Medical Case Reports and ICD Coding, Exams of Nursing

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 Question 1

10 out of 10 points CASE 1 Operative Report PREOPERATIVE DIAGNOSES: Splenic abscesses and multiple intra-abdominal abscesses, related to HIV, AIDS, and hepatitis C. POSTOPERATIVE DIAGNOSES: Splenic abscesses and multiple intra-abdominal abscesses, related to HIV, AIDS, and hepatitis C. (Postoperative diagnoses are reported.) OPERATIVE PROCEDURE:

1. Exploratory laparotomy with drainage of multiple intra-abdominal abscesses.
2. Splenectomy.
3. Vac Pak closure. FINDINGS: This is a 42-year-old man who was recently admitted to the medical service with a splenic defect and found to a splenic vein thrombosis. He was treated with antibiotics and anticoagulation. He returned and was admitted with a CT scan showing mass of left upper quadrant with abscesses surrounding both sides of the spleen (The location of the abscesses are on both sides of the spleen.) , as well as, multiple other intra-abdominal abscesses below the left lobe of the liver in both lower quadrants and in the pelvis. The patient has a psychiatric illness and was difficult to consent and had been anticoagulated with an INR of 3. Once those issues were resolved by psychiatry consultation and phone consent from the patient's father, he was brought to the operating room. OPERATIVE PROCEDURE: The patient was brought to operating room, a time-out procedure was performed. He was already receiving parenteral antibiotics. He was placed in the supine position and then given a general endotracheal anesthetic. Anesthesia started multiple IVs and an arterial line. A Foley catheter was sterilely inserted with some difficulty requiring a Coude catheter. After the abdomen was prepped and draped in the sterile fashion, a long midline incision was made through the skin. This was carried through the subcutaneous tissues and down through the midline fascia using the Bovie. The fascia was opened in the midline. The entire left upper quadrant was replaced with an abscess peel separate from the free peritoneal cavity. This was opened, and at least 3 to 4 L of foul smelling crankcase colored fluid were removed. Once the abscess cavity was completely opened, it was evident that the spleen was floating within this pus(Confirms the location of the abscess.) as had been predicted by the CT. This was irrigated copiously and the left lower quadrant subhepatic and pelvic abscesses (Location of abscesses.) were likewise discovered containing the same foul smelling dark bloody fluid. All of these areas were sucked out, irrigated, and the procedure repeated multiple times. We thought it reasonable to go ahead with the splenectomy. The anatomic planes were obviously terribly distorted. There was no clear margin between stomach spleen, colon spleen, etc., but most of the dense attachments were to the abscess cavity peel. Using this as a guide, the spleen was eventually rotated up and out to the point where the upper attachments presumably where the short gastric used to reside were taken via Harmonic scalpel. The single fire of a 45 mm stapler with vascular load was taken across the lower pole followed by two firings of the echelon stapler across the hilum. This controlled most of the ongoing bleeding. Single bleeding site below the splenic artery was controlled with two stitches, one of 3-0 Prolene and the other of 4-0 Prolene. Because of diffuse ooze in the area and the fact that the patient would be scheduled for a return visit to the operating room tomorrow to reinspect the abscess cavities, it was elected to leave two laparotomy pads in the left upper quadrant and Vac Pak the abdomen. The Vac Pak was created using blue towels and Ioban dressings in the usual fashion with 10 mm fully perforated flat Jackson-Pratt drains brought out at the appropriate level. The patient was critical throughout the procedure and will be taken directly to the intensive care unit, intubated, with a plan for reexploration and removal of the packs tomorrow. The patient received four units of packed cells during the

procedure, as well as albumin and a large volume of crystalloid. There were no intraoperative complications noted and the specimen sent included the spleen. Cultures from the abscess cavity were also taken. What diagnosis code(s) are reported? [a] [b] [c] [d] Specified Answer for: a

B

Specified Answer for: b

D73.

Specified Answer for: c

K65.

Specified Answer for: d

B19.

0

Correct Answers for: a Evaluation Method Correct Answer Exact Match B Correct Answers for: b Evaluation Method Correct Answer Exact Match D73. Exact Match K65. Exact Match B19. Correct Answers for: c Evaluation Method Correct Answer Exact Match K65. Exact Match B19. Exact Match D73. Correct Answers for: d Evaluation Method Correct Answer Exact Match B19. Exact Match D73.

