10 Practice scenarios for inpatient ICD-10CM and PCS

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Real-Life Coder Notes: Biopsies, Queries, Discharge Dispo, and More.

1. The patient underwent open cholecystectomy with needle biopsy of the liver. How is the needle biopsy of liver coded? 

Answer:

0FB00ZX — Biopsy of liver, percutaneous approach, diagnostic.

Wait, but why?

  • They percutaneously (through the skin) grabbed a tissue sample (needle = extraction = diagnostic).
  • No device left in.
  • Liver = body part focus.

  PCS Values Breakdown:

1st = Medical/Surgical

2nd = Hepatobiliary system

3rd = Extraction

4th = Liver

5th = Percutaneous

6th = No device

7th = Diagnostic

Easy rule: Liver + Needle + Sample = 0FB00ZX.  

2. Do We Code Abnormal Labs/Imaging If Doc Doesn’t Say "Clinically Significant"?

 The official coding and reporting guidelines state abnormal findings laboratory, x-ray, pathologic, and other diagnostic results are not coded and reported unless the provider indicates their clinical significance. Hat   

True or False: 

Answer: FALSE.

 If the labs or imaging are documented and meet reporting criteria, you code it. Provider doesn’t have tell that "clinically significant" in big bold letters.

 

3. In the chart there is documentation that states staging form for the carcinoma that has been authenticated by the physician that indicates the stage of the carcinoma. Is this sufficient documentation for validation of the IP Pathology so a query would not be necessary?  True or False 

Answer: TRUE.

If the doc signed off on that carcinoma staging form, No query hustle needed.

 

4. Patient was admitted to the facility on 4/1 for impaction of the intestine. Upon review of the medical record, the CDI Specialist notes that urosepsis is documented in the medical record beginning on 4/6 of the patient stay progress notes. The CDI Specialist notices that the patient has elevated white count 15,000,hypotension, and positive blood cultures for Acinetobacter which were taken on day 4/5. There is no diagnosis of sepsis documented by the physician in the progress notes to date.The patient was placed on Zosyn. what is the appropriate query that we would raise in the scenario? 

Question: What query do we raise?

 Answer:
Query for Sepsis or Urosepsis!

Because the clinical signs are indicative of infection + bloodstream involvement. Don’t sit quietly — you need that sepsis diagnosis clarified.

 

5. Patient was admitted with AKI, CHF and diabetic foot ulcer. Physician has performed debridement for the foot ulcer and administered IV fluids and IV lasix as the treatment for AKI and CHF. DOA query was issued and the response stated all the three dx occasioned the admission. If the query response stated all three, we can defaulty go with higher DRG as PDx?

True or False: We can pick whichever PDx gives the highest DRG?

Answer: FALSE.

You have to pick the diagnosis that required the most resources or drove the admission — not just chase the bigger DRG. Stay ethical.

 

6. Discharge disposition - Discharge summary stated nursing home, Case management stated ICF. Summary of case management stated patient is been transferred to nursing home? What will be the aappropriate DD for the chart? 

Who wins?

  Answer:
ICF — Go with case management documentation!

Tip: Case Management > Discharge Summary when it comes to dispo accuracy.

7. Case management stated home and the patient has signed the refusal to treatment form, What will be the DD for the scenario?

 Dispo Answer:
HOME.

Even if it feels messy, patient rights win. Refused treatment = home discharge.

8. For bone marrow biopsy, the qualifier will always diagnostic? True or False:  

Answer: TRUE.

Bone marrow biopsy = finding stuff out, not fixing stuff. Always diagnostic.

9.  Pt was admitted with breast mass. After excision of the mass, the path report stated breast cancer. A query was initiated to the attending physician who responded as see path report. What will be the next step which should be taken?

 

Now what?

 Answer:
Reissue the query!
Politely (and firmly) ask for direct physician documentation. "See Path" isn't enough. You need the actual words: "Breast cancer" signed off by the doc.

10. A patient underwent an endoscopic brush biopsy of the stomach. What is the procedure code assignment for this biopsy? 

A: 

Procedure Code:
  0DD68ZX — Biopsy of stomach, via natural opening endoscopic, diagnostic.

  PCS Breakdown:

1st: Medical/Surgical

2nd: GI system

3rd: Extraction

4th: Stomach

5th: Percutaneous Endoscopic approach

6th: Brush device

7th: Diagnostic

Super simple:
Endoscope + Brush + Stomach = 0DD68ZX.

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