Case 3 Counseling Note This family of five presents today to discuss the eldest son's addiction to cocaine. The patient states that he has been a user for 3 years and the addictive behaviors have increased over the last 3 months. He has been treated for the last 2 months on an outpatient basis due to his cocaine addiction. The parents want to discuss inpatient treatment. I spent 1 hour with the family discussing the best options for the patient and educating them about substance abuse. ICD-10-PCS Code Assignment:
Character-1 section, The first character is always Have.
Character -2, BodySystem-Assign value Z, None for sll procedures.
Character -3, Root type There are 7root type values which include
Character 4
Each of the root types referred to above have 12 or 13 different specific types of services associated with them ,with the exception of detoxification and family counseling.
ICD 10PCS code are HZ63ZZZ
Case 3 Counseling Note This family of five presents today to discuss the eldest son's addiction...
Case 5 Outpatient Counseling Note This 39-year-old male patient presents today due to ongoing treatment for alcohol addiction using a 12-step approach. He has made significant gains in identifying situations that trigger addictive cravings and techniques to prevent relapse. He has not used in 30 days and is encouraged to attend daily AA meetings and to see me in 4 days. What would be the ICD 10 PCS code
Case 2 Counseling Note This is a 68-year-old female who is being seen today because she feels “tired and very depressed.” She states that she has lost her appetite for the past month and has not been able to sleep well. Her medical doctor requested she see a counselor so that we can do some counseling, see if we can get her back on track, and make life more pleasurable for her again. At this time, she denies any substance...
Case 1 PATIENT: Tom Smith DATE OF SERVICE: 9/10/XX BLOOD PRESSURE: 140/90 WEIGHT: 164 PULSE: Rapid TEMPERATURE: 100 Tom was seen today at the request of his wife for what she suspects is a recurrence of his cocaine dependence. On physical examination, the following was noted: EARS, EYES, NOSE, AND THROAT: Pupils are dilated. HEART: Heart rate is increased; blood pressure is 140/90. ABDOMEN: Soft, nontender, no abnormal masses PSYCHIATRIC: Oriented to time and place. Patient is very talkative and...
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...
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...
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 Physician Office Visit This 39-year-old female recently underwent GYN surgery and now is experiencing sleeplessness, headache, and lack of concentration. Her physical exam is negative. Diagnostic workup concludes ovarian failure. I am referring her to a specialist. Diagnosis: symptomatic postprocedural ovarian failure. ICD-10-CM Code...
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...
Instructions: Review each case study and select the correct ICD-10-CM diagnostic code.no hand writing and answer all the cases Case 1 Emergency Department Note This 9-year-old male patient was brought to the ER by his mother. His left external ear is warm to touch, and it appears red and swollen. He has had a fever of 100 for the past 2 days. Upon otoscopic exam, the middle and inner ear are reviewed with no findings. There is definitely cellulitis of...
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 Physician Office Note 4/25/XX Weight: 154 pounds, decrease from 2 weeks ago; weight then was 160. CHIEF COMPLAINT: loss of weight, here for follow-up from breast biopsy. Sally was seen 2 weeks ago, and I palpated a mass in her left breast. She was...
Case Study #1: Brittany’s Baby Brittany is 20 years old, and can’t wait until her 21st birthday so she can drink legally (even though she plays drinking games regularly with her friends at house parties). She works as a patient care technician at a local hospital and plans to go to nursing school once she saves enough money. She presents in your clinic with nausea/vomiting and fatigue that has been going on for about 5 days. She weighs 155# at...