HIMT 222 Practice exercise for Bacteria Questions
Student name: Academic number:
Q1: Code the following cases. Include disease, morphology codes and the codes for any procedures
- Staphylococcus pneumonia
- Allergic extrinsic asthma
- Acute bronchitis – culture grew Haemophilus influenzae
- CAL with bronchiectasis
- COPD with Asthma
- Acute gingivitis
- Chronic gastritis due to H.pylori
- Acute appendicitis with perforation
- Dermatitis due to insecticide
- Decubitus ulcer of elbow with partial thickness skin loss
- Case study
- This 5-year-old patient admitted as a case of tonsillitis with dehydration
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- 41-year-old woman with obstructive sleep apnoea admitted for CPAP for 3 days
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- This 58-year-old patient with a history of chronic obstructive pulmonary disease presented with an infective exacerbation of her COPD. She was admitted to ICU, intubated and ventilated for 8 hours.no organism was isolated from either sputum or blood cultures. she was started on broad spectrum antibiotics with a marked improvement. HIMT 222 Practice exercise for Bacteria Questions
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- This 7-year-old boy with recurrent tonsillitis and glue ear was admitted to hospital for surgery. He underwent a tonsillectomy, adenoidectomy for enlarged adenoids and bilateral myringotomy with insertion of grommets under a GA. He was discharged home the following day. ASA123456 E
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- Chronic alcoholism patient with hepatitis C carrier was admitted for a colonscopy following recurrent PR bleeding. the patient was given midazolam 5 mg, fentanyl 100 micgm and propoofol 30mg IV for sedation (ASA 123456 E). A hyperplastic colonic polyp was found and excised via coloscopy.no source of bleeding was found .D &A team counselled patient regarding his alcohol consumption.
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This 64 year old male presented with haematemesis, malaena and anaemia.his Hb on admission was 96 and he was transfused with 2 units of packed cells. he underwent endoscopy under sedation that showed an actively perforated and bleed duodenal ulcer, gastric varices and barrett’s oesophagus. HIMT 222 Practice exercise for Bacteria Questions. the perforated ulcer was Overswing with selective vagotomy and the varices were banded. He was started on Losec 20mg b.d. and will need a repeat scope in 6 weeks to confirm heling. ASA 123456 E
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- An 53 year old man was admitted for repair of a recurrent bilateral inguinal hernia with mesh. The repair was performed without complication under GA ASA 3. He is an ex-smoker.
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- Laparoscopic cholecystectomy under GA
ASA 1 2 3 4 5 6 E pathology report was Cholelithiasis acute cholecystitis
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- patient admitted with diarrhoea and vomiting samples for adenovirusantigens was positive and adenoviral enteritis was diagnosed with dehydration
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- Solar keratosis of two lesions (forehead and hand), both excised using local anaesthesia
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DISCHARGE SUMMARY
Name of Patient Date of Admission 02/08/2016
Medical Record No. Date of Discharge 06/08/2016
Age/Sex 49/F Attending Physician
PROVISIONAL DIAGNOSIS: Paraumbilical hernia.
FINAL DIAGNOSIS: Gangrenous and obstruction Paraumbilical hernia
Summary of History and Physical Examinable:
The patient is a 49-year-old female, presented to OPD complaining of paraumbilical swelling for 4 months, increasing in size with pain. She has history of constipation. No diarrhea. No vomiting. The patient surgical history of paraumbilical hernia repair. Irrelevant family history. Not known of any allergies. On examination, the patient looks well, oriented, vitally stable and afebrile. Pain score is 0.
nutritional status is normal. Psychological status is normal. Activity is normal. HIMT 222 Practice exercise for Bacteria Questions
Investigations:
Laboratory, CBC, coagulation profile, urine electrolytes, and random blood sugar.
Operation/Procedure Performed:
Laparoscopic paraumbilical hernia repair with mesh under general anesthesia.
CROSS CONSULTATION:
None.
HOSPITAL COURSE:
Now, the patient is discharged in good condition. She looks hemodynamically stable, and afebrile. Abdomen was soft and lax. No tenderness. The patient developed distention postoperatively, then the distention subsided. Now, the patient is discharged in good condition. No abdominal distention. Bowel sounds are audible.pt ambulating well on regular diet. passed bowel motion.
