
the Surgery section,
subhead Cardiovascu- There are many therapeutic procedures available to treat conditions affecting the
lar System, subsection abdominal aorta and/or iliac arteries. Often, this involves the insertion, positioning, or
Endovascular Repair of deployment of a device known as a covered stent (see Figure 25-6). You may find the
Abdominal Aortic and/ physician documentation may specify an endograft, endovascular graft, a stentgraft,
or Iliac Arteries, directly tube endograft, or endoprosthesis – all of which are variations of a stent.
above code 34701 in CPT codes 34701 through 34834 provide the details of these various procedures
your CPT book. from which you can determine that code which best reports where [which artery] as
well as what specifically was done for this patient.
Jason Antone, a 54-year old, was admitted to the hospital by Dr. Sabrina Jordan, for treatment of a chronic, contained
rupture of an aneurysm of the infrarenal aorta. Jason was prepped and draped in the usual manner, and the proce-
dure to deploy an aorto-bi-iliac endograft was performed.
(continued)
Families.
A vascular family begins with the vessel that branches off from the aorta, femo-
ral artery, or carotid artery and continues to track all vessels that branch from that.
For example, in Table 25-2, in the first order (first column), you see the superior
mesenteric, which is one of the arteries that branch off the aorta. The middle colic,
interior pancreaticoduodenal, jejunal, ileocolic, appendicular, posterior cecal, ante-
rior cecal, marginal, and right colic arteries all branch off the superior mesenteric.
From this point, only the interior pancreaticoduodenal has additional vessels branch-
ing off it—the posterior inferior pancreaticoduodenal and the anterior inferior
pancreaticoduodenal.
TABLE 25-2 Vascular Families: Superior Mesenteric
Middle colic
Posterior inferior
Inferior pancreaticoduodenal
pancreaticoduodenal Anterior inferior
pancreaticoduodenal
Jejunal
Superior mesenteric Ileocolic
Appendicular
Posterior cecal
Anterior cecal
Marginal
Right colic
Left ophthalmic
Left posterior
communicating
Left internal carotid
Left middle cerebral
Left facial
Left lingual
Left external carotid Left occipital
CPT
LET’S CODE IT! SCENARIO
Lisa Westerly, an 11-week-old female, was diagnosed with ventricular septal defect (VSD) after her pediatrician, Dr.
Harris, ordered an echocardiography. A large VSD was identified in the septum. Due to the size of the defect, Dr.
Harris admitted Lisa into the hospital today to close the defect with a patch graft.
First Order Second Order Branch Third Order Branch Beyond Third Order Branches
Iliolumbar
Lateral sacral
Superior gluteal
Umbilical
Superior vesical
Internal iliac Obturator
Inferior vesical
Middle rectal
Inferior rectal
Internal pudendal
Inferior gluteal
Cremasteric
Inferior epigastric
Common iliac External iliac Pubic
Deep circumflex iliac Ascending deep circumflex iliac
Medial descending
Perforating branches
Profunda femoris
Lateral descending
CPT © 2017 American Medical Association. All rights reserved.
Lateral circumflex
Deep external pudendal
Superficial external pudendal
Common femoral Ascending lateral circumflex femoral
Descending lateral circumflex femoral
Transverse lateral circumflex femoral
Geniculate
Popliteal
Superficial femoral Anterior tibial
Peroneal
Posterior tibial
Central Venous Access Procedures
Venous access devices (VAD) can be challenging to report because of the various
types of procedures involved with their insertion as well as the multitude of purposes
for the procedure itself. According to the CPT guidelines, the tip of the VAD or cath-
eter must come to an end in the subclavian vein, brachiocephalic (innominate) vein,
iliac vein, superior or inferior vena cava, or right atrium of the heart to be considered
a central VAD or catheter.
Catheter or Device
A catheter is a tube that is used for various medical reasons. It may be inserted to
withdraw bodily fluids, as a urinary catheter collects urine from the bladder. Cath-
eters can also be used to deliver medications, such as an intravenous (IV) injection of
drugs directly into the patient’s veins. In addition, catheters can be used as a vehicle to
enable the insertion of a device such as a stent.
In this usage, a device is most often a subcutaneous pump or a subcutaneous port
designed to achieve ongoing access internally without the need to repeatedly obtain a
new entry site.
GUIDANCE
CONNECTION Entry Site: Centrally Inserted or Peripherally Inserted
Read the additional
For these procedures, it is important to the coding process that you read the physician’s
explanations in the
notes carefully to determine exactly where on the patient’s body the VAD or catheter
in-section guidelines
was inserted. A centrally inserted device enters the body at the jugular, subclavian, or
within the Surgery
femoral vein or the inferior vena cava. A VAD or catheter that enters the body at either
section, subhead Car-
the basilic vein or the cephalic vein is called a peripherally inserted central catheter,
diovascular System,
often referred to by its initials—a PICC line.
subsection Central
Nontunneled or Tunneled
Venous Access Proce-
dures, directly above A tunneled catheter does exactly as its name describes—it tunnels under the skin.
code 36555 in your These tubes are more flexible; they are inserted into a vein at one location, such as the
CPT book. neck, chest, or groin, and wended through beneath the skin to emerge at a separate site
in the body. A nontunneled catheter is inserted directly into the vein by venipuncture.
CPT
YOU CODE IT! CASE STUDY
Elias McGynty is a 54-year-old male who has significant multivessel coronary artery disease. He has atypical anginal
symptoms, which are probably secondary to his insulin-dependent (type 1) diabetes mellitus. Nonetheless, he is at
risk for ischemia, and in order to reduce this risk, surgical myocardial revascularization is recommended.
PROCEDURE: A coronary artery bypass graft operation utilizing the left internal mammary artery as conduit to the left
anterior descending. The remaining conduit will come from the greater saphenous veins. The risks and benefits of CPT © 2017 American Medical Association. All rights reserved.
this procedure were explained to the patient. He signed the informed consent. The patient tolerated the procedure
well and was brought into recovery conscious and aware.
Francis Lamiere, MD
Endoscopic Procedures
There are times when a physician needs to visually examine and/or obtain a specimen
for pathologic testing of the interior of an organ, such as the throat, stomach, or blad-
der, in order to make a more accurate diagnosis. In these cases, an endoscope may be
used.
An esophagogastroduodenoscopy (EGD), more commonly known as an upper
endoscopy, enables the physician to view the patient’s esophagus, stomach, and duo-
denum without a surgical invasion of the body.
Endoscopic retrograde cholangiopancreatography (ERCP) uses a combination of
x-rays and the endoscope to enable visualization of the patient’s stomach, the duode-
num, and the bile ducts in the biliary tree and pancreas.
Sigmoidoscopy and colonoscopy are endoscopic procedures used to examine the
internal aspects of the lower digestive system. A sigmoidoscopy permits the physician
to visually investigate a patient’s anus, rectum, and sigmoid colon. A colonoscopy
CPT © 2017 American Medical Association. All rights reserved.
permits the physician to look at the entire large intestine: the anus, the rectum, the
descending (sigmoid) colon, the transverse colon, the ascending colon, and the cecum.
Endoscopy can be used for therapeutic procedures as well, as when Dr. Sanger
had to remove a penny (foreign body) from little Billy’s esophagus after he tried to
swallow the coin, code 43247 Esophagogastroduodenoscopy, flexible, transoral; with
removal of foreign body(s).
Gastric Intubation
The insertion of a nasogastric (NG) tube may be done for many reasons. The stomach
contents may need to be removed, pre-surgery, post-surgery, or to remove ingested
substances (commonly known as “pumping the stomach”). In other cases, the tube
may be required to deliver nutrition directly into the stomach. This may be done for
a patient after a surgical procedure on the esophagus or the esophogastric junction.
Alternately, the tube may be inserted through the mouth instead of the nose, known as
oro-gastric tube placement, or percutaneously through the abdominal wall, known as
a gastrostomy tube.
EXAMPLES
43752 Naso- or oro-gastric tube placement, requiring physician’s skill and
fluoroscopic guidance (includes fluorosocpy, image documentation,
and report)
43753 Gastric intubation and aspiration(s), therapeutic, necessitating phy-
sician’s skill (eg. for gastrointestinal hemorrhage), including lavage if
performed
Hernia Repair
A hernia is a situation where an organ pushes through an abnormal opening within
a muscle or other structure that contains it. A hernia may occur in the inner groin
(inguinal hernia), outer groin (femoral hernia), umbilicus (umbilical hernia), between
the esophagus and stomach (hiatal hernia), and as the result of an incision (an inci-
sional hernia)
Of course, the procedure will be different to repair a hernia, as determined by the
anatomical location. As you can see by looking in the CPT Alphabetic Index, just
knowing the physician performed a hernia repair is not enough detail to determine the
code. You must identify, from the documentation, the specific anatomical site.
As with many other procedures, hernia repair can be done as an open procedure or
laparoscopically. With some types of hernias, you may also need to know the patient’s
age. Diaphragmatic, inguinal, and umbilicus hernias are known to occur in neonates
and children. And more specifics are needed about the hernia itself: initial or recur-
rent; incarcerated or strangulated. All of these details will also impact the determina-
tion of the code to report.
CPT
YOU CODE IT! CASE STUDY
Thomas Mouldare, 47-year-old male, was diagnosed with a diaphragmatic (hiatal) hernia that required surgery. Dr.
Wallabee performed a Nissen fundoplication, laparoscopically. The upper area of the stomach (gastric fundus) is
plicated (wrapped) around the distal portion of the esophagus. This is done to support and reinforce the effective-
ness of the lower esophageal sphincter. Then, the esophageal hiatus is sutured to narrow the opening back to the
correct width.
Bariatric Surgery
Bariatric surgical procedures may be performed on the stomach, the duodenum, the
jejunum, and/or the ileum and are most often provided to patients who have been diag-
nosed as morbidly obese. Consideration for performing this surgery may include the
physician’s evaluation of the candidate’s eating behaviors as well as the patient’s pre-
disposition for serious obesity-related co-morbidities such as coronary heart disease,
type 2 diabetes mellitus, and/or acute sleep apnea.
These surgeries may be performed as an open procedure or laparoscopically, and
this detail will affect the determination of the correct code. The four most common
versions of this surgery are
∙ Adjustable gastric band (AGB). See codes 43770–43774. AGB is a procedure
that places a small, adjustable band to create a proximal pouch, thereby limit-
ing the passage of food. The attending physician can increase or decrease the
size of the passage using saline solution to inflate or deflate as needed for the
patient’s situation.
∙ Roux-en-Y gastric bypass (RYGB). See codes 43846, 43847, 43644. RYGB lim-
its food intake by use of a small pouch that is similar in size to that created by
the adjustable gastric band. In addition, absorption of food in the digestive tract
is reduced by excluding most of the stomach, duodenum, and upper intestine
from contact with food by routing food directly from the pouch into the small
intestine.
∙ Biliopancreatic diversion with a duodenal switch (BPD-DS). See codes 43775 and
43843. BPD-DS, most often referred to as a “duodenal switch,” includes transection
of the stomach, a bypass to route digested material away from the small intestine, as
well as re-routing bile and other digestive juices that impair digestion.
∙ Vertical sleeve gastrectomy (VSG). See code 43775. A vertical sleeve gastrectomy
(VSG) is performed and connected to a very short segment of the duodenum, which
CPT © 2017 American Medical Association. All rights reserved.
is then directly connected to a lower part of the small intestine. A small portion
of the duodenum is untouched to provide passage for food and absorption of some GUIDANCE
vitamins and minerals. The distance between the stomach and colon is made much CONNECTION
shorter after this operation, resulting in malabsorption.
Read the additional
A VSG procedure includes the resectioning of the stomach and is most often per- explalnations in the
formed solely as the first stage of the multistaged BPD-DS on those patients deter- in-section guidelines
mined to be unable to go through such a long procedure at one encounter. VSG is not located within the
without benefits, as research has shown that some VSG patients report significant Surgery section, sub-
weight loss. Should a second-stage procedure be performed, that second procedure head Digestive System,
and any others in the sequence would be reported with the appropriate procedure code subsection Bariatric
appended by modifier 58 Staged Procedure. Surgery, directly above
During the postoperative period, adjustments of an adjustable gastric restric- code 43770 in your
tive device is included in the global surgical package and therefore not coded CPT book.
separately.
CPT
LET’S CODE IT! SCENARIO
Justin Abernathy, a 61-year-old male, was suffering from fecal incontinence, diarrhea, and constipation. He came
to the Ambulatory Care Center so that his gastroenterologist, Dr. Minton, could perform a colonoscopy. First, Ellen
Brennon, RN, administered Demerol and Versed by IV, and the patient was brought into the examination room. The
variable flexion Olympus colonoscope was introduced into the rectum and advanced to the cecum. In the midsig-
moid colon, a 3-mm sessile polyp was destroyed. The procedure took about 30 minutes, and Justin tolerated the
procedure well.
Urinary Catheterization
There are many reasons why a urinary catheter might need to be inserted: patients
CPT © 2017 American Medical Association. All rights reserved.
with incontinence, especially those who are chronically bedridden or those with lower
paralysis; those about to go through a surgical procedure, especially when general
GUIDANCE anesthesia is administered; as well as patients who suffer from reduced or blocked
urine flow, such as male patients with enlarged prostates or female patients with uter-
CONNECTION ine fibroid tumors. A patient with reduced renal function may require a catheterization
Read the additional so health care professionals can accurately monitor their urinary output.
explanations in the in- The documentation may include details, such as the type of catheter used, including
section guidelines within a Foley, a Robinson, a Carson, or a Tieman catheter. Each type performs differently
the Surgery with various features, determined by the specific issue being addressed.
section, subhead Uri-
nary System, subsection Urodynamics
Urodynamics, directly
above code 51725 in The codes listed for the procedures in the Urodynamics section, 51725–51798, include
your CPT book. the services of the physician to perform the procedure (or directly supervise the per-
formance of the procedure), as well as the use of all instruments, equipment, fluids,
CPT
YOU CODE IT! CASE STUDY
Rachel Naviga, a 39-year-old female, G3 P3, states she has been dealing with stress incontinence increasingly over
the last several years. She had three vaginal deliveries, with the largest infant weighing 7.5 lb. Rachel states that her
leakage frequency, volume, timing, and associated symptoms (urgency, stress, urinary frequency, nocturia, enuresis,
incomplete emptying, straining to empty, leakage without warning) have become bothersome and she wants to do
something about it.
Today she presents for a complex cystometrogram with voiding pressure study to confirm or deny the diagnosis
of stress urinary incontinence prior to the scheduling of surgery.
Transurethral Surgery
When a diagnostic or therapeutic cystourethroscopic intervention is performed, the
appropriate codes, 52204–52356, include the insertion and removal of a temporary
stent. Therefore, those services are not reported separately—when done at the same
time as the cystourethroscopy (Figure 25-7).
If the physician, however, inserts a self-retaining, indwelling stent during the diag-
nostic or therapeutic cystourethroscopic intervention, use one of the following:
1. Code 52332 with the modifier 51, along with the code for the cystourethroscopy for
a unilateral procedure.
2. Code 52332 with modifier 50 for a bilateral insertion of self-retaining, indwelling
ureteral stents.
Note that when the physician removes the self-retaining, indwelling ureteral stent, use
either 52310 or 52315 with modifier 58.
Urinary Resectoscope
bladder Prostate in urethra
CPT
LET’S CODE IT! SCENARIO
Ena Colby, a 41-year-old female, is admitted today for the surgical removal of a kidney stone. The stone was too big
for her to pass, so Dr. Olympia decided to remove it surgically. The nephrolithotomy, with complete removal of the
calculus, went as planned, and Ena tolerated the entire procedure well.
Penile Plaque
This type of plaque is a flat layer of scar tissue that can form on the inside of a thick
membrane called the tunica albuginea, which envelops the erectile tissues, and is known
as Peyronie disease. This is believed to begin as an inflammation, and the plaque is
benign, not contagious, and not sexually transmitted. However, it can cause discomfort
and pain in men with this condition. There are several ways to treat the problem.
Injections of steroids and chemotherapy agents, such as interferon, can be directly
delivered to the site of the plaque to work to reduce the effect. These procedures may
be reported with
54200 Injection procedure for Peyronie disease
54205 Injection procedure for Peyronie disease; with surgical exposure of
plaque
The plaque can be surgically removed. This procedure may be performed just to excise
the plaque, or it may include the grafting of material to replace tissue that was excised.
54110 Excision of penile plaque (Peyronie disease)
54111 Excision of penile plaque (Peyronie disease); with graft to 5 cm in
length
54112 Excision of penile plaque (Peyronie disease); with graft greater than
5 cm in length
Severe cases may require more extensive reconstruction and will be reported with code
54360 Plastic operation on penis to correct angulation
CPT
YOU CODE IT! CASE STUDY
Glenn Hagger, a 15-year-old male, came to see his regular physician, Dr. Carboni, for help. Glenn and his friends
were fooling around at his father’s construction company, and a staple gun went off, projecting a staple into his
scrotum. Dr. Carboni carefully removed the staple and applied some antibiotic ointment to prevent infection until the
CPT © 2017 American Medical Association. All rights reserved.
(continued)
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
55120 Removal of foreign body in scrotum
This matches the physician’s description perfectly!
GUIDANCE EXAMPLES
CONNECTION 56620 Vulvectomy, simple; partial
Read the additional
The description of this code represents a physician’s statement that he or she
explanations in the
removed less than 80% of the skin and superficial subcutaneous tissues of the
in-section guidelines
vulvar area.
within the Surgery sec-
tion, subhead Female 56633 Vulvectomy, radical; complete
Genital System, subsec-
The description of this code represents a physician’s statement that he or she removed
CPT © 2017 American Medical Association. All rights reserved.
tion Vulva, Perineum,
more than 80% of the skin and deep subcutaneous tissues of the vulvar area.
and Introitus, directly
above code 56405 in
your CPT book. Maternity Care and Delivery
The complete package of services provided to a woman for uncomplicated maternity
care includes the antepartum (prenatal) care, the delivery of the baby, and the post-
partum care of the mother. Similar to working with the services already provided in
the global surgical package, you must know the components of the maternity care
package. This is the only way you can determine what is already included and what
services should be reported separately.
Antepartum Care
∙ Initial patient history
∙ Subsequent patient history
Delivery Services
∙ Admission to the hospital
∙ Admission history and physical examination (H&P)
∙ Management of uncomplicated labor
∙ Delivery: vaginal (with or without episiotomy, with or without forceps) or cesarean
section
Postpartum Care
∙ Hospital and office visits following the delivery
Should a physician provide one portion of the services, but not all, this will affect the
determination of the correct code.
EXAMPLE GUIDANCE
Dr. Barber provided antepartum care for Nancy Trainer. While on vacation in CONNECTION
Europe, Nancy suffered a miscarriage (spontaneous abortion) and lost the baby. Read the additional
Dr. Barber provided postpartum care for Nancy when she returned home. There- explanations in the
fore, instead of reporting in-section guidelines
59400 Routine obstetric care including antepartum care, vaginal delivery within the Surgery sec-
(with or without episiotomy, and/or forceps) and postpartum care tion, subhead Maternity
Care and Delivery,
or directly above code
59510 Routine obstetric care including antepartum care, cesarean delivery, 59000 in your CPT
and postpartum care book.
Dr. Barber’s complete care for Nancy will be reported with two codes:
59425 Antepartum care only; 4–6 visits
59430 Postpartum care only (separate procedure)
CPT © 2017 American Medical Association. All rights reserved.
CPT
LET’S CODE IT! SCENARIO
PATIENT: GLORIA VALDEZ
DATE OF DISCHARGE: 05/30/2018
ADMITTING DIAGNOSIS: Intrauterine pregnancy at 36 weeks and 5 days estimated gestational age. Presented with
contractions and in latent labor.
DISCHARGE DIAGNOSIS: Status post normal spontaneous vaginal delivery at 36 weeks and 5 days estimated ges-
tational age.
HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE: This patient is a 31-year-old G4, P 1-0-2-1 female for whom
I have been attending through all prenatal care. She is at 36 weeks and 5 days estimated gestational age who
(continued)
presented with contractions and in latent labor. On vaginal examination, the patient was found to be 3 cm dilated,
70% effaced and –3 station. The fetal heart tracing at the time was in the 140s and reactive. The patient was admit-
ted to Labor and Delivery for antibiotics and epidural. The patient continued to have a good labor pattern and pro-
ceeded to deliver a viable female infant weighing 5 pounds 7 ounces over an intact perineum with Apgars of 9 and 9
at 1 and 5 minutes. There were no nuchal cords, no true knots, and the number of vessels in the cord were three. Her
postpartum course was uncomplicated and the patient was discharged to home in stable and satisfactory condition
on postpartum day #2.
PROCEDURES PERFORMED: Normal spontaneous delivery and repair of midline episiotomy in the usual fashion.
COMPLICATIONS: None.
FINAL DIAGNOSIS: Status post normal spontaneous vaginal delivery at 36 weeks and 5 days estimated gestational
age.
DISCHARGE INSTRUCTIONS: Call for increased pain, fever, or increased bleeding.
DIET: Advance as tolerated.
ACTIVITY: Pelvic rest for 6 weeks and nothing inserted into the vagina for 6 weeks, i.e., no tampons, douche, or
sex.
MEDICATIONS AND FOLLOWUP: Instructed patient to call me in the morning, or prn with any concerns. Then, I will
see her in the office in 1 week.
Felicia Washington, MD
Skull Surgery
The skull is, technically, the bone-shell that covers and protects the brain and organs
within. To cushion the tissues, blood vessels, and nerves, the dura mater, arachnoid
mater, and pia mater lie between the skull and these components (Figure 25-8).
The complexity of surgical treatment of skull base lesions often demands the skills
of more than one surgeon during the same session. When one surgeon provides one
portion of the procedure and another surgeon a different portion, each surgeon only
uses the code for the surgical procedure he or she performed.
Typically, the segments of the procedure include the following:
1. The approach describes the tactic of the procedure, such as craniofacial, orbitocra-
nial, or transcochlear:
a. Anterior cranial fossa, 61580–61586
b. Middle cranial fossa, 61590–61592
c. Posterior cranial fossa, 61595–61598
2. The definitive describes the procedure itself, such as resection, excision, repair,
biopsy, or transection:
a. Base of anterior cranial fossa, 61600–61601
b. Base of middle cranial fossa, 61605–61613
c. Base of posterior cranial fossa, 61615–61616
3. The repair/reconstruction identifies a secondary repair, such as
a. Extensive dural grafting
b. Cranioplasty
Skull
Pia mater
CPT © 2017 American Medical Association. All rights reserved.
Arachnoid
mater
Dura mater
reported with CPT code 63610 Stereotactic stimulation of spinal cord, percutaneous,
separate procedure not followed by other surgery.
Pain Management
Virtually everyone knows what pain feels like, and this is a very personal evaluation.
Medically speaking, pain is an unpleasant sensation often initiated by tissue damage,
resulting in impulses transmitted to the brain via specific nerve fibers. Most health
care facilities use some type of pain scale from 0 to 10, with 0 indicating no pain at
all and 10 representing excruciating, intolerable pain. In most instances, each number
on the scale is accompanied by an illustration to help patients accurately communicate
what they are feeling. This numeric scale (no illustrations), provided by the National
Institutes of Health, can help improve communication with patients (Table 25-5).
When the documentation indicates that an encounter is prompted by a patient’s
need for pain management, especially when the pain is noted as acute and/or chronic,
there are several options for treatment.
Electrical Reprocessing
Researchers are consistently searching for new ways to help patients manage their
pain. Transcutaneous electrical modulation pain reprocessing (TEMPR), also referred
to as scrambler therapy, administers electrical impulses designed to interrupt pain sig-
nals. Although this experimental procedure uses a type of transcutaneous electrical
nerve stimulation (TENS), it is not the same procedure. Each session lasts about an
hour, with the physician making adjustments approximately every 10 minutes. Each
treatment session is reported with Category III code 0278T.
0278T Transcutaneous electrical modulation pain reprocessing (eg. scrambler
therapy), each treatment session (includes placement of electrodes)
This methodology typically uses pumps, devices that can provide continual delivery
of the drug, biologicals, or genetically engineered encapsulated cells. This route of
administration has been found to be less invasive for the patient and enables treatment
of a larger portion of the central nervous system utilizing the cerebrospinal fluid circu-
lation pathways. Epidural administration tenders the medication into the dura mater of
the spinal cord rather than the subarachnoid space.
EXAMPLES
62350 Implantation, revision, or repositioning of tunneled intrathecal or
epidural catheter, for long-term medication administration via an
external pump or implantable reservoir/infusion pump; without
laminectomy
CODING BITES 62360 Implantation or replacement of device for intrathecal or epidural
drug infusion; subcutaneous reservoir
Whenever you report
62362 Implantation or replacement of device for intrathecal or epidural
the administration of a
drug infusion; programmable pump, including preparation of pump,
drug, you will need the
with or without programming
code for the administra-
99601 Home infusion/specialty drug administration, per visit (up to 2 hours)
tion, such as implan-
tation of a pump or
infusion, as well as a
code to report the spe- Intravenous Therapy
cific drug that is admin-
This may be the administration route with which you are most familiar. The medica-
istered. Most often, the
tion enters the body via the patient’s vein, most often using a point inside the patient’s
codes used to report
antecubital fossa (elbow). If the condition is chronic, a peripherally inserted central
the specific drug come
catheter (PICC) line may be inserted and used for the administration of the medication
from the HCPCS Level II
for the duration of the therapy.
code set. See the chap-
ter HCPCS Level II in
this textbook for more
information on these EXAMPLE
codes.
96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify
substance or drug); initial, up to 1 hour
36568 Insertion of peripherally inserted central venous catheter (PICC),
without subcutaneous port or pump; younger than 5 years
of age
36569 Insertion of peripherally inserted central venous catheter (PICC),
without subcutaneous port or pump; 5 years or older
CPT
LET’S CODE IT! SCENARIO
Gerald Rosen, a 63-year-old male, was admitted for the implantation of a cerebral cortical neurostimulator.
Dr. Grumman performed a craniotomy and then successfully implanted the electrodes.
Endovascular Therapy
Included in this category of neurologic procedures are balloon angioplasties and intra-
vascular stents. You learned about these types of procedures in the Cardiovascular
System section of this chapter. However, the codes here report these procedures when
done intracranially (within the skull) and not intracardially (within the heart).
An intra-arterial mechanical embolectomy or thrombectomy is most often per-
formed to treat an acute ischemic stroke (when a thrombus or embolus blocks blood
flow to the brain).
Now, you know exactly which code to report for this procedure:
61645 Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thromboly-
sis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, cath-
eter placement, and intraprocedural pharmacological thrombolytic injection(s)
Good job!
Vitreous humor
Optic
disk
Iris
Optic
Cornea nerve
Pupil
Lens Fovea
centralis
Aqueous humor
Anterior Retina
chamber
Anterior
cavity Posterior
chamber Choroid
Ciliary body
people aged 12 and over have some type of visual impairment, and about 61 million
adults are believed to be at high risk for acute vision loss.
There are two recesses in the human skull, each known as an orbit, or eye socket.
Within this bony conical orbit sits the contents of the eye and its ancillary parts (mus-
cles, nerves, blood vessels). The optical system is the most complex organ system of
the human body (Figure 25-9).
Ophthalmologists diagnose and treat problems and concerns of the eye and ocular
adnexa (anatomical parts and sites adjacent to an organ). Most commonly, cataracts
are corrected and foreign materials are removed.
Glaucoma Surgery
Glaucoma is a malfunction of the fluid pressure within the eye; the pressure rises to
a level that can cause damage to the optic disc and nerve. Treatment can successfully
prevent blindness or any vision loss from resulting. When eye drops, oral medication,
or laser treatments have failed to control the patient’s glaucoma condition, a trabecu-
lectomy may be performed. This procedure treats glaucoma with an incision into the
trabecular tissue of the eye to drain the excess fluid that has accumulated. In some
cases, a drainage tube is inserted.
CPT © 2017 American Medical Association. All rights reserved.
EXAMPLES
65850 Trabeculectomy ab externo
66170 Fistulization of sclera for glaucoma; trabeculectomy ab externo in
absence of previous surgery
Vitrectomy
Patients diagnosed with diabetes mellitus are at risk for ophthalmic manifestations of
their abnormal glucose levels. Diabetic retinopathy is the most common; it is a condi-
tion that causes damage to the tiny blood vessels inside the retina. In cases where the
bleeding in the eye is severe, a vitrectomy, the surgical removal of vitreous gel from
the center of the eye, may be necessary.
EXAMPLES
65205 Removal of foreign body, external eye; conjunctival superficial
67413 Orbitotomy without bone flap (frontal or transconjunctival approach);
with removal of foreign body
67430 Orbitotomy with bone flap or window, lateral approach (eg, Kroen-
lein); with removal of foreign body
68530 Removal of foreign body or dacryolith, lacrimal passages
Dacryocystorhinostomy
Nasolacrimal duct (NLD) stenosis is a condition that may be congenital or acquired.
A patient may acquire an NLD stenosis as a result of a granulomatous disease, such
as sarcoidosis; a sinus condition; or the formation of dacryoliths (calculus in the lacri-
mal duct or sac). A dacryocystorhinostomy (DCR) is the standard of care for an NLD
obstruction. DCR can be performed using a percutaneous approach by way of a facial
incision or the approach may be via the natural opening of the nose endoscopically.
The procedure is designed to bypass the obstructed nasolacrimal duct and enable tear
drainage directly into the nose from the lacrimal sac.
Fornix
The conjunctival fornix is the
EXAMPLES area between the eyelid and
the eyeball. The superior for-
68801 Dilation of lacrimal punctum, with or without irrigation nix is between the upper lid
CPT © 2017 American Medical Association. All rights reserved.
68815 Probing of nasolacimal duct, with or without irrigation; with insertion and eyeball; the inferior fornix
of tube or stent is between the lower lid and
the eyeball. Plural: fornices
CPT
LET’S CODE IT! SCENARIO
Delores Leon was diagnosed with a herniated orbital mass, OD (right inferior orbit). Dr. Marconi performed an exci-
sion of the mass and repair. From his notes, “The lower lid was everted and the inferior fornix examined. The herniat-
ing mass was viewed and measured at 0.81 cm in diameter. Westcott scissors were used to incise the conjunctival
fornices. The herniating mass was then clamped, excised, and cauterized. It appeared to contain mostly fat tissue,
which was sent to pathology. The inferior fornix was repaired using running suture of 6-0 plain gut. Bacitracin oint-
ment was applied to the eye followed by an eye pad.”
(continued)
Let’s Code It!
The procedure performed was “excision of the mass and repair, right inferior orbit.”
In the CPT Alphabetic Index, turn to excision and review the long list of anatomical sites below. What did Dr.
Marconi excise? Not the eye (that would be removal of the eyeball). He removed a “mass from the eye orbit” and
then “repaired the orbit.”
There is no listing for mass, but you should remember from medical terminology class (or look it up in a medi-
cal dictionary) that another term for mass is lesion. In the Alphabetic Index, find:
Excision . . . Lesion . . another long list. On your scratch pad, write down the codes suggested next to the word
Orbit—61333, 67412, 67420—so that you can check them out. However, while you are here, also write down
the codes suggested for Conjunctiva—68110–68130. Why? Because in the body of the notes, it states “incise
the conjunctival fornices.” This is why it is so important to read the complete notes and not just code from the
procedure statement at the top.
Now, let’s turn to the main portion of the CPT and find the complete code descriptions:
61333 Exploration of orbit (transcranial approach); with removal of lesion
67412 Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of lesion
67420 Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of lesion
68110 Excision of lesion, conjunctiva; up to 1 cm
68115 Excision of lesion, conjunctiva; over 1 cm
68130 Excision of lesion, conjunctiva; with adjacent sclera
Which code description matches the physician’s notes accurately? 68110. Good work!
CPT
YOU CODE IT! CASE STUDY
Ronald Jackson, a 49-year-old male, was working in a metal shop. As he was trimming a steel bar, some metal splinters
got into his eye. Fortunately, Dr. Draman found that the metal pieces presented superficial damage and had not embed-
ded themselves in Ronald’s conjunctiva. Dr. Draman removed all the metal pieces and placed a patch over Ronald’s eye.
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
65205 Removal of foreign body, external eye; conjunctival superficial
Good for you!
EXAMPLES
69100 Biopsy external ear
69209 Removal impacted cerumen using irrigation/lavage, unilateral
69310 Recontruction of external auditory canal (meatoplasty) (eg. for steno-
sis due to injury, infection) (separate procedure)
EXAMPLES
69421 Myringotomy, including aspiration and/or eustachian tube inflation
requiring general anesthesia
69535 Resection temporal bone, external approach
EXAMPLE
69801 Labyrinthotomy, with perfusion of vestibuloactive drug(s), transcanal
69820 Fenestration semicircular canal
Auricle
CPT © 2017 American Medical Association. All rights reserved.
Cochlea
Oval window
Tympanic Round window
membrane
Tympanic
(eardrum)
cavity
External
auditory Auditory
meatus tube
Pharynx
These codes report the insertion of the tube into one ear only. When the physician
performs this for both ears at the same encounter, you will need to append modifier
50 Bilateral procedure to the correct procedure code.
Sometimes, over a period of time, the tubes naturally fall out. However, when the
physician must go in and surgically remove the tubes under general anesthesia, this
procedure will be reported separately:
69424 Ventilating tube removal requiring general anesthesia
CPT
YOU CODE IT! CASE STUDY
Anna Mendoza, a 33-year-old female, has been deaf since she was 11. She is admitted today for Dr. Eberhardt to
put a cochlear implant in her left ear. It is expected that Anna will gain back much of her hearing.
CPT
LET’S CODE IT! SCENARIO
Abbey Reason, a 15-year-old female, was diagnosed 3 years ago with idiopathic pulmonary fibrosis, a chronic
interstitial pulmonary disease. Corticosteroid therapy has not improved her condition, so Dr. Flemming admitted her
today for a double-lung transplantation. The harvesting of the allograft and the preparation of the cadaver donor
double-lung allograft were done by Dr. Orenge. Dr. Flemming only performed the actual lung transplant, en bloc,
along with a cardiopulmonary bypass. Abbey tolerated the procedure well and has an excellent prognosis.
(continued)
Let’s go to the Alphabetic Index and look for transplant. Read down until you find lung. You know that Abbey
received a double-lung transplant, en bloc, with a bypass. That information leads to the suggested code 32854.
Now go to the numeric listing to check the complete code description.
32854 Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass
Terrific! This code matches the notes.
Heart/Lung Transplantation
Similar to the components of the lung transplantation that we reviewed earlier, a heart
transplant, with or without a lung allotransplantation, requires three steps to be per-
formed by a single physician or a team of physicians. Each step has its own codes.
Backbench Work
The actual preparation of the cadaver donor heart, or heart and lung, allograft prior
to the transplant procedure is known as backbench work. The second portion of the
transplant is coded by using either of the following:
33933 Backbench standard preparation of cadaver donor heart/lung allograft
to transplantation, including dissection of allograft from surrounding
soft tissues to prepare aorta, superior vena cava, inferior vena cava,
and trachea for implantation
or
33944 Backbench standard preparation of cadaver donor heart allograft to
transplantation, including dissection from surrounding soft tissues
to prepare aorta, superior vena cava, inferior vena cava, pulmonary
artery, and left atrium for implantation
Liver Transplantation
Again, the components that we have reviewed for the other organ transplants are
involved with a liver allotransplantation.
Backbench Work
The actual preparation of the whole liver graft prior to the transplant procedure is
coded with
47143 Backbench standard preparation of cadaver donor whole liver graft
prior to allotransplantation, including cholecystectomy, if necessary,
and dissection and removal of surrounding soft tissues to prepare
the vena cava, portal vein, hepatic artery, and common bile duct for
implantation; without trisegment or lobe split
47144 with trisegment split of whole liver graft into 2 partial liver grafts (ie.
left lateral segment [segments II and III] and right trisegment [seg-
ments I and IV through VIII])
47145 with lobe split of whole liver graft into 2 partial liver grafts (ie.
left lobe [segments II, III, and IV] and right lobe [segments I and V
through VIII])
In certain cases, and almost always if the donor is living, some reconstruction of the
liver will be required prior to the transplantation. If the notes indicate that a venous
and/or arterial anastomosis was also performed, then you will need to use
47146 Backbench reconstruction of cadaver or living donor liver graft prior to
allotransplantation; venous anastomosis, each
CPT © 2017 American Medical Association. All rights reserved.
Pancreas Transplantation
Again, the components that we have reviewed for the other organ transplants are
involved with a pancreatic allotransplantation.
Donor Nephrectomy
A human can live without one kidney, so the donor can be either deceased (a cadaver)
or living.
50300 Donor nephrectomy (including cold preservation); from cadaver donor,
unilateral or bilateral
or
50320 Donor nephrectomy (including cold preservation); open, from living
donor
or
50547 Laparoscopy, surgical; donor nephrectomy (including cold preserva-
CPT © 2017 American Medical Association. All rights reserved.
tion), from living donor
Backbench Work
Performing the routine preparation of the allograft is coded differently, depending
upon whether the donor is living or a cadaver.
50323 Backbench standard preparation of cadaver donor renal allograft prior
to transplantation, including dissection and removal of perinephric fat,
diaphragmatic and retroperitoneal attachments, excision of adrenal
gland, and preparation of ureter(s), renal vein(s), and renal artery(s),
ligating branches, as necessary
or
50325 Backbench standard preparation of living donor renal allograft prior
to transplantation, including dissection and removal of perinephric fat,
CPT
YOU CODE IT! CASE STUDY
PATIENT: ETHAN NORWOOD, IV
PROCEDURE PERFORMED: Percutaneous kidney transplant biopsy.
DESCRIPTION OF PROCEDURE: After informed written consent was obtained from the patient, he was taken to the
ultrasound suite and placed in the supine position on the stretcher with the left side propped up slightly with towels
for optimal exposure of the transplant. The kidney transplant was localized in the left iliac fossa with ultrasound and
CPT © 2017 American Medical Association. All rights reserved.
a point overlying the lower pole was marked on the skin. The area was then prepped with Betadine and covered
with a sterile fenestrated drape. Lidocaine 1% was infiltrated at the mark superficially and then to less than 1 cm,
as indicated by ultrasound, to the surface of the kidney. A small incision was made at the anesthetized site with a
#11 blade. A 16 gauge Monopty biopsy gun was then introduced through the incision to a depth of less than 1 cm
and fired. A core tissue was obtained and placed in 10% formalin. The procedure was repeated once more, again
yielding a core tissue. It was divided between formalin and Michel’s solution. The procedure was then terminated.
Firm pressure was applied to the biopsy site after each pass including 5 minutes after the last pass. A Band-Aid
was then placed over the incision. A final ultrasound scan showed no obvious evidence of hematoma. A pressure
dressing was applied. The patient tolerated the procedure well. There were no apparent complications. He has
been returned to the floor in satisfactory condition and orders have been written for frequent vital signs, hematocrit,
exam parameters.
Ava Ferrer, MD
(continued)
You Code It!
Read the details about the biopsy that Dr. Ferrer performed and determine the most accurate way to report it.
Step #1: Read the case carefully and completely.
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine these to be the codes?
50200 Renal biopsy; percutaneous, by trocar or needle
76942 Ultrasonic guidance for needle placement (eg biopsy, aspiration, injection, localization device),
imaging supervision and interpretation
Did you find the radiology code for the ultrasound, too? You will learn more about coding for radiology services
in our next chapter of this textbook. However, to get to this code, all you had to do is read the guideline notation
beneath code 50200
(For radiological supervision and interpretation, see 76942, 77002, 77012, 77021)
This notation not only told you how to report the ultrasound service for this biopsy, it also informed you that it
was not already included in the 50200 code.
EXAMPLE
19364 Breast reconstruction with free flap
(Do not report code 69990 in addition to code 19364.)
As you can see, the codes involved are throughout the Surgery section of the CPT.
You might want to go through and mark or highlight the codes, should you be coding
for a physician who works with an operating microscope.
CPT
LET’S CODE IT! SCENARIO
PATIENT: OLIVIA PRIMA
DATE OF PROCEDURE: 07/22/2018
PREOPERATIVE DIAGNOSIS: Right vocal cord lesion
POSTOPERATIVE DIAGNOSIS: Respiratory papilloma
PROCEDURE: Microscopic laryngoscopy with biopsy and papilloma shave
SURGEON: Serita Frapenstein, MD
ASSISTANT: Morris Bershic, MD
ANESTHESIA: General endotracheal
COMPLICATIONS: None
SPECIMENS REMOVED: Biopsy samples sent from the anterior commissure of the vocal cord
INDICATION FOR PROCEDURE: The patient is a 37-year-old female with a 6-month history of isolated hoarseness
with a vocal cord lesion on direct laryngoscopy, who presents for biopsy of the vocal cord lesion.
CPT © 2017 American Medical Association. All rights reserved.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, and an appropriate plane of anes-
thesia was obtained via endotracheal intubation.
The head of the bed was turned 90 degrees. The Dedo laryngoscope was used to visualize the base of tongue, the
bilateral vallecula, both surfaces of the epiglottis, the aryepiglottic folds, the bilateral pyriform sinuses, and hypopharynx.
All of these areas were clear of any lesions or mucosal abnormalities. The true vocal cords were noted to have papilloma-
tous lesions on the right inferior aspect of the cord and the anterior commissure. The false cords and ventricles were clear.
The patient’s larynx was suspended via the laryngoscope. Biopsy samples were taken for frozen and perma-
nent specimens from the anterior commissure lesion. This came back to confirm papilloma. Next, the operating micro-
scope was brought into the field to obtain a detailed visualization of the vocal cord lesion. A straight shaver was then
utilized to remove the papillomatous tissue on the right vocal cord. Care was taken to preserve the mucosa on that
side and not injure the vocal cord. This was done unilaterally again on the right. Appropriate hemostasis was obtained.
The patient tolerated the procedure well. The operating microscope was removed from the field. The patient was
extubated and taken to recovery in stable condition with no immediate complications.
(continued)
Let’s Code It!
As you read in the operative reports, Dr. Frapenstein performed a laryngoscopy using an operating microscope.
First, you must determine the code for the laryngoscopy. Find this in the CPT Alphabetic Index.
Laryngoscopy
with Operating Microscope or Telescope . . . . 31526, 31531, 31536, 31541, 31545, 31546, 31561, 31571
Turn to the main section and find the codes suggested. Remember, you are obligated to read ALL of these
code descriptions to determine which one is most accurate.
31526 Laryngoscopy direct, with or without tracheoscopy; diagnostic, with operating microscope or
telescope
31531 Laryngoscopy direct, operative, with foreign body removal; with operating microscope or
telescope
31536 Laryngoscopy direct, operative, with biopsy; with operating microscope or telescope
31541 Laryngoscopy direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis;
with operating microscope or telescope
31545 Laryngoscopy direct, operative, with operating microscope or telescope, with submucosal removal
of non-neoplastic lesion(s) of vocal cord; reconstruction with local tissue flap(s)
31546 Laryngoscopy direct, operative, with operating microscope or telescope, with submucosal removal
of non-neoplastic lesion(s) of vocal cord; reconstruction with graft(s) (includes obtaining autograft)
31561 Laryngoscopy direct, operative, with arytenoidectomy; with operating microscope or telescope
31571 Laryngoscopy direct, operative, with injection into vocal cord(s), thereapeutic; with operating
microscope or telescope
Now that you know, specifically, what these codes report, go back to the operative notes and abstract the
details, beyond laryngoscopy + operating microscope.
The documentation reads, “Biopsy samples were taken.” . . . This leads you to code 31536. However, the
documentation also states,
“A straight shaver was then utilized to remove the papillomatous tissue on the right vocal cord.”
[NOTE: Use your medical dictionary if you don’t already know that papillomatous tissue is benign.]
. . . This might lead to code 31545 or 31546, except there is documentation that “Care was taken to preserve
the mucosa,” so you know that submucosal tissue was not removed. And there is no mention of a reconstruction
being performed.
So, you can confidently report code 31536. One more thing to check . . . do you need to report a second code
for the use of the operating microscope? Turn to code 69990 and read the guideline carefully. Code 31536 is
included in the “Do not report 69990” notation.
You also know that code 31536 includes the specific detail that an operating microscope was used, therefore
meaning that this tells the whole story and reporting 69990 would just be repetitive. Now, you know the accu-
rate way to report this procedure:
Chapter Summary
When coding surgical procedures, you have the challenge of determining which ser-
vices are included in the procedure code, which services are part of the global pack-
age, and which services must be coded separately.
In addition, it is important to remember that the Surgery section of the CPT book
not only includes codes for reporting services provided in an operating room under
general anesthesia but also includes codes for reporting simple and small procedures
such as removing a splinter.
CHAPTER 25 REVIEW
of the operation and (2) determine which services are included in the code’s descrip-
tion and which services require a separate code. The Surgery section of the CPT book
is divided into subsections identified by the body system upon which the technique
was performed.
CODING BITES
CPT Surgical Package
• Subsequent to the decision for surgery, one related E/M encounter on the date
immediately prior to or on the date of the procedure (including history and
physical).
• Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia.
• The procedure itself.
• Immediate postoperative care, including dictating operative notes and talking
with the family and other physicians/health care professionals.
• Writing orders.
• Evaluation of the patient in the post-anesthesia recovery area.
• Typical postoperative follow-up care.
CHAPTER 25 REVIEW
CPT Surgery Section Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
Part I
1. LO 25.2 The length of time allotted for postoperative care included in the surgi- A. Complex Closure
cal package, which is generally accepted to be 90 days for major surgi- B. Donor Area
cal procedures and up to 10 days for minor procedures.
CPT © 2017 American Medical Association. All rights reserved.
C. Excision
2. LO 25.5 The process of taking skin or tissue (on the same body or another).
D. Full-Thickness
3. LO 25.5 The area or part of the body from which skin or tissue is removed with
E. Global Period
the intention of placing that skin or tissue in another area or body.
F. Harvesting
4. LO 25.1 The methodology or technique used by the physician to perform the
procedure, service, or treatment. G. Intermediate Closure
5. LO 25.2 The accepted principles of conduct, services, or treatments that are
established as the expected behavior.
6. LO 25.5 A method of sealing an opening in the skin involving a multilayered
closure and a reconstructive procedure such as scar revision, debride-
ment, or retention sutures.
7. LO 25.5 The full-thickness removal of a lesion, including margins; includes (for
coding purposes) a simple closure.
8. LO 25.5 The area, or site, of the body receiving a graft of skin or tissue. H. Recipient Area
CHAPTER 25 REVIEW
9. LO 25.5 A multilevel method of sealing an opening in the skin involving one I. Simple Closure
or more of the deeper layers of the skin. J. Standard of Care
10. LO 25.5 A method of sealing an opening in the skin (epidermis or dermis), K. Surgical Approach
involving only one layer. It includes the administration of a local
anesthesia and/or chemical or electrocauterization of a wound not
closed.
11. LO 25.5 A measure that extends from the epidermis to the connective tissue
layer of the skin.
Part II
1. LO 25.6 Surgically opening the fracture site, or another site in the body nearby, A. Allotransplantation
in order to treat the fractured bone. B. Arthrodesis
2. LO 25.6 The treatment of a fracture without surgically opening the affected area. C. Closed Treatment
3. LO 25.6 The insertion of fixation instruments (such as pins) placed across D. Fornix
the fracture site. It may be done under x-ray imaging for guidance
E. Laminectomy
purposes.
F. Manipulation
4. LO 25.6 The surgical removal of a vertebral posterior arch.
G. Open Treatment
5. LO 25.8 Either of the two major veins in the leg that run from the foot to the
thigh near the surface of the skin. H. Percutaneous Skeletal
Fixation
6. LO 25.14 The relocation of tissue from one individual to another (both of the
same species) without an identical genetic match. I. Saphenous Vein
7. LO 25.14 The transfer of tissue from one site to another. J. Transplantation
8. LO 25.6 The immobilization of a joint using a surgical technique.
9. LO 25.6 The attempted return of the fracture or dislocation to its normal align-
ment manually by the physician.
10. LO 25.13 The area between the eyelid and the eyeball.
CPT
Let’s Check It! Concepts
Choose the most appropriate answer for each of the following questions.
Part I
1. LO 25.2 The global surgical package includes all except
a. preprocedure evaluation and management. b. general anesthesia. CPT © 2017 American Medical Association. All rights reserved.
CHAPTER 25 REVIEW
operates, the procedure code should be appended with modifier
a. 54 b. 55 c. 56 d. 77
6. LO 25.5 Excision of lesions is reported
a. with total measurement of all lesions removed in one code.
b. with only the largest lesion coded.
c. with each lesion coded separately.
d. as a part of the total surgical procedure.
7. LO 25.5 The code for excision of a lesion includes this type of repair.
a. Intermediate b. Complex
c. None d. Simple
8. LO 25.5 If the surgeon performs a reexcision of a lesion during a later encounter with the patient, append the
procedure code with modifier
a. 58 b. 59 c. 51 d. 77
9. LO 25.5 If multiple wounds located on the same anatomical site are repaired with the same complexity, report
this procedure by
a. coding each wound separately.
b. coding only the largest wound.
c. adding all the lengths together and coding the total.
d. coding the average of all the wounds repaired.
10. LO 25.5 The elements of determining the most accurate code for a skin graft include all except
a. the size of the recipient area.
b. the type of donor.
c. the location of the recipient area.
d. the type of graft.
Part II
1. LO 25.6 Codes within the musculoskeletal subsection include
a. x-rays. b. cast.
c. medications. d. shoes.
2. LO 25.13 Which of the following is/are part of the inner ear?
a. Auditory ossicles b. Oval window
CPT © 2017 American Medical Association. All rights reserved.
CHAPTER 25 REVIEW
documentation and report, included in the guidelines for _____ will apply.
10. Surgical _____ is a part of a surgical procedure and different methods of destruction are not ordinarily listed sepa-
rately unless the _____ substantially alters the standard _____ of a problem or condition.
CPT
5. Dr. Amerson performs cryotherapy for acne: 13. Dr. Payton excises a malignant lesion from the
a. main term: _____ b. procedure: _____ neck that measured 2.9 cm with margins:
6. Mark Latham was accidentally shot in the arm; a. main term: _____ b. procedure: _____
Dr. Quattlebaum explores and enlarges the wound 14. Dr. Charne excises an ischial pressure ulcer with a
to remove the bullet. Code the exploration of the primary suture:
wound: a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____ 15. Dorothy Loman had a small partial-thickness burn
7. Dr. Hunter applies a uniplane external fixation on her hand. Dr. Beariman performed a debride-
device for temporary stabilization of a radial ment and dressing of the injury:
fracture: a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____
CHAPTER 25 REVIEW
CPT
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate surgery CPT code(s) and modifier(s), if appropriate, for each case study.
1. Jack Friedman, a 41-year-old male, was in a fight at a soccer game and was hit in the head with a bottle,
which caused some deep lacerations in his scalp. Dr. Girald performed a layered closure of the wounds: one
2.0 cm, one 4.5 cm, and two lacerations that were 1.0 cm each in length.
2. Bobby Sherman, a 36-year-old male, cut his left thumb at work on a construction site 2 weeks ago. He did not
get any treatment for the wound, which became infected. Today, Dr. Ravenell admitted Bobby to Westward
Hospital and amputated the thumb. The procedure is made more complicated by the spread of the infection to
the surrounding tissues, as Dr. Ravenell fights to save as much of the hand as possible.
3. Patricia Atkins, a 31-year-old female, has been diagnosed with pleural effusion. Patricia is having difficulty
breathing and is admitted to the hospital, where Dr. Jamison performs a percutaneous pleural drainage and
inserts an indwelling catheter. Dr. Jamison is aided by image guidance. Patricia tolerates the procedure well
and is breathing easier.
4. Kevin Benchley, a 52-year-old male, has been diagnosed with benign prostatic hyperplasia (BPH). Kevin and
Dr. Derek, his urologist, have discussed the options and Kevin has elected to proceed with a TURP. Kevin is
taken to the OR, where he is placed under general anesthesia and the transurethral electrosurgical resection of
prostate, complete is performed without complication. Code the TURP procedure.
5. Dr. Albertson performed a lumbar laminectomy for decompression on Grace James on September 15. One
month later, as originally planned, Dr. Albertson brought Grace back into the OR to implant an epidural drug
infuser with a subcutaneous reservoir. Code both procedures.
6. Bridgette Smith found a sore on her neck. The lab test identified it as a malignant lesion, and Dr. Payas
excised the lesion, which measured 2.9 cm with margins.
7. Alice Milton, a 39-year-old female, was diagnosed with an abdominal wall incisional hernia, which was
repaired using prosthetic mesh. Alice has had recurrent infections. Alice is taken to the OR, where Dr. Gilroy
debrides the infected subcutaneous tissue and removes the prosthetic mesh.
8. Samantha DaVita, a 74-year-old female, has a permanent subcutaneous implanted defibrillator system,
which is not functioning properly. Samantha is taken to the OR, where Dr. Meetze removes and replaces the
implanted defibrillator pulse generator and subcutaneous electrode; 25 minutes of moderate sedation was
achieved. The new defibrillator system is tested and is working within normal limits. The nurse monitored
Samantha’s vital signs during the procedure. Samantha tolerated the procedure well.
9. Having trouble hearing, Ruth Ann Marcelle, a 73-year-old female, came to see Dr. Assiss, an audiologist.
After examination, Dr. Assiss removed the impacted earwax from both ears. Ruth Ann was amazed at the
improvement in her hearing and left the office feeling much better.
The following exercises provide practice in the application of abstracting the physicians’ notes and learning to work
with documentation from our health care facility, Prader, Bracker, & Associates. These case studies are modeled on
real patient encounters. Using the techniques described in this chapter, carefully read through the case studies and
determine the most accurate surgery CPT code(s) and modifier(s), if appropriate, for each case study.
INDICATIONS: The patient is a 4-year-old male brought to the emergency room by his mother. He was
helping his father install a new window when the window fell and shattered. Oscar suffered lacerations
on his left hand, left arm, and left leg.
PROCEDURE: The patient was placed on the table in supine position. Satisfactory anesthesia was
obtained. The area was prepped, and attention to the deeper laceration of the left thigh, right above the
patella, was first. A layered closure was performed, and the 5.1-cm laceration was closed successfully
with sutures. The lacerations on the upper extremity, a 2-cm laceration on the left hand at the base of
the fifth metacarpal and the 3-cm laceration on the left arm, just below the joint capsule in the posterior
position, were successfully closed with 4-0 Vicryl, as well. The patient tolerated the procedures well and
was transported to the recovery room.
Determine the most accurate surgery CPT code(s) and modifier(s), if appropriate.
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: DRESDEN, NELDA
ACCOUNT/EHR #: DRESNE001
Admission Date: 11/01/18
Discharge Date: 11/01/18
DATE: 11/01/18
Preoperative DX: Toxic epidermal necrolysis
Postoperative DX: Same
Procedure: Xenogaft
Surgeon: William Dresser, MD
Assistant: None
Anesthesia: Local
INDICATIONS: The patient is a 29-year-old female with a diagnosis of toxic epidermal necrolysis as a
result of a reaction to procainamide, previously prescribed by a physician no longer in attendance.
PROCEDURE: The patient was placed on the table in supine position. Local anesthesia was adminis-
tered. As soon as patient stated a complete loss of feeling in the left forearm, the dermal xenograft pro-
ceeded. Procedure was repeated for right forearm.
A total of 150 sq. cm of grafting was successfully completed.
Bandages were applied. A prescription for Darvocet N100 po q4–6h prn was given to the patient
before discharge.
Follow-up appointment in office scheduled for 10 days.
WD/mg D: 11/01/18 09:50:16 T: 11/01/18 12:55:01
Determine the most accurate surgery CPT code(s) and modifier(s), if appropriate.
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541 CPT © 2017 American Medical Association. All rights reserved.
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: WHEATON, MARLA
ACCOUNT/EHR #: WHEAMA001
Admission Date: 09/18/18
Discharge Date: 09/18/18
CPT © 2017 American Medical Association. All rights reserved.
DATE: 09/18/18
Preoperative DX: High-grade squamous intraepithelial lesion of the cervix
Postoperative DX: Same
Operation: Loop electrosurgical excision procedure (LEEP) and ECC (endocervical curettage)
Surgeon: Ralph L. Goff, MD
Assistant: None
Anesthesia: General by LMA
Findings: Large ectropion, large nonstaining active cervix essentially encompassing the entire active
cervix
CHAPTER 25 REVIEW
Specimens: To pathology
Disposition: Stable to recovery room
PROCEDURE: The patient was taken to the OR, where she was placed in the supine position and admin-
istered general anesthesia. She was then placed in candy cane stirrups and prepped and draped in the
usual fashion. Her vaginal vault was not prepped. The coated speculum was then placed and the cervix
exposed. It was then painted with Lugol and the entire active cervix was nonstaining with the clearly
defined margins where the stain began to be picked up. The cervix was injected with approximately
7 cc of lidocaine with 1% epinephrine. Using a large loop, the anterior cervix was excised, and then the
posterior loop was excised in separate specimens. Because of the size of the lesion, one piece in total
was not accomplished. Prior to the excision, the endocervical curettage was performed, and specimens
were collected. All specimens were sent to pathology. The remaining cervical bed was cauterized and
then painted with Monsel for hemostasis. The case was concluded with this. Instruments were removed.
The patient was taken down from candy cane stirrups, awakened from the anesthesia, and taken to the
recovery room in stable condition.
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: UPTON, MAXINE
ACCOUNT/EHR #: UPTOMA001
DATE: 09/25/18
Diagnosis: Medulloblastoma
Procedure: Central Venous Access Device (CVAD) insertion
Physician: Vincent Hoyt, MD
Anesthesia: Conscious sedation
PROCEDURE: Patient is a 4-year-old female, with a recent diagnosis of malignancy. Due to an upcoming
course of chemotherapy, the CVAD is being inserted to ease administration of the drugs. The patient
was placed on the table in supine position and 1 mg of Versed was administered IM; moderate sedation
was achieved, 13 minutes. Maxine’s vital signs were monitored by the nurse. The incision was made to
CPT © 2017 American Medical Association. All rights reserved.
insert a central venous catheter, centrally. During the placement of the catheter, a short tract (nontun-
neled) was made as the catheter was advanced from the skin entry site to the point of venous cannula-
tion. The catheter tip was set to reside in the subclavian vein. The patient was gently aroused from the
sedation and was awake when transported to the recovery room.
X-Rays (Radiography)
Radiography is the term that describes the use of x-rays to visualize the visceral aspects
(internal structures) of the human body. An x-ray tube emits a type of electromagnetic
radiation that is passed through and recorded on the opposite side of the anatomical
site being investigated by a digital detector (the digital version of film). Radiologists
can identify bone, muscle, and soft tissue on the image because each absorbs the radia-
tion at differing levels. The resulting contrast records a two-dimensional image for
evaluation and analysis.
Clinical Applications
∙ Chest x-rays are most commonly used to analyze aspects of the lungs.
∙ Skeletal x-rays are frequently used to identify and diagnose fractures, dislocations,
and other abnormalities of the bones.
∙ Abdominal x-rays are used to determine obstructions in any organs within the cavity,
or to illuminate the presence of air or fluid.
∙ Dental x-rays are employed to detect abnormalities such as dental caries or abscesses.
Clinical Applications
∙ Brain function
∙ Neck/head
∙ Vascular system
Clinical Applications
∙ Measuring volumes of brain structures
∙ Measurement of brain tissue
∙ Soft tissue damage CPT © 2017 American Medical Association. All rights reserved.
Clinical Applications
∙ Detection and staging of cancer
∙ Diagnosis of certain dementias such as Alzheimer’s disease
∙ Evaluation of coronary artery disease
Clinical Applications
∙ Assessing the metabolic activity of a skeletal structure
∙ Comparing blood flow to the myocardium at exercise and rest
∙ Determining renal perfusion and drainage
∙ Comparing pulmonary ventilation and perfusion
∙ Assessing the thyroid gland’s appearance and function
Fluoroscopy
Fluoroscopy also utilizes x-rays to visualize internal organ structure and function.
The emission of the x-ray beams is continuous, producing a real-time, dynamic image.
High-density contrast agents, such as barium, might be administered to enable com-
parative data.
Clinical Applications
∙ Hysterosalphingography (HSG)
∙ Retrograde urethrogram
∙ Micturating cysto-urethrogram
∙ Fistulography
∙ Guidance for procedures, such as the reduction of a fracture
Ultrasound (Sonography)
Ultrasound, also known as sonography, uses high-frequency sound waves to capture
cross-sectional images of visceral organs, including the arteries, veins, and lymph
nodes. There are several different types of ultrasound:
∙ A-mode indicates a one-dimensional ultrasonic measurement procedure.
∙ M-mode is also a one-dimensional ultrasonic measurement procedure; however, it
includes the movement of the trace so that there can be a recording of both ampli-
CPT © 2017 American Medical Association. All rights reserved.
Clinical Applications
∙ Abdominal cavity
∙ Pelvic area [NOTE: codes are different for an obstetrical ultrasound vs. nonpreg-
nant pelvic area]
∙ Cardiovascular structures, i.e., echocardiography
Angiography
During an angiography, x-rays are used to identify obstruction or stenosis of an artery
or vein, as well as other problems with the cardiovascular system. Contrast dyes may
be administered to illuminate a specific vessel to enable visualization of blood flow
and blockages.
Clinical Applications
∙ Tracking blood flow through arteries
∙ Identifying blood vessel malformations (thrombi, aneurysms)
∙ Discovering arteriosclerosis
CPT
LET’S CODE IT! SCENARIO
PATIENT: BONNIE SUZETT-ELLENTON
DATE OF STUDY: 06/08/2018
REFERRING PHYSICIAN: Lawrence Chorino, MD
RE: MRI OF THE LUMBAR SPINE
Comparison is made to an earlier exam.
TECHNIQUE: Multiplanar images were obtained using multiple pulse sequences to the lumbar spine. Because of the
postoperative nature of the lumbar spine, additional axial and sagittal postgadolinium T1-weighted images were obtained.
Plain films are not available for comparison; therefore, it will be assumed there is a normal complement of lumbar
vertebrae. Scanning was performed on 0.3-Tesla open bore scanner.
FINDINGS: The examination shows lumbar vertebrae to be in normal overall alignment with preservation in vertebral
body heights and normal signal within the marrow. For descriptive purposes of this study, fairly small disc is noted at
the S1-S2 interspace. The tip of the conus lies near the lower body of L1; we believe this nomenclature is the same
as that used on the prior exam.
Transaxial images show postsurgical changes from prior right semi-hemilaminectomy at the S1 vertebra. Examina-
tion does show the presence of a small annular disc bulge and perhaps some early annular spurring; however, the
traversing S1 nerve roots are unimpeded, and there is no evidence of recurrent focal disc herniation. There is some
normal enhancement seen involving the soft tissues, presumably of a postoperative nature.
At the L4-L5 level, there is likewise no evidence of focal disc herniation or significant central spinal stenosis.
The L3-L4 interspace shows trace annular bulging without focal disc herniation or stenosis. L1-L2 and L2-L3 inter-
spaces show a normal appearance on sagittal imaging.
IMPRESSION: MR examination of the lumbar spine with postsurgical changes from previous right semi-hemilaminectomy at
L5-S1 level on the right.
While there may be some minimal annular bulging and annular spurring at this level, there is no discrete focal disc CPT © 2017 American Medical Association. All rights reserved.
herniation, and traversing S1 nerve roots are not compromised.
The remainder of the lumbar interspaces may show some very minimal disc bulging; however, there is no focal
disc herniation or central spinal stenosis. The cause of the patient’s right lower extremity radicular symptoms cannot
easily be explained on the basis of findings.
