Frequently Asked Questions and Answers about Oral Cancer

Frequently Asked Questions and Answers about Oral Cancer

Oral or mouth cancer is often used to describe a type of cancer that develops in the tissues of the mouth (known as the oral cavity) or the throat area at the back of the mouth (known as the oropharynx). The oral cavity is your mouth and includes parts like the lips, teeth, gums, lining inside the lips and cheeks (called buccal mucosa), front of the tongue, bottom of the mouth, saliva glands and bony roof of the mouth. Some parts at the back of your mouth are not considered part of the oral cavity and hence they are part of the oropharynx. These include – back or base of the tongue, back of the roof of the mouth, (called the soft palate), tonsils and the sides and back of the throat. Regarded as a type of head and neck cancer, these cancers come under the category of oral and oropharyngeal cancer that starts in the cells that line your mouth and throat (classified as squamous cell carcinoma). Over 90 percent of oral cancers begin in the flat cells (squamous cells) that cover the surfaces of the mouth, tongue, and lips. According to reports from the American Cancer Society (ACS), around 53,000 Americans received a diagnosis of oral or oropharyngeal cancer in 2019. The disease is more likely to affect males than females. The average age of diagnosis is 62 years, but about 25 percent of cases occur before the age of 55 years. Early diagnosis of this type of cancer is often difficult, as patients depict no specific signs and symptoms. Billing and coding for this cancerous oral condition can be challenging, as there are several rules that go along with this condition. For precise documentation of this condition, physicians usually rely on the services of a professional medical billing outsourcing company.

Here are some frequently asked questions and answers about oral cancer –

Q: Where does oral cancer occur?

A: About two-thirds of cancer of the mouth occurs in the floor of the mouth and tongue. However, it can also occur in the upper or lower jaw, lips, gums, and cheek lining. Just behind the mouth is an area known as the orophyarnx. Oropharyngeal cancer (one-third of cases) occurs in the back of the tongue, tonsils and throat tissue.

Q: What are the main types of oral cancer?

A: It is estimated that more than 90 percent of all oral cavity tumors are squamous cell carcinomas. Squamous cells make up the lining of the oral cavity. The most common locations for cancer in the oral cavity are the tongue, tonsils, oropharynx (throat), gums and floor of the mouth. On the other hand, tumors that occur in the salivary glands are less common types of oral cancers. These include – adenoid cystic carcinoma, mucoepidermoid carcinoma and polymorphous low-grade adenocarcinoma.

Q: What are the causes of oral cancers?

A: Mouth cancers occur when cells on the lips or in the mouth develop changes (mutations) in their DNA. A cell’s DNA contains instructions that direct a cell what to do. The mutations direct the cells to continue growing and dividing when healthy cells would die. Cancer occurs when a genetic change in the body results in cells growing without control. As these continue to grow and accumulate, they form a tumor. The accumulating abnormal mouth cancer cells can form a tumor. With time, they may spread inside the mouth and migrate to other areas of the head and neck or other parts of the body.

Q: What are the factors that can increase the risk of mouth cancer?

A: Potential risk factors that can increase the chances of mouth cancer include – smoking or chewing tobacco, using snuff (which comes from tobacco), excessive alcohol consumption, human papillomavirus (HPV) infection, gastroesophageal reflux disease (GERD), a weakened immune system, excessive sun exposure to your lips and a previous history of a head and neck cancer.

Q: What are the warning signs of oral cancer?

A: Generally, in the early stages, there are often no signs or symptoms of oral cancer. Smokers and heavy drinkers need to undergo regular checkups with the dentist, as tobacco and alcohol use are serious risk factors for this type of cancer. The dentist may be able to spot any signs at an early stage. Typical symptoms include –

  • Mouth sores or ulcers that bleed easily and do not heal
  • Red or white patches in or behind the mouth
  • Visible change in mouth tissue
  • Unexplained swelling or fullness in neck
  • Unexplained lump in the neck, throat or floor of the mouth
  • Loose teeth
  • Pain and tenderness in teeth or gums
  • Diminished ability to perform normal functions such as opening jaw, chewing or swallowing
  • Difficult or painful swallowing
  • Change in the fit of dentures or partial dentures

Q: How is oral cancer diagnosed, treated and documented?

A: If a person has symptoms that could possibly indicate mouth cancer, a physician as an initial diagnosis will generally enquire about their symptoms, carry out a physical examination and review their personal and family medical history. Physician or dentist will examine the lips and mouth of the patient to check for abnormalities like – areas of irritation, such as sores and white patches (leukoplakia). If any suspicious area is diagnosed, the dentist may remove a sample of cells for lab testing in a procedure called biopsy. The sample cells are analyzed for cancer or precancerous changes that indicate a risk of future cancer.

Once the mouth cancer is diagnosed or confirmed, the physician will further work to determine the extent or stage of cancer. Endoscopy procedure may be performed to look for signs that cancer has spread beyond the mouth area. In addition, a variety of imaging tests like – X-ray, CT scan, MRI and positron emission tomography (PET) scans may be performed to determine the stage and severity of cancer. However, not every patient may need these tests. Physicians will determine which of these tests are appropriate based on individual patient condition.

