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7.16. The following documentation is from the health record of a 52-year-old patient. Discharge Summary Admission...

7.16. The following documentation is from the health record of a 52-year-old patient.

Discharge Summary

Admission Date: 11/14/XX

Discharge Date: 11/17/XX

Discharge Diagnosis: 1. Diabetic ketoacidosis, type 1 diabetes

2. Dehydration

3. Congestive heart failure

4. Aortic valve stenosis

5. Urinary tract infection due to Pseudomonas aeruginosa

6. Hyperkalemia

7. Peripheral vascular disease

8. Hypertension

9. Hyperlipidemia

10. Chronic renal insufficiency

11. Old myocardial infarction

12. Tobacco dependence

13. Coronary atherosclerosis with native coronaries

Admitting Diagnosis: 1. Diabetic ketoacidosis

2. Diabetes mellitus type 1

3. Dehydration

4. Congestive heart failure

5. Hyperkalemia

6. Hyperlipidemia

7. Hypertension

8. Tobacco dependence

9. Severe peripheral vascular disease

10. Atherosclerotic coronary artery disease

11. Urinary tract infection

12. Renal insufficiency

13. History of CVA

Present Illness: A 52-year-old white female with known diabetes mellitus type 1, CVAs, cellulitis, hypertension, chronic renal insufficiency, hyperlipidemia, poorly compliant diabetic. Most recently in hospital from September 3 to September 8 with cellulitis, congestive heart failure, poorly controlled diabetes with diabetic ketoacidosis. Discharged home. She was supposed to be following up with her primary care physician doing b.i.d. Accu-Cheks. She was nauseated for the previous two weeks. As soon as she got nauseated, she quit checking her blood sugar level. She cancelled her physician’s appointment because she was “too sick to go.” She had decreased appetite and was feeling poorly overall. She came to the emergency department with a blood sugar of 737. She had ketones 200 to 250. Her blood urea nitrogen was 75, creatinine 1.8. Her potassium is 6.1, chloride 5, bicarb at 13. Patient is a poor historian, although she is awake and alert at the time of evaluation, on an insulin drip. Overnight her nausea had resolved. The nausea probably occurred because she was in the beginning stages of diabetic ketoacidosis.

Hospital Course: The patient was put on insulin drip. Blood sugars got down. She was put on q.i.d. Accu-Cheks. Once her blood sugar level came down to the 100s, potassium was lowered. I had a very lengthy discussion with patient about the need for keeping physician’s visits and checking blood sugars. The patient was placed on Cipro. Her electrocardiogram showed a prolonged Q T. The patient went to ultrasound and had sludge and possible small stones in her gallbladder, and it was felt that she was able to be discharged home improved.

Discharge Medications/Instructions: Insulin 70/30, 20 units in the a.m., 20 in the p.m., Rezulin 400 mg q. a.m., Tenormin 50 q.d., Plavix 75 q.d., Monoket 10 mg b.i.d., Lasix 20 mg b.i.d., aspirin 325 q. a.m., Zocor 20 once a day, Oxycotin 20 b.i.d., Prozac 20 q. a.m., Vasotec 5 mg q. a.m., Propulsid 10 mg at Ac and HS, Bactrim DS one tablet every 12 hours. She is to see her primary care physician in one week. She is to call if she has any difficulties.

Disposition: Discharged home

History and Physical

Past Medical History: The patient has history of renal insufficiency with a blood urea nitrogen of 30 to 40 with a creatinine of 1.2 to 1.4. She has had a CVA, severe peripheral arterial disease. Echocardiogram done shows aortic stenosis, mitral leaflet thickening, normal left ventricular size, normal diabetes. Smokes three to four packs of cigarettes a day. She has hypertension. She has hyperlipidemia. She is dehydrated. She has a history of atherosclerotic coronary artery disease.

Medications: At the time of admission included Rezulin 40 mg q.d., Prozac 20 q.d., Propulsid 10 a.c. and h.s., Vasotec 2.5 two every morning, Atenolol 50 q. a.m., Plavix 75 q. a.m., Lasix 20 milligrams b.i.d., Novolin 70/30 20 units every a.m., aspirin 325 q. a day, vitamin E, iron, Oxycotin 20 a.m. and h.s., Zocor 20 mg at dinner. The patient has no known drug allergies.

Social History: She is married but her husband lives out of state and works there. She has one daughter. She does not drink and has smoked about three to four packs of cigarettes a day since a teenager.

Physical Exam: At the present time, the patient is afebrile, vital signs are stable. She is awake and alert, oriented times 3.

HEENT: Pupils equal, round, reactive to light and accommodation, extraocular muscles intact, oropharynx benign.

