9/1/2015. Studies (AHIMA)

Transcription

1 9/1/2015 IC CD 10 Coding Supplemental Case Studies Amy Franklin, RN, RAC MT, ICD 10 CM/PCS Trainer (AHIMA)

2 1. DM Case Study 62 y.o. Mr. X has DM with insulin in use, DM Neuropathy and DM Renal insufficiency. Receives Lantus 25 units sq every HS. DIABETES MELLITUS (E08 E13) E08 E09 E10 E11 E12 Diabetes mellitus due to underlying condition Drug or chemical induced diabetes mellitus Type 1 diabetes mellitus Type 2 diabetes mellitus Other specified diabetes mellitus 4 th Digit INCLUDES E11 Type 2 Diabetes Mellitus Diabetes (Mellitus) Due To Insulin Secratory Effect Diabetes NOS Insulin Resistant Diagetes (Mellitus) Use Additional Code To Identify Any Insulin Use (Z79.4) Diabetes Mellitus Due To Underlying Condition (E08. ) Drug Or Chemical Induced Diabetes Mellitus (E09. ) Gentational Diabetes (O24.4 ) Neonatal Diabetes Mellitus (P70.2) Postpancreatectomy Diabetes Mellitus (E13. ) Postprocedural Diabetes Mellitus (E13. ) Secondary Diabetes Mellitus NEC (E13. ) Type 1 Diabetes Mellitus (E10. ) 5 th Digit E11.2 Type 2 Diabetes Mellitus With Kidney Complications E11.21 Type 2 Diabetes Mellitus With Diabetic Nephropathy Type 2 Diabetes Mellitus With Intercapillary Glomerulosclerosis Type 2 Diabetes Mellitus With Intracapillary Glomerulonephrosis Type 2 Diabetes Mellitus With Kimmelstiel Wilson Disease E11.22 Type 2 Diabetes Mellitus With Diabetic Chronic Kidney Disease Use Additional Code To Identify State Of Chroic Kidney Disease (N18.1 N18.6) E11.29 Type 2 Diabetes Mellitus With Other Diabetic Kidney Complications Type 2 Diabetes Mellitus With With Renal Tubular Degeneration Answer: E11.22 Type 2 DM with Diabetic Chronic Kidney Disease E11.40 Type 2 DM with Diabetic Neuropathy, unspecified N18.9 Chronic Renal Insufficiency Z79.4 Long term (current) use of insulin Per Chapter 4 coding Guidelines 3) Diabetes mellitus and the use of insulin If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11, Type 2 diabetes mellitus, should be assigned. Code Z79.4 should not be assigned if insulin is given temporarily to bring a type 2 patient s blood sugar under control during an encounter. Code Z79.4, Long term (current) use of insulin, should also be assigned to indicate that the patient uses insulin.

3 2. Dementia Case Study Mrs. Z has Dementia secondary to Alzheimer s disease. At times she will wander the halls looking for her family members that are not there. DEMENTIA (F ) F02 Dementia in other diseases classified elsewhere Code first the underlying physiological condition, such as: Alzheimer s (G30. ) Cerebral lipiodosis (E75.4) Creutzfeldt Jakob disease (A81.0 ) Dementia with Lewy bodies (G31.83) Frontotemporal dementia (G31.09) Hepatolenticular degeneration (E83.0) Human immunodeficiency virus [HIV] disease (B20) Hypercalcemia (E83.52) Hypothyroidism, acquired (E00 E03. ) Intoxications (T36 T65) Jakob Creutzfeldt disease (A81.0 ) Multiple sclerosis (G35) Neurosyphilis (A52.17) Niacin deficiency [pellagra] (E52) Parkinson s disease (G20) Pick s disease (G31.01) Polyarteritis nodosa M30.0) Systemic lupus erythematosus (M32. ) Trypanosomiasis (B56.,B57. ) Vitamin B deficiency (E53.8) Dementia with Parkinsonism (G31.83) EXCLUDES 2 Dementia in Alcohol And Psychoactive Substance Disorders (F10 F1, with.17,.27,.97) Vascular Dementia (F01.5 ) F02.8 Dementia in other diseases classified elsewhere F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance Dementia in other diseases classified elsewhere NOS F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance Dementia in other diseases classified elsewhere with aggressive behavior Dementia in other diseases classified elsewhere with combative behavior Dementia in other diseases classified elsewhere with violent behavior Use additional code, if applicable, to identify wandering in dementia in conditions classified elsewhere (Z91.83) Answer: G30.9 Alzheimer s Disease, unspecified F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance Z91.83 Wandering in Disease Classified elsewhere

