AAPC Ch. 5: ICD-10-CM Coding Chapters 12-21

In which circumstances would an external cause code be reported?

Causes of injury or health condition. Rationale: ICD-10-CM guideline I.C.20.a.1 states, an external cause code may be used with any code in the range of A00.0-T88.9, Z00-Z99, classification that is a health condition due to an external cause. Though they are most applicable to injuries, they are also valid for use with such things as infections or diseases due to an external source, and other health conditions, such as heart attack that occurs during strenuous physical activity.

According to the ICD-10-CM Official Guidelines for Coding and Reporting, Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A), codes in this range have sequencing priority over what codes?

Codes from all other chapters. Rationale: According to the ICD-10-CM Official Guidelines for Coding and Reporting, Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A), codes in this range have sequencing priority over codes from all other chapters in the ICD-10-CM codebook.

What type of fracture is considered traumatic?

Compound fracture Rationale: Traumatic fractures are a result of a traumatic event, occurrence, or even extreme force (for example, motor vehicle accidents, a fall from greater than standing height or level standing height). Traumatic fractures will always be coded from chapter 19 of the Tabular List. A compound fracture is a type of open traumatic fracture. A pathological fracture is a fracture caused by a disease that led to weakness of the bone structure. Stress fractures are indexed to category M84 in chapter 13. In the ICD-10-CM Alphabetic Index, look for Fracture, traumatic/spontaneous (cause unknown), which states to see Fracture, pathological. These conditions are not listed in the chapter 19 category of fracture codes; they are considered nontraumatic fractures.

A patient returns to her gynecologist's office to review the results of her ultrasound. She has been experiencing heavy bleeding and painful menstruation. The results of the ultrasound reveal the patient has a uterine fibroid measuring 4.0 cm. Select the diagnosis code(s).

D25.9

A 43 year-old female presents to the provider for a diabetic ulcer of the right ankle. What ICD-10-CM codes are reported?

E11.622, L97.319 Rationale: In the ICD-10-CM Alphabetic Index look for Diabetes, diabetic (mellitus) (sugar)/with/skin ulcer NEC and you are directed to E11.622. In the Tabular List below E11.622 there is a note to use an additional code to identify the site of the ulcer (L97.1-L97.9, L98.41-L98.49). A review of this code range identifies L97.319 Non-pressure chronic ulcer of right ankle with unspecified severity. Look in the Alphabetic Index for Ulcer/lower limb/ankle/right which refers you to code L97.319. In the Tabular List under category code L97 there is a note to code first any associated underlying condition, including diabetic ulcers and their corresponding codes. Verify code selection in the Tabular List.

Which statement is true regarding external cause codes? Refer to ICD-10-CM guideline I.C.20.a.6.

External cause codes are never sequenced first

Which statement is true regarding the perinatal period?

It ends at 28 days

A provider performs an incision and drainage on a large abscess on the patient's left leg. What is the diagnosis code?

L02.416

A patient complains of a rash that is extremely itchy. It began when she started using a new laundry detergent. She is examined and the provider diagnoses her with dermatitis, due to exposure to the laundry detergent. What is the diagnosis code?

L24.0

A patient is diagnosed with pressure ulcers on each heel. Each heel displays bone involvement with no evidence of necrosis. Select the diagnosis code(s).

L89.619, L89.629

Case 2 Chief Complaint: Multiple Ulcers. Subjective: The patient returns, accompanied by her caregiver, who states that she believes the ulcers have gotten "about as good as they are going to." The edema of the leg seems to be controlled much better. Objective: Exam reveals marked improvement of the edema of both lower legs, the right is better than the left. All of the ulcers are now extremely superficial and seem to almost be partial thickness skin. There is no cellulitis. The only uncomfortable are seems to be on the sole of the left foot where there are considerable bony abnormality and/or tophaceous deposits, which have distorted the bottom of her foot dramatically. To relieve the left foot pain, a sole nerve block posterior to the lateral malleolus is carried out with a 50:50 mixture of 1% lidocaine with epinephrine and .5% Marcaine. Following this, she gets good relief from the pain of the lateral posterior part of the foot. The legs are cleansed with Hibiclens and multi-layer compression wraps are reapplied by the PA. Assessment: Ulcers are on the feet. Edema is in the lower extremities. Foot pain is treated with a nerve block. Fantastic course to date, thanks to her caregiver. Plan: Continue with wound care as before. Return to the office in six to eight weeks; at which time, assuming everything is going well, we could set up an OR time for panniculectomy. She appears to understand and is willing to proceed. What diagnosis code(s) are reported?

L97.521, L97.511, R60.0, M79.672

A female patient has osteoarthritis localized in the left hip joint due to senile osteoporosis. What ICD-10-CM codes are reported?

M16.7, M81.0 Rationale: In the ICD-10-CM Alphabetic Index, look for Osteoarthritis/secondary/hip, guiding you to code M16.7. Secondary localized osteoarthritis is reported when the osteoarthritis develops as a result of an injury or disease (for example osteoporosis). The osteoporosis is coded as an additional code. In the Alphabetic Index, look for Osteoporosis (female) (male)/senile - see Osteoporosis, age related. Osteoporosis/age-related guides you to M81.0. Verify code selection in the Tabular List.

