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Mod 3--Medicine Section case
studies 2-7, 2-8a, 2-8f 2024-
2025. Questions & Correct
Answers. Graded A+
2-8F DIALYSIS PROGRESS NOTE The patient is discharged from the hospital. The first-listed diagnosis continues to be the complication for which the admission was made. LOCATION: Inpatient, Hospital PATIENT: Grace Hargrove PHYSICIAN: George Orbitz, MD DIALYSIS PROGRESS NOTE: The patient had no more major events during the night. She has less pain. She is eating well. She denies any complaints. She is tolerating peritoneal dialysis very well with 1.5%. Her vital signs are stable. She is afebrile at 36.5° C (Celsius). The plan is to send her home taking Kefzol. She will be discharged home today. Patient agrees with the plan. - ANSSERVICE CODE(S): 90945 ICD-10-CM DX CODE(S): i12.0, n18.6 [Professional Services: 90945 (Dialysis, Peritoneal) ICD-10-CM DX: I12. (Disease/diseased, renal, with, end-stage [failure], due to
hyper- tension), N18.6 (Disease/diseased, renal, with, end- stage [failure], due to hypertension) ICD-9-CM DX: 403. (Hypertension/hypertensive, kidney, with, chronic kidney disease, stage V or end stage renal disease, Unspecified), 585. (Disease/diseased, renal, end stage) RATIONALE: The physician provided a single physician evaluation, which is reported with
- The diagnosis is stated as 403.91/I12.0 and 585.6/N18.6, hypertensive renal disease with end-stage renal disease. The peritonitis has cleared up, and there is no further men- tion of this condition. There is no complication noted in this record because the condition has cleared and the patient is ready to go home.] CASE 2-7 The patient is seen in the dialysis unit, which is an outpatient unit. The facility reports a Z/V code as the primary reason for the encounter followed by the diagnosis(es). The physician reports the ESRD diagnoses for the ESRD management service. The date of this service is the 30th day of services provided to this ESRD patient by Dr. Orbitz. Report the monthly ESRD service code (41) for this 32-year-old
DX: V56.0 (Admission/Encounter, for, dialysis) 403. (Hypertension/hypertensive, kidney, with chronic kidney disease, stage V or end stage renal disease, Unspecified) 585. (Disease/diseased, renal, end stage) 250.40 (Diabetes/diabetic, nephropathy) (This is the cause) 583.81 (Nephropathy, due to diabetes mellitus) (This is the manifestation) 275. (Hyperphosphatemia) 275.41 (Hypocalcemia) 244. (Hypothyroidism) V45.73 (Absence, kidney[s], acquired) RATIONALE: (This Rationale is presented in the student's text.) The physician provided a full month of service to the patient. The codes in the range 90951-90966 are reported only once for each month of physician service and include the management services and evaluations of the patient during the month. This patient was 32 years old, so 90960 is reported. The reason for the encounter was dialysis, and this is the first-listed (primary) diagnosis (Z99.2/V56.0). The Assessment/Plan sections of the report indicate the chronic renal failure due to hyperten- sion. When hypertension is present with renal failure, the Guidelines
direct the coder to assume a cause-and-effect relationship (the hypertension caused the renal disease). The subterms "kidney, with, stage V chronic kidney disease (CKD) or end-stage renal disease (ESR CASE 2-8A This patient has been receiving ambulatory peritoneal dialysis for several years. She has encountered a complication and is admitted to the hospital by Dr. Orbitz for treatment for the complication. The complication is the primary reason for the treatment. This patient has hypertensive renal disease, so review I.C.9.a.2. of the ICD-10- CM Official Guidelines for Coding and Reporting/I.C.7.a.3. for ICD-9-CM before assigning the diagnoses for this case. HISTORY AND PHYSICAL EXAMINATION LOCATION: Inpatient, Hospital PATIENT: Grace Hargrove PHYSICIAN: George Orbitz, MD This 79-year-old woman is being admitted because of acute peritonitis due to peritoneal dialysis. HISTORY OF PRESENT ILLNESS: This patient is a chronic ambulatory peritoneal dialysis patient who is currently on cycle PD (peritoneal dialysis) for 10 hours at night. She was started on dialysis last year and has
(abdominal dis- comfort and/or bloating), for 3 elements for a level 3 or detailed ROS. The PFSH includes the past history in the History of Present Illness section of the report as the physician elicited information on her past illness and surgeries (see highlighted section of the report that fol- lows). In addition to the past history, the social history and the family history are reviewed for a total of 3 PFSH elements or a level 4 or comprehensive PFSH. This is a level 3 or detailed history. The examination included 2 BAs of abdomen (soft) and extremities (only one is counted since the doctor did not specify which extremities), which count as 2 BAs. OSs included cardiovascular, respiratory, integumentary, and neurologic for a total of 6 BAs/OSs for a level 3 or detailed examina
