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0:02 Where everybody, welcome to Roundtable 144. And for the third consecutive roundtable, we are sending registration.
0:11 High watermark, harbor over 3000 registrants today. Last I checked.
0:17 Never thought I’d be saying that URL.
0:20 If there’s anyone that is unable to get in, guess you’re not hearing this message, we are capped at 3000.
0:27 Recording will be made available. So, once again, much credit to you all for taking the time out of your day to join us today.
0:33 My name is Scott …, Vice President of Coding Education and Continuous Improvement, personalizes each division, and it is my pleasure to introduce today’s speaker, Janice ….
0:45 Janice is lacks Health Director of Advanced Education.
0:48 In today’s reviewing, the much awaited aging coding clinic quarter 1, 2022 highlights, then Jenna’s spent the rest, three reconfirm mailbox waiting for this to come.
0:59 So probably coming slash.
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2:27 So that’s it. Thank you for hearing me out, Jenna Stigler.
2:31 Thanks, Scott. Alright, so let’s get started.
2:36 Just going to move the slides. So just so today’s presentation, as Scott mentioned, is on Coding Clinic Q 1, 2022 highlights.
2:44 So I’m not, what that means is I’m not going to be discussing every single coding clinic. We obviously can’t get that all done in one hour.
2:51 There are, and, I mean, I tried to pick the ones that I think are, we see that are probably problematic in our everyday coding, things that we see on a regular date, every everyday basis.
3:02 There are some that I left out just because I thought they were pretty black and white coding clinics, Know, they’re good coding clinics. I think there’s significant interest that there, we had probably previous examples that cover that topic. So I did leave some of those out. Things like observation for suspected condition of a newborn. You know, they didn’t actually have a condition, but they thought they might have a condition, so things like that.
3:26 Obviously, I can’t get it to every single coding clinic, So there are some, there’s a lot of stuff on. There are a couple of coding clinics on breast cancer breast, … reductions. I didn’t, I’m not gonna be able to talk about those today. I don’t have enough time, but I’ll probably be talking about that and in the next couple of quarters will have a breast abreast coding clinic. I mean, Roundtable, probably. That’s, kind of on my list of things to present in the future. So, anyway, and also the kogod related content in this Coding Clinic, It will not be discussed today, again, due to length. Because we already have scheduled Decoded Revisited Coding Coding Roundtable on April 12th. So that’s not this, not not next Tuesday, but the following Tuesday on April 12th. So we will be discussing any coding clinics within Q one, related to …, on that roundtable.
4:16 So let’s officially get started and kinda jump in here. And this is probably one that we see on an everyday basis involving where we have the site of the stroke, but we don’t know what caused the stroke. Is it an embolism? Is it a thrombosis? Is it a stenosis vessel? So the Coding Clinic or the question is a patient presents the hospital with complaints of dizziness, and nausea and vomiting. The MRI of the head demonstrated a large, right posture and fear or cerebral artery.
4:47 Infarction with no evidence of cerebral artery occlusion or high grade stenosis, And the PI CA origen’s patent following diagnostic imaging, the provider diagnostic statement listed.
4:59 Right, Austere, inferior, cerebral artery infarction. What is the appropriate ICD 10 code for the cute, right?
5:06 … infarction when the location of the infarction is identified without evidence of occlusion, status embolism, or thrombosis. So there’s no link there with any of those things. How are we going to code that? The answer is that: we can use the other cerebral infarction for the right, … infarction since the location of the infarction is specified. So I hope hopefully that’s pretty pretty clear there.
5:28 But just kind of an FYI, I always like to throw in a little bit extra in terms of these coding clinics in terms of anatomy. We have the vertebral arteries there supplying the basler arteries, supplying the posterior a cerebral artery. So you can see there, the anatomy there.
5:44 And also, just some information about, you know, typically, when we see patients present, are these, or I should say, these arteries supply, The occipital lobe, inferior, temper temporal lobes, the thalamus, and midbrain. So sometimes you may see this being documented in association with, let’s say, a mid brain, or brain stem stroke, for example.
6:07 And you may see some of these, the symptoms here, and I do put a link, you see where it says reference. There is a link that will take you to this YouTube video, I think it’s racist medecine. They have some great videos and diagrams similar to some other references I’ve shared in the past.
6:24 And they do talk about different symptoms you may see with different types of stroke.
6:30 This is just one example, this was a PCA stroke, but there’s so many different videos I just wanted to put, put this in here, just as a reference guide for different types of stroke strokes. This isn’t specific to this Coding Clinic again, I just wanted to put this in here. If you do need a reference or want to learn more information about different types of strokes, this is a great reference. So I did put a link there at the bottom for everyone, if you’re interested, in just to show you kind of what it looks like. I think it’s a great reference.
7:11 OK, so moving on to the next slide. This is actually a good one. We have come across this on a regular, somewhat, regular regular basis where a patient is admitted for chemo, consolidation, chemotherapy, and they’re also having a bone marrow biopsy. The question is a patient with central nervous system, B, cell acute, Lymphoblastic leukemia is admitted for …, consolidation, chemo immediately following chemotherapy per protocol. And end of induction bone marrow biopsy is performed to evaluate the effectiveness of prior therapy to determine whether the leukemia is in remission the official guidelines for coding and reporting states when treatment is directed at a malignancy, the malignancy a sequenced as the principal diagnosis except when the admissions solely for chemotherapy. So, in this case, the provider clearly documents, the reason for the admission is the administration of chemo and the bone marrow biopsy was part of the treatment protocol.
8:02 When a patient is admitted for chemo, but also as a diagnostic tests such as a biopsy, is in neoplasm assigned as the Principal diagnosis instead of the Z 1111 encounter for indium neoclassic chemotherapy, What is the principal Diagnosis? So, in this case, the answer was to assigns the 51 1 1 encounter for Anna Neoclassic chemotherapy. As the principal diagnosis. We’re going to assign C 91 0 0.
8:24 Acute lymphoblastic leukemia not having achieved admission, remission as a secondary diagnosis.
8:30 In this case, an end of induction bone marrow biopsy was performed to evaluate the effectiveness of prior chemotherapy. Measuring for minimal residual disease. Although the bone marrow biopsy was performed, the administration of entropy co-captain consolidation chemo was the reason for the admission. Consolidation chemo follows the induction initial phase of chemotherapy. The purpose is to destroy any remaining leukemia cells to consolidate the gains obtained and to prevent the cancer from returning.
9:03 Next, we have, and these are, this is probably the area that I’m probably going to spend a little bit of time on, because we’ve had a lot of questions in this area.
9:11 And I’ve actually seen different audited auditors suggest some, some interesting, interesting, interesting things are different facilities. Not everyone’s being consistent with how they’re assigning these codes, so I’m glad we now have official advice on the topic, so that we can all be on the same page. There is definitely different interpretations of the guidelines and I foresee the guidelines for, for this being updated, again, I mean, it’s been updated probably every year since ICD 10 came out regarding the substance use abuse and dependence guidelines. So, hopefully, you know, every year, it gets a little bit clearer.
9:47 And I’m, I’m hopeful that this you’re kind of clears up. All the issues that we have with these codes. So, first up, we have, and this is interesting to this is we’ll get to the next coding clinic as well, but we have alcohol abuse in remission and alcohol dementia. So, a patient with a history of alcohol abuse diagnosed with alcohol dimension presents to the clinic for follow up. Visit the provider document. The alcohol abuse is in remission and the patient’s memories and pair due to alcoholic dementia. So ICD 10 CM does not provide a specific code for alcohol dementia due to alcohol abuse. What are the appropriate code assignments to capture, the patient’s alcohol abuse in, remission with alcoholic dementia? So, we’re going to assign F 10 1, 8 8, so alcohol abuse with other alcohol induced disorder, and F 0 to 8, 0, dementia, and other diseases classified elsewhere without behavioral disturbance for the alcohol dementia.
10:38 We’re also going to assign F 10, 11, alcohol abuse in remission. So, the additional code, the alcohol abuse in remission kind of gives us a little bit more detail that the F 10188 code does not supply right.
10:50 And there’s no, and I put the book here because there’s no nothing in the code book to indicate that you can’t use multiple codes within this category. So, say they say they have, you know, that I have alcohol abuse in remission, and they also have other types of alcohol induced disorder, say they have to sleep disorder, and they also have dementia. There’s nothing that says we can’t use all of these codes to signify all the manifestations of alcohol abuse. So, I thought that was that kind of cleared that up a little bit.
