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Malnutrition is at its most basic level any nutritional imbalance. While it can be overnutrition, such as being overweight, obese, or morbidly obese, providers more commonly equate malnutrition with undernutrition, which is a continuum of inadequate intake, impaired absorption, altered transport, and altered nutrient utilization.

Before 2012, no standard criteria existed for adult or pediatric malnutrition. Providers often equated low serum albumin or prealbumin with malnutrition, even if there was no weight loss or dietary invention. As a result, the Baltimore U.S. Attorney launched fraud and abuse investigations against Johns Hopkins Bayview, Good Samaritan Hospital, and Kernan Hospital, all in Baltimore, within the past five years.

Malnutrition is also underdiagnosed, given the lack of physician knowledge of standardized criteria and a dependence on the serum albumin or prealbumin as a clinical indicator, according to James S. Kennedy, MD, CCS, president of CDIMD in Smyrna, Tennessee.

The landscape changed dramatically in 2012 with the release of a consensus statement by The American

Master malnutrition definitions, coding rules

Don’t forget about approach for ICD-10-PCSMake sure you know the seven different approaches in the Medical and Surgical section.

Start resolving ICD-10-CM questionsSee what AHA’s Coding Clinic has to say about some ICD-10-CM coding questions.

Clinically SpeakingRobert S. Gold, MD, reviews the use and coding of bronchoscopy and transbronchoscopic lung biopsy.

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Inside: Coding Q&A insert

NOVEMBER 2014Volume 22Issue No. 11

Academy of Nutrition and Dietetics (the Academy) and the American Society for Parental and Enteral Nutrition (ASPEN) standardizing the criteria for adult malnutrition.

In their paper, the Academy and ASPEN stated that non-severe (moderate) and severe malnutrition in various inflammatory states should be diagnosed when criteria in at least two of the following six categories are identified:

• Insufficient energy intake• Weight loss• Loss of muscle mass• Loss of subcutaneous fat• Localized or generalized fluid accumulation that

may sometimes mask weight loss• Diminished functional status as measured by hand

grip strength

The Academy and ASPEN do not differentiate be-tween mild and moderate malnutrition in adults, classi-fying both as “nonsevere (moderate)”, Kennedy says.

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November 2014Briefings on Coding Compliance Strategies

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Briefings on Coding Compliance Strategies (ISSN: 1098-0571 [print]; 1937-7371 [online]) is published monthly by HCPro, a division of BLR, 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate: $269/year. • Briefings on Coding Compliance Strategies, P.O. Box 3049, Peabody, MA 01961-3049. • Copyright © 2014 HCPro, a division of BLR. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, a division of BLR, or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email [email protected]. • Visit our website at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of BCCS. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

EDITORIAL ADVISORY BOARDLori Belanger, RN, BSN, RHITInpatient Coder/CDI SpecialistNorthern Maine Medical Center Fort Kent, Maine

Paul Belton, RHIA, MHA, MBA, JD, LLMVice President Corporate ComplianceSharp HealthCare San Diego, California

Gloryanne Bryant, RHIA, CCS, CDIP, CCDS HIM ConsultantFremont, California

William E. Haik, MD, FCCP, CDIPDirectorDRG Review, Inc. Fort Walton Beach, Florida

James S. Kennedy, MD, CCSPresidentCDIMD Smyrna, Tennessee

Laura Legg, RHIT, CCS HIM and Coding Consultant Renton, Washington

Monica Lenahan, CCSManager of Coding Education and ComplianceRevenue Management Centura Health Englewood, Colorado

Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDSDirector of Coding and HIMHCPro Danvers, Massachusetts

Jean Stone, RHIT, CCS, CDIPManager of Clinical Documentation Integrity Program/HIMSLucile Packard Children’s Hospital at Stanford Palo Alto, California

Senior Managing EditorMichelle Leppert, [email protected]

This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission.

ICD-9-CM and ICD-10-CM classifies “non-severe” malnutrition as “unspecified,” meaning the provider would have to document “moderate malnutrition” to obtain the ICD-9-CM or ICD-10-CM code specificity implied in this consensus statement.

ASPEN and the Academy further stated that serum albumin, pre-albumin, and similar biometrics are NOT useful indicators for malnutrition, given that serum levels of these proteins do not change with nutritional interventions, says William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Florida.

“The reason being that they all are actually what we call acute phase reactants, meaning that they’re falsely lowered in patients who have inflammation, even if that inflammation is chronic or very subtle,” Haik says. “A patient with just merely starvation has inflammation, so the other tests we can do show inflammation.”

Pediatric criteria broke new groundNot to be outdone, an interdisciplinary ASPEN

workgroup of physicians, nurses, dieticians, and pharmacists later release standardized pediatric malnutrition criteria in 2013. The American Academy of Pediatrics endorsed the criteria.

Unlike the adult criteria, ASPEN classified pediatric malnutrition according to the age dependent World Health Organization (WHO) (age < 2 years) or CDC (age 2 to 20) anthropometric relationships to growth curves, known as Z-scores, and retained the ICD-9-CM classification of mild, moderate, and severe malnutrition.

“The pediatric criteria is ground-breaking,” says Kennedy. “Coders, clinical documentation specialists, and pediatricians in children’s hospitals now have a definitive reference whereby pediatric malnutrition can be diagnosed and, if present, documented and coded as to measure its impact on resource utilization and outcomes.”

Compliance officers benefit also because Z-scores are not as subjective as some of the metrics in the adult criteria, Kennedy says.

Briefings on Coding Compliance StrategiesNovember 2014

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report 260, Kennedy adds. If coders are uncertain about whether the patient has kwashiorkor, they should query the provider.

CachexiaCachexia is a multifactorial syndrome characterized by

severe body weight, fat, and muscle loss and increased protein catabolism due to underlying disease(s). Ca-chexia is considered the result of the complex interplay between underlying disease, disease-related metabolic alterations, and, in some cases, the reduced availability of nutrients.

