Q:  Would you code long term use of insulin and hypoglycemic as well as presence of insulin pump? 

A:  The code categories for diabetes, other than category I10 for type 1 diabetes, has a “use additional code” note indicating that the type of control (i.e., long term use of medications) should also be assigned.  Any time the patient is on insulin and is a non-type 1 diabetic, this note should be followed and code Z79.4 [Long term (current) use of insulin] should be assigned.  If the patient also has an insulin pump, assign code Z96.41 [Presence of insulin pump (external) (internal)]. 

Q:  Are there any codes used to identify the patient has had the COVID vaccine? Immunization code? 

A:  There is no code to identify that a patient has had the COVID-19 vaccine.  Code Z23 (Encounter for immunization) is only used when the reason for the current encounter is to receive the vaccine.  Please note that the AHA/AHIMA updated the COVID-19 FAQs on August 27, 2021 and it is noted that code Z28.3, Underimmunization status, is not appropriate for reporting patients who have not had the COVID-19 vaccine.  You can view the updated FAQs at: https://www.codingclinicadvisor.com/sites/default/files/Frequently%20Asked%20Questions%20Regarding%20COVID-19_v18%20%28S%29.pdf 

Q:  Would you be able to share what the recommendation is for the coding of the social determinant codes and the benefit of coding these?  My system is not looking to code these. 

A:  The American Hospital Association encourages reporting of social determinants of health (SDOH) to track factors that influence the population’s health.  The guidelines for reporting SDOH can be found in section I.C.21.c.17. and state that codes describing SDOH should be assigned when documented.  The AHA has a document about the important of this data at: https://www.aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-health.pdf.  The Healthy People 2020 initiative of the US government also has information on the importance of this data at: https://health.gov/healthypeople/objectives-and-data/social-determinants-health 

Q:  As you stated:  There is update about the guideline I.B.14 Documentation by Clinicians other Than the Patient’s Provider. I have a question about it. In my inpatient coding auditing, I came across this situation: on the same day note, the clinician documented BMI 35.44 and the provider documented: BMI 37.23. How shall we code this BMI, the provider’s or the clinician’s ? 

In what kind of situation we can use the clinician’s documentation? 

A: We recommend developing an internal policy within your organization when BMI documentation is inconsistently documented among providers and other clinicians.  In the development of this policy, we recommend meeting with clinical staff to determine which documentation should be used for BMI that will yield the most accurate reporting results. 

Q: On section I.B.14 Documentation by Clinicians Other than the Provider-What are some examples of providers and clinicians? 

A: In the guidelines, the term “provider” is used to describe the physician, physician’s assistant, or nurse practitioner responsible for the patient’s care.  The term “clinician” is used to describe other caregivers, whose documentation may be used in limited circumstances.  Clinicians include nurses, dieticians, therapists, emergency medical technicians, etc. 

Q: For breast implant associated anaplastic large cell lymphoma, would you add the complication code to fully explain the patient’s condition? 

A: No, per guideline I.C.2.s., a complication code from Chapter 19 is not assigned to report BIA-ALCL. 

Q: If the Blood alcohol level is only captured as a lab value, can this be coded? 

A: Blood alcohol levels should be coded only when documented by the provider or a clinician other than the patient’s provider.  Lab values alone should not be used as documentation for reporting blood alcohol levels. 

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 20 years of industry experience. She develops and delivers training on ICD-10-CM/PCS and CPT, both virtually and in classroom settings.
Kristi also performs DRG and APC audits and is known for her vast knowledge on coding vascular interventional radiology procedures. Kristi has an extensive background in coding education and consulting and is a national speakers on topics related to ICD-10 and CPT coding as well as code-based reimbursement.

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