Industry hot topics: Insight into ambiguous, inconsistent, conflicting advice and guidance

Coding Clinic, 2Q 2019, Page: 29: Assign only code P22.0, Respiratory distress syndrome of newborn. RDS is a lung disease that affects preterm newborns, and occurs because the infant's lungs are not fully developed, and do not have enough surfactant. Code P22.0 is more appropriate than code P28.5, as RDS is a distinct clinical entity and more specific, while respiratory failure can occur from different causes.

FY 2024 IPPS Update: P22.0, Respiratory distress syndrome of newborn has Excludes2 note for P28.5, Respiratory failure of newborn NOS and P28.5 has Excludes2 note for P22.0.

This is an update from an old edit: Excludes1 note on P28.5 excluding code P22.0.

Excludes2 note means that yes, the patient can have both and both can be coded on the same encounter.

Recommendation: Evaluate the clinical picture to determine if the two conditions are related or unrelated. Code both P22.0 and P28.5 when the circumstances of the patient supports coding of both, respiratory distress syndrome of newborn and respiratory failure of newborn. 

E-mail nchsicd10cm@cdc.gov to communicate these issues that may have been overlooked when this revision was created to alleviate coder confusion.

It is a common misconception that severities across base APR-DRGs can be compared. An SOI value of 2 in one APR-DRG does not necessarily equal an SOI value of 2 in a different APR-DRG. In the 3M encoder, review the Assignment Reports which are available in the Coding & Reimbursement System® via the same-named icon to the left of the APR-DRG text. This report provides the logic used in the SOI/ROM assignments.  

This sequencing has DRG impact. The tabular index has no sequencing instruction and has hierarchy over Coding Clinic. 

Consider requesting clarification:

NCHS: nchsicd10cm@cdc.gov.

AHA: https://www.codingclinicadvisor.com

Code R40.2- is now limited to TBI cases according to an American Hospital Association (AHA) webinar. If coma scale codes are not permitted for non-traumatic injuries and conditions that alter neurological function, there is a risk of inaccurate or incomplete reflection of the clinical picture. The severity of illness, length of stay, and resource utilization are impacted by decreased GCS, or coma, that is not medically induced but is a result of the non-traumatic injury or condition. 

Although Coding Clinic, fourth quarter 2020, p. 91, reflects the revision of the coma scale guideline, clear definitive guidance would be helpful for clarity of use, including unspecified coma. The current guideline notes that they can be used in conjunction with TBI codes. However, it does not specifically state that they are not permitted for use in other cases. Specific clarity such as p. 99 of the Official Guidelines for Coding and Reporting would be helpful: “Do not assign BMI codes during pregnancy.”  Also, GCS is one of the measures in the SOFA score, which is another negative impact of this revision.

UPDATE: Per Coding Clinic, fourth quarter 2021, p. 112,  coma scale codes are to be used only in conjunction with traumatic brain injuries (TBI).

Updated 5/2022

Originally posted 2/26/2021

UPDATED: Diabetes mellitus, uncontrolled

Coding guidance prohibits the presumption or assumption of hyperglycemia versus hypoglycemia from the lab result, which is causing an increase in queries to the provider(s).

The ACDIS Pocket Guide includes criteria for each condition.  

The index leads to hyperglycemia with “poorly controlled” or “out of controlled." Lab orders at some facilities are rejected when only “uncontrolled” DM is documented. 

The need is a default code for “uncontrolled” to alleviate the need for and the increase in queries.   

Recommendation: The Regulatory Committee would like to begin working on a proposal to allow glucose/blood sugar lab findings to support code assignment.  

Please complete this four-question ACDIS survey on this topic to contribute and provide insight on how your facility or organization is handling code assignment and querying guidelines. 

Your answers will help the Regulatory Committee with decisions on a proposal.  

Updated 5/17/2022

Originally posted 2/28/2022

Official Guidelines for Coding and Reporting, 1.C.15.a.1: Should the provider document that the pregnancy is incidental to the encounter, then code Z33.1 (Pregnant state, incidental), should be used in place of any chapter 15 codes. It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.

Official Guidelines for Coding and Reporting, 1.C.21.c.3:  Z33.1 (Pregnant state, incidental).  This code is a secondary code only for use when the pregnancy is in no way complicating the reason for visit. Otherwise, a code from the obstetric chapter is required.

These guidelines appear to conflict. Pregnancy is rarely documented as “incidental” when the reason for admission and focus of treatment are for another reason. 

For example, when an admission is to treat and focus on major trauma and an early pregnancy gestational sac was discovered on ultrasound during trauma work up, it’s unclear if an OB code should be the principal diagnosis (PDX) because it’s not specifically noted as not complicating the pregnancy versus coding the most severe trauma as PDX with Z33.1 as a secondary code because the entire focus was on resolving life-threatening conditions and the pregnancy in no way had impact on the course of treatment.  

