Chapter 5: Coding Practice: Hospital Outpatient Department

A 54-year-old male previously diagnosed with atherosclerotic heart disease of native coronary artery with unstable angina pectoris underwent scheduled right and left cardiac catheterization as an outpatient. The patient has no past history of previous coronary artery bypass graft (CABG) surgery. Cardiac catheterization results revealed 40 percent blockage of the right coronary artery, 70 percent blockage of the left main coronary artery, and 80 percent blockage of the left anterior descending coronary artery. Surgical intervention options to treat the blockages were discussed with the patient, and the patient will be admitted in two days to undergo triple CABG. DIAGNOSIS: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris

I25.110

A 62-year-old male patient with known congestive heart failure registered for outpatient services at the heart failure clinic and receives lifestyle modification counseling about his diet and activities. He received instruction from the dietician about following a low-sodium, low-fat diet, and he was also counseled to avoid tobacco and heavy alcohol use. His current medications were reviewed, and his diuretic dosage was adjusted. DIAGNOSES: Congestive heart failure Dietary counseling

I50.9, Z71.3

A 42-year-old male patient diagnosed with systemic lupus erythematosus received a scheduled transfusion of erythrocytes and platelets in the ambulatory transfusion clinic. DIAGNOSIS: Systemic lupus erythematosus

M32.9

A 45-year-old female patient registered as an outpatient to undergo scheduled hemodialysis. The patient was born with just one kidney, which failed when she was 30 years old. She previously underwent a kidney transplant, which also failed. Currently, dialysis is her only option for her end-stage renal failure as she awaits the availability of another kidney for transplant. The hemodialysis takes three hours and is uneventful. DIAGNOSES: Kidney transplant failure Renal agenesis, unilateral End-stage renal failure Dependence on renal dialysis Awaiting organ transplant Complication following kidney transplant (external cause surgical complication)

T86.12, Q60.0, N18.6, Z99.2, Z76.82, Y83.0

A 39-year-old female patient undergoes a screening electrocardiogram (EKG) as an outpatient. She has a family history of cardiovascular disease. EKG results were negative. The nonspecific T-wave changes illustrated on the EKG were explained to the patient as probably due to anxiety and positional changes. DIAGNOSES: Encounter for screening for cardiovascular disorders Family history of cardiovascular disease

Z13.6, Z82.49