Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate. Remember, check the chapter specific, sub-chapter specific and category specific notations within the Tabular list.

Patient: Winston Waller
Physician: Morris Johnston, MD
August 1, 2018

History

This patient is a 73-year-old male nonsmoker with type 2 diabetes mellitus and hypertension. He presented to this ED with shortness of breath and was found to have had an acute myocardial infarction of the anterior wall of his heart showing an ST elevation that had previously been left untreated. He developed several complications, including renal failure from a combination of cardiogenic shock and toxicity from the dye used for emergency catheterization of his heart.

Hemodialysis was started during this hospitalization because of his renal failure. After spending almost a month in the hospital and developing severe deconditioning, he was discharged to a subacute rehabilitation facility.

Examination

While he was there he was noted to have symptoms consistent with mild depression, as well as a prior history of a major depressive episode in 2016. Mirtazapine (Remeron) 25 mg/day was started.

He was transferred to a skilled nursing unit for another month of rehabilitation management of his medical conditions and then discharged home to the care of his wife.

Be sure to list the codes, one code per box, in the correct order, from top to bottom. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices.

What is/are the correct diagnosis code(s)?