reboot: 2015 Critical ICD-10 Implementation

L I S A S E L M A N - H O L M A N , J D , B S N , R N , H C S - D , H C S - O , C O S - C

Selman-Holman & Associates, LLC

Lisa Selman-Holman, JD, BSN, RN, COS-C, HCS-D, HCS-OHome Health Insight—Consulting, Education and Products for

Home Care and HospiceCoDR—Coding Done Right

Code Pro UniversityAHIMA ICD-10-CM/PCS Approved Trainer

AHIMA ICD-10-CM Ambassador606 N. Bell Ave.

Denton, Texas 76209214.550.1477

972.692.5908 faxLisa@selmanholman.com

www.selmanholmanblog.comwww.selmanholman.com

Implementation Date October 1, 2015

A Thursday

The Latest on the CMS website

January 2013

Obviously we’ll need to make our own timeline.

Slow and steady wins the race?

Transitioning Your Team

What are we waiting on?

5010 already implemented

OASIS C-1/ICD-9—Implemented January 1, 2015

Case mix diagnoses—Finalized

More changes in PPS effective January 1

Grouper logic changes—no later than July 1, 2015 (???)

For hospice—will there be a new payment system?

Testing and dual coding

Schedule training

Select Your Team

Since ICD-10 will affect nearly all areas of your agency, project teams should consist of representatives from key areas of your organization, including:

Senior Management

Health Information Management/Coding

Billing/Finance

Compliance

Information Systems and Technology

Everyone will be affected:

Intake Process

Billing/accounting

Quality Assurance

Clinical processes

Data entry/administrative support

Leadership/management

Coders

Research shows:

21% decrease in productivity related to ICD-10 that is never recovered

2.5 FTEs now will mean 5.65 FTEs for ICD-10

Billing errors because of incorrect or incomplete codes rise to 10% of claims requiring follow-up, correction and re-billing.

What are some of the issues?

Coders will be 20-30% slower even if well trained and practiced.

What is the productivity level you expect now?

OASIS C-1 issues will compound the reduction in productivity

What is your “days to RAP” now?

What can you do to improve that number now and with implementation of ICD-10?

What are some of the issues now?

Little to no clinical information available at referral/intake.

More difficult to identify patient issues

More difficult to develop POC meaningful to the patient

More difficult to provide skilled care that will withstand the scrutiny

How do we get better information to begin with AND

How do we get the clinicians to assess/document better?

What is dual coding? And why is it important?

Coding in ICD-9 and ICD-10

Keeping in mind that everything has to be in ICD-9 now

Faster and more accurate

Analyze what documentation is needed for better coding/better assessments.

Make changes to forms

Make list for intake personnel

Dual Coding Plan

Do you outsource your coding?

First, do NOT depend on the GEMs.

Cannot dual code until the coders have had training.

When will that be?

50 HOURS OF TRAINING AND PRACTICE RECOMMENDED

Sample Dual Coding Plan

Start by running a report on top 20 diagnoses your agency uses.

Kick out V57 codes.

Not just primary diagnoses.

Evaluate whether your list needs to include more than 20.

Code the top 20 diagnoses in ICD-10-CM

Category enough?

What additional information do you need from your referral source and your clinicians to code these well?

Develop quizzes, songs, or play “Who Wants to be a Millionaire” so that these codes are put to memory.

CoDR Sample Dual Coding Plan

Code one case per week in ICD-10-CM until December 31, 2014.

Code three cases per week in ICD-10-CM January 1-March 31, 2015.

Code five cases per week in ICD-10-CM April 1-August 2, 2015.

Begin REAL dual coding August 3, 2015.

Ongoing quizzes, crosswords, etc to ensure increased competency and accuracy January 1-August 2.

Quality audits of all coders.

Milestones - First Steps

Identify who should be involved in the planning committee/task force

Do the preliminary work identifying people and processes and establishing and securing budget.

Before real work can be done someone has to know what ICD-10 coding is and how it will impact processes.

Milestones - Next Steps

Clinical Documentation Improvement for ALL KINDS of reasons

Preliminary assessments of A&P, pathophysiology, pharmacology for clinicians, coders, QA

When should coding training begin and for who?

Dual coding

Milestones - Next Steps

Where is your software vendor in the ICD-10 process?

