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.

26. Patient is a 2-week-old baby who was admitted because of bloody diarrhea and impending dehydration. Lab data showed stool cultures to be negative. A urine culture grew 100,000 colonies of Proteus mirabilis, which might be a contaminant and will be repeated. Hemoglobin 14.7. White count 13,700 with 20 segs, 66 lymphs, and 14 monos. Urinalysis was normal. Electrolytes were normal. During the hospital course, the baby was placed on Lytren, and her neonatal bradycardia was also treated. Questran was added, which firmed up the baby’s stools; however, as soon as Questran was discontinued, the child had seven very loose, watery stools. At that time, because of impending dehydration, an IV was started and IV fluids were administered for 24 hours. The baby was again started on Lytren and on half-strength Nutramigen, which was brought up to full strength. The baby did very well on this; tolerated it well; and had no more diarrhea, vomiting, or blood in her stool. Repeat urine culture was done just prior to discharge, which showed no growth. This proved the first culture to be contaminant. The baby was sent home on Nutramigen to be followed as an outpatient in three days. FINAL DIAGNOSES: Gastroenteritis. Neonatal bradycardia.

28. Patient is a 2-year-old white female who ingested approximately three-quarters of a Fleet enema at home and was brought to the emergency department. Ipecac was administered immediately, and the patient admitted for observation. During hospital course, the patient did not develop any shakiness, and there were no side effects of low calcium and potassium. The child was doing well. No diarrhea developed. No neurological deficit developed. On the third hospital day, patient's vital signs were normal. No evidence of diarrhea noted. Father was instructed to call if any shakiness or diarrhea symptoms develop. Patient discharged home to the care of her father. FINAL DIAGNOSIS: Sodium (basic) phosphate poisoning due to ingestion of Fleet enema, resolved without significant side effects. (Initial encounter.)

30. The patient is a 54-year-old white male who was a passenger in a car his son was driving. Apparently, the boy fell asleep at the wheel; the car was totaled. Patient was brought to the emergency room by ambulance. He is not sure whether he had any head trauma but complains primarily of pain in his left anterior chest and left shoulder. He was seen in the emergency room, which revealed that he had displaced fracture of his left fourth anterior rib. The physician did not see any fracture of the left shoulder but thought that there might be an acromioclavicular separation. The patient was admitted for observation and treatment of his pain. He had tenderness over the left third and fourth anterior ribs and very little use of his left shoulder. He also had tenderness to palpation over the acromioclavicular joint. The patient was admitted and started on analgesics. He did not have much movement of his left shoulder, although this gradually improved during his hospital stay. On the second hospital day, it was noted that he had very little movement of air in the left upper lobe; repeat chest x-ray was obtained, which showed a small pleural effusion on the left and possible pneumonia in the left lower lobe. He was started on Velosef, and the chest x-ray was repeated. The pleural effusion gradually resolved, and the area of pneumonia improved. The patient was continued on the Velosef. He was subsequently discharged. FINAL DIAGNOSES: Automobile accident. Closed fracture, left fourth anterior rib. Possible acromioclavicular joint dislocation, left. Pneumonia. Pleural effusion. (Initial encounter.)

Answer 1

Answer:

26) Neonatal bradycardia. P29.12 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.

Infectious gastroenteritis and colitis, unspecified. A09 is a billable/specificICD-10-CM code that can be used to indicate a diagnosis for reimbursement purpose.

According to final impression:

Noninfective gastroenteritis and colitis, unspecified. K52.9 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.