A 70-year-old white female with pancreatic head carcinoma

A 70-year-old white female with pancreatic head carcinoma, confirmed by previous

percutaneous fine needle aspiration and determined to be unresectable. The patient was

also found to have probable metastasis to the lower lobe of the left lung, and she was

admitted now for resection of the lower lobe of the left lung. The patient had a history of

hypothyroidism and diet-controlled diabetes.

During hospitalization, the patient was continued on Levoxyl, and a “no-concentrated-

sweets diet” was ordered. The patient was taken to the operative suite, where a partial left

lower lobe lung resection was performed. Pathology from this procedure revealed

adenocarcinoma. The patient had an uneventful postoperative course and was discharged

with an appointment to see the oncologist to discuss radiation and chemotherapy options.

DISCHARGE DIAGNOSES: Pancreatic adenocarcinoma metastatic to left lung.

Hypothyroidism. Diet controlled type 2 diabetes mellitus.

PROCEDURE: Left lower lung lobe resection (open).

Assign ICD-10-CM and ICD-10-PCS codes: ___________, ____________,

_____________, _____________, ____________.


Assign and properly sequence the ICD-10-CM diagnosis and ICD-10-PCS procedure

codes for the following hospital inpatient cases.

A 94-year-old male was admitted to the hospital with a chief complaint of abdominal pain

and loss of weight. The patient had a history of coronary artery disease and myocardial

infarction. There is no history of coronary bypass surgery. The patient had a nebulizer at

home and takes metoprolol. These medications were continued during the patient’s stay.

Physical examination revealed abdomen to be tender to palpation in the left mid and

lower quadrants with some rebound. Bowel sounds were present, and there was no

guarding. Blood pressure was normal. Pulse, respirations, and temperature were normal.

During hospitalization, EKG showed sinus rhythm with myocardial changes of ischemia.

Sputum cytology was suggestive of adenocarcinoma, compatible with bronchoalveolar

growth. Chest x-ray showed metastatic lesions and chronic obstructive lung disease in

both lung fields. Barium enema showed adenocarcinoma of proximal sigmoid colon.

Abdominal series showed no evidence of obstruction, but moderate dilation of his

transverse colon was evident. Patient was seen in consultation, and it was decided to do

as little as possible at this time due to the patient’s age and lung conditions.

The patient agreed with this approach and requested discharge to home to receive hospice


DISCHARGE DIAGNOSES: Carcinoma of sigmoid colon. Probable metastatic

bronchogenic carcinoma. End-stage chronic obstructive lung disease. Coronary artery

disease. Previous myocardial infarction.

Assign ICD-10-CM and ICD-10-PCS codes: ___________, ___________

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