Think about how many times each day we access our cerebral filing cabinets for guidelines and other references that we have committed to memory. Then consider how often we actually take time to reference the original source material that is the basis of our industry knowledge. As someone who spent nearly two decades coding and auditing, I knew the guidelines, conventions, and Coding Clinics® like the back of my hand. Although certain topics required research, more often than not my memory served me well.

Then things changed. I was given the opportunity to write educational material – an endeavor that demands precision and accuracy. Writing is a discipline that trains the mind to question assumptions. Everything that is written should be fact-checked and referenced. I can no longer assume that a particular coding reference is remembered correctly-I have to make certain. The opportunity to research and delve into our industry’s core knowledge is a gift. It gives one the opportunity to learn daily and to appreciate the nuances that exist in many of our conventions, references, and guidelines. An individual who remains current in their field has the greatest advantage, so it is essential to carve out time from our busy schedules for self-education.

There is so much material from which to choose, including: A plethora of new Coding Clinics® for ICD-10-CM and ICD-10-PCS, robust changes to the FY 2017 Official Guidelines for Coding and Reporting, significant expansion of the ICD-10-CM and ICD-10-PCS code sets, and new edits to the 2017 CPT code set.

The following is a collection of diverse and varied references that have crossed my desk this week and are in no particular order of importance. They run the gamut from inpatient to outpatient and were used for various purposes: Educational material, questions from clients and consultants, and preparation for speaking engagements. You might find them interesting:

Chapter 23 of the Medicare Claims Processing Manual
10.3 – Outpatient Claim Diagnosis Reporting
(Rev. 3081, Issued: 09-26-14, Effective: Upon Implementation of ICD-10)

For outpatient claims, providers report the full diagnosis code for the diagnosis shown to be chiefly responsible for the outpatient services. For instance, if a patient is seen on an outpatient basis for an evaluation of a symptom (e.g., cough) for which a definitive diagnosis is not made, the symptom is reported. If, during the course of the outpatient evaluation and treatment, a definitive diagnosis is made (e.g., acute bronchitis), the definitive diagnosis is reported. If the patient arrives at the hospital for examination or testing without a referring diagnosis and cannot provide a complaint, symptom, or diagnosis, the hospital reports the encounter code that most accurately reflects the reason for the encounter.

Examples include:

  • Z00.00 Encounter for general adult medical examination without abnormal findings
  • Z00.01 Encounter for general adult medical examination with abnormal findings
  • Z01.10 Encounter for examination of ears and hearing without abnormal findings
  • Z01.118 Encounter for examination of ears and hearing with other abnormal findings

For outpatient claims, providers report the full diagnosis codes for up to 24 other diagnoses that coexisted in addition to the diagnosis reported as the principal diagnosis. For instance, if the patient is referred to a hospital for evaluation of hypertension and the medical record also documents diabetes, diabetes is reported as another diagnosis.

Additional information and training is available on CMS Web site:

ICD-10-CM Official Guidelines for Coding and Reporting: FY 2017
I.A.15. “With”

The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related. The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.

ICD-10-CM Official Guidelines for Coding and Reporting: FY 2017
I.C.12.a.5 “Patients admitted with pressure ulcers documented as healing”

Pressure ulcers described as healing should be assigned the appropriate pressure ulcer stage code based on the documentation in the medical record. If the documentation does not provide information about the stage of the healing pressure ulcer, assign the appropriate code for unspecified stage.

If the documentation is unclear as to whether the patient has a current (new) pressure ulcer or if the patient is being treated for a healing pressure ulcer, query the provider.

For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission.

CPT Codes Removed from Medicare’s IP Only List:

  • 22840 Posterior non-segmental instrumentation (e.g., Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)
  • 22842 Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)
  • 22845 (Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)
  • 22858 (Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure)
  • 31584 Laryngoplasty; with open reduction of fracture
  • 31587 Laryngoplasty, cricoid split

I welcome your thoughts on what I have written and the various references cited in this article. As Anish Kapoor said “All Ideas Grow out of Other Ideas.”

Daniel Land, RHIA, CCS


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