ICD-10-CM. General Surgery. Specialty Code Set Training. Module 5

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1 ICD-10-CM Specialty Code Set Training General Surgery 2014 Module 5

2 Disclaimer This course was current at the time it was published. This course was prepared as a tool to assist the participant in understanding how to prepare for ICD-10-CM. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility of the use of this information lies with the student. AAPC does not accept responsibility or liability with regard to errors, omissions, misuse, and misinterpretation. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free and will bear no responsibility, or liability for the results or consequences of the use of this course. AAPC does not accept responsibility or liability for any adverse outcome from using this study program for any reason including undetected inaccuracy, opinion, and analysis that might prove erroneous or amended, or the coder s misunderstanding or misapplication of topics. Application of the information in this text does not imply or guarantee claims payment. Inquiries of your local carrier(s) bulletins, policy announcements, etc., should be made to resolve local billing requirements. Payers interpretations may vary from those in this program. Finally, the law, applicable regulations, payers instructions, interpretations, enforcement, etc., may change at any time in any particular area. This manual may not be copied, reproduced, dismantled, quoted, or presented without the expressed written approval of the AAPC and the sources contained within. No part of this publication covered by the copyright herein may be reproduced, stored in a retrieval system or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording, or taping) without the expressed written permission from AAPC and the sources contained within. Clinical Examples Used in this Book AAPC believes it is important in training and testing to reflect as accurate a coding setting as possible to students and examinees. All examples and case studies used in our study guides and exams are actual, redacted office visit and procedure notes donated by AAPC members. To preserve the real world quality of these notes for educational purposes, we have not re-written or edited the notes to the stringent grammatical or stylistic standards found in the text of our products. Some minor changes have been made for clarity or to correct spelling errors originally in the notes, but essentially they are as one would find them in a coding setting AAPC 2480 South 3850 West, Suite B, Salt Lake City, Utah CODE (2633), Fax , Printed. All rights reserved. CPC, CPC-H, CPC-P, CPMA, CPCO, and CPPM are trademarks of AAPC. ii ICD-10-CM Specialty Code Set Training General Surgery 2013 AAPC. All rights reserved.

3 ICD-10 Experts Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, CPEDC, CENTC, COBGC VP, ICD-10 Training and Education Shelly Cronin, CPC, CPMA, CPC-I, CANPC, CGSC, CGIC, CPPM Director, ICD-10 Training Betty Hovey, CPC, CPMA, CPC-I, CPC-H, CPB, CPCD Director, ICD-10 Development and Training Jackie Stack, CPC, CPB, CPC-I, CEMC, CFPC, CIMC, CPEDC Director, ICD-10 Development and Training Peggy Stilley, CPC, CPB, CPMA, CPC-I, COBGC Director, ICD-10 Development and Training Contents Documentation Issues Specificity Laterality Time parameters Site Documentation Requirements for Common Conditions in General Surgery Hypertension AAPC. All rights reserved. iii Hernia Cholelithiasis Neoplasm Gastroesophageal reflux Hemorrhoids Appendicitis Constipation Diverticulosis Anal fissure Cholecystitis Regional enteritis Ulcerative colitis

4 One of the big hurdles in the transition to ICD-10-CM is ensuring that the documentation of the providers is supportive of the new coding criteria that will need to be met. You may consider that it is not only the codes that are transitioning, but also the documentation to meet it. Just as in ICD-9-CM, ICD-10-CM contains unspecified codes. But, with the greatly expanded granularity in ICD-10-CM, the unspecified codes will come under greater scrutiny. Working with providers will be essential for correct ICD-10-CM coding to steer them away from the assignment of unspecified codes whenever possible. By understanding the clinical documentation terms you can assist providers with documentation decision trees and the building of templates. Focusing on the clinical terms instead of the code will reinforce documentation concepts allowing for the correct codes to be assigned. Specificity One of the reasons that we are transitioning to ICD-10-CM is the increased specificity to enable conditions to be clearly indicated. Care must be taken to ensure that providers and coders understand where the code set has expanded in order to be able to capture that information and denote it on a claim. Specificity issues include laterality, time parameters, site, and expansion of certain conditions under ICD-10-CM. Laterality The addition of laterality into the code set is one of the reasons for the increased number of codes in ICD-10-CM. ICD-9-CM Cellulitis of arm ICD-10-CM L Cellulitis of right axilla L Cellulitis of left axilla L Cellulitis of right upper limb L Cellulitis of left upper limb L Cellulitis of right lower limb L Cellulitis of left lower limb L Cellulitis of unspecified part of limb When you look at the codes above, there is no reason for the unspecified code to be used. Unspecified codes assigned due to missing laterality have a high probability of being denied. There is no defensible reason not to indicate laterality. This issue may come up in an office using encounter forms, or billing tickets. For instance, the proper documentation may be in the chart note, but a provider may write cellulitis arm on the form. If the person entering the charges and codes into the computer system does not have access to the medical record, the unspecified code would be the only code that could be assigned AAPC. All rights reserved. 51

