MRCH245 PORTFOLIO PROJECT PART I 1

MRCH245 Portfolio Project Part I

Research Paper

Frank Skwierc

Bryant & Stratton College

MRCH245 Inpatient Procedural Coding

Kara Silvers

April, 16, 2016

PART I RESEARCH 2

ABSTRACT

This Portfolio Project is designed to demonstrate the knowledge gained in both Inpatient

Procedural Coding and Inpatient Diagnostic Coding. The Instructor Ms. Kara Silvers requires

that an explanation of the Point of Admissions Indicators used for hospital admission services,

and to provide at least three examples for each of the indicators. Next to select a procedure of

choice that is performed on one of the body systems discussed in this course, identifying

vocabulary terms and guidelines for coding of the procedure. This part of the report should

provide reasons for selecting this particular procedure and must show justification for that

choice. The final part of this report involves selecting a body system from those that were

discussed in the course and identify specific guidelines for coding procedures within that body

system. Again the student must show reasons for selecting that particular body system and show

justification for that choice. This report must be in essay form and done in APA format

approximately four to five pages in length excluding the title page, abstract, introduction, and

reference page.

PART I RESEARCH 3

INTRODUCTION

This research paper will first discuss the four reporting options for Present on Admission

(POA) indicator codes that a coder applies to the billing documentation. Next it will discuss

Endoscopic Operations and Procedures performed on the Female Genital Organs. This

discussion will identify key terms that the Coder will need to be familiar with in identifying

both the diagnosis and procedure involved, as well as, any specific guidelines the coder should

be aware of when coding this procedure. Next this report will discuss the bodies Digestive and

Urinary System, and a common condition these systems can suffer from and is related closely to

Female Genital Organs with diagnoses and procedures that are related. One diagnosis that can

affect all these systems is Endometrioses, the report will discuss this condition and provide

examples of the effects to each system and the organs involved. A short summary will conclude

this report emphasizing the key points a coder should be aware of while coding POA and

Endoscopic Procedures.

PART I RESEARCH 4

Present on Admission (POA)

Present on admission is simply defined as a condition, or injury, that is present at the time the

order for inpatient admission occurs (Bowie, 2015). POA can be as obvious as someone who is

admitted to the emergency room with visible injuries such as sever lacerations or broken bones,

or the patient could be pregnant and ready to give birth. Less obvious reasons for admission

would be the patients’ signs and symptoms which may relate to a serious condition, or a known

condition that has become acute or exacerbate such as COPD or Diabetes Mellitus. The four

code indicators used for coding are as follows:

Y: (Yes, present at the time of inpatient admission).

N: (No, not present at the time of inpatient admission).

U: (Unknown, documentation is insufficient to determine if condition is POA).

W: (Clinically undetermined, provider is unable to clinically determine whether

condition was POA or not) (Bowie, 2015).

Coders should note the POA indicator U should not be used simply because the medical

record is unclear at the time of admission, instead they should query the physician when the

documentation is unclear, so that a more affirmative indicator can be assigned. This also applies

to the indicator W, the coder needs to query the physician, as well as, do a thorough examination

of the patients past medical record to present to the attending physician. Usually, the patients’

history can provide the physician with enough information to make a more precise determination

(Basset, 2016).

Some descriptive examples of the use of the POA indicator Y are as follows:

1. The patient is admitted for a diagnostic work-up for cachexia code (799.4) because the

patient shows signs of ill health and poor nutrition. However, the final diagnosis is

PART I RESEARCH 5

malignant neoplasm of lung with metastasis code (162.9). Here the malignant neoplasm

was clearly present on admission, even though it was not diagnosed until after the

admission (ICD-9-CM, 2014) (Bryant, 2007).

2. A patient who is undergoing outpatient surgery, and during the recovery period the

patient develops atrial fibrillation code (427.31) and the patient is then admitted to the

hospital as an inpatient. The indicator Y is appropriate because the atrial fibrillation

developed prior to admission (ICD-9-CM, 2014) (Bryant, 2007).

