CDI Adult MDC 6 - Digestive Flashcards

Question

# GIB due to Multiple Possible Sources - Coding Clinic 3Q 2018, p16 Question: A patient admitted with hematochezia underwent colonoscopy. The provider’s diagnostic impression included non-thrombosed and non-bleeding internal hemorrhoids, sigmoid diverticulosis, colonic angiodysplasia, and adenomatous cecum polyp. Coding professionals understand that active bleeding does not have to be demonstrated during the hospital stay for the physician to clinically diagnose bleeding, and that the classification makes a linkage between bleeding and angiodysplasia, and diverticulosis with bleeding. **Is it appropriate to assign codes for multiple bleeding sites when more than one finding/possible cause is linked, because of indexing in the classification?**

Answer 1

**Answer:** Assign code K57.31, Diverticulosis of large intestine without perforation or abscess with bleeding, and code K55.21, Angiodysplasia of colon with hemorrhage, for the diverticulosis and colonic angiodysplasia with GI bleeding. Either condition may be sequenced as the principal diagnosis. Assign also codes D12.0, Benign neoplasm of cecum, and K64.8, Other hemorrhoids, for the polyp and internal hemorrhoids. The fact that bleeding is not seen during colonoscopy does not preclude the assignment of a code describing hemorrhage. ICD-10-CM makes a linkage between gastrointestinal hemorrhage and diverticulosis and angiodysplasia; therefore, the provider does not have to link the conditions in the documentation. ## Footnote **Explanation:** In this Coding Clinic from 2018, a patient is admitted with hematochezia. A colonoscopy reveals multiple possible sources of the bleeding, including hemorrhoids, diverticulosis, angiodysplasia and a polyp. The question: “is it appropriate to assign codes for multiple bleeding sites when more than one finding or possible cause is linked by indexing in the diagnostic classification?” The short answer is yes, and any of the conditions may be assigned as principal diagnosis.

Answer 2

* Esophageal ulcers occur in the lower end of the esophagus. If the patient has been admitted with what’s been described as an upper GI bleed, consider an esophageal ulcer as a potential underlying cause, particularly if the patient has a history of GERD, is a chronic user of NSAIDs, smokes or has bulimia. * Clinical Indicators: difficulty swallowing, painful swallowing, hoarse voice, chest pain with eating, decreased appetite, cough. * Treatment: Treatment is focused on the underlying cause, e.g., management of GERD, cessation of smoking, discontinuation of NSAIDs. Esophageal ulcers are prone to recurrence. * Complications of esophageal ulcers include upper GI bleeding and perforation.

Answer 3

* Ischemic colitis is a medical condition in which inflammation and injury of the large intestine result from inadequate blood supply. Ischemic colitis occurs when blood flow to part of the colon is reduced, usually due to narrowed or blocked arteries. * Risk Factors: age 60+, clotting abnormalities, high cholesterol, CHF, previous abdominal surgery, extreme amounts of exercise that decrease blood flow to the colon (marathon running) * Clinical Indicators: acute onset of left-sided abdominal pain, tenderness or abdominal cramping, blood in the stool, bowel urgency, nausea, diarrhea. Symptoms often diminish in 2-3 days. * Diagnostics: abdominal US/CT, MRI of the abdomen, colonoscopy * Treatment: prophylactic antibiotics, IVFs, treatment of the underlying condition, surgical intervention to remove necrotic tissue, repair a perforation, bypass a blocked intestinal artery, or excision of the affected portion of the colon * Complications: bowel obstruction (ischemic stricture), gangrene of the intestine, perforation of the intestine, peritonitis ## Footnote The condition may be misdiagnosed because it can easily be confused with other digestive problems, such as nonspecific abdominal pain or colitis.

Answer 4

* Mallory-Weiss syndrome (MWS) is a condition marked by a tear in the mucous membrane of the esophagus. Most tears heal within 7 to 10 days without treatment, but Mallory-Weiss tears can cause significant bleeding. * Cause: The most common cause of MWS is severe or prolonged vomiting. While this type of vomiting occurs with illness, it also frequently occurs due to chronic alcohol abuse or bulimia. * Clinical Indicators: MWS doesn’t always produce symptoms. This is more common in mild cases when tears of the esophagus produce only a small amount of bleeding and heal quickly without treatment. In most cases, clinical indicators include: abdominal pain severe vomiting hematemesis involuntary retching bloody or black stools * Treatment: The bleeding that results from tears in the esophagus will stop on its own in about 80 to 90 percent of MWS cases. This typically occurs in a few days and doesn’t require treatment. Other treatment options include: surgery (sclerotherapy/coagulation therapy) blood replacement

