Medicare Compliance & Reimbursement

Hint: The “W” code may help with claims processing.

Summer fun often leads to a nighttime trip to the ER. When was the last time you saw a patient with an embedded tick, bee sting reaction, or a pitcher’s shoulder? Now’s a good time to brush up on your summer coding diagnoses with a quick ICD-10 quiz.

Check out the following questions and then determine which diagnosis code you’d assign to the chart before reading our expert answers.

Don’t Dig for Embedded Tick Code

Question 1: A patient presents with a tick embedded in her thigh. She has picked part of the tick out but the rest is still under the skin. The physician evaluates the spot, asks questions about Lyme disease-related symptoms, removes the tick using probing tweezers, and decides to hold off on antibiotic treatment because the patient has no signs of Lyme disease. Which diagnosis code(s) should you report?

Answer 1: You’ll likely report more than one diagnosis code for this scenario, as follows:

• S70.359A (Superficial foreign body, unspecified thigh, initial encounter) for the removal of the superficial foreign body from the leg
• S70.369A (Insect bite [nonvenomous], unspecified thigh, initial encounter) for the bite
• W57.XXXA (Bitten or stung by nonvenomous insect and other nonvenomous arthropods, initial encounter) to indicate an injury from a nonvenomous insect.

If the patient had been discovered to have had Lyme disease, you’d report the appropriate code for that as well (e.g., A69.20, Lyme disease, unspecified).

Is the “W” code necessary? Although your insurers may not require them, the codes in the “External Causes of Morbidity” section of the ICD-10 manual are helpful for claims processing purposes, but the first rule about using these codes is that they should never be listed as the primary diagnosis code. Instead, use the external cause code as secondary codes to provide additional information. While the codes aren’t payment codes, they do explain “how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person’s status (e.g., civilian, military),” according to the ICD-10 manual.

Correct coding requires you to report this added information. “It is appropriate to code all diagnoses that coexist at the time of the visit that affect patient treatment or management,” says Matthew Menendez, vice president of sales and marketing with White Plume Technologies. “As always, make sure documentation supports your coding.”

You’ll Need Details for Sports Injuries

Question 2: A patient comes to the ED with pain in his left shoulder after pitching a double-header baseball game and fears he may have a dislocation. The doctor evaluates the patient, orders and interprets an X-ray, and diagnoses the patient with pitcher’s shoulder due to overuse. Which code(s) should you report?

Answer 2: It’s difficult to say which code applies to this service without more information, because pitchers — or any throwing athletes — can develop myriad conditions related to their sport activity.

You’ll need to ask the physician for more information. If he simply offered a vague diagnosis because he wanted the patient to follow up with an orthopedist the next business day, you may have to report a nonspecific code such as M25.512 (Pain in left shoulder).

If, however, you ask the physician for a more specific diagnosis and he has one, such as bursitis of the shoulder, report that code instead (e.g., M75.52, Bursitis of left shoulder).

Know the Lowdown on Bees

Question 3: A 9-year-old patient develops generalized hives and begins wheezing after what her mother says she believes was a bee sting, and her mother brings her into the ED. The physician diagnoses the patient with an anaphylactic reaction to hymenoptera poisoning and administers an epinephrine shot. Which diagnosis code(s) apply?

Answer 3: Your first thought might be to assign an allergic reaction diagnosis for the patient, but that’s not your best choice in this case. Although allergic reactions are a type of anaphylaxis, grouping them together when it’s time to code will not only result in the wrong ICD-10 code, but will also undermine the severity of the encounter from the payer’s perspective.

Here’s the difference: Allergic responses typically involve local or general reactions to one body system, such as the skin. Anaphylactic shock, by contrast, affects multiple body systems. Anaphylaxis syndrome is an explosive multisystem immune reaction. Generally, skin and respiratory symptoms appear first, but cardiac and gastrointestinal problems may also develop.

To describe the anaphylactic shock, you’ll report T78.2XXA (Anaphylactic shock, unspecified, initial encounter), and to reflect the fact that it was due to a reaction to hymenoptera venom, you’ll report T63.441A (Toxic effect of venom of bees, accidental [unintentional], initial encounter).

You may also report Z91.030 (Bee allergy status) to reflect the fact that the patient was allergic to the bee venom. There is no need to report the diagnosis codes for the symptoms (hives, wheezing) because the anaphylaxis diagnosis code is inclusive of those symptoms.