“Exceptions to the Rule” Coding

Vol. 16 •Issue 25 • Page 6
CCS Prep!

“Exceptions to the Rule” Coding

Coding is not a “one-size-fits-all,” “black-and-white” endeavor. Coders must be aware of many exceptions.

Many new coding professionals are drawn to coding because there are very specific coding guidelines in place that are constantly being updated and revised. This may give the impression that there is very little “gray” area and that the vast majority of coding is predictable. While this may be true for some straight-forward cases (routine OB and newborn cases come to mind), coders should be aware of the not uncommon “exceptions to the rule” guidelines in coding.

Uncertain Diagnosis

One of the most well-known coding guidelines for inpatient cases involves an uncertain diagnosis. “If the diagnosis documented at the time of discharge is qualified as ‘probable,’ ‘suspected,’ ‘likely,’ ‘questionable,’ ‘possible,’ or ‘still to be ruled out,’ code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.” But coders must be aware that the guideline does not apply to Human Immunodeficiency Virus (HIV) infections. Only confirmed cases of HIV infection or illness should be coded and in this context, “confirmation” doesn’t require documentation of positive serology or culture for HIV. The provider’s diagnostic statement that the patient is HIV positive, or has an HIV-related illness is sufficient. Coding staff must also be careful to differentiate between a patient who has been diagnosed as “HIV positive” from one that has developed an HIV-related illness. An asymptomatic HIV positive patient should be classified to code V08; if a definite HIV condition or AIDS has been diagnosed (on a current or past episode of care), code 042 should be assigned. If a patient has an inconclusive HIV serology but no definite diagnosis or manifestations of the illness are present, code 795.71 (Inconclusive serologic test for Human Immunodeficiency Virus) should be assigned.

Chapter 15

Chapter 15’s Newborn (Perinatal) coding guidelines have somewhat similar “exception to the rule” attributes. Once again, the guidelines state that codes from this chapter should not be assigned unless the provider has established a definitive diagnosis. There’s an additional perinatal guideline that specifies that codes should be assigned for conditions that have been specified by the provider as having implications for future health care needs. This guideline should not be used for adult patients. There are also codes specifically developed for newborn patients that are different than those for adult patients with the same condition. For example, a newborn with septicemia [sepsis] should be assigned to code 771.81, with a secondary code from category 041 for the specified bacteria. A code from category 038 (Septicemia) should not be assigned.

Chapter 11

Similarly, many coding guidelines in Chapter 11 related to complications of pregnancy, childbirth and the Puerperium are unlike those for the majority of diagnosis and procedure codes. Chapter 11 codes have sequencing priority over codes from other chapters, although those codes may be used in conjunction with the Chapter 11 codes to further specify conditions. When a patient is pregnant, it is the provider’s responsibility to clearly state whether the condition being treated is not affecting the pregnancy. Physician queries may be required to clarify this point because many providers don’t realize that they need to clearly state whether or not an unrelated condition is affecting a pregnancy. Another example of using different coding guidelines for pregnant patients involves diabetes. The coder must first determine whether the documentation indicates that the diabetes was present before the woman became pregnant or whether it developed during the pregnancy. Some patients develop diabetes during the second or third trimester and this is called gestational diabetes. A patient with gestational diabetes is coded to 648.8X (Abnormal glucose tolerance in pregnancy) but no code from category 250 is assigned. Diabetic patients who become pregnant are typically monitored very closely. These patients are classified to 648.0X (Diabetes mellitus complicating pregnancy), along with a secondary code from category 250 to identify the type of diabetes. In either type of diabetes, code V58.67 (Long-term (current) use of insulin) should be assigned if the diabetes is being treated with insulin.

Cause and Effect

Coders must also be aware of the instances in which ICD-9-CM presumes a cause-and-effect relationship between two conditions. The most common example of this principle involves renal failure and hypertension. The clinical link between these two disease processes is so strong that there is an implied relationship between them. Whenever renal failure and hypertension are documented for the same patient, hypertensive kidney disease is coded and a code from category 403 (Hypertensive kidney disease) should be assigned. However, when hypertension and heart disease are documented together, no related relationship can be assumed. The provider must document a causal relationship between hypertension and heart disease before hypertensive heart disease may be coded. When this causal relationship is clearly identified in the medical record, a code from category 402 (Hypertensive heart disease) should be assigned, with an additional code(s) from category 428 to identify the type of heart failure for those patients with documented heart failure. When a patient has all three conditions (hypertension, renal failure and heart disease), the coder must be especially careful to assign the correct codes. Category 404 (Hypertensive heart and kidney disease) may only be assigned when the causal relationship is documented between the hypertension and heart disease. If this documentation isn’t present, codes for hypertensive kidney disease and separate code(s) for heart disease should be assigned.

Adverse Effects

Many new coders find the issue of differentiating between poisoning and adverse effects of drugs somewhat confusing. The most important thing to remember about adverse effects is that the drug had to have been correctly prescribed and properly administered. The effect of the drug, such as GI bleeding, tachycardia, nausea and vomiting, hepatitis, renal failure, etc. should be coded first, followed by an E-code from the E930 – E949 series of codes to identify the causative substance. Poisonings may be a result of several different factors: there may have been an error in the drug prescription or in the drug administration, an overdose of a drug may have been taken intentionally or accidentally, or a non-prescribed drug may have been taken with a correctly prescribed and properly administered drug. All of these scenarios should be coded as a poisoning. In this situation, the code for the poisoning (from the 960 – 979 series) should be sequenced first, followed by a code for the manifestation. The poisoning E-code should also be assigned and if there is any diagnosis of drug abuse or dependence documented in the medical record, it should be coded as well.


