12 Practice scenarios Inpatient ICD10 CM coding with rationale

Coding and Documentation for Complex Medical Scenarios

 

1. Patient came with HTN, CHF exacerbation and fluid overload. Cardiology consultant documents patient's EF is 30% and also BNP is 3625. Assessment and plan stated HTN, CHF exacerbation with preserved ejection fraction, fluid overload. Patient was treated with IV lasix and IV hydralazine. Discharge summary documents HTN, CHF exacerbation, fluid overload. How to proceed with such a scenario?

Options:

a) Assign HTN with CHF exacerbation as codes

b) Assign HTN with Diastolic CHF exacerbation as codes

c) Assign fluid overload as PDX

d) Assign HTN with CHF exacerbation as codes and query for CHF type

 

Answer: d) Assign HTN with CHF exacerbation as codes and query for CHF type

 

Rationale: The cardiology consultant's documentation of preserved ejection fraction (EF) and the presence of CHF exacerbation suggests the need to assign HTN with CHF exacerbation as codes. However, since the type of CHF (systolic or diastolic) is not clearly specified, it is necessary to query for the specific CHF type.

 

2. Patient underwent spinal surgery where a dural tear was done as an approach to reach the site of surgery, and after the completion of the surgery, durotomy done was repaired with sutures. How will you proceed with the chart?

Options:

a) Query for dural tear in specificity form

b) Query for dural tear in post-op form

c) Not need to code diagnosis as well as the procedure for a dural tear

d) Code both diagnosis as well as the procedure of a dural tear

 

Answer: c) Not need to code diagnosis as well as the procedure for a dural tear

 

Rationale: In this scenario, the dural tear occurred as a part of the surgical approach and was subsequently repaired. It is not necessary to code both the diagnosis and the procedure for the dural tear.

3. Patient is admitted with pancreatitis and sepsis. It's an 8-day stay. Infectious disease consultant stated sepsis, treated with antibiotics - Resolved, and pancreatitis. Blood cultures were taken which showed MRSA bacteremia. In the discharge summary, the final diagnosis is stated as MRSA bacteremia and pancreatitis. How will you proceed with the chart?

Options:

a) Assign sepsis as PDx

b) Query for conflicting diagnosis

c) Query for sepsis ruled in/out

d) None of the above

 

Answer: a) Assign sepsis as PDx

 

Rationale: Based on the documentation, sepsis is the principal diagnosis since it is a more severe condition and the patient was treated for it. The MRSA bacteremia can be coded as an additional diagnosis.

 

4. Uncertain diagnosis can be taken from the discharge summary as well as from the last-day progress notes.

Options:

a) True

b) False

 

Answer: b) False

 

Rationale: Uncertain diagnoses should not be coded based solely on the discharge summary or last-day progress notes. Accurate coding requires clear and definitive documentation of diagnoses.

 

4. Which of the following is not the criteria for the selection of PDX?

Options:

a) Therapeutic workup

b) Diagnostic workup

c) Higher DRG

d) None of the above

 

Answer: c) Higher DRG

 

Rationale: The criteria for the selection of the Principal Diagnosis (PDX) include therapeutic workup, diagnostic workup, and clinical significance. Higher Diagnosis

 

5. Patient is admitted with SOB. After workup, the physician documented that her SOB is most likely due to CHF vs PNA. Acute systolic CHF was treated with IV lasix, and pneumonia was treated with PO antibiotics. What are the appropriate code assignments for the following?

Options:

a) I50.21, J18.9

b) J81.0, I50.22

c) J18.9, I50.20

d) I50.22, J18.1

 

Answer: a) I50.21, J18.9

 

Rationale: The physician documented both acute systolic heart failure (CHF) and pneumonia (PNA) as possible causes of the patient's shortness of breath (SOB). Based on the documentation, the appropriate code assignments would be I50.21 for acute systolic CHF and J18.9 for pneumonia.

