Coding Aortic Valve Stenosis– Be Familiar with the Related Medical Codes

Regarded as one of the most common and serious valve disorders, Aortic valve stenosis (also called aortic stenosis) occurs when the heart’s aortic valve narrows. The aortic valve – a key valve in the body’s blood circulation system – opens to allow blood to flow into the aorta – the main artery that carries blood out of the heart to the body. If you have aortic stenosis, this valve does not open fully and this abnormal narrowing makes it extremely difficult for blood to flow from the heart to the body and onward to the rest of your body. When the blood flow through the aortic valve is reduced or blocked, the heart needs to work harder to pump blood to the body, which can possibly weaken the heart muscles. Treatment for this heart condition depends on the severity of symptoms and may generally include surgery to repair or replace the valve. If left untreated, this condition can lead to serious heart complications. Medical billing and coding for aortic stenosis can be challenging for healthcare providers. Outsourcing to a reliable medical billing and coding company can help in timely claim submission and correct reimbursement.

As per 2018 reports, about 2.5 million people in the United States (over the age of 75 years) suffer from aortic valve stenosis – which is about 12.4 percent of the total population. It is estimated that this figure will increase at a high pace by the end of 2050. Aortic valve stenosis can occur due to several causes like – congenital heart defect, rheumatic fever and calcium buildup on the valves. Early diagnosis and timely treatment can help prevent the incidence of complications like – heart failure, stroke, blood clots, heart rhythm abnormalities (arrhythmias) and even death.

Does Aortic Stenosis Always Produce Symptoms?

Many people with aortic stenosis do not experience noticeable symptoms until the amount of restricted blood flow becomes significantly reduced. In most cases, the signs and symptoms develop when narrowing of the valve is severe. Signs and symptoms of this heart valve disorder may include –

  • Breathlessness
  • Chest pain (angina), pressure or tightness
  • Feeling faint or dizzy or fainting with activity
  • Palpitations or a feeling of heavy, pounding, or noticeable heartbeats
  • Decline in activity level or reduced ability to do normal activities requiring mild exertion
  • Heart murmur
  • Fatigue, especially during times of increased activity

Potential risk factors associated with the condition include – age, history of heart infections, chronic kidney disease, history of radiation therapy to the chest and cardiovascular risk factors such as diabetes, high cholesterol and high blood pressure.

Understanding the Treatment Options

Several diagnostic imaging tests like – echocardiogram, electrocardiogram (ECG), cardiac computerized tomography (CT) scan, chest X-ray, cardiac MRI and cardiac catheterization may be ordered to determine the cause and severity of the condition.

Surgery to repair or replace an aortic valve is the major treatment option for this condition. Surgery options include – aortic valve repair, balloon valvuloplasty and aortic valve replacement. Cardiology medical coding involves using the relevant CPT codes as well as the ICD-10 codes on the medical claims submitted to health insurers for reimbursement.

CPT Codes

  • 33361 – Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach
  • 33362 – Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach
  • 33363 – Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach
  • 33364 – Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open iliac artery approach
  • 33365 – Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach
  • 33366 – Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical exposure
  • 33367 – Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with percutaneous peripheral arterial and venous cannulation
  • 33368 – Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with open peripheral arterial and venous cannulation
  • 33369 – Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with central arterial and venous cannulation

ICD-10 Codes

  • I35 – Nonrheumatic aortic valve disorders
    • I35.0 – Nonrheumatic aortic (valve) stenosis
    • I35.1 – Nonrheumatic aortic (valve) insufficiency
    • I35.2 – Nonrheumatic aortic (valve) stenosis with insufficiency
    • I35.8 – Other nonrheumatic aortic valve disorders
    • I35.9 – Nonrheumatic aortic valve disorder, unspecified

Preventing this heart valve disorder involves incorporating several heart-healthy lifestyle changes into the patient’s life including – consuming a healthy and nutritious diet, maintaining a healthy body weight, getting regular physical activity, avoiding tobacco and managing stress. Women with aortic valve stenosis should consult their physician before becoming pregnant. Treating and managing patients with aortic stenosis can be quite challenging for cardiologists or other physicians. Outsourcing medical billing and coding tasks is a practical option for physicians to ensure appropriate care for their patients as well as accurate clinical documentation of the heart valve-disorder.

