ICD 10 Coding Alert

If you don’t know the diabetes type, you should default to this.

If you missed a key ICD-10 concept in your training, you could be setting yourself up for some headaches after October 1 hits. Check that you haven’t missed these details by looking at these five questions and answers.

Questions 1, 2 Brush Up Your Basics

Question 1: In ICD-10-CM, how many characters can a valid diagnosis be?

Answer 2: Your codes can be 3 to 7 characters in length.

Reference: Official Coding Guidelines Section I.A.2

Question 2: When you see an Excludes 2 note below an ICD-10-CM code, what does it mean?

Answer 2: A type 2 Excludes note represents “Not included here.” An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

Reference: Official Coding Guidelines Section I.A.12

Confront Borderline Diagnoses for Question 3

Question 3: Your physician documents the patient has “borderline diabetes.” How should you report this?

Answer 3: When your physician documents a borderline diagnosis at the time of discharge, then you should code the condition/disease as confirmed — unless the classification provides a specific entry (e.g., borderline diabetes). If a borderline condition has a specific index entry in ICD-10-CM, then you should code this diagnosis that way. Since borderline conditions are not uncertain diagnoses, you should not make any distinction between the care setting (inpatient versus outpatient).

Important: Whenever the documentation is unclear regarding a borderline condition, you should query your physician for clarification.

Reference: Official Coding Guidelines Section I.B.17

Highlight Your “Default” When Type Not Documented

Question 4: Your physician sees a 16 years old patient for diabetes but does not specify the type. What should you do?

Answer 4: You should assign a code from category E13.- (Other specified diabetes mellitus). The age of the patient is not the sole determining factor for the type of diabetes.

Default: When the type of diabetes mellitus is not documented, the default category is E11 (Type 2 diabetes mellitus).

Reference: Official Coding Guidelines I.C.4.a.1 and I.C.4.a.2

Zero In On Your Primary Diagnosis In Chemo Scenario

Question 5: Your physician admits a patient for chemotherapy. She develops uncontrolled nausea and vomiting following the treatment. She is receiving the chemotherapy for ovarian carcinoma with lung metastasis. What should be your principal/first-listed diagnosis?

Answer 5: You should report Z51.11 (Encounter for antineoplastic chemotherapy). When a patient is admitted for the purpose of chemotherapy and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal or first-listed diagnosis is Z51.11.

Reference: Official Coding Guidelines, I.C.2.e.2 and I.C.2.e.3