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ICD-10 Coding Scenarios for Family Practice

By PracticeFusion



Quality clinical documentation is essential for communicating the intent of an encounter, confirming medical necessity, and providing detail to support ICD-10 code selection. In support of this objective, we have provided outpatient focused scenarios to illustrate specific ICD-10 documentation and coding nuances related to your specialty.The following scenarios were natively coded in ICD-10-CM and ICD-9-CM. As patient history and circumstances will vary, these brief scenarios are illustrative in nature and should not be strictly interpreted or used as documentation and coding guidelines. Each scenario is selectively coded to highlight specific topics; therefore, only a subset of the relevant codes are presented.

The following scenarios were natively coded in ICD-10-CM and ICD-9-CM. As patient history and circumstances will vary, these brief scenarios are illustrative in nature and should not be strictly interpreted or used as documentation and coding guidelines. Each scenario is selectively coded to highlight specific topics; therefore, only a subset of the relevant codes are presented.

Family Practice Clinical Scenarios:

Scenario 1: Abdominal Pain

Scenario Details

Chief Complaint

“My stomach hurts and I feel full of gas.”

History

47 year old male with mid-abdominal epigastric pain1, associated with severe nausea & vomiting; unable to keep down any food or liquid. Pain has become “severe” and constant.Has had an estimated 13 pound weight loss over the past month.Patient reports eating 12 sausages at the Sunday church breakfast five days ago which he believes initiated his symptoms.Patient admits to a history of alcohol dependence2. Consuming 5 – 6 beers per day now, down from 10 – 12 per day 6 months ago. States that he has nausea and sweating with “the shakes” when he does not drink.

Exam

VS: T 99.8°F, otherwise normal.Mild jaundice noted.Abdomen distended and tender across upper abdomen3. Guarding is present. Bowel sounds diminished in all four quadrants.Oral mucosa dry, chapped lips, decreased skin turgor

Assessment and Plan

Dehydration and suspected acute pancreatitis.Admit to the hospital. Orders written and sent to on-call hospitalist.1L IV NS started in office. Blood drawn for labs.Recommend behavioral health counseling for substance abuse assessment and possible treatment.Patient’s wife notified of plan; she will transport to hospital by private vehicle.

Summary of ICD-10-CM Impacts

Clinical Documentation

Describe the pain as specifically as possible based on location.When addressing alcohol related disorders you should distinguish alcohol use, alcohol abuse, and alcohol dependence. ICD-10-CM has changed the terminology and the parameters for coding substance abuse disorders. In this encounter note, as the acute pancreatitis is suspected, and the patient’s alcohol intake status is stated, the associated alcoholism code is listed.Abdominal tenderness may be coded. Ideally the documentation should include right or left upper quadrant and indicate if there is rebound in order to identify a more specific code. Currently the ICD-10 code would be R10.819, Abdominal tenderness, unspecified site as the documentation is insufficient in laterality and specificity.

Coding

ICD-9-CM Diagnosis Codes

789.06 Abdominal pain, epigastric 789.60 Abdominal tenderness, unspecified site 782.4 Jaundice NOS 276.51 Dehydration 303.90 Other and unspecified alcohol dependence, unspecified

ICD-10-CM Diagnosis Codes

R10.13 Epigastric pain R10.819 Abdominal tenderness, unspecified site R17 Unspecified jaundice E86.0 Dehydration F10.20 Alcohol dependence, uncomplicated

Other Impacts

No specific impacts noted.

Scenario 2: Annual Physical Exam

Scenario Details

Chief Complaint

“I’m here for my annual check-up.1”

History

73 year old male with history of coronary artery disease, stent placement, hyperlipidemia, HTN and GERD.Recent admission to hospital following a hypertensive crisis. Discharged home on olmesartan medoxomil 20 mg daily.Patient stopped taking olmesartan medoxomil due to side effects2, including a headache that began after starting the medication and still exists, and tiredness.Regular activity includes walking, golfing. Active social life. No complaints of chest pain, or dyspnea on exertion.Last colonoscopy was 9 months ago. No significant pathology found; some diverticular disease.Medications were reviewed.

Exam

Chest clear. Heart sounds normal. Mental status exam intact.EKG shows no changes from prior EKG.Vitals: BP is 159/95, otherwise normal. Per patient, he had good control of BP on meds, but it has risen without medication.BUN/creatinine normal limits.

Assessment and Plan

HTN noted on exam today. Change from olmesartan medoxomil to metoprolol tartrate 50 mg once daily, will titrate dosage every two weeks until BP normalizes.Discussed the importance of daily home BP monitoring, low sodium diet, and taking BP medication as prescribed; he verbalizes understanding.Schedule follow-up visit in two weeks to evaluate effectiveness of new BP medication therapy, and repeat BUN/creatinine.

Summary of ICD-10-CM Impacts

Clinical Documentation

Documenting why the encounter is taking place is important, as the coder may assign a different code based on the type of visit (e.g., screening, with no complaint or suspected diagnosis, for administrative purposes). In this situation, the patient is requesting an encounter without a complaint, suspected or reported diagnosis.Document that the patient is noncompliant with his medication. This “underdosing” concept can often be coded, along with the patient’s reason for not taking the prescribed medications. Document if there is a medical condition linked to the underdosing that is relevant to the encounter, and ensure the connection is clearly made. The ICD-10-CM terms provide new detail as compared to the ICD-9-CM code V15.81, history of past noncompliance. In this case there was no noted history of noncompliance. In this note the side effects of stopping the medication include headache, which remains as a patient complaint for this encounter. When documenting headache do differentiate if intractable versus non-intractable.

Coding

ICD-9-CM Diagnosis Codes

V70.0 Routine medical exam 401.9 Unspecified essential hypertension 339.3 Drug-induced headache, not elsewhere classified

ICD-10-CM Diagnosis Codes

Z00.01 Encounter for general adult medical examination with abnormal findings I10 Essential (primary) hypertension G44.40 Drug-induced headache, not else where classified, not intractable T46.5X6A Underdosing of other antihypertensive drugs, initial encounter Z91.128 Patient’s intentional underdosing of medication regimen for other reason

Other Impacts

Assess if the new patient-centric preventative health incentives for annual exams are relevant to your practice.For hierarchical condition categories (HCC) used in Medicare Advantage Risk Adjustment plans, certain diagnosis codes are used as to determine severity of illness, risk, and resource utilization. HCC impacts are often overlooked in the ICD-9-CM to ICD-10-CM conversion. The physician should examine the patient each year and compliantly document the status of all chronic and acute conditions. HCC codes are payment multipliers.


Reference: https://www.practicefusion.com/icd-10/clinical-concepts-for-family-practice/icd-10-clinical-scenarios/


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