HBU- Practice Exercise
HIMT222-Module 5
Student name:
Academic number:
Q1: Code the following cases. Include disease, morphology codes and the codes for any
procedures
o Staphylococcus pneumonia
o Allergic extrinsic asthma
o Acute bronchitis culture grew Haemophilus influenzae
o CAL with bronchiectasis
o COPD with Asthma
o Acute gingivitis
o Chronic gastritis due to H.pylori
o Acute appendicitis with perforation
o Dermatitis due to insecticide
o Decubitus ulcer of elbow with partial thickness skin loss
Ms. Zainab Al-Swaimil, Certified Clinical Coder trainer and Consultant
HBU- Practice Exercise
HIMT222-Module 5
2. Case study
1. This 5-year-old patient admitted as a case of tonsillitis with dehydration
Description
Code
Principal diagnosis
Additional diagnoses
Principal procedures
Other procedures
2. 41-year-old woman with obstructive sleep apnoea admitted for CPAP for 3 days
Description
Code
Principal diagnosis
Additional diagnoses
Principal procedures
Other procedures
3. This 58-year-old patient with a history of chronic obstructive pulmonary disease
presented with an infective exacerbation of her COPD. She was admitted to ICU,
intubated and ventilated for 8 hours.no organism was isolated from either sputum or
blood cultures. she was started on broad spectrum antibiotics with a marked
improvement.
Description
Code
Principal diagnosis
Additional diagnoses
Principal procedures
Other procedures
4. This 7-year-old boy with recurrent tonsillitis and glue ear was admitted to hospital for
surgery. He underwent a tonsillectomy, adenoidectomy for enlarged adenoids and
bilateral myringotomy with insertion of grommets under a GA. He was discharged home the
following day. ASA 123456 E
Description
Principal diagnosis
Additional diagnoses
Principal procedures
Other procedures
Ms. Zainab Al-Swaimil, Certified Clinical Coder trainer and Consultant
Code
HBU- Practice Exercise
HIMT222-Module 5
5. Chronic alcoholism patient with hepatitis C carrier was admitted for a colonscopy
following recurrent PR bleeding. the patient was given midazolam 5 mg, fentanyl 100
micgm and propoofol 30mg IV for sedation (ASA 123456 E). A hyperplastic colonic polyp
was found and excised via coloscopy.no source of bleeding was found .D &A team
counselled patient regarding his alcohol consumption.
Description
Code
Principal diagnosis
Additional diagnoses
Principal procedures
Other procedures
This 64 year old male presented with haematemesis, malaena and anaemia.his Hb on admission
was 96 and he was transfused with 2 units of packed cells. he underwent endoscopy under
sedation that showed an actively perforated and bleed duodenal ulcer, gastric varices and
barretts oesophagus. the perforated ulcer was Overswing with selective vagotomy and the
varices were banded. He was started on Losec 20mg b.d. and will need a repeat scope in 6
weeks to confirm heling. ASA 123456 E
Description
Code
Principal diagnosis
Additional diagnoses
Principal procedures
Other procedures
6. An 53 year old man was admitted for repair of a recurrent bilateral inguinal hernia with mesh.
The repair was performed without complication under GA ASA 3. He is an ex-smoker.
Description
Code
Principal diagnosis
Additional diagnoses
Principal procedures
Other procedures
7. Cholelithiasis. Laparoscopic cholecystectomy under GA
ASA 1 2 3 4 5 6 E pathology report was Cholelithiasis acute cholecystitis
Description
Code
Principal diagnosis
Additional diagnoses
Principal procedures
Other procedures
8. patient admitted with diarrhoea and vomiting samples for adenovirus antigens was positive and
adenoviral enteritis was diagnosed with dehydration
Ms. Zainab Al-Swaimil, Certified Clinical Coder trainer and Consultant
HBU- Practice Exercise
HIMT222-Module 5
Description
Code
Principal diagnosis
Additional diagnoses
Principal procedures
Other procedures
9. Solar keratosis of two lesions (forehead and hand), both excised using local anaesthesia
Description
Code
Principal diagnosis
Additional diagnoses
Principal procedures
Other procedures
DISCHARGE SUMMARY
Name of Patient
Date of Admission
02/08/2016
Medical Record No.