70 year-old female patient presents with a complaint of right knee pain with weight bearing activities. She is also developing pain at rest. She denies any recent injury. There is pain with stair climbing and start up pain. AP, lateral and sunrise views of the right knee are ordered and interpreted. The diagnosis is right knee pain secondary to underlying localized degenerative arthritis. What ICD-10-CM code(s) is/are reported?

M17.9 Rationale: The scenario is reported with one ICD-10-CM code. In the ICD-10-CM Alphabetic Index look for Arthritis, arthritic/degenerative, which directs you to see Osteoarthritis. Osteoar-thritis/knee directs you to M17.1. When you verify this code in the Tabular List, the code description for M17.1 includes primary osteoarthritis, which is not documented. Look down the category to M17.9 Osteoarthritis of knee, unspecified. This is the appropriate code selection based on the documented diagnosis. You do not report the ICD-10-CM code for knee pain as this is a symptom of the degenerative arthritis and is not reported separately.

A patient underwent debridement of the acromion, subacromial bursectomy, division of the coracoacromial ligament, and an abrasion acromioplasty with Mitek suture placement for recurrent dislocation of the right shoulder in the hospital outpatient surgery department. What ICD-10-CM code is reported?

M24.411 Rationale: Look in the ICD-10-CM Alphabetic Index for Dislocation/recurrent/shoulder which directs you to M24.41-. This code requires a 6th character to specify laterality. Verify code selection in the Tabular List.

An MRI confirmed the patient has sciatica caused by a herniated disc between L5 and S1. She is scheduled for an injection, after which she will be referred to a physical therapist in an effort to avoid surgery. Select the diagnosis code(s).

M51.17

A provider performs an arthroscopic procedure to repair an incomplete right degenerative rotator cuff tear on a patient with primary, degenerative arthritis in the same shoulder. Select the diagnosis codes.

M75.111, M19.011

CASE 6 Office note: RE: Injection, strapping of foot and ankle. Chief complaint: heel pain, 6 months' duration. No inflammation, no heat. Diagnosis: Heel spur. Treatment: Weight reduction, injection of Celestone, Xylocaine plain, pulses good, DTR, vibration and temp normal. Orthotics suggested; better shoes suggested. Lawyer by trade. Criminal trial attorney. Referred by his partner. Discussed diet, orthotic shoes. Return if need be in 61 days. What diagnosis code(s) are reported?

M77.30

A patient with age-related osteoporosis suffers a pathologic fracture to her right hip. She is being seen for this new fracture today. Select the diagnosis code(s)

M80.051A

A 55-year-old female with right hydronephrosis presents for a cystourethroscopy with a retrograde pyelogram. What is the correct diagnosis code?

N13.6

Case 1 Reason for consult: Acute Renal Failure HPI: The patient was followed in the past by my associate for CKD, with baseline creatinine of 1.8 two weeks ago. Found to have severe ARF this morning associated with acidosis and moderate hyperkalemia after presenting to the ER with complaint of dehydration. The patient is admitted under observation status to the hospitalist service and the renal team is called for a consult. ROS: Cardiovascular: Negative for CP/PND. GI: Negative for nausea; positive for diarrhea. GU: Negative for obstructive symptoms or documented exposure to nephrotoxins. All other systems reviewed are negative. PFSH: Negative family history of hereditary renal disease and negative history of tobacco or ETOH abuse. Exam: Constitutional: 99/52, 18, 102. NAD. Conversant. Eyes: anicteric sclera, no proptosis, PERRL. ENMT: Normal aside from somewhat dry mucus membranes. Cardiovascular: RRR, no MRGs, no edema. Respiratory: Lungs CTA, normal respiratory effort. GI: NABS, no HSM. Skin: Warm and dry, decreased turgor. Psychiatric: A&OX3 with appropriate affect. Labs: BUN = 99, creatinine = 3.6, HCO3 = 14, K = 5.9. Impression: 1. New, acute renal failure, due to dehydration. 2. Underlying stage III CKD. 3. Mild hypotension. Plan: 1. Bolus with another liter of NS wide open. 2. Then start D5W with 3 amps of HCO3 at 150 cc/hr. 3. Repeat labs in eight hours. 4. Further diagnostic testing will be ordered if there is no improvement of volume repletion. What diagnosis code(s) are reported?

N17.9, E86.0, N18.3, I95.5

The patient has benign prostatic hyperplasia with urinary retention. What ICD-10-CM code(s) is/are reported?

N40.1, R33.8 Rationale: In the ICD-10-CM Alphabetic Index look for Hyperplasia/prostate/with lower urinary tract symptoms (LUTS), guiding you to code N40.1. In the Tabular List there are instructions below code N40.1 to "Use additional code for associated symptoms, when specified." Code R33.8 is listed for urinary retention. Verify code selection in the Tabular List.

A patient diagnosed with BPH presents with urinary urgency. Select the diagnosis code(s).

N40.1, R39.15

A woman with a long history of rectocele has perineal scarring from multiple episiotomies and has developed a rectovaginal fistula with perineal body relaxation. She has transperineal repair with perineal body reconstruction and plication of the levator muscles to correct these conditions. What ICD-10-CM codes are reported?

N82.3, N90.89 Rationale: The patient has a history of the rectocele; you will not report code N81.6 because that indicates she has a current rectocele. The first diagnosis is rectovaginal fistula. Look in the ICD-10-CM Alphabetic Index for Fistula/rectovaginal which directs you to N82.3. The second diagnosis is perineal scarring. Look in the Alphabetic Index for Scar, scarring/vulva which directs you to N90.89. Verify code selection in the Tabular List.

