Question

Patient reported to the ED with nausea, vomiting, and weakness. The patient is on OxyContin for chronic pain due to unresectable pancreatic cancer. The patient was in extreme pain and decided to double the OxyContin dosage. When this did not relieve the pain, the patient decided to drink whiskey. The patient got very weak and called 911. The patient was admitted for treatment and monitoring. The patient was dehydrated and was treated with IVs; his pain medications were adjusted. Final Diagnosis: Accidental overdose of OxyContin Pain due to pancreatic cancer

Coder 1 Assigned: T40.21, C25.9 Coder 2 Assigned: T51.91xA, C25.9

As the coding supervisor, review the clinical documentation and the codes assigned by each coder.

Answer these 3 questions:

1) What coding quality issues do you find as you are auditing the coders work?

2) What would be your feedback to each coder individually?

3) Are any diagnosis codes missing - if so, what are the diagnoses that should be added to this case?

Answer 1

1) Coding quality issues

• Under coding of Accidental Overdose of Oxycontin

Under coding refers to as providing inadequate information regarding the medical condition.

Here, Accidental overdose of Oxycontin was under coded by coder 1 as T40.21 against

T40.2X1A - Poisoning by other opioids, accidental, initial encounter.

• Missing codes

​​​​​​​The following codes were missed by the two coders

R11.2 - Nausea with vomiting, unspecified

R 53.1 - Weakness

E86.0 - Dehydration

• Unbundling / false reporting

​​​​​​​Coder 2 has falsely reported T40.2X1A - Poisoning by other opioids, accidental, initial encounter as  T51.91xA- Toxic effect of unspecified alcohol.

2) Feedback

CODER 1

I checked at your code and I would like to give some suggestions. Please go through the corrections that I sent you.

• Code Accidental overdose of Oxycontin as T40.2X1A instead of T40.21
• ​​​​​​​The following codes are missing

R11.2 - Nausea with vomiting, unspecified

R 53.1 - Weakness

E86.0 - Dehydration

CODER 2

I checked at your code and found false reporting and missing codes. Please go through the corrections that I sent you.

• Code Accidental overdose of Oxycontin as T40.2X1A instead of  T51.91xA
• ​​​​​​​The following codes are missing

R11.2 - Nausea with vomiting, unspecified

R 53.1 - Weakness

E86.0 - Dehydration

3) Diagnosis codes missing

​​​​​​​The following codes are missing

R11.2 - Nausea with vomiting, unspecified

R 53.1 - Weakness

E86.0 - Dehydration

Add diagnosis DEHYDRATION