The patient was admitted from the emergency department because of chest pain. Following blood work, it was determined that the patient had elevated CPKs and MB enzymes. The EKG shows nonspecific ST changes.
What type of diagnosis might this indicate?
a. Unstable angina
b. Myocardial infarction
c. Congestive heart failure
d. Mitral valve stenosis
A patient is admitted and diagnosed with fever and urinary burning. The discharge diagnosis· is Escherichia coli, urinary tract infection.
Which of the following represents the correct diagnoses and appropriate sequence of those conditions?
a. Fever, urinary burning, urosepsis
b. Fever, urinary burning, sepsis
c. Escherichia coli, urinary tract infection
d. Urinary tract infection, Escherichia coli
A patient was admitted with heart failure within one week of a heart transplant. Due to the timing, the coder thought that it may represent a postoperative transplant rejection following heart transplant.
What action(s) should the coding staff take?
a. Query the physician.
b. Assign the codes for the postoperative transplant rejection.
c. Assign only the code for the transplant rejection.
d. Assign only the code for heart failure.
A patient is admitted to a psychiatric unit of an acute-care facility. The patient experienced the following symptoms almost every day for the last month: loss of interest or pleasure in most or all activities, which is a change from her prior level of functioning. She has also gained 15 lbs, has difficulty falling asleep, feels fatigued, and has difficulty making decisions.
What potential diagnosis most closely fits the patient’s overall symptoms?
a. Insomnia
b. Major depression
c. Reye’s syndrome
d. Bipolar disorder
b
The symptoms provided are indicative of a depressive disorder (Leon-Chisen 2013, 175).
ICD-10-CM: K40.90, B20,
ICD-10-PCS: OYQ50ZZ (Schraffenberger 2013, 82-84,252)
ICD-10-CM: E86.0, I69.391
(Schraffenberger 2013, 131, 209-210).
Stroke= cerebral infarction
ICD-10-CM: G40.909, G50.0
(Schraffenberger 2013,158-159).
Inpatient:
A patient was admitted to an acute care facility with a temperature of 102 and atrial fibrillation. The chest x-ray reveals pneumonia with subsequent documentation by the physician of pneumonia in the progress notes and discharge summary. The patient was treated with oral antiarrhythmia medications and IV antibiotics.
ICD-10-CM: J18.9, 148.91-
In accordance with the UHDDS, both conditions are not equally treated. The pneumonia was treated with IV antibiotics. This diagnosis had greater utilization of resources of medications and staff time compared with the atrial fibrillation, which was treated with oral medication. Because of this, the pneumonia is sequenced first (HHS 2014, Section II, C).
ICD-10-CM: N13.2,
ICD-10-PCS: OT788DZ, OTC08ZZ
(Leon-Chisen 2013, 269).
ICD-10-CM: L89.613, M17.0,
ICD-10-PCS: OJBQOZZ
(Schraffenberger 2013, 265-266, 278, 282-284).
ICD-10-CM: M51.26,
ICD-10-PCS: OSB20ZZ, OQBOOZZ
(Schraffenberger 2013,279, 282-284).
Inpatient:
A single, newborn, term live-born baby boy, born in hospital via vaginal delivery.
ICD-10-CM: Z38.00
(Schraffenberger 2013, 340).
ICD-10-CM: Z38.31, P07.14, P07.35, P55.1
(Schraffenberger 2013, 337).
Inpatient:
A patient is admitted to the acute care facility with chest pain. The patient was awakened from sleep; this was ;:he patient’s first experience with chest pain. The patient was given two nitroglycerin tablets in the emergency department. The chest pain was not relieved, resulting in the diagnosis of new onset unstable angina. Serial CPK was normal. Following a left cardiac catheterization with angiogram of multiple coronary arteries with low osmolar contrast, the patient is found to have arteriosclerotic coronary artery disease.
ICD-10-CM: 125.110,
ICD-10-PCS: 4A023N7, B2111ZZ
(Schraffenberger 2013, 202-204).
ICD-10-CM: C34.31, C79.31,
ICD-10-PCS: OBTFOZZ
(Schraffenberger 2013, Chapter 5, 99).
Inpatient:
A patient has metastatic adenocarcinoma of bone.
ICD-10-CM: C80.1, C79.51
(Schraffenberger 2013, 99).
