Q: What recommendation would you give to the coder when the clinical indicators in the chart do not support sepsis but it’s in the final diagnostic statement?
Q: A patient presents with altered mental status/encephalopathy due to a urinary tract infection (UTI). The patient has a history of dementia. The final diagnosis is encephalopathy due to UTI. Should we code the encephalopathy as a secondary diagnosis because it’s an MCC and not always a symptom of a UTI?
Q: A patient undergoes placement of a MediPort ® to receive chemotherapy for lung cancer. What principal diagnosis should we report? Should we report V58.81 (fitting and adjustment of vascular catheter) or 162.9 (malignant neoplasm of bronchus and lung unspecified)?
Q: Our facility has a question about how other hospitals address this scenario: Patient is discharged to home (discharge status code 01). No documentation exists in the medical record to support post-acute care. Several months later, our Medicare Administrative Contractor (MAC) notifies us that the patient indeed went to post-acute care after discharge. The MAC retracts our entire payment. We need to resubmit the claim with the correct discharge status code. We are reluctant to do so because nothing in the medical record supports the post-acute care provided. Are other hospitals amending the record? If so, which department is adding the amended note?
Q: Which ICD-10-CM external cause code should we report if a patient falls while on an escalator? This is the first time that the patient has been seen for such a fall.
Q: Some of our providers see patients in our local nursing facilities. When these patients are admitted to our hospital, must we retain this documentation in our own records?
Q: What advice can you offer for sequencing pulmonary edema and congestive heart failure when both appear to meet the definition of principal diagnosis?
Q: How will I report the initial insertion of a dual-chamber pacemaker device in ICD-10-PCS? The physician inserted two leads—one into the atrium and one into the ventricle–using a percutaneous approach into the patient’s chest.
Q: A surgeon’s dictated report for a right hip hemiarthroplasty states the following: Of note, while drilling one of our transosseous suture holes with a 2.0 mm drill bit, the end of the drill bit broke off inside of the trochanter. It seemed to be quite deep into the bone and was not retrievable. As such, it was left in place. Should we report 998.4 (foreign body accidentally left during a procedure) for this case?
Q: Using the ICD-10-CM guidelines for the seventh character extensions for fracture codes, how should I identify each of the following? Avascular necrosis following fracture Cast change or removal Emergency treatment Evaluation and management by a new physician Follow-up visits following fracture treatment Infection on open fracture site Malunion of fracture Nonunion of fracture Medication adjustment Patient delayed seeking treatment for the fracture or nonunion Removal of external of internal fixation device Surgical treatment
Q: Can you clarify the requirements surrounding the use of E codes? We have been working on documentation concerns related to patient safety indicator (PSI) 15 and wonder if E codes are required. Can a facility simply decide not to use them?
Q: A patient with undiagnosed syncope is admitted to observation. Later that evening, the patient is diagnosed with syncope and develops complications that warrant an inpatient admission. Should the patient be considered an inpatient from the time inpatient criteria are met or from the time the inpatient order is written?
Q: A patient presents with a sore throat, and the physician states “Sore throat; differential diagnoses include streptococcal sore throat, tonsillitis, postnasal drip.” If the physician doesn’t rule out any of the differential diagnoses, should the coder query for clarification or simply choose one of the differential diagnoses?
Q: One of our orthopedic surgeons started to perform spinal fusions percutaneously. CPT ® provides instruction on how to code this procedure; however, these are inpatient surgeries, so we need an ICD-9-CM code. We’re leaning toward code 81.00 (spinal fusion unspecified). Do you think this is the correct code?
Q: I’ve heard that queries differ between critical access and short-term acute care hospital settings. Is this true, and if so, where can I find more information?
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: Should we query for the specific pulmonary exacerbation of cystic fibrosis (CF)? Coding Clinic states that the exacerbation of CF should be listed first.
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?
QUESTION: I'd like to address our coders' questions on how to code poisoning due to bath salts. Internet research has led me to many different options: codes 977.8 (other specified drug/medicinal), 970.89 (other CNS stimulant), 969.70 (psychostimulant, unspecified), among others. What would you suggest? There don't seem to be any guidelines out there and the coding for this seems to be all over the place.
QUESTION: A patient is admitted with pneumonia and atrial fibrillation and both are present on admission. The patient receives antibiotics for the pneumonia and a pacemaker during the stay, but undergoes no other procedures. Does the procedure automatically make ICD-9-CM code 427.31 for the atrial fibrillation the principal diagnosis?
QUESTION: A patient was exposed to shingles, for which a coder reported ICD-9-CM code V01.79 (exposure to other viral diseases, including HIV). This poses a problem for billing as code V01.79 is a confidential diagnosis, requiring special release of information from the patient and would remain on the insurance record. As an RN and certified coder, I believed code V01.71 (exposure to varicella) is the correct code because the varicella virus causes both chicken pox and shingles. However, I am being overridden by the chief business office. Which code is correct?
