HIM 254: HW for Basic ICD-10 CM/PCS Coding

Intravenous infusion of anti-inflammatory medication for treatment of ulcerative colitis. px code

3E00X3Z

Osteoarthrosis, primary of right ankle

M19.071

Nephritis due to systemic lupus erythematosus

M32.14

51-year-old male with chronic pyelonephritis due to E. coli. 2 dx codes.

N11.8, B96.20

Insertion of venous access device (percutaneous port) via subclavian vein, subcutaneous pocket for port place in chest wall. Device was place for future chemotherapy to treat colon carcinoma and required an incision to create the subcutaneous pocket. 2 px codes

02HV33Z, 0JH60XZ

Insertion of central venous catheter, multilumen, via right subclavian vein for intravenous infusion. px code

05H633Z

(15) PX: Right bronchoscopy with YAG laser photoresection for the destruction of tumor in the right main bronchus. (Neoplasm, Chapter 5)

0B538ZZ

Low anterior resection of sigmoid colon, 30 cm removed, with end to end anastomosis of sigmoid colon. px code

0DBN0ZZ

(13) PX: Open resection and removal of the right lobe of liver due to metastasis from colon carcinoma. (Neoplasm, Chapter 5)

0FT10ZZ

(12) PX: Right breast lumpectomy with open sentinel lymph node biopsy, right axilla. 2 px codes (Neoplasm, Chapter 5)

0HBT0ZZ, 07B50ZX

Removal of implanted venous access device (infusion port) from subcutaneous tissue in chest by incision (chemotherapy completed, no further need for the infusion port) px code.

0JPT03Z

(11) PX: Transurethral endoscopic laser ablation of the prostate due to BPH. (Neoplasm, Chapter 5)

0V508ZZ

(14) PX: Tube thoracostomy-chest tube insertion by incision-for drainage of malignant pleural effusion from right side of pleural cavity. (Neoplasm, Chapter 5)

0W9900Z

44-year-old male with dyspnea and swelling on the left side of his neck was seen today in Dr. Smith's office. Dr. Smith suspected cancer and requests that the patient have a CT scan of the neck. The patient will have a CT scan completed on Thursday and will follow-up with Dr. Smith in 1 week. 2 dx.

R06.00, R22.1

77-year-old with TB of the right knee.

A18.02

52-year-old male with Diphtheritic myocarditis

A36.81

Whooping cough due to Bordetella pertussis with pneumonia.

A37.01

47-year-old admitted with a high fever, elevated white count and general malaise. After work-up it was determined that she had sepsis due to enterococcus. She was started on an antibiotic regimen and her condition improved and she was discharged on day 4.

A41.81

Sepsis due to Enterococcus from perforated diverticulitis of the small and large intestine. (2 codes)

A41.81, K57.40

Gonococcal urethritis

A54.01

52-year-old male with Trichomonal prostatitis.

A59.02

Malignant melanoma of the left shoulder area (Neoplasm, Chapter 5)

C43.62

36-year-old female with carcinoma of her left breast nipple. An excision of the left breast nipple was performed. 1 dx, 1 px.

C50.012, 0HBX0ZZ

33-year-old female with ovarian cancer of her left ovary that is metastatic to her brain. 2 dx.

C56.2, C79.31

47-year-old who was found to have adenocarcinoma of the prostate.

C61

12-year-old male with carcinoma of his right descended testicle. A right orchiectomy was completed. 1 dx, 1 px.

C62.11, 0VT90ZZ

(6) The pt. was dx with carcinoma of the descending colon five years ago with surgical excision of the descending colon. The pt. had completed chemotherapy for the primary malignancy and had no cancer treatment over the past 3 years. The pt's colostomy is functioning well. During a follow-up examination recently, a CT scan of the liver showed suspicious lesion that was later biopsied and found to be a secondary malignant neoplasm that originated in the colon. The pt. visited the oncologist today in Oncology Clinic to review possible treatment options. 5 codes (Neoplasm, Chapter 5)

C78.7, Z85.038, Z90.49, Z92.21, Z93.3

(10) The pt. was dx with an advanced malignant carcinoid tumor of the ascending colon with carcinoid syndrome. Medications are being prescribed to relieve the carcinoid syndrome symptoms. 2 codes (Neoplasm, Chapter 5)

C7A.022, E34.0

Acute lymphoblastic leukemia in remission

C91.01

37-year-old male with CMLL in remission.

C93.11

Borderline glaucoma of right eye

H40.011

Arteriosclerotic heart disease of native coronary artery with angina pectoris

I25.119

Clostridium difficile (c. diff) colitis. This organism was resistant to multiple drugs, antibiotics. (2 codes)

A04.7, Z16.24

17-year-old with astrovirus gastroenteritis.

A08.32

Acute hepatitis C with hepatic coma

B17.11

27-year-old admitted for treatment of her Chronic Hepatitis C resulting from chronic IV drug dependence. 2 dx codes

B18.2, F19.20

36-year-old female with acute myelitis due to HIV. (2 codes.)

B20, G05.4

65-year-old with Viral carditis. A right and left diagnostic cardiac catheterization was performed. 1 dx, 1 px

B33.20, 4A023N8

Candidal esophagitis

B37.81

24-year-old with upper abdominal pain with diagnosis of intestinal myiasis.

B87.82

77-year-old male with lung cancer.

C34.90

68-year-old female with benign neoplasm of the liver.

D13.4

27-year-old female who was found to have an interstitial leiomyoma of her uterus

D25.1

17-year-old female with an adenoma of the Mackenrodt's ligament.

D28.7

(2) Benign carcinoid of jejunum (Neoplasm, Chapter 5)

D3A.011

Benign carcinoid tumor of the appendix

D3A.020

Toxic nodular goiter

E05.20

Morbid obesity with a BMI of 44 in an adult male. 2 codes

E66.01, Z68.41

Prenatal care, normal first pregnancy, second trimester

Z34.02

(8) The reason for the encounter is to receive radiation therapy following the recent dx of carcinoma of the prostate to shrink the tumor prior to planned surgery to explore the tumor site in the next month. 2 codes (Neoplasm, Chapter 5)

Z51.0, C61