Don’t expect them to be through or almost through, but do expect them to know something about ICD-10

Have they done internal testing?

What tools did they build in or are building in to help with the transition?

Will they be beta testers for ICD-10, grouper, etc?

What will be the cost to YOU?

Who is involved in developing the assessment tools?

Gap Analysis

Definition:

“…the comparison of actual performance with potential performance. Gap analysis provides a foundation for measuring investment of time, money and human resources required to achieve a particular outcome.”

Steps in a Gap Analysis

1. Analyze your current situation for each process and system by collecting information and data. (where we are now). Do this by looking at your agency introspectively and asking questions

a. What are we currently doing?

b. Who has the knowledge that you need?

c. Is the information documented anywhere?

d. What is the best way to obtain the information?

Software reports? Interviews? Document review? Observation?

Steps in a Gap Analysis

2. Identify the objectives that must be achieved to achieve the overall goal. (where we need to be)

What are your goals now as to days to RAP?

How long does it take to get assessments complete?

How many assessments are acceptable when first submitted and how many times does the coder have to go back to the clinician for additional information?

What are achievable objectives for each issue identified?

You have to know where you are to know what to do to get where you are going…

Steps in a Gap Analysis

3. Identify how to bridge the gap from the current situation to the desired outcome (how do we get there). Consider what resources you will need to take to reach the objective, and then take action!

a. People

b. Processes

c. Technology

d. Time

e. Materials and Equipment

Areas to be addressed in Gap Analysis

FinancialBilling/Revenue cycleCash FlowBudgetHHRG changes

OperationalIntake/referralIT/Outside

Vendors

ClinicalClinical documentationOASIS C-1 completionCase Management

CodingICD-9 and ICD-

10

Personnel take

information

from referral

source and

directed to ask

certain questions

if information is

not offered, such

as demographic

info, next of kin,

who will sign

F2F,…etc.

Intake will obtain

better clinical

information so

that assessments,

documentation

and coding can be

more accurate

and complete.

Intake needs to have some education in coding to

ensure that clinical information is as complete as

possible at intake stage.

Provide list of questions based on common

diagnoses for referral source so that clinical

information is as complete as possible, e.g.,

osteomyelitis—acute or chronic.

Query the physicians and discharge planners for

additional diagnosis information beginning

immediately as part of our ICD-10 Readiness

Training.

Develop form for querying physicians to identify

missing diagnosis information based on

description of patient, pharmacology,…etc.

Sample Gap Analysis- Clinicians

Assessing clinicians

complete OASIS and

sequence diagnoses based

on the proposed POC—

assessments are mostly

checklists and do not

provide a lot of narrative

clinical information.

Improved documentation to

support skilled care

Improved cues/prompts for

gathering information on

the assessment

Have clinician/coder team

review current assessments to

ensure adequate prompts are

in place for improving

documentation.

Transfer information to new

OASIS C-1.

Evaluate knowledge of

pathophysiology and

pharmacology.

Develop POC based on

diagnosis information and

patient need.

Sample Gap Analysis- Clinicians

Review history and physical

(when available),

assessment and proposed

POC to determine

appropriate sequencing

taking into account coding

guidelines.

Coding within ________

hours of receipt of OASIS

Increased amount of

information at referral

Compliant, accurate

coding based on

documentation

available.

Coding within 24-48

hours of receipt of

OASIS

See above for improved

information

ICD-10 comprehensive training

Evaluate knowledge of

pathophysiology and

pharmacology.

Dual coding plan to improve

efficiency and accuracy of coders

once training has taken place.

Sample Gap Analysis- Coders

Develop POC

based on

completed

OASIS within

____ hours.

Develop patient

centered POC based on

completed OASIS within

48 hours (improved

individualization of the

POC for the patient)

Review the completed OASIS for accuracy and

documentation to support skilled care.

Ensure that the sequencing has been done

correctly to support services provided. Consult

with coders on sequencing questions.

Ensure that correction policy is followed.

Ensure that if F2F is not completed prior to

SOC, that POC is available to physician when

encountering the patient. (Communicate with

physician)

Sample Gap Analysis- QA

_______ days to RAP.

Final claim within ___

days of EOE except in

cases in which the

orders are missing or

F2F is not present on

SOC.

