all information is current as of 3/31/13...

All information is current as of 3/31/13 3/31/2013

www.prestigecodingsolutions.com 1

Presented by:

Latonia Hamilton, MBA, RHIT, CCS, CCS-P

AHIMA-Approved ICD-10-CM/PCS Trainer

April 17, 2013



Review ICD-10-CM Coding Guidelines, documentation needed and clinical indicators for Sepsis, TIA, CVA, CHF, ARF, AKI

Assign ICD-10-CM CODES

3/31/2013www.prestigecodingsolutions.com 2



Guidelines, Clinical Indicators, Documentation needed, Coding Examples



3 or more of the following must be present AND cannot be explained by other disease process :

Vital Signs:◦ Fever > 100.4 F or Hypothermia <96.8 F

◦ Heart Rate >90

◦ Respiratory Rate >20

◦ Blood Pressure <90 systolic or a fall in systolic blood pressure 40 mm/Hg drop

Diagnostics:◦ WBC > 12,000 OR < 4,000 OR 10% Bands

◦ Arterial pCO2 < 32 mm/Hg

◦ Unexplained Hyperglycemia in a NON diabetic patient (Blood sugar > 120)

◦ Increased Anion Gap

◦ Reduced Arterial pH Level

◦ May or may not have positive blood culture

Organ Dysfunction:◦ Acute Renal Failure

◦ Oliguria (<30 cc/hr)

◦ Hypotension

◦ Altered mental status/Encephalopathy

◦ Increase Anion gap

◦ Metabolic acidosis

◦ Elevated lactate level

◦ Shock

Medications:◦ Gentamycin

◦ Penicillin

◦ Ampicillin

◦ Cephalosporin

◦ Nafcillin or Oxacillin

◦ Cefazolin

◦ Vancomycin

References: Beth Burgess and AHA Coding Clinic 2Q 2000 p. 3




Coding Scenario Alphabetic Index Tabular List DocumentationNeeded

Patient presented with tachycardia, tachypnea, and WBC of 18,000. Patient was treated with IV Gentamycin and diagnosed with generalized sepsis.

Sepsis(generalized) (unspecified organism) A41.9

A41.9Sepsis,unspecified organismSepticemia NOS

Specificorganism if known

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Nursing home patient is being treated with IV Vancomycin for E. Coli sepsis.

Sepsis, Escherichia coli (E. coli)A41.5

A41.51 Sepsis due to Escherichia coli [E. coli]

Specific organismcausing sepsis

6




Patient admitted with temp of 101.5, heart rate of 99, BP 89/64. Blood cultures was positive for Staph epi, but thought to be a contaminant. Patient was admitted with probable sepsis.

Sepsis(generalized) (unspecified organism) A41.9

A41.9Sepsis,unspecified organismSepticemia NOS

Probable sepsis documented at the time of discharge.

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Patient was admitted with dysuria, temp 101.5, WBC 14,000. Diagnosis given was urosepsis.

Urosepsis – see condition

Sepsis or UTI with specific organism

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Coding Scenario Alphabetic Index Tabular List Documentation Needed

Female patient takento ER with fever of 100.6, HR of 100, respiratory rate of 22. Diagnosed with severe sepsis with acute respiratory failure. Discharge summary stated gram negative sepsis with acute respiratory failure.

Sepsis, gram-negative (organism) A41.0Severe sepsis R65.20Failure, respiratory, acute J96.00

A41.50 Gram-negative sepsis, unspecifiedR65.20 Severe sepsis without septic shock (Severe sepsis NOS)J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia

Specific gram negative organism, respiratory failure with hypercapnia or hypoxia

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A41.5 Sepsis due to other Gram-negative organisms A41.50 Gram-negative sepsis, unspecified Gram-negative sepsis NOS A41.51 Sepsis due to Escherichia coli [E. coli] A41.52 Sepsis due to Pseudomonas Pseudomonas aeroginosa A41.53 Sepsis due to Serratia A41.59 Other Gram-negative sepsis

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Patient is discharged with a diagnosis of septic shock due to acute meningococcal sepsis.

