Question

Using the techniques described in this chapter, carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate. Remember, check the chapter-specific, subchapter-specific, and category- specific notations within the Tabular List. Stephen Cheng, a 3-month-old male, was born with bilateral hydrocele. He also has reducible inguinal hernias on both sides. The condition has become troublesome, so the parents and Dr. Jamerson, his pediatrician, have decided that surgical correction is warranted. The Chengs bring Stephen to Barton Ambulatory Center today for the Surgery Principal diagnosis What is the correct diagnosis code? Second diagnosis What is the correct diagnosis code?

Answer 1

Principal Diagnosis: P83.5

Secondary Diagnosis: K40.0

Explanation:

Principal Diagnosis is the condition that occurred on admission. The main condition associated with admission is considered as principal Diagnosis. Here, the infant is admitted for surgical correction of bilateral hydrocele. Born with Bilateral Hydrocele is the main condition. So the code of Congenital hydrocele is used. Secondary Diagnosis is the condition associated with the patient that requires treatment. The infant also identified with the condition of reducible bilateral inguinal hernia. So inguinal hernia is considered as a secondary diagnosis.