CRC CASE STUDIES 1

ANS: N18.6, I12.0, E10.22, E10.40, E10.319, Z99.2, I70.209, E78.00, M81.0, Z94.0, Z94.83 Rationale: In this example the patient has hypertension and end stage renal disease. According to the ICD-10-CM guideline I.C.9.a.2, Assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD), are present. ICD-10-CM presumes a cause-and-effect relationship. To locate this code, look in the Alphabetic Index for Hypertension/with/kidney/with/stage 5 chronic kidney disease (CKD) or end stage renal disease (ESRD) I12.0. There is an instructional note that states to "Use additional code to identify the stage of chronic kidney disease (N18.5, N18.6). In this case the patient has end stage renal disease so N18.6 is assigned. The patient is also a type 1 diabetic with diabetic retinopathy and diabetic neuropathy. Combination codes would be reported for these conditions. In the Alphabetic Index, look for Diabetes/type 1/with/neuropathy which directs the coder to E10.40 and Diabetes, diabetic (mellitus) (sugar)/type 1/with/retinopathy which directs the coder to E10.319. Diabetes/type 1/with/chronic kidney disease directs you to E10.22. Next the patient has Atherosclerosis in the extremities; look in the Alphabetic Index for Artherosclerosis which states see Arteriosclerosis. Arteriosclerosis/extremities directs the coder to I70.209. Look in the Alphabetic Index for Hypercholesterolemia which directs the coder to E78.00. The patient also has Osteoporosis. Look in the Alphabetic Index for Osteoporosis which directs the coder to M81.0. Lastly the patient had a kidney and pancreas transplant. To report the status of the transplants, look in the Alphabetic Index for Transplant/kidney which directs the coder to Z94.0 and Transplant/pancreas which directs the coder to Z94.83. Patient is on dialysis repot Z99.6, look for Dialysis/renal (hemodialysis) (peritoneal), status referring you to Z99.2. Verify all code selections in the Tabular List.

1. TRANSPLANT SURGERY Mr. X is a 66 year-old white male who had end stage renal disease and type I diabetes mellitus and underwent combined kidney and pancreas transplantation. He lost his renal allograft from BK viral nephropathy and underwent retransplantation ten years ago. He had problems with renal allograft dysfunction and underwent percutaneous renal allograft biopsy eleven years ago, which revealed hypertensive changes within his kidney. He recently had his lisinopril discontinued. His blood pressures again climbed to an unacceptable level. He had atenolol added. He states that his pulse has slowed down with the atenolol. He has had no trouble with dizziness. He brings his blood pressure cuff with him today. His cuff reads 170/90. My reading with the electronic cuff is 173/84. I am unable to auscultate a pressure in this patient. His log of his blood pressure readings at home in the standing position are usually in the 130 range. I feel that this is an acceptable blood pressure for this patient. We will add no additional antihypertensive medicines. LABORATORY REVIEW (xx/xx/20xx) Sodium 144; potassium 5.0; chloride 109; carbon dioxide 20; white count 7000; hematocrit 31.9; platelet count 264,000; BUN 43; creatinine 1.82; Prograf level 6.4; amylase 28; lipase 69. ASSESSMENT: 1. Hypertension - reasonably controlled. 2. End stage renal disease. On dialysis. 3. Diabetes mellitus type I. 4. Diabetic retinopathy - stable. 5. Diabetic neuropathy. 6. BK allograft nephropathy. 7. Renal allograft rejection - June 1999. 8. Hypercholesterolemia. 9. Atherosclerosis, extremities. 10. Osteoporosis. PLAN: The patient is to continue on the current antihypertensive regimen. We will schedule him for a bone densitometry study on his return. He is provided three cards for stool sampling for guaiac testing. He is to get a blood check in six weeks consisting of a BUN, creatinine, CBC, E-group, Prograf level, glucose, amylase, and lipase and similar labs in 12 weeks to include an ImmuKnow, PTH, calcium, and phosphate. I will see him back in follow-up at that time. He is to continue to keep a log of his chemsticks. Electronically signed by X, MD What are the diagnosis codes?

ANS: I08.1, I42.9, I10, I48.91 Rationale: In this case the patient has severe cardiomyopathy, mitral and tricuspid valve regurgitation, atrial fibrillation and hypertension. Look in the Alphabetic Index for Cardiomyopathy which directs the coder to I42.9; Regurgitation/mitral which says see Insufficiency, mitral. When you reference Insufficiency/mitral (valve)/with/tricuspid it directs the coder to I08.1; Fibrillation/atrial which directs the coder to I48.91; Hypertension which directs the coder to I10. Verify all code selections in the Tabular List.

12. DATE OF CONSULTATION: 02/23/20XX REFERRING PHYSICIAN: S, MD REASON FOR CONSULTATION: Evaluation of mitral valve regurgitation. HISTORY OF PRESENTILLNESS: I was asked by Dr. S to see Mrs. F following her cardiac catheterization. I have reviewed that study and have discussed the case with Dr. S. I have interviewed the patient in the cardiac cath lab holding area in the presence of her daughters. Mrs. F is a very active xx year-old woman who continues to maintain her household and take care of her disabled husband. Approximately six weeks ago she was noted to have atrial fibrillation. An echocardiogram was performed which demonstrated a left ventricular ejection fraction of 20 percent, mitral and tricuspid regurgitation, and moderate pulmonary hypertension. Cardiac catheterization was performed today, which shows normal coronary arteries other than a dilated distal left main coronary artery, moderate mitral regurgitation, and severe left ventricular dysfunction with an ejection fraction of approximately 20 percent. Right heart catheterization showed pulmonary artery pressures to be approximately 1/3 systemic a t 32/11, and cardiac output was 3.3, giving a cardiac index of greater than 2. In discussing the case with Dr. xxxxx, he states that there was no evidence of a flail segment of the mitral valve. The study is not available to me at this time. PAST MEDICAL HISTORY: Atrial fibrillation. PAST SURGICAL HISTORY: Oophorectomy. ALLERGI ES: No known drug allergies. MEDICATIONS: 1 Ziac. 2 Niaspan. 3 Lisinopril. 4 Coumadin, which has been held. PHYSICAL EXAMINATION: GENERAL: Thin woman in no acute distress. IMPRESSION: Severe cardiomyopathy with mitral and tricuspid valve regurgitation. No significant pulmonary hypertension per right heart catheterization. No apparent symptoms of congestive heart failure in spite of extremely poor left ventricular function. Hypertension, controlled on medications. DISCUSSION: I explained to the patient that treatment options include medical therapy and surgery. I gave my opinion that valve repair or replacement is not likely to be beneficial as the le ventricular function will still be terrible. We also discussed that in the absence of symptoms there is questionable benefit of proceeding with surgery, particularly with such a poor left ventricle. RECOMMENDATIONS: Medical management. The patient is not a candidate for cardiac surgery. Dictated and signed by X, MD 02/23/20XX What are the diagnosis codes?

