CCS Chapter 11-17

Codes for symptoms, signs, and ill-defined conditions from chapter 18 of ICD-10-CM cannot be used as principal diagnoses or reasons for outpatient encounters when related diagnoses have been established.

True

External cause codes should never be used as a principal or first listed diagnosis.

True

Selection of codes for alcohol or substance abuse "in remission" requires the provider's clinical judgment and may not be reported without provider documentation.

True

Z codes may be used as a first or additional diagnosis

True

1. A patient is diagnosed with MRSA septicemia and pneumonia due to MRSA. How should this be coded?

A41.02, J15.212

What is a nosocomial infection?

An infection contracted as a result of medical treatment

8. Patient is admitted with severe anemia due to questionable gastrointestinal bleeding. Stools were heme positive in the ED. He was transfused with packed red blood cells from the blood bank with good results. Patient indicates he had a colonoscopy with polypectomy hours before admission. Final diagnoses: (1) Acute posthemorrhagic blood loss anemia complication of polypectomy, (2) peripheral vein transfusion of packed red blood cells.

D62, K91.840, 30233N1

How should hemorrhagic disorder due treatment with anticoagulants like Coumadin or heparin be coded?

D68.32 and T45.515A

1. The patient was admitted for epistaxis due to therapeutic anticoagulation medication for atrial fibrillation. There is recent history of resection of a mass of the vestibule of the mouth with graft repair and radiation therapy. When seen in the physician office, the patient's Coumadin was discontinued due to high protime. Although the Coumadin was stopped, the protime continued to rise. Protime corrected with frozen plasma during hospitalization. Final diagnoses: (1) Epistaxis secondary to hypercoagulability from Coumadin, (2) recurrent cancer of vestibule of the mouth, (3) atrial fibrillation, (4) transfusion nonautologous plasma through peripheral vein.

D68.32, R04.0, T45.515A, C06.1, I48.91, Z79.01, 30233K1

If pain does not resolve within one month, it is considered chronic.

False

1. When a patient is admitted with glaucoma and the stage of the glaucoma progresses during the admission, which stage(s) should be coded?

Only the code for the highest stage documented

A patient is admitted to the ambulatory unit to give blood (autodonor) for surgery he will have the following week. On the way home, the patient experiences syncope and returns to the ambulatory care unit for care. How should the return to the ambulatory care unit be coded?

R55

The diabetes mellitus codes are combination codes that include:

The type of diabetes, the body system affected, and the complication affecting the body system.

When the provider documentation refers to use, abuse, and dependence of the same substance, what is the coding hierarchy

Assign only the code for dependence.

1. A nondiabetic patient was seen by his primary care physician after a sudden onset of sweating, palpitations, and tremors. He was diagnosed as having a spontaneous hypoglycemic episode. Final diagnosis:Hypoglycemia

E16.2

Which of the following is not a type of schizophrenia? A. Paranoid schizophrenia B. Catatonic schizophrenia C. Disorganized schizophrenia D. Global schizophreniaer

Global schizophrenia

Which of the following statements refers to "abnormal findings" for codes describing health examinations with abnormal findings? A. Condition/diagnosis that is newly found B. Change in severity of a chronic condition, during a routine physical exam C. None of the above

A and B

A nursing home resident who sustained a hypoxic brain injury 8 years ago was hospitalized with increasing respiratory failure and fever due to bilateral pneumonia and severe sepsis. The patient has recurrent seizures due to the old intracranial injury, with loss of consciousness from an accidental fall. Final diagnoses: (1) Severe sepsis, (2) bilateral pneumonia, (3) acute respiratory failure, (4) recurrent seizures due to old intracranial injury

A41.9, R65.20, J18.9, J96.00, G40.909, S06.9X9S, W19.XXXS

1. Which of the following types of Z codes are used when the initial treatment of a disease has been completed, but the patient requires continued care during the healing or recovery phase? A. Admission for follow-up examination B. Admission or encounter for aftercare management C. Admission for observation and evaluation D. Screening examinations

Admission or encounter for aftercare management

Secondary diabetes may be due to: A. Drug or chemical B. Infection C. Removal of pancreas D. All of the above

All of the above

Which of the following terms refers to either a reduction in the quantity of hemoglobin or a reduction in the volume of red blood cells? A. Anemia B. Coagulation defect C. Thrombocytopenia D. Leukocytosis

