Question

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
Discharge Summary
PATIENT NAME: Polly Patch
AGE: 72 years old
Polly was admitted from home because she passed out from dizziness. Her daughter called my office, and I admitted her to the medical unit because this is the third time in 2 weeks that she passed out.
On initial examination she was conscious and alert and appeared pale. Physical findings can be found on the history and physical dated 02/13/XX.
CBC, chest x-ray, and EKG were ordered.
CBC revealed a low platelet count of 53,000, supporting a diagnosis of idiopathic thrombocytopenia. Chest x-ray and EKG were normal.
The rest of her 2-day admission was uneventful, and she was discharged home. She was instructed to follow up in my office in 2 weeks or to call my office if her symptoms increase.
ICD-10-CM Code Assignment...........

Case 2
Hospital Note: 3/4/xx
Bob was admitted on Monday with a diagnosis of anemia associated with a primary malignancy of the prostate. Today I ordered a blood transfusion due to his low blood count. CBC is to be repeated after the transfusion. I instructed the charge nurse to call me with the results.
ICD-10-CM Code Assignment......x........ , ......x.......

Case 3
Postsurgical Note
Mary is now 1-day postop for a right breast mass excision. During the surgery she lost a significant amount of blood due to uncontrolled bleeding. A CBC was ordered that showed an abnormally low hematocrit and hemoglobin confirming anemia due to blood loss. She was given a transfusion and has tolerated the transfusion well.
ICD-10-CM Code Assignment.............

Case 4
Office Note
This 6-year-old female was suffering from abdominal pain and was complaining of being tired when she presented to my office 2 days ago. She returns with her mother today because testing confirmed a diagnosis of pernicious anemia. Today she will be started on Vitamin B₁₂ injections and will follow up with me in 2 weeks or if symptoms increase.
ICD-10-CM Code Assignment...............
Case 5
Office Note
This female patient was feeling very weak and lethargic over the last month. She was also suffering from pain in her major joints. Testing confirmed sickle-cell anemia. She is here today to discuss this disease.
ICD-10-CM Code Assignment..........

Case 6
Skilled Nursing Facility Note
This 73-year-old male patient was seen today at the request of the nursing staff. He is experiencing a purple spotted skin rash, abdominal pain, and joint inflammation. He recently had a respiratory bacterial infection, which has cleared. He is also complaining of a headache and loss of appetite.
Assessment: All symptoms support a diagnosis of allergic purpura.
Plan: The patient is to be given Tylenol for pain and Prednisone to relieve GI symptoms.
ICD-10-CM Code Assignment...............

Case 7
Discharge Note
This 39-year-old male patient is being discharged today following a splenectomy. The splenectomy was completed because the patient had hypersplenism, which could not be treated by other more conservative measures. The patient tolerated the procedure and has been instructed to follow the postoperative orders that I have given him. He is to see me in my office in 1 week.
ICD-10-CM Code Assignment.............

Case 8
Office Note
This 72-year-old female patient is being seen in the office today for a follow-up after a series of diagnostic testing. She has been complaining of fatigue, weight loss, fever, shortness of breath, and bone pain in her legs. Diagnostic testing confirmed myelofibrosis. I am going to refer her to Dr. Smith, who specializes in the treatment of this disease. All diagnostic testing results with be forwarded to Dr. Smith.
ICD-10-CM Code Assignment ...............

Case 9
Office Note
This 45-year-old male patient was seen 4 days ago for his annual physical. Blood and urine samples were taken. The patient will return today to discuss the findings. The blood test showed elevated leukocytes, the cause of which is undetermined at this time. I am referring him to Dr. Yan in hematology to follow up on this finding.
ICD-10-CM Coding Assignment.............

Case 10
Hospital Discharge Note
This female 49-year-old patient is being discharged today after a 2-day stay for a transfusion of plasma cryoprecipitate to manage her von Willebrand's disease. Her course of treatment was uneventful, and she is instructed to follow up with me in the office in 2 weeks or sooner if symptoms occur.
ICD-10-CM Coding Assignment...............

Answer 1

ANSWER.

* ICD-10-CM coding.

    Case 1

      * Idiopathic thrombocytopenia - D69.6.

   Case 2

      * Primary malignancy of prostate - C61

        Anemia - D63.0

   Case 3

     * Anemia due to blood loss - D62

   Case 4

     * Pernicious anemia - D51.0

   Case 5

       * Sickle cell anemia - D57.1

   Case 6

       * Allergic purpura - D69.0

Case 7

      * Hypersplenism - D73.1

Case 8

      * Myelofibrosis - D75.81

Case 9

     * Elevated leukocytes - D72.829

Case 10

    * Von willebrand's disease - D68.0