Question

Assume you are a coding supervisor who is reviewing the coding of one of your coders. You have just reviewed a case of a 17-year-old male patient who injured his left knee when playing football. The patient was struck in the knee by another player’s helmet while playing at a Varsity football game.

What is the correct external cause code for injury due to striking against the helmet, initial encounter?...X…...

What is the correct place of occurrence code for this case? ........X.........

What is the correct activity code for this case?...……X…….

Office Visit Note
This 13-week pregnant patient is being seen today for supervision of her first pregnancy.
She states that she feels well and has no complaints or symptoms of complications at this time.
Weight from last visit was 130 pounds.
Vital signs: B/P: 130/80. Temperature: 98.8. Weight on this visit is 132 pounds.
Lungs: Clear
Abdomen: Measurement change is minimal from last visit.
Fetal heart rate: A fetal Doppler was used to listen to the fetal heart rate which is within normal limits.

What is the correct diagnostic code(s) for this case?...…X………. ,...……X…….

This is a 28-year-old patient who presents today expressing anxiety over the fact that his father was just diagnosed with Crohn's disease. His father is 60 years old and has had GI problems for many years. The patient says that he is experiencing some of the same problems his father had prior to this diagnosis, and he would like a complete physical exam to rule out Crohn's disease. A complete physical was performed with no abnormal findings.
ICD-10-CM Code Assignment:...…X………. , ........X......…….

Discharge Note
This 4-day-old infant is being discharged today following a normal delivery. The child did experience noninfectious diarrhea for the last 2 days that has now stabilized. I instructed the mother to supplement her breast feeding with Pedialyte and to call me if the diarrhea increases.
ICD-10-CM Coding Assignment:...…X…….. , ........X......

Discharge Note
This 7-pound, 2-ounce female infant was born 4 days ago and there were no complications during the delivery. The following day the child appeared jaundice and a diagnosis of hyperbilirubinemia was made. She was given phototherapy. She is now stabilized and she is being discharged with no other complications.
ICD-10-CM Code Assignment: ……X……….., .....X...........

Hospital Visit Note
The patient is a newborn infant male, born 2 hours ago to a mother who was experiencing severe hypertension prior to her pregnancy. The mother was being monitored closely for this condition during her current pregnancy because she had difficulty during her last one. It appears now that this baby boy is experiencing some respiratory distress due to the maternal hypertension. Pulse ox reading was 70, and his respirations were elevated. His vital signs at this time are all within normal limits since we started the oxygen. His pulse ox reading is now at 98. He will be monitored until such time as there is no need for the oxygen and his vital signs remain normal.
ICD-10-CM Code Assignment:...…X…….. , ........X.........

Discharge Summary
The patient was discharged in stable condition on 1/20/XX. She is to continue on breast milk and can be supplemented with Similac with iron.
This patient is the product of a full-term gestation. The Apgars were 9 and 10. Birth weight was 6 pounds 10 ounces. Physical examination shortly after birth was negative. The infant's temperature was elevated, and urinalysis revealed a urinary tract infection. The plan was to observe the patient. Antibiotic therapy was started.
She had no difficulty nursing and ate well while she was in the hospital. She had no problems with her bowel movements. On the day of discharge, the patient's weight was down 3 ounces from birth. She will be seen in my office in 7 days.
ICD-10-CM Code Assignment:..........X............,......X....

Answer 1

The correct external cause code for injury due to striking against the helmet, initial encounter is W21 that explains striking against or struck by sport equipment. It mainly describes circumstances causing an injury and it does not indicates nature of the injury. The correct place of occurrence code for this case is Y92.321 here Y92 codes explain the place of occurrence of the external cause. The code Y92.321 describes that the external cause of injury happened in a foot ball field. The correct activity code for this case is Y93.61 that describes injury caused while tackling football. Y 93 describes activity codes when the external cause of injury occurs.

Pregnancy includes three trimesters , first trimester ranges from 0 to 13 weeks, second trimester (14-26 weeks) , third trimester (27-40 weeks). In the given scenario women encounter for supervision of her first pregnancy, the ICD 10 CM code is Z34.91 , Encounter for supervision of normal pregnancy,unspecified,first trimester.

Crohn's disease is also referred as Inflammatory bowel disease. It occurs due to autoimmune disorders that involves in destruction of bowel. It also occurs on hereditary basis transmitting from one generation to other. Increasing age,family history,cigarette smoking, use of NSAIDS, excess alcohol consumption triggers IBD. In the given case study the son came for an encounter to screen for crowns disease as his father diagnosed with same disease. The ICD 10 CM code is Z12.11 , Encounter for screening for malignant neoplasm of colon.