11:19 Um, I also, interestingly, I didn’t attend. I didn’t listen to the, the maintenance meeting, as of yet, I think it was, It was last week, I think, but I remember last year when I listened to it, they did discuss that.
11:33 A lot of the codes in in the, in the F section, you can use those together. There’s no exclusion notes. It wasn’t meant to say that you it’s a hierarchy or anything like that. That’s the kind of stuff, you know, I wish they would publish. No, because who’s gonna spend six hours listening to a maintenance meeting committee meeting?
11:53 You know, some of, you know, I happened to hear it, but those little things really do help in understanding why these codes were created. So, I do highly recommend listening to those meetings so you get a better understanding of why they create codes and the intent of specific codes. To me, it really helps helps in understanding when when it comes to assigning different ICD 10 codes.
12:18 So, this is the one that I, specifically, I think we all have a lot of issues with, Different advice is being given, over the years, I’ve seen different facilities applying the guideline. I mean, it isn’t. It wasn’t very clear, right? So, again, as I mentioned earlier, I suspect this guideline will be revised yet again, and we’ll talk about why.
12:38 But they do give us advice right now.
12:40 So in anticipation for the guideline being updated or clarified, I should say, a patient was admitted for treatment of a … fracture of the right, ankle. The provider documented alcohol abuse, monitor for withdrawal symptoms. The patient also has a history of anxiety and was prescribed cymbalta during hospitalization.
13:00 Based on the width convention, one, a 15, should we assume a link between the anxiety and alcohol abuse, and assign F 10, 180, alcohol abuse with alcohol induced anxiety disorder.
13:11 So, if you do go to the index, you will see with alcohol abuse with anxiety.
13:17 However, we want to talk about the guide. The actual guideline, and I know it’s under, this is the problem, is that the guideline is under psychoactive, substance use, not abuse and dependence.
13:26 As you could see there under number three, it does say that these codes, you know, are to be used when the psychoactive substance use is associated with a substance related disorder. Chapter five disorder, such as sexual dysfunction, sleep disorder, or mental or behavioral disorder, or a medical condition. And it says, such a relationship is document by the provider. And the width guideline does specifically say, such as with sepsis.
13:48 If the chapter specific guideline can overrule can overrule that with guideline. If it’s specifically states such a relationship must be documented by the provider. So sepsis is the one exclusion that we have to the width guideline. But I would say, this is the second guideline that as an exclusion where we need a documented relationship.
14:06 And I think the intent here, is to refer This guideline is meant to refer to all of the codes in, F in the, in the abuse dependence, category, use. But, as you can see, it’s listed under substance use. So I think that’s where the confusion lies. So, I suspect this will be updated for fiscal year 20, 23, but they do give us advice, So, let me read the answer. And it says, no, do not assume a relationship between alcohol abuse and or dependence and anxiety. Although the alphabetical index links alcohol without anxiety disorder and alcohol induced anxiety disorder is part of the code narrative, and alcohol induced anxiety disorder is not the same thing as having anxiety and having alcohol use abuse or dependence.
14:48 Further, the tabular narrative for codes and subcategory F 10, 18 alcohol abuse with other alcohol induced disorders indicates these codes are assigned for alcohol induced disorders, and such a relationship must be documented by the provider. Now, I specifically was not able to locate this in such a relationship must be documented by the provider in my Tabular, in my book. So, I’m not sure specifically what they’re referring to here, because I was not able to locate it, please let me know in the comments if you are able to locate it, But I do see it here in the guidelines.
15:17 Again, it’s under substance use, not used, use abuse and dependence. However, I think the intent was to apply it to all of the codes in the category. So we do now have guidance on that, this we shouldn’t be linking them without a documented relationship.
15:33 They go on to say, Well, chronic alcohol dependence abuse or use may lead to alcohol induced anxiety disorder. There can be other underlying causes of anxiety.
15:41 These conditions should not be linked, unless the provider clearly documents a relationship, OK, So that’s kind of their their clarification on that, and again, suspect that guideline, again to be updated for fiscal year 20 23. Next we have another example that is along the same lines. The question is: Should a combination code be assigned for categories, F tend to F 19 mental and behavioral disorders? Judah psycho, active substance use. Anytime a patient is with a substance abuse or dependence diagnosis also has documented anxiety, mood disorder, sleep disorder, or sexual dysfunction based on the with guideline. The answer is, do not assume a relationship between the substance abuse inter-dependence and anxiety mood disorder, sleep disorder, or sexual dysfunction, although these conditions are terms that are located under with in the index. The Narrative in the Tabular indicates these codes are report it when the condition is document as alcohol induced disorder in such a relationship as documented by the provider. Now, again, I don’t, I don’t see that in my tabular book. I don’t, I looked at the book that’s published on the CMS website.
16:40 I’m not sure what they’re referring to there. But again, it’s, it’s implied somewhat in the guidelines, again, not 100% clear, but I suspect, again, that they’ll update that and make it more clear in the future.
16:57 OK, next we have bulging disk. Now I know when I first started coding bulging disk in ICD nine. I believe index to Herniated disk. Now you have to be very careful. When you are following ICD nine advice, the index could be different. I always am going to see this. you want to check your index also. The sequencing of things may be different. We have different coding guidelines in ICD nine versus ICD 10, the inclusion notes, exclusion notes, the non essential modifiers. They could be different in ICD nine versus ICD 10, so they’ve kind of cleared up a couple of things. We’ll talk, I think someone even mentioned, one of the other ones will be talking about as Nuchal cord.
17:39 But the 1 this 1 is bulging disk. So should we be coding coding bulging disk to herniated disk? Essentially a patient presented with a spinal imaging exam and was diagnosed with the left far lateral disk bulge. At Level L five to S one, there is no alphabetical index entry for disk bulge. Is it appropriate to assume that the disk bulge is the same as in a herniated or displaced disk?
18:02 What is the appropriate code assignment for a left L five to S one for lateral disk bulge?
18:07 We’re going to assign M 5137 other interviews Cipro disk degeneration, number of say cross region for the left, L five to S one far lateral disk bulge. A bulging disk is not the same as a herniated or displaced disk. A bulging disk happens over time due to due to degeneration of the disk. Now I was able to find this was a quote by a doctor at Penn, Penn Medicine, doctor Harvey Smith. And he describes a bulging disk, like letting out air out of a car tire the disk sags and looks like a bolt. Like it’s bulging outward. When a herniated disk, with a herniated disk, the outer covering of the disk as a whole or tear, this causes the nucleus … or the jelly like center of the disk to leak into the spinal canal.
18:55 So just kinda there, you can see here, this is just a slight, kinda looks like flattening. You know, it’s bulging a little bit. Like if you have a flat tire versus a herniated disk, it’s completely all that jelly like material is … through the disk through a hole or tear in the disk. And it’s coming out and leaking into the spinal canal. So that’s kinda, that’s the difference there. And the advice is to just code the district degeneration there.
19:23 Millimeter.
19:27 OK, next, um, this is another good one.
19:29 We’ve I’ve seen different advice being offered on the diverticulitis with intra abdominal abscess are diverticulitis with different manifestations. So, the question is, When a patient is admitted with diverticulitis of the colon and an intra abdominal abscess is code K 65 1 peritoneal abscess assigned along with the K 57 2? Oh, diverticulitis of Large Intestine with perforation in apsis without bleeding. So, yes, we can assign K 57, 200 diverticulitis. a large intestine with perforation.
20:00 An abscess without bleeding followed by the case 65 1 2, further specify the location of the the abscess. This code assignment is supported also by the code also note located under both code categories. The no under Category K 57, Dive Articular, Disease of Intestine, instructs decoding professional to code peritonitis, if applicable, and the No, under category case 65 peritonitis instructs the code, If applicable, diverticula Disease of Intestine. I have that on the next slide. But, just to see the different stages of an abscess, we have Stage one. We have a smaller confined Perry … abscess and then it progresses to a large abscess extending into the pelvis and then we see you know gaseous release of that maybe it’s kind of starting to perforate.
20:47 And release and then stage four is release of that fecal discharge into the peritoneal cavity causing the intro.
20:55 You know the insurer or you know the intra abdominal peritonitis or abscess additional abscesses maybe multiple abscesses.
