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I need your expert help with the following:  7.2. The following...

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I need your expert help with the following:  7.2. The following...

I need your expert help with the following: 

7.2. The following documentation is from the health record of a 34-year-old male patient.

Admission Diagnosis: Sickle cell pain crisis.

Discharge Diagnosis: Sickle cell pain crisis/Staph (Staphylococcus) aureus bacteremia.

Secondary Diagnosis: Sickle cell disease, priapism, chronic lower back pain secondary to sickle cell diagnosis, mild persistent asthma, gastroesophageal reflux disease (GERD), and grade 2 hemorrhoids. Consults: None.

Procedures: PICC line placement, and transesophageal echocardiogram (heart and aorta).

Hospital Course: The patient is a 34-year-old African-American male with a history of sickle cell disease who presented with back pain and whole-body pain, a remote history of some diarrhea and nausea, and some fevers and chills. Blood cultures taken on admission and during his first night as an inpatient grew four out of four bottles of S. aureus. The patient received 1 gm of ceftriaxone in the emergency department and received approximately six days of vancomycin IV as an inpatient. Thereafter he was switched to Ancef 1 gm IV q.8 hours.

To find a source for the patient's Staph. bacteremia, a transesophageal echo-cardiogram was done which did not show evidence of any cardiac vegetations. Because the patient had Staph. bacteremia of unknown source, Infectious Disease was consulted. As per their recommendation, the patient is to be on five weeks of IV Ancef.

At the time of admission, the patient was placed on a PCA pump. He was rapidly weaned off this and he was also placed on some oxygen and was bolused with fluids and kept on maintenance fluids. The patient's clinical status improved rapidly. He was soon weaned off the oxygen, fluids, and pain medications.

At the time of discharge, the patient is afebrile and stable. A PICC line was placed in order to ensure access for the next five weeks, during which he will receive his IV antibiotics. The PICC line was placed percutaneously into the superior vena cava. Home care and home IV teaching was arranged for the patient and his family.

Follow-Up: Hematology was contacted and follow-up will be arranged within the next two weeks. Follow-up will also be arranged with Infectious Disease in five weeks. Home medications include folate 1 mg p.o. q.d.; Flexeril 10 mg p.o. b.i.d.; Ancef 2 gm q.12 IV times five weeks; Phenergan 12.5 mg p.o. q.4 p.r.n. nausea; and Zantac 150 mg p.o. b.i.d. The patient was told to return for fevers, chills, sweats, nausea, vomiting, or bone or muscle pain.

Disposition is to home with home care. Code Assignment Including POA Indicator

ICD-10-CM Principal Diagnosis: __________

ICD-10-CM Additional Diagnoses: __________

ICD-10-PCS Procedure Code(s): __________

7.10. The following documentation is from the health record of a patient admitted with significant aortic and mitral valve stenosis.

Surgery Date: 03/13/XX

Preoperative Diagnosis: Severe aortic and mitral valve stenosis

Postoperative Diagnosis: Severe aortic and mitral valve stenosis

Operative Procedure: Aortic valve replacement using a synthetic valve prosthesis; mitral valve replacement using a 26-mm bovine pericardial valve prosthesis; transesophageal echocardiogram; cardiopulmonary bypass.

Anesthesia: General endotracheal

Description of Procedure: Patient brought to the OR and placed on the OR table in the supine position. Arterial line and Swan-Ganz catheter were placed, general endotracheal anesthesia induced, and the patient prepped and draped in usual fashion. Transesophageal echocardiogram of the heart and aorta was then performed.

Next the chest was opened through a midline median sternotomy incision. The patient was heparinized and aortic and single right atrial cannules were inserted in the usual fashion. Retrograde cardioplegia line was placed through the right atrium in the coronary sinus. The patient was next placed on cardiopulmonary bypass and cooled to 27 degrees centigrade. During the cooling process, the aorta was cross-clamped and 1000 ml of cold cardioplegic solution was given. Inspection of the mitral valve revealed a severely diseased mitral valvular apparatus with calcification in the annulus. A few of the secondary and primary chordae were able to be preserved but the entire anterior leaflet was removed along with decalcifying the annulus. 2-0 Ti-Cron pledgeted sutures were then placed circumferentially in the annulus. Next a 26-mm bovine pericardial valve prosthesis was seated and sutures were placed through the sewing ring of the valve. The atriotomy was closed using double row of 4-0 Prolene sutures.

