Note from the ACDIS Interim Director: Third quarter 2023 Coding Clinic update

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

We had a mid-August surprise with an early release of the third quarter Coding Clinic. It contained 28 pages of advice, much of which was very interesting and somewhat surprising. Because I can’t cover the release in its entirety, I encourage you to review it yourself.  I strongly believe the more you expose yourself to Coding Clinic direction the better you understand how to apply the principles of code assignment. The direction reinforces many concepts such as the Official Guidelines for Coding and Reporting, use of the Alphabetic List indexing and coding conventions. These concepts assist us in succeeding in CDI.

Many CDI programs have or are in the process of expanding into obstetric and perinatal reviews. I find Coding Clinic direction particularly helpful in understanding the nuances of reporting conditions for these encounters. The first question reinforces how codes within Chapters 16 and 17 are to be used.

• Codes within Chapter 16, Certain Conditions Originating in the Perinatal Period, are for use on the newborn’s record. They include conditions that have their origin in the fetal or perinatal period (before birth and through the first 28 days after birth).
• Codes within Chapter 17, Congenital Malformations, Deformations and Chromosomal Abnormalities, may be used throughout the life of the patient. If the congenital condition is corrected, a history code should be assigned to identify the history of the malformation or abnormality.

A question included in this quarter’s release asked what code is assigned when documentation indicates pancytopenia due to radium-223 treatments. It states that when referencing “adverse” of radioactive drugs, NEC” in the Table of Drugs and Chemicals, subcategory T50.8X5, Adverse effects of diagnostic agents, is provided. The answer reinforces that you should always review the code title to ensure it reflects the specific situation. In this case, radium-223 is not a diagnostic agent, it is used to treat cancer. The T50.8X5 code is not accurate. The instruction indicates two codes would be assigned, D61.811, other drug-induced pancytopenia, and T50.995A, Adverse effect of other drugs, medicaments, and biological substances, initial encounter.

This question brings attention to the fact that often the correct code is dependent upon understanding if the medication or intervention is performed for diagnostic or therapeutic purposes. This designation will influence specific code assignment and may impact the DRG grouping and/or medical necessity denials. If the purpose is unclear, a query should be placed for clarification.

The next question speaks to inherent conditions. The question describes a patient with a subcapsular renal hematoma, asking if the acute kidney injury (AKI) is inherent to the hematoma. If the AKI is inherent, meaning all patients with a subcapsular hematoma also will present with an accompanying AKI, the AKI would not be reported. The answer indicates that both N28.89, Other specified disorders of kidney and ureter, and N17.9, Acute kidney failure, are reported. These are unique conditions that should both be reported. There are many historical Coding Clinics that speak to what is considered inherent and what is not. My advice to you, if you are unsure, it’s important to seek historical guidance and any needed clarification from the provider.

The term “integral” is similar to the term “inherent.” Actions considered integral to a procedure are not reported separately. For example, we would not report a side-to-side anastomosis separately when reporting a right colectomy. The ICD-10-PCS Official Guidelines for Coding and Reporting, Section B3.1b states, “procedural steps necessary to close the operative site, including anastomosis of a tubular body part, are not coded separately.”

This Coding Clinic states that when bone marrow aspirate concentrate (BMAC) is obtained and injected as part of an ORIF, the procedures of aspiration and injection would be considered integral to the overall surgical intent and not be reported separately. This direction left me a bit confused, as we do report separately the harvesting of a vein or artery when it is obtained to perform a bypass procedure. Again, an example of the inconsistencies within the directions, reinforcing we must always remain up to date with this instruction and seek guidance when we are unsure.

There were a few questions asking for clarification of the root operation. The root operation indicates the intent or purpose of the surgery. One question describes a Jada® System suction device used to control postpartum bleeding. The answer instructs that although the device is a suction system the purpose of the device was to control the bleeding. The root operation would be control or stopping, or attempting to stop, postprocedural or other acute bleeding. If you didn’t know that there are ways to learn. The first step would be to research the device or procedure. There are so many resources available on the internet, but I find the best option is to go to the specific direction offered by the company producing the device. The second is to query the provider for clarification.

A question related to neurally-adjusted ventilatory assist (NAVA). This system monitors the output of the patient’s respiratory center, by capturing the electrical signal that activates the diaphragm, using a dedicated gastric feeding tube. The ventilator utilizes the electrical activity of the diaphragm to initiate breaths. We are directed to assign a code from table 5A0, Extracorporeal or systemic assistance or performance. The root operation can be either assistance or performance. If the patient is intubated, the root operation would be performance.

Heart failure is differentiated based upon the ejection fraction. The Coding Clinic directs us that documentation of heart failure with improved ejection fraction is the equivalent of heart failure with recovered ejection fraction. Such documentation supports the assignment of a code classifying diastolic heart failure, as directed by the Coding Clinic published third quarter 2020.

With ever-changing legislation, the use of medical marijuana is increasing, leaving us to question how to report prescribed cannabis use. We are to assign the appropriate code for the condition being treated, along with code Z79.899, Other long term drug therapy. We are not to assign a code for unspecified psychoactive substance use in this situation.

The only certainty in our world is change. There will always be new technology, new procedures, new specificity of conditions. The language of healthcare is evolving. This means we will always be learning and asking for direction. We will always be reading Coding Clinic instructions. I encourage you to give it a read and continue to seek clarification as needed. To succeed professionally, we need to ensure we are well informed and apply the appropriate guidance effectively.

Editor’s note: Prescott is the interim director of ACDIS and the CDI education director for HCPro and ACDIS. Contact her at lprescott@acdis.org.