1. A 7 month old male was brought in by his mother who states that he has been coughing for the past 10 days but she has noticed an increased severity in the coughing today with a noticeable high pitched sound at the end of the coughing fit. He has not had a fever just severe coughing with a lot of mucous running from his nose. Cultures were taken positive for B. pertussis. What is the correct ICD 10 CM code? a) A37.90 b) A37.01 c) A37.80 d) A37.00** (1) Rationale: The positive culture for B. pertussis or Bordetella pertussis and the description of the patient s symptoms fits with the diagnosis of Whooping Cough due to Bordetella pertussis code A37.00. To find the code look up: Whooping Cough; due to; Bordetella; pertussis. 2. A 33 year old man presents for biopsy of a mass located in his upper inner quadrant of his right breast. The pathology indicates malignancy that is present at the margins; we have scheduled the patient for a formal excision of this malignancy. What is the correct code? a) C50.211 b) C50.221** c) C50.219 d) C50.229 (1) Rationale: This malignancy is of the male breast located in the right upper inner quadrant of the breast, which correlates the correct code C50.221 Malignant neoplasm of upper inner quadrant of right male breast. To locate code: Neoplasms, breast, upperinner quadrant, malignant primary 3. A 15 year old black male presents for routine follow up for his Sickle cell anemia Hb type C. What is the correct code? a) D57.21 b) D57.80 c) D57.20** d) D57.00 (1) Rationale: Since this case does not indicate that the patient is suffering from crisis due to this condition that means that, the code should be reflective of this fact. The correct code for this case directly correlates to the code D57.20 Sickle cell/hb C disease without crisis. To look up the code: Disease, Sickle cell, Hb C, without crisis. 4. During lysis of adhesions surrounding the kidney for a mass excision, we accidently lacerated the patient s adrenal gland. What is the correct code would be reported for the laceration only? a) T81.89XA b) E36.11 c) T81.9XXA d) E36.12** (1) Rationale: In ICD 10, all accidental lacerations and punctures of organs during a procedure are listed under the organ that was injured. To look up the code start with Complications, Intraoperative (intraprocedural), puncture or laceration (accidental)
(unintentional) (of), endocrine system organ or structure, during procedure on other organ. 5. A patient presented to the ED for treatment of a laceration on his forehead from a fall. The patient seems overly hyperactive, during treatment the patient tested positive for cocaine. What is the correct code for the patient s cocaine results? a) F14.920** b) F14.220 c) F14.120 d) F14.90 (1) Rationale: In this case, we do not know if this patient is dependent or abuses cocaine so the appropriate assignment would be use. Since this patient was obviously intoxicated at the time of the encounter, the code assignment is F14.920 Cocaine use, unspecified with intoxication, uncomplicated. To locate the code: Use (of), cocaine, intoxication, uncomplicated. 6. A patient presents for evaluation of her bilateral carpal tunnel syndrome. The case is reported with code and. a) Answer: G56.01 Carpal tunnel syndrome, right upper limb & G56.02 Carpal tunnel syndrome, left upper limb (1) Rationale: When a patient has a bilateral condition but the code set does not have a bilateral code to report the appropriate coding is to assign the codes for each limb that is affected. To locate the codes: syndrome, carpal tunnel 7. This female patient presents today due to swelling of her left eye. She states that she accidently fell asleep with her contacts in, it was hard to remove but she was able to finally remove them but her eye has remained swollen. What is the correct code for this case? a) H18.211 b) H18.212** c) H18.219 d) H18.213 (1) Rationale: Since this patient was suffering from edema due to her contacts, the appropriate code is H18.212 Corneal edema secondary to contact lens, left eye. To locate the code: Edema, cornea, secondary, due to contact lens 8. A patient presents to the office stating, It feels like there s something in my ears. Upon examination, it was found that the patient has a polyp located in the patient s middle ear bilaterally. What is the correct code for this case? a) H74.40 b) H74.41 c) H74.42 d) H74.43** (1) Rationale: Since this code set has a bilateral code, the appropriate reporting would be for code H74.43 Polyp of middle ear, bilateral. To locate the code: polyp, ear (middle) 9. A patient presents to the ED complaining of an excruciating headache, CT reveals an acute subdural hemorrhage. In review of the patient s history, there is no mention of recent trauma to the patient s head. What is the correct code for this case?
