12 Practice scenarios for inpatient coding. Sepsis, chest pain, CVA, weakness with rationale.

Clinical coding is an essential aspect of healthcare, enabling accurate and effective documentation of patient conditions and treatments. However, there are many nuances and complexities involved in clinical coding, from appropriate query forms to conflicting diagnoses and more. In this blog post, we will cover ten common scenarios in clinical coding and provide best practices and strategies for accurate coding.

We will start by discussing the appropriate query forms to use for sepsis when no infectious condition is available in the chart. We will also cover how to code a patient who has weakness but no history of CVA, and how to determine the primary diagnosis code.

We will also delve into the coding of bed mobility assessments for patients admitted due to functional decline due to age, and how to handle a case where a provider documents chest pain, most likely of gastrointestinal origin, without specifying a particular condition. Additionally, we will provide guidance on how to code inflammation of the lungs and atypical chest pain and hypertension with GERD. It's also important to query the provider for the etiology of chest pain.

Finally, we will discuss the coding of severe sepsis, age-related weakness, conflicting diagnoses, and sepsis syndrome. We will explain the rationale behind each scenario and offer practical tips and strategies for effective and accurate coding.

Whether you're a beginner or an experienced coder, this blog post will provide valuable insights and information for mastering clinical coding and ensuring that your documentation is accurate and up-to-date.

1. What will be the appropriate query form that can be utilized if there are all strong indicators for sepsis but no infectious condition available in the chart?

A. Leading query

B. General query form

C. Specific query form

D. Retrospective query

Answer: B. General query form

Rationale: If there are strong indicators for sepsis but no infectious condition is available in the chart, a general query form should be utilized. This will help to identify any underlying infectious condition that may be contributing to the patient's symptoms.

A general query form is a type of query form that is used to obtain general information about a patient's condition.

2. Pt is admitted to the hospital with weakness. Patient does not have history of CVA. PT was performed in the hospital which enabled the patient to resolve her weakness. Discharge summary documented - lower extermity wekaness. What will be the appropriate PDx for the scenario?

A. R29.91

B. R26.89

C. R53.1

D. R25.2

Answer: A. R29.91

Rationale: The appropriate PDx for this scenario would be R29.91, which is the code for weakness. This is based on the documentation in the discharge summary, which states that the patient had lower extremity weakness.

3. Patient was admitted with functional decline due to his age and admitted to a rehabilitation facility after a serious injury that has left him bedridden. As part of rehabilitation plan, a physical therapist Bed mobility assessment was done for the patient including evaluating the patient's ability to turn over, sit up, and transfer to a wheelchair or standing position. Code the PCS code for the following?

Answer: A. F01ZBZZ

Rationale: The appropriate PCS code for this scenario would be F01ZBZZ, which is the code for bed mobility assessment. This is based on the documentation that bed mobility assessment was done for the patient.So, the code F01ZBZZ can be used to identify an assessment of a patient's ability to move in bed, without the use of any devices.

breakdown of the ICD-10-PCS code F01ZBZZ:

F: Section "Physical Rehabilitation and Diagnostic Audiology"

01: Body System "Motor System"

Z: Root operation "Assessment"

B: Body part "Bed"

Z: Approach "Assessment"

Z: Device "No Device"

4. A 67-year-old patient was admitted to the hospital with chest pain. In the final diagnostic statement, the provider documented chest pain, most likely of gastrointestinal origin.There is no specific condition available in the chart. What will be the appropriate PDX for the scenario?

A. R07.9

B. K22.2

C. R10.9

D. R12

Answer: A. R07.9

Rationale: The appropriate PDX for this scenario would be R07.9, which is the code for chest pain, unspecified. This is based on the provider's documentation that the chest pain was of gastrointestinal origin and no specific condition is available in the chart.

5. What is the code for inflammation of lungs?

A. J45.909

B. J44.9

C. J84.10

D. Query the provider

Answer: D. Query the provider

Rationale: Inflammation of lungs can have various codes depending on the type of inflammation and other associated factors. Therefore, it is important to query the provider to obtain more specific information and documentation before assigning a code.

Querying the provider is a process of seeking additional information or clarification from the provider regarding documentation in the medical record.

6. Patient was admitted with chest pain, hypertension and GERD. After workup physician can confirmed the condition as Atypical chest pain. How will you proceed with this scenario?

Answer: Query for the etiology of chest pain}

Rationale: Atypical chest pain is a non-specific term and can have various etiologies. In order to accurately code the condition, it's important to query the provider for the specific etiology of the chest pain.

7. Patient is admitted with sepsis and has acute respiratory failure. Can we code severe sepsis as confirmed condition.

True or False?

Answer: False

Rationale: In ICD-10-CM, the code for severe sepsis requires documentation of acute organ dysfunction. While acute respiratory failure is an organ dysfunction, it is not specified whether the patient has any other acute organ dysfunctions. Therefore, we cannot assume that severe sepsis is a confirmed condition in this scenario without further documentation from the provider.

8. Age related weakness can be directly taken as confirmed dx if the weakness is happening in an old age patient?

True or False?

Answer: False.

Rationale: Age-related weakness is not a specific diagnosis and cannot be taken as a confirmed diagnosis. The provider must document a more specific diagnosis in order for it to be coded.

9. Patient was admitted with chest pain. Cardiologist after review documented "Unstable angina" on the first day. Later hospital progress notes and discharge summary documented Atypical chest pain. How will you proceed with this scenario?

Answer: Query for conflicting diagnosis.

Rationale: There is conflicting documentation in this scenario, with the cardiologist documenting unstable angina and later progress notes and discharge summary documenting atypical chest pain. In order to accurately code the condition, it's important to query the provider for clarification and to resolve any conflicting diagnoses.

10. Sepsis syndrome can be coded as sepsis?

True or False?

Answer: False.

Rationale: Sepsis syndrome is not a specific diagnosis in ICD-10-CM and cannot be coded. The provider must document a more specific diagnosis of sepsis in order for it to be coded.