Sepsis, meningococcal, acute A39.2Sepsis, with,organ dysfunction, with septic shock R65.21

A39.2 Acute meningococcemia

R65.21 Severesepsis with septic shock

Acute or chronic meningococcalsepsis

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Patient with stage 4 non-small cell carcinoma of RUL lung presents with BP 89/60, WBC 18,000, HR 110, tachypnea. Diagnosed with pseudomonas sepsis, acute on chronic respiratory failure with hypoxia due to lung cancer.

• Sepsis, gram-negative, A41.5

• Failure,respiratory, acute on chronic, with hypoxia J96.21

• Table of Neoplasms, lung, upper lobe, malignant primary C34.1

A41.52 Sepsis dueto pseudomonasJ96.21 acute and chronic respiratory failure with hypoxiaC34.11 Malignant neoplasm of upper lobe, right bronchus or lung

If organ dysfunction is related or unrelated to sepsis

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Septic shock generally refers to circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction.

For cases of septic shock, the code for the systemic infection should be sequenced first, followed by code R65.21, Severe sepsis with septic shock or code T81.12, Postprocedural septic shock. Any additional codes for the other acute organ dysfunctions should also be assigned. As noted in the sequencing instructions in the Tabular List, the code for septic shock cannot be assigned as a principal diagnosis.




If severe sepsis is present on admission, and meets the definition of principal diagnosis, the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2 as required by the sequencing rules in the Tabular List. A code from subcategory R65.2 can never be assigned as a principal diagnosis.

When severe sepsis develops during an encounter (it was not present on admission) the underlying systemic infection and the appropriate code from subcategory R65.2 should be assigned as secondary diagnoses.

Severe sepsis may be present on admission but the diagnosis may not be confirmed until sometime after admission. If the documentation is not clear whether severe sepsis was present on admission, the provider should be queried.




If the reason for admission is both sepsis or severe sepsis and a localized infection, such as pneumonia or cellulitis, a code(s) for the underlying systemic infection should be assigned first and the code for the localized infection should be assigned as a secondary diagnosis. If the patient has severe sepsis, a code from subcategory R65.2 should also be assigned as a secondary diagnosis. If the patient is admitted with a localized infection, such as pneumonia, and sepsis/severe sepsis doesn’t develop until after admission, the localized infection should be assigned first, followed by the appropriate sepsis/severe sepsis codes.




Clinical Indicators, Documentation needed, Coding Examples

G45

Diseases of the Nervous System



Definition◦ “Brief periods of acute ischemic, focal neurologic

insufficiency that lasts from a few minutes to less than twenty-four hours and leave no residual effects; they begin suddenly and subside slowly”

Etiology:◦ Embolic from atherosclerotic plaque◦ Fragments of cardiac valvular vegetations◦ Hypertension◦ Atherosclerosis◦ Disorders of the red blood cells◦ Thrombocytosis

Reference: Clinotes 5th Edition p. 200




Signs and symptoms of carotid, middle cerebral, and vertebrobasilar distribution lesions:◦ Rapid, unilateral graying out of vision (Amaurosis

Fugax), sluggish pupil, pale retina◦ Face-hand, hand-arm, or hemiparetic weakness◦ Aphasia◦ Dysarthria◦ Transient global amnesia◦ Diplopia◦ Ataxia◦ Headache◦ Nonpositional vertigo◦ Deafness

Reference: Clinotes 5th edition p. 200




Treatment◦ Treating any conditions that put the patient at risk for

CVA such as hypertension, hypoglycemia, coronary artery disease

◦ Anticoagulation or antiplatelet therapy◦ Surgery

Carotid endarterectomy (for carotid artery produced TIAs) Vertebral artery endarterectomy, transposition, or

transluminal angioplasty

Medications◦ Heparin, Warfarin (Coumadin), Antiplatelet

Diagnostic Tests◦ CT & MRI, ECG, LP, Cerebral angiography, Ultrasound

Reference: Clinotes 5th edition p. 200





Patient was admitted for headache and new onset of aphasia that lasted two hours. Head CT was obtained and patient was diagnosed with TIA.

