APDC: Relevant conditions and scenarios that affects the eyes – Part 1

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ICD-10-book-cover-for-APDC-series-labelIn everyday International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) Version 2010 coding, answers to your coding questions can be found by reviewing or referring to the ICD-10 coding books. However, in this post I like to highlight some key documentation elements for the eye and adnexa.

On of the first things to take note when coding diseases of the eye and adnexa is when a Health Information Management (HIM) / Medical Records (MR) practitioner coder will find codes with the letter H shared among two chapters of the ICD-10.

I am sure a HIM / MR practitioner must already know that the ICD-10 classification is divided into 21 chapters, the first character of any ICD-10 code is a letter, one letter is generally associated with a particular chapter, except for some letters like the letter H will be found among codes in both Chapter VII, Diseases of the eye and adnexa and Chapter VIII, Diseases of the ear and mastoid process.

I shall not be detailed in this post but I intend to lead a discussion of the various diseases, disease processes, disorders, injuries, and conditions, some diagnostic statements related to diseases of the eye and adnexa.  I shall confine to infectious diseases of the eye, neoplasms of the eye, eyelid disorders, the lacrimal system, the conjunctiva, and end with the sclera, cornea, iris, and ciliary body.

One of the common diseases of the eye and adnexa are due to infections of the eye. I can quickly relate to viral conjunctivitis, eye infections that often involves the conjunctiva that are reported with codes from Chapter 1 Certain Infectious and Parasitic Diseases.  My experiences have shown that only a few eye infections are reported with codes from Chapter 1 while I think the vast majority of eye infections are reported with codes from Chapter 7 – Diseases of the Eye and Adenxa.  Do take note of some types of conjunctivitis that are reported with a single code from Chapter 1.

All parts of the eye may be affected by neoplasms. which may be primary, secondary (metastatic) or benign. Coders then will need to rush into Chapter II – Neoplasms and look up for example, the malignant neoplasms of eye and adnexa under ICD-10 code C69.

Symptoms that include eyelid tenderness or pain, increased tearing, and sensitivity to light are reported as chalazion, when the Meibomian gland (tiny oil gland in the eye) duct is blocked. Blepharitis is an inflammation of the eyelash follicles, along the edge of the eyelid. Entropions, when there is a turning inward of the eyelid so that the eyelashes rub against the surface of the eye can irritate the eye and in severe cases may cause corneal abrasion, ulcer, or scarring. Entropions may be acquired or congenital.  Acquired entropions and ectropions are two conditions that occurs primarily in the elderly (senile populations). Coding chalazion, blepharitis, but less of entropions and etropions (you probably get to code these two if you work at a hospital or eye centre with an eye speciality) are some common diagnoses I have encountered.

Look out for subtle differences in coding for example when coding chronic enlargement of the lacrimal gland as against chronic dacryadenitis. When dacryadenitis is reported alone, then assign code to H04.0 Chronic enlargement of the lacrimal gland, but assign code H04.4 when chronic dacryadenitis is reported.

Several conditions affect the sclera, cornea, iris and ciliary body which are structures in the anterior chamber of the eye. I can think of the cornea which is subject to inflammatory conditions such as corneal ulcer and keratitis, and conditions commonly affecting the iris and ciliary body which include inflammatory conditions such as iritis, iridocylitis, or cyclitis, and even cysts which may form in the iris or ciliary body. Disorders of sclera, cornea, iris and ciliary body are found in the block H15 to H22.

In the next instalment, I shall discuss about cataracts which is the single very common condition affecting the lens, conditions affecting the choroid and retina, moving on to glaucoma which is actually a group of diseases of the eyes characterised by damage of the optic nerve, and end with some conditions affecting the vitreous body and globe.

