Today we're going to talk about Chapter
18 in the ICD-10-CM code book- the 2017
guidelines. Chapter 18 is for signs,
symptoms and abnormal clinical and
laboratory findings not elsewhere
classified. The first thing we are going to do is look at
some general notes. I have two slides
that talk about the general notes that
you might also find at the beginning of
Chapter 18 in the code book. The
conditions and the signs or symptoms
included in Chapter 18 consists of, I have
six bullet point here, cases for
which no more specific diagnosis can be
made even after all the facts bearing on
the case have been investigated. In other
words, you just don't know what's wrong
so you are going to code the
signs and symptoms. For the second bullet point,
signs or symptoms existing at the time
of the initial encounter that proved to
be transient and whose causes could not
be determined. So the person had the sign
or symptom and before they can really
get it (the problem) worked up, it was gone. That's when
you're going to code signs or symptoms.
The third bullet point- provisional
diagnosis in a patient who failed to
return for further investigation or care.
Some appointments were made for
follow-up investigation by the physician
but the patient never came back so the
only thing you can really code would be
the signs or symptoms. Fourth bullet
point- cases that are referred
elsewhere for investigation or treatment
before the diagnosis was made. Let's say
a child is at Denver Health and physicians can't
figure out what's wrong. They transfer the
child to Children's Hospital but they're going to
have on the Denver Health chart just the
signs and symptoms because that's all
they knew at the time the child was
there. The fifth bullet point -cases in
which a more precise diagnosis was not
available for any other reason. In other
words, it doesn't fit any of the above
criteria. You just don't have a reason
or you don't have a final diagnosis.
The sixth and final bullet point-
certain symptoms, for which supplementary
information is provided, that represent
important problems in medical care in
their own right. So if, let's say, you're
doing some research
and you're following a certain condition
and there's a symptom that you always
see on, let's say, sixty percent of the
cases, You might want to be coding that
symptom to follow it to see if maybe
there's something else going on. But you
would have to have direction from the
researcher or from your provider or
your attending physician before you, as a
coder, would know that. So those are all
things that might come into play if you
work in a research hospital or in a
general hospital where you see these
cases where there is no final diagnosis
for any of these reasons. The first
guideline has to do with the use of a
symptom code in the case that's been
given here. The patient was seen in the
ED with complaints of chest pain of
unknown origin. He refused admission to
the hospital and refused completion of
any diagnostic workup. In that case, all
you can code is the chest pain and when you
look in the Index, under the chest pain,
there are several "R" codes that are
differentiated by various descriptors
like where on the chest, the central chest
or other parts of the chest or
other descriptions of that pain. But when
you're just given something like this (scenario),
"chest pain, unknown origin" you would
choose the R07.9 code. The rationale for
this particular scenario would be a code
that would be used when a related
definitive diagnosis was not confirmed
by the provider. This guideline has to do
with the use of a symptom code with a
definitive diagnosis code. This is when
you've got signs or symptoms that are
not routinely associated with the
diagnosis. You would want to code those.
You would not code signs or symptoms
that are inherent to a disease process.
In this particular scenario, the patient
has pneumonia with hemoptysis and not
everybody that has pneumonia has hemoptysis,
so you would code that. In case
you're wondering, hemoptysis is blood
in the sputum.
Here's another example of that same
guideline. The patient has abdominal pain
due to acute appendicitis. This is a
reminder that you would not code
something that is inherent to the
condition. If you have appendicitis, of
course you have abdominal pain, so you
would not code the pain. You would only code
the appendicitis. I do have a note
here to remind you that the codes are
different for appendicitis and acute
appendicitis so you really want to be
looking at your documentation. The
patient was admitted with acute
gastritis with hemorrhage. This is an
example of one of those combination codes
that do include symptoms. This particular
one does. Acute gastritis with bleeding
K29.01 is a code in and of itself. It
includes the hemorrhage or the bleeding
so you would not code the bleeding
separately. This particular guideline is
not in your description of guidelines in
the front of Chapter 18 where it gives you
these examples I go over but I wanted to
include it because, depending on where
you work, you might really use these
codes. In the nursing home where I have
worked four years of my career, we did use
fall codes because of patients (falling). It is pretty
typical in a nursing home for patients to
fall. The difference is the "R" code is
when you don't know the cause of the
fall, so you would just be coding the
fall itself. The Z code would be
when you have a "history of falling". In this
particular scenario, the patient is seen
in the ED after having fallen at the
nursing home. This is his third fall over
the last 10 days. He has a history of
falling over the last two years. So you
would put those two codes. Both of those
codes would be used in this case
because they're both appropriate to use.