Answer 5

* Scleroderma is a group of rare diseases that involve the hardening and tightening of the skin and connective tissues. It is caused by an overproduction and accumulation of collagen in body tissues. In many individuals, the disease process also affects the circulatory system and internal organs, such as the kidneys, lungs, and digestive tract. * Scleroderma affects women more often than men and most commonly occurs between the ages of 30 and 50. There is no cure for scleroderma. * Clinical indicators of scleroderma's digestive impact include GERD, gastroparesis, GI bleed, difficulties with nutrient absorption. * Treatment: a variety of medications can help control scleroderma symptoms or help prevent complications

Answer 6

* There is **no specific lab parameter **indicating “acute blood loss anemia”; however, serial monitoring of the H&H or blood transfusion may be a clinical clue of what the physician may be thinking and treating but not documenting. * ***Remember you are not allowed to assume a diagnosis of acute blood loss anemia from a diagnosis of “blood loss anemia.” The physician must provide explicit documentation of the condition.***

Answer 7

Sample Clarification: * Acute blood loss anemia in the setting of lower GIB requiring treatment with blood replacement * Other; with explanation of the clinical findings * Unable to determine (no explanation for the clinical findings) The medical record reflects the following clinical evidence: * **Clinical Indicators:** blood in stool, guaiac positive, H&H 10 and 24 * **Risk Factor:** Ruptured Diverticulum * **Treatment:** Serial labs and blood replacement

Answer 8

**Answer:** No, it is not acceptable. The Official Coding Guideline Section III.B., states: "Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance. If the findings are outside the normal range and the physician has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the physician whether the diagnosis should be added." Therefore, internal guidelines should not replace physician documentation. Facilities can work together with their medical staff to develop facility specific coding guidelines, which promote complete documentation needed for consistent code assignment. Additionally, these guidelines can guide the coding professionals as to when they should query physicians for clarification of their documentation. Any guidelines developed must be applied consistently to all records coded. An internal facility guideline should not interpret abnormal findings to replace physician documentation or physician query. The guideline may provide assistance in determining when a physician query is appropriate, but it may not interpret abnormal test results. These facility guidelines must not conflict with the "Official ICD-b0-CM Guidelines for Coding and Reporting " developed by the Cooperating Parties and, additionally, they should not be developed to replace the physician documentation needed to support code assignment. ## Footnote **Explanation:** Here’s an important Coding Clinic from 2014 addressing the issue of a facility developing its own internal coding guidelines that would negate the need for a coding professional or CDS to query the physician for a diagnosis of acute blood loss anemia. According to Coding Clinic, it would be inappropriate to assign a diagnosis based on lab values without the physician indicating the clinical significance. However, you may certainly work with your medical staff to develop guidelines that help guide the coding professional or CDS when to query or clarify abnormal lab values with the physician. The guideline must be applied consistently across all records, and it may not be used to interpret abnormal lab results for diagnostic purposes. Finally, the guidelines must not conflict with the Official Guidelines.

Answer 9

* Patients with GI bleed are also at risk for developing hemorrhagic or hypovolemic shock from the loss of circulating blood volume. * Hemorrhagic shock is a condition of reduced tissue perfusion, resulting in the inadequate delivery of oxygen and nutrients that are necessary for cellular function. * Clinical Indicators: The hallmark clinical indicators of shock have generally been the presence of abnormal vital signs, such as hypotension, tachycardia, decreased urine output, and altered mental status. These findings represent secondary effects of circulatory failure, not the primary etiologic event. The patient may also present with pale, diaphoretic skin, and/or confusion/agitation. * Treatment: The primary treatment of hemorrhagic/hypovolemic shock is to control the source of bleeding/fluid loss as soon as possible and to replace that loss. Crystalloid is the first fluid of choice for resuscitation. PRBCs should be transfused if the patient remains unstable after 2000 mL of crystalloid resuscitation. ## Footnote Whenever cellular oxygen demand outweighs supply, both the cell and the organism are in a state of shock. Hypovolemic shock, the most common type, results from a loss of circulating blood volume from clinical etiologies, such as penetrating and blunt trauma, gastrointestinal bleeding, and obstetrical bleeding. Hypovolemia may also result from overwhelming body fluid loss such as that with extensive or full-thickness burns.