Exact Match K65.

 Question 2

8 out of 10 points CASE 2 Dear Dr. Smith, Mr. Martin was seen in the office for continued management of his breast cancer. (This indicates the patient's main reason for the office visit.)He’s having some increasing pain in his breast which is due to the cancer.(Pain related to the neoplasm.) He is also complaining of neck pain. It does not seem to be worse at night; it seems to be worse with activity. He has no other symptoms. Otherwise his review of systems is unremarkable. He’s had no constitutional symptoms. On physical exam, he is alert and oriented. Eyes: EOMI, PERLA, no icterus. The heart had a regular rate and rhythm; S1, S2 within normal limits. The lungs are clear to auscultation and percussion. The abdomen was soft, without masses or organomegaly. He was tender to palpation over the left anterior iliac crest. Otherwise he had no point tenderness over his musculoskeletal system. Neck: Supple. No tenderness, no enlarged lymph nodes in the neck. ASSESSMENT: Adenocarcinoma of the left breast, positive estrogen receptor status. Neck pain. (This is the definitive diagnosis that is reported.) PLAN: The plan is to continue the Tamoxifen at this time. His laboratory studies were reviewed and were essentially unremarkable; however we’ll obtain a bone scan to ascertain the extent of his disease. (This is a male patient.) Sincerely, John Smith, M.D. What diagnosis code(s) are reported? [a] [b] [c] [d] [e]

Specified Answer for: a

C50.

Specified Answer for: b

G89.

Specified Answer for: c

M54.

Specified Answer for: d

Z17.

Specified Answer for: e

Z79.

0

Correct Answers for: a Evaluation Method Correct Answer Exact Match C50. Correct Answers for: b Evaluation Method Correct Answer Exact Match G89. Exact Match M54. Exact Match Z17. Exact Match Z79. Correct Answers for: c Evaluation Method Correct Answer Exact Match M54. Exact Match Z17. Exact Match Z79. Exact Match G89. Correct Answers for: d Evaluation Method Correct Answer Exact Match Z17. Exact Match Z79. Exact Match G89.

Exact Match M54. Correct Answers for: e Evaluation Method Correct Answer Exact Match Z79. Exact Match G89. Exact Match M54. Exact Match Z17. Response Feedback: The patient is being seen for the management of adenocarcinoma of the left breast. In the ICD-10-CM Alphabetic Index, look for Adenocarcinoma which refers you to see also Neoplasm, malignant, by site. Go to the Table of Neoplasms and look for breast and locate the code in the Malignant Primary column which directs you to C50.9-. Refer to the Tabular List for the 5th and 6th characters. This is a male patient and the cancer is in the left breast, which makes C50.922 the correct code to report. The provider documents that the pain is due to cancer. In the Alphabetic Index, look for Pain(s)/acute/neoplasm related which directs you to G89.3. Verify the code in the Tabular List. Both acute and chronic are in parentheses, which indicate these are supplementary words that may be present or absent in the diagnosis without affecting the code number to which it is assigned. ICD-10-CM guideline I.C.6.b.5 indicates that this code is assigned regardless of whether the pain is acute or chronic. The same guideline also states that when the reason for the admission/encounter is management of the neoplasm and the pain associated with the neoplasm is also documented, code G89.3 may be assigned as an additional code. In the Alphabetic Index, look for Pain(s)/neck NEC and you are directed to code M54.2. There is an instructional note under category code C50 to use an additional code to identify the estrogen receptor status. Look for Status/estrogen receptor/positive which directs you to Z17.0. The patient is continuing with tamoxifen; look for Long-term (current) (prophylactic) drug therapy (use of)/tamoxifen (Nalvadex)which directs you to Z79.810.

 Question 3

10 out of 10 points CASE 3 SUBJECTIVE: Low-grade fever at home. She has had some lumps in the abdominal wall and when she injects her insulin; it does seem to hurt there. She stopped four of her medications including Neurontin, Depakote, Lasix, and Premarin, and overall she feels quite well. Unfortunately, she has put on 20 pounds since our last visit. OBJECTIVE: HEENT: Tympanic membranes are retracted but otherwise clear. The nose shows significant green rhinorrhea present. Throat is mildly inflamed with moderate postnasal drainage.

