CDI Adult MDC 6 - Digestive Flashcards
Esophageal Varices: Definition, Clinical Indicators, Treatment, Coding Guielines
Definition: Abnormally dilated submucosal veins in lower third esophagus associated with chronic liver disease (cirrhosis and portal hypertension)
CI: Hematemesis, Syncope, Melena, Hypovolemic Shock
Treatment: Usually requires surgical intervention (Ie: ligation, sclerotherapy)
Coding Guidelines: Require sequencing of cirrhosis as Primary Diagnosis with the Varices as Secondary Diagnosis
Laennec’s Cirrhosis with Esophageal Varices
Coding Clinic - Nov/DEC 1985, p14
Question: If a patient is admitted for Bleeding Esophageal Varices and also has Laennec’s Cirrhosis, what is the proper sequencing of the codes?
Answer: The Cirrhosis of the liver is sequenced first with the bleeding esophageal varices sequenced second.
*Esophageal Varices are a complication of various types of cirrhosis of the liver.
It is coded:
571.2 Alcoholic cirrhosis of the liver
456.20 Bleeding Esophageal Varices in Diseases Classified elsewhere
303.9 Alcoholism, with fifth-digit designation as to type
If the physician establishes a link between the varices and a cirrhosis diagnosis, the underlying causes (cirrhosis) is the primary diagnosis
Clarification Practice: A 64 year old male has been admitted with “bleeding esophageal varices”. He has a 20+ year history of ETOH abuse. The physical exam reveals an enlarged liver with elevated LFTs. An EGD with esophageal banding has been performed this afternoon.
- Bleeding Esophageal Varcies d/t cirrhosis requiring treatment with banding
- Other; with explanation of the clinical findings
- Unable to determine (No explanation of clinical findings)
The Medical Record reflects the following clinical evidence:
** Clinical Indicator: **Enlarged liver, Elevated LFT, Esopahgeal Varices
** Risk Factors: **20+ year history of ETOH Abuse
Treatment: Banding of Esopahgeal Varices
Esophageal Varices
Secondary Diagnoses
-
Peritonitis: Inflammation of Peritoneal Cavity.
* Clinical Indicator: Abdominal Pain, Tenderness, Vomiting, Fever, Peristalsis is absent.
* Treatment: Identify and treat underlying cause; Antibiotics, NGT, O2, Fluids, Electrolyte Replacement.
* Complications: AKI, ARDS, Liver Failure DIC -
Hemorrhagic Shock: A condition of reduced tissue perfusion resulting in inadequate delivery of O2 and nutrients.
* Clinical Indicator: Hypotension, Tachycardia, Decreased UOP, AMS, Pale/Diaphoretic Skin
* Treatment: Identify and control source of bleeding, fluid/blood replacement
Esophageal Banding
-Defintion
-Root Operation
Defintion: A banding procedure that uses an extraluminal device to occlude the esophageal varices; used to control the bleeding from the ruptured varix. Is a Valid OR Procedure.
Root Operation = Occlusion ; Completly closing orifice/lumen
Control of Bleeding: Bleeding Esophageal Varices
A patient with Alcoholic Cirrhosis and Bleeding Esophageal Varices secondary to Portal Hypertension underwent Transorifice Endoscopic Ligation of Esophageal Varices using Bands.
Question: What is the appropriate Root Operation? “Control” or “Occlusion”?
The Esophageal Banding (Ligtation) was the definitive procedure and the varices were being treated to prevent further bleeding.
06L38CZ Occlusion of Esophageal Vein with Extraluminal Device, via Natural or Artificial Opening Endoscopic
Transorifice endoscopic banding of esophgeal varices involves complete occlusion of blood flow and meets the defintion of the root operation “Occlusion”. The lumen of the esophageal vein is being banded, not the esophagus.
Explanation:In this Coding Clinic question, the HIM professional seeks advice for the proper assignment of transorifice endoscopic ligation of esophageal varices. The procedure is considered an occlusion using a band to occlude the esophageal vein to prevent future bleeding. Every clinical situation is different. Always review the body of the procedure note to ensure appropriate procedure assignment.