ANS: G35 Rationale: In this case the patient is diagnosed with secondary progressive multiple sclerosis. Look in the Alphabetic Index for Sclerosis/multiple which directs the coder to G35. Verify all code selections in the Tabular List.

13. NEUROLOGIC FOLLOW-UP: PATIENT: SW DOB: 04/03/XXXX DATE: 02/13/20XX Ms. F returns to my office for a follow-up evaluation on 02/13/XX. I originally saw her on 01/02/XX for evaluation and treatment of multiple sclerosis. The patient reports that she has been stable since her last visit with me. She continues to experience intermittent slurred speech, particularly when she is fatigued. She complains of weakness in the right upper and right lower extremity. She has not experienced any double vision. She denies incontinence of bowel or bladder. She does complain of difficulty ambulating long distances. She denies any dizziness or light headedness. The remainder of the neurologic review of systems is negative. On examination, the patient is a pleasant, well-developed, well-nourished, white female in no acute distress. Her blood pressure is 130/82 with a pulse of 64 and respirations of 18. The patient is alert and oriented to person, place, and time. The patient's speech is fluent. Mild dysarthria is present. Comprehension is intact. Funduscopic examination is normal. Extraocular movements are intact. The face is symmetric without evidence of facial weakness. The tongue is midline without evidence of atrophy or fasciculations. On motor examination, tone is normal. Strength is intact in the left upper and left lower extremities. The patient demonstrates weakness proximally and distally in the right upper and right lower extremities at 4/5 +. Coordination is significant for mild ataxia on finger-finger nose in the right upper extremity. The patient's gait is abnormal. She is wide-based, ataxic, and slightly spastic. Reflexes are two plus and symmetric. Toe responses are flexor bilaterally. Sensory examination is intact to light touch in both upper and lower extremities. My impression is that Ms. F is suffering from secondary progressive multiple sclerosis. She is not a candidate for treatment with immune modulating medication at the present time. The patient verbalized understanding and is agreeable to the evaluation and treatment plan outlined above. The patient will return to my office in twelve months for a re-evaluation. X, MD 02/13/20XX What is the ICD-10-CM code?

ANS: C34.11, C34.12, I10, E78.5, J95.812, I47.1 Rationale: In this case, the patient has bilateral adenocarcinoma of the lung. There is no code for bilateral so two codes will be required. Look in the Alphabetic Index for Adenocarcinoma which says to see Neoplasm, malignant, by site. Look in the Table of Neoplasms for Neoplasm/lung/upper lobe/Malignant Primary column which directs the C34.1-. This code requires a fifth character to identify laterality. In this case it is bilateral, so the correct codes are C34.11 and C34.12. The patient also has hypertension and hyperlipidemia. Look in the Alphabetic Index for Hypertension which directs the coder to I10 and Hyperlipidemia which directs the coder to E78.5. The patient also has paroxysmal supraventricular tachycardia and a postprocedural air leak. Look in the Alphabetic Index Tachycardia/supraventricular which directs the coder to I47.1 and Leak/air/postprocedural which directs the coder to J95.812. Verify all code selections in the Tabular List.

14. St. Somewhere, Hospital, DISCHARGE SUMMARY ADMISSION DIAGNOSES: Bilateral adenocarcinoma of the lung. Hypertension. Hyperlipidemia. DISCHARGE DIAGNOSES: Bilateral adenocarcinoma of the lung. Hypertension. Hyperlipidemia. PROCEDURE: Right upper lobe lobectomy. HISTORY OF PRESENT ILLNESS: Mrs. F is a 64 year-old woman who was found to have bilateral upper lobe lung masses. CT scan of the chest showed them both to be spiculated with the larger one on the right. Percutaneous biopsies of both showed adenocarcinoma. HOSPITAL COURSE: The patient was taken to the operating room on 03/09/XX and underwent right thoracotomy for right upper lobe lobectomy and mediastinal lymph node sampling. She did well from this but did have a persistent air leak which was slow to resolve. Eventually, it did stop, and her chest tube was removed. Final pathology of her lung resection showed a 2.2-cm moderately differentiated adenocarcinoma with all lymph nodes including N1 and N2 being negative for malignancy. Staging was therefore T1bNO. DISCHARGE MEDICATIONS: 1 Cyclobenzaprine 5 mg p.o. b.i.d. 2 Lovastatin 20 mg p.o. at bedtime. 3 Micardis 20 mg p.o. daily. 4 Meloxicam 15 mg p.o. daily. 5 Metoprolol 25 mg p.o. b.i.d. 6 Percocet 1-2 p.o. q.4 hours p.r.n. pain. 7 Citalopram 20 mg p.o. q.a.m. 8 Pepcid 10 mg p.o. p.r.n. heartburn. 9 Metoprolol was started during hospitalization for paroxysmal supraventricular tachycardias. FOLLOW UP: Dr. S in 2-3 weeks. At that time, she will be assessed with regard to her recovery in anticipation of proceeding with left thoracotomy for resection of the left lung cancer. DICTATED: X M.D. <Electronically signed by X, M.D.> XX/XX/20XX Marked as signed. What are the diagnosis codes?

