Coding to New Heights Education Newsletter May 2019 Edition

Peak Health Solutions - May 10, 2019


Welcome to our Monthly Peak Coding Education Newsletter, May 2019 Edition! This month we'll discuss: ICD-10-CM – Coding Underlying Conditions of Dementia – ICD-10-PCS – Mental Health Treatment – CPT – Venous Access Devices – Pro-Fee – Use of Z-Codes for Use, Abuse, Dependence – Anatomy Feature – Arteries of the Brain and Strokes – CDI Corner – Encephalopathy – Pharmacology Spotlight – Medications for Bipolar Disorder – Code Puzzler

In This Issue


Funny Documentation Fail

“The patient has been depressed ever since she began seeing me in 1983"



Coding Underlying Conditions of Dementia

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

Dementia, also referred to as neurocognitive disorder, is most times a manifestation of other conditions. In ICD-10-CM these “other conditions” have an instructional note leading the coder to follow the multiple coding rule. This is when the classification system instructs the coder to “use additional code”. When we see this instructional note we know that both the manifestation (Dementia) and the underlying condition (Alzheimer’s) must be reported. Alzheimer’s is just an example used here, however there are many other conditions for which dementia is a manifestation. Category F02 Dementia in other conditions classified elsewhere lists causal conditions that span five different chapters in ICD-10-CM. I am sure this is not an exhaustive list by any means but I thought it would be interesting to take a closer look at each of these groupings. By becoming familiar with each briefly may help a coder stop and query the physician for a causal relationship if both are documented within the medical record.

In Chapter 1: Certain infectious and parasitic diseases we find the rare condition caused by misfolded forms of prion proteins known as Creutzfeldt-Jakob disease. This condition affects different mammals including humans and is known as mad cow disease in cows. These folded prions can spread asymptomatically throughout a person’s brain for years before causing any problems. Once the symptoms begin it’s a very quick decline with the loss of memory and reasoning. These conditions are reported with the A81 category titled atypical virus infections of the central nervous system. Also, in chapter 1 we find neurosyphilis, an infection in the brain and spinal cord that develops 10 to 20 years after the initial syphilis infection. Dementia due to neurosyphilis is coded A52.17 General Paresis. Dementia can be caused by AIDS and may be documented as AIDS dementia complex. Cognitive symptoms are subtle at first and gradually become more severe leading to a vegetative state. Human immunodeficiency virus [HIV] disease is coded B20 and carries strict sequencing guidelines. Lastly, we find dementia due to trypanosomiasis an infection transmitted by an insect. Code category B56 is used to report African trypanosomiasis also known as sleeping sickness comes from the bite of an infected tsetse fly found only in Africa. Code category B57 is used to report American trypanosomiasis also known as Chagas’ disease that comes from a parasite carried on the Triatomine bug also known as a kissing bug. These insects are found in South and Central America as well as Mexico.

In chapter 4: Endocrine, Nutritional and metabolic disease there are six conditions that can cause dementia. Acquired hypothyroidism coded to the E00-E03 categories can cause dementia as the thyroid hormone has major impacts on cognitive performance in the elderly. Not very common in the U.S., vitamin B deficiencies especially B3 (Niacin) can ultimately lead to cognitive disorders such as dementia. This deficiency could be documented as pellagra and is coded to the E52 category and other vitamin B deficiencies are assigned to the E53 category. Cerebral lipidosis assigned code E75.4 and hepatolenticular degeneration (Wilson’s disease) assigned code E83.0 are genetic disorders. In cerebral lipidosis the person lacks the necessary enzymes to break down lipids allowing them to build up in the cells and tissues especially the brain. In Wilson’s disease the body is not able to eliminate copper properly and instead it builds up in the liver and brain. Finally, hypercalcemia coded E83.52 is a high concentration of calcium in the blood that over time could lead to neurological symptoms such as dementia.