Answer 10

* Duration of hospital stay and mortality increases in patients with UGIB complicated by acute kidney injury (AKI). * Clinical Indicators: AKI is based clinically on RIFLE, AKIN or KDIGO criteria, including serum creatinine, GFR and/or urinary output. Other indicators may include, anorexia, nausea, vomiting, weakness, confusion. * Treatment: Fluid resuscitation, correction of electrolyte imbalances, diuretics or fluid restriction for management of volume overload, discontinuation of any nephrotoxins, hemodialysis. ## Footnote Gastrointestinal bleeding, especially upper gastrointestinal bleeding (UGIB), is a frequently encountered condition that has a high morbidity, leading to increased treatment costs. Duration of hospital stay and mortality increases in patients with UGIB complicated by acute kidney injury (AKI). It has been reported that AKI develops in 1–11.4% of patients with acute UGB.

Answer 11

**Answers:** 1) B. Upper GI Bleed 2) B. No 3) A. Yes 4) D. Peritonitis 5) B. No ## Footnote **Explanation: ** This patient’s principal diagnosis is the upper GI bleed, even though the endoscopy was negative for an active bleeding site. The CT findings provide clinical evidence of a potential important secondary diagnosis—peritonitis. We’ll need to ask a question because we are not allowed to make assumptions of diagnoses from a lab or radiological finding. If you need remediation, review the GI hemorrhage content.

Answer 12

An ulceration can occur almost anywhere along the GI tract including the esophagus, stomach and duodenum. **In the MS-DRG system, most bleeding ulcers will assign to a GI bleed DRG: ** * Bleeding Gastric Ulcer * Bleeding Duodenal Ulcer * Bleeding Peptic Ulcer * Bleeding Gastrojejunal Ulcer The ulcers that are **excluded** from the GI bleed triplet include: * Esophageal (with/without bleeding) * Complicated (ex: specified as perforated) * Uncomplicated A **complicated** ulcer is **perforated**. If there is bleeding associated with the perforation, the ulcer will be assigned as a **GIB**. An **uncomplicated** ulcer is just that; it’s **NOT** bleeding or perforated. ## Footnote It is not likely that a patient with an uncomplicated ulcer would require an inpatient admission. If the documentation does not provide information concerning the inpatient’s ulcer, look for opportunities to further refine the diagnosis, such as ? Bleeding ? Perforated ? Esophageal Capturing this additional information will help support inpatient medical necessity.

Answer 13

* A gastric ulcer occurs when the thick layer of mucus that protects the stomach from digestive juices is reduced. This allows the digestive acids to eat away at the tissues that line the stomach, causing an ulcer. * Clinical Indicators: Abdominal pain that improves with eating, nausea, vomiting, acid reflux, symptoms of anemia, tarry stools, coffee ground emesis. * Risk Factors: Two common causes of gastric ulcers are the H. pylori organism and long-term use of NSAIDs. These cause the thick layer of mucus lining the stomach to become significantly reduced causing the digestive juices to eat away at the lining of the stomach. * Treatment: If the underlying cause is H. pylori, expect the patient to be placed on antibiotics. Proton pump inhibitors and H2 receptor blockers are also commonly prescribed; probiotics. * Complications: Complications include bleeding, perforation, bowel obstruction, peritonitis, and sepsis.

Answer 14

**Answer:** It would be appropriate to assign code K25.4, Chronic or unspecified gastric ulcer with hemorrhage. As stated in the ICD-10-CM Official Guidelines for Coding and Reporting, (I.A.15) the classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. Unless the provider documents a different cause of the bleeding or states that the conditions are unrelated, it is appropriate to assign the combination code for these conditions. ## Footnote **Explanation:** This Coding Clinic from 2017 provides guidance for the appropriate assignment of a GI bleed and gastric ulcers found on EGD. But the physician does not link the two in the documentation. The HIM professional seeks advice about assuming a relationship between the two conditions based on the “with” official guideline. According to Coding Clinic, it would be appropriate to assume this causal relationship linked by the term “with” in the alphabetic index. You would not assume the relationship if the physician documented a different cause of the bleeding.

Answer 15

**Answer:** The definition of the root operation “control” has been revised and is now applicable to correct postprocedural or other acute bleeding. In this case, the bleeding is of the duodenum. Most of the body's organs and tissues are vascular, and they bleed when cut or eroded. Control of bleeding of a cut or eroded body part is coded to the body part where the bleeding was controlled, rather than to a vascular system body part. In this case, the bleeding from the duodenal ulcer was controlled via an endoscopic approach, with clips placed on vessels eroded by the ulcers. Assign the following ICD-10-PCS code: **0W3P8ZZ Control bleeding in gastrointestinal tract, via natural or artificial opening endoscopic** ## Footnote **Explanation:**This clinic and the next provides advice for the capture of procedures performed to control GI bleeding due to ulcers; this first for the endoscopic application of clips to control the bleeding. Use the root operation “control” to assign this valid OR procedure.

