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Presentation on theme: "REVIEW OF CODING CLINIC 1 ST AND 2 ND QUARTER 2011 Stephanie Carlisto, RHIT, CCS."— Presentation transcript:


2 BORDERLINE DIABETES MELLITUS AND BORDERLINE DIAGNOSES How do you code a diagnosis of borderline diabetes? 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. Borderline diagnoses 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.

3 CHRONIC ANEMIA Coding clinics advice regarding how to code chronic anemia is to code it to 285.9, 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.

5 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 patients 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.

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.

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.

9 CHRONIC VENOUS EMBOLISM AND THROMBOSIS Reference is made to the Official Guidelines for Coding and Reporting,Personal history codes explain a patients 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 meanabnormal. They may just be indicating a change. If findings on chart warrant a query, then query the provider.

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.

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

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. 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 Clinics 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 statespancytopenia 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

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

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.

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.

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.

20 BACTEREMIA DUE TO PICC LINE ANNULAR DISC TEAR EMBOLIZATION OF GASTRODUODENAL ARTERY WITH COILS Any tear to the annular portion of a vertebral disc is coded as degeneration whether documented as traumatic or non traumatic Assign code transcatheter embolization for gastric or duodenal bleeding 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

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


23 EXCISIONAL DEBRIDEMENT OF BUTTOCK ABSCESS Documentation in this example is an incision being made into the abscess and stating it wasextensively 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.

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

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

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.

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

29 HIGHLIGHT OF WHATS COMING FOR 3 RD AND 4 TH 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


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