Neck: No significant adenopathy. Lungs: Clear. Heart: Regular rate and rhythm. Abdomen: Soft, obese, and nontender. Multiple lipomas are palpated. ASSESSMENT

**1. Diabetes mellitus, type 1.

2. Diabetic neuropathy.
3. Acute sinusitis. (The definitive diagnoses are reported.)** PLAN: At this time, I have recommended the addition of some Keflex for her acute sinusitis. (Provider treated the acute sinusitis.) I have given her a chair for the shower. They will not cover her Glucerna anymore so a note for that will be required. What diagnosis code(s) are reported? [a] [b] Specified Answer for: a

E10.

0

Specified Answer for: b

J01.

0

Correct Answers for: a Evaluation Method Correct Answer Exact Match E10. Correct Answers for: b Evaluation Method Correct Answer Exact Match J01.

 Question 4

10 out of 10 points CASE 4

S: The patient presents today for reevaluation and titration of carvedilol for his coronary artery disease and hyperlipidemia. (Patient returns for treatment of CAD and hyperlipidemia.) His weight is up 7 pounds. He has quit smoking. He has no further cough and he states he is feeling well except for the weight gain. He states he doesn’t feel he’s eating more, but his wife says he’s eating more. We’ve been attempting to titrate up his carvedilol to 25mg twice a day from initially 6.25mg. He has tolerated the titration quite well. He gets cephalgias on occasion. He states he has a weak spell but this is before he takes his morning medicine. I updated his medical list here today. I gave him samples of Lipitor. O: Weight is 217, pulse rate 68, respirations 16, and blood pressure 138/82. HEENT examination is unchanged. His heart is a regular rate. His lungs are clear. A: 1. CAD

2. Hyperlipidemia (Select the codes for the definitive diagnoses.) P: 1.The plan is samples of Lipitor using the two months’ supply that I have given him.

2. We’ve increased his Coreg to 25mg bid. He’ll recheck with us in six months. What diagnosis code(s) are reported? [a] [b] [c] [d] Specified Answer for: a

I25.

Specified Answer for: b

E78.

Specified Answer for: c

Z79.

Specified Answer for: d

Z87.

Correct Answers for: a Evaluation Method Correct Answer Exact Match I25.

Correct Answers for: b Evaluation Method Correct Answer Exact Match E78. Correct Answers for: c Evaluation Method Correct Answer Exact Match Z87. Exact Match Z79. Correct Answers for: d Evaluation Method Correct Answer Exact Match Z79. Exact Match Z87.

 Question 5

10 out of 10 points CASE 5 PREOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss. POSTOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss. (Report the postoperative diagnosis.) PROCEDURES PERFORMED:

1. Placement of left Nucleus cochlear implant.
2. Facial nerve monitoring for an hour.
3. Microscope use. ANESTHESIA: General. INDICATIONS: This is a 69-year-old woman who has had progressive hearing loss (The diagnosis is documented as the indication for the surgery.) over the last 10-15 years. Hearing aids are not useful for her. She is a candidate for cochlear implant by FDA standards. The risks, benefits, and alternatives of procedure were described to the patient, who voiced understanding and wished to proceed. PROCEDURE: After properly identifying the patient, she was taken to the main operating room, where general anesthetic was induced. The table was turned to 180 degrees and a standard left-sided post auricular shave and injection of 1% lidocaine plus 1:100, epinephrine was performed. The patient was then prepped and draped in a sterile

fashion after placing facial nerve monitoring probes, which were tested and found to work well. At this time, the previously outlined incision line was incised and flaps were elevated. A subtemporal pocket was designed in the usual fashion for placement of the device. A standard cortical mastoidectomy was then performed and the fascial recess was opened exposing the area of the round window niche. The lip of the round window was drilled down exposing the round window membrane. At this time, the wound was copiously irrigated with bacitracin containing solution, and the device was then placed into the pocket. A 1-mm cochleostomy was made, and the device was inserted into the cochleostomy with an advance-off stylet technique. A small piece of temporalis muscle was packed around the cochleostomy, and the wound was closed in layers using 3-0 and 4–0 Monocryl and Steri-Strips. A standard mastoid dressing was applied. The patient was returned to anesthesia, where she was awakened, extubated, and taken to the recovery room in stable condition. What diagnosis code(s) are reported? Selected Answer:

H90.

