Coding to New Heights Education Newsletter April 2019 Edition

Peak Health Solutions - Apr 18, 2019


Welcome to our Monthly Peak Coding Education Newsletter, April 2019 Edition! This month we'll discuss:
ICD-10-CM – Complications and Manifestations of Crohn’s and Ulcerative Colitis, ICD-10-PCS – Operative Note Breakdown of Duodenal Ulcer Repair, CPT – Colonoscopy Polypectomy Techniques, Pro-Fee – DeVinci Robot, Anatomy Feature – The Intestines, CDI Corner – Acute Liver Failure and Hepatic Encephalopathy, Pharmacology Spotlight – Proton Pump Inhibitors and H2 Blockers, Code Puzzler – Small Bowel Resection

In This Issue


Funny Documentation Fail

“In a colonoscopy report: patient had retained foot"



Complications and Manifestations of Crohn’s and Ulcerative Colitis

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP
Lead Educator

Both Crohn’s and Ulcerative colitis are in the noninfectious enteritis and colitis section of ICD-10-CM, known to the medical community as inflammatory bowel disease (IBD). Both conditions hold a CC (complication/comorbid) and HCC (hierarchical condition category) status; therefore, reimbursement can be impacted. Crohn’s disease is assigned to the K50 category and is further divided by location: small intestine, large intestine, or both. Then further subdivided by complication: with rectal bleeding, with intestinal obstruction, with fistula, or with abscess. Ulcerative colitis is assigned to the K51 category and is further divided by location of infection: pancolitis, proctitis, or rectosigmoiditis. Then further subdivided by the same complications as Crohn’s.

Let’s begin by taking a closer look at Crohn’s disease. Crohn’s involves inflammation that extends through the bowel wall and appears in patches anywhere within the GI tract. The most common site of inflammation and abscess is the ilium or end of the small intestine. An abscess is a pus-filled pocket that can appear at not only the site between the small and large intestine but at sites of previous anastomoses, or behind areas of obstruction. Because Crohn’s is an inflammatory disorder scars formulate over time causing the intestinal walls to become narrowed and obstructed. This chronic state of inflammation can also lead to the formation of ulcers that can then form into fistulas. A fistula is an abnormal opening that appears between to body parts. In the case of Crohn’s, they occur between the rectum and the vagina, intestine and skin, or intestine and bladder. As if that wasn’t enough Crohn’s can manifest in other organs of the body. Known as extraintestinal complications the most common areas of concern are bones and joints, the eyes, skin, liver, bile ducts, kidney and pancreas. Both ICD-10-CM categories for Crohn’s and Ulcerative colitis have an instructional note guiding the coder to also code manifestations if identified. More on those extraintestinal complications later.

The major distinguishing difference between both conditions is that ulcerative colitis is limited to the large intestine and appears in a continuous pattern affecting the innermost lining. Looking for documentation of location such as pancolitis (entire large intestine), proctitis (rectum), or rectosigmoiditis (rectum and sigmoid) will help to assign a more specific code. As mentioned earlier the complications of ulcerative colitis are the same as Crohn’s; however, less prone to occur, according to the literature.

Both conditions create an environment of chronic inflammation allowing toxic substances to leak out into the body causing mayhem on other organs. For the bones and joints conditions such as peripheral and axial arthritis, ankylosing spondylitis and sacroiliitis are a possibility. Osteoporosis can be a concern as the patients are on long-term steroids. The eye is another area where these conditions may manifest. Causing anterior uveitis, scleritis, keratitis, and retinal vasculitis. As for the skin, disease manifestations are pyoderma gangrenosum, erythema nodosum, aphthous stomatitis, and vasculitis. Still other conditions such as primary sclerosing cholangitis, pancreatitis, and kidney stones are a possibility.

We learn as coders to “paint” the picture of a patient’s encounter with codes. Medical record documentation may simply state “history of Crohn’s” or “history of ulcerative colitis” which will make it difficult to assign a more specific code. However, these conditions are chronic and may go into periods of remission. Hopefully by reading this article coders will be better armed with the knowledge to dig deeper into the documentation to find the additional details needed to either assign a more specific code or develop a more composed query. .


Repair of perforated duodenal ulcer with onlay Graham patch

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

In this month’s newsletter I thought it would be fun to break down an operative note and apply the PCS codes together. This procedure involves repair of a duodenal ulcer with a patch graft.

