AMBC-299 Week 5 Drill 10 MS-DRG

CCW 7.37. The following documentation is from the health record of a 59-year-old cancer patient. History and Physical Examination Present Illness: The patient is a 59-year-old female admitted with a diagnosis of acute seizure. This patient's illness began last year when she was diagnosed with a metastatic lesion in her brain, which was a metastatic hypernephroma from her right kidney. She had the isolated metastasis removed surgically. She then was scheduled for renal surgery but developed chest pain, and a coronary angiogram revealed severe three-vessel disease, inoperable and not a candidate for any kind of surgical procedure. Since then her treatment has been expectant with treatment of chemotherapy per usual protocols. She did not have any radiation to the brain previously. Her CT scan in the ER last night was showing some questionable areas. Past Medical History: She has had the metastatic lesion to the head, renal carcinoma, and severe coronary artery disease. She had no prior surgeries or illnesses. Review of Systems: Was doing well until yesterday. Family History: She is adopted but has a brother. She is divorced with two children. She is living with her daughter. She is on disability from work. She was employed actively. Physical Examination: She is a well-developed, well-nourished white female. HEENT: Negative Neck: No bruits Chest: Clear Heart: Regular sinus rhythm Abdomen: Soft; no masses Pelvic/Rectal: Deferred at this time Extremities: Negative Neurologic: Negative. At this time, the daughter states that her right leg and arm stiffened out during her seizure. Impression(s): Seizure secondary to metastatic renal to brain. She is to get an MRI done today, and we are going to begin Tegretol. I think she can go home and if she does have metastatic lesion, she will probably need to have radiation done and will be set up through a radiation oncologist whom I think has been consulted previously on her condition. Discharge Summary Admission Date: 06/01/XX Discharge Date: 06/03/XX Consultants: 1. Oncologist 2. Neurosurgeon Discharge Diagnosis 1: Convulsion, secondary to malignant neoplasm of the brain secondary to a hypernephroma Hospital Course: The patient was seen by the neurosurgeon, who felt conservative management was needed. She is going to begin radiation treatment to her head. This will be done as an outpatient in order to control the metastatic disease to the brain. Discharge Medications/Instructions: She was discharged home on: Lopressor 50 mg each morning Decadron 4 mg twice a day Tegretol 200 t.i.d. So, she will be followed then to begin radiation treatment on Monday for follow-up there. Consultation Physical Examination: She is a well-developed, well-nourished white female with partial baldness to the right side of her head. Her neck exam reveals turbulence transmitted from the thorax bilaterally to both carotids. On lung exam there were no crackles or wheezes and her respiratory effort is normal. Cardiac exam reveals S1 and S2 to be physiologic with no S3 or S4 gallop. There is a murmur at the left ventricular apex most compatible with a flow murmur. The apex is not well palpated. She has no gallop or rub appreciated. Abdominal exam is supple without organomegaly. The back exam is normal. Her extremity exam reveals no clubbing, cyanosis, or edema. HEENT exam reveals partial baldness of the right side of the scalp. There is a well healed craniotomy scar. She has no xanthelasma nor is there any gum bleeding. Her musculature and gait are relatively normal without any obvious lateralizing signs. Final Assessment: This is a lady who has incredibly severe coronary disease and a poor prognosis with regard to her heart. She tolerated a craniotomy 6 months ago before knowledge of her coronary artery disease. She could probably tolerate another craniotomy but would be at increased risk for a perioperative infarction during general anesthesia. This would be obviously magnified if she had hemodynamic instability. The anticipated surgery would not involve a vascular challenge as would the nephrectomy. Nonetheless, the general anesthetic would pose a cardiovascular risk that seems to be unpreventable. The plan is to proceed with radiation and reserve surgery for nonavoidable indication. I have discussed this with the radiation oncologist, and the patient is most agreeable with this sort of approach as well. I hope this information can be of some help to you. Thanks again. History of Present Illness: This 59-year-old woman is well known to me, undergoing craniotomy for resection of a metastatic renal cell carcinoma in January of 20XX. At that time she presented with weakness of her left upper and lower extremity. She was doing well until she presented with seizure as a result of her malignant neoplasm of the brain. She was brought to the hospital, underwent a CT scan and subsequent MRI scan that does show a solitary lesion in the postoperative bed consistent with recurrence of her metastatic disease. She has never received whole brain radiation postoperatively. Currently she tells me her right kidney was never resected as she has significant cardiovascular disease and was thought by the cardiologist not to be able to tolerate a nephrectomy. Currently treatment options include: 1: Whole brain radiation 2: Surgical removal of the lesion followed by whole brain radiation if she can obtain surgical clearance 3: Possibility of doing stereotactic radiosurgery on the lesion, again followed by whole brain radiation Recommendations: Currently, I have placed the patient on Decadron 400 mg twice daily and will ask the neurosurgeon and his associates to evaluate the possibility of a craniotomy on the patient. What is the correct MS-DRG for this case?

055, Nervous System Neoplasms without MCC

CCW 7.20. The following is from the health record of a 77-year-old female. Discharge Summary Admission Date: 04/12/XX Discharge Date: 04/15/XX Discharge Diagnosis: 1: Acute renal failure 2: Congestive heart failure 3: Chronic obstructive pulmonary disease (COPD) 4: Leg cellulitis, resolved 5: Seizure disorder 6: Venous insufficiency 7: Osteoarthritis, generalized 8: Morbid obesity 9: Acute ankle arthritis, likely due to gout Discharge Medications: Resume home medications Procedures: None Consults: None Present Illness: This is a 77-year-old female transferred to the acute care ward from a subacute unit for treatment of renal insufficiency. She was originally admitted with a BUN of 32, creatinine 1.4. While on the subacute unit she was diuresed for congestive heart failure and developed acute renal failure. Her BUN rose to 78, creatinine to 2.3. She was transferred to the trauma care unit (TCU) for IV fluids and monitoring for her redevelopment of congestive heart failure. She was developing some rales with IV fluids on the subacute unit. She was monitored closely over the next 3 days. As her BUN and creatinine fell she seemed to tolerate it fairly well symptomatically, having some rales. She had a BUN of 60 and a creatinine of 1.3 on the day of discharge. She was released by the cardiologist that day when he felt she was in no significant congestive heart failure and her BUN and creatinine were improving. She should follow up with the cardiologist in the near future for follow-up electrolytes and reevaluation of her congestive heart failure. While the patient was on the TCU, she also developed some ankle pain. It was somewhat swollen and was given a dose of steroids. She had quick resolution to the pain and swelling and likely this was an episode of acute ankle gouty arthritis. History and Physical Exam Admission Date: 04/12/XX Chief Complaint: Acute renal failure. Present Illness: This is a 77-year-old white female who was transferred down from the subacute unit to the acute care unit for increasing renal insufficiency. The patient was originally admitted on 03/28 with a BUN, creatinine of 32 and 1.4. The patient has been treated with I.V. Ancef and I.V. Lasix for cellulitis and pulmonary edema. Yesterday, her BUN and creatinine were found to be 78 and 2.3. She was transferred to the acute care unit for I.V. fluids and to monitor her renal function. This a.m., she complains of extreme right ankle pain. She denies any trauma to the right ankle, but she does give a history of generalized osteoarthritis. She reports that there is excruciating pain with weight bearing and with any movement. In addition, she reports that the right ankle is very tender to touch. Past Medical History: 1: Obesity 2: Renal failure 3: Bilateral lower extremity cellulitis 4: Hypertension5: Anemia 6: COPD 7: Seizure disorder Current Medications: 1: Lotrisone, b.i.d. topical to breast and groin 2: Prinivil, 40 mg po q. day 3: Dilantin—mg po b.i.d. 4: Benadryl, 25 mg q. 4 hours prn 5: Catapres, 0.1 mg prn 6: Tylox, 1-2 tabs po q.i.d. prn 7: Norvasc, 5 mg po q.day Allergies: No known drug allergies Review of Systems: The patient reports that she does have arthritis in her back and multiple joints. She denies a history of gout. She denies sporadic fevers, chills, cough, abdominal pain, GI or GU complaints. Social History: The patient is a smoker; she has smoked two packs of cigarettes per day for the previous 20 years. Physical Exam: BP 140/70, pulse 100, respirations 24, temperature 97.5. In general, this is an obese white female in no acute distress. HEENT: Atraumatic, normocephalic. Pupils equal, round, and reactive. Oropharynx is clear. Neck: Supple; no lymphadenopathy; trachea midline. Lungs: Lungs reveal few crackles, right base. Heart: Regular rate and rhythm; S1, S2, no murmur, click, gallop, or rub. Abdomen: Protuberant, positive bowel sounds, and nontender. Extremities: Chronic venous changes bilaterally with trace edema. Right lateral malleolus is very tender to palpation, range of motion is limited by pain. There is no calf or thigh tenderness. Laboratory Data/Clinical Tests: Glucose 98, BUN 76, creatinine 2.1, calcium 8.2, sodium 134, potassium 4.4, chloride 94, total CO2 30 Assessment/Plan 1: Renal failure. This is most likely prerenal secondary to overdiuresis. We will hold her diuretics and continue with general I.V. fluids. Her BUN, creatinine is slightly improved today since yesterday with this therapy. Urine electrolytes and eosinophils are currently pending. 2: Right ankle pain. Etiology not completely certain. There is no history of trauma. I question if this could possibly be an inflammatory arthritis monoarticular such as gout. We will check a sed rate and a rheumatoid factor. We will hold off on giving the patient any nonsteroidal anti-inflammatories, in light of her renal failure. We'll continue with the Tylox and give her a trial of SoluMedrol. We'll also check a foot x-ray. 3: Cellulitis. This is stable, off of her antibiotics. 4: Hypertension. We will continue her current treatment. True or False: The assigned MS-DRG for this admission contains a CC or MCC.

