A quarterly publication of the

Central Office on ICD-10-CM/PCS

Volume 7 First Quarter
Number 1 2020
New ICD-10-CM Code History of (Resolved) Diabetes
Vaping-Related Disorder 3 Mellitus and Hypertension 12
Inpatient Detoxification Services 21
In This Issue Intermittent Use of Continuous
Malnutrition 4 Positive Airway Pressure 10
Ask the Editor Leukemic Meningitis 13
Ablation Convergent Procedure Maternal Group B Streptococcus
(Catheter-Based and Infection 10
Thoracoscopic Ablations) 32 Polarity Skin TE™ Application 30
Acute Flaccid Myelitis 14 Portal Hypertensive Gastropathy 15
Acute Upper and Lower Postoperative Hemorrhage
Respiratory Infection 22 Following Cholecystectomy 19
Alcoholic Pancreatitis and Alcohol Pregnancy with History of Genital
Dependence 9 Herpes 20
Anaphylaxis due to Hymenoptera Pseudohyponatremia 15
Venom Immunotherapy 18 Psychoactive Substance Use and
Appendicitis with Perforation and Physical Disorder 9
Gangrene 16 Pulmonary Artery Unifocalization 24
Bipolar Disorder and Recurrent Repair of Buried Penis 31
Major Depressive Disorder 23 Repair of Sternal Dehiscence
Bleeding from Thyroid Bed Using Sternal Talon® Device 29
Following Thyroidectomy 19 Resection of Vascular Malformation,
Bone Marrow Edema 14 Likely Cavernoma 24
Cannabinoid Hyperemesis Syndrome Retracted Jaw (Retrognathia) 21
Associated with Excessive Spinal Fusion without Use of Bone Graft 33
Cannabis Use 8 Spinal Stenosis and Spondylosis
Cervical Spondylosis and Stenosis at Same Vertebral Level 17
with Myeloradiculopathy 17 Staged Arthroplasty Following
Continuous Positive Airway Explant of Elbow Joint Prosthesis 23
Pressure Dependence Status 11 Clarification
Delayed Reconstruction Following Cytokine Release Syndrome 37
Mastectomy Using Gracilis
Musculocutaneous Free Flap 27 Correction Notice
Diabetic Manifestations Following Bypass of Ascending Aorta to
Weight Loss Surgery 12 Brachiocephalic Artery 37
Elephant Trunk Repair of Aortic Degenerative Nontraumatic Tear of
Dissection 25 Long Head of Bicep 38
Esophagogastric Junction Polyp 16
Failed Fecal Transplant 18 Notice
Free Flap Microvascular Breast ICD-10-CM Official Coding
Reconstruction 28 Guidelines - Supplement Coding
History of Fecal Transplant 18 Encounters Related to COVID-19
Coronavirus Outbreak 34

New codes contained in this issue effective with discharges April 1, 2020. Other coding
advice or code assignments contained in this issue effective March 5, 2020.
Coding Clinic for Editorial Advisory Board Jeffrey F. Linzer, M.D., FAAP
Representative, American
ICD•10•CM/PCS Donna Ganzer, Chairman Academy of Pediatrics,
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 New ICD-10-CM Code for
Vaping-Related Disorder
Implementation April 1, 2020
Effective April 1, 2020, code U07.0, Vaping-related disorder, will be
implemented in response to the recent occurrences of vaping related
disorders. The incorporation of this diagnosis code is consistent
with certain provisions of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) for diagnosis coding, including
the Official ICD–10–CM Guidelines for Coding and Reporting, as
maintained and distributed by the U.S. Department of Health and
Human Services.

The code is consistent with the emergency code established by the

World Health Organization (WHO). The code resulted from a meeting
of the WHO Framework Convention on Tobacco Control and the
WHO Family of International Classifications (WHOFIC) Network
Classification and Statistics Advisory Committee (CSAC).

According to the U.S. Centers for Disease Control and Prevention

(CDC), using an electronic cigarette (e-cigarette) is commonly
called vaping. E-cigarettes are also called vapes, e-hookahs, vape
pens, tank systems, mods, and electronic nicotine delivery systems
(ENDS). E-cigarettes work by heating a liquid to produce an aerosol
that users inhale into their lungs. The liquid can contain: nicotine,
tetrahydrocannabinol (THC) and cannabinoid (CBD) oils, and other
substances, flavorings, and additives. THC is the psychoactive mind-
altering compound of marijuana that produces the “high.” The U.S.
Food and Drug Administration (FDA) and the U.S. Centers for Disease
Control and Prevention (CDC) continue to investigate the incidents of
severe respiratory illness associated with use of vaping products.

Coding Clinic First Quarter 2020 3

The new code is in Chapter 22, which is a new chapter within ICD-10-
CM. Chapter 22 has a reserved block of codes for special purposes
(U00-U85). There is also a new section “Provisional assignment of
new diseases of uncertain etiology or emergency use (U00-U49).”
Codes U00-U49 are to be used by WHO for the provisional
assignment of new diseases of uncertain etiology. For more details
refer to the addenda available at: https://www.cdc.gov/nchs/icd/data/
Chapter-22-new-vaping-code-FINAL1.pdf.

There is also a supplement to the ICD-10-CM Official Coding Guide-

lines for coding encounters related to E-cigarettes, or Vaping Product
Use, which was posted on October 17, 2019, available at https://www.
cdc.gov/nchs/data/icd/Vapingcodingguidance2019_10_17_2019.pdf.

Please note: Coding guidance for vaping related injury may be

updated as needed.

Malnutrition
The Central Office on ICD-10-CM/PCS has received multiple inquiries
about the appropriate code assignment for malnutrition, in regards
to disease severity and progression, clinical parameters, etc. The
following questions and answers are being provided to help clarify
these coding issues.

Question:
Is malnutrition considered integral to chronic
illnesses like cancer? For example, if
a provider documents malnutrition in a
cancer patient receiving chemotherapy may
malnutrition be coded separately?

Answer:
While loss of appetite is a common side effect
of chemotherapy, malnutrition is not routinely
associated with cancer and therefore the
Official Guidelines for Coding and Reporting
Section I.B.5 regarding conditions that are an
integral part of a disease process does not
apply. Assign the appropriate malnutrition code
in addition to the code for the specific type of
cancer.

4 First Quarter 2020 Coding Clinic

 Question:
How should malnutrition that progresses in
severity be coded? For example, moderate
protein calorie malnutrition is documented on
admission but progresses to severe protein
calorie malnutrition during the stay. We see this
in very ill patients who have extended lengths
of stay and who due to their illness, are not
able to maintain their nutritional status. Would
this scenario be assigned two codes in a similar
fashion to a pressure ulcer that progresses
during a stay? What would be the appropriate
code assignment and the present on admission
(POA) indicator for a patient that is admitted
with moderate protein calorie malnutrition
that progresses to severe protein calorie
malnutrition?