Attack, transient ischemic, to assign code G45.9

G45.9 Transient cerebral ischemic attack, unspecifiedSpasm of cerebral arteryTIATransient cerebral ischemia NOS

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Patient presented with a temporary blindness. that resulted from transient ischemia caused by an insufficiency of the carotid artery. Final diagnosis was Amaurosis Fugax.

Amaurosis (acquired) (congenital) (see also Blindness)

Fugax G45.3

G45.3 Amaurosis Fugax

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G45

Transient cerebral ischemic attacks and related syndromes

Excludes1:

neonatal cerebral ischemia (P91.0)

transient retinal artery occlusion (H34.0-)

G45.0

Vertebro-basilar artery syndrome

G45.1

Carotid artery syndrome (hemispheric)

G45.2

Multiple and bilateral precerebral artery syndromes

G45.3

Amaurosis fugax

G45.4

Transient global amnesia

Excludes1:

amnesia NOS (R41.3)

G45.8

Other transient cerebral ischemic attacks and related syndromes

G45.9

Transient cerebral ischemic attack, unspecified

Spasm of cerebral artery

TIA

Transient cerebral ischemia NOS

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Guidelines, Clinical Indicators, Coding Examples, Documentation needed



Signs and Symptoms◦ Acute severe headache

◦ Coma

◦ Hemiparesis

◦ Vomiting, dizziness, seizure

◦ Rigid neck, stiff back and legs

◦ Dysphagia◦ Altered mental status◦ Incoordination

◦ hypersomnia

Treatment◦ Surgery – evacuation of hematoma, clipping of aneurysm, burr hole, craniotomy

◦ Bed rest and mild sedation

◦ Corticosteroid therapy◦ IV rehydration lateral ventricular decompression

Medication◦ Anticoagulant

◦ Platelet inhibitor

◦ Sedative

◦ Furosemide

Lab Diagnostic Tests◦ LP, Skull X-ray, CT, MRI, Angiography, cardiac monitoring, ECG for neurologic abnormalities

Clinotes 5th edition pp. 193-199





Patient hasaphasia and left sided hemiparesis on his nondominant side from a CVA 6 months ago.

Hemiparesis –See HemiplegiaHemiplegia, following,cerebrovascular disease, cerebral infarction, I69.35-Aphasia, following, cerebrovascular disease, cerebral infarction, I69.320

I69.354 Hemiplegia and hemiparesisfollowing cerebral infarction affecting left nondominant sideI69.320 Aphasia following cerebral infarction

Type of cerebrovascular disease: cerebral infarction, intracerebral hemorrhage, nontraumatic intracranial hemorrhage, subarachnoid hemorrhage,

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Patient has left sided hemiparesis from a CVA 6 months ago

Hemiparesis –See HemiplegiaHemiplegia, following,cerebrovascular disease, cerebral infarction, I69.35-

I69.354 Hemiplegia and hemiparesisfollowing cerebral infarction affecting left nondominant side

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Ambidextrous patient presented with an acute nontraumatic subarachnoid hemorrhage. Patient also has right hemiplegia from a cerebral infarction 3 years ago.

• Hemorrhage, subarachnoid (nontraumatic) —see Hemorrhage, intracranial, subarachnoid• Hemorrhage,

intracranial, subarachnoid (nontraumatic)(from) I60.9

• Hemiplegia, following, cerebrovascular disease, cerebral infarction I69.35-

• I60.9 Nontraumaticsubarachnoid hemorrhage, unspecified

• I69.351 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side

• Artery involved in hemorrhage

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I60.4

Nontraumatic subarachnoid hemorrhage from basilar artery

I60.5

Nontraumatic subarachnoid hemorrhage from vertebral artery

I60.50

Nontraumatic subarachnoid hemorrhage from unspecified vertebral artery

I60.51

Nontraumatic subarachnoid hemorrhage from right vertebral artery

I60.52

Nontraumatic subarachnoid hemorrhage from left vertebral artery

I60.6

Nontraumatic subarachnoid hemorrhage from other intracranial arteries

I60.7

Nontraumatic subarachnoid hemorrhage from unspecified intracranial artery

Ruptured (congenital) berry aneurysm

Ruptured (congenital) cerebral aneurysm

Subarachnoid hemorrhage (nontraumatic) from cerebral artery NOS

Subarachnoid hemorrhage (nontraumatic) from communicating artery NOS

Excludes1:

berry aneurysm, nonruptured (I67.1)

I60.8

Other nontraumatic subarachnoid hemorrhage

Meningeal hemorrhage

Rupture of cerebral arteriovenous malformation

I60.9

Nontraumatic subarachnoid hemorrhage, unspecified




Guidelines, Clinical Indicators, Coding Examples



Definition: ◦ the heart is unable to pump enough blood to keep up with the body’s demand

Etiology: ◦ CAD, past MI, HTN, arrhythmias, heart valve disease congenital heart disease,

cardiomyopathy, infection of heart valves or heart muscle (endocarditis or myocarditis)

Signs and Symptoms: ◦ dyspnea, orthopnea, tachypnea, sleep apnea, hyponatremia, rales or crackles heard in

the lungs, peripheral edema (swelling in legs, ankles, or feet), ascites, rapid or irregular heartbeat, fluid retention, persistent cough with white or pink blood tinged phlegm

Treatment: ◦ medications, rest, proper diet, sodium restriction, weight reduction, CPAP, BiPAP, ICD,

Bi-Ventricular pacer, heart pump, heart transplant

Medications: ◦ ACE inhibitors, Digoxin, Beta blockers, Diuretics, Vasopressin receptor antagonists

Lab Diagnostic Tests: ◦ Chest x-ray, Echocardiogram, EKG, Blood tests, stress test, CT scan, MRI, cardiac

catheterization Clinotes 5th edition pp. 191-192




Left Heart Only*** ◦ Left ventricular abnormal function ◦ Signs: Pulmonary congestion (effusion; edema)

Right due to Left (Combined)*** ◦ Most common cause of Right HF is Left HF ◦ Signs: Pulmonary and peripheral congestion ◦ Abnormal left ventricular function with elevated RH pressures

Right Heart Failure Only ◦ Underlying lung disease or congenital heart disease with significant

shunting ◦ Signs of peripheral congestion: swollen liver; ascites; peripheral edema;

pleural effusions; Jugular vein distention ◦ Peripheral congestion with pulmonary hypertension and RV pressures with

normal Wedge pressure (Pulmonary venous pressures or PCWP)

***Represents 95% or more of HF Beth Burgess @ Huff DRG Review Services




“Systolic heart failure: This condition occurs when the pumping action of the heart is reduced or weakened. A common clinical measurement is ejection fraction (EF). The ejection fraction is a calculation of how much blood is ejected out of the left ventricle (stroke volume) divided by the maximum volume remaining in the left ventricle at the end of diastole, or when the heart is relaxed after filling with blood. A normal ejection fraction is greater than 55%. Systolic heart failure is diagnosed when the ejection fraction has significantly decreased below the threshold of 55%.

Diastolic heart failure: This condition occurs when the heart can contract normally but is stiff, or less compliant, when it is relaxing and filling with blood. The heart is unable to fill with blood properly, which produces backup into the lungs and heart failure symptoms. Diastolic heart failure is more common in patients older than 75 years of age, especially in patients with high blood pressure, and it is also more common in women. In diastolic heart failure, the ejection fraction is normal or increased.”

http://www.emedicinehealth.com/congestive_heart_failure/page2_em.htm

Everyone with systolic CHF has diastolic dysfunction, BUT not everyone with diastolic CHF has systolic dysfunction. MD HAS to document type of CHF.

