Inpatient Facility Coding & Compliance Alert

A keen eye on documentation and ‘excludes’ will see you through

Understanding these key concepts will downsize your pain management coding challenges under ICD-10. Apply these tactics when you report pain next October. 

1. Learn How to Handle Bilateral Reporting 

Many diagnoses in ICD-10 specify laterality, such as G56.01 (Carpal tunnel syndrome, right upper limb). Others designate that a condition is bilateral (such as M17.0, Bilateral primary osteoarthritis of knee). But how do you handle conditions that are diagnosed as bilateral but don’t have a specific code for such? 

The solution: Report two diagnosis codes. According to ICD-10 Coding Guidelines, “If no bilateral code exists and the condition is bilateral, two codes must be assigned (one for right and one for left) to report the complete condition. In the above example, if the pain management provider documented bilateral carpal tunnel syndrome, you would code both the G56.01 and G56.02 ICD-10 codes.

2. Crack the Combination Codes

You can report a combination code in ICD-10 when you have to:

• Classify two diagnoses 
• Report a diagnosis with an associated secondary process (manifestation) 
• Report a diagnosis with an associated complication. 

For example, M50.12 (Cervical disc disorder with radiculopathy, mid-cervical region) encompasses two diagnoses (cervical disc disorder and radiculopathy). We are yet to learn on the usefulness of these combination codes in times to come. “ We will have to wait for implementation to determine the usefulness (or not) of this approach”, opines Duane C. Abbey, Ph.D., president of Abbey and Abbey Consultants Inc., in Ames, IA.

Coding direction: Do not submit multiple codes when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis or when the alphabetic index instructs you to report the condition that way. However, your providers should clearly indicate the relationship between conditions identified in a patient.

Example: Consider documentation of polyneuropathy and type 2 diabetes versus a single diagnosis of polyneuropathy associated with type 2 diabetes. In the first instance (polyneuropathy and type 2 diabetes), the provider doesn’t provide the “link” that the polyneuropathy is due to the diabetes. So you would report the two conditions as separate diagnoses codes. In the second instance (polyneuropathy associated with type 2 diabetes) documentation clearly indicates that the polyneuropathy is a manifestation of the diabetes. That means you would report the conditions as a single combination code. 

3. Understand Both Types of ‘Excludes’ Notes

Exclusion notes further help you select the most appropriate diagnosis. ICD-10 includes two categories of exclusion notes. “Excludes1” is synonymous with “not coded here”. Any code following an Excludes1 notice should never be reported with the code above the Excludes1 note.

Example: Diagnosis G43.7- (Chronic migraine without aura) has an Excludes1 of G43.0- (Migraine without aura). You cannot submit G43.7 and G43.0 together because the migraine without aura can’t be both “acute” as in G43.0 and “chronic” as in G43.7. Simply report G43.7.

“Excludes2” – or “not included here” – means that although the excluded condition is not part of the condition from which it is excluded, there are times when a patient might have both conditions at the same time. If documentation states that both conditions exist together, you should report both.

Example: Consider diagnosis code group M80.- (Osteoporosis with current pathologic fracture) and the associated Excludes2 condition Z87.310 (Personal history of [healed] osteoporosis fracture). If this is the patient’s first osteoporotic pathologic fracture, it would not be appropriate to also report the Z87.310 code. If the patient had a previous pathological fracture due to osteoporosis in addition to the current fracture, however, you could report both codes with the ICD-10 code for the current fracture listed as primary.

4. Don’t Let Documentation Details Scare You

One myth surrounding ICD-10 is that providers will need to document their services in extraordinary detail in order to report the patient’s condition. Many ICD-10 diagnoses are more specific than their ICD-9 predecessors, but providers should already be including those details in their notes for you to code from. 

For example, ICD-9 code 337.21 (Reflex sympathetic dystrophy of the upper limb) will offer three options under ICD-10: G90.511 (Complex regional pain syndrome I of right upper limb), G90.512 (Complex regional pain syndrome I of left upper limb), and G90.513 (Complex regional pain syndrome I of upper limb, bilateral). If your provider already designates right, left, or bilateral for patients he currently treats for RSD of the upper limb, you have what you’ll need for ICD-10 code selection.