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Coding to New Heights Education Newsletter October 2019 Edition

Peak Health Solutions - Oct 17, 2019


Welcome to our Monthly Coding Education Newsletter, October 2019 Edition! This month we'll discuss: ICD-10-CM – Coding Electrolyte Imbalances, ICD-10-PCS – Duodenal switch, CPT – Parathyroid Autotransplantation, Pro-Fee – Endoscopic Ultrasound Services, Anatomy Feature – The Thyroid and Parathyroid, CDI Corner – “With” instructional note for Diabetes, Pharmacology Spotlight – Hypoglycemics

In This Issue


Funny Documentation Fail

“Pancreatitis of unknown ideology"



Coding Electrolyte Imbalances

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

Electrolytes are compounds occurring naturally in the body and ingested through our diet. A disorder occurs when these compounds become too high or too low. Severe imbalances can cause seizures, coma, and cardiac arrest. Diagnoses such as hypokalemia and hyponatremia are often seen within health record documentation.

Hypernatremia is high concentration of sodium in the blood and is coded E87.0. This code category includes sodium [Na] excess and sodium [Na] overload. The normal range for sodium is 136-145 mEq/L. If dehydration is present assign as an additional code (E86.0). The electrolyte sodium not only regulates fluid balance but is important for maintaining normal blood pressure and supports the work of nerves and muscles. Patients are at risk of developing hypernatremia if they have conditions such as dementia, poorly controlled diabetes, and kidney disease. Hypernatremia can also be caused by severe nausea and vomiting and medications such as diuretics and steroids. The major symptom of hypernatremia is thirst, however, if the patient is unable to access water due to bedbound status or other reasons their thirst may go unfulfilled. In contrast hyponatremia is low concentration of sodium in the blood and is coded E87.1. In hyponatremia, one or more factors — ranging from an underlying medical condition, such as congestive heart failure, kidney and liver disease, to drinking too much water, may cause the sodium in your body to become diluted. Both codes E87.0 and E87.1 in ICD-10-CM carry a CC status meaning they can impact the final DRG.

Acid–base imbalance is an abnormality of the human body's normal balance of acids and bases that causes the plasma pH to deviate out of the normal range (7.35 to 7.45). The pH scale measures how acidic or basic a substance is. Acidosis is excess acid in the blood causing the patient’s pH level to fall below 7.35 and is coded E87.2. This code category includes: lactic acidosis, metabolic acidosis, and respiratory acidosis. Respiratory acidosis occurs when carbon dioxide cannot be removed through exhalation. This could be caused by chest deformities, chest injuries, chest muscle weakness, lung disease, or sedative drug overdose. Metabolic acidosis is when the kidneys cannot remove excess acid from the body. This occurs in conditions such as kidney disease, aspirin overdose, or dehydration. Lactate is a chemical that is formed when sugars are broken down for energy in the absence of adequate oxygen. Lactic acidosis is excess lactic acid caused by cancer, alcohol overdose, seizures, liver failure, hypoglycemia, and vigorous exercise. The opposite of acidosis is alkalosis, an excess of base or alkali, and is coded E87.3. This code category includes metabolic alkalosis and respiratory alkalosis. The kidneys and lungs are responsible for the balance between acid and base in the body. Respiratory alkalosis is a decrease in carbon dioxide levels in the body. This can be caused by hyperventilation, fever, lung or liver disease, or other reasons that cause a lack of oxygen. Metabolic alkalosis is an excess of bicarbonate in the blood seen in kidney disease. Mixed disorder of acid-base balance is coded E87.4 and includes a mix of acidosis and alkalosis or metabolic acidosis and respiratory acidosis for example. All three codes E87.2, E87.3, and E87.4 carry a CC status with potential impact on the final DRG.

Hyperkalemia is high levels of potassium in the blood and is coded E87.5. This code category includes potassium [K] excess and potassium [K] overload. In contrast hypokalemia is low levels of potassium in the blood. The normal range for potassium is 3.5-5.3 mEq/L. Since the kidneys control potassium levels, kidney disease is the most common culprit in both hyperkalemia and hypokalemia. Hyperkalemia can also be present in Addison’s disease, diabetes type 1, and dehydration. Hypokalemia can also be caused by excessive alcohol use, diarrhea, diuretics, primary aldosterones, and diabetic ketoacidosis.

