Coding Tip: Cerebral Infarction When Patient Has Carotid Stenosis
RHIA, CDIP, CCS, CCS‑P, CIRCC
Executive Director Of Education
AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador
Coders have struggled for some time with the dilemma of when to assign the combination code of carotid stenosis, with cerebral infarction (i.e.I63.231) and when to assign separate codes for the specific cerebral infarction and carotid stenosis. (i.e. I66.01 and I65.21). The problem is with how the coder looks at the index and also where the carotid stenosis is, as opposed to where the cerebral infarction is. Also, occlusion is not the same as stenosis in that a patient can have a minimally stenotic carotid that would not cause occlusion of an artery.
What the Index Revels:
When the coder indexes stenosis, carotid the index states “See occlusion carotid.” The coder can see that “with” is linking the cerebral infarction with carotid stenosis in the index:
When the coder indexes infarction, cerebral, there is the term “due to” listed.This means there must be a link by the physician documented. “Due to” is not assumed to exist without physician documentation.
But there is a “see also” note right next to cerebral (cerebral (see also Occlusion, artery cerebral or precerebral, with infarction) I63.9-). If the coder follows that, they will end up with the combination code.
cerebral (see also Occlusion, artery cerebral or precerebral, with infarction) I63.9-
cerebral venous thrombosis, nonpyogenic I63.6
cerebral arteries I63.4-
precerebral arteries I63.1-
cerebral arteries I63.5-
precerebral arteries I63.2-
cerebral arteries I63.5-
precerebral arteries I63.2-
cerebral artery I63.3-
precerebral artery I63.0-
The tabular has this note:
I63 Cerebral infarction
Includes: occlusion and stenosis of cerebral and precerebral arteries, resulting in cerebral infarction
This note is including both occlusion AND stenosis causing cerebral infarction.
Also in the AHA handbook is an example number 28.5 in which a cerebral infarction is linked “with carotid stenosis” and the one combination code, I63.231 is assigned.
What should the coder do?
In reviewing the case from 3Q2018 Coding Clinic page 5, the MI is not coded as associated with a totally occluded coronary artery because the MI is in a different artery. The MI is coded separately from the total occlusion and is not assumed to be related.
Similarly in a case of cerebral infarction with carotid stenosis, the coder should look at CT scans or MRIs to find the location of the cerebral infarction. If the origination is from the carotid stenosis, and it is documented as such, then the combination code would be assigned. However, if the coder sees that the cerebral infarction is in a different artery than the carotid stenosis, or due to another cause, the cerebral infarction would be coded separately with an additional code for the carotid stenosis. The combination code would NOT be assigned. (i.e. I66.01 and I65.21). Cerebral infarctions can be due to other causes such as a thrombus or embolus that are not related to carotid stenosis. Many patients have minimal carotid stenosis but have cerebral infarctions due to other causes.
When it is unclear, and if the facility allows, best practice would be to query the physician to see if the cerebral infarction is related or unrelated to the carotid stenosis. In the interim, if the record is unclear of a relationship between the cerebral infarction and the carotid stenosis, and the facility does not allow query in these cases, it may be best to assign separate codes for the carotid stenosis and cerebral infarction. This is because the code description itself states “Due to” within it. (i.e. Cerebral infarction due to unspecified occlusion or stenosis of unspecified precerebral arteries). HIA is seeking official guidance on this situation.
Coding Clinic 3rd Quarter 2018
ICD-10-CM Official Guidelines for Coding and Reporting
The information contained in this post is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
Coding Tip: New ICD-10-CM General Coding Guideline — Coding for Healthcare Encounters in Hurricane Aftermath
With the Hurricane season in full swing, this new guideline will be helpful in reporting the external cause codes when an injury occurs as a result of the hurricane, and also help in determining sequencing of the reported codes.
The refined Stroke 30-day mortality measure (MORT-30-STK) is a statistic defined as death occurring within 30 days of a diagnosed stroke. The Centers for Medicare & Medicaid Services (CMS) publicly reports a 30-day hospital-level stroke mortality measure on Hospital Compare as part of the Inpatient Quality Reporting (IQR) program.
“Lobar” pneumonia references a form of pneumonia that affects a specific lobe or lobes of the lung. This is a bacterial pneumonia and is most commonly community acquired. Antibiotics are almost always necessary to clear this type of pneumonia.
We have seen a lot of recommendations of late where the coders are coding hydronephrosis, UTI and ureteral stone separately or not with the correct code to include all conditions.
Queries in a Yes/No format are limited to use in the four specific circumstances. This format may not be used when only clinical indicators of a condition are present, but the diagnosis has not been documented in the health record.
Queries written in a multiple-choice format include a short list of options for physician response. These options must be relevant and supported by the clinical indicators included in the query.
Since the implementation of ICD-10-PCS in 2015, yearly changes have been made regarding the definition of, and guidelines associated with, the root operation Control. This has caused coding professionals much confusion in determining whether to assign a procedure to root operation Control, to assign another root operation, or to not assign a procedure code at all.
