IPCasesAnswers

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Edited Nov-07
by Heather Clifford, RHIT, CCS
IPCasesAnswers
A HUGE THANK YOU TO my fellow HIM educators for originally coding and grouping all of these inpatient cases!!! A VERY SPECIAL THANK YOU
to Heather Duvall, Alfred State College student, for being the first to code all cases and ask thoughtful questions for which feedback was developed.
NOTE: This answer key contains ICD-9-CM 2007 codes. Answer keys are no longer updated because Alfred
State College has embedded patient records and answers in their learning management system.
IPCase001
Admission
Diagnosis
780.6
Principal
Diagnosis
590.10
Principal
Procedure
Secondary
Diagnosis
041.4
Secondary
Procedure
Secondary
Diagnosis
Secondary
Diagnosis
276.51
Secondary
Procedure
Secondary
Procedure
CMS-DRG:
320
Kidney and urinary tract infections, age > 17 with CC
MS-DRG:
690
Kidney and urinary tract infections w/o MCC
Secondary
Procedure
Do not report code 305.x for tobacco abuse because it was not medically managed (e.g., treatment, patient counseling).
IPCase002
Admission
Diagnosis
366.9
Principal
Diagnosis
366.9
Principal
Procedure
13.59
Secondary
Diagnosis
496
Secondary
Procedure
Secondary
Diagnosis
Secondary
Diagnosis
V13.5
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
13.71
CMS-DRG:
039
Lens procedures with or without vitrectomy
MS-DRG:
117
Intraocular procedures w/o CC/MCC
Don’t mistakenly assign 13.41 for this case because to assign that code requires documentation of phacoemulsification technique,
which is “a method of emulsifying and aspirating a cataract with a low frequency ultrasonic needle.” (Stedman’s Medical Dictionary)
In this particular case, the patient underwent “extracapsular cataract extraction” (13.59) with “implantation of a lens” (13.71).
IPCase003
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
522.5
522.5
525.8
428.0
414.01
303.90
Principal
Procedure
Secondary
Procedure
23.19
24.5
Secondary
Procedure
CMS-DRG:
138
Mouth procedures without CC or MCC
MS-DRG:
138
Mouth procedures with CC or MCC
Secondary
Diagnosis
Secondary
Procedure
Secondary
Diagnosis
287.30
Secondary
Procedure
Under MS-CMS-DRGs, code 428.0 is not considered a comorbidity, and so it does not impact the CMS-DRG or MS-DRG
assignment. The “unspecified” fifth-digit of “0 “ is added to code 303.9 because patient record documentation does not indicate
whether this condition is continuous, episodic, or in remission.
IPCase004
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Procedure
332.0
276.8
332.0
276.51
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
IPCase005
IPCase006
CMS-DRG:
297
Nutritional and miscellaneous metabolic disorders, age > 17, w/o CC
MS-DRG:
641
Nutritional and miscellaneous metabolic disorders, w/o CC
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
303.00
303.00
303.90
V66.4
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
CMS-DRG:
523
Alcohol/drug abuse or dependency, w/o rehabilitation therapy, w/o CC
MS-DRG:
897
Alcohol/drug abuse or dependency, w/o rehabilitation therapy, w/o MCC
Admission
Diagnosis
Principal Diagnosis
Secondary
Diagnosis
486
482.83
414.01
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
CMS-DRG:
080
Respiratory infections and inflammations, age > 17, w/o CC
MS-DRG:
179
Respiratory infections and inflammations, w/o CC/MCC
Secondary
Diagnosis
Secondary
Procedure
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Procedure
Secondary
Procedure
The patient received ampicillin (antibiotic) to treat the pneumonia. The patient also underwent lab testing to determine which
antibiotic would be most effective. Locate the lab report in the patient record, and notice that the culture revealed gram-negative
bacteria. Thus, the more specific code 482.83 is assigned to this case as principal diagnosis.