References:

  1. Gerard, JT & Bryan, D 2012, Principles of Anatomy & Physiology, 13th edn, John Wiley & Sons, Inc, New Jersey, USA
  2. Michael, M & Valerie, OL 2012, Human anatomy, 3rd edn, The McGraw-Hill Companies, Inc., New York, USA
  3. Phillip, T 2012, Seeley’s principles of anatomy & physiology, 2nd edn, The McGraw-Hill Companies, Inc., New York, USA
  4. World Health Organization 2011, Volume 1 Tabular list, International Statistical Classification of Diseases and Related Health Problems 10th Revision, 2010 edn, Geneva, Switzerland

APDC: Relevant conditions and scenarios that affects the eyes

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ICD-10-book-cover-for-APDC-series-labelIn the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) Version 2010, the Chapter VII: Diseases of the eye, adnexa is dedicated specifically for diseases of the eye and adnexa.

In this first part and the next post(s) dedicated to relevant conditions and scenarios that affects the eyes, I like to present most (if not all) the relevant conditions and scenarios that affects the eyes, which are considered as the most complex of the four special sense organs.

The relevant conditions and scenarios that affects the eyes are those affecting the structures that are specifically related to vision as well as accessory structures. The eyeball, optic nerve, and brain are the structures related to vision typically activated by a stimulus, such as light, in the external environment which is detected by the cells of the eye, thereby sending electrical impulses to the visual center and other parts of the brain. In addition to allowing light perception, the eye performs other tasks such as color differentiation and depth perception. The accessory structures include the eyebrows, eyelids, ocular muscles, and lacrimal glands.

As you can see from the anatomy of the human eye in the image below, the eye is divided into three layers: the fibrous tunic (also referred to as the scleretic coat – the external layer of the eye divided into two parts, the sclera, also called the white of the eye, and the anterior cornea), vascular tunic (also referred to as the uvea or choroid coat – this is the middle layer of the eye and structures contained in the vascular tunic include the choroid, ciliary body and iris), and lastly the retina (the inner layer of the eye, which is composed primarily of nervous tissue including various types of cells for the primary function of image formation).

human-eye-anatomy-[Converted]

As I am not a eye care trained nurse nor an ophthalmologist to provide a full length description of conditions and scenarios  affecting the human eye (nonetheless it is pointless doing so, when one can gain such knowledge from any good Anatomy and Physiology academic textbook), and so I shall confine myself to my perspective of past coding experiences and knowledge of common and top conditions and scenarios affecting the human eye that Health Information Management (HIM) / Medical Records (MR) practitioners may also encounter in their everyday coding duties.

If a HIM / MR practitioner reader was to examine closely the Chapter VII, he or she will find (to my best knowledge) the following ICD-10 categories relevant to the eye and adnexa with conditions and scenarios which demand eye care:

C69.*** Malignant neoplasm

D31.*** Benign neoplasms

H01.***: Conditions of the eyelid

H02.***: Entropions

H04.***: Conditions of the lacrimal system

H05.***: Conditions of the orbit

H10.***: Conjunctival conditions

H15.***: Conditions of the sclera

H16.***: Keratoconjunctivitis

H17.***: Conditions of the cornea

H18.***: Keratopathies

H20.***: Conditions of the iris

H21.***: Disorders of iris and ciliary body

H25.***: Cataracts

H26.***: Cataracts, other

H27.**: Conditions of the lens

H30.**: Chorioretinal conditions

H31.***: Conditions of the Choroid

H33.**: Conditions of the retina

H34.***: Retinal occlusions

H35.***: Retinal changes

H40.***: Glaucoma

H43.***: Vitreous codes

H44.***: Disorders of vitreous body and globe

H44.6**: Unspecified retained (old) intraocular foreign bodies

H47.***: Neuropathies

H51.***: Convergence disorders

H52.***: Refraction Disorders

H53.***: Amblyopia/visual field defects

H54.***: Blindness

H55.***: Nystagmus

H57.***: Pupillary Disorders and ocular pain

H59.***: Disorders following Surgery

R**.***: Sign and symptom codes (headache, weakness, malaise, fever, shock)

R00 – R99: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified as in the case of abnormal results of function studies of peripheral nervous system and special senses, e.g abnormal electroretinogram [ERG]

