CPC Ch4- ICD-10-CM Coding Chapters 1-11

Question 1

A patient is admitted to the hospital for repair of an open fracture, type 1, of the head of the left femur. The patient has been previously diagnosed with symptomatic HIV. Applying the coding concept from ICD-10-CM guideline I.C.1.a.2.b, what ICD-10-CM code(s) is/are reported for the admission?
A. B20
B. S72.052B
C. B20, S72.052B
D. S72.052B, B20

Answer 1

D. S72.052B, B20

Question 2

A 22-year-old female is admitted to ICU for acute renal (kidney) failure due to sepsis (causal organism unknown). Applying the coding concept from ICD-10-CM guideline I.C.1.d.1.b, what ICD-10-CM codes are reported (in the correct sequencing)?
A. A41.9, R65.20, N17.9
B. N17.9, R65.20, A41.9
C. R65.21, A41.9, N17.9
D. N17.9, R65.21, A41.01

Answer 2

A. A41.9, R65.20, N17.9

Question 3

A patient is admitted to the hospital with pneumonia. Testing indicates the patient’s pneumonia is due to Staphylococcus aureus and is methicillin resistant (MRSA). Applying the coding concept from ICD-10-CM guideline I.C.1.e.1.a, what ICD-10-CM code(s) are reported?
A. J18.9
B. J15.212
C. J15.212, A41.02
D. J18.9, A41.02

Answer 3

B. J15.212

Question 4

A 32-year-old female had a mastectomy for breast cancer. The mastectomy completely removed the breast cancer with no further treatment. On a follow-up visit to her oncologist, it is determined the cancer has metastasized to the right lung. The patient is now undergoing a lung resection for the lung cancer. Applying the coding concept from ICD-10-CM guidelines I.C.2.b. and I.C.2.d., what ICD-10-CM codes are reported for the lung resection?
A. C50.911, C78.01
B. Z85.3, C78.01
C. C78.01, C50.911
D. C78.01, Z85.3

Answer 4

D. C78.01, Z85.3

Question 5

A 45-year-old female with ovarian cancer visits her oncologist to receive an injection of Procrit. The Procrit has been prescribed to her for treatment of her anemia resulting from antineoplastic chemotherapy treatment. Applying the coding concept from ICD-10-CM guideline I.C.2.c.2., what ICD-10-CM codes should be reported?
A. D64.81, C56.9, T45.1X5A
B. D64.81, C56.9
C. C56.9, D64.81
D. T45.1X5A, D64.81, C56.9

Answer 5

A. D64.81, C56.9, T45.1X5A

Question 6

A patient with a Pancoast’s tumor in the left lung arrives at the oncologist office for chemotherapy. Applying the coding concept from ICD-10-CM guideline I.C.2.e.2., what ICD-10-CM code(s) should be reported? Note: Use the ICD-10-CM Alphabetic Index instead of the Table of Neoplasms to locate the code for a Pancoast’s tumor.
A. C34.12
B. Z51.11
C. C34.12, Z51.11
D. Z51.11, C34.12

Answer 6

D. Z51.11, C34.12

Question 7

Referencing ICD-10-CM guideline I.A.13, when using a code from category D63 it is also necessary to code first:
A. The hematocrit level of the patient
B. A primary (first-listed) diagnosis
C. The chronic condition causing the anemia
D. The acute condition presented in the patient encounter

Answer 7

C. The chronic condition causing the anemia

Question 8

Mr. McFarland visits his oncologist for prostate cancer. He is reporting more fatigue than usual. Lab tests determine the patient has anemia due to the cancer. Applying the coding concept from ICD-10-CM guideline I.C.2.c.1, what ICD-10-CM codes should be reported for the visit?
A. C61, D63.0
B. C61, D64.81
C. D63.0, C61
D. D64.81, C61

Answer 8

A. C61, D63.0

Question 9

Name an example of when a problem caused by diabetes is NOT sequenced after the code for diabetes. Refer to ICD-10-CM guideline I.C.4.a.5.a.
A. When a patient’s insulin pump malfunctions
B. When the patient has type 2 diabetes
C. When the patient has type 1 diabetes
D. When the patient has end stage renal disease caused by diabetes

Answer 9

A. When a patient’s insulin pump malfunctions

Question 10

A 12-year-old’s diabetes mellitus is well controlled with oral antidiabetic medications. The patient has no complications. Applying the coding concept from ICD-10-CM guidelines I.C.4.a.1, I.C.4.a.2, and I.C.4.a.3, what ICD-10-CM code(s) is/are reported?
A. E11.9, Z79.84
B. E10.9
C. E13.9, Z79.84
D. E08.9, Z79.84

