HIMT 222 Practice exercise for Bacteria Questions

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HBU- Practice Exercise HIMT222-Module 5 Student name: Academic number: Q1: Code the following cases. Include disease, morphology codes and the codes for any procedures o Staphylococcus pneumonia o Allergic extrinsic asthma o Acute bronchitis – culture grew Haemophilus influenzae o CAL with bronchiectasis o COPD with Asthma o Acute gingivitis o Chronic gastritis due to H.pylori o Acute appendicitis with perforation o Dermatitis due to insecticide o Decubitus ulcer of elbow with partial thickness skin loss Ms. Zainab Al-Swaimil, Certified Clinical Coder trainer and Consultant HBU- Practice Exercise HIMT222-Module 5 2. Case study 1. This 5-year-old patient admitted as a case of tonsillitis with dehydration Description Code Principal diagnosis Additional diagnoses Principal procedures Other procedures 2. 41-year-old woman with obstructive sleep apnoea admitted for CPAP for 3 days Description Code Principal diagnosis Additional diagnoses Principal procedures Other procedures 3. This 58-year-old patient with a history of chronic obstructive pulmonary disease presented with an infective exacerbation of her COPD. She was admitted to ICU, intubated and ventilated for 8 hours.no organism was isolated from either sputum or blood cultures. she was started on broad spectrum antibiotics with a marked improvement. Description Code Principal diagnosis Additional diagnoses Principal procedures Other procedures 4. This 7-year-old boy with recurrent tonsillitis and glue ear was admitted to hospital for surgery. He underwent a tonsillectomy, adenoidectomy for enlarged adenoids and bilateral myringotomy with insertion of grommets under a GA. He was discharged home the following day. ASA 123456 E Description Principal diagnosis Additional diagnoses Principal procedures Other procedures Ms. Zainab Al-Swaimil, Certified Clinical Coder trainer and Consultant Code HBU- Practice Exercise HIMT222-Module 5 5. Chronic alcoholism patient with hepatitis C carrier was admitted for a colonscopy following recurrent PR bleeding. the patient was given midazolam 5 mg, fentanyl 100 micgm and propoofol 30mg IV for sedation (ASA 123456 E). A hyperplastic colonic polyp was found and excised via coloscopy.no source of bleeding was found .D &A team counselled patient regarding his alcohol consumption. Description Code Principal diagnosis Additional diagnoses Principal procedures Other procedures This 64 year old male presented with haematemesis, malaena and anaemia.his Hb on admission was 96 and he was transfused with 2 units of packed cells. he underwent endoscopy under sedation that showed an actively perforated and bleed duodenal ulcer, gastric varices and barrett’s oesophagus. the perforated ulcer was Overswing with selective vagotomy and the varices were banded. He was started on Losec 20mg b.d. and will need a repeat scope in 6 weeks to confirm heling. ASA 123456 E Description Code Principal diagnosis Additional diagnoses Principal procedures Other procedures 6. An 53 year old man was admitted for repair of a recurrent bilateral inguinal hernia with mesh. The repair was performed without complication under GA ASA 3. He is an ex-smoker. Description Code Principal diagnosis Additional diagnoses Principal procedures Other procedures 7. Cholelithiasis. Laparoscopic cholecystectomy under GA ASA 1 2 3 4 5 6 E pathology report was Cholelithiasis acute cholecystitis Description Code Principal diagnosis Additional diagnoses Principal procedures Other procedures 8. patient admitted with diarrhoea and vomiting samples for adenovirus antigens was positive and adenoviral enteritis was diagnosed with dehydration Ms. Zainab Al-Swaimil, Certified Clinical Coder trainer and Consultant HBU- Practice Exercise HIMT222-Module 5 Description Code Principal diagnosis Additional diagnoses Principal procedures Other procedures 9. Solar keratosis of two lesions (forehead and hand), both excised using local anaesthesia Description Code Principal diagnosis Additional diagnoses Principal procedures Other procedures DISCHARGE SUMMARY Name of Patient Date of Admission 02/08/2016 Medical Record No. Date of Discharge 06/08/2016 Age/Sex 49/F Attending Physician PROVISIONAL DIAGNOSIS: Paraumbilical hernia. FINAL DIAGNOSIS: Gangrenous and obstruction Paraumbilical hernia Summary of History and Physical Examinable: The patient is a 49-year-old female, presented to OPD complaining of paraumbilical swelling for 4 months, increasing in size with pain. She has history of constipation. No diarrhea. No vomiting. The patient surgical history of paraumbilical hernia repair. Irrelevant family history. Not known of any allergies. On examination, the patient looks well, oriented, vitally stable and afebrile. Pain score is 0. nutritional status is normal. Psychological status is normal. Activity is normal. Investigations: Laboratory, CBC, coagulation profile, urine electrolytes, and random blood sugar. Operation/Procedure Performed: Laparoscopic paraumbilical hernia repair with mesh under general anesthesia. CROSS CONSULTATION: None. HOSPITAL COURSE: Now, the patient is discharged in good condition. She looks hemodynamically stable, and afebrile. Abdomen was soft and lax. No tenderness. The patient Ms. Zainab Al-Swaimil, Certified Clinical Coder trainer and Consultant HBU- Practice Exercise HIMT222-Module 5 developed distention postoperatively, then the distention subsided. Now, the patient is discharged in good condition. No abdominal distention. Bowel sounds are audible.pt ambulating well on regular diet. passed bowel motion. DISCHARGE PLAN: Follow-up in OPD after 5 days. Description Principal diagnosis Additional diagnoses Principal procedures Other procedures Ms. Zainab Al-Swaimil, Certified Clinical Coder trainer and Consultant Code CHAPTER 10 DISEASES OF THE RESPIRATORY SYSTEM (J00–J99) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant TONSILLITIS (ACS 0804) • Tonsillitis not specified as acute or chronic should be coded to acute (J03.