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REVIEW OF CODING CLINIC 1ST AND 2ND QUARTER 2011

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Presentation on theme: "REVIEW OF CODING CLINIC 1ST AND 2ND QUARTER 2011"— Presentation transcript:

1 REVIEW OF CODING CLINIC 1ST AND 2ND QUARTER 2011
Stephanie Carlisto, RHIT, CCS

2 BORDERLINE DIABETES MELLITUS AND BORDERLINE DIAGNOSES
How do you code a diagnosis of borderline diabetes? Borderline diagnoses Code should be based on information in the chart. Physician may need to be queried but without any confirmation, assign a code of 790.2, abnormal glucose. Advice for example of pulmonary hypertension is to, as with diabetes, depending on the documentation on the chart as to whether to code it, or query the physician. If there is no information on the chart to warrant a query, go with the abnormal glucose. If there is, then you may want to query the physician. Same rule applies to borderline diagnoses. That is why it is so important to review the entire chart when the documentation is not clear.

3 CHRONIC ANEMIA Coding clinics advice regarding how to code “chronic anemia” is to code it to , Anemia, unspecified.

4 Broken catheter tip retrieved via thrombectomy
The question asked pertains to how to code a broken catheter tip that occurred during an aspiration of a thrombus. In the question posed, the broken tip was removed. Advice is to assign code 996.1, Mechanical complication of other vascular device, implant, and graft. However, if it cannot be removed, you would assign and 998.4, Foreign body accidentally left during a procedure. There was discussion and physicians felt that if they knew about the broken tip, and removed it, it shouldn’t have to be reported. However, coding clinic stated that for quality of care and quality reporting purposes, it must be reported regardless

5 Chest radiograph showing the embolized catheter fragment (black arrowheads) lodged in the left pulmonary artery. Chest radiograph showing the embolized catheter fragment (black arrowheads) lodged in the left pulmonary artery. Thanigaraj S et al. Chest 2000;117: ©2000 by American College of Chest Physicians

6 Broken needle left during surgery
The example given here was a needle that was lost within the tissue during an aortic valve replacement. After evaluation and a second attempt to retrieve the needle, the surgeon decided it was in the patient’s best interest to leave it alone. As removing it could cause more harm. Advice is to code 998.4, Foreign body accidentally left during a procedure. Though it was decided to leave the needle in, it was not the intent of the original procedure to leave a foreign body behind. Once again for quality purposes, you must report such events. Difference here is if it’s removed you have the one code for mechanical complication, and if it’s not, you must report FB accidentally left in.

7 CHRONIC DEEP VENOUS EMOBISM AND THROMBOSIS
The question here is when does a venous thrombosis become chronic? The answer given is that there are no specific timelines regarding this and assignment of chronic DVT should be based on the providers documentation. Lower-extremity venogram shows a nonocclusive chronic thrombus. The superficial femoral vein (lateral vein) has the appearance of 2 parallel veins, when in fact, it is 1 lumen containing a chronic linear thrombus. Although the chronic clot is not obstructive after it recanalizes, it effectively causes the venous valves to adhere in an open position, predisposing the patient to reflux in the involved segment.

8 CHRONIC VENOUS EMBOLISM AND THROMBOSIS
Should a patient with a history of DVT receiving Coumadin be coded to a history of DVT V12.51, or 453 category for chronic DVT? Query for clarification whether Coumadin is being given prophylactically to prevent a recurrence of the DVT or as treatment for a chronic DVT. Either code may be appropriate. Query for clarification whether it’s being given prophylactically or if it is a treatment for a chronic DVT. Pt. may be susceptible to a recurrence. According to the Official Coding Guidelines, “personal history codes explain the patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require monitoring.”

9 CHRONIC VENOUS EMBOLISM AND THROMBOSIS
Reference is made to the Official Guidelines for Coding and Reporting, “Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require monitoring.”

10 CODE ASSIGNMENT BASED ON UP AND DOWN ARROWS
Advice from Coding Clinic regarding up and down arrows applies to both inpatient and outpatient admissions. It is not appropriate to report a diagnosis based on up and down arrows. Rational being, they do not necessarily mean “abnormal.” They may just be indicating a change. If findings on chart warrant a query, then query the provider. For example, if the physician documents +ETOH does that mean the patient is an abuser, an alcoholic, a social drinker? Does +Na mean hypernatremia or that the patient’s sodium is going back up? Provider needs to write out hyper, hypo, We can’t make assumptions with symbols. It must be clearly documented.

11 DISSECTION OF ARTERY OCCURRING DURING CORONARY ANGIOPLASTY
When a dissection occurs during a PCI (percutaneous coronary intervention), and the physician documents it as a complication, code it to Cardiac complications, and assign code Dissection of coronary artery to further describe the complication. Accidental puncture or laceration would not be appropriate as there was no documentation of an accidental vessel puncture during the intervention. In most cases, the dissections are minor and insignificant clinically and don’t interfere with blood flow within the vessel. Must be documented as a complication by the provider in order to code it.

