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Tag Archives: ICD10

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

Internal auditing strategies for ongoing ICD-10 success

Internal auditing strategies for ongoing ICD-10 success

Editor’s note: This article was modified from HCPro’s latest long-term care title, ICD-10 Compliance: Process Improvement and Maintenance for Long-Term Care, written by Maureen McCarthy, BS, RN, RAC-MT, and Kristin Breese, BSN, BSed, RN, RAC-MT. The complete book helps facilitate ongoing ICD-10 success by arming SNF readers with information and strategies that target the preparation, implementation, and maintenance phases of the fast-approaching coding transition. For more information or to order, call customer service at 800-650-6787 or visit


With the October 1 implementation date of ICD-10 now on a fast track to fruition?and no further delays in sight?even the most committed holdouts in the provider community have kicked off initiatives to ensure staff, outside business partners, and workflows can withstand the major coding transition.

To ensure that preparations made over the past months (or years) ultimately pay off, SNFs should start laying the groundwork for regular facility-wide audits of ICD-10 systems in the aftermath of implementation?a proactive approach that can help providers verify the strength of ongoing transition efforts and catch any snags before they disrupt essential facility processes.

Thus, although the word "audit" can provoke fear and anxiety in providers?often connoting scrutiny and penalties when administered by Medicare contractors?facilities can head off these unsavory external audits, or at the very least reduce negative outcomes, by conducting their own internal varieties.

In a broader sense, frequent self-audits can promote overall business vitality by facilitating the development and maintenance of sustainable processes across the facility, particularly in the face of the impending overhaul to coding methodology and practice.


The scope of self-audits

The Office of Inspector General (OIG) considers ongoing monitoring and evaluation important elements of a healthcare organization’s compliance program and identifies two overarching types of reviews:

1.Standards and procedures reviews, which measure whether internal standards are current and complete, or are in need of an update to reflect regulatory changes

2.Claims submission audits, which gauge whether coding, billing, and documentation are in compliance with payer and government contractors, as well as whether services performed are reasonable and support medical necessity

The OIG states that self-audits, which generally fall into the second category of reviews, can accomplish an array of verification processes. More specifically, the agency explains that these audits can be used to determine whether:

  • Bills are accurately coded and reflect services provided
  • Documentation is complete and correct
  • Services or items provided are reasonable and necessary
  • Any incentives for unnecessary services exist

The baseline audit

SNFs should launch a baseline audit after the first three months of ICD-10 implementation. This initial evaluation will help providers identify areas that need improvement or education. To shape baseline (and subsequent) audits, facilities should consider the following list, which identifies key aspects of major operational areas the ICD-10 transition is likely to affect:


2.Coding/billing in the electronic health record system



5.Strategic considerations


Subsequent audits

Once SNFs have completed their baseline audits, they should analyze the outcomes to develop an auditing compliance plan, which can function as staffs’ blueprint for future documentation, coding, and billing.

The ICD-10 task force, or transition team, should appoint a post-ICD-10 committee to review initial implementation results, evaluate success against established criteria, and identify what works and doesn’t work, especially in the revenue cycle, health information management, and IT realms.

Prior to the October 1 kickoff, this committee should determine which measures will be tracked and collect related preliminary data.

Following the go-live date, this committee?and the facility at large?must be on the lookout for significant post-implementation issues, including claims denials and rejections or coding backlogs. The committee must quickly identify such issues, create feedback loops, and follow the established solution path to remediation?a task that’s best facilitated by routine auditing of both claims and supportive documentation in a patient’s medical record.

Facilities should track all ICD-10 submissions and receipts for 3?6 months after the transition. Quality assurance monitoring should focus on ensuring proper receipt of ICD-10 codes by vendors and payers. Providers should also be sure to address all communications from these sources, as well as trading partners and CMS.


Key takeaways

Routine review of ICD-10 coding will soon become an essential function of all facilities’ quality monitoring systems and resulting performance improvement plans. Auditing documentation for sufficient data to support specificity in ICD-10 diagnosis coding should begin 2?3 months prior to the transition and continue well after October 1. Conducting ongoing auditing is crucial to update or solidify processes that underlie, facilitate, and support ICD-10 coding and claim submission, thereby ensuring a hassle-free conversion to the new system. – Billing Alert for Long-Term Care

ICD10 coding for woman when male infertility is the cause of treatment

Hi all,

I’m hoping for some input on coding ICD10 for a woman receiving fertility treatment – IUI – when the male is infertile. Our providers keep using N46.9 – Male infertility for the woman, but, of course, it rejects as gender mismatch. Would Z31.81 (Encounter for male factor infertility in female patient) be an appropriate billable code for this situation? Any other input?