Jason Kunerreth, MD
Chief of Radiology
EXAMPLES
74261 Computed tomography (CT) colonography, diagnostic, including
image postprocessing; without contrast material
74263 Computed tomography (CT) colonography, screening, including
image postprocessing
Image Guidance
When a procedure is conducted percutaneously, the physician cannot see into the
body. Therefore, in order to ensure that the needle or scalpel finds the correct spot on
an internal organ, image guidance will be used. This may be as simple as a fine needle
aspiration to a biopsy to a more complex surgical procedure.
In some cases, the CPT book will provide you with a code that includes the imaging
guidance; for example:
10021 Fine needle aspiration; without imaging guidance
10022 with imaging guidance
Often, the CPT book, will alert you to the need for a second code to report this
additional service with a notation below the code, such as
(For radiological supervision and interpretation, see 76942, 77002,
77012, 77021)
And more code options can be found in the Radiology section of CPT:
∙ Ultrasonic Guidance Procedures: 76930–76965, 76998
∙ Fluoroscopic Guidance: 77001–77003
∙ Computed Tomography Guidance: 77011–77014
∙ Magnetic Resonance Guidance: 77021–77022
YOU CODE IT! CASE STUDY CPT © 2017 American Medical Association. All rights reserved.
CPT
Every year, Margarette Sanchez gets a mammogram the week before her birthday. She feels fine and no lumps were
noted during her gynecologist’s manual exam. Margarette arrives at the Women’s Imaging Center for her annual
exam.
LET’S CODE IT! SCENARIO CPT © 2017 American Medical Association. All rights reserved.
CPT HCPCS Level II
Roland Dellman, an 8-year-old male, is brought into the emergency department by ambulance. He was skateboard-
ing off a homemade ramp and fell on his neck and shoulder. Dr. Tyner suspects a broken clavicle and orders a com-
plete radiologic exam of the area. This facility does not have a radiologist on staff at this time, so the facility took the
x-ray and the digital images were electronically sent to Radiology Associates in another state. Dr. Neuman reads the
films and sends a report to Dr. Tyner confirming the fracture. Code for Dr. Neuman.
CPT
LET’S CODE IT! SCENARIO
Jalyssa Miland, a 35-year-old female, is 10 weeks pregnant. This is her first pregnancy, and twins run in her family.
In order to determine how many fetuses there are, Dr. Ruber orders a sonogram. Iona Appell is the technician at the
imaging center next door to Dr. Ruber’s office. The Kinsey Imaging Center performs Jalyssa’s real-time transabdomi-
nal exam and sends the documentation to Dr. Ruber so that he can read and interpret the results. A single fetus was
observed.
EXAMPLE
73060 Radiologic examination, humerus, minimum of two views
The “two views” refers to the number of angles, or perceptions, from which the
images were taken, such as anterior and posterior. Such codes represent the norm, or
standard, in imaging when it comes to these certain anatomical sites.
The most common angles, or pathways, of imaging include:
AP Anteroposterior: Front to back.
PA Posteroanterior: Back to front.
O Oblique: At an angle.
RAO Right anterior oblique: At an angle from the right front.
LAO Left anterior oblique: At an angle from the left front.
LPO Left posterior oblique: At an angle from the left back.
Lat Lateral (lat): From one side to the other side.
In those cases when the radiologist takes fewer than the minimum number of views
included in the description, you have to append the radiologic code with modifier 52
Reduced Services.
52 Reduced Services: Under certain circumstances a service or procedure
is partially reduced or eliminated at the physician’s discretion. Under
these circumstances, the service provided can be identified by its usual
procedure number and the addition of modifier 52, signifying that the
service is reduced. This provides a means of reporting reduced services
without disturbing the identification of the basic service.
CPT
YOU CODE IT! CASE STUDY
Carly-Ann Price, an 18-month-old female, is brought into the office of her pediatrician, Dr. Lattel. She fell off the
couch onto a hard tile floor and it appears that her hip is painful to her. Dr. Lattel has his staff take an x-ray of the
pelvis and hip to determine if there is a fracture. He orders only the anteroposterior view to be taken. He does not
subject his patients to radiology exposure unnecessarily, and he believes that the one view will tell him what he
needs to know. The x-ray confirms a hairline fracture, and he applies a cast.
EXAMPLE
Dr. Horace, a radiologist, supervised a radiographic arthrography of Porter Arthrography
Maison’s ankle; later the interpreted results were reported with this code: The recording of a picture of
an anatomical joint after the
73615 Radiologic examination, ankle, arthrography, radiological administration of contrast
supervision and interpretation material into the joint capsule.
Fluoroscope
2. Imaging “with contrast” has some guidelines that you have to know in order to A piece of equipment that
code accurately. emits x-rays through a part
of the patient’s body onto a
a. If the code description includes the term “with contrast,” such as computed fluorescent screen, causing
tomography (CT) with contrast, computed tomography angiography (CTA) the image to identify various
with contrast, magnetic resonance arthrography (MRA) with contrast, or aspects of the anatomy by
magnetic resonance imaging (MRI) with contrast, the injection of the contrast density.
materials, when administered intravenously, is already included in the code and
Computed Tomography (CT)
should not be reported separately.
A specialized computer scan-
b. If the contrast material is injected intra-articularly (into a joint) or intrathe- ner with very fine detail that
cally (into a tendon or sheath), an additional code is reported for the appropriate records imaging of internal
injection. anatomical sites; also known
c. Providing contrast materials orally and/or rectally alone does not constitute an as computerized axial tomog-
raphy (CAT).
exam “with contrast.”
Computed Tomography
Angiography (CTA)
EXAMPLE A CT scan using contrast
Dr. Groder injected Vincent Speck’s elbow intrathecally with contrast materials to materials to visualize arteries
CPT © 2017 American Medical Association. All rights reserved.
do a radiographic arthrography for his tennis elbow. This is reported with these and veins all over the body.
codes: Magnetic Resonance
73085 Radiologic examination, elbow, arthrography, radiological Arthrography (MRA)
supervision and interpretation MR imaging of an anatomical
joint after the administration of
20550 Injection(s); single tendon sheath, or ligament, aponeurosis
contrast material into the joint
(eg. plantar “fascia”)
capsule.
CPT
LET’S CODE IT! SCENARIO
Mark Silver, an 81-year-old male, has been having problems with his memory and his walking. After an extensive
examination, his neurologist, Dr. Chernuchin, orders an MRI, brain, with and without contrast, to determine if Mark is
suffering from hydrocephalus.
CODING BITES
Appropriate HCPCS Level II codes from the range Q9951–Q9969, based on the
number of units, should be assigned to report the contrast materials supplied.
EXAMPLE
Dr. Victoria performed a left internal and external carotid arterial angiography to
check for blockage and immediately performed an intervention procedure. You
would report this by using codes
36224 Selective catheter placement, internal carotid artery, unilateral,
with angiography of the ipsilateral intracranial carotid circulation
and all associated radiological supervision and interpretation,
includes angiography of the extracranial carotid and cervicocer-
ebral arch, when performed
36227 Selective catheter placement, external carotid artery, unilateral,
with angiography of the ipsilateral external carotid circulation
and all associated radiological supervision and interpretation (List
separately in addition to code for primary procedure)
2. In other cases, the diagnostic angiography should be coded separately even though
it is done at the same session as an interventional procedure. This is true if one of
the following conditions has been met:
a. A full diagnostic study is done, no prior catheter-based angiographic study is
available, and the decision to intervene is determined by the diagnostic study.
b. The patient’s condition has changed since a previously done study. GUIDANCE
c. The patient’s condition changes during the interventional procedure that requires CONNECTION
a diagnostic procedure to look at vessels outside of the area. Read the additional
d. The prior diagnostic angiography did not show the applicable anatomy and/or explanations in the
pathology being treated at the session. in-section guidelines
within the Radiol-
ogy section, subhead
CPT © 2017 American Medical Association. All rights reserved.
Diagnostic Venography
Venography The codes for reporting diagnostic venography have guidelines similar to those for
The imaging of a vein after the diagnostic angiography.
injection of contrast material.
1. Some interventional procedure codes include the diagnostic venography when
done at the same time as the procedure. You must read the descriptions carefully to
determine if this is the case.
2. Diagnostic venography done at the same time as an interventional procedure should
be coded separately if one of the following conditions has been met:
a. A full diagnostic study is done, no prior catheter-based venographic study is
available, and the decision to intervene is determined by this diagnostic study.
GUIDANCE
CPT © 2017 American Medical Association. All rights reserved.
b. The patient’s condition has changed since a previously done study.
CONNECTION c. The patient’s condition changes during the interventional procedure and requires
Read the additional a diagnostic procedure to look at vessels outside of the area.
explanations in the d. The prior diagnostic venography did not show the applicable anatomy and/or
in-section guidelines pathology being treated at the session.
within the Radiology 3. Diagnostic venography is included with the code for an interventional procedure
section, subhead and should not be coded separately when that diagnostic venography is performed
Vascular Procedures, for any of the following:
subsection Veins and
Lymphatics, directly a. Vessel measurement.
above code 75801 in b. Postangioplasty or stent venography.
your CPT book. c. Contrast injections, venography, road mapping, and/or fluoroscopic guidance for
the interventional procedure.
Charles Baseman, a 55-year-old male, flew in yesterday from Australia, a 26-hour airplane ride. Since getting off
the plane, he has been having pain in his right calf. Dr. Vernon performed a diagnostic venography to determine if
Charles has deep vein thrombosis (DVT). After completing the procedure, he wrote a report with his interpretation,
which was sent to Charles’s internist.
GUIDANCE
Transcatheter Procedures
CONNECTION
Therapeutic transcatheter radiologic supervision and interpretation codes, when asso-
ciated with intervention, already include Read the additional
explanations in the
1. Vessel measurement. in-section guidelines
2. Postangioplasty or stent venography. within the Radiology
3. Contrast injections, angiography/venography, road mapping, and/or fluoroscopic section, subhead
guidance for the interventional procedure. Vascular Procedures,
subsection Transcathe-
Transcatheter therapeutic radiologic and interpretation services are separately report- ter Procedures, directly
able from diagnostic angiography/venography done at the same time unless they are above code 75894 in
specifically included in the code descriptor. your CPT book.
CPT
LET’S CODE IT! SCENARIO
Dr. Grubman is in the OR today to perform a transcatheter placement of an intravascular stent, percutaneously, in
Olivia Samuel’s common iliac.
You are Dr. Grubman’s coding specialist, so you are going to code only the radiologic supervision and interpreta-
tion of the transcatheter procedure, as well as the placement of the stent itself. Let’s go to transcatheter in the
Alphabetic Index. You will notice that, if you go to placement under transcatheter, you see intravascular stents
indented below. Here, the Alphabetic Index suggests some Category III codes (0075T, 0076T) along with code
ranges 37215–37218, 37236–37239, and 92928–92929.
When you turn to the codes, you realize that they are in the Surgery section, not Radiology. However, they
are the only codes offered by the Alphabetic Index, so let’s take a look at them all. Notice
37236 Transcatheter placement of an intravascular stent(s) (except lower extremity, artery(s) for occlusive
disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial or coronary),
open or percutaneous, including radiological supervision and interpretation and including all an-
gioplasty within the same vessel, when performed; initial artery
(continued)
But we are coding for Dr. Grubman’s radiologic supervision and interpretation for the procedure as well as
the stent placement. Notice that the description for code 37236 includes “radiological supervision and
interpretation.”
Perfect!
Diagnostic Ultrasound
When reporting diagnostic ultrasound services, you need to abstract specific details
CODING BITES about the anatomical sites viewed. As the coding specialist, you must read the report
and pay attention to whether the exam was “complete” or “limited” and choose the
If the reason that an
correct code. The description of an ultrasound exam as being “complete” is deter-
organ was not visible
mined by the specific number of elements, such as organs or areas, that are surveyed
is documented in the
during the test. However, sometimes the full list is not visualized. For example, an
patient’s record, you are
organ may have been previously removed surgically, or another organ may be blocking
permitted to code this
the view. The report that is submitted for the patient’s record, after the exam, should
as “complete.”
note everything that was studied—as well as those elements that should have been but
were not, along with why they were not.
You will find information regarding what is included in a complete exam in
the guidelines shown below each of the ultrasound subheadings: Abdomen and
Retroperitoneum, Pelvis—Obstetrical, Pelvis—Non-obstetrical.
Should an ultrasound exam be performed without a thorough evaluation of an organ
or anatomical region and recording of the image and a final, written report, you are
GUIDANCE not permitted to code the procedure separately.
CONNECTION
Read the additional
explanation in the in- EXAMPLE
section guidelines within
Abdomen and Retroperitoneum
the Radiology section,
subhead Diagnostic A complete ultrasound examination of the abdomen (76700) consists of real-time
Ultrasound, directly scans of the liver, gallbladder, common bile duct, pancreas, spleen, kidney, and
above code 76506 in the upper abdominal aorta and inferior vena cava including any demonstrated
your CPT book. abdominal abnormality.
Let’s say an ultrasound examination is done on Herman Smith’s abdomen. The doc-
umentation includes the physician’s (radiologist’s) interpretation of all organs except
the gallbladder. The patient had his gallbladder removed 1 year prior to this ultrasound
exam. As long as this fact is also documented, code 76700 for a complete ultrasound
examination of the abdomen is accurate. CPT © 2017 American Medical Association. All rights reserved.
You already know that an ultrasound may be called a sonogram. However, other
definitions are important for you to know so that you can determine the best, most
appropriate code. The following terms identify the type of scan:
∙ A-mode indicates a one-dimensional ultrasonic measurement procedure.
CODING BITES
∙ M-mode is also a one-dimensional ultrasonic measurement procedure; however, it
Ultrasound services are includes the movement of the trace so that there can be a recording of both ampli-
especially dangerous tude and velocity of the moving echo-producing structures.
to code from superbills
instead of notes. Make
∙ B-scan indicates a two-dimensional ultrasonic scanning procedure with a two-
certain you get the com-
dimensional display.
plete documentation ∙ Real-time scan indicates that a two-dimensional ultrasonic scanning procedure
before choosing a code. with a display was performed and included both the two-dimensional structure and
motion with time.
CPT
YOU CODE IT! CASE STUDY
Eriq Taleni, a 57-year-old male, was sent to the Kinsey Imaging Center by Dr. Rayman to have an ophthalmic biom-
etry by ultrasound echography, A-scan. After performing the exam, Dr. Turner, the radiologist, wrote in his report that
a second test using intraocular lens power calculation might be necessary to further clarify the condition of the eye.
Dr. Rayman determined that Eriq should wait before having the second test.
26.7 Mammography
CPT © 2017 American Medical Association. All rights reserved.
Until researchers can find a way to prevent breast cancer, the best weapon in the health
care arsenal is early detection—finding the malignancy when it is tiny and easier to
eradicate. Mammography, low-dose radiology, is considered the best method for iden-
tifying a small, otherwise undetectable lump or microcalcification. Mammography
employs low-energy x-rays specifically designed to take and record images of breast
tissue for the discovery of breast lesions.
77065 Diagnostic mammography, including computer-aided detec-
tion (CAD) when performed; unilateral
77066 Diagnostic mammography, including computer-aided detec-
tion (CAD) when performed; bilateral
77067 Screening mammography, bilateral (2-view film study of each
breast), including computer-aided detection (CAD) when
performed
At times, computer-aided detection (CAD) is used in conjunction with the x-ray
imaging. CAD transitions the x-ray image into a digital image, which is then scanned
by a computer, searching for anything that might be abnormal.
CPT
YOU CODE IT! CASE STUDY
Every year, Donna Simmons, 47-year-old female, came in for her annual well-woman exam, and then would go over
to the Imaging Center for her screening mammogram. This year, Dr. Douglas felt a lump during Donna’s manual
exam, so he ordered a diagnostic mammogram for the left breast and a screening mammogram for the right. These
mammograms were provided the next day at the Imaging Center.
26.8 Bone and Joint Studies CPT © 2017 American Medical Association. All rights reserved.
There are many reasons a physician may need information about a patient’s bone
structure and strength, and several imaging techniques that could be used to provide
the most accurate data.
∙ Bone age studies enable the physician to identify the degree of maturation of a
child’s bones.
∙ CT scanography has surpassed orthoroentgenogram in the last decade to determine
leg length discrepancies.
∙ Osseous survey is a radiologic procedure used to identify fractures, tumors, and
degenerative conditions of the bone.
∙ Bone mineral density (BMD) scanning, also called dual-energy x-ray absorptiom-
etry (DXA or DEXA) or bone densitometry, is an enhanced form of x-ray technol-
ogy that is used to measure bone loss.
CPT
YOU CODE IT! CASE STUDY
Rachel VanHeusen, a 65-year-old female, arrived at the Kinsey Imaging Center to have a DEXA bone density study,
both axial and appendicular skeleton. Dr. Underwood, the staff radiologist, analyzed the images and wrote a report.
Now, look up each of these codes and read each complete description to find the one that matches:
Analyze each of these codes’ descriptions. Code 0395T cannot be accurate for this encounter because there is
no mention of electronic brachytherapy being used. Codes 77761, 77762, and 77763 are essentially the same
except for the level of intensity: simple, intermediate, or complex.
Do you know which level is described in the documentation? No, so you need to query the physician. The
physician responds by adding a notation in the patient’s chart that this was a low-dose (simple) application. Now
you have what you need to report:
77761 Intracavitary radiation source application; simple
Good work!
26.10 Nuclear Medicine
Nuclear Medicine Nuclear medicine uses tiny quantities of radioactive material, also known as tracers,
Treatment that includes the in conjunction with a scintillation or gamma camera to record the emissions from the
injection or digestion of tracers to create an image of the anatomical site. Several types of nuclear medicine
isotopes. tests are used to identify a health concern:
∙ Bone scans are used to investigate injuries (fractures, sprains, and strains) as well
as tumors.
∙ Thyroid uptake scans are used to assess thyroid function and record the structure of
the gland.
∙ Heart scans are used to measure heart function, evaluate the existence and extent
of heart muscle damage after a heart attack, and gauge the blood flow to the heart
muscle.
∙ Lung scans are used to determine the presence of blood clots. In addition, scans can
be valuable to calculate the flow of air into and out of the lungs.
∙ Hepatobiliary scans can provide information to evaluate the function of the liver
and the gallbladder.
∙ Gallium scans can be used to identify the presence of infection and some types of
tumors.
In addition to the diagnostic benefits of nuclear medicine, this methodology can
also be used therapeutically to treat hyperthyroidism and thyroid cancer and to help to
correct blood imbalances.
One important point that you have to know as a coding specialist working with
nuclear medicine procedures is that the codes presented in the CPT book do not
include diagnostic or therapeutic radiopharmaceuticals (the drugs or isotopes used in
the treatments). Therefore, you have to code them separately. If the insurance carrier
accepts HCPCS Level II codes, you will use them. You will learn all about HCPCS
Level II codes in Part IV of this textbook.
Radiopharmaceutical therapy, the administration of nuclear drugs, whether given
to the patient orally, intravenously, intracavitarily, interstitially, or intra-arterially, are
reported with codes 79005–79999.
Also note that any chemical pathology or chemical analysis done in connection
with the provision of nuclear medicine treatments should be coded separately from the
Pathology and Laboratory section of the CPT book.
CPT
YOU CODE IT! CASE STUDY
CPT © 2017 American Medical Association. All rights reserved.
Nadya Bartlett, a 43-year-old female, had gained a great deal of weight recently, with no change in her diet or
exercise regimen. After a thorough examination, Dr. Posner ordered nuclear imaging of her thyroid, with uptake.
Radiopharmaceuticals were administered intravenously. The report came back to Dr. Posner with the multiple deter-
minations of Nadya’s exam.
Chapter Summary
Health care technology has advanced tremendously in the area of radiology and imag-
ing. It is important that, as a coding specialist, you understand the differences among
the types of radiologic methods, as well as the components of each. Procedures with
contrast and without contrast, CT scans, MRIs, sonograms, and so many more enable
professionals to look inside the patient in a noninvasive manner, and it is your job to
obtain the correct reimbursement for every procedure.
CODING BITES
Isotopes Used in Nuclear Medicine
1. LO 26.6 The imaging of a vein after the injection of contrast material. A. Angiography
2. LO 26.3 The use of sound waves to record images of internal organs and tis- B. Arthrography
sues; also called an ultrasound. C. Computed Tomography
3. LO 26.6 The imaging of blood vessels after the injection of contrast material. (CT)
4. LO 26.5 A piece of equipment that emits x-rays through a part of the patient’s D. Computed Tomography
body onto a fluorescent screen, causing the image to identify various Angiography (CTA)
aspects of the anatomy by density. E. Fluoroscope
5. LO 26.5 A three-dimensional radiologic technique that uses nuclear technol- F. Magnetic Resonance
ogy to record pictures of internal anatomical sites. Arthrography (MRA)
6. LO 26.5 A specialized computer scanner with very fine detail that records G. Magnetic Resonance
imaging of internal anatomical sites. Imaging (MRI)
7. LO 26.9 The high-speed discharge and projection of energy waves or particles. H. Nuclear Medicine
8. LO 26.5 The recording of a picture of an anatomical joint after the administra- I. Radiation
tion of contrast material into the joint capsule.
J. Sonogram
9. LO 26.10 Treatment that includes the injection or digestion of isotopes.
K. Venography
10. LO 26.5 MR imaging of an anatomical joint after the administration of con-
trast material into the joint capsule.
11. LO 26.5 A CT scan using contrast materials to visualize arteries and veins all
over the body.
CPT
a. diagnosing a condition.
b. preventing the spread of a disease.
c. measuring the progress of a disease.
d. testing the equipment.
3. LO 26.10 Dani Thompson presents for a thyroid carcinoma metastases imaging; limited area (neck and chest
only). What radiology code would you assign?
a. 78012 b. 78013 c. 78014 d. 78015
CHAPTER 26 REVIEW
a. administered a substance to enhance the image.
b. used a black background behind the patient.
c. took the image a second time, to compare to the first.
d. used a blue background beneath the patient.
5. LO 26.4 If the code description includes the phrase “two views” and the radiology reports show that only one
view was taken, you should code the service
a. with that code alone.
b. with that code plus the modifier 52
c. with that code plus the modifier 53
d. with that code plus the modifier 22
6. LO 26.6 Therapeutic transcatheter radiologic supervision and interpretation codes, when associated with inter-
vention, include all of the following except
a. vessel measurement.
b. postangioplasty or stent venography.
c. catheter placement.
d. contrast injections, angiography/venography, road mapping, and/or f luoroscopic guidance for the interven-
tional procedure.
7. LO 26.4 RPO stands for
a. right procedure operation. b. regional protocol obstetric.
c. right posterior oblique. d. right preventive oblique.
8. LO 26.9 Radiation for the treatment of a malignant neoplasm is most often used for
a. diagnostic purposes. b. therapeutic purposes.
c. research purposes. d. prevention purposes.
9. LO 26.1 An x-ray is the same as
a. a CTA. b. a CT. c. an MRI. d. a radiologic exam.
10. LO 26.10 Nuclear medicine uses tiny quantities of radioactive material, also known as _____, in conjunction
with a scintillation or gamma camera to record the emissions from the _____ to create an image of the
anatomical site.
a. isotopes, tracers b. tracers, isotopes
c. tracers, tracers d. tracers, drugs
CPT © 2017 American Medical Association. All rights reserved.
Let’s Check It! Guidelines
CHAPTER 26 REVIEW
1. A service that is _______ provided, unusual, variable, or _______ may require a special report.
2. _______ may be required during the performance of certain procedures or certain imaging procedures may
require surgical procedures to _______ the imaged area.
3. Many services include image guidance, which is _______ separately reportable and is so _______ in the
descriptor or guidelines.
4. When imaging is not included in a _______ procedure or procedure from the _______ section, image guid-
ance codes or codes labeled “radiological supervision and interpretation” may be reported for the portion of the
_______ that requires imaging.
5. The phrase _______ used in the codes for procedures performed using contrast for imaging _______ represents
contrast material administered intravascularly, intra-articularly, or intrathecally.
6. For intra-articular injection, use the appropriate _______ injection code.
7. If radiographic _______ is performed, also use the arthrography supervision and interpretation code for the
appropriate joint.
8. If computed tomography or magnetic resonance arthrography are performed _______ radiographic arthrography,
use the appropriate joint _______ code, the appropriate CT or _______ code, and the appropriate imaging
guidance code for _______ placement for contrast injection.
9. Injection of _______ contrast material is part of the “with contrast” CT, computer tomographic angiography,
magnetic resonance imaging and magnetic resonance angiography procedure.
10. Oral and/or rectal _______ administration alone does not _______ as a study “with contrast.”
11. A written report _______ by the interpreting individual should be considered an _______ part of a radiology
procedure or interpretation.
12. With regard to CPT _______ for radiography services, “images” refer to those acquired in either an _______ or
digital manner.
CPT © 2017 American Medical Association. All rights reserved.
1. Edith Shapin, a 24-year-old female, is pregnant for the first time and is at approximately 11 weeks
gestation. She is brought into the diagnostic center for a fetal biophysical profile with nonstress testing.
2. William Browne, a 15-year-old male, is brought into Dr. Jenkins’s office with severe right leg pain. Dr. Jenkins
takes x-rays of his right femur, AP and PA, to determine whether or not Bill’s leg is fractured.
3. Martha Lightfood, an 82-year-old female, was brought into Dr. Morrison’s office by her daughter because
Martha was complaining of a sharp pain in her chest. After a negative EKG, Dr. Morrison had a quantitative
differential pulmonary perfusion and ventilation study performed, which confirmed a pulmonary embolism.
Martha was taken immediately by ambulance to the hospital. Code the quantitative differential pulmonary
perfusion and ventilation study only.
4. Dr. Logan saw Jason Miolo, a 38-year-old male, with a swollen right eye and loss of vision. Dr. Logan
ordered a CT with contrast of the right eye and area, which revealed marked proptosis of the right orbit,
thrombosis, and enlargement of the right superior ophthalmic vein.
CHAPTER 26 REVIEW
5. Carl Gadsden, a 66-year-old male, was diagnosed with intrinsic laryngeal cancer, supraglottic T1 tumor. With
the tumor confined to one subsite in the supraglottis, Dr. Yoshihashi provided radiation treatment delivery,
with a single port, simple block, of 4.5 MeV.
6. Olivia Kane, a 33-year-old female, came into Kinsey Imaging Center for her annual screening mammogram.
Due to her family history of malignant neoplasms of the breast (both her mother and sister have been diag-
nosed), the mammogram was ordered with computer-aided detection (CAD).
7. Brianna Haralson, a 24-year-old female, is brought into Dr. Duncan’s office with sharp pains in her lower
right abdomen, shooting across to the left side. Dr. Duncan ordered some blood work and an MRA to confirm
the suspected diagnosis of acute appendicitis. Code the MRA.
8. Charles Gresham, a 40-year-old male, was in training at Cape Canaveral when he hit his head in a weightless-
ness simulator, causing him to lose consciousness for 3 minutes. Charles was transported to the nearest hos-
pital, where Dr. Neumours, the ED on-call physician, took a skull x-ray, three views, and did an MRI without
contrast of Charles’s brain.
9. Jonelle Graybar, a 73-year-old female, was experiencing pain in her back that radiated around her trunk. She
was also suffering with spastic muscle weakness. Dr. Maxwell ordered a radioisotope bone scan of Jonelle’s
lumbar spinal area. The scan identified a metastatic invasion of L1–L3.
10. Maxine Zeigleman, newly diagnosed with metastatic lumbar spinal tumors, has been referred to Dr. Appleton
for the creation of a simple radiation therapy plan.
11. Vernon Unger had been diagnosed with a malignancy and came today for intravenous radiopharmaceutical
therapy.
12. Before beginning a series of treatments, Anna Hogan came to the Diagnostic Imaging Center for a metabolic
evaluation PET scan of her brain.
13. Ira Morgan, a 16-month-old male, was brought to radiology for a real-time, limited, static ultrasound of his hips.
14. Xavier Pollack, a 62-year-old male, arrived at the Kinsey Imaging Center to have a SPECT (single photon
emission computed tomography) performed on his left kidney.
15. Dr. Astrone performed a complete ultrasound evaluation of Alden Roberts’s pelvis. The procedure included
evaluation and measurement of Alden’s urinary bladder, evaluation of his prostate and seminal vesicles, and
pathology of his enlarged prostate.
Keith Robbins, MD
KR/mg D: 09/17/18 09:50:16 T: 09/20/18 12:55:01
Determine the most accurate radiology CPT code(s) and modifier(s), if appropriate.
Determine the most accurate radiology CPT code(s) and modifier(s), if appropriate.
CPT © 2017 American Medical Association. All rights reserved.
Radiologist: Eryn Alberts, MD
Clinical Information: Evaluate for VP shunt
No prior studies available for a comparison
TECHNICAL INFORMATION: The examination was performed without the use of intravenous contrast material.
INTERPRETATION: Evaluation of the posterior fossa demonstrates hydrocephalus versus low pressure
communicating hydrocephalus.
Eryn Alberts, MD
EA/mg D: 10/17/18 09:50:16 T: 10/20/18 12:55:01
Determine the most accurate radiology CPT code(s) and modifier(s), if appropriate.
Milton Harrison, MD
Determine the most accurate radiology CPT code(s) and modifier(s), if appropriate.
Kevin Linnard, MD
KL/mg D: 09/29/18 09:50:16 T: 09/30/18 12:55:01
Determine the most accurate radiology CPT code(s) and modifier(s), if appropriate.
CPT © 2017 American Medical Association. All rights reserved.
27
Key Terms
CPT Pathology & Lab
Section
Learning Outcomes
Cytology After completing this chapter, the student should be able to:
Etiology
Gross Examination LO 27.1 Recognize key factors involved in pathology testing.
Laboratory LO 27.2 Identify testing methodologies and sources.
Microscopic LO 27.3 Report panel codes when qualified.
Examination LO 27.4 Analyze blood test reports to ensure accurate reporting.
Pathology LO 27.5 Discern clinical chemistry studies.
Qualitative LO 27.6 Interpret details about molecular diagnostic testing.
Quantitative
Specimen LO 27.7 Distinguish immunologic, microbiologic, and cytopathologic
Surgical Pathology testing.
LO 27.8 Abstract the correct details to report surgical pathology
testing.
LO 27.9 Append the correct modifier, when required.
LO 27.10 Accurately interpret the abbreviations used most often in
pathology and laboratory reports.
828
∙ Other bodily fluids, such as
■ sputum
■ sperm
■ mucus
∙ Tissue
∙ An organ
CODING BITES
When you code pathol-
CODING BITES ogy and laboratory
Every pathology or lab test requires specimens to examine. In some cases, you work, you may be
may need to report the collection of the specimen separately. reporting the work
For example: provided by the profes-
sional performing the
36415 Collection of venous blood by venipuncture test and interpreting the
83930 Osmolality; blood results (the pathologist)
Be alert to the fact that the collection of the specimen may be provided at a sepa- or you may be reporting
rate facility from the lab, in which case, each facility would report the code for the for the facility that pro-
part performed. vided the testing.
As a coding specialist, you may work for a health care organization that has a labo- Specimen
ratory within its facilities, a billing company that codes everything, or an independent A small part or sample of any
facility that does nothing other than taking and analyzing specimens. In any case, you substance obtained for analy-
should understand the different aspects of pathology and lab testing and procedures, as sis and diagnosis.
well as the guidelines involved in coding the services.
CPT
LET’S CODE IT! SCENARIO
Cynthia Cardamen, a 33-year-old female, was not feeling well, so she went to see her family physician, Dr. Slater.
After talking with her and performing an exam, Dr. Slater began to suspect that Cynthia had diabetes mellitus, type
2. Reagan Dram, the nurse, obtained a specimen of capillary blood from Cynthia’s left index finger and took it to
Abbey Carmichael, who ran their in-house lab, for a glucose test to be performed. She used a reagent strip to per-
form the test and delivered the results to Dr. Slater.
36416 Collection of capillary blood specimen (eg. finger, heel, ear stick)
Now, we must report the test that Abbey will perform on this blood specimen. Dr. Slater ordered a blood glucose
test. Turn in the Alphabetic Index to
Glucose
Blood Test................. 82947, 82948, 82950
(continued)
CHAPTER 27 |
This time, we have three different codes to investigate.
82947 Glucose; quantitative, blood (except reagent strip)
82948 Glucose; blood, reagent strip
82950 Glucose; post glucose dose (includes glucose)
Compare the details in these code descriptions to the details you have in the documentation. Code 82948
matches.
36416 Capillary blood, collection
82948 Glucose; blood, reagent strip
Good work!
EXAMPLES
Calcium
82310 Calcium; total
82330 Calcium; ionized
82331 Calcium; after calcium infusion test
82340 Calcium; urine quantitative, timed specimen
The guidelines tell you that, if the documentation does not specify, you may assume
that the examination performed was quantitative. However, remember that documenta-
tion is absolute in the health care industry. Therefore, it is recommended that you query
the lab technician or pathologist and request that the report include this important detail.
Testing Methodologies
For other testing, you might see the details about the methodology of the testing. Some
of the terms you will notice in test descriptions and their codes include
∙ By dipstick
∙ Automated or nonautomated
∙ With or without microscopy
∙ Visual or gross inspection
These terms refer to the methods that the lab technicians use to test the specimen and
obtain the results.
CPT
LET’S CODE IT! SCENARIO
Margaret O’Hanahan came to see Dr. Marinson. She states that she has been feeling a stinging pain when she
urinates. She confirms some lower back aches but denies hematuria. Dr. Marinson asks Margaret to go into the
bathroom and provide a urine sample, which is then tested in the office by dipstick, automated without microscopy.
Urinalysis................81000-81099
Automated................81001, 81003
CPT © 2017 American Medical Association. All rights reserved.
These two listings fit the details according to the documentation, so turn to the Main Section and read these
code descriptions.
81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes,
nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-
automated, with microscopy
81001 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes,
nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated,
with microscopy
81002 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes,
nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-
automated, without microscopy
(continued)
CHAPTER 27 |
81003 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes,
nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated,
without microscopy
81005 Urinalysis; qualitative or semiquantitative, except immunoassays
81007 Urinalysis; bacteriuria screen, except by culture or dipstick
81015 Urinalysis; microscopic only
81020 Urinalysis; 2 or 3 glass test
81025 Urine pregnancy test, by visual color comparison methods
81050 Volume measurement for timed collection, each
81099 Unlisted urinalysis procedure
Go back to the scenario and abstract the details about the test. The documentation states, “dipstick, automated
without microscopy.” When you read all of these code descriptions, you can see that only one accurately reports
this specific test:
81003 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leuko-
cytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents;
automated, without microscopy
Good work!
In addition to how the test is performed, you must also know the type of specimen
CODING BITES involved in the testing and, sometimes, how many specimens or sources are involved.
All the details regarding The type of specimen being tested may change the code. Consider a physician order-
the specimen and the ing a potassium test. Let’s go to the Alphabetic Index for potassium.
testing are important.
There are times when
the code descriptions EXAMPLE
include the type of test,
Potassium................84132
the type of specimen,
or both. Urine............................ 84133
The first code in the example, listed next to the word potassium, is code 84132, but
it does not contain any additional descriptors. However, the second code, listed under
potassium, indicates that it would be the code used if the potassium were tested from
the patient’s urine rather than blood (serum). When you look at the codes’ complete
descriptions in the numeric listing, you see the details shown.
CPT © 2017 American Medical Association. All rights reserved.
EXAMPLE
84132 Potassium; serum, plasma, or whole blood
84133 urine
The listings clearly show that there is a difference as to which code is correct based
on the source of the specimen.
In certain circumstances, an analysis may be performed on multiple specimens col-
lected at different times or from different sources. In these cases, the guidelines tell
you to code each source and each specimen separately. However, be certain to always
read the code descriptions carefully. Some codes already include multiple tests and/or
multiple sources.
27.3 Panels
A pathology report, such as the one shown in Figure 27-1, will typically itemize the
tests performed for the patient along with the results of each test.
CPT © 2017 American Medical Association. All rights reserved.
FIGURE 27-1 Sample lab report showing the tests run as part of a lipid profile
CHAPTER 27 |
When you turn to the Pathology and Laboratory section of the CPT book, you will
CODING BITES notice that many codes include a long list of tests within one code’s description. These
Remember that the groupings of tests commonly performed at the same time are called panels.
codes for testing a
specimen do not include
collecting the specimen.
Collection, such as per- EXAMPLE
forming a biopsy, veni- 80051 Electrolyte panel
puncture, or fine-needle This panel must include the following:
aspiration, is coded
separately by the coder Carbon dioxide (82374)
for the professional who Chloride (82435)
performed the collection. Potassium (84132)
Sodium (84295)
CODING BITES
When all the included
tests of a panel are per- This example shows you that, in order for you to report code 80051 legally and
formed, you must use accurately, the lab must have performed all four tests: carbon dioxide, chloride, potas-
the panel code. Coding sium, and sodium.
the tests individually is If the lab performed fewer than all the tests listed in a panel, you must report the
considered unbundling. code for each test separately; you are not permitted to use the panel code.
Unbundling is unethical Again, the CPT book will help you. Should you have to code any of the tests
and illegal. If fewer tests separately, each test code is given in parentheses right next to the name of the test
are performed, using listed there. From our example, next to carbon dioxide, you can see the number
a panel code with the 82374. Turn to code 82374, and you will see that it is the code for testing carbon
modifier 52 Reduced dioxide alone.
Services is not permit- Let’s say, instead of fewer tests than those listed in a panel, the lab performs more
ted. You must code the tests. The guidelines state that you are to report those additional tests, those not
tests individually. included in the panel code, separately and additionally.
CPT
LET’S CODE IT! SCENARIO
Concerned that Keisha Evans, a 51-year-old female, might be suffering from hypercholesterolemia, Dr. Rawlins
ordered blood work, including a total cholesterol serum test, lipoprotein (direct measurement of high-density lipopro-
tein), and triglycerides. He also added a potassium serum test to the order.
CODING BITES
Experience and practice will help you learn the components of panels. After work-
ing at a lab or for a facility with a lab, you will recognize the lab tests that are typi-
cally performed together and possibly have a panel code grouping them. Should a
test not be in a panel, the Alphabetic Index will direct you to the correct individual
code for that test.
∙ Erythrocyte sedimentation rate (ESR): This test measures the speed with which
red blood cells cling together, fall, and settle in the bottom of a glass tube within
60 minutes. It is used to detect inflammatory, neoplastic, infectious, and necrotic
processes. When inflammation is present, the higher the rate, the greater the amount
of inflammation. Normal range: male = up to 15 millimeters per hour (mm/h);
female = up to 20 mm/h.
∙ Hematocrit (HCT): This test identifies the percentage of RBCs, which is used to
identify anemia. Low counts may indicate bone marrow damage or vitamin defi-
ciency, while high counts may indicate congenital heart disease, renal problems, or
pulmonary disease. Normal range: 34%–45%.
∙ Hemoglobin (Hgb): This test measures oxygen being carried by the RBCs. Low
counts may indicate bone marrow damage or vitamin deficiency, while high counts
may indicate congenital heart disease, renal problems, or pulmonary disease. Nor-
mal range: 11.5–15.5 grams per deciliter (g/dL).
CHAPTER 27 |
Mon Mar 31 10:10:27 2020
LIPID PANEL
Cholesterol H 243 mg/dL (80–199)
Triglycerides 188 mg/dL (30–150)
FIGURE 27-2 Pathology report showing a list of all of the individual blood tests run for the patient, including
results and reference ranges
CPT
YOU CODE IT! CASE STUDY
Rosalyn Alvarez, an 84-year-old female, complained to Dr. Files that she was having severe cramps in her legs and
hands. She said it has been getting worse the last few months. In Rosalyn’s chart, it notes that she has been on
diuretics, so Dr. Files orders blood work to quantify her creatinine levels to check on her kidney function. Thelma
Brooks, RN, performed the venipuncture and sent the blood specimen to the lab.
CPT © 2017 American Medical Association. All rights reserved.
(continued)
CHAPTER 27 |
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the code?
82565 Creatinine; blood
Good job!
Many tests can be easily performed in the physician’s office with a small amount
CPT
YOU CODE IT! CASE STUDY
Charles Endicott, a 31-year-old male, is an up-and-coming stockbroker who does not pay much attention to a proper
diet. He came to see his physician, Dr. Falacci, because he has been experiencing episodes of light-headedness.
Dr. Falacci asks his assistant, Carla Falco, to do a quantitative blood glucose test. Carla takes a blood sample, goes
to the back, and checks the specimen. The results indicate that Charles has hypoglycemia.
CHAPTER 27 |
CPT
YOU CODE IT! CASE STUDY
Parker Thomasini, a 4-year-old male, has a cousin who was diagnosed with cystic fibrosis last year. Recently, he has
been wheezing and has a dry, nonproductive cough. The fact that his cousin has cystic fibrosis means that Parker
has a 25% chance of carrying the disease. Therefore, Dr. Preston ordered a molecular diagnostic test for the muta-
tion of delta F 508 deletion in his DNA by sequencing, single segment.
CPT
LET’S CODE IT! SCENARIO
Nigel Winthrope, a 19-year-old male, was diagnosed with hemophilia many years ago. As a result of a blood trans-
fusion, he contracted HIV. He has come today for lab work to check on his T-cell count, an indicator of whether the
HIV is progressing.
Microbiology
Microbiologic tests use many different methods to study bacteria, fungi, parasites,
and viruses. The specimens used in the tests might be blood, urine, sputum (mucus,
also called phlegm), feces (stool), cerebrospinal fluid (CSF), and other bodily fluids.
Blood cultures are used to diagnose bacterial infections of the blood, sputum cultures
can identify respiratory infections like pneumonia, and stool cultures can confirm the
presence of pinworms and other parasites.
Code descriptions in this subsection may include some specific terms, such as
∙ Presumptive identification. This is the pathologic identification of colony morphol-
ogy; growth on selective media (such as a culture or slide); gram stains; or other
tests such as catalase, oxidase, indole, or urease. For example: 87081 Culture, pre-
sumptive, pathogenic organisms, screening only.
∙ Definitive identification. This is the pathologic identification of the genus or spe-
cies that requires additional testing, such as biochemical panels or slide cultures.
For example: 87106 Culture, fungi, definitive identification, each organism, yeast.
CPT
LET’S CODE IT! SCENARIO
Sally Tong, a 5-year-old female, went to a picnic at the park with her playgroup and had a hamburger, cooked very
rare. Later that evening, her parents rushed her to the hospital because she was vomiting and had severe diarrhea.
Dr. Warner ordered an infectious agent antigen enzyme immunoassay for E. coli O157. Fortunately, the test was
negative, and it turned out that she just had eaten too much ice cream and milk.
CPT © 2017 American Medical Association. All rights reserved.
(continued)
CHAPTER 27 |
83516, 83518, 83519, and 83520 do not come any closer to Dr. Warner’s notes. Let’s turn to the next set of
suggested codes:
87301 Infectious agent antigen detection by immunoassay technique (eg. enzyme immunoassay
[EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]),
qualitative or semiquantitative, multiple-step method; adenovirus enteric types 40/41
Read down the list a little farther:
87335 Escherichia coli O157
When you read the complete description, you get the following:
87335 Infectious agent antigen detection by immunoassay technique (eg. enzyme immunoassay
[EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]),
qualitative or semiquantitative, multiple-step method; Escherichia coli O157
Sometimes, even with the CPT book pointing at codes, it may take a lot of reading to be certain you have the
best, most appropriate code.
CPT
LET’S CODE IT! SCENARIO
Rosalie Panesca, a 47-year-old female, came to see Dr. Sizemore for her annual well-woman checkup. In addition to
the examination, Dr. Sizemore took a Pap smear, to be examined using the Bethesda reporting system with manual
screening. Rosalie’s examination showed she was completely healthy.
88164 Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under
physician supervision
88165 Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening
and rescreening and under physician supervision
88164 Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under
physician supervision
Great job!
cal site from where the specimen was taken. Under each, the sites are listed in alpha- Read the additional
betic order. However, you have to know what happened in the OR to find the correct explanations in the
code because that will change the level involved. in-section guidelines
located within the
Reading the Lab Report Pathology and Labora-
tory section, subhead
You may find a report, such as the one shown in Figure 27-3, that shows the results of
Surgical Pathology,
the surgical pathology along with the pathologist’s interpretation.
directly above code
The physician’s operative report may state a tissue biopsy was taken; however,
88300 in your
you may need more details from the pathologist’s report so you can code this accu-
CPT book.
rately. Remember, when you are reporting a code or codes from the Pathology and
Laboratory section of CPT, you are reporting for the pathologist, not the surgeon.
The code from the Surgery section of CPT will report the collection of the specimen,
while the code from the Pathology and Laboratory section will report the testing of
the specimen.
CHAPTER 27 |
HILL MCGRAW PATHOLOGY LABORATORIES INC.
Warren R. Mulford, MD,. Director
123 Learning Way • Academia, FL 12345
SPECIMEN INFORMATION
CLINICAL INFORMATION
SPECIMEN DATA
GROSS DESCRIPTION:
A. The specimen is a punch biopsy received in immunofluorescence transport medium that measures 0.1 × 0.4 × 0.1 cm. The
specimen is flash frozen and multiple 4 micron sections are cut for manual immunofluorescence staining. The sections are
probed with fluorescein labeled antihuman antibodies against IgG, IgA, IgM, C3, C5b-9, and fibrinogen.
B. Received is a 0.2 cm punch biopsy of skin, submitted complete. The specimen is received in formalin.
C. Received is a 0.2 cm punch biopsy of skin, submitted complete. The specimen is received in formalin.
MICROSCOPIC DESCRIPTION:
All positive and negative controls stained appropriately as required.
RESULTS
DIAGNOSIS:
A. DIRECT IMMUNOFLUORESCENCE, RIGHT UPPER EXTREMITY—NEGATIVE (See Note)
Note: There is no IgG, IgA, IgM, C3, C5b-9, and fibrinogen deposition seen in this specimen. There is no immunofluorescence
evidence of connective tissue, vasculitis, dermatitis herpetiformis, porphyria cutanea tarda, pseudoporphyria, or autoimmune
blistering disease; however, clinical histologic and, if pertinent, serologic correlation is recommended. Multiple immunoreactant
dilutions and sections were performed.
B. PUNCH BIOPSY, LEFT LOWER EXTREMITY—STASIS ECZEMA, TRAUMATIZED AND IMPETIGINIZED
FINAL REPORT
FIGURE 27-3 Sample pathology report showing details and analysis of a surgical specimen
ing the specimen is complex), pathologic examination of a patient’s bone marrow has
many possible uses, including:
∙ To serve as a diagnostic tool for suspected myeloma, leukemia, myelodysplastic
syndromes, and myeloproliferative disorders.
∙ To assess a current diagnosis of thrombocytopenia, anemia, or leukopenia.
∙ To measure quantities of stored iron and marrow cellularity.
∙ To determine neoplasm, infection, fibrosis, or other infiltrative bone disease.
∙ To enable staging of lymphoma and/or other malignant neoplasms.
A patient may have abnormal blood counts for which an explanation has yet to be
identified, or the patient may have other abnormal cells evidenced in circulating
blood. These, as well as a current diagnosis of a bone marrow–related disease (such
as lymphoma) or indications that a malignancy has metastasized into the marrow, are
standard-of-care justifications to obtain and study a bone marrow specimen.
CHAPTER 27 |
Collection of the Specimen
Typically, the specimen is taken from the posterior superior iliac spine of the pel-
vis to acquire a sampling of the blood-forming cells in the marrow space. Evaluation
of a specimen taken by biopsy is considered to be more accurate than one obtained
by aspiration because the quantity of material gathered is greater and therefore more
likely to provide a representative sampling of a wider scope.
When coding for bone marrow biopsy, the first procedure to be reported is for
obtaining the specimen, using either 38220 Bone marrow; aspiration only or 38221
Bone marrow, biopsy, needle or trocar.
Note that the abstraction of bone marrow from a patient is not performed solely for
the lab. Therefore, it is very important to identify, from the documentation, not only
how the bone marrow was taken but also for what purpose. For example, bone marrow
aspiration for platelet-rich stem cell injections are not reported with 38220 but with
code 0232T Injection(s), platelet-rich plasma, any site, including image guidance, har-
vesting and preparation when performed. Harvesting bone marrow for transplantation
is reported with either 38230 Bone marrow harvesting for transplantation; allogeneic
or 38232 Bone marrow harvesting for transplantation; autologous.
When both a bone marrow biopsy and a bone marrow aspiration are performed on
a Medicare beneficiary during the same encounter, do not report code 38220. Instead,
use code G0364 Bone marrow aspiration performed with bone marrow biopsy through
the same incision on the same date of service.
Pathologic Testing
Next, the specimen will be sent to the laboratory for analysis. A bone marrow speci-
men, obtained by either biopsy or aspiration, can enable a hematologist/pathologist to
investigate the patient’s hematopoiesis (the process of forming blood cells), as well as
the shape, size, and quantity of red and white blood cells and megakaryocytes (very
large bone marrow cells that produce blood platelets). Blood cell formation is primar-
ily the responsibility of the red bone marrow, specifically in the sternum, ribs, and
iliac bones (pelvis).
Code 88305 Level IV Surgical pathology, gross and microscopic examination reports
both evaluation of the bone marrow biopsy specimen by the naked eye (gross exami-
nation) and visualization of the specimen using a microscope. When the documenta-
tion states that the specimen was obtained by aspiration, instead of 88305, the analysis
is reported with 85097 Bone marrow; smear interpretation.
It is not uncommon for a decalcification procedure and/or iron staining to be per-
formed at the same time as the surgical pathologic examination. When documenta-
tion confirms this, report these procedures separately using 88311 Decalcification
procedure (list separately in addition to code for surgical pathology examination) and/
or 88313 Special stain including interpretation and report; Group II, all other (e.g., iron,
trichrome) except stain for microorganisms, stains for enzyme constituents, or immuno-
cytochemistry and immunohistochemistry. CPT © 2017 American Medical Association. All rights reserved.
Per CPT parenthetical instruction, you should report one unit of 88313 for each
special stain on each surgical pathologic block, cytologic specimen, or hematologic
smear. Check documentation or query the pathologist performing the testing to ensure
that the notes are clear as to how many blocks, specimens, or smears are tested so that
you can report the accurate number of codes.
Immunophenotyping by flow cytometry provides the identification of cell-specific
antibodies, enabling a more accurate determination of cell percentages as well as iden-
tification of abnormal cell patterns. Report this test using 88184 Flow cytometry, cell
surface, cytoplasmic, or nuclear marker, technical component only; first marker and
88185 each additional marker, as appropriate.
Because 88184 and 88185 are specifically limited to the technical component
only, you will need a code to report the interpretation service separately. Note that no
CPT
YOU CODE IT! CASE STUDY
Danielle Lee, a 37-year-old female, has a history of chronic myeloid leukemia (CML) and came to our facility today
for a bone marrow aspiration, right side posterior iliac crest. Dr. Hansen used a 15-gauge needle to obtain the aspi-
rate including an aspirate clot. The patient tolerated the procedure well.
(continued)
CHAPTER 27 |
Answer:
Did you determine these to be the correct codes for the pathology testing?
Also on occasion, you may find that a lab test has to be repeated, on the same day
for the same patient, in order to get several readings of a level or measurement. When
this is documented, append modifier 91:
The use of testing kits is increasing in health care facilities because they make
it easier to obtain fast, accurate results. When a testing kit is being used, append
modifier 92.
TABLE 27-1 Abbreviations and Acronyms for Most Common Diagnostic and
Laboratory Tests
(continued)
CHAPTER 27 |
APTT Activated partial thromboplastin time
AST Aspartate aminotransferase
BASO Basophiles
BMC Bone mineral content
BMD Bone marrow density
BST Blood serologic test
BUN Blood urea nitrogen
CBC Complete blood count
CEA Carcinoembryonic antigen
CK Creatine kinase
CMV Cytomegalovirus
CO2 Carbon dioxide
CPK Creatine phosphokinase
DIC Disseminated intravascular coagulation
DIFF Differential
EIA Enzyme immunoassay
EOS Eosinophil count
ESR Erythrocyte sedimentation rate
FBS Fasting blood sugar
GTT Glucose tolerance test
HCT Hematocrit
HDL High-density lipoprotein
HGB Hemoglobin
HPF High-power field
INR International normalization ratio
LD Lactic dehydrogenase
LDL Low-density lipoprotein
LFT Liver function tests
LPF Low-power field
LYMPHS Lymphocytes CPT © 2017 American Medical Association. All rights reserved.
Chapter Summary
Pathology and laboratory tests provide health care professionals with definitive evi-
dence as to the condition that may be interfering with a patient’s good health. That
proof will help direct the physician toward a more accurate diagnosis and a beneficial
treatment plan. Lab tests are an invaluable part of the health care toolbox and must be
coded accurately.
CODING BITES
Common Abbreviations Used in Pathology Testing
CPT © 2017 American Medical Association. All rights reserved.
CHAPTER 27 |
CHAPTER 27 REVIEW
CHAPTER 27 REVIEW
CPT
Let’s Check It! Concepts
Choose the most appropriate answer for each of the following questions.
1. LO 27.10 What is the correct abbreviation for a liver function test?
a. INR b. LDL c. LPF d. LFT
2. LO 27.7 What code(s) would you assign for a blood compatibility test by incubation technique, 2 units?
a. 86920 b. 86921, 86921
c. 86921 d. 86922, 86921
3. LO 27.1 A specimen can be
a. blood. b. urine.
CPT © 2017 American Medical Association. All rights reserved.
c. sputum. d. all of these.
4. LO 27.3 When not all of the tests listed in a panel are performed, you should
a. code the panel with modifier 52.
b. code the panel alone.
c. code the tests individually.
d. code the panel with modifier 53.
5. LO 27.2 The guidelines tell you that, if the documentation does not specify, you may assume that the examina-
tion performed was _____.
a. qualitative b. measured
c. quantitative d. none of these
CHAPTER 27 REVIEW
a. hormones. b. blood glucose.
c. electrolytes. d. lipids.
7. LO 27.9 What modifier would you append to a CPT code for a lab test that has to be repeated, on the same day
for the same patient, in order to get several readings of a level or measurement?
a. 99 b. 90 c. 92 d. 91
8. LO 27.4 This test identifies the percentage of RBCs, which is used to identify anemia.
a. BUN b. ESR c. Hgb d. HCT
9. LO 27.8 Surgical pathology may include
a. gross examination.
b. microbiology.
c. genetic testing.
d. nuclear medicine.
10. LO 27.6 _____ testing involves the analysis of specimens to identify any presence of a genetic disorder.
a. Infectious
b. Oncology
c. Genetic
d. Hematology
1. Services in Pathology and Laboratory are provided by a physician or by _____ under responsible supervision of a
_____.
2. It is appropriate to designate _____ procedures that are rendered on the _____ date by _____ entries.
3. Unlisted hematology and coagulation procedure is represented by code _____.
4. A service that is _____ provided, unusual, variable, or new _____ require a _____ report.
5. Pertinent information should include an adequate _____ or description of the nature, _____, and need for the pro-
CPT © 2017 American Medical Association. All rights reserved.
cedure; and the time, _____, and equipment necessary to provide the service.
CHAPTER 27 |
CHAPTER 27 REVIEW
CPT
CPT
2. Deidra Lowe, a 23-year-old female, has been living on the street and in shelters and comes to the free clinic
for a checkup because she is 5 months pregnant. Dr. Ashton orders a complete CBC, automated and appro-
priate manual differential WBC count, hepatitis B surface antigen, rubella antibody, qualitative syphilis test,
RBC antibody screening, blood typing ABO, and Rh factor.
3. Vivian Praxis, a 3-year-old female, is at the office of her pediatrician, Dr. Ashley, for her regular checkup.
Dr. Ashley notices that Vivian is very small for her age and orders a growth hormone stimulation panel to be
done.
4. Jay Zeeman, a 36-year-old male, went to the shore with his friends and feasted on raw oysters and beer. About
7 hours later, after getting home, he began to cough and vomit, and he found blood in his stool. He went to
the walk-in clinic, where Dr. Lanahan ran a smear test for ova and parasites, particularly Anisakis.
CPT
YOU CODE IT! Application
The following exercises provide practice in the application of abstracting the physicians’ notes and learning to work
with documentation from our health care facility, Millard Pathology & Diagnostic Labs. These case studies are
CPT © 2017 American Medical Association. All rights reserved.
modeled on real patient encounters. Using the techniques described in this chapter, carefully read through the case
studies and determine the most accurate pathology and laboratory CPT code(s) and modifier(s), if appropriate, for
each case study. You are coding for the pathologist.
CHAPTER 27 |
CHAPTER 27 REVIEW
Derrick Castel, MD
DC/mg D: 10/17/18 09:50:16 T: 10/20/18 12:55:01
Determine the most accurate pathology and laboratory CPT code(s) and modifiers, if appropriate.
753 LITTLE WEST RD • SOMEWHERE, FL 32811 • 407-555-9371 CPT © 2017 American Medical Association. All rights reserved.
Peter Havner, MD
PH/mg D: 09/29/18 09:50:16 T: 09/30/18 12:55:01
Determine the most accurate pathology and laboratory CPT code(s) and modifiers, if appropriate.
Peter Havner, MD
PH/mg D: 11/15/18 09:50:16 T: 11/20/18 12:55:01
Determine the most accurate pathology and laboratory CPT code(s) and modifiers, if appropriate.
Walter Alchemy, MD
WA/mg D: 09/23/18 09:50:16 T: 09/25/18 12:55:01
Determine the most accurate pathology and laboratory CPT code(s) and modifiers, if appropriate.
CHAPTER 27 |
CHAPTER 27 REVIEW
Derrick Castel, MD
DC/mg D: 06/17/18 09:50:16 T: 06/20/18 12:55:01
Determine the most accurate pathology and laboratory CPT code(s) and modifiers, if appropriate.
CPT
LET’S CODE IT! SCENARIO
Phillip Landstone, a 21-year-old male, came in so Dr. Micah can administer a flu vaccine before he starts volunteer-
ing at Community Hospital. Dr. Micah documents that the vaccine was trivalent, split virus, 0.5 mL dosage, adminis-
tered IM.
If more than one vaccine was administered during the same encounter, there may be
a combination code available for those vaccinations that are typically provided together,
such as the MMR (Measles, Mumps, Rubella) or the DTaP (Diphtheria, Tetanus tox-
oids, and Acellular Pertussis vaccines). It is illegal to report these vaccines individually
if they are administered in a combination.
Medications can be given, or administered, to the patient in several different ways: per-
cutaneous, intradermal, subcutaneous (SC), or intramuscular (IM) injections; intranasal
(INH) or oral (ORAL); intra-arterial (IA) or intravenous (IV). The method of administra-
tion will help you find the correct administration codes 90460–90461 and 90471–90474.
When more than one vaccine is provided on the same date, use the add-on codes for
the administration of the additional injections. You will find that most of the codes are
offered in sets: the first injection, administration, or hour and then the add-on code for
each additional injection, administration, or hour.
CPT
LET’S CODE IT! SCENARIO
Isaac Nelson, a 5-year-old male, came to Dr. Rubino for his MMR vaccine so that he can start kindergarten next
CPT © 2017 American Medical Association. All rights reserved.
month. Dr. Rubino administered an injection subcutaneously. Dr. Rubino met face-to-face with Isaac’s mother and
discussed the importance of the vaccine, as well as indications of a reaction that she should watch for. Isaac chose
a red balloon as his prize for being a good patient.
(continued)
You could go back to the Alphabetic Index, or you could read the instructional paragraph at the beginning of the
Vaccines, Toxoids subsection (where you found the code 90707). You will see that this paragraph tells you that
you must use these codes “in addition to an immunization administration code(s) 90460–90474.” Let’s turn to
the first code, 90460, and read the description:
90460 Immunization administration through 18 years of age via any route of administration, with
counseling by physician or other qualified health care professional; first or only component
of each vaccine or toxoid administered
90461 each additional vaccine or toxoid component administered (list separately in addition to
code for primary procedure)
Now, you have the codes to reimburse Dr. Rubino for the MMR vaccine, as well as his time and expertise in
administering the injection and talking with Isaac’s mother. Remember, the MMR vaccine is a combination vac-
cine with three components. So, you will need to report four codes:
90707, 90460, 90461, 90461
Good job!!
NOTE: If Dr. Rubino had not spent time face-to-face with Isaac and his mother, 90460 would not be used. Instead
you would use codes 90471, 90472, 90472, which do not include the phrase “when the physician counsels
the patient/family” in the code description.
(a) Intradermal
(ID)
Subcutaneous
FIGURE 28-1 An illustration showing various injection routes Source: Booth et al., Medical Assisting, 5e. Copyright ©2013 by McGraw-Hill
Education. Figure 53-5, p. 1081.
Multiple Administrations
When more than one injection or infusion is provided to a patient at the same encoun-
ter, there is a specific order in which you need to report the codes. The sequencing
guidelines are different for those reporting physician services than for those reporting
for the facility.
When you are reporting for the physician’s, or other health care professional’s, ser-
vices, you must read the notes carefully to determine the main diagnosis or reason for
GUIDANCE
the treatment. The primary reason for the injection or infusion should be reported first, CONNECTION
as the “initial” service, no matter in what order the injections were administered. Read the additional
explanations in the
in-section guidelines
EXAMPLE located within the Medi-
CPT © 2017 American Medical Association. All rights reserved.
Wendy comes to see her physician because she has been vomiting a lot over the cine section, subheads
last several days. Dr. Kilmer identifies that she has become dehydrated due to this Hydration, directly
excessive vomiting. Dr. Kilmer gives Wendy an intramuscular (IM) injection of an above code 96360,
antiemetic (a drug to stop vomiting) and then gives her an IV infusion, 45 minutes, and Therapeutic, Pro-
of normal saline for hydration. The primary reason for the encounter is Wendy’s phylactic, Diagnostic
excessive vomiting; therefore, the injection of the antiemetic is the “initial” service, Injections and Infu-
followed by the hydration infusion service. sions (Excludes Che-
motherapy and Other
96372 Therapeutic, prophylactic, or diagnostic injection; subcutaneous or
Highly Complex Drug
intramuscular
or Highly Complex
96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour
Biologic Agent Admin-
NOTE: Remember, you will also need an additional code for the specific anti- istration), directly above
emetic medication that was inside that injection, as well as an additional code for code 96365, both in
the saline. your CPT book.
When you are reporting services on behalf of a facility rather than the providing
professional, the order is determined by the type of service provided as well as the
reason for that service:
1. Chemotherapy service
2. Therapeutic, prophylactic, and diagnostic services
3. Hydration services
Then, the specific service hierarchy is
1. Infusions
2. Pushes
3. Injections
CPT
LET’S CODE IT! SCENARIO
Melissa Fusion, a 51-year-old female, postmastectomy for malignant neoplasm of the breast, has been having che-
motherapy treatments. She was seen today for nausea and vomiting as a result of this therapy. Dr. Saludo ordered
an antiemetic 10 mg IV push and another antiemetic IV infusion over 30 minutes.
CPT
YOU CODE IT! CASE STUDY
Andrew Gitner is admitted today for his chemotherapy, which consists of an antineoplastic drug, 500 mg IV infusion
over 3 hours. Dr. Munch is in attendance during Andrew’s treatment.
CPT
LET’S CODE IT! SCENARIO
Taylor Loeb, a 32-year-old male, was sent to Dr. Panjab for psychotherapy to deal with anger management issues.
Dr. Panjab spent 45 minutes with Taylor in her office.
receive treatment. The correct code for reporting dialysis service is determined by the
patient’s age, where the services are provided, and the level of physician services dur-
ing the encounters.
