As coders, we often encounter common coding scenarios that seem straightforward, but we may need to be reminded of applicable guidelines and coding advice. Sometimes this requires us to seek further clarification if the documentation is not clear. With awareness of the documented circumstances and pertinent guidance, the potential implications for inaccurate coding can be avoided. Read more for an overview of various coding scenarios for which you might be looking for some extra tips.
Catheter-Associated Urinary Tract Infections (CAUTI)
According to the National Healthcare Safety Network (NHSN), urinary tract infections (UTIs) are the most common type of healthcare-associated infections (https://www.cdc.gov/hai/ca_uti/uti.html). UTIs are not only caused by various bacterial, viral and candidal infectious agents but catheter use may also play a role as an etiologic source for the infection. The infectious organism is introduced into the urinary tract via the urinary catheterization. NHSN reports that of the UTIs acquired during hospitalization, 75% are associated with a urinary catheter.
There are several AHA Coding Clinics which address the coding of CAUTIs but the main takeaway is that the provider must clearly document the causal relationship between the urinary catheter and the UTI. Recognizing the need to track CAUTIs with the goal in preventing future occurrences, coders should query the physician regarding the association if the patient has a urinary catheter and then develops a UTI (Coding Clinic 2Q 2012, pp. 20-21).
CAUTIs are coded to the code category, T83.51- Infection and inflammatory reaction due to urinary catheter. The most frequent urinary catheter used is an indwelling urethral catheter with the most common type being the Foley catheter. It is a flexible tube that is passed through the urethra and into the bladder to drain urine. A CAUTI which is due to a Foley catheter is coded to T83.511A, Infection and inflammatory reaction due to indwelling urethral catheter.
A suprapubic catheter (SPC) is a hollow tube which drains urine from the bladder via percutaneous insertion through the abdomen. Coding Clinic 3Q 2009, p. 11 describes the suprapubic catheter, however the coding advice is related to ICD-9-CM. At that time, the code description only described indwelling urinary catheter. In ICD-10-CM, “urethral” is qualified in code T83.511A for indwelling catheter. Though the SPC would be considered an indwelling catheter, it does not involve the urethra. In ICD-10-CM, a CAUTI involving a suprapubic catheter would be coded to T83.518A, Infection and inflammatory reaction due to other urinary catheter.
Coding Clinic, 1Q 2012 pp. 11-12 discusses a patient with a urostomy that is self-catheterized periodically for drainage of urine. However, the patient’s technique is non-hygienic which results in a UTI. The reference specifically applies to ICD-9-CM. However, the concept is applicable in ICD-10-CM with expanded codes with urostomy self-catheter poor hygienic related UTI assigned to the T83.518A code. The code also captures infections related to Hopkins and ileostomy catheters.
When coding UTIs, be aware of the presence of a urinary catheter and seek physician clarification regarding its association to the patient’s infection. This is particularly true in conditions where urinary catheters are common such as in spinal cord injuries, spina bifida and multiple sclerosis.
Fracture Injuries Resulting from Trauma vs. Pathological
Official Guidelines for Coding and Reporting, Section I.C.13.d.2. addresses osteoporosis with current pathological fracture, Category M80-. When a patient has a minor fall or other trauma that would not normally result in a fracture but does because of diseased bone due to osteoporosis, that fracture should be coded to category M80- rather than the traumatic fracture code.
The term “fragility” fracture may be referenced in the clinical documentation. Fragility fractures are those that result from a mechanical force that would not normally result in a fracture. This type of low level trauma has been quantified by the World Health Organization (WHO) as a force that is equivalent to a fall from standing.
The ICD-10-CM alphabetic index has sub-term entry for fragility under fracture, traumatic. It directs the coder to see, Fracture, pathological, due to osteoporosis.
If in doubt whether the fracture is a traumatic fracture vs. a pathological fracture due to osteoporosis, query the physician whether the clinical history is consistent with trauma or pathological etiology (Coding Clinic 2Q 2018, p. 12).
Sequencing of Periprosthetic Fractures
Periprosthetic fractures are not considered complications of the prosthesis nor does it represent a fracture of the prosthesis itself but rather is a fracture that occurs in the surrounding area of the prosthesis (Coding Clinic 4 Q 2016, pp.42-43). A periprosthetic fracture is coded to category M97-, Periprosthetic fracture around internal prosthetic joint.
The etiology of the periprosthetic fracture may be due to trauma or from a pathological source. When the patient is admitted for treatment of the fracture, the type of fracture (i.e. traumatic or pathological) would be sequenced first followed by the periprosthetic fracture code (M97-) as a secondary code.
When there is a fracture (i.e. breakage) of the prosthetic joint itself, category T84.01-, Broken internal joint prosthesis would be assigned.
During surgery for insertion of an implant, an intraoperative fracture may occur. This situation would be coded to M96.6-, Fracture of bone following insertion of orthopedic implant, joint prosthesis, or bone plate.
Essential Modifiers vs Nonessential Modifiers
Essential modifiers are listed as sub-terms under the main term in the ICD-10-CM Index to Diseases and Injuries. The sub-term descriptor is required in the diagnostic statement to assign the appropriate code reflected by the sub-term.
Nonessential modifiers are terms enclosed by parentheses and are used to identify supplementary words or explanatory information that do not affect the code assignment specifically. It is not necessary
for the nonessential modifier to be present in the diagnostic term. It serves to ensure the coder that the correct code has been located whether that nonessential term is present or not. The parentheses designating nonessential modifiers are noted in both the Index and the Tabular Listl.
Hepatic encephalopathy is a good example for demonstrating essential and nonessential modifiers. The alphabetic index refers the coder to see failure, hepatic when the diagnosis is hepatic encephalopathy. The sub-terms under failure, hepatic include with coma, acute or subacute, alcoholic, chronic, due to drugs and postprocedural. These terms are considered essential modifiers which do affect appropriate code assignment.
When the hepatic encephalopathy has been qualified as alcoholic, the sub-term has the words “acute”, “chronic” and “subacute” enclosed in parentheses. These are considered nonessential modifiers. Alcoholic hepatic encephalopathy would be coded to K70.40 whether specified as acute, chronic, or subacute. While hepatic encephalopathy not specified as alcoholic but stated as acute would be coded to K72.00.
with coma K72.91
acute or subacute K72.00
with coma K72.01
due to drugs K71.10
with coma K71.11
alcoholic (acute) (chronic) (subacute) K70.40
with coma K70.41
with coma K72.11
due to drugs (acute) (subacute) (chronic) K71.10
with coma K71.11
due to drugs (acute) (subacute) (chronic) K71.10
with coma (K71.11)