4 3. OSTEOPOROSIS & FRACTURE Case Study 13. Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00- M99) c. Coding of Pathologic Fractures 7th character A is for use as long as the patient is receiving active treatment for the fracture. Examples of active treatment are: surgical treatment, emergency department encounter, evaluation and continuing treatment by the same or a different physician. While the patient may be seen by a new or different provider over the course of treatment for a pathological fracture, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time. 7th character, D is to be used for encounters after the patient has completed active treatment. The other 7th characters, listed under each subcategory in the Tabular List, are to be used for subsequent encounters for treatment of problems associated with the healing, such as malunions, nonunions, and sequelae. Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes. See Section I.C.19. Coding of traumatic fractures. d. Osteoporosis Osteoporosis is a systemic condition, meaning that all bones of the musculoskeletal system are affected. Therefore, site is not a component of the codes under category M81, Osteoporosis without current pathological fracture. The site codes under category M80, Osteoporosis with current pathological fracture, identify the site of the fracture, not the osteoporosis. 1) Osteoporosis without pathological fracture Category M81, Osteoporosis without current pathological fracture, is for use for patients with osteoporosis who do not currently have a pathologic fracture due to the osteoporosis, even if they have had a fracture in the past. For patients with a history of osteoporosis fractures, status code Z87.310, Personal history of (healed) osteoporosis fracture, should follow the code from M81. 2) Osteoporosis with current pathological fracture Category M80, Osteoporosis with current pathological fracture, is for patients who have a current pathologic fracture at the time of an encounter. The codes under M80 identify the site of the fracture. A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone. ICD 10 CM Official Guidelines for Coding and Reporting FY 2015

5 3b. NONTRAMATIC PATHOLOGICAL Fx Case Study Mr. A has no hx of Osteoporosis within his medical record. The surgical report read s/p ORIF of the Right Hip, Pathological Fx. Fracture, pathological (pathologic) (see also Fracture, traumatic) M84.40 Additional Character required Refer to the Tabular List for Character Selection M84.4 Pathologic fracture, not elsewhere classified Chronic fracture Pathological fracture, NOS Collapsed vertebra NEC (M48.5) Pathological fracture in neoplastic disease (M84.5 ) Pathological fracture in osteoporosis (M80. ) Pathological fracture in other disease (M84.6 ) Stress fracture (M84.3) Traumatic fracture (S12., S22., S32.,S42,S52,S62,S72,S82,S92 ) EXCLUDES 2 Personal History Of (Healed) Pathological Fracture (Z87.311) The appropriate 7 th character is to be added to each code from subcategory M84.4. A initial encounter for fracture D subsequent encounter for fracture with routine healing G subsequent encounter for fracture with delayed healing K subsequent encounter for fracture with nonunion P subsequent encounter for fracture with malunion S sequela M Pathologic fracture, femur and pelvis (7 th character required) M Pathological fracture, right femur M Pathological fracture, left femur M Pathological fracture, unspecified femur M Pathological fracture, pelvis M Pathological fracture, hip, unspecified Answer: M84.451D Pathological Fracture, right femur