The patient has a left ovarian pregnancy without intrauterine pregnancy. What ICD-10-CM codes are reported?

O00.202, Z3A.00 Rationale: In the ICD-10-CM Alphabetic Index, look for Pregnancy/ovarian guiding you to code O00.20. In the Tabular List, the 6th character 2 is selected to specify the left ovary. ICD-10-CM guideline I.C.15.b.1 states to not assign codes from category Z34 with Chapter 15 codes. At the beginning of Chapter 15 there is a note to use an additional code from Category Z3A Weeks of gestation, to identify the weeks of gestation for codes O00-O9A. In this case the weeks of gestation is not documented. In the Alphabetic Index look for Pregnancy/weeks of gestation/not specified which directs you to Z3A.00. Verify code selection in the Tabular List.

A patient had a spontaneous complete abortion three days ago. She returns to the ED and is bleeding. After the ED provider examines her, she still has retained products of conception (POC). What ICD-10-CM code is reported for this encounter?

O03.1 Rationale: ICD-10-CM guideline I.C.15.q.2 indicates when a patient has retained products of conception following a spontaneous abortion, report a code from category O03 Spontaneous abortion even when the patient has been discharged with a diagnosis of complete abortion previously. This is an incomplete abortion because there are retained products of conception. Look in the ICD-10-CM Alphabetic Index for Abortion/incomplete (spontaneous)/complicated by/hemorrhage (delayed) (excessive) directing you to O03.1. Verify code selection in the Tabular List.

What ICD-10-CM codes are reported on the maternal record for a delivery of triplets that are all liveborn at 32 weeks of pregnancy?

O30.103, Z37.51, Z3A.32 Rationale: Look in the ICD-10-CM Alphabetic Index for Pregnancy/triplet O30.10-. In the Tabular List, additional characters are required to indicate the number of placenta and the number of amniotic sacs. Because you do not have that documentation, 0 for unspecified is reported as the 5th character. The 6th character 3 is reported to indicate the 3rd trimester (trimesters are listed at the beginning of Chapter 15 in the ICD-10-CM codebook). The complete code is O30.103. Next, look in the Alphabetic Index for Outcome of Delivery/multiple births/all liveborn/triplets Z37.51. The last code indicates the weeks of gestation. Documentation indicates she delivered at her 32nd week. Look in the Alphabetic Index for Pregnancy/weeks of gestation/32 weeks Z3A.32. Verify code selection in the Tabular List.

CASE 5 HPI: 20-year-old female, estimated gestational age 25.3 weeks,(Patient is pregnant.) who presents with red staining after wiping with toilet paper (Patient's complaint.) this afternoon. No abdominal pain. Contractions: Negative. Fetal Movement: Present. ROS: Constitutional: Negative. Headache: Negative. Urinary: Negative. Nausea: Negative. Vomiting: Negative. Past Medical/Family/Social History: Medical History: Negative. Surgical History: Negative. Social History: Alcohol: Denies. Tobacco: Denies. Drugs: Denies. EXAM: General Appearance: No acute distress. Abdominal: Soft. Non-tender. Vagina: Blood clots size: 1.5 cm and amount 2. Discharge:Pink. No hyphae, BV, or TRICH, and CX not irritated. Cervix: Deferred. Uterus: Fundal height: 24 cm. MDM: Labs: FFN, UA R+M, C+S, GC/chlamydia, CBC, type and RH, DAU. Labs reviewed and WNL. Ultrasound: Negative for placenta previa. NOTES: Patient continues with contractions mildly, but does not feel it. Patient given Celestone I/M. D/C and to return tomorrow for repeat Celestone injection. Diagnosis: Threatened premature labor (Report the definitive diagnosis.) What diagnosis code(s) are reported?

O47.02, Z3A.25

A woman is readmitted one week after delivery with a diagnosis of delayed hemorrhage due to retained placental fragments. Which ICD-10-CM code(s) should be reported?

O72.2

A pregnant female, at 21 weeks, is diagnosed with iron-deficiency anemia and is sent to the clinic for a transfusion. Select the diagnosis code(s).

O99.012, D50.9, Z3A.21

Assign the code for feeding problems in newborn.

P92.9

CASE 9 PREOPERATIVE DIAGNOSIS: Congenital hydrocephalus. POSTOPERATIVE DIAGNOSIS: Congenital hydrocephalus. CLINICAL HISTORY: The patient is a 2-month-old boy who was born and was IUGR. He did well for the first several weeks; however, he then developed a large head. Mom noticed full fontanelle arid in the last week or so, and they have noticed the eyes have decreased mobility. He tends to stare straight and has some trouble looking up and even to the sides bilaterally, so she is reported it to her pediatrician. Pediatrician ordered a CT scan and referred the patient. I saw the patient yesterday in clinic. We ordered an HRI; HRT was done this morning. PIRI shows the congenital hydrocephalus; however, it is not a Dandy-Walker. We had a discussion with the family about risks, benefits, potential complications and also different procedures. We talked about a third ventriculostomy however, given the patient's age and the fact was hydrocephalus, he has elected to go with the shunt, Family is comfortable with this and will bringing him to the OR today for shunting. What diagnosis code(s) are reported?

Q03.9

A 4-year-old male is brought to the hospital by his mother. Today he is going to have surgery to repair his Cheiloschisis. Assign the correct code for his condition.

