ans Posted Fri 12th of December, 2014 13:50:46 PM
The patient is seen today. She has been transferred from the ICU to the floor. She has essentially stabilized. Again, she is having some type of seizure activity.
PHYSICAL EXAMINATION: Her vitals overall are fairly well stabilized. Her postoperative dressings have been kept in place to minimized the risk of bleeding. She was sleeping when I saw her so I didnt wake her. Her toes are pink warm. Calves are soft.
IMPRESSION: Seizure, status post left hip bipolar hemiarthroplasty.
PLAN: I will continue to follow up with patient. From my standpoint, she can mobilize and bear weight as tolerated on the left side. We will change her dressings and place TED hose on the left. We will continue to follow her INR and hemoglobin. Of note, she has been made code status.
SuperCoder Answered Fri 12th of December, 2014 17:52:13 PM
Thanks for your question. This appears to be a progress note for a subsequent inpatient visit. Although the risk of complication and or morbidity or mortality is at a high level, the history is at a problem focused level and the exam is at an expanded problem focused level. The procedure code would be 99231; subsequent hospital care, per day, for the evaluation and management of a patient.
The diagnosis of seizure without further specification would be coded as 780.39; other convulsions for ICD-9. ICD-10 coding would be R56.9; unspecified convulsions.
For the diagnosis of status post left hip bipolar hemiarthroplasty your coding would be V43.64; Hip joint replacement for ICD-9. ICD-10 coding would be Z96.642; Presence of left artificial hip joint. Hope this answers your question.