Nov 18, 2012 Review Guidelines for Coding Pregnancy, its' Complications Category:General Posted by: admin Depending on the demographics of the region

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1 Nov 18, 2012 Review Guidelines for Coding Pregnancy, its' Complications Depending on the demographics of the region a hospital serves, its coders could determine code assignment for hundreds of deliveries and pregnancy-related services annually. Therefore, reviewing the related coding guidelines is helpful. Principal diagnosis Coders must remember that pregnancy is a disease process separate from other disease processes that patients may experience, says Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, COBGC. Even when patients present for other conditions (e.g., hypertension management), pregnancy is the principal diagnosis, says Webb, a coder at St. Alphonsus Regional Medical Center in Boise, Idaho, and an AHIMA-certified ICD-10-CM/PCS trainer. A pregnancy diagnosis is always reported first, she says. This may seem counterintuitive to coders trained to report the principal diagnosis as the condition after study that is chiefly responsible for admission, she says. Webb recently coded a case in which a pregnant patient was admitted for treatment of a broken leg. The principal diagnosis was pregnancy because it affected decisions regarding treatment of the leg (e.g., administration of certain drugs or sedation), she says. Sequencing an actual delivery is somewhat different. The ICD-9-CM Official Guidelines for Coding and Reporting, I.C.11.b.4 (p. 45/107) state: "When a delivery occurs, the principal diagnosis should correspond to the main circumstances or complication of the delivery." This guideline further explains that for cesarean deliveries, coders should select the principal diagnosis based on the condition established after study that was responsible for admission. This means that if a patient is admitted with a condition that results in a cesarean delivery, coders should report the condition that prompts the delivery as the principal diagnosis. If the admission is unrelated to the condition that results in a cesarean delivery, coders should report the condition that relates to the admission as the principal diagnosis. Current guidelines indicate that ICD-9-CM code is the principal diagnosis for a woman with a pregnancy complicated by anemia who undergoes a cesarean delivery due to fetal distress not present at admission, says Susan Proctor, RHIT, CCS, CPC, a coding consultant in Willits, Calif., and an AHIMA-certified ICD-10-CM/PCS trainer. Other complications Coders must also capture all other conditions that affect management of a pregnancy, says Proctor. The ICD-9-CM Official Guidelines for Coding and Reporting, I.C.11.a.1 (p. 44/107) state: "It is the provider's responsibility to state that the condition being treated is not affecting the pregnancy." Report all documented conditions unless physicians indicate otherwise, says Proctor. "All conditions are complications unless stated otherwise by the provider, and the Chapter 11 codes are sequenced first," she says. Signs and symptoms Signs and symptoms may also pose coding challenges. This is because physicians often document signs and symptoms that may indicate a more definitive condition, says Webb. Dehydration and excessive vomiting commonly experienced and documented during pregnancy could indicate metabolic syndrome. Elevated blood pressure, severe headaches, and edema could indicate preeclampsia. Query when documentation is vague; the physician may point to a more definitive diagnosis, she says. Failure to progress Physicians continue to document nonspecific terminology despite more specific codes and diagnoses available in ICD-9-CM, says Proctor. Failure to progress (i.e., inability to deliver without a cesarean) is one example, she says. Coding Clinic, July-August 1985, p. 11, instructs coders to report code (uterine inertia, delivered) when physicians document failure to progress. Decreased fetal movement Decreased fetal movement (655.7x) a condition in which a mother cannot feel the fetus move can be an early sign of a problematic pregnancy. Physicians often document this term before administration and interpretation of a fetal non-stress test that indicates normal development, says Webb. The following documentation is necessary to help determine whether decreased fetal movement is present: Was the fetus stressed during the fetal non-stress test? How many heartbeats per minute, including accelerations and decelerations, did the fetus have during the test? Is this normal? How many contractions occurred during the test? What was the patient's blood pressure during the test? Was the patient hydrated or dehydrated during the test? Query when documentation is unclear, says Webb. Fetal conditions and management of mothers Coders should assign codes from the following categories only when the fetal condition is responsible for modifying management of a mother: 655, known or suspected fetal abnormality affecting management of the mother