3. Determining whether a pregnancy complication or obstetrical condition was present at

the time of admission can be tricky for the coder. A birth may or may not occur but the

complication or obstetrical condition maybe determined later. The patient can be

determined later to be in preterm labor code (644.21) this condition surly existed prior to

admission and assigning indicator Y is appropriate (ICD-9-CM, 2014) (Bryant, 2007).

Some descriptive examples of the use of the POA indicator N are as follows:

1. A patient is admitted to the hospital for coronary artery bypass surgery code (36.10).

Postoperatively the patient developed a pulmonary embolism code (415.19). The coder

would assign N on the POA field for the pulmonary embolism. This is an acute condition

that was not present on admission (ICD-9-CM) (Bryant, 2007).

2. If a pregnancy complication or obstetrical condition was not present on admission like

postpartum hemorrhage code range (666.xx) occurs during hospitalization, or fetal

distress code range (768.1 – 768.4) develops after admission is another situation when the

coder should assign indicator N (ICD-9-CM) (Bryant, 2007).

3. If the obstetrical code includes more than one diagnosis and any of the diagnoses

identified by the code were not present on admission the coder should assign indicator N

PART I RESEARCH 6

for example Code (642.7) Pre-eclampsia or eclampsia superimposed on pre-existing

hypertension (ICD-9-CM) (Bryant, 2007).

Lastly if an obstetrical code includes information that is not a diagnosis, the coder should not

consider that information in the POA determination. For example code 652.1x, Breech or

other malpresentation that is successfully converted to a cephalic presentation should be

reported as the present on admission if the fetus was breech on admission. Since the

conversion to cephalic presentation does not represent a diagnosis, the fact that the

conversion occurred after admission has no bearing on the POA determination (ICD-9-CM)

(Bryant, 2007).

Endoscopic/Laparoscopic Operations and Procedures Performed

On the Female Genital Organs

Endoscopic Surgery is a minimally invasive surgery done with the use of a fiber-optic

video camera, refer to as a *Endoscope and done with several types of very thin instruments.

During this procedure the surgeon will make only a few small incisions into the abdomen up to

an inch in length and place plastic tubes call *Ports into these incisions. These ports allow the

camera and instruments access to the inside of the patient. The abdomen is usually *insufflated

with carbon dioxide gas for this procedure and elevates the abdominal wall thus creating working

and viewing space. The reason for using carbon dioxide gas is because it is common to the

human body and can be absorbed by the tissue and removed by the respiratory system. Another

reason is this gas is also non-flammable and surgeons can perform *Electro Surgery (ASGE,

2016) (WebMD, 2016).

This procedure is performed on female genital organs, such as the *Ovaries, *Fallopian

tubes, and *Uterus. A few Laparoscopic procedure codes related to the ovaries are (65.23)

PART I RESEARCH 7

Laparoscopic *Marsupialization of ovarian cyst, and code (65.24) Laparoscopic *Wedge

Resection of ovary, or code (65.25) other laparoscopic local excision or destruction of ovary.

Codes for operations on the fallopian tubes code range (66.0 – 66.99) and those pertaining to the

uterus code range (68.0 – 69.99) contain many procedures that are consider to be endoscopic or

laparoscopic. However, the different approaches can be referred to using different terms but all

the procedures utilize the same procedure. For example: Culdoscopy, which is an endoscopic

insertion through posterior structure of the vagina, Hysteroscopy is the endoscopic insertion

through the uterus, Laparoscopy is the endoscopic insertion through the abdomen,

Peritoneoscopy, is the endoscopic insertion through the abdominal serous membrane cavity

(ICD-9-CM, 2014).

