advanced case studies in icd-10-cm - awc.world ward - adv... · icd-10-cm case case study 1 ©2017...
TRANSCRIPT
©2017 AHIMA’s Intellectual Property. All rights reserved.
Advanced Case Studies in ICD-10-CM
Maria N. Ward, MEd, RHIT, CCS, CCS-PDirector, HIM Practice ExcellenceAHIMA
Objectives
• Identify how to validate the 7th characterapplication
• Analyze provider documentation to utilizethe greater specificity captured within thecoding classification
• Apply ICD-10-CM guidelines and AHACoding Clinic® to further understand thecode set
©2017 AHIMA’s Intellectual Property. All rights reserved.
• Identify how to validate the 7th characterapplication
• Analyze provider documentation to utilizethe greater specificity captured within thecoding classification
• Apply ICD-10-CM guidelines and AHACoding Clinic® to further understand thecode set
ICD-10-CM CaseCase Study 1Case Study 1
©2017 AHIMA’s Intellectual Property. All rights reserved.
ICD-10-CM CaseCase Study 1Case Study 1
3
Terms to Know
• Volar surface: the palm of the hand• Distal: furthest away from the point of
attachment or furthest away from midline• Phalanges – see picture on next slide
– Distal– Middle– Proximal
©2017 AHIMA’s Intellectual Property. All rights reserved.
• Volar surface: the palm of the hand• Distal: furthest away from the point of
attachment or furthest away from midline• Phalanges – see picture on next slide
– Distal– Middle– Proximal
Bones of the Hand
©2017 AHIMA’s Intellectual Property. All rights reserved.5
Bones of the Fingers
©2017 AHIMA’s Intellectual Property. All rights reserved.
Case 1 Review
INDICATION: The patient is a 45 year old righthand dominant man, who is injured when tryingto unjam a snowblower with his left hand earliertoday. This accident occurred on the sidewalkwhile he was removing snow at the apartmentcomplex where he works as a member of themaintenance team. He sustained partialamputations, comminuted fractures andextensive lacerations to his left index, ring, andlong fingers. He presents now for surgicalrevision amputation.
©2017 AHIMA’s Intellectual Property. All rights reserved.
INDICATION: The patient is a 45 year old righthand dominant man, who is injured when tryingto unjam a snowblower with his left hand earliertoday. This accident occurred on the sidewalkwhile he was removing snow at the apartmentcomplex where he works as a member of themaintenance team. He sustained partialamputations, comminuted fractures andextensive lacerations to his left index, ring, andlong fingers. He presents now for surgicalrevision amputation.
7
Case 1 Review (cont)
The wounds were on the volar surface of all3 fingers and involved the distal and middlephalanges of the long and ring fingers. Thebone that was involved was completelycomminuted with fragments approximately 2to 3 mm in size at the largest. So, there wasno possibility of maintaining the injuredportions of the fingers. Revision amputationwas performed by trimming off the extra skinand removing all bone fragments.
©2017 AHIMA’s Intellectual Property. All rights reserved.
The wounds were on the volar surface of all3 fingers and involved the distal and middlephalanges of the long and ring fingers. Thebone that was involved was completelycomminuted with fragments approximately 2to 3 mm in size at the largest. So, there wasno possibility of maintaining the injuredportions of the fingers. Revision amputationwas performed by trimming off the extra skinand removing all bone fragments.
8
Principal diagnosis:S68.621A Partial traumatic transphalangeal
amputation of left index finger, initialencounter
Secondary:S68.625A Partial traumatic transphalangeal
amputation of left ring finger, initialencounter
S68.623A Partial traumatic transphalangealamputation of left middle finger, initialencounter
Case 1 Answers
©2017 AHIMA’s Intellectual Property. All rights reserved.