DISCHARGE PLAN: Follow-up in OPD after 5 days.
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Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant CHAPTER 10 DISEASES OF THE RESPIRATORY SYSTEM (J00–J99) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • Tonsillitis not specified as acute or chronic should be coded to acute (J03.- Acute tonsillitis) • unless a tonsillectomy is performed, in this case the tonsillitis is coded as chronic (J35.0 Chronic tonsillitis). • Chronic = recurrent acute. TONSILLITIS (ACS 0804) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 1.Croup J05.0 2. Acute laryngotracheitis J04.2 3. Tonsillitis J03.9 Admitted with tonsillitis. Tonsillectomy performed under intravenous GA. ASA 1 2 3 4 5 6 E J35.0 41789-00[412] 92514-10[1910] Exercise Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant In ICD-10-AM there are three categories for influenza ➢Influnza virus is known – J09 Influenza due to identified avian influenza virus ➢Do not specify Influnza virus – J10 Influenza due to other identified influenza virus H1N1 influenza – J11 Influenza, virus not identified • Haemophilus influenzae [H. influenzae] cause meningitis, pneumonia and infection The exclusion at the beginning of J10 and J11 remained with the difference. INFLUENZA (J09-J11) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant •HIMT 222 Practice exercise for Bacteria Questions. Pneumonia is an acute inflammation of the alveoli of the lung with consolidation (solidification) and exudation (fluid build-up). • There are four major types: bacterial, viral, aspiration and mycoplasmal. • Most cases of pneumonia will be diagnosed using x-ray findings. These will show the location and extent of the consolidation. Note: evidence of consolidation in the lung on x-ray report does not lead to the diagnosis of pneumonia. Other things such as bleeding or inhalation can cause consolidation. PNEUMONIA (ACS1004) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • In many cases the organism causing the pneumonia may not be identified, but you should always check Microbiological reports, particularly sputum and blood cultures, will describe the organism (if any) thought to be the cause. • Lobar pneumonia means consolidation of the entire lobe and is rarely seen. Note that pneumonia described as ‘lower lobe’ does not necessarily mean that the pneumonia is ‘lobar’. It is just describing the anatomical site of the pneumonia. Therefore, when this term is used it should be clarified with the clinician before assignment of code J18.1 Lobar pneumonia, unspecified. PNEUMONIA (ACS1004) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 1.Klebsiella Pneumonia J15.0 1.Laryngitis with influenza J11.1 1.Bacterial bronchopneumonia J15.9 Exercise Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • The term COPD (synonyms: chronic airway limitation (CAL), chronic obstructive airway disease (COAD)) • is a condition of chronic bronchitis with obstruction possibly due to chronic asthma and/or emphysema or chronic tracheobronchitis. The important terms are chronic and obstruction. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) (ACS1008) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • COPD is chronic condition and patients will usually only be admitted to hospital for treatment of their COPD if they have acute exacerbation. In theses cases use J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection or J44.1 Chronic obstructive pulmonary disease with acute exacerbation. • Do not code any bronchitis or chest infection separately unless the infection is a separate, important condition such as pneumonia. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) (ACS1008) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant Use J44 codes in the following circumstances • For bronchitis that is : ✓Chronic and is in combination with asthma or emphysema. ✓Chronic and involves airways obstruction • For emphysema that is: ✓In combination with chronic bronchitis. If the clinician has documented COPD and emphysema, assign only a code from category J44. • For asthma that: ✓Is In combination with chronic bronchitis ✓involves airways obstruction CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) (ACS1008) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant Discharge summary documented PDx as COAD/Pneumonia. Principal diagnosis J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection Additional diagnosis J18.9 Pneumonia, organism unspecified EXAMPLE : Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant Discharge summary documented PDx as Pneumonia + COPD exacerbation. Principal diagnosis J18.9 Pneumonia, organism unspecified Additional diagnosis J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection EXAMPLE : Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • Asthma is charactrised by wheezing, dyspnea and cough and is usually controlled by drugs. Bronchospasm is a component of an acute asthmatic attack and such an attack rapid treatment to prevent respiratory failure. • Status asthmaticus is an acute severe case of asthma where the patient is not responding to their medication. Assign J46 Status asthmaticus only if the asthma is documented as ‘acute severe’ or ‘refractory’. • Chronic obstructive asthma or asthma and/with COPD should be assigned a code from J44.