Please indicate all ICD-9 diagnosis and procedure codes for the coding scenarios. In addition, assign the POA indicator for each diagnosis code.
1). A patient is admitted with IDDM, out of control. The patient is administered insulin in an attempt to regulate the blood sugar. He has a recently abscessed left molar, which was determined, in part to be responsible for the elevated blood sugar. The patient takes Metformin but ran out of his medication two days ago. He hasn’t been back to the pharmacy for a refill yet. He said he’s been busy and hasn’t had time. The patient had recently been seen in the hospital four weeks earlier for an acute MI of the inferoposterior wall. The patient had an EKG done on this admit to check the status of the MI. He was also started on antibiotics for the tooth abscess. Within two days the blood sugar was under control and the patient was discharged. The patient was reminded about the necessity of filling his prescription and the importance of keeping his blood sugar steady and avoiding medical noncompliance.
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To determine the ICD-9 diagnosis and procedure codes for this scenario, we need to analyze the given information step by step:
1. IDDM, out of control:
- IDDM stands for Insulin Dependent Diabetes Mellitus, which can be coded as ICD-9-CM code 250.0.
- Since the patient's blood sugar is out of control, we can assign the POA indicator as "Y" (indicating Present on Admission).
2. Recently abscessed left molar:
- For the abscessed left molar, we need more specific information to assign the ICD-9-CM diagnosis code. If no further details are provided, we can use a generic code such as 522.5 (Dental abscess).
- Since it was determined to be partially responsible for the elevated blood sugar, we can assign the POA indicator as "Y".
3. Ran out of Metformin:
- This information does not require a specific diagnosis code, as it is related to medication noncompliance.
4. Acute MI of the inferoposterior wall:
- Since the patient had previously been admitted for an acute MI, we need to assign a diagnosis code related to the myocardial infarction.
- The ICD-9-CM code for acute MI of the inferoposterior wall is 410.72.
- Since this occurred four weeks earlier and is not the reason for the current admission, we will not assign a POA indicator for this diagnosis code in the current scenario.
5. EKG done to check the status of the MI:
- An EKG does not require a separate diagnosis code; it is a procedure performed to evaluate the patient's condition.
6. Started on antibiotics for the tooth abscess:
- The administration of antibiotics does not require a separate diagnosis code.
7. Blood sugar under control:
- Since the patient's blood sugar was successfully regulated within two days, there is no need for an additional diagnosis code.
To summarize, the ICD-9 diagnosis and procedure codes for the coding scenario are as follows:
- IDDM, out of control: 250.0 (POA indicator Y)
- Recently abscessed left molar: 522.5 (POA indicator Y)
- Acute MI of the inferoposterior wall: 410.72 (POA indicator not applicable)
- EKG: No specific diagnosis code required
- Antibiotics for tooth abscess: No specific diagnosis code required
- Blood sugar under control: No specific diagnosis code required