A quarterly publication of the

Central Office on ICD-10-CM/PCS

Volume 7 Second Quarter
Number 2 2020
New ICD-10-CM Code Ommaya Reservoir Placement
COVID-19 3 for Cerebrospinal Fluid
Infusion Therapy 16
In This Issue Ommaya Reservoir with
Frequently Asked Questions Ventricular Catheter
Regarding ICD-10-CM Placement 15
Coding for COVID-19 3 Post-Debridement Chronic
Ask the Editor Non-Pressure Ulcer of Foot 19
Arthroscopic Manipulation and Retrolisthesis 21
Nonexcisional Debridement Sacral Pressure Ulcer with
of Knee Joint 26 Excisional and Nonexcisional
Chronic Cerebrovascular Debridement of Same Site 26
Accident/Stroke 29 Sepsis due to Aspiration
Chronic Non-Pressure Ulcer Pneumonia 28
of Heel with Subcutaneous Sepsis due to Gram-Negative
Tissue Exposure 19 Aspiration Pneumonia 28
Degenerative Joint Disease of Sepsis due to Ventilator-
Sacroiliac Joint 14 Associated Pneumonia 17
Diabetes Mellitus and Fournier’s Sinus Bradycardia with
Gangrene 18 Premature Ventricular
Displaced Peripherally Inserted Contractions 23
Central Catheter 21 Spinal Fusion with NuVasive®
Duhrssen Cervical Incision 30 VersaTie® 27
Endoscopic Stapling of Zenker’s Strangulated Ventral Hernia
Diverticulum 25 with Necrotic Bowel and
History of Recurrent Deep Vein Perforation 22
Thrombosis 20 Traumatic Brain Injury with
Intestinal Anastomotic Dehiscence 22 Herniation 31
Leptomeningeal Cyst 24 Unresponsiveness due to
Long-Term (Current) Intranasal Dilaudid 24
Use of Flonase® 14
Correction Notice
Puerperal Sepsis due to
Obstetrical Wound Infection 32
New codes contained in this issue effective with discharges April 1, 2020. Other coding
advice or code assignments contained in this issue effective May 29, 2020.
Coding Clinic for Editorial Advisory Board Jeffrey F. Linzer, M.D., FAAP
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 New ICD-10-CM Code for 2019 Novel
Coronavirus (COVID-19)
Implementation April 1, 2020
Effective April 1, 2020, code U07.1, COVID-19, has been
implemented in response to the recent pandemic. A national
emergency has been declared in the United States concerning the
COVID-19 Outbreak. Given these developments, and the critical need
to report COVID-19 in claims and surveillance data, the Centers for
Disease Control (CDC), under the National Emergencies Act Section
201 and 301, announced a change in the effective date of new
diagnosis code U07.1, COVID-19, from October 1, 2020 to April 1,
2020. This off-cycle update is unprecedented and is an exception to
the code set updating process established under HIPAA.

Code U07.1, COVID-19, may be used for discharges/date of service

on or after April 1, 2020. For guidance prior to April 1, 2020, please
refer to the supplement to the ICD-10-CM Official Guidelines for
coding encounters related to the COVID-19 coronavirus outbreak.

Frequently Asked Questions Regarding

ICD-10-CM Coding for COVID-19

The following questions and answers below represent a selection

that was initially jointly developed and approved by the American
Hospital Association’s Central Office on ICD-10-CM/PCS and the
American Health Information Management Association and posted
on their respective web sites as interim guidance. They are reprinted
here (with some minor editorial revisions) with the approval of the
Cooperating Parties indicating their agreement with the answers as
written.

Coding Clinic Second Quarter 2020 3

 Question:
What is the ICD-10-CM code for COVID-19?

Answer:
ICD-10-CM code U07.1, COVID-19, may be
used for discharges/dates of service on or
after April 1, 2020. The code was developed
by the World Health Organization (WHO) and
is intended to be sequenced first followed
by the appropriate codes for associated
manifestations when COVID-19 meets the
definition of principal or first-listed diagnosis.
For guidance prior to April 1, 2020, please refer
to the supplement to the ICD-10-CM Official
Guidelines for coding encounters related to the
COVID-19 coronavirus outbreak reprinted in
the First Quarter 2020 issue of Coding Clinic,
pages 34-36.

Question:
Is the new ICD-10-CM code U07.1, COVID-19,
a secondary code?

Answer:
When COVID-19 meets the definition of
principal or first-listed diagnosis, code U07.1,
COVID-19, should be sequenced first,
and followed by the appropriate codes for
associated manifestations, except in certain
circumstances when another code would
appropriately be sequenced first, such as
obstetric or lung transplant patients. However,
if COVID-19 does not meet the definition of
principal or first-listed diagnosis (e.g. when it
develops after admission), then code U07.1
should be used as a secondary diagnosis.

Question:
Are there additional new codes to identify
other situations specific to COVID-19? For
example, codes for exposure to COVID-19, or
observation for suspected COVID-19 but where
the tests are negative?

4 Second Quarter 2020 Coding Clinic

 Answer:
No, at the present time, there are no other new
COVID-19-related ICD-10-CM codes. Existing
ICD-10-CM codes, such as code Z20.828,
Contact with and (suspected) exposure to
other viral communicable diseases, should be
assigned when appropriate.