a) I62.03 b) I62.00 c) I62.02 d) I62.01** (1) Rationale: Based on the patient s diagnosis the appropriate code for this case is I62.01 Nontraumatic acute subdural hemorrhage. To locate the code: hemorrhage, subdural (Nontraumatic), acute 10. A 21 year old patient is diagnosed with acute and chronic tonsillitis. What is the correct code(s) for this case? a) J35.01, J03.90 b) J03.91, J35.03 c) J03.90, J35.01** d) J35.01 (1) Rationale: According to the guidelines when a patient has been diagnosed with a condition that is both acute and chronic unless the code description states acute and chronic assign the codes for both and sequence the acute code first followed by the chronic code. In this case J03.90 Acute tonsillitis, unspecified and J35.01 Chronic tonsillitis, to locate the code: tonsillitis, (use the default code for acute) then chronic. 11. A patient presents for a colonoscopy to evaluate the patient s diverticulosis. The scope revealed diverticulosis throughout the patient s intestine without evidence of perforation or bleeding. What is the correct code for this case? a) K57.20 b) K57.50 c) K57.30** d) K57.32 (1) Rationale: Based on the documentation this patient only has confirmed diverticulosis of the intestine, this does not include the small intestine. Because of this, the correct code is K57.30 Diverticulosis of large intestine without perforation or abscess without bleeding. To locate the code: diverticulosis, large intestine 12. A diabetic patient presents today for re evaluation of the pressure ulcer on her left upper back. It is currently at a stage 3. What is the correct code for the patient s pressure ulcer? a) L89.103 b) L89.123** c) L89.113 d) L89.133 (1) Rationale: Based on the documentation this patient s ulcer is located on the left upper back and that it is a stage 3. Because of this the appropriate code for this case is L89.123 Pressure ulcer of left upper back, stage 3 13. A 60 year old patient presents with recurrent symptoms of his primary gout in his right great toe. What is the correct code for this case? a) M1A.0710** b) M1A.00X0 c) M1A.0711 d) M1A.9XX0
(1) Based on the documentation this patient has primary gout that is recurrent making this a chronic condition. Primary gout is also referred to as idiopathic because of this the correct code for this case is M1A.0710 Idiopathic chronic gout, right ankle and foot, without tophus. The seventh character is determined by if this patient is also suffering from tophus, which he is not making the seventh character 0. To locate the code: Gout, chronic, ankle and foot 14. This patient presents post radical prostatectomy complaining of erectile dysfunction. What is the correct code for this case? a) N52.33 b) N52.34 c) N52.39 d) N52.31** (1) Rationale: Because this patient presents with erectile dysfunction status post radical prostatectomy makes the correct code assignment N52.31 Erectile dysfunction following radical prostatectomy. To locate the code: Dysfunction, sexual, male, erectile, postoperative, following, prostatectomy, radical 15. This patient is a pregnant female currently in her second trimester with complaints of burning and itching when she urinates. Upon exam, it is found that this patient has a urinary tract infection. What is the correct code for this infection? a) O23.32 b) O23.92 c) O23.42** d) O23.12 (1) Rationale: This patient has a UTI occurring in her second trimester, because of this the correct code assignment is O23.42 Unspecified infection of the urinary tract in pregnancy, second trimester. Ideally, the documentation would indicate the specific location of the infection such as the bladder or urethra, which would make the code assignment as specific as possible. The documentation would also include the causal organism allowing an additional code to be assigned for this case. To locate the code: Infection, urinary (tract), complicating, pregnancy 16. This is a newborn patient who is small for dates at 1300 grams. What is the appropriate code for this patient? a) P05.15** b) P05.16 c) P05.14 d) P05.2 (1) Rationale: Based on documentation indicating the patients weight and age newborn the appropriate code for this patient is P05.15 Newborn small for gestational age, 1250 1499 grams. To locate the correct code: Small for dates, with weight of, 1250 1499 grams 17. This female patient presents today for evaluation of her cleft palate prior to her reconstruction procedure, which is tomorrow. What is the code for cleft palate? a) Q35.5 b) Q35.1**
c) Q35.7 d) Q35.9 (1) Rationale: The documentation doesn t state that the patient s soft palate is involved, therefore the correct code would be Q35.1 Cleft hard palate. To locate this code: cleft palate, hard 18. This patient recently had her glucose tested and was diagnosed with borderline diabetes. What is the correct code for this case? a) E11.9 b) R73.01 c) R73.09** d) R73.02 (1) Based on the diagnosis the correct code is R73.09 Abnormal glucose. To locate this code: Borderline, diabetes mellitus 19. This patient presents to the ED indicating that his dog bit him on his left lower flank. Upon examination, this wound will require a couple of stitches to close the wound, which is clean. What is the correct code for this injury only? a) S32.144A b) S31.154A** c) S31.154D d) S32.144D (1) Rationale: The correct code assignment for this case is S31.151A Open bite of abdominal wall, left lower quadrant without penetration into the peritoneal cavity, initial encounter. According to the ICD 10 CM manual this code set requires a 7 th character extender and since this patient is receiving active treatment the correct 7 th character is A. To locate this code: Bite, abdomen, wall, left, lower quadrant 20. A female patient presents today complaining that her right pinky finger has swollen and it won t go down because her turtle bit her when she was feeding it. What is the code for the cause of the patient s injury? a) W59.21XA** b) W59.22XA c) W59.21A d) W59.22A (1) Rationale: Based on the documentation this is injury occurred because the patient s pet turtle bit her during feeding. Because this patient is receiving active treatment, the correct code is W59.21XA Bitten by a turtle, initial encounter. This code set is only 5 characters in length, which requires a placeholder in the 6 th character position to accommodate the 7 th character extender. To locate the code: In the external cause index look up Bite, bitten by, reptile, turtle 21. A patient who is set to be discharged from the hospital requires her central line to be removed. What is the correct code for the removal of the catheter? a) Z45.1 b) Z49.01 c) Z45.2** d) Z45.9
(1) The correct code for this case Z45.2 Encounter for adjustment and management of vascular access device. This code includes encounters for removal or replacement of the implanted device. To locate the code: Removal, catheter, vascular