1.
Laterality Just about every ICD-10-CM code that can have a right and left
variation has one, so remember to add this information to anything that has a
right and left option. Based on a recent review of thousands of radiology
documents, many radiologists seem to already be providing this documentation in
many cases, but there are some symptoms and diagnoses that are still routinely
missing this information. Note that for the following diagnoses, certain
information must be documented:
• Breast, lung, and ovarian cancers must specify
right or left breast, lung, or ovary, respectively.
• Tinnitus
and otitis media must specify right or left ear.
• Meniscal
tear must specify right or left knee. To prevent confusion, it’s best to
document this information as part of the diagnosis statement (eg, bucket-handle
tear right medial meniscus) in the impression section rather than leaving it
ambiguous and requiring the coder or computer-assisted coding program to detect
the laterality from the exam title or clinical indication.
2. Encounter Type All
accident and injury ICD-10-CM codes must include a seventh digit to indicate
whether an encounter is initial, subsequent, or sequela in nature. Initial:
This designation relates to when a service was rendered during the patient’s
initial encounter for diagnosis and “active treatment” of the condition. If an
exam is performed during the patient’s initial admission or emergency
department (ED) visit after the injury, document “initial encounter.” The
following are examples of this encounter type:
• an ankle
X-ray for an ED patient after a twisting injury that day (nearly all exams for
ED patients will be initial encounter);
• a brain MRI
for a patient admitted from the ED after concussion;
• an
intraoperative X-ray for a fracture to help with hardware placement for
fixation; and
• a CT of the
chest, abdomen, and pelvis for injuries from a motor vehicle accident.
Subsequent: This relates to a service that was rendered after the initial
diagnosis and treatment were completed, “receiving routine care for the
condition during the healing or recovery phase” (eg, follow-up fracture to
check healing). If the exam is performed after the initial treatment is
completed, document “subsequent encounter.” Examples of these encounters are as
follows:
• a follow-up
tibia-fibula X-ray four weeks after casting to check the healing progress; and
• a follow-up
wrist X-ray at four weeks and six weeks to check on a fracture malunion.
Sequela: Lastly, this documentation is used for complications or conditions
that arise as a direct result of a condition, such as scar formation after a
burn (the scars are a sequelae of the burn). Examples are as follows:
• a knee MRI
for pain due to an old meniscal tear;
• a shoulder
X-ray for pain due to an old rotator cuff tear; and
• a hip X-ray
for gait disturbance due to an old hip fracture.
3.
Fracture Healing Status ICD-10-CM fracture codes require a seventh-digit
character for follow-up (subsequent) exams to indicate the status of healing.
One of the following healing categories should be documented for all follow-up
fracture exams: routine healing, delayed healing, nonunion, or malunion.
4.
Anatomy Some ICD-10-CM codes have very specific anatomy descriptions, more so
than ICD-9-CM. Be as specific as possible when describing anatomy in your
documentation. Here are some examples of the degree of anatomy specificity that
will be required in ICD-10-CM: • For a cerebral infarction, which artery was
affected? Is it the precerebral, cerebral, middle cerebral, anterior cerebral,
posterior cerebral, or cerebellar artery?
• For lung cancer, be sure to designate between the
main bronchus vs. the upper, middle, or lower lobe. Are there overlapping
sites?
• For an
ankle fracture, be sure to document whether it’s the medial or lateral
malleolus. Is the fracture bimalleolar or trimalleolar? If none of these are
specified, you will have to assign the generic “Other fracture of lower leg”
ICD-10-CM code.
• For an
ankle sprain, be sure to specify ligament type, whether it’s the
calcaneofibular, deltoid, or tibiofibular ligament.
Are you Ready for 2015?
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FOR MORE
INFORMATION PLEASE CONTACT:
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Developers of
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Phone: (305)
227-2383
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