Monday, January 2, 2017

Connecting the dots: Diagnosis, Procedures, Documentation

Connecting the dots: Diagnosis, Procedures, Documentation

Originally published on 07.30.2016
Lori-Lynne A. Webb 


In the outpatient setting, we have a different set of “rules” to follow in regard to the official guidelines for coding and reporting in ICD-10cm than those that follow the guidelines for “inpatient” care.  The ICD-10cm guidelines for outpatient coding are followed and are used by hospitals/providers for coding and reporting hospital-based outpatient services, and provider-based office visits.  In addition, the terms “encounter” and “visit” can be used interchangeably.  As a reminder, the guidelines for outpatient coding are different from inpatient coding in the fact that the term “principle diagnosis” is only applicable to inpatient services; as are the coding of probable, suspected, rule outs and inconclusive. 

For those who code outpatient or office based services; instead of reporting a “principle” diagnosis, you would code the first-listed diagnosis, as well as signs and symptoms that are documented by the provider of care.  In some cases, it may take more than one visit or encounter to arrive at and/or confirm a specific “diagnosis”.  ICD-10cm guidelines allow us to continue to report signs and symptoms over the course of the outpatient workup.    The majority of the signs and symptom codes are found in Chapter 18 of the ICD-10cm diagnosis codes, however, other signs and symptom codes can be found in many of the other sections and chapters of ICD-10cm.

When assigning an ICD-10cm diagnosis code for an outpatient surgery, or same-day surgery, it is appropriate to code the “reason” for the surgery as the first listed diagnosis (eg reason for the encounter).  When  coding for an outpatient hospital observation stay, it is appropriate to code the current medical condition as the first-listed diagnosis.  (eg.  pregnant patient with decreased fetal movement) , In addition it is appropriate to code for all additionally documented conditions.  If the patient has chronic diseases noted, the chronic disease or chronic disease status may be coded in addition to the primary “reason” the patient is seeking treatment, but only if the physician documents the chronic condition is impacting the current care or medical decision making of the presenting problem or illness. 

Diagnosis codes are to be used and reported at their highest number of characters available and specificity.   However, sometimes all we have to go by is the documentation of the “signs and symptoms” that the provider of care has documented.   If the provider has not referenced a clinical significance to complaints or ill-defined symptoms, we have to code it as a “sign or symptom” from the ICD-10cm codeset.  It is the providers responsibility to clearly document the patients’ diagnosis.    

Coders are not allowed to “infer” or code directly from an impression on diagnostic reports such as an x-ray, ultrasound, or pathology report.     In the outpatient setting, the provider of care must confirm the diagnosis in the body of the patients’ visit note, procedure /operative note, or progress note.   An example of this is; In the provider notes, the documentation states the patient has an “elevated blood pressure” of 160/90.  As a coder, this does not mean the provider has diagnosed the patient with hypertension, it simply means that today, the patients’ blood pressure is elevated.   However, if the provider  notes that the patient has an “elevated blood pressure of 160/90 today, and will begin treating for hypertension; the coder can code the specific “hypertension” diagnosis rather than the ‘signs and symptom” code of elevated blood pressure.     If the coder does not have more specific information than “hypertension” written in the record; a query to the provider is in order to get the most specificity for coding clarity, and good clinical documentation for the overall quality of medical care.

When assigning codes for an outpatient or ambulatory surgery case, code the diagnosis for which the surgery was performed.  However…. If the post-operative diagnosis is different than the pre-operative diagnosis listed by the surgeon, then code what is reported as the post-operative diagnosis.  In reviewing or auditing an operative record, the surgeon should give both diagnoses.  The rule of thumb, is the coder will defer to coding the diagnosis based on the post-operative notation, or most definitive clinical documentation recorded in the patients’ medical chart. 

When coding a diagnosis for and ambulatory or same-day surgery, the urge to rely on the absolute information from a pathology report can be hard to resist.  As coders, we have been trained to hold or delay submitting the insurance claim pending more information from a pathology report.  Pathology reports contain great information as to sizes, weights, measures, cell types, malignancies, infections, and even more extensive clinical information than is normally reported in an operative/procedure record.

