ICD Q & A

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Question: What is the difference between ICD-10-CM codes M99.73, M99.63 and M99.83 when the diagnosis is foraminal lumbar stenosis and which is the correct code? The patient also has moderate to severe central canal lumbar stenosis due to broad-based disc osteophyte formation.
Answer: The differences in the codes are as follows:
M99.73- Following the index, this code can be obtained by referencing Stenosis, then intervertebral foramina, then disc, and finally, lumbar. If the osteophytes were not documented, this could be the code selection.

M99.63 - describes the same condition as above, including the term osseus, which simply means bony (with bony involvement). Because the osteophytes are included, this appears to be a more optimal selection, based on the information presented.

M99.83 - This code describes other biochemical lesions, NEC. However, by following the neural canal lumbar stenosis, there is a "see also" note at the beginning of the category. According to the Conventions for ICD-10-CM, unlike "see," which is a mandatory instruction, "see also" indicates that another main term may be referenced to provide additional Alphabetical index entries that may be useful. It is not necessary to follow this note when the original main term provided the necessary code. Thus, this rules out M99.83 as the optimal selection.

Without more information regarding the documentation, it is not clear whether or not the provider believes the foraminal lumbar stenosis and the central canal lumbar stenosis are separate conditions. My inclination would be to assign M99.33 - This covers the lumbar central canal stenosis, osseus.  If the foraminal lumbar stenosis is separate, M99.73 could be assigned as well. Finally, the osteophyte can be described with M25.78. Some may believe this is a symptom of the stenosis; others may believe that not all spinal canal stenosis results from an osteophyte, thus it  should be coded. I would have to be swayed by the documentation and treatment rendered.
- Dwan Thomas Flowers, MBA, RHIA, CCS

Question: When a hospice patient had CVA and is discharged from the hospital to nursing home, can we use ICD-9 code CVA 436, since CVA happened 2 weeks ago?
Answer: It all depends on the patient's condition upon discharge/transfer to hospice and whether the patient still has any neurological deficits.  Here are the official coding guidelines on CVA:
Cerebrovascular Accident
ICD-9-CM Official Guidelines for Coding and Reporting
Effective October 1, 2014
Section I. Conventions, general coding guidelines and chapter specific guidelines
The conventions, general guidelines and chapter-specific guidelines are applicable to all health care settings unless otherwise indicated. The conventions and instructions of the classification take precedence over guidelines.
C. Chapter-Specific Coding Guidelines
In addition to general coding guidelines, there are guidelines for specific diagnoses and/or conditions in the classification. Unless otherwise indicated, these guidelines apply to all health care settings. Please refer to Section II for guidelines on the selection of principal diagnosis.
7. Chapter 7: Diseases of Circulatory System (390-459)
b. Cerebral infarction/stroke/cerebrovascular accident (CVA)
The terms stroke and CVA are often used interchangeably to refer to a cerebral infarction. The terms stroke, CVA, and cerebral infarction NOS are all indexed to the default code 434.91, Cerebral artery occlusion, unspecified, with infarction.
Additional code(s) should be assigned for any neurologic deficits associated with the acute CVA, regardless of whether or not the neurologic deficit resolves prior to discharge.
See Section I.C.18.d.3 for information on coding status post administration of tPA in a different facility within the last 24 hours.
c. Postoperative cerebrovascular accident
A cerebrovascular hemorrhage or infarction that occurs as a result of medical intervention is coded to 997.02, Iatrogenic cerebrovascular infarction or hemorrhage. Medical record documentation should clearly specify the cause- and-effect relationship between the medical intervention and the cerebrovascular accident in order to assign this code. A secondary code from the code range 430-432 or from a code from subcategories 433 or 434 with a fifth digit of "1" should also be used to identify the type of hemorrhage or infarct.
This guideline conforms to the use additional code note instruction at category 997. Code 436, Acute, but ill-defined, cerebrovascular disease, should not be used as a secondary code with code 997.02.
d. Late Effects of Cerebrovascular Disease
1) Category 438, Late Effects of Cerebrovascular disease
Category 438 is used to indicate conditions classifiable to categories 430-437 as the causes of late effects (neurologic deficits), themselves classified elsewhere. These "late effects" include neurologic deficits that persist after initial onset of conditions classifiable to 430-437. The neurologic deficits caused by cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition classifiable to 430-437.
Codes in category 438 are only for use for late effects of cerebrovascular disease, not for neurologic deficits associated with an acute CVA.
2) Codes from category 438 with codes from 430-437
Codes from category 438 may be assigned on a health care record with codes from 430-437, if the patient has a current cerebrovascular accident (CVA) and deficits from an old CVA.
3) Code V12.54
Assign code V12.54, Transient ischemic attack (TIA), and cerebral infarction without residual deficits (and not a code from category 438) as an additional code for history of cerebrovascular disease when no neurologic deficits are present.
- Arlene F. Baril, MHA, RHIA, CHC

Question: My patients have to return multiple times during the post op period to receive 1 injection to 1 site per visit. Each visit we bill CPT code 11900 which the insurance denies as inclusive/global to primary (surgery). My interpretation of the code is during 1 visit up to 7 injections to 7 lesions. But, it appears the insurance company combines 7 procedures 11900 on 7 different DOS inclusive to the first 11900 DOS. My question is can you bill multiple 11900 procedures on multiple DOS during post op period, get them to stand alone and paid individually? Is there a modifier that needs to be used so they don't deny inclusive to each other or the surgery?
Answer: After review of the question, I was able to find the below information from CPT Assistant. Based on this research, the codes can be coded and billed separately if they are not related to the previous surgery. If they are related, then they cannot be coded/billed separately -- they are included in the global package.
If these procedures are not related to the previous surgery, I would suggest adding a modifier -79 to the code to see if the procedures are denied even with the modifier.
Further, based on the information below, code 11900 is for injections for up to 7 lesions.
September 2004 page 12: Coding Consultation: Questions and Answers
CPT Assistant, September 2004, Volume 09, Issue 14, page 12
Integumentary System, 11900, 11901 (Q&A)

Question: Is it appropriate to report codes 11900-11901 per injection?
AMA Comment: Codes 11900, Injection, intralesional; up to and including seven lesions, and 11901, Injection, intralesional; more than seven lesions, are intended to treat lesions of the integumentary system-such as keloids, psoriasis, acne (cystic or nodular), and others-by injecting drugs directly into the lesion itself. It would not be appropriate to report codes 11900-11901 per injection as the code descriptor identifies the number of lesions treated, not the number of injections, per se. Code 11900 should be reported once, when one to seven lesions are treated, even if a particular lesion is injected more than once. Code 11901 should be reported only once to indicate the treatment of eight or more lesions. Therefore, code selection should be determined by the number of lesions treated, not by the number of injections.
February 2000 page 11: Coding Consultation
CPT Assistant, February 2000, Volume 02, Issue 10, page 11
Integumentary System, Surgery, 11900, 11901, 11300-11313 (Q&A)

Question: Should I use both codes 11900* and 11901* when reporting eight lesions of intralesional injection?
AMA Comment: If more than seven lesions of intralesional injections are performed, then code 11901* should be used one time to identify the procedure performed. As code 11901* is not an add-on code, it is not appropriate to report it in addition to code 11900*.

May 1998 page 10: Coding Consultation
CPT Assistant, May 1998, Volume 05, Issue 8, page 10
Integumentary, 11900, 11901, 99070 (Q&A)

Question: Does code 11900 and 11901 include the medication or are these codes for the procedure only?
AMA Comment: From a CPT coding perspective, codes 11900 and 11901 do not include the medication. These codes are for the injection only. It is appropriate to report the medication in addition to codes 11900 and 11901 with either the appropriate J-code or 99070.
September 1996 page 5: Coding Commentary
CPT Assistant, September 1996, Volume 09, Issue 6, page 5
A Review of Coding for Intralesional Injections: Lesions of the integumentary system, such as keloids, psoriasis, acne (cystic or nodular), and others may be treated by injecting drugs directly into the lesion itself. To report the treatment of these lesions you would use the following codes:

11900 - Starred CodeInjection, intralesional; up to and including seven lesions
11901 - Starred Codemore than seven lesions

Reporting Treatment of One to Seven Lesions: CPT code 11900 may be used when injecting one to seven lesions. Note that the code describes the number of lesions treated, not the number of injections, per se. The code should be reported once, when one to seven lesions are treated, even if a particular lesion is injected more than once.

Reporting Treatment of Eight or More Lesions: When treating eight or more lesions, you should report 11901 only once to indicate the treatment of eight or more lesions. Do not use 11901 in addition to code 11900, as 11901 is not an "add-on" code. Again, the number of injections into a particular lesion is not a factor in your code selection.

Chemotherapy Administration: It is important to distinguish the treatment of a lesion by injecting a steroidal drug (11900-11901), from intralesional chemotherapy, which is reported with the codes listed below. These codes follow the same reporting rules as the 11900 series.

96405 - Chemotherapy administration, intralesional; up to and including 7 lesions
96406 - more than 7 lesions

You should note that the intralesional injection codes are not intended to be used to report the injection of local anesthetic agents prior to another surgical procedure, such as lesion excision or biopsy.

In these instances, when local anesthesia is used, it is included in the surgical procedure, and not reported separately. (See guideline on page 53, CPT 1996)

Listed Surgical Procedures: Listed surgical procedures include the operation per se, local infiltration, metacarpal/digital block or topical anesthesia when used, and the normal, uncomplicated follow-up care. This concept is referred to as a "package" for surgical procedures. To report a postoperative follow-up visit for documentation purposes only, you should use code 99024.

Injection Types and their Respective Codes:
Steroid - 11900, 11901
Chemotherapy Agent - 96405, 96406
Preoperative Anesthesia - Not coded separately (included in listed surgical procedure)
Diagnostic/therapeutic Anesthetic Agent - 64400, 64530
- Jennifer Clements, RHIT, CCS


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