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Medical Coding News Archives

November Coding Corner

November 10, 2015:

As we start this journey in ICD-10, Optum360 Coding Professionals have identified areas where medical coding professional are struggling for uniformity and correct coding amongst their peers. In the Optum360 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. Screening Codes in general –

The concept for coding a screening code on an encounter has not changed from ICD-9-CM to ICD-10-CM. The basic rules still apply:

  • If the patient is symptomatic – it is not a screening
  • A screening code can be a first listed diagnosis or a secondary diagnosis dependent upon the circumstances of the encounter
  • Additional codes may be used to describe any findings discovered on the screening examination as long as there are not coding conventions (guidelines or excludes notes) that prohibit the use of the screening code with the additional code

2. Diagnostic and Screening Mammograms with Abnormal Findings –

There is an excludes1 note under code Z12.31 Encounter for screening mammogram for malignant neoplasm for code R92.2 Inconclusive mammogram. Coding Clinic First Quarter 2015 page 24 clarifies stating that R92.2 should only be used on diagnostic, follow-up examinations and not on the screening encounter.

3. COPD with Pneumonia

Page 10 of the article Estimating the Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments posted to the CMS website on 2/25/2013 (https://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html) clarifies that the correct code for COPD when it is present with pneumonia is J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection rather than J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation or J44.9 Chronic obstructive pulmonary disease, unspecified.


1. Monitoring versus Measurement –

Deciphering between the root operation monitoring and measurement can be disconcerting. The main concept to keep in mind to distinguish between the two is to ask, “Is the test a snapshot of a single moment in time or is it following the patient’s physiological function over a period of time?” A “snapshot” is considered a “Measurement”; when the function is followed over a continuous period of time that is considered “Monitoring”.

2. Approach for OB lacerations –

Multiple AHA Coding Clinics have been published to clarify the approach for obstetrical laceration repairs. The summary is that first degree/skin lacerations are coded using the approach External. Deeper lacerations should be coded using the Open approach based on the guidance in Coding Clinic Fourth Quarter 2013, pg. 120: “Although the laceration occurred spontaneously, it is nevertheless the means by which the procedure site is exposed.”

3. Coding Vaccination Administration from Orders or Plans –

Procedures, no matter how invasive or non-invasive, should not have a code assigned unless there is documentation that the procedure was actually performed. It is inappropriate to report a code based on a plan or an order. Clear documentation of the administration, including route, date and time, should be present in the documentation prior to assigning a vaccination administration diagnosis or procedure code.


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