Physician services provided during a dialysis month included in these codes are
∙ Determination of the dialysis cycle
∙ Outpatient E/M of the dialysis visits
∙ Telephone calls
∙ Patient management
∙ Face-to-face visit with the patient
Hemodialysis
Hemodialysis is a process that uses a mechanical dialyzer to extract blood via an
intravenous catheter to filter out waste products and excess fluids, and returns the
“cleaned” blood back into the patient via an intra-arterial catheter. Typically, three
GUIDANCE sessions a week are provided.
CONNECTION Prior to beginning ongoing hemodialysis treatments, the nephrologist will order
Read the additional
the insertion of either an arteriovenous fistula (AVF) or an arteriovenous graft
explanations in the
(AVG). For more information on these procedures, see the additional explanations
in-section guidelines
in the in-section guidelines located within the Surgery section, subhead Dialysis
located within the Medi-
Circuit, directly above code 36901 in your CPT book.
cine section, subhead
Hemodialysis procedures are reported with one of two codes determined by the
Dialysis, subsections
number of evaluations provided by the physician during the encounter:
Hemodialysis, directly 90935 Hemodialysis procedure with single evaluation by a physician or
above code 90935; other qualified physician or other health care professional
Miscellaneous Dialysis 90937 Hemodialysis procedure requiring repeated evaluation(s) with or
Procedures, directly without substantial revision of dialysis prescription
above code 90945; and
End-Stage Renal Dis-
When the hemodialysis services are performed by a nonphysician health care profes-
ease Services, directly
sional in the patient’s residence, including a private home, assisted living center, group
above code 90951, all
home, nontraditional provider home, custodial care facility, or a school, use this code:
in your CPT book. 99512 Home visit for hemodialysis
When hemodialysis is provided via an AV fistula, graft, or catheter, there are Category
II codes to report this service:
4052F Hemodialysis via functioning arteriovenous (AV) fistula [ESRD]
4053F Hemodialysis via functioning arteriovenous (AV) graft [ESRD]
4054F Hemodialysis via catheter [ESRD]
Access flow studies may be provided to determine the effectiveness of the dialysis
process.
90940 Hemodialysis access flow study to determine blood flow in grafts
and arteriovenous fistulae by an indicator method
93990 Duplex scan of hemodialysis access (including arterial inflow, body
of access and venous outflow)
CPT
LET’S CODE IT! SCENARIO
Glory Anders, a 61-year-old female, was diagnosed with ESRD 6 months ago. She has just moved to Springfield to
be closer to her daughter and began her daily dialysis on June 20 at the Southside Dialysis Center. Prepare the
claim for dialysis services for June.
Gastroenterology Services
A limited number of tests and services for the gastroenterological system—from the patient’s
mouth down the esophagus to the stomach through the intestinal tract to the rectum—are
included in the Medicine section of the CPT book. The Alphabetic Index will guide you to
the best, most appropriate code in the best section, depending upon the service provided.
CPT © 2017 American Medical Association. All rights reserved.
CPT
YOU CODE IT! CASE STUDY
Paulina Porter, a 39-year-old female, has been battling with indigestion for over a year. After trying virtually every
over-the-counter medication possible, she came to see Dr. Dahl, who decided to administer an esophageal acid
reflux test. The test was administered in the office using a nasal catheter intraluminal impedance electrode. The
45-minute test was recorded and analyzed and interpreted by Dr. Dahl.
CPT
LET’S CODE IT! SCENARIO
Warren Preston, a 61-year-old male, has been having a problem with blurred vision and pain in his eyes. His father
has glaucoma, which makes Warren at high risk for the disease. Therefore, Dr. Coreley is going to perform a bilateral
visual field examination and a serial tonometry with multiple measurements. None of these services is done as a
part of a general ophthalmologic service provided to Warren.
GUIDANCE CONNECTION
Read the additional explanations in the in-section guidelines located within the Medi-
cine section, subhead Ophthalmology, directly above code 92002 in your CPT book.
Otorhinolaryngologic Services
In the Special Otorhinolaryngologic Services portion of the Medicine section are
codes for special services that are not usually included in an office visit or evaluation
encounter in the field of otorhinolaryngology. Otorhinolaryngology
Throughout the listings for codes 92502–92700, you will see all types of tests and The study of the human
services that can help health care professionals diagnose and treat conditions relating ears, nose, and throat (ENT)
to a patient’s ears, nose, and throat and their functions. systems.
CPT
YOU CODE IT! CASE STUDY
Darlene Watson came with her husband, Albert, to see Dr. Hudman because of the problems Albert has been hav-
ing sleeping. Darlene noticed that Albert snores terribly during the night and has, at times, abruptly stopped making
noise. She is concerned that he may have actually stopped breathing during one of his episodes. Dr. Hudman per-
formed a nasopharyngoscopy with an endoscope to check Albert’s adenoids and lingual tonsils. The results of the
exam indicated that Albert is suffering from sleep apnea.
CPT © 2017 American Medical Association. All rights reserved.
(continued)
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
92511 Nasopharyngoscopy with endoscope (separate procedure)
That is exactly what Dr. Hudman did. In addition, he did not perform it as a part of any other service, so it was a
separate procedure. Excellent!
GUIDANCE CONNECTION
Read the additional explanations in the in-section guidelines located within the
Medicine section, subhead Special Otorhinolaryngologic Services, directly above
code 92502 in your CPT book.
CPT
YOU CODE IT! CASE STUDY
Ransom Sweeney was in Dr. Plenmen’s office when Ransom went into cardiac arrest. Dr. Plenmen immediately
performed cardiopulmonary resuscitation (CPR). The nurse called 911, and Ransom was taken to the hospital after
regaining consciousness and being stabilized.
Cardiography
The electronic measurement of heart rhythms very often uses an electrocardiograph
(ECG, also called an EKG, machine). Services involving an electrocardiogram are
coded from the Cardiography subsection.
EXAMPLE
Deliah Munroe experienced a rapid heartbeat and mild pain in her chest. Dr.
Donaldson took a 12-lead routine ECG to rule out a heart attack. He interpreted
the tracing and wrote a report for the file. The code is
93000 Electrocardiogram, routine ECG with at least 12 leads; with inter-
pretation and report
These incredible measuring devices must be programmed, and then data must be
gathered by using in-person and/or remote transmission and interpreted by the physi-
cian. The codes in this subsection report these services.
EXAMPLE
Henriette had a dual-lead pacemaker implanted 3 days ago by Dr. Rasmussen.
She is here to have him do the evaluation and programming.
93286 Peri-procedural device evaluation (in person) and programming of
device system parameters before or after a surgery, procedure, or
test with analysis, review and report by a physician or other quali-
fied health care professional; single, dual, or multiple lead pace-
maker system
Echocardiography
Echocardiography is different from electrocardiography. As the name indicates, an
echocardiogram uses ultrasound (sound waves to produce an echo), rather than a mea-
surement by electronic impulses, as with the ECG.
When coding echocardiography, the codes already include
∙ The exam (the recording of the images of the organ or anatomical areas being
studied).
∙ The interpretation and report of the findings.
You are not permitted to use these codes for echocardiograms that have been taken
when no interpretation or report has been done.
Cardiac Catheterization
The codes available for reporting cardiac catheterization include the following:
Catheter ∙ The introduction of the catheter(s).
A thin, flexible tube, inserted ∙ The positioning and repositioning of the catheter(s).
into a body part, used to inject
fluid, to extract fluid, or to ∙ Recording of the intracardiac and intravascular pressure.
keep a passage open. ∙ Obtaining blood samples for the measurement of blood gases, dilution curves, and/
or cardiac output with or without electrode catheter placement.
∙ Final evaluation and report of the procedure.
CODING BITES
The provision of a cardiac catheterization may require as many as five codes. The
determination of how many of these codes you are responsible for reporting will
depend upon for whom you are coding (which professional or facility):
. The professional service for the catheterization . . . procedure code + modifier 26.
1
2. The administration of the dye . . . procedure code + modifier 51.
3. The radiologist’s supervision and interpretation for the guidance for the injec-
tion of the dye . . . procedure code + modifier 26.
4. The procedure itself, such as coronary artery angiography.
5. The radiologist’s supervision and interpretation of the images.
CPT
LET’S CODE IT! SCENARIO
Mason Franks, a 4-month-old male, was experiencing cyanotic episodes, known as “blue” spells. Dr. Zahn, his pedi-
atrician, performed a transthoracic echocardiogram, which identified a ventricular septal defect and hypertrophied CPT © 2017 American Medical Association. All rights reserved.
walls of the right ventricle. He then performed a right cardiac catheterization that confirmed a diagnosis of a tetral-
ogy of Fallot.
Electrophysiologic Procedures
Intracardiac electrophysiologic studies (EPS) codes include
∙ The insertion of the electrode catheters (usually performed with two or more
catheters).
∙ The repositioning of the catheters.
∙ Recording of electrograms both before and during the pacing or programmed stim-
ulation of multiple locations of the heart.
∙ Analysis of the recorded electrograms.
∙ Report of the procedure and the findings.
There are cases when a diagnostic EPS is followed by treatment (ablation) of the Ablation
problem at the same encounter. When ablation is done at the same time as an EPS, you The destruction or eradication
must code it separately. of tissue.
GUIDANCE CONNECTION
Read the additional explanations in the in-section guidelines located within
the Medicine section, subhead Cardiovascular, subsections Cardiography,
directly above code 93000; Cardiovascular Monitoring Services, directly
above code 93224; Implantable and Wearable Cardiac Device Evaluations,
directly above code 93279; Echocardiography, directly above code 93303;
Cardiac Catheterization, directly above code 93451; and Intracardiac Elec-
trophysiological Procedures/Studies, directly above code 93600, all in your
CPT book.
CPT © 2017 American Medical Association. All rights reserved.
28.7 Pulmonary
Codes 94002–94799 in the Pulmonary subsection identify procedures and tests on
the pulmonary system and include
∙ The exam and/or laboratory procedure.
∙ Interpretation of the findings.
Spirometry
Spirometry, the basis of pulmonary function testing, measures the quantity of airflow
during expiration (exhaling), as well as the speed of this action. The results of this
assessment can provide indications of a wide range of lung diseases.
94010 Spirometry, including graphic record, total and timed vital capacity,
expiratory flow rate measurement(s), with or without maximal volun-
tary ventilation
94060 Bronchodilation responsiveness, spirometry as in 94010, pre- and
post-bronchodilator administration
CPT
YOU CODE IT! CASE STUDY
Carmine Allen, a 2-day-old male, was born at 35 weeks gestation, with a birth weight of 1,450 g. After exhibiting
hypotension, peripheral edema, and oliguria, Carmine was diagnosed by Dr. Yanger with respiratory distress syn-
drome. Dr. Yanger performed the initiation of continuous positive airway pressure ventilation (CPAP).
EXAMPLE
Dr. Bagg conducted percutaneous scratch testing with immediate reactions on
Shelley to identify the cause of her asthma. He tested her for a dozen common
allergens. Report this with 95004 Percutaneous tests × 12 tests.
CPT
LET’S CODE IT! SCENARIO
GUIDANCE
28.9 Neurology and Neuromuscular CONNECTION
Procedures Read the additional
As with so many other headings in this section, the neurology and neuromuscular pro- explanations in the
cedure codes (95803–96020) include the recording of the test as well as the physician’s in-section guidelines
interpretation and report of the findings. located within the Medi-
Acronyms often seen in this arena of health care services include: cine section, subhead
Neurology and Neuro-
EEG Electroencephalogram
muscular Procedures,
EMG Electromyogram
directly above code
EOG Electrooculogram
95803 in your CPT book.
MEG Magnetoencephalography
CPT
LET’S CODE IT! SCENARIO
Ian Ellington, a 47-year-old male, was having a hard time staying awake during the day and asleep during the night.
Dr. Bruse sent him down the hall to have a polysomnography, with three additional parameters, to rule out sleep
CPT © 2017 American Medical Association. All rights reserved.
apnea.
GUIDANCE CONNECTION
Read the additional explanations in the in-section guidelines located within the
Medicine section, subhead Central Nervous System Assessments/Tests (e.g.,
Neuro-Cognitive, Mental Status, Speech Testing), directly above code 96101 in
your CPT book.
CPT
YOU CODE IT! CASE STUDY
Oliver Gates, a 3-year-old male, does not appear to be meeting certain milestones. Dr. Saunders performed a devel-
opmental test known as an Early Language Milestone Screening. Once the test was interpreted, he sent his report
and contacted a speech therapist to consult on a treatment plan.
CPT
YOU CODE IT! CASE STUDY
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
(continued)
Answer:
Did you determine this to be the correct code?
97163 Physical therapy evaluation; high complexity, requiring these components: a history of pres-
ent problem with 3 or more personal factors and/or comorbidities that impact the plan of
care, an examination of body systems using standardized tests and measures addressing a
total of 4 or more elements from any of the following: body structures and functions, activity
limitations, and/or participation restrictions; a clinical presentation with unstable and unpre-
dictable characteristics; and clinical decision-making of high complexity using standardized
patient assessment instrument and/or measurable assessment of functional outcome.
CPT
LET’S CODE IT! SCENARIO
Josie Rossini, a 57-year-old female, was having a problem with menopause. Because of the reported concerns
about hormone replacement therapy (HRT), she decided to try acupuncture. After discussing her symptoms and a
treatment plan, Dr. Kini inserted several needles. The needles were removed 20 minutes later. Dr. Kini reviewed the
follow-up plan and made an appointment for Josie’s next visit. Dr. Kini spent 30 minutes in total face-to-face with
Josie, who reported marked improvement.
Spinal Regions
∙ Cervical, including atlanto-occipital joint
∙ Thoracic, including costovertebral and costotransverse joints
∙ Lumbar
GUIDANCE
∙ Sacral
CONNECTION
∙ Pelvic, including the sacroiliac joint Read the additional
explanations in the
Extraspinal Regions in-section guidelines
located within the Medi-
∙ Head, including temporomandibular joint (but not the atlanto-occipital) cine section, subhead
∙ Upper extremities Chiropractic Manipula-
tive Treatment, directly
∙ Rib cage, excluding costotransverse and costovertebral joints
above code 98940 in
∙ Abdomen your CPT book.
∙ Lower extremities
CPT © 2017 American Medical Association. All rights reserved.
CPT
YOU CODE IT! CASE STUDY
Evan LaVelle, a 37-year-old male who is 6 ft 6 in. tall, has pain in his neck and spine. Dr. Eisenberg, a chiropractor,
provides CMT to his cervical, thoracic, lumbar, sacral, and pelvic regions to alleviate Evan’s pain.
(continued)
Step #2: Abstract the scenario. Which key words or terms describe what service the physician provided to the
patient during this encounter?
Step #3: Are there any details missing or incomplete for which you would need to query the physician? [If so,
ask your instructor.]
Step #4: Determine the correct CPT procedure code or codes to explain the details about what was provided
to the patient during this encounter.
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer:
Did you determine this to be the correct code?
98942 Chiropractic manipulative treatment (CMT); spinal, five regions
Good job!
EXAMPLE
∙ Teaching a diabetic patient how to self-administer insulin injections.
∙ Teaching a caregiver how to change a dressing.
In the chapter CPT Evaluation and Management Coding, you learned about codes
99341–99350 for services provided by a physician at the patient’s home. However,
occasionally a health care professional in your facility other than the physician pro- GUIDANCE
vides services to a patient at his or her home. The person may be a nurse or ther- CONNECTION
apist, for example. For nonphysician clinical professionals, you must use the codes Read the additional
99500–99602 from the Home Health Procedures/Services subsection in the explanations in the
Medicine section. in-section guidelines
located within the Medi-
cine section, subhead
EXAMPLE Home Health Proce-
Shawn Webber, RN, stopped by Beatrice Mulligan’s home to give her an injection dures/Services, directly
of morphine sulfate, 10 mg, IM, for pain management. Report Nurse Webber’s visit above code 99500 in
with 99506 Home visit for intramuscular injections. your CPT book.
CPT
YOU CODE IT! CASE STUDY
Eliot Sharpton is a Certified Diabetes Educator (CDE) and is meeting today with Robyn Wu. She was just diagnosed
with type 2 diabetes mellitus. Eliot spends 30 minutes with her, using the standardized curriculum, to help Robyn
adjust her diet, get some exercise in her routine, and answer questions about her medication.
Chapter Summary
Many services provided by physicians, therapists, chiropractors, and other trained
health care professionals deserve to receive reimbursement. The Medicine sec-
tion contains information about these services. The variety of services included in
the Medicine section emphasizes the fact that finding the correct code begins in the
Alphabetic Index and culminates in the numeric listings.
CPT © 2017 American Medical Association. All rights reserved.
CODING BITES
The Medicine section of the CPT book has codes for services that are supplied
by health care professionals but not represented in any other sections. Services
reported using codes from the Medicine section include these:
• Flu shots
• Vaccinations for the kids to go back to school
• Allergy shots
• Chiropractic services
• Psychotherapy
• Dialysis
CHAPTER 28 REVIEW
CPT Medicine Section Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
CPT
Let’s Check It! Concepts
Choose the most appropriate answer for each of the following questions.
CPT © 2017 American Medical Association. All rights reserved.
a. a category of service.
b. relationship of the patient.
c. type of therapy.
d. qualifications of the treating health care professional.
4. LO 28.4 Dialysis codes are reported by
a. the patient’s age.
b. the number of days treated.
c. the location of treatment (inpatient or outpatient).
d. all of these.
5. LO 28.5 An optometrist is qualified to
a. diagnose and treat serious eye diseases.
b. supply glasses and contact lenses.
c. write prescriptions for the treatment of serious eye diseases.
d. perform surgery.
6. LO 28.6 What code would you assign for a duplex scan of the left radial artery?
a. 93925 b. 93926
c. 93930 d. 93931
7. LO 28.12 Medication Therapy Management Services (MTMS) codes can be reported when all of the following
have been documented except
a. review of the pertinent patient examination.
b. review of medication profile for prescription and nonprescription drugs and herbal supplements.
c. specific recommendations for improving patient health outcomes.
d. recommendations to support the patient’s treatment compliance.
8. LO 28.11 Chiropractic treatment codes are chosen by
a. the time spent face-to-face with the patient.
b. the total number of treatments in a month.
c. the number of regions treated.
d. the age of the patient.
9. LO 28.9 Kinney Harris, a 41-year-old male, was in an automobile accident and was transported to the nearest
hospital, unconscious. The ED physician, Dr. Alexander, attempted to awaken Kinney with stimulants
without success. Dr. Alexander performs an EEG due to Kinney’s comatose condition. What is the cor-
rect code for the EEG? CPT © 2017 American Medical Association. All rights reserved.
a. 95812
b. 95816
c. 95822
d. 95824
10. LO 28.10 Betty Cannon receives an acupuncture treatment, two needles, for a total of 45 minutes of face-to-face
time with Dr. Hamilton. What is/are the correct code(s) for this procedure?
a. 97810
b. 97810, 97811
c. 97813, 97814
d. 97810, 97811, 97811
CHAPTER 28 REVIEW
Refer to the Medicine Guidelines and fill in the blanks accordingly.
99070 not Medicine assessment
add-on identified itself 16 minutes
“Special Report” “separate procedure” independent
independently 59 integral
99600 Introduction supply
nomenclature “Unlisted Procedure” exempt
1. In addition to the definitions and commonly used terms present in the _____, several other items unique to this
section on _____ are defined or identified here.
2. All _____ codes found in the CPT codebook are _____ from the multiple procedure concept.
3. Add-on codes in the CPT codebook can be readily _____ by specific descriptor _____ which includes phrases
such as “each additional” or “(List separately in addition to primary procedure).”
4. The codes designated as _____ should not be reported in addition to the code for the total procedure or service of
which it is considered an _____ component.
5. However, when a procedure or service that is designated as a “separate procedure” is carried out _____ or considered
to be unrelated or distinct from other procedures/services provided at the time, it may be reported by _____, or in
addition to other procedures/services by appending modifier _____ to the specific “separate procedure” code to indi-
cate that the procedure is not considered to be a component of another procedure, but is a distinct, _____ procedure.
6. Supplies and materials over and above those usually included with the procedure(s) rendered are reported sepa-
rately using code _____ or a specific _____ code.
7. A service or procedure may be provided that is _____ listed in this edition of the CPT code book. When reporting
such a service, the appropriate _____ code may be used to indicate the service, identifying it by _____.
8. Unlisted home visit service or procedure is reported with code _____.
9. The psychotherapy services codes 90832-90838 include ongoing _____ and may include informants in the treat-
ment process.
10. Do not report psychotherapy of less than _____ duration.
4. LO 28.4 What physician services are included in the codes during a dialysis month?
5. LO 28.6 What do the available codes for reporting a cardiac catheterization include?
CPT
3. Dr. Kantsiper performs biofeedback training, 10. Dr. McKee completes nitric oxide expired gas
anorectal: determination:
a. main term: _____ b. procedure: _____ a. main term: _____ b. procedure: _____
4. Dr. Abernethy completes a diagnostic transcutane- 11. Dr. Middleton performs an unattended sleep study
ous electrogastrography: with simultaneous recording of heart rate, oxygen
a. main term: _____ b. procedure: _____ saturation, respiratory analysis, and sleep time:
5. Dr. Shutter fits a contact lens for management of a. main term: _____ b. procedure: _____
keratoconus, initial fitting: 12. Dr. Trezevant completes a manual muscle testing
a. main term: _____ b. procedure: _____ with report of extremity:
6. Dr. Sanning completes a positional nystagmus a. main term: _____ b. procedure: _____
test: 13. Dr. Reese performs a chemotherapy administra-
a. main term: _____ b. procedure:_____ tion, intra-arterial; infusion technique, 45 minutes:
7. Dr. Foldings performs a tympanometry and reflex a. main term: _____ b. procedure:_____
threshold measurements: 14. Dr. Kemper performs an anogenital (perineum)
a. main term: _____ b. procedure: _____ examination, magnified in childhood for suspected
trauma:
8. Dr. Edge completes a right heart catheterization
including measurement of oxygen saturation and a. main term: _____ b. procedure: _____
cardiac output: 15. Dr. Guinyard completes a home visit for prenatal
a. main term: _____ b. procedure: _____ monitoring and assessment including fetal heart
rate and nonstress test:
9. Dr. Pugh performs a duplex scan of lower extrem-
ity arteries; complete bilateral study: a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure:_____
CPT
The following exercises provide practice in the application of abstracting the physicians’ notes and learning to
work with documentation from our health care facilities. These case studies are modeled on real patient encounters.
Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate Medicine section CPT code(s) and modifier(s), if appropriate, for each case study.
WESTON HOSPITAL
629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541
PATIENT: HAUPTON, NICHOLAS
ACCOUNT/EHR #: HAUPNI001
DATE: 10/13/18
CHAPTER 28 REVIEW
Robin P. Moss, RN
RPM/mg D: 10/13/18 09:50:16 T: 10/15/18 12:55:01
Determine the most accurate Medicine section CPT code(s) and modifier(s), if appropriate.
Determine the most accurate Medicine section CPT code(s) and modifier(s), if appropriate.
Harvey Shaw
HS/mg D: 09/30/18 09:50:16 T: 09/30/18 12:55:01
Determine the most accurate Medicine section CPT code(s) and modifier(s), if appropriate.
Assessment of expressive and receptive speech and language function; language comprehension,
speech production ability, reading, spelling, writing, using Boston Diagnostic Aphasia Examination.
Interpretation and report to follow.
Total time: 60 minutes
Walter P. Henricks, DC
WPH/mg D: 10/07/18 09:50:16 T: 10/09/18 12:55:01
Determine the most accurate Medicine section CPT code(s) and modifier(s), if appropriate.
CHAPTER 28 REVIEW
RAILS RADIOLOGY
A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: CRESSENA, FRANCIE
ACCOUNT/EHR #: CRESFR001
DATE: 10/15/18
Attending Physician: James I. Cipher, MD
Radiologist: Rhonda E. Beardall, MD
Reason for Exam: MD order—pre-op clearance
EXAMINATION:
1. Chest two views
Chest—AP and lateral views.
Clinical history states evaluation: kidney stone with obstruction.
Slightly elongated thoracic aorta. Prominent left ventricle. No pulmonary vascular congestion. No
acute inflammatory infiltrates in the lungs.
2. ECG, 12 leads
Unremarkable.
Rhonda E. Beardall, MD
REB/mg D: 10/15/18 09:50:16 T: 10/17/18 12:55:01
Determine the most accurate Medicine section CPT code(s) and modifier(s), if appropriate.
Patients come to a physician for help to feel better, or to maintain good health. You
have learned that CPT codes are one of three code sets used to report WHAT the
physician did for the patient during a specific encounter. Now, this chapter provides
you with case studies so you can get some hands-on practice using CPT to report
physician services.
For each of the following case studies, read through the documentation, and determine:
∙ Which code or codes report WHAT the physician did for this patient.
∙ If any modifiers are necessary, and if so, which modifiers, and in what order.
∙ If more than one code is required, the sequence in which to report the codes.
Remember, the notations, symbols, and Official Guidelines—both before each sec-
tion as well as those in some subsections—are there to help you get it correct.
Marlena Hendricks brought her 13-year-old son, Paul, into my office as a walk-in. Paul
stated that he fell through a sliding glass door, while chasing his brother, and sustained
three lacerations: left knee, right knee, and left hand.
After physical examination, Dr. Smyth determined that the wounds of both knees
and left hand required debridement and suture repair using 1% lidocaine for topical
anesthetic.
Left knee: 5.5 cm laceration involving deep subcutaneous tissue and fascia, repaired
with layered closure. Some debridement was performed.
CPT © 2017 American Medical Association. All rights reserved.
Maria Curry, a 39-year-old female, status post right knee arthroplasty, was referred to
our rehabilitation clinic for a physical therapy evaluation by Dr. Hanson, her orthopedic
surgeon. Patient was diagnosed with degenerative osteoarthritis approximately 2 years
ago. As part of my evaluation, I completed a range of motion measurement on both
legs. The physician was provided with a copy of my evaluation and a written report was
developed.
Roger Forchetta, a 33-year-old male, came in to our ophthalmology office today. I last
saw him 6 years ago when he had a corneal ulcer on his right eye. This is now cleared.
He states that over the last few weeks, his vision is “a bit off.”
I began with a complete, interval history. He denied any specific trauma or problems
with his eyes prior to this latest concern. Overall, this patient is a healthy male with an
admitted diet filled with a great deal of fast food and restaurant food.
His external ocular and adnexal areas were unremarkable, free from injury or infec-
tion. The patient has a normal corneal anterior chamber and iris but with very slow dilat-
ing pupils. Ophthalmoscopy shows there is no pseudoexfoliation, but there are dense
juvenile nuclear cataracts on both eyes, the right greater than the left.
I counseled him regarding cataract surgery of this right eye first, and then the left
eye; the need for postop correction; a 4- to 6-week recovery time; and the type of
procedure. He agreed to schedule the procedure for next Friday. Kathy, my assistant,
obtained the appropriate consent form signatures.
Camille Fields, a 67-year-old female, came into our Allergy & Immunology Clinic with
Oscar Pettaway brought his unconscious 3-year-old daughter, Belinda, into the emer-
gency department after finding her on the floor of the bathroom. An empty bottle of his
wife’s thyroid medication, Synthroid, was lying by her side. Oscar told the physician on
call, Dr. Rubinstein, that his wife had just refilled the prescription.
Dr. Rubinstein immediately evaluated Belinda’s condition and, after obtaining per-
mission from Oscar, ordered a gastric aspiration and lavage be done immediately, due
to the poisoning.
Monique Kennard, a 17-year-old female, came into our office today. She is accompa-
nied by her mother, who is very worried about her daughter. Patient states she has been
experiencing wheezing × 10 days. She states the symptoms are worse at night. She
CHAPTER 29 |
was seen a week ago at this clinic and started on a 5-day course of azithromycin with-
out improvement. Yesterday she was seen at an urgent care clinic and prescribed an
albuterol inhaler, amoxicillin/clavulonic acid, and methylprednisolone. Symptoms con-
tinued to worsen throughout the day. Patient reports chest pain attempting to swallow
the amoxicillin/clavulonic acid tablets. Chest pain involves her left upper chest; it does
not radiate. The quality is “heavy.”
VS: 97.9°F, HR 85, RR 25, BP 144/101, SaO2 97%
HEAD/NECK: She is awake and alert, NAD (no apparent distress), HEENT (head, eyes,
ears, nose, throat), NC/AT (normocephalic and atraumatic), EOMI (extraocular move-
ments intact). Left EAC (external auditory canal) is swollen shut; right is occluded with
cerumen. Oropharynx is pink and moist.
HEART: RRR (regular rate and rhythm)
LUNGS: No wheezing, but patient is stridorous
ABDOMEN: Benign/unremarkable
EXTREMITIES: Normal pulses × 4 CN II–XII grossly intact
INTEGUMENTARY: Dermatologic exam reveals no rash
ALLERGIES: NKDA (no known drug allergies)
PMHx (Past Medical History): Unremarkable
SocHx (Social History): Patient denies EtOH (ethanol, alcohol). Denies smoking but
states positive for secondhand tobacco exposure
PLAN: Orders written for CXR (chest x-ray) to be done at imaging center across the road.
Nurse to perform venipuncture for specimens for comprehensive metabolic panel; CBC
complete, automated; and automated differential WBC count.
Patient to return once results are in.
transected.
Code for both Dr. DeTaglia and Dr. Sullivan.
EMERGENCY DEPARTMENT
HISTORY OF PRESENT ILLNESS: The patient came in today for possible reaction
to immunotherapy. She has been seeing Dr. Oligby for allergic rhinitis and asthma.
She states that she is currently building on immunotherapy and yesterday received
CHAPTER 29 |
injections with oak/birch/maple 100 PNU 0.3 mL, grass and ragweed 100 BAU 0.3 mL,
cat/dog 50 BAU 0.3 mL, and mite and mold mix 100 units 0.3 mL. The patient tells
me after the immunotherapy, she went home and within hours felt some chest tight-
ness. The patient used her albuterol inhaler, but the chest tightness got worse and
she ended up taking her Symbicort 160/4.5 two puffs as well as some Claritin. She
continued to feel lethargic and out of breath. She also had an itchy area on her left arm
where she received the cat/dog injection. She was able to go to sleep that night but
woke twice due to wheezing and used her albuterol inhaler and went back to sleep.
When she woke up this morning, she was very tired and dizzy and could not catch
her breath. She used her albuterol inhaler once or twice this morning as well as the
Symbicort and took a tablet of Zyrtec. Then, around 9 or 9:30, when she was at work,
she felt her tongue swelling. During this time, she felt she couldn’t breathe normally.
The albuterol inhaler did not have any benefit; neither did the other medications she
tried. She tells me she had no rash, hives, or vomiting and is not coughing. She tells
me she has not been sick this week. No fever. She has been off of her Symbicort since
November because she felt her asthma is fine. She has had no recent trouble with
asthma. No recent exposure to animals, dust, or other allergens. She is on no new medi-
cations. She has no pets at home and continues to avoid turkey and chicken and has
no new foods during this time. She has a history of anxiety and panic attacks and does
feel she is having one now.
MEDICATIONS: Topamax for migraine headaches, Lexapro
ALLERGIES: NKDA
PHYSICAL EXAMINATION:
GENERAL: The patient is a healthy-appearing, well-nourished, well-developed 45-year-
old female in no acute distress but does appear to be breathing heavy and very shaky
and panicky.
VITAL SIGNS: Height is 63 inches. Weight is 132 pounds. Blood pressure is 106/70.
HEENT: Tympanic membranes are normal. Throat is clear. I did not appreciate any swell-
ing of the tongue or angioedema.
NECK: Supple without adenopathy
LUNGS: Completely clear
HEART: Regular rate and rhythm without murmur
STUDIES: I administered spirometry when she was a little bit more relaxed and achieved
an FEV1 of 3.1 liters or 88% of predicted, FEF25–75 is 118% of predicted. Graphic
record was placed in patient’s chart.
IMPRESSION:
CPT © 2017 American Medical Association. All rights reserved.
1. The patient appears to be having some anxiety and panic now. It is hard to say
whether this started with some mild asthma symptoms as a result of her immuno-
therapy or if this is purely an anxiety issue.
2. Allergic asthma
3. Allergic rhinitis
RECOMMENDATIONS:
1. We recommend a cutback of the dose of immunotherapy at the next visit to oak/
birch/maple 100 PNU at 0.2 mL, grass and ragweed 100 BAU at 0.2 mL,
cat/dog 50 BAU at 0.2 mL, and mite and mold mix 100 units at 0.2 mL
2. Restart Symbicort 160/4.5 two puffs twice daily
3. Zyrtec 10 mg daily for the next week and prior to immunotherapy
OPERATIONS:
. Flexible bronchoscopy
1
2. Cervical mediastinoscopy with biopsy and thyroid isthmusectomy
PROCEDURE: This otherwise normally healthy patient was brought to the operative
suite and placed in supine position. After satisfactory induction of general endotracheal
anesthesia, a flexible Olympus bronchoscope was passed through the endotracheal
tube visualizing the distal trachea, carina, and right and left main stem bronchi of the
CPT © 2017 American Medical Association. All rights reserved.
primary and secondary divisions. No evidence of any endobronchial tumor was noted.
The scope was then withdrawn.
The patient was then prepped and draped in the usual sterile fashion. A shoul-
der roll was placed. A curvilinear incision was made above the suprasternal notch
in the line of a skin crease. Dissection was carried down through the subcutaneous
tissue down through the platysma muscle. The strap muscles were next identified
and laterally retracted. We continued our dissection down to the pretracheal space. A
thyroid isthmusectomy was done without any problems; this gave me clear access to
the pretracheal space. A pretracheal plane was next developed. A mediastinoscope
was placed. I saw multiple, firm right paratracheal lymph nodes. After first aspirating
these structures to make sure they are not vascular in nature, generous biopsies were
taken and sent to pathology for examination. Frozen section analysis revealed these
to be consistent with lymphoma. Excellent hemostasis was obtained. The wound was
CHAPTER 29 |
irrigated using warm antibiotic saline solution. The wound was then closed in layers
using Vicryl sutures. Dressings were applied. Marcaine 0.25% was used as a regional
block. The patient tolerated the procedure and was sent to the recovery room in sta-
ble condition.
CHAPTER 29 |
Part IV
DMEPOS & TRANSPORTATION
There is another portion to the procedure coding system that professional coding spe-
cialists use to report services and treatments. HCPCS (pronounced “hick-picks”) is the
acronym for Healthcare Common Procedure Coding System. You have learned about
the CPT codes used to report physician services and outpatient facility services. This
part of this textbook will give you the opportunity to learn about HCPCS Level II
codes (referred to as HCPCS codes).
DMEPOS is a combination abbreviation that stands for
∙ DME = Durable Medical Equipment
∙ P = Prosthetics
∙ O = Orthotics
∙ S = Supplies
Transportation refers to moving a patient from one point to another, such as ambu-
lance services.
30
Key Terms
HCPCS Level II
Learning Outcomes
Advanced Life After completing this chapter, the student should be able to:
Support (ALS)
Basic Life Support LO 30.1 Abstract physician’s notes to identify the category of HCPCS
(BLS) Level II codes needed.
Chelation Therapy LO 30.2 Employ the Alphabetic Index to find suggested HCPCS
DMEPOS Level II codes.
Durable Medical LO 30.3 Distinguish the types of services, products, and supplies
Equipment (DME) reported with HCPCS Level II codes.
Durable Medical
Equipment LO 30.4 Follow the directions supplied by the notations and symbols.
Regional Carrier LO 30.5 Utilize the additional information provided by Appendices.
(DMERC)
Enteral
Not Otherwise
Specified (NOS)
Orthotic Remember, you need to follow along in
Parenteral
Prosthetic
HCPCS Level II
STOP! your HCPCS Level II code book for an
optimal learning experience.
Self-Administer
Specialty Care
Transport (SCT)
EXAMPLES
C9460 Injection, cangrelor, 1mg
R0076 Transportation of portable EKG to facility or location, per patient
HCPCS Level II codes cover specific aspects of health care services, including
∙ Durable medical equipment
e.g., a wheelchair or a humidifier
■
∙ Dental services
e.g., all services provided by a dental professional
■
906
∙ Transportation services
■ e.g., ambulance services
∙ Vision and hearing services
■ e.g., trifocal spectacles or a hearing screening
∙ Orthotic and prosthetic procedures Orthotic
A device used to correct
■ e.g., scoliosis braces or postsurgical fitting or improve an orthopedic
Not all insurance carriers accept HCPCS Level II codes, but Medicare and Med- concern.
icaid want you to use them. It is your responsibility as a coding specialist to find out Prosthetic
whether each third-party payer with which your facility works accepts HCPCS Level Fabricated artificial replace-
II codes. If not, you have to ask for the payer’s policies on reporting the services and ment for a damaged or miss-
supplies covered by HCPCS Level II. ing part of the body.
EXAMPLES
Medicare accepts HCPCS Level II codes and therefore requires you to code an
injection of tetracycline, 200 mg, with two codes (for administration of the shot
and the drug inside the syringe).
96372 Therapeutic, prophylactic or diagnostic injection (specify substance
or drug injected); subcutaneous or intramuscular
J0120 Injection, tetracycline, up to 250 mg
Yankee Health Insurance does not accept HCPCS Level II codes. This payor
includes reimbursement for the drug in the CPT code for the actual injection.
Therefore, you would only report the one code to get paid for both the service
(the giving of the shot) and the material (the drug inside the syringe).
96372 Therapeutic, prophylactic or diagnostic injection (specify substance
or drug injected); subcutaneous or intramuscular CODING BITES
A physiatrist is a health
care professional who
The process for using HCPCS Level II codes is the same as coding from the CPT uses physical method-
book. You abstract the key words from the physician’s notes regarding the services and ologies to treat illness
procedures, look those key words up in the Alphabetic Index of the appropriate book or injury.
(CPT or HCPCS), confirm the code in the numeric listing, and report the service using These methodolo-
that code. You know how to do this already! However, there are specific elements gies include electrical
unique to HCPCS Level II coding that you need to know. stimulation, heat/cold,
Understanding how to use HCPCS codes accurately will open new employment light, water, exercise,
opportunities for you. In addition to hospitals, physician’s offices, and outpatient clin- manipulation, and
ics, nursing homes, home health care agencies, health care equipment and supply com- mechanical devices.
panies, and other facilities use these codes quite extensively.
HCPCS Level II
LET’S CODE IT! SCENARIO
Carole Shelton, a 47-year-old female, came to see Dr. Giardino, a podiatrist recommended by her primary care
physician, complaining of acute pain in the ball of her left foot. She states that the pain has been ongoing for about
2 months. After examination, and an x-ray of the foot, two views, Dr. Giardino took a walking boot, non-pneumatic,
from the storage room and placed it on her foot. He instructed Carole to wear the boot at all times, except while in
bed, for 6 weeks, and return for a follow-up evaluation.
(continued)
Let’s Code It!
Review the information in the scenario and abstract the services that Dr. Giardino provided: he evaluated her
condition, took x-rays, and provided her with the boot (durable medical equipment).
You have learned about CPT coding, so you can determine that these two codes will be reported for this
encounter:
99202 Office visit, new patient, problem-focused
73620 Radiologic examination, foot; 2 views
Now, you need to report the provision of the boot. It is only right that Dr. Giardino be reimbursed for providing
this to the patient for her use at home. Turn in your HCPCS Level II code book to the Alphabetic Index, and find:
Walking Boot
custom, L4386
off-the-shelf, L4387
Go back to the documentation, which states, “walking boot.” Terrific! Turn in the Main Section of HCPCS Level II
so you can read the complete code descriptions.
L4386 W
alking boot, non-pneumatic, with or without joints, with or without interface material, pre-
fabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to
fit a specific patient by an individual with expertise.
L4387 Walking boot, non-pneumatic, with or without joints, with or without interface material, pre-
fabricated, off-the-shelf
Go back to the documentation. Is there any mention of customization, as mentioned in the description for code
L4386? No, there is not. And the documentation does state that the boot came right out of Dr. Giardino’s stor-
age room.
Now, you can report the three codes for this encounter with confidence: the two CPT codes + this one
HCPCS Level II code.
L4387-LT Walking boot, non-pneumatic, with or without joints, with or without interface material,
prefabricated, off-the-shelf, left foot
Good work!
EXAMPLE
In the Alphabetic Index, you will see
Abciximab, J0130
ReoPro, J0130
In the Alphanumeric Listing, you will see:
J0130 Injection, abciximab, 10 mg
Use this code for ReoPro
Deleted code descriptions are not included in the Alphabetic Index. However, the
new code(s) that are to be used instead of the deleted code are listed:
EXAMPLE
In the Alphabetic Index, you will see
Ventilator
home
used with invasive interface, E0465
In the Alphanumeric Listing, you will see:
E0465 Home ventilator, any type, used with invasive interface, (e.g. trache-
ostomy tube)
The Alphanumeric Listing shows a notation to use one code with another code.
EXAMPLE
In the Alphanumeric Listing, you will see
D2953 Each additional indirectly fabricate post–same tooth
To be used with D2952
HCPCS Level II codes are listed in sections, grouped by the type of service, the
type of supply item, or the type of equipment they represent. However, you should not
assume that a particular item or service is located only in that specific section. Use the
Alphabetic Index to direct you to the correct category in the Alphanumeric Listing of
the book. One type of service or procedure might be located under several different
categories depending upon the details.
EXAMPLE
Transportation services may be identified by A, Q, R, S, T, or V codes.
Transportation
Ambulance, A0021–A0999
Corneal tissue, V2785
EKG (portable), R0076
Waiting time, T2007
HCPCS Level II
LET’S CODE IT! SCENARIO
Priscilla DeLucca, an emergency medical technician (EMT), was called in as an extra ambulance attendant for the
ALS ground transportation of Willow Lawarence, a 12-year-old autistic female.
The T codes (T1000–T9999) are used by Medicaid state agencies to report services,
procedures, and other items for which there are no permanent national codes. You must
communicate with the third-party payer to whom you are sending the claim to ensure
that it accepts T codes. Here are some transportation services that may be reported
using T codes:
T2001 Non-emergency transportation; patient attendant/escort
T2002 Non-emergency transportation; per diem
T2003 Non-emergency transportation; encounter/trip
T2004 Non-emergency transport; commercial carrier, multi-pass
T2005 Non-emergency transportation; stretcher van
T2007 Transportation waiting time, air ambulance and non-emergency vehi-
cle, one-half (1/2) hour increments
T2049 Non-emergency transportation; stretcher van, mileage; per mile
HCPCS Level II
LET’S CODE IT! SCENARIO
Barry Camacho, a 79-year-old male, had a stroke 3 weeks ago. He has now improved sufficiently to be discharged
from the hospital. However, he is not completely well. Barry is being transferred to a short-term rehabilitation facility
to help him regain use of his legs and right arm. Ira Waxen, from Flomenhoff Ambulance Services, drove the wheel-
chair van to take Barry from McGraw Hospital to Flowers Nursing and Rehabilitation Center, a 12-mile ride.
This matches Ira’s documentation, doesn’t it? Yes. In addition, it is the only code shown for that portion of
the service. However, you might also look in the Alphabetic Listing under Transportation, non-emergency,
A0080–A0210, T2001–T2005. Once you review the complete descriptions of the suggested codes, you will
see rather quickly that A0130 is the most specific and accurate.
Now, you must include a code for the mileage traveled by the van. Under Wheelchair, van, non-emergency,
mileage, you get the suggestion for code S0209, and while under Transportation, non-emergency, mileage, you
see S0215. Let’s examine both codes:
S0209 Wheelchair van, mileage, per mile
S0215 Non-emergency transportation; mileage, per mile
Ambulance Origin/Destination
When reporting transportation services to insurance carriers, you have to identify the
origin of service and the destination of service. The most common modifiers for the
origin and the destination of service are one-letter codes that categorize locations.
D Diagnostic or therapeutic site other than “P” or “H” when these are used
as origin codes
E Residential, domiciliary, custodial facility (other than 1819 facility)
G Hospital-based ESRD facility
H Hospital
I Site of transfer (e.g. airport or helicopter pad) between modes of ambu-
lance transport
J Free standing ESRD facility
N Skilled nursing facility (SNF) (1819 facility)
P Physician’s office
R Residence
S Scene of accident or acute event
X Intermediate stop at physician’s office on way to hospital (destination
code only)
Durable Medical Equipment
(DME)
A4206–A8004 Medical and Surgical Supplies Apparatus and tools that
and A9150–A9999 Administrative, Miscellaneous, help individuals accommo-
date physical frailties, deliver
and Investigational pharmaceuticals, and provide
These codes cover medical supplies, surgical supplies, and some services related to other assistance that will last
durable medical equipment (DME). for a long time and/or be used
In almost every health care encounter, materials and supplies are used. The paper to assist multiple patients
used to cover the examination table and the disposable cover on the digital thermome- over time.
ter are good examples. Such medical supplies are used by the health care facility itself. Self-Administer
However, they are not the types of medical and surgical supplies to which the HCPCS To give medication to oneself,
Level II book refers. The codes in the HCPCS Level II book are for reporting supplies such as a diabetic giving her-
given to a patient to self-administer health care at home. self an insulin injection.
A Codes and B Codes
Let’s begin by reviewing the subheadings throughout the A code and B code sections
to get a good idea of which items are covered.
∙ Miscellaneous Supplies: The supplies used by a physician in the course of treatment
(syringes, alcohol wipes, urine test strips, and so on) are included in the amount
reimbursed for the provision of that treatment or service. The codes in miscella-
neous supplies (HCPCS Level II) are used to report, and be reimbursed for, sup-
plies provided to patients for their own use at home. For example, if a diabetic
patient requires a daily insulin shot at home, he or she would need to have syringes
available.
∙ Vascular Catheters: These codes report the use of a disposable drug delivery system
(DDS) as well as implantable access catheters. The codes are not for reporting the
physician’s work to implant the catheter but for the facility to be reimbursed for the
cost of the catheter itself.
∙ Incontinence Appliances and Care Supplies and External Urinary Supplies: The
sections Incontinence Appliances and Care Supplies and External Urinary Supplies
cover urinary supplies that a patient uses when he or she has been diagnosed with
permanent, or chronic, incontinence.
∙ Ostomy Supplies: Patients who have had surgery to create an ostomy need supplies
every day to make their medical situation easier to deal with and to enable them to
live their lives more normally.
EXAMPLES
A4245 Alcohol wipes, per box
A4452 Tape, waterproof, per 18 sq in.
A4490 Surgical stocking above knee length, each
A4637 Replacement, tip, cane, crutch, walker, each
EXAMPLES
A9280 Alert or alarm device, not otherwise classified
A9505 Thallium T1-201, thallous chloride diagnostic, per millicurie
HCPCS Level II
LET’S CODE IT! SCENARIO
Teresa Baum, a 55-year-old female, has been diagnosed with malignant neoplasm of the liver. She has lost all her
hair because of the chemotherapy and radiation treatments. Dr. Colter prescribed a wig to help lift her spirits and
self-esteem.
EXAMPLES
D0240 Intraoral–occlusal film
D1110 Prophylaxis–adult
FIGURE 30-1 An x-ray
D3310 Endodontic therapy, anterior tooth (excluding final restoration)
showing a full-mouth view
NOTE: Prophylaxis is also known as a dental cleaning, and anterior (excluding final is one type of dental
restoration) is one of the codes that can be used to report root canal therapy. service ©Stockbyte/Getty
Images RF
HCPCS Level II
LET’S CODE IT! SCENARIO
Alvin Tunney, an 81-year-old male, came to Dr. Kahn for a complete maxillary denture. His old one was broken
beyond repair, so Alvin needed something immediately.
Dentures D5110–D5899
As you read the full list, you see that the reference matches Dr. Kahn’s notes. Next, turn to the Alphanumeric List-
ing to see which code is the most accurate.
Is there additional information in the notes that will help us determine the best code? They state that Alvin
needed the denture immediately. It leads us directly to this code:
EXAMPLES
• Canes
• Crutches
• Walkers
CODING BITES
Be careful not to confuse the HCPCS Level II E codes with ICD-10-CM E codes,
which report endocrinological illnesses.
EXAMPLES
H0005 Alcohol and/or drug services; group counseling by a clinician
H0038 Self-help/peer services, per 15 minutes
H2020 Therapeutic behavioral services, per diem
EXAMPLES
J0207 Injection, amifostine, 500 mg
J7100 Infusion, dextran 40, 500 mL
J7610 Albuterol, inhalation solution, compounded product, administered
through DME, concentrated form, 1 mg
You will find that drugs identified in the code descriptions are most often the chem-
ical, or generic, name of the pharmaceutical. At times the brand, or trade, name is
listed in the Alphabetic Index and/or in the Table of Drugs in an appendix of your
HCPCS Level II book. If your provider notes refer to a name that you cannot find in
this book, you might need to look in the Physician’s Desk Reference (PDR) to find an
alternate name for the drug.
EXAMPLE
Dr. Valentine asked the nurse to administer a 250 mg tablet, CellCept, PO, to
Benjamin Rudon.
CellCept, generic name mycophenolate mofetil, is classified as an
immunosuppressant.
• Neither name is listed in the Alphabetic Index of HCPCS.
• CellCept is listed in the Table of Drugs.
• Mycophenolate mofetil is listed in the Table of Drugs.
J7517 Mycophenolate mofetil, oral, 250 mg
In the chapter CPT Medicine Section, you learned about coding for the administra-
tion of pharmaceuticals (drugs). Those codes are used for reporting the services—
the labor—of the health care professional who gives the patient the drug. You may
remember that the different methods of administering drugs include
IA Intra-arterial administration
IV Intravenous administration (e.g., gravity infusion, injections, and
timed pushes)
The codes in HCPCS Level II enable you to report and gain reimbursement for the
actual drug or medication, as well as the syringe or IV bag used. The codes cover the
pharmaceutical materials only—not the administration of the drug.
In some cases, you may find DME has been supplied to the patient to provide medi-
cation, or drugs. When the equipment is made available to an individual, it may need
to be reported separately from the drug itself.
HCPCS Level II
LET’S CODE IT! SCENARIO
Janine Howell, a 55-year-old female, came in for her chemotherapy treatment. She is given Myocet, 30 mg/m2 daily
for 3 days, as treatment for metastatic breast neoplasms. This is day 2. The IV infusion takes 51 minutes. She toler-
ates the treatment well, and is discharged home.
HCPCS Level II codes in the Temporary Laboratory and Pathology Services category
include codes for services not listed in the CPT book, including chemistry, toxicology,
microbiology, screening Papanicolaou (Pap) procedures, and numerous blood products.
EXAMPLES
P2031 Hair analysis (excluding arsenic)
P7001 Culture, bacterial, urine; quantitative, sensitivity study
P9051 Whole blood or red blood cells, leukocytes reduced, CMV-negative,
each unit
CODING BITES
Q0000–Q9999 Temporary Codes Assigned by CMS
Remember that you
The Q codes replace the less specific codes that you may find elsewhere in the coding must always choose the
process for casting and splinting supplies when a health care professional cares for a code with the greatest
patient with a fracture. The section also includes codes for certain drugs and services specificity.
having nothing to do with the management of a fracture.
EXAMPLES
Q0113 Pinworm examination
Q2017 Injection, teniposide, 50 mg
Q4049 Finger splint, static
EXAMPLES
T1013 Sign language or oral interpretive services, per 15 minutes
T2022 Case management, per month
T2045 Hospice general inpatient care; per diem
EXAMPLES
V2118 Aniseikonic lens, single vision
V2321 Lenticular lens, per lens, trifocal
V2530 Contact lens, scleral, gas impermeable, per lens
EXAMPLES
V5008 Hearing screening
V5100 Hearing aid, bilateral, body worn
V5364 Dysphagia screening
HCPCS Level II
YOU CODE IT! CASE STUDY
Alfonzo Doyle, a 20-year-old male, lost his eye in a skiing accident and has come to see Dr. Durran to receive his
prosthetic eye. It is a custom-made, plastic prosthesis. Code for the prosthesis only.
Good job!
Solid Triangle
A solid triangle ( ) shown next to a code lets you know that the code’s description
has been changed or adjusted since last year or that a rule or guideline regarding the
code has changed.
EXAMPLES
G8400 Patient with central dual-energy x-ray absorptiometry (DXA)
results not documented, reason not given
L1902 Ankle orthosis, ankle gauntlet or similar, with or without joints,
prefabricated, off-the-shelf
Open Circle
An open circle ( ) next to a code identifies that the code had been deleted but now has
been restored (reinstated).
EXAMPLES
J3090 Injection, tedizolid phosphate, 1 mg
CODING BITES J3380 Injection, vedolizumab, 1 mg
Female Symbol
The female symbol ( ) identifies codes used to report procedures, services, and equip-
ment that can only be performed or used on a female patient.
EXAMPLES
A4286 Locking ring for breast pump, replacement
L8600 Implantable breast prosthesis, silicone or equal
Capital Letter A
The symbol highlights the fact that a code is used only for procedures, services, and
equipment that are performed or used on a patient of a certain age group. Read the
code description carefully to ensure the age limitation of the code matches the patient.
EXAMPLES
A4280 Adhesive skin support attachment for use with external breast
prosthesis, each
A4561 Pessary, rubber, any type
Capital Letter M
The symbol is used to remind you that the code describes maternity procedures,
services, and equipment that are performed or used on a pregnant female 12–55 years
of age.
EXAMPLES
A4284 Breast shield and splash protector for use with breast pump,
replacement
S9001 Home uterine monitor with or without associated nursing services
EXAMPLES
G6018 Ileoscopy, through stoma; with transendoscopic stent placement
(includes predilation)
S9015 Automated EEG monitoring
Notations
Just as in the CPT book, you will find notations (below code descriptions in the Alpha-
numeric Listing) that guide you on the proper use of HCPCS Level II codes.
Always Report Concurrent to the xxx Procedure
This notation directs you to always report this code with a code for another specific
procedure. The notation is similar to the “code also” instruction found in CPT or
ICD-10-CM.
EXAMPLE
A4262 Temporary, absorbable lacrimal duct implant, each
Always report concurrent to the implant procedure.
In the previous example, the “A” code is for the implant itself, and the note reminds
you that you have to code the physician’s services for putting the implant into the
patient.
EXAMPLES
A4450 Tape, non-waterproof, per 18 square inches
See also code A4452
A4452 Tape, waterproof, per 18 square inches
See also code A4450
Clarifications of Coverage
Clarifications of coverage notations are worded differently from code to code but
indicate when to use or not use the code. However, always check with the specific
payer to whom you will be sending the claim.
EXAMPLES
A4570 Splint
Dressings applied by a physician are included as part of the
professional service.
A6260 Wound cleansers, any type, any size
Surgical dressings applied by a physician are included as part of
the professional service. Surgical dressings obtained by the patient
to perform homecare as prescribed by the physician are covered.
EXAMPLES
J0560 Injection, penicillin G benzathine, up to 600,000 units
To report, see J0561
C9026 Injection, vedolizumab, 1 mg
To report, see J3380
EXAMPLES
E1130 Standard wheelchair; fixed full-length arms, fixed or swing-away,
detachable footrests
See code(s): K0001
EXAMPLES
J0585 Injection, onabotulinumtoxinA, 1 unit
Use this code for Botox, Botox Cosmetic
J1160 Injection, digoxin, up to 0.5 mg
Use this code for Lanoxin
EXAMPLES
D2980 Crown repair, by report
Pertinent documentation to evaluate medical appropriateness
should be included when this code is reported.
V2399 Specialty trifocal (by report)
Pertinent documentation to evaluate medical appropriateness
should be included when this code is reported.
EXAMPLE
D3220 Therapeutic pulpotomy (excluding final restoration)—removal of
pulp coronal to the dentinocemental junction and application of
medicament
Do not use this code to report the first stage of root canal therapy.
Medicare Covers . . .
Throughout the HCPCS Level II book, you will see notations giving you information
about coverage, particularly Medicare and Medicaid coverage. You should note that
the book covers the entire nation and that both programs are state-administered. This
means that you should still confirm the terms and policies of what is covered with
your own state’s fiscal intermediary (FI)—the agency or organization that is in charge
of reimbursement for your state’s program. Also check with other third-party payers to
see if they will cover this item or service.
HCPCS Level II
YOU CODE IT! CASE STUDY
Dr. Principe modified Miriam Collins’s left orthopedic shoe by inserting a between-sole metatarsal bar wedge to
accommodate Miriam’s shrinking Achilles tendon. Dr. Principe checked off the code L3649 on the superbill. As the
professional coding specialist, is this the best code available?
(continued)
Step #5: Check for any relevant guidance, including reading all of the symbols and notations.
Step #6: Do you need to append any modifiers to ensure complete and accurate information is provided?
Step #7: Double-check your work.
Answer
Did you find this to be the correct code?
HCPCS Level II
LET’S CODE IT! SCENARIO
Rita Warren came with her husband, Ryan, to see Dr. Capshaw because of the problems Ryan was having sleep-
ing. Dr. Capshaw had performed a nasopharyngoscopy and diagnosed Ryan with sleep apnea. At this encounter,
Dr. Capshaw provided Ryan with an apnea monitor, complete with a recording feature, so that more data could be
collected and Dr. Capshaw could further evaluate his condition.
HCPCS Level II
LET’S CODE IT! SCENARIO
Dr. Bettesh provided Lauren Martins, a 79-year-old female, with a quad cane, after putting on a new handgrip. Code
for the supply only.
CHAPTER 30 REVIEW
HCPCS Level II Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
CHAPTER 30 REVIEW
and equipment that are performed or used on a pregnant female F.
12–55 years of age.
G.
7. LO 30.4 The male symbol. H.
8. LO 30.4 Identifies a specific quantity of material or supply. It is a reminder for I.
you to check the detail in the notes and report the code not only for the
J. Z1111
item it represents but for the amount as well.
9. LO 30.4 Highlights the fact that a code is used only for procedures, services,
and equipment that are performed or used on a patient of a certain age
group.
10. LO 30.4 Identifies a code that is not covered under the skilled nursing facility
(SNF) prospective payment system (PPS).
Part II
Match each HCPCS Level II notation to the appropriate notation description.
1. LO 30.4 This notation cross-references this code with another code that may A. Always report
be similar in description. The notation serves as a reminder for you to concurrent to the xxx
double-check that you are using the most accurate code. procedure
2. LO 30.4 Refers you to a CPT code for a description that is potentially better and B. See also code . . .
may be more specific for reporting what was actually done or given to C. Clarifications of
the patient. coverage
3. LO 30.4 When one code is to be reported with other codes, a notation to D. Report in addition to
“Report in addition to” (a particular code) will identify those circum- code . . .
stances. It not only tells you the circumstances but also tells you which
E. See code(s): . . .
code to use.
F. Determine if an
4. LO 30.4 This notation directs you to always report this code with a code for
alternative HCPCS
another specific procedure.
Level II or a CPT code
5. LO 30.4 This notation indicates when to use or not use the code. better describes . . .
6. LO 30.4 Serves as a warning to you to make certain that there is no better or G. Use this code for . . .
more specific code in either the CPT or elsewhere in this HCPCS Level H. Pertinent documenta-
II book that correctly reports the services or procedures performed. tion to evaluate medical
7. LO 30.4 This notation warns that you need to go back and double-check appropriateness should
the provider’s notes carefully. If this is what was actually done, then be . . .
be certain to attach documentation explaining why that method was I. Do not use this code to
used instead of the newer technique because it is surely going to be report . . .
questioned.
J. Medicare covers . . .
8. LO 30.4 Warns you of circumstances when you are not permitted to use a code. K. Code with caution
9. LO 30.4 Provides you with alternative names, brand names, and other terms that
are also represented by the code’s description.
10. LO 30.4 This notation giving you information about coverage, particularly
Medicare and Medicaid coverage.
11. LO 30.4 Warns you up-front that you should include the proper documentation
along with the claim the first time you submit it, rather than wait to be
asked by the third-party payer, which would delay payment.
CHAPTER 30 REVIEW
Let’s Check It! Rules and Regulations
Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 30.1 List four HCPCS Level II codes specific to aspects for health care services.
2. LO 30.1 Do all insurance carriers accept HCPCS Level II codes? What is the responsibility of the coding spe-
cialist with regards to billing third-party payers?
3. LO 30.2 List five ways to look up the key words after abstracting them from the provider’s notes.
4. LO 30.3 What HCPCS Level II codes represent Procedures and Professional Services (Temporary)?
5. LO 30.4 What does the notation “Use this code for. . .” indicate?
HCPCS Level II
YOU CODE IT! Basics
First, identify the HCPCS Level II main term in the 7. Nonemergency transportation by stretcher van:
following statements; then code the procedure or a. main term: _____ b. procedure: _____
service.
8. A 200-mg injection IM of chloroquine
Example: Airlift by helicopter, one-way: hydrochloride:
a. main term: Ambulance b. procedure: A0431 a. main term: _____ b. procedure: _____
9. An injection SC of 30 mg of codeine phosphate:
Example: A 5 ml injection, IM, of Robaxin:
a. main term: _____ b. procedure: _____
a. main term: Robaxin b. procedure: J2800
10. Dr. Longwell ordered Fosphenytoin, with an ini-
1. A bottle of 50 blood glucose reagent strips: tial dose of 50 mg:
a. main term: _____ b. procedure: _____ a. main term: _____ b. procedure: _____
2. Johannsen Health Care delivered 1000 mL of dis- 11. A 25-mg injection of lepirudin:
tilled water for use with nebulizer: a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____ 12. A seat attachment for a Starke’s walker:
3. Youth-sized disposable incontinence brief, one: a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____ 13. One heel protector:
4. Arterial blood tubing: a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____ 14. Portable non-invasive ventilator:
5. Neonate ambulance transport, one-way, base rate: a. main term: _____ b. procedure: _____
a. main term: _____ b. procedure: _____ 15. Prostate cancer screening, antigen test:
6. Ambulance ride with oxygen administered along a. main term: _____ b. procedure: _____
with other advanced life support (ALS) services:
a. main term: _____ b. procedure: _____
HCPCS Level II
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and find the most accurate
HCPCS Level II code(s) and modifier(s) if appropriate for each case study.
Note: All insurance carriers and third-party payers for the patients accept HCPCS Level II codes and modifiers.
1. Daisha Kurucz, a 23-year-old female, has severe asthma. Dr. Benton ordered a nebulizer, with compressor, for
her to use at home. Code for the home health agency that supplied the equipment.
HCPCS Level II
Date: 12/21/18
Representative: Elizabeth Alexander
Attending Physician: Renee O. Bracker, MD
The Pt is a 27-year-old female who recently returned from working in Africa. She was diagnosed with
variola and has been on a gastric feeding tube to increase her fluids, electrolytes, and calories because
the pharyngeal lesions make swallowing difficult. Nasogastric tubing without a stylet was supplied for
this patient.
A: Variola
P: Service number given to caregiver
Elizabeth Alexander
EA/mg D: 12/21/18 09:50:16 T: 12/22/18 12:55:01
LuAnn Hallmark
LH/mg D: 11/05/18 09:50:16 T: 11/08/18 12:55:01
Salvatore L. Bloome, MD
SLB/mg D: 12/09/18 09:50:16 T: 12/11/18 12:55:01
The health care team extends beyond the physician’s office or hospital. Home care ser-
vices are on the increase as a greater number of patients prefer care in their residences,
whenever possible. The provision of these services enables patients greater comfort
and lowers costs, especially for those with chronic conditions.
In addition, transportation of patients should be recorded and reported for reim-
bursement purposes, as well as the provision of orthotics and prosthetics. And, as you
learned in previous chapters about CPT coding, the provision of medication (drugs) by
a health care professional also must be recorded and reimbursed.
For each of the following case studies, read through the documentation and
determine
∙ What medical supply, equipment, or other item or service was provided to this
patient. Do not code the procedure.