Treatment for mouth cancer may directly depend on the location and specific stage of cancer. It may also depend on overall health and personal preferences of the patient. Patients may either undergo a single treatment or a combination of treatment modalities. Treatment options include surgery, radiation, chemotherapy, targeted drug therapy and immune therapy. Surgery will be done to remove the tumor that has spread and to reconstruct the mouth. Surgery for mouth cancer often affects your appearance, as well as your ability to speak, eat and swallow. Dentists, oncologists or other specialists who offer treatment for mouth cancers need to be reimbursed for the services they provide to the patients. Correct medical codes must be used to document the diagnosis, screening and other procedures performed. Medical billing and coding services offered by established companies can help physicians in using the correct codes for their medical billing process.

Q: What are the ICD-10 codes used for diagnosing mouth cancer?

A: The ICD-10 codes for mouth cancer come under the category – C00-C14 – Malignant neoplasms of lip, oral cavity and pharynx.

C00 Malignant neoplasm of lip

  • C00.0 Malignant neoplasm of external upper lip
  • C00.1 Malignant neoplasm of external lower lip
  • C00.2 Malignant neoplasm of external lip, unspecified
  • C00.3 Malignant neoplasm of upper lip, inner aspect
  • C00.4 Malignant neoplasm of lower lip, inner aspect
  • C00.5 Malignant neoplasm of lip, unspecified, inner aspect
  • C00.6 Malignant neoplasm of commissure of lip, unspecified
  • C00.8 Malignant neoplasm of overlapping sites of lip
  • C00.9 Malignant neoplasm of lip, unspecified

C01 Malignant neoplasm of base of tongue

C02 Malignant neoplasm of other and unspecified parts of tongue

  • C02.0 Malignant neoplasm of dorsal surface of tongue
  • C02.1 Malignant neoplasm of border of tongue
  • C02.2 Malignant neoplasm of ventral surface of tongue
  • C02.3 Malignant neoplasm of anterior two-thirds of tongue, part unspecified
  • C02.4 Malignant neoplasm of lingual tonsil
  • C02.8 Malignant neoplasm of overlapping sites of tongue
  • C02.9 Malignant neoplasm of tongue, unspecified

C03 Malignant neoplasm of gum

  • C03.0 Malignant neoplasm of upper gum
  • C03.1 Malignant neoplasm of lower gum
  • C03.9 Malignant neoplasm of gum, unspecified

C04 Malignant neoplasm of floor of mouth

  • C04.0 Malignant neoplasm of anterior floor of mouth
  • C04.1 Malignant neoplasm of lateral floor of mouth
  • C04.8 Malignant neoplasm of overlapping sites of floor of mouth
  • C04.9 Malignant neoplasm of floor of mouth, unspecified

C05 Malignant neoplasm of palate

  • C05.0 Malignant neoplasm of hard palate
  • C05.1 Malignant neoplasm of soft palate
  • C05.2 Malignant neoplasm of uvula
  • C05.8 Malignant neoplasm of overlapping sites of palate
  • C05.9 Malignant neoplasm of palate, unspecified

C06 Malignant neoplasm of other and unspecified parts of mouth

  • C06.0 Malignant neoplasm of cheek mucosa
  • C06.1 Malignant neoplasm of vestibule of mouth
  • C06.2 Malignant neoplasm of retromolar area
  • C06.8 Malignant neoplasm of overlapping sites of other and unspecified parts of mouth
  • C06.80 Malignant neoplasm of overlapping sites of unspecified parts of mouth
  • C06.89 Malignant neoplasm of overlapping sites of other parts of mouth
  • C06.9 Malignant neoplasm of mouth, unspecified

C07 Malignant neoplasm of parotid gland

C08 Malignant neoplasm of other and unspecified major salivary glands

  • C08.0 Malignant neoplasm of submandibular gland
  • C08.1 Malignant neoplasm of sublingual gland
  • C08.9 Malignant neoplasm of major salivary gland, unspecified

C09 Malignant neoplasm of tonsil

  • C09.0 Malignant neoplasm of tonsillar fossa
  • C09.1 Malignant neoplasm of tonsillar pillar (anterior) (posterior)
  • C09.8 Malignant neoplasm of overlapping sites of tonsil
  • C09.9 Malignant neoplasm of tonsil, unspecified

C10 Malignant neoplasm of oropharynx

  • C10.0 Malignant neoplasm of vallecula
  • C10.1 Malignant neoplasm of anterior surface of epiglottis
  • C10.2 Malignant neoplasm of lateral wall of oropharynx
  • C10.3 Malignant neoplasm of posterior wall of oropharynx
  • C10.4 Malignant neoplasm of branchial cleft
  • C10.8 Malignant neoplasm of overlapping sites of oropharynx
  • C10.9 Malignant neoplasm of oropharynx, unspecified

