ED Coding and Reimbursement Alert

Provide clarification of exact location and cause of back pain.

ICD-10 implementation may have been delayed, but for those of you who have already gotten your training, this ongoing series can help reinforce your content knowledge. Otherwise this introduction to the chapters in ICD-10 will introduce those codes and instructions for ED relevant presentations. Perhaps one of the more challenging sections of ICD-10 for physicians and coders is Chapter 13 covering Diseases of the Musculoskeletal System and Connective Tissue, because they will require a much higher level of specificity for documentation of location and type disorder and external causes of problems, says Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, AHIMA Certified ICD-10 Instructor and President of Edelberg Compliance Associates.   

For example, patients who present with severe joint pain from arthritis will require additional documentation and coding of type of infection, where known, and information on whether or not infection is direct or indirect.  Pain in joints or limbs without a known cause such as from fracture, dislocation, foreign body) will be identified from this chapter of ICD-10. Diagnosis codes for known fractures or dislocations appear elsewhere. Other common musculoskeletal disorders treated in the emergency department include arthritis, recurrent dislocations of joints, joint and tendon disorders such as ganglions or cysts and bursitis, Edelberg adds.

ED focus: Emergency physicians will need to document the condition, location and type (infectious, chronic); causation (chronic, traumatic, post-procedural, infectious, initial, subsequent, sequela, etc.).  If you are a member of the coding staff, a best practice will be to design a form for providing feedback to physicians when too many “unspecified” conditions are coded due to incomplete documentation of details surrounding treatment of the disorder, Edelberg advises.

What If I Have A Pain in the Neck and a Pain in the Back?

Back pain is a common complaint of patients seen in the emergency department.  When possible, physicians should provide clarification of exact location and cause of back pain.  

Also, if other body areas are involved, be sure to identify them as well.  For example, neck and back pain vs. back pain only.  

More specific detail provides a higher level of medical necessity to support the need for diagnostic testing.  For patients that are admitted, a higher level of detail will support the appropriate DRG.   

Pain in limb requires documentation of the exact location of the pain, e.g., lower leg (M79.661-M79.663), thigh (M79.651-M79.659) foot (M79.671-M79.673), toes (M79/674-M79.676); arm (M79.601-M79.603); leg (M79.604-M79.609), upper arm (M79.621-M79.629); forearm (M79.661-M79.639); hands and fingers (MM79.641-M79.646).  Physician documentation will be critical to coding of the correct location and type of pain. q

Look for Cause, Associated Symptoms for Kidney Disease and Cystitis 

Chapter 14 of ICD-10 defines diseases of the genitourinary system and includes many conditions commonly treated in the emergency department including acute and chronic kidney disease, diseases of the urinary tract and diseases of the male and female pelvic organs

You Gotta Be Kid(ney)ing Me! Watch For Underlying Conditions With Renal Diagnoses

Acute kidney failure and its associated conditions are frequently treated in the emergency department and will require focus on several elements.  ICD-10 instructs coding professionals to code any associated underlying conditions which will require attention to documentation of these elements by emergency physicians.  

Kidney failure resulting from trauma is not coded from this section.  T79.5 (Traumatic anuria)   N17.0 (Kidney failure is differentiated as acute [with tubular necrosis]), N17.1 (Acute cortical necrosis), N17.2 (Medullary necrosis), and N17.9 (Acute kidney failure; unspecified non traumatic), says Edelberg.

Documentation tips: Chronic kidney disease (CKD) requires identification and coding first of associated diabetic chronic kidney disease; hypertensive chronic kidney disease and use of an additional code to identify kidney transplant status if applicable.  Chronic kidney disease requires documentation and coding from one of five stages of severity designated from 1-5. These are captured using ICD-10 codes N18.1- N18.5 in which ranging from mild to severe CKD with stage 5 requiring chronic dialysis, Edelberg explains.

GU Codes Also Require Identifications Of Any Infectious Agents

Edelberg offers these tips on coding for common ED genitourinary presentations:

You would report cystitis in addition to the bacterial or viral infectious agent from the B95 through B97 code series. You’ll need further identification of whether it is acute without or with hematuria (N30.00-N30.01), interstitial without or with hematuria (N30.10-N30.11), other without or with hematuria (N30.20-N30.21), trigonitis without or with hematuria (N30.30-N30.31), irradiation without or with hematuria (N30.40-N30.41), other without or with hematuria (N30.80-N30.81) and unspecified without or with hematuria (N30.90-N30.91).

Prostate conditions (N40.0 – 42.0) include enlarged with and without lower urinary tract symptoms, nodular with and without lower urinary tract symptoms, inflammatory disease and other specified and unspecified conditions.

Check for an underlying condition: Inflammatory diseases of the female pelvic organs (N70-N77) include numerous classifications commonly treated in the ED.  Pelvic inflammatory disease requires documentation and coding of the infectious agent (B95-B97).  Unspecified pelvic inflammatory disease, unspecified (N73.9) also requires identification first of any underlying condition when documented.

Context will determine the code choice: Bartholin’s gland cysts (N75.0) and abscesses (N 75.1) are common ED diagnoses as are excessive, frequent and irregular menstruation (N92).  N92 is differentiated by regular cycle, irregular cycle, puberty, ovulation bleeding and excessive bleeding in the premenopausal periods.

Location Drives the Code for Kidney Stones 

One of the more interesting nuances of the GU ICD 10 system relates to kidney stones which are coded based on the detail of where the stone is (kidney, ureter, or bladder). The relevant codes appear below:

Kidney Stone:

• State location of stone as follows
• Kidney / ureter / kidney and ureter
• Bladder
• Urethra

Calculus of kidney and ureter

N20.0 Calculus of kidney
N20.1 Calculus of ureter
N20.2 Calculus of kidney with calculus of ureter
N20.9 Urinary calculus, unspecified
N21 Calculus of lower urinary tract
N21.0 Calculus in bladder
N21.1 Calculus in urethra
N21.8 Other lower urinary tract calculus
N21.9 Calculus of lower urinary tract, unspecified
N22 Calculus of urinary tract in diseases classified elsewhere
N23 Unspecified renal colic.