Module 9: Diseases of the Endocrine System and Nutritional Disorders Exercises

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1 Module 9: Diseases of the Endocrine System and Nutritional Disorders Exercises 1. An 86 year old male with brittle Type I DM is admitted for orthopedic surgery. The physician documents in the operative note bone changes related to DM and the patient undergoes a total hip replacement. Which of the following DRGs would be assigned? A. DRG 628 B. DRG 983 C. DRG 470 D. DRG A 72-year-old female is admitted with bradycardia. The nutritionist is consulted because the patient s daughter is concerned that her mother is not eating well. She appears frail and can t remember when she last had a meal. The albumin is noted to be 1.8 and the patient s BMI is calculated at The physician documents cachexia and starts the patient on high protein supplements. A. What is the PDx? Bradycardia B. What is the Medical DRG assignment? DRG 310 Cardiac Arrhythmia and Conduction Disorders without CC/MCC C. Is there an opportunity to query the physician? Yes; verify malnutrition. Unspecified DRG 309. Severe DRG 308. (Based on the above criteria, the patient appears clinically to have severe malnutrition. Note: Malnutrition (263.9) = (CC); Severe (261) = (MCC). 3. A patient with a history of Type II diabetes is admitted with an open wound infection of the right midfoot, with severe pain and purulent drainage. Due to the depth of the wound a bone scan is ordered which shows bone changes consistent with osteomyelitis. IV antibiotics are initiated and social service is requested to arrange long-term home IV antibiotic therapy.

2 A. Are there any query opportunities in this scenario? Yes B. What condition(s) are identified that require clarification? i. The physician needs to validate the diagnosis of osteomyelitis as documented in the bone scan. ii. Is this diabetic osteomyelitis? iii. If the osteomyelitis is not related/linked to the diabetes, verify acute, subacute, chronic, or other specificity. 4. A 27-year-old patient is admitted through the emergency room after collapsing at a sporting event. A finger-stick glucose level performed by the EMS is recorded as 46. IV glucose was delivered in the field and at the time of ED arrival the patient s glucose level had increased to 115. H/P states Otherwise healthy female admitted with episode of hypoglycemia. A. What is the PDx? Hypoglycemia B. What is the Medical DRG? DRG 641 Nutrition and Miscellaneous Metabolic Disorders without MCC 5. Blood gases are drawn in the ED for a patient brought in with an exacerbation of COPD. ABG results show: ph 7.21 (acid) po2 120 (on 4 liters of O 2 via nasal cannula) (supranormal d/t oxygen) pco 2 of 74 (elevated) HCO3 of 24 (normal) What condition is represented by these findings? Respiratory acidosis 6. The patient is admitted for an elective lap-band procedure. The H/P states reason for admission as 1) admit for lap-band; 2) morbid obesity; 3) OSA; 4) GERD. Per protocol, the dietitian performs a dietary assessment and documents the patient s BMI as 45.6 in the nutrition assessment. A. What is the documentation opportunity for this record? None the BMI can be coded from the dietitian s notes 7. A 17-year-old female with a calculated BMI of 15.2 is admitted for nutritional support. The physician documents the reason for admission as anorexia. A. What is the Principal diagnosis? Anorexia

