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Code This!

Scenario Week of October 04, 2012:
View Current Scenario

Assign the appropriate ICD-9-CM and ICD-10-CM/PCS diagnosis and procedure codes, as appropriate.

CHIEF COMPLAINT: Headache, fever

SCENARIO
A 62-year-old patient presents to the emergency room with worsening headache and flu-like illness. Symptoms of fever, severe headache, lethargy, body aches, and nausea progressed steadily over the past week. Severity of symptoms prompted the patient’s visit to the emergency room.

INITIAL EXAMINATION
The patient presents in marked distress with altered mental status. Physical exam reveals nuchal rigidity and marked pain response. Kerning’s sign is response positive for meningeal irritation with flexion of lower extremities.
Temperature: 104
Oral exam: Dry mucous membranes
Skin: Poor turgor, mild tenting
Ophthalmologic exam reveals photophobia and painful eye movement consistent with inflammation of the optic nerve

PROCEDURE: Lumbar puncture
The patient was positioned for tap. Aseptic solution was applied to the skin and a local anesthetic injected at the puncture site. The biopsy needle inserted at L3-L4. Cerebrospinal fluid was withdrawn and specimen prepared for analysis. The needle was removed and the wound dressed.

RESULTS: Cloudy cerebrospinal fluid (CSF) specimen with normal glucose, but positive protein elevation and pleocytosis at 300 cells/mm3. IgM antibody-capture ELISA serology test positive for antibodies. Positive rapid polymerase chain reaction (PCR).

PROGRESS: The patient was admitted for observation, IV fluids, and supplemental oxygen. She was discharged after 72 hours with resolution of fever, adequate hydration, and return to baseline mental status.

DIAGNOSIS: West Nile virus meningitis, mild dehydration, optic neuritis

Code This! Assign the correct ICD-9-CM and ICD-10-CM/PCS diagnosis and procedure codes.


ICD-9-CM Diagnosis Codes
066.42 West Nile fever with other neurologic manifestation
321.2 Meningitis due to viruses not elsewhere classified
377.39 Optic neuritis, other
276.51 Dehydration

ICD-9-CM Procedure Code
03.31 Spinal tap

ICD-9-CM Rationale
Additional codes are required with code 066.42 to specify the neurological manifestations. Code 321.2 is a manifestation code, requiring the underlying disease to be sequenced first. Code also the optic neuritis and dehydration as documented. AHA Coding Clinic for ICD-9-CM, Fourth Quarter 2004.

ICD-10-CM Diagnosis Codes
A92.32 West Nile virus infection with other neurologic manifestation
G02 Meningitis in other infectious and parasitic diseases classified elsewhere
H46.8 Other optic neuritis
E86.0 Dehydration

ICD-10-PCS Procedure Code
009U3ZX Drainage of Spinal Canal, Percutaneous Approach, Diagnostic

ICD-10-CM/PCS Rationale
In ICD-10-CM, additional codes are required with diagnosis code A92.32 to specify the neurological manifestations. Code G02 is a manifestation code, requiring the underlying disease to be sequenced first. Code also the optic neuritis and dehydration as documented. In the ICD-10-PCS index, refer to “Spinal Canal” under the root operation “Drainage.” The approach is percutaneous (5th character 3), no device remains (6th character Z) and the intent is for diagnostic (7th character X) purposes.

 
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