Injection of Sclerosing Agent into Esophageal Varix
What is the ICD-10-PCS Code Assignment for injection of a sclerosing agent into an Esophageal Varix of the Lower Esophagus?
Coding Clinic 1Q 2013 p27
Assign Code 3E0G8TZ Introduction of Destructive Agent into Upper GI, via Natural or Artificial Opening Endoscopic for the Injection of a sclerosing agent into the esophageal varix.
This is the correct code assignment since the application of a sclerosing agent via injection into a varix prevents bleeding rather than destroying tissue.
Root Operations:
Destruction = Physical eradication of all or a portion of body part by use of energy, force, or destructive agent
Introduction = Putting in or on therapeutic, diagnostic, nutritional, physiological, or prophylactic substance except blood or blood products
Clostridium Difficile Enterocolitis
-Definition
-Clinincal Indicators
-Treatment
Definition: A bacterium that causes symptoms ranging from diarrhea to life-threatening inflammation of the colon.
Clinical Indicators: Usually develop within 5-10 days after starting antibiotics, but may occur as soon as first day or up to 2 months.
The most common symptoms of mild to moderate C Diff Infection are:
-Watery Diarrhea three or more times a day for two or more days
-Mild abdominal cramping and tenderness
Indicators of severe infection Include:
-Watery diarrhea 10 to 15 times a day
-Abdominal cramping and pain, which may be severe/abdominal distention
-Tachycardia
-Fever
-Blood or pus in stool
-Nausea/Dehydration
-Loss of appetitie/Weight loss
-Acute Renal Failure
-Elevated WBC
Treatment: The first step is to discontinue the causative antibiotic. The standard treatment for C. difficile is another antibiotic. These antibiotics keep C. difficile from growing, which in turn treats diarrhea and other complications. For mild to moderate infection, PO Flagyl. For severe cases, vancomycin or Dificid.
Of note: Up to 20% of patients will experience a recurrence of the condition. In some instances, a fecal transplant may be required. Review your patient’s medical record closely.
Extraction Procedures
Fecal transplantation also known as fecal bacteriotherapy, or human probiotic infusion, is a medical treatment for patients with Clostridium difficile (C. difficile) enteritis or ulcerative colitis. C. difficile infection occurs in patients who have been administered antibiotics for a long period of time. The antibiotics destroy important disease-fighting bacterial flora in the intestine. Fecal transplants are believed to restore the bacteria back to normal and the patient can recover. The fecal transplant works by repopulating friendly flora in the infected intestines. The donated feces is screened for disease and then mixed with a saline solution to the consistency of a “milkshake.” The fecal material is administered by enema, nasogastric tube or endoscopy.
Coding Clinic 4Q2017, p41
Explanation:
Some patients with a C. diff infection or ulcerative colitis will undergo a fecal transplant to restore normal bacterial flora into the infected intestine. The donor feces is screened for disease, then mixed into a milkshake consistency with normal saline. The transplant is then administered by enema, NG tube, or endoscopy.
Acute Appendicits with Peritonitis
There are two MSDRG options for the assignment of appendicitis.
The first is for “simple” (acute) appendicitis, an uncomplicated diagnosis
The second, a **complicated ** diagnosis involves appendicitis with a complicating condition, like a malignancy or peritonitis (considered a major digestive disorder).
Review the medical record for these clinical clues to support a potential diagnosis of peritonitis:
― Leakage of bowel contents documented in the OP note
― Pathology report + for E. coli in the peritoneal fluid
― Pathology report documentation of a “perforation” noted on inspection of the appendix
Appendicitis with Sepsis
- If sepsis is confirmed by the physician, assign the sepsis as the PDx from MDC 18, the infectious disease MDC.
- If sepsis is not present on admission, assign sepsis as a secondary diagnosis.
