TUTORIAL:

How to Code an Inpatient Record

Welcome!

Assigning ICD-10-CM and ICD-10-PCS codes to diagnoses and procedures for inpatient records can be somewhat intimidating to
students at first. No fear! I am going to walk you through this entire process, page-by-page, so you learn how to assign codes to
diagnosis and procedures.

You will also see where the codes are entered on a UB-04 claim, which is submitted to third-party payers for processing, resulting in
reimbursement being provided to the hospital (for inpatient stays).

NOTE: Chapter 19 of your textbook contains content about the purpose of the UB-04, which you can review. You will also take the
MEDR 4214 (Insurance and Reimbursement Processing) course in future where you will learn how to complete the UB-04.

At the end of this tutorial, you will also view the results of entering ICD-10-CM and ICD-10-PCS codes in a Diagnosis Related Group
(DRG) grouper, which determines reimbursement provided to the hospital (for inpatient stays).

Remember! Go to http://www.irp.com, click on the Medicare DRG Calculator, and enter patient data and codes assigned to
determine the DRG for each IPCase. Notice that you must select a Y, N, U, W or 1 present on admission (POA) indicator from the
dropdown menu next to each ICD-9-CM diagnosis code entered.

All claims submitted for inpatient admissions to general acute care hospitals or other health care facilities are required to report the
present on admission (POA) indicator, which is assigned by the coder to the principal and secondary diagnoses and external cause
of injury code (E code) reported on the UB-04 or 837 institutional (electronic) claim.

o The coder reviews the patient record to determine whether a condition was present on admission or not.
o Issues related to inconsistent, missing, conflicting, or unclear documentation are resolved by the provider as a result of the
physical query process.

In this context, present on admission is defined as present at the time the order for inpatient admission occurs. Thus, conditions that
develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present
on admission upon admission of the patient as a hospital inpatient. CMS reporting options and definitions include the following:

o Y = Yes (present at the time of inpatient admission)

o N = No (not present at the time of inpatient admission)
o U = Unknown (documentation is insufficient to determine if the condition was present at the time of inpatient admission)
o W = Clinically undetermined (provider is unable to clinically determine whether the condition was present at the time of
inpatient admission or not)
o 1 = Unreported/not used (exempt from POA reporting; this code is equivalent to a blank on the UB-04; however, blanks are
undesirable when submitting these data electronically.)

NOTE: Before entering ICD-10-CM and ICD-10-PCS codes in the Submission assignment for each IPCase, be sure that you have
determined the diagnosis related group (DRG) number. An example of a DRG display is included at the end of this tutorial, and each
element of the DRGs results is explained.
Before Assigning ICD-10-CM and ICD-10-PCS Codes

Before coding inpatient cases, be sure that you understand how to apply each of the following terms and definitions (that are explained
on each subsequent page of this tutorial):

o Admission diagnosis
o Principal diagnosis
o Secondary diagnosis(es)
 Comorbidity
 Complication
o Principal procedure
o Secondary procedure(s)

As you click through this tutorial, you will notice that ...

o each type of diagnosis and procedure is defined.

o examples of each type of diagnosis and procedure are provided.
o an image of an inpatient record face sheet highlights the location of each type of diagnosis and procedure.
o images of additional reports from an inpatient record highlight documentation that coders review to assign the most accurate
and complete:
o
 diagnosis code(s).
 procedure code(s).

NOTE: Diagnoses are assigned ICD-10-CM disease codes. Procedures are assigned ICD-10-PCS procedure codes.
Admitting Diagnosis

The admission diagnosis (or admitting diagnosis) is the initial diagnosis documented by the:

o patient's primary care physician who determined that inpatient care was necessary for:
o
 treatment of a condition diagnosed in the office today (e.g., acute exacerbation of chronic asthma).
 elective surgery, which has already been scheduled (e.g., elective tubal ligation).

NOTE: The patient's primary care physician (who is responsible for admitting the patient to the hospital) or his office staff contacts
the facility's patient registration department to provide the admitting diagnosis. A physician's office staff includes medical assistants,
nurses, physician assistants, nurse practitioners, and so on, any one of whom may be instructed by the primary care physician to
communicate the admitting diagnosis to the hospital's patient registration department. Next, the patient registration clerk (who is
employed in the hospital's patient registration department) keyboards the admitting diagnosis into admission/discharge/transfer (ADT)
software. That admission diagnosis (along with all other patient information) appears on the face sheet of the inpatient record.

o facility's emergency department (ED) physician who provided ED treatment and determined that inpatient care was necessary
(e.g., trauma, heart attack, stroke, and so on).

NOTE: The ED physician documents the admitting diagnosis in the ED record, and the patient registration clerk keyboards the
admitting diagnosis into admission/discharge/transfer (ADT) software. That admission diagnosis (along with all other patient
information) appears on the face sheet of the inpatient record.

o ambulatory surgery unit (ASU) surgeon who performed outpatient surgery and determined that inpatient care was necessary
(e.g., laparoscopic cholecystectomy was converted to open cholecystectomy, requiring postoperative overnight monitoring).

