Monday, July 30, 2012

Code for the Day: Unhappy Monday R45.2

There is a local radio station here in Denver with a deejay whose pet peeve is people complaining about Mondays.  "It's just another day of the week people," I've heard him say more than once.  I'm pretty much an optimist and don't like to get dragged into the Monday doldrums myself, but it is harder for me to get going on a Monday morning. And so I often tag a "Happy Monday" note with a smiley face on emails on Monday mornings.  It's not as much for the recipient - although if it helps them, then yay! - but for me.

So I was trying to decide what kind of code to choose for today and I've had this one jotted down on my virtual post-it for about a week:

  • R45.2 Unhappiness
When I first came across that code, I did a double take.  Did I really just see a code for being unhappy?  Seriously?

In case you're wondering, this code is found in Chapter 18 of ICD-10-CM, Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified.  In other words, it's a symptom code.  Whew!  Thankfully it's not in the mental and behavioral health chapter!  But I, personally, think something is missing here - a couple of nonessential modifiers.

Quick side note for you newbies (and the veterans who have forgotten):  Nonessential modifiers are those words in the index and code descriptions found in parentheses.  These parentheses enclose words that may or may not apply to the patient you are coding.  In this case, I think the following list of nonessential modifiers should be added:
  • Temporary - This could apply to all of us at one point in time or another.
  • Persistent - Seriously.  I know persistently unhappy people.  I've found there are two options: 1) Try to make them smile (or better yet, laugh!); and 2) Stay away.  Persistently unhappy people can be toxic.
  • Monday doldrums - Self explanatory.
  • Monday blahs - See "Monday doldrums"
  • A case of the Mondays - See "Monday doldrums"
Those are my recommendations anyway.  I have many more pressing letters to send in to the Coordination and Maintenance Committee regarding ICD-10-CM coding questions and issues, so I will refrain sending them my ideas for nonessential modifiers for code R45.2. For now. 

So from me to you, I would like to wish you a Happy Monday.  And if you were an R45.2 this morning, may it be temporary.  And here's something I learned from my mom - smiley faces are contagious.  Here's one for you!

Friday, July 27, 2012

Code for the Day - Say Goodbye to the Old Coder Coach

This has been a busy couple of weeks.  I've been able to visit with a lot of people I rarely get to see.  Old friends at a high school reunion.  My brother.  And one of my nearest and dearest BFFs.  A BFF with a marketing degree and a brilliant personal blog.  The same BFF who inspired me to start blogging in the first place.

So as we caught up over dinner tonight, the conversation covered everything from work to personal relationships to her beautiful daughters - and our blogs.  And she offered to rehab my blog for me.  As I watched her work over the Coder Coach blog, I realized the format was old and dying.  And once again I took to my code book. 


Today's code for the day:
  • R54 Age-related debility
That was the old blog.  And what do you think of the new one?

As I learn a few new tricks, I hope you enjoy the enhancements to this site.  Soon I will be adding resource links for all the coder wanna-bes out there as well as my ICD-10 audience.  I may be a good coder, but I still have a lot to learn about blogging!

Thursday, July 26, 2012

No Code Today - Why Isn't There a Code for Struck by Cat?

Meet Jake
Meet Jake.  I can't see your reaction, but I've introduced enough people to Jake that I can pretty much guess.  You were immediately drawn in by his beautiful blue eyes and unusual coloring (he's a blue point Himalayan mix).  He is, without a doubt, one of the most gorgeous cats I've ever seen.  A select few of you - those who really pay attention to detail have zeroed in on  his tag - a skull and cross bones with the words "Bad Kitty."  Some of you have a phobia of cats and were immediately disturbed to see him when you opened up my blog this morning.  I am never one to encourage phobias of cats because I think they're awesome.  But in this case you should be afraid.  Very afraid.  You see, Jake is evil.

Cue intro to "Bad to the Bone" music.