Answer 10

A. E11.9, Z79.84

Question 11

A type 2 diabetic patient with diabetic retinopathy visits his ophthalmologist for blurred vision. After performing a visual acuity test and a dilated eye exam, the provider states the patient has macular edema. Applying the coding concept from ICD-10-CM guideline I.C.4.a, what ICD-10-CM code is reported?
A. E11.311
B. E11.3219
C. E08.311
D. 10.311

Answer 11

A. E11.311

Question 12

A patient with a four-year history of eating disorders is seen in the physician’s office due to significant weight loss over the past three months. She went from 82 pounds down to 53 pounds due to restricting her food intake. She is diagnosed with anorexia nervosa. Select the diagnosis code(s).
A. F50.02
B. F50.05, R63.4
C. F50.01, R63.4
D. F50.01

Answer 12

D. F50.01

Question 13

A patient presents to her physician and tells him she drinks each night when she gets home from work. She asks her physician to recommend an alcohol treatment center because her life has become unmanageable and she wishes to quit drinking. The patient is diagnosed with uncomplicated alcohol dependence. Select the diagnosis code.
A. F10.221
B. F10.20
C. F10.239
D. F10.288

Answer 13

B. F10.20

Question 14

A mother brings her son into the doctor because he has been getting in trouble in school for his behavior. He is not paying attention or following the instructions. He is constantly losing his pencil and forgetting to bring in his homework. After evaluating the child, the provider diagnoses him with attention deficit hyperactivity disorder (ADHD), predominately inattentive type, and sends the patient for a consultation with a psychiatrist to see if medication can help. Select the diagnosis code.
A. F90.0
B. F90.9
C. F90.8
D. F90.2

Answer 14

A. F90.0

Question 15

Referencing ICD-10-CM guideline I.C.6.b.1.a, when should a code from category G89 be reported as a first listed code?
A. Whenever it is documented
B. When the pain control or pain management is the purpose of the encounter
C. Only within the first 72 hours of continuous pain
D. When the pain is chronic

Answer 15

B. When the pain control or pain management is the purpose of the encounter

Question 16

Mr. Elliot visits the surgeon for evaluation for a wedge resection of left lung cancer. During the admission, the patient reports pain in the chest due to the malignancy. Applying the coding concept from ICD-10-CM guideline I.C.6.b.5, what ICD-10-CM code(s) should be reported?
A. C34.92
B. C34.92, G89.3
C. G89.3, C34.92
D. G89.3

Answer 16

B. C34.92, G89.3

Question 17

Mr. Timmins fell off a roof and suffered a spinal injury. As a result of the injury, he has been suffering from chronic pain in his lower back for several years. Today, he presents for insertion of a neurostimulator for pain control. Applying the coding concept from ICD-10-CM guidelines I.C.6.b.1.a and I.C.6.b.1.b.ii, what ICD-10-CM codes should be reported for the pain? (Do not code the external cause.)
A. M54.9, G89.21
B. M54.50, G89.11
C. G89.21, M54.50
D. G89.29, M54.9

Answer 17

C. G89.21, M54.50

Question 18

A patient presents with pigmentary glaucoma bilaterally, moderate stage on the right, mild stage on the left. Reference ICD-10-CM guideline I.C.7.a.3. What ICD-10-CM code(s) is/are reported?
A. H40.1332
B. h40.1312, H40.1322
C. H40.1332, H40.1331
D. H40.1312, H40.1321

Answer 18

D. H40.1312, H40.1321

Question 19

A mother takes her child to the pediatrician because her right eye is red, itchy, with a mucus discharge coming from the eye. The provider documents the child has pink eye. What ICD-10-CM code is reported?
A. H10.011
B. H10.021
C. H10.013
D. H10.023

Answer 19

B. H10.021

Question 20

A patient is having phacoemulsification of an age-related nuclear cataract of the left eye. What ICD-10-CM code is reported?
A. H25.12
B. H26.032
C. H26.9
D. Q12.0

Answer 20

A. H25.12

Question 21

A patient presents with right ear pain and fever. The provider diagnoses acute otitis media. What ICD-10-CM code(s) is/are reported?
A. H92.01, R50.9
B. H66.90
C. H92.01
D. H66.91

Answer 21

D. H66.91

Question 22

A patient sees her provider for spontaneous episodes of vertigo lasting 30 minutes each, fluctuating hearing loss, and tinnitus. The provider performs a hearing test and confirms hearing loss in the right ear. The provider documents the patient has Meniere’s disease in the right ear. What ICD-10-CM code(s) is/are reported?
A. R42, H91.91, H93.11
B. H81.01
C. H93.8X1
D. H81.01, H81.4, H91.21, H93.11

Answer 22

B. H81.01

Question 23

A patient sees his family practitioner for a muted feeling in his ears. The provider determines there is impacted cerumen in both ears. What ICD-10-CM code(s) is/are reported?
A. H61.23
B. H61.21, H61.22
C. H61.23, H90.5
D. H61.21, H61.22, H90.5

