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0:03 Hey, everyone, and welcome to Roundtable 147. Once again, what’s credit to all you here for taking the time out of your day to join us. On last I checked.
0:13 We had over 2000 registrants registrant’s.
0:17 What’s the popularity of today’s topic? We’ll get to in a second metric, vice president coding education, and continuous improvement for Sox’s, each IM division.
0:28 It’s my pleasure, as always, to introduce today’s speaker, Janice ….
0:33 This is Science, Health Director of Events.
0:36 And she’ll be facilitating review of ages Quarter 2, 2022.
0:42 Correct.
0:44 Setting this up with Janice before today’s webinar.
0:47 Learn that this is one of the more relevant coding clinics in recent memory. So looking forward to today’s discussion.
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2:03 So Thanks again for your attention, Janice. Tell us all about Go to. Good Alright. Thanks, Scott, you can hear me write arbitrary: OK, great.
2:13 All right, Hi, everyone, thanks for joining us today, and, as Scott mentioned, I think there’s quite a few good topics or, actually long, I guess, topics: we’ve been waiting for answers to for a very long time.
2:27 And I think we’ve been having discussions about these, and I’m glad I know coders and managers and things are starting to submit questions. So, the more we submit, you know, the more we have these conversations and the more we can get people to different organizations to submit the same question. I think they they publish them because a lot of these don’t end up getting published. Embry. You know, maybe one person has the answer. Not all of us have the answer, so, I’m glad that it looks like some of these. We I’ve had discussions in the past with different organizations, different coders, different auditor, so I’m glad, and I think even some of these may have even been submitted by by our team. So, great job with that. And without further ado, I’m going to get get into some of these. And I actually think I was, I think I actually know who submitted this question.
3:18 So, thank you for submitting this. I know, sometimes I give advice, it’s kind of just the best advice I have, based on what we have available in our guidelines, with previous coding clinics, kind of interpreting, but it’s always good to have the official co-operating parties.
3:34 Officially publish, Publish some of these so that we all are following the same rules. And we’re all following, kind of the same guidance. And we’re not kind of guessing at what we’re doing here. So the first one up is deep tissue pressure injury reveal to be Stage four pressure ulcer. I do have another slide that’s coming up with pictures, so stay tuned for that.
3:58 But just to kind of go over the question, um, we have a morbidly obese patient was admitted to the hospital with a deep tissue pressure injury to the Bilateral Rutile region, which was revealed during the admission to be Stage four pressure ulcer. On admission, wound care described the deep tissue pressure injury as Bilateral inner … folds with vegetable hyper pigmentation during week. one, the deep tissue pressure injury demonstrated areas of moist Black Asher. And subsequently the two sites merged into one wound.
4:28 On the discharge summary, the provider recorded deep tissue pressure injury to the …, present on admission, revealed to be Stage four pressure ulcer. What is the correct ICD 10 CM COTA Summit and present on admission indicator for this case? So, we do have specific coding guidelines when some, when a pressure ulcer progresses from one stage to another, but with deep pressure injury, deep tissue pressure injuries. We can’t always tell the stage. I mean, we’ll see some pictures on the next slide.
4:55 And, you know, we have some, there may not be any open skin but that there’s injury could be all the way down to the bone. We just can’t see it until it’s revealed. So the answer to this, you know, typically, we sign a yes and a no. You know, if it progress from one stage to another. In this case, we’re going to assign LED 9, 1, 5, 4 pressure ulcer of the … region, Stage four, with the POA indicator of Y Once it’s revealed to be a stage for the Stage four Pressure ulcer was not apparent until later in the hospital stay. And it’s not an ulcer that developed during the admission.
5:31 In most deep tissue injury pressure injuries, the true extent of the injury is not known immediately. Typically, pressure ulcer staging is reliant on observable skin characteristics, however, since the extent of the deep tissue pressure injury may be concealed, the color of the skin may not change right away and necrosis may not be evident for several days.
5:50 D T P I’s can be easily misclassified, according to the N P N P slash P or the National Pressure Ulcer Advisory Board, a pressure related intact area of skin.
6:01 A classification that includes Stage one non branch of all your FEMA can exist over a symptom of a more serious deep TPI. And a D TPI is a precursor of a Stage three and Stage four pressure ulcer.
6:14 So let’s go ahead and take a look at our next slide.
6:19 And so we have our Stage one. And we have our Stage 2 Stage 3 stage for suspected deep tissue injury and unstageable.
6:27 So with these different stages, they describe kind of the indications that they may be looking for for each stage of Stage one. For example, we have a non blanch while your theme on localized area of skin. Skin is intact.
6:42 We have Stage two partial thickness loss involving the epidermis and some of the dermis. It looks like a shallow, open ulcer or superficial erosion.
6:52 So those are pretty, you know, pretty obvious when we’re looking at at the at the ulcer we have Stage three full thickness loss of the skin and subcutaneous tissue and then we that we may have some exposed fat but the tendon muscle or bone is not exposed. And then once we get into Stage four we have full thickness skin loss including the epidermis, subcutaneous Tissue. Muscle, bone, or tended may be exposed. And then, when we have a suspected deep tissue injury, we can see that injury goes all the way down to muscle and even bone in that picture.
7:25 But it’s not, it’s not revealed itself yet, um, so, it’s got this dark purple color and color kind of a bruise, it’s non blanching. It feels kind of boggy in nature. And so that they can exactly stage, you know, give it a Stage 1 through 4, but they suspect that it involves deeper tissue and then we have unstageable where we have an HR. So, a little bit different, where we actually have an HR are somewhat of an open wound, but they can’t tell the depth of, you know, the stage. Because it’s covered by Ash are extensive … tissues that are not sure of the depth and they have to clean that away before they can reveal the true depth of that ulcer.
8:07 So kind of if you, if you’re not sure, you know, if you haven’t, just to kind of give up high level overview of the different stages here, and kind of why they advised coding that as a yes for our deep tissue injuries. Hopefully that makes a little bit more sense to you.
8:27 Next we have a couple of other and I saw I believe I saw them discuss some of these other types of pressure injuries on the maintenance maintenance committee meetings in the past.
8:42 And there’s no specific codes for these, they don’t provide pressure injuries for Mirko soul areas.
8:51 So we have first we have pressure injury of the mucosa lip, and this is this example a patient was admitted for treatment of acute respiratory distress due to coven they were intubated.
9:02 Later in this day the patient was identified to have a pressure Lipp, mucosal pressure injury, which is attributed to the pressure from the endo Tracheal tube. What is the appropriate diagnosis codes? So they don’t tell us to assign a complication of a device here. Instead, they say to assign TI 88.8 other specified complications of surgical and medical care. Um it’s not an implanted device. So they say to use that followed by the … 1879 other legions of oral mucosa for the pressure injury of the lip, and then they tell us that Co 2579 infection inflammatory reaction due to other internal devices is not appropriate. Since an ET tube is not considered internal prosthetic device, they go on to say that typical mucosal injuries occur at the mucosal membrane in which a medical device was used.
9:49 And it’s an inflammatory reaction caused by the pressure of the device on the affected area encodes classified in Chapter 12 diseases. The skin and subcutaneous tissue are not appropriate for conditions involving the oral mucosa or mucosal membrane.
10:12 Next, we have pressure injury of penile mucosal Membrane.
