ICD-10 Coding Session PulmonologyDr. Stephen Lucas, MDCritical
Care PulmonologistVictoria A. Weinert, RHIT, CCS Audit and
Compliance Manager, On Assignment
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 infiltrateCBC 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 1.2Case 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
undetermined2. COPD with ongoing tobacco usea. FEV1 1.3 l in 2011b.
Frequent exacerbationsc. Home oxygen use3. Anemia,
normochromic/normocytic4. Coronary artery diseaseS/P CABG, 3
FEV1 1.3What is forced expiratory volume (FEV)?
Coding PneumoniaStep 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
Pneumonia, Left Upper LobeIs 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.
J18 Pneumonia, unspecified organismBronchopneumonia -
inflammation of the bronchioles and acute consolidation in the
lungsLobar pneumonia - complete lobe infectionHypostatic pneumonia
- infection in the lowest portion
Tobacco UsersUse 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)
Coding Clinic 2013, 4th QtrQuestion: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
Coding Clinic 2013, 4th QtrQuestion: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.
Coding Clinic 2013, 4th QtrQuestion: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
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,
Treated with bronchodilatorsIs this for a COPD exacerbation or
is this a maintenance medication?
Coding Case 1What are the diagnoses/procedures?
PneumoniaCOPDTobacco UseOxygen UseAnemia, normocyticCAD, s/p
CABGCoding Case 1
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 SCCCase 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
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.
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 lossAnemia,
microcyticHeavy tobacco use, 70 pack-years and
Coding Clinic, 4th Qtr 2013Question:
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?
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.
Query For ClarificationPhysician 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
Wang Needle AspirationsTransbronchial fine needle aspiration
biopsy is performed during thebronchoscopic procedure to sample
endobronchial or peribronchial lesions andperitracheal or
peribronchial lymph nodes, usually for evaluation of
Coding Case 2What are the diagnoses/procedures?
Diagnoses Case 2Path results: lung and lymphHemoptysisWeight
LossMicrocytic AnemiaSmoker, cigaretteHypertension
Procedures Case 2Bronchoscopy with RUL lung biopsyBiopsy
subcarinal lymph node
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 displacementPost-op hip x-ray: Good positioning of
the prosthesisVenous scan: Acute DVT popliteal vein on rightHgb
(discharge) 9 gm%
Case 3Hospital 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
Case 3Discharge Diagnoses:Fall with intertrochanteric fracture
of the left hip, s/p repairPost-operative deep venous thrombosis,
right popliteal veinAtrial fibrillation, new onsetCoronary artery
disease, non-obstructingAnticoagulation for #2 and #3
Coding Case 3What are the diagnoses/procedures?
Diagnoses Case 3Left intertrochanteric fracturePost-operative
(acute) DVT, right popliteal veinAtrial FibrillationCAD,
non-obstructingTrip and Fall over dog at home
Procedures Case 3Left Hip Arthroplasty
Case 4HPI: 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 8PE: 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
fracturesCT thorax: Multiple left rib fractures, hemopneumothorax,
probable contusion of the left lower lung vs.
aspiration.Hemoglobin: 10.2 gm% at discharge. Medical profile
Case 4Procedures:Endotracheal intubation and mechanical
ventilatory support for 5 daysOpen reduction and placement of
intramedullary rod, left femurBlood transfusion, 2 units packed red
blood cellsHospital 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
Case 4Discharge Diagnoses:Motor Vehicle Accident a.Closed head
injury with coma, improving at dischargeb.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 dischargec.Left clavicular
fracture, non-operative managementd.Fracture left mid-femur, s/p
repair with intramedullary rode.Acute respiratory failure requiring
mechanical ventilator support via endotracheal tube for 5
daysAlcohol abuse with acute intoxicationa. acute withdrawal
Coding Case 4What are the diagnoses/procedures?
Diagnoses Case 4Closed Head InjuryMid-Femur Fracture
(shaft)Pulmonary Contusion/HemopneumothoraxComa, GCS 8 in the
EDMultiple Left Rib FracturesLeft Clavicle FractureAcute
Respiratory FailureAlcohol Abuse, Intoxication and WithdrawalBlood
Alcohol Level, 170 mgTobacco Use
Procedures Case 4ORIF, left femurBlood transfusion, PRBCsChest
Case 5HPI: 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. EKGinferior MI, acute. Chest x-rayclear. Echocardiogram:
left ventricular hypertrophy with EF 40%. No wall motion
abnormality. CBC and Medical profile normal.
Case 5Hospital 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.