21:07 OK, so next slide um, we have I have the book here. You can see the code also known, so mate. Pay attention to your code. Also notes, it does say code. Also, if any, applicable peritonitis. So the next question is a similar coding question. What if they have sigmoid diverticulitis with peritonitis and perforation? So a patient is admitted with peritonitis, likely secondary, to a perforated sigmoid diverticulitis is Coach K 65 9 peritonitis assigned with Kate, 57, 2. Oh, diverticulitis of the Large Intestine with perforation. An abscess without bleeding, yes, we’re going to assign K 57 2 Oh, and the case 65.9, please? No. Effective october first, 2020, the inclusion cermak subcategory K 50 72 has been deleted. Therefore, it would be appropriate to report.
21:56 Both codes for discharge is on or after October 1, 2020.
22:02 So if that was an obvious, they did point that out. I do recommend always reviewing the appendices they had called that’s an addendum to the Appendix E agenda. And you could see everything they added and deleted to the Appendix and the Tabular. So, I think that’s very helpful. And, you know, they don’t always point these things out to us in Coding Clinic.
22:24 And it’s a good place to look in those documents on the CMS or the CDC website.
22:38 Next.
22:40 Now, this was a topic of discussion, for quite awhile.
22:46 I think what made it even more of an issue was an, you know, in an encoder, they had a logic issue. And I think that caused some confusion. They’ve actually fix that pretty quickly in the encoder. But we kind of have to take this and read all their guidelines when applying this, applying. I history of HIV managed by medication. You have to take that with all of the guidelines in mind. So let’s read the question. So, everyone can kind of be up to speed with, with what I’ve, I’ve, I’m talking about, I have talked about this on previous roundtables but if you haven’t been on those, you may not be aware of what I’m talking about. So, the question is, my facility has interpreted the new HIV coding, guideline one, C one, A two, I, history of HIV managed, By medication, to mean, the B 20 HIV disease should be reported for any HIV, positive patient on anti retrovirals, regardless of whether the documentation states, the patient has ever had an HIV defining illness, or has HIV disease. Could you please clarify, if this was the intent of the new guideline?
23:46 So, I mean, I could tell you right here, that was not the intent of the guideline, but let’s keep going. Answer.
23:52 The intent of the guideline is to provide guidance that Code B 20 is appropriate for patients documented with HIV disease on anti retrovirals and to align with the guideline, guidance published, encoding clinic fourth quarter 2020, that clarified HIV disease, specifically classified to B 20.
24:09 It would not be appropriate to report Code B 20 without provider documentation of an HIV related illness, HIV disease or aids. Those are the terms that we can code to be 20. A diagnosis of HIV are HIV positive without documentation of HIV disease, and HIV related illness or aids should not be assigned Code Z 20 should be assigned code Z 21 asymptomatic human immunodeficiency virus infection status.
24:34 However, the provider should be queried for clarification when the documentation is unclear regarding the patient’s HIV status. This is also consistent with the Advice Publishing Coding Clinic first, First quarter 2019 page 8, 8, 8, and 11.
24:47 So, if we read I, History of HIV Manage by Medication, if we read the whole guideline, it says, If a patient was documented with history of HIV disease.
24:56 So, it doesn’t say HIV.
24:58 It says HIV disease, which if we refer to our previous guideline, which is D, Asymptomatic human immuno deficiency virus.
25:08 it says Z 21 asymptomatic human immunodeficiency virus infection status is to please be applied when the patient without any documentation of symptoms is listed as being HIV positive. Known HIV HIV test positive or similar terminology. We do not use this code, meaning Z 21, if the term aids or HIV disease is used for, for used. Or, if the patient is treated for H at any HIV related illness, or is described as having any conditions, resulting from his or her HIV positive status. Use B 20 in these cases. So, if we use these two guidelines together, it should be pretty clear, that they’re referring to HIV disease.
25:44 Now, in terms of grammar, they probably should have put history of HIV disease, inserted disease here.
25:51 I think leaving out that disease right here is what caused the confusion, but they did listed here, and there’s a space there, which is kinda weird. I think that was an afterthought.
26:01 But, yeah, So, again, we have to use all of our guidelines in combination with each other, to understand the next guideline or previous guideline. We can’t just take this, you know, for what it is. We have to look at all of our guidelines in that chapter to make a better decision or interpret interpret our guidelines, and I’m glad they published this. So, we’re all on the same page, now, hopefully. And applying R, Z 21 versus B 20.
26:29 And, of course, we probably have a lot of queries for this, as well. It’s not always clear.
26:35 Next, this is a good one. I’ve seen a lot of different opinions on this, as well.
26:41 And, remember, we do have a coding clinic from ICD nine, but let’s take a look at the question, and then I’ll kind of add my little, my 2% here. A 51 year old patient with severe protein calorie malnutrition due to extreme anorexia nervosa, and binge eating purging type as admitted to the hospital for stabilization of acute medical conditions and weight restoration before being transferred to a residential treatment program specializing in eating disorders.
27:07 The provider also document the patients end stage renal disease, dehydration, and kidney stones or complication caused by the anorexia.
27:13 Some coding professionals are questioning, whether is it appropriate to sequence the anorexia nervosa as the principal diagnosis when the admission is for medical stabilization?
27:21 What is the appropriate Principal diagnosis? In this case, the answer is to assign the … 43 unspecified severe protein calorie malnutrition as the principal diagnosis, as this condition is the reason for the admission.
27:32 Code F 50, 0 to anorexia Nervosa and binge eating purging type, should be assigned as a secondary diagnosis. Since admission was for treatment stabilization of the patient’s acute medical conditions, it would not be appropriate to sequence anorexia nervosa as the principal diagnosis.
27:47 The circumstance of inpatient admission always GOV’s selection of principal diagnosis, the principal diagnosis defined in the uniform hospital data discharge set.
27:56 You, HDS, as a condition established after study to be chiefly responsible for caging the mission of the hospital, patients to the hospital for care. And you can see here in the book, I don’t see any code also, use additional code. We don’t have any sequencing.
28:10 sequencing telling us, You know, we have to code the eating disorder first or we have to code the malnutrition first. So we really want to be careful with, with interpreting older coding clinics, I believe in ICD nine. We did have a sequencing rule for that. I can’t remember exactly, but I believe we did I think it said we had to sequence And then interacts Universa first followed by the Malnutrition. So be careful when applying older coding clinics.
28:37 We don’t have a code also know, again, a code also. No, we don’t have any sequencing or use additional code note. We have nothing here that advises how to sequence.
28:47 How to sequence this? So, I’m glad someone submitted this because if we were following that older coding clinic, we were, most of us were probably coding the anorexia, as the principal diagnosis.
29:05 OK, next we have newborn tight nuchal cord and I believe we also had older advice on this. The newer advice, as of 2000, you know, Q 1, 2022, March 18th, was the effective date. What is the appropriate ICD 10 code assignment for diagnosis of a tight nuchal cord? This is on the newborn record. So, just, tight nuchal cord indicate with compression. Or must the provider document with compression in order to assign PO to five newborn affected by other compression of umbilical cord. So, the answer is, a tight nuchal cord does not necessarily imply compression.
29:41 When coding the newborn’s record, the health record documentation should indicate the infant was affected in some way by the tight nuchal cord.
29:49 So, remember, when we’re coding those newborn’s affected by, we have to make sure that the newborn is actually affected by that condition.
29:57 So, do they have metabolic acidosis? They have late deceleration. Did they have low apgar scores? Are they saying that that nuchal cord in some way impacted the baby? If the documentation is not clear whether the newborn was affected, we can query the provider for clarification. They go on to say, a diagnosis of tight nuchal cord document and the maternal record is not applicable to the newborn. Since the provider would need to document that condition on the newborn’s record, as well as the fact that the infant has been affected by this condition. I’m going to imply from this coding clinic that tight nuchal cord on the mother’s chart also does not imply compression.
30:31 They don’t have one for the maternal record. But based on this, I’m going to say that would remain that would also apply to the maternal if we’re going to assign a nuchal cord on the mom’s chart.
30:46 Yes?
30:48 Next. Now, these were interesting. These kind of go against not this one, the next couple, the Hemo Peritoneum ones, I suspect there’ll be making changes in our code books for fiscal year 20 23.
31:02 And I want to make a note here for this splenic laceration. This is going to be different than the traumatic splenic laceration.
