1.Inpatient admission: The patient has a known diagnosis of prostatic cancer. He started having fevers approximately one week earlier. The fevers did not respond to outpatient antibiotics. Blood and urine cultures showed no growth. He was admitted for workup of the fevers with possible prostatic abscess formation. There were no obvious signs of infection or abscess on a transrectal ultrasound of the prostate. An iodine-123 radioisotope bone scan of the body revealed no skeletal metastases. The antibiotic therapy was changed, and he was given an IV push. He improved and was discharged. Discharge Diagnoses: (1) Fever of unknown origin, (2) cancer of the prostate
2. Inpatient Admission: This HIV-positive patient was admitted with skin lesions on the chest and back. Biopsies were taken, and the pathologic diagnosis was Kaposi’s sarcome. Leukoplakia of the lips and splenomegaly were also noted on physical examination. Discharge Diagnoses: (1) HIV Infection; (2) Kaposi’s sarcoma, back and chest; (3) Leukoplakia; (4) splenomegaly
Need assistance in assigning correct ICD 10 Codes
ICD- 10 codes. (International Classification of Disease).
It is a diagnosis code, required for covered by the health
insurance portability Accountability Act (HIPAA) which includes
doctors, hospitals and health insurance compares these codes need
for diagnosing patients and billing for the services.
Discharge diagnosis:
1, 1, Fever of unknown origin R50.0
2, Cancer of the prostate C61
2, 1, HIV infection
Human Immuno Deficiency Virus B20
2, Kaposi's sarcoma
Kaposi's sarcoma skin (multiple site) C46.0
3, Leukoplakia (lips) K31.21
4, splenomegaly R16.1
1.Inpatient admission: The patient has a known diagnosis of prostatic cancer. He started having fevers approximately...
The patient has a known diagnosis of prostatic cancer. He started having fevers approximately one week earlier. The fevers did not respond to outpatient antibiotics. Blood and urine cultures showed no growth. He was admitted for workup of the fevers with possible prostatic abscess formation. There were no obvious signs of infection or abscess on a transrectal ultrasound of the prostate. An iodine-123 radioisotope bone scan of the body revealed no skeletal metastases. The antibiotic therapy was changed, and he...
1. Inpatient admission: The patient was admitted with possible pyelonephritis; Her complaints were bilateral flank pain and chills. A contrast intravenous pyelogram was normal. Within two days of admission, the character of her pain changed somewhat in that it became primarily in the right upper quadrant. The physician documented in the progress notes that significant features of conversion hysteria were present and accounted for the patient's symptoms. On the third hospital day, the patient's IV was discontinued, lover function tests...
An HIV positive patient was admitted with skin lesions on the chest and back. Biopsies were taken, and the pathologic diagnosis was Kaposi’s sarcoma. Leukoplakia of the lips and splenomegaly were also noted on physical examination. Discharge diagnoses: (1) HIV infection, (2) Kaposi’s sarcoma, back and chest, (3) leukoplakia (4) splenomegaly. What ICD-10-CM codes should be reported? Provide the 2 procedure codes Principal Procedure Secondary Procedure
An HIV positive patient was admitted with skin lesions on the chest and back. Biopsies were taken, and the pathologic diagnosis was Kaposi’s sarcoma. Leukoplakia of the lips and splenomegaly were also noted on physical examination. Discharge diagnoses: (1) HIV infection, (2) Kaposi’s sarcoma, back and chest, (3) leukoplakia (4) splenomegaly. What ICD-10-CM codes should be reported? Provide the codes below. (HINT: There are 4 diagnoses codes and 2 procedure codes.) Fill in the following information: Principal Diagnosis Secondary Diagnosis Secondary...
Inpatient admission: The patient, an obese male, was admitted with generalized abdominal pain suggestive of early appendiciis, although he had a normal white count and normal differential. An intravenous pyelogram and X-ray of the lower gastrointestinal tract with barium enema were negative. All laboratory studies were normal. He improved while in the hospital without a definite cause for his pain ever being identified. He was placed on a low-fat, 1,500-calorie diet prior to discharge. Discharge diagnoses: (1) Abdominal pain of...
#2 Neoplasms (4 diagnoses code and 1 procedure code) A 63-year-old male patient, known to have emphysema, was advised by his physician to be admitted to the hospital to evaluate and treat his worsening lung condition. The patient quit smoking cigars five years ago, after he was told he had emphysema. The patient complained that his coughing and wheezing had become worse and his sputum was streaked with blood. A chest x-ray done on an outpatient basis the previous week...
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...
Case 1-2 LOCATION: Inpatient, Hospital PATIENT: Sorrento Hernandez PHYSICIAN: Rolando Ortez, MD CHIEF COMPLAINT: Prematurity with respiratory difficulty. HISTORY: This is a 30 weeks, 1 day gestation female infant with birth weight of 1808 grams. Mom is a 26-year-old gravida 2, now para 2 mom. Her blood type is O positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, HIV negative, GC negative, chlamydia negative, Group B Strep status unknown. Mom’s MSAFP was elevated at 14.2 with...
Clinical Scenario: REASON FOR CONSULTATION: Desaturation to 64% on room air 1 hour ago with associated shortness of breath. HISTORY OF PRESENT ILLNESS: Mrs. X is 73-year-old Caucasian female who was admitted to the general surgery service 3 days ago for a leaking j-tube which was surgically replaced 2 days ago and is now working properly. This morning at 07:30, the RN reported that the patient was sleeping and doing fine, then the CNA made rounds at 0900 and Mrs....