10:17 Another type of mucosal pressure injury here. And this one’s a little bit different, if we think about a Foley catheter, right? Those are inserted. And the long term, um, those are consider we have a specific code for infection and inflammatory reaction due to indwelling urethra, catheter. So there is no specific code from coastal membrane pressure injuries according, you know, using the standard pressure injury staging system. So, they tell, advise us to use that T D 3511 A, and then we can code, which is the infection for mature a reaction, and then we can code the end 36, 8 other specified disorders of your ….
10:55 And 36.8 is assigned, because the pressure injury of the coastal membrane involved is the penile medius, or external end of the urethra.
11:08 Yes, hmm.
11:11 And I know I’ve come across those on occasion. those pressure mucosal injuries. So hopefully, you know, you have a way to code them going forward with that advice. Now, I know this next couple, we have a couple of pregnancy case examples coming up. And I know these have been long debated for, I think, you know, I feel like many years at this point, you know, different interpretation of the code book of applying the weeks of gestation. So I’m glad they officially published this. We’ve actually had just answered.
11:44 I received different answer, will not different similar answers advising this. But I’m glad they officially published it so that we’re all on the same page and being consistent with how we’re applying these codes. So the question is, Please clarify completed weeks of gestation when assigning codes.
12:02 Oh, 48 0 post term pregnancy 0 48.1. Prolonged pregnancy, oh, 75 82 onset. Spontaneous of labor before 37 weeks, but before 39 weeks, with delivery by Plan C section and oh, 0 to 1 missed abortion and oh, 36.4 maternal care for intra uterine death. So in ICD 10 CM, completed weeks of gestation refers to a full week.
12:29 For example, if the provider documents their gestation at 39 weeks and six days, 39 weeks of gestation is assigned, as the patient has not yet, we reached 40 completed weeks. When the provider’s documentation in the medical record indicates the patient’s pregnancy is over 40 completed weeks to 42 completed week. So 40 weeks, one day, to 42 week, zero days. It is appropriate to assign 0480 … post term pregnancy. If the documentation indicates that the pregnancy has advanced beyond 42 weeks of gestation 42 weeks 1 day, it would be appropriate to assign 0481 prolonged pregnancy.
13:08 Code, Oh, 75, 82 onset spontaneous of labor after 37 weeks of gestation, but before 39 completed weeks of gestation with delivery, by Plan C section may be assigned for a patient with gestation of 39 weeks, zero days up until 38 weeks and six days.
13:26 Code zero or O 0 to 1, mister abortion refers to fetal death that occurs prior to the completion of 20 weeks of gestation thus, including up to 19 weeks and six days. So if they’re 20 weeks and one day, that would be coded to maternal care for intra uterine death or O 364 is assigned for maternal care for intra uterine fetal death after completion of 20 weeks, zero days after station.
13:50 And then of course, as applicable, we would assign any appropriate weeks of gestation of pregnancy for those that that’s applicable for. Now, I want to make a note here that it’s a little bit different. For newborns, right? If they, you know, for prematurity, the doctor will have to say prematurity for newborns. But for pregnancy because we can index, you know as they state, if we can we can specifically index over 40 completed weeks for prolonged post term pregnancy which is a little bit different than you know assigning a prematurity code for a baby and plus specifically that’s that’s specifically documented in our guidelines as well. So just be careful when applying this to the mom versus the baby.
14:39 For prematurity, mm hm.
14:45 OK, so here is the example. And obstetrical patient is admitted to labor and I was kind of referring to this to labor and delivery for a Plan C section due to breach the provider documents, the gestational ages 40 weeks and two days. Is it appropriate to assign code 0 48, point zero, post term pregnancy based on the documentation of gestational weeks alone without documentation of post term, or post dates?
15:10 And the answer is yes, one provider documentation indicates the patient has over 40 completed weeks to 40 completed weeks, gestation it is appropriate to sign 0 48. Oh, post term pregnancy, based on the inclusion term it specifically states pregnancy, over 40 completed weeks to 42 completed weeks gestation. So that’s in the inclusion terms under that code.
15:31 The provider does not have to document post term or post dates assign also the appropriate code for Z three A, weeks of gestation.
15:45 Next, moving on to another pregnancy example, post-partum, sepsis, juda, post-partum, urinary tract infection.
15:57 A patient is a 24 year old patient was admitted with shortness of breath and fever due to post-partum sepsis and post-partum UTI. The patient had a history of spontaneous vaginal delivery one week ago in the Tabular list and excludes OneNote is under oh 85 Shapiro sepsis which prohibits assigning code Oh 8 6 2 Oh, urinary tract infection following delivery, unspecified. What are the diagnosis codes for post-partum sepsis and UTI? We’re going to assign 0 98, 83 other maternal infections.
16:29 And parasitic diseases complicating the pure curium. A 41 9 sepsis unspecified, since the causal organism was not specified In … 86 2 oh, urinary tract infection, falling delivery for the post-partum sepsis and UTI. So, in this case, Code 0 85 Shapiro, sepsis is not appropriate. As pure Purell, sepsis implies an infection of the genital track, not an infection of the urinary track.
16:53 And that’s why there’s an excluded note there.
16:55 So the Centers for Disease Control, um, it’s considered sick, considering a future co-ordination, and maintenance proposal, to expand 0 8 5 to differentiate between pure, Pure Sepsis, not otherwise specified. That is … sepsis with infection of the genital tract and post-partum systemic sepsis without infection of the General Track and other pure payroll Sepsis, as well as deleting the excludes OneNote. So they did provide advice because that excludes OneNote exists, that’s our way to kind of circumvent that and be able to code the sepsis with that UTI code.
17:34 Next, we have light McCain. Coronium stain fluid, and I think we have a coding clinic on this, I guess. The differentiator here is if it’s light makoni, State of Fluid. I guess that’s why this was asked, so a pregnant patient underwent low transverse, and also the fact that they don’t say the patient.
17:53 The baby was in fetal distress. But I believe the other coding Clinic says they weren’t. They didn’t mention anything about fetal distress to but anyway, a pregnant patient underwent a low transverse C section at 38 weeks due to placenta Previa. During the delivery the provider noted light makoni abstain fluid. The infant had no signs of fetal distress with AFCARS of 9 at 1 minute and 9 at 5 minutes. What is the appropriate code assignment for light Makoni State of Fluid in this, In this case, a code. Oh, 77 O Labor and Delivery, Complicated by makoni I’m an antibiotic fluid only assigned in the presence of … stain fluid results in fetal distress in maternal care as effective.
18:28 We’re going to assign owes oh, 7 7 0, labor and delivery, complicated by Makoni M and amniotic fluid for the light makoni. I’m standing since the presence of any makoni I’m standing may indicate that fetal fetal distress or fetal stress. So that’s the answer for that one.
18:49 Now, these next couple, I know for me, I’m happy they finally publish these long awaited.
18:57 I think, you know, 20 years ago when I first started coding, this was a question that I always had, and I’m I’m glad they finally answered this. So, yay, and I think, you know, we had the same issue in ICD nine.
19:11 So, what is the appropriate ICD 10 code for a diagnosis of unspecified, …, and hypercholesterolemia.