ICD-10-CM: C78.7, Z85.3, Z90.13
(Schraffenberger 2013, 478).
ICD-10-CM: T42.4X1A, T45.0X1A, R55-The patient took over-the-counter medications with a prescription medication without consulting the prescribing physician. This is a poisoning.
Per the Official ICD-10-CM Guidelines for Coding and Reporting, I.C.19.e.5.b.: Nonprescribed drug taken with correctly prescribed and properly administered drug: If a nonprescribed drug or medicinal agent was taken in combination jVith a correctly prescribed and properly administered drug, any drug toxicity or other reaction resulting from the interaction of the two drugs would be classified as a poisoning (HHS 2014, Section I, 19, e, Sa; Schraffenberger 2013, 406-407).
ICD-10-CM: T83.51XA, A41.01
(Leon-Chisen 2013, 150, 154, 535).
Inpatient:
Respiratory distress syndrome, 26-day-old baby, temporary tracheostomy completed.
Ambulatory/Outpatient
Noncardiac chest pain, esophageal acid reflux test.
ICD-10-CM: R07.89; CPT: 91034
(Schraffenberger 2013, 362-363; CPT Assistant May 2005,3)
Ambulatory/Outpatient
Annual screening mammogram.
ICD-10-CM: Z12.31
CPT:77057
(Schraffenberger 2013, 462; CPT Assistant March 2007, 7)
Ambulatory/Outpatient
Excision of basal cell carcinoma, 1.9-cm lesion left upper eyelid.
Ambulatory/Outpatient
Metastatic ovarian cancer to the pleura. Thoracoscopic pleurodesis.
Ambulatory/Outpatient
Esophagogastroduodenoscopy with sclerotherapy of esophageal varices.
ICD-10-CM: 185.00;
CPT: 43243
Leon-Chisen 2013, 246; Smith 2015, 115; CPT assistant Spring 1994, 4).
Ambulatory/Outpatient
Cryosurgical destruction of simple papilloma of the penis.
ICD-10-CM: D29.0;
CPT: 54056
(Schraffenberger 2013, 103; Smith 2015, 134).
A patient is admitted to the hospital complaining of abdominal pain. Following evaluation, it was determined that the patient had an intestinal obstruction of the left colon due to adhesions from a prior abdominal surgery. The patient underwent an exploratory laparotomy with lysis of adhesions.
What conditions should be coded?
a. Abdominal pain, abdominal adhesions, abdominal obstruction, laparotomy, lysis of adhesions
b. Abdominal adhesions, abdominal obstruction, postoperative complications of the digestive system, laparotomy, lysis of adhesions
c. Abdominal adhesions with obstruction, lysis of adhesions
d. Abdominal adhesions and abdominal obstruction, postoperative complications of the digestive system, lysis of adhesions
A patient has a principal diagnosis of pneumonia (118.9) (MS-DRG 195).
Which of the following may legitimately change the coding of the pneumonia in accordance with the UHDDS and relevant clinical documentation?
a. Sputum culture reflects growth of normal flora.
b. Patient has a positive gram stain.
c. Patient is found to have dysphagia with aspiration.
d. Patient has nonproductive sputum.
c
Patient is found to have dysphagia with aspiration is the correct answer because it changes the coding to aspiration pneumonia and would result in MS-DRG 179 RESPIRATORY INFECTIONS & INFLAMMATIONS W/0 CC/MCC, which has a weight of 0.9718 (Medicare Grouper Version Used: 31). This is in comparison to MS-DRG 0195, SIMPLE PNEUMONIA & PLEURISY W/0 CC/MCC MDC: 04 which has a DRG weight of 0.6978 (Medicare Grouper Version Used: 31).
A patient is diagnosed with infertility due to endometriosis and undergoes an outpatient laparoscopic laser destruction of pelvic endometriosis.