Transverse aortotomy was then performed and inspection of the aortic valve revealed a trileaflet aortic valve. Excision of the three leaflets was then carried out. The annulus was sized and found to accommodate a synthetic valve prosthesis. Next 2-0 Ti-Cron simple sutures were placed circumferentially in the annulus and then through the sewing ring of the valve. The valve was seated, sutures were tied and there was good seating of the valve. The aortotomy was then closed using double row of 4-0 Prolene sutures.

A de-airing cannula was placed in the ascending aorta and the heart was filled with blood to remove the air. While the lungs were ventilated with the patient in head-down position, light pressure was applied to the carotids. The aorta cross-clamp was removed. The patient was then rewarmed to 37 degrees centigrade. Once the patient was rewarmed with adequate cardiac output and pulse, was weaned from cardiopulmonary bypass. The aortic and right atrial cannulas were removed and protamine was administered. Following adequate hemostasis, the entire mediastinum was irrigated with copious amounts of warm antibiotic solution. Two mediastinal chest tubes were placed for postoperative drainage. A single ventricular pacing wire was placed. Sternotomy was then closed in standard fashion after all instrument and sponges were accounted for. The patient was then taken to the cardiac postprocedural intensive care unit in stable condition.

Which of the following is the correct code set for this inpatient procedure?

 

a. I08.0, 02RF0JZ, 02RG08Z, 5A1221Z

 

b. I08.0, 02RF0JZ, 02RG08Z, 5A1221Z, B24BZZ4

 

c. I05.0, I06.0, 02RF0JZ, 02RG08Z, 5A1221Z, B24BZZ4

 

d. I35.0, I05.0, 02RF0JZ, 02RG08Z, B24BZZ4

 

7.12. The patient is a 56-year-old male who was admitted with a history of hematemesis for the past 36 hours. He also had some tarry black stools and was noted to have a giant gastric ulcer which was actively bleeding. Patient was subsequently referred for surgical intervention.

Final Diagnosis: 1. Acute gastric ulcer

 

2. Chronic pancreatitis

 

3. Liver cirrhosis due to alcoholism

 

4. Cirrhosis due to chronic hepatitis C

 

Procedure Performed: Subtotal gastrectomy with Billroth II anastomosis

Operative Procedure: The patient was brought to the operating room and placed on the table in a supine position, at which time general anesthesia was administered without difficulty. His abdomen was then prepped and draped in the usual sterile fashion. An upper midline incision was made. The peritoneum was then entered using the Metzenbaum scissors and hemostats. A retractor was placed, and he was noted to have a cirrhotic liver with micronodular cirrhosis. The left lobe of the liver was mobilized at that point, and the retractors were placed. On palpation of the stomach along the lesser curvature at approximately the mid portion, there was a large gastric ulcer located in the body of the stomach. At this point, the gastrocolic omentum was taken off the greater curvature of the stomach to the level just above the pylorus. Additionally, the lesser omentum was taken down off the lesser curvature of the stomach to the level of the pylorus. The body of the stomach was then transected approximately 3 cm above the ulcer. At that point, the stomach was reconstructed in a Billroth II fashion by bringing the jejunum through the transverse colon mesentery. Two stay sutures were placed to align the jejunum along the posterior wall of the stomach, and a GIA stapler was used to create the anastomosis without difficulty. The stomach and jejunum were then pulled below the transverse colon mesentery, and this was tacked in several places using 3-0 silk sutures. A feeding jejunostomy tube was then placed distal to this using the feeding jejunostomy kit without difficulty. The abdomen was then irrigated thoroughly using normal saline solution. Hemostasis was achieved using Bovie electrocautery. The midline incision was then closed using #1 PDS in a running fashion. The skin was closed using skin staples. A sterile dressing was applied. The patient was extubated in the operating room and returned to the Intensive Care Unit in guarded condition.

 

Code Assignment Including POA Indicator

 

ICD-10-CM Principal Diagnosis Code(s): __________

 

ICD-10-CM Additional Diagnoses Code(s): __________

 

ICD-10-PCS Principal Procedure Code(s): __________

 

ICD-10-PCS Additional Procedures Code(s): __________

Answer & Explanation

Solved by verified expert
Answered by MagistrateRainHerring19 on coursehero.com

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