S**.***x: S Codes – injury, poisoning and certain other consequences of external causes, involving injury of eye and orbit

T**.***x: T Codes – e.g. FB in cornea

T74.***: adult and child abuse, neglect and maltreatment, using additional code, if desired, to identify current injury to the eye and adnexa (if any)

T36 -T50: Poisoning by drugs, medicaments and biological substances: poisoning by topical agents primarily affecting skin and mucous membrane and by ophthalmological, otorhinolaryngological and dental drugs e.g ophthalmological drugs and preparations as in the case of eye anti-infectives

X00 – X99: External causes of morbidity from e.g exposure to smoke, fire and flames

V01 – V99: External causes of morbidity due to transport accidents

Z00-Z99: Factors influencing health status and contact with health services, e.g examination of eyes and vision

The above list is inclusive of the nine (9) block of codes for coding conditions and scenarios related to eye and adnexa ranging from H00 to H59 in Chapter VII. However, the list also includes codes which are not classifiable to Chapter VII, as you as the interested reader can figure out from the exclusion note right at the beginning of this chapter. Attention is also required  when asterisk categories for this chapter are provided also at the beginning of this chapter for several disorders and glaucoma in diseases classified elsewhere.

Thus, HIM / MR practitioners need to be alert to coding correctly for eye care when they encounter conditions and scenarios  affecting the human eye which were not reported by any eye care speciality, signs and symptoms not specifically eye care, injuries and accident to the eye, top peripheral codes applicable to eye care such as diabetes and hypertension, Late Effect Codes listed as “Sequela” and foreign body in the eye(s).

In the next part, I plan to present a variety of diseases, disorders, injuries, and other conditions involving the eye and adnexa. I will present some images to present the anatomy and physiology of more commonly encountered conditions involving the eye and adnexa, expanding from there to provide a better understanding regarding the part of the eye or adnexa affected and how these conditions affect function.

Following the images of the more commonly encountered various diseases, disease processes, disorders, injuries, and conditions, I will of course present the ICD-10 codes and any coding concepts and guidelines relevant to Chapter VII.

References:

  1. Gerard, JT & Bryan, D 2012, Principles of Anatomy & Physiology, 13th edn, John Wiley & Sons, Inc, New Jersey, USA
  2. Michael, M & Valerie, OL 2012, Human anatomy, 3rd edn, The McGraw-Hill Companies, Inc., New York, USA
  3. Phillip, T 2012, Seeley’s principles of anatomy & physiology, 2nd edn, The McGraw-Hill Companies, Inc., New York, USA
  4. World Health Organization 2011, Volume 1 Tabular list, International Statistical Classification of Diseases and Related Health Problems 10th Revision, 2010 edn, Geneva, Switzerland

JCI Standard MCI.8 – Patient transfers within a hospital

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Patients may be transferred within the hospital during their care or to other settings outside of the hospital based on status and the need to meet their continuing care.

Let us consider the case of a patient who is transferred within the hospital. In this instance, the care team changes and so essential information related to the patient needs to be transferred with him or her to facilitate continuity of care for this patient. Thus, medications and other treatments for this patient can continue uninterrupted, and the patient’s status can be appropriately monitored.

What Health Information Management (HIM) / Medical Records (MR) practitioners need to know is in order to accomplish this information transfer when a patient is transferred within the hospital., the patient’s medical record(s) is transferred or information from the patient’s medical record is summarised at transfer as shown in the graphics below. If you work at a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then this specific requirement is as stated for JCI MCI.8 which states that “Information related to the patient’s care is transferred with the patient.”

Patient-transfer-summary-MCI,8-clipboard

Another point to take note by the general reader is when a patient is transferred to other settings outside the hospital, the transfer process is documented in the patient’s medical record including documentation of any change in patient condition or status during transfer just as in the case for a patient transferred within the hospital, as I had posted in the post 5 transfer process entries that must be entered in a medical record (this link will open in a new tab of your current browser window).

