ALICIA SOTOCPC, CRC, COC

Risk Adjustment Compliance Analyst

DISCLAIMER

• This presentation is based on the presenters education and experience. Every effort was made

to ensure the accuracy of the information presented. Information presented is for education

only and is not intended as a substitute for Coding Guidelines. It is the coder’s responsibility to

use the coding guidelines for accurate coding. The presenter does not accept responsibility for

coding errors, misinterpretations or misuse of information by individuals present.

Coding Example 1• DOS: 07/10/2017

• Gender: F DOB: XX/XX/1976 Pulse: 69 Temp:98.8◦F Weight: 81.40lb Height: 4.4 BMI: 20.84

• HPI: A 41 y.o. female with a history of breast cancer and s/p double mastectomy on 2016 comes in today for follow up of chemotherapy for metastatic

cancer to the hip and femur bone.

• Patient is having some severe pain which seems to originate from her femur bones.

• Problem List/History: Onc Hx : Diagnosed with Breast Cancer in 2015 when a lump was found. A biopsy revealed its malignancy. A double mastectomy

was performed in 2016 and given her aggressive tumor she was started on neo-adjuvant chemo with ddAC on 9/20/16.

• A PET scan in 2016 showed cancer metastasis to the hip and femur bones. Started chemo and radiation therapy which should also help with the pain.

Medications Reviewed:

• Metastron, Bisphosphonates, Maxalt, Tamoxifen, Percocet

• Assessment and Plan:

• Neuropathy due to chemo – adverse effect of the drug cisplatin. Started on Duloxetine. Percocet for pain management.

• Metastatic cancer to hip and femur bone – seeing Oncologist – waiting to start radiation therapy treatments.

• S/P Double Mastectomy – performed in 2016.

Coding Example 1 - Question

• When is a cancer considered active?

• When is a cancer considered History of?

• What type of neoplasms can be considered in Remission?

Coding Example 2

• Chief Complaint: “I am here for my quarterly evaluation of my diabetes.”

• HPI: Patient is a 50-year-old woman with Type 1 diabetes since childhood. She’s been on insulin since age 13. As a result of her

diabetes she has chronic kidney disease and is currently on dialysis for ESRD. She also has diabetic neuropathy affecting both lower

extremities.

• Review of Systems, Physical Exam, Laboratory Tests:

• No changes in underlying condition during the last 3 months. She continues to perform self-testing of her blood sugar levels on a daily

basis, is on dialysis every other day, most recently 24 hours ago, and has not noticed any changes in the numbness in her legs.

• VSS, BP 140/75, P 80, R 16 and T 98.8

• Dialysis fistula without any signs of infection

• Decreased sensation over lower extremities below the knees

• Lab: BUN/Cr nl, K+ 3.5, glu 105, Hgb A1c 7.9

Coding Example 3• Chief Complaint: Wound Check

• HPI: She comes to the office as referral from Dr. Smith for a nonhealing wound on her sacrum that was determined to be a stage IV pressure ulcer. She

has had this for at least 4 weeks now and there has been some purulent and necrotic drainage from the wound. There is concern about surrounding

erythema and low grade fevers. She currently has a fair amount of pain associated with this. She denies any other issues or complaints.

• Review of Systems:

• Skin: Positive for wound.

• Neurological: Positive for weakness.

• Review of Systems:

• Constitutional: She is oriented to person, place, and time. No distress. Somewhat malnourished.

• Skin: Skin is warm and dry. No rash noted. She is not diaphoretic. No erythema. No pallor. She has an open wound on her sacral area that is approximately 2x2

cm in diameter. There is significant necrotic tissues in the wound along with some purulence. This has been cleaned out to the best of my ability today.

There is significant undermining in all directions which will make the wound is seemed to be approximately 5x5 cm in diameter total. It is 3 cm deep. There

is fair amount of surrounding erythema.

• Assessment/Plan:

• Wound of sacral region, initial encounter

• Pressure injury of sacral region, unstageable

• Weakness of both lower extremities

Coding Example 4

• Let’s Assume for these that the face to face encounter contains all the required documentation for the final diagnosis.

• What Code would you use? And Why?

• Hyperkalemia due to CKD

• Chronic Kidney Disease, GFR 40

• Stage 5 CKD on Hemodialysis

• Chronic systolic congestive heart failure due to hypertension with stage 5 CKD

• DM type 2, also on hemodialysis for ESRD

Coding Example 5• Chief Complaint: Follow up for Atrial Fibrillation, Coronary Artery Disease, Congestive Heart failure

• HPI: She is here following up on hypertension CAD and atrial fibrillation

• Review of Systems:

• Cardiovascular: Positive for dyspnea on exertion and palpitations (Palpitations once or twice a week less than 1 minute).

• Musculoskeletal: Positive for back and join pain.

• Assessment/Plan:

• Assessment blood pressure 154/60 with a heart rate of 57. Manual blood pressure obtained was 142/68 with a heart rate of 56. Heart is regular with S1 and S2 with no S3 or S4 noted. No murmur

noted on auscultation. Lungs are clear bilateral. She has no lower extremity edema. She states that she occasionally has a flutter in her chest but she can feel it in its gone Just as fast. She states

that does not even last one minute. She does not have any chest pain/discomfort. She does have mild shortness of breath with extreme activity such as going to shop at Wal-Mart or food lion. She

denies any lightheadedness or dizziness. She denies any presyncopal or syncopal episodes.

