Rebeka Posted Sun 15th of December, 2013 12:58:50 PM
If a patient is admitted with hypoxia due to acute exaberation of COPD and then the final diagnosis is COPD and Klebsiella pneumoniae with respiratory failure would I code 491.21 as the principal diagnosis and the 482.0, 518.81, and 799.02 as the secondary diagnosis? Also what wold the DRG be? Thank you!
SuperCoder Answered Mon 16th of December, 2013 08:39:08 AM
We are working on it.
Rebeka Posted Mon 16th of December, 2013 17:51:57 PM
I do not need the DRG on any of these cases if thatmakes it easier
Rebeka Posted Wed 18th of December, 2013 08:39:42 AM
SuperCoder Answered Wed 18th of December, 2013 09:29:22 AM
Selection of principal diagnosis in this case needs a review of the treatment protocol followed during inpatient stay of the patient. The disease management of COPD and respiratory failure are overlapping and a short description of the treatments given or a discharge summary documentation would help us to provide the appropriate principal diagnosis and the DRG as well.
Rebeka Posted Wed 18th of December, 2013 09:51:46 AM
This is the actual report.
The patient was admitted to the ER with hypoxia due to acute exacerbation of COPD. The ER physician treated the hypoxia and COPD with albuterol inhaler, injections of solu medrol and started an IV of N/S at a rate of 100 cc; the test results came back with elevated WBC and left shift of the neutophils and bands rule out sepsis, the ER physician recommended the patient be admitted with a diagnosis of probable pneumonia with acute respiratory failure. The attending physician saw the patient and ordered the patient to be treated with O2 and BIPAP for the failure; to continue the meds begun in the ER. The patient was kept in the hospital for 5 days. The antibiotics were changed on the third day to PO and the oxygen was converted to use while up out of bed and to stop the use of the BIPAP. The physician listed the final diagnoses as: exacerbation of COPD, Klebsiella Pneumoniae pneumonia with respiratory failure.
Rebeka Posted Wed 18th of December, 2013 13:34:32 PM
This question still needs to be answered
SuperCoder Answered Thu 19th of December, 2013 07:06:33 AM
The principal diagnosis in this case should be "518.81".
SEC. diagnoses: "491.21, 482.0"
Respiratory failure was treated by providing BIPAP ventilation support so the vol.3 should be reported to 93.90
The DRG for the presented scenario would be: 189.