However, the Centers for Disease Control

and Prevention’s National Center for Health
Statistics, the US agency responsible for
maintaining ICD-10-CM in the US, is monitoring
the situation. The off-cycle release of code
U07.1, COVID-19, is unprecedented and is an
exception to the code set updating process
established under the Health Insurance
Portability and Accountability Act (HIPAA).

Question:
We have been told that the World Health
Organization (WHO) has approved an
emergency ICD-10 code of “U07.2 COVID-19,
virus not identified.” Is code U07.2 to be
implemented in the US too?

Answer:
The HIPAA code set standard for diagnosis
coding in the US is ICD-10-CM, not ICD-10.
As shown in the April 1, 2020 Addenda on the
CDC website, the only new code that has been
implemented in the US for COVID-19 is U07.1.

Question:
How should we code cases related to
COVID-19 with date of service or date of
discharge prior to April 1, 2020, the effective
date of ICD-10-CM code U07.1, COVID-19?

Is the ICD-10-CM code U07.1, COVID-19,

retroactive for patients with a date of service or
date of discharge before the April 1, 2020 date?

Coding Clinic Second Quarter 2020 5

 Answer:
No, the code U07.1, COVID-19, is not
retroactive. Please refer to the supplement
to the ICD-10-CM Official Guidelines for
coding encounters related to the COVID-19
coronavirus outbreak for guidance on the
coding of discharges/services provided before
April 1, 2020 reprinted in the First Quarter 2020
issue of Coding Clinic, pages 34-36.

Question:
Should presumptive positive COVID-19 test
results be coded as confirmed?

Answer:
Yes, presumptive positive COVID-19 test
results should be coded as confirmed. A
presumptive positive test result means an
individual has tested positive for the virus at
a local or state level, but it has not yet been
confirmed by the Centers for Disease Control
and Prevention (CDC). CDC confirmation of
local and state tests for the COVID-19 virus is
no longer required.

Question:
How should we handle cases related to
COVID-19 when the test results are not back
yet? The supplementary guidance and FAQs
are confusing since sometimes COVID-19 is
not “ruled out” during the encounter, since the
test results are not back yet.

Answer:
Due to the heightened need to capture
accurate data on positive COVID-19 cases, we
recommend that providers consider developing
facility-specific coding policies to hold back
coding of inpatient admissions and outpatient
encounters until the test results for COVID-19
testing are available. This advice is limited to
cases related to COVID-19.

6 Second Quarter 2020 Coding Clinic

 Question:
Based on the recently released guidelines for
COVID-19 infections, does a provider need to
explicitly link the results of the COVID-19 test
to the respiratory condition as the cause of the
respiratory illness to code it as a confirmed di-
agnosis of COVID-19? Patients are being seen
in our emergency department and if results are
not available at the time of discharge, we are
reluctant to query the physicians to go back and
document the linkage when the results come
back several days later.

Answer:
No, the provider does not need to explicitly link
the test result to the respiratory condition, the
positive test results can be coded as confirmed
COVID-19 cases as long as the test result itself
is part of the medical record. As stated in the
coding guidelines for COVID-19 infections that
went into effect on April 1, code U07.1 may be
assigned based on results of a positive test
as well as when COVID-19 is documented
by the provider. Please note that this advice
is limited to cases related to COVID-19 and
not the coding of other laboratory tests. Due
to the heightened need to uniquely identify
COVID-19 patients, we recommend that
providers consider developing facility-specific
coding policies to hold back coding of inpatient
admissions and outpatient encounters until the
test results for COVID-19 testing are available.

Question:
We are unsure about how to interpret the
newly released COVID-19 guidelines in relation
to the uncertain diagnosis guideline which
refers to diagnoses “documented at the time
of discharge” stated as possible, probable,
etc. Can we code these cases as confirmed
COVID-19 if the test results do not come
back until a few days later and the patient has
already been discharged?

Coding Clinic Second Quarter 2020 7

 Answer:
Yes, if a test is performed during the visit or
hospitalization, but after discharge results
come back positive for COVID-19, then it
should be coded as confirmed COVID-19. This
advice applies to both inpatient and outpatient
encounters.

Question:
Since the new guidelines for COVID-19
regarding sepsis just say to refer to the sepsis
guideline, is that then saying that sepsis would
be sequenced first and then U07.1 for a patient
presenting with sepsis due to COVID-19?

Answer:
Whether or not sepsis or U07.1 is assigned
as the principal diagnosis depends on the
circumstances of admission and whether sepsis
meets the definition of principal diagnosis.
For example, if a patient is admitted with
pneumonia due to COVID-19 which then
progresses to viral sepsis (not present on
admission), the principal diagnosis is U07.1,
COVID-19, followed by the codes for the viral
sepsis and viral pneumonia. On the other
hand, if a patient is admitted with sepsis due
to COVID-19 pneumonia and the sepsis
meets the definition of principal diagnosis,
then the code for viral sepsis (A41.89) should
be assigned as principal diagnosis followed
by codes U07.1 and J12.89, as secondary
diagnoses.

Question:
What is the difference between code
Z03.818, Encounter for observation for
suspected exposure to other biological
agents ruled out, and code Z20.828, Contact
with and (suspected) exposure to other
viral communicable diseases, in relation to
COVID-19? Can you provide examples on how
to apply the codes?

8 Second Quarter 2020 Coding Clinic

 Answer:
Code Z03.818, Encounter for observation
for suspected exposure to other biological
agents ruled out, should be used if a patient is
asymptomatic and there is a possible exposure
to COVID-19 and the patient tests negative
for COVID-19. Per the instructional note under
category Z03, codes in this category may only
be used if a patient has no signs or symptoms.

