Reference no: EM132168701
Please provide reportable ICD -10 diagnostic and procedural codes for the following short Inpatient scenarioswhile using 3M encoder.
1. 81 year old right handed male was admitted with a severe headache, a CT scan of the brain identified a large cerebral hemorrhage which caused left sided hemiparesis and aphasia. Hemiparesis and aphasia resolved before patient went home.
2. 13 year old male was admitted with abdominal pain, localized in the right lower quadrant. The diagnosis of acute appendicitis was made. The patient was taken to the OR (operating room) where a laparoscopic appendectomy was performed. While removing the appendix the surgeon verified the appendix had perforated and caused E. coli localized peritonitis within the peritoneal cavity. Following 2 days of IV antibiotics the patient was able to be discharged home.
3. 22 year old pregnant femaleat 35 weeks pregnancy was admitted to the floor with the diagnosis of acute pyelonephritis due to Pseudomonas requiring IV antibiotics. The fetal heart tones remained stable throughout the hospitalization and the patient was discharged on the third day in stable condition.
4. 44 year old female with history of asthma and multiple sclerosis (MS) was admitted with a severe headache and fever. A diagnostic work up including a lumbar puncture was performed which revealed viral meningitis. Two days later patient went into an acute exacerbation of asthma which was treated with steroids. She remained on her medications during the stay for her MS.
5. This 74 year old male diagnosed with prostate cancer is admitted for open radical prostatectomy and resection of his two regional lymph nodes. They were positive for metastatic disease. Patient required Foley catherization for urinary retention post operatively. In six weeks the patient will be receiving chemotherapy and radiation following his recuperation from his surgery. Patient was discharged in stable condition.
6. This is newborn singleton baby born in this facility 3 minutes ago via vaginal delivery. Baby is 35 weeks preterm, his weight is 2249 g and it is suffering from Respiratory Distress Syndrome. Physician has to place endotracheal tube and initiate mechanical ventilation for next 103 hours. Baby recovers and it is discharged in good condition.
7. This patient was admitted with severe shortness ofbreath. He is 68 year old male (oxygen dependent) with pulmonary fibrosis and emphysema, following a chest x-rays the diagnosis of pneumonia and pleural effusion was made, a thoracentesis with high yield of 1.5 liters was done on the day of discharge with resolution of his symptoms. Following this procedure the patient was discharged to home under family supervision in fair condition.
8. This 87 year old male with Alzheimer's dementia was admitted to the hospital for treatment of his stage II sacral decubitus. During this stay it unfortunatelyprogressed to stage III. The patient was taken to the OR (operating room) where an excisional debridement of the necrotic skin and subcutaneous tissue was done.
9. A 61 year old male was admitted to the hospital with chest pain and epigastric pain. Following a complete cardiac and GI (gastrointestinal) work up, the source of the pain was felt to be acute and chronic cholecystitis with cholelithiasis. He is also monitored and treated for his essential hypertension. The patient was taken to the OR and a laparoscopic cholecystectomy and intraoperative cholangiogram were performed. The patient remained stable throughout his hospitalization and was discharged in good condition on the second post-operative day.
10. A patient is brought to the ER with fever due to cellulitis of abdomen. After further work up of patient, physician documents post procedural sepsis due to MSSA. Patient is s/p appendectomy couple of weeks ago. After treatment, patient stabilized and was discharged home.
11. Patient was admitted with epigastric pain. Detailed work up including EGD was performed. Progress notes and discharge summary consistently state: pain is due to either gastritis or GERD. The patient will have a follow up EGD within the next 6 months.
12. This 58 year old male with hypertensive heart disease was admitted with severe shortness of breath due to exacerbation of his established diastolic congestive heart failure; during the hospitalization, patient was diagnosed three days later with acute prostatitis due to E Coli; this was treated with antibiotics.
13. This 63 female patient was admitted with post-menopausal bleeding. The patient underwent a hysteroscopy. The physician documents adenomyosis and a fibroid of the uterus as the cause of the bleeding. The patient required a transfusion of packed red blood cells (per peripheral vein, percutaneous approach) for her acute blood loss anemia which developed after surgery. The patient did very well and was discharged in very good condition.
14. This 74 year old male fell from a ladder while painting his house. He sustained a left femur shaft fracture and two rib fractures on the right side. Patient underwent ORIF (open reduction/internal fixation) of his femoral fracture. The patient recovered from the procedure and did extremely well during the physical therapy appointments and was discharged home.
15. This 38 year old female patient, pregnant with her third set of twins at 40 weeks gestation, was admitted through the Emergency Room in labor with a diagnosis of oligohydramnios. After ultrasound was done, baby B (#2) was found to be in breech presentation and mother was taken to OR for low cervical Cesarean section. Baby A and baby B were delivered safely and both are healthy.