- Other chronic obstructive pulmonary disease only when documented. • If the only diagnostic information you have is ‘chronic asthma’ assign J45.9 Asthma, unspecified ASTHMA (ACS1002) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • Bronchitis is classified in two different blocks according to whether it is acute or chronic. • In patient under 15 years of age is assumed to be acute even if this is not specified. • Combined with asthma is coded with an asthma code (J45.-). Do not code bronchitis separately. • Allergic is coded to the allergic asthma code (J45.0) Do not code bronchitis separately. • Combined with emphysema is coded to COPD(J44.-) • Obstructive is coded to COPD (J44.-) Bronchitis: Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 1.Acute sever asthma J46 1.Acute exacerbation of COPD. J44.1 1.Asthmatic bronchitis. J45.9 Exercise Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • Accumulation of fluid in the lung tissue and alveolar space is known as pulmonary oedema. Commonly it is due to heart disease, but it can be of non-cardiac origin. • If it is of cardiac origin it is included in the heart failure codes from chapter 9 Disease of the Circulatory System and no code from the respiratory chapter is needed. • When Acute pulmonary oedema is documented without further qualification, it should be coded to I50.1 left ventricular failure. • If it is non-cardiac origin then it should be coded to J81 Pulmonary oedema • The exclusion note in J81 list codes for pulmonary oedema. It lists other codes used for pulmonary oedema of non-cardiac origin. ACUTE PULMONARY OEDEMA (ACS 0920) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 0807 FUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS) ➢ Functional endoscopic sinus surgery (FESS) is a term describing a range of procedures performed for the surgical treatment of sinus disease. ➢ FESS may include a variety of procedures performed in any combination. Therefore, clinical coders should check the operation report and assign only the appropriate codes. These procedures may include: 41737-02 [386] Ethmoidectomy, unilateral 41716-05 [384] Biopsy of maxillary antrum 41716-00 [383] Intranasal removal of foreign body from maxillary antrum Where FESS is documented, also assign 41764-01 [370] Sinoscopy to indicate the endoscopic nature of the surgery. Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant Exercise 42-year-old lady with history of bronchial asthma on medication. She complain of nasal discharge Paroxysmal nocturnal dyspnea (PND) hyopsomia nasal congestion mouth had trial of medical treatment improved but recured after a while final diagnosis Chronic sinusitis, Chronic sinusitis, Chronic rhinitis and nasal polyp She underwent FESS and nasal polypectomy Anaesthesia ASA 2 Operative report Under general anaesthesia with ET T examination showed previous findings bilateral Intranasal maxillary antrostomy and uncinectomy done, bilateral anterior and posterior ethmoidectomy done, bilateral Sphenoidotomy done and nasal polypectomy Patient extubated and send to recovery room in stable condition Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant J32.9 Chronic sinusitis, unspecified J31.0 Chronic rhinitis J33.9 Nasal polyp, unspecified 41716-02 Intranasal maxillary antrostomy, bilateral 41737-03 Ethmoidectomy, bilateral 41752-02 Sphenoidotomy 41764-01 Sinoscopy 41668-00 Removal of nasal polyp 92514-29 GA Uncinectomy (also known as infundibulotomy) involves detachment and removal of the anterior, inferior and superior attachments of the uncinate process. It is performed as part of an intranasal ethmoidectomy in order to gain access to the ethmoid infundibulum, expose the frontal recess and allow visualisation of the frontal recess. Uncinectomy is a fundamental step in functional endoscopic sinus surgery (FESS). Classification It is unnecessary to separately code the uncinectomy when performed as a component of FESS. Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • In respiratory failure the respiratory system is unable to supply adequate oxygen to maintain proper metabolism and/or eliminate carbon dioxide. • Life threatened condition that may be associated with a respiratory condition or a non-respiratory condition. • Blood gas analysis provide evidence of respiratory failure but you must be careful not to assume that the abnormal results are evidence of respiratory failure. • Code respiratory failure if confirmation by clinician. Respiratory Failure (J96) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • Ventilatory support is a process by which gases are moved into the lungs by a device that assists respiration by augmenting or replacing the patient’s own respiratory effort. Ventilatory support can be administered via noninvasive or invasive devices. VENTILATORY SUPPORT (ACS 1006) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant invasive devices. [569] VENTILATORY SUPPORT (ACS 1006) Noninvasive devices. [570] Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • invasive devices. [569] Includes: Endotracheal intubation respiratory assistance mechanical ventilation by: • endotracheal tube (ETT) • nasal • oral • tracheostomy • weaning of intubated (endotracheal tube/tracheostomy) patient by any method Code also when performed: tracheostomy: – percutaneous (41880-00 [536]) – permanent (41881-01 [536] – temporary (41881-00 [536]) VENTILATORY SUPPORT (ACS 1006) Noninvasive devices. [570] Includes: Ventilatory support by: • face mask • mouthpeice • nasal mask/pillows/prongs • nasal/nasopharyngeal tube Excludes: that by: endotracheal intubation (see block [569]) tracheostomy (see block [569]) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant [569] 13882-00 Management of continuous ventilatory support, 24 and < 96 hours 13882-02 Management of continuous ventilatory support, 96 hours [570] 92209-00 Management of noninvasive ventilatory support, 24 and < 96 hours 92209-02 Management of noninvasive ventilatory support, 96 hours (Duration )ventilatory support Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant Classification Code first the ventilatory support (see also Calculating the duration of CVS) a.When both CVS and NIV are used for treatment, code each type separately. Use the appropriate duration extension on each code to indicate how many hours the patient received each type of ventilatory support. b.Subsequent periods of the same type (invasive or noninvasive) of ventilation, when used for treatment (not weaning) should be added together. For example, if a patient is on CVS for the first day of their admission, then on CVS again on the fourth day of their admission, the CVS hours should be added together to arrive at the correct CVS code. Cvs —-niv—-cvs 24—24-24 Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant Classification F. The ventilatory support that is provided to a patient during surgery is associated with anaesthesia and is considered an integral part of the surgical procedure. The patient may remain on ventilatory support for some hours while recovering following surgery. Ventilation of <= 24 hours post surgery should not be coded in these cases. Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant BEGIN calculation of the duration of CVS with one of the following: 1. The patient is intubated anywhere in your hospital, or 2. CVS is started through the patient’s tracheostomy, or 3. At the time of admission for those patients who have been admitted already intubated and ventilated. Calculating the duration of CVS [569] Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant END with: 1. The patient is extubated (the endotracheal tube is removed), or 2. The CVS is ceased after any period of weaning, or 3. Cessation of CVS for patients with a tracheostomy 4. Discharge, death or transfer of a patient on continuous ventilatory support Calculating the duration of CVS [569] The hours of CVS should be interpreted as cumulative hours. Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 1. Acute episode of emphysema.HIMT 222 Practice exercise for Bacteria Questions. 12 year old patient admitted to ICU, intubated via ETT and given mechanical ventilation for 36 hours. J43.9 13882-01[569] 2. Bilateral paralysis of vocal cords. Laryngoscopy performed under GA ASA 123456 E J38.03 41849-00[520] 92514-29[1910] 3. Patient with deviated nasal septum and allergic rhinitis. Septoplasty and turbinectomy performed under GA. ASA 123456 E J34.2 J30.4 41671-02[379] 92514-19[1910] Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 31 DISEASES OF THE DIGESTIVE SYSTEM (K00–K93) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 32 ▪ In admission for treatment of gastroenteritis and dehydration, the gastroenteritis should be sequenced as the principle diagnosis with dehydration (E86 Volume depletion) as an additional diagnosis. ▪ You should only code dehydration or volume depletion if it is documented. Don’t assume that if a patient has rehydration (intravenous fluid administration) that this necessarily indicates dehydration; it may be a preventative measure. Dehydration should be clinically documented before assigning the code. Dehydration with Gastroenteritis (ACS1120) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 33 Exercise 11.1 1. A 35-year-old woman admitted with noninfectious gastroenteritis K52.9 2. A 7-year-old child admitted with gastroenteritis A09.9 3. Patient suffering from viral enteritis and dehydration A08.4 E86 Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 34 The upper GI tract is the mouth, esophagus, stomach, and the first part of the small intestine (duodenum). The lower GI tract from the small intestine to the large intestine (colon) to the anus. Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 35 Upper GI bleeding ▪ Patients who have had upper GI bleeding (for example haematemesis) are often admitted for investigation to find the source of the bleeding. ▪ When investigations find an ulcer, erosion or varices, you can assume that the Condition found is the source of the bleeding and you can code ‘with haemorrhage’. ▪ You can do this even though the patient may not have any bleeding during their investigations or admission. Gastrointestinal Haemorrhage (GI) ACS1103 Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 36 Upper GI bleeding • If a code does not have a “with haemorrhage” distinction use an additional code from category K92 Other diseases of digestive system ▪ In the case of oesophagitis, code oesophagitis (K20 Oesophagitis) and oesophageal haemorrhage (K22.8 Other specified diseases of oesophagus). ▪ Investigation of bleeding not specified as upper GI cannot be linked to any specific condition found as with haemorrhage, Therefore code the symptom necessitating the investigation first, followed by any findings arising from the investigation. Gastrointestinal Haemorrhage (GI) ACS1103 Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 37 Lower GI bleeding ▪ If a patient is being investigated for lower GI bleeding (for example melaena) you should not assume about the source of the bleeding. ▪ In these cases, you need to have clear evidence of the link between the bleeding and any condition found on investigation. ▪ When no cause for the bleeding is found, you should use a code from the category K92 Other diseases of digestive system to indicate that the patient had haematemesis, melaena or gastrointestinal bleeding. Gastrointestinal Haemorrhage (GI) ACS1103 Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 38 The codes for ulcers of the upper GIT are divided according to the site of the ulcer K25.- Gastric ulcer (stomach only) K26.- Duodenal ulcer K27.- Peptic ulcer, site unspecified (gastroduodenal NOS) K28.- Gastrojejunal ulcer Each of these codes must have a 4th character. Look at the 4th character subdivisions listed before the category K25 Gastric ulcer. Ulcers of the Upper Gastrointestinal Tract (K25-K28) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 39 The 4th characters indicate whether the ulcer is ❑ acute or chronic ❑ with or without haemorrhage ❑ with or without perforation ❑ with a combination of haemorrhage and perforation Before choosing a code, you must check for all these clinical details in the medical record. One of the areas that can be difficult to determine is whether there is haemorrhage or bleeding. The following coding standard provides a guide for you when coding gastrointestinal haemorrhage. Ulcers of the Upper Gastrointestinal Tract (K25-K28) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 40 ▪ Sometimes in a history you will see a diagnosis of “PR bleeding”, meaning ‘perrectal bleeding’. Generally, this is a term used to describe bleeding or haemorrhage from somewhere in the gastrointestinal tract, not necessarily bleeding from the rectum. ▪ In most cases, you won’t need to code this bleeding because it will be a symptom of an underlying condition Per-Rectal (PR) Bleeding, NOS (ACS1117) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 41 ▪ A diagnosis of PR bleeding indicates bleeding from the gastrointestinal tract, not necessarily bleeding from the rectum and, therefore, K62.5 Haemorrhage of anus and rectum should not be used. ▪ If investigation has not revealed the actual origin of the haemorrhage or investigation has not been performed, ‘PR bleeding’ should be coded to K92.2 Gastrointestinal haemorrhage, unspecified. Per-Rectal (PR) Bleeding, NOS (ACS1117) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 42 1. Bleeding gastric ulcer treated by gastrectomy (GA). K25.4 , 30509-00 [880], 92514-99 [1910] 2. PR bleeding investigated by colonoscopy under sedation. No abnormalities found. K92.2 , 32090-00[905], 92515-99 [1910] 3. Oesophageal ulcer with oesophageal reflux • K22.1, K21.9 Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 43 ▪ Helicobacter pylori (H. pylori) is a gram-negative bacteria and is a common infection which is associated with chronic gastritis, duodenal and gastric ulcers and MALT lymphoma. ▪ H. pylori can be detected on gastroscopy with a CLO (campylobacter-like organism) test. (you will need to code the intervention as endoscopy with biopsy) Helicobacter/Campylobacter (ACS1122) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 44 EXAMPLE 1: Patient admitted for gastroscopy following one month of dyspepsia. No abnormality