False The MS-DRG for this admission is 684, Renal Failure without CC/MCC.

CCW 7.14. This 56-year-old female was admitted for resection of an adrenal mass. The patient has had hypertension and palpitations of several years' duration treated with Toprol under good control. Ultrasound was done in consideration of the possibility of a mass, and catecholamine studies have been normal. A 4- to 5-cm right adrenal mass was identified. Dr. White had obtained a 24-hour urinary free cortisol, ACTH, and short suppression tests, all of which confirmed the presence of Cushing's syndrome. The patient was not diabetic. She did report weight gain, some shift in body configuration, and easy bruising of several years' duration. The easy bruising was identified on examination in the hospital. Surgery: A 5-cm, well-circumscribed round cortical tumor was resected from the adrenal gland via an open approach. Pathology report confirmed that the tumor was benign. Allergies: No known drug allergies Medications on Discharge: Hydrocortisone, rapidly tapering dose, currently on 40 mg daily; Toprol 50 mg q. a.m.; Prevacid 30 mg q. d.; Lipitor 10 mg q. a.m.; Prempro 0.625/2.5 Physical Exam: Vital signs stable. HEENT: Sclerae and conjunctivae clear. Neck: Supple. No palpable thyroid. Lungs: Somewhat decreased breath sounds currently. There is mild splinting with deep breathing. Abdomen: Tenderness in the incision area. She has active bowel sounds at this time. Extremities: No definite bruises currently. No edema noted. Discharge Diagnosis: Right adrenal tumor with Cushing's syndrome secondary to tumor Plan: The patient appears to have tolerated the surgery well. She will require steroid replacement. Excess cortisol output is presumed entirely due to her tumor, and her ACTH was suppressed previously. As with exogenous steroid therapy, there will be contralateral adrenal suppression. The patient will be tapered rapidly to replacement hydrocortisone levels. We will try the remaining hydrocortisone withdrawal over the next 6 months or so, depending on her ACTH and cortisol responses. She is discharged to home with follow-up in my office in 1 week. Which of the following MS-DRGs is correct for this admission?

614 Adrenal and Pituitary Procedures with CC/MCC

CCW 7.12. Excluding the principal diagnosis, what other code affects the MS-DRG assignment for this admission?

K86.1 Rationale: MS-DRG 327 is the correct MS-DRG assignment. The code K86.1 is a CC, which affects the MS-DRG assignment.

CCW 7.37. Which MDC does this MS-DRG belong to?

MDC 1 Diseases and Disorders of the Nervous System (medical)

CCW 4.13. This 55-year-old female patient is admitted with occlusion of the cerebral arteries resulting in an infarction. The patient suffered a stroke two years ago with residual hemiplegia affecting her left dominant side. Residual aphasia is also present from the previous stroke. What would be the correct code assignment for this case?

MS-DRG: 065 Rationale: For code I63.50, the Alphabetic Index main term is Infarction, subterms cerebral, due to, occlusion NEC, cerebral arteries. For code I69.352 and I69.320, the Alphabetic Index main term is Sequelae, subterms stroke, hemiplegia and also aphasia. The Tabular List is consulted to assign the appropriate sixth character "2" representing left dominant side. A POA indicator is not assigned with I69.352 or I69.320 as category I69 codes (sequela of cerebrovascular disease) are exempt from POA assignment. Code Z86.73, Personal history of transient ischemic attack and cerebral infarction without residual deficits would not be assigned as the hemiplegia is a deficit still present from the previous stroke. Residual conditions from a previous cerebral infarction may be reported with an acute cerebral infarction (CMS 2017a, I.C.9.d.2).

CCW 4.26. A 55-year-old female was admitted with diabetic gastroparesis documented as due to steroid-induced diabetes. The patient is on long-term use of systemic corticosteroids, which are properly taken. What codes would be assigned?

MS-DRG: 074 Rationale: For code E09.43, the Alphabetic Index main term is Diabetes, subterms due to drug or chemical, with gastroparesis. Assign K31.84 for the gastroparesis. There is an instructional note present at K31.84 to code first the underlying disease such as diabetes. Guideline I.B.9 (CMS2017a) states that when the combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code. Refer also to guideline I.B.7, Multiple coding for a single condition (CMS 2017a). At category E09, there is an instructional note to use additional code for the adverse effect. For code T38.0X5A, access the Table of Drugs and Chemicals entry Steroid, adverse effect. All diagnoses are present on admission. For code Z79.52, the Alphabetic Index main term is Long- term drug therapy, subterms steroid, systemic. Code Z79.52 is exempt from POA assignment.

CCW 4.69. This 32-year-old female patient was admitted to undergo extended video EEG monitoring for refractory complex partial epilepsy to determine if she is a candidate for epilepsy surgery. The patient was monitored for three days and her epilepsy medications were adjusted. The rest of her hospital stay was uneventful. What codes are assigned? CCW 4.69. This 32-year-old female patient was admitted to undergo extended video EEG monitoring for refractory complex partial epilepsy to determine if she is a candidate for epilepsy surgery. The patient was monitored for three days and her epilepsy medications were adjusted. The rest of her hospital stay was uneventful. What codes are assigned?

MS-DRG: 101 Rationale: For code G40.219, the Alphabetic Index main term is Epilepsy, with complex partial seizures—see Epilepsy, localization-related, symptomatic, with complex partial seizures, intractable. There is a note in the Alphabetic Index under main term Epilepsy, which identifies that refractory is synonymous to intractable. The POA indicator is "Y," as epilepsy was present on admission. For code 4A10X4Z, the Alphabetic Index main term is Monitoring, subterms central nervous, electrical activity. Table 4A1 is consulted to assign approach value "X" for external approach, and function value "4" for electrical activity. The root operation Monitoring is defined as determining the level of a physiological or physical function repetitively over a period of time.

CCW 4.43. An elderly nursing home patient was admitted for pneumonia. He has frequent aspiration because of difficulty swallowing due to a previous stroke. This pneumonia was documented as aspiration pneumonia. He was also found on admission to have stage 2 decubitus ulcer on the left buttock. The patient received skin care by the nursing staff for this ulcer. What codes are assigned in this case?

MS-DRG: 179 Rationale: The documentation links the aspiration to the pneumonia and meets principal diagnosis reporting guidelines. Secondary diagnosis reporting of the dysphagia due to old stroke and stage two decubitus ulcer were evaluated and utilized nursing resources. For code J69.0, the Alphabetic Index main term is Pneumonia, subterm aspiration. For code I69.391, the Alphabetic Index main term is Dysphagia, subterms following, cerebrovascular disease, cerebral infarction. Instructional notes at I69.391 direct to assign an additional code for the type of dysphagia. For code R13.10, the Alphabetic Index is Difficulty, swallowing—see dysphagia. For code L89.322, the Alphabetic Index main term is Ulcer, subterm decubitus—see Ulcer, pressure, by site; Ulcer, pressure, stage 2, buttock. Code I69.391 is POA exempt. All other diagnoses were present on admission.

