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Medical Coding News Archives

January Coding Corner

January 18, 2017:

In the Optum360 Coding Corner, we highlight areas in which 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)

Aftercare versus follow-up diagnosis codes

It is important that coders understand the differences when assigning an aftercare or a follow up diagnosis to an encounter. An aftercare diagnosis is coded when the initial treatment has been completed and the patient is being seen during the recovery phase of the condition. An aftercare diagnosis should not be coded with an injury diagnosis code. If a patient is being seen for aftercare of an injury, the injury diagnosis code should be used with the appropriate 7th character. A follow-up diagnosis is coded when treatment for the condition has been completed. To accurately reflect the patient encounter, a follow-up diagnosis may be used in conjunction with a history of diagnosis code.


When a patient has a bilateral condition and each side will be treated in separate encounters, the bilateral diagnosis code should be coded for the first encounter. If the condition on the first-treated side has resolved, the unilateral diagnosis should be coded on the subsequent encounter. A bilateral diagnosis could be coded on the subsequent encounter if the condition did not resolve on the first side after treatment.

BMI, ulcers and NIH stroke scale (NIHSS)

Body mass index (BMI), depth of non-pressure ulcers and stroke scale are often times not documented by the physician. According to ICD-10 guidelines, the BMI percentage, ulcer stage and NIHSS can be coded from documentation by a clinician other than a physician. The NIHSS has been added to the guideline as being acceptable to code from non-physician documentation as of October 1, 2016.

ICD-10-PCS Guidelines

Multiple procedures guideline B3.2

An update to the PCS guideline B3.2 has been added when a lesion is excised from the colon. If a lesion is excised from the ascending colon, and a separate lesion is excised from the transverse colon, two PCS codes will be assigned for the encounter. Each excised lesion should be coded separately.

CPT is a registered trademark of the American Medical Association.


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