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Medical Coding News Archives

March Coding Corner

March 14, 2016:

As we continue this journey in ICD-10, Optum360 coding experts have identified areas where coding professionals 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 of the puerperium –

There are two distinct codes to report anemia in the puerperium (postpartum) period, O90.81 Anemia of the puerperium and O99.03 Anemia complicating the puerperium. In order to distinguish which code should be reported, the documentation should specify whether or not the anemia existed prior to delivery. If it is pre-existing, the correct code is O90.81. If it is not, the more appropriate code is O99.03. If it is not specified, O99.03 is the default code according to the ICD-10-CM index.

2. Hypertensive heart disease –

Different than renal disease and hypertension, ICD-10-CM requires a causal or implied relationship between hypertension and heart disease in order to use the combination codes (category I11). If there is no linking documentation, such as “hypertensive” or “due to hypertension”, then individual codes for the hypertension (I10) and heart disease (I50, I51.4-I51.9) should be reported, not the combination code.

3. Human Immunodeficiency Virus (HIV) versus Acquired Immune Deficiency Syndrome (AIDS) –

Asymptotic HIV and HIV/AIDS are separate and distinct disease processes within the ICD-10-CM conventions. The only time the code for asymptomatic HIV (Z21 Asymptomatic human immunodeficiency virus [HIV] infection status) can be reported is if the patient is HIV positive and has never had an HIV-related illness. If the provider documents that the patient has had an HIV-related illness at any time in the past HIV is no longer asymptomatic and the Z21 code should be replaced by B20 Human immunodeficiency virus [HIV] disease. This is also the case if the provider interchangeably uses the terminology AIDS and HIV in the documentation.


1. Peripheral nerve blocks –

A peripheral nerve block is anesthesia that is injected near a specific nerve or bundle of nerves to block sensations of pain from the body region supplied by that nerve(s). When a nerve block is documented it should be coded as regional (3E0T3CZ Introduction of Regional Anesthetic into Peripheral Nerves and Plexi, Percutaneous Approach) rather than local (3E0T3BZ Introduction of Local Anesthetic into Peripheral Nerves and Plexi, Percutaneous Approach).

2. Laminectomy with a spinal fusion –

A laminectomy (removal of the back part of the vertebra that covers the spinal canal) is usually performed to some extent during a spinal fusion as part of the approach. In these routine instances, the excision of the bone would not be reported. However, if any of the following are documented, the laminectomy code may be reported:

  • Decompressive/Decompression laminectomy at same level, above or below, and performed for a diagnosis (claudication, myelopathy, neuropathy, etc.)
  • Gill laminectomy: This is a more extensive decompressive laminectomy that is not inherent and is always therapeutic for a specified diagnosis

3. Excision versus Resection for lymph node removal

Distinguishing whether excision (part of) or resection (all of) should be reported when addressing lymph node removal is dependent on the provider’s documentation of what was removed. The terms “sampling”, “biopsy”, “sentinel node”, and “isolated nodes” indicate an excision rather than resection. The terminology “chain of (lymph) nodes”, “radical resection”, or “modified radical” resection of the lymph nodes indicate a resection. It is important to note that when referencing either radical or modified resection of the lymph nodes, a distinction must be made as to what ‘organ’ the term is linked to: is it the main organ (i.e. radical prostatectomy, etc.) or is it linked to the lymph node removal? If a radical removal of the main organ is discussed, it does not also indicate that a resection of the lymph node was performed.


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