Ok, we'll pick up on Chapter 14. This will be part two.
We're looking at exercise 14.1 number 20.
This one is a little hard for someone
who's just beginning to code, so I thought it was a good idea for us
to work through it little by little, so you can see how we might code it.
The first thing I've done here is show you the pathways.
The first code, "Infection - postprocedural"
because this is "due to acute postoperative
peritonitis" so in
the subterm we're looking for is "postprocedural" and that will
take us to T81.4 and that will be the principal diagnosis.
We'll have to look at how we get these extra characters and we'll look at that
during this podcast. The next code is
"Shock-postprocedural (postoperative) - septic
"Shock", that's referring back to these terms right here and
that is "T81.12 - and always the dash ( - )
means we need more characters so we will be looking at that
and per the Guidelines, a code for "Shock" cannot be the principal (diagnosis).
We know right away that this code describing the
"Shock" is not the principal. Then we look at "Enterococcal sepsis"
A41.81, and last of all our "acute peritonitis" K65.0.
So, we're going to look at
those one at a time.
The first one we'll look at is our "infection - postprocedural."
Let's find that in the Code Book.
In the Alphabetic Index here we go with "Infection."
We're looking for "postprocedural",
Let me slide down,
and here is "postprocedural", and you notice
if the doctor had used the term "postoperative" it's the same code.
Now we're going to go to T81.4
We know that that little icon means we need more characters
to make this a complete code. And, when we look
up in the Tabular "T81.4"
"Infection following a procedure" right away I notice
"7" characters are needed to make this a complete code.
Let me move this up, that's better. "T81.4"
"Infection following a procedure," and here is our exact wording from our documentation,
"Sepsis following a procedure". We need
"Use additional code to identify the infection,"
and the "Use additional code to identify severe sepsis,"
if applicable. Our documentation did not use
the term "severe sepsis". If those terms, those words,
were not used, you do not code them. "Sepsis" and severe sepsis"
are different codes. We know we're in the right category
because we see this is what our documentation says.
We know we have to use an additional code to identify "infection"
and now we're just going to...there's nothing else below it.
So, how do we need seven characters?
We have to go back to the very beginning
of this chapter, where it tells us that we have to identify
the seventh character as the "encounter"
whether it be initial, subsequent, or sequela.
Let's go back to the beginning of the chapter. And,
you may or may not know that Chapter 19 is
"S" and "T" codes. So, "S00 – T88"
These categories
are included in Chapter 19 and we have very
Chapter specific Guidelines for the application of the seventh character in
Chapter 19. I won't go through them verbatim
because these podcasts get so long, but you will
see that "the seventh character 'A', initial encounter, is used while the patient is
receiving active treatment for the condition."
Examples are: surgical treatment, ED (emergency department), and evaluation
by the same or a different physician." This is
what tells us we're going to have to apply that
seventh character.
and then,
the Guidelines go through...here's the initial, and here's the subsequent,
and later on, it goes through the sequela. So please read through all that on your own.
Just be aware that in this case we're talking about the initial encountner.
So, we're talking about the initial encounter
and we know that we had T81.4. We're going to have placeholders
for characters five and six.
So T81.4xxA is a complete code.
I go into a little more explanation here.
You can use an uppercase or a lowercase "x" as long as something
is a placeholder for those fifth and sixth characters.
The next code we're going to look at you see has one placeholder
in the sixth position.
Let's look at that one next.
This one is "Shock-postprocedural (postoperative) - septic"
Ok, it's "Shock", I'm looking for "postprocedural"
I'm going to slide this down.
and here it is "T81.10"
with more characters needed.
Just let me look at some of these subterms to see if any
of these are something we need to look at. Oh,
look there is..."septic". So by going in
another indentation level we've become more specific,
and that takes us to T81.12
with extra characters needed. So, let's look that up in our Tabular.
Now we're T81.1
You see here that we need five characters
and we've only got four, so we know we need that.
"Shock during or resulting from a procedure..."