2 656, other known or suspected fetal and placental problems affecting management of the mother For example, report fetal conditions that require termination of a pregnancy, diagnostic studies, additional observation, or special care. The mere existence of a fetal condition does not justify assigning a code for that condition, according to the guidelines. Complicating matters is that one physician could be treating the mother and another could be monitoring the fetus, says Webb. Interconnected electronic medical records help ensure documentation is updated and available. This isn't always possible, making it difficult for coders to determine whether certain fetal conditions affect the mother, she explains. Normal deliveries Normal deliveries (code 650) are so rare that Proctor asks colleagues to review cases to ensure she didn't forget to code something the physician documented. Coders should remember that in addition to procedures listed under the description for code 650, normal deliveries include induction of labor by artificial rupture of membranes without any indication. Refer to Coding Clinic, Third Quarter 2000, p. 5, for more information. Abortions The term abortion has a legal connotation, but several more specific terms are also associated with this diagnosis, says Webb. These include the following: Spontaneous abortion, including miscarriage (634.x) Legally induced abortion (635.x) Illegally induced abortion (636.x) Unspecified abortion, including retained products of conception following abortion, not classified elsewhere (637.x) Failed attempted abortion (638.x) Intrapartum care Coders often forget to report codes for complications that occur during labor and delivery (codes ), says Webb. For example, when a delivery trauma, such as an episiotomy (73.6), occurs, coders often forget to report a code for cervical laceration (655.3x). Dec 15, 2011 MODIFIER-59 MODIFIER-59 Dec 15, 2011 HEALTH INFORMATION MANAGEMENT HEALTH INFORMATION MANAGEMENT Dec 15, 2011 EXCISIONAL DEBRIDEMENT EXCISIONAL DEBRIDEMENT Coding for Seizures and Epilepsy by Audrey Howard, RHIA, of 3M Consulting Services Seizures are episodes of abnormal electrical brain activity that cause changes in attention or behavior. The term convulsions may be used interchangeably with seizures, but during a convulsion, the body rapidly and uncontrollably shakes. Epilepsy is a brain disorder in which a person has repeated seizures. Also called a seizure disorder, epilepsy may be diagnosed when the patient has two or more unprovoked seizures.

3 Code Assignment A seizure episode is classified to ICD-9-CM code , Other convulsions. This code also includes convulsive disorder not otherwise specified (NOS), fit NOS, and recurrent convulsions NOS. Basically, code is for the single episode of a seizure. Subcategory 780.3, Convulsions, includes the following codes: , Febrile convulsions (simple), unspecified; , Complex febrile convulsions; and , Posttraumatic seizures. Epilepsy and recurrent seizures are classified to category 345. Subcategory includes the following diagnoses: Epileptic convulsions, fits, or seizures NOS; Seizure disorder NOS; and Recurrent seizure disorder NOS. Types of Epilepsy There are two main categories of epilepsy: partial (also called local or focal) and generalized. Partial seizures occur in only one part of the brain. The following are two common types of partial epilepsy: Simple focal seizure is a type of partial epilepsy where the awareness is retained and does not result in loss of consciousness. It may alter emotions or change the patient s senses, such as taste or smell. This type of epilepsy is classified to subcategory 345.5, Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures. Complex focal seizure (subcategory 345.4) alters consciousness resulting in staring or nonpurposeful movements such as hand rubbing, chewing, lip smacking, and walking in circles. Generalized seizures involve all parts of the brain. The following are the six types of generalized seizures: Absence seizures (petit mal): characterized by blank staring and subtle body movements that begin and end abruptly. It may cause a brief loss of consciousness. Tonic seizures: causes stiffening of the muscles and may cause the patient to fall to the ground. Clonic seizures: characterized by rhythmic, jerking muscle contractions that affect both sides of the body at the same time. Myoclonic seizures: associated with sudden brief jerks or twitches on both sides of the body. Atonic seizures: causes patients to lose muscle tone, so they subsequently collapse. Tonic-clonic seizures (grand mal): most intense type of epilepsy causing loss of consciousness, muscle rigidity, and convulsions. Subcategory 345.0, Generalized nonconvulsive epilepsy, includes atonic and typical absences, minor and pykino-epilepsy, petit mal, and akinetic and atonic seizures. Subcategory 345.1, Generalized convulsive epilepsy, includes clonic, myoclonic, tonic, and tonic-clonic epileptic seizures; grand mal; major and progressive myoclonic epilepsy; and Unverricht-Lundborg disease. Notice that petit mal is classified to subcategory 345.0, and grand mal is classified to subcategory However, there are also codes available for petit mal status (345.2) and grand mal status (345.3). Status epilepticus indicates a state of continuous seizure activity

