Inpatient Auditing Cases Question & Answer Guide (With Explanation)

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Inpatient Auditing Cases for the Final Project Inpatient Case 1 – Patient Name: Mary Williams History of Present Illness (HPI): This is a 69-year-old female with a previous myocardial infarction and known hypertension. The patient started complaining of cough, chills, and fever about 4 days prior to admission. One day prior to admission, she started to complain of progressive dyspnea associated with pain in her chest. She went to the emergency department (ED) and was noted to be extremely dyspneic and wheezing. She was given an aerosol treatment with good response. However, chest x-ray showed evidence of bilateral lower pneumonia with a PO2 of 66 and white blood cell count of 12,400, for which admission was advised. The patient had been taking Methyldopa 500 mg b.i.d., Ascriptin one tablet daily, Transderm Nitro 5 once daily, Capoten 30 mg b.i.d., and Lanoxin 0.725 mg daily. The patient had an inferior wall myocardial infarction 10 months ago. She is known to have chronic anxiety problems and had been under the care of the mental hygiene clinic. Physical examination: Revealed a well-developed, well-nourished female whose respirations improved since the aerosol therapy was given. Blood pressure is somewhat elevated. Respirations 24. Pulse 110/minute. HEENT: Unremarkable. No carotid bruits. No distended neck veins. Chest: No deformity. Equal expansion. Lungs: Crepitant rales over the lower half of end hemithorax. No wheezing. No pericardial or pleural rub noted. Heart: Regular rhythm. No murmurs. Abdomen: Soft. Liver, spleen, and kidneys not enlarged. No tenderness. Extremities: No clubbing. No cyanosis. Peripheral pulses strong and equal. Rectal: Deferred. Impression: Lobar pneumonia. Previous inferior wall myocardial infarction. Hypertension. Chronic anxiety. Plan: After appropriate cultures are obtained, the patient will be empirically started on Kefzol. Nasal oxygen will be administered. Patient will be hydrated, and aerosol therapy will be continued. Laboratory data and hospital course: Sputum smear showed moderate white blood cells, many epithelial cells, and many mixed respiratory microflora. Sputum culture showed normal growth. Blood cultures after 10 days showed no growth. Chest x-ray report revealed mild congestive cardiac failure pattern. Significant improvement in congestive heart failure noted on second x-ray but no complete resolution, although the pneumonia has resolved. EKG showed right bundle branch block with old inferior myocardial infarction, left ventricular strain; no change when repeated prior to discharge. The patient’s previous medications were continued during her hospitalization including her anti-anxiety medication Fluozetine, Methyldopa, Ascriptin, Capoten, and Lanoxin for her angina, CHF, and hypertension. After cultures were obtained, she was empirically started on intravenous Kefzol. Because of initial bronchospasm, she was also started on aerosolized bronchodilator therapy consisting of Alupent. She remained afebrile during her stay in the hospital. She had no further wheezing after 24 hours but continued to have crepitant rales in both bases. She had one episode of mild angina pains relieved by nitroglycerin during her stay. With improvement in her respirations and x-ray findings, she was discharged. Her BP was 154/110 on discharge, but this is not considered unusual because her BP is quite unstable as an outpatient, with variable high and low readings. This will, however, be followed up in the office. Final Diagnoses: Bilateral lobar pneumonia Angina and Old myocardial infarction. Hypertension. I10 Chronic anxiety. F41.9 Congestive heart failure not related to hypertension. I50.9 Codes assigned are: Principal diagnosis: J18.9 ✅ Additional diagnoses: I25.2 ✅, I20.9 ✅ Are these the correct codes per the clinical documentation and ICD-10-CM coding guidelines? Yes Is J18.9 the correct principal diagnosis per the clinical documentation and UHDDS guidelines? Yes Are there any missing ICD-10-CM codes? No Remember you are looking for accuracy and completeness in the ICD-10-CM codes assigned. Inpatient Case 2 – Patient Name: Max Spear HPI: The patient is a 72-year-old male with a history of abdominal perineal resection for colon cancer in 2004 left hemicolectomy in 2005 for splenic flexure recurrence of cancer. Subsequent right nephrectomy, right adrenalectomy, right posterior hepatic wedge resection in February of this year for metastatic colon carcinoma. CURRENT ENCOUNTER For this hospital encounter, the patient is admitted with complaints of lower back pain and