Codes and Questions Linger: Q1 Coding Clinic

Here are my thoughts on Coding Clinic, First Quarter, 2023:

• As of April 1, 2023, there are going to be codes for financial abuse, suspected and confirmed, for adult and children, in T74 and T76. I’m glad that there are suspected codes, because it seems like it may be challenging for healthcare providers to make definitive determinations. The legal system may need to be involved to confirm this. Along those lines, I think that the expansion of perpetrator of maltreatment and neglect should have alleged in their titles. Unless I witness maltreatment and neglect in front of me in the emergency department, I am not sure it is my place to declare who is perpetrating anything.
• The new code, Z55.6, Problems related to health literacy may be useful to provide clarity as to why a patient is not being compliant with instructions. Along those lines, subcategory Z91.1-, Patient’s other noncompliance with medication regimen or with renal dialysis is expanding to specify due to financial hardship or for other reason.
• The announcement of the COVID-19 Public Health Emergency ending reminds us that Z11.52, Encounter for screening for COVID-19 will again be fair game for coding. Remember that screening is only done in asymptomatic patients and would not be appropriate if there was known or suspected exposure to COVID-19. You would continue to use Z20.822, Contact with and (suspected) exposure to COVID-19 in those circumstances.
• The first two questions were variations on a theme of acute blood loss anemia due to gastrointestinal bleeding (GIB) with endoscopy and blood transfusion. The issue was determining which condition would be principal diagnosis (PDx). It seems a little confusing because the scenarios are quite similar. In the first case, Coding Clinic stated that since both the anemia and the GIB were present on admission and met the definition of PDx, either could be selected. The acute gastric ulcer found on EGD was non-bleeding and did not have active treatment.

In the second situation, the only difference seemed to be that the lesions found on endoscopy were bleeding and cauterized. Coding Clinic said “the primary focus of the admission was to diagnose and treat the bleeding conditions” which “were responsible for the anemia,” so one of the bleeding conditions should be selected, and they discounted the anemia as a potential PDx. I don’t disagree with choosing one of the bleeding conditions, but I think it is because the procedures done were therapeutic (as opposed to diagnostic EGD without source being identified). One would presume that both cases had anemia of similar and sufficient magnitude justifying admission and transfusions.

• A question (p. 17) was asked regarding a nephrologist documenting CKD G4A3. The response explains that there is a “new categorization” system of chronic kidney disease staging called CGA staging which refers to C, cause, G, glomerular filtration rate (GFR), and A, albuminuria. G4 indicates stage 4 CKD, so N18.4 can be picked up for that verbiage. This system isn’t really new; it has been around since at least 2012 and is found in the 2012 KDIGO practice guidelines for CKD.
• There is a question on page 24 regarding how to code documentation of “liver mass possibly hepatic cholangiocarcinoma, pending pathology.” This invokes the uncertain diagnosis guideline and is an opportunity to educate the physician that the patient will be effectively diagnosed as having the malignancy, eliminating the need for a post-discharge pathology query if positive. If the pathology were to be surprisingly negative, a retrospective query would be necessary for the provider to remove the diagnosis.
• The alphabetic index needs to be edited if the advice regarding acute pulmonary edema in the context of near drowning is to be heeded, and I support that. Edema à lung à due to near drowning currently indexes to T75.1, but the question on page 25 asks about this scenario and Coding Clinic advises using J81.0, Acute pulmonary edema with W67.XXXA, Accidental drowning and submersion while in swimming pool, initial encounter.

As usual, my best advice is to read the Coding Clinic yourself.