Answer 23

A. H61.23

Question 24

Applying the coding concept from ICD-10-CM guideline I.C.9.a.5, how do you code hypertensive retinopathy?
A. First code the hypertension, then the retinopathy
B. First code the retinopathy, then the heart disease
C. First code the heart disease, then the retinopathy
D. Sequencing is based on the reason for the encounter

Answer 24

D. Sequencing is based on the reason for the encounter

Question 25

If an ST elevation myocardial infarction converts to a non-ST elevation myocardial infarction in the course of thrombolytic therapy, how is it coded? (Reference ICD-10-CM guideline I.C.9.e.1)
A. Sequence STEMI first, then NSTEMI
B. Sequence NSTEMI first, then STEMI
C. Code only STEMI
D. Code only NSTEMI

Answer 25

C. Code only STEMI

Question 26

Which of the following does NOT require documentation for a cause-and-effect relationship to be coded? (Reference guidelines I.C.9.a.2 and I.C.9.a.3)
A. Cerebrovascular hemorrhage due to an operation
B. Hypertension and chronic kidney disease
C. Hypertension and encephalopathy
D. All require cause and effect to be documented

Answer 26

B. Hypertension and chronic kidney disease

Question 27

What is an acute exacerbation of asthma or COPD? (Reference ICD-10-CM guideline I.C.10.a.1)
A. Uncomplicated asthma or COPD
B. Worsening or decompensation of asthma or COPD
C. An infection superimposed on asthma or COPD
D. When a condition is severe enough to be admitted to a hospital

Answer 27

B. Worsening or decompensation of asthma or COPD

Question 28

A 12-year-old child presents to the ED with an acute exacerbation of asthma. The patient is wheezing and is having difficulty breathing. She is not responding to the therapy. The physician documents as the final diagnosis asthma with status asthmaticus. What ICD-10-CM code(s) is/are reported?
A. J45.52
B. J45.901
C. J45.902
D. R06.2, J45.901

Answer 28

C. J45.902

Question 29

A patient with COPD visits the physician with acute bronchitis. What ICD-10-CM code(s) should be reported?
A. J20.9
B. J44.9
C. J44.0, J20.9
D. J20.9, J44.0

Answer 29

C. J44.0, J20.9

Question 30

A 39-year-old patient underwent a left femoral hernia repair. The postoperative diagnosis was recurrent left femoral hernia. What is the diagnosis code for this encounter?
A. K41.41
B. K41.91
C. K41.21
D. K40.91

Answer 30

B. K41.91

Question 31

A patient presents for a liver transplant. The provider documents the patient has Laennec’s cirrhosis associated with long term alcohol dependent use. What are the diagnosis codes for this encounter?
A. K74.60, F10.99
B. K70.30, F10.20
C. K76.89, F10.20
D. K70.0, F10.99

Answer 31

B. K70.30, F10.20

Question 32

A patient presents with abdominal pain. The physician performs an abdominal ultrasound and discovers the patient has gallstones and inflammation of the gallbladder. Select the diagnosis code(s).
A. R10.9, K80.10
B. K80.10, K80.20
C. K80.10
D. K80.70

Answer 32

C. K80.10

Question 33

CASE 10

Dear Dr. Smith,

Mr. Martin was seen in the office for continued management of his breast cancer. He’s having some increasing pain in his breast which is due to the cancer. He is also complaining of neck pain. It does not seem to be worse at night; it seems to be worse with activity. He has no other symptoms. Otherwise, his review of systems is unremarkable. He’s had no constitutional symptoms.

On physical exam, he is alert and oriented. Eyes: EOMI, PERLA, no icterus. The heart had a regular rate and rhythm; S1, S2 within normal limits. The lungs are clear to auscultation and percussion. The abdomen was soft, without masses or organomegaly. He was tender to palpation over the left anterior iliac crest. Otherwise he had no point tenderness over his musculoskeletal system. Neck: Supple. No tenderness, no enlarged lymph nodes in the neck.

ASSESSMENT: Adenocarcinoma of the left breast, positive estrogen receptor status. Neck pain.

PLAN: The plan is to continue the Tamoxifen at this time. His laboratory studies were reviewed and were essentially unremarkable; however we’ll obtain a bone scan to ascertain the extent of his disease.

Sincerely,

John Smith, M.D.

What diagnosis code(s) are reported?

Answer 33

C50.922
G89.3
M54.2
Z17.0
Z79.810

Question 34

CASE 9

Operative Report

PREOPERATIVE DIAGNOSES: Splenic abscesses and multiple intra-abdominal abscesses, related to HIV, AIDS, and hepatitis C.

POSTOPERATIVE DIAGNOSES: Splenic abscesses and multiple intra-abdominal abscesses, related to HIV, AIDS, and hepatitis C.

