ICD 10 Coding Alert

Find out one instance where site specificity may not be the best answer.

You can think of diagnosis coding as one part of the foundation necessary to achieve perfectly paid claims — procedure coding alone is not enough.

Use your knowledge to try coding these three scenarios, and then check your answers against the experts’ advice.

Hint: Coverage and payment for procedures your surgeon performs often depend on demonstrated “medical necessity” based on reported ICD-10-CM codes.

Use Two Dx Codes for This Colonoscopy Screening Situation

Scenario: The surgeon begins performing a screening colonoscopy on a patient, but finds and removes polyps during the procedure, with benign neoplasm confirmed by the pathology report. Which diagnosis code(s) apply in this case?

Solution: You’ll need to report two diagnosis codes on your claim to accurately convey the scenario. First, report the screening ICD-10-CM code Z12.11 (Encounter for screening for malignant neoplasm of colon). Medicare has been clear that if the patient presents for screening you have to bill the screening with the Z code, even if the physician finds a problem and treats it.

To avoid denials, you should also report the polyp diagnosis code (D12.6, Benign neoplasm of colon, unspecified) to describe the medical necessity for the polyp removal. If the op report clearly identifies the site of the polyp(s), you should report the site using a more specific code such as D12.4 (Benign neoplasm of descending colon).

Note Presentation with Diarrhea, Confirmation of COVID-19

Scenario: Your general surgeon is called to the emergency department to evaluate a patient with a six-day history of diarrhea, lethargy, and a low-grade fever who is now is experiencing diffuse abdominal pain. On examination, the surgeon hears normal bowel sounds, but notes some wheezing in the chest. The patient reports no cough and no exposure to anyone with coronavirus, but the surgeon orders an abdominal CT scan and a rapid COVID-19 test, which returns positive. Which ICD-10 code(s) apply?

Solution: Your first diagnosis code should be U07.1 (COVID-19). You should also report the patient’s symptoms as a secondary codes, such as R19.7 (Diarrhea, unspecified), R50.9 (Fever, unspecified), and R53.83 (Other fatigue). The surgeon should also report any other possible findings from the abdominal CT scan.

Here’s why: When seeing patients with dates of service on or after April 1, you should use U07.1 as your primary or principal diagnosis code, with the manifestation coded afterward, says Betty Ann Price, BSN, RN, president and founder of Professional Reimbursement and Coding Strategies, and an AHIMA-approved ICD-10-CM trainer. “U07.1 needs to be the primary code, even above respiratory distress or respiratory failure — you must put that U code first with dates of service April 1 or after.”

One rationale for reporting the U code first is that, as with all the temporary federal waivers in place for coronavirus reimbursement, it will be important for payers to see the coronavirus code at the front of your claim, which will unlock many of these special payment circumstances, she says.

Going Too Specific May Be Wrong Here

Scenario: The surgeon performs an elliptical excision of a skin lesion on the patient’s nose, removing at least 1 cm margins around the lesion. The pathologist diagnoses the lesion as melanoma in situ.

Solution: Knowing that the code family C43 (Malignant melanoma of skin) describes malignant melanoma, you might be inclined to report the specific code for “nose,” which is C43.31 (Malignant melanoma of nose). But that would be wrong.

“ICD-10-CM distinguishes malignant melanoma from melanoma in situ,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, CA. These codes are also site specific.

In this case, you should code the pathologist’s findings as D03.39 (Melanoma in situ of other parts of face).

Coder tips: The C43 code family indicates, “Excludes1: melanoma in situ (D03.-).” The note indicates that you should never list D03.- at the same time as C43.- because the two conditions cannot occur together. You must select the most specific code for melanoma — it is either in situ or malignant.

The National Cancer Institute indicates that melanoma in situ is stage 0 melanoma. The abnormal cells are located in the epidermis in stage 0 melanoma.

If the documentation indicates stage I or above, or indicates that the melanoma has metastasized, you’ll know that the melanoma is not in situ.