Today we're going to talk about
the Guidelines for Chapter 1. I've gone into a lot more
detail with Chapter 1 than I will in
subsequent chapters. I want you to
understand how important the guidelines
are and figure out the best way for you
to apply them when you are doing your
homework. I've made some changes to the
annotation which I'll be reviewing in this
PowerPoint. I've also given you some
examples of the various guidelines and
from there we'll see what kind of
questions come up and how you do on your
homework.When you complete your homework
for this class, you will have to tell me
not only the answer, but the pathway that
you used in the Index as well as any
instructional notes and the Guideline
that you applied in order to know how to
code or how to sequence the codes. So
let's get started.
Chapter 1 only had one change to the
guidelines. If you remember your textbook
has 2016 guidelines in it. I''ve given
you the PDF and when scrolling through the PDF, in
bold font are the 2017 Guidelines and the
only addition in 2017
were the Guidelines around the
Zika virus.
Otherwise, everything is the same. So when
you're looking in the code book at those
guidelines, they are accurate as they are
written for everything if you make a
note "Don't forget about Zika!"
Some suggestions for annotations are
given here and you can decide what works
best for you as long as there's some way
that you can consistently annotate this
PDF. I have Adobe Pro on my desktop
which allows me to export the PDF into a
Word document which gives me a lot more
editing options so I would suggest, if
you have Adobe Pro, that you do that.
Export your PDF into a Word
document and edit it. You can also print
the PDF and by hand make these
annotations using markers.
Here's an example
of what I'm doing. I can blow this up. That should help
a little bit. The green are key
terms. "Underlined" has to do with sequencing
directions. We scroll down a little
bit. I use text boxes here to remind me
of the code that's going to be used with the
key term there in green again and
yellow (highlights) are just expansions on
understanding what the guidelines are
saying. So back to my slides. This is one
and here's another one.
It kind of just shows you the same
thing. I will make available the
annotations that are here in this
PowerPoint. You just have to remember that
if you're going to be using the
electronic document, you'll have to save
a new one each time I give you one
because each chapter is being annotated.
The reason why this is so is because I
have only had to use this PDF this
semester. It's never been the case that we
didn't have the correct guidelines in
the codebook. Ok, let's look at the first
guideline which is to code only confirmed
cases of HIV. What that means is whenever
the physician uses the terms "possible" or
"probable" or "suspected" or "questionable" or
"still to be ruled out"- those are all
things that, normally, in an inpatient
setting, you would code as if they (the condition)
existed but there are certain things you
do not code if the physician uses the
term "possible" or "probable". What I've given
you here in this slide is a possible
scenario where the physician might say
patient admitted with anemia with
possible HIV infection. You would only
code the anemia.
I have the anemia here for the Index pathway and
the rationale for the code you selected
is that the HIV is not coded because the
physician stated it is "possible". Only
confirmed cases are coded and there's your
coding guidelines here. Then I had to
note here that this is an exception,
the fact that you are coding something
that uses the term "possible" is an
exception to Section 2 Selection of
Principal Diagnosis, number H "Uncertain
Diagnoses" and then I have it reproduced
here with a copy paste of what that says.
So just remember, for inpatient
hospitalization, when you're using the
terms "possible", "probable", "suspected" in
most cases, you would code that
condition as though it existed.There are
certain exceptions.
HIV is an exception. Later on in this
podcast, we will hear about Zika. The Zika
virus infection is an exception. If the
physician says I suspect Zika virus
infection, you do not code it. You must
code only confirmed *cases of Zika) but we're getting
ahead of ourselves. We'll go back and
look at that a little bit later. There's
some other diagnoses that this is the case as
well and we will be touching base on those
as we move through the guidelines for other chapters.
Another guideline says "Patient admitted
for HIV related condition". This
particular one is pneumocytosis, which is
due to the Pneumocystis carinii
(that is the organism causing the pneumocytosis).
Here I have the pathways and the rationale.
Patient is being admitted with an HIV related
condition so your principal (diagnosis) will always be
B20, followed by whatever those (codes) are for
the reported HIV related conditions. If you
are coding an "unrelated" condition, like if a
patient has anemia but the physician
is saying the anemia is not due
to the HIV, then you're going to make
the anemia be the principal diagnosis and
underlined here, with the guideline, are
the sequencing instructions for how the
coder would sequence these diagnoses.
If a patient is newly diagnosed with HIV, the
point that's being made with this guideline is that
whether the person was diagnosed last
week, last month, two years ago or 10 years
ago, that (time frame) is not determining what the
sequencing directions are. The sequencing
directions are dictated by whether
or not the infection is HIV-related. If
it's HIV- related, the B20 is going to be your
principal diagnosis. If the infection or the
condition is not HIV-related, then that
is going to be the principal (diagnosis) instead of the HIV.