Code Z20.828, Contact with and (suspected)

exposure to other viral communicable diseases,
should be used if a patient has a known or
suspected exposure to COVID-19, is exhibiting
signs/symptoms associated with COVID-19,
and the test results are negative, inconclusive,
or unknown. According to guideline I.C.21.c.1
Contact/Exposure, Z20 codes may be used
for patients who are in an area where a
disease is epidemic. Therefore, due to the
current COVID-19 pandemic, when a patient
presents with signs/symptoms associated with
COVID-19 and is tested for the virus because
the provider suspects the patient may have
COVID-19, code Z20.828 may be assigned
without explicit documentation of exposure or
suspected exposure to COVID-19.

If the test results are positive, code U07.1

should be assigned instead of either code
Z03.818 or Z20.828. An example of the
application of code Z20.828 is a patient with
respiratory signs or symptoms, testing for
COVID-19 is negative, and the patient is
determined to have another condition (e.g. flu,
pneumonia). Codes should be assigned for
the condition (e.g., flu, pneumonia) and code
Z20.828 should be assigned as an additional
diagnosis.

Coding Clinic Second Quarter 2020 9

 Question:
Please provide guidance on correct coding
when the provider has documented COVID-19
as a definitive diagnosis before the test results
are available, and the test results come back
negative.

Answer:
Coding professionals should query the provider
if the provider documented COVID-19 before
the test results were back and the test results
come back negative. Providers should be given
the opportunity to reconsider the diagnosis
based on the new information.

Question:
Please provide guidance on correct coding
when the provider has confirmed the
documented COVID-19 after the test results
come back negative. How should this be
coded?

Answer:
If the provider still documents and confirms
COVID-19 even though the test results are
negative, or if the provider documented
disagreement with the test results, assign code
U07.1, COVID-19. As stated in the Official
Guidelines for Coding and Reporting for
COVID-19, “Code only a confirmed diagnosis
of the 2019 novel coronavirus disease
(COVID-19) as documented by the provider . . .
the provider’s documentation that the individual
has COVID-19 is sufficient.”

Question:
When a patient who previously had COVID-19
is seen for a follow-up exam and the COVID-19
test is negative, what is the best code(s) to
capture this scenario?

10 Second Quarter 2020 Coding Clinic

 Answer:
Assign codes Z09, Encounter for follow-up
examination after completed treatment for
conditions other than malignant neoplasm, and
Z86.19, Personal history of other infectious and
parasitic diseases.

Question:
How should an encounter for COVID-19
antibody testing be coded?

Answer:
For an encounter for antibody testing that is not
being performed to confirm a current COVID-19
infection, nor is being performed as a follow-
up test after resolution of COVID-19, assign
code Z01.84, Encounter for antibody response
examination.

Question:
If a patient has both aspiration pneumonia
and pneumonia due to COVID-19, may code
J12.89, Other viral pneumonia, be assigned
with code J69.0, Pneumonitis due to inhalation
of food and vomit? There is an Excludes1
note at category J12, Viral pneumonia, not
elsewhere classified, that excludes pneumonia
not otherwise specified (J69.0).

Answer:
Yes, both codes may be assigned, as aspiration
pneumonia and pneumonia due to COVID-19
are two separate unrelated conditions with
different underlying causes. This meets the
exception to the Excludes1 guideline as a
circumstance when the two conditions are
unrelated to each other.

Coding Clinic Second Quarter 2020 11

 Question:
For a patient who has HIV/AIDS and is
diagnosed with COVID-19, the guidelines don’t
assume a relationship between COVID-19 and
HIV, so does the provider need to link the two
conditions for coding?

Answer:
Any immunocompromised patient (which
would include HIV patients) is at higher
risk for becoming infected with COVID-19,
but HIV does not cause COVID-19. Code
both conditions separately, with sequencing
depending on the circumstances of admission –
just like a patient suffering from diabetes or any
other chronic condition that puts them at higher
risk for the COVID-19 infection.

Question:
Is there a timeframe for considering the
COVID-19 as history of, or current? For
example, if a patient is documented as having
had COVID-19 four weeks ago and during the
current encounter the patient no longer has
COVID-19, do we use the personal history
code?

Answer:
There is no specific timeframe for when a
personal history code is assigned. If the
provider documents that the patient no longer
has COVID-19, assign code Z86.19, Personal
history of other infectious and parasitic
diseases.

Question:
When a patient is diagnosed with COVID-19,
we understand that signs and symptoms are
not manifestations and would not be separately
coded. We also understand that Guideline
I.C.18.b. states that “signs or symptoms
that are associated routinely with a disease
process should not be assigned as additional

12 Second Quarter 2020 Coding Clinic

 codes, unless otherwise instructed by the
classification.” When a patient diagnosed
with COVID-19 presents with both respiratory
signs/symptoms (e.g., shortness of breath,
cough) and non-respiratory signs/symptoms
(e.g., gastrointestinal problems, dermatologic
or venous sufficiency issues), may the non-
respiratory signs/symptoms/conditions be
coded separately since they are not routinely
associated with COVID-19?

Answer:
Because COVID-19 is primarily a respiratory
condition, any other signs/symptoms would
be coded separately unless another definitive
diagnosis has been established for the
other signs or symptoms. This is supported
by Guideline IC.18.b, “Codes for signs and
symptoms may be reported in addition to a
related definitive diagnosis when the sign or
symptom is not routinely associated with that
diagnosis.”

