HIT 201 ICD-10-CM/PCS Assigning Codes – Flashcards

This 41-year-old male was admitted for closed, left ankle stress fracture, initial encounter. Fracture occurred due to slip on front steps of private residence. HISTORY: HIV positive, AIDS related lymphoma. Currently asymptomatic. 1. What code will be assigned as the principal diagnosis for the hospital admission? 2. Which of the following code assignments would be correctly assigned to this case?

41-year-old female. Heart failure. HISTORY: Acute anterior wall myocardial infarction 2 weeks ago. PROCEDURE(S): Lab workup revealed UTI & E-coli. Electrographic monitoring. FINAL DIAGNOSIS: Acute systolic & diastolic heart failure; acute anerior wall myocardial infarction (2 wks ago), UTI, E-coli. 1. Which of the following codes will be assigned as the principal diagnosis? 2. Which of the codes listed above is incorrect? 3. The code assigned to the "ELECTROGRAPHIC MONITORING" is 4A1204Z. Which character within this code is assigned to the procedure "Function"? (Enter the character within the code). 4. Which of the following statements regarding this case is correct?

22-year-old female, 3rd trimester of pregnancy, admitted for treatment of cytomegalovirus (CMV). HISTORY: HIV positive 1. What code will be assigned as the principal diagnosis for the hospital admission? 2. Which of the following code assignments would be correctly assigned to this case? 3. Three weeks later, this patient is admitted for delivery. Single live birth. HIV status is asymptomatic. Which of the following code sets would be assigned?

45-year-old male symptomatic for HIV admitted for tuberculosis. DISCHARGE DIAGNOSIS: HIV positive, tuberculosis. 1. What code will be assigned as the principal diagnosis for the hospital admission?

82-year-old female admitted for severe sepsis & urinary tract infection. Urine culture revealed E-coli. Encephalopathy. 1. What code will be assigned as the principal diagnosis for the hospital admission? 2. Which of the following code assignments would be correctly assigned to this case?

3-year-old child. Vomiting due to iron ingestion. Grandparents have custody of this child. Grandmother is taking iron supplements for anemia caused by chemotherapy regimen. Child was found in playroom of residence with bottle of iron tablets. Approximately 50 tablets were broken & bitten. It is unknown how much iron may have been ingested. PROCEDURE(S): Gastric lavage with phosphate; administration of phosphate enema. FINAL DIAGNOSIS: Iron intoxication secondary to iron ingestion. Diarrhea. Vomiting. 1. What code will be assigned to the principal diagnosis? 2. The ICD-10-PCS code that would be assigned (if appropriate) to the "GASTRIC LAVAGE" is 3E1G78Z. Which character within this code identifies this as an "UPPER GASTROINTESTINAL PROCEDURE"? (Enter the character within the code). 3. Which of the following code assignments would be correctly assigned to this case?

82-year-old female, mass in right breast, upper outer quadrant. PROCEDURE(S): Breast exam revealed nodule with thickening, suspected carcinoma. LDL cholesterol levels are high. Urinalysis negative, blood work & EKG normal. Mass removed from right breast tested positive for carcinoma. After consultation, a modified radical mastectomy of the right breast was conducted. Removal of breast tumor. Modified radical mastectomy, right, including resection of right axillary lymph nodes. FINAL DIAGNOSIS: Carcinoma of the upper outer quadrant of the right breast with metastasis of 2 out of 14 axillary lymph nodes. 1. What code will be assigned to the principal diagnosis? 2. The code assigned for the procedure "REMOVAL OF BREAST TUMOR" is 0HTT0ZZ. Which character within this code identifies that "NO DEVICE" was left within the breast following the procedure? 3. Which of the following code assignments would be correctly assigned to this case?

61-year-old female experienced sudden episode of amnesia & disorientation of unknown etiology. Patient suffered Stage 3 hypertensive crisis during admission. BP 191/123. Rule out CVA. Rule out brain tumor. HISTORY: Hypertension PROCEDURE(S): Normal EEG. Normal Urinalysis. Cerebral flow, brain scan & CT scan of the brain were normal. Antihypertensive medications were administered via IV & this brought BP to normal levels. FINAL DIAGNOSIS: Transient global amnesia. Hypertension. 1. What code will be assigned to the principal diagnosis? 2. Which of the following code assignments would be correctly assigned to this case?

40-year-old female. Severe pain in right leg with severe inflammation of dermal and subcutaneous layers & infection. Obesity. Patient is 5'4" & weighs 320 pounds. PROCEDURE(S): Whirlpool debridement FINAL DIAGNOSIS: Cellulitis, right lower leg. Morbid obesity due to excessive overeating. 1. What code will be assigned to the principal diagnosis? 2. The ICD-10-PCS code that would be assigned (if appropriate) to the "WHIRLPOOL DEBRIDEMENT" is 0HDKXZZ. Which character within this code identifies that this is a "DEBRIDEMENT PROCEDURE"? (Enter the character within the code). 3. Which of the following code assignments would be correctly assigned to this case?