Correct Answer: Evaluation Method Correct Answer Exact Match H90.

 Question 1

CASE 6

PREOPERATIVE DIAGNOSIS: Cataract, left eye POSTOPERATIVE DIAGNOSIS: Cataract eye Presbyopia PROCEDURE: 1 Cataract extraction with IOL implant 2 Correction of presbyopia with lens implantation PROCEDURE DETAIL: The patient was brought to the operating room under neuroleptic anesthesia monitoring. A topical anesthetic was placed within the operative eye and the patient was prepped and draped in usual manner for sterile ophthalmic surgery. A lid speculum was inserted into the right infrapalpebral space. A 6-0 silk suture was placed through the episclera at 12 o'clock. A subconjunctival injection of non-preserved lidocaine was given. A peritomy was fashioned from 11 o'clock to 1 o'clock with Westcott scissors. Hemostasis was achieved with the wet-field cautery. A 3-mm incision was made in the cornea and dissected anteriorly with a crescent blade The anterior chamber was entered at 12 o'clock and 2 o'clock with a Supersharp blade. Non- preserved lidocaine was instilled into the anterior chamber. Viscoelastic was instilled in the anterior chamber and using a bent 25-guage needle, a 360-degree anterior capsulotomy was performed using Utrata forceps. The capsulotomy was measured and found to be 5.5 mm in diameter. Using an irrigating cannula, the lens nucleus was hydrodissected and loosened. Using the phacoemulsification unit, the lens nucleus was divided and emulsified. The irrigating/aspirating tip was used to remove the cortical

fragments from the capsular bag, and the posterior capsule was polished. Using a curette to polish the anterior capsule, cortical fragments were removed from the anterior lens capsule for 270 degrees. The irrigating/aspirating tip was used to remove the capsular fragments. The anterior chamber and capsule bag were inflated with viscoelastic and using a lens inserter, a Cystalens was then placed within the capsular bag and rotated to the horizontal position. The viscoelastic was removed with the irrigating/aspirating tip and the lens was found to be in excellent position with a slight posterior vault. The wound was hydrated with balanced salt solution and tested and found to be watertight at a pressure of 20 mmHg. Topical Vigamox was applied The conjunctiva was repositioned over the wound with a wet field cautery. The traction suture and lid speculum were removed. A patch was applied. The patient tolerated the procedure well and left the operating room in good condition. What diagnosis code(s) are reported? [a] [b] Specified Answer for: a

H26.

Specified Answer for: b

H52.

Correct Answers for: a Evaluation Method Correct Answer Exact Match H26. Exact Match H52. Correct Answers for: b Evaluation Method Correct Answer Exact Match H52. Exact Match H26.

 Question 2

CASE 7

PROGRESS NOTE

This patient is a 50 year-old female who began developing bleeding, bright red blood per rectum, approximately two weeks ago. She is referred by her family physician. She states that after a bowel movement she noticed blood in the toilet. She denied any prior history of bleeding or pain with defecation. She states that she has had an external hemorrhoid that did bleed at times but that is not where this bleeding is coming from. She is presently concerned because a close friend of hers was recently diagnosed with rectal carcinoma requiring chemotherapy that was missed by her primary doctor. She is here today for evaluation for a colonoscopy.

Physical examination, she appears to be a well appearing 50 year-old, white female. Abdomen is soft, non-tender, non-distended. ASSESSMENT: 50 year-old female with rectal bleeding PLAN: We’ll schedule the patient for an outpatient colonoscopy. The patient was made aware of all the risks involved with the procedure and was willing to proceed. What diagnosis code(s) are reported? Selected Answer:

K62.

Correct Answer: Evaluation Method Correct Answer Exact Match K62.

