INPATIENT CODING QUESTIONS

Please keep this thread limited to INPATIENT coding questions and answers. Thanks!

From Deepa:

Two months back the patient delivered and she had a vaginal tear suture.. After that she started suffering from dyspareunia due to transverse vaginal septum. All these in outside hospital. Now the patient has been admitted in my hospital for excision of vaginal septum. Can you please help me with the codes. This is complication of obstetric procedure. Right? I have a problem in choosing diagnosis code, since it is more than six weeks since she delivered. So am not sure if I can postpartum complication code. Also I cannot choose appropriate procedure code.

2. if the patient has had normal delivery with intact perineum (and everything else is normal) with induction of labor, then what is the diagnosis code? She does not walk in with labor pain. Term post 10 days hence labor is induced, otherwise everything else is normal. So what can be my admitting diagnosis (final dx being 650)?

3. Left cataract operation done last month. nOw again blurring of visionin the same eye. Corneal suction, anterior capsulotomy (cortical washout, IOL implantation and sutures) are procedures done. Please help me with the px codes and dx.

4. chronic liver disease with refractory ascites. Also document says cardiac cirrhosis due to CHF, MR, TR. Ascitic tapping done regularly almost once in every 30 days. Since it is cardiac cirrhosis should I go for

428.0, 424.0, 424.2, 573.0 ???

Lorraine W in Connersville, Indiana said: From Deepa:

Two months back the patient delivered and she had a vaginal tear suture.. After that she started suffering from dyspareunia due to transverse vaginal septum. All these in outside hospital. Now the patient has been admitted in my hospital for excision of vaginal septum. Can you please help me with the codes. This is complication of obstetric procedure. Right? I have a problem in choosing diagnosis code, since it is more than six weeks since she delivered. So am not sure if I can postpartum complication code. Also I cannot choose appropriate procedure code.

1. I consulted Coding Clinic and found a reference from 1st Quarter 1997 stating that Chapter 11 codes may be used for complications extending past the 6-week period. I wouldn't consider the septum a Late Effect--it sounds as if they sutured the laceration incorrectly. Please look through the documentation again to see if there is another medical term for this, possibly 'adhesion'. If it is an adhesion, let me know, for it will be a different code assignment. The term 'septum' has me a bit confused. Without looking at the chart, I can't tell if it is because the previous physician actually sutured the walls (anterior/posterior) together, which would make sense in this scenario. (And if that's the case--good heavens, they need better physicians there!)

Septum, Vagina, Complicating Pregnancy/Puerperium. Fifth digit of 4 as patient delivered before this admit.

E code: Restorative surgery, abnormal reaction/later complication.

E code: Place of occurrence, residential institution/hospital.

Procedure: I'm just not sure I would code it to 'excision of lesion', since this one may be a botched repair in the first place. My gut says to code to Repair of Vagina.

Again, please look through the record to see if there is any indication of adhesion or accidental suturing of the vaginal walls together.

Lorraine W in Connersville, Indiana said: 2. if the patient has had normal delivery with intact perineum (and everything else is normal) with induction of labor, then what is the diagnosis code? She does not walk in with labor pain. Term post 10 days hence labor is induced, otherwise everything else is normal. So what can be my admitting diagnosis (final dx being 650)?

Yes, this is an uncomplicated delivery, 650, with unknown reason for Induction of Labor.

Lorraine W in Connersville, Indiana said: 3. Left cataract operation done last month. nOw again blurring of visionin the same eye. Corneal suction, anterior capsulotomy (cortical washout, IOL implantation and sutures) are procedures done. Please help me with the px codes and dx.

Unless there is other documentation in the record stating the blurring of vision is a complication of the previous surgery, I would simply code the blurring as the principal diagnosis.

As for the procedures, I'm a little stumped with the two sets of descriptions you gave (wish I could see the OP report).

If I'm understanding it correctly (exchange of old lens for a new one, plus irrigation), I would code:

--insertion, intraocular lens prosthesis, secondary (because it wasn't done at the time of initial cataract removal)

--removal, implanted lens

--irrigation, eye (this one I'm not sure about--did they mention any growth/adhesion/film that was irrigated away?)

Lorraine W in Connersville, Indiana said:
4. chronic liver disease with refractory ascites. Also document says cardiac cirrhosis due to CHF, MR, TR. Ascitic tapping done regularly almost once in every 30 days. Since it is cardiac cirrhosis should I go for

428.0, 424.0, 424.2, 573.0 ???

