Using the coding techniques you have learned, carefully read through

Using the coding techniques you have learned, carefully read through the case study and determine the most accurate diagnosis code(s). Remember, check the chapter-specific, subchapter-specific, and category-specific notations within the Tabular List. Then, determine the most accurate ICD-10-PCS procedure code(s). WINTER HILLS MEDICAL CENTER 753 VENTURA BYPASS • CENTRAL, FL 32811 • 407-555-4798 PATIENT: ALBESSI, CARLINA ACCOUNT/EHR #: A018-042365997 DATE: 04/18/23 Attending Physician: Harriet Sarreh, MD Four months ago, this 18-year-old female was hospitalized due to epigastric abdominal pain, lack of appetite and weight loss. She was diagnosed with Crohn’s disease. Hepatic biopsy, that was performed during this hospitalization, showed evidence of an overlap syndrome (cholangitis/hepatitis). She was initially treated with Cortisone and Azathioprine. During the last 4 months, the patient was hospitalized 7 times. She had recurrent attacks of infective cholangitis. She was treated with antibiotics and papillotomy through ERCP. Later on, laparoscopic cholecystectomy was carried out. During postsurgery, after a short period of wellness, the patient suffered from an abdominal pain. Reappearance interpreted, at the beginning, as a light pancreatitis (treated with antibiotic therapy). Subsequently, persisting painful crises were observed despite blood tests substantial stability. Therefore, a MR cholangiography was carried out and revealed an appearance of intrahepatic- and extrahepatic bile duct dilatation, evident also at common bile duct level where the picture seems revealing a relevant stenosis. A biliary stent was placed during ERCP in order to guarantee bile ducts patency. After the procedure, the patient was hospitalized twice due to ascending cholangitis. US showed an occlusion of the biliary stent with overlapped cholangitis. Following the US, an antibiotic therapy has been started with Meropenem, and an ERCP was carried out. ERCP didn’t show any materials obstructing the stent. Biliary washing was within normal limits. Today’s admission is due to reappearance of epigastric pain in the attempt to interrupt the antibiotic therapy. Personal History: 1 year old: Roseola. 4 years old: Salmonellosis. 6 years old: Varicella. Clinical History: Four months ago hospitalization following epigastric abdominal pain, at times postprandial, from 2 weeks linked to ingravescent lack of appetite and weight loss (3 kg in a month). During hospitalization the most significant medical tests carried out were – Ultrasound scan and MR cholangiography with evidence of bile ducts dilatation. – Endoscopy of the bowel with evidence of terminal ileitis and colitis with histologic diagnosis of Crohn’s disease. – Hepatic biopsy with evidence of an overlap syndrome picture (cholangitis/hepatitis). – Lab examinations with finding of elevated levels of IgG (2937) and positive results of C-ANCA antibodies. During this hospitalization, bringing back the antibiotic therapy. Abdomen ultrasound scan with evidence of common bile duct dilatation. Therapy started with Cortisone 50 mg IM and Azathioprine 100 mg IV. Her condition progressively improved and allowed her discharge with the following therapy: Augmentin (1 g × 3); Ciproxin (500 mg × 2); Folina 5 mg (1 tablet every other day); Deltacortene (15 mg daily); Azathioprine (100 mg daily); Lansoprazole (30 mg daily); ursodesossicolic acid (300 mg 4 times a day). Differential Diagnosis: Primary Sclerosing Cholangitis (PSC) with either Crohn’s disease (CD) or more likely Ulcerative colitis (UC) pancolitis Harriet Sarreh, MD

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