Question

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.......

Answer 1

Answer: ICD 10 CM codes are used for coding the diagnosis and the for the reimbursement purpose.

ICD-10cm Code G8012 Dicegnosas 1) Cogneital Spastic farai лis, lapt ) 2) Delayed sleep phase - G47.21 syndrome G56.01 3) Carpal tunnel syndrome 4) Sleop Related leg cromps. 347.62