Diagnosis: Malignant neoplasm of cervix uteri
Patient Name: Johnson, Marlene Medical Record #: 779464 Admission Date: 03/01/YYYY
Assign J44.1 for COPD exacerbation as the first-listed diagnosis. ICD-10-CM instructs us to "use additional code" to identify tobacco history, if applicable. Patient smokes 1 pack of cigarettes per day; therefore, assign F17.210 for "cigarette smoker." Note also indicates that the patient has hypertension so assign I10 as a secondary diagnosis. Lastly, assign Z79.51 for the patient's current use of inhaled steroids.
Patient Name: Greene, Robert Medical Record #: 161725 Admission Date: 09/16/YYYY
Assign M21.41 for the flatfoot deformity as your first-listed diagnosis. Also assign M67.01 for right Achilles tendon contracture, M19.071 for right foot DJD, M20.11 for Hallux abducto valgus and M06.9 for rheumatoid arthritis. In addition, assign diagnosis codes for the chronic conditions that are being treated. The Evans calcaneal osteotomy procedure is classified as a Release procedure in ICD-10-PCS. Thus, instead of locating "Osteotomy" in the ICD-10-PCS index, go to "Release," and subterm "joint" and second qualifier "ankle" to locate the appropriate table. The ICD-10-PCS code for the gastrocnemius release, right calf, is also located by going to index main term "Release." An arthrodesis is classified as a "Fusion" procedure in ICD-10-PCS, and there is use of internal device (K-wire). The cuneiform osteotomy (division) and bone grafting (supplementation) of tarsal, right foot, procedure is classified in ICD-10-PCS as a "Division" procedure (osteotomy) and a "Supplementation" procedure (grafting); thus, two ICD-10-PCS codes are required to classify this procedure.
Patient Name: Borden, Howard Medical Record #: 0001278 Admission Date: 01/15/YYYY
Assign M51.26 as the first-listed diagnosis for lumbar disc protrusion L4-L5 right. Codes for other diagnoses of history of basal cell carcinoma of skin, melanoma, shoulder replacement and allergy to Benzoin Tincture are also assigned.Per the operative report, right-sided L4-L5 micro lumbar discectomy was performed and is assigned to root operation "excision." The "hemi-laminectomy, L5" is NOT coded because ICD-10-PCS guidelines tell us that we do not code procedures that are used as an approach to the operative site unless they meet the guidelines for multiple procedures. We assigned to root operation "excision" because only part of the disc and lumbar vertebrae were removed. Back to quiz summary
Patient Name: Davis, Pamela Medical Record #: 1237777 Admission Date: 04/29/YYYY
Assign S82.831K for nonunion of right distal fibula fracture. An open reduction internal fixation (ORIF) procedure is classified as a "Reposition" in ICD-10-PCS, and the corresponding table allows selection of the internal fixation device. Thus, there is no need to assign a second procedure code for the internal fixation device. Assign 0QSJ04Z only.
Patient Name: Alvarez, Ricardo Medical Record #: 1011229 Admission Date: 07/03/YYYY
Choose an ED visit level and all appropriate dx codes. According to the coding guidelines, it is important to capture not only the diagnosis/injury, but also how the injury happened, the place where the event occurred, the activity at the time of injury, and the patient's status (i.e. civilian, military, volunteer), if applicable.Assign CPT code 73590-LT for x-ray of the left lower leg. Assign CPT code 93971 for the left leg Doppler ultrasound. Patient sustained a crushing injury while working at the bagging line when his leg was grabbed by a belting machine. Assign S87.82XA for pinch injury of left lower leg, W24.1XXA for contact with belting machine, Y99.0 for working civilian, Y92.63 as place of occurrence for "factory," and Y93.H9 for activity involving exterior property and land maintenance, building and construction. In addition, assign F17.200 because "Tobacco 1 pack per day" is documented. "Marijuana use daily" is also documented, however, a code for marijuana use is not assigned without an associated physical, mental or behavioral disorder documented by the provider. The provider did not indicate an associated disorder, therefore, you would not assign a code for marijuana use. (Coding Clinic for ICD-10-CM/PCS, Second Quarter 2018: Page 11
Patient Name: Wilson, Thomas Medical Record #: 873496 Admission Date: 08/23/YYYY
Chronic conditions (e.g., cirrhosis, peripheral vascular disease) that affect the patient and require continuous clinical evaluation or monitoring during hospitalization are assigned ICD-10-CM codes. For example, because this patient has pedal edema, his peripheral vascular disease is a factor; also, the patient's congestive heart failure is impacted by his cirrhosis. ETOH abuse is also indicated, and provider mentions that his drinking more recently "might contribute to his problems;" therefore, a code for alcohol abuse is assigned. The other chronic illnesses that are documented with evidence of current treatment/medication are reported. This includes hypothyroidism, COPD and history of smoking.
