Today we are going to start Chapter 16 in the Coding Handbook which is titled "Mental
Disorders".
This corresponds to Chapter 5 in our code book "Mental, Behavioral, and
Neuro-developmental Disorders".
As a reminder, you are not going to be doing any procedure
coding so you can skip over those parts of the exercises that ask for procedures.
I also want you to be aware of the DSM-V. It
is a code book that's used by psychologists and psychiatrists.
That's all you need to know about it for this course.
Abuse versus dependence, understand that there is a difference
and dependence is the far more serious of the two.
Dependence is linked typically to someone being willing to break the law to
continue their habit and also causes them withdrawal symptoms when they stop using.
This is a hierarchy that is in our Coding Handbook and well as in the Coding Guidelines.
That if you see these terms used in the same documentation, there is a hierarchy as to
how you are going to code them.
Going through the bullet points, I won't read them all,
but using the first one for example: If your documentation says both "use" and "abuse"
you are going to code only the "abuse" code.
There's a "use" code, an "abuse" code, and a "dependence" code.
So that's why you have to have a hierarchy of how you are going to
code them.
The second bullet point: If both "abuse and "dependence" are documented you're
coding only the "dependence".
So what you see is the more serious of the two terms are
the one you are going to code.
So let's look at an example.
This exercise is not in the Coding Handbook.
The patient is admitted to the hospital from the Emergency Department
where he was evaluated for severe pain in his lower back.
We will admit him today to rule out a kidney stone.
The patient is known to the ED staff as a cocaine user.
He has suffered withdrawal in the past six months
when he came to the ED with severe nausea and vomiting, but there are no reports of
any withdrawal thus far.
A psychiatric evaluation was ordered to determine if rehab might be
an option this time.
There are several things we want to look at as a coder when we get
ready to code this.
First of all two things were talked about the user and the withdrawal.
Withdrawal indicates dependence.
So in that case, because of our hierarchy in our Coding
Guideline, we're only going to code the "dependence".
We are not going to code the "use".
Also, what you may remember from our general guidelines
in a hospital, inpatient stay, you can code a "rule out".
So in this case, the physician mentioned "rule out a kidney stone" right
here.
Because it's an inpatient, you can code that kidney stone and that's what we have here
in our pathway.
Kidney stone, another word for that is Calculus.
So when you going into your Alphabetical Index Calculus, sub-term
kidney takes you to N20.0.
Your dependence, sub-term drug, sub-term cocaine takes you
to F14.20.
I also want to bring up another thing that has to do with the Section III
Reporting Additional Diagnosis Guidelines and that would be in this case we would code
the cocaine dependence because this last line here, the doctor has ordered a psychiatric
evaluation.
So one of the Section III Guidelines is clinical evaluation.
Take a minute and look in your guidelines at the Section III,
there are several bullet-points for what makes a diagnosis reportable and review those because
those are things that are going to keep coming up moving through the course.
There is another guideline that talks about "in remission".
A coder cannot select code F10.21, alcohol dependence in remission unless a physician
had said so.
This is one of those very specific cases that the nursing documentation or a
therapist documentation is not going to get it.
You have to have the provider's clinical judgement.
That is true also for the in-remission option for categories F11 through F19 and
this is, as I said, a Coding Guideline.
So here's some examples to keep us straight.
If the physician documented in a medical record the
patient's alcoholism dependence is in remission, you are going to code that F10.21.
If the nursing note mentioned that the patient is
in remission, since he has been hospitalized without any alcohol for the last week, that
is her statement not the provider's judgement.
So even though it may be true, you cannot code from the nursing note.
You can only code from the physician's note that indicates his
or her clinical judgement.
When a patient has a drug dependence and is on medications
for detox or for any maintenance programs to prevent withdrawal, an example is methadone,
the appropriate code for the drug dependence is assigned rather than a code for the methadone
or any other drug that is being given to help with withdrawal.
So here is an example of a case.
The patient is a 33 year old female admitted to the third floor for a fractured
left ankle and I give the example of how specific we can code here.
It is a bimalleolar fracture, non-displaced.
She suffered in a fall in the detox unit this morning.
She has been on methadone several weeks trying to end her opiate dependence.
She will continue to be followed by drug and alcohol therapists while she is here for
treatment of the ankle fracture.
So on the right here, I have the pathway for how you
would get to this S82 category code.
And here is the code for the drug- the opioid drug
dependence.
And I'm bring to your attention again to note that the opioid dependence is
reportable as a secondary diagnosis because the patient is receiving treatment, in this
case therapy while she is in the hospital.
She's in the hospital for the broken ankle but because she is receiving therapy for the
opiate dependence we do code that as a secondary code here.
Code F4 classifies psychological and behavioral factors associated with diseases
classified elsewhere.
This is one of those that you are going to see often associated
with asthma, ulcerative colitis, or dermatitis but there are other disorders that could also
have a psychogenic component.
Here is an example of one.
Psychogenic paroxysmal atrial tachycardia.
