don’t let the coding Get lost in translation CAN YOU CONVERT THESE DISCHARGE SUMMARY SCENARIOS FROM ICD-9 TO ICD-10? By Valerie Fernandez, MBA, CPC, CPC-H, AHIMA ICD-10 Trainer preparation for ICD-10, it is important to review medical records and translate the coding to ICD- 10. Taking one or two office notes, operative reports, or discharge summaries will provide sufficient practice to prepare for the planned implementation date of October 1, 2015. Following are a few sample discharge summaries. Read through them, pick the accurate ICD-9 codes, and then convert them to ICD-10. discharge Summary #1 This patient is a 34-year-old female admitted through the emergency department with severe stabbing, low back pain, and inability to urinate. she has a long history of pelvic inflammatory disease with three surgeries for removal of implants. The CT scan indicated a mass in the area of the kidneys. The patient was admitted and taken to the operating room. an exploratory laparotomy was performed and revealed pelvic inflammatory disease involving both kidneys with dense adhesions. Cultures were positive for chlamydia. Both ureters were almost totally blocked. The adhesions were released. The patient had no pain post-operation. The patient was discharged and informed to return to the physician’s office within one week. WHAT ARE THE ICD-9 CODES FOR THIS ADMISSION? a. 614.9, 079.98, 59.02 b. 614.6, 079.98, 59.02 c. 614.6, 079.98, 54.59 d. 614.3, 079.98, 59.02 The correct answer is b: 614.6, 079.98, 59.02 LET’S TRANSLATE THE ICD-9 CODES TO ICD-10: 614.6 = N73.6 – female pelvic peritoneal adhesions (post-infective) 079.98 = a74.9 – chlamydia infection unspecified 59.02 = 0TN60ZZ and 0TN70ZZ – release ureter right, release ureter left 32 HBma BILLINg • jaNuarY.FeBruarY.2015 Volume 3 of the ICd-10 inpatient procedure codes translates to the Procedure Classification system (PCs). Both ureters had adhesions that were released. 0TN60ZZ is release of adhesions in the right ureter, and 0TN70ZZ is release of adhesions in the left ureter using an open approach. all PCs codes are seven digits and provide detail regarding the section, body system, root operation, body part, approach, device, and qualifier. In this case, the sections of ICd- 10-PCs are medical and surgical, the body system is the urinary system, the root operation is release, the body part is the ureter both left and right, and the approach is open. No devices were used and there were no qualifiers. The root operation release is used as the objective of the procedure, which was to free a body part from an abnormal physical constraint by cutting or by use of force. adhesiolysis falls into this category. discharge Summary #2 This patient is a 62-year-old man admitted due to unstable postinfarct angina. He had bypass surgery 10 years ago. He did well until recently, when he developed angina and had an angioplasty. He subsequently experienced chest pain and an anterior wall myocardial infarction was identified upon admission. The patient then had a coronary arteriography. He once again had chest pain and was admitted to determine if he had experienced another myocardial infarction. The patient had a cardiac catheterization with a complete left heart catheterization, left ventricular cineangiography, coronary arteriography, and bypass visualization. The left ventricle showed severe anterior hypokinesis. The left main coronary artery was obstructed approximately 70 percent. The bypass to the circumflex was normal, but the bypass to the left anterior descending had stenosis. There was a large marginal circumflex artery that had 80 percent stenosis. The patient was scheduled for bypass surgery. using extracorporeal circulation, the left internal mammary artery was anastomosed to the left anterior descending coronary artery and a venous graft was placed from the aorta to the marginal circumflex. in
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