In chapter 6: Diseases of the nervous system we find the more well-known causes of dementia. The most common cause being Alzheimer’s a progressive disease process that affects the brain. Over time patient’s lose their ability to function independently and suffer complications of dehydration, malnutrition, and infection. Codes for Alzheimer’s can be found in the G30 category. Second seat to Alzheimer’s is Lewy Body Dementia also a progressive loss in mental abilities. Lewy bodies are protein deposits that develop in nerve cells in the areas of the brain that control thinking, memory, and movement. Since the area of movement is impacted the patient will show parkinsonism traits such as tremors, slow movement, and rigid muscles. For this reason, code G31.83 also identifies Dementia with Parkinsonism. This is an important distinction as parkinsonism and Parkinson’s are different. Parkinson’s begins with motor symptoms such as tremors and develop dementia symptoms 10 to 15 years later. Parkinson’s is assigned code G20. Huntington’s disease assigned code G10 is a rare genetic disorder leading to a severe decline in thinking and reasoning. A hallmark symptom of Huntington’s disease is uncontrolled movement in the arms, legs, head, face, and upper body. Dementia associated with this disease can occur at any time. Epilepsy and recurrent seizures in older patients have a bidirectional relationship. Patients with epilepsy carry a higher risk of developing dementia and patients with dementia carry a higher risk of developing epilepsy. Epilepsy codes are assigned the G40 category. Frontotemporal dementia coded G31.09 is characterized by atrophy of the frontal and temporal lobes of the brain. These areas of the brain are responsible for personality, behavior and language and when atrophy occurs dramatic changes in behavior occurs. Multiple sclerosis (MS) coded to G35 and Pick’s disease coded to G31.01 round out our diagnoses in chapter 6. Dementia in MS is not as severe as seen in other diagnosis but can occur in varying degrees over time. Typically impacting memory, concentration, problem solving, and mood. Pick’s disease is a rare age-related disease that affects the frontal lobe of brain and therefore speech. Stuttering, hesitative speech and difficulty articulating result.

In chapter 13: Diseases of the musculoskeletal system and connective tissue has two conditions linked to dementia. Polyarteritis nodosa, assigned code M30.0, is a rare disorder identified as inflammation in the walls of medium sized arteries. Arteries in the brain can be impacted 2-3 years after the onset of the disease. Systemic lupus erythematosus (SLE) assigned to category M32 is a common autoimmune disorder with 16,000 new cases diagnosed every year. SLE causes systemic inflammation that affects multiple organs with the kidneys and brain being the most serious. Patients with SLE also carry an increased risk of developing dementia.

And finally, in chapter 19: Injury, poisoning and certain other consequences of external causes there are two injuries that can cause dementia. Traumatic brain injury assigned to the S06 category and intoxications assigned to categories T36 through T65. Dementia linked with an old head injury would require the 7th character for sequela. Dementia from a head injury doesn’t get worse overtime, rather it will improve at a gradual pace over months to years. History of poisonings and intoxication especially alcohol carry an increased risk of developing dementia.

In conclusion, it’s important to remember that the provider must provide linking verbiage for dementia associated with any of these conditions. Hopefully, having read these brief descriptions of various disorders responsible for dementia will assist the coder in developing better queries and have a better understanding of possible connections these conditions have to dementia.


Mental Health Treatment

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

Most coders understand the PCS tables associated with the surgical section since this is obviously the section most used in traditional hospital coding; however, there are other sections in PCS that bear reviewing. Since this month’s newsletter is all about mental illness there are two sections in PCS that address treatments for mental health and substance abuse.

The Mental Health Treatment codes can be found in the GZ1-GZJ PCS tables. Here you can find 12 different modalities used to treat mental illness. Most PCS tables in this section do not have many qualifiers to choose from, however there are 3 tables that do and we will be digging deeper into these options. As for the tables with little to no qualifier options we will at least look at the PCS definition of the modality itself. These are described below:

Crisis intervention is defined in PCS as treatment of a traumatized acutely disturbed or distressed individual for the purpose of short-term stabilization.

Medication management is monitoring and adjusting the use of medications for the treatment of a mental disorder.

Counseling is the application of psychological methods to treat an individual with normal developmental issues and psychological problems in order to increase function, improve well-being, alleviate distress, maladjustment or resolve crises.

Family Psychotherapy is treatment that includes one or more family members of an individual with a mental health disorder by behavioral, cognitive, psychoanalytic, psychodynamic or psychophysiological means to improve functional well-being.

Biofeedback is provision of information from the monitoring and regulating of physiological processes in conjunction with cognitive-behavioral techniques to improve patient functioning or well-being.

