Chapter 11 AAPC Practical application

FOLLOW-UP NOTE DATE: 03/01/20XX DIAGNOSIS: The patient is a 68 year-old female with a diagnosis of recurrent, poorly differentiated, papillary carcinoma of the thyroid gland, initial stage unclear. Initially, this seemed to be a T4a, N1a, MX malignancy. The patient completed 3,000 cGy in ten treatments five months ago. Due to the patient's medical condition and performance status, split-course radiotherapy was offered. The patient received 3,000 cGy with significant improvement of her symptoms with tumor regression. INTERVAL HISTORY: The patient was asymptomatic. She was then noted to develop multiple bilateral lung metastases. Approximately four weeks ago, she developed hoarseness. According to the patient, she was told that the left vocal cord was not mobile due to the disease. The patient also reported a poor appetite. She does have shortness of breath on exertion but denies hemoptysis. PHYSICAL EXAMINATION: Physical examination reveals her weight to be 244 pounds, which represents an eight-pound loss in the past two months. HEENT is unremarkable. Examination of the neck revealed the neck mass to have significantly decreased in size. However, it is hard and fixed. Her lungs are clear to auscultation. Cardiac exam reveals a regular rate and rhythm. Cranial nerves IX-XII are grossly intact. The patient' s Karnofsky performance status is approximately 70. EXT: Some Edema in lower extremities. ASSESSMENT: The patient developed multiple lung metastases, as well as bilateral hilar lymphadenopathy. I do not think that radiotherapy would be beneficial for 'this patient at this time. I advised her that she will need to continue her care with Dr. Y. PLAN: The patient is discharged from this clinic. If she develops an indication for radiotherapy, she will be seen as soon as possible. What are the diagnosis codes? Enter an ICD-10-CM code for each space provided.

C73 C78.01 C78.02 R59.0 Z92.3 R60.0 In this case the patient has recurrent, poorly differentiated papillary carcinoma of the thyroid gland, initial stage unclear. In the Alphabetic Index for Carcinoma/papillary which directs the coder to C73. The patient also has multiple bilateral lung metastases, in the Table of Neoplasms for Neoplasm/lung/Malignant Secondary column which directs the coder C78.0. When you reference C78.0 in the Tabular List there are choices for left and right lung but there is no bilateral choice so two codes would be required C78.01 and C78.02. The patient also has bilateral hilar lymphadenopathy, in the Alphabetic Index look for Lymphadenopathy/localized which directs the coder to R59.0. Z92.3 is reported for having therapeutic radiation. In the Alphabetic Index look for History/personal/radiation therapy referring you to Z92.3. Lastly the patient has edema of the extremities, in the Alphabetic Index for Edema/lower limbs which directs the coder to Edema/legs. Edema/legs directs the coder to R60.0. Verify all code selections in the Tabular List.

DOB: 03/01/xx DATE OF SERVICE: xx/xx/20xx COMMUNITY INTERNAL MEDICINE PROBLEMS: DM 2 with hypertensive heart disease & CKD. Perirectal rash. SUBJECTIVE: Patient is a very pleasant 81 year-old gentleman with the above multiple problems who returns today in follow-up. He has actually been doing quite well. He has been followed in nephrology clinic and recently was evaluated and found to have low vitamin D levels. He is not taking any vitamin D. His lipids and diabetes were checked at that visit.(Labs were ordered for Hyperlipidemia and Diabetes.) He has been feeling well and thinks his sugars are doing well. His weight has been stable, although he has gained two pounds since last year at 166. MEDICATIONS: His current medications are extensive and they are TriCor 145 mg every morning.(Helps reduce Cholesterol and triglycerides in the blood. Supports diagnosis of hyperlipidemia.) Vytorin 10/80 one tablet at bedtime.(A combination drug of ezetimibe and simvastatin. Used to reduce the amount of cholesterol absorbed by the body. Supports diagnosis of hyperlipidemia.) Lisinopril 40 mg a day.(An ACE inhibitor used to treat high blood pressure; can also treat CHF or if a patient has had a recent heart attack.) Clonidine 0.2 mg b.i.d.(Lowers blood pressure by relaxing the blood vessels and allows the heart to beat slowly and easily. Supports Hypertension diagnosis.) Metoprolol ER 100 mg a day.(A beta-blocker that affects the heart and circulation. Used to treat Angina and hypertension.) Amlodipine 2.5 mg a day.(A calcium channel blocker that dilates blood vessels and improves blood flow. Used to treat chest pain and other conditions caused by coronary artery disease and hypertension.) 1 aspirin a day.(Long-term use of aspirin.) Today, vitamin D 1000 International units is added to his medical regimen. Otherwise, he is feeling well. PAST HISTORY: Remarkable for the problems as above. FAMILY HISTORY: Remarkable for his father dying of heart disease at 54.(Family history of heart (cardiovascular) disease.) SOCIAL HISTORY: The patient has been married for 58 years, never used any illicit drugs, drinks no alcohol, and never smoked. HEALTH SCREENING: Colonoscopy is up to date. REVIEW OF SYSTEMS: The patient's weight is 166 pounds. He has no recent fever or chills. No visual disturbances or any hearing loss. No chest pain, shortness of breath, dyspnea on exertion, breast pain or discharge, abdominal pain, change in bowel habits, melena, hematochezia, difficulty with urination, headache, lymph node swelling, or allergy. PHYSICAL EXAM: GENERAL: The patient is a well-developed, pleasant, white male. He is alert, oriented x3 and cooperative. VITAL SIGNS: BP today is excellent at 124/68 in the left arm seated. Pulse 72 and regular. Respiratory rate 14 and unlabored. Temperature 97.2 degrees. HEENT: Remarkable only for poor dentition. NECK: Supple without ND, adenopathy, bruits or thyromegaly. LUNGS: Clear to percussion and auscultation. CARDIOVASCULAR: A non-displaced PMI with a regular rhythm, normal S1 and S2, with an S4 gallop, and multiple systolic clicks. No murmur noted. ABDOMEN: Obese, soft and non-tender with a small reducible umbilical hernia. Bowel sounds are present and normoactive. Multiple bruits are heard in the abdomen. EXTREMITIES: Show no cyanosis, clubbing, edema, or skin lesions. Peripheral pulses are 2+ and symmetrical. NEUROLOGIC: Normal. ASSESSMENT: Severe hypertension with hypertensive heart disease well controlled. (A combination code of hypertensive heart disease with CKD.) Chronic kidney disease. Creatinine has recently increased and is about to be repeated and rechecked by nephrology. Type 2 diabetes mellitus, probably under good control, but will add a hemoglobin A1C to today's lab. Hyperlipidemia has been well controlled, but the patient is not fasting, so we will just simply recheck it when he returns in six months. Perianal dermatitis, improved on Mycolog-II, but still has a little residual and would like to try a different cream. PLAN: I will go ahead and change him from Mycolog -II to Lotrisone cream to be applied b.i.d. for 10 days and then as needed for his perianal dermatitis. I will order a hemoglobin A 1C today and check that and make sure it is still normal. I will see him back in 6 months, with a fasting CMP, lipid panel, hemoglobin A1C, and 25-hydroxyvitamin D level before that visit. Have asked him to add a 1000 IU Vit D capsule to his regimen for low Vitamin D levels. Generated by: X, DO What are the diagnosis codes? Enter an ICD-10-CM code for each space provided.

