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A 60 – year old man was admitted to Hospital A for an acute NSTEMI. Left heart Cath revealed critical stenosis of the coronary arteries. The patient was transferred to Hospital B for coronary artery bypass grafting (CABG). Cardioplegia and hypothermia were achieved. The right greater saphenous vein was used to bring blood from the aorta to the right coronary artery, left coronary artery and left anterior descending artery. All incisions were closed using sutures and patient was taken to recovery. Assign the appropriate diagnosis and procedure codes for Hospital B.
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A single newborn was delivered at 39 weeks via cesarean section because due to shoulder dystocia. Final diagnosis: Cesarean delivery of male infant, shoulder dystocia. Assign appropriate codes for the newborn,
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A patient was admitted for severe right- sided abdominal pain. Work up revealed sever diverticulitis and colonic abscess of the ascending colon. The patient was taken to the OR for a right hemicolectomy. During the procedure, the physician inadvertently perforated the small bowel. Sutures were used to repair the laceration. No other complications were noted. On postop day 2, the patient began vomiting. The physician documented diffuse ileus and nasogastric tube was placed. The patient was maintained on nasogastric suction and IV hydration for the following 2 days. On postop day 4, the tube was removed. He was discharged home in good condition. Final diagnosis: Diverticulitis, colonic abscess and ileus.
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Patient was admitted for back surgery. Diagnoses include: intervertebral disc displacement of the L2- L3 and L3-L4 spaces with spinal stenosis. Patient was taken to the OR where the following procedures were performed: Laminectomy with discectomy of L2-L3 and laminectomy decompression at L3-L4
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Patient is admitted with diabetic ketoacidosis. The patient has neuropathy and end stage renal disease (ESRD) due to hypertension (HTN). The patient is treated for the diabetic ketoacidosis, receiving Lisinopril and is on dialysis for the ESRD. The correct code assignment is.
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Patient was admitted for a right total hip arthroplasty due to severe osteoarthritis. The right femoral head is removed and replaced with a metal stem, which is placed into the center of the femur and a metal socket to allow for a smooth surface. The arthroplasty was performed with no complications. Three days’ post – surgery the patient went into respiratory failure. Endotracheal intubation was performed followed by 15 hours of mechanical ventilation. Final diagnosis: Osteoarthritis of the right hip and postoperative respiratory failure.
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Patient was admitted in pre-term labor with 27-week pregnancy. The fetus was in a complete breech position. Labor ceased within a few hours after admission, but the patient was observed closely because she has a history of being a habitual aborter during second trimester. By the 2nd day, contractions recurred abd she rapidly progressed to complete dilation. Because the fetus remained in breech presentation, an emergent low cervical cesarean section was performed and a healthy baby girl was delivered. The postpartum course was uneventful and the patient was discharged home in good condition on the 3rdday post-delivery. Final diagnosis: preterm delivery, complicated by breech presentation and obstructed labor and habitual aborted.
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A 72 – year old patient with stage 2 pressure ulcer of the sacrum upon admission was admitted for treatment. The physician noted a red and warm area on the patient’s right arm and consulted infectious disease. The patient received Lasix for CHF. Infectious disease states the patient developed cellutis of the arm. At the time of discharge the physician stated that the ulcer progressed to stage 3. What is the appropriate code assignment?
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