Medical Billing and Coding Forum – OB/GYN

7 Benefits of Outsourcing Your Medical Billing with ICD-10

It can be difficult deciding whether to outsource your medical billing or not. With ICD-10 coming in October, There are many benefits of outsourcing your revenue cycle functions. Let’s take a look at 7 of those benefits.

#1 Economy of Scale
A billing service will distribute their expenses through their complete client base, which provide an economy of scale. They are able to operate with lowers costs than what a single practice can and those savings are passed on to their clients, making them very competitive. A billing service is able to afford to hire top-notch staff so you are able to pay less and get more.


#2 Highly Trained Dedicated Specialists
The outsourcing team has just one purpose – its focus is to increase your practice’s profitability. They will review and post payments from the carriers to ensure that you are getting the correct amount and preventing adjustments that are incorrect. Every claim that’s outstanding will be tracked until it is paid in full. The team that handles all elements of your medical billing is the same staff to ensure cohesion.


#3 Gain Control
There’s a mistaken assumption that if you outsource your medical billing you will give up control. In fact, quite the opposite is true. You tend to gain more control. You have a team of dedicate professionals that are taking care of this consuming task. They have the headache of dealing with monthly reports and ensuring that payments are forthcoming in a timely manner and that billing is carried out correctly and with complete transparency.


#4 An Industry That’s Changing
The landscape of healthcare itself is rapidly changing and medical billing has been dragged into the middle of this upheaval. Keeping up with all the changes in the requirements and rules can be difficult. It requires continuous learning. The delete and added CPT codes come out years. Carrier rules and fee changes occur almost daily. Most people simply do not have the necessary time to dedicate to this continuous learning curve. Outsourcing to a team of professionals is very helpful.


#5 Get Paid Faster
Cash flow is the key to your successful practice. Accounts receivable collections have a significant impact on your revenue and your bottom line. This is where outsourcing your medical billing can be beneficial allowing for claims to be submitted faster and with fewer errors. That means you’ll receive your payments in shorter period of time. By outsourcing, you have a team of professionals that all billing to be carried out in a timely manner, and the turnaround time can be significantly reduced.


#6 Focus on What You do Best
You spent so many years going to university to become a doctor so that you can help people. The little free time you have, you probably hate spending on the intricacy of medical billing or maybe you hate having people on staff that cost you a fortune. A better option is outsourcing, where you get a team of professionals at a much lower cost than having your own staff.


#7 Reduced Stress and Increased Cash
A top-notch billing service will charge a percentage for collecting the money but compared to having to run your own billing office and staff it the fee is really quite nominal. You are suddenly getting the highest rate of return from your carriers, which means that you have more disposable income. Almost all practices that outsource their medical billing see an increase in their revenue and a decrease in their billing costs.


ICD-10 is complicated and the number of codes is rising from 13,000 to 68,000. That’s huge! This is going to lead to a significant increase in the number of payer denials and it is expected that there will be a decrease in cycle time. Outsourcing is a great way to save you time and money learning all of the new ICD-10 codes leaving it to a team of well trained professionals.

The post 7 Benefits of Outsourcing Your Medical Billing with ICD-10 appeared first on Outsource Management Group, LLC..

Outsourcing – Outsource Management Group, LLC.

Wiki Icd-10 coding guideline

Shall we bill E11.40(Combination code)for DM and CKD documented with out linakge

In the below link from AHIMA stated we can bill E11.40 combination code since the physician documentation does not need to provide a link between the diagnoses of diabetes and CKD

NOTE-The above mentioned guideline not available in ICD-10-CM Official Guidelines


Medical Billing and Coding Forum – ICD-10

Providers see only minor productivity declines after ICD-10 implementation, according to survey

