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Coding to New Heights Education Newsletter August 2019 Edition

Peak Health Solutions - Aug 15, 2019


Welcome to our Monthly Coding Education Newsletter, July 2019 Edition! This month we'll discuss: ICD-10-CM – Types of Gout, ICD-10-PCS – Coding Guidelines for the Musculoskeletal System, CPT – Stepping Up – Bunion Repair Procedures,  Pro-Fee – Radiostereometric Analysis, Anatomy Feature – Layers of Bone, CDI Corner – Clinical Documentation, Improvement and Social Determinants of Health, Pharmacology Spotlight – DMARDs

In This Issue


Funny Documentation Fail

“Olecranon was dictated and transcribed as 'ole crayon'"



Types of Gout

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP
MRC Content Manager for HIM Inpatient

Gout can be acute or chronic and is a form of arthritis marked by flare-ups inducing intense pain, redness, and swelling in the joint. Most often the big toe is affected but other joints such as elbows, knees, hands, or ankles can be involved. If you review the code categories in ICD-10-CM you will see identical categories for coding chronic and unspecified/acute. Category M1A is titled Chronic Gout and category M10 is titled Gout. I can only assume that the need for two code categories is because the treatment is different. Acute attacks are treated with ice packs and NSAIDs or corticosteroids. Chronic gout is treated with medications such as allopurinol (Zyloprim®, Aloprim®), febuxostat (Uloric®), and probenecid.

Let’s begin by looking at what constitutes acute and chronic. Acute gout affects a limited number of joints and symptoms last a few days or a week with no lasting symptoms. Acute gout flare-ups can lead to chronic gout if those flare-ups occur more than 2 times per year. Chronic gout affects several joints resulting in repeated flare-ups over time and lasting symptoms with permanent joint damage resulting in stiffness and deformity. Acute gout is caused by the accumulation of urate crystals in the joints. Chronic gout induces bumps under the skin, called nodules or tophi. These nodules are made up of urate crystals forming under the skin and in the joints and are painless unless they break and become infected.

The aforementioned code categories are further divided by cause such as idiopathic, lead-induced, drug-induced and gout with kidney disease. Idiopathic gout is diagnosed when the cause is unknown. The term idiopathic means relating to or denoting any disease or condition which arises spontaneously or for which the cause is unknown. Low levels of lead in the blood have been linked to gout. Studies show that levels greater than 80 mcg/dL or 8 times the acceptable level are associated with hyperuricemia, the precursor for gout. Substances such as alcohol and medications such as salicylates, pyrazinamide, ethambutol, nicotinic acid, cyclosporin, 2-ethylamino-1,3,4-thiadiazole, fructose and cytotoxic agents interfere with the kidneys ability to excrete urate or increase the production of uric acid leading to drug-induced gout. The build up of uric acid can cause crystals to form in a joint. Chronic kidney disease can lead to gout, and gout may lead to chronic kidney disease. These two diseases are interrelated since uric acid is filtered through the kidneys. Urate crystals deposit in the kidneys or along the urinary tract forming kidney stones, chronic uric acid interstitial nephropathy, and kidney failure.

As with all code categories there are other and unspecified codes. Be sure to read all documentation carefully when gout is a diagnosis mentioned in a patient’s health record.




Coding Guidelines for the Musculoskeletal System

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
MRC Content Manager for HIM Inpatient

The ICD-10-PCS guidelines can be found on the CMS website and can be downloaded with the link below this article. This article discusses those guidelines that have a specific impact on the musculoskeletal system.

Guideline B3.5 refers to overlapping layers stating to code to the body part identifying the deepest layer. For the musculoskeletal system this means if debridement is done down to and including the muscle the procedure is coded to the muscle body part.

Guideline B3.10a-c provides special instructions for spinal fusion procedures. The body part value for vertebral joints rendered immobile is classified by the level of spine, i.e. thoracic, lumbar, etc. and then by single joint or multiple joints. If multiple vertebral joints are fused separate codes are assigned for each vertebral joint that uses a different device or qualifier. The device value for combinations of devices and materials used on the same vertebral joint are treated in a special way. An interbody fusion device alone or containing bone graft material is assigned to Interbody fusion device value. If only bone graft is used for fusion assign the device value for nonautologous tissue substitute OR autologous tissue substitute. For a mixture of autologous and nonautologous bone graft assign the device value for autologous tissue substitute.