4 lasting for a significant amount of time or having frequent recurrent seizures without regaining full consciousness in between them. This is a life-threatening condition because the brain cannot get enough oxygen to survive. Most of the codes in category 345 require a fifth digit subclassification to complete the code. Fifth digit 0 is for without mention of intractable epilepsy. Fifth digit 1 is with intractable epilepsy and includes the terms pharmaco-resistant, poorly controlled, refractory, or treatment resistant. Codes 345.2, Petit mal status, and 345.3, Grand mal status, do not require fifth digit subclassification. Seizures documented as the late effect of stroke are classified to code , Other late effects of cerebrovascular disease. An additional code may be assigned for the specific type of seizure/seizure disorder (code or category 345) documented. ICD-10-CM Coding for Seizures and Epilepsy Coding for seizures and epilepsy in ICD-10-CM is similar to ICD-9-CM. ICD-10-CM category G40 is titled Epilepsy and recurrent seizures. The following are the fourth character subcategories for epilepsy: G40.0, Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset; G40.1, Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures; G40.2, Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures; G40.3, Generalized idiopathic epilepsy and epileptic syndromes; G40.A, Absence epileptic syndrome; G40.B, Juvenile myoclonic epilepsy [impulsive petit mal]; G40.4, Other generalized epilepsy and epileptic syndromes; G40.5, Epileptic seizures related to external causes; G40.8, Other epilepsy and recurrent seizures; and G40.9, Epilepsy, unspecified. Notice that the above subcategories are mainly separated by localized vs. generalized. In addition, there are separate codes if the epilepsy is idiopathic vs. symptomatic. The fifth and sixth characters will identify the presence or absence of status epilepticus and intractable epilepsy. Convulsions, not elsewhere classified are classified to category R56 and includes the following subcategories: R56.0, Febrile convulsions; R56.1, Posttraumatic seizures; and R56.9, Unspecified convulsions (which includes seizures NOS).

5 Obesity Is a Serious Public Health Problem By Cheryl D'Amato, RHIT, CCS, and Melinda Stegman, MBA, CCS, Ingenix. Obesity is a condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health and reduced life expectancy. Being overweight or obese increases the risk of many diseases and health conditions such as hypertension, heart disease, type 2 diabetes, stroke and sleep disorders. Adult obesity is most commonly caused by a combination of eating too many calories and lack of physical activity, and in some instances genetics or medications. The increased incidence of childhood obesity is linked to a number of reasons including a sedentary lifestyle, social and economic status and eating habits. A person is generally considered overweight if they have a body mass index (BMI) between 25 and Obesity is defined as a BMI of 30 or higher. A BMI over 40 or anyone greater than 100 lbs overweight is generally considered morbidly obese. It is important to note that BMI does not directly measure body fat. As a result, some people, such as athletes who are muscular, may have a BMI that identifies them as overweight even though they do not have excess body fat. BMI measurements are used to categorize patients in a more specific manner than just using the terminology overweight or obese and is calculated based on height and weight. It can be determined by dividing a person's weight in kilograms by their height in meters squared. It can also be calculated by multiplying a person's weight in kilograms by 704.5, and dividing the result by their height in inches twice. Coding Overweight and Obesity Two codes are typically assigned to report overweight and obesity. A code from category 278.0, Overweight and obesity should be reported first and includes the following codes: , Obesity, unspecified , Morbid obesity , Overweight A second code to report the BMI is assigned next. As mentioned above, the BMI codes are used to assist in distinguishing between overweight and obese patients. They also assist in identifying severity and potential health risks and outcomes. For persons over 20 years of age, one of the following BMI codes is assigned if documented: V85.2X, Body Mass Index between 25-29, adult V85.3X, Body Mass Index between 30-39, adult V85.4, Body Mass Index 40 and over, adult For pediatric patients one of the following pediatric BMI codes is used instead: V85.53, Body Mass Index, pediatric, 85th percentile to less than 95th percentile for age

