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.
Why are so many AKI records being denied? It’s hard to give one answer for why so many AKI records are being denied lately, but most appear to be due to the multiple sets of criteria available for use in determining if a patient has AKI, as well as physician documentation. As stated in Part 3 of this series, there are three main criteria/classifications used to diagnose AKI.
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).
In the first parts of this series we looked at definitions of AKI/ARF, causes, coding and sequencing. In Part 3, we will look at what clinical indicators would possibly be present to support the diagnosis of AKI/ARF.
The FY2021 IPPS Proposed Rule is out and here are some highlights from it regarding ICD-10 Code proposals. We will know if these changes are permanent after the public comment period is over on July 10, 2020 and CMS prepares the Final Rule, usually out by August 1.
As discussed in Part 1 of this series, AKI/ARF is a common diagnosis that coders see daily. In Part 2, we are going to focus on the different types/specificity of AKI/ARF. We’ll learn what they mean, as well as how to code the diagnosis.
This is part 1 in a series focused on coding of acute kidney injury (AKI) and/or acute renal failure (ARF). AKI/ARF is reported often, but is also one of the most common diagnosis found in denials.
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.
The biggest reasons why some hospital systems are moving to single path coding is to eliminate duplicative processes and to optimize productivity. In addition, costs are reduced when only one coder “touches” the record and completes both types of coding.
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.
This is part one of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. Many times these departments are separate and the remote environment makes it difficult to interact efficiently between the two departments. In part one, we will discuss the history and objectives of CDI so the coder has a better understanding of CDI’s role.
One reason that coders should report chronic conditions (including history and status codes) on outpatient records is the HCC’s—Hierarchical Condition Categories. The quick and easy explanation of what HCC’s are is each HCC is mapped to certain ICD-10-CM codes or code ranges. HCC coding is designed to estimate future health care costs for patients.
For Part 5 of this 5-part series, we will look at Chapter 4 within ICD-10-CM—E00-E89—Endocrine, Nutritional, and Metabolic Diseases. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 4 of this 5-part series, we will look at Chapter 10 within ICD-10-CM—J00-J99—Diseases of the Respiratory System. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 3 of this 5 part series, we will look at Chapter 9 within ICD-10-CM—I00-I99—Diseases of the Circulatory System. This chapter contains so many of the everyday diagnoses that we code such as hypertension, heart disease and stroke.
For Part 2 of this 5-part series, we will look at Chapter 1 within ICD-10-CM—A00-B99—Certain Infectious and Parasitic Diseases. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 1 of this 5-part series, we will look at Chapter 21 within ICD-10-CM—Z00-Z99—Factors influencing health status and contact with health services. There is no possible way to include every guideline or coding reference for this chapter, but I’ll do my best to touch on some off the most common issues.
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?
The Centers for Disease Control and Prevention (CDC) is in process of developing a new code for the COVID-19 (coronavirus) that will be released October 1, 2020. In the meantime, the CDC has provided advice on coding the COVID-19 coronavirus.
We’re finally at the #1 most common DRG with recommendations by HIA for 2019. Just to recap, HIA reviewed over 50,000 inpatient records in 2019. Most have probably already guessed what the correct DRG would be with the most recommendations. There are just some diagnoses and DRG’s that will always be a thorn in the side for coders. #1 DRG with the most recommendations during HIA reviews : DRG 871—Septicemia or severe sepsis w/o mechanical ventilation >96 hours with MCC
We’re now at the second most common DRG with recommendations by HIA for 2019. Just to recap, HIA reviewed over 50,000 inpatient records in 2019. We are counting down to # 1. #2 DRG with the most recommendations during HIA reviews: DRG 872—Septicemia or severe sepsis w/o mechanical ventilation >96 hours w/o MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #3 DRG 190—Chronic obstructive pulmonary disease with MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #4 is DRG 193—Simple pneumonia & pleurisy with MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #5 DRG with the most recommendations during HIA reviews : DRG 853—Infectious & Parasitic diseases with O.R. procedure with MCC