However, within the guidelines of coding, coders should not assign codes based on the pathology report, unless the physician has confirmed the diagnosis within their operative, procedure, or progress notes.   For example, if the physician notes within the documentation the removal of a “breast lesion/mass” and the pathology record documentation  states “breast carcinoma”, the coder should not code a “breast carcinoma” until the surgeon clarifies or adds this additional information from the pathology report to the operative and/or progress note. 

Pathology reports certainly help us paint the picture to good coding standards, but sometimes do not “help” as much as they can “hinder” the true picture.   When coding for a lesion removal with CPT codes, understanding how lesions are measured, is vital to good documentation of the procedure.  According to the CPT manual guidelines the measurements of the lesion need to include the size of the lesion itself, and include the margins needed for medical necessity prior to excision. 

As part of good clinical documentation, the provider should document and include an accurate measurement of the lesion itself, and the margins to be included.  If the coder relies on only the pathology report,  it may not be an accurate sizing.  Unfortunately when excising specimens, it is common to have the procured tissue “shrink” or the specimen may be “fragmented” upon receipt to the pathology department.  Measurement of the defect size post excision may also be incorrect, as the excision site may “expand” once the tissue has been incised or excised.  Either way, this leads to incorrect documentation and incorrect coding. 

The documentation bottom line is this:
• Measurement of the lesion plus the margins should be made prior to the excision
• Pathology reports should not be used in lieu of physician documentation
• Query the physician regarding the size of the lesion as well as the margins excised if not clearly noted in the operative/procedure note.

Below is a copy of a very generic type of lesion excision query form you can use to communicate to your provider the information you need to accurately code the encounter:

********************************************************************************
EXCISION OF LESION(S) CLARIFICATION

Patient Name: ________________________ : DOB:________________
DOS: _____________ MR #:_________________

Query Date:________       Requested by: _____________

Documentation clarification is required to meet medical record documentation compliance, medical necessity, and accuracy of diagnosis and procedure coding.

In the medical record/operative procedure note, the following information is needed to assign the correct ICD-10cm and CPT code(s). Please provide the following:

o  SIZE of the greatest clinical diameter in centimeters plus margins for each lesion excised

o  DEPTH of the tissue involved for each lesion (e.g., skin, fascia, muscle or bone)

o  Type of CLOSURE for each lesion (e.g., simple, intermediate or complex)


Please document and/or addend the patients’ operative/procedure record to include the requested information above.  This information can be noted in the electronic medical record, or noted on this form as noted by you in the area below.  If you are using this form, please sign and date the attestation/addendum.
*******************************************************************************

The relationship between the documentation and the coding is a very intricate and oftentimes confusing process.  Every chart note, or clinical documentation the record must stand on its own merit.  If the record is audited, the coding should accurately reflect what was noted by the provider.   As a coder, the documentation should always clearly reflect this set of criteria listed below:

·         Clinical Evaluation and work-up to include any pertinent history
·         Diagnostic and/or Therapeutic Treatment(s) carried out or ordered (such as lab tests, x-rays etc.)
·         Continued plan of care or follow up plans
·         Clinical diagnosis of disease, signs and/or symptoms.
·         Documentation of patient education provided in regard to the above

The usage of an electronic medical record for outpatient care and office based services has also been instrumental in giving the coder a clearer picture of the overall care and services provided to the patient.  Many electronic medical records allow the physician to choose the ICD-10cm diagnosis code and include the additional supplies or procedures performed during the visit.  If the provider documents the diagnosis for any performed procedures via an electronic record, the coder now has the additional role of auditing the patient record and the actual diagnosis codes chosen by the provider prior to billing the 3rd party insurance payers. 

If upon review by the coder, that the physician or provider has not chosen the “most specific” of codes, the coder/auditor now has the unique opportunity to easily review, clarify and/or correct any errors quickly and easily prior to a claim being sent out.   In addition, some payers have the capability to accept electronic copies of the patients’ clinical documentation for their review or pre-authorization to expedite payment of services rendered.   

