Code to the Highest Severity
Learning how to follow sequencing instructional notes will guide you to the correct ICD-10 code.
By Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC
With less than a year until ICD-10-CM implementation, you’re probably wondering what the most important message I could deliver to you is to help you prepare. My answer, simply put: Know the coding guidelines. Learning the guidelines will make you an exceptional coder capable of coding all circumstances.
Follow Sequencing Notes
For instance, hierarchy is important in coding. To ascertain hierarchy, you must follow sequencing instructional notes in ICD-10-CM.
Tim has been seen in the past for his continued drug use. He came in recently to visit the doctor and it was apparent he was high. He tells the doctor he keeps trying to stop using, but he just can’t do it. The doctor documents that the patient feels miserable waiting for his next hit. He can’t keep his job and his dependence on his drug abuse is wreaking havoc with his life. The doctor documents use, abuse, and dependence on marijuana.
In this case, you should report only the dependence. It’s not necessary to report the use and abuse. ICD-10-CM Official Guidelines for Coding and Reporting 2014, I.C.5.c.2 states:
Psychoactive Substance Use, Abuse And Dependence
When the provider documentation refers to use, abuse, and dependence of the same substance (e.g. alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern of use based on the following hierarchy:
If both use and abuse are documented, assign only the code for abuse
If both abuse and dependence are documented, assign only the code for dependence
If use, abuse and dependence are all documented, assign only the code for dependence
If both use and dependence are documented, assign only the code for dependence.
In other words: Code to the highest severity. This rule is repeated throughout the guidelines.
Tim is now being seen for his withdrawal symptoms from his drug use. He is experiencing mood swings and disruption in his sleep patterns, as well as weight loss and digestive problems. The physician diagnoses him with marijuana dependence with withdrawal.
In this case, you would code the drug dependence with withdrawal. You would not code the mood swings, sleep disruption, weight loss, or digestive problems because they are routine signs and symptoms of drug withdrawal. ICD-10-CM Official Guidelines for Coding and Reporting 2014, I.C.18.b states:
Use of a Symptom Code with a Definitive Diagnosis Code
Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code.
Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
Learn by Doing: Multiple External Cause Guidelines
See if you can determine correct coding for the next example based on ICD-10-CM Official Guidelines for Coding and Reporting 2014, I.C.20.f:
More than one external cause code is required to fully describe the external cause of an illness or injury. The assignment of external cause codes should be sequenced in the following priority:
If two or more events cause separate injuries, an external cause code should be assigned for each cause. The first-listed external cause code will be selected in the following order:
External codes for child and adult abuse take priority over all other external cause codes.
See Section I.C.19., Child and Adult abuse guidelines
External cause codes for terrorism events take priority over all other external cause codes except child and adult abuse.
External cause codes for cataclysmic events take priority over all other external cause codes except child and adult abuse and terrorism.
External cause codes for transport accidents take priority over all other external cause codes except cataclysmic events, child and adult abuse, and terrorism.
Activity and external cause status codes are assigned following all causal (intent) external cause codes.
The first-listed external cause code should correspond to the cause of the most serious diagnosis due to an assault, accident, or self-harm, following the order of hierarchy listed above.
A 40-year-old patient is treated for a left tibial fracture after being abused during a terrorism attack. At the same time this was going on, he was worried an approaching hurricane was going to destroy the truck he had wrecked while trying to escape the terrorists.
According to the guidelines, we would sequence in the following order:
- Fracture of the left tibia
- Adult abuse
- Cataclysmic event
- Transport accident
Chances are you will never see a terrorist attack during a hurricane that involves abuse and a transport accident, but you will see complex coding situations that will come into play in your day-to-day coding. Learn the guidelines. If you are good with the ICD-9-CM guidelines, the ICD-10-CM guidelines will fall into place for you.
Let me hear you say it: I Can Do 10!
Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC, is vice president of ICD-10 Training and Education at AAPC. She is a member of the Oil City, Pa., local chapter.