Tuesday, July 7, 2020

Book Excerpt: Etiology of Pediatric Respiratory Conditions

By Leah Savage, MSN, RN

There are a number of etiologies leading to pediatric respiratory failure, just as there are with adult patients. To begin with, pediatric patients can come to an acquired extrathoracic airway from an infectious source (e.g., retropharyngeal abscesses, Ludwig’s angina, bacterial tracheitis, acute viral bronchiolitis, bacterial/fungal/viral pneumonia), trauma (such as postop extubation croup, thermal burns, foreign-body aspiration, or direct trauma), allergic reactions, and other causes such as hypertrophic tonsils and adenoids.

Pediatric patients may also enter respiratory failure because of a number of congenital extrathoracic airway conditions. Some of the common conditions are:

  • Subglottic stenosis
  • Subglottic web or cyst
  • Laryngomalacia
  • Tracheomalacia
  • Vascular ring
  • Cystic hygroma
  • Craniofacial anomalies

There are also a number of respiratory pump causes that can lead to respiratory failure such as diaphragm eventration, diaphragmatic hernias, agenesis of the diaphragm, flail chest, kyphoscoliosis, Duchenne muscular dystrophy, Guillain-Barré syndrome, infant botulism, myasthenia gravis, spinal cord trauma, and spinal muscular atrophy. While many of these conditions can be present in adult patients as well, they are particularly risky for pediatric patients due to their less developed airways, etc., as discussed above.

Central control issues can also lead to respiratory failure. Some of these are central nervous system infections, sleep apnea, strokes, traumatic brain injuries, overuse of anti-epileptic drugs leading to apnea, and an underdeveloped brain due to prematurity. As a note, prematurity affects every aspect of the child’s developmental health and can be a significant contributing risk factor for respiratory failure.

A number of intrathoracic airway and lung conditions can also lead to respiratory failure. Many of these conditions are acquired, and therefore they could affect the adult population as well. But, because pediatric patients are still developing, these conditions can be much more severe and lead to larger consequences down the line. These conditions include:

  • Asthma
  • Aspiration
  • Bronchiolitis
  • Bronchomalacia
  • Cardiac abnormalities
  • Pulmonary contusion 
  • Near drowning
  • Pneumonia
  • Pulmonary edema and embolus
  • Sepsis
  • Pulmonary hypertension

Editor’s note: This is an excerpt from the recently released book Pediatric CDI: Building Blocks for Success

Copyright Association of Clinical Documentation Improvement Specialists (ACDIS).  Article reprinted with permission. 

Tuesday, June 30, 2020

Coding Genicular Nerve Blocks and Ablations

This edition of “Spotlight on CPT” presents information on the coding for genicular nerve block(s) and ablation(s).  First things, first.  What is the genicular nerve?  This term refers to several sensory nerves that innervate the knee.  These include the femoral, common femoral, saphenous, tibial, and obturator nerves.  Blocks and ablations can reach several of these nerves and attempt to provide relief to patients with chronic pain from osteoarthritis of the knee. 

Here are a few pictures of that area.

In 2020, the CPT code updates, changed the way that these procedures should be coded.  Let us explore those changes. 

Previously, if a coding professional was assigning a code for a genicular nerve block, that code would have been 64450 for Injection, anesthetic agent; other peripheral nerve or branch.  There was a November 2015 CPT Assistant that instructed coders to only assign the code once for genicular nerve blocks, even if more than one nerve was injected. 

With the 2020 CPT code update, there is a new code for this procedure, 64454. The code’s definition is:  Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed.  Notes that follow the code instruct that all three branches must be injected in order to assign this code.  If all three branches-superolateral, superomedial, and inferomedial are not injected, then the code must have modifier -52 assigned to indicate the reduced services. 

If we turn our attention to an ablation or destruction procedure of the genicular nerve, we previously would have assigned 64640 for Destruction by neurolytic agent; other peripheral nerve or branch when coding for the genicular ablation.  A January 2018 CPT Assistant alerted coding professionals to assign the code three times if all three branches were destroyed and place modifier -59 on the second and third code.

Again, with the 2020 CPT code updates, we find a change.  Now we should assign 64624 for Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed for the ablation/destruction of the genicular nerve(s).  The same note follows this code detailing that all three genicular nerves must be destroyed in order to assign this code, or modifier -52 will need to be appended in order to indicate the reduced service.  Therefore, the advice in the January 2018 CPT Assistant is no longer relevant.

Bear in mind that coding professionals should not be assigning both 64454 and 64624 for the same encounter. 

Now, light has been shed on coding for genicular nerve blocks/ablations.

About the Author
Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.