AAPC CPC Chapter 4

B

A 12-year-old child presents to the ED with an acute exacerbation of asthma. The patient is wheezing and is having difficulty breathing. She is not responding to the therapy. The physician documents as the final diagnosis asthma with status asthmaticus. What ICD-10-CM code(s) is/are reported? A) J45.901 B) J45.902 C) J45.52 D) R06.2, J45.901

C

A 21 year-old male is brought into the ED by his father who states that his son is dizzy and has anxiety. The ED provider runs a drug screen test and the test comes back positive for marijuana use. The final diagnosis is documented as marijuana abuse with anxiety disorder. What ICD-10-CM code is reported? A) F12.129 B) F12.10 C) F12.180 D) F19.10

B

A 22 year-old patient status post-surgery developed a postoperative infection. The patient quickly deteriorated and became septic, developed gas gangrene (gas bacillus infection) and went into postprocedural septic shock. With aggressive intravenous antibiotic management, the patient improved. What ICD-10-CM codes are reported? A) T81.12XA, R65.21, A48.0 B) T81.4XXA, A48.0, T81.12XA C) R65.21, A48.0, T81.12XA D) A48.0, R65.21, T81.4XXA

A

A 22-year-old female is admitted to ICU for acute renal (kidney) failure due to sepsis (causal organism unknown). Applying the coding concept from ICD-10-CM guideline I.C.1.d.1.b, what ICD-10-CM codes are reported (in the correct sequencing)? A) A41.9, R65.20, N17.9 (Sepsis with unknown etiology is primary, followed by required additional severe sepsis code, and followed by associated organ dysfunction code) B) N17.9, R65.20, A41.9 C) R65.21, A41.9, N17.9 D) N17.9, R65.21, A41.01

D

A 32 year-old female had a mastectomy for breast cancer. The mastectomy completely removed the breast cancer. On a follow up visit to her oncologist, it is determined the cancer has metastasized to the right lung. The patient is now undergoing a lung resection for the lung cancer. Applying the coding concept from ICD-10-CM guidelines I.C.2.b. and Section I.C.2.d. what ICD-10-CM codes are reported for the lung resection? A) C50.911, C78.01 B) Z85.3, C78.01 C) C78.01, C50.911 D) C78.01, Z85.3 (c78.01 = Secondary malignant neoplasm of lung to be used as primary diagnosis code, and z85 = history of personal malignant neoplasm used as secondary diagnosis code)

B

A 32 year-old patient with an ophthalmoplegic migraine is not responding to medication and is admitted to the observation unit. What ICD-10-CM code is reported? A) G43.119 B) G43.B1 C) G43.B0 D) G43.101

B

A 33 year-old patient visits his primary care provider to discuss lap band procedure for his morbid obesity. His caloric intake is in excess of 4,000 calories per day and his BMI is currently 45. What ICD-10-CM code(s) is/are reported? A) E66.01 B) E66.01, Z68.42 C) E66.01, Z68.45 D) E66.3, Z68.45

A

A 35 year-old woman is experiencing dizziness with nausea and vomiting. The provider documents auditory vertigo of both ears, possible Meniere's disease. What ICD-10-CM code(s) is/are reported? A) H81.313 (aural vertigo, bilateral) B) R42, R11.2 C) H81.319 D) H93.8X3, R42, R11.2

C

A 45 year-old patient is scheduled to have an INFUSAID pump installed. He has primary liver cancer and the pump is being inserted for continuous administration of 5-FU. A pocket is created just under the skin and the pump is placed in the pocket. A catheter is attached to the pump and to the subclavian vein. The pump is filled with a chemotherapy agent provided by the hospital and the patient is observed for adverse reaction and discharged to home. What ICD-10-CM codes are reported? A) Z51.11, C22.9 B) C22.8, Z51.11 C) Z51.11, C22.8 (encounter for chemotherapy is primary code per I.C.2.e.2) D) C22.9, Z51.12

A

A 50 year-old patient has a mass removed from his chest. The surgeon sends it to pathology. The pathology report indicates the mass is a benign tumor. What ICD-10-CM code is reported? A) D36.7 B) D49.2 C) C79.89 D) C49.3

C

A 50 year-old patient has been diagnosed with elevated blood pressure. The patient does not have a history of hypertension. What is the correct ICD-10-CM code to report? A) I15.0 B) I10 C) R03.0 D) I13.0

