Measles Outbreak in U.S. Breaks History – Raises Concern

Measles Outbreak in U.S. Breaks History – Raises Concern

It has been nearly 20 years since measles was declared eliminated from the U.S. in 2000. Now, it has made a comeback. According to the report from CBS News, starting January of this year, 22 states have experienced a total of 695 cases of measles. Earlier, the annual number of cases had ranged from a low of 37 in 2004 to a high of 667 in 2014. This disease, caused by a highly contagious virus can spread easily through the air when an infected person coughs or sneezes. Infectious diseases such as measles must be accurately and extensively documented using the correct medical codes. Comprehensive documentation creates a clear record of the diagnosis and treatment provided. Medical coding companies assist physicians treating this condition with accurate documentation.

Measles is an acute viral respiratory illness with symptoms such as fever, malaise, cough, Coryza (rhinitis), Conjunctivitis (pink eye), Pathognomonic enanthema (Koplick’s spots) and Maculopapular rash. The condition may also lead to serious illnesses including diarrhea, ear infection and brain damage.

This disease is more likely to spread and cause outbreaks in communities where groups of people are unvaccinated. Common complications from measles include otitis media, bronchopneumonia, laryngotracheobronchitis, and diarrhea. People who are at high risk for severe illness and complications from measles include infants and children aged less than 5 years, adults aged more than 20 years, pregnant women and those with weak immune systems.

Though rapid blood tests are available to detect whether a person is immune based on the level of measles antibodies, these tests are not fully reliable. Though there is no particular treatment for measles, medical care helps relieve symptoms and address complications such as infections.

Vaccination – The Only Way to Prevent Measles

Measles can be prevented by the MMR vaccine, which is only licensed for use in children 12 months through 12 years of age. The CDC recommends the Measles-Mumps-Rubella (MMR) and Varicella (VAR) vaccines, or the combination Measles-Mumps-Rubella-Varicella (MMRV) vaccine, for children 1-12 years of age, given in two separate doses: the first dose at 12-15 months of age and the second dose at 4-6 years of age. While one dose of MMR vaccine is approximately 93% effective at preventing measles; two doses are approximately 97% effective. The second dose is administered to address primary vaccine failure.

Reuters recently reported that with the current measles outbreak, public health experts are concerned about immunity in adults in the United States and they recommend a new vaccination dose for those adults who were vaccinated against measles decades ago. This new vaccine will be depending on when they received the shot and their exposure risk.

Coding Measles

Most health insurance plans cover the cost of vaccines. Medicare prescription drug plans also cover MMR (Measles, Mumps, & Rubella) vaccines. Medical coders must make sure to file medical records with accurate codes –

CPT

  • 90705 Measles virus vaccine, live, for subcutaneous use
  • 90706 Rubella virus vaccine, live, for subcutaneous use
  • 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use
  • 90708 Measles and rubella virus vaccine, live, for subcutaneous use
  • 90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use

ICD-10

  • B05.0 Measles complicated by encephalitis
  • B05.1 Measles complicated by meningitis
  • B05.2 Measles complicated by pneumonia
  • B05.3 Measles complicated by otitis media
  • B05.4 Measles with intestinal complications
  • B05.81 Measles keratitis and keratoconjunctivitis
  • B05.89 Other measles complications
  • B05.9 Measles without mention of complication.

Rubella or German measles is classified under category B06 and includes the following codes:

  • B06.0 Rubella with neurological complications
  • B06.8 Rubella with other complications
  • B06.9 Rubella without complication

Missed measles vaccinations are also a factor contributing to the global rise of this illness. UNICEF has highlighted that over 20 million children missed vaccinations worldwide in the last 8 years, leading to global measles outbreaks. CDC recommends that people who are living in or traveling to any such outbreak areas should check their vaccination status and consider getting a new dose. Physicians serving in affected communities are also advised to confirm that all their patients are up to date with MMR vaccine requirements. Professional medical coding services are available to help busy physicians meet their billing and coding tasks, while they focus on patient care.