In summary, knowing what chronic conditions can cause an electrolyte imbalance will help Coding professionals and CDI specialists know how to interpret lab values and query if necessary.



Duodenal switch

Original Blog Coding Tip by Stephanie Mason CCS, CRC, Manager, HIM Workforce Solutions Revenue Cycle Solutions

With the patient in the supine position under general anesthesia, the abdomen was sterilely prepped and draped in the usual fashion. A transverse incision was made about 18 cm from the xiphoid just to the left of the midline, 12 mm in length. A Visiport was used to pass a 12 mm port and insufflate with CO2. Five mm ports were placed in the subxyphoid, in the left anterior axillary subcostal area and on the right anterior axillary subcostal area and perhaps 3-4 cm below the line between the midline and the right upper quadrant 5 mm port.

I placed a 15 mm port and with these ports in place, I was able to first identify the cecum and run the small bowel to 300 cm from the ileocecal valve, and there I placed 2 endoclips distally and 1 proximally. Then I lifted it up to the area of the duodenum and when I could document that it was going to reach, I proceeded to drop it and place a liver retractor and dissect out the duodenum and 4 cm distal to the pylorus.

I transected it with a tan load staple. I took most of the soft tissue and vasculature on the cephalad side with a Sonicision, which allowed it to drop down to meet the ileum. I then brought the ileum up after transecting the duodenum and I used a 2-0 Vicryl to secure the stapled edge of the duodenum to the edge of the ileum in continuity with an EndoStitch. Then I opened both the duodenum and the ileum with the Sonicision.

I secured the anastomosis with a running 3-0 Vicryl and an outer layer of a running 2-0 Vicryl was then added. We closed the Peterson space with this ileum with a running 2-0 Ethibond. We completed the procedure with the sleeve and 6 cm from the pylorus on the greater curvature, we began a dissection and transection of all of the blood vessels on the greater curvature up to the GE junction. I then utilized the Endo-GIA black staple for the antrum after having the 34-French EZ tube placed by the anesthesiologist passed to the pylorus and using that as a rough gauge, we transected the stomach rather loosely to the edge of the EZ tube. I then used a purple staple and then finally tan staples until we were done.

We removed the stomach through an EndoCatch tube bag through the right upper quadrant 15 mm port, which was then closed with an inlet of 0 Vicryl suture. The area was irrigated and lavaged as was the duodenal area and the EZ tube was withdrawn and the CO2 was allowed to escape. The wounds were then lavaged and closed with staples. The patient tolerated the procedure fairly well.

ICD-10 PCS code assignment:
0DB64Z3 Excision of stomach, percutaneous endoscopic approach, vertical
0D194ZB Bypass duodenum to ileum, percutaneous endoscopic approach

Per AHA Coding Clinic® 2Q 2016 page 31 “Laparoscopic biliopancreatic diversion with duodenal switch” Per this coding clinic, two distinct procedures are completed requiring 2 PCS codes. First, the stomach is divided vertically and approximately 85% is removed (excised). Second, called the malabsorptive portion of the surgery, the portion of the intestine known as the “digestive” loop, is re-routed (bypassed) to reduce calorie absorption, from the duodenum to the ileum.

Root operation Excision “Cutting out or off without replacement a portion of a body part”

Root operation Bypass “Altering the route of passage of the contents of a tubular body part”

They remove or excise all but a sleeve portion of the stomach. Then they transect a portion of the duodenum and form an anastomosis to the ileum creating a duodeno-ileum bypass.


Parathyroid Autotransplantation

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


Parathyroid autotransplantation is the removal of parathyroid glands and re-implantation into muscle pockets located in the sternocleidomastoid muscle or brachioradialis muscle of the non-dominant arm. Here the parathyroid will begin making hormones within 4 to 6 weeks preventing permanent hypoparathyroidism from developing. This procedure seems to be more common in patients undergoing surgical treatment of cancer in the neck area as this procedure can damage the parathyroid glands.

A typical procedure note might look like this:

The patient is taken to the operative suite, prepped, draped, and anesthetized. A small horizontal incision was made in the neck just below the larynx. The skin is separated and overlying muscle pulled back to allow access to the thyroid. A complete thyroidectomy was performed keeping several fragments of parathyroid tissue. A separate incision was made in the sternocleidomastoid muscle to allow a pocket to receive the fragments. The pocket was closed with sutures and neck incision was closed.

