A quarterly publication of the

Central Office on ICD-10-CM/PCS

Volume 10 First Quarter
Number 1 2023

Announcement Problems Related to Education

Guideline Revision for and Health Literacy and
Encounters for COVID 19 Physical Environment 6
Screening 14
New/Revised ICD-10-PCS Codes
In This Issue Laser Interstitial Thermal
April 1, 2023 Code Update Therapy 10
Changes to the ICD-10-CM Temporary Balloon Occlusion
Official Guidelines for of Aorta 9
Coding and Reporting 8
Section 3 – Administration
New/Revised ICD-10-CM Codes Intraosseous Administration
Adult and Child Financial Abuse, of Blood Products 10
Confirmed and Suspected 4
Perpetrator of Maltreatment Section X – New Technology
and Neglect 5 Introduction of New Therapeutic
Substances 11
Z Code Update REGN-COV2 Monoclonal
Other Problems Related to Antibody 12
Inadequate Housing 6 Sabizabulin 12
Patient’s Other Noncompliance Transfusion of New Therapeutic
with Medical Treatment and Substances 12
Regimen 7 Exagamglogene Autotemcel 12
Personal History of Abuse in
Childhood 6 Ask the Editor
Personal History of Adult Acute Blood Loss Anemia
Financial Abuse and Adult due to Angioectasia and
Intimate Partner Abuse 7 Gastric Ulcer 16
Personal History of Child Bilateral Traumatic Amputation
Financial Abuse and Intimate with Stage 1 Placement of
Partner Abuse in Childhood 6 OPRA Device 27

New code assignments contained in this issue effective with

discharges April 1, 2023. Other coding advice or code assignments
contained in this issue effective March 3, 2023.
Carotid Artery Endarterectomy Removal of Autologous Bone
with Imbrication 35 Flap due to Bone Resorption 30
Carotid Artery Pseudoaneurysm Removal of S2-Alar-Iliac Screws 33
Embolization Using Flow Repair of Stage 4 Pressure Ulcer
Diverter Stent and Coils 34 and Application of Amniofill® 34
Diffuse Large B Cell Lymphoma Rotational Vertebral Artery
with Metastasis 22 Syndrome/Mechanical
End-Stage Renal Disease and Vertebral Arteriopathy 36
Fluid Overload 19 Small Cell Lung Cancer with
Erosive Esophagitis with Neuroendocrine Features 21
Bleeding 20 Small Lymphocytic Lymphoma/
Ex-Vivo Liver Tumor Resection Chronic Lymphocytic
and Autotransplantation 38 Leukemia 18
Gastrointestinal Bleeding and Spontaneous Abortion and
Acute Blood Loss Anemia 15 Reporting Obstetric Codes
Intrahepatic Cholestasis of for Chronic Conditions 17
Pregnancy 26 Stage 4 Chronic Kidney Disease
Large Cell Neuroendocrine Documented as CKD G4A3 17
Lung Cancer 20 Stage 2 Placement of OPRA
Maggot Therapy 36 Device 29
Pancytopenia due to Acute Tracheocutaneous Fistula
Myeloid Leukemia 23 Status Post Tracheostomy 30
Pelvic Floor Dyssynergia 24 Zenker’s Diverticulectomy 32
Possible Hepatic
Cholangiocarcinoma 24 Correction Notices
Preload Insufficiency 25 Chronic Kidney Disease Stage 3 39
Pulmonary Edema due to Near Underdosing of Amlodipine 39
Drowning 25

2 First Quarter 2023 Coding Clinic

Coding Clinic for Medical Advisors, Centers for Melissa Koehler, DHA, MBA,
Medicare & Medicaid Services RHIA, CHDA, CCS, CCS-P,
ICD•10•CM/PCS CCDS, CRCR
Published quarterly by the Perry Alexion, M.D.
Edith Hambrick, M.D. Director, HB Coding Operations
American Hospital Association
Karen Nakano, M.D. & Quality, Inova Health System,
Central Office on
Falls Church, VA
ICD-10-CM/PCS Editorial Advisory Board
155 N. Wacker Drive Donna Ganzer, Chairman Edward A. Liechty, M.D.
Chicago, IL 60606. President, Ganzer Network Representative, Amer. Academy
Corporation, Great Neck, NY of Pediatrics, Indianapolis, IN
ISSN 0742-9800
Mary Bowlan, RHIA, CDIP, Jeffrey F. Linzer, M.D., FAAP
Coding Clinic for CCS Representative, Amer. Academy
ICD-10-CM/PCS Regulatory Audit Manager of Pediatrics, Atlanta, GA
Online subscription information University of Arkansas for
Lee R. Morisy, M.D., FACS
can be found at www. Medical Sciences
Representative, Amer. College
codingclinicadvisor.com Little Rock, AR
of Surgeons, Memphis, TN
Click Help Center then
Sue Bowman, MJ, RHIA,
subscriptions for more Bernard Pfeifer, M.D.
CCS, FAHIMA
information. Representative for American
Senior Director, Coding Policy and
Medical Assn., Harwich, MA
Executive Editor Compliance, American Health
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Director, Central Office on Association, Chicago Chief, Classifications and
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Jonathan Gal, M.D., FASA
Centers for Disease Control &
Mount Sinai Health System
Tammy Love, RHIA, CCS, Prevention, Hyattsville, MD
New York, NY
CDIP, Director, Coding
Classification, Policy Evan Pollack, M.D., FACP
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Representative for Amer. College
Technical Advisor, Technology,
Editorial Staff, AHA Central of Physicians, Bryn Mawr, PA
Coding and Pricing Group
Office on ICD-10-CM/PCS Centers for Medicare & Melissa G. Roberts, MHA, RHIT
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Karen Ayala, RHIT
Coding Specialist Centura Health, Centennial, CO

Kristina Cool, RHIA, CCS Subscriptions? Questions? Problems?

Coding Consultant Call 312-422-3366
Toni Hershey, RHIA, CCS Individual answers within AHA Coding Clinic® are available for repro-
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guidelines and advice as designated by the four cooperating parties. The
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cooperating parties listed below have final approval of the coding advice
Halima Zayyad-Matarieh, RHIA provided in this publication: American Hospital Association, American
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Coding Clinic First Quarter 2023 3
 New ICD-10-CM Codes
A summary of changes to ICD-10-CM effective April 1, 2023, are
provided below. Addenda changes demonstrating the specific
revisions to the code titles or instructional notes are not included in
the explanations below. The official ICD-10-CM addenda has been
posted on the Centers for Disease Control and Prevention (CDC)
National Center for Health Statistics (NCHS) website at: https://www.
cdc.gov/nchs/icd/comprehensive-listing-of-icd-10-cm-files.htm

Health-related social needs (HRSNs) are defined as individual level,

adverse social conditions that negatively impact a person’s health and
are significant risk factors associated with worse health outcomes and
increased healthcare utilization. In an effort to enhance the ability to
collect data related to HRSNs, the CDC/NCHS has implemented 42
new diagnosis codes into the International Classification of Diseases,
Tenth Revision, Clinical Modification (ICD-10-CM) for reporting,
effective April 1, 2023.

