ED Coding and Reimbursement Alert

Take the extra time to read the guidelines before you select a code.

You may not have the opportunity to use manifestation and sequela diagnoses in your ED every day, but you’ve got to be prepared to code for them when they add an extra degree of complexity to your dictation report.

Check out how a COVID-19 manifestation and a sequela of a pregnancy turn a routine report into one that requires some extra time and consideration to get right.

Bank on Documentation for This COVID-19 Manifestation Example

Diagnosis: A patient presents complaining of a loss/distortion of smell. He notes that he recently got over a COVID-19 infection, but that the loss of smell didn’t start until one week after he was completely symptom-free of COVID-19, so he’s concerned that it occurred due to another cause. The ED physician orders a maxillofacial computed tomography (CT) scan to check for any other issues.

When you’re evaluating a diagnosis affecting sense of smell, every little detail matters. In fact, there are three different kind of disorders impacting sense of smell that clinicians will often reference:

• Anosmia — The complete or partial loss of sense of smell
• Parosmia — A distortion of sense of smell
• Hyposmia — Reduced ability to detect odors

Given the underlying similarities between anosmia and hyposmia, you may be wondering whether your coding should depend on the medical terminology the provider uses, or whether you should make an inference based on the provider notes as to whether the patient is experiencing one or the other.

The short answer is: it depends on your provider’s documentation. As is the case with all diagnoses, your coding is confined to the provider’s documentation and the pathway routing of the ICD-10-CM Alphabetical Index. However, you can confer with the provider to determine whether a more specific diagnosis, such as one of the three above, is applicable. “Taking a measure such as this is especially important when the Local Coverage Determinations (LCDs) exclusively reimburse for the more specific diagnosis,” explains Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York.

If the provider determines that the loss of smell is related to coronavirus, the first consideration you should make involves sequencing. Consider the following two sets of guidelines surrounding COVID-19 sequencing when the reason for the encounter is a manifestation of COVID-19:

• “When the reason for the encounter/admission is a non-respiratory manifestation (e.g., viral enteritis) of COVID-19, assign code U07.1 (COVID-19), as the principal/first-listed diagnosis and assign code(s) for the manifestation(s) as additional diagnoses.”
• “When the reason for the encounter/admission is a respiratory manifestation of COVID-19, assign code U07.1 as the principal/first-listed diagnosis and assign code(s) for the respiratory manifestation(s) as additional diagnoses.”

For COVID-19-induced loss of smell, you navigate the Alphabetic Index to find Loss (of) ⇒ sense of ⇒ smell ⇒ see Disturbance, sensation, smell. Disturbance, sensation, smell leads you to R43.9 (Unspecified disturbances of smell and taste). If the provider reports anosmia or parosmia, you will report R43.0 (Anosmia) and R43.1 (Parosmia), respectively. You will report hyposmia as R43.8 (Other disturbances of smell and taste).

Conquer This Sequela Diagnosis Using Key Guidelines

Diagnosis: A patient with a previous diagnosis of hyperthyroidism and goiter in pregnancy presents to the ED complaining of an elevated heart rate and dizziness. She reports that hyperthyroidism has continued to persist three months following delivery. The physician records the presenting diagnosis for the visit as associated atrial fibrillation.

You may typically not have the luxury of access to such extensive detail in your dictation report, but this clinical scenario presents an opportunity to utilize a set of lesser understood and utilized ICD-10-CM guidelines. When evaluating this diagnosis, you’ve got take both current and historical context into account for accurate diagnosis code reporting. Specifically, you need to take two primary factors into consideration: postpartum period and sequela status.

Postpartum period, also known as the puerperium or puerperal period, is commonly defined as the six weeks following delivery. Sequela, on the other hand, is not as clear cut in terms of time frames. The ICD-10-CM guidelines describe sequela, or late effects, as the following:

• “A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury.”

Now you’ve got enough information to confirm the patient is experiencing a late effect that’s occurring outside of the postpartum period. In this case, the hyperthyroidism is continuous from the prenatal period to now, but the atrial fibrillation is a newly developed complication (sequela) of the hyperthyroidism. The timing here is especially important because the patient can experience a late effect from a condition that arose during the postpartum period, in which case you would still report the sequela with code O94 (Sequelae of complication of pregnancy, childbirth, and the puerperium). Now get familiar with the guidelines pertaining to O94:

• “Code O94, Sequelae of complication of pregnancy, childbirth, and the puerperium, is for use in those cases when an initial complication of a pregnancy develops a sequelae requiring care or treatment at a future date.
• This code may be used at any time after the initial postpartum period.
• This code, like all sequela codes, is to be sequenced following the code describing the sequelae of the complication.”

Factoring in O94 guidelines, you now know you’ll be reporting at least two diagnosis codes, with the sequela of the complication reported as the first listed diagnosis. Your diagnosis coding will go as follows:

• I48.91 (Unspecified atrial fibrillation)
• O94
• E05.90 (Thyrotoxicosis, unspecified without thyrotoxic crisis or storm)

Note: Unfortunately, unless the provider specifically documents that the atrial fibrillation is “persistent and/ or chronic,” you may not report I48.19 (Other persistent atrial fibrillation) or I48.20 (Chronic atrial fibrillation, unspecified). However, you may send an addendum request to the provider for added specificity. You will report the hyperthyroidism as an additional diagnosis since the diagnosis is still active. However, you will not report a code indicating hyperthyroidism with goiter since the goiter is not currently indicated in the underlying diagnosis.