Hi, looking for guidance and input on these coding exercises!
Evaluate the coding of each of the following scenarios compared to the documentation given. If there is nothing incorrect in the coding, mark as such. If you did find errors, note each and explain why there is an error.
CASE 1
Patti Culbertson was seen in the ambulatory surgery department on February 12.
HISTORY AND PHYSICAL EXAM:
Pain in left foot at the site of the 1st metatarsal. She has NKDA, has been treated for DM Type 2 with Metformin for the past three years under the care of her PCP, Dr. Schwartz. She stands frequently for her job at Macy’s, and it is becoming more difficult to work due to the pain.
On PE, she has a BP of 132/82, pulse 70, respiratory rate 19, temperature of 98.6. HEENT, Heart, Lungs, Abdomen all within normal limits. Extremities were normal other than the bunion on the 1st metatarsal. She will undergo excision of the 1st metatarsal eminence on February 12.
Admitting impression: Bunion, left first metatarsal.
DISCHARGE SUMMARY:
Seen in the ambulatory surgery department on 2/12/13.
Discharge Diagnosis: Bunion with hypertrophy of 1st metatarsal.
ADMISSION HISTORY: Mrs. Culbertson is 50 years old and in generally good health other than her diabetes, type 2, which is well controlled with Metformin.
COURSE IN HOSPITAL: The patient was registered for ambulatory surgery and was taken to the OR suite where she was prepped for osteotomy of the 1st metatarsal. The patient tolerated the procedure well and was discharged at 2:00 P.M. in stable condition.
OPERATION PERFORMED: Osteotomy with partial excision of the 1st left metatarsal head.
DISCHARGE INSTRUCTIONS: Elevate foot; dressing warm and dry; do not change until follow-up appointment with surgeon. Surgical shoe provided, and she is to wear until discontinued by physician’s order. A prescription for Darvocet N 100 mg. q.4h. as needed for pain was given.
CODING – ICD-10-CM as submitted on the claim form:
PDx: M20.10
Procedure: 0QBQ3ZZ (in real life, this would also be assigned a CPT code, but for our purposes, it is simply ICD-10-CM.
□ There are no errors in the coding of this case.
The following errors were found:
CASE 2
Janet Smith was admitted by way of the ED on March 6. She came in complaining of headache, nausea, vomiting, and chest pain. The impression on admission was possible CAD and probable viral gastroenteritis. Only an incidental finding of small, sliding hiatal hernia was found on air contrast upper GI. No ischemia was found on cardiac evaluation. The patine gradually improved and was discharged two days later and is to follow up with her PCP in one week to assess the gastroenteritis and she was advised to seek further evaluation of the hiatal hernia.
DISCHARGE DIAGNOSIS: Probable viral gastroenteritis; hiatal hernia The coder coded: A08.4; I25.10.
PROCEDURES: BD15YZZ
□ This case contains no coding errors.
The following errors were found:
CASE 3
DISCHARGE SUMMARY:
This 32-year-old female was admitted on October 15 with discomfort on her right side. She has no other chronic conditions. Approximately five hours prior to arrival in the ED, she experienced severe discomfort in her lumbar region. She also experienced fever and chills, with temperature of 102.3, for which she took ibuprofen. After an hour, she still had no relief of her symptoms, and came to the ED.
COURSE IN HOSPITAL: The patient was admitted and put on a course of IV gentamicin and cefoxitin. Within 48 hours, her temperature was normal, at 98.6, and she improved greatly. She underwent a pyelogram, which was normal. Urine C&S grew E. coli and showed penicillin and ampicillin resistance. Blood cultures grew E. coli as well, resistant to ampicillin and penicillin. She was diagnosed with herpes simplex on her right upper lip, and was started on Zovirax ointment.
DISCHARGE DIAGNOSIS:
CODING – ICD-10-CM as submitted on the claim form:
Diagnosis: A41.51, A16.11, A16.31, N10, F17.200, V09.0, Z16.11
Procedure: There are no procedure codes submitted.
This case contains no coding errors.
