CDI Adult MDC 7 - Hepatobiliary

Question 1

The Liver
* Functions

Answer 1

• It is responsible for secreting bile, a substance needed to help break down carbohydrates and proteins. The liver also functions as a large filter working to break down toxic substances like drugs and alcohol.

Question 2

Cirrhosis of the Liver

Answer 2

• Cirrhosis of the liver results from damage to the liver cells from alcohol, infection, exposure to toxins, or obstruction.
• Cirrhosis is characterized by nodules and fibrosis that prevent the liver from working properly.

Question 3

Cirrhosis Concomitant Conditions: Peritonitis

• Definition
• Risk Factors
• Clinical Indicators
• Treatment
• If Cirrhosis and Peritonitis are present on admission and meet the definition of principal diagnosis, what is sequenced as the PDX? Why?

Answer 3

• Peritonitis is an inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs.
• Risk Factors: liver disease, esophageal varices, Mallory-Weiss tear, perforated ulcers, cholecystitis, ruptured appendix, peritoneal dialysis.
• Clinical Indicators: rigid/painful abdomen, referred shoulder pain, N/V, chills, fever (usually >100.5), general weakness, tachycardia, hypotension, elevated WBC with left shift.
• Treatment: fluid resuscitation, IV antibiotics, serial labs, supportive care

Of note: If both conditions (cirrhosis and peritonitis) are present on admission and meet the definition of principal diagnosis, assign the peritonitis as the PDx to capture an accurate reflection of severity.

Cirrhosis is a common cause of peritonitis.

Left untreated, peritonitis can cause sepsis and multiple organ failure.

Question 4

Documentation Validation

Clinical Scenario: A 45 yo male has been admitted with an “acute exacerbation of his chronic alcoholic cirrhosis.” On admission from the physician’s office, the patient is noted to have a temp of 101.2 and a pulse rate of 98. The admitting nurse documents the patient’s entire abdomen is rigid and tender to light palpation. A stat WBC returns at 15.2 with 83% segs; a CT of the abdomen is positive for widespread inflammation. The patient is made NPO, CIWA protocol initiated and IV Vancomycin started.

Review this clinical scenario to determine whether there is sufficient evidence of an additional diagnosis that should be clarified with the physician.

Answer 4

• Acute peritonitis due to acute/chronic alcoholic cirrhosis requiring treatment with IV 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: abdominal pain/rigidity, T101.2, P98, WBC 15.2 with 83% segs, CT + for widespread inflammation
Risk Factors: acute/chronic alcoholic cirrhosis
Treatment: IV vancomycin

Clarification Example

Question 5

Esophageal Varices
* Definition
* Esophageal Varices are associated with Chronic Liver Disease such as?
* Clinical Indicators include?
* Treatment includes?
* If the Esophageal Varices are due to Cirrhosis, Coding Guidelines require the sequencing of which as the principal diagnosis?

Answer 5

• Esophageal varices are abnormally dilated veins in the lower third of the esophagus.
• Esophageal varices are associated with chronic liver disease, such as cirrhosis and portal hypertension.
• The clinical indicators include:
  hematemesis
  presyncope/syncope
  melena
  hypovolemic shock
• Treatment:
  endoscopic ligation
  endoscopic sclerotherapy
  octreotide (Sandostatin)
  TIPS procedure

If the esophageal varices are due to cirrhosis, coding guidelines require the sequencing of the cirrhosis as the principal diagnosis.

Question 6

Cirrhosis Concomitant Conditions: Hyponatremia
* Definition - When do clinical manifestations occur?
* Clinical Indicators include?
* Treatment Includes?

Answer 6

• directly related to an impaired ability to excrete ingested water; typically develops slowly (paralleling the rate of progression of the liver disease) and usually produces no obvious clinical manifestations until the serum sodium concentration falls below 120 mEq/L.
• Clinical Indicators: N/V, HA, confusion, lethargy, irritability, muscle weakness, muscle spasm/cramps, seizures, coma.
• Treatment: Patients with symptoms that may be attributable to hyponatremia are often initially treated with hypertonic saline. However, fluid restriction is the primary option to achieve a sustained increase in the serum sodium. If present, hypokalemia should be corrected since this will also tend to raise the serum sodium.

Hyponatremia is a common problem in patients with advanced cirrhosis. Hyponatremia in this patient population is directly related to an impaired ability to excrete ingested water. The severity of the hyponatremia is related to the severity of the cirrhosis. Unfortunately, the presence of hyponatremia is associated with severe ascites, impaired renal function, hepatic encephalopathy, spontaneous bacterial peritonitis, and hepatorenal syndrome.

Hyponatremia in patients with cirrhosis typically develops slowly (paralleling the rate of progression of the liver disease) and usually produces no obvious clinical manifestations until the serum sodium concentration falls below 120 mEq/L. Serum sodium concentrations do not usually fall spontaneously below 120 mEq/L in patients with cirrhosis until they are close to death or there has been an overly aggressive diuresis.

Question 7

Cirrhosis Concomitant Conditions: Hepatic Encephalopathy
* What does Hepatic Encephalopathy result from?
* Is there a laboratory correlation associated with this diagnosis?
* Clinical Indicators include?
* Treatment includes?
* What clinical manifestation is more prominent in Acute Hepatic Encephalopathy?
* How is Chronic Hepatic Encephalopathy controlled? (Clinical Clue)

Answer 7

• It results from the inadequate removal of nitrogenous compounds or other toxins that are ingested or formed in the gastrointestinal tract.
• Hepatic encephalopathy is a “clinical” diagnosis; there is no correlation with LFTs, although ammonia levels are usually elevated.
• Clinical Indicators: Sleep disturbance is often the earliest sign of hepatic encephalopathy. Other clinical indicators include asterixis (flapping hand tremor), hyperreflexia, and a musty odor of the breath. The patient will also exhibit alteration in personality and cognitive function.
• Treatment: Treatment for hepatic encephalopathy involves identifying and treating the underlying liver disease/condition, low protein diet, and lactulose.

The acute form occurs in the setting of fulminant hepatic failure. Cerebral edema is more prominent in acute hepatic encephalopathy than in the chronic form.

