Chapter 19: CPT Evaluation & Management Section Workbook Case 7 Answers and Rationale.

Discharge Summary ^|1|

Hospital Course: The patient was hospitalized two days ago with nausea and vomiting. She had an uneventful hospital course. She was diagnosed with cholelithiasis. General surgery was consulted. Dr. Williams thought this was perhaps causing her upper GI symptoms. She was scheduled for surgery on Monday. She was tolerating a regular diet. Her nausea and vomiting resolved and she desired to be dismissed home. She was found to have a bladder infection. She was started on Levaquin and she also had left eye conjunctivitis and she was given Ciloxan eye ointment for that.

Discharge Diagnoses: ^|2|
1. Cholelithiasis
2. Cystitis
3. Conjunctivitis
4. Hyponatremia
5. Diabetes mellitus type 2
6. Hypertension

Discharge Medications:
Levaquin 500 mg p.o. daily x2 days
Ciloxan ointment, apply b.i.d.to left eye x 4 days/
Zofran 4 mg p.o. q. 4 hours p.r.n. nausea, vomiting #20
Benadryl 25 mg p.o. daily p.r.n. rash
Diovan 320 p.o. daily
Calcium 600 mg p.o. daily
Vitamin C 500 mg p.o. daily.
Metformin 1000 mg p.o. daily
Lipitor 20 mg p.o. at bedtime
Coreg CR 20 mg p.o. daily.

Discharge Diet: Cardiac

Activities: ad lib

Discharge instructions: Patient to be NPO after midnight Sunday.

Dismiss: Home ^|3|

Condition: Good

Follow-up: Follow up with me in 1 week. Follow up on Monday morning for cholecystectomy. NPO after midnight on Sunday. ^|4|

|1| This indicates the provider is discharging the patient. Review the note to make sure discharge services where performed. Look for documented time in the note.
|2| Select a diagnosis code for all discharge diagnoses.
|3| This is confirmation the patient is being discharged to their home.
|4| The patient is scheduled for surgery in one week.

What are the CPT® and ICD-10-CM code(s) reported?
CPT® code: 99238
ICD-10-CM codes: K80.20, N30.90, H10.9, E87.1, E11.9, Z79.84, I10

Rationale:
CPT® code: This is a discharge summary from a hospital. Subcategory-Hospital Discharge Services. In the CPT® Index, look for Discharge Services/Hospital. Discharge services are coded based on time. There is no time documented in the medical record, so the lowest time is selected. The CPT® code 99238 is the correct code. Remember, when reporting the discharge based on time, you would include all time spent by that physician on that date of service, whether it is continuous.

ICD-10-CM codes:
1. Cholelithiasis—In the ICD-10-CM Alphabetic Index, look for Cholelithiasis – see Calculus, gallbladder; Calculus, calculi, calculous/gallbladder referring you to K80.20.
2. Cystitis—Look in the Alphabetic Index for Cystitis. There are no other descriptors, use N30.90. Physician needs to document the infectious agent to report it.
3. Conjunctivitis—Look in the Alphabetic Index for Conjunctivitis NOS referring you to H10.9.
4. Hyponatremia—Look in the Alphabetic Index for Hyponatremia referring you to E87.1.
5. Diabetes mellitus type 2—Look in the Alphabetic Index for Diabetes, diabetic/type 2 referring you to E11.9.
6. The patient is on long-term metformin to control her blood sugar. Look in the Alphabetic Index for Long-term (current) (prophylactic) drug therapy (use of)/oral/hypoglycemia referring you to Z79.84.
7. Hypertension— Look in the Alphabetic Index for Hypertension referring you to I10.

Verify code selections in the Tabular List.