The following errors were found:
Evaluate the coding of each of the following scenarios compared to the documentation given. If there is nothing incorrect in the coding, mark as such. If you did find errors, note each and explain why there is an error.
CASE 1
Patti Culbertson was seen in the ambulatory surgery department on February 12.
HISTORY AND PHYSICAL EXAM:
Pain in left foot at the site of the 1st metatarsal. She has NKDA, has been treated for DM Type 2 with Metformin for the past three years under the care of her PCP, Dr. Schwartz. She stands frequently for her job at Macy’s, and it is becoming more difficult to work due to the pain.
On PE, she has a BP of 132/82, pulse 70, respiratory rate 19, temperature of 98.6. HEENT, Heart, Lungs, Abdomen all within normal limits. Extremities were normal other than the bunion on the 1st metatarsal. She will undergo excision of the 1st metatarsal eminence on February 12.
Admitting impression: Bunion, left first metatarsal.
DISCHARGE SUMMARY:
Seen in the ambulatory surgery department on 2/12/13.
Discharge Diagnosis: Bunion with hypertrophy of 1st metatarsal.
ADMISSION HISTORY: Mrs. Culbertson is 50 years old and in generally good health other than her diabetes, type 2, which is well controlled with Metformin.
COURSE IN HOSPITAL: The patient was registered for ambulatory surgery and was taken to the OR suite where she was prepped for osteotomy of the 1st metatarsal. The patient tolerated the procedure well and was discharged at 2:00 P.M. in stable condition.
OPERATION PERFORMED: Osteotomy with partial excision of the 1st left metatarsal head.
DISCHARGE INSTRUCTIONS: Elevate foot; dressing warm and dry; do not change until follow-up appointment with surgeon. Surgical shoe provided, and she is to wear until discontinued by physician’s order. A prescription for Darvocet N 100 mg. q.4h. as needed for pain was given.
CODING – ICD-10-CM as submitted on the claim form:
PDx: M20.10
Procedure: 0QBQ3ZZ (in real life, this would also be assigned a CPT code, but for our purposes, it is simply ICD-10-CM.
□ There are no errors in the coding of this case.
The following errors were found:
CASE 2
Janet Smith was admitted by way of the ED on March 6. She came in complaining of headache, nausea, vomiting, and chest pain. The impression on admission was possible CAD and probable viral gastroenteritis. Only an incidental finding of small, sliding hiatal hernia was found on air contrast upper GI. No ischemia was found on cardiac evaluation. The patine gradually improved and was discharged two days later and is to follow up with her PCP in one week to assess the gastroenteritis and she was advised to seek further evaluation of the hiatal hernia.
DISCHARGE DIAGNOSIS: Probable viral gastroenteritis; hiatal hernia The coder coded: A08.4; I25.10.
PROCEDURES: BD15YZZ
□ This case contains no coding errors.
The following errors were found:
CASE 3
DISCHARGE SUMMARY:
This 32-year-old female was admitted on October 15 with discomfort on her right side. She has no other chronic conditions. Approximately five hours prior to arrival in the ED, she experienced severe discomfort in her lumbar region. She also experienced fever and chills, with temperature of 102.3, for which she took ibuprofen. After an hour, she still had no relief of her symptoms, and came to the ED.
COURSE IN HOSPITAL: The patient was admitted and put on a course of IV gentamicin and cefoxitin. Within 48 hours, her temperature was normal, at 98.6, and she improved greatly. She underwent a pyelogram, which was normal. Urine C&S grew E. coli and showed penicillin and ampicillin resistance. Blood cultures grew E. coli as well, resistant to ampicillin and penicillin. She was diagnosed with herpes simplex on her right upper lip, and was started on Zovirax ointment.
DISCHARGE DIAGNOSIS:
- 1. Acute pyelonephritis
- 2. Septicemia, resistant to ampicillin and penicillin.
CODING – ICD-10-CM as submitted on the claim form:
Diagnosis: A41.51, A16.11, A16.31, N10, F17.200, V09.0, Z16.11
Procedure: There are no procedure codes submitted.
This case contains no coding errors.
The following errors were found: