ICD Q & A

Coding Q&A: Aug. 16, 2005

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Q: This question specifically relates to Single Organ Exams for E&M coding. I know we are allowed to use the 1995 or 1997 guidelines in general, but are we allowed to use the 1995 guidelines to judge single organ exams? The words are there but many consultants state that all single organ exams should be judged by the 1997 guidelines? Is this true?

A: Every bit of research I did for this question points me in the direction of using the '97 examination guidelines. I did not find anything that states it is OK to use the '95 guidelines for this situation. Quite simply it is because they are the only ones that are completely defined. In the past I have had physicians try to make their own single system specialty exams using the '95 guidelines but when we talked to each of those individual medical societies i.e.: AANS (American Academy of Neurological Surgeons) & AAOS (American Academy of Orthopedic Surgeons) they pointed us to the '97 single system exam criteria.    

Jean Ryan-Niemackl, LPN, CPC
 



Q: How do I code for a radical parametrectomy with right pelvic lymph node dissection with a prior cut through simple hysterectomy, for endometrial stromal sarcoma?

A: Per Grant's anatomy, the space between the layers of the broad ligament is called the parametrium. The parametrium contains the following structures: the uterine artery, the distal portion of the ureter, the proximal part of the round ligament of the uterus, which passes from the uterus to the deep inguinal ring, the ovarian ligament, which connects the ovary to the lateral wall of the uterus between the round ligament of the uterus and the oviduct the uterovaginal venous plexus, the uterovaginal autonomic nerve plexus and the lymphatic vessels. 

The original endometrial stromal sarcoma is still being surgically treated regardless of the prior hysterectomy.

The ICD-9-CM procedure index takes you to 69.19 for excision of broad ligament, paraovarian, round ligament, paramesonephric duct, uterosacral ligament and round ligament. Any additional organs or tissues taken should be coded separately, i.e., extensive pelvic muscle resection, vagina, etc. 

Because the surgeon states "lymph nodes," this should be reported separately.  Lymphatic vessels are often included in surgical resections and should not be reported separately.

Based on the information provided in the question, I recommend coding the following:

DX code:  182.0 Malignant neoplasm of corpus uteri, except isthmus

                              V45.77 Acquired absence of genital organs

PX codes:  69.19 Other excision or destruction of uterus and supporting structures

                              40.3 Regional lymph node excision

Also, I would recommend you review the operative note and pathology thoroughly to see if a vaginectomy {partial or total} was performed. If so, I would add 70.4 Vaginectomy. 

Query the physician for confirmation documentation of any metastatic sites noted in the surgical pathology report prior to reporting.

Gale McNeill, RHIT, CCS
 



Q: Patient admitted with aspiration pneumonia, sepsis and heroin overdose. IV unasyn given on admission. Three days later IV Tequin given. Can sepsis be the principle diagnosis?

A: In answering this question, it helps to reflect upon the definition of "principal diagnosis." The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Discharge Data Set as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

With this in mind, it appears the patient was admitted with concomitant conditions consisting of three separate clinical entities, aspiration pneumonia, sepsis and heroin overdose. On face value, following well established coding principles that permit assignment of either condition as principal diagnosis when more than one condition meets the definition of principal diagnosis, one would be inclined to assign the sepsis or aspiration pneumonia as principal diagnosis. However, in this particular instance, the coder must use as guidance a discussion found in the ICD-9 Official Guidelines for Coding and Reporting, recently updated and effective April 1, 2005. A link to these guidelines may be found here: www.cdc.gov/nchs/data/icd9/icdguide.pdf

Refer to the following citation when within these guidelines: If the term sepsis, sever sepsis, or SIRS are used with an underlying infection other than septicemia, such as pneumonia, cellulitis or a nonspecified urinary tract infection, a code from category 038, should be assigned first, then code 995.91, followed by the code for the initial infection. The use of term sepsis, or SIRS indicates that the patient's infection has advanced to the point of a systemic infection so the infection should be sequenced before the localized infection. The instructional note under category 995.9 instructs to assign the underlying systemic infection first.

As such, the principal diagnosis in your clinical scenario described is that of sepsis, followed by the ICD-9 codes for SIRS, aspiration pneumonia and heroin overdose.

Glenn Krauss, RHIA, CCS, CCS-P
 



Q: What would you suggest using to code "elevated TSH" when used as a reason for further testing? The patient may originally had a symptom/sign that prompted ordering the TSH in the first place, but the follow up studies are being done because the TSH value was abnormal-generally elevated. We understand the basic pathophysiology of hypothyroidism and realize that (eventually) that may be the definitive diagnosis, but at this point in time "elevated TSH" is what we're working with. Options considered include 790.99, other nonspecific findings on exam of blood; 259.9 for unspecified endocrine disorder; or 246.9 for unspecified disorder of thyroid.

A: The proper code I suggest for coding the elevated TSH test would be the code 790.99. If the doctor documents only elevated TSH, the coder can not assume or interpret a diagnosis. For more information on lab tests and where I found the following information, see www.labtestonline.org

A doctor orders a TSH test if you show symptoms of a thyroid disorder. For example, symptoms of hyperthyroidism include heat intolerance, weight loss, rapid heartbeat, nervousness, insomnia and breathlessness.

Common symptoms of hypothyroidism include fatigue, weakness, weight gain, slow heart rate and cold intolerance.

The blood test may be ordered with other thyroid hormone tests and after a physical examination of your thyroid. TSH screening is routinely performed in newborns. The American Thyroid Association recommends that adults older than age 35 be screened for thyroid disease every 5 years although other organizations, such as the U.S. Preventive Services Task Force, challenge this recommendation. Several organizations recommend instead screening women over 50, asymptomatic adults over 60, or those at high risk for thyroid disorders, such as pregnant and postpartum women.

TSH testing is used to: diagnose a thyroid disorder in a person with symptoms, screen newborns for an underactive thyroid, monitor thyroid replacement therapy in people with hypothyroidism, diagnose and monitor female infertility problems, and screen adults for thyroid disorders as recommended by some organizations, such as the American Thyroid Association.

A high TSH result often means an underactive thyroid gland caused by failure of the gland (hypothyroidism), a high TSH result can indicate a problem with the pituitary gland, such as a tumor producing unregulated levels of TSH, in what is known as secondary hyperthyroidism. A high TSH value can also occur in people with underactive thyroid glands who have been receiving too little thyroid hormone medication.

A low TSH result can indicate an overactive thyroid gland (hyperthyroidism). A low TSH result can also indicate damage to the pituitary gland that prevents it from producing TSH. A low TSH result can also occur in people with an underactive thyroid gland who are receiving too much thyroid hormone medication.

Many medications including aspirin and thyroid-hormone replacement therapy may interfere with thyroid gland function test results, so tell your doctor about any drugs you are taking.

When your doctor adjusts your dose of thyroid hormone, it is important to wait at least one to two months before you check your TSH again, so that your new dose can have its full effect.

Extreme stress and acute illness may also affect TSH test results, and results may be low during the first trimester of pregnancy.

Mary Mills, RHIT, CCS
 



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Coding Clinic is published quarterly by the American Hospital Association
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