When a symptom is followed by contrasting or comparative diagnosis What should be sequenced first?

Check out the new look and enjoy easier access to your favorite features

Page 2

October

2019

Ask the Experts
For The Record
Vol. 31 No. 9 P. 30

Question:
I need your expertise for procedural coding this operative note: 58720 vs 49205. Can you provide the reasoning as to why one or another?

Anonymous

Response:
Based on the body of the operative report, they did an exploratory laparotomy, an open salpingo-oophorectomy, and adhesion barrier placement.

58720: Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)

C1765: Adhesion barrier

Exploratory lap: According to the report, “Retractors were used to displace the abdominal wall to allow a thorough abdominal pelvic exploration with findings as noted above. The patient then had abdominal pelvic washings done in the following manner.”

Ovarian mass (which was the ovary per the pathology) removal: fallopian tube and ovary: 58720

The rest of the report is a closure of all the pedicles, ligaments, etc, that they had to dissection to get the mass. This will not be coded separately.

According to the report, “The self-retaining table-mounted Bookwalter retractor was then assembled and placed within the operative field to aid visualization. Adhesions involving the omentum with the anterior abdominal all were taken down with electrocautery and with the LigaSure instrument on a three-bar setting. The large right ovarian mass was displaced anteriorly and superiorly and the right ovarian artery and vein and the utero-ovarian ligament immediately adjacent to the ovary could be double clamped with curved Zeppelin clamps. This pedicle was then double coagulated and transected with the LigaSure instrument and then double ligated with 0 Vicryl ties. Hand-held retractors were used to displace the abdominal wall, at which time the ovarian mass with fallopian tube were delivered out of the operative incision as an intact specimen. The specimen was sent for frozen section pathology analysis.”

Adhesion barrier: C1765

The report says, “It should be noted that two half-sheets of Seprafilm were placed over the right uterine cornua and right pelvic sidewall in an effort to minimize the risk of adhesions in this area during postoperative status. All pads, sponge, lap, instrument, needs, and towels were removed from the operative field and all counts were correct 2X. We then implemented the surgical site infection prevention protocol. All members of the operating room rescrubbed, regowned, and regloved. A separate sterile field instrument tray had been counted and was brought into the operative field. Two full sheets of Seprafilm were placed over the small bowel and omentum in an effort to reduce risk of adhesions to the overlying incision.”

— Tasha Cameron, BS, RHIA, CCS, CDIP, CICA, is a Himagine educator and AHIMA-approved ICD-10-CM/PCS trainer/ambassador at Himagine Solutions Inc.

Question:
Does the symptom followed by two “versus” diagnoses only apply to the principal diagnosis selection, or to the secondary diagnosis also? In the ICD-10-CM Official Guidelines for Coding and Reporting, Section II e, a symptom followed by contrasting/comparative diagnoses (the guideline was deleted in 2014), this is listed under principal diagnosis. If I have a secondary diagnosis with a symptom followed by contrasting/comparative diagnoses, would I code the symptom or the diagnosis? I have been using the guideline for all diagnoses, but I recently started a part-time coding job. In the training videos, it states this only applies to the principal. I will go with their training while working there, but nowhere else I have worked has an audit of my coding discussed this nor in training have I heard this discussed. At my full-time job we really have no idea.

Anonymous

Response:
In previous years, Section II of the ICD-10-CM Coding Guidelines entitled “Selection of Principal Diagnosis” contained coding guidance regarding a symptom followed by contrasting/comparative diagnoses in selection of the principal diagnosis. In this guideline, it stated the symptom code is sequenced first, followed by all the contrasting/comparative diagnoses as additional diagnoses. This guideline was deleted effective October 1, 2014, and therefore no longer applies as part of the selection process for the principal diagnosis.

When considering selection of secondary diagnoses, refer to Section III of the FY 2020 ICD-10-CM Coding Guidelines entitled “Reporting Additional Diagnoses” which states the following:

“For reporting purposes, the definition for ‘other diagnoses’ is interpreted as additional conditions that affect patient care in terms of requiring:

• clinical evaluation; or • therapeutic treatment; or • diagnostic procedures; or • extended length of hospital stay; or

• increased nursing care and/or monitoring.