Adult and Child Abuse, Neglect and Other

Maltreatment, Confirmed and Suspected

Category T74, Adult and child abuse, and other maltreatment,

confirmed, has been expanded with new codes to identify confirmed
and suspected adult and child financial abuse, along with the 7th
character extensions for initial encounter, subsequent encounter and
sequela as follows:

• T74.A1X- Adult financial abuse, confirmed

• T74.A2X- Child financial abuse, confirmed
• T76.A1X- Adult financial abuse, suspected
• T76.A2X- Child financial abuse, suspected

4 First Quarter 2023 Coding Clinic

 Perpetrator of Maltreatment and Neglect

Subcategory Y07.0, Spouse or partner, perpetrator of maltreatment

and neglect, has been expanded and new codes are created to
further describe perpetrators of maltreatment and neglect, as follows:

• Y07.010 Husband, current, perpetrator of

maltreatment and neglect
• Y07.011 Husband, former, perpetrator of
maltreatment and neglect
• Y07.020 Wife, current, perpetrator of maltreatment
and neglect
• Y07.021 Wife, former, perpetrator of maltreatment
and neglect
• Y07.030 Male partner, current, perpetrator of
maltreatment and neglect
• Y07.031 Male partner, former, perpetrator of
maltreatment and neglect
• Y07.040 Female partner, current, perpetrator of
maltreatment and neglect
• Y07.041 Female partner, former, perpetrator of
maltreatment and neglect
• Y07.050 Non-binary partner, current, perpetrator of
maltreatment and neglect
• Y07.051 Non-binary partner, former, perpetrator of
maltreatment and neglect
• Y07.44 Child, perpetrator of maltreatment and
neglect
• Y07.45 Grandchild, perpetrator of maltreatment and
neglect
• Y07.46 Grandparent, perpetrator of maltreatment
and neglect
• Y07.47 Parental sibling, perpetrator of maltreatment
and neglect
• Y07.54 Acquaintance or friend, perpetrator of
maltreatment and neglect

Coding Clinic First Quarter 2023 5

 Z Code Update
Problems Related to Education and Health Literacy and Physical
Environment
A new code Z55.6, Problems related to health literacy, has been
created to provide additional information regarding risks related to
health literacy.

Category Z58, Problems related to physical environment, has been

expanded with new codes to describe basic services unavailable
in physical environment and other problems related to physical
environment as follows:

• Z58.81 Basic services unavailable in physical

environment
• Z58.89 Other problems related to physical
environment

Other Problems Related to Housing and Economic

Circumstances
Code Z59.1, Inadequate housing, has been expanded with new codes
to describe inadequate housing as follows:

• Z59.10 Inadequate housing, unspecified

• Z59.11 Inadequate housing environmental
temperature
• Z59.12 Inadequate housing utilities
• Z59.19 Other inadequate housing

Personal History of Abuse in Childhood

Subcategory Z62.81, Personal history of abuse in childhood, has
been expanded and two new personal history codes have been
created to describe child financial abuse and intimate partner abuse in
childhood as follows:

• Z62.814 Personal history of child financial abuse

• Z62.815 Personal history of intimate partner abuse in
childhood

6 First Quarter 2023 Coding Clinic

Patient’s Other Noncompliance with Medical Treatment and
Regimen
Subcategory Z91.1, Patient’s noncompliance with medical treatment
and regimen, has been expanded and new codes created to identify
other noncompliance with medication and renal dialysis due to
financial hardship or for other reason as follows:

• Z91.141 Patient’s other noncompliance with

medication regimen due to financial
hardship
• Z91.148 Patient’s other noncompliance with
medication regimen for other reason
• Z91.151 Patient’s noncompliance with renal dialysis
due to financial hardship
• Z91.158 Patient’s noncompliance with renal dialysis
for other reason

Personal History of Psychological Trauma, Not Elsewhere

Classified
Subcategory Z91.4, Personal history of psychological trauma, not
elsewhere classified, has been expanded with new codes to describe
personal history of adult financial abuse and adult intimate partner
abuse as follows:

• Z91.413 Personal history of adult financial abuse

• Z91.414 Personal history of adult intimate partner
abuse

Coding Clinic First Quarter 2023 7

 ICD-10-CM Official Guidelines
for Coding and Reporting
FY 2023 -- Updated April 1, 2023
(October 1, 2022 - September 30, 2023)
A summary of the modifications to the ICD-10-CM Official Guidelines
for Coding and Reporting are included below. Narrative changes
appear in bold text. The complete guidelines may be downloaded by
visiting: https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/
ICD10CM/April-1-2023-Update/ICD-10-CM-Guidelines-April%20
1,%20FY2023.pdf

C. Chapter Specific Coding Guidelines…

Chapter 21: Factors influencing health status and contact
with health services (Z00-Z99)…
c. Categories of Z Codes
17) Social Determinants of Health
Social determinants of health (SDOH) codes describing
social problems, conditions, or risk factors that
influence a patient’s health should be assigned when
this information is documented in the patient’s medical
record. Assign as many SDOH codes as are necessary
to describe all of the social problems, conditions, or risk
factors documented during the current episode of care.
For example, a patient who lives alone may suffer
an acute injury temporarily impacting their ability
to perform routine activities of daily living. When
documented as such, this would support assignment
of code Z60.2, Problems related to living alone.
However, merely living alone, without documentation
of a risk or unmet need for assistance at home, would
not support assignment of code Z60.2. Documentation
by a clinician (or patient-reported information that is
signed off by a clinician) that the patient expressed
concerns with access and availability of food would
support assignment of code Z59.41, Food insecurity.
Similarly, medical record documentation indicating the
patient is homeless would support assignment of a
code from subcategory Z59.0-, Homelessness.

8 First Quarter 2023 Coding Clinic

 New ICD-10-PCS Codes
A summary of the ICD-10-PCS changes effective April 1, 2023 is
provided below. The addenda changes demonstrating the specific
revisions to the code titles are not included in the explanations below.
The complete list of ICD-10-PCS code titles, code tables, Index,
Addenda, and a Conversion Table are available on the Centers for
Medicare & Medicaid Services (CMS) website at https://www.cms.gov/
medicare/icd-10/2023-icd-10-pcs.

There are 34 new ICD-10-PCS codes. There are not any revised code
titles or deleted codes.

Section 0 – Medical and Surgical

Temporary Balloon Occlusion of Aorta

At table 02L, Occlusion of Heart and Great Vessels, approach value,

0 Open, was added to body part W Thoracic Aorta, Descending, to
report temporary open balloon occlusions of the descending thoracic
aorta.

