Urology Coding Alert

Home in on a few key guidelines pertaining to diabetes, medical observation, and more.

From April to October of 2020, you’ve probably been made painfully aware of the new ICD-10-CM codes and respective guidelines for COVID-19 reporting. While the COVID-19-related guideline changes all made front page headlines, there changes to other guidelines that you may have overlooked following their October 2020 implementation.

From additional instruction on coding diabetes and puerperal sepsis diagnoses, to new rules on sequencing of observation Z codes, you don’t want to miss out on these new sets of guidelines.

Read on to fill in the last remaining dots and get the full picture of ICD-10-CM guideline changes for 2021.

Decipher New Guidelines Surrounding Diabetes Dxs

First, have a look at Sections I.C.4.a.3 and I.C.4.a.6.a, which include the same guideline as it pertains to primary and secondary diabetes mellitus, respectively:

• If the patient is treated with both insulin and an injectable noninsulin antidiabetic drug, assign codes Z79.4, Long term (current) use of insulin, and Z79.899, Other long term (current) drug therapy. If the patient is treated with both oral hypoglycemic drugs and an injectable non-insulin antidiabetic drug, assign codes Z79.84, Long-term (current) use of oral hypoglycemic drugs, and Z79.899, Other long-term (current) drug therapy.

These guidelines may apply to patients being treated for urologic manifestations and complications due to diabetes diagnoses. Some of these conditions may include bladder cystopathy, urinary tract infections (UTIs), and sexual dysfunction.

Consider Important Rules for Puerperal Sepsis Coding

Next up, there’s an important guideline change to consider surrounding puerperal sepsis diagnoses that may have an influence on your diagnosis coding for obstetrical patients with urinary tract complications during or following obstetrical procedures:

• Code O85 should not be assigned for sepsis following an obstetrical procedure (See Section I.C.1.d.5.b., Sepsis due to a postprocedural infection).

Refresher: According to Dorland’s Illustrated Medical Dictionary, puerperal sepsis, also known as puerperal fever, is “an infectious, sometimes fatal, type of septicemia with fever associated with childbirth; the focus of infection is the uterus, and the etiologic agent is frequently a streptococcus.”

For puerperal sepsis patients treated by your urologist or urogynecologist, you need to consider how these new guidelines change the way you choose a diagnosis code. While O85 (Puerperal sepsis) is still appropriate during most clinical encounters, these new guidelines restrict O85 reporting for puerperal sepsis following an obstetrical procedure. This means that you should only report code O85 for obstetrical patients undegoing procedures that are unrelated to their pregnancy. “Keep in mind that for all intents and purposes, you should always categorize a delivery as an obstetrical procedure with respect to the ICD-10-CM guidelines,” advises Sheri Poe Bernard, CPC, of Poe Bernard Consulting in Salt Lake City.

If the patient is diagnosed with puerperal sepsis during delivery or in the days or weeks following, you should follow the guideline outlined in Section I.C.1.d.5.b, which states the following:

• For infections following a procedure, a code from T81.40, to T81.43 Infection following a procedure, or a code from O86.00 to O86.03, Infection of obstetric surgical wound, that identifies the site of the infection should be coded first, if known. Assign an additional code for sepsis following a procedure (T81.44) or sepsis following an obstetrical procedure (O86.04). Use an additional code to identify the infectious agent. If the patient has severe sepsis, the appropriate code from subcategory R65.2 should also be assigned with the additional code(s) for any acute organ dysfunction.

Don’t Forget About New Observation Code Guidelines

The last new ICD-10-CM 2021 to consider has to do with the following three observation category codes:

• Z03 (Encounter for medical observation for suspected diseases and conditions ruled out)
• Z04 (Encounter for examination and observation for other reasons)
• Z05 (Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out)

In previous versions of the ICD-10-CM guidelines, you’ve received instruction to exclusively report observation codes as first-listed diagnoses. The 2021 guidelines revise the verbiage to state that codes from code range Z03-Z05 should “primarily” be used as principal/ first-listed diagnoses. ICD-10-CM 2021 adds the following instruction outlining what circumstances allow for reporting of code range Z03-Z05 as secondary codes:

• The observation codes are primarily to be used as a principal/first-listed diagnosis. An observation code may be assigned as a secondary diagnosis code when the patient is being observed for a condition that is ruled out and is unrelated to the principal/ first-listed diagnosis (e.g., patient presents for treatment following injuries sustained in a motor vehicle accident and is also observed for suspected COVID-19 infection that is subsequently ruled out).

While this sort of clinical scenario may be few and far between, it’s always important to take note of instances where the guidelines shift from speaking in absolutes (always, never) to offering more leeway on code reporting depending on the clinical situation.