Coding Challenge Archive

HBS is a leader in coding education. View previous coding challenges below. Be sure to checkout the current coding challenge as well.

  • Coding Challenge 1: Fracture
  • Coding Challenge 2: Laminectomy
  • Coding Challenge 3: Insertion of Port-a-Cath
  • Coding Challenge 4: Sepsis Due to Enterococcus

QUESTION:

Ii a patient has a fracture on a radiology report, however, the ER physician documents the final dx as sprain, should the coders be coding fracture?

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

QUESTION:

Do you code both a laminectomy and a dural repair when a physician accidentally nicks the dura during the laminectomy?

SCENARIO:

A 50 year old female present with lumbar stenosis.

Operative Procedure – L2-S1 posterior lumbar decompression.
Pt was flipped prone on a Jackson table with Wilson frame and prepped and draped in standard sterile fashion. Midline incision made with a 10 blade knife. Ligamentous hypertrophy removed with Kerrison rongeurs. Once we had adequately decompressed the spine, it was noted that there was a small dural laceration. A muscle graft was harvested from the operative site and placed down on the dura and fastened with Dura Seal. Sutures were used to reapproximate the skin. Pt was flipped and extubated.

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.”

QUESTION:

How many ICD-10-PCS codes are needed to capture an insertion of a Port-a-Cath?

SCENARIO:

PROCEDURE IN DETAIL: Patient was prepped and draped in sterile fashion. The left subclavian vein was cannulated with a wire. Fluoroscopic confirmation of the wire in appropriate position was performed. Then catheter was inserted after subcutaneous pocket was created in the right chest, the sheath dilators were advanced, and the wire and dilator were removed. Once the catheter was advanced through the sheath, the sheath was peeled away. Catheter was left in place in the SVC, which was attached to hub, placed in the subcutaneous pocket, sewn in place with 2-0 silk sutures, and then all hemostasis was further reconfirmed. No hemorrhage was identified. The port was in appropriate position with fluoroscopic confirmation. The wound was closed in 2 layers, the 1st layer being 3-0 Vicryl, the 2nd layer being 4-0 Monocryl subcuticular stitch. Dressed with Steri-Strips and 4 x 4's. Port was checked. Had good blood return, flushed readily with heparinized saline.

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

QUESTION:

What are the appropriate code assignments for this diagnostic statement?

SCENARIO:

An 80 year old female nursing home patient who presents with mental status change is admitted. After diagnostic studies, the provider diagnosed sepsis due to Enterococcus urinary tract infection (UTI).

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

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