Body Part Approach Device Qualifier

W Thoracic 0 Open D Intraluminal J Temporary
Aorta, 3 Percutaneous Device
Descending

At table 04L, Occlusion of Lower Arteries, approach value 0 Open,

was added to body part 0 Abdominal Aorta to report temporary open
balloon occlusions of the abdominal aorta.

Body Part Approach Device Qualifier

0 Abdominal 0 Open D Intraluminal J Temporary
Aorta 3 Percutaneous Device

These changes will allow the reporting of resuscitative endovascular

balloon occlusion of the aorta (REBOA) when performed via an open
approach to temporarily stop blood flow in the aorta as an adjunctive
therapeutic measure. The primary procedure is coded separately. See
Coding Clinic, Fourth Quarter 2017, page 31, for more information.

Coding Clinic First Quarter 2023 9

 Laser Interstitial Thermal Therapy

At table 0P5, Destruction of Upper Bones, qualifier value 3 Laser

Interstitial Thermal Therapy was added to body part values 3 Cervical
Vertebra and 4 Thoracic Vertebra. The change will enable reporting
of laser interstitial thermal therapy (LITT) of the cervical and thoracic
vertebrae.

Body Part Approach Device Qualifier

3 Cervical 0 Open Z No Device 3 Laser Interstitial
Vertebra 3 Percutaneous Thermal Therapy
4 Thoracic 4 Percutaneous Z No Qualifier
Vertebra Endoscopic

In table 0Q5, Destruction of Lower Bones, qualifier value 3 Laser

Interstitial Thermal Therapy was added to body part values 0 Lumbar
Vertebra and 1 Sacrum to report LITT that is performed on the lumbar
and sacral spine. See Coding Clinic, Fourth Quarter 2022, pages 53-
54, for more information.

Body Part Approach Device Qualifier

0 Lumbar 0 Open Z No 3 Laser Interstitial
Vertebra 3 Percutaneous Device Thermal Therapy
1 Sacrum 4 Percutaneous Z No Qualifier
Endoscopic

Section 3 – Administration

Intraosseous Administration of Blood Products

In the Administration Section, table 302, Transfusion of Circulatory

Body System, the body system/region value A Bone Marrow was
added to the approach value 3 to report transfusion of autologous and
nonautologous blood and substances of the blood. This change will
enable the reporting of intraosseous administration of blood products.

10 First Quarter 2023 Coding Clinic

Body System/ Approach Substance Qualifier
Region
A Bone Marrow 3 Percutaneous H Whole Blood 0 Autologous
J Serum 1
Albumin Nonautologous
K Frozen
Plasma
L Fresh
Plasma
N Red Blood
Cells
P Frozen Red
Cells
R Platelets

Question:
A patient in critical care was administered
fluids and nonautologous whole blood through
bilateral tibial intraosseous lines. What is
the ICD-10-PCS code for blood products
administered through an intraosseous line?

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

302A3H1 Transfusion of nonautologous

whole blood into bone marrow,
percutaneous approach, twice
for the blood infused through
the intraosseous lines.

Section X – New Technology

Introduction of New Therapeutic Substances

In Section X, New Technology, table XW0, Introduction of Anatomical

Regions, value G REGN-COV2 Monoclonal Antibody, was added to
body part 1 Subcutaneous Tissue, to identify the administration of the
combination of 2 monoclonal antibodies, carsirivimab and imdevimab
to treat COVID-19.

Coding Clinic First Quarter 2023 11

Body Part Approach Device/ Qualifier
Substance/
Technology
1 3 Percutaneous G REGN-COV2 6 New
Subcutaneous Monoclonal Technology
Tissue Antibody Group 6

The Substance K Sabizabulin was added to table XW0, Introduction of

Anatomical Regions, at body parts D Mouth and Pharynx, G Upper GI
and H Lower GI to capture administration of sabizabulin, an antiviral/
anti-inflammatory therapeutic that may be used to treat COVID-19.

Body Part Approach Device/ Qualifier

Substance/
Technology
D Mouth and X External K Sabizabulin 8 New
Pharynx Technology
Group 8
G Upper GI 7 Via Natural K Sabizabulin 8 New
H Lower GI or Artificial Technology
Opening Group 8

Transfusion of New Therapeutic Substances

In Section X, New Technology, table XW1, Transfusion of Anatomical

Regions, New Technology value J Exagamglogene Autotemcel was
added to body parts 3 Peripheral Vein and 4 Central Vein, to capture
the intravenous administration of exagamglogene autotemcel (exa-
cel), an autologous ex vivo gene-edited biological product that is
used to increase fetal hemoglobin (HbF) in patients with transfusion-
dependent beta thalassemia (TDT) and severe sickle cell disease
(SCD). HbF is a fetal form of oxygen-carrying hemoglobin that
decreases during infancy but transports oxygen more efficiently than
adult hemoglobin.

First, the patient’s hematopoietic stem cells are harvested from the
blood. Exa-cel is then used to edit the stem cells to produce high
levels of HbF in the red blood cells. The edited cells are transfused
back into the patient via an autologous stem cell transplant through
a central venous catheter. Exa-cel reduces the β globin damage that
occurs in TDT and SCD. The need for red blood cell transfusions

12 First Quarter 2023 Coding Clinic

may be reduced or eliminated in patients with a reduction in severe
vasocclusive episodes due to the increase in total hemoglobin levels.

Body Part Approach Device/ Qualifier

Substance/
Technology
3 Peripheral 3 Percutaneous J Exagamglogene 8 New
Vein Autotemcel Technology
4 Central Vein Group 8

Coding Clinic First Quarter 2023 13

 Announcement
As a result of the COVID-19 Public Health Emergency ending on
May 11, 2023, the FY24 ICD-10-CM Official Guidelines for Coding
and Reporting will be revised to state that code Z11.52, Encounter
for screening for COVID-19, should be assigned for encounters for
screening for COVID-19 infection. This guideline change will become
effective October 1, 2023.

14 First Quarter 2023 Coding Clinic

 Ask the Editor
Question:
A patient was admitted for treatment of
acute blood loss anemia (ABLA) due to
gastrointestinal (GI) bleeding, likely caused
by chronic nonsteroidal anti-inflammatory
drug (NSAID) use. Two units of packed
red blood cells were transfused. An upper
endoscopy revealed non-bleeding gastric
ulcers. The provider’s final diagnostic
statement listed, “Acute blood loss anemia
due to gastrointestinal bleeding.” Since both
anemia and GI bleeding were responsible
for the admission, would they be considered
interrelated and either condition selected as the
principal diagnosis?