Date of Discharge
06/08/2016
Age/Sex 49/F
Attending Physician
PROVISIONAL DIAGNOSIS: Paraumbilical hernia.
FINAL DIAGNOSIS: Gangrenous and obstruction Paraumbilical hernia
Summary of History and Physical Examinable:
The patient is a 49-year-old female, presented to OPD complaining of
paraumbilical swelling for 4 months, increasing in size with pain. She has history
of constipation. No diarrhea. No vomiting. The patient surgical history of
paraumbilical hernia repair. Irrelevant family history. Not known of any allergies.
On examination, the patient looks well, oriented, vitally stable and afebrile. Pain
score is 0.
nutritional status is normal. Psychological status is normal. Activity is normal.
Investigations:
Laboratory, CBC, coagulation profile, urine electrolytes, and random blood sugar.
Operation/Procedure Performed:
Laparoscopic paraumbilical hernia repair with mesh under general anesthesia.
CROSS CONSULTATION:
None.
HOSPITAL COURSE:
Now, the patient is discharged in good condition. She looks hemodynamically
stable, and afebrile. Abdomen was soft and lax. No tenderness. The patient
Ms. Zainab Al-Swaimil, Certified Clinical Coder trainer and Consultant
HBU- Practice Exercise
HIMT222-Module 5
developed distention postoperatively, then the distention subsided. Now, the
patient is discharged in good condition. No abdominal distention. Bowel sounds
are audible.pt ambulating well on regular diet. passed bowel motion.
DISCHARGE PLAN: Follow-up in OPD after 5 days.
Description
Principal diagnosis
Additional diagnoses
Principal procedures
Other procedures
Ms. Zainab Al-Swaimil, Certified Clinical Coder trainer and Consultant
Code
CHAPTER 10
DISEASES OF THE RESPIRATORY SYSTEM
(J00J99)
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
TONSILLITIS (ACS 0804)
Tonsillitis not specified as acute or chronic should be coded to acute
(J03.- Acute tonsillitis)
unless a tonsillectomy is performed, in this case the tonsillitis is coded
as chronic (J35.0 Chronic tonsillitis).
Chronic = recurrent acute.
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
Exercise
1.Croup
J05.0
2. Acute laryngotracheitis
J04.2
3. Tonsillitis
J03.9
Admitted with tonsillitis. Tonsillectomy performed under intravenous GA.
ASA 1 2 3 4 5 6 E
J35.0
41789-00[412]
92514-10[1910]
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
INFLUENZA (J09-J11)
In ICD-10-AM there are three categories for influenza
?Influnza virus is known
– J09 Influenza due to identified avian influenza virus
?Do not specify Influnza virus
– J10 Influenza due to other identified influenza virus
H1N1 influenza
– J11 Influenza, virus not identified
Haemophilus influenzae [H. influenzae] cause meningitis, pneumonia
and infection The exclusion at the beginning of J10 and J11 remained
with the difference.
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
PNEUMONIA (ACS1004)
Pneumonia is an acute inflammation of the alveoli of the lung with
consolidation (solidification) and exudation (fluid build-up).
There are four major types: bacterial, viral, aspiration and mycoplasmal.
Most cases of pneumonia will be diagnosed using x-ray findings. These will
show the location and extent of the consolidation.
Note: evidence of consolidation in the lung on x-ray report does not lead to
the diagnosis of pneumonia. Other things such as bleeding or inhalation can
cause consolidation.
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
PNEUMONIA (ACS1004)
In many cases the organism causing the pneumonia may not be identified, but
you should always check Microbiological reports, particularly sputum and blood
cultures, will describe the organism (if any) thought to be the cause.
Lobar pneumonia means consolidation of the entire lobe and is rarely seen.
Note that pneumonia described as ‘lower lobe’ does not necessarily mean that
the pneumonia is ‘lobar. It is just describing the anatomical site of the
pneumonia. Therefore, when this term is used it should be clarified with the
clinician before assignment of code J18.1 Lobar pneumonia, unspecified.