Chronic hepatic encephalopathy is associated with chronic liver disease and is controlled by daily maintenance doses of lactulose (a clinical clue for chronic hepatic encephalopathy).

Hepatic encephalopathy is a complex neuropsychiatric syndrome that complicates liver disease. The condition can present as an acute or chronic condition.

Question 8

Rationale re Chronic Hepatic Encephalopathy:

Answer 8

If a medication is currently provided to control an existing condition, and the condition has been documented by the provider, it is coded.

There is no need for the condition to be documented as “acute” or “exacerbated” or for there to be a change in the dose or administration of medication from an outpatient to an inpatient status.

If the medication is currently provided but the condition is not documented, it is appropriate to clarify the existence of the condition being actively treated by the provider.

Question 9

Stages of Hepatic Encephalopathy
Grade 1

Answer 9

Mental status
* Euphoria/Depression
* Mild Confusion
* Slurred Speech
* Disordered Sleep

Asterixis
* Yes/No

EEG
* Usually normal

4 stages - NOT required for capture of the diagnosis

The patient’s symptoms of hepatic encephalopathy can range from mild confusion in grade I to coma in grade IV. The physician is not required to stage or grade the patient’s encephalopathy, but this additional description does lend further clinical definition to the patient’s severity of illness and risk of mortality.

Question 10

Stages of Hepatic Encephalopathy
Grade 2

Answer 10

Mental status
* Lethargy
* Moderate Confusion

Asterixis
* Yes

EEG
* Abnormal

4 stages - NOT required for capture of the diagnosis

The patient’s symptoms of hepatic encephalopathy can range from mild confusion in grade I to coma in grade IV. The physician is not required to stage or grade the patient’s encephalopathy, but this additional description does lend further clinical definition to the patient’s severity of illness and risk of mortality.

Question 11

Stages of Hepatic Encephalopathy
Grade 3

Answer 11

Mental status
* Marked Confusion
* Incoherent
* Sleeping but arousable

Asterixis
* Yes

EEG
* Abnormal

4 stages - NOT required for capture of the diagnosis

The patient’s symptoms of hepatic encephalopathy can range from mild confusion in grade I to coma in grade IV. The physician is not required to stage or grade the patient’s encephalopathy, but this additional description does lend further clinical definition to the patient’s severity of illness and risk of mortality.

Question 12

Stages of Hepatic Encephalopathy
Grade 4

Answer 12

Mental status
* Coma

Asterixis
* No

EEG
* Abnormal

4 stages - NOT required for capture of the diagnosis

The patient’s symptoms of hepatic encephalopathy can range from mild confusion in grade I to coma in grade IV. The physician is not required to stage or grade the patient’s encephalopathy, but this additional description does lend further clinical definition to the patient’s severity of illness and risk of mortality.

Question 13

Cirrhosis Concomitant Conditions: Hepatorenal Syndrome (HRS)
* Definition
* Clinical Indicators
* Treatment

Answer 13

• Hepatorenal syndrome (HRS) is the development of renal failure (oliguria in the absence of proteinuria) in patients with advanced chronic liver disease
• Clinical indicators – fatigue, malaise, odd taste, decreased urinary output, creatinine >1.5.
• Treatment requires controlled resuscitation of the kidneys until liver transplant.

• If necessary, seek clarification of acute, chronic, or acute on chronic renal failure as supported by the clinical evidence.

Question 14

Hepatopulmonary Syndrome (HPS)
* HPS is characterized by?
* Clinical indicators
* Treatment
* If a patient presents/develops respiratory manifestations suggestive of respiratory failure in the setting of liver disease what should the CDS do?

Answer 14

• Characterized by: the triad of abnormal arterial oxygenation, in the setting of liver disease, with portal hypertension.
• Clinical indicators – progressive dyspnea, cyanosis, digital clubbing, spider veins.
• Treatment: aside from supplemental O2, no medical therapies are definitively established.

Important Note: If the patient presents/develops respiratory manifestations suggestive of respiratory failure in the setting of liver disease, seek clarification of hepatopulmonary syndrome and respiratory failure (if clinically supported) to more accurately capture SOI/ROM. Assignment of PDx depends on the circumstances of the admission.

Clinical Indicators: Characteristic features of HPS include progressive dyspnea especially with activity. Cyanosis and digital clubbing are typical findings in advanced HPS. Cutaneous spider veins are also commonly seen in patients with HPS.

Diagnostics: Contrast transthoracic echo that is + for right to left shunting; CXR and chest CT to rule out other potential causes.

Treatment: Aside from supplemental oxygen no medical therapies are definitively established. Lowering of portal pressure with transjugular intrahepatic portosystemic shunt (TIPS) has had variable effect on HPS. Rarely, coil embolization may improve oxygenation in selected HPS patients. Liver transplantation should be considered before the development of severe disease.

Question 15

Sample Clarification

Scenario:A 52 yo female with a known history of cirrhosis and portal hypertension presented to the ED with chronic dyspnea now worsening with any activity. She has been on continuous O2 for the last three months. On examination, the patient had pan digital clubbing and central cyanosis. Her vitals were normal except SpO2 which was 86% in lying posture and 80% in standing posture after 3 min (orthodeoxia positive) with a respiratory rate up to 25. The patient was admitted with a diagnosis of “end-stage cirrhosis and respiratory insufficiency.”

The treatment plan included oxygen supplementation and diuretics. The following day she had an endoscopy, which revealed small grade I varices and gastropathy with normal duodenum. She also had an echo, showing EF of 60% with normal left ventricular systolic function, with contrast echo suggestive of right to left intrapulmonary shunting. She was started on a beta blocker and nitrate to reduce portal hypertension. The plan is consultation for liver transplantation.

Answer 15

Sample Clarification:
* Chronic respiratory failure due to hepatopulmonary syndrome requiring oxygen supplementation and consultation for liver transplantation
* 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: Chronic dyspnea, pan digital clubbing and central cyanosis. SpO2 86% in lying posture/80% in standing posture respiratory rate 25. Contrast echo suggestive of right to left intrapulmonary shunting.
Risk Factors: End-stage cirrhosis and portal hypertension.
Treatment: Continuous oxygen supplementation and consultation for liver transplantation, beta blocker and nitrate to reduce portal hypertension.

