Question

Coding Quality in ICD-10-CM

Instructions

Perform a face validity review of the six (6) discharges shown in the table below to ensure compliance to official coding guidelines, which can be found in your codebook or online. Report any coding quality issues you identify from your review. Explain why, and reference the specific coding guidelines that support your explanation of the quality issues you have identified.

For this assignment, you will need to review each code in the table below for notes and you will need to review the coding guidelines for the specific code.

Step 1 - Review each code for notes: In the example below, an Excludes1 note means that the two codes are mutually exclusive; you cannot have both codes together.

Implication: This means that you cannot code D50.0 along with D62 or P61.3. You can only have one of those codes assigned. So, if you see the Principal Diagnosis is D50.0 with a secondary code of P61.3, that is an error.

Step 2 - Review the coding guidelines: You also need to review the coding guidelines Section I A and B (all) and then C for the specific code. For example, if you have a C90 code, you need to look at coding guidelines for Section I.C.2. Look for any notes about how to sequence the diagnoses and more. Examples to watch for: errors such as coding a symptom when a definitive diagnosis is given or newborn codes added to the maternal encounter. Also, review Sections II and III.

The first case in this assignment has been completed for you as an example.

TABLE: Worksheet for Identifying Coding Quality Problems

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.

5.

Principal Diagnosis: R10.9 Unspecified abdominal pain

Diagnosis Index entries containing back-references to R10.9:

• Pain(s) R52 - see also Painful
  • abdominal R10.9

Secondary Diagnosis: K52.9 Noninfective gastroenteritis and colitis, unspecified

Diagnosis Index entries containing back-references to K52.9:

• Cecitis K52.9
• Colitis (acute) (catarrhal) (chronic) (noninfective) (hemorrhagic) K52.9 - see also Enteritis
  • noninfective K52.9
• Diarrhea, diarrheal (disease) (infantile) (inflammatory) R19.7
  • chronic K52.9 (noninfectious)
  • noninfectious K52.9
• Enteritis (acute) (diarrheal) (hemorrhagic) (noninfective) K52.9
  • chronic (noninfectious) K52.9
  • noninfectious K52.9
• Enterocolitis K52.9 - see also Enteritis
  • noninfectious K52.9
• Gastroenteritis (acute) (chronic) (noninfectious) K52.9 - see also Enteritis
  • noninfectious K52.9
• Gastroenteropathy K52.9 - see also Gastroenteritis
• Gastrojejunitis K52.9 - see also Enteritis
• Ileitis (chronic) (noninfectious) K52.9 - see also Enteritis
• Ileocolitis K52.9 - see also Enteritis
• Sigmoiditis K52.9 - see also Enteritis
  • noninfectious K52.9

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