NOTE: The ASU surgeon documents the admitting diagnosis in the ASU record, and the patient registration clerk keyboards the
admitting diagnosis into the admission/discharge/transfer (ADT) software. That admission diagnosis (along with all other patient
information) appears on the face sheet of the inpatient record.

When the patient is discharged from the hospital, coders assign an ICD-10-CM code to the admission diagnosis (or admitting
diagnosis). The admission diagnosis (or admitting diagnosis) is always:

o located on the inpatient face sheet.

o assigned just one ICD-10-CM code.

NOTE: Assign just one admission diagnosis (or admitting diagnosis) code even if more than one admission diagnosis is documented
on the face sheet. Assign a code to the first admission diagnosis (or admitting diagnosis) documented on the inpatient face sheet.

NOTE: Although the admission diagnosis (or admitting diagnosis) is also documented elsewhere in the patient record (e.g., history &
physical examination, admitting progress note, ED record, ASU record), the code is assigned to the admission diagnosis (or admitting
diagnosis) that is located on the inpatient face sheet.

NOTE: In "real life," the admission diagnosis (or admitting diagnosis) documented on the inpatient face sheet may differ from the
admission diagnosis (or admitting diagnosis) that is documented by the attending physician in the history & physical examination or
admitting progress note. When you notice different admitting diagnoses documented in several places on the patient record:

o Assign a code to the first admission diagnosis (or admitting diagnosis) documented on the inpatient face sheet.
o Do not generate a physician query (because the admitting diagnosis does not impact reimbursement).

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Principal Diagnosis

The principal diagnosis is that condition, established after study, which resulted in the patient’s admission to the hospital.

For the purpose coding IPCases in this course, the principal diagnosis is entered on the face sheet. You should review the patient
record to verify the accuracy of that principal diagnosis by reading the discharge summary, operative report and pathology report (if
the patient had surgery), progress notes, and other pertinent documents. If you wonder whether the principal diagnosis is correct on the
IPCase that you are coding, post a query in the discussion board so your instructor can respond.

In "real life," the principal diagnosis may or may not be clearly documented on the face sheet. Sometimes the principal diagnosis is
documented on the discharge summary (or clinical resume). Even if the principal diagnosis is documented by the attending physician,
you still have to review documents in the patient record to verify it.

Sometimes more than one definitive diagnosis is documented for the inpatient admission. However, there is always just one principal
diagnosis code reported. The other definitive diagnoses are coded as secondary diagnoses (e.g., comorbidities, complications, trauma,
and so on).

And, sometimes the attending physician (and other physicians who consult on the case) cannot figure out what is wrong with the
patient, one or more qualified diagnoses will be documented. A qualified diagnosis is a working diagnosis that has not yet been
proven. When a physician documents "rule out," "probable," or "possible," that's a qualified diagnosis. When assigning code(s) to
qualified diagnoses, you can also assign secondary diagnosis codes to signs and symptoms documented by the attending physician.

EXAMPLE: "Rule out myocardial infarction" is documented as the principal diagnosis for a patient who has severe chest pain.
However, even though cardiac tests are negative, the physician still suspects that the patient is having a heart attack. And - this is
important - you should also code the signs and symptoms associated with the qualified diagnosis. So, for "rule out myocardial
infarction," you also assign codes for chest pain, shortness of breath, and so on.

If this does not make sense to you, post a question about it in the discussion board so I can explain in more detail. Better yet, review
the information about "qualified diagnosis" in your textbook and then ask questions. (HINT: Look up "qualified diagnosis" in the
index of your textbook if you cannot easily find it in the chapter.)

NOTE: When assigning codes to outpatient encounters (e.g., physician office visits, ED visits, outpatient visits), when qualified
diagnoses are documented, assign codes to the signs and symptoms only. Do not assign codes to any of the qualified diagnoses. For
example, when "rule out myocardial infarction" is documented on an ED record, assign codes to the chest pain, shortness of breath,
and so on. Do not assign a code to "rule out myocardial infarction."

But, back to the principal diagnosis, which is that condition established after study, which resulted in the patient’s admission to
the hospital. Memorize this! And, be sure you know how to spell the principal in "principal diagnosis!" (Yes, you will be tested on
this.)

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Secondary Diagnosis

Secondary Diagnosis(es) – include comorbidities, complications, and other diagnoses that are documented by the attending physician
on the inpatient face sheet or discharge summary.

o Review inpatient record reports to locate secondary diagnoses that are not documented on the face sheet or discharge
summary.
o
 H&PE documents chronic conditions and personal history (of) and family history (of) conditions, all of which are
assigned codes.
 Ancillary reports (e.g., lab data, X-ray reports, and so on) document type of bacteria that cause infection (lab data),
type of fracture (X-ray report), location of myocardial infarction (electrocardiogram report), and so on.
o If you have a question about whether a code should be assigned to a secondary diagnosis, generate a physician query to
obtain clarification (and to have the attending physician amend the list of secondary diagnoses). (In this course, post the
query in the Discussion Board so your instructor can respond.)