Answer:
It would be appropriate to sequence either
the anemia or the GI bleeding as principal
diagnosis. When both anemia and GI
bleeding are present on admission and meet
the definition of principal diagnosis, either
condition may be sequenced first. The Official
Guidelines for Coding and Reporting, Section
II. B., states, “When there are two or more
interrelated conditions (such as diseases in the
same ICD-10-CM chapter or manifestations
characteristically associated with a certain
disease) potentially meeting the definition of
principal diagnosis, either condition may be
sequenced first, unless the circumstances

Coding Clinic First Quarter 2023 15

 of the admission, the therapy provided, the
Tabular List, or the Alphabetical Index indicate
otherwise.” If, however, one of the conditions is
clearly documented as causing the admission,
then that condition should be designated as the
principal diagnosis.”

Question:
A patient with acute blood loss anemia was
admitted to rule-out gastrointestinal (GI) bleed.
Two units of packed red blood cells were
transfused. An upper endoscopy revealed
oozing from a duodenal angioectasia as well
as from an acute gastric ulcer. Cauterization
of both the ulcer and angioectasia was done
using argon plasma coagulation (APC). Since
both anemia and the bleeding conditions were
responsible for the admission, would they be
considered interrelated and either condition
selected as the principal diagnosis?

Answer:
In this case, the primary focus of the
admission was to diagnose and treat the
bleeding conditions (i.e., angioectasia and
gastric ulcer), which were responsible for the
anemia. Therefore, sequence either code
K25.0, Acute gastric ulcer with hemorrhage,
or code K31.811, Angiodysplasia of stomach
and duodenum with bleeding, as the principal
diagnosis. When there are two or more
interrelated conditions potentially meeting
the definition of principal diagnosis, either
condition may be sequenced first, unless the
circumstances of the admission, the therapy
provided, the Tabular List, or the Alphabetical
Index indicate otherwise.

16 First Quarter 2023 Coding Clinic

 Question:
A patient presented due to spontaneous
incomplete abortion. This patient also had a
history of asthma, which was evaluated and
treated during the admission. An ultrasound
revealed a 10- to 12-week uterus, and a
suction dilation and curettage procedure was
performed. Would asthma be considered a
pregnancy complication that would require an
obstetric code from Chapter 15?

Answer:
No. An obstetric code from Chapter 15 is not
appropriate because the patient is no longer
pregnant. Assign code O03.4, Incomplete
spontaneous abortion without complication,
for the incomplete spontaneous abortion.
Also, assign a specific code for the asthma. If
a specific type of asthma is not documented,
assign code J45.909, Unspecified asthma,
uncomplicated, as an additional diagnosis.

The Official Guidelines for Coding and

Reporting for complications leading to abortion
(I.C.15.Q.3) states that codes from Chapter 15
may be used as additional codes to identify any
documented complications of the pregnancy
in conjunction with codes in categories in O04,
Complications following (induced) termination of
pregnancy, O07, Failed attempted termination
of pregnancy, and O08, Complications following
ectopic and molar pregnancy. This guidance
does not apply to codes from Category O03,
Spontaneous abortion.

Question:
A patient presents due to chronic kidney
disease with acute kidney injury and bladder
mass. The nephrologist documented “CKD
G4A3” with an estimated glomerular filtration
rate of 25 (eGRF25). Is the provider’s
documentation of CKD G4A3 sufficient to
assign a code for stage 4 chronic kidney disease?

Coding Clinic First Quarter 2023 17

 Answer:
Yes. Assign code N18.4, Chronic kidney
disease, stage 4 (severe), for a diagnosis of
CKD G4A3. The provider’s documentation of
CKD G4A3 is synonymous with stage 4 chronic
kidney disease (CKD). This new categorization
of CKD is referred to as CGA staging, and is
based on the cause (C), glomerular filtration
rate (G) and albuminuria (A). CGA provides
a more detailed description of the patient’s
CKD, and the number following ‘G’ describes
the stage. Refer to the following link for further
information about the CGA classification:
http://ckdpathway.ca/Content/pdfs/
Classification_of_CKD.pdf

Question:
A patient with small lymphocytic lymphoma
(SLL)/chronic lymphocytic leukemia (CLL) in
relapse presents to his primary care physician
for follow-up. The provider documented, “No
lymph node involvement.” Would the physician
need to document CLL with SLL of “B-cell type”
in order to assign a code from subcategory
C91.1, Chronic lymphocytic leukemia of B-cell
type, or does the classification presume
“B-cell type” when SLL/CLL is documented
in the health record? Additionally, there
are mutually exclusive Excludes1 notes at
both subcategories C83.0, Small cell B-cell
lymphoma, and C91.1, Chronic lymphocytic
leukemia of B-cell type. What is the correct
ICD-10-CM code assignment for SLL/CLL?

Answer:
ICD-10-CM does not provide a default code
for SLL/CLL. Code assignment depends on
provider documentation whether the cancer
cells are predominantly in the blood and bone
marrow or predominantly in the lymph nodes.
In this case, assign code C91.12, Chronic

18 First Quarter 2023 Coding Clinic

 lymphocytic leukemia of B-cell type in relapse,
for the SLL/CLL since lymph nodes and
lymphoid tissue were not involved.

SLL/CLL is a slow growing lymphoid/

hematopoietic malignancy that affects B
cells. The difference between SLL and CLL
is where the cancer is located. In CLL, the
majority of B lymphocyte cancers cells are in
the bloodstream (i.e., leukemia). Conversely,
in SLL B lymphocyte cancers cells are found
predominantly in the lymph nodes and
lymphoid tissue (i.e., lymphoma). When there
is lymph node involvement, assign a code
from subcategory C83.0, Small cell B-cell
lymphoma, instead of a code from subcategory
C91.1. Query the provider for clarification if the
documentation is unclear.

Coupled together SLL and CLL is expressed

as SLL/CLL. The documentation of SLL/CLL
using a forward slash is the manner in which
the provider documented the condition, and
is not intended to indicate sequencing nor a
contrasting/ comparative diagnosis.

Question:
A patient with hypertension and end-stage renal
disease presents for emergent dialysis due to
fluid overload. The patient has been compliant
with dialysis. Which condition is sequenced as
the principal diagnosis, end-stage renal disease
or fluid overload?

Answer:
Assign code E87.70, Fluid overload,
unspecified, as the principal diagnosis. Fluid
overload is not inherent to end stage renal
disease (ESRD); it is a distinct problem and a
complication of the kidney disease. Typically,
patients in fluid overload who have ESRD are
treated with dialysis. Code E87.70 is assigned

Coding Clinic First Quarter 2023 19

 as the principal diagnosis since this is the
specific condition that required admission to
the hospital. The circumstances of inpatient
admission always govern selection of the
principal diagnosis.

Question:
A patient is diagnosed with hematemesis due
to Grade D erosive esophagitis. What is the
correct code assignment for erosive esophagitis
with bleeding?

