Friday, June 17, 2011

More Updates from Coding Clinic

On June 3 we posted several new Coding Clinic rulings.  Today, we're posting several more updates.  Keep your eyes on this space for more posts on recent Coding Clinic rulings.

Volume:  2011

Issue:  First 

Title:  Systemic Inflammatory Response Syndrome (SIRS) due to Pancreatitis

The questioner asked for clarification of the advice published in First Quarter 2010. In that issue, coders were instructed to assign code 995.93, Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction for SIRS due to a noninfectious condition, such as pancreatitis. Because the etiology of pancreatitis can either be infectious or noninfectious, the questioner asked if the provider be queried.  

Coding Clinic acknowledged that pancreatitis can have various etiologies; however, the majority of cases of pancreatitis are non-infectious. In many cases, the cause is unknown.  If the provider documents specifically that the SIRS is due to infectious pancreatitis, use the infectious SIRS code rather than the noninfectious one.  The provider should be queried if the medical record documentation is not clear.

Volume:  2011

Issue:  First 

Title:  Borderline Diabetes Mellitus

The question of coding a diagnosis of borderline diabetes was posed.

Coding Clinic answered that code assignment should be based on physician documentation, and sometimes might require querying the physician.

If not, a diagnosis of “borderline diabetes” without further confirmation of the disease should be assigned the appropriate code from subcategory 790.2, Abnormal glucose.

Volume: 2011

Issue:  First 

Title:  Chronic Venous Embolism and Thrombosis

The questioner noted that there were codes for chronic venous embolism and thrombosis, and asked when  DVT becomes chronic.

Coding Clinic noted that there were no specific timelines for when DVT or any other condition becomes chronic. The assignment of chronic DVT is based on provider documentation.

 Volume:  s2011

Issue:  First 

Title:  Broken Catheter Tip Retrieved via Thrombectomy

The questioner noted that a patient was admitted for thrombosed arteriovenous graft. An aspiration of thrombus was performed. During the procedure, the catheter tip separated at the entry site of the sheath after access through scar tissue. Open thrombectomy was performed with retrieval of the catheter tip. What is the code assignment for the broken catheter tip?


Coding Clinic advised the questioner to assign code 996.1, Mechanical complication of other vascular device, implant, and graft, for the broken catheter tip.

If the catheter tip had not been retrieved, codes 996.1, Mechanical complication of other vascular device, implant, and graft, and 998.4, Foreign body accidentally left during a procedure, would be assigned.

Note there is a previous Coding Clinic, First Quarter 1995, with  an example of a catheter tip that broke off during chemotherapy infusion.


Issue:  First 

Title:  Broken Needle Left during Surgery

The questioner asked about a needle placed along the right lateral aspect of the sewing ring of the aortic valve and passed through tissue to try to cinch the valve down. The suture broke from the needle and the needle was lost within this tissue.  An x-ray was done which did not reveal the needle. The chest was closed and a second x-ray showed that the needle was to the right of the aortic valve. The chest was reopened but the needle still could not be located or palpated.

 The surgeon decided that continuing to look for the needle was likely to cause the patient more harm than good. Therefore, the chest was closed again, and the patient was transferred to ICU in stable condition.
The questioner asked what the correct diagnosis code assignment is when a provider intentionally leaves a foreign body in the patient and the documentation clearly states that removing the foreign body will cause more harm than good? Would code 998.4, Foreign body accidentally left during procedure, be appropriate?

Coding clinic advised to assign code 998.4, Foreign body accidentally left during a procedure. Although the surgeon made the decision to leave the needle because continuing to search for it might cause harm to the patient, it was not the intent of the original procedure to leave a foreign body behind.

Year:   2011

Issue:  First 

Title:  Coding for Home Health Care

The questioner asked if symptoms codes should be assigned along with the aftercare codes. As an example, they asked if it was appropriate to assign a code for gait abnormality when a patient is receiving home health aftercare following joint replacement? Does the advice change depending on whether this is an outpatient encounter versus an inpatient admission?

Coding Clinic answered that  symptom codes may be assigned in conjunction with V codes when they provide additional information about the specific problem being addressed. In the given example, code 781.2, Abnormality of gait, may be assigned in conjunction with code V54.81, Aftercare following joint replacement.

Year: 2011

Issue:  First 

Title:  Code Assignment Based on Up and Down Arrows

The questioner asked if it was appropriate to assign a diagnosis code for a condition listed with up and down arrows?  Examples were provided:  ↑ cholesterol, or ↑lipids, or ↓hemoglobin and hematocrit, and they wondered if a code should be assigned for hypercholesterolemia, or hyperlipidemia, or low H&H, etc.? They also wondered if the  advice changed depending on whether this is an outpatient encounter versus an inpatient admission?

Coding Clinic advised that it is not appropriate for the coder to report a diagnosis based on up and down arrows, and that diagnosing a patient’s condition is solely the responsibility of the provider.

The use of up and down arrows can have variable interpretations and do not necessarily mean “abnormal.” They could simply be indicating change (including improvement) over past results. Therefore the provider should be queried regarding the meaning of the arrows and request that the appropriate documentation of a condition or diagnosis be provided.

Coding Clinic advised that this response was consistent with the coding guideline on abnormal findings which states: “abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.” The same advice applies for both inpatient and outpatient admissions.

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