A review of cachexia in cancer patients is available at http://www.tinyurl.com/CaCachexia. In this review, the criteria for cancer-related cachexia mirror the Academy/ASPEN criteria for malnutrition. Physicians will use these terms interchangeably, even though they are quite different.

Coders will more often see an actual diagnosis of mild, moderate, or severe malnutrition instead of cachexia, says Mindy Hamilton, RD, LD, a registered dietitian from Kansas City, Missouri. Cachexia may be present, but the patient could be a 90-year-old woman who lives alone, doesn’t take in a lot of food, and still gets the nutrients that she needs, Hamilton says.

Cachexia by itself or due to cancer or malnutrition is classified by the ICD-9-CM Index as 799.4 (cachexia). If the physician only documents cachexia, coders must query to determine cachexia’s etiology, because the ICD-9-CM Alphabetic Index considers cachexia to be integral to a number of other conditions when they coexist, including:• Hypopituitarism• Heart disease• Lead poisoning• Old age• Malaria• Tuberculosis

ICD-10-CM is similar, but differs in that a code for ca-chexia may not be used if marasmus is also documented.

ICD-9-CM classifies the term “wasting” to 799.4, and wasting due to malnutrition is classified as 261. The ICD-9-CM Index to Diseases also classifies the term “emaciation,” an excessive leanness or wasting of the body, as 261 (a MCC in MS-DRGs). Coding Clinic for

Marasmus and kwashiorkorIn the criteria, neither the Academy nor ASPEN

discussed other nutritional definitions, such as marasmus and kwashiorkor, which have challenging ICD-9-CM and ICD-10 codes that affect most severity and risk adjustment methodologies.

Marasmus is generally defined as generalized starvation with loss of body fat and protein. While not common in the United States, it may be seen in patients who have anorexia nervosa or other eating disorders.

Kwashiorkor is generally defined as selective protein malnutrition with edema and a fatty liver. It occurs mainly in connection with acute, life-threatening illnesses such as trauma and sepsis and with chronic illnesses that involve acute-phase inflammatory responses. The now calls kwashiorkor “severe acute malnutrition.”

ICD-9-CM code 260 (kwashiorkor) has generated coding compliance scrutiny exhibited by articles in the California media and investigations by the HHS Office of Inspector General.

The ICD-9-CM Index to Diseases fueled this controversy by classifying any documented protein malnutrition to kwashiorkor (an MCC in MS-DRGs) until advice from Coding Clinic for ICD-9-CM, Third Quarter, 2009, page 6, stated that documented mild or moderate protein malnutrition codes to its respective malnutrition code (a CC in MS-DRGs), not kwashiorkor.

Coding Clinic was silent on how to code “protein malnutrition” without a statement of its severity, lead-ing some hospitals to continue to assign code 260 when the physician only documents protein malnutrition based on the code’s listing in the ICD-9-CM Index to Diseases.

The ICD-10-CM Index to Diseases classified “protein malnutrition” only as E46, (unspecified protein calorie malnutrition), not as kwashiorkor nor with the severity levels associated with the protein-calorie malnutrition codes.

Given that kwashiorkor is rare in the United States and that this diagnosis is being monitored by the OIG, coders should not report ICD-9-CM code 260 (kwashiorkor) when a physician only state protein malnutrition, Haik says.

The physician should explicitly document the term “kwashiorkor” in the medical record before coders



ICD-9-CM, First Quarter 2013, page 13, states that “marasmus” be coded as 799.4, (a CC in MS-DRGs), unless the physician explicitly documents that the patient has malnutrition. Whether this concept applies in ICD-10-CM requires further clarification from Coding Clinic for ICD-10-CM.

While ICD-9-CM classified cachexia due to malnutri-tion as only 799.4, many coders may add an additional code for the documented malnutrition. Auditors may challenge this because the index classifies cachexia due to malnutrition as 799.4, and does not explicitly allow for the addition of a malnutrition code, Kennedy says.

On the other hand, if cachexia only coexists with (and is not “due to”) malnutrition, coders may report an additional code for the documented malnutrition because the provider did not state that the cachexia was due to the malnutrition. (Coding Clinic, Second Quarter, 2012, pp 20-21)

Nutritional deficiency, starvation, and malnutritionIn coding nutritional deficiency states, coders must

remember that ICD-9-CM and ICD-10-CM code assignment is based upon complete and consistent provider documentation of clinically valid conditions and proper use of the ICD-9-CM Index and Table to Diseases. Recovery auditors are authorized to challenge these codes if the circumstances do not support the documented diagnosis upon which the code is based.

Documentation of the term “deficiency” with various adjectives offer coding and compliance challenges. In the ICD-9-CM Index to Diseases, the term “deficiency” with various adjectives include:• Calorie, severe: 261, marasmus• Edema: 262, other severe protein-calorie

malnutrition• Multiple, syndrome: 260, kwashiorkor • Nutrition, nutritional: 269.9, unspecified nutritional

deficiency• Specified NEC: 269.8, other nutritional deficiency• Protein 260: kwashiorkor

“A dietary deficiency in and of itself is not coded as malnutrition unless ICD-9-CM specified adjectives with the deficiency are added to it,” Kennedy says. “Even so, if only a specified nutritional deficiency coding to malnutrition is documented, given the Coding Clinic

advice for emaciation referenced above, I would query the provider to ascertain the validity of the malnutrition code before it is submitted.”

ICD-9-CM classifies starvation and food deprivation by itself with code 994.2 (effects of hunger). Coders can’t assume a patient is malnourished just because the physician writes starvation, Kennedy says. The physician must define and document the malnutrition.

Coders can locate the appropriate code for the degree of malnutrition by first referencing the ICD-9-CM Index to Diseases, following the instructions in the Table to Diseases, and being aware of pertinent Coding Clinic advice.