Patient Name: Weinstein, Michelle Medical Record #: 0001267 Admission Date: 01/15/YYYY
ED E&M codes require three key components (history, examination and medical decision making) to be met and documented to select the appropriate level of service. Assign 99283 for comprehensive history, detailed exam, medical decision making of moderate complexity and severity. The HCPCS level II codes for drugs Albuterol and Atrovent cannot be assigned because detail about dosages is not documented. A physician query would be generated to determine the drug dosages for this case.Per outpatient coding guidelines, qualified (uncertain) diagnoses are not coded; therefore, ONLY assign a diagnosis code for "acute bronchospasm."
Patient Name: Davis, Pamela Medical Record #: 355676 Admission Date: 02/17/YYYY
ED E&M codes require three key components (history, examination and medical decision making) to be met and documented to select the appropriate level of service. The history component includes the chief complaint (CC), history of present illness (HPI), review of systems (ROS) and past medical, family, and social history (PFSH). The extent of the physical examination performed is based on the nature of the presenting problem(s). MDM is determined by the complexity of the encounter (number of diagnoses or management options, amount and/or complexity of data to be reviewed and risk of complications and/or morbidity or mortality). This brief note includes a short description of the presenting problem(s), a limited physical examination and management options/treatment of low complexity. ROS was not documented and the patients PFSH is not indicated, therefore, assign 99282-25 for expanded problem-focused history/exam, medical decision making of low complexity and low to moderate severity.Assign CPT code 73100-RT for X-ray of the right wrist, 2 views.To report closed treatment without manipulation of a fracture the documentation must indicate the materials used for closed fracture treatment as well as a plan for follow-up care of the fracture. A WHFO device is provided, however, the physician does not indicate if that is the definitive treatment for the fracture or any intent to follow-up with the patient so a fracture repair code cannot be assigned.Assign HCPCS code L3809 for the supplies which includes the evaluation and fitting component of the service. Application of the orthotic device is included in the ED visit.Laceration repair for this case is classified as "intermediate" because it involves layered closure (i.e. subcutaneous tissue was re-opposed and sutured, then the skin was re-opposed and sutured). To code multiple wounds of the same complexity and in the same anatomical area, add the length of all wounds sutured as one total length. Therefore, add 2.0 cm + 2.6 cm together to determine the correct code (12052). Do not add modifier -RT to the repair code because even though eyes are directional, the other items included in the code description are not directional (e.g., face, mucous membranes); thus, directional (e.g., -RT, -LT) and bilateral (-50) modifiers are never added to such codes.Injuries are coded from Chapter 19: Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88) with the appropriate 7th character ("A" Initial Encounter, "B" Subsequent encounter, or "S" Sequela). Assign separate codes for each injury with the code for the most serious injury sequenced first. Assign S52.501A for the non-displaced distal right radial fracture. Assign S01.111A for the right eyelid/lower eyebrow laceration. Use secondary code(s) from Chapter 20: External causes of morbidity (V00-Y99) to indicate the cause of injury. Report W01.198A for fall from tripping. Assign place of occurrence code Y92.830 which represents "public park."
Outpatient—Physician's Office (Circulatory) Patient Name: Sheila Thompson Diagnosis: Paroxysmal supraventricular tachycardia The 43-year-old established patient saw her primary physician for follow-up after wearing a Holter monitor for rapid heartbeat, dizziness, and fainting. The physician performed a detailed history and exam and then explained the diagnosis of paroxysmal supraventricular tachycardia. He prescribed a beta-blocker and demonstrated some breathing techniques that she could use to alleviate symptoms. He also advised her that if symptoms became more severe, more aggressive treatment would be explored. Medical decision making was of moderate complexity.
ICD-10-CM I47.1 is reported for paroxysmal supraventricular tachycardia. CPT code 99214 is reported for the level 3 E/M service.
