Coding Q&A

Ask the Experts: August 18, 2014

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Question: At our facility we have used 790.5 Nonspecific abnormal serum enzyme levels for elevated Troponin. Would this be acceptable?

Answer: The use of 790.5 (other nonspecific abnormal serum enzymes levels) or 790.99 (other nonspecific findings on examination of blood, other) is going to depend on the test that was performed:

"Cardiac enzyme studies" measure the levels of enzymes and proteins that are linked with injury of the heart muscle. These include the enzymes creatine phosphokinase (CPK) and creatine kinase (CK), and the proteins troponin I (TnI) and troponin T (TnT). Low levels of these enzymes and proteins are normally found in your blood, but if your heart muscle is injured, such as from a heart attack, the enzymes and proteins leak out of damaged heart muscle cells, and their levels in the bloodstream rise.

Troponin is a complex of three regulatory proteins that is integral to muscle contraction in skeletal and cardiac muscles.  Elevated troponin levels indicate myocardial injury but may occur in critically ill patients.

Abnormal cardiac enzymes is coded to 790.5 as it is a combination of enzymes and proteins.
Abnormal Troponin which is a combination of three proteins would be coded to 790.99.
- Tasha Cameron, RHIA, CCS, CDIP

Question: I am wondering if there is anything in written form that states a coder is required to report all diagnosis listed on a lab order. For example, if a lab order had an invalid diagnosis code listed due to needing a fifth digit, could you just leave that code off or must you query the physician? We have someone in our administration that is telling us to just leave the code in question off the claim.

Answer: In outpatient settings, the diagnosis codes listed on a claim help support medical necessity for the services being rendered and billed.  With lab orders, it is difficult to determine if the code/condition meets the definition of a reportable diagnosis because the coder typically cannot view review of systems, medication lists, or other documentation that often makes a condition meet reporting guidelines.  If a provider includes a diagnosis or diagnosis code on a lab order, it is likely because it is an attempt to support or help support medical necessity for the test.  Based on that thought process, it would be necessary to query the provider for accurate coding.
- Kelley Haddox, RHIT, CCS

Question: We were recently having a discussion about assigning the final diagnosis for an ER visit. For example the physician states "neck pain, cervical sprain." Some believe that neck pain is coded first and the cervical sprain second since that is how the doctor documented it. Others believe the main reason for the visit would be coded first, the cervical sprain, and that the pain is not coded since it is a symptom of the cervical sprain.

Answer: Only cervical sprain should be coded as neck pain is a symptom.
From coding guidelines:
A. Codes for symptoms, signs, and ill-defined conditions
Codes for symptoms, signs, and ill-defined conditions from Chapter 16 are not to be used as principal diagnosis when a related definitive diagnosis has been established.
- Bella Logvinov MBA, CCS, CPC

Question: A patient on initial presentation to the Emergency Dept. was found to be neutropenic and a throat swab was positive for Streptococcus. Patient developed a high fever of 102 after admission. ct scan revealed an abcess of tonsil 475. Patient was treated with abx. Discharge summary: neutropenia due to sepsis and tonsil abcess s/p drainage. Would you code neutropenia due to infectin 288.04 as the principal diagnosis or abcess of tonsil 475 or neutropenia due to sepsis 038.9 288.04, 995.91 etc

Answer: Official ICD-9-CM Guidelines for coding of sepsis instruct coders that sepsis present on admission due to a localized infection requires the sepsis code to be the principal code.   So if there is documentation that the sepsis was present on admission, 475 would not be an appropriate principal diagnosis code in this case.  For sequencing of the neutropenia and sepsis, this question was answered in AHA Coding Clinic for ICD-9-CM, Second Quarter 1996 that the sepsis would be the principal diagnosis, provided it was present on admission.  
- Kelley Haddox, RHIT, CCS

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