Question

Instructions Assign ICD-10-CM codes to the following diagnostic statements. When multiple codes are assigned, make sure you sequence them properly according to coding conventions and guidelines, including the definition of first listed diagnosis. Refer to the diagnostic coding and reporting guidelines for outpatient services in your textbook when assigning codes 1. Fever, difficulty swallowing, acute tonsillitis 2. Chest pain, rule out arteriosclerotic heart disease Hypertension, acute bronchitis, family history of lung cancer Lipoma, subcutaneous tissue of left thigh Audible wheezing, acute exacerbation of asthma Routine annual gynecological visit and exam with Pap smear Laceration of right forearm, severe pain of the left ankle and left wrist, possible left ankle fracture, possible left wrist fracture Pregnancy visit (normal female at 16 weeks, first pregnancy) Renal calculi with hematuria Encounter for occupational therapy, aphasia due to previous cerebrovascular accident 11 Fever, throat pain, acute otitis media, rule out thrush, hemangioma of skin of the face 12 Epstein-Barr mononucleosis 13. Severe nausea and vomiting, gastroenteritis due to salmonella food poisoning 14. Congestive heart failure with bilateral leg edema 15. Elevated fasting blood glucose level of 145 mg/dL 16. Gastroesophageal reflux disease 17. Severe headache, stuffy nose, allergic sinusitis 18. Epigastric abdominal pain, fever, vomiting, tachycardia, acute pancreatitis, cellulitis of right finger 19. Pyogenic arthritis of right knee due to H. Influenzae 20. Acute pericarditis due to tuberculosis

Answer 1

J03.90 1. Fever, difficulty in swallowing, acute tonsilitis.

Rationale: Acute tonsilitis is the principal diagnosis. Tonsilitis caused by virus or bacteria. Fever and difficulty in swallowing are the signs and symptoms of tonsilitis.

R07.9   2. Chest pain, rule out arterosclerotic disease.

Rationale:  In this, chest pain is the principal diagnosis and they are suspecting of arteriosclerotic disease but yet to confirmed. Chest pain was unspecified of the exact location. so it coded as R07.9

I10; J20.9; Z80.1   3. Hypertension, acute bronchitis, family history of lung cancer

Rationale: Hypertension, acute bronchitis, and family history of lung cancer all are considered as the principal diagnosis, So the coding must include all these three conditions.

D17.4   4. Lipoma, subcutaneous tissue of the left thigh.

Rationale:  Neoplasm of the subcutaneous tissue that benign on the left leg. So it is coded as D17.4

J45.901 5. Audible wheezing, acute exacerbation of asthma.

Rationale: The principal diagnosis is an acute exacerbation of asthma and as a result of this wheezing is audible.

Z01.419   6. Routine annual gynecological visit and exam with Pap smear.

Rationale: It is the routine gynecological examination and findings were not reported. So it is coded for a routine examination.

S51.811A; M25.572; M25.532   7. Laceration of the right forearm. Pain left ankle and left wrist. Possible left ankle fracture. Possible left wrist fracture.

Rationale: Laceration and pain in left ankle and wrist are the principal diagnoses. There is a chance of left ankle fracture and left wrist fracture but not confirmed. So it should be included in the coding report.

Z34.02   8. Pregnancy visit (normal female at second trimester, first pregnancy)

Rationale: The pregnant came for routine pregnancy visit of first pregnancy and it mentioned as second trimester. So according to the guidelines it is coded as specified.

N20.0 9. Renal calculi with hematuria.

Rationale: Calculus of the kidney is the principal diagnosis. Blood with urine has occurred due to the calculi. So the kidney calculi is the principal diagnosis.

Z93.3   10. Status post colostomy

Rationale: It defines post colostomy status. So it is coded for that as per guidelines.