Guideline B3.15 provides instruction on fracture treatment. When a displaced fracture is reduced the root operation is Reposition. If a cast or splint is placed at the same time it is not coded separately. Treatment of nondisplaced fracture is coded to the procedure performed, for example, placing a pin in the nondisplaced fracture site is coded to the root operation Insertion.

Guideline B4.3 refers to bilateral body part values and guides the coder to assign a separate procedure code for each side (right or left) unless a value exists for bilateral. Keep in mind the identical procedure must be performed on contralateral body parts.

Guideline B4.5 directs the coder to choose the appropriate body system that is the focus of the procedure when procedures involve tendons, ligaments, bursae and fascia that support a joint. For example, if a procedure is performed on the cruciate ligament in the knee the body system value would be bursae and ligaments. If, however the procedure is performed on the joint structure then the joint body system would be chosen.

Guideline B4.6 give specific body part guidance when procedures are performed on the skin, subcutaneous tissue or fascia overlying a joint. The shoulder area is coded to upper arm, the elbow and wrist areas are coded to the lower arm value, the hip area is coded to upper leg, the knee area is coded to lower leg, the ankle area is coded to the foot body part value.

Guideline B4.7 states if there isn’t a specific body part value for fingers code to the body part value for hand, if there isn’t a specific body part value for toes code to the body part value for foot.

Guideline B5.3b gives the example of closed fracture reduction and the approach value is external because the procedure is performed indirectly by the application of external force.

Guideline B6.1a is related to devices. A device value is chosen only for devices left in place after the procedure. If the device was meant to remain after surgery but for some reason had to be removed before the end of the procedure then both insertion and removal of the device must be coded. In a limited number of root operations there are qualifiers for temporary and intraoperative devices. These options are available for specific procedures on special devices that are used for a brief duration during the procedure.

Guideline B61c instructs the coder to choose root operations Change, Irrigation, Removal, and Revision for procedure performed on the device only.

Staying up-to-date on these PCS guidelines for the musculoskeletal system will ensure appropriate correct coding of procedures performed on joints and bones.



Stepping Up – Bunion Repair Procedures

Submitted by Peggy Hapner, RHIA, CCS, CASCC

For years I have heard from coding professionals that they hate assigning the CPT procedure codes for procedures on the foot – especially bunion repair procedures. In this article I hope to provide information that will aid everyone in the coding of bunion repairs and associated procedures.
Bunions, also known as hallux valgus, is a painful bony eminence that protrudes out from the big toe joint. Often caused by wearing shoes that are too tight or with high heels or by hereditary issues such as bone or joint disease (arthritis) or a flat foot. A bunion forms when the bones that make up the metatarsal phalangeal joint move out of alignment causing the bones to shift that produces the bump.

The most common repair for bunions is the bunionectomy – where the bunion is removed and the bones are placed back in alignment as much as possible. Internal fixation such as a wire or pins may need to be placed to aid in returning the bones back to proper alignment. In the past many of the bunionectomy procedures were identified by eponyms such as Keller, McBride, Mayo, Silver, however in 2017 the AMA removed these legacy names from the code descriptions.
All the bunionectomy procedures include the sesamoidectomy when it is performed. Use modifiers LT and RT to report the appropriate anatomical location. Although rarely performed use the bilateral modifier -50 if the procedure is performed on both feet.

There are a couple of dozen ways to repair bunions in this article we are going to take a look at some of the more common procedures to repair bunions.

Osteotomy – in the bunion procedures when a metatarsal osteotomy is performed it is typically a bone that it cut in a wedge or V-shaped to allow for realignment of the metatarsal. A double step cut osteotomy (both proximal and distal osteotomies) is performed through the neck of the first metatarsal. Proximal phalanx osteotomy is another form of bunion repair in which an osteotomy is performed on the proximal phalanx to realign the toe. Often times bone screws are placed to hold the toe in alignment. The last osteotomy that is described in the CPT code descriptions for bunion repair is the double osteotomy. In this procedure the physician may perform one of three options: proximal phalanx osteotomy with a distal metatarsal osteotomy; proximal phalanx osteotomy with proximal metatarsal osteotomy or a double metatarsal osteotomy. The coder is looking for the documentation of an osteotomy being performed to assign any of the osteotomy codes.

Arthrodesis – in this procedure the physician removes the bunion and then performs a fusion of the first metatarsal and the first cuneiform joint. Often time screws or pins are inserted again to hold the alignment of the bones in the proper anatomical orientation.