ANS: E11.51, R60.9, L60.0, L84, R00.2, E11.628, Z87.891, Z79.82, Z82.49, Z83.2 Rationale: In this case, the patient is diagnosed with Type 2 diabetes, peripheral vascular disease, edema, onychocryptosis, corn/callus and palpitations. Look in the Alphabetic Index for Diabetes/type 2/with/peripheral angiopathy which directs the coder to E11.51; Edema R60.9; Diabetes/type 2/with/skin complication NEC E11.628. Onychocryptosis which directs the coder to L60.0; Corn which directs the coder to L84; and Palpitation which directs the coder to R00.2. The patient also has a documented BMI of 33.92; history of smoking, long-term use of aspirin and a family history of cardiovascular disease. Look in the Alphabetic Index for History/tobacco dependence which directs the coder to Z87.891; Long-term/aspirin which directs the coder to Z79.82; and History/family (of)/disease, cardiovascular which directs the coder to Z82.49. Verify all code selections in the Tabular List.

15. Date: 02/01/20XX 03:15 PM Title: Palliative Foot Care Date of Birth: 04/15/XX Vital Signs: BP: 120/69. Pulse: 53. HT: 5'6". WT: 190 lbs. Subjective: This 67 year-old female presents for diabetic foot care. Nail complaints: Yes Problematic nail location: bilateral Nail thickening: No Nail discoloration: No Nail splitting: no Cosmetically bothersome: No Pain/discomfort: no Pain with ambulation: No Recurrent cellulitis: no Lesion complaints: No Duration: Five months Onset; gradual Context: Symptoms are stable. Treatments attempted: none except palliation Past Medical History: Major Problem: TYPE II DIABETES, heart problems Review of Systems: Constitutional: No fevers, chills, or unexplained weight loss Eyes: No visual changes or eye pain Ears: No hearing loss, otorrhea or ear pain Nose/Mouth/Throat: No nasal congestion, rhinorrhea, oral lesions, postnasal drip or sore throat Cardiovascular: Palpitations Respiratory: No cough, shortness of breath or wheezing Gastrointestinal: No diarrhea, constipation, blood in stools, abdominal pain, vomiting or heartburn Musculoskeletal: No arthralgias, myalgias or joint swelling Skin: No rash or bothersome skin lesions Neurological: No headaches, paresthesias, confusion, dysarthria or gait instability Psychiatric: No anxiety or depression Health Maintenance: Depression Screen Normal Hematologic/Lymphatic: No easy bruising, easy bleeding or swollen glands Allergic/Immunologic: No itching, sneezing, watery eyes, clear rhinorrhea or recurrent infections Endocrine: No polydipsia/polyuria, diaphoresis, or cold/heat intolerance Family History: Coronary artery disease, hypertension. Mother had an anemic blood disorder. Social History: Marital status: Married Lives with spouse Occupation: retired Nutrition: good diet Clinical Elements: Smoking: former smoker Tobacco exposure: No smokers in home. Clinical Elements: Alcohol: Occasional alcohol Illicit drugs: No. Current Medications: Rx: ASPIRI N (long-term) Rx: ATENOLOL Rx: BETAMETHASONE Rx: CLOTRIMAZOLE Rx: FIBER THERAPY Rx: LOSARTAN POTASSIUM-HCTZ Rx: MULTIVITAMI NS Rx: OMEPRAZOLE Rx: SEPTRA DS Rx: SIMVASTATI N Rx: VERAPAMIL HCL Medication Allergies: NKDA Objective: General: Well appearing, well-nourished in no distress. Class findings: Yes Skin pigment discoloration: Yes Edema: Yes Cold feet: Yes Affected nail: Right Affected nail: Left Area of affected nail: Medial lateral Pain with palpation: No Thickening: No Onycholysis; No Discoloration: No Pitting: yellow lncurvation: Yes Hyperkeratotic lesions present: Yes Medial first MTH: Yes right left (mild) Assessment Diagnosis: Onchocryptosis Diagnosis: CORN I CALLUS Major Problem: TYPE II DIABETES: stated as controlled Major Problem: PERIPHERAL VASCULAR DISEASE NOS: Plan: We discussed preventative foot care. We discussed preventative foot hygiene. We instructed the patient on how to care for their feet, and to contact the office if any wounds develop. The nails were trimmed. Antiseptic was applied. Trimmed more than five nails. The hyperkeratotic lesions were sharply pared. Antiseptic was applied. Pared two to four lesions. Procedure: Office Visit Level 2: 99202 SIGNED BY X, MD 02/01/20XX What are the diagnosis codes?