Outpatient—Physician's Office (Ophthalmology) Patient Name: Mary Shelby Diagnoses: Advanced atrophic macular degeneration with subfoveal involvement, left eye; advanced atrophic macular degeneration, right eye A 72-year-old female, who was referred by her optometrist to an ophthalmologist, arrived for her 11 a.m. appointment on April 1. The ophthalmologist is a specialist in retinal-vitreous surgery, and he discussed with the patient treatment options for visual changes in her left eye. The patient had noticed gradually worsening Amsler grid changes and central vision distortion since January. Visual acuity, blood pressure, slit lamp exam, tension, biomicroscopy, optical coherence tomography, and fluorescein angiogram studies were performed. The studies revealed loss of visual acuity of the left eye, blood pressure within normal limits, persistent central pigment epithelial detachment, trace fluid and hemorrhage along the nasal foveal margin, and prominent perifoveal indistinct drusen of the left eye. Upon completion of the E/M service, the physician informed the patient of the diagnoses of advanced atrophic macular degeneration with subfoveal involvement of the left eye, and advanced atrophic macular degeneration of the right eye. He discussed the FDA-approved intravitreal injection of Lucentis for this condition. Because the patient had transportation provided for her return home and a primary caregiver in the home, both eyes were treated with intravitreal injections of Lucentis, 0.1 mg, and follow-up evaluation was scheduled in 2 weeks.
ICD-10-CM code H35.3124 is reported for advanced atrophic macular degeneration with subfoveal occult choroidal neovascularization, left eye, and code H35.3113 is reported for advanced atrophic macular degeneration, right eye. CPT code 67028-50 is reported for the intravitreal injection of a pharmacologic agent into both eyes, code 92235 is reported for fluorescein angiography, and code 99204-57 is reported for the level 3 office visit for the evaluation and management of a new patient. HCPCS level II code J2778 is reported for the injection of ranibizumab, 0.1 mg. (Lucentis is the brand name and ranibizumab is the generic name.).
Outpatient—Physician's Office (Circulatory) Patient Name: Wilbur Glendale Diagnosis: Asystole Procedure: Electrocardiogram A 78-year-old established male patient was brought to Dr. Smith's office by his wife after experiencing dizziness at home. His wife stated that he had been light-headed for most of the morning. During a comprehensive history and examination, the patient became extremely dizzy. The physician performed an electrocardiogram (ECG), during which the patient experienced an episode of syncope. The ECG revealed asystole, and Dr. Smith interpreted the ECG and dictated a report. Dr. Smith inserted an intravenous catheter and then administered 0.1 mg of epinephrine via IV push. The patient was then administered 0.1 mg of epinephrine via IV push x 3 every 5 minutes and cardiopulmonary resuscitation was performed. Sixty minutes of critical care was provided by Dr. Smith at the patient's bedside while his medical assistant arranged for emergency transport of the patient to Beaumont Hospital for further treatment. Medical decision making for this case was of high complexity.
ICD-10-CM code I46.9 is reported for asystole, which is classified as cardiac arrest. CPT code 99215 is reported for the level 4 E/M service. Modifier 25 is added to report an evaluation and management (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health professional. Code 36000 is reported for insertion of the intravenous catheter, code 92950 is reported for cardiopulmonary resuscitation, code 93000 is reported for ECG with interpretation and report, and code 99291 is reported for provision of critical care.
Outpatient—Physician's Office (Cardiology) Patient Name: Nina Lash Diagnoses: Paroxysmal supraventricular tachycardia A 40-year-old established female patient arrived for her appointment with her family physician with complaints of a 5-minute yesterday episode of a sudden, rapid, regular fluttering sensation in the chest accompanied by slight weakness and shortness of breath. As she was lying on the examining table and describing the condition to the physician, the paroxysm again occurred. She was reassured, and an immediate electrocardiogram (ECG) was performed that indicated paroxysmal supraventricular tachycardia. The Valsalva maneuver was tried with ECG monitoring and resulted in termination of the paroxysm. The physician completed the E/M service, discussed the diagnosis, and advised an immediate cardiology consultation.
ICD-10-CM code I47.1 is reported for paroxysmal supraventricular tachycardia. CPT code 99212 is reported for the level 1 office or other outpatient visit for the evaluation and management of an established patient, and code 93000 is reported for "electrocardiogram, routine ECG with at least 12 leads, with interpretation and report."