Principal diagnosis:S68.621A Partial traumatic transphalangeal
amputation of left index finger, initialencounter
Secondary:S68.625A Partial traumatic transphalangeal
amputation of left ring finger, initialencounter
S68.623A Partial traumatic transphalangealamputation of left middle finger, initialencounter
9
Amputation; traumatic; finger; transphalangeal;partial; index (S68.62-)
Case 1 Answers (cont)
©2017 AHIMA’s Intellectual Property. All rights reserved.10
Case 1 Answers (cont)
©2017 AHIMA’s Intellectual Property. All rights reserved.11
Secondary (cont):W31.89XA Contact with other specified
machineryContact; with; machinery; specified NEC (W31.89-)
Y93.H9 Activity, other involving exteriorproperty and land maintenance,building and construction
Activity; property maintenance; exterior (Y93.H9)
Case 1 Answers (cont)
©2017 AHIMA’s Intellectual Property. All rights reserved.
Secondary (cont):W31.89XA Contact with other specified
machineryContact; with; machinery; specified NEC (W31.89-)
Y93.H9 Activity, other involving exteriorproperty and land maintenance,building and construction
Activity; property maintenance; exterior (Y93.H9)
12
Secondary (cont):Y92.480 Sidewalk as the place of occurrence
of the external causePlace of occurrence; sidewalk (Y92.480)
Y99.0 Civilian activity done for income or payStatus of external cause; Civilian activity done for income or
pay (Y99.0)
Case 1 Answers (cont)
©2017 AHIMA’s Intellectual Property. All rights reserved.
Secondary (cont):Y92.480 Sidewalk as the place of occurrence
of the external causePlace of occurrence; sidewalk (Y92.480)
Y99.0 Civilian activity done for income or payStatus of external cause; Civilian activity done for income or
pay (Y99.0)
13
ICD-10-CM CaseCase Study 2Case Study 2
©2017 AHIMA’s Intellectual Property. All rights reserved.
ICD-10-CM CaseCase Study 2Case Study 2
14
Pelvic Fractures
©2017 AHIMA’s Intellectual Property. All rights reserved.
Fibula and Tibial Fractures
©2017 AHIMA’s Intellectual Property. All rights reserved.16
Fibular Head
TibialPlateau
Case 2 Review
The patient is a 42-year-old female with no significantpast medical history who, on 9/23 was struck by anautomobile, suffering a right acetabulum comminutedfracture, mildly displaced fracture of the left superior rimof the pubic ramus, nondisplaced fracture of the leftinferior pubic ramus, mildly displaced fracture of the leftfibular head, and a right lateral tibial plateau fracture.She underwent open reduction with internal fixation ofthe posterior pelvic ring and right acetabulum on 9/29.She underwent open reduction with internal fixation ofher right tibial plateau fracture on 10/4. She is presentlynon-weight bearing, bilateral lower extremities. She isadmitted for intensive physical rehabilitation.©2017 AHIMA’s Intellectual Property. All rights reserved.
The patient is a 42-year-old female with no significantpast medical history who, on 9/23 was struck by anautomobile, suffering a right acetabulum comminutedfracture, mildly displaced fracture of the left superior rimof the pubic ramus, nondisplaced fracture of the leftinferior pubic ramus, mildly displaced fracture of the leftfibular head, and a right lateral tibial plateau fracture.She underwent open reduction with internal fixation ofthe posterior pelvic ring and right acetabulum on 9/29.She underwent open reduction with internal fixation ofher right tibial plateau fracture on 10/4. She is presentlynon-weight bearing, bilateral lower extremities. She isadmitted for intensive physical rehabilitation.
17
Case 2 Review (cont)
PHYSICAL EXAMINATIONCRANIAL NERVES: Cranial nerves II - XII intact,
except for:– III: Oculomotor: Nystagmus– VII: Facial: Left facial droop.
©2017 AHIMA’s Intellectual Property. All rights reserved.
PHYSICAL EXAMINATIONCRANIAL NERVES: Cranial nerves II - XII intact,
except for:– III: Oculomotor: Nystagmus– VII: Facial: Left facial droop.
18
Case 2 Review (cont)
MEDICAL PLANREHABILITATION: Functional deficits due tomultitrauma, including multiple fractures status postopen reduction with internal fixation x 2, resulting inpain, non-weight bearing bilateral lower extremities,debility, and deconditioning requiring comprehensiveinpatient rehabilitation, including physical therapy,occupational therapy, speech-language pathology,psychiatry, and nursing under physiatristsupervision.NEUROLOGIC: Traumatic brain injury - plan forneuropsychiatric testing©2017 AHIMA’s Intellectual Property. All rights reserved.
