CRC CHAPTER 13 EXAM

Question 2 Progress NotesSubjective:CC: Six month follow up, Vision not as good, Difficulty readingHPI: ROS:EYES:blurred vision yes.glare yes.light sensitivity yes. ENT: hearing loss yes. CARDIOLOGY:hypertension yes. HEMATOLOGIC:diabetes yes.HORMONAL:thyroid disorder yes Social History:no Smoking Are you a: nonsmoker.no Alcohol. Medications:Lumigan 0.03 percent solution 1 gtt OU QPMhydrochlorothiazidelevothyroxinefenofibratesimvastatinmetforminglimepiridemetoprolollisinoprilMedication List reviewed and reconciled with the patientAllergies:N.K.D.A. Objective: Past Orders: Examination:Physical Examination:W/MR:1 Wearing OD +0.75+0.50 x 180 = 20/50+2.2 Wearing OS -1.75 +0.50 x 014 = 20/ 200.3 Wearing ADD +2.75 BIF = 5 pt OU.4 Refraction OD +0.50 +1.00 x 005 = 20/30-.5 Refraction OS -1.75 +a.so x 015 = 20/NI.Pupils:RAPD None.Size equal 2 OU.Reactivity reactive to light.Ocular motility:Strabismus None.Versions full.IOP:Applanation OU 10Adnexa:External Normal, OU.Lids Normal, OU.Slit Lamp Exam:Conjunctiva Normal, OU.Cornea Normal, OU.Anterior Chamber Deep & Quiet, OU.Iris Dark Brown.Lens OD, PCIOL in the bag, trace PCO, OS, PCIOL in the bag, Open PC (s/p yag cap).Dilation:OU Tropicamide 1 percent. Optic Nerve:Cup/Disc OD near total shallow, OS.9 shallow. Vitreous:Description OU, Normal. Retina:Macula OU, RPE defects, soft drusen some calcified, focal atr,Vessels OD, Normal, OS hemorrhages in distrib of superotemp arteriole as before.Periphery Normal without tears or holes, OU. Assessment:1 Low-tension glaucoma - od near total, os .9; 24- 2 inf alt defects ou2 Retinal Arterial branch occlusion - os nasal3 Nonexudative senile macular degeneration - os>od4 Nonproliferative Diabetic Retinopathy - ou, mild not requiring therapy Plan:1 Low tension glaucomaContinue Lumigan solution, 0.01 percent, 1gtt, in each affected eye, QPM.2 Nonexudative senile macular degeneration preservision.3 Nonproliferative Diabetic RetinopathyBLOOD SUGAR: Discussed the importance of tight blood sugar control. Procedure Codes: Preventive: Follow Up: Six months with a doctor closer to home Provider: S, M.D., Sign off Status: Complete. 04/15/20XX What are the diagnosis codes? Enter an ICD-10-CM code for each of the spaces provided.

E11.3293, H40.1230, H35.3130, H34.232, I10, E07.9, H35.363, Z79.84 Response Feedback: Rationale: In this case the patient has diabetic retinopathy, low-tension glaucoma, retinal arterial branch occlusion and nonexudative senile macular degeneration. In this case although the patient has diabetic retinopathy, the type of diabetes is not documented. According to ICD-10-CM guideline, I.C.4.a.2, states if the type of diabetes mellitus is not documented in the medical record the default is E11.-, Type 2 diabetes mellitus. Look in the Alphabetic Index for Diabetes, diabetic (mellitus) (sugar)/type 2/with/retinopathy/nonproliferative which directs the coder to E11.329. A 7th character is required to identify laterality. Next, the patient has low-tension glaucoma. Look in the Alphabetic Index for Glaucoma/low tension which says see glaucoma, open angle/low-tension. Glaucoma/open angle/low-tension which directs the coder to H40.12-. This code requires a 6th character to identify laterality and seventh character to identify the stage of the glaucoma. As the patient has bilateral glaucoma the 6th character would be a 3. The stage of the glaucoma is not documented. The correct diagnosis code is H40.1230. The patient has nonexudative senile macular degeneration. Look in the Alphabetic Index for Degeneration/macula, macular (acquired) (age-related) (senile)/atrophic age-related/bilateral which directs the coder to H35.313. The patient also has a left retinal arterial branch occlusion. Look in the Alphabetic Index Occlusion/retinal/branch which directs the coder to H34.23-. This code requires a 6th character to identify laterality which makes H34.232 is the correct diagnosis code. Lastly, the patient has hypertension, thyroid disease and a family history of hypertension. Look in the Alphabetic Index for Hypertension which directs the coder to I10; Disease/thyroid which directs the coder to E07.9. The drusen was also revealed upon physical exam. In the Index, see Drusen/macula see Degeneration/macula/drusen, H35.36-, and report H35.363 for bilateral, as documented OU indicates a bilateral condition. The patients diabetes is controlled with oral medications. Look in the Alphabetic Index for Long-term (current) drug therapy (use of)/oral/hypoglycemics which directs the coder to Z79.84. Verify all code selections in the Tabular List.

Question 4 CHIEF COMPLAINT: Recently diagnosed to have sleep apnea, history of myasthenia gravis and a history of mild intermittent asthma. HISTORY OF PRESENT ILLNESS: This 71-year-old female was referred to me by Dr. S when she was diagnosed to have sleep apnea by Dr. S. She denies any significant cough, fever, chills or night sweats. No weight loss. She had mild dyspnea on exertion. No paroxysmal nocturnal dyspnea or orthopnea. No swelling of the feet. No chest pain to suggest angina. The patient is known to have myasthenia gravis and mild intermittent asthma. PAST MEDICAL HISTORY: She has had a gastric bypass surgery. PERSONAL HISTORY: She quit smoking five years ago. She may have smoked less than a pack of cigarettes a day for 15 years or so. CURRENT MEDICATIONS: Prednisone 5mg a day, Pyridostigmine 60mg two tablets four times a day, Bupropion 150mg a day, Citalopram 20mg at bedtime, Multivitamins. FAMILY HISTORY: Mother had diabetes. Mother and Father had hypertension. SYSTEM REVIEW: HEENT: Noncontributory. CARDIOVASCULAR: Denies hypertension or previous history of ischemic heart disease. RESPIRATORY: Mild exertional dyspnea. GASTROINTESTINAL: Noncontributory. GENITOURINARY: Noncontributory. MIJSCULOSKELETAL: Noncontributory. NEUROPSYCHIATRIC: Diagnosed to have myasthenia gravis by Dr. xxxx. She was recently diagnosed to have sleep apnea. ENDOCRINE: Denies diabetes or thyroid dysfunction. SKIN: Nothing significant. PHYSICAL EXAMNATION: The patient is conscious, alert and oriented, in no acute distress. Vital Signs: Pulse 60, respirations 16, blood pressure 140/90, saturation 96 percent at rest on room air. Weight 173 pounds. MENTAL AND GENERAL STATUS: Normal. HEENT: Head examination is normal. Eyes: Normal. Throat: Normal. NECK: No cervical lymphadenopathy. No carotid bruit could be heard. No increase in jugular venous pressure or pulsation. CHEST: No wheeze or rales could be heard. CARDIOVASCULAR: First and second heart sounds are heard. No murmur, thrill or gallop. No pitting edema. No congestive heart failure. ABDOMEN: Soft and non-tender. No organomegaly. Bowel sounds are active. No tenderness or guarding. PERIPHERAL EXTREMITIES: No cyanosis or clubbing. No pitting edema. LYMPHATIC SYSTEM: No lymphadenopathy. NERVOUS SYSTEM: Normal. OTHER SYSTEM: normal. LABORATORY DATA: No laboratory data is available at this time. IMPRESSION:1 Sleep apnea, moderate to severe.2 Myasthenia gravis.3 Depression4 Mild intermittent asthma. PLAN:I am going to review her sleep study done at xxxx Hospital and also going to get a pulmonary function study.Further recommendations will follow the pulmonary function studies and also reviewing of her sleep study. Thank you for the consultation. Signed by X, MD, 05/01/20XX What are the diagnosis codes? Enter an ICD-10-CM code for each space provided.

G47.30, G70.00, F32.A, J45.20, Z98.84, Z83.3, Z82.49, Z87.891, Z79.52 Response Feedback: Rationale: In this case the patient has sleep apnea, myasthenia gravis, depression, and asthma. Look in the ICD-10-CM Alphabetic Index for Apnea/sleep which directs you to code G47.30. Next, look in the Alphabetic Index for myasthenia/gravis directing you to code G70.00. The patient has depression, look in the Alphabetic Index for Depression which directs you to code F32.A. Asthma is found by looking for Asthma, asthmatic/intermittent (mild) which directs the coder to J45.20. The patient also has a history of bariatric surgery and smoking. She also has a family history of diabetes and hypertension. History of bariatric surgery is found in the Alphabetic Index by looking for Status/bariatric surgery which directs you to Z98.84. History of smoking look in the Alphabetic Index for History/personal of/nicotine dependence which directs you to code Z87.891. Next, the patient has a family history of diabetes and hypertension. Look in the Alphabetic Index for History/family (of)/diabetes mellitus Z83.3 and History/family (of)/disease or disorder (of)/cardiovascular NEC Z82.49. The patient is also taking a systemic steroid, in the Alphabetic Index look for Long term drug therapy use/Steroids/systemic which directs the coder to Z79.52. Verify code selections in the Tabular List.

Question 3 10 out of 10 points DATE OF CONSULTATION: 02/23/20XX REFERRING PHYSICIAN: S, MD REASON FOR CONSULTATION: Evaluation of mitral valve regurgitation. HISTORY OF PRESENTILLNESS: I was asked by Dr. S to see Mrs. F following her cardiac catheterization. I have reviewed that study and have discussed the case with Dr. S. I have interviewed the patient in the cardiac cath lab holding area in the presence of her daughters. Mrs. F is a very active xx-year-old woman who continues to maintain her household and take care of her disabled husband. Approximately six weeks ago she was noted to have atrial fibrillation. An echocardiogram was performed which demonstrated a left ventricular ejection fraction of 20 percent, mitral and tricuspid regurgitation, and moderate pulmonary hypertension. Cardiac catheterization was performed today, which shows normal coronary arteries other than a dilated distal left main coronary artery and moderate mitral regurgitation with an ejection fraction of approximately 20 percent. Right heart catheterization showed pulmonary artery pressures to be approximately 1/3 systemic a t 32/11, and cardiac output was 3.3, giving a cardiac index of greater than 2. In discussing the case with Dr. xxxxx, he states that there was no evidence of a flail segment of the mitral valve. The study is not available to me at this time. PAST MEDICAL HISTORY: Atrial fibrillation. PAST SURGICAL HISTORY: Oophorectomy. ALLERGI ES: No known drug allergies. MEDICATIONS: 1 Ziac. 2 Niaspan. 3 Lisinopril. 4 Coumadin, which has been held. PHYSICAL EXAMINATION: GENERAL: Thin woman in no acute distress. IMPRESSION: Severe cardiomyopathy with mitral and tricuspid valve regurgitation. No significant pulmonary hypertension per right heart catheterization. No apparent symptoms of congestive heart failure in spite of extremely poor left ventricular function. Hypertension, controlled on medications. DISCUSSION: I explained to the patient that treatment options include medical therapy and surgery. I gave my opinion that valve repair or replacement is not likely to be beneficial as the le ventricular function will still be terrible. We also discussed that in the absence of symptoms there is questionable benefit of proceeding with surgery, particularly with such a poor left ventricle. RECOMMENDATIONS: Medical management. The patient is not a candidate for cardiac surgery. Dictated and signed by X, MD 02/23/20XX What are the diagnosis codes? Enter an ICD-10-CM code for each of the spaces provided.

