Advanced Case Studies in ICD-10-CM - awc.world Ward - Adv... · ICD-10-CM Case Case Study 1 ©2017...

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

• 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

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

• 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

Bones of the Fingers

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.

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.

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

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

Amputation; traumatic; finger; transphalangeal;partial; index (S68.62-)

Case 1 Answers (cont)

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)

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)

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)

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)

Pelvic Fractures

Fibula and Tibial Fractures

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.

PHYSICAL EXAMINATIONCRANIAL NERVES: Cranial nerves II - XII intact,

except for:– III: Oculomotor: Nystagmus– VII: Facial: Left facial droop.

PHYSICAL EXAMINATIONCRANIAL NERVES: Cranial nerves II - XII intact,

except for:– III: Oculomotor: Nystagmus– VII: Facial: Left facial droop.

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

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

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,

Fracture, traumatic; pubis; superior rim (S32.51-)

Secondary (cont):S32.592D Other specified fracture of left pubis,

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-)

Secondary (cont):S32.592D Other specified fracture of left pubis,

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-)

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-)

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-)

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)

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)

Femoral Epiphysis

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.

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.

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.

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

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 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.

ASSESSMENT AND PLAN:1. Influenza A2. Sepsis, present on admission

– Fever– Tachycardia– Leukocytosis

3. Polymyalgia rhematica.– Chronic steroid use

ASSESSMENT AND PLAN:1. Influenza A2. Sepsis, present on admission

– Fever– Tachycardia– Leukocytosis

3. Polymyalgia rhematica.– Chronic steroid use

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.

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.

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.

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

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)

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)

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)

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)

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)

References

• AHA Coding Clinic® for ICD-10-CM and PCS• ICD-10-CM Official Coding and Reporting

Guidelines for 2016• Shutterstock

• AHA Coding Clinic® for ICD-10-CM and PCS• ICD-10-CM Official Coding and Reporting

Guidelines for 2016• Shutterstock

Questions?

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Advanced Case Studies in ICD-10-CM - awc.world Ward - Adv... · ICD-10-CM Case Case Study 1 ©2017...

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