OUTPATIENT ICD-9 AND ICD-10-CM CODING

Medical Specialty: Nephrology - Urology

Microscopic hematuria

Description:

Nephrology office visit for followup of microscopic hematuria.

HISTORY OF PRESENT ILLNESS:

The patient is a 78 year-old woman here because of recently discovered microscopic hematuria. History of present illness occurs in the setting of a recent check up, which demonstrated red cells and red cell casts on a routine evaluation. The patient has no new joint pains; however, she does have a history of chronic degenerative joint disease. She does not use nonsteroidal agents. She has had no gross hematuria and she has had no hemoptysis.

REVIEW OF SYSTEMS:

No chest pain or shortness of breath, no problem with revision. The patient has had decreased hearing for many years. She has no abdominal pain or nausea or vomiting. She has no anemia. She has noticed no swelling. She has no history of seizures.

PAST MEDICAL HISTORY:

Significant for hypertension and hyperlipidemia. There is no history of heart attack or stroke. She has had bilateral simple mastectomies done 35 years ago. She has also had one-third of her lung removed for carcinoma (probably an adeno CA related to a pneumonia). She also had hysterectomy in the past.

SOCIAL HISTORY:

She is a widow. She does not smoke.

MEDICATIONS:

  • Dyazide one a day.
  • Pravachol 80 mg a day in the evening.
  • Vitamin E once a day.
  • One baby aspirin per day.

FAMILY HISTORY:

Unremarkable.

PHYSICAL EXAMINATION:

She looks younger than her stated age of 78 years. She was hard of hearing, but could read my lips. Respirations were 16. She was afebrile. Pulse was about 90 and regular. Her gait was normal. Blood pressure is 140/70 in her left arm seated. HEENT: She had arcus cornealis. The pupils were equal. The sclerae were not icteric. The conjunctivae were pink. NECK: The thyroid is not palpated. No nodes were palpated in the neck. CHEST: Clear to auscultation. She had no sacral edema. CARDIAC: Regular, but she was tachycardic at the rate of about 90. She had no diastolic murmur. ABDOMEN: Soft, and nontender. I did not palpate the liver. EXTREMITIES: She had no appreciable edema. She had no digital clubbing. She had no cyanosis. She had changes of the degenerative joint disease in her fingers. She had good pedal pulses. She had no twitching or myoclonic jerks.

LABORATORY DATA:

The urine, I saw 1-2 red cells per high power fields. She had no protein. She did have many squamous cells. The patient has creatinine of 1 mg percent and no proteinuria. It seems unlikely that she has glomerular disease; however, we cannot explain the red cells in the urine.

PLAN:

To obtain a routine sonogram. I would also repeat a routine urinalysis to check for blood again. I have ordered a C3 and C4 and if the repeat urine shows red cells, I will recommend a cystoscopy with a retrograde pyelogram.

  • 599.72; R31.2
  • 599.71; R31.0
  • 599.72; R31.1
  • 599.70; R31.9

Answer

Renal mass - CT-Guided biopsy

Description:

CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.

EXAM:

CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.

REASON FOR EXAM:

This 60 year-old female who was found to have a solid indeterminate mass involving the inferior pole of the right kidney was referred for percutaneous biopsy under CT guidance at the request of Dr. X.

PROCEDURE:

The procedure risks and possible complications including, but not limited to severe hemorrhage which could result in emergent surgery, were explained to the patient. The patient understood. All questions were answered, and informed consent was obtained. With the patient in the prone position, noncontrasted CT localization images were obtained through the kidney. Conscious sedation was utilized with the patient being monitored. The patient was administered divided dose of Versed and fentanyl intravenously.

Following sterile preparation and local anesthesia to the posterior aspect of the right flank, an 18-gauge co-axial Temno-type needle was directed into the inferior pole right renal mass from the posterior oblique approach. Two biopsy specimens were obtained and placed in 10% formalin solution. CT documented needle placement. Following the biopsy, there was active bleeding through the stylet, as well as a small hematoma about the inferior aspect of the right kidney posteriorly. I placed several torpedo pledgets of Gelfoam through the co-axial sheath into the site of bleeding. The bleeding stopped. The co-axial sheath was then removed. Bandage was applied. Hemostasis was obtained. The patient was placed in the supine position. Postbiopsy CT images were then obtained. The patient's hematoma appeared stable. The patient was without complaints of pain or discomfort. The patient was then sent to her room with plans of observing for approximately 4 hours and then to be discharged, as stable. The patient was instructed to remain at bedrest for the remaining portions of the day at home and patient is to followup with Dr. Fieldstone for the results and follow-up care.

