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I’d like to share a recent discussion I had with a coder. She struggled to find a diagnosis code because the term used by the physician was not listed in the ICD-10-CM index, and it was not in the Inclusion Terms for the code she was considering.
I find that one of the most difficult ICD-10-CM codes to translate is R91.8® – Nonspecific abnormal findings of lung field, so we’ll use that code as an example.
But first, let’s go back to diagnosis coding basics.
According to ICD-10-CM, Section I. Conventions, general coding guidelines, and chapter specific guidelines, Includes Notes “This note appears immediately under a three character code title to further define, or give examples of, the content of the category. Inclusion terms “List of terms is included under some codes. These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of “other specified” codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code”.
So, “The inclusion terms are not necessarily exhaustive. This is a key point.
Back to the coding conventions. We find Section B. General Coding Guidelines, Locating a code in the ICD-10-CM, “first locate the term in the Alphabetic Index, and then verify the code in the Tabular List. Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List”. Well, that presented a problem for the coder because she did not locate the term in the index either.
She considered code R91.8® for the term used by the physician. In ICD-10-CM, the inclusion terms for this code are
- Lung mass NOS found on diagnostic imaging of lung
- Pulmonary infiltrate NOS
- Shadow, lung
So, if the physician documented any of these terms, when you go to the index, the terms will bring you back to R91.8®.
But, what about other abnormal findings of the lung field that are not inclusion terms? What if the physician documents “blunting,” “haziness,” “hyperinflation,” “crowding,” “opacities,” “interstitial markings,” or other terms that are not in the index and are not inclusion terms for R91.8®?
Well, we know that coding conventions advise us that “The inclusion terms are not necessarily exhaustive.” If you are using the ICD-10-CM Expert for Physicians (my go-to ICD resource), in the overview of official conventions, it states, “The inclusion terms are not exhaustive. The index may provide additional terms that may also be assigned to a given code”.
Look at it this way, if ICD-10-CM included every possible term that could be used to describe a sign, symptom, or condition, the book would be at least four feet thick! The last edition of ICD-9-CM in 2011 included around 13 thousand codes. The 2020 edition of ICD-10-CM has approximately 72 thousand codes with much smaller print!
This is where our knowledge and expertise of translating the documentation to codes come in. What would be considered an abnormal finding? An abnormal finding would be anything other than what is considered “normal” or what is expected to be found.
So, if the physician documents “blunting” or “haziness” in the impression. Would any of these be normal findings on a chest x-ray?
Check out this site. It provides images and the typical abnormal findings associated with specific diseases.
So, providers may use different terms to describe an abnormal finding and as coders, our responsibility is to translate the language. Sometimes, it’s not an exact translation. That’s why our knowledge of anatomy and physiology and our ability to research is essential.
1https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2019-ICD10-Coding-Guidelines-.pdf
The ICD-10-CM is copyrighted by the World Health Organization (WHO)
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