HIT 108 Respiratory System Coding Cases
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Oakland Community College *
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Dec 6, 2023
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HIT 108 OC1
Spring 2021
Respiratory System Coding
12 Points
Due 3/12/21 at 11:59pm via D2L Assignments Submission Folder
CAHIIM Curriculum
AHIMA Entry-Level Competencies for Health Information Management (HIM)
at the Associate Degree Level
Domain
Bloom’s
Level
Entry-Level Competencies
IV.
Revenue Cycle
Management
3
Apply
IV.1. Validate assignment of diagnostic and procedural
codes and groupings in accordance with official
guidelines.
Review case study #1, #2, #3, #4, and #5 below and assign the ICD-10-CM codes for first-listed
diagnosis and secondary diagnosis(es). In addition, you need to assign the ICD-10-PCS codes for
the principal procedure and secondary procedure(s) if applicable.
Case Study #1
This patient is admitted for pulmonary rehabilitation in a setting of advanced COPD. She also
has HTN and type II diabetes mellitus with peripheral angiopathy. She has been ventilator-
dependent during her previous hospital stay. This patient was discharged home after 5 days.
What are the principal diagnosis and secondary diagnoses that the personnel at this acute care
hospital will report for her stay?
Principal Diagnosis: J44.9
Secondary Diagnosis(es):
I10, E11.51
The principal of procedure is not applicable because the case only mentions rehabilitation which
is not procedural intervention. As well as the secondary procedure is not applicable.
Case Study #2
History and Physical Exam
Present Illness:
This 74-year-old male presented to the emergency room last night with
complaints of increased weakness and shortness of breath. In the emergency room, he was found
to be hypotensive. Blood pressure 83/42 apparently-actually that was the recording at home. In
the emergency room, it was 130/80. He was afebrile, tachypneic per usual respiratory rate of 32,
and admitted with acute pneumonia. He was started on Levaquin. He has a history of purulent
sputum for several days. Since admission, he feels better; tachypnea and weakness have
improved. His blood pressure readings have somewhat improved. His peripheral edema
improved with a diuretic.
Past Medical History:
End-stage pulmonary disease, and congestive heart failure
Family History:
Unremarkable
Social History:
Has six children and is a widower
Physical exam:
On physical examination, blood pressure 120/70, pulse 90, respirations 28. He is
pleasant, alert. No JVD.
Chest:
He has bilateral rales, which are chronic
Heart:
There is a systolic ejection murmur, grade 3, with an S4 gallop.
Extremities:
Extremities reveal trace to +1 peripheral edema. He does have some stasis
pigmentary changes. He does have clubbing of his fingers.
Musculoskeletal
: No atrophic changes
Skin: Unremarkable except as noted
Neurological:
He has no focal sensory or motor deficits and reflexes are physiologic.
Impressions:
I suspect he probably just has purulent bronchitis and that is the cause of his
deterioration. He is on Levaquin and seems to be improving. We will observe until tomorrow. If
still reasonably well, we will let him go.
DISCHARGE SUMMARY
History of Present Illness:
This 74-year old male with end-stage pulmonary fibrosis was
admitted via the emergency room with increased breathlessness. The admitting diagnosis was
pneumonia. While here, he did not develop any significant fever.
Laboratory Studies:
On admission PO
2
58, PCO
2
37, pH 7.45 on 3.5 L, his electrolytes were
normal with the exception of BUN 28, creatinine 1.3, white blood cell count 8.6, hemoglobin
11.4, platelet count slightly low 117, urinalysis fairly unremarkable with trace protein, rare red
and white blood cells.
Hospital Course:
The patient was continued on Levaquin, which had been started one day
previously. His chest x-ray showed decreased cardiac size from the previous examination,
chronic infiltrates bilaterally, no acute infiltrates; pneumonia ruled out. Electrocardiogram
showed sinus rhythm, right bundle branch block, left anterior hemiblock. He did receive
intravenous diuretic and with this did achieve significant diuresis. My concern at the time of
admission was the possible hypotension, which was recorded at home, but all blood pressure
recordings here varied from the 100 to 130 systolic range.
Discharge diagnosis:
probably acute bronchitis with possible mild congestive heart failure
Principal Diagnosis: J20.9
Secondary Diagnosis(es): J98.4,
I50.9, I95.9
The principal procedure is not applicable because the case does not specify a procedural
intervention.
As well as the secondary procedure is not applicable.
Case Study #3
An 80-year-old female patient from a nursing home was admitted to the hospital with coughing
as her main symptom. Swallowing studies revealed she had difficulty swallowing and easily
aspirated particles into her respiratory tract. It was determined that she suffered from aspiration
pneumonia. She also was found to have a superimposed bacterial pneumonia. Both conditions
were treated with intravenous antibiotics, and the patient’s condition improved. After two days,
she was transferred back to the nursing facility for care.
Principal diagnosis: J69.0
Secondary diagnosis(es): J15.9
The principal procedure is not applicable because the case does not specify a procedural
intervention.
As well as the secondary procedure is not applicable.
Case Study #4
A 10-year-old boy was treated in the allergist’s office for childhood asthma. He was treated for
his allergic rhinitis due to pollen and animal dander with his asthma. The patient’s conditions
were well controlled with his current medications.
First-Listed Diagnosis: J45.909
Secondary Diagnosis: J30.89
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Case Study #5
A bilateral tonsillectomy and adenoidectomy was performed on a 9-year-old patient to resolve
his recurrent infections due to hypertrophy of the tonsils and adenoids. No infection was present
at time of the surgery. The patient was admitted as an inpatient for an overnight stay.
Principal diagnosis: J35.3
Principal procedure:
0CJ08ZZ
Secondary procedure(s):
0CB18ZZ
The secondary procedure is not applicable.