Question

what is the rationale for this case?

What is the rationale for the secondary ICD-10-CM codes?

Discharge Summary
The patient was admitted primarily because of uremic symptomatology, namely hyperkalemia/bradycardia and generalized weakness. The patient was admitted because of the aforementioned symptoms. The patient was then taken to ICU for emergent hemodialysis. The patient tolerated the dialysis procedure without any problems. The patient has remained hemodynamically stable throughout this hospitalization. Consultations during this hospitalization including the following: Dr. Elhart of cardiology and Dr. Barnewell of rehabilitation medicine.
Final Examination
Vital signs are stable. Blood pressure: 100/46. Heart rate: 76. Respirations: 20. Temperature: 36.6 degrees C. Saturating 92% on room air. Normocephalic and atraumatic. Pink palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. S1 and S2 are distinct. No S3 or S4. Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.
DISCHARGE INSTRUCTIONS:
Activity level as tolerated. Diet: Renal diabetic diet.
MEDICATIONS:
1. Lipitor 10 mg q.d.
2. Epogen 10,000 units IV every hemodialysis session.
3. Glipizide 10 mg q.d.
4. Levothroid 0.88 mg q.d.
5. Procardia XL 60 mg q.d.
6. Senokot-S 1-4 tabs t.i.d.
FOLLOW-UP APPOINTMENT CARE:
The patient is to be followed up during her hemodialysis sessions in the dialysis unit.
The patient is to be discharged to rehabilitation medicine under the care of Dr. Barneswell for deconditioning.
CONDITION OF DISCHARGE AS COMPARED TO CONDITION ON ADMISSION: Significantly improved.

FINAL DIAGNOSES:
End-stage renal disease on maintenance hemodialysis (Monday, Wednesday, and Friday), secondary to the following: Hypertension. Type 2 diabetes mellitus.Questionable previous chronic use of nonsteroidal antiinflammatory drugs/COX-2 (cyclooxygenase-2) inhibitors. Anemia due to chronic renal failure. Hyperkalemia. Coronary artery disease, congestive heart failure, mild aortic stenosis, status post mitral valve replacement eight years ago (on chronic Coumadin therapy), and atrial fibrillation. Status post carotid endarterectomy seven years ago. Hypothyroidism. Hyperlipidemia. Diverticulosis;
I spent a total of 50 minutes evaluating and discharging the patient today.

Answer 1

# The rationale for this case is the presence of medical problem End stage renal disease along with hypertension and diabetes mellitus which is managed with hemodialysis .

# Rationale for the ICD -10-CM CODE secondary codes are :-

- improve patient care quality and data reporting

- enhance claim processing

- promote interoperability across all industry stakeholders

Using ICD-10-CM code helps to :-

- Support value-based purchasing and Medicare’s anti-fraud and abuse activities by accurately defining services and providing specific diagnosis and treatment information;

- Support comprehensive reporting of quality data;

- Ensure more accurate payments for new procedures, fewer rejected claims, improved disease management, and harmonization of disease monitoring and reporting worldwide; and

- Allow the United States to compare its data with international data to track the incidence and spread of disease and treatment outcomes because the United States is one of the few developed countries not using ICD-10

ICD -10-CM code is the tenth version of international classification of disease and is used by the healthcare workers to code a disease and is also used by the insurance company's for reimbursement purpose.

ICD -10-CM code for :-

Hypertension is I10

Type 2 diabetes mellitus is E11.65

End stage renal disease is N18.6

Coronary artery disease is I25.10

Congestive heart failure is I50.4

Hypothyroidism is E03.8

Hyperlipidemia is E78.4