ICD-10 Coding Session Pulmonology

1. ICD-10 Coding Session Pulmonology Dr. Stephen Lucas, MD Critical Care Pulmonologist Victoria A. Weinert, RHIT, CCSAudit and Compliance Manager, On Assignment

2. Case 1 HPI: Mr. A.B. is a 64 y.o. male who presented to the emergency department on 7/20/2014 with fever, shaking chills, left sided pleuritic chest pain and cough productive of rusty colored sputum. A chest x-ray obtained in the ED revealed a left upper lobe infiltrate and he was admitted for management of a community-acquired pneumonia. Exam: At discharge he was afebrile and felt nearly back to baseline in terms of his respiratory symptoms. BP 140/78, P 78 reg, T 37, SpO2 on 2 l/min nasal cannula 92%. His lung fields had diminished breath sounds and no wheezes or rales. His cardiac rhythm was regular and he had no edema. Lab: CXR on admission: LUL infiltrate CBC on admission: WBC 16, 000 with left shift.Hgb 12.5 MCV 85 BMP on admission: Na 133 K 3.5 Cl 99 HCO3 33 Creat 1.2

3. Case 1 Hospital Course: He was treated with ceftriaxone and azithromycin, supplemental oxygen, IV fluids, and bronchodilators. He improved over 3 days and was discharged to outpatient follow-up in 2 weeks. Discharge Meds: Per Medication reconciliation sheet. Discharge diagnoses: 1. Pneumonia, left upper lobe, etiology undetermined 2. COPD with ongoing tobacco use a. FEV1 1.3 l in 2011 b. Frequent exacerbations c. Home oxygen use 3. Anemia, normochromic/normocytic 4. Coronary artery disease S/P CABG, 3 vessels, 2013

4. “FEV1 1.3” What is forced expiratory volume (FEV)?

5. Coding Pneumonia Step 1.) Seek the code to pneumonia with the causing organism. Step 2.) If sputum is positive, physician needs to confirm findings and make correlation to the organism with the pneumonia. (J12.0-J15.9) Step 3.) If sputum is negative, or physician disagrees (“contaminated”), code to the site (i.e. bronchopneumonia, lobar, hypostatic) Step 4.) If pneumonia is not further classified, use J18.9

6. “Pneumonia, Left Upper Lobe” Is it “Lobar Pneumonia”? Previously believed to be caused by streptococcus pneumoniae and therefore default code was Pneumococcus Pneumonia. ICD-10 no longer makes that assumption, and causative organism should confirmed.

7. J18 Pneumonia, unspecified organism • Bronchopneumonia - inflammation of the bronchioles and acute consolidation in the lungs • Lobar pneumonia - complete lobe infection • Hypostatic pneumonia - infection in the ‘lowest portion’

8. Tobacco Users • Use additional code where applicable, to identify: • Exposure to environmental tobacco smoke (Z72.22) • Exposure to tobacco smoke in the perinatal period (P96.81) • History of tobacco use (Z87.891) • Occupational exposure to environmental tobacco smoke (Z57.31) • Tobacco Dependence (F17.-) • Tobacco Use (Z72.0)

9. Coding Clinic 2013, 4thQtr Question: How would a documented diagnosis of “smoker” be coded in ICD-10-CM? Should it be coded as tobacco use or dependence? Answer: In ICD-10-CM, a diagnosis of “smoker” is coded to dependence. Assign code F17.200, Nicotine dependence, unspecified, uncomplicated, when the provider documents “smoker.” Please note the following reference in the Alphabetic Index to Diseases: Smoker – see Dependence, drug, nicotine

10. Coding Clinic 2013, 4thQtr Question: Can you please define when to use nicotine dependence “uncomplicated”, “in remission”, “with withdrawal”, “with other nicotine-induced disorders” and “with unspecified nicotine-induced disorders? There are currently no ICD-10-CM coding guidelines or ICD-10-CM chapter notes that would assist the medical coder with these definitions. Answer: Although nicotine may not typically be thought of as a psychoactive substance, the Official Guidelines for Coding and Reporting, Section I.C.5.c., applies to categories F10-F19, which includes nicotine dependence. The appropriate codes for “in remission,” “with withdrawal,” etc., within categories F10-F19 are based on provider (as defined in the guidelines) documentation.

