CPB Certification Chapter 4

What is the ICD-10-CM code for fever?

R50.9 This is the code for unspecified fever.

A claim was denied with diagnosis M19.9. What is the reason for the denial?

A 5th character is needed

A female patient presents for an initial encounter for a spontaneous fracture of right humerus due to metastatic bone cancer. She has a history of breast cancer previously removed and no longer receives treatment for it. What ICD-10-CM code(s) is/are reported?

M84.521A, C79.51, Z85.3 First code the pathologic fracture of the humerus, and a "code also" note lets you know to also code the underlying neoplasm (the metastatic bone cancer). A "History of" code is then listed for the breast cancer, since she is no longer receiving treatment for it.

Patient is diagnosed with kidney stones. What ICD-10-CM code is reported?

N20.0

Patient is seen for urinary symptoms that include nocturia, hesitancy, frequency, and a weak urinary stream. Exam reveals that the patient has an enlarged prostate. What ICD-10-CM code(s) is/are reported?

N40.1, R35.1, R39.11, R35.0, R39.12

28-year-old OB patient presents with cramping, bleeding, and passing of tissue. She is diagnosed with a spontaneous abortion. Which ICD-10-CM code is reported?

O03.9

What is the ICD-10-CM code for the first encounter for a left wrist fracture from a fall? Code the injury only, not the External Cause (the fall).

S62.102A A fracture not specified as open or closed should be coded as closed.

A 5-year-old receives 5 percent third degree burns on his right hand and also sustained 10 percent second degree burns on his right upper leg after pulling a pot of boiling water from off the stove onto him. Total body surface area that was burned was 15 percent. What are the correct diagnosis codes for this encounter?

T23.301A, T24.211A, T31.10, X12.XXXA Sequence the highest degree of burn first. Guidelines also state to include a code from category T31 to indicate the total amount of the body that is covered in burns. The 5th character in this code also indicates what percent of the body has suffered 3rd degree burns. The final code shows that this was caused by boiling water.

Mrs. Baker was given Clonidine for her hypertension. She is only supposed to take one tablet in the morning. She mistakenly took two tablets and is now feeling dizzy and nauseated. She is told by her primary care physician to go to the ED and he will meet her there. What ICD-10-CM code(s) is/are reported?

T46.5X1A, R42, R11.0 According to the guidelines on coding for poisonings/improper use of medication, first use a code from category T36-T50. This is the code that includes the drug used, that this was an accidental poisoning, and the character A shows this is the initial encounter. Next, according to guidelines, the manifestations of the poisoning should be coded.

A 16-year-old presents to the emergency room with possible head injury from falling off his skateboard. The patient was wearing his helmet. Examination reveals no outward head injury. What ICD-10-CM codes are reported?

Z04.1, V00.131A, Y93.51 No head injury should be coded since it was only stated as "possible". Instead an Observation Code is used, which are always listed as the primary diagnosis. An External Cause Code can never be listed as the primary diagnosis. The External Cause Codes for the fall from the skateboard and the activity of skateboarding are then listed.

The patient just turned 50 and is here today for a screening colonoscopy. During the procedure, two polyps are found and removed with a snare technique. What ICD-10-CM code(s) is/are reported?

Z12.11, K63.5 ICD-10-CM guidelines state that a screening code can be first listed if it the primary reason for the visit. If a condition is discovered during the screening it may be listed as an additional diagnosis.

When a patient is admitted for chemotherapy for cancer what code is reported as the first listed diagnosis?

Z51.11 ICD-10-CM guidelines state that if the sole reason for a patient encounter is the administration of chemotherapy, assign that code as the first listed/primary diagnosis.

What is the ICD-10-CM code for asthma?

J45.909

What is the ICD-10-CM code for GERD?

K21.9

Patient is here for symptoms of fever, chills, and productive cough. Chest X-ray shows histoplasmosis pneumonia. What ICD-10-CM code(s) is/are reported?

B39.2 This code includes both the infectious agent and the location of the infection, so it is the only one needed

Child is brought in by her mother for a skin rash on her arms, legs, and midsection. Mother states the patient has been playing in a field across from the house. She is diagnosed with chigger bites. What ICD-10-CM code is reported (do not code the External Cause)?

B88.0 The question states not to code the external cause so that can be left out.

Patient is being treated for a metastatic thoracic spinal cord cancer from the lung. What ICD-10-CM codes are reported?

C79.49, C34.90 According to ICD-10-CM, if a patient is being seen primarily to treat a secondary (metastatic) form of cancer that secondary form should be coded first followed by the primary cancer.

A diabetic patient presents with non-pressure diabetic ulcers on the right mid-foot. The necrosis is through the soft tissue, the underlying muscle and tendon with suspected gangrene. He is scheduled for debridement. What code(s) is/are reported for this case?

E11.621, L97.413 The first is a combination code for both the diabetes and the foot ulcer. In the Tabular list under this code, it states to also code for the site of the ulcer and its depth. The gangrene is not coded for since it is only suspected and not a confirmed diagnosis.

A 30-year-old female suffers from menstrual migraines. She is in the ED because the medication has not relieved the migraine. What ICD-10-CM code is reported?

G43.839

Patient presents with difficulty speaking, facial droop, and she is unable to close her left eye. She has no other complaints. She is diagnosed with Bell's palsy. She is prescribed Corticosteroids. She will return in 3 days for follow-up. What ICD-10-CM code(s) is/are reported?

G51.0

A patient presents to the ophthalmologist for follow up of hypertensive retinopathy in both eyes. The retinopathy is due to the patient's malignant hypertension. What ICD-10-CM code(s) is/are reported?

H35.033, I10

Patient is diagnosed with right bundle branch block. What ICD-10-CM code is reported?

I45.10

The patient is being treated for acute-on-chronic pansinusitis. What ICD-10-CM code(s) is/are reported?

J01.40, J32.4 According to coding guidelines, if a combination code is not available for an acute-on-chronic condition, code the acute condition first and then the chronic one.

Patient presents with sore throat and fever. After an Expanded problem focused history and exam, and a positive strep test, the physician diagnosis is strep throat. What diagnosis code(s) is/are reported?

J02.0

What is the ICD-10-CM code for a sore throat?

J02.9