Case 2-2 Coding Quality in ICD-9-CM You have been the coding supervisor for abou
ID: 98704 • Letter: C
Question
Case 2-2
Coding Quality in ICD-9-CM
You have been the coding supervisor for about 6 months at General Hospital. You are settling in and getting a strong grasp of what has been happening in the areas of quality, quantity, work ethic, policies, etc. You have been at the hospital long enough to know that there is a problem with the quality of coding performed. You know that you need to strengthen the quality audits being conducted in order to gain a better understanding of the coding quality problems. There is a lot of work ahead to improve the coding function to achieve a 98% accuracy rate. The last audit showed only an 87% accuracy rate. You decide to begin by conducting a face validity audit of the codes. You print a report of the most recent discharge diagnosis codes to see if you can identify any glaring problems. Perform a face validity review of the first nine discharges shown in Table 2-2 to ensure compliance to official coding guidelines. Report any coding quality issues you identify from our review.
Table 2-2 Worksheet for Identifying Coding Quality Problems
Worksheet for Identifying Coding Quality Problems
Case 1 Principal Diagnosis: B96.20 E. Coli infection
Secondary Diagnosis: N39.0 Urinary tract infection (UTI)
Problem(s) Identified:
Case 2 Principal Diagnosis: A41.2 Staphylococcus septicemia
Secondary Diagnosis: B95.8 Staph infection
Problem(s) Identified:
Case 3 Principal Diagnosis: I25.10 Coronary artery disease (CAD)
Principal Procedure: 021149W Coronary artery bypass graft (CABG) 2 vessel
Problem(s) Identified:
Case 4 Principal Diagnosis: K40.20 Bilateral inguinal hernia
Principal Procedure: 0YUA0JZ Repair, bilateral inguinal hernia
Problem(s) Identified:
Case 5 Principal Diagnosis: I11.9 Hypertensive heart disease
Secondary Diagnosis: I10 Hypertension
Problem(s) Identified:
Case 6 Principal Diagnosis: R40.20 Coma
Secondary Diagnosis: C71.9 Adenocarcinoma brain
Problem(s) Identified:
Case 7 Principal Diagnosis: S06.0X0A Concussion
Secondary Diagnosis: R51 Headache
Problem(s) Identified:
Case 8 Principal Diagnosis: Z51.11 Admission for chemotherapy
Secondary Diagnosis: C50.919 Adenocarcinoma breast
Principal Procedure: 3E06305 Chemotherapy
Problem(s) Identified:
Case 9 Principal Diagnosis: I44.2 Atrioventricular block, complete
Principal Procedure: 0JH606Z Initial insertion of permanent pacemaker
Problem(s) Identified:
Case Studies in Health Information Management Second Edition. ISBN: 1133602681
Worksheet for Identifying Coding Quality Problems
Case 1 Principal Diagnosis: B96.20 E. Coli infection
Secondary Diagnosis: N39.0 Urinary tract infection (UTI)
Problem(s) Identified:
Case 2 Principal Diagnosis: A41.2 Staphylococcus septicemia
Secondary Diagnosis: B95.8 Staph infection
Problem(s) Identified:
Case 3 Principal Diagnosis: I25.10 Coronary artery disease (CAD)
Principal Procedure: 021149W Coronary artery bypass graft (CABG) 2 vessel
Problem(s) Identified:
Case 4 Principal Diagnosis: K40.20 Bilateral inguinal hernia
Principal Procedure: 0YUA0JZ Repair, bilateral inguinal hernia
Problem(s) Identified:
Case 5 Principal Diagnosis: I11.9 Hypertensive heart disease
Secondary Diagnosis: I10 Hypertension
Problem(s) Identified:
Case 6 Principal Diagnosis: R40.20 Coma
Secondary Diagnosis: C71.9 Adenocarcinoma brain
Problem(s) Identified:
Case 7 Principal Diagnosis: S06.0X0A Concussion
Secondary Diagnosis: R51 Headache
Problem(s) Identified:
Case 8 Principal Diagnosis: Z51.11 Admission for chemotherapy
Secondary Diagnosis: C50.919 Adenocarcinoma breast
Principal Procedure: 3E06305 Chemotherapy
Problem(s) Identified:
Case 9 Principal Diagnosis: I44.2 Atrioventricular block, complete
Principal Procedure: 0JH606Z Initial insertion of permanent pacemaker
Problem(s) Identified:
Explanation / Answer
Ans.) Worksheet of coding guidelines --
Case 1. It is the American ICD-10-CM adaptation of N39.0. It portrays the bacterial disease which encroach on the urinary tract, most generally the bladder and the urethra.
Case 2. A41.2 is a billable/particular ICD-10-CM code that can be utilized to show a determination for sepsis because of unspecified staphylococcus which incorporates intense organ brokenness, Staph septicemia, septic stun intense organ brokenness and other staphylococcal disease.
Case 3. It is the American ICD - 10 code i25.10 which symptoms include different sorts of evade joins along with thickening and failure of suppleness of the coronary arteries which eventually results in arterial deficiency (a kind of coronary disease).
Case 4. The ICD – 10 code K40.20 is used for individual inguinal hernia without gangrene not demonstrated as discontinuous. An inguinal hernia is the spillage of stomach pit substance through the inguinal trench. In extraordinary cases blood supply to a bit of inside is deflected.
Case 5. The ICD - 10 code I11.9 is for hypertensive cardiovascular disease. Hypertension has confined codes-nine codes for fundamental hypertension and 5 codes for discretionary hypertension.
Case 6. C71.9 is the 2017 ICD-10 is given to study and analysis of astroblastoma. Its side effect incorporates dangerous neoplasm of brain, unspecified. Essentially, astroblastoma is an unprecedented tumor got from the astroblast a cell which almost looks like sphingioblastoma and astrocytes. There tumors can be found in noteworthy cerebrum domains excepting the central cerebral parts of the globe.
Case 7. Chief Diagnosis: R40.20 Coma is a variation of the ICD – 10 discovering code which for the most part gives data about the obviousness. Its indicative manifestations incorporates blackout without loss of mindfulness, basic counter.
Case 8. C50.919 is the ICD-10 code known for the dangerous neoplasm of unspecified site of unspecified female bosom. It is an option of the ICD 10 CM discovering code C50.919.
Case 9. ICD-10: I44.2 delineates the illnesses of the circulatory framework and indications are finished blockage of atrioventricular.
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