If a physician documents “moderate-severe malnutrition,” coders or CDI specialists must query the physician to determine which term applies, according to Coding Clinic, Third Quarter 2012, p. 10. If the answer is “severe,” assign code 261. If the answer is “moderate,” assign code 263.0 (malnutrition of moderate degree).

“We cannot code that documentation unless we query the physician,” Kennedy says. The answer will affect the MS-DRG because 261 is an MCC, while 263.0 is only a CC.

Coding guidelines impact malnutrition-related code assignment

Coders also need to keep the ICD-9-CM Official Guidelines for Coding and Reporting in mind when coding malnutrition.

Physicians are allowed to think out loud and use terms like “probable,” “suspected,” “likely,” “ques-tionable,” “possible,” or “still to be ruled out” in their documentation, Kennedy says.

However, coders can only report these uncertain conditions if the physician documents them at the time of discharge (e.g. in the discharge summary, discharge note, or discharge order) and if the clinical circumstances or treatment reasonably support the coded diagnosis. Coding Clinic, Third Quarter, 2005, page 22 emphasized that admitting or interim notes cannot be used for uncertain diagnoses.

According to the ICD-9-CM Official Guidelines for Coding and Reporting, coders may report body mass index (BMI) and pressure ulcer stages based on medical record documentation from clinicians (e.g. nurses or dieticians) who are not the patient’s



Don’t forget about approach for ICD-10-PCS

ICD-10-PCS codes consist of seven characters, each of which identifies a unique, specific piece of information. For most of the codes in the Medical and Surgical section, each character represents the same information every time.

The fifth character in every code identifies the ap-proach. In the Medical and Surgical section, coders will find seven different approach characters composed of three components: • Access: The skin or mucous membranes and external

orifices are the two types of access locations, says Laura Legg, RHIT, CCS, AHIMA-approved ICD-10-CM/PCS trainer, and HIM director at Healthcare Resource Group in Spokane Valley, Washington. All approaches except external include one of these two access locations. The physician can cut or puncture the skin or mucous membrane to reach the procedure site. All open and percutaneous values use this access location. Access through an external opening can involve either a natural or artificial orifice.

• Location: Instrumentation is the specialized equip-ment used to perform the procedure, Legg says. All internal approaches require instrumentation. En-doscopic refers to approach values that permit the site to be visualized.

• Method and instrumentation: With procedures on an internal body part, method specifies how the ex-ternal access location is entered, Legg says. The open method specifies cutting through the skin or mucous membrane to expose the site of the procedure.

Defining the approach “The approach identifies the technique used to reach

the procedure site,” says Nena Scott, MS, RHIA, CCS, CCS-P, director of education at TrustHCS in Springfield, Missouri. “There are different approaches based upon each section.”

In the Medical and Surgical section, coders will choose between the following approaches:

• An open approach (character value 0) is defined as cutting through the skin or mucous mem-brane and any other body layers necessary to expose the site of the procedure. The access location for this approach is through either the skin or a mucous membrane. The type of instrumentation used is not applicable, Scott says.

Physicians don’t have to specify “open” in the name of the procedure. For example, a physician may describe an abdominal hysterectomy. The pro-cedure is not defined as “open,” but in the operative report, the surgeon describes cutting through the skin to reach the uterus in order to remove it. If the procedure is performed vaginally, then the approach is not open.

• A percutaneous approach (character value 3) involves entry, by puncture or minor incision, of in-strumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure. The access location for this approach is the skin or mucous membrane with nonvisualization instrumentation such as needles or catheters being

provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis). Coding Clinic, Fourth Quarter, 2008, page 19, however, states that a BMI documented by a dietician cannot be coded unless the provider documents a nutritionally-related diagnosis, such as obesity, overweight, underweight, or malnutrition, Kennedy says. These affirm that the BMI code meets the guidelines’ definition of an additional diagnosis.

While coders may not code obesity, morbid obesity,

or malnutrition from a dietician’s note, given that dieticians are providing direct patient care and are expert in malnutrition’s clinical criteria, some hospitals allow dieticians to add clinically valid nutritional diagnoses to the problem list. If that list is imported into a progress note and authenticated by a treating provider, the condition may then be coded. To ensure coding compliance, the provider should document the progress of the nutritional diagnosis with the dietary intervention and optimally add the nutritional diagnosis to the discharge summary. H



used to reach the operative site. Biopsies can be done via the percutaneous approach when the physician uses a needle to perform the procedure.

• A percutaneous endoscopic approach (char-acter value 4) is defined as entry, by puncture or minor incision, of instrumentation through the skin or mu-cous membrane and any other body layers necessary to reach and visualize the site of the procedure. The access location for this approach is the skin or mucous mem-brane with visualization instrumentation being used to reach the operative site. Laparoscopic procedures are the most common procedures using this approach.

• An approach made via either a natural or artificial opening (character value 7) is defined as entry of instrumentation through a natural or artificial external opening to reach the site of the procedure. The access location for this approach is an orifice with nonvisualization instrumentation being used to reach the operative site. This would include an orifice, such as a nose, ear, or rectum. It would also include an artificial external opening, such as a colostomy. This approach includes instrumentation without visualization. There-fore, an endoscope would not be used to visualize the procedure. An example is insertion of an endotracheal tube, which is done through the mouth without use of an endoscope.

• A natural or artificial endoscopic approach (character value 8) is defined as entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure. The access location for this approach is an orifice with visualization instrumentation being used to reach the procedure site. The access location is still through an orifice, but the difference from the previous approach is the visualization. An example is a sigmoidoscopy. Here, an endoscope is inserted into the rectum to view the sigmoid colon.