Answer 16

**Answer:** When a patient is seen for bleeding and a procedure is performed to control the hemorrhage and prevent a recurrent bleed, assign a code for control of bleeding. Active bleeding does not need to be demonstrated during the encounter to diagnose and treat an acute hemorrhage. Assign the following ICD-10-PCS code: **0W3P8ZZ Control bleeding in gastrointestinal tract, via natural or artificial opening endoscopic** ## Footnote **Explanation:** In this clinic, an injection of epinephrine was used along with clips on an ulcer that was not actively bleeding. So, is it appropriate to index the procedure with the root operation “control”? Coding Clinic advises, “Active bleeding does not need to be demonstrated during the encounter to diagnose and treat an acute hemorrhage.” So, yes, control is the appropriate root operation for the procedure.

Answer 17

* A bleeding ulcer of any kind is a surgical emergency given the subsequent complications (acute blood loss anemia, acute renal failure, hypovolemic shock). * The intent of surgical intervention is to control the frank bleeding or oozing from the ulcer. * Use the root operation CONTROL to index the procedure. ## Footnote **Control:** restoring body part to its normal structure

Answer 18

* Crohn’s and ulcerative colitis are two distinct disease processes, although each causes an inflammatory reaction in the GI tract. * Do not confuse the terms "inflammatory bowel disease" and "irritable bowel syndrome." * Crohn’s disease can occur anywhere along the patient’s GI tract, while ulcerative colitis is limited to the colon. * Ulcerative colitis only affects the innermost lining of the colon; Crohn's disease can occur in all the layers of the bowel walls.

Answer 19

* Affects the entire GI Tract * Most common ite: Terminal end of the small intestine * Patchy appearance * May extend through the entire thickness of the bowel * **Symptoms:** Frequent diarrhea, rectal bleeding, unintended weight loss, fever, abdominal pain, fatigue, poor appetite * **Treatment:** Antibiotics, Aminoglycosides, corticosteroids, immunomodulators to suppress the immune response **Surgical options:** excision/resection of the affected portion of the bowel

Answer 20

* Limited to the large intestine * Most common site: portion or entire colon including the rectum * Continuous pattern of inflammation * Inflammatory process occurs only in the lining of the colon * **Symptoms:** Abdominal pain, blood or pus in stool, fever, unintended weight loss, frequent diarrhea, fatigue, poor apetite, tenesmus * **Treatment:** Antibiotics, Aminoglycosides, corticosteroids, immunomodulators to suppress the immune response **Surgical Options:** Resection of the colon, rectum and anus with the creation of an Ileostomy; Resection of the colon and rectum with creation of an ileal pouch to anus anastomosis **Types of Ulerative Colitis Include:** Ulcerative Proctitis Proctosigmoiditis Left-sided Colitis Pancolitis Acute severe ulcerative colitis **Complications:** GIB, Perforated bowel, Severe Dehydration, Toxic Megacolon

Answer 21

Inflammation is confined to the area closest to the anus (rectum), and rectal bleeding may be the only sign of the disease. This form of ulcerative colitis tends to be the mildest.

Answer 22

Inflammation involves the rectum and sigmoid colon (lower end of the colon). Signs and symptoms include bloody diarrhea, abdominal cramps and pain, and an inability to move the bowels in spite of the urge to do so (tenesmus).

Answer 23

Inflammation extends from the rectum up through the sigmoid and descending colon. Signs and symptoms include bloody diarrhea, abdominal cramping and pain on the left side, and unintended weight loss.

Answer 24

Pancolitis often affects the entire colon and causes bouts of bloody diarrhea that may be severe, abdominal cramps and pain, fatigue, and significant weight loss.

Answer 25

This rare form of colitis affects the entire colon and causes severe pain, profuse diarrhea, bleeding, fever and inability to eat.

Answer 26

* Toxic megacolon occurs when inflammatory bowel diseases cause the colon to expand, dilate, and distend. It is considered a life-threatening condition. * Clinical Indicators: The patient will present with abdominal pain and distention. Other indications include fever, tachycardia, and symptoms of shock. The patient may also experience profuse bloody diarrhea. * Treatment: Surgical intervention including partial and total colectomy. The surgical procedure of choice for toxic megacolon is total colectomy with preservation of rectum and diverting ileostomy. * Complications: The complications associated with toxic megacolon are just as life-threatening: bowel infarction, perforation, peritonitis, and sepsis. ## Footnote **Important Note:** The 30-day mortality rate is 57%, with an in-hospital mortality rate of 49%. You’ll want to ensure you’ve captured all evidence of SOI and ROM.

