Coding Clinic 1st Quarter 2019 – Key Highlights

Below are highlights from Coding Clinic 1st Quarter 2019 – effective with discharges starting March 20th.

Human Immunodeficiency Virus and Related Conditions
• Code B20, HIV disease, may be reported for cases when AIDS is documented, the patient is treated for any documented HIV-related illness or is described by the provider as having a condition resulting from his/her HIV status.
• Terms such as “HIV positive,” “known HIV,” “HIV test positive,” or similar terminology, code Z21, Asymptomatic human immunodeficiency virus (HIV) infection status, should be reported
• If the documentation is unclear or ambiguous regarding the patient’s HIV status, the provider should be queried for clarification.
• Per Coding Clinic, it would not be appropriate to automatically link a diagnosis as an HIV-related condition based solely on the CDC’s AIDS-Defining Illnesses list and/or conditions included in MDC 25.
• The ICD-10-CM classification does not assume a relationship between conditions such as cryptococcal meningitis, recurrent pneumonia, or sepsis as an HIV-related infection therefore, Z21, asymptomatic HIV status should be assigned
• If the provider indicates a condition is an HIV-related illness or if the ICD-10 classification assumes a relationship between a condition and HIV, assign B20, HIV disease
• Examples of when the ICD-10 Index assumes a relationship between AIDS and related conditions are: C46 Kaposi’s sarcoma and B39, Histoplasmosis

Dehydration and Acute Kidney Injury (Acute Renal Failure)
• The sequencing of dehydration and acute kidney injury should be based on the reason for the admission
• Query the physician regarding the principal reason that the patient was admitted, if the reason for the admission is not clearly documented
• There is no rule that acute kidney injury should always be sequenced first
• Many assumed that AKI should be sequenced as the principal diagnosis when a patient is admitted with both AKI and dehydration because AKI could be considered the more severe condition; however, based on the advice given in this Coding Clinic, it is best to query the provider if it is unclear whether the dehydration or AKI was the reason for admission

Emphysema and Acute Exacerbation of Chronic Obstructive Pulmonary Disease
• Coding Clinic maintains the advice that a patient admitted with an exacerbation of COPD with a history of emphysema should only be assigned a single code, J43.9, Emphysema, unspecified due to the excludes1 note found at category J44, Other COPD
• Assigning a single code for emphysema would not allow the acuity to be capture
• Per Coding Clinic, “The Centers for Disease Control and Prevention/National Center for Health Statistics, the organization responsible for revisions to ICD-10-CM, is aware of this issue and has agreed to consider a Coordination and Maintenance proposal for possible revisions to the instructional note”
• This is one of the examples illustrating that the ICD-10 book is not free of inconsistencies and contradictions that need to be addressed, fortunately there is a process for this continuous improvement

Whipple Procedure
• Case examples covering multiple variations of the Whipple procedure were provided in this issue of Coding Clinic
• The intent of the Whipple procedure is to remove the head of the pancreas, which is where most tumors occur, and therefore, prevent the tumor from growing and spreading to other organs. However, because the pancreas is so integrated with other organs, the surgeon must also remove the duodenum, gallbladder, a portion of the common bile duct and sometimes a portion of the stomach. At the completion of the procedure, the surgeon must reconnect the remaining organs to allow for normal digestive function after surgery
• Coders must assign the appropriate “Resection” and/or “Excision” root operations depending on what organs are removed
• Whipple procedures require that the remaining organs be reconnected, therefore, the anastomosis is inherent to the total surgery and not coded separately
• If all the duodenum and ampulla of Vater are resected, the resection of the ampulla is not separately coded
• The ampulla of Vater is the union of the pancreatic duct and the common bile duct, and it protrudes into the duodenum at the major duodenal papilla

Spinal Fusion Performed at Same Level as Decompressive Laminectomy
• It is appropriate to code a decompressive laminectomy even if performed at the same level as the lumbar spinal fusion if there is a distinct surgical objective (e.g. decompression)
• If a decompressive laminectomy is performed to treat a separately documented diagnosis of lumbar spinal stenosis, the root operation Release is coded separately in addition to the root operation Fusion codes
• If the laminectomy is done as an operative approach to prepare for the spinal fusion, it is not coded separately


  1. AHA Coding Clinic – 1st Quarter 2019

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