19:20 So, know, we had some, you know, even when we did reviews, are different facilities had different ways of handling this. You know, some would code both. Someone just code one. So, I’m glad, again, I’m glad we have some consistency here, and they officially published it. So, we have assigned code E 78 0 0, pure hypercholesterolemia. Unspecified, for diagnosis of unspecified, Hyperloop edema, and hyper hypercholesterolemia do not assign code E 875 …, as the … cholesterol.
19:54 … identifies a specific blood lipid elevated.
19:58 Hypercholesterolemia is a high blood cholesterol level Hyperloop Academia’s high end or elevated lipid fats levels in the blood, Providers may use the terms Hyperloop edema and hypercholesterolemia, interchangeably. And of course, we see that all the time, right, as the high blood cholesterol is a lipid disorder. So going forward, we should just be assigning E 7800.
20:25 Next, we have mixed type or liquid damia with hypercholesterolemia. So what is the appropriate codes for diagnosis of mixed Hyperloop edema? With hypercholesterolemia, we’re just gonna assign them mixed type or lipid … for a diagnosis of mixed Hyperloop edema and hypercholesterolemia. I think this one was a little bit more straightforward because of the inclusion terms and the index.
20:47 They say, do not assign E 7800 hypercholesterolemia as that’s included in E 8 72 and you can find that in the index. So findings abnormal inconclusive without diagnosis. So high cholesterol with high triglycerides codes to E 72. And then you could see some, you know, high triglycerides with high cholesterol, high cholesterol with high triglycerides, high triglycerides with high cholesterol, they all index 272. So that one was a little bit more obvious because of the way it was indexed. So we should be good with that one. But they clarified that as well.
21:26 I thought this was another good question that was answered just because when you look up some of these drugs, for example, long term use of eloquence, sometimes they, you know, some of these drugs can have an … and anticoagulant properties. So I thought this was a great question that was asked.
21:44 But a patient was admitted for placement of Watchman left atrial appendage device, secondary to a history of chronic paroxysmal atrial fibrillation with persistent left atrial appendage LL, L a rhombus despite anticoagulation warfarin therapy. The patient is being medically managed on eloquence, is eloquent classified as an anticoagulant or an anti ….
22:05 What is the correct ICD 10 CM code assignment for it to capture the long term use of eloquence? So we’re going to assign Z 7901 long term, current use of anticoagulants for long term use of eloquence. Eloquence is classified as an anticoagulant medication.
22:28 Another great one. I mean, I think I’ve been waiting on the answer for this one for many years, again. Another one that I’ve seen over the years where we’re not sure what the code for this, we kinda just took a stab at it and I’m sure different facilities were using different codes. But when we see metabolic bone disease, just to throw this question out there, what do you typically think of when you think about metabolic bone disease? What do we, where do we see this document it? Or what do you, where do you see this metabolic bone disease? They usually abbreviated MVD, but in the documentation, where do you see this being, this terminology being used?
23:08 Yes, so while I wait for answers for about about NaN, just to clarify. I have some people asking for CEUs.
23:19 There is a link at the end of the presentation that you can use to obtain your CEUs.
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23:40 OK, great. So renal disease, right, We see.
23:44 we see this mineral bone disease being documented with our renal disease. You may see it with other conditions, But most likely, you see that non specific term metabolic bone disease being documented with our renal disease. So the answer to this was to query the provider for clarification about the underlying cause of the … metabolic bone disease.
24:08 Metabolic, metabolic bone diseases. A broad term used to describe a group of bone disorders of bone strength usually caused by mineral abnormalities such as calcium, phosphorus, vitamin D, or magnesium, which, when matter, our metabolic bone disease is a component of another disease process. And most of you had mentioned this renal disease code, the underlying disease or code only the underlying disease. So when we think of mineral, metabolic bone disease, sometimes they don’t really elaborate. But a lot of times, they will say it’s due to secondary hyperparathyroidism or renal …
24:42 dystrophy, so if we have greater specificity, we’re good to go.
24:46 But if not, they say, we can query.
24:50 But if we don’t have any documentation of an underlying disease or or underlying condition.
24:57 We can assign a code from M 89 8 X, other specify disorders of bone for the mineral mineral bone disease.
25:07 And I think this is important because some of those codes can be C Cs when we have a specific, specific metabolic bone disease documented or even maybe not C Cs.
25:18 But they may impact your severity of illness and risk of mortality, depending on what other codes that you have on your case as well.
25:32 So, um, let me keep going. I’ll answer questions at the end. So we have obesity designated by class. I thought this was interesting. They don’t really, I mean, I kind of can think about this a little bit. I kind of was thinking through this a little bit, but they say that the question was a patient presented for follow up of multiple medical conditions. The provider documented class three obesity as one of the patient’s medical condition. Would it be appropriate to assign E 6601 morbid obesity due to accept excess calories based on that providers? That diagnostic statement of Class three, Obesity?
26:08 The answer is, we can code E 6611 morbid severe obesity due to excess calories for Class three obesity Class. three obesity is synonymous with morbid Obesity, which is classified to E 6601 for Class one and Class two. We have to query the provider to determine the type or etiology of obesity if the documentation does not specify this information. So this table is just, I got this from a reference. This is not specific to the Coding Clinic, just for, so we can reference it I don’t know if anyone has any ideas, why they think, you know, they didn’t give us their rationale, which I wish they did, but I can kind of assume, or make an assumption here.
26:45 The reason we can’t take class one or class two, sometimes, if that class to, maybe, they think, you know, they might be in that class to range BMI of 35 to 39 and may still consider them to be morbidly obese, or just obese. So that’s maybe they’re, you know, maybe they have low muscle mass. But they’re still morbidly obese, and their BMI is a little bit lower than expected. I’m just taking a stab at it, I don’t know, exactly the reason for that.
27:12 But if someone’s has severe Class three obesity, the assumption is they’re going to be morbidly obese.
27:21 So that’s my assumption of why we can code severe class three, or class three obesity too morbid. But we can’t code class 1 or 2 to either obesity versus morbid obesity.
27:31 Again, they didn’t elaborate in the coding clinic, but that’s that. I’m just taking a stab at it.
27:37 And assuming that’s why.
27:42 Just a comment: I do see some people saying that they do see class three. It’s not indexable. right now, it may be added to the index for fiscal year 20 22. It’s just it’s we don’t have the final final changes yet. So I don’t I am still kind of involved in, kind of putting together looking at the changes, but it probably will be added to the index.
28:07 Usually when we see these coding clinics, they’re kind of a precursor to what we’re going to see and changes.
28:12 So I’m going to, right now, they’re not, but, again, it’s usually a precursor for what we’re going to see in the future.
28:23 So just a couple of comments. I see some, a couple of people who comment that They do see Class three obesity documented in their records. So now, you don’t have to query for that. You can code it, too.
28:34 Morbid obesity. Now, this is another one. I don’t see this a lot, actually I don’t think I’ve heard about it in the news.
28:41 I’ve heard about it and, you know, sometimes you hear about this stuff in the news and stuff like that. I’ve never actually seen this and let me know in the comments if you’ve actually come across this.
