MEDICAL H1253-03 quiz (GRADED A) answers from all units/ Download To Score An A

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MEDICAL H1253-03 quiz (GRADED A) answers from all units In your ICD-10-CM book, turn to code J17 in the Tabular List. Under this code is a “Code first underlying disease, such as: Q fever" notati... on. What is the code next to the Q fever? - A78 Which of the following embed themselves in host cells and can be difficult to isolate? - viruses Dysentery is transmitted by: - drinking contaminated water. Exposure due to some diseases, such as influenza, can be transmitted by coughing, spitting, talking, and sneezing. This type of exposure is known as: - droplet exposure. Davita, 2 days old, is diagnosed with sepsis due to E. coli. The coder should assign code? - P36.4 The presence of unknown bacteria in the blood may be diagnosed as: - bacteremia is/are any agent that causes disease; a microorganism such as a bacterium or virus. - Pathogen When there are no symptoms or manifestations this is known as: - Asymptomatic. is of long duration; continuing over an extended period of time. - Chronic Refer to the ICD-10-CM Official guidelines I.C.1.a.2.b which states: If a patient with HIV disease is admitted for an condition, the code for the condition should be the principal diagnosis. - unrelated, unrelated What are hookworms, pinworms, and tapeworms examples of? - parasites In your ICD-10-CM turn to code L03.211 in the Tabular List. What notation is found under the code? Excludes2 Tim is concerned he might have been exposed to HIV and comes to see Dr. McGee. This is Tim's first office visit to discuss possible HIV exposure. The coder will assign code: Z20.6. George Honker is diagnosed with acute hepatitis B without delta-agent with hepatic coma. The main term is ; the correct diagnosis code is . Hepatitis, B16.2 Primary immunodeficiency disorders include all of the following except: AIDS. Betty is being seen for a cervical cancer screening: The main term is ; the correct code is . screening, Z12.4 Arthur was diagnosed with cancer of the right acoustic nerve. The coder should assign code: C72.41. The Neoplasm Table is set up as a seven-column table organized by the information in column 1—the anatomical location of the tumor, in alphabetic order. Moving to the right, what information is in the third column? Malignant, secondary Randy Carson, a 53-year-old male, was admitted for chemotherapy due to pancreatic duct cancer. The coder should assign codes: Z51.111, C25.3. If a patient is admitted to the hospital for chemotherapy to treat breast cancer of the right breast, what is the principal diagnosis? Z51.111 The term indicates that the tumor has undergone malignant changes but is still limited to the site where it originated. Ca in situ Benjamin has been diagnosed with an atypical nevus of the trunk: The main term is ; the correct code is . Nevus, D22.5 Which of the following is a common test performed to check for malignant neoplasm of the cervix? Colposcopy Pamela was diagnosed with stage II lung cancer with mets to the brain. The coder should assign codes: C34.90, C79.31. If a patient with cancer is admitted for anemia due to an adverse effect of chemotherapy from breast cancer, what is the principal diagnosis? Anemia What is the correct diagnosis code for a patient being admitted for genetic testing for ovarian cancer? Z15.02 What is the correct code assigned for intraductal carcinoma in situ of the right breast?. D05.11 What is the correct code assignment for a 40-year-old patient who is admitted for prophylactic removal of both breasts due to a strong family history of breast cancer? Z40.01, Z80.3 is glandular secretion in abnormal quantity. Functional Activity When normal cells mutate, they create a: all of these In your ICD-10-CM, turn to code category Z16 in the Tabular List. Under the category code you will find an Excludes1 notation for Sepsis due to Methicillin resistant Staphylococcus Aureus. What code is suggested by this notation? is severe; serious. - A41.02 When a patient acquires a condition that develops as a result of being in a health care facility it is known as a(n) condition. - nonsocomial Staphylococcus aureus is what type of infection? -bacterial Exposure due to physical interaction with blood, bodily fluids, nonintact skin, and mucous membranes can enable a long list of bloodborne pathogens to make their way from one person to another. This type of exposure is known as: -touch exposure. Which of the following is not a communicable disease? -Colitis Which of the following can lay dormant for long periods of time? - viruses Davita, 2 days old, is diagnosed with sepsis due to E. coli. The coder should assign code? - P36.4 When there are no symptoms or manifestations this is known as: - asymptomatic Todd was diagnosed with acute pulmonary coccidioidomycosis. The coder should assign which code? - B38.0 An infection can spread through: - All of these When an infection or virus spreads throughout the entire body it is known as: -systemic Refer to the ICD-10-CM Official Guidelines I.C.2.d which state: When a primary malignancy has been previously or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category , Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. - excised, Z85 Mark is a 25-year-old male admitted with anemia due to antineoplastic chemotherapy used to treat his astroblastoma. The coder should assign which code for the principal diagnosis? -D64.81 Refer to the ICD-10-CM Official Guidelines I.C.2.c.3 which states: When the admission/encounter is for management of dehydration due to the malignancy and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced , followed by the code(s) for the malignancy. First What is the correct code assigned for chronic myelomonocytic leukemia in remission? -C93.11 A physical reaction, such as fever and chills, to an unspecified pathogen is a diagnosis referred to by the acronym -sirs The presence of unknown bacteria in the blood may be diagnosed as: -bactermia Joe was vaccinated for tetanus. He is now experiencing headaches and nausea. Dr. Jameson also notes hypotension as a complication from the vaccination. The coder should assign which code? - T88.1xxa The diagnosis of severe sepsis must include a(n): -organ dysfunction. What is the correct code for a patient diagnosed with sepsis due to group D Streptococcus? - A41.81 Signs of Cellulitis include all of the following except: -hypertension. Chickenpox is a: - viral In your ICD-10-CM book, turn to code J13 in the Tabular List. Under this code is a “Code also associated abscess, if applicable” notation. What is the code listed next to the “Code also associated abscess, if applicable" notation? - J85.1 AMR stands for: - Antimicrobial Resistance Tuberculosis is transmitted by: -air Anna has a family history of breast cancer. The coder should assign code: -Z80.3 What term indicates the tumor has not invaded any adjacent cells? -Benign is the study of the configuration or structure of living organisms. -Morphology What is the correct code assigned for intraductal carcinoma in situ of the right breast? - D05.11 The Neoplasm Table is set up as a seven-column table organized by the information in column 1—the anatomical location of the tumor, in alphabetic order. Moving to the right, what information is in the third column? - Malignant, secondary What is the correct code assignment for a 40-year-old patient who is admitted for prophylactic removal of both breasts due to a strong family history of breast cancer? - Z40.01, Z80.3 When the physician's notes do not include any specific information regarding the nature of the tumor, the coder should select a code from which column? - Unspecified When the physician's notes do not include any specific information regarding the nature of the tumor, the coder should select a code from which column? - secondary, metastasized The term indicates that the tumor has undergone malignant changes but is still limited to the site where it originated -Ca in situ Which of the following is a common test performed to check for malignant neoplasm of the cervix? - Colposcopy The first piece of information a coder needs to report a neoplasm is: -where in the body is the neoplasm located. If a patient is admitted to the hospital for chemotherapy to treat breast cancer of the right breast, what is the principal diagnosis? -Z51.111 Refer to the ICD-10-CM Official Guidelines I.C.2.b which states: When a patient is admitted because of a neoplasm with metastasis and treatment is directed toward the secondary site only, the neoplasm is designated as the principal diagnosis even though the primary malignancy is still present. -primary, secondary Which classification of neoplasm indicates that the pathologist is not able to determine whether the tumor is benign or malignant? -Uncertain Refer to the ICD-10-CM Official guidelines I.C.1.a.2.b which states: If a patient with HIV disease is admitted for an condition, the code for the condition should be the principal diagnosis. - Unrelated unrealated The diagnosis of sepsis must include: -a specified pathogen. If a patient is admitted for dehydration due to the chemotherapy treatments she has been receiving to treat ovarian cancer, what is the principal diagnosis? - E86.0 Which of the following codes is used to report a personal history of malignancy of the pancreas? - Z85.07 In your ICD-10-CM book turn to code category C81 in the Tabular List. Under this code category is an Excludes2 notation including “secondary neoplasm of bone marrow”. What is the code next to the secondary neoplasm of bone marrow? -C79.52 What is the correct principal diagnosis for a patient being seen for radiation therapy to treat prostate cancer? -Z51.0 Malignant cells have metastasized to distant parts of the body is tumor stage . -iv Refer to the ICD-10-CM Official Coding Guidelines I.C.21.c.5 which states: The of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic , not a screening. =--testing, examination If a patient with cancer is admitted for anemia due to an adverse effect of chemotherapy from breast cancer, what is the principal diagnosis? -Anemia Suber Wilson, a 57-year-old male, was diagnosed with a malignant neoplasm of the liver metastasized from the prostate; both sites are being addressed in today’s encounter. Principal diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the anatomical site -Prostate Do any of the following apply to the condition – Malignant, primary Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Excludes2 notation Is there a symbol indicating additional characters are required – No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C61 Second diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the anatomical site - Liver Do any of the following apply to the condition – Malignant, secondary Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C78.7 Ralph Bradley, a 36-year-old male, comes to see Dr. Harper because he is weak, losing weight, and vomiting and has diarrhea with some blood showing. Ralph was diagnosed with HIV 3 years ago. Dr. Harper completes an examination noting paleness, tachycardia, and tachypnea. Ralph is admitted to the hospital. The biopsied tissue from an endoscopy confirms a diagnosis of Kaposi’s sarcoma of gastrointestinal organ. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Human What type - Immunodeficiency virus disease Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - Yes If so does the Code first note apply to the case study – No Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –Yes If so does the Use additional code note apply to the case study – Yes Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B20 Second diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Sarcoma What type- Kaposi’s What is the anatomical site – gastrointestinal organ Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - Yes If so does the Code first note apply to the case study – Yes Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – No If so does the Excludes1 note apply to the case study – No Excludes1 notation Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - No Excludes2 notation Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C46.4 Robin Pullen, a 36-year-old female, comes to see Dr. Ditolla because she is running a fever and has a sore throat and overall body aches. Test results are positive for H1N1. Robin is diagnosed with swine influenza. Explanation Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Influenza What type - Swine Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - Yes Did you code to the highest level of specificity - Yes What is the correct diagnosis code – J09.X2 James Buckholtz, a 3-year-old male, is brought in by his parents. Jimmy has lost his appetite and is losing weight. Mrs. Buckholtz tells Dr. Ferguson that Jimmy’s gums bleed and he seems short of breath. Dr. Ferguson notes splenomegaly and admits Jimmy to Weston Hospital. After reviewing the blood tests, MRI scan, and bone marrow aspiration results, Jimmy is diagnosed with acute lymphoblastic leukemia. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Leukemia What type – acute lymphoblastic Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C91.00 George Donmoyer, a 58-year-old male, presents today with a sore throat, persistent cough, and earache. Dr. Selph completes an examination and appropriate tests. The blood-clotting parameters, the thyroid function studies, as well as the tissue biopsy confirm a diagnosis of malignant neoplasm of the extrinsic larynx. Principal diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the key term – Larynx What type - extrinsic Do any of the following apply to the condition – Malignant, primary Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C32.1 Jenny Cassidy, a 4-year-old female, is brought in by her parents to see her pediatrician, Dr. Harmon. Jenny has a fever and a rash on her back. Dr. Harmon notes a “strawberry tongue.” The completed CBC test confirms a diagnosis of scarlet fever. Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Fever What type – scarlet Do any of the following apply to the condition – uncomplicated Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries – Yes Is there an Includes notation – Yes If so does the Includes note help to clarify – Yes Is there a Code first notation – No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation – Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required – Yes Do you need to use the placeholder “X” – No Did you code to the highest level of specificity – Yes What is the correct diagnosis code – A38.9 Steven Crooks, a 16-year-old male, presents today with a sore throat. Dr. Hoffman notes acute pharyngitis with a low-grade fever, as well as petechiae on the roof of the mouth. A serological test confirms the diagnosis of Epstein–Barr infectious mononucleosis. Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Mononucleosis What type? Epstein-Barr Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B27.00 Kewane Childs, a 44-year-old female, has a history of smoking cigarettes for 15 years; she quit last year. Kewane sees Dr. Cope for a dry cough, hoarse voice, and coughing up blood. Dr. Cope notes crepitation and dyspnea. Kewane is admitted to the hospital. The MRI scan and lung function tests confirm a diagnosis of neoplasm of the trachea, malignant primary. Principal diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the anatomical site -Trachea Do any of the following apply to the condition – Malignant, primary Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –Yes If so does the Use additional code note apply to the case study – Yes Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C33 Second diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – History What type- personal What type-tobacco dependence Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation –No If so does the Includes note help to clarify –No Includes notation Is there a Code first notation - Yes If so does the Code first note apply to the case study – No Is there a Code also notation - Yes If so does the Code also note apply to the case study – No Is there a Use additional code notation –No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – Z87.891 Ben Kenton, a 49-year-old male, presents today with a high fever, chills, nausea, and diarrhea. After an examination and reviewing the results of the blood tests, Dr. Daniels diagnoses Ben with West Nile fever. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Fever What type - West What type - Nile Do any of the following apply to the condition – Unspecified Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – A92.30 Steven Crooks, a 16-year-old male, presents today with a sore throat. Dr. Hoffman notes acute pharyngitis with a low-grade fever, as well as petechiae on the roof of the mouth. A serological test confirms the diagnosis of Epstein–Barr infectious mononucleosis. Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Mononucleosis What type? Epstein-Barr Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B27.00 John Brennen, a 7-year-old male, is brought in by his parents. Johnny has developed a hard cough and says his sides hurt. Dr. Travis, Johnny’s pediatrician, completes blood work and takes a CXR and nasopharyngeal specimen. A subconjunctival hemorrhage is noted in the left eye. Test results confirm a diagnosis of whooping cough due to Bordetella pertussis with pneumonia. Johnny is admitted to Weston Hospital. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Whooping cough Due to - Bordetella pertussis Do any of the following apply to the condition - with pneumonia Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – A37.01 Second diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Hemorrhage What is the anatomical site-conjunctiva What is the laterality - left Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation –Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – H11.32 George Donmoyer, a 58-year-old male, presents today with a sore throat, persistent cough, and earache. Dr. Selph completes an examination and appropriate tests. The blood-clotting parameters, the thyroid function studies, as well as the tissue biopsy confirm a diagnosis of malignant neoplasm of the extrinsic larynx. Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the key term – Larynx What type - extrinsic Do any of the following apply to the condition – Malignant, primary Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C32.1 Mitchell Lane, a 48-year-old male, presents with the complaints of night sweats and weight loss. Dr. Clark completes an examination noting hemoptysis and takes a chest x- ray, which reveals a mass. Mitchell is admitted to Weston Hospital where a CT-guided needle biopsy is then performed. Mitchell is diagnosed with a malignant primary neoplasm of the posterior mediastinum. Principal diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasm What is the anatomical site -Mediastinum What is the location – Posterior Do any of the following apply to the condition -Malignant, primary Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Excludes2 notation Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C38.2 Raykeem McFadden, a 63-year-old female, was last seen in this office 6 months ago for her annual checkup; no concerns were noted at that time. She presents today because of excessive itching after a warm bath. She also complains of a burning sensation in her arms, especially her left arm. Dr. Dingle completes a physical exam and notes aphasia, hepatosplenomegaly, and some loss of physical coordination. Raykeem is admitted to the hospital. The laboratory tests and bone marrow aspiration confirm a diagnosis of polycythemia vera. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Polycythemia What type - Vera Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Excludes2 notation Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – D45 ICD-10-CM code range J00-J99 identifies the Diseases of the - Respiratory system Emily is diagnosed with rat-bite fever. The coder should assign which code? - A25.9 The physician's notes state, "Chest congestion, possible pneumonia." The coder in the physician's office should code: - Chest congestion NEC means - the ICD-10-CM book didn’t provide a code with more details. If one code exists with a description that includes two or more diagnoses identified in one patient at the same time, you must choose the code that includes as many conditions as available. These codes are known as: - combination codes Once you have a suggested code from the Alphabetic Index, Neoplasm Table, Table of Drugs and Chemicals, and/or the Index to External Cause Codes, you will need to find that code in the - Tabular List of Diseases and Injuries. Which of the following would not be considered a systemic condition? - sprain of left corahumeral Susan presents today for procreative management genetic testing. The main term is , and the correct diagnosis code is . - Testing, Z31.438 The correct code for acute and chronic respiratory failure with hypoxia is - J96.21. Outpatient coders cannot assign a diagnosis code for a diagnosis documented as: - All of these The notation identifies codes that cannot be used together on the same health claim form with the originally listed code. - Excludes1 Which code range identifies the diseases of the digestive system? - K00-K95 A is used in the Alphabetic Index to indicate that additional characters are required. - Hyphen An example of a condition is - A wound One disease that affects or encourages another condition is known as a: - underlying condition. What is the first step in looking up an ICD-10-CM diagnosis code? - Look up the main term in the Alphabetic Index. The notation provides you with additional terms and diagnoses that are included in the above code (this code’s description). - Includes Suzie came in contact with a co-worker who was diagnosed with varicella. Suzie has no signs or symptoms of the disease. She visits Dr. Hearn to be on the safe side. The coder should assign code: - Z20.820. Refer to the ICD-10-CM Official Guidelines Section IV.C. This guideline concerns: - Accurate reporting of ICD-10-CM diagnosis codes In the ICD-10-CM Alphabetic Index turn to Disease>Alzheimer’s. What punctuation(s) do you find? - Slanted brackets What is the correct code for a patient being examined for allergies? - Z01.82 The rules for coding uncertain diagnoses for patients of an inpatient facility are different from those for outpatients. You will find the guideline in which section? - Section II.H A code surrounded within italicized, or slanted, brackets - must be included. If two (or more) diagnoses are of equal severity, then report them in order of anatomical site— . -head to toe What section of the ICD-10-CM code book would provide you with a suggested code to describe how a patient was injured? - External Cause of Injuries Index The ICD-10-CM Official Guidelines I.A.16 are guidelines with instructions concerning which word(s)? - “See” and “See Also” Jim is scheduled for respiratory surgery. He presents today for a preoperative examination. The main term is , and the correct diagnosis code is . - Examination, Z01.811 A patient complains of dizziness. The physician states that she has hypertension. The coder should assign a code for: - hypertension. Steve is starting a new job and is required to complete a preemployment examination. Dr. Rogers completed the exam and signs the paperwork. How is this encounter coded? - Z02.1 Matthew came to see Dr. Lindsay complaining of fever, diarrhea, and vomiting. Matthew is diagnosed with influenza with gastrointestinal manifestations. The coder should assign code: - J11.2. A condition that affects the entire body and virtually all body systems, therefore requiring the physician to consider this in his or her medical decision making for any other condition is known as a: - systemic condition. The Tabular List section of the ICD-10-CM book lists every code and its complete description in order by code. - alphanumeric What is the correct external cause code for a patient who fell out of a stationary wheelchair, initial encounter? - W05.0XXA There are times when a fifth, sixth, or seventh character is required, yet there are no fourth, fifth, or sixth characters. In these cases, ICD-10-CM uses a placeholder character, the letter , so the following characters will fall into their correct locations. - X In the ICD-10-CM Alphabetic Index turn to Pneumoconiosis. What punctuation(s) do you find? - Parentheses According to the ICD-10-CM Official Guidelines, I.C.21.c.5: is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease. - screening The word or phrase means the same thing as NEC: The physician specified additional information that the ICD-10-CM book doesn’t have in any of the other codes in the category. - Other specified The notation is a reminder that you are going to need another code to identify the underlying disease that caused the diagnosed condition. -code first A/An notation is a warning to stop and double-check the documentation so you don’t report the code above the notation when a code shown in the notation may be more accurate. - Excludes2 Turn to Hypertension in the ICD-10-CM Alphabetic Index. All of the following are listed as nonessential modifiers except - organic ICD-10-CM code range V00-Y99 identifies - External causes of morbidity Throughout the ICD-10-CM code book you will find which of the following to help guide you to the most accurate code for a patient encounter? - all of these According to the ICD-10-CM Official Guidelines, section corresponds to Selection of Principal Diagnosis. - II Alicia is diagnosed with acute myocarditis due to Streptococcus. The coder should assign which code? - I01.2 NEC stands for: - not elsewhere classifiable. Sylvia McCray, a 17-year-old female, presents today with a headache and dull facial pain between and behind her eyes. Dr. Clayton orders a CT scan, which confirms the diagnosis of acute ethmoidal sinusitis, infection due to staphylococcus. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Sinusitis What is the anatomical site -ethmoidal Do any of the following apply to the condition – Acute Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –Yes If so does the Use additional code note apply to the case study – Yes Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – J01.20 Second diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Infection What type- Staphylococcus Do any of the following apply to the condition – As cause of disease classified elsewhere Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B95.8 Lauren Wheatle, a 68-year-old female, presents today with chest discomfort when resting. Dr. Billings completes an examination with ECG. The ECG reveals an elevated ST segment. Lauren is admitted to the hospital, where blood tests show elevated cardiac enzymes and a cardiac echo confirms the diagnosis of variant angina. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Angina What type- Variant Do any of the following apply to the condition – With documented spasm Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – I20.1 Herman Carson, a 32-year-old male, presents with a severe headache and occasional nosebleeds. Dr. Wells completed an examination recording a blood pressure reading of 180/110. Herman is hospitalized, where an ECG and echocardiogram confirm the diagnosis of malignant hypertension. Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term - Hypertension Do any of the following apply to the condition- None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – I10 Margaret Carll, a 28-year-old female, presents today with the complaint of feeling dizzy and has some headaches. Dr. Dithomas notes a fever and completes an ECG, which shows an ST depression. PMH and PFH are noncontributory. Margaret is admitted to the hospital, where further blood tests, a chest CT scan, and a ventilation scan confirm the diagnosis of hyperventilation (tetany). Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Hyperventilation Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code note Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – R06.4 Elizabeth Hagun, a 35-year-old female, spent yesterday afternoon outside in the full sun; now she is experiencing severe itching. She comes to see Dr. Jerod, who completes an examination and notes skin redness and blistering. Elizabeth is diagnosed with acute dermatitis due to solar radiation. Code the dermatitis. rincipal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Dermatitis What type-Radiation Due to-Sun Do any of the following apply to the condition – Acute Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – No If so does the Excludes1 note apply to the case study – No Excludes1 notation Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – L56.8 will show you alternate terms, alternate phrases, and/or synonyms to provide additional detail or explanation to the description.a.Brackets 2. What section of the ICD-10-CM code book would provide you with a suggested code to describe how a patient was injured?a.External Cause of Injuries Index 3. What is the correct code for a patient being seen for high-risk bisexual behavior?a.Z72.53 4. According to the ICD-10-CM Official Guidelines, section corresponds to Selection of Principal Diagnosis.a.II 5. An example of a condition isa.Wound 6. Once you have a suggested code from the Alphabetic Index, Neoplasm Table, Table of Drugs and Chemicals, and/or the Index to External Cause Codes, you will need to find that code in thea.Tabular List of Diseases and Injuries. 7. Jim is scheduled for respiratory surgery. He presents today for a preoperative examination. The main term is , and the correct diagnosis code is .a.Examination, Z01.811 8. What is the correct code for a patient being examined for allergies?a.Z01.82 9. If one code exists with a description that includes two or more diagnoses identified in one patient at the same time, you must choose the code that includes as many conditions as available. These codes are known as:a.combination codes.10.A located to the left of a code in the Tabular List is a symbol that notifies you that an additional character is required.a.box with a checkmark and number 11. When the physician indicates that the patient’s signs and symptoms may closely lead to two different diagnoses and using the wordversusoror between two diagnostic statements this is known as a/an:a.differential diagnosis. 12. Sam was diagnosed with dysphasia following a nontraumatic intracerebral hemorrhage. The coder should assign code:a.I69.121. 13. The section of the ICD-10-CM code book listing drugs, chemicals, and other biologicals that may poison a patient or result in an adverse reaction is known as the:a.Table of Drugs and Chemicals. 14. Outpatient coders cannot assign a diagnosis code for a diagnosis documented as:a.All of these The condition, after study, that is the primary, or main, reason for the admission of a patient to the hospital for care; the condition that requires the largest amount of hospital resources for care is known as the: a.Principal diagnosis 16.The Neoplasm Table is set up as a seven-column table organized by theinformation in column 1—the anatomical location of the tumor, in alphabetic order. Moving to the right, what information is found in column four?a.Ca in situi.The Neoplasm Table is set up as a seven-column table organized bythe information in column 1—the anatomical location of the tumor, in alphabetic order. Moving to the right, the following six columns show the suggested code in the following order:1.Anatomical location2.Malignant, Primary 3.Malignant, Secondary4.Ca in situ5.Benign6.Uncertain Behavior7.Unspecified Behavior17.The correct code for acute and chronic respiratory failure with hypoxia isa.J96.21. Anna Blanks, a 68-year-old female, presents with a cyst on the anterior wall of her vagina. After an examination, Dr. Hervey takes a tissue biopsy and orders a CT scan. Anna is diagnosed with a primary malignant neoplasm of the Skene’s gland. Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the key term – Skene’s gland Do any of the following apply to the condition- Malignant, primary Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Excludes2 notation Is there a symbol indicating additional characters are required -Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C68.1 Paul Plum, an 8-month-old male, is brought in by his mother to see Dr. Wallace, Paul’s pediatrician. Paul’s stomach feels hard and he is also having some diarrhea and vomiting. Dr. Wallace notes Paul is failing to thrive and hospitalizes him. After blood tests and a hydrogen breath test are completed, Paul is diagnosed with congenital lactase deficiency. Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Deficiency Do any of the following apply to the condition – Lactase Do any of the following apply to the condition – Congenital Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Excludes2 Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – E73.0 Erina Castles, a 43-year-old female, presents today with a few pimples on her chest. Dr. Moss noted some slight redness and swelling in the area and orders blood tests. The results of the blood tests confirm the diagnosis that Erina is a carrier of staphylococcal, methicillin resistant (MRSA). Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term - Carrier What type– bacterial disease Do any of the following apply to the condition- Staphylococcal, methicillin resistant (MRSA) Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code note Is there an Excludes1 notation – No If so does the Excludes1 note apply to the case study – No Excludes1 note Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – Z22.322 Sylvia McCray, a 17-year-old female, presents today with a headache and dull facial pain between and behind her eyes. Dr. Clayton orders a CT scan, which confirms the diagnosis of acute ethmoidal sinusitis, infection due to staphylococcus. Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Infection What type- Staphylococcus Do any of the following apply to the condition – As cause of disease classified elsewhere Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B95.8 Carolyn Mann, a 34-year-old female, presents today with intense itching and a burning sensation of her anus. Dr. Neal completes an examination and diagnoses her with pruritus ani, stage 2. Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Pruritus What is the anatomical site -ani, anus What is the stage-2 Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – L29.0 are known as the official policies issued by the President of the United States. - Executive Orders What is the responsibility of a privacy officer? - To develop and implement privacy policies and procedures What were the HIPAA Privacy Rules written to protect? - An individual's personal health information Which office strongly recommends or mandates a formal compliance program? - OIG What are professional coding specialists obligated to do? - Comply with the Privacy Rule An example of a health care provider, under HIPAA, is: - a dentist. Which of the following is not a section of HIPAA? - Federal False Claims Act Blue Cross Blue Shield is an example of a: - health plan. Under HIPAA, a covered entity includes all of the following except a: - health care school. HIPAA applies to: - all health care workers. Providers are not permitted to use or disclose PHI without a patient's written permission in which instance? - Detailed data sets An example of a federal law is: - HIPAA. As a coder, if you are involved in fraud in your facility, you can: - both be fined and go to jail. What is upcoding? - A code on a claim form that indicates a higher level of service than that which was actually performed Someone convicted of violating HIPAA rules can be charged with: - both civil penalties and criminal penalties. is the act of knowing due to their job position, training, or responsibilities within the organization with regard to filing the claim but purposely don’t ask about the validity of the information, or ignoring the falsity of the information. - Willful ignorance Choosing a code that represents a more intense procedure than that which was actually provided is called: - upcoding. In order to properly code, coders are permitted to: - code documentation written in the medical record. HIPAA violations are reported to which of the following agencies? - Office of Civil Rights in the Department of Health and Human Services When Dr. Katlyn "discloses" PHI, according to HIPAA, it means she is discussing a patient with: - a physical therapist at the hospital. What can the lack of accuracy of coding affect? - It can directly influence reimbursement to providers. A release of information form must: - All of these It is illegal to bill for a component service when - a comprehensive code or combination code is available. Using three codes to report procedures rather than one combination code is called: - unbundling. A $100 fine with no prison time is the penalty for a HIPAA: - civil violation. New CPT codes go into effect each year on: - January 1st. Dr. Pearson inserted a myringotomy tube into Larry's right eustachian tube. To determine the correct code, you will look this up in the Alphabetic Index as: - eustachian tube, inflation, myringotomy Frank is having a rhythm electrocardiography for evaluation of his condition. Look this up in the Alphabetic Index as: - electrocardiography>rhythm>evaluation. MIPS stands for: - Merit-based Incentive Payment System. CPT stands for: - Current Procedural Terminology. The triangle symbol next to a CPT code indicates: - a revised code. A physician performed a colposcopy in the medical office. Which code set would be used? - CPT Which of the following has an indented code description? - 37616 Guidelines for coding radiology procedures can be found: - at the beginning of the radiology section. Locate the Medicine section of the CPT manual. Now locate the in-section guidelines for Immunization Administration for Vaccines/Toxoids. Report code(s) only when the physician or qualified health care professional provides face-to-face counseling of the patient/family during the administration of a vaccine. - 90460 and 90461 Category II codes end in the letter . -F The CPT Alphabetic Index lists entries by all of the following except: - length of time. An open circle with slash symbol next to a code indicates: - exemptions to modifier 51. Category II codes are: - for supplemental tracking of performance measurement. Where will coders find the most accurate information for coding an encounter? - Physician's notes A surgical procedure may be coded from CPT codes - 10021–69990. Physician services for performing an open-heart surgery would be coded from: - 10021–69990. A CT scan would be coded from: - 70010–79999. Which of the following facilities is considered an outpatient facility? - All of these A star symbol next to a CPT code indicates: - telemedicine. An indented description or term indicates that: - it attaches to the description or term that appears at the margin of the column above. The unlisted service or procedure code for a noninvasive vascular diagnostic study is . - 93998 The CPT codes are used to report: - what treatments were provided to the patient. In the CPT book, radiology service codes range from: - 70010–79999 You can use a CPT code to report all of the following except: - a wheelchair. According to HIPAA, if Dr. Briscoe asks John if he would like his wife to also hear about his test results, this falls under: - opportunity to agree or object. The statistics show that for every $1 spent to pay for health care fraud and abuse investigations and prosecutions, the government actually brings in about in money returned. - $4 By catching those who submitted fraudulent claims, approximately was won or negotiated by the federal government during fiscal year 2014. - $2.3 billion According to HIPAA, if Renee accidentally overhears Dr. Moore talking with Nurse Johnson about her neighbor, what does this fall under? - Incidental use and disclosure Before placing a code on a claim, what must a professional coding specialist make certain he or she has? - Supporting documentation What does the sharing of information with someone outside of the health care facility require? - Written permission under HIPAA Which department or act was the Health Care Fraud and Abuse Control Program created by? - Health Insurance Portability and Accountability Act What does the acronym HIPAA abbreviate? - Health Insurance Portability and Accountability Act It is fraudulent for a coder to: - All of these What must written approvals to release PHI include? - Specifically identify the person or organization that will be disclosing the information What is an example of a health plan, under HIPAA? - Aetna health insurance Which of the following is commonly known as the Whistleblower Statute? - Qui tam provision What is the primary purpose of HIPAA's Privacy Rule? - Protecting a patient's health information What amount can one expect to pay in civil penalties for violating HIPAA rules? - Up to $25,000 A $100 fine with no prison time is the penalty for a HIPAA: - civil violation. To know the correct code to use, you should: - follow all guidelines. What are the two main coding professional organizations that have published a code of ethics guide? - AAPC and AHIMA The double sideways triangles next to a CPT code indicate: - new or revised text. A code for a chest x-ray may be found in: - 70010–79999. There are additional guidelines and instructions throughout each section. These guidelines are referred to as . - in-section guidelines An arrow in a circle symbol indicates: - reference to CPT Assistant, Clinical Examples in Radiology, and CTP changes. An add-on code can: - never be used alone. Category II codes are used to: - track and measure performance and the quality of care provided in a health care facility. Dr. West is an anesthesiologist. Codes for the services he provides will come from code range from: - 00100–01999. The bullet symbol next to a CPT code: - identifies a new code, one that is in the CPT book for the first time. A CPT category I code has: - five numbers and are listed in the main text of the CPT book. Which of the following is not an indented code description? - 61680 A code for a urinalysis would be found in: - 80047–89398. The unlisted service or procedure code for a reproductive medicine laboratory procedure is . - 89398 A code for a complete blood count (CBC) test can be found in which range? - 80047–89398. Steps involved in coding the procedures include all of the following except: - verifying the patient’s insurance coverage. A hospital emergency department is considered: - outpatient services. What is the fifth step in the coding process? - Check for any relevant guidance, including reading all of the symbols and notations. Category III codes are: - four numbers followed by the letter T. Rosetta presents today for sclerotherapy of a fluid collection, percutaneous. In the CPT book, which term will you look up in the Alphabetic Index? - Sclerotherapy According to HIPAA, if Dr. Rappier diagnoses Charlene with a contagious disease, he must notify the Department of Health. What circumstance does this fall under? - Public interest According to HIPAA, a Privacy Notice must include: - both contact information for the Department of Health and Human Services and contact information for the facility’s privacy officer. "It’s not my concern. I just do what I am told" is an example of . - Disregard. It is illegal to bill for a component service when: - a comprehensive code or combination code is available. What does the Federal False Claims Act forbid? - Inaccurate submission of health care claims for financial gain A plus sign next to a CPT code: - indicates the code cannot be reported alone. Procedures provided by the physician are reported with what classification system? - CPT A code for a new surgical technique may be found in: - 0042T–0542T. Evaluation and Management codes range from: - 99201–99499. Category III codes are used for: - reporting emerging technology, services, and procedures. When should a coder query the physician? - When there is unclear or missing information necessary to code an encounter Anesthesia codes range from: - 00100-01999 and 99100-99140. laws are those governing the behavior of the actions of the population related to health and well- being. - Criminal What does a compliance program officially do? - Creates policies and procedures to be followed within an organization A covered entity's workforce, under HIPAA, includes all except a(n): - outside computer repair company. Howard Shires, a 78-year-old male, was diagnosed with advanced Alzheimer’s disease about 1 year ago and has been in this facility for approximately 10 months. He was seen today by the nursing facility’s physician, Dr. Bowyer, over concern of the development of urinary and fecal incontinence, as well as a number of other medical problems that have appeared to increase in severity. In addition to the detailed interval history, the physician spoke with family members and the nursing staff. Then, Dr. Bowyer reviewed the patient’s record to create an extended history necessary for an extended review of systems (ROS). Dr. Bowyer performed a comprehensive physical exam to assess all body systems. Afterward, he wrote all new orders due to the dramatic change in the patient’s physical and mental condition. A new complex treatment plan was created. - 99310 Keith Pawley, a 34-year-old male, came to see Dr. Praylow, his dentist, for an implant-supported porcelain crown on his back tooth. - D6065 Carl Gadsden, a 66-year-old male, was diagnosed with intrinsic laryngeal cancer, supraglottic T1 tumor. With the tumor confined to one subsite in the supraglottis, Dr. Yoshihashi provided radiation treatment delivery, with a single port, simple block, of 4.5 MeV. - 77402 Olivia Kane, a 33-year-old female, came into Kinsey Imaging Center for her annual screening mammogram. Due to her family history of malignant neoplasms of the breast (both her mother and sister have been diagnosed), the mammogram was ordered with computer-aided detection (CAD). - 77067 Dr. Astrone performed a complete ultrasound evaluation of Alden Roberts’s pelvis. The procedure included evaluation and measurement of Alden’s urinary bladder, evaluation of his prostate and seminal vesicles, and pathology of his enlarged prostate. - 76856 Before beginning a series of treatments, Anna Hogan came to the Diagnostic Imaging Center for a metabolic evaluation PET scan of her brain. - 78608 Johnette Potash, a 13-year-old female, lost her retainer at camp. She is at Dr. Rivera’s office to get a replacement. - D8692 Premier Life & Health Insurance Company required David Harrison, a 39-year-old male, to get Dr. Dijohn, his regular physician, to complete a certificate confirming that David’s current disability prevents him from working at his regular job and makes him eligible for disability insurance - 99455-32 William Browne, a 15-year-old male, is brought into Dr. Jenkins’s office with severe right leg pain. Dr. Jenkins takes x-rays of his right femur, AP and PA, to determine whether or not Bill’s leg is fractured. - 73552-RT Xavier Pollack, a 62-year-old male, arrived at the Kinsey Imaging Center to have a SPECT (single photon emission computed tomography) performed on his left kidney - 78710-LT Dr. Logan saw Jason Miolo, a 38-year-old male, with a swollen right eye and loss of vision. Dr. Logan ordered a CT with contrast of the right eye and area, which revealed marked proptosis of the right orbit, thrombosis, and enlargement of the right superior ophthalmic vein. - 70481 Allen Jeter, a 48-year-old male, was being prepared for his kidney transplant. The nurse administered 100 mg of Zenapax, IV, parenteral. Code the drug. - J7513x4 Raymond Catertell, a 23-year-old male, is the son of two alcoholics. Dr. Lowen spends 40 minutes with him providing risk factor reduction behavior modification techniques to help him avoid becoming an alcoholic himself. - 99403 After Allen Jeter (previous case study) received his kidney transplant, the nurse gave him an oral dose of 250 mg of CellCept (mycophenolate mofetil) in the hospital. Code the drug. - J7517 Dr. Harrington provided care plan oversight services for Verniece Dantini, one of her patients at the Bracker Assisted Living Center. It took her 20 minutes. - 99339 Edith Shapin, a 24-year-old female, is pregnant for the first time and is at approximately 11 weeks gestation. She is brought into the diagnostic center for a fetal biophysical profile with nonstress testing. - 76818 Dr. Modesta spent 2½ hours evaluating Carolina Tanner upon her admission into the ICU. - 99291 99292x3 Brianna Haralson, a 24-year-old female, is brought into Dr. Duncan’s office with sharp pains in her lower right abdomen, shooting across to the left side. Dr. Duncan ordered some blood work and an MRA to confirm the suspected diagnosis of acute appendicitis. Code the MRA. - 74185 Maxine Zeigleman, newly diagnosed with metastatic lumbar spinal tumors, has been referred to Dr. Appleton for the creation of a simple radiation therapy plan. - 77261 Dr. Kaminsky spends approximately 1 hour in a meeting with an oncologist and a reconstructive surgeon. The three professionals discussed treatments and options for Karyn Cassey, a 41-year-old female, who was recently diagnosed with parosteal osteogenic sarcoma. Code the conference. - 99367 Zena Awtrey, a 58-year-old female, sees Dr. Lunden for the first time for a variety of medical problems. She was diagnosed 5 years ago with insulin-dependent diabetes mellitus with complicating eye and renal problems. In addition, she suffers from hypertensive