.

5-7 days to RAP

Final claim within 10 days

of EOE except in cases in

which the orders are

missing or F2F is not

present on SOC.

Evaluate coders/QA for speed of

completion of coding, ‘locking’ the

OASIS and POC development.

Evaluate ‘bottle necks’ in process and

develop plan to resolve any issues.

Once RAP has been submitted,

evaluate any RTPs and status in DDE.

Follow up immediately to correct any

claims issues. Identify who to go to

for RTPs related to coding.

Identify responsibility for pre-billing

audit and identify criteria for pre-

billing audit. Identify who will

review the coding.

Sample Gap Analysis- Billing

See you on the other side!

So back to those clinical issues…

Little to no clinical information available at referral/intake.

More difficult to identify patient issues

More difficult to develop POC meaningful to the patient

More difficult to provide skilled care that will withstand the scrutiny

How do we get better information to begin with AND

How do we get the clinicians to assess/document better?

Physician Confirmation

Verify with physician: you may not list a diagnosis that is not either documented in the medical record by the physician (H&P, F2F, progress note, problem list, referral info) or documented as confirmed by the physician

Do not list diagnoses based on medications, treatments, or patient/caregiver report without contacting the physician to confirm – document this confirmation in the record

36

Compliance Issues

Your documentation has to support those codes chosen.

Downcodes possible

Allegations of fraud and abuse!!

What Coders Need

Assessing clinicians should try their best to determine primary and secondary diagnoses based on assessment findings and plan of care

Coders will review all documentation provided to determine support for the primary and secondary diagnoses listed, and assign the numerical codes

What Coders Need

Etiology of a wound (pressure ulcer, stasis ulcer, trauma wound, diabetic ulcer?)

Trauma wound—laceration, puncture wound, bite, other?

Stage and location of all pressure ulcer(s)

Severity of non-pressure ulcers

CVA: which side affected?

Organism that caused an infection if known

What Coders Need

Primary or secondary OA?

Acute or chronic osteomyelitis?

What type of angina?

How long ago was the MI? Location?

Is the sepsis resolved?

Is the stenosis resolved?

Malignant, benign, ca in situ?

Primary and secondary sites of the malignancy?

What Coders Need

What type of anemia?

Confirmation of any diabetes manifestations

High blood sugar

Type of diabetes

Type of COPD and any exacerbations

If condition of the bowel, large, small or both?

Any bleeding of GI conditions resolved?

What stage of CKD?

Gustilo grade on open fractures

Fractures

Classifications of fractures:

Open or closed

Gustilo

Displaced or non-displaced

Traumatic or pathological

Traumatic: bone breaks due to fall or injury

Pathological: bone breaks due to a disease of the bone, a tumor or infection

Types of Fractures

What Coders Need

Documentation of any physician confirmation of complications

Documentation of any physician confirmation or clarification of other diagnoses

Asking Physicians for What You Need

Notify them NOW that you need the information

Complete assessment and objective findings a must!!

S-O-A-P

Ask for information in a multiple choice format.

Example

COPD was documented as the inpatient diagnosis. The patient notes that he had increased shortness of breath and coughing for 3 days prior to hospitalization. He continues on antibiotics for 6 more days. Sputum is yellowish-green. Oxygen was increased to continuous and he has two other new medications besides his antibiotics.

Please provide the following information:

Example (con’t)

Do you consider the COPD exacerbated?

Was an infection identified? If so, where? And viral? Bacterial? Organism?

Does the patient have emphysema? Chronic bronchitis? Chronic asthma?

Example

Patient was referred with diagnosis of abnormal gait and history of CVA. Admitting nurse notes that the patient takes Aricept.

What questions should be asked?

Scenario #1

71 year old female admitted to home health on 4-3-2014 after hospitalization for sepsis from MRSA pneumonia and exacerbation of her chronic obstructive asthma. On 4-21-14, she experienced a NSTEMI and while in the hospital had difficulty being extubated because of acute respiratory failure. She had a trach placed and is returning to home care for trach care and teaching as well as observation and assessment. She also has a history of type II DM (insulin dependent), HTN, depression, and AHD with angina. The abx for the MRSA pneumonia were discontinued.

Discussion

We are coding the SOC and then the ROC.

