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52. This patient has been living at home, but his dementia has been getting progressively worse. He was diagnosed with Alzheimer's disease over two years ago. The family called the police because he was missing from home. A search was conducted and an observant passerby called in a report of an elderly man who seemed to be dis-oriented at a nearby public park. He was found after several hours and brought to the hospital. He had fallen in the park and had a laceration on his right knee that required suturing of the subcutaneous tissue and skin. What codes are reported in this case? ICD-10-CM Code(s) with POA Indicator and MS-DRG: ICD-10-PCS Code(s):
4.58. A patient is admitted with an infected right partial hip prosthesis. The prosthesis was removed, and the patient underwent a total hip titanium-polyethylene arthroplasty. What are the correct code assignments? ICD-10-CM Code(s) with POA Indicator and MS-DRG: ICD-10-PCS Code(s):
4.60. Discharge Summary Date of Admission: 06/28/XX Date of Discharge: 07/07/XX Diagnoses: 1. Status post fractured right femoral neck. 2. Chronic obstructive pulmonary disease. 3. Rheumatoid arthritis, steroid dependent. 4. Osteoporosis. Pertinent History: The patient was admitted on the 28th of June after a fall. She did not pass out but just fell and fractured her hip. She fell off of a stool at home. She underwent surgery for this. She had a hemiarthroplasty. She tolerated the procedure well and was transferred to A Pavilion for continued physical therapy and rehabilitation. Pertinent Laboratory: CBC initially showed a white count of 15,400, subsequently the white count is 10,900 with 78 neutrophils. H&H was stable at 12.2 and 36.9. Theophylline level was 10.3, therapeutic. Hospital Course: The patient tolerated physical therapy well. She was able to give her own Lovenox shots. She was anxious to go home on Saturday. Orthopedics had planned for 14 more days of Lovenox, and that will be given by the patient and prescribed by Dr. Thomas's group. She will be back in about 3 weeks. She will continue with her current medications, which are Proventil 2 puffs q.i.d., Fosamax 10 mg q.a.m., Soma 350 mg q.i.d., Lovenox 30 mg q. 12 hours, folic acid 1 mg q. day, Lasix 40 mg b.i.d., Atrovent 2 puffs q. 6 hours, Synthroid 0.075 q day, potassium 20 mEq b.i.d., prednisone 20 mg a day, Theo-Dur 100 mg in the morning and 200 mg in the evening. She takes Sonata and she will continue with 5 mg q.h.S. She will continue with her laxative of choice. She will restart her Nasonex, Celebrex, Vicodin, and Vanceril when she gets home. She will stay on a regular diet. Activities per her primary care physician. She will see me back in 3 weeks. History and Physical Examination Admission Date: 6/28 Chief Complaint: Hip fracture. Present Illness: The patient is a 79-year-old white female who slipped off of a stool in her apartment's kitchen while talking to her daughter. She was apparently trying to do too many things at one time, trying to clean some books or something like that and then just slipped and fell off and fractured her hip. She lives alone and had to call for help. She denies any type of passing out, no head injury, and no history of falling a lot before. Past Medical History: The patient denies any kind of past history of chest pains, exertional chest pain. She stopped smoking some time ago but continues to be mildly short of breath and that has been stable. She has no gastrointestinal (GI) symptoms, only occasionally some mild stress incontinence. Medications: 1. Nasonex nasal spray 2. Soma 350 mg 1 q.i.d. 3. Potassium 10 mEq. 2 b.i.d. 4. Celebrex 200 mg 9.d. 5. Synthroid 0.075 q.d.