3-year-old female, fever, vomiting, abdominal pain & dehydration. Rash on buttocks. Blood culture is positive for Staphylococcus aureus. FINAL DIAGNOSIS: Severe sepsis with septic shock. Acute renal failure, secondary to Staphylococcus aureus septicemia. Diaper rash. Dehydration. 1. Which of the following codes will be assigned first? 2. One of the above codes is incorrect. Which of the codes listed above is incorrect? (Enter the incorrect code in the space below). 3. Which of the following code assignments would be correctly assigned to this case?

40-year-old man admitted for infection of right thumb. The thumb is throbbing, with pus oozing from within the cut & red streaks appear on the inside of his forearm. PROCEDURE(S): Thumb was lacerated 36 hours ago by lawn mower blade while removing a wire that had been caught in the blade. Patient owns a landscape service & was working at the public park. He did not seek medical attention immediately. FINAL DIAGNOSIS: SIRS caused by injury & trauma. 1. What code will be assigned as the principal diagnosis for the hospital admission? 2. Which of the following code assignments would be correctly assigned to this case?

52-year-old male. Melena. HISTORY: Chronic systolic congestive heart failure. PROCEDURE(S): EGC with gastric biopsy. FINAL DIAGNOSIS: Melena, chronic systolic congestive heart failure. 1. Which of the following codes will be assigned as the principal diagnosis? 2. The code assigned to EGD with "GASTRIC BIOPSY" is 0DB68ZX. What is the character assigned within this code which designates the "BODY PART"? (Enter the character used in the code). 3. Which of the following code assignments would be correctly assigned to this case?

15-year-old female involved (front seat passenger) in an automobile accident. Driver hit a tree on passenger side of vehicle due to heavy ice conditions. Car was moving at approximately 20 mph at time of impact. Patient was wearing a seat belt. Shattered glass embedded in scalp. PROCEDURE(S): Suture of lacerations (scalp); extirpation of glass from skin (scalp). FINAL DIAGNOSIS: Lacerations with embedded glass shards in scalp caused by automobile accident. 1. What code will be assigned to the principal diagnosis? 2. The ICE-10-PCS code that would be assigned (if appropriate) to the "SUTURE REPAIR" is 0HQ0XZZ. Which character within this code identifies the "SCALP"? (Enter the character within the code). 3. Which of the following code assignments would be correctly assigned to this case?

Pancreatic head carcinoma, determined to be un-resectable with probable metastasis to the lower lobe of the left lung. PROCEDURE(S): Left lower lung lobe resection. FINAL DIAGNOSIS: Pancreatic adenocarcinoma metastatic to left lung. Hypothyroidism. Type 2 diabetes mellitus. 1. Which of the following codes will be assigned first? 2. One of the above codes is incorrect. Which of the codes listed above is incorrect? (Enter the incorrect code in the space below). 3. The code assigned to the procedure "LEFT LOWER LUNG LOBE RESECTION" is 0BTJ0ZZ. Which character within this code is assigned to the re-section? (Enter the character used in the code). 4. Which of the following code assignments would be correctly assigned to this case?

45-year-old male. Driver of motorcycle, slid on pavement travelling around a curve, lost control of vehicle & crashed into tree going approximately 30 mph. Brought to emergency via ambulance. No apparent head trauma. Chief complaint: pain in left anterior chest & left shoulder. Chest X-ray revealed small pleural effusion on the left, possible pneumonia in the left lower lobe. Patient was started on cephadrine. Follow-up X-ray showed improvement of pneumonia & pleural effusion. FINAL DIAGNOSIS: Motorcycle accident. Closed fracture, left 4th anterior rib. Dislocation of left acromioclavicular joint (150% displacement). Pneumonia. Pleural effusion. 1. What code will be assigned to the principal diagnosis? 2. Which of the following code assignments would be correctly assigned to this case?

35-year-old female admitted for scorpion sting which occurred while gardening at her residence (mobile home). Patient is HIV positive but presents no symptoms. 1. What code will be assigned as the principal diagnosis for the hospital admission? 2. Which of the following code assignments would be correctly assigned to this case?

33-year-old male admitted for abdominal cramping & diarrhea. Consumed tuna sandwich at park concession 11 hour prior to onset of symptoms. Lab tests indicate dehydration. FINAL DIAGNOSIS: Dehydration, salmonella gastroenteritis 1. What code will be assigned to the principal diagnosis? 2. Which of the following code assignments would be correctly assigned to this case?

