Scenario 1: Your patient has been admitted with right-sided hemiparesis after a CVA, which is the main focus of care. PT/INRs have been ordered. The patient also has diagnoses of hypertension and rheumatoid arthritis. Both nursing and PT will be seeing this patient.
I69.351 – hemiplegia following cerebral infarction affecting right dominant side (remember the fourth digit will be a “3” if the patient has had a CVA. In ICD-10, we can make a choice on dominance even if it’s not documented by using the following information: For ambidextrous patients, the default is non dominant; if the left side is affected, the default is non dominant; and if the right side is affected, the default is dominant. IN ICD-9 we would have to query the caregiver, patient, or physician.
I10 – essential primary hypertension
M06.9 – Rheumatoid arthritis
Z51.81, Encounter for drug monitoring
Z79.01 – Long term use of anticoagulants.
Scenario 2: Your patient has been admitted for memory care related to a diagnosis of late onset Alzheimer’s disease with behavioral disturbances. The patient has wandering episodes and lives with his elderly wife, who has limited mobility due to rheumatoid arthritis.
G30.1 – Alzheimer’s disease with late onset
F02.81 – Dementia in other diseases classified elsewhere with behavioral disturbance
Z91.83 – Wandering in diseases classified elsewhere
Z74.2 – need assistance at h one and no other household member able to render care.
Scenario 3: Patient is referred to home health following removal of right knee prosthesis due to MRSA infection, an antibiotic spacer was inserted during surgery. Orders are for skilled nursing to administer IV antibiotics and physical therapy to see patient for teaching about limited range of motion, gait abnormality and muscle weakness of both lower extremities and home safety. The patient is expected to return to surgery for a new prosthesis once the infection is resolved. The patient is a type II diabetic who requires daily insulin. The patient also has primary OA in the left knee and is awaiting surgery to replace that knee as well.
T84.53xD – infection and inflammatory reaction due to internal right knee prosthesis, subsequent episode (The infected prosthesis is clearly the most acute condition and should be listed primary since condition still exists). The T code used is a combination code that includes the complication, location, laterality AND the episode encounter of subsequent.)
B95.62 – MRSA infection as cause of diseases classified elsewhere
E11.9 – Type 2 diabetes without complications (diabetes is an important co-morbidity that will require ongoing monitoring, especially since the presence of infection may impact the patient’s insulin dose.
M17.12 – Unilateral primary osteoarthrosis, left knee (Although OA is resolved from right knee, patient noted to have it in the left knee, which adds to the complexity of care. The arthritis code includes type of oA, location and laterality. Use of abnormal gait and weakness are optional and generally inherent when a joint replacement or explantation is present, and generally should not be used when the underlying etiology is known.
Z45.2 – Encounter for adjustment and management of vascular access device (identifies presence of an IV)
Z79.4 – long term use of insulin
Z89.521 – acquired absence of right knee (This is a combination code that identifies the prosthesis has been explanted, – removed – the location and laterality.)
Scenario 4: Patient admitted to home care with pancreatic cancer and malignant ascites. Patient is having left lower quadrant rigidity with palpitations. Nurse notified physician, but no diagnosis explains the rigidity at this time. Patient to see physician tomorrow.