Question

HILLSIDE HOSPITAL 359 Mountain Pass Road Langston, FL 33993 DISCHARGE CLINICAL RESUME PATIENT DATE OF ADMISSION: DATE OF DISCHARGE: WYLER, WENDY 11/05/18 11/18/18 This is a 36-37-week temale delivered to a 22-year-old, gravida 2, para 1, who was a known breech presentation. Mother presented with complaint of vaginal bleeding, rupture of membranes, and abdominal pain and cramping. On exam found to be complete with large fecal impaction. Fetal heart rate 120 by monitor. To c-section room for disimpaction and cesarean section for breech. Delivered precipitously immediately after impaction was removed, breech presentation. OB moved baby to warmer. She was pale with no respiratory effort or heart rate. Ambu bagged with mask for 30 seconds. Intubation attempted. Code called. UAC was placed. ENT in place and bagged. No heart rate, no breath sounds, pale, cyanotic. Reintubated with chest rise, heart rate about 60. Chest compression stopped when heart rate above 120, color improved. Apgar 0 at 1 minute, 1 at 5 minutes, and 4 at 10 minutes. No spontaneous respiratory effort. Received sodium bicarbonate, epinephrine, and calcium. No grimace, no spontaneous movements. Pupils midpoint, nonreactive to light. NG placed for distended abdomen. Cord pH 7.33. Mother noted to have 50% abrupto placenta. Transferred to Neo. UAC was removed and replaced. UVC also placed. Physical exam: weight 2,620 grams, pink, fontanelle soft, significant clonus of axtremities, tone decreased. Pupils 2 cm and round, nonreactive to light. No movement, no grimace, no suck, good chest rise. Equal breath sounds, no murmur. Pulses 2+. Partusion good. Abdomen soft and full. No masses. Normal fomale genitalia externally. Anus patent. Extremities no edama. Skin-Mongolian spot sacrum and both ams, single café-au-lait spot left flank 1.5 am x 0.5 cm. Palate intact. IMPRESSION: 1. 38-37 week AGA female onary arrest 3. Rule out sepsis 4. At risk for hypoxic ischemic encephalopathy PHYSICAL EXAM: 43 days of age, weight 2,520 grams, head circumference 35, pink. Anterior son soft. Heart-IIWI mu anelle mur radiating to the axilla. Chest clear. Abdomen soft, positive bowel sounds, omy tube intact, wound is okay. Neuro-irritable. The infant has an anal fissure at 12 o'clock which has caused some blood streaks in the stool Continued

This needs to be coded for diagnosis for ICD-CM-10. There are nine separate codes needed for the correct answer.

Answer 1

1. The 36-week pregnant gestational age female ICD-10-CM code is Z3A.36.
2. The cardiac arrest ICD-10-CM code Z86.74 is a billable/specific that can be used to indicate a diagnosis for reimbursement purposes.
3. The respiratory arrest ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes is R09.2.
4. For the rule out sepsis ICD-10-CM code is P36.10.
5. For Hypoxic ischemic encephalopathy, P91.60 is a billable/specific ICD-10-CM code
6. The ICD-10-CM code for seizure is G40.909
7. The ICD-10-CM code is K21.0 for gastro-esophageal reflux disease
8. The ICD-10-CM code for disruption of cesarean delivery wound is O90.0