In this assignment, you will use your coding tools and coding knowledge to accurately locate the ICD-10-CA and CCI codes that reflect the care encounter in the scenario provided.
To complete this assignment:
- Read the case study source documentation below.
- Open WinRecs.
- Instructions on how to complete the assignment in WinRecs can be found .
- Please note, if you are unable to complete the assignment in the WinRecs software, you may use the mock WinRecs Excel template . Please consult with your instructor beforehand.
- Using the information from the source documentation, locate the following data elements and insert them into the appropriate cells within WinRecs.
Data Elements to Abstract Data Element Info Not in EHR Go Documentation Coder Number Your student number/name Chart Number Last Name First Name Birth Date Age Number Legal Sex Province/Territory Issuing - Open the ICD-10-CA and CCI Folio.
- Using Folio, locate the accurate diagnosis and intervention codes, and input them in the appropriate area of WinRecs.
- Using your knowledge on diagnosis typing and sequencing, apply the accurate diagnosis typing and sequencing.
- Open the Demographic tab and locate the coder number field in the Abstract Identification. Enter your student number and name into the coder field for identification.
- Submit your assignment.
Resources:
For your assignment, you can use the following resources:
- Folio ICD-10-CA and CCI
- Canadian Coding Standards
- DAD Abstracting Manual
- WinRecs
Case Study Source Documentation:
Case Study: Inpatient Admission for Complex Medical Management
Patient Information:
Name: Mrs. Elizabeth Thompson
Age: 68 years
DOB: 1956/01/25
Gender: Female
Medical Record Number: T55555
Presenting Complaint:
Mrs. Thompson is a 68-year-old female admitted to the hospital with worsening shortness of breath, productive cough, and swelling in her lower extremities. She reports a history of chronic obstructive pulmonary disease (COPD), hypertension, heart failure, and type 2 diabetes mellitus.
Clinical Assessment:
Upon admission, Mrs. Thompson presents with respiratory distress, tachypnea, and audible wheezing on auscultation. Her oxygen saturation is 88% on room air, and she appears cyanotic. Dr. William Kaiser orders a CT of the lungs with contrast that reveals bilateral pulmonary infiltrates consistent with acute exacerbation of COPD, a pleural effusion, and possible superimposed pneumonia. A bedside thoracentesis with insertion of a chest tube is performed by Dr. Kaiser under a local anesthetic. Mrs. Thompson is sent for an X-ray for confirmation of tube placement. A pulmonary angiogram is negative for a pulmonary embolism. An MRI of the chest confirms COPD exacerbation and pulmonary edema. Additionally, she exhibits signs of volume overload with bilateral lower extremity edema, jugular venous distention, and bibasilar crackles on lung auscultation, indicative of congestive heart failure.
Diagnosis:
- Acute exacerbation of chronic obstructive pulmonary disease (COPD)
- Bacterial pneumonia
- Pleural effusion
- Respiratory distress
- Congestive heart failure
- Type 2 diabetes mellitus with diabetic nephropathy
- Hypertension
Interventions:
- Thoracentesis with insertion chest tube
- CT scan lungs
- Pulmonary angiogram
- MRI chest without contrast
Treatment Plan:
Mrs. Thompson is admitted to the medical ward and initiated on supplemental oxygen therapy to maintain oxygen saturation above 92%. She receives bronchodilators, corticosteroids, and antibiotics for the management of her COPD exacerbation and pneumonia. Diuretics are administered to alleviate fluid overload associated with congestive heart failure. Blood pressure is carefully monitored and managed with antihypertensive medications to optimize cardiac function and reduce strain on the heart. Additionally, Mrs. Thompson’s diabetes is managed with insulin therapy to control blood glucose levels. She is placed on a diabetic renal diet to manage her diabetic nephropathy and prevent further deterioration of kidney function.
Multidisciplinary Approach:
Mrs. Thompson’s care involves a multidisciplinary team, including pulmonologists, cardiologists, endocrinologists, nephrologists, and dietitians. Respiratory therapists provide chest physiotherapy and breathing exercises to improve lung function and facilitate secretion clearance. Physical therapists initiate early mobilization and rehabilitation to prevent deconditioning and improve functional status. Social workers collaborate to address Mrs. Thompson’s social support needs and facilitate discharge planning.
Monitoring and Follow-Up:
Throughout her hospitalization, Mrs. Thompson’s clinical status is closely monitored, with regular assessments of vital signs, oxygen saturation, fluid balance, and glycemic control. Serial chest X-rays and laboratory tests are performed to evaluate treatment response and guide adjustments to therapy.
Upon stabilization of her acute exacerbation and optimization of her chronic conditions, Mrs. Thompson is transitioned to a step-down unit for continued monitoring and rehabilitation. The chest tube is removed, and she is weaned off of the oxygen and stabilized with oxygen saturations at 96%. Discharge planning includes coordination of home healthcare services, medication reconciliation, and education on self-management strategies to promote disease control and prevent future exacerbations.
