An elderly nursing home patient was seen for pneumonia. The patient has frequent aspiration pneumonia because of his difficulty in swallowing (neurogenic) due to a previous cerebral infarction. In addition to the aspiration type pneumonia, the patient also has stage I decubitus ulcers on both his left and right hip. Code this scenario using the ICD-10-CM code set.
J69.0, Pneumonia, aspiration, due to food (regurgitated)
I69.391, Dysphagia, following, cerebrovascular disease, cerebral infarction
R13.19, Dysphagia, neurogenic
L89.211, Ulcer, decubitus – see Ulcer, pressure by site Ulcer, pressure, stage I (healing) (pre-ulcer skin changes limited to persistent focal edema), hip, right.
L89.221, ulcer, decubitus – see Ulcer, pressure by site Ulcer, pressure, stage I (healing) (pre-ulcer skin changes limited to persistent focal edema), hip, left.
Rationale: Documentation substantiates the assignment of aspiration pneumonia as the first listed diagnosis. The neurogenic dysphagia is due to an old cerebral infarction and should be coded. R13.19 is coded in addition to I69.391 due to an instructional note under I69.391 stating “use additional code to identify type of dysphagia, if known (R13.1-).” Two decubitus ulcer codes are required since the patient has ulcers of both the right and left hip.
ICD-10-CM coding tip: If you are looking for a late effect of CVA in the alphabetic index, the fourth digit will be “3!” There are several columns under late effects so make sure you’re in the correct section. Write that tip into your Alphabetic Index to ensure you always remember.
ICD-10-CM Sepsis Scenario:
Patient taken to emergency department after being found semi-conscious with markedly abnormal vital signs, a fever of over 39 degrees C, a heart rate of 100, and a respiratory rate of 22/min. On admission to the ICU the physician documented her condition as severe sepsis with acute respiratory failure. The final diagnosis, provided by the physician, was gram-negative sepsis with acute respiratory failure.
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