AI Medical Coding Practice – Copy and paste this text in ChatGPT with Prompt as Assign ICD-10-CM Codes as per Guidelines.
DATE OF ADMISSION: 06/12/2015
DATE OF DISCHARGE: 06/15/2015
LOS:3
GENDER: Male
AGE: 72
HISTORY AND PHYSICAL
CHIEF COMPLAINT:
Abdominal pain.
HISTORY OF PRESENT ILLNESS:
Mr. ____ is a 72-year-old gentleman who was transferred from an outside hospital directly to the ICU because of hypotension, and CT scan of abdomen findings suggestive of acute cholecystitis.
PAST MEDICAL HISTORY:
Type 2 diabetes, bilateral cataract.
PAST SURGICAL HISTORY:
None.
SOCIAL HISTORY:
He does not smoke or drink alcohol.
ALLERGIES:
NONE.
PHYSICAL EXAMINATION:
GENERAL: He is arouseable but lethargic and unable to follow commands.
RESPIRATIONS: He has bilateral crackles.
CARDIOVASCULAR: S1, S2. Blood pressure in 90s to 100 systolic/40s
ABDOMEN: He has abdominal distention. He is tender on palpation.
EXTREMITIES: No edema.
LABORATORY DATA:
Review of his labs reveals a leukocytosis of 32.9, potassium of 2.8, INR of 1.6 with a PT of 16.6.
CT scan of abdomen results from the outside hospital suggest acute cholecystitis, but no other pathology.
ASSESSMENT AND PLAN:
Mr. ____ is a 72-year-old gentleman with cholecystitis.
Will correct electrolytes and coags.
We will take him to surgery for laparoscopic cholecystectomy. He is placed on IV antibiotics prior to surgery tomorrow and also repleted with IV fluids.
Work type: OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS:
Acute abdomen.
POSTOPERATIVE DIAGNOSIS:
Acute cholecystitis with gangrene
PROCEDURE:
Laparoscopic cholecystectomy.
INDICATION:
Mr. ____ is a 72-year-old gentleman with an acute abdomen. The plan was to take him to surgery for laparoscopic cholecystectomy.
A consent was signed by the wife.
He was taken to the operating room and placed supine on the operating table. After general anesthesia, the abdomen was prepped and draped in the standard surgical fashion. A timeout was done.
A 15 blade was used to make a 1 cm infraumbilical incision. The open Hassan technique was used to gain entrance into the abdominal cavity. He had extensive adhesions from prior operations.
Using the laparoscopic scissor with Bovie, I was able to take down the adhesions. The process lasted about one hour. Most of the adhesions taken down were in the middle aspect of the abdomen.
Prior to taking down the adhesions, I did place my laparoscopic ports. A 12 mm trocar was placed in the subxiphoid region and two 5 mm trocars were placed in the right upper quadrant.
With the adhesions taken down I now focused on the gallbladder.
He was placed in reverse Trendelenburg with the left side down.
The fundus was lifted cephalad above the liver. The infundibulum was retracted inferiorly laterally.
Hook cautery was used to peel the peritoneum from the gallbladder. Using the hook cautery and a Maryland dissector, the cystic duct and cystic artery was identified. I had a good critical view.
Two clips were placed at the proximal aspect of the cystic duct and cystic artery and one clip was placed at the distal aspect of the cystic duct and cystic artery. Scissor was used to come across the cystic duct and cystic artery. Bovie cautery was used to peel off the gallbladder from the gallbladder bed. It was placed in a specimen bag and removed from the patient and sent off to pathology.
The hook cautery was then used to provide adequate hemostasis to the gallbladder bed. There was no evidence of bleeding. All of the clips were well placed.
There was also no evidence of bleeding from the prior lysis of adhesions.
All trocars were removed under direct vision. The fascia of the 1 cm incision was closed with 0 Vicryl. Four-0 Monocryl was then used to close the skin incisions. A total of 30 mL of 0.25% Marcaine with epinephrine was used to provide a local block. Dermabond was then applied.
He tolerated the procedure well.
CONSULTATION REPORT
HISTORY OF PRESENT ILLNESS:
I have been asked to see this 72-year-old gentleman today by Dr. ________ because of atrial fibrillation. The patient was transferred from ____ Hospital with hypotension, and a distended abdomen. He did have atrial fibrillation for about an hour, however, he went back into sinus rhythm. His blood pressure remains stable with multiple pressor agents and bicarbonate injections. He has been seen by pulmonary, renal, critical care and general surgery in the ICU. History is obtained only from the chart.
PAST MEDICAL HISTORY:
Bilateral cataract secondary to diabetes mellitus type II.
MEDICATIONS:
1. Lipitor 10 mg daily.
2. Multivitamin 1 daily.
3. Wellbutrin 100 mg twice daily.
4. Coreg 3.125 mg twice daily.
5. Celexa 20 mg at night.
6. Sliding scale insulin every 6 hours.
7. Atrovent inhalation.
8. Iron replacement 3 times a week.
9. Reglan 5 mg t.i.d. via PEG tube.
10. Midodrine 10 mg daily.
11. Oxycodone 5 mg q. 6 hours p.r.n.
12. Pancrelipase 5000 units 2 capsules 5 times daily.
13. Protonix 40 mg daily.
14. Simethicone 80 mg daily.
ALLERGIES:
HE HAS NO KNOWN DRUG ALLERGIES.
Family history, social history and review of systems are unremarkable.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse 90, blood pressure 87/42, respirations 17.
GENERAL: The patient is an obtunded, unresponsive 72-year-old African-American gentleman who appears acutely ill.
HEENT: EOMI. PEERLA.
CHEST: Reveals diffuse rhonchi.
HEART: Regular rhythm with very distant heart tones. I could not appreciate any murmurs, rubs or gallops.
ABDOMEN: Non tender.
EXTREMITIES: No cyanosis or clubbing, or edema.
NEUROLOGIC: Intact.
Electrocardiogram just performed revealed a sinus rhythm.
Echocardiogram performed this morning revealed moderate segmental left ventricular dysfunction.
LABORATORY DATA:
Laboratory studies have been reviewed.
IMPRESSION:
1. Atrial fibrillation, now back in sinus rhythm.
2. Cholelithiasis, status post surgery.
RECOMMENDATIONS:
1. Resume amiodarone at a low dose.
2. Will repeat EKG and cardiac biomarkers.
The patient is being transferred out of ICU today. Thank you for allowing me to participate in the care of your patient.
DISCHARGE SUMMARY
FINAL DIAGNOSIS:
Acute cholecystitis with gangrene
HISTORY OF PRESENT ILLNESS:
Mr. ____ is a 72-year-old gentleman who was transferred to the intensive care unit from outside hospital due to hypotension with CT scan finding suggestive of some cholecystitis.
He had a past medical history of bilateral cataract secondary to type 2 diabetes awaiting surgery.
ALLERGIES:
NONE.
He was admitted from the outside facility. Upon arrival, he was hemodynamically stable.
He was taken to surgery and laparoscopic cholecystectomy was performed.
The patient became stable after surgery and today, he is discharged to home in a stable condition.
He is to follow up with Gastroenterology for follow up in a week.
___________________________________________________ End_______________________________________________________
AI Medical Coding Tool Response
Based on the provided medical record, here are the appropriate ICD-10-CM codes for this patient:
- Acute Cholecystitis with Gangrene:
- Code: K82.A1
- Explanation: This code is assigned for acute cholecystitis with gangrene. The patient’s records and the postoperative diagnosis confirm this condition.
- Hypotension:
- Code: I95.9
- Explanation: Hypotension is noted in the patient’s history (transferred due to hypotension). I95.9 is used for unspecified hypotension.
- Type 2 Diabetes Mellitus:
- Code: E11.9
- Explanation: The patient has a history of type 2 diabetes. E11.9 is used for type 2 diabetes mellitus without complications.
- Bilateral Cataract:
- Code: H26.9
- Explanation: The patient has a past medical history of bilateral cataract. H26.9 is the code for unspecified cataract.
- Atrial Fibrillation:
- Code: I48.91
- Explanation: The patient experienced atrial fibrillation during the admission, as noted in the consultation report. I48.91 is for unspecified atrial fibrillation.
- Leukocytosis:
- Code: D72.829
- Explanation: The patient’s lab data shows leukocytosis. D72.829 is used for leukocytosis, unspecified.
- Hypokalemia:
- Code: E87.6
- Explanation: The patient had a low potassium level (2.8), which is hypokalemia. E87.6 is the code for hypokalemia.
- Coagulation Defect (INR of 1.6 and PT of 16.6):
- Code: D68.9
- Explanation: The patient’s elevated INR and PT suggest a coagulation defect. D68.9 is used for coagulation defect, unspecified.
- Moderate Left Ventricular Dysfunction:
- Code: I50.32
- Explanation: The echocardiogram revealed moderate segmental left ventricular dysfunction. I50.32 is used for chronic systolic (congestive) heart failure.
- Status Post Laparoscopic Cholecystectomy:
- Code: Z98.891
- Explanation: This code is used to indicate a history of surgery, in this case, the laparoscopic cholecystectomy.
These codes should be carefully reviewed and confirmed with the actual patient record and coding guidelines, as coding accuracy is paramount in medical documentation and billing.