E11.22 N18.9 I13.10 E78.5 E11.620 E55.9 Z79.82 Z82.49 L30.9 In this case the patient has type 2 diabetes mellitus, in the Alphabetic Index for Diabetes, diabetic (mellitus) (sugar)/type 2/with chronic kidney disease which directs the coder to E11.22. A relationship may be assumed between Diabetes type 2 and CKD. The patient has hypertensive heart disease and chronic kidney disease due to hypertensive nephrosclerosis. According to ICD-10-CM guideline, I.C.9.a.3, states assign codes from combination category I13, Hypertensive heart and chronic kidney disease, when both hypertensive kidney disease and hypertensive heart disease are stated in the diagnosis. In the Alphabetic Index look for Hypertension/cardiorenal (disease) which directs the coder to I13.10. There is an instructional note that states to add an additional code for the stage of CKD. As the stage of the CKD is not documented the unspecified code will need to be assigned. In the Alphabetic Index look for Disease, diseased/kidney/chronic which directs the coder to N18.9. The patient has hyperlipidemia, in the Alphabetic Index look for Hyperlipidemia which directs the coder to E78.5. Next, the patient has perianal dermatitis, in the Alphabetic Index look for Diabetes/with/dermatitis which directs the coder to E11.620. The patient has low vitamin D, in the Alphabetic Index look for Deficiency/vitamin/D which directs the coder to E55.9. Last, The patient is on daily aspirin, in the Alphabetic Index look for Long-term (current) (prophylactic) drug therapy (use of)/aspirin which directs the coder to Z79.82. There is also a family history of heart disease. Look in the Alphabetic Index for History/family/disease or disorder (of)/cardiovascular NEC which directs the coder to Z82.49.The patient has perianal dermatitis. In the Alphabetic Index, look for Dermatitis which directs you to L30.9. Verify all code selections in the Tabular List.