CCW 4.92. A 75-year-old male was admitted to the hospital in acute respiratory failure. He has emphysema due to his continuous cigarette smoking for over 50 years. Sputum cultures showed streptococcus A pneumonia. He was intubated in the ER and started on mechanical ventilation. Thirty-six hours later he was extubated and was able to breathe on his own. He was started on Chantix to treat his dependence on nicotine. Diagnosis: Acute respiratory failure, pneumonia due to streptococcus A, and emphysema. What codes are assigned?

MS-DRG: 208 Rationale: Coding Guideline I.C.10.b.1. (CMS 2017a) states that acute respiratory failure may be assigned as the principal diagnosis when it is the condition established, after study, to be chiefly responsible for occasioning the admission to the hospital, and the selection is supported by the alphabetic index and tabular list. For J96.00, the Alphabetic Index main term is Failure, subterms respiration, respiratory. For J15.4, the Alphabetic Index main term is Pneumonia, subterms streptococcal NEC, group, A. For J43.9, the Alphabetic Index main term is emphysema. For F17.210, the Alphabetic Index main term is Smoker—see Dependence, drug, nicotine; Dependence, drug, nicotine, cigarettes. All conditions are present on admission and assigned a POA indicator of Y (yes). For code 5A1945Z, the Alphabetic Index main term is Performance, subterms respiratory, 24—96 consecutive hours, ventilation. For code 0BH17EZ, that Alphabetic Index main term is Insertion, subterms, device, trachea (Coding Clinic, 4th Quarter, 2014).

CCW 7.1. The following documentation is from the health record of an 87-year-old female patient. Discharge Summary History of Present Illness: The patient is an 87-year-old female who was admitted from a nursing home with dehydration and pleural effusion, as well as urinary tract infection and thrombocytopenia with petechial hemorrhage. On admission, she was found to have a platelet count of 77,000 and a hematology consultation was done. The patient denied any bleeding diathesis in the past. She stated that she had recent bruising of the hands related to needle sticks but otherwise has not had any past history of any bleeding disorder. She stated she was taking aspirin on a regular basis. No specific history of hematuria, hematemesis, gross rectal bleeding, or black stools. Past Medical History: Significant for chronic diastolic heart failure and Type 2 diabetes mellitus Medications: Coreg, isosorbide, aspirin, Actos, digoxin, glyburide, hydralazine, furosemide, Ditropan, and potassium Family History: No family history of any bleeding disorder Physical Examination: She is an elderly-appearing white female, somewhat short of breath, using supplemental oxygen. Examination of the head and neck revealed no scleral icterus. Throat was clear. Tongue was papillated. There was no thyromegaly or JVD. There was no cervical supraclavicular, axillary, or inguinal adenopathy. Chest examination revealed rales, bilaterally. There were decreased breath sounds at the right base. There were coarse rales heard in the right midlung field. Heart examination showed rhythm was irregularly irregular. Abdomen examination was difficult to perform. I was unable to palpate the liver or spleen. Bowel sounds were active. Extremities revealed no clubbing, cyanosis, or edema. There were diffuse ecchymoses, especially in the dorsum of the right hand. Laboratory Studies: Hematocrit was 43, white blood cell count 9,000 with 82 percent neutrophils, and the platelet count 77,000. The MCCV was 102. Creatinine was 1.7. Bilirubin was 1.7. The alkaline phosphatase was 122. AST 498, ALT 493, and albumin 3.6. The prothrombin time was 18 seconds and the PTT was 25 seconds. The chest x-ray showed a right pleural effusion. Course in Hospital: The patient was admitted and started on IV fluids. Her diuretics were increased, and she showed a good response with a resolution of her pleural effusion and better control of her congestive heart failure. Hematology consult recommended holding platelet transfusion unless there was evidence of active bleeding. No platelets were given during this admission. The patient was discharged back to the nursing home on day six in improved condition to continue with the same medication regimen as previous to hospitalization. Final Diagnoses: 1. Pleural effusion from acute on chronic diastolic congestive heart failure 2. Dehydration 3. Primary thrombocytopenia with petechial hemorrhage and hematoma of the eyelids and arms and hands 4. Urinary tract infection 5. Type 2 diabetes mellitus

MS-DRG: 292 The correct MS-DRG assignment is 292, Heart Failure and Shock with CC.

CCW 7.12. The patient is a 56-year-old male who was admitted with a history of hematemesis for the past 36 hours. He also had some tarry black stools and was noted to have a giant gastric ulcer which was actively bleeding. Patient was subsequently referred for surgical intervention. Final Diagnosis: 1. Acute gastric ulcer 2. Chronic pancreatitis 3. Liver cirrhosis due to alcoholism 4. Cirrhosis due to chronic hepatitis C Procedure Performed: Subtotal gastrectomy with Billroth II anastomosis Operative Procedure: The patient was brought to the operating room and placed on the table in a supine position, at which time general anesthesia was administered without difficulty. His abdomen was then prepped and draped in the usual sterile fashion. An upper midline incision was made. The peritoneum was then entered using the Metzenbaum scissors and hemostats. A retractor was placed, and he was noted to have a cirrhotic liver with micronodular cirrhosis. The left lobe of the liver was mobilized at that point, and the retractors were placed. On palpation of the stomach along the lesser curvature at approximately the mid portion, there was a large gastric ulcer located in the body of the stomach. At this point, the gastrocolic omentum was taken off the greater curvature of the stomach to the level just above the pylorus. Additionally, the lesser omentum was taken down off the lesser curvature of the stomach to the level of the pylorus. The body of the stomach was then transected approximately 3 cm above the ulcer. At that point, the stomach was reconstructed in a Billroth II fashion by bringing the jejunum through the transverse colon mesentery. Two stay sutures were placed to align the jejunum along the posterior wall of the stomach, and a GIA stapler was used to create the anastomosis without difficulty. The stomach and jejunum were then pulled below the transverse colon mesentery, and this was tacked in several places using 3-0 silk sutures. A feeding jejunostomy tube was then placed distal to this using the feeding jejunostomy kit without difficulty. The abdomen was then irrigated thoroughly using normal saline solution. Hemostasis was achieved using Bovie electrocautery. The midline incision was then closed using #1 PDS in a running fashion. The skin was closed using skin staples. A sterile dressing was applied. The patient was extubated in the operating room and returned to the Intensive Care Unit in guarded condition.

MS-DRG: 327

CCW 4.18. The patient was admitted because of severe abdominal pain. There has been a history of abdominal pain and some bleeding, but never this severe. Because of the symptoms, the patient underwent emergency laparotomy to repair the perforation in the antrum of the stomach by suturing. The physician states: acute peptic ulcer with perforation and bleeding. What codes are assigned for this case?

MS-DRG: 328 Rationale: The Alphabetic Index main term is Ulcer, subterms stomach, acute, with, hemorrhage, and perforation. The procedure was suture of gastric ulcer. The Alphabetic Index main term is Repair, subterm stomach. Documentation indicates a laparotomy was done, therefore the approach value is "0" for open technique.

CCW 4.22. An 80-year-old patient with hypertension was admitted to the hospital for cholecystectomy. The patient underwent an attempted laparoscopic cholecystectomy. Upon entry into the peritoneal cavity, it was noted that there were extensive peritoneal adhesions and the gall bladder could not be visualized. The procedure was converted to an open cholecystectomy with exploration of the common duct and choledocholithotomy. A stone was removed from the common bile duct. Final diagnostic statement: 1. Acute and chronic cholecystitis with choledocholithiasis and cholelithiasis. 2. Hypertension. Correct code assignment is:

MS-DRG: 413 Rationale: For code K80.66, the Alphabetic Index main term is Calculus, gallbladder and bile duct, with cholecystitis, acute, with, chronic cholecystitis. For code K66.0, the Alphabetic Index main term is Adhesions, peritoneum. For code I10, the Alphabetic Index main term is Hypertension. A laparoscopic procedure was attempted but converted to an open procedure. Alphabetic Index main term is Procedure, converted, laparoscopic to open. Also, see Coding Guideline B.3.2.d (CMS 2017b). Multiple procedures are coded if the intended root operation is attempted using one approach but is converted to a different approach. If the laparoscopic procedure had been completed (without converting to open), it would have been coded as a percutaneous endoscopic resection. For code 0FT40ZZ, the Alphabetic Index main term is Resection, subterm gallbladder. The approach value is "0" for open. For code 0FC90ZZ, the Alphabetic Index main term is Choledocholithotomy. For code 0WJG4ZZ, the Alphabetic Index main term is Inspection, subterm peritoneal cavity. The inspection of the peritoneal cavity was performed laparoscopically. Review Coding Guideline B3.11c (CMS 2017b) regarding coding Inspection procedures.

