Question

Provide inpatient discharge scenario and how it could be code by ICD10, you must write the principal diagnosis codes and principal procedure codes?

Answer 1

Scenario: COPD with Acute Pneumonia Example

Scenario Details

Chief Complaint

• “I just got out of the hospital 2 days ago. I’m a little better, but still can barely breathe.”

History

• 67-year-old male with 40 pack/year history of cigarette use (still smoking) and severe oxygen dependent COPD developed cough with increased production of green/gray sputum 2 weeks prior to office visit. Admitted to hospital through Emergency Department with diagnosis of presumed pneumonia superimposed on severe COPD. Hospital exam confirmed acute RLL pneumococcal pneumonia. Patient treated with an IV cephalosporin as he has known penicillin allergy, and was discharge from hospital to home 2 days prior to office visit.
• PMH shows severe O2 dependent COPD, with type II diabetes mellitus secondary to chronic prednisone therapy, which is treated with oral hypoglycemics.

Patient also has known hypertension, on ACE inhibitor therapy.

Review of Systems, Physical Exam, Laboratory Tests

• T 99, BP 145/105, P 92 and irregular, RR 28
• Chest exam shows decreased lung sounds throughout all lung fields except in RLL where there were mild rhonchi and wheezes noted
• ABG’s on 2L O2 by nasal cannula show PO2 62, PCO2 47, pH 7.40
• CXR shows hyperinflation of lungs with small RLL alveolar infiltration. Comparison to CXR from hospitalization shows approximately 75% resolution of pneumonia.
• ECG reveals persistent atrial fibrillation which was not present on previous ECG of 6 months earlier, but had been found at time of recent hospitalization. Labs show finger stick glucose of 195mg%.

Assessment and Plan

• Acute Community Acquired Pneumococcal Pneumonia: continue oral cephalosporin. Schedule office follow up visit in 1 week with repeat CXR.
• Severe COPD: continue O2, low dose Prednisone, and inhaled bronchodilator.
• Chronic Hypoxemic, Hypercarbic Respiratory Failure
• Persistent Atrial Fibrillation: continue digoxin initiated during recent hospitalization
• Hypertension: continue ACE inhibitor therapy
• Diabetes Mellitus, Type II, secondary to prednisone therapy; continue oral hypoglycemic therapy
• Penicillin Allergy
• Tobacco Dependence

Summary of ICD-10-CM Impacts

Clinical Documentation

• ICD-10-CM separates pneumonia by infectious agent. Document the infectious agent of pneumonia, as there are discrete ICD-10-CM codes for each type.
• ICD-10-CM separates by acuity of respiratory failure, and hypoxia or hypercapnia, if present.
• Document drug allergies with ICD-10-CM status” Z” codes from Chapter 21 to identify these.
• Document the type of cardiac arrhythmia. Atrial fibrillation in ICD-10-CM separates into paroxysmal, persistent, chronic, typical, atypical, unspecified. Acute atrial fibrillation defaults to unspecified in ICD-10-CM.
• The Table of Drugs & Chemicals has a code assignment for Adverse effect of the drug that would be followed by the secondary diabetes code. Go to the Volume 3 Index to Table of Drugs and Chemicals. Along the left hand side proceed alphabetically to “Glucocorticoids” and then move horizontally across to the column for Adverse Effect”. In Volume 1 (Tabular List) the instruction at the beginning of the code category T38 are the instructions for the 7th character.
• Note: Drug-induced Diabetes Mellitus is a secondary type of diabetes due to the use of glucocorticoids. This code can only be coded as an “additional code” and would never be first-listed

The code categories for secondary diabetes are :

• Due to underlying disease (E08)
• Due to drug (E09)
• Due to other specified condition such as post pancreatectomy. (E13)

These three categories can never be first-listed per ICD-10-CM guidelines. The underlying cause would be first-listed diagnosis.

Coding

ICD-10-CM Diagnosis Codes

1. J13 Pneumonia due to Streptococcus pneumoniae
2. J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
3. Z99.81 Dependence on supplemental oxygen
4. I48.1 Persistent atrial fibrillation
5. E09.9 Drug or chemical induced diabetes mellitus without complications
6. T38.0x5A Adverse effect of glucocorticoids and synthetic analogues, initial encounter
7. I10 Essential (primary) hypertension
8. Z88.0 Allergy status to penicillin
9. F17.210 Nicotine dependence, cigarettes, uncomplicated