Answer:
Assign code E43, Unspecified severe protein-
calorie malnutrition, and a POA indicator of
“Y” for a moderate protein calorie malnutrition
present on admission that progresses to severe
protein calorie malnutrition during the stay.
When documentation in the medical record
indicates that malnutrition has progressed from
mild to moderate, mild to severe, or moderate
to severe, during an inpatient stay, assign one
code to capture the highest level of severity.
Section I.C.12.b.3 of the Official Guidelines for
Coding and Reporting specifically applies to
pressure ulcers in order to track the change in
stage during an inpatient admission and was
not intended to be applied to other conditions.

Question:
There are various clinical criteria for
malnutrition and payers may require different
criterions for reporting malnutrition. Which
clinical criteria should coding professionals use
when reporting a code for malnutrition?

Coding Clinic First Quarter 2020 5

 Answer:
It is outside the scope of Coding Clinic to
determine, endorse or approve diagnostic
criteria for any condition. While providers
may use a particular clinical definition or set
of clinical criteria to establish a diagnosis,
code assignment is based on the provider’s
documentation, not on a particular clinical
definition or criterion.

Question:
There are new ASPEN clinical indicators for
preterm and neonate malnutrition. Would it
be appropriate to assign codes based solely
on the ASPEN clinical indicators for preterm
and neonate malnutrition, without explicit
documentation of this condition from the
provider?

Answer:
No. The assignment of codes for preterm
and neonate malnutrition should be based on
provider documentation of this condition and
not on clinical indicators, or criterion.

Question:
How should severe malnourishment/severely
malnourished be coded given that “malnourish”
is not found in the Alphabetic Index? Can
we assume this is synonymous to severe
malnutrition?

Answer:
Assign code E43, Unspecified severe protein-
calorie malnutrition. Malnourishment is the
same as malnutrition.

6 First Quarter 2020 Coding Clinic

 Question:
The attending physician states “malnutrition”
with unspecified severity in the record. The final
impression on the dietitian’s consultation was
“Severe Malnutrition.” Could the malnutrition be
further specified as severe malnutrition by using
the specificity in the dietitian’s documentation?

Answer:
No, there are no guidelines permitting the use
of a registered dietician’s documentation of
the degree/severity of malnutrition for code
assignment. The degree/severity of malnutrition
(i.e., moderate, mild, severe) is a part of the
diagnosis of malnutrition, which can only be
made by the provider. According to the Official
Guidelines for Coding and Reporting, “Code
assignment is based on the documentation
by patient’s provider (i.e., physician or other
qualified healthcare practitioner legally
accountable for establishing the patient’s
diagnosis).”

Question:
A registered dietician assessed the patient,
and documented severe malnutrition. Following
dietary assessment, the physician reviews the
information and signs off via e-signature. Since
the dietary assessment contains a diagnosis
to which the physician agrees with per his/her
signed attestation, would it be appropriate to
assign a code for severe malnutrition, in the
inpatient setting?

Answer:
It is beyond the scope of the Editorial Advisory
Board for Coding Clinic for ICD-10-CM/PCS to
address this type of documentation issue. Your
hospital may develop a facility-based policy to
address whether documentation that is signed-
off by the patient’s provider is allowed to be
used for coding purposes.

Coding Clinic First Quarter 2020 7

 Ask the Editor
Question:
A patient presents with recurring nausea and
vomiting for 4-5 days. The provider documented
cannabinoid hyperemesis syndrome. What
is the appropriate code assignment for
cannabinoid hyperemesis syndrome?

Answer:
Assign code R11.2, Nausea with vomiting,
unspecified, along with the appropriate
uncomplicated code from category F12,
Cannabis related disorders, for a diagnosis
of cannabinoid hyperemesis syndrome.
Cannabinoid hyperemesis syndrome is the
definitive diagnosis; however, since there is no
specific code for this condition, the symptom
code for nausea and vomiting should be
assigned. The Official Guidelines for Coding
and Reporting for Syndromes state, “In the
absence of Alphabetic Index guidance, assign
codes for the documented manifestations of the
syndrome.”

When the pattern of substance use (i.e.,

dependence, abuse or use) is not documented,
query the physician for clarification.

Code T40.7X1A, Poisoning by cannabis

(derivatives), accidental (unintentional), initial
encounter, is not appropriate. The condition is
not classified as an acute poisoning, since it is
caused by heavy chronic marijuana use, not by
a single use.

8 First Quarter 2020 Coding Clinic

 Question:
The Official Guidelines for Coding and
Reporting for Psychoactive Substance Use,
Unspecified (I.C.5.b.3.) state, “These codes
are to be used only when the psychoactive
substance use is associated with a physical,
mental or behavioral disorder, and such a
relationship is documented by the provider.”
Coding professionals are unclear as to what
constitutes a “physical disorder.” What does the
term “physical” in guideline I.C.5.b.3 mean?

Answer:
Effective October 1, 2018, the guideline for
psychoactive substance use, unspecified,
(categories F10-F19 with fourth character 9)
was revised and the term “physical” was added,
to capture specific problems, such as sexual
dysfunction and sleep disorder, included in the
chapter 5 codes that are not mental disorders.
This guideline revision was not intended to
suggest other conditions would be classified
as physical disorders when associated with
substance use, abuse and/or dependence.

Question:
A patient is diagnosed with acute alcoholic
pancreatitis due to alcohol dependence. Would
it be appropriate to assign code F10.288,
Alcohol dependence with other alcohol-induced
disorder, as an additional code assignment?

Answer:
Assign codes K85.20, Alcohol induced acute
pancreatitis without necrosis or infection, and
F10.20, Alcohol dependence, uncomplicated,
for the alcoholic pancreatitis and alcohol
dependence. In this context, alcoholic
pancreatitis is not classified as an alcohol-
induced disorder. Therefore, code F10.20 is
assigned rather than code F10.288, Alcohol
dependence with other alcohol-induced
disorder.

Coding Clinic First Quarter 2020 9

 Question:
A 27-year-old female presented for delivery,
at 37 weeks gestation. She was found to have
fluid leak, and fever. The provider diagnosed an
active group B Streptococcus (GBS) infection,
which was treated with penicillin. What ICD-
10-CM code is assigned for an active GBS
infection? Is code assignment affected by the
site of the active culture (e.g., GI tract, urinary
tract, genital tract)?