5 Consider providers that utilize an EMR and choose their own diagnosis codes. If they have pick lists that come up, or type in specific search words for diagnosis, there is a risk that the unspecified codes will populate first. If full descriptors do not show in the EMR fields, the unspecified codes may be chosen by mistake. A thorough check of the EMR and how it looks, how it populates fields, and how providers use it needs to be performed in order to ensure that the most specific code will be chosen and assigned. Time parameters The time parameters acute, chronic, acute on chronic, and recurrent are important documentation factors in ICD-10-CM. The difference between a specific and an unspecified code may be indication of the time parameter. Documentation should include this factor to assign a code to the highest level of specificity. K55.0 Acute vascular disorders of intestine K55.1 Chronic vascular disorders of the intestine Site There are additional codes in ICD-10-CM due to site specificity. Coding for Crohn s disease is a good example of the expansion of site in the code set. Documentation must meet these new criteria to avoid unspecified code usage when possible. A. Patient presents for follow up on Crohn s disease and is doing well. K50.90 Crohn s disease, unspecified. without complications B. Patient presents for follow up on Crohn s disease affecting her small intestine and is doing well with no complications. K50.00 Crohn s disease of small intestine without complications. With just a few additional descriptors a code with the highest level of specificity can be assigned. Documentation Requirements for Common Conditions in General Surgery To assist the providers with clinical documentation improvement, it is necessary that the coder/ auditor/educator understand the documentation requirements of the most commonly coded conditions in their specialty. We will indicate the documentation requirements below for common conditions seen in General Surgery. 52 ICD-10-CM Specialty Code Set Training General Surgery 2013 AAPC. All rights reserved.

6 Hypertension For correct coding for hypertension, documentation should include the following: Type Severity Essential (primary) hypertension Secondary hypertension Neonatal hypertension Associated complications Heart failure End stage renal disease Chronic renal disease Pregnancy Mild Moderate Severe Symptoms/Findings/Manifestations With proteinuria Ulcer related to chronic venous hypertension Temporal factors Acute Chronic Contributing factors Smoking Exposure History of tobacco use Occupational exposure to environmental tobacco smoke Tobacco dependence Tobacco use Not all factors listed above are associated with all hypertension codes, but this shows the comprehensive nature of the ICD-10-CM code structure AAPC. All rights reserved. 53

7 Subjective: 75-year-old female is seen for follow up for chronic hypertension. She has been having ongoing shortness of breath and orthopnea. Recent EKG demonstrates finding consistent with cardiomegaly, but not recent change since a prior EKG. She is on Lasix, Lanoxin and Atenolol. Objective: BP = 175/95. HR = 100. Chest X-ray show mild pulmonary edema. There is 2+ pitting edema in both ankles. Assessment: Hypertension poorly controlled Chronic congestive heart failure I11.0 Hypertensive heart disease with heart failure Hernia For correct coding for hernias, documentation should include the following concepts: Type Femoral Inguinal Umbilical Ventral Paraumbilical Incisional Parastomal ventral Epigastric Hypogastric Midline Spigelian Subxiphoid Diaphragmatic Hiatus Paraesophageal Abdominal NEC Lumbar Obturator Pudendal Retroperitoneal Sciatic 54 ICD-10-CM Specialty Code Set Training General Surgery 2013 AAPC. All rights reserved.