Jake is a rescue.  He was a stray who was pulled off the dangerous streets of a Denver suburb when I adopted him at about 5 months old.  I was immediately smitten!  And let's just say he knew how to get adopted.  He snuggled and purred and then showed off his playful spirit and we were on our merry way.  And then Jake didn't purr again for about 4 years.  As it turned out, he was a manipulative little jerk whose favorite game is ambush.  And I am his favorite target.

I've worked with Jake over the years and now I consider him somewhat of a miracle cat.  The miracle is that he's lived with me for 8 years and I haven't killed him yet.  I lovingly refer to him as my little jerk, but he does have a softer side - thanks in large part to another very even-tempered cat who has shown him how to be civil.  When no one is looking, he's a total mama's boy.

But as he gets older, Jake gets a little more nervous.  He doesn't like crowds and I like to entertain, so Christmas dinner with my entire family resulted in my grandmother getting bitten.  And lately I've had a tendency to drop things on top of his food bowls while I am getting kibble out of the pantry.  In 2 out of the last 3 times, he ended up biting me.  Last night when I dropped something, I immediately reached my hand out to console him and didn't get attacked.  It's true - people don't train cats, cats train people.

So this morning when I opened my eyes and thought, "what will I blog about today?" I focused on Jake and remembered the last scars he left.  A few weeks ago he hit the back of my legs with such force that he not only left bite marks, he left impact bruises. 

And I headed to my encoder. 

You see, there are many external cause codes (what we call E codes in ICD-9-CM) for being struck by animals.  But as I soon found out, there is no code for being struck by a cat.  What?! I double checked.  Yes, there is struck by dog, struck by horse, struck by raccoon (?!), struck by cow, struck by other hoof stock, struck by alligator, struck by pig, struck by dolphin, and struck by various types of specific birds (what the heck is a psittacine anyway?!) - but no code for struck by a cat. 

I suppose it sounds silly - to be struck by a little pussy cat.  But I have to tell you that 13 pounds of force from a cat with a purpose can definitely leave a mark.  And while I can assign a code for the bite - W55.01xA, Bitten by cat, initial encounter - there is no code for the striking part.  Which I find incomprehensible.  Perhaps I should write a letter to the Coordination and Maintenance Committee...

Tuesday, July 24, 2012

Code for the Day: Z99.89 - Dependence on Smartphones?

My brother was in town yesterday and we got the family together and had dinner.  It was organized over a series of text messages as I sat across from my mother and grandmother during lunch on Sunday.  I knew Mom would give the 411 to Dad.  And I texted my BF to give him the invite as well.  Done.  And all in a matter of minutes without talking to any people (other than my mom and grandmother). 

While I had my phone out, I checked Facebook to see if anyone had posted any new pictures from my high school reunion over the weekend.  I love seeing the little red numbers at the top of my Facebook app telling me how many new notifications, messages, and new friend requests I have.  It's more satisfying than seeing the little red numbers by the email icon telling me I have new email.  Because let's face it, most of my email these days is junk mail trying to get me to spend money at one store or another.  And if someone important really wants to reach me, they'll text... But I digress...

So at dinner last night, my brother was telling me about some study saying that we are addicted to technology and it's making us stupid.  Not him and me, per se, but people in general.  Apparently they measured people's brain activity when they were doing mindless things on their smartphones - like checking Facebook - and found there was pathetically low brain activity.  And he told me there was no code for it.  Yet. 

Game on!

No code for it?!  Maybe not a specific code, but I decided I must find one!