Answer:
Assign codes O98.82, Other maternal
infectious and parasitic diseases complicating
childbirth, and B95.1, Streptococcus, group
B, as the cause of diseases classified
elsewhere, for maternal active GBS infection
complicating childbirth. Coding professionals
should not assign codes based on positive
cultures/lab values and/or the site cultured;
code assignment is based on the provider’s
diagnostic statement of the specified condition.

This code assignment can be found in the

Alphabetic Index as follows:

Infection
streptococcal
B genitourinary complicating
childbirth O98.82

Question:
A patient with a past medical history of
obstructive sleep apnea (OSA) is admitted and
placed on continuous positive airway pressure
(CPAP) at night and as needed during the
day. During the admission, the patient was
placed on CPAP overnight for three nights and
once during the day. What is the correct ICD-
10-PCS code for patients who are placed on
CPAP intermittently throughout the admission?
Would an ICD-10-PCS code for “Assistance

10 First Quarter 2020 Coding Clinic

 with respiratory ventilation” be assigned each
time the patient is placed on noninvasive CPAP
during the admission?

Answer:
The CPAP system is a noninvasive ventilation
support system designed to augment a
patient’s ability to breathe on a spontaneous
basis. The code assignment depends on the
number of consecutive hours that the patient
receives CPAP. Based on the documentation
provided, assign the following ICD-10-PCS
code once during the admission:

5A09357 Assistance with respiratory

ventilation, less than 24
consecutive hours, continuous
positive airway pressure, since
the patient received CPAP for
less than 24 consecutive hours.

Facilities may develop their own internal

guidelines, as to whether they wish to code and
report the CPAP support once, multiple times or
not at all.

Question:
For the above patient, who is receiving CPAP
at night and intermittently during the day,
would it be appropriate to assign code Z99.89,
Dependence on other enabling machines and
devices, to describe the patient’s CPAP status?

Answer:
No. Code Z99.89 is not appropriate, as ICD-
10-CM does not specifically classify CPAP
dependence or status. Codes from category
Z99-. Dependence on enabling machines and
devices, not elsewhere classified, should only
be reported when physician documentation
supports dependence.

Coding Clinic First Quarter 2020 11

 Question:
A patient with a long-standing history of
type 2 diabetic polyneuropathy underwent
bariatric surgery. The patient no longer
requires medication for the diabetes
secondary to the significant weight loss, and
in fact, the physician documents that the
diabetes has resolved. The patient has now
developed an ulceration of the right foot with
acute osteomyelitis secondary to diabetic
polyneuropathy. Would these conditions still be
coded as diabetic complications?

Answer:
Assign codes E11.42, Type 2 diabetes
mellitus with diabetic polyneuropathy; E11.69,
Type 2 diabetes mellitus with other specified
complication; E11.621, Type 2 diabetes
mellitus with foot ulcer; M86.171, Other acute
osteomyelitis, right ankle and foot; and L97.511,
Non-pressure chronic ulcer of other part of right
foot limited to breakdown of skin. Assign also
code Z98.84, Bariatric surgery status, for the
post status weight loss surgery.

The patient still has complications associated

with the diabetes, even though glucose levels
have normalized. Codes from category E11,
Type 2 diabetes mellitus are required to capture
the diabetic manifestations.

Question:
A patient underwent bariatric surgery due
to morbid obesity, hypertension and type 2
diabetes mellitus. Because of the surgery,
the patient had lost a significant amount of
weight. The provider documented that the
patient was no longer diabetic or hypertensive
and discontinued medication. There are no
documented manifestations of these conditions
in the health record. Would it be appropriate to
code these conditions when the provider states
“history of” or “resolved”?

12 First Quarter 2020 Coding Clinic

 Answer:
Assign codes Z86.39, Personal history of other
endocrine, nutritional and metabolic disease,
and Z86.79, Personal history of other diseases
of circulatory system, when the provider has
documented these conditions are resolved
and there are no manifestations of diabetes
or hypertension. “History of” can have two
different meanings (e.g., chronic condition or
the condition no longer exists). In this case,
history codes are assigned because the
provider has documented that diabetes and
hypertension have resolved and are no longer
being treated (medication was discontinued).
If the documentation is not clear whether the
patient still has the condition, query the provider
for clarification.

Question:
The provider documented acute myeloid
leukemia (AML) in relapse, cerebral leukemic
meningitis, neutropenic fever, pancytopenia
due to AML and chemotherapy. Previously
published Coding Clinic for ICD-9-CM advice
indicated that unlike solid tumors, neoplasms
that arise in lymphatic and hematopoietic
tissues do not spread to secondary sites. How
is leukemic meningitis coded in ICD-10-CM?

Answer:
Assign code C79.32, Secondary malignant
neoplasm of cerebral meninges, for leukemic
meningitis. In addition, assign a specific code
for the type of leukemia. This condition is a
metastatic infiltration of the cerebral meninges,
and is classified as a secondary malignancy,
not as an infectious meningitis. According to the
National Cancer Institute, leukemic meningitis,
also referred to as leukemic leptomeningitis
and meningeal leukemia, is a secondary
malignancy, in which cancer cells have spread
from the primary site to the meninges of the
brain and spinal cord.

Coding Clinic First Quarter 2020 13

 The Centers for Disease Control and
Prevention’s National Center for Health
Statistics has agreed to consider a
Coordination and Maintenance (C&M) proposal
to index leukemic meningitis.

Question:
Currently, ICD-10-CM does not have a code
that specifically identifies acute flaccid myelitis
(AFM). How is acute flaccid myelitis coded in
ICD-10-CM?

Answer:
Assign code G04.89, Other myelitis, for AFM.
This condition affects the gray matter of the
spinal cord and causes the muscles and
reflexes of the body to weaken. Other signs
and symptoms may include facial drooping/
weakness, trouble moving the eyes, drooping
eyelids, trouble swallowing or slurred speech.
AFM has also been called a “polio-like” illness.
The most recent cases in the United States
have been seen in children.

Question:
The patient presents for outpatient magnetic
resonance imaging (MRI) of the foot. The
findings demonstrated bone marrow edema
of the left first metatarsal. When queried, the
physician confirmed the MRI impression and
stated no other injury was identified. What
diagnosis code should be assigned for bone
marrow edema?

Answer:
Do not assign a code for bone marrow edema
that is associated with an underlying condition
(e.g., osteoarthritis, fracture, infection, etc.). In
that case, code only the associated condition.
Since there was no associated condition, in this
case assign code R93.6, Abnormal findings
on diagnostic imaging of limbs, for the MRI
finding of bone marrow edema of the left first

14 First Quarter 2020 Coding Clinic

 metatarsal. Bone marrow edema found at
another site would be assigned a specific code
in the same category indicating the site.

