Knowledge Base Category -

Question

If a provider has documented diabetes and arthritis, can we code it to diabetes with arthropathy (E11.618)?

Diabetes, diabetic (mellitus) (sugar) (E11.9)

with

arthropathyNEC(E11.618)

Answer

No. Even though the ICD-10 Alphabetic Index has an entry for ‘Diabetes with Arthropathy NEC’, the provider needs to document the relationship between the two conditions; we cannot assume a causal relationship when a diabetic complication is “NEC”.

The “with” guideline does not apply to “not elsewhere classified (NEC)” conditions indexed to broad categories. The specific condition must be linked by the terms “with”, “due to” or “associated with”.

Arthropathy is a general term for any condition that affects the joints. There are many different types of arthropathic conditions that may not be due to diabetes. To link diabetes and arthritis, the provider needs to document the condition as a diabetic complication.

Please be aware of all diabetic NEC complications listed in the Alphabetic Index:

• Arthropathy NEC
• Circulatory complication NEC
• Complication, specified NEC
• Kidney complications NEC
• Neurologic complication NEC
• Oral complication NEC
• Skin complication NEC
• Skin ulcer NEC

References:

• ICD-10-PCS Official Coding Book
• Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2017: Pages 100-101
• Coding Clinic for ICD-10-CM/PCS, Second Quarter 2018: Page 6

Question:

How do we bill mammography services when a beneficiary undergoes a screening and diagnostic mammogram on the same day?

Answer:

According to the MLN educational tool: Medicare Preventive Services (https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html#MAMMO), “if you perform and bill a screening mammogram and a diagnostic mammogram on the same day, use modifier -GG to show a screening mammography turned into a diagnostic mammography.”

Question

We do ultrasound guided prostate biopsies in Radiology and report the ultrasound guidance with CPT code 76742. To report CPT code 76942, should we maintain permanently recorded images?

Answer

Yes, per the parenthetical guidelines in the Diagnostic Ultrasound section of the CPT book, permanently recorded images must be maintained for ultrasound guidance. The physician should also document the use of ultrasound guidance. This documentation can be included in the biopsy report or can be documented as a separate report. Typically, we see only one physician’s report that describes both the prostate needle biopsy as well as the ultrasound guidance.

Did You Know?

When a patient has bi-level positive airway pressure (BiPap) delivered through an endotracheal tube (ETT), the procedure code is different that BiPap (5A09x57), and the case groups to a different DRG.

Why It Matters

When BiPap is delivered through an ETT or tracheostomy, the PCS alpha index sends us to see Performance, Respiratory (5A19###).

Alphabetic Index:

BiPAP – see Assistance, Respiratory 5A09

Via

Endotracheal Tube or Tracheostomy –see Performance, Respiratory

Example: If a patient has a principal diagnosis of pneumonia, unspecified (J18.9), with a secondary diagnosis of acute respiratory failure with hypoxia (J96.01), and the patient is placed on Bipap without an ETT, the case groups to DRG 193 (Simple pneumonia and pleurisy with MCC) with a relative weight of 1.3107.

However, if this same patient is placed on BiPap, via an ETT or tracheostomy, the case groups to DRG 208 (Respiratory system diagnosis with ventilator support) with a relative weight of 2.5423.

Accurate coding of BiPap, via an ETT or tracheostomy, will not only group to a higher-weighted DRG, realizing more appropriate reimbursement, but it will also help to support the resources your facility spends on a patient. p>

What Should I Do?

Thoroughly review the record:

• Watch for words like “intubation” or “successfully intubated”
• Review any procedure reports
• Review all respiratory sheets
• Review nursing notes

References:

• ICD-10-PCS Official Coding Book
• Coding Clinic for ICD-10-CM/PCS, 2014, page 3

Question

I am a new chargemaster (CDM) coordinator at my facility, and my current to-do list involves trying to verify the CPT / HCPCS code assignment for vaccines. How can I determine if the CPT codes assigned in the CDM for pneumonia and influenza vaccines are correct?

Answer

Don’t try to figure it out on your own – you really need the expertise of one of your hospital pharmacists to help you with this. Fortunately, there are only 2 CPT codes to choose from for the pneumonia vaccines, but 20 CPT codes and 6 HCPCS Q codes to choose from for the influenza vaccines. In our experience with pharmacy CDM reviews, hospital pharmacists are usually able to easily tell you which CPT or HCPCS code should be used.

