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7.48. The following documentation is from the health record of a...

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7.48. The following documentation is from the health record of a...

7.48. The following documentation is from the health record of a 32-year-old female patient. Inpatient admission: The patient, gravida II, para 1, was admitted at approximately 32 weeks gestation with mild contractions. She was contracting every seven to eight minutes. An ultrasound showed twins of approximately four pounds each. The patient was given magnesium sulfate to stop the contractions, but she contracted through the drug. After developing a fever with suspected chorioamnionitis, a low cervical cesarean section was performed. The umbilical cord was wrapped tightly around the neck of twin one.

 Discharge diagnoses: Cesarean delivery of liveborn twins prematurely at 32 weeks gestation; chorioamnionitis; umbilical cord compression. 

Code Assignment Including POA Indicator

 ICD-10-CM Principal Diagnosis: 

ICD-10-CM Additional Diagnoses:

 ICD-10-PCS Procedure Code(s):

 

 

 

 

 

 

 

 

7.54. History and Physical Exam

 Present Illness: This 74-year-old male presented to the emergency department last night with complaints of increased weakness and shortness of breath. In the emergency department, he was found to be hypotensive. Blood pressure 83/42 apparently-actually, that was the recording at home. In the emergency department, it was 130/80. He was afebrile, tachypneic per usual, respiratory rate of 32, and admitted with acute pneumonia. He was started on Levaquin. He has a history of purulent sputum for several days. Since admission, he feels better; tachypnea and weakness have improved. His blood pressure readings have somewhat improved. His peripheral edema improved with a diuretic.
Past Medical History: End-stage pulmonary disease, and congestive heart failure 

Family History: Unremarkable

 Social History: Has six children and is a widower 

Physical Exam: On physical examination, blood pressure 102/70, pulse 90, respirations 28. He is pleasant, alert. Color is good. No JVD. 

Chest: He has bilateral rales, which are chronic. 

Heart: There is a systolic ejection murmur, grade 3, with an S4 gallop.

 Abdomen: The abdomen is soft, nontender. No palpable organomegaly.

 Extremities: Extremities reveal trace to 11 peripheral edema. He does have some stasis pigmentary changes. He does have clubbing of his fingers. 

Musculoskeletal: No atrophic changes 

Skin: Unremarkable except as noted 

Neurological: He has no focal sensory or motor deficits and reflexes are physiologic. Impressions: I suspect he probably just has purulent bronchitis and that is the cause of his deterioration. He is on Levaquin and seems to be improving. We will observe until tomorrow. If still doing reasonably well, we will let him go. 

 

Discharge Summary 

History of Present Illness: This 74-year-old male with end-stage pulmonary fibrosis was admitted via the emergency department with increased breathlessness. The admitting diagnosis was pneumonia. While here, he did not develop any significant fever. 

Laboratory Studies: On admission PO, 58, PCO, 37, pH 7.45 on 3.5 L, his electrolytes were normal with the exception of BUN 28, creatinine 1.3, white blood cell count 8.6, hemoglobin 11.4, platelet count slightly low 117, urinalysis fairly unremarkable with trace protein, rare red and white blood cells.

 Hospital Course: The patient was continued on Levaquin, which had been started one day previously. His chest x-ray showed decreased cardiac size from the previous examination, chronic infiltrates bilaterally, no acute infiltrates; pneumonia ruled out. Electrocardiogram showed sinus rhythm, right bundle branch block, left anterior hemiblock. He did receive intravenous diuretic and with this did achieve significant dluresis. My concern at the time of admission was the possible hypotension, which was recorded at home, but all blood pressure recordings here varied from the 100 to 130 systolic range.
Discharge Diagnosis: Probably acute bronchitis with possible mild congestive heart failure. 

What are the correct code sets for this admission? 

a. J20.9, J84.10, 150.9

 b. J44.1, 150.9

 C. J44.1, J20.9, 150.9 

d. 150.9, J20.9, J84.10
 

 

 

 

 

7.58. The following documentation is from the health record of a four-year-old male patient. Case Summary: The patient is a 4-year-old male child who, at the age of two years, swallowed some Drano while playing in the bathroom. He was found at that time with acid burns of the mouth, throat, trachea, and esophagus. Plastic repair has been performed on the mouth and throat. He is now being admitted by a plastic surgeon for plastic reconstruction and removal of scar tissue to the trachea. The patient was admitted, prepped, and taken to surgery where the scar tissue of the trachea was removed, and plastic repair was accomplished. The patient's recovery was uneventful, and the patient was discharged in satisfactory condition three days postsurgery.
 

Which of the following code sets is correct for reporting the diagnoses of the most recent admission? 

a. J39.8, T28.5XXS, T27.4XXS, T28.6XXS

 b. J39.8, T54.3X1S, T27.4XXS, T28.5XXS, T28.6XXS 

C. J39.8, T54.3X1S 

d. T54.3X1S, T28.5XXS, T27.4XXS, T28.6XXS, J39.8

Answer & Explanation

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Answered by MarianRose on coursehero.com

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