I like to conclude that I think it is appropriate for  HIM / MR practitioners who work at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, to take note that transfers within a hospital or to outside the hospital is covered by 1 standard under the Management of Communication and Information (MCI) chapter and by 5 JCI standards under the Access to Care and Continuity of Care (ACC) chapter respectively from the JCI Accreditation Standards For Hospitals, 4th Edition.

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Must medical records show evidence of specialised assessments?

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Let’s look at a simplified diagnostic process from the diagram below, when hearing, visual and dental tests are three common screening tests during the initial assessment during the review of the complaint, history and physical when the patient arrives with complaint at a hospital.

Simplified Diagnostic Process

Diagram credit: Kenneth, RW & John, RG 2010, The well-managed healthcare organization, 7th edn, Health Administration Press, Chicago, Illinois, USA

Auditory testing performed during an initial assessment is usually done with a tuning fork. Tests using a tuning fork are meant for screening only and never used for diagnostic purpose. Auditory testing provides the examiner during initial assessment with a basic idea of whether the patient has for example, a hearing loss. Thus, such a test simply provides an indication of the need for more elaborate testing and referral to a hearing specialist for more accurate testing if a problem is suspected.

Assessment of vision examines both visual acuity and anatomic structures. If you wear glasses, you had your visual acuity tested with the Snellen chart, a chart that contains various-sized letters with standardised numbers at the end of each line of letters. Visual acuity of 20/20 is considered normal. Astigmatism, hyperopia (farsightedness), myopia (nearsightedness) and presbyopia (farsightedness) are common vision related conditions. Assessment of eye structures and function present significant findings and possible causes for condtions like nystagmus and cataracts.

Another initial assessment is the assessment of the mouth, throat, nose, and sinuses which usually follows the examination of the head and neck. Examination of the mouth and throat can help detect abnormalities, for example of the lips. Early detection of oral cancer during an oral examination is an important finding. A deviated septum or detection of sinus infection are two other conditions that maybe detected during this kind of examination. Overall, the patient’s nutritional and respiratory status is also assessed.

From the diagram above, treatment is usually begun once the diagnosis is confirmed by the attending doctor, the initial caregiver. Sometimes, the initial assessment process may identify a need for other assessments.  Thus, patients maybe referred and/or discharged based on their health status and needs for continuing care by other specialised health care providers to support their continuing continued care and learning needs. Patients are referred within the hospital or discharged from the hospital to a health care practitioner outside the hospital, another care setting, home, or family when the additional specialised assessment is identified during the initial assessment.

Health Information Management (HIM) / Medical Records (MR) practitioners must take note that specialised assessments conducted within the hospital should be documented in the patient’s medical record. Medical records documentation must show evidence of specialised assessments conducted within the hospital, especially so if you work at a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, when the JCI Standard AOP.1.10 which states that “The initial assessment includes determining the need for additional specialized assessments.” requires complete documentation in the patient’s medical record of the need for additional specialised assessments conducted within the hospital.

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. Kenneth, RW & John, RG 2010, The well-managed healthcare organization, 7th edn, Health Administration Press, Chicago, Illinois, USA
  3. Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA

Medical Records and the continuum of care

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The individual responsible for the coordination of the patient’s care must be identifiable and available through all phases of inpatient care as the patient moves through a hospital from admission to discharge or transfer, several departments and services and many different health care practitioners who may be involved in providing care. Thus if a patient Nancy is under constant professional supervision, making handoffs efficient and accurate and this creates continuity throughout Nancy’s care. Since she is always in contact with trained staff, any new information regarding her behaviour will be properly notated and added to her medical records file.

In the United States, the National Quality Forum had identified in a 2006 report (Barbara 2011 p.72) the practice of information management in the medical record to document the continuity of care to matching healthcare needs with service capability, as one of the 30 safe practices that basically helps to create and sustain a culture of safety with the eventual goal “to improve the things that help and prevent the things that harm”.