“The [Uniform Hospital Discharge Data Set] item #11-b defines Other Diagnoses as ‘all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.’”

If a coding situation arises in which the provider documents a symptom followed by contrasting/comparative conditions for a secondary diagnosis (eg, “altered mental status, transient ischemic attack vs stroke”), then the provider should be queried. This is especially important when the condition in question may provide a complication or comorbidity or a major complication or comorbidity, and may group the Medicare severity diagnosis-related group to a higher payment tier for the inpatient admission.

— Melody W. Mulaik, MSHS, CRA, FAHRA, RCC, CPC, CPC-H, is the president of Coding Strategies, Inc and Revenue Cycle, Inc.

Question:
What is the correct code for “community-acquired pneumonia”? The pneumonia is not specific to an organism or a lobe. We have been coding it to J18.9, as a simple unspecified pneumonia.

Melissa McCombs, RHIT, CCS
Lackey Memorial Hospital

Response:
Coders should report J18.9, Pneumonia, unspecified organism when the physician or other qualified health care professional documents “community-acquired pneumonia” without greater specificity. ICD-10-CM does not provide a subterm to describe “community acquired” under the pneumonia entry within the Alphabetic Index. According to the Merck Manual, community-acquired pneumonia refers to pneumonia that was acquired outside of the hospital. Documentation of community-acquired pneumonia does not give a clear indication of the causal organism or type of pneumonia. I would recommend full review of the medical record and querying the physician or qualified health care professional for the causal organism, when appropriate.

Resources
Buck’s 2020 ICD-10-CM for Hospitals. Saunders; 2019.

Sethi S. Community-acquired pneumonia. https://www.merckmanuals.com/professional/pulmonary-disorders/pneumonia/community-acquired-pneumonia. Updated March 2019.

— Catrena L. Smith, CCS, CCS-P, CPCO, CPC, CIC, CPC-I, CRC, CHTS-PW, is the audit and education manager at KIWI-TEK.

Q: Is it okay to code a diagnosis if the physician documents two diagnoses using the phrase “versus” between them? For example, the patient arrives with abdominal pain and the physician orders labs and other tests but they all come back normal. In the discharge note, the physician documents “abdominal pain, gastroenteritis versus irritable bowel syndrome (IBS).”

When I first started as a CDI specialist I was told we could not use diagnosis when “versus” was stated, and that we had to query for clarification.

A: Always refer back to the ICD-9-CM (ICD-10-CM/PCS) Official Guidelines for Coding and Reporting if you are unsure of how to sequence or apply codes. Guidelines applicable to your situation are located in Section II, Selection of Principal Diagnosis.

The first guideline states:

“In those rare instances when two or more contrasting or comparative diagnoses are documented as “either/or” (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.”

However, let’s review another guideline from the same section which states:

“When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as secondary diagnoses.”

In the situation described, the physician documented a symptom, abdominal pain, followed by two contrasting diagnoses, gastroenteritis and IBS in the discharge summary. The principal diagnosis is the abdominal pain and secondary diagnoses are the gastroenteritis and the IBS.

If there is no symptom diagnosis documented–for example the physician documents NSTEMI versus GERD–the coder would assign a code for each, sequencing the principal according to the circumstances of the admission (as it tells us to in the Guidelines). Typically, however, the physician will have identified either the presence of the NSTEMI or the GERD, based on enzymes, and other testing.

Consider flagging a record such as this for follow up review the next day. While the physician may not have ruled in or ruled out a given diagnosis at the time of an initial review, once lab results return and treatment is provided, you should have enough information to warrant a query to the physician for a more definitive diagnosis. Such a query might read:

Dr. X,

Mrs. Y was admitted with complaints of chest pain. The history of present illness states NSTEMI vs. GERD. Oxygen, nitroglycerine, and morphine were administered in the ED but provided with no relief. The patient received a GI cocktail and the pain decreased. Cardiac enzymes lab results were negative. EKG shows normal sinus rhythm and an EGD scheduled as outpatient. Can you please clarify the etiology of the chest pain?

_____________Chest pain secondary to GERD, NSTEMI ruled out

_____________Chest pain secondary to NSTEMI

_____________Other

_____________Unable to determine

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at . For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.