Frequently asked question (FAQ)
Query 1: Patient has Non-traumatic rotator cuff tear and also found SLAP lesion. So can we code SLAP LESION because we have only one code for SLAP lesion that belong to traumatic condition.
[S43.431A/ S43.432A]
Expert Answer: Yes, you can code because there is only one code for SLAP lesion either that is by default traumatic.
Query 2:
Patient has osteoarthritis and chronic Pain , what we will code ?
Expert Answer: Since the chronic pain is not at the same location of osteoarthritis so it cannot be considered as the symptom. So we will code both osteoarthritis and chronic pain.
Query 3: Can we consider full thickness rotator cuff tear as complete tear?
Expert Answer: Yes ,full thickness tear is the considered when rotator cuff tear completely detach from bone and in the same way partial tear is considered as incomplete tear.
Query 4: Patient has IBS and Diarrhea and consitpation , what should we code ?
Expert Answer: Coding Clinic, Fourth Quarter 2016: Page 32
IBS article “Irritable bowel syndrome Codes K58.1, Irritable bowel syndrome with constipation, K58.2, Mixed irritable bowel syndrome, and K58.8 Other irritable bowel syndrome, have been created to distinguish types of irritable bowel syndrome. Irritable bowel syndrome (IBS) is characterized by abdominal pain and discomfort, bloating and changes in bowel movement. There are four types of IBS that are based on the predominant alteration in stool consistency: IBS-C, with constipation; IBS-D, with diarrhea; IBS-M, mixed IBS (constipation and diarrhea); and IBS-U, unsubtyped IBS (diarrhea and constipation less than 25% of the time).
Query 5: What is recurrent UTI ?
Expert Answer: Recurrent UTI are mainly caused by reinfection by the same pathogen.
Query 6: Do we code persistence condition like persistent UTI ?
Expert Answer: Yes, Persistence means patient still carrying the same condition.
Query 7: What shoulde we code for Below Condition?
Expert Answer:
Former Smoker or History of Cigaratte: Z87.891
Use of Cigarette: No Code found , Code current condition (F17.210)
Abuse of Cigarette: No Code found , Code current condition (F17.210)
Dependence of Cigarettes: F17.210
For Smoker : Code as nicotine dependence
Nicotine dependence can be
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Chewing Tobacco- F17.220
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Cigarette- F17.210
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Other specified (e Cigarette)- F17.290
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Unspecifed- F17.200
Z87.891 Personal history of nicotine dependence
F17.200 Nicotine dependence, unspecified, uncomplicated
F17.210 Nicotine dependence, cigarettes, uncomplicated
F17.220 Nicotine dependence, chewing tobacco, uncomplicated
F17.290 Nicotine dependence, other tobacco product, uncomplicated
Query 8: Indication : Cirrhosis rule out esophageal varices, History of HCC
Egd done and gastric ulcer was found. Pathology shows negative result. What will be the Pdx?
Expert Answer: Code Cirrhosis as pdx because Egd done for cirrhosis condition to identify the varice of esophagus. So cirrhosis is providing the medical necessity for EGD.
Question 9: What are the difference between 60252 and 60254 ?
Expert Answer:
60252 Thyroidectomy, total or subtotal for malignancy; with limited neck dissection
60254 Thyroidectomy, total or subtotal for malignancy; with radical neck dissection
As per AMA
60252 include the removal of limited no of lymph node of neck.
60254 include the removal of total lymph node of one side of neck.
If Radical resection doen on both side, then use 60254 with modifier 50.
Query 10: What is the appropriate code for diagnosis of unspecfied hyperlipidemia and hypercholesterolemia ? Can we code both E78.5 and E78.00, when both are mentioned in the medical report?
Expert Answer: Based on Coding Clinic for ICD, 2nd Quarter 2022, Page 5
Assign Code E78.00 for diagnosis of unspecfied hyperlipidemia and hypercholesterolemia. Dont assign E78.5 Hyperlipidemia, unspecified because hypercholesterolemia identifies the specific blood lipid elevated.
Hypercholestrolemia means high cholesterol blood level. Hyperlipidemia is high/elevated lipids or fats level in the blood and cholesterol is type of lipid. So hypercholestrolemia is more specific lipid elevation.
Query 11: What is the appropriate code for mixed hyerlipidemia and hyperchoelsteremia ?
Expert Answer: Based on Coding Clinic for ICD 10, 2nd Quarter 2023, Page 9
Assign Code E78.2 for mixed hyerlipidemia and hyperchoelsteremia.
