Excision of Lipomas

Several of the previous “Spotlight on CPT” presentations revolved around lesion excision and repair, so in keeping with that theme, this discussion will address removal of lipomas. 

A lipoma is a fatty tumor. You will recall the suffix - oma means tumor.  This does not always signify a cancerous growth as evidenced here since lipomas are just a tumor of fatty tissue.  Lipomas can be superficial, subfascial, or submuscular, and properly coding the removal of a lipoma depends on the specific depth.  

Let us examine the layers of skin and subcutaneous tissue to get a better understanding of the anatomy we are dealing with.  

Source: https://biology.stackexchange.com/questions/30131/what-is-our-skin-made-up-of

Source: https://www.grepmed.com/images/3881/dermatology-infections-hypodermis-epidermis-diagnosis-layers-skin

As can be identified in these illustrations, the superficial layer of the skin is the epidermis, the dermis is the middle layer, and the hypodermis or subcutaneous layer is the lowest layer.  If the lipoma were located superficially, the removal of the lipoma would be coded to excision of a benign lesion.  The appropriate code would fall into the CPT code range 11400-11446 based on location and size of the lipoma removed.  This is advice that is supplied via the August 2006 CPT Assistant on page 10.  

However, that same CPT Assistant goes on to indicate that when a lipoma is removed from the deeper subcutaneous layer, or beyond (fascia or muscle) then the appropriate code for removal will be found in the musculoskeletal section of the CPT manual.  The index entry would be:

    Excision
       Tumor
          Specific location

Therefore, if we were coding subcutaneous lipoma removal from the forearm the coding path is:

    Excision
       Tumor
          Arm, lower…25075, 25071, 25076, 25073

The codes are divided into two categories: subcutaneous or subfascial.  They are also divided by size: less than 3 cm. or 3 cm. or greater.

Here is an example:

Excision of a 4.5 cm. subcutaneous lipoma from the left forearm would be:
25071  Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; 3 cm. or greater

Often lipomas are encapsulated and easily removed in their entirety.  There are occasions when the lipoma has extensions, or finger-like projections that curl around other structures like nerves, making removal more difficult and piece-meal.  Regardless of the removal, it is important to have a size provided by the surgeon so that an appropriate code can be chosen.  Size is based on the greatest diameter of the lesion plus any margin just like for lesion removals discussed previously.

Remember, the simple or intermediate repair that would be used to close the excision is included in the actual removal code.  However, if a complex repair, perhaps one that would necessitate the undermining of skin, was performed, that can be separately coded.  This information is in the Note section found immediately at the beginning of the musculoskeletal system chapter of the CPT Manual.
  
Now, light has been shed on proper coding for excision of lipomas.

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.

Body Mass Index (BMI)

Body mass index (BMI) is the topic for this monthly edition of “In the kNOW."

Body mass index is a measurement of body fat.  This calculation takes into account a person’s weight and their height.  Results are plotted on a grid, which can indicate where on a spectrum a person’s BMI rates.  High BMIs can be an indicator of high body fat, but not always.  For example, athletes may have high BMIs and yet not carry excess body fat.  For this reason, coding professionals are instructed by the Official Coding Guidelines, specifically I.B.14, to assign a BMI code only when an associated diagnosis, such as obesity, is documented by the patient’s provider.  This point is reiterated in the 4th Qtr. 2018 Coding Clinic and is further clarified by stating that the guidance applies to outpatient as well as inpatient coding.

That same issue of Coding Clinic provides additional information regarding BMI assignment.  Coding professionals are instructed to code the known BMI when an associated diagnosis is documented as long as it meets the definition of a reportable diagnosis.  While there is no list of codes for which it is acceptable to assign a BMI code, that 4th Qtr. Coding Clinic provided some clues.  Those conditions where you could expect to use a BMI code included:

•     Obesity
•     Morbid obesity
•     Overweight*
•     Underweight
•     Malnutrition
•     Anorexia nervosa (or other eating disorder)
•     Cachexia
•     Abnormal weight loss/gain
•     Failure to thrive

Coding Clinic indicated that both obesity and morbid obesity would meet the definition of reportable diagnosis as they are always considered to be of significance clinically, while the diagnosis of overweight is not.  Therefore, if there is no documentation to support clinical significance beyond a statement of overweight, do not assign either a code for overweight or BMI.  Remember that the Official Coding Guidelines Section III. Reporting Additional Diagnoses instructs inpatient-coding professionals to assign codes for other diagnoses that have an impact on patient care.  That would include any condition that requires:

