ANSWER:

Yes absolutely, coders should code the fracture. As you can see below, these coding clinics state any confirmed diagnoses on an outpatient (ER) radiology report should be coded. This applies to any outpatient claim, including SDS and OBS.

RATIONALE/CODING CLINIC REFERENCE:

Outpatient radiology coding

ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2017, Page 5, Effective with discharges: March 13, 2017

Question:

A patient presents to the hospital for outpatient x-rays with a diagnosis on the physician's orders of questionable kidney stone. The abdominal x-ray reveals "bilateral nephrolithiasis with staghorn calculi." No other documentation is available. Is it correct for the facility to report code N20.0, Calculus of kidney, based on the radiologist's diagnosis?

Answer:

It is correct for the facility to report code N20.0, Calculus of kidney. Code to the highest degree of certainty. The radiologist is a physician, and when the x-ray has been interpreted by the radiologist, code the confirmed or definitive diagnosis. The Official Guidelines for Coding and Reporting, Diagnostic Outpatient Services Section IV. K., state, "For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation."

Also refer to Coding Clinic, First Quarter ICD-10 2013, Pages 28-29, Effective with discharges: March 27, 2013

ANSWER:

Correct CPT is 63017, laminectomy with decompression of the spinal cord and 2 or more segments; lumbar

Please be aware, per CPT Assistant July 2012, pg 3-6,14, “the repair of a small intraoperative dural laceration or leak, and the harvesting and placement of a soft tissue graft, muscle, or fat when obtained from the primary surgical incision are considered as part of the instraservice work and are not reported separately.”

ANSWER:

Two ICD-10-PCS codes

• 0JH60WZ: Insertion of TIVAD into Chest Subcutaneous Tissue/Fascia, Open Approach
• 02HV33Z: Insertion of Infusion Device into Superior Vena Cava, Percutaneous Approach

ANSWER:

Assign code A41.81, Sepsis due to Enterococcus, and code N39.0, Urinary tract infection, site not specified, for the UTI.

Rationale: Do not assign code B95.2, Unspecified Enterococcus as the cause of diseases classified elsewhere, as an additional diagnosis. Code A41.81 clearly classifies the causal bacterium for both the sepsis and the UTI. Assigning B95.2 as an additional code is redundant.

Reference: Coding Clinic for ICD-10-CM/PCS, First Quarter 2018: Page 16: Use Additional Code Note for Causal Organism for Localized Infection and Sepsis

ANSWER:

F33.2 Major depressive disorder, recurrent episode, severe without psychotic features

B20 Human immunodeficiency virus [HIV] disease

F11.20 Opiate dependence, uncomplicated

Comments: Depression, specified as severe, was responsible for the encounter and is sequenced as the reason for the admission or principal diagnosis. The depression was not identified as being opiate-induced and therefore code F11.24, Opioid dependence with opioid-induced mood disorder, is not appropriate. The HIV infection contributed to the patient's depression, but the depression was the reason for the encounter. The patient has a hx of HIV related illness, therefore the B20 is the appropriate code here.