IPCase007
IPCase008
Admission
Diagnosis
Principal
Diagnosis
332.0
332.0
Principal
Procedure
Secondary
Procedure
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
CMS-DRG:
012
Degenerative nervous system disorders
MS-DRG:
057
Degenerative nervous system disorders w/o MCC
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
998.59
998.59
682.2
041.4
041.82
E878.6
112.0
V10.05
Secondary
Procedure
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
86.04
86.04
99.21
97.83
CMS-DRG:
418
Post-operative and post-traumatic infections
MS-DRG:
863
Post-operative and post-traumatic infections w/o MCC
The patient was admitted due to infection of surgical wound. The surgery was done during a previous admission.
The staples were removed during this admission. Therefore, assign code 97.83 for staple removal as documented in the
progress notes on 11/18. (If the staples had been removed during previous admission following surgery, you would not assign a code
for staple removal because it would be considered part of the surgical package.)
IPCase009
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
780.39
780.2
780.39
305.1
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Diagnosis
Secondary
Procedure
89.52
CMS-DRG:
141
Syncope and collapse w/ CC
MS-DRG:
312
Syncome and collapse
You might be tempted to assign code 460 for the treatment of the patient’s worsening cold. Please note that treatment was Tylenol
only, and there is no documentation indicating that the patient’s having a cold impacted treatment principal diagnosis. Therefore, do
not assign 460.
IPCase010
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
466.19
466.19
V13.7
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Procedure
Secondary
Procedure
93.94
IPCase011
CMS-DRG:
098
Bronchitis and asthma, age 0-17
MS-DRG:
203
Bronchitis and asthma w/o CC/MCC
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
276.51
276.51
558.9
305.90
332.0
285.9
733.00
716.90
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Diagnosis
Secondary
Procedure
Secondary
Diagnosis
Secondary
Procedure
99.18
CMS-DRG:
296
Nutritional and metabolic disorders, age > 17 w/ CC
MS-DRG:
641
Nutritional and miscellaneous metabolic disorders, w/o MCC
Anemia is documented in the discharge summary, 2nd paragraph in the "SUMMARY."
IPCase012
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
415.19
511.0
492.8
V12.51
V15.82
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
93.96
92.15
CMS-DRG:
089
Simple pneumonia and pleurisy, age > 17, w/ CC
MS-DRG:
195
Simple pneumonia and pleurisy w/o CC/MCC
IPCase013
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
366.9
366.9
998.89
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
13.3
13.71
11.59
13.65
CMS-DRG:
042
Intraocular procedures except retina, iris & lens
MS-DRG:
117
Intraocular procedures except retina, iris & lens w/o CC/MCC
Per the procedure on the face sheet, cataract removal was extracapsular (ECCE, extracapscular cataract extraction) using irrigation
and aspiration technique (13.3). Code 11.59 is assigned for repair of corneal tear, right eye.
The patient had cataract extraction of right eye the previous year, and according to the clinical summary in the Short Stay
Record, presents during this admission for “resuture of right eye.” The diagnosis would be coded as a complication of a previous
surgery (998.89).
IPCase014
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
682.7
682.7
041.11
250.00
414.01
437.0
715.90
290.20
V49.76
294.9
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
CMS-DRG:
278
Cellulitis, age > 17, w/o CC
MS-DRG:
603
Cellulitis w/o MCC
Secondary
Diagnosis
Secondary
Procedure
Secondary
Diagnosis
Secondary
Procedure
The patient was admitted for extensive inpatient treatment and IV antibiotic therapy for cellulitis. There was reference in the
discharge summary that the patient may require extensive debridement, but there is no documentation in the record of anything more
than foot soaks and dressing changes.
IPCase015
Admission
Diagnosis
Principal
Diagnosis
786.07
493.90
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
466.0
041.09
471.9
473.9
E935.3
905.7
Secondary
Procedure
Secondary
Procedure
E929.8
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
CMS-DRG:
097
Bronchitis and asthma, > 17, w/o CC
MS-DRG:
203
Bronchitis and asthma w/o CC/MCC
Patient admitted with wheezing and hypoxemia. Had 3-week history of URI, developing into wheezing and productive cough as well
as two previous trips to E.R. On this 3rd visit to the E.R., the patient was admitted. Physician noted medical history of aspirin use and
current response to aspirin usage did not make condition worse.