Anemia

1. Which of the following anemias is caused by a failure of the bone marrow to produce red blood cells and may be congenital or acquired? A. Bone marrow deficiency anemia B. Sickle-cell anemia C. Aplastic anemia D. Thalassemia

Aplastic anemia

1. Which of the following anemias is caused by a failure of the bone marrow to produce red blood cells and may be congenital or acquired? A. Bone marrow deficiency anemia B. Sickle-cell anemia C. Aplastic anemia D. Thalassemia

Aplastic anemia

An HIV positive patient was admitted with a persistent cough, chest pain, and fatigue. Clinical presentation and sputum cultures confirmed positive tubercle bacilli. The physician diagnosed HIV related tuberculosis, which was treated with anti-TB medications. Final diagnoses: (1) HIV positive status, (2) pulmonary tuberculosis

B20, A15.0

1. A 59-year-old female type I diabetic patient presented with a history of fatigue, loss of appetite, and abdominal pain. Hepatomegaly was present on abdominal ultrasound. Liver biopsy was positive for toxoplasma gondii. Clinical signs were also consistent with acute toxoplasmic hepatitis. Final diagnoses: (1) Acute toxoplasmic hepatitis, (2) type I diabetes mellitus maintained on insulin, (3) percutaneous liver biopsy, (4) abdominal ultrasound

B58.1, E10.9, 0FB03ZX, BW40ZZZ

1. A patient with history of lung cancer, status post chemotherapy and radiation, was seen in the ED for onset of left hip pain that makes it difficult to walk. CT was suspicious for metastasis to the left ilium. MRI confirms bone metastasis. There is a distant past history of cigarette smoking. Final diagnoses: (1) Acute hip pain due to metastatic lesion of the ilium, (2) lung cancer, (3) history of cigarette smoking, (4) CT scan of left hip, (5) MRI left hip.

C79.51, G89.3, M25.552, Z85.118, Z87.891, BQ21ZZZ, BQ31ZZZ

1. An elderly female patient was taken to the emergency medicine department by his family when she became unusually agitated and aggressive. MRI of the brain showed no evidence of infarct, hemorrhage, lesion, or significant abnormality. Infectious workup was also negative. Antibiotic therapy was started with slow improvement in mental status. Antithyroid peroxidase antibodies were positive. Final diagnoses: (1) Altered mental status due to Hashimoto's encephalopathy, (2) MRI brain.

E06.3, G93.49, B030ZZZ

A 47-year-old male was seen in the emergency room with complaints of nausea, vomiting, diarrhea, and cramping. The patient is a known diabetic whose diabetes is secondary to history of blunt trauma to the pancreas. Blood sugar levels on admission were greater than 600.Final diagnoses: (1) Secondary diabetic ketoacidosis, (2) diabetes mellitus secondary to history of blunt trauma to the pancreas.

E13.10, S36.209S

A type II diabetic patient was admitted because of nephrotic syndrome. Renal biopsy of the left kidney found amyloid deposition but was negative for diabetic nephropathy. Rapid deterioration in renal function, sudden increase in proteinuria, and the absence of diabetic retinopathy also ruled out diabetic nephropathy. Final diagnoses:(1) Glomerulonephritis with nephrotic syndrome due to amyloidosis, (2) type II diabetes mellitus, (3) percutaneous biopsy kidney

E85.4, N08, E11.9, 0TB13ZX

1. The patient has generalized pain and tingling across the arms, legs, chest, back, and abdomen. EKG showed normal sinus rhythm, but she was found to have elevated potassium of 7.3, which was treated urgently with standard therapies. There was resolution of pain after corrected potassium levels and dialysis over 3 days of intermittent dialysis. Final diagnoses: (1) Hyperkalemia due to missed regularly scheduled dialysis appointment, (2) end-stage renal disease secondary to rapidly progressive glomerulonephritis, (3) 3 hemodialysis sessions.

E87.5, N18.6, N01.9, Z91.15, Z99.2, 5A1D70Z

1. What is the purpose of External cause of morbidity codes?

External cause codes are assigned as additional codes to indicate how the injury or health condition happened (cause), the intent (unintentional or accidental; intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person's status (e.g., civilian, military).