The tachycardia, here's your pathway and then when your coding the psychogenic part of that,
right here, you're going to start with your main term psychogenic then your sub-term factors
associated with the physical conditions.
In the tabular under F54, there's an instructional
note that says code first the associated physical disorder.
So with as many examples we have looked at in this class often the instructional
notes help us know how to sequence these codes.
PTSD, something you've probably all heard of, I bring this to your attention because
we have not used any of the "Y"codes yet in this course.
This young woman suffers from chronic PTSD as a result of war activity.
So PTSD, Post-Traumatic Stress Disorder.
We are going to start with the main term disorder, post-traumatic,
stress, and that gives us F43.12.
Also note the "chronic" is a essential modifier in this
case it's something we do need to be able to code.
In our Coding Handbook on page 178 it mentions chapter 20, External Causes of
Morbidity and suggests finding the block that includes activities of war.
And that's how I would suggest finding the codes when you
have these kinds of cases and I want to show you that in our code book.
And here you see we are in Chapter 20, External Causes of Morbidity
and let's see Y, here we go, legal intervention, operations of war.
So this tells you where you would start looking for this particular
code.
Some of the hospitals don't use the chapter 20 codes but you would know when your
hired whether or not your supposed to assign those.
Here's an exercise not in the Coding Handbook.
The patient is a 27 year old male hospitalized for a fractured right humerus
initial encounter.
According to the H and P he uses marijuana recreationally and has
a beer or two every night.
In this case we would not code the marijuana or the beer because
of this guideline.
As with all other diagnoses the codes for substance abuse should only
be assigned based on provider documentation and when they meet the definition of a reportable
diagnosis.
Codes are to be used only when the psychoactive substance use is associated
with a mental or behavioral disorder, and such a relationship is documented by the provider.
I think I want us to look at that Section III just to be sure you know what I'm talking
about.
So this is the section that I'm referring to.
Section III Reporting Additional Diagnoses.
It's in your guidelines so just page through until you find it.
If you're wondering as a coder whether or not you code something
during a hospitalization you have to see if these other diagnoses are affecting the patient's
care.
In other words, is it requiring a clinical evaluation?
Is it requiring a therapy?
Is it requiring a diagnostic procedure?
Is it extending the length of the hospital stay?
Or is it requiring increased nursing care and or monitoring?
A diagnosis has to meet one of those five things in order for it for
it to be reportable.
So in this case that we just looked at, if we go back and look
at this one you see that he mentions the marijuana and the beer but this particular hospitalization
is only for that fractured right humerus, nothing else.
So we don't even have to code the marijuana or the beer.
Okay here is another exercise, pain with a psychological component.
We have a guideline that directly addresses any pain disorders that are related to psychological
factors.
And in this case, the patient is a 46 year old female complaining of chronic
pain due to trauma.
The physician feels there is a psychological component to her pain.
So even though we are going to code that G89.21 as her pain, chronic pain.
We are also going to code the pain disorder F45.42 So on the
next slide I have the actual pathway here.
Here's your pain, sub-term chronic, sub-term due to trauma, gives us G89.21.
And pain-psychogenic (any site) gives us F45.41.
And in this case what happens is the alphabetical index is
one of those where it gets us to the neighborhood but when we go to the tabular we are going
to find the right code.
So let's look up F45.41 and see if it does indeed meet our needs.
And when we get in the tabular we have a pain disorder, exclusively related to psychological
factors or we have a pain disorder with related psychological factors.
Code also any associated acute or chronic pain.
So even though the alphabetical index took us here, once we go
into the Tabular and we read this F45.42 is the better code for us because it relates
the fact that this patient does have chronic pain because we gave her a G89 code and this
is the correct psychogenic code not this.
So again just another example of the Alphabetical Index getting you in the neighborhood but
not necessarily in the right house.
This is one of those cases where you may not know
which main term you are going to use, so you are just going to try.
You may think you have to use paranoia, or alcohol.
So this is just showing you the correct pathway with psychosis
being your main term and then following your indentations to get to F10.250.
I bring this one to your attention to talk about the blood
alcohol level and it's one of those things in Chapter 20 that I mentioned earlier that
I think the easiest way to find them is to go to the Y blocks and find the one that includes
the blood alcohol levels.
And I wanted to show you have I have done for blood alcohol
level.
If you go to Chapter 20 and you go down these codes here what I've done under
the Y90, includes blood alcohol level.
That just helps me remember that because this is
kind of vague.
Supplementary factors related to causes of morbidity.
Could be lots of things, but blood alcohol level B.A.L. is how you
might see that documented or abbreviated in the medical record.
Please be mindful that the exercises in this PowerPoint do not address
all of the guidelines.
Exam questions can relate to all the guidelines covered in the
chapters planned for each week.
Not just those in the PowerPoint.
And always follow the assignment schedule with regard to any specific chapter
assignments.
If you have any questions please post them in the discussion board and I will
answer them and I thank you very much for your attention.
Have a good day!