Download ICD-10-CM Other Coding Hot Spots: Part 2 Hospice Case Studies

9/9/2015
ICD-10-CM OTHER CODING
HOT SPOTS:
PART 2 HOSPICE CASE STUDIES
39th Annual Hospice & Palliative Care Conference
Columbia, SC
September 30, 2015
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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.
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Case Study Ms. N
Diagnosis
ICD-10-CM
a
b.
c.
d.
e.
f.
other
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Case Study Ms. N Answers
Diagnosis
ICD-10-CM
c.
Swelling, mass or lump in chest
Exacerbated COPD
Abnormal weight loss
R22.2
J44.1
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
a
b.
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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.
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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-10CM
a
b
c
d
e
f
Other
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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
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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.
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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.
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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 wellcontrolled 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.
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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).
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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?
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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.
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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.
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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
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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.
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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.
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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.
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Case Example Mrs. J
Diagnosis
ICD-10-CM
M1021:
M1023:
M1023:
M1023:
M1023:
M1023:
Other:
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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.
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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
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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.
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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
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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?
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Mr. L Case Study
Diagnoses
ICD-10-CM
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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 “.
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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.
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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
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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
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