Urology Coding Alert

See how the correct choice hinges on your knowledge of anatomy and terminology.

Procedures involving catheter insertions typically go off without a hitch. However, those inevitable mechanical complications that occur are sure to extend all the way to your diagnosis code reporting.

In most cases, remedying a mechanical catheter complication is as simple as a removal and replacement. The same can’t always be said for the coding breakdown. As you’ll see, reaching the correct code requires more than just a foundational knowledge of anatomy. You also need to be able to seamlessly maneuver between the ICD-10-CM Alphabetic Index and Tabular.

Take your catheter complication coding skills to the next level by tackling these two examples.

Consider ICD-10-CM’s Choice of Catheter Complication Terminology

Example: A patient is experiencing pain following placement of a hemodialysis catheter. Further evaluation reveals that the tip of the catheter has broken off.

Coding this case presents a slight challenge unless you’re fluent with hemodialysis catheterizations.

There’s more than one route within the ICD-10-CM Alphabetic Index to the correct code, but a practical starting point is “Complication(s) (from) (of)” since the diagnosis is the direct result of a procedure. From there, you’ll encounter the following sub-terms: catheter (device) ? dialysis (vascular). So long as you’re familiar with the ICD-10-CM code book’s classification of a broken catheter as a “mechanical breakdown,” the rest is smooth sailing. Continuing within the Alphabetic Index, mechanical ? breakdown will land you at code T82.41XA (Breakdown (mechanical) of vascular dialysis catheter, initial encounter).

Discern Between Breakdown and Displacement Terms

Example: A pelvic X-ray reveals a dislodged Foley catheter used for a patient with urinary retention.

Using what you’ve learned in the previous example, you might assume you’ve got the perfect start within the Alphabetic Index. However, you must make sure you avoid not one, but two, fatal mistakes along the way.

You might initially assume that a dislodged catheter meets the same criteria as a “breakdown” of a catheter, but not so fast. The ICD-10-CM code book considers a fractured (or broken) catheter a “breakdown.” But other terms exist as well. In the case of this second example, a “dislodged” catheter meets the criteria for “displacement.”

Coder’s note: “Catheterization displacements and breakdowns have different consequences and rely on different treatment plans,” says Sheri Poe Bernard, CPC, of Poe Bernard Consulting in Salt Lake City. “Relaying these individual diagnoses accurately is vital to coding, reporting, and outcomes tracking — even when it results in no change in payment,” explains Bernard.

Even with this knowledge on hand, you’re not out of the woods yet. Before going any further within the Alphabetic Index, you should take a moment to understand the difference between a few key terms. “When you see the term ‘infusion,’ as it pertains to catheterizations, you should know that you’re working with catheters inserted into either a large vein or artery,” says Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. That point immediately disqualifies any code documented as an “infusion” for coding of this example.

You should also have a proper understanding of what a Foley catheter is, so you don’t feel inclined to go the route of “urinary NEC,” when sub-terms “urethral indwelling” and “urinary NEC” are present. Consider the Dorland’s Illustrated Medical Dictionary definition of Foley catheter: “An indwelling catheter that has a balloon filled with air or liquid to retain it in place in the bladder”

An indwelling catheter is a catheter inserted into the bladder through the urethra. Keep in mind that this description perfectly aligns with the sub-term “urethral indwelling” when you see it listed as an Alphabetic Index sub-term.

Since “breakdown” won’t be included in the code description for this example, you want to take a different approach to reach the correct code. While there are a variety of routes, stay within “Complication(s) (from) (of)” to get to the final diagnosis code. From that key term, go to catheter (device) ? urethral ? indwelling ? displacement, leading you to T83.021A (Displacement of indwelling urethral catheter, initial encounter).