428.23 ( acute on chronic CHF ), 496(COPD), 599.0 (UTI), 041.49 (E.coli), 414.

00
(CAD), 786.05(SOB)
786.59(CP),465.9(URI), 038.9 and 995.90 (SIRS), 789.01(EUQ pain),
995.90 (sirs alone )
781.99(left sided weakness)
038.9, 995.92 (sev sepsis)
038.9, 995.92, 785.52 (septic shock)
131.01(trichomonus vaginitis )
864.00(tramatic acute liver injury)
573.8(for non tramatic)
uro sepsis (599.0 ) only code shd be given,
070.70 (hep c w out mention of h.coma, HCV)
536.8 (Dyspepsia)
V58.11 (chemotherapy)
491.21 (COPD exacer)
345.90(Unspecified epilepsy without mention of intractable epilepsy)
977.9 (polysubstance poisioning )
204.00(b cell ALL/All)
592.1 (calculas in uterus)
757.39 (porokeratosis)
558.9(colitis)
c diffuse colitis (008.45)
787.91 (Diarrhea)
284.19 (pancytopenia)
038.9,995.91 (Sepsis)
204.10(Chronic lymphocytic leukemia, CLL)
289.9 (cytopenia)
780.79 (generalized weakness )
789.59 (asciites)
LEUKOCYTOSIS (288.60)
END STAGE RENAL DISEASE(585.6)
cad(414.01)
v08(HIV +VE)
cytopenia(289.9)
279.50(GRAFT-VERSUS-HOST DISEASE)
238.75(MDS)
518.89(lung lesion)
failure of thive (783.41)
782.3 (LE edema)
428.0(CHF)
459.9 (cardio vascular unspec - this code be used for the senarios involving de
coloration and which involves (atriral) CVS.
Convulsive disorder NOS (780.39)
584.9(AKI)
280.9(Unspecified iron deficiency anemia)
401.9(HTN)
141.9 (tongue malignant neoplasm)
780.96 (pain genralized)
564.09 (drug induced constipation)
250.00(DM)
425.4(idiopathic cardiomyopathy)
428.23(acute on chronic heart failure)
200.70 (large cell lymphoma)
530.81(GERD)
LLE pain (lower or upper ext pain ( 729.5 )
789.30(Abd mass)
202.00(Nocular lymphoma)
564.00(constipation)
285.9(anemia unspec)
403.91(HTN on ESRD)
585.6(ESRD)
202.80(DLBCL)
562.11 (Acute diverticulitis)
244.9(HYPOTHYROIDISM)
365.9 (PERIPHERAL NEUROPATHY)
272.4(HYPERLIPIDEMIA)
300.00(anxiety)
790.6 (abnormal blood chemistry other)
285.9 (symptomatic anemia)
571.5 (cirrhosis of liver)
276.0(hypernatremia)
275.2 (HYPOMAGNESEMIA)
786.50(CP)
288.4(HEMOPHAGOCYTIC LYMPHOHISTOCYTOSIS)
200.50(CNS LYMPHOMA)
784.1 (throat pain)
787.01(N with vomiting)
578.9 (GI bleed)
266.2(b12 deficiency)
157.9 (pancreatic cancer)
322.9(meningitis)
790.29 (hyperglycemia)
714.0(RA)
555.9(crohn's )
567.22(ABD abscess )
560.9(SBO)
787.6 (Incontinence of feces)
153.9(colon ca)
787.20(dyphagia)
783.41(FTT failure to thrive)
251.2 (hypoglycemia)
348.89 (cerebral mass)
288.50(leukopenia)
041.04 (bactremia enterococal)
427.31 (A.fib)
le swelling (729.81)
787.3 (abd distension)
486(pneumonia)
789.5(ascites)
584.9(AKI)
285.9(anemia)
799.02(hypoxia)
285.9(anemia microcytic)
518.81(Acute res failure)
790.6(elevated troponin)
263.9(malnutrition)
719.42(arm pain)
244.9(HYPO THY)
728.88 (Rhabdomyolysis)
714.2 (Adult-onset Still's disease (AOSD)
202.00(FOLICULAR LYMPHOMA)
311 (depression)
780.97(AMS)
682.9 (cellulitis)
572.2(HE- Hepatic Encephalopathy )
276.1(hyponatremia)
571.5 (cirrhosis) for HCV cirrhosis code first 070.70 virus code then cirrhosis
code.