Question:
We frequently see the diagnosis of
pseudohyponatremia with hyperglycemic
patients that are treated with normal saline
infusion. Would pseudohyponatremia
associated with another disease process
be coded? What is the appropriate code
assignment for pseudohyponatremia?

Answer:
Do not assign a code for a diagnosis of
pseudohyponatremia. This condition is an
abnormal lab finding that is always inherent to
an underlying condition. Assign a code for the
underlying condition instead.

Question:
A patient was diagnosed with gastrointestinal
bleeding due to erosive gastritis and portal
hypertensive gastropathy. What is the correct
code assignment for portal hypertensive
gastropathy?

Answer:
Portal hypertensive gastropathy refers to the
changes in the cells of the stomach lining due
to portal hypertension. Assign code K76.6,
Portal hypertension, and code K31.89, Other
diseases of stomach and duodenum, for portal
hypertensive gastropathy. Both codes are
necessary to capture completely the diagnosis
of portal hypertensive gastropathy. Refer to the
ICD-10-CM’s Tabular List of Diseases, which
provides an instructional note as follows:

K76.6 Portal hypertension

Use additional code for any associated
complications, such as: portal
hypertensive gastropathy (K31.89)

Coding Clinic First Quarter 2020 15

 Question:
An 11-year-old patient is admitted with
abdominal pain and vomiting due to
acute appendicitis. During laparoscopic
appendectomy, purulent fluid was found in the
pelvis and the appendix appeared gangrenous
with an area of necrosis and perforation.
What is the diagnosis code assignment for
appendicitis with gangrenous perforation?

Answer:
Assign only code K35.32, Acute appendicitis
with perforation and localized peritonitis, without
abscess. A patient may have appendicitis
and gangrene without perforation, but cannot
have perforation without necrosis/gangrene.
Clinically, appendicitis with perforation indicates
gangrene, so the gangrene is not coded
separately.

Question:
A patient presented for an upper gastrointes-
tinal (GI) endoscopy. Two non-adenomatous
polyps were removed at the esophagogastric
(EG) junction. What is the ICD-10-CM code for
an esophagogastric junction polyp?

Answer:
ICD-10-CM does not specifically classify an EG
junction polyp. Therefore, assign codes K22.8,
Other specified diseases of the esophagus
and K31.7, Polyp of stomach and duodenum.
Both codes are assigned to capture the fact
that the polyp was located at the junction of the
esophagus and stomach.

The Centers for Disease Control and Pre-

vention’s National Center for Health Statistics
has agreed to consider a future Coordination
and Maintenance (C&M) proposal to create a
unique code for esophagogastric junction polyp.

16 First Quarter 2020 Coding Clinic

 Question:
The patient presented with cervical spondylosis
with myeloradiculopathy and stenosis. Since
spondylosis and stenosis are both degenerative
conditions, would unique codes be assigned?
What are the appropriate codes assigned for
C4-C6 spondylosis with myeloradiculopathy,
and C4-C6 stenosis with myeloradiculopathy?

Answer:
Assign codes M48.02, Spinal stenosis, cervical
region, M47.12, Other spondylosis with
myelopathy, cervical region, and M47.22, Other
spondylosis with radiculopathy, cervical region,
for cervical spondylosis with myelopathy and
radiculopathy. All of the codes are needed to
fully capture the diagnostic statement. In ICD-
10-CM, there are no Excludes notes prohibiting
the assignment of codes for both spinal
stenosis with spondylosis.

Question:
The patient is diagnosed with spinal stenosis
and spondylosis at the same vertebral level.
Would unique codes be assigned, since
spondylosis and stenosis are both degenerative
conditions? What are the appropriate codes
assigned for spinal stenosis and spondylosis at
the same site?

Answer:
Assign codes for both spinal stenosis and
spondylosis when the diagnoses are supported
by medical record documentation. Both codes
are needed to fully capture the patient’s
diagnoses. In ICD-10-CM, there are no
Excludes notes prohibiting the assignment of
codes for spinal stenosis with spondylosis.

Coding Clinic First Quarter 2020 17

 Question:
A patient with recurrent Clostridium difficile was
admitted for a fecal transplant following failure
of a prior transplant. What is the ICD-10-CM
diagnosis code for a failed fecal transplant? Is it
coded to transplant failure?

Answer:
Assign only code A04.71, Enterocolitis
due Clostridium difficile, recurrent. It is not
appropriate to assign a code for a transplant
failure for a fecal transplant that did not prevent
a recurrence of Clostridium difficile enteritis. A
fecal transplant is a medical treatment rather
than an “organ/tissue” transplant.

Question:
What is the correct code to capture a history of
fecal transplant?

Answer:
Assign code Z92.89, Personal history of other
medical treatment, for a personal history
of a fecal transplant. A fecal transplant is a
medical treatment rather than an “organ/tissue”
transplant.

Question:
A patient presented for administration of
her first wasp venom injection. Ten minutes
after the injection, the patient started to
experience chest tightness and wheezing.
In the diagnostic statement, the provider
documented “Anaphylaxis due to hymenoptera
venom.” What is the appropriate code for
anaphylaxis due to wasp hymenoptera venom
immunotherapy (VIT)?

Answer:
Assign codes T88.6XXA, Anaphylactic
reaction due to adverse effect of correct drug
or medicament properly administered, initial

18 First Quarter 2020 Coding Clinic

 encounter, and T50.Z95A, Adverse effect of
other vaccines and biological substances, initial
encounter, for anaphylaxis due to wasp VIT.

Question:
A patient underwent hemithyroidectomy for a
neoplasm of the thyroid gland. After noticing
bleeding in the post-operative wound drain, the
provider suspected a hematoma and a bleeding
vessel. After reopening the patient, a pulsatile
vessel was discovered at the inferior aspect
of the thyroid bed, which was clamped and
tied. The surgeon documented, “Complication:
bleeding from the left inferior thyroid bed,
while the patient was in the operating room.”
When assigning a code for the bleeding, is it
appropriate to report a code for the bleeding
organ/structure or the bleeding blood vessel?

Answer:
Assign code E36.01, Intraoperative
hemorrhage and hematoma of an endocrine
system organ or structure complicating an
endocrine system, for post-hemithyroidectomy
bleeding of the left inferior thyroid bed. The
surgeon documented the hematoma/bleeding
occurred in the bed of the thyroid at the site of
the surgery. Therefore, a code is not assigned
for complication of the blood vessel.

