Question

Review each case and underline the diagnoses and procedures to which ICD-10-CM and ICD-10-PCS codes are to be assigned. Then assign appropriate ICD-10-CM and ICD-10-PCS codes for each diagnosis and procedure in correct sequence.

14. Patient admitted to the hospital for cough, shortness of breath, difficulty breathing, and inability to sleep. Upon admission, she was treated with intravenous aminophylline, steroids, and Lasix. She also received oxygen. The second and third day after admission, she was still wheezing throughout lung fields. By the fourth day, her symptoms markedly improved. By the fifth day after admission, the patient was doing well on room oxygen. She was able to ambulate in the hallway without any return of bronchospasms. Patient was discharged with a strict set of instructions. FINAL DIAGNOSES: Asthma with acute exacerbation, resolving. Chronic obstructive pulmonary disease.

16. An 84-year-old white female admitted with dehydration, malnutrition, and late-stage Alzheimer disease. The patient is not on medication for Alzheimer disease. She has had poor to no oral intake over the last several days, and her urine output within the last 15 hours prior to admission was 200 cubic centimeters. She is completely confused and disoriented. Her past history is remarkable for occasional transient ischemic attacks. EKG on the day of admission was essentially normal. Chest x-ray showed a small area of infiltrate in the left upper lung field near the hilum consistent with acute pneumonia, approximately 2 centimeters in diameter. Repeat chest x-ray five days after admission showed clearing of the infiltrate. Electrolytes returned to normal range four days after admission with potassium 4 and sodium 140. Blood cultures were negative. Urine culture showed greater than 100,000 cfu/ml of Streptococcus. Her fever came down 24 hours after admission, and she remained afebrile throughout the hospital course. Other vitals were within acceptable ranges. Appetite was very poor initially but then progressed to 50%–95% intake with all meals. Intravenous antibiotics were administered for pneumonia and urinary tract infection. The patient's intake and outputs were followed; approximately 4,000 cubic centimeters were noted during the first three days, and then this began to stabilize. The patient’s mental status improved quite significantly over the course of the hospitalization, with increased alertness and responsiveness, although she remained confused and disoriented. She was able to sit in a chair without great difficulty and was eating quite well. She was discharged to the skilled nursing facility. FINAL DIAGNOSES: Dehydration. Severe malnutrition. Acute left upper lobe pneumonia, improved. Alzheimer disease. Urinary tract infection due to Streptococcus.

18. Patient admitted with history of left ureterolithiasis status post-left ureteroscopy, laser lithotripsy, and stent placement two years prior. Her stent was removed approximately one month following the procedure; she had no issues until a year later, when she presented to an outside physician complaining of left-sided flank pain. CT scan was performed and revealed left hydronephrosis. She then underwent cystoscopy and retrograde pyelography, which revealed complete obstruction of the mid ureter. Left percutaneous nephrostomy tube was placed, and antegrade pyelogram was completed, which also revealed a complete obstruction. Renal scan was performed, which revealed a nonfunctioning left kidney with 12% function. She was then referred here for evaluation regarding left nephrectomy. Patient was admitted and underwent left nephrectomy without complication. She underwent preoperative bowel prep and was medicated with Kefzol 1 gram intravenous prophalactically. On postoperative day one, the patient was tolerating clear liquids and was out of bed to chair. On postoperative day two, her oxygen was weaned off and she was advanced to a regular diet, which she was tolerating well. On postoperative day three, her Foley catheter was discontinued and she was urinating without difficulty. On postoperative day four, she was afebrile with stable vital signs and good urine output. She had adequate oral intake and was ambulating without difficulty. Patient was discharged home on postoperative day four, doing extremely well after procedure. FINAL DIAGNOSIS: Nonfunctioning left kidney due to hydronephrosis. PROCEDURE: Left nephrectomy (open approach).

Answer 1

Answer

14) the patient is diagnosed with Asthma with acute exacerbations and COPD.

14) Unspecified asthma with (acute) exacerbation. J45.901 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.

Chronic obstructive pulmonary disease, unspecified. J44.9 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.