Question

Worksheet for Identifying Coding Quality Problems
Case 1	Principal Diagnosis: B96.20 Unspecified Escherichia coli as the cause of diseases classified elsewhere Secondary Diagnosis: N39.0 Urinary tract infection, site not specified
Problem(s) Identified: Sequencing—incorrect sequencing of codes Coding Rule Violated: See Section 1.B. and #7 of the coding guidelines. The infection should be listed first followed by the organism causing the infection.
Case 2	Principal Diagnosis: A41.02 Methicillin resistant Staphylococcus aureus sepsis Secondary Diagnosis: B95.62 Methicillin-resistant Staphylococcus aureus infection as cause of diseases classified elsewhere
Problem(s) Identified: Coding Rule Violated:
Case 3	Principal Diagnosis: E10.1 Type 1 diabetes mellitus without complications Secondary Diagnosis: E11.29 Type 2 diabetes mellitus with other diabetic kidney complication
Problem(s) Identified: Coding Rule Violated:
Case 4	Principal Diagnosis: I11.0 Hypertensive heart failure Secondary Diagnosis: I10 Hypertension Secondary Diagnosis: I50.9 Heart failure, unspecified
Problem(s) Identified: Coding Rule Violated:
Case 5	Principal Diagnosis: R10.9 Unspecified abdominal pain Secondary Diagnosis: K52.9 Noninfective gastroenteritis and colitis, unspecified
Problem(s) Identified: Coding Rule Violated:
Case 6	Principal Diagnosis: O80 Encounter for full-term uncomplicated delivery Secondary Diagnosis: Z38.0 Single liveborn infant, delivered vaginally
Problem(s) Identified: Coding Rule Violated:

Answer 1

1.

Diagnosis Index entries containing back-references to B96.20:

• Bacillus - see also Infection, bacillus
  • coli infection B96.20 - see also Escherichia coli
• Colibacillosis A49.8
  • as the cause of other disease B96.20 - see also Escherichia coli
• Escherichia coli (E. coli) B96.20
• Infection, infected, infective (opportunistic) B99.9
  • bacterial NOS A49.9
    • as cause of disease classified elsewhere B96.89
      • Escherichia coli [E. coli] B96.20 - see also Escherichia coli
  • Escherichia (E.) A49.8
    • as cause of disease classified elsewhere B96.20 - see also Escherichia coli

Diagnosis Index entries containing back-references to N39.0:

• Infection, infected, infective (opportunistic) B99.9
  • urinary (tract) N39.0
• Pus
  • in
    • urine N39.0
• Pyuria N39.0 (bacterial)
• Urine
  • pus in N39.0

2.

Diagnosis Index entries containing back-references to B95.62:

• Infection, infected, infective (opportunistic) B99.9
  • bacterial NOS A49.9
    • as cause of disease classified elsewhere B96.89
      • Staphylococcus B95.8
        • aureus (methicillin susceptible) (MSSA) B95.61
          • methicillin resistant B95.62 (MRSA)
  • staphylococcal, unspecified site
    • as cause of disease classified elsewhere B95.8
      • aureus (methicillin susceptible) (MSSA) B95.61
        • methicillin resistant B95.62 (MRSA)
• MRSA (Methicillin resistant Staphylococcus aureus)
  • infection A49.02
    • as the cause of diseases classified elsewhere B95.62
• Staphylococcus, staphylococcal - see also condition
  • as cause of disease classified elsewhere B95.8
    • aureus (methicillin susceptible) (MSSA) B95.61
      • methicillin resistant B95.62 (MRSA)

4.

Principal Diagnosis: I11.0 Hypertensive heart failure

At the point when an individual has hypertension and coronary illness, it is up to the supplier to decide if there is a causal relationship expressed or inferred. This relationship assurance is illuminated in the "Official Guidelines for Coding and Reporting" (draft 2014).

The mix of hypertension and hypertensive coronary illness is as of now coded utilizing the ICD-9 402.xx arrangement of codes. As noted before, every class is right now partitioned into threatening, kind, and unspecified fundamental hypertension with or without heart disappointment. In ICD-10, this is limited to just two base codes:

I11.0, Hypertensive heart disease with heart failure,

Secondary Diagnosis: I10 Hypertension

In ICD-9, fundamental hypertension was coded utilizing 401.0 (dangerous), 401.1 (generous), or 401.9 (unspecified). ICD-10 utilizes just a solitary code for people who meet criteria for hypertension and don't have comorbid heart or kidney malady. That code is I10, (essential) hypertension.

As in ICD-9, this code incorporates "hypertension" however does exclude lifted pulse without a finding of hypertension (that would be ICD-10 code R03.0). In the event that a patient has advanced from hoisted pulse to a formal conclusion of hypertension, a great documentation practice is incorporate the explanation behind advancing the formal analysis. Correspondingly, a solitary somewhat raised pulse perusing ought to be coded with the R03.0 until the point when the formal analysis is built up.

Secondary Diagnosis: I50.9 Heart failure, unspecified

If you do not have a measurement of the left ventricular ejection fraction (typically from an echocardiogram), then you would need to use the more general left ventricular failure code (I50.1).

The three codes for systolic, diastolic, and combined failure also require a fifth digit specifying the acuity of the diagnosis:

• 0, Unspecified,
• 1, Acute,
• 2, Chronic,
• 3, Acute on chronic.

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