today i'm going to talk about chapter 6 guidelines for the codebook. there were no changes to chapter six in 2017 so you can use those guidelines directly in front of the chapter in your code book
icd 9 code lung cancer, when you're doing your homework. the first guideline has to do with dominance, whether a patient's dominant and non-dominant side is affected by the
hemiplegia. in this scenario, a right spastic hemiplegia is documented, unknown whether the patient is right or left hand dominant so our guidelines tell us should the affected side be documented but not specified as dominant or non dominant, you're going to follow this classification system. if the right side is affected, the default is dominant. that
tells us that the fifth character in our code would be "1" indicating right side dominance. in the next guideline, hemiplegia affecting the left side of an ambidextrous patient, the guidelines tell us for ambidextrous patients, the default should be dominant. what that means is that if they're ambidextrous, both sides are equally strong so whatever side is
affected, in this case the left side, we're going to say the left side is dominant. now, let's talk about general coding information in this next coding guideline. we can use codes in category g89 along with codes from other categories and other chapters if the g89 code provides more detail. for example, if the scenario given to us does not
tell us if the pain is acute or chronic and we have g89 codes that say so,then we would use those g89 codes. if the pain in your documentation is not specified as acute or chronic, not specified as post-thoracotomy, post-procedural or neoplasm-related, we do not assign codes from category g89. it has to
have those terms in order for us to use that category. also, a code from category g89 should not be assigned if the underlying diagnosis is known unless the reason for the encounter is pain control. we will go over a few examples of that and get into more detail. a little more coding information, if an admission is for a procedure aimed at
treating the underlying condition, the underlying condition is the principal diagnosis, not a code from g89. oftentimes, pain is integral to any procedure or surgery so unless the physician has documented that the pain is in excess of what one would expect, we would not very often code pain. so you really have to pay attention to
documentation. here's an example of when we could use g89 category codes as our principal (diagnosis). patient presents for steroid injection for control of pain of a chronic right knee due to primary degenerative joint disease (also abbreviated djd. when you look up djd in the index, it takes you to "osteoarthritis" so you can go to osteoarthritis when you see
that medical term djd. in this case, though the patient's presenting for control of pain, not for treatment of a djd so the g89 code would be the principal (diagnosis) because the patient's presenting for control of the pain. if you think about a lot of guidelines, it really is "what is the encounter or is the admission for?" depending upon where
your treatment is directed, it's going to help you determine what the principal diagnosis should be. the guidelines help you with that as well but if you can just keep that in mind. (the question is) where is the treatment directed? it helps you really decide what the principal diagnosis should be. in this scenario, the patient is seen to evaluate chronic left
shoulder pain. you're evaluating the pain. what the guidelines tell it is a g89 would be used in conjunction with codes that identify the site of pain if a category code provides more information. so even though the patient is being seen to evaluate the pain, that pain in the shoulder is going to be the principal diagnosis but the pain in the
shoulder does not tell the doctor or the reader if the pain is acute or chronic and because we have a chronic pain code for specified sites, we would use it in this example. g89.29 we're using that g89 category code because it provides additional information. when you are looking at the sequencing of codes with site-specific pain codes,
again, it depends on what you're being seen for. this is telling us the patient is seen for management of acute traumatic right knee pain. the patient's being seen not to treat the knee, but to manage the pain, so the pain code, acute pain due to trauma, would be the principal diagnosis and a pain in the joint (code) would also be there to identify
the site. the coding guidelines tell us how we would sequence those codes. assign the code for category g89 followed by the code identifying the specific site of pain. here's another example. tests are performed to investigate the source of the patient's chronic epigastric abdominal pain. the pain is being investigated but because we don't know a diagnosis, we
would code the symptoms from chapter 18 in our code book. there is a code for upper epigastric abdominal pain (r10.13). we would also add the g89 code because that tells the doctor and the reader that the pain is chronic. now, some general information about post-operative pain. the provider's documentation should be used to guide
the coding of post-op pain as well as information contained in your code book in section iii and section iv. please take the time to go there. read the guidelines, those at the beginning of the code book or in the case of our 2017 codebook, we would go to the beginning of the pdf or the word document that you're using and read through those times when we
would report additional diagnoses or when we're reporting in the outpatient setting. as i mentioned earlier, pain is associated with a procedure most of the time but we still have to be cognizant of the fact that there are times when we would want to code it. the default for post -thoracotomy and other post-op pain not identified as acute or chronic is to use
the acute form of pain, not the chronic form of pain. routine or expected post-op pain immediately after surgery should not be coded. here's an example. patient's pain pump, the dosage is increased for unexpected extreme pain post-thoracotomy. there is a pain code for post-thoracotomy and the default, because we're not saying if it's
acute or chronic in the scenario, we would code it. i can't imagine how much that hurts because you're actually going through the patient's chest, often going through the ribs, so it would have quite a bit of pain associated with a thoracotomy. that's why there is a unique code for it. i bring this slide to your attention just to point out that chronic pain and chronic
pain syndrome (central pain syndrome) those are different things so be very careful in your reading of documentation that you are picking up the right term with regards to chronic pain. there's no time frame with that. there's no definition of, if your pain's lasted more than a year, it is now classified as chronic.... there's no documentation and no
guidelines around that. so you're just going to depend on your provider's documentation to guide your use of the code for chronic pain. chronic pain syndrome g89.4 and central pain syndromes g89.0 are different than the term chronic pain so if your documentation states those things, you would be looking specifically for those
diagnoses and not a chronic pain diagnosis. it also refers us to chapter 5 in the guidelines in the codebook for pain disorders related to psychological factors. sometimes chronic pain is believed to be related to psychological factors where you would be adding that f45.42 code. now let's talk about pain related to
malignancies or neoplasms. code g89.3 is a code that specifically states pain due to cancer, pain due to malignancy. it doesn't matter if the pain is acute or chronic in those cases. if it's related to malignancy, you're just going to add it to document the patient does have pain related to the malignancy. if the pain related to the malignancy is a
reason why the patient is being treated, that would be your principal diagnosis and the cancer diagnosis would be reported as an additional code. if the reason for the admission was to manage the neoplasm, but the patient has pain associated with the neoplasm, that code g89.3 would be assigned but it would not be the principal (diagnosis). the principal diagnosis would be
the code for the cancer. you see, in italics, it refers us back to the neoplasm chapter, chapter 2 in the code book to review those guidelines as well. here's an example. patient is admitted for pain medication adjustment for chronic pain from bone metastasis. the admission is for the pain due to the malignancy so that would be your principal
diagnosis (g89.3). we would assign the bone cancer, which if it's a metastasis, it's a secondary malignant code so going to the table of neoplasms, you would see "bone" and then the column that says secondary malignant and that would be c79.51 would be your additional code or your secondary code. notice again that the
reason for the encounter or admission is what determines your principal diagnosis. in this example, the patient with lung cancer presents with acute hip pain evaluated and found to have iliac bone metastases. the pain is being evaluated but really, it's the cancer that's driving the admission so the secondary malignant bone
would be your principal diagnosis, followed by the primary malignancy code, and then the pain due to malignancy. if you remember from a previous guideline, it doesn't matter if it's acute or chronic, if it's pain related to malignancy, you just state the g89.3 code. if you have any questions about the chapter 6 guidelines, please post them in the discussion board. as with all
of these podcasts, i encourage you to watch them more than once because i'm hoping by hearing them, you will be reminded when you're doing homework that there is a guideline related to those things. also, as a reminder, i don't cover all the guidelines in the podcast. they would simply be too long but i am hitting on those that we would find
most often in acute care. thank you so much. have a nice evening.
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