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Are you missing out on revenue because of improper coding?
Getting paid requires accurate documentation and selecting the correct codes. In our Coding Case Studies, we will explore the correct coding for a specific condition based on a hypothetical clinical scenario. This scenario involves a patient presenting with symptoms of dementia; see if you can choose the correct codes.
Resident is followed for Dementia, Hypertension, HLD, anxiety, insomnia, and debility. Meds reviewed and updated. Resident continues to be in long term care at facility. Labs reviewed and will be ordered as clinically indicated. Res denies c/o pain.
Review of Systems
Constitutional: Positive for activity change.
HENT: Positive for trouble swallowing.
Respiratory: Positive for cough and shortness of breath.Aspiration PNA
Cardiovascular: Negative for leg swelling. HTN
GI: Positive for constipation.
Musculoskeletal: Positive for back pain and gait problem.
Neurological: Positive for weakness.
Psychiatric/Behavioral: Positive for confusion and sleep disturbance.
Smoking status: Quit 5 years ago
No known allergies
Acetaminophen (Tylenol) 325 mg tablet, Take 650 mg by mouth 3 (three) times daily Maximum dose of acetaminophen is 4,000 mg from all sources in 24 hr
ARIPiprazole (Abilify) 2 mg tablet, Take 4 mg by mouth daily
Donepezil (Aricept) 10 mg tablet, Take 10 mg by mouth, Nightly
Hydrocortisone 0.5 % cream, Apply topically 2 (two) times daily, Apply to rash
Lorazepam (Ativan) 0.5 mg tablet, Take one tablet (0.5 mg total) by mouth daily, 30 tablet
Magnesium hydroxide (Milk of Magnesia) 400 mg/5 mL suspension, Take 30 mLs by mouth nightly as needed for constipation
Trazadone 50 mg tablet. Take 100 mg by mouth nightly.
Constitutional: He appears well-developed.
Head: Normocephalic and atraumatic.
Eyes: EOM are normal. Pupils are equal, round, and reactive to light.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Normal rate, regular rhythm and intact distal pulses.
Pulmonary/Chest: Effort normal and breath sounds normal. o2 sats 95%
Abdominal: Soft. Bowel sounds are normal.
Musculoskeletal: He exhibits no edema, Moves all extremities independently
Neurological: He is alert, Oriented x1, Able to follow simple commands
Skin: Skin is warm and dry, Noted right ankle wanderguard intact
Psychiatric: Cognition and memory are impaired.
Nursing note and vitals reviewed.
Assessment and Plan
Late onset Alzheimer’s disease without behavioral disturbance
Generalized anxiety disorder
Insomnia, unspecified type
Continue meds and therapy as ordered
Meds reviewed and updated
Resident to continue to be in long term care at facility
Documentation Coding Requirements
When documenting dementia, include the following:
With or without behavior disturbance
Sedative, hypnotic or anxiolytic-induced
ICD-10 Codes for Dementia
Vascular dementia with behavioral disturbance P
Vascular dementia without behavioral disturbance P
Dementia in other diseases classified elsewhere without
behavioral disturbance P
Dementia in other diseases classified elsewhere with
behavioral disturbance PP
Unspecified dementia without behavioral disturbance
Unspecified dementia with behavioral disturbance P
Alcohol dependence with alcohol-induced
persisting dementia P
Alcohol use, unspecified with alcohol-induced persisting dementia P
Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced
Sedative, hypnotic or anxiolytic use, unspecified
with sedative, hypnotic or anxiolytic-induced
Inhalant abuse with inhalant-induced dementia
Inhalant dependence with inhalant-induced dementia
Inhalant use, unspecified with inhalant-induced persisting dementia
Other psychoactive substance abuse with psychoactive substance-induced persisting dementia
Other psychoactive substance dependence with psychoactive substance-induced persisting dementia
Other psychoactive substance use, unspecified with psychoactive substance-induced persisting dementia
Other frontotemporal dementia P
Dementia with Lewy bodies P
Code first the underlying physiological condition or sequelae of cerebrovascular disease
Code first the underlying physiological condition, such as:
Alzheimer’s (G30.-), cerebral lipidosis (E75.4), Creutzfeldt-Jakob disease (A81.0-), dementia with Lewy bodies (G31.83), dementia with Parkinsonism (G31.83), epilepsy and recurrent seizures (G40-G40.B19), frontotemporal dementia (G31.09), hepatolenticular degeneration (E83.01), human immunodeficiency virus [HIV] disease (B20), Huntington’s disease (G10), hypercalcemia(E83.52), hypothyroidism, acquired (E01-E03.9), intoxications (T36-T65.94XS), Jakob-Creutzfeldt disease (A81.0-), multiple sclerosis (G35), neurosyphilis (A52.17), niacin deficiency [pellagra] (E52), Parkinson’s disease (G20), Pick’s disease (G31.01), polyarteritis nodosa (M30.0), prion disease (A81.9), systemic lupus erythematosus (M32-M32.9), traumatic brain injury (S06.-), trypanosomiasis (B56-B56.9, B57-B57.5, ), vitamin B deficiency (E53.8)
Use additional code, if applicable, to identify wandering in dementia in conditions classified elsewhere (Z91.83)
Use additional code for blood alcohol level, if applicable (Y90.-)
Use additional code to identify dementia with behavioral disturbance (F02.81), dementia without behavioral disturbance (F02.80)
Alzheimer’s disease with late onset
Dementia in other diseases classified elsewhere without behavioral disturbance
Generalized anxiety disorder