31:10 But this is non traumatic. This is due to an intra-operative complication. So Hemo Peritoneum, with splenic laceration, a patient is admitted with minute three hours falling a colonoscopy with left quadrant pain and was found to have a Grade three splenic laceration with hemo peritoneum due to a colonoscopy. Is it appropriate to assign a code for the Hemo Peritoneum when is associated with a splenic laceration or as the HMO peritoneum considered integral to the laceration and not Code it separately?
31:37 So one would think that it would be integral to to the splenic laceration because the bleed, you know, if someone has a laceration of their Spleen, they’re going to be bleeding and it has to go somewhere. It has to go into the abdominal cavity.
31:48 So, to me, if I before this coding clinic came out, I would have advised not coding the hemo peritoneal because, if someone has a laceration of their Spleen, though, the blood is going to collect in the in the peritoneal cavity. Right?
32:00 However, they’re saying, In order to capture this, fully to capture the patient’s diagnosis, we shouldn’t in this case, because it’s a post-operative complications. We’re going to code 78 100 to accidental puncture and laceration on the screen during Other Procedure. And we’re going to code K 66, 1, Hemo, peritoneum, and why 65 8 other specified misadventures.
32:19 We’re going to code D 78 1 2 is assigned for the splenic laceration. And, of course, we’re not going to code that as the S code, right? If it’s due to a medical procedure, it’s not a traumatic injury. It’s a due to medical intervention, so I still see coders using the S codes for intra-operative lacerations. Please, please, don’t do that.
32:41 But they say of they remind us we shouldn’t be using the S codes for traumatic for non traumatic injuries.
32:48 This is due to medical intervention so we can code the D 78 1 2 for the splenic laceration then also assign the case 66 to capture the hemo peritoneum, and here’s just a picture. I don’t I couldn’t find it there.
33:03 Actually, I couldn’t find a lot of good pictures of human peritoneal, but you could see just the blood building up within the cavity here in the in the peritoneal cavity.
33:19 OK, so next we have, and this is different also from ICD nine, now if we’re clearly going by our coding Guidelines, we would not be picking up Hemo Peritoneum. So this is what I suspect. There’ll be changing, they’ll probably be taking hemorrhagic out of this out of a non essential Meyer fire If something is a non essential modifier, we shouldn’t be kind of like are, we have a coding clinic about. You know, pneumonia.
33:45 We have a hemorrhagic. We used to have a hemorrhagic modifier that was an old coding clinic, we have some other coding clinics, I talk about non essential modifiers. We did talk about this in the last couple of coding clinics.
33:55 If you need more information, you can go look back about more back on those coding or coding roundtable’s regarding non essential modifiers.
34:03 But if we were to follow or non essential modifiers, we wouldn’t be coding the Hemo Peritoneum separately, they say, otherwise. So a patient presented with lower abdominal pain due to left sided ruptured corpus rhodium cysts that resulted in a hemo peritoneum an acute blood loss anemia. Is it appropriate to assign Case 60, 61 hemo Peritoneum when it is associated with a ruptured corpus lithium ovarian cyst? And they say, We’re going to assign an 83 1 to N K 66, while hemorrhagic is a non essential modifier when refer referencing a corpus lithium cyst, both codes are needed to capture the severity of this patient’s condition. So, again, I’m thinking that they’re going to take this out of the code book like they did with the pneumonia and the hemorrhagic pneumonia, they’ll do the same thing here probably.
34:47 Because how do we know that we can, you know, let’s say, or they might even add. Use additional code.
34:52 To show the site of the ham hemorrhage. I’m assuming they’re going to do one or the other because this would be against coding guidelines, right.
35:00 So be, though, making those changes for Fiscal year 20 23.
35:04 The same thing is with a ruptured ovarian cyst with Hemo peritoneum we’re going to code the ovarian cyst followed by the Hemo peritoneum. And then just to show you in the code book. If we go to ovarian, hemorrhagic, normally, if we see this, we’re not going to code that hammered separately.
35:20 But in this case, they tell us that we can go ahead encode it to fully capture the patient’s condition.
35:30 This was an interesting one I’ve actually come across this. We had no idea how we’re going to code this sunken flap syndrome.
35:37 I’m sure some of our clients have seen this or come across this, where, a patient has a history of a traumatic. Brain injury could not not necessarily, also be traumatic brain injury. It could also be.
35:49 It could also be if they had a history of like a brain tumor or something. I didn’t. I was careful in picking the picture. If you, if you’re interested in more pictures, you can definitely Google this. They’re not pretty, so I tried to pick one that wasn’t too bad.
36:05 If you’re interested in more information about this condition, but this patient has a has a history of traumatic brain injury status, post bilateral, craniectomy and is admitted for our school reconstruction duda, bilateral frontal, parietal, cranial defects. The cranial plastic was performed on the right side. However, during the recovery phase, the patient became … encephalitis and … and Braided cardiac. the Physician Note at the previous left side of … Appear, sunken consistent with sunken flap syndrome and paradoxical brain shift, which required left side it reconstruction. where are the Correct code Assignments for sunken flags flap syndrome.
36:38 Assign G 9782 Other post procedural complications Undistorted of the Nervous System an N 95 zero point two other acquired deformity of Head for the Post craniotomy such sunken flap syndrome, based on that use additional Code note located at subcategory Gene 97 8.
36:54 Other intra-operative and post procedural complications and Disorders of the Nervous System assign additional codes to further specify the condition.
37:08 Next, probably a long awaited coding clinic about. Type one, Diabetic Hyperglycemia, Hyper, Glycaemic, … syndrome, A patient is diagnosed with uncontrolled type one, Diabetes Hyperglycemia, an acute hypoglycemic Piper, …. Well. There are syndrome, HHS, both, Hyperglycemia hyper … our respective sub terms of the index entries for Diabetes Type two under the sub term with, however, only hyperglycemia appears as a sub term, the Index entry for Diabetes Type one under the sub turn width.
37:40 What is the correct code assignment for uncontrolled type one Diabetes with HHS, So they tell us, I mean, I’ve I’ve advised different codes for this based on previous advice, they finally gave us some official advice. Here, we’re gonna assign code E 10, 69, type one diabetes with other specified complication E, 10 65 type 1 diabetes, with hypoglycemia an, E 8 7 0, …, and … for HHS, since ICD 10 CM does not provide a specific code for Type one diabetes with … polarity. We’re going to code East 10, 69.
38:13 We’re gonna assign that code, and then further we can assign E tend to capture the hyperglycemia.
38:19 Therefore, each code is needed to completely capture the patient’s condition. Although HHS most often affects individuals with type two, it can also affect people with Type one diabetes. So I’m glad to see finally, a coding clinic published on this, It’s long awaited.
38:35 I’m assuming we’ll probably also have a code in the near future for that as well.
38:40 Now, we also have Type two, Diabetic …, hyper as molar, … State Without acidosis. So, a patient is diagnosed with hypoglycemic …, State without acidosis, and new onset type two diabetes Coding Clinic. Third Quarter 2013 states any combination of the Diabetes Codes can be assigned together unless one diabetic condition is inherent to another is Code 11 65 Type 2 diabetes with hyperglycemia assigned as an additional code. What does the correct code assignment? So in this case, we’re going to assign 11 Type 2 diabetes with Hyperides malaria, without, without …, hypoglycemic. … R Coma, N K H H C. Hypoglycemia is inherent to Code 11, 0 0, Therefore, we’re not going to assign separately from 11 65, and I hope everyone can see the difference between this. And because we have a specific code, in this case for …
39:36 versus Type one, we don’t and that’s why they’re advising, decode It as an additional code, because just other specified complication it’s not telling us what type of complication it is. So in that case, in this specific case, we can assign the hyperglycemia in this case, we shouldn’t be coding the hyperglycemia, because Hyperglycemia Hypoglycemia is integral to our eyebrows similarity with non … hyper … state.
40:05 Hmm.
40:09 And this is another good. one long awaited. I actually see a lot of coding errors on under dosing. This was actually a great question. What if there’s an under dosing with no change in the patient’s condition. So what if the patient’s not taking their blood pressure medication, but it’s not affecting them, or, they’re not, they’re not taking it, they’re taking every other day, or, you know, they’re taking it, supposed to take it twice a day. They take it once a day, but, the patient’s blood pressure is stable, so, should we still assign an under dosing code, non compliance code?