The codes for the above example are:

60240 Thyroidectomy, total or complete and 60512 Parathyroid autotransplantation which is an add on code listed secondary to subtotal thyroidectomy, total thyroidectomy, and parathyroid procedures.

In an issue of AMA CPT Assistant® January 2017 page 7 the question was asked is it appropriate to assign code 60512 parathyroid autotransplantation when the re-implantation site is performed through the same incision for the primary procedure. The answer is no, do not report this add-on code if the implantation is through the same incision as the primary procedure. This code is intended to be reported when the implantation is done at a distant site through a separate incision. This guidance reminds us to carefully read the operative note for the location and technique of re-implantation.

E/M ProFee

Endoscopic Ultrasound Services

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


Detailed diagram of an endoscopic retrograde cholangio pancreatography (ERCP)
Attribution: Cancer Research UK [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

Ultrasound guided procedures done through an endoscope evaluate the digestive system and organs within the vicinity of the ultrasound waves such as the lungs. The ultrasound uses sound waves to form a picture of the internal organs. This technology is extremely helpful in staging cancer because the depth of the tumor and surrounding lymph nodes can be evaluated.

An endoscopy procedure can be performed on the upper and/or lower gastrointestinal (GI) system. The upper GI system includes the esophagus, stomach, and duodenum. The lower GI system includes the large intestine and rectum. By performing ultrasound within these structures, organs in the vicinity such as lungs, liver, gallbladder, pancreas and major blood vessels can be evaluated. Ultrasound technology is also used to better locate tissues for biopsy.

Consider the following procedure:

An endoscope, a thin lighted tube is placed in the patient’s mouth and advanced down into the stomach and duodenum. On the tip of this tube is a small ultrasound probe that emits sound waves. The sound waves bounce off area structures and are recaptured by the probe and converted into images for the provider to analyze. For this example, the pancreas is being evaluated as it sits next to the stomach and small intestine making EUS exam very useful in bringing back detailed images of the pancreas.

The image of the pancreas identifies a suspicious area that is suggestive of a tumor and needs biopsied. Biopsies from this vantage point can be done by fine needle aspiration (FNA) or needle core biopsy. These special biopsy needles are inserted through the wall of the stomach into the pancreas. The EUS allows the provider to direct the needle to the exact location in question by watching the needle placement. Samples are collected and analyzed under a microscope.

This example would be assigned 43238 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures).

The above procedure note was just one possible example of an EUS exam and biopsy. Read the procedure notes very carefully for EUS procedures to evaluate if a biopsy was performed on organs in the area.

Anatomy Feature

The Thyroid and Parathyroid

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

The thyroid gland may be small but it packs a big punch when it comes to having a role in our metabolism, digestion, fertility, weight loss, aging, and much more. In fact, the thyroid typically weighs less than an ounce and measures only 2 inches long but it regulates the metabolic function of every cell in the body. The thyroid gland is a butterfly shaped gland with a right and left lobe joined by the isthmus. Four parathyroid glands sit on the back of the thyroid gland.

The thyroid gland secretes calcitonin, T3 and T4 thyroid hormones. Calcitonin regulates bone growth and the thyroid hormones regulate growth and development of young people and play an important role in maintaining a healthy metabolism throughout life. Thyroid hormones are generated from iodine we take in through our diet and are stored in the thyroid gland. The thyroid gland houses an incredible amount of thyroid hormones, so many that if all were released at once it would kill us. Luckily, close communication occurs between the thyroid, the pituitary gland, and the hypothalamus to maintain T3 and T4 balance.

Over production of thyroid hormones produce symptoms such as increased heart rate, angina, palpitations, hyperventilation, tremors and heat intolerance. Underproduction of thyroid hormones will produce symptoms such as reduced heart rate, tiredness, and cold intolerance.

As an example of how the thyroid hormones work; T3 and T4 regulate heart rate and intestinal digestion. If T3 and T4 levels are low, heart rate may be slower than normal and symptoms of constipation and weight gain will result. If T3 and T4 levels are high, heart rate may be rapid and symptoms of diarrhea and weight loss would result.