•     Clinical evaluation
•     Therapeutic treatment
•     Diagnostic procedures
•     Extended length of stay
•     Increased nursing care or monitoring

Outpatient-coding professionals have a similar instruction under Section IV. Diagnostic coding and Reporting Guidelines for Outpatient Services, J. Code all documented conditions that coexist and require or affect patient care or management.   Whether assigning a code BMI on an inpatient or outpatient record, note that the BMI code is only to be assigned as a secondary code according to the guidelines.

Further direction reminds coding professionals to use the ICD-10-CM instructions when assigning the BMI for adults and utilize the age range 21 years of age or older, while for pediatric patients the age range is 2-20.

Finally, in an update to the 2018 Official Coding Guidelines, Chapter 21: Factors influencing health status and contact with health services (I.B.21.c.3) Z68 Body mass index (BMI) directs coding professionals not to assign a BMI code during pregnancy.

Now you are In the kNOW!!

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.

Field Trip Fiascos

by Dianna Foley, RHIA, CHPS, CCS 


Test your ICD-10-CM external cause coding skills with this short scenario.  Try coding any ICD-10-PCS and CPT as appropriate.

Each of the Klutz children was headed on a class field trip during the month of May.  Not surprisingly, each of them suffered some type of injury while on the outing.  Here is what happened.

Egon’s civics class went to the county courthouse to see the criminal justice system in action.  He was the last one off the bus, and ran up the marble steps to catch up with his group when he slipped and fell.  It was a foggy morning, thus making the marble very slippery.  He ended up with contusions on both knees and elbows.  Luckily, no ER trip was deemed necessary and he was able to participate in the remainder of the day without further incident.

Little Dana did not fare as well on her outing.  Her preschool class went to the Children’s Zoo.  In the petting zoo area, Dana was trying to pet a goat with one hand, while holding food pellets behind her back with the other hand.  Another goat came up behind her, and bit her left hand trying to get the food.  She ended up with a laceration on her left hand; and for safety, a chaperone took her to the ER where Mrs. Klutz joined them.  The ER doc irrigated Dana’s 2 cm. laceration and did a simple repair.  Then little Dana was allowed to go home with her mother.

Janine’s English literature class went to the public library for their field trip.  She was kneeling down to get a book off the bottom shelf when she was struck by a rather large book, which another student had been trying to get off the top shelf.  It was heavier than the student expected, and when he could not catch the book, it crashed down on Janine’s neck and across her entire upper back.  While she ended up being bruised and sore, she recovered quickly.  

The local television station was the location for Raymond’s field trip with his class.  He was walking along with his group when he was distracted by the “green” screen and ended up tripping and falling over a cable that was stretched along the floor.  He was limping after he got home later, so Mr. Klutz took him to the ER where he was diagnosed with a mild left ankle sprain.  Rest, ice, and elevation were recommended for a day or two, and it was not long before Raymond was back to his old self.

Peter’s class spent the day at the museum.  At the lunch, Peter was getting some change from his pocket to get a beverage from the vending machine, when he dropped a quarter.  As Peter reached down to pick it up, another child accidentally stepped down hard on his right index finger, crushing it under his shoe.  Peter experienced immediate pain and swelling of the finger, and it was decided that he needed to go to the ER.  Mrs. Klutz met Peter at the ER, where an x-ray showed a distal, right index finger fracture.  Due to the closed nature of the fracture, the ER doctor decided to perform a closed manipulation of the displaced fracture.  A splint was then applied and then Peter was discharged home with his mother.

Each of the children’s teachers breathed a sigh of relief when the field trips were over.  Glad for the relatively minor injuries as far as the Klutz children go…at least for this year’s trips!
 
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Wound Repair

The previous installment of “Spotlight on CPT” presented information regarding the coding for excision of lesions.  Now, we are going to delve into coding for wound repair.  Wound repair may be need for conditions such as lacerations or post-lesion excisions.  Several pieces of information are crucial for proper coding of repairs.

