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AHA Coding Clinic for ICD-10 covers orthopedic, cardiovascular coding

by Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS
Some interesting tidbits of information can be gleaned from the most recent release of the AHA Coding Clinic for ICD-10-CM/PCS to help coders as they work in the new code set.
I never thought I’d be so eager to read a release about coding instead of the newest James Patterson novel, but this newsletter highlighted topics such as orthopedic screw removals, revision of total knee replacements, heart failure with pleural effusions, leadless pacemakers, the Glasgow Coma Scale, and decompression of the spinal cord. 
Typically, when we see that a device is loose or breaking, we automatically think "that shouldn’t happen," so we opt to code a complication of the device. Well, when this occurs in an orthopedic screw as an expected outcome (typically when the patient begins bearing weight during the recovery/healing process), it should not be coded as a complication.
The correct diagnosis codes would be assigned for the specified fracture site with a seventh character identifying a subsequent encounter with routine healing, along with the external cause code (if known), also as a subsequent encounter. (Remember that place of occurrence, activity, and status codes should only be used for the initial encounter, per the ICD-10-CM Official Guidelines for Coding and Reporting.)
The ICD-10-PCS root operation would be Removal (third character P) for the removal of the screw from the specified bone.
On the other hand, some orthopedic devices can present real complications necessitating removal and replacement. For example, a patient may be admitted for a painful total knee replacement, initial encounter (T84.84xA). In order to remedy this situation, the previously placed components (tibial and femoral) are removed and replaced with new components. This ­scenario leads coders to ponder whether this should be considered a Revision or Replacement, or perhaps something else.
ICD-10-PCS defines a Revision as "correcting, to the extent possible, a portion of a malfunctioning device or the position of a displaced device." In this case, the prosthesis isn’t working exactly the way it should, but the ICD-10-PCS Reference Manual states that "putting in a whole new device or a complete redo is coded to the root operation(s) performed."
Therefore, the correct root operations would be Removal (P) for taking out the old components, then a Replacement (third character R) for putting in/on a synthetic material that takes the place of the body part. 
I am confident many coders noticed that the codes for heart failure (category I50) are mostly identical to their ICD-9-CM counterparts.
But one thing that probably raised some eyebrows for coders was the Excludes2 note at category J91 (Pleural effusion in conditions classified elsewhere), which seemed to state that a code from category J91 would be assigned as an additional code when seen "in heart failure."
Of course, most coders will recall that in ICD-9-CM we normally could not assign a separate code for this situation, based off information in AHA Coding Clinic for ICD-9-CM, Third Quarter 1991. The new issue provides clarification that the same rules apply in ICD-10-CM for pleural effusions seen in heart failure patients.
The pleural effusions would only be reported separately if therapeutic/diagnostic interventions are required. Pleural effusion is commonly seen with congestive heart failure (CHF) with or without pulmonary edema. Usually, the effusion is minimal and resolves with aggressive treatment of the underlying CHF.
The issue also addresses the correct coding of a newer procedure performed for heart blocks: the insertion of leadless pacemakers. You may have asked, as I did, how in the world does this device work if there are no leads to provide the electrical impulses?
This technology has been explored for many years and is finally here. Current pacemaker devices are susceptible to issues such as lead failure or malpositioning, as well as pulse generator pocket complications, such as scar formation or even just the visible presence of the device. In contrast, these new cylindrical devices fit directly into the right ventricle, accessed via a transcatheter approach and placed into the endocardial tissue of the right ventricular apex to provide pacing capabilities.