Accurate Medical Coding – Some Additional Tips and Ideas

Accurate Medical Coding – Some Additional Tips and Ideas

Medical coding, a key factor of revenue cycle management needs to be accurate enough to ensure smooth reimbursement for healthcare providers. Medical coders take information from the medical record documentation and assign appropriate diagnoses and procedure codes. Accurate coding of claims also requires correct clinical documentation from healthcare providers. Experienced medical billing companies provide the services of skilled medical coders, who stay up-to-date with the changing coding guidelines and insurance standards. Along with providing the correct codes and accurately verifying patient details, coders can follow these tips to improve their coding practices. You can also listen to our podcast on key medical coding errors.

Adopt checklists

Medical coding professionals focus on documenting diagnosis, treatments, and results in the form of ICD-10, HCPCS and CPT codes on insurance claim records. Adopting checklists can help these professionals improve medical coding accuracy. It –

  • Reminds coders of additional characters, action and add-on codes, and modifiers that should be reported

  • Helps avoid distractions, resulting in an error in the claim

  • Alerts coders of all crucial federal tracking codes

  • Can improve communication in operating rooms between providers, nurses, and other staff

Review of Systems

Review of systems (ROS) refers to an inventory of body systems obtained by asking a series of questions to identify signs and/or symptoms the patient may be experiencing or has experienced. Such queries made verbally by the physician or hospital staffs, or through patient intake form helps to check the requirement of extended examination and testing. For ROS, 14 systems are recognized including eyes, cardiovascular, respiratory, musculoskeletal, psychiatric, endocrine and more. Documentation includes signs and symptoms of the condition and often auditors commonly watch for indicators of a question that has been asked by the physician or provider and answered by the patient.

Appropriate use of modifiers

Modifiers are required for certain CPT and HCPCS codes. These two-digit codes provide additional information about the procedure performed. These can also be used to identify the body area where the procedure is performed, such as modifier RT for “right side” and LT for “left side”.

Recently the Centers for Medicare & Medicaid Services (CMS) issued a policy change for Modifier 59 Distinct procedural service and the optional patient-relationship modifiers XE, XS, XP, and XU. Starting July 1, 2019, CMS has accepted to process modifier 59 when it is used on either the column 1 procedure or the column 2 procedure. The CCI bundling edit will be bypassed when modifier 59, XE, XS, XP, or XU is used on column 1 and column 2 codes. Note that this policy change does not affect Medicare Managed Care payers, Medicaid, or commercial payers. Recently some non-Medicare payers, such as Horizon Blue Cross Blue Shield have indicated that they recognize these modifiers.

Pay attention to operative reports

While coding, make sure to read the pre- and post-operative reports (OP). Instead of coding from the pre-operative diagnosis, code from the post-operative diagnosis that provides details such as why the procedures were performed, what the physician discovered during the operation and the area where the physician performed the procedure. It is also recommended never to code from the title of the procedure. Also, review the indications sections of the OP report that provides details such as the disease or condition that created the need for the surgery, any indication that the patient is subject to an existing global period and indications that this may be a more difficult procedure.

Code the correct procedure and medical coders can also query the physician if any details are uncertain. Also ensure that the OP report matches the patient.

Check NCCI edits

The CMS has developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. While reporting multiple codes, coders must make sure to check these NCCI edits, which analyzes every pair of codes to see if an edit exists. NCCI includes three types of edits – Procedure-to-procedure edits, Medically unlikely edits (MUE) and Add-on code edits. NCCI Procedure-to-Procedure (PTP) edits prevent improper payment when incorrect code combinations are reported. If there is an NCCI edit, it means a code is denied.

By outsourcing medical billing and coding tasks to an experienced medical billing company, healthcare providers can focus on providing optimal care to patients and stay competitive in the industry without any worries about claim submission and reimbursement.

Medical Coding Steps and Guidelines for Lesion Excision

Medical Coding Steps and Guidelines for Lesion Excision

Skin lesion excision refers to the surgical procedure of removing a cancerous skin lesion and an area of surrounding tissue called the margin. Medical coding services for this biopsy excision involve assigning appropriate CPT codes for the procedure performed. To accurately code for the skin lesion excision, the documentation should include details such as – whether the lesion is benign or malignant, the location of the lesion and the excised diameter of the lesion.