Note that the physician documented “R/O triad asthma.” Triad asthma is a patient who has asthma, sinus disease, and an
aspirin allergy (adverse reaction to aspirin). (Similarly, but not in this particular case, when polyps are seen in association with
asthma and sensitivity to aspirin, they form a three-part symptom complex called "triad asthma" or "Samter's triad.") There is no
single code for “triad asthma;” therefore, assign a code to each of the three “parts.” In this case, assign codes to asthma, sinus
disease, and aspirin allergy.
IPCase016
IPCase017
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
794.8
571.5
V16.0
466.0
276.8
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
48.23
50.11
87.59
87.73
CMS-DRG:
202
Cirrhosis and alcoholic hepatitis
MS-DRG:
434
Cirrhosis and alcoholic hepatitis w/o CC/MCC
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
836.0
844.1
E916
E849.8
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Diagnosis
Secondary
Procedure
80.26
CMS-DRG:
232
Arthroscopy
MS-DRG:
509
Arthroscopy
The operative reports documents only an arthroscopy, but the pathology report documents synovial tissue via debridement. Query
the surgeon to determine if the operative report needs to be edited to reflect synovectomy, and if so assign the corresponding
procedure code (and regroup because the CMS-DRG would change, resulting in increased payment to the facility).
If the surgeon edits the operative report, assign 80.76 (not 80.26). The CMS-DRG changes to 503 – Knee procedures, w/o
PDX of infection.
IPCase018
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
493.90
493.90
780.39
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Procedure
Secondary
Procedure
93.94
IPCase019
CMS-DRG:
098
Bronchitis, age 0-17
MS-DRG:
203
Bronchitis and asthma w/o CC/MCC
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
608.20
608.23
608.83
319
783.40
Secondary
Procedure
Secondary
Procedure
278.00
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
62.2
CMS-DRG:
340
Testes procedures, non-malignancy, age < 17
MS-DRG:
712
Testes procedures w/o CC/MCC
Sequence 608.2 as principal diagnosis because this is the underlying cause for the infarct, testicular appendix.
Don’t assign code 788.30 for “urinary incontinence.” This 4-year-old child is not potty-trained, but this does not constitute
‘urinary incontinence.” (The child is mentally retarded.)
The H&P documents the child is currently on Amoxicillin for an ear infection, but the Amoxicillin is not documented on the
medication administration record. Therefore, the attending physician should be queried to verify that antibiotics were provided during
the inpatient stay. The physician should also be asked if the ear infection should be reported as a comorbidity.
IPCase020
IPCase021
IPCase022
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
600.01
600.01
788.29
782.3
414.01
429.2
V45.81
V15.82
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
Principal
Procedure
Secondary
Procedure
CMS-DRG:
349
Benign prostatic hypertrophy w/o CC
MS-DRG:
726
Benign prostatic hypertrophy w/o MCC
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
721.3
721.3
250.00
564.00
401.9
724.3
722.52
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
Principal
Procedure
Secondary
Procedure
CMS-DRG:
243
Medical back problems
MS-DRG:
552
Medical back problems w/o MCC
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
595.89
595.89
599.0
285.1
344.09
337.3
V44.6
Secondary
Procedure
Secondary
Procedure
Principal
Procedure
Secondary
Procedure
CMS-DRG:
320
Kidney and urinary tract infection, age 0-17, w/o CC
MS-DRG:
689
Kidney and urinary tract infections w/ MCC
Secondary
Procedure
595.89 is assigned because documentation specifies polypoid cystitis
344.09 is assigned because documentation indicates C5-C6 quadriplegia.
Don’t assign 99.04 for transfusion; the patient refused transfusion.
IPCase023
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
683
683
034.0
460
781.6
Secondary
Procedure
Secondary
Procedure
280.9
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
03.31
CMS-DRG:
399
Reticuloendothelial and immunity disorders w/o CC
MS-DRG:
815
Reticuloendothelial and immunity disorders w CC
IPCase024
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
600.01
600.01
401.9
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Procedure
Secondary
Procedure
60.29
CMS-DRG:
337
Transurethral prostatectomy w/o CC
MS-DRG:
714
Transurethral prostatectomy w/o CC/MCC
In October 2003, ICD-9-CM subcategory code 600.0 was expanded to the fifth digit level; hence, 600.01 is assigned.