Answer 27

* Bowel obstructions are one common complication of Crohn's disease; as such, there is an assumed link between the two conditions. * If the patient is admitted with an obstruction due to Crohn’s disease, assign Crohn’s as the principal diagnosis. * When the obstruction is secondary to Crohn's disease, the principal diagnosis is Crohn's disease with obstruction. * If there are potential multiple causes of the bowel obstruction, it may be necessary to seek clarification. * Another common complication for the Crohn’s patient is a rectal abscess. The rectal abscess qualifies as a potential severity diagnosis. ## Footnote **Crohn’s Disease with Rectal Abscess:** This condition may not be addressed in the medical record documentation but might be mentioned on a colonoscopy procedural note. Always review any procedural note carefully to ensure clinically supported diagnoses are captured in the medical record documentation.

Answer 28

Yes, it is appropriate to assign code K50.014, Crohn's disease of small intestine with abscess, along with code K61.1, Rectal abscess, since the additional code provides information regarding the specific site of the abscess. Codes in category K50 describe intestinal abscess only. ## Footnote **Explanation:** This Coding Clinic from 2012 is a reminder to review the medical record closely for the Crohn’s patient. If a rectal abscess is documented and meets the guideline for reporting of a secondary diagnosis, capture the rectal abscess. Assign two separate codes—K50.014 for Crohn’s with abscess, and the second code, K61.1, to identify the type of abscess.

Answer 29

**Answer:** A. Yes. ## Footnote **Explanation:** The correct answer is Yes. In this situation the rectal abscess does meet the definition of a secondary diagnosis since it requires clinical evaluation, therapeutic treatment and increased nursing care.

Answer 30

* The main physiological and pathological changes in patients with obstruction include a dilated bowel proximal to the obstruction site, fluid and electrolyte loss, and infection. * The severity of these changes depends on the site of the obstructed site, the duration of obstruction, and presence (or absence) of any blood supply dysfunction on the bowel wall. * Clinical diagnosis: The diagnosis is usually made based on the patient’s clinical presentation. Obstruction will be further confirmed by radiographic studies. * Clinical Indicators: abdominal pain (persistent and dull), vomiting (late manifestation), abdominal distention (late manifestation), dehydration, hypokalemia. * Treatment: correct dehydration and electrolytes, GI decompression (NG tube), treat the underlying cause.

Answer 31

Adhesions from previous abdominal surgery (most common cause) Hernias containing bowel Crohn's* disease causing adhesions or inflammatory strictures Neoplasms, benign or malignant Volvulus

Answer 32

Neoplasms, benign or malignant Hernias containing bowel Inflammatory bowel disease Adhesions Fecal impaction Diverticular disease Endometriosis

Answer 33

**Clarification Example** * Bowel obstruction d/t Crohn’s disease requiring NGT decompression * Other; with explanation of the clinical findings * Unable to determine (no explanation for the clinical findings) The medical record reflects the following clinical evidence: * **Clinical Indicators:** bowel obstruction * **Risk Factors:** Crohn’s disease, previous multiple bowel surgeries * **Treatment:**NGT, NPO status, IVFs

Answer 34

* Lupus enteritis is defined as either vasculitis or inflammation of the small bowel. * Acute abdominal pain, often nonspecific with diarrhea and vomiting, are typically the cardinal signs for lupus enteritis. * CT of Abdomen is the golden standard for diagnosis with 3 classic patterns suggestive of lupus enteritis: 1. Bowel wall thickening grater than 3mm, also referred to as **Target Sign** 2. Engorgement of the Mesenteric Vessels, also referred to as **Comb Sign** 3. Increased attenuation of mesenteric fat * Clinical indicators: Focal or diffuse abdominal pain is the cardinal manifestation with associated symptoms of nausea, vomiting, ascites, diarrhea, with or without fever, and possible rebound tenderness with guarding * Treatment: Corticosteroids is typically the first-line therapy along with complete bowel rest. Cyclophosphamide or mycophenolate may be recommended for patients with severe or steroid-resistant lupus enteritis. * **Sequenced as the principal diagnosis, the SLE will assign to MDC 8 which more accurately reflects the severity of illness and risk of mortality associated with the systemic disease.** ## Footnote Patients with SLE can often have gastrointestinal tract involvement.