Common Condition that can affect the Urinary System,

Digestive System, and Female Genital Organs

A condition that is a common health problem for women is *Endometriosis, Code range

(617.0 – 617.9) and often it is found on the ovaries, fallopian tubes, the tissue that holds the

uterus in place, or the outer surface of the uterus. It also can be found in the vagina, cervix,

vulva, lungs, brain, and skin, but that is not all. It can appear in the digestive and urinary system,

growing in the bowel, bladder, kidneys, or rectum. The most common symptom women have

with endometriosis is pain and the pain can be very intense causing a trip to the emergency room

and is often mistaken for other conditions for the POA. The pain is usually described as a deep

pain in the pelvic region, or intestinal, during bowel movement, while urinating, menstrual cycle,

or in the lateral region of the back. There may even be stomach (digestive) problems that include

diarrhea, constipation, bloating, or nausea. All these symptoms can be diagnosed to something

other than endometriosis at the POA (Womenshealth.gov, 2016) (ICD-9-CM, 2014).

PART I RESEARCH 8

Diagnosing endometriosis can be difficult for a physician because these symptoms are

common for many other conditions. One way the physician can diagnosis this condition during a

routine gynecological examination through a Pelvic exam coded to (V72.31). Or the physician

would do a blood test or urine test most likely coded (V72.60) to check the levels of

*Gonadotropin it contains. The diagnosis code associated with doing a blood or urine test is

(631.0). Once a hormonal imbalance is discovered the physician may put the patient on

hormonal medicine and if the pain begins to subside there is a good chance you have

endometriosis. However, only a type of endoscopic surgery like Laparoscopy, can truly

determine for sure if you have endometriosis. Often the physician can make this diagnosis just

by seeing the growths, and other times they need to take tissue samples for study (Nichd.nih.gov,

2016) (ICD-9-CM, 2014).

Summery

Before a coder assigns a POA indicator they must consult the categories and codes

exempt from diagnosis list. The coder should leave the POA field blank if the condition is on the

list of ICD-9-CM codes for which this field is not applicable. This would be the only time in

which the field maybe left blank. The reason is these codes represent circumstances regarding

the healthcare encounter or factors influencing health status that do not represent a current

disease or injury or are always present on admission (ICD-9-CM, 2014).

Other conventions the coder should be aware of when coding procedures is the use of

brackets, parentheses, includes, excludes, and inclusion terms. In the tabular the coder should be

weary of the notation Code Also this informs the coder that additional codes may be required for

the category should the documentation mention their application, administration, or additional

synchronous procedures. For example code (66.62) Salpingectomy with removal of tubal

PART I RESEARCH 9

pregnancy. Here it says code also any synchronous oophorectomy and gives codes (65.31,

65.39). The coder should also keep in mind that endoscopic surgery has several different terms

for the approach used and will aide them in choosing the proper code. So they need to be

familiar with these terms. Culdoscopy, Hysteroscopy, Laparoscopy, and Peritoneoscopy.

Finally Chapter 11 codes, Complications of Pregnancy, Childbirth, and the Puerperium

codes (630 – 679) have sequencing priority over codes from other chapters. The only notable

exception to this rule is if the provider documents that the pregnancy is incidental to the

encounter, and if so, code (V22.2) should be used in place of any chapter 11 code.

(*Bolded) Depicts that a definition of the term can be found on the last page entitled Terms.

PART I RESEARCH 1

References Portfolio Project Part I

ASGE: Endoscopic Procedures. (2016). Asge.org. Retrieved 15 April 2016, from

http://www.asge.org/press/press.aspx?id=548

Bassett, M. (2016). The Here and Now ON PRESENT-ON-ADMISSION INDICATORS. For

The Record (Great Valley Publishing Company, Inc.), 28(2), 10-13 4p.

Bowie, M. (2015). Understanding ICD-9-CM Coding (4th ed., pp. 450-492). Boston, MA:

Cengage Learning.

Bryant, G. (2007). POA Indicator Compliance…Is Your Hospital and Coding Staff Ready?

Journal Of Health Care Compliance, 9(5), 21-26.

