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Dx coding for Gastroparesis and Anorexia

  1. #11
    Smile dx coding for gastroparesis
    Medical Coding Books
    Preserene -- Thank you for clinical coding information. I think this could be your specialty. So here is a question for you: How would code the following and in what order?

    1) Anorexia and Gastroparesis. Will continue meoclopramide and resume two week course of Megace.
    2) Shoulder Bursitis. Patient consented for corticosteroid injection for management. Skin was prepped with alcohol x2, anesthetized with topical ethyl cloride....A 22-guage needle was introduced in the subacromial space easily. The space was injected with 4ml of 40 mg of Triamcionlone and lidicaine.

    Your thoughts??

  2. #12
    Default
    You don't get any clear cut ones, do you?
    The doctor is sending some pretty mixed messages about the chest pain - I can't tell you how the nitro fits in...Really, the "non-cardiac" is probably irrelevant, since the doctor used the word "suspect" (assuming this is outpatient)...Can't code for suspected conditions - only definitive Dx, or signs/symptoms. So back to the drawing board...The RCA may be a relevant comorbidity, although I still don't see a way to fit the stent into the MDM. Anyways, I think you're safe with a 99214 and Dx codes you mentioned.

    Reading the note on the Anorexia patient - I can see why you're unsure. So there's no mention of any psych treatment recommendations? It's odd to me that the doctor would prescribe medication to treat a loss of appetite without dealing with the psychiatric aspect of anorexia, if he was referring to anorexia nervosa.

  3. #13
    Wink V45.82
    I am going to change the Doctor's listed heart code 414.01 to a V45.82. It is a slight risk, but even then it will not hurt me that much. Here is why:

    1) The doctor listed history of "RCA stent in 2004." Meaning a PTCA with stent Px.
    2) He gave a trail Rx of Nitroglycerin, which is only for patient that have chest pain due to CAD or angina. It is never given out to patients with just normal, run-of-the-mill chest pain. Nitro is pretty extreme drug, heck, the military uses it in weapons.
    3) The doctor said he will perform a Myoview Stress Test if problems continue.
    4) The doctor put the dx 414.01 on the claim form. This is definitely an incorrect code, but shows a line of thought. So I am going to replace it with V45.82.

    So, yeah, it is a slight risk. But I ask my this question, does it affect the tx? I would say "yes", because of the Nitro.

  4. #14
    Wink
    I was kind of wondering the same thing - I wasn't sure if that would qualify as "drug therapy requiring intensive monitoring for toxicity" or not. But then I decided that that category is probably reserved for chemotherapy, and similar drug therapies - I'd like to know if that's correct.

    I don't think it will have an effect on the overall code, even if you can use it to apply a higher risk level in the MDM. I wouldn't count the "possible Myoview in the future" towards anything, because it wasn't actually ordered or reviewed - it may never even happen - it's just an afterthought. You still only have a detailed history and exam documented, so a high MDM won't get a 99215, just a more solid 99214.

    It's totally irrelevant, but the fact that she was having cardiac problems and taking Darvocet really makes me wonder if the Darvocet was related to the problems somehow (with the FDA recall, and whatnot). Just something to ponder!

  5. #15
    Smile Darvocet...new encounter to look at...
    I am staying with 99214, my thoughts were just on the secondary dx code. Ok, new encounter below....

    Would you mind looking at another one for me, it is kinda different as are many of these I am posting. I just looking for just a HPI level here:

    HPI: He complains of left hip pain with activity such as walking or shoveling. He thinks ED started at the same time of his hip surgery. He has a normal libido. He is interested in meds for ED. He thinks that fasting blood glucoses are ranging about 170 to 150. Denies polyuria or polydipsia.

    Now the MDM: 1) DM. Suspect control will be poor. Need f/u glycohemoglobin and urine micro alubumin. He may need to add sulfourea to regimen to achieve glycemic control. 2) HTN. Control is good. Will continue same antihypertensive regimen. Need clarification on atenolol usage.
    3) Actinic Keratosis. With pts consent, 6 keratoses were destroyed using liquid nitrogen dual freeze technique.
    4) Dyslipidemia. Needs F/u lipid panel to monitor gemfibrozil use.

    I alread know the CPT code for the Karatosis. I am just looking for the MDM level. Thoughts? Feedback??