Answer 35

**Sample Clarification:** * Abdominal pain d/t SLE enteritis requiring treatment with IV steroids * Other; with explanation of the clinical findings * Unable to determine (no explanation for the clinical findings) The medical record reflects the following clinical evidence: * **Clinical Indicators:** abdominal pain with N/V, CT + for ascites, Comb sign, and increased attenuation of mesenteric fat * **Risk Factor:** SLE * **Treatment:** IV steroids, bowel rest

Answer 36

* Patients with this condition continue to experience biliary symptoms associated with gallbladder disease, such as bloating, burping, and intolerance to fatty foods even post-surgery after the removal of the gallbladder. * Risk Factor: s/p cholecystectomy * Clinical indicators include: persistent pain in the upper right abdomen nausea vomiting intolerance to fatty foods referred pain to right shoulder belching bloating dyspepsia biliary colic * Treatment: treatment of symptoms, GI workup, ERCP ## Footnote Review the clinical presentation of the patient carefully. If the patient has a history of cholecystectomy, consider seeking validation of postcholecystectomy syndrome from the physician to more accurately describe the patient's severity of illness. There is no definitive treatment for postcholecystectomy syndrome, but the symptoms do require maintenance. Symptoms occur in 5-40% of patients who undergo cholecystectomy.

Answer 37

**Answer:** Postcholecystectomy syndrome, 576.0, classifies those cases in which symptoms suggestive of biliary tract disease either persist or develop following cholecystectomy but for which no demonstrable cause or abnormality is found on workup. ## Footnote **Explanation:** In 1988, Coding Clinic addressed the diagnosis of postcholecystectomy syndrome, describing it as those cases in which symptoms suggestive of biliary tract disease either persist or develop following cholecystectomy but for which no demonstrable cause or abnormality is found on workup. Postcholecystectomy syndrome is an MDC 7 or hepatobiliary diagnosis.

Answer 38

**Answer:** No ## Footnote **Explanation:** The correct answer is No. The clinical indicators include persistent pain in the upper right abdomen, nausea, vomiting, intolerance to fatty foods, referred pain to right shoulder, belching, bloating, dyspepsia, biliary colic but not localized pain at McBurney’s point which is often associated with appendicitis.

Answer 39

If your patient has nausea and vomiting, review the clinical presentation and treatment regimen closely. It would seem odd to find a patient admitted for vomiting with a treatment regimen including aspiration precautions and IV Clindamycin. If the clinical evidence suggests a diagnosis of aspiration pneumonia or bronchitis, ask a question. The physician may be thinking and treating the condition but not adequately documenting the diagnosis.

Answer 40

* Esophagitis is an inflammation of the lining of the esophagus. * Esophagitis can be caused by several underlying conditions such as reflux, irritation from medications, or infections. * It is usually diagnosed by endoscopic exam. | Esophagitis is one of the diagnoses that is considered a miscellaneous d ## Footnote Investigate the record carefully, especially if the patient undergoes an EGD. If the EGD reveals the characteristic white patches of candida or the pathology returns positive for candida, seek clarification for candidal esophagitis, a major esophageal disorder. This specified type of esophagitis more accurately reflects the SOI and ROM associated with the organism. **Be sure to review any cultures obtained as clinical support for your clarification, but remember, a lone lab value does not adequately support an alternative diagnosis.**

Answer 41

**Answer:** Assign code **K20.0 Eosinophilic esophagitis**, for eosinophilic esophagitis. It would not be appropriate to assign code D72.18, Eosinophilia in diseases classified elsewhere, as eosinophilic esophagitis is specifically indexed to code K20.0 and the code already identifies both the esophagitis and the eosinophilia. ## Footnote **Explanation:**In some instances, the EGD doesn't return positive for candida but for eosinophils. This Coding Clinic advises the assignment of code K20.0, eosinophilic esophagitis rather than D72.18 because the condition can be specifically indexed. Patients at risk include those living in a cold/dry climate, during the spring/fall season of the year, male gender, family history, history of food or environmental allergies, and chronic respiratory disease. The symptoms include dysphagia, food impaction, substernal chest pain, and regurgitation of undigested food. The patient will require treatment with dietary management, proton pump inhibitors, topical steroids, and in many cases, dilation of the esophagus.

