Wiki Mediastinal Mass

[Mrsrpc]

"PREOPERATIVE DIAGNOSIS: Anterior mediastinal mass. POSTOPERATIVE DIAGNOSIS: Anterior mediastinal mass |1|. PROCEDURE PERFORMED: Removal of anterior mediastinal mass by median sternotomy |2|. PLACE OF SERVICE: Hospital. INDICATIONS FOR PROCEDURE: The patient is a 66-year-old, white female who on CAT scan is noted to have anterior mediastinal mass |3|. The patient is taken at this time for surgical resection. INTRAOPERATIVE FINDINGS: Mass in the thymic tissue at the level of the innominate vein. The mass appeared to be thyroid tissue, however, there was no connection with the thyroid gland itself. DESCRIPTION OF PROCEDURE: The patient is taken to the operating room after adequate general endotracheal anesthesia and prophylactic antibiotics. The patient was prepped and draped in the usual sterile fashion. The chest was entered through a standard median sternotomy |4|. The thymic fat was removed from the top of the pericardium up to the innominate vein and the top of the thymic fat. The mass was dissected off the innominate vein and off the left subclavian vein. There were no attachments in the neck. The blood supply was coming in low lateral on the right off of the internal mammary artery. These branches were clipped and divided. The mass was removed on block and sent to pathology. The mass appears to be thyroid tissue, however, is not attached to the thyroid. The blood supply is coming off the right mammary. Following this the area was irrigated; hemostasis was completed. The chest tube was placed into the mediastinum |5|. The sternum was then closed with stainless steel wires. Most of the subcutaneous tissue was closed with running Vicryl subcuticular. 3-0 Vicryl was used to close the skin. Dermabond was applied and dry sterile dressing was applied. The patient received no blood or blood products and returned to recovery in good condition." ICD 10 R22.2 is the answer, but the 2023 ICD 10 code book describes R22 as Swelling, Lump or Mass of Skin and Subcutaneous tissue, with R22.2 being of the trunk. This is clearly not of the skin or SQ tissue; it's lined with connective tissue. I would have coded Disease of Mediastinum NEC. How can I not make this mistake again. I can very seriously argue why the book's answer is incorrect, given the different types of tissue involved. that's just basic A & P. Again, i don't think i can ever see things the way AAPC does

 

[thomas7331]

I understand and agree with your thinking process here. But to arrive at the right code, you have to follow the steps given in the guidelines of using the Alphabetic Index first. Under 'Mass' in the Alphabetic Index, there isn't a choice for 'mediastinal' - the next closest things are 'chest' or 'localized', both of which will direct you to R22.2. While it's true that this isn't a skin or subcutaneous mass, this is still arguably the correct code to classify this condition as documented here. If you follow the directions of the Alphabetic Index, your coding will be supported and is more likely to withstand an audit than if you try to find the best match in the code descriptor, because by doing that you don't have anything to fall back on in terms of being able to show that you followed the coding guidelines.

It may seem counterintuitive, but if you try to choose a code by trying to find the best match in the code descriptor for the condition, based on your knowledge of medical terminology or anatomy rather than of taking the pathway through the Alphabetic Index, you can often end up at the wrong code. Remember that a code isn't a diagnosis, it's just a classification of a group of documented conditions. There may be diseases classified under that particular code that don't necessarily match the wording in the code descriptor. Hope that makes sense and helps some.

 

[lgardner]

I understand and agree with your thinking process here. But to arrive at the right code, you have to follow the steps given in the guidelines of using the Alphabetic Index first. Under 'Mass' in the Alphabetic Index, there isn't a choice for 'mediastinal' - the next closest things are 'chest' or 'localized', both of which will direct you to R22.2. While it's true that this isn't a skin or subcutaneous mass, this is still arguably the correct code to classify this condition as documented here. If you follow the directions of the Alphabetic Index, your coding will be supported and is more likely to withstand an audit than if you try to find the best match in the code descriptor, because by doing that you don't have anything to fall back on in terms of being able to show that you followed the coding guidelines.

