Advanced ICD-10 Coding

Case 16 Page 699, Case 15: Inpatient Admission The coding professional assigned T40.2X4A to capture the patient's diagnosis associated with morphine. What error is depicted with this code assignment?

Your Answer: The classification of poisoning, undetermined should be replaced with the code for adverse effect (T40.2x5A) Nausea and vomiting and urinary retention represent adverse reactions to morphine.

Case 26 Page 657, Case 4: Inpatient Admission The coding professional assigned I25.700 for the principal diagnosis. What error is depicted in this code assignment?

Your Answer: The code erroneously represents arteriosclerosis of bypass grafts The patient has no history of bypass or angioplasty; therefore, the code should be I25.110.

Case 45 Page 651, Case 1: Inpatient Admission The following code assignment was generated from a computerized software program: ICD-10-CM: Z38.62 Triplet liveborn infant, delivered by cesarean P07.17 Other low birth weight newborn P07.30 Preterm newborn, unspecified weeks of gestation P22.1 Transient tachypnea of newborn L22 Diaper dermatitis What error is depicted in this coding assignment?

Your Answer: The code for the birth weight is incorrect. The correct code should be P07.16 for 1500-1749 grams.

Case 38 Page 703, Case 5: Inpatient Admission The following code assignment was generated from a computerized software program: ICD-10-CM: C32.1 Malignant neoplasm of supraglottis J95.2 Acute pulmonary insufficiency following nonthoracic surgery ICD-10-PCS: 0CBS8ZX Excision of larynx What error is depicted in this coding assignment?

Your Answer: The principal diagnosis is incorrect The principal diagnosis is the condition necessitating admission as an inpatient, postoperative respiratory insufficiency. (ICD-10-CM: J95.2, C32.1)

Case 47 Page 651, Case 1: Inpatient Admission The following code assignment was generated from a computerized software program: ICD-10-PCS: 0VBTXZZ Excision of prepuce 5A09357 Assistance with respiratory ventilation, less than 24 consecutive hours, continuous positive airway pressure What error is depicted in this coding assignment?

Your Answer: The root operation is incorrect. The root operation should be Resection because the foreskin, or prepuce, has its own body part and it is completely removed.

Case 43 Page 631, Case 6: Inpatient Admission The following code assignment was generated from a computerized software program: ICD-10-CM: L97.423 Non-pressure ulcer of left heel and midfoot E11.52 Type 2 diabetes mellitus Z94.0 Kidney transplant status Z94.83 Pancreas transplant status What error is depicted in this coding assignment?

Your Answer: The sequencing of the principal diagnosis is incorrect. The code for diabetes peripheral angiopathy with gangrene is the principal diagnosis.

Case 46 Page 651, Case 1: Inpatient Admission The following code assignment was generated from a computerized software program: ICD-10-CM: Z38.62 Triplet liveborn infant, delivered by cesarean P07.17 Other low birth weight newborn P07.30 Preterm newborn, unspecified weeks of gestation P22.1 Transient tachypnea of newborn L22 Diaper dermatitis Which of the following highlights a quality of documentation issue that should be addressed?

Your Answer: Unspecified weeks of gestation The weeks of gestation should be documented in the health record.

Case 36 Page 687, Case 16: Inpatient Admission What is the correct ICD-10-CM code to report the External Cause?

Your Answer: V80.010S The External cause code is used for each encounter for which the injury or condition is being treated. The seventh-character value "S" is added to indicate that this is a sequela of the injury.

Case 6 Page 642, Case 18: Physician Office Visit 1. What is the first-listed code for this visit?

Your Answer: Z34.01 Primigravida indicates that it is the patient's first pregnancy.

Case 30 Page 613, Case 9 (episode 3): Inpatient Admission What is the correct principal diagnosis code for this case?

Your Answer: Z43.2 The ulcerative colitis responded to the previous surgeries and was no longer present; therefore, it is not coded. The sole purpose for this admission is ileostomy closure.

Case 14 Page 675, Case 22: Inpatient Admission 1. What is the ICD-10-CM code assignment for the principal diagnosis? Be careful to enter the alphabetic letters, such as O instead of 0 (zero) and place a decimal point in the correct location. Note the example for hypothyroidism: E03.9

Your Answer: Z51.11 Z51.11 is assigned because the patient was admitted for chemotherapy.

Case 31 Page 613, Case 9 (episode 3): Inpatient Admission In ICD-10-PCS, what is the first root operation performed for this procedure?

Your Answer: excision The answer to this question is "excision." The procedure was ileostomy closure or "takedown, stoma" which has a note to "see Excision and Reposition." Excision of the ends was performed before the anastomosis.

Case 10 Page 635, Case 1 (episode 2): Inpatient Admission The coding professional opts to query the physician for clarification of the postoperative wound infection since he/she perceives it as a quality of care issue. According to AHIMA's Standards for Ethical Coding this is an appropriate use of the query system.

Your Answer: false The documentation is clear; see 4.4 that states: "coding professionals shall not query the provider when there is no clinical information in the health record prompting the need for a query."

Case 3 Page 610, Case 5: Outpatient Visit 1. The diverticular disease mentioned in the case study would be classified to which of the following?

Your Answer: large intestine The classification system differentiates between diverticulitis and diverticulosis. In addition, codes are provided to identify the site, in this case the large intestine.

Case 35 Page 681, Case 7: Inpatient Admission The coding professional assigned 0QS704Z for the open reduction procedure. What error is depicted in this code assignment?

Your Answer: laterality of body part is incorrect The procedure was performed on the right upper femur.

Case 22 Page 632, Case 9: Inpatient Admission The coding professional assigned code M00.261 as the principal diagnosis. What error is depicted in this code assignment?

Your Answer: organism not specified The organism is not specified; the correct code would be M00.861.

Case 48 Page 669, Case 8 (episode 2): Inpatient Admission Which of the following diagnoses would be assigned a code for the principal diagnosis?

Your Answer: secondary malignant neoplasm of lung Note that the code for malignant pleural effusion states to code first the malignant neoplasm.

Case 12 Page 659, Case 10: Inpatient Admission 1. The computerized software program assigned code I82.442 for this case. What type of error is depicted in this code assignment?

Your Answer: site The code assigned was for left tibial vein but it should be iliac vein (I82.522)

Case 13 Page 669, Case 8 (episode 2): Inpatient Admission In ICD-10-CM, which of the following would be selected as the primary site?

Your Answer: unspecified site The primary site was not established.

Case 62 General Surgery Clinic Note The patient was seen in the outpatient surgical clinic for removal of 1 cm lesion of the right neck. During the operative session, the lesion was sent for a frozen section, which revealed basal cell carcinoma. A wide excision was performed. What is the ICD-10-CM code assignment for this surgical visit?

Your Answer:C44.41

Case 25 Page 621, Case 8 (episode 1): Physician Office Visit What is the correct ICD-10-CM code assignment for this visit?

Your Answer:N40.1, R33.8, Z85.51 The patient had not had any recurrence of carcinoma of the bladder. Therefore, code Z85.51 is assigned for history of the bladder cancer. Code R33.8 is assigned as an additional code as indicated by the "use additional code" note at code N40.1.

Case 19 Page 658, Case 5: Inpatient Admission Which of the following codes would be reported to capture the malfunctioning pacemaker?

Your Answer:T82.111A Index to 'malfunction' to 'cardiac electronic device' to 'pulse generator' (T82.111A) - 7th character is needed, this is 'initial encounter', so 'A' is added

Case 20 Page 644, Case 22: Inpatient Admission Which of the following codes would be reported to capture the perineal laceration?

Your Answer: O70.21 Index to 'delivery' to 'complicated by' to 'laceration' to 'perineum' to 'third degree with sphincter' (O70.21)

Case 33 Page 582, Case 1: Inpatient Admission 1. What is the appropriate ICD-10-CM code assignment to capture that the patient was not taking his medication? 2. What is the appropriate ICD-10-PCS code for the procedure?

1. Your Answer: T46.5X6A, Z91.120 Underdosing code is located under the main term Anti-hypertensive drug NEC in the Table of Drugs and Chemicals, and reference the underdosing column. See the Alphabetic Index under the main term Noncompliance. 2. Your Answer: 0T9B70Z Foley catheter placement is classified to the Medical and Surgical Section, root operation "Drainage" with device.

Case 7 Page 668, Case 6: Physician Office Visit 1. What is the correct ICD-10-CM code assignment for this case? Be careful to enter the alphabetic letters, such as O instead of 0 (zero) and place a decimal point in the correct location. Note the example for hypothyroidism: E03.9

1. __________, Your Answer: Z01.411 Category Z01 is used to report other special examinations without complaint, suspected or reported diagnosis. Since the patient presented for a routine exam with no complaints, a code from this category is assigned as the primary diagnosis. 2. __________, Your Answer: N89.8 A mass is not classified to the Neoplasm chapter unless it has been evaluated and determined to be neoplastic. There is no Alphabetic Index entry for the specific site of vagina under Mass. The Index provides direction to "see Disease of specified organ or site for Mass, specified organ NEC." Searching under Disease, vagina, specified NEC leads to code N89.8

Case 15 Page 686, Case 14: Inpatient admission (episode 2) Be careful to enter the alphabetic letters, such as O instead of 0 (zero) and place a decimal point in the correct location. Note the example for hypothyroidism: E03.9 MULTIPLE CHOICE. The shoulder dislocation was not further specified in this case. When using the Index to code this diagnosis, which one of the following does not have a more specific subentry offering a more specific code for site? FILL IN THE BLANK. What code is the principal diagnosis code in this case? TRUE/FALSE. A subluxation of the shoulder joint would be coded in the S43.0 subcategory. FILL IN THE BLANK. Assign the code for the alcohol withdrawal. TRUE/FALSE. The code for the alcohol withdrawal was found under "Withdrawal state" in the Index.

MULTIPLE CHOICE. Your Answer: blade The term "blade" is a nonessential modifier under shoulder, but there is no more specific code available than the nonspecific code option FILL IN THE BLANK. Your Answer: S43.005A Because attempts to reduce the dislocation were unsuccessful in the emergency department, the patient was admitted. Therefore, shoulder dislocation is the principal diagnosis. TRUE/FALSE. Your Answer: true The subcategory S43.0 includes subluxation and dislocation of the shoulder joint (glenohumeral). FILL IN THE BLANK. Your Answer: F10.239 TRUE/FALSE. Your Answer: true

Case 11 Page 636, Case 2: Inpatient Admission 1. What is the principal diagnosis for this case? Be careful to enter the alphabetic letters, such as O instead of 0 (zero) and place a decimal point in the correct location. Note the example for hypothyroidism: E03.9

Your Answer: O90.2 Go to the index locate 'Complications', go down to 'cesarean delivery wound', and then to 'hematoma' to code 'O90.2'

Case 76 DIAGNOSIS: Large left ventricular thrombus POSTOPERATIVE DIAGNOSIS: Left thoracotomy for left ventricular thrombectomy. A small anterior left thoracotomy in approximately the sixth intercostal space was used to expose and open the apex of the left ventricle to extract the thrombus. After removal of the thrombus, the patient's left ventricle showed no evidence of residual thrombus. Her cardiac function was satisfactory following the procedure. What is the ICD-10-PCS code assignment for this procedure?

Your Answer: 02CL0ZZ Extirpation of Matter from Left Ventricle, Open Approach.

Case 54 Emergency Department Record This 30-year-old gentleman was brought into the emergency department after sustaining a fall from tripping on the sidewalk while walking home from a bar. He had been consuming multiple alcoholic beverages earlier this evening. He complains of right elbow pain and a laceration of the left knee. PHYSICAL EXAMINATION: The patient is alert, and oriented but is obviously intoxicated. He has a 4 cm laceration on the lateral aspect of the left knee but has full range of motion with no motor deficits. The wound was explored, irrigated with no foreign material present, closed using 4-0 nylon. The right posterior elbow was dislocated which was reduced; post reduction film shows adequate alignment. Elbow dislocation Laceration of knee Acute alcohol intoxication What is the correct ICD-10-CM code assignment for this case?

What is the correct ICD-10-CM code assignment for this case? Your Answer:S53.124A, S81.012A, F10.129 What is the correct ICD-10-CM External Cause coding assignment for this encounter? (Note: place the 4 codes in the following order: External Cause, Place of Occurrence, Activity and External Cause Status.) Your Answer:W01.0XXA, Y92.480, Y93.01, Y99.8

Case 73 Operative Report DIAGNOSIS: Left temporal brain tumor PROCEDURE: Left temporal craniotomy for excision of brain tumor using neuronavigation assistance. The patient is a 58-year-old female who presented with expressive dysphagia. Diagnostic studies showed extensive infiltrative tumor of the left temporal lobe extending into the ventricular system and to the deep white matter. It was felt that the patient needs surgical decompression of the tumor. A U-shaped incision was planned out in the scalp and an incision was made with a #10 blade. The scalp was then reflected aside. Neuronavigation guidance was used to confirm that an appropriate portion of the temporal skull had been exposed to enable excision of the tumor. A large portion of tumor was excised from the temporal lobe. I took out as much of the tumor as I felt safe to do so with minimal injury to the brain. In addition to the computer assisted procedure code, what is the correct ICD-10-PCS code assignment for this procedure?

Your Answer: 00B70ZZ Excision of Cerebral Hemisphere, Open Approach. Reference the Alphabetic Index or Body Part Key to determine that temporal lobe is classified to Cerebral Hemisphere.

Case 64 Operative Note DIAGNOSIS: Critical left main coronary artery stenosis; severe atherosclerotic disease of all native coronary arteries. PROCEDURES PERFORMED: Urgent coronary artery bypass grafting x 4 with placement of the left internal mammary artery to the left anterior descending coronary artery and placement of reverse saphenous vein grafts from the aorta to the right coronary artery, the obtuse marginal branch of the circumflex, and the diagonal branch. Endoscopic harvesting of the left greater saphenous vein from left leg. What is the ICD-10-PCS code assignment for this case?

Your Answer: 02100Z9, 021209W, 06BQ4ZZ One coronary artery was bypassed with the use of the left internal mammary artery and the saphenous vein was used to bypass the remaining three vessels. According to guideline B3.9, an additional code would be assigned for the harvesting of the saphenous vein.

Case 27 Page 657, Case 4: Inpatient Admission What is the correct ICD-10-PCS code assignment for the PTCA procedure?

Your Answer: 02713ZZ ICD-10-PCS code captures an angioplasty of two vessels without a device.

Case 71 This 62-year-old female has pleural embolization and a lung mass and requires an IVC filter. PROCEDURE: Insertion of IVC filter. PROCEDURE: Sterile prep and drape in the usual fashion was performed of the right neck. Ultrasound was used to identify the right internal jugular vein and access was performed, avoiding the largest portion of the sternocleidomastoic muscle. A micropuncture set was used to access and then J-wire was passed to the inferior vena cava. A dilator was passed followed by the introducer shealth for a Cook Celect IVC filter. An inferior venacavogram was performed and then the IVC filter was positioned and deployed just below the renal vein inflow. There was no significant tilt. The procedure was concluded and a spot film was obtained. The sheath was removed on the right neck and hemostasis was achieved with 5 minutes of compression. The patient was returned to the floor in stable condition. FINDINGS: The right internal jugular vein is widely patent. Inferior venacavogram shows a patent cava with renal vein inflow. The filter was deployed. What is the ICD-10-PCS code assignment for this case (excluding the ultrasound procedure)?

Your Answer: 06H03DZ Insertion of Intraluminal Device into Inferior Vena Cava, Percutaneous Approach.

Case 78 Procedure Report NAME OF PROCEDURE: Fiberoptic bronchoscopy with biopsy. PREOPERATIVE DIAGNOSIS: Right upper lobe lung lesion. POSTOPERATIVE DIAGNOSIS: Right upper lobe lung lesion. MEDICATIONS GIVEN: Codeine 60 mg IM prior to procedure. Atropine 0.4 mg IM prior to procedure. Versed 3 mg given during procedure. INDICATIONS FOR PROCEDURE: Patient is a 75-year-old white male, a farmer and a pipe smoker, who presents with a right upper lobe 4 cm lung lesion. Bronchoscopy is done to evaluate for lung cancer. PROCEDURE: Consent was obtained after the risks and benefits including bleeding and pneumothorax were described to the patient and the patient agreed to proceed with the procedure. He was given Atropine and Codeine prior to going to the Bronchoscopy Suite. Posterior pharynx and vocal cords are visualized and felt to be free of lesion or abnormality. Upper trachea was normal. Left side was normal. Mucosa was normal without erythema, edema, or excessive secretions. Right side had complete obstruction of the apical and posterior segments of the right upper lobe with a lobulated pink lesion that was biopsied. He had good hemodynamic findings at the end of the procedure. Bronchus intermedius was extrinsically narrowed. Right middle lobe appeared free of disease as well as the lower lobes; however, as stated before, the bronchus intermedius had extrinsic compression. CONDITION DURING PROCEDURE: The patient's heart rate remained in the 50s. Blood pressure remained within normal limits. His saturations remained above 97% on 2 liters of supplemental oxygen. He tolerated the procedure well with minimal coughing. He was extubated and sent to the recovery room in satisfactory condition. What is the correct ICD-10-PCS code for this procedure?

Your Answer: 0BBC8ZX Excision of Right Upper Lobe, Via Natural or Artificial Opening Endoscopic, Diagnostic.

Case 75 Operative Report PREOPERATIVE INDICATIONS: POSTOPERATIVE DIAGNOSIS: Left lower lobe abscess. PROCEDURE: Left lower lobectomy. PREOPERATIVE INDICATIONS: The patient is a 36-year-old man with a history of recurrent left lower lobe abscess. This first occurred several years ago, and was treated with antibiotics. He has had a recurrent episode of abscess, and CT scan suggests the presence of a congenital cystic malformation of his left lower lobe. He has been given a course of intravenous antibiotics, and CT scan reveals persistent areas of pustule pockets in his left lower lobe. He is now taken to the operating room for left lower lobectomy. PROCEDURE: The patient was taken to the operating room, placed in the supine position. After initiation of preoperative IV antibiotics and general orotracheal anesthesia, a Foley catheter was placed. The patient was put in the right lateral decubitus position and a left lateral thoracotomy incision was made down through the skin and subcutaneous tissue. Bleeding controlled with electrocautery. Latissimus dorsi and serratus anterior muscles were divided with electrocautery and the fifth rib was cleared from its periosteum. The fifth intercostal space was entered. The left lower lobe and entire left lung was collapsed with a double lumen endotracheal tube, and it was found that the left lower lobe was densely adherent to the lateral chest wall diaphragm. The lung was dissected free from the lateral chest wall and diaphragm with sharp and blunt dissection, although there were many areas where no plane was present and sharp dissection was required in order to free the lower lobe from the chest wall and diaphragm. This resulted in diffuse oozing along the lateral chest wall and diaphragm surfaces. The areas of oozing were packed with a dry sponge and the left lower lobe was then mobilized with Duval clamps. The inferior pulmonary ligament was divided sharply. The inferior pulmonary vein was divided between 2-0 silk ties reinforced with 3-0 silk ligatures. Next, the major fissure was entered, and the pulmonary artery was identified. The branch off the pulmonary artery to the superior segment of the inferior lobe was then cleared from surrounding adhesions, which were multiple and extremely dense from long-term infection. The superior segmental artery was divided between 0 silk ties which were reinforced with a 3-0 silk ligature. Next, the branch to the inferior segments was divided after its take-off from the main pulmonary artery divided between 0 silk ties reinforced with 3-0 silk ligatures. The left lower lobe bronchus was cleared from surrounding tissues and the branch to the superior segment was divided between TA 4.8 mm staples. The bronchus was transected distal to these staples, and the distal bronchus was controlled with a Kelly clamp. The bronchus of the inferior segment was similarly divided after stapling with a 4.8 mm TA stapler, controlling the distal bronchus with a Kelly clamp. After this had been done, there was one further inferior pulmonary vein branch that required ligation between 0 silk ties and 3-0 silk ligatures. This was divided, and the left lower lobe was then completely free and taken off the field, where it was sent to Pathology for immediate culture, frozen and permanent section analysis. The chest was then generously irrigated with normal saline. The diffuse oozing along the diaphragm and lateral chest wall had decreased but had not completely stopped. This was somewhat controlled with electrocautery, 2-0 Vicryl ligatures, and pressure with Avertin gauze. The left upper lobe was expanded with high pressure under water, and it showed no leak at the bronchial stumps. After suctioning free the irrigation fluid, there appeared to be adequate hemostasis, and 2 #32 French chest tubes were placed through the 7th intercostal space laterally. These were sewed into place with 2-0 silk ties, and the ribs were then approximated using simple interrupted #1 Vicryl intercostals sutures. The Bailey rib approximator was used to approximate the ribs, while sutures were being tied down. Latissimus dorsi and serratus anterior muscles were then reapproximated with running 0 Vicryl after the intercostal space had been anesthetized with 0.50% Marcaine. Subcutaneous tissues were closed with a running 3-0 Vicryl and skin was closed with staples. The patient was returned to the recovery room after the wound was dressed with Vaseline gauze 4 x 4's and microfoam tape. Upon arrival in the recovery room he was awake, vital signs stable, dressings dry, with minimal chest tube drainage and no air leak. Estimated blood loss was 1000 cc. COMPLICATIONS: None. FINDINGS: Findings included multiple abscesses with severe inflammation and adhesions of the left lower lobe to the lateral chest wall and diaphragm.

Your Answer: 0BTJ0ZZ Resection of Left Lower Lung Lobe, Open Approach. Left lower lobe is a subdivision of a body part that can be resected in ICD-10-PCS.

Case 70 Operative Note This 59 year-old patient presents with a BMI of 40 with severe Type II diabetes. The surgeon performs a laparoscopic gastric bypass, robot assisted. A small gastric pouch of less than 15 mL was then stapled off. With the use of the robot, the anastomosis was created between the gastric pouch and the jejunum. What is the ICD-10-PCS code assignment for this case?

Your Answer: 0D164ZA, 8E0W4CZ Bypass, Stomach, Percutaneous Endoscopic, Jejunum and Robotic Assistant Procedure.

Case 74 PREOPERATIVE DIAGNOSIS: Foreign body esophagus. POSTOPERATIVE DIAGNOSIS: Foreign body esophagus. PROCEDURE: Removal of foreign body from esophagus. OPERATIVE PROCEDURE: The patient was brought to the emergency room because of a foreign body located in the upper esophagus. After appropriate preoperative evaluation, the patient was brought to the operating room, prepped and draped in the routine sterile fashion. An incision was made low in the front of the neck. The sternomastoid muscles were pulled back. The cranial vessels were moved to the side and protected at all times. The trachea and thyroid were brought to the center. The space behind the esophagus was exposed. The foreign body was removed and sent to Pathology for evaluation. A Penrose drain was placed. The incision was closed with 4-0 Vicryl sutures. The patient tolerated the procedure well. What is the ICD-10-PCS code assignment for this case (excluding the ultrasound procedure)?

Your Answer: 0DC10ZZ Extirpation of Matter from Upper Esophagus, Open Approach.

Case 65 Operative Note PREOPERATIVE DIAGNOSIS: Possible small bowel obstruction due to adhesions. OPERATION: Laparotomy with lysis of adhesions. INDICATIONS: The patient is a 31-year-old male who became ill last evening. He presented with distended small bowel, consistent with small bowel obstruction. NG was tried for conservative treatment. The patient did not improve. FINDINGS: On laparotomy, distal small bowel adhesions from small bowel adherent to the retroperitoneal and pelvic area from past inflammation. DESCRIPTION OF PROCEDURE: After the patient was given general anesthetic, his abdomen was prepped in the usual fashion for a lower midline incision. This was made and carried down through the fascia. Dissection was carried down and the abdomen was entered. The bowel was adhered to the anterior abdominal wall, and this was brought down by sharp dissection. The incision had to be extended superiorly in order to get good exposure. The dissection was then carried to the retroperitoneal pelvic area, where the terminal ileum was adhered to this area. This was dissected free with sharp dissection. Dense adhesions were present. Finally, the dissection was carried around the terminal ileum to the cecum, and the entire small bowel freed. The small bowel was then run from the ligament of Treitz distally and there were no other adhesions present, and no ischemic bowel or injured bowel noted. The right cecum appeared normal. There was no sign of any other inflammation. The splenic flexure and rectal area also appeared normal. Hemostasis was present. The bowel was returned to the abdominal area. The peritoneum was closed with running 0 Vicryl, the fascia with #1 Vicryl, the subcutaneous tissue with 3-0 Vicryl and the skin with skin clips. Dry dressings were applied to the wound. The patient tolerated the procedure well and left the operating room in stable condition. What is the ICD-10-PCS code assignment for this case?

Your Answer: 0DN80ZZ Release, Small Intestine, Open Approach. This procedure required "freeing" the small intestine. The code assigned is for the body part being released, not the anatomical sites that were cut.

Case 55 ENT Clinic This 50-year-old gentleman was seen in the Primary Care Clinic last week and noted to have a lesion in the oropharynx. A neck CT was ordered and the patient was sent to ENT for consultation. The patient has no complaints secondary to this lesion. The physical examination and review of systems was noncontributory. There appears to be a papilloma of the left posterior tonsillar pillar of approximately 4-5 mm. This lesion does not have any ulcerations, no bleeding and it does not look consistent with carcinoma. Neck is without adenopathy or masses. Will follow the patient in one month. ASSESSMENT: Left oropharyneal papilloma What is the correct ICD-10-CM diagnosis code assignment for this encounter?