FINDINGS:

Initial noncontrasted CT localization images reveals the presence of an approximately 2.1 cm cortical mass involving the posterior aspect of the inferior pole of the right kidney. Images obtained during the biopsy reveals the cutting portion of the biopsy needle to extend through the mass. Images obtained following the biopsy reveals the development of a small hematoma posterior to the right kidney in its inferior pole adjacent to the mass. There are small droplets of air within the hematoma. No hydronephrosis is identified.

CONCLUSION:

  • Percutaneous biopsy of inferior pole right renal mass under computed tomography guidance with specimen sent to laboratory in 10% formalin solution.
  • Development of a small hematoma adjacent to the inferior pole of the right kidney with active bleeding through the biopsy needle stopped by tract embolization with Gelfoam pledgets.
  • 189.0, 998.11; C64.1, N99.62; 50592
  • 593.9, 998.11; N28.9, N99.61; 50200, 77012
  • 223.0, 998.11; D30.01, N99.820; 50250
  • 593.2, 998.11; N28.1, N99.821; 50290, 77013

Answer

UTI - Renal US

Description:

Bilateral renal ultrasound.

EXAM:

Bilateral renal ultrasound.

CLINICAL INDICATION:

UTI.

TECHNIQUE:

Transverse and longitudinal sonograms of the kidneys were obtained.

FINDINGS:

The right kidney is of normal size and echotexture and measures 5.7 x 2.2 x 3.8 cm. The left kidney is of normal size and echotexture and measures 6.2 x 2.8 x 3.0 cm. There is no evidence for HYDRONEPHROSIS or PERINEPHRIC fluid collections. The bladder is of normal size and contour. The bladder contains approximately 13 mL of urine after recent voiding. This is a small postvoid residual.

IMPRESSION:

Normal renal ultrasound. Small postvoid residual.

  • 599.60; N13.9; 76705
  • 591; N13.30; 76770
  • 599.0; N39.0; 76775
  • 593.1; N28.81; 76776

Answer

Ureteral stone

Description:

Left flank pain, ureteral stone.

REASON FOR CONSULTATION:

Left flank pain, ureteral stone.

BRIEF HISTORY:

The patient is a 76 year-old female who was referred to us from Dr. X for left flank pain. The patient was found to have a left ureteral stone measuring about 1.3 cm in size per the patient's history. The patient has had pain in the abdomen and across the back for the last four to five days. The patient has some nausea and vomiting. The patient wants something done for the stone. The patient denies any hematuria, dysuria, burning or pain. The patient denies any fevers.

PAST MEDICAL HISTORY:

Negative.

PAST SURGICAL HISTORY:

Years ago she had surgery that she does not recall.

MEDICATIONS:

None.

ALLERGIES:

None.

REVIEW OF SYSTEMS:

Denies any seizure disorder, chest pain, denies any shortness of breath, denies any dysuria, burning or pain. She admits to some nausea and vomiting, but is doing better.

PHYSICAL EXAMINATION:

VITAL SIGNS:

The patient is afebrile. Vitals are stable.

HEART:

Regular rate and rhythm.

ABDOMEN:

Soft, left-sided flank pain and left lower abdominal pain.

The rest of the exam is benign.

LABORATORY DATA:

White count of 7.8, hemoglobin 13.8, and platelets 234,000. The patient's creatinine is 0.92.

ASSESSMENT:

  • Left flank pain.
  • Left ureteral stone.
  • Nausea and vomiting.

PLAN:

Plan for laser lithotripsy tomorrow. Options such as watchful waiting, laser lithotripsy, and shockwave lithotripsy were discussed. The patient has a pretty enlarged stone. Failure of the procedure if the stone is significantly impacted into the ureteral wall was discussed. The patient understood that the success of the surgery may be or may not be 100%, that she may require shockwave lithotripsy if we are unable to get the entire stone out in one sitting. The patient understood all the risk, benefits of the procedure and wanted to proceed. Need for stent was also discussed with the patient. The patient will be scheduled for surgery tomorrow. Plan for continuation of the antibiotics, obtain urinalysis and culture, and plan for KUB to evaluate for the exact location of the stone prior to surgery tomorrow.

