This is a 35-year-old HIV-positive male with progressive lymphadenopathy and unexplained fevers, night sweats, and chills. CT scan of the chest, abdomen, pelvis, and neck showed extensive lymphadenopathy involving mediastinum and left hilum, paratracheal nodal chains, retroperitoneum, right iliac nodal chains, and right inguinal nodes. There were several areas of atelectasis evident in the right lung. Lymph node biopsy suspicious for tuberculosis and in fact was AFB0positive. The patient was placed on respiratory isolation and serial sputums were obtained. The patient's sputum contained positive AFB on concentrated specimen. Also during the course of hospitilization, the patient complained of swelling in the bilateral lower extremities. Dopplers were negative for DVT. The patient will be referred to the clinic for management of his HIV disease and associated tuberculosis. What codes are assigned?
To identify the appropriate codes for this scenario, we need to determine the main diagnosis and any additional diagnoses that need to be coded. Let's break down the information provided:
Main Diagnosis:
- HIV-positive male with progressive lymphadenopathy
- Suspicious lymph node biopsy for tuberculosis, confirmed by positive AFB (acid-fast bacilli) in sputum
- The patient will be referred to the clinic for management of his HIV disease and associated tuberculosis
Additional Information:
- Unexplained fevers, night sweats, and chills
- CT scan findings of extensive lymphadenopathy
- Areas of atelectasis in the right lung
- Complaint of swelling in the bilateral lower extremities, with negative Doppler results for DVT (deep vein thrombosis)
Based on the information provided, the possible codes for this case could include:
1. HIV infection:
- ICD-10-CM code: B20 (HIV disease)
2. Tuberculosis:
- ICD-10-CM code: A15 (Respiratory tuberculosis)
3. Lymphadenopathy:
- ICD-10-CM code: R59.0 (Localized enlarged lymph nodes)
4. Atelectasis:
- ICD-10-CM code: J98.11 (Atelectasis)
5. Swelling in bilateral lower extremities:
- ICD-10-CM code: R60.9 (Edema, unspecified)
Please note that the above codes are general suggestions based on the information provided. It is always best to consult the official coding guidelines and verify the documentation to ensure accurate coding.