12 GASTRIC BAND EROSION WITH INFECTION
Gastric band erosion and infection Mechanical complication Other specified disorders of stomach and duodenum Infection and inflammatory reaction due to device or implant The erosion occurs from the band wearing against the stomach wall, and it cuts through the wall into the stomach. When it erodes into the stomach, bacteria from the stomach can enter under the band and an infection can occur. It is appropriate to assign as many codes as necessary to capture the compete clinical picture. Tell the story… When perforation occurs without infection, use and

13 —25-year-old woman presented for re-inflation of band placed 5 years ago. While inflating band, patient experienced acute pain. CT scan and endoscopy show band partially inside gastric lumen. —25-year-old woman presented for reinflation of band placed 5 years ago. While inflating band, patient experienced acute pain. CT scan and endoscopy show band (arrow in CT) partially inside gastric lumen. Mehanna M J et al. AJR 2006;186: ©2006 by American Roentgen Ray Society

14 IATROGENIC PNEUMOTHORAX
The question is, “does the provider need to document a pneumothorax is a complication before you can assign 512.1?” Coding Clinic’s response is, it must be documented as a complication in order to code it as one, or stated as “Iatrogenic.” The guideline for complications extends to any complications of care, regardless of the chapter the code is located in.

15 PANCYTOPENIA DUE TO DRUGS
When documentation in the chart states “pancytopenia due to chemotherapy” assign code , Other specified aplastic anemias, along with the appropriate E-code to identify the drug. This answer is based on the instructional note under code which states that drug induced pancytopenia is classified to code Pancytopenia is a deficiency of all types of blood cells, including white blood cells, red blood cells, and platelets. It occurs when your body cannot produce enough blood cells because the bone marrow stem cells that form blood cells do not function normally. Pancytopenia has widespread effects on the entire body by leading to oxygen shortage as well as problems with immune function. Aplastic anemia is a medical term that refers to a decrease in production of all types of blood cells.

16 LAPAROSCOPICALLY-ASSISTED HEMICOLECTOMY
When a hemicolectomy is performed with laparoscopic assistance, code V64.41, Laparoscopic surgical procedure converted to open procedure would not be appropriate to code. Rationale is it was a planned laparoscopic- assisted surgery. Correct code assignment would be 45.73, Open and other right hemicolectomy The case involves the planned use of the laparoscope to assist in visualizing the surgery. There is also a smaller incision involved so it may help speed the patient’s recovery time. It is not a true laparoscopic procedure, and it’s included in the “other” part of code

17 POSTOPERATIVE ASPIRATION PNEUMONIA
When there is a diagnosis of postoperative aspiration pneumonia it is appropriate to code both the respiratory complication code and the aspiration pneumonia code Respiratory Complications and Pneumonitis due to solids and liquids, Due to inhalation of food or vomitus. Since the title of code is broad and covers many types of respiratory complications, coding the aspiration pneumonia provides more specificity regarding the type of respiratory complication there was.

18 POSTOPERATIVE HEMORRHAGE AND POSTOPERATIVE HEMATOMA
Before coding any postoperative hemorrhage or hematoma as a complication of care, it must be explicitly documented by the physician that the condition is a complication. Once again, if the indications on the chart are that the hemorrhage or hematoma required clinical evaluation, therapeutic treatment, diagnostic procedures, or increased nursing care and/or monitoring it is appropriate to query the provider. There was concern that there is inconsistency in hospital coding of post op hemorrhages and hematomas because they affect data quality. Guidance from coding clinic leads us back to the Guidelines. Not all conditions that follow surgery are necessarily complications. They may be an expected occurrence or condition. Coders are not the ones to make that determination. All we can do is take the information on the chart and determine if we should get clarification from the physician by querying using the hints here as to whether it met any of this criteria.

19 ACUTE RENAL FAILURE AND END STAGE RENAL DISEASE
Acute renal failure and end stage renal disease (ESRD) can occur during the same hospital encounter with the presence of trauma, adverse effects of medication, infection, volume depletion or whatever may cause the kidneys to stop functioning. It is appropriate to code both if they are documented. Refers us back to CC 3rd q pg 15 which tells us when they are both clearly documented, it is appropriate to code both. Renal spec who clarified that the patient didn’t have end stage. Any doubt or conflict query.