An asymptomatic person, like this person,
is admitted with appendicitis, is HIV-positive, but
no symptoms, you are going to use the Z21 code
for asymptomatic HIV. If the physician had
used the term, "the patient has AIDS" as
you can see from the guideline, you would
have to use B20 or if the patient has had
any history ever of having had an
HIV-related condition, then you are going to
always use B20. You are never going to use
Z21.
If the patient has an asymptomatic HIV
infection and is on medications
for the HIV, it doesn't change anything.
The guidelines tell us that if the
patient is using medication for HIV,
they're still going to be Z21 if they are asymptomatic.
The previously diagnosed HIV related
illness-(this guideline) is making the
point that the patient has appendicitis now which
is not HIV-related.
however, last year he had a Pneumocystis carinii
pneumonia which is an HIV-related
condition, therefore, he would
carry the B20 diagnosis and not Z21.
This guideline has to do with HIV
infection in Pregnancy, Childbirth and
the Puerperium.The Puerperium is a period of
time after the child has been delivered and
then here is your guideline for the O98
code. I have given you a case here where
the patient is a twenty-seven-year-old admitted
with oral thrush associated with her HIV
diagnosis. She is 13 weeks pregnant.
Previously she was asymptomatic, so up
until now, she had a Z21 diagnosis but now
that she has this thrush that's been
associated with HIV,
she's going to carry that B20
diagnosis (code) from now on. The thrush is the B37.0.
You always assign codes for the weeks of gestation (Z3A.13)
The O98 code is
the principal diagnosis because that's
the reason why she's being admitted with the
pregnancy complicated by HIV disease.
Then here in italics, it says codes from
Chapter 15 always take sequencing
priority. That's something that we have
to just remember as we are moving
through the record and I'll be reminding
you of that in your homework and in
different places that Chapter 15
(the pregnancy codes) always take sequencing priority.
It is very, very rare that a pregnant woman
would be admitted to the hospital that
wouldn't have a diagnosis that starts
with "Pregnancy complicated by" whatever
the reason is for her admission.
Obviously, if she's being admitted in labor,
that's different but anything prior to
labor is going to be a complication of
the pregnancy. I have a reference to this
book that I have the screenshot from
here in a later slide but some students
find it helpful to have these types of
tables. You can reproduce this table in
your code book somewhere so that you
have it if that's helpful. You can print the
slides.
However it helps you to learn these
guidelines. Now we finished the HIV
guidelines and now we're going to look at a few others.
This one has to do with infectious agents
as the cause of disease classified to other chapters.
What that is referring to is if there is an
infection and in the description of the
code, it does not mention the organism then
you're going to need to use a code
from the range of the B95 to B97 to be
sure that you can capture the organism
responsible. So here's the case in point.
Patient admitted for treatment of a UTI
caused by E coli. We know that the E. coli
is causing the infection but our code N39.0
does not include the cause of infection.
So we would have to add that code. There is
also an instructional note under the N39.0
code that says, "use
additional code, B95-B97 to
identify the infectious agent". So if we
again look under the main term "infection"
under E. coli as a cause of disease
Infection, E. coli as cause of disease
classified elsewhere, B96.20 and
that would be the organism code so now we know
what the infection is and what's caused it.
The rationale I've given you is the guideline that's
used
and we notice that this guideline tells us
if the organism is not in the code
description, then you're going to have to
add a code that identifies the organism.
We know what it is, we just have
to be sure that we have let the doctor
or the reader know what the
offending organism is.
Okay, here i have taken that same
diagnostic statement and just added the
infection is resistant to Vancomycin.
So now we've got the N39.0 as the infection.
We've added the B96.20
identifying the E. coli
as the organism and now we want to be sure we add
this resistance to vancomycin because
that might be important. I have here the
path and the index and how you find a
code. In the Rationale, you will notice the
guideline that was listed on previous
slide about identifying the cause of
disease with a code from chapter 1
and then the resistance to antibiotic, Z16
code, we would use that as well.
You notice in the guidelines, it always says
the "category" and it says "Category Z16."
That tells us that there's
some characters (in the Tabular) that would
follow that Z16 code so when we go to
the actual category Z16 and we read down we
can identify the drug that the person is
resistant to and in this case, it is
Vancomycin. You can never go by your
guidelines or your Index and say that's
your answer. You have to always go back
to the Tabular, which is where all of the codes in
the back of the code book are to verify that that's your answer.
