ICd-9-Cm code ith poa indicator and ICD-9-Cm procedures codes. Patient was admitted with severe abdominal pain. a history of bleeding, but never sever. Patient because of systoms underwent emergency laparotomy to repair the perforation in the antrum of the stomach by suturing. The physcian states: acute peptic ulcer with perforation and bleeding. Also, patient with chronic systolic congestive heart failure was admitted because of melena. Patient had EGD with biopsy of the stomach and duodenum. ICD-9-CM diagnosis codes and ICD-9_cm procedure codes
ICD-9-CM stands for International Classification of Diseases, 9th Revision, Clinical Modification. It is a coding system used in healthcare to classify and categorize diagnoses and procedures. The Purpose of ICD-9-CM codes is to provide standardized codes for medical diagnoses and procedures to facilitate the collection and analysis of data. The inclusion of a POA (Present on Admission) indicator in ICD-9-CM codes indicates whether a condition was present at the time the patient was admitted to the healthcare facility or if it developed during the course of the hospitalization.
In the case of the patient admitted with severe abdominal pain and a history of bleeding, it is important to determine the appropriate ICD-9-CM diagnosis codes and procedure codes to accurately reflect the patient’s condition and the treatments provided.
The physician’s statement of “acute peptic ulcer with perforation and bleeding” provides a clear diagnosis for the patient. The appropriate ICD-9-CM diagnosis code for this condition would be 531.0, which represents “acute gastric ulcer with hemorrhage and perforation.”
Additionally, the patient’s history of chronic systolic congestive heart failure and the admission for melena (black, tarry stools caused by upper gastrointestinal bleeding) are relevant factors to consider. The appropriate ICD-9-CM diagnosis code for chronic systolic congestive heart failure would be 428.21, and for melena, it would be 578.1.
Regarding the procedure performed, the patient underwent an emergency laparotomy to repair the perforation in the antrum of the stomach by suturing. The appropriate ICD-9-CM procedure code for this procedure would be 44.61, which represents “closure of perforation of stomach.”
Furthermore, the patient had an EGD (Esophagogastroduodenoscopy) with biopsy of the stomach and duodenum. The appropriate ICD-9-CM procedure code for this procedure would be 45.13, which represents “gastroscopy, biopsy.”
In summary, for the patient admitted with severe abdominal pain, the relevant ICD-9-CM diagnosis codes would include 531.0 (acute gastric ulcer with hemorrhage and perforation), 428.21 (chronic systolic congestive heart failure), and 578.1 (melena). The relevant ICD-9-CM procedure codes would include 44.61 (closure of perforation of stomach) for the emergency laparotomy and 45.13 (gastroscopy, biopsy) for the EGD with biopsy.
It is important to note that ICD-9-CM codes have been replaced by ICD-10-CM codes since October 1, 2015. However, for the purpose of this assignment, the ICD-9-CM codes have been used.