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Getting It Right Upfront:
Inpatient Documentation and Coding
October 2015 | Volume 5, Issue 10
REVIEW, REVISE, LEARN:
Principal Diagnosis Revision Results in MS-DRG Movement
October 1, 2015 marked the official transition
of our ICD-9-CM classification system to ICD10-CM and ICD-10-PCS—a milestone for the
coding industry.
This month’s case study illustrates that the lessons
we have learned based on cases coded in ICD-9
still have value and will improve the likelihood of
coding accuracy in ICD-10.
An uncertain di­agnosis on
inpatient cases is allowed if it is
documented as still uncertain at
the time of discharge.
The case below was dual-coded by two different
coding professionals at the hospital. One coding
professional final-coded the case in ICD-9 and
one of the hospital’s ICD-10 trainers coded the
case in ICD-10 for practice purposes, identification of coder-education topics, and to glean any
gaps in physician documentation.
CASE STUDY: Postoperative Infection Following Total Joint Replacement
Admitted: 03/24/15
Discharged: 03/30/15
HISTORY AND PHYSICAL
Chief Complaint: Left hip infection
History of Present Illness: Patient presented
to the office today due to left hip incisional erythema. She was previously placed on Levaquin at
skilled nursing facility. The patient states that she
has had increased left hip pain with incisional
drainage and redness for the past few days. The
patient had a left total hip replacement two
weeks ago.
Past Medical History: Hypertension, CHF, and
COPD.
Past Surgical History: Cholecystectomy, left leg
surgery, tubal ligation.
Review of Systems: Skin: Left hip incision pain
and redness.
Examination: General: Feels well and NAD.
Musculoskeletal: Left hip incisional erythema
with purulent discharge, staples in place, swelling
present with skin tearing at the distal end of the
incision. Left hip moderately tender to palpation. No calf tenderness or swelling.
Assessment: Left hip wound cellulitis
Plan: Left hip I&D tomorrow. Start IV Vanco.
Obtain CRP, ESR, and repeat left hip x-rays.
OPERATIVE REPORT (3/25/15)
Postoperative Diagnosis: Wound infection of
the left hip following hip replacement surgery.
Procedure Performed: Debridement and irrigation of left hip and closure over suction drain.
CONSULTATION REPORT (Infectious
Disease, 3/26/15)
Indication(s): The patient had undergone a total
hip replacement approximately two weeks ago.
She was transferred to a skilled nursing facility
(SNF) for rehabilitation. She was brought back
to the clinic for an examination, which showed
that she had drainage at the skin. The patient was
admitted urgently and was taken to the operating
room for debridement procedure.
History of Present Illness: Left hip replacement
performed on 3/10/15. Patient noticed swelling,
pain, erythema and purulent discharge from the
incision site. Patient admitted to the hospital,
and an incision and drainage was performed on
the wound. Results of the hip swab were positive
for MRSA. Nasal swabs preoperatively were
negative for MRSA and the patient was treated
with appropriate perioperative antibiotic therapy.
There is a concern that she obtained the infection at the SNF. Patient is currently being treated
with IV vancomycin. Hip swab done prior to
admission grew heavy MRSA resistant to erythromycin and tetracyclines. Cultures from the OR
specimens pending at this time. Intra-op synovial
fluid described as turbid with >1200 TNC (48%
polys). The orthopedic surgeon indicated to the
patient that the infection did not tract to the
hardware. The patient has had no fever or chills.
Findings: Skin cellulitis, no evidence of necrosis
or abscess below the fatty layer, intact fascial
closure, and clear synovial fluid.
Operation in Detail: The patient was taken to
the OR and was placed in the supine position.
The hip was prepped with Betadine. Sterile
drapes were then applied. Antibiotic administration was withheld in order to get cultures. The
skin edges were completely ellipsed along with
subcutaneous tissue in order to clean the edges of
the incision. The fatty layer was completely intact and below the fatty layer (she has moderate
obesity) there was serosanguineous fluid above
the fascia. This was sent for cell count and culture. The fascial closure was intact. This was then
opened. The joint fluid was actually relatively
clear. This was sent for cell count and culture as
well. The joint was irrigated with 3 liters of saline
using the jet lavage. The fascia was then closed
with #1 PDS. The fatty layer was irrigated with
another 3 liters of saline using the jet lavage.
A drain was left in that layer for postoperative
drainage. The fatty layer was closed in 2 layers.
Subdermal layer was closed with 2-0 Monocryl.
Skin was closed with nylon and staples. A sterile
compressive dressing was applied.