Q36.9

What is the diagnosis code for an elevated blood pressure reading?

R03.0

The patient was hit in the nose by the ball playing basketball on the varsity team last evening at the gym and woke up with sever epistaxis. The family physician controlled the nasal hemorrhage with cauterization and afterwards packed the nose with nasal packs. What are the correct diagnosis codes?

R04.0, W21.05XA, Y92.39, Y93.67, Y99.8

CASE 3 Subjective: The patient presents today after having a cabinet fall on her.(This describes how the injury occurred.) She states the people who put in the cabinet missed the stud by about two inches. The patient complains of cephalgias,(Patient complaint.) primarily occipital, extending up into the bilateral occipital and parietal regions. The patient denies any vision changes, any taste changes or any smell changes. The patient has marked amount of tenderness across the superior trapezius.(Patient complaint.) Objective: Her weight is 188 which is up 5 pounds from last time, blood pressure 144/82, pulse rate 70, respirations are 18. She has full strength in her upper extremities. DTRs in the biceps and triceps are adequate. Grip strength is adequate. Heart is a regular rate. Lungs are clear. Assessment: 1. Cephalgia 2. Thoracic somatic dysfunction (Select codes for definitive diagnosis.) Plan: The plan at this time is to send her for physical therapy, three times a week times four weeks for cervical soft tissue muscle massage, as well as upper dorsal. We'll recheck her in one month. What diagnosis code(s) are reported?

R51, M99.02, W20.8XXA

Mrs. Bixby, 83, is being admitted for dehydration and anorexia. The probable cause is dementia. She was brought in by her daughter who is visiting from out of town. Her daughter will take her from our office to St. Mary's. The gerontology unit will evaluate her mental condition tomorrow after she is stabilized. How would you code the diagnoses?

R63.0, E86.0

CASE 7 PREOPERATIVE DIAGNOSIS: 1. 2 cm transverse laceration of right forehead. 2. 3 cm stellate laceration of right upper eyelid. 3. 3 cm trap door laceration of right lower eyelid. OPERATIVE DIAGNOSIS: OPERATION PERFORMED: Multiple-layer closure of above lacerations totaling 8 cm. Anesthesia: Local. PREOPERATIVE NOTE: This patient is a 64-year-old white female. She has a very difficult time ambulating, doing so with a walker and intermittently sitting. This evening, unfortunately, she fell from her motorized wheelchair that was moving and struck the right side of her forehead. She was brought to the emergency department where she was thoroughly evaluated by Dr. Tim and is in the process of getting C-spine films and is accordingly in a cervical spine support. I was called to evaluate and treat these lacerations due to their extensive and complex nature. The lacerations are as described above. Forehead laceration is linear, deep, but otherwise uneventful. The upper right eyelid laceration is approximately 3 cm in length and the medial aspect of it is somewhat dusky because it is very thin and devoid of vasculature. The lower eyelid laceration is trap door and somewhat deep. It also becomes very thin at the medial aspect; however, there appears to be no duskiness. It seems to be well vascularized. In any event, we chose to immediately repair these with local anesthesia. DETAILS OF OPERATIVE PROCEDURE: Approximately a total of 6 ml of 2% lidocaine with 1:100,000 epinephrine was infiltrated into the three wounds. They were then thoroughly cleansed with soap, and closure was begun on the upper eyelid. We used 6-0 vicryl subcutaneous sutures to attack the flap back into position, and once this was accomplished, we used individual 6-0 Prolene sutures on the skin to complete the closure. Attention was then turned to the right lower eyelid laceration where essentially an identical procedure was done. The wounds were somewhat similar in that they were flaps pedicled to the lateral towards the medial. Again, we used 6-0 vicryl subcutaneous and 6-0 Prolene individual skin sutures. Finally, attention was turned to the forehead laceration which was similarly closed with these same sutures, 6-0 vicryl subcutaneous and 6-0 Prolene on the skin. The wounds were then dressed with Bacitracin ophthalmic. Patient was instructed to keep them moist at all times and to not let crust form. She was also instructed in the appropriate analgesics to be taken orally and given my office number for a follow-up appointment. At the end of the procedure, she was then sent back to x-ray for CT scan of her C-spine. What diagnosis code(s) are reported?

S01.111A, S01.81XA, V00.811A

A patient has an open displaced fracture of the second cervical vertebra. This is her fifth visit and the fracture is healing normally. What ICD-10-CM code is reported?

S12.190D Rationale: In the ICD-10-CM Alphabetic Index look for Fracture, traumatic/neck/cervical vertebra/second (displaced)/specified type NEC (displaced) guiding you to subcategory S12.190- . In the Tabular List this code is for Other displaced fracture of second cervical vertebra. This is chosen because the original fracture was an open displaced fracture. The 7th character D is chosen to indicate that this is the subsequent encounter for fracture with routine healing.