Outpatient and office based services are not always about illness.  Wellness services, preventive care, pre and post operative care, and specialty specific diagnosis care are all a part of outpatient and office based services.  ICD-10cm has accounted for these types of encounters.  If these encounters are well documented, they also need to be coded, billed and incorporated into the claim.  Many 3rd party payers are now providing coverage for payment of screening services.

The ICD-10cm coding guidelines give clear instruction for how these type of services are to be reported.  Again, it is the physicians role to clearly state within the clinical documentation that the patient has presented for a wellness exam, or has presented for screening testing for specific illnesses or diagnoses (such as a pap test for cervical cancer, a colonoscopy to screen for colon cancer, lab tests for elevated blood sugar/diabetes) .  In these cases the coding should reflect a clear diagnosis of screening.  The screening diagnosis may be the only diagnosis assigned, as it may truly be the only “reason” for the patient visit.  

It is becoming more common that the physician will be following and providing care for both an established chronic problem, and also “screen” for other issues during the same encounter.  If this is the case, the coder needs to audit and review the notes carefully to ensure that the record clearly denotes what has been performed in regard to “follow up” and what has been performed as “screening” (for either wellness, or a suspected illness)   If the record does not clearly show these as separately identifiable services, a physician query and/or addendum is in order.

Last but not least, always “code what the record shows”.  If you are in doubt, query.  Many coders rely on the old adage of “if it wasn’t documented, it wasn’t done”.   This type of coding should no longer be the rule of thumb or status quo.  As a good coder, if it appears in the clinical documentation,  a service or procedure was performed,(but poorly documented) it is well worth the time to investigate, confirm, have the record amended, then coded with accuracy.   




Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.   

HPV: Diagnostics, Coding and Insurance Coverage

HPV:  Diagnostics, Coding and Insurance Coverage
October 8, 2016
Lori-Lynne A. Webb

Human Papilloma Virus also known as HPV is the most common sexually transmitted infection in the United States. HPV is a virus, and is so common that nearly all sexually active men and women get it at some point in their lives. There are more than 150 different types and strains of HPV, and some of the types can cause health problems including genital warts and cancers. HPV is so common that nearly all sexually active men and women get it at some point in their lives.
HPV is named for the warts (papillomas) some HPV types can cause. There are some strains of HPV that can lead to cancer.  Most commonly these HPV strains have been linked to cervical cancer in women.  Unfortunately, there are more than 40 HPV types that can infect the genital areas of both men and women.  However, research has created vaccines that can prevent infection with some of the most common types of HPV.

Human Papillomavirus (HPV), low-risk types are associated with strain(s)  6, 11, 42, 43, 44.  High risk strains have been identified as strain(s) 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68. 

According to the Advisory Committee on Immunization Practices (ACIP) during its February 2015 meeting, it has been recommended that the  9-valent (9 different strains HPV vaccine; also known as 9vHPV) as one of three HPV targeted vaccines that can be used for routine vaccination.  The HPV vaccine is recommended for routine vaccination at age 11 or 12 years and they also recommend vaccination for females aged 13 through 26 years and males aged 13 through 21 years not vaccinated previously.  

Previously, the quadravalent (4-strain) HPV vaccine was only effective against HPV strain(s) 6, 11, 16 and 18.  The 9-valent vaccine is effective against HPV strains 6, 11, 16, 18, 31, 33, 45, 52, and 58.  

Prevention of cervical cancer due to HPV can be initiated with regular screening performed at the same time as the Papanicolaou screening test, also known as a Pap Smear, for cervical cancer.   The PAP looks for abnormal cells on the cervix that could turn into cancer over time. Screening does not eliminate the problem, it allows for these types of diagnoses to be found and treated before they turn into cancer.

