RHIA -ch 8- ICD-10-CM/PCS coding – Flashcards
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pt. admitted with AIDS relaed Kaposi's sarcoma of the skin
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B20 C46.0 AIDS code first if condition is AIDS related
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pt. admitted with severe sepsis due to MRSA with septic shock and acute resp. failure with hypoxia
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A41.02 R65.21 J96.01 first code is MRSA (due to ), second is sepsis, thrid is the resp. failure-the sepsis is due to the MRSA and resp failure is due to all of it.
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amebic abcess of liver and hospital acquired bacterial pneumonia
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A06.4 J15.9 Y95 first-abcess of liver, 2nd- pneumonia, 3rd-nosocomial condition
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fever and severe headache probsably due to viral menigitis
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A87.9 in this case do not code symptoms because definitive dx is known
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HIV postive pt. who is asymptomatic high risk
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Z21 Z72.89 1st-asymptomatic, 2nd high risk never code a B20 unless the pt begins to show symptoms
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female presents with Rt arm dominant paralysis due to childhood poliomyelitis
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B91, G83.21
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pt admitted for chemo for tx of breast cancer with liver mets. had a mastectomy 4 months ago, chemo is given today
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Z51.11, C78.7, z85.3
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pt has history of neoplasm of lung s/p lobectomy admitted after violent seizure lasting more then several minutes. work-up revealed brain mets. seizures treated with IV dilantin
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c79.31, r56.9, z85.118
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pt admitted for dehydration following chemoas treatment for rt ovarian cancer
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e86.0, c56.1
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pt has malignant melanoma of skin of back nose, and scalp. pt to undergo radical excision of the melanoama
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c43.59, c43.31, c43.4
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pt admitted with abdominal pain. CT and MRI revealed malignant neoplasm of head of pancreas with mets to peritoneal cavity
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c25.0, c78.6
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pt to OP clinic with large growth on neck. MRI showed mets to lymph nodes
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c77.0, c80.1
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female admitted with type 2 DM with diabetic ulcer of left heel involving subcutaneous layer of skin
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e11.621, l97.421
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man admitted with acute dehydration secondary to nausea and vomiting due to acute gastroeneritis
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e86.0, k52.9
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pt found in hypoglycemic coma, never been diagnosed as being diabetic
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e15
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pt admitted with aplastic anemia secondary to chemo for multiple myeloma intial encounter
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d61.1, t45.1x5a, c90.00
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pt admitted with gastrointestinal hemmoprhage resulting in acut blood loss anemia
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k92.2, d62
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pt admitted with severe protein calorie malnutrition
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e43
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pt admitted with idiopathic thrombocyutopenia and purpura
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d69.3
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sickle cell anemia with crisis
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d57.00
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sicle cell pain crisis
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d57.00
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pt readmitted ofr post-op anemia due to acute blood loss. pt 5 dyas s/p cholecystectomy
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d62
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anemia due to end stage renal disease- pt treated for the anemia
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d63.1, n18.6
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anemia, neutropenia, and throbocytopenia
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d61.818- pancytopenia
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severe recurrent major depression without psychotic features
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f33.3
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acute alcohol intoxication with BAL of 113mg/100ml
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f10.129, y90.5
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delirium tremens with alcohol dependence
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f10.221
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catatonic schizophrenia
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f20.2
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chronic paranoia due to cocaine dependence with intoxication and drug delirium
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f14.221
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psycogenic paroxysmal tachycardia
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i47.9, f54
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sensorineural deafness of lt ear
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h90.42
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type 2 diabetic with chronic kidney disease requiring dialysis
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e11.22, n18.6, z99.2
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intractable status epilipeticus
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g40.311
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alzheimer's disease and ealry onset dementia, and frquently wanders away from home
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g30.0, f02.81, z91.83
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poliovirus menigitis
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a80.9, g02
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pain contro secondary to metastatic carcinoma of the spinal cord
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g89.3, c79.49, c80.1
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thombosis of the rt middle cerebral artery, with hemiplegia affecting the rt dominant side
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i63.311, i69.351
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hypertensive kidney diease, CKD stage III, acute systolic CHF
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i21.9, n18.3, i50.21
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acute ST inferolateral wall MI, several days later during same episode of care, pt had susstained a subsequent NSTEMI.
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i21.19, 122.2
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atheroclerotic peripheral vascular disease of the lt lower leg with intermittent claudication
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i70.212
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Dr. orders x-ray fo r fever, cough, rule out pneumonia, x-ray shows double pneumonia
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j18.9
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aspiration pneumonia with pneumonia due to staph aureus
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j69.0, j15.211
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acute respiratory failure with hypercapnia due to acute asthmatic bronchitis with status asthmaticus
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j45.902, j96.02 (resp. failure never listed 1st only if absolute reason fro admit)
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influenza and pneumonia
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j11.00
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acute exacerbation chronic obstructive pulmonary disease with hx of tobacco dependence
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j44.1, z87.891
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extrinsic asthma with status asthmaticus and bronchospasm
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j45.902
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infection of the tracheostomy stoma secondary to cellulitis of the neck
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j95.02, l03.221- look under complication, trachostomy
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recurrent incarcerated ventral hernia, surgery is cancelled after cxr showed lower lobe pneumonia
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k43.0, j18.9, z53.09
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acute gastric ulcer with hemorrhage and perforation
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k52.2
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divertculitis of large bowel with abcess
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k57.20
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acute gangrenous cholecystitis with cholelithiasis
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k80.00
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bleeding esophageal varices with alcoholic liver cirrhosis and portal hypertension, alchol dependent
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k70.30, i85.11, k76.6
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rectal bleeding lab results show chronic blood loss anemia CT shows rectal bleeding is due to crohn's disease of descending colon
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k50.111, d50.0
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acute urinary tract infection due to e coli
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n39.0, b96.20
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gross hematuira and benign prostatic hypertrophy
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n40.0, r31.0
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acute renal failure, hypertension
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n17.9, i10
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acute hemorrhagic cystitis
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n30.00 -there is no mention of hematuria
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CKD stage III due to HTN and type 1 DM
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i12.9, e11.22, n18.3
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end stage kidney disease which resulted from malignant hypertension
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i12.0, n18.6
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vaginal delivery of full term liveborn infant after 38 weeks gestation
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O80, z37.0, z3a.38
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pregnancy induced hypertension with severe edema and 24 weeks gestation
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o14.12, z3a.24
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obstructed labor due to breech presentation. single liveborn infant was delivered via cesarean section
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o32.1xx0, z37.0
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gestational diabetes insulin controlled 28 weeks gestation
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o24.414, z3a.28
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Hiv positive female 22 weeks gestation
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098.712, z21, z3a.22
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39 weeks gestation normal single full term newborn , during same episode pt experiances 36-hr delayed hemorrhage following the delivery
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o72.2, z3a39, z37.0
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pt had cholocystectomy 3 days ago and now readmitted with cellulitis at the site of the operative incision
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t81.4xxa, lo3.311- infection following procedure, cellulitis of abdominal wall
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open wound to lt finger with cellulitis due to dog bits initial encounter
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l03.012, s61.201A
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DM type 2 with diabetic heel ulcer with necrosis of the muscle
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e11.621, l97.403- non-pressure ulcer-chronic
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demastitis due to precription topical antibiotic cream used as directed by a physician initial encounter
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l25.1, t49.0z5a- contact dermatitis, adverse affect of local drug
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pressure ulcer of lt buttock stage 2
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L89.322
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stage 1 pressure ulcer of the sacrum during the hospitalization the ulcer progressed to stage 2
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L89.152
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pathological fracture of the lt. femur due to metastatic bone cancer past med history is significant for lung cancerq
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m84.552, c79.51, z85.118
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pt admitted with back pain a myelogram showed reason to be herniated lumbar intervertebral disc with rediculopathy
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m51.16
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pt admitted with pyogenic arthritis of the rt. hip due to strep.
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m00.251
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pt admitted with fracture to the L1 vertebrae secondary to postmenopausal senile osteoporosis, initial encounter
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m80.08xa
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malunion of the medial condyle humeral fracture. original injury occured 4 months ago
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s42.462P
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removal of internal oins from the left ankle. one month ago the pt. sustasined a displaced bimalleolar fracture to the lt. ankle.
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s82.842D
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a newborn born in hosp. vaginal delivery with unilateral hard cleft palate and cleft lip
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z38.00, o37.1
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newborn born in hosp. vaginal delivery physical exam demonstrates molding of the baby's scalp, which resolved prior to D/C w/o treatment
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z38.00
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newborn is transfered to hosdpital Y for treatment of an esophageal atresia. what codes should be repoted for hospital Y.
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q39.0
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pt is admitted with cervical spina bifida with hydrcephalus
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q05.0
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newborn born in hosp., vaginal delivery, and suistained a fracture of the clavicle due to birth trauma
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z38.00, P13.4
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full term infant born in hosp, vaginal delievery diagnosed with polycystic kidneys
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z38.00, q61.19
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full term infant vaginal delievery born in hosp. to a mother who is addicted to cocaine, however the infant tested negative.
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z38.00, z03.79 encounter for suspected maternal and fetal conditon ruled out- (look up encounter, suspected condition rulled out.)
