ICD-10-CM Other Coding Hot Spots: Part 2 Hospice Case Studiescchospice.org/wp-content/uploads/2015/09/G4-Judy-Adams-ICD-10-CM-Other... · •In ICD-9, there is an instructional note

9/9/2015

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ICD-10-CM OTHER CODING

HOT SPOTS: PART 2 HOSPICE CASE STUDIES

39th Annual Hospice & Palliative Care Conference

Columbia, SC

September 30, 2015

Case Study – Ms. N • Ms. N referred to hospice with a large mass in her right

chest involving the middle and lower lobe of the lung , coming through the chest wall and probably to her diaphragm impinging on her liver. MD feels it is most likely new lung cancer, but patient declines a biopsy or further work up or treatment to the lung mass. Patient has lost 15 # weight in last 3-4 weeks, coughing yellow sputum, right sided chest pain with coughing, swallowing issues, nausea & vomiting and increased weakness.

• MS. N was able to go camping 3 months ago, but is currently unable to be left alone due to periods of confusion. She is bedbound, has a foley catheter and is on a pureed diet with nectar thickened fluids. On 4L oxygen for end stage COPD, has DM II, HTN, hx of stomach cancer and A-fib.

2Adams Home Care Consulting, Inc,

Case Study Ms. NDiagnosis ICD-10-CM

a

b.

c.

d.

e.

f.

other


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Case Study Ms. N Answers

Diagnosis ICD-10-CM

a Swelling, mass or lump in chest R22.2

b. Exacerbated COPD J44.1

c. Abnormal weight loss R63.4

d. Dysphagia, unspecified R13.10

e. Dependence supplemental oxygen Z99.81

f. bedbound Z74.01

other Unspecified psychos (confusion)

History stomach cancer

Absence stomach (partial)

R41.0

Z85.028

Z90.3


Case Example – Mr. G• Mr. G was in two car crashes within 2 weeks. The

second accident was a head on collision with a pick-up

truck in which he suffered severe injuries and has been

hospitalized for more than a month. His problem list is

extensive and he suffered an intraparaenchymal

hemorrhage, L fractured ribs, bilateral pneumothorax,

requiring chest tubes, L femur fracture that required

fasciotomies emergently and then second surgery with

nailing, suffered cardiac arrest after arriving at the ER,

patient has been intubated and extubated 3 times, the

last time a week ago. He is now a DNR. He has

dysphagia and a PEG tube was placed approximately 2

weeks ago. He has also had several DVTs while

hospitalized and not able to be fully anticoagulated.

Adams Home Care Consulting, Inc, 5

Case Example – Mr. G - Continued

• He has had a palliative consult and has his wife wishes

to take him home and not return to the hospital. She has

elected hospice care.

• On admission, the patient is total care, not responding to

family members, is unable to swallow and is in danger of

aspiration with a new PEG tube, his hip fracture incision

is well healed and no nursing time will be devoted to

aftercare of the fracture. He has no lingering respiratory

issues, but he does have a stage 2 pressure ulcer on his

right ankle. The physician states that he will most likely

die from aspiration pneumonia or complications of the

DVTs.


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So, let’s Code Mr. G Diagnosis ICD-10-

CM

a

b

c

d

e

f

Other


Mr. G - Answers

Diagnosis ICD-10-CM

a Dysphagia, unspecified stage R13.10

b Acute DVT, unspecified vein(s) I82.40

c Cognitive communication disorder R41.841

d Sequelae of traumatic brain injury

(Concussion) without loss of

consciousness

S06.0x0S

e Stage 2 pressure ulcer R ankle L89.512

f Driver injured in collision with a pick-up

truck in a traffic accident

V43.53


Other Possible codes for Mr. G

• S06.0x1- to S06.0x3-, concussion with loss of

consciousness of 30 minutes or less to 1 hr-5hr 59

min

• S72.92xD, subsequent encounter unspecified

traumatic fracture left femur, closed with routine

healing

• S22.42xD multiple fractures ribs, left side (2 or more

ribs)

• Z86.74 History of cardiac arrest

• Z66 DNR status

• Z93.1Gastrostomy status


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Case Study Mr. S

Mr. S, 85 years old, was referred to hospice from the

hospital where he was treated for MRSA pneumonia and

sepsis with acute and chronic respiratory failure.

MR. S has elected hospice and only wishes to be

kept “comfortable” with minimal treatment for his

medical conditions.