ANS: Z00.01, Z89.511, E11.9, I10, G54.6, Z68.28, Z79.82, Z82.0, Z83.3, Z79.84 Rationale: In this case, the patient presents for a comprehensive medical examination. Look in the Alphabetic Index for Examination/with abnormal findings which directs the coder to Z00.01 (On exam, the provider indicates Phantom Limb on occasion). He had a BKA. To code for this look for Absence/leg/below knee (acquired) which directs the coder to Z89.51-.When referenced in the Tabular List a sixth character is required for laterality. This is of the right leg with correct code Z89.511. The patient also has diabetes. The type of diabetes is not documented. According to ICD-10-CM guideline, I.C.4.a.2, states if the type of diabetes mellitus is not documented in the medical record the default Is E11.-, Type 2 diabetes mellitus. Look in the Alphabetic Index for Diabetes, diabetic (mellitus) (sugar)/type 2 which directs the coder to E11.9. The patient also has hypertension and phantom limb syndrome with pain. Look in the Alphabetic Index for Hypertension which directs the coder to I10, and Phantom limb syndrome/with pain which directs the coder to G54.6. The patient has a BMI of 28.59. Look in the Alphabetic Index for body/mass index (BMI)/adult/28.0-28.9 which directs the coder to Z68.28. The patient also has long term use of aspirin and a family history of Alzheimer's and diabetes mellitus. Look in the Alphabetic Index for Long-term (current) drug therapy (use of)/aspirin which directs the coder to Z79.82; History/family (of)/disease/neurological which directs the coder to Z82.0; and History/family (of)/diabetes mellitus which directs the coder to Z83.3. The patients diabetes is controlled with oral medication. Look in the Alphabetic Index for Long-term (current) drug therapy (use of)/ oral/ hypoglycemics which directs the coder to Z79.84. Verify all code selections in the Tabular List. Although the patient is not obese, the BMI is documented and reported for data collection for quality care initiatives and because the patient has diabetes.

2. DATE 04/01/20xx Medical Office Exam DOB 03/01/XXXX BP: 128/70; Left arm. Pulse: 60, Regular. Temperature: 98 .6 F, Oral. HT: 5'4.5". WT:169 lbs. Respirations: 16. BMI: 28 .59 kg/m2 Smoking status: Never Subjective: This 67 year-old male presents for comprehensive medical examination. Lives with no one. Interim problems since last visit: None Review of Systems: Constitutional: Negative Eyes: Negative Ears, Nose, Mouth, Throat: Negative Cardiovascular: Negative Respiratory: Negative Gastrointestinal: Negative Genitourinary: Negative Musculoskeletal: Negative Skin and /or breasts: Negative: Neurological: Negative Psychiatric: Negative Endocrine: Negative Hematologic/Lymphatic: Negative Allergy/ Immunologic: Negative Past Medical History: HTN NIDDM Past Surgical History: Left Shoulder Rotator Cuff Repair at age xx Right Rotator Cuff Repair at age xx Left Bunionectomy and Hammertoe Repair three years ago Current Medications: Rx: ASPIRIN EC 81M G 1 TAB once daily, days, 30, Ref: 11 Rx: ATENOLOL. 50M G 1 TAB once daily, days, 80, Ref: 4 Rx LOTENSIN HCT 20-25MG 1 TAB daily, days, 80, Ref: 11 Rx: NORVASC 10 MG 1 TAB daily, days, 90, Ref: 4 Rx: GLUCOPHAGE 500MG 1 TAB TID, days, 180: Ref: 5 Rx: VIAGRA 100MG ½-1 tab PRIOR TO INTERCOURSE PR I, days, 6 , Ref: 3 Allergies: NKDA Social History: Tobacco: No Alcohol: Yes Caffeine: Yes Marital status: Single Occupation: Equipment Operator Family History: Diabetes Mellitus and Alzheimer's Objective: General: Well appearing, well nourished, in no acute distress, oriented, normal mood and affect. Skin: Good turgor, no rash or prominent lesions Hair· Normal texture and distribution. Nails: Normal color, no deformities Head: Normocephalic, atraumatic. Eyes: Conjunctiva clear, sclera non-ischemia, EOM intact, PERRL Ears: EAC's clear, TM's translucent, ossicles normal appearance Nose: No external lesions, mucosa non-inflamed, septum and turbinates normal Mouth: Mucous membranes moist, no mucosal lesions Teeth/Gums: No obvious caries or periodontal disease Pharynx: Mucosa non-inflamed, no tonsil hypertrophy or exudate Neck: Supple, without lesions or adenopathy Heart: No cardiomegaly or thrills, regular rate and rhythm, no murmur or gallop Lungs: Clear to auscultation Abdomen: Bowel sounds normal, no tenderness, organomegaly, masses, or hernia Back: Spine normal without deformity or tenderness, no CVA tenderness GU: Penis without lesions, testes normal size without masses, no inguinal hernias Rectal: Normal sphincter tone, no masses palpable, prostate normal size, smooth non-tender and without nodules, no hemorrhoids noted Extremities: Right BKA, stump patent with no lesions, otherwise normal with good capillary refill left Musculoskeletal: No decreased ROM Lymphatic: No lymphadenopathy in cervical axillary or inguinal areas. Neurologic: CN 2-12 normal, Sensation to pain, touch and proprioception normal, phantom limb syndrome with pain on occasion Psychiatric: Oriented times three, intact recent and remote memory, judgment and insight, normal mood and affect. Assessment: Other Problem: MEDICAL EXAM Plan: Laboratory: Other: CBC, CMP, fasting lipid panel, UA, Thyroid Panel, hemoglobin A1C, PSA. Procedures: Colonoscopy: Ordered Patient Counseling: Discussed long-term aspirin prophylaxis for myocardial infarction and decision was to continue. Follow-up: prn or 1 year for physical HTN Rx: NORVASC. 10 MG 1 TA8 daily, 90, HTN Rx: LOTENSIN HCT 20-25 MG 1 TAB DAILY, 90 DM Rx: GLUCOPHAGE 500 MG 1 TAB three times daily, 180 HTN Rx: ATENOLOL 50 MG ·1 TAB once daily, 80, Signed: X, M.D cc: NB, M.D. What are the diagnosis codes?

ANS: J20.9, I10, M80.88XD, E78.5, J30.9, Z87.891 Rationale: In this case the patient has bronchitis, hypertension, hyperlipidemia, allergic rhinitis, and GERD. Look in the Alphabetic Index for Bronchitis/acute which directs the coder to J20.9; Hypertension which directs the coder to I10; Hyperlipidemia which directs the coder to E78.5; Rhinitis/allergic which directs the coder to J30.9. The patient has osteoporosis with compression fracture. Look in the Alphabetic Index for Osteoporosis/with current pathological fracture/vertebra which directs the coder to M80.88-. When you reference this code in the Tabular List a seventh character is required to identify episode of care. This patient is not receiving active treatment for the fracture so the subsequent encounter would be used. The correct code would be M80.88XD. Lastly, the patient has a history of smoking which is reported with Z87.891. Verify code selection in the Tabular List.

3. Progress Note 02/01/20XX Patient MT DOB 06/02/XXXX BP: 140/72, right. Pulse: 72, regular. Temperature 98.2, oral. Ht. 5'9". Wt. 223 lbs. Resp. 18 Smoking status: Former smoker who quit 30 years ago. Subjective: This: 71 year-old male presents with a seven-day history of: Fever: No URI symptoms: No Cough: Yes Productive cough: Yes, occasional blood-tinged sputum Dyspnea: No Review of systems Constitutional: Fatigue Ears, Nose, Mouth, Throat: Clear rhinorrhea Cardiovascular: No chest pain or palpitations; has hypertension and hyperlipidemia Respiratory: As noted above Allergic/ Immunologic: Negative Current Medications (updated 02/01/20XX): Rx: POTASSIUM CHLORIDE 90MG 1 TAB once daily (Replacement therapy for diuretics) Rx· ATENOLOL 50MG 1 TAB once daily (HTN) Rx: FOSAMAX 70MG 1 TAB weekly (Osteoporosis) Rx: LIPITOR 40MG ½ daily (Hyperlipidemia) Rx: FLONASE 50M CC/ACT 2 spray twice daily (allergic rhinitis) Rx: MULTIVITAMINS 1 TAB once daily Rx: FLOMAX 0.4MG 1 TAB daily Allergies: NKDA Past Medical History: Measles and chickenpox as a child Mononucleosis in 1982 Compression fracture T-11, T-12, and L-1 due to Osteoporosis, no surgery due to age Hypertension Hyperlipidemia Bilateral hip pain Deviated nasal septum Allergic rhinitis Posterior vitreous detachment, right eye Bilateral cataracts Past Surgical History: EGD with biopsies Normal total colonoscopy exam by Dr. xxxx on xx/xx/xxxx Social History: Smoking: Former smoker who quit over 30 years ago Environmental smoke exposure: No Objective: General: Alert adult white male in no apparent distress Skin: Good turgor, no rash or prominent lesions Head· Normocephalic, atraumatic Eyes: Conjunctiva clear, sclera non-icteric, EOM intact, PERRL Ears: EACs clear, TMs translucent, ossicles normal. appearance Nose: Normal except mucosa inflamed Mouth: Mucous membranes moist, no mucosal lesions. Pharynx: Mucosa non-inflamed, no tonsillar hypertrophy or exudate Neck supple, without lesions or adenopathy Heart: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop Lungs: Has a few crackles and slight decreased breath sounds in base of lungs with a few rhonchi of upper chest, which clear with auscultation Abdomen: Bowel sounds normal, no tenderness, organomegaly, masses, or hernia Extremities: No amputations or deformities, cyanosis, edema or varicosities, peripheral pulses intact Chest X-Ray: has some increased bronchial markings in both lungs with no acute infiltrates Assessment: 1. Other Problem: ACUTE BRONCHITIS 2. Other Problem: COUGH 3. Major Problem: HYPERTENSION Plan: Laboratory: CBC today Medications: begin Augmentin 875/125 one tab po bid x 10 days. Mucinex DM ·1 tab po q12hrs prn cough. May continue other current medications. Patient education: Patient advised to avoid exposure to dust and smoke and to limit activity pending improvement in symptoms Increase intake of water to improve hydration. May try room humidifier as needed. May use throat lozenge or cough drops as needed for cough. Consider trial of some chicken noodle soup. Continue Fosamax for pathological vertebral compression fracture pain. Follow-up: prn if symptoms worsen or not responding to current treatment within 10 days. Procedure: Office Visit Level 4 99214, EM Code Calc based on 1995 guidelines. Signed by X, MD on 02/01/20xx, 03:15 PM What are the diagnosis codes?

ANS: L02.611, G60.9, I10 Rationale: In this example the patient has cellulitis of the right fourth toe. Look in the Alphabetic Index for Abscess/toe - see also Abscess, foot which directs the coder to L02.61-. This code requires a 6th character to identify laterality. In this case it was the right toe. The correct code would be L02.611. The patient also has neuropathy of unknown origin which means it is idiopathic. Look in the Alphabetic Index for Neuropathy/peripheral (nerve)/idiopathic which directs the coder to G60.9. Lastly, the patient has HTN reported with I10. Verify all code selections in the Tabular List.

4. Patient: WQ DOB: 11/12/XXXX DOS: 06/01/20XX The patient was seen in the office today complaining of toenail bed and painful sore on his right fourth toe. He states it will cause him pain at times. He is a pleasant XX year-old white male. Height is 6 feet and weight 234 pounds. The patient is alert and oriented times three. The patient is well nourished. The patient is in no acute distress. PAST MEDICAL HISTORY: Positive for history of hypertension (stable on medication) and peripheral neuropathy of unknown origin. ALLERGIES: No known drug allergies. MEDICATIONS: In chart and reviewed in detail. PAST SURGICAL HISTORY: Appendectomy and hernia repair. REVIEW OF SYSTEMS: Noncontributory. SOCIAL HISTORY: He denies tobacco use. He does drink alcohol socially. He is retired; however, he still works twice a week in a Pharmacy. PHYSICAL EXAMINATION: VASCULAR EXAM: DP pulse is 2/4 bilaterally and PT pulse is non-palpable. Capillary refill time is slightly delayed. DERMATOLOGICAL EXAM: The patient has an abscess formation of the right fourth toe. Area measures before debridement 0.8 x 0.6 x 0.1. Area is fluid filled. Purulent drainage is identified. Skin is thick and red. Scant amount of dorsal hair growth. No allodynia noted. No other opening or breaches in the skin noted today. NEUROLOGICAL EXAM: Deep tendon reflexes are intact. He demonstrates decreased sensations with reference to 5.07-monofilament wire, sharp/dull testing and vibratory senses and also decreased Ipswich touch test. MUSCULOSKELETAL EXAM: He demonstrates 5/5 with manual muscle testing. Normal gait pattern and normal shoe wear pattern. Edema and neuritis as noted above. He had no X-rays with him today. DIAGNOSES: Abscess formation on right fourth toe, and neuropathy of unknown origin. TREATMENT: We discussed all options with the patient today. Incision and drainage were performed on the right fourth digit. Cultures were taken of the area. We will· start him on cephalexin and gentamicin dressings. Area was flushed with copious amounts of sterile saline solution, wound wash, and Betadine solution. He appeared to have healthy subcutaneous tissue underneath in this area. He denies any fevers, chills, nausea, or vomiting. He knows immediately to call if any problems arise; otherwise, I will see him back early next week Signed by S, DPM, FACFAS 06/01/20XX What are the diagnosis codes?

ANS: I63.81, Z86.73, I65.23, E78.5, I10 Rationale: In this case the patient has a small-vessel stroke or a lacunar stroke in the thalamus, a history of a previous stroke, and narrowing of both the internal carotid arteries. Look in the ICD-10-CM Alphabetic Index for Infarct, infarction/lacunar which directs you I63.81. Look in the Alphabetic Index for History/personal (of)/stroke without residual deficits directing you to Z86.73; and Narrowing/artery/carotid referring you to see Occlusion, artery, carotid. Look in the Alphabetic Index for Occlusion/artery/carotid referring you to I65.2-. This code requires a 5th character to identify laterality. In this case it is bilateral I65.23. The patient also has dyslipidemia and hypertension. Look in the Alphabetic Index for Dyslipidemia directing you to E78.5; and Hypertension referring you to I10. Verify all code selections in the Tabular List.

5. INPATIENT CONSULTATION REPORT Patient DW DOB 09/02/XX DOS 03/23/20XX HISTORY OF PRESENT ILLNESS: I saw the patient, who is a 65 year-old female who appears younger than her age. She is here because of numbness about her face, which came on yesterday. It is still there. She noted symptoms in the arms or the legs. She had been on aspirin and Plavix, and now she is on a heparin drip. Earlier she had an echocardiogram and TEE, which are negative for thrombus in the heart. She had left-sided numbness and weakness in 04/XX, and since then she has been on aspirin and Plavix. She might have had one more episode in between. I reviewed her work up and her carotid duplex scan revealed narrowing of both ICAs less than 50 percent. Her MRI of the brain revealed apparently a right lacunar stroke around the thalamus. She denies any headache or problem with vision or speech or weakness at this time. PAST MEDICAL HISTORY: In addition to right CVA, hypertension, and dyslipidemia. MEDICATIONS: Tricor, metoprolol, ferrous sulfate, calcium with vitamin D, Lasix, multivitamin, oxybutynin, Protonix, and Pravachol. PERSONAL HISTORY: She walks without any assistance inside the house. Outside, she is using a cane or a walker. She does not smoke, nor does she abuse alcohol. NEUROLOGIC EXAMINATION: Normal mental status, speech, and she appears younger than her age. Cranial nerves II through XII are intact. She has no focal weakness. Reflexes are 2+, symmetrical in the upper limbs. In lower limbs, knees are trace. Ankles are absent. Plantars are both down going. Gait exam is deferred. Coordination normal on finger-to-nose testing. Exam of the head and neck and spine unremarkable. IMPRESSION: This lady has a small-vessel stroke or a lacunar stroke in the thalamus or nearby area. She had a right lacunar stroke involving the thalamus on the right side last year on xx/xxxx. She is an aspirin and Plavix failure. I doubt this lady had an embolic or large vessel stroke. I think she had a lacunar stroke due to high blood pressure. Nonetheless, since she is an aspirin and Plavix failure, I agree with the short-term Coumadin maybe for three months or so, but certainly I do not recommend a heparin drip right now. After three months, we can switch her from Coumadin to Plavix. She had a carotid duplex scan last month which revealed narrowing of both the internal carotid arteries less than 50 percent. So, I am now going to repeat that. Her TEE is normal today. We will follow her with you. We will also get a CT of the brain without contrast since she did not have one this time. Thank you for the consult. Signed by D, MD For this case, report the conditions only. What are the diagnosis codes?

ANS: E11.3293, H40.1230, H35.3130, H34.232, I10, E07.9, H35.363, Z79.84 Rationale: In this case the patient has diabetic retinopathy, low-tension glaucoma, retinal arterial branch occlusion and nonexudative senile macular degeneration. In this case although the patient has diabetic retinopathy, the type of diabetes is not documented. According to ICD-10-CM guideline, I.C.4.a.2, states if the type of diabetes mellitus is not documented in the medical record the default is E11.-, Type 2 diabetes mellitus. Look in the Alphabetic Index for Diabetes, diabetic (mellitus) (sugar)/type 2/with/retinopathy/nonproliferative which directs the coder to E11.329. A 7th character is required to identify laterality. Next, the patient has low-tension glaucoma. Look in the Alphabetic Index for Glaucoma/low tension which says see glaucoma, open angle/low-tension. Glaucoma/open angle/low-tension which directs the coder to H40.12-. This code requires a 6th character to identify laterality and seventh character to identify the stage of the glaucoma. As the patient has bilateral glaucoma the 6th character would be a 3. The stage of the glaucoma is not documented. The correct diagnosis code is H40.1230. The patient has nonexudative senile macular degeneration. Look in the Alphabetic Index for Degeneration/macula, macular (acquired) (age-related) (senile)/atrophic age-related/bilateral which directs the coder to H35.313. The patient also has a left retinal arterial branch occlusion. Look in the Alphabetic Index Occlusion/retinal/branch which directs the coder to H34.23-. This code requires a 6th character to identify laterality which makes H34.232 is the correct diagnosis code. Lastly, the patient has hypertension, thyroid disease and a family history of hypertension. Look in the Alphabetic Index for Hypertension which directs the coder to I10; Disease/thyroid which directs the coder to E07.9. The drusen was also revealed upon physical exam. In the Index, see Drusen/macula see Degeneration/macula/drusen, H35.36-, and report H35.363 for bilateral, as documented OU indicates a bilateral condition. The patients diabetes is controlled with oral medications. Look in the Alphabetic Index for Long-term (current) drug therapy (use of)/oral/hypoglycemics which directs the coder to Z79.84. Verify all code selections in the Tabular List.

