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Acute blood-loss anemia
The physician must document that acute blood loss anemia is a complication of surgery in order to assign code 998.11, Hemorrhage complicating a procedure along with the code for acute blood loss anemia, 285.1.
Under the Medicare MS-DRG methodology code 285.1 is considered a complication/comorbidity (CC) and code 280.0 is not. Therefore incorrect code assignment has potential reimbursement implications.
The coder should never assume that hypertension is malignant or benign without physician documentation.
hypertensive cardiovascular disease
Cardiac conditions that are combined with hypertension in category 402 include:
Hypertensive cardiovascular disease
Hypertensive heart disease or failure
Any condition classifiable to 425.8, 428, 429.0-429.3, 429.8, 429.9 due to hypertension
Do not assume the connection unless stated by the physician.
Hypertensive renal disease is due to the presence of chronic hypertension leading to nephrosclerosis and renal damage. It is also an exacerbating or accelerating factor in the progression of other renal diseases, such as diabetic nephropathy.
Includes the following conditions: arteriolar nephritis; arteriosclerosis of kidney; arteriosclerosis of renal arterioles; chronic arteriosclerotic nephritis; interstitial arteriosclerotic nephritis; hypertensive nephropathy; hypertensive renal failure; chronic hypertensive uremia; nephrosclerosis; renal sclerosis with hypertension; any condition classifiable to 585, 586, or 587 with any condition classifiable to 401.
Transient hypertension oc-curring during the postoperative period is coded as:
b) 997.91, 401.9
c) 997.91, 796.2
96.2 (Transient hypertension) The MD has not documented that the transient hypertension is postoperative so the complication code cannot be used. Transient hypertension is considered elevated blood pressure;
A patient has a final diagnosis of malignant hypertension and heart disease. This is coded as:
b) 401.0, 429.9
401.0, 429.9 (Code separately as a causal relationship has not been documented by the MD. OCG 4.5)
How is CHF due to diastolic dysfunction due to hypertension coded?
b) 429.9, 428.0, 401.9
c) 402.91, 429.9
402.91 (Hypertensive cardiovascular disease with CHF)
Which medication is used to treat mild to moderate hypertension or hypertensive crisis and is also a treatment for congestive heart failure?
Furosemide (otherwise known as Lasix)
Nephrosclerosis is coded as:
403.90 (There is no mention of renal failure)
Hypertensive cardiovascular disease with acute renal failure and CHF is coded:
b) 402.91, 584.9
c) 401.9, 428.0, 584.9
Hypertensive heart AND chronic kidney disease
404.0x; Assign as many codes necessary from 428 to identify type of heart failure, if known; 585.x
Management of anemia associated the chemotherapy, immunotherapy, or radiotherapy
If the only treatment is for the anemia, 285.22 is sequenced first followed by code E933.1 with an additional code for the neoplasm.
Neoplasms: Treatment of secondary site
When a patient is admitted because of a primary neoplasm with
metastasis and treatment is directed toward the secondary site only, the
secondary neoplasm is designated as the principal diagnosis even
though the primary malignancy is still present.
meaning that it is a malignancy that has metastasized from another primary location.
Treatment directed at the malignancy
If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis. The only exception is for chemotherapy or radiation therapy (V58.XX), in which case the appropriate V-code is assigned as the principal diagnosis.
If a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only
The secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.
When the admission/encounter is for management of dehydration due to the malignancy, and only the dehydration is being treated
Dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy.
When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy
A code from category V10, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.
This patient was admitted with squamous cell carcinoma of the posterior pharyngeal wall and metastasis to the cervical lymph nodes. He has refused surgery and has elected to begin radiation therapy daily on a 6 MV linear accelerator. Each field was treated twice a day, with customized shielding blocks. The treated areas covered the primary cancer, the suspected areas of extension and the lymph nodes in the neck. Which of the following diagnosis codes should be reported for this encounter?
c. V58.0, 149.0, 196.0
d. 149.0, 196.0
1. c. The encounter for radiation therapy, V58.0, should be the first-listed code and both the code for the primary malignancy (149.0) and the lymph node metastasis (196.0) should be reported.
A 55-year-old patient has a lung mass that was discovered on chest X-ray; he presents to the ambulatory surgery center for a diagnostic bronchoscopy. After anesthetic administration, a fiberoptic bronchoscope is introduced into the bronchial tree, after which a needle is advanced through a channel in the scope and tissue is aspirated from the lung mass for pathologic testing under fluoroscopic guidance. The final diagnosis is oat cell carcinoma. Which of the following represents the appropriate diagnosis and procedure codes?
a. 162.2, 31629
b. 162.9, 31629
c. 162.9, 31625
d. 235.7, 31629
2. b. Because the procedure was a transbronchial aspiration biopsy, code 31629 must be assigned. The carcinoma was not specified as a neoplasm of uncertain behavior so code 235.7 is incorrect; ICD-9-CM directs the coder to 162.9 because a more specific site was not documented.
