Q: A patient has unintentionally failed to take a prescribed dosage of insulin due to his Alzheimer’s dementia (age-related debility), and is admitted for initial care with inadequately controlled Type 1 diabetes mellitus. Which ICD-10-CM code(s) should we assign?
Q: As a traveling consultant, I review many types of inpatient hospital records. As hospitals have implemented electronic health records (EHR), I’ve seen documentation worsen. The ability to cut and paste information in the record has compromised coding accuracy. It has also increased the volume of queries, which frustrates physicians. For example, a physician performs a history and physical (H&P) in his or her office one week prior to admitting a patient to the hospital. The first progress note in the EHR—as well as each subsequent progress note—includes the exact same documentation. This documentation, which continues for four days while the patient is in the hospital, is clearly based on the original H&P. Obviously, the documentation has been copied and pasted from one note to another. Even the patient’s vital signs remain exactly the same as they were in the physician’s office. Coders have no way of knowing whether physicians who treat the patient in the hospital agree with any test findings because residents simply cut and paste the results in each subsequent progress note. Residents claim that they do this solely for the attending physician’s convenience. Clinical documentation improvement (CDI) specialists don’t address the problem because they are more focused on determining the accuracy of the MS-DRG. Is there a solution that will keep physicians, coders, and CDI specialists all on the same page?
Q: I have a question about coding transplant complications. My understanding is if the complication affects the transplanted organ, then coders should assign a code for the transplant complication itself. Is this correct? Consider the following physician documentation: Final A/P: Acute renal failure in patient with history of renal transplant. Should coders report 996.81 (complications of transplanted kidney) and 584.9 (acute kidney failure, unspecified)? Also consider this documentation: CHF in heart transplant patient . Should coders report 996.83 (complications of transplanted heart) and 428.0 (CHF, unspecified)?
Q: I need further clarification regarding documentation of toxic metabolic encephalopathy. I’m trying to code two different cases in which a physician documents acute mental status change secondary to an infectious process . In each case, the patient’s metabolic panels don’t appear to be abnormal; however, one of the patients is septic. The physician thinks that documenting and coding sepsis separately from encephalopathy would result in unbundling. However, I disagree because coding the sepsis separately demonstrates severity. What is the correct logic to use in each of these cases?
Q: A patient has been diagnosed with peritonsillar cellulitis and oropharyngeal cellulitis. The physician documents that he performed a “needle aspiration of the left peritonsillar abscess.” In the body of the operative report, the physician states, “An 18-gauge needle was inserted and 1 cc of pus was aspirated. This was sent for aerobic, anaerobic, C&S [culture & sensitivity], and gram stain. I then put the 18-gauge needle in again and multiple passes were obtained without any aspirate.” Because ICD-9-CM does not include a code for “aspiration of peritonsillar abscess” some coders wanted to use ICD-9-CM procedure code 28.0 (incision and drainage of tonsil and peritonsillar structures) while others want to report code 28.99 (other operations on tonsils and adenoids). Which code is correct?