Coding Clinic, second quarter 2021, pp. 11-12:  Although after query the provider indicated the serosal tear was unavoidable, it was clinically significant, as it required further excision, complicating the surgery. Therefore, the excision of the small intestine is coded. Assign the following procedure code:

Coding Clinic, first quarter 2022, pp. 50-51: Although the surgeon stated that the serosal tear was unavoidable, it does not mean that the tear is not a surgical complication. For example, a serosal tear can range from a small nick requiring no treatment at all, to a major tear requiring removal of a portion of the small intestine. Serosal tears alone do not qualify as reportable diagnoses. If, however, the degree of a serosal tear alters the course of the surgery as supported by the medical record documentation, then the tear should be reported.

Coding Guidelines I.B.16 FY 2023:  There must be a cause-and-effect relationship between the care provided and the condition, and the documentation must support that the condition is clinically significant. It is not necessary for the provider to explicitly document the term “complication.” For example, if the condition alters the course of the surgery as documented in the operative report, then it would be appropriate to report a complication code. Query the provider for clarification if the documentation is not clear as to the relationship between the condition and the care or procedure.

Per Coding Clinic, first quarter 2013, p. 15, fractures of the rib occurring secondary to cardiopulmonary resuscitation (CPR) efforts are not classified as a complication because they are a known risk of this procedure.

Per Coding Clinic, first quarter 2021, p. 5, assign code M96.89, Other intraoperative and post procedural complications and disorders of the musculoskeletal system, as fractures of the rib are a known risk of this procedure.

The tabular index states: 

T81.44:  Sepsis following a procedure

Use additional code to identify the sepsis.

A41:  Other sepsis

Code first postprocedural sepsis (T81.4-)

The Official Guidelines for Coding and Reporting, p. 25 states: For infections following a procedure, a code from T81.40, to T81.43 Infection following a procedure, or a code from O86.00 to O86.03, Infection of obstetric surgical wound, that identifies the site of the infection should be coded first, if known. Assign an additional code for sepsis following a procedure (T81.44) or sepsis following an obstetrical procedure (O86.04). Use an additional code to identify the infectious agent."

Discuss whether or not it is correct to follow the instructional note below as written and assign A41.9 (sepsis, unspecified organism) with T81.44 (Sepsis following a procedure). 

A41.9 is not excluded from the use additional note but does not identify an infectious agent or add specificity to the already identified sepsis as seen in T81.44. The use additional note may need revision to identify the “type” of sepsis (as is seen in the note under O99.21).

Consider requesting clarification:

NCHS: nchsicd10cm@cdc.gov.

AHA: https://www.codingclinicadvisor.com

Recent Coding Clinic advice seems to ask coders to contradict specific physician documentation when a complication of a procedure is documented as “expected.” Such reporting of complications may impact regulatory-based quality measures. 

Example: American Hospital Association (AHA) COVID-19 FAQ #54 says to assign complication codes for barotrauma from mechanical ventilation even though COVID weakened the alveoli making them overinflate.  

Question: The patient is diagnosed with acute COVID-19 viral infection with bilateral pneumonia and adult respiratory distress syndrome (ARDS) resulting in acute hypoxic and hypercapnic respiratory failure. The provider documented that the patient developed acute right-sided hydropneumothorax, likely due to barotrauma due to mechanical ventilation. Since the patient had COVID-19 pneumonia, which can weaken the lungs, would this affect code assignment? How should this case be coded?  

Answer: Assign code U07.1, COVID-19, as the principal or first-listed diagnosis, because the pneumonia is an acute manifestation of the COVID-19 infection. Assign code J12.82, Pneumonia due to coronavirus disease 2019, and code J80, Acute respiratory distress syndrome, as additional diagnoses for the pneumonia and ARDS. In addition, assign codes J95.859, Other complication of respirator [ventilator], J95.811, Postprocedural pneumothorax, and J94.8, Other specified pleural conditions, to capture hydropneumothorax barotrauma due to mechanical ventilation. The presence of COVID-19 does not affect code assignment of hydropneumothorax barotrauma. 

Continue to query the provider whether the condition is a complication when documentation is ambiguous or not explicitly stated as a complication or relation to preexisting condition or other etiology.  

Consider requesting clarification:  

NCHS: nchsicd10cm@cdc.gov 

AHA: https://www.codingclinicadvisor.com

Per Coding Clinic, first quarter 2019, pp. 34-35, J43.9, Emphysema, unspecified, is to be assigned for a patient admitted for COPD exacerbation (J44.1) who also has emphysema.

J43.9 does not capture the acuity of the condition needing admission.  When assigned as a secondary code, it is not a CC and does not potentially impact the severity of illness as J44.1 may.

Consider proposing that the National Center for Health Statistics create a code for emphysema exacerbation and that CMS designate the new code as a CC.

NCHS: nchsicd10cm@cdc.gov

CMS: Marilu.Hue@cms.gov