For coding purposes, the ICD-10-PCS table 02H (Insertion, heart and/or great vessels) does not provide a specific device option for a leadless pacemaker. The correct device character should be D (intraluminal device). The full ICD-10-PCS code to be assigned is 02HK3DZ (Insertion of intraluminal device into right ventricle, percutaneous) to identify a leadless pacemaker. 
Revisions in ICD-10-CM allow coders not only to report a coma (R40.20-, unspecified coma) but also to report codes that incorporate a common tool to assess the depth and duration of comas or impaired consciousness, known as the Glasgow Coma Scale.
Per the Centers for Disease Control and Prevention, this scale helps to gauge the impact of a variety of conditions, such as acute brain damage due to traumatic and vascular injuries or infections and metabolic disorders (e.g., hepatic or renal failure, hypoglycemia, diabetic ketosis).
ICD-10-CM contains subcategories to report the three elements that go into calculating the coma scale:
  • R40.21-, coma scale, eyes open
  • R40.22-, coma scale, best verbal response
  • R40.23-, coma scale, best motor response 
If coders opt to use this reporting option, three codes must be assigned to identify each of the three elements.
Codes for the individual Glasgow Coma Scale scores from these categories can be assigned if the provider documents the numeric values, as opposed to the physical descriptions associated with those numeric values.
The eye opening response is scored as follows:
  • 4, spontaneous eye opening
  • 3, eyes open to speech
  • 2, eyes open to pain
  • 1, no eye opening
The verbal response is divided into five categories:
  • 5, alert and oriented
  • 4, confused, yet coherent, speech
  • 3, inappropriate words and jumbled phrases consisting of words
  • 2, incomprehensible sounds
  • 1, no sounds 
The motor response is divided into six different levels:
  • 6, obeys commands fully
  • 5, localizes to noxious stimuli
  • 4, withdraws from noxious stimuli
  • 3, abnormal flexion, i.e., decorticate posturing, an abnormal posture that can include rigidity, clenched fists, legs held straight out, and arms bent inward toward the body with the wrists and fingers bent and held on the chest
  • 2, extensor response, i.e., decerebrate posturing, an abnormal posture that can include rigidity, arms and legs held straight out, toes pointed downward, and head and neck arched backwards
  • 1, no response 
For example, the documentation states "Glasgow Coma Scale score was obtained upon arrival at the ED; eyes open = 2, best verbal = 3, and best motor = 5." Coders may assign the following:
  • R40.2122, coma scale, eyes open, to pain, at arrival to ED
  • R40.2232, coma scale, best verbal response, inappropriate words, at arrival to ED
  • R40.2352, coma scale, best motor response, localizes pain, at arrival to ED 
Per the Official Guidelines, the seventh characters must match for all three codes.
Subcategory R40.24- (Glasgow Coma Scale, total score) is an additional option provided that identifies the overall score as opposed to each of the three individual elements.
Those codes are:
  • R40.241, Glasgow Coma Scale score 13-15
  • R40.242, Glasgow Coma Scale score 9-12
  • R40.243, Glasgow Coma Scale score 3-8
  • R40.244, other coma, without documented Glasgow Coma Scale score, or with partial score reported 
Codes from R40.24- would not be assigned if the individual scores are documented.
Procedurally, Coding Clinic provided clarification regarding decompressive laminectomies and the assignment of the appropriate body part characters. When assigning an ICD-10-PCS code for a cervical decompressive laminectomy, the body part value states "cervical spinal cord."
The cervical spinal cord is considered a single body part value in ICD-10-PCS and would only be assigned one time regardless of the number of cervical levels decompressed to release the spinal cord.
The vertebral level designations of the cervical spinal cord do not constitute separate and distinct body parts anatomically; therefore, ICD-10-PCS Guideline B3.2 does not apply:
During the same operative episode, multiple procedures are coded if: The same root operation is repeated at different body sites that are included in the same body part value. 
Another note of caution: The ICD-10-PCS Index entry "Laminectomy" instructs coders to see Excision (B), but the objective of a decompressive laminectomy is to release pressure and free up the spinal nerve root. Therefore, the appropriate root operation is Release (N). 


