Wiki Amputation ICD10

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annettebec

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Toes, first and second left toes, amputations:
First and second toe with ulcer, necrosis, and acute and chronic inflammation

What ICD10 would you assign? Any help appreciated
 
Hi annettebec,
There is a little more information needed please for diagnosis assignment. What did the gross and microscopic portions state? Sometimes reviewing those areas of the pathology report is what you need for proper diagnosis assignment.
Let me just throw out a fictional pathology report from the top of my head using your information:

Final diagnosis:
First and Second Left Toe:
Ulcer, necrosis and acute and chronic inflammation

Microscopic:
Both the left hallux and the index toe have both intermediate and surface necrosis of the bone. The soft tissue and skin have necrosis and both acute and chronic inflammation throughout.

Macroscopic:
Received in Specimen bucket labeled AB-999-99999 two individual pieces of tissue with bone.
The first piece is labeled A1A is grossly necrotic measuring 5x4x3 cm and is a dusky red to black tone that is odorous
Representative samples are placed in A1A, A2A, A3A and A4A
The other piece is labeled with A2B that is also grossly necrotic and measures 6x2x2 cm and is dusky red to black tone and the bone is exposed from the tip of the specimen. A small piece from the tip was decalcified and placed in A2B and representative sections were placed in A3B, A4B, A5B, A6B, and A7B.

What did you actually bill for CPT codes? Was it all bundled under one 88305x1 kind of thing? Or did your pathologist's separately identify one specimen from the other in the Gross description to bill them separately? Does my coding scenario make sense to you on what to be looking for?
Please reach out if this didn't assist you, normally the answers I would be looking for would be in the gross and microscopic portions of the pathology report. Yes we focus on the final rendered diagnosis but sometimes the other information we may need for diagnosis code assignment may be located elsewhere.
Have a great evening and reach out if you have any questions,
Dana
 
A Toe, 1ST, 2ND TOE LEFT
.
Clinical History
Trench foot, left

Gross Description
A. Toe
Received in formalin labeled left first and second toe are 2 disarticulated digits. The first toe measures 3.5 x 3 x 3
cm. It contains a large necrotic appearing ulcer on the plantar surface that measures 3.5 x 3 x 2 cm and extends
to the soft tissue resection margin. Second toe measures 3 x 2 x 2 cm. The distal portion of this digit is black.
There is a red-tan ulcerated area on the dorsal aspect of the digit that measures 2 x 1.5 cm and extends to within
0.2 cm of the resection margin. The resection margins of both digits are inked black. Representative sections of
each toe are submitted following decalcification.
A1. Representative cross-section of first toe
A2. Representative cross-section of second toe

Included the rest of the pathology report. Any help appreciated. Thank you
 
Hi annettebec,
If I was coding this accession, I would assign diagnosis code I96 for this scenario. There is no mention of it within the bone.
The reason I state that is we have "necrotic". Reviewing the ICD book for that term in the index it also states to see "gangrene". I moved to the Ulcer section of the index in my ICD book and there is no mention of "necrotic" but if you look at "gangrenous" it states to - "see gangrene". When I review the gangrene in the index it includes (connective tissue) (dropsical) (dry) (moist) (skin) (ulcer) with I96 as the diagnosis code. I therefore moved to the tabular list to validate the diagnosis assignment.
I would have also applied Z89.412 acquired absence of left great toe along with Z89.422 acquired absence of other left toe(s). That is extremely important in my opinion for continued care. I do not know if patient has other medical conditions and with missing two left toes may need assistance with walking, diabetes, so forth and would want this part of their medical record.
I hope I have answered and explained my thought process on how I would have assigned this accession.
Please reach out if you have any additional questions,
Dana
 
danachock said:
Hi annettebec,
If I was coding this accession, I would assign diagnosis code I96 for this scenario. There is no mention of it within the bone.
The reason I state that is we have "necrotic". Reviewing the ICD book for that term in the index it also states to see "gangrene". I moved to the Ulcer section of the index in my ICD book and there is no mention of "necrotic" but if you look at "gangrenous" it states to - "see gangrene". When I review the gangrene in the index it includes (connective tissue) (dropsical) (dry) (moist) (skin) (ulcer) with I96 as the diagnosis code. I therefore moved to the tabular list to validate the diagnosis assignment.
I would have also applied Z89.412 acquired absence of left great toe along with Z89.422 acquired absence of other left toe(s). That is extremely important in my opinion for continued care. I do not know if patient has other medical conditions and with missing two left toes may need assistance with walking, diabetes, so forth and would want this part of their medical record.
I hope I have answered and explained my thought process on how I would have assigned this accession.
Please reach out if you have any additional questions,
Dana
Click to expand...
Hi ladies,
Diagnosis for partial amputation, just the tip, not entire phalanx.. distal half per documentation.
Not sure if I should assign Z89.422 since it was only a portion of the toe.
Any insight appreciated. Thanks
 
Hello hbell339@gmail.com,
You have a fantastic question! When I was a just a pathology coder, I would have assigned the Z89.422 in addition to the rest of the findings in the pathologist's interpretation. Please, allow me to explain my rationale.
First our ICD book states when you refer to Absence (of) (organ or part) (complete or partial). I would try to portrait the history. I don't remember which webinar or seminar I attended, but it was providing the entire picture of what happened.
I also do remember a different either webinar or seminar I attended that stated that a toe amputation may result in loss of ambulation and may require assistance (such as a walking device, or special shoes, or so forth). Therefore, in my thought process, I thought that providing the absence (that our ICD book provides assistance with) may assist in capturing potentially medical necessity.
I am hopeful that I may have provided some assistance with your question.
Thank you for your listening,
Dana
 
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