Today we're going to look at Chapter 18 Diseases of the Nervous System and Sense Organs.
This corresponds to Chapters 6 through 8 in the code book.
But before I do that, I wanted to look at Guidelines, one more time.
I know I talk about them all the time, but
I cannot overemphasize how important they are.
Section I includes the Conventions, the General Coding Guidelines and the Chapter-specific
Coding Guidelines.
Section I.A would be the Conventions, Section I.B would be the General Coding Guidelines
and Section I.C would be the Chapter-specific Coding Guidelines.
Section II is Selection of the Principal Diagnosis, which we talk about some, but we will talk
about more and more going forward.
Section III Reporting Additional Diagnoses and that is when we have looked at that in
past exercises, determining if a diagnosis
met certain criteria, i.e. is it clinically evaluated? Is therapy provided? Is more
nursing time needed, etc.?
Section IV is the Diagnostic Coding and Reporting Guidelines for Outpatient Services. We have
not talked as much about (outpatient).
Primarily, what we have talked about so far are inpatient cases.
There are times we will be talking about encounters in the physician office or clinic and those
Outpatient Guidelines would apply there as well as the
Emergency Department.
That is also a place where the Outpatient Guidelines are applied.
So, to make sure everybody is on the same page, we are in the code book, Section I includes
Conventions, General Coding Guidelines and Chapter-specific Coding Guidelines.
Here's "A", where we have Convention (I.A), Here's "B", General Coding Guidelines (I.B),
which we do use quite a bit.
"C" the Chapter-specific Coding Guidelines (I.C) which we look at quite a bit.
Next is Section II, where we are selecting the Principal (Diagnosis).
Section III, Reporting Additional Diagnoses (this set of criteria here)
and Section IV for Outpatient Services.
So, if you haven't already done so, you have to become very familiar with the Coding Guidelines
so you can code appropriately.
So, for this Chapter 18 (Coding Handbook), we will be looking at Chapter 6 which does
have very specific Coding Guidelines, primarily related to pain more
than anything else.
Down at the bottom here, Chapter 7 starts with Diseases of the Eye.
We turn the page and Chapter 8, you see there are no guidelines. It says
"Reserved for Future Guideline Expansion". That is something we will always notice too.
These same guidelines for the Chapters are found directly in front of the Chapter.
You may wonder why I just went over that again.
Well, we all learn at different speeds and I want to make sure that everybody is learning
and everybody is on the same page when I talk about Guidelines
and referring you back to certain Guidelines.
Let's talk about the Nervous System now. The nervous system is broken down into the Central
Nervous System and the Peripheral Nervous System.
So really, any diagnosis that affects the brain and spinal cord is going to come under
the Central Nervous System and everything else throughout the body is going to come
under the Peripheral Nervous System.
Notice that the Autonomic Nervous System is what regulates the activity of the cardiac
muscle, your heart muscle,
the smooth muscle, which is along your GI tract, and
the glands.
Let's look at Exercise 18.1 #2 and this is a polio virus encephalitis.
I made you a little note here that you code the poliovirus as
poliomyelitis.
The more you are in the code book, this is why I encourage you to just be in it as much
as you can,
You are going to see times when certain words are always used in place of another word and
the same words are not always used in the medical record as they are in the code book.
So you learn what to look for.
This is one example where a poliovirus would be coded as poliomyelitis. Another good example
that I remember when I was learning to code is that an "amputation" is coded as "absence
of limb". You just learn where your pathway begins.
In this case, you can see that poliovirus encephalitis requires two codes. That is one
of the very first Coding Guidelines. "A" is a convention, remember we just looked at Section
I.A. Conventions and this is the "Etiology/Manifestation" convention where you have a "Code first" and
"Use additional code" (instructions).
So when we look up polio, we get this code (A80.9) but if we had started with encephalitis
and had followed down our indentations in the Alphabetical Index, it would have taken
us to the same code.
This is the polio code (A80.9) followed by the manifestation code (G05.3 for encephalitis).
That is a good example of the etiology/manifestation convention.
I have this exercise for a couple of reasons. One is to notice that the terms "intractable"
and "poorly controlled" mean the same thing. "Intractable" is a term that you often read
in the medical record where it describes many things.