  6. #16
    Default
    HPI:
    He complains of left hip pain (HPI Location or ROS M/S)
    with activity such as walking or shoveling. (HPI Context)
    He thinks ED started at the same time of his hip surgery. (HPI - Associated signs/symptoms or timing)
    He has a normal libido. (ROS - GU)
    He is interested in meds for ED. (HPI - Modifying Factor? It's a stretch, if so)He thinks that fasting blood glucoses are ranging about 170 to 150. (ROS - Endocrine or maybe HPI severity)
    Denies polyuria or polydipsia. (ROS - GU and Endocrine)
    Enough for a detailed, but not enough for comprehensive history. There are easily 4 HPI and 2+ ROS. Your PFSH will determine the overall history.


    Now the MDM:
    1) DM. Suspect control will be poor. (Type II Diabetes, Uncontrolled - Connotation suggests this is a new diagnosis [to this provider], perhaps referred to a specialist for diabetic management? If so, this may be a new patient altogether.)
    Need f/u glycohemoglobin and urine micro alubumin. (Data - Labs Ordered)
    He may need to add sulfourea to regimen to achieve glycemic control. (Rx Management?)
    2) HTN. Control is good. Will continue same antihypertensive regimen. Need clarification on atenolol usage. (New problem, stable, with drug therapy; Data - decision to discuss case with another physician; Rx management)
    3) Actinic Keratosis. With pts consent, 6 keratoses were destroyed using liquid nitrogen dual freeze technique. (Co-morbidity)
    4) Dyslipidemia. Needs F/u lipid panel to monitor gemfibrozil use. (Co-morbidity, lab ordered, Rx management)

    I get Extensive Dx/Tx, Limited Data, Moderate Risk = Moderate MDM

  7. Default
    Fred,

    Treatment favors the anorexia and gastroparesis more. So his document is very much synchronysing with them.
    In that case, I would like to give gastroparesis the primary diagnosis than the illdefined condition.

    Megace is used in treating loss of appetite (as an appetite stimulant). Loss of appetite can be caused by both medical and emotional sickness. Anorexia is a generalized term given to a condition with some underlying disease process where as nervosa is an entity by itself and has a definite neuronal factor (psychiatric component) contributing to it and patients are severely anorexic and look very cachatetic.
    Metachlopramide is an antiemetic and gastroprokinetic agent.
    So the physician has aimed at treating symptomatically for anorexia (loss of appetite) and gastroparesis. May be patient had nausea also( not necessarily though)
    At this stage the physician has been very meticulous in documenting the diagnosis as the anorexia and gastroparesis, with the prevailing symptoms and signs he finds in the patients.

    [Before 1980, Nervosa was not officially classified as psychiatric but now it is different]
    .................................................. .................
    As regards Darvoset,

    it is used to treat mild-to-moderate pain. It contains two different medications, acetaminophen (Tylenol®) and propoxyphene napsylate (Darvon-N®). Darvocet is used both for short-term pain (such as after a surgery or dental procedure) and for long-term pain control. Because it contains a narcotic, many healthcare providers like to limit Darvocet use to the shortest period of time possible.
    Moreover narcotic is a medication of choice for the relief of cardiac pain though it is said to have some changes in cardiac rhythm and it is only a prescription drug by by Physicians, who use them with great caution and with great limitations.
    Thank you for this opportunity and your time.

  8. #18
    Thumbs up dx coding for gastroparesis
    Thank you for the workup. Nice. The ROS is Comp; and the PFSH is also Comp. So we have a detailed History.

    The DM and HTN are actually on follow up, but it may not make a difference in the MDM. But this leads to my real question.

    1) Which of the guidelines did you use to grade the HPI?

    2) What is your take on HPI as it relates to chronic problems and the 1995 guidelines? I feel good about some of my codes, but this is a shady area.

  9. #19
    Smile dx coding for gastroparesis
    It sounds like you have a lot of knowledge on the subject. But the ICD-9 book states under the Gastroparesis, to "Code First any Underlying disease or illness." Isn't Anorexia the underlying illness? Or are you saying they are unrelated?

  10. Default
    I had been giving a long thought over it. I was wondering how to assign when the icd says so. But the realty in medicine is what I said. If the doctor documented it as A.nervosa, the matter is so simple. Nervosa doubtlessly takes the priority but the same ICD guidelines about the ill defined condition , does not allow us to do so.
    One thing for sure this anorexia in its true sense do not lead to gastroparesis as A.nervosa does. Now you are the Boss sequence as you find it right.
    SO, they have to be coded as "AND" to its true sense or as it has yet another say "OR"!!
    Can we be off the hook?? in so doing!!

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