28:52 Typically, we see osmotic Demodulation Syndrome. It’s a complication of patients with severe and prolonged hype on a tree Mia and that …
29:03 correct it too rapidly, so, yes, they’re very careful about correcting these patients too quickly because of this possibility. So, the question is, a patient was admitted to the intensive care unit for monitoring of hypo … following treatment with intravenous fluids, the sodium level normalized. However, the patient developed urinary incontinence and the inability to walk or follow commands. Neurology evaluation, noted decreased alertness and ankle colonus.
29:31 MRI of the brain showed restricted diffusion and increased flare signal on the central ponds.
29:36 Could amend caudate and thalamus bilaterally. The provider’s documentation confirm these findings as osmotic demodulation Syndrome or ODS. The condition progressing, the patient is now in a locked in state.
29:49 What is the appropriate ICD 10 CM Code Assignment for Osmotic Demodulation Syndrome? We’re going to code this to G 37 to Central Pontine, my, when my Leno lysis for osmotic Demodulation Syndrome. We’re also going to assign GT 3 5 locked in state and end the T code: 53 X 5, A adverse effect of electrolyte caloric and value Water balanced Agents. For the Lockton State in the adverse effect, the decreased alertness and ankle CONUS would not be coded separately as they are integral to the disease process.
30:21 ODS are Osmotic Demodulation Syndrome, also known as Central pontine Mila … is caused by the destruction of the myelin sheath. Larry Layer covering nerve cells in the middle of the brainstem treatment of … may result in an increased risk of developing ODS. The following entry can be found in the index milena … pontine central G 37.2.
30:46 Um, so just to kind of look at the comments.
30:50 I’ve never seen osmotic de modulation Syndrome document it.
30:57 But, again, I have seen, you know, instances of this discussed in different news outlets and things like that, different medical things that I’ve watched. So, I was somewhat familiar with this.
31:12 But again, I’ve never come across this So I don’t think it’s that common because they are very careful, you’ll probably see them documenting. You know, you know, they don’t want to, they will probably talk about this. I’ve seen the talk about not correcting too quickly. Because of the risk of this syndrome. So you probably have seen that in the documentation. Not specifically calling out the syndrome, but just say, you know, slow, slow, reversal of that. Next, we have serotonin syndrome. We don’t have a specific code for this. So if we think about our coding guidelines as I read through this, you could probably come up with the answer for this. So serotonin syndrome again, there’s no specific code but we do have a guideline regarding syndromes, right, So the question is a patient was admitted with delirium and hallucinations secondary to serotonin syndrome. The provider was queried in class of clarify, that the serotonin syndrome was due to adverse effect of prescribed … and paxil. What is the appropriate … code for serotonin syndrome?
32:07 We’re going to assign our 41 oh just orientation, our 40 43 hallucinations for the delirium and hallucinations. We’re going to assign the T code, the adverse effect codes for both drugs. And then, you know, if we take a look at the guidelines found in Section 119, E five A, encoding an adverse effect of a drug that has been correctly prescribed, improperly administered. We’re going to assign the appropriate code for the nature of the adverse effect. followed by the appropriate codes for the adverse effect of the drug. Also, serotonin syndrome is not specifically classified an ICD 10, when a syndrome is not classified in ICD 10.
32:43 We are going to follow one, be 15 of the guidelines which states in the absence of alphabetical index guidance.
32:49 We’re going to assign codes for the document, documented manifestations of the syndrome.
32:53 Additional codes for manifestations, that are not an integral part of the disease process, may also be assigned when the condition does not have a unique code. So taking a look at the signs and symptoms of serotonin syndrome, these are not an all inclusive list that I have here on the slide.
33:08 Um, we have hyperthermia hyperflex ya, Muscle colonus, Muscle Rigidity, Tremor, daya for recess, ocular colonus.
33:17 Some additional signs and symptoms include agitation, insomnia, confusion, rapid heart rate, high blood pressure, dilated pupils, loss of muscle co-ordination, etcetera. Now, I have seen this on occasion not, it’s still not something that I see every day, but I have seen this, especially if you have a psych unit.
33:38 You may see this a little bit more frequently, or if, um, if you have patients come through your ED, that, our psych patients, you may see this as well, and then they are transferred to the medical floor or even to a psych unit.
33:52 So, I have seen this on occasion, they probably will be stabilized in the medical for and then transferred, probably for they’re sike issue as well.
34:08 Oh, maybe that’s what I was thinking. So someone just mentioned about the, it was, on grey’s anatomy. That’s maybe that’s where I saw it. Yeah. You see that, on the medical show, sometimes good point. So next I’m going to move on to segmental and sub segmental Pulmonary Emboli. I think I know who submitted this as well. So thank you for submitting this, and getting this clarified.
34:32 The patient had a chest CT angiogram, which revealed pulmonary emboli, the segmental, branches of the right middle and lower lobe of the lung. The radiologist’s also noted and bely in the sub segmental branches of the right and left lobe of the lung.
34:46 The providers final diagnostic Statement listed segmental, N sub segmental, Pulmonary emboli, how should this, segmental and sub segmental permanent pulmonary emboli be coded? So we take a look at the lungs and the pulmonary arteries.
35:00 We have our main pulmonary arteries, which would be a saddle embolism, a large clot and the main pulmonary arteries. Then we have R.
35:11 Then we have our larger branches are, segmental branches, these larger branches, coming off of the main pulmonary arteries. And then we have our, kind of our fourth degree.
35:22 Maybe third and fourth degree, these smaller vessels, here that are called R, sub, segmental, Pulmonary Emboli. So these are thought not to be as significant. these little. These little branches over here, you know, versus if they have a saddle and belie, a larger clot in the lungs blocking that whole lung.
35:43 And we have separate codes right for sub, segmental, and segmental, or just our main pulmonary artery codes. So are we to assign both codes here? So the answer is yes.
35:55 We can assign I 2699 and the I 2694, for our other pulmonary embolism and are multiple sub segmental, pulmonary emblem, and belie, Without a court, acute core Pullman Alley for documentation of segmental, and multiple sub segmental, pulmonary emboli. So in this case, the patient had segmental, …, and the proximal branches of the right, middle and lower lobes, as well as bilateral subsidy, mental …. So two codes are needed to fully capture the patient’s condition.
36:25 So again, And so again, these are our sub segmental branches, these kinda third and fourth degree, branches and then we have our segmental branches and then our main pulmonary arteries. So depending on where they were, that pulmonary emboli is more determined, the documentation that you see in the record. And also, they clarified that for us as well. If it’s segmental, we’re going to code … 2609. And if they have both, we’re going to code the I 2609. We have our single sub segmental as well. So just be looking out for that specific specificity.
37:05 Next, this was another good one, I thought. So I’m actually had a recent question on this from one of our coders. Um, they didn’t actually have a fracture. They had a non-union I’m in this case, it’s a non-union of this journal non-union their status post, a hammer. How many stern autonomy for a matter of my mantra valve repair. The example that I had, I believe it was an osteotomy. They are having correction. I think of it was something to do with their hip. I don’t remember exactly the indication. I think it might have been dysplasia, hip dysplasia, or something. They were having an osteotomy for that, but they didn’t actually have a fracture. And they developed this non-union pseudo arthritis following, following, surgery, in this case it’s following Eastern autonomy. So what code are we going to assign.