427.31(Afib)
578.1(melena)
790.99(elevated creatinine)
202.80(DLBCL)
V58.11 (encounter for chemotherapy)
276.7(hyperkalemia)
276.8(hypokalemia)
Upper respiratory infection (acute) (465.9)
338.18(post operative pain ) (post procedural pain)
242.9(hyperthyroidism)
203.00(multiple myeloma )
356.9(p.neuropathy
528.3(celluitis)
301.51 (munchausens syndrome )
820.8(hip fracture)
808.8 (pelvic fracture)
794.8(elevated LFt)
573.8(liver mass)
287.5 (thrombocyropenia)
chronic diastolic heart failure (428.32)
789.0(abd pain)
327.23(OSA)
141.9 (Malignant neoplasm of tongue)
155.0 (Hepatocellular carcinoma (HCC)
528.9 (swollen lower lip)
571.42 (AIH, Autoimmune hepatitis )
6282.2 (grion abscess ()
455.8 hemorrhoidal ulcer
cryptogenic cirrhosis (571.5)
dyspnea (786.09)
780.60(fever) for NTP FEVER add aditional code 288.00 as 1st code then use 780.6
0 or 780.61 check it. max for NTP FEVER (780.61)
705.82(HIDRADENITIS)
135 PULMONARY SARCOIDOSIS
453.40(DVT) check the extremity ( there are additional codes for the extremites.
)
DVT OF UPPER EXTREMITY VEIN (453.83)
lung transplant (V42.6)
284.09(fanconi anemia)
209.60(neuroendocrine carcinoma)
pulmonary embolisam (415.19)
706.1(acne)
300.00(anxiety)
276.7(hyperkalemia)
518.81 (respiratory failure )
511.9(pleural effusion)
786.2(cough)
162.9(NSCLC)
275.42(Hypercalcemia)
786.6(lung mass, mediastenal mass)
345.9 (seizures)
277.3 (Amyloidosis)
458.0(orthostasis)
070.30(HBV)
V42.0 (renal/kidney transplant)
599.70(hematuria)by
282.60 (sickle cell anemia)
783.0( anorexia)
414.01 (CAD)
280.9 (microcystic anemia may be)
590.80 (pyelonephritis)
285.9 (Normocytic anemia)
041.82(enterobacter)
281.1 (b12 deficiency)
790.7 (bacteremia)
AIH (571.42) (Autoimmune hepatitis )
790.4(transaminitis)
174.9 (breast CA)
279.50(Graft-versus-host disease, unspecified)
vein stenosis(459.2)
493.90 (asthma)
V42.7 (liver transplant)
715.9 (osteo arthritis )
298.9 (PSYCHOSIS UNSPECIFIED)
291.81 (ALCOHOL WITHDRAWAL, etoh )
781.94 (facial droop )
515 (Interstitial Lung Disease)
577.8(pancreatic insufficiency)
807.02 ( 2 rib fractures)
595.9 (cystitis)
719.4 (arthralgia)
351.0 (facial plasy)
205.00(AML) relapsed aml has a different code.