ACOG has recommended that women should start getting regular Pap tests at age 21. For women ages 30 and older, the HPV test can be used along with the Pap test. Cervical cancer often does not cause symptoms until it is advanced. The Pap Smear and the HPV tests look for different things: The Pap test is a screening to check the cervix for abnormal cells that could turn into cervical cancer. The HPV test is performed to check the cervix for the virus (HPV) that can cause abnormal cells and cervical cancer.

CMS Policy:
In July of 2015, the Centers for Medicare & Medicaid Services (CMS) came out with the implementation of payment for screening for cervical cancer with HPV testing under National Coverage Determination policy 210.2.1.  Up until this change was implemented, Medicare was covering a screening pap and pelvic exam for its female beneficiaries every 12 or 24 month interval, based upon whether the patient was considered low or high risk.  Unfortunately, at that time HPV screening and testing was not paid for by CMS.   However, CMS has since determined that HPV screening/testing    
In conjunction with the Pap and Pelvic exam is of value, and will allow a screening test once per every 5 years, for beneficiaries aged 30 to 65 years

For Medicare beneficiaries (and some private payers too) HCPCS has implemented code G0476.  HCPCS 2017 Code : G0476; Infectious Agent Detection By Nucleic Acid (Dna Or Rna); Human Papillomavirus (Hpv), High-Risk Types (Eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) For Cervical Cancer Screening, Must Be Performed In Addition To Pap Test . 

The ICD-10cm codes used in conjunction with G0476 are:
1.     ICD-10 Z11.51 Encounter for screening for human papillomavirus (HPV) and Z01.411 Encounter for gynecological examination (general)(routine) with abnormal findings  
OR
2.     Z01.419 Encounter for gynecological examination (general)(routine) without abnormal findings

Once the claim is submitted to your CMS carrier (Such as Medicare,  True Blue, etc) 
a)     Medicare/Medicaid will not apply beneficiary coinsurance and deductibles to claims with the HCPCS code  G0476, HPV screening
 
b)    Part B claims can only be accepted with a Place of Service Code equal to ‘81’, Independent Lab or ‘11’, Office;

c)     This is only effective for claims with dates of service on or after July 9, 2015

d)    If your clams contain HCPCS G0476, HPV screening, more than once in a 5-year period [at least 4 years and 11 months (59 months total) must elapse from the date of the last screening] they will be denied.

e)     CMS will deny line-items on claims containing HCPCS G0476, HPV screening, If the beneficiary is less than 30 years of age or older than 65 years of age.

f)      If you know that the patient is not eligible for payment, then be sure to have the ABN signed, on file and submit the claim with the GA modifier. 

Some provider offices were having problems getting the code G0476 paid, with diagnosis code Z12.4 Encounter for screening for malignant neoplasm of cervix.  The issue with this ICD-10 code is that
a)     CMS policies are only for those FEDERAL programs such as Medicare/Medicaid/Tricare. and they don't necessarily pertain to private insurance payers (such as Blue Cross/Blue Shield/Aetna/etc... )
b)    The HCPCS code G0476 is actually the HCPCS code for the "lab test itself"    therefore that is why only those particular ICD-10 codes would be applicable. 
c)     The ICD-10cm code Z12.4 Encounter for screening for malignant neoplasm of cervix is exactly that -  it is for the"Encounter"  the Office/Visit  aka E&M code.  It not appropriate to append a ICD-10 “encounter for” code to a "lab test" code such as the G00476.
In January of 2015, CPT has revised the HPV test codes by deleting laboratory codes  87620-87622 and adding three new codes 87623-87625 Human Papilloma Virus (HPV).  These new codes have been added to differentiate between high and low risk HPV types.  Low-risk types would be reported with code 87623 and high-risk types with code 87624. Again, these are laboratory codes, not the codes you would normally use in the providers office. 


HPV Vaccinations and Cervical Cancer

Cervical Cancer has been one of the most common causes of cancer death for American women prior to Pap test.
Since the Pap test, cervical cancer mortality has declined by almost 70%.  Most cervical cancers occur in unscreened or
inadequately screened women. According to the American Cancer society, most cases of cervical cancer are diagnosed in women younger than 50, and more than 20% are diagnosed in women over the age of 65.  In the U.S., Hispanic women have been shown to be the most likely demographic to get cervical cancer, followed by African-Americans, Asians, Pacific Islanders, and Whites.  In women over the age of 30 HPV infections are more likely to be persistent and/or  high-grade.  Most HPV-related lesions progress slowly into a cervical cancer.  This slow rate of growth is somewhere between 3 – 7 years on average for a severe dysplasia to progress to invasive cancer.

The HPV strain 16 accounts for nearly 55 – 60%, and the HPV 18 strain accounts for approximately 10 – 15% of those that develop cervical cancer.  The ACS notes that about 10 other HPV strains cause remaining 25 – 35% of cervical cancers.  HPV vaccines are used to prevent HPV infection and therefore cervical cancer.  ACOG and the World Health Organization (WHO) have recommended for women who are 9 to 25 years old, and who have not been exposed to HPV receive the vaccination for HPV virus.  Since the vaccine only covers the partial listing of HPV strains, routine PAP smears should still be a part of cervical cancer screening.  Normally, the vaccines require two or three doses depending on how old the patient is. Vaccinating girls around the ages of nine to thirteen is typically recommended. The vaccines provide protection for at least eight years.  It has also been recommended that young and adolescent men ages 9–26 receive the HPV vaccine for the prevention of genital warts and anal cancer. 

The first FDA approved HPV vaccination came out in 2006 and were targeted to the four most common strains of HPV.  However, improvements and more research has continued to develop better vaccines which now target up to nine of the most common strains of HPV that can potentially cause cervical cancer. 

Coding, Clinical Documentation and Reimbursement

When coding the vaccinations for the HPV vaccine (such as GARDASIL®9 Human Papillomavirus 9-valent Vaccine, Recombinant) Below represents what would normally be coded from the physician/provider office. Modifier -51 should not be reported for vaccines  when performed with the administration procedure code .

90649
CPT
Human Papillomavirus vaccine, types 6, 11, 16, 18, quadrivalent (4vHPV), 3 dose schedule, for intramuscular use
90650
CPT
Human Papillomavirus vaccine, types 16, 18, bivalent (2vHPV), 3 dose schedule, for intramuscular use
90651
CPT
Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 3 dose schedule, for intramuscular use
90471
CPT
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)
Z23
ICD-10-CM
Encounter for Immunization


The clinical documentation for injections and infusions that are “vaccination” based need to clearly reflect this is a “vaccine” as a prophylactic measure and not a diagnostic or therapeutic service.  In addition be sure to inform the provider that these items should be clearly reflected in the record:

·         The site of the injection/infusion
·         The route of the administration (eg.  Intramuscular, subcutaneous, subdermal, intradermal)
·         The substance administered (eg Gardasil-9)
·         The number of units administered  
·         The medical necessity (eg diagnosis)

As, HPV vaccines are fairly new on the market not all insurance payers will reimburse for this service.   CMS/Medicaid eligible or those that have no insurance, may qualify for the Vaccines for Children (VFC) program or have these vaccines proved at a local Health Departments.   Private insurance payers such as Blue Cross, Blue Shield, Aetna, UHC, etc.. will varies based upon how the patient’s insurance plan is written and whether they have immunization coverage as a benefit

As a provider office, it is important that you check with the patients’ plan ahead of time to determine if they will pay for the cost of the vaccine.  If the private insurance payer does not cover the vaccine, the patient would be responsible for the cost.   In this instance it would be advisable to have the patient also sign an Advance Notice of potential non-payment and collect the cost of the service in advance. 

The “average” cost per single dose of an HPV vaccine can ranges between $175 – 250.00 per vial of vaccine serum,  plus an administration fee for the administration of the serum.   Three doses of the vaccine, spaced one month apart  are required to complete the series.  It is imperative that the patient understands the financial cost and the requirement of 3 visits to the provider to obtain the complete series for protection against HPV.




Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 25 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.   

ICD-10cm – 2017 Urinary Diagnosis Codes and Male Genito-urinary Code Update! (Part 2)

ICD-10cm – 2017 Urinary Diagnosis Codes and Male Genito-urinary Code Update!  (Part 2)
November 2, 2016

As we discussed in part one, the ICD-10CM code set used within the United States is maintained by the ICD Coordination and Maintenance Committee.  It is this organization that is responsible for putting for the additions, deletions, and updates to ICD-10-cm code set on a yearly basis.  This committee includes representatives from the National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS). 

The ICD-10cm guidelines, as well as the actual numeric code set, should be reviewed frequently and used as a vital companion reference when coding for diagnosis in physician based and clinical diagnosis services.  As a coding procedure, it is necessary to review all sections of the guidelines to fully understand all of the rules, procedural and instructional processes needed to code clinical documentation presented in the medical records properly. 

The complete ICD-10cm guidelines can be found at the beginning of your ICD-10cm 2017 book and/or e-files.   The new updates for the ICD-10 code set for 2017 actually went into effect on 10/01/2017.  If you haven’t downloaded the new codes, or purchased your books yet, you really need to!  Access to the new updates and revisions is an essential tool for coders and clinical providers.

As we look at some of the codes that affect Urology (genitourinary)  there are a couple of areas that include both male and female gender codes.  Even though we think of the “N” codes as primarily genito-urinary, some of the breast codes are also within the “N” code-set and affect both male and female gender.  Be aware that some carriers have edits in place, that some carriers use edits and tag certain diagnoses as “female” only codes, when in fact they should be for both genders.  If you are getting an edit or denial for an inappropriate gender, be sure to appeal, or contact the carrier/payer so the edit can be corrected. 

Most of the changes in the Urologic code-set is for the codes involving renal tubule-intersitial diseases within the codes of N10 – N16.  Of these the N10 is truly a three-character code, and the revision has been made to make it easier to understand. 

Revise from        N10 Acute tubulo-interstitial nephritis
Revise to           N10 Acute pyelonephritis
Revise from        Acute pyelonephritis
Revise to          Acute tubulo-interstitial nephritis

To completely understand this code revision, be aware that an Acute interstitial nephritis can be the cause of acute renal failure complicated by medications, infection, and/or other causes.  However, with this verbiage change, the physician or provider will only need to provide documentation for  "Acute Pyelonephiritis"  then if more documentation is found, the acute tubulo-interstitial nephritis will fall under this code set.

The next change is for the codeset of N13.  Within this code set there was an addition of the code N13.0 to denote hydronephrosis with a UPJ obstruction.  ICD-10cm also includes guideline direction for an excludes 2 note for the N13.0.  In addition, it includes the revision for verbiage in the N13.6 pyonephrosis code and expanded out that code set.  

Add     N13.0 Hydronephrosis with ureteropelvic junction obstruction
Add  Hydronephrosis due to acquired occlusion of ureteropelvic junction
Add          Excludes2: Hydronephrosis with ureteropelvic junction obstruction due to calculus (N13.2)
No Change     N13.6 Pyonephrosis
Revise from  Conditions in N13.1-N13.5 with infection
Revise to      Conditions in N13.0-N13.5 with infection

As we look at the codes within the code set of N30 – N39 Other diseases of the urinary system,  there were minimal changes, however, the N36.0 Urethral Fistula code had a small revision change, as the excludes 1 notes, show an expanded out code from N50.8  to N50.89 which is now a five-character code from a four-character code.