40:38 So the question is, a patient stopped taking his prescribed Joseph … after running out of his, out of the anti hypertensive medication several days ago. The provider documented the patient’s blood pressure was stable, would it be appropriate to assign a code for under dosing when there’s no documentation of an exacerbation or issue with the patients chronic hypertension.
40:57 The answer is, we’re going to assign the code for under dosing T 46, Um, I, 10 and 0, 1114 patients. Other non compliance, to capture the fact that the patient is not taking the medication as prescribed under dosing guideline does not preclude the assignment of under dosing codes. If the health record documentation does, not specifically State a change in the patient’s condition documentation, that the patient has just continued to prescribe medication on his, her own, his, own, his, or her own, is sufficient for the code assignment. So, what I see, also, what I see coders doing, is coding the under dosing code and code and not coding the non compliance coder coating, the non compliance code and not coding the undergoes encode. So, according to the guideline, the under dosing refers to taking less of a medication then that is what then is what is prescribed by the provider Or the manufacturer’s instructions? And discontinuing the use of prescribed medication, the patient’s own initiative.
41:48 Not directed by the patient’s providers, also, classified as an under dosing.
41:52 And then codes for introducing should ever be assigned as the principle first listed. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction and dose, then a medical condition itself should be coded. Also. Non compliance or complication of care coach should also be used with an under dosing coach. It indicates indicate intent, if known.
42:12 A lot of times, we do see those being missed. So I just wanted to make sure I covered this today.
42:16 Because we do see a lot of errors miss coding of under dosing. And to me, I think this is very important because it can potentially show why patients being admitted. For example, we see a lot of CHF patients coming in. They didn’t take their Lasix as prescribed are coming in with CHF exacerbations. It can impact your re-admission rates, right? And we’re kind of held to certain standards with that. For example, so, just just throwing that out there that we should be making sure that we’re capturing our under dosing.
42:45 I’m gonna around compliance codes if it’s applicable, whether or not the patient’s condition is affected or not, maybe it’s not being affected at this point, but what if they stopped it for two weeks.
42:53 Maybe the patient goes into hypertensive urgency, um, et cetera.
42:59 OK, so next intra-operative … now this is a follow up. Probably something that we need it I think there’s a lot of confusion about the previous Coding Clinic. Second, quarter Coding Clinic 2021, page eight. Regarding an inter … tear, the advice appears to conflict with the official coding guidelines for coding and reporting for documentation of complication of Care 1 be 16, since the provider explicitly documented that no complication occurred.
43:25 In addition, because they tear occurred during a laparoscopic cell, sopping oophorectomy code K, 9972, accidental puncture, and operation of a digestive system, Oregon, or structure during other procedure, should, have been assigned rather than Code K 9971, accidental puncture, and laceration of our digestive system organ, or structure during a digestive system procedure. Dancer, advice, previously published encoding Clinic, does not conflict with the official coding guidelines from a documentation of a complication of care. Since a cause and effect relationship was documented between the surgery in this are also terror.
43:56 This guideline was not intended to mean that the surgeon must specifically document the term complication.
44:01 The surgeon documentation of the … are also terror and the subsequent procedure for repairing the terrorist sufficient documentation to report a complication code.
44:10 Furthermore, the term complication does not imply inappropriate or inadequate care in or unplanned outcome.
44:16 Some issues or conditions occurring as a result of surgery are classified by ICD 10 as a complication whether stated or not, although the surgeon stated that the … was unavoidable, it does not mean that the terrorists not a surgical complication.
44:29 For example, a …
44:30 can range from a small nick requiring no treatment at all to a major terror requiring removal of a portion of the small intestine Or also tears alone do not qualify as a reporter diagnosis.
44:41 If, however, the degree of us are also tear alters the course of the surgery I supported by the medical record documentation then the tears should be reported.
44:49 And there’s lots of different examples provided encoding clinic regarding nus.
44:54 Again, you know, in this case and that Coding Clinic they’re referring to the doctor specifically had to remove part of the small intestines because of this roesel tear. So that then it becomes significant, right? Because it’s altering its altering the course of the surgery.
45:09 Although not explicitly stated in the Q and A the patient has undergone multiple procedures, including cell pink oophorectomy reduction and repair of an incarcerated eventual hernia with … of adhesions. There, were social tear occur during the part of the surgery to repair the ventral hernia and vices of … of the Small Intestine.
45:26 Therefore, Code K 9971, accidental puncture and laceration of our digestive system organ or structure during a digestive system procedure is the correct code assignment.
45:34 So, in terms of that, will have to be a little bit, we’ll have to read, through the documentation to find, is it, you know, digestive system, Oregon? Did it occur during the digestive system, procedure, et cetera, When identifying that code.
45:48 So, you know, it is really hard, sometimes, when you’re reading a coding clinic, because it’s not always, they don’t provide the whole op report, so sometimes it can be a little bit confusing when trying to interpret what they’re saying. So I’m glad they did clarify this.
46:05 And provided a little bit more information about the term complication. We do have, We still have a cause and effect relationship, document it. Again, they didn’t State specifically say it’s a complication, but it was due to the surgery, right?
46:20 Again, we just need that cause and effect relationship, and it impacted the patient’s care significantly. Now, if we’re unsure if it’s, if it’s significant, we can always query, right?
46:28 We have multiple different coding connects that provide different advice for different scenarios, so I definitely refer to those when applying this to your coding.
46:45 OK, so next up they have another clarification about toxic metabolic encephalopathy, due to hepatic. encephalopathy: I think a lot of people were didn’t agree with this. So the question is Coding clinic first, quarter 2021 page, 13 states. That is inappropriate it is appropriate, sorry. It is appropriate to assign codes 92 toxic encephalopathy for toxic metabolic encephalopathy, due to acute on chronic capac encephalopathy, however, this advice does not seem corrections. The provider did not document and associate it toxic substance or an adverse effect of medication.
47:17 Is it appropriate to assign gene 92 when there’s no external agent associated with encephalopathy.
47:22 It would appear that toxic metabolic encephalopathy or any other specific specified type of encephalopathy should only be reported with when linked to another condition besides hepatic encephalopathy or hepatic failure. In this case, it appears that the encephalopathy should be inherent and not, separately reported since it is linked to the liver encephalopathy.
47:39 And the answer is, the encephalopathy that occurs with liver failure is metabolic in nature from toxins generated within the body, not from external toxins.
47:50 The provider has confirmed the diagnosis of toxic metabolic encephalopathy, … 92 8 other toxic encephalopathy. Decode it this code assignment does not imply external toxins and a toxin does not have to come from outside the body in order to assign this code.
48:05 The Alphabetical index for encephalopathy, toxic menopause leads to G 92 8, and inclusion term toxic metabolic encephalopathy confirms that this is the correct code assignment.
48:15 Code assignment is based on the provider’s documentation of the condition, and it’s not based on a particular clinical definition or criterion.
48:22 A code first know instructs that two codes may be required to fully describe this condition if applicable. Toxic metabolic encephalopathy is not inherent to hepatic encephalopathy. Therefore … should be assigned separately to specifically capture that toxic metabolic encephalopathy.
48:37 Code Case 70 Case 72 9 oh hepatic failure unspecified without coma, should be assigned if the only documentation in the medical record is hepatic encephalopathy. Without any further specification of the underlying cause.
48:49 In this case, the underlying cause of the toxic metabolic and … was acute on chronic paddock encephalopathy.
48:56 So I think that clears that up for those that were wondering and were confused about that coding clinic Again.
49:03 Toxic metabolic doesn’t necessarily have to come from external toxins, it could be from toxins generated within the body.
49:12 So next we have post-surgical hematoma the gallbladder faucet.
49:16 So, whereas the gallbladder fast, I couldn’t actually find a great picture for this, I found a picture of the liver with the gallbladder, And if we take out the gallbladder here, it’s that depression, lodging, the gallbladder on the under surface of the liver anteriorly between the quadrant and right lobe. So we have the quadrant lobe here, and then we have the right lobe deliver here. And if we took out this gallbladder, that depression there would be the gallbladder fascia.
49:43 So, the question was, a patient status post laparoscopic … me for chronic biliary disease was free admitted to the abdominal distention. But nausea and vomiting, a CT scan of the abdomen demonstrated a large hematoma of the Gallbladder fossa.
49:57 So within that Gallbladder, fossa, they had a large haematoma.
