Diagnostic Coding

W6: Coding

Your Name:

Part 1

Instructions: Review each case and identify the first-listed diagnosis.

1. Pain, left knee. History of injury to left knee 20 years ago. Patient underwent arthroscopic surgery and medial meniscectomy, right knee (10 years ago). Probable arthritis, left knee.

FIRST-LISTED DIAGNOSIS: ________

2. Patient admitted to the emergency department (ED) with complaints of severe chest pain. Possible myocardial infarction. EKG and cardiac enzymes revealed normal findings. Diagnosis upon discharge was gastroesophageal reflux disease.

FIRST-LISTED DIAGNOSIS: ______

3. Female patient seen in the office for follow-up of hypertension. The nurse noticed upper arm bruising on the patient and asked how she sustained the bruising. The physician renewed the patient’s hypertension prescription, hydrochlorothiazide.

FIRST-LISTED DIAGNOSIS: _______

4. Ten-year-old male seen in the office for sore throat. Nurse swabbed patient’s throat and sent swabs to the hospital lab for strep test. Physician documented “likely strep throat” on the patient’s record.

FIRST-LISTED DIAGNOSIS: _____

5. Patient was seen in the outpatient department to have a lump in his abdomen evaluated and removed. Surgeon removed the lump and pathology report revealed that the lump was a lipoma.

FIRST-LISTED DIAGNOSIS: _____

Part 2

Instructions: Match the diagnosis in the right-hand column with the procedure/service in the left-hand column that justifies medical necessity.

E 6. allergy test a. bronchial asthma

B 7. EKG b. chest pain

A 8. inhalation treatment c. family history, cervical cancer

C 9. Pap smear d. fractured wrist

G 10. removal of ear wax e. hay fever

I_ 11. sigmoidoscopy f. hematuria

J 12. strep test g. impacted cerumen

F 13. urinalysis h. jaundice

H 14. venipuncture i. rectal bleeding

D 15. X-ray, radius and ulna j. sore throat

Part 3

Instructions: Review the following SOAP notes or Operative reports to select the diagnoses that should be reported on the CMS-1500 claim. Then assign ICD-10-CM codes to diagnoses. (The level of service is indicated for each visit.)

16.

S: A 53-year-old new patient was seen today for a level 2 visit. The female patient presents with complaints of polyuria, polydipsia, and weight loss.

O: Urinalysis by dip, automated, with microscopy reveals elevated glucose.

A: Possible diabetes.

P: The patient is to have a glucose tolerance test and return in three days for her blood work results and applicable management of care.

Diagnoses	ICD Codes
Polyuria	R35.8
polydipsia	R63.1
weight loss	R63.4
Urinalysis	R81

17. PREOPERATIVE DIAGNOSIS: Ventral hernia

POSTOPERATIVE DIAGNOSIS: Ventral hernia

PROCEDURE PERFORMED: Repair of ventral hernia with mesh

ANESTHESIA: General

PROCEDURE: The vertical midline incision was opened. Sharp and blunt dissection was used in defining the hernia sac. The hernia sac was opened and the fascia examined. The hernia defect was sizable. Careful inspection was utilized to uncover any additional adjacent fascial defects. Small defects were observed on both sides of the major hernia and were incorporated into the main hernia. The hernia sac was dissected free of the surrounding sub- cutaneous tissues and retained. Prolene mesh was then fashioned to size and sutured to one side with running #0 Prolene suture. Interrupted Prolene sutures were placed on the other side and tagged untied. The hernia sac was then sutured to the opposite side of the fascia with Vicryl suture. The Prolene sutures were passed through the interstices of the Prolene mesh and tied into place, ensuring that the Prolene mesh was not placed under tension. Excess mesh was excised. Jackson-Pratt drains were placed, one on each side. Running sub- cutaneous suture utilizing Vicryl was placed, after which the skin was stapled.

Diagnoses	ICD Codes

18.

PREOPERATIVE DIAGNOSIS: Intermittent exotropia, alternating fusion with decreased stereopsis

POSTOPERATIVE DIAGNOSIS: Intermittent exotropia, alternating fusion with decreased stereopsis

PROCEDURE PERFORMED: Bilateral lateral rectus recession of 7.0 mm

ANESTHESIA: General endotracheal anesthesia

PROCEDURE: The patient was brought to the operating room and placed in the supine position where she was prepped and draped in the usual sterile fashion for strabismus surgery. Both eyes were exposed to the surgical field. After adequate anesthesia, one drop of 2.5 percent Neosynephrine was placed in each eye for vasoconstriction. Forced ductions were performed on both eyes, and the lateral rectus was found to be normal. An eye speculum was placed in the right eye and surgery was begun on the right eye. An inferotemporal fornix incision was performed. The right lateral rectus muscle was isolated on a muscle hook. The muscle insertion was isolated, and checked ligaments were dissected back. After a series of muscle hook passes using the Steven’s hook and finishing with two passes of a Green’s hook, the right lateral rectus was isolated. The epimesium, as well as Tenon’s capsule, was dissected from the muscle insertion and the checked ligaments were lysed. The muscle was imbricated on a 6-0 Vicryl suture with an S29 needle with locking bites at either end. The muscle was detached from the globe, and a distance of 7.0 mm posterior to the insertion of the muscle was marked. The muscle was then reattached 7.0 mm posterior to the original insertion using a cross-swords technique. The conjunctiva was closed using two buried sutures. Attention was then turned to the left eye where an identical procedure was performed. At the end of the case the eyes seemed slightly exotropic in position in the anesthetized state. Bounce back tests were normal. Both eyes were dressed with tetracaine drops and Maxitrol ointment. There were no complications. The patient tolerated the procedure well, was awakened from anesthesia without difficulty, and was sent to the recovery room. The patient was instructed in the use of topical antibiotics, and detailed postoperative instructions were provided. The patient will be followed up within a 48-hour period in my office.