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Medical Coding News Archives

January Coding Corner

January 14, 2016:

As we start this journey in ICD-10, Optum360 coding experts have identified areas where 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. Osteoarthritis and arthritis –

When the documentation does not specify the type of arthritis but does specify laterality, the index should be followed and M19.90 (Unspecified osteoarthritis, unspecified site) should be assigned. However, this is not the case with osteoarthritis, per the index, this condition is classified as primary if not otherwise specified and a code from the M19.0 (Primary osteoarthritis of other joints) category should be assigned. Arthritis and osteoarthritis are not interchangeable terms according to coding conventions. In order for arthritis to be considered “osteo” the following descriptors are needed: deformans, degenerative, senile and/or senescent. Interesting enough, however, if the two are used interchangeably by the provider, the index leads the coder to assume osteoarthritis (Arthritis > meaning osteoarthritis > see Osteoarthritis).

2. Use of codes from B95-B97 (Bacterial and Viral Infectious Agents) –

The codes from this section are used to identify the organism that is not identified in a code for an infectious process. For example, urinary tract infection due to E. coli both N39.0 (Urinary tract infection, site not specified) and B96.20 (Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere) are needed. Whereas, pneumonia due to E. coli needs only one code J15.5 (Pneumonia due to Escherichia coli). If the organism is identified in the code for the infection, adding a code from B95-B97 is redundant. Codes from other ranges in Chapter 1 are not to be used to identify organisms in other conditions.

3. Psychoactive substance use –

Different from psychoactive drug use coding in ICD-9-CM, the ICD-10-CM guidelines state that unspecified use codes from categories F10-F16 should only be used if they meet additional reporting guidelines (Section III) and the use is documented as being associated with a mental or behavioral disorder. This is outlined in Coding Guideline section I.C.5.b.3. For example, if the physician states cocaine use, in order to report a code from the F14.9 category, treatment, monitoring and/or evaluation, etc. would need to be performed in addition to documentation of a behavioral or mental manifestation such as anxiety, delusions or intoxication.


1. Botox injections –

The objective of the procedure must be taken into consideration before assigning a code:

  • If the objective is to destroy a nerve or nerve connection (regardless of the result) and the injection is directly into the nerve (or tissue to be destroyed), the root operation would be Destruction.
  • If the objective is to numb or temporarily shut down a nerve, the introduction code would be used (3E0 table) with a 6th character of N.
  • If the objective is to relax a muscle as in the case of muscle spasticity or overactive bladder, use the introduction code (3E0 table) with the 6th and 7th characters of GC.

2. Tracheostomy approach –

If any type of scope is mentioned the approach value should be 8 based on the definition of via natural orifice endoscopic, “Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure.” A glidescope, lanryngoscope and bronchoscope are all commonly used to visualize the site of the tracheostomy.

3. Augmentation of Labor –

If pharmaceuticals are given to augment a patient’s labor rather than induce it, it should not be coded. If internal coding policies require pharmaceutical induction of labor coded, the drug and method of administration must be considered. Induction of labor can be performed via direct insertion to the female reproductive tract (Cervidil tampon) or intravenous methods (Pitocin drip).


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