Note from the ACDIS Interim Director: First quarter 2024 Coding Clinic update

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

The first quarterly release of Coding Clinic focused on the changes and new codes effective April 1, 2024. If you wish to review the updated Official Guidelines for Coding and Reporting, they can be accessed here.

Notable changes to the guidelines include:

• Section C.1.d.5.b, which speaks to the reporting of sepsis due to a post-procedural infection. This entry reminds us to sequence codes that identify the site of infection first, then follow with the appropriate codes related to sepsis. In addition to the already published listing of codes (grouping T81.41-T81.43 classifying an infection following a procedure and O86.09, Infection of obstetric surgical wound, other surgical site), T81.49, Infection following a procedure, other surgical site, and O86.00-O86.03, Infection of obstetric surgical wound, were added.
• Section C.4.6.b.i, which speaks to secondary diabetes and now offers clear sequencing direction. It instructs us to first assign a code from category E13, Other specified diabetes mellitus, as the principal or first-listed diagnosis and a code from subcategory Z90.41, Acquired absence of pancreas, as an additional code.
• Section C.21.7, which speaks to the assignment of codes classifying aftercare. This section highlights that the aftercare Z code should not be used if treatment is directed at a current, acute disease. In such a case, the diagnosis code should used. The exception to this rule is codes from the Z51 code grouping classifying an encounter for antineoplastic radiation, chemotherapy, or immunotherapy.  The updated wording reminds us that when the encounter is chieflyto receive radiation therapy, chemotherapy, or immunotherapy for the treatment of a neoplasm, these codes should be the first listed.

The April 1 update includes 41 new codes within ICD-10-PCS, six deleted codes, and three code title revisions. A few changes you may note include:

• The device character of radioactive element, Palladium-103 Collagen Implant, was added to the body part value of (0) Brain in table 00H. Palladium-103 Gamma Tiles® are inserted to deliver radiation to intracranial neoplasms. 00H005Z, Insertion of radioactive element, palladium-103 collagen implant into the brain, open approach is assigned. This does not require an additional code identifying brachytherapy.
• The qualifier of F, Irreversible Electroporation, was added to 025, Destruction of heart and Great Vessels, percutaneous approach. Irreversible electroporation for cardiac ablation, also referred to as pulsed field ablation, is performed for pulmonary vein isolation in the treatment of atrial fibrillation. It destroys selected tissue and induces cell death at the opening of the four pulmonary veins within the left atrium.
• A new qualifier value G, Hand-Assisted, was added to a number of tables (related to excision and/or resection in the lymphatic, gastrointestinal, hepatobiliary, and urinary systems). Hand-assisted laparoscopic surgery describes the performance of a mini-laparotomy so that surgeon can insert their hand in addition to the percutaneous approach.
• In table ODX, Transfer of Gastrointestinal System, the body part value of U, Omentum was added with additional qualifiers classifying the thoracic, abdominal, pelvic, and inguinal regions. This change will allow capture of procedures documented as pedicled omentoplasty, or pedicled omental patch.

Two questions reinforce the coding guidelines related to signs and symptoms that are inherent to another condition. The Official Guidelines for Coding and Reporting state, “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.” Because of this:

• Hypothyroidism in the presence of Hashimoto’s thyroiditis (HT) is not reported separately as it is a component of HT.
• It would be inappropriate to assign a code indicating angina in the setting of myocardial infarction.

As with every Coding Clinic, there are always questions related to the reporting of post-operative complications. We are instructed to assign codes M96.89, Other intraoperative and post procedural complications and disorders of the musculoskeletal system, and M43.16, Spondylolisthesis, lumbar region, for documentation of post-laminectomy lumbar spondylolisthesis. The answer reminds us that the Guidelines state, “It is not necessary for the provider to explicitly document the term ‘complication.’ The cause-and-effect relationship documented between the surgery and the condition is sufficient.”

A question related to the reporting of sepsis related to surgical wound reminds us that a code from T81.41 to T81.43, Infection following a procedure that identifies the surgical site, is sequenced before the code for sepsis. These codes differentiate by severity, superficial incisional surgical site, deep incisional surgical site, and organ and space surgical site. They are followed by instruction to use an additional code to identify the infection.

Continuing with a focus on complications, two questions reinforce that a dural tear is clinically significant and should always be reported when documented by the provider, even if described as inherent. Code G97.41, Accidental puncture or laceration of dura during a procedure, is followed by the inclusion term incidental (inadvertent) durotomy.

A question offered further definition of the concept of underdosing. It directed us that it is not appropriate to assign a code for underdosing when a PRN (“as needed”) medication is not taken. For such a situation we would assign code Z91.198, Patient’s noncompliance with other medical treatment and regimen for other reason.

One question emphasizes that critical thinking is required in the process of code assignment. It asked what the correct code is for non-traumatic acute liver injury due to metastatic liver disease and chemotherapy. The question speaks to the fact that documentation of acute liver injury is classified to the S36.11- code grouping, classifying a traumatic injury. This code does not seem to be appropriate to the scenario described above. ICD-10-CM does not specifically classify non-traumatic acute liver injury. The Coding Clinic advice directs us to the code K71.8, Toxic liver disease with other disorders of the liver.

A second question, describing a vertebral artery dissection that occurred related to chiropractic manipulation, reinforces the fact that traumatic injury codes are assigned only when the injury is related to trauma. They should not be assigned for conditions that occur during, or as a result of, a medical intervention, to include chiropractic manipulation.

Lastly, clarification was provided that if an individual experiences cardiac arrest and is resuscitated in the field prior to hospitalization, the I46, Cardiac Arrest code is assigned. The direction reminds us that the patient is receiving continued care related to their cardiac arrest and it should be reported. The CDI educator in me wants to remind you to work to capture the etiology of the cardiac arrest as well.

In closing, I understand AHA Coding Clinics are not the best reads, the plot is often disjointed, and the words may be hard to pronounce, but they are always worth the time. I encourage you to read it in its entirety. I learn every time I pick one up. I can only provide the highlights so there is more for you to learn if you take a moment to review.

Editor’s note: Prescott is the interim director of ACDIS and the CDI education director for HCPro and ACDIS. Contact her at laurie.prescott@hcpro.com.