Explanation:Since there was no documentation of hepatopulmonary syndrome, we’ve asked for clarification of chronic respiratory failure due to HPS. The clarification of chronic respiratory failure is based on the description of chronic dyspnea, continuous oxygen support, clubbing of the fingers and central cyanosis.

Question 16

Clinical Scenario: A 69 yo male arrived via EMS to the ED in respiratory distress. The patient has a history of cirrhosis secondary to ETOH abuse, recurrent pleural effusions and grade 2 esophageal varices. The CXR revealed a complete opacification of right hemithorax due to pleural effusion. The patient was admitted to the ICU with a diagnosis of “recurrent pleural effusion, and cirrhosis.” The treatment regimen includes high flow O2, Lasix 40mg IV BID, IR guided thoracentesis, and CT placement. Thoracentesis removed 3000 ml of pleural fluid described as transudative without active signs of infection. Of note: Pleural Fluid LDH 37, Serum LDH 68.

Question: The CDS should seek clarification for:
1. Acute Respiratory Failure
2. Pleural Effusion d/t Cirrhosis of the Liver
3. Varices d/t Alcoholic Cirrhosis of the Liver

Answer 16

Answer: 2. Pleural Effusion d/t Cirrhosis of the Liver

Explanation:The correct answer is pleural effusion d/t cirrhosis. If you didn’t remember this documentation strategy for pleural effusion from MDC 4, review the content in the next section.

Question 17

Liver Transplant
* Root Operation
* In the assignment of a transplant, you will have to select a qualifier that provides information about the genetic compatibility of the transplant; your options are?

Answer 17

• To index a liver transplant, use the root operation TRANSPLANTATION.

In the assignment of a transplant, you will have to select a qualifier that provides information about the genetic compatibility of the transplant; your options are:

Allogeneic - tissue taken from a different individual
Syngeneic - tissue that has identical genes, such as an identical twin
Zooplastic - tissue taken from an animal

Transplantation: putting in a living body part from a person or animal

Question 18

Transplantation

Answer 18

putting in a living body part from a person or animal

Root Index

Question 19

Syngeneic

Answer 19

tissue from an identical twin

Question 20

Allogeneic

Answer 20

tissue from a different person

Question 21

Zooplastic

Answer 21

tissue from an animal

Question 22

Pleural Effusion
* Other than Cardiopulmonary disease, what is one of the most prominent causes for Pleural Effusions?
* What causes Pleural Effusions associated with Liver Cirrhosis and Ascites?
* Clinical Indicators
* Treatment
* Pleural Effusion due to Cirrhosis/Liver Disease may also be referred to as?
* How is this indexed?

Answer 22

• One of the most prominent causes for pleural effusion other than cardiopulmonary disease is liver cirrhosis.
• The mechanism leading to pleural effusion associated with liver cirrhosis and ascites is the migration of ascitic fluid from the peritoneal cavity into the pleural space.
• Clinical indicators – ascites, dyspnea, cough, transudative pleural fluid.
• Treatment often requires thoracentesis, diuretics, Na restriction, TIPS.
• NOTE: Pleural effusion due to cirrhosis/liver disease may also be referred to as hydrothorax or hydropneumothorax.

Index as: effusion>pleural>in conditions classified elsewhere. If the physician links the effusion to cirrhosis, assign the cirrhosis as the principal diagnosis.

The absence of ascites does not exclude this diagnosis

Risk factors: Liver function deterioration, liver cirrhosis, portal hypertension, ascites

Clinical indicators: Ascites may or may not be present; the absence of ascites does not exclude this diagnosis. Dyspnea to overt respiratory failure may be present, cough, transudative pleural fluid. Typically, the pleural effusion is isolated on the right side. Pleural fluid analysis mirrors the ascitic fluid.

Question 23

Hepatic Duct

Answer 23

Carries bile out of the Liver

Question 24

Cystic Duct

Answer 24

Carries bile into and out of the Gall bladder

Question 25

Bile Duct

Answer 25

Continues to carry bile from Hepatic and Cystic Ducts

Question 26

Portal Vein

Answer 26

Delivers blood from the Intestines to the Liver

Question 27

Hepatic Veins

Answer 27

Carries blood from the Liver to thte Inferior Vena Cava

Question 28

Hepatic Arteries

Answer 28

Carries blood to the Liver from the Aorta

Question 29

Official Guidelines - Chapter 2

Neoplasm Coding General Guidelines
* Treatment directed at the malignancy
* Treatment of secondary site

Answer 29

• If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis.
• The only exception to this guideline is if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy, assign the appropriate Z51.– code as the first-listed or principal diagnosis, and the diagnosis or problem for which the service is being performed as a secondary diagnosis.
• When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.

Question 30

Pancreatic Cancer
* How do clinical indicators in the head of the pancreas differ from clinical indicators in the body/tail of the pancreas?
* Treatment
* Complications

Answer 30

• Clinical indicators (head of pancreas) – weight loss, jaundice, dark urine, pale stools, pruritis, N/V, abdominal/back pain, enlarged cervical lymph nodes.
• Clinical indicators (body/tail of pancreas) – weight loss, abdominal/back pain.
• Treatment requires surgery, chemo, radiation, and/or palliative care.
• Complications: Jaundice, DM (d/t underlying condition; malignant neoplasm), non-infectious SIRS, bowel obstruction, malnutrition, bile duct obstruction, cachexia, DVT, PE.

In general, symptoms appear earlier from cancers in the head of the pancreas compared to those in the body and tail.

Question 31

Liver Cancer
* Risk Factors
* Clinical Indicators
* Treatment
* Complications

Answer 31

• Risk factors: gender (male), chronic viral hepatitis, ETOH use, obesity, type 2 DM, smoking.
• Clinical indicators – weight loss/anorexia, N/V, ascites, enlarged liver, abdominal pain referred to the right shoulder, pruritis, jaundice.
• Treatment requires surgical intervention, chemo, radiation, and palliative care.
• Complications: Non-infectious SIRS, bile duct obstruction, portal HTN, hypercalcemia, HRS, hepatic encephalopathy.