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pre-term infant 34 weeks gestation born via cesarean section and has severe birth asphyxia
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z38.01, p84, p07.37
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preterm infant born in hosp. vaginal delivery 36 weeks gestation is treated for neonatal jaundice
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z38.00, p59.9, p07.39
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1 week old infant admitted with UTI contracted prior to birth. urine culture positive for e-coli.
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p39.3, a49.8
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infant has hypoglycemia and a mother with diabetes
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p70.1
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full term newborn vaginal delivery born in hosp.. birth is complicated by cord compression, which affected the newborn
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z38.00, p02.5
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pt admitted with lower rt quadrant abdominal pain. D/C diagnosis is listed as abdominal pain due to gastroenteritis or diverticulosis
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r10.31, k52.9, k57.90
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pt admitted with hemoptysis, a CT showed a lung mass
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r91.8, r04.2 (code the hemoptysis because reason for CT)
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woman has Pap smear that detected cervical high-risk human papillomavirus (HPV). DNA test was positive.
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r87.810
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pt admitted with malignant asictes with widespread matastatic peritoneal lesions primary site sigmoid colon, sigmoid colon resection 6 months ago
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r18.0, c78.6, z85.038 (be careful- coding book say to code 1st the neoplsm)
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pt admitted with fever due to bacteremia
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r78.81, r50.9 (code the fever because it is reason for amission)
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urinary retention secondary to benign prostatic heypertrophy
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n40.1, r33.8 (watch- pt has LUTS)
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pt has nondisplaced fracture of the left medical malleous, initial encounter
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correct code is- s82.55xa (nondisplaced) (code in book is wrong-s82.52xa-is for diplaced)
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pt admitted with anaphylactic reaction due to eating strawberries, initial encounter
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t78.04xa
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gunshot wound to rt. upper quadrant of the abdomen, which involves moderate laceration to the liver, initial encounter
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s36.115a, s31.600a
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3rd degree burns to thigh and 2nd degree burns to rt. and lt. foot, initial encounter. burns were from hot liquid
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t24.319a, t25.222a, t25.221a
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pt seen for cast removal. 6 weeks ago pt underwent open reduction internal fixation for a displaced fracture lt. radial styloid process
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c52.512D
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pt admitted with left wrist laceration, with embedded glass that involved the radical nerve, initial encounter
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s61.522a, s64.22xa
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pt admitted with lt. nondisplaced comminuted patella fracture, diplaced lt. spiral fracture of the shaft of the fibula, and a displaced comminuted fracture of the shaft of the lt. tibia, initial encounter
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s82.045a, s82.442a, s82.252a
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pt admitted with dizzyness as a result of taking phenobarbital as prescribed, initial encounter
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r42, t42.3x5a
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pt admitted for control of exacerbation of chronic obstructive lung disease. pt stopped taking prednisone as prescribed due to gaining weight, a known side efffect for this drug.
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j44.1, t38.0x6a, z91.14 (be sure to code non-compliance with meds)
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pt admitted for intentional overdose of valium and acute repiratory failure with hypoxia
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t42.4x2a, j96.01 (sequence the intentional OD first, then adverse effect)
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pt admitted for chemo for primary lung cancer, left lower lobe
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z51.11, c34.32
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screening examination for lung cancer
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z12.2
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pt admitted for observation of head injury, pt struck while playing football. pt also suffered a minor laceration to the forehead. head injury was ruled out.
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z04.3, s01.81xa, (lok up encounter for exam and observation following accident)
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root operation-excision gallbladder, endocscopic
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resection- 0FT44ZZ
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root operation-excision descending colon, open
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resection-0DTM0ZZ
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root operation-removal foreign body rt. external auditory canal, via natural opening
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extirpation- 09c37zz
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root operation-amputation first lt. toe
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detachement-0y6q0z0
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root operation-reduction fracture rt. femoral shaft, open
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reposition-04sk0zz
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root operation-colon polyp fulguration
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destruction-0d5e7zz (unsure if this is correct)
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root operation-reattchment fourth finger, rt.
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reattachment-0xms0zz
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root operation-cystoscopy
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inspection-0tjb8zz
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root operation-removal deep lt. vein thrombosis, common illiac, percutaneous
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extirpation-06cd3zz
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root operation-total left knee replacement, autologus tissue
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replacement-0srd07z
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root operation-lysis of abdominal adhesions, surrounding the jejunum, endoscopic
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release-0dna4zz
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root operation- percutaneous angioplasty rt. coronary aartery, itraluminal device, bifurcation
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dilation-02703d6
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root operation-ligation rt. fallopian tube, endoscopic
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occlusion-0ul54zz
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root operation-removal cardiac pacemaker, percutaneous
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removal-02pa3qz (look under heart and great vessels, removal, percutaneous, implantable heart assist system
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root operation-creation of arteriovenous graft brachial artery, upper lt. arm for hemodialysis
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bypass-03180z1
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root operation-lithotripsy left ureter with removal of fragment, percutaneous endoscopic
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extirpation-0tc74zz
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root operation-endometrial ablation of cervical polyps
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destruction-0u5b8zz
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root operation-angioplasty abdominal common left iliac artery, percutaneous with intraluminal device.
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dilation-047d4dz
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root operation-radiofrequency ablation right kidney
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destruction-0t504zz
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root operation-cryoablation external genital warts
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destruction-0u5g8zz
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root operation-gastric lap band for treatment of morbid obesity
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restriction-0dv64cz
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root operation-excisional debridement of a chronic skin ulcer of rt. foot
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excisional-0hbmxzz
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root operation-application of autologous skin graft to the nose s/p excision malignant neoplasm
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replacement-09rkx7z
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root operation-spinal fusion cervical C1-C2, with sythetic substitute, posterior approach, by posterior column
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fusion-0rg20j1
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root operation-tracheostomy, endoscopic
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bypass-0b114f4
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root operation-percutaneous needle biopsy left lung
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excision-0bbl3zx
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root operation-extraction left intraocular lens, open
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extraction-08dk3zz
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root operation-uterine dilation and curratage
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extraction-0udb7zz
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root operation-excision rt. popliteal artery with graft replacement, open, from cadaver
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replacement-04rm0kz
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root operation-mitral valve annuloplasty using ring, open
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supplement-02ug0jz
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root operation-left common carotid endarterectomy, percutaneous
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extirpation-03cj3zz
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excison malignant lesion skin of left ear
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excision-ohb3xzz
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left below the knee amputation, proximal tibia/fibula
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detachment-(low)-0y6j0z1
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thoracoscopic pleurodesis rt. side
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excision-0bbn4zz (how to find-med to respiratory to excision to percutaneous endo).