- Acute tonsillitis) • unless a tonsillectomy is performed, in this case the tonsillitis is coded as chronic (J35.0 Chronic tonsillitis). • Chronic = recurrent acute. Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant Exercise 1.Croup J05.0 2. Acute laryngotracheitis J04.2 3. Tonsillitis J03.9 Admitted with tonsillitis. Tonsillectomy performed under intravenous GA. ASA 1 2 3 4 5 6 E J35.0 41789-00[412] 92514-10[1910] Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant INFLUENZA (J09-J11) In ICD-10-AM there are three categories for influenza ➢Influnza virus is known – J09 Influenza due to identified avian influenza virus ➢Do not specify Influnza virus – J10 Influenza due to other identified influenza virus H1N1 influenza – J11 Influenza, virus not identified • Haemophilus influenzae [H. influenzae] cause meningitis, pneumonia and infection The exclusion at the beginning of J10 and J11 remained with the difference. Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant PNEUMONIA (ACS1004) • Pneumonia is an acute inflammation of the alveoli of the lung with consolidation (solidification) and exudation (fluid build-up). • There are four major types: bacterial, viral, aspiration and mycoplasmal. • Most cases of pneumonia will be diagnosed using x-ray findings. These will show the location and extent of the consolidation. Note: evidence of consolidation in the lung on x-ray report does not lead to the diagnosis of pneumonia. Other things such as bleeding or inhalation can cause consolidation. Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant PNEUMONIA (ACS1004) • In many cases the organism causing the pneumonia may not be identified, but you should always check Microbiological reports, particularly sputum and blood cultures, will describe the organism (if any) thought to be the cause. • Lobar pneumonia means consolidation of the entire lobe and is rarely seen. Note that pneumonia described as ‘lower lobe’ does not necessarily mean that the pneumonia is ‘lobar’. It is just describing the anatomical site of the pneumonia. Therefore, when this term is used it should be clarified with the clinician before assignment of code J18.1 Lobar pneumonia, unspecified. Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant Exercise 1.Klebsiella Pneumonia J15.0 1.Laryngitis with influenza J11.1 1.Bacterial bronchopneumonia J15.9 Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) (ACS1008) • The term COPD (synonyms: chronic airway limitation (CAL), chronic obstructive airway disease (COAD)) • is a condition of chronic bronchitis with obstruction possibly due to chronic asthma and/or emphysema or chronic tracheobronchitis. The important terms are chronic and obstruction. Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) (ACS1008) • COPD is chronic condition and patients will usually only be admitted to hospital for treatment of their COPD if they have acute exacerbation. In theses cases use J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection or J44.1 Chronic obstructive pulmonary disease with acute exacerbation. • Do not code any bronchitis or chest infection separately unless the infection is a separate, important condition such as pneumonia. Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) (ACS1008) Use J44 codes in the following circumstances • For bronchitis that is : ✓Chronic and is in combination with asthma or emphysema. ✓Chronic and involves airways obstruction • For emphysema that is: ✓In combination with chronic bronchitis. If the clinician has documented COPD and emphysema, assign only a code from category J44. • For asthma that: ✓Is In combination with chronic bronchitis ✓involves airways obstruction Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant EXAMPLE : Discharge summary documented PDx as COAD/Pneumonia. Principal diagnosis J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection Additional diagnosis J18.9 Pneumonia, organism unspecified Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant EXAMPLE : Discharge summary documented PDx as Pneumonia + COPD exacerbation. Principal diagnosis J18.9 Pneumonia, organism unspecified Additional diagnosis J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant ASTHMA (ACS1002) • Asthma is charactrised by wheezing, dyspnea and cough and is usually controlled by drugs. Bronchospasm is a component of an acute asthmatic attack and such an attack rapid treatment to prevent respiratory failure. • Status asthmaticus is an acute severe case of asthma where the patient is not responding to their medication. Assign J46 Status asthmaticus only if the asthma is documented as ‘acute severe’ or ‘refractory’. • Chronic obstructive asthma or asthma and/with COPD should be assigned a code from J44.- Other chronic obstructive pulmonary disease only when documented. • If the only diagnostic information you have is ‘chronic asthma’ assign J45.9 Asthma, unspecified Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant Bronchitis: • Bronchitis is classified in two different blocks according to whether it is acute or chronic. • In patient under 15 years of age is assumed to be acute even if this is not specified. • Combined with asthma is coded with an asthma code (J45.