*These complicating conditions matter to your patient’s severity of illness and risk of mortality – make sure you get them documented if clinically appropriate.

Question 32

Biliary Obstruction d/t Hepatocellular Carcinoma -1Q 2016, p18

Question: A 69-year-old patient with nonresectable hepatocellular carcinoma (HCC), status post radioembolization, presented with two weeks of progressive hyperbilirubinemia. He underwent endoscopic retrograde cholangiopancreatography, which revealed biliary obstruction from HCC progression. The provider performed biliary sphincterotomy and insertion of biliary stent into the common bile duct. There is confusion as to whether it is appropriate to sequence the carcinoma as the principal diagnosis, since it is the underlying cause of the obstruction, or whether the obstruction is sequenced as the principal diagnosis, since it was the reason for the admission, and no treatment was directed to the carcinoma.

What is the correct sequencing of the biliary obstruction and the hepatocellular carcinoma for this encounter?

Coding Clinic Advice

Answer 32

Answer:Assign code K83.1, Obstruction of bile duct, as the principal diagnosis. The obstruction was the focus of treatment. Since therapy was only directed at the obstruction, and not the malignancy, the obstruction is sequenced as principal diagnosis. Assign code C22.0, Liver cell carcinoma, as an additional diagnosis. The ICD-10-CM Official Guidelines for Coding and Reporting (2.1.4.) state, When an encounter is for management of a complication associated with a neoplasm, such as dehydration, and the treatment is only for the complication, the complication is coded first, followed by the appropriate code(s) for the neoplasm. The exception to this guideline is anemia.

Explanation:
This Coding Clinic provides guidance for a complication of a neoplasm. Here’s the scenario in question: A 69-year-old patient presents for treatment of an elevated bilirubin level. He has a history of nonresectable liver cancer and is post radioembolization. He undergoes an ERCP which reveals an obstruction from the advancing cancer. During the ERCP, a biliary stent is placed to help relieve the obstruction. The question is what to assign as the principal diagnosis: the obstruction - a complication of the cancer, or the liver cancer.

According to Coding Clinic, assign the obstruction as the principal diagnosis, not the liver cancer, as the focus of the treatment is the obstruction. Capture the liver cancer as a secondary diagnosis.

Question 33

Portal Hypertension
* Definition
* Clinical Indicators
* Treatment
* Complications

Answer 33

• Definition: an increase in the pressure within the portal vein. The increase in pressure is caused by a blockage in the blood flow through the liver. To compensate for the blockage in the liver, varices develop within the esophagus and stomach.
• Clinical indicators – GIB, ascites, encephalopathy, reduced platelets, decreased WBCs.
• Treatment: diet, medication.
• Complications: Bleeding esophageal/gastric ulcers

Question 34

Ablation
* Definition
* These techniques are often used in what patients?
* Ablation may be accomplished with?
* What is the intent of Ablation?
* What is the Root Operation used to index the procedure?

Answer 34

Ablation refers to treatments that destroy liver tumors without removing them. These techniques are often used in patients with no more than a few small tumors but for whom surgery is not a good option. The needle or probe is guided into the tumor with ultrasound or CT scanning.

Ablation may be accomplished with: Radio Frequency, Alcohol, Microwave, Cryosurgery

Regardless of the method used, the intent of the procedure is to destroy the cancer cells.

Root Operation = Destruction

Use the root operation DESTRUCTION to index the procedure.
Destruction: eradicating w/out replacement

Remember to review the procedural note for the laterality of the liver lobe.

Question 35

Radio frequency

Answer 35

A high-frequency current is then passed through the tip of the probe, which heats the tumor and destroys the cancer cells.

Ablation may be accomplished with: Radio Frequency

Remember Ablation refers to treatments that destroy liver tumors without removing them. These techniques are often used in patients with no more than a few small tumors but for whom surgery is not a good option. Ablation involves the needle or probe guided into the tumor with ultrasound or CT scanning. Regardless of the method used, the intent of the procedure is to destroy the cancer cells.

Question 36

Alcohol

Answer 36

This is also known as percutaneous ethanol injection (PEI). In this procedure, concentrated alcohol is injected directly into the tumor to kill cancer cells.

Ablation may be accomplished with: Alcohol

Remember Ablation refers to treatments that destroy liver tumors without removing them. These techniques are often used in patients with no more than a few small tumors but for whom surgery is not a good option. Ablation involves the needle or probe guided into the tumor with ultrasound or CT scanning. Regardless of the method used, the intent of the procedure is to destroy the cancer cells.

Question 37

Microwave

Answer 37

Microwaves are transmitted through the probe and are used to heat and destroy the abnormal tissue.

Ablation may be accomplished with: Microwave

Remember Ablation refers to treatments that destroy liver tumors without removing them. These techniques are often used in patients with no more than a few small tumors but for whom surgery is not a good option. Ablation involves the needle or probe guided into the tumor with ultrasound or CT scanning. Regardless of the method used, the intent of the procedure is to destroy the cancer cells.

Question 38

Cryosurgery

Answer 38

The probe is guided into the tumor and then very cold gases are passed through the probe to freeze the tumor, killing the cancer cells.

Ablation may be accomplished with: Cryosurgery

Remember Ablation refers to treatments that destroy liver tumors without removing them. These techniques are often used in patients with no more than a few small tumors but for whom surgery is not a good option. Ablation involves the needle or probe guided into the tumor with ultrasound or CT scanning. Regardless of the method used, the intent of the procedure is to destroy the cancer cells.

Question 39

“Wedge” Documentation Management

Answer 39

• A wedge biopsy for a liver lesion is considered a diagnostic procedure.
• A wedge resection of the liver is considered a therapeutic procedure.

Both are considered VALID OR procedures but represent different aspects of SOI/ROM.

*The wedge biopsy and the wedge resection assign to two different surgical DRG assignments! A wedge biopsy will assign to a hepatobiliary diagnostic DRG while the wedge resection will assign as a heavily weighted liver procedure. If you are unsure about the intent of the procedure, ask a question!