∙ Whether any modifiers are necessary, and, if so, which modifiers and in what order.
∙ Whether more than one code is required, and, if so, the sequence in which to report
the codes.
Remember, read carefully and completely.
Ryan McNaulty, a 6-year-old male with a defect in bowel function, was hospitalized for
severe constipation. He was given a dose of neostigmine methylsulfate 0.4 mg, IM.
Code for the drug, one date of service, only.
Nadiya Longstep was rescued from her apartment building, which was engulfed in a
two-alarm fire. The firemen carried her out and she was handed over to the EMTs, who
immediately began to examine the burns on 45% of her body. She was having trouble
breathing and was given oxygen. She lost consciousness. CPR was started immediately,
followed by external defibrillation at 200 joules until normal sinus rhythm was rees-
tablished. Orders came through to take her to the MacHill Burn Center unit of Mulford
Hospital immediately.
Daniel Bishop, an 18-year-old male, was in an MVA and subsequently diagnosed with
whiplash, resulting in pain in C2–C4. Dr. Samman recommended traction for his cervical
region, which he could attach to the headboard of his bed at home. Dr. Samman told
Daniel to spend at least 5 hours each night in the traction device for 3 weeks. Follow-up
appointment in 2 weeks.
Zivah Mastriani, a 41-year-old female, was diagnosed with type 2 diabetes mellitus,
and Dr. Ross wrote a prescription for her to obtain a home glucose disposable monitor.
Zivah brought the order to Roxone Home Medical Supplies, where a monitor and test
strips were provided. Harold Carter spent about 20 minutes teaching her how to use it
correctly.
Victor Jeffries, a 71-year-old male, weighs 320 pounds and is currently bedridden due
to a fractured hip. In an effort to prevent any pressure ulcers or decubitus ulcer devel-
opment, Dr. Abreen ordered an air pressure mattress pad for his bed at home.
Anna Cheng, an 83-year-old female, has been exhibiting dysphagia (problems swallow-
ing), resulting in her no longer wanting to eat. Dr. Baldwin inserted a standard gastros-
tomy/jejunostomy tube to enable enteral nutrition for 10 days.
Cecil Denoso, a 27-year-old male, was admitted to the Masters Behavioral Health Cen-
ter due to his current manic state. Dr. Levine ordered Haloperidol 5 mg IM t.i.d. Code for
the drug, one date of service, only.
SUBJECTIVE FINDINGS: This patient is a 55-year-old white female with pain in her
lumbosacral spine, extending into her buttocks bilaterally. She describes the pain
as being sharp and sometimes intense. She states it diminishes to an achy feeling.
She rates its intensity at 10/10 at its worst. Normally, she states it is 6–7/10. She
describes the pain as being ever-present, varying in intensity, increasing with activities
and decreasing with rest. She is using pain medications currently and is able to sleep
through the night.
HISTORY: This patient initially injured her back by catching a falling bookcase. She
had immediate pain that was disabling. The pain was resolved with occasional recur-
rence. She sought intervention last year from doctors, who diagnosed degenerative
disc disease and arthritis. She had a course of physical therapy with some resolution,
CHAPTER 31 |
but recurrence of pain occurred in June secondary to bending over while washing her
hands. She was referred here.
OBJECTIVE FINDINGS:
Observation: This patient appears as a normally developed white female of stated age.
She reports moving with forward flexed posture and an occasional antalgic gait on the
right when the pain is increasing. She currently postures and moves normally.
Palpation: Positive over L5 and S1 and paravertebral muscles at that same level.
Lumbosacral range of motion: Forward flexion 35 degrees with pain at the end of range.
Right side bending 30 degrees with pain at the end of range. Left side bending 35
degrees. Extension 0 degree with pain at the end of range.
Resisted motion: Positive in all directions
DTRs: Hyperreflexive bilaterally
Lasègue’s sign: Positive at 25 degrees bilaterally
Cram test: Positive at 25 degrees bilaterally
Cervical range of motion:
1. Right side bending: Within normal limits, painful
2. Left side bending: Within normal limits
3. Forward flexion: 45 degrees with pain at the end of range
4. Extension: Within normal limits
Radiculopathy: Positive with pain down the left arm and occasional tingling and
numbness
TREATMENT PLAN: We would like to see the patient three times per week to initiate
exercises and modalities to decrease pain and increase range of motion and function.
GOALS: The purpose of physical therapy intervention is to
. Increase range of motion to normal limits.
1
2. Decrease pain to zero.
3. Increase strength and function to normal.
RECOMMENDATION: I discussed with the patient the benefit of using a transcutaneous
electrical nerve stimulation device on her lumbar area. I suggested that she rent the unit
from us to give her the opportunity to try it out and see if it helps to reduce pain at L5–S1.
She agreed, and we provided her with a 2-lead unit. Instructions were for her to use it
every day, 15 minutes, b.i.d., first thing in the morning after getting out of bed and immedi-
ately prior to bed. Richard Penuto, my associate, taught her how to apply the leads and use
the machine. Appointment made for her to return in 2 weeks for evaluation.
Code for the provision of the transcutaneous electrical nerve stimulation device only.
HISTORY OF PRESENT ILLNESS: This patient is a 43-year-old male with pain in his cer-
vical spine. He states that the pain extends over the entire posterior neck and into the
right shoulder, including the upper trapezius. He rates that at a level of 7–8 on a scale
of 10 currently. He states that at its least it is 3–4 on a scale of 10. The patient is using
a cervical collar with good results. He also uses ibuprofen at night.
This patient was involved in an MVA 5 years ago resulting in a fracture of C5. He
had manipulation approximately 3 years ago resulting in pain for approximately
HISTORY: The patient is a 23-year-old black female professional athlete who, last month,
fell on her left elbow while reaching for a ball during a tennis game, sustaining a left distal
humerus fracture. The patient states the following day she had surgery to stabilize the
fracture. The patient was unsure if the surgery performed was for plates and screws.
PAST MEDICAL HISTORY: The patient fractured her right wrist approximately a year ago.
CHIEF COMPLAINT: The patient reports left elbow pain, currently 8/10, at best 7/10,
and at worst 10/10. The patient states she is taking her pain medications, which pro-
vide minimal relief but affect her performance on the court. The patient reports she
does have numbness in the left upper extremity, along the ulnar nerve distribution. The
patient states she does use some ice or heat; it provides minimal relief. The patient is
left-hand dominant.
PHYSICAL EXAMINATION: Left elbow AROM 35–120 degrees. Left elbow PROM
30–135 degrees. Left shoulder AROM within normal limits. Left wrist AROM within
CHAPTER 31 |
functional limits. Left elbow strength 3–/5. Left shoulder strength grossly 4/5. Left wrist
strength grossly 4/5. Left grip strength is 30 pounds. Right grip strength is 55 pounds.
Palpation: The patient is tender to palpation in the posterolateral aspect of the left
elbow. The incision is healed. No signs of infection. No swelling in the left elbow, no
bruising.
GOALS:
. Increase left elbow AROM and PROM to within normal limits.
1
2. Increase left elbow strength to within normal limits.
3. Eliminate pain.
4. Independent with home exercise program.
5. Return function to normal.
TREATMENT PLAN: We would like to see the patient three times a week to initiate and
advance range of motion, stretching and strengthening program to left elbow; may use
modalities as needed for pain control.
RECOMMENDATIONS: To ensure progress to help this patient recover more com-
pletely, I recommend a static progressive stretch elbow device with a range of motion
adjustment for her use at home. I discussed a workout plan, using the equipment, with
Willetta and her coach. They left with the device and instructions. Appointment is made
for her to return in 1 week to begin regular treatment.
Code for the provision of the device only.
SUBJECTIVE FINDINGS: The patient said that he slept well last night.
OBJECTIVE FINDINGS:
General: The patient is a well-developed, obese male in no apparent distress.
Vital signs: Temperature 98.6 degrees, pulse 72, respirations 18, and blood pressure
158/80.
HEENT: Head is normocephalic
Neck: Supple to palpation
Extremities: Examination of the extremities shows incision site to be healing well with-
out any sign of infection or skin breakdown. Peripheral pulses are intact. Minimal edema
in the left lower extremity. Homans sign is absent.
FUNCTIONAL STATUS: Functionally, the patient is able to demonstrate improvement with
full range of motion, −5 to 80 degrees of flexion actively and 86 degrees passively. His
functional gait has advanced 200 feet with the use of front-wheel walker with supervision.
He is supervised level with his bedside commode transfers and contact guard assistance
with shower chair transfers. He is modified independent level with his eating and set up with
his grooming skills. He requires moderate assistance with lower body dressing.
IMPRESSION:
. Polyarthritis
1
2. Left total knee arthroplasty
3. Status post coronary artery bypass graft
4. Chronic obstructive pulmonary disease
Paula, a 4-year-old female, was referred for speech therapy by her school after discus-
sion about parents’ concerns over her difficulties pronouncing certain speech sounds.
These irregular pronunciations were making it challenging for those outside her family
to understand Paula when she spoke to them. Paula had suffered from hearing loss and
had grommets inserted at age 3.
An initial assessment was performed to look at her current speech profile and to pro-
vide information as to whether intervention was needed and, if so, what kind. Assess-
ment results revealed that Paula had difficulties with the ‘t’ and ‘d’ sounds and was
replacing these with ‘k’ and ‘g,’ so ‘letter’ was ‘lekker’ and ‘bed’ was ‘beg’. I explained to
the parents that this is called ‘backing,’ whereby sounds that should be produced at the
front of the mouth are produced at the back of the mouth instead. This is not a process
found in typically developing speech and therefore would be targeted in therapy.
Paula also showed difficulties with other early developing sounds ‘s’ and ‘v.’ These
sounds that are produced with a long flow of air were being cut short so ‘f’ was
‘p’—therefore, ‘fish’ was ‘pish.’ This process is called stopping, which is expected to
have resolved by the age of 3 years and so was also targeted in therapy.
Paula was set up for individual therapy sessions at her home, by me, for 30 min-
utes each visit. The sessions will be focused on developing Paula’s awareness and pro-
duction of the above speech sounds and processes. For each sound, visual materials
including a picture card with the grapheme and cued articulation (similar to a gesture/
sign) are used to help Paula learn them. Before asking Paula to produce any of the
sounds she had difficulties with, Paula was provided with many opportunities to hear
these sounds being produced correctly (this is known as auditory bombardment). Paula
then completed tasks in which she had to discriminate between a target sound, e.g., ‘t,’
and the sound that she replaced it with, e.g., ‘k,’ to ensure she could tell the two apart.
Therapy will then move to production. How each of the sounds is produced in the
mouth will be explained to Paula using words accompanied by diagrams. The first step
is to get Paula to try to produce her new sounds in isolation (e.g., ‘t’) and then com-
bined with a vowel (e.g., ‘tee’). The next steps are to practice new sounds at the start of
words (e.g., ‘tiger’), followed by at the end of words (e.g., ‘boat’) and then in the middle
of words (e.g., ‘bottle’) and finally onto sentences. These will be incorporated into fun
games. Parents will be given activities to practice in between weekly sessions; in addi-
tion, advice on how to support Paula’s new speech sounds in natural conversations
will also be provided. For example, if Paula made an error with one of her new speech
sounds, others will be able to provide her with options, e.g., is it a ‘kiger’ or a ‘tiger,’
emphasizing the correct sound.
PLAN: In addition to the 30-minute sessions at her home, I supply software with
30 minutes of prerecorded sounds and messages so the parents can work with her in
between our sessions.
Code for the one 30-minute home visit by the speech-language pathologist + the
speech software.
CHAPTER 31 |
PART V
INPATIENT (HOSPITAL) REPORTING
Reporting inpatient (hospital) and outpatient encounters requires the same founda-
tional knowledge and skill: anatomy, physiology, and medical terminology. Part V of
this text provides you with the next layer of your learning about coding health care.
In these chapters, you will learn how to employ ICD-10-PCS (International Clas-
sification of Diseases, 10th revision, Procedure Coding System), the code set used
to report the procedures, services, and treatments provided by the acute care facility
(hospital) to inpatients (those who have been admitted).
32
Key Terms
Introduction to
ICD-10-PCS
Learning Outcomes
Approach After completing this chapter, the student should be able to:
Axis of Classification
Body Part LO 32.1 Explain the purpose of ICD-10-PCS codes.
Body System LO 32.2 Identify the structure of ICD-10-PCS codes.
Device LO 32.3 Recognize the proper ways to use the Alphabetic Index and
Qualifier Tables in ICD-10-PCS.
Root Operation Term LO 32.4 Discern the general conventions for using ICD-10-PCS.
LO 32.5 Determine the principal ICD-10-PCS code and proper
sequencing for multiple procedure codes.
950
Section 0 Medical and Surgical
Body System 2 Heart and Great Vessels
Operation 4 Creation: Putting in or on biological or synthetic material to
form a new body part that to the extent possible replicates
the anatomic structure or function of an absent body part
FIGURE 32-1 An example from the Medical and Surgical Tables of 2018 ICD-10-PCS
to an acute care hospital or other inpatient facility). That purpose has led to a new
structure for the codes. In this code set, you will actually build the code. CODING BITES
ICD-10-PCS codes
Seven Characters may include any letter
of the alphabet except
Every ICD-10-PCS code is made up of seven (7) alphanumeric characters, and each the letters O and I. This
character position has its own specific meaning—a specific piece of information relat- is done to avoid any
ing to the procedure, service, or treatment provided. You must read carefully because confusion between the
each section has its own particular use for the character. As always, in coding, you can letter O and the number
never assume! 0 (zero), as well as any
Let’s begin with the first, and largest, section of the ICD-10-PCS code set . . . Medical mix-up between the let-
and Surgical section, just as an example. You will learn all the details about this and all ter I and the number
of the other code set sections in the chapters that follow this one. In this section, the seven 1 (one).
characters describe, in order, the:
1. Section of the ICD-10-PCS code set.
2. Body system upon which the procedure or service was performed.
3. Root operation, which explains the category or type of procedure.
4. Body part, which identifies the specific anatomical site involved in the procedure.
5. Approach, which reports which method was used to perform the service or
treatment.
6. Device, which reports, when applicable, the type of device involved in the service
or procedure.
7. Qualifier, which adds any additional detail.
Let’s go through each of these character positions, one by one, to understand what
each represents. To help illustrate these data points, we are going to use a snippet from
an operative report and build the code as an ongoing example:
Laparoscopic bypass, radial vein to ulnar vein, left, using autologous tissue
substitute
CHAPTER 32
Using this short statement as an example to work with, you are going to build the ICD-
CODING BITES 10-PCS code as you make your way through this chapter. You will learn how each
Using our example . . . character reports a part of the whole story about the specific procedure or service. This
Laparoscopic bypass should then help you understand how to build a code on your own.
You can tell from the
description that this is Section (First Character)
a surgical procedure, The first character in the seven-character sequence identifies the section of the ICD-
so this code is reported 10-PCS code set in which the procedure is listed. There are 17 section titles:
from within the Medical
and Surgical section of 0 Medical and Surgical
ICD-10-PCS. 1 Obstetrics
First character = 0 2 Placement
0 Medical and 3 Administration
Surgical 4 Measurement and Monitoring
5 Extracorporeal or Systemic Assistance and Performance
6 Extracorporeal or Systemic Therapies
7 Osteopathic
8 Other Procedures
9 Chiropractic
B Imaging
C Nuclear Medicine
D Radiation Therapy
F Physical Rehabilitation and Diagnostic Audiology
G Mental Health
H Substance Abuse Treatment
X New Technology
EXAMPLES
An ankle x-ray is an imaging procedure—Section B
A breech extraction is an obstetrics procedure—Section 1
An amputation is a surgical procedure—Section 0
CODING BITES
Using our example . . . radial vein to ulnar vein
Remember learning this in anatomy class? Don’t worry if you don’t; use that anat-
omy resource now. Then, you will know, for certain, that these veins are located
in the arm (upper extremity). Therefore, your second character will report a proce-
dure that was performed on the patient’s upper veins.
First character = 0
Second character = 5
0 Medical and Surgical
5 Upper veins
CHAPTER 32
TABLE 32-1 The Other Sections of ICD-10-PCS and Their Body Systems
CODING BITES
Using our example . . . bypass
Yes, sometimes it really is this easy. The physician uses the same term for the pro-
cedure as the ICD-10-PCS code book does.
First character = 0
Second character = 5
Third character = 1
0 Medical and Surgical
5 Upper veins
1 Bypass
NOTE: They are not all this easy. More to help you interpret root operation terms
in the upcoming chapters.
CHAPTER 32
by the section and body system. This is one of the reasons the Alphabetic Index will
not usually reach this level of specificity.
CODING BITES
Using our example . . . radial vein to ulnar vein, left
You can see how the details are built into the code.
The radial and ulnar veins are both specifically grouped into the category of
brachial veins. Again, If you did not know this offhand, don’t worry. Check your
medical dictionary or anatomy reference. This is one of the wonderful aspects of
being a coder; you can always use your resources to ensure accuracy.
Character 4 will provide the more specific detail, including laterality (right or left).
First character = 0
Second character = 5
Third character = 1
Fourth character = A
0 Medical and Surgical
5 Upper veins
1 Bypass
A Brachial vein, left
CODING BITES
Using our example . . . Laparoscopic
This detail must be provided by the physician in his or her operative notes. The
words may not be identical, so you will have to understand the meaning so you
can interpret.
A laparoscope is an endoscope inserted through an incision in the abdominal
wall (percutaneously), used to visualize the interior of the peritoneal cavity. There-
fore, you would interpret this as a PERCUTANEOUS ENDOSCOPIC approach.
First character = 0
Second character = 5
Third character = 1
Fourth character = A
Fifth character = 4
0 Medical and Surgical
5 Upper veins
1 Bypass
A Brachial vein, left
4 Percutaneous endoscopic
More about the specific approaches coming up in the following chapters.
CODING BITES
Using our example . . . using autologous tissue substitute
For the sixth character, you need to read the notes to determine if any devices,
substances, or other components were used. First, check your ICD-10-PCS sec-
tion to familiarize yourself with what type of details this character, in this table, will
report. Then, you will know what to look for in the documentation.
Here, in our example code, you have already determined that you are work-
ing with the 051 Table in ICD-10-PCS. In this table, the sixth character reports a
device, something that will remain in, or with, the patient after the procedure is
completed. Look at the options you have for the sixth character in this table: tissue
substitutes of various origins. Autologous tissue substitute was used during the
bypass to support the rerouting of the vein.
First character = 0
Second character = 5
Third character = 1
Fourth character = A
Fifth character = 4
Sixth character = 7
0 Medical and Surgical
5 Upper veins
1 Bypass
A Brachial vein, left
4 Percutaneous endoscopic
7 Autologous tissue substitute
Some sections of ICD-10-PCS, such as the Administration section, will have you
report a category of substance, such as anti-inflammatory or antineoplastic, with
the sixth character. When you are working in that section, keep your pharmacol-
ogy reference close at hand.
More about this in the following chapters.
CODING BITES
Using our example . . . to ulnar vein
In this case, there is one more detail that must be explained . . . to what anatomical
site was the radial vein rerouted, or bypassed “to”—a different upper vein.
(continued)
CHAPTER 32
As you have seen throughout this textbook, GUIDANCE CONNECTION icons
direct you to official guidelines that will help you make accurate determinations
for each character. For this case, Guideline B3.6a directs you to specify the body
part bypassed from for the fourth character and the body part bypassed to for the
seventh character. In this table, you only have one choice. However, there may be
occasions in the future where this reminder will come in handy. Good thing these
guidelines are always right there, in the front of your code book.
First character = 0
Second character = 5
Third character = 1
Fourth character = A
Fifth character = 4
Sixth character = 7
Seventh character = Y
0 Medical and Surgical
5 Upper veins
1 Bypass
A Brachial vein, left
4 Percutaneous endoscopic
7 Autologous tissue substitute
Y Upper vein
Again, you will need to look at the table within the section of ICD-10-PCS first to
discover what detail or type of detail this character of this code will report. As you
read earlier, sometimes there is nothing left to share, so you will use the letter
Z No Qualifier.
Don’t worry. More about this all coming in the next chapters.
Placeholder Characters
The letter Z means “not applicable” or “none.” The Z placeholder will be used most
often as the seventh character; however, it can be used in any of the seven character
positions, when needed. It can also be used in multiple positions in one code.
EXAMPLE
Dr. McCoy performed a biopsy on Clark’s neck. The ICD-10-PCS code to report
this would be 0WB6XZX . . .
0 = Medical and Surgical
W = Anatomical regions, general
B = Excision
6 = Neck
X = External
Z = No device
X = Diagnostic
There is no device, so there is nothing to report in the sixth character position. But
you can’t leave that part of the code out. So you put a Z in that spot and report
that there is no device.
EXAMPLE
Dr. Rothwell used a percutaneous endoscope in an attempt to control post-
procedural bleeding in Isaac’s colon, after several polyps had been removed. The
ICD-10-PCS code to report this would be 0W3P4ZZ . . .
EXAMPLES
Root operation terms include bypass, drainage, excision, and insertion.
After you find the root operation term, as stated in the documentation, there are
subentries listed by the following:
∙ Body system
EXAMPLES
Digestive system
Musculoskeletal system
∙ Body part
EXAMPLES
Arm, leg, hand, foot
CHAPTER 32
EXAMPLES
Hysterectomy is listed and then cross-referenced to resection (a root operation
term) and female reproductive system (body system).
Roux-en-Y operation is listed and then cross-referenced to bypass (a root
operation term) and gastrointestinal system or hepatobiliary system and pancreas
(both are body systems).
The Alphabetic Index will usually give you only the first three or four characters of
the seven-character procedure code. You then must go to the Tables to find the addi-
tional characters. You won’t have to be reminded to never code from the Alphabetic
Index with ICD-10-PCS. Often, you won’t be able to code from the Alphabetic Index
alone anymore!
EXAMPLE
Fragmentation
Of the Bladder 0TF8-
For the most part, you will find that the Alphabetic Index will include information
relating to the first three characters. This information will enable you to turn to the
correct page in the Tables and determine the rest of the characters for the code. As
you have seen, virtually all of the sections are consistent with the first three elements.
However, as you get to the last four characters, the information represented by these
characters may change, depending upon what type of procedure was performed or
upon what body system a procedure was performed. This is a major aspect of the flex-
ibility of the ICD-10-PCS system.
The Tables
The Tables are divided by body systems. Of course, like all the other code sets, each
section is in order by the first character in the code. Within each section’s body sys-
tem division, the list continues in order by the root operation term for that procedure.
Each section of the list has a grid that specifies the assigned meaning to each letter
or number along with its position in the seven-character code. (See an example in
Figure 32-2.)
You will go through the grid and construct the correct code based on the physi-
cian’s notes. As you have already learned, all ICD-10-PCS codes are seven characters.
Therefore, you will build the code in this order, as directed by the grid.
∙ First character: Section (such as Medical and Surgical, Mental Health, or
Imaging)
∙ Second character: Body system
∙ Third character: Root operation
∙ Fourth character: Body part or region
∙ Fifth character: Approach
∙ Sixth character: Device
∙ Seventh character: Qualifier
Therefore, when you review the information in Figure 32-2, you can see that the cor-
rect ICD-10-PCS code for Dilation of one site of a Coronary Artery, using an open
approach with an Intraluminal device is 02700DZ.
FIGURE 32-2 Table 027 from the Medical and Surgical Section 2018 ICD-10-PCS
ICD-10-PCS
LET’S CODE IT! SCENARIO
Jahlil Browne was playing football in the park with his friends. A player on the other team hit him at full force in the
chest when he ran to catch a pass. Jahlil was taken to the ED by ambulance and admitted into the hospital with an
open fracture of the third rib, right side. Dr. Wolf operated on Jahlil to insert an internal fixation device, using a per-
cutaneous endoscopic approach to secure the bone together so it can heal properly.
(continued)
CHAPTER 32
Below the main term, insertion, is a list. None of these terms seem to go with this situation. Wait a minute.
Right below this is a main term that does fit: Insertion of device in. Beneath this is a list of anatomical sites. What
anatomical site did the fixation device go onto? Rib. Find
Insertion of device in
Rib
Left 0PH2
Right 0PH1
These four characters are a good start. Remember, all ICD-10-PCS codes require seven (7) characters. You must
go to the Tables to confirm this is correct.
In the Tables, turn to the Medical and Surgical section: 0PH. Look carefully at the second row.
Section 0 Medical and Surgical
Body System P Upper Bones
Operation H Insertion
Body Region Approach Device Qualifier
1 Ribs, 1 to 2 0 Open 4 Internal Fixation Z No Qualifier
2 Ribs, 3 or more 3 Percutaneous Device
3 Cervical Vertebra 4 Percutaneous
4 Thoracic Vertebra Endoscopic
5 Scapula, Right
6 Scapula, Left
OK, let’s build a code:
The section: 0 Medical and Surgical (Dr. Wolf performed surgery on Jahlil)
The body system: P Upper Bones (the ribs are in the upper half of the body)
The root operation: H Insertion (Dr. Wolf inserted a fixation device)
The body part: 1 Ribs, 1 to 2 (as per the physician’s documentation)
The approach: 4 Percutaneous Endoscopic (the documentation states this approach)
The device: 4 Internal Fixation Device (this equipment will stay on Jahlil’s rib after the procedure
until it is healed)
The qualifier: Z No Qualifier
The ICD-10-PCS code to report the repair of Jahlil’s rib is 0PH144Z.
Good job!
ICD-10-PCS
LET’S CODE IT! SCENARIO
Montell was in a car accident and his right knee hit against the steering column. He was admitted into the hospital
and Dr. Tompkins took a high osmolar x-ray of his knee.
The section: B Imaging (you know that x-rays are a type of imaging)
The body system: Q Non-axial lower bones (non-axial means away from the central part of the body,
and you know that the knee is a lower bone)
The root operation: 0 Plain Radiography (also known as x-ray)
The body part: 7 Knee, Right (as per the physician’s notes)
The contrast: 0 High Osmolar (as per the physician’s notes)
The qualifier: Z None
The qualifier: Z None
CHAPTER 32
Appendices
The information shared in the appendices of your ICD-10-PCS code book can be very
valuable as you abstract documentation to interpret to the correct character as you
build your code. In addition to the definitions for each of the major components of the
ICD-10-PCS code, there are also examples, which may help your understanding. And
. . . they are right there in the back of your ICD-10-PCS code book!
Appendices
Components of the Medical and Surgical Approach Definitions
Root Operation Definitions
Comparison of Medical and Surgical Root Operations
Body Part Key
Body Part Definitions
CODING BITES Device Key and Aggregation Table
Device Definitions
Various publishers of
Substance Key/Substance Definitions
the ICD-10-PCS code
Sections B-H Character Definitions
book may present these
Hospital Acquired Conditions
appendices in a differ-
Answers to Coding Exercises
ent order. Don’t worry.
Procedure Combination Tables
The titles should stay
the same. Use the information in these appendices to support your determination of the accurate
characters and the correct ICD-10-PCS code.
EXAMPLE
The third character of the code specifies the root operation term.
GUIDANCE
CONNECTION A2. One of 34 possible values can be assigned to each axis of classification in
the seven-character code: they are the numbers 0 through 9 and the letters
In the front of your ICD- of the alphabet (except I and O because they are easily confused with the
10-PCS code book, numbers 1 and 0). The number of unique values used in an axis of classifica-
look for the page titled tion differs as needed.
ICD-10-PCS OFFICIAL
GUIDELINES FOR COD- When this convention refers to “34 possible values,” it is referring to the fact that
ING AND REPORTING. this code set uses letters of the American alphabet (letters A to Z minus O and I, so
Then, follow along as 26 letters minus 2 = 24 possible letters) plus 10 possible numbers (0–9) = 34 possibili-
we discuss the first sec- ties for each position in each code. And while there may be 34 possibilities, only what
tion, Conventions. is needed is used at this time. This means that this code set has lots of room to grow
and include new codes as they become a part of our standards of care.
A3. The valid values for an axis of classification can be added to as needed.
This convention means that this code set has lots of room to grow and include new
codes as they become a part of our standards of care.
EXAMPLE
If a significantly distinct type of device is used in a new procedure, a new device
value can be added to the system.
A4. As with words in their context, the meaning of any single value is a combina-
tion of its axis of classification and any preceding values on which it may be
dependent.
This convention tells you to interpret each meaning, not only according to each spe-
cific character’s definition, but also in combination with the meanings of the other
characters that are in that table, in that row. It is the total meaning that you must
look at, as well as each individual character. So, if once you put all seven characters
together, something doesn’t make sense, you need to read again.
EXAMPLE
The meaning of a body part value in the Medical and Surgical section is always
dependent on the body system value. The body part value 0 in the Central Ner-
vous body system specifies Brain; the body part value 0 in the Peripheral Nervous
body system specifies Cervical Plexus.
A5. As the system is expanded to become increasingly detailed, over time more
values will depend on preceding values for their meaning.
This convention means that they will continue to expand the system and ensure that
new characters added will not overlap or duplicate the meanings of characters that
already exist in that table, in the row.
EXAMPLE
In the Lower Joints body system:
• Under the root operation Insertion: Table 0SH
Device character 6: value 3 specifies “Infusion Device”
• Under the root operation Replacement: Table 0SR
Device character 6: value 3 specifies “Synthetic Substitute, Ceramic”
A6. The purpose of the Alphabetic Index is to locate the appropriate table that
contains all information necessary to construct a procedure code. The PCS
tables should always be consulted to find the most appropriate valid code.
Essentially, this convention is telling you what you may have learned when coding from
other code sets. Never report a code from the Alphabetic Index. Always refer to the tables
and double-check the meaning for each and every character in that table, in that row.
CHAPTER 32
A7. It is not required to consult the Index first before proceeding to the Tables
to complete the code. A valid code may be chosen directly from the Tables.
This takes convention A6 a little further in telling you that you are NOT required to
ever look in the Alphabetic Index. As you gain more experience, and you are on the
job, you may learn your way through this code set. So, if you are coding for the labor
and delivery services to a pregnant woman, you can go directly to the Obstetrics
tables without looking in the Alphabetic Index if you don’t need the suggestion. And
if you are coding for a psychiatrist providing care to a patient in a behavioral health
hospital, you can go directly to the Mental Health tables.
A8. All seven characters must be specified to be a valid code. If the documenta-
tion is incomplete for coding purposes, the physician should be queried for
the necessary information.
Every character in every code must report the facts, as supported by the physician’s
documentation. If any detail is missing, and you are not able to determine the correct
character, then you must query the physician to have the documentation amended. You
can never assume and never guess.
A9. Within a PCS Table, valid codes include all combinations of choices in char-
acters 4 through 7 contained in the same row of the table. In the example
below, 0HTWXZZ is a valid code, and 0HTW0ZZ is not a valid code.
Section 0 Medical and Surgical
Body System H Skin and Breast
Operation T Resection: Cutting out or off, without replacement, all
of a body part
Body Part Approach Device Qualifier
Q Finger Nail X External Z No Device Z No Device
R Toe Nail
W Nipple, Right
X Nipple, Left
T Breast, Right 0 Open Z No Device Z No Device
U Breast, Left
V Breast, Bilateral
Y Supplemental Breast
This convention tells you how to read the table to build your code. Once you find the
table with the correct first three characters (section, body system, root operation term),
then go down the column to find the correct 4th character. Once you determine this
accurate character, you can only go across in that one row. If you determine that the
procedure was done on the right nipple (character W in the first row), then you only
have one option for the approach: X External. If the documentation states an open
approach was used, then you cannot put 0 Open with W Nipple, Right because they
are on two different rows. This would highlight to you that you need to go back to the
documentation because you can’t build this code from more than one row.
A10. “And,” when used in a code description, means “and/or.”
Take a look at an example: Knee Bursa and Ligament. You would interpret this as
Knee Bursa and Ligament
Knee Bursa
Knee Ligament
EXAMPLE
Lower Arm and Wrist Muscle means lower arm and/or wrist muscle.
EXAMPLE
When the physician documents “cauterization,” the coder can independently cor-
relate “cauterization” to the root operation “destruction” without querying the phy-
sician for clarification.
CHAPTER 32
Chapter Summary
CHAPTER 32 REVIEW
CODING BITES
Additional information The purpose of this chapter is to provide an overview of ICD-10-PCS, giving you an
about ICD-10-PCS can idea of what to expect, and to help you establish a comfort level so that you are not
be found at: apprehensive about the new system. This chapter shared with you the distinct benefits
https://www.cms. of this code set. Then, step by step, the chapter differentiated the way the codes look
gov/Medicare/Coding/ and are constructed. The notations and explanations, exclusive to ICD-10-PCS, are all
ICD10/2018-ICD-10- reviewed. Examples are provided to illustrate the concepts and elements throughout
PCS-and-GEMs.html the chapter.
CHAPTER 32 REVIEW
Introduction to ICD-10-PCS Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
CHAPTER 32 REVIEW
a. body part. b. root operation term.
c. medical procedure. d. body system.
7. LO 32.2 The 17 sections of ICD-10-PCS are identified by
a. numbers 1–17. b. numbers 0–9, then letters B–H and X.
c. letters A–Z. d. alphabetic order by the name of the section.
8. LO 32.2 Placeholders are indicated in ICD-10-PCS with
a. the number 0. b. the letter X.
c. the letter Z. d. the number 9.
9. LO 32.2 An example of an approach is
a. open. b. ileostomy.
c. pacemaker. d. ventricular.
10. LO 32.2 An example of a device, for purposes of ICD-10-PCS coding, is
a. ablation. b. laparoscopy.
c. pacemaker. d. allotransplantation.
11. LO 32.2 The ICD-10-PCS code for the provision of a cesarean section would be found in
a. Section 2 Placement. b. Section 1 Obstetrics.
c. Section B Imaging. d. Section 6 Extracorporeal Therapies.
12. LO 32.2 Coding a chiropractic manipulative treatment would begin in
a. Section 0 Medical and Surgical.
b. Section 4 Measurement and Monitoring.
c. Section 7 Osteopathic.
d. Section 9 Chiropractic.
13. LO 32.2 What is the letter or number that represents the device in code 2W22X4Z?
a. 2 b. W
c. 4 d. X
14. LO 32.2 What is the letter or number that represents the approach in code 3E00X3Z?
a. E b. X
c. 0 d. Z
15. LO 32.2 What is the letter or number that represents the root operation in code 3E1S38Z?
a. 1 b. S
c. 8 d. E
16. LO 32.2 What is the letter or number that represents the section in code 2W10X7Z?
a. 2 b. W
c. 1 d. 0
17. LO 32.2 What is the letter or number that represents the qualifier in code 3E0Y70M?
a. 0 b. Y
c. 7 d. M
18. LO 32.3 The Alphabetic Index will usually give you only the first ________ or ________ characters of the
seven-character procedure code.
a. one, two b. two, three
c. three, four d. five, six
CHAPTER 32
19. LO 32.4 Which ICD-10-PCS general convention states that within a PCS table, valid codes include all combina-
CHAPTER 32 REVIEW
tions of choices in characters 4 through 7 contained in the same row of the table?
a. A1 b. A3
c. A6 d. A9
20. LO 32.5 ICD-10-PCS does not have guidelines for determining the sequencing when reporting more than one
procedure provided during an encounter.
a. True b. False
ICD-10-PCS
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documentation
from our health care facility, Westward Hospital. These case studies are modeled on real patient encounters. Using
the techniques described in this chapter, carefully read through the case studies and determine the most accurate
answers for each case study.
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PATIENT: WELLINGTON, ALISHA
DATE OF ADMISSION: 03/13/18
DATE OF SURGERY: 03/13/18
DATE OF DISCHARGE 03/14/18
PRE-OPERATIVE DX: Right ureteral obstruction secondary to colon cancer
POST-OPERATIVE DX: Same
PROCEDURE: Cystoscopy
Right retrograde pyelogram
Removal and replacement of double-J stent
ANESTHESIA: General
HISTORY/INDICATIONS: This is a 39-year-old female with a history of colon cancer and secondary right
ureteral obstruction who had a stent inserted a number of months ago. At this time, she is in the hospital
and it is time for a stent change. Consequently, the patient presents for the procedure.
In Dr. Johnston’s documentation of Alisha Wellington’s procedure, what is/are the root operation term(s)?
a. Replacement
b. Fluoroscopy
c. Replacement and fluoroscopy
d. Removal
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PATIENT: FIELDING, STEPHEN
DATE OF ADMISSION: 07/15/18
DATE OF SURGERY: 07/15/18
DATE OF DISCHARGE: 07/16/18
PRE-OPERATIVE DX: Superior canalicular laceration
POST-OPERATIVE DX: Same
PROCEDURE: Superior canalicular repair
This patient is a 3-year-old male who is admitted into the Pediatric Unit with a dog bite to left side of face.
HPI: Approximately 3 hours ago, patient was playing with a large dog, the pet of a neighbor. Family wit-
nessed the dog make a single lunge at the boy’s face. Due to the adults’ attempts to intervene, only the
top jaw made contact. The dog did not attack further, and the incomplete bite to the left face was the
only injury sustained. Ophthalmology called in for consult.
POH/PMH/SH: No past ocular history. No past medical history. No current medications or allergies.
Well-adjusted preschool child lives at home with both parents. Childhood immunizations are up-to-date,
according to the mother.
OCULAR EXAM:
• VA 20/25 OD and OS without correction
CHAPTER 32
CHAPTER 32 REVIEW
In Dr. Kernan’s documentation of the procedure on Stephen Fielding, what is the root operation term?
a. Repair
b. Eyelid
c. Canalicular
d. Bite
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PATIENT: O’LEARY, KEVIN
DATE OF ADMISSION: 03/05/18
DATE OF DISCHARGE: 03/17/18
PRE-OPERATIVE DX: Third-degree burn, neck
POST-OPERATIVE DX: Same
PROCEDURE: Skin graft
ANESTHESIA: General
This patient is a 43-year-old male who works as a county firefighter. He is recovering from third-degree
burns on his neck. He was admitted today for the first session of skin grafting. Patient is brought into the
surgical suite and general anesthesia is administered by Dr. Rambeau. Once the patient is unconscious,
he is prepped and draped in the usual, sterile fashion. A split-thickness autograft, which contains the
dermis with only a portion of the epidermis, is taken from a donor site on the patient’s inner thigh, left.
The graft harvested is 11/1000ths of an inch in thickness, using a derma-tome. The graft is carefully
spread on the bare area and held in place with surgical staples. Plasmatic imbibition is initiated. The
graft is meshed with lengthwise rows of short, interrupted cuts, each a few millimeters long, with each
What is/are the root operation term(s), as documented in Dr. Johnston’s procedure notes for Kevin O’Leary?
a. Excision
b. Excision and replacement
c. Replacement and neck
d. Neck
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PATIENT: SWANSONN, HANS
DATE OF ADMISSION: 05/23/18
DATE OF DISCHARGE: 05/23/18
PRE-OPERATIVE DX: Rule out bladder tumor
POST-OPERATIVE DX: Same
PROCEDURE: Cystoscopy, biopsy, and fulguration of bladder
ANESTHESIA: Spinal
INDICATIONS: The patient is a 67-year-old male with a history of grade II superficial transitional cell
carcinoma of the bladder. Cystoscopy showed a suspicious erythematous area on the right trigone. He
presented today for cystoscopy, biopsy, and fulguration. Findings: The urethra was normal; the bladder
was 1+ trabeculated; the mid and right trigone areas were slightly erythematous and hypervascular. No
papillary tumors were noted; no mucosal abnormalities were noted.
PROCEDURE: The patient was placed on the table in supine position. Satisfactory spinal anesthesia was
obtained. He was placed in dorsal lithotomy position and prepped sterilely with Hibiclens and draped in
the usual manner. A #22 French cystoscopy sheath was passed per urethra in atraumatic fashion. The
bladder was resected with the 70-degree lens with findings as noted above. Cup biopsy forceps were
placed and three biopsies were taken of the suspicious areas of the trigone. These areas were fulgu-
rated with the Bugby electrode; no active bleeding was seen. The scope was removed; the patient was
returned to recovery having tolerated the procedure well. Estimated blood loss was minimal.
What is the root operation term identified in Dr. Kernan’s procedure notes about Hans Swansonn?
a. Diagnostic
b. Excision
c. Bladder
d. Endoscopic
CHAPTER 32
CHAPTER 32 REVIEW
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PATIENT: ZANDER, MARISSA
DATE OF ADMISSION: 02/16/18
DATE OF DISCHARGE: 02/18/18
PRE-OPERATIVE DX: Delivery
POST-OPERATIVE DX: Same
PROCEDURE: Cesarean section, classical
In the 40th week of her first pregnancy, a 29-year-old female arrived at labor and delivery at 0830 for a
planned induction of labor due to mild, pregnancy-induced hypertension. After intra-vaginal placement
of misoprostol, the nurse observed her briefly and, at 1100, discharged her from the unit. She went for
a walk with her husband in a park next to the hospital. Patient’s membranes spontaneously ruptured
and she readmitted to the labor and delivery unit. The nurse admitted the patient, took her vital signs,
and checked the fetal heart rate. The mother’s blood pressure was 176/95, but the nurse thought this
was related to nausea, vomiting, and discomfort from the contractions. The resident examined the
mother, determined that her cervix was 5–6 cm, 90 percent effaced, and the vertex was at 0 station.
An internal fetal heart monitor was placed because the mother’s vomiting and discomfort caused her to
move around too much in the bed, making it hard to record the fetal heart rate with an external moni-
tor. The internal monitor revealed a steady fetal heart rate of 120 and no decelerations. The mother
continued to complain of painful contractions and requested an epidural. Shortly after placement of
the epidural, the monitor recorded a prolonged fetal heart rate deceleration. The heart rate returned
slowly to the baseline rate of 120 as the nurse repositioned the mother, increased her intravenous
fluids, and administered oxygen by mask. An epidural analgesia infusion pump was started. The fetal
heart rate strip indicated another deceleration that recovered to baseline. The nurse informed the resi-
dent, who checked the tracing and told her to “keep an eye on things.” The primary nurse noted in the
labor record that the baseline fetal heart rate was “unstable, between 100–120,” but she did not report
this to the resident. The nurse recorded that the fetal heart rate was “flat, no variability.” As the nurse
was documenting this as a non-reassuring fetal heart rate pattern, the patient expressed a strong urge
to push and the nurse called for an exam. A resident came to the bedside, examined the mother, and
noted that she was fully dilated with the caput at +1. A brief update was written in the chart, but the cli-
nician who had performed the exam was not noted. The mother was repositioned and began pushing.
The fetal heart rate suddenly dropped and remained profoundly bradycardic for 11 minutes. The resi-
dent was called and attempted a vacuum delivery since the fetal head was at +2 station. The attending
then entered and attempted forceps delivery. An emergency classical cesarean delivery was performed;
the baby was stillborn. The physician identified a uterine rupture that required significant blood replace-
ment. Whole blood transfusion, nonautologous, was performed, via peripheral vein.
Roxan Kernan, MD—4444
556848/mt98328: 07/17/18 09:50:16 T: 07/17/18 12:55:01
In Dr. Kernan’s documentation on the procedure performed on Marissa Zander, identify the root operation term(s).
a. Extraction
b. Transfusion
c. Percutaneous
d. Extraction and transfusion
EXAMPLES
Dr. Franklin inserted a neurostimulator lead into Matthew Short’s cerebrum, during
an open procedure.
The Body System is reported: Central Nervous System and Cranial Nerves with
a 0 (zero) character.
Identify which body system this anatomical site would report for the second character.
1. Umbilical artery: _____
2. Cervical lymph node: _____
3. Cornea: _____
4. Pharynx: _____
5. Stomach: _____
6. Deltoid muscle: _____
7. Zygomatic process of frontal bone: _____
8. Coccyx: _____
9. Elbow Joint: _____
10. Trachea: _____
CHAPTER 33 |
33.2 Medical/Surgical Root Operations:
Character 3
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated
3 Root operation term
4 Body part (specific anatomical site)
5 Approach used by physician
6 Device
7 Qualifier
Root Operation Term The Medical and Surgical Section uses 31 root operation terms to describe what
The category or classification procedure was performed for the patient during this encounter. Don’t worry—the defi-
of a particular procedure, ser- nitions are listed in the ICD-10-PCS code book. However, you still need to learn and
vice, or treatment. understand them so that you can abstract the operative report or procedure notes accu-
rately and completely from the documentation. Remember that you are required to use
the ICD-10-PCS term definition in its entirety. Also, just as in reporting with CPT pro-
cedure codes, it is important that you understand all of the components of a specific root
operation or procedure. You don’t want to code inclusive components separately or miss
a second code because a component is not part of that procedure automatically. Using
GUIDANCE the root operation term is the most efficient way of using the Alphabetic Index as well.
CONNECTION
Read the ICD-10-PCS Alteration
Official Guidelines for Alteration: Modification of a natural anatomic structure of a body part without
Coding and Reporting, affecting the function of the body part . . . Character: 0 (zero)
Medical and Surgical
Section Guidelines
(Section 0), sub- EXAMPLE
head B3. Root Opera- Alteration is a procedure most often performed for cosmetic purposes, to improve
tion, paragraphs B3.1a the patient’s appearance, such as a face lift.
through B3.16. Rhytidectomy (face lift surgery) is a procedure performed to alter the look of
the skin on the face. Liposuction and breast augmentation are also examples of
this type of procedure.
0J013ZZ Alteration of subcutaneous tissue and fascia, face, percutaneous
approach
Bypass
GUIDANCE Bypass: Altering the route of the contents of a tubular body part . . . Character: 1
CONNECTION Bypass procedures are coded by identifying the body part bypassed “from,” identified
Read the ICD-10-PCS by character 4 (Body Part), and the body part bypassed “to,” identified by character 7
Official Guidelines for (Qualifier).
Coding and Reporting,
Medical and Surgical EXAMPLE
Section Guidelines
A bypass can be performed only on a tubular body part, such as a vein or an artery, the
(Section 0), subhead
esophagus, or the intestines. A colostomy formation is another example of a bypass.
Bypass Procedures,
paragraphs B3.6a, 02114Z8 Coronary artery bypass, one site, percutaneous endoscopic
B3.6b, and B3.6c. approach, rerouted to internal mammary, right side
EXAMPLE
Change is a root operation only used when a device is involved in the procedure—
a device that stays with the patient after the procedure is complete. A urinary cath-
eter change or gastronomy tube change are good examples. Often, this term will
actually be used in the documentation.
0020X0Z Changing a drainage device in the brain, external approach
Control GUIDANCE
CONNECTION
Control: Stopping, or attempting to stop, postprocedural or other acute bleeding
. . . Character: 3 Read ICD-10-PCS
Official Guidelines for
The root operation term Control is used only when the only action taken during this Coding and Reporting,
procedure is the intent to stop the hemorrhage. If this attempt was unsuccessful and Medical and Surgical
another procedure was performed to accomplish this task, such as excision or resec- Section Guidelines
tion, then report the code for that root operation instead of Control. You will not report (Section 0), sub-
both. head Control vs. More
Definitive Root Opera-
tions, paragraph B3.7.
EXAMPLE
Control is a procedure to stop massive bleeding (hemorrhaging).
0W3B0ZZ Control post-procedural bleeding in the pleural cavity, left side,
open approach
Creation
Creation: Putting in or on biological or synthetic material to form a new body part
that to the extent possible replicates the anatomic structure or function of an
absent body part . . . Character: 4
This procedure is used when the physician actually makes a new structure, such as
creation of an artificial vagina during a male-to-female procedure in a gender reas-
signment surgery, procedures to correct congenital anomalies, or replacement of a
dysfunctional heart valve.
EXAMPLES
Creation of a body part, such as a penis or a heart valve, is reported with this root
operation term.
0W4N0J1 Creation of an artificial penis using synthetic substitute, open
approach
024G082 Creation of a mitral valve using zooplastic tissue, open approach
Destruction
Destruction: Physical eradication of all or a portion of a body part by the direct
use of energy, force, or a destructive agent . . . Character: 5
CHAPTER 33 |
Several methodologies are reported as destruction, such as fulguration, the application
of high-frequency electrical current, also known as electrofulguration, when it is used
to destroy tissue (typically malignant neoplasm). Chemical agents, such as salicylic
acid, can also be used to destroy tissue.
EXAMPLE
Destruction is used to describe when the tissue is no longer in existence, and
there is no specimen to send to pathology.
Terms that may be used in the documentation include fulguration, cauteriza-
tion, and cryosurgery.
0U5B8ZZ Fulguration of endometrium, vaginal endoscopic approach
Detachment
Detachment: Cutting of all or a portion of the upper or lower extremities . . .
Character: 6
This is the root operation term for amputation of an arm or a leg, in whole or in part.
EXAMPLE
Detachment is only used to report the amputation of an arm or leg, no other body
part.
0Y6J0Z1 Amputation, directly below knee, left leg, open approach
Dilation
Dilation: Expanding an orifice or the lumen of a tubular body part . . . Character: 7
Remember, an orifice is a natural body opening (such as vagina or anus) and the lumen
of a tubular body part (lumen = “space within the tube”). Blood vessels are tubular
body parts, as are a woman’s fallopian tubes.
EXAMPLES
Dilation is the process of opening a closed tubular body part.
037H34Z Dilation of right common carotid artery, with drug-eluting intralu-
minal device, percutaneous approach
0U7C7ZZ Dilation of the cervix, via natural opening
Division
Division: Cutting into a body part, without draining fluids and/or gases from the
body part, in order to separate or transect a body part . . . Character: 8
EXAMPLE
Division is the separation of body parts.
An episiotomy, an osteotomy, and spinal cordotomy are all good examples.
0K820ZZ Division of sternocleidomastoid muscle, right side, open
approach
EXAMPLE
Drainage is, as it sounds, the process of helping gases or fluids escape.
0W9B30Z Drainage of excess air from left pleural cavity, percutaneous
approach
Excision
GUIDANCE
Excision: Cutting out or off, without replacement, a portion of a body part . . . CONNECTION
Character: B
Read the ICD-10-PCS
Pay close attention to this description of excision. This term has a narrower meaning Official Guidelines for
in ICD-10-PCS than it does in CPT and in many physicians’ notes. Excision is used in Coding and Report-
ICD-10-PCS only when a segment is cut out. This includes obtaining a tissue biopsy, ing, Medical and
performing a lumpectomy, and cutting out a bone spur. However, if the entire organ or Surgical Section
body part is removed, the root operation term used is Resection (even if the physician Guidelines (Section
documents that an organ was excised—you must interpret it). 0), subheads Exci-
sion vs. Resection,
EXAMPLE paragraph B3.8, and
Excision for Graft,
Excision is the surgical removal of a part or portion of a body part, not the entire
paragraph B3.9.
organ.
0FB13ZX Excision, liver, right lobe, percutaneous approach, diagnostic
procedure
Extirpation
Extirpation: Taking or cutting out solid matter from a body part . . . Character: C
This reference to “solid matter” may indicate a blood clot or gallstones when surgi-
cally removed.
EXAMPLE
Extirpation is the surgical removal of a solid formation from within the body.
Some good examples are thrombectomy (surgical removal of a blood clot attached
to the wall of a vein or artery) and cholelithotomy (surgical removal of gallstones).
04CL0ZZ Extirpation of thrombus, femoral artery, left side, open approach
Extraction
Extraction: Pulling or stripping out or off all or a portion of a body part by the use
of force . . . Character: D
EXAMPLE
Extraction may be done by scraping (curettage), pulling, suction, or other process.
Vein stripping, D&C (dilation and curettage), and a cesarean section (extracting
a baby from the womb) are all good examples.
0UDB8ZZ Suction extraction of endometrium, via natural opening, endo-
scopic approach
CHAPTER 33 |
Fragmentation
Fragmentation: Breaking solid matter in a body part into pieces . . . Character: F
An example of fragmentation is lithotripsy—the use of shock waves to break kidney
stones (renal lithiasis) into smaller pieces with the hope that the body will be able to
pass them naturally.
EXAMPLE
Fragmentation is the process of breaking up something in the body into smaller
pieces, such as the procedure of lithotripsy.
0TFCXZZ Fragmentation of stones in the bladder neck, using external
approach
GUIDANCE
CONNECTION Fusion
Read the ICD-10-PCS Fusion: Joining together portions of an articular body part rendering the articular
Official Guidelines for body part immobile . . . Character: G
Coding and Reporting, Arthrodesis, the surgical immobilization of a joint, such as of the spine, is one type of
Medical and Surgical fusion (articular = “joint”).
Section Guidelines
(Section 0), sub-
head Fusion Proce- EXAMPLE
dures of the Spine, Fusion is a procedure that is opposite of division.
paragraphs B3.10a,
0RG40A0 Fusion of cervicothoracic vertebral joint, open procedure,
B3.10b, and B3.10c.
anterior approach, anterior column, using an interbody fusion
device
Insertion
Insertion: Putting in nonbiological appliance that monitors, assists, performs, or
prevents a physiological function but does not physically take the place of a
body part . . . Character: H
This is another opportunity for reading very carefully. In ICD-10-PCS, this root oper-
ation applies only to the placement into the body of a medical device, such as a pace-
maker, that will remain in the body after the procedure is completed.
EXAMPLE
Insertion is the placing of a device into the body.
GUIDANCE 05H933Z Insertion of catheter (infusion device) into right brachial vein,
percutaneous approach
CONNECTION
Read the ICD-10-PCS
Official Guidelines for
Inspection
Coding and Report- Inspection: Visually and/or manually exploring a body part . . . Character: J
ing, Medical and
This root operation term is limited to the physician’s looking at the body part.
Surgical Section
Guidelines (Section
0), subhead Inspec- EXAMPLE
tion Procedures, para- Inspection in this case is just like the English word . . . to look at.
graphs B3.11a, B3.11b,
and B3.11c. 09JEXZZ Inspection of the left inner ear, external approach
EXAMPLE
Map is a methodology that enables the physician to obtain a record of the func-
tion of a specific anatomical part.
00K03ZZ Mapping of brain function, percutaneous approach
GUIDANCE
Occlusion CONNECTION
Occlusion: Completely closing an orifice or lumen of a tubular body part . . . Char- Read the ICD-10-PCS
acter: L Official Guidelines for
There are times when an opening, such as a fistula, or a tubular body part, such as a Coding and Reporting,
fallopian tube, is purposely closed off or blocked. Medical and Surgical
Section Guidelines
(Section 0), sub-
EXAMPLE head Occlusion vs.
Occlusion is the opposite of dilation. Restriction for Vessel
Embolization Proce-
0VLH4ZZ Occlusion of spermatic cords, bilaterally, percutaneous endo- dures, paragraph B3.12.
scopic approach, no device
Reattachment
Reattachment: Putting back in or on all or a portion of a separated body part to
its normal location or other suitable location . . . Character: M
This word is the same as the term most often used by physicians for this procedure,
such as reattaching a finger after it has been severed during an accident.
EXAMPLE
Reattachment is reported for anatomical sites only.
0XMP0ZZ Reattachment of left index finger, open approach
Release GUIDANCE
CONNECTION
Release: Freeing a body part from an abnormal physical constraint by cutting or
by use of force . . . Character: N Read the ICD-10-PCS
Official Guidelines for
The procedure reported with this root operation term involves cutting or separation Coding and Report-
only, such as tendon lengthening, in order to free a body part from some type of ing, Medical and
restriction. Surgical Section
Guidelines (Section
EXAMPLE 0), subheads Release
Procedures, para-
Release is similar to division, so be careful to read the descriptions and the docu-
graph B3.13, and
mentation very carefully.
Release vs. Division,
0LNS0ZZ Release of right ankle tendon, open approach paragraph B3.14.
CHAPTER 33 |
Removal
Removal: Taking out or off a device from a body part . . . Character: P
Read this carefully: As the description specifically states “device,” this can be used
only for this type of procedure—to remove a previously inserted device. As you
abstract the physician’s notes, be cautious of the use of this term in documentation.
The removal of a mole, for example, is really an excision, not a removal.
EXAMPLE
Removal is only used when a device has been removed.
0QP304Z Removal of internal fixation device from left pelvic bone, open
approach
Repair
Repair: Restoring, to the extent possible, a body part to its normal anatomic
structure and function . . . Character: Q
EXAMPLE
Repair is often the therapeutic process of correcting an abnormality.
0CQV8ZZ Repair of left vocal cord, via natural opening, endoscopic
approach
Replacement
Replacement: Putting in or on biological or synthetic material that physically takes
the place and/or function of all or a portion of a body part . . . Character: R
Essentially, this is the placement of a prosthetic device, such as a hip replacement or a
prosthetic heart valve.
EXAMPLE
Replacement is directly related to the use of internal prosthetics.
02RG0JZ Replacement of mitral valve with synthetic prosthesis, open
approach
GUIDANCE Reposition
CONNECTION Reposition: Moving to its normal location or other suitable location all or a por-
tion of a body part . . . Character: S
Read the ICD-10-PCS
Official Guidelines for
Coding and Reporting, EXAMPLE
Medical and Surgical Reposition is the correction that is usually employed with a patient who has a
Section Guidelines dislocation.
(Section 0), sub-
head Reposition for 0PSFXZZ Reposition humeral shaft, right side, external approach
Fracture Treatment,
paragraph B3.15. Resection
Resection: Cutting out or off, without replacement, all of a body part . . .
Character: T
EXAMPLE
Restriction is a surgical methodology for limiting the function, or malfunction, of an
anatomical site.
0DV44CZ Restriction of esophagogastric junction, using extraluminal
device, percutaneous endoscopic approach
Revision
Revision: Correcting, to the extent possible, a portion of a malfunctioning device
or the position of a displaced device . . . Character: W
Again, pay careful attention to the word device. This root operation term can only be
used when a medical device is being fixed.
EXAMPLE
Revision is correcting the internal positioning of a device.
02WA0MZ Revision of cardiac lead, open approach
Supplement
Supplement: Putting in or on biological or synthetic material that physically
reinforces and/or augments the function of a portion of a body part . . .
Character: U
Note: In the Tables section, supplement is in alphabetic order by its character U, not by
the term supplement, so it falls between resection and restriction.
EXAMPLES
Supplement, just as in English, is something that provides support.
0TUB4JZ Supplementation of bladder, percutaneous endoscopic
approach, using synthetic mesh
0YUA47Z Use of autologous tissue substitute mesh to repair an inguinal
hernia laparoscopically, bilateral
CHAPTER 33 |
Transfer
Transfer: Moving, without taking out, all or a portion of a body part to another
location to take over the function of all or a portion of a body part . . . Charac-
ter: X
EXAMPLE
Transfer is the process when the body part transferred still remains connected to
its original vascular and nervous supply.
0JX03ZB Transfer of skin and subcutaneous tissue, scalp, percutaneous
approach
Transplantation
GUIDANCE
Transplantation: Putting in or on all or a portion of a living body part taken from
CONNECTION another individual or animal to physically take the place and/or function of all
Read the ICD-10-PCS or a portion of a similar body part . . . Character: Y
Official Guidelines for ICD-10-PCS uses this term in the same manner that physicians do. However, this
Coding and Reporting, includes more than just organ transplant procedures.
Medical and Surgical
Section Guidelines
(Section 0), sub- EXAMPLE
head Transplantation Transplantation is the implanting of a donor body organ into a recipient.
vs. Administration,
paragraph B3.16. 0TY00Z0 Transplant of an allogeneic right kidney, open approach
Practice interpreting from the common procedure terms used to reference the ICD-10-PCS root opera-
tion term. The Root Operation Definitions Appendix may help you.
11. Colostomy formation: _____
12. Cautery of skin lesion: _____
13. Transluminal angioplasty: _____
14. Choledocholithotomy: _____
15. Free skin graft: _____
16. Adhesiolysis: _____
17. Fallopian tube ligation: _____
18. Diagnostic arthroscopy: _____
19. Ankle arthrodesis: _____
20. Total nephrectomy: _____
21. Esophagogastric fundoplication: _____
The fourth character position identifies the specific body part that is the focus of a
procedure. The operative report or the procedure notes should be clear about these
details. However, sometimes it can be a challenge to match the documentation to the
choices offered in the tables. Following are some guidelines to help you determine the
accurate code in ICD-10-PCS.
General Guidelines
There may be times when the notes are more specific than the code character specifics.
If the physician documents that the procedure was performed on a specific anatomical
site, such as the biceps femoris muscle, yet the listing of body parts under Muscles (Body
System character K) does not provide this detail, you will need to code to the body part
that includes this anatomical site. In this case, you would report Upper Leg Muscle.
Bilateral Procedures
If the documentation identifies that a procedure was performed on both a right body
part and a left body part, and a Body Part code character is available to report the
CHAPTER 33 |
bilateral procedure, that is the one code to report. However, if there is no code char-
acter available to report a bilateral procedure, then you will need to report two codes:
one for each procedure.
EXAMPLES
0HRV3KZ Replacement of breasts, bilateral, percutaneous approach
0CNT8ZZ Release of right vocal cord, via natural opening endoscopic
0CNV8ZZ Release of left vocal cord, via natural opening endoscopic
Coronary Arteries
While the coronary arteries are represented by one code character, there are additional
characters to report when more than one site is treated in this one set of arteries.
EXAMPLE
Dr. Forreau performed an angioplasty in the left anterior descending coronary
artery in two distinct sites with two intraluminal, drug-eluting stents placed.
02713DZ Dilation of coronary artery, two sites, percutaneous approach
with intraluminal device, drug-eluting
Practice using the Body Part Key Appendix and fill in the descriptions used by ICD-10-PCS for coding.
22. Superior olivary nucleus: _____
23. Sigmoid vein: _____
24. Right suprarenal vein: _____
25. Ulnar notch: _____
26. Ventricular fold: _____
27. Sweat gland: _____
28. Optic disc: _____
29. Oropharynx: _____
30. Nasal concha: _____
31. Manubrium: _____
32. Ischium: _____
EXAMPLES
You might see documentation that states:
“. . . Attention was then turned to the patient’s lower abdomen. Incision was
made from symphysis pubis to umbilicus, midline. The incision was carried
down through the dermis, subcutaneous fat, and linea alba using electro-
cautery. Preperitoneal fat was incised using electrocautery. Peritoneum was
grasped with pickups. . . .”
(continued)
CHAPTER 33 |
GUIDANCE You can see that the physician describes the incision made, cutting through the
CONNECTION subcutaneous and adipose layers to the peritoneum (the membrane that lines the
abdominal cavity).
Read the ICD-10-PCS
Official Guidelines for “. . . The patient was taken to the operating room after being administered
Coding and Reporting, an epidural anesthetic, placed in the supine position, prepped and draped
Medical and Surgical in a sterile fashion with a wedge under the right hip. A Pfannenstiel skin inci-
Section Guidelines sion was made and carried down through layers along the old incision
(Section 0), sub- line. . . .”
head Open Approach In this excerpt from an operative report, the physician states this process more
with Percutaneous simply, but you can still understand that the patient is being cut into.
Endoscopic Assistance,
paragraph B5.2.
Percutaneous
Percutaneous: Entry, by puncture or minor incision, of instrumentation through
the skin or mucous membrane and any other body layers necessary to reach
the site of the procedure . . . Character: 3
When a percutaneous approach is used, the physician cannot see inside the body.
Often, a radiologist will provide imaging guidance (which would be reported sepa-
rately). A needle aspiration and needle biopsy are good illustrations of a percutaneous
approach.
EXAMPLE
You might see documentation that states:
“. . . The patient was prepped and draped in the usual fashion. A long, thin
needle is inserted through the patient’s abdominal wall, periumbilical quadrant,
passed into the amniotic sac. Ultrasound guidance is used. When puncture
into the sac is confirmed, a small sample of amniotic fluid is extracted and sent
to the lab. . . .”
A needle is inserted through the dermis (percutaneously) all the way into the amni-
otic sac. The fact that ultrasound guidance was used supports the fact that the
physician could not see where the point of the needle was going (no scope to see
inside; no internal visualization).