Hypnosis is the induction of a state of heightened suggestibility by auditory, visual and tactile techniques to elicit an emotional or behavioral response.

Narcosynthesis is the administration of intravenous barbiturates in order to release suppressed or repressed thoughts.

Group psychotherapy is the treatment of two or more individuals with a mental health disorder by behavioral, cognitive, psychoanalysis, psychodynamic, or psychophysiological means to improve functioning or well-being.

Light therapy is the application of specialized light treatments to improve functioning or well-being.

G Mental Health
Z None
1 Psychological Tests

Character 4
Character 5
Character 6
Character 7
0 Developmental
1 Personality and Behavioral
2 Intellectual and Psychoeducational
3 Neuropsychological
4 Neurobehavioral and Cognitive Status
Z None  Z None   Z None  

As mentioned earlier there are three tables that have several qualifier options and we will now take a closer look at those. First up are psychological tests that are defined in PCS as the administration and interpretation of standardized psychological tests and measurement instruments for the assessment of psychological function. Psychological testing involves the use of standardized tests also called “norm-referenced” so that test takers are evaluated in a similar way. Look to psychological consults, progress notes, and treatment sheets in the patient's record to determine what type of testing was done. As you can see from the PCS table illustrated below there are 5 different qualifiers or options.

G Mental Health
Z None
5 Individual 

Character 4
Character 5
Character 6
Character 7
0 Interactive
1 Behavioral
2 Cognitive
3 Interpersonal
4 Psychoanalysis
5 Psychodynamic
6 Supportive
8 Cognitive-Behavioral
9 Psychophysiological
Z None  Z None  

Z None

Individual psychotherapy is defined in PCS as treatment of an individual with a mental health disorder by behavioral, cognitive, psychoanalytic, psychodynamic, or psychophysiological means to improve functioning or well-being. Let’s take a moment to look at each type of psychotherapy. Interactive simply means the patient must take some type of action or provide input. Behavioral therapy involves teaching how to substitute more desirable responses to undesirable behavior patterns. Cognitive therapy is oriented towards problem solving by focusing on present thinking and not past experiences. Interpersonal therapy is used to treat depression and focuses on the patient’s interpersonal relationships. Psychoanalysis involves analysis between the conscious and unconscious mind by bringing repressed fears and conflicts forward. Psychodynamic therapy also known as insight-oriented therapy focuses on mental and emotional forces and their impact on present behavior. Supportive therapy is allowing the patient to express emotions and offer encouragement. Cognitive-Behavioral therapy helps patients to seek out things to do to make them feel a sense of accomplishment and connection. Psychophysiological therapy involves understanding the interactions between the mind and the body.

G Mental Health
Z None
B Electroconvulsive Therapy

Character 4
Character 5
Character 6
Character 7
0 Unilateral-Single Seizure
1 Unilateral-Multiple Seizure
2 Bilateral-Single Seizure
3 Bilateral-Multiple Seizure
4 Other Electroconvulsive Therapy
Z None  Z None   Z None 

Electroconvulsive therapy (ECT) is a medical treatment for patients who are unresponsive to other treatments for major depression and bipolar disorders.  The patient is anesthetized with a combination of barbiturate and muscle relaxant. Electrodes are placed on the patient's temples and/or forehead.  A measured electrical dose is applied for about a second to induce a convulsion, typically lasting 30 seconds to a minute. Convulsive activity is monitored with EEG and EKG while the patient sleeps through the therapy. PCS offers the options for unilateral and bilateral referring to each brain hemisphere treated.  Unilateral treatments are typically performed on the patient’s nondominant side so there is less impact on memory as seen in the bilateral procedure.  PCS also provide options for single and multiple convulsion achieved for each session.


Venous Access Devices

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

Venous access is necessary for chemotherapy, antibiotics, hemodialysis, nutritional supplementation, repeated blood draws, and other therapeutic medications. The trick is understanding how to assign a CPT code to one of the many different ways this is done. In this article we will review the Venous Access Device section of CPT for placement. Venous access devices are preferred when access is needed over a period of time because repeated needle sticks and IV’s are hard on the body and painful for the patient.

There are six components to consider when coding venous access devices in CPT.

