General Surgery Coding Alert

Prime your general surgeons for reporting laterality and other detail.

Whether you’re well on the way to a smooth ICD-10 transition on October 1, or scrambling with last-minute preparations, we have the tips you need to make sure you’re ready.

Everyone from your general surgeons to your coding staff will benefit from this run-down of basic ICD-10 coding concepts, along with some insider hints for ramping up your code set transition today.

Tip 1: Find Your Codes in ICD-10-CM

The rules for using ICD-10 aren’t so different from what you’re used to with ICD-9. You should always start your ICD-10 code search by looking up the condition in the Alphabetic Index, then turning to the Tabular List to ensure you select the proper code. The Alphabetic Index includes the Index of Diseases and Injury, Index of External Causes of Injury, the Table of Neoplasms, and the Table of Drugs and Chemicals.

Caution: Although “translating” an ICD-9 code to an ICD-10 code using crosswalk software, also called General Equivalence Mapping (GEM), may be helpful, you should be cautious about relying on those tools. “I personally do not like using GEMs because it does not always recognize the best codes, or it gives you several to choose from,” says Elizabeth Earhart, CPC, in Millersville, Pa. 

Instead, use GEMs as an opportunity to see what new documentation requirements you might have under ICD-10, and to educate your general surgeons about those expectations. 

Also, practices should closely examine their high volume services relative to changes in procedure coding, says Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, Iowa. “Computer reports can identify high volume areas, and then the coding changes can be assessed along with possible increased documentation requirements. By focusing on high volume and high-dollar areas, both coding and the supporting documentation can be addressed in a focused manner through increased training.”

Bottom line: Use GEMs now for analysis and training, but once you’re using ICD-10, you should code from your surgeon’s documentation directly into ICD-10, rather than continuing to code using ICD-9 and then trying to “translate” to ICD-10 using a GEM tool.

Tip 2: Understand Code Set Differences

ICD-10 diagnosis codes are 3-7 characters in length and number 68,000 codes, while ICD-9-CM diagnosis codes are 3-5 digits in length and total 14,000. That’s a whole lot more information you need to be aware of using the new code set.

“The granularity of ICD-10 will require more descriptive documentation to allow for matching to the right diagnostic code,” says Gregory Przybylski, MD, at the JFK Medical Center, Edison, N.J.

You’ll find much of that additional information is in the extra characters available in ICD-10 as sixth and seventh digits (ICD-9 tops out at five characters). You should also know that unlike ICD-9 codes, ICD-10 codes have a meaningful pattern for the character positions to the right of the decimal point. The fourth digit represents etiology, the fifth represents anatomic site, and the sixth represents manifestation, and the seventh character may be a letter or number that provides more information about the condition.

Watch placeholder: Because fourth through seventh digits in ICD-10 have specific meaning, some codes may have some “blank” positions, which you should represent with a dummy placeholder, x, (example, S17.0xxA).

Dash: We use an “x” in ICD-9 to show that more digits are required, but because an “x” is a placeholder in ICD-10 the dash has taken its place. When you see a dash at the end of a code, you should know that the code is incomplete. For instance, you might see M84.47- in the Tabular List, meaning you need to review the options to decide how to complete this code. 

Abbreviations: Just like ICD-9, you’ll encounter the following two abbreviations in ICD-10:

• NEC (Not Elsewhere Classifiable): The code might state “other specified” or “specified type NEC.” Use one of these codes if the medical record documents a condition for which ICD-10 doesn’t contain a specific code.

• NOS (Not Otherwise Specified): When the medical record documents less specific information than the codes describe, you’ll need to use an NOS code, which means “unspecified.” 

Punctuation: You’ll also find some familiar punctuation in ICD-10: 

• Parentheses: These indicate non-essential modifiers. They’re words that your surgeon might include in the documentation, but that aren’t required for your code choice. For instance, if you look up hernia in the Alphabetic Index, the entry includes (acquired) (recurrent) K46.9. 

• Brackets: This punctuation encloses synonyms or alternative wordings in the Tabular List. When you find brackets in the Alphabetic Index, this identifies manifestation codes. For instance, you’ll find “Meningitis in bacterial disease NEC A48.8 [G01] in the Alphabetic Index. When you turn to G01, you’ll see the instruction to “code first underling disease,” such as Lyme disease (A69.21)

Follow ICD-10 Guidelines

To make sure you’re ready for the October ICD-10 implementation, here’s a rundown of some crucial coding guidelines you’ll need to know:

Code most specific: Similar to ICD-9 guidelines, the ICD-10 guidelines give this instruction: “Do not code diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ or ‘working diagnosis’ or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.” 

Final diagnosis alert: If your surgeon submits specimens to a pathologist for diagnosis, you might want to wait for the results of the pathology exam to assign the final diagnosis.

Avoid ‘truncated’ codes: If you report a code that doesn’t include the full range of digits required to be a complete code, that’s called a truncated code — and that’s bad. If the code requires a fourth, fifth, sixth, or seventh digit, you can’t just leave off the extra digits because you don’t have specific information. Most categories that require extra digits include NOS codes that you can use if you don’t have more specific information.

Watch “Excludes” notes: ICD-10 has two types of excludes notes. If you see a condition in an “Excludes 1” note, you should never code that condition using the code above the Excludes 1 note, or in addition to the code above the Excludes 1 note. With an Excludes 2 note, you should never use the code above the note to describe the excluded condition, but you might code the conditions together using distinct codes if they occur together. 

Etiology/manifestation: If you’re coding a condition that is a “manifestation” of an “underlying condition” (called the etiology), you should always report the etiology code first. You’ll see this indicated two ways in the Tabular List:

• Manifestation code title will include the phrase “in diseases classified elsewhere,” which means you must report this code second, following the etiology code.

• Manifestation code will include the instruction “code first” with a reference to the etiology code, and the etiology code will include the instruction “use additional code” with a reference to the manifestation code. Code etiology first. 

In the Alphabetic Index, ICD-10 lists the etiology code alphabetically, with the manifestation code in brackets at that entry. 

Phrases: ICD-10 uses the following key phrases that have specific meaning for how you code:

• “code also” meaning you may need two codes to describe a condition, but without mandated sequencing

• “see” and “see also,” meaning you should reference another term in the Alphabetic Index. 

• “and,” meaning “and/or” 

• “with,” meaning “associated with” or “due to.”