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extraction left intraocular lens w/o replacement, percutaneous
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extraction-08dk3zz
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routine insertion of indwelling foley catheter
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drainage-0t9b70z
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EGD with removal of foreign body from duodenum
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extirpation-0dc98zz
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facelift, open
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0w020zz
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normal delivery with episiotomy
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division-ow8nxzz
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percutaneous endoscopic clipping cerebral aneurysm
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restriction-03vg4cz
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left knee arthrocopy with reposition of the anterior horn medial meniscus
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reposition-0msp4zz
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heart transplant using porcine heart, open
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transplantation-02ya0za
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ESWL-(lithotripsy) left ureter
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fragmentation-otf7xzz
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reattachment severed left ear
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reattachement-09m1xzz
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trnasurethral cystoscopy with removal of rt. utertral calculus
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extirpation-otc68zz
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open reduction fracture left tibia
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reposition-0qsh0zz
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percutaneous insertion greenfield IVC filer
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insertion-06h03dz
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incision and drainage external perianal abscess
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drainage-0d9qxzz
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removal foreign body left cornea
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extirpation-08c9xzz
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percutaneous transpositon lt. radial nerve
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reposition-01s63zz
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rt. TRAM pedicle flap reconstruction s/p mastectomy muscle only open
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transfer-0kxk0z
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laparotomy with exploration and adhesiolysis of the left ureter
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release-otn70zz
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thoracentesis rt. pleural effusion
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drainage-0w993zz
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percutaneous radiofrequency ablation of lt. vocal cord
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destruction-0c5v3zz
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excision malignant lesion upper lip
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excision-0cb0xzz
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laparascopic appendectomy
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resection-odtj4zz
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nonexcisional debridement lt. heel ulcer
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extraction-0hdnxzz
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transurethral cystoscopy with fragmentation of bladder neck stones
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fragmentation-0tfc8zz
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laparoscopy with bilateral occlusion fallopian tubes using external clips
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occlusion-0ul74cz
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incision scar contracture rt. knee
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release-0hnkxzz
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colonoscopy with sigmoid colon polypectomy
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excision-0dbn8zz
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a percutaneous fascia transfer to cover defect of the anterior neck
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transfer-0jz43zz
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percutaneous embolization lt. uterine artery using coils
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occlusion-04lf3du
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endoscopic retrograde cholangiopancreatography with lithotripsy of the pancreas
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fragmentation-0ffd8zz
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open left neck total lymphadenectomy
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resection-07t20zz
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percutaneous chest tube placement lt. pneumothorac
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drainage-0w9b30z
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laparoscopy with excision old sutures from the peritoneum
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extirpation-0dcw4zz
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closed reduction with percutaneous internal fixation lt. femoral neck fracture
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reposition-0qsc34z
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laporotomy and drain placement left lobe liver abcess
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drainage-0f9200z
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hysteroscopy with D&C, diagnostic
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extraction-0udb82x
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laparoscopy with destruction of endometriosis lt. ovary
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destruction-0u514zz
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DIP joint amputation left thumb
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detachement-0x6m0z3
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removal rt. index fingernail
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extraction-0hdqxzz
question
percutaneous drainage abdominal ascites
answer
drainage-0w9g3zz
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transurethral endoscopic ablation rt. hepatic duct
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destruction 0f558zz
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ERCP with balloon dilation cystic duct
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dilation-0f788zz
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control of postoperative tonsillectomy is coded to which root operation
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control
question
in med-surg section the 3rd character position represents
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root operation
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in med-surg section the 2nd character position represents
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body sytem
question
in med-surg section the 7th character position represents
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qualifier
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in med-surg section the 4th character position represents
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body part
question
a complete redo of a knee replacemnt requiring a new prothesis is coded to which root operation
answer
revision
question
repostion of a malfunctioning pacemaker lead is coded to which root operation
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revision
question
dilation of ureter with insertion of a stent is coded to which root operation
answer
dilation
question
ERCP with biopsy of the common bile duct. identify the approach
answer
percutaneous endoscopic open
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percutaneous insertion nephrostomy tube. identify the approach
answer
percutaneous
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fulgaration of anal warts. identify the approach
answer
external endoscopic
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percutaneous placement of a pacemaker lead. identify approach
answer
percutaneous
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ESWL left ureter. identify the approach
answer
external
question
laparoscopy with destruction of endometreosis. identify the approach
answer
percutaneous endoscopic
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colonoscopy. identify the approach
answer
via natural or artificial opening
question
open incision into the peritoneal cavity for partial resection of the sigmoid colon
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excision-0dbn0zz
question
colonoscopy with polypectomy of the sigmoid colon
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0dbn8zz
question
open incision into the peritoneal cavity for the removal of the terminal ileum
answer
0dtb0zz
question
ERCP with diagnostic biopsy of the common bile duct
answer
0fb98zx
question
laparoscopic removal of the appendix
answer
0dtj8zz
question
a man hit his head on a rock while swimming in a lake near his cabin resulting in a concussion w/o loss of consciousness. what is the dx, external cause, activity, status and occurance codes to report this injury
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dx-s06.0x0A EC-w22.8xxA activity-y93.11 status-y99.8 occurrence-y92.828
question
dx- corkscrew esophagus
answer
k22.4
question
chronic atrophic gastritis w/o bleeding
answer
k29.40
question
duodenitis w/ bleeding
answer
k29.81
question
stenosis of the duodenum
answer
k31.5
question
esophgeal obstruction
answer
k22.2
question
opioid dependence with opioid-induced mood disorder
answer
f11.24
question
alcohol dependence with alcohol induced sleep disorder
answer
f10.282
question
cocaine abuse with intoxication delerium
answer
f14.121
question
cannibis abuse with intoxication delerium
answer
f12.121
question
alcohol dependence with alcohol induced persisting amnestic disorder
answer
f10.26
question
initial encounter for a pedestiran on a skateboard injured in a collition with a car in a traffic accident
answer
v03.12xA
question
subsequent encounter for a pedestrian injured in a collision with a bus while on foot in a nontraffic accident
answer
v04.00xD
question
initial encounter for a pedestrian on roller skates injured in a collision with 2-wheeled vehicle in a traffic accident
answer
v02.11xa
question
sequela for a pedestrian on roller skates injured on a collision with a 2-wheeled vehicle in a nontraffic accident
answer
vo2.01xs
question
initial encounter for a pedestran on foot injured in a collision with a train in a traffic accident
answer
v05.10xA
question
neoplasm of the islets of langerhans
answer
c25.4
question
neoplasm of overlapping sites of the esophagus
answer
c15.8
question
neoplasm of the jejunum
answer
c17.1
question
neoplasm of the cloacogenic zone
answer
c21.2
question
neoplasm of the rectosigmoid junction
answer
c19
question
aneurysmal varix
answer
I77.0
question
ruptured abdominal aortic aneurysm
answer
I71.3
question
stuttering following an unspecified cerebrovascular disease
answer
I69.923
question
ataxia following a cerebral infarction
answer
I69.393
question
facila droop following an unspecified cerebrovascuar disease
answer
I69.992
question
toxoplasma myositis
answer
b58.82
question
kala-azar
answer
b55.0
question
pulmonary toxoplasmosis
answer
b58.3
question
megacolon in chagas' disease
answer
b57.32
question
acute chagas' disease with myocarditis
answer
b57.0
question
x-linked occular albinism
answer
e70.310
question
oxalosis
answer
e72.53
question
glutaric Type II B
answer
e71.313
question
hurler-scheie syndrome
answer
e76.02
question
mixed hyperglyceridemia
answer
e78.3
question
congenital shortening of the right lower limb
answer
q72.811
question
bilateral webbed toes
answer
q70.33
question
congenital pigeon chest
answer
q67.7
question
congenital dislocatable hip
answer
q65.6
question
acessory hallux
answer
q69.2
question
BT leprosy
answer
a30.2
question
oculoglandular listeriosis
answer
a32.81
question
nasopharyngeal diptheria
answer
a36.1
question
whooping cough due to other bordetella species with pneumonia
answer
a37.81
question
meningococcal retrobulbar neuritis
answer
a39.82
question
nontraumatic subacute subdural hemorrhage
answer
i62.02
question
cerebral atherosclerosis
answer
I67.2
question
occlusion and stenosis of right vertebral artery
answer
I65.01
question
dysarthria following a nontraumatic subarchnoid hemorrhage
answer
169.022
question
nontraumatic intracerebral hemorrhage in the brain stem
answer
i61.3
question
root operation-amputation a the rt. elbow level
answer
detachement-0x6b0zz
question
root operation-left heart catheterization with laser destruction of arrhythmogenic focus -the left atrium
answer
destruction-02574zz
question
root operation-cervical cerclage using shirodkar technique
answer
restriction-0uvc7zz
question
root operation-excision of an abdominal aorta with Gore-Tex graft replacement
answer
replacement-04r00jz
question
root operation-open inguinal herniorrhaphy on the left side
answer
repair-0yq60zz
question
charley horse
answer
m62.831
question
myosititis ossificans progressiva of the rt. ankle
answer
m61.171
question
infective myosititis of a left toe
answer
m60.077
question
nontraumatic ischemic infarction of the flexor policis brevis muscle of the rt. hand
answer
m62.241
question
myosititis ossificans traumatica of left lower leg
answer
m61.062
question
bloodstream infection due to central venous catheter
answer
t80.211
question
ABO incompatability with delayed hemolytic transfusion reaction
answer
t80.311
question
postprocedural septic shock
answer
t81.12
question
dehiscence of closure of the ribs or rib cage
answer
t81.32
question
obstruction due to foreign body accidentally left in body following an injection
answer
t81.523
question
accessory nose
answer
q30.8
question
subglottic web of the larynx
answer
q31.0
question
congenital absence of a lobe of the lung
answer
q33.3
question
bilateral cleft lip
answer
q36.0
question
cleft soft palate with unilateral cleft lip
answer
q37.3
question
3 inch repair of the subcutaneous tissue of the rt. upper arm using an open approach
answer
0jqd0zz
question
surture repair of a left radial nerve laceration
answer
01q60zz
question
closure of an abdominal wall stab wound
answer
0wqf0zz
question
laparotomy with suture repair of blunt force duodenal laceration
answer
0dq90zz
question
suturing the tongue
answer
0cq7xzz
question
insect bite to left eyelid
answer
s00.262A
question
nose bruise initial encounter
answer
s00.33xA
question
laceration of upper lip intial encounter
answer
s01.511A
question
routine healing of type II occipital condyle fracture , follow up visit
answer
s02.111D
question
initial encounter for bruise of the right ear
answer
S00.431A
question
atherosclerosis of native arteries of the right leg with intermittent claudication
answer
i70.211
question
patient diagnosed with atherosclerosis of native arteries of the left leg with ulceration of the ankle
answer
i70.243
question
patient with atherosclerosis of an autologous vein bypass graft in the left leg with intermittent claudication
answer
i70.412
question
atherosclerosis of a nonautologous biological bypass graft of the right leg with ulceration of the plantar surface of the midfoot
answer
i70.534
question
atherosclerosis of nonbiological bypass grafts with gangrene in both legs?