I would code the chf (428.0) as primary, followed by 'cirrhosis, liver, nonalcoholic' (571.5), 424.0, and regurgitation, tricuspid, Other (not 'nonrheumatic'/424.2, which is only coded if the physician specifically states as such), which is 397.0. Add code for ascites if the patient underwent paracentesis.

Is there ANYONE who could help with IN-Patient coding? please e-mail me at mricke@live.com
Thanks much

Can anyone assist me with these two senarios with explianation:

1. A patient was admitted for a total hip replacement for arthritis of the hip. Just prior to the surgery, he developed a fever and ppneumonia was seen on the chest x-ray. The patient was discharged and the surgery was rescheduled. What is the pricipal diagnosis for this admission?

2. A patient was admitted for evaluation of abdominal pain. In the evening after eating dinner, she fell out of bed and sustained a fracture of the femur. The next day she underwent hip replacement surgery and was eventually discharged to a skilled nursing facility for follow-up care. What is the principal diagnosis of this admission?

coderprimary in Greensboro, North Carolina said: Can anyone assist me with these two senarios with explianation:

1. A patient was admitted for a total hip replacement for arthritis of the hip. Just prior to the surgery, he developed a fever and ppneumonia was seen on the chest x-ray. The patient was discharged and the surgery was rescheduled. What is the pricipal diagnosis for this admission?

Principal diagnosis: 716.95, unspecified arthropathy of hip (if osteoarthritis specified, may use 715.35).

Secondary diagnoses: 486, pneumonia unspecified, V64.1, Procedure cancelled d/t contraindication.

The principal diagnosis is always the condition established after study to be chiefly responsible for occasioning admission to the hospital. The patient came to the hospital for repair of hip arthritis, not the pneumonia.

coderprimary in Greensboro, North Carolina said: Can anyone assist me with these two senarios with explianation:

2. A patient was admitted for evaluation of abdominal pain. In the evening after eating dinner, she fell out of bed and sustained a fracture of the femur. The next day she underwent hip replacement surgery and was eventually discharged to a skilled nursing facility for follow-up care. What is the principal diagnosis of this admission?

Principal diagnosis: 789.00, abdominal pain, unspecified site.

Secondary diagnoses: 821.00, fracture of femur, unspecified part, closed; E884.4, Accidental fall from bed; E849.7, Injury or poisoning occurring at/in residential institution (hospital).

Procedure: 81.51, total hip replacement.

The principal diagnosis is the abdominal pain, which led to the admission. The fracture occurred after admission; therefore it is a secondary diagnosis.

Hi Lorraine,
I am a remote hospital coder and I have really been impressed with the advice and assistance you have provided on these forums...hoping we could network further...my email is handmaiden5@bellsouth.net

codercab in Wichita, Kansas said: Is there ANYONE who could help with IN-Patient coding? please e-mail me at mricke@live.com
Thanks much

Sure thing. Email smjohnso2000@yahoo.com
I've been coding 9 years. I'm not perfect but I'm good. lol.

Lorraine W in Connersville, Indiana said: From Deepa:

Two months back the patient delivered and she had a vaginal tear suture.. After that she started suffering from dyspareunia due to transverse vaginal septum. All these in outside hospital. Now the patient has been admitted in my hospital for excision of vaginal septum. Can you please help me with the codes. This is complication of obstetric procedure. Right? I have a problem in choosing diagnosis code, since it is more than six weeks since she delivered. So am not sure if I can postpartum complication code. Also I cannot choose appropriate procedure code.

2. if the patient has had normal delivery with intact perineum (and everything else is normal) with induction of labor, then what is the diagnosis code? She does not walk in with labor pain. Term post 10 days hence labor is induced, otherwise everything else is normal. So what can be my admitting diagnosis (final dx being 650)?

3. Left cataract operation done last month. nOw again blurring of visionin the same eye. Corneal suction, anterior capsulotomy (cortical washout, IOL implantation and sutures) are procedures done. Please help me with the px codes and dx.

4. chronic liver disease with refractory ascites. Also document says cardiac cirrhosis due to CHF, MR, TR. Ascitic tapping done regularly almost once in every 30 days. Since it is cardiac cirrhosis should I go for

428.0, 424.0, 424.2, 573.0 ???

#2 if the patient came in without being in labor post term 10 days and is induced and her reason for admission was for the induction the admit would be post term pregnancy. is she goes on to have a normal delivery over intact perineum then your final dx would be post term pregnancy delivered & your procedure codes would be the manual delivery code & the mode of induction of labor used (medical, artificial rupture of membranes...) 650 would not be appropriate as normal delivery if she was 10 days post term & admitted for induction :

Can anyone please help me code the following inpatient procedures:

Open Laparoscopy, Evacuation of Ascites, Lysis of Adhesions, Exploratory Laparotomy, Extensive Lysis of Adhesions, Peritoneal Cultures, and Multiple Peritoneal Biopsies.