• An approach made via natural or artificial opening with percutaneous endoscopic assistance (character value F) is defined as entry of instrumentation through a natural or artificial external opening and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure. For this approach, the access location is the skin or mucous membrane. The instrumentation is with visualization (endoscope).

An example is a laparoscopic-assisted vaginal hyster-ectomy. In this procedure, the uterus is removed via the vagina, but a laparoscope is used to assist in the procedure.

• An external approach (character value X) is one in which the procedure is either performed directly on the skin or mucous membrane or indirectly by application of external force through the skin or mucous membrane. The method used is direct or indirect application of external force, and no instrumentation is used. An example is a closed fracture reduction.

Each table in ICD-10-PCS also has different com-binations of possible approaches. For example, a physician may remove the prostate using any of these approaches:• Open• Percutaneous• Percutaneous endoscopic• Via natural or artificial opening• Via natural or artificial opening endoscopic

For a resection of the sternum, however, the physi-cian can only use an open approach. That is the only value available in the ICD-10-PCS table.

For removal of an upper tendon, the surgeon can use:• Open• Percutaneous• Percutaneous endoscopic

ICD-10-PCS does not include a choice for a mini-mally invasive approach because this term cannot be defined, says Gretchen Young-Charles, RHIA, senior coding consultant for the American Hospital Association in Chicago.

“There is no consensus among physicians on a definition,” Young-Charles says.

The object of minimally invasive surgery is to leave the body as intact as possible. In order to determine the correct approach, coders must refer to the definitions of the approaches in ICD-10-PCS, Young-Charles says.

Approach guidelinesICD-10-PCS includes specific guidelines to help

coders identify the correct approach.



Start resolving ICD-10-CM questionsMany coders rely on the advice in the American

Hospital Association (AHA)’s Coding Clinic to resolve sticky situations with ICD-9-CM coding. However, the AHA will not be transitioning its current guidance to ICD-10-CM. Instead, in January, it began focusing solely on ICD-10-CM questions to help clear up confusion prior to implementation.

Although Congress mandated an implementation delay earlier this year, the AHA decided to continue focusing on ICD-10-CM questions as opposed to answering additional questions on ICD-9-CM. Coders don’t have to throw out Coding Clinic advice for ICD-9-CM, but they do need to be careful when applying it in

ICD-10-CM, says Nelly Leon-Chisen, RHIA, director of coding and classification for the AHA in Chicago.

For example, Coding Clinic, Third Quarter 2009, stated that hypoxia is not inherent in chronic obstructive pulmonary disease (COPD). When hypoxia is associated with COPD, coders may assign code 799.02 (hypoxemia) as an additional diagnosis if desired, Leon-Chisen says.

When coding in ICD-10-CM, coders should first check to see whether ICD-10-CM includes a combina-tion code for COPD with hypoxia, Leon-Chisen says. They should also check for any instructional notes that specify whether to code hypoxia separately.

“Don’t automatically assume you’re assigning a second

For example, if the physician performs a procedure using an open approach with percutaneous endoscopic assistance, report the approach as open (guideline B5.2), Scott says.

An example is a laparoscopic-assisted sigmoidec-tomy. Although a laparoscope is used to perform the procedure, an incision is also made; therefore, the procedure warrants an approach value of open.

Guideline B5.3a states, “Procedures performed within an orifice on structures that are visible without the aid of any instrumentation are coded to the approach external.”

“Resection of the tonsils is coded to the external approach,” Scott says. Coders might think “external” means “outside of the body” and conclude that the tonsils are not external structures. However, because the procedure is done through an orifice without any instrumentation, the approach is external.

If the physician performs the procedure indirectly by applying external force through the intervening body layers, use external as the approach (guideline B5.3b).

“A closed reduction of fracture is coded to the external approach,” Scott says.

When coding a fracture reduction, be sure to read the entire operative report, not just the title, Scott adds. Physicians may title the procedure “open reduction internal fixation” when they are actually

performing a closed reduction and making the incision only after they reduce the fracture.

For a closed reduction, the approach is external. If the physician makes the incision before moving the bone back into place, use open for the approach. If the physician performs the procedure percutaneously via a device placed for the procedure, report a percutaneous approach (guideline B5.4).

Fragmentation of kidney stone performed via per-cutaneous nephrostomy is coded as a percutaneous approach, Scott says.

Not always obviousIn most cases, the approach should be clear from the

operative report. However, that’s not always the case.A female patient suffered a second-degree perineum

laceration. The physician repaired the tear by suturing the muscle. Which approach should be reported?

For this case, the approach is open even though the physician did not cut down to the muscle, says Young-Charles. “As long as the site is exposed and you can see it, the approach is open,” she says. “It doesn’t matter how the site was opened.”

Another example is a laceration of the liver due to a knife wound. Because the knife wound opened the area and the physician could see the liver, coders would use the open approach character, Young-Charles says. H



code, because the codes may have changed,” Leon-Chisen says. In this instance, the classifications have not changed, so coders may report the hypoxia separately.

Hemiplegia is another example of a ICD-9-CM classi-fication that remains the same in ICD-10-CM. Hemiple-gia is not inherently a part of an acute cerebrovascular accident, but it does affect patient care. It also provides additional information about the severity of the pa-tient’s condition. Therefore, coders should report it even if the hemiplegia resolves, with or without treatment, in both ICD-9-CM and ICD-10-CM, Leon-Chisen says.

Changes in classificationsNot all classifications remain the same in ICD-10-

CM. Hemoptysis (coughing up blood or blood-stained sputum) is not routinely associated with pneumonia. However, when coders look up “pneumonia” in the ICD-9-CM Alphabetic Index, the term is followed by several lines of nonessential modifiers. “This is probably the longest list of nonessential modifiers you’ll find,” Leon-Chisen says.

In ICD-9-CM, coders will not report hemoptysis separately because “hemorrhagic” is one of those non-essential modifiers, Leon-Chisen says. In ICD-10-CM, hemorrhagic is no longer part of the list of nonessential modifiers, so coders can code hemoptysis separately if it is present, she notes.