answer
i70.663
question
hepatic angiomatosis
answer
k76.4
question
alcoholic cirrhosis of the liver with ascites
answer
k70.31
question
chronic hepatic failure with coma
answer
k72.11
question
phlebitis of a portal vein
answer
k75.1
question
hepatic sclerosis
answer
k74.1
question
partial localization-related idiopathic epilepsy with seizures of localized onset, not intractable, without status epilepticus
answer
g40.009
question
common migraine that is not intractable with status migrainosus
answer
g43.001
question
intractable epileptic spasms without status epilepticus
answer
g40.824
question
an intractable persistent migraine aura without cerebral infarction with status migrainosus
answer
g43.511
question
idiopathic hypersomnia without long sleep time
answer
g47.12
question
idiopathic hypotension
answer
i95.0
question
celiac artery compression syndrome
answer
i77.4
question
Raynaud's disease with gangrene
answer
i73.01
question
intraoperative cardiac arrest during cardiac surgery
answer
i97.710
question
dissection of the thoracic aorta
answer
i71.01
question
In the Medical and Surgical section of ICD-10-PCS, which sixth character should you report for an intraluminal device
answer
D
question
For which of the following ICD-10-PCS root operations might you report a character other than Z for the device? a. Release b. Replacement c. Repair d. Resection
answer
replacement
question
What is the correct ICD-10-PCS sixth character for an autologous tissue substitute
answer
7
question
What is the correct ICD-10-PCS sixth character for a partially absorbable mesh
answer
J
question
Which ICD-10-PCS sixth character should you report for a cardiac rhythm related device?
answer
P
question
an initial encounter for a displaced fracture of the medial malleolus of the left tibia
answer
s82.52xA
question
patient presents for a subsequent encounter for an open, displaced type I transverse fracture of the right patella with delayed healing
answer
s82.031H
question
initial encounter for a nondisplaced closed longitudinal fracture of the left patella
answer
s82.025A
question
subsequent encounter for a torus fracture of the upper end of the right fibula with malunion
answer
s82.811P
question
an initial encounter for an open displaced segmental fracture of the shaft of the left tibia?
answer
s82.262B
question
tennis elbow involving the right elbow
answer
m77.11
question
calcium deposits in the bursa of the left wrist
answer
m71.432
question
abscess in the bursa of the right shoulder
answer
m71.011
question
prepatellar bursitis of the left knee
answer
m70.42
question
spontaneous rupture of the flexor tendon in left thigh
answer
m66.352
question
nonvenomous insect bite on his left forearm
answer
s50.862D
question
A patient returns to a physician due to a Salter-Harris Type II physeal fracture of the lower end of the ulna on the left arm that is experiencing delayed healing
answer
s59.022G
question
initial visit for an ulnar collateral ligament strain of the right elbow
answer
s53.441A
question
aftercare visit for the laceration of the flexor muscle on the left ring finger at the forearm level
answer
s56.126D
question
patient's first encounter for an open fracture of the coronoid process of the right ulna? The physician did not document it as displaced or nondisplaced
answer
s52.041B
question
root operation-percutaneous tracheostomy formation with tracheostomy tube placement
answer
bypass
question
root operation-percutaneous replacement of a broken pacemaker lead in left atrium
answer
insertion
question
root operation-laparotomy with removal of pancreatic drain
answer
removal
question
root operation-cervical cerclage using Shirodkar technique
answer
restriction
question
root operation-endoscopic retrograde cholangiopancreatography (ERCP) with lithotripsy of a common bile duct stone
answer
fragmentation
question
pt comes to ER with burns to his upper extremity. first and second degree burns from right elbow to the wrist. he states it was done at work and he spilled hot oil on his arm. what are the diagnosis codes (5) and code the procedure
answer
T22.211A Y99.0 X10.2xxa y92.511 y93.G3 2W2CX4Z
question
pt has a corneal abrasion from a metal object in his left cornea, removal of the foreign body was done with a q-tip and a patch was applied
answer
T15.02xA Z18.10 08c9xzz
question
pt was hit on head, he does not know what with, he was at a restaurant does not know who hit him. he was hit on the back of the head and it caused a large laceration on the occipital, temporal scalp 3 inches in length linear in the horizontal axis. no loss of consciousness. he was also hit on the back. the laceration was cleaned a closed with multiple skin staples. code all (4) also code procedure
answer
S40.012A S01.01xA Y00.xxxA Y92.511 0HQ0XZZ
question
pt was driving in a vehicle that crossed into another lane. he was hit head on at high speed on the passenger side, he had his seatbelt on and remained conscious. complians of pain low down in the transverse pelvis area from the lap belt and has a bruise on the bony prominence. he has an extensive laceration on the left arm/forearm with partial avolusion and deep tissue damage barely into the muscle approximately 3cm wide and 5cm in length, also are other larceations to this arm-lateral and posterior-1.5cm wide, 2cm in length. there is foreign material, glass, and mirror fragments and some swelling and pain in the left ankle.
answer
S51.822A M25.472 V43.52XA Y92.488 Z18.81 S30.1xxa
question
procedure: wounds to arm 3cm wide and 5cm in length- injury to the muscle, 1.5 cm wide and 2cm in length on the left forearm. foreign glass and mirror fragements are removed from the wounds by the nurse during inspection of the wounds.
answer
0JQH0ZZ 0HCEXZZ there were multiple lacerations but only the layered closure is coded, the fragments were removed non-operativly by a nurse
question
pt slammed his right thuimb in a car door, thumbnail is ecchymotic and there is a subungual hematoma, mild swelling on the palmer aspect, limited range of motion. final DX: subungual hematoma, blunt trauma wiht contusion, ritght thumb tip. the hematoma was drained with a hot wire code DX and procedure.
answer
s60.112A W23.1XXA Y92.481 0H9QXZZ
question
4 year old stuck A piece of tissue paper in her left ear at preschool. an otoscope was used with tweezers to remove the paper. code DX and procdure
answer
T16.2xxa H66.92 z18.39 y92.210 09c88zz
question
pt was climbing a power pole and lost his footing then slid down the pole about 10-12 feet up in the air. he lost his hand hold and fell hard on his feet then knock his knees into the pole. pt complains of bilateral knee contusions and pain in his hands. both hands have extensive slivers and supervicial abrasions. he works as a cable technician and was at work at the time. the hands were anesthetized and multiple wood fragements were removed from multiple locations on both hands. code dx (9 codes), code procedure (4)
answer
s61.442A s61.441A s80.01xa s80.02xa w17.89xa w45.8xxa y92.69 y93.39 Y99.0 OHDFXZZ OHDGXZZ OHCFXZZ OHCGXZZ
question
pt was driving semi-truck when driving at a high rate of speed he went off the road and hit the guard-rail, was seatbelted, and did not lose consciousness, complaining of neck and low back pain-mid-lumbosacral, also cervical pain, pain in the temporofrontal area-lacerations 2.5 cm over the eyebrow, 1.5cm laceration on the forehead over left eyebrow, he also had multiple facial lacerations which were much smaller. right rib pain-with small abrasion, and right knee pain with abrasions. code DX (8), code procedure.he also was given a tetenus shot.
answer
s01.81xa s13.4xxa s33.8xxa s00.81xa s80.211a s20.311a v67.5xxa y92.411 0HQ1XZZ 3E0234Z
question
pt was parachuting when he sustained an injury to left ankle and foot. he heard a crunching noise when he landed, there is deformity, no open wounds. x-ray noted a fracture of the fibula. final diagnosis: displace fracture of the shaft of the fibula, closed. sprain of the tibiofibular ligament, left ankle. a close rduction of the fibula was performed without internal fixation.
answer
s82.442a s93.432a v97.22xa y93.39 0QSKXZZ
question
pt comes into ER stating her "legs are numb" on and off (paresthesia) for days. moderate amount of dizziness, pain in right side of chest due to shingles, history of HTN, CAD, and DM type II, she is obese,
answer
B02.9 e11.9 z79.4 r20.2 I10 E66.6 I51.9 Z60.2
question
pt is found unconcious by her sister she apparently had been drinking heavily, there were 4 or 5 1.5 liter bottles of vodka and several emty quart bottles of beer. she did not have anything to eat for 4 days. she has been a heavy drinker for many years, she is a heavy smoker, lives alsone, depressed, HTN, asthma, COPD, hypothyroid and is on hormone replacement therapy. code all DX.
answer
f10.229 f32.9 e86.0 j44.9 f17.210 e03.9 z60.2
question
pt presents with 2 day history of vaginal bleeding, she passed tissue and she states she knows she lost her pregnancy. he LMP was end of may. she did have pregnancy confirmation two weeks later with an estimated consumation of february. code DX
answer
O03.9 0UJD8ZZ
question
pt came in with near syncopal episode pt had headache and felt dizzy. has HTN,
answer
I10 R55
question
pt is 7 weeks pregnant complaining of dizziness-spinning sensation associated with nausea. BP was 130/100, when pt laid on her side vertigo returned. diagnoses listed are : vertigo, positional and HTN possibly secondary to pregnancy. code diagnoses
answer
O26.91 O13.1 H81.10
question
4 year old pt presents with SOB, Fever, sore throat, coughing-dry hacky-nonproductive-increased work of breathing for past 2 days, has HX of asthma and pneumonia. diagnoses are: acute exacerbation of asthma, brochopneumonia.
