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Coding Quality Check: The top three coding variances for ICD-10-CM and PCS

October 19, 2015:

As we start this journey in ICD-10, Optum Coding Professionals have identified areas where coding professional are struggling for uniformity and correct coding amongst their peers. In the Optum Coding Corner we will discuss the top three coding variances for each ICD-10-CM and ICD-10-PCS found on a monthly basis and explore the codes, coding concepts and conventions for those variances. This information comes from Optum360 Enterprise CAC’s data collection.

ICD-10-CM (both Inpatient and Outpatient settings)

1. Diagnoses listed as Past Medical History

There are two important factors to consider when a condition is listed as a past medical history with no indication that it is current and impacting the patient’s care. First, Coding Clinic advice from ICD-9 should be considered (this is allowed per Coding Clinic for ICD-10 First Quarter 2014, page 11). In Coding Clinic Third Quarter 2007 page 13, it is noted that “chronic systemic diseases that ordinarily should be coded even in the absence of documented intervention or further evaluation.” Therefore diagnoses such as (but not limited to) diabetes, Parkinson’s, COPD and hypertension may be coded in absence of treatment or evaluation. The key to this concept is to understand what a chronic systemic condition is. A chronic disease is a long-lasting condition that can be controlled but not cured. A systemic disease is one that affects a number of organs and tissues, or affects the body as a whole. In order to meet this criteria, a diagnosis must be both chronic and systemic.

The second concept that needs to be addressed is that if the condition is not chronic and systemic, then does it meet the criteria for secondary diagnosis? The criteria to be met are listed in ICD-10-CM Coding Guidelines section III and include:

  • Clinical evaluation
  • Therapeutic treatment
  • Diagnostic procedures
  • Extended length of hospital stay
  • Increased nursing care and/or monitoring

If the criteria for neither concept are met, a current code should not be assigned for a diagnosis documented in a historical context, a personal history code would be more appropriate if necessitated by workflow or local coding practice.

2. Nicotine use and dependence (specifically cigarettes and “smokers”)

Frequently coders are interchanging codes from category F17.210 and Z72.0. In order to understand the difference between these two very similar codes, CM Coding Guidelines section I.C.5.b for “Use, Abuse and Dependence” should be consulted. These guidelines state that if use and dependence are both documented, only the code for the dependence should be assigned. Also a peak into the ICD-10-CM index shows that the term “smoker” is classified as dependence on nicotine. Therefore, in order to use Z72.0, the documentation would have to only state “use” and have no mention of being a “smoker.” This makes the default F17.210, dependence rather than use for most documentation of packs per day, etc.

3. Sign and Symptom coding

Codes for signs and symptoms have multiple guidelines to give a foundation for when they are appropriate to be reported. Most of these codes can be found in Chapter 18 of ICD-10-CM (R00-R99), but there are a handful that can be found in the system chapters such as extremity pain (M79.6-) or sore throat (J02.9). In order to report these types of codes the following concepts should be kept in mind:

  • If the code describes a sign or symptom of another related definitive diagnosis established any time after presentation, ie. is a common, integral part of the definitive diagnosis – do not code it
  • If it is not part of a definitive diagnosis in the documentation – code it


1. Body character for vascular access devices (VADs)

Do not use the insertion site for the body part character when coding insertion of VADs. AHA Coding Clinic Third Quarter 2013, page 18 indicates that the body part character for a VAD should be the end placement location, not the insertion site. VADs usually terminate in the subclavian, brachiocephalic or iliac veins, the inferior or superior vena cava or the right atrium, most commonly however, the superior vena cava. Only an x-ray can confirm the tip location, therefore if available, the radiology report should be consulted for the correct body part selection.

2. Repair of obstetrical lacerations

Codes from table 0WQN should not be automatically assigned for specified obstetrical perineal laceration repairs. PCS Coding Guideline B2.1a. indicates that a code from the anatomical sections should not be used if there is a more specific code to be reported. In many cases, the only documentation is the degree of the laceration repair. According to Coding Clinics Fourth Quarter 2013, page 120 and Fourth Quarter 2014 pages 18 and 43, the degree documentation can determine the body part character to use outside of the 0WQ table. If no further information is provided, the following may be assumed by documentation of the degree:

  • First – skin: 0HQ9XZZ
  • Second – muscle: 0KQM0ZZ
  • Third – anal sphincter: 0DQR0ZZ
  • Fourth – rectum: 0DQP0ZZ


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