 By Steven Andrews

A decrease in staff productivity has been the top challenge for providers after ICD-10 was implemented, but relatively few organizations have seen a significant decrease in productivity, according to a recent survey from Navicure.
Despite nearly half of the participants (48%) noting a productivity decline as the top issue, only 13% of administrative staff and 15% of clinical staff saw a significant decrease. Another 46% of administrative staff and 42% of clinical staff didn’t see much of an impact, and the remaining respondents saw a minor impact or didn’t know of one.
The survey included 360 participants representing a broad range of specialties and sizes, with 60% from organizations with one to 10 providers.
Beyond productivity, 20% of respondents said revenue disruption was their top concern. However, 60% of organizations did not see any impact on monthly revenue following the transition. In terms of denial rates, 89% of respondents saw either no change or an increase of less than 10%.
All of these statistics are overwhelmingly positive for the industry, which was subject to constant fear mongering from organizations such as the AMA in the months before the transition, with predictions of massive productivity declines leading to insurmountable revenue problems for countless providers.
Predictions about how much providers would spend to get ready for implementation varied widely, depending on the source. An AMA-funded report from Nachimson Advisors estimated small physician practices would spend approximately $ 57,000-$ 200,000 to get ready. Even though this was already questioned, the actual results from the survey show a much different story.
Half of the respondents spent less than $ 10,000 on training and software updates, with another 14% spending between $ 10,000-$ 50,000. Only 5% spent more than $ 50,000, while 20% weren’t sure how much their organization spent.
And organizations are confident they’re coding correctly. Nearly all of the respondents (99%) reported sending the most specific ICD-10 code either all of the time or sometimes.
Watch for the Revenue Cycle Daily Advisor!
We are happy to announce that beginning January 25 you will be receiving the Revenue Cycle Daily Advisor. This free daily email newsletter combines editorial experts from HealthLeaders Media and HCPro to bring insight and news on every aspect of the revenue cycle, covering topics such as Medicare reimbursement rules and regulations, value-based business models, clinical documentation improvement, health information management issues, patient privacy and security, updates to coding and billing rules, utilization review and case management challenges, and hospital and physician practice reimbursement and compliance.
Your current subscription to APCs Insider will be transferred to the Revenue Cycle Daily Advisor. The last issue of the APCs Insider is scheduled for today, January 22. Please watch for your issue of Revenue Cycle Daily Advisor starting next Monday, January 25. – APCs Insider

Effects of ICD-10 on Coding Production – Example from MGMA Community

Now that ICD-10 has been rolled out, medical coding companies are feeling its effects. The Medical Group Management Association (MGMA) and its affiliates are having to recreate their processes in order to account for the vast increase in the number and variety of codes. What was once a simple system with a mere 13,000 codes is now far more complex with 68,000.

Companies like the Coding Network are forerunners in ICD-10 Readiness, already having switched our processes to get away from the soon-to-be defunct ICD-9. Whether it be a simple audit or a complicated coding project, TCN’s production rate has never been higher.

The post Effects of ICD-10 on Coding Production – Example from MGMA Community appeared first on The Coding Network.

The Coding Network

Newsflash: The AMA is Fighting ICD-10 – is my Blog to Blame?

Okay, so it’s not really news that the American Medical Association is showing R45.4 (Irritability and anger) and R45.5 (Hostility) when it comes to ICD-10.  But are their R45.82 (worries) really worth all the R45.83 (Excessive crying of child, adolescent, or adult)?

Okay, all kidding aside, I hate to admit that blogs like mine might be partly to blame for the backlash, but are they?  In learning ICD-10-CM, it’s just not fun to write blogs and articles about how the ICD-9-CM code for unspecified hypertension will be I10 in ICD-10.  Okay, bad example.  ICD-10 gives us I10 (hypertension).  Oh wait, you’ve heard that one? 

I’ll go out on a limb here and just say it.  Coding is boring.  But I love it anyway and find it fascinating and go out of my way to try to make learning coding fun and enjoyable.  And since in my day job I don’t get to spend a lot of time reflecting on the fun and entertaining external cause codes, I have decided to take to my blog to explore some of the more entertaining ICD-10 codes and inject some humor where I can.  And it’s hard.  Because, as I mentioned, coding is boring.

But with all of the hype on ICD-10 we’ve managed to fool a lot of people into thinking that it’s not really boring no-nonsense work and that what we do is actually very trivial and unimportant.  In an April interview on Fox News, Congressman Ted Poe (R-TX) gave several arguments against ICD-10-CM implementation in the United States and several examples of why the new coding system is ridiculous and unnecessary, including the various codes for injuries by turkeys and dog bites by specific breeds of dogs (BTW – dog bites by breed codes do not exist). 