Answer:
Assign code K22.11, Ulcer of esophagus with
bleeding, for erosive esophagitis with bleeding.
Code K22.11 may be located by referencing the
Index as follows:

Erosion
esophagus
with bleeding K22.11

Category K20, Esophagitis, has an Excludes1

note directing the coding professional to
subcategory K22.1-, Ulcer of esophagus, in
which “Erosion of esophagus” and “Ulcerative
esophagitis” are inclusion terms.

Question:
An 83-year-old male with known cancer of
the right lung with metastasis to the liver
presented with worsening dyspnea on exertion
and fatigue. The patient’s lung carcinoma
was described as poorly differentiated
with neuroendocrine differentiation, non-
small cell carcinoma favoring large cell with
neuroendocrine differentiation as well as large
cell neuroendocrine cancer. The Alphabetic
Index under Carcinoma, large cell/small cell,
leads to category C34, Malignant neoplasm of
bronchus and lung. However, the Index under

20 First Quarter 2023 Coding Clinic

 Carcinoma, neuroendocrine, instructs to see
also Tumor, neuroendocrine. What code is
assigned for the lung cancer in this case?

Answer:
Assign code C7A.1, Malignant poorly
differentiated neuroendocrine tumors, for the
large cell neuroendocrine carcinoma of the
right lung. Malignant poorly differentiated
neuroendocrine carcinoma, of any site is an
inclusion term under code C7A.1. Additionally,
assign code C7B.8, Other secondary
neuroendocrine tumors, for the metastasis to
the liver.

Question:
The patient was admitted for evaluation of a left
lingual lung mass. At discharge, the provider’s
final diagnosis listed, “Small cell lung cancer
(SCLC) with neuroendocrine features (NEF).”
Currently, ICD-10-CM classifies primary
malignant neoplasms of the lung to category
C34, Malignant neoplasm of bronchus and
lung. However, research indicates that SCLC
is a neuroendocrine tumor (category C7A).
Are malignant neoplasms with neuroendocrine
features considered synonymous with
neuroendocrine tumors? What is the
appropriate diagnosis code for SCLC with
neuroendocrine features?

Answer:
Assign code C7A.1, Malignant poorly
differentiated neuroendocrine tumors,
for the SCLC with NEF of the left lingula.
Documentation of small cell lung cancer
or SCLC with neuroendocrine features is
considered a neuroendocrine tumor.

SCLC is a common type of neuroendocrine

lung cancer. SCLC is one of the two major
types of lung cancer that is differentiated by

Coding Clinic First Quarter 2023 21

 the cell type in which the cancer starts. It
is appropriate to assign C7A.1 since SCLC
originates in neuroendocrine tumors within
the lung and a neuroendocrine carcinoma
described as small cell is considered poorly
differentiated.

Question:
The patient was recently diagnosed with
aggressive, diffuse large B-cell lymphoma
in multiple lymphatic sites involving lymph
nodes of the right hilum, right iliac and right
paracolic gutter areas as well metastasis to
the lung, brain and left adrenal gland. How
should we report metastatic sites in a patient
with lymphoma? Does the 5th character “9,”
“Extranodal and other solid organ sites” capture
metastatic sites outside of the lymphatic system
or should each non-hematopoietic metastatic
site be reported separately with codes
from categories C78, Secondary malignant
neoplasm of respiratory and digestive organs,
and/or C79, Secondary malignant neoplasm
of other and unspecified sites? What are the
appropriate codes for diffuse large B-cell
lymphoma involving lymph nodes of multiple
sites with metastases to the lung, brain and left
adrenal gland?

Answer:
Assign codes C83.38, Diffuse large B-cell
lymphoma, lymph nodes of multiple sites,
for diffuse large B-cell lymphoma in multiple
lymphatic sites. Assign code C83.39, Diffuse
large B-cell lymphoma, extranodal and solid
organ sites, for the metastases of B-cell
lymphoma to the lung, brain and left adrenal
gland. Code C83.39 captures metastasis to
sites outside of the lymph nodes and includes
solid organ sites.

22 First Quarter 2023 Coding Clinic

 Diffuse large B-cell lymphoma (DLBCL) is the
most common type of non-Hodgkin lymphoma
(NHL). DLBCL is an aggressive lymphoma
that affects B-lymphocytes, which are the
lymphocytes that make antibodies to fight
infection.

DLBCL can develop in the lymph nodes or in

extranodal sites, which are outside the lymph
nodes, such as gastrointestinal tract, thyroid,
skin, breast, bone, brain, essentially any organ
of the body. Stage IV non-Hodgkin lymphoma
is defined as spread to one or more tissues or
organs outside of the lymphatic system, such
as liver, lungs or bones and may be found in
lymph nodes proximal or distal to these organs.

Question:
A 56-year-old patient with refractory relapsed
acute myeloid leukemia (AML) presented to the
Emergency Department (ED) due to bleeding
gums. Labs were performed in the ED and
the patient was found to have pancytopenia
secondary to AML. The patient failed prior
therapies for AML and was not a candidate for
standard therapy due to comorbidities. She was
admitted for transfusion support only for her
pancytopenia. Does the Official Guidelines for
Coding and Reporting for anemia associated in
malignancy (I.C.2.c.1) apply for pancytopenia?
What is the appropriate principal diagnosis for
this patient?

Answer:
Assign code D61.818, Other pancytopenia, as
the principal diagnosis as that is the reason
for the admission. Assign code C92.02, Acute
myeloblastic leukemia, in relapse, as an
additional diagnosis. The Official Guideline for
Coding and Reporting for anemia associated
in malignancy (I.C.2.c.1) does not apply in this
scenario since pancytopenia encompasses
more than anemia.

Coding Clinic First Quarter 2023 23

 Question:
A patient with a history of constipation
presented for high resolution anorectal
manometry. The provider diagnosed pelvic
floor dyssynergia. In ICD-10-CM, there is no
Alphabetic Index entry for this condition. What
is the appropriate diagnosis code for pelvic floor
dyssynergia (PFD)?

Answer:
Assign code K59.02, Outlet dysfunction
constipation, for pelvic floor dyssynergia. PFD
is a type of anorectal dysfunction that can
cause constipation. This condition is sometimes
referred to as outlet type constipation or
anismus, and is captured with code K59.02.
In PFD, the muscles of the pelvic floor, which
underlay the surface of the bony pelvis, fail
to relax as needed to allow for defecation.
This can lead to some forms of constipation,
incomplete evacuation and straining with bowel
movements.

Question:
A patient is admitted with a liver mass and the
provider’s final diagnostic statement lists, “Liver
mass possibly hepatic cholangiocarcinoma,
pending pathology.” How is this diagnostic
statement coded in the inpatient setting?
Would it be appropriate to apply the Uncertain
Diagnosis Guideline and report the malignancy
for this admission?