Epilepsy, generalized, idiopathic, intractable
The point I wanted to make with epilepsy is taken from the Coding Handbook, p. 205. Similar
to AIDS, you cannot code epilepsy unless you have a physician stating it very clearly that
this person has epilepsy.
I don't know if you have ever known anyone with epilepsy, but it affects their life in
many ways, one of which is they cannot get a drivers license.
In our society, if you live out in the country for example, that 's a very big obstacle to
overcome. So you don't want to ever give someone that diagnosis unless it is very clearly identified.
If it is not clearly identified, a query to the physician is certainly in order.
There are Coding Guidelines that are specific to only certain codes. Coding Guideline
I.C.6.a is for codes from category G81 and subcategories
G83.1, G83.2 and G83.3.
This guideline tells us when information, in other words, the medical record documentation,
is not available regarding whether the affected side is dominant or non-dominant,
and the classification (which is the code) does not provide a default, this is how you
select your code.
If the patient is ambidextrous, the default is dominant.
If your left side is affected, the default is non dominant and if the right side is affected,
the default is dominant because the majority of our population are
right-hand dominant.
I have several children who are left hand dominant, children and grandchildren, who
are left hand dominant, so that is not true in every family. For general purposes, this
is the Guideline we are going to follow.
Also, if a person has hemiplegia and a stroke, (a CVA
or cardiovascular accident) , hemiplegia is not inherent
meaning not everybody that has a stroke has hemiplegia
therefore a code from category G81 is assigned as an additional code even if it has resolved
without treatment by the time the patient is discharged.
It is not uncommon for a patient to come to the ER, be complaining of whatever stroke
symptoms they have, i.e. some weakness on one side and by the time they come into the
hospital, they are treated and they leave, that weakness has subsided or has gotten a
lot better.
You are still going to code it because it did happen and it required additional resources
to take care of the patient.
Ok. Let's look at the Exercise 18.3 #2. A couple of things I want you to notice in this
exercise: a cerebrovascular accident, a cerebral infarct and a stroke are terms that are used
interchangeably in the documentation and that eft-sided weakness is referring to hemiplegia.
You would code the stroke as "accident" (main term),
cerebrovascular (I63.9) and the hemiplegia (G81.9-), that "dash" meaning we need additional
characters so that takes us to the same Guideline that we just looked at a little bit earlier.
When the information is not available regarding the affected side and when the classification
doesn't provide a default, how do you code it?
In this case, we are looking at left sided weakness so we go to this part of the Guideline.
If the left side is affected the default is non dominant.
So the final code is G81.94, Hemiplegia, unspecified, affecting the left non-dominant side. That's
how we get to this code.
Let's look at Exercise 18.3 #3, Severe hypertension and pounding headache due to autonomic dysreflexia
due to fecal impaction. I have a link here to more information and this is talking about
autonomic dysreflexia. If you are working, for example at Craig Hospital or really anywhere,
any trauma center that's treating a spinal cord injury, and rehabbing a spinal cord injury,
autonomic dysreflexia is so important. It can be deadly if it's not addressed quickly.
I used to work in a rehab hospital and part of providing
rehab services to a spinal cord patient is to teach them how to take care of themselves
now they have this injury. One of the things you are teaching is how
to recognize the signs and symptoms that you are getting into trouble with autonomic dysreflexia.
When you go to this code, G90.4, there is an instructional note to use an additional
code to identify the cause. That is where we get to the fecal impaction. You can also
look it up here and of course, the hypertension is coded (I10).
Here's an exercise not in the Coding Handbook. As you know, I like to give you these because
I think we need to look at Exercises that use more of the Coding Guidelines than she
does in the Coding Handbook.
This one is an outpatient. The patient presents to the clinic today for treatment of severe
chronic back pain due to trauma. He will receive injection of steroid into the spinal canal
to help with the pain.
I made a little bit of an exception to the way you are accustomed to seeing these slides.
I moved the pathways over here (on the left) to make room for the guidelines that apply
to this case.
The pathway is Pain, chronic, due to trauma. It's pretty straightforward.
Note that there is an Excludes 2 note under the G89 code where you can use localized pain
by site, lumbar region and that's what we've done.
Excludes 2 notes mean you can code this code and this code. If you had an Excludes 1 note,
you could only code one of those things.
