Chapter 1 Certain Infectious and Parasitic Diseases
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1 Chapter 1 Certain Infectious and Parasitic Diseases 1.1 A patient is seen for right lower leg muscle atrophy that is the result of a previous bout of polio. Chapter 2 Neoplasms 2.1 Small cell carcinoma of right lower lobe of lung with metastasis to the intrathoracic lymph nodes, brain and right rib. Chapter 3 Diseases of the Blood and Blood Forming Organs and Certain Disorders Involving the Immune Mechanism 3.1 Congenital red cell aplastic anemia Chapter 4 Endocrine, Nutritional and Metabolic Diseases 4.1 A 62-year-old male with mild nonproliferative diabetic retinopathy with macular edema. He has type 2 DM and takes insulin on a daily basis. He also has a diabetic cataract in his right eye. What is the correct code assignment?
2 Chapter 5 Mental and Behavioral Disorders 5.2 A 52-year-old with dementia and forgetfulness has been wandering from home and getting lost. The diagnosis is dementia due to early-onset of Alzheimer s disease. Chapter 6 Diseases of the Nervous System 6.2 Left-sided hemiplegia 6.3 Seizure disorder 6.4 Parkinson s disease Chapter 7 Diseases of the Eye and Adnexa 7.1 A patient with moderate primary open-angle glaucoma of the left eye. Chapter 8 Diseases of the Ear and Mastoid Process 8.2 Bilateral conductive hearing loss
3 8.3 Meniere s vertigo of left ear 8.4 Benign paroxysmal vertigo Chapter 9 Diseases of the Circulatory System 9.1 Stage 3 chronic kidney disease with congestive heart failure due to hypertension Chapter 10 Diseases of the Respiratory System 10.1 COPD with emphysema Chapter 11 Diseases of the Respiratory System 11.1 Patient with recurrent right inguinal hernia with gangrene and obstruction Chapter 12 Diseases of the Skin and Subcutaneous Tissue 12.1 Patient with gangrenous pressure ulcer of right hip with cellulitis and pressure ulcer of sacrum documented by a physician. Nursing assessment indicated stage 2 sacral ulcer and stage 3 decubitus ulcer of right hip.
4 Chapter 13 Diseases of the Musculoskeletal System and Connective Tissue 13.1 An 80-year-old female with senile osteoporosis complaining of severe back pain with no history of trauma. Provider documentation reveals pathological compression fractures of several lumbar vertebrae. Chapter 14 Diseases of the Genitourinary System 14.1 An 83-year-old man with complaints of lower abdominal pain and the inability to urinate over the past 24 hours, diagnosed as acute kidney failure due to acute tubular necrosis, caused by a urinary obstruction. The urinary obstruction was a result of the patient s benign prostatic hypertrophy. Chapter 17 Congenital Malformations, Deformations and Chromosomal Abnormalities 17.1 Down Syndrome Chapter 18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings 18.1 Patient with fever of 101 degrees with chills. Lab tests and urinalysis are within normal limits. Physician gives a final diagnosis as fever with chills, possible viral syndrome.
5 Chapter 19 Injury, Poisoning, and Certain Other Consequences of External Causes 19.1 A patient admitted for aftercare following traumatic lateral epicondyle fracture of the right elbow, which is healing normally A patient taking Digoxin is experiencing nausea, vomiting and profound fatigue. The patient indicates that she has been taking the drug as prescribed. Evaluation and treatment focused on adjustment of the medication only. Chapter 21 Factors Influencing Health Status and contact with health services 21.1 A 75-year-old woman was admitted for occupational therapy (OT) following cardiac bypass surgery. She continues to have significant acute post-thoracotomy pain. Assign the correct diagnostic code(s). Code(s): 21.2 This 81 year old female is a resident of the nursing facility due to CHF and atrial fibrillation. She fell from the bed at the nursing facility and was transferred to the hospital. She was readmitted to the nursing facility to resume care and to add PT following an open reduction and pinning of a left comminuted subcapital femoral neck fracture. Assign the correct diagnostic code(s). Code(s):
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Certain infectious and parasitic diseases 0101 Intestinal infectious diseases 0102 Tuberculosis 0103 Infections with a predominantly sexual mode of transmission 0104 Viral infections characterized by skin
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