Answer:
Assign code C22.1, Intrahepatic bile
duct carcinoma, for the possible hepatic
cholangiocarcinoma. In this case, the Official
Guidelines for Coding and Reporting, Section
II.H, would apply. If the diagnosis documented
at the time of discharge is qualified as
“probable,” “suspected,” “likely,” “questionable,”
“possible,” “still to be ruled out,” “compatible

24 First Quarter 2023 Coding Clinic

 with,” “consistent with,” or other similar terms
indicating uncertainty, code the condition as
if it existed or was established. The guideline
pertaining to uncertain diagnosis does not
make a distinction based on the type of disease
(i.e., malignancy or other condition).

Question:
During an outpatient encounter, a 66-year-old
male underwent an invasive cardiopulmonary
exercise test (iCPET). The test summary states,
“Evidence of cardiovascular limitation due to
preload insufficiency, which is most likely due
to occluded inferior vena cava (IVC).” A right
cardiac catheterization was performed, and
the provider diagnosed “preload insufficiency.”
What is the correct code assignment for
preload insufficiency?

Answer:
Assign code R94.39, Abnormal result of other
cardiovascular function study, for preload
insufficiency. Reference the Index to Diseases
as follows:

Findings, abnormal, inconclusive, without

diagnosis
stress test R94.39

According to the ICD-10-CM Official Guidelines

for Coding and Reporting for Outpatient
Services, it is inappropriate to assign codes for
uncertain diagnoses in the outpatient setting.
Therefore, a code would not be assigned for a
diagnosis of “most likely occluded IVC.”

Question:
A patient developed hypoxia due to acute
pulmonary edema following a near drowning in
the pool at his home. The patient was treated
with supplemental oxygen and noninvasive
ventilation (NIV). How is acute pulmonary

Coding Clinic First Quarter 2023 25

 edema due to near drowning coded? ICD-10-
CM’s Index under Edema, lung, due to near
drowning leads to code T75.1 -, Unspecified
effects of drowning and nonfatal submersion.
This appears to conflict with the Excludes1
note in the Tabular List under code T75.1-
, which states to code the specified effects.
When acute pulmonary edema is due to near
drowning, is it appropriate to assign code
J81.0, Acute pulmonary edema, as the effect
of near drowning to fully capture the patient’s
condition?

Answer:
Assign code J81.0, Acute pulmonary edema,
for a diagnosis of acute pulmonary edema due
to near drowning. Codes W67.XXXA, Accidental
drowning and submersion while in swimming-
pool, initial encounter, and Y92.016, Swimming-
pool in single-family (private) house or garden
as the place of occurrence of the external
cause, should also be assigned to indicate the
circumstances.

It is not appropriate to assign code T75.1XX-,

Unspecified effects of drowning and nonfatal
submersion, since the effect of the drowning
is known. The Excludes1 note at code T75.1-
indicates that code T75.1- cannot be assigned
with the code that specifies the effect of the
drowning (acute pulmonary edema), and is
directing the coding professional to only code
the specified effect.

Question:
A patient with a dichorionic diamniotic twin
pregnancy was admitted for a scheduled
primary cesarean section. She was also
diagnosed with intrahepatic cholestasis of
pregnancy. Code O26.62, Liver and biliary
tract disorders in childbirth, was assigned,
to capture the obstetrical complication. ICD-

26 First Quarter 2023 Coding Clinic

 10-CM classifies cholestasis to code K83.1,
Obstruction of bile duct. Is it appropriate to
assign code K83.1, as a secondary diagnosis
when there is no specific documentation of
obstruction?

Answer:
Assign codes O26.62, Liver and biliary tract
disorders in childbirth, E78.79, Other disorders
of bile acid and cholesterol metabolism, and
K76.89, Other specified diseases of liver, for
intrahepatic cholestasis of pregnancy. Codes
E78.79 and K76.89 are assigned because the
condition is both intrahepatic, involving the
liver, and also involving bile acid (cholestasis).
Although ICD-10-CM classifies cholestasis
to code K83.1, Obstruction of bile duct, bile
duct obstruction was not present in this case.
A basic rule of coding is that further research/
review may be required if the code indexed
does not identify the documented condition
correctly.

Question:
A patient with bilateral traumatic above
knee amputations underwent placement
of a Stage 1 Osseointegrated Prostheses
for the Rehabilitation of Amputees (OPRA)
device. Following incision, an osteotomy was
performed. After reaming into the femur and
tapping, the implant was advanced into place,
followed by the central healing screw, the
healing cylinder, and bone graft. The same
procedure was done on the contralateral
side. Would the principal diagnosis be the
traumatic amputation with seventh character
“D” subsequent encounter or is an aftercare
code assigned? Additionally, is Insertion the
appropriate root operation for the procedure?

Coding Clinic First Quarter 2023 27

 Answer:
Assign codes S88.011D, Complete traumatic
amputation at knee level, right lower leg,
subsequent encounter, and S88.012D,
Complete traumatic amputation at knee level,
left lower leg, subsequent encounter, for the
diagnoses. The aftercare Z codes should not
be used for aftercare of injuries. For aftercare
of an injury, assign the acute injury code with
the appropriate 7th character (for subsequent
encounter). The seventh character “A” for
“initial encounter” is not assigned because
the current admission is for placement of the
prosthesis rather than treatment of the original
injury.

For the procedures, assign the following ICD-

10-PCS codes:

0YHC0YZ Insertion of other device into

right upper leg, open approach;
and

0YHD0YZ Insertion of other device into left

upper leg, open approach.

Insertion is the appropriate root operation,

since the OPRA device was implanted into
the lower femur, but does not take the place
of the femur. The root operation definition of
Insertion is putting in a nonbiological appliance
that monitors, assists, performs, or prevents a
physiological function but does not physically
take the place of a body part.

Placement of the OPRA Implant System is

performed in two stages. The components
of the implant allow the prosthesis to attach
directly to the femur. In the first stage, the
fixture is implanted in the femur. Healing takes
approximately 6 months and during this time,
bone grows onto the fixture anchoring it to the

28 First Quarter 2023 Coding Clinic

 femur. The second procedure is performed
after healing is complete. During stage 2,
an abutment is attached to the fixture. The
abutment protrudes outside the skin and
attaches to the prosthetic.

Question:
The same patient presented for Stage 2
OPRA device placement surgery. During
the procedure, the previous incision was
opened and the healing components were
removed from the bone. The abutment screw
intramedullary device was then placed, and the
wound was closed. Is the diagnosis coded as
subsequent encounter for traumatic amputation
or aftercare? Is Insertion or Revision the
appropriate root operation for the second stage
of the procedure?

Answer:
Assign codes S88.011D, Complete traumatic
amputation at knee level, right lower leg,
subsequent encounter, and S88.012D,
Complete traumatic amputation at knee level,
left lower leg, subsequent encounter for the
diagnoses. The seventh character ‘A’ initial
encounter is not assigned because the current
admission is for placement of the prosthesis
rather than for treatment of the original injury.
Additionally, the aftercare Z codes should not
be used for aftercare of injuries.