It may seem counterintuitive, but if you try to choose a code by trying to find the best match in the code descriptor for the condition, based on your knowledge of medical terminology or anatomy rather than of taking the pathway through the Alphabetic Index, you can often end up at the wrong code. Remember that a code isn't a diagnosis, it's just a classification of a group of documented conditions. There may be diseases classified under that particular code that don't necessarily match the wording in the code descriptor. Hope that makes sense and helps some.

One of the main rules, when learning about medical coding, is you MUST use BOTH the Alphabetic Index AND the Tabular List. I think this tends to fall to the wayside as coders become more experienced, but it is an important rule and Thomas' explanation of it, is really great.

 

[Mrsrpc]

Thank you @thomas7331 and @lgardner but the thing is: I DID use BOTH the alpha index and tabular list. I first looked at R22.2 but it says R22 is "localized swelling mass or lump of skin and subcutaneous tissue-- without a semicolon to separate the skin and subq tissue as separate from R22.2 which is of trunk in the Tabular list. So this (to me anyway) indicated that the "of skin and subQ tissue still carried down to the subsection of R22.2. So, being that that is Factually INcorrect as this tissue involved is NOT skin or subQ, I went BACK to the Alpha index to find "Mass Specified Organ NEC" which is factually correct as far what is going on with this patient. It then referred me to Disease by site in this case Mediastinum (which it IS) leading me to J98.59. I corroborated it with the Tabular Index J98.59 Diseases of the mediastinum, not elsewhere classified. The only thing excluded is absess, which this is not.

I'd honestly have more confidence explaining the path I took, using BOTH Alpha index and Tab list, than trying to explain that I coded for a diagnosis that the patient does NOT have. So this is why i don't understand how coders think. Rather than get the correct description of what is in the chart, is it better to be INcorrect with nothing able to support the dx code in the patient chart? (this would be rejected if I tried to argue medical necessity with this false diagnosis, and I have defended medical necessity for a living in court) I would totally lose if I did what was suggested, as I should. The teacher just reiterated the answer, nothing more. Not helpful. Also, I should note that there were examples in the integumentary chapters where coding was DICTATED BY which type of tissue was involved. How could this be any different?

 

[thomas7331]

Thank you @thomas7331 and @lgardner but the thing is: I DID use BOTH the alpha index and tabular list. I first looked at R22.2 but it says R22 is "localized swelling mass or lump of skin and subcutaneous tissue-- without a semicolon to separate the skin and subq tissue as separate from R22.2 which is of trunk in the Tabular list. So this (to me anyway) indicated that the "of skin and subQ tissue still carried down to the subsection of R22.2. So, being that that is Factually INcorrect as this tissue involved is NOT skin or subQ, I went BACK to the Alpha index to find "Mass Specified Organ NEC" which is factually correct as far what is going on with this patient. It then referred me to Disease by site in this case Mediastinum (which it IS) leading me to J98.59. I corroborated it with the Tabular Index J98.59 Diseases of the mediastinum, not elsewhere classified. The only thing excluded is absess, which this is not.

I'd honestly have more confidence explaining the path I took, using BOTH Alpha index and Tab list, than trying to explain that I coded for a diagnosis that the patient does NOT have. So this is why i don't understand how coders think. Rather than get the correct description of what is in the chart, is it better to be INcorrect with nothing able to support the dx code in the patient chart? (this would be rejected if I tried to argue medical necessity with this false diagnosis, and I have defended medical necessity for a living in court) I would totally lose if I did what was suggested, as I should. The teacher just reiterated the answer, nothing more. Not helpful. Also, I should note that there were examples in the integumentary chapters where coding was DICTATED BY which type of tissue was involved. How could this be any different?

I guess my first comment would be: welcome to the world of coding!

