Question

What is the professional code and the cpt icd-10-cm code for this case?

Admitting Diagnosis: Suicide attempt. Inpatient Consult requested by Internal Medicine Provider, Dr. Smith. HPI: The patient is a 17-year-old girl with Salicylate overdose as a suicide attempt. She has a three-year history of depression, suicide attempts and self-mutilating behavior. She had a determined suicide attempt last night at about 1900 by an overdose of aspirin. She has been depressed chronically and has had over 10 suicide attempts, the most recently being 3 weeks ago when she cut her left wrist, the most serious to date. She did write a suicide note stating that she loved and missed her friends in Maryland. She took approximately 30 aspirin over a several hour period because she had a headache. She went to bed and then awoke not able to hear and with her ears ringing. She states she explained this to her mother at that point because as long as she was still alive, she did not want to have that awful ringing in her ears, which is why she sought help. She complains of a chronic, depressed mood, low energy, early morning awakening, low level of interest and concentration. She reports having felt this way since about the 4th grade. She has chronic suicidal ideations but does not have a plan to hurt herself while here at the hospital. She states she will ask for help if she is feeling this way while here. The separation from her friends in Maryland appears to have tipped her over the edge last night. Past Psychiatric History: She had had three previous inpatient hospitalizations on psychiatric wards for about a month each, most recently being a year ago. She has been diagnosed with depression but has had no improvement on any medications. Some of her medications in the past have included Celexa, Wellbutrin, Prozac and Effexor and she has been on no meds in the past year. She has not seen a psychiatrist since moving back three months ago. She did have a psychiatrist that she got along with quite well near the end of her stay in Maryland. Substance Abuse History: She drinks alcohol about four times a month and drinks at parties. She smokes marijuana frequently and she usually does this by herself. She has used cocaine, heroin, and speed, all in the past but nothing at this time. She smokes half a pack of cigarettes a day, drinks 2+ cups of coffee a day, and also takes caffeine tablets. Allergies: No known drug allergies. Her immunizations are reportedly up-to-date. Past Medical History: History of headaches behind the right eye since about the 4th grade. These headaches are associated with nausea, resolve with sleep and come about once a week. Usual trigger is stress. She had an appendectomy at 12 years of age. She reports no other significant past medical history. Social History: She is the second of four daughters in the family. She complains of frequent moves by the family so she feels very disconnected from friends she has made in multiple places. Most recently feels alone without her father. She reports that she has no respect for her mother who is a “fake.” Dad visits sometimes on weekends but is still trying to find a job here. Emergency Room Course: Upon arrival to the emergency room, she was given a gastric lavage with charcoal, of which she drank 50 grams without a problem. She had numerous labs done of which her salicylate level was 47.3, about 12 hours out from the ingestion. Her urine tox screen was otherwise negative. Pregnancy test is negative. Other labs in records. The patient was started on IV fluids with two amps of bicarbonate and 20 mEq of KCL at 250 cc per hour. Physical Exam: Patient was afebrile with normal vital signs. Generally, she was alert and oriented ×3. She was a well-developed and appearing female looking her stated age. She is very pleasant and cooperative through the exam. She was very articulate with a depressed mode though animated when talking. Her speech was appropriate in rate, volume and tone. Her attention and concentration were quite good. HEENT: Pupils are equal, round, reactive to light. Extraocular movements are intact. TMs clear bilaterally. Oropharynx clear with moist mucous membranes. NECK: Supple with shoddy adenopathy. LUNGS: Clear to auscultation with equal breath sounds bilaterally. HEART: Normal S1 and S2, no murmur or gallop. ABDOMEN: Positive bowel sounds, soft, nontender, nondistended, no masses or hepatosplenomegaly. EXTREMITIES: No cyanosis, clubbing or edema. SKIN: Both arms and legs have numerous old scars from self-mutilation. Her right forearm has a more recent abrasion from when she fell down some stairs. There is a more recent cut on the left wrist from the recent suicide attempt three weeks ago. Assessment: This is a 17-year-old with salicylate overdose as a suicide attempt. She is in the toxic range for salicylate overdose. After discussion with toxicology, because her mental status is normal and she is afebrile and appropriate, we decided to admit her to the medicine unit, monitoring her salicylate level, electrolytes and venous pH every 4 hours, alkalizing her urine to a pH greater than 8. We will use D5 .45 normal saline with 3 amps of bicarb at 20 mEq of KCL at a rate of 200 cc per hour as I discussed with Poison Control. We will continue to do checks on her every hour and obtain a psychiatric consult for recommendations on further plans for discharge. We will plan that after 24 hours if her salicylate level is falling and is less than toxic level times 2 greater than 4 hours apart and her electrolytes are stable, we will discharge per the recommendation of the psychiatrist. Suicide precautions while in house.

Answer 1

*Admitting Diagnosis:

Suicide attempt. Inpatient Consult requested by Internal Medicine Provider, Dr. Smith.

