ICD-10-CM Coding Practice: Family Practice / Internal Medicine Case
Alicia: We got a practice from Practicode.
This is actually a Family Practice/Internal Medicine case. I thought we’d work through
it and code it. It’s not very difficult to code, but it will give you an idea what
you will see in Practicode. It’s kind of exciting. All the information that is related
to a person has been redacted, so this is actually a real encounter, but of course Johnny
Smith is a made-up name and Dr. John. We have Mr. Johnny Smith, that this is actually
how it would come to you if you were coding often is you’d have a date of birth and
you’d have a date of service and you want to confirm your date of service. This is Medicare,
when you’re coding sometimes that makes a big difference in what you’re looking
for, and it really depends on what type of coding you’re doing as well. If you’re
doing HCC coding, you will get this case differently than if you’re doing for a physician, just
a regular physician coding. Now, we’re going to do an ICD-10 so we’re not paying attention
to the E/M which is a CPT. We’re going to just pull out the information for diagnoses.
Chief Complaint (CC): Follow-up on hypertension and cholesterol. Patient also needs medications
refilled and lab work. So, we already know, kind of, what’s going on with this patient.
We know he has existing diagnoses of hypertension and cholesterol, but he didn’t tell us what
type of cholesterol he has, did he? HPI: Patient is a 69-year old male who presents
today for his regularly scheduled BP check. Since the last visit status he has, overall,
felt well with no notable interim problems. He remains on Hydrochlorothiazide Oral Tablet
25 mg and Toprol XL Oral Tablet Sustained Release 24 hr 25 mg for blood pressure control.
Hydrochlorothiazide is also called HCTZ because some people don’t like to say hydrochlorothiazide.
I particularly think it’s fun to say, it’s one of those words I can’t say.
Boyd: And you’re kind of weird, yeah. Alicia: Yeah, I’m weird that way. I could
also spell it, you know; I can’t spell the word “beautiful” but I can spell hydrochlorothiazide.
This is actually a “water pill” which would be a support to a blood pressure pill.
He has no additional problems which require addressing at this time – so now we’re
still working with two diagnoses. Due for lab work, leaving the state for 4 months – he’s
probably a snowbirder, he’s going to go down south. Says BP at home usually in 120/70s
– in other words he’s been asked to keep track of his blood pressure and it’s doing
a range, it’s running pretty good there. Review of Systems – this is all information
that’s very important when you have to do your E/M leveling. We’re not doing it so
E/M, we are doing it for the diagnoses; so we’re going to pull out any information
that supports that he has a problem with his blood pressure, he has cholesterol problem.
Constitutional: Denies fatigue, fever, chills, body aches, weight loss, weight gain, loss
of appetite (In other words, he denies all of these things). Eyes: Denies discharge from
eye, eye discomfort, double vision, impaired vision, changes in vision (If you noticed,
these are all things that if a person was having problems with their blood pressure
could be affected). HENT: See HPI (In other words, he’s saying everything that you need
for this, it’s in the HPI). Breasts: See HPI. Cardiovascular: Denies chest pain, irregular
heartbeats, rapid heart rate, syncope, dyspnea on exertion, lower extremity, edema (he denies
any of that). Respiratory: Denies: Shortness of breath, wheezing, cough. Gastrointestinal:
See HPI. Boyd: What does HPI stand for?
Alicia: (History of Present Illness) Boyd: Everybody is reminding me that it’s
actually History of Present Illness. Alicia: And often, you’ll see the doctors
do this a lot. They’re not going to fill this all again, they’re just going to go,
“See HPI, it’s in there.” But see, actually, did he talk about the endocrine system in
the HPI? No. It’s not even mentioned. He said, “Go look in the HPI.”
So, in other words, we have no information there.
Now we have his weight and it’s 211 lbs 6 oz. Now, a lot of times they’ll just give
the BMI because instead of saying somebody is obese, they’ll just say “BMI is –” Height:
6??? BP: 141/97 sitting – that’s an elevated blood pressure but that’s not for us to
determine. Just because we know that…he’s saying “Well, at home, this what I run.”
But it doesn’t matter. And he could have white coat syndrome, it goes up when you go
see the doctor. And his O2 sat is 95%. When you see this, like, “Oh, yeah, he’s got
elevated blood pressure.” But that’s not for you. Like I said, it’s determined.
Physical Examination – this seems to be kind of repetitive, but this what the doctor
sees. Constitutional: Appears well nourished, well developed, alert, in no acute distress.
Eyes: Conjunctiva: Normal. Sclera: White. Pupils and Irises: Pupils equal, round and
reactive to light and accommodation bilaterally. Respiratory: Respiratory Effort: breathing
un-labored. Auscultation of Lungs: Normal breath sounds throughout.