Reason For Visit Patient presents today for a three month recheck for diabetes, hypertension, hyperlipidemia, with lab results. HPI Patient has NIDDM, is doing well, no new complaints. No hyperglycemia or hypoglycemia episodes recently. No nightmares or night sweats, No side effects from his medications. Patient is trying to follow his diet and exercise regimen. A1C is 7.1. Hyperlipidemia: taking on medications daily as recommended, no side effects or muscle aches or pains or GI symptoms. Hypertension: doing well, BP is under good control at home, no chest pain or abdominal pain, no muscle cramps, no swelling of the lower extremities, no acute focal neuro- changes, no headache. ROS Systemic symptoms: Feeling fine and not feeling tired (fatigue). No fever and no chills. Head symptoms: No headache. Neck symptoms: No neck pain. Otolaryngeal symptoms: No postnasal drip and no nasal passage blockage. Cardiovascular symptoms: No chest pain or discomfort. Pulmonary symptoms: No dyspnea, no cough, and no wheezing. Gastrointestinal symptoms: Appetite not decreased. No dysphagia, no heartburn, no nausea, no vomiting, no abdominal pain, and no melena. No diarrhea and no constipation. Genitourinary symptoms: No change in urinary frequency; No dysuria. Musculoskeletal symptoms: No back pain and no soft tissue swelling; hemiparesis, Right. Neurological symptoms: Dizziness. Allergies: No Known Allergies. Current Meds Diovan 320 MG Tablet; TAKE 1 TABLET DAILY; Rx Glipizide 5 MG Tablet; TAKE 1 TABLET DAILY; Rx Hydrochlorothiazide 25 MG Tablet; TAKE 1 TABLET DAILY.; Rx Lisinopril IO MG Tablet; TAKE 1 TABLET DAILY; Rx Metformin HCI 1000 MG Tablet; TAKE 1 TABLET DAILY WITH BREAKFAST; Rx Plavix 75 MG Tablet; TAKE 1 TABLET Monday & Wednesday & Friday for PVD; Rx Vytorin10-80 MG Tablet; TAKE 1 TABLET DAILY; Rx. Vital Signs Recorded by xxxx on xx/xx/xxxx xx:xx PM BP: l54/80, LUE, Sitting. HR: 72, L Radial. Temp: 98.4 F, Tyrnpanic. WT: 206 lb. Physical Exam General appearance: Well-appearing, Active. Right-handed. Neck: No tenderness of the neck. Thyroid: Not diffusely enlarged. Lymph Nodes: Cervical lymph nodes were not enlarged. Supraclavicular lymph nodes were not enlarged. Lungs: Respiratory movements were normal. Normal breath sounds, voice sounds. Cardiovascular system: Heart Rate and Rhythm: Normal. Heart Sounds: Normal. Murmurs: No murmurs were heard. Arterial Pulses: No bruit in the carotid artery. Edema: Not present. Abdomen: Palpation: Abdomen was soft. No abdominal tenderness. Recent lab Results HGB A1C xx/xx/20XX, HGB A1C: 7.1. Active Problems Anterior Wall Chest Pain With Respiration Chronic Obstructive Pulmonary Disease Complete Colonoscopy; 4/XX Essential Hypertension Hemiparesis Dominant Side Only Hyperlipidemia Peripheral Vascular Disease Type II Diabetes Mellitus Assessment Essential hypertension Hyperlipidemia Diabetes mellitus Orders Renew Diovan 320 MG Tablet; TAKE 1 TABLET DAILY; Qty90; R3; Rx. Renew Glipizide 5 MG Tablet; TAKE 1 TABLET DAILY; Qty90; R3; Rx. Renew Hydrochlorothiazide 25 MG Tablet; TAKE 1 TABLET DAILY; Qty90; R3; Rx. Renew Lisinopril 10 MG Tablet; T AKE 1 TABLET DAILY; Qty90; R3; Rx. Renew Metformin HCL1000 MG Tablet; TAKE l TABLET DAILY WITH BREAKFAST; Qty90; R3; Rx. Renew Plavix 75 MG Tablet; TAKE 1 TABLET Monday & Wednesday & Friday; Qty45; R3; Rx. Renew Vytorin 10-80 MG Tablet; TAKE 1 TABLET DAILY ; Qty90; R3; Rx. PQRI HGB A1C 7.0%-9.0%. PQRI LDL-C < 100. PQRI DIASTOLIC < 80. PQRI SYSTOLIC >=140. A Follow-up Visit, three-four Months. HGB AlC; LIPID PROFILE; METABOLIC BASIC ALT; PSA SCREEN ONLY. Dictation Medications reviewed. He was recently butted in the chest by a goat, he feels like it actually helped his breathing by loosening some of the adhesions. He is also complaining of trouble sleeping. I gave him some Ambien to try for his insomnia. Signature Signed By· X, MD; 02/01/20XX 03:01 PM EST; Author. What are the diagnosis codes? Enter an ICD-10-CM code for each space provided.

E11.51 I10 E78.5 J44.9 G81.91 G47.00 R07.1 R42 Z79.84 Z79.02 In this example the patient has type 2 diabetes mellitus, hypertension, hyperlipidemia, PVD, and Hemiparesis. In the Alphabetic Index look for Diabetes, diabetic (mellitus) (sugar)/type 2/with/peripheral angiopathy which directs the coder to E11.51; Hypertension which directs the coder to I10, Hyperlipidemia which directs the coder to E78.5; Disease, diseased/pulmonary/obstructive which directs the coder to J44.9, and Hemiplegia which directs the coder to G81.9. When referenced in the Tabular List there are codes for laterality and dominant versus non-dominant. This documentation shows dominant side. The patient is right-handed therefore the correct code is G81.91. The patient also has insomnia, chest pain and dizziness. In the Alphabetic Index look for Insomnia which directs the coder to G47.00; Pain/chest/on breathing which directs the coder to R07.1; and Dizziness which directs the coder to R42. The patient has diabetes type 2 and is controlled with oral medications. In the Alphabetic Index look for Long-term (current) drug therapy (use of)/oral/hypoglycemia which directs the coder to Z79.84. The patient is on Plavix which is an anti-platelet medication. Look in the Alphabetic Index for Long-term (current) drug therapy (use of)/antiplatelet Z79.02. Verify all code selections in the Tabular List.

