The ER physician documents that the patient is being admitted for hematemesis. The patient has an Hct of 24.3. A transfusion of packed red blood cells is administered (via peripheral vein), and the patient is taken to the OR for an EGD. The EGD reveals that the patient has an acute perforated duodenal ulcer that is causing the bleed. The ulcer is cauterized. The patient is treated with IV antibiotics, omeprazole, and NG tube. The discharge summary lists an additional diagnosis of acute blood loss anemia.
A)D62, K26.2, 0W3P8ZZ, 30233N1
B)K26.2, D62, 0W3P8ZZ, 30233N1
C)D62, K26.1, 0D597ZZ, 30233P0
D)K26.1, D62, 0D598ZZ, 30233P1

Question

Quizplus · Accepted Answer

The primary diagnosis is K26.2 - acute duodenal ulcer with hemorrhage. The secondary diagnosis is D62 - acute blood loss anemia. The procedure performed is an EGD, identified by the root operation "inspection" and the body part "duodenum," which is coded as 0W3P8ZZ. The transfusion of packed red blood cells is not separately coded in this scenario. The patient's Hct level is included in the documentation but is not coded separately. The IV antibiotics, omeprazole, and NG tube are also not coded separately as they are included in the treatment of the duodenal ulcer and acute blood loss anemia. The encounter is coded as an inpatient visit with a principal diagnosis of K26.2 and a secondary diagnosis of D62.

The ER Physician Documents That the Patient Is Being Admitted