8 Laterality Unilateral Bilateral Complicated by With obstruction, without gangrene Causing obstruction without gangrene Incarcerated without gangrene Irreducible without gangrene Strangulated without gangrene With gangrene Without obstruction or gangrene Temporal parameters Not specified as recurrent Recurrent Subjective: This is a previously healthy 45-year-old gentleman. For the past 3 weeks, intermittent episodes of nausea and abdominal pain. On the morning of admission, onset of severe pain with nausea and vomiting seen in the ED, incarcerated umbilical hernia noted, General Surgery called. Objective: As noted, mildly visible bulging in the umbilicus at the superior position. With gentle traction, we were able to feel the herniated contents which could not be reduced Palpation through the hernia sac reveals an approximately 2 cm defect in the umbilicus. ASSESSMENT: Patient presents with an incarcerated umbilical hernia, now for repair with mesh. Chest X-ray, ECG, and labs all within normal limits. K42.0 Umbilical hernia with obstruction, without gangrene Cholelithiasis Site Gallbladder Bile duct Gallbladder and bile duct Complicated by Cholecystitis without obstruction Cholecystitis with obstruction Cholangitis without obstruction 2013 AAPC. All rights reserved. 55

9 Cholangitis with obstruction Without cholangitis or cholecystitis Without cholecystitis without obstruction Without obstruction With obstruction Temporal parameters Acute Chronic Acute and chronic Brief History: This is a 17-year-old African-American female, presented to General Hospital on 08/20 with complaints of RUQ abdominal pain. Pain is intractable and associated with anorexia. Physical examination: afebrile; however, severe right upper quadrant pain with examination as well as Murphy s sign and voluntary guarding. Transaminases markedly elevated. Ultrasound: common bile duct dilated to 1 cm with no evidence of wall thickening, but evidence of cholelithiasis with acute cholecystitis. She presents for operative laparoscopic cholecystectomy. Parents were explained the risks, benefits, and complications of the procedure. K80.00 Calculus of gallbladder with acute cholecystitis without obstruction Neoplasm Morphology Site Malignant Benign Primary Secondary Carcinoma in Situ Uncertain behavior Unspecified Laterality Contributing Factors Exposure to environmental tobacco smoke Exposure to tobacco smoke in the perinatal period History of tobacco use Occupational exposure to environmental tobacco smoke 56 ICD-10-CM Specialty Code Set Training General Surgery 2013 AAPC. All rights reserved.

10 Tobacco dependence Tobacco use Alcohol use and dependence Preoperative Diagnosis: Possible inflammatory bowel disease Postoperative Diagnosis: Polyp of the sigmoid colon Procedure Performed: Total colonoscopy with photography and polypectomy Gross Findings: The patient is being evaluated now for inflammatory bowel disease. Upon endoscopy, the colon prep was good. Able to reach the cecum without difficulty. No diverticluli, inflammatory bowel disease, strictures, or obstructing lesions. Pedunculated polyp approximately 4.5 cm in size located in the sigmoid colon at approximately 35 cm. This large polyp was removed using the snare technique. D12.5 Benign neoplasm of sigmoid colon Gastroesophageal reflux Associated with With esophagitis Without esophagitis Procedure Performed: Esophagogastroduodenoscopy, photography, and biopsy Gross Findings: The patient has a history of epigastric abdominal pain, persistent in nature. She has a history of severe gastroesophageal reflux disease, takes Pepcid frequently. Being evaluated at this time for disease process. Upon endoscopy, the gastroesophageal junction is approximately 40 cm. Inflammation from the lower third of the esophagus up to the gastroesophageal junction. No advancement of the gastric mucosa into the lower one-third of the esophagus. Mild inflammation at the antrum of the stomach. The rest of the exam was within normal limits. Biopsy was obtained of the gastroesophageal junction at 12, 3, 6, and 9 o clock positions to rule out occult Barrett s esophagitis. K21.0 Gastro-esophageal reflux disease with esophagitis Hemorrhoids Type Internal Residual External hemorrhoids Skin tags of anus 2013 AAPC. All rights reserved. 57

