Not surprisingly, coders will have many more options to report how a patient was injured in ICD-10-CM. Betty Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD , and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS , explain how the codes differ from ICD-9-CM E codes, when to report them, and why coders should not be too worried about the transition.
The auditory system has its own code category in ICD-10-CM because of the number of new codes and specificity available. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I , reviews ear anatomy and how to report newly introduced diseases and conditions.
Coders will have many more options to report wrist and hand injuries in ICD-10-CM, with codes for individual fingers, wrist bones, and joints, as well as laterality. Review the anatomy of the wrists and hands in order to take advantage of the specificity available in ICD-10-CM.
Q: I am auditing a note for a fusion. The note lacks detail, therefore is hard to justify. The patient had a prior hardware placement. The note describes dissecting down, debridement of necrotic bone, and tissue work done. This is the entire note, after describing dissection, “Vigorous irrigation with 10 liters of saline and antibiotics was carried out. Hemostasis was maintained. The right S1 screw and rod portion was removed as it was notably loose. Additional decortication and onlay bone grafting was performed at L1-S1. Drains were placed…” They coded: 22612 (arthrodesis, posterior or posterolateral technique, single level; lumbar) Add-on code 22614 (each additional vertebral segment) x4 22852 (removal of posterior segmental instrumentation) In the procedures performed area of the note, they state: Hardware removal, lumbar Revision fusion L1-S1 with onlay bone graft Irrigation and debridement of lumbar spine wound Since there is nothing in the note regarding autografting, I assume this is an allograft? Should this be coded? Also is that documentation enough to justify arthrodesis? Modifier -GC (this service has been performed in part by a resident under the direction of a teaching physician) was appended, although the language was not added for this. I can only assume a resident dictated this.