answer
J45.901 J18.0 Z87.01
question
pt present with HX of suicide attempts pt was in police custody when he told them he had swallowed 80 Effexor 50mg pills. has vomited 2x's. states he is depressed and UA comes back positive for marijuana. pt underwent gastric lavage and activated charcoal. diagnoses were: suicide attampt with effexor overdoes, major recurrent depression. code DX and procedure
answer
T43.212A R11.10 F33.9 F12.90 3E1G78Z
question
5 year old pt ate some shrimp and had swelling and a hive-like rash on his skin specifically neck and face-no orla swelling. pt did cough, pt has HX of asthma. diagnosis was allergic reaction to shrimp with dermatitis.
answer
L27.2 J45.909
question
pt presents with 2 day Hx of swelling on left foot from mosquito bite. after the bite she developed increased swelling, redness, and tenderness in the foot and pain when she walks. diagnosis is cellulitis secondary to mosquito bite left foot.
answer
L03.116 S90.862A W57.XXXA
question
93 year old presents with back pain for last month has UTI fever, HTN, ocular cataracts-blind, hard of hearing. xrsy shows compression fracture of L1 with osteoporosis and scoliosis. diagnoses are : compression fracture L-1, scoliosis and osteoporosis, anemia
answer
m80.88XA M40.295 M41.56 D64.9 I10 H25.9 H54.0 H90.5
question
pt was playing football and working out in practice at school and was shoved by another player and fell on his left arm bending his wrist back. complains of pain and swelling in the dital forearm above the wrist. both radius and ulna are aspect. xray shows a buckle fracture with greenstick type injury proximal to the epiphysis, both radius and ulna. diagnosis is greenstick fracture of diastal radius and ulna . a short arm cast was applied
answer
S52.21XA S52.31XA w03.xxxa y92.321 y99.8 2W3DX2Z
question
pt presents with swelling on the olecranon surface of his right elbow for 3 days, no known trauma, but does state it may be from when he was working on his car doing mechanic work. he was pushing on something and felt it give or pop. history of angina, hiogh cholesterol, HTN, xray shows bone spur. diagnosis listed as olecranon bursitis. bursa is drained
answer
M70.21 I10 I20.9 E78.0 Z95.1 0M933ZZ
question
pt present with dizziness-spinning sensation, it is worse when standing or postional changes, "world is spinning". headache, nausea and vomiting, history of migraines, pt then left against medical advice. diagnoses were: Left AMA, acute vertigo, acute cephalgia with history of migraines-resolved, hyperthyroidism.
answer
H81.10 R51 E05.90
question
pt presents with history of HTN, and breast carcinoma metastatic to lung. pt had witnessed syncopal episode/arrest while getting ready for bath. , pt went into V-fib and then went asystole. pt was pronounced dead. DX was: acute cardiac arrest, HX of breast carcinoma, HTN
answer
I46.9 I10 z85.3 z85.118
question
pt was in shower when she blacked out and became weak, hx of alzhemiers, pt did not fall, DVT, HTN, hypothyroid, arthritis, on coumadin, diagnoses are: TIA with brief altered level of conciousness, chronic dementia with alzheimers, coumadin anticoagulation, hypothyroidism, arthritis. pt had CT scan of brain
answer
G45.9 g30.9 f02.80 e03.9 m12.9 z79.01 CT- B020ZZZ
question
pt presents with difficulty breathing, tightness in throat, acid burning and reflux, . pt vomited and nauseated. states had a feeling of tightness and smothering and felt asthma symptoms. has HX of GERD and mild asthma. DX: GERD, and mild reactive airway disease with asthma
answer
K21.9 J45.909
question
pt has abdominal pain and vomiting. someone had suggested she might be pregnant but she had a tubal ligation 12 year sbefore, she went ahead and did a pregnancy test and it came back postive, she came into thew ER where a repeat pregnancy test was done-negative. diagnoses were: nausea and vmiting secondary to acalculous cholecystitis, elevated liver enzymes, postmenopausal estrogen deficiency, HX of peptic ulcer. pt is also obese.
answer
K81.9 r11.2 e28.39 r74.0 r74.8 z87.19
question
81 year old patient presents with right flank pain worsening, HX of CAD or grafted coronary arteries, s/p CABG, a-fib, on coumadin, osteoporosis, gastritis, HTN, hyperlipidemia, and is a smoker. UA shows leukocytosis and positive nitrates and leukosite esterase. DX is UTI
answer
N39.0 I10 I48.2 M81.0 K29.70 E78.5 I25.810 F17.210 Z95.1
question
pt admitted with AIDS and worsening headaches. HX of cryptococcus infection treated, examination reveals some encephaslopathy, resulting from AIDS progression. HX of smoking, final DX of menigocephalitis due to toxoplasmosis. pt had a diagnostic lumbar puncture. code DX and procedure
answer
B20 B58.2 F17.210 009U3ZX
question
pt admitted for tx of left eyelid chlmydial conjuctivitis due to trachoma, active stage. HX of brittle diabetes mellitus type I, pt underwent conjunctivoplasy and subconjuctival injection of antibiotic. 3 days after the surgery pt became afibrile and complained of left knee pain. xray comfirmed reiter's arthritis of both knees.
answer
a71.1 e10.9 m02.361 m02.362 08QTXZZ 3E0C33Z
question
a 30 year old has a Hx of multiple episodes of exacerbation of shingles, present to ER with low back pain and lower extremity weeakness. final dx of herpes zoster myelitis.
answer
B02.24
question
pt presents with fever, nausea, and vomiting, abdominal cramping, pain and diarrhea-bloody. culture revealed salmonella. pt is mildly dehydrated. final dx: salmonella gastroenteritis and mild dehydration
answer
A02.0 E86.0
question
pt d/cc with urosepsis due to streptococcus, WBC count was 15,000, UA and blood positive for strep. after a query regarding the urosepis, the DR. added "strptococcol B sepsis and UTI due to strep also".
answer
A40.1 N39.0 B95.1
question
pt diagnosed with malignant neoplasm of the upper-outer quardrant of the right breast admitted for chemo. pt is very fragile. pt had port inserted and infused with doxorubicin ( a neoplastic). the cather was not placed properly and hence dislodged. the pt complained of pain at infusion site and it was documented that there was no blood retrun and chemo had infused outside of the vein into the skin.
answer
c50.411 t80.810D z51.11 3E00X05
question
pt admitted with lump in left breast lower outer quadrant. hx of malignant neoplasm in right breast for which she had toalt mastectomy 3 yrs ago. hx alos includes gastric banding. needle biopsy was done and confirmed dx of fibrocystic breast disease. a lumpectomy was performed and the lump was not malignant. final dx: fibrocystic breast disease LOQ,m left breast.
answer
n60.12 z85.3 z90.11 z98.84 0HBU0ZZ 0HBU3zX
question
pt seen for follow-up for jejunum plasmacytoma. MRI revealed malignant neoplasm had grown and and it is questionable if tumor has spread. what is the primary dx?
answer
C90.30 hint- look up plasmocytoma
question
pt seen in office for follow-up of thyroid-adrenocortical insufficiency syndrome. while there she metioned finding lump in her breast. a mamm was ordered-came back normal. due to unstable thyroid pt was admitted and an open biopsy of the right breast was perfoirmed and frozen section revealed andenocarcinoma. immediately a right radical mastectomy was performed followed by replacement with breast implant.
answer
c50.911 e31.0 0HRT0JZ 0HBT0ZX
question
pt has hx of esophageal cancer treated 1 year ago with chemo-completely eraticating it. pt presents now with complaints of lethargy and severe bone pain. pt was admitted for pain management, however a bone scan comfirmed diffuse bone metastasis
answer
c79.51 g89.3 z85.01
question
pt present swith abdominal pain, pelvic lymphadenopathy and hepatomegaly. CT scan shows tumopr in decending colon. lapartomy with resection of decending colon was done and end- to- end anastomosis. a temporary colostomy was placed, a direct anantomisi to abdominal wall. biopsies were also taken of the liver and lymph nodes. pathologgy revealed primat malignant neoplasm of decending colon with metastasis to liver and pelivic lymph nodes.
answer
c18.6 c77.5 c78.7 0DTM0ZZ 0D1M0Z4 0FB00ZX 07BC0ZX
question
pt with recurrent nasopharygeal cancer presents with nasal muscositis with pain, inflammation and irritation of the nasal mucosa. Dr stated pain may be related to radition therapy she receieved for her cancer. decreassed sense of smell, as a complication, final dx: nasal mucositis secondary to radiation therapy, nasopharygeal cancer.
answer
c11.9 j34.81 r43.9 y84.2
question
pt present to ER with headache and severe dizzyness, physical exam showed enlarged spleen and bllod work showed elevated hematocrit, WBC and platelets. dx of polycythemia vera, pt underwent phelebotomy of vein of right hand.
answer
d45 r16.1 059G3ZZ
question
pt admitted with severe chest pain, with cough, dyspnea, and fever. DR documented pt was in the throes of sickle-cell crisis with Hb-SS diease. immediate O2 and non autologous blood trnafusion of RBC was initiated. a peripheral vein was punctured percutaneously.