Percutaneous Endoscopic
Percutaneous Endoscopic: Entry, by puncture or minor incision, of instrumenta-
tion through the skin or mucous membrane and any other body layers neces-
sary to reach and visualize the site of the procedure . . . Character: 4
In this type of approach, a scope is placed through the incision or puncture. A laparo-
scopic procedure is a good example.
EXAMPLES
You might see documentation that states:
“. . . The patient was positioned supine on the operating room table. . . . A small
umbilical incision allowed for introduction of the Veress needle and inflation
of the abdomen to 15 cm of water pressure using carbon dioxide gas. The 0
degree, 5 mm laparoscope was introduced through a 5 mm port at the umbilicus
and 3 additional ports were placed in the usual anatomic positions. The liver
was found to be markedly enlarged. . . .”
EXAMPLE
“. . . A weighted speculum was placed in the posterior vaginal wall and the
right-angle retractor used to visualize the cervix. The cervix was grasped
across the anterior lip with a single-toothed tenaculum. . . . The cervix was cir-
cumferentially excised with the scalpel. . . .”
This excerpt is from the operative notes for a vaginal hysterectomy. Just the name
tells you that the approach was via the patient’s vagina, but you know that the name
is insufficient upon which to support a code. As you read the description of what the
physician did, you know you have the documentation to support the reporting of this
hysterectomy being performed using a vaginal (natural opening) approach.
EXAMPLES
You might see documentation that states:
“. . . The patient was placed in the dorsolithotomy position on a cystoscopy
table, prepped and draped in the usual fashion. A #21 French cystoscope
was passed through the urethra into the bladder. . . .”
The urethra is the anatomical tube that leads from the urinary bladder to the out-
side of the body. This is a natural opening into visceral organs, such as the blad-
der, ureters, and kidneys. The insertion of the cystoscope through the urethra is a
endoscope being used to see inside the body via a natural opening.
“. . . The patient was brought to the operative suite, placed in the supine posi-
tion. After satisfactory induction of general endotracheal anesthesia, a flexible
Olympus bronchoscope was passed through the endotracheal tube, visualizing
the distal trachea, carina, right and left main stem bronchus with primary and
secondary divisions. . . .”
Your understanding of anatomy will help you identify this natural opening—the
pharynx is the medical term for the throat. The bronchoscope was threaded
through the patient’s mouth, down the throat, into the bronchi.
CHAPTER 33 |
Via Natural or Artificial Opening with Percutaneous Endo-
scopic Assistance
Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance: Entry
of instrumentation through a natural or artificial external opening and entry,
by puncture or minor incision, of instrumentation through the skin or mucous
membrane and any other body layers necessary to aid in the performance of
the procedure . . . Character: F
This approach is kind of a combination endoscopic (laparoscopic) approach along
with the use of a natural or artificial opening.
EXAMPLE
You might see documentation that states:
“. . . The endoscope is inserted into the esophagus and down into the esopho-
gastric junction. The anterior aspect of the gastric lining is visualized. A 2.5 cm
incision is made into the right lateral aspect of the abdominal wall to allow for
GUIDANCE the insertion of the gastrostomy tube. . . .”
CONNECTION
This excerpt from the documentation of the placement of a feeding tube (also
Read the ICD-10-PCS known as a G-tube) uses a percutaneous endoscopic gastrostomy (PEG) approach
Official Guidelines for along with the natural opening approach of the mouth for the esophagogastro-
Coding and Report- duodenoscope (EGD).
ing, Medical and
Surgical Section
Guidelines (Section External
0), subhead Exter-
External: Procedure performed directly on the skin or mucous membrane and
nal Approach, para-
procedures performed indirectly by the application of external force through
graphs B5.3a and
the skin or mucous membrane . . . Character: X
B5.3b.
EXAMPLES
CODING BITES You might see documentation that states:
As you abstract the “. . . Used the McIvor mouth gag to retract the tongue and endotracheal
documentation and tube inferiorly, giving good exposure to the oropharynx. The tonsils were
interpret the way the visualized. . . .”
physician describes
As you read this physician’s description, it clearly indicates that the patient’s
how the procedure was
mouth was held open so the tonsils were visualized . . . seen by the naked eye.
performed, you may find
There were no incisions or penetrations through the tissues, neither was any type
Appendix: Components
of scope used.
of the Medical and
Surgical Approach Def- “. . . Upper eyelid incision was performed in the skin with 15 blade scalpel. . . .”
initions in your ICD-10-
The eyelid is right there, on the outside (external) part of the body. Again, no inci-
PCS code book helpful.
sions, penetrations through the tissues, or any type of scope was necessary.
Practice using the Medical and Surgical Approach Definitions Appendix and fill in the approach used
by ICD-10-PCS for coding.
33. Liposuction: _____
34. Sigmoidoscopy: _____
Reading through the Medical and Surgical Section, with a focus on some of the
options for the sixth character, you will find a limited number of descriptors. Let’s take
a closer look at these:
GUIDANCE
Grafts CONNECTION
Autologous Tissue . . . Character: 7
Autologous Venous Tissue . . . Character: 9 Read the ICD-10-PCS
Autologous Arterial Tissue . . . Character: A Official Guidelines for
Coding and Report-
This refers to a graft made with tissue from the patient’s own body. ing, Medical and
Synthetic Substitute . . . Character: J Surgical Section
Guidelines (Section 0),
This explains that the graft material may be carbon fibers, polypropylene, or other subhead B6. Device:
nonhuman substance. General Guidelines,
Nonautologous Tissue Substitute . . . Character: K paragraphs B6.1a,
B6.1b, and B6.1c, as
This graft is made from materials other than the patient’s own tissue. well as subhead Drain-
Zooplastic Tissue . . . Character: 8 age Device, paragraph
B6.2, for more details.
This identifies that the graft was made with tissue from a species other than human.
CHAPTER 33 |
Simple or Mechanical Appliances
Drainage Device . . . Character: 0
Monitoring Device . . . Character: 2
Monitoring Device, Pressure Sensor . . . Character: 0
Infusion Device . . . Character: 3
Extraluminal Device . . . Character: C
Intraluminal Device . . . Character: D
Intraluminal Device, Two . . . Character: E
Intraluminal Device, Three . . . Character: F
Intraluminal Device, Four or More . . . Character: G
Intraluminal Device, Drug-Eluting . . . Character: 4
Intraluminal Device, Drug-Eluting, Two . . . Character: 5
Intraluminal Device, Drug-Eluting, Three . . . Character: 6
Intraluminal Device, Drug-Eluting, Four or More . . . Character: 7
Bioactive Intraluminal Device . . . Character: B
Intraluminal Device, Radioactive . . . Character: T
Implants and Electronic Appliances
Stimulator (Cardiac) Lead . . . Character: M
Cardiac Lead, Pacemaker . . . Character: J
Intracardiac Pacemaker . . . Character: N
Implantable Heart Assist System . . . Character: Q
External Heart Assist System . . . Character: R
Radioactive Element . . . Character: 1
No Device . . . Character: Z
In operative reports and procedure notes, when a device is placed into the patient,
CODING BITES the notes will identify the brand name and details, rather than “synthetic substitute”
or “intraluminal device.” For instance, an AxiaLIF® System is an interbody fusion
Review Appendix:
device used in lower joints, or Ultrapro plug is a synthetic substitute. Don’t panic. You
Device Key and Aggre-
don’t have to memorize these brand names. Just bookmark Appendix: Device Key
gation Table and
and Aggregation Table in your ICD-10-PCS code book.
Appendix: Device Defi-
nitions in the back of
your ICD-10-PCS code EXAMPLES
book. How can you determine if a device was implanted into the patient? The documen-
tation will state something like one of these surgical notes excerpts.
“. . . A Kapandji technique was also used for intrafocal pinning, taking a
0.062 K-wire in both the radial and ulnar aspects of the distal fragment and
elevating it, followed by reducing it, controlling the distal fragment. . . .”
“. . . A Palmaz Blue Genesis stent, 6 x 80 mm was used. It was deployed
across the left renal artery stenosis in good position. . . .”
“. . . A stylet (a thin wire) is inserted inside the center channel of the pace-
maker lead to make it more rigid, and the lead-stylet combination is then
inserted into the sheath and advanced under fluoroscopy to the appropriate
heart chamber. . . .”
Practice using the Device Key Appendix and fill in the device description used by ICD-10-PCS for coding.
44. Bovine pericardial valve: _____
45. Acuity Steerable Lead: _____
This seventh character is required. In many cases, there may be no more details to
add, so you will use the placeholder Z No Qualifier—the equivalent of “not applicable.”
You will find that, depending on the procedure provided, you may need to check the
documentation for applicable details. For instance, when an excision is performed, you
may find a Qualifier character option to explain that this was a biopsy (for diagnostic
purposes . . . character X).
Earlier in this chapter, in the section that discussed root operation terms, you learned
that bypass procedures are coded by identifying the body part bypassed “from,” iden-
tified by character 4 (Body Part), and the body part bypassed “to,” identified by the
character 7 (Qualifier). This is just a reminder that, in some cases, the Qualifier char-
acter will partner with the Body Part character to explain the whole story about the
procedure.
EXAMPLE
0D164JA Gastric bypass, percutaneous endoscopic approach, rerouted
from stomach to jejunum
ICD-10-PCS
LET’S CODE IT! SCENARIO
Callie MacDonald, a 2-year-old female, was admitted to the hospital by her ophthalmologist, Dr. Epps. Her right
lacrimal duct was occluded. After sedation was administered, Dr. Epps probed her nasolacrimal duct and inserted
a transluminal balloon catheter to expand the duct. The balloon was deflated and removed. She tolerated the pro-
cedure well.
(continued)
CHAPTER 33 |
Let’s Code It!
Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for this encounter between Dr. Epps, an ophthalmologist, and Callie MacDonald.
First character: Section: Medical and Surgical . . . 0
Second character: Body System: Eye . . . 8
What root operation term would be most accurate? Read through the scenario carefully. Dr. Epps “expanded”
the duct. The description of the term “dilation” is to expand an orifice or the lumen of a tubular body part.
Third character: Root Operation: Dilation . . . 7
Now, which “tubular body part” was dilated? The scenario states, “Her right lacrimal duct . . .”
You may have been tempted to think “eye”; however, when you get to the table for Eye, Dilation . . . 087, you
will see that “eye” is the Body System and not an option for Body Part.
Fourth character: Body Part: Lacrimal Duct, Right . . . X
Dr. Epps inserted the catheter directly into the duct (this opening is how our tears flow from our eyes). Therefore,
he used a natural opening.
Fifth character: Approach: Via Natural or Artificial Opening . . . 7
Dr. Epps inserted a transluminal balloon catheter; however, then the documentation states, “The balloon was
deflated and removed.” Therefore, there is no Device reported in this position.
Sixth Character: Device: No Device . . . Z
Seventh Character: Qualifier: No Qualifier . . . Z
The ICD-10-PCS code you will report is
087X7ZZ Dilation, lacrimal duct, right, via natural or artificial opening
Good job!!
CHAPTER 33 |
Discontinued Procedures
It has happened: The physician begins a procedure and for some reason must stop
before accomplishing the goal originally planned. Should this occur, you are directed
to report those root operations that were actually done.
GUIDANCE CONNECTION
Read the ICD-10-PCS Official Guidelines for Coding and Reporting, Medical and
Surgical Section Guidelines (Section 0), subhead Discontinued Procedures,
paragraph B3.3, for more details.
EXAMPLE
Dr. Zander has planned a laparoscopic cholecystectomy. The incisions are made
and the scope is inserted. The gallbladder can be visualized. However, before the
organ can be surgically removed, the patient has a seizure. Dr. Zander stops the
procedure and closes the incisions.
0FJ44ZZ Inspection of gallbladder, percutaneous endoscopic approach
ICD-10-PCS
YOU CODE IT! CASE STUDY
Nita Yessa has been in the hospital with a compound fracture of the leg and she was brought into the procedure
room to have her two-lead pacemaker replaced. Dr. Balthazar was able to remove her current pacemaker easily.
However, there was a problem with the new device and he did not want to insert it. He closed the incision and sent
Nita back to her room. He told Rita Holsman, his assistant, to notify him as soon as a new pacemaker was available.
As Guideline B3.3 directs you, when an intended procedure is discontinued, you need to code for what was
actually completed. Dr. Balthazar was able to remove the old pacemaker, so you must code for the removal. You
cannot code for the insertion of the new pacemaker because this was not done.
Good work!
ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: Randolph Joy
HISTORY OF PRESENT ILLNESS: Patient was admitted to the Medical/Surgical floor last evening with acute upper
abdominal pain and dyspnea. Blood work results were inconclusive, as was x-ray. Today, we are going to perform
an EGD to investigate further.
PROCEDURE PERFORMED: Esophagogastroduodenoscopy
MEDICATIONS: Fentanyl 50 mcg, Versed 4 mg.
DESCRIPTION OF PROCEDURE: Informed consent was obtained. The patient was then placed in the left lateral
decubitus position. IV sedation was started in a sequential fashion until the appropriate level of consciousness was
achieved. Hurricaine spray was applied to the back of the throat and the endoscope was then advanced under
direct visualization over the tongue, the esophagus, stomach, and duodenum. It was slowly withdrawn and the
mucosa was carefully evaluated. Duodenal mucosal abnormalities were not visualized. Antegrade and retrograde
views of the stomach did demonstrate some mild nonerosive gastritis, predominantly in the antrum. Portal gastropa-
thy was noted throughout the gastric body, cardia, and fundus. Thickened gastric folds were noted and biopsied.
Retroflexed view as well demonstrated no signs of a gastric varix; no coffee grounds or red blood was seen in the
gastric lumen either. The scope was then withdrawn through the GE junction and careful examination did dem-
onstrate shallow esophageal ulceration distally; biopsies were obtained. The suspicion of Barrett’s esophagus
noted with two salmon tongues of mucosa emanating 1 cm proximal to the GE junction. Careful examination of the
remainder of the esophagus did demonstrate a hyperemic esophagus without further ulceration. The scope was
then withdrawn from the patient and the procedure terminated. It was well tolerated and there were no immediate
complications.
POST-PROCEDURE DIAGNOSES:
1. Probable Barrett’s esophagus
2. Distal esophageal ulceration
3. Thickened hypertrophied gastric folds
4. Portal gastropathy and nonerosive gastritis
IMPRESSION AND PLAN: I suspect this patient’s upper GI bleed is likely related to the ulcerations noted on this
examination. As we await results of biopsies, I will change his proton pump inhibitor from an IV drip to oral and be-
gin oral feeding as well. Hemoglobin and hematocrit will continue to be followed and, if stable, discharge may take
place tomorrow.
(continued)
CHAPTER 33 |
points to the root operation term excision. Do you report two ICD-10-PCS codes? Let’s analyze this. They are two
different reasons for the procedure; however, while an inspection could be done without any excisions, the fact
is that the biopsies could not be acquired without the inspection. Therefore, you only need one code, using the
root operation term Excision.
Third character: Root Operation: Excision . . . B
From what anatomical site were the biopsies taken? The documentation states, “esophageal ulceration distally;
biopsies were obtained.”
Fourth character: Body Part/Region: Esophagus, Lower . . . 3
How did Dr. Ferrante get to the distal (lower) esophagus? The documentation states, “the endoscope was then
advanced under direct visualization. . . .”
Fifth character: Approach: Via Natural or Artificial Opening Endoscopic . . . 8
Sixth character: Device: No Device . . . Z
Our last character will explain the essential reason for this procedure. Was it to gather details to support a diag-
nosis (i.e., diagnostic)? Or was it to repair or fix a problem (i.e., therapeutic)?
Seventh character: Qualifier: Diagnostic . . . X
Now, you can put all of these characters together to report the ICD-10-PCS code, with confidence:
0DB38ZX Esophagogastroduodenoscopy, with biopsies, diagnostic
Good work!
ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: GARY SALTON
PREOPERATIVE DIAGNOSIS: Subdural hematoma, traumatic
HISTORY OF PRESENT ILLNESS: This is a 17-year-old male, legally blind since birth, admitted after an assault.
During the assault, he suffered extensive subarachnoid hemorrhage, LeFort fracture of the face, right arm venous
phlebitis, and subdural hematoma. He was maintained on SICU, prophylaxis Dilantin, because of extensive sub-
arachnoid hemorrhage. He went to the OR for facial ORIF. His course was complicated by ventricular tachycardia,
but he was ruled out for MI at that time. He was started on amiodarone for the rate control. He also suffered a
mandibular fracture so PEG was placed because of his inability to eat. No mention is made of acute seizure in this
patient. There is no report of MRIs anywhere in the documentation. Preadmission summary states intracerebral
hemorrhage and subdural hematoma, although they do not state where. He had to be emergently intubated due
to hypoxemia. Other complications, during his hospital course, include cellulitis around the trach site, FUOs, and
sinusitis. He has phlebitis in his right forearm. Repeat head CT showed increased bilateral frontal subdural hygroma
and subarachnoid hemorrhage. He also developed hyphema of the right eye.
PAST MEDICAL HISTORY: Hypertension
FAMILY HISTORY: Hypertension and stroke
SOCIAL HISTORY: He smokes a pack a day and occasional alcohol. Otherwise, independent prior to the
admission.
MEDICATIONS: Prednisone, bacitracin topical cream, amiodarone, vancomycin, methadone b.i.d., dalteparin subcu
daily, BuSpar 10 mg b.i.d., metoprolol 50 mg b.i.d., Pepcid, and Percocet.
PROCEDURE: Patient was taken to the OR for excision of frontal subdural hygroma and subarachnoid hemor-
rhage for evacuation. Once endotracheal administration of anesthesia was accomplished, patient was prepped
ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: ANABELLE PRESTON
DATE OF OPERATION: 10/18/2018
PREOPERATIVE DIAGNOSIS: Bilateral urolithiasis
POSTOPERATIVE DIAGNOSIS: Bilateral urolithiasis
OPERATIONS PERFORMED:
1. Cystoscopy
2. Right retrograde pyelogram
(continued)
CHAPTER 33 |
3. Right ureteral stent placement
4. Right percutaneous nephrolithotripsy
SURGEON: Sonia Petrosky, MD
ANESTHESIA: Laryngeal mask general
ANESTHESIOLOGIST: Matthew Sorensten, MD
ESTIMATED BLOOD LOSS: Minimal
IV FLUIDS: 2.5 liters crystalloid
DRAINS: A #5-French x 28 cm right double-pigtail ureteral stent and #18-French Foley catheter
COMPLICATIONS: None
INDICATIONS: The patient is a 63-year-old female, admitted last night through the ED with acute right flank pain,
who denies prior history of kidney stones. She underwent parathyroidectomy 3 years ago. She stated that over
the past few weeks she had intermittent right flank pain. An ultrasound showed mild dilation of the right collecting
system with an 11-mm stone. Smaller stones were noted in the left kidney without any hydronephrosis. This was
confirmed on her KUB showing an 11-mm stone in the right mid kidney and three stones on the left measuring
3–6 mm. She has had followup testing showing a 24-hour urine calcium output of only 90 mg. Her serum calcium
level is normal.
DESCRIPTION OF THE PROCEDURE: The patient was brought to the lithotripsy suite. After induction of laryngeal
mask general anesthesia, she was placed in dorsal lithotomy position. Perineum and introitus were prepped and
draped. A #22-French rigid cystoscope was passed per urethra with obturator. The bladder was drained and then
inspected with 12- and 70-degree lenses. She has a central cystocele. Both orifices appear normal. Minimal squa-
mous metaplasia in the bladder neck area and no suspicious mucosal changes elsewhere. No trabeculation noted.
Pollack catheter was threaded into the right ureter and dilute contrast was used to perform segmental pyelogram
images on the right. Distally, multiple pelvic calcifications are lateral to the ureter consistent with phleboliths. No
obvious filling defects seen. There is mild dilation of the majority of the collecting system above the pelvic brim. The
stone appeared to be free floating within the renal pelvis.
Sensor guidewire was threaded up into the kidney. The Pollack catheter was inserted over the wire and the ure-
teral length was estimated. The contrast in the kidney was also allowed to drain to improve visualization of the stone
for lithotripsy. The guidewire was then replaced and the Pollack catheter removed. A #5-French x 28 cm Polaris dou-
ble-pigtail stent was then inserted with good pigtail formation on both ends. Cystoscope was removed and replaced
with an #18-French Foley catheter.
Next, we performed a percutaneous nephrolithotripsy on the right kidney stone in the ureteropelvic junction. The
stone appeared to fragment well. Periodic AP and oblique fluoroscopy was used. The patient was awakened, extu-
bated, and transported to the recovery room in stable condition.
Chapter Summary
This chapter showed you that building a code in ICD-10-PCS may require you to
become familiar with a different perspective and way of interpreting the physician’s
notes. However, it all fits together, even though you will be using your knowledge in a
slightly different way.
The ICD-10-PCS is used for reporting procedures performed in hospital inpatient
health care settings only. And the Medical and Surgical Section code components are
necessary for the largest percentage of procedures provided to patients while admitted
to a hospital.
CODING BITES
Medical and Surgical Section character positions and their meanings:
CHAPTER 33 |
Turbinate, 31. Sternum, 32. Pelvic Bone, 33. Percutaneous, 34. Via Natural or Arti-
CHAPTER 33 REVIEW
ficial Opening Endoscopic, 35. Via Natural or Artificial Opening with Percutaneous
Endoscopic Assistance, 36. External, 37. Open, 38. Via Natural or Artificial Opening,
39. Percutaneous, 40. Percutaneous, 41. Via Natural or Artificial Opening Endoscopic,
42. Open, 43. External, 44. Zooplastic Tissue, 45. Cardiac Lead, 46. Intraluminal
Device, 47. Nonautologous Tissue Substitute, 48. Infusion Device, Pump, 49. Extralu-
minal Device, 50. Synthetic Substitute, 51. Pacemaker, Dual Chamber, 52. Implant-
able Heart Assist System, 53. Monitoring Device, Pressure Sensor, 54. Radioactive
Element
CHAPTER 33 REVIEW
ICD-10-PCS Medical and Surgical Section Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
ICD-10-PCS
CHAPTER 33 REVIEW
with which of the following?
a. 0W4M0J1 b. 0W4N0Z0
c. 0W4N0J0 d. 0W4N071
8. LO 33.2 According to the Official Guidelines for Coding and Reporting paragraph B3.7, the example “Resection
of spleen to stop post-procedural bleeding” is coded to
a. resection. b. control.
c. excision. d. incision.
9. LO 33.2 Extraction of the right cornea, external approach, would be coded with which of these?
a. 08D9XZX b. 08D83ZZ
c. 08DKXZX d. 08D8XZZ
10. LO 33.2 The complete closing of an orifice or a lumen of a tubular body part is known as
a. map. b. occlusion.
c. fusion. d. detachment.
11. LO 33.2 According to the Official Guidelines for Coding and Reporting paragraph B3.14, the example “Severing
a nerve root to relieve pain” is coded to the root operation term
a. release. b. reposition.
c. division. d. restriction.
12. LO 33.2 A diagnostic arthroscopy would be interpreted as
a. bypass. b. extirpation.
c. resection. d. inspection.
13. LO 33.2 An esophagogastric fundoplication would be interpreted as
a. fusion. b. restriction.
c. resection. d. dilation.
14. LO 33.1 The ileum is part of which body system?
a. Upper Intestinal Tract b. Upper Leg
c. Lower Intestinal Tract d. Lower Leg
15. LO 33.3 The appendix that helps you when a specific anatomical site is documented and the body part compo-
nents are not as specific is entitled
a. Definition Key. b. Body Part Key.
c. Device Key. d. Device Aggregation Table.
16. LO 33.4 The approach to a procedure was entry, by puncture or minor incision, of instrumentation through the
skin or mucous membrane and any other body layers necessary to reach the site of the procedure and is
identified with the character 3. What type of approach was used?
a. Open b. External
c. Percutaneous d. Via natural or artificial opening
17. LO 33.4 Endoscopic repair of the urethra via natural opening would be coded with which of these?
a. 0TQC8ZZ b. 0TQD7ZZ
c. 0TQD4ZZ d. 0TQD8ZZ
18. LO 33.5 A cardiac lead, pacemaker implant device is represented by what sixth character?
a. M b. J
c. K d. R
CHAPTER 33 |
19. LO 33.6 A diagnostic qualifier is identified by what letter?
CHAPTER 33 REVIEW
a. X b. Z
c. B d. F
20. LO 33.5 Single upper tooth drainage device implant, open approach, would be coded with which of the
following?
a. 0C9W000 b. 0C9XX02
c. 0C9W0Z1 d. 0C9W001
1. Biopsy procedures are coded using the _____ Excision, Extraction, or Drainage and the qualifier Diagnostic.
2. If the root operations Excision, Repair or Inspection are performed on _____ layers of the musculoskeletal sys-
tem, the body part specifying the _____ layer is coded.
3. If multiple coronary arteries are _____, a separate procedure is coded for each coronary artery that uses a differ-
ent device and/or qualifier.
4. If an _____ is obtained from a different procedure site in order to complete the objective of the procedure, a sepa-
rate procedure is coded.
5. If multiple vertebral joints are _____, a separate procedure is coded for each vertebral joint that uses a different
device and/or qualifier.
6. _____ of a body part(s) performed in order to achieve the objective of a procedure is not coded separately.
7. In the root operation _____, the body part value coded is the body part being _____ and not the tissue being
manipulated or cut to free the body part.
8. Reduction of a displaced fracture is coded to the root operation _____ and the application of a cast or splint in
conjunction with the Reposition procedure is _____ coded separately.
9. If a body system does not contain a _____ body part value for fingers, procedures performed on the fingers are
coded to the body part value for the hand.
10. Procedures performed using the open approach with percutaneous endoscopic assistance are coded to the
approach _____.
11. Procedures performed _____ by the application of external force through the intervening body layers are coded to
the approach _____.
12. Procedures performed percutaneously via a _____ placed for the procedure are coded to the approach _____.
13. A device is coded only if a device remains _____the procedure is completed.
14. Procedures performed on a device _____and not on a body part are specified in the root operations Change, Irri-
gation, Removal and Revision, and are _____ to the procedure performed.
15. A separate procedure to put in a _____ device is coded to the root operation Drainage with the device value
Drainage Device.
CHAPTER 33 REVIEW
Please answer the following questions from the knowledge you have gained after reading this chapter.
1. LO 33.1 List the seven character positions of an ICD-10-PCS Medical and Surgical section code, include each
character’s meaning.
2. LO 33.3 If the notes state a bilateral procedure was performed and there is no code character available to report a
bilateral procedure, how would you report this procedure accurately?
3. LO 33.3 What is the title of the appendix that helps you when a specific anatomical site is documented and the
body part components are not as specific?
4. LO 33.4 List the seven approaches used within the Medical and Surgical section; explain each approach.
5. LO 33.7 The Official Guidelines provide four illustrations of cases when you will report multiple procedures.
What are the four cases?
CHAPTER 33 |
12. Tympanic nerve:
CHAPTER 33 REVIEW
ICD-10-PCS
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most ac-
curate ICD-10-PCS code(s) for each case study.
1. Theron Patel, a 12-year-old male, is experiencing obstructive sleep apnea. Dr. Pascal admits Theron to the
hospital and performs an adenoidectomy, open approach.
2. Juanita Keane, a 38-year-old female, was admitted to Westwood Hospital yesterday. Dr. Chavez performs a
laparoscopic cholecystectomy today.
3. Tom Gilbert, a 29-year-old male, is admitted to Weston Hospital due to severe hypertension. Dr. Benton notes
left kidney atrophy and performs an endoscopic left renal artery biopsy.
4. Bella Cable, a 62-year-old female, has severe pain in her right foot when she walks. Upon examination her
right big toe has turned toward the second toe. Bella is admitted to the hospital, where Dr. Meltzer performs a
bunionectomy, open approach, with a soft tissue correction.
5. Richard McMillan, a 26-year-old male, has had a bad cough for the last 3 months. Therefore, Dr. Skenes
admitted him into the hospital and performed a diagnostic fiberoptic bronchoscopy with hopes of determining
the cause of the irritation.
6. Merle Sims, a 34-year-old female, is a professional runner and has won three marathons. Today, she is admit-
ted to the hospital for a total arthroplasty (replacement) of her right knee, nonautologous tissue substitute,
open approach.
7. Carolyn Bulwark, a 21-year-old female, feels she has “big ears.” Carolyn was admitted to the hospital, where
her external ears were altered bilaterally, percutaneous approach.
8. Harry Matthews, a 48-year-old male, was admitted to Westwood Hospital yesterday. Harry was diagnosed
with esophageal cancer. A middle esophagus bypass, percutaneous endoscopic approach, rerouted to stomach,
was performed today.
9. John Andrews, a 46-year-old male, was admitted to the hospital, where he underwent urinary bladder surgery
2 days ago. Today, John’s urinary bladder drainage device is changed, external approach.
10. Annie Campbell, a 28-year-old female, was admitted to Westwood Hospital. The patient closed the car door
on her foot and severely injured her left foot. Annie’s left 5th toe is completely amputated.
11. Wilburn Backwinkel, a 54-year-old male, has had left upper quadrant pain radiating to his back. Dr. Dix
admits Wilburn to Westwood Hospital, where he performs an endoscopic (via natural opening) inspection of
the pancreatic duct.
12. Lynda Dibble, a 39-year-old female, gave birth to her 4th child 6 months ago. The patient presents today
requesting tubal ligation. Lynda is admitted to Westwood Hospital, where Dr. Connell performs a bilateral
fallopian tube ligation, percutaneous endoscopic approach.
The following exercises provide practice in abstracting physicians’ notes and learning to work with documentation
from our health care facility, Westward Hospital. These case studies are modeled on real patient encounters. Using
the techniques described in this chapter, carefully read through the case studies and determine the most accurate
ICD-10-PCS code(s), if appropriate, for each case study.
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
OPERATIVE REPORT
PATIENT: FASCHEL, MARTIN
DATE OF ADMISSION: 11/15/18
DATE OF SURGERY: 11/16/18
DATE OF DISCHARGE: 11/19/18
ADMITTING DIAGNOSIS: Uncontrolled epilepsy
DISCHARGE DIAGNOSIS: Uncontrolled epilepsy
PROCEDURE PERFORMED: Left vagal nerve stimulator insertion.
SURGEON: Kevin Mulford, MD
ASSISTANT: Denny Granger, MD
ANESTHESIA: General endotracheal
ESTIMATED BLOOD LOSS: Less than 10 mL
COMPLICATIONS: None
DRAINS: None
OPERATIVE FINDINGS: A model 102 generator with 2 mm electrodes was utilized.
INDICATION FOR PROCEDURE: The patient is a 6-year-old child who was found to have progressive
epilepsy. It was recommended that a vagal nerve stimulator be placed. We discussed the options, the
risks, and benefits with the child’s parents, and their questions were welcomed and answered. The pro-
cedure and potential risks of surgery include, but are not limited to, vagal nerve injury, vascular damage,
CHAPTER 33 |
CHAPTER 33 REVIEW
stroke, inoperability, malfunction, the need for continuous monitoring and evaluations, the possible
need for further surgical interventions, among others. With the family’s understanding and permission,
the child was brought to the operating room for this procedure.
DESCRIPTION OF PROCEDURE: After suitable general endotracheal anesthesia was obtained, the
patient was placed in the supine position and the head immobilized in a donut. The skin was pre-
pared using Betadine scrub and solution and a suitable surgical drape. Marcaine with epinephrine was
infiltrated.
Initially, we made a 2.5 cm incision along the neck crease, and the platysma muscle was divided. The
sternocleidomastoid muscle was retracted and dissected medially, and we identified the carotid sheath.
The carotid sheath was opened and we identified the vagal nerve. This was then isolated with vessel
loops.
We then attached the two electrodes in the grounding mechanism using 2 mm size coils. These were
found to be securely placed and a small loop was left for anchoring.
We then prepared the pocket while making a 6 cm curvilinear incision just medial to the axilla. A sub-
cutaneous pocket was created over the pectoralis muscle, and the area was irrigated.
We then used the tunneling device from the cervical to the chest incisions, and the electrodes were
placed in the subcutaneous tunnel. The model 102 generator was then connected to the electrodes. An
impedance test was done and was found to be 1.
The electrode in the subclavian was left with a small loop for growth, and this was anchored to the
fascia using a Vicryl suture.
Subsequently, the generator was turned on at the 0.25 mA at 30 Hz, on 30 seconds, off for 5 min-
utes, with a magnet strength of 0.5 for 60 seconds.
The wounds were then irrigated and subsequently painted with Betadine solution. They were then
closed using 3-0 Vicryl sutures for the deep layer. The skin was approximated using 4-0 Vicryl suture
in a running subcuticular fashion. Steri-Strips were applied, and the patient was awakened and trans-
ported to the recovery room, having tolerated the procedure well.
We discussed the operation, the findings, and the potential implications and complications with the
patient’s family. Their questions were welcomed and answered, and they expressed understanding of
the situation.
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
OPERATIVE REPORT
PATIENT: TUTTLE, BARBIE
DATE OF ADMISSION: 05/07/18
DATE OF SURGERY: 05/08/18
DATE OF DISCHARGE: 05/11/18
ADMITTING DIAGNOSIS: Avascular necrosis with severe collapse, total head involvement, left hip.
DISCHARGE DIAGNOSIS: Avascular necrosis with severe collapse, total head involvement, left hip.
OPERATION PERFORMED: Left total hip arthroplasty.
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
OPERATIVE REPORT
CHAPTER 33 |
CHAPTER 33 REVIEW
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
OPERATIVE REPORT
PATIENT: MAGGUIOTT, FELIX
DATE OF ADMISSION: 01/15/18
DATE OF DISCHARGE: 01/17/18
ADMITTING DIAGNOSIS: Inguinal hernia, left
PROCEDURE: Herniorrhaphy, with synthetic substitute
OPERATION: Left inguinal hernia repair with mesh.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed supine on
the operating room table. After general anesthesia was induced, the left inguinal area was prepped
with Betadine solution and sterilely draped in the usual manner for procedure in this area. The skin and
subcutaneous tissues of the left inguinal area were anesthetized, and an incision beginning at the left
pubic tubercle and extending laterally along natural skin lines was created. The incision was extended
through the subcutaneous tissues to the aponeurosis of the external oblique. Hemostasis was obtained
with the Bovie cautery. The subaponeurotic tissues were anesthetized.
The aponeurosis of the external oblique was incised along the length of its fibers. Care was taken to
avoid the ilioinguinal nerve. At the level of the pubic tubercle, the spermatic cord was bluntly dissected
from its surrounding structures and encircled with a 0.25 inch Penrose drain. The direct hernia sac was
dissected off of the cord structures and invaginated into the preperitoneal space. A search for an indi-
rect component proved fruitless.
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
OPERATIVE REPORT
PATIENT: KENSINGTON, LOUIS
DATE OF ADMISSION: 10/07/18
DATE OF DISCHARGE: 10/09/18
ADMITTING DIAGNOSIS: Chronic anal fissure and anal stenosis.
DISCHARGE DIAGNOSIS: Chronic anal fissure and anal stenosis.
OPERATIONS:
1. V-Y anoplasty.
2. Lateral internal sphincterotomy with fissurectomy.
3. Flexible sigmoidoscopy.
ESTIMATED BLOOD LOSS: 30 mL.
SPECIMENS: No specimens.
DRAINS: A 0.25-inch Penrose to the flap.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: After informed consent was obtained, the patient was taken to the OR.
He was placed in the prone jackknife position and IV sedation was given by the anesthesiologist. The
buttocks were taped laterally, exposing the perianal area. I began with the lubricated scope. The video-
scope was inserted into the rectum and advanced through the colon to about 40 cm. At 40 cm, there
was some angulation and some looping of the scope, and I elected not to proceed beyond this point. I
then began to slowly withdraw the scope, carefully inspecting the lumen. The prep was adequate up to
this point. I withdrew the scope. I noted no tumors or polyps. There was no evidence of colitis or proc-
titis and no diverticular disease was noted. I then desufflated the colon and rectum and removed the
scope.
CHAPTER 33 |
CHAPTER 33 REVIEW
The perianal area was then prepped with Betadine and draped in the usual fashion. I then used a
solution of 0.5% Marcaine with epinephrine and injected about 30 mL perianally as well as intramuscu-
larly to achieve some relaxation of the sphincter muscles. After adequate analgesia was obtained, the
small Ferguson retractor was inserted and the anal canal was inspected. The anterior fissure was very
chronic appearing and measured about 1 × 0.5 cm in size. The anal canal was rather small and there
seemed to be spasm of the distal edge of the internal sphincter muscle.
I then inserted the Buie retractor and opened it to expose the right lateral anal canal. An incision was
made over the anoderm in the right lateral position and then I dissected down to the distal edge of the
internal sphincter muscle, which was easily palpable as a tight band. I used a hemostat to dissect under-
neath it and elevated and divided it for a length of less than 1 cm. This did achieve relaxation of the
sphincter muscle.
Then at this point, I was able to remove the Buie retractor and inserted the Chelsea-Eaton retractor.
There was a definite release of the spasm of the sphincter muscle. However, there was also now obvi-
ous evidence of stenosis of the anal canal and there was no way to bring the mucosal edges together
to cover the sphincterotomy wound without putting tension on the anal canal. Because of this, I did
elect to go ahead with the anoplasty.
I used a marking pen to outline a house-shaped flap on the perianal skin in the right lateral position.
I then anesthetized this area. I used a #15 blade scalpel to incise the skin edges. I then mobilized the
flap by dissecting laterally to give the flap a very broad base. With the lateral dissection, I was then able
to mobilize the flap down into the anal canal to cover up the lateral internal sphincterotomy wound.
The area was irrigated. Then the flap was sewed into place using interrupted sutures, using com-
bination of #3-0 Vicryl and #4-0 Vicryl sutures, using the #3-0 Vicryl primarily on the tension points of
the flap. Once the proximal edge of the flap was sewed to the dentate line, I then came up the anterior
and posterior sides of the flap, suturing again in an interrupted fashion to the cut mucosal edges. I then
used a scalpel to make a small incision in the right posterior position about 1 centimeter or 2 away from
the flap and then used the stab incision to bring a 0.25-inch Penrose through the skin and positioned
it underneath the flap. It was sutured to the skin with a single #3-0 Vicryl suture. The excess drain was
then cut away, leaving about 2 or 3 cm protruding and the remainder positioned underneath the flap.
I then used #2-0 Vicryl and a mattress suture to perform the long portion of the Y of the flap. This was
done on the distal edge of the incision, bringing the two skin edges together with two of these mattress
sutures to form the Y.
At this point, I now just had the remainder of the bottom of the Y portion of the flap to close and this
was done again using a combination of interrupted #3-0 and #4-0 Vicryl sutures. At this point, I had
good hemostasis throughout the flap and the flap appeared to be viable. There was no tension on it.
There was a good color with no blanching noted.
I then directed my attention back toward the anal fissure in the anterior position. The small anterior
tag was excised. That was a small hypertrophied anal papilla. I then mobilized the mucosal side of the
fissure, elevating the mucosa, and a very small amount of muscle as well and then used a #4-0 Vicryl
suture to bring this mucosal edge about halfway up the fissure to partially cover it and facilitate the
healing process. There was a small amount of bleeding that was controlled with the #3-0 Vicryl figure-
of-eight suture.
At this point, I had good release of the anal stenosis and good hemostasis throughout. On further
examination, there was a very small posterior anal fissure, which was simply coagulated with the elec-
trocautery. At this point, the retractor was removed. A roll of Gelfoam was placed in the anal canal and
then a fluffy gauze dressing was placed over the Gelfoam.
The patient was then returned to the supine position and taken to the recovery area in stable condition.
Phillip Carlsson, MD—1111
556845/mt98328: 10/09/18 09:50:16 T: 10/09/18 12:55:01
Learning Outcomes
34
Key Terms
After completing this chapter, the student should be able to: Abortifacient
Laminaria
LO 34.1 Recognize the details reported in the Obstetrics Section of Products of
ICD-10-PCS. Conception
LO 34.2 Interpret the procedure to determine the accurate Obstetrics
root operation term.
LO 34.3 Employ your knowledge of anatomy to determine the body
part treated in Obstetrics coding.
LO 34.4 Determine the approach used for the Obstetrics procedure.
LO 34.5 Identify any devices that will stay with the body after an
Obstetrics procedure.
LO 34.6 Utilize the details required to report the correct qualifier for
an Obstetrics code.
LO 34.7 Analyze all of the details to build an accurate seven-
character Obstetrics code.
All of the codes reporting an obstetrics procedure provided to a pregnant woman who
has been admitted into a hospital will begin with the number one (1).
In this section there is only one body system, that is, the gestational term:
Pregnancy . . . Character: 0
From conception to delivery, procedures, services, and treatments provided to the
products of conception within a woman who is pregnant and has been admitted into a
hospital are reported with codes from this section to report the hospital (facility) care.
Before conception or after the baby is born, the services will be reported from a differ-
ent section of this code set.
Abortion
Abortion: Artificially terminating a pregnancy . . . Character: A
GUIDANCE
Note, this is not typically reporting a voluntary abortion. Those are most often CONNECTION
performed on an outpatient basis. This root operation term refers to a procedure
performed for medical necessity only. Read the ICD-10-PCS
Official Guidelines for
Coding and Report-
EXAMPLES ing, Obstetrics Section
Deena Wolff has been in a coma for a week, as a the result of being raped and Guidelines (Section 1),
beaten. Blood work shows she is pregnant and her injuries make the pregnancy subhead C2. Proce-
not viable. Dr. Owens performed an abortion, vaginal approach, using a vacum dures Following Deliv-
method. ery or Abortion.
10A07Z6 Abortion of products of conception via natural or artificial open-
ing using vacuum
The patient was pregnant with monochorionic twins (twins that share a common
placenta) and there was a problem. Evidence of unbalanced flow of blood from
one twin to the other twin caused twin–twin transfusion syndrome. Because she
was only at 13 weeks, a pregnancy termination was determined to be the best
option for the mother’s health and a future opportunity to get pregnant again. He
performed a dilation and curettage.
10A08ZZ Abortion of products of conception via natural or artificial
opening
Change
Change: Taking out or off a device from a body part and putting back an identical
or similar device in or on the same body part without cutting or puncturing the
skin or a mucous membrane . . . Character: 2
EXAMPLE
Two days ago, Dr. Conners inserted a fetal scalp electrode on Jenna’s 27-gestational-
week-old fetus. Today, Jenna is admitted into the hospital to monitor her and the
fetus, and to change the current electrode to a new one.
102073Z Changing a monitoring device for the products of conception via
natural or artificial opening
GUIDANCE Delivery
CONNECTION Delivery: Assisting the passage of the products of conception from the genital
canal . . . Character: E
Read the ICD-10-PCS
Official Guidelines for
Coding and Report- EXAMPLE
ing, Obstetrics Section The patient is a 31-year-old G2, P0 female at 38 weeks and 5 days estimated
Guidelines (Section 1), gestational age who presented in labor. On vaginal examination, the patient was
subhead C2. Proce- found to be 4 cm dilated, 70% effaced, and –3 station, and the fetal heart tracing
dures Following Deliv- at that time was in the 140s with minimal long-term variability. She was admitted
ery or Abortion. to Labor and Delivery for Pitocin augmentation and amniotomy. She continued to
have a good labor pattern and proceeded to deliver a viable 6-pound, 12-ounce
male infant over an intact perineum with Apgars of 8 and 9 at 1 and 5 minutes.
There were no nuchal cords, no true knots, and the number of vessels in the cord
was three. Her postpartum course was uncomplicated, and the patient was dis-
charged to home in stable and satisfactory condition.
10E0XZZ Delivery of a neonate (products of conception), external
approach
NOTE: The administration of the Pitocin, IV, would be reported separately (you will
learn about these codes in the Placement through Chiropractic Sections (2–9)
chapter, section Reporting Services from the Administration Section.
Drainage
Drainage: Taking or letting out fluids and/or gases from a body part . . . Character: 9
EXAMPLES
Maria Lettio was 39 years old when Dr. Platt confirmed she was pregnant. Today,
she has been admitted into the hospital for a gastroesophageal fundoplication.
While here, Dr. Lowenthal performed an amniocentesis to check the fetus for
genetic abnormalities.
10903ZU Drainage of amniotic fluid, percutaneous approach, for diagnos-
tic purposes
Concern for the existence of alloimmune thrombocytopenia, fetal blood sampling
to assess the baby’s platelet count is performed.
10903Z9 Drainage, fetal blood sampling, percutaneously
The patient’s uterus is compressing due to an overabundance of amniotic fluid.
Therefore, today we will perform an amnioreduction to decompress the womb
to prevent preterm delivery. A needle is inserted into the amniotic cavity and the
excess fluid is removed.
10903ZC Drainage of amniotic fluid, percutaneous approach, for thera-
peutic purposes
Insertion
Insertion: Putting in nonbiological appliance that monitors, assists, performs, or
prevents a physiological function but does not physically take the place of a
body part . . . Character: H
This is another opportunity for reading very carefully. In ICD-10-PCS, this root opera-
tion, insertion, applies only to the placement into the body of a medical device, such
as a monitoring device, that will remain in the body after the procedure is completed.
EXAMPLE
Concerned about the fetus’s sustainability, Dr. Franklin placed a scalp electrode
while Mei Lynn was still in the hospital for another issue.
10H073Z Insertion of monitoring electrode via natural or artificial opening
Inspection
Inspection: Visually and/or manually exploring a body part . . . Character: J
This root operation term is limited to the physician’s looking.
EXAMPLE
Using a scope via a percutaneous incision, Dr. Klotzky viewed the fetus’s position
using an operative fetoscopy.
10J04ZZ Inspection of productions of conception, percutaneous endo-
scopic approach
Removal
Removal: Taking out or off a device from a body part . . . Character: P
Read this carefully: As the description specifically states “device,” this can only
be used for this type of procedure, to remove a previously inserted device. As you
abstract the physician’s notes, be cautious of the use of this term in documentation.
The removal of a mole, for example, is really an excision, not a removal.
EXAMPLE
After gathering the data he needed, Dr. Abernathy removed the electrode that
had been placed on the fetus’s scalp.
10P003Z Removal of monitoring electrode, open approach
Repair
Repair: Restoring, to the extent possible, a body part to its normal anatomic
structure and function . . . Character: Q
EXAMPLES
Dr. Atlante determined that Geena Simpson’s fetus has indications of spina bifida.
He performed a repair of the skin over the spinal opening, in utero, with hopes of
enabling the child to be born without disability.
10Q03ZQ Repair of skin, percutaneous approach
Aortic stenosis may be relieved in utero by performing an aortic balloon valvu-
loplasty. This is accomplished by inserting a needle into the fetal heart through
which the balloon catheter is passed.
10Q03ZF Repair of cardiovascular system, percutaneous approach
Reposition
Reposition: Moving to its normal location or other suitable location all or a por-
tion of a body part . . . Character: S
EXAMPLE
Rae-Ann was in the last stage of labor and ready to deliver when Dr. Bornstine
realized the baby was breech. Externally, he manually manipulated the position of
the baby, and a 7 lb. 3 oz. boy was delivered a short time later.
10S0XZZ Reposition of fetus, external approach
Resection
Resection: Cutting out or off, without replacement, all of a body part . . . Character: T
Remember how this differs from excision. When the entire body part is surgically
removed, it is reported as a resection. If only a portion of the body part is removed, it
is reported as an excision.
EXAMPLE
Dr. Peterson determined that Ursula’s fertilized egg was stuck in her left fallopian
tube and was growing. He had to surgically remove the fallopian tube before it burst.
10T28ZZ Resection of fallopian tube for ectopic products of conception,
via natural or artificial opening endoscopic
EXAMPLE
A percutaneous bone marrow transplant was performed on a 25-gestational-
week-old fetus.
10Y03ZG Transplantation, percutaneous, lymphatics and hemic
Practice interpreting from the common term used to reference the ICD-10-PCS root operation term.
1. Amniocentesis: _______
2. Chorionic villus sampling: _______
3. Surgical treatment of ectopic pregnancy: _______
4. Cerclage of cervix during pregnancy: _______
5. Intrauterine cordocentesis (percutaneous umbilical cord blood sampling): _______
6. Fetal shunt placement: _______
7. Induced abortion, by dilation and curettage: _______
8. Uterine evacuation and curettage: _______
9. In utero fetal kidney transplant: _______
10. Vaginal delivery: _______
11. Hysterorrhaphy: _______
The only procedures reported from this section are those performed on the products Products of Conception
of conception: zygote, embryo, or fetus, as well as the amnion, umbilical cord, and The zygote, embryo, or fetus,
placenta. as well as the amnion, umbili-
When a sperm fertilizes an oocyte (egg), a zygote is created. Two weeks later (after cal cord, and placenta.
fertilization), the zygote becomes an embryo. At week 8, the embryo, about 1 inch in
length, is considered a fetus.
The Obstetrics Section focuses on three body parts, which are not specific ana-
tomical sites with which you are familiar:
As you continue to build a code, you can see that you are telling a story. The first four
characters explain what the physician did and the anatomical site upon which he or she
worked. Now, with the fifth character, you are going to explain how the physician got
to the anatomical site to perform the procedure. You learned in previous chapters that
this is known as the approach.
Open
Open: Cutting through the skin or mucous membrane and any other body layers
necessary to expose the site of the procedure . . . Character: 0
An open procedure is the traditional approach when the physician makes an incision
into the body to access an internal organ.
EXAMPLE
10D00Z1 Cesarean section, low cervical, open incision
Percutaneous
Percutaneous: Entry, by puncture or minor incision, of instrumentation through
the skin or mucous membrane and any other body layers necessary to reach
the site of the procedure . . . Character: 3
Percutaneous Endoscopic
Percutaneous Endoscopic: Entry, by puncture or minor incision, of instrumenta- CODING BITES
tion through the skin or mucous membrane and any other body layers neces- In utero procedures can
sary to reach and visualize the site of the procedure . . . Character: 4 be performed on the
fetus by percutaneous
EXAMPLE endoscopic approach
using a fetoscope.
10Q04ZT Repair of the female reproductive system, products of concep-
tion, via percutaneous endoscopic approach
EXAMPLE
10J17ZZ Inspection of retained products of conception, vaginal approach
EXAMPLE
10S28ZZ Reposition of products of conception from fallopian tube to
uterus, via vaginal endoscopic approach
External
External: Procedure performed directly on the skin or mucous membrane and
procedures performed indirectly by the application of external force through
the skin or mucous membrane . . . Character: X
EXAMPLE
10E0XZZ Delivery of neonate, vaginal delivery, no assistance
Interpret these statements from physicians’ documentation on the approach used to determine the
ICD-10-PCS approach term.
12. Endoscope was inserted into vagina and into the uterus: _______
13. Needle aspiration of amniotic fluid: _______
14. Transverse incision: _______
15. Vaginal delivery: _______
16. Laparoscopic entry into uterus for in vitro surgery: _______
34.5 Obstetrics Devices: Character 6
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system being treated (Pregnancy)
3 Root operation term
4 Body part (Products of Conception)
5 Approach used by physician
6 Device
7 Qualifier
As you can see, a character placed in the sixth position will identify a device that
will remain with the patient after the procedure has been completed. Remember, the
patient for whom the device is involved in care—in this section of ICD-10-PCS—is
the fetus . . . not the mother.
Monitoring Electrode . . . Character: 3
Other Device . . . Character: Y
No Device . . . Character: Z
Fetal monitoring can be performed either internally or externally. When done inter-
nally, the physician will place an electrode (electronic transducer) directly onto the
scalp of the fetus, typically using a natural opening approach (through the vagina/cer-
vix), with the intention of directly and continuously evaluating the fetal heart rate as
well as its variability between beats, particularly in relation to the uterine contractions
of labor. Another device, called an internal uterine pressure monitor (IUPM), may be
used in conjunction with internal fetal heart rate monitoring. Using a catheter inserted
via the vagina/cervix, an IUPM is placed inside the uterus, next to the fetus, to trans-
mit the readings of the contraction pressure to a nearby monitor.
External fetal heart rate monitoring can be accomplished with a handheld electronic
Doppler ultrasonic device, most often used at outpatient prenatal visits. Continuous
electronic fetal heart monitoring, typically used during labor and delivery, consists of
placing an ultrasound transducer on the mother’s abdomen, where it can transfer the
sounds of the fetal heart to a computer. The computer is able to show the heart pattern
on a screen as well as print it out on paper similar to that used during an EKG.
The seventh character is required. In some cases, there may be no more details to
add, so you will use the placeholder letter Z No Qualifier—the equivalent of “not
applicable.”
EXAMPLES
You may read these words in the physician’s documentation:
“ . . . low transverse cesarean section . . .”
“ . . . Lower uterine segment was then scored in a curvilinear fashion . . .”
[extraperitoneal]
“ . . . A vertical incision was made in the umbilicus . . .” [classical]
CODING BITES
Drainage Procedures Read carefully! There
During amniocentesis, or any other drainage procedure performed on a pregnant are two different charac-
woman, the Qualifier character will explain exactly what was drained: ters available to report
the drainage of amniotic
Fetal Blood . . . Character: 9 fluid . . . therapeutic or
Fetal Cerebrospinal Fluid . . . Character: A diagnostic. Check the
Fetal Fluid, Other . . . Character: B documentation to deter-
Amniotic Fluid, Therapeutic . . . Character: C mine why the amniocen-
Fluid, Other . . . Character: D tesis was done.
Amniotic Fluid, Diagnostic . . . Character: U
EXAMPLES
You might see these phrases and descriptions in physician documentation:
“ . . . second trimester amniocentesis . . .” [drainage of amniotic fluid for diag-
nostic/genetic testing]
“ . . . serial vesicocenteses will be performed to check the kidney function
(measuring urinary electrolytes in the fetus’s urine). A needle is inserted into
the fetal bladder and the urine is entirely removed . . .” [drainage of fetal fluid,
other]
“ . . .fetal blood sampling will be done to collect specimens for testing
. . .” [drainage of fetal blood]
Abortive Procedures
When the artificial termination of a pregnancy (abortion) is performed, the Qualifier
character will report the methodology:
Vacuum . . . Character: 6
Laminaria Laminaria . . . Character: W
Thin sticks of kelp-related Abortifacient . . . Character: X
seaweed, used to dilate the
cervix, that can induce abor- ∙ Vacuum: The use of aspiration using a cannula (tube) inserted into the uterus; also
tive circumstance during the known as suction curettage.
first 3 months of pregnancy. ∙ Laminaria: A small rod, created of dehydrated types of kelp, is inserted into the
Abortifacient
cervix for the purposes of dilation.
A drug used to induce an ∙ Abortifacient: A substance, using a pharmaceutical, used to induce expulsion of the
abortion. products of conception.
In Utero Procedures
The Qualifier character will report the body system that was repaired or trans-
planted during an in utero procedure performed on the fetus (root operation repair or
transplantation).
Nervous System . . . Character: E Hepatobiliary and Pancreas . . . N
Cardiovascular System . . . F Endocrine System . . . P
Lymphatics and Hemic . . . G Skin . . . Q
Eye . . . H Musculoskeletal System . . . R
Ear, Nose, and Sinus . . . J Urinary System . . . S
Respiratory System . . . K Female Reproductive System . . . T
Mouth and Throat . . . L Male Reproductive System . . . V
Gastrointestinal System . . . M Other Body System . . . Y
ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: ELICIA MORALISE
DATE OF DELIVERY: 05/29/2018
HISTORY OF PRESENT ILLNESS: The patient is a 26-year-old G1, P0 at 39-3/7 weeks with an EDD of 06/01/2018
based on a 6-week ultrasound. The patient presented to labor and delivery with complaints of contractions every
3 minutes and leaking of fluid since 0400 on 05/28/2018. The patient reports positive fetal movement and denies
vaginal bleeding. Prenatal care began at 9 weeks × 15 visits. Total weight gain was 37 pounds. The patient is A posi-
tive, rubella immune, GBS positive. She has no known drug allergies.
ICD-10-PCS
LET’S CODE IT! SCENARIO
LaToya Donner, a 37-year-old female, is pregnant, G1 P0, second trimester (15 weeks, 3 days), and has been admit-
ted to have some tests, including an amniocentesis. Because she is categorized as eldergravida, Dr. Brummel is
performing this test to determine the health and well-being of the fetus.
ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT NAME: YESSINA CATINA
PHYSICIAN: TRAVIS JONQUIN, MD
DATE OF ADMISSION: 05/28/2018
DATE OF DISCHARGE: 05/29/2018
ADMITTING DIAGNOSIS: Intrauterine pregnancy at 38 weeks and 5 days. Presented with contractions, leakage of
fluid, and decreased fetal movements that day.
HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE: The patient is a 31-year-old G2, P0 female at 38 weeks and
5 days estimated gestational age who presented in labor. On vaginal examination, the patient was found to be 4 cm
dilated, 70% effaced, and –3 station, and the fetal heart tracing at that time was in the 140s with minimal long-term vari-
ability. She was admitted to Labor and Delivery for Pitocin augmentation and amniotomy. She continued to have a good
labor pattern and proceeded to deliver a viable 6-pound, 12-ounce male infant over an intact perineum with Apgars of 8
and 9 at 1 and 5 minutes. There were no nuchal cords, no true knots, and the number of vessels in the cord was three.
Her postpartum course was uncomplicated, and the patient was discharged to home in stable and satisfactory condition.
ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: ISABELLE CALAVERI
DATE: 11/15/18
PROCEDURE: Primary low segment transverse cesarean section
DESCRIPTION OF OPERATION: Due to concern that the umbilical cord was around the fetus’s neck, the patient was
brought to the operating room and placed on the table in supine position, and after adequate epidural anesthesia,
she was prepped and draped in the usual sterile fashion.
A Pfannenstiel incision was made with a clean scalpel. The incision was taken down the fascial layer with a clean
second knife. The fascial layer was incised transversely to the full length of the primary incision. The underlying
muscle bellies were dissected with blunt and sharp dissection. The muscle belly was split in the midline. The peri-
toneum was then grasped between 2 Kelly clamps and elevated. After ensuring no adherent bowel or bladder, the
peritoneum was nicked between clamps. The abdominal cavity was thus entered. The bladder flap was formed with
blunt and sharp dissection and then the uterus was scored in the lower uterine segment in transverse fashion, and
(continued)
the incision was enlarged in elliptical fashion with bandage scissors. The infant was found to be in face presentation
with nuchal cord x1. Mouth and nose were suctioned prior to delivery of rest of the body. The cord was slipped over
the shoulders and then the infant was delivered. It was a living female with Apgars of 8 and 9. There was meconium,
but it was not thick. Cord pH was 7.30. The cord was doubly clamped, cut between the clamps, and the infant was
handed away to the pediatrician, Dr. Toliver. Cord bloods were taken.
The placenta was then manually separated. The edges of the uterine incision were then reapproximated with con-
tinuous running suture of #1 chromic catgut. The second imbricating layer was also sewn using #1 chromic catgut.
Good hemostasis was noted. The abdomen was cleaned of blood and clots. Tubes and ovaries were inspected and
found to be normal. Then, the abdomen was closed in layers after correct sponge, needle, and instrument counts.
The peritoneum was closed with continuous running suture of 0 chromic catgut. The muscle bellies were closed with
interrupted sutures of 0 chromic catgut. The fascia was closed with 2 continuous running sutures of 0 Vicryl begin-
ning at either angle of the incision intermittently overlapping the midline. The subcutaneous tissue was closed with
continuous running suture of 3-0 plain catgut, and the skin was closed with surgical staples. A sterile pressure dress-
ing was applied. Sponge, needle, and instrument counts were correct at the end of the procedure.
Matthew Ansara, MD
Chapter Summary
The services, procedures, and treatments reported with codes from the Obstetrics
Section of ICD-10-PCS are all provided in a pregnant inpatient. The most impor-
tant thing to remember is that, for these procedures, the patient is the product of
conception—what is inside a pregnant patient.
ICD-10-PCS
Let’s Check It! Concepts
Choose the most appropriate answer for each of the following questions.
1. LO 34.4 Within the Obstetric Section, character position 5 represents which of the following?
a. Body system b. Root operation term
c. Approach d. Device
2. LO 34.1 All of the codes reporting an Obstetrics procedure will begin with which section number?
a. 5 b. 4
c. 2 d. 1
3. LO 34.3 The products of conception include
a. zygote and embryo. b. amnion and umbilical cord.
c. placenta. d. all of these.
4. LO 34.2 All of the following are root operation terms in the Obstetrics Section except
a. abortion. b. delivery.
c. irrigation. d. inspection.
5. LO 34.2 Within the Obstetrics Section, character position 5 Approach, the approach to an intrauterine cordocen-
CHAPTER 34 REVIEW
CHAPTER 34 REVIEW
2. Procedures performed on the _____ female other than the products of conception are coded to the appropriate root
operation in the _____ section.
3. _____ is coded to the products of conception body part in the Obstetrics section. Repair of _____ urethral lacera-
tion is coded to the urethra body part in the Medical and Surgical section.
4. Procedures performed following a _____ or abortion for curettage of the endometrium or evacuation of _____
products of conception are _____coded in the Obstetrics section, to the root operation _____ and the body part
Products of Conception, Retained.
5. Diagnostic or _____ dilation and curettage performed during times other than the _____ or post-abortion period
are all coded in the Medical and Surgical section, to the root operation Extraction and the body part _____.
ICD-10-PCS
9. Sherry Moore, a 29-year-old female, is admitted to Westward Hospital for an open in utero fetal mouth repair.
10. Janie Knight, a 16-year-old female, G1 P0, is admitted to Westward Hospital and Dr. Gifford performs an
amniotic fluid test for therapeutic purposes.
11. Sharon Heyward, a 24-year-old female, G2 P1 at 40 weeks gestation, is admitted to Westward Hospital.
Dr. Jessup performs a pelvic examination revealing an open, soft cervix.
12. Kristi Williams, a 31-year-old female, is admitted to Westward Hospital in active labor at 41 weeks gestation.
Dr. Gerald assisted with a vaginal delivery, with high forceps, 4 hours later.
13. Keyana Haulbrook, a 17-year-old female, G1 P0, 12 weeks gestation, is admitted to Westward Hospital to ter-
minate pregnancy due to a genetic defect in the fetus. Abortion was performed by hysterotomy technique.
14. Natalie Phillips, a 32-year-old female, 37.5 weeks gestation, G2 P1, is admitted to Westward Hospital for a
fetal spinal tap, percutaneous.
15. Eleanor Coaxum, a 26-year-old female, G1 P0, 32 weeks gestation, is admitted to Westward Hospital for a
fetal skin transplantation, via natural opening.
ICD-10-PCS
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documenta-
tion from our health care facility, Westward Hospital. These case studies are modeled on real patient encounters.
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-PCS code(s) for each case study.
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
DISCHARGE SUMMARY
PATIENT: ALBERTS, SERITA
DATE OF ADMISSION: 03/05/18
DATE OF DISCHARGE: 03/17/18
ADMITTING DIAGNOSIS: 1. Intrauterine pregnancy at 40 plus weeks.
2. Active labor.
3. History of two previous cesarean sections.
DISCHARGE DIAGNOSIS: 1. Intrauterine pregnancy at 40 plus weeks.
2. Active labor.
3. History of two previous cesarean sections.
OPERATION: Repeat low transverse cesarean section.
FLUIDS: 2500 mL lactated Ringer.
ESTIMATED BLOOD LOSS: 300 mL.
URINE OUTPUT: 125 mL, clear and yellow.