37:46 When it’s not actually a fracture non-union, it’s related to, you know, they put the bones back together after they entered into the operative site and they’re not fusing back together and they have to go in and maybe repair it or monitor it. They suggest in this case to assign M 9689 other intra-operative and post procedural complications and disorders of the musculoskeletal system. And also, you can encode the acquired deformity of the chest and Ribbon this case. So, we’re going to apply this to the other case where they had the osteotomy, the non fusion of the osteotomy I would probably still use that same code. Followed by the deformity of the Hip or Joint or whatever was, was the issue in that case. So I thought this was relevant. We see this. I’ve seen this on occasion. And even recently, I’ve seen it. So I think this is relevant, and we probably, you’re probably going to use this more than you think you will.
38:39 So I just wanted to definitely cover that one briefly for our complication, non-union, not related to a fracture.
38:53 Next, this is another interesting one. When we think about ventricular fibrillation, I actually had this discussion recently as well. Before this coding clinic came out, we have our coding clinic related to our sick sinus syndrome, that pacemaker, everyone hopefully knows what I’m talking about. But we have their pacemaker controlling the sick sinus syndrome. They tell us that we can store code that six sinus syndrome, because the pacemaker is actually controlling and functioning to control and increase the heart rate for a patient. That has six on a syndrome. It doesn’t cure the sick sinus syndrome.
39:25 However, when we think about ventricular fibrillation, and a patient that has an ICD, the purpose of the ICD is to treat that ventricular fibrillation. But if their status post an ICD, is that ICD actively controlling ventricular fibrillation?
39:41 So let’s take a look at the question. A patient is admitted for multiple medical medical conditions and a status post.
39:47 An ICD for ventricular fibrillation, the cardiologist documentation states ventricular fibrillation, remains quiet, no flares No symptoms, no firing is up the … slash CD. Would ventricular fibrillation be considered a chronic condition that always meets reporting requirements? Previously published Coding Clinic advice clarified that for hospital reporting, it is appropriate to assign a code for the specific cardiac condition that is being controlled by the presence of a cardiac device.
40:13 Would it be appropriate to report ventricular fibrillation on a patient who has status post … slash CD placement?
40:19 If the condition did not occur during the admission, the answer is it would not be appropriate to assign a code for ventricular fibrillation in this scenario. Over codes 86 79 personal history of other disease of the circulatory system, and Z 95810 presence of automatic.
40:34 Implantable cardiac defibrillator may be assigned to capture the presence of an ICD in a patient with a history of ventricular fibrillation.
40:42 The Fib is an acute, life-threatening condition that is, should only be reported when it is documented to occur during that admission. In this case, the patient is being followed by a cardiologist, however he is not currently experiencing the Fib and the a slash C D is not firing. This is different, situation from a patient presenting in the ED because of the device is firing due to the occurrence of the fib.
41:03 So I’m gonna stop here for a second so if that device is firing, is that automatically a complication of the device?
41:10 I see this coding coded incorrectly on a regular basis. So I’m asked, I’m gonna throw that in there. As a question, what if the, if the patient isn’t, isn’t V fib and that device is firing? is that a complication?
41:22 The advice previously published in Coding Clinic only applied to sick sinus syndrome as it is a chronic condition in which the device pacemakers constantly function functioning to increase the heart rate, OK, good. So, that if the device is firing, and the patients in V fib or V-tech, that is the purpose of an ICD, right. It’s to defibrillate the hearts of the patient is knocked out of ventricular fibrillation or v-tech or whatever ventricular arrhythmia they’re experiencing. So unless it’s occurring, we’re not going to be coding that in the clue there is that the a slash C D is going to be firing. Is it sometimes firing inappropriately? Yes, But, we’re going to be looking out for that specific documentation that an ICD is going off in appropriately, that would be a complication.
42:06 But, if it’s, and if it’s appropriately firing, we’re not going to be coding that. As a complication, we’re going to be coding it, to whatever the V fib or the DTAC or whatever the patient is experiencing, and they can, they can check the device to see what, what’s going on.
42:20 Um, so, I’m glad they published this one as well. Kind of differing opinions on this. But, this absolutely makes sense to me.
42:33 So, someone’s saying, I just to clarify a C So, this is just a comment. Misfiring is a complication when V fib is not present. So, just to clarify that statement that someone’s making, there is other types of … that the ICD may be treating, or maybe treating … may be treating v-tech, et cetera. So, I wouldn’t say the fib is the only condition that an ICD treats.
42:59 OK, good. So, I do on occasion.
43:01 Do you see that, code it incorrectly? So that’s why I wanted to bring that up.
43:07 Hmm, Alright. Radio embolization of right hepatic lobe.
43:14 So, I know a lot of facilities may not do this, but I thought this was a good one to bring up, because we’ve talked in the past about the intent of a procedure. So this is a good one to kinda think about.
43:27 A patient was diagnosed with right lobe, PATOS, cellular carcinoma, and portal vein invasion was admitted for low dose …. Radio embolization of the right hepatic lobe the right … artery was selectively, catheter ized and a micro catheter was used to administer multiple. Small Aliquot Lots of your Target, 90, microspheres into the right a paddock low via the hepatic artery, followed by sterile D five water in contrast flushes. Imaging obtained following the radio embolization procedure demonstrate at no extra extra hepatic uptake. What is the appropriate code assignment for …, which you could be required one for the occlusion of the vessel and one another for introduction of radioactive material? So, thinking about the intent here, they tell us that we should be coin insertion of the radioactive element into the liver, percutaneous approach for the yttrium 90 Radio embolization, and low dose. We’re going to code it’s …
44:21 Z, and then we’re going to code D F 1, 0 P P B Y Z Low dose rate, or LDR brachia therapy of the liver using other race. Other isotope for the yttrium 90 Microspheres. So, in this case, the objective, the procedure is to deliver the radioactive element not to include a vessel. By definition, embolization is introducing small particles into the circulation rather than just liquid. These particles can be used to deliver a therapeutic substance or to interrupt the blood supply. The health record documentation should state whether the objective is to block a vessel or to deliver a radioactive element. However, when the objective of the procedure is not clear, we’re going to query the provider for clarification. And I do want to make a point here that sometimes they do multiple procedures. Sometimes, they are doing an … to block the flow and they may also be doing a radio embolization. So, just make sure that you’re reading. Also, they tell you that we can query. But sometimes they’re doing bolts.
45:15 They’re doing, they’re kind of, they want to shrink the tumor, are close. Maybe they’re, They’re blocking off another vessel that’s leading to that tumor. We see that a lot and they’re also, they may also do a radio embolization of the art, the hepatic lobe at the same time. So you really want to read those op reports, or there’s IR reports very carefully to determine that as well. So I’m not again. Sometimes they do multiple procedures, and we want to pay attention to the intent for each of those procedures. If all they’re doing is a radio embolization, these are the codes that they tell us that we should be using. And I do have a picture here. You could see their access point there in the groin. They’re going into the liver.
45:56 And they’re inserting those, those brachia therapy.
46:02 Micro spheres, and you could see those little green dots there. Those are all the microspheres, and they’re going to be delivering that radiation to the tumor tissue. Hopefully shrink it, Shrink that tumor treat that tumor.
46:15 Hmm. Hmm, hmm, hmm.
46:22 Next, we have a sacral iliac joint fusion.
46:27 Um, I have some pictures there on what kind of what those devices look like. I wish they were three-d.. You can kind of see them a little bit better. They’re kind of triangular.