Question:
A patient underwent cholecystectomy for
chronic calculus cholecystitis. While taking
down attachments between the gallbladder
and the liver bed, the provider noted an arterial
bleed. The right upper quadrant was packed,
and a vascular clamp was placed across the
porta hepatis to control the bleeding. The
bleeding site was identified as the orifice of the
cystic artery just beyond its takeoff from the
right hepatic artery. The provider documented
“Complication: intraoperative hemorrhage.”

Coding Clinic First Quarter 2020 19

 When assigning the code for the bleed, is
it appropriate to assign a code for bleeding
organ/structure or the bleeding blood vessel
(cystic artery)?

Answer:
Assign code K91.61, Intraoperative hemorrhage
and hematoma of a digestive system organ
or structure complicating a digestive system
procedure, for the intraoperative hemorrhage
at the orifice of the cystic artery beyond the
right hepatic artery, during the cholecystectomy
procedure.

Most of the body’s organs and tissues are

vascular, and they bleed when cut or eroded. If
a vascular procedure is done on an unrelated
vessel, or the injury involves an unrelated
vessel (not linked to the organ where the
surgery was performed), assign code I97.42,
Intraoperative hemorrhage and hematoma
of a circulatory system organ or structure
complicating other procedure, rather than a
chapter specific complication code.

Question:
A patient with history of genital herpes was
admitted for delivery at 39 weeks. There is
no documentation of the patient being treated
with antiviral medication and the patient is
symptom free during the admission. Should
genital herpes be coded as a complication of
the delivery?

Answer:
Assign codes O98.32, Other infections with a
predominantly sexual mode of transmission
complicating childbirth, and A60.09, Herpesviral
infection of other urogenital tract. Although
the patient is not on antiviral medication,
transmission of the herpes virus is a risk to the
fetus and therefore, the infection is coded as a
complication of delivery.

20 First Quarter 2020 Coding Clinic

 Question:
What is the correct code assignment for a
retracted jaw in a newborn?

Answer:
Assign code M26.19, Other specified anomalies
of jaw-cranial base relationship, for a retracted
jaw in a newborn. Recessed jaw is also
known as retrognathia. The Index to Diseases
provides the following entries:

Retrognathia, retrognathism (mandibular)

(maxillary) M26.19

Anomaly, anomalous
jaw - cranial base relationship -- see
Anomaly, dentofacial, jaw -- cranial base
relationship

Anomaly, anomalous
jaw-cranial base relationship specified
type NEC M26.19

Since the anomaly is specified as retracted jaw,

code M26.19 is appropriate.

Question:
A 47-year-old male with a history of alcohol
abuse presented to the emergency department
with complaints of tremors and hallucinations
due to alcohol withdrawal. The patient was
admitted to the medical unit and alcohol
withdrawal protocol was initiated, which
included treatment with IV Ativan. The
patient was also given thiamine, folate and
multivitamins. The patient was transferred
to the ICU for a more aggressive treatment
program using Precedex. Are detox services
that involve medicines such as Ativan and
Precedex separately reported with code
HZ98ZZZ? Alternatively, are the use of these
medications inherent in the detoxification

Coding Clinic First Quarter 2020 21

 services reported with code HZ2ZZZZ? What
ICD-10-PCS code would be assigned for this
admission?

Answer:
If facilities wish to collect this information,
assign the following ICD-10-PCS code:

HZ2ZZZZ Detoxification services for

substance abuse treatment.

This code assignment includes detoxification

services to help the patient stabilize.
Detoxification includes the active management
of withdrawal symptoms. Typically,
pharmacotherapy (code HZ98ZZZ) involves
replacing the substance of abuse over a longer
period to wean the patient (e.g., methadone
maintenance for heroin dependence), which
is different from prescribing Ativan or other
drugs to offset symptoms of alcohol withdrawal,
such as delirium tremens or pending delirium
tremens.

Question:
The patient was admitted and diagnosed with
both acute upper and acute lower respiratory
infection. The upper respiratory infection is
assigned to code J06.9, Acute upper respiratory
infection, unspecified. The lower respiratory
infection is assigned to code J22, Unspecified
acute lower respiratory infection. Category
J06 excludes “acute respiratory infection
NOS (J22),” and code J22 excludes “upper
respiratory infection (acute) (J06.9).” When the
patient has both an unspecified acute upper
and acute lower respiratory infection, what code
is assigned since the code assignments are
mutually exclusive?

22 First Quarter 2020 Coding Clinic

 Answer:
Assign only code J22, Unspecified acute
lower respiratory infection, as it is the more
severe infection. When both upper and lower
respiratory infections are documented, assign
only a code for the lower respiratory infection.

Question:
A patient was diagnosed with bipolar disorder
and major depressive disorder recurrent,
mild. Category F31, Bipolar disease, has
an “Excludes1” note for “major depressive
disorder, recurrent (F33-),” and category F33,
Major depressive disorder, recurrent, has an
“Excludes1” note for “bipolar disorder (F31-).”
What code is assigned when both conditions
are documented?

Answer:
Assign code F31.9, Bipolar disorder,
unspecified. Bipolar disorder includes both
depression and mania, and it is more important
to capture the bipolar disorder. Therefore, a
code for depression would not be reported
separately.

Question:
A patient, who is status post prosthetic joint
removal and placement of antibiotic spacer due
to infected elbow prosthesis, now presents for
removal of the spacer and revision of the total
right elbow prosthesis. What is the principal
diagnosis for this admission?

Answer:
Assign code Z47.1, Aftercare following joint
replacement surgery, as the principal diagnosis,
since subcategory Z47.3-, Aftercare following
explantation of joint prosthesis, does not
contain an appropriate code for elbow joint
prosthesis. Code Z47.1 is the closest available
equivalent to capture care provided following

Coding Clinic First Quarter 2020 23

 elbow joint prosthesis explantation. Although
there is a “Use additional code” note at code
Z47.1, the note would not apply here because
the elbow joint prosthesis has been removed.

Question:
A 36-year-old female who presents with a
ruptured intra-ventricular vascular malformation
with obstructive hydrocephalus and trapped
atrium and temporal horn is admitted to
undergo resection of vascular malformation,
likely cavernoma. The patient was also noted
to be bleeding from the intra-ventricular lesion.
The vascular malformation was located within
the caudate/thalamus junction and within
the ventricle. Once the lesion was excised,
communication between the posterior and
anterior aspects of the frontal horn of the
right lateral ventricle was allowed. What is the
correct ICD-10-PCS code assignment?