Here are some guidelines regarding sepsis. If the
patient had been admitted with sepsis and
the doctor did not identify a cause, then
we can use the A41.9 code. The guideline
also tells us if the type of
infection is not further specified
you're going to assign code A41.9
for sepsis, unspecified organism.
Now, of course there may be times when
you're working with a chart, that when
you first code it, it is an "undetermined"
organism and then later on in the
hospital stay, you find out what the
organism is. Then you're going to delete the
sepsis code and add the more specific code.
The terms "sepsis" and "severe sepsis" are
different. This particular guideline has
to do with the coding of "severe sepsis" and
you see in the diagnostic statement where
the physician states the patient has
developed severe sepsis and acute
kidney failure. You're going to code
the severe sepsis and the failure of the
kidney. I have instructional notes
that are found in the Tabular under each one of
those codes and then here's the
guideline that helps us in this case to
know how we would code this.
The sequencing of codes is important. It's not
good enough to just get the right codes.
The reason for that, as you learn
more about coding, is that the principal
diagnosis is the first diagnosis that you
choose and the one that is chiefly
responsible for the patient's admission
to the hospital. That diagnosis along
with the secondary diagnosis and any
procedures, the patient's age, that kind
of thing, drives what is called the "DRG". The DRG is
part of the payment system for how the
hospital is reimbursed.
So you always want to accurately code the
principal (diagnosis) because that's your principal
driver for which DRG is going to
be selected. We will be talking a lot more
about DRGs later in the course but
the point I want to make is that it's not
good enough to just have the right codes,
you must have them
in the correct order and this Guideline
and many guidelines tell us how to order
the codes. This first one says a code for the
underlying systemic infection is first
(that's your N39.0 code), followed
by a code from subcategory R65.2
and then an additional code for the
associated acute organ dysfunction and that's
your acute kidney failure here (N17.9). Now the
B96 code would go after the N39.0 code
because they go together.
B96 is saying wait, E. coli is the reason
for this UTI so this would be the correct
sequence for this diagnostic statement.
I am going to skip over some of these, not going to
do all the guidelines but just to be
sure you at least have a handle on some of
them. Sepsis due to a postprocedural
infection- this tells us the patient
developed sepsis with MRSA infection of the
incision site following a total hip
replacement so the infection post procedural,
T81.4 is going to be our code.
We put our additional characters here.
Here's an instructional note to "use an additional code to identify the
infection" and in this case, it is Staph aureus
MRSA A49.02
Here are the two guidelines
that inform us as we assign codes here.
The sepsis is due to the postprocedural
infection (T81.4-).This is telling us to do the T81.4-
first and then this one is telling us
to assign the appropriate
combination code for the infection.
The Zika virus just tells us, you are
only going to code a confirmed case. The
doctor doesn't have to tell you why he's
confirming; he's just saying this patient
has Zika. That's all you need is a statement
and you would code A92.5. Again, this is
new for 2017. If you had the case where
the patient has only symptoms and the doctor is
saying. "I think it's probable this is a Zika
infection", you cannot code infection
with the Zika virus if the doctor is using that
term. That term (probable) means it is not
confirmed. In that case, you are only going to code
the symptoms. The next part of the
podcast I want to talk about something I
call "connecting the dots."
It's one thing for me to give you all
these resources. It's another for you to know
how to use them. So I'm going to go
through what my expectations are for
how you're going to learn the guidelines
and apply them when you're completing
your exercises in this course. #1: Prior to
beginning an exercise, review the
guidelines for a given chapter or topic.
For example, in Week 2, we're
studying Chapters 1 and 2 in the
code book, so you would review the
guidelines for those two chapters prior
to beginning Exercise 2.
Then you're going to open Exercise 2 and you're
going to highlight key terms that remind
you of the key terms that you've
identified in the guidelines and those are the ones
in green, with the green highlight.
After you have looked at the key terms in
the Exercise, you're going to go back and
read the guideline for that identified
key term. For example, the first one we're going
to look at is MRSA. If you remember
your Chapter 1 Guidelines, you know there's
something about MRSA in there. You go
to those guidelines that specifically
address MRSA. Then you will complete your
exercise, assign your code, and cite your
Guideline. So if you
remember these are the specific topics
that are in the Chapter 1 guidelines. It
addresses HIV, any infectious agents that
are a cause of disease in other
chapters, infections that are resistant
to antibiotics,
sepsis, severe sepsis and septic shock,
MRSA and MSSA and the Zika virus
which is new this year.
Ok, so let's put that into practice here.
