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Code procedure and diagnosis: The patient’s principal diagnosis is the admission for planned chemotherapy. The reason he needs chemotherapy is one of his secondary diagnosis, that is, Burkitt Lymphoma of the lymph nodes of axilla and upper arm. The patient also had documented conditions of dry eyes, headaches, and back pain due to the lumbar puncture needed to perform the intrathecal (IT) chemotherapy. He also continued to receive treatment for his constipation while in the hospital. These were coded as secondary diagnoses. The record mentions the patient had nosebleeds during last admission but not currently present, so it was not coded. He had mouth sores during last admission, but none present now so this is not coded. The only procedure performed is the principal procedure, that is, the intrathecal (IT) chemotherapy. The chemotherapy is coded to Introduction or Substance in or on.
SCIENCE
HEALTH SCIENCE
NURSING

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