56-year-old female patient with history of Type 2 Diabetes Mellitus. Pain in both hands, suspected vasculitis. Glucose levels are abnormally high & insulin has been increased. HISTORY: Arteriosclerotic changes. Previously treated for diabetic retinopathy. PROCEDURE(S): CBC, urinalysis & chest X-ray with normal results. Hand X-ray showed some bone deterioration. Left percutaneous temporal artery biopsy. FINAL DIAGNOSIS: Type 2 diabetes mellitus, uncontrolled. Probable collagen vascular disease & probable vasculitis of both hands. 1. What code will be assigned to the principal diagnosis? 2. The ICD-10-PCS code assigned for the "ARTERIAL BIOPSY" is 03BT3ZX. Which character within this code identifies that this is a "BIOPSY" procedure? (Enter the character within the code). 3. Which of the following code assignments would be correctly assigned to this case?

87-year-old female. Alzheimers. Shows signs of dehydration & malnutrition. FINAL DIAGNOSIS: Dehydration. Severe malnutrition. Bronchopneumonia. Alzheimer's disease (late-stage). Urinary tract infection due to streptococcus. 1. What code will be assigned to the principal diagnosis? 2. Which of the following code assignments would be correctly assigned to this case?

52-year-old male, admitted for surgical treatment of previously diagnosed distal rectal adenocarcinoma. Chemotherapy & radiation treatments were conducted prior to surgery. He has emphysema. PROCEDURE(S): Abdominoperineal re-section of rectumwith sigmoid coloanal anastomosis & diverting ileostomy. FINAL DIAGNOSIS: Rectal Carcinoma 1. What code will be assigned to the principal diagnosis? 2. The ICD-10-PCS code assigned for the "RECTUM RE-SECTION" is 0DTP0ZZ. Which character within this code identifies the rectum? (Enter the character within the code). 3. Which of the following code assignments would be correctly assigned to this case?

Back pain, low grade fever with chills. Sore throat. HISTORY: Patient experienced malaria while overseas four years ago. PROCEDURE(S): Chest X-ray (normal), urinalysis (normal), CBC (normal), throat culture(positive for Streptococcus) FINAL DIAGNOSIS: Probable exacerbation of malaria. Streptococcal phyaryngitis. 1. What code will be assigned to the principal diagnosis? 2. Which of the following statements is correct? 3. Which of the following statements is correct? 4. Which of the following code assignments would be correctly assigned to this case?

23-year-old male. Nausea, vomiting, excessive thirst & increased frequency of urination. Patient has a history of Type I diabetes diagnosed at age15. Isophane injected 2x daily. FINAL DIAGNOSIS: Type I diabetes with ketoacidosis, severe dehydration. 1. What code will be assigned to the principal diagnosis? 2. Which of the following code assignments would be correctly assigned to this case?

58-year-old female. Metatarsal amputation due to diabetic gangrene of the left foot. HISTORY: Type 2 diabetes diagnosed at age36. Lab cultures are positive for Escherichia coli & Pseudomonas aeruginosa. Broad spectrum antibiotics were administered prior to surgery. FINAL DIAGNOSIS: Type 2 diabetes mellitus with diabetic gangrene, left great toe. Pseudomonas aeruginosa & E-coli. Long term use of insulin. 1. Which of the following codes will be assigned as the principal diagnosis? 2. The code assigned to the "AMPUTATION PROCEDURE" is 0Y6Q0Z0. What is the character assigned within this code which designates "LEFT GREAT TOE"? (Enter the character used in the code). 3. Which of the following code assignments would be correctly assigned to this case?

51-year-old female admitted for right nephrectomy. HISTORY: Nephrotic syndrome PROCEDURE(S): Right nephrectomy (open approach) FINAL DIAGNOSIS: Non-functioning right kidney due to hydronephrosis. 1. What code will be assigned to the principal diagnosis? 2. The ICD-10-PCS code that would be assigned (if appropriate) to the "NEPHRECTOMY" is 0TT00ZZ. Which character within this code identifies the "RIGHT KIDNEY"? (Enter the character within the code). 3. Which of the following code assignments would be correctly assigned to this case?

56-year-old female experiencing diarrhea. HISTORY: Obesity. Gastric bypass surgery 5 years ago. PROCEDURE(S): Colonoscopy with biopsy of the sigmoid colon. FINAL DIAGNOSIS: Diverticulosis of the small intestine. Post-status gastric bypass for obesity. 1. What code will be assigned to the principal diagnosis? 2. The ICD-10-PCS code that would be assigned (if appropriate) to the "BIOPSY OF THE SIGMOID COLON" is 0DBN8ZX. Which character within this code identifies the "EXCISION"? (Enter the character within the code). 3. Which of the following code assignments would be correctly assigned to this case?

