ED Coding and Reimbursement Alert

From vomiting to pressure ulcers, new codes debuted in October for these conditions.

Although the 2020 ICD-10 codes have been in effect since October 1, it’s possible you haven’t had occasion to report many of them yet. Therefore, it’s a good time to test yourself to ensure you know all the new, revised, and deleted diagnosis codes so you can submit accurate claims in the new year.

Determine whether you can answer the following questions before reading the answers.

Cyclical Vomiting Syndrome Has New Code

Question 1: A 7-year-old patient presents to your ED and the parents say she won’t stop vomiting. They tell you that the patient has cyclical vomiting syndrome but hasn’t had a vomiting spell for four months. However, in the past two days, the patient has been vomiting almost every hour. Which diagnosis code applies?

Answer 1: Because the patient’s cyclical vomiting is completely unrelated to any migraines based on this description, you’ll report new code R11.15 (Cyclical vomiting syndrome unrelated to migraine). In the past, you would probably have reported R11.10 (Vomiting, unspecified), but the new options for 2020 give you more flexibility and specificity in coding this condition.

If you see a patient with cyclical vomiting due to a migraine, however, you’ll report one of these two codes, which were revised for 2020:

• G43.A0 (Cyclical vomiting, in migraine, not intractable)
• G43.A1 (Cyclical vomiting, in migraine, intractable).

You would select between these two codes depending on whether the vomiting is intractable (meaning it cannot be controlled).

Get Site-Specific for Pressure Damage

Question 2: A 66-year-old patient presents to the ED with pressure-induced deep tissue damage on her right heel, although the ED physician does not specifically document it as an ulcer. Which code applies?

Answer 2: Effective Oct. 1, ICD-10 has gotten extremely specific with its tissue damage and pressure ulcer diagnosis codes, noting the ulcer stage and location with new and revised codes. One welcome change to the code set for 2020 is the addition of pressure-induced deep tissue damage codes, which apply when the tissue damage falls short of being classified as a staged pressure ulcer. The new codes are as follows:

• L89.506 (Pressure-induced deep tissue damage of unspecified ankle)
• L89.516 (… of right ankle)
• L89.526 (… of left ankle)
• L89.606 (… of unspecified heel)
• L89.616 (… of right heel)
• L89.626 (… of left heel)

Therefore, in this situation, you’d report L89.616 since the deep tissue damage was pressure-induced and occurred on the patient’s right heel.

Denote Presence of Cor Pulmonale for Pulmonary Embolism

Question 3: A 66-year-old patient presents complaining of shortness of breath, and after running a series of tests, the ED physician diagnoses her with a single subsegmental pulmonary embolism. There is no cor pulmonale present. Which code should you report?

Answer 3: The 2020 ICD-10 code set includes a wide variety of additions to the I26.9 category (Pulmonary embolism without acute cor pulmonale), and the one that applies to this situation is I26.93 (Single subsegmental pulmonary embolism without acute cor pulmonale).

What that means: “Cor pulmonale” refers to an abnormal enlargement of the right side of the heart due to a disease of the pulmonary blood vessels or the lungs. It’s very important that physicians document whether cor pulmonale is present now that the diagnosis codes are dependent on it. If you don’t know the type of pulmonary embolism, however, you can always report pulmonary embolism not otherwise specified (NOS), which is coded with I26.99.

Eyeball S02.12 for Orbital Roof Fracture

Question 4: The ED physician sees a patient who was in a car accident and is brought in via ambulance. The patient says she feels fine except for some pain in her left eye where her face hit the steering wheel. The ED physician performs an X-ray and diagnoses the patient with a fracture of the orbital roof on the left eye. Which diagnosis code applies?

Answer 4: About 20 new diagnoses joined the ICD-10 code set this year to reflect orbital fractures, including S02.12 (Fracture of orbital roof), which is the best option for this situation. This code expands out to seven characters to reflect the location of the fracture and whether you see the patient during the initial or subsequent encounter (or if you’re treating sequela).

In this case, you’re treating the left eye for an initial encounter, so the appropriate diagnosis code is S02.122A (Fracture of orbital roof, left side, initial encounter…).