50:02 Surgical exploration revealed No act of leading the liver bed, was Hemo static. A large hematoma was found within the Gallbladder faucet and the space between the liver and the dua denim.
50:11 Along with old blood in the abdomen, evacuation of the hematoma and old blood was performed, the post-operative diagnosis licit post-operative accumulation of intra abdominal hematoma with ….
50:23 What are the correct code assignments to capture these conditions? The answer is we’re going to assign canine 1 8 7 oh, post procedural hematoma digestive system organ or structure. We’re not going to assign a separate code for the Hemo Peritoneum, because the documentation does not support a diagnosis of Hemo Peritoneum.
50:37 The operative Report did not describe any act of bleeding, or Hema Peritoneum only came a hematoma that was old blood, which was essentially part of the hematoma.
50:49 although the post-operative diagnosis recorded, post-operative hemo peritoneum coding professional should review the full body of the operative notes.
50:56 Rather than coding strictly from the title of the report, A hematoma is a collection of clotted or partially caught up blood in an organ and tissue or body space, which is typically due to inadequate hemo stasis. Whereas, … is internal bleeding that accumulates in the ….
51:11 So this one isn’t entirely clear to me. I don’t know what everyone’s thoughts are on this.
51:17 I kind of have to think about this a little bit more and maybe see some documentation. It kind of seems the same to me. I don’t know if anyone has any thoughts about this. Let me know.
51:27 I’m kind of not seeing the difference.
51:35 I don’t know. Let me know your thoughts on this one. Again, I’m not seeing the difference between this or the other ones with the hematoma the hemo peritoneum.
51:45 Next, we have present on admission indicator. For palliative care. It’s no longer an issue about the POA indicator. We’re seeking official guidance from Coding Clinic regarding the appropriate POA for patients receiving palliative care, Effective, October first, coetzee 51 5 was added to the exempt from … Reporting list by the Centers for Disease Control. So, it’s no longer an issue. You don’t have to assign a no, or yes on on that.
52:15 And this is another, another guideline that we, I think we needed some clarification on, and for anyone that’s attended my roundtables in the past, you know, we’ve discussed this probably ad nauseum multiple times over the last year or so. But procedures performed on continuous vessel, so we’re just getting the hang of this. We saw some errors on this, and then they changed the guideline.
52:38 So, for fiscal year, actually, it was probably change prior to fiscal year 20 22, I think it was in a previous Coding Clinic, earlier in the year, I believe in 20: it was either 20, it was in 20 21, and then they, they came out with, it came out the guideline.
52:54 They updated the guideline for fiscal year 20 22, so they’ve received many numerous questions regarding the revised guidelines pertaining to a tubular body part. Guidelines states: if a procedures performed on a continuous section of a tubular body part code the body part value corresponding to the anatomical most proximal, closest to the heart portion of the tubular body part.
53:13 For example, procedure performed on a continuous section of an artery, and the femoral artery to the external iliac artery with the point of entry at the external illiac, is also code it to the external iliac artery body part. The following questions and answers are provided to assist coding professionals and applying this guideline. So I’m happy they did this, it makes more sense. So just to take a look when we have a lesion involving, let’s say it’s involving.
53:36 We’ll just pretend this is the iliac artery and the external iliac artery. And this lesion is involving these two vessels at the bifurcation. And they put in they do I don’t know, let’s say, in the angioplasty. And the lesion is all one legion.
53:53 We’re just going to be coding the one that’s most closest to the heart or proximal to the heart, whereas before I think it was, I think, off the top my head. It was furthest furthest from the entry point.
54:07 So let’s take a look at the questions and kind of take a look at that. So according to the updated guidelines before one see if a carotid endarterectomy is performed on a single continuous legion involving both the common carotid artery and the internal carotid artery, the common carotid artery would be the only binary part code it because it is closest to the heart. We are concerned that data involving carotid endarterectomies would be skewed and procedures performed on both the common carotid and internal carotid arteries would not reflect the complexity involved in the surgery. We’re requesting that coding kind of clarify this issue.
54:38 The procedure code would identify the common carotid artery only if it were a single procedure form conform, performed on one consent newest legion. If, however, the documentation states that they’re separate lesions in separate vessels were identified and treated multiple codes would be assigned to specify distinct procedures performed on multiple body parts. So again, this specific guideline is pertaining to one lesion it, and there the legion is involving overlapping body parts. Were just going to code the body part value corresponding to the closest or proximal to the heart portion of a tool or body part, And I will go over another example in just a little bit. Some more questions here.
55:14 The updated, ICD 10 PCS guidelines for coding and reporting, pertaining to procedures performed on a continuous body part, appears to conflict with the multiple procedures guideline. This guideline, states during the same operative episode, multiple procedures, are coded if the same operation is performed on a different body part as defined by distinct values of the body part character. Guideline before, one C does not indicate that it only applies to certain body parts body systems. Could you please clarify?
55:38 The answer is, the updated guidelines does not conflict with the guideline for multiple procedures. However, guidelines before one C will be clarified further by adding the terms vascular and arterial venous as well as single procedure. So what’s a little bit confusing when that guideline came out was, Did it applied to the gastrointestinal system?
55:56 That’s also a tubular body part: Um, does it, Or does it just apply to vascular body parts? So they clarify that. They’re going to be updating the guideline to include vascular or arterial venous in the guidelines.
56:10 Next, we have a similar question, but asked a different way since the updated PCS guidelines for coding and reporting specifies to her body part. Does this guideline apply to any tubular body parts such as the esophagus Stomach Large and small intestines? And they say, No.
56:26 Guideline before, one C only applies to the vascular creatures such as arteries and veins not other tubular organs, such as esophagus stomach, large, and small intestines.
56:36 Next. Another similar question When applying the ICD 10 official coding guidelines for reporting, does a surgery need to involve a single legion that spans multiple body parts? Yes. This guideline B 401 C only applies to surgeries that involve a single lesion that spans across multiple body parts.
56:54 Next, when assigning codes for procedures involving separate lesions, such as thrombosis clots plaque, within multiple body parts rather than a single continuous lesion, should each procedure be coded separately. The answer is, yes.
57:06 So if we have a, you know, a clot in the iliac artery, we have a plaque in the for moral artery, we’re going to code those all separately.
57:13 When, yes, procedures involving separate, legion’s found an inner on multiple body parts, should be coded separately in the ICD 10 PCS official guidelines.
57:21 Beat guideline P 3 2 states during the same operative episode. Multiple procedures are coded if the same operation is performed on different body parts as defined by distinct values of the body part character. So that guideline just refers to a single lesion that’s spanning multiple body parts.
57:36 So a plac involving involving the external illiac, et cetera.
57:43 Here’s a picture. This is regarding the carotid endarterectomy, so we have one plaque it involves. In this specific example. It involves the common carotid artery and internal carotid artery. A single lesion, in this case, I the picture, does involve the picture I was able to find involves the internal carotid artery, the external carotid artery, and the common carotid artery. So you can see here, this is a single lesion.
58:05 So if we apply this guidance on there, taking out the plaque from within the internal carotid external carotid and the common carotid artery, if we are to apply this guideline, the updated guideline, the most proximate or closest to the heart would be the common carotid artery. And that would be our answer.
58:26 So, even if it just involves the internal carotid and the common carotid, and didn’t you know, involves an external carotid. So according to the updated guideline if a carotid endarterectomy is performed in a single continuous lesion involving the common carotid, and the internal carotid artery, only the body part closest to the heart is coded.
58:44 Based on this guideline, what body part is assignment to endarterectomy is performed on one continuous legion involving both the common carotid and internal carotid arteries. Answer is if an endarterectomy is performed on one continuous lesion involving the common carotid artery and internal carotid artery, the body part identified as the procedure closest Code assigned as the common carotid artery, which is the closest to the heart.
59:04 So you could see there, again, this isn’t this involving the external carotid as well. But let’s pretend it’s not The closest to the heart would be the CCA or the common carotid artery.
59:15 So I just wanted to clarify that.
59:16 I think it clarifies it for me, although I might not like it, you know, for those legion’s above the heart, they did clarify that.
59:28 So I’m good with it.
