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I need a medical coding expert familiar with ICD-10 CM/PCS. Please help me with the diagnosis codes to this case using ICD-10 CM/PCS. Thank you for your help with this.

This is an inpatient progress note.

Principle Problem: Premature Infant of 31 weeks gestation Initial visit

Mode of Delivery: C-Section

Resuscitation: was needed. See completed documentation in the Resuscitation note.

Apgar Scores: 3 (1 min)/ 7 (5min) / (10min) Baby born at outside hospital: No Vascular Access on Admission: PIV Current Feedings/Fluids: NPO Respiratory Support on Admission: CPAP

Patient Family and Prenatal history: as documented by nursing staff. No additions or changes.

ROS 10 system Negative except for respiratory. See completed documentation in Resuscitation note.

Vitals:

Temperature

98.4°F

Pulse

174

Respirations

48

Blood Pressure

50/38

SpO2

94%

Weight

1590g

Length

41cm

Head Circum.

28.5cm

Physical Examination

General: alert, in mild distress and AGA

Head: normocephalic and atraumatic, anterior fontanelle open and flat and molding Eyes: pupils equal, round, and reactive to light and positive red reflex bilaterally ENT: Moist mucous membranes, normal set ears with no pits or tags, patent nares, palate intact, oropharynx clear

Neck: neck supple with full active range of motion, clavicles intact

Chest: tachypneic and grunting

Cardiac: Regular rate and rhythm, normal S1 and S2, no murmur, normal pulses, warm and well perfused

Abdomen: Soft, nontender, and nondistended; normoactive bowel sounds; no mass or hepatosplenomegaly palpated

Back: spine intact

GU: normal male external genitalia, patent anus, uncircumcised and testes descended bilaterally

Musculoskeletal: normal muscle bulk with no contractures and appropriate range of motion

Skin: No rashes or lesions and pink

Neurologic: spontaneous movement of all extremities

Assessment/Plan:

Premature Infant of 31 weeks gestation
Respiratory Distress Syndrome- Admitted on CPAP, follow, CXR pending No surfactant given.
Dichorionic diamniotic twin gestation (Twin B)
SCIENCE
HEALTH SCIENCE
NURSING

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