Just a reminder, when we go through these
guidelines and different scenarios,
they're so short (in length) because we're trying to
capture certain things. In the real world,
you would have an entire chart
and a person in a nursing home is going
to have at least six or seven diagnoses.
Just keep in mind these scenarios are
just to help you understand the
application of a specific guideline. In
the real world. the charts would be much
bigger. This is a very busy slide but I
wanted to keep everything on one slide
to try and talk you through it and how
the guideline applies. There's very few
times as a coder that you can use
documentation that isn't the physician's (documentation).
You may recall you could take nursing
documentation that stages an ulcer. You
could take dietitian information that
talks about the BMI. In this case, you
can take the EMT's documentation from the
field for the different components of a
coma scale. This is an important thing to remember.
In our scenario, the patient is a 23 year
old found down after an unknown injury
with a skull fracture of the frontal
bone with concussion and loss of
consciousness of unknown duration. EMS
evaluates the patient in the field and
reported the individual Glasgow Coma
scores. You see three scores given here.
Score number "3" is equal to eyes open
the speech. The verbal response , score number "4"
is confused but coherent.
Motor response number "6"
corresponds to obeys commands fully.
There are codes for those scores. Our
rationale tells us you're going to code
the coma scale scores or sequence
after the diagnosis codes so the first
thing we're going to do is code the
frontal skull fracture. You're going to
have a 7th character "A" for the initial
encounter. Then you're going to code the
concussion with a loss of consciousness
of unspecified duration, because we don't
know what it (the duration) was. We're going to add a
seventh character "A" for initial
encounter. Then when we get to the coma
scale scores, they will also have a 7th
character but this 7th character is
not a choice of initial, subsequent
or sequelae. This 7th character has to
indicate where the score was taken.
The example we've been given, the 7th
character is "1" that indicates the
score was assigned in the field by the
EMTs. All three of the coma scale scores
have to have the same 7th character, but
not the same 7th character that the
diagnosis codes have. This is important to
remember. You have the rationale there
from this particular coding guideline.
Tt goes through everything. The only
thing that isn't covered in the scenario
is at the very bottom in purple (color font.) At a
minimum, report the initial score that
would also be from the EMTs or the
facility may say "no, we don't want the
total score> We want separate scores for the
eye opening, the verbal and the motor
response. But if you had a total score,
you would code R40.24. Only the
total score would be documented, not the
individual scores. So (you are coding) one or the other
according to our guidelines. This is
important when you are working in any
hospital that has a trauma unit. You will
see head injuries. You will see loss of
consciousness. You will see EMTs bringing
patients in (to the hospital), in a coma. The Glasgow Coma
Scale is very helpful to physicians who
are looking at rehab for this patient
and where do we go from here, the
next step. Sometimes the prognosis is
important. Depending on the physician and
the facility, they look at different
things. I would ask you, because of
the importance of this slide, that you
would review it more than once. You
understand that you do code those
individual scale scores. They must all
have the same 7th character but
that 7th character is not the same
7th character as the diagnosis codes,
quite different.
In this guideline, SIRS due to a
non-infectious process. SIRS is a systemic
inflammatory response syndrome. This
particular one is due to the
pancreatitis. The guidelines tell us
you're going to code whatever the
underlying condition is first. In this
case it's the pancreatitis (K85.10). Then you're
going to code the R65.10. This is
without acute organ dysfunction and if
it's with acute organ dysfunction, it
would be R65.11. If you have any questions
about the Chapter 18 Coding Guidelines,
please post them in discussion board.
i'll do my best to answer them. Have a
good day.