C

A 58 year-old patient sees the provider for confusion and loss of memory. The provider diagnoses the patient with early onset stages of Alzheimer's disease with dementia. What ICD-10-CM codes are reported? A) G30.0, F02.80, F29, R41.3 B) F02.80, G30.0 C) G30.0, F02.80 D) F02.80, G30.0, F29, R41.3

B

A 65 year-old female patient returns to her primary care provider for follow up of an upper respiratory infection diagnosed the previous week. Her condition has not improved and her cough has increased. She has a long history of smoking. She currently smokes one pack a day and is dependent on the cigarettes. She uses a bronchodilator for her COPD. The provider changes her antibiotics to treat her acute bronchitis with COPD. What ICD-10-CM codes are reported for this visit? A) J44.0, Z72.0 B) J44.0, J20.9, F17.210 C) J44.0, J21.9, F17.210 D) J44.9, J20.9, Z72.0

C

A lab screening shows congenital iodine-deficiency hypothyroidism for an infant with identified intellectual disability. What ICD-10-CM code(s) is/are reported? A) F79, E00.9 B) E00.9 C) E00.9, F79 D) E03.8, F79

C

A patient is brought in by the ambulance with seizures. After examination and workup is complete, it is determined the seizures were due to alcohol abuse with intoxication. What ICD-10-CM code(s) is/are reported? A) F10.129 B) G40.509, F10.120 C) R56.9, F10.129 (This was a seizure brought on by the intake of alcohol. Look in the ICD-10-CM Alphabetic Index for Seizure(s) directing you to code R56.9. Documentation states alcohol abuse not alcoholism with intoxication. Look in the Alphabetic Index for Abuse/alcohol/with/intoxication directing you to F10.129.) D) G40.501, R56.9, F10.129

A

A patient is having phacoemulsification of an age-related nuclear cataract of the left eye. What ICD-10-CM code is reported? A) H25.12 B) H26.032 C) H26.9 D) Q12.0

A

A patient is having surgery to repair a recurrent left inguinal hernia without obstruction. What ICD-10-CM code is reported? A) K40.91 B) K40.90 C) K40.21 D) K40.20

C

A patient is seen in the ED for having unprotected sexual intercourse a few months prior. She recently found out that the individual she was with has HIV. She is only being tested for HIV. What ICD-10-CM code(s) is/are reported? A) B20, Z71.7 B) Z21 C) Z11.4 D) B20

B

A patient presents to the ED with weakness on the left side and aphasia. Tests are ordered and the patient is admitted with a cerebrovascular accident (CVA). What ICD-10-CM code(s) is/are reported? A) I63.50 B) I63.9 C) R53.1, R47.01 D) I67.89

C

A patient returns to the provider for an injection to relieve low back pain from a car accident. What ICD-10-CM code(s) is/are reported? A) G89.21, M54.5 B) G89.11, M54.5 C) M54.5 (Pain is not described as acute or chronic, so no g89 code is reported) D) M54.5, G89.11

B

A patient sees her provider for spontaneous episodes of vertigo lasting 30 minutes each, fluctuating hearing loss, and tinnitus. The provider performs a hearing test and confirms hearing loss in the right ear. The provider documents the patient has Meniere's disease in the right ear. What ICD-10-CM code(s) is (are) reported? A) R42, H91.91, H93.11 B) H81.01 C) H93.8X1 D) H81.01, H81.41, H91.21, H93.11

D

A patient with a four-year history of eating disorders is seen in the physician's office due to significant weight loss over the past three months. She went from 82 pounds down to 53 pounds due to restricting her food intake. She is diagnosed with anorexia nervosa. Select the diagnosis code(s). A) F50.02 B) F50.02, R63.4 C) F50.01, R63.4 D) F50.01

C

A patient with chronic back and neck pain developed a drug dependency on oxycodone (opioid). After being taken off the drug, he was seen in the clinic for withdrawal symptoms. What ICD-10-CM codes are reported? A) F11.23, T40.2X5S B) F11.24, T40.2X5D C) F11.23, T40.2X5A D) F11.10, F11.23, T40.2X5A

