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HCCS’s Coding Canapés: Tasty tidbits of coding delivered directly to your desktop!

Coding cervical disc disorder with myelopathy involving different levels.

Outpatient coders for physician offices, clinics in the hospital setting, or ER coders may see a similar situation such as this one with cervical disc disorders.  If there are different levels, how do I know which level to code?  Is it the highest level or all the levels?  See the coding clinic to determine the correct code.

A patient is diagnosed with cervical disc disorder with myelopathy involving different levels.  How do I code this?

Code the highest, most superior level if more than one region in each subcategory is affected. 

Reference:  Coding Clinic, First Quarter ICD-10 2016 Pages: 17 Effective with discharges: March 18, 2016

Selecting the correct root operation for surgeries in inpatient charts.

Do you code surgeries in your inpatient charts?  Maybe the information from this coding clinic will shed some light on selecting the correct root operation.  Is it reposition or immobilization?  Or maybe both?

The patient has infantile idiopathic thoracic scoliosis and is admitted for elongation derotation flexion cast change.  The surgery included traction, a derotation maneuver, extension of the spine, and casting.  How would I code this? 

The correct code is 0PS4XZZ for repositioning the spine.

Reference: Coding Clinic, First Quarter ICD-10 2016 Page: 21 Effective with discharges: March 28, 2016

One of the best (and maybe worst) things about the coding profession is that there is always so much more to learn. The infinite nuances of various continuously changing coding guidelines combined with the wildcard variable of documentation, and evolving HIM technology give us no choice but to take the “never stop learning” philosophy especially seriously. Whether you are one of our coders or not, HCCS is here to help you in your pursuit of knowledge as you grow in your career. Through the Coding Canapés series of posts, we’ll regularly introduce and interpret official guidelines such as AHA’s Coding Clinic. We hope coders everywhere benefit from and even enjoy these posts. Bon Appétit!


Topics: Work From Home, Medical Coding, ICD-10, Coding Canapes, Health Information Management

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