MEDICAL PLANREHABILITATION: Functional deficits due tomultitrauma, including multiple fractures status postopen reduction with internal fixation x 2, resulting inpain, non-weight bearing bilateral lower extremities,debility, and deconditioning requiring comprehensiveinpatient rehabilitation, including physical therapy,occupational therapy, speech-language pathology,psychiatry, and nursing under physiatristsupervision.NEUROLOGIC: Traumatic brain injury - plan forneuropsychiatric testing
19
Principal diagnosis:S32.401D Unspecified fracture of right
acetabulum, subsequent encounter forfracture with routine healing
Fracture, traumatic; acetabulum (S32.40-)
Secondary:S32.512D Fracture of superior rim of left pubis,
subsequent encounter for fracture withroutine healing
Fracture, traumatic; pubis; superior rim (S32.51-)
Case 2 Answers
©2017 AHIMA’s Intellectual Property. All rights reserved.
Principal diagnosis:S32.401D Unspecified fracture of right
acetabulum, subsequent encounter forfracture with routine healing
Fracture, traumatic; acetabulum (S32.40-)
Secondary:S32.512D Fracture of superior rim of left pubis,
subsequent encounter for fracture withroutine healing
Fracture, traumatic; pubis; superior rim (S32.51-)
20
Secondary (cont):S32.592D Other specified fracture of left pubis,
subsequent encounter for fracture withroutine healing
Fracture, traumatic; pubis; specified site NEC (S32.59-)
S82.832D Other fracture of upper and lower endof left fibula, subsequent encounter forclosed fracture with routine healing
Fracture, traumatic; fibula; upper end; specified NEC(S82.83-)
Case 2 Answers (cont)
©2017 AHIMA’s Intellectual Property. All rights reserved.
Secondary (cont):S32.592D Other specified fracture of left pubis,
subsequent encounter for fracture withroutine healing
Fracture, traumatic; pubis; specified site NEC (S32.59-)
S82.832D Other fracture of upper and lower endof left fibula, subsequent encounter forclosed fracture with routine healing
Fracture, traumatic; fibula; upper end; specified NEC(S82.83-)
21
Secondary (cont):S82.141D Displaced bicondylar fracture of right
tibia, subsequent encounter forclosed fracture with routine healing
Fracture, traumatic; tibia; upper end; bicondylar (S82.14-)
S06.9X0D Unspecified intracranial injury withoutloss of consciousness, subsequentencounter
Injury; brain (traumatic) (S06.9-)
Case 2 Answers (cont)
©2017 AHIMA’s Intellectual Property. All rights reserved.
Secondary (cont):S82.141D Displaced bicondylar fracture of right
tibia, subsequent encounter forclosed fracture with routine healing
Fracture, traumatic; tibia; upper end; bicondylar (S82.14-)
S06.9X0D Unspecified intracranial injury withoutloss of consciousness, subsequentencounter
Injury; brain (traumatic) (S06.9-)
22
Secondary (cont):V03.90XD Pedestrian on foot injured in collision
with car, pick-up truck or van,unspecified whether traffic or nontrafficaccident, subsequent encounter
Accident; transport; pedestrian; on foot; collision; car(V03.90) – External Cause Index
H55.00 Unspecified nystagmusNystagmus (H55.00)R29.810 Facial weaknessDroop; facial (R29.810)
Case 2 Answers (cont)
©2017 AHIMA’s Intellectual Property. All rights reserved.
Secondary (cont):V03.90XD Pedestrian on foot injured in collision
with car, pick-up truck or van,unspecified whether traffic or nontrafficaccident, subsequent encounter
Accident; transport; pedestrian; on foot; collision; car(V03.90) – External Cause Index
H55.00 Unspecified nystagmusNystagmus (H55.00)R29.810 Facial weaknessDroop; facial (R29.810)
23
ICD-10-CM CaseCase Study 3Case Study 3
©2017 AHIMA’s Intellectual Property. All rights reserved.
