Seminar 4

Unit 4 Inpatient coding guidelines Principal diagnosis: “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care” Key words are “after study” So, after all tests and exams are complete, what is the reason the patient came to the hospital?

Unit 4 Other (additional) diagnoses “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay” Co morbidity A condition that coexists at the time of admission Complication A condition that occurs during the course of the inpatient hospital episode (post-op infection)

Unit 4 If, at time of discharge, a patient’s diagnosis is not definitive, code : Probable Suspected Likely Questionable Possible Still to be ruled out Code the condition as if it existed

Unit 4 Codes for Symptoms, Signs, & Ill-Defined Conditions Codes for symptoms, signs, & ill-defined conditions are not to be reported as the principal diagnosis when a related definitive diagnosis has been established

Unit 4 Two or more interrelated conditions: When two or more conditions potentially meet the definition of principal diagnosis, either condition may be sequenced first unless the circumstances of the admission state otherwise

Unit 4 Complications of Surgery and Other Medical Care When an admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis

Unit 4 Outpatient and Physician Office Outpatient care (or ambulatory care) Includes any health care service provided to a patient who is not admitted to a facility Care provided in physician’s office, stand-alone health care facility, hospital outpatient, or emergency department, or patient’s home

Unit 4 Primary Care Service Includes both preventive and acute care services Provided outpatient Referred to as the first point of contact Provided by a general practitioner Services include: Annual physical exams Early detection of disease Family planning Immunizations Treatment of minor illnesses and injuries Vision and hearing screening

Unit 4 Ambulatory surgery patients Treated and released the same day Not admitted into the hospital Minor procedures Care provided at outpatient ambulatory clinics and hospitals

Unit 4 Outpatient Coding– Selection of First Listed Diagnosis The diagnosis, condition, problem, or other reason for encounter/visit documented in the patient record to be chiefly responsible for the services provided

Unit 4 V codes: V codes describe the category of problems that need therapeutic intervention but are not considered psychological disorders or mental illness. They identify circumstances when a patient presents with issues or than disease or injury For example: births, immunizations, counseling, follow up appointments (aftercare of a disease or injury—recheck for a cast)

Unit 4 Types of V codes: Personal history Family history Screening (testing of diseases in healthy individuals) After care (initial treatment is complete) Routine and administrative exams

Unit 4 E Codes: An E code describes a cause of injury Poisonings (overdose) Adverse affect of a drug (allergic reaction)

Unit 4 E Codes show: How the injury or poisoning happened Intent (accidental, intentional, assault, suicide) Place where event occurred E codes should not be the primary diagnosis code Assign as many E codes as necessary to completely explain the situation

Unit 4 Fever of unknown origin. Rule out tuberculosis. (Inpatient hospital case) a b c , d. V71.2

Unit 4 Fever of unknown origin. Rule out tuberculosis. (Inpatient hospital case) a b c , d. V71.2

Unit 4 Repair of unilateral direct inguinal hernia a b c d. 53.9

Unit 4 Repair of unilateral direct inguinal hernia a b c d. 53.9

Unit 4 Congenital hydrocephalus a b c d

Unit 4 Congenital hydrocephalus a b c d

Unit 4 Partial spelenectomy a b c d. 41.5

Unit 4 Partial spelenectomy a b c d. 41.5

Unit 4 Bilateral myringotomy with placement of tubes a b c , d , 20.01

Unit 4 Bilateral myringotomy with placement of tubes a b c , d , 20.01

Unit 4 Anorexia nervosa a b c d

Unit 4 Anorexia nervosa a b c d

Unit 4 Congenital hydrocephalus a b c d

Unit 4 Congenital hydrocephalus a b c d

Unit 4 Needle biopsy of cerebral meninges a b c d

Unit 4 Needle biopsy of cerebral meninges a b c d

Unit 4 What is the diagnosis code for: Irritable bowel syndrome

Unit 4 What is the diagnosis code for: Irritable bowel syndrome 564.1

Unit 4 What is the diagnosis code for: Motor vehicle traffic accident involving a collision with a pedestrian

Unit 4 What is the diagnosis code for: Motor vehicle traffic accident involving a collision with a pedestrian E814.9

Unit 4 What is the diagnosis code for: Nausea and vomiting

Unit 4 What is the diagnosis code for: Nausea and vomiting

Unit 4 What is the diagnosis code for: Personal history of penicillin allergy

Unit 4 What is the diagnosis code for: Personal history of penicillin allergy V14.0

Unit 4 What is the diagnosis code for: Pulmonary arteriosclerosis

Unit 4 What is the diagnosis code for: Pulmonary arteriosclerosis 416.0

Unit 4 What is the diagnosis code for: Fall from a ladder

Unit 4 What is the diagnosis code for: Fall from a ladder E881.0

Unit 4 What is the diagnosis code for: Hyperplasia of endometrium

Unit 4 What is the diagnosis code for: Hyperplasia of endometrium

Unit 4 What is the diagnosis code for: History of cancer

Unit 4 What is the diagnosis code for: History of cancer V10.9

Unit 4 Questions???