1. Massachusetts Chapter ACDIS December 2, 2015 Brigham and Women’s Hospital Boston, MA

2.  Under dosing of anticoagulants, initial encounter  Poisoning by anticoagulants, initial encounter  Atrial Fibrillation

3. Answer: Atrial Fibrillation. Per coding guidelines, under dosing can never be the PDX. Coding GUIDELINE: DRUG UNDERDOSING The coding examples will demonstrate the new clinical concept of drug under dosing conveyed in ICD-10. Drug under dosing is a new clinical terminology in ICD-10. ICD-10 contains codes for under dosing, whereas ICD-9 does not. This term identifies situations in which a patient has taken less of a medication than prescribed by their physician or less than instructed by the manufacturer, whether inadvertently or deliberately. For under dosing, assign the code from categories T36 – T50 found in Chapter 19. These codes require a 7th character extension to describe an initial encounter (A), subsequent encounter (D), or sequela encounter (S). Under dosing codes must be identified in the following order: 1. The medical condition is sequenced first. The first-listed code would be the event that is triggered or prolonged due to this circumstance. 2. The under dosing code is listed as the secondary code assignment. Codes for under dosing should never be assigned as principal or first-listed codes. 3. The additional code explains why the patient is not taking the medication(s). Financial hardships and age-related debilities are some examples of under dosing.

4. Fusion procedures are performed only on :  Long bones  Spine  Vertebrae  Joints

5. Answer: Joints

6. Does a lumbar drain trial result in a surgical DRG?

7. Answer: No, it no longer impacts the DRG (does not move to a surgical DRG)

8. In ICD-10-PCS, the root operation is coded according to the objective of the procedure actually performed.  False  True

9. Answer: True

10. Define a Subsequent MI

11. Answer: An MI is considered ‘acute’ in the 4 weeks following the incident. This is revised from the 8 week timeframe in ICD-9. In ICD-10, a subsequent MI is defined as a new MI that occurs within the 4 week “acute” period of the original AMI.

13. Answer: CAD as the PDX w/the acute MI as an MCC

14. What would the PDX be if a patient had an NSTEMI 2 weeks ago, was re-admitted with chest pain, found to have a new NSTEMI, and had a coronary angioplasty w/stent insertion?

15. Answer: The subsequent MI is the PDX. The previous, but still acute, MI and CAD are both secondary diagnoses - but the MI is not an MCC. Sequencing of I22 and I21 codes depends on circumstances of admission. I21 (initial) is sequenced first when a patient is in the hospital due to AMI and suffers a secondary MI while still in hospital. I22 (subsequent) is sequenced first when an MI occurred after discharge for care of initial AMI (within the 4 week time frame).

16. This root operation is used for gender reassignment surgery:  Resection  Creation  Extraction  Excision

17. Answer: Creation

18. A is B is not The assignment of a cardiac arrest code in ICD-10-CM ____ dependent on whether or not the patient is resuscitated.

19. Answer: Is Not Cardiac Arrest, 427.5 Coding Guidelines Coding Clinic, Second Quarter 1988 Code 427.5, Cardiac arrest (excludes that with pregnancy, anesthesia overdose or wrong substance given, and postoperative complications), may be assigned as principal diagnosis in the following instances: ◦ If the patient arrives in the hospital's emergency service unit in a state of cardiac arrest, cannot be resuscitated or only briefly resuscitated, and is pronounced dead with the underlying cause of the cardiac arrest not established (cause unknown), code 427.5 is assigned as the diagnosis. ◦ If the patient arrives at the hospital in a state of cardiac arrest, is resuscitated, and is admitted as an inpatient but dies before the underlying cause of the cardiac arrest is established (cause unknown), code 427.5 is assigned as the principal diagnosis. Code 427.5, Cardiac arrest, may be used as a secondary code in the following instances: ◦ The patient arrives in the hospital's emergency service unit in a state of cardiac arrest and is resuscitated (and admitted) with the condition prompting the cardiac arrest known, such as ventricular tachycardia or trauma. The condition causing the cardiac arrest is sequenced first followed by code 427.5, Cardiac arrest. ◦ When cardiac arrest occurs during the course of hospitalization and the patient is resuscitated, code 427.5 may be used as a secondary code except as outlined in the exclusion note under category 427. When the physician records cardiac arrest to indicate an inpatient death, do not assign code 427.5 when the underlying cause or contributing cause of death is known since the Uniform Hospital Discharge Data Set (UHDDS) has a separate item for reporting deaths occurring during an inpatient stay.

20. A should not be classified as a complication of surgery. B should be classified as a complication of surgery. An appendix that ruptures during an appendectomy :

21. Answer: Should not be classified as a complication of surgery

22. A coding the procedure code only once B coding the procedure code twice In ICD-10-PCS, a bilateral replacement of a joint is usually indicated by:

23. Answer: Coding the procedure twice

24. A RAC B OIG Work plan C PEPPER D Dashboard This is a quarterly report that includes statistical claims data for MS-DRGs which are at risk for incorrect payment due to problems with billing and coding:

25. Answer: C.PEPPER

26. When an encounter is for management of a complication associated with a neoplasm, such as dehydration, and the treatment is only for the complication, then the complication is coded first, followed by the appropriate code for the neoplasm. What is the exception with anemia?

27. Answer: When the admission is for the management of the anemia associated with the malignancy, the treatment is only for the anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by the code for, anemia in neoplastic disease.

28. A POA B HCC C PSI D HAC Identified by the Association for Healthcare Research and Quality (AHRQ), these are conditions that are considered potentially preventable adverse events for hospital inpatients.

29. Answer: C.PSI (Patient Safety Indicator)

30.  If both use and abuse are documented, assign code for _____________.  If both abuse and dependence are documented, assign only the code ______.  If use, abuse and dependence are documented, assign only the code _________.

31.  If use and abuse are documented  If abuse and dependence are documented  If use, abuse, and dependence are documented  Code:Abuse  Code:Dependence Answer:

32. A SOI B POA C ROM D HAC This is a medical classification system which approximates the likelihood of an inpatient hospital death. The categories within the system are: minor, moderate, major and extreme.

33. Answer: C.ROM (Risk of Mortality)

34. Hemorrhagic shock can be captured when documented secondary to spontaneous GI bleed.  True  False

35. Answer: False The CDI professional needs to clarify if hypovolemic shock

36. Uncontrolled DM can still be coded  True  False

37. Answer: True. DM with Hyperglycemia will be coded. NB: DM with Hyperglycemia increases the SOI but if not POA will be considered a HAC

38. A HAC B POA C DRG D HCC This is an undesirable medical condition that negatively impacts a patient, which was not present on admission. This terminology is used by Medicare and Medicaid for determining hospital reimbursement.

39. Answer: HAC

40. A CMI B ROM C HAC D POA This is a value that reflects the diversity and complexity of patients treated at a facility. The value is often used in determining the allocation of resources to care for patients in the group.

41. Answer: A.CMI

42. What are the 7 Characters for PCS coding?

43. Answer:  Section (medical Surgical, OB Osteopathic)  Body system (upper veins, endocrine, GI)  Root Operation (alteration, bypass, creation)  Body Part  Approach  Device  Qualifier

44. http://www.cdc.gov/nchs/data/icd10cm_guidelines_2014.pdf http://www.cdc.gov/nchs/icd/icd10cm.htm#10update Special Thank you to Kelley Sears, RN, CCDS and Cindy Labins, RN, CCDS for developing and presenting this quiz at the Massachusetts Chapter of ACDIS Meeting, December 2, 2015 Brigham and Women’s Hospital Boston, MA