A

A pediatrician sees an 8 month-old patient for ear pulling and excessive crying. The infant is diagnosed with bilateral chronic and acute serous otitis media. What ICD-10-CM code(s) is/are reported? A) H65.03, H65.23 (sequence acute code first, but also include chronic) B) H65.20 C) H65.21, H65.22 D) H65.93

D

A provider performed an aspiration via thoracentesis on a patient in observation status in the hospital. The patient has advanced right lung cancer that has metastasized to the pleura with malignant pleural effusion. Later the same day, due to continued accumulation of fluid, the patient was returned to the procedure room and the same provider performed a repeat thoracentesis. What ICD-10-CM codes are reported? A) C34.91, C78.2, J91.0 B) C78.2, C34.91 C) J91.0 D) C78.2, C34.91, J91.0

D

A young female, was brought to the clinic by her sister. She has had periods of severe depression for many years and is on Lithium. Her provider also manages her manic-depressive psychosis, hypothyroidism, and migraine headaches. Additional medications are Synthroid and Midrin. During the past week, she became manic, running all her credit cards to the limit, getting inappropriately involved in a friend's suicide attempt, quitting her job, and trying to take over the pulpit at church. On the day of the clinic visit, she threatened to strike the telephone repairman with a lead pipe. She was admitted for Lithium adjustment. Diagnoses are: moderate manic-depressive bipolar with circular current manic state, hypothyroidism, and migraine. What ICD-10-CM codes are reported? A) F31.32, E03.9, G43.909 B) F31.89, G43.911, E03.8 C) F31.62, E03.9, G43.911 D) F31.12, E03.9, G43.909

C

A young male, was brought to the clinic by his mom. He has had periods of major depression for many years and is on Lithium. His provider also manages his migraine headaches and epilepsy. During the past week, he became psychotic, hearing voices to kill himself and intense feelings of worthlessness. On the day of the clinic visit, he had an epileptic seizure that could not be controlled by medication. He was admitted for Lithium adjustment. Final diagnoses are: Severe depression with psychotic behavior and epileptic seizure poorly controlled with medication. What ICD-10-CM codes should be reported? A) F33.3, G43.909, G40.909 B) F33.2, G40.909 C) F33.3, G40.919 D) F33.1, G43.919, G40.919C

C

According to ICD-10-CM guidelines, what is the maximum length of time for a A) Only at the time of occurrence B) Eight weeks C) Four weeks (28 days) D) One week

C

An HIV positive patient was admitted with skin lesions on the chest and back. Biopsies were taken, and the pathologic diagnosis was Kaposi's sarcoma. Leukoplakia of the lips and splenomegaly were also noted on physical examination. Discharge diagnoses: (1) HIV infection, (2) Kaposi's sarcoma, back and chest, (3) leukoplakia (4) splenomegaly. What ICD-10-CM codes should be reported? A) Z21, C46.0, K13.21, R16.1 B) R16.1, C46.0, R16.1, Z21 C) B20, C46.0, K13.21, R16.1 D) B20, C46.0, K13.21, R16.1, Z21

C

An elderly male patient presents to the ED complaining of a high fever the day prior to the encounter and of extreme lethargy. He has a history of benign hypertension which has been elevated. On arrival he was examined and admitted, with possible septic urinary tract infection and concern for his elevated blood pressure. He was noted to have hematuria. Positive UTI and pseudomonas showed in the urine culture and IV antibiotics were administered. During the course of the day, his fever decreased and his lethargy improved. He was noted to have hematuria. As the IV fluids were decreased, he resumed a benign hypertensive state. On the next hospital day, the urine was clear and he was discharged on oral antibiotics, with septicemia ruled out. What ICD-10-CM codes should be reported? A) I10, B95.6, R31.9, N39.0 B) B96.5, N39.0, I10, R31.9 C) N39.0, B96.5, I10 D) B95.6, A41.52, N39.0, I10

C

Patient with coronary arteriosclerosis disease (CAD) sees his cardiologist to discuss a coronary artery bypass graft (CABG). This will be the patient's first CABG. What ICD-10-CM code is reported? A) I25.759 B) I25.810 C) I25.10 D) I25.720

