Documentation Dissection - AAPC

[Pages:1]Documentation Dissection

Operative Report Preoperative Diagnoses: Splenic abscess and multiple intra-abdominal abscess, related to HIV, AIDS, and hepatitis C. Postoperative Diagnoses: Splenic abscess and multiple intra-abdominal abscess, related to HIV |1|, AIDS |2|, and hepatitis C |3|. Operative Procedure:

1. Exploratory laparotomy with drainage of multiple intra-abdominal abscesses. 2. Splenectomy. 3. Vac Pak closure. _____________________________________________________________ |1| Diagnosis related to HIV results in AIDS (B20) being reported as the primary diagnosis. |2| The patient has AIDS. |3| Hepatitis C is relevant because it may have an impact on the patient's treatment and recovery. _____________________________________________________________ What ICD-10-CM diagnosis/es code(s) is/are reported? ICD-10-CM Codes: B20, D73.3, K65.1, B19.20 Rationale: The patient is diagnosed with abscesses on the spleen and intra-abdominal cavity (related to his HIV), AIDS and hepatitis C. According to Official Coding Guidelines 1.C.1.a.2., if a patient is admitted for an HIV-related condition, the principal diagnosis should be B20, followed by additional diagnosis codes for all reported HIV-related conditions. In the Index to Diseases and Injuries, look for AIDS; you are referred to B20. In the Tabular List, category B20 instructions are to use additional code(s) to identify all manifestations of HIV infection. The spleen and abdominal abscesses are HIV-related conditions. In the Index to Diseases and Injuries, look for Abscess/spleen and you are referred to D73.3; locate Abscess/intra-abdominal (see also abscess, peritoneum) and you are referred to K65.1. An instructional note at K65 says to use an additional code (B95?B97) to identify the infectious organism. Since this is not included in documentation a code is not used. The diagnosis for hepatitis C is relevant and should be reported because hepatitis C may have an impact on the patient's recovery. From the Index to Diseases and Injuries, look for Hepatitis/C (viral). There is no additional information regarding the hepatitis which makes B19.20 the only option. Verify all codes in the Tabular List.

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