Recently I have been asked if a nurse can code findings in discharge summaries from the referring hospitals as an active dx without a query from the resident’s physician. Please see an excerpt from the guidelines below.

Please refer to the ICD -10 guidelines https://www.cms.gov/files/document/fy-2024-icd-10-cm-coding-guidelines.pdf

Two of the most potential areas that may cause confusion is the ability to code abnormal findings identified in xrays or other diagnostic results and when a Z code can be a principal code.

This is from the guidelines listed in the link above:

B. Abnormal findings

Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.

Please note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a provider.

ICD-10-CM Official Guidelines for Coding and Reporting

FY 2024

Page 109 of 120

Question that is often asked is if a Z code can be the principal dx?

0. K. Admissions/Encounters for RehabilitationWhen the purpose for the admission/encounter is rehabilitation, sequence first the code for the condition for which the service is being performed. For example, for an admission/encounter for rehabilitation for right-sided dominant hemiplegia following a cerebrovascular infarction, report code I69.351, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, as the first-listed or principal diagnosis.If the condition for which the rehabilitation service is being provided is no longer present, report the appropriate aftercare code as the first-listed or principal diagnosis, unless the rehabilitation service is being provided following an injury. For rehabilitation services following active treatment of an injury, assign the injury code with the appropriate seventh character for subsequent encounter as the first-listed or principal diagnosis. For example, if a patient with severe degenerative osteoarthritis of the hip, underwent hip replacement and the current encounter/admission is for rehabilitation, report code Z47.1, Aftercare following joint replacement surgery, as the first-listed or principal diagnosis. If the patient requires rehabilitation post hip replacement for right intertrochanteric femur fracture, report code S72.141D, Displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, as the first-listed or principal diagnosis. ICD-10-CM Official Guidelines for Coding and Reporting. FY 2024 Page 108 of 120

The information presented is informative and does not constitute direct legal or regulatory advice

September 2024\Skilled Nursing Support\maria.messina@skillednursingsupport.com

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