Cardiovascular: Heart: Auscultation (he listens) of Heart: Regular rate and rhythm, no murmurs,
gallops or rubs. Peripheral Vascular System: Carotid Arteries: Normal pulses bilaterally,
no bruits present. (These are all types of sounds that they would hear).
Extremities: No cyanosis, clubbing or edema, normal capillary refill; distal hair distribution
normal. (When you get to be older, they talk about the hair on your extremities because
it indicates stuff). These are all stuff that if he was having
problems with his heart and it was getting exacerbated or moving into another disease
process, this would indicate that. Abdominal: Soft, nontender.
Assessment – is just another word for “this is my diagnosis.” Benign essential hypertension
(I have no idea why these are there) overall stable with satisfactory control. Hypercholesterolemia
(so there’s this cholesterol). That’s his diagnoses. What’s he going
to do about it? He’s going to order a lipid panel and a CMP. Medications – he’s going
to keep him on hydrochlorothiazide and pravastatin (cholesterol medication) and this is the generic
name for Toprol that he was taking. Disposition – he wants him to return to
the clinic in 6 months and he has electronically signed it. There’re all kinds of things
you have to know about the electronic signature. But we can now support by the medications
that he’s on that he’s benign essential hypertension and he’s got hypercholesterolemia,
which is pure cholesterol. So, when we go to code this, I10 is essential
(primary) hypertension. Now, if you are a coder, you would know that in ICD-9 essential
hypertension is 401.9, but benign hypertension is 401.0. And we have a diagnosis of benign
so we would use ICD-9, 401.0. But, there’s something interesting here
and I’m going to show you a document camera snapshot of the ICD-10 manual. But, first,
let’s talk about the pure hypercholesterolemia which is E78.0 because this is actually in
endocrine system; your cholesterol and all that stuff is all being done by the endocrine
system. Let’s look real quick, I10, so look you
got here Diseases of the Circulatory System just like in ICD-9, you have your range. It
starts with I10 and goes to I21.02. We’re in hypertensive diseases and it’s saying:
use additional code for these codes (I10-I15) to identify. And then it’s telling you pay
attention. If it’s stated that that guy smokes, you would have been able to use this
code with your hypertension. Now, is essential (primary) hypertension,
I10; but where’s the benign? And you look down here, it’s like, “Oh, my gosh! It’s
not there. Did they just get rid of benign?” But then, look right here, “Includes,”
it includes high blood pressure, hypertension, and look – benign. So, unlike ICD-9, I10
covers all of these other different types of hypertension, malignant was a different
code. Essential was 401.9, this was 401.0, malignant was I think 401.1 or 2, I can’t
remember, because malignant you didn’t code very much. But, anyway, they’re all included
in I10, so you only have to code one code that encompasses all of those codes that you
did before. Then, here we’ve got an “Excludes.”
If you have hypertension because of a complication in pregnancy, these are the codes you need
to go look at. If you have this type of hypertension, they’re telling you, “Yup! You’re in
the right section, you just need to move over, we’re going to jump to I60.” And it is
– I see someone saying, “But, I thought it was more specific.” It actually is more
specific because look down here, you’ve got hypertensive heart with heart failure,
hypertensive heart without heart failure. Now, you get into the hypertensive chronic
kidney diseases, it’s much more specific. Now, of course, your hypertension is not bilateral
so you have no laterality here. Boyd: You want to check the answers there
just to make sure that you didn’t say something backwards? I’m not sure what they were saying
when they said, “malignant equals 401.0.” Alicia: 401.0 is malignant HTN, 401.1 is benign.
Thank you, Nancy, you’re right. Yeah, 401.1 – is benign and 401.9 is essential and 401.0
is malignant. Very good, thanks Nancy. Yeah, that’s what I get for trying to do these
off the top of my head. I’ve been doing ICD-10 so long I’m forgetting ICD-9, these
ones that I’ve got memorized. But I can tell you that this is probably the very first
ICD-10 that you’ll memorize because you’ll use it a lot, hypertension is one of those
things you just do again and again and again. And it’s so easy to remember, I10. Good,
we’ve got really savvy people here tonight. Boyd: A good one from Beth, no coding out
of the mind index. Alicia: Oh, yeah, there you go. You get dinged
for that Beth if you code from the mind. [Laughs] Boyd: Beth just dinged you.
Alicia: She did. She dinged me good. Boyd: Everybody’s fair comments in the chat,
you got some great support here from people and they’re saying a lot of kudos to you
being a great teacher. Alicia: Oh, thanks.
Boyd: I’ve seen that from a lot of people tonight.
Alicia: Oh, good, good…Always double check those codes I’m throwing at you.