6 4. FRACTURE Femur Case Study Mr. Y was admitted s/p surgical repair of the Right Hip Fx, after sustaining a fall down the basement stairs in his home. Fracture, Traumatic (Abduction) (Adduction) (Separation) (See Also Fracture, Pathological) T14.8 Hip See Fracture, Femur, Neck Neck See Fracture, Femur, Upper End, Neck Neck S72.00 Base (Displaced) S72.04 Nondisplaced S72.04 Specified NEC S72.09 Additional Character Required Refer to the Tabular List for Character Selection S72 Fracture of Femur NOTE A fracture not indicated as displaced or non displaced should be coded to displaced. The open fracture designations are based on the Gustilo open fracture classification. A fracture not indicated as open or closed should be coded to closed. Traumatic Amputation of Hip and Thigh (78. ) EXCLUDES 2 Fracture of Lower Leg and Ankle (S82. ) Fracture of Foot (S92.) Periprosthetic Fracture Of Prosthetic Implant Of Hip (T84.040, T84.041) The appropriate 7 th character is to be added to all codes from category S72 [unless otherwise indicated]. A Initial Encounter for Closed Fracture B Initial Encounter for Open Fracture Type I or Ii C Initial Encounter for Open Fracture Type Iiia, Iiib, or Iiic D Subsequent Encounter for Closed Fracture with Routine Healing E Subsequent Encounter for Open Fracture Type I or Ii with Routine Healing F Subsequent Encounter for Open Fracture Type Iiia, Iiib, or Iiic with Routine Healing G Subsequent Encounter for Closed Fracture with Delayed Healing H Subsequent Encounter for Open Fracture Type I or Ii with Delayed Healing J Subsequent Encounter for Open Fracture Type Iiia, Iiib, or Iiic with Delayed Healing K Subsequent Encounter for Fracture with Nonunion M Subsequent Encounter for Open Fracture Type I or I With Nonunion N Subsequent Encounter for Open Fracture Type Iiia, Iiib, or Iiic with Nonunion P Subsequent Encounter for Closed Fracture with Malunion Q Subsequent Encounter for Open Fracture with Type I or Ii with Malunion R Subsequent Encounter for Open Fracture Type Iiia, Iiib, or Iiic with Malunion S Sequela S72.0 Fracture of head and neck of femur EXCLUDES 2 Physeal fracture of upper end of femur (S79.0) S72.00 Fracture of unspecified part of neck of femur Fracture of hip NOS Fracture of neck of femur NOS S Fracture of unspecified part of neck of right femur S Fracture of unspecified part of neck of left femur S Fracture of unspecified part of neck of unspecified femur Answer: S72.001D = Fx of unspecified part of neck of Right Femur, subsequent encounter

7 5. COPD Case Study Mr. Z has been on Oxygen for years and has a Dx of COPD. CHRONIC OBSTRUCTIVE PULMONARY DISEASE [COPD] (J44.9) Asthma with Chronic Obstructive Pulmonary Disease Chronic Asthmatic (Obstructive) Bronchitis Chronic Bronchitis with Airways Obstruction INCLUDES Chronic Bronchitis with Emphysema Chronic Emphysema Chronic Emphysematous Bronchitis Chronic Obstructive Asthma Chronic Obstructive Tracheobronchitis Code also type of asthma, if applicable (J45. ) Use additional code to identify: Exposure to environmental tobacco smoke (Z77.22) History of tobacco use (Z87.891) Occupational exposure to environmental tobacco smoke (Z57.31) Tobacco dependence (F17. ) Tobacco use (Z72.0) Bronchiectasis (J47. ) Chronic bronchitis NOS (J42) Chronic simple and mucopurulent bronchitis (J41. ) Chronic tracheitis (J42) Chronic tracheobronchitis (J42) Emphysema without chronic bronchitits (J43. ) Lung diseases due to external agents (J60 J70) J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection Use additional code to identify the infection J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation Decompensated COPD Decompensated COPD with (acute) exacerbation EXCLUDES 2 Chronic Obstructive Pulmonary Disease [COPD] With Acute Bronchitis (J44.0) J44.9 Chronic Obstructive Pulmonary Disease, Unspecified Chronic Obstructive Airway Disease NOS Chronic Obstructive Lung Disease NOS Answer: J44.9 COPD, Unspecified