C11 Malignant neoplasm of nasopharynx

  • C11.0 Malignant neoplasm of superior wall of nasopharynx
  • C11.1 Malignant neoplasm of posterior wall of nasopharynx
  • C11.2 Malignant neoplasm of lateral wall of nasopharynx
  • C11.3 Malignant neoplasm of anterior wall of nasopharynx
  • C11.8 Malignant neoplasm of overlapping sites of nasopharynx
  • C11.9 Malignant neoplasm of nasopharynx, unspecified

C12 Malignant neoplasm of pyriform sinus

C13 Malignant neoplasm of hypopharynx

  • C13.0 Malignant neoplasm of postcricoid region
  • C13.1 Malignant neoplasm of aryepiglottic fold, hypopharyngeal aspect
  • C13.2 Malignant neoplasm of posterior wall of hypopharynx
  • C13.8 Malignant neoplasm of overlapping sites of hypopharynx
  • C13.9 Malignant neoplasm of hypopharynx, unspecified

C14 Malignant neoplasm of other and ill-defined sites in the lip, oral cavity and pharynx

  • C14.0 Malignant neoplasm of pharynx, unspecified
  • C14.2 Malignant neoplasm of Waldeyer’s ring
  • C14.8 Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx

Q: What lifestyle measures need to be adopted to prevent the incidence of oral cancer?

A: There is no proven way to prevent the occurrence of mouth cancer. However, it is possible to reduce the risk of mouth cancer by taking some important measures like –

  • Avoid chewing betel nut
  • Avoid excessive alcohol consumption
  • Avoid excessive sun exposure to your lips
  • Conduct regular dental check ups
  • Monitor for frequent changes in the mouth and consult a dentist (if required)
  • Stop the usage of any form of tobacco product
  • Take the vaccination to protect against HPV
CoronaVirus (CoV) Outbreak – Declared a Global Emergency by WHO

CoronaVirus (CoV) Outbreak – Declared a Global Emergency by WHO

Recently, the world news was flooded with reports of the outbreak of a novel coronavirus (nCoV) in the city of Wuhan in China’s Hubei Province. As the outbreak continues to spread and represents a risk outside China, on January 31, 2020, the World Health Organization (WHO) declared the new coronavirus as a global emergency.

It was on December 31, 2019 that the WHO was alerted to several cases of pneumonia in Wuhan City, Hubei Province of China. One week later, on January 7, Chinese authorities confirmed that they had identified a new virus. The new virus belongs to the large family of coronaviruses that cause illnesses such as the common cold, and more severe diseases such as SARS (Severe Acute Respiratory Syndrome) and MERS (Middle East Respiratory Syndrome). However, it did not match any other known virus. This has raised serious concern because when a new virus appears, the severity of its effect on people cannot be generally understood or measured.

This new virus has been temporarily named “2019-nCoV.” It causes respiratory illness of varying severity. Infectious diseases caused by CoV must be extensively documented using the correct medical codes. Comprehensive documentation requires a clear record of symptoms, causes, diagnosis and treatment modalities offered. Medical billing and coding companies can help physicians treating this condition with accurate documentation.

Latest reports (as of January 31, 2020) say that there are about 9800 confirmed cases of nCoV in mainland China. The death toll from the novel coronavirus outbreak increased to 213 in China. According to the World Health Organization (WHO), 98 international cases has been reported in 18 other countries, but no deaths.The potency and movement of the virus has rallied the cooperation of the World Health Organization (WHO), the U.S. Centers for Disease Control and Prevention (CDC) and other agencies to effectively combat it.

According to the World Health Organization (WHO), corona viruses are responsible for 15 to 30 percent of common colds. Like other viruses, nCoV originated from animals. They are called coronaviruses because under a microscope, the viruses have crown-like spikes protruding from their surfaces. Such spikes affect the way a virus binds onto a host cell and infects it. These are zoonotic, meaning they are transmitted between animals and people. People in China infected with nCoV either worked or frequently shopped in the Huanan seafood wholesale market in the centre of the Chinese city which sold live or newly slaughtered animals.

Symptoms of nCoV may appear in as few as 2 days or after 14 days of exposure. One of the common symptoms associated with this infectious disease is pneumonia. Persons who got infected are reported to suffer other respiratory symptoms including cough, fever, breathing difficulties, sneezing, a runny nose, fatigue, sore throat and exacerbated asthma. In severe cases there can be organ failure. Severe infections are more common in people with heart or lung diseases, people with weakened immune systems, infants, and older adults.

Coronavirus infections can be diagnosed through a physical exam and a complete medical history and review of symptoms. The virus responsible can be diagnosed by taking a sample of respiratory fluids, such as mucus from the nose, or blood. As there is no cure for this virus infection, treatment includes over-the-counter medications (like acetaminophen, ibuprofen or naproxen to reduce pain and fever), taking adequate rest and avoiding over-exertion, drinking plenty of fluids, avoiding smoking/smoky areas and using a clean humidifier or cool mist vaporizer. Recovery of a patient will depend on the strength of their immune system. Many of those people who suffered death are known to have been already in poor health.