11. Coding Clinic 2013, 4thQtr Question: A patient, who has been a cigarette smoker for 20+ years, presents with chronic obstructive pulmonary disease (COPD). Would it be appropriate for the coder to assume that the COPD was caused by the cigarettes and assign code F17.218, Nicotine dependence, cigarettes, with other nicotine induced disorders; or must the provider document the causal relationship? Answer: No, it is not appropriate to assign code F17.218, unless the provider documents a cause and effect relationship between the smoking and COPD. For a current smoker with COPD and no documented linkage, assign codes J44.9, Chronic obstructive pulmonary disease, unspecified and F17.210, Nicotine dependence, cigarettes, uncomplicated.

12. Treated with “bronchodilators” Is this for a COPD exacerbation or is this a maintenance medication?

13. Coding Case 1 What are the diagnoses/procedures?

14. Coding Case 1 • Pneumonia • COPD • Tobacco Use • Oxygen Use • Anemia, normocytic • CAD, s/p CABG

15. Case 2 HPI: Mr. C. D. is a 58 y.o. man who smokes cigarettes (2 ppd at present) who presented with dyspnea and hemoptysis. Chest x-ray and CT imaging demonstrated a speculated 4.5 cm lung mass in the right mid-lung associated with right hilar and sub-carinal adenopathy. He reported a 15 lb weight loss over the past 2-3 months. Exam: At discharge he had minimal streaky hemoptysis and was less dyspneic. He had no fever during the hospitalization. His lungs had diminished breath sounds generally and crackles over the right lower lung field. His cardiac exam was normal except for diminished pulses in his feet. Lab: Hgb 11.0 with MCV 73. Electrolytes normal. Chest radiographs: right mid-lung mass with hilar and subcarinal adenopathy. Transbronchial lung biopsy histology report yielded diagnosis of squamous cell carcinoma. Wang needle biopsy also positive for SCC

16. Case 2 Hospital Course: He was admitted because of the severity of his hemoptysis. He was stabilized with antibiotics/steroids/bronchodilators and cough suppressants. He underwent bronchoscopy with findings as above. He was stable after the bronchoscopy and discharged after several hours of observation. Bronchoscopy results will be discussed with him in the office in 2 days. Discharge Meds: Per reconciliation sheet

17. Case 2 Procedure: Bronchoscopy with transbronchial biopsy using fluoroscopic guidance. Findings: Diffuse bronchitis with blood coming from the right upper lobe, superior segment. Carina was splayed. Transbronchial biopsies of the RLL superior segment were obtained as well as washings. A Wang needle aspirate of the sub-carinal node was performed.

18. Case 2 Discharge Diagnoses: • Final path: Squamous Cell Carcinoma of the superior segment of the RUL of the Left Lung. Subcarinal lymph node positive for tumor. • Hemoptysis secondary to #1. • Weight loss • Anemia, microcytic • Heavy tobacco use, 70 pack-years and ongoing • Hypertension

19. Coding Clinic, 4thQtr 2013 Question: “Hemorrhagic” is no longer a non-essential modifier for pneumonia in the ICD-10-CM Index to Diseases. Is a code reported for hemoptysis when it occurs with pneumonia? Answer: Sequence the appropriate code for the pneumonia first. Assign code R04.2, Hemoptysis, as an additional code when the condition occurs with pneumonia. Although code R04.2 is a Chapter 18 code, codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with the diagnosis.

20. Query For Clarification “Physician with dyspnea and hemoptysis and found to have RUL mass and adenopathy. Discharge diagnoses include microcytic anemia. Can you clarifying the anemia further: _Microcytic anemia due to chronic blood loss _Microcytic anemia due to acute blood loss _Microcytic anemia due to neoplastic disease _Microcytic anemia due to other cause, please specify___________________________________

21. Wang Needle Aspirations Transbronchial fine needle aspiration biopsy is performed during the bronchoscopic procedure to sample endobronchial or peribronchial lesions and peritracheal or peribronchial lymph nodes, usually for evaluation of malignancy.

22. Coding Case 2 What are the diagnoses/procedures?

23. Diagnoses Case 2 • Path results: lung and lymph • Hemoptysis • Weight Loss • Microcytic Anemia • Smoker, cigarette • Hypertension

24. Procedures Case 2 • Bronchoscopy with RUL lung biopsy • Biopsy subcarinal lymph node

25. Case 3 HPI: Mrs. F. is an 80 y.o. woman who was living independently until she tripped over her dog as she was exiting her home to take the dog for a walk and suffered a fracture of the left hip. Exam: She is hemodynamically stable and has a normal mental status. There are post-operative changes in the left hip, but otherwise the exam is unremarkable and unchanged from admission. Lab: EKG: Atrial fibrillation with rate of 90/min. Left hip x-ray: Intertrochanteric fracture with displacement Post-op hip x-ray: Good positioning of the prosthesis Venous scan: Acute DVT popliteal vein on right Hgb (discharge) 9 gm%

