YOU WERE LOOKING FOR: Icd-10-cm Coding Scenarios With Answers
Below you will find a article that does a great job of explaining GEMs although it does mention the "possible" implementation of ICD and we all know that it is not possible, but a definite reality. Of course, this is a very simplistic view and since...
Remember - there are many places that notes appear - at the beginning of a chapter - at the beginning of a category - at the beginning of a 4th digit subcatgory or a 5th digit subcategory - and under the specific code. Just like in ICD-9, you have...
Now do not just skim it but read it over and have your coding staff and even CDI staff also read it over. Next thing to do is to schedule a meeting to discuss with both groups of professionals, a virtual meeting will work. Allow enough time for a discussion of the guidance contained in this issue. Ask during your discussion if there are any documentation concerns or issues to consider; or documentation issues that could arise in the future in relation to the coding advice. Consider preparing and offering some education to physicians; hospitalists, intensivists, and ED physicians are a good place to start. If there are questions that your own staff including CDI have that you believe needs further clarification, be sure to submit a question to AHA Coding Clinic through their online portal, there is no fee for this which is a great benefit, go to: AHA Coding Clinic codingclinicadvisor. As always, follow up within days with a coding audit to validate some of the specific coding areas from this issue.
You may want to even consider the services and assistance that an external coding consulting vendor can offer. RMC is a woman-owned, US-based and operated company which specializes in a variety of medical coding and auditing services. Contact us here. Contact Us.
All rights reserved. Renee StantzQ: An year-old female patient is seen for an ankle sprain. This block instructs us to use a fifth, sixth and seventh digit: S First of all, some payers have stated that they are not going to reimburse claims with unspecified ICDCM codes. Also, government and third-party payers are going to assign severity and risk scores based on the diagnosis codes billed , and these scores will help you justify higher level codes and better reimbursement. For coders, I suggest a written query to the physician requesting the following additional information: Which ankle, right or left? Is this the initial, subsequent or sequel encounter? How did this injury happen? Where did this injury happen?
Once the physician responds, you can then choose the correct specific code. For instance, the physician may indicate that this is the initial encounter for this problem, and the patient sprained her right ankle when she slipped on ice on the driveway while going to the mailbox.
In support of this objective, we have provided outpatient focused scenarios to illustrate specific ICD documentation and coding nuances related to your specialty. As patient history and circumstances will vary, these brief scenarios are illustrative in nature and should not be strictly interpreted or used as documentation and coding guidelines. Each scenario is selectively coded to highlight specific topics; therefore, only a subset of the relevant codes are presented. Pain is a dull ache. Reports 2 periods in the last year. Historically cycles have been regular lasting 28 — 30 days each. LMP was 4 months ago. No family history of ovarian or cervical cancer. Patient had a benign ovarian cyst successfully removed at age Exam Abdomen is soft. RLQ is tender to palpation. No rebound tenderness or guarding of abdomen. Bowel sounds normal in all 4 quadrants. Pelvic shows cervical motion tenderness and adnexal tenderness on the right. Mild right ovarian tenderness. No palpable ovarian or uterine enlargement.
Urine pregnancy test is negative. Assessment and Plan Given patient history and clinical findings right ovarian cyst is suspected. Order transvaginal ultrasound to rule out ovarian cyst. Patient counseled on pain relief exercises. Pain Rx also given. Scheduled a follow-up visit in 1 week. This information needs to be captured in the note. Providing a detailed description of the pain characteristics is important as well. The documentation and context of the pain presentation will determine if additional codes are assigned, that is, if the pain is considered part of the disease process, an additional code for pain will not be listed. To address this point in the coding section we have presented both combinations N It is important to include the patient history, as this can justify additional diagnostic testing. In ICDCM abdominal tenderness is differentiated to address the rebound characteristic with different codes.
Providing the patient history can justify additional diagnostic tests such as the ultrasound here. LMP December 20, Last Pap was normal. No history of STD. No significant changes over the last year. Positive family history for breast cancer — mother and all three sisters. Sisters are BRCA. Reports finding a small lump in left breast. Exam Pelvic exam is normal.