Impression: Surgical site infection, left prosthetic hip: Await culture results and continue IV
Vanco. Long-term therapy: PICC placement and
IV abx with rifampin for 6 weeks followed by
long-term suppressive antibiotic therapy.
Recommendation: Patient underwent left hip
replacement complicated by likely hardware
MRSA infection. Early infections (< 30 days)
can be treated with debridement and retention
of prosthesis if no sinus tract developed. Culture
results will dictate therapy options. Swab sample
is not usually indicative of infection source unless Staph aureus is present, then source is likely
Staph. Despite this not being a deep infection,
MRSA is tough to treat. We will plan for 6
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Getting It Right Upfront: Inpatient Documentation and Coding
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weeks of antibiotic therapy, as if the joint were
involved, likely augmented with rifampin and
possibly with oral suppression after that.
PROGRESS NOTES
Admit Note (Orthopedic Surgeon, 3/24/15):
68-year-old female s/p left THA on 3/10/15
admitted for left hip cellulitis. The wound began
to drain 2–3 days ago, and she contacted our
office yesterday. She will need to have a surgical
debridement. I informed her that we will most
likely use a VAC dressing unless the contamination is superficial only. She has moderate obesity
with regard to the fatty layer in the hip region
thus we need to be careful with closing prematurely if there is high degree of contamination.
Brief Op Note (Orthopedic Surgeon, 3/25/15):
Postop Diagnosis: Left hip infected. Procedure
Performed: I and D left hip. Findings: Left hip hematoma and serosanguinous drainage, no frank
purulence. Two cultures were sent including left
hip deep joint fluid. Postop Plan: IV antibiotics,
PT/OT and await cultures.
Daily Progress Note (Orthopedic Physician
Assistant, 3/26/15): Pain within patient’s comfort level. Vital signs are stable, afebrile. Wound
is clean and dry, has no erythema or purulence.
Dressing in place, drain in place – output 105
cc. Plan: ID consult, currently on IV Vanco,
await final cultures. Plan for discharge to SNF vs.
home care depending on final ID recommendations for antibiotics.
Daily Progress Note (Orthopedic Surgeon,
3/26/15): The superficial skin swab from the
clinic upon presentation 2 days ago is growing
MRSA. The deeper intraoperative cultures are
pending—one specimen from above the fasciae
below the fatty layer and one from the joint itself.
The total nucleated cell counts for both of the
intraoperative fluid collections are low with low
poly percentage (below what would be expected
for 2 weeks post recent surgery). Clinically this
is NOT a deep infection. However, given the
potential negative consequences of “under treatment,” I would recommend treatment for several
weeks. We will discuss with ID about the drug of
choice and the route of administration.
Procedure Note (Registered Nurse, 3/27/15):
Consulted for PICC placement. The right arm
was infiltrated with 1% Lidocaine subcutaneously
and intradermal. A 5-French double lumen catheter was inserted into the right basilic vein and
advanced using ultrasound guidance. 40 cm total
length. X-ray to evaluate proper catheter tip location was performed. Tip placement was verbally
confirmed to be in good position by radiologist.
Daily Progress Note (Orthopedic Physician
Assistant, 3/27/15): POD2 status post left hip
Volume 5, Issue 10 | Page 2
From the Desk of the Doc-U-Mentor
Robert S. Gold, MD
Isn’t it interesting how the
opinion of a physician who
“was there” (performed the
actual procedure) has been
disregarded, but codes are
assigned based on the documentation of the
consulting physicians (who had nothing to do
with the case and are just guessing)?
This was a superficial wound infection—period.
There is no implication whatsoever that the
prosthesis had anything to do with it, which is
why the surgeon excluded it from involvement.
That being said, let’s talk about the consideration of the patient’s transfusion and the
so-called “acute blood loss anemia.” First of
all, the patient came into the hospital with a
hemoglobin of 8.4 (ranging from 8.8 - 8.0) and
after an operation that consisted of no blood
loss, had a hemoglobin of 6.9—this in spite of
the fact that the patient received about 2 liters
of crystalloid.
I&D, left THA on 3/10/15. Waiting for final
cultures from surgery, continue Vanco IV, start
rifampin 600 mg daily for 6 weeks, monitor
CBC, BMP, CRP. PICC placed, appreciate ID
recommendations. Discharge once we get final
culture results.
Daily Progress Note (Infectious Disease,
3/27/15): Objective: Micro: Left hip intraop
synovial culture—no growth. Left hip intraoperative deep tissue--Staph aureus (sensitivity pending). Assessment: Intraoperative cultures growing
Staph aureus. Infected surgical site. Though
prosthesis not directly involved, it is at risk and
therefore will plan treatment for 6 weeks.
