Wednesday, December 21, 2016
Oncology Case Study
Adenocarcinoma of right breast, Total right mastectomy
History of Present Illness
50-year-old female with known carcinoma of the left breast with widespread right pulmonary and bone metastases. No further treatment since mastectomy. Patient has completed her third round of chemotherapy for the lung and bone metastases. The patient was now admitted for treatment of lumps of the lower-outer quadrant of the right breast.
Past Medical History
History of Left breast carcinoma
Bone and lung metastases
History of Left breast mastectomy
Pertinent Physical Exam
Temperature temp 36.2, HR 102, RR 18 B/P 126/88
Neuro: AAOX3, PEARL
Resp: Bilateral Breath Sounds, decrease on right side
Cardiac: pulses strong and equal, positive
Extremities: Trace edema in upper extremities, lower extremities with evidence of chronic insufficiency
ABD: round and soft to palpation with positive bowel sounds.
Impression and Plan
The patient was now admitted for treatment of lumps of the lower-outer quadrant of the right breast. A right mastectomy has been recommended as treatment for the lumps of the right breast due to the patient’s history of right breast carcinoma with metastases. The patient has agreed to the recommended treatment.
Course in Hospital
Percutaneous needle biopsy of upper quadrant of right breast. Biopsy specimen was sent for frozen section with adenocarcinoma of right breast being diagnosed. An open total right mastectomy was then performed.
D24.2 Benign neoplasm of right breast
C79.51 Secondary malignant neoplasm of bone
C78.01 Secondary malignant neoplasm of right lung
Z85.3 Personal history of malignant neoplasm of breast
Z90.12 Acquired absence of left breast and nipple
0HTT0ZZ Resection of Right Breast, Open Approach
0HBT3ZX Excision of Right Breast, Percutaneous Approach, Diagnostic
Pregnancy, Childbirth and the Puerperium Practice/Sample questions (PART-2).
1. Family planning counseling
2. Encounter for insertion of intrauterine contraceptive device. Insertion of intrauterine contraceptive device
3. Encounter for removal of intrauterine contraceptive device. Removal of intrauterine contraceptive device
4. Essential hypertension, Admitted for sterilization, Laparoscopy with bilateral partial salpingectomy
5. Endometriosis of uterus, Admitted for sterilization, Bilateral laparoscopic tubal ligation via electrocautery for sterilization
6. Term pregnancy, with breech delivery , female infant, followed by sterilization. Vacuum breech extraction. Laparoscopic occlusion of bilateral fallopian tubes with Falope (external)
7. Elderly primigravida (37 years old); 40 weeks gestation, spontaneous delivery of living female infant. Manually assisted delivery. Episiotomy and repair
8. Term pregnancy , 39 weeks gestation, living dichorionic twins (diamniotic sacs), cesarean delivery performed because fetal stress noted prior to labor. Low cervical cesarean delivery
9. Delivery , 38 weeks gestation, living child, ROA presentation. Fetal cardiac rhythm monitoring during labor, Episiotomy and episiorrhaphy.
10. Uterine pregnancy, 39 weeks gestation, delivered with obstructed labor due to transverse lie presentation, Pre-existing hypertension with mild preeclampsia , single Liveborn. Manually assisted delivery
11. Intrauterine pregnancy, 37 weeks gestation, delivered spontaneous. Third-stage hemorrhage with anemia secondary to acute blood loss, Monochorionic twins, both liveborn, diamniotic placenta
12. Pregnancy, 38 weeks gestation, delivered , frank breech presentation with liveborn male infant, Partial breech extraction with mid-forceps to after coming head
13. Term pregnancy, 40 weeks gestation, delivered, spontaneous, Liveborn, male infant, Assisted spontaneous delivery, Elective sterilization following delivery, Bilateral endoscopic ligation and crushing of fallopian tubes
14. Intrauterine pregnancy , 26 weeks gestation, with complicating incompetent cervix, undelivered, Shirodkar cervical cerclage operation.
15. Gestational hypertension, Pregnancy , third trimester, 29 weeks gestation, undelivered
16. Intrauterine pregnancy, 38 weeks gestation, delivered, right occipitoanterior, liveborn male infant, Episiotomy that extended to second-degree lacerations, perineum, Amniotomy for induction of labor, Low-forceps delivery with episiotomy, Repair of perineal laceration
Pregnancy, Childbirth and the Puerperium Practice/Sample questions (PART-1).
1.Antepartum supervision of pregnancy in patient with history of three previous stillbirths, 12 weeks gestation
2. Office visit for routine prenatal care, for primigravida patient with no complications, second trimester
3. Office visit for care of 40-year-old patient who is in the fourth month of her third pregnancy
4. Intrauterine pregnancy , spontaneous delivery, single liveborn O80
5. Intrauterine pregnancy , 12 weeks gestation, undelivered, with mild hyperemesis gravidarum
6. Intrauterine pregnancy, 39 weeks, delivered, left occipitoanterior, single liveborn. Primary uterine inertia
7. Cesarean delivery of stillborn at 38 weeks gestation owing to placental infarction
8. Intrauterine pregnancy , with pernicious anemia , second trimester
9. Induction of labor by cervical dilation
10. Assisted spontaneous delivery
11. Vaginal delivery using low forceps
Pregnancy Sample charts/Cases
1. 36 year old G2 P1 woman at 26 weeks pregnant and is being seen for gestational hypertension. At this time, she is not having any other problems. What is the correct diagnosis code(s)?
O13.2 Gestational Diabetes
O09.522 Elderly Multigravida
Z3A.2626 Weeks Pregnant
2. A G1P0 patient was admitted in active labor at 38 completed weeks of gestation. She is a type 2 diabetic, monitored through this pregnancy with no complications and no use of insulin. A second degree perineal laceration occurred during delivery and was repaired. A female infant was delivered with Apgar scores of 9 and 9.
O70.1 Perineal Laceration
O24.12 DM Type 2
E11.9DM w/ No Complications
Z3A.3838 Weeks Gestational Age
Z37.0 Single Liveborn
3. A 25 year old patient was admitted with difficulty breathing. She has AIDS and is 21 weeks pregnant. Workup reveals Pnueumocystis Carinii Pneumonia (PCP).
O98.712 Pregnancy complicated by HIV Disease
B59 PCP (pneumonia)
Z3A.2121 Weeks Gestational Age
4. A G3P2 patient was admitted at approximately 34 weeks gestation with a history of contractions for the last 24 hours. She was having contractions every 5 to 8 minutes. An ultrasound showed an intrauterine fetal death of triplet 2, but the other two were progressing normally. The contractions stopped for about 24 hours and then restarted. It was noted by the physician that the continued contractions were due to fetus 2. The patient was given magnesium sulfate for tocolysis which was unsuccessful. The patient developed a fever with an infection of the amniotic sac. The patient continued to be in active labor and due to the infection was allowed to spontaneously deliver the three infants, two liveborn and one fetal death. The patient experienced no postpartum complications. Assign the diagnoses codes.
O60.14X2 Preterm Labor
O36.4XX2 Intrauterine Fetal Death
O30.103 Triplet Gestation
O41.1030 Infection of Amniotic Sac
Z3A.3434 Weeks Gestation
Z37.61 Outcome of Delivery
ICD-10-PCS Practice Case Scenarios
Preoperative Diagnosis: Extensive laceration, distal left index finger with partial severance of distal phalanx
Postoperative Diagnosis: Same
Operation: Open reduction internal fixation distal phalanx L index finger with Kirschner wire stabilization; nonexcisional debridement of laceration of L index finger; repair laceration
L middle finger
Procedure: Pt prepped & draped in the usual manner after axillary block administered. Pt had a Miter saw go into his index finger, lacerating the dorsal radial aspect of index finger at distal phalangeal phalanx level. Saw went into base of nail. We used C-arm fluoroscopy to thoroughly evaluate area & then inflated tourniquet to 280 mm of Mercury after arm exsanguinated. Wound thoroughly irrigated w/saline solution to which antibiotics were added & subcutaneous tissue debrided of all devitalized tissue, trash, & foreign bodies present in tissue. Then used Kirschner wire of 0.045 inches in dia. & drilled across fracture site in joint to totally stabilize area. Once this in place, then very carefully closed skin w/ interrupted running 5-0 Ethibond suture. Area of laceration on middle finger just distal to insertion of extensor tendon. Looked like bulk of nail bed would be viable, some damage to base of nail bed. Laceration of left middle finger, which extended into subcutaneous tissue, then repaired w/ 4-0 Vicryl sutures. Large compression dressing applied.
0PSV04Z Reposition, Phalanx, Finger, Left (0PSV) In Index
Reduction, Fracture, see Reposition
0JQK0ZZ Repair, Subcutaneous Tissue and Fascia, Hand, Left (0JQK)
Suture, Laceration repair, see Repair
***If a procedure is performed on a portion of a body part that does not have a separate body part value, code the body part value corresponding to the whole body part***
Preoperative Diagnosis: Left upper eyelid laceration & chin laceration
Postoperative Diagnosis: Same
Operation: Repair of L upper eyelid & chin lacerations
Procedure: After patient suitably prepared under general anesthesia, left upper eyelid & chin were dressed & draped with Betadine. Left upper eyelid laceration (3 cm) inspected. It did appear to go through left upper eyelid canaliculus. Distal end could be seen, proximal end could not. It was elected not to try to repair canaliculus. One interrupted 6-0 silk suture placed through lid margin & then 3 interrupted 5-0 Vicryl sutures placed through deep tissue. Running 6-0 silk suture then placed through skin. 2.0 cm chin laceration of skin closed w/three interrupted 6-0 silk sutures. Gentamicin ointment applied to lacerations and dressing placed
over left eye. Patient tolerated procedure well & left OR in stable condition.
08QPXZZ Repair, Eyelid, Upper, Left (08QP)
Suture, Laceration repair, see Repair
0HQ1XZZ Repair, Skin, Face (0HQ1XZZ)
***Components of a procedure specified in the root operation definition and explanation are not coded separately. Procedural steps necessary to reach the operative site and close the operative site are also not coded separately.
Example: Resection of a joint as part of a joint replacement procedures is included in the root operation definition of replacement and is not coded separately. Laparotomy performed to reach the site of an open liver biopsy is not coded separately.***
Top 10 ICD-10-CM Questions (PART 1)
Diabetes Mellitus with Diabetic Ketoacidosis
1Q. How would we code a patient that presents with Type 2 diabetes mellitus with diabetic ketoacidosis?
1A. When a patient presents with diabetes mellitus with ketoacidosis we would use the ICD‐10 code E13.10 (other specified diabetes mellitus with ketoacidosis without coma).
While we do have few perfect choices, it was deemed important to identify that this patient does have ketoacidosis.
Handling Coding Disputes with Payers
2Q. How do we address coding disputes with payers, when what they require goes against AHA Coding Clinic advice orthe CMS official guidelines?
2A. The first thing that we need to do is determine that this is really a coding dispute and not a coverage or payment issue. So one of the first things that we should do is contact the payer and ask for clarification if we are not sure of the reason for the denial.
If we find that the payer truly does have a policy that conflicts with the official coding rules or guidelines, we should make every effort to resolve this issue. One of the first things to do is send the payer a copy of the guidelines with an explanation of how their policy and the guidelines conflict.
If the payer refuses to change their policy, proceed to ask for a copy of their requirements in writing.
It is important to keep track of all correspondence that has transpired between you and the payer. Keep track of dates and the names of the people with whom you have communicated. You should also verify the existence of the policy in question with supervisory staff.
It is also important to keep a file of all of the documentation that you have received from the payer. You should be able to reproduce these documents in the event of an audit. DOCUMENT. DOCUMENT. DOCUMENT.