Outpatient—Physician's Office (Musculoskeletal) Patient Name: Brad Ferrington Diagnosis: Dislocated right shoulder Procedure: Closed reduction of dislocated right shoulder with provision of sling An established patient presented to his primary doctor with pain in his right shoulder. He said he was driving his car to the store the day before to pick up some milk for his wife when another car exiting the parking lot hit his car. He said that his left shoulder hit the driver's side door and that he could not understand why his right shoulder hurt so much. A complete shoulder X-ray performed in the office confirmed a dislocation of the right shoulder. The physician explained that indirect force was expelled when he hit his left shoulder, and this caused the dislocation of the right shoulder. The doctor performed a closed reduction of the shoulder and placed the arm in a sling. The physician then continued with an exam to ensure that there were no other injuries. He instructed the patient to use ice and take Tylenol for pain. Medical decision making was low.
ICD-10-CM code S43.004A is reported for dislocated shoulder (initial encounter), code V43.52XA is reported for automobile traffic accident involving the driver, and code Y92.481 is reported for parking lot as place of occurrence. CPT code 99213-57 is reported for the level 2 E/M service, (modifier -57 indicates the "decision for surgery"); code 23650-RT is reported for the closed treatment of the dislocated shoulder, right; and code 73030-RT is reported for the shoulder X-ray, right. HCPCS level II code A4565 is reported for provision of the sling.
Outpatient—Physician's Office (Poisoning) Patient Name: Mary Ballard Diagnosis: Cholinergic toxic syndrome A 40-year-old established patient visited the physician's office after experiencing symptoms of dizziness, headaches, excessive salivation, and lacrimation. Five days ago, the patient was started on treatment of 5 mg pilocarpine hydrochlorothiazide (HCTZ) tablets, 3 times each day for dry mouth. That treatment was prescribed for the side effect of dry mouth, which resulted from radiation therapy for cancer of the larynx. The patient stated she took more of the pilocarpine HCTZ medication than prescribed because she was hoping for faster results. A detailed history and physical were performed along with a drug assay, which revealed that the patient was experiencing cholinergic toxic syndrome as a reaction to the overdose of pilocarpine HCTZ. The physician ordered 0.02 mg atropine sulfate to be injected intramuscularly to counteract the cholinergic toxic syndrome reaction. The physician spent 30 minutes discussing with the patient the importance of taking the pilocarpine HCTZ medication as prescribed.
ICD-10-CM code T44.1X1A is reported for cholinergic toxic syndrome because the patient accidentally took more than the prescribed amount of a medication (initial encounter), which makes this case an unintentional (accidental) poisoning. Do not assign codes for dry mouth, adverse reaction to radiation therapy, or history of larynx cancer because these conditions were not medically managed or treated during the office visit. Documentation is for treatment of the accidental drug poisoning (cholinergic toxic syndrome) only. CPT code 99214 is reported for the total time spent on the encounter, code 96372 is reported for the intramuscular injection of a drug, and code 80299 is reported for the drug assay laboratory test. Do not assign code 98960 for patient education; the physician discussion about the importance of taking the patient's medication as prescribed is included in the E/M service code. HCPCS level II codes J0461, J0461 are reported for 0.02 mg of atropine sulfate (and because 0.2 mg was administered, code J0461 would be reported once on the CMS-1500 claim with 2 as the number of units).
45-year-old female underwent total abdominal hysterectomy during the inpatient hospital admission due to a Class IV (carcinoma cells present) Pap test result that was confirmed by colposcopy.A metastatic survey, including cystoscopy and sigmoidoscopy (with biopsies), intravenous pyelogram, and chest x-ray, all performed previous to admission on an outpatient basis, revealed no signs of metastasis. The patient chose to undergo surgery that preserves ovarian function.
ICD-10-CM: C53.9 ICD-10-PCS: 0UT90ZZ, 0UT90ZZ
Hospital—Inpatient (Gynecology)Patient Name: Sally StraightDiagnosis: Malignant neoplasm of cervix uteriA 45-year-old female underwent total abdominal hysterectomy during the inpatient hospital admission due to a Class IV (carcinoma cells present) Pap test result that was confirmed by colposcopy.A metastatic survey, including cystoscopy and sigmoidoscopy (with biopsies), intravenous pyelogram, and chest x-ray, all performed previous to admission on an outpatient basis, revealed no signs of metastasis. The patient chose to undergo surgery that preserves ovarian function. Instructions:Assign ICD-10-CM and ICD-10-PCS codes for this case. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code.
