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Original Question

Mr. Browne is a 66-year-old man with a history of cerebrovascular accident who is seen in the emergency department for complaints of chest pain and oral phase dysphagia. He is noted to have a temperature of 101 degrees upon examination. He is admitted as a hospital inpatient for further evaluation and treatment. Mr. Browne has a history of type 2 diabetes mellitus and hypertension. Lab tests include a white blood cell count with differential and a chest x-ray. Results reveal that Mr. Browne has pneumonia, and a sputum culture is ordered. The sputum culture results are negative. A percutaneous endoscopic gastrostomy (PEG tube) is inserted to assist with his nutrition, which is difficult due to his dysphagia. He is administered respiratory therapy for pneumonia. His feeding is done via the PEG tube. His oral antihypertensive and diabetic medications are continued as an inpatient. After several days he is discharged to a skilled nursing facility for further care. FINAL DIAGNOSES: Viral pneumonia. Oral phase dysphagia due to previous cerebrovascular accident (CVA). Type 2 diabetes mellitus. Hypertension. PROCEDURE: Insertion of percutaneous endoscopic gastrostomy (PEG tube). a. Assign ICD-10-CM codes to the principal diagnosis of viral pneumonia. b. Assign an ICD-10-PCS code to the principal procedure.

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