Coding Clinic Advice Highlights from First Quarter

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Original story posted on: May 6, 2019

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Guidance and advice effective with discharges occurring on and after March 20, 2019.

 For coding and CDI (clinical documentation improvement/integrity) professionals, it’s exciting to read over the American Hospital Association (AHA) Coding Clinic on ICD-10-CM/PCS. This publication is a must-have document with must-follow guidance.

Although ICD10 University held a webinar regarding this topic in April, let’s take a look at some highlights from the first quarter of 2019.

First, please note that the AHA Central Office is the publisher of the AHA Coding Clinic for ICD-10-CM and ICD-10-PCS and the AHA Coding Clinic for HCPCS. AHA Coding Clinic for ICD-10-CM and ICD-10-PCS represents a formal cooperative effort between the AHA, the American Health Information Management Association (AHIMA), the Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), and the Centers for Medicare & Medicaid Services (CMS). 

There were two featured topics within the publication this time:

  • HIV and related conditions
  • Whipple procedure(s)

HIV, or human immunodeficiency virus, and AIDS, or acquired immunodeficiency syndrome, have many related conditions, but sometimes the coding professional is unsure if a specific condition is “related” or not.

Provider documentation is critical for accurate coding, as we know, but there can still be confusion. There may be situations in which the clinical documentation does not provide the linkage of HIV to another condition; in such a scenario we need to query for clarification.

  • When a patient has a history of HIV and also has pneumonia, you cannot assign the B20 code. Rather, assign Z21, Asymptomatic human immunodeficiency virus infection status.
    • You may need to query the physician for clarification regarding the patient’s HIV status and whether the pneumonia is related to HIV (do not assume).
  • ICD-10-CM code B20 is for Human immunodeficiency virus (HIV) disease. Provider documentation must state that the patient has AIDS or HIV in order to assign B20.
  • We/you cannot automatically link B20 to related conditions based on the clinical illness list(s).
    • Example: CDC AIDS-related illness list
  • Assign code Z21, Asymptomatic human immunodeficiency virus (HIV infection status):
    • When the clinical documentation states “HIV positive,” or “known HIV,” or “HIV test positive.”
    • Query the provider if the documentation is not clear.

Additional advice to be aware of:

  • Develop internal coding guidelines (a policy) to help promote and obtain complete and specific documentation.
  • Internal coding guidelines cannot interpret abnormal findings due to a lack of clinical documentation.
  • Your internal coding guidelines cannot conflict or be contrary to the Official Guidelines for Coding and Reporting.
  • Check on state-specific reporting requirements regarding HIV/AIDS (i.e., California).
  • Provider awareness and education on the HIV ICD-10- CM classification can help.
  • Identify when to query the provider.
    • Follow the practice brief from February 2019 AHIMA/ACDIS, “Achieving a Compliant Physician Query Practice.”

The Whipple procedure is usually required due to pancreatic cancer. Surgical treatment via “Whipple” can have several different versions. Surgical goals are primarily to remove to the head of the pancreas, but often, due to the nature of the organ and disease, additional resections are needed for the following organs:

  • Duodenum
  • Gallbladder
  • Common bile duct
  • Portion of stomach

Conventional Whipple procedure is a “pancreaticoduodenectomy” or “pancreatoduodenectomy,” which includes removal of head of the pancreas and the encircling loop of the duodenum. Then there is a reconstructing of a large part of the gastrointestinal tract. A Pylorus sparing Whipple results in improved nutritional status post-op. With ICD-10-PCS, the approach choices include:

  • Open, laparoscopic, and with or without robotic assistance

The Whipple procedure removes involved body parts, and in ICD-10-PCS, that means excision. If complete removal of the pancreas is performed, then “resection” is used for coding. Anastomosis is considered inherent to the procedure and is not coded separately. When the surgery includes a diagnostic laparoscopy, resection of the duodenum and gallbladder, excision of the stomach, pancreas, common bile duct, and jejunum, ICD-10-PCS code assignment includes (open up your code books) seven PCS codes to capture the full extent of this surgical procedure:

  • Resection of duodenum, open
  • Resection of gallbladder, open
  • Excision of stomach, open
  • Excision of pancreas, open
  • Excision of common bile duct, open
  • Excision of jejunum, open
  • Inspection of peritoneal cavity, perc. endoscopic

(There are three additional surgical scenarios within this Coding Clinic issue, so be sure to review these carefully.)