The policies in the IPPS/LTCH PPS final rule further advance the agency’s priority of creating a patient-centered healthcare system by achieving greater price transparency, interoperability, and significant burden reduction so that hospitals can operate with better…
In this current, ever-changing healthcare climate, health systems face many challenges. Facilities large and small must be dedicated to improving documentation and reducing complications, HACs, infection rates, and readmissions as they endeavor towards value-based care. Coding inaccuracies can really undermine…
It’s imperative, in today’s challenging healthcare environment, that organizations demand complete and accurate coding practices from their vendors if they want: Appropriate and timely reimbursement; Representative quality measures; Improved CMI; Reduction in payor denials and; Mitigation of compliance risks.
In addition to positive clinical indicators documented at the time of admission, any of these that occur within the few days after admission should also be included. This will support the fact that sepsis could have developed after admission. It is important that a POA query give equal attention to what supports POA yes, as well as POA no to avoid the appearance of a leading query.
This major proposed rule addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute.
For example, open the ICD-11 online link and click on “Browse the release version.” Then choose “Coding Tool” tab at the top. We chose “sepsis.” Sepsis without shock is coded to 1G40. Sepsis with septic shock is coded 1G41. A bit different than ICD-10!
Did you know that by coding hypertension with associated CKD correctly along with any surgical dialysis access creation on patients admitted with hypertension, will keep the case out of the AHRQ PQI #07: Hypertension Admission Rate quality measure?
On June 18, 2018, the World Health Organization (WHO) released a preview of its new International Classification of Diseases (ICD-11). ICD-11 will be formally presented at the World Health Assembly on May 2019 for adoption by Member States, and will come into effect the 1st of January 2022. The advanced preview will allow countries to plan how to use the new version to prepare translations and train health professionals.
From a coding perspective, the IABP is not classified as a device such as the VAD’s. The IABP is not coded as a device within ICD-10-PCS and is coded with the root operation of “Assistance.” The ICD-10-PCS code for insertion of an IABP for continuous pumping would be 5A02210, Extracorporeal or Systemic Assistance, Physiologic Systems, Assistance, Cardiac, Continuous, Output, Balloon Pump.
The key to a quality physician query is the question. The question provides direction for the choice of clinical indicators and options for response. So why do so many coders have trouble writing the question? My theory is that coders overthink the question rather than keeping it simple and to the point. The best way to get a physician to answer a query is with a question that makes sense and eliminates guessing as to what is being asked.
Locating ventilator times were difficult in the paper medical record, but has not become any easier with the implementation on the electronic health record (EHR.) Coders should be encouraged to review the record for exact ventilator times. As mentioned above, this could come down to minutes when selecting the correct ICD-10-PCS code.
Hamilton. If you haven’t seen it, you’ve heard of it. The Broadway mega-hit has been the toughest ticket on Broadway since its debut in 2015. For the uninitiated, Hamilton explores the life and triumphs of the previously obscure “ten-dollar founding father,” Alexander Hamilton, through rap, hip-hop, and musical theatre.
Procedure code assignment for excisional debridement has always been a focus area in coding audits. The biggest concern is whether or not the debridement is truly excisional in nature, and if the documentation truly supports an excisional debridement. HIA has written a previous Coding Tip on determining nonexcisional vs excisional debridement.
Beth Martilik, MA, RHIA, CDIP, CCS Assistant Director of Education AHIMA Approved ICD‑10 Trainer and Ambassador The ultimate goal of a physician query is to obtain clarity to physician documentation in the patient’s health record. In order to accomplish this goal,...
Kim Carrier RHIT, CDIP, CCS, CCS-P Director of Coding Quality Assurance AHIMA Approved ICD-10-CM/PCS Trainer New Technology-ICD-10-PCS Section “X” DRUGS Section “X” is a separate place within ICD-10-PCS for certain new technology procedures (such as new technology...
Beth Martilik, MA, RHIA, CDIP, CCS Assistant Director of Education AHIMA Approved ICD‑10 Trainer and Ambassador “A leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or...
Pat Maccariella‑Hafey, RHIA, CDIP, CCS, CCS‑P, CIRCC Executive Director Of Education AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador Bronchoscopy with Removal of Mucus Plugs or Foreign Body HIA has previously discussed the coding of bronchoscopy with...
Most queries are written to clarify documentation as it relates to reimbursement. However, code assignment not only impacts reimbursement, but also other significant uses of coded data. Ideally, queries would be written as necessary to ensure data integrity and full and complete documentation.
The rules about coding probable, possible and questionable diagnoses did not change with the implementation of ICD-10-CM. A possible, probable, suspected, likely, questionable, or still to be ruled out condition can be coded if still documented as such at the time of discharge.
Many organizations routinely perform internal audits as part of a compliance plan. Internal auditors have an insider’s view of the work flow of the organization. Unfortunately, they are auditing their coworkers, friends or employers.
Anyone who has coded or reviewed documentation in a teaching facility is familiar with the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1. This section of the manual contains the guidelines for teaching physicians.
Kim Carrier RHIT, CDIP, CCS, CCS-P Director of Coding Quality Assurance AHIMA Approved ICD-10-CM/PCS Trainer Chronic kidney disease (CKD) is the gradual loss of kidney function. The function of your kidney is to filter waste and excess fluids from your blood and...