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Ask the Experts: Nov. 13, 2012

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Q: At my facility we perform continent ileostomies (BCIR) procedures. We use as our PDX: 569.69 and Ulcerative Colitis as our secondary diagnosis. We were told by an auditor not to use 556.9 because Ulcerative colitis was no longer present. She stated that a proctocolectomy had been performed and that procedure eliminated the Ulcerative colitis. Coding Clinic, 2Q 2005, Vol. 22, No. 2, pps. 11-12 states you can. Please advise your opinion on this matter.

A: I do not agree with the auditor, as Crohn's disease is a chronic disease that can be coded.  However, I disagree with both your principal and secondary diagnosis code selections.

As per Coding Clinic, 4Q 1998, 569.69 was replaced with 569.42 to identify a complication of ileostomy.

New code: 569.62 Mechanical complication of colostomy and enterostomy
Malfunction of colostomy and enterostomy

It is also the recommended code from Coding Clinic, 2Q 2005, Vol. 22, No. 2, pps. 11-12, that you referenced:

Assign code 569.62, Mechanical complications of colostomy and enterostomy, for the malfunctioning continent ileostomy, as the principal diagnosis. Code 555.9, Regional enteritis, Unspecified site, should be assigned as an additional diagnosis for the Crohn's disease. Crohn's disease commonly involves the small intestine, but can also include the large bowel. Because the extent of intestinal involvement in the Crohn's disease was not specified, code 555.9 was assigned.

As referenced in the above Coding Clinic, Crohn's disease codes to 555.9 not 556.9.  Here is what is covered under 555.9:

2012 ICD-9-CM Diagnosis Code 555.9
Regional enteritis of unspecified site

•Gastrointestinal disorder characterized by chronic inflammatory infiltrates, fibrosis affecting all layers of the serosa, and development of noncaseating granulomas; most common site of involvement is the terminal ileum with the colon as the second most common.

•Chronic inflammation of the gastrointestinal tract, most commonly the bowel. Crohn's disease increases the risk for colon cancer.

•A gastrointestinal disorder characterized by chronic inflammation involving all layers of the intestinal wall, noncaseating granulomas affecting the intestinal wall and regional lymph nodes, and transmural fibrosis. Crohn disease most commonly involves the terminal ileum; the colon is the second most common site of involvement.

•Inflammation of the intestines, but usually only of the small intestine. Regional enteritis increases the risk for developing colon cancer. Also called Crohn's disease.

•Short description: Regional enteritis NOS.

•ICD-9-CM 555.9 is a billable medical code that can be used to specify a diagnosis on a reimbursement claim
-Arlene Baril, MS, RHIA

Q: Can CPT code 28190 be used for coding foreign body removal from the foot, removed without incision? Lay description of the code includes incision, but several consultants are telling us that incision isn't required.

A: Coding Clinic for HCPCS, 4Q 2006, pp. 7-9, states that an incision must be made to remove the foreign body before code 28190 can be coded. If no incision is made, then the removal should be considered inherent to the services provided during that encounter.

Further, Coders' Desk Reference has the following information for code 28190:

"Subcutaneous refers to something under the skin. An incision is made through the skin and it is reflected to expose the foreign body. It is removed and the wound is irrigated and the wound is closed. A dressing is applied and aftercare may include antibiotic injection into the wound and orally. Weight bearing is allowed as the wound heals. Report 28192 if the foreign body lies deeper in the foot. Report 28193 if repair of torn tendon, nerves, and blood supply is required."
-Jennifer Clements, RHIT, CCS

Q: What is the difference between CPT codes 32421 and 32422? My physician documents he left a catheter in place for continued drainage. Can the catheter be interpreted as a tube to support coding of 32422?

A: The difference between 32421 and 32422 is that when a physician performs 32421 a simple puncture for aspiration, no tube is left in place. 32422 does involve a tube being inserted and left in place at the end of the procedure.  A catheter left in place would qualify for 32422.

Here is Coder's Desk Reference's description of 32422: "The physician removes fluid from the chest cavity by puncturing through the space between the ribs. To enter the chest cavity, the physician passes a small trocar or needle over the top of a rib, punctures through the chest tissues between the ribs, and enters the pleural cavity. Separately reportable image guidance may be used. The physician advances the catheter over the needle or small trocar into the chest cavity. The sharp instrument is removed leaving one end of the plastic catheter in place within the chest cavity. A syringe is attached to the outside end of the catheter and fluid is removed from the chest cavity by pulling back on the plunger of the syringe. The outside end of the tube may be connected to a water seal system to prevent air from being sucked into the chest cavity and to allow continuous or intermittent removal of fluid."
-Christina Benjamin, MA, RHIA, CCS, CCS-P

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