Indeed, there are some very silly external cause codes, but in an article by the American Health Information Management Association, which wasn’t as well publicized as Congressman Poe’s interview, AHIMA states that there is no national mandate to report external cause codes in ICD-10-CM.  In fact, if providers are not reporting E codes in ICD-9-CM, they won’t be required to report external cause codes in ICD-10-CM.  And since the 1500 billing form, which is used by physicians to report codes to Medicare, only has space for four diagnosis codes, the external cause codes are not likely to play a large role in pro-fee coding and billing.  And then all that’s left is those boring codes in the remaining ICD-10 chapters.

But why isn’t anyone pointing that out?  Well, I suppose it’s just more fun to talk about a code for being pecked by a chicken.  Or struck by a chicken (is that a live chicken or, say, a frozen chicken from the supermarket?!).  But in reality, we are training coders on the important enhancements that ICD-10 coding brings.  Here are a couple of important “for instances” for you:

  • Somewhat simplified sepsis coding (okay, so they couldn’t do it all, but we’ll take somewhat simplified over super confusing any day)
  • One diagnosis code for admission for vaccination (the procedure code indicates the specific vaccine given)
  • OB codes that actually make sense – most of them classify conditions by trimester rather than that “delivered with antepartum complication” nonsense
  • New and specific codes for subsequent acute myocardial infarction (AMI) that occurs within the timeframe of an initial AMI
  • Codes for blood alcohol level (here in Colorado we’re waiting for the blood marijuana content codes – I’m pretty sure Washington is interested too)
  • Bye-bye to encounter for therapy codes (talk about administrative burden – insurance companies hate those V codes for admission for physical/occupational/speech therapy codes; the new code system has a way of denoting that an injury is in the healing phase)
  • Combination codes for diabetic complications (because half the time coders forget to code the second code anyway)

Now don’t get me wrong.  I am not saying that physicians won’t be impacted at all because they will.  We will be asking them to document more clearly but in general we want documentation that really should already be there.  It’s nice to know whether the left or right femur is broken.  I’m pretty sure that it’s not just the coders who are interested.  And even though physicians won’t have to code ICD-10-PCS procedure codes, we will be prompting them for more specific documentation within operative reports. 

And while we’re at it, let’s talk about the volume of codes.  Yes, there are a lot more ICD-10-CM codes than ICD-9-CM codes.  That’s to be expected when they create codes for left, right, bilateral, and unspecified where applicable.  And my favorite quote regarding this issue came from Don Asmonga of AHIMA at a conference last spring: “There are a lot of words in the dictionary, but that doesn’t mean you use all of them.”  Indeed.  There are many codes that we will never use.  And coders aren’t supposed to memorize codes anyway.  In the training I’ve done thus far, coders have actually expressed that having more codes is better – they are able to better drill down to what’s really going on with the patient instead of sticking a junky nonspecific code on the case.

So if you come across a physician who is arguing against ICD-10 implementation, I would suggest that you put the kibosh on the fun code talk and get straight to the boring benefits.  Will ICD-10 impact patient care?  Probably not as directly as nurse finding a medication error before meds are administered.  But the data that is collected on the back end will have implications for future quality initiatives; in fact many of the quality initiatives coming up depend on ICD-10 data.  Besides, even the boring ICD-10-CM codes are more exciting than the same old boring ICD-9-CM codes that no other industrialized nation in the WORLD uses anymore.  I mean, I hate to play the peer pressure card, but seriously, we should be leaders in in medicine – and in collecting medical data.  Who else is on board?
Coder Coach

