Microsoft word - 10a online cdi bootcamp module 10 exercises - answers.docx
Module 10: Diseases of the Neurological System Exercises
1. An eighty-six-year-old with 20-year history of Type I DM and significant
peripheral vascular disease presents for an open approach carotid endarterectomy for carotid stenosis. Patient has surgical history of fem-pop bypass graft and CABG. His CHF is maintained on Lasix.
a. What is the PDX? Carotid Stenosis b. What is the procedure? Carotid Endarterectomy c. MCC/CC: None at this time d. Assign the DRG: 039 Extracranial Procedures without CC/MCC e. Is there a query opportunity? Yes; type/acuity of CHF f. If so, what is the query DRG? DRG 038 Extracranial Procedures with CC (no documentation/indication of acute CHF) Note: CHF – the type, probably chronic, is a CC. Unspecified CHF (428.0) is not a CC or MCC. Carotid Stenosis (433.10); Carotid Endarterectomy (38.12); Type/acuity of CHF – (428.xx)
2. A sixty-five-year-old with Type I diabetes presents with new onset mental status
changes. CT of head shows cerebrovascular atherosclerosis. Symptoms resolve within eight hours. Patient discharged with “CVA ruled out.”
a. What is the PDX? Mental Status Changes b. What is the procedure? Head CT (not a qualifying OR procedure) c. MCC/CC: None d. Assign the DRG: DRG 948 Signs and Symptoms without MCC e. Is there a query opportunity? Clinical significance of the CT findings – validate cerebrovascular atherosclerosis?
f. If so, what is the query DRG? DRG 072 Non-specific Cerebrovascular Disorders without CC/MCC Note: Mental status changes (780.97); Cerebrovascular atherosclerosis (437.0); “Mental status change” = “altered mental status”
3. A patient fell from a ladder at home and was found unconscious at the scene.
EMS report notes response from time of call was 35 minutes and the patient was still unconscious on their arrival. The hospital was 20 minutes away, and the patient regained consciousness shortly after arrival at the ER. CT reveals subdural hematoma, documented by physician in Progress Notes.
a. What is the PDX? Subdural hematoma b. What is the procedure? None c. MCC/CC: None d. Assign the DRG: 087 Traumatic Stupor and Coma without CC/MCC e. Is there a query opportunity? Yes – have the attending MD validate the loss of consciousness and the length of time (only in EMS report at this time)
f. If so, what is the query DRG? If LOC is < 1 hour Æ DRG 087; if LOC is > 1 hour or of unspecified duration Æ DRG 084
Note: There is a code range for hematoma, brain
• by specific site
• following injury or non-traumatic
• with or without open wound, and • the level of consciousness
o unspecified o no loss o brief < 1 hour o moderate = 1-24 hours o prolonged > 24 hours o or “with loss of unspecified duration” For this example, the PDx code is (852.20) subdural hematoma following injury, w/o mention of open intracranial wound, unspecified state of consciousness. Also, the patient was unconscious as documented, but the time needs to be validated in order to choose the most specific code and the MS-DRG. This example has a total of 55 minutes, but also needs to be verified and for the total time.
NONTRAUMATIC STUPOR & COMA W MCC NONTRAUMATIC STUPOR & COMA W/O MCC TRAUMATIC STUPOR & COMA, COMA >1 HR TRAUMATIC STUPOR & COMA, COMA >1 HR TRAUMATIC STUPOR & COMA, COMA >1 HR W/O CC/MCC TRAUMATIC STUPOR & COMA, COMA <1 HR TRAUMATIC STUPOR & COMA, COMA <1 HR TRAUMATIC STUPOR & COMA, COMA <1 HR W/O CC/MCC CONCUSSION W MCC CONCUSSION W CC CONCUSSION W/O CC/MCC
4. A patient with a history of hypertension was admitted through the ED with
symptoms of facial drooping and blurry vision. Symptoms began at 10:00 AM. The patient was evaluated in the ED at 11:45 AM and admitted to the neurology floor for continued work-up. The ED CT was negative for infarct or hemorrhage. The patient was discharged home the next evening at which time the symptoms were resolving. The physician’s impression in the final progress note: “TIA”.
a. What might you clarify with the physician in a post-discharge query?