His attending physician has ordered palliative care

plus lab draws for PT/INR weekly and PRN.

Adams Home Care Consulting, Inc. 10

What’s in his medical record?

• Mr. S presented to the ER with acute respiratory distress

and was unable to catch his breath with 5 L of oxygen.

His color was ashen, his fingertips were blue-tinged, and

he had a nearly constant productive cough with dark

yellow-brown tinged mucous.

• He was immediately treated for acute respiratory failure.

The MD felt Mr. S also had some chronic respiratory

failure, but was uncertain of the underlying etiology.

• His chest x-ray showed bilateral pneumonia with infiltrates

to both lungs.

• The sputum culture was positive for MRSA.


Hospital Medical Record information

• The H&P notes that Mr. S:

• Had not been seen by a physician for at least 5 years

• Had been having increasing respiratory problems, low energy, and declining ability to provide self care over the last 2-4 months

• Has no history of cardiac, renal, or other system diseases

• Has been a diabetic for 15 years, which is well-controlled with oral hypoglycemics

Impression (hospital admission): frail elderly gentleman with bilateral MRSA pneumonia and acute and chronic respiratory failure.


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Hospital Course

• Mr. S was in the hospital for 9 days. He was first in the respiratory ICU, where he was on a ventilator for 4 days.

• The day he was scheduled to be transferred from ICU, he complained of severe chest pain and increased dyspnea. An X-ray confirmed a pulmonary embolism, and he was kept in respiratory ICU for 3 more days while he was treated with anticoagulants, respiratory therapy, nebulizers, and continued IV antibiotics.

• Mr. S was then transferred to a step down unit for further observation. On the second day in the step down unit, Mr. S decided he wanted to go home with no further heroic measure and was transferred to hospice.


Mr. S – Nursing Assessment

• He has finished his antibiotics for his pneumonia.

• He is dyspneic with minimal activities, with rales and rhonchi

in both lungs. He has audible wheezing .

• His cardiac status is non-remarkable – BP and heart rate are

WNL.

• He has Type 2 diabetes, which was controlled with oral

hypoglycemics, but he was changed to sliding scale insulin

during his hospitalization. Current BS is 140.

• He has an order for Coumadin 5 mg. per day and will require

PT/INR checks weekly to start this week due to the

pulmonary emboli which Mr. S is still wanting to treat (at least

for now).


Assessment – continued • He has pronounced muscle weakness in all

extremities.

• Mr. S can transfer from bed to chair with minimal

assist and requires moderate assistance plus a

walker to ambulate 40 feet on even surface. He

states his legs “feel like jelly.”

• He requires assistance with all ADLs and is unable to

complete IADLs. He was able to do some of his own

ADLs prior to this hospitalization.


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What additional information

is needed for Mr. S?

• Was an underlying diagnosis determined for his

respiratory failure?

• Does Mr. S still have acute and chronic respiratory

failure?

• Clarification of diabetic treatment at home – will he return

to his oral hypoglycemic or continue on insulin? Will this

contribute to his terminal status?


Clarifications Received from Attending

MD

• Was an underlying diagnosis determined for his respiratory failure?

• Suspected idiopathic pulmonary fibrosis

• Does Mr. S still have acute and chronic respiratory failure?

• No, only chronic respiratory failure upon discharge

• Clarification of diabetic treatment at home – will he return to his oral hypoglycemic or continue on insulin?

• Will continue on sliding scale insulin at least for a little while to see if he stabilizes.


So, let’s Code Mr. S

Diagnosis ICD-10-CM

a

b

c

d

e

f

Other


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Ssshhh - I’m thinking about the

answer.


Possible Answers for Mr. S

Diagnosis ICD-10-CM

a Chronic respiratory failure J96.10

b Acute pulmonary embolism I26.99

c Diabetes mellitus type 2 without

complications

E11.9

d Muscle weakness (generalized) M62.81

e Therapeutic drug monitoring Z51.81

f LT use of anticoagulants Z79.01

Other Personal history of pneumonia

Personal history of MRSA

Z87.01

Z86.14


Key Points

• It is definitely possible to have acute and chronic

respiratory failure in Hospice.

• Coders should always query the physician to determine if

the patient still has acute and/or chronic failure when

discharged from the hospital if the record is not clear.

• In this situation, idiopathic pulmonary fibrosis was

suspected as the underlying cause of the patient’s

acute illness and respiratory failure.

