Using Techniques Described Explained for Students (Easy Guide)

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Original Question

Using the techniques described in this chapter, carefully read through the case study and determine the most accurate ICD-10-PCS code(s). Patient: Poppy Browning DATE: 9 April 2024 MRN: A399523147 Physician: Carla Firmann, MD Second hospitalization, 1 month later, following appearance of arising colics, difficult to treat with pain medications, high body temperature, and increase in inflammation ratings, symptoms consistent with picture of infective cholangitis. Therefore, the picture was resolved with antibiotic therapy and with carrying out a papillotomy by means of ERCP. Discharged under antibiotic therapy with Ciprofloxacin, Cortisone, and Azathioprine. Third hospitalization, 3 days after discharge from previous hospitalization, following arising colics with progressive ultrasound scan dilatation of bile ducts and evidence of dropsy of the gallbladder. Moreover, 48 hours following hospitalization, amylase increase (600 UI/l) was detected. The IgG4 dosage (18 mg/dl) was within normal limits, excluding a possible autoimmune hepatitis/pancreatitis syndrome. ERCP performed with dilatation and cleaning of the common bile duct that involved the spillage of corpuscular material and bile with purulent appearance bringing about a fast improvement of symptomatology and a rapid reduction in the amylase values. Later on, laparoscopic cholecystectomy was carried out. During postsurgery, after a short period of wellness, the patient suffered from an abdominal pain. Reappearance interpreted, at the beginning, as a light pancreatitis (treated with antibiotic therapy). Subsequently, persisting painful crises were observed despite blood tests showing substantial stability. Therefore, an MR cholangiography was carried out (images enclosed on CD) that has revealed an appearance of intra- and extrahepatic bile duct dilatation, evident also at common bile duct level where the picture seems to reveal a relevant stenosis: “Intrahepatic bile ducts with clear wall irregularity and with minimal stenosis followed by dilatations in a picture to be related to the base pathology. Irregularity at the extrahepatic bile ducts and at the common bile duct level too, the common bile duct distal region appears moderately reduced in diameter, also in papillary region, also as a result of papillotomy.” In the light of the aforesaid, a biliary stent was placed during ERCP in order to guarantee bile ducts patency. The clinical picture, after surgery, was stable with occasional presence of pains involving mainly the right hypochondrium without any characteristics of biliary colics. At discharge, blood tests showed evidence of improvement of the hepatic cytolisys index (AST 28, ALT 38) with still elevated values of gammaGt (197) and APC 2.02 mg/dl probably linked to the inflammatory pathology rather than to an infective event. Discharge with indication to follow a therapy with Deltacortene to scale down the Azathioprine and antibiotic therapy with Augmentin. Fourth hospitalization, 1 month later, in gastroenterology department for clinical test: The patient reported slight painful crisis in epigastric region; at examinations APC negativization (0.59) and a further reduction in GGTs with transaminase substantially stable. Therefore, the therapy with Amoxicillin + Clavulanic Acid was suspended and Metronidazole 250 mg was prescribed three times a day every other week. Fifth hospitalization during the same month, following an episode of infective cholangitis with blood tests that showed transaminase on the increase (ALT 248, AST 114, GGT 281) with leukocytosis (WBCs 13,000, Neutrophils 88%, Lymphocytes 7.9%) and elevated APC (4.48). Therapy started with Augmentin (1 g × three times a day) for 7 days and then end. At the end of the 7 days, preventive treatment prescribed with Cotrimoxazole (tablet 160+800) one tablet twice a day. Sixth hospitalization, 2 weeks after the previous one, following epigastric pain and nausea, occurred after 1 day from Augmentin interruption and 1 day after the beginning of therapy with Cotrimoxazole. The most significant lab examinations at admission: CRP = 1.92 mg/dl; GGT 129 U/L; AST = 29 u/l; ALT = 97 U/L. Abdomen ultrasound scan with evidence of common bile duct dilatation. “Dilatation of the proximal and medial segment of the common bile duct, with diameter up to 10 mm, in whose context binary images are appreciated referable to the well-known stent. A moderate ectasia of intrahepatic bile ducts is connected, in particular in the left parts.” To treat the severe painful symptomatology, a therapy with Ketorolac Tromethamine 90 mg in 250 cc in continuous infusion was started. Because of the increase in the inflammation ratings and in the dilatation of the common bile duct at the abdominal ultrasound scan, supposing an occlusion of the biliary stent with overlapped cholangitis, an antibiotic therapy has been started with Meropenem 1 g × 3, IV, and a high osmolar ERCP was carried out. ERCP didn’t show any materials obstructing the stent. Biliary washing was within normal limits. Therapy prescribed at home: Augmentin (1 g × 3); Ciproxin (500 mg × 2); Folina 5 mg (one tablet every other day); Deltacortene (25 mg daily); Azathioprine (100 mg daily); Lansoprazole (30 mg daily); Ursodesossicolic Acid (300 mg three times a day). Be sure to list the codes, one code per box, in the correct order, from top to bottom. If there are 2 or more similar codes, list the code as xn where n is the number of similar codes. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Determine the most accurate ICD-10-PCS code(s). Tip: Don't forget your HCPCS Level II drug codes. The number of spaces provided does not indicate the number of codes required to accurately report this encounter.

 

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