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.
We have finished with the step-by-step coding tidbits on coding of spinal fusions. If you were not able to catch Parts 1-13 of this series focused on spinal fusions, please visit hiacode.com/topics/series/spinal-fusion-coding/.
In Part 12, we focused on intra-operative peripheral neuro monitoring used during spinal fusion surgery. In Part 13, we are going to focus on harvesting of autograft and is it coded. Remember in Part 6, we learned that autograft is bone from the patient.
In Part 11, we focused on identifying the computer assisted navigation used during spinal fusion surgery. In Part 12, we are going to focus on intra-operative peripheral neuro monitoring.
In Part 10, we focused on identifying whether or not hardware from a previous spinal fusion is coded. In Part 11, we are going to discuss computer assisted navigation.
In Part 9, we focused on identifying if decompression was also performed and if so, on which body part. In Part 10, we are going to focus on identifying if hardware was removed from a previous fusion site.
In Part 8, we focused on identifying if a discectomy was performed, and if so, if it was a partial or a total discectomy. In Part 9, we are going to focus on identifying if a decompression was performed, and if so, was it of the spinal cord, spinal nerves or both?
In Part 7, we focused on identifying any instrumentation that may be used during a spinal fusion. In Part 8, we are going to focus on identifying if a discectomy is performed and if this is an excision or a resection of the disc.
In Part 6, we focused on identifying the type of bone graft product used for the spinal fusion. In Part 7, we are going to focus on identifying any instrumentation or device used.
In Part 5, we focused on identifying the approach being used for the spinal fusion. In Part 6, we are going to focus on identifying the type of bone graft used for the spinal fusion.
In Part 4, we focused on determining the spinal column being fused. In Part 5, we are going to focus on identifying what approach is being used to complete the spinal fusion (anterior, posterior or both).
This past year, HIA implemented “Buddy Up,” a program designed to help the new hire have a smooth transition into their new HIA roles with the assistance of a “buddy.” What is a Buddy? The Buddy is simply a peer who can guide the new hire in order to make them feel more comfortable. We are very proud of this program and have many success stories that we would like to share. Take a look at the wonderful feedback we have received below.
In Part 3, we focused on determining the level of the fusion(s) and how to determine the number of vertebrae fused. In Part 4, we are going to focus on identifying which column is being fused (anterior, posterior or both).
Part 3: Spinal Fusion Coding — Determine the Level(s) or Region of Fusion and Number of Vertebrae Fused
In Part 1, we learned the diagnoses associated with the need for spinal fusions, and in Part 2 the need to identify if the fusion is an initial or refusion of the vertebrae. In Part 3, we are going to focus on determining the level(s) of fusion, as well as the number of vertebrae fused.
In Part 2, we are going to look at the differences between initial fusion and a refusion. In ICD-9, there were specific codes to show if the fusion was an initial fusion, or if it was a refusion. In ICD-10-PCS, initial fusions and refusion procedures are coded to the same root operation “fusion.”
This is Part 1 of a 14 part series focusing on education for spinal fusions. Spinal fusion coding is a tough job for coders. There are so many diseases/disorders that result in the need for spinal fusion, and even more choices in reporting the ICD-10-PCS codes.
The official definition from the Centers for Medicare & Medicaid Services (CMS) states that a Medicare overpayment is a payment that exceeds amounts properly payable under Medicare statutes and regulations. When Medicare identifies an overpayment, the amount becomes a debt you owe the Federal government.
The question asked in a physician query may be the most important element of the document. Query questions need to be as simple and concise as possible. The physician should have no doubt what the coder is asking.
Coding complications of transplanted organs has always been a coding dilemma. With the implementation of ICD-10-CM that didn’t change. However, coders have multiple directives to help in determining what a complication of the transplant is vs. non-transplant conditions and diseases.
We interviewed our most productive coders, reviewers and members of our education team, asking them what steps they take to find a rhythm that works for them. This week, we talked with Beth Martilik, MA, RHIA, CDIP, CCS, Assistant Director of Education, about the steps she takes to find her routine.
With the implementation of ICD-10-CM came more codes for reporting many different conditions and diseases, and atrial fibrillation is one of those. For many years there was only one code available for reporting this condition, even when the physician further specified the type of atrial fibrillation that the patient had. In ICD-10-CM, there are four codes to report atrial fibrillation.
We have a case where the physician removes mucoid casts found during bronchoscopy. We have also seen mucus plugs removed during bronchoscopy. The MD performs bronchial washings then removes a large amount of tenacious and thick mucoid casts via bronchoscopy. Is this coded drainage, extirpation or excision? What body part is used?
The key to making the query process more efficient is to look for words or documentation while reviewing the record that may signal a potential query opportunity and to note the finding at that time. By the time a coder reaches the end of a record, documentation may have been found to eliminate the need for the query.
Question: This patient is noted to have “Lymphangitic carcinomatosis of lungs with mediastinal lymph nodes.” How would I code the diagnosis? Would I code metastatic cancer to the lung (C78.01) or metastatic cancer to the lymph nodes (C77.1)?
This would be considered a “mechanical” complication of the stent graft since the MD states it is a fracture of the endograft and it is folded over on itself. I would change T82.898A TO T82.598A for Other mechanical complication of other cardiac and vascular devices and implants, initial encounter. I did not use “displacement” because the surgeon did not state that the graft was displaced, only that it collapsed upon itself causing obstruction.
We interviewed our most productive coders and reviewers, asking them what steps they take to find a rhythm that works for them. This week, we talked with Valerie Abney, CDIP, RHIT, CCS, about the steps she takes to find her routine.
Osteoporosis alone is responsible for over a million fractures every year. Stress fractures are not as common but they do occur. There are more than 1 million total joint replacements in the U.S. each year, so there was a need to create codes for injuries that occur around or near the prosthesis. These are called “periprosthetic” fractures.
Back in April, the Office of the Inspector General (OIG) published a report detailing its findings from a review of two groups of high-risk diagnosis codes, acute stroke and major depressive disorder. The objective was to determine whether selected diagnosis codes submitted to the Centers for Medicare and Medicaid Services for use in CMS’s risk adjustment program complied with Federal requirements.
There seems to be differences of opinions on the issue of a 40w0day gestation Can you clarify if P08.21 should be assigned for 40w0day infant or if it would not be assigned unless the infant’s gestation age was 40w1day or greater?
Coders may find situations where a patient is documented as meeting SIRS or sepsis criteria, or has some clinical indicators reflective of possible sepsis, but the physician never documents sepsis as a diagnosis. Should the coder always query for sepsis in these instances?