A comorbidity is any condition that co-exists during the relevant episode of care and affects the treatment provided to the patient.

A complication is any condition that arises during the relevant episode of care and affects treatment provided to the patient.

Assign codes to secondary diagnoses (or generate a physician query about a secondary diagnosis) if the diagnoses are managed by one
or more of the following methods:

o clinical evaluation of the condition (e.g., ancillary tests such as radiology, laboratory, and so on)
o therapeutic treatment of the condition (e.g., medication, surgery, therapy such as physical or respiratory, and so on)
o diagnostic procedures performed to evaluate the condition (e.g., exploratory surgery, -oscopies, biopsies, and so on)
o extended length of hospital stay (e.g., patient's length of stay was increased by days, weeks or months due to medical
management of chronic conditions or treatment of complications that developed after admission)
o increased nursing care or monitoring (e.g., chronic condition such as hypertension that requires nursing staff to monitor
blood pressure; chronic condition such as diabetes that requires nursing staff to provide patient teaching; and so on)

Secondary diagnoses are documented by physicians on the:

o Facesheet
o Discharge summary
o Discharge progress note
o Consultation report
o Ancillary reports (e.g., lab data, X-ray reports, and so on)
o Anesthesia record
o Operative report
o Pathology report
o Etc.

When assigning ICD-9-CM codes to secondary diagnoses, review the patient record to locate supporting documentation that allows
you to assign the most specific code possible.

EXAMPLE: The face sheet documents “urinary tract infection” as a secondary diagnosis. Upon review of laboratory test results, the
coder determines that E. coli bacteria is the cause of the urinary tract infection. Thus, the coder assigns a code for the urinary tract
infection (599.0) and another code for the E. coli bacteria (041.4).

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Principal Procedure

The following instructions should be applied in the selection of principal procedure, and they provide clarification regarding the
importance of the relation to the principal diagnosis when more than one procedure is performed:

1. When the procedure is performed for definitive treatment of both the principal diagnosis and secondary diagnosis, sequence the
procedure performed for definitive treatment most related to principal diagnosis as the principal procedure.

2. When the procedure is performed for definitive treatment and diagnostic procedures are performed for both the principal
diagnosis and secondary diagnosis, sequence the procedure performed for definitive treatment most related to principal diagnosis
as the principal procedure.

3. When a diagnostic procedure was performed for the principal diagnosis, and a procedure is performed for definitive treatment of a
secondary diagnosis, sequence the diagnostic procedure as the principal procedure because the procedure most related to the
principal diagnosis takes precedence.

4. When no procedures performed were related to the principal diagnosis, but procedures were performed for definitive treatment or
diagnostic procedures were performed for the secondary diagnosis, sequence the procedure performed for definitive treatment of
the secondary diagnosis as the principal procedure.

Thus, the principal procedure is that procedure performed for therapeutic rather than diagnostic purposes, or that procedure performed
which is most closely related to the principal diagnosis, or that procedure performed to treat a complication.

NOTE: Remember that you select just one principal procedure for each inpatient record. The above definition helps to remind you to
select the therapeutic procedure as the principal procedure. However, if a therapeutic procedure was not performed during the
inpatient stay, then you can assign a code to a diagnostic procedure as the principal procedure. (Also, remember that you will assign
codes to secondary procedures, which can be either therapeutic or diagnostic. Assigning codes to secondary procedures is discussed on
the next page of this tutorial.)

NOTE: Procedures performed for diagnostic purposes (e.g., biopsy, colonoscopy) are assigned codes for inpatient admissions. Do not
confuse diagnostic procedures with ancillary tests (e.g., lab tests, x-rays). Ancillary tests are not coded for inpatient admissions.

Procedures performed for therapeutic purposes are considered surgery, and they are usually performed in the hospital operating room,
and the patient receives anesthesia. Therapeutic procedures include appendectomy, cholecystectomy, coronary artery bypass graft,
herniorrhaphy, and so on.

Procedures performed for diagnostic purposes are also considered surgery, and they might be performed in the hospital operating
room (e.g., laparoscopy) or in the patient's room (e.g., tissue biopsy). Diagnosis procedures include biopsy, -oscopy, exploratory
surgery, and so on. All such procedures performed for diagnostic purposes are assigned codes.

Ancillary tests (e.g., lab tests, x-rays, and so on) are not considered secondary procedures, which means ICD-10-PCS codes are also
not assigned to them for inpatient cases.