Daily Progress Note (Orthopedic Surgeon,
3/28/15): Afebrile. Some tachycardia in interval. LLE wound with minimal drainage, no
surrounding erythema, no purulence. Wound
culture done on 3/25 w/ MRSA. POD3 after left
hip I&D. Will transfuse 2u PRBC for post-operative anemia. Continue vanco/rifampin per ID.
Blood Administration Flowsheet (Nursing,
3/28/15): 2 units packed RBCs transfused. Line:
PICC, right basilic vein.
Daily Progress Note (Orthopedic Surgeon,
3/29/15): Afebrile. Status post I&D of left hip
infection. Appropriate response to transfusion.
Continue vanco/rifampin per ID for MRSA.
Discharge home once antibiotics are arranged for
through home health.
Daily Progress Note (Orthopedic Physician
Assistant, 3/30/15): No new complaints. Dress-
The low number was dismaying to the attending physicians, so they transfused two units
of packed cells. Yes, this was anemia, but it
was present on admission (POA). The drop in
hemoglobin was hemodilution but no additional anemia—just a drop in hemoglobin. The
patient needed cells to provide oxygen to the
body, which was the reason for the transfusion.
If the hemoglobin had not been so low, the
physicians would have waited three days and
the level would have come back to preoperative
levels by itself.
Finally, let’s look at what the surgeon actually
did during the operative procedure. He did a
wide “excision” of the infected skin and subcutaneous tissue and collected samples for culture.
This, according to AHA Coding Clinic (Third
Quarter, 2008), was truly an excisional debridement of an infected wound, with skin widely
excised (even back to healthy tissue).
ing changed, new Aquacel dressing in place.
Anticipate discharge today with home health
once all services are set up.
DIAGNOSTIC DATA
Laboratory: 3/24/15: WBC 13.4, Hgb 8.8, Hct
28.6, CRP 17.2. 3/26/15: WBC 11.0, Hgb 7.6,
Hct 24.8. 3/28/15: Hgb 6.9. 3/29/15: WBC 7.8,
Hgb 10.2, Hct 33.1.
Pathology: Soft tissue, left hip (3/25/15): Hemorrhage and degenerating fat with surrounding
fibrovascular stroma. Patchy acute inflammation,
up to 10 neutrophils per high-powered field.
Microbiology: Left hip wound culture (3/25/15):
Rare growth Methicillin resistant Staph aureus.
Left hip deep joint fluid anaerobic and gram stain
(3/25/15): No anaerobes isolated at 5 days.
Radiology: Chest X-ray (3/27/15): Right-sided
PICC line is seen with its tip in the SVC.
DISCHARGE SUMMARY
Reason for Admission: Left hip pain, left hip
infection
Principal Diagnosis: Wound infection of the
left hip following total hip replacement
Principal Procedure: Debridement and irrigation of the left hip and closure over suction drain
Hospital Course: Patient was admitted for left
hip I&D. No intraoperative complications were
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Getting It Right Upfront: Inpatient Documentation and Coding
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noted. Patient was admitted for IV antibiotics, pain control, physical therapy and DVT
prophylaxis. The patient’s incision was benign at
discharge. Discharged with home health services.
Medications on discharge include vancomycin
200 mL intravenously every 12 hours for 36 days
and oral rifampin 600 mg daily for six weeks.
ICD-9-CM and ICD-10-CM/PCS Code Assignment Comparison
The tables below compare a few ICD-9-CM and ICD-10-CM codes related to the case study and
the 2015 version of ICD-10-CM and ICD-10-PCS codes. For more details, go to http://www.cms.
gov/Medicare/Coding/ICD10/.
