Employed as a Clinical Code Case Study - ACCD Coding Query Responses - Type II DM and Alzheimer’s Disease - Nursing Assessment Answer

Assessment Task:

Nursing Assessment Answer

 SCENARIO -

You are employed as a clinical coder at a nearby hospital. Your manager has been reviewing everyone’s coding output for the past month and has identified a few issues that need some attention. They have picked out five (5) episodes that best exemplify some of these issues and would like everyone’s input as to what the errors might be and how they might be prevented in the future. To streamline the process, your manager has decided to provide you with a summary of the key elements of each episode, along with the codes that have been assigned and the AR-DRG that the episode is currently grouped to. You are required to do the following: Review the short summaries that have been provided for each episode and then fully code each of them yourself. Review the codes that were assigned for each episode, along with the AR-DRG that each episode was grouped to. Compare the codes that you assigned to those that are shown. As you compare each code, assume that the summaries are correct and a true reflection of what was documented in the original medical record (i.e. if there are any errors, they are with the original codes and/or the AR-DRG assigned). Prepare a written response that outlines your findings for each episode. Start each episode by presenting the codes that you have assigned (include COF's where appropriate). Follow each set of codes with a detailed explanation of the errors that you believe were made with the original codes. For each error identified, you must include the following information: Explain what the specific error is.

Explain what the correction should be. Offer some ideas as to what might have led to that specific error. Suggest how the same error might be prevented in the future. Your responses should be supported with evidence to support your claims/assertions. The “evidence” can include things such as external reference material, specific ICD-10-AM and/or ACHI coding conventions, specific Australian Coding Standards or any other relevant coding advice (e.g. as provided through ACCD coding query responses) that you feel best supports your argument. Episodes related to this assessment are downloadable from the 'Additional Resources' section.

Episode 1
This 71-year-old patient was admitted with Cataracts. In theatre, the patient underwent a Phacoemulsification with insertion of an IOL under IV sedation and a peribulbar block. The patient complained of a headache in the PACU and so was given paracetamol. They stayed overnight due to their dementia. The patient also has Type II DM, and Alzheimer’s disease.

Code Assignment:
Principal Diagnosis                 (COF2) E10.36

Additional Diagnoses              (COF2) E10.9
                                                (COF1) R51
                                               (COF2) U79.1
                                               (COF2) F03

Interventions                             42698-07
                                                  92514-29
                                                  92511-29

AR-DRG                                   C16Z [Lens Procedures]

Episode 2
This 19-year-old male was admitted after he had accidentally taken a double dose of his antipsychotic medication. He was unconscious on arrival and mechanical ventilation via an ETT was required for a period of 7 hours.

Code Assignment:
Principal Diagnosis               (COF2) R40.2

Additional Diagnoses            (COF2) Y49.5
                                              (COF1) Y92.9
                                              (COF2) U73.9

Interventions 92209-01
AR-DRG                                B74B [Nontraumatic Stupor and Coma, Minor Complexity]

Episode 3
The 60-year-old man was admitted with an exacerbation of his COPD with pneumonia. He was provided with chest physiotherapy and IV antibiotics before his condition improved. His COPD was due to his smoking, and so he was seen by the psychologist to provide him advice on how to quit.

Code Assignment:
Principal Diagnosis                           (COF1) J18.9
Additional Diagnoses                        (COF2) J44.9
                                                          (COF2) Z72.0
                                                          (COF2) U83.2

Interventions                                         95550-00
                                                              95550-10

AR-DRG E62B [Respiratory Infections and Inflammations, Minor Complexity]

Episode 4
This 15-year-old female was admitted with pelvic pain 2 days post a hysteroscopy. She was observed and had a CT scan of her pelvis and abdomen before being discharged home.

Code Assignment:
Principal Diagnosis                       (COF2) T81.83

Additional Diagnoses                      (COF2) Y84.9
                                                       (COF2) Y92.9
                                                       (COF2) U73.9
Interventions                                  56401-00 56409-00

AR-DRG X63B [Sequelae of Treatment, Minor Complexity]

Episode 5
This 34-year-old woman was admitted and underwent a total mastectomy and complete axillary clearance under general anaesthetic (ASA 1). She had a biopsy 3 days earlier, which revealed Carcinoma of NST. Two of the axillary lymph nodes were positive for metastatic carcinoma. She was discharged home.

Code Assignment:

Principal Diagnosis                       (COF2) C50.9
Additional Diagnoses                    (COF2) M8010/3
                                                      (COF2) C77.3
                                                      (COF2) M8010/6

AR-DRG                                        J62B [Malignant Breast Disorders, Minor Complexity]

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