Coding Primary Lateral Sclerosis (PLS) – Quality Documentation is Vital

Primary lateral sclerosis (PLS) is a rare, neuromuscular disorder that affects the central nervous motor neurons (also called corticospinal neurons) and causes them to slowly break down. The condition may lead to painless but progressive weakness and stiffness of the voluntary muscles that control your legs, arms and tongue. PLS occurs when nerve cells in the motor regions of the cerebral cortex (the thin layer of cells covering the brain, for high level mental functions) gradually degenerate, causing movements to be slow. In most cases, this motor neuron disease affects the legs first, followed by the body, trunk, arms and hands, and, finally the bulbar muscles (muscles that control speech, swallowing, and chewing). The condition can happen at any age, but it generally occurs for the age group of 40 – 60 years. This condition is more common in men than in women. Documenting and coding this neuro muscular disorder requires correct recording of all the prominent symptoms and treatment modalities offered. Medical coding outsourcing is an option worth considering as this can help neurologists ensure accurate and timely claim filing and reimbursement.

In primary lateral sclerosis (PLS), nerve cells in the brain, which control movement, fail over time. This in turn may cause movement problems, such as slow movements, balance problems and clumsiness. Often, PLS disorder is mistaken for another, more similar motor neuron disease called amyotrophic lateral sclerosis (ALS). However, the progression of PLS is slower than ALS and in most cases is not serious.

Signs and Symptoms of PLS

In most cases, the initial symptom of PLS is progressive muscle weakness and stiffness of the voluntary muscles of the legs. The disorder usually affects one leg and then progresses to the other. Some of the other associated symptoms include –

  • Stiffness, weakness and spasticity in your legs
  • Weakness and stiffness progressing to your trunk, then your arms, hands, tongue and jaw
  • Hoarseness, reduced rate of speaking, slurred speech and drooling as the facial muscles weaken
  • Difficulty with balance and clumsiness as the leg muscles weaken
  • Difficulties with swallowing and breathing (late in the disease)

The above mentioned symptoms may at first appear in your hands or tongue and then progress down to your spinal cord to your legs. However, these symptoms usually take years to progress.

Correctly Diagnosing and Treating Primary Lateral Sclerosis (PLS)

There is no single, definitive test that correctly confirms a diagnosis of primary lateral sclerosis (PLS). As the signs and symptoms of PLS often mimic several other neurological disorders like multiple sclerosis and amyotrophic lateral sclerosis (ALS), physicians may conduct a wide range of diagnostic imaging tests to rule out the possibility of other diseases.

The initial diagnosis of this motor neuron disorder will begin with a detailed physical and neurological examination and evaluation of previous medical history. Neurologists offering treatment for this condition may conduct a wide range of diagnostic imaging tests such as – Magnetic resonance imaging (MRI), nerve conduction studies, Electromyogram (EMG), Spinal tap (lumbar puncture) and certain blood tests (to check for infections) to evaluate the symptoms and make a correct diagnosis of the condition.

Treatment modalities for this condition include – medications (such as baclofen, tizanidine (Zanaflex), clonazepam, amitriptyline and antidepressants (to reduce muscle spasms and help drooling problems), physical therapy exercises, speech therapy and assistive devices (such as a cane, walker or wheelchair) as PLS progresses.

Neurology medical coding involves the use of specific ICD-10 codes to document any such conditions, including primary lateral sclerosis (PLS). ICD-10-CM codes used to indicate a diagnosis of PLS for reimbursement purposes include –

  • G12.23 – Primary lateral sclerosis
  • G12.24 – Familial motor neuron disease
  • G12.25 – Progressive spinal muscle atrophy
  • G12.29 – Other motor neuron disease

Even though there is no cure for primary lateral sclerosis (PLS), there are several lifestyle habits that can be followed to maintain muscle function for as long as possible. Staying physically active by engaging in different kinds of exercise programs and consuming a balanced healthy diet may help avoid excessive weight gain and added pressure on your joints, thereby slowing the progression of the disease.