CASE 4 CHIEF COMPLAINT: Right shoulder injury.(Patient's complaint.) MODE OF ARRIVAL: Private vehicle. HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old male who states that just prior to arrival he was going into a supermarket (Where accident occurred) when the revolving door suddenly slammed on him(How accident happened). It caught him across the right side of his chest anteriorly and posteriorly.(Location of the chest injury.) He was unable to liberate himself from the door, and an employee had to help him out. He denies any current shortness of breath, although did say he had the wind knocked out of him. He complains of pain in the anterior and posterior chest wall, posteriorly medial to the scapula. He denies any numbness, tingling or weakness in his right arm; however, he does state that it seems to be painful and difficult for him to either lift or even drop his arm. He again denies any numbness, tingling, or weakness distally. He denies any injury to his head or neck; although, he had a temporary episode of spasms on the left side of his neck. He has not taken anything for pain. REVIEW OF SYSTEMS: Negative for fevers, chills, or unintentional weight loss. No neck pain, numbness, tingling, weakness, nausea, vomiting, shortness of breath, hemoptysis or cough. All other systems have been reviewed and are negative except as noted. PHYSICAL EXAMINATION: General: The patient is awake and alert, lying comfortably in the treatment bed, he is nontoxic in appearance. Vital Signs: Temperature= 98.3, pulse= 81, respirations= 16, blood pressure= 134/81, pulse oximetry= 95% on room air. HEENT: The head is normocephalic and atraumatic. Neck: Non-tender to palpation in the posterior midline. The trachea is midline. There is no subcutaneous emphysema. There is no tenderness over the paraspinous muscles. Heart: Regular rate and rhythm without murmurs Lungs: Clear to auscultation bilaterally without wheezes, crackles or rhonchi. The chest wall does expand symmetrically. Thorax/Chest Wall: Demonstrates mild tenderness anteriorly and demonstrates distinct tenderness posteriorly along the medial aspect of the scapula. No bruising or ecchymosis is noted on the skin of the chest wall. Patient keeps his right shoulder lowered. There is no deformity noted. There is no tenderness over the right clavicle. No bony deformity is noted there. There is no subcutaneous emphysema of the chest wall. Extremities: Warm and dry without clubbing, cyanosis or edema. Grip strength is 5/5 bilaterally. Patient can flex and extend all fingers without difficulty. He can pronate and supinate at the elbow. He complains of pain in the shoulder when he flexes and extends at the elbow. Normal radial and ulnar pulses are appreciated in the bilateral upper extremities. Capillary refill is brisk. Sensation is normal in all nerve distributions in the bilateral arms. Abdomen: Soft, non-distended. Non-tender. Diagnostics: Two views of the chest, PA and lateral, and three views of the right shoulder were obtained. ED course: The patient received a total of 2 mg of Dilaudid for pain, 1 mg of sublingual Ativan. His arm was placed in a sling This was well tolerated and the patient was discharged home. Medical Decision Making: It appears the patient has an anterior chest wall and a posterior chest wall contusion. The exact reasoning why he has so much difficulty moving the shoulder is unclear at this time, as he is completely neurologically intact from what I can tell. He can adduct and abduct at the shoulder, as I have seen him do it as he was moving around to be examined. X-rays demonstrate no evidence of fracture or dislocation. At this point, I am discharging the patient home, having him use ice packs, doing prescriptions for pain medications and having him return for new or worsening symptoms. IMPRESSION: 1 Anterior and posterior chest wall contusion. 2 Right shoulder injury. (Report codes for the definitive diagnosis.) PLAN: Discharge home. Return for new or worsening symptoms. Sling for comfort. What diagnosis code(s) are reported?

S20.211A, S20.221A, S49.91XA, W23.0XXA, Y92.512

A male patient was a passenger in an automobile involved in a serious collision with another automobile. He sustained a closed fracture of the coronoid process of the jaw and an open left shaft fracture, Type 1, of the radius with an open, Type 1 shaft fracture of the left ulna. What are the diagnosis codes?

S52.302B, S52.202B, S02.630A, V43.32XA

CASE 8 PREOPERATIVE DIAGNOSIS: Right forearm radial shaft fracture with possible mild distal radioulnar joint subluxation. POSTOPERATIVE DIAGNOSIS: Right forearm radial shaft comminuted fracture with possible mild distal radioulnar joint subluxation. ANESTHESIA: Axillary block with general anesthesia. OPERATION: Right radius fracture open reduction and internal fixation with closed reduction distal radioulnar joint INDICATIONS: This is a 22-year-old male, who sustained a right forearm fracture injury as indicated above and in the medical records and office notes. DESCRIPTION OF PROCEDURE: The patient was placed under axillary block in the holding area, followed by general in the operating room. Patient identification, correct procedure, and site were confirmed. Antibiotics were provided in an appropriate fashion preoperatively. A dorsal/posterior approach to the fracture was performed with a standard recommended incision, location and technique. The interval between the extensor carpi radialis brevis and extensor digitorum communis was developed. The extensor pollicis brevis and the abductor pollicis were gently retracted one way or the other to expose the fracture site, and the fracture was just beneath this area. The radial sensory nerve was identified and protected throughout the procedure. The fracture was exposed with minimal soft tissue stripping. The bone holding forceps were placed on either side of the fracture, the overriding fracture was manipulated with gentle traction, and the fracture reduced. This effectively reduced the distal radioulnar joint. A small fragment, Synthes DCP locking plate was utilized to fix the fracture. Eight holes were utilized. Due to the nature of the fracture and the anatomy, there were three screws distal, four screws proximal, and the last hole was at the area of the fracture. Initially to achieve satisfactory bone to plate contact, three lag screws were required and these were placed initially. This was followed by placement of the remaining screws that were utilized proximal and distal to the fracture site to be locking screws. Intraoperative X-rays utilizing the C-arm were performed throughout the procedure to guide fracture reduction and hardware replacement. Final X-rays demonstrated excellent alignment of the fracture in the distal radioulnar joint. Excellent coaptation of the bony surfaces was obtained. Final irrigation of the wound was performed. The wound was closed in layers in a standard fashion. Splints were applied. Total tourniquet time was approximately 60 minutes. The patient tolerated the procedure well and went to the recovery room in satisfactory condition. Sponge and needle count is correct x2. Estimated blood loss is minimal. What diagnosis code(s) are reported?

