An elderly male patient presents to the ED complaining of a high fever the day prior to the encounter and of extreme lethargy. He has a history of benign hypertension which has been elevated. On arrival he was examined and admitted, with possible septic urinary tract infection and concern for his elevated blood pressure. He was noted to have hematuria. Positive UTI and pseudomonas showed in the urine culture and IV antibiotics were administered. During the course of the day, his fever decreased and his lethargy improved. He was noted to have hematuria. As the IV fluids were decreased, he resumed a benign hypertensive state. On the next hospital day, the urine was clear and he was discharged on oral antibiotics, with septicemia ruled out. What ICD-10-CM codes should be reported?
A) I10, B95.6, R31.9, N39.0
B) B96.5, N39.0, I10, R31.9
C) N39.0, B96.5, I10
D) B95.6, A41.52, N39.0, I10
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?
A) F33.3, G43.909, G40.909
B) F33.2, G40.909
C) F33.3, G40.919
D) F33.1, G43.919, G40.919C
Patient presents to this clinic with palpitations, weight loss, bulging eyes and extreme nervousness. The tests ordered come back positive with Graves' disease. Select the ICD-10-CM code(s) to report.
B) E05.00, R00.2, R63.4, H57.8, R45.0
C) R00.2, R63.4, H57.8, R45.0, E05.01
An HIV positive patient was admitted with skin lesions on the chest and back. Biopsies were taken, and the pathologic diagnosis was Kaposi's sarcoma. Leukoplakia of the lips and splenomegaly were also noted on physical examination. Discharge diagnoses: (1) HIV infection, (2) Kaposi's sarcoma, back and chest, (3) leukoplakia (4) splenomegaly. What ICD-10-CM codes should be reported?
A) Z21, C46.0, K13.21, R16.1
B) R16.1, C46.0, R16.1, Z21
C) B20, C46.0, K13.21, R16.1
D) B20, C46.0, K13.21, R16.1, Z21
A young female, was brought to the clinic by her sister. She has had periods of severe depression for many years and is on Lithium. Her provider also manages her manic-depressive psychosis, hypothyroidism, and migraine headaches. Additional medications are Synthroid and Midrin. During the past week, she became manic, running all her credit cards to the limit, getting inappropriately involved in a friend's suicide attempt, quitting her job, and trying to take over the pulpit at church. On the day of the clinic visit, she threatened to strike the telephone repairman with a lead pipe. She was admitted for Lithium adjustment. Diagnoses are: moderate manic-depressive bipolar with circular current manic state, hypothyroidism, and migraine. What ICD-10-CM codes are reported?
A) F31.32, E03.9, G43.909
B) F31.89, G43.911, E03.8
C) F31.62, E03.9, G43.911
D) F31.12, E03.9, G43.909
Four years post hepatic transplant, the patient is diagnosed with combined hepatocellular carcinoma and cholangiocarcinoma of the liver. What ICD-10-CM codes are reported?
A) T86.49, C80.2, C22.0
B) C80.2, C22.0
C) C80.2, C22.0, C22.1, Z94.4
D) T86.49, C80.2, C22.0, C22.1, Z94.4
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?
A) T81.12XA, R65.21, A48.0
B) T81.4XXA, A48.0, T81.12XA C) R65.21, A48.0, T81.12XA
D) A48.0, R65.21, T81.4XXA
Follow-up Visit: The patient has some memory problems. She is hard of hearing. She is legally blind. Her pharmacist and her family are very worried about her memory issues. She lives at home, family takes care of laying out her medications and helping with the chores, but she does take care of her own home to best of her ability.
Exam: Pleasant elderly woman in no acute distress. She has postop changes of her eyes. TMs are dull. Pharynx is clear. Neck is supple without adenopathy. Lungs are clear. Good air movement. Heart is regular. She had a slight murmur. Abdomen is soft. Moderately obese. Non-tender. Extremities; no clubbing or edema. Foot exam shows some bunion deformity but otherwise healthy. Light touch is preserved. There is no ankle edema or stasis change. Examination of the upper arms reveal good range of motion. There is significant pain in her shoulder with rotational movements. It is localized mostly over the deltoid. There is no other deformity. There is a very slight left shoulder discomfort and slight right hip discomfort.
2. Right shoulder pain.
3. Benign hypertensive cardiovascular disease.
4. Type 2 diabetes good control. Most recent AlC done today 5.9%. Liver test normal. Cholesterol 199, LDL a little high at 115.
1. I offered her and her family neuropsychological evaluation to evaluate for dementia. Her system complex is consistent with dementia, whether it be from small vascular disease or Alzheimer's is unknown. At this point, they would much rather initiate treatment than go through an exhaustive neuropsychological test.
2. For the shoulder we decided on right deltoid bursa aspiration injection. She has had injection for bursitis in the past and prefers to go this route. She will ice and rest the shoulder after injection.
3. Follow up in 3 months.
Procedure: Aspiration injection right deltoid bursa. The point of maximal tenderness was identified, skin was prepped with alcohol. A 25-gauge, 1 ½-inch needle was advanced to the humerus and then aspirated. 1 cc of 0.25% Marcaine mixed with 80 mg Depo Medrol was deposited. Needle was withdrawn. Band-aid was applied. Post injection she had marked improvement; increased range of motion consistent with good placement of the medication. She was started on Cerefolin, plus NAC and Aricept starter pack was given with email away script. Follow-up in 3 months and we will reassess her dementia at that time.
What diagnosis code(s) are reported? Dx #1: E11.9 Dx #2: M25.511 Dx #3: I11.9 Dx #4: F03.90
CC: HTN INTERVAL HISTORY: No new complaints. EXAM: NAD. 130/80, 84, 22. Lungs are clear. Heart RRR, no MRGs. Abdomen is soft, non-tender. No peripheral edema. IMPRESSION: Stable HTN on current meds. PLAN: No changes needed. RTC in six months with labs.
What diagnosis code(s) are reported?
PREOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss.
POSTOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss.(Report the postoperative diagnosis.)
1. Placement of left Nucleus cochlear implant.
2. Facial nerve monitoring for an hour.
3. Microscope use.
INDICATIONS: This is a 69-year-old woman who has had progressive hearing loss (The diagnosis is documented as the indication for the surgery.) over the last 10-15 years. Hearing aids are not useful for her. She is a candidate for cochlear implant by FDA standards. The risks, benefits, and alternatives of procedure were described to the patient, who voiced understanding and wished to proceed.
PROCEDURE: After properly identifying the patient, she was taken to the main operating room, where general anesthetic was induced. The table was turned to 180 degrees and a standard left-sided post auricular shave and injection of 1% lidocaine plus 1:100,000 epinephrine was performed. The patient was then prepped and draped in a sterile fashion after placing facial nerve monitoring probes, which were tested and found to work well. At this time, the previously outlined incision line was incised and flaps were elevated. A subtemporal pocket was designed in the usual fashion for placement of the device. A standard cortical mastoidectomy was then performed and the fascial recess was opened exposing the area of the round window niche. The lip of the round window was drilled down exposing the round window membrane. At this time, the wound was copiously irrigated with bacitracin containing solution, and the device was then placed into the pocket. A 1-mm cochleostomy was made, and the device was inserted into the cochleostomy with an advance-off stylet technique. A small piece of temporalis muscle was packed around the cochleostomy, and the wound was closed in layers using 3-0 and 4-0 Monocryl and Steri-Strips. A standard mastoid dressing was applied. The patient was returned to anesthesia, where she was awakened, extubated, and taken to the recovery room in stable condition.
What diagnosis code(s) are reported?
Dear Dr. Smith,
Mr. Martin was seen in the office for continued management of his breast cancer.(This indicates the patient's main reason for the office visit.) He's having some increasing pain in his breast which is due to the cancer.(Pain related to the neoplasm.) He is also complaining of neck pain. It does not seem to be worse at night; it seems to be worse with activity. He has no other symptoms. Otherwise his review of systems is unremarkable. He's had no constitutional symptoms.
On physical exam, he is alert and oriented. Eyes: EOMI, PERLA, no icterus. The heart had a regular rate and rhythm; S1, S2 within normal limits. The lungs are clear to auscultation and percussion. The abdomen was soft, without masses or organomegaly. He was tender to palpation over the left anterior iliac crest. Otherwise he had no point tenderness over his musculoskeletal system. Neck: Supple. No tenderness, no enlarged lymph nodes in the neck.
ASSESSMENT: Adenocarcinoma of the left breast, positive estrogen receptor status. Neck pain. (This is the definitive diagnosis that is reported.)
PLAN: The plan is to continue the Tamoxifen at this time. His laboratory studies were reviewed and were essentially unremarkable; however we'll obtain a bone scan to ascertain the extent of his disease.(This is a male patient.)
John Smith, M.D.
What diagnosis code(s) are reported?
PREOPERATIVE DIAGNOSES: Splenic abscesses and multiple intra-abdominal abscesses, related to HIV, AIDS, and hepatitis C.
POSTOPERATIVE DIAGNOSES: Splenic abscesses and multiple intra-abdominal abscesses, related to HIV, AIDS, and hepatitis C. (Postoperative diagnoses are reported.)
1. Exploratory laparotomy with drainage of multiple intra-abdominal abscesses.
3. Vac Pak closure.
FINDINGS: This is a 42-year-old man who was recently admitted to the medical service with a splenic defect and found to a splenic vein thrombosis. He was treated with antibiotics and anticoagulation. He returned and was admitted with a CT scan showing mass of left upper quadrant with abscesses surrounding both sides of the spleen(The location of the abscesses are on both sides of the spleen.), as well as, multiple other intra-abdominal abscesses below the left lobe of the liver in both lower quadrants and in the pelvis. The patient has a psychiatric illness and was difficult to consent and had been anticoagulated with an INR of 3. Once those issues were resolved by psychiatry consultation and phone consent from the patient's father, he was brought to the operating room.
OPERATIVE PROCEDURE: The patient was brought to operating room, a time-out procedure was performed. He was already receiving parenteral antibiotics. He was placed in the supine position and then given a general endotracheal anesthetic. Anesthesia started multiple IVs and an arterial line. A Foley catheter was sterilely inserted with some difficulty requiring a Coude catheter. After the abdomen was prepped and draped in the sterile fashion, a long midline incision was made through the skin. This was carried through the subcutaneous tissues and down through the midline fascia using the Bovie. The fascia was opened in the midline. The entire left upper quadrant was replaced with an abscess peel separate from the free peritoneal cavity. This was opened, and at least 3 to 4 L of foul smelling crankcase colored fluid were removed. Once the abscess cavity was completely opened, it was evident that the spleen was floating within this pus(Confirms the location of the abscess.) as had been predicted by the CT. This was irrigated copiously and the left lower quadrant subhepatic and pelvic abscesses (Location of abscesses.) were likewise discovered containing the same foul smelling dark bloody fluid. All of these areas were sucked out, irrigated, and the procedure repeated multiple times.
We thought it reasonable to go ahead with the splenectomy. The anatomic planes were obviously terribly distorted. There was no clear margin between stomach spleen, colon spleen, etc., but most of the dense attachments were to the abscess cavity peel. Using this as a guide, the spleen was eventually rotated up and out to the point where the upper attachments presumably where the short gastric used to reside were taken via Harmonic scalpel. The single fire of a 45 mm stapler with vascular load was taken across the lower pole followed by two firings of the echelon stapler across the hilum. This controlled most of the ongoing bleeding. Single bleeding site below the splenic artery was controlled with two stitches, one of 3-0 Prolene and the other of 4-0 Prolene. Because of diffuse ooze in the area and the fact that the patient would be scheduled for a return visit to the operating room tomorrow to reinspect the abscess cavities, it was elected to leave two laparotomy pads in the left upper quadrant and Vac Pak the abdomen. The Vac Pak was created using blue towels and Ioban dressings in the usual fashion with 10 mm fully perforated flat Jackson-Pratt drains brought out at the appropriate level. The patient was critical throughout the procedure and will be taken directly to the intensive care unit, intubated, with a plan for reexploration and removal of the packs tomorrow. The patient received four units of packed cells during the procedure, as well as albumin and a large volume of crystalloid. There were no intraoperative complications noted and the specimen sent included the spleen. Cultures from the abscess cavity were also taken.
What diagnosis code(s) are reported?
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)?
A) A41.9, R65.20, N17.9 (Sepsis with unknown etiology is primary, followed by required additional severe sepsis code, and followed by associated organ dysfunction code)
B) N17.9, R65.20, A41.9
C) R65.21, A41.9, N17.9
D) N17.9, R65.21, A41.01