Primary Diagnosis, or Not?

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There have been many discussions among coders on when a code should not be reported as a primary diagnosis.

Yes, CMS does publish a list of unacceptable principal ICD-10-CM diagnosis codes for inpatient (facility) services, but let’s focus on outpatient professional services and translate ICD-10-CM coding conventions for first listed/primary diagnosis coding rules.

For my example, I’m citing Section I. Conventions, general coding guidelines, and chapter specific guidelines, Section 13. Etiology/manifestation convention (“code first,” “use additional code,” and “in diseases classified elsewhere” notes.)

We’re going to focus on etiology and manifestation sequencing today.  We’ll review Sequela codes and coding for Conditions due to external or toxic agents at another time.

Etiology/Manifestation codes:

Etiology is the underlying disease and must be sequenced as primary to the manifestation (condition caused by (due to) the underlying disease) code. 

According to ICD coding conventions, the manifestation code is never reported as the primary diagnosis.  In your ICD-10-CM book (yes, you know by now, I still use my books), the manifestation codes are identified in italics and are highlighted in blue.

Let’s review an example.  D63® category describes Anemia in chronic diseases classified elsewhere.  According to ICD-10-CM, codes that include the description, “in diseases classified elsewhere” as never primary (first listed).

We are drilling down into the category to D63.1® – Anemia in chronic kidney disease.  This code is in italics and is highlighted in blue, so we know it’s a manifestation code.  The patient has chronic kidney disease and anemia.  According to the instructional notes under the code, we have to code first the underlying chronic kidney disease.  Chronic kidney disease is the etiology (underlying disease), which is the primary/first listed code and the manifestation (the condition caused by the underlying disease) is Anemia. 

Code first, but not designated as a manifestation code:

ICD-10-CM provides instructional notes on codes that are not in italics or highlighted in blue to “code first” other conditions.  These codes are not specified as manifestation codes, but the conditions may be due to an underlying cause.

For example, in the I50® category, Heart failure is not highlighted in blue and is not in italic font, so we know it’s not a manifestation code; however, ICD-10-CM instructs us to “code first” other listed conditions.    

Any of the I50 category codes cannot be sequenced as primary (first listed) if the provider also documents any of the conditions included in the category’s instructional notes.

Suppose the provider documented “acute on chronic right heart failure” (I50.813), but did not report any of the conditions listed in the instructional note to “code first.” In that case, it is appropriate to assign I50.813 as the primary diagnosis.

The most important take-away is, before you determine that a code can or cannot be reported as primary, you must understand etiology and manifestation and read the instructional notes in ICD-10-CM.

ICD-10® is copyrighted by the World Health Organization (WHO)

ICD – ICD-10-CM – International Classification of Diseases …. https://www.cdc.gov/nchs/icd/icd10cm.htm

ICD-10-CM Coding Overlapping Breast Quadrants

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How do you determine overlapping breast quadrants?

Let’s review breast anatomy.

https://www.researchgate.net/figure/Breast-quadrants-definition-Upper-Outer-UOQ-Upper-Inner-UIQ-Lower-Outer-LOQ_fig4_322351773

In the documentation that I’ve coded or audited, the providers document the location of a lump or mass using o’clock.

On the right breast, the upper inner quadrant translates to 12-3 o’clock. The lower inner quadrant translates to 3-6 o’clock. The lower outer quadrant translates to 6-9, and the upper outer quadrant translates to 9-12 o’clock.

On the left breast, the upper outer quadrant translates 12-3 o’clock, the lower outer quadrant translates 3-6 o’clock, the lower inner quadrant translates 6-9 o’clock, and the upper inner quadrant translates to 9-12 o’clock.

Let’s review the ICD-10-CM codes for an Unspecified lump in the breast. 

Category N63 includes an unspecified code that should be assigned when the provider does not specify which breast has a lump or mass – N63.0®.  The category also includes diagnosis codes to assign when providers document right or left breast but do not specify the quadrant – N63.10® and N63.20®. These codes should be a last resort because we should always query our providers for specificity.

ICD-10-CM also provides codes to report mass or lump in the axillary tail (an extension of the upper lateral quadrant of the breast) N63.3® category and subareolar – N63.4® category.

