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ICD-10 documentation tips: Top 10 diagnosis codes in anesthesiology

The number of diagnosis codes has expanded from 13,000 ICD-9 codes to 68,000 ICD-10 codes, with 78 percent of ICD-9 diagnosis codes mapping 1-to-1 with an ICD-10 code, either exactly or approximately.

Most ICD-10 diagnosis codes still provide for unspecified options, and about half of the ICD-10 codes that do not have an ICD-9 counterpart are related laterality. External cause reporting and encounter type make up another large part of the new ICD-10 codes.

Specific to the Anesthesiology specialty, there were fifteen ICD-9 diagnosis codes that made up 25% of the average practice charge volume, and seventy ICD-9 diagnosis codes that made up 50% of the average practice charge volume.

Specific Elements for Common Conditions

Below is a list of the Top 10 diagnosis codes used in the specialty of anesthesiology. Knowing these key documentation concepts for the most commonly used diagnosis codes is one of the best ways for physicians to continue their smooth transition to ICD-10 in 2016. This article focuses on the specific elements that are available for these common conditions. Providing these elements within the dictated report will be necessary in order to minimize unspecified codes, which will be essential in continuing to limit the impact of the transition to ICD-10 as much as possible.

#1 – Thoracic/Lumbar Radiculopathy
The top diagnosis code for anesthesiology is Lumbar Radiculopathy, which makes up almost 5% of total anesthesiology charge volume. There is a 1-to-4 crosswalk for thoracic and/or lumbar radiculopathy, meaning there is a greater specificity in ICD-10 versus ICD-9. Additional documentation is needed to define exact anatomical location.

• ICD-9 Code: 724.4 – Thoracic or lumbosacral neuritis or radiculitis, unspecified.
• ICD-10 Code:
o M54.14 – Radiculopathy, thoracic region
o M54.15 – Radiculopathy, thoracolumbar region
o M54.16 – Radiculopathy, lumbar region
o M54.17 – Radiculopathy, lumbosacral region

#2 – Normal Vaginal Delivery
The second most commonly used diagnosis code is Normal Delivery, which makes up approximately 3% of the total volume. Normal delivery is a 1-to-1 crosswalk from ICD-9 to ICD-10. If more specific information can be provided, then it should be included. While there were outcome of delivery codes in ICD-9, there were no codes for number of weeks or trimester specification for obstetrical services. However, ICD-10 allows for the specific number of weeks to be added for all pregnancy diagnosis codes including for normal delivery.

ICD-9 Code: 650 Normal Delivery

ICD-10 Code: O80 Encounter for full-term uncomplicated delivery

Other Related codes related to the outcome of delivery:
• Z37.0 Single Live Birth
• Z37.1 Single Stillbirth
• Z37.2 Twins, Both Liveborn
• Z37.3 Twins, One Liveborn and One Stillborn
• Z37.4 Twins, Both Stillborn
• Z37.9 Outcome of Delivery Not Specified

Number of Weeks
• Z3A.00 Weeks of Gestation of Pregnancy Not Specified
• Z3A.01 Less than 8 Weeks Gestation of Pregnancy
• Z3A.XX Where XX = the Number of Weeks Gestation

#3 – Screening Colonoscopy
The third highest volume diagnosis in anesthesiology is Screening Colonoscopy. This represents approximately 2.5% of the total volume. There is a 1-to-1 crosswalk for screening colonoscopy. It is important to note that a screening colonoscopy is characterized as without signs and symptoms or a previously diagnosed condition (history of colon polyps, history of colon cancer, etc.)

• ICD-9 Code: V76.51 Special Screening for Malignant Neoplasm - Colon
• ICD-10 Code: Z12.11 Encounter for screening for malignant neoplasm of colon

#4 – Cataract
The fourth most common code (almost 2% of the diagnosis codes reported) is Unspecified Cataract. There is a 1-to-1 crosswalk for an unspecified cataract. However, specifically defined cataract is further defined by laterality. There are many specified types – here are some typically seen in anesthesiology.

• ICD-9 Code: 366.9 Unspecified cataract
• ICD-10 Code: H26.9 Unspecified Cataract

Other Related Codes with More Specificity:
• H25.10 Age-related nuclear cataract, unspecified eye
• H25.11 Age-related nuclear cataract, right eye
• H25.12 Age-related nuclear cataract, left eye
• H25.13 Age-related nuclear cataract, bilateral (Age-related = senile)
• H25.9 Unspecified age-related cataract (senile)
• H26.101 Unspecified traumatic cataract, right eye
• H26.102 Unspecified traumatic cataract, left eye
• H26.103 Unspecified traumatic cataract, bilateral
• H26.109 Unspecified traumatic cataract, unspecified eye

#5 – Other Acute Postoperative Pain
The fifth diagnosis on the Top 10 list is Other Acute Postoperative Pain. There is a 1-to-1 crosswalk. Using this diagnosis is straight forward and there are no concerns with further specificity with this code, just a change in the ICD-10 description.
• ICD-9 Code: 388.18 – Other Acute Postoperative Pain
• ICD-10 Code: G89.18 Other Acute Postprocedural Pain

#6 – Osteoarthritis, Unspecified Whether Generalized or Localized, Lower Leg
Number 6 on the Top 10 list is Osteoarthritis, Unspecified Whether Generalized or Localized, Lower Leg. In ICD-10, Osteoarthritis (of any joint) is subdivided by type (Primary, Post-Traumatic or Secondary) and further subdivided by laterality (Unspecified, Right, Left or Bilateral). The default code option when both knees are affected is primary osteoarthritis; however, when only one knee is affected, the default code is unspecified type.