Billing and coding for this infectious disease could be complex as there are several rules related to reporting the condition correctly. Infectious disease specialists must make sure that they correctly diagnose the symptoms of nCoV and report it using the right medical codes. Medical billing outsourcing services provided by reputable medical billing companies can help physicians use the correct codes for their billing purposes. ICD-10 codes used to signify nCoV diagnosis are –

  • B34.2 – Coronavirus infection, unspecified
  • B97.2 – Coronavirus as the cause of diseases classified elsewhere
    • B97.21 – SARS-associated coronavirus as the cause of diseases classified elsewhere
    • B97.29 – Other coronavirus as the cause of diseases classified elsewhere

People in poor health are at maximum risk of getting infected from nCoV. A key concern is the range of severity of symptoms – some people appear to suffer only mild illness while others are becoming severely ill. This makes it more difficult to establish the true numbers infected and the extent of transmission between people.

There is no vaccine available that can prevent the spread of this new coronavirus. The World Health Organization (WHO) recommends people to take simple precautions in order to reduce exposure to and transmission of the virus. Some of the top prevention strategies include – washing hands thoroughly and frequently (with an alcohol-based hand rub or warm water and soap), covering the mouth and nose with a flexed elbow or tissue when sneezing or coughing, avoiding close contact with anyone who has a fever or cough, avoiding direct, unprotected contact with live animals and surfaces in contact with animals, avoiding consumption of raw or under cooked animal products and avoiding contact with people displaying symptoms. People who are living in or traveling to nCoV outbreak areas should consider wearing masks to prevent the spread of virus.

Just as for other infectious diseases, accurate and timely documentation of diagnosis and treatment procedures is vital in this regard. Medical coding tasks can be outsourced to a reliable physician billing company that offers the services of AAPC-certified coding specialists to ensure correct and timely medical coding, billing and claims submission.

Reporting Rosacea: An Overview of Diagnosis, Treatment and Coding

Reporting Rosacea: An Overview of Diagnosis, Treatment and Coding

Rosacea is a common inflammatory skin condition that causes redness and visible blood vessels in your face. The redness can slowly spread beyond the nose and cheeks to the forehead and chin. Often mistaken for acne, eczema, or a skin allergy, this condition may also produce small, red, pus-filled bumps. There are several signs and symptoms associated with the condition which may flare up for a period of weeks to months and then diminish for a while. Common signs and symptoms include – facial redness, swollen red bumps, visible broken blood vessels, large pores and excess facial skin around the nose. The exact causes of this condition are unknown but a number of factors can trigger symptoms. If left untreated, redness and swelling associated with this condition can get worse and might become permanent leading to severe complications. As there are several rules related to reporting this inflammatory skin condition, dermatology medical billing and coding can be complex. Dermatologists and other physicians treating this condition need to be familiar with the specific ICD-10 codes and outsourcing medical coding to an experienced service provider is a reliable strategy to ensure this.

Reports suggest that rosacea affects about 16 million people in the United States. It is estimated that 1 in 20 people is affected by this chronic skin condition. The disease most commonly affects middle-aged women in the age group of 30 – 60 years, who have fair skin. However, when it occurs in men, the condition tends to be severe and may eventually cause the nose to become enlarged (rhinophyma). Fair-skinned individuals and people who blush easily seem to be more susceptible to this condition.

Types of Rosacea

There are four different subtypes of rosacea namely –

  • Subtype one, known as erythematotelangiectatic rosacea (ETR) – symptoms include – facial redness, flushing, and visible blood vessels.
  • Subtype two, papulopustular (or acne) rosacea – often affects middle-aged women and involves acne-like breakouts.
  • Subtype three, known as rhinophyma – a rare form which usually affects men and causes thickening of the skin on the nose.
  • Subtype four, known as ocular rosacea – symptoms are centered on the eye area

Each of these above subtypes involves different symptoms that vary from one person to another.

How Is Rosacea Diagnosed and Treated?

As there is no specific test for diagnosing this skin condition, physicians may begin their initial evaluation by conducting a detailed study about the patient’s medical history, check their symptoms and perform a physical examination of their skin. In some cases, physicians may conduct certain tests to rule out other conditions, such as other forms of acne, psoriasis, eczema or lupus.
Treatment modalities may involve a combination of prescribed medications (applied to the skin) and oral drugs (pills, tablets, or capsules) for controlling the symptoms. These include topical antibiotics (like metronidazole, tretinoin, benzoyl peroxide, and azelaic acid), oral antibiotics (like tetracycline, minocycline, and erythromycin), and steroid eye drops like blephamide and tetracyclines. The duration of your treatment depends on the type and severity of your symptoms. However, recurrence of the symptoms is very common. Laser therapy may help reduce the redness of enlarged blood vessels.

Dermatologists and other specialists providing treatment (that involves diagnosis, screening and other tests) for rosacea patients need to be adequately reimbursed for their services. The diagnosis must be carefully documented using the appropriate medical codes. Medical billing and coding services offered by experienced providers can help physicians use the correct codes for their medical billing purposes.