Question 40

Wedge Resection
* For what purpose is a wedge resection performed: diagnostic or therapeutic?
* What Root Operation is used to index the procedure?

Answer 40

• A wedge resection is performed for therapeutic purposes
• During a wedge resection, suspicious tissue is EXCISED as a therapeutic measure; use the root operation excision to index the procedure

Considered a Valid OR procedure

Excision: cutting out or off, without replacement, a portion of a body part

Question 41

Wedge Biopsy
* For what purpose is a wedge biopsy performed: diagnostic or therapeutic?
* What Root Operation is used to index the procedure?
* What qualifier is used to capture the intent of the wedge biopsy?

Answer 41

• A wedge biopsy is performed for diagnostic purposes – an important point to remember.
• During a wedge biopsy, a small piece of tissue is excised for pathological study.

Important Note: Remember to use the qualifier DIAGNOSTIC to capture the intent of the wedge biopsy!

Considered a Valid OR procedure

Excision: cutting out or off, without replacement, a portion of a body part

Question 42

Pancreatitis
* Definition
* Clinical Indicators
* Risk Factor
* Treatment
* Complications

Answer 42

• Pancreatitis: an inflammatory condition of the pancreas.
• Clinical indicators – upper abdominal pain that radiates into the back, swollen/tender abdomen, N/V, fever, tachycardia.
• Risk factor: gallstones.
• Treatment requires fluid resuscitation, NPO x48 hrs, nutritional support, pain control, surgical intervention (ERCP, sphincterotomy, etc.)
• Complications: Ascites, pancreatic pseudocyst, pancreatic necrosis.

Acute pancreatitis is an inflammatory condition of the pancreas. The most common cause of acute pancreatitis is gallstones. It is believed stones that get stuck in the common bile duct impinge on the main pancreatic duct, causing an obstruction of the normal flow of pancreatic fluid and leading to pancreatic injury.

Question 43

Pancreatitis Documentation Management: SLE
* Acute Pancreatitis is more likely to appear as what type of manifestation of SLE?
* If the Physician links the pancreatitis to SLE, what is assigned as the PDX?
* Treatment includes?

Answer 43

• Acute pancreatitis is more likely to appear as an initial manifestation of SLE or within the first two years of the disease.
• If the physician links the pancreatitis to the systemic lupus, assign the lupus as the principal diagnosis.
• Treatment: IV steroids, oral taper of prednisone, IV fluids, NPO, immunosuppressants in serious cases of SLE.

If not clear in the documentation, seek clarification of a link between the patient’s SLE and pancreatitis, especially if the patient has been newly diagnosed with SLE.

Question 44

Documentation Validation

Clarification Example

Clinical Scenario: A 31 yo female recently diagnosed with SLE presents to the ED with complaints of abdominal pain radiating to her back with N/V and anorexia x5 days. Physical exam notes a distended abdomen with rebound tenderness. She denies any ETOH abuse. The CT of the abdomen performed in the ED reveals mild ascites with inflammation of the pancreas. Laboratory results demonstrate ETOH negative, amylase of 653 and lipase 1020. She has been admitted with “acute pancreatitis.” Her treatment regimen includes IV steroids, IV fluids, NPO, and GI consultation.

Pancreatitis Documentation Management: SLE

Answer 44

Clarification Example
* Acute pancreatitis likely d/t SLE 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 distention, rebound tenderness, ascites, pancreatic inflammation per CT, amylase 653, lipase 1020
Risk Factor: SLE
Treatment: IV steroids, NPO, GI consult

Question 45

SIRS Clinical Indicators

Answer 45

Temperature < 36 or Temperature > 38
Pulse > 90
Respirations > 20 or PaCo2 < 32

WBC < 4,000, WBC > 12,000, or > 10% bands

Question 46

Documentation Clarification

Clarification Example

Scenario: A 32 yo male presents with acute abdominal pain that he localizes to his upper midline. Temp is noted at 100.2 and he is nauseated. His abdomen is tender to light palpation and his amylase is significantly above normal at 312. He has a long history of alcohol abuse and “frequent admissions for pancreatitis.” He is admitted with “acute pancreatitis.” On day two of the admission, his temp increases to 101.2 with a pulse rate of 98 and respirations at 24. His anion gap is elevated at 24 but his blood cultures drawn at admission are negative. His IVFs have been increased to 125 cc/hr and he has been given a one-time dose of IV Decadron.

SIRS Clinical Example

Answer 46

Sample Clarification:
* SIRS d/t acute pancreatitis requiring treatment with IV Decadron
* 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: temp of 101.2, pulse rate 98, anion gap at 24
Risk Factor: acute pancreatitis
Treatment: increased IVFs, IV Decadron

2 of 4 clinical indicators (Temperature, Pulse, Respirations, WBC) suggest a diagnosis of SIRS.

Question 47

Pancreatic Pseudocyst
* Definition
* Clinical Indicators

Answer 47

• A fluid-filled sac that forms in the abdomen and is comprised of pancreatic enzymes, blood, and necrotic tissue.
• Clinical indicators – abdominal pain/tenderness, diarrhea, ascites, N/V/D, weight loss, jaundice.
• Treatment: Non-Surgical or Surgical
  Non-surgical: monitoring, endoscopic/external drainage
  Surgical: The goal of the surgery is to create a connection between the cyst and a nearby organ such as the stomach or small intestine. The pseudocyst is then drained through that organ.

Surgical procedures include: Cystogastrostomy, Cystojejunostomy, Cystoduodenostomy

The type of surgical procedure depends on the location of the cyst.

Another potential complication of acute and chronic pancreatitis is the pseudocyst.

Question 48

Cystogastrostomy

Answer 48

In this procedure, a connection is created between the back wall of the stomach and the cyst such that the cyst drains into the stomach.

Question 49

Cystojejunostomy

Answer 49

In this procedure a connection is created between the cyst and the small intestine so that the cyst fluid is drained directly into the small intestine.

Question 50

Cystoduodenostomy

Answer 50

In this procedure a connection is created between the duodenum and the cyst to allow drainage of the cyst content into duodenum.

