Health Information Management

I'm done with Christmas

HIM-HIPAA Insider, December 29, 2014

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On the 12th day of Christmas my true love gave to me 12 drummers drumming and the noise is unbelievable. I’ve got a migraine.

I didn’t see any lights or odd visual disturbances beforehand, so this is a migraine without aura. And that makes the coding pretty simple. Migraines with aura have a lot more choices.
For a migraine without aura, we need to know whether it is intractable or not intractable. Intractable means it doesn’t respond to treatment. We’re way too early in the process to know that, so for now, we’ll call it not intractable and see how the medication works.
The other piece of information we need to know is whether the patient is status migrainosus, meaning the migraine has lasted for at least 72 hours. I’m on hour two, so no status migrainosus. That gives us G43.009 (migraine without aura, not intractable, without status migrainosus).
Unfortunately, that’s not our only medical issue in the house today. Several of our drummers have developed carpal tunnel syndrome. This is another easily coded malady. We just need to know laterality to choose from:
  • G56.00, carpal tunnel syndrome, unspecified upper limb
  • G56.01, carpal tunnel syndrome, right upper limb
  • G56.02, carpal tunnel syndrome, left upper limb
How would we code the carpal tunnel surgery in ICD-10-PCS? Granted, most people have this procedure on an outpatient basis, but someone may opt to have this done during a hospital stay for another procedure.
First we need to know the root operation. Let’s back up a step. What is the body system? Well, what is actually involved in a carpal tunnel procedure? The physician cuts the carpal ligament to free the median nerve.
Are we performing a procedure on the ligament or the nerve? Actually, the purpose of the procedure is to free the nerve, which falls under root operation Release (freeing a body part from an abnormal physical constraint by cutting or by the use of force).
The physician isn’t freeing the ligament, he or she is freeing the nerve. That makes our body system (second character) the peripheral nervous system and the body part (fourth character) the median nerve.
If you look at table 01N (release of the peripheral nervous system), you’ll see a long list of nerves. What you don’t see is laterality. That comes in the ICD-10-CM code for this particular procedure.
The approach can be:
  • Open (0)
  • Percutaneous (3)
  • Percutaneous endoscopic (4)
The final two characters for this procedure will be ZZ because those are our only choices.
For a percutaneous carpal tunnel release procedure, we would report 01N53ZZ.
As the day winds down (and so do the drummers), Mr. Whiskers makes his final play for the partridge in the pear tree on the patio. He has perfected his stealth approach and is making his way to the base of the tree. Wait, he’s got something in his mouth. Ew, it’s a dead mouse. And he’s leaving it at the base of the tree. How sweet. He wants to be friends. I guess there can be peace on Earth. Unless he’s trying to lure the partridge down so it’s easier prey. I wouldn’t put anything past that cat.
This article originally appeared on HCPro’s ICD-10 Trainer blog.


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