Dont assign E78.00 Pure hypercholesterolemia, unspecified because hypercholesterolemia is included in E78.2.
Query 12: How are old/Chronic/degenerative tears of the ligament,muscle or tendon coded ? ICD-10 CM index instruct to see "Sprain" for tear of ligament and to "see Strain" for tear of muscle or tendon. Codes categorised under Sprain or strain refer to current injuries. What is the ICD Code for (SLAP) tear
Expert Answer: Based on Coding Clinic for ICD 10, 2nd Quarter 2019, Page 26
Assign a code from subcategory, S43.43_ when the documentation supports a SLAP tear or lesion. Although these tear might be described as degenerative, they are usually the result of repetive trauma.
Query 13: What is separate procedure in CPT ?
Expert Answer: Separate procedure designation is the used throughout the code set to identify the services and procedures which are normally included in another procedure(s) and considered as integral component of another procedure or appropriately reported only when performed independently from other procedure.
Query 14: Pathology sample : Right sided colon polyps ?
So what part of colon we will code.
Expert Answer: Here, Right side means ascending colon and Left side means descending colon.
Query 15: Patient has History of chronic tension headache, can we considered headache as chronic condition.
Expert Answer: Here As from source, this condition cant be said chronic , sometime it exist long and continous and sometime for last for few days only.
Query 16: A 55 year old male underwent screening colonscopy and a large polyp was found, Due to it size and the inabiity to the gastroenterologist to visualise the base of the polyp, it was only partially removed. The pathology confirmed tubulovillous adenoma and provider recommended a followup colonoscopy in three months, How would this encounter will be coded ?
Expert Answer: Assign Z12.11 as pdx and put D12.6 as Sdx.
Screening,Survilience & Followup colonoscopy
Based on Coding Clinic, First Quarter 2017: Page 18
Query 15: The patient came for direct rigid layrngoscopy , the patient also come earlier for this problem 1 month ago and medication was given. Today in this encounter dilation was done at 6 degree clock and then again at 9 degree clock. Also CO2 laser was used and circular incision was done at the subglottis region. Suggest what will be the code ?
Expert Answer: Take this as subsequent encounter because dilation was done twice. Code 31529.There is unlisted code for the incision of the subglottis region through laryngoscopy. So also code 31599
Query 16:
Patient is scheduled for laparoscopy Cholecystectomy and the procedure get aborted , would you bill 47562 with 53 modifier or just 49320 ?
PREOPERATIVE DIAGNOSIS: Cholelithiasis.
POSTOPERATIVE DIAGNOSIS: Severe macronodular cirrhosis with ascites.
PROCEDURES PERFORMED: Diagnostic laparoscopy.
SURGEON: Counseling MD
ANESTHESIA: General.
PATHOLOGY SPECIMEN SENT: None.
ESTIMATED BLOOD LOSS: 50 mL.
DESCRIPTION OF SURGERY: The patient was brought to the operating room and general anesthesia induced. The abdomen was sterilely prepped and draped in usual fashion. The abdomen was entered through a small incision below the umbilicus using the Optiview port site technique. A good pneumoperitoneum at 15 mmHg was obtained without difficulty. Laparoscope was inserted. There was no evidence of any intraabdominal injury from the trocar insertion. Under direct visualization, a 12 mm trocar was then placed to the right of the patient's falciform ligament followed by two 5 mm trocars along the midclavicular anterior axillary lines. The patient was then placed in a steep reverse Trendelenburg position.
Of note, the liver was diffusely macular nodular in appearance. There was evidence of cirrhosis in the perihepatic spaces. The gallbladder did have some omentum sucked about it, this was taken down with Harmonic; however, on manipulation of the gallbladder there was probably a 50 mL bleed from the liver bed with just simply grasping the gallbladder. Therefore, due to the severe liver disease and obvious friability of the liver bed from this the procedure was aborted. Therefore, the patient was placed back in supine position. The pneumoperitoneum was released and trocars were removed. The patient was then awakened from anesthesia, extubated and transferred to the recovery room in stable condition.
Expert Answer:
Since the procedure is aborted you have to check whether physician intiated working on gall bladder on not, if they only inspected and didnt start any porcedure like clipping the cystic duct and artery. If they worked on this then you have to use 53 Modifier.
If they only inspect the gallbladder and liver through the laparoscopy procedure.Then the diagnostic laparoscopy is the correct code.
Also in both case you have to put Z53.8 as sdx