ED Coding and Reimbursement Alert

Hint: Not all pneumonia codes are in the pneumonia section of ICD-10.

One of the most interesting features of working in an ED is that you see different diagnoses every day. But that can also be one of the most challenging parts of being in an ED, since you see so many varying conditions that it can be hard to keep track of the ICD-10 codes for all of them.

Check out the following three case studies and determine whether you can assign the right diagnoses for these conditions before you review the coding solutions.

1. General Abdominal Pain

Scenario:  A 37-year-old man presents to the ED with abdominal pain. The physician notes complaints of generalized abdominal pain for one day, with flatus, no vomiting or diarrhea. Last bowel movement (BM), the same morning, was of hard consistency. Abdomen examination reveals decreased bowel sounds, generalized tenderness to deep palpitation in abdomen. The provider finds there is no localized abdominal tenderness or any palpable masses during the exam and nothing remarkable shows up on ultrasound.

Coding Solution: Here you may have two options to choose from since the physician didn’t come to a definitive diagnosis. You may code R10.84 to denote generalized abdominal pain, and to depict generalized abdominal tenderness, you may report R10.817 (Generalized abdominal tenderness).

In abdominal pain coding, you will typically encounter only six characters, such as R10.811 (Right upper quadrant abdominal tenderness), found under R10.8 (Other abdominal pain). Typically, ICD-10 coding also depends on whether the patient is being seen for initial encounter or subsequent encounter but this is not the case in abdominal pain coding.

Some payers may give heavier “weight” to a report of tenderness rather than just pain, since this sometimes connotes a more serious cause, so if both are options, opt for R10.817, says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California.

2. Lymphoid Interstitial Pneumonia

Scenario: A 59-year-old male patient arrives at the ED with complaints of increasing dyspnea, chronic cough, and fever. Your physician performs a thorough evaluation, noting parotid enlargement, hepatosplenomegaly, and presence of lymphadenopathy. He orders a chest x-ray and pulmonary function tests to check for diffusing capacity and determination of lung volumes. He sends biopsy samples to the lab for histological studies, and subsequently confirms a diagnosis of idiopathic lymphoid interstitial pneumonia.

Coding Solution: To report this condition, you’ll assign code J84.2 (Lymphoid interstitial pneumonia), which isn’t actually included in the pneumonia section of the ICD-10 manual. Instead, you’ll find it in the “Other interstitial pulmonary diseases” section of the book. The best way to find codes when you can’t locate them in the pneumonia section is to use the index in the front of the ICD-10 manual.

3. Systolic Heart Failure

Scenario: A patient presents with dyspnea and peripheral edema, and says that she has had a cough for about two weeks. The ED physician performs an examination and finds that the dyspnea has been happening for several months, and is worse on exertion. The physician orders an ECG and chest x-ray, as well as brain natriuretic peptide (BNP) tests. He documents a diagnosis of HFrEF in the documentation, indicating heart failure. Which code should you report?

Coding Solution: When the physician writes HFrEF, that’s the acronym for heart failure with reduced ejection fraction, which is also known as systolic heart failure. When a patient has systolic heart failure, the left ventricle of her heart is not able to contract normally, so her heart can’t pump with enough force to push enough blood into circulation.

If you look under category I50.2- (Systolic (congestive) heart failure), you will see two included conditions -- heart failure with reduced ejection fraction (HFrEF) and systolic left ventricular heart failure. This is where your HFrEF acronym comes into play.

When you are reporting systolic congestive heart failure, look to the following code choices:

• I50.20 (Unspecified systolic (congestive) heart failure)
• I50.21 (Acute systolic (congestive) heart failure)
• I50.22 (Chronic systolic (congestive) heart failure)
• I50.23 (Acute on chronic systolic (congestive) heart failure).

If the physician doesn’t have any additional details in the documentation, you should ask for more information so you can select the right code.