For the procedures, assign the following ICD-

10-PCS codes:

0YHC0YZ Insertion of other device into

right upper leg, open approach;
and

0YHD0YZ Insertion of other device into left

upper leg, open approach.

Coding Clinic First Quarter 2023 29

 Insertion is the appropriate root operation, since
the implant was implanted into the lower femur,
but does not take the place of the femur. The
root operation definition of Insertion is putting in
a nonbiological appliance that monitors, assists,
performs, or prevents a physiological function
but does not physically take the place of a body
part. Additionally, assign codes for the removal
of the healing components from the bone.

Question:
A 75-year-old patient had previously
undergone creation of a tracheostomy that
was subsequently taken down. Since that
time, the tracheostomy site has remained open
with greenish discharge without significant
improvement. The patient is now admitted
for surgical closure of the tracheocutaneous
fistula. What is the appropriate ICD-10-CM
code assignment for a tracheocutaneous fistula
following tracheostomy reversal? Would the
fistula be coded as a persistent postoperative
fistula or a complication of the tracheostomy?

Answer:
Assign code J39.8, Other specified diseases
of upper respiratory tract, as this is the best
available option to specify the site of the fistula.
The intent of the procedure (tracheostomy)
is to create a fistula/stoma and failure of the
stoma to close spontaneously is not classified
as a “persistent postoperative fistula” nor as
a complication of the stoma. Therefore, code
T81.83XA, Persistent postprocedural fistula,
initial encounter, is not appropriate.

Question:
A patient with a history of acute subdural
hematoma secondary to a motor
vehicle accident previously underwent
hemicraniectomy followed by cranioplasty

30 First Quarter 2023 Coding Clinic

 using autologous bone flap. On a follow-up
examination, the provider noted that the patient
had bone resorption of the autologous bone
flap. What is the appropriate code assignment
for bone flap resorption?

Answer:
Assign code T86.838, Other complications
of bone graft, followed by code M95.2, Other
acquired deformity of head, for the bone flap
resorption. Although bone flap resorption is
not specifically indexed in ICD-10-CM, code
T86.838 is the appropriate code assignment
for bone graft complications that are specified
but not specifically classified in ICD-10-CM.
Code M95.2 is assigned to further specify the
complication.

Question:
This same patient presented for removal of
their autologous bone flap to allow the site to
heal for placement of a synthetic cranioplasty
implant at a later time. At surgery, an incision
was made and the scalp flap was elevated.
The previous plating system plates and the
bone flap were both removed. The dura and
dural graft substitute were both found to be
intact. The bone was sent to pathology to
rule out infection versus avascular resorption.
The wound was irrigated, a drain was placed
in the subgaleal space and the surgical site
was closed. We are not sure if the bone flap
removal should be reported as excision of
skull since the flap was previously placed as a
replacement of the skull, or if the root operation
“Removal” should be reported to capture the
removal of the autologous bone flap? What is
the appropriate ICD-10-PCS code for removal
of autologous bone flap?

Coding Clinic First Quarter 2023 31

 Answer:
Assign the following procedure code:

0NP007Z Removal of autologous tissue

substitute from skull, open
approach, for the removal of the
autologous bone flap from skull.

In this case, the previously placed graft was

resorbed, instead of healing and becoming a
replacement for the damaged portion of the
skull, therefore the root operation Removal
more accurately describes the procedure
performed.

Question:
A patient with Zenker’s diverticulum and
dysphagia presented for diverticulectomy.
Prior to the procedure, a laryngoscopy and
hypopharyngoscopy revealed a large deep
Zenker’s diverticulum, along with a thick
hypertrophic cricopharyngeal bar. Endoscopic
endocautery was used to create a horizontal
mucosal incision over the cricopharyngeal bar
and the mucosa was elevated away from the
bar. The central portion of the cricopharyngeus
muscle was then resected, followed by
excision of the Zenker’s sac. The mucosa
was then stitched closed. In the Second
Quarter 2020 issue of Coding Clinic, the root
operation “Division” was advised for Zenker’s
diverticulectomy, however, this procedure
appears to be performed using a different
surgical technique. What are the appropriate
root operations for this procedure?

Answer:
Assign the following procedure codes:

0DB18ZZ Excision of upper esophagus,

via natural or artificial opening
endoscopic, for the Zenker’s
diverticulectomy.

32 First Quarter 2023 Coding Clinic

 0KB44ZZ Excision of tongue, palate,
pharynx muscle, percutaneous
endoscopic approach, for the
excision of hypertrophic
cricopharyngeal bar.

The percutaneous endoscopic approach value

is assigned because approach value “8,” Via
natural or artificial opening endoscopic, is
not available in the ICD-10-PCS table 0KB,
Excision of Muscles. Zenker’s diverticulectomy
procedures may be performed using different
surgical techniques and code assignment
should be based on provider documentation of
how the procedure was performed, i.e., division
or excision.

Question:
A patient with a history of prior L1-L5 fusion
with XLIF cages and an extension of fusion
down to S2 with alar-iliac (S2AI) screws
presents for surgical intervention due to pain
from prominent hardware and the S2AI screws.
During surgery, a dissection was made from
T10 to the sacrum including the S2AI screws,
taking down all the posterior elements and all
the old hardware, including set screws and
rods, secondary to looseness. The S2AI screws
were removed and an attempt was made to
place a new S2AI screw on the left as well as
the right, however due to prior complaints of
significant pain from the old S2AI screws, a
decision was made not to place S2AI screws
at this juncture. What is the correct code
assignment to capture the removal of the S2AI
screws?

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

Coding Clinic First Quarter 2023 33

 0QP104Z Removal of internal fixation
device from sacrum, open
approach, for removal of the
S2AI screws from each side of
the sacrum.

Question:
A patient is admitted for surgical excision and
myocutaneous flap reconstruction of stage
IV pressure ulcers of the right ischium and
sacrum. Both ulcers were completely excised
from surrounding healthy tissue by the use
of electrocautery down to the sacrum and
coccyx. Myocutaneous flaps were developed;
the wounds were irrigated, and prior to flap
advancement closure, the surgeon placed
AmnioFill® into both the sacral and ischial
wounds over the sacrum. In this case, it
appears the AmnioFill® was not a skin
replacement. What is the correct ICD-10-PCS
code for the placement of AmnioFill® into the
ischial and sacral wounds?

Answer:
Do not assign a code for the placement of the
AmnioFill®. The application of AmnioFill® is not
separately coded since the use of AmnioFill®
would be considered integral to the total
procedure.