Editor’s note: McCall is the director of HIM and coding for HCPro, a division of BLR, in Danvers, Massachusetts. She oversees all of the Certified Coder Boot Camp programs. McCall works with hospitals, medical practices, and other healthcare providers on a wide range of coding-related custom education sessions. For more information, see article was originally published in Briefings on Coding Compliance Strategies. – JustCoding News: Inpatient

Letter from the editor: Accessing your newsletter content

The challenges healthcare professionals tackle each day don’t wait for solutions, and neither should you. That’s why Briefings on Coding Compliance Strategies is transitioning to a more frequent and robust publishing model this winter and expanding into a JustCoding membership.

Your updated member benefits gain you access to content and tools on JustCoding (JC)—with new resources added weekly to the website ( You’ll use the same login information you previously used to access Briefings on Coding Compliance Strategies at to access the articles and full-issue PDF at JC.

Plus, as a JC member, you gain instant access to more than 100 resources in our forms and tools library, including white papers, books, webcasts, and much more. If you are already a JC member, you will continue to receive the news and analysis you’ve come to rely on, plus expanded member benefits coming in December.

To help readers keep tabs on available content, we will announce new articles in JustCoding and Revenue Cycle Daily Advisor, HCPro’s daily e-newsletter for HIM directors and coders and coding managers. At the end of each month, we’ll roll the corresponding weekly articles into a digital issue of Briefings on Coding Compliance Strategies that mirrors the current format. As a member of JC, you can continue to download and print high-quality PDFs of the current issue, as well as several years of back issues of Briefings on Coding Compliance Strategies, directly from JC’s website. Printed editions of Briefings on Coding Compliance Strategies will no longer be mailed to subscribers.


We’re looking forward to delivering your coding and billing guidance and commentary in a timelier, efficient, and convenient manner. Feel free to contact editor Amanda Tyler at with any questions. – Briefings on Coding Compliance Strategies

Comment on Tips to Pass AAPC’s CPC Exam by Zen Weller

I found it very helpful to tab the sections that are most used, and that I knew I would need immediate reference to. For example, if you know you have trouble remembering POS numbers, it would be a good idea to tab the appendix that lists them (in my CPT version when I tested, this is Appendix M). You may want to tab the HCPCS modifier appendix, or the CPT modifier appendix; Both good ideas for taking the CPC exam. Look through your conventions in the ICD book as well. These rules are extremely important for the exam.. Get familiar with them, and tab the ones you may have trouble remembering. Sepsis, HIV, and pregnancy conventions are a few to note. Basically, go through your books, and note the areas that you feel the least comfortable with, so that you can reference them quickly.. Keep in mind that the exam is really only to prove that you know “how” to use the references. Cater your notes and tabs to your own specific needs. Great luck to you!

Comments for AAPC Knowledge Center

QW modifier

I work at a university student health center and our lab has the designation of high complexity regarding tests we are able to perform. Does anyone know if I need to add the QW modifier to our lab tests that are listed in the waived status under CLIA? Since we are approved for high complexity testing I wasn’t sure if the waived status under CLIA would apply to us. Thanks!

Medical Billing and Coding Forum – Modifiers

30th anniversary celebration: Never stop learning

30th anniversary celebration

Never stop learning

by Keith Olenik, MA, RHIA, CHP


My original career choice in high school was to pursue a degree in medicine. It was my father, a high school librarian, who discovered an undergraduate degree option of medical record administration as opposed to the typical pre-med route of biology. I had no knowledge of what this program would truly entail other than a combination of medicine, business, and legal coursework. What did it matter since my ultimate goal was to become a physician?

The desire to pursue additional years of education to become a doctor went out the window after about three years of undergraduate education. It was then that I had a sudden realization?becoming a physician wasn’t for me. I was reintroduced to medical record administration and have been in HIM ever since. After 30 years in HIM, it’s a decision I don’t regret at all.

I really had no idea what I had got myself into after graduation, despite a good education that included excellent professional practice experience. My lack of experience was quickly resolved by my first job as a director of medical records for a large nursing home and rehabilitation hospital that required hands-on work due to limited staff. The ability to apply classroom learning in the real world soon solidified my understanding of what HIM meant to an organization.

After about six months on the job, I was asked to help provide oversight for registration, quality assurance, and utilization review based on my demonstrated ability to manage a function and, most important, apply regulations to ensure compliance for licensure. It became readily apparent there were many more opportunities available to me with the education and profession I had?at the time?rather blindly chosen.