In order to code this encounter accurately, what steps must the coder take?
a. Review the operative report to determine what procedure codes to use and also to determine the site or sites of endometriosis so codes with the highest specificity may be assigned, and use infertility as a principal diagnosis.
b. Review the operative report to determine where the laser was used in the pelvis so the site or sites of endometriosis can be specified, and assign a principal diagnosis of infertility.
c. Review the operative report to determine where the laser was used in the pelvis so the site or sites of endometriosis can be specified as principal, and assign a secondary diagnosis of infertility.
d. Review the operative report to determine what procedure codes to use and also to determine the site or sites of endometriosis so codes with the highest specificity may be assigned, and use the diagnosis of infertility as a secondary condition.
d
There may be endometrial implants throughout the pelvic cavity which may attach to various anatomic structures such as the fallopian tube, ovary, and omentum. These locations should be identified so that the appropriate diagnostic codes can be assigned and the appropriate procedure codes can be assigned based on the destruction of the endometrial implants. Therefore, the correct answer is to review the operative report to determine what procedure codes to use and determine the site or sites of endometriosis so that codes with the highest specificity may be assigned. Also, use the diagnosis of infertility as a secondary condition (Schraffenberger 2013, 296; Leon-Chisen 2013, 33, 271).
A patient was admitted to the emergency department for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also had angina and chronic obstructive pulmonary disease.
List the diagnoses that would be coded in the order of sequence.
a. Abdominal pain, infectious gastroenteritis, chronic obstructive pulmonary disease, angina
b. Infectious gastroenteritis, chronic obstructive pulmonary disease, angina
c. Gastroenteritis, abdominal pain, angina
d. Diarrhea, chronic obstructive pulmonary disease, angina
A patient was admitted to the endoscopy unit for a screening colonoscopy. During the colonoscopy, polyps of the colon were found and a polypectomy was performed.
What diagnostic codes should be used and how should they be sequenced?
Z12.11 Encounter for screening for malignant neoplasm of colon
D12.6 Benign neoplasm of colon, unspecified
a. Z12.11
b. Dl2.6 Encounter for screening for malignant neoplasm of colon Benign neoplasm of colon, unspecified
c. Zl2.ll,Dl2.6
d. D12.6, Z12.11
023-Other benign neoplasms of skin Includes: Benign neoplasm of hair follicles Benign neoplasm of sebaceous glands Benign neoplasm of sweat glands Excludes 1: benign lipomatous neoplasms of skin (017.0-017.3) melanocytic nevi (022.-)
When coding benign neoplasm of the skin, the section noted above directs the coder to:
a. Use category D23 for benign neoplasm of sweat glands
b. Use category D23 for melanocytic nevi
c. Use category D23 for benign lipomatous neoplasms of skin
d. Use category D23 for malignant neoplasm of the skin
a
Excludes note 1 is defined as never code here (HHS 2014, I.A.12.a, 10).
023-Other benign neoplasms of skin Includes: Benign neoplasm of hair follicles Benign neoplasm of sebaceous glands Benign neoplasm of sweat glands Excludes 1: benign lipomatous neoplasms of skin (017.0-017.3) melanocytic nevi (022.-)
When coding benign lipomatous neoplasms of skin, the section noted above directs the coder to:
a. Use category D23
b. Use a code from D17.0-D17.3
c. Use code E88.2
d. Use category D22
b
Excludes note 1 is defined as never code here (HHS 2014, I.A.12.a, 10).
A patient was discharged from the same-day-surgery unit with the following diagnoses: posterior subcapsular mature incipient senile cataract right eye, diabetes mellitus, hypertension, and was treated for mild acute renal failure. Which codes are correct?
E11.9 -Type 2 diabetes mellitus without complications
E11.29 -Type 2 diabetes mellitus with other diabetic kidney complication H25.9 -Unspecified age-related cataract
H25.21 -Age-related cataract, morgagnian type, right eye
H25.041 -Posterior subcapsular polar age-related cataract, right eye
I10-Essential hypertension
112.9 -Hypertensive chronic kidney disease with stage 1 through stage 4, or unspecified chronic kidney disease N17.9 -Acute kidney failure, unspecified
a. H25.21, E11.29, 112.9, N17.9
b. H25.041, E11.9, 110, N17.9
c. H25.9, E11.29, 112.9, N17.9
d. H25.041, E11.9, !12.9
b
The patient has posterior subcapsular mature incipient senile cataract right eye, diabetes mellitus (with no designated causal relationship to the cataracts), hypertension, acute renal failure. The hypertension is not related to the renal failure as it is acute and not chronic. Because of this, a combination code for hypertension and chronic renal failure is not coded (HHS 2014, Section I.B.9, 14).