Please note: During the surgery, Open Laparoscopy was converted to an Exploratory Laparotomy.

Thank you very much.

For this procedure (and mind you one would need to see the operative report to be sure that this is the accurate assignment of codes applied)If this was intened to be an exploratory laparoscopy that was converted to open exploratory laparotomy & lysis of the adhesions & biopsies were done during this episode in the course of the exploratory laparotomy then you would not code the exploratory lap, only the lysis of adhesions & peritoneal biopsies. The laparotomy would at this time be considered the approach (which you would not code). You can go onto ICD9.chrisendres.com for a free online searchable 2009 ICD-9-CM.

ccs in Portland, Oregon said: For this procedure (and mind you one would need to see the operative report to be sure that this is the accurate assignment of codes applied)If this was intened to be an exploratory laparoscopy that was converted to open exploratory laparotomy & lysis of the adhesions & biopsies were done during this episode in the course of the exploratory laparotomy then you would not code the exploratory lap, only the lysis of adhesions & peritoneal biopsies. The laparotomy would at this time be considered the approach (which you would not code). You can go onto ICD9.chrisendres.com for a free online searchable 2009 ICD-9-CM.

I agree with you that exploratory laparotomy shouldn't be coded when it is used as approach.It is however coded when it is used in 2 instances.Exploratory lap + incidental appendectomy and 2.exploratory lap + biopsy. In the example posted it was mentioned that biopsy was done,so I believe that exploratory laparotomy should be coded also

I need help coding Inpatient Scenarios.If Interested Please email me at tdasu@hotmail.com

A patient comes in with chest pain and after test were ran the consult doctor notes the etiology of the chest pain being coronary spasm secondary to his cocaine abuse. The other doctor states chest pain consistent with acute coronary syndrome,now resolved. Also, Rhabdomylosis, History of CAD status post PCI,and Mild exacerabation of COPD.Would u code the 411.1 as principal and then728.88 .

noname in San Gabriel, California said: I agree with you that exploratory laparotomy shouldn't be coded when it is used as approach.It is however coded when it is used in 2 instances.Exploratory lap + incidental appendectomy and 2.exploratory lap + biopsy. In the example posted it was mentioned that biopsy was done,so I believe that exploratory laparotomy should be coded also

Sometimes these laporascopy are bundled together so you dont need to add additional codes. So you need to read what the OP report states what tool was used and why.

louise in Nashville, Tennessee said: A patient comes in with chest pain and after test were ran the consult doctor notes the etiology of the chest pain being coronary spasm secondary to his cocaine abuse. The other doctor states chest pain consistent with acute coronary syndrome,now resolved. Also, Rhabdomylosis, History of CAD status post PCI,and Mild exacerabation of COPD.Would u code the 411.1 as principal and then728.88 .

You need to query the main physician on his diagnosis and also i wonder which other doctor were you referring to : consult, referral, specialist. "Usually the main doctor who does the patient care is the what the principal dx is what you code by. It seems you need to code the cocaine abuse as principal dx ( it's what trigger the admit.), and then coronary spasm , ( chest pain is a symptom that doesn't need to be coded if there;'s a dx given.)

Dr Guptha in Hyderabad, India said: visit www.medicalcodingexperts.com or www.medesun.com for inpatient coding training. Best of luck.

don't go to these websites, it's a scam and waste of money. Get training by AHIMA or AAPC affilated colleges that are certified by these 2 major Coding groups. Don't waste time on these websites who are SCAMS! PLEASE!! these websites are not affiliated and lack the necessary training you need to be successful in your careers!

louise in Nashville, Tennessee said: A patient comes in with chest pain and after test were ran the consult doctor notes the etiology of the chest pain being coronary spasm secondary to his cocaine abuse. The other doctor states chest pain consistent with acute coronary syndrome,now resolved. Also, Rhabdomylosis, History of CAD status post PCI,and Mild exacerabation of COPD.Would u code the 411.1 as principal and then728.88 .

you also need to code the COPD (496) ( and CAD (414.01), it's a major cc per Coding Clinic, just like any serious diagnosis etc;