VISIT TYPE: Office Visit DOS: 02/02/20XX Reason(s) for visit: 1. check up 2. review lab work 3. rhinorrhea for three weeks. 4. neck pain 5. cough and phlegm for more than two years 6. diabetes:Stable. Risk factors: obesity and age. She manages with diet and BG testing at home.(Diagnosis of Diabetes is managed by diet and lab testing.) Pertinent negatives include chest pain and dyspnea. Patient is compliant with follow-up appointments and educational materials. Chronic Problems: Diabetic polyneuropathy, stable. Diabetic nephropathy COPD, mild CKD stage 2 Hyperlipidemia MDD recurrent, moderate GERD, controlled with meds (Gastroesophageal reflux disease is a digestive disease in which stomach acid or bile irritates the food pipe lining. Treated with Nexium.) Past Medical/Surgical: None Medications: All Current as of today Drug Name: Qty./Sig: Dexamethasone .25 percent apply two times a day (A corticosteroid that helps prevent inflammation. Treatment helps with breathing disorders such as COPD.) Xanax .5 mg, take one tablet TID prn Astepro 411 mcg each nostril, QD (An antihistamine that prevents or treats nasal symptoms of rhinitis allergies.) Skelaxin 800 mg QID, prn (A muscle relaxant. Blocks nerve pulses in the brain.) Neurontin 400 mg BID, prn Lipitor 40 mg QD (To lower bad cholesterol and increase good cholesterol) Spiriva 18 mcg, prn (A bronchodilator that relaxes muscles in the airways and increases air flow to the lungs. Used to treat COPD.) Wellbutrin Sr 150 mg QD (An antidepressant to treat major depressive disorder) Xopenex 45 mcg, 2 puffs Q8 hrs, prn (A short-acting bronchodilator that relaxes muscles in the airways and increases air flow to the lungs. Used to treat COPD.) Amitriptyline Hcl 25 mg, QHS Stool Softener 100 mg BID Nystatin 200mg 5 cc swish n spit QID Nasonex 50 meq, two sprays each nostril, QD (Treatment for seasonal or year-round allergies.) Ultracet 37.5/325mg every six hours prn pain Nexium 20 mg QD (Decreases the amount of acid produced in the stomach. Treats symptoms of GERD and other chronic conditions involving excessive stomach acid.) Social History:Smoker: Stopped cigarette smoking 10 years ago Review of Systems: HEENT: Positive for rhinorrhea. Respiratory: Positive for productive . Negative for dyspnea. Musculoskeletal: Negative for bone/joint symptoms, except positiove for neck pain. Vital Signs: BP 136/72 P 62 Temp 97.6 Resp. 16 Physical Exam: Nose/Mouth/Throat: Right and Left Turbinates: mild hypertrophy. Respiratory: Auscultation with bilateral posterior decreased breath sounds and coarse breath sounds.Dry cough.(Decreased breath sounds and coarse breath sounds with dry cough supports COPD.) Cardiovascular: Regular heart rate and rhythm. No murmurs, gallops, or rubs. Musculoskeletal: Muscle spasm in cervical spine with decreased ROM to the left more than the right.(Decreased ROM to the left more than right supports muscle spasms.) Assessment/ Plan: DM w/renal manifestations type II. DM w/neuro manifestations, type II. Acute neck pain, continue Skelaxin med Muscle spasms of head or neck, acute (Treated with Skelaxin. Exam shows muscle spasms in cervical spine with decreased ROM.) COPD, continues to cough, repeat PFT (Chronic obstructive pulmonary disease. Chronic inflammatory lung disease that causes obstructed airflow from the lungs. Treated with Dexamethasone, Spiriva, Xopenex, and pulmonary function tests.) Restrictive lung disease, Chronic Rhinitis, Acute (Lasting three weeks. Patient is being treated with Astepro an antihistamine and Nasonex.) Chronic bronchitis with emphysema, Chronic (Chronic bronchitis with chronic emphysema is included in COPD.) Orders: Follow up six months Lab Studies: Comp Metabolic panel (14); HGBA1C;(HGBA1C lab orders are to manage diabetes or related complications of diabetes.) Lipid panel Document Generated By: X, MD. on 02/02/20XX at 02:01 PM What are the diagnosis codes? Enter an ICD-10-CM code for each space provided.

E78.5 E11.22 N18.2 E11.42 M54.2 M62.838 J00 F33.1 K21.9 J34.3 Z87.891 Rationale: In this example the patient has diabetes with renal manifestations, Chronic Kidney Disease (CKD) stage 2, and polyneuropathy. These are reported with the use of combination codes. In the Alphabetic Index look for Diabetes, diabetic/type 2/with/chronic kidney disease which directs the coder to E11.22. Also, in the Alphabetic Index look for Diabetes/type 2/with polyneuropathy which directs the coder to E11.42. The patient has hyperlipidemia with medication, in the Alphabetic Index look for hyperlipidemia which directs the coder to E78.5. The patient is continuing to have neck pain and muscle spasms of the cervical spine. In the Alphabetic Index look for Pain/neck NEC which directs the coder to M54.2 and then Spasm/muscle NEC which directs you to code M62.838. This would be coded as "other muscle spasm" as the site is in the documentation and there is no specific diagnosis for this condition. The patient is taking Wellbutrin for depression. In the Alphabetic Index look for depression/major depressive/recurrent/moderate which takes the coder to F33.1. The patient has chronic airway obstruction and chronic bronchitis with emphysema. Look for Bronchitis/chronic/emphysematous refers you to code J43.9. Review coding clinic 2019 quarter 1. Next the patient has acute rhinitis, in the Alphabetic Index look for Rhinitis/acute which directs the coder to J00. The patient also has chronic GERD, in the Alphabetic Index look for Disease/gastroesophageal reflux (GERD) which directs the coder to K21.9. Hypertrophy of turbinates is found in the Alphabetic Index under Hypertrophy, hypertrophic/nasal/turbinate, J34.3. Verify all code selections in the Tabular List. Patient was a past smoker. Look for History/personal/nicotine dependence referring you to code Z87.891.

02/01/20XX- Transcription: (P) Internal Medicine Provider: X, MD Location of Care: AAPC Provider Group Internal Medicine DATE OF SERVICE: 08/01/20XX Patient is coming in at this time for evaluation of his blood pressure (BP). Patient is an 83-year-old female who has undergone recent colon resection for her colon cancer back in 20XX. Since that time has been doing well and had no major problems.She is on hydrochlorothiazide 25 daily. BP: 140/76. Pulse: 78. WT: 140 pounds. HT: 64 inches. Her heart is regular. Her lungs are clear with no rales, rhonchi, or wheezing. No edema. She has a skin cancer on her nose and I will refer him to dermatology. She also has several actinic keratoses of the scalp and I will have Dr. X follow that as well. She has a little bit of a neuralgia or neuropathy in her feet, a burning sensation. We have talked about things that she can do to help that. I am going to have her try some gabapentin 100 mg daily. ASSESSMENT: An 83-year-old female with hypertension, skin cancer of the nose, mild neuropathy of her feet, and history of colon cancer. PLAN: At this point she will be placed on gabapentin 100 mg daily for the neuropathy in the feet. For the skin cancer he will be referred to Dr. X. For her hypertension she is given a refill on hydrochlorothiazide 25 once a day. RTC in four months. Electronically Signed by X, MD on 02/01/20XX at 1:22 PM What are the diagnosis codes? Enter an ICD-10-CM code in each space provided.

