This article provides a sample solution and responses to Unit 3 Initial Discussion Post I ICD-10 CODES
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Unit 3 Initial Discussion Post I ICD-10 CODES
The World Health Organization (WHO) develops the diagnosis classification system known as the International Classification of Diseases (ICD) as used throughout the world (Horsky et al., 2017). Within the United States, ICD-10-CM is the clinical modification of ICD -10 adapted for Health Statistics by the Centers for Disease and Control Prevention in compliance with the HIPAA from October 1, 2015, and replaced the ICD-9-CM code set. Since all healthcare professionals have a mandatory duty to record a diagnostic code on health insurance claims, I selected the following codes after going through the Week 3 SOAP note of the bipolar patient.
| ICD-10 Diagnosis Code | ICD-10 Description |
| F31.4 | Bipolar disorder presenting episode is severe depression but with no psychotic features. |
| T50.992A | Initial encounter, intentional self-harm, poisoning by other drugs, medications, and biological substances |
| F43.21 | Adjustment disorder with depressed mood. |
| R 46.0 | Low level of personal grooming |
| Z72.0 | Tobacco use |
| T14.91XD | Attempted suicide, subsequent encounter |
| R73.03 | Abnormal levels of serum enzymes |
As I went through the Week 3 SOAP note of the 31- year old patient with Bipolar disorder, it is indicative that the patient has a chronic history of mental illness going back to her teenage years when she was hospitalized twice for depression. The bipolar diagnosis is reinforced by the current depressed with no psychotic features, as the chief informant happens to be the patient’s sister tells. The adjustment disorder with depression rests on the fact that the patient has lost her parents recently and in an unexpected way.
This could account for the adjustment disorder indicative of an incomplete grief cycle (Morttazavi et al., 2020). The suicidal ideation is warranted by the suicide attempt, a note, and empty bottles. The rest of the codes are also supported by the patient’s past medical history, social history, and abnormal laboratory findings. How to properly document the patient’s conditions since this plays a role in CMS reimbursement. Bielby et al. (2014) opine that incorrect documentation can lead to loss of revenue for the facility.
References
Horsky, J., Drucker, E. A., & Ramelson, H. Z. (2017). Accuracy and completeness of clinical coding using ICD-10 for ambulatory visits. In AMIA Annual Symposium Proceedings (Vol. 2017, p. 912). American Medical Informatics Association.
Mortazavi, S. S., Assari, S., Alimohamadi, A., Rafiee, M., & Shati, M. (2020). Fear, loss, social isolation, and incomplete grief due to COVID-19: a recipe for a psychiatric pandemic. Basic and clinical neuroscience, 11(2), 225.
Bielby, J. A., Comfort, A., Reed, A., & Wiedemann, L. A. (2014). Clinical Documentation Guidance for ICD-10-CM/PCS-Retired. Journal of AHIMA, 85(7), 52-55.
Discussion Response 1
Hi Judi,
Your sentiments on your limited experience with ICD-10 coding, I am sure, represent the views of so many other students in this class whose approach to this challenge demonstrates that to a true nurse, nursing is a calling, not a job. Like many other nurses, one comes to discover that the ICD- 10 coding is not a clinical pass-time practice to assign haphazardly(Boyd et al., 2018).
. This is because HIPAA and other requirements demand that these codes form the basis of reimbursement for services offered.
Every nurse should be aware that mastering the ICD- 10 code is not easy, but it is also not impossible. All that one has to do is practice since clinical documentation shows that the correct code is found within the patient’s health record (Quan et al., 2013). When utilized to its maximum potential, the ICD-10 can describe the severity of a patient’s illness besides the reimbursement for the healthcare organization.
References
Boyd, A. D., Jianrong‘John’Li, C. K., Zaim, S. R., Krive, J., Mittal, M., Satava, R. A., … & Lussier, Y. A. (2018). ICD-10 procedure codes produce transition challenges. AMIA Summits on Translational Science Proceedings, 2018, 35.
Quan, H., Eastwood, C., Cunningham, C. T., Liu, M., Flemons, W., De Coster, C., … & IMECCHI investigators. (2013). Validity of AHRQ patient safety indicators derived from ICD-10 hospital discharge abstract data (chart review study). BMJ Open, 3(10).
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Discussion Response 2
Hi,
Your post was informative and concise. Appropriate coding using the ICD-10 has several benefits to the patient, the physician, and the organization in general. Weiner (2018) avers that ICD -10 diagnosis coding is necessary for the era of big data as it helps to reinforce the leveraging of information collected during routine health care processes. The result is that the providers can better comprehend indicators of clinical outcomes. Additionally, the healthcare system in context can implement data-driven measures meant to enhance outcomes and assess the changing impact as healthcare continues to be transformed.
While it is true that proper documentation of a condition, whether active, in remission, or historical, helps in reimbursement, the nurse practitioner should familiarize themselves with the tenth revision of ICD as it expands on the number of categories about 5000 to 8000 (Kusnoor et al., 2020). This means that besides the reimbursements, the coding also helps in disease surveillance whenever necessary.
References
Kusnoor, S. V., Blasingame, M. N., Williams, A. M., DesAutels, S. J., Su, J., & Giuse, N. B. (2020). A narrative review of the impact of the transition to ICD-10 and ICD-10-CM/PCS. JAMIA Open, 3(1), 126-131.
Weiner, M. G. (2018). Point: is ICD-10 diagnosis coding important in the era of big data? Yes. Chest, 153(5), 1093-1095.