While in the hospital, an external, single read, EKG was performed on the patient. The root operation term used for this ICD-10-PCS code is:
Monitoring: determining the level of a physiological or physical function repetitively over a period of time
Performance: completely taking over a physiological function by extracorporeal means
Measurement: determining the level of a physiological or physical function at a point in time
Assistance: taking over a portion of a physiological function by extracorporeal means
Measurement: determining the level of a physiological or physical function at a point in time
69620-Myringoplasty (surgery confined to drumhead & donor area)
J44.1– Chronic asthmatic bronchitis with acute exacerbation
J96.02-Acute respiratory failure with hypercapnia
Randy has been home from Iraq for three months and comes in to see Dr. Jones for his weekly appointment. He has recurring flashbacks of his time in the war zone, and he is having difficulty sleeping. Dr. Jones is providing therapy for his on-going PTSD. The correct code is:
F43.10 Post-traumatic stress disorder, unspecified
F51.02 Adjustment insomnia
F43.11 Post-traumatic stress disorder acute
F43.12 Post-traumatic stress disorder chronic
A) F43.12
B) F43.10
C) F51.02
D) F43.11
F43.12 –Post-traumatic stress disorder chronic
38100-Splenectomy; total (separate procedure)
39501-Repair laceration of diaphragm any approach
C43.59-Malignant melanoma of other part of trunk
C43.31-Malignant melanoma of nose
C43.4-Malignant melanoma of scalp & neck
In ICD-10-PCS, a PET imaging of the myocardium using Rubidium 82?
PET imaging, myocardium using Rubidium 82
1. Section = C (The Nuclear Medicine Section)
3. Root operation = 3 (Positron Emission Tomographic —(PET) Imaging)
5. Radionuclide = Q (Rubidium 82)
Injection of anesthesia for nerve block of the brachial plexus.
S82.55XA-Non-displaced fracture of medial malleolus of left tibia, initial encounter
A preterm infant, 34 weeks gestation, is born via cesarean section and has severe birth asphyxia.
Z38.01-Single live-born infant, delivered via cesarean
P07.37-Preterm infant, 34 weeks
A woman has a vaginal delivery of a full-term live-born infant after 38 weeks gestation.
O80-Vaginal, full-term live-born delivery
Z37.0-[Outcome of delivery] single live-born infant
Z3A.38-After 38-week gestation
A patient is admitted for control of exacerbation of chronic obstructive lung disease. The patient had stopped taking the prednisone as prescribed due to gaining weight, a known side effect for this drug.
T38.0x6A, J44.1, Z91.14
T38.0x6A, Z91.14, J44.0
J44.0, T38.0x6A, Z91.14
J44.1, T38.0x6A, Z91.128
J44.1-Chronic obstructive lung/pulmonary disease with exacerbation COPD
Z91.128-Intentional under-dosing
G83.21-Right arm [dominant] paralysis (monoplegia)
B91-Due to childhood [sequela] poliomyelitis Sequela=Poliomyelitis (acute)=B91
A87.9 – Viral meningitis, unspecified
61154 -Burr holes with evacuation and/or drainage of hematoma extradural or subdural
Identify the correct root operation for the following:
Uterine dilation and curettage
64836-Suture of distal nerve ulna motor
64837-Suture of each additional nerve hand or foot
Patient undergoes total thyroidectomy with parathyroid auto-transplantation.
60240-Thyroidectomy total or complete
60512-Parathyroid autotransplantation
The baby was having trouble passing through the vaginal canal, so Dr. Jones use forceps to help him along. Baby Boy was born at 12:57 pm. The root operation term used for this ICD-10-PCS code is:
-Extraction: pulling or stripping out or off all or a portion of a body part by the use of force
-Delivery: assisting the passage of the products of conception from the genital canal
-Abortion: artificially terminating a pregnancy
-Drainage: taking or letting out fluids and/or gases from a body part
Extraction: pulling or stripping out or off all or a portion of a body part by the use of force
Z51.11– Admitted for chemotherapy
C78.7– Metastasis [secondary] neoplasm of liver
Z85.3-[Personal history] breast cancer
43336-(repair, para esophageal hiatal hernia via thoracoabdominal incision)
Face-lift utilizing the superficial musculoaponeurotic system (SMAS) flap technique.
15829– Superficial musculoaponeurotic system (SMAS) flap
A patient is admitted with an exercise-induced bronchospasm.
J45.990-Exercised-induced bronchospasm
Patient with chronic otitis media requiring trans tympanic Eustachian tube catheterization.
69799-unlisted procedure, middle ear
A patient is admitted with anemia due to end-stage renal disease. The patient is treated for anemia.
N18.6– End-stage renal disease
A patient admitted with gross hematuria and benign prostatic hypertrophy.
N40.0-Benign prostatic hypertrophy
38240-hematopoietic progenitor cell (HPC) allogenic transplantation per donor
28899-RT-Unlisted procedure foot & toes (Right side)
Laparoscopic repair of umbilical hernia
Patient was admitted with hemoptysis and underwent a bronchoscopy with transbronchial lung biopsy. Following the bronchoscopy, the patient was taken to the operating room where a left lower lobe lobectomy was performed without complications. Pathology reported large cell carcinoma of the left lower lobe.
31628, 32480
32405, 32484
31625
32440
31628-Bronchoscopy with transbronchial lung biopsy single lobe.
32480-Removal of lung, other than pneumonectomy, single lobe (lobectomy)
25246-Injection procedure for wrist arthrography
73115-Radiologic examination wrist arthrography radiological supervision & interpretation
HZ88ZZZ-(Substance Abuse Treatment program, psychiatric medication evaluation)
1. Section = H (The Substance Abuse Treatment Section)
3. Root operation = 8 (Medication Management)
4. Qualifier = 8 (Psychiatric Medication)
Caloric vestibular test using air, monothermal
92538-caloric vestibular test with recording, bilateral; monothermal
Open I&D of a deep abscess of the cervical spine
22010-incision and drainage, open, of deep abscess, spine, cervical
15877-suction assisted lipectomy of trunk
15879-50-suction assisted lipectomy of lower extremity (thighs) Modifier 50 for bilateral procedure
A woman experienced third-degree burns to her left thigh and second-degree burns to her right and left foot, initial encounter. She stated that the burns were from an accidental spill of hot coffee at a nearby café.
T24.312A, T25.221A, T25.222A, X10.0xxA, Y92.511
T24.31xA, T24.331A, T24.332A
T24.719A, T25.222A, T25.221A
T24.319A, T25.229A, Y92.511
T24.312A– Third-degree burns, left thigh, initial encounter
T25.221A-Second-degree burns, right foot, initial encounter
T25.222A-Second-degree burns, left foot, initial encounter
X10.0XXA– Contact with hot liquid [hot coffee], initial encounter
0QR00JZ-(Replacement of L2 vertebra, open)
1. Section = 0 (The Surgery Section)
2. Body system = Q (Lower bones)
3. Root operation = R (Replacement)
4. Body Part = 0 (Lumbar vertebra)
6. Device = J (Synthetic substitute)
7. Qualifier = Z (No qualifier)
Sophie came in to see her regular physician to ask him to complete the paperwork so Medicare will pay for her wheelchair. The code for this is:
Z00.00 Encounter for general adult medical examination without abnormal findings
Z02.79 Encounter for issue of other medical certificate
Z04.2 Encounter for examination and observation following work accident
Z07.1 Encounter for disability determination [Encounter for issue of medical certificate of incapacity]
A) Z04.2
B) Z07.1
C) Z00.00
D) Z02.79
82465-Cholesterol, serum or whole blood total
83718-Lipoprotein direct measurement high density cholesterol, (HDL)
Patient undergoes enucleation of left eye, and muscles were reattached to an implant.
In ICD-10-PCS, percutaneous radio frequency ablation of the left vocal cord
0C5V3ZZ– (Percutaneous radio-frequency ablation of the left vocal cord)