A procedure closely related to the principal diagnosis includes cholecystectomy for principal diagnosis of cholecystitis when patient
also undergoes hiatal hernia repair (for secondary diagnosis of hiatal hernia). Both procedures are therapeutic in nature, but the
cholecystectomy was performed to treat the principal diagnosis of cholecystitis.

Procedure performed to treat a complication: Principal diagnosis is myocardial infarction. Patient fell out of bed during
hospitalization and sustained fractured left femur (head), which is a complication. Patient undergoes cardiac catheterization (related to
myocardial infarction) and open reduction with internal fixation (to treat fractured left femur). Principal procedure is open reduction
with internal fixation (ORIF) because it was performed to treat the complication. The cardiac catheterization is a diagnostic procedure,
and is not sequenced first in this case. [However, if the patient had undergone coronary artery bypass graft (CABG) in addition to
cardiac catheterization and ORIF, the CABG would be sequenced as the principal procedure.]

NOTE: Patients admitted as an inpatient to the hospital might not have undergone therapeutic procedures or, in fact, any surgical
procedures at all. All inpatients undergo ancillary testing, which may include laboratory, x-rays, ultrasounds, CT scans, and so on.
However, ancillary tests are not assigned ICD-10-PCS codes when performed during an inpatient admission.

NOTE: Medicare patient records do not require identification of the principal procedure. Implementation of MS-DRGs by CMS
resulted in reprogramming of grouper software to allow coders to enter procedure codes in order of date the procedure was performed;
the grouper selects the procedure codes that impact MS-DRG assignment and sequences procedure codes in proper order. However,
other DRG groupers do require identification of the principal procedure; therefore, to develop the skill of identifying the principal
procedure, you will select the principal procedure when assigning procedure codes to inpatient records in this course.

EXAMPLE: An inpatient diagnosed with a myocardial infarction underwent a cardiac catheterization and aortocoronary bypass
surgery during the same admission. The aortocoronary bypass surgery is the principal procedure because it was performed for
therapeutic rather than diagnostic purposes. The cardiac catheterization is a diagnostic procedure, which means in this case it is
sequenced as a secondary procedure. (Students are encouraged to review the definitions of these procedures located in their medical
terminology and pathophysiology textbooks, and in their medical dictionary.)

EXAMPLE: An inpatient diagnosed with chronic obstructive pulmonary disease (COPD) underwent a chest x-ray and a lung volume
test performed by a respiratory therapist. The patient's COPD was successfully treated with medication. Both the chest x-ray and lung
volume test are considered ancillary tests, which means there are no procedures to which codes are assigned for this inpatient
admission; thus, there is no principal procedure.

EXAMPLE: An inpatient diagnosed with heart failure fell out of bed during her stay and sustained a fractured hip. The patient
underwent EKG, chest x-ray, administration of medication, and open reduction internal fixation (ORIF) surgery to treat the fractured
hip. The principal procedure is the ORIF. The EKG and chest x-ray are ancillary tests, which are not assigned ICD-9-CM codes. The
administration of medication also is not coded because it is a nursing care responsibility.

EXAMPLE: The inpatient was diagnosed with an open fracture of the right humerus, closed fracture of the left tibia. The patient
underwent x-rays of the right humerus and left tibia. Surgery performed during the inpatient stay included open reduction with internal
fixation (ORIF) of the fractured right humerus with casting and closed reduction of the left tibia with casting. The principal diagnosis
is "open fracture of the right humerus" because of the two traumatic conditions the open fracture is considered more severe. Thus, the
principal procedure is the ORIF of the fractured right humerus. The secondary procedure is the reduction of the left tibia with casting.
(Do not assign a separate code to the casting of the humerus or the tibia; casting is considered part of the ORIF procedure and the
closed reduction, respectively.)

NOTE: The inpatient face sheet below does not include documentation of a principal procedure. However, the patient might still have
undergone a procedure that should be coded. Be sure to review the patient record to determine whether a principal procedure and
additional procedures were performed (and documented elsewhere in the patient record).

Read the progress notes to locate procedures that were performed in the patient's room (e.g., percutaneous biopsy). For the patient's
comfort and care, procedures that do not require the administration of general anesthesia or are non-invasive can be performed in the
patient's room.

Locate and read operative reports, which document procedures that require the administration of anesthesia or are invasive. (In "real
life," an operative report might have been dictated and transcribed, but not yet filed in the record. Thus, you would locate the stack of
"loose filing" to find the operative report and file it in the record so it can be used to assign procedure codes.)

If you determine that progress notes do not document procedures or you do not locate an operative report, it is likely that surgery was
not performed on the patient. Therefore, procedure codes are not assigned.
Secondary Procedures

Secondary procedure(s) are additional procedure(s) performed for therapeutic or diagnostic purposes.

NOTE: Procedures performed for diagnostic purposes (e.g., biopsy, colonoscopy) are assigned codes for inpatient admissions. Do not
confuse diagnostic procedures with ancillary tests (e.g., lab tests, x-rays). Ancillary tests are not coded for inpatient admissions.