Your Answer: D10.5 Documentation is specific for benign neoplasm of tonsillar pillar

Case 84 Operative Report PREOPERATIVE DIAGNOSIS: Right thyroid nodule POSTOPERATIVE DIAGNOSIS: Same. OPERATION PERFORMED: Right thyroid lobectomy. ANESTHESIA: General. BLOOD LOSS: Minimal. COMPLICATIONS: None. BRIEF HISTORY: Patient's a 30-year-old male who was referred to me for an evaluation of a fairly large right thyroid nodule. He's otherwise healthy. He doesn't have a significant history of exposure to radiation or any other risk factors. He was offered a fine-needle aspiration. He actually had somewhat of an enlarged right lobe but also a nodule that is most prominent in the isthmus. He was offered fine-needle aspiration but would just like to proceed with surgery. He would like the lobe removed and, if I have a high suspicion intraoperatively, he would like to proceed with a total thyroidectomy, but as it stands now, plan is for a right thyroid lobectomy including the isthmus and a possible near-total thyroidectomy if we are suspicious intraoperatively. OPERATIVE REPORT: Patient was taken to the operating room, placed in the supine position. He underwent general anesthesia with no difficulty. Once asleep, we prepped and draped in the usual fashion and made our standard cervical collar incision. We dissected down sharply through the subcutaneous tissue and platysma muscle and then raised our subplatysmal flaps. We then tacked these up to the drapes for retraction purposes and divided sharply in the midline between the muscles down to the level of the thyroid. We began on the right side, elevating the strap muscles off of the thyroid and retracting them out laterally. Like I said, the isthmus was rather enlarged, very round nodule, and the right lobe was not necessarily nodular but just slightly enlarged. We got over to the top of the superior pole of the right lobe. We divided the superior pole vessels and tied everything off with 3-0 silk ties. This went without any difficulty. Once the superior pole was mainly down, we rolled the gland medially and identified the recurrent laryngeal nerve. We had to divide a small portion of the inner aspect of the muscle to get good visualization, but the nerve was found and care was taken not to injure it or get near it. With the nerve in view, we then took down the lower pole attachments, again tying everything off with 3-0 silk ties. We used multiple Leahey clamps to control the gland and then, with the nerve in view, continued taking all other attachments. We left a small amount of residual thyroid tissue at the insertion site of the nerve, but everything else was taken cleanly off the trachea until we were just past the midline and this large, nodular isthmus. I then placed the Crile clamp between the isthmus and the left lobe, and the lobe and isthmus were removed. We oversewed the remnant with a running 3-0 silk. We then checked for hemostasis. There was a little oozing from the remnant at the site of the nerve, and we controlled that with 1 or 2 clips. Other than that, things looked good. We reapproximated the midline strap muscles with a running Vicryl. The platysma was closed with a few chromics, and the skin was closed with Prolene.

Your Answer: E04.1 Nontoxic single thyroid nodule Your Answer: 0GTH0ZZ Resection of Right Thyroid Gland Lobe, Open Approach. The right lobe is a subsection that is identified under the root operation Resection.

Case 69 Operative Report DIAGNOSIS: Sigmoid diverticular stricture, chronic diverticular disease, cholecystitis PROCEDURE: Laparoscopic sigmoid colectomy and cholecystectomy Patient presents with a history of diverticulitis and diverticular disease and microperforation, and chronic cholecystitis. She had a preoperative colonoscopy, which showed a stricture and inability to pass the colonoscope. Patient was prepped and draped in the usual fashion. After insufflation of the abdomen, a 5 mm trocar followed by the laparoscope was then placed. A 10 mm right lower quadrant port, 10 mm epigastric, and 5 mm right upper quadrant port were placed under direct visualization. The gallbladder was removed first and then we began the colon resection. The sigmoid colon was then removed through the HandPort incision. Next, the assistant placed the stapler through the rectum and an end-to-end anastomosis was created. This was checked with a proctoscope and there were no leaks. The ports were removed and the fascia and skin was closed. What is the ICD-10-PCS code assignment for this case?

Your Answer: 0FT44ZZ, 0DTN4ZZ Resection of gallbladder and sigmoid colon. Percutaneous endoscopic approach. Proctoscope is integral to the operative procedure.

Case 63 General Surgery Clinic Note PREOPERATIVE DIAGNOSIS: Recurrent abscess, right breast. POSTOPERATIVE DIAGNOSIS: Recurrent abscess, right breast. OPERATION: Right breast biopsy. INDICATIONS: This lady had developed recurrent abscess in the right breast. This presents at about a 12:00 position and is associated with a mass. This was felt to require excisional biopsy for definitive treatment. PROCEDURE: Patient was positioned supine on the operating table. The right breast was prepped and draped in the usual fashion. The area along the edge of the areola was infiltrated with 1% Xylocaine and an incision made along this line. Small flaps were raised using the electrocautery unit. There was marked induration and great thickening scar tissue. This was excised with a margin of normal tissue surrounding it. This appeared to be primarily in the subcutaneous and superficial breast tissue. During the course of the dissection, several abscess cavities were entered. This material was cultured for both aerobic and anaerobic organisms. No residual masses were present. Hemostasis was obtained using electrocautery unit. A 1/4-inch Penrose drain was placed in the depths of the incision. The wound was closed loosely with interrupted mattress sutures of 3-0 nylon. The patient tolerated the procedure well and was taken to the recovery room in good condition. What is the ICD-10-PCS code assignment for this case?

Your Answer: 0HBT0ZX Excision, Right Breast, Open approach for diagnostic purposes (qualifier of "X")

Case 72 Operative Report PREOPERATIVE DIAGNOSIS: Bradycardia, atrial fibrillation. POSTOPERATIVE DIAGNOSIS: Bradycardia, atrial fibrillation. OPERATION: Insertion of VVI pacemaker. FINDINGS: This patient has long pauses of asystole associated with atrial fibrillation. He is on Coumadin therapy. The patient has been on an external pacemaker for several days. He now requires a single chamber. THRESHOLD OBTAINED AT TIME OF SURGERY: Output 0.5 volts, current 0.7 milliamps, impedance 630 ohms, R waves 7.2 millivolts. There was no diaphragmatic stimulation with 10 volts. PROCEDURE: The patient was placed in the supine position. The neck and pectoral areas were prepared with iodoform. Draping was applied. A plastic drape was placed on the wound area. Lidocaine 1% was used in the left subclavicular area for local anesthesia, and an incision was made to create a pacemaker pocket in the subcutaneous tissue. The wound was subjected to hemostasis with electrocoagulation and compression. The wound was dry at the time of the insertion of the pacemaker. The needle was inserted into the subclavian vein and after many tries, satisfactory placement of the needle in the subclavian vein was obtained. A guide wire was inserted through the needle and a dilator was placed over the guide wire. The sleeve was left in and the guide wire and the dilator were both removed. The pacemaker electrode was inserted and passed down into the right ventricle with a curved stylet. The curved stylet was removed and a straight stylet was inserted. Under fluoroscopic control, the pacemaker electrode tip was positioned in the tip of the right ventricle inferiorly. The pressure obtained in this position was excellent. The pacemaker was connected and the pacemaker electrode was sutured to the pectoral tissue with two 2-0 silk sutures. The pacemaker took over the pacing thereafter. The wound was then closed using 3-0 Vicryl in two layers and skin staples were applied. Dressing was applied. The patient tolerated the procedure satisfactorily. During the procedure, the wound was irrigated with Ancef solution. The patient was also given one gram of Ancef IV before the incision was made. What is the ICD-10-PCS code assignment for this procedure? (Do not code the fluoroscopy procedure)

Your Answer: 0JH604Z, 02HK3JZ Insertion of Pacemaker, Single Chamber into Chest Subcutaneous Tissue and Fascia, Open Approach. Insertion Pacemaker Lead into Right Ventricle, Percutaneous Approach.

Case 37 Page 687, Case 16: Inpatient Admission What is the correct ICD-10-PCS code assignment for this procedure?

Your Answer: 0QTF0ZZ The root operation is Resection.

Case 79 Operative Report PREOPERATIVE DIAGNOSIS: Desired infertility. POSTOPERATIVE DIAGNOSIS: Same. OPERATION PERFORMED: Bilateral tubal ligation with Falope ring, via laparoscope. ESTIMATED BLOOD LOSS: Minimal FLUIDS: 1300 cc Plasma-Lyte. FINDINGS: This 40-year-old female is a gravida III, para 3 who was thoroughly counseled concerning the risks of bilateral tubal ligation and still desired infertility via this method. She was taken to the operating room and following general endotracheal anesthesia, was prepped and draped in a sterile manner in the dorsolithotomy position. The uterus was axial in direction and was sounded to 8 cm. A Hulka tenaculum was placed in the cervix for uterine movement. An infraumbilical incision was made, and a trocar was placed into the abdomen. Following insufflation, normal tubes, ovaries, and uterus were noted. A suprapubic incision was made and a trocar placed under direct visualization. There was no bleeding. The Falope ring applicator was then used to ligate each fallopian tube bilaterally. The lower sheath was then removed under direct visualization, and there was no bleeding. After deinsufflation of the abdomen, the upper sheath was also removed, and the patient was taken to the recovery room in stable condition. What is the correct ICD-10-PCS code for this procedure?

Your Answer: 0UL74CZ Occlusion of Bilateral Fallopian Tubes with Extraluminal Device, Percutaneous Endoscopic Approach.

Case 56 Mental Health Clinic Note The patient comes in for a follow-up visit stating that he feels much better on 100 mg Wellbutrin compared to how he was feeling on Paxil. He finds himself less irritable and less willing to procrastinate as well. Patient mentions that he occasionally has difficulty getting to sleep at night. Because of history of alcoholism, he takes a homeopathic medication called Calm Forte. The patient was cautioned to the use of non FDA-approved medications because of the possibility of dependence and other drug interactions. No psychotic features noted. No auditory or visual hallucinations. Mood is euthymic. Alert and oriented x 3. Memory is fair. Attention and concentration is fair. Judgment and insight fair. PLAN: Continue on medication Wellbutrin SA 100 mg p.o. q.d. Follow-up in a month or give us a call in case there are any concerns or questions. DIAGNOSIS: Major depression. History of alcohol dependence. What is the correct ICD-10-CM diagnosis code assignment for this encounter?

Your Answer: F32.9, F10.21 Based on the default code assignment in the ICD-10-CM Alphabetic Index, a history of alcohol dependence is coded as dependence in remission.

Case 66 Operative Report PREOPERATIVE DIAGNOSIS: Menometrorrhagia. Dysfunctional uterine bleeding. Uncontrolled bleeding hormonally and negative endometrial biopsy. POSTOPERATIVE DIAGNOSIS: Menometrorrhagia. Dysfunctional uterine bleeding. Uncontrolled bleeding hormonally and negative endometrial biopsy. OPERATION PERFORMED: Vaginal hysterectomy. Since there was no mention of the ovaries being removed, this was not a total hysterectomy. I have altered the operation performed. ESTIMALTED BLOOD LOSS: 100-150 cc. FLUID REPLACED: 1,000 cc. COMPLICATIONS: None. Uterus: 200 grams. INDICATIONS: The patient is a 42-year-old white female gravida 3, para 3, with menstrual bleeding which had been extremely heavy over the last year. The patient was seen for heavy cycle bleeding, hemorrhages. The patient was bleeding to the point where she was flooding and tampons were "just washed out." An endometrial biopsy was performed. The patient's menstrual bleeding was attempted to be controlled hormonally without success. She is to now undergo a vaginal hysterectomy. PROCEDURE: The patient had adequate epidural anesthesia. She was prepped with Betadine and placed in the dorsal lithotomy position in English stirrups. A weighted speculum was placed, and a single toothed tenaculum was used to grasp the cervix. Posteriorly, the vaginal mucosa was incised. The peritoneum grasped and identified and incised. The posterior cul-de-sac was entered. Cardinal ligaments were clamped, incised, and ligated bilaterally. With this, an incision was made circumferentially around the cervix at the level of the bladder. The bladder was then bluntly dissected off the cervix. Bladder pillars were clamped, incised, and ligated with blunt dissection. The peritoneum was grasped, incised, and the Deaver retractor was entered. With this, the vessels were clamped, incised, and ligated bilaterally, working up the broad ligament with successive bites. Once the level of the utero-ovarian ligaments and vessels were reached, they were clamped, incised, and ligated. This was performed bilaterally. The uterus was removed in toto along with the cervix. A free tie and a transfixation ligature were placed on both pedicles. On inspection no abnormalities were noted. Hemostasis was adequate. The peritoneum was then closed with 0 Vicryl in a running pursestring fashion. The mucosa was then closed with figure-of-eights, with 0 Vicryl. The patient tolerated the procedure well. Needle, instrument and sponge counts were correct at the termination of the procedure times 2. A Foley catheter was draining clear urine. Estimated blood loss was 100 to 150 cc. Fluid replaced was 1,000 cc. The patient was taken to the recovery room in good condition without any complications or problems. What is the ICD-10-PCS code assignment for this case?

Your Answer: 0UT97ZZ, 0UTC7ZZ Both the uterus and cervix were resected via natural opening.

Case 77 Operative Report DIAGNOSIS: Ascites PROCEDURE: Paracentesis The abdomen was imaged with ultrasound in the RUQ, LUQ, RLQ and LLQ. A hypoechoic area, consistent with fluid, was found in the RLQ of the abdomen. After careful consideration of the area, appropriate needle placement was found and marked. The area was then sterilely prepped and draped in the usual fashion with chlorhexidine swab. The area was then anesthetized with 10cc of 1% lidocaine. A #11 blade was then used to make a small nick, through which a 8-French, 18-gauge needle/catheter system was advanced under direct ultrasound guidance into the fluid collection. The catheter was then advanced and the needle was removed. A total of 2900 cc of serous fluid was removed without apparent complication. The catheter was then removed and bandage was applied. No leak seen after removal of the catheter. What is the correct ICD-10-PCS code for this procedure?

Your Answer: 0W9G3ZZ Drainage of Peritoneal Cavity, Percutaneous Approach.

Case 67 Operative Report PREOPERATIVE DIAGNOSIS: Right inguinal hernia. POSTOPERATIVE DIAGNOSIS: Direct inguinal hernia PROCEDURE PERFORMED: Right inguinal herniorrhaphy with mesh, Lichtenstein procedure. INDICATIONS FOR PROCEDURE: This is a 34-year-old male with a right inguinal hernia for over one year. He denies any other comorbidities; no COPD, no asthma, no enlarged prostate. He does engage in multiple rigorous strenuous activities. DETAILS OF PROCEDURE: The patient was taken to the operating room and placed on the operating table in the supine position at which time he was prepped and draped in the usual sterile fashion. An elliptical incision was made over the right inguinal hernia site. A scalpel was used to dissect down to the subcutaneous tissue, exposing the external oblique. This was opened with a #11 blade down from the superficial ring to the pubic tubercle. At that time, the medial and lateral borders of the external oblique were dissected down, and adequate hemostasis was achieved. The hernia sac was then reduced back down into the abdomen, and a figure-of-eight stitch was used to close the floor initially. At this point, a piece of mesh was used and sewn into the conjoin tendon and pubic tubercle on the lateral side. This was also done on the medial side. After the mesh was sewn into place, a fingertip breadth was opened in the ring so that the cord would not be strangulated. This was adequate size. There were no signs of necrosis or ischemia. The shelving border was then closed with a 3-0 Vicryl suture. The skin was approximated and closed with staples. The patient tolerated the procedure well. He had bilaterally descended testicles and no signs of ischemia. He had no hematoma at the time. The patient was then awakened in the recovery room at which time he was talking, alert and oriented times three. He was then sent to the recovery room for postoperative pain medication and fluid hydration. He is to be discharged to follow up in 2 weeks. What is the ICD-10-PCS code assignment for this case?

Your Answer: 0YU50JZ Supplement, Right Inguinal Region with Synthetic Substitute, Open Approach. Mesh was used to reinforce; therefore, the root operation is Supplement.

Case 68 Operative Report PREOPERATIVE DIAGNOSIS: Missed abortion. POSTOPERATIVE DIAGNOSIS: Same. MATERIAL TO LAB: Products of conception. OPERATION PERFORMED: Suction curettage. INDICATIONS: This patient is a 25-year-old white female gravida III, para 2, currently at 13 weeks intrauterine pregnancy. The patient is status post vaginal probe ultrasound showing positive cardiac activity 1 week ago. Repeat of this several days ago showed no evidence of cardiac activity. It was repeated again 24 hours later showing no cardiac activity. The patient has been counseled and requests suction curettage. FINDINGS: Normal products of conception. 12-week size uterus, otherwise normal. DESCRIPTION OF OPERATION: After adequately being counseled, the patient was taken to the operating room and placed in the high lithotomy position. IV sedation and pain medication were given and a speculum placed in the vagina. Single tooth tenaculum was placed on the anterior lip of the cervix and a #14 suction curet introduced into the uterine cavity. The vacuum was applied. The products of conception were removed, and a ring forceps was introduced into the uterine cavity to check for extra tissue. None was found. The patient was taken out of high lithotomy position, taken to the recovery room in good condition. There were no complications. What is the ICD-10-PCS code assignment for this case?

Your Answer: 10D17ZZ Extraction, Products of Conception, Retained, Via Natural or Artificial Opening.

Case 1 Page 589, Case 5: Outpatient Clinic Visit 1. What is the correct coding and sequencing for this case?

Your Answer: B20, F11.20, Z53.1 Code B20 is assigned for all HIV infections and is designated as the reason for the encounter when the patient was seen for HIV infection or a related condition. Code L04.0, acute lymphadenitis of face, head and neck should NOT be assigned along with code B20 because of the Excludes 1 note at category L04 excluding HIV disease resulting in generalized lymphadenopathy (B20). Reference the index for reference to F11.20 for opioid dependence. Code Z53.1 may be assigned to show the refusal of medication for religious reasons.

Case 17 Page 671, Case 14: Outpatient Clinic Visit What is the ICD-10-CM code assignment for this case? Be careful to enter the alphabetic letters, such as O instead of 0 (zero) and place a decimal point in the correct location. Note the example for hypothyroidism: E03.9

Your Answer: C90.20 Plasmcytoma is referenced in the Alphabetic Index, with the subterm "extramedually." The final coding selection is made from the Tabular List.

Case 2 Page 598, Case 6: Inpatient Admission 1. What code is the principal diagnosis for this case?

Your Answer: K29.01 K29.01 is a combination code that includes both the gastritis and hemorrhage.

Code 57 Emergency Department Record This 36-year-old male has a history of persistent migraine headaches, now lasting over 10 days. He is being followed by Neurology who has been treating him with steroid taper. Patient states that the steroid has not affected the headache's severity to date. He has been given valproate sodium 100 mg IV in the past and has had excellent results and would like to have this therapy repeated. VITAL SIGNS: Temperature 98.2, pulse 81, respirations 18, blood pressure 129/79, weight 173 pounds. HEENT: TMs were normal. Pupils are equally round and reactive to light. Extraocular muscles are intact. Fundoscopic exam within normal limits. Neurologic: Cranial nerves II-XII are grossly intact. Motor, sensory, cerebellum and gain are intact bilaterally. PLAN: Patient was given valproate sodium 100 mg IV over 15 minutes with excellent results. He will follow up as needed with the Neurology Clinic. DIAGNOSIS: Persistent migraine headaches, intractable. What is the correct ICD-10-CM diagnosis code assignment for this encounter?

