Question

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 the inferior vena cava.
He has been asymptomatic. The stenosis was first noticed when he underwent a chest x-ray to evaluate a possible injury after a chest trauma 1 year ago. He also had an ultrasound completed that confirmed the diagnosis.
Vital signs: B/P: 120-80. Temperature: 98.6. Weight: 155 pounds.
ECG: Taken today is normal
HEENT: Normal
Lungs: Clear
Heart: Normal rate and rhythm.
Abdomen: Soft, no masses noted.
Extremities: Reflexes within normal limits. There is no evidence of varicose veins or other abnormalities at this time.
Plan: It was explained to the patient and his parents that many patients with stenosis of the inferior vena cava develop chronic venous insufficiency and deep vein thrombosis. Because of this I am scheduling the patient for compression ultrasonography with color Doppler assessments and helical computer tomography. The findings from this test will determine if additional imaging is necessary and if the patient needs to be placed on any anticoagulant therapy or other medications or therapy regimen.
The patient will return to my office after completion of the testing.

What is the correct ICD-10-CM diagnostic code(s) for this case?...……X………...

Physician Office Hematology Note:
This 63-year-old white male presents today to review laboratory findings. He cut his hand 3 weeks ago, and the wound bled for a considerable amount of time. He was referred to me from this primary care provider. Blood work was ordered at that time.
Laboratory Findings:
Abnormal prothrombin time
Allergies:
The patient has no known allergies.
Review of Systems:
This patient was treated 5 years ago for anemia.
Physical Examination:
HEENT: No findings
Heart: RSR without murmur
Neck: Supple
Extremities: The wound has healed.
Lungs: Clear
Abdomen: Soft and nontender
Assessment and Plan:
This patient has an abnormal prothrombin time that needs to be investigated further.
I am ordering additional testing to rule out vitamin K deficiency. Patient will be scheduled for follow-up after testing results are obtained.

What is the correct ICD-10-CM diagnostic code(s) for this case? .......X..........,.X.............

Physician Office Note:
This 15-year-old female patient was playing softball and attempted to catch a ball and fell on her right shoulder 2 days ago. She then presented to the emergency room and an x-ray was obtained; at that time the x-ray showed no fractures. She was referred to me for follow-up.
Patient History:
There is no significant medical history for this patient.
Physical Examination:
HEENT: Normal
Heart: Within normal limits
Extremities: The right shoulder is painful to touch, and there is limited mobility at this time. There are no other findings noted.
Skin: There are no breaks in the skin at the sight of the right injury. There are no other findings.
Assessment:
Diagnosis: Right shoulder sprain and pain
Plan:
This patient should continue to ice the shoulder and rest the shoulder for the next 5 to 6 days. She was instructed not to play softball at this time.

What is the correct ICD-10-CM diagnostic code(s) for this case?......X............

Answer 1

Answer: ICD 10 CM codes are the international classification of diseases system which is mainly used by the healthcare professionals to classify the diagnosis procedures and symptoms for the reimbursement purpose.

The ICD 10 CM codes are:

• Respiratory distress syndrome, type 2 - J80
• Stenosis of inferior vena cava - Q26. 0,
• Deep vein thrombosis - I82. 40
• Vitamin K deficiency - E56. 1
• Abnormal prothrombin time - R 79.1
• Right shoulder sprain and pain - S43. 401A