COMMON DIAGNOSIS ERRORS
We all understand the importance of collecting information from provider documentation and accurately applying ICD-10-CM codes. These codes paint a picture of the overall clinical nature of the patient encounter, as well as the severity of the illness(es) the patient is experiencing. Let’s review some the most miscoded hierarchal condition categories (HCCs).
History of Cerebral Infarction vs Cerebral Infarction with Residual Deficits
A commonly miscoded HCC is related to stroke. A common error is coding history of cerebral infarction (stroke) versus cerebral infarction with residual deficits and coding the stroke as current when it is not. Patients with a history of stroke may present with residual deficits. Many of the residual deficits of a cerebral infarction have HCCs. For Example: A provider’s documentation states a patient has a history of stroke. In the physical exam, the provider indicates the patient has right hemiplegia due to a previous stroke. In this case, it would be inappropriate to code Z86.73. Instead, you would code I69.351 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side to capture the current sequela of the stroke. Note: Sequela for hemiplegia, hemiparesis and monoplegia must identify whether the dominant or nondominant side is affected.
For ambidextrous patients, the default should be dominant.
For left side affected, the default should be non-dominant.
For right side affected, the default should be dominant.
Sequela of cerebral infarction codes include (not inclusive list):
I69.334 Monoplegia of upper limb following cerebral infarction affecting left non-dominant side
I69.341 Monoplegia of lower limb following cerebral infarction affection right dominant side
I69.351 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side
I69.354 Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side
Old Myocardial Infarction vs Acute Myocardial Infarction
Acute myocardial infarction (AMI) is often miscoded in the context of when it occurred. According to the ICD-10-CM codes from category I21, Acute Myocardial Infarction, may be reported for encounters occurring while the myocardial infarction is equal to or less than four weeks old, and the diagnosis meets the definition for reporting additional diagnosis. Providers should be reminded and encouraged to report the date of the AMI as part of the clinical documentation. Coding I25.2 Old Myocardial Infarction would be inappropriate if the provider documents that the patient was diagnosed within the four week period. After the four week period, if the patient is continuing to need care or treatment, it is inappropriate to continue to code the AMI as current. It is also incorrect to code the AMI as resolved or old if the patient is still being treated for the infarction. Code Z48.812 Encounter for surgical aftercare following surgery on the circulatory system would be the appropriate code for patient continuing to be treated for myocardial infarction beyond the first 28 days. In addition to I25.2, myocardial infarction codes include (not inclusive list):
I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery
I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery
I21.3 ST elevation (STEMI) myocardial infarction of unspecified site
I21.4 Non-ST elevation (NSTEMI) myocardial infarction
I21.A1 Myocardial infarction type 2
Acute/Chronic Deep Vein Thrombosis vs. History of Deep Vein Thrombosis
When coding for deep vein thrombosis (DVT) review provider documentation to ensure it supports coding acute or chronic DVT. Don’t assume the patient has a current acute or chronic DVT just because they are on anticoagulants or have an embolism protection device such as a inferior vena cava filter in place. If the DVT has resolved, report Z86.718 Personal history of other venous thrombosis and embolism. A diagnosis for current DVT should only be reported when the condition is active and present. DVT code include (not inclusive list):
I82.401 Acute embolism and thrombosis of unspecified deep veins of right lower extremity
I82.432 Acute embolism and thrombosis of left popliteal vein
I82.521 Chronic embolism and thrombosis of right iliac vein
I82.542 Chronic embolism and thrombosis of left tibial vein
As you can see, it is important to review the providers records and understand the coding guidelines to accurately code conditions. Sometime the smallest details can change the coding dramatically.
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