Heart failure clinical indicators

Clinical Indictors of Heart failure

Abnormal BNP result

Abnormal Chest x-ray result

Abnormal Echocardiograph results

Abnormal Left Ventricular Ejection Fraction %

Abnormal O2 Sat%

Ascites

Chest Pain

Congestive Hepatomegaly

Cough

Dyspnea/shortness of breath

Edema

Filling pressure

Hypoxia

IV Diuretic

Moderate / Severe Pulmonary Hypertension

PO Diuretic

Pulmonary Edema

Respiratory Rate

Tachypnea

Valve prolapse

Valve regurgitation

Valve stenosis

H/O Ischemic Cardiomyopathy

Tachycardia

S3 or S4 on auscultation/Gallop/Murmur

Volume Overload/hemodialysis

Asthma&COPD Clinical Indicators

Clinical Indicators of Asthma

Abnormal pulmonary function test or chest x-ray

Airflow obstruction

Asthma

Bronchitis

Chest pain/tightness

COPD

Cough-productive/nonproductive

Dyspnea

Dyspnea on exertion

Exposure to smoke, chemicals or air pollution

Home O2/BiPAP/CPAP

Hypoxia

Increased irritation/swelling of airway mucous lining

Low Oxygen saturation

Abnormal O2 sat

PaCO2 > 50 mm/Hg

PaO2 < 60 mm/Hg

Pulmonary Edema

Respiratory distress/insufficiency

Abnormal respiratory rate

Use of accessory muscles/tripoding

Wheezing

Tachypnea

Clinical Indicators of COPD

Abnormal O2 sat

Abnormal pulmonary function test or chest x-ray

Abnormal Respiratory rate

Airflow obstruction

Asthma

Bronchitis

Chest pain/tightness

COPD

Cough-productive/nonproductive

Dyspnea

Exposure to smoke, chemicals or air pollution

Home O2/BiPAP/CPAP

Hypoxia

Increased irritation/swelling of airway mucous lining

PaCO2 > 50mm/Hg

PaO2 < 60mm/Hg

Pulmonary Edema

Respiratory distress/insufficiency

Use of accessory muscles/tripoding

Wheezing

Tachypnea

Principal Diagnoses - TIPS

Pdx: Two or More Diagnoses - Tips

Present on admission does not equal reason for admission

Look at what condition appears to be most closely related to the signs, symptoms and other findings that were noted on admission

Reason for presentation to the Emergency Department is not always the reason for inpatient admission

One condition may have necessitated inpatient admission, while the other may have been manageable in the outpatient setting

Chronic conditions and/or acute conditions, may be incidental to the reason for admission

These should not be reported as principal diagnosis

For patients transferred into our facilities, be sure to identify the reason for the transfer

Usually, it is due to the fact that the level of service needed by the patient could not be performed at the originating facility

Sequencing

Objectively evaluate the circumstances of admission and sequence accordingly.

Review physician’s workup and treatment provided – it may be that the two conditions are not as equal as they initially appeared. 

Principal Diagnosis - Inpatient

Principal Diagnosis

Often, instructions in the code book, or other official guideline, provide sequencing direction even though multiple conditions may meet the definition of Principal Diagnosis.

Be mindful of:

1.       Uniform Hospital Discharge Data Set (UHDDS) definition

2.       Chapter-Specific guidelines

3.       Uncertain Diagnoses

4.       Two or more diagnoses

Selection of Principal Diagnosis

The circumstances of inpatient admission always govern the selection of principal diagnosis.

The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

Principal Diagnosis: Uncertain Diagnosis

Official Guideline: If the [principal] diagnosis documented at the time of discharge is qualified as ‘probable’, ‘suspected’, ‘likely’, ‘questionable’, ‘possible’, ‘still to be ruled out’, or other similar terms indicating uncertainty, code the condition as if it existed or was established.

Remember to distinguish between ‘Rule out’ diagnoses versus ‘Ruled out’ diagnoses

Principal Diagnosis: Two or More Diagnoses

Official Guideline: In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis, as determined by the circumstances of admission, diagnostic workup, and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.

This rule now applies to a symptom followed by two or more comparative or contrasting diagnoses. Code the comparative/contrasting diagnoses, do NOT code the symptom.

A symptom(s) followed by contrasting/comparative diagnoses

GUIDELINE HAS BEEN DELETED EFFECTIVE OCTOBER 1, 2014

The Official Guideline for two conditions as Principal Diagnosis is much more strictly defined than both conditions merely being present at the time of admission.

It is always inappropriate to base coding decisions solely on reimbursement or public reporting implications. 

Pressure Ulcers

Pressure Ulcer evolving to another Stage

If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned:

One code for the site and stage of the ulcer on admission

A second code for the same ulcer site and the highest stage reported during the stay.

Pressure ulcers described as healing should be assigned the appropriate pressure ulcer stage code based on the documentation in the medical record.

For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission.

Hypertension combinations

Hypertension

The classification presumes a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the term “with” in the Alphabetic Index.

These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.

Hypertension with Heart Disease

Hypertension with heart conditions classified to I50.- or I51.4-I51.9, are assigned to a code from category I11, Hypertensive heart disease.

The same heart conditions (I50.-, I51.4-I51.9) with hypertension are coded separately if the provider has specifically documented a different cause. Sequence according to the circumstances of the admission/encounter

Hypertensive Chronic Kidney Disease

Assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD), are present. CKD should not be coded as hypertensive if the physician has specifically documented a different cause.

Hypertensive Heart and Chronic Kidney Disease

Assign codes from combination category I13, Hypertensive heart and chronic kidney disease, when there is hypertension with both heart and kidney involvement. If heart failure is present, assign an additional code from category I50 to identify the type of heart failure.

Hypertensive Crisis

Assign a code from category I16, Hypertensive crisis, for documented hypertensive urgency, hypertensive emergency or unspecified hypertensive crisis. Code also any identified hypertensive disease (I10-I15). The sequencing is based on the reason for the encounter

ICD-10-PCS Root Operation Test

ICD-10-PCS Root Operation Test

ICD-10-PCS Practice Questions:

Root Operations to Take Out Some or All of a Body Part

Excision, Resection, Detachment, Destruction, and Extraction

1.    Sigmoidoscopy with rectal polyp fulguration

Root Operation – Destruction

2.    Laparotomy with complete removal of sigmoid colon

Root Operation – Resection

3.    Left 5^th toe ray amputation at the metatarsal-phalangeal joint

Root Operation – Detachment

4.    Laparoscopic removal of right ovarian cyst

Root Operation – Excision

5.    Diagnostic dilatation and curettage

Root Operation – Extraction

6.    Bone marrow aspiration left iliac crest

Root Operation – Extraction

7.    EGD with gastric biopsy

Root Operation – Excision

8.    L5-S1 discectomy via laminotomy with moderate-sized fragments retrieved

Root Operation – Excision

9.    Left upper lobectomy of lung via thoractom

Root Operation – Resection

10.  TURP (transurethral resection of prostate)

Root Operation – Excision

11.  Open retropubic prostatectomy

Root Operation – Resection

12.  Laparoscopic endometrial ablation

Root Operation – Destruction

13.  Revision of right BKA to AKA

Root Operation – Detachment

14.  Amputation above right knee, distal shaft of femur (Definition of Low:  Amputation at the distal portion of the shaft of the humerus or femur)

Root Operation – Detachment

15.  Cauterization of nosebleed

Root Operation – Destruction

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