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 Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer

Senior Consultant

Kristi is a senior consultant with more than 25 years of industry experience; she is responsible for the development of web-based, instructor-led, and webinar training materials; conducting training in ICD-10-CM/PCS and CPT; and performing DRG and APC audits. Kristi has an extensive background in coding education and consulting and is a national speaker and published writer on topics related to ICD-10 and CPT coding and code-based reimbursement. She has designed and developed training programs for inpatient and outpatient hospital-based coding, with a focus on vascular interventional radiology, interventional cardiology, orthopedics, and obstetrics.

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).


  1. margaret adams

    Thank you for a very informative update on CM codes!
    your Tip Sheet Answer to the last Q. If the physician documents elevated LFTs without additional information … does not tell the coder if they need to query the provider if there is no specific documentation as to which LFT value is elevated, or if the coder can use lab results. Thanks for clarifying.

    • kkluglein

      Hi Margaret,

      If the provider only documents “elevated LFT,” code R94.5, Abnormal results of liver function studies or the coder may query the provider for clarification. Coders should never code directly from lab results for liver tests.

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