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
Exercise
1.Klebsiella Pneumonia
J15.0
1.Laryngitis with influenza
J11.1
1.Bacterial bronchopneumonia
J15.9
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
CHRONIC OBSTRUCTIVE PULMONARY
DISEASE (COPD) (ACS1008)
The term COPD (synonyms: chronic airway limitation (CAL), chronic
obstructive airway disease (COAD))
is a condition of chronic bronchitis with obstruction possibly due to
chronic asthma and/or emphysema or chronic tracheobronchitis. The
important terms are chronic and obstruction.
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
CHRONIC OBSTRUCTIVE PULMONARY
DISEASE (COPD) (ACS1008)
COPD is chronic condition and patients will usually only be admitted to
hospital for treatment of their COPD if they have acute exacerbation.
In theses cases use J44.0 Chronic obstructive pulmonary disease with acute
lower respiratory infection or J44.1 Chronic obstructive pulmonary disease
with acute exacerbation.
Do not code any bronchitis or chest infection separately unless the infection
is a separate, important condition such as pneumonia.
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
(ACS1008)
Use J44 codes in the following circumstances
For bronchitis that is :
?Chronic and is in combination with asthma or emphysema.
?Chronic and involves airways obstruction
For emphysema that is:
?In combination with chronic bronchitis. If the clinician has documented COPD
and emphysema, assign only a code from category J44.
For asthma that:
?Is In combination with chronic bronchitis
?involves airways obstruction
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
EXAMPLE :
Discharge summary documented PDx as COAD/Pneumonia.
Principal diagnosis
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
Additional diagnosis
J18.9 Pneumonia, organism unspecified
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
EXAMPLE :
Discharge summary documented PDx as Pneumonia + COPD exacerbation.
Principal diagnosis
J18.9 Pneumonia, organism unspecified
Additional diagnosis
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory
infection
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
ASTHMA (ACS1002)
Asthma is charactrised by wheezing, dyspnea and cough and is usually controlled by
drugs. Bronchospasm is a component of an acute asthmatic attack and such an attack
rapid treatment to prevent respiratory failure.
Status asthmaticus is an acute severe case of asthma where the patient is not
responding to their medication. Assign J46 Status asthmaticus only if the asthma is
documented as ‘acute severe’ or ‘refractory’.
Chronic obstructive asthma or asthma and/with COPD should be assigned a code from
J44.- Other chronic obstructive pulmonary disease only when documented.
If the only diagnostic information you have is chronic asthma assign
J45.9 Asthma, unspecified
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
Bronchitis:
Bronchitis is classified in two different blocks according to whether it is acute or chronic.
In patient under 15 years of age is assumed to be acute even if this is not specified.
Combined with asthma is coded with an asthma code (J45.-). Do not code bronchitis separately.
Allergic is coded to the allergic asthma code (J45.0) Do not code bronchitis separately.
Combined with emphysema is coded to COPD(J44.-)
Obstructive is coded to COPD (J44.-)
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
Exercise
1.Acute sever asthma
J46
1.Acute exacerbation of COPD.
J44.1
1.Asthmatic bronchitis.
J45.9
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
ACUTE PULMONARY OEDEMA (ACS
0920)
Accumulation of fluid in the lung tissue and alveolar space is known as pulmonary oedema.
Commonly it is due to heart disease, but it can be of non-cardiac origin.
If it is of cardiac origin it is included in the heart failure codes from chapter 9 Disease of the
Circulatory System and no code from the respiratory chapter is needed.
When Acute pulmonary oedema is documented without further qualification, it should be
coded to I50.1 left ventricular failure.
If it is non-cardiac origin then it should be coded to J81 Pulmonary oedema
The exclusion note in J81 list codes for pulmonary oedema. It lists other codes used for
pulmonary oedema of non-cardiac origin.
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
0807 FUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS)
? Functional endoscopic sinus surgery (FESS) is a term describing a range of procedures
performed for the surgical treatment of sinus disease.
? FESS may include a variety of procedures performed in any combination. Therefore,
clinical coders should check the operation report and assign only the appropriate codes.
These procedures may include:
41737-02 [386]
Ethmoidectomy, unilateral
41716-05 [384]
Biopsy of maxillary antrum
41716-00 [383]
Intranasal removal of foreign body from maxillary antrum
Where FESS is documented, also assign 41764-01 [370] Sinoscopy to indicate the endoscopic
nature of the surgery.
