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proper coding for this sample report?

  1. #1
    Atlanta Perimeter
    Default proper coding for this sample report?
    Medical Coding Books
    A 34 y/o male was admitted to the hospital with a three day history of visual changes in his right eye including intermittent blurring, light flashes, and “seeing spots”. The physician documented the following in the H&P: history of HIV currently on HAART; Pneumocystis carinii pneumonia in 2006 labs one month ago showed increased viral load and CD4 count of 100. Severe lumbar degenerative disc disease with narcotic dependence was also noted. The Ophthalmology service was consulted and diagnosed retinitis. Eye cultures collected on admission reported Cytomegalovirus. The patient was treated with IV Gancyclovir and Similasan eye drops. Duragesic patch was placed for management of chronic back pain, and the patient was instructed to discontinue all previously prescribed pain medications. A PICC was placed and the patient was discharged to home health to continue IV antivirals. Final diagnoses per DS: CMV, DDD.

    Principal diagnosis code:

    Secondary diagnosis code(s):

    ICD-9-CM procedure code(s):


    I was informed to code 042 for the principal dx. My opinion was the pt came in for an eye problem (CMV) and not the HIV. I get confused with that part. The secondary dx also confused me and how to properly list them. I chose the CMV,DDD as secondary. I also coded the retinitis (would that be too much)? Should I leave that one out due to signs and symptoms? I coded the PICC line insertion as my procedure code. Don't know if that was correct. If I missed any related secondary dx, please inform me. Any help on this doozie would be greatly appreciated. Don't worry about the DRG portion if you don't have access or understand it.


  2. #2
    Columbia, MO
    I answered this under general discussion, also you now say this is a sample report, Is this for a class or test question?

    Debra A. Mitchell, MSPH, CPC-H

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