ICD-10: Coding Snapshot
CHIEF COMPLAINT: Buttock abscess.
HISTORY OF PRESENT ILLNESS: This patient is a 24-year-old African-American female who presented to the hospital with buttock pain. She started off with a little pimple on the buttock. She was soaking it at home without any improvement. She came to the hospital on the first. The patient underwent incision and drainage in the emergency department. She was admitted to the hospitalist service with elevated blood sugars. She has had positive blood cultures. Surgery is consulted today for evaluation.
PAST MEDICAL HISTORY: Diabetes type 2, poorly controlled
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS: Insulin, metformin, Glucotrol, and Lipitor. Insulin has been used for 3 years.
REVIEW OF SYSTEMS: Significant for pain in the buttock. Otherwise negative.
GENERAL: This is an overweight African-American female not in any distress.
VITAL SIGNS: She has been afebrile since admission. Vital signs have been stable. Blood sugars have been in the 200 range. HEENT: Normal to inspection. NECK: No bruits or adenopathy. LUNGS: Clear to auscultation.CV: Regular rate and rhythm. ABDOMEN: Protuberant, soft, and nontender. EXTREMITIES: No clubbing, cyanosis or edema. RECTAL EXAM: The patient has a drained abscess on the buttock cheek. There is some serosanguineous drainage. There is no longer any purulent drainage. The wound appears relatively clean. I do not see a lot of erythema.
ASSESSMENT AND PLAN: Left buttock abscess. Diabetes type 2. I do not believe surgical intervention is warranted. I have recommended some local wound care. Please see orders for details.
ICD-10-CM Code(s): L02.31 Cutaneous abscess of buttock
E11.9 Type 2 diabetes mellitus without complication
Z79.4 Long-term (current) use of insulin
Rationale: This patient has a buttock abscess and type 2 diabetes mellitus. There is no documentation that the abscess is due to the diabetes, so a combination code is not utilized. The patient is taking multiple drugs for her poorly controlled diabetes, including insulin. If a type 2 diabetic patient uses insulin, code Z79.4 should also be assigned.
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