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CASE SCENARIOS FOR CODING
INSTRUCTIONS: The following 12 case scenarios provide a brief summary of a patient case. Review the scenario to determine what ICD-10-CM and ICD-10-PCS codes should be reported. Be sure to note what care setting in which the patient is receiving care as this is important! The patient is receiving: Inpatient Care Apply UHDDS definitions and Official Coding Guidelines for coding and reporting. Apply POA Indicators Y = Yes - present at the time of admission N = No - not present at the time of admission U = Unknown - documentation is insufficient to determine if the condition is present on admission W = Clinically Undetermined - Provider is unable to clinically determine whether the condition was present on admission or not. Exempt = Exempt from POA reporting. The condition must be on the list of ICD-10-CM codes for which this field is not applicable. make a DRG Sheet for each case so you have the information readily available to enter the DRG number. If the patient's age is 65 or more, use the Medicare Grouper. If the patient's age is less than 65, use the APR grouper. Outpatient Clinic Care Apply outpatient coding guidelines. Emergency Department Care Apply outpatient coding guidelines Question 1 Inpatient admission: The patient, a 79-year-old man, was admitted through the emergency department for severe urinary retention. In the emergency department, it was also determined that his hypertension was accelerated. He had been
hospitalized three months earlier for identical problems, and he said he had not taken any of his medications since the last hospitalization, as he could not afford the cost. The urinary retention was relieved by placement of a Foley catheter. Medications were started, and the hypertension improved rapidly. The patient was evaluated for the extent of benign prostatic hypertrophy. Transurethral resection of the prostate was recommended, but it was refused by the patient. Discharge diagnoses: (1) Hypertensive urgency, (2) acute urinary retention secondary to benign hypertrophy of the prostate, (3) noncompliance with treatment program. Find the below DRG #: DRG 315 - Other Kidney and Urinary Tract Procedures with MCC Admitting Diagnosis Code: N39.0 - Urinary tract infection, site not specified Principal Diagnosis Code: I12.9 - Hypertensive heart and chronic kidney disease, unspecified Secondary Diagnosis Code - POA1: R33.8 - Other retention of urine Secondary Diagnosis Code - POA2: N40.1 - Enlarged prostate with lower urinary tract symptoms Secondary Diagnosis Code - POA3: Z91.19 - Patient's intent not to undergo other specified medical treatment Secondary Diagnosis Code - POA4: Secondary Diagnosis Code - POA5: Principal Procedure Code: No principal procedure was mentioned in the scenario. Analysis of the Case Patient Information Patient Age: 79 years old (Medicare Grouper applies). Reason for Admission: Severe urinary retention with accelerated hypertension. Treatment and Outcome: o Foley catheter was placed to relieve urinary retention. o Medications started for hypertension, which improved. o The patient refused a recommended transurethral resection of the prostate (TURP). Discharge Diagnoses
- Hypertensive urgency (accelerated hypertension).
- Acute urinary retention secondary to benign prostatic hypertrophy (BPH).
Field Code DRG #: 700 - Other Kidney and Urinary Tract Diagnoses with MCC Admitting Diagnosis Code: R33.8 – Other retention of urine Principal Diagnosis Code: R33.8 – Other retention of urine Secondary Diagnosis Code
- POA1: I16.0 – Hypertensive urgency **Secondary Diagnosis Code
- POA2: N40.1** – Benign prostatic hyperplasia with LUTS **Secondary Diagnosis Code
- POA3: Z91.120** – Patient's intentional underdosing (financial) Principal Procedure Code: 0T9B70Z – Insertion of Foley catheter Rationale for Changes The admitting diagnosis and principal diagnosis were both driven by urinary retention, as this was the immediate reason for admission and intervention. Hypertensive urgency was a secondary but significant condition requiring treatment and is coded accordingly. Noncompliance with treatment (Z91.120) was specified as due to financial hardship, aligning with coding guidelines. The Foley catheter insertion was the principal procedure performed to address the patient's condition Question 2 Inpatient admission: The 56-year-old male patient was admitted for recurrent epistaxis that did not respond to nasal packing in the emergency department. He was status post myocardial infarct seven weeks earlier, with no current symptoms. An EKG was performed to evaluate the status of the MI. The patient also suffered from a deviated nasal septum. Multiple attempts were made to stop the bleeding with more packing, but none was successful for more than a few hours. Therefore, the following procedures were performed:
- anterior and posterior nasal packing,
- endoscopic ethmoidal artery ligation,
- endoscopic septoplasty. He was transfused via peripheral vein with two units of packed red cells during the operation.