26. Case 3 Hospital Course: This elderly but independent 80 y.o. woman tripped over her dog and suffered a fracture of the left hip. There was no loss of consciousness. She was taken to the OR on the morning after admission for arthroplasty of the left hip and she did well until day 3 post-op when she complained of right calf pain. A venous scan demonstrated acute popliteal vein DVT. Her admission EKG showed atrial fibrillation with rates of 90-110/min. This is a new finding. She was started on Xarelto for stroke prophylaxis. When the DVT was detected she had already been started on Xarelto, so no additional therapy for the DVT was necessary. She will be transferred to a rehabilitation center and then home. Outpatient follow-up has been arranged. Discharge Meds: Per reconciliation sheet.

27. Case 3 Discharge Diagnoses: • Fall with intertrochanteric fracture of the left hip, s/p repair • Post-operative deep venous thrombosis, right popliteal vein • Atrial fibrillation, new onset • Coronary artery disease, non-obstructing • Anticoagulation for #2 and #3

28. Coding Case 3 What are the diagnoses/ procedures?

29. Diagnoses Case 3 • Left intertrochanteric fracture • Post-operative (acute) DVT, right popliteal vein • Atrial Fibrillation • CAD, non-obstructing • Trip and Fall over dog at home

30. Procedures Case 3 • Left Hip Arthroplasty

31. Case 4 HPI: Mr. H. is a 37 y.o. male involved in a motorcycle accident on the day of admission who suffered the above injuries. He was intoxicated at the time of the accident with a blood alcohol level of 170 mg%. GCS in the ED on arrival was 8 PE: At the time of discharge he was awake and alert and reasonably oriented. He was taking feeding by mouth without difficulty and able to participate with his therapists. His chest tube had been removed. He had no IV lines at discharge. He required moderate analgesia for his injuries. Lab: CT head: No intracranial injury. No skull or facial fractures CT thorax: Multiple left rib fractures, hemopneumothorax, probable contusion of the left lower lung vs. aspiration. Hemoglobin: 10.2 gm% at discharge. Medical profile normal.

32. Case 4 Procedures: Endotracheal intubation and mechanical ventilatory support for 5 days Open reduction and placement of intramedullary rod, left femur Blood transfusion, 2 units packed red blood cells Hospital Course: He was intubated in the Emergency Department, given IV fluids and eventually 2 units of PRBCs. He was taken to the operating room for repair of his left femur fracture. Gradually, by day four the patient was responding to commands. He was able to be weaned from the ventilator and extubated on the 5th hospital day. He had manifestations of mild alcohol withdrawal and was treated with the CIWA protocol. He was stable and transferred to the rehabilitation center on the 9th hospital day. Outpatient follow-up arranged. Medications: Per reconciliation sheet

33. Case 4 Discharge Diagnoses: Motor Vehicle Accident a. Closed head injury with coma, improving at discharge b. Blunt chest trauma, left chest, with pulmonary contusion, multiple rib fractures and hemopneumothorax, S/P chest tube placement with resolution of hemopneumothorax. Improving contusion at discharge c. Left clavicular fracture, non-operative management d. Fracture left mid-femur, s/p repair with intramedullary rod e. Acute respiratory failure requiring mechanical ventilator support via endotracheal tube for 5 days Alcohol abuse with acute intoxication a. acute withdrawal syndrome Tobacco use

34. Coding Case 4 What are the diagnoses/procedures?

35. Diagnoses Case 4 • Closed Head Injury • Mid-Femur Fracture (shaft) • Pulmonary Contusion/Hemopneumothorax • Coma, GCS 8 in the ED • Multiple Left Rib Fractures • Left Clavicle Fracture • Acute Respiratory Failure • Alcohol Abuse, Intoxication and Withdrawal • Blood Alcohol Level, 170 mg • Tobacco Use

36. Procedures Case 4 • ORIF, left femur • Blood transfusion, PRBCs • Chest tube placement

37. Case 5 HPI: Mr. J. is a 56 y.o. man who presented to the hospital Emergency Department by ambulance with 45 minutes of severe substernal chest pain and EKG changes of an acute ST segment elevation inferior myocardial infarction. He was taken immediately to the catheterization lab for primary intervention. Exam: At discharge he was pain free and ambulating in the hallway. He had clear lungs, a regular cardiac rhythm with a rate of 75-80/min, no gallop, and about 2+ peripheral edema (no worse than usual for him). Lab: CK 590 with MB of 35. Troponin peaked at 23. B-NP 300 on admission. EKG—inferior MI, acute. Chest x-ray—clear. Echocardiogram: left ventricular hypertrophy with EF 40%. No wall motion abnormality. CBC and Medical profile normal.