Though lesion excision coding seem to be complex, reporting excision of benign (non-cancerous) and malignant (cancerous) skin lesions can be made easy with some steps such as the following.

Check pathology reports

Before assigning the codes, check the pathology reports to confirm whether the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior. While benign lesions or one of uncertain behavior (indications of atypia or dysplasia) are reported using CPT codes 11400-11471, malignant skin lesions can be documented with codes ranging from 11600 to 11646. Malignancy may be primary (malignancy at the site where a cancer begins to grow), secondary (malignancy has spread from the primary site to other parts of the body), or in-situ (an early-stage tumor that may evolve into an invasive malignancy).

An AAPC article recommends coders to assign an unspecified diagnosis and a benign lesion excision CPT® code (11400-11471) if there is no pathology report available to confirm the diagnosis. However, if the provider performs a re-excision to obtain clear margins at a later operative session, report the same diagnosis as that used for the initial procedure.

Consider location

To assign the correct codes, it is important to know the anatomic location from which the lesion(s) is excised. It is recommended to group together multiple areas within a single set of codes. Site-specific classifications can be used to report each skin lesion excision independently as –

Benign lesion

  • Trunk, arms, legs – 11400-11406
  • Scalp, neck, hands feet, genitalia – 11420-11426
  • Face, ears, eyelids, nose, lips, mucous membrane – 11440-11446

Malignant lesion

  • Trunk, arms, legs – 11600-11606
  • Scalp, neck, hands, feet, genitalia – 11620-11626
  • Face, ears, eyelids (skin only), nose ,lips – 11640-11646

Size of lesion and margin matters

The size of lesion as well as margin (the area surrounding the lesion that is also removed) is of great importance when reporting skin lesion excision. Physicians should document the measurement of the lesion plus margin before the excision. Coders can use the greatest measurement of the diameter (distance across the lesion) and add to that the margin required for complete excision (determined by the physician). If the physician does not document a margin, it is advised to use the greatest measurement given. According to CPT® instructions, “Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that [most narrow] margin required for complete excision.”

Make sure no codes are selected based on the size of the incision and/or the resulting surgical wound. Also remember that a coder should not make any assumptions about the size of the excision other than what is stated.

Simple repairs can be bundled with excision

Even if CPT® guidelines state that all lesion excision codes include simple wound closure, it allows separate coding for intermediate (12031-12057) and complex (13100-13153) repairs. But payers who follow National Correct Coding Initiative (NCCI) edits will bundle intermediate and complex repairs into excision of benign lesions of 0.5 cm or less (11400, 11420, and 11440).
When multiple lesions are removed by the surgeon, each will be treated as a separate procedure. Here add modifier 59, distinct procedural service to the second and subsequent codes for excisions in the same general location.

Coders should also pay careful attention to code descriptors. An example is discussed in AAPC’s blog session – if the surgeon removed a malignant lesion from a patient’s right shoulder and the lesion measured 1.0 cm at its widest prior to excision and the surgeon allowed a margin of at least 1.0 cm on all sides, for a total excised diameter of 3.0 cm (1.0 cm + [2 x 1.0 cm]), the correct code to use is “11603 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm”.

Outsourcing medical coding is a practical solution for busy physicians. While outsourcing any such coding tasks, practices must choose professional medical billing and coding companies, as they can provide the services of experienced coding specialists.

Also read our blog on skin biopsy 2019 coding updates!

Reporting and Coding Different Types of Hernia

Hernia is a common problem which causes a localized bulge in the abdomen or groin. The condition occurs when there is a weakness or hole in the peritoneum – the muscular wall that usually keeps abdominal organs in place. This weakness in the peritoneumallows organs and tissues to push through, or herniate, producing a bulge. Generally, a hernia develops between your chest and hips. The condition causes very few symptoms or sometimes no symptoms at all, although in some cases you may notice a swelling or lump in your tummy (abdomen) or groin. The lump may disappear when you lie down, and sometimes it can be pushed back. Coughing or straining may make it reappear.Most hernias aren’t immediately life threatening, but they don’t improve on their own and can lead to severe, life-threatening complications. Medications and self-care measures can help reduce the immediate symptoms to some extent. Physicians, in most cases will recommend surgery to fix a hernia that’s painful or enlarging. As reimbursement rules, regulations, and payer policiesare subjected to changes frequently, partnering with an experienced medical billing and coding company is the best option to ensure clean and accurate claims for hernia surgery.