IPCase025
IPCase026
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
610.1
610.1
785.6
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
85.21
40.23
CMS-DRG:
262
Breast biopsy and local excision for non-malignancy
MS-DRG:
581
Other skin, subcutaneous tissue and breast procedure w/o CC/MCC
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
493.92
493.92
780.39
382.9
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
CMS-DRG:
098
Bronchitis and asthma, age 0-17
MS-DRG:
203
Bronchitis and asthma w/o CC/MCC
Secondary
Diagnosis
Secondary
Procedure
“Congenital anomaly to chest wall” and “adjustment problems” were documented in the record, but not treated. Therefore, do not
assign codes.
Don’t assign code 787.03 for vomiting because this was documented as part of systemic review in History report as occurring
before school in the morning, and there is no evidence of treatment for vomiting during this admission.
IPCase027
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
787.91
008.8
276.51
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
CMS-DRG:
184
Esophagitis, gastroenteritis and miscellaneous digestive disorders, age 0-17
MS-DRG:
392
Esophagitis, gastroenteritis and miscellaneous digestive disorders w/o MCC
Query the physician about documenting “diaper rash” on face sheet. It is also apparent that “dehydration” was treated (when
physician orders are reviewed).
IPCase028
Admission
Diagnosis
Principal
Diagnosis
Secondary Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
276.8
276.8
218.9
574.20
721.0
562.10
552.3
Secondary Procedure
Secondary
Procedure
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
CMS-DRG:
297
Nutritional and miscellaneous metabolic disorders, age > 17 W/O CC
MS-DRG:
641
Nutritional and miscellaneous metabolic disorders w/o MCC
Do not assign a code to “degenerative disc disease,” which is documented on the cervical spine x-ray because the attending
physician does not confirm that diagnosis elsewhere in the patient record. There is also no documented treatment of “degenerative
disc disease.”
IPCase029
IPCase030
IPCase031
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
590.80
590.10
041.4
466.0
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
CMS-DRG:
322
Kidney and urinary tract infections, age 0-17
MS-DRG:
690
Kidney and urinary tract infections w/o MCC
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
787.03
558.9
463
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
CMS-DRG:
184
Esophagitis, gastroenteritis and miscellaneous digestive disorders, age 0-17
MS-DRG:
392
Esophagitis, gastroenteritis and miscellaneous digestive disorders w/o MCC
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
558.9
003.0
276.51
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
CMS-DRG:
572
Major gastrointestinal disorders and peritoneal infections
MS-DRG:
373
Major gastrointestinal disorders and peritoneal infections w/o CC/MCC
Secondary
Procedure
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Procedure
Secondary
Procedure
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Procedure
Secondary
Procedure
IPCase032
IPCase033
IPCase034
Admission
Diagnosis
Principal
Diagnosis
604.99
604.99
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
599.0
041.4
V45.77
V45.79
V14.0
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
598.9
Principal
Procedure
Secondary
Procedure
87.73
87.77
CMS-DRG:
350
Inflammation of the male reproductive system
MS-DRG:
728
Inflammation of the male reproductive system w/o MCC
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
735.0
735.0
727.1
754.52
401.9
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
77.51
78.58
93.53
CMS-DRG:
225
Foot procedures
MS-DRG:
505
Foot procedures w/o CC/MCC
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
789.06
789.06
535.50
486
491.9
530.10
530.5
V58.61
Secondary
Procedure
Secondary
Procedure
Secondary
Diagnosis
V43.3
Principal
Procedure
IPCase035
Secondary
Procedure
Secondary
Procedure
CMS-DRG:
182
Esophagitis, gastroenteritis and miscellaneous digestive disorders, age 18+ w/ CC
MS-DRG:
391
Esophagitis, gastroenteritis and miscellaneous digestive disorders w MCC
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
378.00
378.00
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
15.11
15.11
CMS-DRG:
041
Extraocular procedures except orbit, age 0-17
MS-DRG:
115
Extraocular procedures except orbit
IPCase036
IPCase037
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
463
493.90
780.39
463
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
CMS-DRG:
098
Bronchitis and asthma, age 0-17
MS-DRG:
203
Bronchitis and asthma w/o CC/MCC
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
784.7
785.59
285.1
784.7
401.9
721.90
782.1
564.00
369.00
429.2
Secondary
Procedure
Secondary
Procedure
Principal
Procedure
Secondary
Procedure
Secondary
Diagnosis
Secondary
Procedure
Secondary
Procedure
21.02
CMS-DRG:
576
Septicemia w/o MV 96+ hours age >17
MS-DRG:
872
Septicemia w/o MV 96+hours w/o MCC
Control of epistaxis by posterior packing (21.02) was done in E.R.