ICD-10 Codes for Rosacea

  • L71 – Rosacea
  • L71.0 – Perioral dermatitis
  • L71.1 – Rhinophyma
  • L71.8 – Other rosacea
  • L71.9 – Rosacea, unspecified

Practicing or incorporating certain lifestyle changes and home remedies may help reduce the signs and symptoms of rosacea or prevent flare-ups. Protecting your skin (by wearing hats and avoiding midday sun) and treating your skin gently (by using moisturizer) can help prevent flare-up and occurrence of symptoms to a great extent.

Medical coding for inflammatory skin conditions can be complex. By outsourcing these tasks to a reliable and established medical billing and coding company (that provides the services of AAPC-certified coding specialists), healthcare practices can ensure correct and timely medical billing and claims submission.

Coding Pressure Ulcers – Quality Documentation is Critical

Coding Pressure Ulcers – Quality Documentation is Critical

Pressure Ulcers

Pressure ulcers/injuries are a common adverse event that medical coding companies help physicians report. The codes for pressure ulcers and non-pressure chronic ulcers are located in ICD-10 chapter 12, Diseases of the skin and subcutaneous tissue (L00-L99). Coding skin ulcers is complex and depends on the condition as described in the clinical documentation. Quality documentation is critical for accurate code assignment:

  • The documentation should specify if the ulcer is a pressure ulcer or a non-pressure ulcer and also the stage of the ulcer as defined by the National Pressure Ulcer Advisory Panel (NPUAP)
  • The concept of laterality (such as, left or right) should be included in the clinical documentation
  • Present on admission codes for pressure ulcers should be accurately assigned, including ulcers that progress during an inpatient stay

According to a 2017 Health Research & Educational Trust (HRET) report, studies show that each year more than 2.5 million patients in U.S. acute-care facilities suffer from pressure ulcer/injuries and 60,000 die from their complications. Treating a single full-thickness pressure ulcer/injury cost as much as $70,000 in 2006, and every year, billions of dollars are spent on the treatment of pressure ulcer/injury in the United States. Inaccurate coding of this high-cost, high-volume can have a negative impact on the provider’s bottom line.

Pressure Ulcer Definition and Risk Factors

The NPUAP defines a pressure injury as “localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device”. The injury can present as intact skin or an open ulcer and may be painful. It develops as a result of extreme and/or prolonged pressure or pressure in combination with shear.

Risk factors for pressure ulcers include advanced age, immobility, incontinence, inadequate nutrition and hydration, neuro-sensory deficiency, device-related skin pressure, multiple comorbidities and circulatory abnormalities.

Category L89 in ICD-10

Pressure ulcer/injury codes are located in the ICD-10 code category L89. There are more than 160 combination codes in the ICD-10 category L89 which identify the site, stage, and generally, the laterality of the ulcer. ICD-10 code category L89.4- is used to report pressure ulcers that span multiple body parts, (contiguous site of back, buttock, and hip).

ICD-10 uses the five stages of pressure ulcers defined by the NPUAP:

Stage 1, non-blanchable erythema
Stage 2, partial-thickness
Stage 3, full-thickness skin loss
Stage 4, full-thickness tissue loss

Unstageable: In addition to these 4 stages, a pressure ulcer may be unstageable due to the following:

  • The ulcer cannot be examined at a particular time – i.e., it’s under a dressing or not debrided
  • The injury is covered by an eschar or blister
  • The ulceris in evolution and the final extent of injury is unclear until the dead tissue demarcates from adjacent viable tissue

Deep Tissue Injury: The NPUAP defines another stage based on findings that suggest damage to underlying tissue – deep tissue injury. Signs include intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. In a rapidly developing pressure ulcer, subcutaneous tissue can become necrotic before the epidermis erodes. Thus, a small ulcer may in fact represent extensive subcutaneous necrosis and damage.

Pressure Ulcer Documentation and Coding – Key Considerations

In October 1, 2017, the guidelines for reporting pressure ulcers were expanded to include greater specificity. Many factors go into documenting and reporting pressure ulcers correctly:

  • Knowing ICD-10 instructions on coding pressure ulcers such as:
    • Assigning as many codes from category L89 as needed to identify all the pressure ulcers the patient has, if applicable
    • Also coding any associated gangrene (I96)
  • Reviewing the documentation: In case the specific stage of the ulcer is not mentioned in the clinical documentation, the AAPC recommends that the coder should examine the documentation for language that matches the NPUAP definitions in order to code the ulcer to a particular stage.
  • Reporting if present on admission (POA) or not: The following reporting designations should be used for POA reporting:
    Y = Yes (present at the time of inpatient admission);
    N = No (not present at the time of inpatient admission);
    U = Unknown (documentation is insufficient to determine if condition was POA);
    W = Clinically undetermined (provider is unable to clinically determine whether condition was POA); and
    1 = Exempt from POA reporting
  • Coding site and stage of the ulcer at admission: In a recent For the Record article, an expert explains that if a pressure ulcer is present on admission (POA), but is healed at the time of discharge, then the site and stage of the ulcer at admission should be coded. Additionally, if the patient came in with a pressure ulcer at one stage and the ulcer progressed to a higher stage during the admission, then two separate codes should be assigned. In this case, the present on admission (POA) indicator would be different for each of the codes assigned. Pressure ulcers with a POA designation that heal before discharge from an inpatient stay should be reported using the code related to the stage of the ulcer upon admission.
  • Diagnosis must come from a physician: While non physician clinicians can document the depth and stages of pressure ulcers, the For the Record article points out that the diagnosis must be documented by a physician. Physician follow-through with the diagnosis is crucial as hospitals should understand the prevalence of pressure ulcers entering their facilities. In a June 2018 ACP Hospitalist report, staff plastic surgeon and medical director of wound care at the Cleveland Clinic in Ohio Christi M. Cavaliere, MD stresses that hospitals should document the pressure ulcer within 24 hours of admission, failing which it will be considered a hospital-acquired pressure ulcer. For instance, a POA designation is crucial if the patient is coming from a nursing home, where a pressure would be usually present.
  • Code additional diagnoses: Pressure ulcers may present with complications such as sepsis, cellulitis, osteomyelitis, gangrene, and sepsis arthritis, that require further treatment. Complications treated during hospitalization should be coded as additional diagnoses.


With all these complexities, the support of an experienced medical coding service provider can be invaluable for reporting pressure ulcers correctly for optimal reimbursement. Coders in reliable medical coding outsourcing companies have the knowledge needed to ensure accurate reporting of diagnostic details. They will also query the physician for clarification if the documentation is incomplete or obscure.

Coding Pressure Ulcers – Quality Documentation is Critical

Reporting Tuberculosis Diagnosis and Testing

Reporting Tuberculosis Diagnosis and TestingAccording to the World Health Organization (WHO), tuberculosis (TB) is second biggest infectious killer of adults worldwide. In the US, more robust control programs have reduced the number of TB cases, but recent reports indicate that the disease, though curable and totally preventable, still remains a threat. In March, Huffington Post reported on the rise in TB cases in 19 states, including New York, California, Florida and Texas, Connecticut, Tennessee and Colorado. Infectious disease specialists and pulmonologists can rely on medical coding outsourcing companies to report TB diagnosis and screening accurately.

An infectious disease that most often affects the lungs, TB is spread through the air when the person with the disease coughs and sneezes. TB can also affect other parts of the body such as the kidney, spine and brain. The Centers for Disease Control and Prevention (CDC) estimates that that up to 13 million people in the US have latent tuberculosis infection (LTBI), that is, TB bacteria are present within their body but are not infectious. Overall, without treatment, this can progress to an active TB infection as they grow weaker because of risk factors such as HIV, weakened immune systems, diabetes, smoking and intake of immune-suppressing medications.

TB Screening Recommendations and Guidelines

Given that TB is still around, physicians should test for latent TB in patients who are at risk for infection and who would benefit from treatment, as well as in patients who have signs and symptoms of the TB. The final recommendation statement on screening for latent tuberculosis infection (LTBI) released by the U.S. Preventive Services Task Force (USPSTF) in 2016 recommends screening among adults who are at increased risk of tuberculosis, but who do not have symptoms. The CDC, the American Thoracic Society, and the Infectious Diseases Society of America recommend that clinicians screen for LTBI only among high-risk populations and when treatment is feasible. According to the CDC, persons at risk for developing tuberculosis include those:

  • Who have an increased likelihood of exposure to persons with tuberculosis disease
  • With clinical conditions or other factors associated with an increased risk of progression from LTBI to tuberculosis disease.

ICD-10 Codes to Indicate Diagnosis of TB

ICD-10 codes in the category A15 – A19 are used indicate a confirmed diagnosis of TB for reimbursement purposes.

A15 – A19 Tuberculosis

Includes: infections due to Mycobacterium tuberculosis and Mycobacterium bovis

Excludes: congenital tuberculosis (P37.0)

pneumoconiosis associated with tuberculosis (J65)

sequelae of tuberculosis (B90.-)

silicotuberculosis (J65)

A15 Respiratory tuberculosis, bacteriologically and histologically confirmed

A15.0  Tuberculosis of lung, confirmed by sputum microscopy with or without culture

A15.2  Tuberculosis of lung, confirmed histologically

A15.3  Tuberculosis of lung, confirmed by unspecified means

A15.4  Tuberculosis of intrathoracic lymph nodes, confirmed bacteriologically and histologically

Excludes: specified as primary (A15.7)

A15.5  Tuberculosis of larynx, trachea and bronchus, confirmed bacteriologically and histologically

A15.6  Tuberculous pleurisy, confirmed bacteriologically and histologically

Excludes: in primary respiratory tuberculosis, confirmed bacteriologically and histologically (A15.7)

A15.7  Primary respiratory tuberculosis, confirmed bacteriologically and histologically

A15.8  Other respiratory tuberculosis, confirmed bacteriologically and histologically

A15.9  Respiratory tuberculosis unspecified, confirmed bacteriologically and histologically