ICD-9 Code: 715.96 Osteoarthritis, Unspecified whether generalized or localized, lower leg
• ICD-10 Code:
o M17.0 Bilateral primary osteoarthritis of the knee
o M17.10 Unilateral primary osteoarthritis, unspecified knee
o M17.11 Unilateral primary osteoarthritis, right knee
o M17.12 Unilateral primary osteoarthritis, left knee
o M17.2 Bilateral post-traumatic osteoarthritis of the knee
o M17.30 Unilateral post-traumatic osteoarthritis, unspecified knee
o M17.31 Unilateral post-traumatic osteoarthritis, right knee
o M17.32 Unilateral post-traumatic osteoarthritis, left knee
o M17.4 Other bilateral secondary osteoarthritis of knee
o M17.5 Other unilateral secondary osteoarthritis of knee
o M17.9 Osteoarthritis of knee, unspecified

#7 – Cholelithiasis (Calculus of gallbladder without mention of cholecystitis or obstruction)
The seventh diagnosis on the Top 10 list is Cholelithiasis. There is a 1-to-1 crosswalk with this code from ICD-9 to ICD-10. There are also additional codes (similar to those in ICD-9) to further define cholelithiasis with complications (acute, chronic, combined and with or without obstruction).
ICD-9 Code: Calculus of gallbladder without cholecystitis or obstruction
ICD-10 Code: K80.20Calculus of the gallbladder without cholecystitis without obstruction

Other Related Codes
• K80.00 Calculus of gallbladder with acute cholecystitis without obstruction
• K80.01 Calculus of gallbladder with acute cholecystitis with obstruction
• K80.10 Calculus of gallbladder with chronic cholecystitis without obstruction (cholelithiasis with cholecystitis NOS)
• K80.11 Calculus of gallbladder with chronic cholecystitis with obstruction
• K80.12 Calculus of gallbladder with acute and chronic cholecystitis without obstruction
• K80.13 Calculus of gallbladder with acute and chronic cholecystitis with obstruction
• K80.18 Calculus of gallbladder with other cholecystitis without obstruction
• K80.19 Calculus of gallbladder with other cholecystitis with obstruction
• K80.21 Calculus of gallbladder without cholecystitis with obstruction

#8 – Calculus of Kidney
The diagnosis of Calculus of Kidney is eighth on the Top 10 list. It has a 1-to-1 crosswalk from ICD-9 to ICD-10. However, there is also a new combination code that combines a Kidney Stone and a Ureteral Stone into one code. In ICD-9, when a patient presented with both a kidney stone and a ureteral stone it was reported with two different codes. While similar codes exist in ICD-10 for these two conditions, there is a third code which combines them into one reportable code.

• ICD-9 Code
o 592.0 Calculus of Kidney
o 592.1 Calculus of Ureter

• ICD-10 Code
o N20.0 Calculus of Kidney
o N20.1 Calculus of Ureter
o N20.2 Calculus of Kidney with Calculus of Ureter

#9 – Brachial Neuritis or Radiculitis (Cervical Radiculopathy)
The diagnosis of Cervical Radiculopathy is ninth on the Top 10 list. Similar to lumbar radiculopathy, cervical radiculopathy has been expanded with a 1-to-3 crosswalk from ICD-9 to ICD-10 to allow greater specificity by anatomical location.

• ICD-9
o 723.4 Brachial Neuritis or Radiculitis NOS Cervical Radiculitis- Radicular Symptoms of Upper Limbs

• ICD-10
o M54.11 Radiculopathy, occipito-atlanto-axial region
o M54.12 Radiculopathy, cervical region
o M54.13 Radiculopathy, cervicothoracic region

#10 – Abdominal Pain, Unspecified Site
The last diagnosis code on the Top 10 list is Abdominal Pain, Unspecified Site. Although there is a 1-to-1 crosswalk with a similar unspecified ICD-10 code, ICD-10 provides for specific coding with the documentation of location, laterality and type of pain. If available, these three important elements should be documented to allow for more specificity in coding services.

• ICD-9: 789.00 Abdominal Pain, Unspecified Site
• ICD-10: R10.9 Unspecified Abdominal Pain

Other Related Codes with More Specificity:
• R10.0 Acute abdomen
• R10.10 Upper abdominal pain, unspecified
• R10.11 Right upper quadrant pain
• R10.12 Left upper quadrant pain
• R10.13 Epigastric pain
• R10.2 Pelvic and perineal pain
• R10.30 Lower abdominal pain, unspecified
• R10.31 Right lower quadrant pain
• R10.32 Left lower quadrant pain
• R10.33 Periumbilical pain
• R10.84 Generalized abdominal pain

While obtaining the level of detail needed to avoid unspecified codes is not always possible, providing the elements mentioned above when available could reduce potential reimbursement issues as well as provide valuable data on how patients are being treated and cured.

Pamela Linton, CPC, CANPC is an anesthesia coding specialist with Zotec Partners.

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