59:29 Now next, we have umbilical cord sampling. You know, we see a lot of babies they do umbilical cord blood collected for blood typing and testing. Would it be appropriate to assign, for reasons of cord blood stem cells for the collection of umbilical cord blood for sampling? If not, what is the appropriate code? They say, It’s not appropriate to assign 68550 Z T four races of cord blood stem cells from vocal cord sampling. Collection of the vocal cord blood is a routine part of the newborn’s, Karen, an ICD 10 PCS code is not assigned. This is not the same as for recess for cord blood stem cells and is not a separately reportable service. So we now have advice for that.
60:13 I have a couple more coding clinics here, I know I’m right at one o’clock. So the webinar is officially over, you can stay on for, I just have a couple of more to go through. If you want to stay overnight, we’ll stay on for questions.
60:27 And I’ll quickly go through these. So septic arthritis. Osteomyelitis of the pubic synthesis, this is actually a good one.
60:35 There’s no specific code for are code for subject arthritis of the pubic synthesis joint. So they they did say that we can use M 86 8 X a other … for the ICO of the pubic synthesis joint. And of course, we can encode the specific.
60:51 In this case, it was E coli, They, they are talking about creating a code for specifically for septic arthritis of the pubic synthesis Joint. I have a picture here. It shows the pubic synthesis and the joint itself is right here.
61:06 Also, when they’re doing a procedure of this, you know, they’re doing an aspiration fluid biopsy of the pubic synthesis joint. How are we going to code this?
61:16 There’s no option for pubic synthesis joints. So they tell us to use drainage of the left pelvic bone and drainage of the right pelvic bone.
61:24 Because there’s no option for drainage of the pubic synthesis joint.
61:29 So we have Ooops skipped backwards.
61:35 So that’s an interesting one. I’m sure that will come in handy. Next we have this is actually probably when you probably see move or fat necrosis from retro Peritoneum in space, or see us. I’m probably saying that incorrectly.
61:48 But they’re removing this fat necrosis, so I guess what is the Is it excision? Is it extra patients doing a …
61:56 of the the chronic fat, um, and also they took out fat from the space of rats Razzi us so they scoop this out with their fingers and a sponge and what codes they’re asking: what code should be assigned for this. So we have extra patient of matter from retro peritoneum and you can see the retro … is the space behind the …
62:20 right here.
62:23 And then we have they also removed matter from the pelvic cavity for the path for the fat removal of the … the space of rett’s retsina. It’s in the retro pubic space, and the retro.
62:37 And that’s the space between the … synthesis, pubic, bone, and the bladder that space of ritzy us.
62:44 Again, I’m probably mispronouncing that. But that’s that space right here and they’re removing that fat necrosis.
62:50 So I thought that was an interesting one. A lot of times, we can’t find body part values for things and I, I think, it’s great when they do. We write in about these. Some of, these can be a little bit confusing, when our body part key doesn’t give us and, you know, tell us the body part we should be using for that.
63:06 So they do tell us just to use pelvic cavity for for that.
63:13 And then, provisional total hip arthroplasty.
63:16 The patient underwent A they had a hip for moral neck fracture with an Open Left Total Hip. They had to remove following removal of the moral head trial for moral head and neck metal on poly. Ethylene components were placed at the acid tapping. Michelle was child for fit. So they’re putting in the trial fitting, fitting in these trial components, but then temporarily or I should say, the patient D compensate it and they were not able to put in the final final.
63:45 Components, the temporary Assa tabular liner and for moral trials were left in place to be exchanged for final implants at a later date. So what code should be assigned? and what is the correct operation? They tell us to code the replacement of the hip joint. For the provisional total hip arthroplasty, in this case, the actual hip was still replaced, even though they’re there.
64:04 They’re the provisional implants. So we do have advice on that at this point.
64:10 And then we also have a robotic assist at low interior resection of the colon. I have a picture here of, it’s interesting. It comes up a little bit blurry on the slide, deck hopefully not. When you print, you know, on the slides themselves, on my side. It’s not but on my presentation is so I apologize about that. They’re talking about a patient undergoing.
64:31 You know, there’s a lot of confusion still I think about when they do make a small incision to remove the Oregon. So let me just read the question so a patient underwent a robotic assist at low interior colon resection. We also want to pay attention when they say Lauren tearing colon resection, what are they actually resetting?
64:49 At surgery the … was established repotting ports were placed in the splenic fracture was mobilized, laparoscopically, followed by robotic excision. Incision was made. The sigmoid colon was pulled through the incision, skeletonized, extra properly. … was then performed and inspect it via proctor scope. What is the appropriate approach value for this procedure? So we’re going to assign the approach value for percutaneous endoscopic, for the robotic assisted, sigmoid collect me, with primary …. In this case, the surgery was performed laparoscopically. toward the end of the procedure. A small incision was made to divide skeletonized and remove the specimen.
65:26 According to ICD 10 PCS guideline P five to be procedures performed using the percutaneous endoscopic approach with incision or extension of an incision to resist the removal of Oliver portion of a body part or to …, tubular body part to complete the procedure R, code it to the approach value, percutaneous endoscopic. So, I think there was some discussion about, well, they, you know, just they made the decision to actually you know.
65:47 Excise, Excise, the sigmoid colon, they’re doing that outside the body.
65:54 So it looks like, according to this Coding Connect, that, that would still be percutaneous endoscopic, because they’re still doing that just to remove the organ itself.
66:03 Um, so, that’s how that’s how I’m reading this. Let me know your thoughts on this. I’m assuming that’s why they publish this because there was a lot of questions on that.
66:15 So, that’s all I have for today. Just a reminder, you can download your CEU certificate by visiting the following link. Um, you have two weeks to download it from today. Reminder, sorry, ex employees, Please refer to the Yammer group for additional information about webinars.
66:32 And that’s all I have for today in terms of our presentation.
66:37 In terms of registering for the upcoming webinar, please check out our website. You can just Google … webinars and it’ll bring you right to our page on our webinars and you can register for the Roundtable 445. I think I saw a couple of questions on that.
66:53 All of our, if you just, like I said, if you Google …
66:55 Webinars, instead of giving you the actual website, you can actually go to this website, WW dot CX, health dot com slash front slash resources slash webinars. It should take you right to the page, and you can register for any upcoming events.
67:15 OK, so let me go to Questions. I have a ton of them.
67:19 Um.
67:24 OK, so initially, the question is, if the imaging doesn’t indicate a cause, would you send a query to try to get them to clarify?
67:32 I would think that would be an internal policy if you would want them to, if you need that information for some reason.
67:41 I don’t know if they really know I guess there’s they possibly think it’s a thrombosis or embolism, if they have some under underlying, maybe potential underlying causes that may be maybe they have a-fib, and that could be a potential source of embolism. Every case, what is I’m thinking, is going to be different for that.
67:58 So, I can’t speak, say that, you know, every single case I would be querying for …, for specificity.
68:14 OK, so question, I guess I already answered this question, but just to revisit that, one of the coding clinics, I’m just reading the question. State, tight, nuchal cord doesn’t not, doesn’t necessarily imply compression when coding the Newborn’s record. Does this mean when we’re coding the Moms Wrecker record? We shouldn’t pick the code cord around the neck with compression. So based on that Coding Clinic, I’m going to say, we shouldn’t be choosing with compression.
68:36 Because it says it doesn’t indicate, even though we’re talking about then it’s a newborn coding clinic, they state that it doesn’t necessarily mean that those with, with compression.
68:44 So I would say we shouldn’t be using with compression going forward from March 18th on.
68:52 Um.
68:59 So alcoholic some, there’s some people asking about does an alcoholic equal dependence.
69:04 Please check your code book and C, C that can also be an adjective, they no longer codes to dependence If I’m if I remember correctly. Correct me if I’m wrong.
69:16 I think there’s another coding clinic on that as well. If you’re not familiar with it.
69:20 They have to state if it’s dependence, abuse or use, but that there is a hierarchy, if they’re saying dependence, that weird co-dependence over abuse overuse.
69:33 If a patient just has HIV and they don’t don’t document HIV disease.
69:40 Those terms that we discussed, if they have an HIV developing, if they don’t have an HIV defining condition.
69:50 You need that specific documentation as outlined in that guideline.
70:04 OK, Great, so I have someone indicating, which I thought I didn’t, I kind of forgot to mention this, but, um, someone wrote into Coding Clinic about Traumatic Splenic Laceration and they said, Decode Case 60 61. I mean, this isn’t officially published, but I thought it was interesting that they didn’t publish that, because if you index, Hemo Peritoneum traumatic, it goes to unspecified Injury of the peritoneal.
