Question

A 75 year old patient, Lucy Sales, was admitted because of chronic diarrhea and dehydration. She has a history of herpes zoster with residual monoparesis of her right upper extremity. She has been treated as an outpatient with heavy doses of Neurontin with no significant relief. On day 3 of her stay, a chest x-ray showed left lower lobe pneumonia. The patient is placed on Levaquin for the pneumonia. She also has a colonoscopy during this admission to determine the cause for her iron deficiency anemia that is found on this admission. Colonoscopy with biopsies were taken of the small bowel as well as the rectosigmoid area showed no specific etiology. After 6 days in the hospital, patient is discharged in an improved condition.

Coder I assigned the following codes and POA indicators E86.0 – Y, D50.9 – Y, J18.9 – N, G83.21 – Y, B94.9 - Y, 0DBK0ZX As the coding supervisor, review the clinical documentation, the diagnosis & procedure code(s), & POA indicators assigned by this coder.

Answer these 4 questions:

1) What coding quality issues do you find as you are auditing the coder’s work?

2) What would be your feedback to this coder?

3) Are any diagnosis code(s) missing? If so, what are the diagnoses that should be added to this case?

4) Is the ICD-10-PCS code correct? If not, what is the correct ICD-10-PCS code?

Answer 1

1) Coding quality issues

• Under coding of herpes zoster infection
• Unblunding / false reporting in case of colonoscopy
• Missing code for diarrhea

2) Feedback

I checked at your code and I would like to get some help. Please go through the following suggestions I sent you.

• B02.23 - Postherpetic Polyneuropathy (instead of B94.9)
• 0DJD8ZZ - Inspection of the lower intestinal tract, via natural or artificial opening, endoscopic (instead of ODBKOZX)
• R19.7 - Diarrhea Unspecified

3) Yes diagnosis code for diarrhea is missing

• R19.7 - Diarrhea Unspecified

4) ICD-10-PCS Code mentioned is incorrect.

correct ICD-10-PCS code is 0DJD8ZZ - Inspection of the lower intestinal tract, via natural or artificial opening, endoscopic