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Pre-Procedural Anxiety DX for Spinal Injections

  1. #1
    Post Pre-Procedural Anxiety DX for Spinal Injections
    Medical Coding Books
    I code for a couple of anesthesiologists in a Pain Management practice who use sedation during epidural steroid injections, radiofrequencies, nerve root blocks, etc. to ensure that the patient's anxiety does not prevent them from correctly placing needles into the patient's spine. In order to correctly bill moderate sedation, I need the appropriate medically necessary ICD-10 code for pre-procedural anxiety. I think this code should be F41.9 as it includes Anxiety NOS. I work with another coder who disagrees, as this is an unspecified code. Not every patient that we treat is sedated, but most seem to be, and if time isn't met for sedation to be billed, they self-pay for the sedation.

    "Pre-op evaluation: ASA 2, anxious about procedure, requests sedation" is usually what is documented by the doctors.

    I have only been coding for 6 months, and I am wondering if anyone has guidance for me that will assist me in properly coding the moderate sedation for these procedures. I have noticed that the LCD for Jurisdiction F (Utah) was really only for MAC, even though moderate is mentioned.

    Thanks for any help you may have. I find it really difficult to get a cited, straightforward answer to my coding questions, so yours are valued.

  2. #2
    Default
    I'm also seeing F43.0 "Acute stress reaction" as a possibility, maybe?

  3. #3
    Default
    F40.231
    Fear of injections and transfusions

    F41.9
    Anxiety disorder, unspecified

    Z92.83
    Personal history of failed moderate sedation

    _________________________________________
    Above are some ICD-10 codes that come to mind. For radiofrequency ablation, I believe you will find per the local coverage determinations policies that it is understood by the carrier that sedation is required for this type of procedure although some might also have policy against paying for anesthesia for pain management procedures. Another option is not just ICD-10 for anxiety but a medical necessity form that is filled out by the physician that covers multiple risk factors that patient might have and why the patient would benefit from sedation. When reviewing "Acute Stress Reaction" a lot information comes up about that condition and it might over reach what is trying to relayed Below is some information that I was looking at on that condition:

    Acute stress reaction (also called acute stress disorder, psychological shock, mental shock, or simply shock) is a psychological condition arising in response to a terrifying or traumatic event. It should not be confused with the unrelated circulatory condition of shock.

    "Acute stress response" was first described by Walter Cannon in the 1920s as a theory that animals react to threats with a general discharge of the sympathetic nervous system. The response was later recognized as the first stage of a general adaptation syndrome that regulates stress responses among vertebrates and other organisms.

    The onset of a stress response is associated with specific physiological actions in the sympathetic nervous system, both directly and indirectly through the release of adrenaline and to a lesser extent noradrenaline from the medulla of the adrenal glands. These catecholamine hormones facilitate immediate physical reactions by triggering increases in heart rate and breathing, constricting blood vessels. An abundance of catecholamines at neuroreceptor sites facilitates reliance on spontaneous or intuitive behaviors often related to combat or escape.

    Normally, when a person is in a serene, unstimulated state, the "firing" of neurons in the locus ceruleus is minimal. A novel stimulus, once perceived, is relayed from the sensory cortex of the brain through the thalamus to the brain stem. That route of signaling increases the rate of noradrenergic activity in the locus ceruleus, and the person becomes alert and attentive to the environment.

    If a stimulus is perceived as a threat, a more intense and prolonged discharge of the locus ceruleus activates the sympathetic division of the autonomic nervous system (Thase & Howland, 1995). The activation of the sympathetic nervous system leads to the release of noradrenaline from nerve endings acting on the heart, blood vessels, respiratory centers, and other sites. The ensuing physiological changes constitute a major part of the acute stress response. The other major player in the acute stress response is the hypothalamic-pituitary-adrenal axis.

  4. #4
    Smile Sorry... more questions about this.
    Thank you so much for the F40.231 and Z92.83 information. I am having trouble understanding what Failed Moderate Sedation means, and why it would necessitate moderate sedation in future procedures. Could you explain?

    Would you agree that F41.8 is inappropriate for "anxious about procedure?" The description states "Other specified anxiety disorders" and conditions included (but not limited to??) in this code are: "Anxiety with depression," (which, upon researching, I found takes 6 months to diagnose), "Anxiety hysteria," and "Mild anxiety and depressive disorder." I feel uncomfortable using this unless there is documentation of anxiety and depression or anxiety hysteria specifically in the note. Any thoughts?

    I'm also trying to understand why a patient's long-term use of opiate analgesic (Z79.891) constitutes necessity for sedation. Do you have any insight on this?

    I also understand that in many cases, the unspecified code is the most appropriate- however, do you have any knowledge about whether or not these codes are non-payable by the majority of carriers? I've heard that the clearinghouse will reject them or they will be red-flagged. Is this correct? Should I counsel the physicians against using these unless they are the last resort (F41.9, for example)?

    Thank you for your time, patience, and knowledge.

  5. #5
    Default
    The failed moderate sedation code would be to indicate that is the reason you are not billing for example 99144 and are billing 01936 done by a separate provider using MAC or general anesthesia, but this might be something that the provider fails to documents the reason conscious sedation can not be used and instead MAC or general by a separate provider.

    With other specified anxiety disorders, I think "other" versus "unspecified" would be for a condition that ICD-10 does not have a specific entry to describe the condition, I don't know if having anxiety about having a needle placed in your spinal region is a condition or more just a general concern about the pain that has to be endured and the concern about dural puncture or other complications that could result. So I think other or unspecified would be ok but Anxiety NOS (not otherwise specified) the generic form of having anxiety about having injection procedure can be just an unspecified code. And not think that the clearinghouse will be holding the claim for that diagnosis. Below is excerpt from AIHMA & CMS regarding unspecified ICD-10 codes and the coverage. In regards to Z79.891, I think Z79.891 might mean the patient has had tolerance for certain medications that might affect a response to a lower level of sedation for the patient.

    F41.8
    Other specified anxiety disorders

    Anxiety depression (mild or not persistent)
    Anxiety hysteria
    Mixed anxiety and depressive disorder

    Below is a CMS link

    https://www.cms.gov/Medicare/Coding/...10Overview.pdf

    In both ICD-9-CM and ICD-10-CM, sign/symptom and unspecified codes have acceptable, even necessary, uses. While you should report specific diagnosis codes when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, in some instances signs/ symptoms or unspecified codes are the best choice to accurately reflect the health care encounter. You should code each health care encounter to the level of certainty known for that encounter.
    If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (for example, a diagnosis of pneumonia has been determined but the specific type has not been determined). In fact, you should report unspecified codes when such codes
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    most accurately reflect what is known about the patient’s condition at the time of that particular encounter. It is inappropriate to select a specific code that is not supported by the medical record documentation or to conduct medically unnecessary diagnostic testing to determine a more specific code.





    Below is from AIHMA

    http://bok.ahima.org/PdfView?oid=300625


    Using Sign/Symptom and Unspecified Codes
    Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.
    If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflects what is known about the patient’s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation.
    Last edited by dwaldman; 01-08-2016 at 11:39 PM.

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