Endometriosis | womenshealth.gov. (2016). Womenshealth.gov. Retrieved 14 April 2016,

from

http://womenshealth.gov/publications/our-publications/fact-sheet/endometriosis.html

ICD-9-CM for Hospitals--Volumes 1, 2, & 3. (2014). Salt Lake City, UT

Laparoscopy. (2016). WebMD. Retrieved 15 April 2016, from

http://www.webmd.com/digestive-disorders/laparoscopy-16156

Dictionary and Thesaurus | Merriam-Webster. (2016). Merriam-webster.com. Retrieved 15

April 2016, from http://www.merriam-webster.com/medical

What are the treatments for endometriosis? (2016). Nichd.nih.gov. Retrieved 14 April 2016,

from https://www.nichd.nih.gov/health/topics/endometri/conditioninfo/Pages/

treatment.aspx#s urgical

PART I RESEARCH 1

Terms

Endoscope: An illuminated usually fiber-optic flexible or rigid tubular instrument for

visualizing the interior of a hollow organ or part (as the bladder or esophagus) for diagnostic or

therapeutic purposes that typically has one or more channels to enable passage of instruments (as

forceps or scissors).

Insufflated: Is the act of blowing something (such as a gas, powder, or vapor) into a body

cavity. Insufflation has many medical uses, most notably as a route of administration for various

drugs.

Electro Surgery: The surgical use of high-frequency electric current for cutting or destroying

tissue, as in cauterization.

Port: 1). A small medical device (as of plastic or titanium) that is implanted below the skin, is

attached to a catheter typically inserted into a blood vessel, and has a small opening through

which a needle can be inserted to administer fluids or drugs or withdraw blood. 2). An incision

(as one made between intercostal spaces) for passing a medical instrument (as an endoscope) into

the body.

Ovaries: One of the typically paired essential female reproductive organs that produce eggs and

in vertebrates female sex hormones, that occur in the adult human as oval flattened bodies about

one and a half inches (four centimeters) long suspended from the dorsal surface of the broad

ligament of either side, that arise from the mesonephros, and that consist of a vascular fibrous

stroma enclosing developing egg cells.

Fallopian tubes: Either of the pair of tubes that carry the eggs from the ovary to the uterus—

called also uterine tube.

PART I RESEARCH 1

Uterus: An organ in a female for containing and nourishing the young during development prior

to birth that has thick walls consisting of an outer serous layer, a very thick middle layer of

smooth muscle, and an inner mucous layer containing numerous glands, and that during

pregnancy undergoes great increase in size and change in the condition of its walls—called also

womb.

Marsupialization: To open (as the bladder or a cyst) and sew by the edges to the abdominal

wound to permit further treatment (as of an enclosed tumor) or to discharge pathological matter

(as from a hydatid cyst).

Wedge Resection: Any of several surgical procedures for removal of a wedge-shaped mass of

tissue (as from the ovary or a lung).

Ligation: The surgical process of tying up an anatomical channel (as a blood vessel).

Salpingectomy: Surgical excision of a fallopian tube.

Hysterectomy: Surgical removal of the uterus.

Endometriosis: A condition when the tissue of the uterus grows outside of the uterus in areas of

the body where it does not belong.

Gonadotropin: A glycoprotein hormone similar in structure to luteinizing hormone that is

secreted by the placenta during early pregnancy to maintain corpus luteum function and

stimulate placental progesterone production, is found in the urine and blood serum of pregnant

women, is commonly tested for as an indicator of pregnancy, is used medically to induce

ovulation

MRCH 245 PORTFOLIO PROJECT PART 1

MRCH245 Portfolio Project Part II

Coding Scenario

Frank Skwierc

Bryant & Stratton College

MRCH245 Inpatient Procedural Coding

Kara Silvers

April, 23, 2016

PART II CODING 2

ABSTRACT

Portfolio project part two is a coding scenario in which we are required to extract the

necessary information from the medical report supplied and determine what codes are needed to

code this case study properly, as well as, report to Instructor Ms. Silvers if the information meets

medical necessity. This should be a two to three page report excluding title and reference page.

