Case 5
Inpatient Drug and Alcohol Facility Progress Note
I was called by the nurse to see this newly admitted patient. He is
having drug-induced tremor. At this time we have not determined his
drug of choice. He will be placed in the detox unit to be monitored
for 48 hours.
ICD-10-CM Code Assignment ....x........
Case 6
Sleep Clinic Assessment
This 59-year-old male completed a 14-hour sleep analysis. He was
able to sleep during the analysis.
He was found to have abnormal breathing during the testing period.
After analysis of all data, a diagnosis of primary central sleep
apnea is supported. The patient was instructed to make an
appointment to follow up on these findings in my office.
ICD-10-CM Code Assignment......x.......
Case 7
Clinic Note
This 13-year-old male presents to the clinic today because there
has been an increase in the frequency of his seizures. Vital Signs:
BP 115/ 75, weight 126 pounds, temperature 98.6.
HEENT: Normal
Lungs: Clear
Heart: Normal rate and rhythm
Abdomen: Non-distended, no splenomegaly or masses.
Extremities: Reflexes within normal limits.
I discussed with the patient's mother the need to adjust his
medications. She was instructed to increase the dose as per order.
I would like to see the patient in 4 weeks to follow up to see if
the epileptic simple partial seizures are continuing to
increase.
ICD-10-CM Code Assignment.......x........
5. G25.1 for drug induced tremor
6. G47.31 for primary central sleep apnea
7. G40.109 foe epileptic simple partial seizure
Case 5 Inpatient Drug and Alcohol Facility Progress Note I was called by the nurse to...
Case 1 Clinic Note This 57-year-old female patient comes to the clinic today for her annual physical. HEENT: Normal LUNGS: Clear ABDOMEN: Soft, nontender RECTAL EXAM: Refused NEUROLOGICAL: Congenital spastic paralysis, left leg There are no physical findings that need to be addressed at this time. I have reviewed her care plan, and she should continue per her care plan at the residential home where she resides. ICD-10-CM Code Assignment.....x........ Case 2 Sleep Clinic Note This patient returns today following...
Case 1 Clinic Note This 57-year-old female patient comes to the clinic today for her annual physical. HEENT: Normal LUNGS: Clear ABDOMEN: Soft, nontender RECTAL EXAM: Refused NEUROLOGICAL: Congenital spastic paralysis, left leg There are no physical findings that need to be addressed at this time. I have reviewed her care plan, and she should continue per her care plan at the residential home where she resides. ICD-10-CM Code Assignment.....x........ Case 2 Sleep Clinic Note This patient returns today following...
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Instructions: Review each case study and select the correct ICD-10-CM diagnostic code. "Please be aware that when an answer consists of more than one code, there will be an answer blank for each code." Case 6 Inpatient Progress Note This 74-year-old patient was admitted 3 days ago with symptoms of nausea, vomiting, and abdominal pain. Diagnostic testing confirmed botulism food poisoning. Nursing has been instructed to follow appropriate protocol documented by myself at the time of admission. ICD-10-CM Code Assignment……x…….....
Instructions: Review each case study and select the correct ICD-10-CM diagnostic code.no hand writing and answer all the cases Case 1 Emergency Department Note This 9-year-old male patient was brought to the ER by his mother. His left external ear is warm to touch, and it appears red and swollen. He has had a fever of 100 for the past 2 days. Upon otoscopic exam, the middle and inner ear are reviewed with no findings. There is definitely cellulitis of...
Instruc Instructions: Review each case study and select the correct ICD-10-CM diagnostic code. Please be aware that when an answer consists of more than one code, there will be an answer blank for each cod tions: Review each case study and select the correct ICD-10-CM diagnostic code. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code, NO hand writing and code all the cases Case 1 Office...
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Instructions: Review each case study and select the correct ICD-10-CM diagnostic code. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code. Case 1 Discharge Summary PATIENT NAME: Polly Patch AGE: 72 years old Polly was admitted from home because she passed out from dizziness. Her daughter called my office, and I admitted her to the medical unit because this is the third time in 2 weeks that...
instructions: Review each case study and select the correct ICD-10-CM diagnostic code. Do not assign place of occurrence, activity code, or external cause status code unless instructed to do so for the case. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code. I need the code not the category Case 1 Emergency Department Note Justin was brought to the emergency room with a broken left tibia. Justin...