11 Internal hemorrhoids without mention of degree Prolapsed hemorrhoids degree nto specified Severity First degree Grade/Stage I hemorrhoids Hemorrhoids (bleeding) without prolapse outside of anal canal Second degree Third degree Grade/Stage II hemorrhoids Hemorrhoids (bleeding) that prolapse with straining, but retract spontaneously Grade/Stage III hemorrhoids Hemorrhoids (bleeding) that prolapse with straining and require manual replacement back inside anal canal Fourth degree Associated with Thrombosis Grade/Stage IV hemorrhoids Hemorrhoids (bleeding) with prolapsed tissue that cannot be manually replaced External hemorrhoid thrombosis Perianal hematoma Thrombosed hemorrhoids NOS Reason For Procedure: Grade I and II hemorrhoids Procedure Performed: Transanal hemorrhoidal dearterialization (THD) / hemorrhoidopexy Findings and Procedure: The patient was brought to the operating room. After administration of general anesthesia, placed on the operating room table in the prone jackknife position. Starting at the 12 o clock position, working clockwise, the terminal branches of the hemorrhoidal vessels were identified at the 1:00, 3:00, 5:00, 7:00, 9:00, and 11:00 o clock positions using the Doppler signal. At each location, the vessels were identified and a figureof-eight suture was used to occlude the artery with good interruption of the Doppler signal. At each location, hemorrhoidopexy was performed in the standard fashion taking care to stay approximately 1.5 cm above the dentate line. At the end of the procedure, the anus was thoroughly inspected. No bleeders were identified. K64.0 First degree hemorrhoids K64.1 Second degree hemorrhoids 58 ICD-10-CM Specialty Code Set Training General Surgery 2013 AAPC. All rights reserved.

12 Appendicitis Temporal parameters Acute Chronic Recurrent Associated Complications Generalized peritonitis Appendicitis (acute) with generalized (diffuse) peritonitis following rupture or perforation of appendix Appendicitis with peritonitis NOS Perforated appendix NOS Ruptured appendix NOS Localized peritonitis Acute appendicitis with localized peritonitis with or without rupture or perforation of appendix Acute appendicitis with peritoneal abscess Subjective: Patient is a 23-year old male in excellent health, suddenly seized in the middle of the night by a severe attack of indigestion accompanied by cramp-like pains above and around the umbilicus. No appetite and some nausea. Objective: Exam: patient is lying on his back with his right thigh flexed. Slightly increased temp of F. Patient now localizes his pain to the lower right quadrant. On palpation of the abdomen, marked localized tenderness and some rigidity in the right iliac fossa are noted. Pressure with the fingertip shows the area of greatest tenderness is located near McBurney s point. Positive psoas sign. Labs: elevated C-reactive protein level, elevated WBC count, and neutrophilia. CT scan confirmed acute appendicitis with localized peritonitis. K35.3 Acute appendicitis with localized peritonitis Constipation Type Slow transit Outlet dysfunction 2013 AAPC. All rights reserved. 59

13 Subjective: Patient presents for follow-up for constipation. She complained of issues all my life with slow bowels. She has been using Correctol. This tends to give her runny stools for a day and then constipation again the next day. She has tried taking Colace. This was not helpful. Patient sent to us to rule out pathology. She was sent for a transit study and now presents for results. Objective: On exam, abdomen is soft and diffusely tender to a mild degree. Bowel sounds active. I informed the patient she has slow transit constipation. Discussed the nature of the condition and ways she can improve her bowel habits. Will send her back to her primary care physician for follow up of her condition. Patient may return if non-surgical treatment unsuccessful. K59.01 Slow transit constipation Diverticulosis Site Small intestine Diverticular disease of the small intestine Large intestine Diverticular disease of the large intestine Small and large intestine Diverticular disease of the small and large intestine Associated Complications Perforation or abscess Without perforation or abscess With bleeding Without bleeding Procedure: Colonoscopy performed on a patient with a family history of colonic polyps. Findings: Diverticulosis of the sigmoid colon Description of Procedure: The patient was placed in left lateral decubitus after appropriate sedation. Digital rectal examination was done, which was normal. Endoscope was introduced and passed through a rather spastic tortuous sigmoid colon with multiple diverticula seen throughout the sigmoid colon. The scope then was advanced through rest of the descending colon, transverse colon to ascending colon and cecum. Terminal ileum was briefly reviewed, appeared normal and so did cecum after fecal material was irrigated out. Rest of exam was within normal limits. Excess of air insufflated was removed. The endoscope was withdrawn. K57.30 Diverticulosis of large intestine without perforation or abscess without bleeding Z83.71 Family history of colonic polyps 60 ICD-10-CM Specialty Code Set Training General Surgery 2013 AAPC. All rights reserved.