Variety, relationships, and out-of-the-box thinking: Keys to success

During my career, I have had the opportunity to work in almost every healthcare setting and learn the subtle differences and similarities of each. The development of relationships with peers within the organization was critical to these learning experiences. My peers provided the benefit of their educational background and how these other areas are influenced by HIM. Through this expanded understanding of the healthcare industry, I began to see that HIM plays an integral role that offers value to every organization.

The key to demonstrating this value required thinking outside the box and being willing to take on new responsibilities or offer suggestions for process improvement. Typically, HIM is viewed as the people who tell you what can’t be done based on regulations, laws, or standards. Over the years, I have turned that perspective around and provided suggestions for getting things done while ensuring compliance?a perspective that is much better received and valued.


Stay active and educated

Another key component of a successful career in HIM was deciding to become active in the profession. The time I spent volunteering in the early days with the local association and later serving at the national level has paid off tenfold. Participating as a volunteer provides opportunities to learn and create connections outside the workplace. My network of professional colleagues has been an invaluable resource for my personal and professional growth. Being able to pick up the phone or send an email to request advice on any type of work issue is a benefit that many don’t take advantage of, despite being a member of AHIMA.

My career in HIM has definitely not been boring. It has given me the opportunity to work as a director, Medicare auditor, contract coder, educator, sales representative, and most recently a consultant. The ability to take what I learned through formal education, professional activities, and on-the-job training and apply it to many different roles was unimaginable when I started out in the field. Ongoing education in both formal and informal settings has been the underpinning of managing my journey through the various roles and job settings.

Education is a critical component of our profession. As a working professional, providing learning opportunities for students has been another key factor in my career. I strongly encourage my peers to make time for pursuing additional education and offering their knowledge to future HIM professionals to help ensure their success. We have a responsibility to the industry to make HIM insight and principles available to every organization attempting to manage the ever-increasing volume of data that must be translated into meaningful information.



Editor’s note

Olenik has more than 30 years of experience working with provider healthcare delivery systems as a member of senior management and as a consultant. He specializes in methods to streamline business operations, evaluate and implement information technology applications, and enhance productivity through process improvement. Olenik holds a B.A. in health information management from the University of Kansas and an M.A. in Health Services Management with an emphasis in Computer Resources Management from Webster University. He is a member of AHIMA and has been on the board of directors for the association and the foundation. Olenik is an approved ICD-10-CM/PCS trainer. He also belongs to the HIMSS and has served as an annual program reviewer. Opinions expressed are that of the author and do not represent HCPro or ACDIS. – HIM Briefings

Manifestation Codes


I have a chart where the px has been diagnosed with Lewy Body Dementia. I coded it with the G31.83 code followed by the F02.80 code. The documentation does not state whether or not the condition exist with or without behavioral disturbance and I cannot query the provider. So my auditor asked that I remove the F02.80 code. I thought this code is mandatory if it is in brackets. She says it only applies "if applicable" And since I don’t knowif the px has a behavioral disturbance or not, I have to remove the F02.80 code.

Can someone weigh in on this and let me know if my interpretation is correct? Or if my auditors interpretation is correct.

Medical Billing and Coding Forum – Diagnosis Coding

How coders can build a successful relationship with their physicians

How coders can build a successful relationship with their physicians

by Sue Egan, CPC, CCD

All coders know that working with physicians is not always a positive experience.

It can be tough providing them education or getting responses from queries. Conversely, providers are busy and typically do not like anything to do with coding. When they hear coding they often take that to mean more work on their part.I have been working with providers for many years and the one thing coders always ask me is, ‘What is your secret for getting along so well with doctors and engaging them to change behavior?’

Building a relationship with your providers can make both of your lives easier. Outlined are a number of ideas that can facilitate building a strong relationship with your physicians.