bilateral thigh pain times 2 months’ duration, increasing in intensity. PHYSICAL EXAM Physical exam: Examination on admission: Temperature 99, pulse 72, respirations 24, blood pressure 150/90. The exam was remarkable for left lower quadrant colostomy from previous surgery, mildly tender lumbar spine, and the patient was barely able to stand. It was also noted that the patient had decreased sharp, dull discrimination on the neural examination of the lateral thighs. LAB DATA Lab data: On admission the lab values were; Urinalysis: Specific gravity 1.021, pH 5; chem tests were negative; nitrite negative; blood negative, 12 white blood cells, moderate bacteria. The clinical chemistry results were: serum sodium 141, BUN 42, potassium 4.9, chloride 104, CO2 28, glucose 99, creatinine 1.8, SGOT 12, SGPT 16, alkaline phosphatase 68, total protein 6.6 albumin 3.8, total bilirubin 0.7, direct bilirubin 0.0, GGT 87, calcium 10.3, magnesium 2.0, phosphorus 3.2, uric acid 5.7, PT 12.9, PTT 28.4, white blood cell count 8.0, hemoglobin 15.0, hematocrit 43.8, platelets 223,000. The CEA level was noted to be 508 ng/mL on admission. Metastatic workup for the colon carcinoma revealed no evidence of metastatic disease to the head or the thoracic and cervical spine. RADIOLOGIC STUDIES Radiologic studies: CT and MRI revealed left celiac ganglion node plexus enlarged, suspicious for metastasis. Multiple small lung nodules bilaterally suspicious for metastasis. Pathologic fracture of L2, with compression of L2, effacement of the spinal canal space and apparent cord compression at the L2 level. Subsequent urine culture grew out greater than 105 Pseudomonas aeruginosa, which was sensitive to Ciprofloxacin. The patient was treated with Ciprofloxacin 500 mg PO q 8 hours, and subsequent urine culture showed no growth. HOSPITAL COURSE Hospital course: The patient was taken to the operating room for L2 laminectomy with decompression and anterior allograft bone fusion. The postoperative course was marked by slow recovery with nausea and difficulty with pain control. The patient slowly improved and began ambulating 8 days later. The patient fell 3 days later while ambulating but had no significant injuries. Further physical therapy was marked by continued improvement in ambulation with walker and no further setbacks. Clinically, the patient is afebrile without signs and symptoms of infection, no CVA tenderness, and no dysuria. The patient will be discharged home today. Condition on discharge fairly good. Treatment: The patient will go home on Vicodin (PO q 4 to 6 hours for pain) and Capoten. He will resume Capoten b.i.d. dosing per his internist’s recommendations, 25 PO b.i.d. Prognosis: The long-terms prognosis is poor because the patient has metastatic colon CA: short-term prognosis is fairly good with improvement in ambulation. Ambulation with assistance with walker. Final Diagnoses: Pathologic compression fracture of L2 vertebra, compression of cord at L2, Metastatic colon cancer to lung and bone and UTI due to Pseudomonas. B96.5 Codes assigned are: Principal diagnosis: Pathological Fracture of L-2, 2/2 Metastatic Cancer M84.58XA Additional diagnoses: Metastatic cancer to lung C78.01 Metastatic cancer to bone C79.52 Presence of colostomy Z93.3 Z85.038 History of cancer of the colon G99.2 ❌ N39.0 UTI Procedure codes assigned: 0GB00ZZ ❌ 0SG00K0 ✅ F07L6FZ ✅✅ Are these the correct codes per the clinical documentation and ICD-10-CM/PCS coding guidelines? No Is N39.0 the correct principal diagnosis per the clinical documentation and UHDDS guidelines? No Are there any missing ICD-10-CM codes? Yes Inpatient Case 3 – Patient Name: Henry San Sebastian HPI: This 71-year-old male was a pedestrian who was struck by a motor vehicle. He had no loss of consciousness at the scene but was confused at the time of admission. He had vital signs that were stable in the field. He sustained head lacerations which did not require suturing. Steri-strips were applied to the head lacerations. Physical exam Physical examination: The patient was alert but confused. He was in a cervical collar and had a laceration of the scalp posteriorly and a small laceration under the chin. Chest: Clear to auscultation. Heart: Regular. Abdomen: Soft and nontender with positive bowel sounds. He had a palpable right inguinal hernia(k40.20), which was large. Extremities: His pedal pulses were intact bilaterally. He was able to move all extremities well. Head and neck examination: Revealed eyes intact. Neck was nontender to palpation, but the patient remained in the C-collar. Lab data Laboratory data and hospital course: Chest x-ray and EKG revealed no gross lesions. The EKG revealed atrial fibrillation. Laboratory examination was unremarkable. Chest x-ray revealed cardiomegaly. Odontoid tomograms did not show a fracture. He had a right small subarachnoid hemorrhage on CT scan of the head. Hospital course The patient was admitted to the intensive care unit for observation. He was stable in the ICU and transferred to the ward, where he was monitored on telemetry. Social Work was immediately contracted for discharge planning. Neurosurgery was consulted. They thought the patient had a traumatic subarachnoid hemorrhage, which was small, and they would follow it clinically. They stated that he had a history of syncope and suggested an MRI of his head. On September 7, the patient was attempting to ambulate when the Trauma Service noted he had left knee pain. X-rays revealed a Schatzker IV tibial plateau fracture. The patient was then evaluated preoperatively for open reduction and internal fixation of his left lower extremity. Preoperative laboratories were unremarkable. Both the patient and his wife refused surgery. The decision was made to treat the tibial plateau fracture in a long-leg plaster cast. The patient was casted by the orthopedic service technician with no anesthesia. X-rays following placement of the plaster showed adequate reduction of the fracture. It was discussed with the patient and his wife that arthroplasty of the knee may be required in the future, but the tibial fracture would be well treated in the plaster. It was the preference of the surgical team to perform open reduction and internal fixation, but the patient and his wife were against a surgical procedure at that time. Psychiatry was also consulted to evaluate the competency of the patient. They thought that the patient was somewhat demented, but that he did understand the benefits and risks of surgery and was competent to make decisions. On September 9, the patient was noted to be quite lethargic and had apnea as well. Neurosurgery evaluated the patient and administered intravenous fluids. They checked lab values and found the patient was hypovolemic (e86.1). The patient improved following the administration of IV fluids. By September 10, the patient was oriented and much improved. He was discharged to home on September 15. At the time of discharge, vital signs were stable, and he was afebrile. Circulation, motor skills, and sensory functions of the left lower extremity were intact. The plaster was intact. Final diagnoses: Closed head trauma with subarachnoid hemorrhage. Closed left tibial plateau fracture. Dementia senile. Hypovolemia. Codes assigned are: Principal diagnosis: S06.6X1A Additional diagnoses: F03.90 Senile dementia ✅ V09.3XXA ✅ Pedestrian injured in unspecified traffic accident, initial encounter Are these the correct codes per the clinical documentation and ICD-10-CM coding guidelines? no Is S06.6X1 the correct principal diagnosis per the clinical documentation and UHDDS guidelines? yes Are there any missing ICD-10-CM codes? Yes Inpatient Case 4 – Patient Name: Lucas Washington Discharge Summary History: The patient is a 70-year-old white male with chronic renal failure due to unknown etiology. He has had a renal transplant since 1977. He has had presumed chronic rejection, and he is admitted at this time for the placement of an AV fistula in anticipation of chronic dialysis therapy. Hospital course: His history and physical examination are recorded elsewhere. He was admitted on March 5th, and right radiocephalic AV fistula was performed on March 6th. The bruit was excellent at the end of the care, and he was discharged on March 8th. Laboratory test revealed a white count of 10.5, hematocrit 21.3, platelet count 506,000, albumin 4.1, creatinine 7.78, BUN 99, uric acid 6.1, phosphorus 4.9, calcium 8.9, sodium 141, potassium 5.8, chloride 111, CO2 18. A repeat potassium was 3.9 after treatment with Kayexalate. A chest x-ray was normal. EKG was normal. His blood pressure remained in the 130/80 to 140/90 range on the antihypertensives that will be listed below. Assessment: 1. Creation of an AV fistula. 2. End-stage renal disease. 3. Hypertension. 4. Status-post renal transplant with chronic rejection. Plan: He will be discharged on the following medications: Kayexalate 2 tablespoons 1 a.m.; Imuran 50 mg 2 daily; Tenormin 100 mg daily; Zantac 150 mg b.i.d.; Loniten 5 mg b.i.d.; Prednisone 10 mg daily; Tylenol PRN. He will also be on Titralac 1 t.i.d./ Stuartnatal 1 + 1 daily; and Bicitra 1 tablespoon t.i.d. He will be followed in the dialysis unit. Operative Report Diagnosis: End-stage renal disease, status post-transplant with rejection, hypertensive renal disease. Preoperative note: This patient with end-stage renal disease, status postop living renal transplant, now with rejection. He is anticipated to need hemodialysis. He is taken to the operating room at this time for the creation of an AV fistula at the right radial artery. Description of procedure: The patient was taken to the operating room and, after satisfactory axillary block of the right upper extremity, the arm was prepped and draped in a sterile fashion. Patient was noted to have satisfactory right cephalic vein, and it was elected to investigate the possibility of creating a right radiocephalic AV fistula to provide needed bypass for dialysis. A vertical incision was then created over the radial aspect of the distal forearm. Sharp dissection was utilized to isolate a 4-cm segment of the cephalic vein. Venous branches were divided between 5-0 sild sutures. A similar length of radial artery was isolated with branches being divided between 5-0 silk sutures. A longitudinal venotomy was then created for a distance of 1.3 cm. A #4 Fogarty irrigating catheter was then passed proximally up the extremity to the level of the axilla with no evidence of outflow obstruction. A dilute Heparin solution was then instilled in the vein as the catheter was withdrawn. An arteriotomy of similar distance was then created, and a side-to-side anastomosis was constructed with a running 7-0 Prolene suture. Prior to completion of the anastomosis, the proximal and distal vessel loops on the radial artery were alternately released to permit retrograde flushing and antegrade flushing of the system. The anastomosis was then complete, and all vessel loops were removed, and a satisfactory thrill was appreciated over the anastomosis. It was elected to place a 3-0 silk tie around the cephalic vein distal to the anastomosis to prevent venous hypertension of the hand. The wound was irrigated with saline and dilute Neomycin solution. Satisfactory hemostasis was noted. Subcutaneous tissues were closed with interrupted 3-0 Dexon sutures, and the skin approximated with interrupted 4-0 Ethilon sutures placed in a vertical mattress fashion. The wound was covered with day gauze and vertically oriented tape to secure it in place, and the patient transferred to the ward, having tolerated the procedure well. Codes assigned are: Principal diagnosis: N18.6 Additional diagnoses: None Procedure codes assigned: 031B0ZZ Are these the correct codes per the clinical documentation and ICD-10-CM/PCS coding guidelines? Is N18.6 the correct principal diagnosis per the clinical documentation and UHDDS guidelines? Are there any missing ICD-10-CM codes? Inpatient Case 5 – Patient Name: Russell Jackson Discharge Summary History and physical findings: This 71-year-old male is a nursing home resident because of a cerebrovascular accident two years ago. He has had numerous hospital admissions for pneumonia and other infectious complications. On the day of admission (04/21), the patient was noted to be clammy, with tachypnea, to have decreased level of responsiveness, and to show increased fever. He was seen in the ER, where evaluation revealed the presence of probable sepsis. The patient was found to have renal insufficiency with both his BUN and creatinine elevated. His WBC count was 23,000 with decreased hemoglobin and hematocrit. He was admitted for treatment of Escherichia coli sepsis. Physical examination revealed an elderly male who as aphasic and with a right hemiplegia from a previous CVA. The heart had a regular rhythm. The lungs were clear. The abdomen was soft. Clinical findings: Follow-up chemistry showed progressive decline in the BUN and creatinine to near-normal levels. Initial white blood cell count was 23,7000. Final blood count was 9,000. The urinalysis showed white cells too numerous to count. The urine culture had greater than 100,000 colonies of E. coli and group D strep, which revealed the cause of the UTI. Repeated blood cultures grew E. coli with the same sensitivities as that of the urine. There were no acute abnormalities noted. EKG showed sinus tachycardia and low lead voltage, otherwise was normal and unchanged. Hospital Course: The patient was initially started empirically on Primaxin. He underwent fluid rehydration and his electrolytes were followed closely. Electrolytes improved through his hospital stay. He was continued on IV Primaxin until the date of discharge, when he was changed to Cipro by tube. All of the bacteria grown in the urine and in the blood, were sensitive to the Cipro. The chest x-ray showed no change from previous admissions, and he was followed closely with additional oxygen as needed. The patient does have a history of chronic obstructive lung disease and was given both respiratory and oxygen therapy during this admission. During this admission, speech and occupational therapy were asked to evaluate the patient due to his aphasia and hemiplegia. Nephrology was also consulted to review his renal status. At this time, the patient has reached maximum hospital benefit and will be switched to oral antibiotics and returned to the nursing home. His tube feedings which were done during this inpatient visit, will continue at the nursing home. The patient was discharged on 05/04. Discharge Diagnoses: E. coli sepsis, UTI due to E. coli and group D strep, renal insufficiency, Chronic obstructive lung disease, CVA with right hemiplegia. Codes assigned are: Principal diagnosis: A41.51 Additional diagnoses: N28.0, N39.0, J44.9, I69.351 Are these the correct codes per the clinical documentation and ICD-10-CM coding guidelines? Is A41.51 the correct principal diagnosis per the clinical documentation and UHDDS guidelines? Are there any missing ICD-10-CM codes? Inpatient Case 6 – Patient Name: Mario Fugo The patient is a 51-year-old male who is a type 1 insulin-dependent diabetic. He was admitted to UCLA medical center per physician documentation for the treatment of a grade III foot ulcer which involved necrosis of the muscle on the left foot with gangrenous changes resulting from diabetic neuropathy, atherosclerosis, and chronic peripheral vascular insufficiency. Excisional debridement of the ulcer to the muscle was done during this hospital admission. After 5 days in the hospital the patient was discharged to rehab in good condition. Codes assigned are: Principal diagnosis: E10.69 Additional diagnoses: I70.202, I96, G62.9, L97.523 Procedure codes assigned: 0JDR0ZZ Are these the correct codes per the clinical documentation and ICD-10-CM/PCS coding guidelines? Is E10.69 the correct principal diagnosis per the clinical documentation and UHDDS guidelines? Inpatient Case 7 – Patient Name: Lisa Fuller Discharge Summary Pertinent History: The patient is a 68-year-old female admitted through the Emergency Department. The patient’s abdomen is enlarged to about 18-week size; however, the patient states she has actually lost 22 pounds over the past few weeks. Patient says her appetite has disappeared. The patient is admitted for workup and definitive treatment. Hospital Course: The patient’s CT scan and MRI revealed a suspicious mass in the pelvis. The patient was taken to surgery, where exploration revealed, and pathology report later confirmed right ovarian cancer. A radical abdominal hysterectomy was performed for ovarian carcinoma, which in this case included removal of the uterus and upper vagina. Also performed were regional pelvic lymph nodes dissection with the entire lymph node chain being removed. The patient also had a bilateral salpingo-oophorectomy. The patient tolerated the procedure well. Discharge instructions: The patient was discharged home to see me in the office in one week for the removal of staples and scheduling of an oncologist consultation. Codes assigned are: Principal diagnosis: C79.61 Additional diagnoses: None Procedure codes assigned: 0UT90ZZ, 0UTG0ZZ, 0UT20ZZ, 0UT70ZZ, and 07TC0ZZ Are these the correct codes per the clinical documentation and ICD-10-CM/PCS coding guidelines? Is C79.61 the correct principal diagnosis per the clinical documentation and UHDDS guidelines? Are there any missing ICD-10-CM codes? Inpatient Case 8 – Patient Name: Mary Redding Discharge Summary History of Present Illness: The patient is an 80-year-old female with a known history of advanced metastatic carcinoma of the breast, widely metastatic. The patient was admitted because of increasing shortness of breath and severe pain. The pain, which was worse in her left chest, was associated with increasing shortness of breath. At the time of admission, the patient was in so much pain that she was unable to remember her history. The patient initially presented for congestive heart failure over one year ago. This was subsequently found to be secondary to metastatic breast cancer, post left mastectomy, three years ago. The patient had previously been on chemotherapy. Laboratory Data and Hospital Course: The patient was treated initially with IV pain medication to control her pain. Subsequently, she became able to be stable on oral medication. By the time of discharge, the patient was stable on oral Vicodin, and she was able to eat. Blood sugars were improved, and her Tolinase was withheld. Laboratory results at the time of discharge included BUN 17, creatinine 1, sodium 151, potassium 4.5, chloride 105, CO2 25, alkaline phosphatase elevated at 170 with GGT 267, SGOT 68. Admission BUN was up to 38 with