Question

16 The patient is a 61-year-old female who is being seen in the hematology-oncology clinic for a follow-up visit. Eighteen months ago, the patient was diagnosed with an aggressive form! of breast cancer and was treated with a mastectomy and chemotherapy that was completed in the past six months. Recently, she was found to be anemic and underwent a bone marrow biopsy that revealed myelodysplastic syndrome. During this visit, the patient complained of generalized fatigue and shortness of breath for the past couple of days. Blood was drawn in the clinic for a hemoglobin/hematocrit and the results returned with hemoglobin of 3.4 and hematocrit of 8.4. On physical exam the patient was noted to be weak, orthostatic, and short of breath on exertion. She said she has not noticed any blood in her stools or blood in her urine. Arrangements were made for the patient to be taken to the hospital and placed in observation status. Blood transfusions will be administered over the next 24 hours, the number to be deter- mined by her response to the first two units ordered. The physician documented the patient's reason for being in the clinic today as myelodysplastic syndrome in a patient with a past history of carcinoma of the breast. The physician also documented in the clinic notes that he was unable to determine during this visit whether the condition was the result of her previous chemotherapy. It was stated that while she is in the observation status at the hospital it would be investigated with more testing. Principal Diagnosis: Secondary Diagnoses: Principal Procedure: Secondary Procedura

please provide ICD-10-CM codes

Answer 1

Here the main symptoms are due to anaemia resulting from MDS.

The principal diagnosis is Anaemia of MDS

Principal procedure is Bone marrow examination both cytological with immunohistochemistry and gene study for pinpointing the underlying pathology.

Secondary procedure should be whole body scan screening mammography and other lab tests to exclude to recurrence and metastasis to other sites,though it depend s on the staging of previous breast cancer at the time of diagnosis

The ICD -10-CM code

D46.9 is a ICD-10-CM code for billing purpose of MDS.This means Myelo dysplastic syndromme is a diagnosis which is eligible for reimbursement and this particular code will deal with the processing of reimbursement