by Sharme Brodie, RN, CCDS
Many coders and CDI specialists have memorized portions of the ICD-9-CMOfficial Guidelines for Coding and Reporting and issues of Coding Clinic for ICD-9-CM. Although many of the ICD-10Official Guidelines for Coding and Reporting remain the same, none of Coding Clinic’s previous advice can be applied to the new code set.
Without years of new Coding Clinic advice under their belts, staff members may need some time before they exhibit the same ease when applying new codes to the documentation provided. No one can say with certainty how smoothly the transition from ICD-9-CM to ICD-10-CM/PCS will be, and because ICD-10-PCS is a completely new system (which has not been used by any other country), we will experience growing pains.
CDI staff need to learn what information the coding staff needs to correctly code a chart.
Coding Clinic for ICD-10-CM/PCS, Third Quarter 2014, provided an example of this on p. 3, in the discussion of correctly coding a modified Blalock-Taussig shunt procedure. When coding Bypass procedures, there will be two general guidelines. The first applies to general bypasses; the fourth character represents the body part bypassed “from” and the seventh character will represent the body part bypassed “to.” The second applies to coding coronary artery bypass procedures, where the meaning of these characters will be different; the fourth character represents the number of arteries involved in the procedure, and the seventh character will represent the area bypassed “to.”
A fair amount of advice in this Coding Clinic pertains to two principal documentation dilemmas. The first regards coding and documentation for a condition that is a manifestation secondary to a disease process. The second concerns when a step in a procedure is inherent to that procedure and therefore would not be coded separately. These represent dilemmas because at times the opposite can be true—a condition can be coded separately because although it is a manifestation, is it not considered integral to the disease process; similarly, a step in the procedure may not always be inherent.
Coding Clinic essentially tells us that each individual case needs to be decided based on the documentation provided. If the CDI specialist or coder isn’t sure if the condition, or step, is integral, he or she should query the physician to clarify the situation before coding the chart. Charts involving interventions or procedures should be vetted by the CDI staff so the coders don’t have to worry about querying.
A CDI specialist with some surgical experience may be able to help in this regard, particularly if he or she understands the steps performed during a given surgical procedure.
Sepsis concerns
On p. 4 of the same Coding Clinic, a question was asked regarding ICD-10-CM codes for a patient diagnosed with SIRS and pneumonia without the presence of sepsis. SIRS in ICD-10-CM is going to be coded differently than in ICD-9-CM. ICD-10-CM does not provide a separate code or index entry for SIRS due to an infectious process. If the documentation appears to meet the criteria for sepsis, but the physician does not document sepsis, a query should be asked. If sepsis is not present, no other code would be necessary.
Use of imaging reports
As in previous Coding Clinic advice, now restated for ICD-10-CM, coders and CDI specialists will be able to use imaging reports to provide greater specificity of an anatomical site as documented by the physician. The example given in this particular edition was of a patient diagnosed with cerebral infarction or hemorrhagic stroke.
Coding Clinic stated that it will continue to be appropriate to use the imaging report to document the location of the stroke or infarction. With this advice being carried over to ICD-10-CM/PCS, the increase of queries for this new code set may not be as high as anticipated.
Coding for devices
Many questions in the Second Quarter 2014 issue seek clarification regarding coding for devices. ICD-10-PCS requires all seven digits to assign an accurate code; this means that coders will need to know the type of device in many situations for accurate code assignment.
As such, CDI specialists will need to review the entire procedural note for an accurate description of the device and the intent for which the device is being used.
One tip on assigning device values: Keep an updated device key with definitions of those devices most frequently used at your facility.
Coding Clinic (p. 5) provides a few device definitions.
Integra® and Dermagraft®, it states, are skin substitute products and are biologically derived, so their value would be coded as “non-autologous tissue substitute.” Another non-autologous tissue substitute that is porcine derived is OASIS® acellular matrix.
Coding Clinic explains that if the material used is derived from a living or biologic basis, it should be coded as “non-autologous tissue substitute;” otherwise, it is considered synthetic.
If living or biologic material is mixed with synthetic material, it should be coded as “non-autologous.” If two separate products are used (synthetic and biologic), they should be coded separately.
Per the ICD-10-PCSOfficial Guidelines for Coding and Reporting (B6.1a), a device is coded only if the device remains after the procedure. The ICD-10-PCSOfficial Guidelines for Coding and Reporting (B6.1b) also state that materials such as sutures, ligatures, radiological markers, and temporary postoperative wound drains are considered integral to the performance of a procedure and are not coded as devices.
Coding Clinic (p. 8) tells us fixation instrumentation (e.g., rods, plates, and screws) is integral to a spinal fusion and would be included in the Fusion root operation.
Editor’s note: Brodie is a CDI education specialist for HCPro in Danvers, Massachusetts. Contact her at sbrodie@hcpro.com.