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Congestive heart failure Failure, heart, congestive (compensated) (decompensated) I50.9

I50.9Heart failure, unspecifiedBiventricular (heart) failure NOSCardiac, heart or myocardial failure NOSCongestive heart diseaseCongestive heart failure NOSRight ventricular failure (secondary to left heart failure)

Acuity and type

Chronic diastolic heart failure Failure, heart, diastolic,chronic (congestive) I50.32

I50.32Chronic diastolic (congestive) heart failure

Acuity and type

Acute systolic heart failure Failure, heart, systolic, acute (congestive) I50.21

I50.21Acute systolic (congestive) heart failure

Acuity and type

Acute on chronic diastolic and systolic heart failure

Failure, heart, diastolic, combined with systolic (congestive), acute, and (on) chronic (congestive) I50.43

I50.43Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure

Acuity and type

33



Guidelines, Clinical Indicators, Coding Examples, Documentation needed



Chapter 10 Diseases of the respiratory system (J00-J99)

When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site (e.g. tracheobronchitis to bronchitis in J40).

Use additional code, where applicable, to identify: exposure to environmental tobacco smoke (Z77.22) exposure to tobacco smoke in the perinatal period (P96.81) history of tobacco use (Z87.891) occupational exposure to environmental tobacco smoke (Z57.31) tobacco dependence (F17.-) tobacco use (Z72.0)

35



Definition: Impairment of the gas exchange between air and circulating blood

Etiology◦ Asthma, COPD, emphysema

◦ Pneumonia

◦ Cardiogenic pulmonary edema◦ CVA, central nervous disorders

◦ Drug overdose, Trauma

Signs and Symptoms:◦ Peripheral edema, respiratory acidosis, hyperkalemia

◦ Wheezing, use of accessory muscles, poor air movement

◦ Hypoxemia, hypercapnia

Treatment:◦ Humified oxygen, High flow oxygen (>4 to 6L NC or non-rebreather mask)

◦ Mechanical ventilation, PEEP, CPAP

Medication:◦ Dopamine, bronchodilator, antibiotic, diuretic

Lab Diagnostic Test◦ ABG: pO2 <60 mm Hg, pCO2 > 50 mm Hg, pH < 7.30

◦ O2 SATs < 88%

◦ Chest x-ray◦ Electrocardiogram

◦ Pulmonary function test

◦ Sputum culture and sensitivity Clinotes 5th edition p. 248 and Beth Burgess of Huff DRG Review Services




“Hypoxemic respiratory failure (type I) is characterized by an arterial oxygen tension (Pa O2) lower than 60 mm Hg with a normal or low arterial carbon dioxide tension (Pa CO2). This is the most common form of respiratory failure, and it can be associated with virtually all acute diseases of the lung, which generally involve fluid filling or collapse of alveolar units. Some examples of type I respiratory failure are cardiogenic or noncardiogenic pulmonary edema, pneumonia, and pulmonary hemorrhage.

Hypercapnic respiratory failure (type II) is characterized by a PaCO2 higher than 50 mm Hg. Hypoxemia is common in patients with hypercapnic respiratory failure who are breathing room air. The pH depends on the level of bicarbonate, which, in turn, is dependent on the duration of hypercapnia. Common etiologies include drug overdose, neuromuscular disease, chest wall abnormalities, and severe airway disorders (eg, asthma and chronic obstructive pulmonary disease [COPD]).”

http://emedicine.medscape.com/article/167981-overview

37





Patient presented to ER with wheezing, hypoxia and use of accessory muscles. She transferred to another facility due to with respiratory failure with hypoxia.