8 6. DEPRESSION Case Study Mrs. Y has been treated for Depression NOS for years within the SNF. DEPRESSIVE DISORDER (F32.9) F32 INCLUDES Major Depressive disorder, single episode Single Episode of Agitated Depression Single Episode of Depressive Reaction Single Episode of Major Depression Single Episode of Psychogenic Depression Single Episode of Reactive Depression Single Episode of Vital Depression Bipolar Disorder (F31. ) Manic Episode (F30. ) Recurrent Depressive Disorder (F33. ) EXCLUDES 2 Adjustment Disorder (F43.2) Review with Your Team F32.0 Major Depressive Disorder, Single Episode, Mild F32.1 Major Depressive Disorder, Single Episode, Moderate F32.2 Major Depressive Disorder, Single Episode, Sever Without Psychotic Features F32.3 Major Depressive Disorder, Single Episode. Sever With Psychotic Features F32.4 Major Depressive Disorder, Single Episode, In Partial Remission F32.5 Major Depressive Disorder, Single Episode, In Full Remission F32.8 Other Depressive Episodes F32.9 Major Depressive Disorder, Single Episode, Unspecified Depression NOS Depressive disorder NOS Major depression NOS Answer: F32.9 Major Depression, single episode, unspecified

9 7. CHF Case Study Mrs. X was admitted from the hospital with CHF. CONGESTIVE HEART FAILURE [CHF] Failure, Heart, Congestive (compensated) (decompensated) I50.9 Tabular index Heart failure, unspecified Biventricular (heart) failure NOS Cardiac, heart or myocardial failure NOS Congestive heart disease Congestive heart failure NOS Right Ventricular failure (secondary to left heart failure) Fluid Overload (E87.70) I50 Heart failure Code first: Heart failure complicating abortion or ectopic or molar pregnancy (O00 O07, O08.8) Heart failure following surgery (I97.13 ) Heart failure due to hypertension (I11.0) Heart failure due to hypertension with chronic kidney disease (I13. ) Obstectric surgery and procedures (O75.4) Rheumatic heart failure (I09.81) Cardiac Arrest (I46. ) Neonatal cardiac failure (P29.0) Answer: I 50.9 Congested Heart Failure NOS

10 8. PRESSURE ULCER (L89) Case Study Mr. S was admitted with a Stage 4 pressure ulcer on the right buttocks. L89.3 Pressure ulcer of buttock L89.30 Pressure ulcer of unspecified buttock L Pressure ulcer of unspecified buttock, unstageable L Pressure ulcer of unspecified buttock, stage 1 L Pressure ulcer of unspecified buttock, stage 2 L Pressure ulcer of unspecified buttock, stage 3 L Pressure ulcer of unspecified buttock, stage 4 L Pressure ulcer of unspecified buttock, unspecified stage L89.31 Pressure ulcer of right buttock L Pressure ulcer of right buttock, unstageable L Pressure ulcer of right buttock, stage 1 L Pressure ulcer of right buttock, stage 2 L Pressure ulcer of right buttock, stage 3 L Pressure ulcer of right buttock, stage 4 L Pressure ulcer of right buttock, unspecified stage L89.32 Pressure ulcer of left buttock L Pressure ulcer of left buttock, unstageable L Pressure ulcer of left buttock, stage 1 L Pressure ulcer of left buttock, stage 2 L Pressure ulcer of left buttock, stage 3 L Pressure ulcer of left buttock, stage 4 L Pressure ulcer of left buttock, unspecified stage Answer: L Pressure ulcer of right buttock, stage 4

11 9. PNEUMONIA CASE STUDY Mr. G is in the SNF in a long term bed, he was just dx with pneumonia. Pneumonia (J18.9) Pneumonia (acute) (double) (migratory) (purulent) (septic) (unresolved) J18.9 J12 Viral pneumonia, not elsewhere classified J13 Pneumonia due to Streptococcus pneumonia J14 Pneumonia due to Heomphilus influenza J15 Bacterial pneumonia, not elsewhere classified J16 Pneumonia due to other infectious organisms, not elsewhere classified J17 Pneumonia in diseases classified elsewhere J18 Pneumonia, unspecified organism Code first associated influenza, if applicable (J09.X1, J10.0, J11.0 ) Abscess of lung with pneumonia (J85.1) Aspiration pneumonia due to anesthesia during labor and delivery (O74.0) Aspiration pneumonia due to anesthesia during puerperuim (O89.0) Aspiration pneumonia due to solids and liquids (J69. ) Aspiration pneumonia NOS (J69.0) Congenital pneumonia (P23.0) Drug induced interstitial lung disorder (J70.2 J70.4) Interstitial pneumonia NOS (J84.9) Lipid pneumonia (J69.1) Neonatal aspiration pneumonia (P24. ) Pneumonitis due to external agents (J67 J70) Pneumonitis due to fumes and vapors (J68.0) Usual interstitial pneumonia (J84.17) J18.0 Bronchopneumonia, unspecified organism Hypostatic bronchopneumonia (J18.2) Lipid pneumonia (J69.1) EXCLUDES 2 Acute bronchiolitis (J21. ) Chronic bronchiolitis (J44.9) J18.1 Lobar pneumonia, unspecified organism J18.2 Hypostatic pneumonia, unspecified organism Hypostatic bronchopneumonia Passive pneumonia J18.8 Other pneumonia, unspecified organism J18.9 Pneumonia, unspecified organism Answer: J18.9 Pneumonia, unspecified organism

