ICD Coding Question

[Ketina]

How do I a code a diagnosis of a patient with CHF w/ PE. The ICD-9-CM Physician coding book by Optum said not to code the PE if it is a symptom of CHF and no therapeutic treatment hasn't been performed. But this case scenario, a thoracentesis has been performed to drain the fluid of the patient's chest. I coded it as 428.0 511.9, is that correct?

 

[Alicia Scott]

I am not seeing anything that states that you can not code PE with CHF but there are a lot coding clinics with 428.0. You see PE is so often associated with CHF. The fluid will build up in the abdomen and in the lungs, especially if they lay flat for a long time. I did find this though:
Pleural effusions are commonly associated with CHF. Because pleural effusions re integral to the underlying disease of CHF, the effusions are not reported separately unless significant and separate treatment is directed toward the effusion (e.g., a thoracentesis was performed).

Since they did a thoracentesis your coding is correct.

 

[Ketina]

Thank you!!!! I'm doing this!! Thank you, Alicia! Understanding more about coding everyday. !!!

 

[Ketina]

PREOPERATIVE DIAGNOSIS
Right tympanic membrane perforation.

POSTOPERATIVE DIAGNOSIS
Right tympanic membrane perforation with acute suppurative otitis media, and conductive hearing loss.

PRIMARY PROCEDURE
RIGHT EAR EXAMINATION UNDER ANESTHESIA.

INDICATIONS FOR PROCEDURE
The patient is a 15-year-old child with history of a right tympanic membrane perforation, as well as right conductive hearing loss. Exam in the office revealed a posterior superior right marginal tympanic perforation. Risks and benefits of surgery including risk of bleeding, general anesthesia, hearing loss as well as recurrent perforation were discussed with the mother. The mother wished to proceed with surgery.

FINDINGS AND PROCEDURE
The patient was brought to the room, placed in supine position, given general endotracheal anesthesia. The postauricular crease was then injected with 1% Xylocaine with 1:200,000 epinephrine along with the external meatus. An area of the scalp was shaved above the ear and then also 1% Xylocaine with 1:200,000 epinephrine injected. A total of 4 mL local anesthetic was used. The ear was then prepped and draped in the usual sterile fashion. The microscope was then brought into view, and examining the marginal perforation, the patient was noted to have large granuloma under the tympanic membrane at the anterior border of the drum. The granulation tissue was debrided as much as possible. Decision was made to cancel the tympanoplasty after debriding the middle ear space as much as possible. The middle ear space was filled with Floxin drops. The patient woke up from anesthesia,was extubated, and brought to recovery room in stable condition. There were no intraoperative complications. Needle and sponge count was correct. Estimated blood loss: Minimal.

My answers are : Right typmanic membrane perforation, 384.20 with acute supperative otitis media, 382.00
then on another line conductive hearing loss,389.02.
The physician didn't state the right ear in the diagnosis only in the report so am I correct with the codes.

 

[Ketina]

Update!
Okay I submitted my quiz to the online program. I got a 84%. Which is okay but the question that I asked earlier they marked it wrong. I emailed the instructor and told her it is correct. They have it wrong. I want my points for it. I wished I had discovered CCO first. This online program is credited by CMT people. Alicia, thank you!