Discharge diagnoses:
- Severe and recurrent epistaxis,
- post myocardial infarct,
- deviated nasal septum. DRG #: DRG 476 - Nose, Mouth, and Throat Procedures with MCC Admitting Diagnosis Code: R04.0 - Epistaxis Principal Diagnosis Code: R04.0 - Epistaxis Secondary Diagnosis Code - POA1: I21.9 - Acute myocardial infarction, unspecified Secondary Diagnosis Code - POA2: J34.89 - Other specified disorders of nose and nasal sinuses Principal Procedure Code: 09H03DZ - Control Hemorrhage in Nasal Sinus, Open Approach What Happened to the Patient? Admission Reason: o The patient, a 56-year-old man , was admitted to the hospital because of recurrent epistaxis (severe nosebleeds). o The nosebleed was so severe that nasal packing in the emergency room did not stop it. Medical History: o The patient had a myocardial infarction (heart attack) seven weeks ago, but he had no current heart symptoms. o He also had a deviated nasal septum (a crooked wall inside the nose). Procedures Performed: o Anterior and posterior nasal packing (to stop the bleeding). o Endoscopic ethmoidal artery ligation (tying off the artery that caused the bleeding). o Endoscopic septoplasty (fixing the deviated nasal septum). o Blood transfusion (two units of red blood cells were given because the patient lost blood). Discharge Diagnoses: o Severe and recurrent epistaxis (main problem). o Post myocardial infarction (history of a heart attack). o Deviated nasal septum (a condition that was treated with surgery).
I21.9 (Heart attack): This reflects the patient’s history of a heart attack. Even though it wasn’t an active issue, it affected the care plan, especially during surgery. J34.89 (Other nasal disorders): This code reflects the deviated nasal septum , which was treated surgically during the stay. POA Indicators: Y = Yes means both of these conditions were present when the patient was admitted. Principal Procedure Code 09H03DZ - Control of hemorrhage in nasal sinus, open approach: o This code describes the surgical procedure to stop the bleeding by controlling the artery (ethmoidal artery ligation). o Even though the procedure was done endoscopically , this code is the most accurate description for "control of hemorrhage." How Was the Answer Reached? To determine the correct codes and DRG:
- The main reason for admission (severe nosebleed) became the principal diagnosis (R04.0).
- The procedures performed to treat the nosebleed, including artery ligation and septoplasty, were considered for coding.
- The history of heart attack (I21.9) and deviated nasal septum (J34.89) were secondary diagnoses, as they impacted treatment or were addressed during the stay.
- The DRG was assigned based on the principal diagnosis and the significant nose procedures. Final Answer Summary Field Code/Description DRG #: 476 - Nose, Mouth, and Throat Procedures with MCC Admitting Diagnosis Code: R04.0 – Epistaxis Principal Diagnosis Code: R04.0 – Epistaxis Secondary Diagnosis Code - POA1: I21.9 – Acute myocardial infarction Secondary Diagnosis Code - J34.89 – Other nasal disorders
Field Code/Description POA2: Principal Procedure Code: 09H03DZ – Control of hemorrhage in nasal sinus Question 3 Inpatient admission: The reason for the 45-year-old male patient's admission was substernal chest pain with some arm involvement. A combined right and left selective low osmolar contrast coronary angiography with fluoroscopy and a bilateral low osmolar contrast pulmonary angiography were performed. No coronary artery disease or pulmonary embolus was found. Discharge diagnosis: Chest pain without occlusive coronary artery disease. DRG #: DRG 313 - Chest Pain Admitting Diagnosis Code : R07.9 - Chest pain, unspecified Principal Diagnosis Code: R07.9 - Chest pain, unspecified Principal Procedure Code: 04H03JZ - Dilation of Right Coronary Artery, Bifurcation, with Intraluminal Device, Open Approach Secondary Procedure Code : 04H03JZ - Dilation of Left Coronary Artery, Bifurcation, with Intraluminal Device, Open Approach What Happened to the Patient? Reason for Admission: o A 45-year-old male was admitted due to substernal chest pain (pain in the center of the chest) that involved his arm. o Chest pain like this often raises concerns for heart-related issues or blood clots in the lungs (pulmonary embolism). Procedures Performed: o Coronary Angiography: A procedure that uses dye and X-rays to look at the blood flow in the heart's arteries. This checks for blockages in the coronary arteries. Right and left selective coronary angiography (both coronary arteries were evaluated). o Pulmonary Angiography: A test to check for blockages or clots in the lung arteries. o No evidence of coronary artery disease (blockages) or pulmonary embolus (lung clots) was found. Discharge Diagnosis:
- B34C1ZZ – Fluoroscopy of pulmonary arteries, bilateral (pulmonary angiography). These codes better describe the diagnostic nature of the procedures. Revised Summary Field Code/Description DRG #: 313 - Chest Pain Admitting Diagnosis Code: R07.9 – Chest pain, unspecified Principal Diagnosis Code: R07.9 – Chest pain, unspecified Principal Procedure Code: 02B43ZZ – Fluoroscopy of coronary arteries, bilateral Secondary Procedure Code: B34C1ZZ – Fluoroscopy of pulmonary arteries, bilateral Simplified Explanation (Middle School Level) Imagine you feel a strong pain in the middle of your chest, and it scares you because it might be a heart problem. You go to the hospital, and the doctors run special tests to see if the blood vessels in your heart or lungs are blocked. They use dye and X-rays to look closely at the blood flow in your heart and lungs. Luckily, the tests show that everything is normal—no blockages! So, the doctors say the pain isn’t from a heart attack or blood clot. When doctors record the visit:
- They write down chest pain as the main issue (R07.9).
- The tests (coronary and pulmonary angiography) are recorded as procedures to check blood flow. Since no treatment (like opening a blocked artery) was needed, the hospital stay is grouped under DRG 313 - Chest Pain. Key Takeaways
- Principal Diagnosis: Chest pain remains the focus because no disease was found.
- Procedure Codes: Correct codes reflect the diagnostic angiography (looking for blockages), not treatment procedures like dilation.
- DRG 313: Fits the case because it groups patients admitted for chest pain without serious findings or major procedures. Question 4 Inpatient admission: The patient has a known diagnosis of prostatic cancer. He started having fevers approximately one week earlier. The fevers did not respond to outpatient antibiotics. Blood and urine cultures showed no growth. He was admitted for workup of the fevers with possible prostatic abscess formation. There were no obvious signs of infection or abscess on a transrectal ultrasound of the prostate. An iodine-123 radioisotope bone scan of the body revealed no skeletal metastases. The antibiotic therapy was changed, and he was given an IV push. He improved and was discharged. Discharge diagnoses: (1) Fever of unknown origin (2) cancer of the prostate. DRG #: DRG 867 - Other Infectious and Parasitic Diseases Diagnoses with MCC Admitting Diagnosis Code: C61 - Malignant neoplasm of prostate Principal Diagnosis Code : R50.9 - Fever, unspecified Secondary Diagnosis Code - POA1: Principal Procedure Code: No principal procedure was mentioned in the scenario. Patient Case Summary Reason for Admission o The patient has known prostatic cancer. o He started having fevers about a week ago, and antibiotics didn’t work. o No infections were found in blood or urine tests, and imaging (ultrasound) ruled out a prostate abscess. o A bone scan revealed no cancer spread to the bones (no metastasis). o The patient's condition improved with IV antibiotics. Discharge Diagnoses o (1) Fever of unknown origin o (2) Cancer of the prostate Coding and Rationale DRG Assignment
Final Summary Field Code/Description DRG #: 867 - Other Infectious and Parasitic Diseases Diagnoses with MCC Admitting Diagnosis Code: C61 - Malignant neoplasm of prostate Principal Diagnosis Code: R50.9 - Fever, unspecified Secondary Diagnosis Code: C61 - Malignant neoplasm of prostate (POA: Y) Principal Procedure Code: No procedure Explanation (Middle School Level) The patient had prostate cancer and came to the hospital because he had a fever that wouldn’t go away. The doctors tested his blood, urine, and prostate to see if there was an infection or abscess, but they found nothing. A special bone scan showed the cancer hadn’t spread to his bones. The doctors gave him IV antibiotics , and he got better, so they sent him home. Here’s how the hospital records this:
- The main issue was the fever (this becomes the principal diagnosis : R50.9).
