Hi, it's Cindy. Today we're going to talk about Chapter 14
in the Coding Handbook. As you may recall from the Assignment Schedule
Chapter 14 in Coding Handbook corresponds with Chapter 1 in
the ICD-10-CM Code Book. The first thing I want to
do is go over "gram stains".
You may not be familiar with "gram stains" or understand that terminology because maybe you've not
been exposed to it before. I just want to review with you what it means
to the doctor and how it helps determine how the doctors going to treat
the patient. What happens is, the doctor comes
in, he orders either a "gram stain" or he may order
"culture and sensitivity" right off the bat, to find out what is causing someone's
infection. Not all bacteria can be classified
as "gram positive" or "gram negative" but there is a table in your
Coding Handbook, Table 14.1. We'll go to our document camera
and this is a great table to show you
the different types of bacteria and what causes
what and how the doctor knows how to treat it, for example
here is E. coli. As we know E. coli can cause urinary tract
infections and pretty horrific G.I. infections especially
in small children. So you really have to
capture the information you need of what's causing an infection
so you can start treating it. That is a very important.
Here you see "Listeria" which made the news about two summers ago
when the cantaloupe was contaminated with listeria.
People got very sick, some people died. Here's your
"staphylococcus" which we will talk about a little bit later in this lecture,
about "MRSA", "methicillin-resistant staphylococcus aureus",
"strep-throat" you probably all have heard of.
That's the "streptococcus" organism here.
Just to kind of give you a background, many of these can cause urinary tract infections.
I've seen Klebsiella, Morganella, Neisseria, Proteus,
Pseudomonas, all can cause urinary tract infections.
You may have heard of Salmonella, that's a food
poisoning organism. So just be aware of the different Gram-Positive
and Gram-Negative bacteria and what that means.
This is what it looks like under the microscope. My very first career
out of my bachelor's degree was in medical technology and I worked
in medical technology for five years before I went back and got my Master's in education.
So I learned a lot and it was a very interesting field,
it's behind the scenes, there is not a lot of glamour working
in the lab because there is a lot of body fluids, stool samples,
and all kinds of yucky stuff, but it's extremely important to
help the doctor know what he needs to do. And just
knowing whether or not an organism is Gram-positive or Gram-negative
helps the doctor determine know how he's going to treat something.
That Gram stain tells him if the bacteria's
Gram-positive or Gram-negative, which shape it is, how much
of it there is, is there bacteria in the cells and outside the cells,
are there red blood cells or white blood cells there
and is there in fungi? Fungi is yeast and molds. They look very, very
different under the scope. The doctor may
also order a Culture and Sensitivity. Culture is just to grow
a bacteria in media, like a petri dish.
And then the sensitivity test is just to determine which
antibiotic inhibits the growth. When I was
working in medical technology I would swab the media with
whatever we were working with: urine, stool, sputum.
I would swab it on the culture
so it's going to grow, and then there would be little discs that
went on top of that and each disc was impregnated with
a different antibiotic and if the bacteria was sensitive to that antibiotic
then you had no growth around that disc. I'm not sure what it looks like
now but I can't imagine it's very different although, I'm sure, it's more
streamlined than it used to be when I was doing it. Ok, enough about that.
Let's start looking at our Coding Handbook
and exercises. The first diagnosis is the
"chronic gonococcal cystitis." Our pathway
is "Cystitis" then "gonococcal" A54.01.
When we look at our Alphabetic Index
you're going to see that "chronic" and "gonococcal" are the same indentation
level in the Alphabetical Index and that's important.
When we look in our Code Book, here's "Cystitis"
and we start looking down here for "acute"
here's "chronic"
but when I look in these
subterms, none of them are "gonococcal"
so we're going to go back to that indentation level and start looking for "gonococcal".
We have to go back to the top of the page,
and there it is A54.01.
So then we're going to look that up in our Tabular.
Now, we're in our Tabular
"A54.01 Gonococcal cystitis
and urethritis, unspecified" and if you remember from previous
lectures the word "and" in the Code Book can mean
"and" or it can mean "or" and in this case it
means "or" because our patient has "gonoccocal cystitis"
they do not have "urethritis".
So A54.01 is the right code and I don't see
anything up here to give us any coding instructions other than
that, so we're going to go with that as our code for
"chronic gonoccocal cystitis." Then if we
look at out rationale, the only thing I'm going to talk about is
in the Coding Handbook to remind you on page 148 it tells us
when the main term has been located, the main term in this case is
"cystitis", a subterm for the organism
always takes precedent over more general
subterms such as "acute" or "chronic" when both
occur at the same indentation level. Remember "chronic"
in "gonoccocal" were at the same indentation level.