Coding sepsis in ICD-9

Systemic, 995.91, localized infection

Coding sepsis in ICD-10

Systemic, R65.2- only if organ failure, localized infection

M1020/M1022 Description M1024

038.12 MRSA Sepsis

995.91 Sepsis

482.42 MRSA pneumonia

493.22 Chronic asthma, exacerbated

250.00 Diabetes, Type 2

414.00 AHD

311 Depression

401.9 HTN

413.9 Angina

V58.67 Use of insulin

Code the SOC!

M1020/M1022 Description M1024

410.72 NSTEMI

493.22 Chronic asthma, exacerbated

518.81 Respiratory Failure

414.00 ASHD

V55.0 Attention to tracheostomy

250.00 Diabetes, Type 2

311 Depression

413.9 Angina

401.9 HTN

V12.61 History of pneumonia

V58.67 Use of insulin

V12.04 History MRSA

Code the ROC!

M1021/M1023 Description

A41.02 MRSA Sepsis

J44.0 Chronic obstructive pulmonary disease with lower respiratory infection

J15.212 MRSA pneumonia

E11.9 DM , Type 2

I25.119 AHD of native coronary artery with unspecified angina

F32.9 Depression

J44.1 COPD with exacerbation

I10 HTN

Z79.4 Long term use of insulin

ICD-10 Answers!

Description

I21.4 Non-ST elevation MI (NSTEMI)

J44.1 COPD with exacerb

J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia

Z43.0 Attention to tracheostomy

I25.119 AHD of native coronary artery with unspecified angina

E11.9 DM , Type 2

F32.9 Depression

I10 HTN

Z87.01 History pneumonia

Z86.14 History MRSA

Z79.4 Use of insulin

ICD-10 Answers!

Scenario #2

66 year old female has bladder cancer with mets to the bone, adrenal gland and R lung. She experiences chronic pain due to her cancer. While standing at home, she suddenly feels a sharp pain in her right hip. Upon admission to the hospital, it is determined that she has a fractured hip at the neck of the femur related to mets to the bone. She also has a hx of HTN. She is being admitted to home health for pain management and physical therapy.

M1020/22

Description ICD-9 M1024

M1020 Aftercare of fracture hip V54.23 733.14

M1022 Mets to bone 198.5

M1022 Bladder ca 188.9

M1022 Mets to adrenal gland 198.7

M1022 Mets to lung 197.0

M1022 Neoplasm pain 338.3

HTN 401.9

Answers!

Answers in ICD-10!

M1021/23 Description ICD-10

Pathologic fracture in neoplastic dz, right femur, routine healing

M84.551D

Mets to bone C79.51

Bladder Ca C67.9

Mets adrenal gland, unspec C79.70

Mets lung, R C78.01

Neoplasm related pain G89.3

HTN I10

Scenario #3

72 year old female pt. has OA of the right knee and has elective TKA performed by her orthopedic surgeon. She had a TKA for OA in her left knee in 2006. While in rehab following her right TKA, she falls and dislocates the joint of her left knee. She was taken to surgery and had an open reduction and repair of the left knee prosthesis. She has a history of severe major depressive disorder and is actively in psychotherapy. She also has a history of HTN, CKD. She is admitted to home health for physical therapy.

Discussion

OA is resolved.

Joint replacement and joint revision

Although the patient had a fall and dislocated her left knee prosthesis, she no longer has the problem so no external cause code.

Answers!M1020/22

Description ICD-9 M1024

M1020 Admit for PT V57.1

M1022 Aftercare joint replacement V54.81

M1022 Aftercare revision joint replacement

V54.82

M1022 Major depressive disorder 296.23

M1022 Hypertensive chronic kidney dz

403.90

M1022 CKD, unspecified 585.9

History of fallKnee

V15.88

V43.65

Answers in ICD-10!M1021/23 Description ICD-10

Aftercare following joint replacement surgery

Z47.1

Aftercare following explantation of knee jointprosthesis

Z47.33

Major depressive disorder, severe

F32.2

Hypertensive CKD I12.9

CKD, NOS N18.9

History of fall Z91.81

Presence of artificial knee joint bilateral

Z96.653

Scenario #4

77 year old male had a rotator cuff repair (no injury) on April 9. The following day, he presents to the ER with shortness of breath lasting 6 hours. He is diagnosed with a NSTEMI, acute on chronic Congestive Systolic HF, and exacerbation of his COPD. During his hospital stay, he experiences difficulty eating, and is found to have an esophageal stricture and a G tube is placed. He also has a history of HTN and Stage III CKD. He is on continuous oxygen at home. (There is no documentation that any of these issues were related to the shoulder surgery). He is being admitted to home health on April 15 for O&A of cardiac and respiratory status, G Tube care and enteral feeding teaching. PT and OT will work on the shoulder.