• However, we cannot code a suspected diagnosis. Plus, a

biopsy would be required for this diagnosis, and Mr. S was

too sick to tolerate this during his hospitalization.


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Key Points

• Potentially either chronic respiratory failure or the acute pulmonary embolism could be determined as the principal diagnosis.• The acute pulmonary embolism code is the default code,

unless the physician specifies chronic pulmonary embolism for 3-6 months after onset.

• Long-term insulin use is coded for diabetics (other than Type I), but not for temporary insulin use. In this scenario, there is indication that the sliding scale insulin may only be used short-term.

• Muscle weakness is a symptom and if pronounced may help paint the picture. Generalized weakness is considered “normal” following respiratory illness.


Key Points

• Z codes for therapeutic drug monitoring and long-term

anticoagulant use are relevant , because of the need for

medication teaching, lab draws, and close monitoring of

the effect of his new high-risk anticoagulant therapy.

• In ICD-9, there is an instructional note at V58.83 to use an

additional code for any long-term drug use, which

indicates that the drug must be sequenced after V58.83.

• In ICD-10, there is a code also note at Z51.81 and Z79.2

noting that two codes may be required to fully describe a

condition, but this does NOT provide sequencing direction.


Key Points

• The history of pneumonia should be coded for Mr.

S, since he just finished his antibiotics, and he has

other conditions that put him at a high risk for

recurrence of the pneumonia. He will need to be

closely monitored.

• The recent history of MRSA is also relevant.


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Interactive Case Study – Mrs. J

• Mrs. J was found unconscious at home and taken

to the ER where she was diagnosed with a

massive stroke resulting from intracranial

hemorrhage and immediately transferred to

hospice, as she was moved to the ICU. She is

unconscious, has quadriplegia, and dysphagia.


Case Example Mrs. J

Diagnosis ICD-10-CM

M1021:

M1023:

M1023:

M1023:

M1023:

M1023:

Other:


Mrs. J Case Example Answers

Diagnosis ICD-10-CM

Other sequelae of other nontraumatic

intracranial hemorrhage

I69.298

Unspecified coma R40.20

Other paralytic syndrome following other

nontraumatic intracranial hemorrhage, bilateral

I69.265

Quadriplegia, unspecified G82.50

Dysphagia following other nontraumatic

intracranial hemorrhage

I69.291

Dysphagia, unspecified R13.10


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Key Points

• Mrs. J is a good example of the new sequela

codes for cerebrovascular disease in which the

underlying cause for the cerebrovascular disease

is identified in the sequelae codes.

• Many of these codes are full combination codes, but

some require an additional code to describe the

situation.

• Other sequela, other paralytic syndrome, and

dysphagia, defined in this situation, are three of those

codes that require an additional code to fully describe

the patient situation.


Sequela of CV Disease Categories

• The I69 category are combination codes that identify both the underlying etiology at the 4th character and the residual (sequela) at the 5th and 6th character:

• I69.0-, Sequelae of nontraumatic subarachnoid hemorrhage

• I69.1-, Sequelae of nontraumatic intracerebral hemorrhage

• I69.2-, Sequelae of other nontraumatic intracranial hemorrhage

• I69.3-, Sequelae of cerebral infarction

Sequelae of stroke NOS

• I69.8-, Sequelae of other cerebrovascular diseases

• I69.9-, Sequelae of unspecified cerebrovascular diseases


Key Points (cont.)

• While this situation is actually a hospice one,

because the patient remains in an acute setting, it

emphasizes that coding follows the guidelines for

the hospice benefit, rather than the actual setting

the patient is in.

• For example, once a patient is transferred to hospice,

even though the patient remains in an acute care

setting, the focus of care changes from curative to a

focus on symptom management and palliative care.


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Case Example Ms. Z

• 32 year old Patient with history of anoxic brain injury due to

PEA (Pulseless Electrical Activity) arrest in April 2015. has

mentality of 8-9 year old, blindness in R eye, blurry vision in

left, deafness S/P cochlear implant, left calcaneal osteomyelitis,

brittle Type 2 diabetes mellitus, Type 4 RTA (Renal Tubular

Acidosis), anxiety, chronic diarrhea, nicotine dependence.

• Patient admitted to home health on 7/12/15 due to brittle

diabetes, delirium with agitation (changed to acute on chronic

altered mental status).

• She has been hospitalized twice in the last 10 days for

agitation/combative behavior. Physician has confirmed delirium

superimposed on dementia

• She also picks at skin and has multiple open wounds.