So because "gonoccocal" describes the organism, that
code takes precedence. That's what that means.
I also want to interject here that you may not always have
a Guideline that's going to affect your code assignment.
Most of the time you will, but not always. If you're finding that
you just don't know which one would fit, maybe there isn't one.
That's why you're going to use Answer Keys.
I like using Answer Keys because it gives a student immediate feedback
on a question. I believe homework should
help us learn something and we should not be punished is we don't do it correctly.
So my request of you is
that you at least attempt to find codes. I don't want you to
not attempt to find something and then submit a blank
homework and then this gives you access to the
Answer Key and then you can just copy and paste into your graded document
and submit that. You haven't learned as much, I don't think, as
you would've learned if you had tried to find the code. You really need to get
familiar with the Code Book and the only way to do that is to search it, to look for things.
So, I do expect you, at a minimum, to be able to find codes,
tying them with the Guideline, maybe a little bit tricky at first
but the more we do these, the better you're going to get at it.
In the long run you're going to thank me for all this work because
it will show you, you will know when you finish this course, how the
Guidelines impact the selection of the code. That is what I'm trying
to do here. Alright, our next exercise
is an "anaerobic gram-negative sepsis"
and the "name of a specific gram-negative organism is not given"
in this case but we're going to find when we start looking for our codes that
we don't need a specific name'; we just need to know that
it's an "anaerobic gram-negative." If you don't know the term "anaerobic"
that means that this organism can grow without air,
without oxygen. That is significant in a deep wound,
for example, where we might see
"anaerobes" growing. The code we're going to look for
as our main term is "sepsis", then "gram-negative"
then "organism", I'm sorry, "sepsis"
"gram-negative", then anaerobic. "Organism" is like a
a nonessential modifier for the "gram-negative" term in this case.
Let's go to our Alphabetical Index.
Here we are in our Alphabetical Index, and here we are with "Sepsis"
and we're looking for "gram-negative
- "anaerobic", and here we go
"gram-negative" - "anaerobic" A41.4
Now we'll go to the Tabular.
Now that we're into the Tabular, I just want to bring to your attention
the category A41 has
a lot of information on it before you actually get to the codes.
This little "fourth" right here tells us that to be
complete, this needs a 4th character. Right now, it only has three (characters).
Then we have some instructional notes. "Code first:"
any of these things. And, in our case,
we don't have this information but if we did
we would do that. We would code first any of those.
In "Excludes 1", as a reminder, we do not code
this code, "A41 category", with any of these
and then "Excludes 2" is
telling us that the patient could have this and
any of these. So it is possible for the patient to have both.
A lot of instructional notes here and always read those.
Chances are good that when you get into the hospital record, you have a lot of
more information than just these one liners.
Move down here, so, A41
Here we go, A41.4 -
"sepsis due to anaerobes"
So for this specific diagnosis I just
chose a very simple
diagnosis of "sepsis" to assign the appropriate code.
I have a slide on "MRSA" just to remind
you that there are different codes for "methicillin-resistant"
staph and "methicillin-susceptible" staph. These are very
common infections, especially in nursing homes and in hospitals.
Our first "MRSA" question is "sepsis" due to
"MRSA". So our pathway is
"Sepsis" as our main term and we just follow the path
"Staphylococcus" - "aureus" - "methicillin resistant"
In our Alphabetical Index.
We're under "Sepsis" and we're looking for
"staphylococcus", and what's interesting
is that they have the "MSSA" up here but not the "MRSA",
so we just keep looking down because we want "staphylococcus"
"Staphylococcus" - "aureus" - "methicillin susceptible" we
don't want that — "methicillin resistant" A41.02
That's the one we want
and we go to the Alphabetical Index, A 41.02
"Sepsis due to methicillin resistant staph aureus"
So that is the diagnosis.
And, for this diagnosis
there is a Guideline that talks about combination codes for "MRSA."
When a patient is diagnosed with an infection due to "MRSA"
and that infection has a combination code that includes the causal
organism, that's your code. It's important in this
particular Guideline to pay attention to what the Guideline is telling you NOT
to code. Your'e not going to code B95.62
and you're NOT going to assign a code from the
Z16.11 "resistance to penicillin"
because this code already says
"methicillin resistant". You don't want to code unnecessarily.
So that one takes care of that diagnosis.
Before we go into this one I'm going to do a separate recording
because it's long but I think it's very informative
and I don't want to make these recording so long that they become laborious.
So, I'm going to end this one for now. We will do part two in a couple of minutes.