Coders will report the appropriate pneumonia code first, followed by R04.2 (hemoptysis) as an additional code, if present.

Respiratory conditionsTobacco use and dependence can increase a patient’s

risk of developing respiratory illness. ICD-9-CM has code 305.1 to report tobacco use disorder (tobacco dependence).

In ICD-10-CM, the term “smoker” defaults to de-pendence. Under the term “smoker,” the ICD-10-CM Alphabetic Index directs coders to “see dependence, drug, nicotine.”

“The important thing to note is that ‘smoker’ takes us to dependence, not use,” Leon-Chisen says.

Unfortunately for coders, Coding Clinic does not include definitions for terms such as: • Uncomplicated • In remission • With withdrawal

Although coders may not think of nicotine as a psy-choactive substance, the codes for nicotine dependence are in the same range as other psychoactive substances. The guidelines are pretty clear when it comes to using codes in categories F10–F19, Leon-Chisen says.

The appropriate codes for “in remission,” “with withdrawal,” etc., within categories F10–F19 are based on provider documentation (see ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.5.c.).

What Coding Clinic is and isn’t

The American Hospital Association (AHA) publishes

Coding Clinic on a quarterly basis and uses the publication

to address questions submitted from the healthcare

industry. Coders, as well as payers, use Coding Clinic

advice to determine accurate code assignment. However,

coders and auditors need to remember that Coding Clinic

does not provide clinical criteria for establishing diagnoses,

says Nelly Leon-Chisen, RHIA, director of coding and

classification for the AHA in Chicago.

Coding Clinic provides clinical “clues,” not “criteria,”

she says. In addition, Coding Clinic has no authority to

provide clinical definitions. Coding Clinic also does not

replace physician documentation regarding the clinical

significance of a patient’s condition, Leon-Chisen says.

“We have periodically provided information on the type

of documentation that can be used for coding.”

Coding should be supported by the physician

documentation, Leon-Chisen says. “Coding Clinic is not

a substitute for the physician’s clinical judgment.” Instead,

Coding Clinic provides guidance on what codes can be

reported based on already-documented diagnoses.

Information provided in Coding Clinic may still be

useful to understand clinical clues regarding signs or

symptoms that may be integral (or not) to a condition.

However, coders need to be careful because ICD-10-

CM has new combination codes, as well as instructional

notes, that may or may not be consistent with ICD-9-

CM, Leon-Chisen says.



More importantly, the patient must have a condition related to the substance use, abuse, or dependence, and it must meet the definition of a reportable diagnosis, Leon-Chisen says. The physician must document the relationship between the diagnosis and the substance use, abuse, or dependence.

Consider this scenario: A patient who has been a smoker for more than 20 years is diagnosed with COPD. Coders cannot assign code F17.218 (nicotine dependence, cigarettes, with other nicotine induced disorders) unless the provider has documented a cause-and-effect relationship, Leon-Chisen says. Without documented linkage, coders should assign: • J44.9, chronic obstructive pulmonary disease,

unspecified • F17.210, nicotine dependence, cigarettes,

uncomplicated

“We may think about this and say, ‘We know COPD is often caused by smoking,’ but you need to have the documentation in order to make that linkage,” Leon-Chisen says. “We can’t make that linkage without the documentation.” (For more on use, abuse, and depen-dence, see the sidebar on p. 8.)

The ICD-10-CM guidelines and notes in the Tabular Index tell coders that they need to include a separate code to identify tobacco dependence and use with almost every single condition from the respiratory section, says Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, of Safian Communications Services in Orlando, Florida.

“This is going to be new, and you may need to have a little chat with the physicians to make sure they’re ask-ing the question of the patient,” Safian says.

Not every patient with COPD or emphysema or asthma has this condition as a result of smoking, she adds. “The point here is to track those who do have the condition as a result of smoking.”

Consider another scenario: A patient is admitted through the ED for smoke inhalation with acute respiratory failure. ICD-10-CM does include a code for respiratory conditions due to smoke inhalation. It does not, however, include any guidelines or instructional notes to tell coders to report an additional code for acute respiratory failure to specify what kind of respiratory condition the patient had.

For this case, coders should report the acute

Use, abuse, and dependence hierarchy

Coders will need to understand the distinction between

use, abuse, and dependence in ICD-10-CM, says Shelley

C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I,

AHIMA-approved ICD-10-CM/PCS trainer, of Safian Com-

munications Services in Orlando, Florida.

Use identifies that the patient consumes a substance

on a regular basis by his or her own initiative, even though

the substance is known to be a detriment to one’s health.

Use shows no obvious clinical manifestations.

Abuse describes the patient’s habitual consumption of

a substance by his or her own initiative, even though the

substance is known to be a detriment to one’s health or is

not taken for therapeutic purposes. Clinical manifestations

are evident as signs and symptoms develop.

Dependence indicates the patient’s compulsive,

continuous consumption of a substance, which has

resulted in significant clinical manifestations, as well as

a physiological need for the substance in order to function

normally. Any interruption results in signs and symptoms

of withdrawal. In addition, the effects of the substance

diminish, requiring the patient to increase the quantity

consumed to achieve the same physical, emotional, and

psychological effects.

Coders must follow the ICD-10-CM hierarchy when

reporting use, abuse, and dependence, Safian says. The

ICD-10-CM guidelines state:

• If both use and abuse are documented, assign only the

code for abuse

• If both abuse and dependence are documented, assign

only the code for dependence

• If both use and dependence are documented, assign

only the code for dependence

• If use, abuse, and dependence are all documented,

assign only the code for dependence



respiratory failure, unspecified whether with hypoxia or hypercapnia (J96.00) as the principal diagnosis, Leon-Chisen says. In addition, coders should report the following secondary diagnoses:• T59.811A, toxic effect of smoke, accidental (unin-

tentional), initial encounter• J70.5, respiratory conditions due to smoke

inhalation

Coding from prior encountersOne question that continually arises is whether coders

can look back in the patient’s record and pick up previ-ously documented diagnoses. The short answer is no.

