星空入口

See how the correct choice hinges on your knowledge of anatomy and terminology.

Procedures involving catheter insertions typically go off without a hitch. However, those inevitable mechanical complications that occur are sure to extend all the way to your diagnosis code reporting.

In most cases, remedying a mechanical catheter complication is as simple as a removal and replacement. The same can鈥檛 always be said for the coding breakdown. As you鈥檒l see, reaching the correct code requires more than just a foundational knowledge of anatomy. You also need to be able to seamlessly maneuver between the ICD-10-CM Alphabetic Index and Tabular.

Take your catheter complication coding skills to the next level by tackling these two examples.

Consider ICD-10-CM鈥檚 Choice of Catheter Complication Terminology

Example: A patient is experiencing pain following placement of a hemodialysis catheter. Further evaluation reveals that the tip of the catheter has broken off.

Coding this case presents a slight challenge unless you鈥檙e fluent with hemodialysis catheterizations.

There鈥檚 more than one route within the ICD-10-CM Alphabetic Index to the correct code, but a practical starting point is 鈥淐omplication(s) (from) (of)鈥� since the diagnosis is the direct result of a procedure. From there, you鈥檒l encounter the following sub-terms: catheter (device) ? dialysis (vascular). So long as you鈥檙e familiar with the ICD-10-CM code book鈥檚 classification of a broken catheter as a 鈥渕echanical breakdown,鈥� the rest is smooth sailing. Continuing within the Alphabetic Index, mechanical ? breakdown will land you at code T82.41XA (Breakdown (mechanical) of vascular dialysis catheter, initial encounter).

Discern Between Breakdown and Displacement Terms

Example: A pelvic X-ray reveals a dislodged Foley catheter used for a patient with urinary retention.

Using what you鈥檝e learned in the previous example, you might assume you鈥檝e got the perfect start within the Alphabetic Index. However, you must make sure you avoid not one, but two, fatal mistakes along the way.

You might initially assume that a dislodged catheter meets the same criteria as a 鈥渂reakdown鈥� of a catheter, but not so fast. The ICD-10-CM code book considers a fractured (or broken) catheter a 鈥渂reakdown.鈥� But other terms exist as well. In the case of this second example, a 鈥渄islodged鈥� catheter meets the criteria for 鈥渄isplacement.鈥�

Coder鈥檚 note: 鈥�Catheterization displacements and breakdowns have different consequences and rely on different treatment plans,鈥� says Sheri Poe Bernard, CPC, of Poe Bernard Consulting in Salt Lake City. 鈥淩elaying these individual diagnoses accurately is vital to coding, reporting, and outcomes tracking 鈥� even when it results in no change in payment,鈥� explains Bernard.

Even with this knowledge on hand, you鈥檙e not out of the woods yet. Before going any further within the Alphabetic Index, you should take a moment to understand the difference between a few key terms. 鈥淲hen you see the term 鈥榠nfusion,鈥� as it pertains to catheterizations, you should know that you鈥檙e working with catheters inserted into either a large vein or artery,鈥� says Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. That point immediately disqualifies any code documented as an 鈥渋nfusion鈥� for coding of this example.

You should also have a proper understanding of what a Foley catheter is, so you don鈥檛 feel inclined to go the route of 鈥渦rinary NEC,鈥� when sub-terms 鈥渦rethral indwelling鈥� and 鈥渦rinary NEC鈥� are present. Consider the Dorland鈥檚 Illustrated Medical Dictionary definition of Foley catheter: 鈥淎n indwelling catheter that has a balloon filled with air or liquid to retain it in place in the bladder鈥�

An indwelling catheter is a catheter inserted into the bladder through the urethra. Keep in mind that this description perfectly aligns with the sub-term 鈥渦rethral indwelling鈥� when you see it listed as an Alphabetic Index sub-term.

Since 鈥渂reakdown鈥� won鈥檛 be included in the code description for this example, you want to take a different approach to reach the correct code. While there are a variety of routes, stay within 鈥淐omplication(s) (from) (of)鈥� to get to the final diagnosis code. From that key term, go to catheter (device) ? urethral ? indwelling ? displacement, leading you to T83.021A (Displacement of indwelling urethral catheter, initial encounter).