Question:
A patient with a pseudoaneurysm of the
right internal carotid artery (ICA) presented
for endovascular embolization. Following
percutaneous access, intracranial views
confirmed pseudoaneurysm of the cervical
right internal carotid artery extending into the
petrous (intracranial) segment of the artery.
A duo microcatheter was placed into the
pseudoaneurysm for coil delivery. Through a
second catheter, a Surpass® Flow Diverter
was deployed covering the entry into the

34 First Quarter 2023 Coding Clinic

 pseudoaneurysm. Then, three coils were
successfully deployed into the pseudoaneurysm
to facilitate thrombosis. AP and lateral
projections demonstrated coil mass within the
pseudoaneurysm facilitating contrast stasis and
adequate coverage of the pseudoaneurysm
neck by the flow diverter. When a flow diverter
is used in combination with coil embolization, is
the flow diverter considered an adjunct device
and not coded separately? What ICD-10-PCS
codes are assigned in this case?

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

03VK3HZ Restriction of right internal

carotid artery with intraluminal
device, flow diverter,
percutaneous approach, for
placement of the flow diverter
stent; and

03VK3DZ Restriction of right internal

carotid artery with intraluminal
device, percutaneous approach,
for placement of coils.

In this case, two codes are assigned because

separate devices were used to treat the
pseudoaneurysm and there is no guideline or
instruction that prevents coding both of these
devices separately when both are used.

Question:
A patient with left carotid artery occlusion
underwent left internal and common carotid
artery endarterectomy with internal carotid
artery imbrication due to carotid loop. At
surgery, an arteriotomy of the common carotid
artery was made and extended across the
bulb through the level of the internal carotid
artery where critical stenotic plaque was noted.

Coding Clinic First Quarter 2023 35

 The endarterectomy plane was established
in the bulb and was extended retrograde in
the common carotid artery where the plaque
was transected. Eversion endarterectomy
was performed in the external system and the
plaque was then elevated out of the remainder
of the internal carotid artery. Due to carotid
loop, the internal carotid artery was imbricated
with Prolene to shorten the length so that there
would not be a loop. The arteriotomy was then
closed with a bovine pericardial patch using
running 6-0 Prolene. What is the correct root
operation for the imbrication, Restriction or
Repair?

Answer:
The carotid artery imbrication was performed at
the site of the patch angioplasty and a separate
code would not be assigned for the imbrication.
Assign only the root operation Supplement for
the patch angioplasty.

Question:
A patient presented to the hospital with a
plantar heel ulcer of the left foot with exposed
fat. The patient was evaluated and deemed
to be a poor surgical candidate. Medical
maggots were applied to treat the ulcer. Would
maggot therapy be coded as a non-excisional
debridement? What is the appropriate ICD-10-
PCS code assignment for maggot therapy?

Answer:
Yes, maggot therapy is coded as non-excisional
debridement. Assign the following procedure
code:

0JDR0ZZ Extraction of left foot

subcutaneous tissue and fascia,
open approach, for the medical
maggot therapy of the left
plantar heel ulcer.

36 First Quarter 2023 Coding Clinic

 Question:
A seven-year-old child who has experienced
recurrent strokes secondary to C1-C4 rotational
vertebral artery syndrome (mechanical
rotational arteriopathy), also known as Bow
Hunter’s syndrome, presents for management
of the condition. Bow Hunter’s syndrome
refers to vertebro-basilar insufficiency caused
by mechanical compression of the vertebral
arteries when the head is turned to the side.
Per the Alphabetic Index at “Syndrome,
vertebral, artery, compression, see Syndrome,
anterior, spinal artery, compression, cervical,
one is directed to code M47.012, Anterior spinal
artery compression syndromes, cervical region.
Alternatively, at Compression, vertebral artery,
cervical, one is directed to code M47.022,
Vertebral artery compression syndromes,
cervical region. In addition, Insufficiency,
arterial, vertebral, directs to code G45.0,
Vertebro-basilar artery syndrome. What is
the appropriate diagnosis code for rotational
vertebral artery syndrome?

Answer:
Assign code M47.022, Vertebral artery
compression syndromes, cervical region, for
rotational vertebral artery syndrome, C1-C4
(mechanical rotational arteriopathy). Assigning
a code for compression of the vertebral artery
is more specific than a code for compression of
an anterior spinal artery. Additionally, assign the
appropriate Z code for history of stroke without
residual deficits (Z86.73) or history of stroke
with sequelae (category I69), depending on
the documentation in the record. In this case,
a code from category G45- Transient cerebral
ischemic attacks and related syndromes, is not
assigned since the patent did not experience a
transient ischemic attack.

Coding Clinic First Quarter 2023 37

 Rotational vertebral artery syndrome is
an uncommon cause of vertebral artery
compression and stroke. Patients with
rotational vertebral artery syndrome will
typically have a history of recurrent strokes or
transient ischemic attacks.

Question:
A 16-year-old with fibrolamellar hepatocellular
carcinoma presented for resection of liver
tumor. The main tumor was on the left side
with extensive tumor thrombus in the portal
vein. The patient also had a small lesion in the
middle of the right lobe. In order to effectively
remove the extensive left tumor thrombus and
right lobe lesion, it was decided to perform the
resection with ex vivo approach followed by
autotransplantation. Prior to explantation, the
major vessels including the major hepatic veins
were clamped and the liver was subsequently
removed and taken to the back table for the
resection procedures. The liver was flushed and
then submerged with cold histidine tryptophan
ketoglutarate (HTK) solution. The tumors were
resected and the liver was then flushed again
and reimplanted into the patient. How is the
explantation and subsequent reimplantation
of the liver coded? Would it be appropriate to
assign the root operation Transplantation to
capture the complexity of the procedure?

Answer:
Assign codes for the procedures performed
(i.e., tumor excision). The fact that the
procedures were performed ex vivo does not
impact code assignment.

A transplantation code is not assigned as this

is not a true transplant since the patient’s own
liver was implanted back into the patient. Root
operation “Transplantation” is defined in ICD-

38 First Quarter 2023 Coding Clinic

 10-PCS as “Putting in or on all or a portion of
a living body part taken from another individual
or animal to physically take the place and/
or function of all or a portion of a similar body
part.”

Correction Notices
Chronic Kidney Disease, Stage 3
Coding Clinic, Fourth Quarter 2022, page 6,
contained a misprint. Code N18.30, Chronic
kidney disease, stage 3 unspecified, should
have been assigned instead of N18.3 for stage
3 CKD.

Underdosing of Amlodipine
The answer published in Coding Clinic, First
Quarter 2022, page 36, about underdosing
of Amlodipine was incorrect. Assign code
T46.1X6A, Underdosing of calcium-channel
blockers, initial encounter, rather than
code T46.5X6A, Underdosing of other
antihypertensive drugs, initial encounter,
for underdosing of Amlodipine. Although
Amlodipine may be prescribed to treat
hypertension, the drug class is calcium channel
blocker.

Coding Clinic First Quarter 2023 39