I08.1, I42.9, I10, I48.91 Response Feedback: Rationale: In this case the patient has severe cardiomyopathy, mitral and tricuspid valve regurgitation, atrial fibrillation and hypertension. Look in the Alphabetic Index for Cardiomyopathy which directs the coder to I42.9; Regurgitation/mitral which says see Insufficiency, mitral. When you reference Insufficiency/mitral (valve)/with/tricuspid it directs the coder to I08.1; Fibrillation/atrial which directs the coder to I48.91; Hypertension which directs the coder to I10. Verify all code selections in the Tabular List. Pulmonary hypertension is not coded because it is not an active diagnosis due to the heart catheterization.

Question 5 RETURN OFFICE VISIT 03/24/20XX PRIMARY CARE PHYSICIAN: S, DO Cardiologist: C, DO CHIEF COMPLAINT: Cardiomyopathy, Hypertension IDENTIFYING DATA: Mr. D is a 70 year-old male. HISTORY OF PRESENT ILLNESS He has had no chest discomfort suggestive of ischemia. The patient complains of palpitations. The patient rates the symptoms as mild. The patient describes the palpitations as occasional skipped beats. He states anxiety, stress and caffeine makes it worse. The palpitations are associated with dyspnea. The patient visits the office to be evaluated for dyspnea. The patient rates the severity of the shortness of breath as mild. The shortness of breath is aggravated by moderate activity, after the patient climbs 10 stairs. Associated symptoms include anxiety and fatigue. Pertinent negatives include chest pressure, fever, hemoptysis, lower extremity edema, neuromuscular weakness and night sweats. His last known Echo (EF .40). CARDIAC HISTORY Risk Factors: 1 Dyslipidemia 2 Former Tobacco Abuse: cigarettes (Quit six yrs ago, Tobacco per day: 2.00, Years used: 27.00, Pack years: 54) 3 Hypertension CHRONIC CONDITIONS Shortness of breath Hyperlipidemia Cardiomyopathy Carotid ASO ASHDS Native Coronary Artery Hypertension, Benign CHF, Left CARDIOVASCULAR PROCEDURES Echo/MUGA: Echo (EF.40) - xx/xx/20XX Echo (LVEF 30-35%.) - xx/xx/20XX Electrophysiology: EKG (Sinus Rhythm) - xx/xx/20XX Vascular: Carotid Duplex (Mild plaque.) - xx/xx/20XX INTERIM HISTORY: None PAST MEDICAL HISTORY: Mildly Dilated Ascending Aorta, GERD, Chest Pain, Bipolar Disorder, Mild to Moderate LV Systolic Dysfunction, Dyslipidemia, Coronary Artery Disease, CVA. Hypertension, CABG (Triple Bypass) PRE-VISIT MEDICATIONS: Crestor Seroquel Digoxin Fenofibrate Fluoxetine Hcl Ambien Diazepam Gabapentin Klorcon M20 Lamotrigine Furosemide Warfarin Sodium Lisinipril Carvedilol Trilipix ALLERGIES/lNTOLERANCES: None SOCIAL HISTORY FAMILY: Single ALCOHOL: No RACE: White ETHNICITY: Not Hispanic or Latino REVIEW OF SYSTEMS: RESPIRATORY - Negative for hemoptysis. Positive for dyspnea. CONSTITUTION - Negative tor fever, night sweats. Positive for fatigue. CARDIOLOGY - Negative for chest pressure, chest pain, syncope. VASCULAR - Negative for edema. NEUROLOGY - Negative for muscular weakness. PSYCHOLOGY - Positive for anxiety and bipolar disorder. PHYSICAL EXAM: CONSTITUTION - The patient is 6 feet 2 inches tall, and weighs 218 lbs. The BMI is 28. 1 Kg/m2. Blood pressure in the right arm is 110/68 mmHg in the sitting position. The pulse is 74/min. The rhythm is regular. The respirations are 12/min. Nourishment, Overweight. NECK: JVP, Less Than 8. RESPPIRATORY: Respirations, Non-labored Breath Sounds are Clear Throughout CARDIAC: Rhythm is Regular. Palpation - PMI Normal. Heart Sounds: S1 Normal, S2 Normal. Murmurs: None. ABO - Carotid: Bilateral Normal Pulse, No Bruits Noted. Radial: Bilateral Normal Pulse. ABO - Tenderness: None. Palpation Son, No Guarding. EXTREMITY: Lower Extremity Edema Absent. PSYCHOLOGY: A & O x 3, currently stable. TESTING REVIEWED TODAY· None IMPRESSION AND PLAN 1 Hypertension. Benign: Well controlled on medical therapy. 2 Hyperlipidemia: Lab to be drawn before the next visit: Lipids, LFTs. 3 Family Hx of Cardiovascular Disease 4 Tobacco Abuse, History of 5 Shortness of Breath: This condition is stable Patient is NYHA functional Class II. 6 Cardiomyopathy: His ejection fraction is greater than 35 percent. 7 CAD. Native Vessel: S/P CABG 8 Carotid ASO: He has mild carotid plaque. 9 Left Heart Failure 10 Myocardial Infarction, Old ORDERS 1 Have a Lipid Profile drawn before next visit 2 Have LFTs drawn before next visit MEDICATION CHANGES 1 Discontinued SEROOUEL (OUETIAPINE FUMARATE) 100 mg Electronically Authenticated by: X, DO 03/24/20XX 04:30 PM What are the diagnosis codes? Enter an ICD-10-CM code in each space provided.

I11.0, E78.5, Z87.891, I25.10, I65.29, I50.1, I25.2, I42.9, Z68.28, F31.9, F41.9, Z86.73, E66.3, Z79.01, Z95.1, Z82.49 Response Feedback: Rationale: In this case the patient has hypertension, hyperlipidemia, and is a former cigarette smoker. Look in the Alphabetic Index for Hypertension, hypertensive/heart/with/heart failure which directs the coder to I11.0 and there is a note in the Tabular List to also code the type of heart failure which is left heart failure in this case; look in the Alphabetic Index for Failure, failed/heart/left and the coder is directed to see also Failure, ventricular, left. Look for Failure, failed/ventricular/left and the coder is directed to I50.1. Look for Hyperlipidemia which directs the coder to E78.5; and History/personal (of)/tobacco dependence which directs the coder to Z89.891. The patient also has CAD, carotid ASO (arteriosclerosis obliterans), cardiomyopathy, and old MI. Look in the Alphabetic Index for Disease/artery/coronary which directs the coder to I25.10; Arteriosclerosis/carotid which says see Occlusion, artery, carotid - Occlusion/artery/carotid which directs the coder to I65.2-. This code requires another character to further specify condition. In this case we do not have additional information which makes the correct code I65.29. Next, the patient has an old MI. Look in the Alphabetic Index for Infarction/myocardium, myocardial/healed or old which directs the coder to I25.2. The patient has cardiomyopathy and a documented BMI of 28.1. Look in the Alphabetic Index for Cardiomyopathy which directs the coder to I42.9 and Body/mass index (BMI)/28.0-28.9 which directs the coder to Z68.28. The patient has bipolar disorder, anxiety, history of CVA, and the patient is overweight. Look in the Alphabetic Index for Disorder/bipolar which directs the coder to F31.9; Anxiety which directs the coder to F41.9; History/personal (of)/cerebral Infarction without residual deficit which directs the coder to Z86.73; and Overweight which directs the coder to E66.3. The patient is also on long-term anticoagulants and has a bypass graft. Look in the Alphabetic Index for Long-term/anticoagulants which directs the coder to Z79.01; Presence (of)/aortocoronary (bypass) graft which directs the coder to Z95.1. There is a family history of cardiovascular disease. Look for History/family/disease/cardiovascular NEC referring you to Z82.49. Verify all code selections in the Tabular List.

Question 10 XYZ Medical Center Inpatient ConsultDATE OF CONSULTATION: 04/01/20XXREFERRING PHYSICIAN: S, MD REASON FOR CONSULTATION: Evaluation and treatment of coronary and valvular cardiac disease. HISTORY OF PRESENT ILLNESS: I was asked by Dr. M to see Mr. D following his cardiac catheterization. I have reviewed that study and his echocardiogram. I have interviewed and examined the patient in his hospital room in the presence of his wife.Mr. D is a 67 year-old man with known coronary disease, having undergone previous stenting remotely. He and his wife describe an approximately one-month history of increasing fatigue. He has also had a one-week history of increasing dyspnea on exertion and presented to the hospital several days ago after he developed paroxysmal nocturnal dyspnea. Echocardiography demonstrated moderate tricuspid regurgitation with tricuspid jet consistent with a 67-mmHg gradient, indicating significant pulmonary hypertension.The patient has done well with medical management consisting primarily of diuresis, and he states that his breathing is much better now. Cardiac catheterization was performed today which demonstrates 3- vessel coronary artery disease including occlusion of the right coronary artery with left-to-right collateral filling of the relatively small posterior descending artery, sequential 70% stenosis in the mid left anterior descending artery, 80 percent stenos is in the obtuse marginal artery, and depressed left ventricular function with an ejection fraction of approximately 35 percent with moderate mitral regurgitation. The patient had an episode of atrial fibrillation yesterday that responded to loading with amiodarone with resumption of sinus rhythm. On admission, he was noted to be moderately anemic with a hematocrit of 34, and he does describe dark-colored stool. PAST MEDICAL HISTORY:1 Hypertension.2 Diabetes mellitus.3 Obstructive sleep apnea, which has resolved with weight loss and apparent uvulectomy. PAST SURGICAL HISTORY1 Surgery on uvula.2 Right knee arthroscopy. ALLERGIES:No known drug allergies. MEDICATIONS:1 Doxazosin 2 mg p.o. at bedtime.2 Metformin 500 mg p.o. b.i.d.3 Metoprolol succinate 25 mg p.o. daily.4 Multivitamin. REVIEW OF SYSTEMS:CONSTITUTIONAL: No fevers, chills, or weight loss.RESPIRATORY: Minimally productive cough of whitish sputum.HEART: Does describe tightness in his chest and left arm but is not sure what causes it and apparently it occurs at rest.NEUROLOGIC: No history of stroke or transient ischemic attack.GASTROINTESTINAL: Complains of dark-colored stool. No history of ulcers known.GENITOURINARY: No dysuria.HEMATOLOGIC: No bleeding tendencies.ENDOCRINE: Recently diagnosed with diabetes.MUSCULOSKELETAL: Complains of right knee pain with walking and climbing stairs that does limit mobility.PHYSICAL EXAMINATION:GENERAL: Well-developed, well-nourished man in no acute distress.VITAL SIGNS: Weight 170 pounds.HEENT: Head normocephalic atraumatic.NECK: No masses or bruits.CHEST: Clear to auscultation without retractions or rales.HEART: Regular rate and rhythm with grade 1/6 systolic murmur heard best at the apex. Pulses 2+ in bilateral radial arteries. No palpable pedal pulses.ABDOMEN: Soft, non-tender, non-distended. No pulsatile mass.EXTREMITIES: No edema. No varicose veins.NEUROLOGIC: No focal deficits. DIAGNOSTIC STUDIES:IMAGING: Echocardiogram and cardiac catheterization as above. Chest x-ray at the time of admission showed pulmonary edema.LABORATORY DATA: Hematocrit 34, platelets 371. Creatinine 1.3. Troponin at the time of admission was 0.5. IMPRESSION:1 Three-vessel coronary artery disease.2 Pulmonary hypertension.3 Anemia.4 Hypertension.5 Diabetes mellitus. DISCUSSION:I had a long talk with the patient and his wife regarding treatment options for his cardiac disease, both coronary and valvular. We discussed medical management and surgery, which would consist of coronary artery bypass grafting. Dr. xxxxx does not feel that the coronary anatomy is suitable for stenting. We discussed risks of cardiac surgery, including bleeding, infection, heart attack, stroke, renal failure, need for permanent pacemaker, and death. PLAN:Will check stool guaiac for anemia and dark stools. If patient is shown to have blood in his GI tract, he will need a colonoscopy. Anticipate coronary artery bypass grafting, mitral valve repair or replacement, and tricuspid valve repair. Patient is agreeable with proceeding with that operation and understands the risks and benefits but would like to wait until after Labor Day. Anticipate patient being discharged home by Dr. xxxxx when he is suitably medically managed, including following his renal function. Again, he may need colonoscopy prior to surgery. Dictated and signed C, MD 04/01/20XX What are the diagnosis codes? Enter an ICD-10-CM code for each space provided.

I25.10, I27.20, D64.9, I10, E11.9, I48.91, I08.1, M25.561, Z79.84 Response Feedback: Rationale: In this case the patient has CAD, pulmonary hypertension, anemia, hypertension and diabetes. Look in the Alphabetic Index for disease/artery/coronary which directs the coder to I25.10; Hypertension/pulmonary which directs the coder to I27.20; Anemia which directs the coder to D64.9; and Hypertension which directs the coder to I10. In this case the type of diabetes is not documented. According to ICD-10-CM Coding Guideline, I.C.4.a.2, states if the type of diabetes mellitus is not documented in the medical record the default Is E11.-, Type 2 diabetes mellitus. Look in the Alphabetic Index for Diabetes, diabetic (mellitus) (sugar)/type 2 which directs the coder to E11.9. The patient also has atrial fibrillation and tricuspid insufficiency. Look in the Alphabetic Index for Fibrillation/atrial which directs the coder to I48.91 and Regurgitation/tricuspid which says see Insufficiency, tricuspid. When you reference Insufficiency/tricuspid (valve) (rheumatic)/with/mitral it directs the coder to I08.1. Look in the Alphabetic Index for Pain(s)/joint/knee M25.561 is reported. Patient is taking an oral antidiabetic in the Alphabetic Index look for Long term (current) (prophylactic) drug therapy (use of)/oral/antidiabectic drug which directs the coder to Z79.84. Verify all code selections in the Tabular List.

Question 7 INPATIENT CONSULTATION REPORT Patient DW DOB 09/02/XX DOS 03/23/20XX HISTORY OF PRESENT ILLNESS: I saw the patient, who is a 65 year-old female who appears younger than her age. She is here because of numbness about her face, which came on yesterday. It is still there. She noted symptoms in the arms or the legs. She had been on aspirin and Plavix, and now she is on a heparin drip. Earlier she had an echocardiogram and TEE, which are negative for thrombus in the heart.She had left-sided numbness and weakness in 04/XX, and since then she has been on aspirin and Plavix. She might have had one more episode in between. I reviewed her work up and her carotid duplex scan revealed narrowing of both ICAs less than 50 percent. Her MRI of the brain revealed apparently a right lacunar stroke around the thalamus. She denies any headache or problem with vision or speech or weakness at this time. PAST MEDICAL HISTORY: In addition to right CVA, hypertension, and dyslipidemia. MEDICATIONS: Tricor, metoprolol, ferrous sulfate, calcium with vitamin D, Lasix, multivitamin, oxybutynin, Protonix, and Pravachol. PERSONAL HISTORY: She walks without any assistance inside the house. Outside, she is using a cane or a walker. She does not smoke nor does she abuse alcohol. NEUROLOGIC EXAMINATION: Normal mental status, speech, and she appears younger than her age. Cranial nerves II through XII are intact. She has no focal weakness. Reflexes are 2+, symmetrical in the upper limbs. In lower limbs, knees are trace. Ankles are absent. Plantars are both down going.Gait exam is deferred. Coordination normal on finger-to-nose testing. Exam of the head and neck and spine unremarkable. IMPRESSION: This lady has a small-vessel stroke or a lacunar stroke in the thalamus or nearby area. She had a right lacunar stroke involving the thalamus on the right side last year on xx/xxxx. She is an aspirin and Plavix failure. I doubt this lady had an embolic or large vessel stroke. I think she had a lacunar stroke due to high blood pressure. Nonetheless, since she is an aspirin and Plavix failure, I agree with the short-term Coumadin maybe for three months or so, but certainly I do not recommend a heparin drip right now. After three months, we can switch her from Coumadin to Plavix. She had a carotid duplex scan last month which revealed narrowing of both the internal carotid arteries less than 50 percent. So I am now going to repeat that. Her TEE is normal today. We will follow her with you. We will also get a CT of the brain without contrast since she did not have one this time. Thank you for the consult.Signed by D, MD For this case, report the conditions only. What are the diagnosis codes? Enter an ICD-10-CM code for each of the spaces provided.

I63.81, Z86.73, I65.23, E78.5, I10 Response Feedback: Rationale: In this cases the patient has a small-vessel stroke or a lacunar stroke in the thalamus, a history of a previous stroke, and narrowing of both the internal carotid arteries. Look in the ICD-10-CM Alphabetic Index for Infarct, infarction/lacunar which directs you to I63.81. Look in the Alphabetic Index for History/personal (of)/stroke without residual deficits directing you to Z86.73; and Narrowing/artery/carotid referring you to see Occlusion, artery, carotid. Look in the Alphabetic Index for Occlusion/artery/carotid referring you to I65.2-. This code requires a 5th character to identify laterality. In this case it is bilateral I65.23. The patient also has dyslipidemia and hypertension. Look in the Alphabetic Index for Dyslipidemia directing you to E78.5; and Hypertension referring you to I10. Verify all code selections in the Tabular List.

Question 6 Neurology Outpatient ConsultPatient: SDReferring Physician: S, MD Date of Visit: 05/01/20XX Chief Complaint: Status post-cerebral vascular accident. History of Present Illness: This is a 68 year·old male who comes today for his first visit accompanied by his wife. The patient had a cerebral vascular accident on 04/01/thisyr and on 04/04/20XX with left-sided weakness. The patient had no seizures. Past Medical & Surgical History: Hypertension, Hypercholesterolemia, No heart disease. Medications: Plavix 75 mg (long-term use), Lisinopril, Pantoprazole, Lipitor Family History: Noncontributing. Allergies: Unknown. Social History: The patient does not smoke cigarettes or drink alcohol. Review of Systems: Constitutional: Patient reported weight gain. Neurologic: Patient has weakness and numbness due to CVA. Ears, Nose & Throat: Denied cough, nosebleed or snoring. Cardiac: He denied irregular heartbeat or chest pain. Respiratory: Denied recent cold or bronchitis. GI: Denied nausea, vomiting or diarrhea. GU:Denied bladder infection or bloody urine. Musculoskeletal: Denies any pains. Skin: Denied skin rash or itching. Psychiatric: Denied depression or anxiety. Endocrine: Denied thyroid problems or diabetes mellitus. Hematologic: Denied anemia or bleeding problems. Immunologic: Denied allergies or frequent infections. Eyes: He complained of blurring of vision. Physical Examination:Height: 5 feet 9 inchesWeight: 203 poundsBlood Pressure: 150/80 General Appearance: Elderly man in no acute respiratory distress. Head and Neck: Atraumatic, supple without bruits.Heart: Regular rate and rhythm, no murmur. Lungs: clear. Extremities: Without clubbing, cyanosis or edema. Neurological Examination: Mental status: Fully conscious, oriented x three, normal language and speech. The patient is slow in responses to questions.Cranial Nerves II through XII: Sharp discs, pupils equal and reactive to light. Extraocular muscles intact. No facial weakness. Tongue protruded in the midline.Motor Examination: Strength 4/5 in left upper extremity proximally and distally, 4/5 in left iliopsoas, 5/5 in left tibialis anterior muscle. Deep tendon reflexes are 0/4 in right biceps, triceps, knees and ankle, 2/4 in left biceps and knee, 0/4 in left triceps and ankle. Toes equivocal bilaterally.Sensory Examination: Normal to pinprick sensation. Cerebellar: Normal finger-to-nose bilaterally.Gait: Spastic hemiplegic gait.There is increased muscle tone in the left upper extremity. Assessment and Plan:Status post cerebral vascular accident with non-dominant residual left spastic hemiparesis. Recommend carotid ultrasound.Hypertension. The patient was advised to follow up with Dr. S. Thank you for letting us share in the care of Mr. D. Signed by X, MD 05/02/20XX What are the diagnosis codes? Enter an ICD-10-CM code for each of the spaces provided.

I69.354, I10, E78.00,Z79.02 Response Feedback: Rationale: In this example the patient is status post cerebral vascular accident with residual left spastic hemiparesis. Look in the Alphabetic Index for Hemiplegia/following/stroke which directs the coder to I69.35-. When referenced in the Tabular List there are codes for laterality and dominant versus non-dominant. This documentation indicates the left non-dominant side reporting code I69.354. The patient also has hypertension, hypercholesterolemia and long term use of anticoagulant. Look in the Alphabetic Index for Hypertension which directs the coder to I10; Hypercholesterolemia which directs the coder to E78.00; and Long-term/antiplatelet directs the coder to Z79.02. Verify all code selections in the Tabular List.

Question 1 Progress Note 02/01/20XX Patient MT DOB 06/02/XXXX BP: 140/72, right. Pulse: 72, regular. Temperature 98.2, oral. Ht. 5'9". Wt. 223 lbs. Resp. 18 Smoking status: Former smoker who quit 30 years ago. Subjective: This: 71 year-old male presents with a seven-day history of: Fever: No URI symptoms: No Cough: Yes Productive cough: Yes, occasional blood-tinged sputum Dyspnea: No Review of systems Constitutional: Fatigue Ears, Nose, Mouth, Throat: Clear rhinorrhea Cardiovascular: No chest pain or palpitations; has hypertension and hyperlipidemia Respiratory: As noted above Allergic/ Immunologic: Negative Current Medications (updated 02/01/20XX): Rx: POTASSIUM CHLORIDE 90MG 1 TAB once daily (Replacement therapy for diuretics) Rx· ATENOLOL 50MG 1 TAB once daily (HTN) Rx: FOSAMAX 70MG 1 TAB weekly (Osteoporosis) Rx: LIPITOR 40MG ½ daily (Hyperlipidemia) Rx: FLONASE 50M CC/ACT 2 spray twice daily (allergic rhinitis) Rx: MULTIVITAMINS 1 TAB once daily Rx: FLOMAX 0.4MG 1 TAB daily Allergies: NKDA Past Medical History: Measles and chickenpox as a child Mononucleosis in 1982 Compression fracture T-11, T-12, and L-1 due to Osteoporosis, no surgery due to age Hypertension Hyperlipidemia Bilateral hip pain Deviated nasal septum Allergic rhinitis Posterior vitreous detachment, right eye Bilateral cataracts Past Surgical History: EGD with biopsies Normal total colonoscopy exam by Dr. xxxx on xx/xx/xxxx Social History: Smoking: Former smoker who quit over 30 years ago Environmental smoke exposure: No Objective: General: Alert adult white male in no apparent distress Skin: Good turgor, no rash or prominent lesions Head· Normocephalic, atraumatic Eyes: Conjunctiva clear, sclera non-icteric, EOM intact, PERRL Ears: EACs clear, TMs translucent, ossicles normal. appearance Nose: Normal except mucosa inflamed Mouth: Mucous membranes moist, no mucosal lesions. Pharynx: Mucosa non-inflamed, no tonsilar hypertrophy or exudate Neck supple, without lesions or adenopathy Heart: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop Lungs: Has a few crackles and slight decreased breath sounds in base of lungs with a few rhonchi of upper chest, which clear with auscultation Abdomen: Bowel sounds normal, no tenderness, organomegaly, masses, or hernia Extremities: No amputations or deformities, cyanosis, edema or varicosities, peripheral pulses intact Chest X-Ray: has some increased bronchial markings in both lungs with no acute infiltrates Assessment: 1. Other Problem: ACUTE BRONCHITIS 2. Other Problem: COUGH 3. Major Problem: HYPERTENSION Plan: Laboratory: CBC today Medications: begin Augmentin 875/125 one tab po bid x 10 days. Mucinex DM ·1 tab po q12hrs prn cough. May continue other current medications. Patient education: Patient advised to avoid exposure to dust and smoke and to limit activity pending improvement in symptoms Increase intake of water to improve hydration. May try room humidifier as needed. May use throat lozenge or cough drops as needed for cough. Consider trial of some chicken noodle soup. Continue Fosamax for pathological vertebral compression fracture pain. Follow-up: prn if symptoms worsen or not responding to current treatment within 10 days. Procedure: Office Visit Level 4 99214, EM Code Calc based on 1995 guidelines. Signed by X, MD on 02/01/20xx, 03:15 PM What are the diagnosis codes? Enter an ICD-10-CM code in each of the spaces provided.

J20.9, I10, M80.08XD, E78.5, J30.9, 87.891 Response Feedback: Rationale: In this case the patient has bronchitis, hypertension, hyperlipidemia, allergic rhinitis, and GERD. Look in the Alphabetic Index for Bronchitis/acute which directs the coder to J20.9; Hypertension which directs the coder to I10; Hyperlipidemia which directs the coder to E78.5; Rhinitis/allergic which directs the coder to J30.9. The patient has osteoporosis with compression fracture. Look in the Alphabetic Index for Osteoporosis/age-related/with current pathological fracture/vertebra which directs the coder to M80.08-. When you reference this code in the Tabular List a seventh character is required to identify episode of care. This patient is not receiving active treatment for the fracture so the subsequent encounter would be used. The correct code would be M80.08XD. Lastly, the patient has a history of smoking which is reported with Z87.891. Verify code selection in the Tabular List.

Question 9 TRANSPLANT SURGERYMr. X is a 66 year-old white male who had end stage renal disease and type I diabetes mellitus and underwent combined kidney and pancreas transplantation. He lost his renal allograft from BK viral nephropathy and underwent retransplantation ten years ago. He had problems with renal allograft dysfunction and underwent percutaneous renal allograft biopsy eleven years ago, which revealed hypertensive changes within his kidney. He recently had his lisinopril discontinued.His blood pressures again climbed to an unacceptable level. He had atenolol added. He states that his pulse has slowed down with the atenolol. He has had no trouble with dizziness. He brings his blood pressure cuff with him today. His cuff reads 170/90. My reading with the electronic cuff is 173/84. I am unable to auscultate a pressure in this patient. His log of his blood pressure readings at home in the standing position are usually in the 130 range. I feel that this is an acceptable blood pressure for this patient. We will add no additional antihypertensive medicines. LABORATORY REVIEW (xx/xx/20xx)Sodium 144; potassium 5.0; chloride 109; carbon dioxide 20; white count7000; hematocrit 31.9; platelet count 264,000; BUN 43; creatinine 1.82;Prograf level 6.4; amylase 28; lipase 69. ASSESSMENT:1. Hypertension - reasonably controlled.2. End stage renal disease. On dialysis.3. Diabetes mellitus type I.4. Diabetic retinopathy - stable.5. Diabetic neuropathy.6. BK allograft nephropathy.7. Renal allograft rejection - June 1999. 8. Hypercholesterolemia.9. Atherosclerosis, extremities.10. Osteoporosis. PLAN:The patient is to continue on the current antihypertensive regimen. We will schedule him for a bone densitometry study on his return. He is provided three cards for stool sampling for guaiac testing. He is to get a blood check in six weeks consisting of a BUN, creatinine, CBC, E-group, Prograf level, glucose, amylase, and lipase and similar labs in 12 weeks to include an ImmuKnow, PTH, calcium, and phosphate. I will see him back in follow-up at that time. He is to continue to keep a log of his chemsticks. Electronically signed by X, MD What are the diagnosis codes? Enter an ICD-10-CM code for each space provided.

N18.6, I12.0, E10.22, E10.40, E10.319, Z99.2, I70.209, E78.00, M81.0, Z94.0, Z94.83 Response Feedback: Rationale: In this example the patient has hypertension and end stage renal disease. According to the ICD-10-CM guideline I.C.9.a.2, Assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD), are present. ICD-10-CM presumes a cause-and-effect relationship. To locate this code look in the Alphabetic Index for Hypertension/with/kidney/with/stage 5 chronic kidney disease (CKD) or end stage renal disease (ESRD) I12.0. There is an instructional note that states to "Use additional code to identify the stage of chronic kidney disease (N18.5, N18.6). In this case the patient has end stage renal disease so N18.6 is assigned. The patient is also a type 1 diabetic with diabetic retinopathy and diabetic neuropathy. Combination codes would be reported for these conditions. In the Alphabetic Index, look for Diabetes/type 1/with/neuropathy which directs the coder to E10.40 and Diabetes, diabetic (mellitus) (sugar)/type 1/with/retinopathy which directs the coder to E10.319. Diabetes/type 1/with/chronic kidney disease directs you to E10.22. Next the patient has Atherosclerosis in the extremities; look in the Alphabetic Index for Artherosclerosis which states see Arteriosclerosis. Arteriosclerosis/extremities directs the coder to I70.209. Look in the Alphabetic Index for Hypercholesterolemia which directs the coder to E78.00. The patient also has Osteoporosis. Look in the Alphabetic Index for Osteoporosis which directs the coder to M81.0. Lastly the patient had a kidney and pancreas transplant. To report the status of the transplants look in the Alphabetic Index for Transplant/kidney which directs the coder to Z94.0 and Transplant/pancreas which directs the coder to Z94.83. Patient is on dialysis repot Z99.6, look for Dialysis/renal (hemodialysis) (peritoneal), status referring you to Z99.2. Verify all code selections in the Tabular List.

Question 8 DATE 04/01/20xx Medical Office Exam DOB 03/01/XXXXBP: 128/70; Left arm. Pulse: 60, Regular. Temperature: 98 .6 F, Oral. HT: 5'4.5". WT:169 lbs.Respirations: 16.Smoking status: NeverSubjective: This 67-year-old male presents for comprehensive medical examination. Lives with no one.Interim problems since last visit: NoneReview of Systems:Constitutional: NegativeEyes: NegativeEars, Nose, Mouth, Throat: NegativeCardiovascular: NegativeRespiratory: NegativeGastrointestinal: NegativeGenitourinary: NegativeMusculoskeletal: NegativeSkin and /or breasts: Negative:Neurological: NegativePsychiatric: NegativeEndocrine: NegativeHematologic/Lymphatic: NegativeAllergy/ Immunologic: NegativePast Medical History:HTNNIDDMPast Surgical History:Left Shoulder Rotator Cuff Repair at age xxRight Rotator Cuff Repair at age xxLeft Bunionectomy and Hammertoe Repair three years agoCurrent Medications:Rx: ASPIRIN EC 81M G 1 TAB once daily, days, 30, Ref: 11Rx: ATENOLOL. 50M G 1 TAB once daily, days, 80, Ref: 4Rx LOTENSIN HCT 20-25MG 1 TAB daily, days, 80, Ref: 11Rx: NORVASC 10 MG 1 TAB daily, days, 90, Ref: 4Rx: GLUCOPHAGE 500MG 1 TAB TID, days, 180: Ref: 5Rx: VIAGRA 100MG ½-1 tab PRIOR TO INTERCOURSE PR I, days, 6 , Ref: 3Allergies: PenicillinSocial History:Tobacco: NoAlcohol: YesCaffeine: YesMarital status: SingleOccupation: Equipment Operator Family History:Diabetes Mellitus and Alzheimer'sObjective:General: Well appearing, well nourished, in no acute distress, oriented, normal mood and affect.Skin: Good turgor, no rash or prominent lesionsHair· Normal texture and distribution.Nails: Normal color, no deformitiesHead: Normocephalic, atraumatic.Eyes: Conjunctiva clear, sclera non-ischemia, EOM intact, PERRLEars: EAC's clear, TM's translucent, ossicles normal appearanceNose: No external lesions, mucosa non-inflamed, septum and turbinates normalMouth: Mucous membranes moist, no mucosal lesionsTeeth/Gums: No obvious caries or periodontal diseasePharynx: Mucosa non-inflamed, no tonsil hypertrophy or exudateNeck: Supple, without lesions or adenopathyHeart: No cardiomegaly or thrills, regular rate and rhythm, no murmur or gallopLungs: Clear to auscultationAbdomen: Bowel sounds normal, no tenderness, organomegaly, masses, or herniaBack: Spine normal without deformity or tenderness, no CVA tendernessGU: Penis without lesions, testes normal size without masses, no inguinal herniasRectal: Normal sphincter tone, no masses palpable, prostate normal size, smooth non-tender and without nodules, no hemorrhoids notedExtremities: Right BKA, stump patent with no lesions, otherwise normal with good capillary refill leftMusculoskeletal: No decreased ROMLymphatic: No lymphadenopathy in cervical axillary or inguinal areas.Neurologic: CN 2-12 normal, Sensation to pain, touch and proprioception normal, phantom limb syndrome with pain on occasionPsychiatric: Oriented times three, intact recent and remote memory, judgment and insight, normal mood and affect.Assessment:Other Problem: MEDICAL EXAMPlan:Laboratory: Other: CBC, CMP, fasting lipid panel, UA, Thyroid Panel, hemoglobin A1C, PSA.Procedures: Colonoscopy: OrderedPatient Counseling:Discussed long-term aspirin prophylaxis to prevent a myocardial infarction and decision was to continue.Follow-up: prn or 1 year for physicalHTN Rx: NORVASC. 10 MG 1 TA8 daily, 90,HTN Rx: LOTENSIN HCT 20-25 MG 1 TAB DAILY, 90DM Rx: GLUCOPHAGE 500 MG 1 TAB three times daily, 180HTN Rx: ATENOLOL 50 MG ·1 TAB once daily, 80, Signed: X, M.Dcc: NB, M.D. What are the diagnosis codes? Enter an ICD-10-CM code for each space provided.

Z00.01, Z89.511, E11.9, I10, G54.6, Z88.0, Z79.82, Z82.0, Z83.3, Z79.84 Response Feedback: Rationale: In this case, the patient presents for a comprehensive medical examination. Look in the Alphabetic Index for Examination/with abnormal findings which directs the coder to Z00.01 (on exam, the provider indicates Phantom Limb on occasion). He had a BKA. To code for this look for Absence/leg/below knee (acquired) which directs the coder to Z89.51-.When referenced in the Tabular List a sixth character is required for laterality. This is of the right leg with correct code Z89.511. The patient also has diabetes. The type of diabetes is not documented. According to ICD-10-CM guideline, I.C.4.a.2, states if the type of diabetes mellitus is not documented in the medical record the default Is E11.-, Type 2 diabetes mellitus. Look in the Alphabetic Index for Diabetes, diabetic (mellitus) (sugar)/type 2 which directs the coder to E11.9. The patient also has hypertension and phantom limb syndrome with pain. Look in the Alphabetic Index for Hypertension which directs the coder to I10, and Phantom limb syndrome/with pain which directs the coder to G54.6. Look in Alphabetic Index for History/personal of/allergy/penicillin referring you to Z88.0. The patient also has long term use of aspirin and a family history of Alzheimer's and diabetes mellitus. Look In the Alphabetic Index for Long-term (current) drug therapy (use of)/aspirin which directs the coder to Z79.82; History/family (of)/disease/neurological which directs the coder to Z82.0; and History/family (of)/diabetes mellitus which directs the coder to Z83.3. The patient's diabetes is controlled with oral medication. Look in the Alphabetic Index for Long-term (current) drug therapy (use of)/ oral/ hypoglycemics which directs the coder to Z79.84. Verify all code selections in the Tabular List. Although the patient is not obese, the BMI is documented and reported for data collection for quality care initiatives and because the patient has diabetes.