Question

what is the rationale for this case? What is the rationale for the ICD-10- codes for this case? Dear Dr. X, as you know, the patient is a 53-year-old male who presented to the Emergency Room on the day of this consult complaining of burning right lower quadrant pain. On exam, he was found to have wheezing, coughing to go along with his right lower quadrant pain. You are kind enough to refer him for general surgical consultation for this right inguinal pain. PAST MEDICAL HISTORY: Significant for tobaccoism, nocturia and hypertension. PAST SURGICAL HISTORY: He denies any. MEDICATIONS: Atenolol 50 mg p.o. daily, DDAVP 0.2 mg daily and Lortab 5 mg 1-2 p.o. q.4h. p.r.n. pain. ALLERGIES: He denies any allergies. FAMILY HISTORY: He relates a history of coronary artery disease. SOCIAL HISTORY: He is married, lives at home with his wife. Smokes a pack of cigarettes a day. Denies any use of alcohol. No recreational drugs. REVIEW OF SYSTEMS: Consistent with current complaints, past medical and surgical history and also includes recent drainage of a gluteal abscess. PHYSICAL EXAMINATION: GENERAL: I see an awake, alert and oriented male who is in no acute distress. VITAL SIGNS: Revealed blood pressure 155/83, heart rate of 83, respiratory rate of 18, his temperature is 98.6, he is 6 feet tall and weighs 174 pounds. HEENT: Normocephalic and atraumatic. Eyes PERRLA with EOMI. Sclerae are pink and moist. Conjunctivae are clear and noninjected. No signs of icterus or drainage. Tympanic membranes exhibit light reflex. External auditory canals are patent. External ears are without deformity. Nasal mucosa is pink and moist. Septum is in midline and nonperforated. No signs of epistaxis, rhinorrhea or polyps. Mouth, tongue and uvula are midline without tremor or exudate. I see no oral lesions. NECK: Supple. Trachea is midline. Thyroid is nonpalpable. I hear no carotid bruits, no JVD. CHEST: His chest has increased AP diameter. His chest rise is symmetrical with inspiration with some mild accessory muscle use with inspiration. LUNGS: He has diffuse expiratory wheezing throughout. HEART: Regular rate and rhythm. Normal S1, S2. I hear no heaves, clicks, thrills, gallops, rubs or murmur. ABDOMEN: His abdomen is flat and soft. He has good quality bowel sounds. I do not illicit any peritoneal signs or guarding. There are no abdominal bruits auscultated. I do not palpate any McBurney point tenderness. No Murphy sign. No Lloyd sign. I do palpate any organomegaly. There is no tenderness to palpation or percussion. GENITOURINARY: He has a reducible right inguinal hernia. He has an uncircumcised male. I see no exudate or masses. His testes are descended bilaterally. There are no masses or tenderness to palpation. RECTAL: Hemoccult is negative. He has normal tone, normal prostate. EXTREMITIES: He has tobacco stains on his right thumb and pointer finger. He has +2/4 pulse in all peripheral and central arteries. There is no edema, no varicosities noted. He moves all extremities with full range of motion. NEUROLOGIC: He is awake, alert and oriented to person, place and time. His eyes, PERRL with EOMI. Muscle strength is +4/5. DTRs are +2/4. He has normal speech, normal cognitive affect. Cranial nerves II through XII are grossly intact. LYMPHATICS: I do not palpate any anterior cervical, posterior cervical, supraclavicular or inguinal adenopathy. X-ray shows hyperinflation of his lungs. LABORATORY DATA: His UA is negative. His INR is 1.085, CK of 47, troponin 1.002. White blood cell count of 4.4, hemoglobin and hematocrit of 15.1 and 43 with a platelet count of 228,000. Blood sugar is 95. He has a BUN is 7, creatinine 1.1, sodium 139, potassium 4, chloride of 104, CO2 of 24, lipase of 51 and his total bilirubin is 0.3. His total protein 7.2. Stools hemoccult negative. EKG is sinus rhythm Thank you for allowing me to play a role in the patient's care. I have seen and examined him and reviewed his chief complaint, history of chief complaint, lab and x-rays and I have the following impressions: 1. Reducible right inguinal hernia. 2. Chronic obstructive pulmonary disease. 3. Wheezing. 4. Hypertension. 5. Nocturia. RECOMMENDATIONS: 1. Medical therapy for his multiple medical and pulmonary problems. 2. Elective right inguinal herniorrhaphy once pulmonary condition is optimized.

Answer 1

According to the patients condition, his current diagnosis is right inguinal heria.

The ICD 10 Code for it is as follows:

Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent. K40.90 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.

The patient also has a history of

1) COPD: 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.

2) Hypertension: code is I10, Essential (primary) hypertension.

The treatment decided to do for the patient is

Right inguinal herniorrhaphy:

Hernia repair

CPT code	Descriptor
Laparoscopic hernia repair
49650	Laparoscopy, surgical; repair initial inguinal hernia
49651	Laparoscopy, surgical; repair recurrent inguinal hernia
49652	Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible.