Clinical Scenarios

Quality clinical documentation is essential for communicating the intent of an encounter, confirming medical necessity, and providing detail to support ICD-10 code selection. In support of this objective, we have provided outpatient focused scenarios to illustrate specific ICD-10 documentation and coding nuances related to your specialty. 

The following scenarios were natively coded in ICD-10-CM and ICD-9-CM. As patient history and circumstances will vary, these brief scenarios are illustrative in nature and should not be strictly interpreted or used as documentation and coding guidelines. Each scenario is selectively coded to highlight specific topics; therefore, only a subset of the relevant codes are presented.

Scenario 1: Hypertension/Cardiac Clearance

Scenario Details 

Chief Complaint 

• “Dr. Smith asked that you check my hypertension prior to my surgery.” 

History 

• 81 year old male scheduled for a TURP in 5 days. Dr. Smith requested evaluation for hypertension and cardiac clearance assessment for surgery1 .

 • Inferior wall MI one year ago, received thrombolytic therapy and experienced complete resolution of his symptoms. Last EF (last month) was 50%. 

• Regular physical activity includes walking, swimming, and golfing. He denies SOB with exertion. 

• No history of cerebrovascular disease. No DM, CHF, renal failure, or angina. 

• Has history of essential hypertension and was prescribed metoprolol succinate once daily by PCP, but patient is not taking as he cannot afford it2 . 

Exam

• Patient is an 81 year old male in no acute distress. Height and weight are appropriate for age. 

• Vitals taken; BP is elevated at 157/92. 

• Chest is clear. Physical exam is normal. No pedal edema. 

• EKG shows nonspecific T-wave changes. 

• Labs show creatinine at 1.5, a slight increase from his baseline and possibly indicating early renal insufficiency3 .

Assessment and Plan 

• Will have PCP monitor BUN & Creatinine for renal function and nephrology referral if necessary. 

• HTN4 is likely due to patient’s noncompliance with metoprolol succinate. Will coordinate with Dr. Smith as unclear if he was aware of financial situation. Change to propranolol 20 mg, 2 tab PO daily, first dose administered in office. Provided 30 day supply of free propranolol samples. 

• Reevaluate HTN4 in 3 days; if improving then clear for surgery.

Summary of ICD-10-CM Impacts

1.Clinical Documentation 1.Documenting why the encounter is taking place is important, as the coder will assign a different code for a routine visit vs. a surgery clearance vs. an initial visit. 

2.If known, it is important to document whether or not patients are compliant with their medications. “Underdosing” is a new concept in ICD-10-CM and can be captured along with the diagnoses, such as this case for metoprolol succinate. When an issue with underdosing is noted, document if the matter is new or has been recurrent. The ICD-10-CM terms provide new detail as compared to the ICD-9-CM code V15.81, history of past noncompliance. In this case there was no noted history of noncompliance. 

3.Documentation indicates that lab results reveal “a slight increase his baseline and possibly indicating early renal insufficiency. Guidelines allow the reporting of additional diagnosis to support the abnormal test result. 

4.In ICD-10 CM coders are provided the “Use Additional Code” note under the Hypertensive diseases (I10-I15) block. If known, document whether or not the patients have the following: exposure to environmental tobacco smoke, history of tobacco use, occupational exposure to environmental tobacco smoke, tobacco dependence, and or tobacco use. In this case there was no noted history of the above.

Coding

ICD-9-CM Diagnosis Codes

401.9 Unspecified essential hypertension

794.31 Nonspecific abnormal electrocardiogram [ECG] [EKG]

794.4 Nonspecific abnormal results of function study of kidney

412 Old myocardial infarctions 

N/A 

N/A 

V72.81 Pre-operative cardiovascular examination

ICD-10-CM Diagnosis Codes

I10 Essential (primary) hypertension

 R94.31 Abnormal electrocardiogram [ECG] [EKG] 

R94.4 Abnormal results of kidney function studies 

I25.2 Old myocardial infarction 

T46.5X6A Underdosing of other antihypertensive drugs, [initial encounter] 

Z91.120 Patient’s intentional underdosing of medication regimen due to financial hardship 

Z01.810 Encounter for pre-procedural cardiovascular examination

Other Impacts 

For hierarchical condition categories (HCC) used in Medicare Advantage Risk Adjustment plans, certain diagnosis codes are used as to determine severity of illness, risk, and resource utilization. HCC impacts are often overlooked in the ICD-9-CM to ICD-10-CM conversion. The physician should examine the patient each year and compliantly document the status of all chronic and acute conditions. HCC codes are payment multipliers.