20 BACTEREMIA DUE TO PICC LINE ANNULAR DISC TEAR EMBOLIZATION OF GASTRODUODENAL ARTERY WITH COILS
Code reason for encounter (pdx) and then bacteremia due to PICC line as secondary diagnoses also code the type of bacteria if documented Infection due to central venous catheter Bacteremia Other Staphylococcus Any tear to the annular portion of a vertebral disc is coded as degeneration whether documented as traumatic or non traumatic In the example given, the patient was admitted for ac on chr resp failure. The doctor noticed the picc site had a mold like substance and ordered blood cultures which came back positive for staph epidermidis. The physician was queried about the infection due to the picc and he documented that the bacteremia was probably due to the PICC. In this case, the patient didn’t exhibit any signs of sepsis and the doctor just happened to notice the picc had a mold like substance. Documentation on the chart warranted the query for the relationship of the picc to the bacteremia. PDX is still ac on chr resp failure as the reason for the encounter. The usual cause of annular tearing is from a combination of degeneration and trauma; although, genetics may have an influence on the development of this syndrome. The surgical introduction of various substances into the circulatory system to obstruct specific blood vessels. Pt had empiric embolization of the gastroduodenal artery with multiple pushable coils. Assign code transcatheter embolization for gastric or duodenal bleeding

21 CYSTOCELE REPAIR W/MESH AND RECTOCELE REPAIR W/SUTURES
When one repair is done with mesh and the other done with sutures, it is appropriate to use 2 codes to describe what was done Repair of rectocele Repair of cystocele with graft or prosthesis In this example, you would not use repair of cystocele and rectocele with mesh, because one was done with sutures. To accurately code both 2 codes are required.

22 DYNESYS DYNAMIC STABILIZATION DEVICE WITH FUSION
Fusion devices were designed to provide rigid stability to the spine while boney incorporation of the fusion mass was achieved. The goal of the new generation of devices is to allow controlled motion in such as way as to achieve more normal movement of the spine.

23 EXCISIONAL DEBRIDEMENT OF BUTTOCK ABSCESS
Documentation in this example is an incision being made into the abscess and stating it was “extensively excised.” Direction is to code 86.22, Excisional debridement of wound, infection, or burn. The incision in this example being an important component to the definitive procedure which is the excisional debridement. Look for key terms to describe the procedure. Even though he talks about incising the abscess to get inside and break up all of the cavities within the wound, he does mention excision in his narrative.

24 MAPPING AND ABLATION OF ATRIAL TACHYCARDIA VIA TRANSEPTAL APPROACH
The approach does not play a part in assignment of the codes for this procedure. Code 37.34, Catheter ablation of lesion or tissue of heart for the ablation 37.26, Cardiac electrophysiologic stimulation and recording studies 37.27, Cardiac mapping

25 THROMBOSIS OF FEMORAL POPITEAL BYPASS GRAFT
To describe this condition it is appropriate to use 2 codes , Other complications of internal (biological) (synthetic) prosthetic device, implant, and graft, Due to other vascular device, implant and graft , Arterial embolism and thrombosis, Lower extremity The instructional note at subcategory instructs the coder to “use additional code to identify complication such as venous embolism and thrombosis. Not due to disease, but a clot formation.

26 PROPHYLACTIC BILATERAL MASTECTOMY DUE TO POSITIVE BRCA MUTATION
Assign code V50.41, Prophylactic organ removal, Breast as principal diagnosis And V84.01, Genetic susceptibility to malignant neoplasm of breast If patient has a history of breast cancer, assign code V10.3, Personal history of malignant neoplasm, breast The BRCA1 gene belongs to a class of genes known as tumor suppressor genes. BRCA1 regulates the cycle of cell division by keeping cells from growing and dividing too rapidly or in an uncontrolled way. It inhibits the growth of cells that line the milk ducts in the breast. More than 600 mutations in the BRCA1 gene are known. Many are associated with an increased risk of cancer. These mutations can be changes in one or a small number of DNA base pairs, or, in some cases, large rearrangements of DNA. A mutated BRCA1 gene usually makes a protein that does not function properly because it is abnormally short. The defective BRCA1 protein is unable to help correct mutations that occur in other genes. These defects accumulate and may allow cells to grow and divide uncontrollably to form a tumor. Also depending on history of radiation for tx of ca assign V15.3

27 MEDICAL MARIJUANA METHADONE MAINTENANCE
Assign code V58.69, Long-term use of other medications, for marijuana taken for medicinal purposes. Assign code , Opioid type dependence, unspecified for patients who are on methadone maintenance because of heroin addiction. The difference here is the marijuana is being prescribed for the patient for medicinal purposes. In the case of methadone maintenance, it is being used for a maintenance program to prevent the patient from going through withdrawal symptoms for heroin addiction. Official Guidelines state that subcategory V58.6 is not used for detox or maintenance.

28 PERINATAL PERIOD The perinatal period ends on the 29th day of life. The day of birth is counted as “0” days.

29 HIGHLIGHT OF WHAT’S COMING FOR 3RD AND 4TH QUARTER
Aftercare following organ transplant versus follow-up following surgery Assignment of code for newborn (perinatal) conditions Bronchial biopsy versus lung biopsy Failed transbronchial lung biopsy Clinical significance of obesity and coding of BMI Correct application of nonessential modifiers Acute kidney injury, diabetic nephropathy and chronic kidney disease, stage III Lupus nephritis and acute renal failure Sepsis with an underlying localized infection Plus, highlights of FAQs from FY 2012 code changes

30 QUESTIONS?


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