Yes, I love purple.  And polka dots.
First of all, I didn't spend a lot of time researching this supposed study.  Partly because I really think he's right - I do think smartphones can reduce us to potatoes quicker than a TV (if we let it) and partly because I have ADD, but mostly because - hello! - I have a job!  Which means I have limited time.  Okay, I looked a little.  I googled it, of course, and found what some are lovingly referring to as Ari Gold syndrome.  That's a reference to the manic agent played by Jeremy Piven on HBO's Entourage in case you missed it.  And the article hit a little too close to home.  I sleep with my iPhone on the nightstand.  I check email and Facebook first thing in the morning.  I have been guilty of texting my BFF while my BF is trying to talk to me.  I can't let go of my old iPhone in case the new one breaks.  I have multiple cases for both phones (see picture).  And I am sorely disappointed that I can't find a place to hang the cute Coach charm I had on my Blackberry on my iPhone (the Blackberry was a long time ago and way before I entered into a commitment with Apple!) .  But after reading the article, I decided to make a conscious effort to stop. Well, slow down anyway.

So here's the scoop.  Is there a code for Ari Gold syndrome?  Well let's break down the symptoms of Ari Gold syndrome  - these are things like sleeping next to your phone, being disappointed when there are no emails, Facebook, or Twitter updates, buying "outfits" for your phone (guilty - again, I refer you to the picture), ignoring people in your immediate presence because you are too busy texting or Facebooking or tweeting or whatever.  If the worst thing in the world you can imagine is losing your smartphone, you might have Ari Gold syndrome.  If you can't communicate without all the LOLs, BRBs, BFFs, and BFs (please note - the text lingo was used on purpose in this posting to drive home my point!), you might have Ari Gold syndrome.  If you get a sudden rush every time the text message tone rings, you might have Ari Gold syndrome.  I'm no doctor, but this sounds like dependence to me. 

And even though I've had a long day and really don't want to see another code for another 10 hours or so, I looked it up.  And alas, there it was - the code for the day - and the closest thing I could find to smartphone dependence:
  • Z99.89 Dependence on other enabling machines and devices
Okay, here we go.  Coders all across America are screaming at their computers after reading this.  They are probably saying this is a medical device code, but it doesn't say that.  It says other enabling machines and devices.  What is a smartphone anyway?  I rest my case.
 This is also what I refer to as the Wall-E effect (great movie - rent it if you haven't seen it!).  And it's the reason the ICD-10 Task Force I chair in Colorado never meets via conference call.  Because we need to renew the art of meeting and talking to people in person.  It's why I always recommend to new students who are looking for work as coders to go to meetings and talk to people.  Using the latest form of smartphone technology is a great skill to have.  So is effective face-to-face conversation. 

So if you found this blog through Facebook, Twitter, or Linkedin - welcome!  If you are reading it right now on your smartphone, bravo!  And now I challenge you to put down your smartphone and go have a nice conversation with someone.  I need to go check Facebook.  Ha!  Just kidding!  Okay, seriously, I will check Facebook and then go read one of those paper things.  What are they called?  Oh yeah, books.

Monday, July 23, 2012

Code for the Day: Mondays and Debridement

Happy Monday!  Sorry if you find the statement annoying or offensive.  I am actually not a fan of Mondays.  As my Tinkerbell coffee mug reminds me, "Mornings are not magical" - and neither are Mondays.  This is why the Tinkerbell mug is my Monday choice for guzzling (partially caffeinated) coffee.  I try not to fall into the misery that many do on Mondays, though, because I don't want to set a negative tone for the week.  But I got a double whammy today.  Not only is it Monday, I had an email from a client this morning asking me a question about coding debridement.

Deep sigh.  Sip some coffee.  Get ready for the long email explanation back.

If you've coded at all recently, you know that debridement codes are under scrutiny by Medicare's recovery audit contractors (RAC) because of the vast payment differences between nonexcisional and excisional debridement.  And as I dusted off what has become my typical response to the documentation requirements for coding excisional debridement, this morning I found myself doing additional research.  And it reminded me of what is often the next question when I give advice for coding debridement in ICD-9-CM: will this be fixed with ICD-10-PCS?  Well, in a word, no.  As a matter of fact, it's going to be worse.

Sorry to add more bad vibes to your Monday.  Go grab another cup of joe and we'll talk about it.  Go ahead.  I'll wait....

