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 Assignment.............
Case 2
Clinic Visit
The patient presents today with symptoms of excessive thirst and
frequent urination, which has been going on for approximately 1
month. The patient states that these symptoms are affecting her
sleep, and she is concerned that there might be something wrong.
Patient denies any shortness of breath, nausea, or stomach
cramping. The patient does state that her mother had type 2
diabetes, and she is fearful since the symptoms are similar. The
patient states that she was borderline diabetic during her
pregnancy.
WEIGHT: 198 lb Temp: 98.7 BP: 110/70
HEART: No murmurs, RRR
LUNGS: Normal
SKIN: Warm and dry
EXTREMITIES: No edema
We did a finger stick, which indicated an elevated blood sugar
level of 201. An HgA1C was ordered, which came back at a level 9.
With these results and the symptoms involved, type 2 diabetes is
the diagnosis. We will try to control her diabetes with diet,
exercise, and Glucophage. She will be set up for diabetic education
as soon as possible.
ICD-10-CM Code Assignment......x...... ,........x......... ,
.......x.......
Case 3
S: This patient is a 68-year-old female presenting with severe
muscle cramps most evenings. Sometimes the cramping wakes her out
of a sound sleep. This has been going on for several months and
doesn't seem to be getting better.
O: Pleasant older female, well nourished, and in no acute distress.
Weight is 175 lb; blood pressure is 176/72; temperature, 98.4;
pulse, 72; and respiration, 18. Skin: Normal and dry to touch; no
rashes. Heart: No murmurs. Lungs: Clear. Extremities: No edema,
clubbing, or cyanosis.
LAB RESULTS: Hemoglobin, 11.6; hematocrit, 35.3; potassium is 5.6,
which is slightly elevated.
A & P: Hyperkalemia. I gave the patient a form that lists foods
high in potassium content. I asked her to limit her intake of these
foods as much as possible. If this approach works and the cramping
lessens, we can avoid medication. She is willing to try this for 2
weeks. If she has not improved over that time, we will explore
other options.
ICD-10-CM Code Assignment......................
Case 4
This patient presents today with a history of thyroid problems 6
years prior to today's visit. Today she is complaining of some
tingling in the hands and feet, some lethargy, and some anxiety. We
ran some lab tests, which showed low serum and urinary calcium, as
well as low urinary phosphate with increase in the serum phosphate.
Parathyroid hormone levels were almost absent. It was determined
that the patient has hypoparathyroidism.
ICD-10-CM Code Assignment...............
Case 5
A 2-month-old male presents with chronic, severe diarrhea and
fatigue. His growth is stunted. His family is concerned because he
has been treated for several different disorders, none of which
have been the problem. After extensive lab testing over the last
week, we found very low-density lipoprotein levels. We now have a
definite diagnosis of Andersen's disease and will begin vitamin E
therapy.
ICD-10-CM Code Assignment.............
Case 6
The patient presents today as a follow-up for her type 2 DM with
Charcot's joints. There is no change in her medical, family, or
social history. On exam, there are no abnormal findings in the
cardiac, abdominal, or respiratory systems. Her knees are swollen
with instability. Pain is moderate at this time. She is instructed
to continue on her current medications with no changes. She is to
follow up with me in 4 months.
ICD-10-CM Code Assignment...............
Case 7
Physician's Office Visit
John, a 56-year-old male, presents to the office today to discuss
the results of recent laboratory tests.
Chief compliant: Over the last 2 months, John has felt lethargic
and drowsy after eating large meals. He complains of extreme thirst
and frequent urination.
Physical Exam:
HEENT: All exam areas are within normal limits. His breath has a
fruity odor.
Heart: Normal rate and rhythm
Abdomen: Soft, nontender
Extremities: No edema, skin dry and clear
Physical exam is unremarkable
Laboratory Findings: For the last 3 weeks, John has had a fasting
plasma glucose level that has been over 140 mg/dL on three of three
occasions.