ICD-9-CM ICD-9-CM Descriptors
Codes
ICD-10-CM
Codes
ICD-10-CM Descriptors
998.59
Other postoperative infection
T81.4XXA
E878.1
Surgical operation with implant of artificial
internal device causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Cellulitis and abscess of leg, except foot
L03.116 (CC)
Infection following a procedure,
initial encounter
No external cause code needed
Hospital MS-DRG When Coded in
ICD-9-CM (Grouper Version 32)
MS-DRG Assigned: 464 Wound debridement
and skin graft except hand, for musculo-connective tissue disorder with CC
Volume 5, Issue 10 | Page 3
682.6
(CC)
041.12
Methicillin resistant staphylococcus aureus
B95.62
Hip joint replacement by other means
Z96.642
Cellulitis of left lower limb
Methicillin resistant Staphylococcus aureus infection as the cause of
disease classified elsewhere
Presence of left artificial hip joint
Relative Weight: 3.0085
Medicare Payment: $19,555
V43.54
Hospital ICD-9 Code Assignments
ICD-9-CM ICD-9-CM
Procedure Procedure
Codes
Descriptors
ICD-10-PCS
Codes
ICD-10-PCS Descriptors
86.22
Excisional
debridement
of wound/infection/burn
0JBM0ZZ Excision of left upper
leg subcutaneous
tissue and fascia,
open approach
80.85
Local excision/ 0S9B00Z
destruction of
lesion of joint
of hip
0 – Medical and surgical (section)
J – Subcutaneous tissue and fascia (body system)
B – Excision (root operation)
M – Subcutaneous tissue and fascia, left upper leg (body part)
0 – Open (approach)
Z – No device (device)
Z – No qualifier (qualifier)
0 – Medical and Surgical (section)
S – Lower Joints (body system)
9 – Drainage (root operation)
B – Hip joint, left (body part)
0 – Open (approach)
0 – Drainage device (device)
Z – No qualifier (qualifier)
Principal Diagnosis:
996.66 YInfection and inflammatory reaction
due to internal joint prosthesis
Secondary Diagnoses:
998.59 Y (CC) Other postoperative infection
682.6 Y (CC) Cellulitis and abscess of leg,
except foot
285.1 N (CC) Acute posthemorrhagic anemia
428.0 Y Congestive heart failure, unspecified
496
Y Chronic airway obstruction
401.9 Y Essential hypertension, unspecified
benign or malignant
278.00 Y Obesity, unspecified
041.12 Y Methicillin resistant staphylococcus
aureus
V43.64 E Hip joint replacement by other
means
E878.1 Y Surgical operation with implant
of artificial internal device causing
abnormal patient reaction, or later
complication, without mention of
misadventure at time of operation
Procedure Codes:
80.85 Local excision/destruction of lesion of
joint of hip
In ICD-9, excisional debridement of the skin and/or subcutaneous tissue is coded to 86.22. In ICD10-PCS, two separate body system values (character 2) exist depending on if just the skin was debrided
or if subcutaneous tissue was also debrided. To illustrate, the following PCS code options were considered in this case for the excisional wound debridement of the left hip:
0JBM0ZZ
Excision of the left upper leg subcutaneous tissue and fascia, open approach
0HBJXZZ Excision of left upper leg skin, external approach
According to ICD-10-PCS guideline B3.5, when an excision is performed on overlapping layers, the
body part specifying the deepest layer is coded. In this case, the details of the operative report indicate
that the subcutaneous tissue was the deepest tissue excised; therefore, the body system value J for subcutaneous tissue and fascia was selected.
Relative Weight: 2.0500
I50.9
Y Heart failure, unspecified
Revised Payment: $13,325
J44.9
Y Chronic obstructive pulmonary
disease, unspecified
86.22 Excisional debridement of wound/infection/burn
Relative Weight Change: -0.9585
I10
Y Hypertension
38.97 Central venous catheter placement with
guidance
Hospital ICD-10 Code Assignments
E66.9
Y Obesity
Principal Diagnosis:
B95.62 Y Methicillin resistant Staphylococcus aureus infection as the cause of
disease classified elsewhere
99.04 Packed cell transfusion
Hospital MS-DRG When Coded in
ICD-10-CM/PCS (Grouper Version 32)
MS-DRG Assigned: 857 Postoperative or posttraumatic infections with OR procedure with CC
T81.4XXA Y Infection following a procedure, initial encounter
Secondary Diagnoses:
Z96.642 E Presence of left artificial hip joint
L03.116 Y (CC) Cellulitis of left lower limb
D64.9 Y Anemia, unspecified
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Getting It Right Upfront: Inpatient Documentation and Coding
Volume 5, Issue 10 | Page 4
| CASE STUDY ... continued from page 3 |
Procedure Codes:
0JBM0ZZ Excision of left upper leg subcutaneous tissue and fascia, open approach
0S9B00Z Drainage of left hip joint with drainage device, open approach
02HV33Z Insertion of infusion device into
superior vena cava, percutaneous
approach
30243N1 Transfusion of nonautologous red
blood cells into central vein, percutaneous approach
Lessons for the Hospital to Learn
The revision of the principal diagnosis in this
case from an infection of a joint prosthetic to an
infection of a surgical wound results in MS-DRG
movement in both ICD-9 and ICD-10. The official coding guideline II.H for selection of principal diagnosis allows for an uncertain diagnosis on
inpatient cases, if documented at discharge as still
uncertain (i.e., not ruled in or out), to be coded
as if the condition existed or was established.
During the hospital course of our case study,
the medical record documentation includes
differential diagnosis statements such as “left
hip replacement complicated by likely hardware
MRSA infection.” After study (i.e., surgical
inspection of the surgical site and deep wound
cultures), the orthopedic surgeon documented in
the discharge summary that the diagnosis was a
“wound infection of the left hip following total
hip replacement.” This condition is classified to
ICD-9 code 998.59 based on the index listing for
infection ➞ postoperative wound.
The fact that the infectious disease consultant
and orthopedic surgeon agreed to treat the
patient as if the joint were infected with six weeks
of IV antibiotics does not change the fact that an
infection of the prosthetic joint was ruled out.
A question about code assignment included in
the AHA Coding Clinic (page 5, first quarter
2014) could create some confusion on this topic.
The following information was included in the
question: “a patient was admitted to the hospital
for treatment of an infected total knee arthroplasty and wound dehiscence” and the provider’s
final diagnostic statement was “dehiscence and
wound infection with corynebacterium of right
total knee replacement.”
According to AHA Coding Clinic, code 996.66
would be assigned as the principal diagnosis.
Similar to our case study, the physician documentation in the medical record at the time of
discharge should clearly indicate whether or not
the joint prosthesis site was infected or suspected
to be infected (996.66) or if only the surgical
incision site was infected (998.59).
In addition to the principal diagnosis revision,
the diagnosis code for anemia was revised during
the dual-coding exercise. When coded in ICD-9,
the coding professional selected CC 285.1 for
acute blood loss anemia. The documentation in
the medical record stated “postoperative anemia”
without a link to blood loss.
Based on indexing in ICD-9 and ICD-10,
anemia ➞ postoperative leads to the assignment
of an unspecified anemia diagnosis code — 285.9
and D64.9 respectively. Note that the term
“acute” continues to be a non-essential modifier
in ICD-10 for the index listing for anemia ➞
due to (acute) blood loss.
Four ICD-10-PCS Guidelines Revised for 2016
The 2016 version of the Official ICD-10-PCS
Coding Guidelines contains revisions to four
coding guidelines to provide more clarity. The
revisions to these guidelines are printed in italic
below:
Inspection Procedures: B3.11b—If multiple
tubular body parts are inspected, the most distal
body part (the body part furthest from the starting
point of the inspection) is coded. If multiple nontubular body parts in a region are inspected, the
body part that specifies the entire area inspected
is coded. Examples: Cystoureteroscopy with
inspection of bladder and ureters is coded to the
ureter body part value. Exploratory laparotomy
with general inspection of abdominal contents is
coded to the peritoneal cavity body part value.
Biopsy procedures: B3.4a—Biopsy procedures
are coded using the root operations Excision,
Extraction, or Drainage and the qualifier Diagnostic. [Deleted: The qualifier Diagnostic is used
only for biopsies] Examples: Fine needle aspiration
biopsy of lung is coded to the root operation
Drainage with the qualifier Diagnostic. Biopsy
of bone marrow is coded to the root operation
Extraction with the qualifier Diagnostic. Lymph
node sampling for biopsy is coded to the root
operation Excision with the qualifier Diagnostic.
Multiple procedures: B3.2—During the same
operative episode, multiple procedures are coded
if:
b. The same root operation is repeated in multiple body parts, and those body parts are separate
and distinct body parts classified to a single ICD10-PCS body part value. [Revised from: The same
root operation is repeated at different body sites that
are included in the same body part value] Example:
Excision of the sartorius muscle and excision
of the gracilis muscle are both included in the
upper leg muscle body part value, and multiple
procedures are coded.
Body Part General Guidelines: B4.1b—If the
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prefix “peri” is combined with a body part to
identify the site of the procedure, and the site
of the procedure is not further specified, then the
procedure is coded to the body part named. This
guideline applies only when a more specific body
part value is not available. Examples: A procedure
site identified as perirenal is coded to the kidney
body part when the site of the procedure is not
further specified. A procedure site described in the
documentation as peri-urethral, and the documentation also indicates that it is the vulvar tissue
and not the urethral tissue that is the site of the
procedure, then the procedure is coded to the vulva
body part.
The 2016 files for ICD-10-CM and ICD10-PCS are available at https://www.cms.gov/
Medicare/Coding/ICD10/. Using the links on the
left-hand side of this page, navigate to the 2016
pages for ICD-10-PCS and GEMs, which contain a PDF file of the 2016 Official ICD-10-PCS
Coding Guidelines.
Editors
Sandy Routhier, RHIA, CCS
AHIMA-Approved ICD-10-CM/PCS
Trainer and Ambassador
Physician Advisor
Robert S. Gold, MD
CEO, DCBA Inc.
Atlanta, GA
Janis Oppelt
Editor, MedLearn Publishing
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