I10 C44.301 G62.9 L57.0 Z85.038 In this case the patient has hypertension, in the ICD-10-CM Alphabetic Index look for Hypertension which leads the coder to I10. Next, the patient has skin cancer of the nose, in the Neoplasm Table look for Neoplasm/skin/nose which directs the coder to C44.301. The patient also has mild neuropathy of her feet, in the Alphabetic Index look for neuropathy which directs the coder to G62.9. Neuropathy in both feet is considered polyneuropathy. Look in the Alphabetic Index for Polyneuropathy and you are directed to G62.9. Next, the patient has actinic keratoses of his scalp, in the Alphabetic Index look for Keratosis/actinic which directs the coder to L57.0. The patient has a history of colon cancer, in the Alphabetic Index look for History/personal (of)/malignant neoplasm (of)/colon NEC which directs the coder to Z85.038. Verify all code selections in the Tabular List.

Subjective: The patient is an 84 year-old diabetic female who presents today for evaluation and treatment of his painful ingrown toenails.(Painful ingrown Toenails is the main reason for the visit.) Past treatment has consisted of self-care. The patient is here today for ongoing palliative treatment. Examination: Vascular: The pedal pulses are rated as ¼ in both feet. The digital capillary filling time is rated as 3+ seconds.(Pedal pulses rated as ¼ in both feet and digital capillary time is 3+ seconds is evidence of peripheral venous disease (PVD)) There is evidence of moderate peripheral venous disease. Dermatological: The skin texture, temperature and turgor are normal for the patient's stated age. The patient has age-associated onychocryptosis and dystrophic nails involving all ten toes. Neurological: The patient's feet possess tactile sensations that are grossly intact. Musculoskeletal: Hammertoes of three digits. Assessment: At risk patient with diabetes requiring insulin and hypertension treated with lisinopril.(An ACE inhibitor used to treat high blood pressure; can also treat CHF or if a patient has had a recent heart attack.) I have prescribed long-term palliative debridement of his toenails (Long term debridement of toenails supports painful ingrown toenails to prevent possible infection. This is a preventive service not palliative care.) to prevent possible pedal infection. Treatment: The patient's toenails were manually debrided with a bone cutter.Dystrophic nail plate thickness was reduced to normal nail plate thickness with an electric rotary bur. RTC in two months. Signed by: X, DPM 06/01/20XX What are the diagnosis codes? Enter an ICD-10-CM code in each space provided.

I10 E11.51 L60.0 L60.3 M20.40 Z79.4 The patient has hypertension which is reported with I10. In this case 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. The documentation also states there is evidence of moderate peripheral venous disease. Because peripheral angiopathy is listed as a term under Diabetes/with, it is considered a causal relationship. Look in the Alphabetic Index for Diabetes, diabetic (mellitus) (sugar)/type 2/with/peripheral angiopathy which directs the coder to E11.51. The patient is being treated for his painful ingrown toenails and dystrophic nails. In the Alphabetic Index look for Ingrowing/nail (finger) (toe) which directs the coder to L60.0. Then in the Alphabetic Index look for Dystrophy, dystrophia/nail L60.3. The patient also has hammertoes, in the Alphabetic Index look for Hammer toe (acquired) NEC which states to (see also Deformity, toe, hammer toe). Look at Deformity/toe/hammer toe which directs the coder to M20.4-. When this code is referenced in the Tabular List the code needs a 5th character for laterality. Although the documentation states he has hammertoes of the lesser digits it does not tell us if it is the left or right foot or both. The correct code would be M20.40 for Other hammer toe(s) (acquired), unspecified foot. The patient's diabetes is controlled with insulin. Look in the Alphabetic Index for Long-term (current) drug therapy (use of)/insulin which directs the coder to Z79.4. Verify all code selections in the Tabular List.

DOB: 08/01/xx DATE OF SERVICE: 03/01/20XX CARDIOLOGY Coronary disease/LV dysfunction: Cardiogenic shock, severe MR, CABG May 20XX, 25 percent EF. Improved 20XX to 45 percent, but in March this year, 30 percent with probable apical polypoid thrombus. INTOLERANT BETA-BLOCKERS. Treadmill 30 minutes five days a week with improved exercise tolerance over the past year. I think the Aldactone may have helped this considerably, feels much better, heart rate peaks now at 125. He is denying chest pain, PND, orthopnea, edema, palpitations, syncope, TIA. BNP was 85 in March. 1. Aortic stenosis. 3. M/sec velocity with a 23 mm mean gradient in March. 2. Hypertension runs 100 to 110 at home. Cr 1.5, K 4.6 last week. 3. Atrial fibrillation, asymptomatic, recurred a year ago. Diltiazem dose reduced to 180. It is needed for rate control and recognized or is a negative inotrope. 4. Lipids - 99/77/40/44 last week. 5. History of GI bleeding on NSAIDs. He is denying abdominal pain, nausea, vomiting, melena, hematemesis. MEDICATIONS: 1. Cardizem 180. 2. Lasix 40. 3. Vytorin 80 one-half. 4. Lisinopril 5. Prilosec. 6. Flomax 0.4. 7. Aldactone 25. PHYSICAL EXAMINATION: VITAL SIGNS: BP: 110/80. P: 68 regular. T: afebrile. WT: 179 lbs, 81 kg. GENERAL: Alert, oriented. NECK: No neck vein distention. No carotid bruits. LUNGS: Clear to auscultation and percussion. Respiratory effort normal. ABDOMEN: Soft, non-tender. No masses, no organomegaly, no bruit. Abdominal aorta not enlarged. CARDIAC: Precordium quiet. No rub or gallop. There is a 2/6 systolic ejection murmur over the precordium. EXTREMITIES: Pulses 112 or less in the feet. No edema. No cyanosis. IMPRESSION: 1. Coronary artery disease, coronary artery bypass graft 2006 (redo). Severe MR then.MR now mild. 2. Left ventricle dysfunction with apical thrombus. (REFUSES ICD). 3. INTOLERANT TO BETA-BLOCKERS. 4. Aortic stenosis, moderate or worse. 5. Hyperlipidemia. 6. Hypertension. 7. History of gastrointestinal bleeding. PLAN: 1. Reviewed Vytorin, some studies on Zetia versus niacin, which I think are irrelevant to his condition. 2. Discussed ICD pro/cons, he declines. 3. Answered questions about NSAID, which he I think he ought to avoid on the basis of (a). Renal dysfunction. (b). History of GI bleeding. 4. Return four months. Schedule echo then. Electronically signed by X, MD What are the diagnosis codes? Enter an ICD-10-CM code for each space provided. You are not required to code the long term use of medications for this case.

I25.10 I24.0 E78.5 I08.0 I11.9 I51.9 I48.91 N28.9 Z95.1 Z87.19 Z79.1 Rationale: In this case the patient has coronary artery disease, in the Alphabetic Index look for Disease/coronary (artery) which states see Disease, heart, ischemic, atherosclerotic when Disease/heart/ischemic/atherosclerotic (of) is referenced in directs the coder to I25.10. When looking at this documentation it does not specify the coronary artery that has the atherosclerosis. It could be the one that had the bypass graft or it could be the other one so we cannot make the leap to use the code I25.810. Next report mitral regurgitation. Note that this patient is also diagnoses with aortic stenosis. Look in the Alphabetic Index for Regurgitation/mitral (valve) - see Insufficiency, mitral. Next look in the Alphabetic Index for Insufficiency/mitral/with aortic valve disease referring you to I08.0. Next the patient has a left ventricle dysfunction with apical thrombus, in the Alphabetic Index look for Thrombosis/ventricle/not resulting in infarction which directs the coder to I24.0. Next, the patient has Hyperlipidemia, in the Alphabetic Index look for Hyperlipidemia which directs the coder to E78.5. The patient is also diagnosed with aortic stenosis, which is included in I08 with mitral insufficiency. When a patient has involvement of both the aortic and mitral valves the condition defaults to rheumatic or unspecified unless the documentation specifically indicates the conditions are not rheumatic. . The patient is not diagnosed as having congestive heart failure. Next, look for Dysfunction/ventricular referring you to I51.9. Next code for the hypertension. ICD-10-CM coding guideline I.C.9.a.1 hypertension with a heart condition (I50.-, I51.4 - I51.9) report from category code I11. Because the patient does not have heart failure report code I11.9. The patient has asymptomatic atrial fibrillation, in the Alphabetic Index for Fibrillation/atrial which directs the coder to I48.91. The patient has renal dysfunction. There is no look up for renal dysfunction but if you reference Dysfunction/kidney refers you to see Disease, renal. When you go to Disease/renal it directs the coder to N28.9. Lastly, code for the presence of the aortocoronary bypass graft. In the Alphabetic Index look for Presence (of)/ aortocoronary bypass graft which directs the coder to Z95.1. The patient is taking NSAIDS for history of GI bleed, in the Alphabetic Index look for History of/personal/disease or disorder of/digestive system which directs the coder to Z87.19. The patient is also taking NSAIDS, in the Alphabetic Index look for Long term drug therapy use/Non-steroidal anti-inflammatories (NSAID) which directs the coder to Z79.1. Verify all code selections in the Tabular List.Rationale: In this case the patient has coronary artery disease, in the Alphabetic Index look for Disease/coronary (artery) which states see Disease, heart, ischemic, atherosclerotic when Disease/heart/ischemic/atherosclerotic (of) is referenced in directs the coder to I25.10. When looking at this documentation it does not specify the coronary artery that has the atherosclerosis. It could be the one that had the bypass graft or it could be the other one so we cannot make the leap to use the code I25.810. Next report mitral regurgitation. Note that this patient is also diagnoses with aortic stenosis. Look in the Alphabetic Index for Regurgitation/mitral (valve) - see Insufficiency, mitral. Next look in the Alphabetic Index for Insufficiency/mitral/with aortic valve disease referring you to I08.0. Next the patient has a left ventricle dysfunction with apical thrombus, in the Alphabetic Index look for Thrombosis/ventricle/not resulting in infarction which directs the coder to I24.0. Next, the patient has Hyperlipidemia, in the Alphabetic Index look for Hyperlipidemia which directs the coder to E78.5. The patient is also diagnosed with aortic stenosis, which is included in I08 with mitral insufficiency. When a patient has involvement of both the aortic and mitral valves the condition defaults to rheumatic or unspecified unless the documentation specifically indicates the conditions are not rheumatic. . The patient is not diagnosed as having congestive heart failure. Next, look for Dysfunction/ventricular referring you to I51.9. Next code for the hypertension. ICD-10-CM coding guideline I.C.9.a.1 hypertension with a heart condition (I50.-, I51.4 - I51.9) report from category code I11. Because the patient does not have heart failure report code I11.9. The patient has asymptomatic atrial fibrillation, in the Alphabetic Index for Fibrillation/atrial which directs the coder to I48.91. The patient has renal dysfunction. There is no look up for renal dysfunction but if you reference Dysfunction/kidney refers you to see Disease, renal. When you go to Disease/renal it directs the coder to N28.9. Lastly, code for the presence of the aortocoronary bypass graft. In the Alphabetic Index look for Presence (of)/ aortocoronary bypass graft which directs the coder to Z95.1. The patient is taking NSAIDS for history of GI bleed, in the Alphabetic Index look for History of/personal/disease or disorder of/digestive system which directs the coder to Z87.19. The patient is also taking NSAIDS, in the Alphabetic Index look for Long term drug therapy use/Non-steroidal anti-inflammatories (NSAID) which directs the coder to Z79.1. Verify all code selections in the Tabular List.

