Read the mini medical record of the patient’s encounter below. Using your ICD-10

Question

Read the mini medical record of the patient’s encounter below. Using your ICD-10-CM code book, assign and sequence the ICD-10-CM diagnosis codes. Post your code(s) and your rationale (the reason why).

12.10 INPATIENT HOSPITAL              Gender: M               Age: 45

Reason for admission: sudden onset of pain and swelling in left hip, fever

Testing: arthrocentesis, blood culture, X-ray

Assessment: bacterial pyogenic arthritis due to Pseudomonas aeruginosa, likely due to patient’s intravenous drug abuse

3 codes required

Explanation / Answer

Ans: The code indicates a diagnosis that can be used for reimbursement purposes.

ICD-10-CM Diagnosis Code is M25.559 for the pain in hip. It indicate the sign of a diseases associated with the musculoskeletal system and connective tissue M00-M99.

Code for the testing of arthrocentesis, blood culture, X-ray is R78.81.

Code for the bacterial pyogenic arthritis is M00.869.

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