Reference no: EM133329575

Case - Patient Name: Max Spear

HPI: The patient is a 72-year-old male with a history of abdominal perineal resection for colon cancer in 2004 and left hemicolectomy in 2005 for splenic flexure recurrence of cancer. Subsequent right nephrectomy, right adrenalectomy, right posterior hepatic wedge resection in
February of this year for metastatic colon carcinoma.

For this hospital encounter, the patient is admitted with complaints of lower back pain and bilateral thigh pain times 2 months' duration, increasing in intensity. Physical exam: Examination on admission: Temperature 99, pulse 72, respirations 24, blood pressure 150/90. The exam was remarkable for left lower quadrant colostomy from previous surgery, mildly tender lumbar spine, and the patient was barely able to stand. It was also noted that the patient had decreased sharp, dull discrimination on the neural examination of the lateral thighs.

Lab data: On admission the lab values were; Urinalysis: Specific gravity 1.021, pH 5; chem tests were negative; nitrite negative; blood negative, 12 white blood cells, moderate bacteria. The clinical chemistry results were: serum sodium 141, BUN 42, potassium 4.9, chloride 104, CO2  28, glucose 99, creatinine 1.8, SGOT 12, SGPT 16, alkaline phosphatase 68, total protein 6.6 albumin 3.8, total bilirubin 0.7, direct bilirubin 0.0, GGT 87, calcium 10.3, magnesium 2.0, phosphorus 3.2, uric acid 5.7, PT 12.9, PTT 28.4, white blood cell count 8.0, hemoglobin 15.0, hematocrit 43.8, platelets 223,000. The CEA level was noted to be 508 ng/mL on admission. Metastatic workup for the colon carcinoma revealed no evidence of metastatic disease to the head or the thoracic and cervical spine.

Radiologic studies: CT and MRI revealed left celiac ganglion node plexus enlarged, suspicious for metastasis. Multiple small lung nodules bilaterally suspicious for metastasis. Pathologic fracture of L2, with compression of L2, effacement of the spinal canal space and apparent cord compression at the L2 level. Subsequent urine culture grew out greater than 105 Pseudomonas aeruginosa, which was sensitive to Ciprofloxacin. The patient was treated with Ciprofloxacin 500 mg PO q 8 hours, and subsequent urine culture showed no growth.

Hospital course: The patient was taken to the operating room for L2 laminectomy with decompression and anterior allograft bone fusion. The postoperative course was marked by slow recovery with nausea and difficulty with pain control. The patient slowly improved and began ambulating 8 days later. The patient fell 3 days later while ambulating but had no significant injuries. Further physical therapy was marked by continued improvement in ambulation with walker and no further setbacks. Clinically, the patient is afebrile without signs and symptoms of infection, no CVA tenderness, and no dysuria. The patient will be discharged home today.

Condition on discharge fairly good.

Treatment: The patient will go home on Vicodin (PO q 4 to 6 hours for pain) and Capoten. He will resume Capoten b.i.d. dosing per his internist's recommendations, 25 PO b.i.d. Prognosis:

The long-terms prognosis is poor because the patient has metastatic colon CA: short-term prognosis is fairly good with improvement in ambulation. Ambulation with assistance with walker.

Final Diagnoses: Pathologic compression fracture of L2 vertebra, compression of cord at L2, Metastatic colon cancer to lung and bone and UTI due to Pseudomonas. Codes assigned are:
Principal diagnosis: N39.0
Additional diagnoses: Z85.038, G99.2

Procedure codes assigned: 0GB00ZZ and 0SG00K0

Question: Are these the correct codes per the clinical documentation and ICD-10-CM/PCS coding guidelines? Is N39.0 the correct principal diagnosis per the clinical documentation and UHDDS guidelines? Are there any missing ICD-10-CM codes?