Primary Care Coding Alert

Perceiving -due to,- -benign- could land you with incorrect dx.

Be careful that your septicemia, diabetes, and hypertension savvy don't leak into your diagnostic code choice, or you could end up with an unsupported code. See if you-re inferring too much with this quick quiz.

Question 1: A physician is treating a patient in the hospital and billing initial and subsequent care with documented diagnosis of "urosepsis." Should you code 038.9?

Answer 1: No, said Sandy Nicholson, MA, RHIA, CCS-P, in "Establishing Medical Decision Making Level (MDM): Expert Secrets Revealed" at The Coding Institute's National Coding and Reimbursement Conference in Orlando.

"038.9 (Unspecified septicemia) is not the code to use for "urosepsis." That term means a urinary tract infection (UTI).

You instead have to use 599.0 for "Urosepsis." If you look this up 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 advises. If all he says is "urosepsis", then code the UTI.

Code 038.9 means the patient has septicemia, which could be due to a UTI. But you must see those words --"septicemia due to" -- to use 038.9.

Because septicemia is a severe presenting problem, "038.9 supports a higher level of hospital care (such as 99223 and 99333) than 599.0 does," Nicholson points out.

Question 2: An elderly patient requires treatment for a documented diagnosis of "Charcot foot." You know the main cause of the condition in the United States is uncontrolled type II diabetes mellitus (DM). Can you code 250.00?

Answer 2: 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 neurosyphilis (094.x), Nicholson says.

Coders have no choice but to assign neurosyphilis 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 laundry list note of chronic diseases and conditions describes hypertension is with "HTN." Should you report 401.1 or 401.9?

Answer 3: You have to assign the fourth digit of 9 (401.9, Unspecified essential hypertension). To use 401.1 (Benign essential hypertension), the physician has to document something more, such as "benign," Nicholson stresses.

But the real concern is whether you should list the hypertension diagnosis. You would list the diagnosis if the physician documents treating the condition or if the condition affects the treatment, notes Vicky Varley O-Neil, CPC, CCS-P, owner of The Hazlett Group, a practice management consulting firm based in Birmingham, Ala.

O-Neil recommends following these guidelines:

- "Chronic disease: Chronic diseases treated on an ongoing basis may be coded as many times as the patient receives treatment for the condition.

- Coexisting conditions: Code all conditions that coexist at the time of the encounter only if they affect patient care or management."