detected on gastroscopy, Helicobacter pylori detected on CLO test. Codes: K30 Dyspepsia 30473-01 [1008] Panendoscopy to duodenum with biopsy The code B96.81 (Helicobacter pylori) is not assigned in this case because there is no documented association between the H. pylori infection and the dyspepsia. Helicobacter/Campylobacter (ACS1122) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 45 EXAMPLE 2: Patient admitted for panendoscopy. A biopsy was taken of the duodenal cap. Findings: chronic duodenal ulcer. Pathology result: positive CLO test. Codes: K26.7 Duodenal ulcer, chronic without haemorrhage or perforation B96.81 Helicobacter pylori [H. pylori] as the cause of diseases classified to other chapters 30473-01 [1008] Panendoscopy to duodenum with biopsy The code B96.81 (Helicobacter pylori) is assigned in this case because it was found in the presence of a duodenal ulcer with which it is generally associated. Helicobacter/Campylobacter (ACS1122) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 46 • CLO test means ‘Campylobacter-like organism’ and should be coded as a biopsy. If the CLO test is positive, this indicates the presence of Helicobacter (a ‘Campylobacter-like organism’). Helicobacter/Campylobacter (ACS1122) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 47 ❑Sometimes a patient will have the clinical symptoms of appendicitis (for example abdominal pain, nausea, vomiting, anorexia, low grade fever) and be given a diagnosis of ‘appendicitis’ and have an appendicectomy performed yet the histopathology report for the removed appendix may show no evidence of inflammation. This does not necessarily mean that you should not code the appendicitis because occasionally appendicitis can subside spontaneously. The important thing is whether the clinician has made a diagnosis of appendicitis. Appendicitis (ACS1101) and Mesenteric Adenitis with Appendicectomy (ACS1111) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 48 • ACS 1101 provides you with guidelines for situations when there is a discrepancy between the clinical diagnosis and the histopathology report. ❑If a clinical diagnosis of appendicitis is recorded, then it should be coded even if there is no evidence of appendicitis on the histopathology report. ❑ If the clinical diagnosis is abdominal pain and there is no histopathological evidence of appendicitis, then code the abdominal pain. ❑If the clinical diagnosis is abdominal pain and there is histopathological evidence of an appendiceal condition (eg acute appendicitis, subacute appendicitis, faecolith, then code the appendiceal condition and not the abdominal pain. Appendicitis (ACS1101) and Mesenteric Adenitis with Appendicectomy (ACS1111) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 49 Acute appendicitis with perforation. Laparoscopic appendicectomy under inhalation GA. ASA 123456 E K35.0 30572-00 [926] 92514-10 [1910] Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 50 Look at categories K80 Cholelithiasis and K81 Cholecystitis in the ICD10-AM Tabular List. There are always fifth characters to be added to the codes in K80 Cholelithiasis to indicate whether the calculi (or gallstones) are causing obstruction or not. if the patient has gallstones as well as an inflamed gall bladder (cholecystitis) then you only use the code from K80 Cholelithiasis and you should not add a code for the cholecystitis. Cholelithiasis and Cholecystitis K80 and K81 Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 51 • Diagnosis Chronic cholecystitis due to the presence of gallstones K80.10 Calculus of gallbladder with other cholecystitis, without mention of obstruction. Cholelithiasis and Cholecystitis K80 and K81 • Chronic cholecystitis with cholelithiasis Cholecystectomy with exploration of the common bile duct performed under general anaesthetic. ASA 123456 E K80.10 30454-01 [965] 92514-19 [1910] Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 52 When coding abdominal hernias, you need to know the following: • the site of the hernia (inguinal, femoral, umbilical etc.) • for inguinal and femoral hernias, whether it is unilateral or bilateral (on one side or both) • for inguinal hernias, whether it is recurrent or not (there is a 5th character for this in K40) • whether it is causing bowel obstruction • if the herniated bowel is gangrenous or not The note at the beginning of the block tells you that if the patient has both obstruction and gangrene then you should use the gangrene code. Hernias K40-K46 Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 53 Examples • Diagnosis Recurrent inguinal hernia K40.91 Unilateral or unspecified inguinal hernia, without obstruction or gangrene, recurrent • Diagnosis Right femoral hernia with bowel obstruction and gangrene K41.4 Unilateral or unspecified femoral hernia, with gangrene Hernias K40-K46 Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 54 • Bilateral gangrenous inguinal