Chapter 4 - ICD-10-CM Chapters 1-11

T81.4XXA, T81.12XA, A48.0

A 22 year-old patient status post-surgery developed a postoperative infection. The patient quickly deteriorated and became septic, developed gas gangrene (gas bacillus infection) and went into postprocedural septic shock. With aggressive intravenous antibiotic management, the patient improved. What ICD-10-CM codes are reported?

Z51.11, C22.8

A 45 year-old patient is scheduled to have an INFUSAID pump installed. He has primary liver cancer and the pump is being inserted for continuous administration of 5-FU. A pocket is created just under the skin and the pump is placed in the pocket. A catheter is attached to the pump and to the subclavian vein. The pump is filled with a chemotherapy agent provided by the hospital and the patient is observed for adverse reaction and discharged to home. What ICD-10-CM codes are reported?

I12.0, N18.6

A 54 year-old male goes to his primary care provider with dizziness. On physical exam his blood pressure is 200/130. After a complete work-up, including laboratory tests, the provider makes a diagnosis of end stage renal disease and hypertension. What are the appropriate diagnosis codes for this encounter?

G30.0, F02.80

A 58 year-old patient sees the provider for confusion and loss of memory. The provider diagnoses the patient with early onset stages of Alzheimer's disease with dementia. What ICD-10-CM codes are reported?

J44.1

A 70 year-old patient with COPD is admitted to the hospital for acute exacerbation of bronchial asthma. What diagnosis code is reported?

J45.901

A 9 year-old with a history of reactive airway disease (RAD) was admitted into overnight observation with complaints of a two-day history of increased wheezing. Parents stated that nebulizer treatments were not helping. After monitoring and additional treatments given while in observation, breathing was stabilized. Documented diagnosis is RAD exacerbation. What ICD-10-CM code(s) is/are reported?

G89.3, C79.51

Mrs. Johnson is here today to receive an intercostal nerve block to mitigate the debilitating pain of her malignancy. Her cancer has metastasized to her bones in her thoracic spine. What ICD-10-CM codes are reported?

When a patient's insulin pump malfunctions.

Name an example of when a problem caused by diabetes is NOT sequenced after the code for diabetes. Refer to ICD-10-CM guideline I.C.4.a.5.a.

A40.1, J15.3, R65.20

Patient is admitted to the hospital with streptococcal group B severe sepsis which has caused pneumonia. What codes are assigned?

D62

Patient with postoperative anemia due to acute blood loss during the surgery needs a blood transfusion. What ICD-10-CM code is reported?

J12.0

Pneumonia due to adenovirus. What ICD-10-CM code is reported?

I50.22, I10

The patient has a history of unstable angina, hypertension, and chronic systolic heart failure. He is seen in the ED after prolonged chest pain that was not relieved by medication. Cardiac enzymes are elevated, and EKG shows anterior infarct. A decision was made to perform a cardiac catheterization and coronary angiography. Left heart catheterization was performed in order to perform a left ventriculogram. He tolerated the procedure well and will be discharged. His final diagnosis is chronic systolic heart failure and hypertension. The two conditions are unrelated. What ICD-10-CM code(s) is/are reported?

I21.09

The patient was given thrombolytic therapy for an acute myocardial infarction (STEMI) of the anterolateral wall which converted to a NSTEMI. What ICD-10-CM code is reported?

Any complication associated with diabetes.

What does the 4th character in diabetes mellitus diabetes codes indicate?

A41.9, R65.20, N17.9

A 22-year-old female is admitted to ICU for acute renal (kidney) failure due to sepsis (causal organism unknown). Applying the coding concept from ICD-10-CM guideline I.C.1.d.1.b. what ICD-10-CM codes are reported (in the correct sequencing)?

S81.819A, B20

A 23 year-old patient presents to the Emergency Department with a cut on his leg. He is a confirmed AIDS patient as documented in the record. What ICD-10-CM codes should be reported?

G43.B1

A 32 year-old patient with an ophthalmoplegic migraine is not responding to medication and is admitted to the observation unit. What ICD-10-CM code is reported?

E05.10

A 32 year-old patient with hyperthyroidism has an ultrasound to determine why her neck is enlarged. The results of the ultrasound reveal a uninodular goiter. What ICD-10-CM code is reported?

H81.313

A 35 year-old woman is experiencing dizziness with nausea and vomiting. The provider documents auditory vertigo of both ears, possible Meniere's disease. What ICD-10-CM code(s) is/are reported?

E11.622, L98.429, Z79.4

A 45 year-old-male patient has developed an ulcer on his upper back. He has had diabetes for several years and is on insulin. The provider determines that the ulcer is due to his diabetes. What ICD-10-CM codes are reported?

J96.00, J90

A 63 year-old came in to the ED with severe shortness of breath and goes into respiratory failure. He was intubated and admitted for acute respiratory failure. Chest X-ray shows he has pulmonary effusion. What ICD-10-CM code(s) is/are reported?

J44.0, J20.9, F17.210

A 65 year-old female patient returns to her primary care provider for follow up of an upper respiratory infection diagnosed the previous week. Her condition has not improved and her cough has increased. She has a long history of smoking. She currently smokes one pack a day and is dependent on the cigarettes. She uses a bronchodilator for her COPD. The provider changes her antibiotics to treat her acute bronchitis with COPD. What ICD-10-CM codes are reported for this visit?

E00.9, F79

A lab screening shows congenital iodine-deficiency hypothyroidism for an infant with identified intellectual disability. What ICD-10-CM code(s) is/are reported?

C18.7

A male patient is seen by his primary care provider for rectal bleeding and persistent intestinal cramps. After a colonoscopy with biopsy, the results come back and the provider documents that the patient has malignant neoplasm in his sigmoid colon. What ICD-10-CM code(s) is/are reported?

S72.052B, B20

A patient is admitted to the hospital for repair of an open fracture, type 1, of the head of the left femur. The patient has been previously diagnosed with symptomatic HIV. Applying the coding concept from ICD-10-CM guideline I.C.1.a.2.b., what ICD-10-CM code(s) is/are reported for the admission?

I12.0, N18.5, I51.5

A patient is seen for his hypertension with stage 5 CKD and myocardial disease. The conditions are stable and he is told to continue with his medications. The myocardial disease is unrelated to the hypertension. What ICD-10-CM codes are reported?

F10.20

A patient presents to her physician and tells him she drinks each night when she gets home from work. She asks her physician to recommend an alcohol treatment center because her life has become unmanageable and she wishes to quit drinking. The patient is diagnosed with uncomplicated alcohol dependence. Select the diagnosis code.

I63.9

A patient presents to the ED with weakness on the left side and aphasia. Tests are ordered and the patient is admitted with a cerebrovascular accident (CVA). What ICD-10-CM code(s) is/are reported?

H40.1312, H40.1321

A patient presents with pigmentary glaucoma bilaterally, moderate stage on the right, mild stage on the left. Reference ICD-10-CM guideline I.C.7.a.3. What ICD-10-CM code(s) is/are reported?

H66.91

A patient presents with right ear pain and fever. The provider diagnoses acute otitis media. What ICD-10-CM code(s) is/are reported?

M54.5

A patient returns to the provider for an injection to relieve low back pain from a car accident. What ICD-10-CM code(s) is/are reported?

N18.3, D63.1

A patient sees the nephrologist for a B-12 injection to treat erythropoietin resistant anemia due to stage 3 chronic kidney disease. What ICD-10-CM codes are reported?

F50.01

A patient with a four-year history of eating disorders is seen in the physician's office due to significant weight loss over the past three months. She went from 82 pounds down to 53 pounds due to restricting her food intake. She is diagnosed with anorexia nervosa. Select the diagnosis code(s).

D49.7, E24.9, I10

A patient with a history of hypertension controlled with medication presents to the outpatient hospital radiology department for an ultrasound due to a suspected suspicious mass. The patient's provider performed an ACTH and a 24-hour urinary free cortisol and short suppression test confirming the diagnosis of Cushing's disease. The radiology report indicated a 5.5 cm right adrenal mass that appeared well circumscribed and rounded. The final diagnosis indicated Cushing's disease secondary to a right adrenal tumor. What ICD-10-CM codes are reported?

F11.23, T40.2X5A

A patient with chronic back and neck pain developed a drug dependency on oxycodone (opioid). After being taken off the drug, he was seen in the clinic for withdrawal symptoms. What ICD-10-CM codes are reported?

C78.2, C34.91, J91.0

A provider performed an aspiration via thoracentesis on a patient in observation status in the hospital. The patient has advanced right lung cancer that has metastasized to the pleura with malignant pleural effusion. Later the same day, due to continued accumulation of fluid, the patient was returned to the procedure room and the same provider performed a repeat thoracentesis. What ICD-10-CM codes are reported?

F33.3, G40.919

A young male, was brought to the clinic by his mom. He has had periods of major depression for many years and is on Lithium. His provider also manages his migraine headaches and epilepsy. During the past week, he became psychotic, hearing voices to kill himself and intense feelings of worthlessness. On the day of the clinic visit, he had an epileptic seizure that could not be controlled by medication. He was admitted for Lithium adjustment. Final diagnoses are: Severe depression with psychotic behavior and epileptic seizure poorly controlled with medication. What ICD-10-CM codes should be reported?

The malignancy is reported first, followed by the code for the anemia.

According to ICD-10-CM guidelines, when a patient is seen for management of anemia due to malignancy, how is it reported?

A bilateral code can be used to report the type of glaucoma and the stage of glaucoma.

According to the ICD-10-CM guidelines, how is bilateral glaucoma of the same type and stage reported?

F12.10

What ICD-10-CM code is reported for a patient who is a habitual abuser of cannabis?

I12.9, N18.3

What ICD-10-CM codes are reported for uncontrolled hypertension with stage 3 chronic kidney disease?

I11.0, I50.1

What codes, according to ICD-10-CM guidelines, describe a patient that has hypertension with left heart failure?

C78.5

What diagnosis code is reported for secondary neoplasm of the descending colon?

Methicillin Resistant Staphylococcus Aureus

What does MRSA stand for?

Worsening or decompensation of asthma or COPD

What is an acute exacerbation of asthma or COPD? Reference ICD-10-CM guideline I.C.10.a.1.

No time frame

What is the time frame defining when pain becomes chronic?

R75

When a patient has a blood test for HIV that is inconclusive, what ICD-10-CM code is assigned?

When it occurs after admission.

When do you code acute respiratory failure as a secondary diagnosis?

It has been excised, no evidence of any existing primary malignancy, and there is no further treatment directed to the site.

When is it appropriate to use history of malignancy from category Z85?

E85.4, N08

A patient with amyloidosis being treated for glomerulonephritis. What ICD-10-CM codes are reported?

J44.0, J20.9

A patient with COPD visits the physician with acute bronchitis. What ICD-10-CM code(s) should be reported?

Code only STEMI

If an ST elevation myocardial infarction coverts to a non ST elevation myocardial infarction in the course of thrombolytic therapy, how is it coded? Reference ICD-10-CM guideline I.C.9.e.1.