“For every encounter or admission, all of the diagnoses that you code should be reflected in the documentation for the current encounter,” says Gretchen Young-Charles, RHIA, senior coding consultant for the AHA. “If it’s not, you don’t want to pick it up.” (See Coding Clinic, Third Quarter 2013, pp. 27–28.)

If a condition is documented on a previous encoun-ter, it may not be relevant for the current encounter, Young-Charles says. If the coder believes the condition is relevant to the current encounter, he or she must query the physician to provide documentation so the condition can be reported.

Don’t rely on the patient’s historical problem list either, Young-Charles says. A condition on that list may not be a problem during the current encounter or admission.

The same holds true for recurrent conditions that are still valid. The physician should document the recurrent condition during each encounter or admission, Young-Charles says. “If it’s not documented in the health record, it is not appropriate to go back to a previous encounter to pick that information up.”

Coders should work with physicians to make sure the provider understands the importance of including a complete diagnosis and continuing to document chronic or long-standing conditions for each admission.

Coding for rehabilitationCoding for rehabilitation changes quite a bit in ICD-

10-CM, says Anita Rapier, RHIT, CCS, senior coding consultant for the AHA. ICD-10-CM classifies rehabilitation as aftercare. It does not include an equiv-alent to ICD-9-CM code category V57 (care involving use of rehabilitation procedures).

When a patient has an encounter or admission for rehabilitation, coders should first report the code corresponding to the condition for which services are being performed. In other words, if a patient comes in for rehabilitation for right-sided dominant hemiplegia following a stroke, coders would report ICD-10-CM code I69.351 (hemiplegia and hemipa-resis following cerebral infarction affecting right dominant side) first.

If a patient is in rehabilitation for hemiparesis or aphasia due to a stroke, code the neurological deficit first, Rapier says. The patient is in rehabilitation to deal with sequela from the stroke, not to treat the acute cerebrovascular accident.

As stated in the ICD-10-CM guidelines, coders should use codes from category I69 (sequela of cerebrovascu-lar disease) to identify conditions classifiable to catego-ries I60–I67 as the causes of sequela or neurological deficits themselves classified elsewhere, Rapier says.

“When coding for the sequela of a stroke, the sequela is your principal diagnosis,” she says.

However, if the condition is no longer present, coders will report the appropriate aftercare code, Rapier says.

For example, a patient with severe degenerative osteoarthritis of the hip underwent hip replacement surgery and now is seen for rehabilitation. Report code Z47.1 (aftercare following joint replacement surgery) as the principal or first-listed diagnosis, Rapier says.

Not all patients undergoing rehabilitation have suffered a stroke. Consider this example. A patient is admitted for an inpatient rehabilitation stay following surgical treatment of a displaced fracture of the right intertrochanteric femur. During the stay, the patient receives physical therapy (PT), occupational therapy (OT), and fracture aftercare.

“Keep in mind that in ICD-10-CM, for injuries, fractures, and some complication codes, you have a seventh character that describes the episode of care,” Rapier says.

Because this patient is post-treatment for a fracture and is going to rehabilitation for aftercare, PT, and OT, coders should assign the fracture code with the seventh character D to indicate this is a subsequent encounter, Rapier says (see Coding Clinic, Fourth Quarter 2013, pp. 127–129).



TBB or not TBB, that is the question

the respiratory tract, or has some condition that impairs breathing; the procedure can also be used to diagnose infection or malignancy.

The goal is to look down the trachea to see the mainstem bronchi to the right and left lung, then to go farther into the tubes to look at the two lobar bronchi on the left and the three on the right. The physician may look down as far as possible via these bronchi into the segmental bronchi of the lungs.

If a foreign body is in the lung, the physician may grasp it with a forceps inserted into a side tunnel and remove it. If is the patient has a mucus plug or a blood clot, the physician may aspirate it. If pus is present, the physician can sample it and send it to the microbiology lab. If the physician sees irritation, a growth on the wall of the bronchi, or some visible abnormality, he or she can biopsy it with biopsy forceps.

The main elements of virtually every diagnostic bron-choscopic procedure are:• Visualization of the tubes—the bronchoscopy• Washing—inserting saline solution into the

segmental orifices and sucking it out for microbiologic or microscopic examination of cells retrieved with the saline

• Brushing—inserting a pipe cleaner–like device into bronchial segments that are too small for the scope to get into and scrubbing off some cells for histologic examination

• Biopsy of a lesion on the wall of the bronchus or area of irritation that the endoscopist can see

That’s ICD-9-CM Volume 3 code 33.24.

by Robert S. Gold, MD

Physicians use a lot of shortcuts and abbreviations. Some of them may even make it to the official abbreviation list at a hospital. Some don’t. Even if they do, some physicians will use the wrong term.

An example of this confusion appeared in the January Medicare Quarterly Provider Compliance Newsletter regarding proper identification and ICD coding of a procedure performed by a pulmonologist:• Bronchoscopy with biopsy, 33.24• Bronchoscopic lung biopsy, 33.27

As many of you know, the future holds a new way of evaluating operative procedures in order to assign appropriate ICD-10-PCS codes. The mainstay of this technique is to have the coder read the operative procedure and assign codes based on what the physi-cian did. Gone are the days that one will easily find an operative code for a procedure by just looking at what the surgeon said he or she did.