answer
d57.01 30233P1
question
pt has syptoms of acute respiratory distress, pulmonary edema and hypotension within 2 hrs of a blood trnasfusion due to blood loos for chronic anemia. lab test show increase WBC. pt responded well to tx of CPAP and added O2 and hemodynamic support with no sequlae
answer
d50.0 j95.84
question
pt presents with malaise and splenic enlargement. lab work reveals severe neutropenia and leukopenia. bone marrow biopsy aspiration was done with specialized needle-a stilette. revealed hypercellular bone marrow. biopsy was taken from th eilliac crest of the upper right femur. the needle in a rotating fashion punctured and broed through the skin, subcutaneous tissue, and periosteum. with force the bone marrow contents were suctioned and a core of bone obtained.
answer
d73.81 07DR3ZX
question
pt presents for initiation of thrombin inhibitor therapy to treat thromobocytopenia due to recent administration of heparin for unstable angine.
answer
d75.82 i20.0 t45.515A
question
pt with hx of gastric ulcers admitted for upper gastrointestinal bleed 2 weeks ago resulting in transfusin of RBC's. 2 days ago she noticed purpura on her tongue and cheeks, then began urinary and vaginal bleeding. presents with post-tranfusion purpura and was given IVIG for first time.
answer
d69.51 k25.4 t45.8z5a
question
pt presents to oncologist for follow-up for care and the dx is listed as anemia of chemo. pt underwent left breast mastectomy 8 weeks ago after dx of breast cancer of left breast, central portion. surgery was folloed by radition therapy- though none administered on this admit.
answer
d64.81 c50.112 t45.1x5a
question
type 2 diabetic admitted for evaluation of bilateral lower extremity pain and blurred vision. admitting dx was PVD, and probably diabetic retinopathy. doppler ultrasound revealed microagiopathy of lower extrmeities. hx of chewing tobacco. opthamaologist diagnoses pt with proliferative retinopathy for which he underwent laser photocoagulation, left retina. also has chronc bronchitis. final dx: diabetic peripheral vascular disease.
answer
e11.51 e11.359 f17.220 j41.0 085H3ZZ
question
pt went to ER after fainting and remained unconscious for 10-15 minutes, pt had chills and nausea. hx of peptic ulcers, HTN. lab work showed low bood glucose due to inadequate food intake this AM. final dx: reactive hypoglycemia
answer
r55 e16.1 k25.9 i10
question
pt admitted with glucose of 525. was immediately started on sliding scale insulin schedule. 25 yr hx of type 2 diabetes and states he forgot to take his insulin. hx of chronic lympocytic leukemia w/o remission.
answer
e10.65 c91.11 z79.4
question
patinet admitted with diabetic neuropathy secondary to diabeted from chronic therapeutic adrenocorticosteroid.
answer
e09.40 t38.05a
question
pt presents to ER from nursing home in dehydrated state. IV fluids were started. pt has had the stomach flu for 2 days with diarrhea and vomiting, lab show pt is hyponatremic, final dx: hyponatremia and stomach flu (viral gastroenteritis)
answer
e87.1 a08.4 3eo337z
question
pt admitted to substance abuse center for management of 10 year valium abuse/drug addiction. as part of detox she was started on phenobarbital, thiamine and mulitvitamins. also underwent rehab in the form of group therapy/12-step program. final dx: valium addiction
answer
f13.20 HZ2ZZZZ HZ43ZZZ
question
pt admitted with hx of IV drug (heroine) dependence. has been nauseated vomiting, diarrhea and abdominal pain. appetite decreased with dizzy spells. she is dehydrated. syptoms are typical of heroine withdrawl. she was given IV fluids and methadone, started on 5-day detox -with clonidine. final dx: heroine withdrawl
answer
F11.23 e86.0 HZ2ZZZZ
question
pt presents to ER she is chronic abuser of cocaine and alcohol (abuse and dependence). curently alcohol intoxicated. hx of CAD, CHF, DM type II has been on insulin for 3 yrs. pt transferred to detox unit and rehab. pehab includes counceling, and med managemnet with methadone maintenance. final dx: alcohol dependence with intoxication and cocain dependence.
answer
f10.220 f14.20 i25.10 i50.9 e11.9 z79.4 HZ2ZZZZ HZ81ZZZ
question
pt seen in office for alcoholism eval. daily drinker for 20 yrs. pt has passive aggressive personality on librium. goes to AA, pt has developed alcoholic liver damage. final dx: alcohol dependence-periodic use, passive-agressive personality, alcoholic liver damage
answer
f10.20 k70.9 f60.89
question
pt admitted for acute abdominal pain, has hx of alcohol dependence. after ultrasound showed alcohol induced chronic pancreatitis. pt observed for withdrawl symptoms, antaabuse was given as part of detox program. final dx: alcohol induced chronic pancreatitis.
answer
k86.0 HZ2ZZZZ BW40ZZZ
question
pt who uses marijuanan regularly on a recreational basis sees Dr. for falling asleep on the job. final dx: marijuanan abuse resuting in sleepiness on the job
answer
f19.182 f12.188
question
pt present to Dr. office for routine renwal of dilantin. pt has not been taking meds properly, pt has intellectual disability-mildly mentally challenged since malignancy of parietal-occipital lobe excised yrs ago. after the excision of the tumor she began to have seizures. final dx: underdosing of dilantin, mild metal retardation and seizures resulting fron cerebral neoplasm.
answer
r65.9 t42.0x6a f70 z91.19 z85.841
question
pt brought to ER by police, requesting eval because pt was disorderly at scene of MVA in which he was involved. admitted to psych unit and dx was reavealed to be organic brain syndrome with pre-senile dementia; probable alzheimer's-early onset
answer
g30.0 f02.81
question
pt admitted from a SNF with paraplegia blurred vision, glucosuria. she recovered from severe sepsis 6 months ago-which accounts for her paraplegia. elevated blood sugar along with paraplegia and blurred vision led her Dr. to suspect critical illness polyneuropathy. test include percutaneous muscle biopsy of the right and left lower legs-using a suction needle. test reveal pt does have CIP.
answer
B94.9 g62.81 G82.22 r81 h53.8 0KBT3ZX 0KBS3ZX
question
PT HAS HX OF cad HAD HEART TRANSPLANT 1 YR AGO AND NOW PRESENTS WITH ATHEROSCELROSIS IN THE BYPASS GRAFT OF THE TRANSPLANTED HEART DUE TO LIPID-RICH PLAQUE. INTRAVASCULAS SPECTROSCOPY WAS USE TO DX THE PROBLEM. PT ALSO HAD SEVERE CHEST PAIN DOCUMENTED AS UNSTABLE ANGINA.
answer
I25.760 8e023dz
question
pt had end stage heart failure due to malignant hypertension is admitted for implantation of DeBakey axial flow ventricular assit device.
answer
i11.0 02HA0QZ
question
pt admitted to rehab for multiple therapies following a CVA. final diagnostic statemnt listed residual oropharyngeal dysphagia and residual left sided (non-dominasnt) hemiparesis due to CVA
answer
i69.391 i69.354 r13.12 z51.89
question
pt has CAD admitted with unstable angina. pt had left heart cath performed during this admit, which showed chronic total occlusion in a native vessel
answer
i25.110 4A023N7
question
pt admitted with fever and cough with blood-tinged sputum. after study Dr. documented pulmonary septic emboli due to respiratory syncytial virus
answer
i26.90 b97.4
question
pt is dx with hypertensive end stage renal disease 5 yrs ago has been on dialysis via his synthetic AV dialysis graft-left forearm. currently on anticoagulants due to hx of thrombosis. admitted for thrombectomy of the graft. brachial vein was punctured and balloon catherter inserted. the balloon was passed just passed th clot inflated and in retrograde fasion as the catherter was pulled out the clot came with it. in addtion they administered an injection of Activase. final dx: thrombosis of AV renal dialysis graft.
answer
t82.868D i12.0 n18.6 z99.2 z79.01 z86.718 05CA3ZZ 3E03317
question
pt has hx of CAD and unmstable angina, has deteriorated to the point of recommendation of coronary artery bypass surgery. a left heart cath was done one day prior to admit indicating blockage of left anterrior decending artery. also had HTN, taken to OR where via open approach the left internal mammary artery was directly grafted to the LAD artery just beyone the site of the blockage. percutaneous bypass was also used during surgery.
answer
i25.110 i10 02100z9 5a1221z
question
pt dx with CAD of 3 coronary arteries. he undergoes coronary artery bypass surgery (CABG), using 3 saphenous vein grafts to aorta with cardiopulmonary bypass
answer
i25.10 5a1221z
question
pt dx with 3rd degree atrioventricular heart block, needed an emergency admit for pacemaker insertion. a dual chamber pacemake, pulse generator and antimicrobial envelope were inserted. one lead was placed in the ritgh ventricle, and one in the right atrium. via tansvenous percutaneous approach , pulse generator and envelope were placed in the chest via percutaneous approach
answer
i44.2 0JH636Z 02H63JZ 3E0132A
question
pt presents with incideous headache, confusion, blurred vision, and nausea. BP was 120/100. DR documentent hypertensive encephalopathy. has HTN, BP upon D/C was 140/90
answer
I67.4 I10
question
pt has hx of DVT, developed stasis dermatitis which worsened and resulted in vericose ulcer of her lower left leg (skin deep) with severe inflammation. pt admitted for greater saphinous vein stripping and excision of the skin ulcer.