-). Do not code bronchitis separately. • Allergic is coded to the allergic asthma code (J45.0) Do not code bronchitis separately. • Combined with emphysema is coded to COPD(J44.-) • Obstructive is coded to COPD (J44.-) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant Exercise 1.Acute sever asthma J46 1.Acute exacerbation of COPD. J44.1 1.Asthmatic bronchitis. J45.9 Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant ACUTE PULMONARY OEDEMA (ACS 0920) • Accumulation of fluid in the lung tissue and alveolar space is known as pulmonary oedema. Commonly it is due to heart disease, but it can be of non-cardiac origin. • If it is of cardiac origin it is included in the heart failure codes from chapter 9 Disease of the Circulatory System and no code from the respiratory chapter is needed. • When Acute pulmonary oedema is documented without further qualification, it should be coded to I50.1 left ventricular failure. • If it is non-cardiac origin then it should be coded to J81 Pulmonary oedema • The exclusion note in J81 list codes for pulmonary oedema. It lists other codes used for pulmonary oedema of non-cardiac origin. Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant 0807 FUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS) ➢ Functional endoscopic sinus surgery (FESS) is a term describing a range of procedures performed for the surgical treatment of sinus disease. ➢ FESS may include a variety of procedures performed in any combination. Therefore, clinical coders should check the operation report and assign only the appropriate codes. These procedures may include: 41737-02 [386] Ethmoidectomy, unilateral 41716-05 [384] Biopsy of maxillary antrum 41716-00 [383] Intranasal removal of foreign body from maxillary antrum Where FESS is documented, also assign 41764-01 [370] Sinoscopy to indicate the endoscopic nature of the surgery. Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant Exercise 42-year-old lady with history of bronchial asthma on medication. She complain of nasal discharge Paroxysmal nocturnal dyspnea (PND) hyopsomia nasal congestion mouth had trial of medical treatment improved but recured after a while final diagnosis Chronic sinusitis, Chronic sinusitis, Chronic rhinitis and nasal polyp She underwent FESS and nasal polypectomy Anaesthesia ASA 2 Operative report Under general anaesthesia with ET T examination showed previous findings bilateral Intranasal maxillary antrostomy and uncinectomy done, bilateral anterior and posterior ethmoidectomy done, bilateral Sphenoidotomy done and nasal polypectomy Patient extubated and send to recovery room in stable condition Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant J32.9 Chronic sinusitis, unspecified J31.0 Chronic rhinitis J33.9 Nasal polyp, unspecified 41716-02 Intranasal maxillary antrostomy, bilateral 41737-03 Ethmoidectomy, bilateral 41752-02 Sphenoidotomy 41764-01 Sinoscopy 41668-00 Removal of nasal polyp 92514-29 GA Uncinectomy (also known as infundibulotomy) involves detachment and removal of the anterior, inferior and superior s of the uncinate process. It is performed as part of an intranasal ethmoidectomy in order to gain access to the ethmoid infundibulum, expose the frontal recess and allow visualisation of the frontal recess. Uncinectomy is a fundamental step in functional endoscopic sinus surgery (FESS). Classification It is unnecessary to separately code the uncinectomy when performed as a component of FESS. Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant Respiratory Failure (J96) • In respiratory failure the respiratory system is unable to supply adequate oxygen to maintain proper metabolism and/or eliminate carbon dioxide. • Life threatened condition that may be associated with a respiratory condition or a non-respiratory condition. • Blood gas analysis provide evidence of respiratory failure but you must be careful not to assume that the abnormal results are evidence of respiratory failure. • Code respiratory failure if confirmation by clinician. Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant VENTILATORY SUPPORT (ACS 1006) • Ventilatory support is a process by which gases are moved into the lungs by a device that assists respiration by augmenting or replacing the patient’s own respiratory effort. Ventilatory support can be administered via noninvasive or invasive devices. Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant VENTILATORY SUPPORT (ACS 1006) invasive devices. [569] Noninvasive devices. [570] Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant VENTILATORY SUPPORT (ACS 1006) • invasive devices. [569] Noninvasive devices. [570] Includes: Endotracheal intubation Includes: respiratory assistance Ventilatory support by: • • • • mechanical ventilation by: face mask mouthpeice • endotracheal tube (ETT) • nasal • oral • • tracheostomy Excludes: weaning of intubated (endotracheal tube/tracheostomy) patient by any method that by: nasal mask/pillows/prongs nasal/nasopharyngeal tube Code also when performed: endotracheal intubation (see block [569]) tracheostomy: tracheostomy (see block [569]) – percutaneous (41880-00 [536]) – permanent (41881-01 [536] – temporary (41881-00 [536]) Ms. Zainab Al-Swaimil, Certified Clinical Coder and Consultant (Duration )ventilatory support [569] 13882-00 Management of continuous ventilatory support, 24 and

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