TUTORIAL: How to Code an - Cengage
TUTORIAL: How to Code an Inpatient Record
Welcome!
Assigning ICD-10-CM and ICD-10-PCS codes to diagnoses and procedures for inpatient records can be somewhat intimidating to students at first. No fear! I am going to walk you through this entire process, page-by-page, so you learn how to assign codes to diagnosis and procedures.
You will also see where the codes are entered on a UB-04 claim, which is submitted to third-party payers for processing, resulting in reimbursement being provided to the hospital (for inpatient stays).
NOTE: Chapter 19 of your textbook contains content about the purpose of the UB-04, which you can review. You will also take the MEDR 4214 (Insurance and Reimbursement Processing) course in future where you will learn how to complete the UB-04.
At the end of this tutorial, you will also view the results of entering ICD-10-CM and ICD-10-PCS codes in a Diagnosis Related Group (DRG) grouper, which determines reimbursement provided to the hospital (for inpatient stays).
Remember! Go to , click on the Medicare DRG Calculator, and enter patient data and codes assigned to determine the DRG for each IPCase. Notice that you must select a Y, N, U, W or 1 present on admission (POA) indicator from the dropdown menu next to each ICD-9-CM diagnosis code entered.
All claims submitted for inpatient admissions to general acute care hospitals or other health care facilities are required to report the present on admission (POA) indicator, which is assigned by the coder to the principal and secondary diagnoses and external cause of injury code (E code) reported on the UB-04 or 837 institutional (electronic) claim.
o The coder reviews the patient record to determine whether a condition was present on admission or not. o Issues related to inconsistent, missing, conflicting, or unclear documentation are resolved by the provider as a result of the
physical query process.
In this context, present on admission is defined as present at the time the order for inpatient admission occurs. Thus, conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission upon admission of the patient as a hospital inpatient. CMS reporting options and definitions include the following:
o Y = Yes (present at the time of inpatient admission) o N = No (not present at the time of inpatient admission) o U = Unknown (documentation is insufficient to determine if the condition was present at the time of inpatient admission) o W = Clinically undetermined (provider is unable to clinically determine whether the condition was present at the time of
inpatient admission or not) o 1 = Unreported/not used (exempt from POA reporting; this code is equivalent to a blank on the UB-04; however, blanks are
undesirable when submitting these data electronically.)
NOTE: Before entering ICD-10-CM and ICD-10-PCS codes in the Submission assignment for each IPCase, be sure that you have determined the diagnosis related group (DRG) number. An example of a DRG display is included at the end of this tutorial, and each element of the DRGs results is explained.
Before Assigning ICD-10-CM and ICD-10-PCS Codes
Before coding inpatient cases, be sure that you understand how to apply each of the following terms and definitions (that are explained on each subsequent page of this tutorial):
o Admission diagnosis o Principal diagnosis o Secondary diagnosis(es)
Comorbidity Complication o Principal procedure o Secondary procedure(s)
As you click through this tutorial, you will notice that ...
o each type of diagnosis and procedure is defined. o examples of each type of diagnosis and procedure are provided. o an image of an inpatient record face sheet highlights the location of each type of diagnosis and procedure. o images of additional reports from an inpatient record highlight documentation that coders review to assign the most accurate
and complete: o diagnosis code(s). procedure code(s).
NOTE: Diagnoses are assigned ICD-10-CM disease codes. Procedures are assigned ICD-10-PCS procedure codes.
Admitting Diagnosis
The admission diagnosis (or admitting diagnosis) is the initial diagnosis documented by the:
o patient's primary care physician who determined that inpatient care was necessary for: o treatment of a condition diagnosed in the office today (e.g., acute exacerbation of chronic asthma). elective surgery, which has already been scheduled (e.g., elective tubal ligation).
NOTE: The patient's primary care physician (who is responsible for admitting the patient to the hospital) or his office staff contacts the facility's patient registration department to provide the admitting diagnosis. A physician's office staff includes medical assistants, nurses, physician assistants, nurse practitioners, and so on, any one of whom may be instructed by the primary care physician to communicate the admitting diagnosis to the hospital's patient registration department. Next, the patient registration clerk (who is employed in the hospital's patient registration department) keyboards the admitting diagnosis into admission/discharge/transfer (ADT) software. That admission diagnosis (along with all other patient information) appears on the face sheet of the inpatient record.
o facility's emergency department (ED) physician who provided ED treatment and determined that inpatient care was necessary (e.g., trauma, heart attack, stroke, and so on).
NOTE: The ED physician documents the admitting diagnosis in the ED record, and the patient registration clerk keyboards the admitting diagnosis into admission/discharge/transfer (ADT) software. That admission diagnosis (along with all other patient information) appears on the face sheet of the inpatient record.
o ambulatory surgery unit (ASU) surgeon who performed outpatient surgery and determined that inpatient care was necessary (e.g., laparoscopic cholecystectomy was converted to open cholecystectomy, requiring postoperative overnight monitoring).