ICD-10-CM: C53.9 ICD-10-PCS: 0UT90ZZ, 0UT90ZZ
Outpatient—Physician Office (Musculoskeletal and Connective Tissue) Patient Name: Mary Smith A patient is seen at a physician's office for an initial visit, complaining of pain and limited range of motion of her right pinky finger knuckle. Level 2 evaluation and management (E/M) service was provided during which the physician examines the joint and notices a solid mass. Two-view x-ray of right pinky finger reveals no arthritis or stalk-like growth. The diagnosis is ganglion cyst, little finger knuckle joint, right. The patient is scheduled for outpatient surgery to remove the ganglion.
Instructions: Assign ICD-10-CM and CPT codes for this case. ICD-10-CM: CPT: , Hide Feedback Partially Correct Check My Work Feedback ICD-10-CM code M67.441 is reported for the ganglion cyst of the right hand. CPT code 99203 is reported for the level 2 new patient E/M service and code 73140-RT is reported for the right pinky finger x-ray.
Hospital—Inpatient (Circulatory) Patient Name: Patrick Donovan Diagnosis: Second-degree atrioventricular heart block Procedure: Initial insertion of dual-chamber pacemaker A 65-year-old patient is admitted to a hospital with a diagnosis of second-degree atrioventricular heart block. The patient underwent subcutaneous insertion of a dual-chamber (atrial and ventricular) permanent pacemaker with transvenous electrodes.
Instructions: Assign ICD-10-CM and CPT codes for this case. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code. ICD-10-CM: CPT: Hide Feedback Partially Correct Check My Work Feedback ICD-10-CM code I44.1 is reported for second-degree atrioventricular heart block. CPT code 33208 is reported for initial insertion of dual-chamber pacemaker.
Hospital—Inpatient (Gynecology) Patient Name: Sally Straight Diagnosis: Malignant neoplasm of cervix uteri A 45-year-old female underwent total abdominal hysterectomy during the inpatient hospital admission due to a Class IV (carcinoma cells present) Pap test result that was confirmed by colposcopy. A metastatic survey, including cystoscopy and sigmoidoscopy (with biopsies), intravenous pyelogram, and chest x-ray, all performed previous to admission on an outpatient basis, revealed no signs of metastasis. The patient chose to undergo surgery that preserves ovarian function.
Instructions: Assign ICD-10-CM and ICD-10-PCS codes for this case. ICD-10-CM: ICD-10-PCS: , Hide Feedback Correct Check My Work Feedback ICD-10-CM code C53.9 is reported for malignant neoplasm of cervix uteri, unspecified. ICD-10-PCS code 0UT90ZZ is reported for resection of uterus, open approach, and code 0UTC0ZZ is reported for resection of cervix, open approach; both codes are required to classify a total abdominal hysterectomy.
Physician Office—Family Practice Patient: Jake Atkins Chief Complaint: "My stomach hurts, and I feel full of gas." This 37-year-old established male patient presents with epigastric pain in the mid-abdominal region associated with constant nausea and vomiting. He is unable to keep down food or liquids. Pain is "severe and constant." The patient has had an estimated 18-pound weight loss over the past month. He reports eating 12 pieces of bacon at a holiday breakfast last week, which is when his symptoms started. An Evaluation and Management exam was performed: Vital signs reveal 99.8°F temperature, otherwise normal. Abdomen is distended and tender across upper abdomen. Guarding is present. Bowel sounds are diminished in all four quadrants. Assessment: Epigastric abdominal tenderness. Dehydration. Suspected acute pancreatitis. Medical decision making of low complexity. Plan: Inpatient hospitalization. Orders documented and sent to hospitalist. Patient's spouse was notified of plan, and she will transport to hospital by private vehicle now.
Partially Correct Check My Work Feedback ICD-10-CM code E86.0 is reported for dehydration. ICD-10-CM code R10.816 is reported for epigastric abdominal tenderness. Do not report an ICD-10-CM code for suspected acute pancreatitis, which is a qualified diagnosis (uncertain diagnosis). CPT code 99213 is reported for evaluation and management of the patient in an outpatient or other (e.g., physician office) setting; the physician documented an Evaluation and Management exam and medical decision making of low complexity.