6 V85.54, Body Mass Index, pediatric, greater than or equal to 95th percentile for age BMI pediatric codes are assigned for person's age 2-20 years of age. The percentiles are based on the growth charts published by the CDC. A child in the 85th to 95th percentile is considered at risk and corresponds to a BMI of 25. Children over the 95th percentile have the most severe level of childhood obesity, which corresponds to a BMI of 30. There are no hard set weight ranges used as criteria for coding the diagnoses of overweight or obesity because everyone is different. These diagnoses are documented by the physician who takes the patient's height and weight into consideration first. Only code the condition that is documented by the physician. If there is conflicting documentation, the attending provider should be queried for clarification. Coders should not calculate the BMI. The BMI code assignment should be based on the documentation in the medical record, which may be included in a dietitian's note. This is an exception to the guideline that requires code assignment be based on the documentation by the physician or any qualified healthcare practitioner who is legally accountable for establishing the patient's diagnosis. While BMI may be reported using the dietitian's documentation, the codes for overweight and obesity can only be based on the provider's documentation. Only when the provider has specifically documented overweight, obesity or morbid obesity can the coder use the dietitian's note to assign the appropriate BMI code from category V85. For obstetric patients with obesity assign code 649.1X, Obesity, complicating pregnancy, childbirth or the puerperium, first followed by the appropriate obesity and BMI codes. Review the following Coding Clinics for more information on coding overweight and obesity; 1st Quarter 1999, 4th Quarter 2001, 3rd Quarter 2003 and 4th Quarter 2004, 4th Quarter 2005, 2nd Quarter 2006, and 2nd Quarter Test your knowledge on overweight and obesity coding with the following quiz: Questions: 1. A patient presents to the clinic for continued evaluation of sleep apnea. During the visit he is seen by a dietician for diet counseling. The dietician note indicates the patient is obese and has a BMI of 33. The physician lists the patient's diagnosis as sleep apnea. What diagnoses codes should the facility assign for this clinic visit? a , , V85.33 b , V85.33 c d ,

7 2. A patient presents to the hospital for delivery. The physician documents that the patient has had a high risk pregnancy because of obesity and is admitted for induction of labor. The patient delivers her baby and before discharge is seen by a dietician who documents a post delivery BMI of 41. The diagnoses documented by the physician on discharge are; Delivered single newborn and pregnancy complicated by obesity. What diagnoses codes should be assigned for this case? a , , V85.4, V27.0 b , , V85.4, V27.0 c. 650, V27.0 d , , V85.4, V27.0 Answers 1. c. Code is assigned to report the sleep apnea. In this instance codes for obesity and BMI are not assigned because the obesity is not substantiated in the medical record by the physician. The physician can be queried for clarification. 2. b. Code is assigned as the principal diagnosis to report the delivery in a pregnancy complicated by obesity. Code , Obesity, is assigned next because even though the patient's BMI is 41 the physician does not document morbid obesity. Code V85.4 indicates the BMI of 41. Code V27.0 may also be assigned to report the outcome of the delivery, single live born.

There are several types of epilepsy. Each of them have different causes, symptoms and treatment.

There are several types of epilepsy. Each of them have different causes, symptoms and treatment. 1 EPILEPSY Epilepsy is a group of neurological diseases where the nerve cell activity in the brain is disrupted, causing seizures of unusual sensations, behavior and sometimes loss of consciousness. Epileptic