4 ICD-10 Tips for General Surgeons

Lea Chatham December 19th, 2013

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Kareo ICD-10 resources

By Lisa A. Eramo

How can general surgeons ensure a successful transition to ICD-10?

The best ICD-10 advice actually applies to all providers: Document the way in which you think clinically. Tweet This

Robert S. Gold, MD, CEO of DCBA, Inc., a company that provides ICD-10 documentation improvement education for hospitals and physician practices, says general surgeons must describe the condition for which they’re performing surgery with as much precision as possible. The words they document should incorporate the same terminology they would use to explain the condition to another physician. This is the only way to ensure accurate code assignment.

Gold provides some tips for general surgeons to help them stay on track now and once ICD-10 goes into effect on October 1, 2014.

Tip #1: Note combination codes for digestive conditions. Certain digestive conditions are now combination codes that require specific information for coding. For example, the code for gastritis and duodenitis (K29.-) requires surgeons to document with or without bleeding. The code for acute appendicitis (K35.-) requires surgeons to specify with generalized or localized peritonitis. The codes for gastric ulcers (K25.-) incorporate acute and chronic as well as with hemorrhage, perforation, or both. Review Chapter 11 of the ICD-10-CM Manual to get a better sense of the type of documentation that’s required.

Tip #2: Document laterality, when appropriate. When a general surgeon operates on a diseased organ that is part of a pair (e.g., legs, hands, ovary, etc.), he or she must document laterality. For example, when a patient undergoes a left upper lobectomy, document the specificity, such as malignant neoplasm of left upper lobe or left mainstem bronchus, as appropriate for the case. Many codes in ICD-10-CM include laterality, and it’s beneficial for general surgeons to review the codes they report most often to determine what documentation is required.

Tip #3: Document the presence of any manifestations. Many ICD-10-CM codes incorporate manifestations, thus necessitating the need for clear documentation so coders can assign the appropriate code. For example, codes for atherosclerosis incorporate claudication, ulceration, gangrene, and rest pain. This is in addition to laterality.

Pay close attention to cholelithiasis (K80.-). Surgeons must document the location of the stones in the biliary tract (i.e., in the gallbladder, bile duct, or common duct) with or without obstruction as well as the presence of any acute or chronic cholangitis (i.e., the presence of any infection of the biliary tract above the stone) or cholecystitis.

Tip #4: Review inflammatory diseases of the abdomen. General surgeons generally operate on the following three inflammatory diseases:

  • Diverticular disease: Diverticular disease (K57.-) can manifest as symptomatic diverticular disease without infection (i.e., diverticulosis), or there may be an inflammation (i.e., acute or chronic diverticulitis). Surgeons must document the specific section of the bowel that includes the diverticulosis or acute diverticulitis. When operating on the large intestine (colon), specify whether the disease affects the right colon (specify cecum, ascending colon, hepatic flexure, or transverse colon) or left colon (specify splenic flexure, descending colon, sigmoid colon, recto-sigmoid junction, or rectum).
  • Ulcerative colitis (K51.-): Document the portion of the bowel that is affected by the disease. This disease usually starts low in the large intestine and progresses upward. Thus, surgeons should identify the most proximal area involved (i.e., rectum, sigmoid colon, left colon, transverse colon, pancolitis).
  • Crohn’s disease (regional enteritis): Document the specific area(s) of the small or large intestine in which the Crohn’s disease (K50.-) exists.  It may involve individual areas (i.e., the duodenum, jejunum, ileum, colon, or rectum), all of the colon, or it may skip areas that involve multiple segments of the intestinal tract.

* Note that all three of the above conditions may have four potential complications, each of which is built into the ICD-10-CM code for the disease itself. These potential complications include:

  • Bleeding
  • Obstruction
  • Fistula
  • Abscess

Be sure to document the presence of any of these complications so coders can assign the correct code.

For more tools and information about ICD-10, visit the Kareo ICD-10 resource page.

About the Author

Lisa A. Eramo

Lisa A. Eramo is a freelance writer/editor specializing in health information management, medical coding, and healthcare regulatory topics. She began her healthcare career as a referral specialist for a well-known cancer center. Lisa went on to work for several years at a healthcare publishing company. She regularly contributes to healthcare publications, websites, and blogs, including the AHIMA Journal and AHIMA Advantage. Her focus areas are medical coding, and ICD-10 in particular, clinical documentation improvement, and healthcare quality/efficiency.

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