  • 592.0, 787.04; N20.0, R11.14
  • 592.9, 787.02; N20.9, R11.0
  • 593.4, 787.03; N13.8, R11.11
  • 592.1, 787.01; N20.1, R11.2

Answer

Hydronephrosis

Description:

Marked right hydronephrosis without hydruria.

CHIEF COMPLAINT:

Right hydronephrosis.

HISTORY OF PRESENT ILLNESS:

The patient is a 56 year-old female who has a history of uterine cancer, breast cancer, mesothelioma. She is scheduled to undergo mastectomy in two weeks. In September 1999, she was diagnosed with right breast cancer and underwent lumpectomy and axillary node dissection and radiation. Again, she is scheduled for mastectomy in two weeks. She underwent a recent PET scan for Dr. X, which revealed marked hydronephrosis on the right possibly related to right UPJ obstruction and there is probably a small nonobstructing stone in the upper pole of the right kidney. There was no dilation of the right ureter noted. Urinalysis today is microscopically negative.

PAST MEDICAL HISTORY:

Uterine cancer, mesothelioma, breast cancer, diabetes, hypertension.

PAST SURGICAL HISTORY:

Lumpectomy, hysterectomy.

MEDICATIONS:

Diovan HCT 80/12.5 mg daily, metformin 500 mg daily.

ALLERGIES:

None.

FAMILY HISTORY:

Noncontributory.

SOCIAL HISTORY:

She is retired. Does not smoke or drink.

REVIEW OF SYSTEMS:

I have reviewed his review of systems sheet and it is on the chart.

PHYSICAL EXAMINATION:

Please see the physical exam sheet I completed. Abdomen is soft, nontender, nondistended, no palpable masses, no CVA tenderness.

IMPRESSION AND PLAN:

Marked right hydronephrosis without hydruria. She believes she had a CT scan of the abdomen and pelvis at Hospital in 2005. I will try to obtain the report to see if the right kidney was evaluated at that time. She will need evaluation with an IVP and renal scan to determine the point of obstruction and renal function of the right kidney. She is quite anxious about her upcoming surgery and would like to delay any evaluation of this until the surgery is completed. She will call us back to schedule the x-rays. She understands the great importance and getting back in touch with us to schedule these x-rays due to the possibility that it may be somehow related to the cancer. There is also a question of a stone present in the kidney. She voiced a complete understanding of that and will call us after she recovers from her surgery to schedule these tests.

  • 590.80; N12
  • 593.5; N13.4
  • 591; N13.30
  • 590.80; N13.6

Answer

Foul-Smelling Urine

Description:

Foul-smelling urine and stomach pain after meals.

CHIEF COMPLAINT:

Foul-smelling urine and stomach pain after meals.

HISTORY OF PRESENT ILLNESS:

Stomach pain with most meals x one and a half years and urinary symptoms for same amount of time. She was prescribed Reglan, Prilosec, Pepcid, and Carafate at ED for her GI symptoms and Bactrim for UTI. This visit was in July 2013.

REVIEW OF SYSTEMS:

HEENT:

No headaches. No visual disturbances, no eye irritation. No nose drainage or allergic symptoms. No sore throat or masses. Respiratory: No shortness of breath. No cough or wheeze. No pain. Cardiac: No palpitations or pain. Gastrointestinal: Pain and cramping. Denies nausea, vomiting, or diarrhea. Has some regurgitation with gas after meals. Genitourinary: "Smelly" urine. Musculoskeletal: No swelling, pain, or numbness.

MEDICATION ALLERGIES:

No known drug allergies.

PHYSICAL EXAMINATION:

General:

Unremarkable.

HEENT:

PERRLA. Gaze conjugate.

Neck:

No nodes. No thyromegaly. No masses.

Lungs:

Clear.

Heart:

Regular rate without murmur.

Abdomen:

Soft, without organomegaly, without guarding or tenderness.

Back:

Straight. No paraspinal spasm.

Extremities:

Full range of motion. No edema.

Neurologic:

Cranial nerves II-XII intact. Deep tendon reflexes 2+ bilaterally.

Skin:

Unremarkable.

LABORATORY STUDIES:

Urinalysis was done, which showed blood due to her period and moderate leukocytes.

ASSESSMENT:

  • UTI.
  • GERD.
  • Dysphagia.

