This is a Case Study for someone familiar with 3MEncoder.

This is a case study. Please answer the 5 questions below in bold letters. Week 2 Case2

LOCATION: Inpatient, Hospital

PATIENT: Sorrento Hernandez

PHYSICIAN: Rolando Ortez, MD

CHIEF COMPLAINT: Prematurity with respiratory difficulty.

HISTORY: This is a 30 weeks, 1 day gestation female infant with birth weight of 1808

grams. Mom is a 26-year-old gravida 2, now para 2 mom. Her blood type is O positive,

antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen

negative, HIV negative, GC negative, chlamydia negative, Group B Strep status

unknown. Mom’s MSAFP was elevated at 14.2 with a 1:180 risk for Down syndrome. No

neural tube defect. No amniocentesis performed. She was on prenatal vitamins. First

pregnancy went to 35 weeks without complications. He is doing well at 10 years of age;

however, he does have Noonan syndrome.

Although this is my first visit, I did attend the delivery of the baby. Spontaneous cry

noted, and Apgar score was 7 at 1 minute, with points off for color, tone, and grimace,

and then at 5 minutes, Apgar score of 8 with points off for grimace and tone. The infant

was then brought back to the NICU for further management. Baby’s face does look

somewhat dysmorphic with concerns for Noonan syndrome; very small posterior

pharyngeal space was noted with difficult intubation, and after several attempts, the

anesthesiology department was called and the infant was intubated. Throughout the

intubation attempts, standard procedure was followed and the baby tolerated the

attempts very well. The intubation was performed because of concerns of

hypoventilation noted on exam with decreased breath sounds bilaterally as well as

increased work of breathing.

Umbilical artery catheter was also placed without difficulty. First blood sugar did come

back at 23, a peripheral IV was placed promptly, and 2 cc/kilo of D10 was given along

with placing the infant on D10 at 80 cc/kilo. Second blood sugar has come back

elevated. Chest x-ray is obtained, as well as abdominal films, and shows good

placement of the UAC at T7, and the endotracheal tube is also in good placement and

is a 3.02. The OG has been advanced. The lung fields do show significant granularity

present. No pneumothorax, no cardiomegaly. Blood gas is 7.32, PCO2 of 50, PO2 of 100

and that is on a setting of 22/4, rate of 60% and 80% FIO2.

PHYSICAL EXAMINATION: Currently is intubated, her weight is 1808 grams. OFC is

30.5 cm, length is 39.4 cm. Heart rate is in the 130s to 140s. Respiratory rate is at 60 on

the ventilator.

O2 sat. is in the mid 90s. Blood pressure is right arm, 67/34 with a mean of 46, right leg

67/32 with a mean of 44.

Mild splitting of the cranial sutures is noted along with open posterior and anterior

fontanel. Red reflex ×2. Eyes appear to have hypertelorism present and questionable

epicanthal folds along with some down-slanting palpebral fissures. Ears appear to be

low set and posteriorly rotated. Palate is intact. There is a small retropharyngeal space.

Clavicles are intact. I do not appreciate any webbing on the neck. Nipples, questionable,

mildly wide spaced. Lungs at this time are clear to auscultation. She has good

symmetric aeration; minimal chest rise noted. Prior to that, lungs were remarkable for

decreased aeration with crackles. Heart is regular rate and rhythm, no murmurs noted.

Femoral pulses palpable, cap refill less than 2 seconds. Abdomen is without

hepatosplenomegaly, three-vessel cord. Genitourinary: Normal female. Extremities:

Adequate range of motion, no contractures or hip abnormalities noted. Skin is ruddy in

complexion. Neurologic Exam: Hypotonia diffusely.

Developmental assessment: No breast buds, soft pinna with minimal recoil, no creases

on the feet, consistent with a 30-week preterm infant.

IMPRESSION

1. Premature female infant.

2. Respiratory distress due to hyaline membrane disease as well as a component of

hypoventilation secondary to maternal elevated magnesium.

3. Observation for sepsis.

4. Maternal hypermagnesemia with elevated magnesium in the infant as well.

5. Family history of Noonan syndrome in an older brother.

PLAN: Admission to the NICU. Intubation has been performed, and she is on

mechanical ventilation. Will go ahead with the surfactant therapy per protocol, close

cardiorespiratory monitoring and monitoring of blood gases and chest x-rays. NPO

status, and she will be on D10 with 0.94 mEq of calcium gluconate added to run at 80

cc/kilo/day. Ampicillin and gentamicin administered per protocol. Blood cultures have

been obtained as well as a CBC, magnesium level, and further glucose monitoring. She

will also need chromosomal testing, and that will be drawn in the near future. Also, head

ultrasound at 6 days of life will need to be performed. I have not talked with the mother.

Her condition has deteriorated post cesarean section and she is not available at this

time. I have talked in detail with the father in regard to the above, including possibility of

further deterioration prompting transfer to another facility. All of his questions have been

addressed.

Abstracting & Coding Questions:

1. Was this the initial or subsequent visit?

2. Does the age of the patient affect CPT code selection?

3. What two factors affect diagnosis code assignment?

4. What CPT code(s) would be reported for this case?

5. What ICD-10-CM code(s) would be reported for this case?