ICD-10-CM CaseCase Study 3Case Study 3
24
Femoral Epiphysis
©2017 AHIMA’s Intellectual Property. All rights reserved.25
Case 3 Review
DIAGNOSIS:Left hip endstage secondary arthritis due to trauma
FINDINGS:Significant deformation of the femoral head was noted.Osteophyte formation was also noted, particularly over theanterior aspect of the acetabulum. There was no evidenceof infection.
©2017 AHIMA’s Intellectual Property. All rights reserved.
DIAGNOSIS:Left hip endstage secondary arthritis due to trauma
FINDINGS:Significant deformation of the femoral head was noted.Osteophyte formation was also noted, particularly over theanterior aspect of the acetabulum. There was no evidenceof infection.
26
Case 3 Review (cont)
INDICATIONS: The patient is a 26-year-old gentleman whosustained an injury while playing basketball at the age of16. He had what appeared to be a slipping capital femoralepiphysis. He underwent pinning of this. Approximately fourmonths after this, the screw was removed. The patient hashad worsening hip pain, particularly over the last year. Heis now having difficulty with daily activities, such as gettingon his shoes and socks. He has failed conservativetreatment, including activity modification.
©2017 AHIMA’s Intellectual Property. All rights reserved.
INDICATIONS: The patient is a 26-year-old gentleman whosustained an injury while playing basketball at the age of16. He had what appeared to be a slipping capital femoralepiphysis. He underwent pinning of this. Approximately fourmonths after this, the screw was removed. The patient hashad worsening hip pain, particularly over the last year. Heis now having difficulty with daily activities, such as gettingon his shoes and socks. He has failed conservativetreatment, including activity modification.
27
Principal Diagnosis:M12.552 Traumatic arthropathy, left hipArthropathy; traumatic; hip (M12.55-)
Secondary:S79.012S Salter-Harris Type I physeal fracture
of upper end of left femurSlipped, slipping; epiphysis; capital femoral; acute (on
chronic) (S79.01-)
M25.752 Osteophyte, left hipOsteophyte; hip (M25.75-)
Case 3 Answers
©2017 AHIMA’s Intellectual Property. All rights reserved.
Principal Diagnosis:M12.552 Traumatic arthropathy, left hipArthropathy; traumatic; hip (M12.55-)
Secondary:S79.012S Salter-Harris Type I physeal fracture
of upper end of left femurSlipped, slipping; epiphysis; capital femoral; acute (on
chronic) (S79.01-)
M25.752 Osteophyte, left hipOsteophyte; hip (M25.75-)
28
ICD-10-CM CaseCase Study 4Case Study 4
©2017 AHIMA’s Intellectual Property. All rights reserved.
ICD-10-CM CaseCase Study 4Case Study 4
29
Case 4 Review
SOCIAL HISTORY: Patient lives at homewith his wife. He is an ex-smoker havingsmoked 2 to 3 packs per day for more than30 years. He quit smoking in 1983. Hedrinks scotch and beer, about 2 to 3 times aweek but denies heavy drinking.
©2017 AHIMA’s Intellectual Property. All rights reserved.
SOCIAL HISTORY: Patient lives at homewith his wife. He is an ex-smoker havingsmoked 2 to 3 packs per day for more than30 years. He quit smoking in 1983. Hedrinks scotch and beer, about 2 to 3 times aweek but denies heavy drinking.
30
Case 4 Review (cont)
ASSESSMENT AND PLAN:1. Influenza A2. Sepsis, present on admission
– Fever– Tachycardia– Leukocytosis
3. Polymyalgia rhematica.– Chronic steroid use
©2017 AHIMA’s Intellectual Property. All rights reserved.
ASSESSMENT AND PLAN:1. Influenza A2. Sepsis, present on admission
– Fever– Tachycardia– Leukocytosis
3. Polymyalgia rhematica.– Chronic steroid use
31
Case 4 Review (cont)
DISCHARGE DIAGNOSIS:1. Respiratory distress, resolved.2. Sepsis, resolved.3. Flu A.4. Polymyalgia rhematica.5. History of prostate cancer, diagnosed 15
years ago.6. History of brachytherapy.7. GERD.
©2017 AHIMA’s Intellectual Property. All rights reserved.
