Charlene Posted Fri 26th of January, 2018 15:23:36 PM
OP note for cysto
Preop dx: microhematuria Postop dx: Bladder diverticulum, but otherwise normal cysto. Within body of op note the following conditions are mentioned: lateral lobe hypertrophy without lobes meeting midline and trabeculation.
Is it appropriate to only submit microhematuria and diverticulum? Or is necessary to report prostate hypertrophy and trabeculation also?
SuperCoder Answered Mon 29th of January, 2018 04:36:32 AM
As per the presented documentation, code the primary diagnosis as Bladder diverticulum by N32.3.
And the secondary diagnosis by N40.1 (for prostate hypertrophy) and R31.29 (for microhematuria)
Charlene Posted Tue 30th of January, 2018 13:11:02 PM
Thank you for the previous reply. I'd like to know by what basis prostate hypertrophy should be reported from the body of the note, but not the bladder trabeculation.
SuperCoder Answered Wed 31st of January, 2018 05:01:21 AM
As per the provided documentation, Diverticulum of bladder is a definitive diagnosis code. Bladder trabeculation would be covered up in the definitive diagnosis code of Diverticulum bladder.
As per CMS, a secondary code is useful to fully describe a condition. The sequencing rule is the same as the etiology/manifestation pair, “use additional code” indicates that a secondary code should be added, if known. That’s why we are coding for specific conditions; i.e., prostate hypertrophy (as a secondary disagnosis).
There won’t be any issue if you code bladder trabeculation as a tertiary diagnosis.
Hope that helps!
Charlene Posted Thu 01st of February, 2018 14:15:54 PM
1) What is meant by bladder trabeculation being "COVERED UP" in the diagnosis code of bladder diverticulum?
2) I understand BPH with lower tract symptoms N40.1 requires a secondary diagnosis code if manifestation is known. I thought the only secondary manifestations related to N40.1 were listed underneath the heading; example, incomplete bladder emptying R39.14. Micohematuria R31.29 is not in the list.
SuperCoder Answered Mon 05th of February, 2018 05:54:10 AM
Bladder diverticulum has trabeculated bladder wall as one of its causes of occurrence. We do not need to code both for Bladder diverticulum as well as bladder trabeculation. The intent of using the ICD 10 code is to provide the definitive diagnosis code for which the patient is undergoing treatment. Trabeculation is more of a symptom here which is leading to a major precise problem of bladder diverticulum.
It is not necessary that the codes mentioned underneath the heading as secondary manifestations related to N40.1, are the only eligible ICD 10 codes that can be billed as secondary codes. It all depends on the provided documentation. The data provided on website/books does not always contain all the related information. Your medical documentation will decide the appropriate usage of ICD 10 CM codes.
Charlene Posted Mon 05th of February, 2018 11:58:56 AM
Thank you for explaining this coding situation so clearly.
SuperCoder Answered Mon 05th of February, 2018 23:42:52 PM