Answered: pneumonia was beginning to clear, but…

Understanding Health Insurance: A Guide to Billing and Reimbursement

14th Edition

ISBN:9781337679480

Author:GREEN

Publisher:GREEN

Chapter10: Coding Compliance, Clinical Documentation Improvement, And Coding For Medical Necessity

Section: Chapter Questions

Problem 3R

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Question #9: An 85-year-old woman has been coughing up some sputum, has not been eating well, sounds congested, and was admitted for a probable bronchitis. EKG showed atrial fibrillation with a controlled ventricular response, left bundle branch block. On examination, a sacral decubitus was noted on the left side. Admission chest x-ray showed cardiomegaly without any infiltrates. Repeat chest x-ray the following day revealed a right lower lobe bronchopneumonia. Cultures revealed Group A Streptococcus. Three days after admission, a chest x-ray reveled that the pneumonia was beginning to clear, but there was mid congestive heart failure with small bilateral pleural effusions. The patient was admitted and started on chest physical therapy (PT) and later intermittent positive pressure breathing (IPPB). Ancef was began as well as intravenous fluids. Betadine and sugar compound were begun for sacral decubitus. While she was on Ancef, her Macrodantin was held. Her cough was very poor. The chest physical therapy seemed to help ring it up. We had to add IPPB to help bring up the sputum. Initially, her second chest x-ray showed progression. Later there was improvement; but then the patient went into congestive heart failure, and lasix was begun. The patient did improve after several days, and she was able to sit on the side of the bed prior to discharge. She looked much better and was discharged home on bed rest, low-salt diet. Final Diagnoses: Right lower pneumonia due to Group A Streptococcus. Congestive heart failure. Sacral decubitus.

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