Your search for This 82-year-old female was admitted for acute exacerbation of chronic obstructive pulmonary disease. The progress notes indicate that the patient received a transfusion for anemia. The discharge diagnoses state acute exacerbation of chronic obstructive pulmonary disease and pancytopenia. Transfusion of non autologous packed red blood cells was given via peripheral vein. What codes are assigned for this case
491.21, 284.19, 99.04
To assign the appropriate codes for this case, we will need to consult the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and the Current Procedural Terminology (CPT) coding systems. Here's how you can determine the relevant codes:
1. Determine the diagnosis codes:
- "Acute exacerbation of chronic obstructive pulmonary disease" can be coded as J44.1 (Chronic obstructive pulmonary disease with acute exacerbation).
- "Pancytopenia" is a condition characterized by decreased counts of red blood cells, white blood cells, and platelets. In ICD-10-CM, it can be coded as D61.9 (Aplastic anemia, unspecified).
2. Identify the procedure code for the transfusion:
- "Transfusion of non-autologous packed red blood cells" refers to the administration of packed red blood cells from a donor to the patient. In CPT, this is typically reported with codes from the 36430-36440 series. However, these codes specifically refer to transfusion via the central venous system, not the peripheral vein.
Based on the information provided, it appears that the transfusion was performed via a peripheral vein, which may be reported differently. To find the appropriate code, it would be best to consult specific coding guidelines or references.
3. Assign additional codes if needed:
If there are any other significant diagnoses or procedures documented in the medical record, they should also be coded.
Please note that the above codes are suggestions based on the information provided, and the final code assignment should be done by a qualified medical coder based on the complete documentation in the medical record. It's important to consider additional details, such as any other relevant diagnoses, procedures, or specific guidelines that may apply.