Treatment of AIDS-related illness. PROCEDURE(S): Diagnostic fiberoptic bronchoscopy with cell washings for specimen collection. FINAL DIAGNOSIS: AIDS-related Pneumocystitis carinii & oral candidiasis. 1. Which of the following codes will be assigned first? 2. One of the codes (above in Question 1) is incorrect. Which code is incorrect & would not be used in coding this case? 3. The code assigned to the procedure is 3E1F88X. Which of these 7 characters is assigned to the "BODY SYSTEM/REGION"? (Enter the character used in the code). 4. Which of the following code assignments would be correct for this case?

Patient admitted for cholecystectomy. PROCEDURE(S): Open cholecystectomy with choledochlithotomy. FINAL DIAGNOSIS: Acute & chronic cholecystitis with cholelithiasis, hypertension. 1. What code will be assigned to the principal diagnosis? 2. The code assigned to the cholecystectomy is 0FB400X. Which character assigned within this code represents the "HEPATOBILIARY SYSTEM & PANCREAS"? (Enter the character used in the code). 3. Which of the following code assignments would be correct for this case?

8-day-old infant. Impending dehydration & diarrhea. Premature birth at 37 weeks. Apnea. Bradycardia. FINAL DIAGNOSIS: Non-infective gastroenteritis, Neonatal apnea. Bradycardia 1. What code will be assigned as the principal diagnosis? 2. Which of the following code assignments would be correct for this case?

Female HIV-positive 32-year-old patient admitted for tubal ligation. FINAL DIAGNOSIS: HIV positive, asymptomatic. elective sterilization. 1. What code will be assigned as the principal diagnosis? 2. The procedure code assigned to the "STERILIZATION" is 0U578ZZ. What is the character assigned within this code which identifies that this is a "MEDICAL & SURGICAL" procedure? (Enter the character used in the code). 3. Which of the following code assignments would be correct for this case?

53-year-old male admitted for acute exacerbation of chronic obstructive pulmonary disease (COPD), anemia, pancytopenia. PROCEDURE(S): Percutaneous administration, whole blood transfusion FINAL DIAGNOSIS: Acute exacerbation of COPD, acquired pancytopenia 1. What code will be assigned to the principal diagnosis? 2. Which of the following code assignments would be correctly assigned to this case?

73-year-old male. Shortness of breath with minimal exertion. Chest discomfort. PATIENT HISTORY: Long term smoker (30+ years), chronic lung infections. FAMILY HISTORY: Diabetes. PROCEDURE(S): 1. Physical examination reveals rhonchi. 2. CT scan reveals right upper lobe lesion. 3. Bronchoscopy with biopsy is performed. 4. Pathology report identifies non-small lung carcinoma. 5. Patient discharged & scheduled for chemotherapy. 6. Bronchoscopy of right lung via artificial opening, with biopsy of upper lobe of right lung. FINAL DIAGNOSIS: Non-small cell carcinoma of the right upper lobe, primary site. 1. Which of the following codes will be assigned as the principal diagnosis? 2. Which of the codes listed above is assigned to the bronchoscopy? (Enter the correct code in the space below). 3. The code assigned to the "UPPER LOBE BIOPSY OF THE LUNG" is 0BBX8ZX. Which character within this code is assigned to the biopsy "EXCISION"? (Enter the character used in the code). 4. Which of the following statements are correct regarding this case?

78-year-old male. Cough & difficulty breathing. Bronchospasms. History of chronic obstructive pulmonary disease. History of asthma. Patient is a non-smoker. Claims to have lived with smokers throughout his life. PROCEDURE(S): Aminophylline & Lasix were administered intravenously. FINAL DIAGNOSIS: Severe persistent asthma with acute exacerbation. Chronic obstructive pulmonary disease. Long term exposure to second-hand tobacco smoke. 1. What code will be assigned to the principle diagnosis? 2. Which of the following code assignments would be correctly assigned to this case?

History of breast cancer with metastases to bone & liver. She is currently undergoing chemotherapy (long term). FINAL DIAGNOSIS: Anemia in neoplastic disease. Carcinoma of the right breast with metastases to bone & liver. 1. Which of the following codes will be assigned as the principle diagnosis? 2. Which of the following code assignments would be correctly assigned to this case?

19-year-old African-American. Sickle-cell crisis & acute chest syndrome, fever. HISTORY: Tested & diagnosed at birth with sickle-cell anemia. Father has sickle-cell anemia. FINAL DIAGNOSIS: Sickle-cell disease with crisis, acute chest syndrome, fever. 1. Which of the following codes will be assigned as the principle diagnosis? 2. Which of the following code assignments would be correctly assigned to this case?