CCW 4.60. Discharge Summary Date of Admission: 06/28/XX Date of Discharge: 07/07/XX Diagnoses: 1. Status post fractured right femoral neck. 2. Chronic obstructive pulmonary disease. 3. Rheumatoid arthritis, steroid dependent. 4. Osteoporosis. Pertinent History: The patient was admitted on the 28th of June after a fall. She did not pass out but just fell and fractured her hip. She fell off of a stool at home. She underwent surgery for this. She had a hemiarthroplasty. She tolerated the procedure well and was transferred to A Pavilion for continued physical therapy and rehabilitation. Pertinent Laboratory: CBC initially showed a white count of 15,400, subsequently the white count is 10,900 with 78 neutrophils. H&H was stable at 12.2 and 36.9. Theophylline level was 10.3, therapeutic. Hospital Course: The patient tolerated physical therapy well. She was able to give her own Lovenox shots. She was anxious to go home on Saturday. Orthopedics had planned for 14 more days of Lovenox, and that will be given by the patient and prescribed by Dr. Thomas's group. She will be back in about 3 weeks. She will continue with her current medications, which are proventil 2 puffs q.i.d., Fosamax 10 mg q.a.m., Soma 350 mg q.i.d., Lovenox 30 mg q. 12 hours, folic acid 1 mg q. day, Lasix 40 mg b.i.d., Atrovent 2 puffs q. 6 hours, synthroid 0.075 q day, potassium 20 mEq b.i.d., prednisone 20 mg a day, Theo-Dur 100 mg in the morning and 200 mg in the evening. She takes Sonata and she will continue with 5 mg q.h.S. She will continue with her laxative of choice. She will restart her Nasonex, Celebrex, Vicodin, and Vanceril when she gets home. She will stay on a regular diet. Activities per her primary care physician. She will see me back in 3 weeks. History and Physical Examination Admission Date: 6/28 Chief Complaint: Hip fracture. Present Illness: The patient is a 79-year-old white female who slipped off of a stool in her apartment's kitchen while talking to her daughter. She was apparently trying to do too many things at one time, trying to clean some books or something like that and then just slipped and fell off and fractured her hip. She lives alone and had to call for help. She denies any type of passing out, no head injury, and no history of falling a lot before. Past Medical History: The patient denies any kind of past history of chest pains, exertional chest pain. She stopped smoking some time ago but continues to be mildly short of breath and that has been stable. She has no gastrointestinal (GI) symptoms, only occasionally some mild stress incontinence. Medications: 1. Nasonex nasal spray 2. Soma 350 mg 1 q.i.d. 3. Potassium 10 mEq. 2 b.i.d. 4. Celebrex 200 mg q.d. 5. Synthroid 0.075 q.d. 6. Vicodin p.r.n.7. Fosamax 10 mg q.a.m. 8. Theo-Dur 200 mg ~ in the morning and 1 in the evening 9. Folic acid 1 q.d. 10. Lasix 40 mg b.i.d. 11. Prednisone 10 mg. 2 g.d. 12. Vanceril inhaler 13. Atrovent inhaler 14. Albuterol inhaler Allergies: Halcion, which causes her to hallucinate. Medical History: Her medical history includes rheumatoid arthritis, chronic obstructive pulmonary disease (COPD), osteoporosis, and congestive heart failure (CHF). Social History: She is a widow, stopped smoking 12 years ago. Does not use any alcohol. Family History: Noncontributory. Physical Examination: Finds her alert and oriented in no acute distress. Her blood pressure is 140/68, pulse 74, respirations 18. She was afebrile. HEENT: Examination was negative. Neck: Supple without any adenopathy, no bruit was heard. Chest: Clear to auscultation. Heart: Sounds regular without any murmur or gallop. Abdomen: Soft, positive bowel sounds, nontender, no bruits heard. Extremities: Showed normal vascular status. Laboratory and X-Ray Data: She has a complete blood count (CBC) and urinalysis essentially normal. EKG shows no acute changes. Chest x-ray is pending at this time. If that is normal, she will be able to go on to surgery; that is decided on by Dr. Rowan. Impression(s): 1. Fracture right femoral neck. 2. Chronic obstructive pulmonary disease and rheumatoid arthritis. She is steroid dependent so we are going to increase the amount of steroids that she is taking right now. Continue her on her inhalers and restart her oral medications as directed later. Operative Report Date: 06/28 Preoperative Diagnosis: Displaced right femoral neck hip fracture. Postoperative Diagnosis: Displaced right femoral neck hip fracture. Operation: Right hip hemiarthroplasty (Zimmer LD/Fx cemented monopolar metal prosthesis). Anesthesia: Spinal. Indications: This is a 79-year-old, previously ambulatory female with a history of rheumatoid arthritis, osteoporosis, steroid-dependent, and emphysema, with the above diagnosis. Risks, benefits, and alternatives of the above procedure were explained to the patient in detail, and she consented to proceed. Operative Procedure: The patient was taken to the operating room and placed in the lateral position on the transfer bed, where spinal anesthesia was administered. She was transferred to the left lateral decubitus position on a beanbag on the operative table. Padded all bony prominences. Peritoneum was sealed off with Steri-Drape. The right hip was prepped and draped in the usual sterile fashion. Longitudinal incision over the greater trochanter and proximal femur was performed curving posteriorly proximally along the gluteus maximus. Sharp dissection to the skin, Bovie dissection to the subcutaneous tissues down to tensor fascia lata, identifying the greater trochanter. Besides the tensor fascia lata and along with the incision splitting the fibrous gluteus maximus, controlling bleeders with Bovie cautery. Piriformis was identified and short external rotators were tagged with a #5 Tycron suture. These are moved from their insertion. T capsulotomy was performed. Displaced hip fracture was identified, femoral head was removed and measured, copious irrigation was performed, acetabular was visibly and palpable normal appearing. Sagittal saw was used to make cut in the femoral neck. Box osteotome was used to gain lateral entrance to the canal. The canal finder was used, easily locating the femoral canal. Sequential broaching was performed up to a 14, which fit well. Stating the appropriate anteversion. Trawled with an endofemoral head. Had full range of motion without instability and grossly equal leg lengths. I could bring the hip and knee up to 90 degrees of flexion, neutral adduction, start to internally rotate to 30 degrees before it would become unstable. Hip was redislocated, trial components were removed. Measured the canal for a centralizer. I placed a distal cement restrictor 2 cm distal to the component. Copious lavage of the canal was performed and brushed. Acetabulum was irrigated clean; palpable and visibly free of loose fragments. It was packed off with lap sponge. Dried the femoral canal. Placed cement in the femoral canal with retrograde manor using proximal pressurizer. Placed the 14-mm Zimmer LD/Fx with a distal centralizer in the appropriate anteversion, held in place with a cement set. Copious irrigation was performed. After the cement set, placed the final endo head, tapped into position with Morris taper, reduced the head. Could take the hip through the same range of motion without any instability. The short external rotator is in the drill holes in the greater trochanter. The tensor fascia lata closed with interrupted 0-0 VICRYL suture. We copiously irrigated each layer. Subcutaneous tissue closed with interrupted 2-0 VICRYL sutures, skin was closed with staples. Sterile dressing was applied.