One of the common symptoms associated with the condition is a bulge or painless lump in the affected area. However, the condition may be the cause of serious discomfort and pain, with symptoms often becoming worse when standing, straining or lifting heavy items. Other associated symptoms include sudden, severe pain or discomfort in the affected area (especially when bending over, coughing, or lifting), nausea, vomiting, constipation, a feeling of pressure/heaviness in the abdomen, aburning, gurgling, or aching sensation at the site of the bulge, chest pain, acid reflex and difficulty swallowing.

Types of Hernia

  • Inguinal hernia – This is one of the most common types of hernia which mainly affects men. It occurs when the intestines push through a weak spot or tear in the lower abdominal wall, often in the inguinal canal.
  • Hiatal hernia – This condition is most common in people over 50 years old. It occurs when part of your stomach protrudes up through the diaphragm into your chest cavity.
  • Umbilical hernia – This condition occurs when the intestines bulge through their abdominal wall near the belly button. It is more common among babies below 6 months. This is the only type of hernia that often goes away on its own as the abdominal wall muscles get stronger, typically by the time the child becomes 1 year old.
  • Femoral hernia –This type occurs when fatty tissue or a part of your bowel pokes through into your groin at the top of your inner thigh.
  • Incisional/ventral hernia – The condition arises when tissue pokes through a surgical wound in your abdomen that hasn’t fully healed.
  • Epigastric hernia – It occurs when fatty tissue pokes through your abdomen, between your navel and the lower part of your breastbone (sternum).
  • Diaphragmatic hernia – This type of hernia occurs when organs in your abdomen move into your chest through an opening in the diaphragm. This condition can also affect babies if their diaphragm doesn’t develop properly in the womb.

There is no specific cause or reason for a hernia to occur (except the case of incisional hernia that occurs due to a complication of abdominal surgery). They are generally caused by a combination of muscle weakness and strain. The condition occurs more commonly in men than in women and the risks increases with age. Other factors that increase your risk of developing a hernia include family history of the condition, obesity, chronic cough, constipation and conditions like cystic fibrosis, enlarged prostate, peritoneal dialysis, abdominal fluid and undescended testicles.

Diagnosis and Treatment Methods

Hernias are usually diagnosed through a detailed physical examination wherein your physician may feel for a bulge in the abdomen or groin that gets larger when you stand, cough or strain. Diagnostic imaging tests like X-ray, Ultrasound and Endoscopy may be conducted to correctly diagnose the symptoms and determine the exact type of hernia.

Treatment options for this condition depend on the size and type of hernia and the severity of your symptoms. Enlarging or painful hernias usually require surgery to relieve discomfort and prevent serious complications.There are two main types of surgical intervention for hernia –open surgery and laparoscopic operation (keyhole surgery). In the case of open surgery, the surgeon makes an incision and pushes the protruding tissue back into your abdomen. On the other hand, laparoscopic is a less invasive technique where several small incisions are made in your abdomen, thereby allowing the surgeon to use various special instruments to repair the hernia.

General surgery medical coding involves using the specific ICD-10 diagnosis codes, CPT procedure codes, HCPCS codes and MS-DRG codes for reporting hernia on your medical claims.

ICD -10 Codes to Indicate a Diagnosis of Hernia

K40 – Inguinal hernia

  • K40.0 – Bilateral inguinal hernia, with obstruction, without gangrene
  • K40.1 – Bilateral inguinal hernia, with gangrene
  • K40.2 – Bilateral inguinal hernia, without obstruction or gangrene
  • K40.3 – Unilateral inguinal hernia, with obstruction, without gangrene
  • K40.4 – Unilateral inguinal hernia, with gangrene
  • K40.9 – Unilateral inguinal hernia, without obstruction or gangrene