PLAN:

  • Cipro 500 mg b.i.d. x five days. Ordered BMP, CBC, and urinalysis with microscopy.
  • Omeprazole 20 mg daily and famotidine 20 mg b.i.d.
  • Prescriptions same as #2. Also referred her for a barium swallow series to rule out a stricture.
  • R82.90, 530.3, 787.1; 791.9, K22.2, R12
  • 599.0, 530.81, 787.20; N39.0, K21.9, R13.10
  • 599.70, 530.5, 787.20; R31.9, K22.4, R13.10
  • 791.7, 530.9, 787.29; R82.99, K22.9, R13.19

Answer

Renal stone - Shockwave lithotripsy

Description:

Right shockwave lithotripsy.

PREOPERATIVE DIAGNOSIS:

Right renal stone.

POSTOPERATIVE DIAGNOSIS:

Right renal stone.

PROCEDURE:

Right shockwave lithotripsy.

ANESTHESIA:

LMA.

ESTIMATED BLOOD LOSS:

Minimal. The patient was given antibiotics preoperatively.

HISTORY:

This is a 47 year-old male who presented with right renal stone and right UPJ stone. The right UPJ stone was removed using ureteroscopy and laser lithotripsy and the stone in the kidney. The plan was for shockwave lithotripsy. The patient had duplicated system on the right side. Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE was discussed. Options such as watchful waiting, passing the stone on its own, and shockwave lithotripsy were discussed. The patient wanted to proceed with the shockwave to break the stone into small pieces as possible to allow the stones to pass easily. Consent was obtained.

DETAILS OF THE OPERATION:

The patient was brought to the OR. Anesthesia was applied. The patient was placed in the supine position. Using Dornier lithotriptor total of 2500 shocks were applied. Energy levels were slowly started at O2 increased up to 7; gradually the stone seem to have broken into smaller pieces as the number of shocks went up. The shocks were started at 60 per minute and slowly increased up to 90 per minute. The patient's heart rate and blood pressure were stable throughout the entire procedure.

The patient was brought to recovery in stable condition. The plan was for the patient to follow up with us and plan for KUB in about two to three months.

  • 592.9; N20.9; 50592
  • 593.2; N28.1; 50592
  • 592.1; N20.1; 50590
  • 592.0; N20.0; 50590

Answer

Overactive Bladder

Description:

Overactive bladder with microscopic hematuria.

REASON FOR VISIT:

Overactive bladder with microscopic hematuria.

HISTORY OF PRESENT ILLNESS:

The patient is a 56 year-old noted to have microscopic hematuria with overactive bladder. Her cystoscopy performed was unremarkable. She continues to have some episodes of frequency and urgency mostly with episodes during the day and rare at night. No gross hematuria, dysuria, pyuria, no other outlet obstructive and/or irritative voiding symptoms. The patient had been previously on Ditropan and did not do nearly as well. At this point, what we will try is a different medication. Renal ultrasound is otherwise unremarkable, notes no evidence of any other disease.

IMPRESSION:

Overactive bladder with microscopic hematuria most likely some mild atrophic vaginitis is noted. She has no other significant findings other than her overactive bladder, which had continued. At this juncture what I would like to do is try a different anticholinergic medication. She has never had any side effects from her medication.

PLAN:

The patient will discontinue Ditropan. We will start Sanctura XR and we will follow up as scheduled. Otherwise we will continue to follow her urinalysis over the next year or so.

  • 596.4, 599.72; N31.2, R31.2
  • 596.59, 599.71; N31.9, R31.0
  • 596.52, 599.70; N31.8, R31.9
  • 596.51, 599.72; N32.81, R31.2

Answer

Neurogenic bladder

Description:

Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week.

HISTORY OF PRESENT ILLNESS:

The patient presents today as a consultation from Dr. ABC's office regarding the above. He has history of neurogenic bladder, and on intermittent self-catheterization 3 times a day. However, June 24, 2008, he was seen in the ER, and with fever, weakness, possible urosepsis. He had a blood culture, which was positive for Staphylococcus epidermidis, as well as urine culture noted for same bacteria. He was treated on IV antibiotics, Dr. XYZ also saw the patient. Discharged home. Not taking any antibiotics. Today in the office, the patient denies any dysuria, gross hematuria, fever, chills. He is catheterizing 3 times a day, changing his catheter weekly. Does have history of renal transplant, which has been followed by Dr. X and is on chronic steroids. Renal ultrasound, June 23, 2008, was noted for mild hydronephrosis of renal transplant with fluid in the pericapsular space. Creatinine, July 7, 2008 was 2.0, BUN 36, and patient tells me this is being followed by Dr. X. No interval complaints today, no issues with catheterization or any gross hematuria.