Question:
How should we code neonates/newborns that
test positive for COVID-19?

Answer:
When coding the birth episode in a newborn
record, the appropriate code from category
Z38, Liveborn infants according to place of
birth and type of delivery, should be assigned
as the principal diagnosis. For a newborn
that tests positive for COVID-19, assign code
U07.1, COVID-19, and the appropriate codes
for associated manifestation(s) in neonates/
newborns in the absence of documentation
indicating a specific type of transmission. For
a newborn that tests positive for COVID-19
and the provider documents the condition was
contracted in utero or during the birth process,
assign codes P35.8, Other congenital viral
diseases, and U07.1, COVID-19.

Coding Clinic Second Quarter 2020 13

 Ask the Editor
Question:
A patient is diagnosed with bilateral lower
sacroiliac degenerative joint disease (DJD).
When referencing the Index to Diseases under
Degenerative, joint disease, ICD-10-CM directs
the coding professional to see “Osteoarthritis.”
However, the Index to Diseases does not
specifically classify osteoarthritis (OA) of
the sacroiliac joint. What is the appropriate
code assignment for bilateral lower sacroiliac
degenerative joint disease (DJD)?

Answer:
Assign code M46.1, Sacroiliitis, not elsewhere
classified. DJD of the sacroiliac joint is caused
by degeneration, leading to inflammation of
the sacroiliac joint. Currently, the ICD-10-CM
does not have a unique code for DJD of the
sacroiliac joint; therefore, code M46.1 is the
closest available alternative. The National
Centers for Health Statistics has agreed to
consider a future ICD-10 Coordination and
Maintenance (C&M) proposal for creation of a
new code for DJD/osteoarthritis of the sacroiliac
joint.

Question:
What is the appropriate diagnosis code for
long-term (current) use of a topical intranasal
steroid, such as Flonase®? Even though it is
administered intranasal, would Flonase® be
considered an inhaled steroid?

14 Second Quarter 2020 Coding Clinic

 Answer:
Assign code Z79.899, Other long-term (current)
drug therapy, for the long-term use of a topical/
local intranasal steroid, such as Flonase®.

While Flonase® is classified as a corticosteroid,

it is not considered an inhaled steroid
(administrated by an inhaler or nebulizer into
lungs), nor a systemic steroid (given orally or by
injection and distributed throughout the body).

Question:
A patient with a history of acute myeloblastic
leukemia presented with an intracranial
recurrence. An Ommaya reservoir with
ventricular catheter was placed for the
intrathecal delivery of medication. A previous
twist drill hole in the skull was expanded around
the Ommaya reservoir and was able to fit into
a bony pocket but the inner cortical bone was
not expanded beyond the twist drill hole. Next,
a ventricular catheter was attached to the
reservoir and the other end was navigated via
the drill hole into the foramen of Monro. What is
the appropriate ICD-10-PCS code for insertion
of an Ommaya reservoir intra-cranially for
delivery of medication?

Answer:
Assign the following ICD-10-PCS codes

00H633Z Insertion of infusion device into

cerebral ventricle, percutaneous
approach, for the insertion of
the catheter portion of the
Ommaya into the cerebral
ventricle; and

Coding Clinic Second Quarter 2020 15

 0JHS33Z Insertion of infusion device into
head and neck subcutaneous
tissue and fascia, percutaneous
approach, for the placement of
the Ommaya reservoir portion
into the bony pocket of the skull.

Although the reservoir was placed in the skull,

there is no specific device value for infusion
device that corresponds to the body part
value describing skull bone; therefore, the
closest available equivalent is head and neck
subcutaneous tissue and fascia. An Ommaya
reservoir is a surgically implanted dome-shaped
device that provides direct access to the
cerebrospinal fluid (CSF) for the administration
of medication, such as chemotherapy and
antibiotics. The device also enables sampling of
CSF and consists of a small port that is placed
underneath the skull, which is attached to a
catheter and threaded into the ventricle of the
brain.

Question:
A patient who is diagnosed with spinal muscular
atrophy status post spinal fusion, presented for
insertion of an intraspinal Ommaya reservoir
via laminectomy for cerebrospinal fluid (CSF)
infusion therapy. Dissection was carried down
to the spinal bone mass, where a drill was
utilized to reach the lumbar canal. A needle
was then placed into the lumbar subarachnoid
space and the catheter was threaded up to
the mid thoracic level. The catheter was then
tunneled out through the paraspinous muscle
to a new subcutaneous pocket that was
created under direct vision off the right flank. An
Ommaya reservoir was then connected to the
spinal catheter. What is the ICD-10-PCS code
for insertion of an Ommaya reservoir into the
flank for delivery of medication?

16 Second Quarter 2020 Coding Clinic

 Answer:
Assign the following ICD-10-PCS codes:

00HU03Z Insertion of infusion device into

spinal canal, open approach,
for the insertion of the catheter
into the spinal subarachnoid
space; and

0JHT03Z Insertion of infusion device into

trunk subcutaneous tissue and
fascia, open approach, for the
insertion of the reservoir into the
subcutaneous pocket in the right
flank.

The Ommaya reservoir can also be used

with an intrathecal catheter connected via the
spinal canal, to deliver intrathecal medication
for patients who have undergone spinal fusion
surgery.