Did You Know?

It is common for a surgeon to perform a fusion on the anterior column and the posterior column of the spine through a single incision.

Why It Matters

The codes for anterior and posterior spinal column fusion will group to the higher-weighted DRG group (453-455). You could be under-coding and losing out on thousands of dollars of reimbursement for your facility.

What Can I Do?

First, make sure you are familiar with the anatomy and the terms describing the anterior and posterior columns.

The anterior column consists of:

• Anterior longitudinal ligament
• Vertebral body
• Intervertebral Disc
• Annulus Fibrosus
• Posterior Longitudinal Ligament

The posterior column consists of:

• Pedicles
• Transverse Process (gutter)
• Lamina
• Facets
• Spinous Process

The anterior column fusion is usually what is described first in the Operative Report and is often coded correctly. However, the posterior fusion is typically overlooked and not reported. One of the reasons may be the unfamiliarity with the terms describing the posterior column. For example, a surgeon may document that bone graft was placed in the “gutters”. Gutters is another term to describe the Transverse Process, so bone graft placed in the gutters is a posterior spinal fusion.

Based on the above information, there should be a code for fusion of the anterior column and a code for the posterior column in order for the claim to group to the appropriate higher-weighted DRG.

Did you know?

Previously, there were only three ICD-10-CM codes to identify personal history of carcinoma in-situ. These sites only included the breast, cervix uteri, and other site. Effective October 1, 2019, six new codes were created for personal history of in-situ neoplasms (Z86.002 – Z86.007). Two of these sites are listed below:

• Melanoma (Z86.006) (Personal history of melanoma in-situ)
• Skin (Z86.007) (Personal history on in-situ neoplasm of skin)

Why Should I Care?

ICD-10-CM codes are used for numerous occasions, i.e., accurate payments, quality management, data statistics, public health reporting, etc. The more accurate and specific codes are reported, the more accurate and specific data outcomes will be.

What Should I Do?

Report the new codes, if the documentation describes more specific sites, to allow for more specific coding and reporting of personal history of carcinoma in-situ sites.

Question

Is it appropriate for hospitals to code and submit an outpatient surgery claim before the pathology report is available? At our hospital we do a lot of skin excisions, but we code the record and bill the claim before we have the pathology report. Therefore, there are times when the malignant skin cancers are not reported on the claim since we do not know about it at the time of coding.

Answer

Yes, it is appropriate / allowed for hospitals to code and submit a claim before the pathology report is available to the coder for review. It is up to the individual hospital to determine this process. For additional discussion, refer to Coding Clinic, 1st quarter 2017, page 15.

Question:

What is the significance of coding the National Institutes of Health Stroke Scale Scores (NIHSS) that were implemented in 2017?

Answer

The NIHSS is a neurological exam that is scored on all acute stroke patients. The provider or clinician will calculate and document the score. The coder is to assign R29.7—based on the score or scores.

CMS has been gathering claims data on strokes from July 1, 2018 - June 30, 2021 which will be publically reported in FY 2022. For FY 2023 the data will start affecting hospital reimbursement as part of the 30-Day Stroke Mortality Measure. Hospitals should report the first NIHSS, which is typically documented after arrival to the hospital along with the appropriate stroke code. You may report additional NIHSS codes and use the POA indicator No for those additional codes.

In a recent Wednesday@One article (link) and related Infographic, RTMD’s claims data revealed only 40.1% of the claims included an NIHSS code. The reason the reporting of the NIHSS codes is so low may be due to the wording of the coding guideline. The guideline states, codes R29.7—may be used in conjunction with the stroke codes, so many hospitals are opting not to code them.

The main point of this article is to make sure you always report a NIHSS code with an acute stroke code and that they appear on the claim. Omitting the R29.7- code will adversely impact your hospital’s future reimbursement.

Question:

During cataract extraction, the physician sometimes injects an antibiotic into a part of the eye anatomy. Can we code the injection procedure(s) in addition to the cataract extraction CPT code?

Answer

No, do not code the eye injection in addition to the CPT code for the cataract extraction. This applies to the injection of an antibiotic as well as steroids and non-steroidal anti-inflammatory drugs Specific examples of injections not separately reportable with the cataract extraction code include: anterior chamber, intravitreal, retrobulbar, Tenon’s capsule, and subconjunctival.