  • Age - is the patient younger or older than 5 years old.
  • Tunneled or Non-Tunneled – determine this by reviewing the procedure documentation looking for clues, i.e., direct puncture access is non-tunneled and Hickman, Broviac, and Groshong are tunneled catheters.
  • Port or no port – typically placed for long-term access and documentation will support creation of subcutaneous pocket. It is accessed via a special needle called a Huber needle. Smaller ports placed in the arm can be punctured up to 1,000 times and larger ports placed in the chest can be punctured up to 2,000 times
  • Pump instead of Port – also has a subcutaneous component that being a pump used to administer medication over a longer period time.
  • Central or Peripheral insertion – PICC lines are peripherally inserted as they are placed in the veins of the upper extremities and are used when access is needed over a short period of time. Peripheral access includes basilic, cephalic, or saphenous vein. Central venous access includes catheter placement in the jugular, subclavian, brachiocephalic, iliac, or femoral vein or SVC, IVC, right atrium catheter entry site.
  • Image guidance or no guidance – code selection is based on utilization of image guidance. Keep in mind codes with image guidance include image documentation and all associated radiological supervision and interpretation required to perform the insertion. Modifier 52 should be appended to the procedure code if final tip location is not confirmed.

Note: Mid-line catheters are not coded in this section of codes. A midline catheter terminates in peripheral veins and is therefore not considered a central venous access device.


A port-o-cath is completely implanted underneath the skin allowing the patient to bathe and swim without risk of infection.  A port can remain in use for months to years.


A PICC line or Peripherally inserted central catheter can be used for one to six weeks and are easier to remove.  Typically, they are placed in a large vein of the arm and threaded up to a large vein to the right of the heart.  


E/M ProFee

Z-Codes for Use, Abuse, and Dependence

Submitted by Heather Saunders, CPC, CEDC, CEMC, CHCAS, CHCA, Lead Pro-Fee Auditor

Use identifies that the patient consumes a substance on a regular basis by his or her own initiative, even though the substance is known to be a detriment to one’s health. Use shows no obvious clinical manifestations.

Abuse describes the patient’s habitual consumption of a substance by his or her own initiative, even though the substance is known to be a detriment to one’s health and is not taken for therapeutic purposes. Clinical manifestations are evident as signs and symptoms develop. For example, drug abuse, alcohol abuse.

Dependence indicates the patient’s compulsive, continuous consumption of a substance, which has resulted in significant clinical manifestations, as well as a physiological need for the substance in order to function normally. Any interruption results in signs and symptoms of withdrawal. In addition, the effects of the substance diminish, requiring the patient to increase the quantity consumed to achieve the same physical, emotional and psychological effects.

It is important to read through the documentation in order to support the use of the ICD-10-CM codes. ICD-10 provides specificity which is enhanced through the use of combination codes that report the substance (e.g. cocaine), the pattern of consumption (e.g. abuse) and various other factors such as the current state of the condition (e.g. in withdrawal) and/or the presence or absence of mental disorders induced by use of the substance (e.g. with delirium).

The availability of combination codes that report mental disorders associated with the use of nicotine, alcohol or psychoactive substances is important because codes that report the pattern of use as “use, unspecified” are only assigned when the record documents that the patient is using the substance but has not specified the use as either abuse or dependence and the use is associated with a mental or behavioral disorder and the relationship is documented by the provider (see ICD-10-CM Coding Guidelines Chapter 5. b. 3)


Current state of the condition: Category F10 is divided into 3 subcategories based on pattern of use: use, abuse and dependence. Depending on the subcategory, options are available to report the possible current state of the condition.

  • Use: with intoxication
  • Abuse: uncomplicated, with intoxication
  • Dependence: uncomplicated, with intoxication, with withdrawal, in remission

Associated mental disorders: depending on the subcategory and the pattern of use, the state of the condition can be reported as uncomplicated or complicated by certain associated mental disorders which may include –

  • Delirium
  • Mood disorder
  • Psychotic disorder with delusions
  • Etc.

Tobacco (Nicotine)

Dependence by product: Category F17 is divided into only one subcategory based on pattern of use: dependence. This subcategory is further divided by tobacco product –

  • Cigarettes
  • Chewing tobacco
  • Other tobacco product
  • Unspecified

Current state of the condition: Category F17 has options available to report the possible current state of the condition.