OPERATIVE PROCEDURE:

1. Exploratory laparotomy with drainage of multiple intra-abdominal abscesses.
2. Splenectomy.
3. Vac Pak closure.

FINDINGS: This is a 42-year-old man who was recently admitted to the medical service with a splenic defect and found to a splenic vein thrombosis. He was treated with antibiotics and anticoagulation. He returned and was admitted with a CT scan showing mass of left upper quadrant with abscesses surrounding both sides of the spleen, as well as, multiple other intra-abdominal abscesses below the left lobe of the liver in both lower quadrants and in the pelvis. The patient has a psychiatric illness and was difficult to consent and had been anticoagulated with an INR of 3. Once those issues were resolved by psychiatry consultation and phone consent from the patient’s father, he was brought to the operating room.

OPERATIVE PROCEDURE: The patient was brought to operating room, a time-out procedure was performed. He was already receiving parenteral antibiotics. He was placed in the supine position and then given a general endotracheal anesthetic. Anesthesia started multiple IVs and an arterial line. A Foley catheter was sterilely inserted with some difficulty requiring a Coude catheter. After the abdomen was prepped and draped in the sterile fashion, a long midline incision was made through the skin. This was carried through the subcutaneous tissues and down through the midline fascia using the Bovie. The fascia was opened in the midline. The entire left upper quadrant was replaced with an abscess peel separate from the free peritoneal cavity. This was opened, and at least 3 to 4 L of foul smelling crankcase colored fluid were removed. Once the abscess cavity was completely opened, it was evident that the spleen was floating within this pus as had been predicted by the CT. This was irrigated copiously and the left lower quadrant subhepatic and pelvic abscesses were likewise discovered containing the same foul smelling dark bloody fluid. All of these areas were sucked out, irrigated, and the procedure repeated multiple times.

We thought it reasonable to go ahead with the splenectomy. The anatomic planes were obviously terribly distorted. There was no clear margin between stomach spleen, colon spleen, etc., but most of the dense attachments were to the abscess cavity peel. Using this as a guide, the spleen was eventually rotated up and out to the point where the upper attachments presumably where the short gastric used to reside were taken via Harmonic scalpel. The single fire of a 45 mm stapler with vascular load was taken across the lower pole followed by two firings of the echelon stapler across the hilum. This controlled most of the ongoing bleeding. Single bleeding site below the splenic artery was controlled with two stitches, one of 3-0 Prolene and the other of 4-0 Prolene. Because of diffuse ooze in the area and the fact that the patient would be scheduled for a return visit to the operating room tomorrow to reinspect the abscess cavities, it was elected to leave two laparotomy pads in the left upper quadrant and Vac Pak the abdomen. The Vac Pak was created using blue towels and Ioban dressings in the usual fashion with 10 mm fully perforated flat Jackson-Pratt drains brought out at the appropriate level. The patient was critical throughout the procedure and will be taken directly to the intensive care unit, intubated, with a plan for reexploration and removal of the packs tomorrow. The patient received four units of packed cells during the procedure, as well as albumin and a large volume of crystalloid. There were no intraoperative complications noted and the specimen sent included the spleen. Cultures from the abscess cavity were also taken.

What diagnosis code(s) are reported?

Answer 34

B20
D73.3
K65.1
B19.20

Question 35

CASE 8

S: The patient presents today for reevaluation and titration of carvedilol for his coronary artery disease and hyperlipidemia. His weight is up 7 pounds. He has quit smoking. He has no further cough and he states he is feeling well except for the weight gain. He states he doesn’t feel he’s eating more, but his wife says he’s eating more. We’ve been attempting to titrate up his carvedilol to 25mg twice a day from initially 6.25mg. He has tolerated the titration quite well. He gets cephalgias on occasion. He states he has a weak spell but this is before he takes his morning medicine. I updated his medical list here today. I gave him samples of Lipitor.

O: Weight is 217, pulse rate 68, respirations 16, and blood pressure 138/82. HEENT examination is unchanged. His heart is a regular rate. His lungs are clear.

A:

1. CAD
2. Hyperlipidemia

P:

1. The plan is samples of Lipitor using the two months’ supply that I have given him.
2. We’ve increased his Coreg to 25mg bid. He’ll recheck with us in six months.

What diagnosis code(s) are reported?

Answer 35

I25.10
E78.5
Z87.891
Z79.899

Question 36

CASE 7

Follow-up Visit: The patient has some memory problems. She is hard of hearing. She is legally blind. Her pharmacist and her family are very worried about her memory issues. She lives at home, family takes care of laying out her medi­cations and helping with the chores, but she does take care of her own home to best of her ability.

Exam: Pleasant 85-year-old woman in no acute distress. She has postop changes of her eyes. TMs are dull. Pharynx is clear. Neck is supple without adenopathy. Lungs are clear. Good air movement. Heart is regular. She had a slight murmur. Abdomen is soft. Moderately obese. Non-tender. Extremities; no clubbing or edema. Foot exam shows some bunion deformity but otherwise healthy. Light touch is preserved. There is no ankle edema or stasis change. Examination of the upper arms reveal good range of motion. There is significant pain in her shoulder with rotational movements. It is localized mostly over the deltoid. There is no other deformity. There is a very slight left shoulder discomfort and slight right hip discomfort.

Impression:

1. Dementia
2. Right shoulder pain.
3. Benign hypertensive cardiovascular disease, a complication of diabetes.
4. Type 2 diabetes good control. Most recent AlC done today 5.9%. Liver test normal. Cholesterol 199, LDL a little high at 115.

Plans:

1. I offered her and her family neuropsychological evaluation to evaluate for dementia. Her system complex is consistent with dementia, whether it be from cerebral small vessel disease or Alzheimer’s is unknown. At this point, they would much rather initiate treatment than go through an exhaustive neuropsychological test.
2. For the shoulder we decided on right deltoid bursa steroid injection. She has had injection for bursitis in the past and prefers to go this route. She will ice and rest the shoulder after injection.
3. Follow up in 3 months.

Procedure: Injection right deltoid bursa. The point of maximal tenderness was identified, skin was prepped with alcohol. A 25-gauge, 1 ½-inch needle was advanced to the posterolateral edge of the acromion and into the subacromial space and then aspirated. 1 cc of 0.25% Marcaine mixed with 80 mg Depo Medrol was deposited. Needle was withdrawn. Band-aid was applied. Post injection she had marked improvement; increased range of motion consistent with good placement of the medication. She was started on Cerefolin, plus NAC and Aricept starter pack was given with email away script. Follow-up in 3 months and we will reassess her dementia at that time.

What diagnosis code(s) are reported?

Answer 36

F03.90
M25.111
I11.9
E11.59

Question 37

CASE 6

Subjective: Here to follow up on her atrial fibrillation. No new problems. Feeling well. Medications are per medication sheet. These were reconstituted with the medications that she was discharged home on.

0bjective: Blood pressure is 110/64. Pulse is regular at 72. Neck is supple. Chest is clear. Cardiac normal sinus rhythm.

Assessment: Atrial fibrillation, currently stable

Plan:

1. Prothrombin time to monitor long term use of anticoagulant.
2. Follow up with me in one month or sooner as needed if she has any other problems in the meantime. Will also check a creatinine and potassium today.

What diagnosis code(s) are reported?

Answer 37

I48.91
Z51.81
Z79.01

Question 38

CASE 5

PREOPERATIVE DIAGNOSIS: Cataract, left eye

POSTOPERATIVE DIAGNOSIS: Cataract left eye, Presbyopia(Report the postoperative diagnosis.)

PROCEDURE:

1. Cataract extraction with IOL implant
2. Correction of presbyopia(Patient is also diagnosed with presbyopia.) with lens implantation

PROCEDURE DETAIL: The patient was brought to the operating room under neuroleptic anesthesia monitoring. A topical anesthetic was placed within the operative eye and the patient was prepped and draped in usual manner for sterile ophthalmic surgery. A lid speculum was inserted into the right infrapalpebral space. A 6-0 silk suture was placed through the episclera at 12 o’clock. A subconjunctival injection of non-preserved lidocaine was given. A peritomy was fashioned from 11 o’clock to 1 o’clock with Westcott scissors. Hemostasis was achieved with the wet-field cautery. A 3-mm incision was made in the cornea and dissected anteriorly with a crescent blade The anterior chamber was entered at 12 o’clock and 2 o’clock with a Supersharp blade. Non-preserved lidocaine was instilled into the anterior chamber. Viscoelastic was instilled in the anterior chamber and using a bent 25-guage needle, a 360-degree anterior capsulotomy was performed using Utrata forceps. The capsulotomy was measured and found to be 5.5 mm in diameter. Using an irrigating cannula, the lens nucleus was hydrodissected and loosened. Using the phacoemulsification unit, the lens nucleus was divided and emulsified. The irrigating/aspirating tip was used to remove the cortical fragments from the capsular bag, and the posterior capsule was polished. Using a curette to polish the anterior capsule, cortical fragments were removed from the anterior lens capsule for 270 degrees. The irrigating/aspirating tip was used to remove the capsular fragments. The anterior chamber and capsule bag were inflated with viscoelastic and using a lens inserter, a Cystalens was then placed within the capsular bag and rotated to the horizontal position. The viscoelastic was removed with the irrigating/aspirating tip and the lens was found to be in excellent position with a slight posterior vault. The wound was hydrated with balanced salt solution and tested and found to be watertight at a pressure of 20 mmHg. Topical Vigamox was applied The conjunctiva was repositioned over the wound with a wet field cautery. The traction suture and lid speculum were removed. A patch was applied. The patient tolerated the procedure well and left the operating room in good condition.

