Hello, today we're going to start Chapter 15, Endocrine, Nutritional and Metabolic
Diseases in our Coding Handbook which corresponds to
Chapter 4 in our ICD-10-CM Code Book.
This chapter includes diabetes which is probably one of the more common diagnosis
you're going to see in the hospital.
So we're going to spend quite a bit of time talking
about diabetes and different manifestations of that.
As a reminder, as you go through the Coding Handbook
you're going to see several examples of procedures coding
just ignore those.
As we've talked about in the past just as a reminder ICD-10-PCS is taught in HIT231.
It's a different Code Book, it's a different format.
It's a totally different language that you're learning, however, if you do decide
that you want to become a coder down the road, you are going to have
to know ICD-10-CM, which is this course, ICD-10-PCS
which is HIT231 and the CPT Book which is HIT241.
All three of those languages, if you will, are on the
CCS exam.
So, just as a reminder there.
As an overview of the types of diabetes that you're going
to be coding Type 1, it's often called juvenile diabetes,
but it really has nothing to do with the age of the patient.
This type of diabetes is "characterized by the body's failure
to produce any insulin", so we do not add code Z79.4 for long term use of insulin
for patients with a Type 1 diabetes because they need that
insulin to stay alive, so, we just assume that they are getting that insulin
and it is not coded with a Type 1.
Type 2, the body is producing insulin but it's not enough, or
what it's producing is not sufficient in quality to be able to manage the glucose
in the body.
Those patients need the insulin and that's when you're going to use
that Z79.4 code.
Be mindful that you do not use the Z79.4 code if the insulin is being
given temporarily.
If someone who's not normally on insulin comes into the the ER with a really high blood sugar, the
doctor may order insulin just to bring that sugar down but we're not
going to code that (temporary use) unless that insulin is prescribed.
When we start looking in the Alphabetical Index
for types of diabetes, we are going to start with the first axis being
the type and then underneath that in the Alphabetical Index
you will see the different complications and manifestations.
Diabetes can cause many different things at the same time.
Some can be "acute", some can be "chronic".
It's not unusual for a diabetic patient to have many
"E" codes.
Assign as many codes as you need to, to identify all of the conditions that the patient
has.
There is such a thing as secondary diabetes, and that's
when it's been caused by another condition or an event.
It's very common to see this in infections or when the pancreas is removed.
When we get to nutritional disorders, as a reminder from our previous lectures,
the BMI (body mass index) documentation can be obtained
from dietician or other provider notes and that is an exception to
the Guideline that requires all documentation be based upon physician
documentation.
Fluid overload is another one of those terms you often read
in the hospital and you're going to code that based upon what causes
that fluid overload.
If the patient is in congestive heart failure we do not code fluid overload because that
is a manifestation of congestive heart failure
and what you often see just to know how to diagnose that.
Ok, let's look at some of the exercises 15.1 number two and this is a secondary diabetes
due to pancreatic malignancy and snowflake cataract.
I had not heard that term snowflake cataract, that was a new one for me.
The cataract in this case is a manifestation of the diabetes.
You know from our previous Chapter 29, how to code that pancreatic cancer.
You're looking in your Table of Neoplasm.
Under Neoplasm you have pancreas, then in the malignant primary column
you have C25.9 and it is your primary diagnosis
and then the diabetes, we're going to look in the Alphabetical Index on how to
find that code.
Let's move to our Alphabetical Index and we are in diabetes and we're going to move
down to "due to underlying conditions"
keep going down, and here we are, "due to underlying condition", now there was
another "due to" up here, so we don't get confused,
the first "due to" is drug or chemical.
We're going to keep moving down to get to "underlying condition".
And here we go...
If you're wondering why are we coding "due to"?
It's because the patient has the cancer and the
documentation told us this is secondary diagnosis "due to"
the malignancy.
That's why we're going to diabetes with the subterm "due to underlying condtion"
and there's a cataract here, E08.36, so that's our diabetic cataract code.
When we go to the Tabular E08.36 "Diabetes mellitus due to underlying condition
with diabetic cataract."
We are in the E08 category so we always want to go
the top of this category to see if there is any instructional
notes that we would use in this category.
And, we get up to, let's see – we need to go to the next column
– here we go
"Diabetes mellitus due to underlying condition" - "Code first
the underlying condition", and we see malignant neoplasms is one of those conditions.
This helps us to know how we sequence those codes.
We're going to code first our malignancy and use an additional code to identify any
insulin use.
Let's see if our documentation gave us any information on that.