The thyroid gland is a very important gland in the body controlling many functions. The body can live without it but hormone replacement would be required for life.


with-455-wide-BCDI Corner

“With” instructional note for Diabetes

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

ICD-10-CM classification presumes a causal relationship between diabetes and several acute and chronic conditions. According to ICD-10-CM official guidelines for coding and reporting I.A.15 “With” should be interpreted to mean "associated with" or "due to" when it appears in a code title, the index under a main or subterm, or an instructional note in the Tabular List. The word “with” in the Alphabetic Index is sequenced immediately following the main term or subterm, so it will not appear in alphabetical order.

Under the main term Diabetes in the index, the subterm "with" indicates a list of conditions in which the classification assumes a linkage--such as dermatitis, foot ulcer, or gangrene to name a few. If the physician documentation specifies that diabetes mellitus is not the underlying cause of the other condition, the condition should not be coded as a diabetic complication.

In AHA Coding Clinic® second quarter 2018, pages 6-7 the question was asked, "Would it be appropriate to assign code E11.618, Type 2 diabetic arthropathy when the documentation supports arthritis and diabetes?" The index entry for "diabetes with arthropathy" looks like this

Diabetes, diabetic (mellitus) (sugar)
--arthropathy NEC E11.618

The answer stated the "with" guideline does not apply to "not elsewhere classified (NEC)" as they can refer to a wide range of conditions. The conditions need to be linked by documentation of “with," "due to" or "associated with." Since arthropathy refers to any diagnosis affecting the joints, the provider would have to document the specific condition as a diabetic complication. Coding professionals cannot assume a causal relationship between diabetes and a complication from a broad category (NEC).



Pharmacology Spotlight


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


Type 2 diabetes can be described as a syndrome characterized by insulin deficiency, insulin resistance and increased hepatic glucose output. The role of hypoglycemic medications is to correct one or more of these physiologic abnormalities. The American Diabetes Association recommends a trial of diet and exercise as the first line of treatment. If the desired level of glycemic control is not achieved within a three-month period, pharmacologic intervention is required.

There are five classes of hypoglycemic drugs:

Sulfonylureas – (identified by [S] in the chart below) are the most widely used class of drugs and appear to function by stimulating insulin secretion.

Metformin – (identified by [M] in the chart below) is effective only in the presence of insulin with its major effect increasing insulin action. Metformin promotes weight reduction and stabilization which is in contrast to the increased appetite and weight gain often induced by insulin and sulfonylureas.

Thiazolidinediones – (identified by [T] in the chart below) reverses insulin resistance by acting on muscle, fat and to some degree the liver to increase glucose utilization and diminish glucose production.

Alpha-glucosidase inhibitors – (identified by [A] in the chart below) is a class of drugs that inhibits enzymes in the stomach that convert dietary starch and other complex carbohydrates into simple sugars resulting in a slower absorption of glucose after meals.

Meglitinides – (identified by [Meg] in the chart below) are a class of drugs that stimulate the pancreas to release insulin in response to a meal. It acts by closing the ATP-dependent potassium channels in functioning pancreatic beta cells. This in turn depolarizes the beta cells leading to the opening of calcium channels and influx of calcium. This influx of calcium induces insulin secretion.

The table below demonstrates some common brand names for these five different classes of hypoglycemic medications. Some of the brands are a combination of Metformin and the other classes. Those are identified by [M-Combo]. This list may be useful when reviewing the health record.

Acarbose® [A] Fortamet® [M-Combo] Inokana® [A] Prandin® [Meg]
Actoplus Met® [M-Combo] Glimepiride® [S] Janumet® [M-Combo] Precose® [A]
Actos® [T] Glucophage® [S] Januvia® [A] Qtern® [A]
Amaryl® [S] Glucotrol® [S] Jentadueto® [M-Combo] Repaglinide®
Avandamet®  [M- Combo] Glucovance® [M-Combo] Kazano® [M-Combo] Riomet® [M-Combo]
Avandia® [T] Glumetza® {M-Combo] Kombiglyze® [M-Combo] Sitagliptin® [A]
Diabinese® [S] Glyburide® [S] Metformin® [M] Starlix® [Meg]
DiaBeta® [S] Glynase® [S] Onglyza® [A] Synjardy® [M-Combo]
Duetact® [T-Combo] Glyset® [A] Oseni® [A] Xigduo® [M-Combo]
Farxiga® [A] Invokamet® [A] PrandiMet® [M-Combo]  

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