Resection of proximal phalanx base – the physician will remove the bunion in addition to removing the base of the proximal phalanx. This allows for better alignment of the big toe and is often held in place by a Kirschner wire.

Another bunion that might be identified in the documentation is not in the CPT code range for the 1st metatarsal bunions (28292-28299) as it is a bunion or bunionette of the fifth metatarsal head. This procedure was known in the past as a Tailor’s bunionectomy but is now referred to as an ostectomy of the fifth metatarsal head (bunionette). It is coded to 28110 in the CPT coding manual.

In addition to these procedures that we have discussed above the physician may perform some repair of tissue, ligaments or tendons around the big toe. It is important for the coder to follow any coding edits that may present themselves when adding these additional procedures. Follow the NCCI edits and the definition of modifier 59 in the CPT code book. It may not always be appropriate to append modifier 59.

And as always when in doubt of the documentation reach out to the orthopedic physician to clarify any questions prior to coding the bunion repair procedure.


Radiostereometric-400E/M ProFee

Radiostereometric Analysis

Submitted by: Dee Mandley, RHIT, CCS, CCS-P, CDIP
MRC Content Manager for HIM Inpatient

Category III codes in the CPT Manual are identified by 4 numeric characters and a letter “T” at the end. These codes identify emerging technologies, services, and procedures and should be reported instead of an unlisted category I code. Category III codes exist so that specific data can be gathered; however, most are considered experimental, investigational, and non-covered. Coders should keep in mind it is always important to code a procedure, test or service based on the documentation in the medical record, even if it’s a Category III code and may not be covered.

Radiostereometric analysis (RSA) is helping surgeons to predict how long a joint implant will last by taking two x-rays from different directions at the same time, creating a “stereo” image. This x-ray allows surgeons to measure precisely how the body and the implant are interacting. While this is great for the patient it is also providing research information to improve implant design and technology for future patients. This information demonstrates precisely how much position change has occurred since implantation of the prosthesis.

The codes for this technology are listed below and specific to joint areas.

  • Codes 038T Radiologic examination, radiostereometric analysis (RSA); spine, (includes cervical, thoracic, and lumbosacral, when performed)
  • 0349T Radiologic examination, radiostereometric analysis (RSA); upper extremity(ies), (includes shoulder, elbow, wrist, when performed)
  • 0350T Radiologic examination, radiostereometric analysis (RSA); lower extremity(ies), (includes hip, proximal femur, knee, ankle, when performed)

Often Category III codes become Category I codes so it is important to become familiar with emerging technologies.



Anatomy Feature

The Layers of Bone

MRC Content Manager for HIM Inpatient

There are 206 bones in the adult human body and each bone is made up of four basic layers.

The first layer is the periosteum a thin outer hard membrane containing blood vessels, nerves, and lymphatic vessels. The periosteum is where tendons and ligaments attach to the bones.

The second layer known as cortical or compact bone, is a hard tissue that provides support, protection, and movement for the body. Compact bone is responsible for storing and releasing calcium. Calcium enables blood to clot, muscles to contract, and heart to beat.

The third layer is the cancellous bone also referred to as trabecular. The trabecular layer is spongy bone located at the ends of long bones, the ribs, vertebra, and skull. This is where red bone marrow is housed.

The fourth layer of bone, known as marrow, comes in two varieties – red and yellow. Red bone marrow also known as myeloid tissue found in the trabecular is responsible for the production of red blood cells, platelets, and most white blood cells. Interesting fact – red blood cells are created at a rate of 2 million per second! Yellow bone marrow produces some white blood cells and is made up of mostly fat cells. When we are born all marrow is red and as we get older the red converts to yellow. In cases of severe blood loss, the body can convert the yellow marrow back to red to increase red blood cell production.

Once we reach adulthood our bones completely regenerate at a rate of every ten years through a process called remodeling. Keeping our bones healthy with minerals such as calcium, zinc, and magnesium and vitamins such as D, K, and A allows the best environment for remodeling to occur..


CDI Corner

Clinical Documentation Improvement and Social Determinants of Health

Submitted by: Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP, CCDS-O
CDI Education & Compliance Manager, MedPartners

The Clinical Documentation Improvement (CDI) profession continues to evolve as its importance strengthens. The significant role CDI plays in healthcare has become apparent with the transition from the inpatient to the outpatient environment and from a financial to a quality focus. As the healthcare focus now shifts to population health, the CDI professional should be prepared to include a focus on the Social Determinants of Health (SDOH) to their role.

