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March 27, 2018

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Medical Coding News Archives

October Coding Corner

October 11, 2016:

In the Optum360 Coding Corner, we will highlight areas that medical coding professionals are struggling for uniformity and correct coding amongst their peers. In this article, we will discuss coding variances for ICD-10-CM, ICD-10-PCS and/or CPT® found on a monthly basis and explore the codes, coding concepts and conventions for those variances. We will also highlight new coding information when applicable, to keep the coding community informed.

ICD-10-CM (both Inpatient and Outpatient settings)

Other, Other specified and Unspecified diagnosis codes

Diagnosis codes should be coded to the highest level of specificity according to the documentation. If the documentation is vague or unclear, then an unspecified diagnosis code can be reported. If the documentation is unclear and a more specified diagnosis code cannot be reported, it is not appropriate to pick an “other” or “other specified” diagnosis code. Each diagnosis code reported should reflect what is documented by the physician. If the physician documentation continues to be unclear, provider education is necessary to ensure that each and every patient encounter is documented to the highest level of specificity.


Moderate Sedation

Currently Moderate Sedation (MS) is not separately reported with 446 CPT® codes. With the 2017 CPT® update, MS can be separately reported based on the number of minutes the MS was administered. Currently MS is reported with codes 99143, 99144 and 99145 (Moderate sedation services). These CPT® codes will be deleted with the update and new CPT® codes 99151 -99153 (Moderate sedation services 15 minutes or more 5 years or younger) and 99155-99157 (Moderate sedation services 15 minutes or more 5 years or older) have been created to reflect the amount of time MS will be administered. If MS is administered for 10 minutes or less, a CPT® code for MS is not separately reported.

Incision and Drainage simple versus complex

Coding of Incision and drainage (I&D) procedures in CPT® requires specific documentation from the physician. CPT® codes 10060 (Incision and drainage of abscess; simple or single) and 10061 (Incision and drainage of abscess; complicated or multiple) are used to report I&D. If the documentation does not clearly state that I&D is complex, coders cannot make this assumption. If the medical coder is unsure if an I&D procedure qualifies as simple or complex, then query the physician for further clarification.


Root operation Perfusion

A new root operation Perfusion has been added to the Extracorporeal Therapies section with the 2017 PCS Update. Root operation Perfusion is defined as “extracorporeal treatment by diffusion of therapeutic fluid.” This root operation can be reported as of October 1, 2016.

Root operation Control

The definition of root operation Control has been changed with the 2017 PCS Update. Root operation Control is now defined as “stopping, or attempting to stop, postprocedural or other acute bleeding.” The term “other acute bleeding” has been added to the definition of Control. As before, if a more definitive root operation such as Excision or Detachment is performed to control the bleeding then that root operation is reported instead of Control.

*CPT is a Registered Trademark of the American Medical Association


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