Answer:
In this case, the provider documented,
“Intraventricular vascular lesion, likely a
cavernoma.” However, it is unclear whether the
lesion is an arteriovenous malformation (AVM)
or a developmental venous anomaly (DVA).
Therefore, query the provider for clarification. If
the surgeon confirms that the lesion is a DVA,
only the excision of intracranial vein code is
reported, and the following procedure code
would be assigned:

05BL0ZZ Excision of intracranial vein,

open approach.

Question:
A two-year-old male with Tetralogy of Fallot with
pulmonary atresia, and major aortopulmonary
collateral arteries (MAPCA) presents for
pulmonary artery unifocalization. Via a redo
median sternotomy, the pericardium was

24 First Quarter 2020 Coding Clinic

 accessed and the Blalock-Taussig (BT)
shunt was doubly ligated and divided. Non-
duplicate MAPCAs to the left and right lung
were taken off the descending aorta and
unifocalized together with the native pulmonary
arteries (PAs). These required extensive
patching with PhotoFix (bovine) pericardium.
A right ventriculotomy was performed, and
an 8 mm Gore-Tex® conduit was sewn into
the unifocalized PAs distally and the right
ventricular outflow tract proximally. How is
pulmonary artery unifocalization coded?

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

021K0JP Bypass right ventricle to

pulmonary trunk with synthetic
substitute, open approach, for
the Gore-Tex® portion of the
bypass conduit; and

02UP08Z Supplement pulmonary trunk

with zooplastic tissue, open
approach, for pulmonary artery
plasty using PhotoFix (bovine)
pericardium to form a single
pulmonary artery trunk conduit
for the distal anastomosis with
the Gore-Tex®.

In unifocalization, the misdirected blood vessels

are rerouted into a single vessel (or into the
pulmonary artery if it is present), which is then
attached to the right ventricle of the heart
through a conduit.

Question:
A patient with a thoracoabdominal aortic
dissection presents for repair. After median
sternotomy, the ascending aorta was divided

Coding Clinic First Quarter 2020 25

 and trimmed down to the sinotubular junction. A
Hemishield Dacron graft was fashioned end-to-
end to the aorta at the junction. The ascending
aorta was further abbreviated to allow hemiarch
resection. A Gore-Tex® fixed elephant trunk
endoprosthesis was then passed into the
open arch, under direct vision. The endograft
was deployed and secured to the edge of the
hemiarch incision on the lesser curvature. A
hole was developed in the endograft for the
left subclavian artery. Through this, a Gore
Viabahn covered endograft was passed into
the left subclavian artery and remained in the
lumen. The subclavian endograft was secured
with sutures to the aortic endograft, which was
then sewn to the aortic arch. Then another
piece of Hemishield graft was beveled to size
and anastomosed end-to-end to the aortic arch.
What are the correct ICD-10-PCS codes for
repair of the aorta with hemiarch Dacron graft
replacement, fixed elephant trunk Gore-Tex®
endograft, and placement of endograft in the
left subclavian artery origin?

Answer:
Assign the following procedure codes:

02RX0JZ Replacement of thoracic aorta,

ascending/arch with synthetic
substitute, open approach, for
the replacement of a portion of
the ascending aorta with Dacron;

02VW0DZ Restriction of thoracic aorta,

descending with intraluminal
device, open approach, for
the endoprosthesis placed in the
descending portion of the
thoracic aorta; and

26 First Quarter 2020 Coding Clinic

 03H40DZ Insertion of intraluminal device
into left subclavian artery, open
approach, for the endograft
extension placed in the left
subclavian.

The hybrid repair of complex aortic aneurysms

using aortic arch replacement along with a
fixed elephant trunk endograft is a relatively
new surgical technique. As in this case, it can
be performed as a single procedure, using
a replacement prosthesis for the proximal
portion of the aorta and an endograft in the
distal portion. These techniques are separate
surgical objectives classified as different root
operations in ICD-10-PCS, and so separate
codes are assigned. In this particular case,
an endograft extension was placed from the
thoracic aorta endograft into the subclavian
artery to maintain patency of the subclavian.
It is coded separately using the root operation
Insertion because the subclavian extension is
not integral to aortic aneurysm repair.

Question:
A patient who is status post left side
mastectomy due to left breast cancer presents
for delayed reconstruction. The reconstruction
was performed using a left vertical upper
gracilis musculocutaneous free flap. There
does not appear to be a qualifier under the
root operation “replacement” to capture
the use of the gracilis musculocutaneous
free flap. How should we report left breast
reconstruction using left vertical upper gracilis
musculocutaneous free flap?

Answer:
Assign the following procedure codes:

0HRU07Z Replacement of left breast with

autologous tissue substitute,
open approach; and

Coding Clinic First Quarter 2020 27

 0KBR0ZZ Excision of left upper leg muscle,
open approach, for the left
breast delayed reconstruction
using vertical upper gracilis
musculocutaneous free flap.

Currently, there is no specific qualifier to identify

a vertical upper gracilis musculocutaneous
free flap in ICD-10-PCS. Therefore, qualifier
“Z,” No qualifier, should be used for the code
assigned from table 0HR for the vertical upper
gracilis musculocutaneous free flap. In this
scenario, harvesting of the flap is separately
reported to capture the vertical upper gracilis
musculocutaneous free flap. Both codes
are needed to fully capture the procedure
performed.

Question:
A patient, who has a history of breast cancer
and is status post mastectomy, presented for
a free abdominal superficial inferior epigastric
artery (SIEA) tissue flap reconstruction.
Postoperatively a change in the color of the
flap with decreased signals was noted and the
patient was taken back to the operating room.
There was no blood flow from the internal
mammary vein so it was decided to utilize the
external jugular vein instead. A neck incision
was made exposing the external jugular
vein. A saphenous vein graft was harvested
for additional length. A subcutaneous tunnel
was created from the left neck to the chest
and the vein graft was passed through the
tunnel. The proximal saphenous vein graft
was anastomosed to the left external jugular
vein (EJV) and the distal saphenous vein graft
was anastomosed to the superficial inferior
epigastric vein (SIEV). What is the ICD-10-
PCS code to capture the SIEV to EJV bypass
utilizing a saphenous vein graft?

28 First Quarter 2020 Coding Clinic

 Answer:
Assign the following codes:

051Q49Y Bypass left external jugular vein

to upper vein with autologous
venous tissue, percutaneous
endoscopic approach, for the left
external jugular to superficial
inferior epigastric vein bypass
via saphenous vein graft; and

06BQ0ZZ Excision of left saphenous

vein, open approach, for the
harvesting of the graft.

