Inpatient Facility Coding & Compliance Alert

Question: A patient fell while intoxicated and was admitted because of a fractured humerus (surgical neck). The patient was having DT’s and was also diagnosed with acute respiratory failure and aspiration pneumonia. Additional diagnoses were malnutrition from alcohol and chronic obstructive asthma. He has a history of ischemic cardiomyopathy. What would be the principal and secondary diagnoses?

Michigan Subscriber

Answer: You should include several diagnoses on the patient’s chart, starting with 812.01 (Fracture of surgical neck of humerus closed) as the primary. Secondary and additional diagnoses should be:

• 518.81 – Acute respiratory failure
• 305.00 – Nondependent alcohol abuse unspecified drinking behavior
• 263.9 – Unspecified protein-calorie malnutrition
• 493.20 – Chronic obstructive asthma, unspecified
• 507.0 – Pneumonitis due to inhalation of food or vomitus.

Your final selection is a DRG of 562 (Fracture, sprain, strain and dislocation except femur, hip, pelvis, and thigh with MCC).