  • Documentation clarification inquiries for the hospital are likely to support physician billing. Communicate to the physicians that if the hospital is asking for documentation it will better support their billed services as well. Complete and accurate documentation will hold up to increased scrutiny by payers.
  • Demonstrate why. When you ask a physician to change the way he or she documents in the medical record, show them why it matters. Show how accurate and complete documentation enables appropriate risk adjustments for the patients a physician treats. Remind physicians that good documentation can prove that the patients he or she treats really are sicker than others. This approach is more effective than stating the hospital will get a higher paid DRG.
  • Knowing when to step away will help you keep a positive relationship with a provider.
    • Regardless of how important the material is you want to educate the provider on, if he or she has a patient that has just passed away, now is not the time to share?they won’t remember what you tell them. Let the provider know you recognize the situation and will reschedule.
    • If you know a physician is overwhelmed or is having a really bad day, then recognize that now may not be a good time and offer to reschedule.
  • Be available. When approaching a physician for one-on-one education, be flexible in your availability. This could mean coming in early to meet with a doctor before his or her first case. If the physician can meet at lunch, do it. Recognizing the physician’s workload demands and being flexible will yield many benefits to the relationship.
  • Be prepared. Physicians will ask you a question once, maybe twice, where you can say, ‘I don’t know,’ but chances are they won’t ask a third time. Be creative in your response. Instead, try saying, ‘You know, I just read something about that, let me go back and make sure I am giving you the most updated information,’ or ‘I just saw something on this, I am not sure if it was CMS or carrier directed. Let me find it and get back with you.’ Once you lose a physician’s trust, it is very difficult to regain it.
  • Don’t waste their time. One of the biggest complaints I have heard from doctors is related to queries they deem as a waste of time. Make sure the query or question you are asking is
    • Addressed to the right physician/provider
    • Relevant to the patient care being provided
    • The information you are basing your query on is accurate
  • Walk in their shoes for a day. Offer to round with them, where you can provide live audit and education to the provider. See how their days really are. In most cases, you will be amazed at how much they get done.
  • Be a better listener. Some coding and documentation guidelines are not clinical in nature and providers can get frustrated by being asked to document things that aren’t clinically significant (e.g., family history for the 85-year-old patient). Sometimes your provider may just need to vent this frustration and while you may not have a resolution to offer, listening and understanding can go a long way in building rapport.
  • Ask questions. Ask your provider how they translate a patient visit into medical record documentation. Questions that might solicit opportunities for improved documentation may include:
    • What questions are they asking when interviewing the patient?
    • What concerns do they have?
    • What is the patient experiencing? You can utilize this information to point out how the documented note can better demonstrate the patient’s current condition and treatment plan.
  • Share the good as well as the bad. When a physician is doing a really great job documenting timely, accurately, and completely, give them a shout out. Or, when they answer queries timely, let them know. A quick note with a smiley face or even a gold star will be very much appreciated. Positive recognition given to one physician and not another often results in the physician inquiring how he or she can get recognition.
  • Sports and (other interests). While engaging physicians in discussions such as sports is completely unrelated to coding and documentation, it can pay off significantly. Many providers are very loyal to their alma mater’s college football and basketball teams. Relationship building can be accelerated when you engage physicians in areas of personal interest. Gaining an understanding of a physician’s college coach, conference, and team standing, and discussing this information with a physician can go a long way to building a relationship. But sports isn’t the be-all, end-all. If you know a doctor has a particular interest (cooking, piano, horror movies, or painting) learning a little about that interest can go a long way. Expanding your knowledge is a good thing and building your relationship with that provider is a great thing.
  • Empathy. It is important to remember that physicians are busy with competing priorities. Providers often get interrupted while they are dictating and/or documenting their notes, and when they leave something out of their notes, it is not intentional.


Recognizing that one of our major responsibilities as coders and documentation specialists is to make the physician’s job easier and their data as accurate as it can be is essential.

Avoid approaches that make them feel like they have done something wrong. Let providers know your job is ‘to make you look as good as you are.’



Editor’s note

Egan is an associate director with Navigant Consulting and has been working with providers, of all specialties, for more than 25 years. She works with providers to improve documentation as well as provide education and training related to CPT coding. Sue has lived in Charlotte, North Carolina, for the last 23 years, enjoys traveling with friends, and relaxing at home with a good book and her cats. Opinions expressed are that of the author and do not represent HCPro or ACDIS. – HIM Briefings