14 Anal fissure Temporal parameters Acute Chronic Subjective: Patient presents for evaluation of acute anal fissure. Patient reports he had 1 month of constipation. During one bowel movement, after heavy straining, he felt searing pain. There was blood in the commode and on the toilet paper. Pain occurs with sitting, moving, defecating, and even coughing. It usually is throbbing in quality and is constant throughout the day. He went to his family physician who diagnosed an acute anal fissure. Objective: After Lidocaine jelly applied, DRE performed. 10 mm X 2 mm anal fissure present. K60.0 Acute anal fissure Cholecystitis Temporal parameters Acute Chronic Acute with chronic Associated Complications Choledocholithiasis Cholelithiasis Reason for Procedure: Chronic cholecystitis without cholelithiasis Procedure: Laparoscopic cholecystectomy Brief Description: The patient was brought to the OR and anesthesia was induced. The abdomen was prepped and draped. Incision was made below the umbilicus and camera port was placed into the peritoneal cavity under direct visualization. Once insufflation was adequate, additional ports were placed. Upon visualization, it is noted that the gallbladder appears moderately edematous. The gallbladder was grasped and retracted. The cystic duct and cystic artery were circumferentially dissected and a critical view was obtained. The cystic duct and cystic artery were then doubly clipped and divided and the gallbladder was dissected off the liver bed with electrocautery and placed in an Endo Catch bag. The gallbladder fossa and clips were examined and looked good with no evidence of bleeding or bile leak. The ports were removed under direct vision with good hemostasis. The gallbladder in its Endo Catch bag was removed. The ports were closed. The patient tolerated the procedure well. K81.1 Chronic cholecystitis 2013 AAPC. All rights reserved. 61

15 Regional enteritis Anatomic location Small intestine Crohn s disease (regional enteritis) of duodenum Crohn s disease (regional enteritis) of ileum Crohn s disease (regional enteritis) of jejunum Regional ileitis Terminal ileitis Large intestine Crohn s disease (regional enteritis) of colon Crohn s disease (regional enteritis) of large bowel Crohn s disease (regional enteritis) of rectum Granulomatous colitis Regional colitis Both small and large intestine Complicated by Without complications Rectal bleeding Intestinal obstruction Fistula Abscess Manifestations Pyoderma gangrenosum Melissa returns for follow up with her mother after endoscopy and labs. She originally presented for intermittent ulcers in her mouth over a 2-3 year period that had become more frequent. She was experiencing abdominal pain, and upon questioning, admitted to 5 to 10 loose, brown, and often watery stools a day for up to 3 weeks at a time, five or more times this year. She admitted to current rectal bleeding and using sanitary pads to conceal it. Her mother was unaware of these issues. The patient has experienced a 10 lb weight loss over the past month. Endoscopy revealed inflammation, granulomatous appearance, and multiple areas of aphthous ulcers throughout the small intestine, most notably in the terminal ileum. Endoscopy and biopsy confirmed Crohn s disease of the small intestine. Colonoscopy ruled out UC. Negative IgA ruled out celiac. Stool was negative for o & p and common pathogens. K Crohn s disease of small intestine with rectal bleeding 62 ICD-10-CM Specialty Code Set Training General Surgery 2013 AAPC. All rights reserved.

16 Ulcerative colitis Anatomic location Entire colon Rectum Pancolitis Proctitis Rectum with sigmoid colon Left-sided Complicated by Rectosigmoiditis Without complications Rectal bleeding Intestinal obstruction Fistula Abscess Manifestations Pyoderma gangrenosum Emily is here today for surgical evaluation for her ulcerative colitis. She is a 29-year-old female at her lowest body weight since adulthood. She has chronic diarrhea, abdominal pain and cramps, weight loss, fatigue, fever, and night sweats. Her symptoms had become worse, colonoscopy performed, which now shows extension to pancolitis with abscess. She is taking prednisone, mesalamine, and azathioprine, but these medications are not bringing her relief. All treatment options discussed. K Ulcerative (chronic) pancolitis with abscess 2013 AAPC. All rights reserved. 63

ICD-10-CM. Gastroenterology. Specialty Code Set Training. Module 1

ICD-10-CM. Gastroenterology. Specialty Code Set Training. Module 1 ICD-10-CM Specialty Code Set Training Gastroenterology 2014 Module 1 Disclaimer This course was current at the time it was published. This course was prepared as a tool to assist the participant in understanding