Neurosurgery Coding Alert

Report both acute and chronic conditions that your patient has.

The ICD-10-CM manual seems voluminous. You may be operating under the assumption that ICD-9 codes will always multiply into more specific options. However, that isn't always the case. Conditions requiring two more ICD-9 codes right now might be simplified into a single ICD-10 option in 2013. Let us look for examples from a variety of disease conditions that your patient is likely to be having.

Best bet: To determine whether you should report multiple codes or a single ICD-10- CM code, you need to read your coding guidelines. Keep an eye out for phrases like "use additional code" or "code first."

Capture Single Condition with Multiple Codes

True, you may find that a patient requires multiple ICD-10 codes to fully qualify the condition he or she has.

"Use additional code:" When you're searching the Tabular List, you'll find "use additional code" notes in situations where you should use a secondary code to fully describe a condition. For instance, you might tack on B95 (Streptococcus, staphylococcus, and enterococcus) as a secondary code to identify the bacteria causing the patient's infection.

"Code first:" You might come across "code first" notes in the Alphabetic Index. This means you should code the underlying condition first. For instance, under the B39 (Histoplasmosis) category, you'll see "code first associated AIDS (B20)."

"Code, if applicable, any causal condition first:" If you see "Code, if applicable, any causal condition first," then you may use this code as a principal diagnosis when your physician hasn't specified the causal condition. If the physician has specified the causal condition, however, then you should code that as the principal diagnosis. For instance, under N13.8 (Other obstructive and reflux uropathy), you'll see "Code first, if applicable, any causal condition, such as enlarged prostate (N40.1)." That means if the provider diagnosed an enlarged prostate, then you would code N40.1 as your principal diagnosis.

Finally, you should be aware that you may need to report multiple codes for late effects and complication codes.

Bonus concept: Suppose a patient has a condition that is both acute (subacute) and chronic. How should you report this? According to the ICD-10-CM Official Guidelines for Coding and Reporting, you should code both acute (subacute) and chronic. List the acute (subacute) code first. For instance, a patient might have both acute thyroiditis (E06.0) as well as chronic thyroiditis with transient thyrotoxicosis (E06.2). You would report both codes with E06.0 listed first.

Report Multiple Conditions with Single Code

However, rather than code multiple diagnoses for a condition, you may find that ICD-10- CM already has a single code that reflects a combination.

Combination codes (which are a single, unique code) specify:

Two diagnoses

A diagnosis with an associated secondary process (manifestation)

A diagnosis with an associated complication

Examples: You will find such combinations as I25.110 (Arteriosclerotic heart disease of native coronary artery with unstable angina pectoris), K50.013 (Crohn's disease of small intestine with fistula), and K71.51 (Toxic liver disease with chronic active hepatitis with ascites).

If you scan the Alphabetic Index, you will find combination codes listed as subterm entries, and you'll find them specified in the inclusion/exclusion notes in the Tabular List.

Rule: You can only assign a combination code when the physician fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs you.

Don't use multiple codes when a single combination code clearly identifies all the elements exist.

What should you do when a patient has a complication or manifestation that isn't listed in a single combination code? That's when you can use the secondary code(s).

Can You Report Same Diagnosis More Than Once?

You may be wondering if you can report the same diagnosis code more than once, and the answer is no.

In other words, if a patient has two different conditions that a single combination code describes, then you should only report that single combination code once.

Also, this rule applies to bilateral conditions when you don't have any distinct codes describing laterality. If the condition occurred on both the left and right side and your code states "bilateral," then you should report that bilateral diagnosis code only once.