Medical coding for various neurological conditions can be problematical. For accurate and timely medical billing and claims submission, healthcare practices can outsource their medical coding tasks to a reliable and professional medical billing company that provides the services of AAPC-certified coding specialists.

Documenting and Coding Subdural Hematoma – Know the ICD-10 Codes

Documenting and Coding Subdural Hematoma – Know the ICD-10 Codes

Head injury is a serious condition that requires immediate medical attention. Generally, a person suffering from a head injury may not initially experience any feelings of being sick, but bleeding can occur within the skull. Internal bleeding can lead to serious consequences, including severe brain damage and even death. One type of internal bleeding in the skull is called subdural hematoma. Also called a subdural hemorrhage, this condition occurs when a vein located below the skull ruptures and starts to bleed. The blood collects between the skull and the surface of the brain. As the volume of hematoma (blood clotting) increases, brain parenchyma gets compressed and displaced, and the intracranial pressure may rise and cause herniation, leading to unconsciousness and death. Subdural hematomas can be caused by minor accidents to the head, major trauma, or the spontaneous bursting of a blood vessel in the brain (aneurysm). Treatment for this head injury is generally based on the type and severity of the injury. Typically, surgery is recommended for most subdural hematomas. However, very small hematomas may be carefully monitored first to see if they heal without having an operation. Neurosurgeons or neurology specialists who provide appropriate treatment for this type of injuries should also ensure that the medical coding for this condition is properly done on the medical claims. Proper coding on the medical claims is crucial for medical coding companies to ensure accurate documentation and reimbursement.

Subdural Hematoma

Subdural hematoma can be either acute or chronic. Acute subdural hematoma is the most dangerous type usually caused by a vehicle accident, a blow to the head or a fall from a height. Such cases form quickly and are often harder to treat. It is estimated that the death from an acute subdural hematoma is more than 50 percent. Chronic subdural hematoma on the other hand, is caused by mild or repeated head injuries. These are more common among older adults who repeatedly fall and hit their heads.

Common Symptoms

The symptoms of subdural hematoma can depend on the type of injury (whether it’s acute or chronic) and can vary from one person to another. Symptoms of an acute subdural hematoma occur rapidly following an injury. In cases of chronic subdural hematoma, symptoms are more likely to develop slowly or may not develop at all. Common symptoms include –

  • Severe headache
  • Vision problems
  • Slurred speech
  • Seizures
  • Mood swings
  • Loss of consciousness or passing out
  • Dizziness and vomiting
  • Confusion
  • Apathy and weakness

Other potential risk factors that could increase a person’s chances of developing subdural hemorrhage include – patient’s age, medical conditions (that cause blood clotting issues), long-term alcohol use or abuse, blood thinners (such as warfarin or aspirin) and repeated head injuries (such as from falls or sports).

How a Subdural Hematoma Is Diagnosed

Diagnosing subdural hematoma quickly is important so that the treatment programs can be initiated immediately. Timely treatment may help minimize the risk of severe complications or even death. In most cases, head hemorrhage is quite difficult to diagnose as certain types do not depict any specific symptoms quickly or may have not have an obvious cause.

As part of the initial diagnosis, physicians will conduct a thorough physical and neurological examination to check for blood pressure and pulse, reflexes and balance, vision (the way the eyes respond to light) and the patient’s ability to answer questions and remember things. Physicians will also ask several questions about – occurrence of any head injuries (past and present), pain symptoms developed, medications taken, medical health problems and alcohol or drug consumption habits.

Several diagnostic tests like computed tomography (CT), or magnetic resonance imaging (MRI) scans will be conducted to get a clear picture of the different parts of the brain, skull, veins and other blood vessels and to check for any specific signs of blood clotting. If the physician identifies bleeding in any area, the source of the bleeding will be determined and a plan of action developed to address the specific issue. In addition, neurologists will also check your blood pressure and heart rate and recommend a detailed blood test to check for the total blood count. A complete blood count measures your red blood and white blood cell count and platelet count. A low level of red blood cells can indicate significant blood loss.