hernias. Repair with tantalum mesh using spinal block (infusion). ASA 123456 E K40.10 30615-00 [997] 92508-39 [1909] • Parotitis K11.2 • Strangulated umbilical hernia causing obstruction K42.0 Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 55 • In the procedure classification ACHI, the term ‘panendoscopy’ when used to describe an examination of the digestive tract includes duodenoscopies, gastroscopies, ileoscopies (via the mouth) and OGDs (oesophagogastroduodenoscopies). Panendoscopy (ACS 0024) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 56 • Endoscopic Examination of Lower GI Tract Colonoscopies used to examine the ascending colon, caecum or ileum are coded to 32090-00[905] Fibreoptic colonoscopy to caecum. This is the default code for colonoscopy with no further information. Panendoscopy (ACS 0024) ❑The hepatic flexure is the right colonic flexure at the top of the ascending colon where the ascending colon turns to become the transverse colon. Therefore, colonoscopies which view the sigmoid colon, descending colon, splenic flexure (left colonic flexure) or transverse colon are all included in the code 32084-00 [905] Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 57 Scirrhous adenocarcinoma of colon. Short colonoscopy with biopsy done under sedation ASA 1 2 3 4 5 6 E C18.9 M8141/3 32084-01[911] 92515-19[1910] Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 58 • Patient admitted with chest pain. An EGD was performed under sedation which showed ulcerative oesophagitis as the cause of the pain. The stomach and duodenum were both normal. ASA 123456 E K21.0 30473-00 [1005] 92515-19 [1910] • Patient admitted with abdominal pain. A colonoscopy to the transverse colon was performed under sedation and revealed inflammation. A biopsy was taken via the colonoscope and the histopathology reported ulcerative colitis. ASA 123456 E K51.9 32084-01 [911] 92515-29 [1910] Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant DISEASES OF THE SKIN AND SUBCUTANEOUS TISSUE (L00–L99) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant ▪ Cellulitis is an acute inflammation of a localised area of skin. The area is red, hot and oedematous and often the nearby lymph nodes are also inflamed. ▪ The codes for cellulitis in the category L03 Cellulitis will often be used in conjunction with other codes. Cellulitis may be the result of a break in the skin and the type of break (for example open wound or ulcer) may need to be coded as well. ▪ In these cases, the principal diagnosis is the open wound or ulcer and the cellulitis is an additional diagnosis. ▪ If the patient is admitted for treatment of the cellulitis, without any treatment of a wound or ulcer, then the cellulitis becomes the principal diagnosis. Cellulitis (ACS 1210) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • – Orbital cellulitis is a much more serious condition due to the risk of the inflammation spreading to involve the eye or intracranial cavity. • – Orbital cellulitis should be assigned code H05.0 Acute inflammation of orbit • Periorbital cellulitis ▪ should be coded to L03.2 Cellulitis of face ▪ with an additional code of H00.0 Hordeolum and ▪ other deep inflammation of eyelid being used for eyelid involvement. It is important to make a distinction between two types of cellulitis – orbital and periorbital. Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • Patient with cellulitis of his left leg from his toes to his knees • L03.11 , L03.02 Excercise Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • Dermatitis is an inflammation of the skin. • In this block the terms dermatitis and eczema mean the same thing. • There are many causes of dermatitis and they have different codes in ICD-10- AM, therefore it is essential that you have as much information as possible about the type of dermatitis before selecting a code. Dermatitis and Eczema (L20-L30) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • The broad types of dermatitis classified in this block are • Atopic • Seborrhoeic • Diaper (nappy) • Allergic contact • Irritant contact (nonallergic) • Exfoliative • lichen simplex chronicus and prurigo • Pruritus • You need this level of detail to code dermatitis accurately, so it is important that clinicians provide this information in the medical record. Dermatitis and Eczema (L20-L30) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • Dermatitis caused by new brand of face make-up • L25.0 Exercise Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • – Debridement of skin and subcutaneous tissue involves removing foreign material and contaminated or dead tissue from around an injury or infected skin lesion. • It can be either excisional or nonexcisional. • – Examples of nonexcisional debridement techniques are brushing, scrubbing, washing or irrigating to remove foreign matter, slough or dead tissue from a lesion. • – Excisional debridement involves the surgical