…or is it?
When I was taking coding classes on Thursday evenings in the mid-90s, everyone in my class – including the instructor – had the same dilemma. There was a great new show on TV called “ER.” And it was on during coding class. Bearing mind that DVR didn’t exist at the time, sometimes we were able to talk our instructor into letting us go early and she would joke with us and tell us she’d give us extra credit if we went home and coded “ER,” that is, translate the conditions of the patients of the week into codes. I don’t know if anyone actually did. I certainly didn’t because I was just trying to understand the clinical lingo and decide what was important and what wasn’t. So now it’s your turn – how would you code this hospital inpatient scenario?
“CC: Pt adm w/ c/o CP, SOB, fever, weakness. PMH: CHF, HTN, DM type 2. Findings: Temp 102. BP: 100/65. CXR w/ infiltrates. Labs: WBC 40,000, sputum (-), BC (-). Assessment: sepsis, pna. Plan: IV abx, IVF, repeat BC.”
Statements such as these are a reality and before you can look up a code in a book, you first have to know what to look up. It often reminds me of my elementary school teachers telling me if I didn’t know how to spell a word to look it up in the dictionary. I remember thinking, “How do I look it up in the dictionary if I can’t spell it?!” Of course, we all learned to sound out the word and attempt to look it up in the dictionary. But coding is a little trickier because physician short hand is difficult to decipher if you don’t have any clinical knowledge. And before you can translate a clinical statement into codes, you first have to translate it into English!
Have you figured out the scenario above? Here’s the answer:
-038.9 Unspecified septicemia
-486 Pneumonia, organism unspecified
-428.0 Congestive heart failure, unspecified
-401.9 Unspecified essential hypertension
-250.00 Diabetes mellitus, without mention of complication, Type II or unspecified
But how do you get there? That’s the question. So I will break down the coder’s thought process as he/she reads the statement and determines what to code.
Step 1: Translate the clinical shorthand into English.
The statement above, if written out long hand, would read as follows: “Chief complaint: patient admitted with complaints of chest pain, shortness of breath, fever, and weakness. Past medical history: congestive heart failure, hypertension, type 2 diabetes mellitus. Findings: Temperature 102 degrees. Blood pressure: 100/65. Chest x-ray with infiltrates. Labs: white blood count 40,000, negative sputum culture, negative blood cultures. Assessment: sepsis, pneumonia. Plan: intravenous antibiotics, intravenous fluids, repeat blood cultures.”
Step 2: Determine what brought the patient to the hospital and the underlying cause of that problem.
The patient had several complaints: chest pain (CP), shortness of breath (SOB), fever, and weakness. The patient’s fever was high and blood pressure was low. Tests showed infiltrates on chest x-ray, which is indicative of pneumonia and labs showed a high white blood cell (WBC) count, which is indicative of infection and blood and sputum (respiratory secretions) cultures did not grow any bacteria – but if the patient was on antibiotics before the cultures were taken, they may not grow any bacteria. The final assessment was sepsis and pneumonia. Symptoms of sepsis are weakness, fever, hypotension (low blood pressure), and high WBC count. Symptoms of pneumonia are chest pain, shortness of breath, fever, high WBC count, and weakness.
Step 3: Assign codes for the reason that brought the patient to the hospital.
Knowing that we don’t code symptoms when an established associated condition is present, we can narrow the final coding down to the sepsis and pneumonia. Coding rules tell us that coding for sepsis requires two codes: 038.9 and 995.91 and pneumonia without further specification is coded to 486. Of course, if this were a real hospital, we hopefully would have more specific documentation telling us the causative organism of both the sepsis and the pneumonia. That would require more digging through the record.
Step 4: Determine if there are other conditions that should also be reported.
In this case, the patient has a past medical history of congestive heart failure (CHF), hypertension, and type 2 diabetes mellitus. All of these are chronic conditions that impact the care of the patient and should therefore be coded. We can then add codes 428.0, 401.9, and 250.00. We can’t assume a cause and effect relationship between the CHF and hypertension because it’s not documented by the physician and we would want to look for documentation of a specific type of congestive heart failure (e.g., acute on chronic diastolic heart failure) and any diabetic complications.
So coding is just looking up a code in a book. At least that’s the tangible part of it. The rest of it is the thought process that goes behind it and explains why, if you watch coders work, you will see them spend most of their time staring at a computer screen or flipping through a medical record. I often compare coding to doing a word search: you have to sort through all the gobbledygook (i.e., pages of clinical mumbo jumbo) to find the right word to look up in the codebook.
You either found this explanation horribly boring or oddly fascinating. If you belong in the latter category, welcome to the wonderful world of coding. You're going to love it.