If our documentation doesn't mention the insulin
use, so we're not going to code that, but we are going to code the malignancy first
as instructed by our instructional notes.
Many times when you don't know how to sequence your codes, your instructional notes
really help you with that.
Let's look at the next one.
This is Exercise 15.1 number seven and I wanted to use this one just to have
you be mindful to always use the more specific code.
If we look up impotence in our Alphabetical Index
we get the N52.9 code.
.8 and .9 are both non-specific or not as
specific as the characters .0 through .7, so
even though the Alphabetical Index gets us in the neighborhood in the Tabular
you always want a more specific code if you can find one
and because we know that impotence is a male sexual dysfunction
and erectile dysfunction, we could look at it this way
looking up at "Dysfunction - sexual - male - erectile"
each one of those subterms and then under erectile
there's a "due to" and under that "disease - classified elsewhere"
That would be the correct code and the more specific code because we know
that his impotence is "due to" the diabetes and when we go to
N52.1, there is an instructional note "code first"
underlying disease then out diabetes type 2 with
neuropathy, E11.40.
So let's look up, first of all just to show you the importance
of indentations that we often have in this course, I want us to look up
this disfunction in the Alphabetical Index
Ok, we're in the Alphabetical Index: Dysfunction - sexual
here's "female" let's look down to find "male" here's "male"
we're looking for "erectile", here's "erectile" "drug induced", "due to"
"disease classified elsewhere" in N52.1, so that is the more specific
and, I believe, the more accurate code in this case.
So let's look at the "E" code.
Remember just a few slides ago we talked about diabetes being
the first access is the type.
So when you're in your Alphabetical Index here's your Diabetes type 1, you're
going to move down to find Diabetes type 2
"with neuropathy" and, here is your "neuropathy"
E11 with "neuropathy", here we go, E11.40
So let's look that up in the Tabular.
In the Tabular we're in E 11.40 Type 2 Diabetes with
"diabetic neuropathy" unspecified.
Unspecified means that you see these other terms "mononeuropathy"
and "polyneuropathy" in our documentation it didn't really specify
that so we have to use the unspecified code in this case.
Exercise 15.2 number four.
A type 1 diabetic developed hypoglycemia, which is a low sugar,
even though she had taken only took the prescribed dose of the insulin and she did not alter
her exercise or her eating regimen.
And if we coded this, it would be diabetes type 1
with hypoglycemia.
One reason why I wanted to use this particular exercise is we're going
to see a little bit later, depending on if the insulin is too much or too little, you
have either an under-dosing or a poisoning.
But in this case, the patient, the documentation tells us the patient took only the prescribed
dose.
So there is no under-dosing and there is no poisoning because of taking too much.
So you're simply going to code the diabetes type one with the hypoglycemia.
I included this exercise because I don't like the way
the documentation is written.
This is the way it is in the text book.
It implies by using "with' this way that the mental disabilities
are related to the cystic fibrosis.
And, they are not.
So to make our point, let's look in the alphabetical index under fibrosis,
cystic to show you what I'm talking about.
So in the alphabetical index we have fibrosis, cystic,
with, and you look at the things you can have with cystic fibrosis.
The obstruction, fecal impaction, intestinal manifestations,
and specified manifestations.
I suppose that the intellectual disability could be tied
back as a specified manifestation, but I have never heard of that.
I can do some research and see if that's a possibility.
But without more information I would just use the E84.90
code instead of this manifestation, specified manifestations code.
So that's why I question this right here.
I'm not seeing intellectual disabilities being tied back to cystic fibrosis.
I wanted to show you why I don't like the way this is written.
I did some research and intellectual impairment is not typically associated
with cystic fibrosis.
They have many other problems but that's not one of them.
And when we look in our alphabetical index you see
the cystic fibrosis here, with these different problems, none of which are related to intellectual
ability.
I think whoever wrote that exercise should've made the distinction somehow, either
with a semicolon or something that the two things were not connected.
And I have here on the right, the pathway for how you would
get the mild intellectual disability.
As I've mentioned in previous podcasts, I'm not going
to look up every single one of these.
By giving you the pathway I think you can do that on
your own.
It allows us to spend more time on things that aren't in the coding handbook.
The next exercise, 15.3 number 9, deals with the morbidly obese patient with a BMI of 39.
And I have here the rational and the pathway for how you would get to those codes.
As a reminder, we can use BMI documentation from
a dietitian to help us know what we can code.
Exercise 15 number 11 is a fluid overload due to a transfusion.
You may remember in an earlier slide in this podcast I talked about
how you code fluid overload depends on circumstances.