Coding for Cervical Cancer Screening – Pap test results, definitions and ICD-10

This was originally written back in April of 2016….  
Cervical Cancer Screening – Pap test results, definitions and ICD-10
A Cervical cancer screening test, also known as a Pap (Papanicolaou test) is used to find abnormal changes in the cells of the cervix.  If abnormal cells are found, those cells can potentially mutate into cancer cells within the cervix.   Cervical cancer screening includes the Pap test and, some providers also perform an HPV (Human Papilloma Virus) test. 
When the provider performs a screening or diagnostic Pap test, both tests use cells taken directly from the cervix. The cells that are removed from the cervix, put into a special liquid and sent to the laboratory for testing.  If only the Pap test is performed, the cells are reviewed and examined to see if any “abnormal” cells are present with “normal cells”.  When the HPV testing is performed, the cells are then reviewed to see if the HPV virus is present within that sample.  Most pathology labs will sample for 13 or 14 of the most common high-risk HPV types. 
According to ACOG (The American College of Obstetrics and Gynecology), the main cause of cervical cancer is infection with HPV. Unfortunately, there are many types of HPV, and some of the HPV infections are considered “high-risk” types.  It has been determined that with the most common cases of cervical cancer; most cervical cancers are narrowed down to two high-risk types of HPV—type 16 and type 18.  It is the abnormal cell types that can be found with these screening tests.  Abnormal changes can range from mild to a full blown case of cervical cancer.
Pap tests are most commonly procured at the time of the well woman exam, and are performed primarily as a screening tool for cervical cancer.  However, with the Pap test, sometimes the cells from the vagina are taken if the woman does not have a cervix. 
Pathology Acronyms and Definitions
As coders, we must know and understand all definitions that affect the diagnosis codes that we append to the procedure codes.  It is extremely important that we do not append an incorrect diagnosis to a patients’ medical record or billing.   The acronyms for cervical cancer screening tests are numerous.  Many of these terms have similar sounding verbiage, yet the definitions do not mean the same things. 
When reviewing the pathology documentation, the term ASCUS, is commonly seen.  This acronym means “Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASCUS)”.   Squamous intraepithelial lesion (SIL) is an acronym used to describe Pap test results. “Squamous” refers to the type of cells that make up the tissue that covers the cervix. SIL is not a diagnosis of pre-cancer or cancer.  In ICD-10 the term SIL is not noted, however, ICD10cm does refer to many of the other acronyms associated with pathology cells and cell types that are found with the Pap test.
The Pap test is most commonly performed as a screening test for changes to the cells within the cervix, but can also be used as a diagnostic tool too.   The changes in cell types found on the cervix can be a possible pre-cursor to a cervical cancer, or can be completely benign. If the changes in some of the cells cannot be exactly diagnosed, or noted by how severe the changes are in cervical cells, this would be documented on the pathology report as an ASCUS pap finding. 
To correctly code for an ASCUS pap we would look at the code of R87.610.  (R87.610 Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US).  The R87 code set is part of the codes that are symptoms, signs and abnormal clinical and laboratory findings.  In addition to the ASCUS documentation on a pap result, the terms LGSIL and HGSIL may also be found.   LGSIL acronym stands for “Low grade squamous intraepithelial lesion on cytologic smear of cervix” . The term HGSIL is for the notation of “High grade squamous intraepithelial lesion on cytologic smear of cervix”.
Abnormal cytological findings in specimens from female genital organs
*      R87.610 Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US)
*      R87.612 Low grade squamous intraepithelial lesion on cytologic smear of cervix (LGSIL)
*      R87.613 High grade squamous intraepithelial lesion on cytologic smear of cervix (HGSIL)
Atypical squamous cells, cannot exclude HGSIL the possibility that there have been changes in the cervical cells found that raise concern for the presence of HGSIL.
Atypical glandular cells (AGC)—Glandular cells are another type of cell that makes up the thin layer of tissue that covers the inner canal of the cervix. Glandular cells also are present inside the uterus. An AGC result means that changes have been found in glandular cells that raise concern for the presence of pre-cancer or cancer.
If the term cervical dysplasia is documented, this term indicates that abnormal cells were found on the surface of the cervix.  A cervical dysplasia is classified as mild, moderate or severe, depending on the appearance of the abnormal cells.  Cervical dysplasia can disappear on its own or, it can develop into a more malignant form such as a neoplasm/cancer. Cervical dysplasia is also known as a Cervical Intraepithelial Neoplasia, or denoted as CIN. 
In ICD-10, if the term “mild cervical dysplasia” is documented and/or the term CIN I the corresponding code in ICD-10cm is to be coded to N87.0.    If the term “moderate cervical dysplasia”  and/or CIN II is documented, those terms correlate to be coded as N87.1.    However, if the term “severe cervical dysplasia”  and/or CIN III is documented , ICD-10cm guides us to the code set of D06.# and is denoted in ICD-10cm as a carcinoma in situ of the cervix uteri.   If the provider did not specify if the dysplasia is mild, moderate or severe, then the unspecified code of N87.9 should be chosen.   If the documentation is noted to be severe, then the code chosen in the D06’s needs to be specified as to endocervix, exocervix, other parts of cervix, or unspecified.   As you can see from the codes below a severe dysplasia is considered to be a carcinoma, in situ; meaning it is contained within the cervix . 
D06 Carcinoma in situ of cervix uteri is a specific ICD-10-CM diagnosis code D06.0 Carcinoma in situ of endocervix is a specific ICD-10-CM diagnosis code D06.1 Carcinoma in situ of exocervix is a specific ICD-10-CM diagnosis code D06.7 Carcinoma in situ of other parts of cervix is a specific ICD-10-CM diagnosis code D06.9 Carcinoma in situ of cervix, unspecified
 N87 Dysplasia of cervix uteri is a specific ICD-10-CM diagnosis code N87.0 Mild cervical dysplasia is a specific ICD-10-CM diagnosis code N87.1 Moderate cervical dysplasia is a specific ICD-10-CM diagnosis code N87.9 Dysplasia of cervix uteri, unspecified
Glandular cells are another type of cell that make up the thin layer of tissue that covers the inner canal of the cervix.  Atypical glandular cells (AGC) can also be denoted on the pathology report, and those cells may be present in the specimen that was procured at the time of the Pap test.  These glandular cells also are present inside the uterus.  If a pap test denotes the patient has an AGC result, this represents changes have been found in glandular cells, which raises the concern for the presence of pre-cancer or cancer not only on the cervix, but a possibility of cancer cells that may be present in the uterus.
If the patient does have an abnormal cervical cancer screening (Pap) test result, the patient may require further testing. The first line of treatment is most often a repeat Pap test or a repeat Pap test and include testing for high-risk types of HPV.  Additional testing or procedures are recommended as a follow-up to some abnormal test results.  In addition to the Pap test, the provider may want to perform a colposcopy, biopsy, and endocervical sampling.  A colposcopy procedure is an examination of the cervix with a magnifying device that includes the tools to take a more in-depth sample of the cervix or targeted area on the cervix.
If an area of abnormal cells is seen, the physician may decide to perform a cervical or vaginal biopsy.   An endocervical and possibly an endometrial sample biopsy also may be done if the initial pap did show AGC.  As with any screening or diagnostic testing, follow up with the provider is crucial. 
When coding any of these tests, be sure that all results are clearly documented by the provider.   When coding for the initial procurement of the pap test, the codes below would be used  to bill for the procedure/procurement of the pap specimen, and for connecting the diagnosis driver to the screening process through the designation of an E&M code for the Wellness/well-woman exam. 

