An 86-year-old patient is admitted for monitoring and observation related to an episode of secondary thrombocytopenia (still resolving), which was due to an adverse reaction to ciprofloxacin used to treat a UTI. The UTI has been resolved. The patient is confined to a wheelchair due to hemiplegia on his dominant side as a late effect of CVA two years ago. He has recently established a Living Will that specifies he does not want to be resuscitated if he should experience a cardiac arrest and the physician has added a DNR order to the Plan of Care.
287.49, secondary thrombocytopenia
E930.8, Adverse Effect in therapeutic use of other specified antibiotic NEC (remember when coding an adverse effect to code the “effect” first followed by the E-code for the substance.
438.21, LE of CVA, hemiplegia of dominant side
V13.02, History of UTI (The patient is no longer under treatment, but the history is pertinent to the overall POC and should be coded.)
V46.3, Wheelchair dependence (This helps show his current functional limitation)
V49.86, DNR status (Further describes the patient’s status as long as the physician has added a DNR to his orders. This code is not used just because patient has developed a DNR. There should be a copy of the out of hospital DNR order at the patient’s bedside in the home and a copy of all paperwork related to the DNR or advanced directive in the home health record.
Patient has Type I diabetes with both retinopathy and End Stage Renal Disease. He attends dialysis three times per week. He also has HTN and has just been discharged from the hospital for an exacerbation of acute on chronic diastolic and systolic heart failure. Skilled nursing is ordered to monitor the CHF, medication compliance, obtaining weights, assessing lung sounds and edema, and teaching.
I50.43, Acute on Chronic combined (congestive) and diastolic (congestive) heart failure (This is the focus of care so it’s coded primary.
E10.22, Type I DM with Diabetic CKD
I12.0, Hypertensive CKD with Stage 5 or ESRD (The link between HTN is assumed, and it’s stated with diabetes. Instructions state to sequence ESRD after both HTN and DM.)
E10.319, Type I DM with unspecified diabetic retinopathy without macular edema
Z99.2, dependent on renal dialysis (Instructions also state to code dialysis when patient receives it.) ALSO NOTE that insulin is not coded with Type I diabetes.
New Scenarios for 9/29/2014
Patient with paranoid schizophrenia is admitted to home health. The skilled nurse will be providing Haldol injections BID as a new treatment for the schizophrenia, until the caregiver is proficient in administering the drug. Patient also has CHF, HTN, and Type II DM.
A 68-year-old woman with multiple sclerosis is referred to home health or PT, SN, OT following a number of recent falls related to progression of the disease. She has additional related diagnoses of neurogenic bowel and bladder, and requires intermittent catheterization, but is not incontinent. Nursing is needed to assess the patient’s competency and teach safe self-catheterization techniques, as the patient has had several recent UTIs. She also has a diagnosis of hypertension.
Look for the answers and new scenarios next Monday!