Common ICD-10 Coding Errors Found in Audits: Part 4
The following is the fourth installment in a six-part coding education series from our Executive Director of Education, Patricia Maccariella-Hafey, RHIA, CDIP, CCS, CCS-P, CIRCC. In this series, Patricia reviews common ICD-10 CM and PCS coding errors discovered in audits and how they may impact reimbursement. Part four in our series takes a closer look at common errors in Biopsy Diagnostic Qualifier X and EGD with Biopsy Body Parts.
Before we jump into part four, please note the seven characters for medical and surgical procedures section and their meanings:
10. Biopsy Diagnostic Qualifier X
The problem in this instance is that coders are not applying the 7th character “X-Diagnostic” correctly.
Biopsy Diagnostic Qualifier X: B3.4a
Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic. The qualifier Diagnostic is used only for biopsies.
A colonoscopy with biopsy of transverse colon is coded to root operation Excision and qualifier Diagnostic. If a colonoscopy is done to remove a polyp, and the polyp is sent to pathology, do NOT use qualifier X –diagnostic.
Biopsy with Definitive Treatment: B3.4b
If a diagnostic Excision, Extraction, or Drainage procedure (biopsy) is followed by a more definitive procedure, such as Destruction, Excision or Resection at the same procedure site, both the biopsy and the more definitive treatment are coded.
Biopsy of lesion of the left parotid gland, followed by resection of entire left parotid gland – codes are assigned for both the diagnostic Excision and Resection of left parotid gland.
Example: Excision of RUL of Lung Due to Cancer
Patient has undergone previous CT of the lung with identification of a right upper lobe mass, and patient was scheduled for surgery to remove the mass. Patient is admitted inpatient and undergoes open removal of the mass right upper lobe with margins. The specimen is sent to pathology where adenocarcinoma of the lung is diagnosed. The lung tissue margins are clear. The patient is discharged.
Would the coder assign the 7th character of “X Diagnostic” to the excision code?
No, for the case where a planned mass excision from the right upper lobe is performed, only one code for the excision of the mass is assigned with qualifier Z.
Example: Video-Assisted Thoracoscopic Wedge Resection
History & Physical Examination (H&P): “Mr. XXX is here today to discuss options for diagnosing his progressive diffusing capacity dysfunction, now down to 59% predicted. He has significant exposure history including smoking. Previous FOB/BAL showed eosinophilia and was thought to be related to medications that has since been stopped. He is here to discuss tissue diagnosis… Mr. XXX has what appears to be progressive and diffuse pulmonary interstitial disease. There is volume loss in the right hemi thorax. No significant mediastinal lymphadenopathy. Would agree with tissue sampling to make a definitive diagnosis of the cause of the fibrosis…”
Op note: “…Right-sided video-assisted thoracoscopic exploration with wedge resection of the middle lobe and the upper lobe…”
Indication for the procedure: “…an unfortunate 68-year-old gentlemen who presents with worsening SOB and dyspnea on exertion. He has undergone bronchoscopy in the past with biopsies, brushing and cultures and these have been diagnostic. His disease has progressed and he was therefore, referred for possible tissue biopsy.”
Op note: “… I palpated the lung, and along with the tactile stimulus, as well as CT scan findings, the areas were chosen in the upper lobe, as well as the middle lobe for biopsy. An Endo-GIA stapler was used to divide these small portions of lung from the remainder of the lung. These both were placed in an EndoCatch pouch. A small portion of each specimen was sent for microbiology and gram stain, culture and sensitivity. The remaining majority of the specimen was sent for permanent analysis.”
Pathology: Lung, right middle lobe, wedge biopsy shows advanced interstitial pneumonia with a usual interstitial pneumonia pattern.
11. EGD with Biopsy Body Parts
The problem is that many times during EGD, the physician biopsies the antrum of the stomach. ICD-10-PCS assigns this body part to stomach, pylorus.
Antrum of Stomach classified as Pylorus
The index says for pyloric antrum, use stomach, pylorus. This includes pyloric antrum; pyloric canal and; pyloric sphincter.
Dorland’s Medical Dictionary states: “antrum, pyloric is the dilated portion of the pyloric part of the stomach, distal to the body of the stomach and proximal to the pyloric canal. It is also called also gastric antrum and antrum of stomach… “pylorus, the distal aperture of the stomach, opening into the duodenum, variously used to mean pyloric part of the stomach and pyloric antrum, canal, opening or sphincter.”
EGD with Biopsy of Antrum: 0DB78ZX
The information contained in this coding advice is valid at the time of posting. Readers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
In the past, there had been an Excludes1 note at I46.- Cardiac arrest that excluded R57.0, Cardiac shock. HIA had also received a letter from AHA on a case in the past that had stated that only I46.- Cardiac arrest would be coded if both were documented. In addition, the Third Quarter Coding Clinic page 26 had a similar case that asked if both could be coded, and AHA had instructed that only I46.9, cardiac arrest, cause unspecified would be coded if both were documented and that the CDC would be looking at possible revision to the Excludes1 note.
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In previous parts of this series we looked at the definitions of AKI/ARF, causes, coding and sequencing, and the common clinical indicators that patients present with that are diagnosed with this condition. In Part 4, we will look at the documentation that should be present to report the diagnosis without fear of denial, as well as when a query is needed to clarify the diagnosis.
If the facility does a COVID-19 test, and test is negative, do I need a diagnosis code. The answer is yes, you will report a Z-code. The Z-code depends on the record documentation and circumstances of testing. For any patient receiving a COVID-19 test, if negative, there MUST e a Z-code to describe why the test was taken. (Test negative for COVID-19 and MD does not override negative results).
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With the proliferation of COVID-19 cases, we thought we would put together a quick reference listing of some of the common scenarios that coders have asked about. As with all coding, coders should follow Official Guidelines for Coding and Reporting and the COVD-19 Frequently Asked Questions document by the AHA.
Effective March 1, Medicare will pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, not just services related to COVID-19. This great for providers whose patients are reluctant to visit the office.
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Effective with 4/1/2020 discharges, ICD-10-CM code U07.0 is used to report vaping -related disorders. ICD-10-CM code U07.0 (vaping related disorder) should be used when documentation supports that the patient has a lung-related disorder from vaping. This code is found in the new ICD-10-CM Chapter 22. U07.0 will be in listed in the ICD-10-CM manual under a new section: Provisional assignment of new disease of uncertain etiology or emergency use.
The US government and public-health officials are urging consumers to utilize telemedicine for remote treatment, fill prescriptions and get medical attention during the new coronavirus pandemic. The goal is to keep people with symptoms at home and to practice social distancing if their condition doesn’t warrant more intensive hospital care.
Coronavirus: Tips for working from home. Companies around the world have told their employees to stay home and work remotely. Whether you’re a new to this concept or a work from home veteran, here’s some tips to staying productive from our #HIAfamily.
This is the final part of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. In this part, we provide an actual example of an effective communication response to CDI.
This is part two of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. In this part, we discuss mismatches and how to best go about resolving them. In part three we will provide a case example of best practice interaction.
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The HIM world has been buzzing recently with discussion of “Social Determinants of Health” and coded data. What does this mean for coders and the HIM field?
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