MS-DRG: 470 Rationale: The patient fell from the stool leading to the traumatic fracture. The physician did not identify the fracture as pathological or correlate the osteoporosis to the fracture in any way. For code S72.001A, the Alphabetic Index main term is Fracture, traumatic, subterms femur, upper end, neck. The Tabular List is consulted to assign seventh character "A" representing initial encounter for closed fracture. For code I50.9, the Alphabetic Index main term is Failure, subterms heart, congestive. For code J43.9, the Alphabetic Index main term is Emphysema. Emphysema was selected as it is a more specific respiratory condition. The physician could be queried to determine if there was also an obstructive component to the emphysema that would lead to a code in J44. For code M06.9, the Alphabetic Index main term is Arthritis, subterm rheumatoid. For code M81.0, the Alphabetic Index main term is Osteoporosis. For code Z87.891, the Alphabetic Index main term is History, subterms personal, tobacco dependence. Assign a code from category Z79 if the patient is receiving a medication for an extended period as a prophylactic measure, treatment of a chronic condition or a disease that requires a lengthy course of treatment. Do not assign for medication being administered for a brief period of time, medications for detoxification or maintenance programs or to treat an acute illness or injury (CMS 2017a, I.c.21.c.3). For code Z79.52, the Alphabetic Index main term is Long-term drug therapy, subterms steroids, systemic. For code Z79.83, the Alphabetic Index main term is Long-term drug therapy, subterm bisphosphonates. Diagnosis codes Z79.52 and Z79.83 are assigned because they influence treatment for the fracture. For code W08.XXXA, the External Cause Index main term is Fall, subterms from, off, out of, furniture NEC. For code Y92.030, the Alphabetic Index main term is Place of occurrence, subterms residence, apartment, kitchen. For code Y99.8, the Alphabetic Index main term is External cause status, subterm specified NEC. For code Y93.E9, the Alphabetic Index main term is Activity, subterm household maintenance NEC. Codes Z87.891, Z79.52, Z79.83, Y92.030, Y99.8, and Y93.E9 are POA exempt. All other conditions were present on admission. The Alphabetic Index main term is Replacement, subterms joint, hip, right, femoral surface. The Table is consulted to assign approach character "0" for open, device character "1" representing synthetic substitute, metal and qualifier "9" for cemented.

CCW 4.99. Discharge Summary The patient is a 45-year-old female who fell while walking her dog. She was walking on the sidewalk in her neighborhood and accidently tripped and subsequently fell. She sustained a comminuted fracture of the shaft of her right tibia confirmed by x-ray done in the emergency room. She also hit her head on a fire hydrant and suffered a slight concussion but no loss of consciousness. The patient also had a splinter of wood in her elbow from the fall. The patient was admitted and taken to surgery, where an open reduction with internal fixation was accomplished with good alignment of fracture fragments. Postop course was uneventful and the patient was discharged home with daily physical therapy.

MS-DRG: 494 Rationale: For S82.251A, the Alphabetic Index main term is Fracture, traumatic, subterms tibia (shaft), comminuted. The Tabular List is consulted to assign the sixth character "1" for displaced right and seventh character "A" for initial encounter for closed fracture. A fracture not indicated as open or closed is coded closed and a fracture not indicated as displaced or not displaced is coded to displaced (CMS 2017a, I.C.19.c). For S06.0X0A, the Alphabetic Index main term is Concussion. The Tabular List is reviewed to assign sixth character "0" representing without loss of consciousness and seventh character "A" for initial encounter. For S50.359A the Alphabetic Index main term is Splinter, see Foreign body, superficial, by site. For W01.198A, the External Cause Alphabetic Index main term is subterms Fall, due to, slipping, with subsequent striking against object, specified NEC. The Tabular List is consulted to assign seventh character "A" for initial encounter. For Y92.480, the Alphabetic Index main term is Place of occurrence, subterm street or highway, sidewalk. For Y93.K1, the External Cause Alphabetic Index main term is Activity, subterm walking an animal. For Y99.8, the External Cause Alphabetic Index main term is External cause status, subterm specified NEC. Code Y92.480, Y93.K1 and Y99.8 are POA exempt. The other conditions were present on admission. The Alphabetic Index main term is Reposition, subterms tibia, right. Table 0QS is reviewed to assign approach value "0" for open and device value "4" for internal fixation device.

CCW 4.53. This patient was admitted for treatment of a traumatic left second metatarsal fracture. The fracture site was opened and reduced, followed by placement of three internal Kirschner wires. Two pins were then placed via open approach, and an external fixator frame was connected to the pins to provide pressure and hold them in reduction. What codes are assigned in this case? Do not assign external cause codes.

MS-DRG: 505 Rationale: The Alphabetic Index main term is Fracture, subterms metatarsal bone, second. Fractures not stated as open or closed are coded to open and fracture not stated as displaced or nondisplaced are coded to displaced (CMS 2017a, I.C.19.c). Two procedure codes are required, one for the open reduction internal fixation of the metatarsal fracture and a second for the application of the external fixator. For code 0QSP04Z, the Alphabetic Index main term is Reposition, subterms metatarsal, left. The Table is consulted to assign the approach value "0" for open and device value "4" for internal fixation device. For code 0QHP05Z, the Alphabetic Index main term is Insertion of device in, subterms metatarsal, left. The Table is consulted to assign the approach value "0" for open and device value "5" for external fixation device.

CCW 4.96. This 32-year-old patient was brought to the emergency department after a gas leak caused an explosion at his home. He was admitted with third-degree burns of the upper back involving 9 percent of the body surface. What codes are assigned?

MS-DRG: 934 Rationale: For T21.33XA, the Alphabetic Index main term is Burn, subterms back, upper, third degree. For T31.0, the Alphabetic Index main term is Burn, subterm extent, less than 10 percent. For W40.1XXA, the External Cause Alphabetic Index main term is Explosion, subterms explosive, gas. For Y92.009, the External Cause Alphabetic Index main term is Place of occurrence, residence. A code from category Y93 is not assigned as the activity is not stated in the documentation (CMS 2017a, I.C.20.c). Code Y92.009 is not assigned a POA indicator as it is on the POA exempt list. All other conditions are present at the time of admission.

CCW 4.46. This 85-year-old patient, who is a resident at the skilled nursing facility, was admitted with a severe decubitus ulcer on the right buttock, stage 2, and a small chronic ulcer on the left heel limited to the skin area. Patient also has Alzheimer's disease. The treatment was an excisional debridement of the skin of the heel and an open excisional debridement into the gluteus maximus muscle of the buttock. What is the code assignment?

MS-DRG: 571 Rationale: For code L89.312, the Alphabetic Index main term is Ulcer, subterm decubitus—see Ulcer, pressure, by site; Ulcer, pressure, stage 2, buttock. The Tabular List is consulted to assign additional characters that designate laterality and stage. For code L97.421, the Alphabetic Index main term is Ulcer, subterm lower limb, heel, left, with skin breakdown only. For codes G30.9 and F02.80, the Alphabetic Index main term is Disease, subterm Alzheimer's. All conditions were present on admission. Two procedure codes are required as the debridements occurred in different body parts (CMS 2017b, B3.2a). The excisional debridement of the buttock ulcer is described as excision of muscle. For code 0KBN0ZZ, the Alphabetic Index main term is Excision, subterms muscle, hip, right. To identify the appropriate body part, review the Body Part Key anatomical term, gluteus maximus muscle, which refers the coding professional to PCS description, hip muscle. For code 0HBNXZZ, the Alphabetic Index main term is Excision, subterms skin, foot, left. The approach is external as this includes procedures performed directly on the skin.

CCW 7.50. The following documentation is from the health record of a 57-year-old male patient. Preoperative Diagnosis: Chronic right calf skin ulcer with necrosis of the bone Postoperative Diagnosis: Same with E. coli sepsis with acute respiratory failure and disseminated intravascular coagulation (DIC) after admission Procedure: Right below-the-knee amputation (BKA) Description of Procedure: The patient was brought to the operating room and placed supine on the operating room table. The patient was placed under general endotracheal anesthesia. A tourniquet was placed on the right proximal thigh and the right lower extremity was prepped and draped in a standard sterile fashion. A below-the-knee amputation was carried out directly below the tibial tubercle with a posteriorly based flap. The skin and soft tissue were cut sharply to bone along the line of the skin incision. Once the soft tissue was incised the tibia and fibula were provisionally cut with an oscillating saw and the remainder of the right lower extremity was removed and sent to pathology. Next, the tibia and fibula were dissected out subperiosteally proximal to the anterior portion of the skin incision and recut with the oscillating saw. The anterior portion of the tibia was beveled again with the oscillating saw and smoothed with a rasp. The fibular cut was beveled in a lateral to medial direction while extending posteriorly. The nerves and blood vessels were then addressed. The anterior tibial and posterior tibial arteries, as well as the peroneal artery and attendant veins, were suture ligated with #1 Vicryl suture. The anterior and posterior tibial nerves and peroneal nerve were also identified, pulled out of the wound, cut short, and allowed to retract back into the soft tissue. In addition, large veins were identified and ligated. The tourniquet was then released for a total tourniquet time of 32 minutes and minimal bleeding was encountered. Several smaller bleeders were ligated. There was some clotting observed, which was important as the blood clotting was of significant concern preceding this operation. The wound was closed over a medium Hemovac drain with two limbs, with the posterior flap brought anteriorly. The fascia was closed using interrupted 1 Vicryl suture, and the subcutaneous tissue was closed using interrupted 3-0 Monocryl suture in a simple buried fashion. Staples were placed at the level of the skin in the interest of time. After a sterile compressive dressing was placed and Hemovac drain extension and reservoir were attached and activated, the patient was awoken from anesthesia and sent to the ICU in unchanged condition.