M1020/22 Description ICD-9 M1024

M1020 NSTEMI 410.72

M1022 Acute on chronic systolic failure 428.23

M1022 CHF 428.0

M1022 COPD, exacerbated 491.21

M1022 Esophageal stricture 530.3

M1022 Attention to G tube V55.0

Hypertensive CKDCKD stage 3Aftercare MSOxygen

403.90

585.3

V58.78

V46.2

Answers!

Answers in ICD-10!Description ICD-10

NSTEMI I21.4

COPD, exacerbated J44.1

Acute on chronic systolic (congestive) heart failure I50.23

Esophageal stricture K22.2

Attention to artificial opening, stomach Z43.1

Hypertensive CKD I12.9

CKD, Stage III N18.3

ASHD without angina I25.10 ????

Encounter for other orthopedic surg aftercareOxygen

Z47.89

Z99.81

Scenario #5

71 year old female being admitted to home health following hospitalization. She was admitted to the hospital and found to have a chronic peritoneal abscess secondary to a perforated large bowel diverticulum. She underwent a rectosigmoidresection and construction of a colostomy. She became weak and deconditioned during her hospitalization. She has a past medical history of HTN and diabetes. She is being admitted for observation and assessment, colostomy care, dressing changes and teaching and PT for strengthening. Her surgical wound is healing well however she remains on abx for the abscess.

M1020/22

Description ICD-9 M1024

M1020 Pelvic abscess (peritoneal) 567.22

M1022 Attention to colostomy V55.3

M1022 Diabetes 250.00

M1022 Hypertension 401.9

M1022 Muscle weakness 728.87

M1022 Aftercare following surgery V58.75

Surgical dressing changesAntibiotics

V58.31

V58.62

Answers!

Answers in ICD-10!

Description ICD-10

Peritoneal abscess K65.1

Attention to colostomy Z43.3

Diabetes E11.9

Hypertension I10

Muscle weakness M62.81

Aftercare following surgery Z48.815

Surgical dressing changes Z48.01

Long term use of antibiotics Z79.2

Scenario #6

68 year old male uncontrolled diabetic patient being admitted to home health following hospital stay for hypoglycemia of unknown etiology (glucose was 29 when in ER and as low as 38 while hospitalized). Blood sugars continue to be low. Also treated in hospital for pneumonia (resolved), acute on chronic respiratory failure, and emphysema. Patient also presents with metastatic stage IV poorly differentiated adenocarcinoma of the R lung, which is currently being treated with Taxotere. Has a recent history of glucose as high as 600 following Neulasta treatment. Multiple ulcers and cellulitis of bilateral lower legs noted. Other diagnoses include: hypertension, hypercholesterolemia, cad and recurrent pleural effusion (currently resolved). Home health nursing ordered upon hospital discharge for diabetic management, wound care to BLE and monitoring of overall status. O2 dependent.

Discussion

Acute on chronic respiratory failure can be coded in homecare if there is evidence that it still exists (pneumonia is resolved so doc should be queried)

M1020/22 Description ICD-9 M1024

M1020 Diabetes, uncontrolled w/hypoglycemia

250.82

M1022 Emphysema 492.8

M1022 Primary lung Ca 162.9

M1022 Ulcers, lower leg 707.19

M1022 Cellulitis, leg 682.6

M1022 CAD 414.00

HTNMets unknown siteOxygen use

401.9

199.1

V46.2

Answers!