  • Uncomplicated
  • In remission
  • Withdrawal

Nicotine induced disorders: Category F17 does not have codes for specific mental disorders. Beyond pattern of use and current state of the condition additional subdivisions of specificity include –

  • Opioid related disorders (F11)
  • Cannabis related disorders (F12)
  • Sedative, hypnotic or anxiolytic disorders (F13)
  • Cocaine related disorders (F15)
  • Hallucinogen related disorders (F16)
  • Inhalant related disorders (F18)
  • Other psychoactive substance related disorders (F19)

Current state of the condition: Categories F11-16, F18-19 have options available to report the possible current state of the condition

  • Use
  • Abuse
  • Dependence

The specificity of codes that are now available for reporting use, abuse and dependence provide a much more complete and accurate clinical picture of the patient’s condition

Here are some questions and answers related to the use of these codes.

Per ICD-10-CM Guidelines there is a note under F10 Alcohol related disorders that states
Alcohol withdrawal is classified to dependence only (F10.23); there is no combination code for alcohol abuse with withdrawal. When alcohol abuse and alcohol withdrawal are documented for the same encounter, query the provider for clarification.

Tip: Assign when documentation indicates alcohol withdrawal without dependence; do not assign an additional code for withdrawal

Per Coding Clinic First Quarter ICD-10 2018 page 16


A 21-year-old was admitted due to alcohol abuse and the provider documented alcohol withdrawal. The physician was queried and clarified that the patient had alcohol withdrawal, but was not alcohol dependent. We are not able to code a diagnosis of alcohol withdrawal without dependence. How can we accurately code this case?


In ICD-10-CM, alcohol withdrawal is categorized as alcohol dependence. ICD-10-CM does not classify alcohol withdrawal with alcohol abuse. If the physician has been queried and confirmed alcohol abuse, rather than dependence, code only "alcohol abuse" and do not assign a code for withdrawal.

Coding Scenario 1: A 47-year-old female was seen for alcohol dependence. The physician did not document the pattern of use and only provided a diagnosis of alcohol dependence in the health record. However, a counselor who worked with the client documented in the record that the pattern of use is continuous and that the client consumes a large quantity of vodka on a daily basis. The counselor is not legally qualified to render a medical diagnosis.

According to Coding Clinic for ICD-9-CM the pattern of use must be documented by a provider who is legally responsible for making the diagnosis. This is consistent with ICD-10-CM Official Guidelines for Coding and Reporting.

For tobacco use, abuse and dependence the term “tobacco” is not specific enough. The new codes now have cigarettes, chewing tobacco and other tobacco products. Make sure you know which one is being documented.

Note under section F17.2-Nicotine dependence
Assign F17.200-nicotine dependence, unspecified, uncomplicated when provider documentation indicates “smoker” without further specification.

Per ICD-10-CM Coding Clinic, Fourth Quarter 2013, Page 108

How would a documented diagnosis of "smoker" be coded in ICD-10-CM? Should it be coded as tobacco use or dependence?

In ICD-10-CM, a diagnosis of "smoker" is coded to dependence. Assign code F17.200, Nicotine dependence, unspecified, uncomplicated, when the provider documents "smoker." Please note the following reference in the Alphabetic Index to Diseases:
Smoker - see Dependence, drug, nicotine

Per ICD-10-CM Coding Clinic, Second Quarter ICD-10 2017, Page 27

In the ICD-10-CM Index to Diseases, history of drug dependence has a note to "see Dependence, drug, by type, in remission." However, history of tobacco/nicotine dependence is indexed to code Z87.891, Personal history of nicotine dependence. The instructions to code history of drug dependence as remission, and history of tobacco dependence as history, appear to be inconsistent and seem to conflict with the guideline to assign a code for remission when documented by the provider. When do you report drug remission versus drug history?

Codes for drug dependence with remission and history of nicotine dependence are assigned based on how the condition is indexed in the classification. For example, if the provider documents history of cocaine dependence, assign code F14.21, Cocaine dependence, in remission. Assign code Z87.891, Personal history of nicotine dependence, for history of tobacco dependence. The ICD-10-CM classifies a history of nicotine dependence differently than other types of drug dependence, and there is a unique code for "history of nicotine dependence." This is an exception, to drug dependence, as history of drug dependence is classified by "type of drug, in remission."

