What is the ICD-10 coding for a 49-year-old smoking male patient with history of hypertension, uncontrolled diabetes and hyperlipidemia
Fist, here is a typical note for an established patient, let's call him Joe (obviously not a real patient name), who presented to be seen after a rather long gap in care of over a year. He had been diagnosed with diabetes, high blood pressure and high lipids about 15 months ago, but has failed to return to follow-up appointments until now.
CHIEF COMPLAINT: Multiple Issues
HISTORY:49-year-old smoking male patient with history of hypertension, diabetes, hyperlipidemia, presenting today for followup. He has not been seen for his diabetes for over a year. Is not taking his metformin, after he run out of it many months ago. Not checking his sugars. Some polyuria at night. He ran out of his blood pressure medications a few months ago, too. Has been having erection problems for over a year. Cialis helped in past, but has not taken it recently. No testosterone check in past. Resumed smokingd after quitting briefly on Chantix 15 months ago. Is interested in trying Chantix again.
Denies chest pain shortness of breath or abdominal pain.
Rest of ROS checked and negative.
PFSH reviewed w/ pt today and updated.
Ibuprofen 200 mg tablet 4 tab(s) PO QAM
Chantix Starter Pack 0.5 mg-1 mg tablet Start: 0.5 mg PO qd x3 days, then 0.5 mg PO bid x4 days, then 1mg PO BID for 1 week.
Atenolol 100 mg tablet 1 tab(s) PO once a day
Simvastatin 40 mg tablet 1 tab(s) PO once a day (On Hold)
MetFORMIN 500 mg tablet 1 tab(s) PO 2 times a day (On Hold)
Hydrochlorothiazide-Lisinopril 12.5 mg-10 mg tablet 1 tab(s) PO once a day (On Hold)
penicillin -- Pt was a child and does not khow the reaction
Diabetes type II / DM II
Benign essential hypertension
Tobacco Use Disorder
Obstructive Sleep Apnea (Adult)
Body Mass Index Between 31.0-31.9 Adult
Mother - Comments: Alive with diabetes. Father - Comments: Alive and healthy
Alcohol Use: Yes Moderate.
Marital Status: Married.
Recreational Drug Use: None.
Smoking Status: Smoker, current status unknown (2 packs per day).
VITALS: Weight: 214 lbs, BMI: 31.6, Pulse: 92, BP: 150 / 88 [arm - sit] Pain: 2 of 10.
VS: as above.
_Constitutional: General appearance of patient normal.
- no JVD
- no chest dullness or hyperresonance,
- nl breath sounds b/l, no crackles, wheezes or rubs.
- regular rate and rhythm, no abnl sounds and murmurs.
- pedal pulses w/ nl amplitude.
- no extremities edema and/or varicosities
- no neck/supraclavicular LAD
- gait and station normal
- no rashes
- no induration, subcutaneous nodules or tightening
- vibratory sense in both big toes absent, tested with tuning fork
- nl affect
257.2 Hypogonadism New Problem
250.02 Diabetes Mellitus Without Mention of Complication Type II or Unspecified Type Uncontrolled Not Improved
401.1 Benign essential hypertension Not Improved
305.1 Tobacco Use Disorder Not Improved
A1C HEMOGLOBIN A1C routinely request completion in 1 week
CMP routinely request completion in 1 week
MICROALBUMIN - QUANTITATIVE - URINE routinely request completion in 1 week
CBC routinely request completion in 1 week
LIPID PANEL routinely request completion in 1 week
TESTOSTERONE TOTAL routinely request completion in 1 week
MEDICATION MANAGEMENT: REFILL: Atenolol 100 mg 1 tab(s) PO once a day(Disp #: 30 / Refills: 11)
REFILL: metFORMIN 500 mg 1 tab(s) PO 2 times a day(Disp #: 60 / Refills: 5)
REFILL: simvastatin 40 mg 1 tab(s) PO once a day(Disp #: 30 / Refills: 5)
REFILL: Chantix Starter Pack 0.5 mg-1 mg Start: 0.5 mg PO qd x3 days, then 0.5 mg PO bid x4 days, then 1mg PO BID for 1 week.(Disp #: 1 / Refills: 0)
RESUME: metformin 500 mg was taken off of hold
RESUME: simvastatin 40 mg was taken off of hold
Plan Comments:Interval labs for diabetes and low testosterone and everything else as above.
Resume his blood pressure medications, cholesterol medication, and metformin.
Chantix for smoking cessation. Pros and cons discussed. Risks factors including risk of suicidal ideation discussed.
Coding This Encounter In ICD-10
The note above has included, in the Assessment section, the ICD-9 codes and their corresponding description. For your convenience, I am going to list them again in the table below, together with their ICD-10 equivalent(s). A short discussion will follow after the ICD-9/ICD-10 comparison table.
|257.2 - Hypogonadism New Problem||E29.1 - Testicular hypofunction|
|250.02 - Diabetes Mellitus Without Mention of Complication Type II or Unspecified Type Uncontrolled||E11.65 - Type 2 diabetes mellitus with hyperglycemia|
|272.2 - Hyperlipidemia||E78.2 - Mixed hyperlipidemia|
|401.1 - Benign essential hypertension||I10 - Essential (primary) hypertension|
|305.1 - Tobacco Use Disorder||F17.200 - Nicotine dependence, unspecified, uncomplicated
F17.210 Nicotine dependence, cigarettes, uncomplicated
In this example of an established patient with multiple chronic health issues coming for follow-up - or rather to resume care for his chronic issues, the ICD-10 coding is quite similar to ICD-9. A typical coder should have no difficulty in finding and using the appropriate ICD-10 codes for such an encounter. Most of the ICD-9 diagnoses above have a clear, unique ICD-10 equivalent, and there is no real need for increased specificity or detail in ICD-10, except for the last diagnosis. As illustrated in the table above, while ICD-9-CM lists only one code for Tobacco Use Disorder (305.1), in ICD-10-CM there is the option to select code F17.210 to specify that the fact that in this case, the tobacco dependence is to cigarettes, not to other tobacco products. Whether this degree of specificity would really add to the value of care for this patient is questionable, but that is an entirely different discussion...
I hope this helps you in your efforts to code better in ICD-10.
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