Question

Code the following inpatient scenario by assigning ICD-10-CM codes only, do not assign ICD-10-PCS codes:

The patient was admitted after visiting the emergency department for shortness of breath, chest pain, hypoxia, and a white cell count of 32,600. The patient had a history of chronic obstructive pulmonary disease. Interstitial infiltrate at the right middle and lower lobes of the lung was seen on chest X-ray. Sputum culture grew Streptococcus pneumoniae. He tolerated the antibiotics, and the symptoms improved significantly.

Discharge diagnoses: (1) Right lower lobe pneumonia due to Streptococcus pneumoniae, (2) acute exacerbation of chronic obstructive lung disease.

Answer 1

According to ICD-10-CM code

• J13, streptococcal pneumoniae,lobar streptococcus pneumoniae
• J44.1, Chronic obstructive pulmonary disease with (acute) exacerbation
• R09.02 Hypoxemia,Hypoxemia (low blood oxygen); Hypoxia (low oxygen levels):

Shortness of breath, chest pain,and a white cell count of 32,600 are symptoms of Pneumonia ,so those are covered under J13 title code.

Streptococcus pneumoniae is the cause for pneumonia. Streptococcus is one of the organism specified in the title of code J13.

Code J44.1 is assigned for Chronic obstructive pulmonary disease with (acute) exacerbation Exacerbations of COPD have short- and long-term clinical implications which needs clinical evaluation. Therefore, it is listed as an additional code.

Code R09.02, Hypoxemia, is assigned as an additional diagnosis for the hypoxia because it is not a symptom of pneumonia.