38. Case 5 Hospital course: He presented to the ED with symptoms of acute MI and an EKG consistent with acute inferior injury. He was taken to the cath lab immediately. LHC to measure left ventricular systolic pressure: 20/end diastolic pressure: 45%. Coronary angiography demonstrated 100% occlusion of the RCA. Balloon angioplasty followed by placement of a Taxus (DES) to the right coronary occlusion with good result. He had transient heart block that required a temporary pacemaker for 48 hours. After that he remained in sinus rhythm. He was started on aspirin and Plavix, lovastatin, carvedilol and nitrates. He will be referred to cardiac rehabilitation and see his cardiologist in 2 weeks. The importance of managing his sleep apnea appropriately was stressed. Discharge Meds: Per reconciliation sheet.

39. Case 5 Discharge Diagnoses: Acute ST segment elevation MI a. 100% occlusion mid-right coronary artery, S/P placement of drug-eluting stent b. Transient complete heart block managed with temporary pacemaker c. Moderate Left Ventricular systolic dysfunction (Systolic EF 40%), severe chronic CHF yet compensated at this time d. Hyperlipidemia Tobacco use Hypertension with left ventricular hypertrophy Obstructive sleep apnea, non-compliant with CPAP a. Nocturnal hypoxemia Obesity, BMI 32 Chronic venous insufficiency, negative venous scan for acute clot this admission

40. “Hypertension with left ventricular hypertrophy” I51 Excludes 1 Any condition in I51.4-I51.9 due to hypertension (I11.-) Any condition in I51.4-I51.9 due to hypertension and chronic kidney disease (I13.-) Heard disease specified as rheumatic (I00-I09)

41. Excludes Notes Excludes 1 the codes excluded should never be used at the same time as the code above the Excludes1 note. Excludes 2 indicates that the condition excluded is not part of the condition represented by the code, and a patient may have both conditions at the same time, therefore it is acceptable to use both the code and the excluded code together, when appropriate.

42. Coding Case 5 What are the diagnoses/procedures?

43. Diagnoses Case 5 • STEMI, RCA • Complete Heart Block • Hypertensive Heart Disease • OSA • Non-compliance with CPAP • Obesity, BMI 32 • Chronic Venous Insufficiency • Hyperlipidemia Tobacco use

44. Procedures Case 5 • DES, RCA • Coronary Angiogram • Temporary Pacemaker

45. Case 6 HPI: Mrs. L. is a 67 y.o. woman admitted with hypotension, fever, chills and evidence of severe sepsis thought to be from a urinary tract infection. Exam: At discharge her vital signs were normal (on her usual anti-hypertensive meds) and she was feeling well. Lungs and heart were normal. She had no edema and her mental status was normal. Lab: Urine and 2/2 blood cultures grew E. coli. Initial white count was 30,000 with a strong left shift and her hemoglobin was l5.5 (thought secondary to hemoconcentration). At discharge her creatinine was 2.3 (her baseline) and her urine was clear.

46. Case 6 Hospital Course: She was given 3 liters of normal saline in the first 2-3 hours after presentation to the ED. A central venous catheter was placed for monitoring the resuscitation. Catheterization via the jugular vein and placed in the superior vena cava at the juncture of the right atrium. She require norepinephrine for BP support for about 8 hours. She developed mild interstitial pulmonary edema which was managed with BiPAP for about 6 hours. After 14 hours in the ICU, she improved steadily with resolution of her hemodynamic instability and fever. She was initially treated with ceftriaxone, but was switched to oral cephalexin on hospital day 4. Outpatient follow-up has been arranged. Discharge Meds: Per reconciliation sheet.

47. Case 6 Discharge diagnoses: Severe sepsis secondary to complex urinary tract infection a. Acute renal injury, resolving b. Hypotension requiring pressors c. Mild non-cardiogenic pulmonary edema, managed with non-invasive ventilation d. E. coli bacteremia Nephrolithiasis Chronic kidney disease, stage 3 Hyperuricemia with gout Hypertension

48. Coding Case 6 What are the diagnoses/procedures?

49. Diagnoses Case 6 • E. coli sepsis, severe • Acute renal injury • Pulmonary edema • UTI • Nephrolithiasis • CKD, 3 • Hyperuricemia w/ gout • Hypertension

50. Procedures Case 6 • BiPAP • Norepinephrine Infusion • CVC, for monitoring