Case Example Ms. Z• Patient with brittle type 2 diabetes, history of anoxic brain

injury, mentality of 8-9 year old, blindness in R eye, blurry

vision in L eye, deafness, left calcaneal osteomyelitis, etc.

Diagnoses ICD-10-CM


Case Example Answers Ms. Z• Patient with brittle type 2 diabetes, history of anoxic brain

injury, mentality of 8-9 year old, blindness in R eye, blurry

vision in L eye, deafness, left calcaneal osteomyelitis, etc.

Diagnoses ICD-10-CM

Type 2 diabetes mellitus with other diabetic kidney

complications

E11.29

Renal tubular acidosis Type IV N25.89

Anoxic brain damage G93.1

Delirium superimposed on dementia F05

deafness H91.9

Blindness on right, low vision on the left (blurry) H54.11

History of cardiac arrest Z86.74

Osteomyelitis (L calcaneal) M86.9


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Interactive Case Study

• Mr. L is admitted to the hospice inpatient unit after surgical repair of a R hip fracture within the last 5 days. He is also noted to have extensive Parkinson’s disease. He has had a steady decline since the injury and surgery. He is not progressing with PT, is not eating well, is having severe acute pain since his surgery (beyond what is typically expected) and increased agitation from delirium and hallucinations.

• The MD has stated the terminal diagnosis is the hip fracture and confirmed dementia with behavioral disturbance.

• What diagnoses should we code for Mr. L?


Mr. L Case Study

Diagnoses ICD-10-CM


Case Example Answers

ICD-10-CM

Right hip fracture subsequent episode S72.001D

Parkinson’s Disease G20

Dementia in diseases classified elsewhere

with behavioral disturbance

F02.81


Other Possible diagnosis that would require MD verification:

Acute post procedural (G89.18) or post trauma (G89.11) pain

Delirium superimposed on dementia (F05)

Hallucinations - auditory (R44.0), visual hallucinations (R44.1),

tactile or other (R44.2), or Unspecified (R44.3)

Loss of appetite (R63.0)

agitation (R45.1)

Did he experience adverse effects from the anesthesia at

surgery (T41.45xD)

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Key Points Mr. L • The healing traumatic fracture can be used as a primary

or secondary code based on the physician’s decision, but needs further support for hospice appropriateness.• Research has shown that elderly patients who experience a

hip fracture have a high incidence of death within 6-12 months.

• What are the actual effects of the hip fracture that are contributing to Mr. L’s terminal prognosis of 6 months or less?

• Without obtaining more information from the physician, it would be difficult to support this patient as hospice appropriate.

• The clinical narrative describing Mr. L’s previous functioning and his current limitation would greatly help “paint the picture “.


Case Example – Mr. M

• Mr. M has a malignant carcinoid tumor of the stomach. He had a partial gastrectomy of 2/3 of his lower stomach and a portion of the duodenum six weeks ago. The cancer was thought to be resolved with the gastrectomy. However, 6 weeks after his surgery, he developed postgastrectomy dumping syndrome and intestinal malabsorption caused by the partial gastrectomy. He currently has severe protein calorie malnutrition, a weigh loss of 40# within the last three months. His BMI is 18 and the physician has determined that his carcinoid tumor has reoccurred in the remaining portion of his stomach.

• Mr. M has decided he wishes not further active treatment and has elected hospice.


Case Example Mr. M

Diagnoses ICD-10-CM

a

b

c

d

e

f


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Case Example Answers Mr. M Diagnoses ICD-10-CM

a Malignant carcinoid tumor of the stomach C7A.092

b Post gastrectomy dumping syndrome K91.1

c Post surgical malabsorption K91.2

d Severe level of protein-calorie malnutrition E43

e Acquired absence of partial stomach Z90.3

f BMI of 19 or less Z68.1


What Questions do you have?

Presented by:

Judy Adams, RN, BSN, HCS-D, HCS-O

Adams Home Care Consulting, Inc.

Asheville, NC

Email: [email protected] or

[email protected]

Phone: (828) 424-7493


mailto:[email protected]

mailto:[email protected]

Documents

ICD-10-CM Other Coding Hot Spots: Part 2 Hospice Case Studiescchospice.org/wp-content/uploads/2015/09/G4-Judy-Adams-ICD-10-CM-Other... · •In ICD-9, there is an instructional note