Question

A 62-year-old woman, on disability because of emphysema, is brought to the emergency department from home by fire department ambulance. The patient complained of sudden sharp chest pain, shortness of breath, and a nonproductive hacking cough. The patient has been under treatment for COPD and emphysema for more than 5 years and is dependent on oxygen. The patient described the pain as being on the left side with referred pain up to the shoulder. The patient was cautious when moving to protect her chest and shoulder. In the emergency department a chest x-ray and continuous pulse oximetry was ordered. Pulse oximetry showed low oxygen saturation. Physical examination revealed diminished breath sounds bilaterally, but significantly worse on the left side. The chest x-ray revealed a collapsed lung on the left side and fluid in the pleural space. The patient was admitted. A chest tube was inserted for pleural drainage and aspirate air and re-expand the lung. Follow-up chest x-ray showed the lung had re-expanded to its normal size, and the pleural effusion's fluid appeared to be reabsorbed and resolved. The physician's discharge diagnoses were COPD and emphysema with left side secondary spontaneous pneumothorax and pleural effusion. Identify and code the 4 medical codes for this scenario.

Answer 1

Important findings:

-sharp chest pain

-collapsed lung on the left side and fluid in the pleural space

-pleural effusion

Final diagnosis:

-COPD and emphysema

-left sided secondary spontaneous pneumothorax

-pleural effusion

The codes are as follows:

-J44.9 (COPD with emphysema)

-J93.12 (secondary spontaneous pneumothorax)

-J91.8 (pleural effusion)

-R09.02 (hypoxemia or low oxygen saturation)

The fourth diagnosis – R09.02 is taken because this condition is neither inclusive nor resolved on discharge.