Procedures performed for therapeutic purposes are considered surgery, and they are usually performed in the hospital operating room,
and the patient receives anesthesia. Therapeutic procedures include appendectomy, cholecystectomy, coronary artery bypass graft,
herniorrhaphy, and so on.

Procedures performed for diagnostic purposes are also considered surgery, and they might be performed in the hospital operating
room (e.g., laparoscopy) or in the patient's room (e.g., tissue biopsy). Diagnostic procedures include biopsy, -oscopy, exploratory
surgery, and so on. All such procedures performed for diagnostic purposes are assigned codes.

Ancillary tests (e.g., lab tests, x-rays, and so on) are not considered secondary procedures, which means ICD-9-CM codes are also not
assigned to them for inpatient cases.

NOTE: Patients admitted as an inpatient to the hospital might not have undergone therapeutic procedures or, in fact, any surgical
procedures at all. All inpatients undergo ancillary testing, which may include laboratory, x-rays, ultrasounds, CT scans, and so on.
However, ancillary tests are not assigned ICD-10-PCS codes when performed during an inpatient admission.

NOTE: The inpatient face sheet below does not include documentation of secondary procedures. However, the patient might still have
undergone a procedure that should be coded. Be sure to review the patient record to determine whether secondary procedures were
performed (and documented elsewhere in the patient record).

Read the progress notes to locate procedures that were performed in the patient's room (e.g., percutaneous biopsy). For the patient's
comfort and care, procedures that do not require the administration of general anesthesia or are non-invasive can be performed in the
patient's room.

Locate and read operative reports, which document procedures that require the administration of anesthesia or are invasive. (In "real
life," an operative report might have been dictated and transcribed, but not yet filed in the record. Thus, in "real life," you would
thumb through "loose filing" to locate the operative report and file it in the record so it can be used to assign procedure codes.) If you
do not locate progress notes that document procedures or an operative report, it is likely that surgery was not performed on the patient.
Therefore, procedure codes are not assigned.
Consent to Admission

The consent to admission is not reviewed for coding purposes. This means that coders can skip over this report.

The consent to admission is generated by the patient registration department (or admitting department) during registration of the
patient for inpatient admission to the hospital.

The health information department's analysis clerk reviews the completed consent to admission as part of the discharged patient record
analysis procedure.

o If the analysis clerk notices that an consent to admission is incomplete, s/he brings it to the attention of her supervisor.
o The supervisor then communicates with the patient registration department manager so that clerks receive in-service
education about the proper completion of an consent to admission.

NOTE: It's too late for an consent to admission to be completed once the patient record is being reviewed as part of the health
information department's discharged patient record analysis process. The form has to be completed as part of the patient registration
inpatient admission process.
Advance Directive

The advance directive is not reviewed for coding purposes, which means that coders can skip over this report.

The advance directive is generated by the patient registration department (or admitting department) during registration of the patient
for inpatient admission to the hospital.

The health information department's analysis clerk reviews the completed advance directive as part of the discharged patient record
analysis procedure.

o If the analysis clerk notices that an advance directive is incomplete, s/he brings it to the attention of her supervisor.
o The supervisor then communicates with the patient registration department manager so that clerks receive in-service
education about the proper completion of an advance directive.

NOTE: It's too late for an advance directive to be completed once the patient record is being reviewed as part of the health
information department's discharged patient record analysis process. The form has to be completed as part of the patient registration
inpatient admission process.
Discharge Summary

The discharge summary is crucial to complete coding of diagnoses and procedures on any inpatient records. Quite often, even though
the attending physician documents diagnoses and procedures on the face sheet, the discharge summary contains additional information
that can be used to assign the most specific code to each diagnosis and procedure.

NOTE: In "real life" if the coder uses the discharge summary to assign more specific codes to diagnoses and procedures documented
on the face sheet, the coder does not generate a physician query. Likewise, for the purposes of this coding assignment, students will
use the discharge summary diagnoses to assign codes to diagnoses and procedures. Generate a physician query in the Discussion
Board about any condition(s) or procedure(s) if you are not sure whether you are to assign a code; your instructor will reply to clarify
whether a code is to be assigned or not.

Notice on the discharge summary report, below, that the admission diagnosis is documented in addition to the final diagnosis (which is
the principal diagnosis in this case). Do not assign a code to the admission diagnosis on the discharge summary because you already
assigned a code to the admitting diagnosis located on the face sheet.

The discharge summary summarizes the patient's hospital course, documenting diagnostic test results, treatment administered
(including surgery, if performed), discharge status, and follow-up instructions.

