This 65-year-old chronic cigarette smoker for the past 40 years was admitted to the hospital with acute exacerbation of her chronic obstructive pulmonary disease. She has a history of anxiety syndrome due to hypothyrodism, and it maintained on medications for both the anxiety and the hypothyrodism. No symptomatology at the time of admission. On hospital day 2, she developed extreme anxiety and a psychiatric consultation was ordered. What codes are assigned in this case?
ICD-9-CM Diagnosis Code(s) with POA Indicator and MS-DRG:________________
ICD-10-CM Code(s):____________________
This 65-year-old chronic cigarette smoker for the past 40 years was admitted to the hospital with acute exacerbation of her chronic obstructive pulmonary disease. She has a history of anxiety syndrome due to hypothyroidism, and is maintained on medications for both the anxiety and the hypothyroidism. No symptomatology at the time of admission. On hospital day two, she developed extreme anxiety and a psychiatric consultation was ordered. What codes are assigned in this case?
To assign the appropriate codes for this case, we will need to provide ICD-9-CM diagnosis codes with POA (Present on Admission) indicator and MS-DRG (Medicare Severity Diagnosis Related Group) and ICD-10-CM codes.
ICD-9-CM Diagnosis Code(s) with POA Indicator and MS-DRG:
1. Chronic Obstructive Pulmonary Disease (COPD) exacerbation - The specific code will depend on the severity and acute exacerbation type. For example, ICD-9-CM code 491.21 might be applicable for exacerbation of COPD with (acute) exacerbation type, with the fourth character indicating the severity. The POA indicator will indicate whether this condition was present on admission. The corresponding MS-DRG will depend on the specific severity and other factors.
2. Anxiety syndrome due to hypothyroidism - The specific code for this condition will depend on the documentation and underlying cause. For example, ICD-9-CM code 300.02 might be applicable for Generalized Anxiety Disorder. The POA indicator will indicate whether this condition was present on admission. The corresponding MS-DRG will depend on other factors.
ICD-10-CM Code(s):
1. Chronic Obstructive Pulmonary Disease (COPD) exacerbation - The specific code will depend on the severity and acute exacerbation type. For example, ICD-10-CM code J44.1 might be applicable for exacerbation of COPD. The documentation will need to specify the severity, whether it is acute or chronic, and the type of exacerbation.
2. Anxiety disorder due to hypothyroidism - The specific code for this condition will depend on the documentation and underlying cause. For example, ICD-10-CM code F06.4 might be applicable for Anxiety disorder due to another medical condition. The documentation should specify the underlying medical condition causing the anxiety.
Please note that the specific codes may vary based on the documentation and guidelines provided by the healthcare facility or coding authority. It is always recommended to consult the official coding resources and guidelines for accurate code assignment.
To determine the appropriate codes for this case, we need to look up the relevant diagnosis codes in the ICD-9-CM and ICD-10-CM code sets. Here's how you can do it:
Step 1: Identify the key diagnoses in the case description.
In this case, the key diagnoses are:
1. Chronic obstructive pulmonary disease (COPD) with acute exacerbation.
2. Anxiety syndrome due to hypothyroidism.
Step 2: Locate the diagnosis codes in the ICD-9-CM code set.
For the first diagnosis, chronic obstructive pulmonary disease with acute exacerbation, you can search for it in the ICD-9-CM code set. The relevant code for COPD with acute exacerbation is usually found in the range of 490-496.
For the second diagnosis, anxiety syndrome due to hypothyroidism, you need to find the specific code for anxiety syndrome due to hypothyroidism in the ICD-9-CM code set. You can search for "anxiety syndrome" or "hypothyroidism" to locate the appropriate code.
Step 3: Assign POA Indicator.
In the case of POA (Present on Admission) indicator, it indicates whether the diagnoses were present at the time the patient was admitted to the hospital or if they developed during the hospital stay. Since the patient developed extreme anxiety on hospital day 2, you would need to determine whether it was present upon admission.
Step 4: Find the appropriate MS-DRG (Medicare Severity-Diagnosis Related Group) code.
The MS-DRG is used to classify similar types of patients for payment purposes. To determine the MS-DRG code, you would need to consider all relevant diagnoses and procedures performed during the hospital stay, as well as any complications or comorbidities.
Step 5: Locate the diagnosis codes in the ICD-10-CM code set.
After assigning the ICD-9-CM codes and determining the MS-DRG, you can look up the corresponding ICD-10-CM codes for the diagnoses.
Please note that due to the complexity and specificity of medical coding, it's recommended to consult the official coding books or seek assistance from a certified coder for accurate and up-to-date information.
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