6. Progress Notes Subjective: CC: Six month follow up, Vision not as good, Difficulty reading HPI: ROS: EYES: blurred vision yes. glare yes. light sensitivity yes. ENT: hearing loss yes. CARDIOLOGY: hypertension yes. HEMATOLOGIC: diabetes yes. HORMONAL: thyroid disorder yes Social History: no Smoking Are you a: nonsmoker. no Alcohol. Medications: Lumigan 0.03 percent solution 1 gtt OU QPM hydrochlorothiazide levothyroxine fenofibrate simvastatin metformin glimepiride metoprolol lisinopril Medication List reviewed and reconciled with the patient Allergies: N.K.D.A. Objective: Past Orders: Examination: Physical Examination: W/MR: 1 Wearing OD +0.75+0.50 x 180 = 20/50+2. 2 Wearing OS -1.75 +0.50 x 014 = 20/ 200. 3 Wearing ADD +2.75 BIF = 5 pt OU. 4 Refraction OD +0.50 +1.00 x 005 = 20/30-. 5 Refraction OS -1.75 +a.so x 015 = 20/NI. Pupils: RAPD None. Size equal 2 OU. Reactivity reactive to light. Ocular motility: Strabismus None. Versions full. IOP: Applanation OU 10 Adnexa: External Normal, OU. Lids Normal, OU. Slit Lamp Exam: Conjunctiva Normal, OU. Cornea Normal, OU. Anterior Chamber Deep & Quiet, OU. Iris Dark Brown. Lens OD, PCIOL in the bag, trace PCO, OS, PCIOL in the bag, Open PC (s/p yag cap). Dilation: OU Tropicamide 1 percent. Optic Nerve: Cup/Disc OD near total shallow, OS.9 shallow. Vitreous: Description OU, Normal. Retina: Macula OU, RPE defects, soft drusen some calcified, focal atr, Vessels OD, Normal, OS hemorrhages in distrib of superotemp arteriole as before. Periphery Normal without tears or holes, OU. Assessment: 1 Low-tension glaucoma - od near total, os .9; 24- 2 inf alt defects ou 2 Retinal Arterial branch occlusion - os nasal 3 Nonexudative senile macular degeneration - os>od 4 Nonproliferative Diabetic Retinopathy - ou, mild not requiring therapy Plan: 1 Low tension glaucoma Continue Lumigan solution, 0.01 percent, 1gtt, in each affected eye, QPM. 2 Nonexudative senile macular degeneration preservision. 3 Nonproliferative Diabetic Retinopathy BLOOD SUGAR: Discussed the importance of tight blood sugar control. Procedure Codes: Preventive: Follow Up: Six months with a doctor closer to home Provider: S, M.D., Sign off Status: Complete. 04/15/20XX What are the diagnosis codes?

ANS: G47.30, G70.00, F32.9, J45.20, Z98.84, Z87.891, Z83.3, Z82.49, Z79.52 Rationale: In this case the patient has sleep apnea, myasthenia gravis, depression, and asthma. Look in the ICD-10-CM Alphabetic Index for Apnea/sleep which directs you to code G47.30. Next, look in the Alphabetic Index for myasthenia/gravis directing you to code G70.00. The patient has depression, look in the Alphabetic Index for Depression which directs you to code F32.9. Asthma is found by looking for Asthma, asthmatic/intermittent (mild) which directs the coder to J45.20. The patient also has a history of bariatric surgery and smoking. She also has a family history of diabetes and hypertension. History of bariatric surgery is found in the Alphabetic Index by looking for Status/bariatric surgery which directs you to Z98.84. History of smoking look in the Alphabetic Index for History/personal of/nicotine dependence which directs you to code Z87.891. Next, the patient has a family history of diabetes and hypertension. Look in the Alphabetic Index for History/family (of)/diabetes mellitus Z83.3 and History/family (of)/disease or disorder (of)/cardiovascular NEC Z82.49. The patient is also taking a systemic steroid, in the Alphabetic Index look for Long term drug therapy use/Steroids/systemic which directs the coder to Z79.52. Verify code selections in the Tabular List.