What diagnosis code(s) are reported?

Answer 38

H26.9
H52.4

Question 39

CASE 4

SUBJECTIVE: Low-grade fever at home. She has had some lumps in the abdominal wall and when she injects her insulin; it does seem to hurt there. She stopped four of her medications including Neurontin, Depakote, Lasix, and Premarin, and overall, she feels quite well. Unfortunately, she has put on 20 pounds since our last visit.

OBJECTIVE:

HEENT: Tympanic membranes are retracted but otherwise clear. The nose shows significant green rhinorrhea present. Throat is mildly inflamed with moderate postnasal drainage.

Neck: No significant adenopathy.

Lungs: Clear.

Heart: Regular rate and rhythm.

Abdomen: Soft, obese, and nontender. Multiple lipomas are palpated.

ASSESSMENT

1. Diabetes mellitus, type 1.
2. Diabetic neuropathy.
3. Acute sinusitis.

(The definitive diagnoses are reported.)

PLAN: At this time, I have recommended the addition of Keflex for her acute sinusitis.(Provider treated the acute sinusitis.) I have given her a chair for the shower. They will not cover her Glucerna anymore so a note for that will be required.

What diagnosis code(s) are reported?

Answer 39

E10.40
J01.90

Question 40

CASE 3

CC: HTN

INTERVAL HISTORY: No new complaints.

EXAM: NAD. 130/80, 84, 22. Lungs are clear. Heart RRR, no MRGs. Abdomen is soft, non-tender. No peripheral edema.

IMPRESSION: Stable HTN(Patient is diagnosed with hypertension.) on current meds.

PLAN: No changes needed. RTC in six months with labs.

What diagnosis code(s) are reported?

Answer 40

I10

Question 41

CASE 2

PREOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss.

POSTOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss.(Report the postoperative diagnosis.)

PROCEDURES PERFORMED:

1. Placement of left Nucleus cochlear implant.
2. Facial nerve monitoring for an hour.
3. Microscope use.

ANESTHESIA: General.

INDICATIONS: This is a 69-year-old woman who has had progressive hearing loss (The diagnosis is documented as the indication for the
surgery.) over the last 10-15 years. Hearing aids are not useful for her. She is a candidate for cochlear implant by FDA standards. The risks, benefits, and alternatives of procedure were described to the patient, who voiced understanding and wished to proceed.

PROCEDURE: After properly identifying the patient, she was taken to the main operating room, where general anesthetic was induced. The table was turned to 180 degrees and a standard left-sided post auricular shave and injection of 1% lidocaine plus 1:100,000 epinephrine was performed. The patient was then prepped and draped in a sterile fashion after placing facial nerve monitoring probes, which were tested and found to work well. At this time, the previously outlined incision line was incised and flaps were elevated. A subtemporal pocket was designed in the usual fashion for placement of the device. A standard cortical mastoidectomy was then performed and the fascial recess was opened exposing the area of the round window niche. The lip of the round window was drilled down exposing the round window membrane. At this time, the wound was copiously irrigated with bacitracin containing solution, and the device was then placed into the pocket. A 1-mm cochleostomy was made, and the device was inserted into the cochleostomy with an advance-off stylet technique. A small piece of temporalis muscle was packed around the cochleostomy, and the wound was closed in layers using 3-0 and 4–0 Monocryl and Steri-Strips. A standard mastoid dressing was applied. The patient was returned to anesthesia, where she was awakened, extubated, and taken to the recovery room in stable condition.

What diagnosis code(s) are reported?

Answer 41

H90.3

Question 42

CASE 1

PROGRESS NOTE

This patient is a 50 year-old female who began developing bleeding, bright red blood per rectum(Patient’s presenting complaint.), approximately two weeks ago. She is referred by her family physician. She states that after a bowel movement she noticed blood in the toilet. She denied any prior history of bleeding or pain with defecation. She states that she has had an external hemorrhoid(This is reported by the patient, but not documented in the exam or assessment, so it is not coded.) that did bleed at times but that is not where this bleeding is coming from. She is presently concerned because a close friend of hers was recently diagnosed with rectal carcinoma requiring chemotherapy that was missed by her primary doctor. She is here today for evaluation for a colonoscopy.

Physical examination, she appears to be a well appearing 50 year-old, white female. Abdomen is soft, non-tender, non-distended.

ASSESSMENT: 50 year-old female with rectal bleeding(Report the code documented in the assessment.)

PLAN: We’ll schedule the patient for an outpatient colonoscopy. The patient was made aware of all the risks involved with the procedure and was willing to proceed.

What diagnosis code(s) are reported?

