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
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 sent for a biopsy. She is here today for follow-up.
BREAST: Mass present in left breast; right breast has no masses present.
ABDOMEN: Normal, no masses or tenderness.
The patient is anxious about results of biopsy.
Pathology report reviewed with patient that confirmed cancer of central portion, left breast. The patient was referred to Dr. Smith at West Oncology.
ICD-10-CM Code Assignment.......x.......

Case 2
Inpatient Discharge Summary
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old with a known history of cancer of the lung with metastasis to the brain.
Cancer of lung was resected 6 months ago. The patient was admitted because his daughter noticed him getting weaker and because he was not eating or drinking well for the last 2 days. He has undergone chemotherapy and radiation in the past 5 months, and he has asked for the treatment to be stopped.
Upon examination at the time of admission, he was dehydrated and weak due to lack of eating.
HOSPITAL COURSE: The patient requested that he receive care only for his dehydration. He was given IV hydration and refused all other treatment.
MEDICATIONS AT DISCHARGE: The patient was discharged on Vicodin for pain management, 1 every 4 hours as needed for pain.
DISCHARGE DIAGNOSES: Dehydration, metastatic cancer to the brain; history of lung cancer
ICD-10-CM Code Assignment......x...... , ......x........,.......x........

Case 3
Oncology Clinic Note
The patient was seen today to receive his first chemotherapy treatment for his diagnosis of acute lymphoid leukemia.
EXAM:
VITALS: Temperature 98.9, B/P 125/80. Pulse: regular.
LUNGS: Normal
ABDOMEN: Soft, no masses noted.
HEENT: Normal
HEART: Normal rate and rhythm
Chemotherapy schedule was reviewed, and side effects of treatment were discussed.

Chemotherapy was given; the patient tolerated treatment well.
ICD-10-CM Code Assignment.....x...... , ......x......
Case 4
Clinic Visit
Ellen is a 65-year-old female who presents today with severe headaches and blurred vision. She said these symptoms have been going on for approximately 2 weeks. She says that the pain is 10 out of 10 and that nothing seems to help relieve it. She has a history of breast cancer, which has been in remission for 1 year. A CT scan of the head and neck reveals a tumor in the temporal lobe of the brain.
A biopsy was performed and confirmed this to be a metastasis from the breast tumor.
ICD-10-CM Code Assignment.....x........ , ......x........
Case 5
Clinic Visit
A 52-year-old female presented with a 1-year history of epiphora. During this year, the tears were not bloodstained but very much a nuisance to the patient. CT revealed a small tumor connected to the right lacrimal sac and duct. Incisional biopsy revealed a benign tumor of the right lacrimal sac. The patient was treated by removing the tumor.
ICD-10-CM Code Assignment.....x........

Answer 1

Case 1

C50.112 - Malignant neoplasm of the central portion of left female breast

Case 2

E86.0 - Dehydration

C79.31 - Secondary malignant neoplasm of brain

Z85.118 - Personal history of other malignant neoplasm of bronchus and lung

Case 3

C91.00 - Acute lymphoblastic leukaemia not having achieved remission

Z51.11 - Encounter for antineoplastic chemotherapy

Case 4

Z85.3 - Personal history of malignant neoplasm of breast

C79.31 - Secondary malignant neoplasm of brain

Case 5

D31.51 - Benign neoplasm of right lacrimal gland and duct