This 47-year-old female patient has a palpable lump in her right breast and also a smaller lesion in the left breast that was identified on mammography. This lesion was also identified by a radiological marker on this visit. She had an excisional biopsy on both sides in an ambulatory surgery center. The specimen from the right breast was found to have breast malignancy with clear margins, and the smaller lesion on the left breast was found to have fibrocystic disease only. Which of the following diagnosis and procedure code sets is most appropriate?
a. 174.9, 610.1, 19120-RT, 19125-LT, 19290-LT
b. 611.72, 610.1, 19120-5
c. 174.9, 610.1, 19120-50, 19125-50, 19290-50
d. 174.9, 610.2, 19120, 19125-59, 19290
3. a. Separate CPT codes with RT and LT modifiers indicate that separate different procedures were performed on each breast for this patient. This is why the 50 (bilateral procedure) modifier should not be assigned. An excisional biopsy was performed on the right (19120) and an excisional biopsy via needle localization technique was performed on the left side (19125 & 19290). The final diagnosis of breast malignancy was made, which should be reported as the first-listed diagnosis (174.9), with a secondary code for the fibrocystic disease (610.1).
A 72-year-old male had previously undergone total hip replacement. He now returns with a loosened acetabular component that is causing significant pain. The patient was admitted and taken to the operating room for a procedure that included removal and replacement of the acetabular component only, using a metal-on-polyethylene bearing surface. The appropriate diagnosis codes are:
d. The diagnosis code 996.41 (fifth digit required) indicates a loosening of the prosthetic joint and the V-code indicating hip replacement status also requires a fifth digit.
A 69-year-old woman has had significant problems with infections since her previously total hip replacement. She is now admitted for revision of the joint prosthesis, which included combined components, ceramic-on-ceramic implant bearing surface and removal of previously placed cement spacers. The appropriate diagnosis codes are:
b. The principal diagnosis is infection of the joint prosthesis (996.66), and the joint previously replaced and being treated on this admission involved the hip (V43.64).
A 67-year-old male patient had a previously placed knee joint prosthesis and now returns with a peri-prosthetic fracture. No trauma was documented. Surgery included replacement of the femoral and tibial components. The appropriate diagnosis codes are:
a. . Since the problem with the joint prosthesis involved a peri-prosthetic fracture, assign code 996.44 as the principal diagnosis. The V43.65 code appropriately reflects a knee replacement status.
What is staging of cancer?
Staging is the process of finding out how far the cancer has spread (metastasized). Numerous tests can be performed to help determine this.
Some symptoms of DEHYDRATION
Nausea, vomiting, fatigue, loss of appetite, thirst, constipation, rapid heart-rate, etc.
Hypertensive nephropathy (or "hypertensive nephrosclerosis", or "Hypertensive renal disease") is a medical condition referring to damage to the kidney due to chronic high blood pressure. It is a cause of ESRD.
Chronic Diabetic Complications
Renal, vascular and nervous systems are common complications, which are coded first to the appropriate diabetic code, 250.4X-250.8X, with an additional code to identify the specific complicating condition or manifestation. Diabetic patients will often have more than one complication present at the same time. In these instances more than one code from subcategories 250.4x-250.8x should be used along with a manifestation code for each.
Documentation that indicates a cause and effect relationship
includes "due to," "caused by," and "secondary to."
When there is no documentation indicating that the condition is related to the diabetes, code the condition first and the diabetes as an additional code.
If the documentation is unclear regarding what type of diabetes a patient has
Then query the physician as to whether or not the patient's diabetes is uncontrolled or controlled.
250.4X, Diabetes with Renal Manifestations
Chronic renal failure, nephrosis and nephritis are common diabetic complications. To code diabetic nephropathy assign 250.4X and 583.81, Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere. Diabetic nephrosis and diabetic nephrotic syndrome are coded to 250.4X and 581.81, Nephrotic syndrome in diseases classified elsewhere.
250.5X, Diabetes with Opthalmic Manifestations
Diabetic retinopathy is often seen in diabetic patients. Patients who have been diabetic for a long time and/or those who have poor control of blood sugar levels are more likely to develop diabetic retinopathy. Diabetic retinopathy is coded with 250.5X and 362.0X depending on the type of retinopathy.
250.6X, Diabetes with Neurological manifestations
Peripheral, cranial and autonomic neuropathies are very common chronic manifestations of diabetes. For example, the codes for peripheral (or cranial) neuropathy are 250.6X and 357.2, Polyneuropathy in diabetes. For autonomic neuropathy assign 250.6X and 337.1, Peripheral autonomic neuropathy in disorders classified elsewhere.