K41 – Femoral hernia

  • K41.0 – Bilateral femoral hernia, with obstruction, without gangrene
  • K41.1 – Bilateral femoral hernia, with gangrene
  • K41.2 – Bilateral femoral hernia, without obstruction or gangrene
  • K41.3- Unilateral femoral hernia, with obstruction, without gangrene
  • K41.4 – Unilateral femoral hernia, with gangrene
  • K41.9 – Unilateral femoral hernia, without obstruction or gangrene

K42 – Umbilical hernia

  • K42.0 – Umbilical hernia with obstruction, without gangrene
  • K42.1 – Umbilical hernia with gangrene
  • K42.9 – Umbilical hernia without obstruction or gangrene

K43 – Ventral hernia

  • K43.0 – Incisional hernia with obstruction, without gangrene
  • K43.1 – Incisional hernia with gangrene
  • K43.2 – Incisional hernia without obstruction or gangrene
  • K43.3 – Parastomal hernia with obstruction, without gangrene
  • K43.4 – Parastomal hernia with gangrene
  • K43.5 – Parastomal hernia without obstruction or gangrene
  • K43.6 – Other and unspecified ventral hernia with obstruction, without gangrene
  • K43.7 – Other and unspecified ventral hernia with gangrene
  • K43.9 – Ventral hernia without obstruction or gangrene

K44 – Diaphragmatic hernia

  • K44.0 – Diaphragmatic hernia with obstruction, without gangrene
  • K44.1 – Diaphragmatic hernia with gangrene
  • K44.9 – Diaphragmatic hernia without obstruction or gangrene

K45 – Other abdominal hernia

  • K45.0 – Other specified abdominal hernia with obstruction, without gangrene
  • K45.1 – Other specified abdominal hernia with gangrene
  • K45.8 – Other specified abdominal hernia without obstruction or gangrene

K46 – Unspecified abdominal hernia

  • K46.0 – Unspecified abdominal hernia with obstruction, without gangrene
  • K46.1 – Unspecified abdominal hernia with gangrene
  • K46.9 – Unspecified abdominal hernia without obstruction or gangrene

CPT Codes

Inguinal Hernia

  • 49492 – Repair, initial inguinal hernia, preterm infant (younger than 37 weeks gestation at birth), performed from birth up to 50 weeks post conception age, with or without hydrocelectomy; incarcerated or strangulated
  • 49495 – Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; reducible
  • 49496 – Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; incarcerated or strangulated
  • 49500 – Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible
  • 49501 – Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; incarcerated or strangulated
  • 49505 – Repair initial inguinal hernia, age 5 years or older; reducible
  • 49507 – Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated
  • 49520 – Repair recurrent inguinal hernia, any age; reducible
  • 49521 – Repair recurrent inguinal hernia, any age; incarcerated or strangulated
  • 49525 – Repair inguinal hernia, sliding, any age
  • 49650 – Laparoscopy, surgical; repair initial inguinal hernia
  • 49651 – Laparoscopy, surgical; repair recurrent inguinal hernia

Hiatal Hernia

  • 43332 – Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; without implantation of mesh or other prosthesis
  • 43333 – Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis
  • 43334 – Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; without implantation of mesh or other prosthesis
  • 43335 – Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; with implantation of mesh or other prosthesis
  • 43336 – Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; without implantation of mesh or other prosthesis
  • 43337 – Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; with implantation of mesh or other prosthesis

Umbilical Hernia

  • 49580 – Repair umbilical hernia, younger than age 5 years; reducible
  • 49582 – Repair umbilical hernia, younger than age 5 years; incarcerated or strangulated
  • 49585 – Repair umbilical hernia, age 5 years or older; reducible
  • 49587 – Repair umbilical hernia, age 5 years or older; incarcerated or reducible

Femoral Hernia

  • 49550 – Repair initial femoral hernia, any age; reducible
  • 49553 – Repair initial femoral hernia, any age; incarcerated or strangulated
  • 49555 – Repair recurrent femoral hernia; reducible
  • 49557 – Repair recurrent femoral hernia; incarcerated or strangulated