answer
i83.228 l97.821 z86.718 06dq0zz 0hblxzz
question
pt has persistant atrial fibrillation and hypetensive heart disease admitted for Maze procedure
answer
i48.1 i11.9 02564zz 8e023dz
question
pt has psudomanal pneumonia treat with antibiotics for several days, symptoms did not abate. she was admitted as result of the psudomanal pneumonia a pleural empyema developed in the left pleura. underwent thoracoscopic pleural biopsy followed by insertion of chest tube, fluid was removed. final dx: pyothorax/empyema due to bacterial pneumonia
answer
j85.1 b96.5 0BBP4ZX 0W9B30Z
question
pt admitted with SOB, unresponsive to nebulizer. pt had theophyline level of 5.9. xray showed no infiltrates. pt recieved steroids, and resp. therpay tx. final dx: severe persisitant asthma with status asthmaticus; acute exacerbation of COPD
answer
j44.1 j45.52
question
pt admitted with fever and cough. xray revealed pneumonia in left lower lobe of lung. sputum culture identified klebsiella. pt started on ciproflaxin. hx of cystic fibrosis. final dx: pneumonia due to klebseiellla and cystic fibrosis.
answer
j15.0 e84.0
question
pt evaluated for bronchial asthma with COPD, atherosclerotic heart disease (native artery), HTN. UA reveals bateria and WBC, pt put on antibiotic for UTI final dx:bronchial asthma with COPD and bacterial cystitis
answer
j44.9 j45.909 i25.10 n30.90 b96.89 i10
question
pt has hx of COPD admitted with productive cough, wheezing, SOB. arter study-pt has acute bronchial infection (parainfluenza virus) in addtion to COPD. pt smokes,
answer
j44.0 j20.4 f17.210
question
pt admitted with complaint of nausea and vomiting and diarrhea. pt taks digitalis for supraventricular tachycardia, also has UTI. lab results reveal an interaction between the digitalis and the antibiotic ampicillian the pt is taking for the UTI.
answer
k52.1 r11.2 t46.0x5a t36.0x5a i47.1 n39.0
question
pt seen in ER for severe chest pain admitted to rule out AMI. hx of GERD. a diagnostic EGD was done. ER Dr. dx reflux esophagitis with parastaltic of very high amplitude. dx of dyskinesia was made on the esophageal motility study.
answer
k21.0 k22.4 0DJO8ZZ 4A0B88Z
question
pt admitted with chronic nodular diffuse liver cirrhosis due to hx of alcoholism-in remission. pt now admitted for an allogenic cadaveric liver transplant performed with no cpmplications
answer
k70.30 f10.21 0FY00Z0
question
pt admission with massive lower GI bleed. pt has hx of dualdenal ulcer-bleeding was thought to have originated there. EGD showed no evidence of ulcer or active bleeding. colonoscopy reveal sigmoid angiodysphasia that was hemmorrhging profusely. bleeding controlled by endoscopic eletrocauterization with heated metal device. pt also transfused PRBC for blood loss anemia
answer
k55.21 d62 0DJ08ZZ 0D5N8ZZ
question
pt has esophageal reflux admitted with hemoptaisi and dysphagia. hx of GERD. endoscopy revealed acute esophagitis of lower part of esophagus but no evidence of bleeding . a laporscopic nissen fundoplication at the gastroesophgeal junction. the surgeon freed the fundus by undermining it.
answer
k21.0 0DV44ZZ
question
pt has lou gerigs disease experienced rapid progression of muscle weakness and paralysis. he opted for placement of naso-gastric tube feeding several weeks ago. pt presents with infected esophagostomy site. documentationn plus lab tests confirm septicemia due to MRSA. while hospitalize pt underwent change of feeding tubes, eternal approach.
answer
k94.32 a41.01 g12.21 0D20XUZ
question
pt admitted with hx of anorexia gas malaise weight loss and abdominal pian in right lower quardrant, with diarrhea occasionally. a colonoscopy with biopsy of ascending colon reveal granulomatous colitis
answer
k50.10 0DBK8ZX
question
folowing abdominal surgeries pt admitted for lysis of adhesions located throughout the abdominal wall, scars were taken down via laparascopic approach.
answer
k66.0 0DNW4ZZ
question
pt has gangrenous pressure ulcer of right hip (upper femur) and a pressure ulcer of the sacrum documented by DR. nursing indicates stage II decubitus ulcer of sacrum and stage IV decubitus ulcer of the right hip involving some muscle tissue. Dr. perfromed non-excisional debridement of sacral ulcer and excision of hip ulcer. final dx: stage IV decubitus ulcer of hip.
answer
i96 L89.214 L89.152 0JD70ZZ 0KBQ0ZZ
question
pt with chronic purulent and flamed acne rosacea resulting in permanent scarring of her cheeks had a skin graft procedure. inderwent wide excision of the rosacea of her lower lip external with full thickness graft over the defect, lower lip.
answer
L71.9 0CR1X7Z 0CB1XZZ
question
pt is 2 yrs CVA has severe mulitiple joint contractures sequlea of the stroke and bedridden for past 2 yrs. pt developed a stage II pressure ulcer on her coccyx involving subcutaneous tissue, as well as a stage IV pressure ulcer on her elbows, bilateral (one on each elbow at the lower end of the humerous)-down to the bone. underwent debridement of elbow ulcers and excisional debridement of coccygeal ulcer. final dx: stage IV elbow pressure ulcers, bilateral
answer
i69.398 m24.50 L89.014 L89.024 L89.153 0jb70zz 0rbm0zz 0rbl0zz
question
pt is resident of nursing home, admitted to hosp. with severe stage IV decubitus ulcer of the right bottock all the way down to the bone. pt also has a small chronic ulcer of the right heel, limited to the skin-only requiring dressing change. hx of generalized atherosclerosis of both lower extrmeities. the stage IV ulcer was surgically treated, final dx: decubitus ulcer of buttock stage IV.
answer
L89.314 L97.411 I70.203 0QB20ZZ
question
pt present for tx of stage II healing pressure ulcer of the right ankle underwent wound management therapy by irrigation of wound followed by hydrotherapy.
answer
L89.512 3E10X8Z F08G5BZ
question
pt admitted for IV antibiotic treatment of cellulitus of left leg secondary to a minor scratch. by the 3rd hosp. day,erythema had improved. hx of opid drug abuse-with drug seeking behavior, all narcotics were DC'd with no signs of withdrawl. final dx: cellulitis of left leg
answer
L03.116 F11.10
question
pt admitted with left hip pain for 3 weeks, xray revealewd a pathological fracture of left femoral neck. pt denies any recent trauma. hx of osteoporosis and hypthyroidism. pt taken to OR where open reduction with internal fixation was performed. final dx: pathological fracture of left hip due to age related osteoporosis.
answer
M80.052A M16.9 E03.9 0QS704Z
question
pt admitted with complain of 1 yr hx of low back pain due to herniated necleus pulposus. depite several meds, he has chronic and debilitating back pain, and presents for surgical intervention. a lumbosacral diskectomy was performed with removal of the disc at L4-L5 and L5-S1. using a stylet, a cannula was inserted through the back into the center of the intervertebral disc. the stylet was removed and the cannula in place a dekompressor (fluroscopic) was used for the disckectomy. spinal stabilization followed, with pedicle screw based spinal stabilization device inserted into the posterior lumbar space at L4-L5.
answer
M51.27 0SB43ZZ 0SH33CZ
question
pt dx with cervical spondylosis with spondylogenic compression of the cervical spinal cord (myelopathy). she is s/p CVA x 6 yrs with right sided hemiparesis, hx of senile osteoporosis. pt is right handed.
answer
m81.0 m47.12 I69.351
question
pt admitted with complaint of left knee swelling and pain, on and off for past 3 yrs. arthrocentesis was performed to darin (aspirate) off excess fluid. cytoloic culture revealed mixed flora for which antibiotics were prescribed. xray revealed inflammation of the bursa. the pt was administer a cortisone injection. final dx: infective bursitis of the left knee.
answer
m71.162 b96.89 0S9D3ZX 3E0U33Z
question
pt seen in dr. office complaining of lumbar pain, chills, dysuria, and fever. because of hx of bladder cancer 1 yr ago, dr. admitted her for further work-up. he suspected acute pyelonephritis and dx was confirmed on unrine culrture results. positive for e. coli, in additon a diagnositic cystourethroscopy was performed.
answer
n10 b96.20 z85.51 0TJB8ZZ
question
pt is postmenopausal experiencing urine leakage during coughing or sneezing. dx was overactive bladder with stress urinary incontinence following IVP of the kidney, bladder and ureters using fluoscopy with high contrast. underwent urinary bladder suspension-a burch urethropexy, laparoscopic approach.
answer
n39.3 n32.81 0TSD4ZZ BT140ZZ
question
pt presents from SNF with recent kidney infection, has been treated with antibiotics but has not responded. symptoms: low grde fever, abdominal cramps, and dysuria. MRI of kidneys revealed infection of right renal pelvis blood cultures were negative. urine culture positive for enteroccus.
answer
n28.85 b95.2 BT33ZZZ
question
pt present to dr. office for annual gynecological exam. complains of bump in vagina. a 9-cm benign cyst was discovered on vaginal wall. hx of hypertensive heart disease with CHF. pt was admitted and using a needle the cyst was drained.