Keep in mind that the discharge summary serves more than one purpose. In addition to documenting diagnoses and procedures
performed during the inpatient stay, the discharge summary provides an overview about the entire inpatient stay. The latter is very
helpful when the patient's care is transferred to another provider.
History & Physical Examination

The history & physical examination is reviewed to learn more about why the patient was admitted to the hospital and to get an idea of
the initial diagnostic and treatment plans.

o Diagnoses documented in the history & physical examination report are tentative, and they are almost never coded as
discharge diagnoses.
o An exception would be "personal history of" or "family history of" codes, which are assigned for the purpose of data capture
for research and education.
o Another exception is chronic conditions (e.g., hypertension, chronic asthma, diabetes mellitus, COPD, and so on) for which
the patient requires medically management during the inpatient stay (e.g., diagnostic tests, administration of medication by
nursing staff, and so on).

In the history & physical examination below, you will notice that the patient's brother has been diagnosed with epilepsy. You will also
notice that the patient has a history of smoking cigarettes. Assigning codes to family history of and personal history of conditions is
permitted because they do not impact the DRG assignment (or increase the reimbursement rate).

EXAMPLE―FAMILY HISTORY OF: The patient receives inpatient treatment for acute bronchitis, and upon review of the patient
record the coder notices that there is a family history of lung cancer. Because both conditions are associated with the respiratory
system, assigning a code to the family history of lung cancer is appropriate (in addition to a code for acute bronchitis, which is
sequenced as the principal diagnosis).

EXAMPLE―PERSONAL HISTORY OF: The patient undergoes inpatient treatment for cerebral aneurysm, and upon review of the
patient record the coder notices that the patient has a personal history of traumatic brain injury because the patient was in a vehicle
accident 10 years ago and sustained a fractured skull, concussion, and brain hemorrhage. Because both conditions are associated with
the brain, assigning a code to the personal history of traumatic brain injury is appropriate (in addition to a code for cerebral aneurysm,
which is sequenced as the principal diagnosis).

NOTE: Students and new coders often struggle with the decision whether or not to assign codes to family history of and past history
of conditions. The good news is that even if you mistakenly assign family history of and personal history of codes based on
documentation in the patient record, the codes do not impact the reimbursement to the hospital. That means such codes are unlikely to
be "counted against" the coder or the hospital as coding errors or fraud/abuse. To be sure, however, when on the job query your coding
mentor or supervisor.

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Progress Notes

Progress notes contain statements related to the course of the patient’s illness, response to treatment, and status at discharge. They
also facilitate health care team members’ communication because progress notes provide a chronological picture and analysis of the
patient’s clinical course — they document continuity of care, which is crucial to quality care. As a minimum, progress notes should
include an admission note, follow-up notes, and a discharge note. The frequency of documenting progress notes is based on the
patient’s condition (e.g., once per day to three or more times per day).

Coders review progress notes to locate:

o documentation that clarifies a final diagnosis documented on the face sheet and/or discharge summary, which could result in
the assignment of a more specific code number.

EXAMPLE: The principal diagnosis documented on the face sheet states Cataract. Review of progress notes indicates
that the right eye contains the cataract. Depending on HIM policy, the coder would either use this information to assign
the ICD-10-CM code or generate a physician query to allow the physician to document laterality (right or left) as part
of the principal diagnosis on the face sheet.

NOTE: ICD-10-CM classifies the laterality of paired organs (e.g., eyes, ears, breasts, fallopian tubes, kidneys, and so
on). Codes for each organ as well as unspecified laterality also exist. An unspecified code is never be reported because
a review of the record will reveal which side is impacted.

o any procedures that were performed in the patient's room (e.g., biopsy).

NOTE: Ancillary tests (e.g., EKGs, lab tests, x-rays, and so on) are not coded as procedures for inpatient cases.

NOTE: When documentation of procedures performed in the patient's room are located in progress notes, depending
on HIM policy, the coder either assigns a procedure code or generates a physician query to ask the doctor to document
complete procedure(s) on the face sheet (referring to the progress note).

o documentation that results in the assignment of a more specific code. Depending on HIM policy, the coder either assigns the
specific code or generates a physician query that directs the physician to the progress note where documentation was located
so s/he can review it, and allows the physician to document a more complete diagnosis on the face sheet if appropriate.

EXAMPLE: Upon review of the face sheet, the coder notices a final diagnosis of acute appendicitis. Upon review of
the progress notes, the coder notices documentation of acute appendicitis with perforation. Thus, the coder either
assigns the more specific ICD code or generates a physician query to determine whether the physician should
document with perforation as part of the acute appendix final diagnosis located on the face sheet.

NOTE: For the purpose of the IPCases coding assignment, students should post queries in the Discussion Board to receive
clarification from their instructor. Be sure to post queries using proper sentence structure, grammar, and punctuation. And, copy/paste
or keyboard the pertinent content from the progress notes so the instructor can reply.