70:29 So if this Splenic, if the Splenic laceration is bleeding into the Peritoneum, it kinda doesn’t make sense to code unspecified injury event peritoneum with a splenic laceration. But again, that’s not officially published but I do have one person on the call saying that they wrote your coding clinic and they said to also code the case. 60 61 with the traumatic splenic laceration, which is a little strange I’m hoping that they publish that one.
70:57 So, in terms of the Hema Peritoneum with acute blood loss anemia, would you code the anemia? Yes, if there are, if it meets the definition of reporting? Absolutely.
71:07 Not everyone with bleeding is going to end up with anemia, right? So.
71:12 I would absolutely be coding, nephew boss anemia.
71:20 So, again, those codes for referring back to the tight nuchal cord of the newborn. I’m not talking about the mother but the new newborn. Those codes in that category say that they have to state that it’s impacting the care of the baby. So, the answer is, yes, If they are stating that the nuchal cord is impacting the baby.
71:37 Um, as outlined in that Coding Clinic, you can go ahead and pick it up, but I see a lot of coders picking up those P codes. When it’s, the maternal condition is not impacting the baby.
71:47 You want to be very careful. You can obviously query, If you see some kind of you know acidosis deceleration, you can query to see if that impacted the baby. But you can’t code something without them telling us that it impacted the baby in that in those code categories.
72:06 Yeah. So I have another person that’s saying, I have a very similar chart returned to me with a splenic traumatic laceration with chemo peritoneum. I coded the human …, and it was denied by the payer. I coded this as it was significant bleeding and was monitored. I’ve seen other splenic lacerations without a significant human … does this need?
72:22 Does this new Coding Clinic advice, apply traumatic spun incarcerations?
72:27 I would say, no, I would definitely write to them about that, because they didn’t address that in this Coding Clinic.
72:31 If you index Traumatic Hemo peritoneal, it goes to unspecified injury of peritoneum. Are of interest I think abdominal cavity or something but we know that injury is involving the spleen. So that, when I’m on the fence about I personally wouldn’t code it without clarification from Coding Clinic.
72:52 K, The K Code, I mean, it’s due to trauma, so I’m a little bit hesitant using that K code. So, again, I think we need to write an effort and get them to officially publish it.
73:02 It looks like someone did write in to Coding Clinic about it, and they got a response, but it wasn’t officially published, So I don’t know the answer to that. 100%.
73:11 I’m just using Get, providing my personal opinion.
73:22 That’s a good point. So, great point. So, if we need to code code also, hemo peritoneum to fully capture the patient’s clinical condition, why haven’t they decided we should also code the bowel obstruction and neoplasm or other specified causes? That’s a great point for bowel obstruction due to cancer of the intestine. That’s a great point. I don’t know.
73:42 Maybe they’ll change that in the future. It really doesn’t make sense. We used to code it and then they put that inclusion term in the code book. So, now we can’t code it.
74:00 OK, so thank you. So I had a question about where in the tabular narrative for codes for subcategory alcohol abuse with other induce alcohol indoor disorders indicate these codes are assigned for alcohol induced disorders, and such a relationship must be documented by the provider. This person just gave their 2%: I’m thinking that the reference regarding the narrative tabular narrative is referring to the category descriptions, IE alcohol abuse with alcohol induced disorder.
74:25 Yeah, I’m not sure it’s I mean, it’s not, but it’s not clear to me.
74:29 Alcohol induced is specifically stated in the description. OK, yeah, I can see your point, that makes sense. That seems to infer that the specific condition would need to be linked. OK, yeah, I can see that. Thank you for that. I wasn’t seeing it when I was.
74:43 I wasn’t getting it when, when I was reading it, but I still thought that we shouldn’t be artists automatically assigning it based on our guidelines.
74:54 Um, some of these questions, if you have a quite specific coding question, please send it to my e-mail. I don’t have my code book or anything. Up at this time.
75:03 It will take me take me a while to answer specific coding questions, Please send, you know, you can send it to my e-mail or, sorry, simple ways you can post it in the coding question group if you if you, if you want.
75:27 Um.
75:30 I’m just reading some of the questions. Some of these have already been answered.
75:36 For the Nuchal Cord Coding Clinic, since it states that there has been no documentation of babies affected, does that mean we don’t code it at all? Yes. If it’s if the baby is not being affected, were not coding it, right. That’s for any of those key codes in that maternal condition affecting newborn category.
75:52 Um.
75:55 If you suspect that it is, if maybe the baby has some other conditions, and you suspect maybe that is the cause, you can always query for clarification if that, if you know the cause of if there is any contribution from other conditions.
76:16 Another question about registration, you can register via our website. If you don’t have, You can also e-mail us if you need that information, but it’s right on our website, you can self serve.
76:30 Um.
76:37 Yeah, I don’t understand that to Eleanor. If there was still active bleeding with with the Hemo Peritoneum, why don’t we just code post-operative hemorrhaged? That’s what I would think.
76:45 but their logic doesn’t, it’s kind of defies logic. To me I don’t really understand the difference. Between those, I think there’ll be a lot of follow up to those those coding clinics.
76:59 So someone is asking is a GI tract considered a tubular body part? Yes, but they clarified that and said that they’re going to update the guideline to state that that guideline just refers to vascular or vascular organs.
77:22 OK, so if someone’s just letting me know that, I should check the definition between hemorrhage hematoma and Sir Roma, um, since the example only has a hematoma and not active bleeding.
77:35 You would see, in a Hemo peritoneum, you would not assign a code for Hemo, Peritoneum for active bleeding. I guess.
77:44 I still have to wrap my brain around that one.
77:50 So, how would you code the patch graph following the endarterectomy if the Legion extends from the common carotid an internal external credit? and they do a bovine grafting, tunnel external and a common carotid? I believe the Coding Clinic addresses that I think we’d still only code it to the common carotid.
78:05 I’m doing this off the top of my head, so please correct me if I’m wrong. Karen, if you want to send me a separate e-mail, so I can remember to look back at that. I believe we still on, like, if you look back at the old Coding Clinic on the Illiac, for moral one, I think we just code. And I could be wrong, because I’m doing this off the top of my head. I believe we just code the common from what we’re just coq code the common carotid for that.
78:29 Thank you, everyone, OK, great, someone said it’s not blurry when they print it.
78:40 And just to make a note about that, under dosing guidelines, someone’s saying that you can’t use it as the principal. Yes, we know that, You have to be careful with reading coding clinics. They don’t always advise sequencing that was just for that specific example.
78:52 If a person has, if a person presents, a person isn’t gonna present to the hospital with no symptoms, and we’re never going to use under dosing as the principal diagnosis, right? This was just, the patient is just this scenario. A coding scenario, it wasn’t advising sequencing. It was just stating, this is how you code it.
79:09 So see, please be careful when you’re applying your reading coding clinic guidance.
79:13 It doesn’t necessarily unless they say this is the PBX, or this is how we, how we sequence something. It’s not always, we’re not always telling us how we should be sequencing something. They’re just saying, these are the codes for that condition.
79:26 So, referring back to that coding clinic about under dosing, we specifically stated that the under dosing should not be used as the principal diagnosis. That wasn’t the case the patient didn’t present for an under dosing. It was just a scenario where the patient happened to, you know, the provider happened to: note that the patient wasn’t taking their blood pressure medication.
79:50 You’re welcome, everyone. Thank you so much.
79:53 Thank you. I’ll let marketing know about the date is wrong.
80:03 OK, so if there’s separate lesions in the common carotid and the internal carotid, and both, R, and R, both, code it, yeah. So referring back to those coating clinics. If they’re separate lesions, you can code them separately If it just one lesion. You’re going to code the one proximal to the heart.
80:43 All right, so I’m gonna end it here if I didn’t get to.
80:47 If I didn’t get to your question and you still would like an answer, please e-mail me.
80:51 You, and I’ll address that, your question separately for time sake. So I’m going to end it here. Thank you so much everyone again. We’ll be discussing the covert stuff on April 12th on our next round table, so not that next Tuesday the following Tuesday. We’ll be discussing all the code that we’re going to revisit Covert Answer some outstanding question, go over some scenarios, and also go over the coding, the new codes, encoding clinics that were published in this coding clinic. So, thank you, everyone. Have a great, great rest of your week, and until next time.