HPI:

The patient is a 17-year-old girl with Salicylate overdose as a suicide attempt. She has a three-year history of depression, suicide attempts, and self-mutilating behavior. She had a determined suicide attempt last night at about 1900 by an overdose of aspirin. She has been depressed chronically and has had over 10 suicide attempts, the most recent being 3 weeks ago when she cut her left wrist, the most serious to date. She did write a suicide note stating that she loved and missed her friends in Maryland. She took approximately 30 aspirin over several hour periods because she had a headache. She went to bed and then awoke not able to hear and with her ears ringing. She states she explained this to her mother at that point because as long as she was still alive, she did not want to have that awful ringing in her ears, which is why she sought help. She complains of a chronic, depressed mood, low energy, early morning awakening, low level of interest and concentration. She reports having felt this way since about the 4th grade. She has chronic suicidal ideations but does not have a plan to hurt herself while here at the hospital. She states she will ask for help if she is feeling this way while here. The separation from her friends in Maryland appears to have tipped her over the edge last night.

Past Psychiatric History:

She had had three previous inpatient hospitalizations on psychiatric wards for about a month each, most recently being a year ago. She has been diagnosed with depression but has had no improvement on any medications. Some of her medications in the past have included Celexa, Wellbutrin, Prozac and Effexor and she has been on no meds in the past year. She has not seen a psychiatrist since moving back three months ago. She did have a psychiatrist that she got along with quite well near the end of her stay in Maryland.

Substance Abuse History:

She drinks alcohol about four times a month and drinks at parties. She smokes marijuana frequently and she usually does this by herself. She has used cocaine, heroin, and speed, all in the past but nothing at this time. She smokes half a pack of cigarettes a day, drinks 2+ cups of coffee a day, and also takes caffeine tablets.

Allergies:

No known drug allergies. Her immunizations are reportedly up-to-date.

Past Medical History:

History of headaches behind the right eye since about the 4th grade. These headaches are associated with nausea, resolve with sleep and come about once a week. Usual trigger is stress. She had an appendectomy at 12 years of age. She reports no other significant past medical history. Social History: She is the second of four daughters in the family. She complains of frequent moves by the family so she feels very disconnected from friends she has made in multiple places. Most recently feels alone without her father. She reports that she has no respect for her mother who is a “fake.” Dad visits sometimes on weekends but is still trying to find a job here.

Emergency Room Course:

Upon arrival to the emergency room, she was given a gastric lavage with charcoal, of which she drank 50 grams without a problem. She had numerous labs done of which her salicylate level was 47.3, about 12 hours out from the ingestion. Her urine tox screen was otherwise negative. The pregnancy test is negative.

Other labs in records.

The patient was started on IV fluids with two amps of bicarbonate and 20 mEq of KCL at 250 cc per hour.

Physical Exam:

The patient was afebrile with normal vital signs. Generally, she was alert and oriented ×3. She was a well-developed and appearing female looking at her stated age. She is very pleasant and cooperative throughout the exam. She was very articulate with a depressed mode though animated when talking. Her speech was appropriate in rate, volume, and tone. Her attention and concentration were quite good.

Review of the system:

HEENT:

Pupils are equal, round, reactive to light. Extraocular movements are intact.

TMs clear bilaterally.

Oropharynx clear with moist mucous membranes.

NECK:

Supple with shoddy adenopathy.

LUNGS:

Clear to auscultation with equal breath sounds bilateral.

HEART:

Normal S1 and S2, no murmur or gallop.

ABDOMEN:

Positive bowel sounds, soft, non-tender, non-distended, no masses or hepatosplenomegaly.

EXTREMITIES:

No cyanosis, clubbing or edema.

SKIN:

Both arms and legs have numerous old scars from self-mutilation. Her right forearm has a more recent abrasion from when she fell down some stairs.

Assessment:

This is a 17-year-old with salicylate overdose as a suicide attempt. She is in the toxic range for salicylate overdose. After discussion with toxicology, because her mental status is normal and she is afebrile and appropriate, we decided to admit her to the medicine unit, monitoring her salicylate level, electrolytes and venous pH every 4 hours, alkalizing her urine to a pH greater than 8.

Here we can see :

Expanded problem-focused history

Expanded problem-focused examination

Medical decision making of moderate complexity

Presenting problem(s): Moderate severity

Thus we can apply the CPT code as 99283

We can apply the ICD code as :

F15: Mental and behavioral disorders due to use of other stimulants, including caffeine

F33.3 :

Recurrent depressive disorder, current episode severe with psychotic symptoms

A disorder characterized by repeated episodes of depression, the current episode being severe with psychotic symptoms and with no previous episodes of mania.

Endogenous depression with psychotic symptoms

Manic-depressive psychosis, the depressed type with psychotic symptoms

Recurrent severe episodes of:

• major depression with psychotic symptoms
• psychogenic depressive psychosis
• psychotic depression
• reactive depressive psychosis