ICD-10: Coding Snapshot
Chief Complaint: Increased work of breathing
Trish is a three-month-old girl brought in by her mom. She started getting ill about a week ago. Her mom says she has been using the vaporizer and thinks it has helped. The patient’s cough has gradually worsened and three days ago she had a significant increase in her cough. She also has increased congestion. Two days ago she was brought in and was given Xopenex 2 puffs every 4 to 6 hours, but mom states this has not helped. Today, she had increased work of breathing and gagging with feedings. She began to have emesis with feedings today with a fever of 101 degrees, so mom has brought her back in.
ROS: Otherwise negative.
Medications: Other than Xopenex recently given, none.
Family history: Mother, father, and brother all have asthma. Father smokes around child in and out of house.
Examination: VSS, but patient fussy. Respiratory rate between 36 and 44, patient is saturating 100% on one-half liter, and 89% on room air. Non-toxic child, but increased work of breathing. HEENT: PERRLA. TMs intact and clear. CHEST: symmetrical expansion and retractions. LUNGS: The patient has diffuse crackles bilaterally, with some wheezing, no rales, or rhonchi. CARDIO: 2/6 vibratory ejection murmur. ABDOMEN: Soft, nontender. NABS
LABS in Urgent Care today: CBC, which shows a white blood cell count of 20.8 with a hemoglobin of 10.7, hematocrit of 31.3 with platelet count of 715,000 with neutrophils, 2 bands, and 7% monocytes. UA obtained is negative. CRP was noted to be 2.0. Chest e-ray show no significant change since previous X-ray, but does indicate bronchial thickening.
ASSESSMENT: Acute bronchiolitis. Patient will be admitted and put on bronchiolitis pathway providing this patient with aggressive suctioning and supplemental oxygen as needed. Due to strong family history of asthma and exposure to smoke, we will monitor the patient closely.
J21.9 Acute bronchiolitis, unspecified
Z77.22 Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic
Z82.5 Family history of asthma and other chronic lower respiratory diseases
Rationale: Since the child is diagnosed with acute bronchiolitis, the coughing, work of breathing, and posttussive emesis is not coded separately. The family history of asthma and the exposure to smoke are both important to code as they relate to the patient’s respiratory issue.