A16 Respiratory tuberculosis, not confirmed bacteriologically or histologically

A16.0  Tuberculosis of lung, bacteriologically and histologically negative

A16.1  Tuberculosis of lung, bacteriological and histological examination not done

A16.2  Tuberculosis of lung, without mention of bacteriological or histological confirmation

A16.3  Tuberculosis of intrathoracic lymph nodes, without mention of bacteriological or histological confirmation

Excludes: when specified as primary

A16.4  Tuberculosis of larynx, trachea and bronchus, without mention of bacteriological or histological confirmation

A16.5  Tuberculous pleurisy, without mention of bacteriological or histological confirmation

Excludes: in primary respiratory tuberculosis

A16.7  Primary respiratory tuberculosis without mention of bacteriological or histological confirmation

A16.8  Other respiratory tuberculosis, without mention of bacteriological or histological confirmation

A16.9  Respiratory tuberculosis unspecified, without mention of bacteriological or histological confirmation

A17.9  Tuberculosis of nervous system, unspecified

A18   Tuberculosis of other organs

A18.0 Tuberculosis of bones and joints

A18.1  Tuberculosis of genitourinary system

A18.2  Tuberculous peripheral lymphadenopathy

Excludes: tuberculosis of lymph nodes:

A18.3  Tuberculosis of intestines, peritoneum and mesenteric glands

A18.4  Tuberculosis of skin and subcutaneous tissue

Excludes: lupus erythematosus

A18.5  Tuberculosis of eye

Excludes: lupus vulgaris of eyelid

A18.6  Tuberculosis of ear

Excludes: tuberculous mastoiditis

A18.7  Tuberculosis of adrenal glands

A18.8  Tuberculosis of other specified organs

A19     Miliary tuberculosis

A19.0  Acute miliary tuberculosis of a single specified site

A19.1  Acute miliary tuberculosis of multiple sites

A19.2  Acute miliary tuberculosis, unspecified

A19.8  Other miliary tuberculosis

A19.9  Miliary tuberculosis, unspecified

Reporting the Skin Tests for Tuberculosis

There are two screening methods available for LTBI:

  • the Mantoux tuberculin skin test (TST), and
  • Interferon-gamma release assays (IGRAs)

The CDC recommends screening with either these methods, but not both.

  • Tuberculosis Testing (Mantoux/Purified Protein Derivative (PPD)

    – Administration of PPD

    CPT Code 86580 Skin test; tuberculosis, intradermal

    ICD-10 code Z11.1 Encounter for screening for respiratory tuberculosis

    Note: Since the PPD test is a screening test, it includes administration of the test. A separate administration code should not be reported for this test.

    – Reading of PPD Test

    If patient returns to have a nurse read the test results, report the following codes:

    CPT code 99211 Office or other outpatient services (nurse visit or negative outcome)

    Z11.1 Encounter for screening for respiratory (nurse visit or negative outcome);

    CPT code 99212-99215 Office or outpatient services (physician services for positive encounter)

    R76.11 Nonspecific reaction to tuberculin skin tuberculosis (if test is positive)

  • Interferon-gamma release assays (IGRAs) for LTBI

    The two FDA approved IGRA testing methods are: QuantiFERON-TB Gold In-Tube (QFT-GIT) and T-SPOT.TB (T-Spot])

    CPT 86480 Tuberculosis test, cell medicated immunity antigen response measurement; gamma interferon (QuantiFERON-TB Gold In-Tube [QFT-GIT)

    CPT 86481 Tuberculosis test, cell mediated immunity antigen response measurement; enumeration of gamma interferon-producing T-cells in cell suspension (T-SPOT.TB [T-Spot])

    IGRAs require a single blood sample. The skin test reaction is measured in millimeters of the “induration” after 48 to 72 hours. These assays require laboratory processing within 8 to 30 hours after collection.

Other relevant CPT Codes

TB-specific tests

87555  Infectious agent detection by nucleic acid (DNA or RNA); Mycobacterium tuberculosis, direct probe technique

87556  Infectious agent detection by nucleic acid (DNA or RNA); Mycobacterium tuberculosis, amplified probe technique

87557  Infectious agent detection by nucleic acid (DNA or RNA); Mycobacterium tuberculosis, quantification

Nonspecific TB tests

71020  Radiologic examination, chest, 2 views, frontal and lateral

71260  Computed tomography, thorax; with contrast material(s)

87116  Culture, tubercle, or other acid-fast bacilli (e.g., TB, AFB, and mycobacteria) any source, with isolation and presumptive identification of isolates

87118  Culture, mycobacterial, definitive identification, each isolate

87143  Culture, typing; gas liquid chromatography (GLC) or high pressure liquid chromatography (HPLC)

As physicians intensify their efforts to put an end to the disease, medical billing and coding outsourcing is a practical option to ensure proper claim submission and reimbursement.

