without hand writing and use ICD10 AM cods only 4. This 65 year old woman was ad
ID: 244219 • Letter: W
Question
without hand writing and use ICD10 AM cods only
4. This 65 year old woman was admitted for Ultra low resection of a rectal tumour. This was performed under GA (ASA 1 234 5 6 E). Liver mets were also noted. Postoperatively she was dehydrated & given IV fluids. On day 3 postop, she developed SOB and a chest x-ray was ordered. APO was diagnosed & she was started on IV Lasix. The following night she had another episode of APO and a cardiology consult was sought. TOE was perfomed which showed abnomal LV function and ejection fraction. She was stabilised with supplemental oxygen and GTN infusion. Principal diagnosis: Rectal Adenocarcinoma MRD/Case ID Description Codes COF Principal Diagnosis Additional Diagnosis Princip:1 ProcedureExplanation / Answer
1. Principal diagnosis:Description- Malignant neoplasm of rectum. It is a primary or progressive metastasis of malignant neoplasms which involves the rectum.
Codes -C20
2.Additional Diagnosis:Acute Pulmonary edema: It is accumulation of fluid in the lung tissues resulting in improper gas exchange causing difficulty in breathing,coughing and shortness of breath.
Codes -J81.0
3.Principal Procedure :Ultra Low resection of the rectum.-This is a procedure in which the rectum is completely removed.
Code -3202800
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