Question:
A patient with a complicated past medical his-
tory is admitted for severe sepsis due to venti-
lator-associated pneumonia (VAP). The VAP is
due to Escherichia coli and methicillin suscepti-
ble Staphylococcus aureus. Would VAP be con-
sidered a complication or a localized infection?
What are the appropriate code assignments
and sequencing of sepsis due to VAP?

Answer:
The VAP is the localized infection, which is
sequenced after the underlying systemic
infection, sepsis. In this case, sequence either
code A41.51, Sepsis due to Escherichia coli
[E. coli], or A41.01, Sepsis due to Methicillin
susceptible Staphylococcus aureus, as the
principal diagnosis. Codes J95.851, Ventilator
associated pneumonia, and R65.20, Severe
sepsis without septic shock, should be
assigned as additional diagnoses.

Coding Clinic Second Quarter 2020 17

 The Official Guidelines for Coding and
Reporting, Section I.C.1.d.4, states, “If the
reason for admission is sepsis or severe sepsis
and a localized infection, such as pneumonia
or cellulitis, a code for the underlying systemic
infection should be assigned first and the code
for the localized infection should be assigned
as a secondary diagnosis.”

Question:
The patient, who is a type 2 diabetic, presents
with Fournier’s gangrene. The Alphabetic Index
under the main term “diabetes” provides a
subentry “with gangrene.” Does this subentry
include Fournier’s gangrene? What are the
appropriate code assignments for Fournier’s
gangrene in a diabetic patient?

Answer:
No, Fournier’s gangrene is not a type of
diabetic gangrene. In this case, there is no
documentation of a peripheral angiopathy
(circulatory disorder). The Alphabetic Index
under diabetes with gangrene leads to code
E11.52, Type 2 diabetes mellitus with diabetic
peripheral angiopathy with gangrene. Although
diabetes may predispose some patients to
develop Fournier’s gangrene, this is not a
diabetic gangrene nor a peripheral angiopathy,
which progresses more slowly and occurs
secondary to circulatory issues. Fournier’s is
a bacterial necrotizing soft tissue infection,
which can occur due to trauma, postoperative
complications, or other causes.

Assign codes N49.3, Fournier gangrene,

and E11.9, Type 2 diabetes mellitus without
complications. Assign an additional code from
categories B95-B97 to identify the infectious
agent, if known.

18 Second Quarter 2020 Coding Clinic

 Question:
A patient with Type 2 diabetes mellitus presents
to outpatient wound care for debridement of
a chronic non-pressure ulcer of the right heel.
The provider documented that the ulcer was
necrotic with exposed subcutaneous tissue.
For the purposes of code assignment, should
documentation of “subcutaneous tissue
exposure” be interpreted to mean fat level
exposure?

Answer:
Yes. The subcutaneous tissue includes the fat
layer. Assign codes E11.621, Type 2 diabetes
mellitus with foot ulcer, and L97.412, Non-
pressure chronic ulcer of right heel and midfoot
with fat layer exposed, for the right heel non-
pressure ulcer.

Question:
A patient presented to wound care for
debridement of a non-pressure chronic ulcer
of the left lateral foot. The ulcer is documented
as having visible skin breakdown prior to
debridement and visible subcutaneous tissue
without necrosis, post-debridement. In the
outpatient setting, when a non-pressure
chronic ulcer is documented as one severity
pre-debridement and a different severity post-
debridement, are one or two codes reported? If
one, which severity level is assigned?

Answer:
Assign only code, L97.512, Non-pressure
chronic ulcer of other part of right foot with
fat layer exposed. The subcutaneous tissue
includes the fat layer. In the outpatient setting,
codes are assigned to the highest degree of
certainty for that encounter/visit, which is similar
to coding the post-operative diagnosis.

Coding Clinic Second Quarter 2020 19

 Excisional debridement is typically done
layer-by-layer to excise all devitalized tissue
until all non-viable tissue has been removed.
Therefore, following debridement, the true
depth of the ulcer can appear deeper, as its full
extent will be uncovered. This is not the same
as ulcer progression and does not indicate the
ulcer has progressed or worsened.

The guideline requiring two codes for ulcers

that progress to another severity does not
apply to the outpatient setting. The guideline
was intended for inpatient hospital reporting to
allow the most accurate reporting of the present
on admission (POA) indicator in order to track
the change in severity during an inpatient
admission.

Question:
A 79-year-old patient presents for a follow-up
visit for multiple conditions, including personal
history of recurrent deep vein thrombosis
(DVT) of the lower extremity. The patient was
initially anticoagulated with Coumadin but was
switched to Xarelto®.

Some coding professionals at our facility feel

that a diagnosis of history of recurrent DVT in
a patient on anticoagulation therapy should be
coded as a chronic DVT. However, other coding
professionals believe that history of recurrent
DVT without any further specification should
be reported with the default code assignment
of acute DVT. What is the appropriate code
assignment for personal history of recurrent
deep vein thrombosis of the lower extremity?

Answer:
Based on the health record documentation,
assign codes Z86.718, Personal history of other
venous thrombosis and embolism, and Z79.01,
Long term (current) use of anticoagulants,

20 Second Quarter 2020 Coding Clinic

 for history of recurrent deep vein thrombosis
of the lower extremity on long term use of
anticoagulant medication. In this case, the
patient presented for a follow-up visit and had
no evidence of an acute, current or recurrent
DVT nor complications from the thrombus.
Chronic DVT is a thrombus that is one month
to several months old and usually involves
symptoms, such as chronic swelling, ulceration,
cellulitis, or other complication. Recurrent DVT
indicates the condition has occurred more than
once. The provider would need to document
recurrent or chronic DVT, to code it as such.

