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

1. ICD-10-CM Index – Varix, esophagus