DESCRIPTION OF OPERATION: The patient was identified and taken to the operating room. Appropri-
ate anesthesia was administered. The patient was placed in the dorsal supine position with a leftward
tilt and prepped and draped in the usual sterile fashion. Following that, a low Pfannenstiel skin inci-
sion was made with a #10 scalpel. This incision was carried down to the underlying layer of fascia with
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
OPERATIVE REPORT
PATIENT: HUDSON, LYNN
ACCOUNT/EHR #: HUDSLY001
DATE OF ADMISSION: 17 March 2018
ATTENDING PHYSICIAN: Denny Stewart, MD
ANESTHESIA: Epidural type of delivery: NSVD
CONDITION OF PERINEUM: MLE
EPISIOTOMY: Midline performed
VAGINA/CERVIX: Intact
DELIVERED: Live, single-born female, weight 7 lb. 2 oz. @ 02:17
TYPE OF STIMULATION: Mouth suction
CHAPTER 34 REVIEW
CONDITION: Good
BIRTH INJURY: None
APGAR RATING: 1 min. = 9 . . . 5 min. = 9
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
OPERATIVE REPORT
PATIENT: CARROLL, DAWN
ACCOUNT/EHR #: CARRDA001
DATE OF ADMISSION: 21 MARCH 2018
ATTENDING PHYSICIAN: Steven Phifer, MD
In the 40th week of her first pregnancy, a 34-year-old woman arrived at Labor and Delivery at 5:00 a.m.
for a planned induction of labor due to mild, pregnancy-induced hypertension. After intravaginal place-
ment of misoprostol, the nurse observed her briefly and, at 9:00 a.m., discharged her from the unit. She
went for a walk with her husband in a park next to the hospital.
Patient’s membranes spontaneously ruptured, and she returned to the Labor and Delivery unit.
Patient’s vital signs were taken, and the fetal heart rate checked. The mother’s blood pressure was
182/97, but the nurse thought this was related to nausea, vomiting, and discomfort from the contractions.
The resident examined the mother, determined that her cervix was 5–6 cm, 90 percent effaced, and
the vertex was at 0 station. An internal fetal heart monitor was placed because the mother’s vomiting
and discomfort caused her to move around too much in the bed, making it hard to record the fetal heart
rate with an external monitor. The internal monitor revealed a steady fetal heart rate of 120 and no
decelerations.
The mother continued to complain of painful contractions and requested an epidural. Shortly after
placement of the epidural, the monitor recorded a prolonged fetal heart rate deceleration. The heart
rate returned slowly to the baseline rate of 120 as the nurse repositioned the mother, increased her
intravenous fluids, and administered oxygen by mask.
An epidural analgesia infusion pump was started. The fetal heart rate strip indicated another decel-
eration that recovered to baseline. The nurse informed the resident, who checked the tracing and told
her to “keep an eye on things.”
The primary nurse noted in the labor record that the baseline fetal heart rate was “unstable, between
100–120,” but she did not report this to the resident.
The nurse recorded that the fetal heart rate was “flat, no variability.” As the nurse was documenting
this as a nonreassuring fetal heart rate pattern, the patient expressed a strong urge to push and the
nurse called for an exam.
A resident came to the bedside, examined the mother, and noted that she was fully dilated with the
caput at +1. A brief update was written in the chart, but the clinician who had performed the exam was
not noted.
WESTWARD HOSPITAL
Masters, FL 33955
OPERATIVE REPORT
ACCOUNT/EHR #: FAULMA001
ANESTHESIA: General
Patient is in her 12th week of pregnancy. She presented to the emergency department with severe
cramping and vaginal bleeding. After examination the patient was diagnosed with an incomplete early
spontaneous abortion and a D&C was recommended. The patient was fully counseled as to the risks
and benefits of the D & C and admitted to the hospital. The patient agreed to the procedure.
The patient was then taken to the operating room and placed in a supine position on the operat-
ing room table. General endotracheal anesthesia was administered, and once adequate anesthesia
was demonstrated, the patient’s legs were then placed in candy cane stirrups. The patient was then
prepped and draped in the standard D&C surgical fashion.
The patient was placed in 10 degrees of Trendelenburg. The patient was given 100 mg of doxy-
cycline. The bladder was then decompressed and approximately 45 mL of urine was produced. A
weighted speculum was placed in the posterior vagina and the cervix was grasped with single-tooth
tenaculum. Uterus sounded to 8.2 cm. The cervix was then serially dilated with Hanks dilator. An 8 cm
straight suction curette was then introduced and a suction curettage was performed. Once all products
of conception were evacuated, a sharp curettage was performed until a gritty surface was appreciated
on all four quadrants of the uterus. No further bleeding was noted. Products of conception were then
examined on the back table, which was grossly consistent with products of conception.
The patient tolerated the procedure and anesthesia well, was awakened from anesthesia without
complications, and was transported to the recovery room in stable condition.
Sandra Lindler-6789
558645/mt98328: 03/25/18 09:50:16 T: 03/26/18 12:55:01
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
OPERATIVE REPORT
PATIENT: HOFFMEIER, KATHLEEN
ACCOUNT/EHR #: HOFFKA001
DATE OF ADMISSION: 28 MARCH 2018
ADMITTING DIAGNOSIS: Right tubal ectopic pregnancy
PROCEDURE: Operative laparoscopy, right salpingectomy.
SURGEON: William G. Cohen, MD
ANESTHESIA: General
This 28-year-old female presents to the emergency room with vaginal bleeding and belly pain that gets
worse with movement. Patient states she is pregnant at approximately 8 weeks gestation, G1 P0. Ultra-
sound report showed a mass near the cul-de-sac. The patient denies any medical or surgical history. No
known allergies. Family history is noncontributory. The patient was admitted to the hospital.
The patient was taken to the OR, where general anesthesia was easily obtained. The patient was
then prepped and draped in a sterile fashion and placed in dorsal lithotomy position. A weighted specu-
lum was introduced into the patient’s vagina for cervical visualization. Once the cervix was visualized,
a single-toothed tenaculum was applied to the upper lip of the cervix, and acorn manipulator was intro-
duced into the patient’s cervix.
Attention was then drawn to the abdomen, where a 10 mm horizontal incision was done below the
umbilicus and carried down all the way to the fascia. Under direct visualization, a 10 mm trocar was
introduced into the patient’s abdomen. Once intraperitoneal placement was confirmed, pneumoperito-
neum was started. Opening pressure was 3 mmHg; pneumoperitoneum was obtained.
Once pneumoperitoneum was obtained, a second port was put two fingerbreadths above the pubic
symphysis, and under direct visualization, a 5 mm trocar was then introduced into the patient’s abdo-
men. The patient was placed in Trendelenburg position. Pelvic structures were revealed; ampullary
ectopic was noted on the right side with some amount of hemoperitoneum and moderate amount of
free fluid.
Attention was focused on the right fallopian tube, which initially was incised where the ectopic preg-
nancy was and products of conception were removed. Since no hemostasis was able to be obtained
from the incision site from the salpingostomy and due to the amount of dense adhesions on that fal-
lopian tube, decision was then made to proceed with right salpingectomy, so the IP ligament was
identified and fallopian tube was then grasped by the fimbria and incised from the mesosalpinx. Good
hemostasis was noted from the fallopian tube sites and the operative site. Specimen was then removed
from the patient’s abdomen. Copious irrigation was done and all clots and debris were removed from
the patient’s abdomen. Once good hemostasis was noted from the patient’s abdomen, pneumoperi-
toneum was deflated and all trocars were removed. Infraumbilical fascia was closed with 0 Vicryl and
interrupted suture. The skin was closed with 4-0 Vicryl. The right infrapubic and suprapubic ports were
closed with 0 Vicryl in running fashion, and third port, which was introduced two fingerbreadths above
the pubis symphysis and 6 cm in the midaxillary line, under direct visualization, was also closed with 4-0
Monocryl. Sponge, lap, and needle counts were correct x2. The patient was taken to the recovery room
in stable condition.
1040
You might have noticed that these are slightly different meanings for characters
2 and 4 than those in the Medical and Surgical Section and Obstetrics Section.
The codes from the Placement Section only report procedures that are noninvasive,
meaning that the outer layer of the skin is not punctured and no incision is made.
CHAPTER 35 |
Change
Change: Taking out or off a device from a body part and putting back an identical
or similar device in or on the same body part without cutting or puncturing the
skin or a mucous membrane . . . Character: 0
Caution! This root operation term means the same as it does in the Medical and Sur-
gical Section and the Obstetrics Section; however, the character used to report this in
the Placement Section is different.
EXAMPLE
2W05X3Z Change external back brace
Compression
Compression: Putting pressure on a body region . . . Character: 1
EXAMPLE
2W1RX7Z Placement of intermittent pressure device on lower left leg
Dressing
Dressing: Putting material on a body region for protection . . . Character: 2
EXAMPLE
2W2EX4Z Placement of bandage on right hand
Immobilization
Immobilization: Limiting or preventing motion of an external body region
. . . Character: 3
EXAMPLES
2W3KX1Z Application of a splint to a left finger
2W5MX3Z Removal, G3 XL post-op knee brace, left leg
Packing
Packing: Putting material in a body region or orifice . . . Character: 4
EXAMPLES
2W48X5Z Packing to wound on right upper extremity
2Y41X5Z Packing of nasal cavities due to epistaxis
Removal
Removal: Taking out or off a device from a body part . . . Character: 5
Read this carefully: As the description specifically states “device,” this can be used
only for this type of procedure—to remove a previously placed device. As you abstract
the physician’s notes, be cautious of the use of this term in documentation.
EXAMPLE
2W5TX0Z Removal of traction apparatus from left foot
Traction
Traction: Exerting a pulling force on a body region in a distal direction . . .
Character: 6
Notice that Traction is presented as a root operation term as well as traction apparatus
that is offered as an option for the device used.
EXAMPLE
2W62X0Z Traction apparatus placed at neck
Anatomical Orifices
Mouth and Pharynx . . . 0 Ear . . . 2 Female Genital Tract . . . 4
Nasal . . . 1 Anorectal . . . 3 Urethra . . . 5
CHAPTER 35 |
Character Position 5: Approach
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical region/orifices
3 Root operation term
4 Body region/orifice
5 Approach used by physician
6 Device
7 Qualifier
This one is easy; there is only one choice. Remember that all procedures reported from
the Placement Section do not involve incisions or punctures. This means all of these
devices are external.
External Approach . . . Character: X
It makes sense that there are several options for the character to report a device because
Placement that is really the primary activity of this section: placement of a device.
To put a device in or on an
Traction Apparatus . . . Character: 0
anatomical site.
Splint . . . Character: 1
Cast . . . Character: 2
Brace . . . Character: 3
Bandage . . . Character: 4
Packing Material . . . Character: 5
Pressure Dressing . . . Character: 6
Intermittent Pressure Device . . . Character: 7
Wire . . . Character: 9
Other Device . . . Character: Y
No Device . . . Character: Z
EXAMPLES
You might see phrases such as these in the documentation:
“. . . and a short arm splint, right side, was applied. . . .”
2W38X1Z Immobilization using a splint, upper extremity, right
“. . .The new Philadelphia collar was removed . . .”
2W52X3Z Removal of neck brace
There are no details reported by the Qualifier position, so the only option is Z No
Qualifier.
ICD-10-PCS
LET’S CODE IT! SCENARIO
Michael Shinto, a 31-year-old male, was in a fight at a bar and was punched in the face. Along with other injuries,
Michael’s lower jaw was dislocated. Dr. Northrop admitted Michael into the hospital due to internal bleeding. Once
in his room, Dr. Northrop took Michael to the procedure room to wire his jaw to immobilize it and permit it to heal.
CHAPTER 35 |
35.2 Reporting Services from the
Administration Section
Character Definitions
The meanings for the Administration Section characters are shown in the following
table:
For the most part, these character positions have different meanings than the other sec-
tions you have already learned about.
Procedures reported from the Administration Section will all begin with the
number 3.
EXAMPLE
Roy Shearmann, a 47-year-old male, was diagnosed with myelodysplastic syn-
drome several months ago when he presented with progressive pancytopenia.
Since admission, he has undergone treatment with antibiotics and has received
transfusion of nonautologous packed RBCs, administrated via peripheral vein, IV.
The patient continues on weekly Procrit. Code for the blood transfusion.
30233N1 Transfusion, nonautologous red blood cells, peripheral vein,
percutaneously
EXAMPLE
Illanya Sibgame, a pleasant 55-year-old female patient, is admitted to undergo
treatment for a non-Hodgkin lymphoma. While admitted, intrathecal chemo-
therapy, DepoCyt 50 mg (a low-dose interleukin-2 drug), was administered. She
did tolerate all treatments well with no complication noted, and once stable, was
made ready for discharge home.
3E0R303 Introduction of low-dose interleukin-2 antineoplastic, intrathecal
CHAPTER 35 |
Specifically for this section, the fourth character position will report the anatomical
site into which the substance is administered. Be careful. This may be different from
the site expected to benefit from the ultimate effect of this substance. For example, if
the substance is administered intradermally (such as an intradermal patch), the body
system/region would be skin and mucous membrane, whereas an IM (intramuscular)
injection would be reported as the muscle in this character position. IA (intra-arterial)
Administration or IV (intravenous) administrations would be reported to the peripheral artery or
To introduce a therapeutic, peripheral vein, respectively. However, if a catheter is used—for example, to travel to
prophylactic, protective, diag- administer the substance directly to a clot—this would be reported as a central artery
nostic, nutritional, or physi- or central vein, per the documentation.
ological substance. Oddly, there is an exception. When an irrigating substance (such as saline solu-
tion) is administered into an indwelling device (reported as body system C Indwelling
Device), the body system/region will be Z None.
This character will provide additional detail about the substance, if necessary.
EXAMPLES
Autologous . . . Character: 0
Nonautologous . . . Character: 1
Oxazolidinones . . . Character: 8
No Qualifier . . . Character: Z
ICD-10-PCS
LET’S CODE IT! SCENARIO
Sean McRoyale, a 41-year-old male, was admitted into McGraw Hospital. Dr. Toller administered nonautologous
pancreatic islet cells, intravenously.
(continued)
CHAPTER 35 |
Fourth character: Body Region: Peripheral Vein . . . 3
Venipuncture is performed percutaneously, directly into the vein.
Fifth character: Approach: Percutaneous . . . 3
There are many, many choices in this sixth character column. The documentation states, “pancreatic islet cells”
as the substance. Find it, and make certain it is on the same row as Peripheral Vein.
Sixth character: Substance: Pancreatic Islet Cells . . . U
What type of cells? The documentation states, “nonautologous.”
Seventh character: Qualifier: Nonautologous . . . 1
The ICD-10-PCS code you will report is
3E033U1 Introduction of nonautologous pancreatic islet cells, percutaneous, to peripheral vein
Good job!
EXAMPLE
An ECG measures the electrical activity of the heart at one point in time, whereas
a Holter monitor continuously monitors the heart’s rhythms over 24–48 hours.
1. ECG reported with 4A02X4Z Measurement of cardiac electrical activity,
external
2. Holter reported with 4A12XFZ Monitoring cardiac rhythms, externally
CHAPTER 35 |
The specific body system being measured or monitored is identified by the character
Measurement in the fourth position. Note that this section includes measurement or monitoring of
To determine a level of a a patient’s metabolism, temperature, or sleep. These are reported with a body system
physiological or physical of Z None.
function.
EXAMPLES
Central Nervous System . . . Character: 0
Cardiac System . . . Character: 2
Respiratory System . . . Character: 9
The approaches for this section are those you have come to know: 0 Open, 3 Percuta-
neous, 4 Percutaneous Endoscopic, 7 Via Natural or Artificial Opening, 8 Via Natural or
Artificial Opening Endoscopic, and X External.
In this character position, you will identify the specific body function being measured or
monitored, such as rhythm (F) of the heart or pressure (B) of the blood within the veins.
This character may also report a device, such as a pacemaker (S) or defibrillator (T).
Characters are available for measuring and/or monitoring a patient’s metabolism
(6), temperature (K), or sleep (Q), such as a sleep study. These three functions use a
body system character of Z None.
EXAMPLES
4A0HXCZ External measurement of fetal heart rate
4A1ZXQZ 48 hour sleep study, external monitoring
This character will provide additional detail about either the body part or system or the
procedure performed.
EXAMPLES
4A10X4G Monitoring of central nervous system activity, intraoperatively,
external
4A143J1 Monitoring of peripheral pulse, venous, external
Katrina Vales is a 17-year-old female with a history of asthma who was admitted with status asthmaticus. Once they
were able to stop the current attack, Dr. Giffen measures her respiratory volume using a spirometer.
(continued)
CHAPTER 35 |
The documentation states, “measures her respiratory volume. . . .”
Sixth character: Function/Device: Volume . . . L
On this row, there is only one option for the seventh character.
Seventh character: Qualifier: No Qualifier . . . Z
The ICD-10-PCS code you will report is
4A09XLZ Measurement of respiratory volume
Good job!
For the most part, the character positions for the Extracorporeal or Systemic Assis-
tance and Performance Section have similar meanings as in the other sections about
which you have already learned.
EXAMPLE
5A05221 Hyperbaric oxygenation of a wound, continuous (an example of
assistance because this is done to improve—or assist—the heal-
ing of the wound)
CHAPTER 35 |
The specific body systems being supported by these procedures are
Cardiac System . . . Character: 2
Circulatory System . . . Character: 5
Respiratory System . . . Character: 9
Biliary System . . . Character: C
Urinary System . . . Character: D
EXAMPLE
5A1D00Z Filtration of a single period of duration, urinary system (hemodi-
alysis takes over the physiological function of the urinary system
by extracorporeal means)
EXAMPLE
After the surgery, Brandon was kept on a ventilator for 31 hours.
5A1945Z Respiratory ventilator, 24–96 consecutive hours
EXAMPLE
5A2204Z Restoration of heart rhythm, single event (performing CPR)
ICD-10-PCS
LET’S CODE IT! SCENARIO
Linus Garza, a 63-year-old male, was in the hospital for surgery on his leg. During Linus’s admission, Dr. Reagan
ordered a CPAP machine to treat Linus’s obstructive sleep apnea, only at night.
(continued)
CHAPTER 35 |
You already learned that extracorporeal means “outside of the body.” You also need to know how a CPAP
machine works.
First character: Section: Extracorporeal or Systemic Assistance and Performance . . . 5
There is only one body system option for this section.
Second character: Body System: Physiological Systems . . . A
A CPAP machine helps the body’s breathing; it does not breathe for the patient. Therefore, assistance is the
appropriate root operation term.
Third character: Root Operation: Assistance . . . 0
The CPAP assists the patient’s breathing, so this is the Respiratory system.
Fourth character: Body System: Respiratory . . . 9
How long was Linus to be using the CPAP continuously? The documentation states, “only at night,” therefore,
less than 24 hours.
Fifth character: Duration: Less than 24 Consecutive Hours . . . 3
There is only one option for the sixth character, but it fits because ventilation, in health care, is breathing.
Sixth character: Function: Ventilation . . . 5
What does CPAP stand for?
Seventh character: Qualifier: Continuous Positive Airway Pressure . . . 7
The ICD-10-PCS code you will report is:
5A09357 CPAP ventilation, less than 24 consecutive hours
Good job!
For the most part, the character positions for the Extracorporeal or Systemic Thera-
pies Section have similar meanings as in the other sections about which you have
Procedures reported from the Extracorporeal or Systemic Therapies Section will all
begin with the number 6.
There are 11 root operation terms used to report procedures in this section.
CHAPTER 35 |
Atmospheric Control: Extracorporeal control of atmospheric pressure and com-
position . . . Character: 0
Decompression: Extracorporeal elimination of undissolved gas from body fluids
. . . Character: 1
Electromagnetic Therapy: Extracorporeal treatment by electromagnetic rays
. . . Character: 2
Hyperthermia: Extracorporeal raising of body temperature . . . Character: 3
Hypothermia: Extracorporeal lowering of body temperature . . . Character: 4
Pheresis: Extracorporeal separation of blood products . . . Character: 5
Phototherapy: Extracorporeal treatment by light rays . . . Character: 6
Ultrasound Therapy: Extracorporeal treatment by ultrasound . . . Character: 7
Ultraviolet Light Therapy: Extracorporeal treatment by ultraviolet light . . .
Character: 8
Shock Wave Therapy: Extracorporeal treatment by shock waves . . . Character: 9
Perfusion: Extracorporeal treatment by diffusion of therapeutic fluid . . .
Character: B
CHAPTER 35 |
When pheresis is performed, the Qualifier will specify what was used:
Erythrocytes . . . Character: 0
Leukocytes . . . Character: 1
Platelets . . . Character: 2
Plasma . . . Character: 3
Stem Cells, Cord Blood . . . Character: T
Stem Cells, Hematopoietic . . . Character: V
Ultrasound therapies performed on the circulatory system will utilize a Qualifier char-
acter to identify which specific vessels are being treated, when applicable:
Head and Neck Vessels . . . Character: 4
Heart . . . Character: 5
Peripheral Vessels . . . Character: 6
Other Vessels . . . Character: 7
No Qualifier . . . Character: Z
All other root operation terms (therapies) reported from this section have only one
option:
No Qualifier . . . Character: Z
ICD-10-PCS
LET’S CODE IT! SCENARIO
Nathan Teeger, a 17-year-old male, was out walking near the ski resort where he was vacationing. He fell into a soft
bed of snow and could not get out. The ski patrol took 5 hours to find him. At the hospital, Dr. Golden used hyperther-
mia to warm his body gently back to normal temperature. A single treatment was sufficient.
Procedures reported from the Osteopathic Section will all begin with the
number 7.
CHAPTER 35 |
Character Position 3: Root Operation
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical regions
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier
There is only one root operation used when reporting osteopathic services:
Somatic Treatment: Manual treatment to eliminate or alleviate somatic dysfunction and
Related to the body, espe- related disorders . . . Character: 0
cially separate from the brain
or mind.
EXAMPLE
7W03X2Z General mobilization of the lumbar region
EXAMPLE
7W06X8Z Isotonic muscle energy application to lower extremities
EXAMPLE
7W05X4Z Indirect treatment of the pelvic region
CHAPTER 35 |
There is only one option for this character in the Osteopathic Section:
No Qualifier . . . Character: Z
ICD-10-PCS
LET’S CODE IT! SCENARIO
Diane DeLucca, a 39-year-old female, was admitted due to a nerve condition in her face. After the results of the
tests were analyzed, Dr. Slack diagnosed her with Bell’s palsy. Dr. Slack, an osteopath, performed a facial release.
Procedures reported from the Other Procedures Section all begin with the number 8.
There is just one root operation term used to report procedures in this section.
Other Procedures: Methodologies that attempt to remediate or cure a disorder or
disease . . . Character: 0
CHAPTER 35 |
EXAMPLE
8C01X6J Collection of cerebrospinal fluid
EXAMPLE
Nervous System . . . Character: 1
Circulatory System . . . Character: 2
Head and Neck Region . . . Character: 9
Integumentary System and Breast . . . Character: H
Lower Extremity . . . Character: Y
The fifth character position, reporting the approach, will provide you with options
with which you have become familiar: 0 Open, 3 Percutaneous, 4 Percutaneous Endo-
scopic, 7 Via Natural or Artificial Opening, 8 Via Natural or Artificial Opening Endo-
scopic, and X External.
EXAMPLE
8E0W8CZ Procedure on trunk region, via natural or artificial opening
endoscopic, robotic-assisted
Anesthesia . . . Character: 0
In Vitro Fertilization . . . Character: 1
Breast Milk . . . Character: 2
Sperm . . . Character: 3
Yoga Therapy . . . Character: 4
Meditation . . . Character: 5
Isolation . . . Character: 6
Examination . . . Character: 7
Suture Removal . . . Character: 8
Piercing . . . Character: 9
Prostate . . . Character: C
Rectum . . . Character: D
With Fluoroscopy . . . Character: F
With Computerized Tomography . . . Character: G
With Magnetic Resonance Imaging . . . Character: H
No Qualifier . . . Character: Z
CHAPTER 35 |
ICD-10-PCS
LET’S CODE IT! SCENARIO
Gillian Petrovic, a 31-year-old female, just gave birth via c-section. The nurse provided a pump so that Gillian could
collect breast milk for the baby.
There is only one root operation used when reporting chiropractic services:
Manipulation: Manual procedure that involves a directed thrust to move a joint
past the physiological range of motion, without exceeding the anatomical
limit . . . Character: B
EXAMPLE
9WB1XBZ Non-manual manipulation of the cervical region
CHAPTER 35 |
Character Position 4: Body Region
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Anatomical regions
3 Root operation term
4 Body region
5 Approach
6 Method
7 Qualifier
EXAMPLE
9WB7XKZ Manipulation of upper extremities, externally, with mechanical
assistance
EXAMPLE
9WB4XFZ Manipulation of sacrum, external direct visceral method
ICD-10-PCS
LET’S CODE IT! SCENARIO
Ethan Logan, a 49-year-old male, works in a warehouse and hurt his back. He was admitted into the hospital for
tests to determine the extent of the injury. While in the hospital, Dr. Maggun, a chiropractor, performed mechanically
assisted manipulation on his lumbar region.
(continued)
CHAPTER 35 |
You will find only one option for each of the first three characters in this section.
First character: Section: Chiropractic . . . 9
Second character: Body Region: Anatomical Regions . . . W
Third Character: Root Operation: Manipulation . . . B
What region of Ethan’s body did Dr. Maggun treat?
Fourth character: Body Region: Lumbar . . . 3
There is only one option here for the fifth character, and it works because chiropractic treatments are done from
outside the body.
Fifth character: Approach: External . . . X
What method did Dr. Maggun use on Ethan? The documentation states, “mechanically assisted. . . .”
Sixth character: Method: Mechanically Assisted . . . K
Seventh character: Qualifier: None . . . Z
The ICD-10-PCS code you will report is
9WB3XKZ Chiropractic manipulation of the lumbar region using mechanical assistance
Good job!
ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: ALEX RENETTA
DATE OF ADMISSION: 06/14/2018
ADMITTING DIAGNOSIS: Crush fracture of left lower leg and foot
PAIN MANAGEMENT: The patient has stated that he is in severe pain. However, he is a recovering drug addict,
clean 7 years, and will not accept any narcotics.
Dr. Donnatelli, an acupuncture physician, came in and used acupuncture methodologies to result in anesthesia
effect for the left extremity. The patient was relieved by the treatment and the orthopedic surgeon was able to
manipulate and cast the leg.
Code for Dr. Donnatelli.
ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: TRAVIS CLAYTON
PREOPERATIVE DIAGNOSES:
1. C5–6 facet fracture
2. Left C6 radiculitis
POSTOPERATIVE DIAGNOSES:
1. C5–6 facet fracture
2. Left C6 radiculitis
OPERATIONS PERFORMED:
Attempted closed reduction of vertebral fracture and subluxation with traction.
OPERATION: The patient was taken to the OR and placed in the supine position. Using 1% lidocaine and antibiotic
ointment, Gardner-Wells tongs were placed in line with the external auditory meatus approximately a centimeter
above the ear. The anesthesiologist, Dr. Mastrioni, administered conscious sedation. The patient tolerated the
placement of tongs very well.
Ten pounds of traction were then added and a lateral C-arm image obtained, which showed persistent subluxation.
Manual traction was then applied and maneuvers attempted with rotation as well as flexion and extension in an attempt to
reduce the fracture. However, persistent subluxation was noted, and the decision was made to proceed with open reduction.
The patient was then administered general anesthetic with use of in-line traction. SSEP and EMG monitoring leads
were placed. A Foley catheter was in place. Preoperative antibiotics were administered. SCDs were applied. The
patient’s arms were tucked to the side. The cervical spine and the left anterior iliac crests were prepped and draped
in the standard sterile fashion.
(continued)
CHAPTER 35 |
Fourth character: Body Region: Neck . . . 2
Fifth character: Approach: External . . . X
Sixth character: Device: Traction Device . . . 0
Seventh character: Qualifier: No Qualifier . . . Z
Now, put it all together and report this ICD-10-PCS code:
2W62X0Z Traction apparatus, neck
Good job!
ICD-10-PCS
LET’S CODE IT! SCENARIO
Bruce Diaz, a 73-year-old male, was in a car accident and was admitted into the hospital with a concussion and
a fractured shoulder. His recent medical history reveals reduced renal function, so Dr. Wester ordered a session of
dialysis, to be done bedside. Teena Strunk came up with a mobile unit and performed the hemodialysis.
Chapter Summary
This chapter has given you the opportunity to walk through the Placement (2),
Administration (3), Measurement and Monitoring (4), Extracorporeal or Sys-
temic Assistance and Performance (5), Extracorporeal or Systemic Therapies (6),
Osteopathic (7), Other Procedures (8), and Chiropractic (9) sections of ICD-10-
PCS. You have seen how each character position is important to reporting all of the
pertinent details of a procedure, service, or treatment. You have learned that, in each
section, the same character can have a different meaning. However, you always have
the tables there to provide the options and their meanings to build the accurate code.
CHAPTER 35 REVIEW
Placement through Chiropractic Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
Sections
Let’s Check It! Terminology
Match each key term to the appropriate definition.
1. LO 35.4 Outside of the body. A. Administration
2. LO 35.1 To place a device in or on an anatomical site. B. Extra-articular
3. LO 35.3 To determine a level of a physiological or physical function. C. Extracorporeal
4. LO 35.6 Related to the body, especially separate from the brain or mind. D. Measurement
5. LO 35.8 Located outside a joint E. Placement
6. LO 35.2 To introduce a therapeutic, prophylactic, protective, diagnostic, nutri- F. Somatic
tional, or physiological substance.
CHAPTER 35 |
2. LO 35.1 Within the Placement Section, character position 3 Root Operation, Putting pressure on a body region
CHAPTER 35 REVIEW
CHAPTER 35 REVIEW
of a physiological or physical function repetitively over a period of time (identified by number 1) is known as
a. an abortifacient. b. monitoring.
c. measurement. d. laminaria.
14. LO 35.3 Within the Measurement and Monitoring Section, character position 6, measuring a patient’s tempera-
ture would be reported with which character?
a. F b. S
c. Q d. K
15. LO 35.3 Within the Measurement and Monitoring Section, character position 6, a sleep study would be reported
with which character?
a. B b. Q
c. X d. Z
CHAPTER 35 |
8. LO 35.5 Within the Extracorporeal or Systemic Therapies Section, character position 7 Qualifier, ultrasound ther-
CHAPTER 35 REVIEW
apies performed on the circulatory system, peripheral vessels, would be reported with which character or
number?
a. 6 b. X
c. 5 d. Z
9. LO 35.6 Within the Osteopathic Section, character position 6 represents which of the following?
a. Anatomical region b. Method
c. Body region d. Qualifier
10. LO 35.6 All of the Osteopathic Section procedures will begin with which section number?
a. 5 b. 4
c. 7 d. 1
11. LO 35.6 Within the Osteopathic Section, which of the following is an option for character position 3 Root Operation?
a. Treatment b. Manipulation
c. Phototherapy d. Electromagnetic therapy
12. LO 35.6 Within the Osteopathic Section, character position 6, which number identifies low velocity–high amplitude?
a. 0 b. 3
c. 5 d. 8
13. LO 35.7 All of the Other Procedures Section procedures will begin with which section number?
a. 5 b. 8
c. 7 d. 9
14. LO 35.7 Within the Other Procedures Section, character position 2 Body System, an indwelling device is identi-
fied with which of the following characters?
a. H b. E
c. Y d. C
15. LO 35.7 Within the Other Procedures Section, character position 5 Approach, a procedure performed via natural
or artificial opening is identified with which character or number?
a. 7 b. 3
c. 8 d. X
16. LO 35.7 Within the Other Procedures Section, character position 6 Method, acupuncture would be identified
with which character or number?
a. B b. 6
c. 0 d. D
17. LO 35.8 All of the Chiropractic Section procedures will begin with which section number?
a. 5 b. 8
c. 7 d. 9
18. LO 35.8 Within the Chiropractic Section, character position 2 Anatomical Regions, you have one option for the
character. Which of the following represents the anatomical regions?
a. B b. W
c. X d. Z
19. LO 35.8 Within the Chiropractic Section, character position 5 Approach, you have one option for the character.
Which of the following represents the approach?
a. Open b. Percutaneous
c. Via natural or artificial opening d. External
CHAPTER 35 REVIEW
will be reported with which character?
a. G b. F
c. J d. L
ICD-10-PCS
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-PCS code(s) for each case study.
1. Marvin Dunham, a 68-year-old male, is admitted to the hospital with a deep laceration to the forehead.
Dr. Wallace applies a pressure dressing to his head to control the bleeding.
2. Tony Botnet, a 62-year-old male, has a nose bleed that will not stop bleeding. Tony’s hemoglobin has
dropped, so he is admitted to the hospital. Dr. Caulkins packed his nasal cavity, external approach, to control
the bleeding.
3. Harry Watson, a 32-year-old male, is admitted to the hospital with a hemoglobin of 5.6 g/dL. Dr. Hanks per-
forms a red blood cell transfusion, peripheral vein, percutaneous, nonautologous.
4. Angela Niles, a 58-year-old female, has been in the hospital for 3 days with a peritoneal cavity indwelling
device. Dr. Adams performs an irrigation of the device with irrigation substance, percutaneous approach.
5. Cynthia Yackey, a 9-year-old female, is admitted to Westward Hospital with an unexplained high fever.
Dr. Hamilton measures Cynthia’s temperature.
6. Steven Wallace, an 18-year-old male, wanted to join his college’s football team. The team physical examina-
tion revealed a cardiac abnormality. Steven is admitted to Westward Hospital, where Dr. Jefferson monitors
Steven’s total cardiac activity under stress.
7. Meagan Garrison, a 43-year-old female, presents today with shortness of breath and a dry cough. Dr. Mansfield
admits Meagan to the hospital and monitors her respiratory capacity, external approach.
8. Mason Dugan, a 57-year-old male, has been hospitalized for a week. Mason’s lungs were not performing; he
was placed on a respiratory ventilator 5 days ago.
9. Kwakita Sumwalt, a 39-year-old female, presents today in cardiac dysrhythmia. Dr. Tumbokon admits
Kwakita to Westward hospital and restores Kwakita’s normal sinus rhythm.
10. Barbara Bell, a 33-year-old female, has been in the hospital for 4 days. Barbara has been complaining of right
foot pain, so Dr. Harrison performs extracorporeal shockwave therapy, right heel, single treatment.
CHAPTER 35 |
CHAPTER 35 REVIEW
11. Duncan Bowens, a 64-year-old male, has been hospitalized with diabetic polyneuropathy. He has also been
diagnosed with urinary incontinence. Today Duncan receives a single treatment of electromagnetic therapy
for his incontinence. Code today’s treatment.
12. Kimberly Morgan, a 59-year-old female, was in a car accident and has been hospitalized for 2 days. She is
currently having lower back pain. Today she receives an osteopathic treatment, lumbar region, low velocity–
high amplitude, external approach, to relieve the pain. Code today’s treatment.
13. Twanda Walters, a 34-year-old female diagnosed with trigeminal neuralgia, was admitted to Westward Hos-
pital for stereotacic radiosurgery, which is scheduled for later in the week. Today Twanda is in pain and
receives an acupuncture treatment, integumentary system, percutaneous approach, no qualifier. Code today’s
treatment.
14. Robert Thompson, a 16-year-old male, is admitted to the hospital with severe neck pain. Dr. Bell performs a
chiropractic manipulation of the cervical region, mechanically assisted, external approach, to try and relieve
the pain.
15. Susan Chapman, a 37-year-old female, is having chronic hip pain and has been admitted to Westward Hos-
pital. Dr. Dugan performs a chiropractic manipulation of the pelvic region with long and short lever specific
contact, external approach.
ICD-10-PCS
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documenta-
tion from our health care facility, Westward Hospital. These case studies are modeled on real patient encounters.
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-PCS code(s) for each case study.
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
DISCHARGE SUMMARY
PATIENT: NATHANSON, MYRA
DATE OF ADMISSION: 05/30/18
DATE OF DISCHARGE: 06/01/18
ADMITTING DIAGNOSIS: Status asthmaticus
DISCHARGE DIAGNOSIS: 1. Status asthmaticus.
2. Bronchiolitis, empirically treated.
CONSULTANTS: None.
BRIEF HISTORY: The patient is a 17-year-old white female with known history of asthma since infancy,
possible environmental allergies, who presented with progressive wheezing and respiratory distress
for the past 2 days. The patient had been doing well on only p.r.n. medications per family’s report. How-
ever, just previous to admission, the patient was exposed to dust and other particles after moving into
a new house. After conservative treatment at home, the patient was brought into the emergency room,
where she did not improve on albuterol, Atrovent treatments, or intravenous steroids immediately. Initial
examination showed tachycardia of 128, rest tachypnea of about 35–40, and inspiratory and expira-
tory wheezes and rhonchi on lung examination. The patient was referred for admission for evaluation of
worsening asthma and possible pneumonia.
Determine the most accurate ICD-10-PCS code(s) for the administration of the medications.
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
DISCHARGE SUMMARY
PATIENT: WARTTEL, JUDITH
DATE OF ADMISSION: 07/15/18
DATE OF SURGERY: 07/29/18
DATE OF DISCHARGE: 08/01/18
ADMITTING DIAGNOSIS: Peripheral vascular disease
DISCHARGE DIAGNOSIS: Peripheral vascular disease, status post right above-knee amputation.
PROCEDURES:
1. Hyperbaric oxygen therapy.
2. Hemodialysis.
3. Lower extremity arterial Doppler.
CHAPTER 35 |
CHAPTER 35 REVIEW
4. A 2D echocardiogram with left ventricular hypertrophy, inferior septal hypokinesis and mildly
impaired left ventricular function, sclerotic aortic valve, moderate mitral and severe tricuspid
insufficiency.
5. Lower extremity Doppler negative for deep venous thrombosis. Initial lower extremity Doppler posi-
tive for calf deep venous thrombosis in the right lower extremity.
DISCHARGE DIAGNOSES:
1. Peripheral vascular disease, status post right above-knee amputation.
2. End-stage renal disease.
3. Non-insulin diabetes mellitus.
4. Hypertension.
5. Atrial fibrillation.
6. Mild congestive heart failure.
7. Protein depletion.
8. Anemia of chronic disease and postoperative anemia.
9. Hypothyroidism.
HOSPITAL COURSE: The patient was initially admitted with right lower extremity calf thrombosis and
cellulitis of the right calf. The patient was seen by renovascular surgery and infectious disease. At that
time, she was started on IV antibiotics. She was continued with hyberbaric oxygen therapy (HBO), which
had been performed as an outpatient. The patient had a repeat lower extremity Doppler, which did not
reveal DVT; anticoagulation was discontinued at that time. The patient was seen by the pain manage-
ment service. The patient was seen by cardiology for wide complex tachycardia that was self-limiting.
No further workup was warranted by cardiology other than echo at this time. The patient’s Coumadin
was stopped and she was placed on Plavix due to bleeding. The patient continued on IV antibiotics and
wound care. The patient’s family requested a second opinion on above-knee amputation, as they were
wishing for a below-knee amputation. Dr. Gerald saw the patient and advised the same. The patient
underwent an AKA by Dr. Gerald without significant complications.
The patient was somewhat weak after surgery. She will continue with HBO and antibiotics. She was
transferred to the floor from the PCU. She will continue with good pulmonary toilet. She was started
back on Plavix and Coumadin was not restarted. She continued on hemodialysis. Accu-Chek and slid-
ing scale insulin were performed. The patient was arranged for skilled nursing facility (SNF) placement;
however, prior to SNF placement, she slipped out of the bed and fell on her stump. Initial x-ray showed
possible fracture. CT showed no fracture. The patient also had a full spinal x-ray and right shoulder x-ray
performed without significant abnormalities. There was an area seen on the right shoulder x-ray, in the
right parotid region, that appeared calcified; however, the patient does wear a bridge and had it on at
the time of the x-ray, most likely representing these findings. I would recommend follow-up x-ray in 1
month of the right mandibular area to ensure this is unchanged.
The patient is discharged to skilled nursing facility at this time. She has finished HBO at this time. She
will continue with hemodialysis as an outpatient. She is no longer on antibiotics. She will continue with
blood sugar control. I still recommend a follow-up right mandibular x-ray in 3 to 4 weeks to ensure there
are no changes and this definitely was the patient’s bridge. She will follow with renovascular surgery, ID,
cardiology, and skilled nursing facility MD once discharged.
Roxan Kernan, MD—4444
556848/mt98328: 08/01/18 09:50:16 T: 08/01/18 12:55:01
Determine the most accurate ICD-10-PCS code(s) for the hyperbaric oxygen therapy and hemodialysis.
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
DISCHARGE SUMMARY
PATIENT: KENSINGTON, CHARLES
DATE OF ADMISSION: 01/15/18
DATE OF DISCHARGE: 01/17/18
ADMITTING DIAGNOSIS: Confusion, staring
DISCHARGE DIAGNOSIS: Possible TIA
This is an outpatient 58-year-old right-handed white male with a history of episodes of confusion and
staring. He had an abnormal EEG in the past.
Routine 18-channel digital EEG was obtained to rule out any seizure activity or focal abnormalities.
FINDINGS: Background rhythm during awake stage shows well-organized, well-developed, average
voltage 8 to 9 Hertz alpha activity in the posterior regions. It blocks with eye opening and it is bilater-
ally synchronous and symmetrical. No spike-and-wave discharges or any lateralizing abnormalities are
seen. Photic stimulation did not produce any abnormalities. Hyperventilation was performed for 3 min-
utes. No abnormalities were found during the procedure. Intermittent EMG artifacts were seen. Stage II
sleep was not achieved.
IMPRESSION: Normal awake study. No epileptiform discharges or any other paroxysmal activities or
focal abnormalities seen. Clinical correlation is recommended.
Kenzi Bloomington, MD—7777
556839/mt98328: 01/17/18 09:50:16 T: 01/17/18 12:55:01
CHAPTER 35 |
CHAPTER 35 REVIEW
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
DISCHARGE SUMMARY
PATIENT: HELMSLEY, GRAYSON
DATE OF ADMISSION: 10/07/18
DATE OF DISCHARGE: 10/09/18
ADMITTING DIAGNOSIS: Abnormal liver function, weight loss
DISCHARGE DIAGNOSIS: Metastatic pancreatobiliary carcinoma and metastatic disease to the perito-
neal wall and the dome of the bladder
The patient is a 57-year-old male who was recently admitted to the hospital with significant weight loss
associated with abnormal liver function tests. A CAT scan of the abdomen and pelvis noted a large
mass in the tail of the pancreas and multiple hypodensities in the liver. He was seen in consultation
and was subjected to a CAT scan–guided liver biopsy. He was also subjected to tumor markers that
included a CEA and a CA19-9. He was noted to have markedly elevated CA19-9 at 2050. His CEA was
4.3 and his alfa-fetoprotein was less than 1.2.
The CAT-guided liver biopsy noted a high-grade infiltrating adenocarcinoma that was CK-7 and CAM
5.2 positive. The hepar antigen was negative. Based on this immunohistochemical staining, he was
noted to have a metastatic pancreatobiliary carcinoma. His staging workup with CAT scan of the chest
noted nonspecific mediastinal and axillary lymphadenopathy. The bone scan was essentially negative
for metastatic disease. The CAT scan of the pelvis noted an enlarged prostate with questionable inflam-
matory changes on the dome of the bladder. Based on this evaluation, he was diagnosed with meta-
static pancreatobiliary carcinoma and metastatic disease to the peritoneal wall and the dome of the
bladder.
Following his diagnosis, he was referred to me and has been started on palliative chemotherapy with
Gemzar. He has been tolerating Gemzar without much adverse effects. He was admitted to the hospital
early this morning with uncontrolled blood sugars. The most likely etiology of his uncontrolled blood
sugars is prednisone therapy.
Phillip Carlsson, MD—1111
556845/mt98328: 10/09/18 09:50:16 T: 10/09/18 12:55:01
Determine the most accurate ICD-10-PCS code(s) for the administration of the chemotherapy.
You might have noticed that character positions here have many of the same meanings
as for those in the Medical and Surgical Section. You learned a lot about imaging
services when you learned about coding from the Radiology Section of CPT, so you
have a bit of a head start for these procedures.
Character Position 1: Imaging Section B
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Body part (specific anatomical site)
5 Contrast
6 Qualifier
7 Qualifier
All of the codes from this section will begin with the letter B.
The body systems of the Imaging Section are very similar to those you learned about
for the Medical and Surgical Section:
Central Nervous System . . . Character: 0
Heart . . . Character: 2
Upper Arteries . . . Character: 3
Lower Arteries . . . Character: 4
Veins . . . Character: 5
Lymphatic system . . . Character: 7
Eye . . . Character: 8
Ears, Nose, Mouth, and Throat . . . Character: 9
Respiratory System . . . Character: B
Gastrointestinal System . . . Character: D
Hepatobiliary System . . . Character: F
Endocrine System . . . Character: G
Skin, Subcutaneous Tissue and Breast . . . Character: H
Connective Tissue . . . Character: L
Skull and Facial Bones . . . Character: N
Non-Axial Upper Bones . . . Character: P
Non-Axial Lower Bones . . . Character: Q
Axial Skeleton, Except Skull and Facial Bones . . . Character: R
Urinary System . . . Character: T
Female Reproductive System . . . Character: U
Male Reproductive System . . . Character: V
Anatomical Regions . . . Character: W
Fetus and Obstetrical . . . Character: Y
CHAPTER 36 |
From the brain to the toes, each body part is listed, specific to the body system in
conjunction with the root type.
EXAMPLES
Brain . . . Character: 0, under Central Nervous System, CT Scan
Coronary Artery, Single . . . Character: 0, under Heart, Fluoroscopy
Thoracic Aorta . . . Character: 0, under Upper Arteries, Plain Radiography
Abdominal Aorta . . . Character: 0, under Lower Arteries, MRI
Epidural Veins . . . Character: 0, under Veins, Plain Radiography
As you learned earlier in this textbook, there are several types of imaging procedures
performed with contrast materials. These materials may be barium or an iodine dye
that is injected to highlight or make the visceral organs and body parts more clearly
seen in the image.
High Osmolar High Osmolar . . . Character: 0
An ionic water-soluble iodin- Low Osmolar . . . Character: 1
ated contrast medium. Other Contrast . . . Character: Y
None . . . Character: Z
Low Osmolar
A non-ionic water-soluble ∙ High Osmolar: Also known as ionic contrast media. Examples include diatrizoate,
iodinated contrast medium. metrizoate, and iothalamate.
∙ Low Osmolar: Also known as organic or non-ionic contrast media. Examples
include iopamidol, ioxilan, and ioversol.
EXAMPLE
You might see something like this in the documentation about an MRI taken:
“. . . Multiplanar sagittal, coronal and axial images were obtained through the
left forearm prior to and following contrast administration using diatrizoate.
Markers have been placed near the patient’s indicated site of swelling, which
includes the dorsum of the distal left forearm and also over the wrist. . . .”
EXAMPLE
You might see something like this in the operative report:
“. . . The wire was then passed down to the superior vena cava without dif-
ficulty under direct fluoroscopy. . . .”
“. . . With fluoroscopy, the catheter was then checked. It was noted to be in
the superior vena cava just above the right atrium. . . .”
ICD-10-PCS
LET’S CODE IT! SCENARIO
Belinda Crandel, a 59-year-old female, has a family history of osteoporosis and was admitted into the hospital with
a hairline fracture of the right hip. Dr. Franklin took a plain radiographic densitometry of her right hip to see if osteo-
porosis was an underlying cause of the fracture.
(continued)
CHAPTER 36 |
Let’s Code It!
Let’s go through the steps of coding for ICD-10-PCS and determine the code or codes that should be reported
for the procedure that was performed.
First character: Section: Imaging . . . B
What body system was imaged? The documentation states, “her right hip,” which is a non-axial (not the head or
torso) lower bone.
Second character: Body System: Non-Axial Lower Bones . . . Q
What type of imaging was used? The documentation states, “plain radiographic.”
Third character: Root Operation: Plain Radiography . . . 0 (as in Zero)
Which specific body part was imaged? The documentation states, “her right hip.”
Fourth character: Body Part: Hip, Right . . . 0
There is no mention of any contrast being used, and there is only one option for the sixth character.
Fifth character: Contrast: None . . . Z
Sixth character: Qualifier: None . . . Z
The documentation does provide the detail for you to determine the accurate seventh character, where it states,
“densitometry.”
Seventh character: Qualifier: Densitometry . . . 1
The ICD-10-PCS code you will report is
BQ00ZZ1 Plain radiography densitometry, right hip
Good job!
2 Body system
3 Root type
4 Body part
5 Radionuclide
6 Qualifier
7 Qualifier
EXAMPLES
Central nervous system . . . Character: 0
Lymphatic and Hematologic System . . . Character: 7
Respiratory System . . . Character: B
Urinary System . . . Character: T
CHAPTER 36 |
The codes from the Nuclear Medicine Section only report procedures that are nonin-
vasive, meaning that the outer layer of the skin is not punctured and no incision is made.
Planar Nuclear Medicine Imaging: Introduction of radioactive materials into the
body for single-plane display of images developed from the capture of radio-
active emissions . . . Character: 1
Tomographic (Tomo) Nuclear Medicine Imaging: Introduction of radioactive mate-
rials into the body for three-dimensional display of images developed from the
capture of radioactive emissions . . . Character: 2
Positron Emission Tomographic (PET) Imaging: Introduction of radioactive materials
into the body for three-dimensional display of images developed from the simul-
taneous capture, 180 degrees apart, of radioactive emissions . . . Character: 3
Nonimaging Nuclear Medicine Uptake: Introduction of radioactive materials into
the body for measurements of organ function, from the detection of radioac-
tive emissions . . . Character: 4
Nonimaging Nuclear Medicine Probe: Introduction of radioactive materials into
the body for the study of distribution and fate of certain substances by the
detection of radioactive emissions; or alternatively, measurement of absorp-
tion of radioactive emissions from an external source . . . Character: 5
Nonimaging Nuclear Medicine Assay: Introduction of radioactive materials into
the body for the study of body fluids and blood elements, by the detection of
radioactive emissions . . . Character: 6
Systemic Nuclear Medicine Therapy: Introduction of unsealed radioactive materi-
als into the body for treatment . . . Character: 7
This section has only one option for the character reported in the sixth position:
None . . . Character: Z
CHAPTER 36 |
Character Position Character Meaning
3 Root type
4 Body part
5 Radionuclide
6 Qualifier
7 Qualifier
There are no details reported by this Qualifier position, so the only option is . . .
None . . . Character: Z
ICD-10-PCS
LET’S CODE IT! SCENARIO
Oscar Farrell, an 83-year old male, was admitted into the hospital with dyspnea and chest pain. Dr. Lowenthal did a
PET imaging of his lungs and bronchi, using Fluorine 18.
CHAPTER 36 |
There are only four root types used to describe the modality of these procedures:
Beam Radiation . . . Character: 0
Brachytherapy . . . Character: 1
Stereotactic Radiosurgery . . . Character: 2
Other Radiation . . . Character: Y
∙ Beam Radiation: Also known as external beam therapy (EBT), it uses one or more
beams of high-energy x-rays directed at a patient’s tumor.
∙ Brachytherapy: This method uses radioactive seeds that are placed in, or near, the
tumor (internally). These seeds produce a high radiation dose in a limited manner,
directly to the tumor. Use of this process controls the radiation exposure to sur-
rounding, healthy tissues.
∙ Stereotactic Radiosurgery: This radiation methodology uses a focused high-power
energy on a small area of the body, sometimes using a tool known as a CyberKnife.
NOTE: Radiosurgery is not a surgical procedure; it is a treatment with no incisions
made into the body.
EXAMPLES
Brain Stem . . . Character: 1, under Central and Peripheral Nervous System
Thymus. . . Character: 1, under Lymphatic and Hematologic System
Nose . . . Character: 1, under Ear, Nose, Mouth, and Throat
Bronchus . . . Character: 1, under Respiratory System
EXAMPLE
You may read something like these in the documentation:
“. . . Palladium 103 radioactive seeds were implanted according to the pre-
planned computer calculation—a total of 56 seeds through 16 needles, each
seed containing 1.04 mCi per seed. . . .”
“. . . We implanted a total of 54 iodine-125 radioactive seeds through
12 needles with each seed containing 0.373 millicurie per seed. . . .”
CHAPTER 36 |
Character Position 7: Qualifier
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type (Modality)
4 Treatment site
5 Modality qualifier
6 Isotope
7 Qualifier
This character will report that this radiation treatment was provided during a surgical
procedure—or not.
Intraoperative . . . Character: 0
No Qualifier . . . Character: Z
ICD-10-PCS
LET’S CODE IT! SCENARIO
Richard Raddison has been having severe pain in his stomach and was admitted into the hospital for tests. It was
determined that Richard had malignant lesions in the fundus and pylorus areas of his stomach. Dr. Benjamin per-
formed brachytherapy on Richard Raddison’s stomach using Cesium 137, high dose rate.
ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: CARL BERGERON
ORDERING PHYSICIAN: Elias Madison, MD
HPI: Patient was admitted yesterday after falling in his office with no apparent reason. A 5 cm laceration on his scalp
confirms that he hit his head on the desk, as he fell.
IMAGING: MRI OF THE HEAD
The MRI of the head shows diffuse atrophy. There is no abnormality of the craniocervical junction. There is a small
probable mucus retention cyst in the inferior right maxillary sinus. The brainstem is grossly intact. There is a slight
increase in atrophy with regards to the left temporal lobe in comparison to the right. This is mild asymmetry, how-
ever. No large territorial defects are noted.
There is, however, noted on both the T2 and FLAIR images an area of very vague high signal along the left mid
lateral ventricle region. This area of white matter suggests some probable demyelination. This is brought up in par-
ticular because, when contrast was given, there was a very vague sliver of enhancement directly in that area. This
is seen on coronal imaging as well. This could be related to some collateral vessels and they are seen with contrast.
Collateral vessels will be necessary due to the absence of good flow to the left MCA and ICA distribution on the
left on the MRA, which will be described further following this report. Therefore, that is felt the most likely etiology.
Other etiologies on this very vague and subtle enhancement would be tumor or luxury blood flow around a recent
small ischemic insult. I would recommend that this simply be followed up over time in approximately 6 to 9 months
or sooner if symptoms change.
There is no other area of enhancement of concern that is noted. We do see some asymmetry to the vascular
venous drainage pattern with the gadolinium on the axial images in the posterior fossa and around the tempo-
ral lobe region on the left, which most likely again is related to the change in collateral flow to the left cerebral
hemisphere.
The IAC and cerebellopontine angle regions do not show masses. No enhancing abnormality is noted to suggest
an acoustic tumor. The inner ear and mastoid air cells are well aerated.
IMPRESSION:
1. Diffuse atrophy.
2. FLAIR and T2 weighted images suggest some ischemic high signal changes in the white matter adjacent to
the left lateral ventricle. In this area, with gadolinium, a small sliver of enhancement persists on both axial and
coronal images. This sliver of enhancement may be related to collateral blood flow or luxury perfusion or recent
ischemic insult. It could, though felt less likely, be related to mild enhancement of an underlying tumor. I feel this is
less likely, and in light of no change in clinical symptoms, I would recommend simply a repeat MRI with gadolinium
in approximately 6 to 9 months.
3. No other abnormal enhancement is noted.
4. There is a mild increase in atrophy with regards to the left temporal lobe when compared to the right; however,
this is diffuse and subtle.
5. The internal auditory canal and cerebellopontine angle regions are normal in appearance.
Lawrence Katenberg, MD, Radiology
Let’s Code It!
According to the documentation, Dr. Katenberg is interpreting an MRI done of Carl’s head. Let’s determine the
seven characters needed to build this code.
First character: Section: Imaging . . . B
Second character: Anatomical Regions . . . W
(continued)
CHAPTER 36 |
Third character: Root Operation: Magnetic Resonance Imaging (MRI) . . . 3
Fourth character: Body Part: Head . . . 8
Was contrast used? The documentation states, “when contrast was given.” There is only one choice to report
that contrast was used.
Fifth character: Contrast: Other Contrast . . . Y
Sixth character: Qualifier: Unenhanced and Enhanced . . . 0
Seventh character: Qualifier: None . . . Z
Now, put it all together and report, with confidence, this code:
BW38Y0Z MRI, head, unenhanced and enhanced
Good work!
ICD-10-PCS
LET’S CODE IT! SCENARIO
The patient is a 71-year-old female who was admitted last night due to subacute progressive spasticity over the
last 7 months, increased difficulty walking, increased difficulty moving her right arm and hand, as well as increased
rigidity. Her primary care physician has taken multiple MRIs, which included contrast, and there did not seem to be
any abnormalities on his review.
She was given a provisional diagnosis of cerebral palsy, which does not fit with the natural course of this disease,
as she was normal when she was a child. There seems to be an extrapyramidal as well as pyramidal component on
examination today, but I do not appreciate spastic paraparesis as she was previously evaluated to have. The time
course and progression of symptoms suggest a degenerative process with pyramidal and extrapyramidal component
that could be part of secondary parkinsonian spectrum disease. Perhaps there is a hereditary component to this.
I ordered lab work today to include ferritin, ceruloplasmin, copper, and liver function tests and Wilson disease
screening. Also, as per my earlier order, she has just had a PET imaging with C-11 of her brain.
(continued)
CHAPTER 36 |
CHAPTER 36 REVIEW
Chapter Summary
Imaging is a wonderful way for a physician to see inside the body to help determine a
diagnosis. Nuclear medicine techniques enable the assessment of metabolic functions
and can be used for either diagnostic or therapeutic purposes. And radiation therapies
provide an efficacious way to treat malignancy. When provided to a patient who has
been admitted into the hospital, these services and treatments are reported with a code
from one of these sections.
CODING BITES
For those Imaging, Nuclear Medicine, and Radiation Therapy services that use
pharmaceuticals, you will need an additional code to report more details about the
specific contrast material. You can find these drug codes in your HCPCS Level II
code book.
Examples
(Contrast) High Osmolar contrast material, up to 149 mg/ml iodine concentration,
per ml . . . code Q9958
(Contrast) Low Osmolar contrast material, 400 or greater mg/ml iodine concentra-
tion, per ml . . . code Q9951
(Radionuclide) Technetium 99m arcitumomab, diagnostic, per study dose, up to
45 millicuries . . . code A9568
(Isotope) Iodine I-125 serumalbumin, diagnostic, per 5 microcuries . . . code A9532
CHAPTER 36 REVIEW
Imaging, Nuclear Medicine, and Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
CHAPTER 36 REVIEW
Choose the most appropriate answer for each of the following questions.
1. LO 36.1 Within the Imaging Section, character position 5 represents which of the following?
a. Body system b. Contrast
c. Device d. Qualifier
2. LO 36.1 All of the codes reporting an Imaging Section procedure will begin with what section letter?
a. A b. B
c. D d. F
3. LO 36.1 All of the following would be found within the Imaging Section, character position 3 Root Type, except
a. x-ray. b. CT scan.
c. PET. d. MRI.
4. LO 36.1 Within the Imaging Section, character position 6 Qualifier, which of the following are available options?
a. Unenhanced and enhanced b. Laser
c. Intravascular optical coherence d. All of these
5. LO 36.2 Within the Nuclear Medicine Section, character position 1 is identified by which of the following sec-
tion letters?
a. E b. B
c. D d. C
6. LO 36.2 Within the Nuclear Medicine Section, which character position represents the radioactive materials—
the source of the radiation being used?
a. 5 b. 4
c. 3 d. 2
7. LO 36.2 Introduction of radioactive materials into the body for three-dimensional display of images developed
from the capture of radioactive emissions, identified by the character 2, is known as
a. positron emission tomographic (PET) imaging. b. planar nuclear medicine imaging.
c. nonimaging nuclear medicine uptake. d. tomographic (tomo) nuclear medicine imaging.
8. LO 36.3 Within the Radiation Therapy Section, which character position describes the modality of the
procedure?
a. 5 b. 4
c. 3 d. 2
9. LO 36.3 Californium would be classified as
a. a treatment site. b. an isotope.
c. a modality. d. a qualifier.
10. LO 36.3 Within the Radiation Therapy Section, character position 7 Qualifier, which of the following characters
represents the radiation treatment provided during a surgical procedure?
a. Z b. 0
c. X d. 1
CHAPTER 36 |
Rev. Confirming Pages
2. LO 36.1 List the types of qualifiers found in the Imaging Section, character position 7, Qualifier; include the
CHAPTER 36 REVIEW
ICD-10-PCS
YOU CODE IT! Practice
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-PCS code(s) for each case study.
1. Edward Baker, a 26-year-old male, was riding his dirt bike and fell off, hurting his left ankle. Ed presents to
Westward Hospital, where Dr. Dyson takes an x-ray, without contrast, of the ankle. Dr. Dyson also notes
hemarthrosis and admits Ed to Weston Hospital. Code the x-ray.
2. Phoebe Eaddy, a 16-year-old female, complains of urinary dribbling and feels like her bladder is still full
after voiding. Phoebe was diagnosed with type 1 diabetes 3 years ago. Dr. Barbato admits Phoebe to Weston
Hospital and performs an ultrasound of Phoebe’s urethra, which reveals nerve damage caused by her diabetes.
Code the ultrasound.
3. Hugo Abbott, a 49-year-old male, has been diagnosed with osteosarcoma of his right knee. Hugo has been
having difficulty, so Dr. Simmons admits Hugo to Westward Hospital, where an MRI, without contrast, of his
right knee is performed.
4. Gregg Huggins, a 25-year-old male diagnosed with Graves’ disease, is admitted to the hospital for a planar
nuclear medicine imaging procedure of his thyroid gland, iodine 123 (I-123).
5. Hazel Baker, a 51-year-old female, is admitted to the hospital for a tomographic nuclear medicine imaging
procedure of her parathyroid glands, radionuclide—technetium 99m (Tc-99m).
6. Susan Gibbons, a 43-year-old female, is admitted to Westward Hospital for a positron emission tomographic
(PET) imaging procedure of the lungs and bronchi, radionuclide—fluorine 18 (F-18).
7. Glenda McMahon, a 41-year-old female, is admitted to the hospital due to severe abdominal pain. Dr. Har-
mon performed a liver and spleen tomography.
8. Joe Jefferson, a 72-year-old male, is admitted to the hospital with heart palpitations and edema of his legs and
feet. Dr. Moss performs a heart positron emission tomographic (PET) scan.
9. Frank Ogburn, a 48-year-old male, has unexplained skeletal pain and is admitted to Westward Hospital so
Dr. Cannon can perform a systemic nuclear medicine therapy whole body scan, strontium 89 (Sr-89).
10. Ozie Lewis, a 73-year-male, has been diagnosed with esophageal cancer. Ozie was admitted to Westward
Hospital for beam radiation therapy to the esophagus, photons 1–10MeV.
11. Jeff McCord, a 37-year-old male, was admitted to Westward Hospital 3 days ago and has been diagnosed with
lymphatic cancer. Today Jeff receives his first treatment of brachytherapy of the inguinal lymphatic nodes,
low dose rate, iridium 192 (Ir-192).
12. Harry Glover, a 38-year-old male, was admitted to Westward Hospital for sterotactic gamma beam radiosur-
gery on his eye.
13. Alna Lindsay, a 68-year-old female, was admitted to Westward Hospital today for brachytherapy of the hypo-
pharynx, low dose rate, iodine 125 (I-125) treatment.
14. Charles Medlin, a 31-year-old male, has been diagnosed with a lung tumor and was admitted to Westward
Hospital for stereotactic particulate radiosurgery.
The following exercises provide practice in abstracting physicians’ notes and learning to work with documenta-
tion from our health care facility, Westward Hospital. These case studies are modeled on real patient encounters.
Using the techniques described in this chapter, carefully read through the case studies and determine the most
accurate ICD-10-PCS code(s) for each case study.