46:39 But I don’t have that option to show a three-d..
46:42 So probably if you go online and look for a video, you could probably find a video that kind of shows the three-d. nature of those devices.
46:50 But anyway, so patient has a left sided, joint instability and degeneration of underwent a left sided, percutaneous secret, illiac, joint fixation and fusion, using three triangular fixation bone in growth devices.
47:05 So if we think about the sacred earlier joint, it’s this area. So we have the sacrum and the iliac Joint, and this becomes, and this is important when it comes to our fusion codes.
47:18 During the procedure through a small incision, a dissection was made down through the skin to the fascia. The K wire was advanced into position, and a soft tissue dilate or approach were used to implant the first triangular boney in growth.
47:30 And this is kind of what it looks like, close up. It’s kind of triangular in shape.
47:35 And then they have these little holes holes there, so that they’re placed on there, that bone can grow their cause, and create some stability in that joint. All three implants were noted to be placed in the appropriate positions. None were near this S one or S one for men. And all we’re well within the body of the sacred ALA. What is the appropriate ICD 10 PCS code for a secret illiac joint infusion procedure using triangular fixation bone in growth devices?
48:03 We’re going to code zero S G 8 3 4 Z. Fusion of this left secretly, joint with an internal fixation device, percutaneous approach for insertion of A secretly a joint, and fusion cage using triangular fixation bone in growth devices. Triangular fixation bone ingroup devices are designed to stabilize infused the secretly joined by minimizing joint movement. And rotation while the poorest coating provides a favorable environment for bony in growth resulting in a fusion. This minimally invasive procedure differs from more traditional fusion surgeries that can involve crafting for active packing a bone into the joint. The root operation of fusion, isn’t it? This is the thing I wanna point out here, does not require the use of bone graft, except for cases describing spinal fusion. So it involves the sake of Allah and the illiac bone. So this isn’t a secret, fusion is a sacred iliac joint fusion.
48:55 So the fusion involving bone graft is only applying to our spinal fusion.
48:59 If we go ahead and look at our, Our coding guidelines, that bone graft requirement, again, is only applicable to our are spinal fusion cases. The PCS guidelines for fusion are specific to spine Fusion and do not apply to fusion of other body parts, and we’ve had other coding clinics on this before regarding other types of fusions. Also if you look at the codes that we have, you’ll also see that we have other options.
49:29 We also have other coding clinics if they use this boney, you know, fixation of this pony in growth, triangular in a fixation device and they also use a bone graft. Let’s just say they did, you can code those different.
49:41 We don’t have a hierarchy, like we do with spinal fusion, so you can code this fusion of the secretly joint with internal fixation device and then fusion of the secretly joint with any, you know, other type of … or … tissue substitute or synthetic whatever’s. whatever they’re placing there. So you may have multiple codes for that, depending on what type of devices they’re using.
50:08 Next, temporary permanent pacemaker placement. I specifically, haven’t seen this document, and I’m sure some of you on this call may have seen this. But I thought, this was a good one to bring up.
50:21 A patient has a trans, usually, it’s just see, temporary pacemakers in place. But a patient has trans catheter aortic valve. Replacement for. … stenosis find the tavern procedure. The patient developed a complete heart block injunction operate cardia. A temporary permanent pacemaker was placed in the right ventricle, and was removed. Percutaneous Lee a day later the TP pacemaker placement involved insertion of a fixated lead, unlike a temporary trends Venus pacemaker placement, but an additional code be assigned for the lead insertion. So typically when we code these we code the insertion or the performance of the cardiac pacing.
50:57 In this case, we’re gonna also code the insertion of the pacemaker, lead into the right ventricle. And then for the removal, we can code the removal of the cardiac lead from the heart, percutaneous approach, for the removal of the pacemaker lead, from the bite right ventricle.
51:15 Next, I think this is another good topic. I’ve seen a lot of confusion I actually wrote to Coding Clinic, and we’ll get to that in a second. But I actually wrote to Coding Clinic about another example. And I’ll get to that when I’m done discussing this one, but we have trans Bronchioles lung biopsy using Alligator Forceps. So a patient presented for trans bronchitis, lung biopsy due to Hiller left, lymphatic, apathy. And Media National at an apathy, trans Bronco biopsies of a legion of the left upper lobe were performed using alligator forceps.
51:45 The sampling device penetrated the full thickness of the Brachial wall to obtain the biopsy of the lung tissue.
51:50 For biopsy samples were obtained, the surgeon noted that the trends Bronco biopsy technique was carried out because the sampling site was not visible. Endoscopic. Lee is not clear what your operation excision or extraction would be assigned. What is the correct root operation for trans Bronco biopsy of the left upper along using alligator forceps. So typically, when we use forceps, we’re going to be coding that to excision.
52:12 This is the picture of what an alligator forceps looks like. We’re going to assign excision of the left upper low, via natural, or artificial opening, endoscopic diagnostic for this alligator Forceps or a type of cutting tool. Typically alligator forceps or used to remove intact piece of tissue and they use it for sepsis code it to the root operation excision. So when we talk about extraction, we’re talking about needle. Aspirations in which a vacuum inside the syringe causes a collection of individual cells to be suctioned or aspirated into the needle and syringe.
52:44 So we have newer updated coding coding guidance on aspiration, needle aspiration biopsies. I’m can anyone tell me what some other one, what are some other examples of extraction, when we have biopsies again, forceps is, has always been coded to excision extraction. We have a lot more extraction tables now. I mean, they’ve advised us that needle aspirations are coded to extraction, anybody have any thoughts on this?
53:16 What other and or what other issues do you see see when you’re coding your biopsies?
53:33 OK, so we have Nito apps, needle Aspiration. Biopsies are coded to extraction. I’m thinking just, you know, what about brush biopsies? Is that, are those code, it to excision versus extraction? That’s kind of where I was going with this.
53:47 OK, thank you. Someone just commented. So brush biopsies are coded to extraction, kind of a little bit, I didn’t want to bring this up, but I think it’s a good discussion point. That we have another coding clinic. I’m talking about extraction of the bone marrow codes too.
54:03 Or cord needle biopsy codes to co-ordinate a biopsy of the of the bone marrow I think it was in.
54:12 Fourth quarter coding clinic, maybe even first quarter, I forget the exact coding clinic off the top of my head. But I was just having this discussion recently with somebody codes to extraction. But if you go into the index in the code book and you go to core needle biopsy, it takes you to excision. So, I think there’s a bit of a conflict there. So, I’m just letting everyone know that, based on the index, it looks like we should be coding it to excision based on the coding advice. And I think it may have a, do something with the, with, the, the fact that it’s a bone marrow biopsy versus other, you know, lung liver.
54:49 Um, et cetera. So, I did see clarification from Coding Clinic regarding core needle biopsies. I know the method is a little bit different than needle Aspiration biopsies.
55:02 But I did, again, I’m not going to, I don’t have the official advice yet. So, I am not going to discuss that now, I’m just letting you know that I did submit that. And when I do get the advice, I will share it with everyone. I do, I do see different facilities applying that differently.
55:20 So, I just wanted to bring that up. That may be something you want to bring up with your facility to see how people are handling that.
55:27 Again, the Coding Clinic for Bone marrow Core core bone marrow Biopsy.