 Question 3

CASE 8

Subjective: Here to follow up on her atrial fibrillation. No new problems. Feeling well. Medications are per medication sheet. These were reconstituted with the medications that she was discharged home on. 0bjective: Blood pressure is 110/64. Pulse is regular at 72. Neck is supple. Chest is clear. Cardiac normal sinus rhythm. Assessment: Atrial fibrillation, currently stable Plan:

1. Prothrombin time to monitor long term use of anticoagulant.
2. Follow up with me in one month or sooner as needed if she has any other problems in the meantime. Will also check a creatinine and potassium today. What diagnosis code(s) are reported? [a] [b] [c]

Specified Answer for: a

I48.

Specified Answer for: b

Z79.

Specified Answer for: c

Z51.

Correct Answers for: a Evaluation Method Correct Answer Exact Match I48. Correct Answers for: b Evaluation Method Correct Answer Exact Match Z79. Correct Answers for: c Evaluation Method Correct Answer Exact Match Z51.

 Question 4

CASE 9

Follow-up Visit: The patient has some memory problems. She is hard of hearing. She is legally blind. Her pharmacist and her family are very worried about her memory issues. She lives at home, family takes care of laying out her medications and helping with the chores, but she does take care of her own home to best of her ability. Exam: Pleasant elderly woman in no acute distress. She has postop changes of her eyes. TMs are dull. Pharynx is clear. Neck is supple without adenopathy. Lungs are clear. Good air movement. Heart is regular. She had a slight murmur. Abdomen is soft. Moderately obese. Non-tender. Extremities; no clubbing or edema. Foot exam shows some bunion deformity but otherwise healthy. Light touch is preserved. There is no ankle edema or stasis change. Examination of the upper arms reveal good range of motion. There is significant pain in her shoulder with rotational movements. It is localized mostly over the deltoid. There is no other deformity. There is a very slight left shoulder discomfort and slight right hip discomfort. Impression:

1. Dementia
2. Right shoulder pain.
3. Benign hypertensive cardiovascular disease.
4. Type 2 diabetes good control. Most recent AlC done today 5.9%. Liver test normal. Cholesterol 199, LDL a little high at 115. Plans:
5. I offered her and her family neuropsychological evaluation to evaluate for dementia. Her system complex is consistent with dementia, whether it be from small vascular disease or Alzheimer’s is unknown. At this point, they would much rather initiate treatment than go through an exhaustive neuropsychological test.
6. For the shoulder we decided on right deltoid bursa aspiration injection. She has had

injection for bursitis in the past and prefers to go this route. She will ice and rest the shoulder after injection.

3. Follow up in 3 months. Procedure: Aspiration injection right deltoid bursa. The point of maximal tenderness was identified, skin was prepped with alcohol. A 25-gauge, 1 ½-inch needle was advanced to the humerus and then aspirated. 1 cc of 0.25% Marcaine mixed with 80 mg Depo Medrol was deposited. Needle was withdrawn. Band-aid was applied. Post injection she had marked improvement; increased range of motion consistent with good placement of the medication. She was started on Cerefolin, plus NAC and Aricept starter pack was given with email away script. Follow-up in 3 months and we will reassess her dementia at that time. What diagnosis code(s) are reported? [a] [b] [c] [d] Specified Answer for: a

F03.

Specified Answer for: b

M25.

Specified Answer for: c

I11.

Specified Answer for: d E11. Correct Answers for: a Evaluation Method Correct Answer Exact Match E11. Exact Match M25. Exact Match I11. Exact Match F03. Correct Answers for: b Evaluation Method Correct Answer Exact Match M25. Exact Match I11. Exact Match F03. Exact Match E11.

Correct Answers for: c Evaluation Method Correct Answer Exact Match I11. Exact Match F03. Exact Match E11. Exact Match M25. Correct Answers for: d Evaluation Method Correct Answer Exact Match F03. Exact Match E11. Exact Match M25. Exact Match I11.

 Question 5

CASE 10

CC: HTN

INTERVAL HISTORY: No new complaints.

EXAM: NAD. 130/80, 84, 22. Lungs are clear. Heart RRR, no MRGs. Abdomen is soft, non-

tender. No peripheral edema. IMPRESSION: Stable HTN on current meds.

PLAN: No changes needed. RTC in six months with labs.

What diagnosis code(s) are reported? [a] Specified Answer for: a

I

0

Correct Answers for: a Evaluation Method Correct Answer Exact Match I