The first piece of information related to repair that coders must be familiar with is that when performance of a repair is with adhesive strips only, it is not appropriate to use a repair code.  Instead, utilize an appropriate E&M code.  Code other methods of wound repair utilizing sutures, staples, and tissue adhesives from the appropriate classification: simple, intermediate, or complex.
Secondly, the distinctions between the three classifications of wound repair listed above (simple, intermediate, and complex) are provided below:

• Simple: 12001-12018 
• for superficial wounds (epidermis, dermis, subcutaneous tissue)
• Single layer closure 
• Local anesthesia included 
• Chemical or electrocautery of wound not closed

• Intermediate: 12031-12057 
• for deeper layers of subcutaneous or superficial fascia 
• Layered closure required 
• Or single layer closure when extensive removal from very contaminated wound occurs

• Complex: 13100-13153  
• for wounds that need more than layered closure 
• Scar revision 
• Debridement 
• Extensive undermining 
• Stents or retention sutures

As with coding for excision of lesions, when coding wound repairs, coders will note that consideration must be given to specific variables in order to arrive at the correct code assignment.  Determination of the repair classification (simple, intermediate, or complex) is the initial choice a coder must make.  Then, anatomical site is the next consideration.  In this step, coders will notice that the anatomical site division changes depending on the type of repair performed.  It is vital that coders choose the correct type of repair and corresponding anatomical site to arrive at the accurate code range.  The final variable to be determined is the size of the repair.  Centimeters are the measurement used to determine the size of the repair.  

Performance of more than one repair requires coders to add together the lengths of all repairs from the same classification (simple, intermediate, or complex) and located in the same anatomical site grouping to get one code.  For example, if a 2 cm simple repair is done of the leg and a 3 cm simple repair is done of the trunk, then the CPT code assignment is 12002 for 5 cm total simple repair and not 12001 (leg) and 12002 (trunk).

Coders should not add lengths of different classifications of repairs nor different anatomical site groupings in order to arrive at a CPT code assignment.  This means that if there are two lacerations repaired on the leg, one simple and the other intermediate, it is not appropriate to add the lengths together to assign the CPT code.  Instead, assign a separate code for each repair based on length since they were of different classifications.  

The use of add-on codes is a specific distinction noted in the coding of complex repairs.  Each anatomical subdivision includes an add-on code to capture increased size of the repair.  The add-on codes represent each additional 5 cm or less when calculating size beyond the previous code.  For example, when coding a complex repair of the trunk that is 8 cm in length, a coder should assign 13101 for the repair up to 7.5 cm and then also assign the add-on code 13102 for the additional 0.5 cm to make the 8 cm total.  Assign, the add-on codes as many times as necessary to capture the repair length.  For example, if the complex repair of the trunk was 20 cm, use code 13101 for the initial 7.5 cm and then assign 13102 times 3 to capture the remaining 12.5 cm of the complex repair.  

A final point to make regarding wound repair is that when coding for lesion removal, remember that simple repairs are included in the lesion removal code and not separately assigned.

Now, light has been shed on coding wound repairs.

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.

Passion for Politics

by Clarice Warner, RHIA, CCS-P, CPC, CHC

Have you ever had a passion for something. Something totally unexpected. Well recently, I’ve had the passion for politics.  Yes, politics.  I guess it started with me becoming a delegate for OHIMA. This year, I was provided the opportunity to attend AHIMA’s Hill Day and it was a great experience.  On March 25th and 26th, delegates from all 50 states gathered in Washington D.C. to visit our respective elected officials. I had the opportunity to visit with a member of Senator Rob Portman’s staff, a member of Senator Sherrod Brown’s staff and almost everyone in representative Steve Chabot’s office.  I also got an opportunity to meet with him personally as well.  As you can see the the elected officials showcase their pride in their states and the communities that they represent.   It was great to see the mementos and keepsakes displayed in their offices.

There were several issues that we brought before the officials.  The first one is to encourage notes sharing with patients in real time.  Unfortunately, our pervasive culture in medicine has kept real-time access of notes from getting into the hands of patients despite the numerous benefits of sharing notes with patients in real time.  The vast majority of hospitals and physician offices do not engage in systematic note sharing so AHIMA’s recommendation to Congress using its oversight authority to promote efforts such as open notes, the Medicare and Medicaid payment programs including the promoting interoperability programs, the MIPS improvement activity performance category and other innovative payment models so that the practice of note sharing benefits patients nationwide.

