Part B Insider (Multispecialty) Coding Alert

Urosepsis = UTI

No, said Sandy Nicholson, MA, RHIA, CCS-P, in the presentation, Establishing Medical Decision Making Level (MDM): Expert Secrets Revealed at The Coding Institute's National Coding and Reimbursement Conference in Orlando.

038.9 is not the code to use for urosepsis. That term refers to a urinary track infection (UTI).

You instead have to use 599.0 (Urinary tract infection, site not specified) for Urosepsis. If you look up this term in the ICD-9 manual, it directs you to 599.0.

Action: When you see urosepsis, go back and ask the physician if he is treating a simple UTI or sepsis due to UTI, Nicholson advised. If all he says is urosepsis, then code the UTI.

Remember: Code 038.9 supports a higher-level of hospital care than 599.0 will.

Question 2: A 67-year-old patient requires treatment for a documented diagnosis of Charcotfoot. You know the main cause of the condition in the U.S. is uncontrolled type II diabetes. Can you code 250.00 (Diabetes mellitus without mention of complication; Type II or unspecified type, not stated as uncontrolled)?

Answer: Unless the documentation specifies Charcot foot due to diabetes (250.62, Diabetes with neurological manifestations, type II or unspecified type, uncontrolled), you have to code the general reason for Charcot foot, which is tertiary syphilis (094.x), Nicholson says.

Coders have no choice but to assign syphilis when documentation indicates only "Charcot foot."

Coders are supposed to go by the rules and definitions that CPT and ICD set out, Nicholson stresses.

Question 3: The only way a note describes hypertension is with HTN. Should you report 401.1 (Essential hypertension, benign) or 401.9 (Essential hypertension, unspecified)?

Answer: You have to assign the fifth digit of 9 (401.9). To use 401.1, the physician has to document something more, such as benign.

Question 4: A patient had rectal cancer in 2001 and is coming in now for a follow-up yearly visit. Would you code it history of ? Is there a timeframe on how many years before history is coded?

Answer: As soon as the physician ends treatment of the tumorand there is no evidence of cancer at that site, you may apply a history of cancer diagnosis.

There's no time qualification. You should look for documentation that your patient has had an exam that shows no sign of cancer if youwant to use V10.06 (Personal history of malignant neoplasm; rectum, rectosigmoid junction, and anus).