Patient Name: Walters, Mags Medical Record #: 100021 Admission Date: 11/07/YYYY
Patient complains of right left knee pain. Radiologist's impression is unremarkable. Therefore, assign a diagnosis code to "right left knee pain. M25.562
Patient Name: Bornman, Carole Medical Record #: 1011302 Admission Date: 04/12/YYYY
Patient presented to the ED complaining of a rash. Impression is acute allergic reaction to unknown irritant with urticarial and pruritis. Assign T78.40XA for the allergic reaction. In addition, assign L50.0 and L29.9 as additional codes to indicate the type of reaction. Patient has a known dust and mold allergy, however, this cannot be confirmed as the reason for her current allergic reaction. Assign Z91.048 to indicate allergy status.The key components listed on the case should be used to select the proper E&M code level. Assign 99283 for expanded problem focused history/exam, medical decision making of moderate complexity and severity.Per the ED Course, the patient was treated with Epinephrine 1:1000, 0.3 mL subcutaneously and 50 mg Benadryl intramuscularly. Assign CPT code 96372 x2 for the injections. Assign HCPCS codes J1200 and J0171 for the drugs administered.
Patient Name: Rosenblatt, Jennifer Medical Record #: 0001317 Admission Date: 02/15/YYYY
Patient presents to emergency department for a knee contusion. Assign a diagnosis code to the injury and additional external cause codes per documentation in the patient's record for cause and place of injury. Impression states "acute right knee contusion and abrasion," therefore, assign S80.01XA and S80.211A as the injuries codes. Assign W22.09XA to represent "strike against cabinet," and place of occurrence code Y92.009 for "home."Assign 99282 for The CPT evaluation and management component which was problem focused, medical decision making of low complexity and low to moderate severity. In addition, there is documentation of the RT Knee x-ray, CPT code 73560-RT.
Patient Name: White, Blanche Medical Record #: 334357 Admission Date: 04/26/YYYY
Patient presents with abdominal pain, nausea, vomiting, and weakness. After further review, it was determined that the admitting symptoms were due to the definitive diagnosis of cholecystitis with cholelithiasis, which is assigned to code K80.10 as the first-listed diagnosis. Fever is a common sign of the cholecystitis with cholelithiasis, so it is considered integral to the principal dx and is not coded.Patient is also diagnosed with "confusion." The source of her confusion is not indicated; therefore, code R41.0, Disorientation, is assigned.Type 2 diabetes and HTN are both chronic illnesses that are documented and treated; therefore, report E11.9 and I10 as additional diagnoses. The instructional note for code E11.9 says to use additional code to identify diabetes control. Patient is treated with Amaryl, so code Z79.84 is also assigned to indicate use of anti-diabetic drugs. In ICD-10-CM, a diagnosis of "smoker" is assigned to code F17.200. (Coding Clinic, Fourth Quarter 2013: Page 108) In addition, report status Z codes for allergy to penicillin and amoxicillin.
Patient Name: Murphy, Jenn Medical Record #: 199670 Admission Date: 01/08/YYYY
Patient underwent routine mammography with family history of breast cancer. Per section I.C.21.c.5. in the ICD-10-CM Guidelines for Coding and Reporting, if additional conditions are documented on the screening mammography, secondary ICD-10-CM codes should be added to the encounter to capture these conditions. Family history would be captured as the secondary dx. In addition, assign CPT code 77067 for the bilateral screening mammography Diagnosis Code(s): ICD-10-CM 1.Z12.31 2.Z80.3 Procedure Code(s): CPT/HCPCS Level II Code Modifier(s) 1.77067
Patient Name: Smiley, Linda Medical Record #: 158470 Admission Date: 11/01/YYYY
Patient's diagnosis is atrial fibrillation, I48.91, which is treated by a transesophageal echocardiography (TEE) guided cardioversion. In addition, assign codes to HIV disease and history of melanoma. Incidentally, a PFO was discovered on the TEE. Report Q21.1, Atrial septal defect. In ICD-10-PCS, procedure code 5A2204Z is assigned for cardioversion and B245ZZ4 for TEE procedure.