MS-DRG: 579 Rationale: 579, Other skin, subcutaneous tissue & breast procedures with MCC

CCW 7.13. Discharge Summary Principal Diagnosis: Morbid obesity Principal Procedure: Open Roux-en-Y gastric bypass, removal of gastroplasty ring, gastric (G) tube prior placement; gastroscopy History of Present Illness: The patient is a 55-year-old white female with a history of gastroplasty ring placement in 1979 who comes to Dr. Smart for revision by doing a Roux-en-Y gastric bypass because of recurrence of her morbid obesity. Her morbid obesity is complicated by gastroesophageal reflux disease (GERD) and obstructive sleep apnea (OSA). Past Medical History: (1) Morbid obesity. (2) OSA. (3) GERD. Past Surgical History: (1) Gastroplasty in 1979. (2) Laminectomy. Allergies: Keflex Medications: Pepcid q. d. Physical Examination: Vital signs: Afebrile, vital signs stable. General: No acute distress. Cardiovascular: regular rate and rhythm. Abdomen: Soft, nontender, nondistended. Impression: A 55-year-old white female with a history of gastroplasty, needing a revision into a Roux-en-Y gastric bypass after morbid obesity not secured. Hospital Admission: The patient was admitted through same-day surgery and taken to the operating room for open Roux-en-Y gastric bypass with removal of a gastroplasty ring, and G tube placement. Afterward, she was taken to the ICU because of her obstructive sleep apnea. She was monitored closely, did very well, and afterward, she was transferred to the floor. She was full advanced to activities of daily living through our gastric bypass protocol. She advanced to gastric bypass soft diet by postoperative day four. She did well with this. On postoperative day five, she was deemed ready to go home. She understands her discharge instructions and will be given pain medications as well as continue prescription for Zantac for her GERD and for marginal ulcer prophylaxis. Condition on Discharge: Stable on postoperative day five from open Roux-en-Y gastric bypass Disposition: The patient was discharged home with family. Medications: Resume previous home medications. The patient can resume her Pepcid, or she can continue taking Zantac 150 b.i.d. Follow-up: The patient will follow up with Dr. Smart. Diet on Discharge: Gastric bypass soft diet. She has been instructed by a dietician two times already. Operative Report Preoperative Diagnosis: Morbid obesity with gastroplasty dysfunction Postoperative Diagnosis: The same Operation: Revision gastroplasty to Roux-en-Y gastric bypass Indications: This 55-year-old lady had undergone a Silastic ring gastroplasty by another surgeon in 1979 at a weight of more than 250 lb. She had done well for a long time and then had started regaining her weight and also developed significant gastroesophageal reflux disease. A gastric endoscopy done preoperatively during this admission showed that the Silastic ring of her gastroplasty had eroded into the gastric lumen with a wide outlet from the pouch and also with a separate dehiscence of the staple line. The erosion was due to the patient's increased weight gain. In the interim, she had developed sleep apnea but did not have hypertension or diabetes. Following the endoscopy and because of being on disability related to a laminectomy and to spinal problems, the excess weight seemed to aggravate her disability and seemed a justifiable reason for a surgical intervention. Description of Procedure: With the patient supine on the operating table and under satisfactory general anesthesia, we attempted a right and then left subclavian line but had difficulties with the wire guide. Subsequently, a neck central line was placed and the abdomen was prepped and draped in a sterile manner. An upper midline incision was made and carried through the fat by tearing and through the fascia with the cautery. There were adhesions immediately of omentum to the anterior abdominal wall and also to the lower abdominal wall where a paramedian incision had been. These were all lysed, which was not difficult. The gallbladder was emptied sufficiently to know that there were no stones. The uterus and ovaries were surgically absent. We began by lysing adhesions on the undersurface of the left lobe of the liver to the stomach until we were able to uncover the old gastric pouch and appreciate the location of the staple line. I could also appreciate where the Silastic ring was, separate from the nasogastric tube, which was brought inside. We dissected around the distal esophagus and brought a long Penrose drain around it for retraction purposes. I held up the portion of the stomach near the lesser curve where the Silastic ring was palpable, and we used the cautery to enter into the lumen to find the ring. Its suture was cut and the ring was removed and sent to pathology. The opening made for the gastrotomy was closed with interrupted 2-0 silk sutures. We then dissected a little more proximal to this location along the lesser curve to go around the serosa of the stomach to its backside. A 12 French Robinson catheter was put along this tract and turned around to come to hold the lesser omentum on traction. We also divided some of the gastrocolic omentum to gain access from the lateral side to the posterior lesser sac. We then used a 45-mm blue load endoscopic autosuture stapler to staple and transect the stomach at the lesser curve transversely to create the posterior part of our pouch. When this was done, there was still a small hole into the distal stomach and perhaps into the proximal pouch where the staples had found the tissue too thick to seal completely. On the gastric pouch side, this was managed by an over-and-over suture of 2-0 Prolene from one edge to the other. On the gastric side, this was managed with interrupted 2-0 silk sutures. We then dissected behind the stomach up to the angle of His and eventually were able to pass the 12 French Robinson catheter through the angle of His and around the stomach to represent the pathway for the stapler to go at a later time. We lifted the omentum upward and identified the ligament of Treitz. The jejunum was divided a measured 7.5 inches beyond that ligament, and the mesentery at that level was divided using the endoscopic stapler. The small bowel was then measured from that point to the cecum, which proved to be 204 inches, and we selected a 72-inch Roux limb length. The side-to-side jejunojejunostomy was created with the biliopancreatic limb and the Roux limb using an outer running 3-0 Prolene seromuscular layer and an inside GIA stapled anastomosis. The Prolene was continued over the holes made for the stapler and also used to invert the stapled edge of the biliopancreatic limb. The aperture between the two mesenteric leaves was closed with a couple of 3-0 silk sutures. We then made a channel through the omentum up to the transverse colon and then across the gastrocolic omentum to allow the Roux limb to lie easily antecolic up near the pouch. When this placement was assured, the Roux limb was fixed to the end of our pouch with three interrupted 3-0 silk seromuscular sutures. The cautery was used to make an opening in the jejunum in the gastric wall and the posterior part of the anastomosis was done with interrupted 3-0 VICRYL suture. An opening was made in the Roux limb through which a 10-mm Hegar dilator was passed through the jejunal and gastric sides of the anastomosis. That anastomosis was then sutured with the VICRYL over the dilator and then further reinforced with interrupted 3-0 silk seromuscular sutures. When this was done, we removed the dilator and passed the nasogastric tube through the anastomosis to lie in the Roux limb. The end of the Roux limb was then oversewn with a running 3-0 Prolene suture. After this, we used the 60-mm blue load endoscopic stapler to begin to transect the gastric pouch from the remainder of the stomach, going vertically towards the angle of His. It ultimately took three 45-mm cartridges after the first 60-mm cartridge in order to complete this, but it was done satisfactorily. We used 2-0 Prolene to oversew that vertical staple line throughout its length. We also used the 2-0 Prolene to oversew the gastric staple line throughout its length. The anastomosis in the pouch looked fine, and we made sure that the nasogastric tube was movable within the pouch. We then created a gastrostomy to the distal stomach, with a 2-0 silk purse-string suture near the greater curve. A 22 French Foley catheter was brought through a left upper quadrant stab wound and on into the stomach, and the balloon was filled. A purse-string suture was tied, and a couple of 2-0 silk sutures between stomach and abdominal wall were placed. After this, we irrigated the abdomen with an antibiotic solution containing Kantrex and bacitracin. All of the bowel and omentum was laid back in its normal position, and there was no tension on the Roux limb. The fascia was then closed with a running #1 loop PDS suture. The subcutaneous fat was cleaned with antibiotic solution and the skin was closed with 3-0 VICRYL dermal sutures and 3-0 VICRYL subcuticular sutures. The patient tolerated the procedure well and was taken to the SICU. Estimated blood loss was 350 mL, and the sponge count was correct.