Open up Exercise 2
Now when you open up Exercise 2, you're
going to see this first one has already been
done for you but just to walk you
through this part of the exercise I'm
going to do that. So when we read the
first one, MRSA screen positive, we know
that in the guidelines there were
specific guidelines that address MRSA.
A screen is just referring to a
"colonization", that term you may remember
also from the guidelines. This particular
diagnostic statement does not mention an
infection, so we're going to go with the
whole idea of a colonization, so now you
know MRSA screen or colonization and your're
going to go back, open your guidelines,
and here we are.
I have scrolled down to the section that
addresses MRSA. The first section talks
about combination codes for MRSA. That
doesn't really apply here. We scroll down
"other codes for MRSA"' and that
doesn't apply here. Here's your
colonization guideline (I.C.1.e.1.c)
As a reminder, this would be section "1"
"C" which is Chapter specific guidelines,
Chapter 1 and then e.1.c is
just the breakdown of the guidelines as
you move down in the Roman numeral numbering
system. MRSA screen (colonization) that is referring
to a "carrier" so it is Z22.322.
so highlight that, go back in here and do
this. You can also go into your
guidelines and that is this coding
guideline.
If you want to remove that highlight, you
could do that. It won't let me (remove the highlight).
That's okay. I would suggest
that you just in some way identify
your guideline. You notice how all these
fonts and font sizes are
different.
What you can do highlight the whole
thing, go up here and choose "Times New Roman 12"
(as the font and font size) now they all look the
same.
Now that takes care of assigning your
guideline. You still have to tell me
what pathway you used in the Index.
So if you're looking for this
in the Index and when you look this up,
the main term is "colonization".
I'm not sure why that's highlighted. I don't know.
Anyway, I'm not sure why that is highlighted,
but it's okay.
What's important is you've shown me your
pathway and you told me what guideline.
Ok, let's look at the next one and this
one you see there's an MRSA
colonization and an infection, so if you are
you push down the CTRL button,
CTRL key, you can highlight
MRSA colonization, push down CTRL key
and then MRSA infection of the urinary
tract, then you're going to push the
green, so there you've got a colonization
and an infection. If you remember from your
guidelines, let's go back in
and here it is right here. If a patient is
documented as having both, you're going to
code Z22.322 and a code for the
infection. Then we would do that. So this is how I expect
you to use the guidelines. You can learn
this way but unless you are reading them
at least two or three times each time
you do an exercise in that chapter, you are
just not going to remember them. You
can't memorize them. There's too many but
you can become familiar enough with them
over time that you know there's an MRSA
guideline in Chapter 1.
You may not remember the specific
guideline, but you know it's in Chapter
1. That becomes especially important
when looking at sequencing different
codes. That (sequencing) too is difficult to
memorize because it's very specific to
individual cases or scenarios so you have
to always be willing to go back and look
at those guidelines over and over and
over. Later on, as we look at Encoders and
Computer-Assisted Coding as the way this
is actually completed in the field, you
will find that there are edits in
software that pick up on when the coder
haven't followed a guideline but at this
stage of the game, you as a student needs
to understand where those guidelines
come from that are part of the
software package and how you would use
them. If you are coding in a physician's
office or a smaller practice, you may not have
an Encoder or Computer-Assisted Coding,
so a coder has to always know how to use
their (code) book first and foremost because that
is your guide. Also, the Encoder and the
Computer-Assisted Coding reference
Coding Clinic, which if you remember from
your reading, is the publication that comes
out once a quarter that
crystallizes, if you will, guidelines or
clarifies guidelines when coders send in
individual questions because they are just fuzzy as to how
the Guideline will be applied. The people at
the Coding Clinic would answer their
questions. Also, I want to mention that
hospitals have departments, large
hospital systems have departments called
"Nosology". Nosology is the study of
a branch of medicine that
deals with the classification of
diseases and sometimes you can get an
answer quicker from your Nosology
Department than you can from Coding
Clinic but just be aware that those are both
resources that you might be using. Ok, the
next several slides I'm not going to go
over as part of the podcast but just be aware
that they are taken from this book
"ICD-10 Coding Guidelines Made Easy 2017"
Some students find that to have
guidelines and tables like this is very
helpful.
It's not required in any way for this
course. It's just a suggestion.
I put some of the tables here and i just
put them on the document camera and made
screenshots of them. You can use it that
way or you can buy the textbook. If you
want to do that, I have
given you the
author and I bought it on amazon.com
just for reference but personally, I like
the guidelines the way I have them
better than the table but again you have
to do what helps you. We all learn differently so
you have to do whatever works best for
you
Thank you so much and I hope you have a good day.