Question

A 6-year-old child is brought to the ED by his mother. Three weeks ago he was treated for a streptococcal throat infection. He is still complaining of a sore throat and has been lethargic. The boy looks pale and his throat is still red. Pus and petechiae previously noted are absent. The child had been experiencing nose bleeds the past couple of days. He is admitted for further workup because he has a history of acute lymphoblastic leukemia, and his physician is concerned that he may be out of remission. Upon further workup, the boy is diagnosed with an acute viral upper respiratory infection. His leukemia remains in remission.

What is the coding for this case?

A. C91.01, Z85.6
B. J06.9, Z85.6
C. C91.01, J06.9
D. J06.9, C91.01

Answer 1

In ICD-10 coding, the correct codes for the case of a 6-year-old child diagnosed with an acute viral upper respiratory infection with a history of acute lymphoblastic leukemia in remission are J06.9 for the viral infection and Z85.6 for the history of leukemia.

Step-by-step explanation:

The case presented involves a 6-year-old child with a history of acute lymphoblastic leukemia (ALL) who was initially treated for a streptococcal throat infection and is now presenting with symptoms of an acute viral upper respiratory infection, while his leukemia remains in remission.

The appropriate coding for this case must reflect the current diagnosis and account for the child's medical history. Considering the ICD-10 coding system, the most fitting codes would be J06.9 for acute upper respiratory infection, unspecified, and Z85.6 for personal history of leukemia. These codes together encapsulate the present diagnosis of the viral infection and the historical context of the child's leukemia without indicating that the leukemia is active, as the child is confirmed to be in remission.