In the codes for other specified disorders of the urethra code N36.8;  ICD-10cm now denotes an "Excludes 1" notation 
No Change   N36.8 Other specified disorders of urethra
Add     Excludes1: congenital urethrocele (Q64.7)
           Add   female urethrocele (N81.0)


A small verbiage change was made for the code N39.42 as they added the diagnosis of insensible (urinary) incontinence under the code N39.42
No Change   N39.42 Incontinence without sensory awareness
                    Add Insensible (urinary) incontinence

The code set for N39.49 Other specified urinary incontinence actually added two new codes for 2017.  These additions are very important as the previous code set we had to choose a much more vague diagnosis, where these new codes give us much better specificity. 
Add N39.491 Coital incontinence
Add N39.492 Postural (urinary) incontinence


The next area of revision is within the codes specific to the male genital organs, and specifically regarding the prostate.  The N40 code set simply added some verbiage revisions  however, the N42.3 code set for dysplasia of prostate includes deletions within verbiage.  Below outlines the added new codes, which encompass the deletion verbiage within the previous "excludes" notes. 

No Change N42.3 Dysplasia of prostate
Delete Prostatic intraepithelial neoplasia I (PIN I)
Delete Prostatic intraepithelial neoplasia II (PIN II)
Delete Excludes1: prostatic intraepithelial neoplasia III (PIN III) (D07.5)

Add N42.30 Unspecified dysplasia of prostate

Add N42.31 Prostatic intraepithelial neoplasia
Add PIN
Add Prostatic intraepithelial neoplasia I (PIN I)
Add Prostatic intraepithelial neoplasia II (PIN II)
Add Excludes1: prostatic intraepithelial neoplasia III (PIN III) (D07.5)

Add N42.32 Atypical small acinar proliferation of prostate

Add N42.39 Other dysplasia of prostate

The N50 Other and unspecified disorders of male genital organs code set includes codes for much better specificity for genital pain.  ICD-10cm 2017 deleted many diagnoses that were previously housed within the code set to now having a specific diagnosis added for better specificity.  This is a huge boon to coders that previously used the non-specified codes for testicular pain and scrotal pain.   As you can see below, there is also added specificity for laterality on the testes.

No Change N50.8 Other specified disorders of male genital organs
Delete Atrophy of scrotum, seminal vesicle, spermatic cord, tunica vaginalis and vas deferens
Delete Edema of scrotum, seminal vesicle, spermatic cord, testis, tunica vaginalis and vas deferens
Delete Hypertrophy of scrotum, seminal vesicle, spermatic cord, testis, tunica vaginalis and vas deferens
Delete Ulcer of scrotum, seminal vesicle, spermatic cord, testis, tunica vaginalis and vas deferens
Delete Chylocele, tunica vaginalis (nonfilarial) NOS
Delete Urethroscrotal fistula
Delete Stricture of spermatic cord, tunica vaginalis, and vas deferens

Add N50.81 Testicular pain
Add N50.811 Right testicular pain
Add N50.812 Left testicular pain
Add N50.819 Testicular pain, unspecified

Add N50.82 Scrotal pain

Add N50.89 Other specified disorders of the male genital organs
Add Atrophy of scrotum, seminal vesicle, spermatic cord, tunica vaginalis and vas deferens
Add Chylocele, tunica vaginalis (nonfilarial) NOS
Add Edema of scrotum, seminal vesicle, spermatic cord, tunica vaginalis and vas deferens
Add Hypertrophy of scrotum, seminal vesicle, spermatic cord, tunica vaginalis and vas
deferens
Add Stricture of spermatic cord, tunica vaginalis, and vas deferens
Add Ulcer of scrotum, seminal vesicle, spermatic cord, testis, tunica vaginalis and vas deferens
Add Urethroscrotal fistula

ICD-10cm 2017 also addressed the erectile dysrunction codes and revised the verbiage, in addition to adding new codes for specificity.  The subtle verbiage change of "post surgical"  to "post procedural" is a huge change in interpretation for coding and payer compensation.  In addition to verbiage changes, the addition of four new codes will really enhance the coding specificity for urologic surgical procedures in relation to erectile dysfunction. The breakout below shows these revisions and additions.
Revise from N52.3 Post-surgical erectile dysfunction
Revise to     N52.3 Postprocedural erectile dysfunction