S52.351A

A 4 year-old is brought into the ED crying. He cannot bend his left arm after his older sister pulled it. The provider performs an X-ray and it shows the patient has a dislocated Nursemaid's elbow. The ED provider reduces the elbow successfully. The patient is able to move his arm again. What ICD-10-CM codes are reported?

S53.032A, X50.9XXA Rationale: In the ICD-10-CM Alphabetic Index look for Nursemaid's elbow directing you to S53.03-. In the Tabular List, 6 th character 2 is reported for the left elbow and 7 th character A is applied for the initial encounter. The patient's arm was injured due to his sister pulling on it. In the ICD-10-CM External Cause of Injuries Index look for Pulling, excessive which directs you to X50.9. In the Tabular List, seven characters are needed, reporting X50.9XXA.

A 63 year-old fractured her scaphoid bone in her right wrist three months ago in an accident. She now presents with a nonunion of the scaphoid bone. What ICD-10-CM code is reported?

S62.001K Rationale: A nonunion fracture is when the broken bone has failed to heal or is not healing. According to ICD-10-CM guideline I.C.19.c.1 Care of complications of fractures, such as malunion and nonunion, is reported with the appropriate 7th character for subsequent care. The fracture was due to an accident and there is no mention of osteoporosis so this is a traumatic fracture. In the ICD-10-CM Alphabetic Index, look for Fracture, traumatic/scaphoid (hand) and you are directed to see also Fracture, carpal, navicular. In the Alphabetic Index, look for Fracture, traumatic/carpal bone(s)/navicular guides you to S62.00-. In the Tabular List a 6th character 1 is selected for the right wrist and 7th character K is selected for a subsequent encounter for fracture with nonunion. Verify code selection in the Tabular List.

A 7 year-old female patient was seen in the emergency department after being bitten by a dog. The child received treatment for the puncture wounds to her left leg. She also received a rabies vaccine because the dog was known to have rabies. What ICD-10-CM codes are reported?

S81.852A, Z20.3, Z23, W54.0XXA Rationale: The child had puncture wounds to her left leg from a dog bite. Look in the ICD-10-CM Alphabetic Index for Bite(s) (animal) (human)/leg (lower) S81.85-. In the Tabular List, 6th character 2 is reported for the left leg and 7th character A is applied for the initial encounter. She did not have rabies but was exposed to it because the dog was known to have rabies. This exposure to rabies is reported. Look in the Alphabetic Index for Exposure (to)/rabies directing you to Z20.3. She received a rabies vaccination. Look in the Alphabetic Index for Immunization/encounter for directing you to Z23. Next, the circumstances for the injury are reported. The only thing we know is that it is a dog bite. Look in the ICD-10-CM External Cause of Injuries Index for Bite, bitten by/dog directing you to W54.0-. In the Tabular List the 7th character A is applied for the initial encounter. Two placeholder Xs are used for the 5th and 6th characters to keep the 7th character in the 7th position. Verify code selection in the Tabular List.

The provider performs an open reduction and internal fixation for left fibula and tibia fractures. Select the codes.

S82.402A, S82.202A

A 60 year-old patient sustained a comminuted left calcaneal fracture after falling from a ladder. Initial ED treatment consisted of diagnostic radiology studies and surgical ORIF was performed 9 days later. The patient now presents to the orthopedic clinic for evaluation and cast change. The fracture is healing normally. What ICD-10-CM code(s) is/are reported?

S92.002D, W11.XXXD Rationale: A comminuted fracture is one in which a bone is broken, splintered, or crushed into a number of pieces; therefore, it is considered displaced. Look in the ICD-10-CM Alphabetic Index for Fracture, traumatic/tarsal bone(s)/calcaneus directing you to subcategory S92.00-. The Tabular List indicates seven characters are needed to complete the code. The 6th character 2 indicates laterality as left. The patient has completed the initial fracture treatment phase and is healing normally; therefore, the 7th character D is chosen for subsequent encounter for fracture with routine healing. Cast change and removal are listed as examples of fracture aftercare in the ICD-10-CM guideline I.C.19.c.1. ICD-10-CM guideline I.C.20.a.2 instructs you to use the external cause code for the length of the treatment. In the ICD-10-CM External Cause of Injuries Index look for Fall, falling/from, off, out of/ladder directing you to category W11. In the Tabular List, there is a note that the code requires seven characters. The 4th, 5th, and 6th characters are reported with placeholder Xs and the 7th character chosen is D for subsequent encounter. The complete code is W11.XXXD. Verify code selection in the Tabular list.

A patient presented to the emergency department with second degree burns to both forearms, which makes up 9 percent TBSA. She is three months pregnant, 12 weeks. The burns are not affecting the pregnancy. Select the diagnosis codes.

T22.212A, T22.211A, T31.0, Z33.1

A child is seen in a hospital based pediatric clinic for active treatment of 10% first and second degree burns to the left calf area and 5% third degree burns on her right hand. What ICD-10-CM codes are reported?