Can someone be my inpatient coding mentor. I would like to get my CCS before ICD-10 takes affect..Also could recommend books to learn more about inpatient coding.. I have the CCS PRG and it doesn't tell me EVERYTHING..Thank you

valdenise38@yahoo.com

Hello valerie,
I would like to recommend to you , the CCS Coding exam review book by Carol Buck. I bought mine from Barnes and Noble. I read the Coding Clinic too and ofcourse experience in inpatient coding helps a lot too. Good Luck
Leena Daniel CCS,CPC.rt
New York

Radiologist dictated that he performed a CT guided aspiration of a paravertebral fluid collection. Our auditor said that it should be coded to CT guided aspiration of the soft tissue. Please advise, what ICD-9 procedure codes you would suggest and why? Thanks for your time

I HAVE BEEN ASKED TO SEE IF I CAN GET CLARIFICATION ON THIS. AT THE HOSPITAL WHERE I WORK ON THEIR H&P THERE IS A SECTION WHERE THE DOCTOR DOCUMENTS -- CT HEAD- MASS, OF INSTANCE. I WOUNLD NOT CODE THIS UNLESS IT WAS DOCUMENTED FURTHER IN THE CHART. OTHER CODERS FEEL THAT SINCE IT IS ON THE H&P THEY WOULD CODE IT. ?????

KMcCool,CCS in Washington, District of Columbia said: I HAVE BEEN ASKED TO SEE IF I CAN GET CLARIFICATION ON THIS. AT THE HOSPITAL WHERE I WORK ON THEIR H&P THERE IS A SECTION WHERE THE DOCTOR DOCUMENTS -- CT HEAD- MASS, OF INSTANCE. I WOUNLD NOT CODE THIS UNLESS IT WAS DOCUMENTED FURTHER IN THE CHART. OTHER CODERS FEEL THAT SINCE IT IS ON THE H&P THEY WOULD CODE IT. ?????

Depending on where in the H&P. If it is under exam findings or the like, I would not code it. If it is in the assesment I would.

Valerie in Moreno Valley, California said: Can someone be my inpatient coding mentor. I would like to get my CCS before ICD-10 takes affect..Also could recommend books to learn more about inpatient coding.. I have the CCS PRG and it doesn't tell me EVERYTHING..Thank you

valdenise38@yahoo.com

Hello Valerie,

I am also planning to have CCS before November 2010 however I dont have proper guidance to prepare. If you have anything plese help me out.

Thanks,
Dhanesh CPC

Hello new coders to be. The best place to get coding books to help prepare for the test is Loma Linda University Medical Center book shop. I think you can order books on line also. LLUMC is a allied health care University. I got my inital CCS there. Also get the 'CLINOTES". It has most diseases, Signs adn symptoms of the disease, med used to treat the disease, and the some lab tests used. Very helpful. Also there are weekend seminars that go over the test and gives you help in how to answer the test and how to stude. One place that does this is Codebusters. I have had my CCS for 10 years and I passed on the first go round using the books not an encoder. Good luck and if you need more help or if I can mentor some I will. Dena Reeves CCS

I will be taking an inpatient coding test at my local hospital, hoping to get a job. I havn't had inpatient experience. I am a CCA. Hoping someone could kind of tell me what kind of things I should know to pass an inpatient coding test for employment.

maegene in Pikeville, Kentucky said: I will be taking an inpatient coding test at my local hospital, hoping to get a job. I havn't had inpatient experience. I am a CCA. Hoping someone could kind of tell me what kind of things I should know to pass an inpatient coding test for employment.

I would try to review the ICD 9 Official Guidelines for the current year and REALLY focus on your selection of Principal Diagnosis & Procedures. Also if you can get your hands on ANY Coding Clinic's review them. If they give you any "instructions" read them carefully for codes they DON'T want assigned. Basically you are going to try to capture anything invasive on an inpt setting (that's just a general suggestion, not all inclusive). If you can get your hands on any Clinical Coding Workout books. Also if you can go onto AHIMA website and do the CCS exam practice questions. GOOD LUCK.

Is there any group or consulting service that offers a subscription or fee based aid to help with difficult coding scenarios if you are the only coder and don't have anyone in the organization to get help from?

CAN SOMEONE BE MY INPATIENT CODING MENTOR. I WOULD LIKE TO GET MY CCS BEFORE ICD-10 TAKES
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anderio04 in new york, New York said: CAN SOMEONE BE MY INPATIENT CODING MENTOR. I WOULD LIKE TO GET MY CCS BEFORE ICD-10 TAKES
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Sure. I will help you.

I would like to become an independent coder and biller. I am finishing my finals classes in Medical Administration and would like to know where to start after graduation to be an independent coder? Can anyone help so I can start working on my own? What steps do I need to take?

How would I code this case?