DISCHARGE DIAGNOSIS:1. Respiratory distress, resolved.2. Sepsis, resolved.3. Flu A.4. Polymyalgia rhematica.5. History of prostate cancer, diagnosed 15
years ago.6. History of brachytherapy.7. GERD.
32
Case 4 Review (cont)
In summary, the patient is an 80-year-old malewith a past medical history of polymyalgiarheumatica, on prednisone therapy for the past3 years, who presented to the emergencydepartment complaining of cough, fever, andmyalgias. He was admitted due to productivecough, low-grade fever, and myalgias andconcern for the possibility of sepsis as well asinfluenza A. His respiratory panel returnedinfluenza A positive, and he was initiated on theoseltamivir therapy due to his history ofimmunosuppression with steroids.
©2017 AHIMA’s Intellectual Property. All rights reserved.
In summary, the patient is an 80-year-old malewith a past medical history of polymyalgiarheumatica, on prednisone therapy for the past3 years, who presented to the emergencydepartment complaining of cough, fever, andmyalgias. He was admitted due to productivecough, low-grade fever, and myalgias andconcern for the possibility of sepsis as well asinfluenza A. His respiratory panel returnedinfluenza A positive, and he was initiated on theoseltamivir therapy due to his history ofimmunosuppression with steroids.
33
Principal Diagnosis:A41.89 Other specified sepsisSepsis; specified organism (A41.89)
Secondary:J10.1 Influenza due to other identified
influenza virus with other respiratorymanifestations
Influenza; due to; identified influenza virus NEC (J10.1)R09.02 HypoxemiaHypoxemia (R09.02)
Case 4 Answers
©2017 AHIMA’s Intellectual Property. All rights reserved.
Principal Diagnosis:A41.89 Other specified sepsisSepsis; specified organism (A41.89)
Secondary:J10.1 Influenza due to other identified
influenza virus with other respiratorymanifestations
Influenza; due to; identified influenza virus NEC (J10.1)R09.02 HypoxemiaHypoxemia (R09.02)
34
Secondary (cont):M35.3 Polymyalgia rheumaticaPolymyalgia; rheumatica (M35.3)K21.9 Gastro-esophageal reflux disease
without esophagitisDisease; gastroesophageal reflux (K21.9)Z87.891 Personal history of nicotine
dependenceHistory; personal; tobacco dependence (Z87.891)
Case 4 Answers (cont)
©2017 AHIMA’s Intellectual Property. All rights reserved.
Secondary (cont):M35.3 Polymyalgia rheumaticaPolymyalgia; rheumatica (M35.3)K21.9 Gastro-esophageal reflux disease
without esophagitisDisease; gastroesophageal reflux (K21.9)Z87.891 Personal history of nicotine
dependenceHistory; personal; tobacco dependence (Z87.891)
35
Secondary (cont):Z85.46 Personal history of malignant
neoplasm of prostateHistory; personal; malignant neoplasm; prostateZ79.52 Long term (current) use of systemic
steroidsLong-term drug therapy; steroids; systemic (Z79.52)Z92.3 Personal history of irradiationHistory; personal; irradiation (Z92.3)
Case 4 Answers (cont)
©2017 AHIMA’s Intellectual Property. All rights reserved.
Secondary (cont):Z85.46 Personal history of malignant
neoplasm of prostateHistory; personal; malignant neoplasm; prostateZ79.52 Long term (current) use of systemic
steroidsLong-term drug therapy; steroids; systemic (Z79.52)Z92.3 Personal history of irradiationHistory; personal; irradiation (Z92.3)
36
References
• AHA Coding Clinic® for ICD-10-CM and PCS• ICD-10-CM Official Coding and Reporting
Guidelines for 2016• Shutterstock
©2017 AHIMA’s Intellectual Property. All rights reserved.
• AHA Coding Clinic® for ICD-10-CM and PCS• ICD-10-CM Official Coding and Reporting
Guidelines for 2016• Shutterstock
Questions?
©2017 AHIMA’s Intellectual Property. All rights reserved.
Questions?
38
Thank You!
©2017 AHIMA’s Intellectual Property. All rights reserved.
Thank You!