As I said in my earlier post above, I do actually agree with your thought process. I think you came to R22.2 and J98.59, then you are arriving at the two best codes to represent a condition that doesn't have its own specific code. Just based on my own experience in coding, I personally would select R22.2 because 1) an undiagnosed mass is generally considered a sign/symptom and not a disease, so the R code classification is more appropriate in that sense; and 2) the mediastinum is actually a location in the body and not an organ, so you're going to have more trouble defending that 'organ NEC' selection in the index if you're audited; and 3) though R22.2 does appears incorrect due to the category being a skin/subcutaneous mass, there is no excludes note there to direct you to a different place. When the Alphabetic Index clearly directs you to a code, if you let a contradictory code descriptor send you off into a search for a different code, this can get you into trouble more often than not, so I think this consideration weighs strongly.

All that said, I do think either of these codes is OK - neither one is clearly right or wrong and each has its own reasonable argument to support it. Truthfully, I think it's extremely unlikely that there would be any financial or compliance impact if one of the codes was selected over the other in a real-world situation. And it's completely normal for two different coders to come up with different sets codes for the same charts, especially in situations where guidelines aren't clear and when judgment is required. If I was auditing this case, I would consider both codes to be valid answers, and I would classify this as a 'variance' rather than an error. I've always advocated for taking an approach to coding that differentiates between a true error and simply a difference in judgement when navigating the grey areas of coding. Unfortunately, few organizations handle audits this way and most coders, when they select a code that is different from the code that the auditor selected, are simply assigned an error just as you were here. This is always demoralizing to coders (and physicians too, when they are audited on coding), and in my opinion, not a good way to manage coding quality. On the other hand, organizations never require 100% coding quality (and wouldn't ever get it if they did), so there's always a tolerance built in for these kinds of discrepancies, and a I think a coder's best attitude is to not to worry too much over every audit error - just make sure you're meeting or exceeding your quality goals and don't try to aim for perfection.

Just my thoughts and sorry to run on, but I hope that may help some.

 

[Mrsrpc]

I guess my first comment would be: welcome to the world of coding!

As I said in my earlier post above, I do actually agree with your thought process. I think you came to R22.2 and J98.59, then you are arriving at the two best codes to represent a condition that doesn't have its own specific code. Just based on my own experience in coding, I personally would select R22.2 because 1) an undiagnosed mass is generally considered a sign/symptom and not a disease, so the R code classification is more appropriate in that sense; and 2) the mediastinum is actually a location in the body and not an organ, so you're going to have more trouble defending that 'organ NEC' selection in the index if you're audited; and 3) though R22.2 does appears incorrect due to the category being a skin/subcutaneous mass, there is no excludes note there to direct you to a different place. When the Alphabetic Index clearly directs you to a code, if you let a contradictory code descriptor send you off into a search for a different code, this can get you into trouble more often than not, so I think this consideration weighs strongly.

All that said, I do think either of these codes is OK - neither one is clearly right or wrong and each has its own reasonable argument to support it. Truthfully, I think it's extremely unlikely that there would be any financial or compliance impact if one of the codes was selected over the other in a real-world situation. And it's completely normal for two different coders to come up with different sets codes for the same charts, especially in situations where guidelines aren't clear and when judgment is required. If I was auditing this case, I would consider both codes to be valid answers, and I would classify this as a 'variance' rather than an error. I've always advocated for taking an approach to coding that differentiates between a true error and simply a difference in judgement when navigating the grey areas of coding. Unfortunately, few organizations handle audits this way and most coders, when they select a code that is different from the code that the auditor selected, are simply assigned an error just as you were here. This is always demoralizing to coders (and physicians too, when they are audited on coding), and in my opinion, not a good way to manage coding quality. On the other hand, organizations never require 100% coding quality (and wouldn't ever get it if they did), so there's always a tolerance built in for these kinds of discrepancies, and a I think a coder's best attitude is to not to worry too much over every audit error - just make sure you're meeting or exceeding your quality goals and don't try to aim for perfection.

Just my thoughts and sorry to run on, but I hope that may help some.

Thank you for the clarification. I am getting frustrated by my lack of progress, and it seems it is only on the real-world type of questions, which many people who take a course don't even look at and still pass the test. That said, I still try to do these types of questions because I know they are the closest to what I'll see in actual practice. It's helpful to know that, while I may not see the documentation the way every single other person does, at least I'm not crazy ;0)