Review your patient’s medical record closely. If there is clinical evidence of sepsis at the time of admission, clarify the diagnosis with the physician.
Appendicitis with Sepsis Clinical Example
Scenario: This 69 yo female patient presented with lethargy, a temp of 102.5, RR 26, and an elevated WBC with a differential consisting of 34% bands. She is being treated with IVF resuscitation and a combination of Vancomycin and Levaquin. An emergent appendectomy has been performed for a ruptured appendix.
Sample Clarification:
* Sepsis, POA in the setting of ruptured appendix requiring aggressive treatment with IVFs and Vancomycin
* 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: lethargy, RR 26, temp 102.5, 34% bandemia
* Risk Factor: Ruptured Appendix
* Treatment: Appendectomy, IVFs, IV Vancomycin
Explanation:
In the clinical presentation of this patient admitted with a ruptured appendix, is acute appendicitis the best diagnosis for this patient? Probably not based on the available information. Note the clarification has been formatted specifically for sepsis, present on admission.
Root Operation: Appendectomy
An appendectomy is generally performed to cut out or off, without replacement, all the appendix. This is the definition of the root operation RESECTION, the root operation used for appendectomy.
Important Note: Like other surgical procedures, the intent of the intervention can change once the surgeon enters the patient’s abdomen. Review the operative note closely. If the appendix is very friable, the surgeon may elect to resect a portion of the cecum. This additional surgical work will impact the DRG assignment, as will a colostomy that might be required for concomitant diagnoses of sepsis, peritonitis, or infarcted bowel.
Appendicitis Requiring Resection of the Cecum
Question: A 55-year-old woman presents to the hospital with a five-day history of abdominal pain, fever and chills. An exploratory laparotomy was performed which revealed a perforated appendix. The entire appendix was gangrenous down to the base, which was extremely thin-walled and friable. Therefore, the surgeon performed an ileocecectomy, which included the entire cecum, the terminal ileum and the appendix.
Is it appropriate to assign separate codes for resections of the appendix and the cecum along with excision of the terminal ileum?
Coding Clinic 3Q 2014, p6
Answer:An ileocecectomy is a surgery performed to remove the cecum (first part of the large intestine) and the ileum (end part of the small intestine). A complete resection of the cecum always includes part of the terminal ileum (ileocecal valve); the appendix is removed as well. No separate or distinct surgery is carried out to remove the ileum and appendix. Do not separately code the excision of adjacent structures that are an inherent part of the procedure to resect an entire body part. Assign the following ICD-10-PCS code for the ileocecectomy.
0DTH0ZZ Resection of cecum, open approach
Explanation:This Coding Clinic provides the advice for the appropriate assignment of a resection of the cecum in an appendectomy patient. A 55-year-old female was admitted with a five-day history of abdominal pain accompanied by chills and fever. An exploratory lap revealed a gangrenous appendix. The appendix was removed along with the cecum, the starting point of the large intestine. You’ll assign only the resection of the cecum since the appendix is considered an appendage of the cecum. The resection is considered a major bowel procedure.
Colon Cancer
-Definition
-Clinical Indicators
-Treatment
-3 Acute Complications
**Defintion: **Colon cancer is a malignant tumor arising from the inner wall of the large intestine.
The most common metastatic sites are: Liver, which can lead to jaundaice and biliary obstruction, lungs, brain, abdominal cavity (ovaries for females)
Clinical Indicators: Patients in the early stage of colon cancer may have no symptoms, but the most common symptoms do involve gastrointestinal bleeding and an unexplained fever.
Risk Factors: Family history of colon cancer, colon polyps, ulcerative colitis
Treatment: Depends on size, location, metastatic sites
Complications: GIB, Bowel Obstruction, Bowel Perforation
Bowel Obstruction
-Obstruction caused by colon cancer is mainly manifested as ___________ obstruction
-The main physiological and pathological changes in patients with obstruction due to colon cancer include:
-Clinical Indicators:
-Clinical diagnosis:
-Treatment:
-The obstruction caused by colon cancer is mainly manifested as mechanical obstruction.
-Physiological and pathological changes include: Dilated colon 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 Indicators: Patients with a bowel obstruction from colon cancer will present with dull, persistent abdominal pain. Vomiting, abdominal distention, dehydration and electrolyte abnormalities are considered late manifestations.
-Clinical diagnosis: The diagnosis is usually made based on the patient’s clinical presentation. Obstruction will be further confirmed by radiographic studies.
-Treatment: For cancer patients, treatment is focused on correcting dehydration and GI decompression. Surgical intervention may be used to resect the offending tumor, but if resection is not possible, the surgeon may elect to bypass the obstruction with a colostomy.
Coding Clinic Advice - Intestinal Obstruction d/t Peritoneal Carcinomato
How is bowel obstruction due to peritoneal carcinomatosis coded?
Coding Clinic 2Q2017, p10
Answer: Assign only code C78.6, Secondary malignant neoplasm of retroperitoneum and peritoneum, as instructed by the Excludes 1 notes found under codes K56.60, Unspecified intestinal obstruction, and K56.69, Other intestinal obstruction, which state: “intestinal obstruction due to specified condition-code to condition.”
Explanation: This Coding Clinic from 2017 provides guidance for the appropriate capture and coding of an obstruction due to peritoneal carcinomatosis. In this situation, the malignancy is assigned as the principal diagnosis based on the instructional notes for obstruction due to a specified condition.
Colectomy
-Root Operation
-Types of coloectomy operations
If a portion of the bowel was removed (partial colectomy), index the procedure with the root operation EXCISION.
If the entire portion of bowel (ex: transverse colon) is removed, index the procedure with the root operation RESECTION.
- Total colectomy involves removing the entire colon.
- Partial colectomy involves removing part of the colon and may also be called subtotal colectomy.
- Hemicolectomy involves removing the right or left portion of the colon.
- Proctocolectomy involves removing both the colon and rectum.
- Excision: takes out some of a body part
- Resection: takes out all of a body part
Colostomy
-Definition
-Root Operation
Definition: A colostomy reroutes the contents of the bowel to an opening in the abdominal wall.
You will use the root operation BYPASS to assign the creation of a colostomy.
In this bypass procedure, the body part represents the “from” and the qualifier the “to.” For example, the transverse colon is being rerouted to a cutaneous opening.
Bypass: altering the route of passage of the contents of a tubular body part
Chemotherapy Administration
* Is Chemotherapy a Valid or Non-valid OR Procedure?
* What is the Root Operation for chemotherapy administration?
- Chemotherapy administration is a non-valid OR procedure
- During chemo administration, a therapeutic product is being introduced into the patient’s body. Use the root operation INTRODUCTION to index the administration of chemotherapy.
Here’s the graphic for chemo: Using the root operation INTRODUCTION, assign the body system or region where the procedure occurs—not the intended target for the chemo. Next is the approach—either percutaneous or open. Assign the substance and the qualifier.
Introduction: putting in or on a therapeutic substance except blood or blood product
Testing Your Knowledge
Clinical Scenario: A 41 yo female with an inoperable stage 4 colon tumor presents with bowel obstruction. The surgeon has opted to perform a colostomy for symptomatic relief.
Use this root operation for the procedure:
1. Excision
2. Resection
3. Bypass
Answer: 3) Bypass.
Remember the Root Operation for a colostomy is Bypass. In the Bypass procedure, the body part represents the “from” and the qualifier the “to”.
For example, the transvere colon is being rerouted to a cutaneous opening.
GIB Secondary to Gastric Ulcer - Coding Clinic 3Q2017, p27
Question: A patient presents due to acute gastrointestinal bleed (GIB). An esophagogastroduodenoscopy (EGD) was performed, which showed gastric ulcers as well as portal hypertension. The physician does not link the bleeding to the ulcer nor is it documented that these conditions are unrelated. Under the revised “With” guideline, it appears that we may assume a relationship between the gastrointestinal bleed and the ulcer.