12 10. MI Case Study Mr. Y was admitted today from home and had an Acute MI 2 weeks ago. Acute Myocardial Infarction (I21) Infarct, Infarction Myocardium, myocardial (acute) (with stated duration of 4 weeks or less) I21.3 Ischemic heart diseases (I20 I25) Use additional code to identify presence of hypertension (I10 I15) I21 ST elevation (STEMI) and non ST elevation (NSTEMI) myocardial infarction Cardiac Infarction Coronary (Artery) Embolism Coronary (Artery) Occlusion INCLUDES Coronary (Artery) Rupture Coronary (Artery) Thrombosis Infarction of Heart, Myocardium, or Ventricle Myocardial Infarction Specified As Acute or With a Stated duration of 4 Weeks (28 Days) or Less From Onset Use additional code, if applicable, to identify: Exposure to Environmental Tobacco Smoke (Z77.22) History of Tabacco Use (Z87.891) Occupational Exposure to Environmental Tobacco Smoke (Z57.31) Status Post Administration Of Tpa(Rtpa) In A Different Facility Within The Last 24 Hours Prior to Admission to Current Facility (Z92.82) Tobacco Dependence (F17 ) Tobacco Use (Z72.0) Old Myocardial Infarction (I25.2) EXCLUDES 2 Postmyocardial Infarction Syndrome (I24.1) Subsequent Myocardial Infarction (I22 ) I21.3 ST Elevation (STEMI) myocardial infarction of unspecified site Acute transmural myocardial infarction of unspecified site Myocardial infarction (acute) NOS Transmural (Q wave) myocardial infarction NOS Answer: I21.3 ST Elevation (STEMI) myocardial infarction of unspecified site

13 11. ORTHOPEDIC AFTERCARE (Z47) Case Study Mr. T was admitted s/p Left TKA. Z 47 Orthopedic aftercare Aftercare for healing fracture code to fracture with 7 th character D Z 47.1 Aftercare following joint replacement surgery Use additional code to identify the joint (Z96.6 ) Z 47.2 Encounter for removal of internal fixation device Encounter for adjustment of internal fixation device for fracture treatment code to fracture with appropriate 7 th character Encounter for removal of external fixation devise code to fracture with 7 th character D Infection or inflammatory reaction to internal fixation device (T84.6 ) Mechanical complication of internal fixation device (T84.1 ) Hip Replacement Z47.1 Aftercare following joint replacement surgery Use additional code to identify the joint (Z96.6 ) Z96.64 Presence Of Artificial Hip Joint Hip Joint Replacement (Partial) (Total) Z Presence Of Right Artificial Hip Joint Z Presence Of Left Artificial Hip Joint Z Presence Of Artificial Hip Joint, Bilateral Z Presence Of Unspecified Artificial Hip Joint Knee Replacement Z47.1 Aftercare following joint replacement surgery Use additional code to identify the joint (Z96.6 ) Z96.65 Presence Of Artificial Knee Joint Z Presence Of Right Artificial Knee Joint Z Presence Of Left Artificial Knee Joint Z Presence Of Artificial Knee Joint, Bilateral Z Presence Of Unspecified Artificial Knee Joint K. Admissions/Encounters for Rehabilitation When 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 no longer present, report the appropriate aftercare code 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. ICD 10 CM Official Guidelines for Coding and Reporting FY 2015 ANSWER: Z47.1 Aftercare following joint replacement surgery Z Presence Of Left Artificial Hip Joint