Answer 42

**Answer 1:**Assign the following ICD-10-PCS code: **0DD68ZX** Extraction of stomach, via natural or artificial opening endoscopic, diagnostic, for the endoscopic brush biopsy of the stomach **Answer 2:**The jet lavage debridement is considered nonsurgical mechanical debridement. It does not involve cutting away or excising devitalized tissue. Assign the following ICD-10-PCS code: **0KDS0ZZ**   Extraction of right lower leg muscle, open approach When multiple layers of the same site are debrided, assign only a code for the deepest layer of debridement. In this instance, only debridement of the muscle as the deepest layer is assigned. | The root operation value “D” Extraction, has been added to the following ## Footnote The change will allow the capture of additional detail for the root operation “Extraction,” including percutaneous aspiration biopsies and brush biopsies for the respiratory, gastrointestinal, and lymphatic body systems, and nonexcisional debridement for the muscles, tendons and bones body systems. **Explanation:**Brush biopsies (including GI sites) are assigned to root operation Extraction, therefore the previous advice provided per Coding Clinic 1Q 2016 regarding the assigning of Excision for a brush biopsy of the esophagus is no longer valid.

Answer 43

* Chemotherapy can cause inflammation anywhere along the GI tract resulting in the symptoms generally associated with Gastroenteritis *"GE"* * Gastroenteritis caused by chemotherapy (or exposure to other toxic substances) is referred to as “toxic gastroenteritis.” * ***Important Note:* The inclusion terms for toxic gastroenteritis include drug-induced gastroenteritis, drug-induced colitis, and drug-induced diarrhea.** | **Do not assume a link between the two conditions** ## Footnote Colitis and gastroenteritis as miscellaneous GI disorders do not capture the appropriate SOI when the condition is caused by exposure to radiation or a toxic agent, such as chemotherapy. The patient with toxic gastroenteritis or radiation colitis will present with symptoms mimicking colitis or gastroenteritis. Consider this documentation strategy for any cancer patient admitted with a non-infectious form of gastroenteritis.

Answer 44

**Sample Clarification:** * Toxic gastroenteritis d/t chemotherapy requiring treatment with IV antibiotics and IV fluids * Other; with explanation of the clinical findings * Unable to determine (no explanation for the clinical findings) The medical record reflects the following clinical evidence: * **Clinical Indicators:** “non-infectious GE” * **Risk Factor:** chemotherapy * **Treatment:** IV fluids, antibiotics, NPO status

Answer 45

* Gastroparesis, or gastric stasis, is a disorder of delayed gastric emptying in the absence of mechanical obstruction. It occurs when the nerves to the stomach are damaged and don’t work properly. * Diabetes is the most common cause. * Risk factors: diabetes mellitus, prior gastric surgery with or without vagotomy, a preceding infectious illness, pseudo-obstruction, collagen vascular disorders, and anorexia nervosa * The clinical indicators are a set of largely nonspecific symptoms such as early satiety, bloating, nausea, anorexia, vomiting, abdominal pain, and weight loss. Among these, vomiting and postprandial fullness are the most common. * Treatment: **Drugs used to relieve nausea and vomiting in gastroparesis include promotility drugs such as Reglan and erythromycin*, anti-nausea medications, and serotonin antagonists (Zofran). **Drugs used to relieve abdominal pain in gastroparesis include nonsteroidal anti-inflammatory drugs, low-dose tricyclic antidepressants, and drugs that block nerves that sense pain such as Neurontin.* ***Erythromycin is an antibiotic. At doses lower than those used to treat infections, erythromycin stimulates contractions of the muscles of the stomach and small intestine and is useful for treating gastroparesis.** ## Footnote *Of note: Evidence suggests that after 10-20 years of clinically apparent diabetes, 30-60% of diabetics develop overt signs of visceral autonomic neuropathy, of which gastroparesis is one form. Diabetic gastroparesis is detected with equal frequency in type 1 and type 2 diabetics. If the clinical evidence suggests a diagnosis of diabetic-related gastroparesis, seek clarification from the physician. Diabetic-related gastroparesis is an MDC 1 diagnosis.*

Answer 46

**Answer:** Aspiration Bronchitis

Answer 47

Answers: 1) A. Esophagitis 2) C. Esophagitis d/t Candida 3) D. Extraction

Answer 48

* Diabetes is a common cause of gastroparesis * There is an assumed link between DM and gastroparesis; as such, assign the appropriate E10 or E11 code assignment. * **However, if the condition has not been diagnosed as gastroparesis, you may be required to seek clarification from the physician.**

Answer 49

* Hernia: a protrusion of a part or structure through the tissue that normally contains it * During the patient’s hernia repair, the surgeon returns the bowel back to its normal anatomic position. In some instances, the muscle wall will need to be reinforced with mesh to prevent a recurrence of the hernia. When your patient undergoes a herniorrhaphy, one of two actions are being performed—a **“REPAIR”** or **“SUPPLEMENT.”** These are the root operations that you’ll use to index a hernia repair, including a procedure for failed mesh graft. | Repair without mesh uses “repair." If mesh is used, use “supplement”. ## Footnote **Repair:** restoring, to the extent possible, a body part to its normal anatomic structure and function **Supplement:** putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion or body part If the patient undergoes a hernia repair without mesh, use the root operation “repair." If mesh is used, use “supplement” instead. This detail is available in the body of the operative report.