answer
n89.8 I11.0 I50.9 0U9G3ZZ
question
pt seen in ER complaining of feeling as if he cannot completely empty his bladder. a voiding cystourethrogram using radio-contrast and fluoscopy revealed severe urinary retension as the result of an enlarged prostate. a transurethral ultrasound laser-induced prostatectomy (TULIP) was done in which the entire protate was vaporized using a laser. a resectoscope was introduced through the urethra followed by the vaporization.
answer
n40.1 r33.8 0VT08ZZ BT1BYZZ
question
pt dx with end stage renal disease admitted for insertion of perioneal dialysis device for continuous ambulatory dialysis. hx of uncontrolled HTN-leading to total renal failure. following incision into the abdomen a permanent tube for fluid exchange was placed. pt also underwnet 2 peritoneal dialysis sessions.
answer
I12.0 N18.6 0WHG33Z 3E1M39Z
question
pt underwent a loop electrosurgical excision procedure (LEEP) of the endocervix and fractional dilation and curettage for postmenopausal bleeding. surgery was uncomplicated. an exam of tissue revealed severe cervical dysplasia. within 2hr post-op there was excessive bleeding and a vaginal pack was placed. pt was readmitted. a hysteroscopy reveald a nicked and hemorrhaging blood vessel originating in the endocervix, uterine neck. via hysteroscopy the bleedin stopped after suture repair of blood vessel. final dx: serve cervical dysplasia and post-op bleeding.
answer
n99.820 d06.0 n95.0 0UQC8ZZ
question
15 yr old pt admitted at 30 weeks gestation with abdominal pain and questionable labor. on exam she was 50% effaced and tight fingertip dilated with cephalic presentation. placed on terbutaline, she recovered. final dx: premature labor, undelivered.
answer
o60.03 z3a.30
question
pt admitted with dx of inevitable abortion. water broke at home and she passed some tissue. on exam membranes were visible and fetal head palpable. some blood and amniotic fluid were in the vault. most of the fetus was passed spontaneuosly but US following the abortion indicated not all had been expelled. a D;C with aspiration curattage was done to deliver the retained fetal tissue. urine was suspicious for UTI, culture showed e. coli. final dx: spontaneous incomplete abortion 19 weeks gestation complicated by UTI.
answer
O03.38 B96.20 Z3a.19 10D17ZZ
question
an elderly prinigravida, 40 yr old pt at 12 weeks gestation. during routine visit an US indicated the fetus was ancephalic. an intauterine saline injection produced an incomplete abortion followed by dilation and curettage. final dx: therapeutic abortion secondary to fetal abnormality
answer
o35.0xx0 z3a.12 10a07zx 10d17zz
question
pt full term 41 weeks admitted in active and obstructed labor due to frank breech presentation. c-section performed via low cervical incision. 7lb 5 oz male infant was delivered. no postpartum complications. final dx: breech presentation with obstructed labor.
answer
o64.1xx0 z37.0 z3a.41 10d00z1
question
pt admitted in labor 40 week gestation, dilated 7-8 cm fetal distress noted. US was done revealed meconium stained fluid. pt rapidly progressed to complete dilation. infants head visible in ocipito-anterior position. low forceps were applied a midline episiotomy was performed and infant was delivered followed by episiotomy repair. final dx: term delivery of live born infant, meconium-stained fluid-related fetal distress.
answer
o77.0 z3a.40 z37.0 10D07Z3 0W8NXZZ
question
pt who is 6 week postpartum seen in dr. office with flu-like symptoms, body aches, fever 101, elevated WBC, and weakness. lab work postiive for e. coli septicemiafinal dx: pierperial septicemia
answer
o85 b96.20
question
pt admitted for observation for fetal complications from a previous amniocentesis procedure done 2 weeks ago. high-risk prgnancy complicated by conjoined twin gestation, undelivered, second trimester at 27 weeks gestation
answer
035.7xx0 o30.022
question
4 day old infant is readmitted to hospital with neonatal staph sepsis
answer
P36.30
question
10 day old infant admitted with pneumonia due to respiratory syncytial virus. pt hx includes prematurity. treated with ribavairn and bronchodialators.
answer
P23.0 B97.4 J12.1
question
15 day old infant admitted for repair of bilasteral undecended testes trapped in the inguinal canal. in OR, he underwent a bilateral laparscopic orchiopexies in which punchture was made to pass the scope. on post-op day 2 a paralytic ileus was visualized on KUB. infant began vomiting, and nasogastric tube was placed and he was maintained on suction of the stomach and IV hydration. on day 4 the ileus self-corrected andf tube was removed. final dx: undecended testes.
answer
Q53.21 P76.1 0VSC4ZZ 0D9670Z
question
10 day old infant to ER after mother observed respiratory distress. infant had severe cyanosis and tachycardia, he was intubated and put on ventilator, a diagnostic echocardiogram revealed persistant fetal circulation. he was taken off after 2 days
answer
P29.3 OBH18EZ 5A1945Z
question
2 day old infant dx at birth with an ompalocele, a pice of jejunum was herniated into the navel. a laparoscopic herniorrhaphy was performed in which a small incision was made in the abdomen to allow passage of a scope. final dx: omphalocele (only code dx and procdeudre, not outcome, delivery gestation etc...)
answer
Q79.2 0WQF4ZZ
question
infant born vaginally at stork hosp. 36 week gestation and weighs 2,480 kg. dr. documents premature infant in chart. infant is transferred to white cloud hosp. which has level III neonatology unit. dr at white cloud diagnoses: prematurity, jaundice, transient tachypenia, molding of the head, syndactyly (webbing of skin) and transient hypoglycemia. sepsis was suspected and ruled out. infant recieve phototherapy twice,
answer
P07.39 P07.18 P22.1 P70.4 P59.0 Q70.11 6A651ZZ
question
live-born female infant post-term 42 weeks gestation delivered c-section. she exhibited reduced subcutaneous fat, skin was loose, dry, peeling, overgrown toenails and fingernails, and meconium-stained umbilical cord. no sign of fetal distress.
answer
z38.01 p08.21 p96.83
question
term birth living male vaginally delivered, mother chronic alcoholic. newborn place in ICU to observe for alcohol-related problems. fetal alcohol syndrome was diagnosed and infant was treated for alcohol withdrawl with meds.
answer
z38.00 q86.0 p96.1 HZ89ZZZ
question
premature infant with birth weight of 1300grams tranfered from happy valley hosp. to university hosp. NICU for tx of neonatal bradycardia of premature newborn, treated with caffeine citrate
answer
p29.12 p07.15 p07.30
question
full term newborn born on way to hosp. and was admitted to neonatal nursery with anemia due to blood loss from umbilical stump.
answer
z38.1 p51.9 p61.3
question
acute graft versus host disease resulted in rejection of bilateral transplanted kidneys 6months ago. both kidney resected after which a non-tunnled central venous catheter was incerted for temporary hemodyalysis. the CVC was placed percutaneously into the left subclavian vein through the superiror vena cava with fluroscopic assisstance. pt then recieved first course of dialysis. (do not code fluroscopy)
answer
t86.11 d89.810 z98.85 0TT20ZZ 05H633Z 5A1D00Z
question
pt with hypertensive ESRD maintained on peritoneal dialysis with a tenckhoff catheter was admitted for revision of the dislodged catheter, a mechanical complication. w/ fluroscopy the device was repositioned after which the pt recvd 2 dialyiss tx prior to D/C, (do not code fluroscopy)
answer
t85.621A I12.0 N18.6 0WWG3JZ
question
pt started on ativan one month ago for anxiety induced panic attakcs. presented to ER complaining of acute confusion detyermined to be due to the ativan. pt took more than she was prescribed. final dx: drug induced acute confusion-accidental poisoning
answer
t42.4x1a f13.221
question
pt underwent resection of sigmoid colon 1 week ago found to be andenosarcoma. no metastasis was noted. pt on 5 week course of chemo. pt is readmitted with cutaneous wound abcess at the wound site in lower abdominal wall with inflammation and drainage. a wound culture was done, dx of wound abcess with staph wound infection. wound was cleaned and irrigated pt started on IV antibiotics and wound was dressed. pt also recvd high dose interferon infusion chemo via peripheral vein. final dx: post-op staph wound infection.
answer
t81.4xxa l02.211 b95.8 c18.7 3E10X8Z 3E03305
question
pt brought to hosp. after fall from scaffolding while working on construction site of new bank building. he struck his head and experienced a brief period of inconciousness (less then 1 hr). pt found to have an open skull fracture of the left frontal bone as well as a laceration and contusion. the skull fracture was reduced after extensive debridement. (be sure to assign Y codes)
answer
s02.0xxB s06.2x2a w12.xxxa y92.61 y93.h3 y99.0 0NS20ZZ 0NB20ZZ
question
pt admitted after suicide attempt by ingesting 20 digoxin pills. she arrived at ER in ventricular fibrillation. pt suffered from depression and expressed suicidal ideation during past yr on and off. pt went into cardiac arrest and expired.
answer
t46.0x2a I49.01 I46.2 F33.9 R45.851