Answer 42

K62.5

Question 43

When is it appropriate to use history of malignancy from category Z85?
A. When the patient cancels treatment for that site.
B. It has been excised, no evidence of any existing primary malignancy, and there is no further treatment directed to the site.
C. Once the malignancy is removed from that site but the patient is still receiving chemotherapy.
D. When five years has passed after surgery.

Answer 43

B. It has been excised, no evidence of any existing primary malignancy, and there is no further treatment directed to the site.

Question 44

According to the ICD-10-CM guidelines, how is bilateral glaucoma of the same type and stage reported?
A. Three codes are reported; one code for the type of glaucoma and two codes to indicate the stages of glaucoma.
B. One code is used to report the type of glaucoma; the stage of glaucoma is not reported.
C. A bilateral code can be used to report the type of glaucoma and the stage of glaucoma.
D. One code is used to report the stage of glaucoma; the type of glaucoma is not reported.

Answer 44

C. A bilateral code can be used to report the type of glaucoma and the stage of glaucoma.

Question 45

What does the 4th character in diabetes mellitus diabetes codes indicate?
A. If the diabetes is primary or secondary diabetes.
B. Type of diabetes (type 1, type 2, secondary).
C. The condition as controlled or uncontrolled.
D. Any complication associated with diabetes.

Answer 45

D. Any complication associated with diabetes.

Question 46

When the type of diabetes mellitus is not documented in the medical note, what is used as the default type?
A. Secondary diabetes
B. Can be type 1 or 2
C. Type 2
D. Type 1

Answer 46

C. Type 2

Question 47

What does MRSA stand for?
A. Methicillin Resistant Streptococcus Aureus
B. Mild Resistance Streptococcus Aureus
C. Methicillin Resistant Staphylococcus Aureus
D. Moderate Resistance Susceptible Aureus

Answer 47

C. Methicillin Resistant Staphylococcus Aureus

Question 48

A patient is seen in the ED for having unprotected sexual intercourse a few months prior. She recently found out that the individual she was with has HIV. She is only being tested for HIV. What ICD-10-CM code(s) is/are reported?
A. B20
B. B20, Z71.7
C. Z21
D. Z11.4

Answer 48

D. Z11.4

Question 49

A 21-year-old male is brought into the ED by his father who states that his son is dizzy and has anxiety. The ED provider runs a drug screen test and the test comes back positive for marijuana use. The final diagnosis is documented as marijuana abuse with anxiety disorder. What ICD-10-CM code is reported?
A. F12.10
B. F19.10
C. F12.129
D. F12.180

Answer 49

D. F12.180

Question 50

A patient has a history of MRSA. She has just been diagnosed with pneumonia due to possible staphylococcus aureus. What ICD-10-CM code(s) is/are reported?
A. J18.9, B95.62
B. J18.9
C. J18.9, Z86.14
D. Z86.14, B95.62

Answer 50

C. J18.9, Z86.14

Question 51

A 50-year-old patient has a mass removed from his chest. The surgeon sends it to pathology. The pathology report indicates the mass is a benign tumor. What ICD-10-CM code is reported?
A. D49.2
B. C79.89
C. C49.3
D. D36.7

Answer 51

D. D36.7

Question 52

Patient is admitted to the hospital with streptococcal group B severe sepsis which has caused pneumonia and acute renal failure. What codes are assigned?
A. A40.1, J15.3, R65.20, N17.9
B. A40.1, J15.3
C. A41.9, J15.3, R65.21, N17.9
D. A41.9, R65.21, N17.9

Answer 52

A. A40.1, J15.3, R65.20, N17.9

Question 53

What ICD-10-CM code is used for the first episode of an acute myocardial infarction?
A. I21.9
B. I22
C. I25.3
D. I21

Answer 53

A. I21.9

Question 54

A confirmed HIV positive patient presents to the clinic for a medication refill for a condition not related to his HIV. What ICD-10-CM codes are reported?
A. Z20.6, Z76.0
B. Z76.0, R75
C. B20, Z76.0
D. Z76.0, Z21

Answer 54

D. Z76.0, Z21

Question 55

A pediatrician sees an 8-month-old patient for ear pulling and excessive crying. The infant is diagnosed with bilateral chronic and acute serous otitis media. What ICD-10-CM code(s) is/are reported?
A. H65.93
B. H65.03, H65.23
C. H65.20
D. 65.21, H65.22

Answer 55

B. H65.03, H65.23

Question 56

What is the time frame defining when pain becomes chronic?
A. The 30th day
B. No time frame
C. After the global period
D. One year

Answer 56

B. No time frame

Question 57

Patient with coronary arteriosclerosis disease (CAD) sees his cardiologist to discuss a coronary artery bypass graft (CABG). This will be the patient’s first CABG. What ICD-10-CM code is reported?
A. I25.10
B. I25.720
C. I25.759
D. I25.810