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
Exercise
42-year-old lady with history of bronchial asthma on medication. She complain of nasal
discharge Paroxysmal nocturnal dyspnea (PND) hyopsomia nasal congestion mouth had
trial of medical treatment improved but recured after a while final diagnosis Chronic
sinusitis, Chronic sinusitis, Chronic rhinitis and nasal polyp
She underwent FESS and nasal polypectomy
Anaesthesia
ASA 2
Operative report
Under general anaesthesia with ET T examination showed previous findings bilateral
Intranasal maxillary antrostomy and uncinectomy done, bilateral anterior and posterior
ethmoidectomy done, bilateral Sphenoidotomy done and nasal polypectomy
Patient extubated and send to recovery room in stable condition
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
J32.9
Chronic sinusitis, unspecified
J31.0 Chronic rhinitis
J33.9
Nasal polyp, unspecified
41716-02
Intranasal maxillary antrostomy, bilateral
41737-03
Ethmoidectomy, bilateral
41752-02
Sphenoidotomy
41764-01
Sinoscopy
41668-00
Removal of nasal polyp
92514-29 GA
Uncinectomy (also known as infundibulotomy) involves detachment and removal of the anterior, inferior and
superior attachments of the uncinate process. It is performed as part of an intranasal ethmoidectomy in
order to gain access to the ethmoid infundibulum, expose the frontal recess and allow visualisation of the
frontal recess. Uncinectomy is a fundamental step in functional endoscopic sinus surgery (FESS).
Classification
It is unnecessary to separately code the uncinectomy when performed as a component of FESS.
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
Respiratory Failure (J96)
In respiratory failure the respiratory system is unable to supply adequate oxygen to
maintain proper metabolism and/or eliminate carbon dioxide.
Life threatened condition that may be associated with a respiratory condition or a
non-respiratory condition.
Blood gas analysis provide evidence of respiratory failure but you must be careful not
to assume that the abnormal results are evidence of respiratory failure.
Code respiratory failure if confirmation by clinician.
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
VENTILATORY SUPPORT (ACS 1006)
Ventilatory support is a process by which gases are moved into
the lungs by a device that assists respiration by augmenting or
replacing the patient’s own respiratory effort. Ventilatory
support can be administered via noninvasive or invasive devices.
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
VENTILATORY SUPPORT (ACS 1006)
invasive devices.
[569]
Noninvasive devices.
[570]
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
VENTILATORY SUPPORT (ACS 1006)
invasive devices. [569]
Noninvasive devices. [570]
Includes:
Endotracheal intubation
Includes:
respiratory assistance
Ventilatory support by:
mechanical ventilation by:
face mask
mouthpeice
endotracheal tube (ETT)
nasal
oral
tracheostomy
Excludes:
weaning of intubated (endotracheal tube/tracheostomy) patient by any method
that by:
nasal mask/pillows/prongs
nasal/nasopharyngeal tube
Code also when performed:
endotracheal intubation (see block [569])
tracheostomy:
tracheostomy (see block [569])
– percutaneous (41880-00 [536])
– permanent (41881-01 [536]
– temporary (41881-00 [536])
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
(Duration )ventilatory support
[569]
13882-00
Management of continuous ventilatory support, 24 and < 96 hours
13882-02
Management of continuous ventilatory support, 96 hours
[570]
92209-00
Management of noninvasive ventilatory support, 24 and < 96 hours
92209-02
Management of noninvasive ventilatory support, 96 hours
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
Classification
Code first the ventilatory support (see also Calculating the duration of CVS)
a.When both CVS and NIV are used for treatment, code each type separately. Use the
appropriate duration extension on each code to indicate how many hours the patient
received each type of ventilatory support.
b.Subsequent periods of the same type (invasive or noninvasive) of ventilation, when used
for treatment (not weaning) should be added together. For example, if a patient is on CVS
for the first day of their admission, then on CVS again on the fourth day of their admission,
the CVS hours should be added together to arrive at the correct CVS code.
Cvs ----niv----cvs
24---24-24
Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant
Classification
F. The ventilatory support that is provided to a patient during surgery is associated with anaesthesia
and is considered an integral part of the surgical procedure. The patient may remain on ventilatory
support for some hours while recovering following surgery. Ventilation of
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