We can get the easy coding out of the way first. 

If the provider documents lump or mass at 2 o’clock in the right breast, we would translate this to the right upper inner quadrant, and we would assign code N63.12®

But, what if the providers document a lump or mass at 6 o’clock in the right breast?

This area is in the middle of the lower inner quadrant and the lower outer quadrant.  That’s an overlapping quadrant, and ICD-10-CM provides codes to assign for overlapping quadrants (AHA Coding Clinic, Fourth Quarter, 2019, Page 12).

It’s the same if the provider documents 3 o’clock, 9 o’clock, or 12 o’clock.  These locations overlap two quadrants. 

3 o’clock is in the middle of the right breast upper inner and lower inner quadrants and left breast upper outer and lower outer quadrants.  6 o’clock is in the middle of the right breast lower inner and lower outer quadrants and left breast lower outer and lower inner quadrants.  9 o’clock is in the middle of the right breast lower outer and upper outer quadrants and left breast lower outer and lower inner quadrants.  12 o’clock is in the middle of the right breast upper outer and upper inner quadrants and the left breast upper inner and upper out quadrants.

So, the correct ICD-10-CM code for mass or lump at 6 o’clock in the right breast is N63.15®.

October is National Breast Cancer Awareness Month (NBCAM).  If you are in the age range or risk category, please schedule your screening mammogram.

Coding Clinic® is a registered trademark of the American Hospital Association Clinic

ICD-10® is copyrighted by the World Health Organization (WHO)

ICD – ICD-10-CM – International Classification of Diseases …. https://www.cdc.gov/nchs/icd/icd10cm.htm

ICD-10-CM Coding Screening and Diagnostic Mammograms

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October is National Breast Cancer Awareness Month (NBCAM),  a yearly campaign to raise awareness of the importance of early screening, raise funds for breast cancer research, and provide information and support to men and women affected by breast cancer.

From the coding perspective, are you assigning the correct ICD-10-CM codes?

There have been disagreements among coders on when/how to assign diagnoses for personal or family history of breast cancer when screening and diagnostic mammograms are performed.  There’s also debate on whether the personal history or family history code should be primary.

I’ll present each scenario, and then provide coding guidance from AHACoding Clinic^®.  Due to copyright rules, I can only summarize the guidance.  I will include the references for your review (if you have a subscription to Coding Clinic).

I started my search with ICD-10-CM codes for screening, but all of the Coding Clinics referenced advice from ICD-9-CM.

According to Coding Clinic, ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2015 Pages: 20-21 Effective with discharges: November 13, 2015, unless there’s new guidance for ICD-10-CM/ICD-10-PCS, the advice given for ICD-9-CM/ICD-9-PCS will remain.

Scenario #1: An asymptomatic woman with a family history of breast cancer presents for a screening mammogram. The provider documents “family history of breast cancer” as the reason for the mammogram.

What is the primary diagnosis code?

According to ICD-9-CM Coding Clinic, Second Quarter 2003, Page: 4 Effective with discharges August 1, 2003, Screening mammogram due to family history, V76.11, Special screening for malignant neoplasm, Breast, Screening mammogram for high-risk patient with additional diagnosis for family history of.

ICD-9-CM code V76.11 maps to ICD-10-CM code Z12.31

Scenario #2:  An asymptomatic woman with a personal history of breast cancer presents for a follow-up mammogram.  The provider documents “personal history of breast cancer” as the reason for the mammogram. 

What is the primary diagnosis code?

According to ICD-9-CM Coding Clinic, Second Quarter 2003, Page: 5 Effective with discharges August 1, 2003, Follow-up mammogram, V67 category (follow-up examination) is primary and additional diagnosis code V10.3 (personal history of).

ICD-9-CM code V67 maps to ICD-10-CM code Z08 and instructs us to use additional code to identify the personal history.

ICD-9-CM code V103 maps to Z85.3 and Z85 category instructs us to code first any follow up examination after treatment of malignant neoplasm (Z08).

Since the provider specified “history of” we know it is not a current condition.

If you are in the age range or risk category, please schedule your screening mammogram.