Answer 57

A. I25.10

Question 58

A patient with chronic back and neck pain developed a drug dependency on oxycodone (opioid). After being taken off the drug, he was seen in the clinic for withdrawal symptoms. What ICD-10-CM codes are reported?
A. F11.23, T40.2X55
B. F11.23, T40.2X5A
C. F11.10, F11.23, T40.2X5A
D. F11.24, T40.2X5D

Answer 58

B. F11.23, T40.2X5A

Question 59

A patient is admitted after being found unresponsive at home. The patient had right-sided hemiplegia and aphasia from a previous CVA. The provider documents a current cerebral infarction due to occlusion of the right middle cerebral artery as the final diagnosis and the patient is transferred for rehabilitation. What ICD-10-CM code(s) is/are reported?
A. I63.511, I69.351, I69.320
B. I67.89, I69.954, R47.01
C. I65.319
D. I67.89, I69.959, I69.920

Answer 59

A. I63.511, I69.351, I69.320

Question 60

What ICD-10-CM codes are reported for uncontrolled hypertension with stage 3 chronic kidney disease (CKD)?
A. I12.9, N18.9
B. N18.30, I12.9
C. I12.9, N18.30
D. N18.9, I12.3

Answer 60

C. I12.9, N18.30

Question 61

Friends brought a young male with type 1 diabetes to the emergency department (ED), in a comatose state. He was admitted with ketoacidosis and was resuscitated with saline hydration via insulin drip. After regaining consciousness, the patient reported that the morning of admission he was experiencing nausea and vomiting and decided not to take his insulin because he had not eaten. He was treated with intravenous hydration and insulin drip. By the following morning, his laboratory work was within normal range and he was experiencing no symptoms. What ICD-10-CM code(s) are reported?
A. E11.01, Z79.4
B. E10.10, R06.4, Z79.4
C. E11.01, R06.4
D. E10.11

Answer 61

D. E10.11

Question 62

After referral from the ED, a patient sees an ophthalmologist to examine an old injury with a retained magnetic iron metal foreign body in his posterior wall within the right eye. There is concern for an infection. What ICD-10-CM codes are reported?
A. H44.641, Z18.11
B. S05.51XD, Z18.11
C. S05.51XA, Z18.11
D. H44.741, Z18.11

Answer 62

A. H44.641, Z18.11

Question 63

The patient has a history of unstable angina, hypertension, and chronic systolic heart failure. He is seen in the ED after prolonged chest pain that was not relieved by medication. Cardiac enzymes are elevated, and EKG shows anterior infarct. A decision was made to perform a cardiac catheterization and coronary angiography. Left heart catheterization was performed in order to perform a left ventriculogram. He tolerated the procedure well and will be discharged. His final diagnosis is chronic systolic heart failure and hypertension. The two conditions are unrelated. What ICD-10-CM code(s) is/are reported?
A. I50.22, I10
B. I11.0
C. I11.0, I50.22
D. I11.0, I10

Answer 63

A. I50.22, I10

Question 64

A patient arrives to the emergency department (ED) by ambulance with convulsions. After examination and workup is complete, it is determined the convulsions were due to alcohol abuse with intoxication. What ICD-10-CM code(s) is/are reported?
A. G40.501, R56.9, F10.129
B. F10.129
C. R56.9, F10.129
D. G40.509, F10.120

Answer 64

C. R56.9, F10.129

Question 65

A patient with metastatic bone cancer (primary site unknown) presents to the oncologist’s office for a chemotherapy treatment. On examination the oncologist finds the patient to be severely dehydrated and cancels the chemotherapy. The patient receives intravenous hydration in the office and reschedules the chemotherapy treatment. What ICD-10-CM codes are reported?
A. C40.30, E86.0, C79.51
B. C79.51, E86.0
C. E86.0, C80.1, C79.51
D. E86.0, C79.51, C80.1

Answer 65

D. E86.0, C79.51, C80.1

Question 66

A patient with hypertension presents to the outpatient hospital radiology department for an ultrasound due to a suspected suspicious mass. The patient’s provider performed an ACTH and a 24-hour urinary free cortisol and short suppression test confirming the diagnosis of Cushing’s disease. The radiology report indicated a 5.5 cm right adrenal mass that appeared well circumscribed and rounded. The final diagnosis indicated Cushing’s disease secondary to a right adrenal tumor. The hypertension is due to the Cushing’s syndrome. What ICD-10-CM codes are reported?
A. D49.7, E24.9, I15.2
B. C74.91, E24.9, I15.2
C. D49.7, I15.2
D. C74.91, E24.9, I10

Answer 66

A. D49.7, E24.9, I15.2

Question 67

A patient with type 2 diabetes presents with diabetic macular edema and proliferative diabetic retinopathy in the right eye. What ICD-10-CM code(s) is/are reported?
A. E11.3511
B. E11.311, E11.3519
C. E11.3519
D. E11.9, E11.311, E11.3519