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Doctors Orders

Doctors orders (or physicians orders) direct the diagnostic and therapeutic patient care activities (e.g., medications and dosages,
frequency of dressing changes, and so on). They should be:

o Clear and complete

o Legible, if handwritten
o Dated and timed
o Authenticated by the responsible physician

NOTE: Think of doctors orders (or physician orders) as prescriptions for care while the patient is an inpatient. When a patient visits
the physician in the office, the doctor often “prescribes” a medication or lab test. In the hospital, the physician documents numerous
such “prescriptions” as physician orders.

NOTE: Coders do not review doctors orders (or physician orders) during the assignment of codes to inpatient diagnosis or
procedures.

NOTE: When completing the IPCases assignment, students will not review doctors orders (or physician orders) during the assignment
of codes to inpatient diagnosis or procedures.
Laboratory Data

Laboratory data (or clinical laboratory reports) document the name, date and time of lab test, results, time specimen was logged
into the lab, time the results were determined, reference section (that contains normal ranges for lab values), and initials of the
laboratory technician. Examples include:

o Blood chemistry (e.g., blood glucose level, WBC, CBC, urinalysis, culture and sensitivity)
o Therapeutic drug assay (e.g., drug level in blood)
o Blood gases (e.g., oxygen saturation)
o Cardiac enzymes
o Blood types
o Blood factor (Rh)
o Genetic testing

NOTE: Coders do not assign ICD-10-PCS codes to laboratory data (or clinical laboratory reports), which are considered ancillary
tests (e.g., EKGs, lab reports, X-rays). However, coders do review laboratory data when assigning ICD-10-CM codes to inpatient
diagnoses. The coder uses data from laboratory reports to assign a more specific code number. If the coder is unsure about assigning
the more specific code s/he generates a physician query.

EXAMPLE: Upon review of the face sheet, the coder notices a final diagnosis of urinary tract infection. Upon review of laboratory
data, the coder notices documentation of urinary culture positive for streptococcus bacteria. Thus, the coder assigns a code for
streptococcus as an additional code.

NOTE: For the purpose of the IPCases coding assignment, students should post queries in the Discussion Board to receive
clarification from their instructor. Be sure to post queries using proper sentence structure, grammar, and punctuation. And, copy/paste
or keyboard the pertinent content from the laboratory data so the instructor can reply.
Laboratory Data (continued)

This is a continuation of laboratory data documented in IPCase001. Refer to the previous page for information about interpreting
laboratory data for the purposes of ICD-10-CM/PCS coding.

In the laboratory data report below, the patient's blood was cultured and although no bacteria was noted at 24 hours, the final report
revealed strep viridans bacteria that was resistant to two medications but susceptible to eight other medications.

Thus, upon review of this laboratory data by the attending physician, if a physician order for Cephalothin or Penicillin G had been
documented (and either medication administered to the patient), the physician would write a new order to discontinue the resistant
medication. The physician would also document a new order for a medication to which the bacteria is susceptible, selecting one of the
eight medications that are preceded by an S on the laboratory data report.
Laboratory Data (continued)

This is a continuation of laboratory data documented in IPCase001. Refer to the first page about Laboratory Data for information
about interpreting laboratory data for the purposes of ICD-10-CM/PCS coding.

In the laboratory data report below, the patient's blood was cultured and the 1st preliminary report showed no bacteria was noted at 24
hours, and the 2nd preliminary report showed no growth on 24 hour subculture.

This could be a false positive, which means that the laboratory test may have been improperly conducted or the laboratory equipment
malfunctioned.
Laboratory Data (continued)

This is a continuation of laboratory data documented in IPCase001. Refer to the first page about Laboratory Data for information
about interpreting laboratory data for the purposes of ICD-10-CM/PCS coding.

In the laboratory data report below, the patient's blood was tested for chemistry profile and revealed both normal and abnormal results.
The abnormal results are circled on the laboratory data report, and the attending physician would review the results and determine an
appropriate treatment plan (e.g., writing physician orders to treatment elevated serum glutamic oxalocetic transaminase and elevated
uric acid).
Laboratory Data (continued)

This is a continuation of laboratory data documented in IPCase001. Refer to the first page for information about interpreting
laboratory data for the purposes of ICD-10-CM/PCS coding.

In the laboratory data report below, the patient's urine was cultured, and the smear revealed 1+ white blood cells, 4+ gram negative
rods, and the clean catch culture revealed greater than 100,000 Escherichia coli bacteria. The report also revealed that the bacteria that
was resistant to five medications but susceptible to seven other medications.

Thus, upon review of this laboratory data by the attending physician, if a physician order for one of the resistant medications been
documented (and any of the medications were administered to the patient), the physician would write a new order to discontinue the
resistant medication. The physician would also document a new order for a medication to which the bacteria is susceptible, selecting
one of the seven medications that are preceded by an S on the laboratory data report.