3 B. What is the current DRG assignment? DRG 641 Nutritional and Miscellaneous Metabolic Disorders without MCC C. What documentation clarification opportunities exist for this record? Review for type/severity of malnutrition and also validate the type of anorexia (Anorexia Nervosa) D. Assuming all documentation clarifications receive a positive response, what is the most appropriate DRG assignment Anorexia Nervosa is the PDx DRG 883 Disorders of Personality and Impulse Control (MDC 19 Mental Diseases and Disorders) Note: Anorexia (code 783.0). Anorexia nervosa (code 307.1). Refer to Coding Clinic 2 nd Qtr 2006: Question: Coding Clinic Fourth Quarter 1989 advised the sequencing of code 307.1, Anorexia nervosa, as principal diagnosis for anorexia with severe malnutrition since anorexia implies malnutrition. However, at my facility, we see patients with malnutrition so severe they require medical intervention for stabilization of body function. The monitoring and treatment for these patients may extend for months. We do not have a psychiatric ward and we aren t associated with a psychiatric facility so no formalized psychiatric care is rendered beyond a psychiatric consultation. Since the primary reason for the admission is malnutrition, is it appropriate to sequence code 263.9, Unspecified protein-calorie malnutrition, as principal diagnosis? Answer: Assign code 307.1, Anorexia nervosa, as the principal diagnosis. Code 261, Nutritional marasmus, should be assigned as an additional diagnosis for the severe malnutrition. For some anorexic patients, the weight loss is so severe that it leads to malnutrition. Code 261 further describes the severity of the patient s condition. However, it is appropriate to sequence the underlying condition (anorexia nervosa) as the principal diagnosis. This advice applies for both medical/surgical and psychiatric facilities and supersedes advice previously published in Coding Clinic Fourth Quarter 1989, page 11, where only code was assigned. and 4 th Qtr For some anorexic patients, the weight loss is so severe, that it leads to malnutrition. The underlying condition is the PDx. Code also the malnutrition as the secondary code, once documented as well CC 4 th Qtr 1989: Question: A patient was admitted with a 15-year history of anorexia. Her weight on admission had decreased from 81 pounds to 51 pounds. She was admitted to increase her body weight and for nutritional counseling. She was transferred to a psychiatric facility once her weight improved. Is the principal diagnosis anorexia nervosa or severe malnutrition? Answer: The principal diagnosis is anorexia nervosa, Because anorexia nervosa implies malnutrition, an additional code for malnutrition is not necessary.

4 8. A patient is admitted with a history of diabetes, PVD, ischemic ulcers of bilateral lower extremities and non-healing ulcer wounds of the left 4 th and 5 th toes. The decision is made to perform an amputation of the left 4 th and 5 th toes. The H/P states 1) PVD; 2) non-healing wounds (L) 4 th /5 th toes; 3) diabetes; 4) (B) LE ulcers. A. What condition(s) require clarification for appropriate code assignment? Is there a link between the patient s diabetes and PVD? Are the toe wounds (and/or leg wounds) diabetic ulcers or due to diabetic PVD? B. What is the PDx? Ulcer toes C. What is the Surgical DRG assignment? With query: DRG 581 Other Skin, Subcutaneous & Breast Procedure without CC/MCC. If the query was answered confirming all diabetic related: 1.What is the PDx? Diabetic ulcers / diabetic PVD 2. What is the Surgical DRG assignment? IF the diabetic PVD was sequenced as the PDx, the DRG would change to DRG 257 Upper Limb and Toe Amputation for Circulatory System Disorders without CC/MCC. Notes: Lower extremity ulcer (code ); toes (707.15); Diabetic ulcer (250.80, ); Diabetic PVD ( and ). Note: = atherosclerosis of the extremities with ulceration). Cause-and-effect relationship between diabetes and the PVD has to be stated in the documentation. (CC 2 nd Qtr 1994, 3 rd Qtr 1991) 9. Mrs. Jones was transferred from a post-acute care facility where she was a resident after undergoing a right below-the-knee amputation 2 weeks ago. Her past medical history includes Type I diabetes, uncontrolled, PVD and CKD III. She was admitted with a diagnosis of a stump infection. During the stay the orthopedic surgeon performs a revision of the stump. A. What is the PDx Stump infection B. What is the Surgical DRG? DRG 476 Amputation for Musculoskeletal System and Connective Tissue Disorders without CC/MCC Notes: Codes (amputation stump complication infection) plus (CKD), and 84.3 (Revision of amputation). Add the code for organism if known. Verify the CKD for this admission. CKD 4 and 5 are CCs, and ESRD is a MCC for example purposes. Also, validate the control of her diabetes and if the PVD is also diabetic related. 10. A patient is admitted is admitted with intractable nausea and vomiting. Her PMH includes Type II diabetes, CKD and neuropathy. A gastric emptying study is performed and the impression is gastroparesis, which is documented by the attending physician.

5 A. What is the PDx? Gastroparesis B. What is the DRG assignment? DRG 392 Esophagitis, gastroenteritis, & Misc Digestive Disorders without MCC. C. What condition(s) may require clarification? Is there a link between the patient s diabetes, gastroparesis, CKD and neuropathy? D. If there IS a diabetic link, what is the PDx? Diabetic gastroparesis i. What is the DRG assignment? DRG 074 Cranial and Peripheral Nerve Disorders without MCC Note: Gastroparesis (536.3) and diabetic gastroparesis (250.6x and 536.3). CKD stage?

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