In summary, as always, the provider documentation needs to support the ICD-10-CM codes being used. If, in doubt, send a query for more specificity.


Arteries-of-the-Brain-700X456Anatomy Feature

Arteries of the Brain and Strokes

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

Stroke is the third leading cause of death in the U.S. with an estimated 140,000 deaths per year and is the number one cause for long term disability. Hypertension and smoking are the leading culprits of a cerebrovascular accident. This month’s anatomy article will concentrate on the major arteries supplying blood to the brain and what stroke symptoms would most likely occur if one of these arteries suddenly became occluded.

There are four main arteries identified specifically in ICD-10-CM as locations for embolism, thrombosis or other occlusion or stenosis. The middle cerebral artery, anterior cerebral artery, posterior cerebral artery, and the cerebellar artery. Al of these arteries are bilateral and are highlighted with a star in the graphic above.

The middle cerebral artery (MCA) is the largest branch rising from the internal carotid and the vessel most involved in a stroke. This vessel supplies blood to the temporal, anterolateral frontal, and parietal lobes of the brain. A lacunar infarct occurs when small vessels running off of the middle cerebral artery are blocked. When this occurs contralateral paresis and sensory loss in the lower face and arm can occur. If the portion of the MCA controlling the dominant hemisphere is blocked global aphasia will result and if the nondominated hemisphere is blocked lack of spatial awareness will result.

The anterior cerebral artery (ACA) supplies blood to the frontal lobe of the brain and if blockage occurs here it affects logical thought, personality, and voluntary movement especially in the legs. Since the left side of the brain controls the right side of the body and the right side of the brain controls the left side of the body, blockage here will produce weakness in the opposite leg. Another telltale sign of an ACA stroke is urinary incontinence.

The posterior cerebral artery (PCA) supplies blood to the temporal and occipital lobes of the brain. A stroke here is typically embolic arising from vertebral basilar arteries or the heart. Although PCA strokes are uncommon they present with general symptoms such as headache, dizziness, and confusion. These strokes produce contralateral sensory symptoms such as being able to write but not read, color blindness and inability to see to-and-fro movements.

The cerebellar arteries supply blood to the cerebellum and are further divided by location as superior, anterior inferior, and posterior inferior. The cerebellum controls balance and coordination of body and eye movements. A stroke in this area of the brain will produce symptoms of dizziness, headache, double vision, difficulty walking, and tremors. These symptoms can be produced by any number of conditions leaving an PCA stroke misdiagnosed. There are however some trademark signs and those are shaking body, jerking in the arms, legs, and eyes.

Encephalopathy-350X350-BCDI Corner


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

The hallmark sign of encephalopathy that all CDI Specialists and coders should know is that it is always caused by something else and once the underlying condition is treated the encephalopathy will clear. That being said encephalopathy is acute in nature with improvement within days to weeks after treatment of underlying condition is treated. Keeping this in mind encephalopathy is rarely the principal diagnosis with the exception of metabolic encephalopathy due to UTI. UTI is not a likely cause of inpatient admission. Chronic encephalopathy does exist but is usually due to trauma or damage from drug abuse. There are four common types of encephalopathy. Toxic, metabolic, septic, and hepatic. Hepatic encephalopathy was discussed in an article in last month’s newsletter. See April 2019 Peak educational newsletter for information on this.

Toxic encephalopathy is an alteration in mental status caused by exposure to a toxin. First you must determine if the toxicity is a poisoning or adverse effect as ICD-10-CM has sequencing guidance in this scenario. Look for documentation of any of the following laundry list of signs and symptoms for toxic encephalopathy: problems of memory and concentration, difficulty controlling limbs, bowels, and bladder, sleep disorders, headaches, sleep apnea, general weakness, convulsions, disturbances in the senses like loss of smell or hearing. In the scenario of adverse effect, the toxic encephalopathy code is listed first followed by the adverse effect code. In the situation of poisoning the code for the chemical or drug responsible is listed first followed by the code for toxic encephalopathy. Along with common signs and symptoms the clinical indicators to search for in the documentation are: toxicology screens with abnormal values, discharge of suspected causal medication and the use of binding medications that help rid the body of the drug such as lactulose or kayexalate. Documentation improvements regarding the patient's baseline mental status and the return once the underlying toxicity is cleared can be very helpful as well.