Smoker (tobacco user vs. dependence)
3Q. Physician documents that the patient is a smoker. How is this coded in ICD‐10‐CM? Would we code this as abuse or dependence?
3A. In ICD‐10, when the provider documents that the patient is a “smoker” we would use the code F17.200 (Nicotine dependence unspecified, uncomplicated).
Diabetes and Osteomyelitis
4Q. Does ICD‐10 assumes a link between diabetes and osteomyelitis?
4A. Yes, ICD-10-CM does assume a relathionship between diabetes and osteomyelitis as per 2016 October guidelines.
Pneumonia and Hemoptysis
5Q. In ICD‐10 hemorrhagic is no longer a nonessential modifier for pneumonia. Is it appropriate to report a separate code for hemoptysis?
5A. Yes, it would be appropriate to separately report a code for the hemoptysis. You would report code R04.2.
Admission for Rehabilitation
6Q. Does ICD‐10 allow for the coding of the acute CVA when the patient is admitted to an inpatient rehab facility?
6A. No, for ICD‐10 we will use a code from the subcategory I69.3, sequlae of cerebral infarction, as the principal diagnosis.
Admission for Rehabilitation following Cerebral Infarction
7Q. A patient is admitted to an inpatient rehab facility following an acute CVA, with aphasia. The patient also has several comorbid conditions. How would this case be coded in ICD‐10?
7A . In this instance, the aphasia (I36.321) is the principle diagnosis. The codes for the co‐morbid
conditions would also be coded.
Admission for Rehabilitation following Femur Fracture Treatment
8Q. Patient is admitted to an IRF following treatment for an acute intertrochanteric femur fracture for physical therapy. How would this visit be coded?
8A. For this particular encounter we would use code S72.141D; displaced intertrochanteric fracture of right femur, subsequent encounter.
Encounter for Dialysis
9Q. Since ICD‐10 does not have a code that is equivalent to V56.0, encounter for dialysis, how would these cases be coded in ICD‐10?
9A. In ICD‐10‐CM these encounters will be coded to the underlying disease/reason for the dialysis at the principle diagnosis.
42 Weeks of Gestation
10Q. ICD‐10 has two codes for a gestational age of 42 weeks or more. 42 weeks or more Z3A.42 or Z3A.49 greater than 42 weeks. We need a better understanding of when we would use these codes.
10A. We would assign code Z3A.42 for any number days in week 42 up to the beginning of week 43.
We would assign the code Z3A.49 for a gestational date of 43 weeks.
Clinical Indicators of Urinary
Burning on urination
Documentation of "urosepsis" (must be clarified as SIRS/Sepsis or UTI)
Documentation of “UTI”
Fever ≥38ºC within 48 hrs of cath removal
Indwelling catheter (current or recent)
Urine culture ≥ 100,000 colonies with no more than 2 organism growth
WBC count > 1200mm
Urine nitrites Urine esterase
Clinical Indicators of Renal
Abnormal BUN Creatinine ratio
Abnormal Serum Osmolality
Abnormal Urine Osmolality
Documentation of “CKD” or “CRF”
Acute/Chronic Renal Insufficiency
50% increase in Cr from baseline
Clinical Indicators of PNEUMONIA
Abnormal Blood Pressure
Abnormal chest pain
Abnormal Chest X-ray results
Abnormal O2 Sat.
Abnormal resp. rate
Abnormal respiratory rate_
Abnormal sputum (colored/blood tinged/clear)
Abnormal WBC result
Recent aspiration and/or vomiting
Elevated WBC History or current CVA
Impaired gag reflex
Neutrophilia/ Abnormal Neutrophil count
Positive Blood Cultures
Positive Sputum Culture
Positive swallowing study/MBS
Decreased breath sounds/rales
Clinical Indicators of HYPERTENSION
Abnormal Creatinine level
Altered Mental Status
Anti-hypertensive IV Meds
DBP > 90
Hx of CVA
Hx of heart failure
Hx of renal failure, CKD or renal stenosis
SBP > 140
Weakness/tingling of arms/face/legs