astrocytoma (191)
728.86 (Necrotizing fasciitis)
250.10 (DKA check 5th digit)
719.17 (HEMARTHROSIS ANKLE)
785.0(TRACHYCARDIA)
785.50(shock)
coagulopathy (286.9)
577.0(pancreatitis)80
578.0 (hematemesis)
782.4 (jaundice)
892.0 (foot wound)
790.4(Nonspecific elevation of levels of transaminase or lactic acid dehydrogena
se)
511.89 (hydropneumothorax)
478.4 (vocal cord polyps)
478.5 (Leukoplakia - of vocal cords)
784.42 (HOARSENESS)
alcohol dependence (303.9)
781.3 (atxia)
789.59 (ascites)
780.97 (ALTERED MENTAL STATUS)
V72.81 (Pre-operative cardiovascular examination)
INSOMNIA (780.52)
generalized pain (780.96)
agitation (307.9)
625.8 (ovarian mass)
446.4 (WEGENER'S GRANULOMATOSIS, (GPA))
578.0 (Hematemesis)
786.30 (Hemoptysis, )
796.2 (Elevated blood pressure )
434.91 (stroke, CVA, cerebral infraction)
416.8 (pulmonary hypertension)
282.62 (Sickle-cell crisis)
282.60 (Sickle-cell anemia )
959.9 (INJURY SITE UNSPECIFIED)
E888.9 (UNSPECIFIED FALL)
753.1 (Autosomal dominant polycystic kidney disease (ADPKD) )
567.23 (Spontaneous bacterial peritonitis (SBP))
255.41 (Adrenal insufficiency )
246.8 (thyroid mass)
784.2 (neck mass)
organisam code second then infection (dout ask any once once)
eX:-enterobacter bactremia =790.7(bactremia), enterobacter 041.85
px...............................
90935(HD)HEMODIALYSIS
31500 (INTUBATION ETT)
36620 (ARTERIAL LINE )
36556 (CENTRAL VENOUS CATHETHER)
CIRCUMCISION (54150)
49083 (PARACENTESIS)
32555 (ThORACENTESIS)
SUB,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ONCOLOGY .
MOSTLY NON BILLABLE CRNPS
CAN COUNT SYSTEM AS PROBS
should not code for social worker and pharm D..
in trma consulation select billing area as if tramatic 10194 if non tramatic 103
57
For plastic surgery SER:-sur, DIV:-plastic surgery, B Area :-10123, BA # 9047.
if IVR note and IVr px is on the same date dont code that service (mostly in sa
me day visti IVR speks about the px so should not codde that service.)
if on the same day first there is service then Px is done then we neeed to code
IVR ask to swapna or any other .
PSY
Delirium and atrivan can be taken as risk in PSY charts
-------------------------
IDMN: Missing comprehensive exam, hence downcoded Initial Visit to SV
IINF: Time based coding for DOS:----.
IINF: Two physicians billed the same day for DOS ----------
IDMN: Missing attending notes for date 06/29/2014 (missing discharge day managme
nt details)
IDMN: Missing detail history and exam, hence downcoded intial visit to SV,------
--------is involved
IDMN: Detail history, hence downcoded initial visit to 992..; resident is involv
ed.
IDMN: Missing Comprehensive history, hence downcoded initial visit to 99221; Res
ident is involved
IOTH: DOS considered as 07/15/2014 in page #25 of PN 1 to 5.
IDMN: EPF exam, hence downcoded initial Consult to 99233; resident is involved
ILNK: Attending linked to wrong resident hence considered attending note alone
IDOS: considering dos 10/17/2014 on page # 4 and page # 9 as 10/18/2014
If discharge page (not at all resident and att present ) is not present, then
use comment
IDDA: Discharge note missing-Chart abstracted
IOTH: Coded as per Chicano, Marge feedback "No additional notes. Please code a
vailable
notes in the chart and add comment to encounter" date on September 3.
ICCR: patient is intubated hence considering history as comprehensive.
Resident is involved.
Resident is not involved.
