Question

DIAGNOSES include:
1. Chronic pelvic pain secondary to pelvic metastatic clear cell carcinoma of unknown primary location.
2. Vena cava syndrome post placement of Hickman catheter. 3. Anemia due to chronic disease. 4. Hypertension.
HOSPITAL COURSE: The patient is a 78-year-old female whom we have been following in our clinic for hypertension and also chronic pudendal nerve pain. She had been recently diagnosed with pelvic metastatic clear cell carcinoma, which her primary location is unknown at this time. She will be discussing this further after the pathology reports are read. During her hospital stay a Hickman catheter was placed in order to have IV access for pain medication or future cancer therapy. She was also admitted for chronic pain. She did develop swelling of her arms and neck. She was brought to interventional radiology and she did have venography and the Hickman catheter was removed. Her swelling to her arms and neck have decreased greatly. She denies any shortness of breath. No choking sensation as previously noted. Her pain has been managed well with fentanyl patch at 175 mcg. She has also been on IV heparin therapy for anticoagulation following the vena cava syndrome. Today, the patient has been having complaints of nausea. She did get some dexamethasone IV for her nausea, which did improve later this morning. Her blood pressure has been under good control. Her labs today include a WBC of 5.18, hemoglobin 7.8, hematocrit 23.7, protime 14.4, INR 1.5, PTT 39.6, BUN 6, sodium 139, potassium 4.2, CO2
27.2. DISCHARGE PLANS:
1. IV heparin is discontinued. She will be switched over to Lovenox 1 mg/kg subcutaneously daily. The patient will have Home Health to help her set up these injections.
2. She will continue with the fentanyl patch 175 mcg for the pain. 3. She will receive 40,000 units subcutaneously of Procrit at the Cancer Center one time per week. We will follow up in 3 days with a CBC and a basic metabolic panel.
4. Follow-up appointment at the Hypertension Center on November 2 at 10:30 in the morning. Will also check CBC and a basic metabolic panel, PTT, PT, and INR before that appointment.
5. Hold potassium supplements for now. 6. She may use Phenergan p.o. 12.5 mg 1-2 tablets p.o. p.r.n. every 6 hours for nausea.

In Appendix A of this workbook you will find a section titled Reports, which contains originals reports. Read the reports indicated below and supply the appropriate CPT and ICD-10-CM codes.

CPT Code:

ICD-10-CM Code (secondary neoplasm):

ICD-10-CM Code (primary neoplasm):

ICD-10-CM Code (vena cava syndrome):

ICD-10-CM Code (catheter complication):

ICD-10-CM Code (hypertension):

ICD-10-CM Code (nerve pain):

ICD-10-CM Code (anemia, in (due to) (with), neoplastic disease):

Answer 1

ICD-10-CM Code

1. Secondary neoplasm: C79.89 - Secondary malignant neoplasm of other specified sites. Includes cancer metastatic to soft tissue of pelvis.

2. Primary neoplasm: C80.1 - Includes malignant primary neoplasm of unspecified location.

3. Vena cava syndrome: I82.210 - Acute thrombosis of superior vena cava.

4. Catheter complication: T82.49XA - Includes mechanical complications of venous catheter.

5. Hypertension: I10 - Primary hypertension

6. Nerve pain: M79.2 - Includes unspecified neuralgia (nerve pain). R52 is used for unspecified chronic malignant pain.

7. Anemia in neoplastic disease: D63.0, Anemia due to antineoplastic chemotherapy: D64.81