B20, D73.3, K65.1, B19.20

CASE 1 Operative Report PREOPERATIVE DIAGNOSES: Splenic abscesses and multiple intra-abdominal abscesses, related to HIV, AIDS, and hepatitis C. POSTOPERATIVE DIAGNOSES: Splenic abscesses and multiple intra-abdominal abscesses, related to HIV, AIDS, and hepatitis C. (Postoperative diagnoses are reported.) OPERATIVE PROCEDURE: 1. Exploratory laparotomy with drainage of multiple intra-abdominal abscesses. 2. Splenectomy. 3. Vac Pak closure. FINDINGS: This is a 42-year-old man who was recently admitted to the medical service with a splenic defect and found to a splenic vein thrombosis. He was treated with antibiotics and anticoagulation. He returned and was admitted with a CT scan showing mass of left upper quadrant with abscesses surrounding both sides of the spleen(The location of the abscesses are on both sides of the spleen.), as well as, multiple other intra-abdominal abscesses below the left lobe of the liver in both lower quadrants and in the pelvis. The patient has a psychiatric illness and was difficult to consent and had been anticoagulated with an INR of 3. Once those issues were resolved by psychiatry consultation and phone consent from the patient's father, he was brought to the operating room. OPERATIVE PROCEDURE: The patient was brought to operating room, a time-out procedure was performed. He was already receiving parenteral antibiotics. He was placed in the supine position and then given a general endotracheal anesthetic. Anesthesia started multiple IVs and an arterial line. A Foley catheter was sterilely inserted with some difficulty requiring a Coude catheter. After the abdomen was prepped and draped in the sterile fashion, a long midline incision was made through the skin. This was carried through the subcutaneous tissues and down through the midline fascia using the Bovie. The fascia was opened in the midline. The entire left upper quadrant was replaced with an abscess peel separate from the free peritoneal cavity. This was opened, and at least 3 to 4 L of foul smelling crankcase colored fluid were removed. Once the abscess cavity was completely opened, it was evident that the spleen was floating within this pus(Confirms the location of the abscess.) as had been predicted by the CT. This was irrigated copiously and the left lower quadrant subhepatic and pelvic abscesses (Location of abscesses.) were likewise discovered containing the same foul smelling dark bloody fluid. All of these areas were sucked out, irrigated, and the procedure repeated multiple times. We thought it reasonable to go ahead with the splenectomy. The anatomic planes were obviously terribly distorted. There was no clear margin between stomach spleen, colon spleen, etc., but most of the dense attachments were to the abscess cavity peel. Using this as a guide, the spleen was eventually rotated up and out to the point where the upper attachments presumably where the short gastric used to reside were taken via Harmonic scalpel. The single fire of a 45 mm stapler with vascular load was taken across the lower pole followed by two firings of the echelon stapler across the hilum. This controlled most of the ongoing bleeding. Single bleeding site below the splenic artery was controlled with two stitches, one of 3-0 Prolene and the other of 4-0 Prolene. Because of diffuse ooze in the area and the fact that the patient would be scheduled for a return visit to the operating room tomorrow to reinspect the abscess cavities, it was elected to leave two laparotomy pads in the left upper quadrant and Vac Pak the abdomen. The Vac Pak was created using blue towels and Ioban dressings in the usual fashion with 10 mm fully perforated flat Jackson-Pratt drains brought out at the appropriate level. The patient was critical throughout the procedure and will be taken directly to the intensive care unit, intubated, with a plan for reexploration and removal of the packs tomorrow. The patient received four units of packed cells during the procedure, as well as albumin and a large volume of crystalloid. There were no intraoperative complications noted and the specimen sent included the spleen. Cultures from the abscess cavity were also taken. What diagnosis code(s) are reported? Dx #1: Dx #2: Dx#3: Dx#4:

C50.922, G89.3, M54.2, Z17.0, Z79.810

CASE 2 Dear Dr. Smith, Mr. Martin was seen in the office for continued management of his breast cancer.(This indicates the patient's main reason for the office visit.) He's having some increasing pain in his breast which is due to the cancer.(Pain related to the neoplasm.) He is also complaining of neck pain. It does not seem to be worse at night; it seems to be worse with activity. He has no other symptoms. Otherwise his review of systems is unremarkable. He's had no constitutional symptoms. On physical exam, he is alert and oriented. Eyes: EOMI, PERLA, no icterus. The heart had a regular rate and rhythm; S1, S2 within normal limits. The lungs are clear to auscultation and percussion. The abdomen was soft, without masses or organomegaly. He was tender to palpation over the left anterior iliac crest. Otherwise he had no point tenderness over his musculoskeletal system. Neck: Supple. No tenderness, no enlarged lymph nodes in the neck. ASSESSMENT: Adenocarcinoma of the left breast, positive estrogen receptor status. Neck pain. (This is the definitive diagnosis that is reported.) PLAN: The plan is to continue the Tamoxifen at this time. His laboratory studies were reviewed and were essentially unremarkable; however we'll obtain a bone scan to ascertain the extent of his disease.(This is a male patient.) Sincerely, John Smith, M.D. What diagnosis code(s) are reported? Dx #1: Dx #2: Dx #3: Dx #4: Dx #5:

E10.40, J01.90

CASE 3 SUBJECTIVE: Low-grade fever at home. She has had some lumps in the abdominal wall and when she injects her insulin; it does seem to hurt there. She stopped four of her medications including Neurontin, Depakote, Lasix, and Premarin, and overall she feels quite well. Unfortunately, she has put on 20 pounds since our last visit. OBJECTIVE: HEENT: Tympanic membranes are retracted but otherwise clear. The nose shows significant green rhinorrhea present. Throat is mildly inflamed with moderate postnasal drainage. Neck: No significant adenopathy. Lungs: Clear. Heart: Regular rate and rhythm. Abdomen: Soft, obese, and nontender. Multiple lipomas are palpated. ASSESSMENT 1. Diabetes mellitus, type 1. 2. Diabetic neuropathy. 3. Acute sinusitis. (The definitive diagnoses are reported.) PLAN: At this time, I have recommended the addition of some Keflex for her acute sinusitis.(Provider treated the acute sinusitis.) I have given her a chair for the shower. They will not cover her Glucerna anymore so a note for that will be required. What diagnosis code(s) are reported? Dx #1: Dx #2:

I25.10 , R78.5, Z87.891, Z79.899

CASE 4 S: The patient presents today for reevaluation and titration of carvedilol for his coronary artery disease and hyperlipidemia.(Patient returns for treatment of CAD and hyperlipidemia.) His weight is up 7 pounds. He has quit smoking. He has no further cough and he states he is feeling well except for the weight gain. He states he doesn't feel he's eating more, but his wife says he's eating more. We've been attempting to titrate up his carvedilol to 25mg twice a day from initially 6.25mg. He has tolerated the titration quite well. He gets cephalgias on occasion. He states he has a weak spell but this is before he takes his morning medicine. I updated his medical list here today. I gave him samples of Lipitor. O: Weight is 217, pulse rate 68, respirations 16, and blood pressure 138/82. HEENT examination is unchanged. His heart is a regular rate. His lungs are clear. A: 1. CAD 2. Hyperlipidemia (Select the codes for the definitive diagnoses.) P: 1.The plan is samples of Lipitor using the two months' supply that I have given him. 2. We've increased his Coreg to 25mg bid. He'll recheck with us in six months. What diagnosis code(s) are reported? Dx #1: Dx #2: Dx #3: Dx #4:

H90.3

CASE 5 PREOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss. POSTOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss.(Report the postoperative diagnosis.) PROCEDURES PERFORMED: 1. Placement of left Nucleus cochlear implant. 2. Facial nerve monitoring for an hour. 3. Microscope use. ANESTHESIA: General. INDICATIONS: This is a 69-year-old woman who has had progressive hearing loss (The diagnosis is documented as the indication for the surgery.) over the last 10-15 years. Hearing aids are not useful for her. She is a candidate for cochlear implant by FDA standards. The risks, benefits, and alternatives of procedure were described to the patient, who voiced understanding and wished to proceed. PROCEDURE: After properly identifying the patient, she was taken to the main operating room, where general anesthetic was induced. The table was turned to 180 degrees and a standard left-sided post auricular shave and injection of 1% lidocaine plus 1:100,000 epinephrine was performed. The patient was then prepped and draped in a sterile fashion after placing facial nerve monitoring probes, which were tested and found to work well. At this time, the previously outlined incision line was incised and flaps were elevated. A subtemporal pocket was designed in the usual fashion for placement of the device. A standard cortical mastoidectomy was then performed and the fascial recess was opened exposing the area of the round window niche. The lip of the round window was drilled down exposing the round window membrane. At this time, the wound was copiously irrigated with bacitracin containing solution, and the device was then placed into the pocket. A 1-mm cochleostomy was made, and the device was inserted into the cochleostomy with an advance-off stylet technique. A small piece of temporalis muscle was packed around the cochleostomy, and the wound was closed in layers using 3-0 and 4-0 Monocryl and Steri-Strips. A standard mastoid dressing was applied. The patient was returned to anesthesia, where she was awakened, extubated, and taken to the recovery room in stable condition. What diagnosis code(s) are reported? Dx #1:

H26.9 (Other Catarac, unspecified), H52.4 (Presbyopia)

CASE 6 PREOPERATIVE DIAGNOSIS: Cataract, left eye POSTOPERATIVE DIAGNOSIS: Cataract eye Presbyopia PROCEDURE: 1 Cataract extraction with IOL implant 2 Correction of presbyopia with lens implantation PROCEDURE DETAIL: The patient was brought to the operating room under neuroleptic anesthesia monitoring. A topical anesthetic was placed within the operative eye and the patient was prepped and draped in usual manner for sterile ophthalmic surgery. A lid speculum was inserted into the right infrapalpebral space. A 6-0 silk suture was placed through the episclera at 12 o'clock. A subconjunctival injection of non-preserved lidocaine was given. A peritomy was fashioned from 11 o'clock to 1 o'clock with Westcott scissors. Hemostasis was achieved with the wet-field cautery. A 3-mm incision was made in the cornea and dissected anteriorly with a crescent blade The anterior chamber was entered at 12 o'clock and 2 o'clock with a Supersharp blade. Non-preserved lidocaine was instilled into the anterior chamber. Viscoelastic was instilled in the anterior chamber and using a bent 25-guage needle, a 360-degree anterior capsulotomy was performed using Utrata forceps. The capsulotomy was measured and found to be 5.5 mm in diameter. Using an irrigating cannula, the lens nucleus was hydrodissected and loosened. Using the phacoemulsification unit, the lens nucleus was divided and emulsified. The irrigating/aspirating tip was used to remove the cortical fragments from the capsular bag, and the posterior capsule was polished. Using a curette to polish the anterior capsule, cortical fragments were removed from the anterior lens capsule for 270 degrees. The irrigating/aspirating tip was used to remove the capsular fragments. The anterior chamber and capsule bag were inflated with viscoelastic and using a lens inserter, a Cystalens was then placed within the capsular bag and rotated to the horizontal position. The viscoelastic was removed with the irrigating/aspirating tip and the lens was found to be in excellent position with a slight posterior vault. The wound was hydrated with balanced salt solution and tested and found to be watertight at a pressure of 20 mmHg. Topical Vigamox was applied The conjunctiva was repositioned over the wound with a wet field cautery. The traction suture and lid speculum were removed. A patch was applied. The patient tolerated the procedure well and left the operating room in good condition. What diagnosis code(s) are reported? Dx #1: Dx #2:

I48.91 (atrial fibrillation, unspecified), Z79.01 (long-term use of anticoagulants), Z51.81 (therapeutic drug monitoring)

CASE 7 PROGRESS NOTE This patient is a 50 year-old female who began developing bleeding, bright red blood per rectum, approximately two weeks ago. She is referred by her family physician. She states that after a bowel movement she noticed blood in the toilet. She denied any prior history of bleeding or pain with defecation. She states that she has had an external hemorrhoid that did bleed at times but that is not where this bleeding is coming from. She is presently concerned because a close friend of hers was recently diagnosed with rectal carcinoma requiring chemotherapy that was missed by her primary doctor. She is here today for evaluation for a colonoscopy. Physical examination, she appears to be a well appearing 50 year-old, white female. Abdomen is soft, non-tender, non-distended. ASSESSMENT: 50 year-old female with rectal bleeding PLAN: We'll schedule the patient for an outpatient colonoscopy. The patient was made aware of all the risks involved with the procedure and was willing to proceed. What diagnosis code(s) are reported? Dx #1: K62.5 CASE 8 Subjective: Here to follow up on her atrial fibrillation. No new problems. Feeling well. Medications are per medication sheet. These were reconstituted with the medications that she was discharged home on. 0bjective: Blood pressure is 110/64. Pulse is regular at 72. Neck is supple. Chest is clear. Cardiac normal sinus rhythm. Assessment: Atrial fibrillation, currently stable Plan: 1. Prothrombin time to monitor long term use of anticoagulant. 2. Follow up with me in one month or sooner as needed if she has any other problems in the meantime. Will also check a creatinine and potassium today. Dx #1: Dx #2: Dx #3:

I10

CASE 9 Follow-up Visit: The patient has some memory problems. She is hard of hearing. She is legally blind. Her pharmacist and her family are very worried about her memory issues. She lives at home, family takes care of laying out her medications and helping with the chores, but she does take care of her own home to best of her ability. Exam: Pleasant elderly woman in no acute distress. She has postop changes of her eyes. TMs are dull. Pharynx is clear. Neck is supple without adenopathy. Lungs are clear. Good air movement. Heart is regular. She had a slight murmur. Abdomen is soft. Moderately obese. Non-tender. Extremities; no clubbing or edema. Foot exam shows some bunion deformity but otherwise healthy. Light touch is preserved. There is no ankle edema or stasis change. Examination of the upper arms reveal good range of motion. There is significant pain in her shoulder with rotational movements. It is localized mostly over the deltoid. There is no other deformity. There is a very slight left shoulder discomfort and slight right hip discomfort. Impression: 1. Dementia 2. Right shoulder pain. 3. Benign hypertensive cardiovascular disease. 4. Type 2 diabetes good control. Most recent AlC done today 5.9%. Liver test normal. Cholesterol 199, LDL a little high at 115. Plans: 1. I offered her and her family neuropsychological evaluation to evaluate for dementia. Her system complex is consistent with dementia, whether it be from small vascular disease or Alzheimer's is unknown. At this point, they would much rather initiate treatment than go through an exhaustive neuropsychological test. 2. For the shoulder we decided on right deltoid bursa aspiration injection. She has had injection for bursitis in the past and prefers to go this route. She will ice and rest the shoulder after injection. 3. Follow up in 3 months. Procedure: Aspiration injection right deltoid bursa. The point of maximal tenderness was identified, skin was prepped with alcohol. A 25-gauge, 1 ½-inch needle was advanced to the humerus and then aspirated. 1 cc of 0.25% Marcaine mixed with 80 mg Depo Medrol was deposited. Needle was withdrawn. Band-aid was applied. Post injection she had marked improvement; increased range of motion consistent with good placement of the medication. She was started on Cerefolin, plus NAC and Aricept starter pack was given with email away script. Follow-up in 3 months and we will reassess her dementia at that time. What diagnosis code(s) are reported? Dx #1: E11.9 Dx #2: M25.511 Dx #3: I11.9 Dx #4: F03.90 CASE 10 CC: HTN INTERVAL HISTORY: No new complaints. EXAM: NAD. 130/80, 84, 22. Lungs are clear. Heart RRR, no MRGs. Abdomen is soft, non-tender. No peripheral edema. IMPRESSION: Stable HTN on current meds. PLAN: No changes needed. RTC in six months with labs. What diagnosis code(s) are reported? Dx #1:

A

Four years post hepatic transplant, the patient is diagnosed with combined hepatocellular carcinoma and cholangiocarcinoma of the liver. What ICD-10-CM codes are reported? A) T86.49, C80.2, C22.0 B) C80.2, C22.0 C) C80.2, C22.0, C22.1, Z94.4 D) T86.49, C80.2, C22.0, C22.1, Z94.4

B

If a diabetic patient uses insulin, and the type of diabetes is not documented, what type of diabetes would be coded according to ICD-10-CM guidelines? A) Secondary diabetes B) Type 2 C) Type 1 D) The use of insulin does not specify that a patient is a certain type of diabetes

C

If an ST elevation myocardial infarction coverts to a non ST elevation myocardial infarction in the course of thrombolytic therapy, how is it coded? (Reference ICD-10-CM guideline I.C.9.e.1) A) Sequence STEMI first, then NSTEMI B) Sequence NSTEMI first, then STEMI C) Code only STEMI D) Code only NSTEMI

A

Patient with postoperative anemia due to acute blood loss during the surgery needs a blood transfusion. What ICD-10-CM code is reported? A) D62 B) D53.0 C) D50.0 D) D64.9

A

Name an example of when a problem caused by diabetes is NOT sequenced after the code for diabetes. Refer to ICD-10-CM guideline I.C.4.a.5.a. A) When a patient's insulin pump malfunctions. B) When the patient has Type II diabetes. C) When the patient has Type I diabetes. D) When the patient has end stage renal disease caused by diabetes.

