An outbreak of Legionnaire’s disease has plagued residents of the South Bronx area of New York City this summer. At least 12 people have died from the disease and greater than 100 have been sickened by it. The source of the infection has been linked to water cooling towers in the area.
Assign the ICD-10-CM code for Legionella pneumonia. Continue reading
A 37-year old male with a long-standing history of the diagnosis of gender identity disorder is currently undergoing counseling and medical therapy in an effort to work toward physically modifying his body to better match his psychological gender identity. The patient is scheduled to undergo an orchiectomy penectomy and surgical construction of a vagina in the near future.
Assign the ICD-10-CM code for the diagnosis of gender identity disorder.
What ICD-10-PCS code will be used for the procedure of a surgical construction of a vagina using autologous tissue procedure for this patient? Continue reading
A 37-year old male was found unresponsive in a bedroom at his home by a family member. Paramedics arrived and found the patient pulseless and not breathing. The patient’s skin was cool and cyanotic. The family member said the patient had been using Oxycodone for long-standing back pain for the past two to three years. A prescription bottle for the drug was found at the scene. The patient was transported to a nearby Emergency Room where he was pronounced dead. The Emergency Room physician recorded the diagnoses of: Continue reading
A 62-year old male who was diagnosed with pancreatic cancer two weeks ago, was admitted to the hospital with malaise, fever, and an elevated WBC of 15.21 k/uL. The patient was diagnosed with sepsis. Blood cultures were positive for carbapenem-resistant Enterobacteriaceae (CRE). Infectious Diseases was consulted. A review of the patient’s history revealed that the patient had undergone an ERCP with biopsy of the pancreas approximately two weeks ago at which time a diagnosis of cancer of the head of the pancreas was made. It was eventually determined that the patient had been contaminated with the CRE organism from the duodenoscope used during the ERCP. The patient was discharged to an extended care facility with a PICC line for ongoing IV antibiotic therapy. Assign diagnosis codes for this inpatient encounter and sequence appropriately. Continue reading
An 11-year old boy with severe autism presents to the Emergency Department with a fall from a 4-5 foot round hay bale. He landed backwards on his left arm and chest two hours ago at his family’s farm. His father was present at the time of the fall and states that he did not lose consciousness, but might have “gotten the wind knocked out of him.” He got up afterwards and was ambulatory. His parents brought him in because he was not moving his left arm and was supporting it with his right arm. On examination, the left arm is minimally swollen and there is moderate pain. Pain is relieved with positioning and immobilization of the arm. The exam was difficult due to pain and the patient’s autism. Intranasal fentanyl was administered so proper assessment could be completed. Continue reading
A subway train car filled with thick black smoke due to an electrical malfunction. One woman on board had difficulty breathing and collapsed to the floor of the train, unconscious. Fellow passengers began performing CPR in an effort to help the woman. Emergency workers arrived and transported the woman to the Emergency Room of a nearby hospital. Resuscitative efforts were continued to no avail and the woman expired. The Emergency Department physician recorded the following diagnoses: acute respiratory failure due to smoke inhalation.
Assign diagnosis codes for this outpatient encounter. Continue reading
A 72 –year old male was admitted to the hospital with a chief complaint of a fever with a temperature of 101° F and feeling ill with worsening chills, cough, nasal congestion and body aches that began two days prior to admission. A chest x-ray revealed bilateral infiltrates in both lower lobes of the lungs. A viral culture was positive for AH3N2 influenza. The patient received antiviral medication and supportive care. The patient recovered enough to be discharged three days later with a diagnosis of pneumonia due to AH3N2 influenza.
Assign ICD-10 diagnosis codes for the inpatient hospitalization. Continue reading
A 49-year old female arrived in the trauma ED via helicopter in cardiac arrest after sustaining a stab wound to her upper torso. The patient was attacked by an unknown assailant with a knife (found at the scene) as she was walking to her car in a parking lot. The patient was unable to be resuscitated and expired. The Emergency Department physician documented the following diagnoses:
1. Penetrating laceration of anterior left thorax with near complete laceration of thoracic aorta
Assign diagnosis codes for this Emergency Department encounter. Continue reading
A 70-year old man presented at an Ambulatory Surgery Center for an upper GI endoscopy to be evaluated for the cause of his recent complaints of some dysphagia. The patient received Midazolam 6mg IV and Fentanyl 100 mcg IV and Benzocaine spray was applied to the back of his throat. After obtaining informed consent, the endoscope was passed under direct vision. It was introduced through the mouth and advanced to the second part of the duodenum. A small hiatal hernia was present. A mild Schatzki ring was found at the gastroesophageal junction at 35 cm. A TTS dilator was passed through the scope. Dilation with at 15-16.5-18 mm x 240 cm CRE balloon (to a maximum balloon size of 18 mm) dilator was performed with mild treatment effect. The esophageal body mucosa appeared mildly corrugated. Biopsies were taken from the upper and lower esophagus. At that point, the patient went into cardiac arrest. We quickly removed the endoscope and began resuscitative efforts. The patient was emergently transferred to the local hospital. Postprocedure diagnoses: Schatzki ring, hiatal hernia, cardiac arrest. Continue reading
A two-year old was brought to the Emergency Department by his parents with a chief complaint of wheezing. The parents stated that the child developed what appeared to be a cold the day before admission, with symptoms of a runny nose and slight cough. On the morning of admission, the child started wheezing and appeared to have difficulty breathing. The child was examined and lab tests were performed. The patient was admitted to the Pediatric unit for respiratory support and treatment with an admitting diagnosis of bronchiolitis. Laboratory testing isolated and identified enterovirus D68 (EV-D68). The patient’s respiratory symptoms stabilized then abated and patient was discharged home after four days with a diagnosis of acute bronchiolitis with bronchospasm due to EV-D68. Continue reading