 

6. Patient was admitted to the hospital for elective cholecystectomy. The patient also had AKI, CHF, and atrial fibrillation, which were treated with IV fluids, IV cardizem, and lasix. The patient underwent Lap. Cholecystectomy for choledocholithiasis but developed bradycardia, for which treatment continued for 2 more days, and got discharged. Assigned the PDx for the following.

Options:

a) K80.50

b) K80.20

c) K80.80

d) K80.10

 

Answer: a) K80.50

 

Rationale: The patient was admitted for elective cholecystectomy due to choledocholithiasis. The appropriate Principal Diagnosis (PDx) would be K80.50, which represents choledocholithiasis without mention of obstruction.

 

7. COPD with acute exacerbation was not present on admission. Assign POA for COPD exacerbation.

Options:

a) Y

b) N

c) U

d) W

 

Answer: b) N

 

Rationale: The COPD exacerbation was not present on admission, indicating that it is a hospital-acquired condition. The appropriate Present on Admission (POA) indicator for COPD exacerbation would be "N" (No) to reflect that it developed during the hospital stay.

 

8. Patient is admitted with pneumonia, and the provider documents Pseudomonas as the causal organism a few days later. Assign POA for Pseudomonas.

Options:

a) Y

b) N

c) U

d) W

 

Answer: a) Y

 

Rationale: The provider documented Pseudomonas as the causal organism for pneumonia. Since it was present on admission, the appropriate Present on Admission (POA) indicator for Pseudomonas would be "Y" (Yes).

 

9. Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are coded and reported when the provider does not indicate their clinical significance. True or False.

Options:

a) True

b) False

 

Answer: b) False

 

Rationale: Abnormal findings should not be coded and reported unless the provider indicates their clinical significance. Accurate coding requires documentation of the clinical significance of the abnormal findings.

 

10. A patient is admitted with severe abdominal pain in the right lower quadrant, and an admitting diagnosis of probable acute appendicitis is given. The white blood cell count is slightly elevated. The patient is taken to surgery, where a normal appendix is found, but an inflamed Meckel's diverticulum is removed. Give the PDX?

Options:

a) Q43.0

b) K35.8

c) K37

d) K35.9

 

Answer: a) Q43.0

 

Rationale: The patient's initial admitting diagnosis was probable acute appendicitis, but during surgery, a normal appendix was found and an inflamed Meckel's diverticulum was removed. The correct Principal Diagnosis (PDX) in this case would be Q43.0, which represents Meckel's diverticulum.

 

11. Patient, who is status post open reduction internal fixation (ORIF) due to a left arm fracture, underwent delayed closure of the wound. At surgery, the wound was irrigated down to the bone using pulsatile lavage, and delayed primary closure was performed with wide skin clips. Assign PDX for the following.

Options:

a) Z48.1

b) T84.0XXA

c) S52.9XXA

d) Z47.1

 

Answer: a) Z48.1

 

Rationale: In this case, the patient underwent delayed closure of a wound that was irrigated down to the bone and had delayed primary closure using wide skin clips. The appropriate Principal Diagnosis (PDX) for this scenario would be Z48.1, which represents the encounter for the care and examination of a surgical wound.

 

12. A 55-year-old male is admitted for recurrent gastric reflux with esophagitis diagnosed previously. He recently had an increase in reflux with an episode of near aspiration and epigastric burning that awakened him at night. Further history suggested that the patient had a significant episode of chest pain 5 weeks prior to this admission but was never seen for treatment.

Options:

a) K21.0

b) K21.9

c) R07.9

d) R13.10

 

Answer: a) K21.0

 

Rationale: Based on the provided information, the patient is admitted for recurrent gastric reflux with previously diagnosed esophagitis. The episode of near aspiration and epigastric burning indicates an exacerbation of the condition. Additionally, the history of significant chest pain 5 weeks prior suggests a potential underlying cause for the reflux symptoms. The appropriate Principal Diagnosis (PDX) code for this scenario would be K21.0, which represents gastro-esophageal reflux disease (GERD) with esophagitis.