55:36 For a solid piece of bone marrow, they say to use extraction. If you index, go to your index in the book, core needle biopsy says to see excision diagnostic. So, to me, that’s a bit of a conflict, again, it may have to do with it being a bone marrow versus another site. So, I’m just seeking clarification on that for the feet for future reference. Because I think that’s a little bit confusing.
56:02 So, again, waiting on that response.
56:08 Oh, thank you. So, the coding clinic is root operation for bone marrow biopsy coding clinic, fourth-quarter.
56:16 Is that the right?
56:17 This is a somewhat newer coding clinic I don’t think that’s the right coding clinic.
56:24 Yes. So, needle aspiration biopsies are go to code it to extraction just to clarify that versus a core needle biopsy.
56:34 Finally, we have ankle distraction procedures.
56:39 A patient with post traumatic arthritis of the left ankle was admitted for distraction arthroplasty, an ankle distraction, frame, and ring replied that just a third of the tibia and stabilized with pins. A trans molecular wire was pleased to the tower to identify the center of the rotation and guide the binding building. Sorry, not binding building at the latter. on medial destruction. Hinges a foot ring was attached to the hinges and stabilized the foot and wires through the … and tell her neck.
57:07 The wires were 10 tensioned, and the and the interior locking rod was pleased to hold the ankle neutral position destruction was placed across the ankle at four mm, and bone marrow aspirin stem cells were inserted into the ankle joint. What is the PCS code for distraction arthroplasty of the ankle with application of an external hinged? Fix ader is the procedure a distraction of the ankle joint or the tarsus joint. So they tell us that we should assign reposition of the left ankle joint with external fixation, percutaneous approach for application of external hinged, fixate or distract the ankle. The surgery is performed to move the ankle joint to the neutral position, to allow healing and repair in the mechanical sense. In this case, the distraction involved movement or reposition of the ankle joint. So, there’s a picture of an example of a hinged ankle fixation device for destruction arthroplasty.
57:56 Um, there’s there’s a few different examples that you can find online. That’s the one I just chose for, visual to kind of understand what they’re doing here.
58:07 Again, we want to understand the intent of the procedure. And based on the documentation, of course, we don’t have the Opera report. But based on the the intent of this procedure, it would be ankle joint, instead of the, the tarsus joint.
58:20 Yes.
58:25 In this coding Clinic, we also had a couple of coding clinics regarding frequently asked questions regarding coding clinic. The first one, a patient who had contracted … 19 during the second trimester of pregnancy delivered a healthy newborn, would code is a 28 2 2.
58:44 Exposure to … team be assigned to identify the newborn’s exposure, they say, do not assigned Z 28, 2 2 since the provider documentation does, not indicate the infant was affected by the maternal covert infection, their history of a coded infection.
59:00 So, they say No for that. In that particular case, the question is, What is the correct coding? And sequencing of an immunocompromised patient? With sickle cell disease, who presents and sickle cell crisis triggered by a covered 19 infection? I’ve seen this quite a few times. Not necessarily sickle cell crisis, but other different scenarios, where, you know what condition was triggered by the coven infection. It’s not the You know, it wasn’t a direct effect of the coven, but an underlying condition was triggered. So the sickle cell disease is not a manifestation of …, but the sickle cell crisis is directly linked to covert 19 infection. We’re going to assign the appropriate code from D 57.
59:37 and the use 71, The sequencing would depend on the circumstance of admission. Or The Cove in 19 infection triggered an acute sickle cell crisis. Sickle cell disease is not a manifestation of … in 19.
59:48 So, just another thought process there, when you see that, I’ve seen, actually, I’ve seen that quite a bit, not necessarily sickle cell, but other conditions.
59:59 We also have a question about when a patient receives a transplant from a positive … organ donor. So we have an organ donor that came in, Brain dead who is covered 19 positive patient, accepted the Oregon.
60:17 Since the donor was covered in 19 positive, it was decided anticoagulation was needed due to likely covert 19 viremia and the patient was started on … Heparin. The donor organ was successfully transplant and the patient will start on daily dose of aspirin for three months. As well as due to The Cove. In 19 positive organ donation, is there an ICD 10 CM Diagnosis Code to capture that the recipient received a donor organ that was positive for … in 19 at the time of donations. So, the answer was to sign Z 28 due to exposure to covert 19 to identify that the recipient received a donor organ that was positive for covert 19.
60:52 Also, we have another question about we have those new codes for the … mob, and the I don’t even know how to say this sill, gabba, mob the UVA shelled. There’s a pre-exposure prophylactics treatments, So these are given this, these drugs are given to patients that are either allergic to vaccinations.
61:14 And, or, they have a severe immune compromised status to prevent them from getting Corvair. So, they tell us what, you know, if they’re coming in for treatment of this. For this.
61:28 For this prophylactic treatment we can assign Z 29 8 encounter for other specified prophylactic measures For this pre-exposure prophylactics treatment. Has anyone coded this yet?
61:40 I believe I say, it’s more probably an outpatient thing, but it has anyone come across this yet?
61:50 And I think we’re basically done. So if you have to go, you can go, I’m gonna stay on and answer questions.
61:58 I think this is my last one. So reporting additional diagnosis in the outpatient setting. This is just a clarification I think.
62:04 A lot of us disagreed or were a little bit unclear about the Coding Clinic 2020 page, 33 third, quarter regarding a mental disorder during an ER visit for an unrelated condition. Because the mental disorder was not treat it.
62:19 We’re requesting clarification because this appears to conflict with existing outpatient guidelines. And they say the advice published in third quarter 2020 does not conflict with the official guidelines for coding and reporting.
62:31 So that’s kind of the official answer there for that code, all documented conditions that coexist at the time of the encounter, I think that was, I mean, I don’t really think they clarify it at all. They’re kind of saying the same thing. I think in that case, they didn’t specifically say that. The the medication the patient was on It was for treatment of their mental disorder, I think that’s why kind of where they’re coming from. With that versus someone that, you know, specifically say, I think they reference another coding clinic about Crohn’s disease and they’re on a specific medication for the Crohn’s disease, although, you know, it’s a chronic condition, although they don’t really say how they’re treating it. I guess that’s the difference. So I don’t really think this helps and clarifying that coding clinic at all, but I’m making an assumption there based on my understanding of the guidelines.
63:19 Um, so that’s it for today. I will stay on for questions.
63:25 Or you can download your C by visiting the website on your screen at this point or you can wait for the follow-up e-mail, you do have two weeks from today to download the CEU, please note, these are AHIMA only.
63:38 If you RSI ex employee, please refer to the Yammer group for specific information about CEUs and other coding. Other guidelines and references.
63:48 We do. How’s everything there And all the information you need regarding CEUs.
63:56 So, that’s all I have for today. Please note, that was just, that’s not every single coding clinic. That’s just a high level overview of the coding clinics, just to get it out to everyone and a brief review of the Coding Clinic. So, definitely refer to the whole Coding Clinic for more information.
64:13 So, thanks, everyone. I, again, I will stay on to answer questions as they relate. There’s quite a few questions, so I’m going to answer the ones that relate to specific information in this issue.
64:33 So just scrolling back up here.
64:38 So someone had a question about partial thickness of the epidermis. I would look at your index. I don’t recall the exact terminology, but if you can index specific term terms in the index, I know in some cases, we can, for your ulcers, you’ll have to refer to your your index and refer to if that’s in the index or inclusion notes in your book.
