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: ___________, ___________