Question

This is a 19-year-old with a living-related donor kidney transplant as of last month and admitted to hospital for possible sepsis.

HISTORY: This patient has type 1 diabetes and had been on dialysis for a number of years before transplantation. She received her mother’s kidney on the 14th of last month from the Medical Center Transplant Program in Dallas. She was there this Tuesday for a transplant visit and apparently did not feel well, but they were not certain whether this was a problem or not; but they did go ahead and do blood cultures and called the public health nurse, who was visiting the patient today, and said that one of the cultures was positive for group B strep. The home health nurse called me and stated that the patient has really gone downhill the past few days and was quite fatigued with generalized malaise. Denied cough, fever, or shaking chills but looked poor overall, and the nurse was quite concerned. We recommended she be brought here for evaluation and treatment as an emergency. After arrival here, she was in no acute distress. Initially, she had bibasilar crackles on deep breathing; however, most of these cleared. I cannot hear any significant pulmonary abnormality on auscultation or percussion. Her heart is normal regular rhythm. No significant murmurs, rubs, S3, or S4. Her
abdomen is negative. Her left lower-quadrant kidney is nontender. She has no edema and no lateralizing neural sounds. She is a little lethargic. She does not feel warm. Apparently, she is afebrile. Her blood pressure is normal, and she is not tachycardic, but she simply does not look well. Past history, social history, and system review are per our recent old chart and noncontributory at present.

CLINICAL IMPRESSION: One positive group B strep blood culture, significance, and/or etiology to be determined. My impression at this time is probably a significant finding, and I suspect that this will become a progressive syndrome if not treated. 

ADDITIONAL DIAGNOSES: 1. Living-related donor kidney transplant 2. Diabetes mellitus type 1 3. Hypertension PLAN: Repeat culture. Culture urine. Do chest x-ray stat and repeat lab. Will empirically treat pending results at this time,

Read the reports indicated and supply the appropriate CPT (Evaluation/Management) code.

Answer 1

CPT codes(current Procedural codes)
- Blood culture(repeat)
Blood culture - 87040
Modifier -91 should be used in case of repeat clinical diagnostic lab tests done on the same day. Here we no need to use modifier -91 as it was not repeated on the same day.
culture urine - 87086
Chest X-ray (one view)- 71010
ICD-10-cm (International classification of diseases) codes:
1, living-related donor kidney transplant - Z94.0
2, Type I diabetes mellitus -E10.9
3, Hypertension - I10
Evaluation and management code 99235 is not correct.
Evaluation and management code 99236 is valid for this patient because it was done in the inpatient care unit. It has taken comprehensive history, examination, and medical decision making of high complexity(sepsis)
coordination of care done with primary health nurse and physician provided consistent with nature of the problem(living donor kidney transplant, type I diabetes, hypertension). this illness shows high severity than moderate severity due to blood culture positive results. All this assessment and history collection and evaluation of the previous history and reports will take nearly 55 minutes at the bedside in the patient unit.