Pap smear performed. Left breast examined normal except for 1. Mass is tender, easily moveable, firm to touch. Axilla normal, without palpable nodes. Right breast normal. Assessment and Plan Normal pelvic exam. Will confirm Pap results with the patient. Scheduled fine needle aspiration of left breast mass at the end of this week — with Dr. Scheduled a follow-up visit in 1 week to discuss aspiration results and next steps. There are different diagnosis codes for each. The rationale for abnormal findings in this encounter is based on the presence of the breast lump. Using ICD-9 codes, Pap smear coding may vary by payor. In some cases payors reimburse for the retrieval of the Pap smear by the physician, and the screening Pap smear at a specific frequency e. With the new terminology associated with ICDCM codes this point will need to be assessed and confirmed so correct code assignment can occur. Capture that information as appropriate in your note. ICDCM can now capture the side of the body.
There are separate codes for left and right breast diagnoses. As the clinical status for this patient is not known, it does not have right versus left, e. It is important to describe the mass in as much detail as possible. Capturing the appropriate side of the body is important, as some payers may deny claims without this information. Scenario 3: Preeclampsia.
This quiz will evaluate your coding knowledge and point out any weaknesses. Each correct answer is worth one point. However, if you disagree with our answer to any question, please research the issue. Mistakes happen. The correct answer to each question will appear once you have submitted your answer to each question. You score will appear at the end of the ICDCM Theory Quiz in the form of the number of questions that were correct, and your percentage of correct answers. The ICDCM Theory Quiz is to be used for the purpose self instruction and learning as well as your own personal continuing education. Please follow these instructions: Number 1. Number 2. Save this document to your desktop.
Number 3. Send it to the intended recipient. Each question has only 1 correct answer. You will be able to view each question and the both the correct and incorrect answers at the conclusion of each question. There is no time limit on this quiz. When reviewing your quiz answers, note that the the red X indicates an incorrect answer. The green checkmark indicates the correct answer. If you disagree with an answer, please be sure to research it on your own. Good luck. You can take this quiz multiple times.
For more information on this code, click here. The code was developed by the World Health Organization WHO and is intended to be sequenced first followed by the appropriate codes for associated manifestations when COVID meets the definition of principal or first-listed diagnosis. Question 7: Is code B The code does not distinguish the more than 30 varieties of coronaviruses, some of which are responsible for the common cold. Due to the heightened need to uniquely identify COVID until the unique ICDCM code is effective April 1, providers are urged to consider developing facility-specific coding guidelines that limit the assignment of code B Because code B Assign a code s explaining the reason for encounter such as fever, or Z Can you clarify whether the record needs to have a copy of the lab results or what lab tests are approved for confirmation? It is not required that a copy of the confirmatory test be available in the record or documentation of the test result.
A presumptive positive test result means an individual has tested positive for the virus at a local or state level, but it has not yet been confirmed by the Centers for Disease Control and Prevention CDC. Patients are being seeing in our emergency department and if results are not available at the time of discharge, we are reluctant to query the physicians to go back and document the linkage when the results come back several days later.
Please note that this advice is limited to cases related to COVID and not the coding of other laboratory tests. Due to the heightened need to uniquely identify COVID patients, we recommend that providers consider developing facility-specific coding guidelines to hold back coding of inpatient admissions and outpatient encounters until the test results for COVID testing are available. Question Since the new guidelines for COVID regarding sepsis just say to refer to the sepsis guideline, is that then saying that sepsis would be sequenced first and then U For example, if a patient is admitted with pneumonia due to COVID which then progresses to viral sepsis not present on admission , the principal diagnosis is U On the other hand, if a patient is admitted with sepsis due to COVID pneumonia and the sepsis meets the definition of principal diagnosis, then the code for viral sepsis A See Questions 38 and 39 for updated advice regarding the coding for encounters for testing for COVID and COVID has not been confirmed Question Please provide guidance on correct coding when the provider has documented COVID as a definitive diagnosis before the test results are available, and the test results come back negative.
Providers should be given the opportunity to reconsider the diagnosis based on the new information. Question Please provide guidance on correct coding when the provider has confirmed the documented COVID after the test results come back negative. How should this be coded? There is an Excludes1 note at category J12, Viral pneumonia, not elsewhere classified, that excludes pneumonia not otherwise specified J This meets the exception to the Excludes1 guideline as a circumstance when the two conditions are unrelated to each other.