Answer 50

* In some instances, previously placed grafting material may fail, causing a reoccurrence (recurrent) hernia. If a ‘redo’ hernia repair is because of a failed mesh graft from a previous hernia repair, then the hernia is **NOT** the principal diagnosis, it’s the failed mesh graft, a *complication* of a medical device. * This complication of treatment is not an MDC 6 diagnosis but an MDC 21 complication diagnosis and, as an MDC 21 PDx, more accurately describes the patient's severity of illness. ## Footnote Under these circumstances, it is important to have the physician validate in the documentation the failed graft as the underlying cause of the recurrent hernia.

Answer 51

* During a hernia repair, an adhesiolysis may be required. Dense significant adhesions requiring tedious dissection adds OR time and additional work to an otherwise routine hernia repair. * If the documentation suggests significant adhesiolysis but it is not well documented, seek clarification from the physician regarding the clinical significance of the adhesions. * **Of note, the adhesiolysis takes precedence in the surgical hierarchy, not the hernia repair.** ## Footnote A patient who is admitted for a hernia repair may require ‘additional surgical work.’ As you review the hernia repair operative note, look for indicators of additional surgical work.

Answer 52

Your patient may require an adhesiolysis for abdominal adhesions. You will use the root operation **RELEASE** since the intent of the procedure is to release an anatomical structure from a band of adhesions * **Release**: freeing a body part from an abnormal physical constraint by cutting or by the use of force *When a release is performed, none of the constrained organ is removed. Appropriate assignment requires the capture of each organ released during the adhesiolysis; laterality may be required.

Answer 53

**Answer:** In this instance, the lysis of adhesions is separately coded (root operation Release), because it was more than simply procedural steps necessary to reach the operative site. According to the ICD-10-PCS Official Coding Guidelines, B3.13, "In the root operation Release, the body part value coded is the body part being freed and not the tissue being manipulated or cut to free the body part." Therefore, the body part value for the lysis of adhesions is the greater omentum. ## Footnote **Explanation:** Many patients, especially those with a history of inflammatory bowel disease or multiple GI surgeries, are at risk for the development of adhesions, strong bands of connective tissue that develop in response to inflammation. Adhesions can cause pain, obstruction, and incarceration of surrounding tissues and organs. Lysis of adhesions is often considered inherent to procedures involving the abdomen and pelvis and would not require the assignment of an additional procedure code. However, if the adhesions are dense, significant, require additional work, increase the duration of the surgery or impede the progression of the procedure until they are removed, the lysis should be captured. When in doubt, question the surgeon.

Answer 54

*During a hernia repair, a bowel manipulation may be required to address a portion of compromised bowel (bowel that might be twisted or kinked). *An incarcerated or strangulated hernia requiring the surgeon to manipulate the bowel back into position represents additional surgical work as well as increased SOI and ROM. *Do not confuse bowel manipulation with a standard running of the bowel conducted prior to the closure of the surgical wound. * **Bowel manipulation takes precedence in the surgical hierarchy. The bowel manipulation procedure would be considered the principal procedure—not the hernia repair.**

Answer 55

* During a bowel manipulation, the surgeon moves the bowel to a more suitable location. Bowel manipulation is the manual untwisting or un-kinking of the bowel. * Use the root operation REPOSITION to index the procedure. | Reposition: moving, to normal or other suitable location ## Footnote Remember, do not confuse bowel manipulation with the standard running of the bowel which is inherent to all bowel procedures as the surgeon inspects the bowel prior to closing.

Answer 56

You’ll note the only procedure that is listed as being performed is an incisional hernia repair. However, as we review the body of the report, we find the following statement:* "There were a couple of areas where it looked like the bowel had twisted on itself. It appeared dusky so we untwisted the entirety of the bowel, we ran the entire bowel, and determined it to be completely viable."* We will need to clarify with the physician the bowel manipulation based on the evidence found in the report. * Hernia repair is considered a minor procedure. * Manipulation of the bowel is considered a major digestive procedure that will influence DRG assignment.

Answer 57

**Answer: No** ## Footnote **Explanation:** The correct answer is NO. The CDS should seek clarification of a cause-and-effect relationship between the recurrent hernia and the failed mesh graft. If you need to remediate this strategy, review the hernia repair content.