65:02 I don’t know, I would have to look at the book for that for specific to apply that.
65:10 So the question is, referring back to deep tissue injury with with POA of yes the reason this question was asked because we have a guideline to only code the specificity of that deep tissue injury. I can’t recall the exact guideline off the top of my head, but I think that was why that question was asked. You would only code.
65:28 Once it’s revealed you’d only code the specificity, there was another coding clinic that addressed that portion of it, You just code the greater specificity for the stage of, once it’s revealed, you don’t always, it’s not always revealed during a stay, so you don’t always know that, but if it is revealed you just coded the the depth of the deep tissue injury, once it’s revealed.
66:04 Um.
66:11 I think I addressed all the questions about the CEU.
66:20 There’s information on that on the screen at this point if you need more information.
66:33 OK, some, some, some of these are just comments.
66:43 OK?
66:48 OK, so just to clarify, going back to the Hyperloop idea. So of course, if all they document is Hyperloop edema, we can still code the … code.
66:58 You you’re going to be basing this on documentation.
67:02 If they say hypercholesterolemia and …, you know, if they don’t say, one, if they just say, one or the other, you’re going to coach of the specificity, that you have documented a lot of times. We see, you know, they say, both, right. So what are we going to do? if they say both? In that case if they sign hybrid, if they say Hyperloop edema in OneNote and they say, hypercholesterolemia And another note, we can we’re just going to sign the hypercholesterolemia.
67:39 So talking about the chronic kidney disease with mineral bone disease, sometimes those mineral, those those like hyper calcium and things are included in the hyperparathyroidism, off the top of my head. I have to go through the pathway. I think it’s worth hyperparathyroidism like those, some of those no electrolyte disturbances are included or excluded from those. So just be careful with with assigning those codes and check your excludes notes.
68:10 I think I answered this one already, but is class, if class for obesity is class three indexable? No, it’s not at this point, and probably, again, as I mentioned earlier, it probably will be added to the index in the near future.
68:34 Just some more comments. Some people, just so if you’re just to point out, some people have seen class three obesity documented maybe on the anesthesia record.
68:46 So that’s just another place people are seeing it. Document it.
68:49 Yeah, I mean, the that chart that I got. So someone just mentioning if you Google it, cluster is defined as morbid obesity.
68:59 Class 2 and 2, 1, and two are defined as obesity. So that’s where I was going with that.
69:05 They’re not defined as morbid obesity in the, in, in that, in other googling that I did. So I’m just guessing that some doctors may feel that someone’s morbidly obese, if they’re close to. I don’t know.
69:26 OK, another comment, We see a lot of class three obesity documented.
69:37 I see a couple of comments saying, Yay for the segmental and sub segment or PE class clarification.
69:47 So I’m in the so someone’s asking about the comments and questions were in the question. I have no way of letting everyone see the question. There’s no setting and within this platform, to show the questions.
70:08 So … can now apply be spinal to spinal fusions. We have a specific code for pseudo arthritis, right, for spinal fusions. I believe off the top my head we do have a specific code for that.
70:23 If you index that, you should be able to find it.
70:33 Hmm.
70:47 So if there are, if they so the question is about a-fib: if the patient has a history of a-fib and is on …, but it’s not currently experiencing a-fib. Would you code a-fib and long term use of anticoagulant or just the long term use of anticoagulant?
71:01 If there are, I mean, if there are, if there are no longer an a-fib, maybe they had a, a cardioversion or … or maze procedure or something, they could be on the anticoagulant for, something else.
71:13 I don’t really see that that often they usually say they’re on on it for a-fib, I would still consider that treatment or they go in and out of a-fib. Typically they’re also gonna probably be on some type of anti arrhythmic drug.
71:29 If they’ve had a history of some type of ablation procedure or something like that you might want to be careful about picking that a-fib up without supporting documentation that it’s still current condition.
71:41 They may have some other indications for being on anticoagulation besides a history of a-fib.
71:58 I have a question about the difference about pacemaker devices. We can do a whole, whole webinar on that. I’ll note that, I don’t have time to go through that today.
72:12 Um, so, specifically, it’s a fixed. The temporary permanent is fixated.
72:19 It’s actually inserted into the ventricle versus just being trans venus’ in nature.
72:28 For a quick answer.
72:37 Have someone asking a question about post-operative heart block. So if there’s a clear causal relationship, I mean, it depends on the type of heart surgery if they’re doing an ablation and it’s causing a purposely creating that heart block. I would not coded at all, in the case of a task or procedure. They may be having a maze procedure, if they’re purposely inducing a heart block. I would not be coding not, but you’re gonna want to follow the coding guidelines and you want to see a clear causal cause. A causal relationship there if it’s related to the surgery or not?
73:23 No, this isn’t pre recorded. I can’t, I’m answering questions as I go along. I can’t. I’m doing the best I can. I can, I would never get finished with this webinar.
73:37 Church?
73:47 Well, there is, so under the bone marrow, there is a, there is a body part for drainage except I can’t remember if there’s one for excision.
74:02 I don’t have it, I don’t have it. I just thought I’d discuss, I don’t have the Coding Clinic, um, it’s a newer coding clinic. It was based on sort of bone marrow coding clinic. You could probably just search bone marrow and it should come up in your search.
74:15 I don’t have the exact coding clinic up.
74:28 So this is a great question with the two new coding clinics, regarding exposure to covert code, they say, not to code the Z 28 to chew on the newborn chart. So that was because I think that was also because the patient was in their second trial. It was, they had Covidien a History of Kobe. They didn’t actually currently have coven.
74:47 But would you add it to the or So would you add it if the newborn chart if a covert test was administered to the newborn avi? Yes, I would definitely added if they were administered a covert test to the newborn.
75:07 Another question about, baby born in the hospital, mom had a history of covert baby was tested, coven Negative, I would add it, in that case.
75:29 Someone’s asking if there’s a questionnaire once you sign out of once you sign out of the goto Webinar a webinar when I’m trying to a survey should pop up for you.
75:44 Nope, these are not approved for APC.
75:52 For our website and our, our information, it says A AHIMA only.
75:57 If you’re a socs employee, please check Yammer.
76:23 Thank you, everyone. So, I think we’re running, I mean, I’m kind of over by 15 minutes or so, so I’m gonna let everyone go. You can’t read, there is an e-mail address if you need any, other questions answered.
76:38 So, I’m gonna let everyone go and get back to your day. Thank you so much for attending, thank you for your questions. Thank you for participating, it’s always great when you have a lot of questions.
76:48 And you’re, you know, participating in the webinar, so I thank you for that. I’m just gonna read, you know, if you’re you missed it for some reason again, you can download the CEU by visiting the … health resource page. That’s listed on the link on your screen. It’s also in the documents that you can download in the download the handout section. So I will stay on for another two minutes if you need to download that. And also you will receive a follow-up e-mail with a link to download the CEU.
77:22 Yes?
77:26 No problem. You guys are funny. Thank you.
77:51 Alright, I’ll stay on for one more minute.
77:54 If you need to download the documents, again, they’re sent with the follow up e-mail. I know some people don’t get them, so or they have them blocked. So.
78:08 Yes.