IPCase038
IPCase039
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
309.1
309.1
301.6
737.30
305.00
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
CMS-DRG:
426
Depressive neuroses
MS-DRG:
881
Depressive neuroses
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
250.02
250.03
401.9
303.90
305.1
368.8
V15.1
Secondary
Procedure
Secondary
Procedure
Principal
Procedure
Secondary
Procedure
CMS-DRG:
294
Diabetes, age > 35
MS-DRG:
639
Diabetes w/o CC/MCC
Secondary
Procedure
Patient was admitted with uncontrolled diabetes but he was not on insulin, so assign 250.02 as admission diagnosis. He was treated
with insulin during say and discharged with insulin, so code 250.03 as principal diagnosis.
Do not code tiredness, dry mouth, passing excessive water, hungriness as these are all symptoms of diabetes (250.03).
Assign code 303.90 for history of alcohol problem. Alcoholism is a lifetime illness, whether the alcoholic is recovering (not
currently drinking) or not. We don’t know the status of the alcoholism, so code as unspecified.
Coding flattened diaphragm is optional. This could be the reason for tobacco counseling. Code would be 793.2, Nonspecific
abnormal findings on radiological and other examination of intrathoracic organ.
IPCase040
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
493.02
493.10
518.82
780.39
382.9
Secondary
Procedure
Secondary
Procedure
312.81
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
93.96
CMS-DRG:
096
Bronchitis and asthma, age > 17, w/ CC
MS-DRG:
202
Bronchitis and asthma w CC/MCC
Assign 493.10 to “acute and chronic asthma” because discharge summary documents “secondary to pulmonary infection.” The ICD
index entry is “asthma, infective 493.1” and then assign 5 th digit 0 due to no documentation about status asthmaticus.
You should query the physician about code 518.82 because the patient’s nasopharaynx culture revealed 4+ step pneumoniae
and 3+ gram neg. rods.” Perhaps the patient has pneumonia (481).
IPCase041
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
366.9
366.9
426.4
429.3
244.0
784.0
721.90
V10.11
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
Principal
Procedure
Secondary
Procedure
13.59
IPCase042
CMS-DRG:
039
Lens procedures with or without vitrectomy
MS-DRG:
117
Intraocular procedures w/o CC/MCC
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
552.21
552.21
402.90
429.2
618.00
Secondary
Procedure
Secondary
Procedure
721.0
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
53.61
CMS-DRG:
160
Hernia procedures except inguinal and femoral, age >17, w/o CC
MS-DRG:
355
Hernia procedures except inguinal and femoral w/o CC/MCC
Report code 552.21 because documentation indicates that the hernia became partially obstructed shortly before admission.
IPCase043
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
366.16
366.16
V71.89
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
13.59
13.71
CMS-DRG:
039
Lens procedures with or without vitrectomy
MS-DRG:
117
Intraocular procedures w/o CC/MCC
IPCase044
Admission
Diagnosis
Principal
Diagnosis
378.00
378.00
Principal
Procedure
Secondary
Procedure
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
15.3
IPCase045
CMS-DRG:
041
Extraocular procedures except orbit, age 0-17
MS-DRG:
115
Extraocular procedures except orbit
Admission
Diagnosis
Principal
Diagnosis
Secondary
Diagnosis
Secondary
Diagnosis
600.01
600.01
599.0
041.7
Principal
Procedure
Secondary
Procedure
Secondary
Procedure
Secondary
Procedure
60.29
57.32
CMS-DRG:
336
Transurethral prostatectomy w/ CC
MS-DRG:
713
Transurethral prostatectomy w/ CC/MCC
Secondary
Diagnosis
Secondary
Procedure
You should query the physician about the documented “extremely tight anus,” which affected treatment because it might also be the
reason for laxative administration.
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