Anesthesia Coding Alert

Skipping the Tabular List can cause trouble for you and your patients.

Finding the correct diagnosis codes for a case can be hard enough. But you also need to make sure you’re following the rules for putting the codes in the proper order. Even anesthesia coders, who typically report only enough diagnosis codes to indicate the reason for surgery, need to know these rules.

For one thing, you should follow the official rules and guidelines. But these rules also are important when diagnoses help support a physical status code on a private insurance claim or when the diagnosis supports medical necessity for anesthesia for services that typically don’t require anesthesia.

Start here: Sequencing requires a firm understanding of how to navigate the ICD-10-CM code set, said Sharon J. Oliver, CPC, CDEO, CPMA, CRC, AAPC Approved Instructor, coding consultant and owner of Medical Coding & Consultants in Jonesborough, Tennessee, at the beginning of her HEALTHCON Regional 2022 presentation “ICD-10-CM Sequencing: The Right Way.” Instructions are woven into several sections of the diagnosis code set, including general and chapter-specific guidelines. The tips below can help take the confusion out of this nuanced area of diagnosis coding.

End Your Etiology/Manifestation Confusion

One element of sequencing that’s absolutely vital is abiding by the etiology/manifestation convention, says Jan Blanchard, CPC, CPMA, consultant at Vermont-based PCC.

ICD-10-CM Official Guideline 1.A.13 addresses this. Basically stated, it requires you to sequence the underlying condition first “if applicable, followed by the manifestation.” This refers to the Code first, Use additional code, and In diseases classified elsewhere notes you see in the tabular section of ICD-10-CM. “Use additional is the requirement that the underlying condition be sequenced first followed by manifestations,” Blanchard adds.

Example: Suppose documentation shows a patient has dementia due to Alzheimer’s disease and is displaying agitation. If you search for the Alzheimer’s disease codes (G30.-) first, you’ll find a Use additional code note that will direct you to codes for various conditions, including dementia with behavioral disturbance (F02.81-, F02.A1-, F02.B1-, F02. C1-). For the example, the relevant code is F02.811 (Dementia in other diseases classified elsewhere, unspecified severity, with agitation).

If you started by finding F02.811, you would see a symbol by that code showing that it is a manifestation code. A note with F02.- tells you to Code first the underlying physiological condition. One example is Alzheimer’s (G30.-).

Remember Medical and Financial Benefits of Accurate Coding

Clinically, of course, there are good reasons to follow the sequencing guidelines. “The code sequence paints a hierarchical picture of the patient’s condition, as the underlying causes and relationship(s) between diseases and symptoms are expressed by way of the codes’ place in the lineup,” Blanchard points out. From a coding perspective, this also means listing the most specific diagnosis codes first.

But as is so often the case in medical coding, there are also financial stakes attached to the guidelines. “Correct sequencing avoids denials and sometimes assures maximum benefits for the patients. Although many diagnosis codes can be included on a claim, some payers will only look at the first diagnosis code or the first few listed diagnosis codes when assigning benefits,” notes JoAnne M. Wolf, RHIT, CPC, CEMC, coding manager at Children’s Health Network in Minneapolis.

Sequencing also “grows ever more important as more and more carriers assign complexity scores to patients covered by value-based care plans,” Blanchard concludes.

Don’t Let Assumptions Derail Your Coding

“Stick with the very basics of ICD-10-CM coding: index first, then tabular,” says Blanchard. “So long as you always consult the tabular section of your ICD-10-CM manual when using a new-to-you code, you’ll never wonder if you’re working with a code for which sequencing rules need to be applied. Make sure to review pairs of Use additional code notes at the etiology code, and Code first notes at the manifestation code to ensure proper sequencing order in the guidance,” Blanchard adds.

Expert tips: “Tab your copy of ICD-10-CM with reminders. Often, instructions appear in one place, but aren’t repeated by each code,” said Oliver. “Everything needs to be read together. There is no such thing as remembering everything and knowing what to code without looking at the notes and the guidelines,” Oliver continued.

And think past the initial claim, too. When you report multiple diagnosis codes, not only do you need to be sure the documentation supports them, but you also need to be sure to provide that supporting documentation to an auditor or chart reviewer if the claim is chosen for review.