Question 51

Acute liver failure
* Definition
* Clinical Indicators
* Risk Factors
* Treatment

Answer 51

• Acute liver failure is a complex clinical syndrome that results from a sudden and severe loss in hepatocyte function in a patient without pre-existing liver disease.
• Rapid deterioration of liver function results in coagulopathy, usually with an INR greater than 1.5, and alteration in mental status in a previously healthy individual.
• Clinical indicators – AMS, encephalopathy, cerebral edema, jaundice, ascites, RUQ tenderness, hematemesis, melena, hypotension, tachycardia.
• Risk factors include viral infections and exposure to toxins
• Treatment depends on the underlying cause and any complications. Drug therapy usually includes diuretics, barbiturates, and benzodiazepines.

Treatment: The most important aspect of treatment for acute liver failure is to provide good intensive care support. Specific therapy is dependent on the cause of the patient’s liver failure and the presence of any complications.

Question 52

Cerebral Edema
* Clinical Indicators
* Treatment

Answer 52

• Clinical indicators – HA, dizziness, nausea, lethargy, loss of coordination, loss of ability to see/speak, seizures, memory loss, incontinence, AMS.
• Treatment requires ICU admission with mannitol, hyperventilation, hypertonic NaCL, induced hypothermia, barbiturates.

Acute liver failure (ALF) is a complex clinical syndrome that results from a sudden and severe loss in hepatocyte function in a patient without pre-existing liver disease. In many cases, progressive multi-organ failure ensues in combination with cerebral edema.

Question 53

Sample Clarification

Sample Clarification:

Scenario: A 33 yo female has been admitted with “acute liver failure.” She has a history of chronic hepatitis B which she contracted from a blood transfusion while on a mission trip to Malawi. On admission she was also noted to be incontinent of urine and lethargic with altered mental status. A stat CT of the head is positive for “edema” and IV mannitol has been added to the treatment regimen. Respiratory therapy is setting up for controlled hyperventilation per physician’s orders.

Cerebral Edema Clinical Example

Answer 53

Sample Clarification:
* Cerebral edema in the setting of acute liver failure requiring treatment with IV mannitol and hyperventilation
* 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: urinary incontinence, lethargy, altered mental status, CT + for “edema”
Risk Factor: acute liver failure
Treatment: IV mannitol, controlled hyperventilation

Explanation: Although the CT of the head is positive for edema, we must ask the physician to clarify or clinically validate this diagnostic finding. Remember we are not allowed to capture diagnoses from lab values or diagnostic results without the physician’s validation of the associated diagnosis.

Question 54

Acute Cholecystitis
* Definition
* Clinical Indicators
* Risk Factors
* Treatment
* Complications

Answer 54

• An inflammation of the gallbladder.
• Clinical indicators – RUQ pain that radiates into the chest and back, nausea, intolerance to fatty foods, dyspepsia/bloating, clay-colored stools.
• Risk factors include gallstones, Caucasian females over the age of 40, obesity.
• Treatment requires IVFs, NPO status, empiric antibiotics, pain control, surgical intervention.
• Complications: Hydrops of the GB, gallstone pancreatitis, subphrenic abscess, peritonitis, sepsis.

Question 55

Hydrops of the Gallbladder
* Definition
* Commonly caused by?

Answer 55

• An overdistention of the gallbladder which is filled with mucoid or clear/watery content
• Commonly caused by an impacted stone that results in outlet obstruction of the gallbladder.

Hydrops of the gallbladder qualifies as a CC for MSDRG assignment

Important Note: Review the preop diagnostic studies closely (CT or US) for evidence of “wall thickening” of the gallbladder or “edematous gallbladder,” or “dilated gallbladder,” or “fluid in the wall of gallbladder.” In the op note, there may be additional clinical evidence, i.e., “needle aspiration of the gallbladder.”

Question 56

Documentation Validation: Hydrops of the Gallbladder

Documentation Validation

Clinical Scenario: A 76 yo female presents to the ED with complaints of abdominal pain x5 days. A stat CT of the abdomen reveals a mildly distended gallbladder with stones and pericholecystic inflammation. She is admitted with “acute cholecystitis” and medically cleared for surgery.

An open resection of the gallbladder is performed without complication. A review of the op note reflects the following: “acutely infected gallbladder with a thick rind, edema and significant inflammation. There was an impacted stone at the gallbladder neck. The gallbladder required drainage of approximately 50 mL of while bile prior to resection…”

Answer 56

Clarification Example
* Hydrops of the gallbladder d/t impacted stone requiring drainage of the gallbladder
* 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: edematous, inflamed gallbladder filled with 50 mL of clear bile
Risk Factor: impacted stone at the gallbladder neck
Treatment: drainage of the gallbladder prior to resection

Question 57

Cholecystitis Documentation Management: Sepsis
* If Sepsis and Cholecystitis are confirmed by the Physician on admission, what is assigned as the Principal Diagnosis?
* If Sepsis is not present on admission, how is it assigned?

Answer 57

• If sepsis is confirmed by the physician, assign the sepsis as the principal diagnosis and the cholecystectomy from MDC 18, the infectious disease MDC.
• If the sepsis is not present on admission, assign the sepsis as a secondary diagnosis.

Question 58

Cholecystitis Clinical Example

Sample Clarification

Scenario: A 32 yo female was admitted last evening with increasing RUQ pain, lethargy, temp of 102.4, resp 24, and 24% bands per differential. A stat GB US revealed multiple stones and sludge. Her admitting diagnosis according to the H&P is “acute cholecystitis.” She required fluid resuscitation in the ED and was given IV vancomycin prior to admission to the ICU. ID and surgical consults are pending to determine whether the patient is appropriate for cholecystectomy while still febrile.

Sample Clarification

Answer 58

Sample Clarification:
* Sepsis, POA in the setting of acute cholecystitis requiring fluid resuscitation and IV vancomycin
* SIRS d/t a non-infectious process, POA in the setting of acute cholecystitis requiring fluid resuscitation and IV 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: temp 102.4, R24, P98, 24% bands, lethargy
Risk Factor: acute cholecystitis
Treatment: IV vancomycin, fluid resuscitation, ICU admission

Explanation: Since cholecystitis is not generally associated with an infectious process, we’ve offered the physician two diagnostic options, sepsis and non-infectious SIRS. If the physician documents sepsis, present on admission, assign sepsis as the principal diagnosis. If the physician documents SIRS, you’ll assign acute cholecystitis as the principal diagnosis.