Cart ll Intermediate Coding Exercises 6. Vicodin pr.n. 7. Fosamax 10 mg q.a.m. 8. Theo-Dur 200 mg in the morning and 1 in the evening 9. Folic acid 1 q.d. 10. Lasix 40 mg b.i.d. 11. Prednisone 10 mg. 2 g.d. 12. Vanceril inhaler 13. Atrovent inhaler 14. Albuterol inhaler Allergies: Halcion, which causes her to hallucinate. pulmonary disease (COPD), osteoporosis, and congestive heart failure (CHF). Medical History: Her medical history includes rheumatoid arthritis, chronic obstructive Social History: She is a widow, stopped smoking 12 years ago. Does not use any alcohol. Family History: Noncontributory. Physical Examination: Finds her alert and oriented in no acute distress. Her blood was negative. Neck: Supple without any adenopathy, no bruit was heard. Chest: pressure is 140/68, pulse 74, respirations 18. She was afebrile. HEENT: Examination Clear to auscultation. Heart: Sounds regular without any murmur or gallop. Abdomen: Soft, positive bowel sounds, nontender, no bruits heard. Extremities: Showed norma vascular status. Laboratory and X-Ray Data: She has a complete blood count (CBC) and urinalysis essentially normal. EKG shows no acute changes. Chest x-ray is pending at this time If that is normal, she will be able to go on to surgery; that is decided on by Dr. Rowan Impression(s): 1. Fracture right femoral neck. 2. Chronic obstructive pulmonary disease and rheu-matoid arthritis. She is steroid dependent so we are going to increase the amount of steroids that she is taking right now. Continue her on her inhalers and restart her oral medications as directed later. Operative Report Date: 06/28 Preoperative Diagnosis: Displaced right femoral neck hip fracture. Postoperative Diagnosis: Displaced right femoral neck hip fracture. Operation: Right hip hemiarthroplasty (Zimmer LD/Fx cemented monopolar metal prosthesis). Anesthesia: Spinal. Indications: This is a 79-year-old, previously ambulatory female with a history of rheumatoid arthritis, osteoporosis, steroid-dependent, and emphysema, with the above diagnosis . Risks, benefits, and alternatives of the above procedure were explained to the patient in detail, and she consented to proceed. Operative Procedure: The patient was taken to the operating room and placed in the lateral position on the transfer bed, where spinal anesthesia was administered. She
Case was transferred to the left lateral decubitus position on a beanbag on the operative table. Padded all bony prominences. Peritoneum was sealed off with Steri-Drape. The right hip was prepped and draped in the usual sterile fashion. Longitudinal incision over the greater trochanter and proximal femur was performed curving posteriorly proximally along the gluteus maximus. Sharp dissection to the skin, Bovie dissection to the subcutaneous tissues down to tensor fascia lata, identifying the greater trochanter. Besides the tensor fascia lata and along with the incision splitting the fibrous gluteus maximus, controlling bleeders with Bovie cautery. Piriformis was identified and short external rotators were tagged with a #5 Tycron suture. These are moved from their insertion. T capsulotomy was performed. Displaced hip fracture was identified, femoral head was removed and measured, copious irrigation was performed, acetabular was visibly and palpable normal appearing Sagittal saw was used to make cut in the femoral neck. Box osteotome was used to gain lateral entrance to the canal. The canal finder was used, easily locating the femoral canal. Sequential broaching was performed up to a 14, which fit well. Stating the appropriate anteversion. Trawled with an endofemoral head. Had full range of motion without instability and grossly equal leg lengths. I could bring the hip and knee up to 90 degrees of flexion, neutral adduction, start to internally rotate to 30 degrees before it would become unstable. Hip was redislocated, trial components were removed. Measured the canal for a centralizer. I placed a distal cement restrictor 2 cm distal to the component. Copious lavage of the canal was performed and brushed. Acetabulum was irrigated clean; palpable and visibly free of loose fragments. It was packed off with lap sponge. Dried the femoral canal. Placed cement in the femoral canal with retrograde manor using proximal pressurizer. Placed the 14-mm Zimmer LD/Fx with a distal centralizer in the appropriate anteversion, held in place with a cement set. Copious irrigation was performed. After the cement set, placed the final endo head, tapped into position with Morris taper, reduced the head. Could take the hip through the same range of motion without any instability. The short external rotator is in the drill holes in the greater trochanter. The tensor fascia lata closed with interrupted 0-0 VICRYL suture. We copiously irrigated each layer. Subcutaneous tissue closed with interrupted 2-0 VICRYL sutures, skin was closed with staples. Sterile dressing was applied. ICD-10-CM Code(s) with POA Indicator and MS-DRG: ICD-10-PCS Code(s):