SDSU ICD 10 CM Coding and DRG Questions

Initial Post:After reading the coding scenario, indicate in your discussion
post the following items. (You may also include in your initial
post any instructions or notes that you saw in both the index
and the tabular and any actions you took including your
rationale.) When preparing your post, do the following:
1. Code the case using the ICD-10-CM Code Book and
then code it again using the 3M Encoder from the vLab.
Compare your codes and process for each, and ability
to see instructional notes and other resources.
2. This is an inpatient case. Can you find the MS-DRG
and APR-DRG?
○ Make sure DRGFinder is selected on the first
screen of the Encoder where you enter the patient
age.
○ The first diagnosis you enter is the admission
diagnosis. The second diagnosis is the principal
diagnosis. These may or may not be the same
depending on whether or not there was a
definitive diagnosis at the time the patient was
admitted. After you enter the principal diagnosis
you should see the MS-DRG. You can continue
adding secondary diagnoses and see if it changes
the MS-DRG.
○ To get the APR DRG or the All Patient Refined
DRG, go back to the first screen (by choosing next
patient) and change Medicare to one of those
other options.
3. Are any codes marked as a CC or MCC? What does
that mean and why is it important?
4. Assign the POA indicators. These are required for all
inpatient diagnosis codes, both principal and secondary.
5. Find a coding clinic article that relates to a condition
coded. See instructions in earlier modules about
accessing coding clinic. Cite the source (year, edition)
of the coding clinic where the article or Q&A was
located.
6. Find the UHDDS definition for significant procedures.
How does that affect what you code for inpatients?
7. What was the primary reason the patient originally
came into the ER? Is this different than the primary
reason the patient was admitted to inpatient status?
Case Scenario:
A 4-year-old boy was brought to the emergency department by
his mother, who stated the child had become ill very rapidly
over the course of 1 day. He had been treated for a right ear
infection at the pediatric clinic last week. Upon physical
examination, the emergency department physician noted a high
fever, drowsiness, and stiffness in the neck. The mother
reported the child had said his head hurt and also reported that
he had vomited at home. The physician noted slight rash on the
child’s upper trunk and axilla bilaterally. Suspicious of
meningitis, the physician requested and obtained a pediatric
consult. The emergency department physician and pediatrician
obtained consent for a diagnostic spinal tap, which was
performed, and the child was admitted to the pediatric unit.
Over the next couple of days, the pediatrician made the
diagnosis of bacterial meningitis with the causative organism of
haemophilus influenzae (H. influenzae) based on the physical
findings and the examination of the cerebrospinal fluid obtained
by the spinal tap. The child is treated with intravenous
antibiotics and other medications as well as supportive care.
The pediatrician found the acute suppurative otitis media of the
right ear still needed treatment. The child made a full recovery
but will be followed closely as an outpatient to determine
whether any effects of the meningitis, such as hearing loss,
occur later. The child was discharged to the care of his mother.