ICD Q & A

Ask the Experts: Jan. 22, 2013

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Q: How would you code a procedure that started as a diagnostic endoscopy, and then the physician changed to a surgical endoscopy? Would you code it as diagnostic, surgical or both?

A: According to Outpatient Code Editor: Diagnostic procedure will be bundled with surgical, therefore is not appropriate to code. The Medicare NCC edits consider this separate reporting of codes that are components of the comprehensive procedure if billed for services provided to the same beneficiary by the same physician on the same day. These codes will be rebundled by your Medicare payor and payment will be based on surgical code only.

The exception will be that if these codes represent a different session, surgery, site, lesion, or injury, then use of an appropriate modifier on the excluded code will differentiate the services provided and will notify the payor to bypass this edit.
- Bella Logvinov MBA, CCS, CPC


Q: Please clear up the confusion about coding a diagnosis with a "?" before or after it. I cannot find a coding guideline that answers this but Faye Brown says it's acceptable.

A: The ICD-9-CM Official Guidelines for Coding and Reporting do have guidelines specific to that issue. In Section II, Selection of Principal Diagnosis, under bullet H is the following:

H. Uncertain Diagnosis

If the diagnosis documented at the time of discharge is qualified as "probable," "suspected," "likely," "questionable," "possible," or "still to be ruled out," or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. (Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.)

The guideline does show up again under the next section for reporting additional diagnoses. As you can see this can only be used on inpatient cases so what happens on for an outpatient encounter?

The guidelines do address this issue in Section IV, which is in regard to Outpatient Encounters.

I. Uncertain diagnosis

Do not code diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis" or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. (Note: This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.)
-Lisa L. Withers, RHIA, CCS


Q: How would you code "gallstone pancreatitis?" The patient does have a cholecystectomy performed. When using 3M the "acute pancreatitis" is considered the principal diagnosis (dx). I was wondering if we could use the cholecystitis dx, whether it be acute or chronic, as the principal dx in order to get a MCC from the "acute pancreatitis" (gallstone pancreatitis). It seems some coders are doing this but others are reluctant.

A: The Coding Clinic, 2nd Q, 1996, pg. 13-15, includes many examples of this particular case. "The correct coding and sequencing of gallstone pancreatitis depends on the location of the gallstone and the reason for treatment. Assign the appropriate code from category 574, Cholelithiasis. Review the record and query the physician regarding the pancreatitis. Assign code 577.0 for acute pancreatitis, or 577.1 for chronic pancreatitis."

The correct assignment is dependent on the circumstances of admission as well as on the individual documentation related to the gallstone pancreatitis.
-Tasha Cameron, RHIA, CCS


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