Answers in ICD-10!Description ICD-10

Diabetes with hypoglycemia without coma

E11.649

Emphysema J43.9

Primary lung ca R C34.91

Ulcers, lower leg right L97.819

Ulcers, lower leg left L97.829

Cellulitis, lower limb right L03.115

Cellulitis, lower limb left L03.116

ASHD without angina I25.10

HypertensionMets unknown siteOxygen use

I10C79.9Z99.81

Scenario #7

76 yo male patient with recent surgery (TURP) for prostate cancer with mets to inguinal lymph nodes on the left. Incision and drainage for large amounts of lymph drainage with packing. He fell off his bed 2 months ago and has a wound on his leg that has never healed due to the venous insuffiency/stasis in that left leg. He is also diabetic and stepped on a nail in his back yard. That left food wound has also never healed and the muscle is necrotic. Wound care ordered to all 3 wounds and Lupron injections.

Chronic Wound

Our patient’s lower extremity wound originated as a trauma wound due to a fall. The patient also has diagnoses of venous insufficiency and stasis dermatitis. The physician stated the wound is not healing due to the venous insufficiency. Is there a point in time when the wound is no longer classified as a traumatic wound and considered a stasis ulcer for M1330?

M1330, “Does this patient have a Stasis Ulcer?” identifies patients with ulcers caused by inadequate circulation in the area affected. The healing process of other types of wounds, e.g. traumatic wounds, surgical wounds, burns, etc., may be impacted by the venous insufficiency, but it would not change the traumatic or surgical wound into a venous stasis ulcer.

Jan 2013

Discussion

With the loss of protective sensation, if trauma happens in the diabetic foot, often the patient is unaware, and left without check, can lead to further complications. While a MD has to classify any wound, any wound caused from internal factors (such as callus formation, deformity, PAD) or external factors (such as trauma, shear) are considered diabetic wounds.

While these conditions seem the same, the difference is the underlying conditions of the wounds. A trauma wound to an area of venous insufficiency= trauma wound, and a trauma wound to a diabetic foot=diabetic foot ulcer. In addition, if a trauma wound happens on a lower extremity of a diabetic patient, this does NOT make it a diabetic wound, but continues to be a trauma wound.

M1020/22 Description ICD-9 M1024

M1020 Trauma wound, L leg delayed healing

891.1

M1022 Diabetes with other specified manifestations

250.80

M1022 Ulcer foot 707.14

M1022 Prostate Ca 185

M1022 Mets to lymph nodes 196.5

M1022 Venous stasis 459.81

Use of Lupron V07.59

Answers!

Answers in ICD-10!Description ICD-10

Laceration without foreign body left lower leg

S81.812D

Fall from bed W06.xxxD

Diabetes with foot ulcer E11.621

Foot ulcer left foot, necrotic muscle L97.423

Prostate Ca C61

Mets to inguinal nodes left C77.4

Venous insufficiency I87.2

Use of Lupron Z79.818

Advanced Case #8

A diabetic patient was hospitalized for I & D of an abscess on her right foot. One week after discharge the patient was seen in the ER due to a low grade fever and inflammation of her right foot & ankle were noted. She was readmitted to the hospital and diagnosed with acute osteomyelitis of her foot & ankle. IV antibiotics were started for a culture of MRSA. The patient is being discharged home with orders for HH nursing to continue the IV antibiotics for 4 more weeks, wound care and monitoring of her diabetes. At this point the osteomyelitis is the greater concern as the wound is responding well to treatment.

ICD-9

M1020 – 250.80 Diabetes with other manifestations

M1022 – 731.8 Other bony changes in diseases classified elsewhere

M1022 – 730.07 Acute osteomyelitis of the foot & ankle

M1022 – 682.7 Abscess of foot

M1022 – 482.42 MRSA M1022 – V58.81 Fitting &

adjustment of vascular catheter

Additional dx’s : V58.62 Long term use of antibiotics

ICD-10

M1021 – M86.171 Acute osteomyelitis of right foot & ankle

M1023 – L02.611 Abscess of right foot

M1023 – B95.62 MRSA M1023 – E11.9 DM M1023 – Z45.2 Fitting &

adjustment of a vascular catheter

M1023 - Z79.2 Long term use of antibiotics

Answers!

Mr. Bob has an infected gastrostomy with cellulitis. He has fallen and has a lacerated right knee. He really should have had stitches but his wife couldn’t take him to the physician by herself. The edges are not approximated. You’ve described it to the physician and he wants steri strips on the wound to see if it will heal. Mr. Bob is a MRSA carrier so the physician wants nursing to do the wound care. Upon assessment you find a stage 1 pressure ulcer on his bottom (right). Mr. Bob has dementia and wanders and has hypertensive systolic heart failure.

Case #9

ICD-9-CM

536.41 Infection of gastrostomy

682.2 Cellulitis trunk

891.1 open wound knee, complicated

707.05 Pressure ulcer, buttock

707.21 Stage 1

402.91 hypertensive heart disease with heart failure

428.20 systolic heart failure

294.21 Dementia, unspecified with behaviors

V40.31 Wandering

V02.54 Carrier, MRSA

ICD-10-CM

K94.22 Gastrostomy infection

L03.311 Cellulitis, abdomen

S81.011D Laceration without foreign body, right knee

L89.311 Pressure ulcer of R buttock, stage 1

I11.0 Hypertensive heart disease with heart failure

I50.20 Unspecified systolic heart failure

F03.91 Dementia, unspecified with behaviors

Z91.83 Wandering

Z22.322 Carrier, MRSA

Answers!

Ten days ago a 74 yo man with a history of ASHD with angina was admitted to the ER via ambulance. He was experiencing severe angina, diaphoresis & nausea. It was determined that he was having an ST elevation MI involving the left anterior descending coronary artery. tPAwas administered and the MI converted to a NSTEMI. Once stable, he was then transferred to the Big City Heart Hospital. Two days later he had a second heart attack (no details) more severe than the first. He was taken to surgery for angioplasty and a drug-eluting stent was placed. He spent another week in the hospital but is now being discharged with orders for home health nursing. In addition to his cardiac issues he is on insulin due to a pancreatectomy performed last year due to a large pancreatic cyst.

Case #10

ICD-9

M1020 – 410.92 Acute MI NOS

M1022 – 410.12 Acute MI of anterolateral (wall) with contiguous portion of intraventricular septum

M1022 – 414.01 CAD of native vessels

M1022 – V45.82 S/P percutaneous transluminal coronary angioplasty

M1022 – 251.3 Postproceduralhypoinsulinemia

M1022 - 249.00 Secondary diabetes without complications

Add’l dx – V88.11 Acquired total absence of pancreas, V58.67 Insulin use

ICD-10

M1021 – I22.9 Subsequent myocardial infarction (acute) NOS

M1023 – I21.02 STEMI involving L anterior descending coronary a.

M1023 – I25.119 ASHD with angina NOS

M1023 – Z95.5 Angioplasty with stent (implant)

M1023 - E89.1 Postproceduralhypoinsulinemia

M1023 – E13.9 Other specified DM without without complications

Add’l dx - Z90.410 Acquired total absence of pancreas, Z79.4 Insulin use

Answers!

Ms Kaye was riding her bicycle 3 years ago when she was hit by a car. She sustained a subdural hemorrhage and had to be resuscitated at the scene. She has monoplegia of the right leg (dominant side) and is chair bound, an amputated arm below the right elbow, pseudobulbar affect, and dysphasia. She is admitted to home care because there has been a change to her anti-seizure medication as she began having seizures again. This is the third time her medications have been changed in the last six weeks. Skilled nursing is ordered for monitoring of the seizure medication and observation and assessment, teaching on new medications—Nuedexta and anti-seizure med. PT is ordered for strengthening and transfer training for a new caregiver. She was also recently started on anti-depressants for mild MDD.

Case #11

ICD-9-CM

345.81 Other forms of epilepsy and recurrent seizures, intractable

344.31 Monoplegia of lower limb affecting dominant side

784.59 dysphasia

907.0 Late effect of intracranial injury without mention of skull fracture

310.81 pseudobulbar affect

296.21 MDD, single episode, mild

V49.65 Acquired absence, above elbow

V58.83 Encounter for monitoring

V58.69 Other long term medication

V12.53 Personal history of Sudden cardiac arrest

ICD-10-CM

G40.919 Epilepsy, unspecified, intractable, without status epilepticus

G83.11 Monoplegia of lower limb affecting right dominant side

R47.02 dysphasia

S06.5x8S Traumatic subdural hemorrhage with loss of consciousness of any duration with death due to other cause before regaining consciousness

F48.2 Pseudobulbar affect

F32.0 MDD, single episode, mild

Z89.211 Acquired absence of right upper limb above elbow

Z74.09 Other reduced mobility

Z51.81 Monitoring

Z79.899 Other long term drug therapy

Z86.74 Personal history of sudden cardiac arrest

Answers!