Case 5Discharge Diagnoses:Acute ST segment elevation MIa. 100%
occlusion mid-right coronary artery, S/P placement of drug-eluting
stentb. Transient complete heart block managed with temporary
pacemakerc. Moderate Left Ventricular systolic dysfunction
(Systolic EF 40%), severe chronic CHF yet compensated at this
timed. HyperlipidemiaTobacco useHypertension with left ventricular
hypertrophyObstructive sleep apnea, non-compliant with CPAPa.
Nocturnal hypoxemiaObesity, BMI 32Chronic venous insufficiency,
negative venous scan for acute clot this admission
Hypertension with left ventricular hypertrophyI51 Excludes 1Any
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)
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.
Coding Case 5What are the diagnoses/procedures?
Diagnoses Case 5STEMI, RCAComplete Heart BlockHypertensive Heart
DiseaseOSANon-compliance with CPAPObesity, BMI 32Chronic Venous
InsufficiencyHyperlipidemia Tobacco use
Procedures Case 5DES, RCACoronary AngiogramTemporary
Case 6HPI: 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
Case 6Hospital 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.
Case 6Discharge diagnoses:Severe sepsis secondary to complex
urinary tract infectiona. Acute renal injury, resolvingb.
Hypotension requiring pressorsc. Mild non-cardiogenic pulmonary
edema, managed with non-invasive ventilationd. E. coli
bacteremiaNephrolithiasisChronic kidney disease, stage
3Hyperuricemia with goutHypertension
Coding Case 6What are the diagnoses/procedures?
Diagnoses Case 6E. coli sepsis, severeAcute renal
injuryPulmonary edemaUTINephrolithiasisCKD, 3Hyperuricemia w/
Procedures Case 6BiPAPNorepinephrine InfusionCVC, for
Case 7HPI: Mr. N is a 50 y.o. man who presented to the Emergency
Department semi-obtunded and found to be in respiratory failure
(pCO2 >90 mmHg). During the attempt to intubate him, evaluation
of upper airway with glide scope demonstrated a large mass
obstructing the larynx and he was immediately taken to the
operating room. Squamous cell carcinoma of the larynx was diagnosed
and he was transferred to the ICU on mechanical ventilation via the
tracheostomy. Patient was taken off the vent 27 hours later.Exam:
At discharge he is tolerating his tube feedings. He has a moderate
amount of secretions from his tracheostomy which are yellow-brown.
His lung sound are obscured by tracheostomy noise. His cardiac
rhythm is regular. BP normal. No edema. The gastrostomy tube is
well-positioned and functioning normally. He is able to communicate
with alphabet board.
Lab: Hemoglobin 9.3 gm%, Medical profile normal except HCO3 34
from his chronic CO2 retention. K 3.5.
Case 7Hospital course: He was found to have upper airway
obstruction from a laryngeal cancer. Patient was take to the OR for
a tracheostomy that was placed through surgical incision and PEG
feeding tube was placed with endoscopic guidance. Radiation therapy
was initiated to the larynx. Outpatient chemotherapy will follow as
outpatient. He is unable to care for himself and has been placed in
a nursing facility. Discharge Meds: Per reconciliation sheet.
Case 7Discharge Diagnoses:Squamous cell carcinoma of the larynx
with upper airway obstruction causing acute on chronic respiratory
failurea. Tracheostomy place on 8/3/14 (day of admission)b. S/P
direct laryngoscopy with biopsy of larynxc. Initiation of radiation
therapy to larynxHeavy tobacco use, 50-60 pack-years, recently
quitCOPD, unquantified, but severe by clinical and radiologic
assessmenta. Chronic hypercarbic and hypoxemic respiratory failure
(compensated)b. Long term oxygen therapy prescribed this
admissionWeight loss, probably 30 lbs in 4-5 monthsDysphagia, S/P
placement of gastrostomy tubeChronic anemia
Query For ClarificationPhysician with laryngeal squamous cell
carcinoma. Discharge diagnoses include chronic anemia. Can you
clarifying the anemia further:_chronic anemia due to blood
loss_simple anemia_chronic anemia due to neoplastic disease_chronic
anemia due to other cause, please specify______________________
Coding Case 7What are the diagnoses/procedures?
Diagnoses Case 7Squamous cell carcinoma, larynxChronic
Respiratory Failure, hypoxemic and hypercapniaLaryngeal
ObstructionDysphagiaChronic AnemiaWeight LossCOPDH/O tobacco
Procedures Case 7TracheostomyPEGRadiationVentilation, Inspection