Clinic Overflowing with Helpful Guidance

Clinic Overflowing with Helpful Guidance

Today I am going to go over what I picked up from the American Hospital Association’s (AHA’s) Coding Clinic for the second quarter of 2023. It was chock-full of interesting advice.

Two weeks ago, I went over COVID-19 screening. I think Coding Clinic should have explained why we continue to use Z20.822, Contact with and (suspected) exposure to COVID-19 after May 11, instead of just noting that “this advice is consistent with current coding guidance.” In theory, once there is no longer an epidemic or pandemic, we should be using “contact with” and “suspected exposure” only when we recognize that is the probable scenario. In practice, they are setting the timeline as the end of the fiscal year in which the pandemic ended (that is, 2023).

I learned a new code in my review! There is a code, R97.21, Rising PSA following treatment for malignant neoplasm of prostate. This offers a solution on how to code biochemically recurrent prostate cancer, post-prostatectomy, and salvage radiation therapy. The Coding Clinic indicated that, since the prostate had been resected, the culprit has to be a metastasis, and since the site is unknown, you can use C79.9, Secondary malignant neoplasm of unspecified site. My new code is also used because that was how they diagnosed it – that is what “biochemically recurrent” means.

A question was posed regarding a patient getting a workup for a suspected malignancy, when an excisional biopsy of a supraclavicular lymph node revealed metastatic non-small cell lung cancer. The question related to the sequencing of the primary and secondary malignancies. Although the procedure is ostensibly linked to the secondary malignancy, the primary malignancy is the condition responsible for both the metastasis and the overall workup/hospital admission. The response is to sequence the primary lung cancer as principal diagnosis (PDx). One should only sequence metastasis as PDx if it is the only focus for diagnostic or therapeutic treatment.

An interesting question was asked about venous thoracic outlet syndrome causing left upper extremity swelling and acute left subclavian deep vein thrombosis. The indexing led to G54.0, Brachial plexus disorders, but the questioner proposed I87.1, Compression of vein, as a more accurate clinical representation. The reviewer agreed that since the pathology involved the vein, not nerves, further research should lead the coder to I87.1. To my clinician brain, “compression” usually indicates external forces impacting on the anatomy, like a tumor pressing on the trachea. However, ICD-10-CM indexes kink, obstruction, stenosis, and stricture to “compression of vein,” too.

On page 10, there is a question about a patient with pre-existing Type 2 diabetes presenting with hyperglycemia believed to be secondary to autoimmune diabetes after initiation of immunotherapy medication. The answer was to use only E11.65, Type 2 DM with hyperglycemia and T45.1X5A, Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter, for the exacerbation of the disorder of sugar metabolism. I couldn’t help but wonder – where would you go if there were no underlying, pre-existing Type 2 diabetes? In that case, the diabetes code would be E09.65, Drug or chemical induced diabetes mellitus with hyperglycemia.

Page 15 features a question about a post-abortion complication. A patient presents for an elective termination of pregnancy due to a genetic abnormality and sustains uterine atony and hemorrhage. If there were a post-abortion code analogous to O72.1, Other immediate postpartum hemorrhage, that would be the right choice. However, since there is not, the advice is to use O04.6, Delayed or excessive hemorrhage following (induced) termination of pregnancy, plus the code for the maternal care for the chromosomal abnormality. Currently, there is an Excludes1 note at O04 precluding concomitant use of Z33.2, Encounter for elective termination of pregnancy, but this will become an Excludes2 on Oct. 1. For this particular code, it makes sense, because excessive hemorrhage could occur at the time of the encounter for the termination (or could be delayed until a subsequent visit).

My final comment is that the reason why linkage is assumed resulting in the “with” guidance is that the conditions with the assumed causal relationship are commonly associated, not because the ICD-10-CM classification mandates it. It is the other way around; ICD-10-CM acknowledges the near-inevitable relationship between, for instance, hypertension and heart failure, or diabetes and chronic kidney disease, by assuming causality unless specified otherwise. The words “due to” do establish the relationship if the provider documents them (e.g., hypertension due to hyperthyroidism à I15.2, Hypertension secondary to endocrine disorders).

Please review the Coding Clinic guidance yourself. There are more nuggets to collect.

And I’d like to extend an invitation to all to join me on LinkedIn on Thursday at 1:30 p.m. EST for my next “Ask Dr. Remer.” You can find the link on my company page, Erica Remer, MD, Inc. Hope to see you then.

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Erica Remer, MD, FACEP, CCDS, ACPA-C

Erica Remer, MD, FACEP, CCDS, ACPA-C has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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