• I have discussed with her that we can attempt 2 cut her amiodarone in half as she is currently taking amiodarone 200 milligrams daily and drop her down to 100 milligrams daily and see how she

does. She states that she feels really secure with the medication as is and knows that it does have some side effects and she is willing to take that chance. She states she does not want to go back

into the atrial fib and make her feel that bad again. She continues to take her Coumadin she does follow with her primary care for her INR checked in which she states that she just had completed

last week and she was 3.0 and she has an appointment this week for follow-up.

• PROBLEMS ADDRESSED THIS VISIT:

• Chronic coronary artery disease – I25.10

• Essential hypertension – I10

• Persistent atrial fibrillation – I48.1

Coding Example 6

• Reason for Visit: Alzheimer’s Disease

• HPI: 98 yr old F is being seen today in follow-up for LTC recertification and follow-up for multiple chronic medical conditions. Patient's PMHx

includes: Alzheimer's dementia, osteoporosis, depression, HTN and hypothyroidism. Patient has been a resident at The Gardens since June of

2016. Patient has not required any recent emergency department visits or hospitalizations. Patient has not required any recent antibiotic use

for infections. During today's encounter patient is seen in the common area. She denies any pain, shortness of breath, or cough. She has no

acute complaints. She continues to be followed by psychiatry services for Alzheimer dementia. She continues on numerous psychotropic. ADLs/IADLs reviewed

– pt dependent.

• Review of Systems:

• Gastrointestinal: Negative for nausea and vomiting. Colostomy in place

• Musculoskeletal: Positive for arthralgias and gait problem. Bilateral knee pain

• Neurological: Positive for weakness. Negative for tremors, seizures, syncope, speech difficulty and numbness.

• Psychiatric/Behavioral: Positive for confusion. Negative for agitation and behavioral problems.

Coding Example 7

• Patient seen today for obesity. Patient has a history of diabetes and COPD. She is always tired and finds it

difficult to lose weight due to lack of motivation and finds it hard to catch her breath with exertion. She

has tried every diet possible without success. She consumes over 2000 calories a day and snacks

constantly. She claims that she started gaining weight when she was put on insulin. Height and weight

today is recorded at 5 feet 6 inches, 265 pounds with a BMI of 50. Her blood pressure was within normal

range, will order labs for A1C and lipids.

• Assessment; Morbid Obesity, DM type 2

Coding Example 8

• Patient seen today to evaluate and determine treatment options for her right-sided thoracic back pain due

to motor vehicle accident. History of neck and back pain, and headaches as a result of mva. No radiating

pain, pain mainly in the upper back and neck area. Localized tenderness and pain with limited ROM. MRI

shows thoracic bulge disk protrusion at T5-T6. Trigger point injections failed to provide relief of pain.

Discussed thoracic epidural steroid injection is reviewed; contacted her PCP to discuss interruption of

anticoagulation theory due to bleeding disorder. She will return 4-6 weeks after injection to assess

progress. Patient agrees and understands treatment plan.

• Assessment; Pain in thoracic spine, thoracic radiculopathy

Coding Example 9

• 35 year old female with history of depression. Is in the office crying and overall unhappy. She has been

seen in the office for this condition several times in the past year. She was referred to mental health

provider who diagnosed her with major depression and prescribed meds. She has been taking Zoloft

which helps most of the time and needs a refill.

• Assessment; Depression

Coding Example 10

• Patient arrived via ambulance. The patient’s condition upon arrival was fair.

• The patient is a 79-year-old female with COPD, CHF, dementia and malnutrition who was transferred from a local

nursing home for evaluation of GI bleed The patient is a poor historian and not able to provide any history. EMS

and nursing home staff reported that the patient started with diarrhea today, after having a "explosive" episode of

diarrhea had a large amount of bright red blood per rectum. This occurred twice prior to arrival. On arrival to

emergency department the patient was noted to have a bleeding external hemorrhoid A Rhino rocket was used to

apply pressure to this hemorrhoid and gauze packing with hemostasis. Approximately 1 hour after initial

evaluation the patient then had a more significant approximately 800 cc bowel movement with dark blood and

clots. After this large bloody bowel movement the patient did have transient hypotension which was responsive to

IV fluid hydration. Once patient's family arrived they report that the patient has had a prior history of similar GI

bleed. The patient is on no current NSAIDs or anticoagulation.

Coding Example 10 - Continues

• Labs: The patient's CBC shows a normal white count of 8000, H&H is 11 and 34. Normal platelet count of 257.

Electrolytes show an elevated BUN of 72 and creatinine of 1 9, potassium 5 9"- C02 is 30. Anion gap of five. LFTs

are unremarkable. Urinalysis negative

• EKG: Normal sinus rhythm, LAFB and right bundle-branch block, no change when compared to EKG from

04/20/2008. No acute Ischemia, interpretation by EDMD.

• CXR: COPD, no acute infiltrate or free air.

• CONSULTS The patient's findings were reviewed with GI. Patient to have emergent endoscopy otherwise will

consult the morning Agrees with bleeding scan. Reviewed with PCP on call at 20:20

• Visit Diagnosis: Lower GI Bleed, Transient Hypotension, Bleeding external hemorrhoid

• HOW WOULD YOU CODE THIS VISIT?

REFERENCES

• ICD-10-CM

• AMA Risk Adjustment Documentation & Coding

• https://www.cms.gov/

QUESTIONS