7. CHIEF COMPLAINT: Recently diagnosed to have sleep apnea, history of myasthenia gravis and a history of mild intermittent asthma. HISTORY OF PRESENT ILLNESS: This 71 year-old female was referred to me by Dr. S when she was diagnosed to have sleep apnea by Dr. S. She denies any significant cough, fever, chills or night sweats. No weight loss. She had mild dyspnea on exertion. No paroxysmal nocturnal dyspnea or orthopnea. No swelling of the feet. No chest pain to suggest angina. The patient is known to have myasthenia gravis and mild intermittent asthma. PAST MEDICAL HISTORY: She has had a gastric bypass surgery. PERSONAL HISTORY: She quit smoking five years ago. She may have smoked less than a pack of cigarettes a day for 15 years or so. CURRENT MEDICATIONS: Prednisone 5mg a day, Pyridostigmine 60mg two tablets four times a day, Bupropion 150mg a day, Citalopram 20mg at bedtime, Multivitamins, Proventil inhaler prn. FAMILY HISTORY: Mother had diabetes. Mother and Father had hypertension. SYSTEM REVIEW: HEENT: Noncontributory. CARDIOVASCULAR: Denies hypertension or previous history of ischemic heart disease. RESPIRATORY: Mild exertional dyspnea. GASTROINTESTINAL: Noncontributory. GENITOURINARY: Noncontributory. MIJSCULOSKELETAL: Noncontributory. NEUROPSYCHIATRIC: Diagnosed to have myasthenia gravis by Dr. xxxx. She was recently diagnosed to have sleep apnea. ENDOCRINE: Denies diabetes or thyroid dysfunction. SKIN: Nothing significant. PHYSICAL EXAMINATION: The patient is conscious, alert and oriented, in no acute distress. Vital Signs: Pulse 60, respirations 16, blood pressure 140/90, saturation 96 percent at rest on room air. Weight 173 pounds. MENTAL AND GENERAL STATUS: Normal. HEENT: Head examination is normal. Eyes: Normal. Throat: Normal. NECK: No cervical lymphadenopathy. No carotid bruit could be heard. No increase in jugular venous pressure or pulsation. CHEST: No wheeze or rales could be heard. CARDIOVASCULAR: First and second heart sounds are heard. No murmur thrill or gallop. No pitting edema. No congestive heart failure. ABDOMEN: Soft and non-tender. No organomegaly. Bowel sounds are active. No tenderness or guarding. PERIPHERAL EXTREMITIES: No cyanosis or clubbing. No pitting edema. LYMPHATIC SYSTEM: No lymphadenopathy. NERVOUS SYSTEM: Normal. OTHER SYSTEM: normal. LABORATORY DATA: No laboratory data is available at this time. IMPRESSION: 1 Sleep apnea, moderate to severe. 2 Myasthenia gravis. 3 Depression 4 Mild intermittent asthma. PLAN:I am going to review her sleep study done at xxxx Hospital and also going to get a pulmonary function study. Further recommendations will follow the pulmonary function studies and also reviewing of her sleep study. Thank you for the consultation. Signed by X, MD, 05/01/20XX What are the diagnosis codes?

ANS: I69.354, I10, E78.00, Z79.02 Rationale: In this example the patient is status post cerebral vascular accident with residual left spastic hemiparesis. Look in the Alphabetic Index for Hemiplegia/following/stroke which directs the coder to I69.35-. When referenced in the Tabular List there are codes for laterality and dominant versus non-dominant. This documentation indicates the left non-dominant side reporting code I69.354. The patient also has hypertension, hypercholesterolemia and long term use of anticoagulant. Look in the Alphabetic Index for Hypertension which directs the coder to I10; Hypercholesterolemia which directs the coder to E78.00; and Long-term/antiplatelet directs the coder to Z79.02. Verify all code selections in the Tabular List.

9. Neurology Outpatient Consult Patient: SD Referring Physician: S, MD Date of Visit: 05/01/20XX Chief Complaint: Status post-cerebral vascular accident. History of Present Illness: This is a 68 year·old male who comes today for his first visit accompanied by his wife. The patient had a cerebral vascular accident on 04/01/thisyr and on 04/04/20XX with left-sided weakness. The patient had no seizures. Past Medical & Surgical History: Hypertension, Hypercholesterolemia, No heart disease. Medications: Plavix 75 mg (long-term use), Lisinopril, Pantoprazole, Lipitor Family History: Noncontributing. Allergies: Unknown. Social History: The patient does not smoke cigarettes or drink alcohol. Review of Systems: Constitutional: Patient reported weight gain. Neurologic: Patient has weakness and numbness due to CVA. Ears, Nose & Throat: Denied cough, nosebleed or snoring. Cardiac: He denied irregular heartbeat or chest pain. Respiratory: Denied recent cold or bronchitis. GI: Denied nausea, vomiting or diarrhea. GU: Denied bladder infection or bloody urine. Musculoskeletal: Denies any pains. Skin: Denied skin rash or itching. Psychiatric: Denied depression or anxiety. Endocrine: Denied thyroid problems or diabetes mellitus. Hematologic: Denied anemia or bleeding problems. Immunologic: Denied allergies or frequent infections. Eyes: He complained of blurring of vision. Physical Examination: Height: 5 feet 9 inches Weight: 203 pounds Blood Pressure: 150/80 General Appearance: Elderly man in no acute respiratory distress. Head and Neck: Atraumatic, supple without bruits. Heart: Regular rate and rhythm, no murmur. Lungs: clear. Extremities: Without clubbing, cyanosis or edema. Neurological Examination: Mental status: Fully conscious, oriented x three, normal language and speech. The patient is slow in responses to questions. Cranial Nerves II through XII: Sharp discs, pupils equal and reactive to light. Extraocular muscles intact. No facial weakness. Tongue protruded in the midline. Motor Examination: Strength 4/5 in left upper extremity proximally and distally, 4/5 in left iliopsoas, 5/5 in left tibialis anterior muscle. Deep tendon reflexes are 0/4 in right biceps, triceps, knees and ankle, 2/4 in left biceps and knee, 0/4 in left triceps and ankle. Toes equivocal bilaterally. Sensory Examination: Normal to pinprick sensation. Cerebellar: Normal finger-to-nose bilaterally. Gait: Spastic hemiplegic gait. There is increased muscle tone in the left upper extremity. Assessment and Plan: Status post cerebral vascular accident with non-dominant residual left spastic hemiparesis. Recommend carotid ultrasound. Hypertension. The patient was advised to follow up with Dr. S. Thank you for letting us share in the care of Mr. D. Signed by X, MD 05/02/20XX What are the diagnosis codes?