Question

An 80-year-old male was brought to the emergency department by his family with the chief complaint of “nose bleed.” The patient is taking coumadin under prescription by his internist for chronic atrial fibrillation. The patient is also known to have congestive heart failure. The patient said his nose began bleeding about two hours ago and he was unable to stop the bleeding with other methods he had used in the past. He reported that he had these nose bleeds before today. However, today the bleeding is more pronounced and could not be stopped at home. In the ED, the physician is able to control the bleeding somewhat but recognized that an ENT physician should be called in for a consultation. The patient’s laboratory work revealed anemia and an EKG showed the existing atrial fibrillation. Because of his various conditions, his internist admitted to the hospital. He was seen by the ENT physician, who was able to stop the bleeding with an anterior and posterior packing. The packing was removed on day 2, and the epistaxis had stopped. Repeated laboratory work confirmed the physician’s diagnosis of “chronic blood loss anemia.” The patient continued to receive medications for chronic atrial fibrillation and congestive heart failure, and new medications were started to treat the anemia. The patient’s coumadin was continued, but the dosage was lowered. In the physician’s discharge progress note, he wrote “epistaxis due to coumadin therapy with resulting chronic blood loss anemia in a patient with chronic atrial fibrillation and congestive heart failure.”

Primary diagnosis: ______________

Secondary diagnosis:

1. _______________

2.________________

3._________________

4._________________

5.__________________

Principal procedure:

Please provide ICD-10-CM and ICD-10-PCS codes.

Answer 1

Primary diagnosis: Chronic blood loss anemia

Secondary diagnosis:

1.Epistaxis

2. treatment of anticaogulants

3. chronic atrial fibrillation

4. Congestive heart failure

• ICD 10CM code for epistaxis - R04.0
• ICD 10CM code for longterm treatment of anticoagulants - Z79.01
• ICD 10CM code for congestive heart failure - I50.9
• ICD 10CM code for chronia anemia - D63.8

Treatment procedures (with ICD-10-PCS code) for epistaxis including topical vasoconstriction,chemical cautery,electrpocautery,nasal packing,posterir gauze packing,arterial ligation or embolization.CHF treatments including coronary bypass surgery(02120Z9),heart valve repair or replacement(02RF3KZ),implantable cardoverter defibrillators(02H73KZ),cardiac resynchronization therapy(0JH607Z),ventricular assist device.

ICD 10 PCS Code for treatment of epistaxis - 2Y41X5Z