A

Patient is admitted to the hospital with streptococcal group B severe sepsis which has caused pneumonia. What codes are assigned? A) A40.1, J15.3, R65.20 (guideline I.C.1.d.4 if the reason for admission is both sepsis or severe sepsis and a localized infection, such as pneumonia or cellulitis, a code for the systemic infection is assigned first, followed by the code for the localized infection.) B) A41.9, R65.21 C) A40.1, J15.3 D) A41.9, J15.3, R65.21

D

Patient presents to this clinic with palpitations, weight loss, bulging eyes and extreme nervousness. The tests ordered come back positive with Graves' disease. Select the ICD-10-CM code(s) to report. A) E05.01 B) E05.00, R00.2, R63.4, H57.8, R45.0 C) R00.2, R63.4, H57.8, R45.0, E05.01 D) E05.00

C

Referencing ICD-10-CM guideline I.A.13, when using a code from category D63 it is also necessary to code first: A) The hematocrit level of the patient B) A primary (first-listed) diagnosis C) The chronic condition causing the anemia D) The acute condition presented in the patient encounter

B

Referencing ICD-10-CM guideline I.C.6.b.1.a., when should a code from category G89 be reported as a first-listed diagnosis? A) Whenever it is documented B) When the pain control or pain management is the purpose of the encounter C) Only within the first 72 hours of continuous pain D) When the pain is chronic

B

The patient has a history of unstable angina, hypertension, and chronic systolic heart failure. He is seen in the ED after prolonged chest pain that was not relieved by medication. Cardiac enzymes are elevated, and EKG shows anterior infarct. A decision was made to perform a cardiac catheterization and coronary angiography. Left heart catheterization was performed in order to perform a left ventriculogram. He tolerated the procedure well and will be discharged. His final diagnosis is chronic systolic heart failure and hypertension. The two conditions are unrelated. What ICD-10-CM code(s) is/are reported? A) I11.0 B) I50.22, I10 C) I11.0, I10 D) I11.0, I50.22

B

The patient was given thrombolytic therapy for an acute myocardial infarction (STEMI) of the anterolateral wall which converted to a NSTEMI. What ICD-10-CM code is reported? A) I22.8 B) I21.09 C) I21.29 D) I22.0

C

The provider sees a 70 year-old patient with documented history of being combative and aggressive in the nursing home. The provider diagnoses the patient with dementia and refers the patient to a neurologist for further evaluation. What ICD-10-CM code(s) is/are reported? A) F03.90 B) F03.90, F03.91 C) F03.91 D) F03.91, F03.91

C

What ICD-10-CM code is reported for a patient who is a habitual abuser of cannabis? A) F12.159 B) F12.121 C) F12.10 D) F12.129

A

What ICD-10-CM code is used for the first episode of an acute myocardial infarction? A) I21.9 B) I22 C) I21 D) I25.3

D

What ICD-10-CM codes are reported for uncontrolled hypertension with stage 3 chronic kidney disease? A) I12.9, N18.9 B) N18.9, I12.3 C) N18.3, I12.9 D) I12.9, N18.3

C

What diagnosis code is reported for secondary neoplasm of the descending colon? A) C19 B) D01.0 C) C78.5 D) C18.6

B

What does MRSA stand for? A) Mild Resistance Streptococcus Aureus B) Methicillin Resistant Staphylococcus Aureus C) Methicillin Resistant Streptococcus Aureus D) Moderate Resistance Susceptible Aureus

A

When it is documented that the patient is both using tobacco and has a dependence on tobacco, how is this reported in ICD-10-CM? A) The dependence on tobacco is the only code reported based on the hierarchy in the ICD-10-CM guidelines. B) The use of tobacco and the dependence on tobacco are both reported. C) The use of tobacco is reported with a code for history of tobacco use to report the dependence on tobacco. D) The use of tobacco is the only code reported because it is considered acute.

C

When the type of diabetes mellitus is not documented in the medical note, what is used as the default type? A) Secondary diabetes B) Type 1 C) Type 2 D) Can be type 1 or 2