Treatment options for subdural hemorrhage may mainly depend on the type and severity of injury. Surgery will be recommended as the best option in most cases of subdural hemorrhage. Surgical techniques include craniotomy (a section of the skull is temporarily removed in order to access and remove the hematoma) and burr holes (a small hole is made in the skull and a tube is inserted through the hole to help drain blood clots). However, very small subdural hematomas may be carefully monitored first to see if they heal without having an operation.

Neurosurgery medical coding involves using the specific ICD-10 diagnosis codes for reporting subdural hematoma on the medical claims they submit to health insurers for reimbursement.

ICD-10 Codes to Use for “Subdural Hemorrhage”

S06.5 – Traumatic subdural hemorrhage
S06.5X – Traumatic subdural hemorrhage
S06.5X0 – Traumatic subdural hemorrhage without loss of consciousness

  • S06.5X0A – Traumatic subdural hemorrhage without loss of consciousness, initial encounter
  • S06.5X0D – Traumatic subdural hemorrhage without loss of consciousness, subsequent encounter
  • S06.5X0S – Traumatic subdural hemorrhage without loss of consciousness, sequela

S06.5X1 – Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less

  • S06.5X1A – Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, initial encounter
  • S06.5X1D – Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, subsequent encounter
  • S06.5X1S – Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, sequela

S06.5X2 – Traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes

  • S06.5X2A – Traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, initial encounter
  • S06.5X2D – Traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter
  • S06.5X2S – Traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, sequela

S06.5X3 – Traumatic subdural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes

  • S06.5X3A – Traumatic subdural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
  • S06.5X3D – Traumatic subdural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter
  • S06.5X3S – Traumatic subdural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela

S06.5X4 – Traumatic subdural hemorrhage with loss of consciousness of 6 hours to 24 hours

  • S06.5X4A – Traumatic subdural hemorrhage with loss of consciousness of 6 hours to 24 hours, initial encounter
  • S06.5X4D – Traumatic subdural hemorrhage with loss of consciousness of 6 hours to 24 hours, subsequent encounter
  • S06.5X4S – Traumatic subdural hemorrhage with loss of consciousness of 6 hours to 24 hours, sequela

S06.5X5 – Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level

  • S06.5X5A – Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
  • S06.5X5D – Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter
  • S06.5X5S – Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela

S06.5X6 – Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving

  • S06.5X6A S06.5X6 – Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
  • S06.5X6D S06.5X6 – Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter
  • S06.5X6S S06.5X6 – Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela

S06.5X7 – Traumatic subdural hemorrhage with loss of consciousness of any duration with death due to brain injury before regaining consciousness

  • S06.5X7A – Traumatic subdural hemorrhage with loss of consciousness of any duration with death due to brain injury before regaining consciousness, initial encounter

S06.5X8 – Traumatic subdural hemorrhage with loss of consciousness of any duration with death due to other cause before regaining consciousness

  • S06.5X8A – Traumatic subdural hemorrhage with loss of consciousness of any duration with death due to other cause before regaining consciousness, initial encounter

S06.5X9 – Traumatic subdural hemorrhage with loss of consciousness of unspecified duration

  • S06.5X9A – Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter
  • S06.5X9D – Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, subsequent encounter
  • S06.5X9S – Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, sequela

With early treatment of these injuries, patients will have better chances of full recovery. The speed of recovery often depends on the type and extent of damage the hematoma has caused to the brain. It is estimated that only 20-30 percent of people can expect to see a full or nearly full recovery of brain functioning. Even after the treatment for subdural hematoma, many patients are left with some long-lasting problems like mood swings, memory/concentration problems, seizures, speech problems and weakness in limbs. In some cases, there are chances that the symptoms may come back and hence surgery to drain the hematoma may need to be repeated.

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

Documenting and Coding Subdural Hematoma – Know the ICD-10 Codes

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.