1. Section = 0 (The Surgery Section)
2. Body system = C (Mouth and Throat) (The vocal cords are in the throat .)
3. Root operation = 5 (Destruction) (Ablation = surgical destruction of a body part)
4. Body part = V (Vocal cord, left)
5. Approach = 3 (Percutaneous approach)
7. Qualifier = Z (No Qualifier)
In ICD-10-PCS, percutaneous endoscopic clipping cerebral aneurysm
03VG4CZ-(Percutaneous endoscopic clipping cerebral aneurysm)
1. Section = 0 (The Surgery Section)
2. Body system = 3 (Upper arteries) Cerebral arteries are in the brain
3. Root operation = V (Restriction)
4. Body part = G (Intracranial artery)
5. Approach = 4 (Percutaneous endoscopic approach)
6. Device = C (Extraluminal device)
7. Qualifier = Z (No Qualifier)
L25.1-Dermatitis due to drugs in contact with skin
T49.0x5A-Topical antibiotic cream causing an adverse effect, initial encounter
I21.19-ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall
I22.2- Subsequent Non-ST elevation (NSTEMI) myocardial infarction
In ICD-10-PCS, EGD with removal FB from duodenum
0DC98ZZ-(EGD with removal FB from duodenum)
1. Section = 0 (The Surgery Section)
2. Body system = D (Gastrointestinal System) – An EGD (Esophogastroduodenoscopy)
3. Root operation = C (Extirpation) – Removal of the FB (foreign body)
5. Approach = 8 (Via natural or artificial opening endoscopic approach)
7. Qualifier = Z (No Qualifier)
XK02303- (Administration, concentrated bone marrow aspirate, percutaneously in muscle)
1. Section = X (The New Technology Section)
2. Body system = K (Muscles, Tendons, Bursae, and Ligaments)
3. Root operation = 0 (Introduction)
5. Approach = 3 (Percutaneous)
6. Device/Substance/Technology = 0 (Concentrated bone marrow aspirate)
7. Qualifier = 3 (New Technology Group 3)
A D&C is performed for postpartum hemorrhage.
67917-E1-repair of the tarsal strip (ectropion). (E1 is a modifier meaning left upper eyelid).
15820-E2-Blepharoplasty, lower eyelid.(E2 is a modifier meaning lower left eyelid).
Dr. Gastron fulgurated a rectal polyp of the patient. The root operation term used for this ICD-10-PCS code is:
A) Extraction: pulling or stripping out or off all or a portion of a body part by the use of force
B) Destruction: physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent
C) Extirpation: taking or cutting out solid matter from a body part
D) Removal: taking out or off a device from a body part
A patient is admitted with withdrawal delirium tremens with alcohol dependence.
F10.231-Withdrawal delirium tremens with alcohol dependence
K92.2-Gastrointestinal hemorrhage
In ICD-10-PCS, laparoscopic appendectomy
0DTJ4ZZ- (Laparoscopic appendectomy)
1. Section = 0 (The Surgery Section)
3. Root operation = T (Resection) (The entire appendix was removed, so it is resection
7. Qualifier = Z (No Qualifier)
14301- Adjacent tissue transfer or rearrangement any area defect 30.1 sq cm to 60.0 sq cm
42215 – Palatoplasty for cleft palate, major revision
40700- Plastic repair of cleft lip/nasal deformity, primary partial or complete unilateral
A 10 sq cm epidermal auto-graft to the face from the back
R87.810- Cervical Pap smear, DNA positive
S42.462P- Fracture, medial condyle humeral fracture, malunion, (P)=subsequent encounter
Identify the correct root operation term used in ICD-10-PCS for the following:
A transfusion of whole blood was administered to the patient.
An established patient returns to the physician’s office for follow-up on his hypertension and diabetes. The physician takes the blood pressure and references the patient’s last three glucose tests. The patient is still running above-normal glucose levels, so the physician decides to adjust the patient’s insulin. An expanded history was taken, and a physical examination was performed.
99213
99202
99232
99214
Patient has been followed by his primary care physician for elevated PSA. Patient underwent prostate needle biopsy in the physician’s office 2 weeks ago, and the final pathology was positive for carcinoma. Patient is admitted for prostatectomy. The frozen section of the prostate and one lymph node is positive for prostate cancer with metastatic disease to the lymph node. Prostatectomy became a radical perineal with bilateral pelvic lymphadenectomy.
55815
55815, 38562
38770
55845
33533– Coronary artery bypass using arterial graft(s) single
33518– 2 venous grafts (list separately in addition to code for primary procedure)
Laparoscopic retroperitoneal lymph node biopsy
38570- Laparoscopy with retroperitoneal lymph node biopsy
Laser destruction of extensive herpetic lesions of the vulva
56515– Destruction of lesions, vulva; extensive
Identify the correct approach term used in ICD-10-PCS for the following:
In ICD-10-PCS, identify the approach for a needle biopsy.