- The prostate cancer is also recorded because it’s a big health condition that could affect his recovery (coded as C61 ).
- Since no surgery or major procedure was done, no procedure codes are added. The hospital groups this case under DRG 867 , which covers fevers and infections when a big health condition like cancer is also involved. Question 5 Inpatient admission: The two-year-old patient had an acute onset of fever and some shaking chills at home. He was thought to have experienced a febrile seizure and was admitted for workup and treatment. There was some infiltrate in the right lung per chest X-ray. All laboratory work was within normal limits. He was observed
during his stay. No problems were noticed, and he remained afebrile after the first day. He was discharged for office follow-up. Discharge diagnosis: Rule out febrile seizure. Find the below DRG # : Admitting Diagnosis Code : Principal Diagnosis Code : Question 5: DRG #: DRG 101 - Seizures with MCC Admitting Diagnosis Code: R56.9 - Unspecified convulsions Principal Diagnosis Code: R56.9 - Unspecified convulsions Principal Procedure Code: No principal procedure was mentioned in the scenario. Question 6 Inpatient admission: The patient was admitted through the emergency department with possible acute cholecystitis. She had severe abdominal pain and a markedly elevated white count. A gallbladder ultrasound, fluoroscopic cholecystogram using Visipaque contrast, and bilateral Visipaque contrast intravenous pyelogram were all normal. The next day her pain was almost gone, and the white blood count dropped to nearly normal. It was not felt worthwhile to continue the workup. Discharge diagnoses: (1) Abdominal pain, (2) leukocytosis. find the below DRG # : Admitting Diagnosis Code : Principal Diagnosis Code : Secondary Diagnosis Code : POA Principal Procedure Code : Secondary Procedure Code: Secondary Procedure Code: Question 6:
First Listed Diagnosis Code : AdditionalDiagnosis Code : AdditionalDiagnosis Code : Question 9 Inpatient admission: The patient, a woman with type 1 diabetes, was admitted because of increased swelling of the right foot that was determined to be an abscess. Staphylococcus aureus grew from the abscess. She underwent a percutaneous incision and drainage of the foot abscess. Her course in the hospital otherwise was essentially unremarkable. The foot gradually improved with antibiotic therapy, hyperbaric oxygen therapy, and daily whirlpool therapy. Discharge diagnoses: (1) Abscess right foot, (2) type 1 diabetes mellitus. find the below DRG # : Admitting Diagnosis Code : Principal Diagnosis Code : Secondary Diagnosis Code : POA Secondary Diagnosis Code : POA Principal Procedure Code : Secondary Procedure Code: Secondary Procedure Code: Question 10 Inpatient admission: The 1-year-old child was admitted with a fever and lethargy. When admitted, he was responsive but lethargic. The physical examination was within normal limits except for the left eardrum, which was reddened. He was placed on intravenous antibiotics after the full septic workup was complete. Improvement was evident by the next day, when he was alert, active, and started on feedings. He became afebrile and was discharged on oral antibiotics for otitis media, with sepsis ruled out. Discharge diagnoses: (1) Fever, (2) otitis media. find the below
DRG # :
Admitting Diagnosis Code : Principal Diagnosis Code : Question 11 Inpatient admission: The patient, a 10-month-old male, presented with acute stridor and respiratory distress. His mother felt that he had possibly choked on a peach. Nothing was seen on chest X-ray. A rigid bronchoscopy ruled out foreign body, but the findings were consistent with croup. He was discharged on medication to follow up with his pediatrician in one week. Discharge diagnosis: Croup. find the below DRG # : Admitting Diagnosis Code : Principal Diagnosis Code : Principal Procedure Code: Question 12 Emergency department visit: A 26-year-old male, involved in a car crash, was taken to the local emergency department (ED) in a coma, where he was diagnosed with a traumatic brain injury with loss of consciousness of one hour. Glasgow coma scale (GCS) was 6 on arrival in the ED. Patient was transferred to a trauma center for further care. Discharge diagnosis: Traumatic brain injury. find the below First Listed Diagnosis Code : Additional Diagnosis Code : Additional Diagnosis Code :