In this case, when it's due to a transfusion it falls under the E87.71 code.
Exercise 15.3 number 3 has congenital myxedema.
That's pretty straightforward.
But this one, inappropriate anti-diuretic hormone secretion syndrome,
is a little more challenging.
So I wanted to show you the pathway when you're looking
this up in the alphabetical index.
Anti-diuretic is your main term.
That's a tough one.
And you see here in the alphabetical index.
There you go.
I know when I first started looking for this term I was looking for syndrome as
my main term.
There are no entries under syndrome for anti-diuretic hormone.
So then you just start looking other places.
And I looked under inappropriate and
there was nothing there.
But then when I went to the next term, anti-diuretic, I did find
it.
So sometimes you just have to look around and try all the different terms until you
find the term or terms that describe the condition.
If the record did not state the type of diabetes, there is a default, and that is in one of
our coding guidelines that I've quoted here.
If the type of diabetes mellitus isn't documented in the medical record, the default is E11.-
type 2.
Of course the dash meaning additional characters may be needed.
Something to always keep in mind on a good test question.
Okay, here's an example not in the coding handbook that
relates to the under-dosing of insulin.
The patient was admitted for treatment due to
complications from type two diabetes which include diabetic polyneuropathy and proliferative
diabetic retinopathy with macular edema.
The patient was using an insulin pump at home,
however she told the physician it had not been working correctly for sometime and she
found out this morning from a service technician the pump was not delivering the full prescribed
dose of insulin.
So what this patient has described is an under-dosing of insulin, which
is a mechanical failure of that pump.
And we have a guideline specifically related to
complications due to insulin pump malfunctions.
Under-dose of insulin due to insulin pump failure is an under-dose assigned to a code
from subcategory T85.6, which is mechanical complication of other specified, internal
and external prosthetic devices, implants and graphs that specifies the type of malfunction
as the principal code.
So that's telling us right away that's our principal diagnosis.
followed by the code T38.386 under-dosing of insulin.
Additional codes should be assigned for the type of diabetes and any complications due
to the under-dosing.
So let's look at how our pathways would look for this particular case.
There is a column in the table of drugs and chemicals
for under-dosing.
And we would look up insulin as our substance.
And here would be your under-dosing code.
So that takes care of that T38 code.
And we would add the 6th character "A" for initial encounter.
Our documentation tells us that this is an initial encounter.
But this T85 code, we need to find that one.
And that is found in the alphabetical index under complication.
Insulin pump mechanical breakdown get's us to T85.614A.
The under-dosing code we have here below, T38.386, we know this person has diabetes
with polyneuropathy.
That is an E11.42 with retinopathy proliferative with macular edema,
E11.351 and is on insulin.
So here's the same case, the very same case, the same
diabetes.
Only this time, an overdose of insulin is considered a poisoning.
Under-dosing is when she's not getting what was prescribed.
Overdosing is when she is getting more than prescribed.
And that overdose is considered a poisoning.
So you're going to go back to that T85.6 code.
This time your T38 code is a poisoning code, not an under-dosing code.
And then of course, your additional codes assigned for diabetes and any associated complications.
This is another exercise not in the coding handbook.
The patient had a total pancreatectomy last month.
And as a result has now developed secondary diabetes
mellitus and uses insulin.
We have a guideline that speaks directly to secondary diabetes
mellitus due to a pancreatectomy, and it gives us our E89.1 code here for post procedural
hypoinsulinemia .
My, goodness.
You assign a code from E13 for your secondary
diabetes, and the Z90.41 code for acquired absence of pancreas.
Of course, it mentions she uses insulin.
So that's our Z79.4 code.
So whenever you see documentation that talks about a total or a partial, it's a different
code.
Total or partial pancreatectomy, you're going to be reminded of this.
You're going to be reminded of this coding guideline.
This goes as our pathways for how we would work
through that problem.
Note that there is an instructional note below the E89.1 code that
tells us to use that Z90.41-code for the absence of the pancreas, acquired absence--meaning
the patient had it removed.
And then, our post pancreatectomy E13 code and our insulin.
The secondary diabetes comes under the specified type code for diabetes which
is E13.9.
Here's our insulin and here's our absence of pancreas.
The exercises in this PowerPoint do not address all the guidelines
for Chapter four.
Exam questions may relate to all the guidelines.
So be sure you cover everything in your code book and always follow
your assignment schedule in regard to any specific chapter assignments.
If you have any questions, please post them in discussion
board and I'll try to answer them from everyone.
Thank you.