T23.301A, T24.232A Rationale: Burns are classified as burns or corrosions in ICD-10-CM. In this scenario, there is no specification as to what caused the burns, but they are stated as burns. ICD-10-CM guideline I.C.19.d.1 indicates to sequence first the code that reflects the highest degree of burn when more than one is present. In this case, the third degree burn on the right hand is listed first. In the ICD-10-CM Alphabetic Index, look for Burn/hand(s)/right/third degree directing you to T23.301-. In the Tabular List, a 7th character A is reported for the initial encounter (active treatment). ICD-10-CM guideline I.C.19.d.2 indicates to code burns of the same site, but of different degrees to the subcategory identifying the highest degree recorded. Therefore, report second degree burns to the left calf. Look in the Alphabetic Index for Burn/calf/left/second degree T24.232. In the Tabular List a 7th character A is reported for the initial encounter. ICD-10-CM guideline I.C.19.d.6 indicates a code from category T31 is reported when there is mention of a third-degree burn involving 20% or more of the body surface. This does not apply in this case, so a code from T31 is not required (unless reporting for a burn unit or other facility requiring the additional data). The codes in the burn section have a note to use additional external cause codes to identify the source, place and intent of the burn. This information is not known in this case so it cannot be reported. Verify code selection in the Tabular List.

A patient visits the ED for ringing in the ears, nausea, vomiting and drowsiness. During the history taking, the provider learns the patient has been taking 2 aspirins every hour for the last three days. After examination and performing blood tests the provider diagnoses the patient with aspirin poisoning. What ICD-10-CM codes are reported?

T39.011A, H93.13, R11.2, R40.0 Rationale: Over the counter medication taken in an improper dosage is considered a poisoning. ICD-10-CM guideline I.C.19.e.5.b states "When coding a poisoning or reaction to the improper use of a medication (for example: overdose, wrong substance given or taken in error, wrong route of administration), first assign the appropriate code from categories T36-T50." This was an accident (taken incorrectly). In the ICD10-CM Table of Drugs and Chemicals, look for Aspirin/Poisoning, Accidental (unintentional) column directing you to T39.011. In the Tabular List this code needs a 7th character. The seventh character chosen is A. The first code to assign is the poisoning, T39.011A. The codes for the manifestations are assigned next and are found in the ICD-10-CM Alphabetic Index by looking for Tinnitus (ringing in the ear) H93.1-, 5th character 3 for both ears; Nausea/with vomiting (R11.2); and Drowsiness (R40.0). Verify code selection in the Tabular List.

A patient was prescribed an antidepressant. She forgot she had taken her pills for the day and took another pill by accident. She is now complaining of dizziness and excessive sweating. Select the diagnosis codes in the correct sequence.

T43.201A, R42, R61

A patient was treated in the emergency department for a nasal fracture. Bleeding was controlled, a splint applied, and the patient sent home. He returned to the ED several hours later with new bleeding from both nares due to the fracture. The ED provider had to repack the nose and insert new splints to stabilize the fracture. What ICD-10-CM code(s) is/are reported for the second ED visit?

T79.2XXA, S02.2XXA Rationale: Per ICD-10-CM guideline I.C.19.a indicate the 7th character A for initial encounter is used for each encounter when the patient is receiving active treatment, examples of which are provided as surgical treatment, emergency department encounter, and evaluation and continued treatment by the same or different provider. Because the patient in this scenario presents for the second time to the ED for continued care of the fracture, 7th character A is used. Look in the ICD-10-CM Alphabetic Index for Hemorrhage, hemorrhagic/traumatic/recurring or secondary (following initial hemorrhage at time of injury) which guides you to T79.2-. Next, look for Fracture, traumatic/nasal (bone(s)) which guides you to code S02.2. The correct 7th character for both codes is A. Two Xs are needed for the 5th and 6th characters of both. Verify code selection in the Tabular List.

A patient was sent home with a PICC line for Vancomycin treatment at home. He returns to his physician with an infection due to the PICC line. The infection is determined to be MRSA. Select the diagnosis code(s) in the correct sequence.

T80.218A, A49.02

The patient is in for an initial replacement of a leaking dialysis catheter. What ICD-10-CM code is reported?

T82.43XA Rationale: A leaking dialysis catheter would be a complication. In the ICD-10-CM Alphabetic Index look for Complication/catheter (device) NEC/dialysis (vascular)/mechanical/leakage, guiding you to subcategory code T82.43. The Tabular List indicates seven characters are needed to complete the code. The 6th character is for the placeholder X and the 7th character is A for the initial encounter. T82.43XA is the correct code.

When a patient presents for a screening test and the provider finds something abnormal, what diagnosis code should be sequenced first? Refer to ICD-10-CM guideline I.C.21.c.5.

The Z code to identify the screening

A code from categories Q00-Q99 can be used until the patient reaches what age? Refer to ICD-10-CM guideline I.C.17.

They can be used throughout the life of the patient.

What does the root word colp/o stand for?

Vagina Rationale: Colp/o is the combining form referring to the vagina. As examples, colpocele (N81.5) and colpocystitis (N76.0) are medical conditions of the vagina.

When should a code for signs and symptoms be report? Refer to ICD-10-CM guidelines I.C.18.a and I.C.18.b.