Diagnostic bronchoscopyBronchoscopy is a technique whereby a physician

sedates a patient and uses topical anesthesia to numb the patient’s mouth, tongue, throat, and vocal cords. Bronchoscopy may also be performed on a patient who is under general anesthesia, or who has a tracheostomy in place. It is usually a diagnostic procedure to identify whether the patient has something obstructing the airway, is bleeding from

Postoperative seromaA seroma is an accumulation of clear bodily fluids in

an area where tissue has been surgically removed. After surgery, the capillaries in the wound site have increased permeability; as a result, the area becomes filled with fluid, and the fluid buildup becomes a sac. Seromas are commonly seen in female patients who are post-mastectomy or post-lumpectomy, Rapier says.

When coders look up seroma in the ICD-10-CM

Alphabetic Index, they are directed to see hematoma. The specific code assignment depends on the body

system involved in the surgery, Rapier says. For example, if a patient develops a seroma following a cardiac bypass, cardiac catheterization, or other circulatory system procedure, ICD-10-CM includes specific codes in subcategory I97.6- (postprocedural hemorrhage and hematoma of a circulatory system organ or structure following a procedure). H



Bronchoscopy proceduresSometimes a diagnostic bronchoscopy may turn into

a therapeutic one. For example, the physician may find a mucus plug to explain atelectasis and remove that plug. Alternatively, a bronchoscopy can start out as therapeutic. For example, patients with cystic fibrosis come in periodically to get their bronchi cleaned out and irrigated so they can go back to school in a lot more comfort.

Once in a while a patient will have a mass in the lung tissue noted on a chest x-ray, but the character of this mass is unknown. Obviously, the most important thing to evaluate is if it represents cancer and whether it is a primary lung cancer or one that has metastasized from another organ.

If the mass is near the center of the chest, near the heart and the main split of the trachea, the physician can likely evaluate it with a regular diagnostic bronchoscopy. However, if the lesion is peripheral—near the chest wall and NOT near the center of the chest (a “coin” lesion)—there’s no way that a bronchoscopy can see it because the bronchial tubes are too small for a scope to enter. Remember, the endoscopist has to see the lesion if he or she is performing a bronchoscopy with biopsy.

In the case of peripheral coin lesions, the physician can approach the mass in several ways. One way is to do a percutaneous lung biopsy. Using radiographic control, someone inserts a needle through the chest wall toward, and hopefully into, the lesion and takes a “bite” of it (ICD-9-CM 33.26). Another possibility is doing a thoracoscopic procedure in the OR, putting a large tube into the chest through a skin incision and seeing if the lesion can be visualized from the surface of the lung and biopsied (ICD-9-CM 33.20). Finally, the physician can always perform a formal thoracotomy, doing the diagnosis and treatment in one fell swoop (ICD-9-CM 33.25 if biopsy of bronchus, 33.28 if biopsy of lung).

Transbronchoscopic lung biopsyClinicians are recognizing, however, that some of

these masses don’t need removal, or the patient is unable to undergo a formal thoracotomy but might respond to treatment after diagnosis with a lesser procedure.

So, if we have a coin lesion, a transbronchoscopic lung biopsy may be performed. Preparing the

patient the same way as for a routine bronchoscopy, the physician inserts the bronchoscope and, using x-ray guidance, advances as far as possible into the appropriate bronchus that will aim at the lesion seen on the x-ray. Then the physician tells the patient to hold his or her breath and jams biopsy forceps though the wall of the bronchus and into the lesion to take a bite of it. The physician does this again and again until he or she has a few pieces of tissue to submit to the pathologist to discover whether the physician obtained a sample of the lesion. That’s ICD-9-CM Volume 3 code 33.27.

Here’s a caveat. Sometimes, doing a regular diagnostic bronchoscopy, physicians can see that something is pushing against the wall of one of the bronchi from the outside, but they can’t see what that something is. They just see an impression of its effect. This may be an area of narrowing with normal-looking mucosa over it, and maybe the endoscopist can’t even get by the narrowed area. Or when looking down the scope, rather than seeing a sharp cutoff where two or more bronchi are supposed to extend from, the endoscopist may see considerable blunting of the carina (the split). He or she will know that something outside the bronchus is causing that blunted appearance—possibly a lymph node, a mediastinal tumor of some sort, lung cancer, or an abscess. Again, the endoscopist pushes the biopsy forceps through the wall of the bronchus into the thing he or she cannot see and takes samples. This is transbronchoscopic, as well. If it’s a needle biopsy of the lung, it’s ICD-9-CM Volume 3 code 33.26, just as the percutaneous approach above.

Transbronchoscopic just means that something was done through the bronchoscope. It does not define what was done. If the physician says “transbronchoscopic biopsy,” it’s probably a bronchial biopsy. If the physician says “transbronchoscopic lung biopsy,” it’s probably a lung biopsy—but be sure that’s what was done.

Basically, read what the physician did, and you can code it. Don’t rely on what the physician said he or she did. H

EDITOR’S NOTEDr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician CDI programs including needs for ICD-10. Contact him at 770-216-9691 or [email protected]. If you have a specific procedure or condition you would like Dr. Gold to address in his column, contact Senior Managing Editor Michelle Leppert at [email protected].

A supplement to Briefings on Coding Compliance Strategies

A monthly service of Briefings on Coding Compliance Strategies

NOVEMBER 2014

Coding Q&A

Q My colleagues and I continually wrestle with this question: Must all diagnoses on an inpatient chart

be listed in the discharge summary for them to be coded?

A A lot of confusion and misinformation exists re-garding where and/or how many times a diagnosis

has to be documented in order for it to be “reportable.” First and foremost, before coders can report a diag-

nosis, it must be relevant to the current episode of care and not integral to another condition. It must also meet UHDDS criteria as a reportable diagnosis, meaning it:• Requires diagnostics, evaluation, and/or treatment• Increases nursing care and/or the length of stay

Assuming all these requirements are met, does

the location of the diagnosis within the health record matter? No, as long as it is not an uncertain diagnosis. These can only be reported in the inpatient setting if the diagnosis is uncertain at the time of discharge.