Metabolic encephalopathy and septic encephalopathy are coded to the same code in ICD-10-CM, G93.41 Metabolic encephalopathy, with septic encephalopathy listed below it in the tabular list. A metabolic cause is one that comes from inside the body such as dehydration, acidosis, infection, hyponatremia, hypoglycemia, hyperglycemia. Once this internal cause is corrected the encephalopathy will clear. Common causes are: Infection (sepsis), vitamin deficiencies, electrolyte imbalances, acute kidney injury, hypoxia or hypercapnia. Altered mental status is often documented as delirium. If this occurs it would need to be clarified with the attending physician as to the possibility of septic/metabolic encephalopathy.

Coding encephalopathy as a secondary diagnosis often has major impact on the final DRG so if documentation is unclear query the physician to prevent denials down the road.



Pharmacology Spotlight

Medications for Bipolar Disorder

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

This month the pharmacology spotlight will discuss Bipolar disorder because the ICD-10-CM codes for Bipolar disorder carry a CC (Comorbid/Complication) and HCC (Hierarchical Condition Category) status impacting reimbursement. Bipolar disorder is a manic-depressive illness with type I being defined by manic episodes lasting 7 days or more with such severe symptoms that the patient must be hospitalized. This article will focus on the primary medication used to treat Bipolar disorder - Lithium with brand names of Lithobid®, Eskalith® , Eskalith-CR®. Because Lithium can cause thyroid and kidney issues periodic lab work is conducted to assess blood levels. Lithium is effective at stabilizing mood and preventing extreme highs and lows characteristic of the disorder. Side effects of the drug are poor concentration, hand tremor, weight gain, thirst, increased urination, drowsiness, and muscle weakness.

If Bipolar disorder is listed in a patient’s problem list be sure to check their list of medications for antipsychotics and other mood stabilizing drugs.


The Code PuzzlerCode-Puzzler-350X350-C

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 65-year-old male had undergone a laparoscopic cholecystectomy 3 days prior. Patient was acting normally at 10 pm and awoke at 2 am with aphasia and right hemiplegia. Patient arrived via EMS to the ER at 3:15am. Due to “wake-up” stroke and previous surgery he was not eligible for tPA treatment. His NIHSS was 19. CT Angiogram with low osmolar contrast confirmed occlusion of the left MCA. CT perfusion study shows hypoperfusion of the left MCA territory. He was taken immediately to surgery for percutaneous mechanical thrombectomy with stent retriever and suction aspiration was performed with successful thrombolysis in cerebral infarction (TICI) 3 revascularization. A diffusion- weighted MRI scan showed no infarction. He had a full recovery and was discharged 3 days later.

Assign ICD-10-CM/PCS and CPT code

ANSWER:  Highlight the text below to see if you were correct!

I63.512 Cerebral Infarction due to unspecified occlusion or stenosis of left middle cerebral artery
R29.719 NIHSS score 19
R47.01 Aphasia
G81.91 Hemiplegia, Unspecified affecting right dominant side

03CG3Z7 Extirpation of Matter from Intracranial Artery using Stent Retriever, Percutaneous Approach
B32R1ZZ Computerized Tomography of Intracranial Arteries using Low Osmolar Contrast

61645 Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter placement, and intraprocedural pharmacological thrombolytic injection (s)

70496 Computed tomographic angiography, head, with contrast material (s), including non-contrast images, if performed, and image postprocessing

CPT® codes, descriptions and other data are copyright 1966, 1970, 1973, 1977, 1981, 1983-2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. U.S. GOVERNMENT RIGHTS. CPT is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which were developed exclusively at private expense by the American Medical Association, 330 N. Wabash Ave., Suite 39300, Chicago, IL 60611-5885. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015 (b) (2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1 (a) (June 1995) and DFARS 227.7202-3 (a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. This file may not be sold, duplicated, or given away in whole or in part without the express written consent of the American Medical Association. To purchase additional CPT products, contact the American Medical Association customer service at 800-621-8335. To request a license for distribution of products with CPT content, please see our Web site at or contact the American Medical Association Intellectual Property Services, 330 N. Wabash Ave., Suite 39300, Chicago, IL 60611-5885, 312-464-5022.


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