Coding Tip: Unspecified Condition Codes and Combination Codes
Pat Maccariella‑Hafey
RHIA, CDIP, CCS, CCS‑P, CIRCC
Executive Director Of Education
AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador
One area that coders struggle with is when to report a separate condition code when an already assigned combination code includes the condition. For example, if an obstetric patient is admitted and delivers, and the physician documents “obstetric patient delivered with anemia,” should both code O99.02 Anemia complicating childbirth and D64.9, Anemia, unspecified be coded or should only O99.02 be assigned?
The answer is that only code O99.02, Anemia complicating childbirth should be assigned. Coders may argue that there is a “code also” note under O99.- in the tabular that states “Use additional code to identify specific condition.” However, note the word “specific” in that note In our case, the unspecified anemia is not a specific type of anemia, so an additional code would NOT be assigned. Had the physician documented “iron deficiency anemia” then code D50.9, Iron deficiency anemia would have been coded since this is a specific type of anemia.
The same would be true in an obstetric delivery patient in which the physician documented “obesity complicating pregnancy.” Code O99.214, Obesity complicating childbirth would be coded, however it would be unnecessary to code E66.9, Obesity, unspecified as it is not a specific code. Code O99.214 already has “obesity” within the combination code. Had the physician documented “morbid obesity,” then code E66.01, Morbid obesity would be added as it is a specific code.
References That Support the Decision
There are several references that support the above determination. Coding Clinic, Third Quarter, 2018, page 4 has an example of diabetic atherosclerotic peripheral artery disease. It was asked if the specific I70.2- code should also be coded. AHA replied to only code the E11.51 code unless an additional code provides specificity about the atherosclerosis, such as the vessel, manifestations or laterality. “Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis. When the combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code.”
In Coding Clinic, First Quarter, 2017, page 25, the advice is to NOT report unspecified, uncomplicated asthma code J45.909 with COPD code J44.9, as it isn’t a type of asthma.
In the AHA Handbook, Chapter 24, it states “When a code from chapter 15 describes the condition adequately, only that code is assigned. It is appropriate, however, to assign an additional code when it provides needed specificity.”
So in summary, the coder should NOT report a secondary code for a condition that is already included in a combination code, unless that secondary code provides specificity of the that condition.
References
AHA Coding Clinic, Third Quarter, 2018, page 4
AHA Coding Clinic, First Quarter, 2018, page 16
AHA Coding Clinic, Fourth Quarter, 2017, page 96
AHA Coding Clinic, First Quarter, 2017, page 25
AHA ICD-10 Coding Handbook, Chapter 24, Other Conditions Complicating Pregnancy, Childbirth, or the Puerperium
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.
Popular Posts
Part 6: Spinal Fusion Coding — Identify the Type of Bone Graft Used for Fusion
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.
Part 5: Spinal Fusion Coding — Identifying the Approach Being Used for 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).
HIA Launches Buddy Up Program for New Hires
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.
Part 4: Spinal Fusion Coding — Identifying the Column Being Fused
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.
Subscribe to our weekly newsletter
Latest News
Part 6: Spinal Fusion Coding — Identify the Type of Bone Graft Used for Fusion
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.
Part 5: Spinal Fusion Coding — Identifying the Approach Being Used for 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).
HIA Launches Buddy Up Program for New Hires
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.
Part 4: Spinal Fusion Coding — Identifying the Column Being Fused
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.
Part 2: Spinal Fusion Coding — Initial Fusion or Refusion
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.”
Part 1: Spinal Fusion Coding — Diagnoses Responsible
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.
What’s the Best Defense? A Good Offense
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.
Query Tip: Writing a Query Question – Simple and Concise is the Key
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 Tip: Coding Complications of Transplanted Organs
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.
Find Your Routine: Take Advantage of Educational Opportunities
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.
Coding Tip: Atrial Fibrillation
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.
Coder Q&A with Pat Macc: Mucoid Casts and Mucus Plugs
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?
Query Tip: How to Be More Efficient
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.
Coder Q&A with Pat Macc: Metastatic Cancer
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)?
Coding Tip: Root Operation Selection Excision vs. Resection
Coding these can be challenging for coders when trying to decipher the operative notes and terms that are used. The physicians are still using the terms excision and resection interchangeably and review of the entire operative note is required to select the appropriate root operation. Remember, it is the coder’s responsibility to determine the root operation based on the details from the physician in the operative report.
Coder Q&A with Pat Macc: Collapse of an Endograft
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.
Find Your Routine: Be Flexible, Not Frustrated
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.
Coding Tip: Periprosthetic Fracture Reporting and Sequencing
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.
OIG Takes Notice of Coding Errors
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.
Coder Q&A with Pat Macc: Coding for Newborn
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?
Query Tip: When to Query for Sepsis
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?
Coder Q&A with Pat Macc: Principal Dx Selection
In this example, would it be appropriate to code the complication code T82.03XA, Leakage of heart valve prosthesis, initial encounter as the principal diagnosis over the HFpEF (heart failure exacerbation) code?
Keeping a Healthy CMI
A higher CMI corresponds to increased consumption of resources and increased cost of patient care, resulting in increased reimbursement to the facility from government and private payers, like CMS. We know that documentation directly impacts coding.
Coding Tip: Spinal Procedures Reported in Addition to the Fusion
With the implementation of ICD-10-PCS more codes were developed in order to accurately report procedures. Spinal fusion coding is still a problematic coding issue and at times, even a coder’s nightmare. Coders often report only the code for the fusion thinking that one code would include all of the other procedures that are performed.
Coder Q&A with Pat Macc: Procedure Coding for a Breast Procedure
Answer: I would code 0HPT0NZ for removal of tissue expander from right breast, open and change 0HPT0JZ, removal of synthetic substitute from right breast, open, for removal of the acellular dermal matrix to 0HPT0KZ, Removal of nonautologous tissue substitute from right breast, open approach.
Coding Tip: “Code First” Instructional Notes in ICD-10-CM
There are certain conditions that have instructional notes in the ICD-10-CM tabular/coding conventions that guide the coder in sequencing. This is especially true when the condition has a common manifestation or underlying conditions of a chronic disease. If there is a “code first” note in the tabular, the coder should follow this instruction and sequence the underlying etiology or chronic condition first followed by the manifestation as an additional diagnosis.
Find Your Routine: Tools to Tackle Unpredictable Days
When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our series, Find Your Routine, we interviewed our most productive coders and reviewers and asked them what steps they take to find a rhythm that works for them. This week, we talked with Meghan Schumacher, CPC, CPMA, Provider Coding Consultant at Health Information Associates, Inc., about the steps she takes to find her routine.
Time is Money
Last year, the Office of Inspector General (OIG) performed an investigation that found, “between 2014 and 2016, Medicare Advantage organizations overturned 75% of their preauthorization and payment denials upon appeal,” which is why, at HIA, we always advise our clients to engage in the appeals process.