This page addresses follow-up questions and additional information pertinent to our webinar
What’s New? Third Quarter Coding Update.
** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.

Q: Coding Clinic says that if “diabetes without complication” is documented and there is other documentation that the patient has a condition that is assumed to be due to diabetes, such as peripheral angiopathy, that the provider should be queried to see if the peripheral angiopathy is unrelated to the diabetes. What if “diabetes without complication” is documented with an ICD-10-CM code from a “pick list” where the provider chose the condition from a list?
A: Some electronic health record (EHR) systems allow the provider to choose an ICD-10-CM code with its code description and it populates the diagnosis field in the EHR. Hospitals should develop a policy on whether coders can code from this documentation. Hospitals should, however, reference Coding Clinic, 4th Quarter 2015, page 34, which states that code numbers are not the same as a diagnosis and should not be used in place of a written diagnostic statement.

Q: When a device is used for an off-label use, such as using aneurysm clips to clamp nerve roots, how do you know what to code?
A: Always refer back to the intent of the procedure and apply root operation definitions to the procedure performed.

Q: Per Coding Clinic, “…it is appropriate to code congenital anomalies, such as Mongolian spots, when identified by the provider since they can have implications for further health care needs.” However, ICD-10-CM coding guideline states to “Assign codes for conditions that have been specified by the provider as having implications for future health care needs.” If Mongolian spots is documented in the physical exam but the provider does not explicitly state that the condition has implications for future healthcare needs, should Mongolian spots be coded?
A: We recommend using caution when assigning a code for Mongolian spots when the provider has not indicated it is a significant condition or that it will require care in the future. While Coding Clinic is an official coding resource, the coding guidelines take precedence over Coding Clinic advice. Additionally, the addition of code Q82.5, Congenital non-neoplastic nevus, with a principal diagnosis from category Z38 will increase the MS-DRG and could give the appearance of upcoding of the condition and its significance are not well documented. It should be noted that the addition of this code does not impact reimbursement under APR-DRGs.

Looking for additional information on this topic?