Neck: Supple without adenopathy or jugular venous distention

Lungs: Clear to auscultation

Heart: Reveals a regular rate and rhythm without murmurs, gallops, or rubs

Abdomen: Soft, nontender, positive bowel sounds, no masses noted

GU: Deferred

Extremities: No edema. She has a baseline edema currently. Pulses are absent, pedal pulses.

Laboratory: At the time of admission, her glucose was 737, blood urea nitrogen 75, creatinine 1.8, acetone greater than 200, less than 250, sodium 136, potassium 6.1, chloride 95, bicarb of 13. Her hemoglobin was 13.9 and hematocrit of 44.1, white blood cell count of 9.2 with a left shift showing 80.2 percent neutrophils, 16.2 percent lymphocytes. Platelets were 241,000. Urinalysis shows positive nitrites, greater than 1,000 glucose, 30 protein, 15 ketones, trace hemoglobin. She had 13 white blood count per high power field. Rare red per high power field, 21 bacteria. Gram stain on her u/a showed no organisms seen.

Impression(s): ___________________________________________ 1. Diabetic ketoacidosis

2. Diabetes mellitus type 1

3. Dehydration

4. Congestive heart failure

5. Hyperkalemia

6. Hyperlipidemia

7. Hypertension

8. Tobacco dependence

9. Severe peripheral vascular disease, arterial in nature

10. Atherosclerotic coronary artery disease

11. Urinary tract infection

12. Renal insufficiency

Plan: Admit, hydrate. She has been on insulin drip, we will d/c this now and change to q. 4 Accu-cheks and continue sliding scale. Hopefully on 16th be able to reinstitute her routine meds. Her potassium has now come down to the mid 4’s secondary to her hydration and her sugar being driven intracellular with the insulin drip. I have impressed upon the patient the need for checking blood sugars and keeping M.D. appointment versus death in the future. The patient is on Cipro for her urinary tract infection. Further workup as indicated during hospital stay.

Code Assignment Including POA Indicators

ICD-10-CM Principal Diagnosis:

ICD-10-CM Additional Diagnoses:

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

it needs the icd10 cm and pcs code

Expert Solution

ICD 10 CM Codes for Principal and additional diagnosis

Diagnosis	ICD 10 Codes
ICD 10 CM Principal Diagnosis- Diabetic Ketoacidosis	E1010- Type 1 DM with ketoacidosis without coma
Additional diagnosis: Dehydration	E86.0
Congestive heart failure	I50.9 includes Cardiac, heart or myocardial failure Not Otherwise Specifies(NOS),Congestive heart disease,Congestive heart failure NOS
Hyperkalemia	E87.5 (acute hyperkalemia, chronic hyperkalemia, high, dietary potassium intake finding, drug-induced hyperkalemia)
Hyperlipidemia	E78.5 (used for Hyperlipidemia, Unspecified, a disorder of lipoprotein metabolism other lipidemias)
Hypertension	I11.0, Hypertensive heart disease with heart failure,
Tobacco dependence	F17.2 for Nicotine dependence
Severe peripheral vascular disease, arterial in nature	I73.9 for Peripheral Artery Disease, Peripheral vascular disease, unspecified, also includes Intermittent claudication,Peripheral angiopathy NOSand Spasm of artery
Atherosclerotic coronary artery disease	I25.10 - Atherosclerotic heart disease of native coronary artery without angina pectoris
Urinary tract infection	N39.0 for Urinary tract infection, site not specified
Renal insufficiency	Code N28.9 is for Disorder of kidney and ureter, unspecified. Also applicable for Nephropathy NOS,Renal disease (acute) NOS,Renal insufficiency (acute) ------------------------------------- Code N18.9 - Chronic kidney disease, unspecified. Applicable for Chronic renal disease, Chronic renal failure NOS, Chronic renal insufficiency,Chronic uremia NOS,Diffuse sclerosing glomerulonephritis NOS.

In addition to this ICD-10- CM codes few more conditions included in discharge diagnosis

Aortic valve stenosis	I35.0 - Nonrheumatic aortic (valve) stenosis
Urinary tract infection due to Pseudomonas aeruginosa	B96.5, Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere. Applicable for Bacterial infection due to pseudomonas,Pseudomonas infection,Pseudomonas urinary tract infection,Urinary tract infection due to pseudomonas.
Old myocardial infarction	I25.2- Old myocardial infarction

ICD-10-PCS Procedure Code(s)

Ultrasonography abdomen	BW40ZZZ
ECG	4A02X4Z
Blood tests(CBC,elecrolytes)	8C02X6K: Collection of Blood from Indwelling Device in Circulatory System.
Echocardiogram	B24BZZ4: Ultrasonography of Heart with Aorta, Transesophageal.
urinanalysis	CPT 81025, Under Urinalysis Procedures(not ICD 10 PCS)

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