Coding Hint: This chart has 1 principal diagnosis, 13 secondary diagnosis codes, and 5 Z codes. In this case, the Z codes include two status heart procedure codes and three long-term drug use codes.

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Coding Hint: This chart has 1 principal diagnosis, 13 secondary diagnosis codes, and 5 Z codes. In this case, the Z codes include two status heart procedure codes and three long-term drug use codes.

Coding Hint: This chart has 1 principal diagnosis, 13 secondary diagnosis codes, and 5 Z codes. In this case, the Z codes include two status heart procedure codes and three long-term drug use codes.

Admission Diagnosis:
Renal Failure

Discharge Diagnosis: (all present on admission)
ARF on stage 3 CKD
C. Difficile colitis
UTI
Gout

Secondary Diagnoses:

Patient Active Problem List

Diagnosis

  • Heart replaced by transplant
  • Sinus node dysfunction
  • HTN (hypertension)
  • Hyperlipidemia
  • DM type 2 (diabetes mellitus, type 2)
  • Hypomagnesemia
  • Systolic heart failure
  • Right bundle branch block
  • Morbid obesity
  • Cellulitis of forearm, left
  • Congestive heart failure, NYHA class II
  • Pacemaker
  • Long term current use of systemic steroids
  • Long-term use of immunosuppressant medication

Consults:
Rheumatology
Cardiology
Infectious Disease

Procedures: TTE
CT

Hospital Course:

This patient was transferred from an outside facility where he was initially treated for acute hypoxic respiratory failure 2/2 medications and subsequently developed AKI with a creatinine of 4.6 from his baseline of 2.4-2.8. At the time of admission he was on room air and creatinine was 2.7. Echo was repeated showing EF 25-30 (which is about baseline), cyclosporine 72 and mycophenolate 0.9.

Cardiology was consulted on admission and agreed advised to restart home doses of immune suppression once levels resulted. On 6/7 his creatinine began to rise to a high of 5.6 on 6/8 and WBC increased to a high of 31. Infectious disease recommended linezolid and cefepime which was stopped 6/10. He was changed to ceftriaxone then to cipro PO for a klebsiella UTI. He denied diarrhea; however c diff resulted positive, therefore he was started on flagyl, initially IV, then switched to PO after which his WBC improved. He was given a small amount of fluids and his creatinine returned to baseline of 2.8 at discharge. Rheumatology was consulted as he has tophaceous gout (due to renal impairment) with a uric acid of 11.4. They recommended increasing prednisone to 7.5mg daily with increasing to 20mg in case of flares and adding allopurinol 100mg daily. Prior to discharge he was restarted on carvedilol which he had not been taking for quite some time.

Physical Exam:
General: alert, no distress
HEENT: Normocepahlic and atraumatic
Neck: Supple, no palpable lymphadenopathy
Pulmonary: Clear to auscultation bilaterally without any wheezing, rales, or ronchi
Cardiac: S1 S2, RRR, no rubs, murmurs, gallops
GI/Abdomen: obese, normal bowel sounds, soft, non-tender, no palpable masses. No guarding or rebound
Extremities: no edema, redness or tenderness in the calves or thighs, tophi over elbows, L wrist incision CDI
Skin: Skin color, texture, turgor normal. No rashes or lesions
Musculoskeletal: Full ROM in the bilateral upper and lower extremities. 5/5 muscle strength at the bilateral shoulder, elbow, wrist, hip, knee, and ankle joints
Neuro: CN II-XII grossly intact bilaterally w/o focal deficits

Click the links below for further documentation:

Discharge Labs

Discharge Medication List

  1. FILL IN THE BLANK.
    Enter the proper code(s) in the blank(s) provided. If a specific category of code is not applicable, please leave the box blank. When entering multiple codes in the same box, separate them with a comma and a space (i.e. E11.9, I10). For each diagnosis code, add the applicable POA indicator, in parentheses, following the code, for example E11.9(Y). There is no POA indicator assigned for the Admit diagnosis.Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. There is a list of Z codes that may only be principal/first-listed diagnosis in the Coding Guidelines. This means that they are not appropriate in a secondary position. If a Z code is the Admit and/or Principal Diagnosis position, please list them in the appropriate boxes. If however a Z code is not a principal/first-listed diagnosis, enter it in the Z Code box. External cause codes are never listed as the Admit/Principal Diagnosis. Any External cause codes will be listed in the External cause of morbidity code(s) box.
    1. Admit Diagnosis Code:
    2. Primary ICD-10-CM Code:
    3. Secondary ICD-10-CM Code(s):
    4. Z Code(s):
    5. External Cause of Morbidity Code(s):
 

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