Next is align HIPAA right of access with the ONC’s Health IT certification functionality with all of the laws that we have for access to patient information individuals ability to access and use their health information continues to be a challenge and AHIMA recommends law makers to revise the definition of the designated record set (DRS) and require certified Health IT to provide the amended DRS to patients electronically while maintaining computability.  Further, regulators should develop guidance and request regular feedback from stakeholders on continued barriers to delivering this right under HIPAA.  This revision will provide greater clarity and predictability of what constitutes the DRS to both providers and patients.

Next is patient matching.  Since 1999, Congress has prohibited the use of appropriations by the U.S. Department of Health and Human Services (HHS) to promulgate or adopt any standard for unique health identifier until legislation is enacted specifically approving the standard.  This limitation has been included in every subsequent appropriations bill since fiscal year 1999 and is often seen as a barrier to public private sector collaboration and accelerating and scaling effective patient identification and matching solutions and AHIMA’s request to Congress is to omit the 1999 language in the fiscal year 2020 appropriations legislation to empower HHS to work with industry to advance a nationwide patient matching strategy. 

And lastly, extending HIPAA’s individual right of access to non-covered entities.  With all the rules and laws the ability of individuals to access and use their health information continues to be a challenge.  This challenge has only compounded in recent years with the proliferation of mobile health and health social media applications which are typically not covered by HIPAA’s right of access.  Such technologies are examples of HIPPAs non-covered entities (NCEs).  While Congress has passed several policies with HHS and has implemented a host of programs to improve patient data access, patients find that they have little access to and control of their health information collected by most HIPAA NCEs such as Fitbit and health apps. AHIMA recommends that lawmakers develop or directs HHS to define HIPAA NCEs in law and at a minimal extend HIPAA’s right of access to NCEs.  The goal of such a policy is to create a uniform data access policy for individuals using technology developed by an entity that produces and or manages their individually identifiable health information regardless of commercial or legal status.  We presented these issues to our elected officials and had 15-20 minute conversations with them.  Most of them were really interested in the NCEs because that was relatable. Everyone could relate to that and how that could potentially affect their constituents.

Is this the kind of work that you would be interested in?  Do you also have a passion for politics?  If so, feel free to volunteer for OHIMA and/or local American Health Information Management Association organizations. 

About the Author

Clarice Warner, RHIA, CCS-P, CPC, CHC is the Corporate Director of Corporate Responsibility for the Mercy Health Corporate Office in Cincinnati, Ohio.  She is also the Founder and Education Director for the Professional Reimbursement Network.  Clarice serves as a 1st-year Director and Delegate on the OHIMA FY 2018-19 Board of Directors, overseeing the Public Good strategy and Advocacy Committee.   

Intestinal Polyps

A polyp, is a polyp, is a polyp.  Right? 

The short answer is no, and in this edition of “In the kNOW”, the discussion looks at the different types of intestinal polyps and the proper code assignment for each.

 
First, let’s define an intestinal polyp.  A growth in the lining of the intestine is a polyp.  Non-neoplastic or neoplastic are categories of colonic polyps.  Non-neoplastic polyps generally do not evolve into a cancerous condition, whereas neoplastic polyps may progress to cancer.  Non-neoplastic polyps include inflammatory, hyperplastic, and hamartomatous polyps.  Serrated and adenomatous types of polyps are considered neoplastic polyps.  Sessile serrated polyps can be precancerous.  Intestinal polyps described as sessile are flat, while those characterized as pedunculated arise from a stalk. 

If the only description a coding professional has of a polyp of the colon is the term “polyp”, the ICD-10-CM code assigned should be K63.5, which according to a 1st Qtr. 2017 Coding Clinic is the also the code to be assigned when the polyp is described as hyperplastic.  Remember, that an outpatient coder can use the pathology report to determine if the polyp is further specified as adenomatous or inflammatory.  This would permit the assignment of a different code.  However, an inpatient coder may find that same information on a pathology report but would need to query the physician for agreement before assigning the more specific code. 

A diagnosis of an inflammatory polyp of the colon is correctly coded to K51.40 with further specificity if various other complications co-exist such as an abscess, a fistula, rectal bleeding, intestinal obstruction, or other complication.  

