Transcript Borderline diagnoses

REVIEW OF CODING CLINIC 1ST
AND 2ND QUARTER 2011
Stephanie Carlisto, RHIT, CCS
BORDERLINE DIABETES MELLITUS AND
BORDERLINE DIAGNOSES
How do you code a diagnosis of
borderline diabetes?
Code should be based
on information in the
chart. Physician may
need to be queried
but without any
confirmation, assign a
code of 790.2,
abnormal glucose.
Borderline diagnoses
Advice for example of
pulmonary
hypertension is to, as
with diabetes,
depending on the
documentation on the
chart as to whether to
code it, or query the
physician.
CHRONIC ANEMIA
Coding clinics advice regarding how to
code “chronic anemia” is to code it to
285.9, Anemia, unspecified.
Broken catheter tip retrieved via
thrombectomy
The question asked pertains to how to code
a broken catheter tip that occurred during an
aspiration of a thrombus. In the question
posed, the broken tip was removed.
Advice is to assign code 996.1, Mechanical
complication of other vascular device,
implant, and graft. However, if it cannot be
removed, you would assign 996.1 and 998.4,
Foreign body accidentally left during a
procedure.
Chest radiograph showing the embolized catheter fragment (black arrowheads) lodged in the
left pulmonary artery.
Thanigaraj S et al. Chest 2000;117:1209-1211
©2000 by American College of Chest Physicians
Broken needle left during surgery
The example given here was a needle that was
lost within the tissue during an aortic valve
replacement. After evaluation and a second
attempt to retrieve the needle, the surgeon
decided it was in the patient’s best interest to
leave it alone. As removing it could cause more
harm.
Advice is to code 998.4, Foreign body
accidentally left during a procedure. Though it
was decided to leave the needle in, it was not
the intent of the original procedure to leave a
foreign body behind.
CHRONIC DEEP VENOUS EMOBISM AND
THROMBOSIS
The question here is when does
a venous thrombosis become
chronic?
The answer given is that there are no
specific timelines regarding this and
assignment of chronic DVT should be
based on the providers documentation.
CHRONIC VENOUS EMBOLISM AND
THROMBOSIS
Should a patient with a history of DVT
receiving Coumadin be coded to a history of
DVT V12.51, or 453 category for chronic DVT?
Query for clarification whether Coumadin is
being given prophylactically to prevent a
recurrence of the DVT or as treatment for a
chronic DVT.
CHRONIC VENOUS EMBOLISM AND
THROMBOSIS
Reference is made to the Official
Guidelines for Coding and Reporting,
“Personal history codes explain a
patient’s past medical condition that no
longer exists and is not receiving any
treatment, but that has the potential for
recurrence, and therefore may require
monitoring.”
CODE ASSIGNMENT BASED ON UP
AND DOWN ARROWS
Advice from Coding Clinic regarding up
and down arrows applies to both
inpatient and outpatient admissions.
It is not appropriate to report a diagnosis
based on up and down arrows. Rational
being, they do not necessarily mean
“abnormal.” They may just be indicating
a change. If findings on chart warrant a
query, then query the provider.
DISSECTION OF ARTERY OCCURRING
DURING CORONARY ANGIOPLASTY
When a dissection occurs during a PCI
(percutaneous coronary intervention), and
the physician documents it as a
complication, code it to 997.1 Cardiac
complications, and assign code 414.12
Dissection of coronary artery to further
describe the complication.
GASTRIC BAND EROSION WITH
INFECTION
Gastric band erosion and infection
• 996.59 Mechanical complication
• 537.89 Other specified disorders
of stomach and duodenum
• 996.69 Infection and
inflammatory reaction due to
device or implant
—25-year-old woman presented for re-inflation of band placed 5 years ago. While inflating
band, patient experienced acute pain. CT scan and endoscopy show band partially inside
gastric lumen.
Mehanna M J et al. AJR 2006;186:522-534
©2006 by American Roentgen Ray Society
IATROGENIC PNEUMOTHORAX
The question is, “does the provider need
to document a pneumothorax is a
complication before you can assign
512.1?”
Coding Clinic’s response is, it must be
documented as a complication in order to
code it as one, or stated as “Iatrogenic.”
The guideline for complications extends
to any complications of care, regardless
of the chapter the code is located in.
PANCYTOPENIA DUE TO DRUGS
When documentation in the chart states
“pancytopenia due to chemotherapy”
assign code 284.89, Other specified
aplastic anemias, along with the
appropriate E-code to identify the drug.
This answer is based on the instructional
note under code 284.1 which states that
drug induced pancytopenia is classified to
code 284.89
LAPAROSCOPICALLY-ASSISTED
HEMICOLECTOMY
When a hemicolectomy is performed with
laparoscopic assistance, code V64.41,
Laparoscopic surgical procedure converted
to open procedure would not be
appropriate to code.
