Medical Coding and Diagnosis Quiz

Carcinoma in Situ

• Refers to tumor cells in the initial stage of malignancy, remaining confined to the original site without invading surrounding tissue.
• Common example includes intraepithelial infiltrating.

Patient Cases and Diagnoses

• Elevated CPK and MB enzymes, along with ST changes on an EKG, may indicate a myocardial infarction (MI).
• For urinary tract infections, Escherichia coli is coded as a secondary diagnosis when a definitive diagnosis is provided.
• In cases of post-heart transplant patients with unclear documentation, coders should query the physician for clarity.
• Symptoms like loss of interest, weight gain, fatigued state, and sleep difficulties suggest a diagnosis of major depression.

Inpatient Admission Coding Examples

• A patient with AIDS underwent an inguinal herniorrhaphy; necessary ICD-10 codes include K40.90 for hernia and B20 for AIDS.
• A 75-year-old presented with dehydration post-stroke; codes related to dehydration and I69.391 for stroke should be used.
• Alcohol detoxification with liver cirrhosis would require coding for both conditions, including F10.229 for alcohol dependence.
• For exploratory laparotomy due to intestinal obstruction, only abdominal adhesions with obstruction will be coded, excluding abdominal pain as it is merely a symptom.

Diagnosis and Treatment Procedures

• Pneumonia treated with IV antibiotics takes precedence in coding over atrial fibrillation managed with oral medications.
• Women giving birth may require coding for hemorrhage occurring after delivery but before placenta expulsion.
• For cancer treatments such as lobectomy for lung cancer, both primary and metastatic sites must be accurately coded.
• Documentation of patient care and responses, such as treatment records, must be adequately reflected in medical records.

Outpatient and Ambulatory Coding Examples

• Noncardiac chest pain and tests like esophageal acid reflux require specific ICD-10-CM and CPT codes.
• Annual screening mammograms and excisions of basal cell carcinoma have designated diagnostic and procedural codes for accurate tracking.
• Surgical procedures like hysteroscopy for dysfunctional uterine bleeding must document both the action taken and the associated conditions.

Documentation and Authentication

• Key aspects of medical record adequacy include clear documentation of patient care actions and their responses.
• Authentication of entries serves to verify the authorship and integrity of medical documents, requiring signatures for validation.
• Regulations delineated in medical staff bylaws outline necessary documentation requirements and penalties for noncompliance.

Overall Diagnosis Coding Considerations

• The act of coding for multiple conditions must adhere to guidelines that prioritize definitive diagnoses over mere symptoms.
• Changes in coding based on additional complications (e.g., aspiration pneumonia due to dysphagia) affect health classifications and reimbursement structures.
• Proper coding of treatments and diagnoses involves reviewing operative reports and citing specifics of patient conditions for accuracy and compliance with regulations.### Screening Colonoscopy Coding
• Z12.11: Used for encounters involving screening for malignant neoplasm of the colon.
• D12.6: Represents benign neoplasm of the colon, unspecified.
• Correct coding sequence prioritizes screening colonoscopy (Z12.11) followed by the polyp code (D12.6).
• Option c (Z12.11, D12.6) is the correct coding sequence.

Benign Neoplasms of Skin Coding

• Category D23 includes other benign neoplasms of skin, including those of hair follicles, sebaceous glands, and sweat glands.
• Excludes benign lipomatous neoplasms and melanocytic nevi; these should not be coded under D23.
• Correct code for benign neoplasm of sweat glands is found in category D23, making option a correct.

Coding for Benign Lipomatous Neoplasms

• When coding benign lipomatous neoplasms of the skin, the appropriate range is D17.0-D17.3.
• D23 is not applicable for benign lipomatous neoplasms, thus option b is the correct choice.

Multiple Diagnoses Discharge Coding

• Relevant diagnoses include posterior subcapsular cataract in right eye, diabetes mellitus, hypertension, and mild acute renal failure.
• E11.9: Code for Type 2 diabetes mellitus without complications.
• H25.041: Correct code for posterior subcapsular polar age-related cataract in right eye.
• I10: Represents essential hypertension but does not combine with acute renal failure as it is temporary.
• N17.9: Code for unspecified acute kidney failure.
• Correct combination of codes for this discharge is option b (H25.041, E11.9, I10, N17.9).

Coding Acute Exacerbation of COPD

• Acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) is coded as J44.1.
• Hypertension is documented alongside chronic renal disease, requiring combined coding due to their relationship.
• Stage of chronic kidney disease must also be accounted for in the coding process.