Patient Name: Wilson, Thomas Medical Record #: 873496 Admission Date: 01/10/YYYY E.H.R. Resources
Report J18.9, Pneumonia, as the principal diagnosis.The patient also has severe COPD. Per Coding Clinic, Third Quarter 2016: Page 16, report code J44.0, Chronic obstructive pulmonary disease with acute lower respiratory infection" when pneumonia is present with COPD.In ICD-10-CM, a diagnosis of "smoker" is assigned to code F17.200. (Coding Clinic, Fourth Quarter 2013: Page 108) Additional diagnoses to report are coronary artery disease of the native coronary artery and history of bladder cancer.
Patient Name: Smith, Amy Medical Record #: 0001249 Admission Date: 11/07/YYYY
The exam was initially performed to check the anatomy of the fetus. It was discovered that the fetus was in a transverse position. Therefore, for the diagnosis code, assign O32.2XX0, Maternal care for transverse and oblique lie. For ICD-10-CM category Z3A, 20 weeks of gestation is documented on sonogram. CPT code 76815 is utilized for the OB sonogram.
Patient Name: Harrison, John Medical Record #: 157222 Admission Date: 12/15/YYYY
This patient is undergoing a CT of the abdomen and pelvis region because of weight loss s/p colostomy. Report R63.4, Abnormal weight loss and Z93.3, Colostomy status. The radiologist noted incidental findings of kidney atrophy, cyst of (R) kidney, hypodense liver and post operative cholecystectomy which are also coded.Assign CPT code 74177 for CT Abdomen with contrast. Diagnosis Code(s): ICD-10-CM 1.R63.4 2.Z93.3 3N28.1 4.N26.1 5.K76.89 6.Z90.49 Procedure Code(s): CPT/HCPCS Level II Code Modifier(s) 1.74177
Patient Name: Bannister, Meg Medical Record #: 0129781 Admission Date: 11/11/YYYY
U/S Abdomen was ordered due to Hepatitis C and an abnormal liver function test (LFT). Assign CPT code 76700 for US Abdomen Complete. "History of" is a common phrase documented by physicians and may include active conditions. Although the diagnostic imaging report states "History" of Hepatitis C and abnormal LFT, these conditions are the reason that the ultrasound is being performed, therefore, they are considered active conditions unless otherwise stated by the provider. Assign B19 .20, Hepatitis C; and R94.5, Abnormal results of LFT. Incidental finding of gallstone scan also be coded. Do not code "mild hepatomegaly" as the radiologist is uncertain if this is normal for the patient. Back to quiz summary B19.20, R94.5, K80.20 PROCEDURE CODE:76700
Patient Name: Wilson, Thomas Medical Record #: 873496 Admission Date: 08/11/YYYY
Urinary tract infection (UTI) is coded as established for inpatient cases, even though the qualified term "possible" is included with the diagnosis. Do not code "dysuria" because it is a symptom of possible UTI. In addition, other chronic illnesses that are documented with evidence of current treatment/medication are reported. This includes CAD, hyperlipidemia, hypertension, anxiety/depression, GERD, renal insufficiency and osteoarthritis. Report status Z codes for allergy status to Codeine, Zithromax and Penicillin.
Patient Name: Greene, Robert Medical Record #: 694171 Admission Date: 05/07/YYYY
liotibial band (ITB) rupture = iliotibial band tear = iliotibial band laceration. The iliotibial band is fascia that covers the thigh muscle from the hip to the tibia. There is a condition called "ITB syndrome," which is a kind of seizing up of the fascia, usually due to extreme exercise. However, ITB syndrome does not apply to this case because the patient fell, and that fascia ruptured/tore/lacerated. ITB rupture is a trauma code, and so the initial encounter character must also be assigned. "Hematoma" is classified as "contusion," and the type of encounter must be assigned to the code; the patient record (history and physical examination) documents the initial encounter, and so "initial encounter" does not have to be entered after the "hematoma ..." diagnosis on the face sheet. Do not assign ICD-10-CM code Y92.9 (place of occurrence unspecified) or Y93.9 (activity unspecified), per CMS official coding guidelines. The procedure "evacuation of hematoma" is classified as "extirpation," and site is "Skin" of "left upper leg." The repair of the ITB rupture is coded as "repair" of "subcutaneous tissue and fascia," "left upper leg" in ICD-10-PCS.