Here's the deal.  In ICD-10-PCS - which, by the way, is completely different than coding in ICD-9-CM - we code according to root operations.  Debridement fits into two different root operations, depending on the method used: excision and extraction.  Here are the definitions of these root operations - straight from the ICD-10-PCS code set:
  • Excision - Cutting out or off, without replacement, a portion of a body part
  • Extraction - Pulling or stripping out or off all or a portion of a body part by the use of force
As you can see, excision involves cutting.  With a sharp instrument.  Like a scalpel.  So logic dictates that an excisional debridement would code to excision.  Easy peasy!

As far as extraction is concerned - first of all, ouch.  Lots of interesting things fall under extraction, like cesarean section, dilation and curettage, and of course, nonexcisional debridement.  Nonexcisional debridement can be performed using various methods, such as using enzymes, ultrasound, or simply sloughing off the tissue with gauze.

As you can see, not only does the debridement issue not go away with PCS, it has the potential to get a lot worse.  We can code excision or extraction or almost any body part.  So we still need to know these important elements in order to properly code:
  • Condition requiring debridement (e.g., ulcer, fracture)
  • Location of the debridement (e.g., foot, sacrum)
  • Depth of debridement (we code to the deepest layer)
  • Method(s) used to remove tissue (e.g., cutting away of tissue)
  • Specific tissue removed (e.g., skin, muscle) - the removal of "necrotic tissue" doesn't help us for coding purposes!
  • Instruments used to remove tissue (e.g., scalpel, scissors) 
To make it even more interesting, there is no default here like there is in ICD-9-CM.  So tell your doctors they need to be specific or we will be querying even more than we do now!

Want to see what this might look like?  Here's an example of a patient presenting with a right foot ulcer involving only the skin (note that the ICD-10-CM code specifies depth of ulcer involvement too).  A couple of disclaimers here - the reimbursement information is estimated based on the current MS-DRG grouper version 29.0 and the hospital base rate is fictional - I just wanted to give you an idea of the payment differences between excisional and nonexcisional debridement.  Also, the only codes I grouped are the ones you see here.
I don't want you to get hung up on the money here, other than to realize the potential compliance issues this presents.

Don't you feel so much more equipped to handle your Monday now?  See you Tuesday!

Friday, July 20, 2012

Code for the Day

I wish I had a humorous and witty code for the day, but I'm just not feeling that chipper this morning.  I did say that my codes for the day would be inspired by my daily life.  And today's inspiration is drawn from the terrible tragedy at a movie theater not to far from me here in the suburbs of Denver.  While I'm not the type to go to a midweek midnight showing of the latest movie, I am the type of person who has friends who are the type to go to a midweek midnight showing of the latest movie.  I am happy to report that those friends who are "most likely to" have checked in on Facebook this morning.  But there are many who weren't so lucky and my heart goes out to them and their families.

A quick recap in case you haven't seen any news today - a man apparently burst into a packed movie theater and threw some gas canisters into the crowd and waited for them to explode before opening fire on the defenseless audience.  At this time, it sounds like 12 are dead and many others are being treated at Denver's various trauma centers.  

So today's code for the day came to mind as I was listening to the news and a PR statement from a local hospital where some people were treated.  I was paying particular attention because I used to work at this hospital.  And when the spokesperson said they weren't sure what kind of gas was in the canisters, but it was a type of tear gas or something similar and people are being treated for eye irritation and burns, my first thought was - how awful and my second thought was there's a unique ICD-10 code for chemical  burns.  Sorry, I just can't turn off the coder inside!

In ICD-10-CM, we have newly divided burn codes - those for thermal burns and those for corrosion.  I don't know about you, but I think this distinction is a long time coming.  Like burns, corrosions are also classified by depth, or degree of the chemical burn as first, second, or third degree.  So for example, let's say someone was admitted with second degree chemical burns to the face.  This is coded as:
  • T20.60xA, Corrosion of second degree of head, face, and neck, unspecified site, initial encounter
So I ask you - as you do your daily coding, do your physicians document degrees of severity on chemical burns?  

