4 Practice Scenarios ICD-10-CM Inpatient: Newborn Respiratory Distress, HIV+ Labor, Bronchoscopy, Anemia GI Bleed

ICD-10 Coding Guide for Newborn Conditions and Labor Complications

Unlock accurate and compliant ICD-10-CM coding with this essential guide. Learn how to assign diagnosis codes for newborn respiratory conditions, labor complications, maternal HIV, and diagnostic procedures. We also explain the importance of issuing physician queries for better specificity and documentation accuracy.

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1. ICD-10 Coding: Newborn Delivered via C-Section with Respiratory Distress (TTN vs. RDS)

Question:

What are the correct diagnosis codes for a newborn delivered via C-section and admitted with respiratory distress due to transient tachypnea (TTN) vs. respiratory distress syndrome (RDS)?

Options:

a. Z38.01, P22.0, P22.1
b. Z38.00, P22.0, P22.1
c. Z38.01, P22.0, P22.2
d. Z38.00, P22.0, P22.2

Correct Answer: a. Z38.01, P22.0, P22.1

ICD-10 Code Descriptions:

• Z38.01 – Liveborn infant, delivered by cesarean

• P22.0 – Transient tachypnea of newborn (TTN)

• P22.1 – Respiratory distress syndrome of newborn (RDS)

Rationale:

Since the newborn was delivered via C-section, Z38.01 is the correct principal diagnosis. The newborn experienced respiratory distress due to TTN and/or RDS, requiring the use of both P22.0 and P22.1 as secondary diagnosis codes.

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2. ICD-10 Coding: G2P1 Mother in Labor with HIV Status and Normal Vaginal Delivery

Question:

What is the correct principal diagnosis (PDx) for a G2P1 patient admitted with labor pain, who has a history of HIV, and delivers a baby boy weighing 2560g via normal vaginal delivery?

Options:

a. O80, Z21
b. O98.72, Z21, Z37.0
c. O98.7, B20
d. Z21, O80

Correct Answer: b. O98.72, Z21, Z37.0

ICD-10 Code Descriptions:

• O98.72 – Human immunodeficiency virus [HIV] disease complicating childbirth

• Z37.0: Single live birth (mandatory outcome code).

• Z21 – Asymptomatic human immunodeficiency virus [HIV] infection status

Rationale:

The patient had HIV complicating labor, which makes O98.72 the correct PDx. Since the HIV is asymptomatic, we use Z21. Birth weight isn’t coded unless it has a clinical impact or complication during delivery.

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3. Procedure Coding: Bronchoscopy with BAL

Question:

What is the body part involved in a bronchoscopy with BAL (bronchoalveolar lavage)?

Options:

a. Trachea
b. Lung
c. Bronchus
d. Larynx

Correct Answer: c. Bronchus

Clarification: May also be "Lower Lobe Bronchus" depending on documentation.

ICD-10-PCS Code Reference:

• 0BJ – Inspection of bronchus

• 0BJK – Inspection of lower lobe bronchus, via natural or artificial opening

Rationale:

Although the fluid is retrieved from the alveoli, the lavage is performed through the bronchus. Coding should reflect the specific bronchial region involved, based on procedure documentation.

4. Physician Query Requirement for Anemia in GI Bleed Case

Question:

True or False: A query should be issued to clarify the type of anemia in a patient with GI bleeding and anemia when no etiology is identified, and the patient receives a blood transfusion.

Options:

a. True
b. False

Correct Answer: a. True

Rationale:

To code anemia accurately, especially in the context of a GI bleed with unknown cause, further specificity is needed (e.g., is it acute blood loss anemia, iron deficiency, etc.?). A physician query is necessary for clear documentation and appropriate code selection.