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Comprehensive
iHuman Case Study:
30-Year-Old Female
Reason for Encounter
Neck Pain (Class,
Exams of Nursing
Match each key term to the appropriate definition. - ANSWERS -
- Intervertebral Disc A fibrocartilage segment that lies between vertebrae of the spinal column and provides cushioning and support.
- Articulation A joint.
- Site The specific anatomical location of the disease or injury.
- Vertebra A bone that is a part of the construction of the spinal column.
- Laterality The right or left side of anatomical sites that have locations on both sides of the body. Jane Timmerman was diagnosed with lower back strain,
subsequent encounter. What is the correct code? - ANSWERS -
S39.012D
___ is an autoimmune systemic inflammatory disease that affects joints as well as the surrounding muscles, tendons, and ligaments.
- ANSWERS -Rheumatoid arthritis A chronic degeneration of the articular cartilage simultaneous with the formation of bone spurs on the underlying bone within a
joint is known as - ANSWERS -osteoarthritis.
___ is a condition in which the sternocleidomastoid muscles become spasmed (shortened), causing the head to bend to one side and the chin to the opposite side.
Multiple Choice - ANSWERS -Torticollis
Sammie Blane was diagnosed with cervicothoracic postural
kyphosis. How is this coded? - ANSWERS -M40.
A systemic rheumatic disorder characterized by inflammatory and degenerative changes in the skin and muscles is known as -
ANSWERS -dermatopolymyositis
M80, M81). Though the portion of the bone affected may be at the joint, the site designation will be the bone, not the joint.
- Bone, joint, or muscle conditions that are ethe result of a healed injury are usually found in Chapter 13.
- 7th character A is for use as long as the patient is receiving active treatment for the fracture. Refer to the Official Guidelines and select the correct choices in the dropdown box according to the Chapter 13, Diseases of the Musculoskeletal System and Connective Tissue, Chapter-Specific
Coding Guidelines. - ANSWERS -1. Osteoporosis is a systemic
condition, meaning that all bones of the musculoskeletal system are affected.
- Category M81, Osteoporosis without current pathological fracture, is for use for patients with osteoporosis who do not currently have a pathologic fracture due to the osteoporosis, even if they have had a fracture in the past.
- For patients with a history of osteoporosis fractures, status code Z87.310, personal history of (healed) osteoporosis fracture, should follow the code from M81.
- Category M80, Osteoporosis with current pathological fracture, is for patients who have a current pathologic fracture at the time of an encounter.
- A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone. First, identify the condition in the following diagnoses; then code
the diagnosis. - ANSWERS -1. Infective myositis, left foot:
a. Main term: myositis b. diagnosis: M60.
- Pyogenic arthritis, left knee a. arthritis b. M00.
- Foreign body granuloma of soft tissue, right thigh a. granuloma b. M60.
- Juxtaphalangeal distal osteoarthritis a. osteoarthritis b. M15.
- Nontraumatic rupture of the muscle, left shoulder a. rupture b. M62.
- Ankylosis of right wrist a. ankylosis b. M24.
- Abscess of tendon sheath, right forearm a. abscess b. M65.
- Spinal stenosis, cervicothoracic region a. stenosis b. M48.
- Calcific tendinitis, left pelvic region a. tendinitis b. M65. Nancy Nottingham, a 52-year-old female, presents today with a severe burning pain and swelling in her upper right arm and fingers. Dr. Olden notes edema and allodynia. After a thorough examination, Nancy is diagnosed with reflex sympathetic
dystrophy (RSD). - ANSWERS -Principal diagnosis:
Where should you begin to look up the code in the coding manual
- Index to Diseases and Injuries What is the key term - Syndrome What type - Pain
What type - Complex region What is the anatomical site - Upper limb Do any of the following apply to the condition - None of these What is the laterality - Right Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries
- Yes Is there an Includes notation - No If so does the Includes note help to clarify - No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - No If so does the Use additional code note apply to the case study - No Use additional code notation Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder "X" - No Did you code to the highest level of specificity - Yes
If so does the Use additional code note apply to the case study - No Use additional code notation Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder "X" - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - M75. Sharron Webster, a 3-year-old female, was brought in by her parents to see her pediatrician, Dr. Surrant, 4 days ago. Sharron had a boil on her left thigh that Dr. Surrant incised and drained. Sharron is now running a fever of 102 F. Dr. Surrant decides to admit Sharron to Weston Hospital. The MRI scan revealed abscess of the vastus intermedius muscle. A wound culture grew Staphylococcus aureus. Sharron is diagnosed with pyomyositis. -
ANSWERS -Principal diagnosis:
Where should you begin to look up the code in the coding manual
- Index to Diseases and Injuries What is the key term - Myositis What type - Infective What is the anatomical site - Lower limb What is the location - Thigh Do any of the following apply to the condition - None of these
What is the laterality - Left Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries
- Yes Is there an Includes notation - No If so does the Includes note help to clarify - No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - Yes If so does the Use additional code note apply to the case study - Yes Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder "X" - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - M60.
Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder "X" - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - B95. Tamara Gibbons, a 37-year-old female, presents today with pain on the inside of her right knee. Dr. Booker completes a history and physical examination. After reviewing the MRI results, Tamara is
diagnosed with Plica syndrome. - ANSWERS -Principal diagnosis:
Where should you begin to look up the code in the coding manual
- Index to Diseases and Injuries What is the key term - Plica What type - Syndrome, knee Do any of the following apply to the condition - None of these What is the laterality - Right Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries
- Yes Is there an Includes notation - No If so does the Includes note help to clarify - No Includes notation Is there a Code first notation - No
If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - No If so does the Use additional code note apply to the case study - No Use additional code notation Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder "X" - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - M67. Jay Lawson, a 13-year-old male, is brought in by his parents to see Dr. Bouknight, his pediatrician. Jay is complaining of left hip pain and stiffness. Dr. Bouknight completes a physical examination and notes limited left hip motion as well as soft tissue swelling. Jay is admitted to Weston Hospital. Aspiration of synovial fluid reveals an elevated cell count of 136 cells/mL with 52% being polymorphonuclear leukocytes. Jay is diagnosed with intermittent
hydrarthrosis. - ANSWERS -Principal diagnosis:
Where should you begin to look up the code in the coding manual
- Index to Diseases and Injuries
Did you code to the highest level of specificity - Yes What is the correct diagnosis code - M12. Terrell Meddy, a 58-year-old male, comes in today to see Dr. McNair with the complaint his left elbow is stiff, painful and feels warm. Terrell doesn't remember hitting his elbow on anything. After an examination, Dr. McNair diagnosis Terrell with olecranon
bursitis of the elbow. - ANSWERS -Principal diagnosis:
Where should you begin to look up the code in the coding manual
- Index to Diseases and Injuries What is the key term - Bursitis What is the anatomical location - Elbow What type - Olecranon Do any of the following apply to the condition - None of these What is the laterality - Left Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries
- Yes Is there an Includes notation - Yes If so does the Includes note help to clarify - Yes Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation
Is there a Use additional code notation - Yes If so does the Use additional code note apply to the case study - No Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder "X" - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - M70. Shirley Moody, an 11-year-old female, is brought in by her mother. Mrs. Moody states that Shirley is experiencing severe muscle weakness. Dr. Bernstein completes a physical examination and notes heart arrhythmias, aphasia, and dyspnea. Shirley says that the weakness seems to last about 4 hours and comes and goes. Dr. Bernstein admits Shirley into the hospital and orders an electromyographic (EMG) test. The results of the ECG, EMG, and muscle biopsy confirm the diagnosis of hypokalemic periodic
paralysis. - ANSWERS -Principal diagnosis:
Where should you begin to look up the code in the coding manual
- Index to Diseases and Injuries What is the key term - Paralysis What type - Periodic Do any of the following apply to the condition - None of these
speech problems. Dr. Hunt notes misalignment between the teeth of the dental arches as Angie's jaw closes. Dr. Hunt completes a thorough examination and the appropriate tests. Angie is
diagnosed with malocclusion, Angle's class II. - ANSWERS -
Principal diagnosis: Where should you begin to look up the code in the coding manual
- Index to Diseases and Injuries What is the key term - Malocclusion What type - Angle's What class - II Do any of the following apply to the condition - None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries
- Yes Is there an Includes notation - No If so does the Includes note help to clarify - No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - No If so does the Use additional code note apply to the case study - No Use additional code notation Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No
Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder "X" - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - M26. Ned Taylor, a 33-year-old male, presents today with severe weakness in his left hip. Dr. Louthan notes enlarged neck lymph node, a rash, and high fever. Ned admits to some eye and chest pain with general lethargy. After a thorough examination, Dr. Louthan decides to admit Ned to the hospital. The laboratory test and MRI confirmed the diagnosis of arthritis of the hip due to
O'nyong-nyong fever. - ANSWERS -Principal diagnosis:
Where should you begin to look up the code in the coding manual
- Index to Diseases and Injuries What is the key term - Arthritis What type - O'nyong-nyong Do any of the following apply to the condition - None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries
- Yes Is there an Includes notation - Yes If so does the Includes note help to clarify - Yes Is there a Code first notation - No