How should we report gastric ulcer in a patient with gastrointestinal bleeding?
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.
Explanation: In this Coding Clinic from 2017, a coding professional seeks direction concerning the assumption of a relationship between a gastric ulcer identified by EGD and GI bleeding. According to Coding Clinic, it would be appropriate to assume a cause-and-effect relationship between the two conditions since they are linked by the term “with” in the alphabetic index, unless the physician documents a different cause for the bleeding.
Gastrointestinal Hemorrhage
* Definition
* GIB is often divided into — GIB or — GIB
* In most cases of GIB, what will be assigned as the PDX?
Definition:Gastrointestinal (GI) bleeding refers to any bleeding that starts in the gastrointestinal tract.
Bleeding may come from any site along the GI tract, but is often divided into:
* Upper GI bleeding: esophagus, stomach, duodenum
* Lower GI bleeding: remainder of the small intestine (ileum, jejunum), large intestine, rectum, anus
- In most cases of GI bleed, the lesion identified as the cause of bleeding will be assigned as the principal diagnosis.
Your documentation management will include ensuring the appropriate lesion or underlying cause has been identified. Do not make any assumption between a GIB and a potential underlying cause.
GI Bleed
* The diagnosis of GIB is based on?
* Often a GIB is a clinical manifestation of …?
* If a link is established between a GIB and a potential underlying cause, what becomes the principal diagnosis?
- The diagnosis of GI bleed is often a clinical diagnosis based on simple diagnostic assessment (guaiac) rather than observed frank hemorrhage.
- Often a “GIB” is a clinical manifestation of an underlying condition. Review the clinical evidence closely and seek clarification of an alternative principal diagnosis if clinically appropriate. Do not make any assumption between a GIB and a potential underlying cause.
- If a link is established, assign one of the following underlying causes as the principal diagnosis:
Esophageal ulcer
Ischemic colitis
Mallory Weiss tear
Scleroderma
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: 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.
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.
GIB d/t Esophageal Ulcer
* Where do esophageal ulcers typically occur in the esophagus? What clinical information in the documentation should the CDI be looking for?
* Clinical Indicators
* Treatment
* Complications
- 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.
GIB d/t Ischemic Colitis
* Definition
* Risk Factors
* Clinical Indicators
* Diagnostics
* Treatment
* Complications
- 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
The condition may be misdiagnosed because it can easily be confused with other digestive problems, such as nonspecific abdominal pain or colitis.
GIB d/t Mallory Weiss Tear
* Definition
* Cause
* Clinical Indicators
* Treatment
- 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
GIB d/t Scleroderma
* Definition
* Risk Factors
* Clinical Indicators
* Treatment
- 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
GIB Secondary Diagnoses: ABLA
* Is there a specific lab paramteter indicating ABLA? What clinical clue may indicate the Physician is thinking and treating but not documenting ABLA?
* Can you assume a diagnosis of acute blood loss anemia from a diagnosis of “blood loss anemia”?
- 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.
Acute Blood Loss Anemia Clinical Example - Sample Clarification
Scenario: A 55 yo male presented to the ED complaining of frank blood in his stool; he tested guaiac positive. His H&H on admission was 10 and 24 – he was transfused with two units of PRBCs and taken emergently to the endoscopy suite where a bleeding diverticulum was found. He had been diagnosed with lower GI bleed d/t ruptured diverticulum and anemia. His inpatient orders include H&H q4 hours with an order to infuse another unit of PRBCs.
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
Internal Guidelines for ABLA - Coding Clinic 1Q2014, p15
Question:We are considering developing internal coding guidelines and obtaining medical staff approval to code acute blood loss anemia. The guidelines would specify lab values pre- and post-surgery, as well as some clinical signs to allow coders to code acute blood loss anemia without the need to have physician documentation.
Would this be acceptable?
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.
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.