K50.111– Crohn’s disease of large intestine with rectal bleeding.
D50.0– Iron deficiency anemia, secondary to blood loss (Chronic)
Z04.3 – Observation, head injury, ruled out
S01.81xA- Minor laceration, forehead, (A)= initial encounter
Services were provided to a patient in the emergency room after the patient twisted her ankle stepping down from a curb. The emergency room physician ordered X-rays of the ankle, which came back negative for a fracture. A problem-focused history/physical examination with straight forward decision making were performed, and ankle strapping was applied. A prescription for pain was given to the patient. Code the emergency room visit only.
99281
99282
99211
99201
99281 – physician completed a problem-focused history, problem-focused examination, and straightforward medical decision-making for an emergency department visit.
(Code 99201 should not be used since it is for an office or other outpatient visit for a new patient. Code 99211 should not be used since it is for an office or other outpatient visit for an established patient. Although code 99282 is for an emergency room visit, it should not be used because it requires 3 components: expanded problem-focused history, expanded problem-focused examination, and medical decision-making of low complexity).
Patient was involved in an accident and has been sent to the hospital. During transport, the patient develops breathing problems and, upon arrival at the hospital, an emergency transtracheal tracheostomy was performed. Following various X-rays, the patient was diagnosed with traumatic pneumothorax. A thoracentesis with insertion of tube was performed.
31610, 32555
31610, 32554
31603, 32554
31603, 31612
31603, 32554 (A code of 31603 is needed for the transtracheal tracheostomy procedure (tracheostomy, emergency procedure; transtracheal). An additional code of 32554 is needed for the thoracentesis procedure that was performed (thoracentesis, needle or catheter). Code 31610 should not be used since it is for tracheostomy, fenestration procedure with skin flaps. Code 32555 should not be used since it is for needle or catheter thoracentesis with aspiration of the pleural space with imaging guidance. Code 31612 should not be used since it is for percutaneous tracheal puncture with transtracheal aspiration and/or injection).
A patient is admitted for gestational diabetes, insulin-controlled, 28 weeks gestation.
O24.414 – Gestational diabetes, insulin-controlled
In ICD-10-PCS, left knee arthroscopy with reposition of the anterior horn medial meniscus
0SSC4ZZ- Left knee arthroscopy with reposition of the anterior horn medial meniscus
1. Section = 0 (The Surgery Section)
2. Body system = S (Lower Joints)
3. Root operation = S (Reposition)
4. Body part = D (Knee Joint, Left)
5. Approach = 4 (Percutaneous endoscopic approach)
7. Qualifier = Z (No Qualifier)
In ICD-10-PCS, removal FB left cornea
08C9XZZ – Removal FB left cornea
1. Section = 0 (The Surgery Section)
2. Body system = 8 (Eye) The cornea is a part of the eye
3. Root operation = C (Extirpation) removing a FB (foreign body)
4. Body part = 9 (Cornea, left)
5. Approach = X (External approach)
7. Qualifier = Z (No Qualifier)
Patient arrives in the emergency room via a medical helicopter. The patient has sustained multiple life-threatening injuries due to a multiple-car accident. The patient goes into cardiac arrest 10 minutes after arrival. An hour and 30 minutes of critical care time is spent trying to stabilize the patient. Code only critical care.
99291, 99292
99285, 99288, 99291
99291, 99292, 99285
99282
99291, 99292
Code 99291 should be used for the first 74 minutes of critical care in the emergency department. An additional code 99292 should also be reported for the remaining 16 minutes of critical care given to the patient in the emergency department.Code 99282 and code 99285 should not be used since these are codes for emergency department visits, not specifically critical care.
Identify the correct root operation term, used in ICD-10-PCS, for the following:
Removal deep left vein thrombosis
(Excision: Cutting out or off, without replacement, a portion of a body part
Extirpation: Taking or cutting out solid matter from a body part
Removal: Taking out or off a device from a body part
Resection: Cutting out or off, without replacement, all of a body part)
Ureterolithotomy completed laparoscopically
1. Section = 2 (The Placement Section)
2. Body system = Y (Anatomical Orifices)
3. Root operation = 4 (Packing)
6. Device = 5 (Packing material)
7. Qualifier = Z (No Qualifier)
Patient undergoes X-ray of the foot with three views.