heart disease with episodes of congestive heart failure. Her peripheral vascular disease has worsened, and she can walk only a block before being crippled with extreme leg pain. The patient reports that a new problem has surfaced: throbbing headaches with radiating neck pain. Dr. Lunden and Zena thoroughly discuss her health concerns and issues. In order to manage and investigate the multiplicity of problems, Dr. Lunden takes a complete PFSH. A complete review of systems (ROS) is performed and comprehensive physical exam is completed. Dr. Lunden has to take a multitude of factors into consideration, as the patient’s problems are highly complex. - 99205 Martha Lightfood, an 82-year-old female, was brought into Dr. Morrison’s office by her daughter because Martha was complaining of a sharp pain in her chest. After a negative EKG, Dr. Morrison had a quantitative differential pulmonary perfusion and ventilation study performed, which confirmed a pulmonary embolism. Martha was taken immediately by ambulance to the hospital. Code the quantitative differential pulmonary perfusion and ventilation study only. - 78598 Bernard Kristenson moved into the Prader Assisted Living Center today. Dr. Ramada, the center’s resident physician, introduced himself to Bernard and then took an extended HPI and pertinent PFSH. Dr. Ramada performed a comprehensive examination. After reviewing the results of the examination, Dr. Ramada found management of Barnard’s case to be moderate complexity. - 99326 Roberta Henthorne, a 52-year-old female, was recuperating from surgery to repair a complex fracture of her tibia and a compound fracture of her ankle. To help her be more comfortable, Dr. Locklear ordered a fixedheight hospital bed, without side rails and with a mattress, for her to use at home. Code for the DME only. - E0290 Dennis Lederrick, a 39-year-old male, had surgery on his left foot. To enable him to take a shower safely, Dr. Willrodt gave him a tub stool to sit on. - E0245 Vernon Unger had been diagnosed with a malignancy and came today for intravenous radiopharmaceutical therapy. - 79101 Jonelle Graybar, a 73-year-old female, was experiencing pain in her back that radiated around her trunk. She was also suffering with spastic muscle weakness. Dr. Maxwell ordered a radioisotope bone scan of Jonelle’s lumbar spinal area. The scan identified a metastatic invasion of L1–L3. - 78300 Scott Zamcho came home from serving in the Marines a double amputee, having had both legs damaged badly in a suicide bomber’s attack. Dr. Lovell supplied him with an amputee wheelchair, desk height, with detachable arms and no footrests or leg rests. - E1172 Sandra Lewis, a 55-year-old female, has been experiencing pain in her lower left back that wraps around to her inner thigh. Dr. Janson does a renal ultrasound, limited, real time with image documentation. - 76775 Jamie Farmer, a 32-year-old male, goes to his family physician, Dr. Mitchell, for a tetanus shot after stepping on a rusty nail at the beach. While there, he asks Dr. Mitchell to look at a cut on his left hand. Dr. Mitchell examines the wound and tells him to keep the wound clean and bandaged. Dr. Mitchell documents a brief HPI and performs a limited exam of the left hand, MDM straightforward. Code only the E/M. - 99212-25 - PATIENT: HOLDER, ANDREW ACCOUNT/EHR #: HOLDAN001 DATE: 12/10/18 - - Procedure Performed: CT brain w/o contrast - Radiologist: Michael B. Hawkins, MD - Clinical Information: Evaluation for VP shunt, postsurgical - Attending Physician: Renee O. Bracker, MD - TECHNICAL INFORMATION: Contiguous 3-mm-thick axial images were obtained through the skull base and posterior fossa structures followed by 7-mm-thick axial images through the remainder of the brain. The examination was performed without the use of intravenous contrast material. - The scan was performed at an independent imaging center and sent to me via secured PACS system, so I could interpret. - - INTERPRETATION: Evaluation of the posterior fossa demonstrates bilateral vertebral artery calcification. No abnormal intra- or extra-axial collections are noted. There is no evidence of midline shift. - - Analysis of the region of the sella turcica demonstrates calcification, likely atherosclerotic involving the cavernous carotid arteries bilaterally seen on series 2 image 7. - - Supratentorially, the lateral ventricles are prominent in size. A ventriculostomy catheter is seen coursing from the region of the postcentral sulcus with its distal tip terminating within the frontal horn of the right lateral ventricle abutting the septum pellucidum. Hypodensity is seen within the periventricular white matter particularly abutting the frontal horns of the lateral ventricles bilaterally. There is a mild degree of cerebral volume loss. No abnormal intra- or extra-axial collections are noted. - - Evaluation of the visualized skull and paranasal sinuses demonstrates a right parietal burr hole defect for placement of the patient’s ventriculostomy catheter. A subcutaneous ventriculostomy valve is seen on series 3 image 26. - - RECOMMENDATIONS: There is mild prominence of the lateral ventricles bilaterally without evidence of dilation of the cerebral aqueduct or fourth ventricle. - - MBH/mg D: 12/10/18 09:50:16 T: 12/12/18 12:55:01 - ------- 70450-26 ATIENT: TURNER, CHARLES ACCOUNT/EHR #: TURNCH001 DATE: 10/01/18 Attending Physician: Renee O. Bracker, MD S: This 27-year-old male was brought to the ED by ambulance after he was found unconscious on the living room floor. He regained consciousness within several minutes but complained of a severe headache and nausea. Pt states that the last thing he remembers he was on a ladder, changing a light bulb. He believes he lost his balance trying to reach too far and fell, hitting his head on the end-table. O: Ht 5’10”, Wt 195 lb., R 16. Head: Scalp laceration on the right posterior parietal bone. Bruise indicates trauma to this area. Eyes: PERRLA. Neck: Neck muscles are tense; there is minor pain upon rotation of the head. Musculoskeletal: All other aspects of the shoulders, arms, and legs are unremarkable. X-rays of skull, two views, and soft tissue of the neck are all benign. A: Concussion P: 1. MRI to rule out subdural hematoma 2. Repair laceration and bandage ROB/mg D: 10/01/18 09:50:16 T: 10/05/18 12:55:01 ------ 99281 PRADER, BRACKER, & ASSOCIATES A Complete Health Care Facility 159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789 PATIENT: HENSLEY, ERNEST ACCOUNT/EHR #: HENSER001 DATE: 09/29/18 Attending Physician: Benjamin L. Johnston, MD Referring Physician: Oscar R. Prader, MD S: Pt is a 35-year-old male, referred by Dr. Prader for a consultation regarding a sore on his left temple, at the hairline. Pt states he is very involved in water sports. He knows the importance of sunscreen; however, he does not always remember to put it on. He has not had any dermatologic concerns prior to this. Patient states that his skin is occasionally dry and that he has adult onset acne. O: Ht 6’1”, Wt 225 lb., R 17, T 98.6. After an examination of the skin along the hairline, as well as the rest of the face and neck, a culture is taken of the lesion. The pathology report confirms a malignant melanoma of the skin of the scalp. A: Malignant melanoma, scalp P: 1. Discuss surgical and pharmaceutical options for treatment 2. Report sent to Dr. Prader ORP/mg D: 09/29/18 09:50:16 T: 10/01/18 12:55:01 99242 KINSEY IMAGING CENTER 951 SYDNEY STREET • SOMEWHERE FL 32811 • 407-555-3573 PATIENT: WILLARD, NADINE ACCOUNT/EHR#: WILLNA001 DATE: 09/29/18 Procedure Performed: CT angiography of the head, without contrast and with contrast Radiologist: Kevin Linnard, MD Referring Physician: Renee O. Bracker, MD INDICATIONS: Left CVA IMPRESSIONS: The current study is compared with the previous one of 05-25-14. Compared with the previous study, there is a focal area of hypodensity present in the right posterior cerebral arterial distribution adjacent to the falx, a finding suspicious for a small acute infarction, nonhemorrhagic, most likely the parieto-occipital branch. No other abnormality detected. There are no intra- or extra-axial hemorrhages. There is no significant midline shift or hydrocephalus. Small new area as described above is suspicious for an area of acute infarction in the right posterior cerebral arterial distribution, likely the occipital branch. Please clinically correlate. Kevin Linnard, MD KL/mg D: 09/29/18 09:50:16 T: 09/30/18 12:55:01 ---- 70496 PRADER, BRACKER, & ASSOCIATES A Complete Health Care Facility 159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789 PATIENT: SARGENT, ALEXANDER ACCOUNT/EHR #: SARGAL001 DATE: 10/25/18 Attending Physician: Renee O. Bracker, MD S: This 85-year-old male is seen today at Northside Assisted Living Center, where he has been living for the last 6 months. The last time I saw this patient was right before he moved into the center. Nurse Thomas states that he has been complaining of mild abdominal pain and some discomfort upon urination. Other than this issue, he has been well and stable. O: Ht 5′6.5″, Wt 145 lb., R 18, P 73, BP 137/81. Abdomen is unremarkable. No masses or rigidity noted. A: Suspected bladder infection P: Order written for UA to rule out bladder infection. ROB/mg D: 10/25/18 09:50:16 T: 10/28/18 12:55:01 ------ 99334 PATIENT: JAQUARD, JOEL ACCOUNT/EHR #: JAQUJO001 DATE: 10/01/18 Procedure Performed: X-rays, skull, two views CT, soft tissue of neck, with contrast MRI, brain stem Radiologist: Robyn Campbell, MD Referring Physician: Renee O. Bracker, MD INDICATIONS: Concussion, after fall from ladder IMPRESSIONS: 1. Full muscle and tendon retraction of the supraspinatus and infraspinatus structures. 2. Bruising and possible microfractures to the skull at occipital base. 3. Other partial tearing of the superior aspect of the semispinalis capitis RC/mg D: 10/01/18 09:50:16 T: 10/02/18 12:55:01 ------- 70250 70491 70551 ATIENT: BURMAN, CECILIA ACCOUNT/EHR #: BURMCE001 DATE: 10/17/18 Procedure Performed: MRI, brain, no contrast MRA, brain, no contrast MRA, neck, no contrast Radiologist: Eryn Alberts, MD Clinical Information: Evaluate for VP shunt No prior studies available for a comparison TECHNICAL INFORMATION: The examination was performed without the use of intravenous contrast material. INTERPRETATION: Evaluation of the posterior fossa demonstrates hydrocephalus versus low pressure communicating hydrocephalus. Eryn Alberts, MD EA/mg D: 10/17/18 09:50:16 T: 10/20/18 12:55: --------- 70551 70544 70547 PATIENT: SAVOY, MARCELLA ACCOUNT/EHR #: SAVOMA001 DATE: 09/17/18 Procedure Performed: MRI, Spinal canal, thoracic, 3 views CT, abdomen/pelvis Radiologist: Keith Robbins, MD Referring Physician: Oscar R. Prader, MD INDICATIONS: Probable metastatic disease, T1–T3, asymptomatic; metastatic mucinous adenocarcinoma of unknown primary IMPRESSIONS: MRI scans also showed edema at T1, T2, and T3, but no obvious metastatic disease. In the course of her evaluation, a CT of the abdomen and pelvis showed some mild common bile duct dilation, but no obvious primary malignancy. Keith Robbins, MD KR/mg D: 09/17/18 09:50:16 T: 09/20/18 12:55 --------- 72146 74176 PATIENT: CARLYLE, JOY ACCOUNT/EHR #: CARJAY001 DATE: 11/05/18 Representative Technician: LuAnn Hallmark Attending Physician: Renee O. Bracker, MD The Pt is a 72-year-old female diagnosed with adult kyphosis caused by poor posture. Dr. Bracker prescribed bed rest on a firm mattress with pelvic traction attached to the footboard. At 5:00 p.m. on this date, I delivered a bed board and the traction frame to Ms. Carlyle’s home. I placed the bed board underneath the existing mattress in order to create a firm surface upon which the patient could sleep. I then attached the traction frame to the footboard of the existing bed. I spent 45 minutes instructing the patient, her family, and caretaker on the proper use of the equipment, how to properly get into and out of the traction, and the expected sensations. A: Adult kyphosis P: Follow up in 2 weeks to see if patient has any questions or concerns. LuAnn Hallmark LH/mg D: 11/05/18 09:50:16 T: 11/08/18 12:55:01 ------- e0890 e0273 ATIENT: BALMORAL, MARK ACCOUNT/EHR #: BALMAR001 DATE: 10/26/18 Attending Physician: Oscar R. Prader, MD Pt is a 61-year-old male with metastatic testicular tumors. He comes in today for the administration of cisplatin solution, IV, 20 mg. It is the first of five treatments he will receive this week. IV infusion given over 7 hours. Patient reports mild nausea. Refuses any pharmaceutical treatment for that side effect of this treatment. Patient discharged at 4:15 p.m. ORP/mg D: 10/26/18 09:50:16 T: 10/27/18 12:55:01 ------ J9060x2 Ira Morgan, a 16-month-old male, was brought to radiology for a real-time, limited, static ultrasound of his hips. - 76886 Dr. Logan saw Jason Miolo, a 38-year-old male, with a swollen right eye and loss of vision. Dr. Logan ordered a CT with contrast of the right eye and area, which revealed marked proptosis of the right orbit, thrombosis, and enlargement of the right superior ophthalmic vein. - 70481 Dr. Sloan provided a complete set of dentures, maxillary and mandibular, for Cheryl Delaney. - D5110 D5120 Muddy Hambaugh, a 27-year-old female with a history of bipolar disorder, was given an injection IM of Thorazine, 45 mg. Code for the drug. - J3230 Due to his condition, Daniel Hair (previous case study) had an unscheduled dialysis treatment at the nearest hospital outpatient department; this hospital is not certified as an ESRD facility. - G0257 Petula Carter, a 4-day-old female, currently weighs 2,000 grams and requires intensive cardiac and respiratory monitoring. This is her third day in the NICU, and Dr. Wadhwa comes in to do his E/M of her condition. - 99479 Daisha Kurucz, a 23-year-old female, has severe asthma. Dr. Benton ordered a nebulizer, with compressor, for her to use at home. Code for the home health agency that supplied the equipment. - E0570 Clifton Beckman, a 15-year-old male, sat in poison ivy while camping in the woods. Dr. Gregg prescribed a portable sitz bath for him to use at home. - Clifton Beckman, a 15-year-old male, sat in poison ivy while camping in the woods. Dr. Gregg prescribed a portable sitz bath for him to use at home. Shirley Loveichelle, an 82-year-old female, was having trouble eating for such a long period of time that she was exhibiting signs of malnutrition. Therefore, Dr. Milliner ordered enteral formula (Ensure) to be administered through a feeding tube at 500 calories per day. Code for the nutritional supplement only - B4150x5 - Royce Onoton’s legs have finally healed to the point that he can be discharged from the nursing facility, where he has been for the last 6 weeks. Before he can go home, Dr. Zandi comes in for the final examination and to provide continuing care instructions to Royce’s wife, who will be caring for Royce at home. Dr. Zandi prepares the discharge records and writes a prescription for Royce for pain. This whole process takes Dr. Zani about 45 minutes to complete. - --- 99316 Tom Seihill, a 23-year-old male, was admitted into the hospital 2 days ago for bronchitis. While in the hospital, Tom requested that his family physician, Dr. Selbiger, perform a circumcision, so Dr. Selbiger called in Dr. Wacker, a urologist, for a consultation. Dr. Wacker discussed the request with Tom and took a brief history and performed a limited genitalia examination. Afterward, Dr. Wacker made a straightforward decision and recommended that Raymond have the surgical procedure done at a later date as an outpatient procedure. Code for Dr. Wacker’s services ■ 99251 Raymond Johnston, a 3-year-old male, showed no sign of improvement after 5 days of antibiotic therapy, so Dr. Servina admits Raymond into the hospital with a diagnosis of bacterial pneumonia. At Raymond’s admittance, his vitals showed a temperature of 38.3°C (101°F), with a mild rash on his torso. The following day, Dr. Servina performed a problem-focused history and examination with MDM of low complexity. Code Dr. Servina’s visit on the second day. - 99231 PATIENT: VANCE, TOMIKA ACCOUNT/EHR #: VANTOM001 DATE: 12/09/18 ------ G0105-74: HCPCS PATIENT: ADDLER, ANNETTE ACCOUNT/EHR #: ADDLAN001 DATE: 12/21/18 ---- B4082 PATIENT: JOHNS, CHARLENE ACCOUNT/EHR #: JOHNCH001 DATE: 08/09/18 -----70486 PATIENT: MURRAY, CARMEL ACCOUNT/EHR #: MURRCA001 DATE: 07/23/18 ------- 72040 PATIENT: LEAMAN, HESTER ACCOUNT/EHR #: LEAMHE001 DATE: 10/01/18 ----- 99471 What character position represents the approach in the ICD-10-PCS code? - Fifth What letter or number represents the body part in code 10908Z9? - 0 How many body systems are there in ICD-10-PCS that are