SDOH are socioeconomic factors that have been shown to be fundamental to the wellbeing of a population and are key determinants in population health. The Centers for Disease Control and Prevention (CDC) describes social determinants of health as “conditions in the places where people live, learn, work, and play (that) affect a wide range of health risks and outcomes.”

When one reviews the Official Guidelines for Coding and Reporting (OGCR) categories Z55-Z65 that describe social determinants of health, topics are seen in:

  • problems related to education and literacy
  • problems related to employment and unemployment
  • problems related to housing and economic circumstances
  • problems related to social environment
  • problems related to upbringing, primary support group and family circumstances
  • problems related to psychosocial circumstances

The importance of addressing social determinants of health is highlighted in Healthy People 2020, where one of the four overarching goals is to “create social and physical environments that promote good health for all” (CDC 2019).

As Population Health and SDOH become a community focus in healthcare, it is imperative that CDI views and speaks of the patient as a whole person, not simply a DRG (Diagnosis Related Group) or RAF (Risk Adjustment Factor). With the continuum of care prominent in healthcare, the setting (hospital, office or home, for example) is transitioning to a secondary focus when physical, mental and social health of the person is considered.

Social determinants of health will assist in pinpointing the areas of greatest need for a population and can help move the individual from “doing the best they can with what they have” to the next level. As we begin to view the patient as a whole person outside of the typical healthcare setting, the verbiage “patient” becomes limiting, with the verbiage “person” or “individual” preferred over the term “patient”.

The role that CDI plays in the social determinants of health is that of a gatekeeper, but its importance in this role is vital to the individual and the future of population health. With congruence among case management, social work, and nursing, collaboration on an SDOH initiative benefits who we serve – the person. Providing educational sessions by collaboration with the aforementioned departments along with healthcare providers will ensure the appropriate questions are included on a template. This is an essential step in the process. It may also be necessary for the CDI professional to go one step further and work with Health Information Management (HIM) and IT support to ensure the various documents are available at discharge so the appropriate SDOH codes can be assigned based on documentation from those departments.

Our view on the medical record must be widened when it pertains to social determinants of health because this documentation is most likely not found in provider documentation. According to Coding Clinic® 1Q 2018 p. 18, Coding of social determinants of health using non physician documentation, these codes describe social factors, not medical factors, and therefore, can be assigned using non-provider documentation from care clinicians. This makes sense because nursing spends the majority of the time with the patient, and case management/social work is focused on these social factors by their scope of work.

Providing education and assistance with the identification and appropriate ICD-10-CM code assignment of the social determinants of health will help complete the puzzle on health status along with providing statistical data on the effects of SDOH on illness. The data that is collected by this team initiative is valuable to research organizations such as the CDC, as it continues to explore the effects of SDOH on disease and illness in its quest to improve outcomes.

Social determinants of health are important indicators of an individual’s health status because they have been shown to be influencers in disease and illness. The predominant goal of CDI is to assist in ensuring the documentation in the entire medical record completely and precisely portrays the person’s health status. It is crucial that we begin to look at the person as a whole by considering socioeconomic factors in addition to medical factors. The role of the CDI professional as gatekeeper of the medical record will continue to serve the individual as a whole being, with the promise of a complete, precise depiction of their health status, now and in the future..



Pharmacology Spotlight


Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
MRC Content Manager for HIM Inpatient

DMARDs is short for disease-modifying antirheumatic drugs. These drugs are used to treat rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, juvenile idiopathic arthritis or lupus by decreasing inflammation and slowing the progression of disease. These drugs slow or stop the immune system from attacking the joints helping patients achieve remission. They are not pain relievers but over time pain decreases due to the decrease in inflammation and joint damage.

Available in traditional and targeted options DMARDs either restrict the immune system on a broad basis or block targeted pathways inside the immune cells. The most commonly used DMARDs are methotrexate with the brand name of Trexall®, hydroxychloroquine with the brand name of Plaquenil®, sulfasalazine with the brand name of Azulfidine® and leflunomide with the brand name of Arava).

Often coders must code chronic conditions and have to determine if the patient is undergoing active treatment. By knowing a few of the medications used to treat the chronic conditions listed in this article the coder will have an easier time determining active treatment.

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