Incisional/Ventral Hernia

  • 49560 – Repair initial incisional or ventral hernia; reducible
  • 49561 – Repair initial incisional or ventral hernia; incarcerated or strangulated
  • 49565 – Repair recurrent incisional or ventral hernia; reducible
  • 49566 – Repair recurrent incisional or ventral hernia; incarcerated or strangulated
  • +49568 – Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair)
  • 49652 – Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible
  • 49653 – Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); incarcerated or strangulated
  • 49654 – Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); reducible
  • 49655 – Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated
  • 49656 – Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible
  • 49657 – Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated

Epigastric Hernia

  • 49570 – Repair epigastric hernia (eg, preperitoneal fat); reducible (separate procedure)
  • 49572 – Repair epigastric hernia (eg, preperitoneal fat); incarcerated or strangulated

Diaphragmatic Hernia

  • 39501 – Repair, laceration of diaphragm, any approach
  • 39503 – Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or without creation of ventral hernia
  • 39541 – Repair, diaphragmatic hernia (other than neonatal), traumatic; chronic

HCPCS Codes

  • C1726 – Catheter, balloon dilatation, non-vascular
  • C1781 – Mesh (implantable)
  • C9364 – Porcine implant, permacol, per square centimeter

MS-DRG Codes

Repair of Diaphragmatic Hernia (Hiatal Hernia, Paraesophageal Hernia)

  • 326 – Stomach, Esophageal and Duodenal Procedures W MCC
  • 327 – Stomach, Esophageal and Duodenal Procedures W CC
  • 328 – Stomach, Esophageal and Duodenal Procedures W/O CC/MCC

Hernia Repair – Inguinal, Femoral

  • 350 – Inguinal and Femoral Hernia Procedures W MCC
  • 351 – Inguinal and Femoral Hernia Procedures W CC
  • 352 – Inguinal and Femoral Hernia Procedures W/O CC/MCC

Hernia Repair – Other (Epigastric, Incisional/Ventral, Lumbar, Parastomal, Spigelian, Umbilical)

  • 353 – Hernia Procedures Except Inguinal and Femoral W MCC
  • 354 – Hernia Procedures Except Inguinal and Femoral W CC
  • 355 – Hernia Procedures Except Inguinal and Femoral W/O CC/MCC

Integrating positive lifestyle habits can help treat the symptoms of hernia in the long run. These include – making dietary changes, avoiding large or heavy meals, stopping the habit of smoking and doing certain kind of exercises (that help strengthen the muscles around the hernia site) and maintaining a healthy body weight.

Medical billing and coding requires knowledge regarding the right coding modifiers and payer-specific medical billing are essential for correct and on-time reimbursement. With all the complexities involved, the support of a reliable and experienced medical coding service provider can be useful for reporting hernia surgical repair procedure correctly.

Osteomyelitis Coding in ICD-10 — Ensure Specificity

Osteomyelitis Coding in ICD-10 — Ensure Specificity

Osteomyelitis is an infection in the bone. The infection can spread from nearby tissue or originate in the bone itself if a fracture or other trauma exposes the bone to infection. Osteomyelitis can be classified as acute, sub-acute, and chronic. Compared to ICD-9, there are specific guidelines and codes for reporting osteomyelitis in ICD-10 where acute, sub-acute and chronic osteomyelitis are grouped into additional subcategories. Further, ICD-10 differentiates between sub-acute infections and acute infections which have their own subcategories. Expert coders in medical coding companies can help physicians report osteomyelitis using appropriate ICD-10 codes based on the type, location, and acuity (acute, subacute, hematogenous, and/or chronic).

Causes and Risk Factors

Osteomyelitis is caused by an infecting organism, typically staphylococcus bacteria. Trauma, surgery, the presence of foreign bodies, or the placement of prostheses can compromise bone integrity and cause bone infection to develop. Osteomyelitis can also occur when infections reach the bone through the bloodstream. People with chronic health conditions such as diabetes mellitus and peripheral vascular disease, and smokers have a higher risk of developing chronic osteomyelitis. In children, osteomyelitis appears in the arm or leg bone.

Symptoms

Signs of osteomyelitis include fever, swelling, warmth and pain in the area of the infection, and fatigue. However, the condition can manifest without symptoms in infants, older adults and people whose immune systems are compromised.