I hope everyone has a safe and happy weekend and let's hope next week's inspiration comes from something happier.

Thursday, July 19, 2012

ICD-10 Code for the Day

I received an email from a former coworker today, who was looking everywhere she could think of to find a posting I made about a code for the day.  She was checking Linkedin.  What she found was a snarky comment I made on my personal Facebook page earlier this week.  Actually, I also made another posting last week with a code for the day. So no wonder she thought it was "out there," so to speak.  And since I've been feeling rather uninspired to blog lately, I decided to go public with the code for the day and post it here.

Before I get to the first official Coder Coach Code for the Day, let me tell you this: these codes will be ICD-10 codes because I've been living and breathing ICD-10 lately and it's given me the opportunity to find some very interesting codes.  It's also led me to some very inspiring philosophical questions - you know, something along the line of why do we have an ICD-9-CM code for vomiting alone (787.03) and not one for vomiting in a group?  Couldn't a code for vomiting in a group come in very handy for St. Patrick's Day, New Years Eve, and countless 21st birthday parties?!  I know, I know, the code is really differentiating between vomiting with and without nausea.  But this gives you an idea of what goes through my mind as I read some code descriptions.  Besides, coding can be so boring, so why not make it fun and amusing?

So now that we've established my unique brand of coder humor, you need to know that there is no method to my madness regarding the selection of the code for the day.  I am not going to start at the beginning of ICD-10.  I am not going to randomly open an ICD-10-CM or ICD-10-PCS code book and pick a code.  The code (or codes) I choose will most likely be something inspired by a daily event or something I come across in my work and find incredibly interesting.  For example, last Tuesday, I worked a 16 hour day.  I started to come up with one code on the following day, but upon further reflection, I decided two would more accurately and completely report my condition (and we coders are about accuracy and completeness!):
  • Z72.820, Sleep deprivation 
  • F15.20, Other stimulant dependence [caffeine)] uncomplicated
I suppose coders who know ICD-10 will tell me I sequenced it wrong since the substance abuse code should go first followed by the Z code (which is ICD-10's equivalent of an ICD-9 V code), but I decided since one led to the other - that is, the sleep deprivation led to an excessive need for coffee on Wednesday, the sequencing was appropriate in my case.  And these codes will not be reported on a claim to CMS on behalf because 1) I didn't see a health care professional and 2) I don't have Medicare (how old do you think I am anyway?!). 

What I find interesting here is the new subcategory of Z codes for sleep problems - the one that jumped out at me was poor sleep hygiene.  I first found the set of codes while doing a documentation review for a sleep lab clinic in preparation for ICD-10.  I admit.  I had to google it.  What is sleep hygiene?  If I drool in my sleep, does that mean I have poor sleep hygiene?  Turns out it means a host of other things like irregular sleeping habits or leaving the lights on when you're trying to sleep.  Come to think of it, I think my head hit the pillow around 3am Wednesday morning and I was up again around 7am, so perhaps I should have added Z72.821, Inadequate sleep hygiene to the list above as well.

And really, I am not addicted to caffeine.  Anymore.  But I sure felt like I needed it on Wednesday.  The uncomplicated part could probably be argued by my boyfriend since I was pretty much exhausted for the rest of the week.  But really, the ICD-10 code is more referring to medical complications of drug dependence.  Think I'm kidding about the classification of caffeine as a drug you can be addicted to?  That part is no joke.  When you look up addiction, it takes you to dependence and caffeine is listed right there in the index!

This the kind of thing you'll have to look forward to in my Code for the Day posts.  Consider it my way of shaking my pom pons and getting you excited about ICD-10 again - since we still don't have a final rule yet.  I'm still plowing ahead and getting ready and I think the least I can do is make a little fun for my readers.

If you found a code that tickles your funny bone, send it to me at!