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Code This!

Scenario Week of November 15, 2012:
View Current Scenario

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

CHIEF COMPLAINT: Shoulder pain, fever

SCENARIO: A 65-year-old patient presents to the emergency room with right shoulder pain and fever. The patient is five days status post steroid injection of preservative-free Methylprednisolone Acetate 80 mg/ml for shoulder pain and immobility due to localized primary glenohumeral joint osteoarthritis with chronic adhesive capsulitis. Records match CDC confirmation of contaminated product as one of three implicated drug lots currently under recall.

INITIAL EXAMINATION: The patient is an otherwise healthy, 65-year old male. He presents with a reddened, painful swelling at the infection site over the right glenohumeral joint. Exam: Physical exam reveals markedly increased, pain, erythema and pain response. Temperature: 102.5, BP 120/75

PROCEDURE: Arthrocentesis. After skin preparation and identification of the needle insertion site, a 22-gauge needle was inserted creating a small skin wheal with local anesthetic into the subcutaneous tissue and along the joint aspiration pathway. An 18-guage needle was inserted through the skin and into the right glenohumeral joint space. A fluid sample was removed from the joint. The needle was withdrawn and pressure was applied with satisfactory results.

RESULTS: Synovial fluid specimen is positive for Exserohilum rostratum.

PROGRESS: The patient was admitted and placed on empiric IV antibiotic therapy and IV fluids. Based on culture results, the patient was placed on Voriconazole therapy, beginning with a loading dose of 6 mg/kg every 12 hours for two doses, followed by 4 mg/kg every 12 hours in accordance with CDC recommendations. He was discharged with resolution of fever and significant clinical improvement with a prescription for oral Voriconazole.

DIAGNOSIS: Exserohilum rostratum iatrogenic septic arthritis due to contaminated Methylprednisolone Acetate (PF)

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


ICD-9-CM Diagnosis Codes
999.39 Infection following other infusion, injection, transfusion or vaccination
117.8 Infection by dematiacious fungi, [Phaehyphomycosis]
711.61 Arthropathy associated with mycoses
E875.1 Contaminated or infected blood, other fluid, drug or biological substance, contaminated substance injected or used for vaccination
715.11 Osteoarthrosis, localized primary, shoulder region
726.0 Adhesive capsulitis of shoulder

ICD-9-CM Procedure Code
81.91 Arthrocentesis

ICD-9-CM Coding Rationale
Code 999.39 represents the infection as a complication of the previous injection procedure. External cause code E875.1 details the circumstance, as a contaminated substance prepared for injection procedure. Code 81.91 represents the diagnostic removal of synovial fluid to obtain the specimen for analysis of causal pathogen. Code 711.61 is a manifestation code, requiring the underlying disease (117.8) be sequenced first. Exserohilum rostratum is a dematiaceous (darkly pigmented) soil and plant-derived fungus which causes phaeohyphomycosis (an opportunistic fungal infection) in humans. Code also the chronic, underlying conditions: 715.11 for osteoarthritis of the shoulder as described and 726.0 for adhesive capsulitis.

ICD-10-CM Diagnosis Codes
T80.29XA Infection following other infusion, transfusion and therapeutic injection, initial encounter
B43.8 Other mycoses, not elsewhere classified, other specified mycoses
M01.X11 Direct infection of right shoulder joint in infectious and parasitic diseases classified elsewhere
Y64.1 Contaminated medical or biological substance, injected or used for immunization
M19.011 Primary osteoarthritis, right shoulder
M75.01 Adhesive capsulitis of right shoulder

ICD-10-PCS Procedure Code
0R9J3ZX Drainage of Right Shoulder Joint, Percutaneous Approach, Diagnostic

ICD-10-CM/PCS Coding Rationale
Code T80.29XA represents the infection as a complication of the previous injection procedure. This code requires a placeholder X in the sixth character position and a seventh character A to report the status of the encounter. External cause code Y64.1 details the circumstance, as a contaminated substance prepared for injection procedure. ICD-10-PCS code 0R9J3ZX represents the diagnostic removal (seventh character X) of synovial fluid via percutaneous approach (fifth character 3) to obtain the specimen for analysis of causal pathogen. Code M01.X11 is a manifestation code, requiring the underlying disease (B43.8) be sequenced first. Code also the chronic, underlying conditions: M19.011 for osteoarthritis as described and M75.01 for adhesive capsulitis. ICD-10-CM provides specification of laterality for these conditions.

 
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