need to learn case CDI- how to solve step by step
I have read CDI pocket guide and I do know how to find PDx and also DRG from ICD DRG book but I have no idea how to answer step by step , trying to get remote jobs, and this is last year one remote company asked me to do 20 cases like this with any open resources. But I want to learn how to do this step by step, without using any resource of internet.
case:
HPI: 75-year-old male presented to the ER for difficulty breathing, cough with green sputum, and fever.
ER assessment: “Audible wheezing, intercostal retractions and tachypnea. Only able to speak 1-2 words at a time.”
Vital signs on arrival to ER: T 101.9 F, HR 113, BP 100/52, RR 28, O2 saturation 82% on room air
Labs: WBC 23.0 with 90% Neutrophils, Sodium 133 (repeat 133), BUN/Cr/GFR 30/1.9/45 (repeat 22/1.0/60), ABGs: pH 7.35, pCO2 40, pO2 80 (on 100% FiO2)
CXR: Right upper lobe consolidation, cardiomegaly
ER treatment: BiPAP (FiO2 100%), Rocephin IV, Zithromax IV, Solu-Medrol 125 mg IV
ER impression: COPD, Pneumonia, Hypoxia
H&P: Pneumonia, COPD exacerbation with hypoxia – patient now on 5L nasal cannula
PMH: CVA with right hemiparesis, COPD, dysphagia, diabetes mellitus type 2, hypertension, CKD, CAD
Inpatient orders: Daily CBC & BMP, Zosyn IV, Vancomycin IV, Solu-Medrol 80 mg IV BID, O2 titrate to keep sats >90%
A. What is the working PDx and DRG?
B. List all potential queries. Also list the impact each query will likely have if agreed.
C. Assuming the intent of your queries are agreed and documented by the provider, would there be a change to the working PDx and/or DRG? Explain.
D. Which code selection(s) is/are appropriate for this patient?
a. J189 Pneumonia, unspecified
b. J441 COPD with acute exacerbation
c. J440 COPD with acute lower respiratory infection
d. All of the above
e. A & B
f. A & C
E. Choose one of the potential queries (in part B- and write an AHIMA compliant query.