Provident has been engaged in ongoing DRG audits since ICD-10 was implemented in October 2015. We have identified potential DRG audit target areas related to our audit work, changes to the ICD-10 codeset, and Coding Clinic updates. We will be posting cases regularly in our newsletter. Please see this edition’s case study below:
Case Summary
73-year-old male with history of cirrhosis and colon CA, s/p resection and colostomy, presents with episodes of hematemesis and blood in colostomy bag. He was found during EGD to have bleeding esophageal varices and underwent esophageal banding.
DRG Options
Note: Full listing of secondary diagnoses and procedure code assignment not shown
Audit Considerations & Strategies
- The coder originally assigned I85.01 (esophageal varices with bleeding as the principal diagnosis) with K74.60 (cirrhosis of liver) as a secondary diagnosis
- Following the ICD-10-CM Index: Varix, esophagus, in (due to), cirrhosis of liver, the coder is directed to assign I85.11 (secondary esophageal varices with bleeding)
- 11 has an instructional note to “code first underlying disease”, which in this case is K74.60 (cirrhosis of liver)
- However, the current documentation does not link the bleeding esophageal varices to the cirrhosis, so a query is necessary
- Query example below:
Patient is a 73-year-old male with a history of cirrhosis who presents with one episode of hematemesis as well as noted maroon-colored blood in his colostomy bag.
Patient underwent an EGD with noted bleeding esophageal varices. To ensure the patient’s condition is accurately reflected, please select from the following options:
- Bleeding esophageal varices were due to cirrhosis
- Bleeding esophageal varices were unrelated to cirrhosis
- Bleeding esophageal varices were due to other cause (specify)
- Unable to determine
If the provider links the bleeding esophageal varices to the cirrhosis, the DRG will shift from 370 to 432
- Whenever reviewing cases with bleeding esophageal varices always look to see if the underlying cause is specified by the provider
- If the etiology of the varices is not documented, query for clarification
References
- ICD-10-CM Index – Varix, esophagus