MS-DRG: 621 Rationale: MS-DRG 621 O.R. Procedures for Obesity W/O CC/MCC Endocrine, Nutritional, and Metabolic Diseases and Immunity

CCW 4.36. The 56-year-old patient who has type 1 diabetes mellitus is admitted with acute renal failure. Past medical history includes: benign hypertension, diabetic chronic kidney disease stage 4. What codes are assigned?

MS-DRG: 684 Rationale: For code N17.9, the Alphabetic Index main term is Failure, subterms renal, acute. For code I12.9, the Alphabetic Index main term is Hypertension, subterm kidney, with, stage 1 through 4 chronic kidney disease. Notice the Excludes2 note at category I12 indicating that acute renal failure is not included in this code. An instructional note is present at I12.9 and E10.22 directing to assign an additional code to identify the stage of the chronic kidney disease. For code N18.4, the Alphabetic Index main term is Disease, subterms kidney, chronic, stage 4. For code E10.22, the Alphabetic Index main term is Diabetes, subterm Type 1, with, chronic kidney disease. Note that, unlike ICD-9-CM, ICD-10-CM does not offer separate code selections for "benign" or "malignant" hypertension. They are now included as non-essential modifiers under Hypertension in the Alphabetic Index.

CCW 4.32. This 80-year-old female patient was admitted with fever, malaise, and left flank pain. A urinalysis was performed and showed bacteria more than 100,000/mL. This was followed by a culture, showing Escherichia coli growth documented as acute pyelonephritis due E. coli. On day 2 the patient had an exacerbation of chronic obstructive pulmonary disease (COPD) and was treated with an inhaler. This resolved the same day. Patient is also on current medication therapy for hypertension and arteriosclerotic heart disease (ASHD) of the native vessels. What codes are assigned for this encounter?

MS-DRG: 690 Rationale: The symptoms of the acute pyelonephritis are not coded, as they are integral to the acute pyelonephritis. The additional conditions meet reporting guidelines as secondary diagnoses because they are current conditions evaluated and/or treated during the hospitalization. For N10, the Alphabetic Index main term is Pyelonephritis, subterm acute. For code B96.20, the Alphabetic Index main term is Infection, subterms bacterial, as cause of disease classified elsewhere, Escherichia coli (E. coli) B96.20. For code J44.1, the Alphabetic Index main term is Disease, subterms lung, obstructive (chronic), with, acute, exacerbation NEC. For code I25.10, the Alphabetic Index main term is Disease, subterms heart, ischemic, atherosclerotic. For code I10, the Alphabetic Index main term is Hypertension. All conditions except the exacerbation of COPD were present at the time of admission. POA reporting guidelines for combination codes instructs coding professional to report N (no) if any part of the combination code was not present on admission and assign Y (yes) if all parts of the combination code were present on admission.

CCW 4.66. This patient was admitted with a large pelvic mass and underwent an exploratory laparotomy. Pathology confirmed carcinoma of the left ovary with extensive metastasis to the omentum. A total greater omentectomy, excision of left ovarian mass, and radical abdominal hysterectomy were performed, which in this case included removal of the uterus and upper vagina. Bilateral salpingo-oophorectomy was also performed. What codes are assigned?

MS-DRG: 737 Rationale: For code C56.2, the Table of Neoplasms main term is ovary, column, malignant primary. For code C78.6, the Table of Neoplasms main term is omentum, column, malignant secondary. For code 0DTS0ZZ, the Alphabetic Index main term is Resection, subterms omentum, greater. For code 0UT90ZZ, the Alphabetic Index main term is Resection, subterm uterus. For code 0UTC0ZZ, the Alphabetic Index main term is Resection, subterm cervix. For code 0UBG0ZZ, only part of the vagina was removed so the root operation is Excision. For code 0UT20ZZ, the Alphabetic Index main term is Resection, subterms ovary, bilateral. For code 0UT70ZZ, the Alphabetic Index main term is Resection, subterm fallopian tubes, bilateral. Refer to Coding Guideline B3.2a (CMS 2017b) regarding assignment of multiple procedure codes.

CCW 4.86. This is a 26-year-old patient who had a previous cesarean section via a low transverse incision for delivery for fetal distress. She had normal antepartum care and has had no complications. We are going to attempt a VBAC for this delivery. She is admitted in her 38th week in labor. The fetus is in cephalic position and no rotation is necessary. The labor continues to progress and five hours later she is taken to delivery. During the delivery she was fatigued, so low outlet forceps were required over a midline episiotomy which was subsequently repaired by an episiorrhaphy. A single liveborn infant was delivered. What codes are reported?

MS-DRG: 775 Rationale: For O75.81, the Alphabetic Index main term is Exhaustion, subterm maternal, complicating delivery. For O34.211, the Alphabetic Index main term is Cesarean delivery, previous, affecting management of pregnancy, low transverse scar. For Z37.0, the Alphabetic Index main term is Outcome of delivery, subterms single, liveborn. For Z3A.38, the Alphabetic Index main term is Pregnancy, subterms weeks of gestation, 38 weeks. Maternal fatigue, O75.81, was not present on admission so a POA indicator of N is assigned. The previous cesarean delivery, O34.21, and weeks of gestation Z3A.38, were present on admission so POA indicator of Y is assigned for both codes. Code Z37.0 is exempt from POA reporting. The low outlet forceps procedure is assigned from the Obstetrics Section as this procedure was per- formed on the products of conception. For code 10D07Z3, the Alphabetic Index main term is Extrac- tion, subterms products of conception, low forceps. The Table is reviewed to assign approach value "7" for via natural opening, and qualifier value "3" representing low forceps. The episiotomy is per- formed on the pregnant female rather than the products of conception; therefore, the procedure code is assigned from the Medical and Surgical Section. For code 0W8NXZZ, the Alphabetic Index main term is Division, subterm perineum, female. The Table is consulted to assign approach value "X" for external as the episiotomy is performed directly on the skin. The episiorrhaphy is not coded separately per CMS 2017b, B3.1b, which states that procedural steps necessary to reach the op- erative site and close the operative site are not coded separately.

CCW 4.40. This 25-year-old homeless patient was admitted with difficulty breathing. She has AIDS and is in the 21st week of pregnancy. Workup shows Pneumocystis carinii pneumonia. What codes are assigned in this case?

MS-DRG: 781 Rationale: In accordance with guideline I.C.15.f, during pregnancy, a patient admitted because of an HIV-related illness should receive a principal diagnosis from subcategory O98.7- , followed by the code(s) for the HIV-related illness (CMS 2017a). For code O98.712, the Alphabetic Index main term is Pregnancy, subterms complicated by, infection, human immunodeficiency. For code B20, the Alphabetic Index main term is Human, subterm immunodeficiency virus disease. The pregnancy is also complicated by the Pneumocystis carinii pneumonia, which meets reporting guidelines for a secondary diagnosis. For code O99.512, the Alphabetic Index main term is Pregnancy, complicated by, pneumonia. For code B59, the Alphabetic Index main term is Pneumocystis carinii pneumonia. For code Z3A.21, the Alphabetic Index main term is Pregnancy, subterms weeks of gestation, 21 weeks. For code Z59.0, the Alphabetic Index main term is Homelessness. All conditions were present on admission except Z59.0 which is exempt.