Osteomyelitis – Types

Acute osteomyelitis is characterized by localized pain, soft-tissue swelling, and tissue warmth at the site of the infection as well as typical symptoms such as fever, irritability, fatigue, and nausea. It is easier to treat

In sub-acute osteomyelitis, symptoms are less severe than acute osteomyelitis and develop at a less rapid pace. Sub-acute osteomyelitis may be characterized by only moderate, localized pain without any systemic issues.

Chronic osteomyelitis is a severe, persistent inflammation/infection that is difficult to treat and can recur. A chronic infection also may be accompanied by a draining sinus, involving a higher risk for complications. Chronic multifocal osteomyelitis (chronic recurrent multifocal osteomyelitis) is a rare condition that mainly affects children. Symptoms include bone inflammation in multiple areas, severe pain, fever gait problems, and even skin changes.

ICD-10 codes to Report Osteomyelitis

In ICD-10, the codes to report osteomyelitis are in the M86-series. An ICD-10 Monitor article explains the circumstances for using these codes:

Acute and sub-acute osteomyelitis: There are three subcategories for reporting acute and sub-acute osteomyelitis using ICD-10 (including M86.0 to M86.2). Codes from subcategory M86.1 are used to report direct inoculation osteomyelitis.

Chronic osteomyelitis: There are four subcategories for reporting chronic osteomyelitis (including M86.3 to M86.6).

Other osteomyelitis: In ICD-10, 8 reports other osteomyelitis and are two additional subcategories for the reporting this condition. Currently regarded as a sub-acute condition, Brodie’s abscess is characterized by the presence of a bone abscess surrounded by dense fibrous tissue and sclerotic bone. Unspecified osteomyelitis is reported by subcategory M86.9.

M86 Osteomyelitis
M86.0 Acute hematogenous osteomyelitis
M86.1 Other acute osteomyelitis
M86.2 Subacute osteomyelitis
M86.3 Chronic multifocal osteomyelitis
M86.4 Chronic osteomyelitis with draining sinus
M86.5 Other chronic hematogenous osteomyelitis
M86.6 Other chronic osteomyelitis
M86.8 Other osteomyelitis
M86.9 Osteomyelitis, unspecified

Codes M86 to M86.8 are non-billable and coders must use specific codes that describe the diagnosis in more detail. Code M86.9 is a billable code that is valid for submission for HIPAA-covered transactions. M86.3 is a combination code that captures chronic types (in which a draining sinus is present).

Specific sites for subcategories M86.0-M86.6 include: Shoulder, Humerus, Radius/ulna, Hand, Femur, Tibia/fibula, Ankle/foot, Other specified sites, and Multiple sites. The following are examples of specific, billable codes that identify etiology, anatomic site, severity, and other details:

M86.061 acute hematogenous osteomyelitis, right tibia and fibula
M86.062 acute hematogenous osteomyelitis, left tibia and fibula
M86.131 other acute osteomyelitis, right radius and ulna
M86.132 other acute osteomyelitis, left radius and ulna
M86.241 subacute osteomyelitis, right hand
M86.242 subacute osteomyelitis, left hand
M86.371 chronic multifocal osteomyelitis, right ankle and foot
M86.372 chronic multifocal osteomyelitis, left ankle and foot

The ICD-10 Monitor article offers the following additional guidance for reporting osteomyelitis:

  • An additional code from categories B95-B97 should be assigned to identify the infectious agent.
  • A code from subcategory M89.7 should be reported to identify any major osseous defects.
  • In ICD-10, there is no separate designation for periostitis (inflammation of the membrane covering a bone) without mention of osteomyelitis. There are specific entries for periostitis of the dentoalveolar structures and jaw, and for periostitis due to certain infectious organisms, such as gonorrhea, syphilis, tuberculosis, and yaws. All other types are reported with a code from subcategory M86.0 along with a secondary code to identify the infectious organism.

With specific guidelines and additional code choices for osteomyelitis in ICD-10, reporting the condition correctly can be a challenge. Outsourcing medical coding and billing to an expert can ensure accurate coding and billing for error-free claim submission and optimal reimbursement.