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;