First Listed Diagnosis Code: S06.9X9A - Traumatic brain injury without loss of consciousness, initial encounter Additional Diagnosis Code: Additional Diagnosis Code: Please note that for some scenarios, no specific DRG number or principal procedure code was mentioned in the provided information. You may need to consult the latest coding guidelines and resources for the most accurate and up-to-date coding information. Step-by-step explanation Question 1: DRG #: DRG 315 - Other Kidney and Urinary Tract Procedures with MCC This DRG is assigned because the patient had urinary retention and hypertensive urgency, which required medical management and treatment. Admitting Diagnosis Code: N39.0 - Urinary tract infection, site not specified This code reflects the urinary tract infection as the admitting diagnosis. Principal Diagnosis Code: I12.9 - Hypertensive heart and chronic kidney disease, unspecified The principal diagnosis is based on the hypertensive urgency, which was a significant condition. Secondary Diagnosis Codes: POA1: R33.8 - Other retention of urine (present on admission) POA2: N40.1 - Enlarged prostate with lower urinary tract symptoms (present on admission) POA3: Z91.19 - Patient's intent not to undergo other specified medical treatment (present on admission) POA4: POA5: These codes indicate other conditions and patient history. Question 2: DRG #: DRG 476 - Nose, Mouth, and Throat Procedures with MCC This DRG is assigned due to the multiple procedures performed on the nasal and throat area. Admitting Diagnosis Code: R04.0 - Epistaxis This code reflects the reason for admission, which was severe and recurrent epistaxis. Principal Diagnosis Code: R04.0 - Epistaxis The principal diagnosis is the same as the admitting diagnosis. Secondary Diagnosis Codes: POA1: I21.9 - Acute myocardial infarction, unspecified (present on admission) POA2: J34.89 - Other specified disorders of nose and nasal sinuses (present on admission) Principal Procedure Code: 09H03DZ - Control Hemorrhage in Nasal Sinus, Open Approach
This code represents the principal procedure performed during the admission. Question 3: DRG #: DRG 313 - Chest Pain This DRG is assigned because the patient was admitted with chest pain. Admitting Diagnosis Code: R07.9 - Chest pain, unspecified The admitting diagnosis reflects the reason for admission. Principal Diagnosis Code: R07.9 - Chest pain, unspecified The principal diagnosis is also chest pain. Principal Procedure Code: 04H03JZ - Dilation of Right Coronary Artery, Bifurcation, with Intraluminal Device, Open Approach This code represents the principal procedure performed during the admission. Question 4: DRG #: DRG 867 - Other Infectious and Parasitic Diseases Diagnoses with MCC This DRG is assigned due to the fever and the possibility of prostatic abscess. Admitting Diagnosis Code: C61 - Malignant neoplasm of prostate This code reflects the known diagnosis of prostatic cancer. Principal Diagnosis Code: R50.9 - Fever, unspecified The principal diagnosis is the fever. Secondary Diagnosis Code: POA1: No specific secondary diagnosis code was provided in the scenario. Principal Procedure Code: No principal procedure was mentioned in the scenario. Question 5: DRG #: DRG 101 - Seizures with MCC This DRG is assigned due to the rule-out of febrile seizure in a child. Admitting Diagnosis Code: R56.9 - Unspecified convulsions This code reflects the rule-out of febrile seizure. Principal Diagnosis Code: R56.9 - Unspecified convulsions The principal diagnosis is the same as the admitting diagnosis. Principal Procedure Code: No principal procedure was mentioned in the scenario. Question 6: DRG #: DRG 390 - G.I. Obstruction with MCC This DRG is assigned due to the abdominal pain and leukocytosis. Admitting Diagnosis Code: R10.9 - Unspecified abdominal pain This code reflects the abdominal pain as the admitting diagnosis. Principal Diagnosis Code: R10.9 - Unspecified abdominal pain The principal diagnosis is the same as the admitting diagnosis. Secondary Diagnosis Code - POA1: R74.8 - Abnormal serum enzyme levels (present on admission) Principal Procedure Code: 0FB60ZZ - Inspection of Large Intestine, Via Natural or Artificial Opening, Endoscopic