Subjective CHIEF COMPLAINT(S): Patient complaining of sore throat times five days, runny nose for times two days, loss of appetite times five days, cough for times two days. HPI: The patient is here for a follow up as above, osteoarthritis, Alzheimer's disease with dementia, Congestive heart failure (Osteoarthritis, Alzheimer's disease with dementia, and congestive heart failure are conditions that are lifelong.) ROS: GEN Constitutional: Loss appetite times five days EYES: Negative eye systems review. HENT: Sore throat times five days,(Sore throat for five days indicates pharyngitis.) runny nose times two days, HEART/Cardiovascular: CHF followed by Dr. Smith; negative heart and cardiovascular systems review. LUNGS/Respiratory: Cough times two days, mainly at night.(A night cough is a sign of acute bronchitis.) ABD/Gastrointestinal: Negative abdominal/gastrointestinal review. GENT/Genitourinary: Negative genital, urinary and rectal systems review. Musculoskeletal (BJE): Osteoarthritis followed by Dr. Jones; otherwise negative musculoskeletal systems review. Confined to wheelchair. NEURO/Neurological: Negative neurological systems review. PSYCH/Psychiatric: Alzheimer's dementia followed by Dr. Williams; otherwise, negative psychiatric systems review. Endocrine: Negative general-endocrine systems review. SKIN/Integumentary: Rash on back of neck.(Rash on the neck.) There was no change in the past medical, family and social history from the last visit. Objective Vital Signs: BP: 110/70. HT: 65 in. Pulse: 80 /min. RR: 16 /min. T: 97.7 F. WT: 104lbs 0oz. EXAM: HEENT: Pharynx erythematous. (Erythematous (redness) of pharynx supports acute pharyngitis.) CHEST: Normal. CARDIOVASCULAR: normal ABDOMEN: Normal. MUSCULOSKELETAL: The patient is sitting in a wheelchair. RECTAL: Not examined. EXTREMITIES: Normal. No edema. SKIN: Normal. NEUROLOGICAL: Normal. Assessment Prescription Refill 1. Pharyngitis, acute (Primary reason for visit is acute pharyngitis.) and Bronchitis, acute Zithromax z-pack (Zithromax (Z-pack) is an antibiotic that fights bacteria. Treatment for Acute pharyngitis.) 250mg as per instructions on pack #1 and prescription done electronically. Plan 1. The patient had atherosclerosis of the aorta on previous chest X-ray; the patient is medically stable with no symptoms at this time. The patient will be continued on medical management to prevent any exacerbation of symptoms. 2. Medications Follow Up three months Signed by X, MD 03/01/XX What are the diagnosis codes? Enter an ICD-10-CM code in each space provided.

J20.9 J02.9 M19.90 I50.9 I70.0 G30.9 F02.80 R21 Z99.3 In this case the patient has acute pharyngitis and acute bronchitis. In the Alphabetic Index look for Bronchitis/acute which directs the coder to J20.9 and Pharyngitis which directs the coder to J02.9. Next, the patient has osteoarthritis, Alzheimer's disease and CHF. In the Alphabetic Index look for Osteoarthritis which directs the coder to M19.90; Disease/Alzheimer's which directs the coder to G30.9. There is a code in brackets alerting you to code F02.80 to report the dementia. Failure, failed/heart/congestive directs the coder to I50.9. The patient has atherosclerosis of the aorta. In the Alphabetic Index look for Atherosclerosis which states (see also Arteriosclerosis) Arteriosclerosis/aorta which directs the coder to I70.0. The patient has a rash on the back of neck, in the Alphabetic Index look for Rash which directs the coder to R21. The patient is confined to a wheelchair. In the Alphabetic Index, look for Dependence/on/wheelchair which directs the coder to Z99.3. Verify all code selections in the Tabular List.

Progress Note 02/15/20XX S: 69-year-old female who is now status post thoracotomy, seeing her cardiologist one month ago and again in about two months. She is doing well postoperatively. All cardiovascular function will be deferred to her cardiologist. She was seen by Dr . Y for a dominant mass in the left thyroid just prior to her cardiovascular eval it was found to be benign and the left lobe was resected. She feels that it is "filling up again" and wants to go back to see him for reevaluation. Mammogram is due in December, order is written. Prescriptions need refilling. Her plantar fasciitis that she was planning on having surgery on before she had her valve replacement for severe aortic stenosis is again bothering her. A referral back to Dr. xxxx is okay if she wishes to proceed. BP: 130/88. Pulse: 72. WT: 228 lbs. Objective: Pulmonary functions show small airways 53 percent, 60 percent post-bronchodilator (see PFTs for full information). EKG: 12-lead EKG, unremarkable. SKIN, examination shows a thyroidectomy scar with fullness on the left side. No dominant mass. HRT, regular rate and rhythm with holosystolic murmur that transmits into the carotids. Marked S2. LUNGS, clear. ABD, obese. No masses, rebound, rigidity or guarding. BACK, no CVA tenderness. EXT, some edema. Assessment: 1. Edema. 2. Aortic valve replacement. 3. Chronic obstructive pulmonary disease. 4. Hypertension. 5. Coronary artery disease. P: As above. Refilled medications. Rx: SYNTHROID 0.075MG 1 TAB QD , 30, Ref: 12 Rx: POTASSIUM CHLORIDE 20meq 1 qd , 30, Ref: 12 Rx: PLAVIX 75MG 1 TAB QD , 30, Ref: 12 Rx: NORVASC 5MG 1 TAB QD , 30, Ref: 12 Rx: LISINOPRIL 40mg 1 tab qd , 30, Ref: 12 Rx: GLUCOPHAGE 500MG 1 TAB BID , 60, Ref: 12 Rx: COREG 6.25MG 1 TAB BID , 60, Ref: 12 Signed by X, MD 02/15/20XX What are the diagnosis codes? Enter an ICD-10-CM code for each space provided.