Operation: Diagnostic laparoscopy converted to exploratory laparotomy and repair of perforated duodenal ulcer with Graham patch

Description of procedure: After the patient was placed under general anesthesia the lower chest and abdomen were prepped and draped in the usual sterile fashion. After insufflating the abdomen, ports were inserted in preparation of laparoscopy. Diagnostic laparoscopy was performed. A perforated duodenal ulcer and hiatal hernia were discovered. There was significant distention of the stomach, proximal duodenum, and transverse colon. There were significant inflammatory changes in the right upper quadrant, making the exposure suboptimal. A decision was made to convert the procedure to open procedure after confirming a diagnosis of an acute perforated duodenal ulcer.

  • PCS Guideline B3.2d – The intended root operation is attempted using one approach, but is converted to a different approach
  • Root Operation – Inspection – defined as visually or manually exploring a body part
  • 0WJG4ZZ Inspection of Peritoneal Cavity, Percutaneous Endoscopic Approach

Pneumoperitoneum was desufflated and all ports were removed. A midline incision was made just below the xyphoid and extended just above the umbilicus. The right upper quadrant was copiously irrigated with warm saline. Some of the fibrinous material was evacuated manually. The perforated ulcer was repaired with interrupted 2-0 Vicryl sutures and tested and found to be airtight. An omental patch was fashioned and this was used as onlay Graham patch. This was sutured to the area of repair over the first portion of the duodenum as an onlay patch. All areas were copiously irrigated. Abdomen and port sites were closed in layers. The patient was transferred to the recovery room.

  • Root Operation – Supplement – defined as putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part
  • 0DU907Z Supplement Duodenum with Autologous Tissue Substitute, Open Approach

This operative note allowed us to utilize our knowledge of PCS coding guidelines with the converted approach and our knowledge of root operation definitions. Putting aside a few minutes a week to review the root operation definitions can be helpful in becoming more proficient in PCS coding.



Colonoscopy Polypectomy Techniques

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP
Lead Educator

Polypectomy techniques are as varied as the polyp’s themselves. Choosing the correct removal technique depends on size and location. Providers must be skilled in a variety of removal methods as the decision for removal is often made during the colonoscopy procedure. As coders, we too must be skilled in knowing how to assign the appropriate CPT procedure codes for each of the techniques as well as applying coding rules and guidelines.

Coding software provides the coder with the choices of cold biopsy forceps, hot biopsy/bipolar cautery, mucosal resection, and snare technique. This article will describe the types of polyps and the technique typically utilized for their removal.

Polyps come in all shapes and sizes and are documented with a variety of descriptive words. The term diminutive means tiny-typically less than 5 mm in size. Pedunculated are raised mushroom like growths with a stalk and sessile polyps are flat.

Cold biopsy forceps are the method of choice for removal of small polyps that are 1-3 mm in size. The procedure code assigned for this is 45380 Colonoscopy flexible; with biopsy single or multiple. The cold forceps technique is assigned to the biopsy CPT code since the biopsy forceps are utilized and can completely remove a tiny polyp.

The hot biopsy forceps/bipolar cautery removal technique is used to remove slightly larger polyps than described above, typically 3-6 mm. Hot forceps use electrocautery to destroy residual polyp tissue. The polyp is pulled into the colon lumen to create a tent-like effect and electrocautery is applied at the base of the polyp. This allows the polyp tissue to be preserved inside the forceps and sent to pathology for histological examination. Electrocautery forceps are either monopolar or bipolar. Monopolar forceps create heat in the metal portion of the forceps cup by causing current to flow from the device through the patient to a grounding pad. Bipolar forceps use current that runs from one portion of the forceps device to the other which in turn heats the metal allowing for cauterization. The procedure code assigned for this technique is 45384 Colonoscopy flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps.

Snare polypectomy is the preferred technique for polyps 1 cm or larger and the snare can be either hot or cold. A snare is a self-contained metal ring that is opened over the polyp and then closed entrapping polyp tissue for resection. A picture of this can be seen above. Some phrases to be on the lookout for when snares are being described are: hot snare, monopolar snare, cold snare, or bipolar snare. The procedure code assigned for this technique is 45385 Colonoscopy flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.

Endoscopic Mucosal resection or EMR is typically used for sessile polyps that are 2 cm or larger. CPT code 45390 Colonoscopy flexible; with endoscopic mucosal resection involves three components and without clear documentation of all three this code cannot be assigned. The three components are a submucosal injection (often saline) to “lift” the polyp, demarcation of the polyp created by the injection isolating it from deeper tissue layers, and finally the snare resection of the polyp.

The colonoscopy procedure note may also describe tattooing. This is done for polyps that are suspicious for cancer. The physician injects dye into the area so it can be more easily found during surveillance colonoscopy. The procedure code assigned for this adjunct procedure is 45381 Colonoscopy flexible; with directed submucosal injection, any substance.

