ICD -10-CM AND ICD -1 0-PCS CODE ( ?S ) ?FOR: Inpatient Patient Name: Dorothy Becker DOB: 02-10-67 ?Sex: F Date of Admission: 08-04-XX Date of Discharge: 08-08-XX Discharge Summary Discharge Diagnoses Acute LLE cellulitis OSA COPD Htn Hyperlipidemia DM II with peripheral neuropathy Osteoarthritis, generalized Morbid obesity History of Present Illness: This is a 51 ?y/o African-American female who presents to the ER with complaints of left lower extremity pain, swelling and warmth. She denies any known fevers or chills, no chest pain, shortness of breath, no known injuries to legs. She does state that she has had cellulitis of the left leg in the past about 6 ?months ago. She states that she has been diagnosed with MRSA infections in the past. Hospital Course: The patient was admitted to Dr. ?Meadows. She was initially started on Clindamycin, but due to her history of MRSA, infectious disease did see the patient and they recommended changing antibiotic regimen to Diflucan, Ceftriaxone, and Vancomycin. She was also provided miconazole topical powder to her bilateral feet in between the toes bases and Ace wrap was applied to the left lower extremity and changed daily. We
The Correct Answer and Explanation is :
Based on the provided discharge summary, the following ICD-10-CM and ICD-10-PCS codes are appropriate for the diagnoses and hospital course of Dorothy Becker:
ICD-10-CM Codes:
- Acute Left Lower Extremity (LLE) Cellulitis:
- L03.115 – Cellulitis of left lower limb
- The patient presents with acute left lower extremity pain, swelling, and warmth, indicative of cellulitis. The code L03.115 is used to classify cellulitis of the left lower limb.
- Obstructive Sleep Apnea (OSA):
- G47.33 – Obstructive sleep apnea (adult) (pediatric)
- The patient’s diagnosis of OSA is indicated, which is a common condition characterized by episodes of breathing cessation during sleep.
- Chronic Obstructive Pulmonary Disease (COPD):
- J44.9 – Chronic obstructive pulmonary disease, unspecified
- The patient has a history of COPD, which is included in her diagnoses.
- Hypertension (HTN):
- I10 – Essential (primary) hypertension
- The patient has hypertension, which is managed alongside her other conditions.
- Hyperlipidemia:
- E78.5 – Hyperlipidemia, unspecified
- This code represents the condition of hyperlipidemia, as diagnosed during the hospitalization.
- Diabetes Mellitus Type 2 with Peripheral Neuropathy:
- E11.42 – Type 2 diabetes mellitus with diabetic polyneuropathy
- The patient has type 2 diabetes with peripheral neuropathy, which is managed during the admission.
- Osteoarthritis, Generalized:
- M15.9 – Osteoarthritis, unspecified
- Generalized osteoarthritis is noted in the patient’s history, though further details on the affected joints are not specified.
- Morbid Obesity:
- E66.01 – Morbid (severe) obesity
- The patient is diagnosed with morbid obesity, a significant factor in her overall health.
ICD-10-PCS Codes (For Procedures):
Since the summary focuses on treatment and management rather than surgical procedures, we will code the medical treatments provided during the hospital stay:
- Antibiotic Therapy:
- The patient received a regimen that included Ceftriaxone, Vancomycin, and Diflucan, which would typically fall under “administration of medications,” but ICD-10-PCS codes for outpatient drug administration are not applicable in this case.
- Wound Care (Ace Wrap and Dressing):
- 0H4J0ZZ – “Change dressing, left lower extremity”
- This is a procedure code for changing a dressing on the patient’s left lower extremity.
In summary, the appropriate ICD-10-CM codes represent the patient’s diagnoses and conditions upon discharge, including cellulitis, OSA, COPD, hypertension, hyperlipidemia, diabetes with neuropathy, osteoarthritis, and morbid obesity. The ICD-10-PCS codes document specific medical treatments, including antibiotic administration and dressing changes for wound care. The patient’s medical course and hospital stay involved careful management of these chronic conditions.