Why medical
coders shouldn't worry about memorizing ICD-10 codes
You want to
scare the beeswax out of a healthcare professional, talk about how many ICD-10
diagnosis codes there will be. Sixty-eight
thousand codes. Who's going to memorize all those.
No one. That's
because no one needs to memorize all the diagnosis codes. Medical coders will
memorize the ICD-10 codes that become most familiar to them. The others can be
accessed or found quickly by medical coders who understand how they are
memorized.
Be ready to code for gallbladder attacks
A patient comes
in to the ER complaining of sharp pain in the upper abdomen that began after
lunch and continued “for some time,” followed by nausea and vomiting.
The physician
orders an ultrasound and diagnosis the patient with cholelithiasis. The
physician recommends surgery and after obtaining patient consent, performs a
laparoscopic cholecystectomy with cholangiography. The pathology report states
“acute cholecystitis with cholelithiasis.”
Meet the disease
Before
determining a diagnosis and coding the procedure, coders might benefit from
understanding a little bit about the condition.
Cholecystitis
and cholelithiasis are conditions that affect the gallbladder, a sac located
under the liver. The gallbladder stores and concentrates bile produced by the
liver. Before a person eats, the gallbladder is approximately the size of a
pear.
During a meal,
the gallbladder pushes bile through ducts into the small intestine. The bile
aids in digestion of fats.
After a meal,
the gallbladder is flat and empty.
The following
diseases may attack the gallbladder:
- Gallstones—hard,
pebble-like formations that develop in the gallbladder
- Cholecystitis
(chronic/acute)—inflammation of the gallbladder
- Polyps—growths
of tissue in the gallbladder
- Tumors—abnormal
growths on the gallbladder and bile ducts
- Biliary
dyskinesia—bile does not flow from the gallbladder or common bile duct and
backs up in the gallbladder
Patients may
also suffer from cancer of the gallbladder, which is difficult to diagnose
because it does not have specific symptoms. In addition, the location of the
gallbladder also makes this cancer difficult to detect.
Gallstones
lodges in the duct can prevent the flow of pancreatic enzymes causing acute
pancreatitis.
ICD-9-CM
includes the following code choices under cholelithiasis:
- 574.00,
Calculus of gallbladder with acute cholecystitis; without mention of
obstruction
- 574.10, Calculus
of gallbladder with other cholecystitis; without mention of obstruction
- 574.20,
calculus of gallbladder without mention of cholecystitis; without mention
of obstruction
- 574.30,
calculus of bile duct with acute cholecystitis; without mention of obstruction
- 574.40,
calculus of bile duct with (chronic) cholecystitis; without mention of
obstruction
- 574.60,
calculus of gallbladder and bile duct with acute cholecystitis; without
mention of obstruction
Note that the
fifth digit for these codes denotes without mention of obstruction (0) or with
obstruction (1).
Other diseases
of the gallbladder include:
- 575.10,
cholecystitis,(unspecified)
- 575.11,
chronic cholecystitis
- 575.12,
acute and chronic cholecystitis
- 575.3,
hydrops of gallbladder
- 575.6, cholesterolosis
of gallbladder (strawberry gallbladder)
- 575.8, biliary dyskinesia
Diagnose the
problem
The first thing
to determine is which ICD-9-CM diagnosis code the surgeon should use.
Coders have
four possible codes based on the scenario above.
- 789.01,
pain right upper abdominal quadrant
- 787.01,
nausea and vomiting
- 574.20,
calculus of gallbladder without mention of cholecystitis
- 574.00, acute cholecystitis with cholelithiasis without mention of obstruction
Pain in the
upper right side or upper middle of the abdomen is the main symptom of
cholecystitis, also known as gallstones. Nausea and vomiting are also common
symptoms. The Official ICD-9-CM Guidelines for Coding and Reporting state:
Signs and
symptoms that are associated routinely with a disease process should not be
assigned as additional codes, unless otherwise instructed by the
classification.
Other signs and
symptoms of cholecystitis include:
- Pain that
wakes a patient a night
- Pain
following meals
- Intolerance
of fattyfoods
- Burning
sensation in the stomach
- Diarrhea
- Loss of
appetite
- Fever
Because
abdominal pain, nausea, and vomiting are common symptoms of cholecystitis,
coders should not assign codes for the symptoms.
That leaves two
choices: 574.20 or 574.00. The physician initially diagnosed cholelithiasis
(574.00). However, the pathology report provides more information.
The final
diagnosis based on the pathology report is acute cholecystitis with
cholelithiasis, which makes the correct code 574.00, saysPlouffe.
Dissecting the
procedure
Physicians can
use three different procedures to perform a cholecystectomy (removal of the
gallbladder):
- Laparoscopic
cholecystectomy: the physician makes four small slits in the abdomen and
uses laproscopic instruments to remove the gallbladder.
- Open
cholecystectomy: the physician makes an incision on the right side of the
abdomen under the rib cage and removes the gallbladder.
- Single-site
da Vinci® surgery: This is a robotic-assisted surgery (da Vinci Surgical
System is the name of the device). In this procedure, the physician
remover the gallbladder through a single small incision in the belly
button similar to traditional single-port laparoscopy.
In some cases
the surgeon begins the procedure as laparoscopic, but converts it to an open
procedure. In this case, coders should only report the CPT® code for the open
procedure.
In addition to
the primary diagnosis code, report ICD-9-CM code V64.41 (laparoscopic surgical
procedure converted to open procedure). ICD-10-PCS instructs coders to report
both procedures—an open cholecystectomy and an inspection for the laparoscopic
procedure. ICD-10-CM does not contain a code equivalent to V64.41.
Outpatient coders will not be able to indicate when a surgeon converts a
laparoscopic procedure to an open one.
The possible
CPT codes for a laparoscopic cholecystectomy include:
- 47562,
laparoscopy, surgical; cholecystectomy
- 47563,
laparoscopy, surgical; cholecystectomy with cholangiography
- 47564,
laparoscopy, surgical; cholecystectomy with exploration of common duct
- 47570,
laparoscopy, surgical; cholecystoenterostomy
- 47579,
unlisted laparoscopy procedure, biliary tract
The surgical
laparoscopy always includes the diagnostic laparascopy, Plouffe says. Do not
code the diagnostic laparoscopy separately.
CPT codes for
an open cholecystectomy include:
- 47600,
cholecystectomy;
- 47605,
cholecystectomy; with cholangiography
- 47610,
cholecystectomy with exploration of common duct;
- 47612,
cholecystectomy with choledochoenterostomy
- 47620,
cholecystectomy with transduodenal sphincterotomy or sphincterplasty, with
or without cholangiography
- 47999,
unlisted procedure, biliary tract
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