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Issue #42 - December 13, 2013

AAPC ICD-10 Tips and Resources


Featured Article
In the News
Coding Snapshot
ICD-10 Strategies
ICD-10 Resource


Code Set Boot Camps:
St. Louis, MO 12/19
Charleston, SC 12/19
Atlanta, GA 1/6
Atlanta, GA 1/9
Dallas/Ft Worth, TX 1/9
Jacksonville, FL 1/9
Fort Myers, FL 1/9

Implementation Boot Camps

Anatomy & Pathophysiology Online

Code Set Training


It's that time of year again. Time for family and friends to get together to celebrate the joy of the holiday season. Merry Christmas and Happy Holidays. Hope you enjoy the story.

Santa's Fall
A jolly old man in a red suit was up on the rooftop of the Moore house at approximately 22:00 hours on 12/24/13 when he W13.2XXA to the ground and suffered an S89.91XA, S79.911A, and S59.911A. A Mr. Clement C. Moore, who heard such a clatter and sprang from his bed to see what was the matter, called 9-1-1 and an ambulance arrived and rushed Mr. S. Claus to the local emergency department for immediate care.

A 2 view X-ray of the right hip, 2 view X-ray of the right tibia and fibula, and 2 view X-ray of the right forearm were orders as the patient complained of M25.551 and M79.661. The x-rays were interpreted by the Radiologist and the tibia/fibular x-ray confirmed a S82.221A. The other 2 x-rays came back normal.

While in the emergency department, the physician cleansed and closed a S51.811A with steri-strips. The physician also requested a consultation from the Psychiatry department because the patient continued to express concern over his "reindeer" and "getting toys delivered all over the world before morning." The Orthopaedic surgeon evaluated the patient in the ED and manipulated the fracture and applied a cast.

The psychiatrist, Dr. Virginia O'Hanlon, saw the patient and found him to be suffering from F43.11 and recommended placing the patient on Buspar.

The patient's lab work revealed that he had R73.9. He was also found to be E66.01. Upon questioning, the patient stated that his diet consisted mainly of cookies and treats. The patient was diagnosed with E11.9 with a recommendation for 500 milligrams of Metformin ER daily, and E66.01. He also had a Z68.42.

The patient was discharged from the emergency department at 0300 hours on 12/25/13. Post-discharge prescriptions were written, and discharge records were prepared. The Orthopaedic surgeon wanted to place the patient in a rehabilitation facility the patient refused stating that he just wanted to go home and that his wife and their many "little helpers" would take care of him.

The patient then laid a finger aside of his nose and a few seconds later all of the hospital could hear sleigh bells and the sound of hoof prints coming from the roof of the hospital. The patient was taken by wheelchair to the roof, where there was an elderly woman and many little people in an empty sleigh with 9 reindeer at the front. The woman stated that she and the "elves" had taken care of deliveries for the patient. The patient let out an elated, "Ho, ho, ho." They both entered the sleigh and the reindeers took flight. As they flew out of sight the hospital staff heard Santa proclaim, "Merry Christmas to all. ICD-10's out of sight!"

NOTE: Santa Claus, being well over the age of 65, has traditional Medicare as his primary payer. Of course, he could be considered a working elderly under Medicare but Santa, Mrs. Claus, and the elves are covered under a single, small group health plan with fewer than 20 employees. When Santa returned to the North Pole he filed suit against Mr. Moore because of the injuries sustained from the fall from the icy roof of Mr. Moore's house but the case was thrown out of court when Mr. Moore filed a trespassing charge against Santa stating he had no business being up on his roof in the first place.

Mr. Moore was added to Santa's naughty list.


NCD's and ICD-10
CMS has released updated National Coverage Determinations (NCD's) and Local Coverage Determinations (LCD's), along with Change Requests (CRs) associated with its ICD-10 conversion activities. They have produced a table that contains the information that will be updated periodically.


A patient presents to the urgent care center. She went out at 2:00 am the morning after Thanksgiving for Black Friday shopping to try to get some good deals. She arrived at Target and there were already a hundred other shoppers waiting. The patient lined up with the other shoppers outside the store. When the store opened, the patient was crushed in a stampede in the parking lot when everyone started running for the store. She is complaining of shortness of breath and painful respiration.

Upon examination, the patient is in apparent distress with elevated blood pressure due to pain. She is tender in the chest area. X-ray reveals fracture of 2 ribs on the right side and 1 rib on the left.

Assessment/Plan: Closed fracture of 3 ribs. Elevated blood pressure due to pain. Patient wrapped to decrease pain and assist with breathing. Prescription for pain medication given.

ICD-10-CM Codes:
S22.43XA Multiple fractures of ribs, bilateral, initial encounter
W52.XXXA Crushed, pushed or stepped on by crowd or human stampede, initial encounter
Y92.481 Parking lot as the place of occurrence of the external cause
Y93.02Activity, running
Y99.8 Other external cause status

Rationale: The guidelines (I.C.19.a) state that most categories in chapter 19 have a 7th character requirement for each applicable code. Most categories, with the exception of some fractures, have three 7th character values. In this case, the patient suffered multiple fractures. This is the first presentation of the patient for treatment, making it an initial encounter. There are two choices for subcategory S22.4-, Multiple fractures of ribs, A for initial encounter for closed fracture, and B, for initial encounter for open fracture. According to the guidelines (I.C.19.c) a fracture not indicated as open or closed should be coded to closed. The correct 7th character extender for this scenario is A.

With an the patient presents for the first time with an injury, depending on the payer, the external cause of morbidity codes may need to be reported. According to the guidelines (I.C.20.a.2), an external cause code, with the appropriate 7th character, should be assigned for each encounter for which the injury or condition is being treated. In this case, the external cause is the patient being crushed in a stampede.

Guideline I.C.20.b states that a place of occurrence code is used only once, at the initial encounter for treatment. In this case, this is the first presentation for treatment, so the place of occurrence, the parking lot, should be reported. There is no indication of the activity engaged in at the time of the injury, and as the patient is a child, the patient status is not applicable, so these two things would not be reported.

Guideline I.C.20.c. states a code from category Y93 should be assigned to describe the activity the patient was involved in at the time of the injury. An activity code is used only once, at the initial encounter for treatment.

Guideline I.C.20.k states a code from category Y99 should be assigned to indicate the work status of the person at the time the event occurred. In this scenario, the patient was out shopping, which would fit under "other external cause status."


We will be sharing a number of strategies to help your practice successfully implement ICD-10-CM. Please remember to track your progress in your ICD-10 Implementation Tracker on AAPC's website.

Assessing coverage determinations
Now that it is less than a year until ICD-10 goes live, it is time to start assessing payers' coverage determinations. You will want to look through them and see what ICD-10-CM codes will be acceptable for certain procedures under the new code set. This will give the practice time to discuss with the payers if there are codes that are not included that the practice believes should be covered. It will also assist decisions the practice may need to make in regards to participation in some plans. Depending on the number of plans that the practice participates in, this can be a lengthy process that needs to be done thoroughly in order to make sure that the practice does not suffer under ICD-10-CM.


Myocardial Infarction (MI) Quick Reference Guide
ICD-10 ResourceAAPC has created a coding resource for myocardial infarctions (MI). The resources are created to help make the transition to the new system. These complimentary sheets can be downloaded and make great desk references for your specialty practice.

ICD-10 Tips and Resources is offered as a benefit to AAPC members and we hope you find the information useful. If you'd rather not receive future issues of ICD-10 Tips and Resources, please log in to your account and change your email preferences.

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