1. The patient presented to the hospital with recent escalation of symptoms of schizophrenia that include delusions and auditory hallucinations. She is admitted for reassessment and increase in antipsychotic medication for treatment of chronic schizophrenia paranoid type. Final diagnosis: Chronic schizophrenia paranoid type

F20.0

1. If hemiplegia occurs in conjunction with an acute cerebrovascular accident and the hemiplegia resolves prior to discharge, it should not be coded.

False

ICD-10-PCS provides codes for mental health and substance abuse in the same section—Mental Health.

False

Only one code from categories E08-E13 (diabetes mellitus) can be assigned per patient encounter.

False

The aftercare Z codes should be used to report aftercare for injuries

False

1. A 67-year-old male was found by his family in an altered state. He has a 50-year history of seizure disorder, so paramedics were called to the home where they witnessed a grand mal seizure. The patient's family tells doctors that he has acute bronchitis and has been poorly compliant with his antiepileptic medications. Patient is admitted in a nonresponsive and lethargic state. CT of head is negative for significant acute pathology. Final diagnoses: (1) Postictal state following grand mal seizure, (2) epilepsy, (3) acute bronchitis, (4) CT of head.

G40.409, J20.9, Z91.14, BW28ZZZ

1. Patient was diagnosed with a left humeral fracture when she fell after tripping over a rug at home. The arm was placed in a sling until reduction with internal fixation could be performed at a later date, and the patient was given medication for control of pain. The patient was seen the next day because the pain was not well controlled. No recent or remote tobacco, alcohol, or illicit drug use was documented. Patient is currently being admitted for acute pain control protocol. Final diagnoses: (1) Admit due to poor pain control, (2) fracture of the humerus, (3) hypertension, (4) NIDDM.

G89.11, S42.302A, I10, E11.9, W18.09xA

1. The patient has uncontrolled intraocular pressures that are as high as the mid 30s due to severe stage primary open angle glaucoma (POAG). Surgery was performed to better control pressure through Baerveldt glaucoma implant placement into the right anterior chamber. Final diagnosis: Baerveldt drainage device to right eye due to POAG.

H40.1113, 089230Z

The patient is an 81-year-old female who presented to the emergency department in a coma after having suffered a large intraventricular hemorrhage due to hypertension. How should this be coded?

I61.5, R40.20, I10

1. A patient was admitted with methicillin resistant Staphylococcus aureus (MRSA) cellulitis and abscess of the left thigh due to continuous self-prescribed steroid injections. Patient treated with intravenous antibiotics and excisional debridement. Final diagnoses: (1) Cellulitis and abscess of the thigh due to contaminated needle, (2) self-prescribed steroid abuse, (3) MRSA, (4) excisional debridement skin and fascia.

L03.116, L02.416, B95.62, F55.3, W46.1xxA, 0JBM0ZZ

How should an unconfirmed diagnosis of HIV infection be coded?

It should not be coded as confirmed; this condition is an exception to the general guideline for "possible," "probable" conditions.

A 47-year-old obese male was admitted with chest pain and difficulty swallowing, resulting in regurgitation. The patient has a history of coronary artery disease (CAD), but tests ruled out angina. Based on negative test results and the patient's history, it was established that the chest pain was probably related to a heavy meal. Final diagnoses: 1) Probable gastroesophageal reflux disease (GERD), (2) CAD, (3) Obesity

K21.9, I25.10, E66.9

1. The female patient was admitted with right lower quadrant abdominal pain, diarrhea, fever, chills, and nausea for the past 5 days. Blood and stool cultures were negative. CT of the abdomen ruled out colon disease but was positive for ascites and cirrhosis. This was consistent with the patient's history of cirrhosis due to hemochromatosis. The patient refused paracentesis. Antibiotics were started with improvement of pain and diarrhea. At discharge, the differential diagnosis was acute gastroenteritis or spontaneous bacterial peritonitis. Final diagnosis: (1) Abdominal pain of the right lower quadrant due to gastroenteritis versus spontaneous bacterial peritonitis, (2) cryptogenic cirrhosis due to hemochromatosis

K52.9, K65.2, R18.8, K74.69, E83.119, BW20ZZZ

A patient was admitted for lower gastrointestinal bleeding that is secondary to recurrent diverticulitis of the sigmoid colon. She was transfused due to blood loss anemia. Final diagnoses: (1) Diverticulitis sigmoid colon, (2) gastrointestinal bleed, (3) blood loss anemia, (4) peripheral vein transfusion of packed red blood cells from the blood bank

K57.33, D50.0, 30233N1

1. A patient is admitted because of confusion and altered level of consciousness and coma. Patient is alert but not oriented to place or time. CT of abdomen shows cirrhosis of the liver. An ultrasound guided paracentesis is performed. Final diagnoses: (1) Hepatic encephalopathy due to alcoholic cirrhosis of liver, (2) ascites, (3) alcohol dependence, (4) paracentesis, (5) CT of abdomen, ultrasound of liver.