Your Answer: G43.019 ICD-10-CM has an expanded code selection for migraines that identifies the severity and type.

Case 51 Physician Office Record REASON FOR VISIT: Left eye is red and swollen. HISTORY: This 35-year-old male patient has a history of recurrent herpes on his ear and face for the past 14 years intermittently. Three days ago, he began feeling a tingling sensation around the eye. He states it was the same type of sensation that he gets prior to his herpes attack. Pain level is 9 out of 10. PYSICAL EXAMINATION: Blood pressure 132/82. Respirations are 20. Pulse is 76. Temperature is 97.9. ASSESSMENT: Patient's right eye is unremarkable; however his left eye is very infected with clear drainage. The upper eyelid is beefy and red. ASSESSMENT: Left eyelid infection (blepharitis), possible herpes. PLAN: Patient is being referred to the eye doctor now. What is the correct ICD-10-CM code for the first-listed diagnosis?

Your Answer: H01.004 Blepharitis is the medical term for inflammation of the eyelid. Reference the Alphabetic Index under the main term Blepharitis, and subterm left, upper. Coding guidelines for outpatient encounters state not to code possible or probably diagnoses; therefore, herpes is not assigned a code.

Case 9 Page 586, Case 11: Inpatient Admission 1. What is the principal diagnosis for this case? Be careful to enter the alphabetic letters, such as O instead of 0 (zero) and place a decimal point in the correct location. Note the example for hypothyroidism: E03.9

Your Answer: H66.92 Fever is a symptom and is an inherent part of otitis media and is not coded in this case.

Case 81 Discharge Note This patient is a 68-year-old patient that presents with sudden onset of precordial chest discomfort. An ECG is consistent with an acute inferior ST-elevation myocardial infarction. Diagnostic studies confirm an occlusion of the distal RCA. The percutaneous intervention included dilation with 3.5 x 16 VeriFLEX bare-metal stent deployed at 12 atmospheres. The stent was postdilated with 3.75 x 12 Quantum Apex balloon to a maximum of 14 atmospheres. There was a final excellent angiographic result with a 0% residual stenosis.

Your Answer: I21.11 ST elevation involving right coronary artery. Your Answer: 02703DZ Dilation of Coronary Artery, One Site with Intraluminal Device, Percutaneous Approach.

Case 23 Page 601, Case 9: Neurology Clinic Visit What is the correct ICD-10-CM code assignment to capture the paralysis of the left arm? Be careful to enter the alphabetic letters, such as O instead of 0 (zero) and place a decimal point in the correct location. Note the example for hypothyroidism: E03.9

Your Answer: I69.334 Monoplegia, as a sequela of the previous stroke, is coded in the I69.3 subcategory. Because the patient is right-handed, the left side is considered nondominant. In coding late effects of cerebrovascular disease, a combination code identifies both the residual and the late effect; therefore, only code I69.334 is required. Because the residual was the reason for her visit, this code is listed as the reason for the encounter.

Case 82 Discharge Note DIAGNOSIS: Left lower extremity intermittent claudication with high grade left popliteal artery stenosis. PROCEDURE: Diamondback atherectomy, left popliteal stenosis; low-pressure balloon angioplasty of left popliteal stenosis.

Your Answer: I70.212 Atherosclerosis of native arteries of extremities with intermittent claudication, left leg. Your Answer: 04CN3ZZ Extirpation of Matter from Left Popliteal Artery, Percutaneous Approach

Case 42 Page 626, Case 2: Inpatient Admission The following code assignment was generated from a computerized software program: ICD-10-CM: L89.152 Pressure ulcer, sacral region Q05.2 Spina Bifida Z98.2 Presence of cerebrospinal fluid drainage device ICD-10-PCS: 0H56XZZ Destruction of back skin What error is depicted in this coding assignment?

Your Answer: ICD-10-CM code for pressure ulcer represents the incorrect stage. The patient has a stage 3 pressure ulcer and the code states stage 2.

Case 32 Page 586, Case 12: Inpatient Admission The following code assignment was generated from a computerized software program: ICD-10-CM: J05.0 Acute obstructive laryngitis [croup] ICD-10-PCS: 0BJ07ZZ Inspection of tracheobronchial tree

Your Answer: ICD-10-PCS approach is incorrect The approach should be "8" for Via Natural or Artificial Opening Endoscopic (0BJ08ZZ)

Case 34 Page 681, Case 7: Inpatient Admission The coding professional assigned the ICD-10-CM code of S72.21XA to report the fracture of the femur. What error is depicted in this code assignment?

Your Answer: Incorrect site The fracture is intertrochanteric not subtrochanteric. The correct code assignment is S72.141A.

Case 53 Inpatient Case The patient is a 61-year-old male with a common variable immunodeficiency who presented with a 4-week history of worsening cough. The patient has had a several year history of recurrent aspiration pneumonia. Several weeks prior to admission, he had been treated with a 5-day course of Ceftin and then 5-day course of Bactrim, followed by 5-day course of Levaquin, which he did not improve symptomatically. He was admitted for evaluation and treatment. DISCHARGE DIAGNOSIS: Recurrent aspiration pneumonia The patient was initiated on meropenem upon admission and continued throughout the admission. He will continue this for a total of a 10-day course arranged through home fusion. His shortness of breath improved throughout his hospitalization. Pulmonary consultation confirmed that the aspiration of food is due to the patient's acute exacerbation in bronchiectasis. Common Variable Immunodeficiency. The patient elected to receive his immunoglobin treatment at home. The patient was instructed to optimize his immune supplementation therapy, especially in the setting of his recurrent aspiration pneumonia. What is the correct ICD-10-CM code assignment for this case?

Your Answer: J69.0, J47.1, D83.9 Although the common variable immunodeficiency was not treated, it was clinically evaluated with a treatment plan.

Case 86 PREOPERATIVE DIAGNOSIS: Acute and chronic cholecystitis and cholelithiasis. POSTPERATIVE DIAGNOSIS: Acute and chronic cholecystitis and cholelithiasis. PROCEDURE PERFORMED: Cholecystectomy DESCRIPTION OF PROCEDURE: The patient was placed on the operative table in the supine position. A general anesthesia was administered by the anesthesiologist. The operative field was prepped and draped appropriately. The abdominal cavity was entered through a right subcostal incision. Bleeding was controlled with electrocautery. Upon entering the abdominal cavity, exploration revealed a slightly distended gallbladder. There were 2 large stones in it, as seen on preoperative ultrasound. There were some adhesions, which were lysed. The hepatic flexure and duodenum were reflected. The right lobe of the liver was reflected. The gallbladder was dissected in retrograde fashion. When the cystic artery was reached, it was dissected, divided, and ligated with 2-0 silk. The cystic duct was then carefully dissected, divided, and ligated with 2-0 silk. Bleeding was controlled. The abdomen was irrigated with saline and the saline was aspirated. It was then irrigated with Bacitracin solution and that was also aspirated. The abdomen was closed as follows: the peritoneum and posterior rectus fascia were closed with a running suture of 0 chromic catgut, the anterior rectus fascia with interrupted figure-of-eight sutures of Vicryl, the subcutaneous tissue with a running suture of 2-0 plain and the skin was closed with staples. Dressings were then applied. The patient tolerated the procedure well and was taken to the recovery room in good condition.

Your Answer: K80.12 Calculus of the gallbladder with acute and chronic cholecystitis without obstruction. Your Answer: 0FT40ZZ Resection of Gallbladder, Open Approach.

Case 24 Page 616, Case 16: Inpatient Admission What is the correct ICD-10-CM code assignment for this case?

Your Answer: K85.90, K50.90 Patients symptomatology and treatment were related to pancreatitis. Crohn's disease, a coexisting condition, is coded because it was also treated.

Case 58 Dermatology Clinic The patient returns to the clinic for treatment of his stage III left pressure skin ulcer. On exam, the wound looks fairly good. The diameter of the buttocks wound is approximately 1 to 1-1/2 inches. There is no erythema, purulent drainage or sign of infection. There is no bony exposure noted and wound edges are without signs of necrosis. We recommend he continue his local wound care regiment and will following in 2 months to see how the healing of the wound is progressing. DIAGNOSIS: Ulcer, left buttocks What is the correct ICD-10-CM diagnosis code assignment for this encounter?

Your Answer: L89.323

Case 83 Discharge Note DIAGNOSIS: Severe degenerative arthritis of the right hip PROCEDURE: Right total hip arthroplasty, open. The patient has primary arthritis of the right hip and has been experiencing pain and swelling. After failure of conservative therapy, the patient elected to have a total hip arthroplasty. DEVICES:A 32 mm cobalt chromium head, polyethylene liner was cemented for pressurization into the intramedullary canal of the femur.

Your Answer: M16.11 Unilateral primary osteoarthritis, right hip. Your Answer: 0SR9029 Replacement of Right Hip Joint with Metal on Polyethylene Synthetic Substitute, Cemented, Open Approach.

Case 52 Inpatient Case DISCHARGE NOTE: This 73-year-old female was admitted with increased shortness of breath that was worse with exertion. The patient has a history of chronic kidney disease with an acute exacerbation. The chronic kidney disease is secondary to hypertension. She presents with shortness of breath and an anion gap of 15, pH of 7.24, elevated BNP, and hemoglobin of 6.8. Nephrology was consulted and believes that she should receive dialysis secondary to acute failure. DISCHARGE DIAGNOSIS: 1. Acute-on-chronic renal failure The patient symptomatically improved dramatically after her first session of dialysis. It is probable that she had some fluid overload. 2. Anemia The patient was admitted with hemoglobin of 6.8. After she was transfused with one unit of blood, her hemoglobin increased to 9. Iron studies did not show evidence of iron deficiency anemia. It appears that the anemia was due to end-stage renal disease. What is the correct ICD-10-CM code assignment for this case?

Your Answer: N17.9, I12.0, N18.6, D63.1, Z99.2 Assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension and a condition classifiable to category N18 are present. If the patient has hypertensive chronic kidney disease and acute renal failure, an additional code for the acute renal failure is required.

Case 21 Page 643, Case 19: Physician Office Visit What is the correct ICD-10-CM code assignment for the first-listed code for this visit? Be careful to enter the alphabetic letters, such as O instead of 0 (zero) and place a decimal point in the correct location. Note the example for hypothyroidism: E03.9

Your Answer: O21.0 The hyperemesis gravidarum is before 20 weeks and stated to be mild. Index to 'pregnancy' to 'complicated by' to 'hyperemesis' (O21.0)

Case 85 Operative Report PREOPERATIVE DIAGNOSIS: Term intrauterine pregnancy. Breech presentation. Active labor. Frank breech. POSTOPERATIVE DIAGNOSIS: Term intrauterine pregnancy. Breech presentation. Active labor. Frank breech. PROCEDURE: Primary low transverse cesarean section. ASSISTANT: NONE. ANESTHESIA: Epidural. ESTIMATED BLOOD LOSS: About 500 mL. MEDICATIONS: Included IV Pitocin after the delivery of the placenta and cefotetan 2 grams IV. INDICATIONS: The infant was in breech presentation; therefore, a C-section was performed. FINDINGS: Normal bilateral tubes, ovaries. Delivery of a viable female, Apgars 8 and 9, 6 pounds and 12 ounces. OPERATIVE PROCEDURE: After the patient was appropriately consented, consent was signed and placed in the chart. The patient was taken to the operating room. Epidural anesthesia was dosed. Subsequently, patient prepped and draped in the usual sterile fashion. A Pfannenstiel skin incision was carried down to the level of the fascia. The fascia was explored and dissected off the rectus muscle. Muscle was split in the midline. Peritoneum entered bluntly and incision extended superiorly and inferiorly. Bladder blade was placed in. Visceroperitoneum was dissected. Lower uterine incision was created with sharp scalpel and infant delivered in breech presentation without any difficulty. Bulb suction of the oropharynx and nasopharynx and handed to pediatric nursing in attendance. Cord blood was obtained. Placenta was delivered. Uterus was externalized. Intrauterine cavity cleaned with clean laps and bilateral tubes and ovaries appeared normal. Uterine incision was closed with 0 chromic running locking fashion and figure-of-eight suturing. The uterus was placed into the abdominal cavity. Copious amount of irrigation was used. Muscle was approximated with 2-0 chromic. Fascia was closed with 0 Vicryl. Subcutaneous tissue irrigated, small bleeders were electrocauterized and the skin was closed with staples. Needle, instrument and lap counts were correct and accounted for times 2. The patient to recovery room in stable condition.

Your Answer: O32.1XX0 Maternal care for breech presentation, 7th character not applicable. Your Answer: 10D00Z1 Extraction of Products of Conception, Low Cervical, Open Approach.

Case 28 Page 644, Case 23: Inpatient Admission What is the correct ICD-10-CM code assignment for the principal diagnosis for this case? The coding professional assigned 0WQNXZZ for the repair of the episiotomy. What error is depicted with this code assignment?

Your Answer: O34.212 Your Answer: The repair code is integral to the episiotomy procedure

Case 89 PREOPERATIVE DIAGNOSIS: Mediastinal mass. POSTOPERATIVE DIAGNOSIS: Mediastinal mass. PROCEDURE: Mediastinoscopy with biopsy PROCEDURE: The patient was brought to the operating room, prepped and draped in the routine surgical manner. An incision was made in the notch above the sternum. The mediastinoscope is inserted and exploration carried out between the trachea and the major vessels. The mediastinal lymph nodes, thymus and thyroid are all visualized and a biopsy is performed through the mediastinoscope. The scope is removed and the incision is closed with sutures and Steri-strips are applied. The patient tolerated the procedure well.

Your Answer: R22.2 Mass, Trunk. Your Answer: 0WBC4ZX Excision of Mediastinum, Percutaneous Endoscopic Approach, Diagnostic.

Case 5 Page 685, Case 14: Emergency Department Visit 1. What is the correct ICD-10-CM code assignment for this visit?

Your Answer: R56.9 Code R56.9 is appropriate for this encounter. "Probable" conditions are not coded in the outpatient setting.

Case 4 Page 626, Case 1: Inpatient Admission 1. What is the correct ICD-10-CM coding and sequencing for this case?

Your Answer: S01.01xA, L03.811, H60.12 Note the Excludes 2 note under L03.211 specifically states "cellulitis of ear."

Case 87 PREOPERATIVE DIAGNOSIS: Left zygomatic fracture. POSTOPERATIVE DIAGNOSIS: Left zygomatic fracture. PROCEDURE PERFORMED: Open reduction of left zygomatic fracture. DESCRIPTION OF PROCEDURE:The patient was taken to the operating room and placed in the supine position. An adequate level of general endotracheal anesthesia was induced and maintained. The left face and temporal area were prepped and the left face was draped. Approximately 1-cm vertical incision was made in the temporal area immediately within the hairline superior to the zygomatic arch. Dissection was taken down to temporalis fascia. The temporalis fascia was incised, and a large Boise elevator was inserted beneath the temporalis fascia and beneath the zygomatic arch. The zygomatic arch was out-fractured with only minimal difficulty, into an appropriate alignment. The small incision was then closed with interrupted 4-0 Prolene sutures. Bucket handle splint was applied over the zygomatic arch and the patient was returned to the recovery room in satisfactory condition.

Your Answer: S02.40FA Zygomatic fracture, left side, initial encounter for closed fracture. Your Answer: 0NSN0ZZ Reposition Left Zygomatic Bone, Open Approach.

Case 59 Orthopedic Clinic The patient is a 33-year-old male who wrecked on his mountain bike, approximately 1 year ago, after bumping his wife's bike, going over the handlebars and landing on his left shoulder. At that time, he was noted to have a clavicle fracture. He was treated conservatively with a sling. Lately, he has been experiencing pain on movement in the distal third of his clavicle. On physical exam today, his left upper extremity, he does have a palpable and visual defect of the distal third of his clavicle with the clavicle riding high. Any kind of motion in his shoulder goes through the fracture site rather than the AC joint. Palpation of the area is relatively non-tender; however, I am able to depress the clavicle 1-2 cm, depending on the position of his shoulder. He has no tenderness about the acromion. He has negative impingement. He has good strength with external and internal rotation as well as flexion and abduction; however, these maneuvers do cause significant motion through the fracture site and he complains of some pain with external rotation and flexion at the elbow. He is neurovascularly intact distally. X-ray performed today in the office shows a nonunion at the distal third of the clavicle with approximately 2-3 cm of distal clavicle attached to the acromion. ASSESSMENT/PLAN: Nonunion distal third clavicle fracture on the left side. I feel that the patient would benefit from an open reduction and internal fixation. What is the ICD-10-CM code assignment for this encounter? (Note: the External Cause codes are not included in this answer)

Your Answer: S42.032K Research the anatomical grouping to reveal that the distal third of the clavicle is considered lateral.

Case 80 Operative Report PREOPERATIVE DIAGNOSIS: Healed right bimalleolar ankle fracture with retained metal hardware. POSTOPERATIVE DIAGNOSIS: Healed right bimalleolar ankle fracture with retained metal hardware. PROCEDURE: Removal of metal hardware from right lateral ankle. INDICATIONS FOR SURGERY: Patient is a 51-year-old woman who is approximately 10 months status post open reduction and internal fixation of a right bimalleolar type ankle fracture. She is now taken to the operating room for removal of the metal plate and screws. DESCRIPTION OF PROCEDURE:The patient was positioned in a supine position on the operating room table. After the satisfactory induction of general anesthesia delivered with a mask, a well-padded tourniquet was placed at the right upper thigh. The right leg was sterilely prepped and draped free in the usual sterile fashion. Her previous lateral incision was incised longitudinally in line with the skin incision. Dissection was carried down through the subcutaneous tissue and the plate overlying the lateral fibula was exposed. The 5 screws in the plate were removed, after which the plate was removed. There was a separate lag screw located anteriorly over the distal fibula. The head of this was identified by sharp dissection. The area was irrigated with lactated Ringer's solution. The wound was anesthetized with approximately 15 cc of a 0.50% Marcaine, following which the subcutaneous tissue was reapproximated using interrupted 2-0 Vicryl sutures and the skin was closed using a running subcuticular stitch of undyed 5-0 PDS suture. Steri-Strips were applied to the incision followed by adaptic 4x4 gauze, sterile 6 inch cast padding, and a well-padded, short leg, walking cast. The tourniquet was released, tourniquet time being approximately 25 minutes. Estimated blood loss was negligible. There were no complications. The patient tolerated the procedure well, was awakened from anesthesia, and taken to the recovery room in satisfactory condition.

Your Answer: S82.841D The 7th character extension is for the subsequent encounter for normal healing period. Your Answer: 0SPF04Z Removal of Internal Fixation Device from Right Ankle Joint, Open Approach.

Case 18 Page 662, Case 17: Inpatient Admission In this case, the diagnosis of "acute myocardial infarction" would be classified to which of the following?

Your Answer: STEMI of inferior wall The correct code assignment would be I21.19 (STEMI) myocardial infarction involving other coronary artery of inferior wall.

Case 8 Page 670, Case 11: Outpatient Visit 1. Which of the following Official Coding Guidelines governs a coder's action for classifying the diagnosis of "probable neoplastic disease?"

Your Answer: Section IV. H The guideline states "do not code diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis" or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for visit. "Please note: This differs from the coding practices used by short-term, acute care, long-term care, and psychiatric hospitals.

Case 40 Page 657, Case 3: Inpatient Admission The following code assignment was generated from a computerized software program: ICD-10-CM: I65.22 Occlusion and stenosis of left carotid artery I69.390 Apraxia following cerebral infarction I69.391 Dysphagia, following cerebral infarction R13.12 Dysphagia, oropharyngeal phase ICD-10-PCS: 03QJ0ZZ Repair, Left Common Carotid What error is depicted in this coding assignment?

Your Answer: The ICD-10-PCS root operation is incorrect. The root operation should be Extirpation.

Case 60 General Surgery Clinic Note SUBJECTIVE: The patient is status post a total colectomy with ileostomy performed by me 2 weeks ago, following which he developed a wound dehiscence. The patient is seen every other day by the home health nurses for wound dressing changes and his wife does them the other days. He has no complaints at this time. OBJECTIVE: There are 2 areas along the midline incision, which are healing by secondary intention. The wounds are clean with no drainage and have good beginning granulation tissue on either side. The width is approximately 1-2 cm at its widest. IMPRESSION: Wound dehiscence status post colectomy. PLAN: We will continue with daily dressing changes. The wound is healing well and we will see the patient back in 2 to 3 weeks for a wound check. What is the ICD-10-CM code assignment for this encounter?

Your Answer: T81.31XD The treatment was directed at the wound dehiscence and the visit is subsequent.

Case 88 Operative Report PREOPERATIVE DIAGNOSIS: Malfunctioning pacemaker lead. POSTOPERATIVE DIAGNOSIS: Displaced pacemaker lead. PROCEDURE PERFORMED: Ventricular lead reposition. PROCEDURE:With the patient in the supine position on the operating table with satisfactory anesthesia standby, the area over the pacemaker pocket was infiltrated with 1% plain Xylocaine and the previous incision opened. There was a small amount of serous fluid in the pocket. The 2 leads were disconnected and the atrial lead, which was Model 4439, serial number 1234, was then checked. It was satisfactory. The output was 2.0 volts, current 4.3 mA, impedance 460 ohms and P wave 1.0 mV. This was felt to be satisfactory so the atrial lead was not repositioned. The anatomical positioning looked excellent. The ventricular lead was then disconnected and withdrawn and then reinserted into the apex of the right ventricle where the acute thresholds were 0.7 volts output, 0.8 mA current, 800 ohms impedance and 20.07 mV R wave. There was no stimulation at the diaphragm at 10 volts. The ventricular lead was then sutured in place with 2-0 black silk suture as well as the atrial lead and they were connected to a pacemaker, the pulse generator and functioned satisfactorily. The sponge and instrument counts were correct. Hemostasis was excellent with cautery. Routine closure with #3-0 Vicryl subcutaneously and 4-0 Vicryl subcuticularly. The patient tolerated the procedure well and transferred to the recovery room in stable condition.

Your Answer: T82.120A Displacement of cardiac electrode, initial encounter. Your Answer: 02WA0MZ Revision of Cardiac Lead in Heart, Open Approach.

Case 61 Orthopedic Clinic Note This new patient is seen today for evaluation of his left index finger. It appeared he had an arthroplasty of his PIP joint 25-30 years ago, by report. He awoke about a week ago with significant pain in his PIP joint and decreased range of motion. He thinks he slept on it wrong and may have broken it. The finger is somewhat swollen as is the joint region. It has not really improved much in the past week. He was seen in the Walk-In Clinic. They suspected a periprosthetic fracture. On reviewing his x-rays, I do not see any evidence of a periprosthetic fracture. There is evidence of a prosthesis in place. EXAM: he has a significantly swollen PIP joint. His range of motion is from full extension to about 20 degrees of flexion. His MP joint motion is also limited. He is swollen but not acutely red and there is no streaking. It does not appear infected. There is no drainage. He has sensation that is intact distally as is his capillary refill. IMPRESSION: Prosthetic joint failure, left index finger. PLAN:I am suspicious that the patient's implant has failed. I do not think that he has a fracture, per se. He is of the belief that he has a fracture, however, and does not want to rush into any kind of revision of his prosthesis. I think that the ultimate would be a fusion of his PIP. He is also not interested in rushing into this. He would like to give the finger a little bit more time to heal in case that it may be just a fracture. I think this is perfectly all right, and I did place him in an aluminum-foam splint for comfort that we supplied. Plan to see him back in two weeks, at which point we will reassess and again discuss the possibilities regarding possible resection arthroplasty and fusion. DIAGNOSIS: Dislocation of prosthesis, left index finger. What is the ICD-10-CM code assignment for this encounter?

Your Answer: T84.028A, Z96.692

Case 39 Page 660, Case 12: Inpatient Admission The following code assignment was generated from a computerized software program: ICD-10-CM: M31.6 Other giant cell arteritis ICD-10-PCS: 03BS0ZZ Excision, right temporal artery 03BT0ZZ Excision, left temporal artery What error is depicted in this coding assignment?

Your Answer: The 7th character in both ICD-10-PCS codes is incorrect The 7th characters should be "X" for diagnostic because biopsies were performed.

Case 50 Page 687, Case 15 (episode 3): Orthopedic Clinic Visit The following code assignment was generated from a computerized software program: ICD-10-CM: S82.852S Displaced trimalleolar fracture V00.131S Fall from skateboard ICD-10-PCS: 2W5RX2Z Removal of cast What error is depicted in this coding assignment?

Your Answer: The 7th character is incorrect for both ICD-10-CM codes. The 7th character extension of "D" should be assigned to indicate subsequent encounter.

Case 44 Page 631, Case 6: Inpatient Admission The following code assignment was generated from a computerized software program: ICD-10-PCS: 0Y6J0Z1 Detachment of left lower leg What error is depicted in this coding assignment?

Your Answer: The 7th character qualifier is incorrect. The qualifier "low" should be assigned for the 7th character to report the distal portion of the shaft of the tibia and fibula.

Case 49 Page 669, Case 8 (episode 2): Inpatient Admission The following code assignment was generated from a computerized software program: ICD-10-PCS: 0W993ZX Drainage of right pleural cavity 0BBK3ZX Excision of right lung What error is depicted in this coding assignment?

Your Answer: The Drainage code has the wrong 7th character qualifier. The objective of the Thoracentesis was drainage of the pleural effusion to assist with breathing, not diagnostic

Case 41 Page 642, Case 16: Inpatient Admission The following code assignment was generated from a computerized software program: ICD-10-CM: O60.12X0 Preterm labor, second trimester with preterm delivery second trimester O87.2 Hemorrhoids in the Puerperium Z37.0 Single live birth Z3A.25 25 weeks gestation of pregnancy ICD-10-PCS: 10D00Z0 Extraction, products of conception What error is depicted in this coding assignment?

Your Answer: The ICD-10-PCS qualifier is incorrect. The ICD-10-PCS qualifier should reflect, "low cervical."

Case 29 Page 616, Case 17 (episode 2): Inpatient Admission The following code assignment was generated from a computerized software program: ICD-10-CM: K35.3 Acute appendicitis with localized peritonitis ICD-10-PCS: 0DTJ4ZZ Resection of appendix

Your Answer: The approach is incorrect for the ICD-10-PCS code The approach is open, not percutaneous endoscopic (0DTJ0ZZ)