CODING & DOCUMENTATION
Fam Pract Manag. 2015 Nov-Dec;22(6):39.
Author disclosure: no relevant financial affiliations disclosed.
A patient came in to the office two to three weeks after having the upper pinna of her ear pierced twice. Her skin had completely healed over the backs of the earrings, and I performed an incision of the pinna for removal of the earrings. Should I report this procedure as removal of a foreign body, and if so, what ICD-10 codes are applicable?
The earrings should be considered superficial foreign bodies, and codes S00.451A (right ear) and S00.452A (left ear) are used to report an initial encounter for superficial foreign body of the ear (including the pinna). The ICD-10 alphabetic index for retained foreign body (superficial without open wound) directs readers to see foreign body, superficial, ear (S00.45-). Because an incision was necessary to remove the earrings, use the procedure code 10120 or, if the procedure was complicated, code 10121. If removal of a foreign body does not require incision, the work is included in the evaluation and management service that is reported.
What is the correct ICD-10 code for an encounter to remove stitches from a wound to the leg when the original procedure was performed in the emergency department?
This service should be reported with the appropriate code for the injury including seventh character D (e.g., S81.811D, for subsequent care of a laceration without foreign body of the right lower leg). Seventh character D (subsequent encounter) is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. It should be used regardless of whether care is provided by the same or different physician. The ICD-10 guidelines instruct that 7th characters should be used rather than aftercare Z codes to identify subsequent care for conditions such as injuries or poisonings, so Z48.02, encounter for removal of sutures, should not be used in this case.
Immunizations during a well-child exam
Should ICD-10 code Z23 be reported in addition to the code for a well-child exam when routine immunizations are provided at the same encounter?
Yes. There is a “code first” note for code Z23 instructing you to first list the code for the routine childhood examination. This is a change from ICD-9, where immunizations appropriate for age were included in code V20.2, routine infant or child health check, as an example of the reasons for an encounter.
Documenting obesity diagnoses
We are being asked to indicate on claims whether obesity is due to excess calories or other reasons. Is this information necessary for coding?
Familiarity with the ICD-10 code set is necessary to recognize documentation elements that support reporting of the more specific codes. However, when a more specific diagnosis is not supported by the documentation, it is correct to report the unspecified code. If the documentation includes an indication that obesity is due to excess calories, codes E66.01 (morbid obesity due to excess calories) and E66.09 (obesity due to excess calories) may be reported rather than E66.9 (obesity, unspecified). A code from category Z68, body mass index, may be reported secondary to the diagnosis code for obesity when body mass index is documented in the patient record.
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