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 Note
This 7-year-old male presents today with redness OU. Upon
examination, the conjunctiva are swollen. He is experiencing no
other symptoms.
Dx: acute conjunctivitis
Eye ointment given. Instructed to return in 10 days.
ICD-10-CM Code Assignment.......x......
Case 2
ER Visit Note
This 37-year-old male presents to the ER with pain in his eye. Exam
shows an object in the right lower eyelid. Because the object is
deeply embedded in the skin, I am asking for a consultation from
Dr. Ferrar. The object is retained in the lower right eyelid. The
patient was sent to Dr. Ferrar's office.
ICD-10-CM Code Assignment......x......, ......x........
Case 3
Office Visit Note
This 54-year-old man works on a dairy farm and 2 weeks ago he "got
something in my eye." Exam of the eyes reveals that there are no
foreign objects in the eyes at this time. The left eye is red and
there is an abscess of the right upper eyelid. The patient was
given antibiotics, drops, and patient education material. He was
instructed to follow up with me if the eye becomes worse or in 10
days.
ICD-10-CM Code Assignment.............
Case 4
Ambulatory Surgery Discharge Note
This 74-year-old female patient underwent cataract extraction with
intraocular lens replacement in her left eye due to anterior
subcapsular polar senile cataracts. The surgery was uneventful and
she was instructed to follow up in my office in 6 days.
ICD-10-CM Code Assignment .............
Case 5
Office Note
This 1-year-old male child presents to the office today from a
referral from Dr. Smith in pediatrics.
Dr. Smith has noted altered eye movements upon examination.
Examination:
The child's left eye has a convergent concomitant strabismus. Right
eye is normal.
Treatment:
At this time I am going to conservatively treat the child and cover
the right eye to force the left eye to function normally. If the
eye does not respond, I will then discuss with the parents the need
for corrective lenses or surgical intervention if more conservative
treatment fails.
ICD-10-CM Code Assignment.............
Case 6
Office Note
This 53-year-old female patient returns to the office today to
follow up after having fluorescien angiography.
She still reports loss of central vision. At this time she is still
able to read. She is also a smoker.
I have reviewed the angiography report, which confirms macular
degeneration in both eyes. I informed the patient that cigarette
smoking is a risk factor that contributes to the disease and
advised her to stop smoking. I also informed her that she should
wear sunglasses that block ultraviolet light and gave her
information about the disease process. She is to read the
information that contains information about laser surgery and the
risks and benefits of this surgery for this disease. I would like
to see her in 4 months to assess the disease process.
ICD-10-CM Code Assignment........x.......,.......x.......
Case 7
Office Note
This 4-year-old male patient is brought to my office today by his
mother. She states that he is consistently confusing the colors red
and green. I had the child view various Ishirara Color test plates
and testing revealed color blindness.
ICD-10-CM Code Assignment:............
Case 8
This 69-year-old male patient presents to the office today
complaining of an irregular floating spot in his left eye and
blurred vision.
Ophthalmoscope Examination:
Examination revealed no findings in the right eye.
In the left eye there is a separation of the inner layers of the
retina with fluid in the subretinal space.
There is also a retinal break.
Assessment: retinal detachment with retinal break
Plan: Patient will be scheduled for surgery
ICD-10-CM Code Assignment.............
Case 9
Observation Note
This patient is being placed in observation due to an increase in
the symptoms of her acute angleclosure glaucoma in her right eye,
severe stage. She is being placed on IV meds to see if symptoms
decrease. She will be monitored and then admission for peripheral
iridectomy will be made if needed.
ICD-10-CM Code Assignment............
Case 10
Office Note
Upon examination there is a small mass on the patient's right upper
eyelid. On eversion of the lid there is elevated reddish yellow
area on the conjunctival surface. The patient was instructed to
apply warm compresses to open the mass and to place Sulfomamide eye
drops in the eye as prescribed.
Assessment: chalazion
ICD-10-CM Code Assignment...............
Case 1
H10.33 - Unspecified acute conjunctivitis, bilateral
Case 2
H02.812 - Retained foreign body in the right lower eyelid
Z18.9 - Retained foreign body fragments, unspecified material
Case 3
H00.031 - Abscess of the right upper eyelid
Case 4
H25.032 - Anterior subcapsular polar age-related cataract, left eye
Case 5
H50.00 - Strabismus, convergent concomitant
Case 6
H35.30 - Unspecified macular degeneration
Z72.0 - Tobacco use
Case 7
H53.50 - Unspecified colour vision deficiencies
Case 8
H33.002 - Unspecified retinal detachment with the retinal break, left the eye
Case 9
H40.211 - Acute angle-closure glaucoma, right eye
Case 10
H00.11 - Chalazion right upper eyelid
Instruc Instructions: Review each case study and select the correct ICD-10-CM diagnostic code. Please be aware that when...
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...
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.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-PCS code. one code only just he code please Case 1 Transfusion Unit Note This 67-year-old female is diagnosed with leukemia and presents today for a nonautologous transfusion of platelets due to a low platelet count. The transfusion was completed in the left arm in a peripheral vein percutaneously. The patient tolerated the procedure well and was told to follow up with her physician in 4 days. ICD-10-PCS Code Assignment....…1…... Case...
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...
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. 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 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...