Q: For alcohol and drug withdrawal, what is the default code if the doctor does not document use or dependence?
A: The alphabetic index lists dependence as the default and this is reiterated in Coding Clinic, Second Quarter 2015: Page 15. However, if documentation exists that the patient has use or abuse with withdrawal and dependence is not documented, the appropriate code for use or abuse should be assigned.
Q: Will the physician have to document the type of stage 3 CKD or can we pull that information from lab documentation?
A: The provider must document the type of stage 3 CKD (3a or 3b) and the coder should not use lab documentation to make that determination herself. If the provider does not state whether the type is 3a or 3b, the coder should query for clarification.
Q: Would code O34.22 only be used during a delivery encounter or could it be used if the patient presents for laparoscopic or hysteroscopic repair of an isthmocele outside of the pregnancy period?
A: According to the ICD-10-CM Official Guidelines for Coding and Reporting (I.C.15.o.), “Chapter 15 codes may also be used to describe pregnancy-related complications after the peripartum or postpartum period if the provider documents that a condition is pregnancy related.” If the provider indicates that the isthmocele is due to a cesarean section, code O34.22 may be assigned if the patient presents for repair.
Q: If the physician documents elevated LFTs without additional information, can the coder use the lab report to identify which lab value is elevated since there is no unspecified code?
A: The ICD-10-CM index lists code R79.89 (Other specified abnormal findings of blood chemistry) as the default for abnormal liver function tests (LFTs). This is a nonspecific code and does not specifically identify the LFT.
Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer
Kristi has served the Colorado Health Information Management Association (CHIMA) as board Director, co-chair of the Data Quality Committee, and co-chair for the ICD-10 Task Force. She is also a past president of the Northern Colorado Health Information Management Association (NCHIMA). Kristi is the proud recipient of the 2011 AHIMA Triumph Award for Mentoring for her voluntary work as the “Coder Coach.” She has also received awards from CHIMA for Distinguished Member (2018) and Outstanding Volunteer (2013) and from AHIMA for Roundtable Achievement in Coding Excellence (RACE).