Here are the three guidelines. They are in a similar family
in that I.C.6.b.1.a, I.C.6.b.1.b.i and I.C.6.b.1.b.ii. This is when you are using the code G89 as
the principal (diagnosis) or the first-listed. In this case, since we are in a clinic, it
would be called "first-listed". It would not be called "principal".
You are using G89 as your first-listed (diagnosis) and that is acceptable because pain management
is the reason for this person's encounter and the underlying cause should be reported
as an additional diagnosis.
This one also applies. Codes from category G89 may be used in conjunction with codes
that identify the site of pain because it provides additional information. M54.5 does
not tell the reader if the pain is acute or chronic. The G89.21 code (chronic) gives more
information.
Last of all, the sequencing, if the pain management is why someone is there, G89 is the first
code followed by the site of pain. But if the patient is in the hospital or clinic for
any other reason, that site specific pain is coded first followed by the G89 category
code.
So hopefully, you can see where I used all three of those coding guidelines to be sure
I was coding this correctly.
Now, let's move on to Chapter 7, which is Eye Disorders. In the (2016) Coding Handbook,
on p. 218, Table 18.1, the author has created a table that includes those Coding Guidelines
from Chapter 7 but also she added more information regarding if the classification includes laterality
or not.
For example, for some codes, you have a 5th, 6th or 7th character that identifies if it's
right, left or bilateral; other codes do not.
That is why you need a Table, like what the author provided, to be sure you are coding
those accurately.
Two guidelines I want to talk about from Chapter 7:
Patient admitted with glaucoma and the stage evolves during admission (becoming worse or
becoming better), you are going to assign the code for the highest stage that's documented.
A patient comes in with Stage 1, it evolves to Stage 3 and resolves by the time they leave
the hospital back to Stage 1, you are going to code Stage 3 (the highest stage documented).
Also, the indeterminate stage glaucoma: The 7th character "4" is indeterminate, based
upon the clinical documentation the physician has provided. The "4" is used when the doctor
cannot make a determination. That is different than there being no documentation regarding
the stage.
So, be careful you don't confuse the 7th character "4" with a 7th character of zero (when there's
no documentation).
Ok, let's look at one of these. Glaucoma secondary to posterior dislocation of the lens, right
eye. If we looked up "Glaucoma", in dislocation of the lens, we get see Glaucoma, secondary.
When we go there, we get to H40.5-, look that up in the Tabular, there is an instructional
note to "code also the underlying eye disorder".
It's the right eye, so the 5th character is "1".
There is no 6th character so the placeholder "X" has to be used and because there is no
indication of a stage in this documentation, the 7th character is "0". The final code is
H40.51x0.
Then we look up the underlying eye disorder we talked about here, Dislocation, lens, posterior
H27.13-. Since it is the right eye, the 6th character is "1", so the final code is H27.131.
Notice how, as with all our exercises, we are following our instructional notes very
carefully to be sure we are sequencing them correctly and to be sure we are covering what
the code book is advising us.
OK, let's look at one of the Exercises that has to do with the Ear in our Coding Handbook.
Perforation of the tympanic membrane due to chronic suppurative otitis media, right ear
Sometimes you don't put the terms in this order that I have shown you in the Pathways,
so then you will try another way. Eventually, you figure it out and you get to this pathway,
Otitis, media, suppurative, chronic H66.3-
There is an instructional note with H66.3- "Use additional code for any associated perforated
tympanic membrane (H72.-)
In the H66.- code, the 6th character is a "1" for the right ear. We use the placeholder
"x" for the 5th character position so that we could have a 6th character. The final code
is H66.3x1.
For the performation of the tympanum, H72.9-
The right ear is a 5th character "1", so the final code is H72.91. There is an instructional
note to code first any associated otitis media, so we know that the H66.3x1 code is going
to go first, and then the H72.91 code.
As with all of our Power Points (PPTs), please be mindful that exercises do not address all
of the guidelines.
Exam questions may relate to all guidelines covered in the chapters for each week, not
just the guidelines covered in the PPT.
Always follow the Assignment Schedule with regard to specific Chapter assignments. Post
any questions you have in Discussion Board along with the path you used to find an answer,
and Iwill attempt to answer them.
Have a good day.