Question

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 echocardiogram 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): ___________________________________________

Answer 1

Answer:

POA indicator is an alpha character assigned to the principal diagnosis code and any secondary diagnosis codes reported for each inpatient admission.POA indicator are distinct from diagnosis codes and are not part of ICD 10 CM codes.

ICD 10 cm is the code set for diagnosis coding and is used for all health care settings in the United States.

ICD 10PCS is used in hospital inpatient settings for inpatient procedure.

ICD-10-CM principal diagnosis

v2019A

ICD-10-CM principal diagnosis code(v2019A) is primarily responsible for the admission of the patient to the hospital for care during this hospitalization.

ICD code for sickle cell pain crisis is :D57.219

ICD-10CM Additional Diagnosis

v2019A

ICD 10 CM Coding convention requires the underlying condition be sequenced first followed by the manifestation.Whenever such a combination exists there is a Use Addtitional Code note at the etiology code,and a Code First note at the manifestation code.

ICD-10-PCS Procedure code

ICD-10-Procedure Coding System is an international system of medical classification used for procedure coding.This procedure coding system is used to gather data,collect information,determine payment,and support the electronic health records for all inpatient services and procedures performed in the U.S

PCS code for PICC line insertion is 02HV33Z