The report should contain a brief summary of the information used to determine each code, the

method used in determining the codes you assign, including the conventions and protocols.

Finally, it should provide a description of the health care professionals you might need to

collaborate with to code the procedure accurately, as well as, your reasoning in choosing these

particular individuals. Once part two of the portfolio project entitled “Coding Scenario” is

completed it is to be combined with part one entitled “Research Paper” and uploaded to the

E-portfolio account.

PART II CODING 3

INTRODUCTION

The Coding Scenario provided by Ms. Silvers consist of three parts a Face Sheet,

Diagnoses and Procedures section, and finally the Operative Report. While summarizing this

Coding Scenario I will provide information on the codes I have selected and explain why I

selected these codes and how I located them in the ICD-9-CM and explain why I believe these

codes are necessary for reimbursement for provider services. Should the documents Ms. Silvers

provided prove to need additional information before submitting for reimbursement, because of

lack of Medical Necessity, or clarification of the procedure performed, that requires making a

query, or requesting any additional reports from other technicians, nurses, or staff, I believe is

needed to complete the forms necessary for reimbursement will also be explained. While doing

this review I will also make note of the Individuals that will aide me in accomplishing the

Coding and Reimbursement Process. I will begin with the Face Sheet.

PART II CODING 4

REVIEW OF CODING SCENARIO

The Face Sheet contains information about the patient such as their name, contact

information, demographics, attending physician, as well as, the date and time of visit with the

medical record number that is assigned to this individual. The information on the Face Sheet

appears to be clear, concise, and complete, for coding this scenario and even provides the coder

information that the procedure that is going to be performed as an Outpatient procedure which is

noted in the date of visit part of the Face Sheet. Knowing this is important to the coder because

it affects the patients billing. Inpatient stays are when a physician formally admits the individual

to the hospital, for a stay of two days or more. However, you are an Outpatient even if you are

being provided hospital services that require the patient to stay overnight after a surgery was

performed. Without a formal declaration from the physician stating that the patient is being

admitted as an Inpatient the patient is always considered as an Outpatient (Medicare.gov, 2016)

(Silvers, 2016).

Section two of the Coding Scenario, “Diagnoses and Procedures”, provides information

about the principal diagnosis, in this case, “Persistent Epigastric Pain”, diagnosis code (789.06),

entitled abdominal pain in the ICD-9-CM. The coder can locate this code in one of two ways in

the ICD-9-CM index. The coder can check the index for the word “Pain” and recognize that

epigastric relates to the digestive system particularly abdominal and see a general code (789.0)

with a “√” symbol indicating an additional digit is necessary to complete the code, and then

proceed to the tabular to complete the code, or they can proceed further down the index under

pain until they see the word epigastric that displays a completed code of (789.06). Even with

this code a wise coder will still proceed to the tabular to confirm the code as the correct one

(ICD-9-CM, 2014) (Silvers, 2016).

PART II CODING 5

Section two also outlines the “Principal Procedure”, here the coder will find the name of

the procedure provided by the physician, in this case, “EGD with Biopsy”, and this briefly stands

for “Esophagogastroduodenoscopy with Biopsy” and can be coded as procedure code (45.16) as

it appears in the ICD-9-CM index for procedures. However, a wise coder will want to view the

Operative report before assigning this code as the final procedure code. This section also

includes a list of items, tools, and labs, necessary to complete this procedure. This section also

appears to be complete, clear, and concise (ICD-9-CM, 2014) (Silvers, 2016).