removal or cutting away of this matter. • Debridement (ACS1203) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • – According to ACS 1203, most debridement’s are excisional and you should code them as excisional. • – You should only use the codes for nonexcisional debridement if this is documented in the record or the clinician confirms that the procedure was nonexcisional. • There are separate codes for debridement’s of burns and soft tissue. • – If ‘nonexcisional debridement’ is documented or the surgeon confirms that the debridement was ‘nonexcisional’ assign: • 90686-00 [1627] Nonexcisional debridement of burn or • 90686-01 [1628] Nonexcisional debridement of skin and subcutaneous tissue Debridement (ACS1203) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • Staphylococcal infection of the skin of the arm with debridement using local anaesthetic. • L08.9 , B95.8 , 90665-00 [1628] Exercise Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • The block [1635] Repair of wound of skin and subcutaneous tissue has different codes for repairs of superficial wounds and deep wounds. • superficial wound repair involves a simple repair of one layer of the epidermis, dermis or subcutaneous tissue with sutures. • Codes indicating superficial repair from this block should only be used if there is no deeper tissue repair Repair of Wound of Skin and Subcutaneous Tissue (ACS1217) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • EXAMPLE : • Superficial wound to forehead. No damage to underlying structures. • Procedure:Repair of superficial wound of forehead. • Code: 30032-00 [1635] Repair of wound of skin and subcutaneous tissue of face or neck, superficial Superficial repair Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • A deep wound repair refers to deeper or more complex lacerations where layered suturing techniques are required. • The deep or soft tissue involved may include structures such as muscle, tendon, fascia, ligaments, nerves, blood/lymph vessels or joints/synovial tissue. • Repairs of these individual sites should be coded. A code from block [1635] does not need to be coded when there is a deep wound repair – this is inherent in the procedure (see example 3 in ACS 1217). Repair of Wound of Skin and Subcutaneous Tissue (ACS1217) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • EXAMPLE : • Traumatic wound to right hand involving damage to nerve and tendon. • Procedure:Repair of nerve and tendon right hand. • Codes: 39300-00 [83] Primary repair of nerve • 47963-02 [1467] Repair of tendon of hand, not elsewhere classified • (See also ACS 1908 Laceration with nerve and tendon damage.) Deep wound repair Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • Where no specific soft tissue structure is identified as being repaired assign a code from block [1635] for repair involving soft tissue (see example 2). • EXAMPLE : • Deep wound of hand with soft tissue involvement. • Procedure:Repair of deep wound of hand requiring layered suturing. • Codes: 30029-00 [1635] Repair of wound of skin and subcutaneous tissue of other site, involving soft tissue Repair of Wound of Skin and Subcutaneous Tissue (ACS1217) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • Pressure ulcer, or decubitus ulcer, is an inflammation or sore of the skin over a bony prominence. • They are caused by prolonged pressure on a body area in a patient confined to bed. • These ulcers are graded according to their severity. Decubitus Ulcer and Pressure Area (ACS1221) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • ACS 1221 provides the coder with information on how to code these based on either documentation of the stage of the ulcer (I, II, III or IV) or its severity. • – If the patient has multiple ulcer sites of differing stages, assign only one code to indicate the highest stage. • – If a patient has diabetes mellitus with a decubitus ulcer of a site other than the foot, assign E1-.69 • *Diabetes mellitus with other specified complications by following the index pathway: • Diabetes • – with ulcer E1-.69 Decubitus Ulcer and Pressure Area (ACS1221) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • – Assign also the appropriate code from L89 Decubitus ulcer and pressure area as per the general classification principles for diabetes mellitus in ACS 0401 Diabetes Mellitus and Impaired Glucose Regulation which states: • – In addition to the impaired glucose regulation and diabetes code(s) from E09–E14, assign codes from other chapters when necessary, to fully describe the clinical diagnosis. These additional codes should be sequenced AFTER the E09-E14 code(s). Diabetes mellitus with decubitus ulcer, other than foot Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant • Scrotal cyst. Excision of scrotal cyst using injection of epidural anaesthetic. ASA 1 • L72.9 , 31230-05 [1620], 92508-19 [1909] Exercise. HIMT 222 Practice exercise for Bacteria Questions