Failure, respiratory, with hypoxia J96.91

J96.91 Respiratory failure, unspecified with hypoxia

Acute or chronicHypoxia, hypercapnia

38




Patient was admitted through ER for generalized sepsis. Patient has a history of systolic CHF. Two days following admission, patient had an exacerbation of systolic CHF and went into acute hypercapnic respiratory failure unrelated to sepsis.

• Sepsis (generalized) (unspecified organism) A41.9

• Failure, heart, systolic (congestive), acute, and (on) chronic (congestive) I50.23

• Failure, respiratory, acute, with hypercapnia J96.02

• A41.9 Sepsis, unspecified organism Septicemia NOS

• I50.23 Acute on chronic systolic (congestive) heart failure

• J96.02 Acute respiratory failure with hypercapnia

39




Nursing home patient is admitted with aspiration pneumonia and acute respiratory failure. Patient was started on IV antibiotics. Patient was a DNR and died 6 hours later.

Pneumonia, aspiration J69.0Failure, respiratory, acuteJ96.00

J69.0Pneumonitis due to inhalation of food and vomitAspiration pneumonia NOSCode alsoany associated foreign body in respiratory tract (T17.-)J96.00Acute respiratory failure, unspecified whether with hypoxia or hypercapnia

What did patient aspirate on (food, milk, vomit, oil, blood, detergent, etc.)Was there a foreign body in the respiratory tract?

40



Guidelines, Clinical Indicators, Coding Examples, Documentation Needed



Definition: ◦ Sudden, severe onset of inadequate kidney function

Etiology:◦ Prerenal: decreased renal blood flow caused by hypovolemia,

hepatorenal syndrome, vascular problems or infection◦ Intrinsic: involves damage to the renal tubule cells caused by

ischemia in the kidneys (lack of oxygen) or by exposure to nephrotoxic agents e.g. Acute tubular necrosis (ATN)

◦ Postrenal: occurs because of urinary tract obstruction

Signs and Symptoms:◦ Oliguria, nausea and/or vomiting, hydronephrosis, metabolic

acidosis, lethargy caused by the toxic waste products, edema from salt and water overload

Treatment Activity:◦ Bladder catheterization, monitoring fluid intake and output

Lab Diagnostic Tests: ◦ BUN and creatinine levels, renal ultrasound, renal biopsy

42



Stage Serum Creatinine Urine Output

1 1.5 – 1.9 times baseline within 7 day period

OR > 0.3 mg/dl increase over 48

hrs.

<0.5 ml/kg/hr for 6-12 hrs.

2 2.0 – 2.9 times baseline <0.5 ml/kg/hr for > 12 hrs.

3 3.0 times baseline OR

Increase serum creatinine > 4.0mg/dl

OR Initiation of renal

replacement RX

<0.3 ml/kg/h for > 24hrs.




N17.0 Acute kidney failure with tubular necrosis◦ Acute tubular necrosis◦ Renal tubular necrosis◦ Tubular necrosis NOS

N17.1 Acute kidney failure with acute cortical necrosis◦ Acute cortical necrosis◦ Cortical necrosis NOS◦ Renal cortical necrosis

N17.2 Acute kidney failure with medullary necrosis◦ Medullary [papillary] necrosis NOS◦ Acute medullary [papillary] necrosis◦ Renal medullary [papillary] necrosis

N17.8 Other acute kidney failure N17.9 Acute kidney failure, unspecified◦ Acute kidney injury (nontraumatic)

Excludes2: traumatic kidney injury (S37.0-)

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AHIMA ICD-10-CM Coder Training Manual

Beth Burgess, Huff DRG Review Services

Clinotes 5th edition






Latonia Hamilton, MBA, RHIT, CCS, CCS-P

AHIMA-Approved ICD-10-CM/PCS Trainer

[email protected]

[email protected]

www.prestigecodingsolutions.com

704-315-4083


mailto:[email protected]

mailto:[email protected]

http://www.prestigecodingsolutions.com/

all information is current as of 3/31/13...

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