K70.40, K70.31, F10.20, 0W9G3ZZ, BF45ZZZ, BW20ZZZ

1. A diabetic nursing home resident was admitted with a one-week history of swelling of the left foot. The physician documents the swelling could be due to cellulitis or primary gouty arthritis and treats the patient for both conditions. Final diagnoses: (1) Swelling of the foot due to cellulitis or gout, (2) diabetes mellitus

L03.116, M10.072, E11.9

1. A 34-year old female at 24 weeks gestation was seen in follow-up due to findings of glycosuria. Her fasting venous plasma glucose is 143 mg/dl. Given this finding, the diagnosis of gestational diabetes mellitus is established. Family history reveals that both parents have diabetes mellitus. The patient was started on both dietary and insulin therapy. Final diagnoses: (1) Gestational diabetes mellitus, (2) pregnancy, (3) insulin maintenance, (4) family history of diabetes mellitus.

O24.414, Z83.3, Z3A.24

Complete the following statement: Postoperative pain immediately after surgery should be coded

Only when the patient develops an unusual or inordinate amount of pain.

Which of the following conditions is not considered an affective disorder? A. Major depressive disorder B. Paranoid schizophrenia C. Bipolar disorder D. Anxiety disorder

Paranoid schizophrenia

Which of the following statements is true with regards to coding pregnant diabetic women? A. Pregnant women who are diabetic should be assigned a code from category O24, Diabetes mellitus in pregnancy, childbirth and the puerperium. No code other diabetes code (E08-E13) should be assigned. B. Pregnant women who are diabetic should be assigned the appropriate diabetes code (E08-E13) first, followed by a code from category O24, Diabetes mellitus in pregnancy, childbirth and the puerperium. C. Pregnant women who are diabetic should be assigned a code from category O24, Diabetes mellitus in pregnancy, childbirth and the puerperium, first, followed by the appropriate diabetes mellitus code (E08-E13). D. Pregnant women who are diabetic should be assigned either a code from category O24, Diabetes mellitus in pregnancy, childbirth and the puerperium, or the appropriate diabetes mellitus code (E08-E13). The sequencing does not matter.

Pregnant women who are diabetic should be assigned a code from category O24, Diabetes mellitus in pregnancy, childbirth and the puerperium, first, followed by the appropriate diabetes mellitus code (E08-

1. An 85-year-old male with aortic stenosis and coronary artery disease status post coronary artery bypass graft, presents to the emergency department (ED) with sharp stabbing pressure-type chest pain in the epigastric area. The patient reported this discomfort was different from that experienced prior to his previous myocardial infarction and was given sublingual nitroglycerin and oxygen, with no improvement. He was later given parenteral Nubain and gastrointestinal cocktail, which provided some pain relief. Cardiac workup was negative for acute myocardial infarction. The physician listed epigastric pain as the final diagnosis. What are the appropriate diagnosis codes?

R10.13, I35.0, I25.10, I25.2, Z95.1

When a diagnostic statement of anemia is not qualified in any way, what should the coder do? A. Review the record for a surgical procedure; and if the patient had surgery, code as anemia due to acute blood loss. B. Review the medical record before assigning an unspecified type of anemia. C. Review the medical record to determine if the patient has been prescribed iron tablets, and code as iron-deficiency anemia. Review the medical record to determine if the patient has received chemotherapy, and assign the code for anemia due to antineoplastic chemotherapy

Review the medical record before assigning an unspecified type of anemia.

If the coder notes clinical findings outside the normal range but no related diagnosis is stated, what should the coder do?

Review the medical record to determine whether additional tests and/or consultations were carried out related to these findings or whether specific related care was given, and ask the physician whether a code should be assigned.