Rationale is it was a planned laparoscopicassisted surgery.
Correct code assignment would be 45.73,
Open and other right hemicolectomy
POSTOPERATIVE ASPIRATION
PNEUMONIA
When there is a diagnosis of
postoperative aspiration pneumonia it is
appropriate to code both the respiratory
complication code and the aspiration
pneumonia code.
997.39 Respiratory Complications and
507.0 Pneumonitis due to solids and
liquids, Due to inhalation of food or
vomitus.
POSTOPERATIVE HEMORRHAGE AND
POSTOPERATIVE HEMATOMA
Before coding any postoperative hemorrhage or
hematoma as a complication of care, it must be
explicitly documented by the physician that the
condition is a complication.
Once again, if the indications on the chart are that the
hemorrhage or hematoma required clinical evaluation,
therapeutic treatment, diagnostic procedures, or
increased nursing care and/or monitoring it is
appropriate to query the provider.
ACUTE RENAL FAILURE AND END STAGE
RENAL DISEASE
Acute renal failure and end stage renal
disease (ESRD) can occur during the
same hospital encounter with the
presence of trauma, adverse effects of
medication, infection, volume
depletion or whatever may cause the
kidneys to stop functioning.
It is appropriate to code both if they
are documented.
BACTEREMIA DUE TO PICC LINE
ANNULAR DISC TEAR
EMBOLIZATION OF GASTRODUODENAL
ARTERY WITH COILS
Code reason for encounter
(pdx) and then bacteremia
due to PICC line as secondary
diagnoses also code the type
of bacteria if documented
Any tear to the annular portion
of a vertebral disc is coded as
degeneration whether
documented as traumatic or
non traumatic
999.31 Infection due to central
venous catheter
790.7 Bacteremia
041.19 Other Staphylococcus
Assign code 44.44 transcatheter
embolization for gastric or
duodenal bleeding
CYSTOCELE REPAIR W/MESH AND
RECTOCELE REPAIR W/SUTURES
When one repair is done with mesh and
the other done with sutures, it is
appropriate to use 2 codes to describe
what was done.
70.52 Repair of rectocele
70.54 Repair of cystocele with graft or
prosthesis
DYNESYS DYNAMIC STABILIZATION
DEVICE WITH FUSION
EXCISIONAL DEBRIDEMENT OF BUTTOCK
ABSCESS
Documentation in this example is an incision
being made into the abscess and stating it was
“extensively excised.”
Direction is to code 86.22, Excisional
debridement of wound, infection, or burn.
The incision in this example being an important
component to the definitive procedure which is
the excisional debridement.
MAPPING AND ABLATION OF ATRIAL
TACHYCARDIA VIA TRANSEPTAL
APPROACH
The approach does not play a part in
assignment of the codes for this
procedure.
Code 37.34, Catheter ablation of lesion or
tissue of heart for the ablation
37.26, Cardiac electrophysiologic
stimulation and recording studies
37.27, Cardiac mapping
THROMBOSIS OF FEMORAL POPITEAL
BYPASS GRAFT
To describe this condition it is appropriate
to use 2 codes
996.74, Other complications of internal
(biological) (synthetic) prosthetic device,
implant, and graft, Due to other vascular
device, implant and graft
444.22, Arterial embolism and thrombosis,
Lower extremity
PROPHYLACTIC BILATERAL
MASTECTOMY DUE TO POSITIVE BRCA
MUTATION
Assign code V50.41, Prophylactic organ
removal, Breast as principal diagnosis
And V84.01, Genetic susceptibility to
malignant neoplasm of breast
If patient has a history of breast cancer,
assign code V10.3, Personal history of
malignant neoplasm, breast
MEDICAL MARIJUANA
METHADONE MAINTENANCE
Assign code V58.69,
Long-term use of
other medications, for
marijuana taken for
medicinal purposes.
Assign code 304.00,
Opioid type
dependence,
unspecified for
patients who are on
methadone
maintenance because
of heroin addiction.
PERINATAL PERIOD
The perinatal period ends on the 29th day
of life. The day of birth is counted as “0”
days.
HIGHLIGHT OF WHAT’S COMING FOR
3RD AND 4TH QUARTER
 Aftercare following organ transplant versus follow-up following surgery
 Assignment of code 779.89 for newborn (perinatal) conditions
 Bronchial biopsy versus lung biopsy
 Failed transbronchial lung biopsy
 Clinical significance of obesity and coding of BMI
 Correct application of nonessential modifiers
 Acute kidney injury, diabetic nephropathy and chronic kidney disease, stage III
 Lupus nephritis and acute renal failure
 Sepsis with an underlying localized infection
 Plus, highlights of FAQs from FY 2012 code changes
QUESTIONS?