Question:
How is a diagnosis of retrolisthesis coded?
Retrolisthesis is not indexed in ICD-10-
CM; however, it appears to be a form of
spondylolisthesis.

Answer:
Assign the appropriate code from subcategory
M43.1, Spondylolisthesis. Retrolisthesis refers
to backward slippage of a vertebra, and ICD-
10-CM classifies any slippage of the vertebra
as a spondylolisthesis.

Question:
A 61-year-old patient was recently admitted for
chronic osteomyelitis and abscess of the left
distal femur. During that previous admission,
she underwent incision and drainage of the
abscess and placement of a peripherally
inserted central catheter (PICC). The patient
was discharged to a skilled nursing facility,
where she pulled out the PICC line. She was
transported to the emergency department
and the provider documented “PICC line
displacement.” The patient was readmitted,
and Interventional Radiology replaced the
PICC line. What is the correct diagnosis code
assignment for a displaced PICC line?

Coding Clinic Second Quarter 2020 21

 Answer:
Assign code T82.524A, Displacement of
infusion catheter, initial encounter, for the
displaced PICC line. Although the patient
displaced her own catheter, it is not positioned
in the intended vessel, and is appropriately
coded as a complication. Code Z45.2,
Encounter for adjustment and management of
vascular access device, would not be assigned,
as this code assignment is only used for routine
encounters for catheter care.

Question:
What are the appropriate diagnosis codes for
a strangulated recurrent incisional hernia with
necrotic bowel and perforation? Would multiple
codes be assigned to capture the patient’s
conditions?

Answer:
Assign codes K43.1, Incisional hernia
with gangrene, and K63.1, Perforation of
intestine (nontraumatic), for the recurrent
incisional hernia with necrotic small bowel
and perforation, to fully capture the patient’s
condition.

Question:
A patient who is status post colectomy
presents with chills, abdominal pain, and
fever. On examination, he was found to have
feculent wound drainage and was diagnosed
with anastomotic dehiscence of the small
bowel to the transverse colon. Coding
professionals can arrive at different codes,
based on how the condition is referenced
in the Index (Dehiscence-internal operation
wound vs. Complication-anastomosis). What
is the appropriate code assignment for an
anastomotic dehiscence of the small bowel to
the transverse colon?

22 Second Quarter 2020 Coding Clinic

 Answer:
Assign codes K91.89, Other postprocedural
complications and disorders of digestive
system, and T81.32XA, Disruption of internal
operation (surgical) wound, not elsewhere
classified, initial encounter, for the dehiscence
of the intestinal anastomosis. Both codes are
needed to fully describe the patient’s condition.
The note found at code K91.89 instructs to
use an additional code to further specify the
disorder. Although guideline I.C.19.g.5 indicates
complications specifically indexed to a T
code in chapter 19 would not be assigned a
complication code from a body system chapter,
in this case, code K91.89 provides information
about the body system involved that is not
captured in the T code.

Question:
A patient presented with palpitations and
presyncopal symptoms, which he experienced
while going from a sitting to standing
position. The provider diagnosed sinus
bradycardia and multiple premature ventricular
contractions. Code I49.3, Ventricular premature
depolarization, cannot be assigned with code
R00.1, Bradycardia, unspecified, based on the
Excludes1 note at category I49-, Other cardiac
arrhythmias. However, there is an Excludes 2
note at category R00-, Abnormalities of heart
beat, which allows the reporting of codes in that
category with specified arrhythmias (I47-I49).
Should codes for sinus bradycardia and
premature ventricular contractions be assigned
together?

Answer:
Assign both code I49.3, Ventricular premature
depolarization, and code R00.1, Bradycardia,
unspecified. Although there is an Excludes1
note at category I49-, Other cardiac
arrhythmias, for sinus bradycardia, these are

Coding Clinic Second Quarter 2020 23

 distinct (unrelated) cardiac conditions, which
can exist independently. In order to convey the
complete clinical picture, code both conditions.

Question:
The patient became unresponsive after
receiving intravenous Dilaudid. The provider
documented “Unresponsiveness due to
Dilaudid.” How is this diagnosis coded?

Answer:
Assign codes R40.4, Transient alteration of
awareness, and T40.2X5A, Adverse effect of
other opioids, initial encounter.

Question:
A 15-year-old male presented with a growing
mass on the right side of his head. After
diagnostic workup, the provider documented
“Craniofacial deformity secondary to
leptomeningeal cyst/growing skull fracture.”
He underwent frontotemporal craniotomy with
periosteal dural graft for repair of growing skull
fracture. What are the appropriate diagnosis
code assignments for leptomeningeal cyst/
growing skull fracture?

Answer:
Assign code G93.89, Other specified disorders
of brain, for leptomeningeal cyst. Also, assign
code S02.91XS, Unspecified fracture of skull,
sequela, since the leptomeningeal cyst/growing
skull fracture is a late effect of the fracture.

Leptomeningeal cysts, also called growing skull

fractures, are expanding skull fractures that
develop near post-traumatic encephalomalacia.
The term “leptomeningeal cyst” is a misnomer,
because it is not a cyst, but an extension of the
encephalomalacia, and is typically seen several
months post-trauma, and usually develops
following linear fracture with an underlying dural
tear, and may result in herniation of the brain.