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PATIENT: ALTERMANN, AMANDA
DATE OF ADMISSION: 8/01/18
DIAGNOSIS: Concussion
REFERRING PHYSICIAN: Jacob Huffman, MD
Pt is a 52-year-old female, who presented to the emergency room accompanied by her husband, Ron.
Pt is complaining of a severe headache and seeing stars. Her husband said she was standing on a lad-
der when she fell off, striking her head; she lost consciousness for approximately 3 minutes. Dr. Huffman
notes some disorientation, slurred speech, and a delay in response to his questions. Amanda is admit-
ted to the hospital with a concussion. A skull x-ray without contrast and brain MRI without contrast are
both performed.
Determine the most accurate ICD-10-PCS code(s) for the imaging procedure(s).
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
RADIOLOGIST REPORT
PATIENT: GRIFFTH, KERRAN
DATE OF ADMISSION: 08/19/18
DATE OF DISCHARGE: 08/23/18
PREOP DIAGNOSIS: Right ureteral obstruction secondary to colon cancer
POSTOP DIAGNOSIS: Right ureteral obstruction secondary to colon cancer
SURGEON: Roger Abernathy, MD
ANESTHESIA: Moderate sedation
CHAPTER 36 |
CHAPTER 36 REVIEW
Operation:
1. Cystoscopy
2. Right retrograde pyelogram with contrast
3. Removal and replacement of double-J stent
HISTORY/INDICATIONS: This is a 32-year-old female with a history of colon cancer of the cecum and
secondary right ureteral obstruction who had a stent inserted a number of months ago. At this time, she
is in the hospital and it is time for a stent change. Consequently, the patient presents for the procedure.
PROCEDURE: The patient was taken to the operating room and there she was given midazolam, 0.5mg,
positioned in the dorsal lithotomy position, and the genitalia scrubbed and prepped with Betadine.
Sterile towels and sheets were utilized to drape the patient in the usual fashion. A cystoscope was intro-
duced into the bladder. The ureteral catheter was identified. It was grabbed and removed without any
difficulty. Subsequently, the cystoscope was reinserted into the bladder and the right ureteral orifice
was identified over a Pollack catheter. A glide wire was inserted into the right collecting system. Some
contrast was injected and a hydronephrotic right side was noted. Then, the wire was placed through the
Pollack catheter. With the wire in position, over the wire a 7 French 26 cm double-J stent was inserted.
Excellent coiling was noted fluoroscopically in the kidney and distally with a cystoscope. The bladder
was then drained and again it was inspected prior to removal. There was no evidence of any tumors or
lesions in the bladder. The stent was in good position. The cystoscope was removed and the patient
was taken to the recovery room awake and in stable condition.
Roger Abernathy, MD
556848/mt98328: 08/23/18 09:50:16 T: 08/23/18 12:55:01
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
RADIOLOGY SUMMARY
PATIENT: LACTANA, LAVINIA
DATE OF ADMISSION: 03/05/18
DATE OF DISCHARGE: 03/17/18
ADMITTING DIAGNOSIS: Bilateral breast asymmetry and ptosis, status post left lumpectomy and radia-
tion therapy for cancer.
DISCHARGE DIAGNOSIS: Bilateral breast asymmetry and ptosis, status post left lumpectomy and radia-
tion therapy for cancer.
This 41-year-old single female is status post surgery cleared for bilateral high dose brachytherapy with
palladium 103.
Patient tolerated her first treatment and was returned to her room.
Jennell Goren, MD
556845/mt98328: 03/17/18 09:50:16 T: 03/17/18 12:55:01
CHAPTER 36 |
CHAPTER 36 REVIEW
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
JOANNE STAFFORD, MD
556845/mt98328: 10/09/18 09:50:16 T: 10/09/18 12:55:01
Determine the most accurate ICD-10-PCS code(s) for the imaging procedure(s).
The root type terms are unique to report procedures in this section.
EXAMPLES
Neurological System—Whole Body . . . Character: 3
Circulatory System—Upper Back/Upper Extremity . . . Character: 5
Genitourinary System . . . Character: N
CHAPTER 37 |
The character placed in this position will provide additional detail about the root type.
EXAMPLES
Under Root Type Speech Assessment, the fifth character may identify
Motor Speech (B) or Fluency (D)
while under Root Type Activities of Daily Living, the fifth character may report
Feeding/Eating (2) or Home Management (4)
EXAMPLES
F06Z9PZ Orofacial myofunctional speech treatment using a computer
F13ZC1Z Hearing assessment pure tone stenger, with audiometer
ICD-10-PCS
LET’S CODE IT! SCENARIO
Elias Garmine, a 67-year-old male, was admitted after having a stroke (CVA). Anita Cohen, a certified physical thera-
pist, is working with him on functional ambulation due to right-side hemiplegia.
CHAPTER 37 |
Character Position 1: Mental Health Section G
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier
Procedures reported from the Mental Health Section will begin with the letter G.
EXAMPLES
Developmental . . . Character: 0, under Psychological Tests
Interactive . . . Character: 0, under Individual Psychotherapy
Educational . . . Character: 0, under Counseling
Unilateral-Single Seizure . . . Character: 0, under Electroconvulsive Therapy
CHAPTER 37 |
Character Position 5: Qualifier
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body system
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier
The only option in this position is
None . . . Character: Z
ICD-10-PCS
LET’S CODE IT! SCENARIO
While in the hospital for repair of a stomach ulcer, Carlos Weiner, a 53-year-old male, was behaving oddly.
Dr. Albessi performed some neuropsychological testing.
(continued)
CHAPTER 37 |
Character Position Character Meaning
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier
Substance Abuse Procedures reported from the Substance Abuse Treatment Section will all begin
Regular consumption of a sub- with the letter H.
stance with manifestations.
Character Position 2: Body Systems
Character Position Character Meaning
1 Section of the ICD-10-PCS book
2 Body systems
3 Root type
4 Type qualifier
5 Qualifier
6 Qualifier
7 Qualifier
There is only one option for the second character:
None . . . Character: Z
EXAMPLES
12-Step . . . Character: 3, under Individual Counseling
Interactive . . . Character: 5, under Individual Psychotherapy
Nicotine Replacement . . . Character: 0, under Pharmacotherapy
CHAPTER 37 |
In this character position, the only option is
None . . . Character: Z
ICD-10-PCS
LET’S CODE IT! SCENARIO
Harrison Argan has been in the New Horizons Substance Abuse Rehabilitation Hospital for 2 weeks now. Today,
Dr. Lerner meets with Harrison for medication management with his methadone maintenance treatment plan.
CHAPTER 37 |
Currently, in this section, there are only five body systems from which to choose:
Cardiovascular System . . . Character: 2
Skin, Subcutaneous Tissue, Fascia, and Breast . . . Character: H
Muscles, Tendons, Bursae and Ligaments . . . Character: K
Bones . . . Character: N
Joints . . . Character: R
Anatomical Regions . . . Character: W
Extracorporeal . . . Character: Y
CHAPTER 37 |
External: Procedures performed directly on the skin or mucous membrane and
procedures performed indirectly by the application of external force through the
skin or mucous membrane . . . Character: X
Bones
Magnetically Controlled Growth Rod(s): Magnetically controlled growth rods are
new innovations, especially for children requiring spinal surgery for scoliosis.
Instead of sequential surgical procedures to adjust the rods as children grow,
the surgeon can use a magnetic device, in the office, to lengthen the rods, in just
minutes . . . Character: 3
Joints
Intraoperative Knee Replacement Sensor: Intraoperative sensors are a disposable
tibial insert used to aid orthopedic surgeons in placing prosthetic joint compo-
nents during knee replacement surgery . . . Character: 2
Interbody Fusion Device, Nanotextured Surface: The fusion of vertebral joints is
not new, but the use of the nanotextured surface is now reported with a code
built from this new table . . . Character: 9
Interbody Fusion Device, Radiolucent Porous . . . Character: F
Anatomical Regions
Ceftazidime-Avibactam Anti-infective: This is provided for the treatment of adult
patients with complicated intra-abdominal infections and complicated urinary tract
Extracorporeal
Endothelial Damage Inhibitor: Endothelial dysfunction describes manifestations
of cardiovascular risk including diminished production and reduced availability
of nitric oxide as well as the possible imbalance in the relative contribution of
endothelium-derived relaxing and contracting factors . . . Character: 8
CHAPTER 37 |
The reporting of these procedures will use the character 1 (the number one) or 2 (the
number two). Each year, this character will change as new codes are added to this
specific section. So, for 2017, the seventh character options are
New Technology Group 1 . . . Character: 1
New Technology Group 2 . . . Character: 2
New Technology Group 3 . . . Character: 3
The next year that innovations are approved and added to the code set, they will be
identified with a qualifier of 3. This will continue each year, as new details are placed
into the code set.
ICD-10-PCS
LET’S CODE IT! SCENARIO
Carl Terrosa, a 45-year-old male, has been trying to lower his cholesterol; however, he was diagnosed with two
severely calcified coronary lesions. He was admitted to the hospital so Dr. Garrison could perform orbital atherec-
tomy, a new technology to remove the calcification in two sites. Unlike some previous methodologies, this is per-
formed percutaneously, reducing the risk and Carl’s length of stay.
ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT NAME: ALFREDO SUGERMAN
DATE OF EVALUATION: 11/16/2018
ATTENDING PHYSICIAN: Oscar Clarice, MD
(continued)
CHAPTER 37 |
Sixth character: Qualifier: None . . . Z
Seventh character: Qualifier: None . . . Z
Now, you can report this ICD-10-PCS code with confidence:
GZ14ZZZ Neurobehavioral and cognitive status psychological tests
ICD-10-PCS
LET’S CODE IT! SCENARIO
PATIENT: FRANCIS FREDERICKS
The patient had been seen by this department for a clinical swallowing evaluation. At that time, he had reported 3 to
4 months of coughing with liquids, approximately one time per week. He had a barium swallow, which showed one
episode of aspiration with appropriate cough response. Given the patient’s complaints of coughing with thin liquids
and possible reflux-related symptoms, an objective swallowing evaluation was recommended. However, the patient
chose not to follow up for further objective testing at that time.
Admitted today for left side weakness, he is reporting that dysphagia has persisted, and now he feels as though
he can cough or choke several times a day with either liquids or solids. He is on a regular diet. He takes his pills with
water without difficulty. He has a reported 5- to 10-pound weight loss over the past several months that has been
unexplained. His physician has asked him to gain some weight to improve his nutritional status. He has no recent
history of pneumonia. The patient does complain of feeling as though he has sluggish passage of his meals and
sometimes this will cause him to stop eating early. He has a feeling of increased mucus with frequent throat clear-
ing throughout the day, and he complains of frequent heartburn. He is not on any proton pump inhibitor regimen at
this time.
PAST MEDICAL HISTORY: Coronary artery disease requiring LAD stent placement, hypertension, hyperlipid-
emia, asymptomatic right carotid stenosis, chronic anemia due to renal disease, chronic renal insufficiency that
is stable.
CLINICAL OBSERVATIONS: I am performing this swallow dysfunction study at the request of Dr. King. He uses a
walker due to knee trouble and the weakness, but he is brought to our office by an orderly in a wheelchair. He is fully
alert and oriented, slightly hard of hearing. He is able to provide a comprehensive history. Good speech intelligibility.
Vocal quality is slightly raspy, although otherwise within normal limits for age and gender.
ORAL PERIPHERAL EXAM: The patient has naturally present dentition, in poor condition. There is bilateral palatal
elevation, good lingual and labial strength and range of motion, and good ability to maintain intraoral pressure.
Cough is strong and unproductive. There is good hyolaryngeal elevation and excursion to palpation.
SWALLOWING EVALUATION: Administered p.o. trials of ice chips, thin puree, and particulate solid.
ORAL PHASE: The patient is able to self-feed appropriately. He has good bolus containment and timely anterior to
posterior transit with mildly delayed trigger of pharyngeal swallow overall. Question premature spillage with multiple
sips of thin liquids.
PHARYNGEAL PHASE: Audible and question slightly discoordinated swallowing pattern for multiple sips of thin liq-
uids. One swallow required for single sips of thin, puree, and particulate solids. No overt clinical signs or symptoms
of aspiration after any p.o. trial, although the patient reports that he had slight difficulty with the initial sip of water,
feeling like it might head down the wrong pipe.
SUMMARY AND IMPRESSION: The patient is an 87-year-old male with a several-year history of reported dys-
phagia to solids and liquids. This can happen several times per day. Clinically, he does not show significant overt
clinical signs of aspiration, although question discoordinated swallowing pattern for thin liquids, especially when
given larger quantities. This is likely consistent with the one incidence of symptomatic aspiration on a barium swal-
low in the past. The patient also complains of multiple symptoms that appear consistent with laryngopharyngeal
reflux, and these include increased mucus, throat clearing, and globus sensation. He reports frequent heartburn
CHAPTER 37 |
ICD-10-PCS
LET’S CODE IT! SCENARIO
George is a 19-year-old male, self-referred for inpatient treatment due to drug and alcohol abuse. He is currently
unemployed and homeless, and has charges pending due to a number of “bounced” checks written over the past
several months. George reports that both of his parents were drug addicts and he experienced physical, sexual, and
emotional abuse throughout childhood at their hands. His father died of liver disease at the age of 37.
George also reports that, at the age of 12, he was kicked out of his family’s home because his father suspected
that he was gay. Although they live in the same town, he has not had any contact with either parent for 7 years.
George describes his relationship with his younger sister as “fair.” He is not presently involved in a steady relation-
ship but does have a network of friends in the local gay community with whom he has been staying off and on. At
the time that he left home, George survived by becoming involved in sexual relationships with older men, many of
whom were also abusive. He has had numerous sexual partners (both male and female) over the past 7 years, has
traded sex for drugs and money, has had sex under the influence of drugs and alcohol, and has been made to have
sex against his will. George identifies himself as bisexual, not gay.
George first used alcohol at age 11, when he had his first sexual encounter with a man. He began using other
drugs, including inhalants and marijuana, by age 16 and amphetamines and cocaine by age 17. At 18, 3 months prior
to entering treatment, he began using crack.
This first individual counseling session was focused on this basic, interpersonal foundation to enable us to establish an
efficacious treatment plan. George is strong in his desire to get clean, and I have assured him that we can help him here.
Chapter Summary
This chapter has given you the opportunity to walk through the Physical Rehabilita-
tion and Diagnostic Audiology (F), Mental Health (G), Substance Abuse Treat-
ment (H), and New Technology (X) sections of ICD-10-PCS. You have seen how
each character position is important to reporting all of the pertinent details of a proce-
dure, service, or treatment. You have learned that, in each section, the same character
can have a different meaning. However, you always have the Tables there to provide
the options and their meanings to build the accurate code.
CODING BITES
More Information:
Physical Medicine and Rehabilitiation
https://medlineplus.gov/ency/article/007448.htm
National Alliance on Mental Illness (NAMI)
https://www.nami.org/Learn-More/Treatment
Substance Abuse and Mental Health Services Administration
http://www.samhsa.gov/treatment
CHAPTER 37 REVIEW
Physical Rehabilitation and Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
CHAPTER 37 |
7. LO 37.3 All of the codes reporting a Substance Abuse Treatment Section procedure will begin with which sec-
CHAPTER 37 REVIEW
tion letter?
a. F b. H
c. J d. K
8. LO 37.3 Within the Substance Abuse Treatment Section, the encounter documents Not a treatment modality but
helps the patient stabilize physically and psychologically until the body becomes free of drugs and the
effects of alcohol, represented by the character 2. This is known as
a. individual psychotherapy. b. medication management.
c. pharmacotherapy. d. detoxification services.
9. LO 37.3 Within the Substance Abuse Treatment Section, what character position adds detail to the description of
the Root Type?
a. 4 b. 5
c. 6 d. 7
10. LO 37.4 All of the codes reporting a New Technology procedure will begin with the section letter
a. Z b. X
c. Y d. W
ICD-10-PCS
ICD-10-PCS
YOU CODE IT! Application
The following exercises provide practice in abstracting physicians’ notes and learning to work with documentation
from our health care facility, Westward Hospital. These case studies are modeled on real patient encounters. Using
the techniques described in this chapter, carefully read through the case studies and determine the most accurate
ICD-10-PCS code(s) for each case study.
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PROGRESS NOTES
CHAPTER 37 |
CHAPTER 37 REVIEW
Determine the most accurate ICD-10-PCS code(s) for the Ceftazidime-Avibactam Anti-infective.
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
DISCHARGE SUMMARY
PATIENT: GILLINS, MARTIN
DATE OF ADMISSION: 07/15/18
DATE OF SURGERY: 07/29/18
DATE OF DISCHARGE: 08/01/18
DIAGNOSIS: Left below-knee amputation
DISCHARGE DIAGNOSIS: Pt is a 67-year-old male with a history of peripheral arterial disease and
lower extremity bypass surgeries who was admitted with gangrene of left foot. The patient underwent
left below-knee amputation.
PAST MEDICAL HISTORY: Hyperlipidemia and hypertension.
SOCIAL HISTORY: Lives with wife.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: At the time of admission, the patient was afebrile. Vital signs are stable.
Temperature 97.7. Blood pressure 131/71. Oral mucosa was moist. Sclerae anicteric. Lungs: Bilaterally
clear to auscultation. Heart: Regular. Abdomen: Scaphoid. Right foot intact. Minimal erythema. Minimal
edema.
HOSPITAL COURSE: Dr. Norcross notes patient is medically stable. Compression was not used due
to the significant ischemia. The patient was placed on Avelox. Bowels moved on a regular basis. The
patient responded to rehabilitation well. Appetite is improving. Albumin was 2.7. Hemoglobin was 11.4.
The patient was able to perform all ADLs with supervision. Good range of motion was noted to the left
knee. No dehiscence was found. Wife will act as caregiver and was trained in wound care manage-
ment. The patient was discharged to wife.
Karen Norcross, MD
556848/mt98328: 08/01/18 09:50:16 T: 08/01/18 12:55:01
Determine the most accurate ICD-10-PCS code(s) for the caregiver training.
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PATIENT: WRIGHT, ROBBIN
DATE OF ADMISSION: 03/05/18
DATE OF DISCHARGE: 03/17/18
ADMITTING DIAGNOSIS: Marijuana abuse
ATTENDING PHYSICIAN: Jennell Goren, MD
Robbin Wright, a 16-year-old female, presented to Dr. Goren complaining of a cough and a sore throat,
lasting about 1 week. She and her mother deny fever, nasal congestion, or runny nose. She says she feels
more tired than usual and her mom states that she hasn’t been getting out of bed to go to camp or any
other activities. Mom seems most worried that she is much less active than she usually is and that she has
been hanging out with her friends until late at night. Patient states that her “mom won’t get off my back.”
She admits that her grades had been dropping before summer break, and she quit the baseball team.
Mom leaves the room, and patient admits to smoking pot every day, usually several times a day, for the
past 8 or 9 months or so. She denies any other drug use and states smoking pot is “no big deal.”
After discussion with the patient and her parents, Robbin is admitted into a substance abuse hospital
to treat her high level of irritability and anxiety and for daily individual and group behavioral counseling.
Upon admission:
PE: Physical examination is remarkable only for a mildly erythematous throat without petechiae. Lungs
are slightly congested, and the rest of her exam is normal. Vital signs are also unremarkable. A rapid
strep screen is negative.
FIRST DAY—INDIVIDUAL COUNSELING: Discussion with patient about side effects and risks of abus-
ing pot. She states she has tried to quit but can’t make it through an entire day without smoking. It is
pointed out to her that her pot use is already having a negative impact on her life (absence and lack
of interest in school). We discussed options and methodologies for her quitting with reduced effects.
Blood is taken to record the levels of THC, and she agrees to regular surveillance.
Plan: Marijuana abuse behavioral counseling; daily individual counseling; daily group counseling.
Reevaluation after six (6) full days of residential treatment.
Jennell Goren, MD
556845/mt98328: 03/17/18 09:50:16 T: 03/17/18 12:55:01
CHAPTER 37 |
CHAPTER 37 REVIEW
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
PHYSICAL REHABILITATION ASSESSMENT
PATIENT: LEWTER, GENE
DATE OF ADMISSION: 01/15/18
DATE OF DISCHARGE: 01/17/18
DIAGNOSIS: 1. Acute myofascial strain.
2. Acute exacerbation of chronic low back pain.
SUBJECTIVE: The patient is a 47-year-old male. The patient came in for back pain. He was initially eval-
uated by Dr. Bruce Allen for back pain for the last 2 days. He said it was in the mid back, going down to
the left knee, with some paresthesias in the feet and numbness in the feet. Movement, remaining still,
and laying on a side seem to relieve pain. Lying directly on his back increases the pain. No problems
with urination. No fever or chills. No nausea, vomiting, or diarrhea. No abdominal pain.
PAST MEDICAL HISTORY: Significant for back injury. He had anterior fusion of L3–L4 in the past. He
has had multiple episodes, about one a month, since the surgery of exacerbation of his chronic back
pain. This typical pain pattern with numbness and radiation down the leg, he states, is nothing unusual
for the last multiple episodes. He has had no bladder or bowel dysfunction.
SOCIAL HISTORY: He is a smoker.
OBJECTIVE: The patient is alert, in no acute distress, obviously uncomfortable however. C-spine is neg-
ative. He is tender over the mid back, L2 through L4, with paravertebral muscle spasm that is palpable,
also quite tender. Decreased range of motion. The patient is alert and orientated x3. No motor deficits.
Strength 5/5. He does have diminished left patellar reflex. Decreased sensory on the left great and little
toes, medial aspect of the foot, and lateral aspect on the plantar surface of the foot. Sensory is intact.
INTERVENTION: Motor and nerve function assessment, range of motion, and joint integrity of lower
back and lower extremity were performed.
ASSESSMENT:
1. Acute myofascial strain.
2. Acute exacerbation of chronic low back pain.
PLAN: Percocet 5 mg 1–2 q. 4–6 hours as needed for pain, Soma one, three times a day, Indocin SR
75 mg b.i.d. with food. Follow up with the specialist who did his back surgery for reevaluation of his
increasing back pain over the last several years. Any acute problems, recheck sooner. Any problems
with bladder or bowel, recheck immediately.
Roberta Opell, PT
556839/mt98328: 01/17/18 09:50:16 T: 01/17/18 12:55:01
Determine the most accurate ICD-10-PCS code(s) for the motor function assessment.
WESTWARD HOSPITAL
591 Chester Road
Masters, FL 33955
HISTORY OF PRESENT ILLNESS ADMISSION
JOANNE STAFFORD, MD
556845/mt98328: 10/09/18 09:50:16 T: 10/09/18 12:55:01
Determine the most accurate ICD-10-PCS code(s) for the cognitive status test.
CHAPTER 37 |
38 Inpatient Coding
Capstone
Learning Outcomes
After completing this chapter, the student should be able to:
LO 38.1 Correctly abstract patient records to determine accurate cod-
ing using ICD-10-CM and ICD-10-PCS code sets.
Reporting the procedures provided to a patient who has been admitted into an inpa-
tient facility can cover a broad spectrum. The cases in this chapter will support your
learning using ICD-10-PCS procedure codes.
Remember, read carefully and completely.
H&P
Nestor Gonzalez, a 69-year-old previously healthy male, was seen in my office with
a cough productive of thick purulent sputum of 3 days duration. Fever was present and
he reported dyspnea on exertion.
Vital signs—BP 96/60 mm Hg, P 116 beats/min, RR 24 breaths/min, T 103.5°F rectal.
On examination, he appeared acutely ill.
Lung examination revealed scattered ronchi, which were greater on the right than
the left.
I determined that the patient needed to be admitted into the hospital right away.
Upon admission: Bronchoscopic aspiration specimen culture, C&S, and gram stain.
Blood tests and sputum culture were ordered and a chest x-ray taken.
RESULTS: Chest x-ray showed increased opacity in the lung field indicating pneumonia,
as suspected; culture confirmed E. coli with Shiga toxin.
Dx: Community-acquired pneumonia due to Escherichia coli 0157 with Shiga toxin
Treatment: IV ciprofloxacin 300 mg q 12h, infused over 60 minutes
Dr. Ryan MacDoule
H&P
Patient is Tina LeBrock, a 71-year-old female with known unstable angina due to
coronary artery disease. During the week prior to admission, she underwent an outpa-
tient procedure of diagnostic heart catheterization. At the time of this heart catheteriza-
tion procedure, the patient was found to have occlusion of the left anterior descending
coronary artery in two separate locations.
Due to the findings from this diagnostic procedure, the patient is now admitted for
a scheduled percutaneous transluminal coronary angioplasty (PTCA) with a plan for
stent insertions. The patient also has known secondary diagnoses of hypertension,
1140
hyperlipidemia, and current tobacco use. The hypertension, hyperlipidemia, and unsta-
ble angina are currently being treated with medications.
The patient was taken to the procedure room and underwent a PTCA of the left ante-
rior descending coronary artery with insertion of two Taxus drug-eluting stents, one at
each occlusion site.
Dr. Lawrence Marcheon
CHAPTER 38 |
Microbiological cultures taken during surgery confirmed the diagnosis of P. aeru-
ginosa infection. During the hospital stay, antibiotics were administered intravenously
according to microbe sensitivity (antibiogram) and our infection protocol: gentamicin
240 mg once a day and ciprofloxacin 200 mg twice a day for the first 5 postoperative
days. Starting on the sixth postoperative day, gentamicin combined with ceftazidime
500 mg twice a day was administered, and was continued for 9 days.
The patient was discharged home with no complaints. He was prescribed oral rifampicin
300 mg twice a day for the next 2 months. Full weight-bearing was allowed after 6 weeks.
Three months later, the patient fell on a slippery street and sustained an axially dis-
placed fracture of proximal metaphysis of tibia and fibula. This time treatment was con-
servative: closed reduction was achieved and maintained in a long-leg cast. Follow-up
x-ray on December 14, 2017, showed that bone fragments were still in satisfactory
alignment and there was evidence of callus formation. The patient returned to work and
his usual activities in January 2018.
On March 9, 2018, the patient was admitted to the hospital again because of a spi-
ral dislocated fracture in left femoral distal diaphysis. The femur was shortened and
displaced axially in varus position. Skeletal traction (5 kg) was applied primarily, and
surgery was performed later. Offstripping of femoral periosteum in both fragments was
seen during surgery. Internal fixation of the left femoral bone was achieved with an AO
plate and screw. The patient recovered and was discharged on March 17, 2018. He
was told to limit weight-bearing for the next 2.5 months and to walk with crutches.
Unfortunately the patient didn’t follow these instructions, and the plate broke off the
bone in its distal part due to walking. An open reosteosynthesis (exchange of screws
and repositioning of the plate) was performed this morning (May 15, 2018).
CHAPTER 38 |
Therefore, at discharge the patient underwent therapy with:
Zarontin 80 mg × 2 a day at 8 a.m. and 8 p.m. for 1 week
Zarontin 80 mg + 160 mg at 8 a.m. and 8 p.m. for 1 week
Zarontin 160 mg × 2 a day at 8 a.m. and 8 p.m. then continues.
Brain MRN is carried out under sedation and resulted within normal limits apart from
a “slight signal alteration involving the posterior peri-ventricular white substance of
both sides, of nonspecific nature, and bilateral otomastoiditis, opacification of maxillary
sinuses, of ethmoid cells and of sphenoidal sinuses bilaterally. Asymmetry of temporal-
basal superficial vessels, due to ectasia of a vessel on the left side, is observed.”
His parents noticed, when he was sleeping, a kind of limbs restlessness (arms and
legs) sometimes, after a few hours and early in the morning. Moreover, it often hap-
pened, and still happens, also in the evening (7 p.m.–8 p.m.) and, sometimes, also when
going to bed (between 9:30 p.m. and 10:30 p.m.) that the child complains he is cold,
repeating this several times.
In the current month he had his first two epileptic seizures. The first one occurred
while he was sleeping in the afternoon (he woke up catatonic, staring, with little
response to questions and, sometimes, mainly his right side was a bit rigid) and ended
after about 10 minutes when he fell asleep; when he woke up, the patient took about 2
hours to recover either his mood or his right eye and his stomach soreness.
The second one occurred in the morning when he was in the clinic to check ethosuxi-
mide dosage and to carry out a specialist follow-up visit. On awakening a 30-seconds-long
crisis occurred, with remarkable tremors to arms, legs, eyes, and twisted and munching
mouth.
Following these events, his physician changed the therapy, introducing the following
outline:
Depakin oral suspension 80 mg at 8 a.m. and 80 mg at 8 p.m. for 7 days
Depakin oral suspension 120 mg at 8 a.m. and 120 mg at 8 p.m. for 7 days
Depakin oral suspension 160 mg at 8 a.m. and 160 mg at 8 p.m. as maintenance
After 1 week of minimum dosage, no real crisis occurred; when sleeping, the child
unceasingly turns; he wriggles his lower and upper limbs, either at about 2 a.m. (in a
more intense way also for a half hour at intervals until he goes back to sleep) or at about
4/5 a.m. and on waking up for several minutes.
So there are two potential diagnoses:
1) Focal-Onset Epilepsy.
It is possible the patient has seizures that begin on the left side of his brain (which
would cause symptoms on the right side of the body like shaking of his right hand and
rigidity of his right side). These can potentially spread to the whole brain, causing the
whole body to shake, as was the case with his second seizure. The most important test
is the MRI, which showed no cause for the seizure (such as a tumor, stroke, or malforma-
tion). This is a good sign as there is a much better chance to outgrow seizures if the MRI
is normal. The findings in the sinuses and mastoid wouldn’t cause these seizures. They
are incidental findings but should be evaluated by an Ears/Nose/Throat doctor.
CHAPTER 38 |
infective event. Discharge with indication to follow a therapy with Deltacortene to scale
down the Azathioprine and antibiotic therapy with Augmentin.
Fourth hospitalization, 1 month later, in gastroenterology department for clinical test:
The patient reported slight painful crisis in epigastric region; at examinations APC nega-
tivization (0.59) and a further reduction in GGTs with transaminase substantially stable.
Therefore, the therapy with Amoxicillin + Clavulanic Acid was suspended and Metroni-
dazole 250 mg was prescribed three times a day every other week.
Fifth hospitalization during the same month, following an episode of infective chol-
angitis with blood tests that showed transaminase on the increase (ALT 248, AST 114,
GGT 281) with leukocytosis (WBCs 13,000, Neutrophils 88%, Lymphocytes 7.9%) and
elevated APC (4.48). Therapy started with Augmentin (1 g × three times a day) for
7 days and then end. At the end of the 7 days, preventive treatment prescribed with
Cotrimoxazole (tablet 160+800) one tablet twice a day.
Sixth hospitalization, 2 weeks after the previous one, following epigastric pain and
nausea, occurred after 1 day from Augmentin interruption and 1 day after the beginning
of therapy with Cotrimoxazole.
The most significant lab examinations at admission: CRP = 1.92 mg/dl; GGT 129 U/L;
AST = 29 u/l; ALT = 97 U/L.
Abdomen ultrasound scan with evidence of common bile duct dilatation. “Dilata-
tion of the proximal and medial segment of the common bile duct, with diameter up to
10 mm, in whose context binary images are appreciated referable to the well-known stent.
A moderate ectasia of intrahepatic bile ducts is connected, in particular in the left parts.”
To treat the severe painful symptomatology, a therapy with Ketorolac Tromethamine
90 mg in 250 cc in continuous infusion was started.
Because of the increase in the inflammation ratings and in the dilatation of the com-
mon bile duct at the abdominal ultrasound scan, supposing an occlusion of the biliary
stent with overlapped cholangitis, an antibiotic therapy has been started with Merope-
nem 1 g × 3 and a high osmolar ERCP was carried out.
ERCP didn’t show any materials obstructing the stent. Biliary washing was within
normal limits.
Therapy prescribed at home:
Augmentin (1 g × 3); Ciproxin (500 mg × 2); Folina 5 mg (one tablet every other day);
Deltacortene (25 mg daily); Azathioprine (100 mg daily); Lansoprazole (30 mg daily);
Ursodesossicolic Acid (300 mg three times a day).
CHAPTER 38 |
In March of 2018, the patient was seen in the office. She is still very emotionally
unstable. She is crying, depressed (not suicidal), and stressed about her new home. She
wants to move to a different senior housing unit because it would be on the bus route,
making it easier to get around. She has also hired a middle-aged woman as a caregiver.
Today, 9 months after moving to the new facility, she becomes acutely ill with psy-
chotic symptoms and severe paranoia. She hallucinates that men and women are in her
bed and calls others all hours of the day. I admitted her into a hospitalized psychiatric
unit and she shows improvement over about 14 days without antipsychotic medication.
IV Haloperidol 2.5 mg q30 min x3h.
Diagnosis: Delusional disorder, Acute Post Traumatic Stress Disorder
CHAPTER 38 |
have a medial defect suggesting a direct hernia. A large size left 3D Prolene mesh was
then placed in the preperitoneal space and placed over the floor of the inguinal canal
and stapled to the symphysis pubis and anterior abdominal wall along the upper edge
of the mesh with a stapler.
The lower edge was anchored to the abdominal wall with Tisseel fibrin glue. The pre-
peritoneal space was then deflated. All trocars were withdrawn. The defect in the rectus
sheath was closed with figure-of-eight 0 Vicryl suture. The skin incisions were closed
with subcuticular 5-0 Monocryl suture. Sterile dressings were then applied. The patient
tolerated the procedure well and was brought to the recovery room in stable condition.
Needle and sponge counts were correct.
PROCEDURE: Laparoscopic repair of bilateral inguinal hernias
Lawrence Podentale, MD
PROCEDURES PERFORMED:
. Repeat low transverse cesarean section
1
2. Bilateral tubal ligation
COMPLICATIONS: None
PERTINENT FINDINGS/HISTORY AND PHYSICAL: Refer to the detailed admission dictation.
The patient is a 35-year-old gravida 6, now para 3-0-3-3 female, who was admitted
at term for repeat cesarean section and sterilization. The patient had previous cesarean
sections for labor arrest, for an infant weighing 9 pounds 12 ounces, and elective repeat.
The patient strongly desired repeat cesarean section. She also wanted to have a tubal
ligation and signed the appropriate consent forms. Patient is well aware of the risks,
options, failure rates, and permanency of sterilization procedures. Her antenatal course
was significant for development of A1 diabetes with blood sugars in excellent control,
on diet only. The patient declined genetic screening because of advanced maternal age.
LABORATORY INVESTIGATIONS: The patient’s admission hemoglobin was 11.1 with
hematocrit of 33.4 and platelet count 196,000. Her postoperative hematocrit was 32.2.
HOSPITAL COURSE: The patient was admitted on the morning of her scheduled surgery.
Detailed informed consent was again obtained. Under spinal anesthesia, uncomplicated
repeat low transverse cesarean section and bilateral tubal ligation were performed. A
viable male infant with Apgars of 9 and 9 with birth weight of 8 pounds 6 ounces was
delivered. The patient’s postoperative course was uneventful. She remained afebrile
with stable vital signs. She returned quickly to good ambulation and regular diet. She
had normal GI function return. Her incision healed nicely. Her lochia was light.
Discharge examination revealed negative HEENT, neck, heart, lung, extremities, and
abdominal examinations.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: Discharged to home.
DISCHARGE INSTRUCTIONS:
ACTIVITY: Slow increase as tolerated. No heavy lifting. Strict pelvic rest.
DIET: Regular.
MEDICATIONS: Colace p.r.n., Tylenol p.r.n., and prenatal vitamins. The patient is breast-
feeding. Prescriptions for Percocet 325/5 tablets, #30, no refills, 1 to 2 p.o. q.4–6 h.
p.r.n. pain and ibuprofen 800 mg, #20, no refills, 1 p.o. q.8 h. p.r.n. pain.
Follow up as an outpatient in the office in 1 week.
The patient has received routine verbal instructions and agrees to comply. She
knows to contact us immediately should she develop any signs or symptoms of compli-
cations such as fevers, chills, drainage from the incision, abdominal distention, nausea,
vomiting, heavy vaginal bleeding, leg redness or swelling, chest pain, chest pressure,
or shortness of breath.
CHAPTER 38 |
CASE STUDY #13: WARREN ELLIS
DATE OF CONSULTATION: 11/16/2018
REFERRING PHYSICIAN: Charles Craigen, MD
REASON FOR CONSULTATION: Evaluation and management of painful lymphadenitis.
Thank you for this infectious disease consultation.
HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old male who about 3 days
prior to admission noticed what appeared to be a painful inguinal lymph node on the
left that seemed to progressively increase in size. This started while on a business trip,
but after he returned to work, he noticed it became a lot more tender and swollen.
He finally presented to the emergency department after having a couple of days of
onset of fever and was admitted for further evaluation. The patient on arrival did have
a low-grade temperature of 100. He was started initially on Flagyl and Cipro, that was
changed to doxycycline and Rocephin, and now he is on Zithromax and vancomycin.
The patient does not have any known infection as far as he knows. The patient has
not had any exposure to tuberculosis, although he said that he has had weight loss and
some night sweats, but this has only started since the onset of his symptoms about
a week ago. He has not had any long-term weight loss or long-term night sweats or
cough. The patient had traveled for that weekend prior to getting his onset of symp-
toms, but he did not do any camping. He does have two cats at home but no obvious
cat bite or scratches as far as he knows. The patient has also been involved in a new
sexual relationship about several months ago and has not had an HIV test recently. He
had one 2 years ago that he reports was negative. No other history of sexually transmit-
ted diseases to his knowledge.
REVIEW OF SYSTEMS: Unremarkable other than mentioned above. The patient had
diarrhea 1 day prior to admission and currently still has diarrhea.
PAST MEDICAL HISTORY: Hypertension, history of kidney stones, depression, migraines.
PAST SURGICAL HISTORY: Cyst removed from the right leg.
ALLERGIES: No known allergies.
MEDICATIONS: List is currently reviewed and the antibiotics are listed above in the HPI.
SOCIAL HISTORY: The patient does not use tobacco, alcohol, or drugs. He is divorced
from his first wife but is living with a new girlfriend. He has four children, all of whom live
at home with him.
FAMILY HISTORY: Negative for immune dysfunction.
PHYSICAL EXAMINATION: General: The patient is alert and oriented and in no acute
distress. He is afebrile. Temperature 96.5, pulse 70, respirations 19, and blood pres-
sure 115/73. HEENT: Pupils are equal and reactive. Head is normocephalic and atrau-
matic. Sinuses are nontender. Oropharynx is clear without lesions. Neck: Supple without
lymphadenopathy. Heart: Regular rate and rhythm. Lungs: Clear to auscultation bilater-
ally. Abdomen: Soft, nontender, and nondistended with no rebound or guarding. Good
bowel sounds are heard. Genitourinary: The left groin reveals tender adenopathy.
There is definite swelling and a mass felt in the left inguinal area. There is no obvious
cut or scratches seen. The rest of the inguinal area appears fairly unremarkable without
lesions or blisters seen. Lower extremities are without edema, clubbing, or cyanosis,
and appeared normal. Skin: Reveals no rashes. Neurologic: Grossly nonfocal.
LABORATORY DATA: Laboratory data have been reviewed and showed an ele-
vated white count of 16. There is a band neutrophilia of 27%. Liver function tests are
DATE OF STUDY: 02/22/2018
ORDERING PHYSICIAN: Harrison Brady, MD
DATE OF INTERPRETATION OF STUDY:
Echocardiogram was obtained for assessment of left ventricular function. The patient
has been admitted with diagnosis of syncope. Overall, the study was suboptimal due to
poor sonic window.
FINDINGS:
. Aortic root appears normal.
1
2. Left atrium is mildly dilated. No gross intraluminal pathology is recognized, although
subtle abnormalities could not be excluded. Right atrium is of normal dimension.
3. There is echo dropout of the interatrial septum. Atrial septal defects could not be
excluded.
4. Right and left ventricles are normal in internal dimension. Overall left ventricular sys-
tolic function appears to be normal. Eyeball ejection fraction is around 55%. Again,
due to poor sonic window, wall motion abnormalities in the distribution of lateral
and apical wall could not be excluded.
5. Aortic valve is sclerotic with normal excursion. Color flow imaging and Doppler
study demonstrates trace aortic regurgitation.
6. Mitral valve leaflets are also sclerotic with normal excursion. Color flow imaging and
Doppler study demonstrate trace to mild degree of mitral regurgitation.
CHAPTER 38 |
7. Tricuspid valve is delicate and opens normally. Pulmonic valve is not clearly seen.
No evidence of pericardial effusion.
CONCLUSIONS:
. Poor quality study.
1
2. Eyeball ejection fraction is 55%.
3. Trace to mild degree of mitral regurgitation.
4. Trace aortic regurgitation.
HOSPITAL COURSE: The patient responded well to individual and group psycho-
therapy, milieu therapy, and medication management. As stated, family therapy was
conducted.
DISCHARGE ASSESSMENT: At the time of discharge, the patient is alert and fully ori-
ented. Mood euthymic. Affect broad range. She denies any suicidal or homicidal ide-
ation. IQ is at baseline. Memory intact. Insight and judgment good.
PLAN: The patient may be discharged as she no longer poses a risk of harm towards
herself or others. The patient will continue on the following medications: Ritalin LA 60 mg
q.a.m., Depakote 500 mg q.a.m. and 750 mg q.h.s., Abilify 20 mg q.h.s. Depakote level on
date of discharge was 110. Liver enzymes drawn were within normal limits. The patient
will follow up with Dr. Petrikas for medication management and Dr. Sanders for psycho-
therapy. All other discharge orders per the psychiatrist, as arranged by social work.
Learning Outcomes
Automobile Insurance After completing this chapter, the student should be able to:
Capitation Plans
LO 39.1 Define the role of health insurance and managed care plans
Centers for Medicare
& Medicaid Ser- in the delivery of health care services.
vices (CMS) LO 39.2 Identify and define the types of health insurance plans.
Dependents LO 39.3 Explain the types of compensation used in health care
Diagnosis-Related reimbursement.
Group (DRG) LO 39.4 Describe the information available for proper coding from
Disability
NCCI edits and NCD and LCD.
Compensation
Discounted FFS LO 39.5 Utilize Place-of-Service and Type-of-Service codes as
Electronic Media required.
Claim (EMC) LO 39.6 Create a system for organizing claims, understanding deni-
Electronic Remittance als, and filing appeals.
Advice (ERA)
Eligibility Verification
Episodic Care
Explanation of Ben-
efits (EOB) 39.1 The Role of Insurance in Health Care
Fee-for-Service (FFS) A health insurance policy is a contractual agreement between an insurance carrier
Plans (company) and an individual related to health care issues. And the basis of this con-
Gatekeeper tract is risk. Insurance is just like gambling in Las Vegas. Basically, the insurance
Health Care company is betting that a certain event will not happen to you, such as you getting
Health Maintenance sick. If that happens, it would have to pay your medical bills. On the other side of the
Organization table, you are betting (by paying an insurance premium) that you will have a major
(HMO) illness or health catastrophe. Think about it—if you knew for a fact that you would
Insurance Premium never get ill or have any injury, and would only have to go to the doctor for your annual
Liability Insurance checkups, would you pay all that money every month for insurance premiums? Of
Managed Care course not. You are betting that you will, at some point, get all that money back, when
Point-of-Service (POS) you need it to pay for some type of treatment.
Preferred Provider When managed care was developed, the health insurance industry realized that it
Organization (PPO) could lower its risk (and save money) if it could keep people healthy by encouraging
Remittance Advice them to go to the doctor for regular checkups, tests, and so forth. This thinking cre-
(RA) ated a major change in the health insurance industry and in the medical care industry,
Third-Party Payer increasing the focus of health care delivery to include preventive care, rather than only
Tracer therapeutic (medical) care.
TriCare Medical care is the identification and treatment of illnesses and injuries—in other
Usual, Customary, and words, whatever a health care provider does to help you with a health problem or con-
Reasonable (UCR) cern that you have (Figure 39-1).
Workers’ Preventive care is provision of services designed to prevent the problem from mani-
Compensation festing (developing) or to discover it in early stages when it is more easily corrected.
Preventive care includes well-baby visits (Figure 39-2), screenings, diagnostics, and
Insurance Premium routine checkups.
The amount of money, often The term health care refers to a combination of these two types of services.
paid monthly, by a policyholder
or insured, to an insurance
company to obtain coverage.
1156
Managed Care
A type of health insurance
coverage that controls the
care of each subscriber (or
insured person) by using a pri-
mary care provider as a cen-
tral health care supervisor.
Health Care
The total management of an
individual’s well-being by a
health care professional.
CODING BITES
FIGURE 39-1 Treatment of a broken leg is an example of medical care Medical Care + Preven-
©ERproductions Ltd/Blend Images LLC RF
tive Care = Health Care
EXAMPLES
Dr. Michaelson examines Paul and gives him a shot of antibiotics to help Paul get
rid of an infection. The doctor has identified Paul’s illness and is treating that ill-
ness. This is medical care.
Dr. Calavari knows Katrina works at a day care center and gives her a flu shot
to help her avoid getting the flu. The doctor is preventing Katrina from becoming
ill. This is preventive care.
We all know that every organization needs to have money coming in so that it can
stay in business. The physician provides a service to his or her patients and expects CODING BITES
to be paid for those services. That money is what keeps a practice open and allows it
to pay your salary. If enough people don’t pay their bills, then an office must lay off The process of getting
people (and that could mean you!). Or you might not be able to get that next raise, even information and submit-
if you deserve it. ting claims to the third-
By now, you understand how important all of this information is and how you have party payer is key to the
a personal stake in completing claim forms correctly. As you transfer information from survival of your health
patient registration forms and other documents, be certain to care facility and all the
people it employs.
∙ Double-check your work to make sure it is accurate.
∙ Confirm that the form is completely filled out, with no necessary information
missing.
∙ Verify the spelling of every name and the accuracy of every number.
It all must be absolutely correct.
Most third-party payers, including Medicare, prefer claim forms to be submitted
Electronic Media Claim (EMC) electronically. An electronic media claim (EMC), also called an electronic claim, is
A health care claim form that evaluated more quickly than a print claim form. Accepted claims are paid faster. Years
is transmitted electronically. ago, it was not unusual for health care facilities to wait 4 to 6 months to receive pay-
ment from an insurance company. With electronic claims, this time has been reduced
to 2 to 3 weeks.
Increased use of technology in this process also means that there is an excellent
chance a computer will be reviewing your claim form. During the initial processing
of a claim you have sent, the computer will only compare letter to letter and number
to number, looking for an exact match to the letters and numbers in their files. Then,
claims with errors, such as invalid policy numbers or missing information, will be
rejected and returned to you.
EXAMPLE
The computer cannot scan your claim form and say, “Oh, I can see this is a typo.
They really meant to put a W instead of a U.” No, all the computer knows is that
the letter is supposed to be a U and it is not. And the claim will be rejected.
The Participants
Essentially, there are three participants in each health care encounter, or visit:
CODING BITES
Party #1: The health 1. The physician or health care provider.
care provider 2. The patient—the person seeking services.
Party #2: The patient 3. The insurance carrier covering the costs of health care activities for the patient.
Party #3: The insurance
carrier Some people get their health insurance policies through a program at their place
of employment, some through the government, and others directly with the insurance
carriers as individual policyholders. It doesn’t matter very much to the health care
Third-Party Payer facility. In any case, a third-party payer will pay, in part, the patient’s bills for ser-
An individual or organization vices that your facility will provide. Health insurance carriers are often referred to as
that is not directly involved in third-party payers. This means that someone not directly involved in the health care
an encounter but has a con- relationship is paying for the service. The health care provider is party #1, the patient
nection because of its obliga- is party #2, and the insurance carrier is party #3—the third party. Therefore, the insur-
tion to pay, in full or part, for
ance company is the third-party payer.
that encounter.
In a preferred provider organization (PPO), physicians, hospitals, and other health Preferred Provider
Organization (PPO)
care providers join together and agree to offer services to members of a group (often
A type of health insurance
called subscribers) at a lower cost or discount. These plans usually permit the individ-
coverage in which physicians
ual subscriber (the patient) to choose the physician or specialist to see, with a discount provide health care services
for staying in the network by using a physician who is a member of the plan. If the to members of the plan at a
individual chooses a physician who does not belong to the network, or is not partici- discount.
pating with that PPO, the individual will pay a penalty or receive less of a discount
in the cost of those services. This can give the individual more control over his or her
health care. It can save time and money, as well.
Some PPO plans require the patient to satisfy a deductible first before benefits
begin. (See the section Individual Insurance Contributions later in this chapter.) Typi-
cally, a higher deductible will translate into a lower monthly premium for this type of
insurance coverage.
EXAMPLE
If a person covered under a PPO plan is having problems sneezing and knows the
problem is his or her allergies, the individual can choose an allergist—a provider
who specializes in the treatment of allergies—from the PPO network without hav- CODING BITES
ing to go to his or her primary care physician for a referral. If the plan were an PPOs typically Permit
HMO, the person would have to make an appointment with the PCP first, in order the Patient to Opt (or
to get the referral to the allergist. Then, the person could make an appointment to choose) his or her physi-
see the allergist. cian or specialist.
CODING BITES
POS plans combine features of an HMO and a PPO.
Centers for Medicare & Med- became the Centers for Medicare & Medicaid Services (CMS). Many health care
icaid Services (CMS) professionals still refer to this agency as “HicFah” and to the CMS-1500 claim form
The agency under the Depart- as the “HicFah 1500.” Old habits take a while to change. At least you now understand
ment of Health and Human that these two acronyms refer to the same federal organization.
Services (DHHS) in charge of Medicare is a national health insurance program that pays, or reimburses, for
regulation and control over
health care services provided to those over the age of 65 (see Figure 39-3). In addi-
services for those covered by
Medicare and Medicaid.
tion, this plan may cover individuals who are under the age of 65 and are permanently
disabled (such as the blind), as well as those with end-stage renal disease (ESRD)
who are suffering from permanent kidney failure and require either dialysis or a kid-
CODING BITES ney transplant.
MedicaRE = REtired Medicaid is a plan that pays for, or reimburses, medical assistance and health care
people (who are over services for people who are indigent (low-income) (see Figure 39-4). The program
the age of 65) is jointly funded by the federal and state governments. Each state government then
administers its own plan. This means that each state determines who is eligible and
MedicaID = InDigent, or
what services are covered. It is important to know that each state has its own require-
low-income, individuals
ments, in case you have a patient that has just moved to your state. Each state may even
have a unique name or term for its program. For example, in California the program is
called Medi-Cal.
TriCare TriCare
A government health plan that TriCare offers the most common health care plans you will encounter when caring
covers medical expenses for for individuals in the military and their families (see Figure 39-5). This program was
the dependents of active-duty formerly known as CHAMPUS.
service members, CHAMPUS-
TriCare was created to help the following individuals receive better access to
eligible retirees and their
families, and the dependents of
improved health care services:
deceased active-duty members. ∙ Active-duty service members (ADSM), also known as sponsors.
Dependents ∙ The dependents (spouses and children) of ADSMs.
Individuals who are sup- ∙ Surviving spouses and surviving children of deceased ADSMs.
ported, either financially or
with regard to insurance cov- ∙ Retired service members, their spouses, and their children.
erage, by others. ∙ Surviving spouses and children of deceased retired members.
TriCare was created to provide health care benefits for the dependents of those
serving in the uniformed services and retirees. ADSMs are those from any of the
seven uniformed services, including the U.S. military (the Army, Navy, Air Force,
Marine Corps, and Coast Guard), as well as those serving in the Public Health
Service, National Guard and Reserve, and the National Oceanic and Atmospheric
Administration (NOAA). Eligibility for TriCare is determined by the services and
information is maintained in the Defense Enrollment Eligibility Reporting System
(DEERS).
Joe Hines works as an electrician for a small company. One day, he falls off a ladder at work and injures
his back severely. He is taken to the emergency room by ambulance, and the attending physician
orders x-rays and a CT scan. The tests confirm that Joe’s spine is broken in two places and a cast is
applied around Joe’s entire torso. After a week in the hospital, Joe is discharged. The physician’s dis-
charge orders state that Joe is to stay in bed for 7 months, in traction, while the fracture heals. A home
health agency is contracted to provide a trained health care professional to go to Joe’s house to care
for him and attend to his needs around the clock.
1. In this scenario, what type of insurance will be responsible for the payment of each of Joe’s
expenses due to this accident?
Liability Insurance Liability insurance is commonly part of a person’s homeowners or business own-
A policy that covers loss or ers insurance. This type of policy covers losses to a third party caused by the insured
injury to a third party caused or something owned by the insured. In other words, the insurance company will pay
by the insured or something for, or reimburse for, any harm or damage done to someone else (not a member of the
belonging to the insured. household or the business).
Sarah goes over to Margaret’s house for dinner. After a delicious meal, Sarah walks toward the door to
leave and go home. As she turns to say goodnight to Margaret, Sarah trips and falls. Margaret calls the
paramedics, and, at the hospital, the x-rays ordered by the attending physician confirm that Sarah has
indeed broken her wrist. A cast is applied, and Sarah is sent home with a prescription for pain medica-
tion. The attending physician advises Sarah to see her primary care physician in 1 week for a follow-up.
2. What type of insurance will cover Sarah’s medical expenses?
Kyle, a fifth-grade student, slipped down the stairs at school. Typically, the school’s liability policy would
cover the damage, or medical expenses. The school is the insured, and the student is the third party.
3. If a faculty member and a student are walking through the cafeteria of the school and both slip and
fall, what types of policies will cover any injuries that might be caused by the fall?
EXAMPLE
Three people, each with a different insurance carrier, go to the same physician for
a flu shot (injection). Insurance carrier #1 has agreed to pay the physician $20 for
giving the injection. Insurance carrier #2 has agreed to pay the physician $22.50,
and insurance carrier #3 has agreed to pay the physician $18 for the same injec-
tion. Your office should charge all patients the same amount. This is known as the
charged amount. However, insurance carriers working with your office on a fee-
for-service contract will pay only the amount stated on their fee schedule. That’s
all they will pay and no more. This is called the allowed amount.
Capitation Plans
Agreements between a phy-
sician and a managed care
Capitation Plans organization that pay the
physician a predetermined
With capitation plans, the insurance company pays the physician a fixed amount of amount of money each month
money for every individual covered by that plan (often called members or subscrib- for each member of the plan
ers) being seen by that physician. Physicians get this amount of money every month, who identifies that provider
as long as they are listed as the physician of record (primary care physician (PCP)) as his or her primary care
for that individual. Whether the insured person goes to see that physician once, three physician.
times, or not at all during a particular month, the physician’s office will be paid the
CODING BITES same amount. This plan is like the dinner special at your local restaurant. You pay one
CAPitation plans pay price, which includes soup, salad, all-you-can-eat entrée, and dessert. If you don’t eat
by the cap. One cap your soup, you do not pay any less; if you get seconds on the entrée, you do not pay
goes on one head, any more.
and the insurance car-
rier is going to pay the Episodic Care
physician for each cap,
or head—that is, per An episodic care agreement between insurer and physician means the provider is paid
person. one flat fee for the expected course of treatment for a particular injury or illness. This
is like the meal deal of health care. One package price includes all of the services and
treatments necessary for the proper care of the patient’s condition in accordance with
the accepted standards of care.
Episodic Care
An insurance company pays a
provider one flat fee to cover
the entire course of treatment EXAMPLE
for an individual’s condition. Audrey Callahan fell off her bicycle and broke her arm. The x-ray shows that it is
a simple, clean fracture and the physician applies a cast. The doctor schedules a
follow-up appointment for her and expects that she will not need much other atten-
tion until the cast comes off in 6 weeks. At that time, an x-ray will confirm that the
fracture has healed properly and the cast will be removed. This entire sequence of
events, and treatment, is very predictable for a routine simple fracture. Therefore,
the insurance company has agreed to pay the physician one flat fee for this event,
rather than having the physician’s office file a claim for each procedure and service
individually: the first encounter; the first x-ray; the application of the cast; the follow-
up encounter; the last encounter; the last x-ray; and removal of the cast.
Audrey Callahan’s physician is being reimbursed under an episodic care agree-
ment with the insurance carrier.
Diagnosis-Related Group Diagnosis-related groups (DRGs) are a type of episodic care payment plan used
(DRG) by Medicare to pay for treatments and services provided to beneficiaries who have
An episodic care payment been admitted into an acute care hospital (inpatients). DRGs are categorized by the
system basing reimburse- principal (first-listed) diagnosis code and take into consideration elements such as
ment to hospitals for inpatient the patient’s age and gender and the presence of any complications or manifesta-
services upon standards of
tions (additional diagnoses or conditions). You read more about DRGs in the chapter
care for specific diagnoses
grouped by their similar usage
titled Inpatient (Hospital) Diagnosis Coding.
of resources for procedures,
services, and treatments. Patient/Beneficiary Out-of-Pocket Contributions
Patients with insurance policies often contribute to reimbursing providers for their
health care services, in addition to paying monthly premiums. The following are the
most common methods used for the individual’s payments:
Usual, Customary, and Rea- 1. Co-payment (also known as the co-pay). The co-payment is usually a fixed amount
sonable (UCR) of money that the individual will pay each time he or she goes to a health care pro-
The process of determining a vider. It may be $10, $15, $20, or more. Each policy is different. As a matter of fact,
fee for a service by evaluating the co-pay on the same policy for the same patient may be different, depending on
the usual fee charged by the whether this is a visit to a family physician, a specialist, or the hospital.
provider, the customary fee
2. Co-insurance. Co-insurance is different from the co-payment because it is based
charged by most physicians
in the same community or
on a percentage of the total charge rather than a fixed amount. The percent-
geographical area, and what age that the patient pays is most often calculated on the usual, customary, and
is considered reasonable by reasonable (UCR) charge that has been determined for this type of visit or pro-
most health care profession- cedure. Frequently, the individual is required to pay 20% of the total allowed
als under the specific circum- amount by the physician or facility, but that might differ for various types of poli-
stances of the situation. cies and carriers.
CODING BITES
The various amounts for the co-pay, the co-insurance, and the deductible are
good examples of why it is so essential that you contact the insurance carrier for
every patient to verify the patient’s coverage and eligibility for certain procedures
and treatments and to see if the deductible has been met for the year.
MACRA
Medicare Access and CHIP Reauthorization Act (MACRA) has been designed
to reward health care providers for quality patient care and to ultimately reduce costs.
As a part of this, the Quality Payment Program was also implemented. This program
incorporates important advances to ensure that electronic health information will be
available when and where clinicians need it so optimal care can be provided.
The Quality Payment Program includes two paths:
∙ Advanced Alternative Payment Models (APMs)
∙ Merit-Based Incentive Payment System (MIPS)
Both of these paths require use of certified EHR technology to exchange information
across providers and with patients to support improved care delivery, including patient
engagement and care coordination. In addition, this program requires EHR manufac-
turers to publish application programming interfaces (API), which increase interoper-
ability (making it easier for software programs such as smartphone apps to access
information from other programs) for certified health IT.
Physicians have options and began participating in this program as early as January
2017.
EXAMPLE
23680 Open treatment of shoulder dislocation, with surgical or anatomical
neck fracture, with manipulation
20690 Application of a uniplane (pins or wires in 1 plane), unilateral, external
fixation system
These codes report two procedures that would not be performed at the same time
for the same patient, according to the standards of care. This is an example of a
PTP edit.
EXAMPLE
72270 Myelography, 2 or more regions, radiological supervision and
interpretation
The MUE edit for this code is a maximum of one for a patient per date of service
because the code description states “two or more.” Therefore, reporting this code
more than once for the same patient on the same date would not be accurate.
FIGURE 39-7 NCD for Adult Liver Transplantation (in part) Source: CMS.gov
(continued)
Place of Place of Service
Service Code(s) Name Place of Service Description
41 Ambulance—Land A land vehicle specifically designed, equipped, and staffed for lifesaving and
transporting the sick or injured.
42 Ambulance—Air or An air or water vehicle specifically designed, equipped, and staffed for lifesav-
Water ing and transporting the sick or injured.
43–48 Unassigned N/A
49 Independent Clinic A location, not part of a hospital and not described by any other Place-of-
Service code, that is organized and operated to provide preventive, diagnostic,
therapeutic, rehabilitative, or palliative services to outpatients only.
50 Federally Qualified A facility located in a medically underserved area that provides Medicare
Health Center beneficiaries preventive primary medical care under the general direction of a
physician.
51 Inpatient Psychiatric A facility that provides inpatient psychiatric services for the diagnosis and
Facility treatment of mental illness on a 24-hour basis, by or under the supervision of a
physician.
52 Psychiatric Facility— A facility for the diagnosis and treatment of mental illness that provides a
Partial Hospitalization planned therapeutic program for patients who do not require full-time hospital-
ization, but who need broader programs than are possible from outpatient visits
to a hospital-based or hospital-affiliated facility.
53 Community Mental A facility that provides the following services: outpatient services, includ-
Health Center ing specialized outpatient services for children, the elderly, individuals who
are chronically ill, and residents of the CMHC’s mental health services area
who have been discharged from inpatient treatment at a mental health facility;
24-hour-a-day emergency care services; day treatment, other partial hospital-
ization services, or psychosocial rehabilitation services; screening for patients
being considered for admission to state mental health facilities to determine the
appropriateness of such admission; and consultation and education services.
54 Intermediate Care A facility that primarily provides health-related care and services above the
Facility/ Individu- level of custodial care to individuals but does not provide the level of care or
als with Intellectual treatment available in a hospital or SNF.
Disabilities
55 Residential Substance A facility that provides treatment for substance (alcohol and drug) abuse to live-
Abuse Treatment in residents who do not require acute medical care. Services include individual
Facility and group therapy and counseling, family counseling, laboratory tests, drugs
and supplies, psychological testing, and room and board.
56 Psychiatric Residen- A facility or distinct part of a facility for psychiatric care that provides a total
tial Treatment Center 24-hour therapeutically planned and professionally staffed group living and
learning environment.
57 Nonresidential Sub- A location that provides treatment for substance (alcohol and drug) abuse on an
stance Abuse Treat- ambulatory basis. Services include individual and group therapy and counsel-
ment Facility ing, family counseling, laboratory tests, drugs and supplies, and psychological
testing.
58–59 Unassigned N/A
60 Mass Immunization A location where providers administer pneumococcal pneumonia and influenza
Center virus vaccinations and submit these services as electronic media claims, paper
claims, or using the roster billing method. This generally takes place in a mass
immunization setting, such as a public health center, pharmacy, or mall but may
include a physician office setting.
Type-of-Service Codes
In addition to providing pre-categorization of procedures, Type-of-Service (TOS)
codes are also used to ensure that procedures, services, and treatments, along with the
Place-of-Service codes, are used to determine appropriateness of location and service.
Using the criteria for medical necessity from the insurance carrier that denied the
claim (different carriers may have different criteria), review the patient’s health
record to confirm that this individual and this particular encounter meet all of the
requirements. Again,
∙ Double-check the diagnosis and procedure codes to make certain they all accu-
rately represent what occurred during that visit.
∙ Call and speak with the claims examiner to identify exactly what he or she
thought the problem was with the claim. This conversation may give you some
insight into what you should be looking for as you review the patient’s chart.
∙ Get support materials from your health care professionals, particularly the attend-
ing physician on this case. Copies of articles or pages from credible sources, such
as The Merck Manual, the New England Journal of Medicine, or other qualified
sources of research, will help support your claim.
∙ If this patient encounter was the result of another provider referring the indi-
vidual to your physician for additional treatment, the referring physician might
agree to write a letter supporting your office.
3. Write a letter to the third-party payer’s appeals board, or to whomever the claims rep-
resentative instructs you to send the documentation, outlining all of the information
you have gathered to corroborate specifically why the denial should be overturned.
a. Include copies of supporting documentation, such as pages from the National
Library of Medicine’s website or a letter from the referring provider.
b. In addition, request that a qualified health care professional licensed in the area
of treatment or service under discussion be the one to review your appeal. This
may provide a more agreeable opinion as to the medical necessity of your claim
and get it approved.