Was this a suspected stroke (based on the length of symptoms and the physician’s definition of stroke vs. TIA)?
Note: Recommend to check the definition and parameters of what constitutes a stroke with your hospital’s stroke committee.
5. Sylvia, a long-time diabetic, was brought to the ED after a “sinking spell” she
experienced while shopping at the mall. She is known to be non-compliant with her diet and at her last doctor visit complained of alternating numbness and “pins and needles” in her feet. Her bedside glucose levels range from 215-375. Her physician increases her oral anti-diabetic medication and discharges her home. The physician’s impression is “syncope”.
a. What is the PDx? Syncope b. What is the current DRG assignment? DRG 312 Syncope c. Is there a query opportunity? Yes; if the syncope was due to her diabetes and if diabetic autonomic neuropathy was confirmed as the cause of the symptoms.
d. What is a potential DRG? DRG 074 Cranial and Peripheral Nerve disorders without MCC
Note: Syncope (780.2); With query: PDx: Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled (250.60) – defaults to type 2, not stated as uncontrolled; Secondary: Peripheral autonomic neuropathy in disorders classified elsewhere (337.1); If the syncope was due to her diabetes without mention of neuropathy, the accurate MS-DRG ÆDiabetes – 639 (w/o CC/MCC).
6. A six-year-old girl was brought into the ED by EMS after answering a 9-1-1 call
for seizures. Upon arrival her rectal temperature was 104.6o F. The mother states that the child hadn’t been feeling well and that “a virus was going around” at school. The child was admitted to the pediatric floor and antipyretics administered. Blood and throat cultures were drawn but came back negative. The child was discharged home after 48 hours. Final impression: “febrile seizures”.
a. What is the PDx? Febrile seizures b. What is the current DRG assignment? DRG 101 c. Is there a query opportunity? Yes – possible viral infection d. What is (are) potential DRG(s)? DRG 866 Viral Illness without MCC
Note: Viral infection, unspecified (viral syndrome) (079.99). If documented as "Possible” viral syndrome or “rule/out” viral syndrome, must be mentioned at the time of discharge in order to code this diagnosis. Refer to Coding Clinic 3rd Qtr 2005 and 4th Qtr 2006 for explanation of simple and complex febrile seizures. Febrile seizures without any further documentation defaults to “simple”, code 780.31, (which lasts for about 10 minutes and does not recur within 24 hours). There is no other documentation to explain “complex” febrile seizures, which lasts longer than 15 minutes, is localized to one part of the body, or recurs within 24 hours. Febrile seizures may indicate an infection of the nervous system such as an abscess, meningitis, or encephalitis, but most of these seizures are triggered by a viral infection such as pneumonia, URI, pharyngitis, or otitis media. Both codes are included in the DRG 101.
7. Bob, an 82-year-old male is brought to the ED by his son for complaints of
confusion and increasing inability to care for himself. He was diagnosed 10 years ago with Parksinson’s disease. Bob has been living independently but recently his son states that when he visits his father is poorly-groomed, and that spoiled food is piled up in the kitchen and living room. Bob is admitted with a diagnosis of “altered mental status”.
a. What is the current PDx? Altered Mental Status b. What is the current DRG assignment? DRG 948 Signs and Symptoms without MCC
c. Is there a query opportunity? Yes; Parkinson’s dementia
d. With appropriate clarification, what is the potential DRG assignment?
DRG 057 Degenerative Nervous System Disorders without MCC
Note: MD must link the AMS to the Parkinson’s disease and as document as “dementia”.