An elderly woman was seen in the ER after falling over her daughter’s pot bellied pig. She sustained a trimalleolar fracture of her left leg and fractures of her 8th & 9th left ribs as her torso hit the couch arm. She was in severe pain and was experiencing difficulty breathing. An ORIF was performed on her leg. The rib fractures were taped but it was discovered that they caused subcutaneous emphysema. Even though she spent 18 days in a SNF the patient is still unable to walk post-op due to severe acute pain related to her trauma and her inability to maintain her non-weight bearing status. She is to remain confined to a wheelchair until her weight bearing status changes as she is considered to be a significant fall risk. Her incisions look good and require no care at this point.

Case #12

ICD-9

M1020 – V54.16 Aftercare for healing traumatic fracture of lower leg

M1022 – V54.19 Aftercare for healing traumatic fracture of other bone

M1022 – 958.7 Subcutaneous (traumatic) emphysema

M1022 – 338.11 Acute traumatic pain

M1022 – V46.3 Dependence on wheelchair

M1022 – V15.88 History of falls

ICD-10

M1021 – S82.852D Traumatic displaced trimalleolar fracture of L leg

M1023 – S22.42xD Traumatic multiple fractures of ribs, left side

M1023 – T79.7xxD Subcutaneous (traumatic) emphysema

M1023 – G89.11 Acute traumatic pain

M1023 – Z99.3 Dependence on wheelchair

M1023 – Z91.81 History of falls

Answers!

Mr. Simpson has a new onset of left sided flaccid hemiplegia. He has been undergoing radiation treatment of brain mets. The primary site is the left lung. The hemiplegia is documented as an adverse effect of the radiation. He has severe intractable pain related to the brain mets.

Other diagnoses include chronic respiratory failure compounded by altitude hypoxia. He was discharged from a hospital in Denver to his home in Winter Park and he is not tolerating the 9000+ altitude. He is on oxygen.

He has a history of prostate cancer. Skilled nursing, PT and OT are ordered.

Case #13

ICD-9-CM

342.00 Flaccid hemiplegia affecting unspecified side

E879.2 Radiological procedure and radiotherapy as the cause of abnormal reaction, without mention of misadventure

198.3 Secondary neoplasm of brain

162.9 Primary malignant neoplasm of lung

338.3 Neoplasm related pain

518.83 Chronic respiratory failure

E902.0 Residence or prolonged visit at high altitude

V46.2 Supplemental oxygen

V10.46 Personal history prostate cancer

ICD-10-CM

G81.04 Flaccid hemiplegia affecting left nondominant side

Y84.2 Radiological procedure and radiotherapy as the cause of abnormal reaction, or of a later complication, without mention of misadventure…

C79.31 Secondary neoplasm of the brain

C34.92 Primary malignant neoplasm of left lung

G89.3 Neoplasm related pain

J96.11 Chronic respiratory failure with hypoxia

W94.11xD Exposure to residence or prolonged visit at high altitude

Z99.81 dependence on oxygen

Z85.46 personal history of prostate cancer

Answers!

A patient is admitted to the ER with severe abdominal pain. He is taken to the OR for an exploratory laparotomy where it is determined that his appendix has burst. Post-op day 2 he becomes febrile & c/o increased abdominal pain. A paracentesis was performed & the patient is taken back to surgery. After copious irrigation of his abdominal cavity & excision of damaged peritoneal tissue it is determined that he has generalized peritonitis from the ruptured appendix. Antibiotics are started intravenously. Despite aggressive treatment the patient then develops sepsis. All cultures (fluid, tissue, blood) come back positive for staph. After spending a few days in intensive care he is transferred back to the floor where the surgical drain is removed and a wound vac placed. He’s stable & insists on being sent home to be cared for by his wife who is a retired oncology RN. He is referred to home health with orders for wound care and IV antibiotics for 6 more weeks.

Case #14

Lisa Selman-Holman

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Selman-Holman & Associates, LLC

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