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Coding Recommendations - Feature Article 08/15/98
   

Procedure Practice
    

Using ICD-9-CM and CPT-4, assign codes for the procedure(s) described in this "real-life" discharge summary.

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Patient Name: Sweetwater, John

MR#: 102938

Admitted: 8/1/98

Discharged: 8/5/98

Pertinent History and Physical Exam: The patient is a 56-year-old, insulin-dependent diabetic with longstanding diabetic peripheral neuropathy and Kimmelstiel-Wilson syndrome on twice weekly hemodialysis. He has had IDDM since the age of 32. His last discharge from this hospital was 2 months ago following treatment of urosepsis. He did well at home for several weeks. I then saw him in the office and noted an ulcerated area on the plantar surface of the left foot. The ulcer was debrided and the patient was placed on p.o. antibiotics. The ulcer failed to respond to conservative therapy, and upon follow-up office visit gangrene was noted. The patient is admitted for further treatment. Current medications include Humulin, Lasix, and Kay Ciel.

Lab Data: Admission glucose was 360, Hgb. 13.4, Hct. 38, WBC 14.8. Urinalysis was normal. Biochemical profile: sodium 142, potassium 4.2, chloride 113, CO2 18, BUN 71, creatinine 5.8, LFTs normal, albumin 3.6, calcium 8, phosphorus 7.2, magnesium 2.2, cholesterol 181, triglycerides 65.

Hospital Course: The patient was treated with IV Cipro. He was seen by the infection control nurse and vascular surgery was consulted. The patient had a 3.0 cm. diameter ulcer involving the plantar aspect of the left foot at the head of the 2nd metatarsal with surrounding gangrene. Bone scan revealed osteomyelitis of the 2nd and 3rd metatarsals. Diagnosis of diabetic ulcer with osteomyelitis secondary to diabetic peripheral neuropathy was made. The patient underwent a left forefoot amputation on the 2nd hospital day. Pathology report confirmed acute osteomyelitis. Postoperatively the patient’s wound healed well with the aid of whirlpool treatments and daily dressing changes. The patient was transferred to the hemodialysis unit on hospital day #3 for his routine scheduled hemodialysis. On the day of discharge the patient was switched to p.o. antibiotics. He was discharged with home health services to continue daily Silvadene dressings and to conclude his course of oral antibiotics.

     

Using the above samples, do your own coding and then compare it with our recommendations.

Notice: This part of our web site was prepared to assist in understanding and maintaining good coding skills. For proper use of this feature, reference must be made to official coding guidelines when necessary. The information here presented is only to be used as a supplement to those guidelines. Laguna Medical Systems, Inc., makes no representations or guarantees as to amounts that will be paid by Medicare or other third party payers.
 

 

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