8. Myra, a 68-year-old female, is admitted to the medical floor due to continued
weight loss. Her PMH history includes hypertension, stroke (6 months ago) and CAD. The diagnostic work-up includes a bedside speech and swallow evaluation. Based on the outcomes of the bedside evaluation a video swallow evaluation is performed that shows that Myra has severe progressive dysphagia and chokes on most food consistencies.
The dietitian is consulted to provide diet and supplement recommendations and social services are contacted to arrange outpatient speech therapy. The physician’s discharge diagnoses were as follows: 1) weight loss; 2) dysphagia; 3) history of CVA; 4) hypertension; 5) CAD.
a. What is the current PDx? Weight loss b. What is the current DRG assignment? DRG 641 Nutritional and Miscellaneous Metabolic Disorders without MCC
c. Is there a query opportunity? Dysphagia as a late effect of stroke and possibly malnutrition (would have to analyze the rest of the record to see if the patient meets criteria for malnutrition, and if so, what stage)
d. With appropriate clarification, what is the potential DRG assignment?
DRG 057 Degenerative Nervous system Disorders without MCC
Note: Weight loss (783.21); PDx: Dysphagia as a late effect of stroke (438.82); would also add an additional code to identify the type of dysphagia, if known (787.20-787.29)
9. A patient who was recently diagnosed with a probable malignant neoplasm of the
brain is admitted for surgical excision of the tumor. During the procedure a Gliadel® wafer is inserted in the tumor bed.
What is the medical PDx? Probable malignant neoplasm of the brain
b. What is the medical DRG? DRG 055 Nervous System Neoplasms without MCC
What is the procedure? Craniotomy with insertion of Implantation of chemotherapeutic agent
d. What is the surgical DRG assignment? DRG 023 Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis with MCC or Chemo Implant Note: Insertion of Gliadel wafer (00.10) (brain wafer chemotherapy); Excision of the tumor (code 01.59). (The DRG would be 027 without the insertion of the wafer). **Verify the morphology of the neoplasm. Recommend before coding any “malignant” neoplasm, verify the pathology report and the physician’s documentation. Even though coding guidelines state that “possible” malignant neoplasm of the brain is documented at the time of discharge, one would not want to label that patient with having “cancer” when they indeed may not have the diagnosis confirmed.
10. A patient is admitted for a percutaneous angioplasty of the right carotid artery for
carotid stenosis. PMH includes hypertension, atherosclerosis, CAD, diabetes and
What is the medical PDx? Carotid Stenosis
b. What is the medical DRG? DRG 068 Nonspecific Cerebrovascular Accident and Precerebral Occlusion without Infarction without MCC
Is there a query opportunity? Yes; type/chronicity of CHF (possible CC), type/control of diabetes, type of hypertension (benign, malignant)
d. What is the procedure? PTA of carotid artery e.
With appropriate clarification, what are potential DRGs? DRG 039 Extracranial Procedures without CC/MCC; IF the type of CHF can be specified in the documentation ÆDRG 038 Notes: Carotid artery stenosis – unilateral w/o cerebral infarction (433.10); PTA of carotid artery (00.61); CHF – specified as to type, either documenting “chronic” or “unspecified” would be a CC;
The 82nd Annual Meeting of Japan Sociological Society (Oct 12, 2009) Reappraising Garfinkel’s notion of “self-organizing” setting An example of negotiation over treatment at a mental clinic In his seminal book Studies in Ethnomethodology, Harold Garfinkel recommended seeing any social setting as “self-organizing with respect to the intelligible character of its own appearances as eithe
DECEMBER 2003 Volume 2, Issue 10 AS PRESENTED IN THE DEPARTMENT OF ANESTHESIOLOGY, FACULTY OF MEDICINE UNIVERSITY OF MONTREAL Biochemical Terrorism: Committee for Continuing What the Anesthesiologist Should Know Medical Education Department of Anesthesiology University of Montreal MAJOR DANIEL AUDY, MD, FRCPS, B.SC. BIOCHEMISTRY, CDPierre Drolet, MD Chairman and E