EXAMPLE
Christopher Novack, a 67-year-old male, is seen by his family physician after stat-
ing that he was driving to his office earlier and felt so dizzy he had to pull over.
While waiting for the dizziness to pass, he felt his heart beating rapidly, and he
began to sweat. He was worried that he was having a heart attack and came right
over to see Dr. Bennetti.
Dr. Bennetti, knowing that Chris had been diagnosed with type 2 diabetes melli-
tus, checked his glucose levels and found them to be grossly abnormal, causing the
dizziness and sweating. He administered an injection of insulin. Then, Dr. Bennetti
checked Chris’s heart with a 12-lead EKG. The results were negative.
When you perform your medical necessity review, you can see that the code
for type 2 diabetes mellitus will justify the glucose test and the injection of the
insulin.
However, if you do not have a second diagnosis code for his rapid heartbeat,
the claim would be rejected. Without the code for rapid heartbeat, there is no
medical justification provided on the claim form for performing an EKG.
Subsequent Denials
There are additional steps that can be taken to appeal a second or third denial. Some-
times an insurance carrier will deny a claim, hoping that you will give up and it will
not have to pay. However, most of the time, subsequent denials are just a matter of poor
communication between the insurance carrier and the health care facility. Remember,
although it is an insurance carrier’s responsibility and obligation to pay claims, it is
also its responsibility and obligation to protect its assets from fraud. Primarily, it is
this intention that creates the circumstance of a falsely denied claim. However, after
you have exhausted all efforts within the insurance carrier’s organization to get the
carrier to see your side and pay the claim, you have additional options:
1. Many states have state boards and/or review panels for this type of situation. Expe-
rienced health care providers, with varying areas of specialization, sit on these
review boards. Their duty is to go over all the details of the case; examine the
patient’s health record, the claim form, and all other documentation; and evaluate
the insurance carrier’s basis for denying the claim. They have the right, empowered
by the state government, to override the insurance carrier’s decision and force the
carrier to pay the claim. Bringing an appeal to this type of review board is an option
to both health care professionals and individuals alike.
2. If the patient is covered under an employer’s self-insured health plan, the state
board is usually not an option for appeal. However, the federal government oversees
and regulates self-insured plans and can provide you with an appeals process. At
the very least, these insurers are required to have an in-house appeal board that will
hear your case.
Surprisingly, you have an excellent chance of winning an appeal when you han-
dle it properly. Researchers have found very high success rates for providers who file
appeals. Therefore, if a claim is denied, it is worth the time to look into the reasons for
denial and possibly exercise the right to appeal.
Writing Letters of Appeal
When a claim has been denied and you have gathered all the documentation to support
your position that the denial is incorrect, you need to write a formal letter of appeal.
This letter should contain the following:
Recipient: Call the third-party payer and get the name, title, and address of the
person to whom you should address this letter. Make certain you double-check the
spelling of the person’s name—don’t assume. Even a name as straightforward as
John can also be spelled Jon or Jahn. Just ask!
RE: In the space between the recipient’s name and address, and the salutation, you
need to include identification regarding the person to whom this letter refers. This
should be indented to your one-inch tab position. The details that should be shown
in this area of the letter are
Patient Name:
Policyholder Name:
Policy Number:
Date(s) of Service:
Claim Number:
Total Amount of Claim: $
Salutation: Always begin the letter with a proper business salutation to the recipient
by name. For example, Dear Mr. Smith: or Dear Ms. Jones (followed by a colon).
Avoid generic salutations such as To Whom It May Concern unless the insurance
carrier will not release the name of the person designated to receive appeal letters
and has instructed you to address this letter to a department or title.
Paragraph 1: State briefly and directly why you are writing this letter. This is a
summary or condensed version of the rest of the letter. Be factual, not emotional.
Be specific about when and/or how you were informed that the claim was denied
and the reasons stated by the insurance carrier for the denial. This paragraph is to
make certain that you and the reader of this letter are on the same page (pardon the
pun!). It is difficult to capture and retain someone’s attention to what you are saying
if he or she doesn’t know to what or whom you are referring.
EXAMPLES
1. Our claims service representative, Raul Vega, told us that the above claim was
denied due to a lack of medical necessity. This letter is an official notice that we
wish to appeal this decision.
2. On November 3, 2018, our office received a notice stating that the above-
mentioned claim was denied because of lack of coverage. This letter is to
appeal this decision.
Paragraph 2: Itemize all the facts/evidence you have to support your position that
you should be paid. Explain what documentation you have to encourage them to
change their minds and approve/pay your claim. This list may contain highlights
from the physician’s notes outlining why the procedure was medically necessary.
You might include statistics proving that this procedure is no longer considered
experimental but is now widely accepted as the new standard of care. Attach
copies (never originals) of documents that contain the information and refer to
those attachments in this portion of the letter. In reality, this section of the let-
ter may need to be longer than one paragraph. Write what you need to establish
your rationale, but remember that this is not creative writing. Do not use flowery
language or get long in your explanation. Be direct and to the point and include
just the facts.
Paragraph 3: Use paragraph 3 (the last paragraph) to clearly define where this dis-
cussion should go next. Of course, you want them to just reconsider and pay the
claim; however, you will need to keep this a bit more open-ended. Offer to pro-
vide any additional documentation the insurance carrier may feel necessary. Supply
your contact information (office phone number, e-mail address, fax number) even if
it is right there on the letterhead. Set an appointment generally (i.e., “I will call you
next week”) to follow up with this person. The purpose of this statement is to keep
this appeal moving in a direction toward acceptance and payment. You do not want
this letter to get buried on a busy desk. In addition, mark your calendar and call
when you said you would. It is your responsibility to keep this issue on the top of
the insurance carrier’s priority list. You know that old saying, “The squeaky wheel
gets the grease.” This means that those that speak up get the attention.
EXAMPLES
1. If you need any more information, to bring this to a quick resolution, please
contact me at . . . .
2. I will call you at the end of the week to discuss this matter further. In the mean-
time, if you need to contact me, please do so at . . . .
Closing and Signature: All business letters should contain a closing, as well as
the signature and title of the person sending the correspondence. Sincerely or Sin-
cerely yours (followed by a comma) are the most common closings. After leaving
four lines blank to make room for your signature, key in your full name. Directly
underneath your name, key in your title (e.g., Insurance Specialist). If you are going
to attach copies of important documentation to this letter, you need to note this
under your signature. Leave one empty line under your title, and key in Enclo-
sure or Enclosures or Enc. This notation points the recipient to the additional pages
included in the envelope.
Chapter Summary
A fundamental part of an insurance coding and medical billing specialist’s job is to
work with the insurance companies that will reimburse your health care facility for
the services and procedures you provide to your patients. You need to understand
how your facility will be paid (such as fee-for-service, capitation, or episodic care); be
able to distinguish among the types of policies (such as HMOs, PPOs, and managed
care policies, as well as Medicare, Medicaid, and TriCare plans); and quickly identify
which is responsible for sending payment to you. This will help your billing efforts be
more efficient and get paid more quickly.
The procedures you develop and abide by for tracking the health insurance claim
forms you submit is almost as important as the coding process itself. Some health
care offices do not have a routine for handling situations, such as lost claims or denied
claims. However, you must realize how important this is to the overall financial well-
being of your facility.
When you are organized, and keep a tracking log of all the claims you submit,
your work is easier and your success rate is higher. Appealing denied claims is a part
of your career, and it is an important part of the entire medical billing and insurance
claims process.
CODING BITES
The basic reimbursement methods are applicable across all types of health
care, and include capitation, fee for service, episodic (global) payment, and cost
reimbursement.
It is the provider’s responsibility to confirm the method of reimbursement prior
to providing services.
For more information on the newest program, MACRA, go to
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-
and-APMs.html
CHAPTER 39 REVIEW
Reimbursement Enhance your learning by
completing these exercises and
more at connect.mheducation.com!
Part I
1. LO 39.2 A physician, typically a family practitioner or an internist, who serves A. Automobile Insurance
as the primary care physician for an individual. This physician is B. Capitation Plans
responsible for evaluating and determining the course of treatment or
C. Centers for Medicare
services, as well as for deciding whether or not a specialist should be
& Medicaid Services
involved in care.
(CMS)
2. LO 39.1 A type of health insurance coverage that controls the care of each sub-
D. Dependents
scriber (or insured person) by using a primary care provider as a cen-
tral health care supervisor. E. Disability
Compensation
3. LO 39.2 A type of health insurance that uses a primary care physician, also
known as a gatekeeper, to manage all health care services for an F. Discounted FFS
individual. G. Episodic Care
4. LO 39.2 A policy that covers loss or injury to a third party caused by the insured H. Fee-for-Service (FFS)
or something belonging to the insured. Plans
5. LO 39.1 The total management of an individual’s well-being by a health care I. Gatekeeper
professional. J. Health Care
6. LO 39.3 An insurance company pays a provider one flat fee to cover the entire K. Health Maintenance
course of treatment for an individual’s condition. Organization (HMO)
7. LO 39.2 The agency under the Department of Health and Human Services L. Insurance Premium
(DHHS) in charge of regulation and control over services for those
M. Liability Insurance
covered by Medicare and Medicaid.
N. Managed Care
8. LO 39.3 Payment agreements that outline, in a written fee schedule, exactly how
much money the insurance carrier will pay the physician for each treat-
ment and/or service provided.
9. LO 39.3 An extra reduction in the rate charged to an insurer for services pro-
vided by the physician to the plan’s members.
10. LO 39.1 The amount of money, often paid monthly, by a policyholder or
insured, to an insurance company to obtain coverage.
11. LO 39.2 Auto accident liability coverage will pay for medical bills, lost wages,
and compensation for pain and suffering for any person injured by the
insured in an auto accident.
12. LO 39.3 Agreements between a physician and a managed care organization that
pay the physician a predetermined amount of money each month for
each member of the plan who identifies that provider as his or her pri-
mary care physician.
13. LO 39.2 A plan that reimburses a covered individual a portion of his or her income
that is lost as a result of being unable to work due to illness or injury.
14. LO 39.2 Individuals who are supported, either financially or with regard to
insurance coverage, by others.
Part II
CHAPTER 39 REVIEW
1. LO 39.6 An official request for a third-party payer to search its system to find A. Electronic Media Claim
a missing health claim form. It is also a term used for a replacement (EMC)
health claim form resubmitted to replace one that was lost. B. Electronic Remittance
2. LO 39.3 The process of determining a fee for a service by evaluating Advice (ERA)
the usual fee charged by the provider, the customary fee charged by C. Eligibility Verification
most physicians in the same community or geographical area, and what
D. Explanation of Benefits
is considered reasonable by most health care professionals under the
(EOB)
specific circumstances of the situation.
E. Point-of-Service (POS)
3. LO 39.6 Remittance advice that is sent to the provider electronically.
F. Preferred Provider
4. LO 39.2 A type of insurance plan that will allow an HMO enrollee to choose his
Organization (PPO)
or her own nonmember physician at a lower benefit rate, costing the
patient more money out-of-pocket. G. Remittance Advice
(RA)
5. LO 39.1 An individual or organization that is not directly involved in an encoun-
ter but has a connection because of its obligation to pay, in full or part, H. Third-Party Payer
for that encounter. I. Tracer
6. LO 39.6 Another type of paper remittance advice, more typically sent to the J. TriCare
policyholder. However, some in the industry use the term EOB inter- K. Usual, Customary, and
changeably with RA. Reasonable (UCR)
7. LO 39.2 A type of health insurance coverage in which physicians provide health L. Workers’ Compensation
care services to members of the plan at a discount.
8. LO 39.2 A government health plan that covers medical expenses for the
dependents of active-duty service members, CHAMPUS-eligible
retirees and their families, and the dependents of deceased active-
duty members.
9. LO 39.2 An insurance program that covers medical care for those injured or for
those who become ill as a consequence of their employment.
10. LO 39.1 A health care claim form that is transmitted electronically.
11. LO 39.6 The process of confirming with the insurance carrier that an individual
is qualified for benefits that would pay for services provided by your
health care professional on a particular day.
12. LO 39.6 Notification identifying details about a payment from the third-party
payer.
Part III
1. LO 39.2 May cover medical expenses caused by a car accident. A. Co-payment
2. LO 39.2 Preferred provider organization. B. DRG
3. LO 39.3 A fixed amount paid each visit by the individual. C. Fee-for-Service
4. LO 39.3 Payment, per service provided, from the insurance company. D. PPO
5. LO 39.2 A government program for indigent and needy people. E. Medicaid
6. LO 39.3 An episodic-care payment system basing reimbursement to hospitals F. Auto Insurance Policy
for inpatient services upon standards of care for specific diagnoses
grouped by their similar usage of resources for procedures, services,
and treatments.
CHAPTER 39 REVIEW
Choose the most appropriate answer for each of the following questions.
1. LO 39.1 Medical care is defined as
a. identification and treatment of illness and/or injury.
b. services to prevent illness such as a routine checkup or wellness visit.
c. laboratory services.
d. only those services performed by a medical doctor.
2. LO 39.2 An organization that depends on the services of a gatekeeper is
a. a preferred provider organization.
b. Medicare.
c. a health maintenance organization.
d. a not-for-profit hospital.
3. LO 39.3 A capitation plan pays the provider
a. per specific service.
b. per member every month.
c. for treatments in a hospital only.
d. one flat fee per illness or condition.
4. LO 39.2 Medicare is a government plan that covers primarily
a. military personnel. b. poor and needy.
c. those over the age of 65. d. government employees.
5. LO 39.4 When CMS computers evaluate submitted claims to look for pairs of codes being reported that are
known to be mutually exclusive procedures, this is also known as _____ edits.
a. LCD b. NCD
c. PTP d. MUE
6. LO 39.2 TriCare provides health care benefits for the dependents of
a. state workers.
b. those serving in the uniformed services.
c. athletes.
d. health care workers.
7. LO 39.5 What specific location does POS code 23 identify?
a. Urgent Care Facility b. Assisted Living Facility
c. Telehealth d. Emergency Room—Hospital
8. LO 39.6 The HIPAA Health Care Payment and Remittance Advice is the electronic transmission of payment,
using HIPAA-approved secure data sets. The transmission has two parts: the _____ and the _____.
a. claim, transaction b. transaction, document
c. document, claim d. date, carrier name
9. LO 39.3 When an individual pays a percentage of the total charge, it is called the
a. deductible. b. co-payment.
c. co-insurance. d. premium.
10. LO 39.2 CMS stands for
a. Centers for Medical Services. b. Corporation of Medical Systems.
c. Centers for Medicare & Medicaid Services. d. Cycle of Medical Selections.
Let’s Check It! Which Type of Insurance?
CHAPTER 39 REVIEW
Match the situation with the type of insurance that would cover the expenses. Answers
may be used more than once.
A. Health Insurance 1. LO 39.2 Mrs. Matthews, a teacher at Medical Coder Academy, slipped in her
B. Workers’ Compensation office, fell, and hurt her back.
C. Medicaid 2. LO 39.2 Ralph broke his leg and must be in traction for 9 months. What plan
will help him pay his rent and electric bill?
D. Disability
Compensation 3. LO 39.2 Mary Lou was at the mall, shopping for a birthday present, when she
slipped on a wet floor and broke her hip.
E. Liability Insurance
4. LO 39.1 Keith was walking down the stairs in his house, fell over his son’s toy,
F. TriCare
and twisted his ankle.
G. Automobile Insurance
5. LO 39.2 Marlene was driving to work when another car hit her from behind.
H. Medicare The EMTs took her to the hospital with a sprained ankle and sore neck.
6. LO 39.2 Harvey caught a cold when he went fishing last weekend.
7. LO 39.2 Jared enrolled in the insurance coding program at the local college.
While leaving after his first class, another student bumped into him, he
banged his head on a shelf, and he got a scalp laceration.
8. LO 39.2 At home after his 85th birthday party, Jack tripped on the rug, fell, and
broke his hip.
9. LO 39.2 Suzette’s husband is in the Marines. She is pregnant with their first
child.
10. LO 39.2 James is out of work and has no prospects. He is broke and has a really
bad sore throat.
Sources of Directives
Many different types of laws and regulations exist to direct certain behaviors of those
individuals working in health care, on both the clinical side and the administrative
side. Federal and state governments and their agencies initiate these directives.
FIGURE 40-1 U.S. Congress’s Federal Register showing official details relating to
the Privacy Act (in part) Source: gpo.gov
There is a hierarchy established that sets the level of authority, which begins at the
top with the U.S. Constitution as the first and foremost directive. In 1787, at the Con-
stitutional Convention in Philadelphia, Pennsylvania, the Constitution of the United
States was determined to be the highest and foremost of enacted law. Article VI of the
Constitution states:
“This Constitution, and the Laws of the United States which shall be made in
Pursuance thereof; and all Treaties made, or which shall be made, under the
Authority of the United States, shall be the supreme Law of the Land; and
the Judges in every State shall be bound thereby, any Thing in the Constitu-
tion or Laws of any State to the Contrary notwithstanding.”
Following the U.S. Constitution is federal law—those laws established by the U.S.
Congress. State constitutions, state statutory laws, and then local laws complete the
bottom tiers.
Statutory Laws Statutory laws, most often referred to as statutes, are created and enacted by the
Laws that are enacted by fed- federal and state legislatures (Congress). Members of Congress are responsible for
eral and state legislature. writing the law. Then, once passed by votes in the House and the Senate, it is said to
be “enacted.” Because federal statutes take precedence over state statutory laws, state
and local legislatures are not permitted to enact a law that contradicts any current fed-
eral law. This way, no one has to worry about which law takes dominance because this
order of priority is already established.
There are circumstances, however, where the federal law provides some flexibility
in behavior and the state law is more exact about the required behavior. In these cases,
the state law would take precedence. For example, the federal law commonly called
HIPAA’s Privacy Rule (Health Insurance Portability and Accountability Act) empow-
ers a health care provider to use his or her judgment whether or not to reveal protected
health information to authorities when a patient is diagnosed with a contagious dis-
ease. However, virtually every state has a law that makes the reporting to authorities of
a patient diagnosed with a contagious disease mandatory. The state law does not con-
flict with the federal law; it is actually more specific in its directive about behavior, so
it overrules the federal law. This example is one that illustrates how important it is for
all health care professionals to be familiar with both federal and state laws that govern
their job responsibilities.
EXAMPLES
The Emergency Medical Treatment and Active Labor Act (EMTALA)
The Affordable Care Act (ACA)
Equal Employment Opportunity Act (EEO)
EXAMPLES
United States v. Windsor
Mutual Pharmaceutical Co. v. Bartlett
Adoptive Couple v. Baby Girl
Administrative laws are those created and monitored by administrative agencies Administrative Laws
that have been given the responsibility to oversee specific areas, such as health care. Also known as rules and regu-
The creation and implementation of specific rules and regulations have been delegated lations, these are created and
to those agencies created by Congress, under the Administrative Procedures Act, so adjudicated by administrative
each agency can ensure its assigned tasks can be accomplished. For example, Congress agencies given authority by
Congress.
created the Centers for Disease Control and Prevention (CDC) as an administrative
agency of the federal government to oversee issues related to contagious diseases. The
CDC, therefore, has the authority to establish rules and regulations and to enforce those
regulations (as long as they are consistent with the statute under which the agency was
created). One of these rules is the mandated reporting of infectious diseases. Several
surveillance information systems are used to enable the required reporting of these
diagnoses; some are direct to the CDC while others are channeled through state depart-
ments of health first. However, if a particular diagnosis of an infectious disease is not
reported, as required, the CDC has the authority to take action for noncompliance.
In Figure 40-3, you can see a screen shot of the website Regulations.gov. This web-
site provides you with a searchable database of all federal agency regulations.
EXAMPLE
Centers for Medicare & Medicaid Services (CMS) has established its “rules of par-
ticipation” for health care participating providers.
Criminal law seeks to control the behavior of people and companies when their Criminal Law
actions are related to the health, welfare, and safety of an individual or property with Laws governing the behavior
the intention of protecting public order. Criminal activity is divided into two types, of the actions of the popula-
determined by the severity of the infraction: misdemeanors and felonies. tion related to health and
well-being.
∙ A misdemeanor is a lesser offense, such as driving under the influence, public nui-
sances, and certain traffic violations. These infractions are adjudicated in local
courts and are punishable with fines, penalties, and possible sentences of incarcera-
tion to county jail for up to 364 days.
CHAPTER 40 |
(Slip Opinion) OCTOBER TERM, 2012 1
Syllabus
NOTE: Where it is feasible, a syllabus (headnote) will be released, as is being
done in connection with this case, at the time the opinion is issued. The syl-
labus constitutes no part of the opinion of the Court but has been prepared by
the Reporter of Decisions for the convenience of the reader. See United States
v. Detroit Timber & Lumber Co., 200 U.S. 321, 337.
Federal Food, Drug, and Cosmetic Act (FDCA) requires manufacturers to gain Food and
Drug Administration (FDA) approval before marketing any brand-name or generic drug in
interstate commerce. 21 U. S. C. §355(a). Once a drug is approved, a manufacturer is pro-
hibited from making any major changes to the “qualitative or quantitative formulation of the
drug product, including active ingredients, or in the specifications provided in the approved
application.” 21 CFR §314.70(b)(2)(i). Generic manufacturers are also prohibited from
making any unilateral changes to a drug’s label. See §§314.94(a)(8)(iii), 314.150(b)(10).
In 2004, respondent was prescribed Clinoril, the brand-name version of the nonsteroidal
anti-inflammatory drug (NSAID) sulindac, for shoulder pain. Her pharmacist dispensed a
generic form of sulindac manufactured by petitioner Mutual Pharmaceutical. Respondent
soon developed an acute case of toxic epidermal necrolysis. She is now severely disfigured,
has physical disabilities, and is nearly blind. At the time of the prescription, sulindac’s label
did not specifically refer to toxic epidermal necrolysis. By 2005, however, the FDA had rec-
ommended changing all NSAID labeling to contain a more explicit toxic epidermal necroly-
sis warning. Respondent sued Mutual in New Hampshire state court, and Mutual removed
the case to federal court. A jury found Mutual liable on respondent’s design-defect claim
and awarded her over $21 million. The First Circuit affirmed. As relevant, it found that
neither the FDCA nor the FDA’s regulations pre-empted respondent’s design-defect claim.
It distinguished PLIVA, Inc. v. Mensing, 564 U. S. ___—in which the Court held that failure-
to-warn claims against generic manufacturers are pre-empted by the FDCA’s prohibition on
changes to generic drug labels—by . . .
FIGURE 40-2 The use of case law is cited in this Supreme Court opinion regard-
ing a drug approval case Source: Supreme Court of the United States Syllabus
∙ A felony is much more serious. This is a crime in violation of state or federal law
and often carries a sentence of anywhere from 1 year to life in prison. Health care
claims that are fraudulent and abusive of the reimbursement system constitute
criminal activity and are an example of a felony. The Department of Justice, in con-
junction with states’ attorneys general, investigates accusations of these improper
actions.
In Figure 40-4, you can see a release from the FBI reporting a guilty plea from a
Civil Law man in Ohio who was investigated and found guilty of criminal activity—involving
Laws that govern the relation- billing Medicare and Medicaid for home health care services.
ships between people, and Civil law governs the conduct of those involved in a relationship: between private
between businesses. companies, individuals, and sometimes the government. Most often, a civil complaint
FIGURE 40-4 A brief summary of a case where a man pleads guilty to health care
fraud Source: “Orange Man Pleads Guilty to Health Care Fraud Charges Related to Overbilling Medicaid and Medi-
care by $2.5 Million,” FBI, U.S. Attorney’s Office, April 15, 2013.
or lawsuit will result from one party accusing the other of failure to comply with the
terms of a contract. There are many instances of contractual relationships throughout
the health care industry. Physicians and health care facilities may contract with a man-
aged care organization; some facilities use contract workers to fill in for staff members
on vacation; a family may contract with a home health care agency for services to
a homebound patient; and the federal government may contract for health care ser-
vices from a professional that does not include direct patient care. Figure 40-5 shows
specific language that may be included in one of these contracts. The violation of a
patient’s confidentiality falls into this category because, in the United States, privacy
CHAPTER 40 |
FIGURE 40-5 A partial example of language used in a contract for health care
services that does not always include direct patient contact Source: Acquisition.gov
is considered a civil right. This is why an alleged violation of privacy laws is handled
through the Office of Civil Rights (OCR) within the Department of Health and Human
Services (DHHS) of the federal government.
EXAMPLE
Corbin Bloom wants a nose job (rhinoplasty); however, he cannot afford it. The
insurance carrier will not pay for cosmetic surgery, so the coder changes the code
to indicate that Corbin has a deviated septum requiring surgical correction so that
the insurance carrier will pay for the procedure. That is coding for coverage and is
fraud.
3. If you find yourself in an office or facility that insists that you include codes for pro-
cedures that you know, or believe, were never performed at a level of intensity or
complexity as described by the code, this might be fraudulent behavior known as
upcoding—the process of using a code that claims a higher level of service, or a more Upcoding
severe illness, than is true. Upcoding is considered falsifying records. Even if all you Using a code on a claim form
do is fill out the claim form, you are participating in something unethical and illegal. that indicates a higher level
of service or a more severe
aspect of disease or injury
EXAMPLE than that which was actual
Erica Forney, a 69-year-old female, in the hospital for a broken hip, had her and true.
glucose level checked by the nurse, and it was at an abnormal level. Dr. Magnus
ordered additional tests to rule out diabetes mellitus. Coding that Erica has diabe-
tes is upcoding her condition and will fraudulently increase reimbursement from
Medicare by changing the diagnosis-related group (DRG). In addition, placing a
chronic disease on her health chart when she doesn’t have it will cause her prob-
lems later on.
4. It is not permissible to code and bill for individual (also known as component) ele-
ments when a comprehensive or combination (bundle) code is available. This is
referred to as unbundling and is illegal. Unbundling
Coding the individual parts of
For Medicare billing, refer to the Medicare National Correct Coding Initiative
a specific diagnosis or proce-
(CCI), which lists standardized bundled codes. The CCI is used to find coding dure rather than one combina-
conflicts, such as unbundling, the use of mutually exclusive codes, and other unac- tion or bundle that includes all
ceptable reporting of CPT codes. When these errors are discovered, those claims of those components.
are pulled for review and may be subject to possible suspension or rejection.
Mutually Exclusive Codes
Codes that are identified as
EXAMPLE those that are not permitted
Dr. Hayden’s notes indicate that Rico was experiencing nausea and vomiting. to be used on the same claim
form with other codes.
Instead of coding R11.2 Nausea with vomiting, the coder unbundles, coding
R11.0 Nausea alone and R11.11 Vomiting alone. Double Billing
Sending a claim for the sec-
ond time to the same insur-
5. If you resubmit a claim that has been lost, identify it as a “tracer” or “second sub- ance company for the same
mission.” If you don’t, you might be found guilty of double billing, billing the procedure or service, pro-
insurance company twice for a service provided only once. This also constitutes vided to the same patient on
fraud. the same date of service.
CHAPTER 40 |
6. You must code all conditions or complications that are relevant to the current
CODING BITES encounter. Separating the codes relating to one specific encounter and placing them
Always read the com- on several different claim forms over the course of several different days is neither
plete description in legal nor ethical. It not only indicates a lack of organization of the office but also
the provider’s notes in can cause suspicion of duplicating service claims, known as double billing. Even
addition to referenc- if you are reporting procedures that were actually done for diagnoses that actually
ing the encounter form exist, remember that the claim form is a legal document. All data on that claim
or superbill, and then form, including dates of service, must be accurate. Do not submit the claim form
carefully find the best until you are certain it is complete, with all diagnoses and procedures listed. If it
available code that sup- happens that, after you submit a claim, an additional service provided comes to
ports medical neces- light (such as a lab report with an extra charge that didn’t come across your desk
sity according to the until after you filed the claim), then you must file an amended claim. While not ille-
documentation. gal because you are identifying that the claim contains an adjustment, most third-
party payers really dislike amended claims. You can expect an amended claim to be
scrutinized.
All the activities mentioned here are considered fraud and are against the law.
It is not worth breaking the law and being charged with any of these penalties just
to hang onto a job.
EXAMPLES
Hospitals
Intensity-Modulated Radiation Therapy
We will review Medicare outpatient payments for intensity-modulated radiation
therapy (IMRT) to determine whether the payments were made in accordance
with Federal requirements. IMRT is an advanced mode of high-precision radio-
therapy that uses computer-controlled linear accelerators to deliver precise
radiation doses to a malignant tumor or specific areas within the tumor. Prior OIG
reviews have identified hospitals that have incorrectly billed for IMRT services. In
addition, IMRT is provided in two treatment phases: planning and delivery. Certain
services should not be billed when they are performed as part of developing an
IMRT plan.
Selected Inpatient and Outpatient Billing Requirements
We will review Medicare payments to acute care hospitals to determine hospitals’
compliance with selected billing requirements and recommend recovery of over-
payments. Prior OIG reviews and investigations have identified areas at risk for
noncompliance with Medicare billing requirements. Our review will focus on those
hospitals with claims that may be at risk for overpayments.
Who Is Liable?
Which staff members are responsible for ensuring that a facility or provider complies
with FCA? All individuals and facilities that are involved in the creation and submis-
sion of claims—requests for reimbursement—based on coverage provided by govern-
mental programs, such as Medicare or Medicaid, are responsible for complying with
this law. Legally, these entities are referred to as federal contractors. Some people read
the word contractor and immediately think of construction projects. However, in these
cases, this phrase refers to one signing a contract to do business with a government
program, that is, a participating provider. The Department of Justice takes enforce-
ment of the FCA seriously. (See Figure 40-6 for just one example.)
FIGURE 40-6 An extract from a press release from the Department of Justice con-
cerning a case enforcing the False Claims Act Source: “Justice Department Recovers Nearly $6 Billion
from False Claims Act Cases in Fiscal Year 2014,” Department of Justice, Office of Public Affairs, November 20, 2014.
CHAPTER 40 |
What Is a Claim?
Needless to say, this law requires the proper behavior of individuals filing claims for
reimbursement. So, let’s begin with the FCA’s specific definition of what a claim is:
“a demand for money or property made directly to the Federal Government or to a
contractor, grantee, or other recipient.”*
Under the requirements of the individual state governments, this would be a demand
for reimbursement from the state government or other entity within.
EXAMPLES
Actual knowledge:
“I know that the procedures documented in the patient’s record were not actu-
ally performed.”
Willful ignorance:
“I don’t know for a fact, and I don’t want to know.”
Disregard of the truth:
“It’s not my concern. I just do what I am told.”
Essentially, this means that an individual is required to comply with this law if, as part of
his or her job, the individual knows the accuracy of the information on the claim, or should
know the accuracy of the information. If your job involves anything to do with the creation
and submission of a claim to any third party, it is your responsibility to know for a fact that
the information is true. And no court will accept your excuse that you “didn’t know.”
The Health Insurance Portability and Accountability Act of 1996, known as HIPAA
(pronounced hip-aah), was enacted by the federal government and directly applies to CODING BITES
you as a coding professional. Like most federal laws, HIPAA covers many different
Be very careful when
issues and concerns. The Privacy Rule is one part of this law that you are obligated to
writing or typing this
know and understand.
acronym. It is HIPAA . . .
one P and two As.
HIPAA’s Privacy Rule
HIPAA’s Privacy Rule was written to protect an individual’s privacy with regard HIPAA’s Privacy Rule
to personal health information, without getting in the way of the flow of data that is A portion of HIPAA that
necessary to provide appropriate care for that patient. Essentially, the lawmakers tried ensures the availability of
to make certain that a patient’s information is easily accessible to those who should patient information for those
have access to it [such as the physician, insurance coder and biller, and therapist] who should see it while pro-
tecting that information from
and, at the same time, keep it secured against unauthorized people [such as potential
those who should not.
employers, coworkers, or neighborhood gossips] so that they do not see things they
have no business seeing.
EXAMPLE
Health care providers as defined by HIPAA: physicians, dentists, hospitals, clinics,
pharmacies, laboratories, and so on.
Health plans are described as organizations that provide and/or pay for health care
services as their main reason for being in business. They include health insurance
carriers, HMOs, employee welfare benefit plans, government health plans (such as
CHAPTER 40 |
TriCare, Medicare, and Medicaid), and group health plans provided through employ-
CODING BITES ers and associations. It doesn’t matter whether the plan is offered to an individual or a
Respecting a patient’s group—all companies offering this coverage are included.
privacy is also a sign
of respect for the per-
EXAMPLE
son. When you are the
patient, you want to be Health care plans as defined by HIPAA: Medicare, Medicaid, TriCare, BlueCross
treated with respect. So BlueShield, Prudential, and so on.
following HIPAA’s Pri-
vacy Rule is not just the In addition, technology has created another type of organization involved in this
law of the United States; process, called a health care clearinghouse. These companies help process electronic
it is the law of treating health insurance claims. Medical billing services, medical review services, and health
people fairly. information management system companies are included in this definition.
EXAMPLE
Health care clearinghouses as defined by HIPAA: National Clearinghouse, NDC
Electronic Claims, WebMD Network Services, and others.
The workforces of covered entities are also included under HIPAA. A covered enti-
ty’s workforce consists of every person who is involved with the company—full time,
part time, volunteer, intern, extern, physician, nurse, assistant—and this has nothing
to do with whether they are paid. Everyone must comply with the terms of this law.
CHAPTER 40 |
prepare a health insurance claim form to send to the patient’s insurance company so it
will pay your office for the procedures provided. On that claim form, you must put the
patient’s full name and address, birth date, diagnosis codes, and procedure codes. As
you learned earlier in this chapter, each piece of data is not necessarily confidential.
When you put all this information together in one place, it becomes PHI because this
health information (diagnosis and procedure codes) is now connected to a specific per-
son (identified by the name, address, birth date, etc.) on one piece of paper. However,
you must disclose this information to the insurance carrier in order to get paid. You are
disclosing the information because the insurance company personnel who will read this
claim form do not work for your health care facility—they are an outside company.
EXAMPLE
Dr. Royan indicates that his patient, Caleb Carter, needs some lab work. Dr. Royan
will use Mr. Carter’s PHI in his orders for which tests should be performed. Then
you need to call the laboratory and disclose Mr. Carter’s PHI (his name and diag-
nosis) along with what specific tests should be performed by the lab.
Remember that everyone in your office and everyone at the insurance carrier and
the lab is a member of a covered entity’s workforce. You are all bound by the same
terms of the HIPAA law and cannot reveal any patient’s PHI, except under particular
circumstances (such as use and disclosure), unless you have the patient’s written per-
mission (Figure 40-7).
FIGURE 40-7 A partial summary of a case where HIPAA violations cost a health
care facility big money Source: “$750,000 HIPAA Settlement Underscores the Need for Organization Wide
Risk Analysis,” HHS Press Office, December 14, 2015.
ADDRESS ADDRESS
CITY/STATE CITY/STATE
IV. The information to be disclosed from my health record: (check appropriate box(es))
Only information related to (specify)
If you would like any of the following sensitive information disclosed, check the applicable box(es) below:
Alcohol/Drug Abuse Treatment/Referral HIV/AIDS-related Treatment
Sexually Transmitted Diseases Mental Health (Other than Psychotherapy Notes)
Psychotherapy Notes ONLY (by checking this box, I am waiving any psychotherapist-patient privilege)
V. I understand that I may revoke this authorization in writing submitted at any time to the Health Information Management Department, except to the
extent that action has been taken in reliance on this authorization. If this authorization was obtained as a condition of obtaining insurance coverage or
a policy of insurance, other law may provide the insurer with the right to contest a claim under the policy. If this authorization has not been revoked, it
will terminate one year from the date of my signature unless a different expiration date or expiration event is stated.
This information is to be released for the purpose stated above and may not be used by the recipient for any other purpose. Any person who knowingly and willfully requests
or obtains any record concerning an individual from a Federal agency under false pretenses shall be guilty of a misdemeanor (5 USC 552a(i)(3)).
PATIENT IDENTIFICATION NAME (Last, First, MI) RECORD NUMBER
ADDRESS
FIGURE 40-8 Example of authorization form to release health information Source: Department of Health and Human Services,
Form IHS-810 (4/09)
CHAPTER 40 |
Permitted Uses and Disclosures
The Privacy Rule outlines six circumstances in which health care professionals are
permitted, with or without written patient permission, to use their best professional
judgment as to whether or not they should use and/or disclose a patient’s PHI.
1. To the individual. Health care professionals can use their best professional judg-
ment to decide whether or not a patient should be told certain things contained in
his or her health care record. Questions come up especially when mental health
issues and terminal conditions (when a patient is almost certain to die in the near
future) are concerned and there is doubt if the patient can deal with the medical
facts. In almost all cases, providing patients with their own PHI is allowed.
2. Treatment, payment, and/or operations (TPO). This means that health care pro-
fessionals are free to use and/or disclose PHI when it comes to making decisions,
coordinating, and managing the treatment of a patient’s condition.
In addition, PHI can be disclosed for payment activities, such as billing and
claims processing, as mentioned earlier in this chapter. In this description, the term
operations refers to the health care facility’s own management of case coordination
and quality evaluations.
EXAMPLE
A physician needs to be able to discuss PHI details with a therapist so that,
together, they can establish a proper course of treatment for the patient.
3. Opportunity to agree or object. This relates to a more informal situation where the
patient is present and alert and has the ability to give verbal permission or not with
regard to a specific disclosure.
One important point to remember: Although it is much easier to simply ask
someone for his or her oral approval than to go get a form and make the patient sign
first, it is in your best interest to get written approval whenever possible. People’s
memories may fail, or they may change their mind later about what they really did
tell you. If there is nothing on paper, you cannot prove what was said. For your own
protection, get it in writing whenever possible!
EXAMPLE
Asher Grimm is about to hear Dr. Brant explain his test results. Asher’s wife is in
the waiting room. Dr. Brant may ask Asher if it is okay to invite his wife in and per-
mit her to hear this information, too. Asher can then say, “Yes, that is fine” or “No,
I don’t want her to know about this.” Dr. Brant then must abide by what the patient
requests.
4. Incidental use and disclosure. As long as reasonable safeguards are in place, this
CODING BITES portion of the rule addresses the fact that information might accidentally be used or
Incidental is close to disclosed during the regular course of business.
the word accidental—if
someone accidentally
EXAMPLE
overhears what you say.
Dr. Holloway comes out of an examining room and approaches Nurse Miller stand-
ing at the desk. This is a back area, and patients are not generally in this hallway,
so Dr. Holloway speaks to the nurse in a normal tone of voice to instruct her on
preparing Mrs. Hunter for a procedure. All of a sudden, another patient comes
around the corner, lost on her way back to the waiting room, and overhears the
conversation.
EXAMPLE
In the hallway outside the exam room, the physician would only need to say,
“Serita, please prepare Mrs. Hunter for her examination.” She would not need
to include other details about Mrs. Hunter, such as, “Serita, please prepare Mrs.
Hunter for her examination. You know she has a terrible rash on her thighs. I sus-
pect that it’s poison ivy. However, it could be a sexually transmitted disease. We’ll
have to find out how many sexual partners she has had in the last 6 months.” All
that extra information is unnecessary to the proper care of Mrs. Hunter at this
moment.
5. Public interest. There are times when the public’s best interest may prompt disclos-
ing what you know about a patient. Very often, this is mandated by state laws, which
would then take priority over the federal HIPAA law. In other words, if the federal
law says you are allowed to tell, and your state’s law says you must tell—then, you
must! These situations include the reporting of suspected abuse (child abuse, elder
abuse, neglect, domestic violence) and the reporting of sexually transmitted and
other contagious diseases. You are included in the health care team and must think
about the community, which must be warned if someone is walking around with a CODING BITES
contagious (communicable) disease. Most states require notification to the police in Remember that, when
cases where the patient has been shot or stabbed. It is your responsibility to find out there is a state or fed-
what the laws are in your state and how to correctly file a report. eral mandate to report
If the physician does not report suspected child abuse of one of your patients, it (that means you have no
is your obligation to pick up the phone and call. choice; you must report
to the proper author-
6. Limited data set. For research, public health statistics, or other health care oper- ities), this does not
ations, PHI can be revealed, but only after it has been depersonalized. In other apply only to the physi-
words, if the data that connect this information to a specific individual are removed cian of your practice but
or blacked out, the information is no longer individually identifiable health infor- also applies to you.
mation, so it does not need to be protected any longer.
EXAMPLE
You can release a health record that has no name, address, telephone number,
e-mail address, Social Security number, or photographs attached to it. Even certain
physician’s notes can be released after they have been stripped of personal data.
Following is a sample portion of a record that can be shown without fear of violat-
ing anyone’s privacy:
“_____ is 33 years old. Back in April, _____ was in a motor vehicle acci- CODING BITES
dent while he was on the job. _____ is complaining about some neck This law simply assures
pain. _____ has tingling into the left hand.” every person coming to
The example above is a direct quote from the medical record of an actual patient your health care facility
after the specified direct identifiers have been removed. You cannot connect this that his or her personal
health information to any one particular person. Therefore, the information is no and private information
longer protected and can be used for research and in other ways that may help will be protected and
the community. treated with respect.
CHAPTER 40 |
Privacy Notices
HIPAA instructs all its covered entities to create policies and procedures with regard
to the use and disclosure of PHI. In addition, the law actually states that, once policies
and procedures are developed, the facilities must follow these policies. Copies of the
written policy must be given to every patient and posted in a general area where it can
be seen by all patients.
Notices of Privacy written in compliance with HIPAA’s Privacy Rule must contain
the following points:
1. A full description of how the covered entity may use and/or disclose a patient’s PHI.
2. A statement about the covered entity’s responsibility to protect a patient’s privacy.
3. Complete information about the patient’s rights, including contact information for
the Department of Health and Human Services (DHHS), should the patient wish to
lodge a complaint that his or her privacy was violated.
4. The name of a specific employee of the covered entity, who must be named as pri-
vacy officer. This person’s name, as well as contact information, must be included
in the written notice to handle patients’ questions and complaints.
The covered entity must receive written acknowledgment from each patient stating
that he or she received the written privacy practices notice. This is usually one of the
papers that a patient has to sign when going to a health care facility for the first time.
One of the most important aspects of this portion of the Privacy Rule is that the law
specifically says that the covered entity not only has to create these policies and proce-
dures but also has to abide by them. If it doesn’t, it is considered to be in violation of
federal law and punishable by fines and/or imprisonment.
Although some health care staff members feel that HIPAA and its Privacy Rule are
a pain in the neck, think about what this law actually means: respecting your patients’
privacy and dignity. Isn’t that what you expect from your health care professionals
when you go for help? It is not enough that only the doctor be bound to protect the
patient’s information as confidential because the doctor is no longer the only person
who has access. Your health care facility is no place for gossip. You might find this
person’s hemorrhoids funny or that person’s rash gross. As a professional, you should
not be concerned with entertaining your friends with your patients’ private circum-
stances. How would you feel if it were your personal problem that your health care
team members were giggling about with their friends? Or you might consider tell-
ing your brother that his girlfriend came in with a sexually transmitted disease. You
cannot! Everyone is entitled to privacy. As difficult as it may be, you must remain a
professional.
CODING BITES
Just because you can take a look at any patient’s chart doesn’t mean you should.
In your facility, you will probably be granted permission to access patients’ charts
so you can do your work. Under certain circumstances you may be tempted
to look, not for your job but because the patient is your friend or neighbor or a
celebrity. You may think no harm is being done, just caring or curiosity. But there is
harm, and you are prohibited, by law, to do this.
Back in October 2007, 27 employees of a New Jersey hospital were fired or
put on suspension for looking at George Clooney’s file after he was brought into
the emergency department (ED) following a motorcycle accident.
You could be the president of the hospital and have your best friend come into
the ED of your hospital. Without specific permission from that patient, you would
be forbidden from looking at the record. Every individual has the right to make
his or her own decision about who should know what about his or her own health
information.
FIGURE 40-9 A press release from the Department of Health and Human Services with details about violators of
HIPAA facing consequences Source: “HHS requires California medical center to protect patients’ right to privacy,” U.S. Department of Health and
Human Services, June 13, 2013.
CHAPTER 40 |
Civil Penalties
1. $100 with no prison for each single violation of a HIPAA regulation with a maxi-
mum of $25,000 for multiple violations of the same portion of the regulation during
the same calendar year.
EXAMPLE
You tell your best friend that Oliver Tesca, whom you both went to school with,
came into your physician’s office and tested positive for a sexually transmitted dis-
ease. You, of course, swear her to secrecy. Later that day, she bumps into Oliver’s
fiancée and feels obligated to tell her about Oliver’s condition. Oliver puts two and
two together, after his fiancée breaks up with him, and he files a complaint that
you disclosed his PHI without permission. You and/or your physician is fined $100.
Criminal Penalties
2. Up to $50,000 and up to 1 year in jail for the unauthorized or inappropriate disclo-
sure of individually identifiable health information.
EXAMPLE
After you are fined the $100 civil penalty for the inappropriate disclosure of Oliver
Tesca’s PHI, you and/or your physician is charged with criminal penalties for the
same disclosure, including a fine of $50,000 and a year in jail.
EXAMPLE
Your best friend since high school, Sally-Anne Hoskins, just got a great job as a
pharmaceutical representative. To help her, you give her a list of 250 patients
from your facility who have been diagnosed with diabetes so she can advertise
her company’s new drug to them. You and she both know this is illegal, so you
tell Sally-Anne that you got permission from each of the patients to release the
information (and that is a lie). After a patient complains to DHHS, the investiga-
tion discovers your relationship with Sally-Anne. You and your physician are fined
$100,000 per occurrence (that’s for each person on the list), as well as sentenced
to 5 years in prison. FYI: 250 × $100,000 = $25 million!
EXAMPLE
A famous television star is a patient of the physician’s office down the hall from
yours. You get a call from a tabloid newspaper offering you $50,000 for any infor-
mation on the celebrity’s health. So you call the manager of the pathology lab
and tell him you are filling in at the other physician’s office and need test results
for Mr. TV. Then you call the tabloid reporter and tell him what you found out. You
used deception (you lied about working in the other physician’s office) to gain PHI,
which you then sold for personal financial gain. You (and possibly your physician)
are fined a quarter of a million dollars and sentenced to 10 years in prison—
definitely not worth it!
CODING BITES
From Fact Sheet: The Health Care Fraud and Abuse Control Program Protects Con-
sumers and Taxpayers by Combating Health Care Fraud, dated February 26, 2016.
“In Fiscal Year (FY) 2015, the government recovered $2.4 billion as a result
of health care fraud judgements, settlements and additional administrative
impositions in health care fraud cases and proceedings. Since its inception in
1997, the Health Care Fraud and Abuse Control (HCFAC) Program has returned
more than $29.4 billion to the Medicare Trust Funds. In this past fiscal year, the
HCFAC program has returned $6.10 for each dollar invested.”
Source: justice.gov
CHAPTER 40 |
40.6 Codes of Ethics
There are two premier trade organizations for professional coding specialists. Each
has published a code of ethics to guide members of our industry on the best profes-
sional way to conduct themselves.
GUIDANCE CONNECTION
AHIMA Code of Ethics
This Code of Ethics sets forth ethical principles for the health information management
profession. Members of this profession are responsible for maintaining and promoting
ethical practices. This Code of Ethics, adopted by the American Health Information Man-
agement Association, shall be binding on health information management professionals
who are members of the Association and all individuals who hold an AHIMA certification.
The following ethical principles are based on the core values of the American
Health Information Management Association and apply to all health information
management professionals. Health information management professionals must:
1. Advocate, uphold, and defend the individual’s right to privacy and the doc-
trine of confidentiality in the use and disclosure of information.
2. Put service and the health and welfare of persons before self-interest and
conduct themselves in the practice of the profession so as to bring honor to
themselves, their peers, and the health information management profession.
3. Preserve, protect, and secure personal health information in any form or
medium and hold in the highest regard the contents of the records and other
information of a confidential nature, taking into account the applicable stat-
utes and regulations.
4. Refuse to participate in or conceal unethical practices or procedures.
5. Advance health information management knowledge and practice through
continuing education, research, publications, and presentations.
6. Recruit and mentor students, peers, and colleagues to develop and
strengthen a professional workforce.
7. Represent the profession accurately to the public.
8. Perform honorably health information management association responsibili-
ties, either appointed or elected, and preserve the confidentiality of any privi-
leged information made known in any official capacity.
9. State truthfully and accurately their credentials, professional education, and
experiences.
10. Facilitate interdisciplinary collaboration in situations supporting health infor-
mation practice.
11. Respect the inherent dignity and worth of every person.
Reprinted with permission from the American Health Information Management Association. Copyright ©2015
by the American Health Information Management Association. All rights reserved. No part of this may be repro-
duced, reprinted, stored in a retrieval system, or transmitted, in any form or by any means, electronic photo-
copying, recording, or otherwise, without the prior written permission of the association.
GUIDANCE CONNECTION
AHIMA Standards of Ethical Coding
Coding professionals should:
1. Apply accurate, complete, and consistent coding practices that yield quality
data.
2. Gather and report all data required for internal and external reporting, in
accordance with applicable requirements and data set definitions.
3. Assign and report, in any format, only the codes and data that are clearly and
consistently supported by health record documentation in accordance with
applicable code set and abstraction conventions, and requirements.
4. Query and/or consult as needed with the provider for clarification and addi-
tional documentation prior to final code assignment in accordance with
acceptable healthcare industry practices.
5. Refuse to participate in, support, or change reported data and/or narrative
titles, billing data, clinical documentation practices, or any coding related
activities intended to skew or misrepresent data and their meaning that do
not comply with requirements.
6. Facilitate, advocate, and collaborate with healthcare professionals in the pur-
suit of accurate, complete and reliable coded data and in situations that sup-
port ethical coding practices.
7. Advance coding knowledge and practice through continuing education,
including but not limited to meeting continuing education requirements.
8. Maintain the confidentiality of protected health information in accordance
with the Code of Ethics.
9. Refuse to participate in the development of coding and coding related tech-
nology that is not designed in accordance with requirements.
10. Demonstrate behavior that reflects integrity, shows a commitment to ethical
and legal coding practices, and fosters trust in professional activities.
11. Refuse to participate in and/or conceal unethical coding, data abstraction,
query practices, or any inappropriate activities related to coding and address
any perceived unethical coding related practices.
Reprinted with permission from the American Health Information Management Association. Copyright ©2015
by the American Health Information Management Association. All rights reserved. No part of this may be repro-
duced, reprinted, stored in a retrieval system, or transmitted, in any form or by any means, electronic photo-
copying, recording, or otherwise, without the prior written permission of the association.
CHAPTER 40 |
GUIDANCE CONNECTION
AAPC Code of Ethical Standards
Members of the American Academy of Professional Coders shall be dedicated
to providing the highest standard of professional coding and billing services to
employers, clients and patients. Professional and personal behavior of AAPC
members must be exemplary.
AAPC members shall maintain the highest standard of personal and profes-
sional conduct. Members shall respect the rights of patients, clients, employers
and all other colleagues.
Members shall use only legal and ethical means in all professional dealings and
shall refuse to cooperate with, or condone by silence, the actions of those who
engage in fraudulent, deceptive or illegal acts.
Members shall respect and adhere to the laws and regulations of the land and
uphold the mission statement of the AAPC.
Members shall pursue excellence through continuing education in all areas
applicable to their profession.
Members shall strive to maintain and enhance the dignity, status, competence
and standards of coding for professional services.
Members shall not exploit professional relationships with patients, employees,
clients or employers for personal gain.
Above all else we will commit to recognizing the intrinsic worth of each member.
This code of ethical standards for members of the AAPC strives to promote
and maintain the highest standard of professional service and conduct among its
members. Adherence to these standards assures public confidence in the integ-
rity and service of professional coders who are members of the AAPC.
Failure to adhere to these standards, as determined by AAPC, will result in the
loss of credentials and membership with the American Academy of Professional
Coders.
Copyright © 2014, American Academy of Professional Coders. All rights reserved. Reprinted with permission.
GUIDANCE CONNECTION
Federal Sentencing Guidelines Manual: The Seven Steps to Due Diligence
1. Establish compliance standards and procedures
2. Assign overall responsibility to specific high-level individual(s)
3. Use due care to avoid delegation of authority to individuals with an inclination
to get involved in illegal actions
4. Effectively communicate standards and procedures to all staff
5. Utilize monitoring and auditing system to detect non-compliant conduct
6. Enforce adequate disciplinary sanctions when appropriate
7. Respond to episodes of non-compliance by modifying program, if necessary
Source: United States Sentencing Commission. (2014, November 1). 2014 USSC Guidelines Manual, ussc.gov
Chapter Summary
Knowing your legal and ethical responsibilities as a health care professional will give
you a strong foundation for a healthy career. HIPAA’s Privacy Rule, along with the
codes of ethics from both AHIMA and AAPC, should help guide you through any
challenges.
For all of those providing health care services, the federal and state governments
have crafted and enacted laws and regulations designed to ensure honest, safe, and
appropriate behaviors from all involved. The Federal Register is the daily journal of
the U.S. federal government, used to inform citizens of the actions of the federal gov-
ernment. The hierarchy established for the levels of authority begin with the U.S. Con-
stitution, followed by federal statutory law, state constitutions, state statutory laws,
and local laws. Executive orders, issued by the president of the United States, have the
same authority as federal statutes. Common law, also known as case law, is created by
a judicial decision made during a court trial and it establishes precedence. Administra-
tive laws are the rules and regulations established by administrative agencies in their
efforts to encourage compliance so they can complete their assigned tasks. The viola-
tion of criminal law may be a misdemeanor (lessor offense) or a felony (more serious
offense). Civil laws govern the conduct of two individuals or entities in a contractual
agreement or a civil wrongdoing, known as a tort.
Confidentiality, honesty, and accuracy are the watchwords that all health informa-
tion management professionals should live by.
CODING BITES
Medical records, also known as patient charts, whether in paper or electronic
form, are legal documents. As business records, they can be used as evidence in
a court of law, and can be required by issuance of a subpoena duces tecum.
As per the HIPAA Privacy Rule, a “designated record set” must be specified
by each health care organization. Essentially, this is a collection of files (paper or
electronic) that include:
• the medical records and billing records about individuals maintained by, or for,
a covered health care provider;
• the enrollment, payment, claims adjudication, case study, or medical manage-
ment record systems maintained by or for a health plan; or
• documentation used for the provider or plan to make decisions about
individuals.
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c. restrict health care professionals from doing their jobs.
d. protect an individual’s privacy and not interfere with the flow of information necessary for care.
2. LO 40.4 Protected health information (PHI) is
a. any health information that can be connected to a specific individual.
b. a listing of diagnosis codes.
c. current procedural terminology.
d. covered entity employee files.
3. LO 40.4 According to HIPAA, covered entities include all except
a. health care providers. b. health plans.
c. health care computer software manufacturers. d. health care clearinghouses.
4. LO 40.4 The term use per HIPAA’s Privacy Rule refers to the exchange of information between health care
personnel
a. and health care personnel in other health care facilities. b. and family members.
c. in the same office. d. and the pharmacist.
5. LO 40.4 The term disclosure per HIPAA’s Privacy Rule refers to the exchange of information between health
care personnel
a. and health care personnel in other covered entities. b. and family members.
c. in the same office. d. and the patient.
6. LO 40.4 Which of the following is not a covered entity under HIPAA?
a. County hospital b. BlueCross BlueShield Association
c. Physician Associates medical practice d. Computer technical support
7. LO 40.6 There are two premier trade organizations for professional coding specialists. Each organization has a
code of ethics to guide members on the best professional way to conduct themselves. These two organi-
zations are
a. AHIMA and OFR. b. GPO and AAPC.
c. AHIMA and AAPC. d. HIPAA and EEO.
8. LO 40.4 According to HIPAA’s rules and regulations, a covered entity’s workforce includes
a. only paid, full-time employees.
b. only licensed personnel working in the office.
c. volunteers, trainees, and employees, part time and full time.
d. business associates’ employees.
9. LO 40.4 HIPAA’s Privacy Rule has been carefully crafted to
a. protect a patient’s health care history.
b. protect a patient’s current medical issues.
c. protect a patient’s future health considerations.
d. all of these.
10. LO 40.4 A written form to release PHI should include all except
a. specific identification of the person who will be receiving the information.
b. the specific information to be released.
c. legal terminology so it will stand up in court.
d. an expiration date.
CHAPTER 40 |
11. LO 40.4 Those who are permitted to file an official complaint with DHHS are
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Please answer the following questions from the knowledge you have gained after read-
ing this chapter.
1. LO 40.4 Why was HIPAA’s Privacy Rule written?
2. LO 40.2 Explain double billing. Is it permissible practice for a professional cod-
ing specialist?
3. LO 40.1 Explain civil law in relation to the health care industry.
4. LO 40.3 What is the False Claims Act’s definition of a claim and what is the
knowledge requirement?
5. LO 40.7 What are the federal sentencing guidelines manual’s seven steps to due
diligence for an effective compliance program?
All you need to do is change the one number of the code and Felecia can have the relief she so desperately needs.
As the professional coding specialist in this office, what should you do?
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APPENDIX
CodePath: For more information on determining level of history, see Let’s Code It!
Chapter 23, Section 23.4 Types of E/M Services – Level of Patient History (beginning
on page 648).
1216
New Patient/ Established/
Step 3. Key Components Initial Subsequent
Physical Examination
Problem-Focused: A limited exam of the affected body area or organ system
Expanded Problem-Focused: A limited exam of the affected body area or organ
system and other symptomatic or related organ system(s)
Detailed: An extended exam of the affected body area(s) and other symptomatic
or related organ system(s)
Comprehensive: A general multisystem exam -or- a complete exam of a single
organ system
CodePath: For new Patients … You can only code as high as your lowest key component.
GLOSSARY
1218
Axis of Classification A single meaning within the code set; Carrier An individual infected with a disease who is not ill but
providing a detail. can still pass it to another person; an individual with an abnormal
gene that can be passed to a child, making the child susceptible to
B disease.
Cataract Clouding of the lens or lens capsule of the eye.
Bacteria Single-celled microorganisms that cause disease.
Category I Codes The codes listed in the main text of the CPT
Basic Life Support (BLS) The provision of emergency CPR, book, also known as CPT codes.
stabilization of the patient, first aid, control of bleeding, and/or
Category II Codes Codes for performance measurement and
treatment of shock.
tracking.
Basic Personal Services Services that include washing/bathing,
Category II Modifiers Modifiers provided for use with
dressing and undressing, assistance in taking medications, and
Category II CPT codes to indicate a valid reason for a portion of a
assistance getting in and out of bed.
performance measure to be deleted from qualification.
Behavioral Disturbance A type of common behavior that
Category III Codes Codes for emerging technology.
includes mood disorders (such as depression, apathy, and
euphoria), sleep disorders (such as insomnia and hypersomnia), Catheter A thin, flexible tube, inserted into a body part, used to
psychotic symptoms (such as delusions and hallucinations), and inject fluid, to extract fluid, or to keep a passage open.
agitation (such as pacing, wandering, and aggression). Cecum A pouchlike organ that connects the ileum with the large
Benign Nonmalignant characteristic of a neoplasm; not infectious intestine; the point of connection for the vermiform appendix.
or spreading. Centers for Medicare & Medicaid Services (CMS) The agency
Benign Prostatic Hyperplasia (BPH) Enlarged prostate that under the Department of Health and Human Services (DHHS) in
results in depressing the urethra. charge of regulation and control over services for those covered by
Biofeedback Training to gain voluntary control of automatic Medicare and Medicaid.
bodily functions. Cerebral Infarction An area of dead tissue (necrosis) in the brain
Bladder Cancer Malignancy of the urinary bladder. caused by a blocked or ruptured blood vessel.
Blepharitis Inflammation of the eyelid. Cerebrovascular Accident (CVA) Rupture of a blood vessel
causing hemorrhaging in the brain or an embolus in a blood vessel
Blister A bubble or sac formed on the surface of the skin,
in the brain causing a loss of blood flow; also known as stroke.
typically filled with a watery fluid or serum.
Certified Registered Nurse Anesthetist (CRNA) A registered
Blood Fluid pumped throughout the body, carrying oxygen and
nurse (RN) who has taken additional, specialized training in the
nutrients to the cells and wastes away from the cells.
administration of anesthesia.
Blood Type A system of classifying blood based on the antigens
Character A letter or number component of an ICD-10-PCS
present on the surface of the individual’s red blood cells; also
code.
known as blood group.
Chelation Therapy The use of a chemical compound that binds
Body Part The anatomical site upon which the procedure was
with metal in the body so that the metal will lose its toxic effect.
performed.
It might be done when a metal disc or prosthetic is implanted in
Body System The physiological system, or anatomical region, a patient, eliminating adverse reactions to the metal itself as a
upon which the procedure was performed. foreign body.
Bulbar Conjunctiva A mucous membrane on the surface of the Chief Complaint (CC) The primary reasons why the patient has
eyeball. come for this encounter, in the patient’s own words.
Bulla A large vesicle that is filled with fluid. Cholelithiasis Gallstones.
Burn Injury by heat or fire. Chondropathy Disease affecting the cartilage [plural:
chondropathies].
C Choroid The vascular layer of the eye that lies between the retina
and the sclera.
Capitation Plans Agreements between a physician and a managed
care organization that pay the physician a predetermined amount of Chronic Long duration; continuing over an extended period of
money each month for each member of the plan who identifies that time.
provider as his or her primary care physician. Chronic Kidney Disease (CKD) Ongoing malfunction of one or
Carbuncle A painful, pus-filled boil due to infection of the both kidneys.
epidermis and underlying tissues, often caused by staphylococcus. Chronic Obstructive Pulmonary Disease (COPD) An ongoing
Carcinoma A malignant neoplasm or cancerous tumor. obstruction of the airway.
Care Plan Oversight Services E/M of a patient, reported in Ciliary Body The vascular layer of the eye that lies between the
30-day periods, including infrequent supervision along with sclera and the crystalline lens.
preencounter and postencounter work, such as reading test results Civil Law Laws that govern the relationships between people, and
and assessment of notes. between businesses.
Class A Finding Nontraumatic amputation of a foot or an integral management of a patient’s specific health concern. A consultation
skeletal portion. is planned to be a short-term relationship between a health care
Class B Finding Absence of a posterior tibial pulse; absence or professional and a patient.
decrease of hair growth; thickening of the nail, discoloration of Cornea Transparent tissue covering the eyeball; responsible for
the skin, and/or thinning of the skin texture; and/or absence of a focusing light into the eye and transmitting light.
posterior pedal pulse. Corneal Dystrophy Growth of abnormal tissue on the cornea,
Class C Finding Edema, burning sensation, temperature change often related to a nutritional deficiency.
(cold feet), abnormal spontaneous sensations in the feet, and/or Corrosion A burn caused by a chemical; chemical destruction
limping. of the skin.
Classification Systems The term used in health care to identify Covered Entities Health care providers, health plans, and health
ICD-10-CM, CPT, ICD-10-PCS, and HCPCS Level II code sets. care clearinghouses—businesses that have access to the personal
Clinical Laboratory Improvement Amendment (CLIA) Federal health information of patients.
legislation created for the monitoring and regulation of clinical CPT Code Modifier A two-character code that may be appended
laboratory procedures. to a code from the main portion of the CPT book to provide
Clinically Significant Signs, symptoms, and/or conditions present additional information.
at birth that may impact the child’s future health status. Criminal Law Laws governing the behavior of the actions of the
Closed Treatment The treatment of a fracture without surgically population related to health and well-being.
opening the affected area. Critical Care Services Care services for