Discussion with Patient: I discussed with John that he has diabetes
mellitus. Patient educational information was given and he was
referred to the Diabetic Clinic to attend educational classes. He
was given information about the need to maintain a well-balanced,
nutritious diet. His diabetes will be managed by diet therapy. He
is to schedule an appointment and to return to my office in 4
weeks.
Assessment: type 2 diabetes
ICD-10-CM Code Assignment...............
Case 8
Skilled Nursing Facility Visit
This 86-year-old female patient has resided in the facility for 18
months.
Skin: There is a chronic ulceration of the skin of the left heel
and midfoot. There is not breakdown into the fatty layer, muscle,
or bone.
Assessment: DM, type 2, with skin ulceration on heel and
midfoot
ICD-10-CM Code Assignment........x......... ,
........x.......
Case 9
Inpatient Progress Note
This 10-year-old male patient is a type 1 diabetic. He was admitted
from the emergency room because he is in a coma. He is being seen
today for discharge. His insulin levels were adjusted and he can be
discharged.
Discharge Diagnosis:
Type 1 diabetes with ketoacidosis with coma
ICD-10-CM Code Assignment........x......... , .......x......
Case 10
Physician's Office Visit
This 69-year-old patient is seen today for type 2 diabetes with
diabetic neuropathy, controlled with insulin. The patient was
instructed to follow up in 2 months or sooner if glucose levels
change.
ICD-10-CM Code Assignment................,................
Answer:
Case 1 : Symptomatic postprocedural ovarian failure- E89. 41
Case 2 : Type 2 diabetes mellitus - E11. 8
Case 3 : Hyperkalemia - E87. 5
Case 4 : Hypoparathyroidism - E20. 9
Case 5 : Anderson's disease - E75. 21
Case 6 : Type 2 diabetes mellitus with charcot's joint - E11. 610
Case 7 : Type 2 diabetes mellitus - E11. 8
Case 8 : Type 2 diabetes mellitus- E11. 8
Skin ulceration on heel and midfoot - L97. 409
Case 9 : Type 1 diabetes mellitus - E10. 9
Ketoacidosis with coma - E10. 11
Case 10 : Type 2 diabetes with diabetic neuropathy - E11. 40
Instructions: Review each case study and select the correct ICD-10-CM diagnostic code. Please be aware that...
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...
Instruc 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 cod tions: 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, NO hand writing and code all the cases Case 1 Office...
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 S: A 55-year-old male presents today with severe abdominal pain, nausea, and vomiting, persistent over the last 24 hours. Diarrhea has developed, and abdominal cramping is also present. The patient states that he cannot keep anything down. Upon questioning, he states that he attended...
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...
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 6 Inpatient Progress Note This 74-year-old patient was admitted 3 days ago with symptoms of nausea, vomiting, and abdominal pain. Diagnostic testing confirmed botulism food poisoning. Nursing has been instructed to follow appropriate protocol documented by myself at the time of admission. ICD-10-CM Code Assignment……x…….....
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 6 Emergency Department Visit A 59-year-old male presented to the ED with dyspnea on exertion, fevers, and cough. A routine chest x-ray was completed to rule out pneumonia. The x-ray revealed a mass in the left lung. The patient was instructed to follow up with...
instructions: Review each case study and select the correct ICD-10-CM diagnostic code. Do not assign place of occurrence, activity code, or external cause status code unless instructed to do so for the case. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code. I need the code not the category Case 1 Emergency Department Note Justin was brought to the emergency room with a broken left tibia. Justin...
Instructions: Review each case study and select the correct ICD-10-CM diagnostic code. Do not assign place of occurrence, activity code, or external cause status code unless instructed to do so for the case. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code. Case 1 Emergency Department Note Justin was brought to the emergency room with a broken left tibia. Justin was sky diving and, due to a...
Instructions: Review each case study and select the correct ICD-10-CM diagnostic code. Do not assign place of occurrence, activity code, or external cause status code unless instructed to do so for the case. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code. Case 6 Emergency Department Note This 29-year-old male was riding his motorcycle with other cyclists on a recreational ride and hit a deer when he...
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...