Health Information Management

Catch up on Coding Clinic guidance

HIM-HIPAA Insider, March 29, 2011

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Be sure to take a look at Coding Clinic, 3rd and 4th quarters 2010, if you haven't already. Highlights from these two issues include:

  • When a primary lung cancer metastasizes into another lobe of the lung, the second lesion should receive an additional code as a metastasis-not as a primary lesion. However, coders cannot assume that a second lesion is a metastasis or a primary cancer of both lungs. If two primary lesions occur in the same lobe, a coder may report only one code. (3rd quarter, p. 3)
  • Count the period of ventilator weaning during the process of withdrawing the patient from ventilator support. The duration includes the time the patient is on the ventilator as well as the weaning period. It ends when the mechanical ventilation is turned off (after the weaning period). (3rd quarter, pp. 3-4)
  • Report complication code 997.02 (iatrogenic cerebrovascular infarction or hemorrhage) as well as code E934.4 (drugs, medicinal and biological substances causing adverse effects in therapeutic use) in the instance of a patient whose hemorrhagic conversion was caused by tPA therapy. (3rd quarter, p. 5)
  • Excisional debridement of the fascia to the bone should be reported with 83.39 (excision of lesion of other soft tissue) and not a code for excisional debridement of the bone. (3rd quarter, p. 11)
  • When physicians document "hypertensive urgency," a query is necessary to determine the specific type of hypertension. (4th quarter, p. 9)
Editor’s note: To read more, access this article in the March issue of Briefings on Coding Compliance Strategies.

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