Question 59

Scenario:
A 42 yo female is admitted with sepsis d/t cholecystitis. 28 hours after admission, she develops acute renal failure that does not respond to fluid resuscitation. She requires emergent dialysis.

Yes or No?
Since there is no documented history of kidney disease, the CDS is allowed to assume the organ failure is d/t the sepsis.

Answer 59

The correct answer is NO – we are not allowed to assume a diagnosis of severe sepsis in the patient with organ failure. The physician must document the cause-and-effect relationship

Question 60

Cholecystectomy
* A cholecystectomy is often included in the treatment regimen for which patients?
* What occurs during a cholecystectomy procedure?
* What Root Operation is used to index the procedure?

Answer 60

• The treatment regimen for a patient with cholecystitis often involves the surgical removal of the gallbladder.
• During a cholecystectomy, the entire gallbladder will be removed.
• Use the root operation “RESECTION” to index the procedure.

A cholecystectomy may be performed using various approaches and might include additional surgical work not always listed in the operative report section of “Procedures Performed.”

It is important to review the body of the operative note closely to determine the intent and extent of the procedure.

Question 61

Laparoscopic Cholecystectomy

Answer 61

Use the root operation RESECTION for a lap chole.

During a laparoscopic cholecystectomy the surgeon removes the gallbladder through several small incisions in the abdomen. The surgeon inflates the abdomen with carbon dioxide and then inserts the laparoscope into an incision near the navel. The surgeon uses a video monitor as a guide while inserting the surgical instruments into the other incisions. In some instances, the surgeon may opt to perform an intraoperative cholangiogram to reveal the anatomy of the bile ducts prior to the removal of the gallbladder.

Resection: Cutting out or off, without replacement, all of a body part

Important Note: A basic laparoscopic cholecystectomy takes about 45 minutes from start to finish. You should be suspicious if the operative report reflects the patient was on the operating table for longer than 45 minutes. Your first consideration should be conversion of the endoscopic procedure an open procedure because of an enlarged or very fragile gallbladder.

*If the gallbladder is edematous or fragile (friable), the surgeon may elect to convert the laparoscopic procedure to an open resection.

Question 62

Open Cholecystectomy

Answer 62

Use the root operation RESECTION to index an open cholecystectomy.

When laparoscopic cholecystectomy is not possible or cannot be completed safely, open cholecystectomy is indicated. The surgeon will make the incision either under the border of the right rib cage or in the middle of the upper part of the abdomen.

Resection: cutting out or off, without replacement, all of a body part

*If many gallstones or stone fragments are found during the open procedure, the surgeon may elect to explore the common bile duct for additional stones, fragments, or evidence of obstruction.

Question 63

Common Bile Duct Exploration

Answer 63

Use the root operation EXTIRPATION to index the procedure
-During a common bile duct exploration, the surgeon will often remove a gallstone or stone fragment from the duct.

For correct DRG assignment, two procedures must be assigned: the resection of the gallbladder and the procedure performed on the common duct.

The procedure of the common duct will be assigned as the principal procedure as it reflects the additional acuity of the surgical intervention.

Extirpation: taking/cutting out solid matter

During a cholecystectomy, the surgeon may elect to explore the common bile duct to ensure that stones, stone fragments, or obstruction have been surgically addressed. Often the need for this additional surgical work has been identified during an intraoperative cholangiogram.

If a stone/fragment is not removed, the duct has simply been explored. Index the procedure with the root operation inspection, instead.

Question 64

Incision of the Cystic Duct

Answer 64

Use the root operation EXTIRPATION to index the procedure if a stone is removed

The incision of the cystic duct (e.g., with inspection or removal of stone) is considered additional surgical work if performed during the same surgical episode as a cholecystectomy or CDE.

Extirpation: taking/cutting out solid matter

Diagnostic studies, such as a cholangiogram, may reveal the need to explore the cystic duct, the duct that connects the gallbladder to the common bile duct. The surgeon may also elect to incise the cystic duct during a cholecystectomy or common duct exploration to remove a stone or stone fragment.

If a stone/fragment is not removed, index the procedure with the root operation most closely associated with the surgical work performed, e.g., inspection, dilation, drainage, etc.

Question 65

Extirpation of the Ampulla of Vater

Answer 65

Use the root operation EXTIRPATION to index the procedure.
The correct body part is the ampulla of Vater.

Clinical clues in the Op-Note: an Olive, Debakey, or Robinson dilator is used to dilate the sphincter of Oddi; a Fogarty catheter is used to retrieve the stone/fragment from the ampulla.

It is the additional surgical work, the dilation of the ampulla of Vater, that is sequenced as the principal procedure – not the cholecystectomy.

If a stone or stone fragment has entered the hepatobiliary duct work, it may traverse the length of the duct work only to become lodged in the ampulla of Vater. It is through the ampulla that bile is deposited into the duodenum. To retrieve the stone/fragment in the ampulla of Vater, the surgeon will dilate the sphincter of Oddi, then use a small catheter to retrieve the stone/fragment.

*Remember, the extirpation (removal of stone) from the ampulla of Vater performed with a cholecystectomy is considered additional surgical work.

Question 66

Documentation Question: Extirpation of Cystic Duct

Documentation Question: Extirpation of Cystic Duct
Review this operative note shared by a CDI team:
“I used a right angle to identify the cystic duct and the neck of the gallbladder and removed the stones that were remaining within the cystic duct and neck of gallbladder, and then over-sewed this area with interrupted 2-0 silk sutures.“

Question: The team reached out to Nuance’s HIM and compliance professionals for recommendation of the proper assignment for the removal of stones from the cystic duct and gallbladder neck.

The operative note snippet gives you insight into the importance of investigating the body of the procedure report.

Answer 66

Answer: Based on the documentation provided, we recommend assigning (0FC80ZZ) Extirpation of Matter from Cystic Duct Open Approach as the documented removal of stones from the cystic duct reflects a distinct procedure indexed to a distinct root operation (Extirpation) and body part character (cystic duct) within ICD-10-PCS.

