General Surgery Coding Alert
Focus Appendicitis Dx Coding
Don’t miss pregnancy impact. When your surgeon treats a patient with appendicitis, you may find coding the case is easy on the procedure side but complicated on the diagnosis side. Look to ICD-10-CM guidelines and the following expert tips for a roadmap to reporting the correct diagnosis codes for your appendicitis cases. Without Surgery, Code Symptoms Sometimes your surgeon will evaluate a patient with suspected appendicitis but decide not to perform surgery. In those cases, without a final diagnosis, you’ll need to know how to corral the best codes to describe the patient’s symptoms. For instance: Patient presents with right lower quadrant discomfort. Your diagnosis code choices for are: To choose the correct code, you’ll need to distinguish R10.813 and R10.823. Rebound tenderness involves pain or tenderness that is more pronounced after a sudden release of pressure, such as when the surgeon presses on the abdomen and then rapidly removes their hand. Rebound tenderness often indicates an intraperitoneal inflammatory process or a more serious surgical problem, says Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York Stony Brook. Documentation: Your surgeon’s encounter notes should include specific language to differentiate pain, tenderness, or rebound tenderness, as well explicit indication of the site of abdominal discomfort. With that information, you can choose among the following ICD-10-CM options: Because ICD-10-CM does not offer a code for “unspecified” or “other” site, if the patient has pain or tenderness in multiple sites in the abdomen, you will need to report multiple codes, one for each site. Code Appendicitis Dx from Op Note When your surgeon performs an appendectomy for appendicitis, specific information from the op note should guide you to the correct diagnosis code. Acute: The first information you need is whether the case is acute appendicitis or “other” or “unspecified.” An acute condition is severe, with sudden onset, and leads to the K35 (Acute appendicitis) code family. If the op note indicates acute appendicitis, you’ll need to decipher the following details from the documentation: Armed with that information, you can choose the correct, specific code from the following list: If the appendicitis is not acute, or the op note or pathology report doesn’t specify, look to the following code options: Pregnancy Changes Dx Coding If your surgeon performs an appendectomy for a pregnant patient, you may need to skip using a K35-K37 code as the first-listed diagnosis. Here’s why: The ICD-10-CM guidelines provide instructions under “General Rules for Obstetric Cases” that states the following sequencing priority for codes from Chapter 15 (O00-O9A, Pregnancy, Childbirth and Puerperium): Realizing that you should use a chapter 15 code as the principal diagnosis, you should turn to codes from category O99 (Other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium) as the first-listed diagnosis for conditions such as appendicitis that could affect the pregnancy. Do this: When your surgeon performs an appendectomy for a pregnant patient with appendicitis, the first-listed diagnosis should be O99.61- (Diseases of the digestive system complicating pregnancy). This code requires a sixth digit, says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, CA. If you don’t include the sixth digit, this “could be a reason for a denial,” she adds. The six-digit code choices are O99.611, O99.612, O99.613, or O99.619 for first, second, third, or unspecified trimester. Following the ICD-10-CM instruction to “Use additional code to identify specific condition,” you should also report the appropriate appendicitis code for the case, such as K35.20.
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