When it is not integral to the definitive diagnosis

CASE 10 This 67-year-old Medicare patient is seen for a screening Pap and pelvic examination at our office today. She is an established patient and is complaining of abnormal vaginal discharge on and off for approximately three weeks. She denied any trauma. Patient is not sexually active and her LMP was ten years ago. She denies any chest pain, shortness of breath or urinary problems. Patient had Pap and pelvic exam one year ago and is requesting a Pap and pelvic exam today. Patient was presented with an ABN which was signed. Past Medical History: Two vaginal deliveries, one in 1965 and another in 1967. Allergies, unknown. Medications include Micardis 80 mg for hypertension. She does not smoke or drink. She is married and lives with her husband. Examination: Vital signs: BP= 125/70. Pulse= 85, respirations= 20. Height= 5' 5". Weight= 135 lbs. Well-developed, well-nourished female in no acute distress. HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular muscles are intact. Neck: Thyroid not palpable. No jugular distention. Carotid pulses are present bilaterally. Breasts: Manual breast exam reveals no masses, tenderness or nipple discharge. The breasts are asymmetrical with no nipple discharge. Abdomen: No masses or tenderness noted. No hernias appreciated. No enlargement of the liver or spleen. Pelvic: Vaginal examination reveals no lesions or masses. Discharge is noted and a sample was collected for testing and sent to an outside laboratory for testing. No bleeding noted. Examination of the external genitalia reveals normal pubic hair distribution. The vulva appears to be within normal limits. There are no lesions noted. A speculum is inserted. There is no evidence of prolapse. The cervix appears normal. A cervical smear is obtained and will be sent to pathology. The speculum is removed and a manual pelvic examination is performed. It appears that the uterus is smooth and no masses can be felt. Rectal examination is within normal limits. Screening occult blood is negative. Uterus is not enlarged. Urinary: Urethral meatus is normal. No masses noted for urethra or bladder. Assessment and Plan: Routine Pap and pelvic; vaginal discharge. Patient had Pap and pelvic examination one year ago. Patient was sent to our in-house lab for blood draw today, and she is to follow-up in one week for lab results. What diagnosis code(s) are reported?

Z01.411, N89.8

The provider orders serum blood tests as part of a pre-employment physical exam. What is the diagnosis?

Z02.01

Patient is in the facility here today for a screening colonoscopy. During the procedure, a polyp is found and removed with a hot biopsy technique. How would this be reported?

Z12.11, K63.5 Rationale: ICD-10-CM guideline I.C.21.c.5 indicates, "A screening code may be a first listed code if the reason for the visit is specifically the screening exam...Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis." For this question, the screening code is reported first. Look in the ICD-10-CM Alphabetic Index for Screening/colonoscopy which directs you to Z12.11. Then, look for Polyp, polypus/colon which directs you to K63.5 as the secondary diagnosis. Verify both code selections in the Tabular List.

The patient's dense breast tissue made the screening mammogram unreadable, and she is here today for a breast ultrasound. Her mother and sister both have history of breast cancer. What are the correct diagnosis codes?

Z12.39,R92.2, Z80.3

A male newborn, delivered vaginally in the hospital, is born with jaundice. Select the diagnosis code(s) for the newborn's record.

Z38.00, P59.9

The hospital documentation states "normal vaginal delivery, live birth, female, with down syndrome." Select the correct code(s) for the infant's record.

Z38.00, Q90.9

A baby boy is born by cesarean section in the hospital. ABO incompatibility was documented, but the Coomb's test was negative, ruling out the ABO incompatibility, so no treatment was given. What ICD-10-CM codes are reported for the newborn's record?

Z38.01, Z05.8 According to ICD-10-CM guideline 1.C.15.a.2 chapter 15 codes are only used on the maternal record. Per ICD-10-CM guideline I.C.16.a.2 when coding the birth episode in a newborn record, assign a code from category Z38 Liveborn infants according to place of birth and type of delivery, as the principal diagnosis. Code Z38.01 is found in the ICD-10-CM Alphabetic Index by looking for Newborn (infant) (liveborn) (singleton)/born in hospital/by cesarean. ABO incompatibility was documented but ruled out due to the Coomb's test being negative. Look in the Alphabetic Index for Observation/newborn (for)/ruled out/specified condition NEC referring you to Z05.8. Report only codes Z38.01 and Z05.8.

Newborn twin girls were delivered in the hospital via cesarean section at 27 weeks, weighing 850 grams for twin A and 900 grams for twin B. Both were diagnosed with extreme immaturity. What ICD-10-CM codes are reported for both twins?

Z38.31, P07.03, P07.26 Rationale: Per ICD-10-CM guideline I.C.16.a.2 indicates when coding the birth episode in a newborn record, assign a code from category Z38 Liveborn infants according to place of birth and type of delivery, as the principal diagnosis. A code from this series is assigned only once to a newborn at the time of birth. In the ICD-10-CM Alphabetic Index look for Newborn/twin/born in hospital/by cesarean, directing you to code Z38.31. In the Alphabetic Index also look for Low/birthweight/extreme/with weight of/750-999 grams directing you to code P07.03. Additionally, look in the Alphabetic Index for Immaturity (less than 37 completed weeks)/extreme of newborn (less than 28 completed weeks of gestation)/gestational age/27 completed weeks directing you to code P07.26. Verify all code selections in the Tabular List. There is also an instructional note under category P07 to code the birth weight before the gestational age.