Note that effective January 1, , there is a new code, J Code both conditions separately, with sequencing depending on the circumstances of admission — just like a patient suffering from diabetes or any other chronic condition that puts them at higher risk for the COVID infection. If the provider documents that the patient no longer has COVID, assign the appropriate personal history code code Z Question When a patient is diagnosed with COVID, we understand that signs and symptoms are not manifestations and would not be separately coded. We also understand that Guideline I. This is supported by Guideline IC. For a newborn that tests positive for COVID and the provider documents the condition was contracted in utero or during the birth process, assign codes P Question What is the correct sequencing for a patient who is status post lung transplant admitted for management of respiratory manifestations of COVID? This sequencing is supported by the Tabular List note at code T Later the same day, the patient presented to the emergency department with pneumothorax and was readmitted due to increasing shortness of breath and for pneumothorax evacuation.
Chest tube was inserted, the patient improved and was discharged. How should the readmission be coded? If the documentation is not clear regarding whether the physician considers a condition to be an acute manifestation of a current COVID infection vs. The patient now presents to the emergency department with shortness of breath and is admitted. A personal history code is not appropriate because as stated in guideline I. Question A patient was diagnosed with COVID infection a week ago and is admitted after developing acute onset shortness of breath associated with upper back pain as well as dizziness without syncope.
What are the appropriate codes? Per the instructional note under code U Question A patient is readmitted due to shortness of breath following a previous admission for COVID and associated respiratory failure. He has completed treatment, but he cannot go back to the nursing home until he tests negative for COVID, so he is admitted to the skilled nursing facility SNF unit at the hospital until he tests negative and can return to the nursing home where he resides. What code should be assigned for the hospital SNF unit stay? Do not assign a code for the pneumonia as the condition has resolved. Question A patient was transferred from a short-term acute care hospital to a long term acute care hospital LTCH for continued treatment of acute hypoxic respiratory failure due to COVID What are the appropriate codes for the LTCH admission? Question A patient was transferred from an acute care hospital to a rehab facility due to sequelae of a COVID infection, including critical illness myopathy and peroneal palsy in the right lower extremity.
What codes should be assigned? Assign code B Question A patient was transferred from an acute care hospital to a rehab facility for deconditioning for generalized debility due to prolonged hospitalization for COVID which has now resolved. Assign the appropriate personal history code code Z Do not assign code B Should code Z The ICDCM Official Guidelines for Coding and Reporting state that codes in category Z20, Contact with and suspected exposure to communicable diseases, are for patients who are suspected to have been exposed to a disease by close personal contact with an infected individual or are in an area where a disease is epidemic.
Coding guidance will be updated as new information concerning any changes in the pandemic status becomes available. For symptomatic individuals with actual or suspected exposure to COVID and the infection has been ruled out, or test results are inconclusive or unknown, assign code Z If disseminated intravascular coagulation DIC is documented, assign code D65, Disseminated intravascular coagulation [defibrination syndrome], instead of code D Therefore, the code assignment depends on the provider documentation. For documentation of viral shedding in a patient with a personal history of a COVID infection rather than an active infection, assign code Z If the documentation is not clear as to whether the patient has an active COVID infection or a personal history, query the provider.
As stated in the ICDCM Official Guidelines for Coding and Reporting, in the absence of Alphabetic Index guidance for coding syndromes, assign codes for the documented manifestations of the syndrome. The appropriate personal history code is Z If the provider documents that the symptoms are the result residual effect of COVID, assign code s for the specific symptom s and code B According to the ICDCM Official Guidelines for Coding and Reporting, a sequela is the residual effect condition produced after the acute phase of an illness or injury has terminated. Question A patient presents to the emergency department with complaints of throat tingling and chest tightness following administration of the COVID vaccine.
How should this case be coded? Question A patient presents to the emergency department with complaint of malaise following administration of the COVID vaccine. B95A, Adverse effect of other viral vaccines, initial encounter. Question A patient presents to the emergency department via ambulance after complaining of hives and swelling, severe breathing problems, and swelling in the throat, following administration of the COVID vaccine.
The current ICDCM indexing for anaphylactic reaction to immunization points to a code for serum reaction. Although subcategory T Question Should normal or expected side effects of the COVID vaccination be coded for patients seeking medical care or for patients in nursing homes, hospitals, etc. Assign the code for the nature of the effect e. After more than a 2 month stay, the patient is now transferred to a long-term care hospital LTCH with acute respiratory failure for tracheostomy weaning. Diagnosis on admission was history of COVID, acute respiratory failure, and tracheostomy dependence. May we assign code J Assign the appropriate respiratory failure code based on the response, followed by code B Patient is status post prolonged hospitalizations for respiratory failure and critical illness secondary to COVID pneumonia.
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