Here's some "Excludes" notes, none of which apply
to us. This "septic shock" R65.21
is a severe sepsis. The "R" code is severe sepsis.
Ours is not that. So we know that these don't apply
to us in this case.
"Postprocedural septic shock"
Here we go, this is us. It tells us we need seven
characters.
Also, code first underlying infection, this
instructional note does apply to us. "Use additional code to identify
any associated organ dysfunction" and our
documentation did not give us that
but we know we're on the right track.
One, two, three, four, five are here, so our sixth character is
going to have to be the placeholder "x" because our seventh character
is going to be our encounter which in this case is initial,
so our seventh character is going to be an "A". That explains how we get
back to this code right here "T81.12xA"
I have this Guideline
here just to help us in the sequencing of this two
"T.81" codes and this is the Guideline the I used
"for cases of septic shock, the code for the systemic infection
should be sequenced first, followed by the code
for the "Severe sepsis" OR Code T81
"T81.12" which is for shock.
Also in this Guideline it tells us that the code for septic shock can not
be assigned as a principal. This one is so long that I have to have a second
slide because it also uses this particular
Guideline for "postprocedural infection and postprocedural septic shock"
because it tells us exactly how
we sequence these codes. "If a postpocedural
infection has resulted in postprocedural septic shock
the code for the precipitating complication, such as T81.4-
infection following a procedure, should be coded
first followed by code T81.12-
"postprocedural septic shock". A code for the
systemic infection should also be assigned."
And there's your Guideline. This particular case had me looking for
Guidelines to help know how to sequence those two things.
There was also an instructional note that said code your
infection, and there is your infection—your entercoccus infection,
we'll go through that in a second, and the K65.0 is the peritonitis.
We're getting there, we're getting our way through this code.
I want to spend a little more time on some other examples.
HIV is infection that you're
going to see on all of your exams, both on the mock exam in HIT 289,
on the RHIT National Exam, and of course, on the coding exams.
because it's so important and it has very specific coding Guidelines for
an individual who has been diagnosed as being HIV positive.
Here's an example. Someone has come in with "candidiasis of the esophagus,
opportunistic, secondary to AIDS." When you see
that term "opportunistic" that tells you that this is directly
because of the AIDS. It is a related condition.
Our path is to start with our main
term "Human - immunodeficiency virus (HIV)
(infection) B20. I'm going to trust that you can find
that on your own and "Candidiasis or candidal -
esophagus B37.81"
The rationale for that
is the patient admitted for HIV related condition, and here's
where I've quoted that Guideline.
The next example is a "positive HIV test
in a patient who is asymptomatic, presenting no related symptoms, and
has no history of HIV infection," the only thing he has is
a positive test. So, the "Test" is your main term -
HIV - positive, giving you Z21.
And the Guideline for that is an asymptomatic HIV.
You've got a very specific Guideline telling you to use Z21.
This is someone who is asymptomatic,
there's no documentation of any symptoms he's just simply,
(he or she) is simply listed as HIV positive. If
the documentation said that the patient has AIDS, then you would use B20,
not the Z21 code, the Z21 code is reserved
for those people that have had the positive HIV test.
Here's an example for a patient admitted for an
unrelated condition who also has AIDS.
This person has "acute appendicitis", this comes under this code , K35.80
The B20 is the AIDS then the C46.0
is the sarcoma. Here's your pathway
to get to those codes.
In your Guideline is for patients with HIV disease admitted
for an unrelated condition. It tells us exactly how to sequence that.
The code for the unrelated condition is your principal.
Then your next diagnosis would be your B20,
followed by any additional codes, in this case, the "Kaposi's sarcoma"
would be the last code.
That's what I have for Chapter 14.
If you have any questions, please post them in the discussion board and I will attempt
to answer them. When you post a question I expect you to show me
in your question, what pathway you were using. That way
I can see if there's a specific place that I can tell you to look
differently or go in a different direction to find the correct code.
Our next podcast will be Chapter 29
which is Neoplasm. This corresponds to Chapter 2
in the ICD-10-CM Book, Neoplasm. I'll talk to you then.