General Surgery Coding Alert

The medical record documents a diabetic patient with an inguinal hernia and a resolved thrombophlebitis incident. You're coding for the hernia repair -- what diagnosis code(s) should you use?

A surgical patient's seemingly unrelated condition could impact the level of care. You need to tell the whole story of coexisting conditions when you select ICD-9 codes for a case.

"The real issue from the perspective of ICD-9 Coding Clinic is when and which co-morbidities you need to code," says John F. Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop and Associates.

Obey the following ICD-9 guidelines to make sure you capture pertinent diagnostic information and cut through extraneous patient background:

Whether for inpatient or outpatient surgery, you need to zero in on the reason for the procedure when you select a claim's first ICD-9 code. ICD-9 inpatient guidelines call this the "principal diagnosis," while outpatient guidelines call it the "first listed condition," but the code choice should be the same.

Bottom line: Both inpatient and outpatient guidelines direct you to select the condition that is "chiefly responsible" for the surgical procedure.

That means for our hypothetical hernia-repair patient,you should list 550.xx (Inguinal hernia) as the reason for the surgery.

Tip: "You should always list an ICD-9 code to the highest level of specificity," says La Donna Brown, CPC, coding specialist with Sanford Clinic Vascular Associates in Sioux Falls, S.D.

An inguinal hernia requires a fifth digit, which means that you must select the most accurate description from the following codes:

• 550.0x -- Inguinal hernia, with gangrene

• 550.1x -- Inguinal hernia, with obstruction, without mention of gangrene

• 550.9x -- Inguinal hernia, without mention of obstruction or gangrene.

Select the appropriate fifth digit as follows:

• 0 -- unilateral or unspecified (not specified as recurrent)

• 1 -- unilateral or unspecified, recurrent

• 2 -- bilateral (not specified as recurrent)

• 3 -- bilateral, recurrent.

If your surgeon simply documents an "inguinal hernia," you would have to choose 550.90 for the diagnosis.

Assigning a diagnosis code for the condition chiefly responsible for the surgery isn't enough, according to ICD-9 inpatient and outpatient guidelines.

"You also need to list diagnosis codes for coexisting conditions," Brown says.

Inpatient guidelines define these as "additional conditions that affect patient care in terms of requiring:

• clinical evaluation; or

• therapeutic treatment; or

• diagnostic procedures; or

• extended length of hospital stay; or

• increased nursing care and/or monitoring."

Similarly, the outpatient guidelines instruct you to "code all documented conditions that coexist at the time of the encounter and require or affect patient care, treatment, or management."

Example: Let's say the medical record for the patient undergoing the hernia repair documents type II diabetes that requires insulin with no mention of complications.

Do this: The correct diabetes code is 250.00 (Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled), because the medical record does not document any continuing blood vessel damage or disease that would warrant reporting 250.70 (Diabetes with peripheral circulatory disorders ...) based on the past thrombophlebitis event.

Identify medication: Because the patient has type II diabetes but receives insulin, you'll have to report an additional code to document the medication: V58.67 (Long term [current] use of insulin).

What about reporting the resolved thrombophlebitis?You should not code it as a current disorder (451.9,Phlebitis and thrombophlebitis of unspecified site). The condition has resolved and is not present at the time of surgery. The ICD-9 guidelines clearly state, "Do not code conditions that were previously treated and no longer exist."

Caveat: But the guidelines also state that "history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment." Does that mean that you should you report V12.52 (Personal history of certain other diseases, thrombophlebitis)?

"You should not report the personal history code in this case because it does not contribute to current care," Bishop says. "The surgical team will provide the same leg protection whether or not the patient had a past thrombophlebitis incident that is not currently being treated."

When reporting multiple diagnoses, be sure to adhere to ICD-9's ordering rules. Here's how:

• You should always code first the condition that is chiefly responsible for the surgery or other patient encounter.

• Next, you should list any coexisting conditions that affect patient care -- in no particular order except as ICD-9 instructs.

Solution: In this case, you should code the diabetes before the insulin use. ICD-9 guidelines indicate that the "use additional code" instruction means that you should sequence the additional code second. The diabetes fifth digit "0" states "Use additional code, if applicable, for associated long-term (current) insulin use."

Final ICD-9 coding for this case: 550.90, 250.00, V58.67.

Resource: You can access the ICD-9 coding guidelines at  www.cdc.gov/nchs/data/icd9/icdguide09.pdf.