PREOPERATIVE DIAGNOSIS: Cataract right eye.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION PERFORMED: Extra capsular cataract extraction with implantation of a 16 Diopter
posterior chamber lens, (a Sinskey style posterior chamber lens) in the ciliary sulcus.
I coded the procedure as 13.59 and the diagnosis as 366 what is wrong with what I used and what is missing?

my next question

When is it do you code the history of illness or personal illness of a patient? Do you code either when it relates to the patient current diagnosis or procedures? I need to know if I am right in a case I am coding. Such as this previous case I mention earlier Cataract right eye. No personal history of the disease, but FAMILY HISTORY: She has a brother who had retinal detachment. Would I code this?

I get 366.9 for the cataract and 13.59 and 13.71

Maxine of Ocala Fl said: my next question

When is it do you code the history of illness or personal illness of a patient? Do you code either when it relates to the patient current diagnosis or procedures? I need to know if I am right in a case I am coding. Such as this previous case I mention earlier Cataract right eye. No personal history of the disease, but FAMILY HISTORY: She has a brother who had retinal detachment. Would I code this?

According to guidelines you code any chronic illnesses that are currently being treated or affect current management of the patient

RobinSewell in Stuart, Florida said: According to guidelines you code any chronic illnesses that are currently being treated or affect current management of the patient

Could someone please help me: I am currently enrolled in a CPT Coding class and need to interview someone with 7 questions, its basic question about your job? Thanks to anyone who responds to this.

Tasha

Maxine of Ocala Fl said: How would I code this case?

PREOPERATIVE DIAGNOSIS: Cataract right eye.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION PERFORMED: Extra capsular cataract extraction with implantation of a 16 Diopter
posterior chamber lens, (a Sinskey style posterior chamber lens) in the ciliary sulcus.
I coded the procedure as 13.59 and the diagnosis as 366 what is wrong with what I used and what is missing?

Thank you for your help

I have a diagnosis for a patient that says, " acute abd pain due to bilateral pneumonia." This is for a pt that was seen in the er room. do I code the abd pain first and then the bilateral pneumonia
Thanks

Since a dx of pneumonia has been established, you would code that first.

can someone help out with medical coding need to ask 5 questions

niyah in El Paso, Texas said: can someone help out with medical coding need to ask 5 questions

Go ahead. I will do my best

Emergency, Radiology, and Pathology/Laboratory Services
Using your CPT® and HCPCS codebooks, code the following case:
A 26-year-old female presented to the Emergency Department with complaint of severe headaches of 16-hour duration. A detailed history and examination were performed. The MDM was of moderate complexity. Following are the services that were provided:

Service Description CPT®/HCPCS Code(s):
E/M service __________
Glucose, body fluid _________
Total protein ______
Smear Gram stain ________
Aerobic culture of lumbar fluid, bacteria ________
Lumbar puncture ___________
Fluoroscopy, 30 minutes
Fluoroguidance, spinal
CT scan, brain w/o contrast

please email me directly. i tried posting the codes and the forum moderator thinks it is vulgar language!
mdbilling@comcast.net

I have an inpatient coding question.

I'm studying the Icd-9-cm guidelines and in Section IV it says:

"The Uniform Hospital Data Discharge Set (UHDDS)defintion of principal diagnosis applies only to inpatients in acute, short-term, long-term care and psychiatirc hospitals."

From what I've learned so far, the term principal diagnosis applies to all inpatients. I checked Section II of the guidelines and it says:

"...the application of the UHDDS defintions has been expanded to include all non-outpatient settings(acute care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc)."

I understand what the principal diagnosis is, but I'm not sure to what it applies. I know applies to non-outpatient settings. Does this mean all non-outpatient setting or only some?

"The Uniform Hospital Data Discharge Set (UHDDS)defintion of principal diagnosis applies only to inpatients in acute, short-term, long-term care and psychiatirc hospitals."

This sentence seems to limit the definiton of principal diagnosis to only certain inpatients. It makes it seem like the term principal diagnosis applies only to acute, short-term, long-term care and psychiatric hospital inpatients and not to other types of inpatient.

My problem is that a previous guideline (Section II) says the defintion has been expanded to includes all non-outpatient settings.

So does principal diagnosis apply to all inpatient or only some?

i have taken the basic medical coding and billing class. i do work in medical records now but im not coding yet. i want to start out with the lowest certification possible which test should i take

This question has come up for discussion a few times. I hope someone can give me their input.

When coding a psychiatric inpatient admit on a pregnant woman, do you use the pregnancy codes? I have always been under the impression that basic coding guidelines apply.
Thanks for your help!