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

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

I usually enjoy the second quarterly Coding Clinic release each year, as it is often the one that is most “meaty” in its offerings, meaning it brings a little food for thought and a variety of direction. This one did not disappoint! The menu of 31 pages covered topics such as intestinal obstructions, asthma, chronic obstructive pulmonary disease (COPD), cerebral petechia hemorrhage, dementia in the setting of epilepsy, and recrudescence of symptoms status post cerebral vascular accident. Certainly, I can’t cover it all in this summary, so I encourage you to read the publication in its entirety and ensure your understanding of the subjects at hand. Or, to continue with this analogy, ensure you sample the entire menu.

There are a number of historical Coding Clinics related to the reporting of COPD and this publication added a few more to the plate. Citing what appears to be conflicting instruction within the Alphabetic Index and the Tabular List, the first question pertained to the reporting COPD accompanied by asthma. When both conditions are documented, the guidance instructs us to assign J44.89, Other specified chronic obstructive pulmonary disease. A separate code for asthma should not be assigned unless the asthma is specified (mild intermittent, mild, moderate or severe persistent asthma), or is described as an exacerbation. We are not to report J45.909, Unspecified asthma, uncomplicated, as it is not a type of asthma.

A second question further stresses how important it is to obtain specificity with these diagnoses. It reminds us that emphysema is a form of COPD, so if the two diagnoses are documented, the J43.9 code classifying emphysema, unspecified, is the only code reported. No additional code for COPD is needed unless the COPD is further specified, as with infection or exacerbation. When further specified, we would need the additional code to fully capture the true “flavor” of the encounter.

A third course of COPD was served related to the reporting of COPD and bronchiectasis. When the COPD is not further specified (with infection or with exacerbation), the only code reported would be from the J47 code category classifying bronchiectasis. So, after being served a meal of chronic lung disease, what do you bring home in your doggy bag? Best practice is to obtain specificity in the type of asthma, the presence of a COPD exacerbation, or a related infectious process.

I am now going to let my analogy of meals, menus, and food be set aside for a moment, as such a comparison for the next question is just unappetizing at best. The instruction correctly indicates that constipation is considered integral to fecal impaction. If both are present, report the K56.41 code classifying fecal impaction, as this is the more severe of the two conditions. 

The indexing of dementia lists “Dementia… in (due to)” followed by epilepsy, in diseases specified elsewhere, and offers food for thought—is this considered an assumed relationship based upon the “with” convention? If both dementia and epilepsy are documented within the record, can we then automatically assign the code F02.80, dementia, in other diseases classified elsewhere? The answer instructed us to query if the provider does not clearly clarify the relationship because dementia can contribute to epilepsy and conversely epilepsy can contribute to dementia. This chicken/egg scenario complicates the relationship between the two and how they should be reported.

Just like every meal should include a vegetable side, every Coding Clinic publication must include a question related to the sequencing and reporting of cancer. This question and answer reminds us that cancer that has been resected and no longer present is reported as a personal history, and if the treatment is applied to complications of the metastases, the metastatic disease is sequenced first. No big surprise, but this is a topic often confusing to new CDI professionals.

This Coding Clinic taught me a new word. Recrudescence of a stroke or infarction describes the reoccurrence of stroke-related deficits from a previous or old stroke. This word was added to the Alphabetic Index FY 2024. When it is used in documentation, it indicates the presence of sequelae and should be reported as such. For example, if the documentation describes facial weakness as a recrudescence of a prior stroke, the I69.392 code classifying facial weakness following cerebral infarction would be assigned.

While we are discussing cerebral infarction, there is direction that documentation of cerebral petechial hemorrhage is to be reported under I61.8, Other nontraumatic intracerebral hemorrhage. Providers might describe such an event as a microbleed, which is often associated with chronic hypertension, cerebral amyloid angiopathy, and diffuse axonal injury.

Many people appreciate a good surf and turf. Indeed, there is no rule that says you cannot serve lobster with steak. The next question speaks to the type 2 Excludes note at subcategory G93.4, Other and unspecified encephalopathy, which allows the reporting of G93.41 with code G92.8, Other toxic encephalopathy when appropriate. Just as the surf and turf are not mutually exclusive, if the encephalopathy is identified as being due to more than one cause, both can be reported.

We will end this meal with a bit of dessert. Dessert often contributes to the release of insulin, and those with diabetes often need assistance in managing their glucose levels. The question asks if it would be appropriate to assign a code from the Z79 code category classifying long-term (current) drug therapy for a newly prescribed hypoglycemic (anti-diabetic) medication based upon an intended long-term use to manage the chronic condition. The answer stated that, indeed, it would be appropriate to capture this information.

So, in conclusion, there is a lot to digest in this second quarterly Coding Clinic and is worth the read. So please take the time to review these and read the Q&As in their entirety. Such an activity is time well-spent and will strengthen your skills in recognizing opportunities in record review. They might even spark your tastebuds to further explore certain conditions or increase efficiency in the use of the Alphabetic Index or Tabular Lists of ICD-10.

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.