identified by the second character? - 31 In code 031209B, the second character "3" represents which body system? - Upper arteries In the Alphabetic Index Hysterectomy, Total is listed and then cross-referenced to . - Resection What letter or number represents the section in code 4A14352? - 4 What character position represents the section in the ICD-10-PCS code? - First When no procedures are performed that are related to principal diagnosis procedures performed for definitive treatment and diagnostic procedures were performed for secondary diagnosis, the coder would . - sequence procedure performed for definitive treatment of secondary diagnosis as principal procedure, since there are no procedures related to principal diagnosis How many approaches are identified by the fifth character in ICD-10-PCS? - 7 Susan had a total mastectomy performed. What root operation character will be used? - T resection Mr. Johnson was admitted for physical rehabilitation after a stroke. What section number or alpha character represents these services? - F A(n) adds any additional information. - Qualifier What letter or number represents the device in code 7W04X4Z? - 4 What does PCS stand for? -Procedure Coding System What is an example of a Root Operation? - Insertion All of the following are types of devices that are described by the sixth character except: - any device that does not remain after the procedure. What is the root operation for implantation of a pacemaker? - Insertion What is the root operation for revision of right hip replacement? - Revision’’ The external approach would be appropriate for: - a closed fracture reduction. The PCS description of a sweat gland is: - skin The main difference between character position 2 (body system) and character position 4 (body part) is: - body part is where the procedure was performed An example of a code representing the use of an allogeneic graft is: - 02YA0Z0. Body parts are identified in different ways. What is another way to refer to a finger? - Hand A patient had a left axillary sentinel node biopsied to confirm a diagnosis. What is the root operation? - Excision A patient suffered a severe head injury in an auto accident. He was rushed to the hospital and taken to surgery, where a craniotomy was done to remove a subdural hematoma from the brain. What is the correct code? - 00C40ZZ If the wrist is injured but wrist is not listed as an option, which term(s) could be used? - Lower arm Refer to the ICD-10-PCS Official Guideline B3.3. What does this guideline discuss? - Discontinued procedures What is the section character for radiation therapy? - D Nonautologous tissue substitute is: - taken from another person. The root operation of map applies to: - cardiac and brain mapping. Bella Cable, a 62-year-old female, has severe pain in her right foot when she walks. Upon examination her right big toe has turned toward the second toe. Bella is admitted to the hospital, where Dr. Meltzer performs a bunionectomy, open approach, with a soft tissue correction. - Where should you begin to look up the code in the coding manual - ICD-10-PCS Alphabetic Index - What is the type of procedure - Bunionectomy - Is this an excision or a resection - Excision - What is the anatomical site - Metatarsal - What is the laterality - Right - What is the approach - Open - Character 1: Section Character 0 - Character 2: Body System Character Q - Character 3: Root Operation Character B - Character 4: Body Part Character N - Character 5: Approach Character 0 - Character 6: Device Character Z - Character 7: Qualifier Character Z - What is the correct code - 0QBN0ZZ Wilburn Backwinkel, a 54-year-old male, has had left upper quadrant pain radiating to his back. Dr. Dix admits Wilburn to Westwood Hospital, where he performs an endoscopic (via natural opening) inspection of the pancreatic duct. ■ Where should you begin to look up the code in the coding manual - ICD-10-PCS Alphabetic Index ■ What is the type of procedure - Inspection ■ What is the anatomical site - Pancreatic duct ■ What is the approach - Via natural opening endoscopic ■ Character 1: Section: Medical and Surgical: Character 0 ■ Character 2: Body System: Character F ■ Character 3: Root Operation Character J ■ Character 4: Body Part Character D ■ Character 5: Approach Character 8 ■ Character 6: Device Character Z ■ Character 7: Qualifier Character Z ■ What is the correct code - 0FJD8ZZ Juanita Keane, a 38-year-old female, was admitted to Westwood Hospital yesterday. Dr. Chavez performs a laparoscopic cholecystectomy today. - Where should you begin to look up the code in the coding manual - ICD-10-PCS Alphabetic Index - What is the type of procedure - Cholecystectomy - Is this an excision or a resection - Resection - What is the anatomical site - Gallbladder - What is the approach - Percutaneous Endoscopic - Character 1: Section Character 0 - Character 2: Body System Character F - Character 3: Root Operation Character T - Character 4: Body Part Character 4 - Character 5: Approach Character 4 - Character 6: Device Character Z - Character 7: Qualifier Character Z - What is the correct code - 0FT44ZZ Theron Patel, a 12-year-old male, is experiencing obstructive sleep apnea. Dr. Pascal admits Theron to the hospital and performs an adenoidectomy, open approach. - Where should you begin to look up the code in the coding manual - ICD-10-PCS Alphabetic Index - What is the type of procedure - Adenoidectomy - Is this an excision or a resection - Resection - What is the anatomical site - Adenoids - What is the approach - Open - What is the character 1: Section Character - 0 - What is the character 2: Body System Character - C - What is the character 3: Root Operation Character - T - What is the character 4: Body Part Character - Q - What is the character 5: Approach Character - 0 - What is the character 6: Device Character - Z - What is the character 7: Qualifier Character - Z - What is the correct code: 0CTQ0ZZ - PATIENT: LATCHMAN, VICTOR DATE OF ADMISSION: 03/05/18 DATE OF DISCHARGE: 03/17/18 - Where should you begin to look up the code in the coding manual - ICD-10-PCS Alphabetic Index - What is the type of procedure - Reposition - What is the anatomical site - Joint - What is the location - Elbow - What is the laterality - Right - What is the character 1: Section Character - 0 - What is the character 2: Body System Character - R - What is the character 3: Root Operation Character - S - What is the character 4: Body Part Character - L - What is the character 5: Approach Character - 0 - What is the character 6: Device Character - Z - What is the character 7: Qualifier Character - Z - What is the correct code: 0RSL0ZZ Paige Henderson, a 42-year-old female, comes in today with the complaint of numbness in her left little finger. Dr. McKenna notes Paige has difficulty performing fine motor movements with her left hand and fingers. After an examination and the appropriate tests, Dr. McKenna diagnoses Paige with tardy ulnar nerve palsy, left arm. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Palsy What is the anatomical site – Ulnar nerve What is the laterality - Left Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – G56.22 Eric Lewter, a 56-year-old male, presents with the feeling of tiredness but has been sleeping a lot over the last 3 to 4 months. Eric is accompanied by his wife, Peggy, who states she has noticed some mild mood changes as well. Dr. Shealy completes a thorough examination and the appropriate tests and diagnoses Eric with Kleine-Levin syndrome (KLS). Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Syndrome What type – Kleine-Levin Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – No If so does the Excludes1 note apply to the case study – No Excludes1 notation Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – G47.13 Victor Lockhart, a 29-year-old male, presents today with a fever of 100.6 F. He says 1 minute he is sweating and the next he is shivering and his stomach hurts. Dr. Osterlund documents paleness and tenderness in the right hypochondria region. Victor is admitted to Weston Hospital, where blood tests, a liver function test, and a CT scan confirm the diagnosis of amebic liver abscess due to Entamoeba histolytica. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Abscess What is the anatomical site - Liver What type - amebic Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – A06.4 Monica Pressley, a 37-year-old female, comes to see Dr. Wheaten today because she has been having diarrhea and abdominal cramping and states her heart feels like its quavering. The MRI scan confirms a diagnosis of benign pancreatic islet cell adenoma. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Adenoma What type – Islet cell What is the anatomical site -Pancreas Do any of the following apply to the condition – Benign Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation –No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Excludes2 notation Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – D13.7 Kewane Childs, a 44-year-old female, has a history of smoking cigarettes for 15 years; she quit last year. Kewane sees Dr. Cope for a dry cough, hoarse voice, and coughing up blood. Dr. Cope notes crepitation and dyspnea. Kewane is admitted to the hospital. The MRI scan and lung function tests confirm a diagnosis of neoplasm of the trachea, malignant primary. Principal diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the anatomical site -Trachea Do any of the following apply to the condition – Malignant, primary Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –Yes If so does the Use additional code note apply to the case study – Yes Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C33 Second diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – History What type- personal What type-tobacco dependence Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation –No If so does the Includes note help to clarify –No Includes notation Is there a Code first notation - Yes If so does the Code first note apply to the case study – No Is there a Code also notation - Yes If so does the Code also note apply to the case study – No Is there a Use additional code notation –No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – Z87.891 Harold Darden, a 5-month-old male, is brought in by his parents for a checkup. Dr. Hottel notes muscle weakness and a weak cry. Mrs. Darden says that Harold seems to have some difficulty swallowing. Harold is admitted to Weston Hospital. The genetic blood tests, EMG, and NCV all confirm a diagnosis of infantile spinal muscular atrophy, type I. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Atrophy What type – Muscular Anatomical site – Spinal What type – Infantile, type I Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – No If so does the Excludes1 note apply to the case study – No Excludes1 notation Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – G12.0 April Carter, a 56-year-old female, was brought to the emergency department by a friend who found her in a stupor. After Dr. Hoogenboom completed a thorough examination and after documenting posturing, echolalia, and echopraxia, April is admitted for further psychological testing. After reviewing the test results, Dr. Hoogenboom diagnoses April with schizophrenic catatonia. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Schizophrenia What type - Catatonic Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – F20.2 Jane Ellerbe, a 36-year-old female, presents today to see Dr. Molly, her dentist. Dr. Molly’s dental hygienist cleans Jane’s teeth and Dr. Molly completes a dental examination. Dr. Molly notes no abnormalities. Principal diagnosis: Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Examination What type - Dental Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify - Yes Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - No If so does the Use additional code note apply to the case study - No Use additional code notation Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - Z01.20 Ralph Bradley, a 36-year-old male, comes to see Dr. Harper because he is weak, losing weight, and vomiting and has diarrhea with some blood showing. Ralph was diagnosed with HIV 3 years ago. Dr. Harper completes an examination noting paleness, tachycardia, and tachypnea. Ralph is admitted to the hospital. The biopsied tissue from an endoscopy confirms a diagnosis of Kaposi’s sarcoma of gastrointestinal organ. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Human What type - Immunodeficiency virus disease Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - Yes If so does the Code first note apply to the case study – No Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –Yes If so does the Use additional code note apply to the case study – Yes Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B20 Second diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Sarcoma What type- Kaposi’s What is the anatomical site – gastrointestinal organ Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - Yes If so does the Code first note apply to the case study – Yes Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – No If so does the Excludes1 note apply to the case study – No Excludes1 notation Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - No Excludes2 notation Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C46.4 Kelley Dumont, a 19-year-old female, comes in to see Dr. Molusky. Kelley complains that she feels powerless and depressed. Kelley is accompanied by her mother. Mrs. Dumont states that Kelley has given up activities and has become fearful. Dr. Molusky completes a psychological examination and diagnoses Kelley with chronic paranoid reaction. Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Paranoid What type – Reaction Do any of the following apply to the condition – Chronic Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – F22 Gregory Abreu, a 37-year-old male, was previously diagnosed with African rhodesiense trypanosomiasis infection due to Trypanosoma bruceri. Greg presents today with the complaint of a severe headache and a stiff neck. Greg says he feels so bad that it actually hurts to walk. Dr. Crumpler notes a fever of 102F and shivering. Greg is admitted to Weston Hospital, where the results of a lumbar puncture confirm an elevated CSF pressure of 24 cm H2O. Gregory is diagnosed with meningitis. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Trypanosomiasis What type – African Do any of the following apply to the condition - By trypanosome brucei What type - Rhodesiense Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B56.1 Second diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Meningitis Due to – African trypanosomiasis Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - Yes If so does the Code first note apply to the case study – Yes Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – G02 Ross Risinger, a 47-year-old male, presents today for screening of a malignant neoplasm of the prostate. Ross’s grandfather died of prostate cancer. Dr. Richardson completes the appropriate test; results were negative. Principal diagnosis: Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Screening What type - Neoplasm What is the location - Prostate Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify - No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - Yes If so does the Use additional code note apply to the case study - Yes Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study - No Excludes2 notation Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - Z12.5 Second diagnosis: Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - History What type - Family What type - Malignant What is the anatomical site - Prostate Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify - No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - Yes If so does the Code also note apply to the case study - No Is there a Use additional code notation - No If so does the Use additional code note apply to the case study - No Use additional code notation Is there an Excludes1 notation - No If so does the Excludes1 note apply to the case study - No Excludes1 notation Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study - No Excludes2 notation Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - Z80.42 Andrew Medders, a 12-year-old male, is brought in by his parents to see Dr. Hearn, his pediatrician. Andrew has been cross and having some temper tantrums. Dr. Hearn notes Andrew has yawned three times since he has been in the examination room. Dr. Hearn also notes minor periorbital dark circles and slight periorbital puffiness. Andrew admits he has not been sleeping well. Andrew is diagnosed with sleep deprivation Principal diagnosis: Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Deprivation What type - Sleep Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify - No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - No If so does the Use additional code note apply to the case study - No Use additional code notation Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - Z72.820 Bennie Cantrell, a 45-day-old male, is brought in by his parents for a well-baby check. Dr. Davis notes that Bennie’s heel prick is slow to coagulate and stop bleeding. After the appropriate tests, Dr. Davis diagnoses Bennie with hemophilia A, symptomatic carrier. Principal diagnosis: Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Examination Child’s age - Over 28 days old What type of findings - Abnormal Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify - No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - Yes If so does the Use additional code note apply to the case study - Yes Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - Z00.121 Second diagnosis: Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Hemophilia What type - A Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify - No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - No If so does the Use additional code note apply to the case study - No Use additional code notation Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - D66 Third diagnosis: Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Carrier What type - Genetic What type - Hemophilia A Do any of the following apply to the condition - Symptomatic Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify - No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - No If so does the Use additional code note apply to the case study - No Use additional code notation Is there an Excludes1 notation - No If so does the Excludes1 note apply to the case study - No Excludes1 notation Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study - No Excludes2 notation Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - Z14.02 Joan Kenney, a 27-year-old female, is having difficulty breathing. Dr. Aung documents a fever of 101 F and facial edema. Joan recently returned home from a trip to Asia. Joan said they were contending with some sort of larval infestation in Asia. Joan is diagnosed with nasopharyngeal myiasis. rincipal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Myiasis What type - nasopharyngeal Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B87.3 Jenny Cassidy, a 4-year-old female, is brought in by her parents to see her pediatrician, Dr. Harmon. Jenny has a fever and a rash on her back. Dr. Harmon notes a “strawberry tongue.” The completed CBC test confirms a diagnosis of scarlet fever. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Fever What type – scarlet Do any of the following apply to the condition – uncomplicated Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries – Yes Is there an Includes notation – Yes If so does the Includes note help to clarify – Yes Is there a Code first notation – No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation – Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required – Yes Do you need to use the placeholder “X” – No Did you code to the highest level of specificity – Yes What is the correct diagnosis code – A38.9 Donna Burgess, a 33-year-old female, comes to see Dr. Freeman today with a headache, fever, and chest pain. The ELISA serological test confirms a diagnosis of Coxsackie B virus infection with pericarditis. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Coxsackie What type - pericarditis Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B33.23 Ben Kenton, a 49-year-old male, presents today with a high fever, chills, nausea, and diarrhea. After an examination and reviewing the results of the blood tests, Dr. Daniels diagnoses Ben with West Nile fever. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Fever What type - West What type - Nile Do any of the following apply to the condition – Unspecified Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – A92.30 Elizabeth Conyers, a 56-year-old female, presents with unexplained weakness, weight loss, and dizziness. Dr. Amos completes a thorough examination and does a work-up. The protein electrophoresis (SPEP) and quantitative immunoglobulin results confirm the diagnosis of Waldenström’s macroglobulinemia. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Waldenström’s What type - macroglobulinemia Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C88.0 George Donmoyer, a 58-year-old male, presents today with a sore throat, persistent cough, and earache. Dr. Selph completes an examination and appropriate tests. The blood-clotting parameters, the thyroid function studies, as well as the tissue biopsy confirm a diagnosis of malignant neoplasm of the extrinsic larynx. Principal diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the key term – Larynx What type - extrinsic Do any of the following apply to the condition – Malignant, primary Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C32.1 Phillip DeLorne, a 21-year-old male, presents with a sore on his left ear of approximately 5-weeks duration. Philip says it just won’t get well. Dr. Duruy notes a pink lump on Philip’s pinna and a biopsy is taken, which confirms a diagnosis of melanoma in situ of the left external ear. rincipal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Melanoma What is the anatomical site -ear (external) What type – in situ What is the laterality - left Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation –No If so does the Excludes1 note apply to the case study – No Excludes1 notation Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Excludes2 notation Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – D03.22 Brent Brooke, an 18-year-old male, presents for immunizations before joining the army. Brent passes out when given an injection. Dr. Meetze diagnoses Brent with fear of injections. Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Phobia What type – Injection Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – No If so does the Excludes1 note apply to the case study – No Excludes1 Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – F40.231 Melissa Roxburgh, a 21-year-old female, presents for a checkup. Melissa states she is deliberately trying to lose weight, exercises strenuously, and uses appetite suppressants. Dr. Fritz documents a BMI of 16.5, hypotension, and tachycardia as well as Melissa’s inability to concentrate. Dr. Fritz decides to admit Melissa. After reviewing the laboratory results and a psychological evaluation, Melissa is diagnosed with anorexia nervosa, restricting type. Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Anorexia What type – Nervosa What type - Restricting type Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – F50.01 Carol Abuelo, a 39-year-old female, presents today with general restlessness. Dr. Sabbagha documents unintentional and uncontrollable movements as well as slowed saccadic eye movements. Carol is admitted. An MRI scan reveals atrophy of the caudate nuclei and genetic tests confirmed the diagnosis of Huntington’s chorea. Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Chorea What type – Huntington’s Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – Yes If so does the Code also note apply to the case study – No Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – No If so does the Excludes1 note apply to the case study – No Excludes1 notation Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – G10 Kevin Genutis, a 24-year-old male, presents with the complaint of experiencing early orgasm and ejaculation, usually a minute or two after beginning sexual activity. Dr. Fox completes an examination and diagnoses Kevin with premature ejaculation. Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Ejaculation What type - Premature Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – No If so does the Excludes1 note apply to the case study – No Exludes1 notation Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – F52.4 Ruby Jenkins, a 26-year-old female, presents with popping or clicking sounds in her ears. After a thorough examination and the appropriate tests, Dr. Thompson diagnoses Ruby with palatal myoclonus. Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Myoclonus What type – Palatal Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – G25.3 Daniela Wiebenga, an 11-year-old female, is brought in by her mother. Mrs. Wiebenga is concerned because Daniela is starting to knock over objects and drop things, mostly in the morning. Daniela says it’s hardest in the morning and seems to get better as the day progresses. Dr. Jefferson orders an EEG, which reveals spikes and waves, and admits Daniela. After a full workup, Daniela is diagnosed with juvenile absence epilepsy. here should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Epilepsy What type – Juvenile What type of Juvenile - Absence Which of the following apply to the condition - Not intractable Which of the following apply to the condition - Without status epilepticus Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – G40.A09 Martha Henry, a 38-year-old female, was diagnosed with breast cancer. Martha had a mastectomy 1 month ago and Dr. Martin chose to delay the breast reconstruction. Martha presents today for the breast reconstruction procedure. Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Encounter What type - Breast reconstruction following mastectomy Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify - No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - No If so does the Use additional code note apply to the case study - No Use additional code notation Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - Z42.1 Nellie Preacher, a 27-year-old female, is in her second trimester of pregnancy, G2 P1. Nellie presents today for her regular checkup. Dr. Williams notes no abnormalities and tells Nellie she is doing fine. Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Pregnancy What type - Supervision What type - Normal What is the trimester - Second Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify - No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - No If so does the Use additional code note apply to the case study - No Use additional code notation Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study - No Excludes2 notation Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - Z34.82 Alexandra Smith, a 31-year-old female, presents today to donate blood platelets for her child, who has been diagnosed with thrombocytopenia. Principal diagnosis: Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Donor What type - Blood What type - Specified component Do any of the following apply to the condition - Specified donor Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify - Yes Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - No If so does the Use additional code note apply to the case study - No Use additional code notation Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - Z52.098 Charles Copeland, a 48-year-old male, presents today to see Dr. McElmurray. Charles is scheduled to have a cardiac pacemaker implanted. Dr. McElmurray completes the pre-procedural cardiovascular examination and clears Charles for the implant. Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Examination What type - Pre-procedural What type - Cardiovascular Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify - Yes Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - No If so does the Use additional code note apply to the case study - No Use additional code notation Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - Z01.810 Tammy Coco, a 33-year-old female, went on a tour of 19th century buildings last week. The company that conducted the tour just announced asbestos was found in some of these buildings. Tammy comes to see Dr. Kiefer today because she is concerned she might have been exposed to asbestos. Dr. Kiefer completes the appropriate tests, which return a negative result for asbestos exposure. Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Exposure What type - Asbestos Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify - Yes Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - Yes If so does the Code also note apply to the case study - No Is there a Use additional code notation - No If so does the Use additional code note apply to the case study - No Use additional code notation Is there an Excludes1 notation - No If so does the Excludes1 note apply to the case study - No Excludes1 notation Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - Z77.090 Van Poteat, a 59-year-old male, was diagnosed with colon cancer and now has an end colostomy. Van comes to see Dr. Holland, who inspects and cleans the colostomy opening. Dr. Holland tells Van he is doing well. Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Attention to What - Colostomy Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify - Yes Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - No If so does the Use additional code note apply to the case study - No Use additional code notation Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - Z43.3 Gayle Cassels, a 12-year-old female, is brought in by her mother to see Dr. Kellum. Gayle has had a fever for 3 days with a head cold. Dr. Kellum notes conjunctivitis, an erythematous rash on the head and neck, as well as Koplik’s spots on the inside of Gayle’s mouth. The salivary measles-specific IgA test confirmed the diagnosis of measles. Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Measles Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B05.9 John Brennen, a 7-year-old male, is brought in by his parents. Johnny has developed a hard cough and says his sides hurt. Dr. Travis, Johnny’s pediatrician, completes blood work and takes a CXR and nasopharyngeal specimen. A subconjunctival hemorrhage is noted in the left eye. Test results confirm a diagnosis of whooping cough due to Bordetella pertussis with pneumonia. Johnny is admitted to Weston Hospital. Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Whooping cough Due to – Bordetella pertussis Do any of the following apply to the condition – with pneumonia Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries – Yes Is there an Includes notation – Yes If so does the Includes note help to clarify – Yes Is there a Code first notation – No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation – Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required – Yes Do you need to use the placeholder “X” – No Did you code to the highest level of specificity – Yes What is the correct diagnosis code – A37.01 Second diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Hemorrhage What is the anatomical site – conjunctiva What is the laterality – left Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries – Yes Is there an Includes notation – No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation – No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation – Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required – Yes Do you need to use the placeholder “X” – No Did you code to the highest level of specificity – Yes What is the correct diagnosis code – H11.32 Mendenhall Aguirre, a 37-year-old male, presents today with a burning sensation during urination. Dr. Boykin collects a penile swab specimen for a microscopic examination, which confirms trichomonal prostatitis. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Prostatitis What type - Trichomonal Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – A59.02 Steven Crooks, a 16-year-old male, presents today with a sore throat. Dr. Hoffman notes acute pharyngitis with a low-grade fever, as well as petechiae on the roof of the mouth. A serological test confirms the diagnosis of Epstein–Barr infectious mononucleosis. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Mononucleosis What type? Epstein-Barr Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B27.00 Babbs Fisher, a 48-year-old female, just returned from an African vacation. Babbs is brought in by her husband, George, who noticed she was acting confused. Dr. Carla notes a low fever. Babbs states she feels tired and has a sore throat. She started vomiting this morning and admits to abdominal pain. Dr. Carla examines Babbs and orders an enzyme-linked immunosorbent assay (ELISA) test, which confirms the diagnosis of Ebola virus. Babbs is admitted to Weston Hospital for treatment. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Ebola virus Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – A98.4 Lee Greenwalt, a 9-year-old male, is brought in by his parents. Lee is not feeling well and is losing weight. Mrs. Greenwalt states Lee seems to be sweating at night. Dr. Moon documents a bitonal cough, a temperature of 100 F, and a general weakening. Lee is admitted to Weston Hospital. Test results confirm a diagnosis of tuberculosis of tracheobronchial lymph nodes. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Tuberculosis What is the anatomical site – Tracheobronchial Do any of the following apply to the condition – Lymph glands or nodes Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries – Yes Is there an Includes notation – Yes If so does the Includes note help to clarify – Yes Is there a Code first notation – No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation – Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required – Yes Do you need to use the placeholder “X” – No Did you code to the highest level of specificity – Yes What is the correct diagnosis code – A15.4 suber Wilson, a 57-year-old male, was diagnosed with a malignant neoplasm of the liver metastasized from the prostate; both sites are being addressed in today’s encounter. Principal diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the anatomical site -Prostate Do any of the following apply to the condition – Malignant, primary Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Excludes2 notation Is there a symbol indicating additional characters are required – No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C61 Second diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the anatomical site - Liver Do any of the following apply to the condition – Malignant, secondary Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C78.7 James Buckholtz, a 3-year-old male, is brought in by his parents. Jimmy has lost his appetite and is losing weight. Mrs. Buckholtz tells Dr. Ferguson that Jimmy’s gums bleed and he seems short of breath. Dr. Ferguson notes splenomegaly and admits Jimmy to Weston Hospital. After reviewing the blood tests, MRI scan, and bone marrow aspiration results, Jimmy is diagnosed with acute lymphoblastic leukemia. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Leukemia What type – acute lymphoblastic Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C91.00 William Amerson, a 41-year-old male, comes in for his annual eye examination. Dr. Leviner notes a benign right conjunctiva nevus. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Nevus What is the anatomical site -conjunctiva What is the laterality- Right Do any of the following apply to the condition – benign Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Excludes2 notation Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – Z01.01 Secondary diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Nevus What is the anatomical site -conjunctiva What is the laterality- Right Do any of the following apply to the condition – benign Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Excludes2 notation Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – D31.01 Mitchell Lane, a 48-year-old male, presents with the complaints of night sweats and weight loss. Dr. Clark completes an examination noting hemoptysis and takes a chest x-ray, which reveals a mass. Mitchell is admitted to Weston Hospital where a CT-guided needle biopsy is then performed. Mitchell is diagnosed with a malignant primary neoplasm of the posterior mediastinum. Principal diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasm What is the anatomical site -Mediastinum What is the location – Posterior Do any of the following apply to the condition -Malignant, primary Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Excludes2 notation Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C38.2 Raykeem McFadden, a 63-year-old female, was last seen in this office 6 months ago for her annual checkup; no concerns were noted at that time. She presents today because of excessive itching after a warm bath. She also complains of a burning sensation in her arms, especially her left arm. Dr. Dingle completes a physical exam and notes aphasia, hepatosplenomegaly, and some loss of physical coordination. Raykeem is admitted to the hospital. The laboratory tests and bone marrow aspiration confirm a diagnosis of polycythemia vera. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Polycythemia What type - Vera Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Excludes2 notation Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – D45 Kelley Young, a 39-year-old female, presents to Dr. Clerk with the complaints of sudden blurred vision, dizziness, and numbness in her face. Kelley states she feels very weak and has headaches. Dr. Clerk admits Kelley to the hospital. After reviewing the MRI scan, her hormone levels from the blood workup, and urine tests, Kelley is diagnosed with a primary malignant neoplasm of the pituitary gland. rincipal diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the anatomical site - Pituitary gland Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation –No If so does the Use additional code note apply to the case study – No Use additional code note Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Excludes2 notation Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C75.1 Ralph Flower, a 27-year-old male, presents today for his annual flu vaccination. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term - Vaccination Do any of the following apply to the condition – initial encounter Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - Yes If so does the Code first note apply to the case study – No Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code note Is there an Excludes1 notation – No If so does the Excludes1 note apply to the case study – No Excludes1 note Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Excludes2 note Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – Z23 Audrey Harkey, a 33-year-old female, comes to see Dr. Blankenship. Audrey is accompanied by her husband, Henry. Audrey complaints of fever, a stiff neck, and headaches. Henry states he is concerned because he has noticed some confusion. Audrey is admitted to the hospital, where a lumbar puncture is performed; 5 ml of cerebrospinal fluid is drawn. Test results confirm Dr. Blankenship’s diagnosis of tuberculous meningitis. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Meningitis What type-Tuberculous Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – A17.0 Erina Castles, a 43-year-old female, presents today with a few pimples on her chest. Dr. Moss noted some slight redness and swelling in the area and orders blood tests. The results of the blood tests confirm the diagnosis that Erina is a carrier of staphylococcal, methicillin resistant (MRSA). Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term - Carrier What type– bacterial disease Do any of the following apply to the condition- Staphylococcal, methicillin resistant (MRSA) Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code note Is there an Excludes1 notation – No If so does the Excludes1 note apply to the case study – No Excludes1 note Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – Z22.322 Jan McKenzie, a 68-year-old female, presents today to see Dr. McLeod due to restlessness and being anxious. Jan retired 3 months ago. Dr. McLeod notes Jan is having difficulty adjusting to retirement. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Problem What type-adjustment Do any of the following apply to the condition – retirement Do any of the following apply to the condition-None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code note Is there an Excludes1 notation – No If so does the Excludes1 note apply to the case study – No Excludes1 note Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Excludes2 note Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – Z60.0 Anna Blanks, a 68-year-old female, presents with a cyst on the anterior wall of her vagina. After an examination, Dr. Hervey takes a tissue biopsy and orders a CT scan. Anna is diagnosed with a primary malignant neoplasm of the Skene’s gland. Principal diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the key term – Skene’s gland Do any of the following apply to the condition- Malignant, primary Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - No If so does the Excludes2 note apply to the case study – No Excludes2 notation Is there a symbol indicating additional characters are required -Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C68.1 Gloria Leugers, a 37-year-old female, comes to see Dr. Lewis with a fever, weakness, and abdominal pain. Blood tests reveal a hemoglobin of 8.6 and UA is positive for blood. Gloria is admitted to Weston Hospital and diagnosed with schistosomiasis disorder in the kidney. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Disorder What is the anatomical location-Kidney What type- Schistosomiasis Do any of the following apply to the condition – Unspecified Is there a manifestation code- Yes Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B65.9 What is the manifestation code- N29 PRADER, BRACKER, & ASSOCIATES A Complete Health Care Facility 159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789 PATIENT: CHARLES, KAREN ACCOUNT/EHR #: CHARKA001 DATE: 08/11/18 Attending Physician: Renee O. Bracker, MD Patient, a 43-year-old female, presents today to discuss pathological findings of recent exploratory laparotomy. Patient is 4 days’ status post lysis of adhesions; total abdominal hysterectomy; bilateral salpingo-oophorectomy; partial omentectomy; excision of small and large bowel implants; pelvicabdominal peritoneal stripping; placement of intraperitoneal port-a-cath; and enterolyses. The ovaries were found to be poorly differentiated; serous carcinoma extended to the left fallopian tube. The right fallopian tube was found to have serosal fibrosis consistent with tubo-ovarian adhesion. A broad-based endometrial polyp was found in the endometrium while the myometrium showed leiomyomata, adenomyosis, and multifocal serosal implants of poorly differentiated ovarian serous carcinoma. The specimen from the omentum was found to be metastatic adenocarcinoma consistent with ovarian origin. Lastly, the specimens from both the small and large bowel were positive for metastatic, poorly differentiated ovarian serous carcinoma. The histomorphologic features of poorly differentiated ovarian serous carcinoma closely resemble that of a poorly differentiated fallopian tube primary adenocarcinoma. The bilateral ovarian involvement supports the primary ovarian origin of the neoplasm. ASSESSMENT: Metastatic adenocarcinoma of the omentum; metastatic carcinoma of the small and large intestines. ORP/pw D: 08/11/18 09:50:16 T: 08/13/18 12:55:01 Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the anatomical site – Intestine What location - Small What type – Malignant, secondary Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation - No Is there a Use additional code notation – No Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C78.4 Secondary diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the anatomical site – Intestine What location - Large What type – Malignant, secondary Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation - No Is there a Use additional code notation – No Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C78.5 Third diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the anatomical site – Omentum What type – Malignant, secondary Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation - No Is there a Use additional code notation – No Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C78.6 Fourth diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – History What type- Personal What type – Malignant neoplasm What is the anatomical site –Ovaries Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - Yes Is there a Code also notation - Yes Is there a Use additional code notation – Yes Is there an Excludes1 notation – No Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – Z85.43 Fifth diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – History What type- Personal What type – Hysterectomy Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes Is there a Code first notation - No Is there a Code also notation - Yes Is there a Use additional code notation – No Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – Z90.710 PRADER, BRACKER, & ASSOCIATES A Complete Health Care Facility 159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789 PATIENT: PORTER, KELSEY ACCOUNT/EHR #: PORTKE001 DATE: 10/16/18 Attending Physician: Oscar R. Prader, MD Kelsey is a straight “A” student at the state university. He is well liked and respected, handsome, tall, and personable. However, he is finding it increasingly difficult to socialize with his friends without the need to, unobtrusively, wash his hands for fear of contamination. He began carrying antibacterial wipes for those occasions when he could not get to a sink. He had difficulty tolerating medication to help defuse these feelings, and he has found talk therapy to be of little benefit. He stated that he came to my office with his parents, desperately hoping to get some relief. After a thorough 2½-hour evaluation, I diagnosed Kelsey with OCD. Diagnosis: Obsessive-compulsive disorder (OCD). Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Disorder What type – Obsessive-compulsive Do any of the following apply to the condition - Unspecified Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes Is there a Code first notation - No Is there a Code also notation – No Is there a Use additional code notation – No Is there an Excludes1 notation – No Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – F42.9 WESTON HOSPITAL 629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541 PATIENT: LYNCH, VICTOR ACCOUNT/EHR #: LYNVIC001 DATE: 10/16/18 Attending Physician: Renee O. Bracker, MD S: This is a 3-year-old male who is recovering from a mild case of the Flu and suddenly began vomiting. The babysitter may have given him aspirin by accident instead of acetaminophen. Luke’s mother brought him to the ED for unexplained irritability and restlessness. He later develops convulsions, which are treated with anticonvulsants. He is admitted to PICU. O: T: 36.7, P: 102, R 48, BP 115/69, oxygen saturation 99% in room air. Height, weight, and head circumference are all at the 50th percentile. PERRLA. No signs of external trauma. Sclera nonicteric. EOMs cannot be fully tested, but they are conjugate. TMs are normal. Neck reveals no adenopathy. He is agitated and uncooperative. Heart regular without murmurs or gallops. Lungs are clear. Abdomen— normal bowel sounds. No definite tenderness. No inguinal hernias are present. He moves all extremities. LABS: Serum bilirubin: normal. Serum AST and ALT: increased. Serum ammonia: increased. Prothrombin time: prolonged. A CT scan of the brain shows cerebral edema. Neurologic symptoms rapidly deteriorate and he becomes unresponsive. Patient is intubated and put on mechanical ventilation and IV fluid is started. A liver biopsy reveals diffuse, small lipid deposits in the hepatocytes (microvesicular steatosis) without significant necrosis or inflammation. A: Reye’s syndrome. P: Continue to follow and treat. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Reye’s syndrome Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - Yes Is there a Code also notation – No Is there a Use additional code notation – No Is there an Excludes1 notation – No Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – G93.7 PATIENT: MURPHY, ADRIENNE ACCOUNT/EHR #: MURPAD001 DATE: 08/11/18 Attending Physician: Renee O. Bracker, MD Pt is admitted with a chief complaint of shortness of breath of approximately 7 to 10 days duration and a feeling of uneasiness and discomfort. Pt was found to be HIV-positive in May 2014, and diagnosed with AIDS in February 2016. Patient also complains of vision loss. She states she can’t see and it hurts when you touch her eyes and face PE: Ht: 5’4”, Wt: 126, T: 101.6. The physician notes pustules on forehead, right eye, and bridge of nose. A Tzanck smear with methylene blue stain was performed; results positive. DX: Herpesviral keratoconjunctivitis (simplex), secondary to AIDS Plan: Acyclovir, IV: 10mg/kg q 8 hr ROB/pw D: 08/11/18 09:50:16 T: 08/13/18 12:55:01 Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term - HIV Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes Is there a Code first notation - Yes Is there a Code also note - No Is there a Use additional code notation - Yes Is there an Excludes 1 note - Yes Is there an Excludes 2 note – Yes Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B20 Secondary diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term - Herpes What type - keratoconjunctivitis Do any of these conditions apply - as cause of disease classified elsewhere Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes Is there a Code first notation - No Is there a Code also note - No Is there a Use additional code notation - Yes Is there an Excludes 1 note - Yes Is there an Excludes 2 note – Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B00.52 PATIENT: HOBARTH, CHANTEL ACCOUNT/EHR #: HOBACH001 DATE: 08/11/18 Attending Physician: Oscar R. Prader, MD S: Pt is a 45-year-old female diagnosed with bladder cancer four years ago. She underwent chemotherapy and radiation treatments and is now malignant-free for 18 months. Since being malignant-free she comes in for an abdominal scan every six months. Pt has no signs or symptoms indicating a return of the malignancy. O: Ht 5′5″. Wt. 137 lb. R 18. T 99. BP 128/81. Abdomen appears to be normal upon manual examination. Results of CT scan indicated no abnormalities. A: Personal history of bladder cancer P: Pt to return PRN Principal diagnosis: Where should you begin to look up the code in the coding manual – Index of Diseases and Injuries What is the key term- History What type- personal Do any of the following conditions apply- malignant neoplasm What is the anatomical site-bladder Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - Yes Is there a Code also note - Yes Is there a Use additional code notation - Yes Is there an Excludes 1 notation - No Is there an Excludes 2 note –Yes Is there a symbol indicating additional characters are required- Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – Z85.51 PATIENT: FALCONE, ANTONIO ACCOUNT/EHR #: FALANT001 DATE: 10/16/18 Attending Physician: Renee O. Bracker, MD Antonio, a 43-year-old male, was referred by his therapist of 3 years, Ms. Benton, for psychiatric evaluation and consideration of medication to treat worsening depression. At the initial interview, Antonio’s wife, Marie, an attorney, was present to provide some history and perceptions. She was quite cooperative yet strangely detached. She answered all of the questions that I asked in a genuine manner. All pathological causes of sadness have been ruled out. A complete workup is performed. It gradually became clear that the source of Antonio’s persistent depression was his wife’s lack of accountability and responsibility in the marriage. She was frequently late for sessions, with no notice. Antonio always wanted to be a family man. Marie refuses to work at the marriage, crushing Antonio’s expectations of a satisfying marriage. Antonio checked into a hotel 500 miles away from home and threatened suicide 2 days ago. When Antonio returned, he came directly to my office. This episode was due to his wife’s lack of therapy participation. Antonio stated he feels like a failure because he can’t make the marriage work. Suicide seemed to be a viable exit strategy from the pain. My recommendations were that an environment change was needed to recover from the suicidal ideation. Antonio was experiencing continued depression caused by this environment in which his level of control over the outcome was minimal. This led to more severe and frequent depression. I advised him to stay out of the house. Diagnosis: Major depressive disorder, recurrent, moderate Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Disorder What type – Depression Do any of the following apply to the condition - Recurrent Do any of the following apply to the condition - Current episode What level - Moderate Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes Is there a Code first notation - No Is there a Code also notation – No Is there a Use additional code notation – No Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – F33.1 ATIENT: LESZEK, OGLEV ACCOUNT/EHR #: LESZOG001 DATE: 10/17/18 Attending Physician: Renee O. Bracker, MD S: This 13-year-old male was last seen in this office for his back-to-school annual exam 3 months ago. This exam revealed a healthy young man without any significant medical history. Today Oglev presents complaining of a cough and a sore throat, of approximately 1 week duration. He is accompanied by his mother. He and his mother deny fever, nasal congestion, or runny nose. He says he feels more tired than usual, and his mom states that she can’t get him out of bed to go to school. Oglev has been truant from school over the last 6 weeks. Patient states that his “mom won’t get off my back.” He admits that his grades have been dropping and he quit the baseball team. Mom leaves the room, and patient admits to smoking pot every day, sometimes several times a day, for the last month or so. He denies any other drug use and states smoking pot is “no big deal.” O: Physical examination is remarkable only for a mildly erythematous throat without petechiae. Lungs are clear, and the rest of his exam is normal. Vital signs are also unremarkable. COUNSELING: Patent is assured that doctor-patient confidentiality is secure. We discussed side effects and risks of abusing pot. He states he has tried to quit but can’t make it through an entire day without smoking. It is pointed out to him that his pot use is already having a negative impact on his life. He understands that his parents need to know about this but that he must tell them himself. We discussed options and methodologies for his quitting with reduced effects. He agrees to regular surveillance. A: Marijuana abuse counseling P: Refer to drug counselor Principal diagnosis: Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Counseling What type - Drug abuser Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation - No Is there a Use additional code notation - Yes Is there an Excludes1 notation - No Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - Z71.51 Second diagnosis: Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Abuse What type - Drug What type - Cannabis Do any of the following apply to the case study - Uncomplicated Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes Is there a Code first notation - No Is there a Code also notation - No Is there a Use additional code notation - No Is there an Excludes1 notation - Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - F12.10 PATIENT: DAWSON, WILSON ACCOUNT/EHR #: DAWSWI001 DATE: 08/11/18 Attending Physician: Renee O. Bracker, MD Pt is a 47-year-old male with left breast carcinoma, terminal stage, metastatic to the brain and liver. Wilson is undergoing chemotherapy and has become dehydrated, showing signs of confusion and disorientation. He is admitted to Weston Hospital for rehydration. Procalamine 3%, IV, 50mL/hr was given for 12 hours. Patient stabilized and was discharged home with no other treatment. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Dehydration Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation – No Is there a Code first notation - No Is there a Code also notation - No Is there a Use additional code notation –Yes Is there an Excludes1 notation – Yes Is there an Excludes2 notation - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – E86.0 Second diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the anatomical site – Breast What is the gender – Male What is the laterality - Left What type – Malignant, primary Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes Is there a Code first notation - No Is there a Code also notation - No Is there a Use additional code notation – Yes Is there an Excludes1 notation – Yes Is there an Excludes2 notation - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C50.922 Third diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the anatomical site – Brain What type – malignant, secondary Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation - No Is there a Use additional code notation – No Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C79.31 Fourth diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the anatomical site – Liver What type – Malignant, secondary Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation - No Is there a Use additional code notation – No Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C78.7 PATIENT: YAN, MARANDA ACCOUNT/EHR #: YANMAR001 DATE: 10/16/18 Attending Physician: Oscar R. Prader, MD S: This is a 23-year-old female who presents with a chief complaint of clumsiness and blurred vision. Patient states she had been feeling fine until about 10 days ago when she noticed some numbness and weakness in her right leg, and suddenly her vision became blurry. O: VS are normal. She is alert but subdued, afebrile with some ataxia noted. HEENT exam is notable for severe visual loss and pale optic discs on funduscopy. Her heart, lungs, and abdomen are normal. She is noted to have a hyporeflexive paraparesis noted on the right. I decided to admit her to the hospital. An MRI scan shows multiple lesions in the periventricular white matter and cerebellum. Pattern visual evoked responses showed markedly delayed latencies. Corticosteroids are prescribed. Prognosis—a full recovery within 10–14 days. A: Multiple sclerosis (MS) P: Continue to follow and treat with traditional medication. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Sclerosis What type- multiple Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation – No Is there a Use additional code notation – No Is there an Excludes1 notation – No Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – G35 PATIENT: MYRICK, JULIE ACCOUNT/EHR #: MYRIJU001 DATE: 10/16/18 Attending Physician: Oscar R. Prader, MD S: Julie, a 47-year-old female, came to see me because her youngest son was getting married, leaving her alone. She stated that, over the last several weeks, she had begun having panic attacks whenever she thought about the upcoming separation. Patient has tried cognitive behavioral therapy and different medications without success. O: CBC results showed the size of her red blood cells (MCV) was slightly abnormal. The range was 80– 100, and she was 101. Evidence-based medicine has documented an elevated MCV could indicate a B12 deficiency, so I had Julie do a Schilling test, which was positive. A: Panic disorder without agoraphobia, vitamin B12 deficiency. P: Rx B12 injections; patient to return in 10–14 days. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term –Disorder What type - Panic Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes Is there a Code first notation - No Is there a Code also notation – No Is there a Use additional code notation – No Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – F41.0 Second diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Deficiency What type – Vitamin What type – B12 Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation – No Is there a Use additional code notation – No Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – E53.8 PATIENT: BELLOW, SANDRA ACCOUNT/EHR #: BELLSA001 DATE: 10/17/18 Principal diagnosis: Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Counseling What type - Genetic NEC Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation - No Is there a Use additional code notation - No Is there an Excludes1 notation - Yes Is there an Excludes2 notation - No Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - Z31.5 Second diagnosis: Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Testing What type - Genetic What type - Disease carrier status for procreative management Male or female - Female Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation - No Is there a Use additional code notation - Yes Is there an Excludes1 notation - Yes Is there an Excludes2 notation - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - Z31.430 PATIENT: ELLIOTT, ELLYN ACCOUNT/EHR #: ELLIEL001 DATE: 10/16/18 Principal diagnosis: Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Examination What type - Medical What type - Pre-employment Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation - No Is there a Use additional code notation - No Is there an Excludes1 notation - Yes Is there an Excludes2 notation - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - Z02.1 PATIENT: OAKWOOD, QUENTIN ACCOUNT/EHR #: OAKWQU001 DATE: 09/16/18 Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Pain Do any of the following apply to the condition – Acute Due to- Neoplasm related Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation – No Is there a Code first notation - No Is there a Code also notation - Yes Is there a Use additional code notation –No Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – G89.3 Second diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the anatomical site – Bone What type – Malignant, secondary Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation - No Is there a Use additional code notation – No Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C79.51 Third diagnosis: Where should you begin to look up the code in the coding manual – Table of Neoplasms What is the anatomical site – Liver What type – Malignant, secondary Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation - No Is there a Use additional code notation – No Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C78.7 Fourth diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – History What type- Personal What type – Malignant neoplasm What is the anatomical site –Prostate Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - Yes Is there a Code also notation - No Is there a Use additional code notation – Yes Is there an Excludes1 notation – No Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – Z85.46 The code description that states “diseases classified elsewhere" means that: the condition has its own code within this code set. Jamie Holstein tested positive for HIV five years ago. She has now begun showing signs and symptoms of the disease. The coder should assign code: B20. is the reaction of tissues to infection or injury; characterized by pain, swelling, and erythema. Inflammation Inflammation Which of the following are named by their shape? Bacteria Eugene Williams was diagnosed with pneumococcal streptococcus pneumoniae meningitis. The main term is ; the code is . Meningitis, G00.1 Signs and symptoms of an existence of infection include all except a(n): rash. All of the following are types of pneumonia except: phlegm. What is the correct code assigned for an encounter for prophylactic surgery for risk factors related to malignant neoplasm of the ovary? Z40.02 What is the correct diagnosis code for multiple myeloma? C90.00 The term identifies the anatomical site to which the malignancy . secondary, metastasized is a malignant neoplasm or cancerous tumor. Carcinoma What is the correct principal diagnosis for a patient being seen for a malignant melanoma of the right lower eyelid, including canthus? - C43.112 A common test for malignant neoplasm of the lung is: chest x-ray. Refer to the ICD-10-CM Official Coding Guidelines I.C.21.c.5 which states: A code may be a code if the reason for the visit is specifically the screening exam. screening, first-listed M codes identify the of the neoplasm. behavior and histology An increase in a patient’s white blood cell count is also known as: leukocytosis. is the classification of neoplasms primarily by anatomical site. Topography Neoplasms with overlapping boundaries are known as: contiguous. Steven Jordan, a 51-year-old male, comes to see Dr. Kolb because he is experiencing nausea and vomiting and his stool is unusually light in color. Steven is accompanied by his wife, Sally. Sally says her husband seems confused and less alert lately. Upon examination, Dr. Kolb notes hepatosplenomegaly, jaundice, and RUQ tenderness. Steven is admitted to the hospital, where blood test results confirm the presence of IgG anti- HAV antibodies. Steven is diagnosed with acute hepatitis A. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – hepatitis What type - A Do any of the following apply to the condition - Without hepatic coma Do any of the following apply to the condition – Acute Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code First notation Is there a Code also notation - No If so does the Code also note apply to the case study – No Code Also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B15.9 [Show More]

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