Health Information Management

Latest AHA Coding Clinic for ICD-10 covers orthopedic, cardiovascular coding

HIM-HIPAA Insider, December 7, 2015

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Typically, when we see that a device is loose or breaking, we automatically think “that shouldn’t happen,” so we opt to code a complication of the device. Well, when this occurs in an orthopedic screw as an expected outcome (typically when the patient begins bearing weight during the recovery/healing process), it should not be coded as a complication.

The correct diagnosis codes would be assigned for the specified fracture site with a seventh character identifying a subsequent encounter with routine healing, along with the external cause code (if known), also as a subsequent encounter. (Remember that place of occurrence, activity, and status codes should only be used for the initial encounter, per the ICD-10-CM Official Guidelines for Coding and Reporting.)

The ICD-10-PCS root operation would be Removal (third character P) for the removal of the screw from the specified bone.

This article was originally published in Briefings on Coding Compliance Strategies. Subscribers can access the full article in the December 2015 issue.



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