24 Second Quarter 2020 Coding Clinic

 Question:
A patient is admitted for transoral Zenker’s
diverticulectomy. During surgery, the scope
was positioned, and an endovascular
gastrointestinal stapler was passed transorally
with the staple load in the true esophagus and
the anvil in the diverticulum pouch. The stapler
was engaged and fired. Repeat endoscopy
confirmed the common channel had been
appropriately managed with resolution of the
Zenker’s diverticulum. What is the ICD-10-PCS
code assignment for this procedure?

Answer:
Assign the following procedure code:

0K844ZZ Division of tongue, palate,

pharynx muscle, percutaneous
endoscopic approach, for
division of the cricopharyngeus
muscle.

In Zenker’s diverticulum, the pharyngeal

muscle is too tight and squeezes the pharynx,
so that it bulges above the esophagus and
forms a pouch. The goal of surgery is to sever
the common wall between the esophageal
lumen and the diverticulum containing the
cricopharyngeus muscle in order to create a
common cavity between the esophagus and
the diverticulum. Stapling of the common wall
results in cricopharyngeal myotomy and fusion
of the pouch lumen and esophagus.

The percutaneous endoscopic approach value

is assigned because the approach value, via
natural or artificial opening endoscopic, is not
available in the ICD-10-PCS table 0K8, Division
of Muscles.

Coding Clinic Second Quarter 2020 25

 Question:
A patient, who is diagnosed with a stage IV
sacral decubitus ulcer and wet gangrene,
underwent excisional and nonexcisional
debridement, down to and including muscle,
fascia, and bone. Since debridement of
necrotic gangrenous tissue appears to be the
sole objective of the procedure, the multiple
procedure guideline does not appear to apply.
What is the appropriate code assignment for
excisional and nonexcisional debridement of
the same site and depth?

Answer:
Assign the following procedure code:

0QB10ZZ Excision of sacrum, open

approach, for excisional and
nonexcisional debridement of
the sacrum down to and
including muscle, fascia, and
bone.

Excision is the definitive treatment performed

at the site, and when both excisional and
nonexcisional debridement of the same site
are performed, only the excisional debridement
code is reported.

Question:
A patient presents with a painful knee, status
post right total knee replacement. In the
operative suite, arthroscopic manipulation of
the right knee was performed under anesthesia
to break up the adhesions. Next, arthroscopic
inspection revealed peripatellar, suprapatellar,
medial, and lateral gutter scar tissue, which
was removed by non-excisional debridement.
How should non-excisional debridement of
the knee be coded since there is no body part
value for joint in the root operation Extraction?

26 Second Quarter 2020 Coding Clinic

 Answer:
Assign the following procedure code:

0SNC4ZZ Release right knee joint,

percutaneous endoscopic
approach, for the release of scar
tissue in the knee joint.

Based on the documentation in the operative

report, the procedure was done to release
the knee joint. In this case, scar tissue was
removed to free the joint.

Question:
A patient with multiple spinal conditions,
including previous fusion, severe
kyphoscoliosis, and severe spinal and foraminal
stenosis, presents for corrective surgery. Prior
fusion instrumentation was removed, new
instrumentation was placed, and a new fusion
was performed in the lumbar spine.

In addition to the multiple spinal procedures

performed, a NuVasive® VersaTie®
polyethylene tether was woven through the
interspinous ligaments via drill holes that
were placed at the base of T8. The tether
was returned in a weave fashion and after full
tension was achieved, the tie was locked into
place to the VersaTie® connectors that were
placed at T11-T12. What is the appropriate root
operation for placement of tether from T8-T12?

Answer:
Do not assign an additional code for the
placement of the VersaTie® tether. Fixation
instrumentation is integral to the fusion
procedure and no additional code is assigned.

Coding Clinic Second Quarter 2020 27

 Question:
When the provider documents “sepsis due to
aspiration pneumonia,” is a code for the sepsis,
or the aspiration pneumonia assigned as the
principal diagnosis?

Answer:
Assign code A41.9 Sepsis, unspecified
organism, as the principal diagnosis. Codes
J18.9, Pneumonia, unspecified organism, and
J69.0, Pneumonitis due to inhalation of food
and vomit, should be assigned as additional
diagnoses. Sepsis indicates infection and the
body’s response to it. Aspiration pneumonia
may be just from the direct effect of inhaled
material, such as a chemical effect, or it
may involve infection; however, for sepsis to
result, it would need to involve an infectious
pneumonia. Therefore, codes J18.9 and
J69.0 are both needed to show the presence
of a localized infection (pneumonia and
unspecified organism) as well as pneumonia
due to aspiration. When sepsis and aspiration
pneumonia are related (i.e., sepsis due
to aspiration pneumonia or sepsis related
to aspiration pneumonia) and present on
admission, sepsis should be sequenced as the
principal diagnosis.

Question:
A patient was discharged with the following
diagnoses: 1. sepsis secondary to aspiration
pneumonia, 2. aspiration pneumonia secondary
to probable gram-negative bacteria. Both
diagnoses were present on admission. Should
this be coded as sepsis due to gram-negative
pneumonia?

28 Second Quarter 2020 Coding Clinic

 Answer:
When sepsis and aspiration pneumonia
are related and present on admission, the
sepsis should be sequenced as the principal
diagnosis. Assign code A41.50, Gram-negative
sepsis, unspecified, as the principal diagnosis.
Codes J15.6, Pneumonia due to other Gram-
negative bacteria, and J69.0, Pneumonitis
due to inhalation of food and vomit, should
be assigned as additional diagnoses. The
pneumonia is a gram-negative bacterial
aspiration pneumonia and is the localized
infection that has led to sepsis. Code J69.0 is
assigned to capture aspiration pneumonia.