In fact, the continuity of care (or continuum of care) is among a list of indicators (Judith, H and Paul, D 2009) including access, effectiveness, communication and participation, care and physical comfort, human needs, efficiency, information, and involvement of family and friends on quality care as identified by consumers (patients) who prefer holistic health care and published by the Picker Institute in Europe.

The opportunity to assess continuity of care issues to “trace” the care experiences that a patient had during his or her stay in the hospital is often used in the individual patient tracer activity conducted during the on-site survey under Tracer methodology, which is an evaluation method used to analyse a hospital’s system of providing care, treatment, and services using actual patients as the framework for assessing a hospital’s Joint Commission International (JCI) international standards compliance, i.e a hospital which is already accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status. The medical records of patients currently receiving care in the unit/setting are often used in such evaluations.

As continuity of care is a critical component of patient safety, Health Information Management (HIM) / Medical Records (MR) practitioners must be able to identify who is the responsible individual expected to provide documentation related to the patient’s plan of care because this individual is usually identified in the patient’s medical record or in another manner made known to the hospital’s staff, for example a list of doctors and their specimen signatures.

HIM / MR practitioners are expected to know that this single individual may be a doctor or other qualified individual who has the overall responsibility for coordination and continuity of the patient’s care or particular phase of the patient’s care. This individual is or was providing the oversight of care for a patient during the entire hospital stay which will improve continuity, coordination, patient satisfaction, quality, and potentially the outcomes and thus is desirable for certain complex patients and others in the hospital.

Patients may be delivered in a wide range of community and hospital-based settings and moved from one phase of care to another (for example, from surgical to rehabilitation). The ability to share information between these settings may be limited and fragmented, as a result what usually happens is delays in care when health care providers who are poorly informed ‘reinvent the wheel’ and begin to duplicate procedures and investigations. If the individual originally responsible for the patient’s care continues to oversee all the patient’s care, then a reduction in the quality of care will not be likely nor will it impair continuity of patient care or threaten the patient’s safety. But if this individual originally responsible for the patient’s care changes, this individual would need to collaborate and needs to communicate with the other health care practitioners.

What if the patient goes to multiple doctors in multiple settings that do not have an integrated information system when the health care delivery organisation cannot provide coordination and continuity? I think a patient can take charge of his or her data although it is a challenging responsibility, and so I would advocate and believe that the personal health records approach can bring together a patient’s health information.

If you are a HIM / MR practitioner practising at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then beware that the JCI Standard ACC.2.1 which states that “During all phases of inpatient care, there is a qualified individual identified as responsible for the patient’s care.”

This will require you to:

  1. be aware that the process of continuity of care according to Michelle and Mary (2011, p.71) includes “documentation of patient care services so that others who treat the patient have a source of information from which to base additional care and treatment”
  2. be able to identify from the medical record the individual responsible for the coordination of the patient’s care through all phases of inpatient care had duly provided documentation in the clinical record related to the patient’s plan of care
  3. maintain a list of individuals who are qualified to assume responsibility for the patient’s care and who can be identified to the hospital’s staff by using a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries; I had covered on this aspect in the post JCI Standard MCI.19.2 & MCI19.3 – Patient Clinical Record
    (this link will open in a new tab of your current browser window)
  4. be aware that other consultants, on-call doctors, locum tenets, or others take responsibility of the patient as identified in a hospital policy that identifies the process for the transfer of responsibility from the responsible individual to another individual during vacations, holidays, and other periods and they assume this responsibility when they duly document their participation/coverage in the medical record
  5. be aware that the JCI Standard ACC.2.1 is included in the Medical Records Review Tool

References:

  1. Barbara JY (ed.) 2011, Principles of risk management and patient safety, Jones & Bartlett Learning, Sudbury, MA, USA
  2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  3. Joint Commission International, 2010, Hospital Survey Process Guide (HSPG), 4th edn, JCI, USA
  4. Judith, H and Paul, D (eds.) 2009, Patient Safety First Responsive Regulation In Health Care, Allen & Unwin, New South Wales, Australia
  5. Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA