Question

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
S: A 55-year-old male presents today with severe abdominal pain, nausea, and vomiting, persistent over the last 24 hours. Diarrhea has developed, and abdominal cramping is also present. The patient states that he cannot keep anything down. Upon questioning, he states that he attended a neighborhood clambake and ate at least a dozen raw clams. No over-the-counter (OTC) medications were tried because the patient cannot keep anything down.
O: Pleasant, alert gentleman who appears in mild discomfort. Vital signs: Temp—99, pulse—70, resp—22, BP—120/75. Skin: Warm and clammy.
HEENT: Unremarkable except for dryness around conjunctiva and the mouth. The patient appears slightly dehydrated.
Neck: No JVD; no thyromegaly or bruits.
Lungs: Clear to auscultation and percussion.
Heart: No murmurs.
Extremities: No edema.
A: Food poisoning due to salmonella
P: Will order a suppository to help with the nausea. Stressed the importance of forcing fluids once the suppository has had time to work. The patient will call in the morning if he does not feel better. If he is improving, he will follow up as needed.
ICD-10-CM Code Assignment………x…….

Case 2
S: A 19-year-old woman presents today with slight fever, cough, and fatigue for 4 days. OTC medications were tried with little relief. No other family members are symptomatic. No nausea or vomiting, no shortness of breath.
O: Vital Signs: Temp—98.7, BP—100/72; Skin: warm and dry; HEENT: TM's normal; throat is slightly red; Neck: normal; Lungs: clear; Heart: RRR.
A: Viral Infection
P: I explained to the patient that I think this is a viral infection and could have come on in a variety of different ways. I suggested Advil for comfort and plenty of fluids. The patient requested an antibiotic. I explained that since this infection was viral in nature, an antibiotic would not be effective. She said she would try the Advil and notify us if she does not improve in 7–10 days.
ICD-10-CM Code Assignment……x………..

Case 3
S: This is a 29-year-old female who presents today with fever and nausea for 3 days. The patient has tried over-the-counter cold and flu medicine with no results. No other family members are ill at this time. Temp. has been running between 99 and 102°F. When asked about any other symptoms, the patient states that she "feels like my heart is racing sometimes." The patient has not voided in 2 days.
O: Respirations: 31; Pulse: 100; BP: 150/90. She is alert, oriented, and in no acute distress.
Lungs: Clear, no rhonci or wheezing.
HEENT: WNL.
Skin: Clammy to touch.
Heart: RRR with no murmurs.
Abdomen: Soft and nontender.
Extremities: Ankle edema +12.
A: Staphylococcus septicemia
P: The patient is admitted to the hospital and will follow staphylococcus septicemia protocol.
ICD-10-CM Code Assignment………x………

Case 4
Dr. Malik had just returned from a trip to overseas. He was providing free medical care to the people of a small village in a very desolate region of central Africa. Upon his return, he suddenly developed a severe headache, pain in his joints and back, and an extremely high fever. After extensive testing, combined with the fact that he had just returned from overseas, it was determined that Dr. Malik had contracted African tick typhus.
ICD-10-CM Code Assignment……x………

Case 5
Kaley presented today with an unsightly sore on the lower lip and onto the skin. The patient said this is extremely painful and occurs usually around the time of her period. After a brief examination, Dr. Snyder diagnosed Kaley with herpes simplex, at which time he prescribed medication that will help relieve her symptoms.
ICD-10-CM Code Assignment……x……..

Answer 1

Case 1

A02.9 - Salmonella infection

Case 2

B34.9 - Viral infection

Case 3

A41.2 - Staphlococcal septicemia

Case 4

A77.1 - African tick typhus

Case 5

B00.9 - Herpes simplex infection