EDITOR’S NOTE: This is the second in a two-part series.
There were very few changes to the ICD-10-CM Draft code set for 2013 – as was expected due to the partial code freeze that will be in effect through 2014.
Changes in the 2013 ICD-10-CM Draft code set primarily consisted of adding a few terms and correcting typos in the Alphabetic Index, and adding inclusion terms and correcting typos in the Tabular List. Even without significant changes to this year’s draft code set, however, there is updated information in the 2013 Official Guidelines for Coding and Reporting. In this installment: Borderline Diagnosis and Influenza Codes.
There also are new guidelines related to reporting conditions documented as “borderline.” The official guidelines state the following:
“If the provider documents a ‘borderline’ diagnosis at the time of discharge, the diagnosis is coded as confirmed unless the classification provides a specific entry (e.g., borderline diabetes). If a borderline condition has a specific index entry in ICD-10-CM, it should be coded as such. Since borderline conditions are not uncertain diagnoses, no distinction is made between the care setting (inpatient versus outpatient). Whenever the documentation is unclear regarding a borderline condition, coders are encouraged to query for clarification.”
Example: Borderline glaucoma, right eye
There is an entry for “glaucoma, borderline” in the Alphabetic Index, so the condition is reported with a code from subcategory H40.00. In this case the condition affects only the right eye, so it is coded as follows:
H40.001 – Preglaucoma, unspecified, right eye
Example: Borderline anemia
There is no entry for borderline anemia. The condition is reported with the code for unspecified anemia since no additional information is provided. Alternatively, the provider may be queried in order to obtain additional information so that a more specific code can be assigned.
H64.9 – Anemia, unspecified
Familiarity with the coding rules related to influenza coding is important because only confirmed cases of influenza fall under categories J09 and J10. This guideline is an exception to the reporting of uncertain diagnoses in the inpatient setting.
Category J09 reports influenza viruses due to certain identified influenza viruses, which include influenza documented by the provider as avian/bird, swine, other animal origin or A/H5N1. Category J10 reports influenza due to other identified influenza virus. Assignment of these codes is based on the provider’s diagnostic statement.
A positive laboratory test for the specific avian or other novel influenza A virus (or for another identified influenza virus) is not required.
If the provider documents the specific type of influenza as “suspected,” “possible” or “probable” avian, other novel type A virus or other specified type, a code from category J11 (Influenza due to unidentified virus) is reported.
Example: Diagnosis of Type A H1N1 influenza with typical symptoms of fever, nasal secretions, cough and body aches
J10.1 – Influenza due to other identified influenza virus with respiratory manifestations
The diagnostic statement indicates that the type of flu is the H1N1 virus, with respiratory manifestations. Even though the documentation does not reference a positive laboratory test, the influenza is coded as confirmed based on the provider’s documentation.
Example: Diagnosis of influenza with fever, headache and upper respiratory symptoms, probably avian type.
J11.1 – Influenza due to unidentified influenza virus with respiratory manifestations
Because the documentation uses the qualifier “probably,” the type of influenza is not considered to be “confirmed” and the code for an unidentified influenza virus is reported.
Even though few changes are expected to the ICD-10-CM Draft code set for the next few years, it is important to review the guidelines annually. Additional guidelines and reporting clarifications should be expected as more coders begin training under ICD-10-CM and requesting clarification related to code assignment and sequencing of codes.
About the Author
Lauri Gray, RHIT, CPC, has worked in the health information management field for 30 years. She began her career as a health records supervisor in a multi-specialty clinic. Following that she worked in the managed care industry as a contracting and coding specialist for a major HMO. Most recently she has worked as a clinical technical editor of coding and reimbursement print and electronic products. She has also taught medical coding at the College of Eastern Utah. Areas of expertise include: ICD-10-CM, ICD-10-PCS, ICD-9-CM diagnosis and procedure coding, physician coding and reimbursement, claims adjudication processes, third-party reimbursement, RBRVS and fee schedule development. She is a member of the American Academy of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA).
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