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Medical Coding News Archives

August Coding Corner

August 17, 2016:

As we continue this journey in ICD-10, Optum360 Coding Professionals have identified areas where medical coding professionals are struggling for uniformity and correct coding amongst their peers. In the Optum360 Coding Corner, we will discuss coding variances for 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. Glaucoma Coding

When reporting codes from category H40 (Glaucoma) it is necessary that the documentation states the type and stage of the Glaucoma. This specificity of diagnosis Glaucoma was not necessary in the now retired ICD-9-CM. Specifically when coding Glaucoma categories H40.1 (Open-angle glaucoma), H40.2 (Primary angle-closure glaucoma), H40.3 (Glaucoma secondary to eye trauma), H40.4 (Glaucoma secondary to eye inflammation), H40.5 (Glaucoma secondary to other eye disorders) and H40.6 (Glaucoma secondary to drugs) it is necessary to add a 7th character to identify the stage.

2. Activity code

Multiple ICD-10-CM codes are necessary to tell a complete picture of a patient’s illness or injury. When an injury diagnosis code is reported then it is necessary to add the appropriate Activity diagnosis code (Y93) to describe the injury.


1. Perineal laceration

This topic was covered in the 4th quarter 2015 of this newsletter but this is still a subject with inconsistent coding. This information is consistent with AHA Coding Clinic 1st Quarter 2016. Review this coding clinic for more detail description of each individual repair because this is a brief synopsis. When coding a perineal laceration repair during delivery it is important that the coder understand the anatomy of each perineal degree. A first degree perineal laceration involves a tear of the perineal skin extending into the vaginal mucosa and PCS code 0HQ9XZZ should be reported. A second degree tear does not extend into the anal sphincter muscle. The injury of a second degree tear involves the vaginal wall and perineal muscle and should be reported with PCS code 0KQM0ZZ. A third degree tear extends into anal sphincter. A fourth degree laceration extends through the anal sphincter into the rectal mucosa. A third degree laceration is reported with PCS code 0DQR0ZZ and a fourth degree laceration with 0DQP0ZZ.

2. Endarterectomy with patch angioplasty

According to AHA Coding Clinic 1st Quarter 2016, when an endarterectomy is performed with a patch angioplasty two PCS codes should be reported to accurately describe the operation. Root operation Supplement should be chosen for the patch angioplasty procedure. The patch is not an integral part of the procedure and a separate PCS should be reported.

3. Root Operation Control

Root operation control is chosen when documentation reflects control of post procedural bleeding. This root operation is not reported for intra-operative bleeding. When documentation states the physician had to control post-tonsillectomy then it would be appropriate to choose root operation Control.


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