CCW 4.74. The patient is an 18-day-old baby girl admitted after it was noticed she was developing drainage from the umbilical cord. Upon admission she was placed on intravenous Cefotaxime and Ampicillin, later changed to Cefotaxime and Clindamycin. A culture taken from the umbilical stump grew Staphylococcus aureus and Group H streptococcus. After the first day, there was great improvement, and the baby continued to improve. She remained afebrile, has continued to eat very well, and she shows no sign of abdominal tenderness or peritonitis. The mother was instructed to watch the child closely and to notify the office if there is any redevelopment of the redness, swelling, or discharge. Recheck in two weeks for one month check-up. Discharge diagnosis: Staphylococcus aureus and Group H streptococcus omphalitis of the newborn. What codes are assigned?

MS-DRG: 793 Rationale: For code P38.9, the Alphabetic Index main term is Omphalitis. For code B95.61, the Alphabetic Index main term is Staphylococcus, subterms, as cause of disease classified elsewhere, aureus. For code B95.4, the Alphabetic Index main term is Streptococcus, subterm specified NEC, as cause of disease classified elsewhere.

CCW 4.5. The patient has peripheral neuropathy of multiple joints of the lower extremities secondary to severe rheumatoid arthritis for which he is taking azathioprine. The patient is admitted for azathioprine drug-induced aplastic anemia that was discovered in the clinic today. What code(s) is(are) assigned for this case?

MS-DRG: 810 Rationale: When coding anemia due to drugs, assign two codes, one for the specific type of anemia documented and the adverse effect to identify the drug. For code D61.1, the Alphabetic Index main term is Anemia, subterms aplastic, due to, drugs. For code T45.1X5A, the Table of Drugs and Chemicals substance is Azathioprine, and the column is adverse effect. For code M05.59, the Alphabetic Index main term is Neuropathy, subterm peripheral (nerve) (see also Polyneuropathy); Polyneuropathy, in (due to), rheumatoid arthritis—see Rheumatoid, polyneuropathy; Rheumatoid, polyneuropathy, multiple sites.

CCW 7.21. The following documentation is from the health record of a 71-year-old male patient. Discharge Summary History and Physical Findings: This 71-year-old male is a nursing home resident as a result of a cerebrovascular accident two years ago. He has had numerous hospital admissions for pneumonia and other infectious complications. On the day of admission (4/21), the patient was noted to be clammy, with tachypnea, to have decreased level of responsiveness, and to show increased fever. He was seen in the ER, where evaluation revealed the presence of probable sepsis. The patient was also found to have renal insufficiency with BUN and creatinine elevated. His WBC count was 23,000 with decreased hemoglobin and hematocrit. He was admitted for treatment of Escherichia coli sepsis. Physical examination revealed an elderly male who was aphasic and with a right hemiplegia from a previous CVA. The heart had a regular rhythm. The lungs were clear. The abdomen was soft. Significant Lab, X-Ray, and Consult Findings: Follow-up chemistry showed progressive decline in the BUN and creatinine to near-normal levels. Initial white blood cell count was 23,700. Final blood count was 9,000. The urinalysis showed white cells too numerous to count. The urine culture had greater than 100,000 colonies of E. coli and group D strep, which revealed the cause of the UTI. Repeated blood cultures grew E. coli with the same sensitivities as that of the urine. There were no acute abnormalities noted. EKG showed sinus tachycardia and low lead voltage, otherwise was normal and unchanged. Course in Hospital: The patient was initially started empirically on Primaxin. He underwent fluid rehydration and his electrolytes were followed closely. Electrolytes improved through his hospital stay. He was continued on IV Primaxin until the date of discharge, when he was changed to Cipro by tube. All of the bacteria grown in the urine and in the blood were sensitive to the Cipro. The chest x-ray showed no change from previous admissions, and he was followed closely with additional oxygen as needed. The patient does have a history of chronic obstructive lung disease and has required intermittent oxygen therapy at the nursing home. At this time, the patient had reached maximal hospital benefit. He was switched to oral antibiotics. He was to continue on tube feedings, which he was tolerating quite well. The patient was discharged back to the nursing home on 5/4. Discharge Diagnoses: E. coli sepsis UTI due to E. coli and Group D strep Renal insufficiency Chronic obstructive lung disease CVA with right hemiplegia

MS-DRG: 872 Rationale: The MS-DRG assignment is 872, Septicemia without Mechanical Ventilation 96+ Hours without MCC.

CCW 4.50. This patient has been living at home, but his dementia has been getting progressively worse. He was diagnosed with Alzheimer's disease over two years ago. The family called the police because he was missing from home. A search was conducted and an observant passerby called in a report of an elderly man who seemed to be disoriented at a nearby public park. He was found after several hours and brought to the hospital. He had fallen in the park and had a laceration on his right knee that required suturing of the subcutaneous tissue and skin. What codes are reported in this case?

MS-DRG: 988 Rationale: For codes G30.9 and F02.81, the Alphabetic Index main term is Disease, subterm Alzheimer's, with behavior disturbance. F02.81 includes a note to assign an additional code, if applicable, to identify wandering in dementia, Z91.83. For code S81.011A, the Alphabetic Index main term is Laceration, subterm knee. For code W19.XXXA, the Alphabetic Index main term is Fall. For code Y92.830, the External Cause Index main term is Place of occurrence, subterm park (public). For code Y99.8, the Alphabetic Index main term is External cause Status, subterm specified NEC. Codes Z91.83, Y92.830, and Y99.8 are POA exempt. All other conditions were present on admission. The Alphabetic Index main term is Repair, subterms subcutaneous tissue and fascia, lower leg, right.

CCW 4.64. This 45-year-old female patient was diagnosed with right breast carcinoma three years ago, at which time she had a mastectomy performed with chemotherapy administration. She has been well since that time with no further treatment but yearly checkups. She has metastasis in three axillary lymph nodes. She is admitted now with visual disturbances, dizziness, headaches, and blurred vision. Workup was done that revealed metastasis to the brain. What is the correct code assignment for this admission?

MS-DRG:055 Rationale: The reason for admission is the metastatic brain cancer. The breast cancer was excised, so it is coded as history. The metastasis to the axillary lymph nodes is still present and should be coded. For code C79.31, the Table of Neoplasms main term is brain, column malignant secondary. For code C77.3, the Table of Neoplasms main term is lymph, gland, axilla, column malignant secondary. For code Z85.3, the Alphabetic Index main term is History, subterms personal, malignant neoplasm, breast. Category Z85 is on the POA exempt list. Therefore, no indicator is assigned to Z85.3. All other conditions were present on admission. An additional code of Z90.11 could be assigned to indicate that the right breast had been removed. This code can be found in the Alphabetic Index under Absence, breast.

CCW 7.53. The following documentation is from the health record of a 65-year-old male patient. Hospital Course: This unfortunate gentleman was discharged from the hospital yesterday after being treated for several days for congestive heart failure. He presented back to the hospital within 24 hours after he developed significant respiratory discomfort and shortness of breath. He was found to be in acute respiratory failure with hypoxia and have pneumonia. The patient required intubation with subsequent mechanical ventilation in the emergency room. His x-ray showed diffuse infiltrates bilaterally, a condition also consistent with possible congestive heart failure. The patient did not have an elevated BNP. He was taken to the intensive care unit for further evaluation and treatment. It was explained to his wife and family that he was critically ill, and his survival was very guarded. The patient required blood pressure support. He was treated for pneumonia and his sputum cultures grew methicillin-resistant Staphylococcus aureus. He was treated with vancomycin. After admission, the patient also experienced a stroke with right-sided hemiparesis. He was found to have a left-sided internal carotid artery stenosis and this was determined to be the cause of the cerebral infarction. He was felt not to be a surgical candidate because he was critically ill. He was placed on Bumex infusion for his congestive heart failure. His respiratory status remained very tenuous despite maximum medical management. He was placed on parenteral nutrition via peripheral vein. His condition never improved despite all efforts. He remained poorly responsive, and he developed acute renal failure, as well. On day 15, it was clear that his survival was unlikely. His family asked that his ventilator support be discontinued. Shortly after the ventilator was discontinued the patient expired. Discharge Diagnoses 1: Acute respiratory failure secondary to methicillin-resistant S. aureus pneumonia and congestive heart failure 2: Cerebrovascular accident with infarction 3: Acute renal failure 4: Lung mass 5: Chronic obstructive pulmonary disease 6: Diabetes mellitus 7: Hemiplegia secondary to stroke Operative Procedures Mechanical ventilation greater than 96 hours

Which of the following is the correct MS-DRG for this case? 207, Respiratory System Diagnosis with Ventilator Support 96+ Hours