The ICD-10-CM coding of emphysema was also cited in the latest edition of Coding Clinic, with the AHA providing guidance for the following clinical scenarios:
 

If a patient has COPD in exacerbation and emphysema, what do we assign? Which of the following? (Note that emphysema is a form of COPD.)

  • J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
  • J43.9 Emphysema, unspecified

Remember, instructional note “excludes 1” at J44 does not allow for codes J43.9 and J44.1 to be coded together. Thus, we only code J43.9 Emphysema, unspecified. There is a concern that this instructional note does not allow for the full acuity of this disorder to be captured, and so the Coordination and Maintenance Committee is looking into this for future revision of the instructional note. Note that AHA Coding Clinic for the fourth quarter of 2017 also provided this coding advice: only assign J43.9 when COPD is in exacerbation and emphysema is present.

Another scenario is the following:

 If a patient has emphysema and COPD but is being treated for acute bronchitis, what is the correct code(s) to assign? Which of the following?

  • J44.0 Chronic obstructive pulmonary disease with an acute lower respiratory infection
  • J43.9 Emphysema, unspecified
  • J20.9 Acute bronchitis, unspecified

Again, it was stated in the Coding Clinic that “emphysema is a form of COPD.” There is an instructional note “excludes 1” at J44, which, as mentioned, does not allow J44.0 and J43.9 to be coded together. We would assign codes J43.9 and J20.9 when a patient has emphysema, COPD, and acute bronchitis. The Coordination and Maintenance Committee is also looking into a future revision with the instructional note. This respiratory diagnosis coding might be an area for auditing.

Another common clinical situation that produces confusion is when a patient has sick sinus syndrome (SSS) and there is a cardiac pacemaker device present. Do we code the SSS also?

Yes, also code the SSS diagnosis (I49.5) along with the code for the presence of pacemaker device (Z95.0).  Even with the presence of the pacemaker, the SSS is still present (albeit managed/monitored); it has not been cured. Also, follow the ICD-10-CM Official Coding & Reporting Guidelines for “other diagnoses.”

 The Official Guidelines for Coding and Reporting state that for reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care, in terms of requiring:

  • Clinical evaluation;
  • Therapeutic treatment;
  • Diagnostic procedures;
  • Extended length of hospital stay; or
  • Increased nursing care and/or monitoring.

Be sure to review the full narrative within the latest AHA Coding Clinic. This guidance applies to all settings. Think about conducting some audits with Z95.0, and ensure that accurate and compliant coding is performed.

Sequencing principal diagnosis codes when both acute renal injury, or ARI (acute renal failure), and dehydration are present and being treated will depend on the documentation. For inpatient coding, the reason for the admission will determine the principal diagnosis. There is no specific coding rule to sequence ARI as the principal diagnosis. If the documentation is not clear, then query the provider.

In the ICD-10-PCS coding section, a question regarding coding a colon interposition surgery was addressed. The blood supply and colon is kept intact during surgery, and when the colon interposition is complete, this results in the root operation of “transfer.” For example (for the esophagus):

  • 0DXE0Z5 Restriction large intestine to the esophagus, open approach, for colon interposition
  • Esophagectomy is performed first.

When the surgery is being done in order to perform harvesting of the colon for a free graft, then the root operation is “replacement.”

Another ICD-10-PCS coding question centers on the GI tract. There are times when a small bowel obstruction can require surgery. If surgery is needed, a midline incision will be made, and the abdomen will be examined to identify where the obstruction is. If blockage material is at the ileum and milking of the intestine is performed, the ICD-10-PCS code would only need to represent the examination or inspection. Assign Code 0DJD0ZZ, Inspection lower intestinal tract, open. The milking of material into the intestine is not coded separately.


Within the “questions and answers” portion of the latest Coding Clinic, there were 25 diagnostic topics discussed, and coding guidance was provided. In addition, there were 16 inpatient procedural coding topics covered. Be sure to read over the full content of the issue, as this article contains only some of the topics of the published guidance.

It’s important to note that the guidance and advice are effective with discharges occurring on and after March 20, 2019.

Reference: www.ahacentraloffice.org/aboutus/aboutus.shtm; AHA Coding Clinic 2019 Q1

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICd-10-CM/PCS Trainer, is a 40-year HIM coding professional, focusing on compliance and ethics. She is a member of the ICD10monitor editorial board, and a popular panelist on Talk Ten Tuesdays.

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