creatinine 1.3 secondary to dehydration. By the time of discharge, these had improved. Admission glucose 225, down to 110 at discharge. Patient treated with Lanoxin and Lasix for CHF. Medications at Discharge Include: Aldactone, 25 mg twice a day; Lanoxin, 0.0125 mg daily; Metamucil 5 cc in 4 ounces of juice twice a day; Tolinase, 250 mg half tablet b.i.d. (but hold if preceding Accu-Chek is less than 125); Reglan, 10 mg p.o. a.c.; Pepcid, 20 mg b.i.d.; Lasix, 40 mg daily; Vicodin tablets, 1 every 3 hours p.r.n. for pain. Discharge Diagnosis: 1. Uncontrolled pain, secondary to widely metastatic breast carcinoma 2. Dehydration 3. Type 2 diabetes mellitus, uncontrolled 4. Congestive Heart Failure Codes assigned are: Principal diagnosis: C50.919 Additional diagnoses: E86.0, E11.65, I50.9 Are these the correct codes per the clinical documentation and ICD-10-CM coding guidelines? Is C50.919 the correct principal diagnosis per the clinical documentation and UHDDS guidelines? Are there any missing ICD-10-CM codes? Inpatient Case 9 – Patient Name: Luz Gonzalez This is a 71-year-old female admitted with a complaint of right-sided weakness. She denies any fever, shortness of breath, cough, headaches, or chest pain. The patient has NIDDM, controlled by diet. The patient currently smokes a half pack of cigarettes per day. Mild right-sided paralysis was found on physical examination. The patient is right-handed. Gadolinium-enhanced brain MRI demonstrated subacute middle cerebral artery infarct in the left basal ganglia. Discharge diagnosis was CVA, subacute infarct. Physical therapy and speech therapy for her hemiparalysis and dysphasia started and will continue at the rehab facility where she was transferred to. Codes assigned are: Principal diagnosis: I63.9 Additional diagnoses: E11.9, F17.210 Procedure codes assigned: B030Y0Z Are these the correct codes per the clinical documentation and ICD-10-CM/PCS coding guidelines? Is I63.9 the correct principal diagnosis per the clinical documentation and UHDDS guidelines? Are there any missing ICD-10-CM codes? Inpatient Case 10 – Patient Name: Henry Fields A six-month-old baby with a left-sided, incomplete upper cleft lip and cleft soft palate is admitted and undergoes surgical repair of both deformities requiring incisions to accomplish the corrections. Codes assigned are: Principal diagnosis: Q35.3 Additional diagnoses: Q36.9 Procedure codes assigned: 0CQ3XZZ, 0CQ0XZZ Are these the correct codes per the clinical documentation and ICD-10-CM/PCS coding guidelines? Is Q35.3 the correct principal diagnosis per the clinical documentation and UHDDS guidelines? Inpatient Case 11 – Patient Name: Rita Smallwood The patient is an 18-day-old baby girl admitted after it was noticed she was developing drainage from the umbilical cord. Upon admission she was placed on intravenous Cefotaxime and Ampicillin, later changed to Cefotaxime and Clindamycin. A culture taken from the umbilical stump grew Staphyloccus aureus and Group H streptococcus. After the first day, there was great improvement, and the baby continued to improve. She remined afebrile, has continued to eat very well, and she shows no sign of abdominal tenderness or peritonitis. The mother was instructed to watch the child closely and to notify the office if there is any redevelopment of the redness, swelling, or discharge. Recheck in two weeks for one-month check-up. Discharge diagnosis: Staphylococcus aureus and Group H streptococcus omphalitis of the newborn. Codes assigned are: Principal diagnosis: P38.9 Additional diagnoses: None Procedure codes assigned: None assigned per the documentation and UHDDS guidelines Are these the correct codes per the clinical documentation and ICD-10-CM coding guidelines? Is P38.9 the correct principal diagnosis per the clinical documentation and UHDDS guidelines? Are there any missing ICD-10-CM codes? Inpatient Case 12 – Patient Name: Miles Queensland This patient was admitted with increasing shortness of breath, weakness, and non-productive cough. Treatment included oxygen therapy and a bronchoscopy of the left and right bronchus. Final diagnoses listed as acute respiratory insufficiency due to an acute exacerbation of chronic obstructive pulmonary disease (COPD). Codes assigned are: Principal diagnosis: J96.00 ❌ Additional diagnoses: J44.1 Procedure codes assigned: 0BJ08ZZ ✅ Inspection of Tracheobronchial Tree, Via Natural or Artificial Opening Endoscopic Are these the correct codes per the clinical documentation and ICD-10-CM/PCS coding guidelines? Is J96.00 the correct principal diagnosis per the clinical documentation and UHDDS guidelines?

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