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.
Orthopedics
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.
Cardiovascular
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.
Neurology
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 www.hcprobootcamps.com.This article was originally published in Briefings on Coding Compliance Strategies.