CPT codes 99384 – 99387 (new patient)
CPT codes 99394 – 99397 (established patient)
ICD-10: Z12.4 Encounter for screening for malignant neoplasm of cervix
ICD-10: Z12.72 Encounter for screening for malignant neoplasm of vagina
ICD-10: Z12.79 Encounter for screening for malignant neoplasm of other genitourinary organs
HCPCS: Q0091 Screening Pap smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory
            Note: The HCPCS Code Q0091 is a HCPCS code developed by Medicare for services provided to Medicare patients.  Medicare allows payment of code Q0091 for the collection of the pap specimen itself, and should only be reported if performed as a screening process.  The Q0091 is not to be reported if the pap testing is performed for a diagnostic or medically indicated reason.
In the table below, the most common CPT and HCPCS codes reported out by the laboratory for testing
Code Number
Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, direct probe technique (Deleted 12-31-2014)
Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, amplified probe technique (Deleted 12-31-2014)
Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus (HPV), human, quantification (Deleted 12-31-2014)
Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44) (New 01-01-2015)
Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) (New 01-01-2015)
Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed (New 01-01-2015)
Cytopathology, cervical or vaginal, (any reporting system) collected in preservative fluid, automated thin layer preparation, manual screening under physician supervision (ThinPrep)
Cytopathology, cervical or vaginal, (any reporting system) collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening under physician supervision
Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision
Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision
Cytopathology, slides, cervical or vaginal, with manual screening and computer-assisted rescreening under physician supervision
Cytopathology, slides, cervical or vaginal, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision
Cytopathology, slides, cervical or vaginal, (Bethesda System); with manual screening and computer-assisted rescreening under physician supervision
Cytopathology, slides, cervical or vaginal, (Bethesda System); with manual screening and computer-assisted rescreening using cell selection and review under physician supervision
Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision
Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening, under physician supervision
HCPCS (normally used for Medicare patients)
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician
Screening cytopathology, smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under physician supervision
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system, under physician supervision
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under physician supervision
Screen cytopathology smears, cervical or vaginal, performed by automated system under physician supervision
Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening
Screening Papanicolaou smear, cervical, or vaginal, up to three smears, by technician under physician supervision
Screening Papanicolaou smear, cervical, or vaginal, up to three smears, requiring interpretation by physician
Wrapping it up
As a coder, remember to code what you know, and do not assume a correlation, or that similar “sounding” terms really mean the same thing.   If in doubt, or the documentation does not appear to be clear or is confusing, query the provider.  Good patient care requires the provider to accurately reflect the patient care via their documentation in the medical record.  Our job, as a coder, is to correlate the coding and billing to reflect the medical that was documented and provided by the physician.  If you are unsure about the coding guidelines utilize your resources such as CPT, ICD-10cm, ICD-10pcs and HCPCS. 

