Monthly CDI Scenario Discussion – December 2019

Topic:  GI bleeding

Scenario: 

80 y/o female presents with coffee ground hematemesis with a PMH of GERD, CAD, and Iron deficiency Anemia. She has home medications of Protonix PO daily, SlowFe PO daily, and ASA 81mg PO daily.

H&P notes:  “acute upper GI bleed” with non-compliance with the Protonix and SlowFe because she says “they make her constipated.”

Day 1 Progress note: HGB stable, 7 on admission with a baseline of 10, 1 unit PRBCs transfused.

Day 2 Progress note: Esophagogastroduodenoscopy completed with findings of grade D esophagitis with ulceration and duodenitis. IV PPI and Iron initiated, will transition to PO prior to discharge and resume ASA at discharge.

Question:   Are there any query opportunities based on the scenario stated above?

Discussion: 

Alphabetic Index lists the following code titles:

  • Duodenitis with bleeding, K29.81
  • Ulcer of esophagus with bleeding, K22.11

Consider the coding guideline “with” and pertinent Coding Clinic Advice (included in CDI Educational Tips) when considering the principal diagnosis.

Patient presented with indicators of acute blood loss anemia.

UASI Recommendation: 

  • Query for acute blood loss anemia.  Pt. was noted with a 3gm Hbg drop, treatment of 1 unit of PRBC and findings from EGD demonstrating duodenitis and an esophageal ulcer.

Documentation without clarification:

Principal diagnosis: K22.11 Ulcer of esophagus with bleeding

Secondary diagnoses: K29.81 Duodenitis with bleeding, K21.0 Gastro-esophageal reflux disease with esophagitis, D50.9 Iron deficiency Anemia, I25.10 CAD, T47.1X6A Underdosing of other antacids and anti-gastric-secretion drugs, initial encounter, T45.4X6A Underdosing of iron and its compounds, initial encounter, Z91128 Patient’s intentional underdosing of medication regimen for other reason

PCS: 0DJ08ZZ Inspection of Upper Intestinal Tract, Via Natural or Artificial Opening Endoscopic

DRG 382 Complicated Peptic Ulcer without CC/MCC                         RW= 0.7914, GMLOS= 2.4, SOI/ROM: 2/1

Documentation with clarification:

Principal diagnosis: K22.11 Ulcer of esophagus with bleeding

Secondary diagnoses: K29.81 Duodenitis with bleeding, K21.0 Gastro-esophageal reflux disease with esophagitis, D50.9 Iron deficiency Anemia,I25.10 CAD, T47.1X6A Underdosing of other antacids and anti-gastric-secretion drugs, initial encounter, T45.4X6A Underdosing of iron and its compounds, initial encounter, Z91.128 Patient’s intentional underdosing of medication regimen for other reason, D62 Acute post hemorrhagic anemia

PCS: 0DJ08ZZ Inspection of Upper Intestinal Tract, Via Natural or Artificial Opening Endoscopic

DRG 381 Complicated peptic ulcer w CC                 RW=1.0767, GMLOS=3.2, SOI/ROM: 2/1

CDI Educational Tips: 

  • Official Coding Guideline I.A.15 titled (“with”): “The word ‘with’ or ‘in’ should be interpreted to mean ‘associated with’ or ‘due to’ when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.”
  • Coding Clinic for ICD-10-CM/PCS, Hematemesis due to Ulcerative esophagitis and Duodenitis Coding Clinic Third Quarter 2018: Page 22

Question:

A patient presents with coffee ground hematemesis and has esophagogastroduodenoscopy (EGD) performed.  The provider’s final diagnostic statements lists, “acute upper gastrointestinal hemorrhage, ulcerative esophagitis, and duodenitis.”  Is it appropriate to assign combination code for ulcerative esophagitis with bleeding and duodenitis with bleeding, to capture multiple bleeding sites?

Answer:

Yes.  Assign codes K22.11, Ulcer of esophagus with bleeding, and K29.81, Duodenitis with bleeding, for the ulcerative esophagitis and duodenitis with hematemesis.  Since the classification links the hemorrhage in both conditions, it is appropriate to assign the combination codes indicating “with bleeding.”

This is a short synopsis of a possible patient record and is not intended to be all inclusive.  This is for educational purposes only and not intended to replace your institutional guidelines.  

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