Question

Write a scenario in which a patient is admitted with two or more interrelated conditions. Provide the codes you used, and include the steps followed for locating the diagnoses.

Answer 1

Diagnosis: COPD with Acute Pneumonia

71-year-old male came to the hospital with breathing difficulty. Is a chronic smoker, smokes about 7 to 8 packets/day. He is a known case of COPD. He developed cough with increased sputum production green/grey in colour 2 weeks prior to office visit. He got admitted to hospital through through the ER with a suspected diagnosis of pneumonia superimposed on severe COPD. Chest Xray was perforemed and confirmed the presence of acute RLL pneumococcal pneumonia. Patient is allergic to pencillin. So IV cephalosporin was started and was discharged 3 days prior to the current visit.

He has a Past Medical History of severe O2 dependent COPD, with type II diabetes mellitus secondary to chronic prednisone therapy, and is on (OHGA) oral hypoglycemic agent for the same. Patient is also a known case of hypertension, and is on ACE inhibitor therapy. On admission patient vaerbalised “I just got out of this hospital 3 days back. I’m feeling little better, but still this breathing problem troubles me.”

On admission  Physical assessment showed: T 99, BP 148/110, P 98 and irregular, RR 26, Chest assessment showed decreased lung sounds in all the lung fields except in Right Lower Lobe. Mild rhonchi and wheezes were noted in the RLL.

Lab and radiology findings were : ABG on 2L Oxygen administered via nasal cannula showed PO2 62, PCO2 47, pH 7.40, Chest X ray revealed hyperinflation of lungs with minor amount of  RLL alveolar infiltration. Comparison to CXR from previous hospitalization showed  approximately 80% resolution of pneumonia.An ECG was also taken which showed persistent atrial fibrillation which was not seen in the an ECG taken 6 months back. Random Blood Sugar level was 186 mg/dl.

Treatment plan is as follows:

Continue oral cephalosporin with a follow up visit in 1 week and repeat CXR then, for Acute Community Acquired Pneumococcal Pneumonia:

For Severe COPD: inhaled bronchodilator.,continue O2 via nasal cannula and low dose Prednisone

Chronic Hypoxemic, Hypercarbic Respiratory Failure

Continue digoxin initiated during recent hospitalization for Persistent Atrial Fibrillation:

Continue the ACE inhibitor therapy for Hypertension:

Continue oral hypoglycemic therapy for Diabetes Mellitus, Type II, secondary to prednisone therapy;

Penicillin Allergy

Tobacco Dependence

Points to be rememvered before coding the conditions using ICD 10 CM codes

• ICD-10-CM separates pneumonia by infectious agent. There are different codes for each type, so document as per the infectious agent of pneumonia  .
• ICD-10-CM separates respiratory failure byhypoxia or hypercapnia, if present and by by acuity
• Use ICD-10-CM status” Z” codes inorder to document drug allergies
• Document the type of cardiac arrhythmia.
• There is a a code assignment for adverse effect of the drug in the Table of Drugs & Chemicals
• Drug-induced DM is a secondary type of diabetes due to the use of glucocorticoidsand and this would never be first-listed and can be coded only as an “additional code”.

For secondary diabetes, the code categories are : Due to underlying disease (E08),Due to drug (E09) and Due to other specified condition such as post pancreatectomy. (E13). The underlying cause of DM must be first-listed diagnosis and later the other 3 categories as mentioned above.

Coding: ICD-10-CM Diagnosis Codes

J13 Pneumonia due to Streptococcus pneumoniae
J44.0 COPD with acute lower respiratory infection
Z99.81 Dependence on supplemental oxygen
I48.1 Persistent atrial fibrillation
E09.9 Drug or chemical induced DM without complications
T38.0x5A Adverse effect of glucocorticoids and synthetic analogues
I10 Essential (primary) hypertension
Z88.0 Allergy status to penicillin
F17.210 uncomplicated Nicotine dependence, cigarettes,