Section three the “Operative Report” shows the preoperative diagnosis, persistent

epigastric pain which we already know is coded (789.06), plus loss of appetite and loss of weight

which can be coded in ICD-9-CM tabular “Symptoms, Signs, and Ill-Defined Conditions to

codes 783.0 loss of appetite, and code 783.21 loss of weight. These diagnosis codes should

appear in section 21 of the CMS 1500 “Health Insurance Claim Form”, because they are related

to item 24E in section 24 of this form to back up medical necessity for procedures, services, or

supplies, the coder will also note in the postoperative diagnosis that gastric folds in the fundus

and curvature of the stomach are reported and can be coded as (535.20) since no hemorrhage is

reported this all can appear in section 21 of the CMS 1500 as well. All of these diagnosis codes

are necessary to show Medical Necessity for the procedure that was performed that will appear

in section 24E of the CMS 1500 form which I have identified as ICD-9-CM procedure code

(45.16), “Esophagogastroduodenoscopy with Biopsy”. (ICD-9-CM, 2014) (OMB-0938-1197

FORM 1500, 2014) (Silvers, 2016).

SUMMERY

I found that the information provided by Ms. Silvers is sufficient enough to identify

preoperative and post-operative codes for the diagnoses, and the procedure, I feel that is far from

PART II CODING 6

adequate to complete the forms necessary for reimbursement. Before I could fill out these forms

I would first want to get together with the person at admissions and locate they type of insurance

the patient is using, and once I have done that contact and third party insurance provider for any

policy information that relates to the claim. Because the patient was anesthetized I will need the

NPI of the anesthesiologist and a report to include in the reimbursement form. This also holds

true for lab work mentioned in this scenario. So I will need to send a query for the report, so that

the physician can make a more complete diagnosis. Because the procedure report mentions

multiple biopsies being taken during this procedure, I will need to query the physician to provide

the exact number of these additional biopsies so that I can include any additional time, work, and

effort that was involved, as well as, show medical necessity, so that proper reimbursement is

made to the provider. Finally I will want to contact the billing department to ensure that things

like surgical supplies has the correct provider information and that billing provider information is

correct. All of this goes to show how complex and detailed Medical Reimbursement and Coding

can truly be (OMB-0938-1197 FORM 1500, 2014) (Silvers, 2016).

PART II CODING 7

References Portfolio Project Part II

Are you an inpatient or an outpatient? | Medicare.gov. (2016). Medicare.gov. Retrieved 22 April

2016, from https://www.medicare.gov/what-medicare-covers/part-a/inpatient-or

outpatient.html

Bowie, M. (2015). Understanding ICD-9-CM Coding (4th ed., pp. 450-492). Boston, MA:

Cengage Learning.

ICD-9-CM for Hospitals--Volumes 1, 2, & 3. (2014). Salt Lake City, UT

Medical Dictionary. (2016). TheFreeDictionary.com. Retrieved 22 April 2016, from

http://medical-dictionary.thefreedictionary.com/

National Provider Identifier (NPI) Placement on CMS–1500 Claim Form. (2016).

Wpsmedicare.com. Retrieved 22 April 2016, from

http://www.wpsmedicare.com/j5macpartb/claims/submission/npioncms1500.shtml

OMB-0938-1197 FORM 1500 (02-12) Title: SampleCMS1500_0212_040114_2. (2014) (1st ed.,

p. Sample Form). Retrieved from https://www.cms.gov/Medicare/CMS-Forms/CMS-

Forms/Downloads/CMS1500.pdf

Rakvit, A. (2016). How to Effectively Code for Endoscopic Procedures in Gastroenterology (1st

PART II CODING 8

ed.). Huston: Texas Tech University Health Science Center. Retrieved from

http://static.aapc.com/a3c7c3fe-6fa1-4d67-8534-a3c9c8315fa0/e0bdf19e-6a7c-4179-

9300-8acc467f224e/123c2d97-250b-4764-b455-3e36f802d1ef.pdf

Silvers, K. (2016). MRCH245, Portfolio Project Part II Coding Scenario. Lecture, Bryant &

Stratton Online Education.