IMPRESSION:

  • Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week, we again reviewed the technique of catheterization, and he has no issues with this.
  • Recurrent urinary tract infection, in a patient who has been hospitalized twice within the last few months, he is on steroids for renal transplant, which has most likely been overall reducing his immune system. He is asymptomatic today. No complaints today.

PLAN:

Following a detailed discussion with the patient, we elected to proceed with intermittent self-catheterization, changing catheter weekly, and technique has been discussed as above. Based on the recent culture, we will place him on Keflex nighttime prophylaxis, for the next three months or so. He will call if any concerns. Follow up as previously scheduled in September for re-assessment. All questions answered. The patient is seen and evaluated by myself.

  • A. 596.59, V42.89, V58.64; N31.9, Z94.89, Z79.1
  • B. 596.54, V42.0, V58.65; N31.9, Z94.0, Z79.52
  • C. 596.55, V44.59, V58.61; N36.44, Z93.59, Z79.01
  • D. 596.89, V42.0, V58.67; N32.89, Z94.0, Z79.4

Answer

ESRD

Description:

Patient with end-stage renal disease secondary to hypertension, a reasonable candidate for a kidney transplantation.

I had the pleasure of seeing the patient in the transplant clinic today. As you know, he is a 41-year-ole black male who was diagnosed with end-stage renal disease secondary to hypertension. He has been on hemodialysis since 02/2008. He is in my clinic for evaluation for cadaver kidney transplantation.

PAST MEDICAL/SURGICAL HISTORY: Briefly, his past medical history is significant for hypertension of more than 5 years, asthma, and he has been on Advair and albuterol. He was diagnosed with renal disease in 02/2008 and has since been on hemodialysis since 02/2008. His past surgical history is only significant for left AV fistula on the wrist done in 04/2008. He still has urine output. He has no history of blood transfusion.

PERSONAL AND SOCIAL HISTORY: He is a nonsmoker. He denies any alcohol. No illicit drugs. He used to work as the custodian at the nursing home, but now on disability since 03/2008. He is married with 2 sons, ages 5 and 17 years old.

FAMILY HISTORY:

No similar illness in the family, except for hypertension in his one sister and his mom, who died at 61 years old of congestive heart failure. His father is 67 years old, currently alive with asthma. He also has one sister who has hypertension. The rest of the 6 siblings are alive and well.

ALLERGIES:

No known drug allergies.

MEDICATIONS:

Singulair 10 mg once daily, Cardizem 365 mg once daily, Coreg 25 mg once daily, hydralazine 100 mg three times a day, Lanoxin 0.125 mg once daily, Crestor 10 mg once daily, lisinopril 10 mg once daily, Phoslo 3 tablets with meals, and Advair 250 mg inhaler b.i.d.

REVIEW OF SYSTEMS:

Significant only for asthma. No history of chest pain normal MI. He has hypertension. He occasionally will develop colds especially with weather changes. GI: Negative. GU: Still making urine about 1-3 times per day. Musculoskeletal: Negative. Skin: He complains of dry skin. Neurologic: Negative. Psychiatry: Negative. Endocrine: Negative. Hematology: Negative.

PHYSICAL EXAMINATION:

A pleasant 41 year-old African-American male who stands 5 feet 6 inches and weighs about 193 pounds. HEENT: Anicteric sclera, pink conjunctiva, no cervical lymphadenopathy. Chest: Equal chest expansion. Clear breath sounds. Heart: Distinct heart sounds, regular rhythm with no murmur. Abdomen: Soft, nontender, flabby, no organomegaly. Extremities: Poor peripheral pulses. No cyanosis and no edema.

ASSESSMENT AND PLAN:

This is a 49-year old male who was diagnosed with end-stage renal disease secondary to hypertension. He is on hemodialysis since 02/2008. Overall, I think that he is a reasonable candidate for a kidney transplantation and should undergo a complete pretransplant workup with pulmonary clearance because of his chronic asthma. Other than that, I think that he is a reasonable candidate for transplant.

I would like to thank you for allowing me to participate in the care of your patient. Please feel free to contact me if there are any questions regarding his case.

  • 403.91, 585.6, V45.11; I12.0, N18.6, Z99.2
  • 403.11, 585.5, V45.12; I12.0, N18.5, Z91.15
  • 404.02, 586, V45.87; I12.9, N19, Z98.85
  • 403.01, 584.9, V46.8; I12.9, N17.9, Z99.89

Answer