65771 Radial keratotomy procedure.
B02000Z – CT scan of brain, high osmolar contrast taken with and without contrast
1. Section = B (The Imaging Section)
2. Body system = 0 (Central Nervous System) (Brain is part of the CNS.)
3. Root operation = 2 (Computerized Tomography, CT Scan)
5. Contrast = 0 (High Osmolar)
6. Qualifier = 0 (Unenhanced and Enhanced)
7. Qualifier = Z (No Qualifier)
Identify the correct root operation, used in ICD-10-PCS, for the following:
Resection: Cutting out or off, without replacement, all of a body part
Patient underwent anoscopy followed by colonoscopy. The physician examined the colon to 60 cm.
The patient is on vacation and presents to a physician’s office with a lacerated finger. The physician repairs the laceration and gives a prescription for pain control and has the patient follow up with his primary physician when he returns home. The physician completes problem-focused history and physical examination with straightforward medical decision making. Also checked is a laceration repair for a 1.5 cm finger wound.
99201, 12001
99212, 13131
12001
99201-51
99201, 12001 – Since a new patient had an office visit for the simple repair of a laceration, code 99201 for the new patient office visit and 12001 for the simple repair of the 1.5 cm laceration.
Code 99212 should not be used since it is for an established patient office visit with a problem-focused history and examination and straightforward medical decision-making—the scenario was for a new patient, not an established patient. Code 13131 should not be used since it is for complex repair of the hands 1.1 cm to 2.5 cm—the scenario identified a simple repair, not a complex repair.
Identify the correct root operation term used in ICD-10-PCS for the following:
Endometrial ablation of cervical polyps
69635 – Tympanoplasty with incision of the mastoid (tympanoplasty with mastoidotomy). This code includes the tympanoplasty as well as the mastoid incision. No additional codes are needed.
Code 69646 should not be used since it is for radical or complete tympanoplasty with mastoidectomy and ossicular chain reconstruction—it does not cover mastoidotomy. Code 69642 should not be used since it is for tympanoplasty with mastoidectomy and ossicular chain reconstruction—it does not cover mastoidotomy. Code 69641 should not be used since it is for tympanolasty with mastoidectomy without ossicular chain reconstruction—it does not cover mastoidotomy.
Hepatobiliary system and pancreas
Hepatobiliary system and pancreas The common bile duct is part of the Hepatobiliary System and Pancreas.
Gastrointestinal system: While the liver and pancreas are accessory organs to the gastrointestinal system, the duct is considered part of the hepatobiliary system because it connects the liver (hepato-) to the gallbladder to carry the bile (-biliary).
Endocrine system: This system of hormones has no connection to the bile duct.
Lymphatic and hemic systems: The lymph node system or the blood (hemic) are related.
A patient is admitted with acute gastric ulcer with hemorrhage and perforation.
K25.2 –Acute gastric ulcer with hemorrhage and perforation.
This one combination code includes all of the key details.
Identify the correct root operation term used in ICD-10-PCS for the following:
Removal: Taking out or off a device from a body part
In ICD-10-PCS, thoracentesis right pleural effusion
0W993ZZ – Thoracentesis, right pleural effusion
1. Section = 0 (The Surgery Section)
2. Body system = W (Anatomical Regions, General) The pleural cavity is the space between the lung and the chest wall. Plural effusion is a condition when this space accumulates too much fluid, preventing the lungs from expanding completely.
3. Root operation = 9 (Drainage) (The suffix “-centesis” means puncture.)
4. Body part = 9 (Pleural cavity, right))
5. Approach = 3 (Percutaneous approach) (The suffix “-centesis” means puncture.)
6. Device = Z (No device)
7. Qualifier = Z (No Qualifier)
Joan’s mother had breast cancer, so she is getting a mammogram. The code to report the medical necessity for this encounter is:
C50.919 Malignant neoplasm of unspecified site of unspecified female breast.
Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
Z80.3 Family history of malignant neoplasm of breast
Z85.3 Personal history of malignant neoplasm of breast
A) C50.919
B) Z80.3
C) Z85.3
D) Z12.31