Question 67

Cholecystitis Clinical Example

Sample Clarification
Scenario:
A 45 yo female was admitted early this morning with “acute cholecystitis.” She was medically cleared in the ED and underwent an open cholecystectomy at 6:30am. She is recovering in her room without obvious complication. While reviewing her procedural note you find this documentation:

“…Two stay sutures of 3-0 silk were placed in the common bile duct and the duct was opened longitudinally between these two sutures. Several stone fragments were immediately noted in the lumen and were removed. A biliary Fogarty, size #5, was passed into the distal common duct into the duodenum. The balloon was inflated and then withdrawn. One additional stone fragment was retrieved…”

The surgeon’s documentation lists “open cholecystectomy” as the procedure performed.

Answer 67

Sample Clarification:
* Stone removal from Ampulla of Vater performed during the open cholecystectomy
* No additional procedures performed during the open cholecystectomy
* Other procedure (please define)

The medical record reflects the following clinical evidence:
Clinical Indicators: acute cholecystitis
Risk Factor: 45 yo female
Treatment: biliary Fogarty passed into the distal duodenum, balloon inflated, stone fragment retrieved

Please clarify the definitive procedure in the progress notes and discharge summary.

Explanation: On the Scenario tab, the portion of the operative report that is in colored text is especially intriguing. These four short lines of documentation are the information we need to seek further clarification of additional surgical work from the surgeon.

Question 68

Cholecystectomy with Liver Repair
* If there is minimal bleeding during the gallbladder removal requiring cauterization, is the cauterization used to control the bleeding captured as additional surgical work?
* If the bleeding is more than expected and documented as such, and the liver requires extensive cauterization or application of sutures to control the bleeding, how is the additional surgical work captured?
* If the liver repair is performed in combination with a cholecystectomy, what is assigned as the principal procedure?

Answer 68

When the gallbladder is removed from the gallbladder bed (the liver) during a cholecystectomy, the liver may sustain damage. A small or minimal amount of bleeding from the liver is expected; the cauterization used to control the bleeding is not captured as additional surgical work.

However, if the bleeding is more than is expected and is documented as such, and the liver requires extensive cauterization or the application of sutures to control the bleeding, capture the additional surgical work as a repair of the liver.

If the repair is performed in combination with a cholecystectomy, assign the repair as the principal procedure.

Question 69

Liver Repair

Answer 69

Use the root operation CONTROL to index the procedure. Select peritoneal cavity as the body part, as this is the closest available equivalent.

The repair of the liver may be accomplished by several different approaches although it is likely that the procedure will be performed as an open approach. Closely review the procedure note to determine approach and laterality of the liver lobe

Currently, there is no liver or hepatobiliary body part available for selection for the root operation of Control. The most appropriate option is to report a suture or extensive cauterization of the liver bed as Control > peritoneal cavity.

Control: Stopping or attempting to stop, postprocedural bleeding or other acute bleeding

Question 70

Postcholecystectomy Syndrome Reminder

This diagnosis is applied to patients who continue to experience symptoms associated with gallbladder disease such as bloating, burping, and intolerance to fatty foods after the removal of the gallbladder.

Answer 70

• Postcholecystectomy Syndrome classifies those cases in which symptoms suggestive of biliary tract disease either persist or develop following a cholecystectomy, but for which no demonstrable cause or abnormality is found on workup.
• Clinical indicators – RUQ pain, referred pain into the right shoulder, N/V, intolerance to fatty foods, belching/bloating/dyspepsia.
• Treatment: symptom relief.

Risk factor: s/p cholecystectomy

Question 71

Postcholecystectomy Syndrome Clinical Example

Sample Clarification

Scenario: A 77 yo female patient who is s/p lap chole x 3 months was admitted last evening with nausea, abdominal pain after meals, and bloating. She describes these symptoms as being the same pre-operatively. Her ERCP was negative for retained stone fragments. Her treatment regimen includes pain control, NPO status, and IVFs at 125cc/hr. Discharge is anticipated in the AM.

Sample Clarification

Answer 71

Sample Clarification:
* Postcholecystectomy syndrome after cholecystectomy requiring ERCP
* 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: nausea, abdominal pain after meals, bloating
Risk Factor: s/p cholecystectomy 3 months ago
Treatment: ERCP, NPO, IVFs, pain control

Question 72

**Clinical Scenario: **
An 80 yo female was admitted yesterday with a diagnosis of “acute cholecystitis.” In the ED, her labs showed: WBC 24, 85% segs and 12 bands.

Her triage VS reflect: T 100.8, P 102, R 22, BP 106/58.

After 1L NS bolus and initiation of IV Vancomycin, she was taken to the OR. The op-report reveals a post-op diagnosis of “gangrenous gallbladder with ? perforation…acutely inflamed abdomen.” In the body of the report: “open chole…small fragment of stone successfully removed with the Fogarty…additional liter of antibiotic solution used to flush the cavity.”

Questions
1) What is the patient’s Principal Diagnosis?
2) What is a potential alternative principal diagnosis?
3) What is a potential secondary diagnosis?
4) What root operation will you use to index the cholecystectomy?
5) Is there evidence of additional surgical work? Yes/No
6) What was the additional surgical work performed/what’s your root operation?
7) Would you have to seek clarification for the additional work?

Answer 72

Answers:
1) Acute Cholecystitis
2) Sepsis is acceptable, but either sepsis POA or sepsis present on admission is more accurate
3) Peritonitis
4) Resection
5) Yes
6) Extirpation of ampulla of Vater
7) Yes

Explanation: The patient’s working principal diagnosis is acute cholecystitis with a potential alternative principal diagnosis of sepsis that was present on admission. The potential secondary diagnosis is peritonitis. Index the cholecystectomy with the root operation resection. There is clinical evidence of additional surgical work – the extirpation of the ampulla of Vater. Use the root operation extirpation to index the procedure, but you would need to seek further clarification of the procedure.

If you missed any of these questions, review the content for cholecystitis and cholecystectomy.