“Bypass” is the correct root operation as the

venous portion of the vascularization has failed
and the blood is now being re-routed utilizing
the external jugular vein. The bypass is coded
with the qualifier Upper Vein for the SIEA,
because the abdominal flap graft is taking the
place of the breast. Therefore, the breast is the
site of the procedure and the target vessel of
the bypass is classified as an upper vein rather
than a lower vein.

Percutaneous approach is the correct approach

as the saphenous vein graft was tunneled from
the external jugular to epigastric vein. However,
since there is not a percutaneous approach
value in table 051, percutaneous endoscopic
approach is assigned.

Question:
A patient post-sternotomy presented with
sternal dehiscence and underwent debridement
of the sternum with insertion of Sternal Talon®
plating. The sternum was debrided with a
saw and pectoralis flaps were advanced
but left connected to the chest wall. Sternal
Talon® plates were placed across the sternum
beginning at ribs 3-6. Each plate was anchored

Coding Clinic First Quarter 2020 29

 with screws lateral to the sternum. The sternum
and manubrium were reapproximated at the
midline with the titanium plates and screws.
The pectoralis muscles were sutured together
at the fascia level over the plates. The fascia
and chest wall were then reapproximated. How
is this procedure coded?

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

0PH000Z Insertion of rigid plate internal

fixation device into sternum,
open approach, for the repair of
the sternum with insertion of the
Sternal Talon® device.

The objective of the procedure is to insert the

device to hold the sternum closed.

Question:
The patient had previously undergone
placement of autograft and homograft due to
full thickness burns and is now admitted for
failure of the previously placed autograft and
homograft. During surgery, the affected areas
were excised and debrided, a new homograft
was placed, and full thickness skin was
harvested for anticipated Polarity SkinTE™
grafting. During this admission, the patient
also underwent removal of the homograft,
debridement of the affected areas and
placement of full thickness Polarity SkinTE™
graft. What is the appropriate root operation
for application of the full thickness Polarity
SkinTE™ graft?

Answer:
Assign the appropriate code for the full-
thickness autologous tissue substitute,
with the root operation “Replacement,” for
the placement of the full thickness Polarity
SkinTE™ graft.

30 First Quarter 2020 Coding Clinic

 The excision of failed autograft and homograft,
followed by replacement with full thickness
Skin TE™ graft, support the root operation
“Replacement” - Putting in or on biological or
synthetic material that physically takes the
place and/or function of all or a portion of a
body part.

Question:
A morbidly obese man presented for surgical
repair of a buried penis. The patient underwent
escutcheonectomy. At surgery, the penis
was degloved to the suspensory ligament.
Escutcheonectomy was performed with
removal of excess suprapubic skin, fat and
tissue. Split-thickness skin graft was excised
from the right upper thigh. The graft was used
to cover the penis where it had been degloved.
What are the appropriate ICD-10-PCS codes
for surgical repair of a buried penis?

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

0JB80ZZ Excision of abdomen

subcutaneous tissue and fascia,
open approach, for the
escutcheonectomy

0VUS07Z Supplement penis with

autologous tissue substitute,
open approach, for the skin graft
to the penis; and

0HBHXZZ Excision of right upper leg skin,

external approach, for the split
thickness skin graft harvest from
the right thigh.

The split thickness skin graft to the penis is

coded to the root operation Supplement. If
the scrotal fat pad is also excised, it can be

Coding Clinic First Quarter 2020 31

 coded separately in table 0VB, Excision, male
reproductive system.

Question:
The patient is a 65-year-old man, who presents
with symptomatic persistent atrial fibrillation
(AF) despite medical therapy, and was
referred for redo ablation procedure. A hybrid
ablation convergent procedure was done, in
which the cardiologist performed a catheter-
based ablation in the electrophysiology (EP)
laboratory, and the cardiothoracic surgeon
performed an ablation via a thoracoscopic
(subxiphoid) approach. During the procedure,
the skin over the xiphoid was incised and
the fascia was divided. The xiphoid was
dissected until the pericardium was reached
and a window was created. The cannula was
inserted, as was the zero degree scope. The
ablation was started using end contact probe.
Overall, 26 ablation lines were created going
sequentially from the right side to the left side
as high up towards the roof at the pericardial
reflection as feasible.

The patient was transferred to the EP

laboratory and underwent targeted
ablation under fluoroscopic guidance with
electroanatomic mapping (EAM). Protamine
was then used to reverse anticoagulation and
the sheaths were pulled. How should a hybrid
ablation convergent procedure done via two
surgical approaches be coded?

Answer:
Assign the following procedure codes:

02584ZZ Destruction of conduction

mechanism, percutaneous
endoscopic approach, for the
ablation using the thoracoscopic
(subxiphoid) approach, and

32 First Quarter 2020 Coding Clinic

 02583ZZ Destruction of conduction
mechanism, percutaneous
approach, for the ablation
performed using a catheter-
based approach.

This type of procedure uses both surgical and

catheter based techniques to block conduction
mechanisms. Do not assign a separate code
for the EAM (electroanatomic mapping). The
EAM was done to assist in the performance of
the ablation procedure and is not a separate
diagnostic mapping.

Question:
A patient with progressive idiopathic
thoracolumbar scoliosis, spondylosis with
foraminal stenosis and rib cage deformity was
admitted for spinal fusion surgery. Through a
right thoracotomy approach, a right anterior
spinal fusion was performed with placement
of screws into the vertebral body and seating
of a rod cord at T5-T11. Significant correction
of the scoliosis curve was obtained across the
thoracic levels. The patient was repositioned
for exposure of the left side to complete left
anterior spinal fusion at T11-L4. Screws were
placed into the vertebral body and a rod cord
was secured across the levels with significant
correction of the scoliosis and derotation of
the lumbar segments. What are the code
assignments for this procedure?

Answer:
In ICD-10-PCS, this procedure is not classified
as a fusion, but rather as an anterior vertebral
tethering procedure. Reposition is the
appropriate root operation. Assign the following
ICD-10-PCS codes:

0PS404Z Reposition thoracic vertebra with

internal fixation device, open
approach; and

Coding Clinic First Quarter 2020 33

 0QS004Z Reposition lumbar vertebra with
internal fixation device, open
approach, for this case.

Notice
ICD-10-CM Official Coding Guidelines - Supplement
Coding Encounters Related to COVID-19 Coronavirus Outbreak
Effective: February 20, 2020

This following guidance is posted on the Centers for Disease Control

and Prevention’s National Center for Health Statistics website: https://
www.cdc.gov/nchs/data/icd/ICD-10-CM-Official-Coding-Gudance-
Interim-Advice-coronavirus-feb-20-2020.pdf

Introduction
The purpose of this document is to provide official diagnosis coding
guidance for health care encounters and deaths related to the 2019
novel coronavirus (COVID-19) previously named 2019-nCoV.