Since the procedure of polypectomy has proven remarkable for reducing the risk of colorectal cancer, the removal techniques will continue to evolve. Coders must continue to stay up-to-date on the latest techniques to remain skillful in this area.


E/M ProFee

DaVinci® Code

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP, Lead Educator AND Heather Saunders, CPC, CEDC, CEMC, CHCAS, CHCA, Lead Pro-Fee Auditor

The DaVinci is a robot used to assist in laparoscopic surgery. A picture of this “little” guy is above.

Robotic-assisted surgery refers to technology that allows the surgeon to operate from a console, remote from the patient and not in sterility. It should be considered a computer-aided tool and therefore integral to the primary surgical procedure. The American Medical Association (AMA) CPT Editorial Panel determined that there was no need for a new CPT code or unique modifier for surgical procedures performed using robotic assistance. Direction was given to use the CPT code that accurately describes the basic laparoscopic surgical procedure.

Use of modifier 22 (Increased procedural service) is not appropriate if the sole purpose is to report the use of robotic assistance. The additional time and effort spent setting up, docking and un-docking the robot are not reimbursable. Modifier 22 may only be used when substantial additional work is performed and specifically documented in the procedure note. That additional work could be noted as: increased intensity, time, technical difficulty of procedure, severity of patient’s condition, and physical and mental effort required unrelated to robotic assistance.

HCPCS code S2900 – Surgical techniques requiring use of robotic surgical system (listed separately in addition to code for primary procedure), was effective July 2005 and can be used by the hospital to report the use of robotic assistance. However, it is a non-reimbursable code under Medicare and may not be recognized as a separately billable and payable service by a majority of leading commercial payers.

You may be thinking then why invest in such an expensive piece of equipment if you can’t bill separately for it. If you are a facility that deals in high volumes of procedures that can be done with the DaVinci. The answer is yes, cost savings occurs due to shorter lengths of stay, quicker recovery time, and fewer complications and who wouldn’t want better outcomes for their patients.


Coding-to-New-Heights-Intestines-450X282Anatomy Feature

The Intestines

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP
Lead Educator

At nearly 250 square centimeters the intestines boast a very large surface area in our bodies. The job of the intestines is to absorb nutrients from what we eat as it winds through those 250 centimeters. Most digestion occurs in the small intestine, at only an inch in diameter and 7 meters long, the small intestines are further subdivided by regions. The duodenum is first in line from the stomach and extends roughly 26 cm. receiving the food we eat and breaking it down into its most basic units. Next up is the jejunum extending roughly 2.5 meters is where the bulk of absorption takes place. Finally, the ileum, the longest portion of the small intestine at roughly 3.5 meters is where the last of the nutrients are absorbed before being handed off to the large intestine.

The large intestine is where the final stages of digestion take place absorbing water and vitamins. The vitamins absorbed here are ones created by the fermentation process between the final waste products and residing bacteria. The length of the large intestine is roughly 1.5 meters. Often colonoscopy procedure notes will describe components of the procedure by location in centimeters from anus to cecum. I thought it might be helpful to provide those measurements. From anus to rectum the measurement is 0-4 cm, from rectum to rectosigmoid it’s 4-16 cm, from rectosigmoid to sigmoid it’s 15-17 cm, from sigmoid to descending colon it’s 17-57 cm, from descending to transverse colon it’s 57-82 cm, from transverse colon to ascending colon it’s 82-132 cm, from ascending to cecum it’s 132-147 cm, and finally the cecum resides at the 150 cm mark.

I don’t know about you, but I personally continue to be amazed by the human body. Just knowing that what I eat passes through nearly 28 feet of intestinal surface area is leaving me to question my food choices.  

Coding-to-New-Heights-Liver-Failure-350X350-BCDI Corner

Acute Liver Failure and Hepatic Encephalopathy

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

The code category for liver failure in ICD-10-CM is an interesting one. Much direction is given in the form of includes notes, excludes 1 and 2 notes, code first direction, and use additional code. First, we must look at the types of liver failure. The classification system identifies acute or subacute, chronic, or due to drugs. Second, we must determine if coma is present. This article will begin with some background on causes of liver failure and then discuss other terms used to document coma.

According to Marino’s The ICU Book fourth edition there are two types of liver failure, acute liver failure and acute on chronic liver failure. The ICU book states that most causes of acute liver failure in patients without chronic disease is viral hepatitis or drug-induced injury such as acetaminophen overdose. Most common causes of liver failure in patients with chronic liver disease usually come from an infection or a variceal hemorrhage.