The coding professional should follow guideline

1.C.1.d.4, Sepsis and severe sepsis with a
localized infection, which states, “if the reason
for admission is both sepsis or severe sepsis
and a localized infection, such as pneumonia or
cellulitis, a code(s) for the underlying systemic
infection should be assigned first and the code
for the localized infection should be assigned
as a secondary diagnosis.”

Question:
An 84-year-old male with chronic gait
instability is admitted after a fall. The provider’s
documentation states that the patient’s gait
instability is related to chronic cerebrovascular
accident (CVA). How is gait instability due to
chronic CVA coded?

Answer:
Although the index leads to code I63.9,
Cerebral infarction, unspecified, based on
the documentation, the patient does not have
a current cerebrovascular infarction. Assign
code R26.89, Other abnormalities of gait and
mobility and code I69.398, Other sequelae of
cerebral infarction. The gait instability is coded
as a late effect or sequela (neurological deficit),
associated with the patient’s previous CVA.

Coding Clinic Second Quarter 2020 29

 Question:
A patient with twin pregnancy presented with
Twin A in a frank breech position too low in the
vagina for a cesarean section. The decision
was made for a vaginal breech delivery. The
head of Twin A was noted to be entrapped
in the cervix so a Duhrssen incision was
performed to facilitate delivery. After Twin A
was delivered, Twin B experienced recurrent
prolonged heart decelerations prompting
cesarean delivery of Twin B. After surgical
closure of the cesarean section, the cervix
was examined and bleeding was noted from
the Duhrssen incision, which was closed with
suture. What ICD-10-PCS code is assigned
for a Duhrssen cervical incision and is an
additional code assigned for the repair?

Answer:
The purpose of the Duhrssen incision is to
widen the opening of the incompletely dilated
cervix to facilitate delivery of the trapped fetal
head. Although Division is the appropriate root
operation, ICD-10-PCS table 0W8 does not
provide a body part value for Cervix. Therefore,
the root operation Dilation is the closest
available option. Coding a Duhrssen incision is
similar to coding an episiotomy. The repair of
the incision is integral to the procedure and not
coded separately. Assign the following ICD-10-
PCS code:

0U7C7ZZ Dilation of cervix, via natural or

artificial opening, for the
Duhrssen incision.

30 Second Quarter 2020 Coding Clinic

 Question:
A patient, who had suffered a traumatic brain
injury (TBI) without loss of consciousness
secondary to a high-speed motor vehicle
accident, developed brain herniation. There is
an Excludes1 note that prohibits assigning code
G93.5, Compression of brain, with codes from
subcategories S06.2, Diffuse traumatic brain
injury, and S06.3, Focal traumatic brain injury.
How should herniation of the brain due to TBI
not further specified be coded?

Answer:
If the physician does not provide further
specificity about the type of brain injury, assign
codes S06.9X0A, Unspecified intracranial injury
without loss of consciousness, initial encounter,
and G93.5, Compression of brain. The
Excludes1 note prohibits assigning code G93.5
together with codes from subcategories S06.2,
Diffuse traumatic brain injury, and S06.3, Focal
traumatic brain injury, not subcategory S06.9.

Coding Clinic Second Quarter 2020 31

 Correction Notice
Puerperal Sepsis due to Obstetrical
Wound Infection

Question:
In the Fourth Quarter 2018 issue of Coding
Clinic, page 23, and Second Quarter 2019
issue, page 39, it was advised to report code
O85, Puerperal sepsis, in addition to codes
O86.02, Infection of obstetrical surgical
wound, deep incisional site, and O86.04,
Sepsis following an obstetrical procedure, to
capture sepsis due to deep incisional infection
of cesarean wound. Is code O85 appropriate
for sepsis that occurs in the postpartum
period regardless of cause, including surgical
wound infections? Are all three codes needed
to capture sepsis that occurred due to the
obstetrical surgical wound infection?

Answer:
Coding Clinic, Fourth Quarter 2018, page 23,
and Second Quarter 2019, page 39, advised
to assign code O85, Puerperal sepsis, as
an additional diagnosis to capture sepsis
due to deep incisional infection of cesarean
wound. Although the use additional code note
at O86.04 instructs to assign an additional
code to identify sepsis, puerperal sepsis is a
postpartum infection involving the genital tract.
Therefore, code O85 is not appropriate. When
sepsis is due to an obstetric procedure, assign
code O86.04, instead of code O85. Code
O86.04 is more specific to the type of infection.

Therefore, assign codes O86.02, Infection of

obstetrical surgical wound, deep incisional site,
and O86.04, Sepsis following an obstetrical
procedure, for sepsis due to deep incisional
infection of cesarean wound.

32 Second Quarter 2020 Coding Clinic

 The Official Guidelines for Coding and
Reporting for sepsis due to a postprocedural
infection state, “For infections following a
procedure, a code from T81.40, to T81.43
Infection following a procedure, or a code from
O86.00 to O86.03, Infection of obstetric surgical
wound, that identifies the site of the infection
should be coded first, if known. Assign an
additional code for sepsis following a procedure
(T81.44) or sepsis following an obstetrical
procedure (O86.04). Use an additional code to
identify the infectious agent.

Coding Clinic Second Quarter 2020 33

34 Second Quarter 2020 Coding Clinic