ACDIS tip: AHA Coding Clinic, third quarter 2022 update

CDI Strategies - Volume 16, Issue 44

by Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC

The American Hospital Association (AHA) Coding Clinic released their third quarter 2022 publication, but if you are looking for groundbreaking direction or exciting new challenges, you will be disappointed. This release offered no more than six questions related to sequencing, primarily related to the sequencing of cancer and related complications. Perhaps after so many recent controversial Coding Clinic releases, the AHA thought it best to get back to the basics of code assignment. But before I get to the sequencing guidance, I will first touch on the other areas covered in the publication.

Monkeypox is all over the news. This virus is very similar to the smallpox virus. Although it is rarely fatal, it can contribute to acute illness in those individuals who are immunocompromised. The United States Department of Health and Human Services declared monkeypox a public health emergency in August of this year. Coding Clinic reinforced that there are no specific coding guidelines for the reporting of monkeypox. When sequencing diagnoses, we are to follow the Official Guidelines for Coding and Reporting and assign the diagnosis, condition, or problem identified as being chiefly responsible for the encounter. There is no specific sequencing instruction for the B04 code classifying monkeypox.

When documentation identifies an exposure to monkeypox, we are to assign code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. Monkeypox is thought to be contagious from the start of symptoms until the rash is healed and a fresh skin layer is formed and intact. Documentation of a “history of monkeypox” is reported with code Z86.19, Personal history of other infectious and parasitic diseases.

The reporting of conditions related to pregnancy can be a challenge. I do encourage you to review the guidelines if this is an area for which you review records. The question describes a woman presenting with end-stage ischemic cardiomyopathy due to a peripartum spontaneous coronary artery dissection (SCAD) that occurred 10 years prior, and asks if peripartum cardiomyopathy should be reported with the O94 code classifying sequelae of complication of pregnancy, childbirth and puerperium.

The answer reminded us to read the record very carefully. We cannot report peripartum cardiomyopathy, because the patient did not have peripartum cardiomyopathy, she had peripartum SCAD, which contributed to end-stage ischemic cardiomyopathy. Two codes would be assigned: I25.5, Ischemic cardiomyopathy, and O94, Sequelae of complication of pregnancy, childbirth, and the puerperium. The specific nature of the late effect (i.e., the ischemic cardiomyopathy) is sequenced first, followed by the O94 code.

There was a question related to the insertion of a preCARDIA device and how this should be reported. This device is now being used to treat an acute decompensation of heart failure. A balloon catheter and a pump controller are used to occlude the superior vena cava intermittently. The goal is to rapidly reduce congestion in the venous system (cardiac preload), contributing to improved cardio-renal function. This intervention allows for improved response with a goal of shorter length of stay and fewer hospital readmissions. The assigned code is 5A02110, defining the root operation of assistance with cardiac output using balloon pump as intermittent.

There are also instructions stating that, since there is no unique code within ICD-10-CM to capture lymphoma, not further specified, “in remission” we are to report the lymphoma as being a personal history with the Z85.72 code.

There were several questions related to sequencing instructions within the Tabular list, asking when and how these directions should be followed. The first question pertained to the relationship between E88.81, Metabolic syndrome, and E66.01, Morbid obesity due to excess calories. The E88.81 code is followed by a “use additional code” note, instructing us to follow this code with the associated manifestation. So, if both diagnoses are present, the metabolic syndrome (etiology) would be followed by the morbid obesity (manifestation). 

There were a few scenarios that focused on sequencing as related to cancer and related complications. The answers were consistent with the direction published in section I.C.2.1.4 of the Official Guidelines of Coding and Reporting that states, “When an encounter is for management of a complication associated with a neoplasm and the treatment is only for the complication, the complication is coded first, followed by the appropriate code(s) for the neoplasm.”

The first example described an individual admitted with an intracerebral hemorrhage and vasogenic edema related to known brain metastases. Either the nontraumatic intracerebral hemorrhage or the cerebral edema could be reported as the principal diagnoses, with the codes classifying the primary and secondary malignancies as secondary codes.

In contrast, the next question addressed an encounter for which a patient with known adenocarcinoma of the lower esophagus was admitted with ataxia and diplopia. The work-up determined the presence of a new metastases to the brain, contributing to a non-traumatic intracerebral hemorrhage, as the cause of the symptoms on presentation. The patient underwent a resection of the lesion within the brain. In this case, the principal diagnosis would be the secondary malignant neoplasm of the brain, and the complication of the cerebral hemorrhage would be sequenced as the secondary diagnosis.

The Official Guidelines instructions state, “Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a ‘use additional code’ note at the etiology code, and a ‘code first’ note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.”

These scenarios can be confusing. I know I asked numerous questions of the coding team related to oncology admissions when I first started in CDI. But the direction within the Coding Clinic is very clear: consistently apply the Tabular list instructions (code first and use additional code notes) as well as the direction within the Official Guidelines.

It is always educational to review the AHA Coding Clinics. Although there may be times when the instruction is not very clear, we become stronger CDI professionals the more we read and understand. I always tell people to actually read the Coding Clinic guidance and, if someone quotes a line or two from a Coding Clinic, go back and read it in its entirety. These questions are related to very specific situations, and often a few words can be taken out of context or incorrect assumptions can be made. So, my disclaimer today is that there are a number of questions and answers that I did not discuss here, but those that I did are still worth your time to actually review and ensure you are applying the directions of accurately. I learn every time I read this instruction, and often I can apply the instruction to other similar situations. I know that they are not the most riveting read with an intriguing plot line and fully developed characters, but sometimes we can still learn a life lesson or two.

Editor’s note: Prescott is the interim director and director of CDI education for ACDIS, based in Middleton, Massachusetts. Contact her at