IINF: Nikin April CRNP, R09571
___________________________________________
EX:- diarrhea- c.diff = then code only for c.diff (then diarrhea is symtom in th
is)
766.21 (WEEKS)
767.19 (CAPUT)
041.02 (GBS+ve)
V05.3 (vacinnation)
757.33(mongolian spot)
774.6(FETAL/NEONATAL JAUNDICE UNSPECIFIED)
785.2 (Heart murmurs)
V50.2 (diagnosis for circum px)
hypoglycemia(775.6)
hypothermia(
trachypenia (
FEEDING PROBLEM (779.31
any res severe condition
21
NEW born guidlines
V30.--=Single liveborn
V31.0--=Twin birth, mate liveborn
V32.0--=Twin birth, mate stillborn
V33.0--=Twin birth, unspecified whether mate liveborn or stillborn
V34.0--=Other multiple birth (three or more), mates all liveborn
V35.0--=Other multiple birth (three or more), mates all stillborn
V36.0--=Other multiple birth (three or more), mates liveborn and stillborn
V37.0--=Other multiple birth (three or more), unspecified whether mates liveborn
or stillborn
seq in new born
===>deli-gbs-caput-weeks- other conditions like judi,,, etc..then vaccination-ci
rcum.
==> PDx should be delivery (check type of delivary SVD or c-section), then infec
tion code
==>if weeks is 40 or more than 40 then use code 766.21
==> check the document for any conditions such as CAPUT (head injury),
if CAPUT (767.19) is there then code ids as delivary+caput+infectin+weeks
==> mongolian spot, +ve murmur and trachypenia shd also be coded
==> d/c can be given based on PMD fallow up, discharge summary and by header of
the page.
==> CIRCUMCISION (54150) and icd V50.2. Add 25 modifier to e/m service on same
day.
==> seqencing:-delivary, condition, infection, weeks
part 2 ==> biling service PFC (but check regarding provider) should only given t
o certain providers (such as who come under spec (FAM- Family medicine) BENNETT
IAN, Teel joseph & mario Demarco.
==> No consults are coded for newborn charts except for Derm consults. Since th
e newborns are non Medicare, we are not assigning GC modifier.
==> if we get an NICU admit then check for the name of the BB or BG and then che
ck that name containg ms-word document in the folder of the same date, then open
the document.
access folder is located at ""\\hydlanfnp01\medicalcoding$\UPENN\Upenn IP__BPO M
C F037\UPENN IP Confidential\HUP\Team info ""
if the document is not found in the folder the check in EPIC.
after opening that document check for the DOL :- if intial it shd be DOL:-0, ag
e, delivary, weight, and active problems (code only active problems ( in active
probls also dont code all )not inactive probls) , cultures,
==>in problem list if there is Respiratory Distres or any res condition and in p
lan if it mentioned as RES:- RA then dont code any respiratory condition. if an
y res condition present in examination and mention as RA in plan we hav to code
res condition.

==>sequencing :- conditions (only some of them are documented) to code and casid
erd as risk are 1) maternal chorioamnionitis, (shd be coded only for admission,
dont code if it id in subsiq),
repiratory failure, NAS (779.5), hypoglycemic,and hemarrages 2)feeding ( feeding
shu be coded only if it is less than 90) 779.31 3) BCx code (V29.0)
then 4) weight, 5) weeks, 6) delivary.
if the conditions are three present then code the fourth code priority as weeks
code.
==> CPT codes for Intial visit critical neonate - 99468
==> CPT codes for Intial visit intensive neonate - 99477
------------------------------------------------------
Ecode is not required for 8 and 9 hundered series
If we give trama as a subsiquent , then we have to check in the Ed if any trama
IC has been done or not. (if the chart admit date is on 12 and trama is on 13th
as lokin lik sub siquent vist)
check in ED at the last but 1 page (screen shot given in "hpi word document") FE
E ABSTRACTION DATA.
and also check for the icds in in the progress notes at radialogy tests if not t
hen check for nay clue.
ICDS for unspec injury site:-959.9 and unspecified accident -E928.9
TRA billing SER- TRa provider, billing area -10194, 9059
________________________
Do not code for Speech pathology, Hyperbaric medicine, Radiation oncology,
Occupational therapy, Podiatry, social worker, outpatient MD notes, PMD and
LMD notes.
o No consults are coded for newborn charts except for Derm consults.
o Since the newborns are non Medicare, we are not assigning GC modifier.
take SCHUTTA MARK H as a default for diabetic when there isn o attending ...sam
e a palliative care
IN derm chart for calculating exam ( everything should be ful ) see att schedule
sheet for for pic