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 sleep testing completed last
week. The testing revealed abnormal sleep patterns. I discussed
with the patient if she is experiencing any stress or anxiety. She
denies both.
She also stated that she does not want to take any sleep-aid
medications at this time. I referred her to the educator at this
clinic to discuss treatment options other than medications. She
should return in 1 month.
DIAGNOSIS: Delayed sleep phase syndrome
ICD-10-CM Code Assignment .......x........
Case 3
Office Note
This 49-year-old secretary is being seen today for pain that is
present in her right hand. She has had a series of imaging that
showed no fractures or other abnormalities.
Upon exam she has weakness and pain, and she complains of
disturbances of sensations in her right hand.
DIAGNOSIS: carpal tunnel syndrome
ICD-10-CM Code Assignment .......x.......
Case 4
This 39-year-old male presents today because of pain in his right
leg that occurs at night. He describes this as a cramping feeling.
He states that he has not injured his leg in the past or in the
recurrent days.
EXAM:
HEENT: Normal
LUNGS: Clear
EXTREMITIES: Normal to touch and neurological testing
I instructed him to heat his leg prior to going to bed and offered
to give him a referral to PT at this time. He stated he wanted to
try the at-home treatment first. Since this is only occurring at
night when sleeping, I feel that this is sleep-related leg
cramps.
ICD-10-CM Code Assignment.......x........
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........
Case 8
Discharge Note
Mary Smith, a 43-year-old, is being discharged home today following
her admission 3 days ago. At the time of admission she was
experiencing a severe headache. After diagnostic testing, it was
confirmed that she had a persistent migraine, with aura with
cerebral infarction with refractory migraine and status
migrainosus. She is to follow up with me in my office in 2
weeks.
ICD-10-CM Code Assignment......x........
Case 9
Office Note
This 84-year-old male patient is seen today to follow up on the
results of various tests to determine the cause of the pain he
experiences on the left side of his face. Diagnostic findings from
testing have been nonconclusive. At this time there is no
underlying reason for the atypical facial pain. He was given
Vicodin and instructed to take when pain level is over 5. If other
symptoms occur, he was instructed to call the office or go to the
emergency room.
ICD-10-CM Code Assignment......x..........
Case 10
Inpatient Admission Note
This 73-year-old female is being admitted today because she has
ovarian cancer and she continues to experience pain. She has
refused all treatment for the cancer. The pain is very acute at the
present time and she is admitted for IV pain management. Nurses
were advised to follow pain management protocols.
ICD-10-CM Code Assignment......x........,....x.......
Case 1 Clinic Note This 57-year-old female patient comes to the clinic today for her annual...
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 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...
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...
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.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...
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…….....
Inpatient Physician’s Progress Note This 2-day-old infant examined today to follow-up after the results of diagnostic tests. Blood gas: Study indicates reduced oxygen tension and ineffective gas exchange. Chest X-ray: presence of infiltrate Infant continues to exhibit signs of infant respiratory distress syndrome, type 2. Orders: Continue titrated oxygen and aerosol infusion of Survanta. What is the correct ICD-10-CM diagnostic code(s) for this case? .......X.......... Physician Office Note This 15-year-old male patient presents today to monitor his congenital stenosis of...
Office Note This 78-year-old male returns to the office today to follow-up on diagnostic testing completed due to his ongoing muscle aches, myalgia, stiffness, and muscle weakness. Laboratory testing: Urinalysis was positive for hemoglobin. The urine myoglobin test and serum myoglobin test were both positive. The serum CPK value was high. Following these values additional testing was completed that confirmed elevated muscle enzymes in the blood. Because of these findings a diagnosis of rhabdomyolsis was confirmed. Plan: I discussed with...
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...
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 Emergency Department Visit A 59-year-old male presented to the ED with dyspnea on exertion, fevers, and cough. A routine chest x-ray was completed to rule out pneumonia. The x-ray revealed a mass in the left lung. The patient was instructed to follow up with...