Question

Case 1 PATIENT: Tom Smith DATE OF SERVICE: 9/10/XX BLOOD PRESSURE: 140/90 WEIGHT: 164 PULSE: Rapid TEMPERATURE: 100 Tom was seen today at the request of his wife for what she suspects is a recurrence of his cocaine dependence. On physical examination, the following was noted: EARS, EYES, NOSE, AND THROAT: Pupils are dilated. HEART: Heart rate is increased; blood pressure is 140/90. ABDOMEN: Soft, nontender, no abnormal masses PSYCHIATRIC: Oriented to time and place. Patient is very talkative and admits to not eating for the last 36 hours with no sleep for the last 48 hours. The lack of sleep is cocaine induced. Patient admits to using cocaine over the last month and recent days. Referral made for inpatient treatment. ICD-10-CM Code Assignment.......x.......... Case 2 Nursing Facility Note of 2/7/XX Sally Andover was admitted on 2/5/XX because of her medical conditions and her inability to care for herself at home. She was mildly cooperative throughout the exam. However, her dementia makes her obviously confused, and she has a diagnosis of senile dementia. Her medications were reviewed. Her full medical history and physical was completed 2/5/XX by Dr. Jones. HEENT: Normal LUNGS: Clear ABDOMEN: Soft, nontender; active bowel sound; no masses noted HEART: Regular rhythm without murmurs, pulses normal TEMPERATURE: 98.8 BLOOD PRESSURE: 125/85 PULSE: Regular Medication orders written. ICD-10-CM Code Assignment.......x....... Case 3 Psychiatric Office Note Terry was seen today experiencing symptoms of mania, speech disturbances, and lack of sleep for 3 days due to his bipolar disorder. Patient states that he has not been taking his medications. I discussed with the patient the importance of taking his medications and instructed him to regularly take them. Current issues that create stress for the patient were discussed, including marital distress and financial issues. Patient was instructed to follow up at 1 month due to this current manic bipolar episode. ICD-10-CM Code Assignment: Case 4 Emergency Department Note PATIENT: Samantha Hill DATE OF SERVICE: 12/31/XX AGE: 23 Samantha was brought in by ambulance. She was at a New Year's Eve's party, and she had been drinking alcohol for 4 hours and passed out. According to her friend who accompanied her to the ER, Mary does not have an alcohol addiction and has no known medical conditions. Physical Exam: Pupils are dilated. HEART: Heart rate is decreased. ABDOMEN: No abnormal findings Patient has limited response to questions. While she was in the emergency room, she started to vomit. She was observed for 7 hours and then sent home. She was advised to seek counseling for possible alcohol addiction. DIAGNOSIS: Alcohol use with intoxication ICD-10-CM Code Assignment.....x......... , .....x.........

Case 5
Physician's Office Note
NAME: John Nown DATE OF SERVICE: 3/1/XX
BLOOD PRESSURE: 130/83 WEIGHT: 168 TEMPERATURE: 98.6
John is being seen today at his request because he has felt tired and has lost his appetite for the last 3 weeks since his wife died. He has no other complaints at this time.
He said he wants to make sure that he has no physical problems. Reviewing his record, I noted that all of his immunizations are current and that he is not due for any additional preventative medicine testing at this time.
Physical Exam:
HEENT: Within normal limits
HEART: Normal R&R, no murmurs
ABDOMEN: Soft and nontender, no masses; active bowel sounds
EXTREMITIES: Within normal limits
Patient is oriented to time, person, and surroundings with no confusion. Patient expressed that he is sad because of the loss of his wife. I told the patient that his tiredness is most likely due to the loss of his wife and that there are no abnormal physical findings at this time.
DIAGNOSIS: Adjustment disorder with depressed mood.
PLAN: Patient refused antidepressive medications and said he would seek counseling if he felt he needed it. He was instructed to call the office if he experienced any other symptoms and said he wanted to follow up with me in 3 weeks.
ICD-10-CM Code Assignment.....x.....

Case 6
Office Visit
This 39-year-old male patient is being seen today to follow up on his treatment for bouts of decreased need for sleep, optimism, and marked hyperactivity and talkativeness. He states that these have decreased over the last month since he has been regularly taking his medications. I instructed him to continue on meds as prescribed and to follow up with me in 2 months, or sooner if symptoms increase. Assessment: Ongoing hypomania
ICD-10-CM Code Assignment.......x........

Case 7 Emergency Department Note The 48-year-old woman is brought to the ED today by her mother. This patient is profoundly retarded, which is complicating the examination. Mother states that the patient has had bouts of hypoglycemia and she is not eating well today. The patient has been very "low on energy" per mother. Vital signs: B/P: 120/85, Temperature: 100.1, Weight: 160 pounds HEENT: Normal Abdomen: Soft, nontender. No masses noted. Lungs: Clear Blood sugar was taken and found to be 45. Patient was started on IV. Blood sugar was then again taken and rose to 90. Patient's mother was given information about hypoglycemia and instructed to follow up with the patient's primary care provider as soon as possible. ICD-10-CM Code Assignment .....x.........,......x........ Case 8 Outpatient Addiction Clinic Note This 48-year-old male presents today at the clinic and appears to be intoxicated. He states that he has been treated numerous times for his addiction to alcohol and needs to be seen today. Review of his records indicates alcohol dependence. His blood alcohol level is currently 125 mg/100 ml. He was seen by the crisis team and they determined that he needs to have further treatment. This was discussed with the patient and he agreed to be transferred to an inpatient facility for detox and admission. ICD-10-CM Code Assignment:.......x...... , .......x....... Case 9 Discharge Note This 59-year-old male patient is being discharged today following a 34-day length of stay due to his latent schizophrenia. The details of his treatment can be found in the treatment plan. He has been making steady progress throughout his stay. He will continue to be monitored by outpatient services. ICD-10-CM Coding Assignment......x..... Case 10 Admission Note This 63-year-old female is being admitted to rehab for opioid use. Laboratory testing confirmed opioid use. At this time she is exhibiting perceptual disturbances due to the opioid intoxication. She is to be admitted for further evaluation. ICD-10-CM Coding Assignment..........

Answer 1

Case 1:

ICD 10-CM Code:

• F14.220- Cocaine dependence with intoxication, uncomplicated.
• F14.282- Cocaine dependence with cocaine induced sleep disorder.

Case 2:

ICD 10-CM Code:

F03.90- Unspecified dementia without behavioral disturbance.

Case 3:

ICD 10-CM Code:

F31.10- Bipolar disorder, current episode manic without psychotic features, unspecified.

Case 4:

ICD 10-CM Code:

• F10.129- Alcohol abuse with intoxication, unspecified
• F10.229- Alcohol dependence with intoxication, unspecified

Case 5:

ICD 10-CM Code:

F43.21- Adjustment disorder with depressed mood.

Case 6:

ICD 10-CM Code:

F30.3- Manic episode in partial remission.

Case 7:

E16.2- Hypoglycemia, unspecified.

Case 8:

• F10.229- Alcohol dependence with intoxication, unspecified
• Z71.41: Alcohol abuse counselling and surveillance of alcoholic

Case 9:

F20.9: Schizophrenia, unspecified

Case 10:

F11.159- Opioid abuse with opioid-induced psychotic disorder, unspecified.