An 87-year-old woman was admitted to the hospital due to a fracture of her left femur after a fall. Her son relates his mother has shown increasingly odd behavior. She seemed to think that he was trying to snatch her purse as he helped her into the car for a ride to church. As she became upset, she tried to get away from him and tripped in her confusion. During the physician's examination, she was disoriented and displayed irrational fears. An open reduction is performed with placement of a metal plate and large screw across the fracture into the femoral head to hold the bones in place.Final diagnoses: (1) Intertrochanteric fracture of the left femur, (2) probable early Alzheimer's dementia with behavioral disturbance, (3) hypertension, (4) fall, (5) open reduction with internal fixation.

S72.142A, G30.0, F02.81, I10, W19.xxxA, 0QS704Z

When the reason for admission is both sepsis (or severe sepsis) and a localized infection (e.g., pneumonia or cellulitis), which condition should be assigned as the principal or first-listed diagnosis?

Sepsis or severe sepsis

What does the term "severe sepsis" usually refer to?

Sepsis with associated acute or multiple organ dysfunction

A 53-year-old male patient status post coronary artery bypass graft (CABG) was readmitted to the hospital after he developed redness and purulent drainage deep from the sternal wires. The patient quickly deteriorated after admission, became septic, and went into shock two days after admission. With aggressive intravenous antibiotic management, the patient improved and was later discharged. The physician also documented Methicillin resistant Staphylococcus aureus sepsis and postoperative septic shock from the sternal infection. How should this case be coded?

T81.42XA, T81.44XA, T81.12XA, A41.02,Z95.1,

Which of the following statements is true regarding a patient with documented sickle-cell trait? A. The patient has sickle-cell disease. B. Both of the patient's parents carried the sickle-cell gene. C. The code for sickle-cell disease should be assigned. The patient received the sickle-cell gene from only one parent and is a carrier of the trait

The patient received the sickle-cell gene from only one parent and is a carrier of the trait.

A postmenopausal patient is seen as an outpatient for a bone density study to evaluate for osteoporosis. She has no other signs or symptoms at the present time. What diagnosis code should be used to report this encounter`

Z13.820, Encounter for screening for osteoporosis Z78.0, Asymptomatic menopausal state

1. A 58-year-old man tested positive for MRSA on routine nasal culture on admission to the hospital. He did not have an infection. How should this be coded?

Z22.322

Which of the following major types of diabetes is characterized by the body's failure to produce insulin at all, or by an absolute decrease in insulin production? A. Type 1 B. Type 2 C. Type 3 D. Secondary diabetes

Type 1

When is it appropriate to assign codes for abnormal findings in the acute inpatient hospital setting?

When the physician has not been able to arrive at a definitive related diagnosis and lists the abnormal finding itself as a diagnosis

Codes from chapter 18 are assigned as secondary codes under which of the following circumstances?

When the symptom or sign is not integral to the underlying condition

A patient had carcinoma of the descending colon, which was resected one year prior to this outpatient encounter. Patient is now seen for colonoscopy to evaluate anastomosis and remaining colon. Colonoscopy showed a normal anastomosis and no evidence of cancer recurrence. Assign the appropriate diagnosis and procedure code(s) and sequence according to coding guidelines`

Z08, Z85.038, 0DJD8ZZ

A patient is seen in the outpatient clinic for colonoscopy due to family history of colon cancer. The patient has no personal history of gastrointestinal disease and is currently without signs and symptoms. Assign the appropriate diagnosis code(s) and sequence according to coding guidelines.

Z12.11, Z80.0

A woman with no symptoms is referred to the hospital outpatient x-ray department for screening mammogram. The patient is considered high risk for breast cancer secondary to family history of breast malignancy in the mother and sister. How should this encounter be coded?

Z12.31, Z80.3

A patient is being seen for home care for dressing changes for treatment related to a healing stage 3 pressure ulcer of the left heel. How should this encounter be coded?

Z48.00, L89.623

8. The patient with prostate cancer was admitted for chemotherapy; however, during physical examination, the patient was found to be short of breath with a rapid heart rate. There was no known history of cardiac or infectious conditions; basic metabolic panel was normal. Chemotherapy was held for a couple of days while erythropoietin was given for anemia. Final diagnoses: (1) Symptoms related to chemotherapy-induced aplastic anemia, (2) adenocarcinoma of the prostate.

Z51.11, D61.1, T45.1x5A, C61

8. A patient is seen by her physician for drug level monitoring due to management of Factor V Leiden mutation. Final diagnoses: (1) Factor V Leiden mutation, (2) anticoagulation therapy

Z51.81, D68.51, Z79.01