Colon polyps described as adenomatous are coded as benign neoplasms with further specification as to the location if it is known.  An adenomatous polyp of the ascending colon codes to D12.2.  The 2nd Qtr. 2018 Coding Clinic clarified that sessile serrated polyps should also be considered to be adenomatous in nature, thereby classifying them as benign neoplasms in the D12 category as well. 

An important point to note is that hyperplastic polyps that are specified by location (i.e. transverse colon) are not to be coded to the D12 benign neoplasm category.  A 2nd Qtr. 2015 Coding Clinic states that hyperplastic and adenomatous polyps are not the same, and that all hyperplastic polyps, regardless of location within the colon, are to be coded to K63.5.

Adenomatous colon polyps may be designated as tubular or tubulovillous and both types are coded to the benign neoplasm D12 category.  However, if the description of the polyp is that of villous adenoma, the complexion changes, and now a coding professional will assign a code from Neoplasm, uncertain behavior, by site - category D37.4.  A Coding Clinic from 2nd Qtr. 2005 made coders aware that when high-grade dysplasia is noted in an adenomatous polyp it does not alter the code assignment.  The code will still be in the D12 category.

Now you are In the kNOW!!

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.

Book Excerpt: Creating a Career Ladder

By Cheryl Ericson, MS, RN, CCDS, CDIP, Stephanie Hawley, RN, BSN, ACM, and Anny Pang Yuen, RHIA, CCS, CCDS, CDIP

Historically, CDI specialists transition to CDI from case management or HIM/coding due to the lack of experienced CDI specialists in the world. Today, those who do hold multiple years’ worth of CDI experience often earn top-dollar when changing careers and/or have moved up to management or director positions. Those coming into the role now, are often home-grown, mentored, and educated by existing staff.

As a result, CDI departments need to develop (or at least begin thinking about establishing) a career ladder for their programs. Career ladders help provide mobility to those who’ve served multiple years in the role and who’ve now been tasked with additional responsibilities such as mentoring new hires, educating physicians, and expanding review focus areas. The objective of a career ladder is to motivate existing staff, specifically the younger generation, to stay in the field of CDI. Many individuals will seek other opportunities when they no longer feel that there are career advancement opportunities or compensation growth. Currently, most CDI departments consist of either a CDI director or CDI manager and CDI specialists. These CDI specialist positions typically do not indicate levels of experience, which may pose some salary negotiation issues for the hiring CDI manager and the human resources department.

Typically, an entry level CDI specialist has 0–2 years of experience; a midlevel CDI specialist has 2–4 years of CDI experience, and may have obtained appropriate credentials. There is frequently a misconception that a CDI specialist position is a lateral move from a compensation perspective for a nurse coming from the clinical world, but in truth it really is not a lateral move, because a new skill set will be acquired on the job as a CDI specialist. Additionally, a CDI specialist role includes other perks, like not needing to work weekends, nights, or holidays, which may not be always true in the clinical setting. Therefore, as the CDI industry continues to expand, we may see additional benchmarks and guidance on how to appropriately pay CDI professionals based on their level of experience and expertise. Those interested in learning more about current trends in CDI compensation and salary should look to the annual salary survey reports published by ACDIS.
The career ladder structure and associated compensation increments will hopefully establish a common industry standard in terms of staffing and department structure.


Example of a CDI career ladder

CDI manager
• 5+ years of experience in CDI
• CCDS or CDIP credential
• Support effective CDI department staff activities and manage performance of CDI department and staff
• Provide staff with continuing CDI education and training
• Reconcile fellow CDI specialists’ entries in CDI tracking tool to ensure accuracy of provider clarification, abstraction of clinical indicators, and the assignment of initial DRG and working DRG
• Generate CMI report and CDI dashboard for metrics analysis
• Provide educational presentations to various physician groups on specific documentation improvement topics
• Active participation in team meetings, physician education, and leadership meetings

CDI Specialist Level 3
• 3+ years of experience in CDI
• CCDS or CDIP credential
• Assist CDI manager with reconciliation of data
• Assist CDI manager with educational presentations
• Assist CDI manager with team training
• Maintains productivity standards

CDI Specialist Level 2
• 2–4 years of experience in CDI
• CCDS or CDIP credential
• Maintain productivity standards

CDI Specialist Level 1
• 0–2 year of experience in CDI
• Maintain productivity standards


Editor’s note: This article is an excerpt from the Complete Guide to CDI Management

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