Note that this urine culture is dated 4/28/YYYY, while the blood culture laboratory data report (on a previous page) was dated
4/29/YYYY. With these urine culture laboratory data results, the attending physician may have documented a physician order for the
blood culture to determine if the bacteria had spread to the blood (and, it had).
Laboratory Data (continued)

This is a continuation of laboratory data documented in IPCase001. Refer to the previous page for information about interpreting
laboratory data for the purposes of ICD-10-CM/PCS coding.

In the laboratory data report below, the patient's complete blood count (CBC) reveals an abnormal white blood cell count. That
abnormal result is circled on the laboratory data report. The attending physician would review the results and determine an appropriate
treatment plan, which in this case involved writing physician orders for blood culture laboratory testing (that revealed bacteria and
resulted in the administration of appropriate medication).
Radiology Report

Radiology reports (or X-ray reports) document the name and date of x-ray, reason for x-ray, results, conclusion, and signature of the
radiologist. Examples include:

o Chest x-ray
o Fluoroscopy
o Intravenous programed
o Mammogram
o Other x-rays (e.g., bones)
o Scans
o Ultrasound
Electrocardiogram

An electrocardiogram (abbreviated as ECG or EKG) reports document the date, time, results, and signature of the interpreting
physician.
Graphic Chart

Nursing staff generate a graphic chart to document the patient's:

o vital signs (blood pressure, pulse, respirations, temperature, weight)

o diet and appetite
o bathing
o fluid intake (oral fluids, IV fluids, blood)
o fluid output (urine, stool, emesis, nasogastric)

The graphic chart is not reviewed for the purpose of assigning codes.
Graphic Chart (continued)

This is a continuation of the graphic chart documented in IPCase001. Refer to the previous page for information about the graphic
chart.
Medication Administration Record (MAR)

The medication administration record (MAR) documents medications administered by nurses along with date and time of
administration, name of drug, dosage, route of administration (e.g., orally, topically, by injection, or infusion), and initials of nurse
administering medication. Any patient reactions to drugs administrated are documented in nurses notes.

The coder reviews the MAR to determine if medications are administered for which no diagnosis was documented on the face sheet or
discharge summary.

EXAMPLE: The patient is administered insulin during an inpatient admission; however, there is no diagnosis of diabetes mellitus
documented on the face sheet or discharge summary. The coder should generate a physician query to ask the attending physician the
reason for administration of insulin.
Medication Administration Record (MAR) (continued)

This is a continuation of the medication administration record (MAR) documented in IPCase001. Refer to the previous page for
information about the MAR.
Intravenous (IV) Therapy Record

Intravenous (IV) therapy records provide consistent and accurate documentation for IV catheter insertion, monitoring of insertion
sites, and dressing changes.

NOTE: IV therapy records can also serve as a system for charging and retrieving statistical data about infection and phlebitis rates for
infection control and quality management purposes.

The coder does not use the IV therapy record when assigning codes.
Patient Property Report

The patient property report document items that patients bring with them to the hospital.

The coder does not use the patient property report when assigning codes.
Nurses Notes

The nurses notes contain documentation about daily observations about patients, including an initial history of the patient, patient’s
reactions to treatments, and treatments rendered.

The coder does not use the nurses notes when assigning codes.
Nurses Notes (continued)

This is a continuation of the nurses notes documented in IPCase001. Refer to the previous page for information about the nurses
notes.
Nurses Notes (continued)

This is a continuation of the nurses notes documented in IPCase001. Refer to the previous page for information about the nurses notes.
Nurses Notes (continued)

This is a continuation of the nurses notes documented in IPCase001. Refer to the previous page for information about the nurses notes.
Nurses Notes (continued)

This is a continuation of the nurses notes documented in IPCase001. Refer to the previous page for information about the nurses notes.
Nurses Notes (continued)

This is a continuation of the nurses notes documented in IPCase001. Refer to the previous page for information about the nurses notes.
Nursing Discharge Status Summary

The nursing discharge status summary (or nursing discharge summary) documents patient discharge plans and instructions.

The coder does not use the nursing discharge status summary (or nursing discharge summary) when assigning codes.
Sample UB-04 for an Inpatient (IP) Case

This sample UB-04 contains patient data, ICD-10-CM diagnosis codes, and an ICD-10-PCS procedure code.

In "real life," no one actually completes a UB-04 claim. Patient data and codes (e.g., ICD-10-CM, ICD-10-PCS) are entered in the
hospital's computer system, and the UB-04 claim is populated (filled out) with the data and codes.

The hospital's billing department is responsible for reviewing the completed UB-04 claim to verify its accuracy and submitting it to
third-party payers. When third-party payers deny a claim, the billing department collaborates with the health information department
to re-review the submitted claim to fix data entry and coding errors.

(© Pennsylvania Department of Public Welfare. Permission to reuse in accordance with TEACH Act provisions.)
Assigning the DRG

The last step to coding inpatient records is calculating the diagnosis-related group (DRG) at the www.IRP.com web site.

NOTE: The admission diagnosis code is not entered in a DRG grouper.