So let’s recap. We have a diagnosis that is related to the current episode of care, isn’t integral to another condition, meets UHDDS criteria as a reportable diagnosis, and is supported by the health record, but doesn’t appear in the discharge summary.

The ICD-9-CM Official Guidelines for Coding and Reporting state:

If the provider has included a diagnosis in the fi-nal diagnostic statement, such as the discharge sum-mary or the face sheet, it should ordinarily be coded. Some providers include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous admission that have no bearing on the current stay. Such conditions are not to be reported and are coded only if required by hospital policy.

However, to my knowledge, no requirement exists stating a reportable diagnosis must be in the discharge summary. In fact, for many organizations, the provider who documents the discharge summary is likely a hospitalist who may not reiterate or reconfirm diagnoses that he or she is not evaluating.

Documentation that supports code assignment can come from other providers such as consultants, anesthesiologists, or other treating providers (i.e., one who is legally responsible for diagnosing a patient). These types of issues have been addressed in many issues of the AHA’s Coding Clinic for ICD-9-CM:• Findings of a consulting physician may be reported

as a diagnosis provided there is no conflicting documentation by the attending or another physician. (Coding Clinic, January 2004)

• Code assignment may be based on other physician documentation (i.e., consultants, residents, anes-thesiologists, etc.), as long as there is no conflicting information from the attending physician. (Coding Clinic, Third Quarter, 2008)

Some organizations are being very conservative by self-imposing these types of criteria, usually in response to debates with payers regarding the relevance of some diagnoses. Being super conservative has many negative impacts such as potential assignment to a much lower-paying MS-DRG when the documentation supports a higher-paying one. Patients will appear less “sick,” rendering a lower case-mix index.

Organizations with these types of limitations should also realize that with EHR tools such as “cut and paste,” the diagnoses listed on the discharge summary may still be debated if they are not clinically supported as being relevant to the current admission. The ICD-9-

We want your coding and compliance questions!The mission of Coding Q&A is to help you find an swers to your urgent coding/compliance questions.

To submit your questions, contact Briefings on Coding Compliance Strategies Senior Managing Editor Michelle Leppert, CPC, at [email protected].

A monthly service of Briefings on Coding Compliance Strategies

and Cheryl Ericson, MS, RN, CCDS, CDI-P, AHIMA-approved ICD-10-CM/PCS trainer, CDI education director for HCPro, answered this question.

Q The primary physician documented subacute cere-bral infarction, and I am wondering whether I should

code this to a new cerebral vascular accident (CVA) or not since the term “subacute” doesn’t really fall anywhere.

A The ICD-9-CM Official Guidelines for Coding and Reporting offer no definition as to what is

considered acute, subacute, or chronic. I have found sub-acute to mean something in between acute and chronic, which is a vague description. For questions such as this, I refer to the AHA’s Coding Clinic for assistance.

Coding Clinic, First Quarter 2011, p. 21 states:Question: How is the diagnosis documented as

“subacute deep vein thrombosis (DVT)” coded? There are index subentries for acute and chronic, but not for subacute?

Answer: Assign code 453.89, acute venous embolism and thrombosis of other specified veins, for a diagnosis of subacute DVT.

This reference does not specifically describe a CVA, but it does offer guidance that the term subacute is interpreted as being acute. For more guidance related to CVA look at Coding Clinic, Second Quarter 2013, p. 10.

Although this Coding Clinic is addressing the fact two codes would be assigned due to the fact there was both an ischemic and hemorrhagic stroke, it also reinforces that the wording of subacute would apply to the codes for a CVA versus codes for a history of CVA. Coding Clinic offers much guidance when we encounter those “gray” areas of the code set and should be the reference that you seek in such situations.

Laurie Prescott, MSN, RN, CCDS, CDI education specialist for ACDIS and HCPro, answered this question.

CM Official Guidelines for Coding and Reporting state, “The listing of diagnoses in the patient record is the responsibility of the attending provider.”

The attending provider’s documentation supersedes all others if there is a conflict. However, as long as there is no conflicting documentation from another physician, you can report the diagnoses from other providers who give direct patient care.

According to Coding Clinic, January 2004: Medical record documentation from any physician

involved in the care and treatment of the patient, including documentation by consulting physicians, is appropriate for the basis of code assignment … [if] there is no conflicting documentation from another physician (including the attending physician). This information is consistent with the American Health Information Management Association’s (AHIMA) documentation guidelines.

The discharge summary is supposed to be a compre-hensive summary of the entire inpatient stay, listing all relevant conditions/procedures. But sometimes it’s merely a duplication of the history and physical with a short paragraph titled “Hospital Course.”

Coders must thoroughly review the entire medical record for all relevant diagnoses, not just the ones on the discharge summary. Coders may start with the discharge summary (if one is in the chart at the time of coding) and work backwards.

The UHDDS defines the attending provider as the clini-cian of record at discharge who is responsible for the dis-charge summary. As such, if there is a conflict, then yes, the discharge summary would trump any other source. That doesn’t mean the discharge summary is the only source of documentation to support code assignment.

Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of coding and HIM for HCPro, a division of BLR, in Danvers, Massachusetts,

Coding Q&A is a monthly service to Briefings on Coding Compliance Strategies subscribers. Reproduction in any form outside the subscriber’s institution is forbidden without prior written permission from HCPro, a division of BLR. Copyright © 2014 HCPro, a division of BLR, Danvers, MA. Telephone: 781-639-1872; fax: 781-639-7857. CPT codes, de scriptions, and material only are Copyright © 2014 American Medical Association. CPT is a trademark of the American Medical As sociation. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The American Medical Association assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

BCCS, P.O. Box 3049, Peabody, MA 01961-3049 • Telephone 781-639-1872 • Fax 781-639-7857

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