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Coding Q&A: July 5, 2006

Q: We are in discussion with a National Highway Traffic Administration consultant over the meaning of E-code 816, motor vehicle traffic accident due to loss of control, without collision on the highway. Two questions: Would this include a rollover which did not collide and remained on the highway? Is the "Includes" list meant to be exhaustive in the latest ICD-9-CM?

A: Thank you for your interesting question. The answer to your first question is yes, E816 Motor vehicle traffic accident due to loss of control, without collision on the highway, includes a rollover. Listed in the Includes notes to the right side of the bracket is the alternative wording or further explanations that include the word "overturning." The answer to your second question is per the conventions in the ICD-9-CM Official Guidelines for Coding and Reporting (Section 1, A4) state in part, "The inclusion terms are not necessarily exhaustive."

When you are deciding which E code to use, another helpful hint is to read the Excludes notes with the E code you are considering. In the case of E816, the main operative deciding words are "without collision" vs. the E code category ranges that are excluded, E810-E815, which state "with collision". Specifically, if you compare code E815 with E816 and the instructional notes for both the differences can be analyzed for the correct choice per the chart documentation. Another section of the ICD-9-CM book to review with the consultant is the Definitions and Examples Related to Transport Accidents at the beginning of the E Code Supplementary Classification that include sections (e) to (k) that pertain to motor vehicle accidents.

Kathy Myrick, RHIT, CCS

Q: I am looking for Coding Guidelines in relation to the new electronic health records (EHRs) that are in use. The General Surgery group I work for recently implemented an EHR and it has everything you ever wanted to know about the patient and then some available at the physician's fingertips. When the patient comes in for a visit all of this "info" is displayed for the provider to see, (whether or not it is relevant to today's visit). Previously to the implementation of the EHR, I always coded my E&M visits based on what was in the dictation. Using the old adage, "If it wasn't documented, you can't bill for it." Now, I am being told to "upcode" the visits based on the plethora of data that the physician would/could see on the screen. Each encounter is still dictated just as they previously were, but even if the physician didn't mention an item, I am being told to include them to determine my level of service. Personally, I don't feel comfortable doing that, and am reaching out hoping someone has guidelines that I could use to either support or refute my position. Your suggestions would be greatly appreciated.

A: There should be a way to track all of that in your EHR software. I agree with you that it is wrong to upcode without appropriate documentation, but if you are able to track that the physician has accessed the information and keep that information according to the appropriate statute of limitations, you should be fine. If you are not able to track (most vendors should be HIPAA compliant at this point), educate your physicians that the documentation is required for coding.

Leah Grebner, MS, RHIA, CCS

Q: I need to know what the CPT code is for removal of a foley catheter.

A: Actually there is no CPT code for removal of foley catheter. There is an ICD-9-CM code for removal of indwelling (Foley) catheter 97.64, but there is no corresponding HCPCS Level I (CPT) or Level II code. 

Therefore, the service or procedure would be included in the E/M as it is not specialized or surgical and does not involve any unique equipment or supplies.

To support my conclusion, I would like to point out the following CPT guidelines for removal of the externally accessible renal pelvis catheter: "For removal without replacement of an externally accessible ureteral stent not requiring fluoroscopic guidance, see Evaluation and Management services codes." And "Removal of nephrostomy tube not requiring fluoroscopic guidance is considered inherent to E/M services. Report the appropriate level of E/M services provided."

It seems to me that if the removal of this sort of device w/o any specialized equipment does not qualify for a separate CPT code, removal of a foley certainly would not, and the service would be included in the E/M.

Christina Benjamin, CCS

Q: Alcoholic Cirrhosis, status post pulmonary stents, placed on cpap and hepatopulmonary syndrome due to Alcoholic Cirrhosis is the diagnosis given as the primary diagnosis by the physician. However, severe hypoxemia was what they treated throughout his 3 week stay, and although hypoxemia is a symptom, I would like to use as my principal dx. Unless I have missed it, there isn't a code for 'Hepatopulmonary' syndrome but hypoxemia is due to low levels of oxygen in the blood hence his sob., which was the focus instead of using Alcoholic Cirrhosis as the pdx. Please clarify.

A: The code for Hepatopulmonary Syndrome is 572.8 for 'other sequelae of chronic liver disease.' Use the same logic as if you were to code Hepatorenal Syndrome due to Alcoholic Chirrhosis. Follow the manifestation coding rules of the official coding guidelines. The hypoxemia cannot be PDX, because it is a symptom of the hepatopulmonary syndrome. Also code the alcoholic cirrhosis as an additional diagnosis.  I hope this helps.

Mary Mills, RHIT, CCS

Q: What is the proper ICD-9 code for "Mixed Dementia"? I work in a long-term care facility, and am seeing this term used more often by our physicians. Many of these residents have been diagnosed previously with Alzheimer's dementia, but physicians have changed to "mixed dementia."

A: It could be that the physician is noting that other diseases are the underlying cause of the dementia in addition to or other than the Alzheimer's. Dementia can be the manifestation of many other disorders including those labeled as a kind of dementia themselves such as frontal dementia. If, for example, the physician confirms that indeed the Alzheimer's as well as other pathologies are the underlying cause of the dementia, then I would continue to code all the underlying mental disorders followed by 294.10. 

Without any further clarification, I suggest continuing to assign the Alzheimer's code 331.0 and to code 294.8 for the mixed dementia. The 294.8 code is like an "other" code; for instance, in my experience in long-term care, I noted that that code was assigned for the following diagnosis "dementia with psychotic features." It would be more accurate to use this code because the physician is no longer specifically relating the Alzheimer's or any other disorder directly to the dementia. It would be well to get clarification on this matter.

Christina Benjamin, CCS

The consultants, their companies and ADVANCE do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information.

Coding Clinic is published quarterly by the American Hospital Association
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ICD Q & A Archives


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