Reference no: EM133345783

Using the coding scenario:

1. Code the case using the ICD-10-CM Code Book and then code it again using the 3M Encoder from the vLab.  Compare your codes and process for each, and ability to see instructional notes and other resources.
2. This is an inpatient case.  Can you find the MS-DRG and APR-DRG? 
   • Make sure DRGFinder is selected on the first screen of the Encoder where you enter the patient age.
   • The first diagnosis you enter is the admission diagnosis.  The second diagnosis is the principal diagnosis.  These may or may not be the same depending on whether or not there was a definitive diagnosis at the time the patient was admitted.  After you enter the principal diagnosis you should see the MS-DRG.  You can continue adding secondary diagnoses and see if it changes the MS-DRG.
   • To get the APR DRG or the All Patient Refined DRG, go back to the first screen (by choosing next patient) and change Medicare to one of those other options.
3. Are any codes marked as a CC or MCC?  What does that mean and why is it important? 
4. Assign the POA indicators.  These are required for all inpatient diagnosis codes, both principal and secondary.
5. Find a coding clinic article that relates to a condition coded.  See instructions in earlier modules about accessing coding clinic.  Cite the source (year, edition) of the coding clinic where the article or Q&A was located.
6. Find the UHDDS definition for significant procedures.  How does that affect what you code for inpatients? 
7. What was the primary reason the patient originally came into the ER?  Is this different than the primary reason the patient was admitted to inpatient status?

Principal Diagnosis code:

Index entries:

Secondary diagnosis code(s):

Index entries:

Case Scenario:

A 4-year-old boy was brought to the emergency department by his mother, who stated the child had become ill very rapidly over the course of 1 day. He had been treated for a right ear infection at the pediatric clinic last week. Upon physical examination, the emergency department physician noted a high fever, drowsiness, and stiffness in the neck. The mother reported the child had said his head hurt and also reported that he had vomited at home. The physician noted slight rash on the child's upper trunk and axilla bilaterally. Suspicious of meningitis, the physician requested and obtained a pediatric consult. The emergency department physician and pediatrician obtained consent for a diagnostic spinal tap, which was performed, and the child was admitted to the pediatric unit.

Over the next couple of days, the pediatrician made the diagnosis of bacterial meningitis with the causative organism of haemophilus influenzae (H. influenzae) based on the physical findings and the examination of the cerebrospinal fluid obtained by the spinal tap. The child is treated with intravenous antibiotics and other medications as well as supportive care. The pediatrician found the acute suppurative otitis media of the right ear still needed treatment. The child made a full recovery but will be followed closely as an outpatient to determine whether any effects of the meningitis, such as hearing loss, occur later. The child was discharged to the care of his mother.