250.7X, Diabetes with peripheral circulatory disorders
Peripheral vascular disease is also a common diabetic complication. Peripheral vascular disease is coded to 250.7X and 443.81, Peripheral angiopathy in diseases classified elsewhere. Diabetic arteriosclerosis with gangrene is coded to 250.7X, 440.2, Arteriosclerosis of arteries of the extremities and 785.4, Gangrene.
Diabetes with ischemic heart disease
(410-414) are coded as separate entities and are not included in code 250.7X.
Diabetes with cerebrovascular disease
Cerebrovascular disease (430-438) are coded as separate entities and are not included in code 250.7X.
Diabetes with ulcers
Assign codes 250.6x or 250.7x as appropriate and 707.1x ulcer of lower limbs, except decubitus. If the cause of the diabetic ulcer is not known assign code 250.8x, Diabetes with other specified manifestation.
Diabetes with osteomyelitis
Assign codes 250.8x, 731.8, Other bone involvement in diseases classified elsewhere and 730.0x, Acute osteomyelitis.
1. A patient with diabetic neuropathy is admitted to the hospital because of uncontrolled diabetes. Which of the following is the correct diagnosis code assignment?
a. 250.92, 250.62, 357.2
b. 250.62, 250.92, 357.2
c. 250.93, 250.63, 357.2
d. 250.62, 357.2
e. 250.63, 357.2
1) d. Code 250.62, Diabetes with neurological manifestations, Type II or unspecified, uncontrolled, is assigned as the principal diagnosis. Code 357.2, Polyneuropathy in diabetes, is assigned as an additional diagnosis to identify the neuropathy. Code 250.9x, Diabetes with unspecified complication, would not be assigned as an additional diagnosis. Code 250.9x is never assigned with any other code from the 250.0x-250.8x series. When the specific complication is identified it would be incorrect to also assign a code stating "unspecified complication." Code 250.92 would have been appropriate if "uncontrolled diabetes" was documented without mention of any further manifestations;
2. A patient with Type II diabetes mellitus with diabetic peripheral neuropathy fails to adjust his insulin drug dosage and participates in strenuous activity. The patient is admitted with a blood sugar of 30. The discharge diagnosis is hypoglycemia. Which of the following is the correct diagnosis code assignment?
a. 250.60, 250.80, 337.1
b. 250.80, 250.60, 337.1
c. 250.62, 250.82, 337.1
d. 250.82, 250.62, 337.1
2) b. 250.80, Diabetes with other specified manifestations is assigned as the principal diagnosis. Hypoglycemia in diabetic patients is coded to other specified complications and is not identified using an additional code for the hypoglycemia. Codes 250.60, Diabetes mellitus with neurological manifestations and 337.1, peripheral autonomic neuropathy in disorders classified elsewhere are assigned as secondary diagnoses to identify the diabetic peripheral neuropathy. The fifth digit of 0 is assigned to indicate Type II diabetes, not stated as out of control. There is no documentation that the diabetes was out of control only that the patient failed to adjust his insulin in anticipation of strenuous activity and this resulted in hypoglycemia;
3. A patient is seen and treated for a decubitus ulcer of the heel. The physician also documents IDDM with peripheral vascular disease. Which of the following is the correct diagnosis code assignment?
a. 250.70, 707.0, 443.81
b. 250.71, 707.0, 443.81
c. 707.0, 250.70, 443.81
d. 707.0, 250.71, 443.81
3) c. The decubitus ulcer code 707.0 is sequenced first. Decubitus ulcers are not considered complications of diabetes. Code also 250.70 to identify the diabetes with peripheral vascular manifestations is assigned as an additional diagnosis. The fifth digit of 0 is assigned because the type of diabetes is not identified. IDDM or insulin dependent does not necessarily mean Type I diabetes. Code 443.81, peripheral angiopathy in diseases classified elsewhere, is also assigned to identify the peripheral vascular manifestation.;
A patient with IDDM is admitted in a hyperosmolar coma with blood sugars out of control. During the hospital stay, insulin was regulated and the coma resolved. This patient also has diabetic nephropathy with a complication of nephrotic syndrome. Which of the following is the correct diagnosis code assignment?
a. 250.23, 250.43, 581.81
b. 250.22, 250.42, 581.81
c. 250.32, 250.42, 581.81
d. 250.32, 250.43, 581.81
4) b. Code 250.22, Diabetes with hyperosmolality is assigned as the principal diagnosis. The code for diabetes with hyperosmolality includes the associated coma. Codes 250.42, Diabetes with Renal Manifestations and 581.81, Nephrotic syndrome in diseases classified elsewhere are assigned as additional diagnosis to identify the diabetic nephropathy with nephritic syndromes. Both diabetes codes use the fifth digit 2 because the diabetes is documented as uncontrolled but the type is not documented. IDDM or insulin dependent does not necessarily mean Type I diabetes. Type II diabetics may also be insulin dependent.
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