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Medical Coding News Archives

February Coding Corner

February 16, 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. Anemia –

Anemia in neoplastic disease (D63.0), chronic kidney disease (D63.1) and other chronic disease(s) (D63.8), in addition to anemia due to antineoplastic chemotherapy (D64.81) should not be reported if there is not an established link documented between the anemia and the causative factor defined in the code title. For example, a patient with both anemia and cancer should not be assumed to have anemia in neoplastic disease but rather both conditions would be reported separately. AHA Coding Clinic supports this advice in Third Quarter 2012, “…the provider needs to document the linkage, except for situations where the classification assumes an association (e.g., sickle cell anemia with acute chest syndrome, hypertension with chronic kidney involvement, etc.)…The fact that a patient has two conditions that commonly occur together does not necessarily mean they are related.”

2. Somatic dysfunction –

The Journal of the American Osteopathic Association describes somatic dysfunction as, “impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements.” Although somatic dysfunction may be documented, it must also meet the criteria for secondary diagnosis. This would usually consist of osteopathic manipulative treatments (OMT). It also cannot be attributed to being a contributing factor to a condition that can be reported elsewhere per the note under the M99 category (Biomechanical lesions, not elsewhere classified) in the ICD-10-CM tabular.

3. Difficulty breathing versus dyspnea –

Dyspnea and other respiratory abnormalities were classified with the same code (786.09) in ICD-9-CM. In that classification system, difficulty in breathing (DIB) was included in 786.09 because it is an “other respiratory abnormality”. In ICD-10-CM “dyspnea” is classified in the R06.0x category and “other abnormalities of breathing” in R06.8x. Therefore, the appropriate code assignment for difficulty breathing in ICD-10 is R06.89 as dyspnea may include DIB but is not synonymous with it.


1. Induction of labor –

Medical induction of labor may be delivered in multiple forms. It is imperative that the type and route are accurately documented to assign the appropriate ICD-10-PCS code. The two most common FDA approved methods are:

  • Pitocin – intravenous
  • Cervidil – vaginal insert

It is also important to recognize that “cervical ripening” occurs naturally and unless otherwise indicated, those terms should not be assumed to mean the patient’s labor was medically induced. Note that these codes are only reported when the medication is given for induction not augmentation of labor.

2. Cemented versus uncemented versus no qualifier –

When the documentation does not mention cement(ing) during a joint replacement it does not necessarily indicate that the replacement is “uncemented.” A cemented prosthesis is attached to the bone with epoxy cement, whereas an uncemented has mesh holes in the surface of the prosthesis allowing natural bone growth to anchor the device. If the documentation is insufficient to determine if either of these prostheses are used, the 7th character should be Z, No qualifier.

3. Epidural for anesthesia –

Do not assign a code for anesthesia in ICD-10-PCS when administered for a surgical or non-surgical procedure as it is inherent in the procedure. This includes epidurals administered for analgesia during labor and delivery.


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