Donna Wilson, RHIA, CCS SCHIMA State Coding Roundtable Coordinator

 I would like to know how we should code a Davinci Robotic hysterectomy with bilateral salpingo-oophorectomy?  These are done laparascopically but the physician also goes thru the vaginal to extend the incision and the entire uterus, cervix, tubes and ovaries are detached and brought out through the vagina…  Is this a vaginal hysterectomy or a abdominal hysterectomy?

 AHA Coding Clinic for ICD-9-CM Volume rd Quarter - Number Ask the Editor Prophylactic Organ Removal with Finding of Ovarian Malignancy - page 5

 Question:  The patient is a 56 year-old female who is admitted for a prophylactic robotic-assisted laparoscopic total abdominal hysterectomy and bilateral laparoscopic salpingo- oophorectomy due to a high familial risk for ovarian cancer. A malignancy is subsequently found in the uterus. Should a code for the malignancy be assigned as the principal diagnosis? Or, should a code from category V50.4 be assigned as principal diagnosis?

 Assign code V50.42, Prophylactic organ removal, Ovary, as the principal diagnosis, since this was the reason for admission. Codes 182.0, Malignant neoplasm of corpus uteri, except isthmus, V50.49, Prophylactic organ removal, other, and V16.41, Family history of malignant neoplasm, Ovary, should be assigned as additional diagnoses. For the procedures, assign code 68.41, Laparoscopic total abdominal hysterectomy, code 65.63, Laparoscopic removal of both ovaries and tubes at the same operative episode, and code 17.42, Laparoscopic robotic assisted procedure.

 How would you code possible H1N1 when you will not be receiving confirmation of positive/negative results?  What if the patient has pneumonia would you use or with a secondary code of 486?

 AHA Coding Clinic for ICD-9-CM Volume th Quarter - Number  Clarifications Changes to the Official Guidelines for Coding and Reporting - page 155.

 Code only confirmed cases of avian influenza (code 488.0, Influenza due to identified avian influenza virus) or novel H1N1 influenza virus (H1N1 or swine flu, code 488.1).  This is an exception to the hospital inpatient guideline Section II, H. (Uncertain Diagnosis).

 In this context, "confirmation" does not require:  documentation of positive laboratory testing specific for avian or novel H1N1 influenza.  However, coding should be based on the provider's diagnostic statement that the patient has avian or novel H1N1 (H1N1 or swine flu) influenza.

 If the provider records "suspected or possible or probable avian or novel H1N1 influenza ( H1N1 or swine flu)," the appropriate influenza code from category 487 should be assigned.  A code from category 488, Influenza due to certain identified avian influenza viruses, should not be assigned.

 If the patient has Pneumonia with Influenza unspecified =  If the patient has a provider's diagnostic statement of H1N1 (novel) with pneumonia- then the code assignment would: 

 If the report states “compatible with pneumonia” on the impression can we code the pneumonia on an OP claim?

 Probable or suspected condition in outpatient setting:  Coding Clinic, Third Quarter 2005 Page: 21 to 22 Effective with discharges: September 15, 2005

 Our pathologists and radiologists frequently document interpretations in the outpatient setting with terms such as "consistent with," "compatible with," "indicative of," "suggestive of," and "comparable with." When queried, they state that they are not 100% certain that the patient has the condition. Should we assign a code for these conditions as if they were confirmed? 

 These terms fit the definition of a probable or suspected condition. According to the Official Guidelines for Coding and Reporting (Section IV), in the outpatient setting diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis" are not coded.  Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.

 The new E codes are very confusing and all of the coders I have spoken to are having problems using or feeling comfortable w/them.  We don't know if we are using them correctly.  I was able to find little information online especially about the external cause status(E000.x) section.

 AHA Coding Clinic for ICD-9-CM Volume th Quarter - Number Clarifications  Changes to the Official Guidelines for Coding and Reporting - page 155

 Activity codes (categories E001-E030) are intended to be used to describe the activity of a person seeking care for injuries as well as other health conditions, when the injury or other health condition resulted from an activity or the activity contributed to a condition.  Each facility should adopt a hospital specific guideline for the correct coding of E001- E030).

 Connolly (NC AND SC RAC) found approximately 233 total automated denials for North Carolina.  Approximately 300 total automated denials for South Carolina.  /pages/approved_issues.aspx /pages/approved_issues.aspx

 CMS reports that, to date, more than 100 audit requests have been submitted to CMS for new issue review.  DRG and coding validations are likely to begin in November 2009 at the earliest.

 Donna D. Wilson, RHIA,CCS.  Senior Director.  Compliance Concepts, Inc.   /21/2015 Donna D. Wilson, RHIA,CCS 22