QUESTION: Do you predict coder productivity will decline as a result of ICD-10? If so, what do you think the declines will be six months after implementation?
QUESTION: Our pulmonologists are not comfortable documenting acute respiratory failure unless the patient is on a ventilator. Also, they rarely document chronic respiratory failure, even in chronic obstructive pulmonary disease (COPD) patients on continuous home oxygen. I’m trying to develop standard query forms for acute and chronic respiratory failure and am running into these obstacles. How do you recommend handling this problem?
QUESTION: A physician documents in an operative report debridement of a necrotic muscle (not due to an open wound). Must the physician also document how the muscle is removed to report ICD-9-CM procedure code 83.45 (other myectomy)? Is this considered excisional or nonexcisional debridement? What documentation is required to code the removal of a necrotic portion of a muscle?
QUESTION: How will we be able to code for procedures such as Billroth procedures, Roux-en-Y anastomoses, and Whipple’s procedure when eponyms won’t be used in ICD-10-PCS?
QUESTION: For a healing traumatic finger amputation with concern but no diagnosis of infection at the amputation site (the physician prescribed Bactrim), is it correct to assign code V54.89 (other orthopedic aftercare) and ICD-9-CM code 886.x (traumatic amputation of finger)?
QUESTION: We are having a discussion about how to code when the studies section of the history and physical (H&P) indicates that the chest x-ray showed atelectasis or that an electrocardiogram showed right bundle branch block with anterior fascicular block. Some of us believe that it’s okay to code the diagnosis (i.e., atelectasis) if the provider states that the testing “showed” the diagnosis, whereas others believe we cannot code the diagnosis as it is a lab/testing result, and the provider could just be reading the results onto his or her H&P dictation. I realize you cannot go to the testing result itself and code from it directly. However, I argue that it would be okay to code for it because the provider is using this information to make decisions about care, testing, and procedures, and he or she indicates the testing results in the H&P body. What are your thoughts?
QUESTION: Recently, reviewers have denied diagnostic code 584.9 (acute renal failure [ARF]) based on lab values. The diagnosis is well documented and treated by the attending physician, but reviewers are stating the lab values do not support the diagnosis of ARF. The lab values (creatinine/blood urea nitrogen) went from normal to abnormal, and we found no definitive standards for lab parameters to meet the definition of ARF. Following coding guidelines for reporting secondary diagnoses, the ARF was clinically evaluated, the patient received therapeutic and diagnostic procedures, and there was an extended length of stay/increased nursing care. As coders, we feel it is inappropriate to question the physician’s clinical judgment, and reporting the ARF as a secondary diagnosis is correct. Based on the documentation in the record, is it appropriate to code the ARF?
QUESTION: Can a patient have encephalopathy after surgery? For example, a patient becomes confused post-surgery and is transferred from the medical-surgical floor to the intensive care unit, where he or she receives high doses of pain medication via IV. However, the patient recovers well and the confusion disappears after the IV fluids and reduction in pain medication and oxygen. Would it be appropriate to query the physician regarding encephalopathy and its possible cause, or would this be a red flag for auditors? The situation did extend the patient’s length of stay by one day.
QUESTION: A physician admits a 30-year-old male with lower abdominal pain. A CT scan showed consistency with perforated appendicitis. However, the patient had an appendectomy 10 months prior. The physician documents "appendiceal stump syndrome." How should I code this case?
QUESTION: I have a question regarding the coding of a computer-assisted fluoroscopy. Consider the following documentation: Use and interpretation of intraoperative fluoroscopy. After positioning the patient, the posterior lumbar area was prepped and draped in the standard sterile fashion. The prior incision was marked with a marking pen. C-arm fluoroscopy was used to map an incision extending from the tip of the spinous process of L2 to that of L5. After performing a time-out, this incision was infiltrated with local anesthetic and incised with a 10-blade scalpel. Dissection proceeded through the subcutaneous fat using Bovie monopolar cautery. Self-retaining retractors were applied. Dissection then proceeded in the midline through the avascular plane through the lumbodorsal fascia and musculature using the Bovie. Self-retaining retractors were deepened. Would you assign a procedure code for the fluoroscopy for this inpatient procedure or would it just be inclusive in the procedure? There seems to be confusion when comparing this procedure in an inpatient setting vs. an outpatient setting.
QUESTION: A patient had an aneurysm at arteriovenous (AV) fistula, and the physician excluded the aneurysm between two clamps, ends oversewn, and excised the aneurysm. The physician used a tunneler to tunnel an 8 mm Flixine graft from the arterial to the venous side, and two end-to-side anastomoses were then performed at the vein and arterial end. Should we report code 39.42 (revision of AV shunt for renal dialysis) with code 38.63 (other excision of vessel), or code 38.43 (resection of vessel with replacement), or another code(s)?