Coding Pressure Ulcers – Quality Documentation is Critical

Diagnosing and Documenting Pneumonitis – An Overview

Pneumonitis is a general term that refers to inflammation of lung tissue. Also referred to as hypersensitivity pneumonitis, this disorder is caused when a person has an allergic reaction in their lungs caused by certain inhaled substances. This inflammation makes it harder for the lungs to function properly and may sometimes even damage the lungs permanently. Pneumonitis is not a specific disease but a sign of an underlying problem. The condition tends to occur when an irritating substance of any kind is introduced into the lungs causing the tiny air sacs in the lungs to become inflamed and lead to breathing difficulty. In most cases, lifestyle factors such as occupation, location, age and gender can increase the risk of this disease. A person who works with harsh chemicals or irritants is more likely to develop pneumonitis than others. Some other causes include – radiation treatment, drugs and antibiotics, molds and bacteria and exposure to birds, bird feathers, or excrement. If diagnosed early, hypersensitivity pneumonitis is treatable by avoiding exposure to the environmental substances or with medicines such as corticosteroids that reduce inflammation. For accurate clinical documentation of this lung condition, physicians can benefit from the services of medical billing outsourcing companies.Diagnosing Pneumonitis

Signs and Symptoms of Pneumonitis

One of the most common symptoms of hypersensitivity pneumonitis is shortness of breath accompanied by a dry cough. If left untreated, the condition gradually develops into chronic pneumonitis, which can result in scarring (fibrosis) in the lungs. Common signs and symptoms include –

  • Fatigue
  • Loss of appetite
  • Unintentional weight loss
  • A burning sensation in the chest
  • Fever
  • Tiredness

The initial symptoms may last for as little as 12 hours, but may continue for several days in some individuals.

Diagnosing and Documenting Pneumonitis

As pneumonitis symptoms are similar to that of other lung disorders, it is difficult to accurately diagnose the same. As part of the initial diagnosis, physicians will conduct a detailed physical exam and evaluate the patient’s previous medical history. They will try to find out the exact substances or factors the patient has come into contact with that could cause pneumonitis. To distinguish pneumonitis from other lung disorders, physicians may conduct one or more of the following tests –

  • Blood tests to evaluate the levels of white blood cells in the body
  • Diagnostic imaging tests such as Chest X-ray and Computerized tomography (CT) to check for fluid or inflammation in the lungs
  • Pulmonary function tests such as – Spirometry, Bronchoscopy, Surgical lung biopsies and Oximetry

Treatment advice for pneumonitis in most cases will involve recommendation from the physicians to eliminate or reduce exposure to the allergen or chemical irritating your lungs. Avoiding the irritant is often enough to prevent the pneumonitis from reoccurring or getting worse. However, this may not be always possible, especially when chemotherapy or radiation treatments are involved.

Pulmonologists who treat pneumonitis rely on reputable medical billing companies to code the condition accurately. The following ICD-10 codes are relevant with regard to pneumonitis–

  • J67 – Hypersensitivity pneumonitis due to organic dust
    • J67.0 – Farmer’s lung
    • J67.1 – Bagassosis
    • J67.2 – Bird fancier’s lung
    • J67.3 – Suberosis
    • J67.4 – Maltworker’s lung
    • J67.5 – Mushroom-workers lung
    • J67.6 – Maple-bark-stripper’s lung
    • J67.7 – Air conditioner and humidifier lung
    • J67.8 – Hypersensitivity pneumonitis due to other organic dusts
    • J67.9 – Hypersensitivity pneumonitis due to unspecified organic dust
  • J68 – Respiratory conditions due to inhalation of chemicals, gases, fumes and vapors
    • J68.0 – Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors
    • J68.1 – Pulmonary edema due to chemicals, gases, fumes and vapors
    • J68.2 – Upper respiratory inflammation due to chemicals, gases, fumes and vapors, not elsewhere classified
    • J68.3 – Other acute and sub acute respiratory conditions due to chemicals, gases, fumes and vapors
    • J68.4 – Chronic respiratory conditions due to chemicals, gases, fumes and vapors
    • J68.8 – Other respiratory conditions due to chemicals, gases, fumes and vapors
    • J68.9 – Unspecified respiratory condition due to chemicals, gases, fumes and vaporsDocumenting Pneumonitis
  • J69 – Pneumonitis due to solids and liquids
    • J69.0 – Pneumonitis due to inhalation of food and vomit
    • J69.1 – Pneumonitis due to inhalation of oils and essences
    • J69.8 – Pneumonitis due to inhalation of other solids and liquids

Prevention of pneumonitis may involve making certain lifestyle changes to protect health. If the condition is not well controlled over time, this chronic inflammation can cause irreversible scarring of the lungs that may severely impair its ability to function. Lifestyle changes to prevent this chronic lung condition include – avoiding chemical irritants and wearing a face mask when dealing with birds, bacteria, or mold of any kind as much as possible.

Treating and managing patients with pneumonitis and taking care of the necessary documentation simultaneously can be quite demanding for physicians. Managing pulmonary medical billing and coding will be much easier for pulmonologists who partner with a medical billing and coding service provider. With an experienced team of AAPC-certified coders and billing professionals to assist them, medical coding and timely claim submission would be easier; these services would also help ensure appropriate reimbursement.