ggparker14
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Can anyone please help me with accurateness of final dx of respiratory arrest, hypoglycemia unspecified and PEA.
Would I be correct in coding 799.1, 250.80 & 427.9?
Thanks for any help.
HPI note reads: Patient presents with loss of consciousness, with chief complaint of being unresponsive, no palpable BP, aganol breathing and mottling to lower extremities. EMS arrived and patient was hardly breathing, and was non-responsive. They tried to get a glucose level and 2 different machines would not give a reading.
PE: Const: she appears distressed (nearly apic).
Head: Normocephalic and atraumatic. Right ear: exterrnal ear normal; Left ear: external ear normal.
Mouth/Throat: No oropharyngeal exudate.
Eyes: right eye exhibits no discharge. Left eye exhibits no discharge. L pupil is 8mm and not responsive; R pupil is 6 mm and not responsive.
Neck:normal range of motion. neck supple.
Cardiovascular: No heart sounds. Normal sinus on the monitor. No pules on arrival.
Pulmonary/Chest: She is in respiratory distress. She has no wheezes. She has no rales. Breathing only 2 times a minute.
Abdominal: Soft. Exhibits no distension. There is no tenderness.
Musculoskeletal: Exhibits no edema and no tenderness.
Neuro: Only sign of neuro activity is a rare spontaneous breath.
Skin: no erythema.
No pulse on arrival and hardly breathing. She is 100% O2. D50 ordered and given. Within 15 min. put is breathing on own. Patient has regained pulse.
At this time it appears the problem was severe prolonged hypoglycemia.
MDM: Final dx: Respiratory arrest, Hypoglycemia unspecified, PEA
Would I be correct in coding 799.1, 250.80 & 427.9?
Thanks for any help.
HPI note reads: Patient presents with loss of consciousness, with chief complaint of being unresponsive, no palpable BP, aganol breathing and mottling to lower extremities. EMS arrived and patient was hardly breathing, and was non-responsive. They tried to get a glucose level and 2 different machines would not give a reading.
PE: Const: she appears distressed (nearly apic).
Head: Normocephalic and atraumatic. Right ear: exterrnal ear normal; Left ear: external ear normal.
Mouth/Throat: No oropharyngeal exudate.
Eyes: right eye exhibits no discharge. Left eye exhibits no discharge. L pupil is 8mm and not responsive; R pupil is 6 mm and not responsive.
Neck:normal range of motion. neck supple.
Cardiovascular: No heart sounds. Normal sinus on the monitor. No pules on arrival.
Pulmonary/Chest: She is in respiratory distress. She has no wheezes. She has no rales. Breathing only 2 times a minute.
Abdominal: Soft. Exhibits no distension. There is no tenderness.
Musculoskeletal: Exhibits no edema and no tenderness.
Neuro: Only sign of neuro activity is a rare spontaneous breath.
Skin: no erythema.
No pulse on arrival and hardly breathing. She is 100% O2. D50 ordered and given. Within 15 min. put is breathing on own. Patient has regained pulse.
At this time it appears the problem was severe prolonged hypoglycemia.
MDM: Final dx: Respiratory arrest, Hypoglycemia unspecified, PEA