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 Answer keys are no longer updated because Alfred State College has embedded patient records and answers in their learning management system.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.