J44.9 E08.9 I10 I25.10 M72.2 R60.0 E07.89 Z95.2 Z79.02 Rationale: In this case the patient has COPD, hyperlipidemia, hypertension, CAD, plantar fasciitis. In the Alphabetic Index look for Disease, diseased/pulmonary/chronic obstructive which directs the coder to J44.9; Hyperlipidemia which directs the coder to E78.5; Hypertension which directs the coder to I10; Disease/artery/coronary which directs the coder to I25.10; and Fasciitis/plantar which directs the coder to M72.2. The patient also has some edema of the extremities in the Alphabetic Index look for Edema which directs the coder to Edema/legs which directs the coder to R60.0. The patient had a thoracotomy and now has fullness of the thyroid but no mass. The patient had a partial thyroidectomy and is coming in for postop care. In the Alphabetic Index look for hypothyroidism/surgery or status of/thyroidectomy which directs the coder to E08.9. There is no code for fullness of the thyroid so other specified thyroid disorder would be appropriate. In the Alphabetic Index look for Disorder/thyroid/specified which directs the coder to E07.89. Lastly, the patient had aortic valve replacement, in the Alphabetic Index look for Presence/heart valve which directs the coder to Z95.2. Patient is currently taking plavix, in the Alphabetic Index look for Long term current drug therapy/antiplatelet which directs the coder to Z79.02. Verify all code selections in the Tabular List.

Consultation Report Date of Consultation: 04/01/20XX Referring Physician: X, MD TYPE OF CONSULTATION: Nephrology. REASON FOR CONSULTATION: Abnormal renal function. HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old lady referred through the courtesy of Dr. M because of abnormal renal function. The patient has a history of hypertension, and thyroid cancer, recent status post chemotherapy. She was admitted five days ago with vomiting and dehydration. The labs on admission revealed a BUN of 31 with a creatinine of 2.0, which has increased up to BUN of 65 and a creatinine of 3.9. The patient has also had hypotensive episodes. This consultation was requested for evaluation of her renal condition. ALLERGIES: The patient is allergic to ace inhibitor, penicillin, and sulfa drugs. PAST MEDICAL HISTORY: 1. Hypertension. 2. Atherosclerotic heart disease. (Do not code atherosclerotic heart disease, there is no documented support as a current condition.) 3. Hypothyroidism.(Do not code hypothyroidism, there is no documented support as a current condition.) 4. Thyroid cancer. SOCIAL HISTORY: The patient denies smoking. She denies alcohol use. She denies drug use. FAMILY HISTORY: The family history is noncontributory PHYSICAL EXAMINATION: VITAL SIGNS: BP: 109/50. Pulse: 78 per minute. Respirations: 18 per minute. Temperature: 96.8. GENERAL: The patient is awake, alert, and oriented times three, not in any distress. HEENT: Negative. NECK: The neck is supple. There is positive mass in the anterior area of the neck. LUNGS: The lungs are clear to auscultation. HEART: Normal S1 and S2. ABDOMEN: The abdomen is soft and non-tender. Bowel sounds are present and normal. EXTREMITIES: There is no pitting edema. NEUROLOGICAL: Normal. LABORATORY DATA: The chemistry shows a sodium of 131, potassium of 3.9, chloride of 92, C02 of 23, glucose of 84, calcium of 7.9, BUN of 65, and creatinine of 3.8. The CBC has a white blood cell count of 6.4, hemoglobin of 10.3, hematocrit of 30.8 and platelet count of 122,000. IMPRESSION: 1. Chronic kidney disease, stage 3,(Primary reason for visit is Chronic kidney disease stage 3.) with superimposed acute renal failure, likely secondary to over-diuresis as well as acute tubular necrosis due to hypotensive episodes. 2. Thyroid carcinoma. Patient still has a mass on the anterior neck. Will discuss in having the thyroid and mass removed. 3. Hypertension.(Hypertension and CKD have a presumed relationship. Report with a combination code.) RECOMMENDATIONS: 1. Strict intake and output. 2. Urinalysis with microscopic. 3. Intravenous fluids at 60 mL per hour. 4. Discontinue diuretics. 5. Renal ultrasound. 6. Hold antihypertensive medication for blood pressure equal to or less than 140/70. 7. Continue current medication. I will follow the patient with you. Thank you very much for allowing me to participate in the management of this patient. Signed by: X, MD What are the diagnosis codes? Enter an ICD-10-CM code for each space provided.

N18.3 N17.0 I12.9 C73 Z88.8 Z88.0 Z88.2 Z92.21 In this case the patient has hypertension, stage 3 chronic kidney disease with superimposed acute renal failure. In the Alphabetic Index look for Disease/kidney/chronic/stage 3 which directs the coder to N18.3. Look in the Table of Neoplasms for Thyroid (gland) and report the code from the Primary Column C73. Although the patient is post-chemotherapy, there is no mention of removal or eradication of the cancer. Refer to ICD-10-CM coding guideline, I.C.2.d. Failure/renal/acute/with/tubular necrosis which directs the coder to N17.0; and Hypertension, hypertensive/kidney/with/stage 1 through 4 chronic kidney disease which directs the coder to I12.9. The patient also has allergies to medications including ace inhibitor, penicillin, and sulfur drugs. In the Alphabetic Index look for History of/personal/allergy to/drugs, medicaments and biological/specified substance directs you to Z88.8. Next for penicillin allergy, in the Alphabetic Index look for History of/personal/allergy to/penicillin it directs you to Z88.0. Finally, allergy to sulfur drugs, in the Alphabetic Index look for History of/personal/sulfonamides which directs the coder to Z88.2. The patient is status post chemotherapy. Look in the Alphabetic Index for History/personal (of)/chemotherapy for neoplastic condition which directs you to Z92.21. Verify all code selections in the Tabular List.