Add N52.35 Erectile dysfunction following radiation therapy

Add N52.36 Erectile dysfunction following interstitial seed therapy
AddN52.37 Erectile dysfunction following prostate ablative therapy
Add Erectile dysfunction following cryotherapy
Add Erectile dysfunction following other prostate ablative therapies
Add Erectile dysfunction following ultrasound ablative therapies
Revise from N52.39 Other post-surgical erectile dysfunction
Revise to     N52.39 Other and unspecified postprocedural erectile dysfunction
In part 1 of this article series we also addressed the mastitis codes below. Again, these codes are not necessarily "gender specific" and mastitis can develop in both male and female breasts.   We included these in both part 1 and part 2 of this series, as these codes truly cross the gender male/female anatomy boundaries.

ICD-10cm 2017 added
Add N61.0 Mastitis without abscess
Add Infective mastitis (acute) (nonpuerperal) (subacute)
Add Mastitis (acute) (nonpuerperal) (subacute) NOS
Add Cellulitis (acute) (nonpuerperal) (subacute) of breast NOS
Add Cellulitis (acute) (nonpuerperal) (subacute) of nipple NOS
Add N61.1 Abscess of the breast and nipple
Add Abscess (acute) (chronic) (nonpuerperal) of areola
Add Abscess (acute) (chronic) (nonpuerperal) of breast
Add Carbuncle of breast
Add Mastitis with abscess
The N64 category only had a minor change in the revision from a 5-character code to a 6-character code.
No Change N64.1 Fat necrosis of breast
No Change Code first
  Revise from:  breast necrosis due to breast graft (T85.89)
  Revise to: breast necrosis due to breast graft (T85.898)
This is also a "repeat" of information from part 1, in this 2 part series.  As we have previously reviewed for ICD-10cm 2017 pertaining to both urologic and gynecologic surgery, The following codes were revised and added to separate out terms that were previously combined. 
In N99.92 it states “Postprocedural hemorrhage and hematoma” and this was revised to simply be “post procedural” hemorrhage.  ICD-10 then included expansion for a 6th character for added specificity.   The verbiage removal of “hematoma” was then added to seroma and added to the code set N99.84, with the expansion of the 6th character for increased specificity. 
·         Revise from: N99.82 Postprocedural hemorrhage and hematoma of a genitourinary system organ or structure following a procedure

·         Revise to:  N99.82 Postprocedural hemorrhage of a genitourinary system organ or structure following a procedure

o    Revise from N99.820 Postprocedural hemorrhage and hematoma of a genitourinary system organ or structure following a genitourinary system procedure
o    Revise to N99.820 Postprocedural hemorrhage of a genitourinary system organ or structure following a genitourinary system procedure

o    Revise from N99.821 Postprocedural hemorrhage and hematoma of a genitourinary system organ or structure following other procedure
o    Revise to N99.821 Postprocedural hemorrhage of a genitourinary system organ or structure following other procedure

·         Add N99.84 Postprocedural hematoma and seroma of a genitourinary system organ or structure following a procedure

o    Add N99.840 Postprocedural hematoma of a genitourinary system organ or structure following a genitourinary system procedure

o    Add N99.841 Postprocedural hematoma of a genitourinary system organ or structure following other procedure

o    Add N99.842 Postprocedural seroma of a genitourinary system organ or structure following a genitourinary system procedure

o    Add N99.843 Postprocedural seroma of a genitourinary system organ or structure following other procedure

As ICD-10cm continues to be improved, we should also remember the goal of working hand in hand with the clinical providers of care to ensure that the clinical documentation of the patient record is clearly reflected by the procedure and diagnosis codes chosen and billed to the insurance payers.  The patients’ medical record documentation is essential for determining the most appropriate codes and reimbursement.  Failing to provide clear, concise and accurate documentation can lead to incorrect and/or inaccurate medical care and diagnosis; inappropriate or incorrect claims for services; claim denials or the worst case scenario of allegation of fraud/abuse.    The verbiage revisions,  added codes and expanded code set characters within ICD-10cm in 2017 is a welcome addition to making our job as coders that much better.


Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.