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at or you can also find current coding information on her blog site:   

Lori-Lynne’s Coding Coach Blog

From the Trainer: ICD-10 FAQ #1 – If the US is the last to implement, why are there so many unknowns?

For the last year, I’ve traveled across the country providing ICD-10-CM and ICD-10-PCS education to coders and clinical documentation specialists.  Our company’s model provides three separate training sessions for our clients: basic, intermediate, and advanced.  This means lots of repeat visits to each client, lots of really hard questions, and tons of professional growth for me.  I thought it was time to start a new series here on my Coder Coach blog: ICD-10 FAQs.  This is a question I’ve been asked a lot lately as we get into advanced trainings and more controversial topics:

If the United States is the last country to implement ICD-10, why are there so many unanswered coding questions and why do we have to wait for Coding Clinic advice?

While it seems logical that someone would have figured out all of this ICD-10 stuff within the last 20 years as we’ve been “messing around” here in the US (please note the sarcasm, because I don’t really think we’ve been messing around; we’ve actually been quite busy), the reality of the situation is that the US version of ICD-10 is different from everyone else’s.  The core ICD-10 code set was developed by the World Health Organization (WHO) and classifies causes of morbidity (i.e., diagnoses) and every country has the ability to adapt it further (e.g., ICD-10-CA in Canada, ICD-10-AM in Australia, ICD-10-CM in the US).  Two things should have jumped out at you based on this statement:

  1. ICD-10 diagnosis codes may be different in Canada, Australia, and the US
  2. The international code set does not  include procedures

Let’s tackle #1 first.  The US version of the ICD-10 diagnosis codes, ICD-10-CM, is a clinical modification (BTW – that’s what the “CM” stands for; it’s not “coding manual” like some people seem to think).  It is based on the WHO version, but has been adapted for use here in the good ole United States of America.  I haven’t had a ton of time to compare it to the original, but what I do know about the CM version is this:
  • The Excludes1/Excludes2 convention, which solves a lot of problems from ICD-9 (and creates a few new ones) is not part of the WHO version
  • The use of 7th character extensions for injuries and poisonings is not part of the WHO version
  • The expansion of the external cause codes, which are not required for reporting, are not nearly as extensive in the WHO version
  • While we have adapted diabetes terminology in the US to Type 1 and Type 2 diabetes, the WHO version still uses the insulin-dependent diabetes mellitus (IDDM) and noninsulin-dependent diabetes mellitus (NIDDM) terminology that we’ve worked so hard to banish from our medical record documentation here in the States
Most of the really hard diagnosis questions I get about coding ICD-10 diagnoses revolve around the changes that are unique to the CM version.
As for the procedural component, ICD-10-PCS (which stands for procedure coding system), that was developed in the US by CMS under contract with 3M.  Although I’ve heard that other countries have plans to adopt PCS, right now the US is the only country using it.  Although other countries have procedural coding systems, it’s important to remember that we are the only ones using coding for reimbursement.  For that reason, we will likely place more weight on those procedure codes than other countries and when it comes to PCS, it’s uncharted territory.
Hopefully that answers a couple of questions about the ambiguity of ICD-10.  And may I also just point out that this is nothing new.  Coding has always undergone an evolutionary process.  We have seen it with ICD-9-CM and CPT.  It’s the reason we have official publications like the Coding Clinic and CPT Assistant.  If you are not familiar with these publications, you need to be.  They are official resources that answer a lot of questions.  And as of second quarter of this year, the American Hospital Association has stopped publishing Coding Clinic for ICD-9-CM and is only publishing Coding Clinic for ICD-10-CM/PCS.  My colleagues and I have been monitoring the publication very carefully each quarter because their advice does change some previous assumptions many have made based on what we know about these new coding systems.

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