Chronic kidney disease is caused by hepatitis B or C, fatty liver disease, autoimmune liver disease, metabolic or inherited liver disease, or alcohol induced. Alcohol induced liver damage can be further defined to specify alcoholic fatty liver, alcoholic hepatitis, and alcoholic cirrhosis. Each of these conditions could result in acute on chronic liver failure as mentioned in The ICU Book. For the coder or CDI specialist most acute liver failure codes are in the K72 code category unless caused by drug toxicity then the category is K71. These codes carry an MCC (Major Complication/Comorbid Condition) and HCC (Hierarchical Condition Category) status; therefore, impacting MS-DRG and/or APR-DRG assignment.

Once the type of liver failure is identified it must be determined if coma is also present as this is an additional characteristic found in this code category. Hepatic encephalopathy is listed in the includes notes under the code category. Other terms for hepatic encephalopathy are hepatic stupor, hepatic coma, porto-systemic encephalopathy, hepato-cerebral encephalopathy. Of course, we shouldn’t jump to the conclusion that hepatic encephalopathy is the same as coma. If the documentation is conflicting and imprecise, we should query the physician. In my research for this article I stumbled across criteria developed by West Haven for grading hepatic encephalopathy and included it here.

West Haven Criteria for Semi-quantitative Grading of Mental Status
Grade 1 Trivial lack of awareness
Euphoria or anxiety
Shortened attention span
Impaired performance of addition
Grade 2 Lethargy or apathy
Minimal disorientation for time or place
Subtle personality change
Inappropriate behavior
Impaired performance of subtraction
Grade 3 Somnolence to semi-stupor, but responsive to verbal stimuli
Gross disorientation
Grade 4 Coma (unresponsive to verbal or noxious stimuli)

The CDI Corner articles are meant to provide background and terms related to diseases and conditions. Hopefully, this helps to find clues within clinical documentation leading to more precise coding. Or at the very least offer assistance in providing clinical indicators needed for query generation.



Pharmacology Spotlight

Proton Pump Inhibitors and H2 Receptor Blockers

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

If you are one of the one in five Americans who suffer from GERD (gastroesophageal reflux disease) you are most likely familiar with PPI’s and/or H2 Receptor Blockers. Proton Pump Inhibitors (PPI for short) are drugs such as Nexium®, Prilosec®, Prevacid®, Aciphex®, Protonix®. They bind with cells in the stomach that produce hydrochloric acid essentially shutting down production for up to 24 hours a day. H2 Receptor Blockers are drugs such as Zantac®, Pepcid AC®, and Tagamet®. These medications block the signal that triggers hydrochloric acid production and work up to 12 hours a day.

Hydrochloric acid is responsible for breaking down proteins in the stomach and has a Ph of 2 meaning its strong enough to dissolve metal! Luckily, this acid is ultimately neutralized by chemicals in the small intestine. These medications are prescribed for people who suffer from GERD, gastritis, stomach ulcers, peptic ulcers, or erosive esophagitis. The side effects of taking these drugs in the short term are mild but long-term use can lead to more serious issues. These more serious issues are still being investigated. I suppose this can be said with most medications taken over a long period of time.


The Code PuzzlerCoding-to-New-Heights-Code-puzzler-350X350-B

This month’s puzzler comes from Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP
Lead Educator

Here’s the scenario – as it appeared in the record. Good Luck!

On admission:

A 50-year-old male presented to the emergency room with severe LUQ abdominal pain and diarrhea. He has been treated for Crohn’s disease of the small intestine since the age of 19 and maintained on long term steroid treatment. His x-ray showed small bowel obstruction and abscess at the terminal ileum. He was admitted with Crohn’s flare and small bowel obstruction and taken to surgery for resection of bowel obstruction.

Once patient was prepped for surgery and general anesthesia administered the surgeon made an abdominal incision. The surgeon resected a segment of jejunum and performed an anastomosis between the remaining bowel ends. The surgeon then identified a second section of small bowel. The selected segment of small bowel was isolated and divided proximally and distally; a partial excision of the terminal ileum was performed to release the obstruction. The remaining intestinal ends were reapproximated using staples. The incision was closed. The patient was transferred to the recovery room in stable condition.

Assign the ICD-10-CM diagnosis and ICD-10-PCS and CPT procedure codes for this case.

ANSWER:  Highlight the text below to see if you were correct!
K50.014 Crohn’s disease of small intestine with abscess
K50.012 Crohn’s disease of small intestine with intestinal obstruction
Z79.52 Long-term (current) use of systemic steroids
0DBB0ZZ Excision of ileum, open approach
0DBA0ZZ Excision of jejunum, open approach
44120 Enterectomy, resection of small intestine; single resection and anastomosis
44121 Enterectomy, resection of small intestine; each additional resection and anastomosis

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