NOTE: The ASU surgeon documents the admitting diagnosis in the ASU record, and the patient registration clerk keyboards the admitting diagnosis into the admission/discharge/transfer (ADT) software. That admission diagnosis (along with all other patient information) appears on the face sheet of the inpatient record.
When the patient is discharged from the hospital, coders assign an ICD-10-CM code to the admission diagnosis (or admitting diagnosis). The admission diagnosis (or admitting diagnosis) is always:
o located on the inpatient face sheet. o assigned just one ICD-10-CM code.
NOTE: Assign just one admission diagnosis (or admitting diagnosis) code even if more than one admission diagnosis is documented on the face sheet. Assign a code to the first admission diagnosis (or admitting diagnosis) documented on the inpatient face sheet.
NOTE: Although the admission diagnosis (or admitting diagnosis) is also documented elsewhere in the patient record (e.g., history & physical examination, admitting progress note, ED record, ASU record), the code is assigned to the admission diagnosis (or admitting diagnosis) that is located on the inpatient face sheet.
NOTE: In "real life," the admission diagnosis (or admitting diagnosis) documented on the inpatient face sheet may differ from the admission diagnosis (or admitting diagnosis) that is documented by the attending physician in the history & physical examination or admitting progress note. When you notice different admitting diagnoses documented in several places on the patient record:
o Assign a code to the first admission diagnosis (or admitting diagnosis) documented on the inpatient face sheet. o Do not generate a physician query (because the admitting diagnosis does not impact reimbursement).
(Refer to image on next page.)
Principal Diagnosis
The principal diagnosis is that condition, established after study, which resulted in the patient's admission to the hospital.
For the purpose coding IPCases in this course, the principal diagnosis is entered on the face sheet. You should review the patient record to verify the accuracy of that principal diagnosis by reading the discharge summary, operative report and pathology report (if the patient had surgery), progress notes, and other pertinent documents. If you wonder whether the principal diagnosis is correct on the IPCase that you are coding, post a query in the discussion board so your instructor can respond.
In "real life," the principal diagnosis may or may not be clearly documented on the face sheet. Sometimes the principal diagnosis is documented on the discharge summary (or clinical resume). Even if the principal diagnosis is documented by the attending physician, you still have to review documents in the patient record to verify it.
Sometimes more than one definitive diagnosis is documented for the inpatient admission. However, there is always just one principal diagnosis code reported. The other definitive diagnoses are coded as secondary diagnoses (e.g., comorbidities, complications, trauma, and so on).
And, sometimes the attending physician (and other physicians who consult on the case) cannot figure out what is wrong with the patient, one or more qualified diagnoses will be documented. A qualified diagnosis is a working diagnosis that has not yet been proven. When a physician documents "rule out," "probable," or "possible," that's a qualified diagnosis. When assigning code(s) to qualified diagnoses, you can also assign secondary diagnosis codes to signs and symptoms documented by the attending physician.
EXAMPLE: "Rule out myocardial infarction" is documented as the principal diagnosis for a patient who has severe chest pain. However, even though cardiac tests are negative, the physician still suspects that the patient is having a heart attack. And - this is important - you should also code the signs and symptoms associated with the qualified diagnosis. So, for "rule out myocardial infarction," you also assign codes for chest pain, shortness of breath, and so on.
If this does not make sense to you, post a question about it in the discussion board so I can explain in more detail. Better yet, review the information about "qualified diagnosis" in your textbook and then ask questions. (HINT: Look up "qualified diagnosis" in the index of your textbook if you cannot easily find it in the chapter.)
NOTE: When assigning codes to outpatient encounters (e.g., physician office visits, ED visits, outpatient visits), when qualified diagnoses are documented, assign codes to the signs and symptoms only. Do not assign codes to any of the qualified diagnoses. For example, when "rule out myocardial infarction" is documented on an ED record, assign codes to the chest pain, shortness of breath, and so on. Do not assign a code to "rule out myocardial infarction."
But, back to the principal diagnosis, which is that condition established after study, which resulted in the patient's admission to the hospital. Memorize this! And, be sure you know how to spell the principal in "principal diagnosis!" (Yes, you will be tested on this.)
(Refer to image on next page.)
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- guide to clinical validation documentation and coding sample
- nature of injury part of body cause of injury 01 no
- nature of accident nature of injury body part code table
- reviewing the 4th universal definition of myocardial
- tutorial how to code an cengage
- coding an acute myocardial infarction unravelling the mystery
- myocardial infarction mi quick reference
- coding clinic for icd 10 cm pcs
Related searches
- how to start an event
- how to start an argumentative essay example
- how to start an essay samples
- how to start an essay about yourself
- how to have an open house
- how to start an essay introduction examples
- how to title an essay
- how to write an explanatory essay
- how to get an installment loan
- how to market an application
- how to write an argumentative essay
- how to stop an offset