“Exception to the rule” coding also pertains to ICD-9-CM procedure codes. New coders are taught that surgical “exploration” is not coded separately if it’s incidental to further surgery. An exploratory laparotomy that’s followed by an appendectomy is not coded separately. However, if a patient undergoes an open cholecystectomy and a common duct exploration is performed, it’s coded with 51.41, 51.42 or 51.51, depending upon the reason for the procedure. This is an especially important guideline because it affects the inpatient DRG assignment and corresponding reimbursement.

As the above examples demonstrate, coding is not a “one-size-fits-all,” “black-and-white” endeavor. Coders must be aware of the many exceptions to the rule and should review each record carefully to determine the best way to tell the story of the patient episode of care through the language of codes.

1.A patient with known lung cancer was scheduled to be admitted to the hospital for chemotherapy. In the emergency department on the day of admission he was found to have a significant pleural effusion and a decision was made to do a thoracentesis to determine whether the malignancy had metastasized. The pleural fluid was positive for malignant cells and the attending physician documented pleural mets. Chemotherapy was then provided. The appropriate diagnosis codes for this encounter are:

a. V58.11, 162.9, 197.2

b. V58.11, 162.9

c. 197.2, 162.9

d. 197.2, 162.9, V58.11

2.A 58-year-old male presented to his physician complaining of difficulty with urination. During the previous 2 weeks, he has had a need to urinate often, during the day, but it is especially troubled at night, with urgency and decrease in the size and force of the urinary stream. Rectal exam indicated 2+ enlargement of prostate and a urinalysis was negative for infection. A diagnosis was made of LUTS (lower urinary tract symptoms) due to BPH (benign prostatic hypertrophy). The appropriate diagnosis code(s) for this encounter is/are:

a. 600.01

b. 600.01, 788.43, 788.41, 788.63, 788.62

c. 600.00, 788.43, 788.41, 788.63, 788.62

d. 788.43, 788.41, 788.63, 788.62

3.A patient with recently diagnosed breast cancer had a left mastectomy as the initial phase of treatment. She now presents to the hospital for a prophylactic mastectomy of the right breast. Previous testing revealed a genetic susceptibility to breast cancer and her mother and sister both had the disease. The appropriate diagnosis code(s) for this encounter is/are:

c. 174.9, V84.01, V16.3

d. V50.41, V84.01, V16.3

4. A patient was seen in a facility’s outpatient surgery area and had a laparoscopic cholecystectomy performed for chronic cholecystitis and cholelithiasis. Post-operatively the patient was somewhat slower to respond than normal and complained of vague pain. The patient was kept overnight and converted to an inpatient status, although there was no specific diagnosis documented by the attending physician as the reason for admission. The appropriate diagnosis code(s) for this encounter is/are:

a. 574.10

b. V58.9, 574.10

c. 338.18, 574.10

d. V58.75, 574.10

This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS, an Ingenix Company, (www.hssweb.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.

Answers to CCS PREP!: 1. c. ICD-9-CM Official Guidelines for Coding and Reporting, chapter 2 specific guidelines indicate that: “When the reason for admission/encounter is to determine the extent of the malignancy, or for a procedure such as paracentesis or thoracentesis, the primary malignancy or appropriate metastatic site is designated as the principal or first-listed diagnosis, even though chemotherapy or radiotherapy is administered.” Code V58.11 (Encounter for antineoplastic chemotherapy) should only be assigned as a principal or first-listed diagnosis unless the patient was admitted for both chemo and radiation therapy; 2. b. Code 600.01 should be sequenced as the first-listed diagnosis because the urinary problems are due to BPH and the patient does exhibit lower urinary tract symptoms (LUTS). Effective Oct. 1, 2006, a “Use additional code” note was added under code 600.01, instructing the coder to assign additional symptom codes to specifically classify the types of lower urinary tract symptoms that the patient is experiencing. 3. b. ICD-9-CM Official Guidelines for Coding and Reporting, V-code specific guidelines indicate that: “For encounters specifically for prophylactic removal of breasts, ovaries or another organ due to a genetic susceptibility to cancer or a family history of cancer, the principal or first listed code should be a code from subcategory V50.4, Prophylactic organ removal, followed by the appropriate genetic susceptibility code and the appropriate family history code. If the patient has a malignancy of one site and is having prophylactic removal at another site to prevent either a new primary malignancy or metastatic disease, a code for the malignancy should also be assigned in addition to a code from subcategory V50.4;” and 4. a. ICD-9-CM Official Guidelines for Coding and Reporting, Section II (Selection of Principal Diagnosis) specific guidelines indicate that: “When a patient receives surgery in the hospital’s outpatient surgery department and is subsequently admitted for continuing inpatient care at the same hospital: If no complication, or other condition, is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis.” It would also be acceptable to query the physician for clarification of the reason the patient was admitted for inpatient care.

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