The COVID-19 caused an outbreak of respiratory illness, and was

first identified in 2019 in Wuhan, Hubei Province, China. Since then,
thousands of cases have been confirmed in China, and COVID-19
has also spread internationally, including in the United States.

Investigations are ongoing. The most recent situation updates are

available from the CDC web page, About 2019 Novel Coronavirus
(COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/index.html

The confirmed COVID-19 infections can cause a range of illness, from

little to no symptoms, to those affected being severely ill and even
dying. Symptoms can include fever, cough, and shortness of breath.
Symptoms may appear from 2 to 14 days after exposure, based on
the incubation period for other coronaviruses, such as the MERS
(Middle East Respiratory Syndrome) viruses. https://www.cdc.gov/
coronavirus/2019-ncov/about/symptoms.html

This guidance is intended to be used in conjunction with the current

ICD-10-CM classification and the ICD-10-CM Official Guidelines for
Coding and Reporting (effective October 1, 2019) and will be updated
to reflect new clinical information as it becomes available. https://www.
cdc.gov/nchs/data/icd/10cmguidelines-FY2020_final.pdf.

34 First Quarter 2020 Coding Clinic

The ICD-10-CM codes provided in this document are intended to pro-
vide information on the coding of encounters related to coronavirus.
Other codes for conditions unrelated to coronavirus may be required
to fully code these scenarios in accordance with the ICD-10-CM Offi-
cial Guidelines for Coding and Reporting. A hyphen is used at the end
of a code to indicate that additional characters are required.

General Guidance

Pneumonia
For a pneumonia case confirmed as due to the 2019 novel
coronavirus (COVID-19), assign codes J12.89, Other viral pneumonia,
and B97.29, Other coronavirus as the cause of diseases classified
elsewhere.

Acute Bronchitis
For a patient with acute bronchitis confirmed as due to COVID-19,
assign codes J20.8, Acute bronchitis due to other specified
organisms, and B97.29, Other coronavirus as the cause of diseases
classified elsewhere. Bronchitis not otherwise specified (NOS)
due to the COVID-19 should be coded using code J40, Bronchitis,
not specified as acute or chronic; along with code B97.29, Other
coronavirus as the cause of diseases classified elsewhere.

Lower Respiratory Infection

If the COVID-19 is documented as being associated with a lower
respiratory infection, not otherwise specified (NOS), or an acute
respiratory infection, NOS, this should be assigned with code J22,
Unspecified acute lower respiratory infection, with code B97.29,
Other coronavirus as the cause of diseases classified elsewhere. If
the COVID-19 is documented as being associated with a respiratory
infection, NOS, it would be appropriate to assign code J98.8, Other
specified respiratory disorders, with code B97.29, Other coronavirus
as the cause of diseases classified elsewhere.

ARDS
Acute respiratory distress syndrome (ARDS) may develop in with
the COVID-19, according to the Interim Clinical Guidance for
Management of Patients with Confirmed 2019 Novel Coronavirus
(COVID-19) Infection. https://www.cdc.gov/coronavirus/2019-ncov/
hcp/clinical-guidance-management-patients.html

Coding Clinic First Quarter 2020 35

Cases with ARDS due to COVID-19 should be assigned the codes
J80, Acute respiratory distress syndrome, and B97.29, Other
coronavirus as the cause of diseases classified elsewhere.

Exposure to COVID-19
For cases where there is a concern about a possible exposure
to COVID-19, but this is ruled out after evaluation, it would be
appropriate to assign the code Z03.818, Encounter for observation for
suspected exposure to other biological agents ruled out.

For cases where there is an actual exposure to someone who is

confirmed to have COVID-19, it would be appropriate to assign the
code Z20.828, Contact with and (suspected) exposure to other viral
communicable diseases.

Signs and Symptoms

For patients presenting with any signs/symptoms (such as fever, etc.)
and where a definitive diagnosis has not been established, assign the
appropriate code(s) for each of the presenting signs and symptoms
such as:

• R05 Cough
• R06.02 Shortness of breath
• R50.9 Fever, unspecified

Note: Diagnosis code B34.2, Coronavirus infection, unspecified,

would in generally not be appropriate for the COVID-19, because the
cases have universally been respiratory in nature, so the site would
not be “unspecified.”

If the provider documents “suspected”, “possible” or “probable”

COVID-19, do not assign code B97.29. Assign a code(s) explaining
the reason for encounter (such as fever, or Z20.828).

This coding guidance has been developed by CDC and approved

by the four organizations that make up the Cooperating Parties: the
National Center for Health Statistics, the American Health Information
Management Association, the American Hospital Association, and the
Centers for Medicare & Medicaid Services.

Reference
COVID-10 clinical presentation:
https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html

36 First Quarter 2020 Coding Clinic

 Clarification
Cytokine Release Syndrome

There has been some confusion regarding

advice published in Coding Clinic, Second
Quarter 2019 page 24, for cytokine release
syndrome (CRS). The advice states to assign
code E88.3, Tumor lysis syndrome, for CRS.
However, code assignment for CRS may not
be the same in every case, as some patients
may not present with tumor lysis syndrome.
Therefore, code assignment for CRS would
be based on the specific manifestations
documented by the provider. As previously
stated, this advice is supported by the guideline
stating in the absence of Alphabetic Index
guidance, assign codes for the documented
manifestations of the syndrome. Additional
codes for manifestations that are not an integral
part of the disease process may also be
reported when the condition does not have a
unique code.

Correction Notice
Bypass of Ascending Aorta to
Brachiocephalic Artery

Coding Clinic, Third Quarter 2019, pages 30-

31, contained an omission. A new qualifier
value Innominate Artery was added to ICD-
10-PCS table 021, Bypass, heart and great
vessels, for fiscal year 2020. The Third Quarter
issue became effective October 1, 2019;
therefore, code 021X0JA, Bypass thoracic
aorta, ascending/arch to innominate artery with
synthetic substitute, open approach, would be
assigned, for the bypass of the ascending aorta
to the brachiocephalic artery rather than code
021X0JB.

Coding Clinic First Quarter 2020 37

 Non-Traumatic Long Head of Biceps
Tendon Tear

Coding Clinic, Second Quarter 2019, page 27,

advised the assignment of code S46.11-, Strain
of muscle, fascia and tendon of long head
of biceps, for a non-traumatic biceps tendon
tear. The description of the tear, “long head
of biceps” was inadvertently omitted from the
question.

38 First Quarter 2020 Coding Clinic