Seqencing

sparkle77

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Where can I get more practice with/test my knowledge of sequencing? I feel my knowledge is somewhat shallow when it comes to "applying theory to practice" for multiple manifestations of disease processes and/or multiple conditions/multi-system failure. The reason this is so tricky for me is because I'm coding for physician services in an inpatient setting for a practice that is not affiliated with the hospital, so I have to go by the outpatient guidelines. Let me give you just one example of why the nature of these types of encounters makes this so confusing.

This could be a fairly typical case, but I am making up the circumstances. This stuff is not easy :eek:

Ms. A comes to the ER with severe epigastric abdominal pain, N/V, and fever. The lab work also then shows she has leukocytosis and abnormal LFT's. Ultrasound of the abdomen also shows evidence of gallstones with a distended gallbladder and dilation of the CBD. Pt also has multiple medical comorbidities including recurrent bacterial pneumonia, COPD, a fib, and cirrhosis w/coagulopathy chronic liver disease unknown. The patient also has a history of GERD. Sepsis is also being written down in her chart as a r/o. Gastroenterology is asked to consult but decides to monitor her for a day or two to see whether her bilirubin elevation resolves before doing an ERCP. In the meantime an additional liver workup is ordered, which comes back largely negative at the next follow-up. The doctor writes that he is not sure of the etiology of her leukocytosis, but suspects cholangitis given her rising bilirubin an ERCP is warranted.

Typically, the doctor will have a list under "impression" with all of the r/o diagnoses and everything the patient has had since admission and sometimes "history of" diagnoses which the patient may or may not still have. Do you see my dilemma? When they are inpatient, the lines get very blurred as to what may be causing what because they often have multiple comorbidities so the outpatient guidelines make no sense. The leukocytosis could have multiple causes but it is a sign/symptom the doctor has under impression and is probably d/t cholangitis so how does something like this come in in terms of the sequencing because I have to code the bacterial pneumonia too since it is under impression. Some nonspecific kinds of lab results could also be important in terms of diagnosis because they could indicate a worsening of a chronic disease but the Dr may not be able to definitively diagnose the cause yet or further specify the chronic condition (they may only know the patient has "cirrhosis" but may not be able to discern the cause of this or why the patient's liver tests are elevated). If we coded both leukocytosis and bacterial pneumonia on the same claim it seems like it could really be a red flag to the payer but clearly the leukocytosis is important and relevant to the encounter because it is a sign of another working diagnosis. I really just want to feel more confident about how I am sequencing things.
 

TheStephCode

Networker
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I might suggest the ICD-10-CM Study Guide from AAPC. It breaks down the guidelines for each chapter of the code set and addresses sequencing. Each chapter has practice tests. If you want something a bit more in depth I recommend the ICD-10-CM and ICD-10-PCS Coding Handbook, with Answers by Nelly Leon-Chisen. I have both at my side at all times while working.
 
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